Entire Nursing Content- Remar Flashcards
1
Q
What Blood Type is the Universal Donor?
A
o-
2
Q
What blood type is the Universal recipient?
A
AB+
3
Q
Antidote for Acetylsalicytic Acid? (Aspirin)
A
Activated Charcoal
Acetylsacitic acid increases the effects of Methotrexate (Chemo & Rheumatoid Arthritis Med)
Monitor H&H,INR & Renal Function
4
Q
What test confirms Acid Reflex (GERD)?
A
Barium Swallow Fluoroscopy
5
Q
What CD4 count indicate AIDS?
A
Less than 200
Zidovudine is the med of choice for AIDS
6
Q
Digoxin…. HOLD HR<60
S/S of toxicity: Yellow spots, Nausea, Vomiting, ABD Pain
What do we treat with?
A
Digibind or Charcoal
7
Q
Client has Bronzed Color Skin (hyperpigmentation), Lethargy, weakness, & weight loss.
What’s the diagnosis?
A
Addison’s Disease
8
Q
Client had an amputation. Pain still felt at that location even though limb Is gone.
What kind of limb pain is it?
A
Phantom Limb Pain
Note: Post Op AMputattion, keep limb up 1st 24hrs, then PRONE Position twice daily to prevent flexion.
9
Q
Client with aneurysm have severe pain, NV, tachycardia, decreased LOC and BP 60/30 & a Bruit is heart on auscultation .
What has occured?
A
Aneurysm RUPTURE
Avoid Straining, Lifting, Exerting
Take meds on schedule, report severe back/flank pain.
10
Q
Client has localized tenderness @ McBurney’s point.
Diagnosis?
A
Appendicitis
NPO-No Opiods-No Heat-No Laxatives-No Enemas
11
Q
Client with an spinal cord injury at T6 or above is known to have what condition?
A
Autonomic Dysreflexia
Can be caused by a full bladder or fecal impaction
Place client in High Fowlers, Check for bladder distention. Loosen restrictive clothing. Client need to void/have BM.
12
Q
Crainial Nerve 7 is known as what medical condition?
A
Bells Palsy
“I have 7 Bells”
13
Q
Client is straining to urinate, have decreased urine stream, and dribbling urine flow & feeling the need to go all the time.
Diagnosis?
A
BPH
Treat BPH with a TURP & monitor for bleeding/hemorrhage.
Post TURP to prevent blood clot, CBI continuous bladder irrigation.
14
Q
Male Client with pale blue and cold hands and feet, which may tingle or be painful. Diagnosis?
A
Buerger’s Disease
15
Q
Client with tooth decay, electrolyte imbalances , ulcers and cardiac arrythimias. They usually at normal weight but may also use enemas, drugs, diets & pills to try to lose weight. They often binge and purge.
Diagnosis?
A
Bulimia Nervosa
Supervise during meals
Assess suicidal potential
Establish diet plan
Antidepressants
16
Q
What to CAUTION mean for cancer?
A
Change in bowel or bladder
Any sore that dont heal
Unusual bleeding/discharge
Thickening in breast
Indigestion
Obvious change in wart
Nagging cough or hoarseness
17
Q
Internal/Sealed radiation
- Most dangerous
-Implant is inside
-All body fluids are radioactive
-If implant fall out, pick up with Long handle forceps/put in lead container.
-Private room/bathroom. Limit visitors. rotate staff.sign at door/bedside.
-To reduce nausea….admin Reglan (Metoclopramide)
A
18
Q
Client have milky/white painless lens, blurred vision.
Diagnosis?
A
Cataracts
19
Q
Client with Celiac Disease eat Rice & Corn. What foods must be avoided? (BROW)
A
Barley
Rye
Oats
Wheat
20
Q
Agnosia is the inability to..
A
use objects correctly.
