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COMP 1 A Flashcards

1
Q

Which of the following clients scenarios would warrant IMMEDIATE follow up ?
A. a client who just received a promotion.
B. a client who has just retired, diagnosed with terminal cancer and depression and is the caregiver for his parents.
C. A client who has just been diagnosed with type 2 diabetes
D. A client that attends support groups following a stroke.

A

B. a client who has just retired, diagnosed with terminal cancer and is the caregiver for his parents.

SLIDE 1 SUCIDE IN THE ELDERLY RISK FACTORS

  1. Loss of spouse or close loved one
  2. Retirement
  3. Moving to an assisted living facility/losing independece
  4. Stress(possible caretaker stress)
  5. Depression
  6. White elderly males are 4x more likely to commit suicide
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2
Q

You are the nurse on a elderly mental health facility. Which of the following patient statements would require further intervention?
A. “I am going to give all of my things away”.
B. “I should avoid abusing alchohol or drugs when I am stressed.”
C. “I know my family will miss me and I will miss them when I am gone”.
D. “Although I am, old I still enjoy playing tennis.”

A

A. “I am going to give all of my things away”.

SLIDE 2 SUICIDE IN THE ELDERLY: WARNING SIGNS

1. Depressed mood (frequently crying more than usual
2. Making statements like, Just forget about me, I am no use anymore , You will be better off when i’m gone
3. Abusing prescription drugs or alcohol
4. No longer interested in things gthey once enjoyed
5.Giving away possessions

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3
Q

You are a nurse conducting a family intervention. Which of the following actions can the clients family can due to prevent suicide for elderly family members?
A. Leave the patient isolated
B. Taking the client out to do things they enjoy
C. Discouraging the client to establish new friendships and support groups
D. Encourage the client use utilize their lethal weapons daily.

A

B. Taking the client out to do things they enjoy

SLIDE 3 SUICIDE IN THE ELDERLY PREVENTION

  1. Spend quality time with your elderly loved one
  2. If concerned about an elderly relative speak to their physician immediately
  3. Take them out to do things they enjoy
  4. Encourahe them to join a community/support group
  5. Limit access to lethal weapons
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4
Q

You are nurse conducting a dietary survery for a client with cancer. Which diet would warrant that the client understands?
A. high fat, low protein foods, low carbs
B. fresh fruits, large meals and hot foods
C. High protein, high carbs, no fresh fruits , small meals
D. High proteinm low carbs, large meals, eat most calories at first

A

C. High protein, high carbs, no fresh fruits , small meals

SLIDE 4 - SPECIALIZED DIET : CHEMO PATIENT

High protein, high carbs, no fresh fruits , small meals, eat most calories at first

GRILLED CHICKEN BROCCOLI, OR SALMON

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5
Q

You are nurse conducting a dietary survery for a client with Gastroesphogeal Regurgitation Disease(GERD). Which diet would warrant that the client understands?
A. Low fat, high protein foods, no caffiene,no carbonation, no spicy, sit up 1 hour after eating
B. fresh fruits, large meals and hot foods
C. High protein, high carbs, spicy foods , small meals
D. High proteinm low carbs, large meals, lay down 30 minutes after eating

A

A. Low fat, high protein foods, no caffiene,no carbonation, sit up 1 hour after eating

SLIDE 4 - SPECIALIZED DIET : GERD PATIENT

Low fat, high protein foods, no caffiene,no carbonation, sit up 1 hour after eating, no chocolate , no citrus foods, small prequent meals, HOB ELEVATED WEDGE PILLOW

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6
Q

You are nurse conducting a dietary survery for a client with PEPTIC ULCER DISEASE. Which diet would warrant that the client understands?
A. increase alcohol intake, caffiene intake, high fats
B. I should eat 3-4 hours before bed
C. no alcohol, no fatty foods, no acidic foods , no caffiene
D. I should eat in 30 minutes if my deudenal ulcer is bleeding

A

SLIDE 4 - SPECIALIZED DIET : PUD PATIENT

  1. ACOID ALCHOLOL
  2. AVOID CAFFIENE
  3. NO FATTY FOODS
  4. DONT EAT 3-4 HOURS BEFORE BED
    5. NPO IF BLEEDING
  5. AVOID ACIDIC FOODS
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7
Q

You are nurse conducting a dietary survery for a client with Ulcerative Collitis. Which diet would warrant that the client understands?
A. high fat, low protein foods, low carbs
B. fresh fruits, large meals and hot foods
C. decrease fluid intake , high carbs, no fresh fruits , small meals
D. High protein, low residue , high calories , increase fluid intake.

A

D. High protein, low residue , high calories , increase fluid intake.

SLIDE 4 - SPECIALIZED DIET : ULCERATIVE COLLITIS PATIENT

  1. High protein,
  2. low residue ,
  3. high calories ,
  4. increase fluid intake.
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8
Q

You are nurse conducting a dietary survery for a client with Diverticulitus. Which diet would warrant that the client understands?
A. low fiber, clear liquids, antibiotics anticipated
B. fresh fruits, large meals and hot foods
C. high fiber, caffeine, no fresh fruits , small meals
D. High protein low carbs, large meals, eat most calories at first

A

A. low fiber, clear liquids, antibiotics anticipated

SLIDE 4 - SPECIALIZED DIET : DIVERTICULITIS PATIENT

A. low fiber, clear liquids, antibiotics anticipated

  1. low fiber,
  2. clear liquids,
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9
Q

You are nurse conducting a dietary survery for a client with diverticulosis. Which diet would warrant that the client understands?
A. high fiber, low protein foods, increase fluids, avoid nuts , seeds and kernels
B. fresh fruits, large meals and sunflower seeds
C. High protein, high carbs, no fresh fruits , small meals
D. High protein low carbs, large meals, eat most calories at first

A

A. high fiber, low protein foods, increase fluids, avoid nuts , seeds and kernels

SLIDE 4 - SPECIALIZED DIET : DIVERTICULOSIS PATIENT

  1. high fiber,
  2. low protein foods,
  3. increase fluids,
  4. avoid nuts , seeds and kernels
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10
Q

You are nurse conducting a dietary survery for a client with Chrons disease. Which diet would warrant that the client understands?
A. high fat, low protein foods, low carbs
B. fresh fruits, large meals and hot foods
C. High protein, high calorie, low fiber, avoid: dairy. ceffeien , raw fruits and veggies, and grains
D. High protein low carbs, large meals, eat most calories at first

A

High protein, high calorie, low fiber, avoid: dairy. ceffeien , raw fruits and veggies, and grains

SLIDE 4 - SPECIALIZED DIET : CHROHNS PATIENT

  1. High protein,
  2. high calorie,
  3. low fiber,
  4. avoid: dairy, caffeine, raw fruits and veggies, and grains
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11
Q

You are the nurse traing a new grad who is conducting care for a client with Bucks traction. Which action made by the new grad nurse will require immediate follow up?
A. The new grad nurse inspects the skin at least once per 8 hours
B. The new grad nurse states that she will not release the weights unless specifically ordered by the physciam
C. The new grad nurse states that the weights must hang freely.
D. The foot of the bed is kept elevated.
E. The new grad nurse states that she shoukd provide pin site care

A

E. The new grad nurse states that she shoukd provide pin site care

SLIDE 5 - BUCKS TRACTION

  • Often used to restore normal bone alignment and length. Reduces pressure on nerves, and reduces the risk of developing skeletal abnormalities.
    • Inspect the skin at least once Q8H
    • Never release the weights of traction unless specifically ordered by the physician.
    • The weights must hang freely.

