Adult Flashcards

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
What are symptoms of autonomic dysreflexia?
- HTN - bradycardia - pounding headache - nasal congestion - sweating - restless
26
Interventions for autonomic dysreflexia
- make sure catheter is draining - make sure bowel is not impacted - immediately place in High fowler's
27
risk factors for cholelithiasis
4 F'S - female, fat, forty, fertile - US southwestern hispanic or Native american is highest risk - fasting (decreased gallbladder movement)
28
patient presents with: dyspnea, diaphoresis, anxiety, restless, cough, and chest pain. What does this indicate and what do you do?
indicates air embolus - central line associated complication Intervention: position patient on left side to displace air to the right side of the heart
29
when should compression stockings be placed on a client?
after elevation of the limbs | or when there is minimal dependent edema
30
the nurse should be most concerned if a patient having an acute asthma attack auscultates _____.
decreasing breath sounds - indicates severe spasm or obstruction (inspiratory wheezing is also a major concern)
31
Cushing's syndrome is caused by _____
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
32
What does it indicate when S3 (ventricular gallop) is heard?
Left-sided heart failure | normal in kids
33
A finding of ______ in a client with bulimia requires IMMEDIATE notification to the HCP.
hoarse voice that is barely audible (laryngitis)
34
osteoarthritis is characterized by joint pain that is relieved by ______.
resting - rheumatoid arthritis pain is relieved by ROM
35
characteristics of osteoarthritis
- crepitus w/ ROM - pain worsens with activity - affects weight-bearing joints - joint atrophy - tylenol and NSAIDs - corticosteroid injections
36
characteristics of RA
- Joint stiffness in the AM - joint tenderness - joint swelling - decreased ROM - encourage range of motion
37
Phalen maneuver
assessing for symptoms of carpal tunnel syndrome - put back of hands together and bend both wrists at the same time to produce paresthesia
38
what can cause a falsely HIGH blood pressure reading
- short cuff - repeating assessments too quickly - positioning artery BELOW the heart - deflating the cuff too quickly
39
cataracts occurs when the lens becomes less ____ and more ____.
less hydrated and more dense
40
clients diagnosed with PUD should avoid:
``` rich in cream or milk aspirin alcohol meat extracts caffeinated beverages ```
41
HPV vaccine is recommended at ages ____ to reduce risk of ______ cancer.
at ages 11-12 | to reduce risk of CERVICAL/PENILE cancer
42
If a client has low back pain, the nurse should ask ___?
how many rest periods the client gets during work hours * should avoid standing for long periods of time
43
Diet for patient w/ CKD
- low sodium, potassium, phosphorus - adequate calcium - limit protein *decrease diary intake because even though they are hypocalcemic, dairy products are high in phosphorus
44
If female client's dialysate outflow is cloudy, determine if ________.
she is menstruating. blood from uterus can be pulled through into the dialysate
45
before a skin biopsy, it is most important to assess if the patient is using ______.
antiplatelets
46
a client with addison's disease should _____ their sodium intake
INCREASE
47
symptoms of addison's disease
- hyponatremia - hypoglycemia - hyperkalemia - hyperpigmentation - lethargy, weakness, fatigue
48
patient's with addison's disease need lifelong _______.
lifelong steroid replacement
49
When taking corticosteroids,receiving _____ should be avoided.
vaccinations - because of decreased ability to mount an inflammatory response
50
interventions for if a ventilator alarm is activated:
- assess breath sounds FIRST - assess for hypoxia and vital signs - then check the tubing for excessive fluid
51
What meds would be given in an anaphylactic reaction?
- epinephrine IM - diphenhydramine IV - prednison IV - albuterol via nebulizer
52
symptoms of vitamin B 12 deficiency:
- fatigue - constipation - diarrhea - sore tongue
53
After a seizure, ______ and _____ are common.
postictal confusion and sleepiness
54
post-lumbar puncture, the client should remain ____ in bed for ____ hours.
remain flat in bed for at least 8 hours
55
What is the crede maneuver?
often used for patients with SCI | manually apply pressure to bladder to aid in complete emptying - reduces risk for infection
56
Bell's Palsy
- 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
57
The weight of the body when using crutches should be transferred to the _____.
hands and arms crutches should be placed 8-10 inches in front with each step
58
How should the patient post-cataract surgery be positioned in the immediate post-op period?
on the unaffected side or on back with the head slightly elevated
59
Interventions for dumping syndrome
- avoid empty carbs and fiber - eat lying down or lay down after meals - avoid drinking fluids with meals - eat small meals more frequently
60
What is Guillain-Barre syndrome?
