Comprehensive Review Flashcards
Right sided or Left sided heart failure?
Weight gain
Right
What is a published false statement that is damaging to a person’s reputation called?
Libel.
What type of therapy will a patient with A FIb need to be on?
Anticoagulant therapy.
What age is associated with associate play?
3-4 years
What is normal CO2 for ABG’s?
45-35
What is the first sign you will see in a patient with increased ICP?
Change in LOC
Headache, dilated pupils, vomiting, nasal stiffness.
Normal range for INR.
0.9-1.2 seconds
What do patients that are at risk for PE need to do?
Exercises!
What medication is given to treat SIADH?
Vaptans
How can tumor lysis syndrome and Cushing’s syndrome affect the kidneys?
They both can cause acute kidney failure.
What are signs and symptoms of digoxin toxicity?
Green/ yellow halos around lights. Blurred vision. Visual disturbances. Anorexia. Headache. Confusion. Dizziness. Bradycardia.
Describe spectator play.
A child will observe other children play.
In an emergency, when beds are needed for incoming patients, what patients are sent out to make room?
The most stable patients.
Why is it important for mom to empty play during labor?
Because a full bladder will slow the progression of labor.
What is rheumatoid arthritis?
Autoimmune disease that affects all joints.
How do you teach a patient the proper use of a can?
Carry the cane on the strong side and move forward with the weak side.
What do you do when you see assystole?
Check the lead placement, assess patient and start compressions if indicated.
What acid base imbalance do you suspect with for a patient who has the flu and is vomiting and dehydrated?
Metabolic alkalosis.
What type of room is needed for patients with TB?
Negative air pressure room.
What age is associated with speculator play?
2-2.5 years
What medication can be given to lower potassium levels in a patient in DKA?
Kayexalate
What are acetylcholinesterase inhibitors used for?
Treatment of myasthenia gravis.
Can PPN go in a peripheral line?
Yes, PPN is not as concentrated as TPN.
What is a hemothorax?
When blood accumulates in the pleural space around the lung, causing the lung to collapse, usually occurs low in the lung lobes.
What happens in both the patient with tumor lysis syndrome and Cushing’s syndrome?
Hyperkalemia occurs as the destroyed cells release the potassium from inside and it enters the blood stream.
Right sided or Left sided heart failure?
Decreased BP from heart failure.
Right
Right sided or Left sided heart failure?
Confusion, restlessness.
Left
Describe solitary play.
The child will play on their own.
What are examples of isotonic IV fluids?
Normal Saline
Lactate Ringers
What is primary prevention in health care?
Taking preventative steps before the problem develops such as: Vaccines Health fairs Diet modifications Providing patient education
Describe breaths associated with kussmaul .
Rapid, deep and labored – common in DKA.
What type of patient will diversion activities work best with?
Alzheimer’s patients.
What does the nurse monitor for when a patient who previously displayed lethargy and has been on the meds for a while suddenly displays energy and optimism?
Monitor for suicide as they now have the energy to carry out their suicide plans.
What are signs and symptoms of anemia?
Tachycardia
Fatigue
SOB
Low O2 sat
What are signs and symptoms of hyperkalemia?
Cardiac arrhythmias Nausea Fatigue Muscle weakness Tingling sensations
How do you treat digoxin toxicity?
Give digibind
When can restraints be used in mental health?
When the patient presents a safety risk to themselves or to others.
Transition duration.
60-90 seconds long.
What are signs and symptoms of Grave’s Disease?
Exophthalmos Tachycardia Absence of menstruation Anxiety Diarrhea Enlarged thyroid Hair loss Hand tremor Insomnia Irritability Muscle weakness Nervousness Puffy skin changes on the shin Weight loss
If a patient has a basal skull fracture and you think you have a CSF leak, what does the nurse do?
Check the fluid for proteins and glucose (CSF contains both of these).
The fluid will dry with a halo around the drainage spot.
What can pericarditis and a clogged chest tube cause?
Cardiac tamponade.
What occurs in a disaster that is different from a normal ER situation.
There are not enough resources to handle the patient load, so the priority patient is different in the field than in the ER.
Where is the ileostomy placed?
RLQ of abdomen (Expect stool to be liquid)
If the pharmacy does not have TPN when you need it, what can you run in its place?
D10 or D20. TPN has a lot of glucose so these will hold until TPN is available.
What are the signs and symptoms of a retinal detachment?
Curtains over the eyes
Black spots in the field of vision
No pain in retinal detatchment
If a patient with abdominal surgery suddenly eviscerates the wound, what do you do?
Call for help (rapid response) first as the patient is at risk for death, then cover with sterile gauze with sterile saline to moistens the gauze.
What are normal digoxin levels?
0.5-2
Right sided or Left sided heart failure?
Pulmonary congestion.
Left
What are signs and symptoms of a clogged chest tube?