Foot of the bed is kept elevated.

  • Care involves considerations of immobility (stool softener, DVT prophylaxis, respiratory and skin considerations, etc)
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12
Q

You are on a nephrology unit conducting care for a client with Glomerulonephrirtis. Which of the follwing is an expected finding? Select all that Apply
A. Polyuria
B. Oliguria
C. Generalized edema
D. Weight loss
E. Hematuria
F. Dyspnea
G. Orthopnea
H. Hypotension
I. Proteinuria
J. Hypernatremia
K. Headache

A

B. Oliguria
C. Generalized edema
E. Hematuria
F. Dyspnea
G. Orthopnea
I. Proteinuria
K. Headache
J. Hypernatremia
SLIDE 6 - Glomerulonephritis

Definition - Inflammation of the glomeruli of the nephron typically followed by a streptococcal infection.

    • Characteristics - decreased urination (oliguria),
  2. generalized edema,
  3. dusky/coffee-colored urine (hematuria),
  4. dyspnea and
  5. orthopnea,
  6. hypertension,
  7. Headache,
  8. LOW GFR BELOW 90
  9. HIGH BUN ABOVE 20,
  10. HIGH specific gravity ABOVE 1.030.
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13
Q

You are on a nephrology unit conducting care for a client with Glomerulonephrirtis. Which of the following diets should the patient be on?
A. Low sodium , low protein, high carbs, decrease fluid intake
B. High sodium, low residue
C. high protein , no caffeine, no spicy
D. do not rest 30 minutes after eating

A

A. Low sodium , low protein, high carbs, decrease fluid intake
SLIDE 6 - Glomerulonephritis
* * Diet and restrictions - Low sodium, low protein lots of carbohydrates. Fluid restriction, monitor intake and output.
* Interventions - Fix the cause (strep), daily weight, input and output. Monitor blood pressure.
* Medications - antibiotics (for primary infection), antihypertensives, diuretics.

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14
Q

You are on a nephrology unit conducting care for a client with Glomerulonephrirtis. What nursing intervention is expected?
A. Monitor blood pressure and daily weights
B. Increase intravenous fluids
C. Request a high sodium diet
D. Administer prescribed Desmopressin

A

A. Monitor blood pressure and daily weights
SLIDE 6 - Glomerulonephritis
* Interventions - Fix the cause (strep), daily weight, input and output. Monitor blood pressure.
* Medications - antibiotics (for primary infection), antihypertensives, diuretics.

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15
Q

You are on a nephrology unit conducting care for a client with Glomerulonephrirtis. Which of the follwing medications would you anticipate to be prescribed?
A. Acyclovir
B. Streptomycin
C. Epinephrine
D. Naloxone

A

SLIDE 6 - Glomerulonephritis
B. Streptomycin
* Medications - antibiotics (for primary infection), antihypertensives, diuretics.

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16
Q

What type of precaution should a client with Disessimated herpes zoster be placed?
A. Airborne
B. Contact
C. Droplet
D. Standard

A

A. Airborne

Herpes Zoster, aka shingles, the same virus that causes varicella (chickenpox). Primary infection with VZV causes varicella. Once the illness resolves, the virus remains latent in the dorsal root ganglia
SLIDE 7 HERPES ZOSTER
Disseminated Herpes zoster requires airborne precautions until lesions have crusted over.

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17
Q

rA nurse is a assessing a clientws skin who has suspected herpes zoster. What finding would indicate the client has herpes zoster?
A. curved redenned linear ridges
B. Painful itchy blisters
C. dry inflammed scales on skin
D. irregular brown border

A

B. Painful itchy blisters

Herpes Zoster, aka shingles, the same virus that causes varicella (chickenpox). Primary infection with VZV causes varicella. Once the illness resolves, the virus remains latent in the dorsal root ganglia
SLIDE 7 HERPES ZOSTER

B. Painful itchy blisters

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18
Q

What medication would you anticipate for the provider to prescribe for a client with Herpes Zoster?
A. Valcyclovir
B. Furosemide
C. Bactroban
D. Metoprorlol

A

A. Valcyclovir

Herpes Zoster, aka shingles, the same virus that causes varicella (chickenpox). Primary infection with VZV causes varicella. Once the illness resolves, the virus remains latent in the dorsal root ganglia
SLIDE 7 HERPES ZOSTER

Treated with Valcyclovir (Valtrex).

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19
Q

What is Desmopressin used for? SELECT ALL THAT APPLY

A. Increases urination
B.prevents bedwetting
C.increases factor 8 for hemophilia
D.decreases blood pressure
E. Increases capillary refill
F. Increases availble fluid volume

A

B.prevents bedwetting
C.increases factor 8 for hemophilia
E. Increases capillary refill
F. Increases availble fluid volume

SLIDE 8- DESMOPRESSIN

Uses:
1. DI, decreases urination
2. Enuresis- prevent bed wetting
3. Hemophilia- increases factor 8

Therapeutic affect
- increase blodd pressure
- decreases urination

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20
Q

What are the s/s for fractures?
A. absent of pain
B. swelling
C. tenderness
D. Nausea
E. Decreased range of motion
F. Bruising
G. Discoloration
H. Deformitity or bump that’s not usually on your body

A

B. swelling
C. tenderness
E. Decreased range of motion
F. Bruising
G. Discoloration
H. Deformitity or bumo that’s not usually on your body

SLIDE 9 FRACTURES
1. Pain
2. Swelling
3. Tenderness
4. Decrease rom
5. brusiing
6. discoloration
7. deformity

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21
Q

Which of the following is a complication of compartment syndrome
A. deep burning ache
B. Stridor
C. Fever
D. Nasusua

A

A. deep burning ache
SLIDE 9 FRACTURES

  1. Burning pain/deep ache
  2. Swelling/bulging muscle
  3. Numbeness
  4. Weakness
    5. Extreme pain with movement
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22
Q

A nurse is comnducting a research project about skeletal traction. Which of the following statements are true about skeletal traction?
A. skeletal traction is more powerful and has greater fragment control than skin traction.
B. you should not initiate pinsite care.
C. Skeletal traction is permanent
D. bucks traction is a type of skeletal traction

A

A. skeletal traction is more powerful and has greater fragment control than skin traction.
SLIDE 9 FRACTURES and TRACTION
1. Bucks traction: realign broken bones, correct contractures, and for knee immobilization
2. Bucks extension applied to the distal end of a fractured lower limp

  1. Skeletal traction: skeletal traction is more powerful and has greater fragment control than skin traction.
  2. It permits pull up to 15% to 20% of body weight for the lower extremity
  3. Skeletal traction is temporary
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23
Q

