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Galen Comprehensive Review > Comp 3 Study Guide > Flashcards

Comp 3 Study Guide Flashcards

1
Q

These patients are at an increased risk for latex allergies

A

Spina bifida and multiple sx

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2
Q

ESKD what is expected?

A

Creatinine of 2.7 is expected - kidneys are damaged!!!

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3
Q

Scabies interventions

A

Wash/ c hot water
Ointment neck down for 8-14 hours

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4
Q

Priority patients

A

Burns on chest
6y/o c HR 130 @ rest
Sodium 125
Stroke pt becomes restless
4 y/o laceration falling asleep
Temp greater than 1degree TPN, kidney transplant, Graves’ disease

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5
Q

Male prostate high risk age

A

40-49 y/o

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6
Q

Increased risk for cervical cancer

A

24 y/o AA female hx of HPV

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7
Q

What do you monitor for following a bronchoscopy?

A

Hemoptysis

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8
Q

A patient c septic shock is given LR @30 mg/kg and their BP is still low what is the next action?

A

Administer vasopressin to increase BP

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9
Q

What can you delegate to the LPN?

A

Blood sugar check, dressing changes, reassess, reinforce teaching, past med hx,

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10
Q

What is important to remember about Lithium?

A

Stay hydrated, dehydration causes toxicity

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11
Q

A patient is experiencing hypothermia, how do you rewarm them?

A

Trunk first then extremities

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12
Q

What is concerning about a baby at 6 months?

A

Tripling their weight, they should only double it

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13
Q

A patient is sexually assaulted what do you do first?

A

Assess their injuries

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14
Q

When do you get the rubella titer?

A

After delivery

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15
Q

What is important to know about peritoneal dialysis?

A

It’s is a sterile procedure, in hospital and at home
Cloudy= infection (peritonitis)

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16
Q

What do you need to do for a colonoscopy?

A

Bowel prep
Yogurt diet

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17
Q

What are important interventions to use for a client with GERD?

A

Wedge pillow, sit up after meals, no caffeine, no smoking, no carbonated or spicy foods

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18
Q

A client who had a kidney transplant one week ago, what is important to assess?

A

If the BP goes down that is good!

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19
Q

An infant is projectile vomiting what condition is suspected?

A

Pyloric stenosis

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20
Q

What is the max time for a tube feed?

A

24 hours

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21
Q

What is the max time for Lipids?

A

12 hours

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22
Q

A client with a TPN starts feeling fullness what should the nurse do?

A

Stop the feed, check residual, assess tubing for kinks

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23
Q

What is important to know about celiac disease?

A

They have gluten allergies, can have rice, avoid oatmeal, rye and wheat

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24
Q

Why would the HDL be high in a client following the correct diet?

A

Genetics

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25
Q

What conditions are associated with respiratory acidosis?

A

COPD, asthma

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26
Q

What is HHS and what is important?

A

HHS is BG >600, no ketones, metabolic alkalosis,
patient needs to maintain hydration

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27
Q

What interventions are important for dumping syndrome? (3)

A

Increase protein
Lay down after meals
No fluids while eating

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28
Q

What is the appropriate response to a crying baby c a cleft palate?

A

Swaddle, hold close and rock

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29
Q

Where do you auscultation the aortic valve?

A

Right sternal border 2nd intercostal space

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30
Q

What is lateral violence?

A

Bullying, NOT sexual harassment

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31
Q

A client is experiencing PVCs what should you do?

A

Check peripheral pulses, client is most likely experiencing hypomagnesemia

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32
Q

What is important about PKU?

A

Breastfeeding mothers should avoid aspartame

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33
Q

What is DKA?

A

Diabetic keto acidosis, metabolic acidosis, BG >300, ketones in urine, monitor hydration

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34
Q

A client presents with Hypovolemic shock what is the priority?

A

Replace fluids then give O2

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35
Q

A client post op a VP shunt what is the priority?

A

Raise hob 30

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36
Q

A client c IBS is prescribed loperamide what is the nursing action?

A

Call provider, they cannot have loperamide (anti diarrheal)

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37
Q

What is Coumadin (warfarin) indicated for and what is the INR range?