21
Q
Client cant communicate properly is known as
A
Expressive Aphasia
22
Q
Client taking Compazine Should be monitored for What type of extrapyramidal reactions? (DAT)
A
Dystonia
Tardy Dyskinesia
Akathisis
to decrease extrapyramidal effects admin… Benztropine
23
Q
Client with buffalo hump, moon face, hirsutism, gained 20th, and lethargic
Diagnosis?
A
Cushings
Tx: Hypophysectomy or Adrenalectomy
then they will be on Life long Glucocorticoids
24
Q
Client has abdominal pain, Diarrhea, Weight loss, and Potassium 2.0z This condition affects digestive tract from mouth to anus and can’t be cured with surgery. Dairy & High Fiber meals should be avoided.
Diagnosis?
A
Chrohns Disease
(inflammation of bowels)
can lead to colon cancer
25
Clients stool presents with Steatorrhea (greasy, foul smelling,pale stool) & Thick, Sticky mucous causing possible obstructions.
Diagnosis?
Cystic Fibrosis
admin Pancreatic Enzymes
Sweat Test Diagnose It >60
High Calorie High Protein Diet
Postural Drainage to clear mucous
Genetic counseling before having another child
26
Child Drooling, Lost Voice(Dysphonia), and Can’t Swallow (Dysphagia) & Must go to Hospital Immediately.
Diagnosis?
Epiglottis
Airway is Priority!!!
27
Client having Blurry And Tunnel Vision & Seeing Halos. (Due to increased intraocular pressure)
Diagnosis?
Glaucoma
Admin Miotics
(Pilocarpine or Timolo)
28
Child have increased Bilirubin levels & Jaundice Skin.
Hyperbilirubinemia
How do you treat it?
Phototherapy
-Keep 18” Under lights
- Only keep diaper on
-Cover Eyes
-Turn off lights q8hrs for 15mins
- Monitor Temp
29
Client with Uncontrolled Dance like Movements called Chorea, & impaired judgment & cognition.
Diagnoses?
Huntingtons Disease
(Inherited Disorder 30-50 y/o)
30
Client with 3-4 watery stools, Fatty (Steatorrhea) stools and anorexia & fistulas that’s associated with smoking.
Diagnosis?
Crohn’s Disease
NPO- Bowel Rest- Steroids
31
Non-smoking Client have BLOODY diarrhea, weight loss & requires surgery to remove colon.
Diagnosis?
Ulcerative Colitis
-Decrease Fiber, Increase Protein
-Admin Sulfasalazine
32
How often should Incentive Spirometry Be administered to the client?
10 Times per hour
33
At what age do influenza vaccine be administered?
6 months
34
At what age MMR & Varicella start to be given?
12 months
35
When is Hep B be administered?
@BIRTH, 2, & 6 months
36
Baby presents with bulging fontanelles & Increased vitals.
Seizure precautions should be implemented.
Diagnosis?
Increased Intracranial Pressure
37
Laminectomy
Post op: Log Roll Client
38
What is Lead Poisoning Treatment?
Chelating Agents via IM injections.
39
Client had a bite from a Tick. How long after the bite can they be tested for Lyme Disease?
4-6 weeks
Doxycycline for adults
Amoxicillin for children
40
To prevent Lymphedema the affected area should be elevated.
Diagnosis?
Mastectomy
41
Client has severe sudden attacks of tinnitus, unilateral hearing loss, dizziness and NV.
Diagnosis?
Meniere’s Syndrome
-Bed rest in quiet room
-Move head slowly
- Sedatives
-Low playing music to keep calm
-If surgery removal of labyrinth
42
Client has +Kernigs & Brudzinski’s Sign. Michal Rigidity, headache, NV
Diagnosis?
Meningitis
-Isolation
-Antibiotics
-initiate Seizure Precautions
-Monitor LOC
43
Blackish-Bluish Spots on infant is known as?
Mongolian Spots
44
A psychiatric disorder that causes a person to self inflict injury/harm to his/her body?
Munchausen
45
Client with autoimmune disease resulting in extreme fatigue and muscle weakness. Difficulty talking, Chewing, Weak muscle eyes, Visual disturbances, & Unsteady gait.