What are the 5 P’s a nurse mst assess for for a patient with fractures

A

SLIDE 9 FRACTURES and TRACTION

  1. Pain
  2. Pallor
  3. Pulse
  4. Paresthesia
  5. Paralysis
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24
Q

Your client has been admited to the emrgency department with a closed tibial fracture. What is teh nurses next action? Select all that apply
A. Lower the afftefcted limb
B. Elevate the affected limb 2-3 hours a day
C. ICE the fracture for 24- 48 hours 10-20 min per day
D.Increase range of motion in the affected limb
E. Immobilze the affected limb with a cast or sling
F. Administer pain medication

A

SLIDE 9 FRACTURES and TRACTION

  1. B. Elevate the affected limb 2-3 hours a day
  2. C. ICE the fracture for 24- 48 hours 10-20 min per day
  3. E. Immobilze the affected limb with a cast or sling
  4. F. Administer pain medication

RICE

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25
Your client has overdosed on diazepam is admitted to the emergency room. What statement is true regarding power of attorney? A. the power of attorney is able to make choices for the patient if they are not alert and oriented B. The power of attorney can make choices for the client if they are alert and oriented C. The power of attorney should not be informed of all the options of treatment D. The client cannot pass on authority over health decisions to the power of attorney if they are not alert and oriented.
A. the power of attorney is able to make choices for the patient if they are not alert and oriented **SLIDE 10:PATIENT RIGHTS AROUND TX** **treatment choice** Treatment Choice * Give all options around treatment * Pt is of sound mind to make a choice. * If pt is not of sound mind pt's
POA can make the choice. **treatment refusal** Treatment Refusal * All options are given * Pt is of sound mind and able to make a decision * Pt has the right to refuse treatment provided even after they have signed the consent form.
26
What is the antidote for magnesium? What is the normal range?
**SLIDE 11- MAGNESIUM** Calcium gluconate Magnesium normal range- 1.5-2.5
27
Which of the following conditions is magnesium used to treat? A. Narcotic overdose B. Eclampsia C. Diarrhea D. Hypermagnesium
**SLIDE 11- MAGNESIUM** B. Eclampsia used to treat 1. mg electrolyte abnormalities 2. eclampsia 3. constipation
28
EKG CHANGES DURING HYPERMAGNESIUM
**SLIDE 11- MAGNESIUM** -PROLONGED PR INTERVAL -INCREASED QT INTERVAL -INCREASE IN QRS DURATION -**HEART BLOCK**
29
EKG CHANGES DURING HYPOMAGNESIUM
**SLIDE 11- MAGNESIUM** P-R widening of the interval prolongation an increase interval, widening of the QRS in the Q-T interval or an increase in complex, and peaking of the T Waves -Torsades de pointes. block.
30
s/s of hypermagnesium
1. **SLIDE 11- MAGNESIUM** Cause: Renal failure, over-correction of hypomagnesemia 1. weakness, 2. decreased respiratory drive 3. muscle spams, 4.hyporeflexia, 5. **hypotension,** TX * Loop diuretics * **Dialysis** * Calcium Gluconate *
31
s/s of hypomagnesmia
Cause: Alcoholism, hypocalcemia, 1. muscle spasms 2. hypereflexia 3. diahrea TX: * Monitor cardia rhythym * administer Mag PO * **Administration of Mag IV needs to be given very slowly**
32
Which of the following statements are false regarding incident reports? A. Incident repots should be documented in the patients chart B. Medical errors would need documentation as an incident report C. Adverse reactions to medications need documentation as an incident report D. Lost or stolen items need documentation as an incident report E. Falls or injuries including the client and visitor need documentation as an incident report
A. Incident repots should be documented in the patients chart **SLIDE 12 incident reports** 1. **INCIDENT REPORTS DO NOT CO IN PT CHARTS** INCIDETNT. WILL BE COMPLETED FOR THE FOLLOWING * MED ERRORS * ADV REACTIONS * FALLS/INJURIES * LOST/STOLEN ITEMS
33
You are nurse on the PACU. What is the first thing you should do when a patient is getting admitted? A. Confirm the clients identity with the ID band B. Obtain baseline vitals C. Assess the clients skin color D. Assess for signs of lethargy
A. Confirm the clients identity with the ID band **SLIDE 13 PACU NURSING INTERVENTION POST OP** **1. Identify the patient WITH ID BAND** 2. Assessment of the surgical site and drainage tubes during handoff report 3. **Check vital signs** 4. Monitor the rate and patency of IV fluids and IV access 5. Assessing the patients level of sedation, skin color and tugor , and circulation in extremities 6. Treat pain, nausea, and other post-operative symptoms of anesthesia and administer medication as prescribed 7. Assess mental status and body temperature 8. Monitor and recognize evidence of fluid and electrolyte imbalances 9. Monitor intake and output closely including wound drainage 10. Recognize signs of fluid imbalances 11. Perform hand washing before and after contact with the patient 12. Turn the patient to sides every 1 to 2 hours 13. Maintain the patient's good body alignment
34
Which of the following statements are the benefits of physical therapy for a stroke patient? A. Physical therapy assist with fine motor skillls and ADL'S B. Physical therapy provides teachings on assistive devices such as canes walkers , and crutches C. Physical therapy assist with bathing, eating , and dressing D. Physical therapy assist with regaing psychosocial confidence
B. Physical therapy provides teachings on assistive devices such as canes walkers , and crutches **SLIDE 14 PT AND OT THERAPY** 1. Focuses on regaining mobility 2. Helps to regain movement and function after illness/injury 3. Reduces pain and improves joint function 4. Tx tgrough exccercise ,massage , gait, and balance training
35
Which of the following statements are the benefits of occupational therapy for a stroke patient? A. Occupation therapy provides teachings on assitive devices B. Occupational therapy focuses on regaing mobility in lower extremities C. Occupational therapy assist with bathing, eating , and dressing D. Occupational therapy assist with excercise, massages, gait, and balance training
C. Occupational therapy assist with bathing, eating , and dressing **SLIDE 14 PT AND OT THERAPY** 1. **Focus is on life activities, fine motor skills, ADL'S** 2. Bathing 3. Dressing 4. Eating 5. Use of assitive devices improve these aspects of diling 6. Use of normal adaptive equipment to injury or restrictions
36
What is the proper way to use a cane
weak leg with cane then strong leg -put cane on strong side ## Footnote 1. Stand at the affected side of the client when am- bulating; use of a gait or transfer belt may be necessary. 2. The handle should be at the level of the client’s greater trochanter. 3. The client’s elbow should be flexed at a 15- to 30-degree angle. 4. Instruct the client to hold the cane 4 to 6 inches (10 to 15 cm) to the side of the foot. 5. Instruct the client to hold the cane in the hand on the unaffected side so that the cane and weaker leg can work together with each step. 6. Instruct the client to move the cane at the same time as the affected leg.
37
What is the proper way to use a walker
1. Stand adjacent to the client on the affected side. 2. Instruct the client to put all four points of the walker flat on the floor before putting weight on the hand pieces. 3. Instruct the client to move the walker forward, followed by the weaker foot and then the good foot.
38
What is the proper way to go up the stairs with crutches
