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Adult Flashcards

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1
Q

What medications should be held prior to dialysis treatment?

A
  • cardiac
  • antihypertensives
  • antibiotics

*DON’T hold analgesics or insulin

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2
Q

What could cause weight gain over time in a patient receiving peritoneal dialysis?

A

high glucose content in dialysate increases the amount of fluid that is removed during dialysis exchange

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3
Q

What action can help to initiate outflow if not enough fluid is returning after peritoneal dialysis ?

A

shift patient position

monitor for constipation - could be cause for insufficient outflow

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4
Q

What complications should you monitor for after dialysis treatment?

A
  • peritonitis
  • disequilibrium syndrome
  • risk for infection/clots (AV fistula)
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5
Q

Symptoms of headache, fatigue, nausea after dialysis treatment

A

disequilibrium syndrome

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6
Q

Client has continuous sensation to urinate after TURP. Is this normal?

A

Yes

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7
Q

Things to monitor post-TURP

A
  • bleeding
  • bladder spasms
  • severe hyponatremia from CBI
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8
Q

symptoms of hemolytic blood transfusion reaction

A

low back pain, N/V, hypotension, fever, tachycardia, hemoglobinuria, flushing, chills

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9
Q

Cause of myasthenia gravis

A

low acetylcholine and excessive cholinesterase -

causes weakness and fatigue of VOLUNTARY muscles

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10
Q

Symptoms of myasthenia gravis

A

weakness, fatigue, diplopia, difficulty breathing, dysphagia, respiratory failure

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11
Q

What antihypertensive medication is less effective in African Americans?

A

beta blockers

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12
Q

Interventions for dumping syndrome

A

Goal: slow down speed of food and nutrients through system

  • avoid empty carbs and fiber
  • eat smaller meals frequently
  • lie down after eating
  • don’t drink fluids with meals
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13
Q

Treatment for psoriasis

A

sunlight/ UV therapy

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14
Q

procedures that use contrast dye

A
  • pyelogram
  • cardiac catheterization
  • contrast CT
  • myelogram

*Assess for allergies!

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15
Q

Interventions for IV Pyelogram

A
  • bowel prep
  • NPO after midnight
  • assess for allergies
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16
Q

What is the purpose of IV Pyelogram

A

X-ray of kidneys, ureters, and bladder that uses contrast dye

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17
Q

Interventions post- cardiac cath

A
  • keep flat for 6-12 hours
  • encourage fluid intake
  • neurovascular a/s
  • pressure dressing to insertion site
  • assess for hematoma
  • manage pain
  • report lightheadedness, chest pain, numbness, tingling
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18
Q

Correct positioning during and after liver biopsy

A

During: supine and right arm raised and extended behind head

After: Right lateral position w/ small towel under site

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19
Q

how many mL are in 1 cup?

A

240 mL

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20
Q

What is Systemic Lupus Erythematous ?

A

chronic, systemic, inflammatory disease that causes vasculitis of the small vessels, leading to necrosis and inflammation

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21
Q

What lab values are elevated in SLE?

A
  • Elevated ESR and CRP

- Monitor BUN and Cr for signs of kidney damage

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22
Q

What is the priority before starting Tracheostomy suctioning?

A

hyper-oxygenate the patient!

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23
Q

What is proper trach suctioning?

A
  • start suctioning once you’re INSIDE the chest
  • intermittent suction while swirling out (10 seconds)
  • normal suction pressure: 90-120
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24
Q

What are diabetic sick-day rules?

A
  • check blood glucose every 3-4 hours
  • can become hyperglycemic from stress of being sick
  • can become hypoglycemic from N/V and lack of food
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25
Q

What are symptoms of autonomic dysreflexia?

A
  • HTN
  • bradycardia
  • pounding headache
  • nasal congestion
  • sweating
  • restless
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26
Q

Interventions for autonomic dysreflexia

A
  • make sure catheter is draining
  • make sure bowel is not impacted
  • immediately place in High fowler’s
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27
Q

risk factors for cholelithiasis

A

4 F’S

  • female, fat, forty, fertile
  • US southwestern hispanic or Native american is highest risk
  • fasting (decreased gallbladder movement)
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28
Q

patient presents with: dyspnea, diaphoresis, anxiety, restless, cough, and chest pain.

