athabasca nurs 400 Flashcards
the nurse is caring for a patient with a chest tube during the assessment palpates a crackling area (crepitus) around the insertion site. What to do?
draw a circle around the area to see if the subcutaneous emphysema is resolving
assessing the clients understanding of medication use. A medication that may cause a complication with diabetes?
steroids
pt has aortic stenosis, feeling tired, naps daily. Apical heart sounds 2cm left of mediclavicular line. Crackles lower lungs.B/P 110/90. Wt gn 5.5 lbs in 24 hours. Number one priority?
crackles
care of ileostomy. Pt at risk for anemia; because?
iron absorption depends on simultaneous bile salt absorption in the terminal ileum
pt with end stage pancreatic cancer decides to terminate medical intervention. what to expect when consulting palliative care?
referral for bereavement
evaluating pin insertion/skeletal traction. what indicates complication?
loose pins
48 hours post lower lobectomy, receiving morphine via PCA. c/o pain left thorax - worse with coughing
check pca
asthma pt/ beclomethasone inhaler. To assess if client is rinsing mouth look for?
thrush
pt had chemo. WBC count 2300mm. HGB 98 platelets 80,000, potassium 3.8. symptom that takes priority?
Fever
ICU pt. Jugular vein distention noted
++poor cardiac output
Parkinsons pt. rx levadopa makes improvement in what area?
muscle rigidity
evaluation of cranial nerves on routine exam. To assess cranial nerve X11 ( hypoglossia) nurse should test?
protrude tongue
which WBC is most numerous?
neutrophils
nurse should teach client about what potential risk factor for the development of colon cancer?
history of inflammatory disease
diabetes pt says if I avoid carbs my diet will be okay. Nurse should reply on the knowledge that diabetes affects which nutrients
carbs
focused assessment of bladder cancer includes looking for what common sign?
hematuria
how to explain to female elderly decreasing in height
related to menopause and loss of bone density
21 days post hemicolectomy. pt having difficulty maintaining an adequate intake of metabolic needs for optimal healing. The nurse should recommend?
nasogastric feeding tube with protein supplement
which combination of adverse affect should be monitored when administering IV insulin to a patient with diabetic ketoacidosis
hypoglycemia and hyperkalemia
a client is scheduled to receive PHY through a nasogastric tube and has a tube feeding supplement bed is elevated to 30 degrees. prior to administering med nurse should?
flush with water
medical nurse educator is reviewing a clients recent episode of metabolic acidosis with members of the nursing staff. what should the educator describe as the role of the kidneys in metabolic acidosis? (acid)
kidneys excrete hydrogen (acid pee) ions and conserve bicarbonate (tums) ions to help restore balance
A client has been prescribed hydrochlorothiazide (potasium conserver) to treat heart failure. The nurse should tell the client to report…
muscle weakness ( pee out potasium, lack of potasium)
a client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?
the severity of discomfort isnt related to the size of varicoities.
Primary cancer prevention program an oncology nurse answers questions from the public at a health laryngeal cancer
laryngeal cancer is one of the most preventable types of cancer
client with thrombocytopenia secondary to leukemia develops epistatxis, The nurse should instruct
sit up lean forward
nurse is caring for a client with a chest tube inserted 12 hours ago for tx of pleural effusion. Which assessment is more determining the clients response to the treatment?
breathing dif
a client with venous insufficiency
the severity of discomfort isnt related to the size of varicosites
A client with a serum glucose level of 618 mg/dl is admitted to the facility. He’s awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6º F (38.1º C), heart rate of 116 beats/minute, and blood pressure of 108/70 mm Hg. Based on these assessment findings, which nursing diagnosis takes the highest priority?
deficient fluid volume related to osmotic diuresis
which registered nurse should be assigned to the patient who had a chest tube yesterday?
cardiovascular
pt reports dull headache, and dizziness, increased pulse rate. The results of arterial bld gas analysis are aa follows; PH pressure of carbon dioxide 50mm, 6.7kpa, bicarbonate 24. These findings indicate which of the following imbalances?
respiratory acidosis
the nurse should teach the patient with hep A
increase carbs and protein diet
routine check up for aids pt; most common cancer
Kaposi sarcoma
pt with choleithasis has a gallstones lodge in common bile duct. When assessing the client the nurse expects to note;
pale stools.. clay like
which one of the following expected outcomes about nutrition would be appropriate for a client who has had a total gastrectomy for gastric cancer?
learn self admin of feeds every 4
pt with trach tube, 3 days post insertion, what should nurse do?
sterile catheter each time suctioning
pt with T5 spinal injury. Pt on bed rest, foley catheter. C/o headache, diaphoresis/ nausea. What is the nursing priority?
removing any stimulus to skin
which of the following assessment findings in an elderly client require intervention?
change in mole/ elevated irregularly shaped mole
pt with blistering wounds cause NYD chemical agent. Intervention?
irrigate with water
assessment of pt with tracheotomy tube. Pt has bilateral upper lobe ronchi. Unable to cough up secretions. Intervention?
sterile suction
pt dx with skull fracture post MVA, presents with increased drowsiness. Pt is at risk for?
concussion
complication of trach tube
damage to laryngeal nerve
pt with above knee amputation, develops dime size red spot on dressing 45 minutes post recovery.
reinforce dressing
stroke pt, transferred to rehab. Neurological deficit that could lead to skin break down?
inability to express need r
incontinence
Pt with right hip fracture, right hip pain, unable to move. Further assess right leg to determine..