1. Up the stairs a. The client moves the unaffected leg up first. b. The client moves the affected leg and the crutches up. ## Footnote The distance between the axillae and the arm pieces on the crutches should be 2 to 3 finger widths in the axilla space. 3. The elbows should be slightly flexed, 20 to 30 degrees, when the client is walking.
39
What is the proper way to do down the stairs with crutches
Down the stairs a. The client moves the crutches and the affected leg down. b. The client moves the unaffected leg down. ## Footnote The distance between the axillae and the arm pieces on the crutches should be 2 to 3 finger widths in the axilla space. 3. The elbows should be slightly flexed, 20 to 30 degrees, when the client is walking.
40
Which of the following statements are false about drawing peak and trough level? A. You must monitor for otottoxicity and nephrotxiticity if a client is on gentamycin or vancomycin B. peak levels should be drawn 4 hours after administration C. monitor for hearing loss and low urine output D. Through levels are taken right before administration of the next dose of the medication
B. peak levels should be drawn 4 hours after administration **SLIDE 15 PEAK AND THROUGH** **1. Monitor for hearing loss and low urine output** **2. Peak levels are drawn 30 minutes after med administration** 3. Helps monitor for antibiotic toxixcity 4. For gentamicin/ vancomycin a peak and trough will need to be prescribed due to ototoxicity and nephrotoxicity. ## Footnote S/E OF VANCOMYCIN GI DISTRESS, DIZZY , DROWSY, THROMOPHLEBITIS ADV EFFECTS OF VANCOMYCIN; NEPHROTOXIXTY, STEVEN JOHNSIN SYNDROME, OTOTOXICITY(permenat hearing loss)
41
What are contraindications for Broncosopy?
**SLIDE 16 BROCHOSCOPY** 1. HISORY OR RECENT mi 2. Unstable Angina 3. Head trauma 4. Prone to ICP ex, Meningitis, ## Footnote used to look directly in airway, navigation: throat trachea and into the airway
42
Which of the followiing should the nurse report for the provider after the client recieved a Bronchoscopy? A. Increased hemoptysis B. sore throat C. Respiration rate from 18 to 15 D. O2 saturation 94
A. Increased hemoptysis **SLIDE 16 BROCHOSCOPY** COMPLICATION **1. Bleeding(monitor for hemotysis** 2. fever 3. Hypoxemia 4. Laryngospasm 5. Pneumothorax 6. Chest tighntness ## Footnote PRE PROCEDURE ACTIONS 1. Maintain NPO (nothing by mouth) status as prescribed. 2. Assess the results of coagulation studies. 3. Remove dentures and eyeglasses. 4. Instruct the client to perform good mouth care to prevent bacteria from entering into the lungs from the oropharynx. 5. Establish an intravenous (IV) access as neces- sary, and administer medication for sedation as prescribed. A local anesthetic spray may be used; instruct the client not to swallow the spray and to expectorate any excess into a ba- sin. 6. Have emergency resuscitation supplies read- ily available. POST PROCEDURE ACTIONS 1.
43
According to the CDC, when should the MMR vaccine be given to children? A. at birth B, 12 months and at 4-6 years old C. 4 months D. 6 months
B. 12 months and at 4-6 years old **SLIDE 17 VACCINE AND TITERS** Titers comes back positive -there is still immunity if titer is negative there is no immunity **will need vaccine**
44
Your pregnany client does not know if she has immunity to rubella. After birth a titer is performed and it comes back negative. What is the best nursing action? A. Administer the Rubella vaccine after the delivery of her planned second pregnancy. B. Administer the prescribed rubella vaccine today with her consent. C. Teach the client that the Rubella vaccine can only be given while pregnant. D. The patient has immunity to Rubella.
B. Administer the prescribed rubella vaccine today with her consent. Titers comes back positive -there is still immunity if titer is negative there is no immunity **will need vaccine** **SLIDE 17 VACCINE AND TITERS** TYPE OF TITERS 1. measles mumps and rubella 2. Tuberculosis 3. Varicella 4. Hep B 5. Dtap
45
What would be an example of a client developing active immunity? A. a client who is being given immunoglobulin B. a client who has been infected with flu C. a new born baby who recieves antibodies from mom D. A client taking plasmapharesis
B. a client who has been infected with flu **SLIDE 17 VACCINE AND TITERS** Active immmunity -protection produced by own immunity from exposure to foreign microbes **PERMANENT** ARTIFICAL 1. Vaccines Natural 2. getting an infection Passive Immunity- Protection given via injections or from antibodies from another person or animal **SHORT TERM**
46
What would be an example of Passive Immunity A. A person recieving the flu vaccine B. a client who has been infected with flu C. a new born baby who recieves antibodies from mom D. A client who was exposed to carbon dioxide
C. a new born baby who recieves antibodies from mom Active immmunity -protection produced by own immunity from exposure to foreign microbes **PERMANENT** Passive Immunity- Protection given via injections or from antibodies from another person or animal **SHORT TERM** ARTIFICAL 1. Monoclonal antibodies ex, immunoglobulin, Natural 2. Maternal Antibodies ## Footnote They all have names that include 'mab' at the end of their generic name. For example, trastuzumab (Herceptin) and rituximab (Mabthera). Some MABS help the immune system to attack and kill cancer cells. These MABs are also a type of immunotherapy.
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You suspect that your client may have Tuberculosis. What plan of care is anticipation? Select all that apply. A. monitor blood pressure B. precribed x-ray C. administration of furosemide D. diagnostic sputum sample E. droplet precaution F. Airborne isolation precaution G. Negative pressure room
B. precribed x-ray D. diagnostic sputum sample F. Airborne isolation precaution G. Negative pressure room **SLIDE 17 VACCINE AND TITERS** ## Footnote + RESULT MEANS YOU HAVE THE VACCINE OR YOU ARE INFECTED WITH TB + 5 INDURATION IF IMMUNOSUPRESSED + 10 INDURATION IF NORMAL
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Which of the following are risk factors for Colorectal Cancer?SELECT ALL THAT APPLY A. Lung cancer B. Age older than 50 y/o C. Family history of Colorectal Cancer D. Previous Colorectal polyps E. History of Chrons disease F. History of Ulverative Collitis G. Ventricular Septal Defect H. Women I. Diet high in fiber
B. Age older than 50 y/o C. Family history of Colorectal Cancer D. **Previous Colorectal polyps** E.**History of Chrons disease** F. History of Ulverative Collitis **SLIDE 18 COLORECTOL CANCER** B. Age older than 50 y/o C. Family history of Colorectal Cancer D. Previous Colorectal polyps E. History of Chrons disease F. History of Ulverative Collitis G. History of ovarian or breast, endometrial and stomach cancers
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What are the signs and symptoms of a Coloretal Cancer? SELECT ALL THAT APPLY A. changes in bowel habits B. anorexia C. polyphagia D. weight gain E. changes in bladder habit F. nasua and vomitting G. elevated WBC H. Elevated Liver enzymes I. Loss of blood from GI
A. changes in bowel habits B. anorexia C. weightloss E. changes in bladder habit F. naseua and vomitting G. **elevated WBC** I. Loss of blood from GI **SLIDE 19 - EXPECTED FINDINGS OF COLORECTAL CANCER**