A

DVT, Afib
INR 2-3

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38
Q

A child c WBC of 3.9 is scheduled for a vaccine what is the priority?

A

Call provider, child is immunocompromised and cannot have the vaccine

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39
Q

What can’t a child have before 1 y/o?

A

Honey

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40
Q

What community program can be used for primary prevention?

A

Stress management

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41
Q

The clients trach ties are moving in and out while coughing, is this expected?

A

No, they are too loose. One finger should fit under ties.

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42
Q

Who can remove the chest tube?

A

Only the provider

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43
Q

After a biopsy who can check v/s?

A

PCA

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44
Q

What food is contraindicated in atherosclerosis?

A

Eggs

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45
Q

What client populations need interdisciplinary care?

A

Parkinson’s
Cystic fibrosis

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46
Q

A client with sickle cell should avoid what?

A

High altitudes

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47
Q

A PCA needs further education if they say what about radiation?

A

Radiation materials stay in the room like v/s machine (WRONG)

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48
Q

What is the nursing intervention when FHR is 180?

A

Lay mom on left side
N FHR 110-160

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49
Q

What is important to teach a group of men?

A

Make sure they do testicular checks each month after showering

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50
Q

What is important to do for PUD peptic ulcer disease? (3)

A

Type and cross
NPO and NG tube
Triple therapy tx: two antibiotics and one PPI

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51
Q

A client is post mortem what is important ?

A

Take lines out before the autopsy

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52
Q

What is the common cause of a GI bleed c black tarry stool?

A

H.pylori

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53
Q

Cardiac strip asystole, what is the priority?

A

CPR

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54
Q

A 65 y/o is on a low cholesterol diet and has a high LDL, what is the next nursing action?

A

Call provider, something is wrong

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55
Q

What condition is associated with respiratory alkalosis?

A

Hyperventilation

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56
Q

What is important to remember about ceftriaxone?

A

Be cautious if client has PCN allergy

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57
Q

What client should be referred to an outside agency?

A

Stage three pressure ulcer

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58
Q

The UAP reports the clients O2 saturation of 89%, you check the chart and the client has COPD, what is the next nursing action?

A

Document the normal finding

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59
Q

What activity should a 5 y/o do?

A

Play c dolls and coloring book

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60
Q

What is important to remember about beclamethasone?

A

Rinse mouth

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61
Q

Patient took an entire bottle of amitriptyline what should the nurse do next?

A

Ask if they were trying to kill themselves

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62
Q

What is considered secondary prevention in regards to breast cancer?

A

Breast exam

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63
Q

When should a breast exam be done?

A

7 days after period

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64
Q

How do you doff PPE?

A

Alphabetical order:

Gloves
Googles
Gown
Mask

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65
Q

A client with a detached retina in the right eye will experience what?

A

Dark spots in the right eye

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66
Q

Where is insulin absorbed the fastest?

A

Abdomen

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67
Q

What order do you delegate?

A

Assess
Plan
Communicate
Surveillance
Evaluate
Feedback

68
Q

A client with thyroid dysfunction has a temperature of 100 degrees what is the priority?

A

The temp indicates thyroid storm

69
Q

What is important about ciproflaxcin?

A

Report deep tendon pain

70
Q

A client c MI reports pain decreased from 6 to 3, what is the next nursing action?

A

Give another nitro

71
Q

A patient c pericarditis will experience what?

A

No vesicular breath sounds

72
Q

A client had a spontaneous delivery what is important to do for when the head is delivered?

A

Suction nasopharynx

73
Q

What is important to monitor with tumor lysis syndrome?

A

Hyperkalemia

74
Q

What is important to check when a client is on -statins?

A

Liver enzymes

75
Q

A client with a chest tube has output of 175ml/hr what is the next nursing action?

A

Follow up

76
Q

What is important to remember for a child that is dying?

A

Do the essential activities only

77
Q

When should the HPV vaccine be given?

A

Ages 9-26, before you’re sexually active

78
Q

A client has a HR of 60 and is prescribed metoprolol

A

Follow up

79
Q

A client is experiencing cramping with their enema, what is the next nursing action?

