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Comprehensive ATI Review

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Most common cause of hyperthyroidism
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Grave’s Disease
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S/S of thyroid storm
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hyperthermia, HTN, delirium, vomiting, abdominal pain, hyperglycemia, tachydysrhythmias
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Antidote for Valium intoxication
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Flumazenil (Romazicon)
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Valium, monitor for what?
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decreased respirations
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Appropriate actions for bacterial meningitis
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droplet precautions, decrease environmental stimuli, maintain best rest w/ HOB at 30, seizure precautions, replace fluid and electrolytes
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position crutches on affected or unaffected side when sitting or rising from chair?
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unaffected side 2-3 finger widths Crutches no weight bearing Tripod position weight on UNAFFECTED side. advance both crutches and affected extremity move unaffected forward (beyond crutches) advance both crutches then affected extremety continue sequence (steps equal length) Crutches with weight bearing move crutches forward about 1 step length move AFFECTED leg forward level with crutches move unaffected leg forward continue sequence (steps equal length)
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Intervention for sprain
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(PRINCE) Protect, Rest, Ice, NSAIDs, Compress, Elevate
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Airborne Precautions
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Used to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). Airborne precautions require: – A private room – Masks/ respiratory protection devices for caregivers and visitors -Negative pressure airflow exchange in the room of at least six exchanges per hour.
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Droplet Precautions
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Protect against droplets larger than 5 mcg (streptococcal pharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma, pneumonia, meingococcal pneumonia/sepsis, pneumonic plague). Droplet precautions require: – A private room or a room with other clients with the same infectious disease -Masks
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Contact Precautions
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MRS WEE) Multidrug resistant organism, respiratory infection, skin infection (varicella, diphteria, shingle, impetigo, scabies), wound infection, enteric infection (c-diff), eye infection Protect visitors and caregivers against direct client/ environmental contact infections(respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, scabies, multi-resistant organisms). Contact precautions require: – A private room or a room with other clients with the same infection – Gloves and gowns worn by the caregivers and visitors. – Disposal fo infectious dressing material into a single, nonporous bag without touching the outside of the bag.
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use of restraints
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provider must rewrite order every 24h, Toileting and ROM exercises and assessment of neurovascular and neurosensory status q2h, tie to bed frame (loose knots that are easily removed)
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Care for Pt who has clostridium difficile
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contact precautions, encourage increased fluid intake, antiemetics, antimicrobial therapy
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clinical manifestations of smallpox
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high fever, fatigue, sever headache, rash (starts centrally and spreads outward) that turns to pus-filled lesions, vomiting, delirium, excessive bleeding
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sealed radiation implant
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pt in private room, nurse should wear dosimeter film badge, visitors limited to 30m visits and maintain distance of 6ft, visitors who are pregnant or under 16yrs. should not contact Pt, lead container in room, instruct pt to call nurse for assistance with elimination
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Latent phase of labor
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1st part of the 1st stage of labor, lasts 4-6h, cervix 0-3cm, contractions irregular, mild to mod frequency 5-30m and duration of 30-45s, some dilation and effacement, pt talkative and eager Use slow/ deep breathing
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Periodic FHR Changes
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Variable Cord Compression Move client Early Head Compression Identify progress Acceleration Other (Okay) No action needed Late Placental Insufficiency Execute action fast
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equation for calculating due date
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1st day of last period + 1yr – 3 months + 7d = due date
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grains per day
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6 oz whole grains (cereals , rice, pasta) 1 oz = one slice of bread, 1 cup cereal 1/2 cup cooked pasta
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veggies per day
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2.5 cups (raw, cooked, or juice) broccoli, carrots dry beans and peas, corn, potatoes, tomatoes
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fruits per day
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2 cups (1 small banana, orange, 1/4 cup dried apricots)
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milk per day
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3 cups (2% milk, yogurt, cheese)
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protein per day
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5.5oz (one small chicken breast 3 oz, one egg 1 oz, 1/4 cup dried cooked beans 1oz
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nutrients for healthy nervous system
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B complex vitamins (thiamine, niacin, B6 & B12, Ca, and Na
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Oils
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6 tsp (canola, corn, olive, nuts, olives and some fish)
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Lab Results of an MI
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elevated troponin, CK-mb enzymes, elevated LDH
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daily % calories from protein
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10%
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daily % calories from carbs
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45-65%
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daily % calories from fat
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20-35%
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expected physiological changes of aging
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decreased EVERYTHING (skin turgor, wt, chest wall movement, senses, ht, subQ fat)
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measures to prevent injury with osteoporosis
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Ca supplementation, adequate amounts of protein, mag, vit. K, Vit D, wt-bearing exercises, remove throw rugs, provide adequate lighting, clear walkways, mark thresholds, doorways and steps
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African American women are at increased risk for what?