Shorter than unaffected leg
Humlin 70/30 contains what ?
70% NPH and 30% regular
elderly pt thrombotic CVA, right side flaccid. When planning care rehab starts with?
on admission
pt being treated for iron deficiency anemia with ferrous sulfate. Assess for use of which medicine? ( when anemia continues)
aluminum hydroxide
pt receiving antibiotics to treat gram negative bacterial infection.pt having adverse effect d/t desctuction of norm flora in stomach
diahrea
assessing a client with atrial septal defect (ASD). What requires immediate intervention?
bubbling in water chamber or
serous drainage in chamber
Nurse planning a discharge, for stroke patient with right sided weakness. Family concerned about continued rehab on discharge
Inform case manager
Client with COPD develops cor pulmonale. What assessment data would alert the nurse
Edema and neck vein distended
Or undergoes cystoscope, which assessment is most appropriate
Asses urine for excessive bleeding
Pt with chest tube. Chest tube accidentally disconnects. What to do?
Clamp it
W/C Pt comes for follow up of pressure ulcers on buttocks. Family changing hydocolliod drsgs every 3-5 days. Past few weeks, less time in chair, use of cushion. During follow up, no cushion, dry dressing, how should nurse respond?
Ask client to explain treatment regimine
After evaluating a pt for hypertension, doc orders 50mg atenol. What therapeutic effect is expected?
Decreased cardiac output, decrease systolic and diastolic
Pt with abdominal distension, sharp pains, distinct rhythmic pulsation to mid line. Vss. Prioritiy intervention
Asculate for bruit and notify doc of findings
Nurse teaches pt with type 1 diabetes, maintaining stable blood glucose levels. Nurse should suggest ? To minimize the rise in bold sugars post meals
Fiver
Meats
Dairy
How long does iv Lasix take to work on heart failure
30-60 min
Post transverse colectomy. Anxious, pain 8/10, sbg 7.8
Priority pain. Give morphine
Developing a long term care plan for the client with multiple sclerosis, nurse should teach prevention of?
Contractures
On admission PH 7.2 PA02 64, PaCO2 60 and HCO3-22. Chest tube inserted oxygen at 4l, 30 min post repeat abgs= Ph 7.3 pao2 76, paco2 50, hco3 22
Improving resp status
Colchine for gout, watch for ? adverse reaction
Diarrhea
0xygen is at 2l/min for COPD.y?
Co2 retention—
Terminal cancer patient in hospice. How to treat nausea and vomiting
Iv antiemetic
Pt prescribed hydrochlorothizide
Tell patient to watch for
Weakness
60yr old in ER. Substernal chest pain. Radiates to shoulder and left arm. Dx of acute MI. Admission rx of o2 4l/p nasal cannula, Cbc, 12 lead ecg, chest radiograph, 2mg morphine.
First task?
Morphine
Oxygen at 2l per min for COPD because?
Low therapy because
H
The nurse is checking laboratory values on a patient who has crackling rales in the lower lobes, 2+ pitting edema, and dyspnea with minimal exertion. Which of the following laboratory values does the nurse expect to be abnormal?
B-type natriuretic peptide (BNP).
The client’s symptoms suggest heart failure. BNP is a neurohormone that is released from the ventricles when the ventricles experience increased pressure and stretch, such as in heart failure. A BNP level greater than 51 pg/mL is often associated with mild heart failure; and, as the BNP level increases, the severity of heart failure increases. Potassium levels are not affected by heart failure. CRP is an indicator of inflammation. It is used to help predict the risk of coronary artery disease. There is no indication that the client has an increased CRP. There is no indication that the client is experiencing bleeding or clotting abnormalities, such as those seen with an abnormal platelet count.
a fourth hear sound indicates
failure of ventricle ( weak) to eject all blood
pt day 3, post abd surgery. no bowel movement but passing gas.
ambulate 3x per day
er patient acute heart failure. What lab values do you check prior to admin medication.
platelets
pt with rib fractures, pneuomothroax, chest tube.
fluid in water seal column fluctuating with each breath.
A client’s chest tube is connected to a chest tube drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that
the chest tube system is functioning properly.
Fluctuation of fluid with respirations in the water-seal column indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client’s skin around the chest tube insertion site. A leak in the system is indicated when bubbling occurs in the water-seal column.
seeks medical attention after developing acute abdominal pain
auscultate with bell of stethoscope
The nurse has just received change-of-shift report about these four patients. Which patient should the nurse assess first?
older adult tia
nurse is preparing to administer blood to a client who requires postoperative blood replacement. the nurse should use a blood administration set that
must be filtered
newly diagnosed with radiation induced thrombocytopenia the nurse should include which intervention in the care plan
inspect skin for petechie
doctor told my wife cervical cancer is curable. Is he just trying to make us feel better
true cure rate is almost 100%
client has severe diarrhea that has lasted for two days nurse should assess for
arrhythmia