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You are caring for a client with Colorectal Cancer. What complication should you report to the primary care provider? SELECT ALL THAT APPLY A. weightloss of 10 wounds in a month B. Constant vomitting C. Tachycardia on telemonitor and hypotension D.Weakness E. Boardlike rigid abdomen
C. Tachycardia on telemonitor and hypotension E. Boardlike rigid abdomen **SLIDE 20 COMPLICATIONS OF COLORECTAL CANCER** * bowel perforation with **peritonitis** * Ancess or fistula formation * **Hemorhage** * Fluid and electrolyte imbalce due to nausea and vomitting DX 1. Masses noted on barium enema 2. colonoscopy 3. CT Scan 4. Sigmoidoscopy
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Nursing Interventions for Colorectal cancer?
**SLIDE 21 NURSING INTERVENTIONS COLORECTAL CANCER** 1. Monitor for s/s of bowel perforation, fever and pain 2. **Hemorrhagic shock (low bp, tachycardia, hypovolemia, oliguria)** 3. Monitor for intestinal obstructiion like severe vomitting with fecal content 4. PateNT airway** PRIORITY PATIENT FOR SEVERE VOMITTING RISK FOR ASPIRATION** 5. **KEEP PATIENT NPO** 6. **IV HYDRATE CLIENT WITH NS** **NOTIFY DOC IF ANY OF THESE OCCURS**
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What is HIPAA
**SLIDE 22 LEGAL ISSUES- HIPAA** A federal law required of national standard to protect sensitive patient health information **(PHI)** from being disclosed without the patients consent or knowledge
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Can patients have access to copies of their personal records upon request? A, yes B, no
A, yes **SLIDE 22 LEGAL ISSUES- HIPAA** -patients health info is only to be accesed by authrized parties **Nurses and other hcw msut be very careful to keep info about patient confidential only share info with hcw who need info to plan or give proper care to the patient**
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Which of the following patient conditions would need nitroglycerin administered? A. a client with hypotension B. a client with pulmonary hypertension C. a client reporting angina D. a client with raynauds disesease
C. a client reporting angina **SLIDE 23 NItro** USES 2. 1. ANGINA 2. CAD Mechanism of action : vasodilator decreases BP. decreases workload and oxygen consumption
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Which of the following are common side effects of nitroglycerin? Select all that apply A. hypertension B. oliguria C.Headache D. dizziness E. Nause and vomitting F. flushed skin
C.Headache C.Headache D. dizziness E. Nause and vomitting F. flushed skin Hypotension **SLIDE 23 NItro**
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Which of the following are adverse effects of nitroglycerin? Select all that apply A. tachycardia B. oliguria C.orthostaic hypotension D. dizziness E. Nause and vomitting
A. tachycardia C.orthostaic hypotension **SLIDE 23 NITRO**
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Patient teaching for Nitroglycerin
**LIGHT RETRAINT CONTAINER-IN THE DARK** * Patient Teaching: * Take at the onset of chest pain not relieved by rest * **One tablet under the tongue, takes 1-3 min. to take effect** If angina does not stop in 5 min call 911 and take another dose. **No more that 3 doses in 15 min** * Keep in dark bottle in a cool dry place.r * **Throw out medication after 3 months no longer effective** * Change positions slowly can cause dizziness. * May tingle/burn under the tongue * Make sure family knows where med is and always carry it with you.
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S/S OF SEPTIC SHOCK AND TX
1. FLUSHED PINK SKIN 2. TACHYPNEA 3. BOUNDING PULSE 4. CYANOSIS 5. PALE SKIN 6. SHALLOW RAPID RESPIRATIONS 7. WEAK RAPID AND THREADY PULSE 8. HYPOTENSION TX: **IV FLUIDS**, ANTIBIOTICS, OXYGEN, **VASOPRESSORS**, MECHANICAL VENTILATOR **SLIDE 24 SHOCKS**
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S/S OF NEUROGENIC SHOCK AND TX
1. WARM FLUSHED SKIN 2. PALE SKIN 3. BRADYCARDIA 4. HYPOTENSION 5. BOUNDING PULSE TX : O2 , FLUIDS VASOPRESSOR **SLIDE 24 SHOCKS**
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S/S OF HYPOVOLEMIA SHOCK AND TX
1. SHALLOW RAPID RESP 2. COOL CLAMMY SKIN 3. PALE SKIN 4. THREADY RAPID PULSE 5. HYPOTENSION 6. OLIGURIA 7. MAP BELOW 60 TX; FLUID, BLOOD TRANSFUSION, LYING FLAT, VASOPRESSORS, O2 **SLIDE 24 SHOCKS**
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S/S OF CARDIOGENIC SHOCK AND TX
1. COOL,CLAMMY SKIN 2. THREADY RAPID PULSE 3. SHALLOW RESP 4. HYPOTENSION 5. GALLOP RHYTHM 6. FAINT HEART SOUNDS 7. MAP BELOW 60 TX; DOBUTAMINE , DIGOXIN, VASOPRESSORS NO FLUIDS, ANTIARRHYTHMICS **SLIDE 24 SHOCKS**
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Which of the following statements are true about TPN? a. you should change tpn tubing D48 hours b. When the dressing is soiled wait 24 hours to change it c. Hang 0.9 NS when the TPN runs out d. tpn should be administered in a line by itself through a central line
d. tpn should be administered in a line by itself through a central line **SLIDE 25-TPN** **TPNS CAN BE GIVEN** * PICC LINE * CENTRAL LINE * FULLY IMPLANTED CATHETER * EXTERNAL TUNNELED CATHETER What patienys require TPN 1. GI BLEED 2. IBS 3. RECEIVING CHEMOTHERAPY 4. SMALL OR LARGE BOWEL OBSTRUCTIONS
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Which of the following statements **requires follow up** regarding TPN? A. strict aseptic technique when changing IV tubing, dressing and TPN solution. B. Change TPN dressing when soiled. C. blood sugar checks every 2-4 hours. D. is verified by one nurse prior to administration.
D. is verified by one nurse prior to administration. **Slide 26 -TPN** **-hang d10 or d20 to prevemt hypoglycemia**
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NURSING INTERVENTIONS FOR TPN
**Slide 26 -TPN** 1. Monitor for s/s of fluid overload 2. Monitor renal staus **3. Acchucheck Q2-4HRS** 4. Monitor increased temp or signs of infection **5. Strict aseptic technique when changing IV tubing, dressings, and TPN solution.** **6. Requires 2 nurses to check the bag against the orders and sign off in MAR** 7. TPN HANGS FOR EVERY 24 HOURS 8. CHANGE TPN TUBING , BAG , AND SOLUTION EVERY 24 HOURS
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You are nurse working a medical surgical unit. You realized you administered the wrong medication to the wrong patient. What is the nurses priority action? A. Notify the phycisian B. Complete an incident report C. Assess for any adverse effects to the patient D. Call a rapid response
C. Assess for any adverse effects to the patient **SLIDE 27 MEDICATION ERRRORS** INTERVENTIONS 1. Patient first!!! Assess s/s of adverse reactions 2. Notify PCP and immediate supervisor 3. Complete an incident report
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Which of the following statments are false regarding baclofen? A, you should avoid direct sunlight on this medication B. Side effects include diahreha C. You should increase fiber with this medication. D. This medication is a CNS depressant and should not be taken with Benadryl
B. Side effects include diahreha **SLIDE 28-MULTIPLE SCLEROSIS BACLOFEN** s/e 1. constipation 2. hypotension 3. dizziness 4. drowsiness 5. nausea Patient Teaching -increase fiber on this med due to constipation -dont take with bendaryl -Take 30 mins before meals -Avoid direct sunlight on this med ## Footnote BACLOFEN IS A MUSCLE RELAXER