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cervical cancer
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African Americans are at increased risk for what?
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heart disease and stroke
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What populations are at greater risk for diabetes?
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American Indians, Alaskan natives, African Americans & Hispanics
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Discharge teaching on breast engorgement
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Nonlactating Clients: avoid nipple stimulation & apply cold compresses 15m on and 45m off, cabbage leaves placed inside bra, pain meds, supportive bra. Lactating Clients: manually express some milk, frequent feeding or pumping, warm shower, beast massage, supportive bra, maternal meds after feed to avoid cross-over to breast milk.
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to lose 1 lb of body fat per week, an adult must have an energy deficit of ____ cals/day
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500 or 3,500 cal/wk
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Positive symptoms of schizophrenia
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hallucinations, delusions, alterations in speech, bizarre behavior
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Negative symptoms of schizophrenia
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flat, blunt affect; algoia (poverty of thought/speech); avolition (lack of motivation); anhedonia (lack of pleasure/joy); anergia (lack of energy)
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Nursing interventions for domestic partner abuse
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help Pt develop a safety plan, identify behaviors and situations that might trigger violence and provide information regarding safe places to live; encourage participation in support groups
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Nursing interventions for Pt who is manic
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decrease stimulation, frequent rest periods, observe for escalating behavior, provide outlets for physical activity, provide portable nutritious food, use a calm, matter-of-fact approach, give concise explanations
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Nursing interventions for alcohol withdrawal syndrome
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self-assess ones own feelings regarding abuses; use open-ended questions, close/one-on-one observation; low-stimulation enviro, encourage attendance of self-help groups
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Nursing interventions for Pt with PTSD
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provide safety and comfort, remain w/ Pt through episode, give reassurance, group/family therapy is best, assist client to eval. coping mechanisms that work, assist Pt in determining triggers
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Nursing interventions for dementia
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reinforce reality, orientation to Person Place Time, encourage reminiscence about happy times, talk about familiar things, minimize need for decision making and abstract thinking to avoid frustration
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Ileostomy Care
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apply skin barriers to stoma, empty bag when it is 1/3 full, assess for fluid and electrolyte imbalances
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Normal post-op output for an ileostomy is what?
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1 L/day; may be bile colored and liquid; normal to see small amounts of blood
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Stoma appearance should normally look
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pink or red and moist/red and beefy
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Steps in performing closed intermittent irrigation
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clamp catheter w/ injection port and extension tubing, cleanse port slowly inject syringe w/ irrigant into catheter remove syringe and unclamp allow irrigant to drain into drainage bag
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Benefits of applying ice to extremity
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decreases inflammation, bleeding, fever, swelling, muscle spasms and pain
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Kosher foods
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animals which chew cud and have split hooves (cattle, sheep, goats, & deer), seafood with fins and scales, NO PORK (hotdogs, sausage, gelatin), and no meats mixed with milk
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Nutritional needs for Hepatic Encephalopathy
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high carb, high cal, low to mod fat, and low to mod protein; small, frequent meals; supplement w/ vitamins (B complex), folic acid, and iron
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Nursing intrvetions for Pt receiving TPN
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monitor serum and urine glucose, monitor for “cracking” of solution, use sterile technique when changing central line, bag and tubing should be changed q24h
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TPN fluid overload is evidenced by what?