A

Lower the bag

80
Q

What is important to do for a PEG tube?

A

Rotate 360, every day

81
Q

A 4 y/o client on antibiotics

A

Give vaccines

82
Q

A client on internal radiation has had a visitor in their room for 2 hours what is the nursing priority?

A

See them first, visits are limited to 30 min a day, radiation exposure

83
Q

What is important about ACE inhibitors?

A

Cannot have potassium sparing diuretics

84
Q

A client stated her 11 y/o sits in the front seat, what is the nursing priority?

A

Follow up, has to be 12 and at least 5 foot

85
Q

If a client experiences a left sided CVA what would be impaired?

A

Communication

86
Q

A client with acute pancreatitis has pain of 7 after medication, what is the action?

A

See them first , they are a priority

87
Q

What precautions is Herpes Zoster (varicella)?

A

Airbone

88
Q

What is expected with AKI?

A

Hgb 33
N 37-52

89
Q

A client with a pacemaker is feeling dizzy what is important?

A

Assess them first!!! Pacemaker may not be synced, very dangerous

90
Q

What is important about transcribing a telephone order?

A

Repeat it back

91
Q

A new RN should get what patient?

A

Asthma patient getting discharged

92
Q

Invasion of privacy of famous patient, what is important?

A

Terminate

93
Q

A client just had sx on femur and is now restless what is the next nursing action?

A

Call rapid, fat embolism

94
Q

What is important about a MDI?

A

Wait 2 minutes between each puff

95
Q

What is important about external radiation?

A

No direct sunlight for 1 year

96
Q

What is important about allopurinol?

A

Increase fluids

97
Q

What is important about phenytoin?

A

Oral hygiene to prevent gingival hyperplasia

98
Q

What is important for TURP?

A

Teach kegels

99
Q

What precautions are Hep B?

A

Standard

100
Q

What is important about Ménière’s disease?

A

Low sodium diet

101
Q

Follow up at health fair?

A

Ex smoker of 2 months c BP 140/90

102
Q

A client with INR of 3.5 wants to leave AMA what is important to tell them?

A

They have risk for bleeding

103
Q

What vaccine do you get at 18?

A

Meningitis

104
Q

A client has a BP of 92/58 after a kidney transplant, what do you do?

A

See them first, they are a priority, BP should be normal

105
Q

What is the diet for Coumadin?

A

Do not change diet
Avoid high vitamin K food

106
Q

What PPE is used with MRSA?

A

Gloves and gown

107
Q

What reduces the spread of MRSA?

A

CHG bath

108
Q

What PPE do you wear for pertussis?

A

Droplet: mask within 3 ft, or wears mask outside room

109
Q

What is important to assess for in bucks traction?

A

Skin breakdown

110
Q

A child c asthma is using their rescue inhaler q 2hr while awake

A

This is priority

111
Q

When does the second stage of labor start?

A

Cervix completely dilated, baby at -1 station

112
Q

What is the expected urine output for a baby

A

3ml/hr

113
Q

What prevents DVT?

A

PROM

114
Q

Priority teaching for thrombocytopenia?

A

Risk for bleeding

115
Q

What is a common vitamin deficiency c ETOH

A

Vitamin b6

116
Q

What is important to know about glargine?

A

Do not mix

117
Q

What do you do if a clients aPTT on heparin is 30

A

Increase the heparin

118
Q

What is the approximate IM needle gauge and size?

A

25g 1 inch needle

119
Q

What are s/s of hypothyroidism?

A

Dry skin, menorrhagia, brittle nails

120
Q

A client 2 hours post op lumbar puncture reports a HA what is the nursing action?

A

See patient first, priority, ICP

121
Q

A client exhibiting violent behavior needs?

A

One to one monitoring

122
Q

Additional teaching with informed consent is needed if

A

Signed by nurses to indicate patient understanding, pt can sign and not understand

123
Q

A baby on the mother/baby unit has a HR of 95 what is the nursing action?

A

Priority patient, see first

124
Q

How do you administer eye gel?