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You are the nurse assigned to a client with multiple sclerosis. Which of the following statements made by the patient requires further teaching? A. I should walk with my feet wide apart. B. I should avoid extreme heat. C. When I am sick I should use over the counter medication. D. I should take frequent rest periods when excercising
C. When I am sick I should use over the counter medication. **SLIDE 28-MULTIPLE SCLEROSIS PT TEACHING** **Teaching** 1. Teach to avoid otc medication due to complications 2. Engery conservation techniques' 3. avoid extreme temperatures and humidity 4. avoid overexertion 5. avoid people with infection 6. no vigorous exercise 7. Walk with feet wide apart **NEED INTERDISCIPLINARY CARE**
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What are the s/s of MS
**SLIDE 29 S/S OF MS** 1. Fatigue 2. weakness 3. Numbness 4. Visual disturbances 5. incontinence 6. gait disturbances , ATAXIA 7. clumsy 8.PAIN 9.LOSS OF BALANCE 10.DYSPHAGIA 11.TREMORS WITTH MOVEMENT
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Which of the following signs and symptoms should the nurse report to the provider for a client diagnosed with Multiple sclerosis? SELECT ALL THAT APPLY A. Fatigue B. Bladder spacisity C. Increased pain D. Tremors with movement E. Dysphagia F. Diplopia
C. Increased pain E. Dysphagia **SLIDE 29 COMPLICATIONS OF MS** CALL MD FOR **DYSPHAGIA:NEED SPEECH EVAL AND NPO** UNCONTROLLED PAIN
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Which of the following is a suspected sympton of parkinsons disease? A. Akathasia B. Tardive Dyskenia C. Dystonia D. Dandruff greasy scalp and forehead
D. Dandruff greasy scalp and forehead **SLIDE 30 PARKINSONS DISEASE** **1. Tremors at rest** **2. Bradykinesia or slow movement** **3. Muscle stiffness or rigidity** 4. Muscle aches and pains 5. Shuffling gait (disturbance of balance and coordination) **6. Depression** 7. Anhedonia 8. fear and anxiety **9. drooling** 10. speech changes 11. cramped hand writing 12. insomia (sleeping problem) 13. urinary problems and constipation **14. dandruff and greasy scalp and forehead** **15. dysphagia** **OCCUPATIONAL THERAPY CAN HELP WITH ADL, BATHING, FINE MOTOR SKILLS**
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What 4 out of 5 scenarios would an Interdisplnary team be needed. A. a client with hip dysplasia B. A client with Multiple sclerosis C. A client with Parkinsons D. A first time mom who is addicted to narcotics E a patient with depression
**SLIDE 31 INTERDISCIPLINARY CARE** A. a client with hip dysplasia B. A client with Multiple sclerosis C. A client with Parkinsons D. A first time mom who is addicted to narcotics
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You are a Sexual Assult Nurse in the Emergency Department. A client has just been admitted due to being assulted sexually after a night out with friends. What would be the **most**correct response by the nurse? A." I will stay with you" B. "Let me go find help" C. "Tell me more about what led to you being assulted" D. "Everything will be fine"
A." I will stay with you" **SLIDE 32 -THERAPEUTIC COMMUNICATION** *** Offering Self- example ("| will stay with you")** * Using Empathy * Closed vs Open Ended Questions * Use of Silence * Clarification * Reflection/ Repeating- example **("What do you think?", "I can see you are having a hard time" "What are your concerns?")** * Paraphrasing * Summarizing * Using unfinished statements * Giving Information * Stating Implied thoughts and feelings *** Exploring - example - ("Tell me more!")**
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What does the Kubler ross stages of grief consist of?
**SLIDE 33 KUBLER ROSS:STAGES OF GRIEF** 1. Denial 2. Anger 3. Bargainaing 4. Depression 5. Acceptance
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Which of the following statements is an example of Denial according to the Kubler Ross? A. “No, it can't be me!” B. “Why me? This is not fair.” C. “I will do anything to have him back D. “Somehow this is going to be okay.” *
A. “No, it can't be me!” **SLIDE 33 KUBLER ROSS:STAGES OF GRIEF** Denial: the client has difficulty believing in an expected or actual loss/terminal * Anger: client directs anger toward the self, others, a deity, objects the current circumstances * Bargaining: The client negotiates for more time or cure. * Depression: The client is overwhelmingly saddened by the inability change the situation * Acceptance: The client acknowledges
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Which of the following statements is an example of Anger according to the Kubler Ross? A. “No, it can't be me!” B. “Why me? This is not fair.” C. “I will do anything to have him back D. “Somehow this is going to be okay.”
B. “Why me? This is not fair.” Denial: the client has difficulty believing in an expected or actual loss/terminal * Anger: client directs anger toward the self, others, a deity, objects the current circumstances * Bargaining: The client negotiates for more time or cure. * Depression: The client is overwhelmingly saddened by the inability change the situation * Acceptance: The client acknowledges
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Which of the following statements is an example of Bargaining according to the Kubler Ross? A. “No, it can't be me!” B. “Why me? This is not fair.” C. “I will do anything to have him back D. “Somehow this is going to be okay.”
C. “I will do anything to have him back Denial: the client has difficulty believing in an expected or actual loss/terminal * Anger: client directs anger toward the self, others, a deity, objects the current circumstances * **Bargaining: The client negotiates for more time or cure.** * Depression: The client is overwhelmingly saddened by the inability change the situation * Acceptance: The client acknowledges
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Which of the following statements is an example of Depression according to the Kubler Ross A. “No, it can't be me!” B. “I've been crying more than usual, i dont think life is worth living.” C. “I will do anything to have him back D. “Somehow this is going to be okay.”
B. “I've been crying more than usual, i dont think life is worth living.” Denial: the client has difficulty believing in an expected or actual loss/terminal * Anger: client directs anger toward the self, others, a deity, objects the current circumstances * Bargaining: The client negotiates for more time or cure. * Depression: The client is overwhelmingly saddened by the inability change the situation * Acceptance: The client acknowledges
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Which of the following statements is an example of Acceptance according to the Kubler Ross A. “No, it can't be me!” B. “I've been crying more than usual, i dont think life is worth living.” C. “I will do anything to have him back D. “Somehow this is going to be okay.”
D. “Somehow this is going to be okay.” Denial: the client has difficulty believing in an expected or actual loss/terminal * Anger: client directs anger toward the self, others, a deity, objects the current circumstances * Bargaining: The client negotiates for more time or cure. * Depression: The client is overwhelmingly saddened by the inability change the situation * Acceptance: The client acknowledges
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WHICH OF THE FOLLOWING PATIENTS ARE AT HIGH RISK FOR SUICIDES?SELECT ALL THAT APPLY A. a 15 year old girl who has just been broken up with B. a first time mom after gvivng birth C. A white elderly man who just loss his spouse D. I client who insist on givivng away all of his personal items