What does this indicate and what do you do?

A

indicates air embolus - central line associated complication

Intervention: position patient on left side to displace air to the right side of the heart

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29
Q

when should compression stockings be placed on a client?

A

after elevation of the limbs

or when there is minimal dependent edema

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30
Q

the nurse should be most concerned if a patient having an acute asthma attack auscultates _____.

A

decreasing breath sounds - indicates severe spasm or obstruction

(inspiratory wheezing is also a major concern)

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31
Q

Cushing’s syndrome is caused by _____

A

chronic exposure to excess corticosteroids

  • edema of LE
  • at risk for infections because of immune system suppression
  • hypokalemic
  • hyperglycemia
  • weakness
  • hypernatremia
  • risk for weak bones
  • risk for cataracts
  • weight gain
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32
Q

What does it indicate when S3 (ventricular gallop) is heard?

A

Left-sided heart failure

normal in kids

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33
Q

A finding of ______ in a client with bulimia requires IMMEDIATE notification to the HCP.

A

hoarse voice that is barely audible (laryngitis)

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34
Q

osteoarthritis is characterized by joint pain that is relieved by ______.

A

resting

  • rheumatoid arthritis pain is relieved by ROM
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35
Q

characteristics of osteoarthritis

A
  • crepitus w/ ROM
  • pain worsens with activity
  • affects weight-bearing joints
  • joint atrophy
  • tylenol and NSAIDs
  • corticosteroid injections
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36
Q

characteristics of RA

A
  • Joint stiffness in the AM
  • joint tenderness
  • joint swelling
  • decreased ROM
  • encourage range of motion
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37
Q

Phalen maneuver

A

assessing for symptoms of carpal tunnel syndrome

  • put back of hands together and bend both wrists at the same time to produce paresthesia
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38
Q

what can cause a falsely HIGH blood pressure reading

A
  • short cuff
  • repeating assessments too quickly
  • positioning artery BELOW the heart
  • deflating the cuff too quickly
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39
Q

cataracts occurs when the lens becomes less ____ and more ____.

A

less hydrated
and
more dense

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40
Q

clients diagnosed with PUD should avoid:

A 
rich in cream or milk 
aspirin 
alcohol 
meat extracts
caffeinated beverages
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41
Q

HPV vaccine is recommended at ages ____ to reduce risk of ______ cancer.

A

at ages 11-12

to reduce risk of CERVICAL/PENILE cancer

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42
Q

If a client has low back pain, the nurse should ask ___?

A

how many rest periods the client gets during work hours

  • should avoid standing for long periods of time
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43
Q

Diet for patient w/ CKD

A
  • low sodium, potassium, phosphorus
  • adequate calcium
  • limit protein

*decrease diary intake because even though they are hypocalcemic, dairy products are high in phosphorus

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44
Q

If female client’s dialysate outflow is cloudy, determine if ________.

A

she is menstruating. blood from uterus can be pulled through into the dialysate

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45
Q

before a skin biopsy, it is most important to assess if the patient is using ______.

A

antiplatelets

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46
Q

a client with addison’s disease should _____ their sodium intake

A

INCREASE

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47
Q

symptoms of addison’s disease

A
  • hyponatremia
  • hypoglycemia
  • hyperkalemia
  • hyperpigmentation
  • lethargy, weakness, fatigue
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48
Q

patient’s with addison’s disease need lifelong _______.

A

lifelong steroid replacement

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49
Q

When taking corticosteroids,receiving _____ should be avoided.

A

vaccinations - because of decreased ability to mount an inflammatory response

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50
Q

interventions for if a ventilator alarm is activated:

A
  • assess breath sounds FIRST
  • assess for hypoxia and vital signs
  • then check the tubing for excessive fluid
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51
Q

What meds would be given in an anaphylactic reaction?

A
  • epinephrine IM
  • diphenhydramine IV
  • prednison IV
  • albuterol via nebulizer
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52
Q

symptoms of vitamin B 12 deficiency:

A
  • fatigue
  • constipation
  • diarrhea
  • sore tongue
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53
Q

After a seizure, ______ and _____ are common.