To diagnose it a Tensilon Test is used.
Diagnosis?
Myasthenia Gravis
If Muscle Strength is increased, They are Positive for MG.
46
What is the chest pain that is not relieved by rest or nitro? Client will have sudden crushing pain that radiates to Jaw, shoulders, back and lasting >30mins.
Myocardial Infarction
Meds: MONA
Morphine
O2
Nitroglycerin
Aspirin
Place Patient on Bed Rest
47
Chest Pain lasting 3-5 mins and is Relieved By Rest & Nitroglycerin is known as?
Angina
-Unstable angina occurs while client is resting
TX: Nitroglycerin 3 tabs up to 5 mins sublingual .
Low cholesterol diet
Exercise & Stop Smoking
Avoid if male client takes viagra (Sildenafil)
48
What is the number one complaint in client taking nitroglycerin?
Headache
Other: Hypotension-tachycardia-syncope -dizziness
49
What is the aminoglycoside med given for GI tract before surgery to decrease bacteria and also given in clients with hepatic encephalopathy when ammonia levels are elevated?.
Neomycin Sulfate
50
Client just had an antipsychotic and have extreme fever, tachycardia, altered LOC, Seizures, Muscle Rigidity and elevated WBC or LFT.
What syndrome is they experiencing?
NMS
Neuroleptic Malignant Syndrome
Discontinue Med, Initiate Seizure Precautions, & admin Antipyretics to decrease fever.
51
To determine the length of the NG tube placed in the client, where do we measure? (from what to what?
Nose to the Earlobe to Xiphoid Process
52
To Aspirate for gastric content in client with NG Tube, the PH level should be less than?
4
53
S/S of NSAID (Aspirin) Toxicity?
Tinnitus
54
What is given to treat
Aspirin Toxicity?
Activated Charcoal or Sodium Bicarbonate
55
What is the Vitals in client with orthostatic hypotension?
(BP & HR)
BP decreased
HR increased
Check BP while client lying down, sitting up, & Standing.
Wait 5 mins between measurements.
Admin IVF
56
Client has heberden's nodes on the joints of fingers, joint pain & stiffness that is relieved by rest.
Diagnosis?
Osteoarthritis
ED:
If exercising STOP if pain occur
Lose weight to help take stress off joints
Hot/Cold Therapy
Use assistive devices (canes, braces, etc.)
57
Client with Pancreatitis (Acute) have bluish-purplish bruising around the UMBILICUS. What is this sign called?
Cullen's Sign
Note: Turner's sign is grey/blue color of the FLANKS
58
Client is shuffling steps, loss of balance , Bradykinesia, tremors in hands/feet at rest.
Diagnosis?
Parkinsons
Assess Neuro status
Swallowing ability
Asst with ambulation
Encourage fluids
High Calories/Fiber
Low Protein
MED: Levodopa or Carbidopa-Levodopa
59
Client with hx of alcohol abuse presents with abdominal pain, NV, Board like abdomen.
Diagnosis?
Pancreatitis (Acute)
60
Client with Peptic Ulcer Disease c/o Pain with meals or after eating. What type of Ulcer is this?
A. Duodenal Ulcer
B. Gastric Ulcer
Gastric Ulcer
61
Client's Legs is Hairless , cool, pale and have thick toe nails.
Diagnosis?
Peripheral Arterial Disease
"Dangle Legs"
ED: No smoke, No wear tight clothes, No Heat to Legs
Exercise & Inspect skin daily
Bypass surgery or angioplasty improves PAD
62
Client has a tumor that causes HTN, Sweating, Weight loss and Hyperglycemia.
Diagnosis ? (Begin with a Ph)
Pheochromocytoma
TX: Surgical removal of one of both adrenal glands
Post Op: Glucocorticoids
63
Client have streaks up the arm that are red, warm and painful.
Condition?
Phlebitis
Remove IV, Apply Warm towel, Assess for infection.
