question

What to do first with pt w/ toxic shock syndrome?

answer

Give fluids! 0.9% NaCl at 150 cc/hr (even more important than IV abx)

question

In 3rd trimester, women get ___ which makes them feel faint.

answer

Hypotensive syndrome causing reduction in CO (The large uterus compresses the inferior vena cava and aorta when the woman is supine

question

Tenacious = You should do what when secretions are like this?

answer

Thick Give liquids

question

RR and pulse ___ when pulse is needed

answer

Increase

question

It's most important to suction when ___

answer

Lung sounds are congested

question

If a pt undergoing peritoneal dialysis isn't returning the solution, what do we do?

answer

Turn from side to side, ambulate, or change position NEVER advance catheter

question

How to ID a 3 yr old with no ID band?

answer

Ask parents. He/she may not know first and last name

question

Peritoneal dialysis: What would you observe if there is a malfunction in system? ___ is normal for the pt to feel.

answer

Leakage of fl on dressing/bed Abdominal pain (or rectal?), especially during first few infusions due to peritoneal irritation.

question

Remember to ___ when doing a sterile procedure (gloves)

answer

Pour the sterile water into the container before putting on gloves

question

When going to an underdeveloped country, to protect yourself from Hep A:

answer

Cook veggies Drink only bottled water Don't drink iced drinks or soups DO try new foods, part of the culture (just make sure it is prepared safely)

question

For a pt on dialysis 3x/wk, they should have what done before given digoxin?

answer

Blood level checked Ignore dialysis... it's a distractor The Digoxin dose is adjusted to the patient's clinical condition, and is monitored by blood levels. Therapeutic range: 0.5-2.0 ng/ml

question

What kind of drug is Marplan?

answer

MAO inhibitor (No aged cheese, red wine, yogurt, beer, and chocolate... tyramine)

question

During the first 6-8 hours after birth, respiratory rate ___ , and ___(lungs).

answer

May be as high as 60-80 breaths/min Crackles/Rales may be heard (normal to have some fl in lungs)

question

Tamoxifen citrate (Nolvadex) acts as a(n) ___(hormones)

answer

Estrogen antagonist

question

Which of the following findings should cause the nurse to rule out the occurrence of infiltration of the IV?

answer

The fluid in the IV tubing becomes pink-tinged when the tubing is pinched. (This is how we know it is properly placed) (Good to know!)

question

Immediately after a percutaneous liver biopsy, the nurse should place the patient in which of the following positions?

answer

Right side lying to prevent hemorrhage!

question

A 17-year-old boy is admitted to the adolescent unit with a diagnosis of orchitis. It is MOST important for the nurse to ___

answer

Elevate the patient's scrotum on towels.

question

What is orchitis?

answer

Acute inflammation of testes

question

Two days after admission to the hospital, a patient admitted with depression complains "I'm too tired to take a shower. Please don't bother with me today." Which of the following actions, if taken by the nurse, would be MOST appropriate?

answer

Assist the patient to meet hygiene needs that day. (This achieves the goal of meeting the patient's needs for A.M. care.)

question

The nurse is caring for a 56-year-old man who had a tracheostomy performed yesterday. Which of the following symptoms would require an intervention by the nurse?

answer

The patient's secretions from the tracheostomy are thick, yellow, and dry. Indicated dehydration and potential for obstruction

question

For a 4 yr old, offer this snack __

answer

Carrot sticks over a banana (which is messy and may need help opening)

question

A 42-year-old woman with a diagnosis of endolymphatic hydrops (Ménière's disease) is seen in the cinic. The nurse would expect the client to exhibit?

answer

Vertigo, tinnitus, neurosensory hearing loss.

question

During patient rounds, the nurse on a psychiatric unit discovers a man in the bathroom attempting to harm himself. Which of the following actions should the nurse take FIRST?

answer

Stay with pt... safety!

question

For a question like this: "A patient is admitted to the hospital for treatment of low back pain. The patient's wife tells the nurse that her husband has increased his alcohol intake since he injured his back several months ago. Based on this information, the nurse should observe for which of the following symptoms?" They are asking us too look for __ s/s not __ s/s

answer

Withdrawal Acute intoxication (does not indicate pt is drunk)

question

What is important teaching for pt with emphysema?