A

postictal confusion and sleepiness

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54
Q

post-lumbar puncture, the client should remain ____ in bed for ____ hours.

A

remain flat in bed for at least 8 hours

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55
Q

What is the crede maneuver?

A

often used for patients with SCI

manually apply pressure to bladder to aid in complete emptying - reduces risk for infection

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56
Q

Bell’s Palsy

A
  • can use heat on affected side of face
  • don’t bend over b/c of IOP
  • do isometric exercises
  • use artificial tears
  • place eye shield over eye at bedtime
  • avoid cold winds b/c of nerve ending sensitivity
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57
Q

The weight of the body when using crutches should be transferred to the _____.

A

hands and arms

crutches should be placed 8-10 inches in front with each step

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58
Q

How should the patient post-cataract surgery be positioned in the immediate post-op period?

A

on the unaffected side or on back with the head slightly elevated

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59
Q

Interventions for dumping syndrome

A
  • avoid empty carbs and fiber
  • eat lying down or lay down after meals
  • avoid drinking fluids with meals
  • eat small meals more frequently
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60
Q

What is Guillain-Barre syndrome?

A

autoimmune attack on the peripheral nerve myelin - can be triggered by a viral infection

affects the PERIPHERAL nervous system

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61
Q

interventions for Buck’s traction

A
  • weights should always hang freely
  • keep HOB 15-20 degrees
  • keep on strict bedrest
  • turn q 2 hours to unaffected side
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62
Q

interventions for rheumatoid arthritis

A
  • heat
  • ROM exercises
  • weight reduction
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63
Q

immediately report _____ after thyroidectomy

A

hoarse voice

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64
Q

symptoms of neuroleptic malignant syndrome

A

fever, tachy, incontinence, muscle rigidity, seizures, sweating, salivation

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65
Q

PPE order

A

Donning - gown, mask, eye shield, glove

Removing - gloves, goggles, gown, mask

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66
Q

correct pursed lip breathing

A
  • tighten stomach muscles when breathing out
  • take 2x as long to breathe out than breathing in
  • pretend you’re whistling when you breathe out
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67
Q

Preparing for cardioversion

A
  • administer sedative/hypnotic (midazolam)
  • assess heart rhythm
  • hold digoxin 48 hours before
  • don’t drive for 24 hours after
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68
Q

adventitious breath sounds

A

rales - crackling or gurgling on inspiration
rhonchi - musical sounds or vibrations on expiration
wheeze - squeaky sounds on inspiration and expiration
pleural friction rub - grating sound during I and E

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69
Q

what to do during a PTSD flashback?

A

maintain a safe distance and limit stimuli

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70
Q

Walking with a cane

A

hold cane in unaffected arm
move weak leg first
then strong leg

CANE, WEAK, STRONG

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71
Q

R.A.C.E

A

rescue/remove
alarm
contain/confine
evacuate

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72
Q

using a hydraulic lift

A

used to move patient from bed to chair

  • suspend patient in the sling above the bed before moving the lift
  • leave the sling in place under the patient once seated
  • set lift base in widest position
  • gently push on knees when lowering the patient
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73
Q

symptoms of VTE

A 
unilateral leg edema
extremity pain
warm skin
erythema 
heaviness in the chest - PE
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74
Q

time frame for activated charcoal

A

within one hour of ingestion

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75
Q

septic shock: early and late stage

A

early:
strong bounding peripheral pulses and hyperventilation, warm dry skin

late:
weak or absent peripheral pulses and decreased respirations, cool clammy and pale

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76
Q

interventions post-myelogram

A
  • encourage oral fluid intake
  • lie flat for 12-24 hours to prevent headaches
  • monitor V/S and neuro signs
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77
Q

multiple sclerosis

A

demyelination of neurons

urinary retention
hyperreflexia
numbness or tingling
decreased short-term memory

interventions:

  • ambulate as tolerated
  • don’t overexert
  • don’t force spastic extremities open
  • avoid overexposure to heat or cold
  • include ROM exercises
  • participate in social activities
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78
Q

myasthenia crisis

A 
dyspnea
anoxia
cyanosis 
absent cough/swallow reflex 
increased HR, BP, RR
79
Q