A. a 15 year old girl who has just been broken up with C. A white elderly man who just loss his spouse D. I client who insist on givivng away all of his personal items **SLIDE 34- SUICIDAL IDEATIONS** (Preoccupation with suicidal thoughts , contemplation, wishes) -recent break up -loss of partner -Givivng away personal items
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should a patient who has tuberculosis be a shared room? A. yes B. No
**SLIDE 35 ISOLATION PRECAUTIONS** B. No
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Your client id admitted with Ventricular Tachycardia with pulse. What is the nurses best action? A. Administer amiodarone B. Administer high quality CPR C. continue to monitor and document D. Aminister Heparin
A. Administer amiodarone **SLIDE 36- VTACH** Interventions 1. Amiodarone 2. External defibrillator (WITH SYMPTOMS) 3. Implanatable Cardioverter (NO SYMPTOMS V GETS THE D
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Causes of Metabolic alkolosis
-vomitting -dehydration -antacids -NG TUBE IUSE -BLOOD TRANSFUSIONS
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Your new born client has just been delivred from a mother who has used ellict drugs throughout her pregnancy. What action would be appropriate for the Health care provider to initiate? A. Interdiciplinary meeting B. Dietary Consult C. Intervention with close family members D. Psychotherapy
A. Interdiciplinary meeting **SLIDE 37 Neonatal Abstienece Syndrome** -occurs in babaies who are exposed to drugs in the womb **MOM NEEDS INTERDISCPLINARY CARE**
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Your new born client has just been delivred from a mother who has used ellict drugs throughout her pregnancy. What finding would warrant immediate intervention? A. Hydrocephalus B. Mangolian spots C.Acrocyanosis D.High piched cry
D.High piched cry **SLIDE 37 Neonatal Abstienece Syndrome** 1. Tremors 2. Seizure 3. Overactive reflexes 4. Tight muscle tone 5. Fussiness 6. poor feeding and sucking 7. breathing problems 8. tachypnea 9. fever 10. sweating 11. diarrhea 12. throwing up
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Your new born client has just been diagnosed with neonatal abstinence syndrome. What nursing intervention is anticipated? A. swaddling baby B. cool mist air C. prepare for intubation D. antibiotic administration
**SLIDE 37 Neonatal Abstienece Syndrome** A. swadaling baby 1. Monitor respiratory status 2. Monitor Cardiac Status 3. Hold firmly and closely during feeding and care 4. seizure precautions 5. small frquent feeds allow extra time 6. monitor intake and output 7. Swaddle and decrease stimulation 8. **A team approach to the care of the mother is needed**
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What plan of care is expected for a client with a fracture? Select all that apply A. Ice fracture for 24-48 hours B. Administer pain medication C. Immobolize fracture with sling or cast D. Elevate affected limb E. Monitor for skin redness for swelling
**A. Ice fracture for 24-48 hours** B. Administer pain medication C. Immobolize fracture with sling or cast D. Elevate affected limb E. Monitor for skin redness for swelling **SLIDE 38 CARE OF BROKEN ARM** -neurochecks for decreased sensation and numbness
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What plan of care is expected for a client with a fiberglass cast? Select all that apply A. keep cast dry B.. cover cast when showering C. Stick items in cast D. Do not use lotions or oils near cast E. Limit mobility of fingers F. notify physician if you feel a hot spot or smell an odor G Increase activity like playing catch with affected arms
A. keep cast dry B.. cover cast when showering D. Do not use lotions or oils near cast **F. notify physician if you feel a hot spot or smell an odor** **SLIDE 38 CARE OF FIBERGLASS CAST** -do not stick items in cast -permon finger winggling consistently limit actity and mobility of affected arm
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You suspect your client to have hip dysplasia in the right leg. What clinical finding would you expect to assess? SELECT ALL THAT APPLY A. a fold in the right leg B. Nausea C. Pain in hip D. popping/ snapping sensation E. Hyperreflexia F. Limp when walking G. The left leg is longer than the right leg
A. a fold in the right leg **D. popping/ snapping sensation** F. Limp when walking G. The left leg is longer than the right leg **SLIDE 39- HIP DYSPLASIA** -limited rom in affected leg
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Does a client with hip dysplasia require interdisciplinary care? A. yes B. No
A. yes **SLIDE 39- HIP DYSPLASIA**
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What is the tx for hip dyplasia
**pavlick harness and spica cast are recommede for younger children** -surgery intervention is last resort and only after 6 months of age **SLIDE 39- HIP DYSPLASIA**
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Which of the following is a complication of Streptococcal Infection. a. Abcess around tonsills or in neck b. polyuria c. janeway lesions d. temperature of 95.0F
a. Abcess around tonsills or in neck **SLIDE 40- Complications of Streptococcal Infections** 1. Abcess around tonsills or in neck 2. Swollen lympnodes 3. Rheumatic fever 4. Sinus infection 5. Glomerulophrirtis 6. Ear infections 7. Akute Kidney Injury secondary to Glomerulophrirtis
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Which of the following is a sign and symptom of Glomerulophrirtis? A. Kussmal respirations B. Ketones in urine C. nocturia D. Proteinuria
D. Proteinuria **SLIDE 40 STREP COMPLICATIONS** 1. Headache 2. fever 3. hypertension 4. hematuria 5. proteinura 6. facial swelling 7. edema 8. nausea and vomitting **cREATNINE LAB WILL BE INCREASED SHOWS INDICATION OF KIDNEY DAMAGE**
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Which of teh following statemts is true about restraint? A. You will need a new prescription Q48 hours B. Assessment of the patient in restraints must be completed every 2-4 hours C. Music should not be used as a restraint D. You can apply restraints on a client if they are screaming | q
B. Assessment of the patient must be completed every 2-4 hours **SLIDE 41 RESTRAINTS -must have an order to use retraints **-assessment of patient in restraints must be completed Q2-4 hours** **LEAST TO MOST INVASIVE** 1. Mittens 2. Wrist 3. Vest 4. Arms and legs 5. Leather
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After administering the wrong medication to the wrong patient and asessinng your patient, What should you do next?
**IMMEDIATE ASSESSMENT AND NOTIICATION OF PHYSICIAN** Report and chart medication in health record' incidentreport * inform the patient and offer plan of action * Observe of patient for possible effects * review systems and investigate cause of mistake. **SLIDE 42 wrong med admin**
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You are a diaster traige nurse assigned 4 patients. Which of the following patients will take immediate priorty and would be tagged **red**? A. Client with hypotension and chest pain B. A client with an open fracture C. A client with a UTI D. a client with grey matter