answer

Small frequent feedings to increase caloric intake and limit SOB caused by eating. Fluids should be encouraged to help liquefy secretions

question

Cardiac catheterization, normal feelings:

answer

Fluttering (Palpitations may occur when catheter is passed through the myocardium causing extra systoles) Pain during procedure (NOT days after)

question

A chest x-ray reveals a right-sided pneumothorax for a 60-year-old woman. The nurse would expect to hear ___. You would NOT hear ___

answer

Reduction of breath sounds on the right side. (because no air can come into a collapsed lung) Wheezes (this happens in partially closed airways)

question

A 14-year-old boy is admitted to the hospital to repair extensive facial scarring sustained in a car accident two years ago. The nurse assesses the boy's understanding of the operation. Which of the following responses, if made by the client to the nurse, indicates that the boy has the capacity for abstract thinking?

answer

"The doctor talked to me about the different techniques involved and the risk of the skin grafts being rejected." (Abstract = able to understand w/o without concrete statements or examples)

question

If choosing between fixing a call light and mopping the floor in a visitor area ___

answer

Fix the call light. Pt's come first. Hmmmm

question

Preterm labor is confirmed by ___ . The patient will have ___ .

answer

2 contractions lasting at least 30 seconds in a 15-minute period Cervical dilatation and effacement.

question

What should the nurse do before performing oral hygiene with a cuffed tracheostomy tube?

answer

Inflate the tracheostomy cuff and continue with oral hygiene.

question

Cuff is inflated (cuffed trach) when:

answer

During continuous mechanical ventilation, during and after eating, during and one hour after a tube feeding, when patient is unable to handle oral secretions, and when the patient may aspirate.

question

prednisone (Orasone): Most important to check ___

answer

BGs (more important than HTN and wt gain)

question

The physician asks the nurse to obtain a urine sample from a patient with an indwelling catheter. To obtain the urine specimen the nurse should ___

answer

Clamp catheter tubing below the porthole. (The porthole is WHERE you collect the sample... so you don't want to clamp above it- you wouldn't get any urine)

question

What is the first stage of a situational crisis?

answer

Denial

question

Subtotal thyroidectomy: What is not a normal finding post op? What is?

answer

Difficulty speaking Temporary hoarseness and NG tube attached to intermittent suction is draining a moderate amount of translucent fluid

question

A 72-year-old woman is receiving TPN (total parenteral nutrition) via the internal jugular vein. What should the nurse do if the next container of TPN solution is not available when it is needed?

answer

Hang a container of 10% D/W until the new solution is available. (A hypertonic glucose solution must be used until the solution is available to prevent rebound hypoglycemia.) DON'T stop or slow it down

question

Total hip arthroplasty is scheduled for a 54-year-old man with a degenerative joint disease of the left femoral head. How should the nurse position the man's left leg following surgery?

answer

Abducted with the toes pointing upward. (Duh! Remember wedge?)

question

The nurse assesses a patient who has a chest tube and a three-chamber water-seal drainage system (Pleur-evac) connected to suction. Which occurrence would require an intervention by the nurse?

answer

Continuous bubbling in the water-seal chamber. Indicates leak

question

What is an expected finding in a Pleur-evac?

answer

Continuous bubbling in the suction control chamber The fluid in the chest tube fluctuates with the patient's respirations

question

During the second stage of labor, the patient's husband asks the nurse if he can go get a cup of coffee from the cafeteria. The nurse should ___

answer

Tell him it's best to stay with his wife (It's ok to TELL him something... she needs him at this time)

question

A 10-day-old infant is being breastfed. The home care nurse would expect the infant's stool to appear

answer

Yellow, pasty, and have a sour milk odor. (Thought breastfed babies didn't have stinky poo... but apparently it is sour)

question

A unit of packed red blood cells (RBCs) is ordered for a 56-year-old man receiving total parenteral nutrition (TPN) through a single lumen subclavian catheter. To implement the order the nurse should expect to___

answer

Administer the RBCs through a newly inserted peripheral IV line.