Interventions for AAA:

A 
bruit over aorta
increase fluid intake and fiber 
don't lift heavy objects
don't palpate mass 
immediately report SOB, chest/back pain, difficulty swallowing
80
Q

signs of autonomic dysreflexia

A 
HTN
bradycardia 
pounding HA
nasal congestion
flushing above 
pale below 
goosebumps 
restless 
sweating
81
Q

interventions for autonomic dysreflexia

A

make sure catheter is draining
bowel are NOT impacted
IMMEDIATELY place in High fowler’s

82
Q

What confirms diagnosis of glomerulonephritis?

A

positive ASO titer

differentiate from UTI b/c negative for WBC and no bacteria in urine

83
Q

post thyroidectomy, monitor for which electrolyte imbalance?

A

hypocalcemia

and monitor for thyroid storm!

keep calcium gluconate for IV administration ready

84
Q

Thyroid storm

A

increased temp, BP, HR, RR
agitation
seizures
tremors

Give propranolol - bring down HR and BP
Give D5W - restore glycogen stores
antithyroid meds

85
Q

signs of bacterial meningitis

A 
headache 
photophobia 
nuchal rigidity 
changes in LOC 
fever 
brudzinski and Kernig's

*DROPLET for 24 hours until after ABX start

restrict fluids b/c of ICP

86
Q

client with meniere’s disease should have a _____ diet.

A

low sodium to decrease fluid retention

87
Q

symptoms of mononucleosis

A 
malaise 
fever
severe sore throat 
headache 
epistaxis

*monitor for splenomegaly!!

88
Q

what do positive nitrates in a urinalysis indicate?

A

presence of E. Coli

89
Q

Controlling odor and gas in colostomy care

A

cranberry juice, yogurt, buttermilk, deodorant, crackers and toast

don’t skip meals, chew gum, smoke, drink beer

90
Q

cocaine withdrawal symptoms

A

cravings
depression
fatigue
hypersomnia

91
Q

alcohol withdrawal

A

tremors, increased HR, anxiety, insomnia, hallucinations

  • peaks in 24-48 hours
  • determine when last drink was
  • quiet, well-lit room
  • initiate seizure precautions
92
Q

phlebitis vs infiltration

A

phlebitis - red and warm around site and up vein
DC IV, warm/moist compress

infiltration - swelling at insertion site
D/C IV and elevate the arm

93
Q

interventions for paracentesis

A

measure weight before and after
measure abdominal girth before and after
have BP cuff to monitor for hypotension

94
Q

why should a client with PAD be encouraged to exercise?

A

because exercising increases collateral circulation

95
Q

understanding of aseptic technique dressing changes

A

wash hands!
use only what HCP ordered
have someone look at wound every dressing change
throw dressing away wrapped in nonsterile glove

96
Q

when should the nurse irrigate the NG tube?

A

if they check the tube and it is not patent and not draining

check for patency by aspirating stomach contents first and then by auscultation

97
Q

what is the most important thing to check for post thyroidectomy surgery?

A

monitor for signs of respiratory distress every hour from swelling

98
Q

What should the nurse instruct the patient to do if the client feels faint?

A

place the client’s head between the knees

99
Q

exercise for osteoarthritis

A

warm-up exercises before and after
don’t exercise severely painful joints
swimming is a helpful exercise

100
Q

Expected findings in burn resolution

A

pain around periphery
increased edema
elevated hematocrit

*gastric pH less than 5 is UNEXPECTED –> at risk for Curling’s ulcer (develops 24 hours after severe burn)

101
Q

signs to monitor for post bronchoscopy

A

signs of respiratory distress
tachycardia
respiratory stridor
retractions

depressed gag reflex, sputum streaked with blood and sore throat - expected findings

102
Q

characteristics of diabetes insipidus

A

deficiency of ADH

  • increased UO
  • dilute urine
  • specific gravity < 1.005
103
Q

what is normal specific gravity?

A

1.010 - 1.030

104
Q

What is given for diabetes insipidus?