64
Pregnant older woman have bright red painless blood on her bed sheets.
Diagnosis?
Placenta Previa
TX: Bed Rest-C:section-Blood Transfusion- Frequent Vitals-Fetal Ultrasound-Fetal Heart Monitoring.
65
Pregnant have sudden painful bleeding with contractions & uterine tenderness that can cause Disseminated intravascular Coagulation (DIC).
(The placenta detaches itself from uterine wall)
Diagnosis?
Abruptio Placenta
TX: Bed Rest-C:section-Blood Transfusion- Frequent Vitals-Fetal Ultrasound-Fetal Heart Monitoring.
66
Rules of Nines..
What percentage is the Torso? (Front/Back)
36%
- Each Arm: 9%
-Each Leg: 18%
- Perineum: 1%
- Heck & Neck: 9%
67
Client has sharp pain on inspiration, SOB, Tachycardia and decreased breath sounds.
Fluid in pleural space is known as?
Pleural Effusion
TX: Thorancentesis
(Chest tube may be needed after)
68
Increase in RBC, Platelets & Leukocytes =Thick Blood, Increased clotting is known as ?
Polycythemia Vera
TX: Phlebotomy
(blood draws several times a year)
69
What is presbycusis?
Hearing Loss
70
When is RhoGam shot given in Pregnant Woman?
Given is Mom is RH- & Baby is RH+.
given 28 weeks gestation and within 72 hrs after delivery.
71
Antidote for Magnesium Sulfate?
Calcium Gluconate
72
How many arteries and veins do the umbilical cord have?
2 Arteries, 1 Vein
73
RhoGam is given to pregnant clients when the mom is _________ and the baby is ________?
Mom RH-
Baby RH+
74
Meds to Treat Pre-Term Labor
"I-N-M-T"
"Its Not My Time"
Indomethacin (NSAID)
Nifedipine (Ca Channel Blocker)
Magnesium Sulfate
Terbutaline (Watch for Increased HR)
75
To determine Fetal Heart Rate:
"VEAL CHOP"
What do Late Decelerations indicate?
Placental Insufficiency (BAD SIGN)
76
To determine Fetal Heart Rate:
"VEAL CHOP"
What do Variable Decelerations indicate?
Cord Compressions
77
To determine Fetal Heart Rate:
"VEAL CHOP"
What do Early Decelerations indicate?
Head Compressions
78
To determine Fetal Heart Rate:
"VEAL CHOP"
What do Accelerations indicate?
Oxygenation is OK
79
Interventions for Pregnant client having fetal distress?
"LION"?
Left Side Lying
IVFs
Oxygen via facemask
Notify Hcp
80
Interventions for Client have Group B Strep?
(SEPSIS!!!)
IVFs
81
Client have blurred vision, see floaters, black spots and flashes of light.
Diagnosis?
Retinal Detachment
- Cover both eyes with patches
- No coughing, sneezing, strict Bed rest, Elevate HOB
- Surgery to reattach retina
82
Client presents with fatigue, weight loss, and low grade fever. The ESR will be elevated and Joints BILATERALLLY will be affected.
Diagnosis?
Rheumatoid Arthritis
-Encourage client to exercise
- Take showers in am
83
Med of Choice for Scabies?
Permethrin 5%
84
Client with Shingles have itching vesicals grouped together on top of red rash that's painful, fever and feeling malaise. What type of precautions should be placed on?
Respiratory Isolation
- Rash will be unilateral
- Cool compresses
85
When should TPN tubing be changed?
Daily
- Change the TPN bag q24hr
- If TPN not avail, hang 10ths % Dextrose Water
86
If the client is NOT on ventilator but has a trach, How should the Cuff Be?
Deflated or Inflated?
DEFLATED!
(Dont Block Airway)
87
If client coughing strongly and trach becomes dislodged , interventions?
Keep Airway Opened by reinserting obturator or grabbing retention sutures.