autoimmune attack on the peripheral nerve myelin - can be triggered by a viral infection affects the PERIPHERAL nervous system
61
interventions for Buck's traction
- weights should always hang freely - keep HOB 15-20 degrees - keep on strict bedrest - turn q 2 hours to unaffected side
62
interventions for rheumatoid arthritis
- heat - ROM exercises - weight reduction
63
immediately report _____ after thyroidectomy
hoarse voice
64
symptoms of neuroleptic malignant syndrome
fever, tachy, incontinence, muscle rigidity, seizures, sweating, salivation
65
PPE order
Donning - gown, mask, eye shield, glove | Removing - gloves, goggles, gown, mask
66
correct pursed lip breathing
- tighten stomach muscles when breathing out - take 2x as long to breathe out than breathing in - pretend you're whistling when you breathe out
67
Preparing for cardioversion
- administer sedative/hypnotic (midazolam) - assess heart rhythm - hold digoxin 48 hours before - don't drive for 24 hours after
68
adventitious breath sounds
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
69
what to do during a PTSD flashback?
maintain a safe distance and limit stimuli
70
Walking with a cane
hold cane in unaffected arm move weak leg first then strong leg CANE, WEAK, STRONG
71
R.A.C.E
rescue/remove alarm contain/confine evacuate
72
using a hydraulic lift
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
73
symptoms of VTE
``` unilateral leg edema extremity pain warm skin erythema heaviness in the chest - PE ```
74
time frame for activated charcoal
within one hour of ingestion
75
septic shock: early and late stage
early: strong bounding peripheral pulses and hyperventilation, warm dry skin late: weak or absent peripheral pulses and decreased respirations, cool clammy and pale
76
interventions post-myelogram
- encourage oral fluid intake - lie flat for 12-24 hours to prevent headaches - monitor V/S and neuro signs
77
multiple sclerosis
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
78
myasthenia crisis
``` dyspnea anoxia cyanosis absent cough/swallow reflex increased HR, BP, RR ```
79
Interventions for AAA:
``` 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
signs of autonomic dysreflexia
``` HTN bradycardia pounding HA nasal congestion flushing above pale below goosebumps restless sweating ```
81
interventions for autonomic dysreflexia
make sure catheter is draining bowel are NOT impacted IMMEDIATELY place in High fowler's
82
What confirms diagnosis of glomerulonephritis?
positive ASO titer differentiate from UTI b/c negative for WBC and no bacteria in urine
83
post thyroidectomy, monitor for which electrolyte imbalance?
hypocalcemia and monitor for thyroid storm! keep calcium gluconate for IV administration ready
84
Thyroid storm
increased temp, BP, HR, RR agitation seizures tremors Give propranolol - bring down HR and BP Give D5W - restore glycogen stores antithyroid meds
85
signs of bacterial meningitis
``` 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
client with meniere's disease should have a _____ diet.
low sodium to decrease fluid retention
87
symptoms of mononucleosis
``` malaise fever severe sore throat headache epistaxis ``` *monitor for splenomegaly!!
88
what do positive nitrates in a urinalysis indicate?
presence of E. Coli
89
Controlling odor and gas in colostomy care
cranberry juice, yogurt, buttermilk, deodorant, crackers and toast don't skip meals, chew gum, smoke, drink beer
90
cocaine withdrawal symptoms
cravings depression fatigue hypersomnia
91
alcohol withdrawal
tremors, increased HR, anxiety, insomnia, hallucinations - peaks in 24-48 hours - determine when last drink was - quiet, well-lit room - initiate seizure precautions
92
phlebitis vs infiltration
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
interventions for paracentesis
measure weight before and after measure abdominal girth before and after have BP cuff to monitor for hypotension
94
why should a client with PAD be encouraged to exercise?
because exercising increases collateral circulation
95
understanding of aseptic technique dressing changes
wash hands! use only what HCP ordered have someone look at wound every dressing change throw dressing away wrapped in nonsterile glove
96
when should the nurse irrigate the NG tube?
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
what is the most important thing to check for post thyroidectomy surgery?
monitor for signs of respiratory distress every hour from swelling
98
What should the nurse instruct the patient to do if the client feels faint?
place the client's head between the knees
99
exercise for osteoarthritis
warm-up exercises before and after don't exercise severely painful joints swimming is a helpful exercise
100
Expected findings in burn resolution
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
signs to monitor for post bronchoscopy
signs of respiratory distress tachycardia respiratory stridor retractions depressed gag reflex, sputum streaked with blood and sore throat - expected findings
102
characteristics of diabetes insipidus
deficiency of ADH - increased UO - dilute urine - specific gravity < 1.005
103
what is normal specific gravity?