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weight gain > 1kg/day and edema
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Interventions for chronic renal failure
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diet high in carbs and mod. fat, control protein intake, restrict Na, K, Ph, and Mg
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Sleep promotion
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bedtime routine, min number of times pt is awakened, assist w/ personal hygiene or back rub, exercise 2hr before bed, limit fluids 2-4hr before bed
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Intermittent tube feedings
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HOB @ 45 degrees feed and 1hr after feeding, admin. solution at room temp, formula is administered q4-6h in equal portions of 200-300mL over a 30m-60m time frame Flush 30mL every 4 hours
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Bariatric surgeries Dietary planning
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limited to liquids or pureed foods for first 6wks, meal size shouldn’t exceed 1c, vit & min supplements
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Foods that can cause odor for ostomy
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fish, eggs, asparagus, garlic, beans, and dark green leafy veggies
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Foods that can cause gas for ostomy pt
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dark green leafy veggies, beer, carbonated beverages, dairy products, and corn
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What type of diet should a client who has dysphasia be on?
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Pureed or mechanical soft diet
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Contraindications for the use of Isosorbide Mononitrate (IMDUR) For Angina
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Headache hypersensitivity to nitrates, traumatic head injury b/c med can increase ICP, use cautiously in Pt taking Hypotension: antiHTN meds or have renal or liver dysfucntion
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If Pt develops reflex tachycardia from taking Imdur give what?
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metoprolol (Lopressor)
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Atorvastatin (lipitor) purpose
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decrease manufacture of LDL and VLDL and increase HDLs; promotes vasodilation, decreased plaque site inflammation, and decreased risk of thromboembolism
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S/E of Atorvastatin (Lipitor)
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Hepatotoxicity (liver fxn tests after 12wks then q6m); myopathy (obtain baseline CK levels); peripheral neuropathy (notify provider)
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Teaching for Atorvastatin (Lipitor)
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don’t take with grapefruit juice, take in evening
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S/E of Metoclopramide (Reglan) For Heartburn (antiematic)
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EPS (bradykinesia, tremor, rigidy) (notify Ph, admin benadryl), hypotension, sedation, anticholinergic effects
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Doxazosin (Cardura) For HTN and BPH
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venous & arterial dilation, smooth muscle relaxation of prostatic capsule and bladder neck
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Teaching and S/E of Alpha Blockers Doxazosin (Cardura) or Prazosin (Minipress)
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1st dose orthostatic hypotension (syncope, dizzy or faint) take 1st dose at night and monitor BP 2hr after 1st dose, avoid activities requiring mental alertness for first 12-24h, instruct pt to change position slowly, take with food
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Clozapine (Clozaril) Chlorpromazine (Neg and Pos s/s Schizophrenia) S/E What to do?
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neg and pos s/s of schizophrenia, relief of psychotic symptoms DRINK FLUIDS AVOID SUNLIGHT New onset diabetes/loss of glucose control (report s/s of increased thirst, urination, appetite), wt gain, hypercholesterolemia, orthostatic hypotension, anticholinergic effects, symptoms of agitation, dizziness, sedation, and sleep disruption, mild EPS such as tremor, risk for dyslipidemia, risk for fatal agranulocytosis (baseline & wkly monitor of WBC, notify of S/S of infection) Stop med for signs of neuroleptic malignant syndrome
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Therapeutic effect of Levothyroxine (Synthroid)
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For Hypothyroidism: decreased TSH 0.3-3.0, normal T4 levels, absence of hypothyroidism symptoms (depression, wt gain, bradycardia, anorexia, cold intolerance, dry skin, menorrhagia); takes several wks to notice a therapeutic effect
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Long-term adverse effects of Haloperidol (Haldol)
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Tardive dyskinesia (involuntary movements of tongue and face, lip smacking, involuntary movments of arms, legs, and trunk)
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Effectiveness of Allopurinal (Zyloprim) is evidenced by
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Improvement in pain caused by gout attack (decreased joint swelling, redness), decreased number of gout attacks, decreased uric acid levels
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Leukotrien Modifiers Montelukast (Singulair)
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suppress inflammation, bronchoconstriction, airway edema, and mucus production long-term therapy for asthma and to prevent exercise-induced bronchospasm Take once daily at bedtime
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Assessment of DI
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Decreased urine specific gravity and osmolality Hypernatremia Hypokalemia Increased urinary output Dehydration, weight loss and dry skin