Give O2
88
Client have a productive cough, night sweats, chills, low grade fever & weight loss with a Mantoux (PPD) test is >10. Diagnosis?
TB
-airborne precautions
-Negative pressure room (6 Fresh air exchanges per hour
- Vitamin B6 will be depleted
-Avoid Alcohol to prevent Hepatoxicity
89
Client have 20 Bloody Diarrhea Stools per day, abdominal pain, Weight loss and NV
Diagnosis?
Ulcerative Colitis
- removal od large intestine/rectum
-Post OP: Ileostomy
Low Fiber diet/avoid fiber; Fat greasy foods to decrease diarrhea---avoid alcohol & caffeine, Increase Fluid intake
90
Which vitamin is important in Blood Clotting?
Vitamin K (Green, Leafy Veggies)
91
Which vitamin is important in Eye Sight?
Vitamin A (Oranges, dark green, leafy veggies)
92
Which vitamin is important in Pernicious Anemia?
Deficiency in Vitamin B12
(Client will have paresthesia in hands and feet)
93
Which vitamin should be taken with iron?
Vitamin C
94
Child presents with hepatomegaly, acidosis, hypoglycemia and delayed growth.
(Liver glycogen disease)
Diagnosis?
Von Gierke's Disease
- Frequent Meals
-Allopurinol for gout
-Liver transplant
95
Genetic Defect that causes copper buildup that the body is unable to remove?
Wilson's Disease
- Avoid food High in Copper: Lamb, shellfish, vegetable juice, nectarines, dried beans, chocolate, multivitamins
96
How to Don (Put on) PPE? (GMGG)
Gown-Mask-Goggles-Gloves
97
How to DOFF (Remove) PPE? (GGGM)
Gloves-Googles-Gown-Mask
(remove the dirtiest first)
98
What infections are treated w/Standard Precautions ? (SHH...)
Shingles-HIV-Hepatitis
Hand Hygiene & PPE
99
Client with MRSA , C-Diff or Scabies should be placed on what type of Precautions )
Contact Precautions (DORMS)
- Private room w/sign on door. Cohort is fine
- Upon entrance/Exit wash hands with soap & water. Use disposable gowns, etc.
- Keep Stethoscope , BP cuff etc. In
100
Client with Influenza B, Pertussis: Whooping Cough, Strept Group A, Epiglottis, Meningitis, should be placed on what type of Precautions )?
Droplet Precautions (SPIDERMAN)
101
Client with shingles, measles, TB (suspected or confirmed), Varicella or chicken pox should be placed on what type of Precautions?
Airborne/Respiratory Precautions
- N95 Mask & Neg Pressure Room (6-12 air exchanges)
-Close the door when exiting
- Varicella is not contagious when all lesions are dried & crusted
102
What type of Precautions Used for EBOLA?
ALL PRECAUTIONS!!
Standard- Contact- Airbourne
103
How long should a Judaism (Jew) wait to receive dairy product after meat/poultry is consumed?
3-6hrs
- No Pork/Shellfish/Fish without Scales
-Dont admin oral drugs that contain Gelatin (gummies & Capsules)
104
Jehovah's Witness DONT accept blood transfusions. What do they accept instead of blood?
Erythropoeitin (Poetin alfa) & IV iron
- If child is in danger-- Admin the Blood! Save the child!
--Hemorrhaging: admin IVF & NSS 1st
105
What religion of client who is Lacto Ovo. Vegetarian ?
Hinduism
- No Types of Meat
- Avoid Dairy
-No Circumcision
-Can get Mechanical Valve Replacement
106
When should a urine culture be collected ?
Early in the am after waking
107
Urine specimen should not be taken from the bag. Use aseptic technique to transfer specimen from the collection port.
True or False?
True
108
What position should the client be placed in for a Enema?
Sims
- Hang enema bag no more than 12" in above rectum
-Retain for 5-10 mins
-Abdominal Cramping = Slow the Rate!
109
Blood Transfusion should be transfused within how many hours?