1.010 - 1.030
104
What is given for diabetes insipidus?
desmopressin nasally or SQ for life
105
defibrillator
- 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
what does subcutaneous emphysema post chest-tube removal indicate?
pneumothorax! observe for respiratory distress and contact HCP
107
Sengstaken-Blakemore tube
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
what are 2 notable symptoms of type 1 diabetes?
excessive thirst and weight loss
109
bulge test
confirms presence of fluid in the knee ask the client to lie down and extend the legs on the bed
110
chest tube
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
normal CVP range
3-12 mm Hg reading of 8 mmHg indicates desired response to fluid replacement
112
early and late stages of hepatic encephalopathy
early: - impaired thought processes, insomnia or sleep disturbances, writing changes or hand tremors late: - asterixis, lethargy, extended sleep patterns, decerebrate posturing, hyperventilation
113
expected urinalysis results for UTI
WBCs and RBCs present | for inflammation and bleeding from bladder mucosa irritation
114
obtaining throat culture
rub cotton swab over both tonsillar areas and posterior pharynx
115
what should be assessed post pneumonectomy?
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
interventions for chronic constipation
- increase intake of cereals, fresh fruits and veggies - plan day to be around usual time of defecation - establish daily exercise pattern
117
lumbar puncture
- does NOT use general anesthesia - fluids NOT restricted - no compression bandage - CAN use analgesics after for headaches
118
what indicates a client undergoing alcohol withdrawal symptoms will go into withdrawal delirium?
increased pulse rate
119
what is an adverse effect of magnesium sulfate?
CNS depressant --> decreases blood flow to the kidneys watch for decreased UO
120
Jackson-Pratt drain should always be attached to ____.
the patient's gown or pajamas only
121
positioning post-mastectomy
semi-fowler's position with affected arm elevated facilitates removal of fluid from venous pathways and lymphatic system - enhances circulation and prevents edema
122
what is treatment for head lice?
gamma hexachloride shampoo - apply to dry hair and work into lather for 4-5 minutes
123
correct precautions for Measles (rubella)?
droplet precautions
124
care of open Kaposi's sarcoma lesions
clean with soap and warm water every day and cover with sterile dressings to prevent secondary infection
125
care of herpes simplex virus abscesses
clean 2x a day with diluted solution of povidone-iodine and leave open to air
126
causes of autonomic dysreflexia
full bladder impaction pressure on skin cold draft
127
what do you administer in autonomic dysreflexia if BP does not go down after relieving bladder or impaction?
hydralazine hydrochloride IV
128
principles for radiation therapy
time distance shielding *lead apron should be used when the nurse has to spend any length of time at a close distance
129
signs and symptoms of opioid (heroine) withdrawal what is the antidote?
N/V, abdominal cramping, restlessness Nalaxone - response will be N/V, HTN, tachycardia
130
what info about medications should be included in change of shift report?
new medication orders recent PRN administrations symptoms unrelieved by administered meds
131
what should be monitored after administered naloxone?
monitor rate of respirations
132
symptoms of acute GN
``` fever chills hematuria dyspnea weight gain, edema HTN headache decreased LOC confusion abdominal/flank pain ```
133
how often should pedal pulses be checked post- cardiac cath?
immediately after procedure and q 15 minutes for several hours after
134
patients with SLE should avoid _____
all direct exposure to sun or UV light | don't work/dig in a garden for risk for injury
135
Continuous ambulatory ECG
- no electric razor or hairdryer - keep a log of all activities - no bathing/showering
136
when going upstairs with a cane, you should step up firs with your _____ leg.
strong
137
symptoms: respiratory failure flaccid paralysis urinary retention _____?
guillain-barre syndrome
138
treatment for itching in hepatitis A
calamine lotion and antihistamines
139
report ______with hyperparathyroidism (sign of urinary calculi)
hematuria
140
frontal lobe of brain controls:
``` personality changes voluntary activity concentration motivation ability to plan problem solving ```
141
precautions for DISSEMINATED herpes zoster
airborne and contact
142
why should the client diagnosed with chronic adrenal insufficiency avoid exposure to infection?
exposure to infection, cold, or excessive fatigue can cause circulatory collapse
143
enteral feedings via NGT
- 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
polyarteritis nodosa
inflammation of the small arteries causing diminished blood treatment w/ cortisone is increased survival rate
145
where are signs of jaundice best observed in asian americans?
posterior hard palate
146
symptoms of early-stage Alzheimer's
recent memory loss and changes in motor activity - pacing, wandering, agitation
147
post concussion syndrome
- 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
why does a client with TB need vit B6 supplementation?
to prevent the side effects of isoniazid - peripheral neuropathy, dizziness, and ataxia
149
what vitamin supplementation does a client with chronic alcoholism need?
all B vitamins but especially vitamin B1 (Thiamine) - thiamine deficiency is the primary cause of alcohol-related changes
150
what is a common cause of chronic gastritis?
