Adult 1 Flashcards
a) Inc erythrocyte sedimentation rate is always occurred?
b) brachytherapy?
c) hypovolemia manifestations?
a) inflammatory process
b) a type of internal radiation
need to stay still in the bed during each treatment session
c) restlessness, tachycardia, hypotension, dec pulses, cool extremities and dec urine output
a) ginko biloba causing?
b) manifestation hypoxia?
c) Pain upper left quadrant?
a) inc bleeding
b) Inc HR and BP
c) Pancreatitis
a) has anorexia, low-grade fever, night sweats, and productive cough. manifestation of?
b) epoetin alfa trart for? and ADR?
c) hypokalemia manifestations?
a) TB
b) anemia and HTN
c) Hypoactive bowel sounds(dec smooth muscle contraction in GI)
Also shallow respirations occur
a) mastectomy?
b) insomnia?
c) Hemolytic transfusion reactions?
d) Hemolutic manifestations?
a) surgical removal of one or both breasts
b) trouble falling asleep
c) infusion of incompatible blood products and create a systemic inflammatory response
d) low back pain, hypotension, tachycardia, and apprehension(anxiety or fear)
a) propranolol ADR?
b) mannitol ADR?
a) A night cough,dry eyes and vision changes, dry mouth, abdominal cramping, constipation, and diarrhea
b) Crackles heard on auscultation
Mannitol is an osmotic diuretic, Tachycardia, dyspnea and dec oxygen saturation, electrolyte loss.
Inc urine output is a therapeutic effect.
migraine, stroke, or meningitis?
a) Hand grasps
b) Numbness
c) Aphasia
d) Visual changes
e) Family history
a) migraine, stroke, and meningitis
b) migraine, stroke
c) migraine, stroke
d) migraine, stroke, and meningitis
e) migraine, stroke
migraine, stroke, and meningit
a) stroke and meningitis nurogical manifestation will resolve?
b) administer sumatriptan for?
c) sumatriptan ADR?
c) fibrinolytic therapy for?
a) would not resolve after 1 hr.
b) migraine
used to treat an occurring migraine, not prevention
only PRN
c) Chest pain
d) stroke
a) BUN should >20, and Urine specific gravity be elevated means?
b) acetaminophen max dose?
c) ibuprofen can cause?
d) contraindicated for older pt when they have pain?
a) dehydration
b) 4g/day
c) GI bleeding
d) Meperidine
Chemotherapy
considerations
Protect from infection!
Take temp daily
Report fever grater than 37.8(100)
Assing private room
Avoid crowads
Wash toothbrush daily in the dish washer or bleach solution
Internal radiation
Brachytherapy
Considarations
Protect us from the pt!!
Wear a dosimeter badge(nurse)
Wear a lead apron
Limit visiter 30 mins and 6 feet distance
Pt need to remain in the position
Do not disgard pt’s trach in trash bag
Pragnant individual visit once daily
External radiation
considarations
Do not remove radiation tattos(marking)
Avoid tight clothes
Do not exprose the sun
a) glomerulonephritis with oliguria,manifestations?
b) Extremity cool upon palpation post-ope developing what?
c) DKA, glucose reading less than what indicates improvement in the client’s status.
a) metabolic acidosis, dec heg d/t decreased RBC production and hyperphosphatemia
b) acute compartment syndrome.
c) 300
a) barium contrast. what is it? and side effect?
b) GCS scored?what’s worse and what’s best?
c) opioid for pain management,what’t to teach?
a) radiographic contrast=inc fluid intake
severe constipation
b) 3 is worst and 15 the best
c) void every 4hr to dec the risk of urinal retention
Chest tube
a) continuous bubbling in the water seal chamber is?
b) first time, monitor the drainage from the chest tube every?
c) place pt in what position?
d) Strip(pinch) the drainage tubing to ensure it is patent?
a) indication of a leak
b) 15 min for the first 2 hr to identify excessive drainage
c) high-Fowler’s
d) NO! never! inc pressure
Chest tube
a) Place two rubber-tipped hemostats in the client’s room?
b) Palpate the chest tube insertion site for subcutaneous emphysema?
c) Ensure that all chest tube connections are securely attached?
a) Yes.
in case of an emergency, such as chest tube dislodgment.
b) Yes.
this is a manifestation of an air leak
c) Yes.
to reduce the risk of a tension pneumothorax.
a) Pedal pulse range
b) metformin teaching?
a) 0-nonpalpable,1+ barely detectable,2+ is slightly diminished,3+ normal
b) take with meal
A pt who had total knee arthroplasty. What instruction should the nurse include?