4 hours
- Get blood from blood bank, verify product with type & Crossmatch & 2 client identifiers with another nurse at patient's bedside. Make sure its compatible
- Stays with patient first 15mins and get vitals
UAP can get vitals after the initial 15 mins
110
What type of Burn?
No blisters, Pink/Red
Tender, May be painful, Epidermis
A. Full Thickness
B. Partial Thickness (2nd Degree)
C. Superficial (First degree)
Superficial (first degree)
111
What type of Burn?
Skin is Raw Red, Moist, Painful and May Blister
A. Full Thickness
B. Partial Thickness (2nd degree)
C. Superficial (first degree)
Partial Thickness (Second degree)
112
What type of Burn?
Skin is black/brown/yellow/pearly white and leathery. Blood vessels and bones may be seen... little to no pain.
A. Full Thickness
B. Partial Thickness
C. Superficial (First Degree)
Full Thickness
113
What is done in Emergency Burn Care ?
Fluids Immediately!
Elevate Extremities
114
115
What is the Parkland Formula for Burns?
(Calculates the fluid replacement needed in first 24hrs after a burn injury)
4ml X Body Weight X BSA
- 1/2 of total volume is given in the first 8 hours
- 1/2 of total volume is given over the next 16hrs
* Only partial thickness and full thickness burns are included in calculation
116
How often is the Porcine (Pig) Valve replacement is replaced?
Every 15 years
- No Muslims, No Jews, 7th day adventist
- Bovine (Cow) is replaced q15yrs
-Prosthetic (Mechanical) is NOT replaced.
- we worried about rejection of valves
117
Client with MUFFLED HEART sounds, JVD, Decreased BP, Increased HR & Drop in systolic BP of 10 points. (Beck's Triad)
Diagnosis?
Cardiac Tamponade
TX: Pericardiocentesis (Will increase BP)
- Cardiac Tamponade comes with acute pericarditis
118
Client BP 90/40, HR 92, having chest pain that RADIATES Midscapular or Upper Back...
Diagnosis?
Aortic Dissection (Emergency)
- We FOA Hemorrhage (which is why BP decreases)
TX: IVF & Beta Blockers
119
Client has precordial chest pain that radiates to the back.
Diagnosis?
Acute Pericarditis
- Ask "Recent Upper Respiratory Infection"
120
Client with bilateral edema , Brown discoloration, ulcers around ankle and upward.
Diagnosis?
Venous Insufficiency
TX: SCD twice daily- Ulnar Boot (hip)
- No pillows behind the knees
121
Client with DVT (Vein issue) have unilateral edema, the right calf larger than the left calf and have warmth erythema.
How should the legs be positioned?
Elevate Legs!
-Risk for PE- Dont massage site!
-Warm compresses
-Heparin
-Early ambulate
122
IV Drug user with nail bed hemorrhage, B-Splinter fingernails., Right sided HF symptoms & Triscupid Regurgitation.
Diagnoses?
Bacterial Endocarditis
- Antiembolism Stockings
- PE risk!
- IV Antibiotics
-NO hard flossing
-Assess for Petechiae
- Valve Replacement : Warfarin for Life
123
Child has Conjunctivitis, Red Rash, Aneurysm, Seizures, Strawberry Tongue, Hands/Feet peeling (desquamation)
Diagnosis?
Kawasaki Disease
- Report Fever Immediately
-Monitor the heart
-IV immuniglobin & Aspirin to prevent aneurysm
-No Live vaccines
124
Client have a fever of 105, Red Hot Joints, chorea, swelling in joints & subcutaneous nodules.
Diagnosis? (A-R-F)
Acute Rheumatic Fever
TX: Penicillin IM Monthly
DO cardiac Checks
Valve Replacement
125
Client is cyanotic, diaphoretic and tachypneic
Diagnosis?