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Desmopressin (DDAVP) For Diabetes Insipidus
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promote absorption of water within the kidneys; cause vasoconstriction; tx of diabetes insipidus Effectiveness of DDAVP is evidenced by: reduction in the large volumes of urine output associated with diabetes insipidus to normal levels
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Contraindications to MMR Immunization
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pregnancy, allergy to gelatin and neomycin, hx of thrombocytopenia, immunosuppression, recent blood transfusion; common cold NOT a contraindication
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Administration of Enoxaparin (Lovenox) Anticoagulant
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subq q12h for 2-8d; use 20-22G needle to draw up; 25-26G needle to admin; admin in abdomen at least 2″ away from umbilicus; apply pressure for 1-2m after injection; DON’T RUB
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Teaching about iron supplements
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take with orange juice on empty stomach; may cause constipation, N/V/D, can turn stool a dark green/black color
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Furosemide (Lasix) Purposes of Use
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block reabsorption of Na and chloride and prevent reabsorption of water; cause extensive diuresis Used for: pulmonary edema caused by HF, emergent need for rapid mobilization of fluid
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S/E of Furosemide (Lasix)
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dehydration, hypoNa, hypoCl, hypoTN, hypoK OTOTOXICITY
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Teaching on Lasix
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avoid admin late in day, report significant wt loss, lightheadedness, dizziness, GI distress, and general weakness, observe for signs of low Mg levels such as muscle twitching and tremors
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Sedative/ Hypnotic Medications Eszopiclone (Lunesta) Temazepam (Restoril) Zolpidem tartrate (Ambien)
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Use cautiously with mental depression avoid with alcohol and medications with CNS depression S/E Dry mouth, decreased libido, respiratory depression
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Opioids (relief and sedation)
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Duragesic, Dilaudud, Morphine, Demerol, Codeine, oxycodone
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Opioid antagonist nalaxone (Narcan)
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used for respiratory depression
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Ace Inhibitors (end in “pril”)
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Used for: HTN, HF, MI, diabetic neuropathy Monitor potassium levels K+ persistent non-productive cough
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SSRI (Duloxetine, Fluoxetine, Escitalopram, Fluvoxamine, Paroxetine, Sertraline) Teaching
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Avoid alcohol, do not discontinue abruptly, monitor for agitation, confusion and halluciations within the first 72 hours. S/E Weight gain, sexual dysfunction, fatigue, drowsiness May cause serotonin syndrome (2-72 hrs after start of treatment): tremors, agitation, confusion, anxiety and hallucinations
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When should admin RhoGAM
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when mom is Rh-negative and had Rh-positive infant; admin w/n 28 weeks (3rd trimeter) and 72h after birth Spontaneous abortion, amneoscentesis
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Does does Magnesium Sulfate do?
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relaxes smooth muscle of the uterus and inhibits uterine activity by suppressing contractions
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What are s/s of Mag sulfate toxicity? What is the antidote for Mag Sulfate?
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loss of Deep Tendon Reflexes, urinary output < 30ml/hr, resp depression, pulmonary edema, and/or chest pain Calcium Gluconate to fix!
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What are the contraindications for Mag sulfate?
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active vagninal bleeding, dilation of cervix is > 6cm, chorioamnionitis, > 34 wks gestation, acute fetal distress, severe pregnancy induced HTN or eclampsia
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Indications to withhold Propranolol (inderal) Beta Blocker
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bradycardia, SOB, edema, fatigue, AV block, Pt has asthma
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ANGINA Containdications for vasodilators Nitros
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CLIENTS WITH A HEAD INJURY Hypotensive risk with antihypertensive meds Erectile dysfunction meds (life threatening hypotension)
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Uses for methadone (Dolophine)
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relief of mod to severe pain; sedation; reduction of bowel motility
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Equation for calculating pulse pressure
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systolic – diastolic = pulse pressure 120-80=40
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When should a trough level be scheduled for a once daily dosing of Gentamycin?
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1hr prior to next dose
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When should a peak level be drawn for divided doses of Gentamycin?
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30m after admin of med or infusion has finished
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When should a trough level be drawn for divided doses of Gentamycin?