Flex the foot every hour when awake
The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.
DO NOT place a pillow under the knee(would allow your knee to stay slightly flexed) to prevent flexion contractures, elevate the leg when sitting in a chair to reduce edema and pain.
DO NOT abduct leg, keep the operative leg in a neutral position when resting in bed.
Medications
a) neutralize gastric acid
b) reduce the growth of ulcer-causing bacteria Helicobacter pylori
c) coat the stomach lining
d) suppressing gastric acid production
a) Antacids, such as aluminum hydroxide
b) Antibiotics, such as amoxicillin
c) Anti-ulcer medications, such as sucralfate
d) Omeprazole/PPI
Meningitis
manifestations
Hand grasps
Visual changes
Nuchal rigidity(stiff neck)
Photophobia
Positive Kernig’s sing Brudzinski’s sign
droplet precautions
Brudzinsk’s sing?
Place pt in the supine position
Place the hand behind the pt’s neck
Bend pt’s head toward chest
A pt who has meningitis and is at risk for Increased ICP. What to do?
Implement seizure precautions
Neuro check at least q2hr
Avoid opioid
Turn off the room light
Avoid coughing
Monitor for impaired extraocular movement(eye)
A pt who has bactereia meningitis. What action the nurse should take?
Monitor tachycardia
provide emesis basin
administer antipyretic(reduces fever) medication
perform skin assessment
HOB 30 degress
a) Aphasia
b) Ataxia
c) Heminaopsia
a) loss of ability to understand or express speech
b) muscle control in their arms and legs
c) blindness over half the field of vision.
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse except?
a. Confusion
b. Peripheral edema
c. Facial flushing
d. Hyperreflexia
Confusion
A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client’s level of consciousness will decrease and coma may occur.
Facial flushing and warmth are manifestations of metabolic acidosis. Pale, cyanotic, dry skin is a manifestation of respiratory acidosis as ineffective breathing causes a lack of perfusion to the tissues. Hyporeflexia, not hyperreflexia, is a manifestation of respiratory acidosis. As acidosis increases, hyperkalemia can occur, causing muscle weakness, flaccid paralysis, and hyporeflexia.
A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe?
a. Dextrose 5% in 0.9% sodium chloride
b. Dextrose 5% in lactated Ringer’s
c. 3% sodium chloride
d. 0.45% sodium chloride
0.45% sodium chloride
A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.
A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium?
a. 1/2 cup chopped celery
b. 1 cup plain yogurt
c. 1 slice whole grain bread
d. 1/2 cup cooked tofu
b
A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect?
a. Hepatic failure
b. Abdominal pain
c. Slow peripheral pulses
d. Increase in cardiac output
Slow peripheral pulses
Hypophosphatemia causes slow peripheral pulses that are difficult to detect and can eventually result in cardiac muscle damage.
A nurse is reviewing the medical record of a client who had diabetes mellitus and is recieving regular insulin by continous IV infustion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider?
a. Urine output of 30 mL/hr
b. Blood glucose of 180 mg/dL
c. Serum potassium 3.0 mEq/L
d. BUN 18 mg/dL
c
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess?
a. Deep-tendon reflexes
b. Cardiac rhythm
c. Peripheral sensation
d. Bowel sounds
Cardiac rhythm
When using the airway, breathing, circulation approach to client care, the nurse should determine that assessing the cardiac rhythm is the priority. Calcium levels below the expected reference range can cause ECG changes, bradycardia, or tachycardia.
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis?
a. PaO2
b. PaCO2
c. Sodium
d. Bicarbonate
PaCo2
With respiratory alkalosis, the PaCO2 level is decreased.