(Air-....E)
Air Embolism
TX: Occlusine Dressing
100% O2 nonrebreather
Left Lateral Position
126
Client with severe SOB & Orthopnea, Tachycardia, tachypnea, Large amount of blood tinged, frothy sputum , cold clammy skin, cyanotic, wheezing, crackles and gurgling respirations
Diagnosis? P.... E
Pulmonary Edema
- HIGH FOWLERS
- O2-Check lung sounds- IV access- Diuretic-Morphine-Foley Cath
- Intubate and mech vent if needed
127
Where is Friction Rub heard at during auscultation?
ERB's
128
S/S of Spironolactone ? (K+ sparing)
Gynecomastia (male breast tissue)
- Sulfa Patients can have
Other K+ Sparing: SAMA
Spironolactone
Aldactone
Milirone
Amiloride
129
Patient gained weight over last few weeks.
Admin a Loop Diuretic: -IDE
BumetanIDE
TorsemIDE
FurosemIDE
What is the signs/symptoms of Loop Diuretic?
OOHH DANG
Orthostatic Hypotension
Ototoxcity
HYPOKALEMIA
HYPOmagnesium (Tremors)
Dehydration
Allery: Sulfa drugs (SAT)
Nephrotoxicity
Gout (uric acid build up)
- Check potassium levels prior to admin
-CHeck BUN & Creatinine levels
- BUN (6-20)
- Creatinine (0.6-1.3) ....FOA 2.0 or around
130
Chest Tube System
If the drainage system cracks or break what should the nurse do?
Remove the broken or cracked system and replace with new system.
- The chest tube is inserted into a bottle of sterile water.
- Keep a clamp at bedside, in case it needs to be changed (dont clamp without hcp order)
- Maintain the drainage system (CHEST TUBE/BOTTLE WATER at level of chest
131
Chest Tube System
what do continuous vigorous bubbling indicate?
Air Leak!
132
If fluctuations if the chest tube system stop, what to do?
Change position of resident
Check for kinks & occlusions
133
If there is No fluctuations on the chest tube, what do that mean?
Lungs Re-Expanded
134
Continuous/Gentle Bubbling on the chest tube system indicates?
Its working correctly in the suction control chamber
135
Client have dull lung sounds that could be caused by trauma, cirrhosis, infection or burns.
Diagnosis?(Pleural .....E)
Pleural Effusion
TX: Thorancentesis
136
Med treated for THRUSH?
Nystantin (Swish & Swallow)
137
Client with Atelectasis (Collapse of Lung).
Treatment?
Ambulate CLient
Incentive Spirometer
138
Client with pleuritic chest pain, crackles, wheezes, sputum, increased tactile remits, dullness to percussion.
Diagnosis?
Pneumonia
TX: Incentive Spirometer
Antibiotics, supportive measures , annual flu shot, pneumococcal vac & smoking cessation
139
Client presents with a seal like barking cough, running nose and stridor.
Diagnoses?
LaryngoTracheoBronchitis
TX: Open airway- supportive measures to decrease swelling (before we have to intubate them)
140
Client with Muffled voice, deviated Uvula, fever, and pooling of saliva & Increased Neutrophils.
Diagnosis? (What type of absess?)
Peritonsillar Absess
TX: Incision & Drainage
ABX (Antibiotic therapy)
141
Client have cold symptoms, with difficulty breathing and wheezing due to what condition that is mostly caused by RSV?
Bronchiolitis
- NO Antibiotics
- Supportive Measures ONLY
-If Severe: Mechanical Vent
142
Client with a Violent Cough "Whooping Cough"
lasting >2 weeks.
Diagnosis?
Pertussis
TX: High Fowlers
Every close contact with patient must be treated
143
Client weighs 165lbs and is 5' 9" tall
What is the BMI?
24.4
-165
-69"
Divide weight (Lbs) by Height (Inches) squared
Multiply by 703
Round to one decimal place
(165lbs/69"/69") X 703 =
144
Client has hemoptysis, hoarseness, unintentional weight loss, chest pain, wheezing and a cough.
Diagnosis?