question

Blood is never given ____ since blood cells may coat and block the catheter lumen.

answer

piggyback, or given through a central line

question

A woman comes to the hospital in labor at 35 weeks gestation. Which of the following statements, if found by the nurse in the patient's chart is unexpected?

answer

Results of her CBC are: RBC 4.9 million/mm3, hematocrit 45%, hemoglobin 15 g/dL. (These are normal findings... which would be unexpected for preterm labor)

question

The nurse supervises a nursing assistant caring for a 20-year-old man after an appendectomy. Which of the following observations would require an intervention by the nurse?

answer

The nursing assistant massages the patient's legs using long, firm strokes. (May increase risk of pulmonary emboli from a leg thrombus... use stockings)

question

A 28-year-old woman is admitted to the psychiatric hospital. She has not slept for several nights, is talking rapidly and paces the floor wringing her hands. The HIGHEST nursing priority during the first few days of hospitalization for this patient is to ___

answer

Provide rest, food, and liquids for the patient. (Maslow's Heiarchy)

question

The wife of a client with a history of a myocardial infarction (MI) and congestive heart failure (CHF) tells the nurse that she doesn't want her husband to be kept alive on machines if his heart stops. It is MOST important for the nurse to ___

answer

ASSESS first... determine if the wife understands the consequences of this decision.

question

pancreatin (Creon): Should be given ___ (when?) Also, give ___ Can be given ___ Do not ___

answer

Just before meals so the enzymes are available for the digestion of starches, fats, and protein. Juice afterwards Sprinkled on soft food Chew pill

question

What indicates an obstruction of bile drainage after a cholecystectomy?

answer

Light stools and dark urine

question

Don't assign a nurse to a pt who ___

answer

Needs involved assessment/teaching (ie discharge teaching)

question

The clinic nurse is planning care for a 56-year-old woman with osteoporosis. The nurse should recommend which of the following exercises?

answer

Daily walking 1 mile (Walking is considered wt bearing)

question

DPT and OPV immunizations are given to children at ____ (age)

answer

2, 4, 6, and 18 months and at age 4-6

question

When are babies expected to cut first two bottom teeth?

answer

6 months

question

CPR for 4 mo old infant: Position___ Breaths___ Pulse___

answer

Do NOT hyperextend neck... do chin tilt DO cover nose and mouth with your mouth DO use brachial artery to find pulse rather than carotid

question

A woman in the transition phase of labor complains of lightheadedness and a tingling sensation in her fingers. The nurse should ___

answer

Have her breath into a paper bag (These are signs of hyperventilation and the bag is the tx for that)

question

What indicates a significant reaction to a true Mantoux test for a patient that is HIV positive?

answer

There is a 5 mm area of induration on the inner aspect of the left forearm. It is positive for people NOT HIV positive at 10 mm

question

Delegation: 2 days post op Trach or strait cath pt retaining urine. An RN should ___ LPV should___

answer

Take the Trach pt Take the strait cath

question

What is a typical CPM setting after a TKA?

answer

20-50 degrees flexion and 10 degrees extension (Definitely NOT 90 degrees... that is goal for discharge)

question

Activity therapy: group members work on ____ to promote ___

answer

Specific tasks together Socialization and increase self-esteem.

question

A 19-year-old college student has a Mantoux test performed as part of a routine physical examination. To evaluate the test, the nurse should ___

answer

Palpate the injection site assessing for an area of induration. (Redness without induration is not generally significant)

question

Which of the adverse side effects of NSAIDS is serious enough to alert the physician?

answer

Stomach pain (May indicate GI bleeding)

question

Cytoxan is ___ (What type of med)?an alkylating type of chemotherapy

answer

An alkylating type of chemotherapy

question

What is hepatic encephalopathy?

answer

Brain dysfunction and damage caused by increased ammonia in the blood, resulting from severe liver disease

question

neomycin sulfate (Mycitracin) does what?

answer

Reduces bacterial production of ammonia in the intestine and blood.