Low output of chest tube
Patient is in panic and agitated state
What locations of the lung field are best to hear normal breath sounds?
Vesicular and bronchovesicular.
Right sided or Left sided heart failure?
Cool extremities.
Left
How do you teach a patient to use cane/crutches when going up stairs?
Go up with the good and down with the bad.
What two questions do you ask a patient who you suspect is a suicide risk?
- “Are you thinking of hurting yourself?”
2. “Do you have a plan to hurt yourself?”
How do you prevent SIDS?
Place the child on their back to sleep.
What insulin can never be mixed?
Glargine, a long acting insulin
Therapeutic range of PTT with heparin.
1.5-2.5 times the normal range.
Describe breaths associated with air trapping.
Difficulty during expirations.
What does a patient with TB need to wear when being removed from the room?
A surgical mask.
Right sided or Left sided heart failure?
Tachypnea
Left
What acid base imbalance do you suspect for a patient who is hyperventilating?
Respiratory alkalosis as they are expelling all of the CO2 by rapid breathing.
Describe dressing changes for patients receiving TPN infusions.
Need to be sterile due to increased risk for infection.
Active duration.
40-60 seconds long.
Patient that has a chest tube with a thoracentesis: how do you measure the drainage that will be seen from the chest tube in the collection chamber?
You would just mark it on the device itself.
What are the three parts of the first stage of labor?
Latent
Active
Transition
How do you watch a patient with anorexia eat?
You just monitor to make sure they are eating.
What are signs and symptoms of Meniere’s syndrome?
Tinnitus and vertigo
What is the antidote for heparin?
Protamine sulfate.
Describe a healthy looking stoma.
Moist and bright red.
What is the treatment for Addison’s disease?
Replace what is missing – give cortisol.
How often do you check vitals for a patient receiving a blood transfusion?
Every 15 minutes in the first hour.
Right sided or Left sided heart failure?
Crackles or wheezes in lungs.
Left
Describe bronchial breath sounds.
Normal sounds heard over substernal notch. The sounds are louder. Expiration lasts longer. Silent internal.
Know the significance between a schizophrenic patient and pre packaged food.
No answer – just need to know.
What occurs if the nurse pull more than 200 mL of residual from a patient prior to tube feeding?
Hold the feeding. The stomach is not processing the feeding quickly so the nurse does not need to put any more in.
Describe borderline personality.
More than likely to self mutilate.
What is a power of attorney?
The person who has been assigned to make the decisions for the patient if the patient is not able to make their own health care decisions.
What is normal range of hematocrit?
37%-52%
What happens in osteoarthritis?
From wear and tear of specific joints, affects only the worn down joints.
Where do you hear bronchovesicular breath sounds?
In the mid-chest area or in the posterior chest between the scapula.
What lab values are associated with heparin?
aPPT and PTT
What is Grave’s Disease?
An autoimmune response where the thyroid is overstimulated, creating hyperthyroidism in the patient.
Why does a patient with command hallucinations need immediate intervention?
Because the patient may be hearing a command to harm themselves or others.
When can an infant be given rice cereal?
6 months
Latent contractions.
3-30 minutes apart.
What does intussusception and tetralogy of fallot have in common?
The patient will put their knees to their chest to help them breath for tetralogy of follow and the intussuscpetion patient will do this to alleviate the pain.
When does a baby first roll over?
About 4 months
How do you speak to a patient who is having command hallucinations?
Let them know that you believe what they are saying but that you don’t hear them. Try to find out what the patient is hearing. It is real to the patient so do not deny that this is happening to them. Never ask them “why” as it may upset them.
What is secondary prevention in health care?
Taking steps to screen patients who are at risk, such as:
Colonoscopy screenings
BP screenings
What age is associated with cooperative play?
4-6 years.
What angle is insulin injected at?
90 degrees
Where are restraints tide to?
The bed frame. They should not be tied to any moveable part of the bed.
Where is the colostomy placed?
Can be placed on right or left side but the left side will be more formed stools.
When do you admit a client with MS to the psych unit?
When they are depressed and not eating.
Disaster drill – deviated trachea/ RR 20
No anwer – just need to know.
Right sided or Left sided heart failure?
Decreased cardiac output.
Left
What can cause lipodystrophy?
Injections repeatedly in the same spot.
Right sided or Left sided heart failure?
Fatigue
Left
Describe course crackle breath sounds.
Abnormal breath sounds that are low pitched. They are louder and longer.
Describe associate play.
Children will be playing the same game or activity but will not be working together or making connections with peers.
What is the dietary teaching for a patient with diverticulosis?
High fiber to keep shit moving along and to prevent pockets from rupturing. No seeds and low residue.
What are the signs and symptoms of glaucoma?
Blurry spots in several places in the field of vision.
Possible peripheral vision loss
No pain in glaucoma.