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right before next dose
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S/S of dehydration
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hyperthermia, tachycardia, thready pulse, hypoTN, orthostatic hypotension, decreased CVP, tachypnea, dizziness, cool clammy skin, diaphoresis, sunken eyeballs
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S/S for overhydration
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tachycardia, bounding pulse, HTN, tachypnea, increased CVP, confusion, muscle weakness, wt gain, ascites, dyspnea, crackles
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S/S of hyponatremia
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hypothermia, tachycardia, rapid thready pulse, hypoTN, ortho hypo, headache, confusion, decreased DTRs, hyperactive bowel sounds
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S/S of hypernatremia
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hyperthermia, tachycardia, rapid thready pulse, ortho hypo, restlessness, irritability, muscle twitching, reduced to absent DTRs, hyperactive bowel sounds
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S/S of hypokalemia
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hyperthermia, weak irregular pusle, hypoTN, resp. distress, muscle cramping, hypoactive DTRs, PVCs, bradycardia, decreased motility
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S/S of hyperkalemia
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slow, irregular pulse; hypoTN, restlessness, irritability, weakness with ascending flaccid paralysis, N/V/D, hyperactive bowel sounds
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S/S of hypocalcemia
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muscle twitches/tetany, hyperactive DTRs, positive Chvostek’s sign (tapping on the facial nerve triggering facial twitching), positive Trousseau’s sign (hand/finger spasms with sustained blood pressure cuff inflation), seizures
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S/S of hypomagnesaemia
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hyperactive DTRs, muscle tetany, positive Chvostek’s and Trousseau’s signs, hypoactive bowel sounds, paralytic ileus
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Complications following a hypophysectomy (removal of pituitary gland)
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monitor for bleeding and nasal drainage for possible CSF leak (assess drainage for glucose or halo sign); assess neurological condition every hour for first 24h and every 4h after
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Nursing Interventions for preventing delays in healing
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encourage an intake of 2-3L of fluid/d, increase protein, keep serum albumin levels above 3.5
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Meds for Sinus Tachycardia
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amiodarone, adenosine, and verapmil; synchronized cardioversion
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S/S of hyperglycemia
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BG > 250, thirst, freq. urination, hunger; warm, dry flushed skin; weakness; malaise; rapid, weak pulse; hypoTN, deep rapid respirations
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Complication of pericarditis
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cardiac tamponade (hypoTN, muffled heart sounds, JVD, paradoxical pulse)
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Pericarditis commonly follows a
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respiratory infection
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S/S of pericarditis
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chest pressure/pain, friction rub, SOB, pain relieved when sitting and leaning forward
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Fasting blood glucose
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post pone admin of antidiabetic med until after levels are drawn; ensure pt has fasted for 8hr prior to blood draw
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Oral glucose tolerance test
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fasting blood glucose level drawn at start then pt consumes a specified amount of glucose. Blood glucose levels drawn every 30m for 2hrs; instruct client to consume balanced diet for 3d prior then fast 10-12hr
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Glycosylate hemoglobin (HgA1c)
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best indicator for average blood glucose level for the past 120d; normal range is 4-6%, diabetic range is 6.5-8%
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Evaluating proper placement of NG tube
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aspirate to collect gastric contents and test pH (4 or less) before feeding. Hold if residual is >100 mL, X-Ray Injecting air into tube to listen over abdomen is NOT an acceptable practice
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IV Urography Procedure
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used to detect obstruction, assess for a parenchymal mass, and assess size of kidney Before procedure check allergy to iodine and check creatinine levels because dye can cause renal failure.
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Complications of chest tube insertion
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air leaks – monitor the water seal chamber for continuous bubbling (air leak); tension pneumothorax – sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstruction may cause this Tidaling in water seal chamber is normal!