A

desmopressin nasally or SQ for life

105
Q

defibrillator

A
  • don’t touch the bed when using the defibrillator
  • check it every 8 hours
  • should always be plugged in
  • don’t place paddles over electrodes
106
Q

what does subcutaneous emphysema post chest-tube removal indicate?

A

pneumothorax!

observe for respiratory distress and contact HCP

107
Q

Sengstaken-Blakemore tube

A

triple lumen gastric tube that compresses esophageal varices and also has a NG suction lumen

if client is in respiratory distress:

  • cute balloon ports
  • remove the tube
108
Q

what are 2 notable symptoms of type 1 diabetes?

A

excessive thirst and weight loss

109
Q

bulge test

A

confirms presence of fluid in the knee

ask the client to lie down and extend the legs on the bed

110
Q

chest tube

A

expected findings:

  • 2 cm of water in water seal chamber
  • clots of blood observed in collection chamber (hemothorax)

unexpected:
- constant bubbling in water-seal chamber (AIR LEAK)

111
Q

normal CVP range

A

3-12 mm Hg

reading of 8 mmHg indicates desired response to fluid replacement

112
Q

early and late stages of hepatic encephalopathy

A

early:
- impaired thought processes, insomnia or sleep disturbances, writing changes or hand tremors

late:
- asterixis, lethargy, extended sleep patterns, decerebrate posturing, hyperventilation

113
Q

expected urinalysis results for UTI

A

WBCs and RBCs present

for inflammation and bleeding from bladder mucosa irritation

114
Q

obtaining throat culture

A

rub cotton swab over both tonsillar areas and posterior pharynx

115
Q

what should be assessed post pneumonectomy?

A

position of the trachea in the sternal notch because a tracheal shift could cause and increase in pressure on the operative side and cause pressure against the mediastinal area

116
Q

interventions for chronic constipation

A
  • increase intake of cereals, fresh fruits and veggies
  • plan day to be around usual time of defecation
  • establish daily exercise pattern
117
Q

lumbar puncture

A
  • does NOT use general anesthesia
  • fluids NOT restricted
  • no compression bandage
  • CAN use analgesics after for headaches
118
Q

what indicates a client undergoing alcohol withdrawal symptoms will go into withdrawal delirium?

A

increased pulse rate

119
Q

what is an adverse effect of magnesium sulfate?

A

CNS depressant –> decreases blood flow to the kidneys

watch for decreased UO

120
Q

Jackson-Pratt drain should always be attached to ____.

A

the patient’s gown or pajamas only

121
Q

positioning post-mastectomy

A

semi-fowler’s position with affected arm elevated

facilitates removal of fluid from venous pathways and lymphatic system - enhances circulation and prevents edema

122
Q

what is treatment for head lice?

A

gamma hexachloride shampoo - apply to dry hair and work into lather for 4-5 minutes

123
Q

correct precautions for Measles (rubella)?

A

droplet precautions

124
Q

care of open Kaposi’s sarcoma lesions

A

clean with soap and warm water every day and cover with sterile dressings to prevent secondary infection

125
Q

care of herpes simplex virus abscesses

A

clean 2x a day with diluted solution of povidone-iodine and leave open to air

126
Q

causes of autonomic dysreflexia

A

full bladder
impaction
pressure on skin
cold draft

127
Q

what do you administer in autonomic dysreflexia if BP does not go down after relieving bladder or impaction?

A

hydralazine hydrochloride IV

128
Q

principles for radiation therapy

A

time
distance
shielding

*lead apron should be used when the nurse has to spend any length of time at a close distance

129
Q

signs and symptoms of opioid (heroine) withdrawal

what is the antidote?

A

N/V, abdominal cramping, restlessness

Nalaxone - response will be N/V, HTN, tachycardia

130
Q

what info about medications should be included in change of shift report?

A

new medication orders
recent PRN administrations
symptoms unrelieved by administered meds

131
Q

what should be monitored after administered naloxone?

A

monitor rate of respirations

132
Q

symptoms of acute GN

A 
fever
chills
hematuria
dyspnea 
weight gain, edema 
HTN 
headache
decreased LOC 
confusion 
abdominal/flank pain
133
Q

how often should pedal pulses be checked post- cardiac cath?