What is unexpected in an epidural?
Hypotension
Dizziness
Depressed RR
Nausea
**The patient must be monitored for these!
What meds are used to treat Cushing’s?
Meds that lower cortisol like ketoconazole, milotane or metyrapone.
What does high hemoglobin mean?
Poor heart or lung function – The body makes more hemoglobin to compensate in order to carry more oxygen in the body.
What is patient teaching that is associated with internal radiation?
Flush the toilet twice
No children visitors
No visitors can stay longer than 30 minutes a day
Wash clothes separately from others
What happens to the skin of a patient with Cushing’s?
Fail skin from excessive steroids which can cause poor wound healing.
What is the first sign of pre-eclampsia?
Decreased urine output as organ perfusion drops by 40-60%
If someone makes a false and defamatory oral statement about a person, what can they be charged with?
Slander.
What acid base imbalance do you suspect for a patient with cystic fibrosis or COPD?
Respiratory acidosis since the patient is retaining CO2 and cannot expel out with the lungs.
A patient from foreign country presents to the ER with coughing, SOB, fever and night sweats. What is the priority?
Place the patient in a negative pressure, airborne precaution room as this may be TB.
What is patient teaching associated with a walker?
Do not use the walker to stand up.
Walker should be above the patients waist.
Arm angle shoul be about 30 degrees.
Look straight ahead while walking, do not look down.
Move the walker ahead one foot at a time.
Describe breaths associated with apneustic.
Neurological – sustained respiratory effort
If you have a patient with SIADH and you are concerned about fluid overload, what would you expect the MD to order for IV fluids?
Hypertonic fluids to pull the excess fluid from the extravascular space. The patient would also be on sodium restriction.
Normal platelet count.
150,000-400,000
If a patient had a CVA and his developed unilateral neglect as a result, what side do you approach the patient?
You approach them on the unaffected side.
What type of patient presents the most danger to themselves or to others?
A patient who is having command hallucinations: not sure what the hallucinations are telling the patient to do and may cause harm to themselves or to others.
What will you see in V Fib?
Smaller peaks that in V Tach and peaks are not rounded. They are more pointed.
What vital sign is to be concerned with for thyroid storm?
Elevated temperature.
What increases the risk of gout?
Excess intake of purine, meats and alcohol.
What are three nursing interventions to prevent aspiration in tube feedings?
- Elevate HOB prior to feedings and afterwards.
- Check residual before feeding.
- Check for placement by checking the pH of the residual.
Normal age range – A/P diameter widened or R.E.M. Increased.
Look this up!
Decscribe antisocial personality.
More than likely to have a criminal behavior.
How do you walk with a cane?
Place the cane on the strong side, move the cane forward with the weak side.
What is normal respiration rate?
12-20 breaths per minute
What is Cushing’s?
Hypersecretion of adrenal hormones.
What dieases call for airborne precautions?
Measles
TB
Chicken pox
Open lesions on shingles or herpes
Active contractions.
2-5 minutes apart.
How long does it take for a pressure ulcer to form?
2 hours.
If you patient with a spinal cord injury complains of a headache what can you do?
Sit them up
Check foley for kinks
Active dilation.
4-7 cm
What is important nursing consideration reagarding intermediate insulin?
Never shake it; gently roll it between hands to mix it.
What do ACE inhibitors, spironolactone and Addison’s disease all have in common?
All are at risk for hyperkalemia if not carefully monitored.
How would you assess a black tag if the same patient symptoms were to come to the ER.
That patient would be your priority. That’s the patient you would see first.
If an IV ls infusing over a 4 hour droid but its late in running, can you increase the rate to catch up?
No, that will create fluid overload in the patient.
What is the best exercise for osteoporosis?
Anything that is weight bearing on the long bones like walking or jogging.
What is the most accurate and reliable indicator of fluid gain or loss?
Daily weights
Right sided or Left sided heart failure?
Angina
Left
What are four major elements to therapeutic communication?
- Ask open ended questions
- Never ask “why” as it can make them defensive.
- Ask them, “tell me more about it”.
- Yes clarifying statements.
What do you need to teach your patient who is taking a bisphosphonate for osteoporosis?
Take the medication with a full glass of water, sit upright for at least 30 minutes and take it on an empty stomach.
What is the initial treatment for DKA?
Insulin first (that will fix the problem)
Right sided or Left sided heart failure?
Pink, frothy sputum.
Left
Right sided or Left sided heart failure?
Swollen hands and fingers.
Right
What does TPN have in common with blood products?
You need two RN’s to verify before administering.
How you do position a wheelchair for the patient?
Place is on the strong side of the patient at a 45 degree angle from the bed.
When does the anterior fontanelle close?
9-18 months
What is the effect of glucose with Peg feeding and TPN on the serum?
Elevated blood glucose.
Can you use D5 for a patient who’s TPN is not available?