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Pt teaching for external radiation therapy
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gently wash skin over the irradiated area w/ mild soap and water, DON’T remove radiation tattoos, DON’T apply powders or lotions, wear soft clothing over irradiated area, avoid tight clothing, DON’T expose area to sun or heat
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Infectious Mononucleosis
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Spread? saliva Transmission Precautions? Standard Contact Incubation Time? 4-6 Weeks S/S: fever, soar throat, swollen lymph glands, increased WBC, atypical lymphocytes, splenomegaly, enlarged liver Complication: ruptured spleen
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Nursing Interventions for Pt who has HSV-2
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monitor fetal well-being, fetal consequences include miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible c section if lesions present during labor
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Early S/S of cold stress in infant
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auxiliary temp < 97.7, increased resp. rate, increased HR, mottled skin
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Late S/S of cold stress in infant
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apneic periods, bradycardia, acrocyanosis, decreased activity
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Indications for use of cardioversion
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Atrial dysrhythmias, SVT, vent. tachy w/ pusle & tx of choice for pt who are symptomatic
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S/S of Hypoglycemia
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shakiness, diaphoresis, anxiety, nervousness, chills, nausea, headache, weakness, confusion
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Tx for Hypoglycemia
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4oz OJ or 2 oz grape juice or 8 oz milk recheck BG in 15m if still low (<70) give 15g more carbs recheck BG in 15m, if w/n norm limits eat 1g protein (peanut butter, cheese)
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Nursing Interventions for increased ICP
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Keep HOB at 30 degrees, avoid extreme flexion, extension, or rotation of the head and maintain in midline neutral position; keep body aligned avoid hip flextion/extension; minimize endotracheal or oral suctioning; instruct pt to avoid coughing or blowing nose
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S/S of Bacterial Vaginosis
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vaginal odor, discharge, dysuria
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Nursing Interventions for Boggy Uterus Postpartum
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massage first then administer oxytocin
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what acid-base imbalances w/ a pt with chronic emphysema most likely have?
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resp. acidosis and compensatory metabolic alkalosis
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Respiratory Syncytial Virus Transmission Precautions
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Contact Precautions PPE: Gloves, Gown (mask and goggles as needed) Private Room Gloves and gown by visitors Disposal of infectious dressing material into nonporous bag Dedicated equipment to room or disinfect Droplet Precautions PPE: Mask when 3 feet of the client Private room Keep door closed In Baby: Maintain normal body temperature
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Care at Birth
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Vital signs should be checked on admission/birth and every 30 min x 2, every 1 hr x 2, and then every 8 hr. Weight should be checked daily at the same time, using the same scale. Inspect the newborn’s umbilical cord. Observe for any bleeding from the cord, and ensure that the cord is clamped securely to prevent hemorrhage. In the first 6 to 8 hr of life as body systems stabilize and pass through periods of adjustment, observe for periods of reactivity. First period of reactivity – The newborn is alert, exhibits exploring activity, makes sucking sounds, and has a rapid heart rate and respiratory rate. Heart rate may be as high as 160 to 180/min, but will stabilize at a baseline of 100 to 120/min during a period that lasts 15 to 30 min after birth. Period of relative inactivity – The newborn will become quiet and begin to rest and sleep. The heart rate and respirations will decrease, and this period will last from 30 min to 2 hr after birth. Second period of reactivity – The newborn reawakens, becomes responsive again, and often gags and chokes on mucus that has accumulated in his mouth. This period usually occurs 2 to 8 hr after birth and may last 10 min to several hours.