A

immediately after procedure and q 15 minutes for several hours after

134
Q

patients with SLE should avoid _____

A

all direct exposure to sun or UV light

don’t work/dig in a garden for risk for injury

135
Q

Continuous ambulatory ECG

A
  • no electric razor or hairdryer
  • keep a log of all activities
  • no bathing/showering
136
Q

when going upstairs with a cane, you should step up firs with your _____ leg.

A

strong

137
Q

symptoms:
respiratory failure
flaccid paralysis
urinary retention

_____?

A

guillain-barre syndrome

138
Q

treatment for itching in hepatitis A

A

calamine lotion and antihistamines

139
Q

report ______with hyperparathyroidism (sign of urinary calculi)

A

hematuria

140
Q

frontal lobe of brain controls:

A 
personality changes 
voluntary activity
concentration
motivation 
ability to plan
problem solving
141
Q

precautions for DISSEMINATED herpes zoster

A

airborne and contact

142
Q

why should the client diagnosed with chronic adrenal insufficiency avoid exposure to infection?

A

exposure to infection, cold, or excessive fatigue can cause circulatory collapse

143
Q

enteral feedings via NGT

A
  • aspirate and measure amount of gastric aspiration
  • measure pH of aspirate
  • clamp feeding tube at the end
  • HOB 30 degrees
  • warm formula to room temp
  • intermittent feedings - 30 minutes minimum

verifying placement and checking pH must be done by RN only

144
Q

polyarteritis nodosa

A

inflammation of the small arteries causing diminished blood

treatment w/ cortisone is increased survival rate

145
Q

where are signs of jaundice best observed in asian americans?

A

posterior hard palate

146
Q

symptoms of early-stage Alzheimer’s

A

recent memory loss and changes in motor activity - pacing, wandering, agitation

147
Q

post concussion syndrome

A
  • persistent headache for 2 weeks or more
  • notify continuous vomiting
  • don’t resume contact sports
  • trouble remembering small details
  • no recollection of evens about the incident
148
Q

why does a client with TB need vit B6 supplementation?

A

to prevent the side effects of isoniazid - peripheral neuropathy, dizziness, and ataxia

149
Q

what vitamin supplementation does a client with chronic alcoholism need?

A

all B vitamins but especially vitamin B1 (Thiamine) - thiamine deficiency is the primary cause of alcohol-related changes

150
Q

what is a common cause of chronic gastritis?

A

H. Pylori

151
Q

positioning after intracapsular cataract extraction

A

semi-fowler’s or non operative side

152
Q

fluorescein angiography

A

measures circulation in the retina

  • avoid sunlight directly after
  • temporary yellow skin staining
  • increase fluids to excrete dye
153
Q

what should the nurse be concerned about after a TURP?

A

elevated temperature
bladder spasms
leaking fluid around catheter
hemorrhage

*urge to void is normal

154
Q

what should you do if a depressed client does not eat meals?

A

ask the client to identify her favorite foods

155
Q

autologous blood donation

A
  • can give up to 5 wks before surgery
  • can give 2-4 units of blood
  • no blood draws within 3 days of surgery
  • take iron supplements
156
Q

signs of heat stroke

A

hypotension, tachypnea, tachycardia, elevated temp, hot and dry skin

157
Q

Gtube with frequent loose stools - caused by ____

A

if liquid medication that has sorbitol is given through the tube.
if the client is allergic - can cause diarrhea

158
Q

normal IOP

A

10-21 mm Hg

159
Q

moist-to-dry dressing

A

remove gauze dressing
observe wound
clean wound
apply moist gauze

160
Q

sexual activity post MI

A

tolerate 1 city block or 2 flights of stairs without SOB or chest pain

stay supine
not after heavy meal

161
Q

stroke risk factors

A 
male
african american
substance abuse (cocaine)
smoking 
alcohol 
diabetes 
obesity
heart murmur
oral contraceptive use 
sedentary lifestyle 
history of MI
high cholesterol
162
Q

treatment for DVT

A

bedrest w/ leg elevated
anticoagulants
warm, moist soaks

163
Q

halo vest traction

A

report IMMEDIATELY if client has pain while chewing

pain w/ jaw movement 24-48 hours after indicates skull pins slipped into temporal plate