No, D10 is the lowest you can use.
What cancers are associated with smoking?
Lung and bladder cancers.
Who can get myxedema coma?
In patients with hypothyroid who has a stressful event.
What is the purpose of having core measures for surgery?
For infection prevention prevention of serious cardiac events and prevention of DVTs.
How do you check for blood pooling in a patient with an abdominal trauma?
Measure and monitor abdominal girth.
Right sided or Left sided heart failure?
Tachycardia, palpitations.
Left
What is tension used for?
Testing of myasthenia gravis.
Who is at highest risk for DI?
Patients who had the pituitary gland removed as this is where the ADH hormone comes from.
What makes up Cushing’s Triad?
Irregular respirations
Bradycardia
Systolic HTN (widened pulse pressure)
What is the diagnostic test for appendicitis?
Ultrasound
What is the universal blood donor?
O -
What is the concern in DI patients?
Dehydration from all the diuresis.
What factors increase the risk of developing a latex allergy?
Overexposure to latex products over a period of time.
Multiple surges
Eating kiwi or bananas.
What is a thyroid storm?
A life-threatening health condition that is associated with untreated or under treated hyperthyroidism.
What are the modifiable risk factors for health considerations?
Things that you can change yourself life eating a healthy diet, getting more exercise and stop smoking.
What is the diagnostic test for gallstones?
ERCP
Why does TPN infusions increase infections?
Increased glucose in TPN decreases healing factors.
Example of slander:
My neighbor is being abused by her husband.
Right sided or Left sided heart failure?
S3/S4 gallop.
Left
What are the diet modifications for GERD?
No spicy foods, no caffeine, no red meat.
Stay upright after meals
Eat smaller, more frequent meals
Right sided or Left sided heart failure?
JVD
Right
What is the twist for a patient on digoxin?
Heart healthy foods with high potassium. If potassium is low, that will increase risk for digoxin toxicity.
What is the universal blood recipient
AB +
Ped med – call dr to verify order
No anser – just know it.
What is it called when baby is below the icheal spine?
Positive station (Baby is about to come out)
Should you rub the injection site after giving insulin?
No
When can an infant hold a bottle on their own?
6 months.
How do you get a patient out of V Tach?
Ask them to Vaal down as this may put them back into NSR.
What is the effect of St. John’s Wort and birth control?
It lowers the effectiveness of the birth control.
Therapeutic range for INR with warfarin/ Coumadin.
2-3 times the normal range.
How do you prevent tissue from dying in compartment syndrome and intercerebral hemorrhage?
Turn the patient every two hours to assess and prevent.
What labs are abnormal in Addison’s disease?
Potassium is high.
Sodium and glucose are low.
Do you aspirate insulin?
No
What is the patient teaching needed for a patient with internal radiation?
Do not wash off the markings on the site of treatment.
No sun exposure on the site for up to a year.
No visitors can stay longer than 30 minutes a day.
What are the signs and symptoms of basal skull fracture?
Raccoon eyes.
Describe histrionic personality.
Attention seeking behaviors; drama queen.
If you verbally threaten someone, what is it called?
Assault.
What does a bipolar manic depressed patient display?
They can have suicidal ideations with a flight of ideas and be impulsive and act on their thoughts immediately without regard for consequences.
What is it called when baby is above the ischeal spine?
Negative station (Baby is not read to come out)
What happens in SIADH?
Body has increased levels of ADH and the body holds onto the water. Hyponatremia occurs from all the fluid excess.
If you physically touch someone without their consent, what is that called?
Battery.
Describe rhonchi breath sounds.
Abnormal breath sounds that are continuous. They are low pitched and have a gurgling quality.
Why do you stay with a mom after she births the baby?
You want to help promote bonding.
When a patient is transferred to a floor, what is the first thing that is checked?
Vital signs are the priority to check.
Starts in the back and radiates to the front is a characteristic of ?
True labor
What insulins are clear?
Rapid acting, short acting and glarging
Therapeutic range for PT with warfarin/ Coumadin.
1.5-2.5 times the normal range.
What happens as a result of hypocalcemia?
CATS! Convulsions or seizures Arrrhythmias Tetany Stridor
What needs to be at bedside for a patient who recently had a thyroidectomy?
Tracy kit.
What is a green tag in a disaster?
These are the walking wounded who are not seriously hurt and can even help others.
Right sided or Left sided heart failure?
Polyuria at night
Right
What do you look for in a hemothorax or pneumothorax?
Tracheal deviation.
How can you prevent pressure ulcers from forming?
Reposition every two hours and do a skin assessment to identify any suspicious areas.
What does hyperkalemia cause in an EKG?
Peaked T wave
What is different in DKA and HHS?
There are ketones in the urine with DKA.
When does a baby ambulated independently?
12 months.