H. Pylori
151
positioning after intracapsular cataract extraction
semi-fowler's or non operative side
152
fluorescein angiography
measures circulation in the retina - avoid sunlight directly after - temporary yellow skin staining - increase fluids to excrete dye
153
what should the nurse be concerned about after a TURP?
elevated temperature bladder spasms leaking fluid around catheter hemorrhage *urge to void is normal
154
what should you do if a depressed client does not eat meals?
ask the client to identify her favorite foods
155
autologous blood donation
- 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
signs of heat stroke
hypotension, tachypnea, tachycardia, elevated temp, hot and dry skin
157
Gtube with frequent loose stools - caused by ____
if liquid medication that has sorbitol is given through the tube. if the client is allergic - can cause diarrhea
158
normal IOP
10-21 mm Hg
159
moist-to-dry dressing
remove gauze dressing observe wound clean wound apply moist gauze
160
sexual activity post MI
tolerate 1 city block or 2 flights of stairs without SOB or chest pain stay supine not after heavy meal
161
stroke risk factors
``` male african american substance abuse (cocaine) smoking alcohol diabetes obesity heart murmur oral contraceptive use sedentary lifestyle history of MI high cholesterol ```
162
treatment for DVT
bedrest w/ leg elevated anticoagulants warm, moist soaks
163
halo vest traction
report IMMEDIATELY if client has pain while chewing pain w/ jaw movement 24-48 hours after indicates skull pins slipped into temporal plate
164
chronic venous insufficiency
thick, dark skin pain in dependent positions crater-like lesions
165
toxic shock syndrome
no superabsorbent tampons no vaginal products with deodorants contact HCP if vomiting/diarrhea change tampons q 4 hours
166
risk factors for colorectal cancer
``` age over 50 african american first degree relative high protein, fat, low fiber diet hx of IBD ```
167
Breast self-examination
use pads of first 3 fingers in gentle rotating motion
168
precautions for influenza
droplet for 7 days or until 24 hours after symptom resolution
169
signs of dehydration
dry skin tachycardia cold extremities increased thirst
170
airborne precautions
TB measles varicella - disseminated interventions: door closed N95 mask mask during transport
171
droplet precautions
``` influenza meningococcal meningitis diphtheria pertussis mumps group A strep pneumonia ``` interventions: door open keep 3 feet face mask during transport
172
what to do if tracheostomy tube is dislodged
replace the tube! OR ``` extend neck to maintain patent airway call for help place supine check breath sounds use hemostat to open airway ```
173
sexual activity after vasectomy
wear a condom for 6 weeks after surgery because some sperm may remain in the vas deferens for up to 6 weeks
174
anterior wall MI has a high risk for ______.
heart failure auscultate lung fields!
175
what do you do if muscle spasms increase in a client placed in balanced suspension traction?
assess the traction weight
176
patient in balanced suspension traction is allowed to move _____ but not _______
up and down but NOT side to side
177
self-catheterization
keep catheter in plastic bag catheterize q 6-8 hours wash with soap and water prior don't need sterile gloves
178
diet for crohn's disease
``` low fat high protein low residue high calories non irritating ```
179
priority of the nurse when a client is contaminated with unidentified hazardous material?
determine what decontamination occurred in the field
180
turning a patient post lumbar laminectomy
place pillow between client's legs and turn the client
181
what class of antibiotics have cross allergies with penicillins?
cephalosporins
182
what should tracheostomy cuff pressure be?
< 20 mm Hg wall suction can be
183
symptoms of Lyme disease
``` rash intermittent fever headache fatigue muscle pain stiff neck ```
184
expected breath sounds in chronic bronchitis
sonorous wheezes or rhonchi | from excessive mucous production
185
what is important to monitor in a client after a stroke?
auscultate lung q4 hours because decreased O2 levels increases ICP - also puts patient at risk for aspiration
186
what electrolyte imbalance is possible after thyroidectomy ?
hypocalcemia injured parathryoid gland causes decreased hormone levels monitor for tingling of fingers, toes, lips
187
clients at risk for metabolic acidosis
type 1 diabetes salicylate toxicity - med is acidic acute kidney failure severe diarrhea
188
kosher diet
no dairy and meat at the same time no shellfish or scavenger fish- must have scales no pork products no gelatin foods
189
midstream urine for C/S
clean urinary meatus with antiseptic solution void into sterile container container must NOT touch penis
190
order for physical assessment
inspection palpation percussion auscultation
191
myasthenia gravis interventions
avoid alcohol, heat, stress, OTC meds thicker liquids better spread out activities avoid stress and infection
192
enema
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
interventions for hyperemesis gravidarum
``` 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 ```