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Intervening to Promote Bonding
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Facilitate the bonding process by placing the infant skin-to-skin in the en face position with the client immediately after birth. Promote rooming-in as a quiet and private environment that enhances the family bonding process. Promote early initiation of breastfeeding, and encourage the client to recognize infant readiness cues. Offer assistance as needed. Teaching the client about infant care facilitates bonding as the client’s confidence improves. Encourage the parents to bond with their infant through cuddling, bathing, feeding, diapering, and inspection. Provide frequent praise, support, and reassurance to the client as she moves toward independence in caring for her infant and adjusting to her maternal role. Encourage the client/parents to express their feelings, fears, and anxieties about caring for their infant
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Combination Oral Contraceptives Contradictions
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1. Are smokers and over the age of 35. 2. Have a history of thrombophlebitis and cardiovascular events. 3. Have a family history or risk factors for breast cancer. 4. Are experiencing abnormal vaginal bleeding. 5. Use cautiously in clients who have hypertension, diabetes mellitus, gall bladder disease, uterine leiomyoma, seizures, and migraine headaches
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Left Sided Heart Failure
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Dyspnea, orthopnea (shortness of breath while lying down), nocturnal dyspnea Fatigue Displaced apical pulse (hypertrophy) S3 heart sound (gallop) Pulmonary congestion (dyspnea, cough, bibasilar crackles) Frothy sputum (can be blood-tinged) Altered mental status Manifestations of organ failure, such as oliguria (decrease in urine output
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Right Sided Heart Failure
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Jugular vein distention Ascending dependent edema (legs, ankles, sacrum) Abdominal distention, ascites Fatigue, weakness Nausea and anorexia Polyuria at rest (nocturnal) Liver enlargement (hepatomegaly) and tenderness Weight gain Cardiomyopathy (leading to heart failure)
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Compartment Syndrome
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1. Compartment syndrome (ACS) is assessed by using the five P’s (pain, paralysis, paresthesia, pallor, and pulselessness). 2. Increased pain unrelieved with elevation or by pain medication. 3. Intense pain when passively moved. 4. Paresthesia or numbness, burning, and tingling are early signs. 5. Paralysis, motor weakness, or inability to move the extremity indicate major nerve damage and are late signs. 6. Color of tissue is pale (pallor), and nail beds are cyanotic. 7. Pulselessness is a late sign of compartment syndrome. 8. Palpated muscles are hard and swollen from edema. 9. If untreated, tissue necrosis can result. Neuromuscular damage occurs within 4 to 6 hr. Surgical treatment is a fasciotomy.
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Vitamin to prevent neural defects
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Folate is a B-vitamin found in spinach and leafy green vegetables, dried beans, liver, and citrus fruits. In vitamin supplements and fortified foods such as breakfast cereal, it is usually found in the form “folic acid.”
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Disposing of insulin syringes at home
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Coffee container on a high shelf
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Status Epilepticus Meds
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Lorazepam (Ativan) Drug of choice Diazepam (Valium) Phenytoin (Dilantin) (IV Slowly) Fosphenytoin (Cerebyx)
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Brachytherapy (Radiation)
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Radiation source is within the client who emits radiation and is a hazard to those around for a period of time.
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Varicella/ Chickenpox
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Direct contact and airborne precautions. 2-3 week incubation. Contagious until all lesions have scabbed. Pregnant women should not be in contact.
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Amount of calcium needed daily
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1,000-1,200 mg a day. 600 mg at a time.
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Refeeding Syndrome
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Potassium, magnesium, and phosphate move intracellularly during enteral nutrition, electrolyte disturbances can result. Patients who are severely malnourished are at high risk for refeeding syndrome and require careful management of fluid and electrolytes when tube-fed. For patients who are severely ill or malnourished, provide feedings at 50% of estimated requirements and increase gradually over 24 to 48 hours if careful monitoring does not suggest clinical or biochemical abnormalities. Circulatory collapse that occurs when a client’s completely compromised cardiac system is overwhelmed by a replenished vascular system after normal fluid intake resumes.
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Anorexia Abnormal Lab Values
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1. Hypokalemia 2. Serum Albumin less than 3.5 (malnutrition) 3. Anemia and leukopenia with lymphocytosis 4. Possible impaired liver function, shown by increased enzyme levels 5. Possible elevated cholesterol 6. Abnormal thyroid function tests. 7. Elevated carotene levels, which cause skin to appear yellow. 8. Decreased bone density 9. Abnormal blood glucose level 10. ECG changes
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Cranial nerve XI (Spinal accessory)
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Function of the nerve: Motor – Turning head, shrugging shoulders System: Head and neck
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Mother’s Tests at 12 weeks
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Ultrasound chorionic villi sampling NT Down Syndrome
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Amniocentesis
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Performed at 14-16 weeks assess fetal lung maturity and well being Rh-negative mothers get Rhogam Complications are bleeding, contractions, signs and symptoms of infection
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peripherally inserted central catheter (PICC)
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catheter used for long-term intravenous access and inserted in the basilic or cephalic vein just above or below the antecubital space with the tip of the catheter resting in the superior vena cava Needs an informed consent
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How to access a venous access port (port a cath)
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don a mask-use surgical asepsis- don sterile glove -prime access cap, extension tubing and non coring needle with pre filled NS syringe -cleanse the site with chlorahexadine for 30 seconds -immoblize the device with non dominant hand forming a U with index and thumb -insert non-coring, non-barbed (Huber) needle with dominant hand in a 90 degree angle Most facilities’ policies allow access to the implanted port with the same needle for 7 days.