What do compartment syndrome and intercerebral hemorrhage have what in common?
There is excess blood trapped in an area. Decreased blood perfusion leads to hypoxia in the compressed area.
How long can blood be hung for?
A maximum of 4 hours.
When is the mother 100% effaced?
During the transition part of the first stage of labor.
What does low hematocrit signify?
Fluid volume overload, as the excess fluid will dilute the hematocrit count
What is SIDS?
Sudden infant death syndrome.
What are signs and symptoms of cardiac tamponade?
Muffled heart sounds Paradoxical pulses Decreased heart rate Dysphasia Fatigue Hypotension
Where do you hear vesicular lung sounds?
Over the thorax.
What is the normal amount of wet diapers for an infant in one day?
6-8 wet diapers in one day.
What acid base imbalance is suspected for a pediatric client with cystic fibrosis and the O2 sat is 78?
Respiratory acidosis.
Describe bronchovesicular breath sounds.
Normal sounds that are heard on the 1st and 2nd intercostal space anteriorly and between scapulae posteriorly. It has intermediate intensity. Inspiration equals expiration.
What must a nurse wear in an airborne precaution room?
N95 respiratory or a fit mask.
What type of diet is needed for chronic renal failure?
Low phosphate.
Contractions will stop with sleep or ambulation is a characteristic of what?
False labor.
Right sided or Left sided heart failure?
Oliguria during the day.
Left
Latent duration.
30-40 seconds long.
What is normal potassium level?
3.5-5
When the patient is having diarrhea, what metabolic disorder does this cause?
Metabolic acidosis.
What will you see in normal sinus rhythm?
HR between 60-100
P waves before the QRS
QRS occurs at regular intervals
Right sided or Left sided heart failure?
Weakness
Left
If the babinksi’s reflex does not disappear, what does that typically indicate?
Abnormalities in the motor control pathways leading from the cerebral cortex and is widely uses as a diagnostic aid in disorders of the central nervous system.
Normal range for PTT.
60-70 seconds
What is a yellow tag in a disaster?
This is someone who is urgent but not emergent. They need attention and care but they can wait.
Latent dilation.
1-3 cm
Why does the patient who has had a thyroidectomy sometimes experience hypocalcemia?
The parathyroid glands sometimes are removed and the patient will then experience hypocalcemia as a result. PTH is responsible for pulling calcium from the bones into the blood.
Can you give a 2 month old water in hot summer?
Look this up!
Describe fine crackle breath sounds.
Abnormal breath sounds that are discontinuous. They are high pitched and a popping quality.
What are characteristics of the schizophrenic patients?
Loners who hear voices and has hallucinations that can be auditory, visual, command, tactile, olfactory.
Describe wheeze breath sounds.
Abnormal breath sounds that are continuous that are high pitched. They sound musical.
What does the nurse do after pulling the residual from a tube feeding?
Replace the residual to prevent electrolyte imbalances.
Know how to chart a patient fall.
No answer just need to know.
What does it mean when a patient with a basal skull fracture has bruising in different places of the body?
It’s a bad sign.
Normal white blood cell count.
5,000-10,000
What are the cluster B personality disorders?
Narcisistic
Antisocial
Borderline
Histrionic
What do you tell a diabetic patient who is doing self-injections to do in order to prevent lipodystrophy?
Rotate injection sites.
What needs to be checked for on a blood transfusion order?
Blood type
Signed consent form
NS is only fluid that can be run with blood products
At least a 20 gauge (ideally 18)
Run over 4 hours
Watch for reactions in the first 15 minutes
VS every 15 minutes in the first hour.
What happens in diabetes insipidus?
Kidneys fail to respond to ADH and you cant retain any fluids.
Large amount of dilute urine.
What is myxedema coma?
A condition associated with very low hypothyroid,
Describe urgent, related to ER triage.
This patient can wait an hour or so to be seen.
What is the priority assessment of a patient with abdominal trauma?
Vital signs
Peripheral distal pulses
What is malignant hyperthermia?
An adverse reaction to anesthesia; with a temperature can be as high as 105 degrees F.
What is the normal range for hemoglobin?
12-18
Right sided or Left sided heart failure?
Dyspnea, breathlessness
Left
Normal range for aPPT.
30-40 seconds
What side does the trachea move to?
It will deviate to the unaffected side caused by the pressure in the affected side.
If a patient with lethargy and DM with elevated glucose, what acid base imbalance do you suspect?
Metabolic acidosis because glucose is acidic and that cause is metabolic in nature.
Describe the second stage of labor.
From dilation to birth of child.
Transition contractions.
1.5-2 minutes apart.
What type of precautions are needed for anthrax?
Contact
What isolation precautions are needed for a patient with pertussis?
Droplet.
Right sided or Left sided heart failure?
Dizziness.
Left
Describe the mother during the transition part of the first stage of labor.