A

Nose outward, inner canthus to outer

125
Q

A wound goes from sanguineous to serosanguineous what is the next nursing action?

A

Continue to monitor, the wound is healing as expected

126
Q

A client has a potassium of 2.4 what is important?

A

Do not get client out of bed

127
Q

Follow up when flushing PRBCs?

A

Flushing with D5W (WRONG), only ns

128
Q

A client with insomnia what is important?

A

Do activities early

129
Q

Discharge what patient

A

Tonsillectomy

130
Q

What is the onset for lispro?

A

15-30 minutes, fast acting

131
Q

A client loses their dentures what is the nursing action?

A

Fill out an incident report

132
Q

When do you get a colonoscopy?

A

Age 50 the every 10 years

133
Q

When do you do prostate exams?

A

Every year c digital

134
Q

Suicide risk

A

Old man lose wife
Teen losing wt after breakup

135
Q

What is important about statin medications?

A

Check liver enzymes

136
Q

What is important about bacterial meningitis?

A

Wear mask outside room

137
Q

A client with High top shoes and foot drop what is important?

A

Assess pressure points

138
Q

What is macular degeneration?

A

Central vision loss

139
Q

What is important about trach ties?

A

1 finger should fit between
Replace new ties before removing old ones

140
Q

What is important about BPH?

A

Avoid decongestants

141
Q

What is important about Kawasaki?

A

Give immunoglobulins

142
Q

Further teaching c fiscal responsibility?

A

Letting family help WRONG ( not fiscal )

143
Q

What do you do for a picc line or triple lumen?

A

Flush c 10 ml ns

144
Q

What is the dawn phenomenon?

A

Higher BG in morning is expected

145
Q

What is important about fidelity?

A

Keeping commitments

146
Q

What is expected with intussusception?

A

Currant jelly like stool, knee to chest for comfort

147
Q

What is important to know about the cath lab and HCT

A

Hct 33% is bad
Normal 37-52

148
Q

What is important about abruptio placentae?

A

No oxygen, very painful

149
Q

What is classified as emergent?

A

Lung collapse
Hemorrhage
MI

150
Q

What is classified as urgent?

A

Multiple fx, +1 pedal pulses

151
Q

What is important about Addison’s disease?

A

Everything is low (BP, BG, wt) except potassium

152
Q

A new grad shaves a client with a disposable razor and shaving cream on the clients operative side, what is the next nursing action?

A

Follow up, supposed to use electric razor

153
Q

AKI at risk for volume depletion will have

A

Decreased pulse pressure

154
Q

A client is given a statin for hyperlipidemia what should the nurse check?

A

Liver enzyme

155
Q

A nurse should follow up if a client is taking prednisone and their fasting glucose is 190

A

Yes!!!

156
Q

A client is taking an ACE inhibitor what medication should the nurse question?

A

Spironolactone, potassium sparing, already monitoring hyperkalemia c ace -prils

157
Q

A client c emphysema should not

A

talk and walk

158
Q

What priority assessment is important for BKA? Below knee amputation

A

Hypovolemic shock- bleeding

159
Q

Follow up with a open radical prostatectomy

A

Pt states I will not be able to take a shower for 2 weeks (wrong)

160
Q

Thoracentesis call provider if ,

A

HR increases

161
Q

Further teaching: mom states what about rhogam shot

A

Allow my body to fully remove the placenta lining (WRONG)

162
Q

What is a positive sign of pregnancy?

A

Heartbeat

163
Q

What are the nursing considerations for status asthmaticus?

A

MEDICAL EMERGENCY
sit up, O2, prepare for intubation, epi, steroids!!!!

164
Q

What are the s/s of status asthmaticus? (5)

A

Blue tinged color to lips/fingers
SOB
Fatigue
Sweating
Wheezes

165
Q

What are the important nursing interventions to implement when caring for a client with status asthmaticus? (7)

A

Monitor ABCs- airway priority
keep patient calm
Auscultate lung sounds
Monitor skin color and any retractions of the chest
Instruction in the appropriate use of inhalers o
Identify triggers that may induce an attack
Strongly discourage smoking

Galen Comprehensive Review (2 decks)

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