question

An elderly, confused client in an extended care facility talks to the nurse about his thoughts in relation to his fantasy world. The nurse should ___

answer

Speak to him in simple sentences about present events. (Guess it's not ok to let him live in his fantasy world)

question

Where does nitroglycerine (Transderm Nitro) need to be placed?

answer

Abdomen, chest, upper arm, forearm, or anterior thigh (must not be hairy though)

question

In caring for a patient with primary adrenocortical insufficiency (Addison's disease), the nurse would expect which of the following laboratory findings? Increased ___ Decreased ___

answer

Potassium Sodium and glucose

question

Toxic effects are generally related to theophylline levels in serum greater than ___

answer

20 mg/ml

question

Patients with anorexia have a high risk for fluid and electrolyte imbalances, particularly ___, and subsequent decreased ___ and cardiac dysrhythmias

answer

hypokalemia cardiac output

question

To assure a safe hospital environment for a 2-year-old girl, the nurse should:___

answer

remove equipment from the bedside table.

question

Following a total hip replacement, the legs need to be kept ___

answer

Abducted (to prevent dislocation) *Think triangle pillow

question

How do you explain phantom limb pain to a pt?

answer

The brain sends signals to your leg that cause it to feel like your leg is still there.

question

The nurse on a psychiatric unit enters a patient's room to administer medications. A 56-year-old man admitted with bipolar disorder approaches the nurse and begins to throw things. The nurse should___

answer

sit down and ask the patient what is bothering him. (couldn't pay me enough to do that for a living!)

question

Pt has a radium implant: Visitors should ___. Nurses should ____ linen

answer

Limit the time visiting and keep their distance (no lead apron) Keep the linen in the room until implant is removed (in case it falls out in the sheets)

question

Two weeks of hospitalization for treatment of tuberculosis, what should the pt do when in public? How long do they take meds? They should avoid ___

answer

Cover mouth with kleenex when coughing or sneezing (Not necessary to wear mask) 9 months Large crowds

question

Child afraid of monsters and boogymen: ___

answer

Put night light in room (DON'T reassure them that there is no such thing... blocks communication)

question

What is NOT normal development in a 9-month-old child? Grasping with ___

answer

Whole hand (palmar grasp)

question

For CPR of infant, compress ___, ___ neck, and ___ (breaths)

answer

1/2-1 inch in depth DON'T hyperextend... tilt chin cover nose and mouth

question

The expected outcome for aerosol therapy for a CF pt is ___

answer

loose, productive coughs

question

Pt wants to read their chart, what do you do?

answer

Relay request to nurse's supervisor. (Follow chain of command) They will then stay in the room and explain terms/ answer questions.

question

Antacids ___ absorption of iron.

answer

Reduce (Don't take together)

question

Crutches: Where is wt supposed to be placed?

answer

On the handpieces... NOT the foam pads on the underarm piece. (crutch paralysis)

question

Following a right modified radical mastectomy, how do you place the arm?

answer

Elevate the patient's right arm, keeping the hand at the highest point. (Prevents edema)

question

The nurse discovers a patient lying face down on the floor. Which of the following actions should the nurse take FIRST?

answer

Determine whether the patient is responsive. (Think CPR... after you shake and shout, you check airway)

question

Buck's extension traction: It is MOST important for the nurse to ___

answer

provide thorough skin care q 2 hours.

question

What should the nurse do if she/he finds that a physician's order has not been implemented correctly? (Such as a dressing change)

answer

The nurse reports to the nursing supervisor and should communicate any discrepancies in patient care to the nurse's supervisor

question

The nurse knows that the test for phenylketonuria (PKU) is MOST reliable ___

answer

AFTER a source of protein has been ingested

question

NPH insulin peaks in ___. So if they were given some at 7 am and need the dosage reduced, you would expect to find ___

answer

8-16 hours them confused at 4

question

Sleepiness is associated with ___glycemia

answer

hyper

question

What's a normal catheter size for a child? How far in does the cath go?

answer

6,8, or 10 French catheter 1 in

question

When should a child not have head lag anymore?

answer

By 5 months (or sooner)

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