Tired
Irritable
Anxious
Restless
What will you see in V Tach?
Tombstones and tombstones with higher peaks than V Fib.
What is the normal amount per hour of chest tube drainage?
100 mL/ hour
If a vial of insulin reads 70/30, what does that mean?
It is 70% NPH and 30% regular insulin
If a healthcare professional fails to act in the manner that a prudent person would, what is that called?
Negligence.
How do you assess a patient with abdominal trauma?
Monitor cap refill Check BP, HR Assess for bruising Check for respirations Look for signs of hemorrhaging Check bowel sounds Check for blood pooling Monitor LOC I's/O's for kidney perfusion Monitor distal pulses
Describe vesicular breath sounds.
Normal sounds heard over periphery. Gentle rustling sound that fades on expiration.
What are the dietary considerations for a patient on digoxin?
They need consistent potassium levels and they should eat bananas, sweet potatoes and avacados.
Describe breaths associated with hyperventilation.
Rapid, deep respirations, more than 20 breaths per minute.
When should a male perform testicular self examination?
After a warm shower.
What is normal sodium levels?
135-145
What type of container should nitro be kept in?
Original glass container with a tight lid.
What does the EKG strip look like for a patient having a fib?
No P wave before the QRS
The QRS is irregular
What are signs and symptoms of hypernatremia?
Weakness Lethargy Irritability Edema SeizureS Neurological damage Coma
How tight can restraints be?
Must be able to place 2 finger widths under restraint.
Right sided or Left sided heart failure?
Weak peripheral pulses.
Left
How do you assess the blink reflex?
Use a cotton ball and touch the side of the eye or blow air into the eye.
Describe the fourth stage of labor.
Expulsion of placenta to homeostasis.
What herb cannot be mixed with levodopa?
Caba Caba
How is the vision impaired in the patient with macular degeneration?
The patient will experience a loss of central vision.
What is normal pH for ABG’s?
7.35-7.45
What does high hematocrit signify?
Dehydration as the lack of fluid increases the amount of hematocrit compared to fluid volume.
What are the five areas that you listen to the heart?
Aortic Pulmonic Erb's Point Tricuspid Mitral
What are normal lithium levels?
0.5-1.5
Can warfarin and heparin be used at the same time?
Yes, heparin can be given until the warfarin is at therapeutic level to bridge over to warfarin only.
What is normal pH for residual taken from tube feedings?
0-4
Why do infants and the elderly develop dehydration easier?
Infants have not yet developed normal kidney function and the elderly are experiencing a loss of kidney function as they grow older.
Normal red blood cell count.
4.2-6.1 mm cubed
With does a baby sit up unsupported?
8-9 months
For the patient who is exhibiting air hunger, what will you see and hear?
Restlessness, stridor and use of accessory muscles.
Why don’t you palpate the abdomen of a patient with abdominal trauma?
Because it can cause more harm.
What unit will a women with cervical cancer that is getting the procedure done next day be admitted to?
Mom/ baby unit.
What is a medical emergency for the patient with cirrhosis?
When they have varicose that rupture and hemorrhage; the patient can bleed out in minutes.
What is the antidote for warfarin/ Coumadin?
Vitamin K.
What is the position to place the patient who is delivering and has a prolapsed cord?
Trendelenberg.
How do you check for placement of a PEG tube?
You do not need to. They are held in place.
How do you treat myxedema coma?
Oxygenate first. ABC’s.
Is true labor sporadic or consistent?
Consistent.
Peg feeding bags and TPN tubing is changed how often?
Every 24 hours.
When is it most painful for a patient with osteoarthritis?
In the evening or at the end of every day.
Describe the third stage of labor.
Birth of child to expulsion on placenta.
How do you correct V Fib?
Define the patient to correct the rhythm.
When does an infant triple their weight?
12 months
When does the posterior fontanelle close?
About 3 months
What is the primary area to focus in SIADH patients?
Lung sounds as the patient is carrying excess fluids which may settle in the lungs.
What is the initial treatment for HHS?
Fluids first, this will reduce the hyperosmolarity in the blood.
What is HIT?
Heparin induced thrombocytopenia, where there are mini clots throughout the body and clotting factor pays attention to the mini clots and then bleeding occurs.
Describe the first stage of labor.
From beginning of labor to dilation.
Right sided or Left sided heart failure?
Dependent edema
Right
What is the priority intervention for a patient with increased ICP?
Raise the HOB.
What is a black tag in a disaster?
This is a dead or dying patient who you move on from to treat the more likely to survive patient.
What are signs and symptoms of a thyroid storm?
Tachycardia
Hypertension
Increased body temperature
What is the best exercise for osteoarthritis?
Non weight bearing exercise. Swimming is a good example.
What conditions could potentially occur as a result of fluid volume back up as a result of decreased cardiac output?