A. Client with hypotension and chest pain **SLIDE 43 DISASTER TRAIGE*** 1. shock 2. Compromised airway 3. Unstable wounds 4. Chest Trauma 5. Vital sign instability 6. hemmrohage 7. Respiratory distress
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Which of the following statements are true about the yellow tag during a disaster triage? A. The care cannot be delayed and they will need immediate help. B. They are classified as urgent and require treatment within 30 minutes to an hour. C. A client with dilated pupils would be considered to be a yellow tag. D. A client without a pulse is classified as a yellow tag
B. They are classified as urgent and require treatment within 30 minutes to an hour. **SLIDE 43 DISASTER TRAIGE*** **1. Open fractures with palpable dital pulse** 2. Large wounds 4. Abdonimal pain severe 5. Kidney stones 6. Soft tissue injuries
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You are a diaster traige nurse assigned 4 patients. Which of the following patients will take least priorty and would be tagged **green**? A. Client with hypotension and chest pain B. A client with an closed fracture C. A client with a sickle cell D. a client with grey matter coming out of the brain
B. A client with an closed fracture **SLIDE 43 DISASTER TRAIGE*** 1. Infections 2. Minor burns and lacerations **3. Closed fractures** **CARE CAN BE DELAYED 2 HOURS OR LONGER**
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Which of the following statements are true about the black tag during a disaster triage? A. The care cannot be delayed and they will need immediate help. B. They are classified as urgent and require treatment within 30 minutes to an hour. C. A client with dilated pupils would be considered to be a yellow tag. D. A client without a pulse is classified as a black tag
D. A client without a pulse is classified as a black tag **SLIDE 43 DISASTER TRAIGE*** 1. Pulselessness 2. Apnea 3. Severe neurological trauma **4. Full thickness burns >60% total body surface area**
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Which of the following requires airborne precaution? A. Severe Acute Respiratory Syndrome B. Rubella C. Pertussis D. Influenza
A. Severe Acute Respiratory Syndrome **SLIDE 44 AIRBORNE PRECAUTIONS** 1. Measles 2. Rubeola 3. Varicella-Zoster (Chickenpox and shingles) 4. Variola 5. Disseminated Herpes Zoster
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What are patients at risk for after and prior to a colonoscopy? A. Fluid volume overload B. Jugular vein distenstion C. Dehydration D. Bounding pulse
C. Dehydration **SLIDE 45- COLONSCOPY** also at risk for hypovolemia ## Footnote colonoscopy loojs for polps and signs of bleeding , can remove polyps
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What age should a colonoscopy screening begin? A. 20 B. 50 C.85 D. 75
B. 50 EVERY 10 YEARS UNTIL THE AGE OF 75 **SLIDE 45- COLONSCOPY** 1. **SHOULD NOT CONTINUE AFTER AGE OF 85** Patient teaching -avoud tobacco -start aspirin therapy at ages 50-59 y/o -excercise -high fiber diet weight reduction strategy
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Your pregnant clients titer for rubella is negative. What is the nurses next action? A. Document and monitor the client B. Administer the rubella vaccine around 26-28 weeks C. Assess vital signs D. Administer the rubella vaccine after birth of her child.
**SLIDE 46 VACCINATION SCHEDULE** D. Administer the rubella vaccine after birth of her child.
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What vaccine should be given at birth? A. Hep B B. MMR C. HPV D. Influenze
A. Hep B **SLIDE 46 VACCINATION SCHEDULE**
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Which vaccines are **contraindicated** for pregnant women? SELECT ALL THAT APPLY A. Covid-19 B. MMR C. Flu vaccine D. Flumax E.Varicella F. HPV G. Tdap
B. MMR D. Flumax D. Flumax E.Varicella F. HPV **SLIDE 46 VACCINATION SCHEDULE** ## Footnote pregnany women can recience tdap , flue vaccine im , covid 19 vaccine
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What vaccines are given in 2 months SELCT ALL THAT APPLY A.Hep B B. IPV C. RV D.Dtap E. Hib F. MMR
A.Hep B B. IPV C. RV D.Dtap E. Hib **SLIDE 46 VACCINATION SCHEDULE**
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What vaccines are given in 4 months SELECT ALL THAT APPLY A. RV B.HIB C.IPV D.Dtap E. PCV F. Hep B G. Hep A
A. RV B.HIB C.IPV D.Dtap E. PCV **SLIDE 46 VACCINATION SCHEDULE**
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What vaccines are given in 6 months SELECT ALL THAT APPLY A. HEP B B.RV C.HIB D.IPV E. DTAP F.HEP A G. Influenza
A. HEP B B.RV C.HIB G. Influenza D.IPV E. DTAP **SLIDE 46 VACCINATION SCHEDULE**
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What vaccine are given with 12-18 months. SELECT ALL THAT APPLY A.Rotavirus B. hep b C. MMR D. Varicella E. Hep a F. Dtap G. PCV
B. hep b C. MMR D. Varicella E. Hep a F. Dtap G. PCV **SLIDE 46 VACCINATION SCHEDULE**
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What should you report to the provider if a client is taking Clozapine? A. flu like symptoms B. Weight gain C. Increase in cholesterol D. Constipation
**A. flu like symptoms** **SLIDE 47 -CLOZAPINE** S/e 1. drowsiness 2. constipation 3. confusion 4. dizziness 5. sweating 6. trembling 7. excess saliva **most serious affect neutropenia**
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Should you clean a hearing aid with dripping wet cloth with chemicals? A.yes B. NO
B. NO -NO ALCOHOL **SLIDE 48- PATIENT TEACHING HEARING AID** 1. Have extra batteries 2. Clean w/soap and water 3. Take batteries out at bedtime 4. If volume needs adjusted higher than normal, there may be a blockage (wax) or low battery
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When you are clearing out the reciever end of the hearing aid, shoukld you insert the pick further after you meet resistance? A. yes B. no
B. no **SLIDE 48- PATIENT TEACHING HEARING AID** insert pick into opening until you meet resistance , then scoop back out, repeat until openeing is free of wax -never put nothing in microphone , turn headset upside down , lose debris will fall out
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What conditions are contraindicated to place an IV in their right arm?
**SLIDE 49- STARTING AN IV** 1. AV FISTULA 2. MASECTOMY 3. PARALYSIS 4. LYMPH NODE REMOVAL
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What type of dressing is used to keep angiocath in place after placing an IV? A. Tegaderm B. Occlusion C. Biodegradable D. Gauze
**SLIDE 49- STARTING AN IV** A. Tegaderm 1. You shouldplace an IV from a 15-30 degree angle 2. Label site with initials , date, time , gauge 3. **if patient complanes of pain , remove IV and place in other arm**
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Should you ever shave or slap a patients skin prior to IV insertion without their permission? A. Yes B. No
B. No
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should you avoid excessive heat with MS? A. No B. Yes
B. Yes **SLIDE 50- MS TEACHING**' 1. Get plenty of rest, extreme tiredeness is a s/s of MS 2. Plan activities in advance **3. Avoid excessive heat** 4. Use cane or other aid to help you get around and conserve energy 5. Stretching can be useful with meds to help with stiff musclese 6. Physical therapist can determin which exercise is safe for them 7. Swimming is good , temp doesnt increase 8. never swim alone

NUR 283 TRANSITION (6 decks)

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