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Does Port need flushing?
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-open ended= require heparin flushing -valved= does not require heparin
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Vancomycin Precautions
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Causes: Ototoxicity and nephrotoxicity Monitor creatinine and BUN Peak and Trough Levels Therapeutic Range 20-40 mcg/dL Infusion reactions (rash, flushing, tachycardia, hypotension) Thrombophlebitis DON’T TAKE WITH LOOP DIURETICS (OTOTOXICITY)
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Who Cannot Give Consent
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kids less than 18 intoxicated- blood alcohol level of .08 client with a dose of morphine
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a nurse is caring for a client with a hx of agression, the client is playing cards and throws them at other patients- what should you do
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ask the client how he is feeling (therapeutic cmcn) not take the cards away (this will increase aggression) explaining unit rules will not help either
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Cocaine/Amphetamines
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Dilated pupils, tachycardia, elevated BP, impaired judgement, grandiosity, paranoia with delusions
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Opiates (Heroin, fentanyl)
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Constricted pupils, decreased respirations, decreased BP, initial euphoria followed by dysphoria
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Dialysis Teaching
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Pt needs to report: muscle cramps, headache, nausea, or dizziness (hypotension)
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Total Gastrectomy
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is total removal of the stomach; long term complication include dumping syndrome- undigested food rapidly enters the duodenum or jejunum usually 5-30 minutes after eating, epigastric pain with cramping, loud hyperactive bowel sounds- managed primarily with smaller and more frequent meals- no liquids with meals- increase in protein and fats- reduce carbs; Anemia may also be problem after gastric surgery due to decreased iron absorption; intrinsic factor is also lost so B12 cant be absorbed; folic acid deficiency, poor absorption of nutrients
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Gastrectomy Medications Needed
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Vitamin B12 is absorbed in the stomach and must be supplemented with regular injections by patients who underwent a total gastrectomy. Absorption may be impaired in those who still have part of their stomach, so it is necessary to have B12 levels checked periodically. Supplementation with folate, iron, and calcium may also be necessary to correct deficiencies caused by the surgery.
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Purpose of Telemetry
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Detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle
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Gestational Hypertension
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20 weeks of pregnancy
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Seizure Precautions
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Rescue equipment at bedside Establish IV Site Position seizing pt to ground, stay with them Protect Head If in bed, pad side-rails Side lie with head flexed and slightly forward Loosen restrictive clothing Document time, behavior, aura, etc. Report seizure to the provider
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In Case of Fire
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Rescue Pull Alarm Aim Contain Squeeze Extinguish Sweep
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Bacterial Meningitis sign of ICP
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Nuchal Ridgidy, Kernig’s Sign Sign of ICP: Memory Loss
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To Promote Wound Healing
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Protein and Vit A
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Digoxin Toxicity
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Diarrhea, Nausea and Muscle Weakness 0.8-2.0
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Theophyline Toxicity
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Hypotension, Albuminuria, Tachycardia and Anorexia 10-20
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Valporic Acid for Seizure Control
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Hepatotoxic, report jaundice
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Warfarin
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Do not take with acetaminophen report dark stools
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Signs of Peritonitis
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Rigid, Board Like Abdomen Absent Bowel Sounds Fever High WBCs
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Rheumatoid Arthritis
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Use cold to edematous joints
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Suctioning Airway
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Use surgical asepsis No more than three consecutive times When resistance is met, retract 1-2cm
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Dumping Syndrome
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No liquids or carbs!
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Right CVA
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Minimizes problems Short attention span Impaired judgement and time Impulsive
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Left CVA
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Impaired speech and comprehension Slow and depressed
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HGB
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12-18
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Hit
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37%-52%
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gtt
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Volume/time * gtt = gtt 1 min 100ml/20min * 10gtt 50 gtt 1 min If given hours multiply by 60