CHF
Superior vena cava syndrome
Pericarditis
What is priority intervention for a patient following a femoral occlusion graft?
Assess circulation in post of leg.
What patient is the priority patient in the field?
The patient that is most likely to survive which means you move on from the black tag to the red tag.
How many feet away from the patient requires a mask with a patient on droplet precautions?
Within 3 feet of the patient would require a mask.
Right sided or Left sided heart failure?
Nocturia at night.
Left
What does low hemoglobin mean?
Anemia
What cranial nerve is assessed for swallow function?
9th cranial nerve or the hypoglossal nerve.
When is rheumatoid arthritis most painful?
In the morning.
What is normal HCO3 for ABG’s?
22-26
Describe cooperative play.
Children will use their social skills to interact and play with their friends.
Describe narcisistic personality.
A patient who likes to bring attention to themselves.
If your patient received 400 mL/ hr of fluid, but only 100 mL/ hr was ordered, what do you do?
Assess the patient.
What is an ilealconduit?
Use of a segment of the ileum for the diversion of urinary flow from the ureters. the segment is resected from the intestines with nerves and blood supply intact. The proximal end of the segment is closed, forming a pouch, and the ends of the ureters are sutured to it. The distal end is brought to the outside of the abdominal wall and effaced to form a stoma. The remaining ends of the small intestine are anastomosed to reestablish bowel continuity, the ileal loop no longer being a part of the intestinal tract.
What is a patient with Meniere’s syndrome at risk for?
Falls/ injuries
What can increase stress do to a patient with gout?
Increase flare ups. Decrease stress to decrease episodes.
What age does stranger anxiety develop in a baby?
7 months.
Right sided or Left sided heart failure?Enlarged liver and spleen.
Right
What GI disorder is directly associated with gastric cancer?
H. Pylori.
Define frequency related to labor.
Beginning of one contraction to the beginning of the next.
What are signs and symptoms of hyponatremia?
Nausea and vomiting Headache Confusion Loss of energy and fatigue Muscle weakness, spasms or cramps SeizureS Coma
What is the main concern during the fourth stage of labor?
Hemorrhage.
What herb or supplement reduces effectiveness of birth control?
St. John’s Wort
What is the dietary teaching for a patient with diverticulitis?
Low fiber.
What is the proper order for abdominal assessments?
Inspect
Auscultation
Percussion
Palpate
How do you watch a patient with bulimia eat?
You watch them for at least one hour after to make sure they are not vomiting it back up.
What is Addison’s disease?
HYPOsecretion of the adrenal hormones.
What isolation precautions are needed for TB and varicella?
Airborne
What is the most important thing to remember to do when working with a patient who is a suicide risk?
Ask them is they have a plan to commit suicide.
What is a DNR and who decides it?
An order where the patient does not wish to be resuscitated; The patient decides this while they are still able to make the decision for themselves.
What med is given for DI?
Vasopressin, desmopressin
What type of room is needed for a patient with TB?
Negative air pressure room.
What labs are associated with warfarin/ Coumadin?
PT and INR
What is a pneumothorax?
When air enters the pleural space around the lung causing the lung to collapse, usually occurs high in the lung lobes.
Right sided or Left sided heart failure?
Increased BP from excess blood volume.
Right
What do you do if you see a nurse walk out of the bathroom with blood on the AC?
Report it the the nursing supervisor.
How long does it take tissue to die in compartment syndrome and intercerebral hemorrhage?
2 hours.
What are the signs and symptoms of lithium toxicity?
Nausea/ vomiting (first sign)
Diarrhea
What herb or supplements prolong anastethsia?
Kava
Valerian root
St. John’s Wort
What effect does someone who eats licorice and takes digoxin for heart failure at risk for?
Reduced potassium
Increased risk of digoxin toxicity
What age does the babinski’s reflex disappear?
2 years.
Transition dilation.
7-10 cm
How is insulin mixed?
Clear to cloudy
How often are restraints checked?
Every 30 minutes.
A child in a room with other children but chooses to play with blocks by themselves is an example of what type of play?
Solitary play.
Normal albumin level.
3.5-5
What is tertiary preventions in health care?
Treating the condition after it has developed so that is does not worsen.
Therapeutic range of aPPT with heparin.
1.5-2.5 times the normal range.
What happens to a patient taking lithium who also has low sodium?
They can become toxic very easily.
What herbs or supplements need to be stopped before any surgery?
Ginkgo Kava Ginger, garlic, gingseng Fish oil Feverfew
What is the priority assessment of an ostomy?
Skin assessment and assessment of the stoma.
What is the smallest gauge needle that can be used for blood transfusions?
20 gauge.
What does obesity and gout have in common?
Uric acid increases and increases risk of a MI.
Define duration, related to labor.
Beginning of one contraction to the end of the same contraction.
If the mother is delivering and a cord is seen, what is important to remember?