164
Q

chronic venous insufficiency

A

thick, dark skin
pain in dependent positions
crater-like lesions

165
Q

toxic shock syndrome

A

no superabsorbent tampons
no vaginal products with deodorants
contact HCP if vomiting/diarrhea
change tampons q 4 hours

166
Q

risk factors for colorectal cancer

A 
age over 50 
african american
first degree relative 
high protein, fat, low fiber diet
hx of IBD
167
Q

Breast self-examination

A

use pads of first 3 fingers in gentle rotating motion

168
Q

precautions for influenza

A

droplet for 7 days or until 24 hours after symptom resolution

169
Q

signs of dehydration

A

dry skin
tachycardia
cold extremities
increased thirst

170
Q

airborne precautions

A

TB
measles
varicella - disseminated

interventions:
door closed
N95 mask
mask during transport

171
Q

droplet precautions

A 
influenza
meningococcal meningitis
diphtheria 
pertussis 
mumps 
group A strep 
pneumonia

interventions:
door open
keep 3 feet
face mask during transport

172
Q

what to do if tracheostomy tube is dislodged

A

replace the tube!

OR

extend neck to maintain patent airway
call for help
place supine 
check breath sounds 
use hemostat to open airway
173
Q

sexual activity after vasectomy

A

wear a condom for 6 weeks after surgery because some sperm may remain in the vas deferens for up to 6 weeks

174
Q

anterior wall MI has a high risk for ______.

A

heart failure

auscultate lung fields!

175
Q

what do you do if muscle spasms increase in a client placed in balanced suspension traction?

A

assess the traction weight

176
Q

patient in balanced suspension traction is allowed to move _____ but not _______

A

up and down

but NOT side to side

177
Q

self-catheterization

A

keep catheter in plastic bag
catheterize q 6-8 hours
wash with soap and water prior
don’t need sterile gloves

178
Q

diet for crohn’s disease

A 
low fat 
high protein 
low residue
high calories 
non irritating
179
Q

priority of the nurse when a client is contaminated with unidentified hazardous material?

A

determine what decontamination occurred in the field

180
Q

turning a patient post lumbar laminectomy

A

place pillow between client’s legs and turn the client

181
Q

what class of antibiotics have cross allergies with penicillins?

A

cephalosporins

182
Q

what should tracheostomy cuff pressure be?

A

< 20 mm Hg

wall suction can be

183
Q

symptoms of Lyme disease

A 
rash
intermittent fever
headache
fatigue
muscle pain
stiff neck
184
Q

expected breath sounds in chronic bronchitis

A

sonorous wheezes or rhonchi

from excessive mucous production

185
Q

what is important to monitor in a client after a stroke?

A

auscultate lung q4 hours because decreased O2 levels increases ICP - also puts patient at risk for aspiration

186
Q

what electrolyte imbalance is possible after thyroidectomy ?

A

hypocalcemia

injured parathryoid gland causes decreased hormone levels

monitor for tingling of fingers, toes, lips

187
Q

clients at risk for metabolic acidosis

A

type 1 diabetes
salicylate toxicity - med is acidic
acute kidney failure
severe diarrhea

188
Q

kosher diet

A

no dairy and meat at the same time
no shellfish or scavenger fish- must have scales
no pork products
no gelatin foods

189
Q

midstream urine for C/S

A

clean urinary meatus with antiseptic solution
void into sterile container
container must NOT touch penis

190
Q

order for physical assessment

A

inspection
palpation
percussion
auscultation

191
Q

myasthenia gravis interventions

A

avoid alcohol, heat, stress, OTC meds
thicker liquids better
spread out activities
avoid stress and infection

192
Q

enema

A

hold irrigation set 12-18 inches above rectum
insert irrigation tube 3-4 inches into rectum
position client in sim’s position
warm water slightly higher than body temp

193
Q

interventions for hyperemesis gravidarum

A 
start IV for hydration 
intake and output q 4 hours
NPO to rest GI 
weight check q AM
all meds IV to rest GI
bed rest to conserve energy

NCLEX (5 decks)

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