Need to keep pressure off of the cord and do not push the cord back in.
What are signs and symptoms of hypokalemia?
Cardiac arrhythmias Constipation Fatigue Rhabdomyolysis Weakness or muscle spasms Paralysis
Resp increased bed to 45 degrees.
No answer – just know it.
What are the diet modifications for gout patients?
Low purine foods
No alcohol
No processed meats
Define paradoxical pulses.
BP 10 mm Hg or high on expiration than inspiration.
What is the primary nursing intervention for the patient who is suffering from PTSD?
Make sure that the patient knows that they are safe.
What is the treatment of cardiac tamponafe?
Pericardiocentesis.
What does hypokalemia cause in EKG’s?
U wave just after the T wave.
What insulins are cloudy?
NPH, an intermediate acting insulin
When can parents bath their newborn?
Once the umbilical cord falls off.
Normal potassium level.
3.5-5
What is a big concern in A Fib?
Blood clots in the atrium where the pooling blood occurs as it is not pumped out.
What does hemoglobin measure?
Protein level on the RBC to measure oxygen levels.
What age is associated with solitary play?
0-2 years
RA non pharmacological treatment is?
Relaxation techniques.
Normal range for PT.
11-12.5 seconds
Does anthrax need to be in an airborne precaution room?
No because this comes from tiny spores that are not suspended in the air.
What do you do if your patient with a basal skull fracture has raccoon eyes?
Provide them ice since it is an expected finding.
What is expected in an epidural?
Numbness below that point of injection, pain relief, numbness and tingling.
TPN; 110.8 temp – assess the client first
No answer– just need to know.
What do you do when a patient with Grave’s disease has an increase in tremors, restlessness and temperature?
Notify the doctor.
Why do you double a 2 year old’s height?
To get an estimate of adult height.
Client is going to surgery and states the they want to keep the room cold because their grandfather died when it was hot., what do you do?
Call the doctor to come talk to the client.
How much fluids should a patient with kidney stones drink?
3-4 L/ day
What are the important dietary considerations for a patient on Coumadin?
Tell them to keep following the same diet that they always have followed and do not deviate from the diet as it may affect Coumadin levels.
What labs are abnormal in Cushing’s?
Potassium is low.
Sodium and glucose are high.
Describe breaths associated with Cheyenne-Stokes.
Neurological – alternating patterns of depth separated by brief periods of apnea.
What angle are insulin injections given?
90 degree angle.
Right sided or Left sided heart failure?
Pallor
Left
Describe emergent, related to ER triage.
This patient needs to be seen right now.
How do you safely handle a patient who is displaying anxiety and panic?
Speak in a calm, reassuring voice and move them a quiet area and reduce external stimulation.
If a patient with pericarditis complains of pain, what is the best position to place them in to relieve the pain?
Tripod, leaning over the bedside table.
If a patient has a chest tube, what do you expect to see in the water seal chambers?
Intermittent bubbling.
What happens to a patient who is on an NG tube and is vomiting?
Alkalosis as the acidic component is lost in the vomit.
What mental health patient is most at risk of suicide?
Schizophrenic patient.
How do you prevent heat loss in a newborn infant?
Dry them Wrap in a blanket Place skin to skin Place a cap Monitor glucose levels
What is the blink reflex and what does it do for a person?
Automatic response of the 5th and 7th nerves to protect the eye from dryness or damage.
A woman in a motor vehicle accident with a hematoma, do you assess vitals or bowel sounds first?
LOOK THIS UP!
What can happen if you stop TPN too quickly? Why does this happen?
Hypoglycemia; the glucose can drop fast as the patient is used to receiving and the pancreas is not making enough for the body as it relied on the TPN for the level.
Right sided or Left sided heart failure?
Hacking cough, worse at night.
Left
What is the nurse’s priority assessment when running IV fluids?
Respiratory to monitor for fluid overload.
What is a red tag in a disaster?
The most emergent patient that needs to be cared for right now.
What do you do if there is more than 100 ml/hr in the collection chamber of a chest tube?
Call the MD, there is an active bleed.
If the patient is restless and agitated can you proceed with a lumbar puncture?
Nope.
Where will you see a pressure ulcer form?
Over bony prominences.
What is considered a toxic lithium level?
Anything above 1.5.
Why is it a medical emergency for the patient with a detached retina and placental abruption?
The blood vessels detach and lose the source of oxygen; reduce tissue perfusion.
Where do you hear bronchial lung sounds?
Over the trachea.
What line must TPN go into and why?
A central line because it is too concentrated to go in a peripheral line.
How much exercise should a patient with osteoporosis get?
Weight bearing exercise 30 minutes a day, everyday.
What does thyroid storm and organ rejection have in common.
Hyperpyrecia: Watch for eleven aged temperature.
When does an infant double their weight?
6 months