LUNG CANCER
-Airway is Priority
- Fowlers-O2-Chemo-Radiation-Chest Tube-Ambulate
- Incentive Spirometer
145
Client have Swelling, Pain and Coolness at IV site.
What is this called?
IV Infiltration
-Remove IV immediately
- Elevate Extremity
- warm or cool compress
-dont rub to avoid development of hematoma
146
Obese client who had abdominal surgery has opened wound edges and the bowels or other abdominal contents is visible. (protruding of internal organs)
Diagnosis?
Wound Evisceratiion
-Call for help & stay with client
- Place client in LOW FOWLERS w/knees bent
- Cover wound with sterile normal saline dressing & keep the dressing moist
- Vitals & monitor closely for shock
- Prepare client for surgery
147
The separation of wound edges at the suture line is known as?
Wound dehiscence
148
Client with cerebral palsy uses a crutch gait that allows weight bearing and one foot placed in front of the other.
Which crutch gait is being used?
Four-Point Gait
-Right crutch then left foot. Left crutch , right foot)
149
Crutch gait used for no weight bearing status or partial weight bearing status?
3 point gate
(Both crutches and foot of affected extremity advanced together, followed by the foot of unaffected extremity)
150
The crutch on the affected side and the unaffected foot are advanced at the same time is known as which crutch gait?
2 point gate
151
CRUTCH SAFETY
- Look forward NOT down when walking
- Use Backpack to carry any items (Hands Free)
- Keep rubber tips of crutches dry
-Elbows flexed at 90 degrees
- Proper fitting of sling
152
When walking up the stairs with crutches, what leg is advanced first?
The "Good Leg"
Think of it as Good Going Up to Heaven
(When going downstairs, use the affected leg 1st)
153
The Cane should be on which side of the body?
STRONGER Side
-Hold cane on stronger side and move cane before moving weaker leg ALWAYS
154
How should you walk downstairs with a CANE?
Cane 1st
weaker leg, then stronger leg
155
How should you walk upstairs with a CANE?
Stronger leg first
Cane then weaker leg
156
157
How do you mix Insulin?
“Nicole - Ritchie-RN”
NPH (intermediate- put air in 1st)
then Regular (air into)
draw Regular
then draw NPH
158
3 Main s/s of Diabetes? (Ps)
PolyUria
Polydipsia (Thirsty)
PolyPhasia (Hungry)
159
Unconscious Hypoglycemic Diabetic Resident Unable to Swallow.
What to administer?
IV Dextrose
160
Diabetes Insipidus
“Pissing A lot, So Dry inside”
Caused by Lithium or Lung Disease
Client will have Polyuria & Polydipsia, Dehydration & increased NA
What is the Treatment for DI?
Desmopressin & IVF
Note: if too much decompression, can lead to water intoxication. (can lead to seizures, neuro damage or death)
161
SIADH
“Soaked Inside”
client will have fluid retention, crackles, JVD, and decreased urinary output
Interventions?
Fluid Restriction
Seizure Precautions
Neuro checks
Strict monitoring of I&O
3% NaCl
Demeclocine
162
What is the Treatment for ALL GI disorders? (NIPPA)
NPO
IVF
Pain Meds (PRN)
-Prazoles
Anti-Emetic (PRN) (Ondansetron-Metoclopramide)
163
Client is Screaming & Drawing the knees up to chest crying with abdominal pain. Bilious Vomit, A mass that is Sausage Shaped Mass & Current Jelly Stools .
Diagnosis?
Intussuception
164
Client Have olive shaped mass & projectile vomiting.
Diagnosis?
Pyloric Stenosis
TX: NIPPA
165
Baby refuse meals and had no meconium for 24-48hrs. Bilious Vomit. Toxic Megacolon.
Diagnosis?
Hirschsprung’s Disease
TX: NIPPA
stool softener is contraindicated
166
Child is Coughing, Choking & Cyanotic. Drooling, with a Distended Abdomen.
Diagnosis?
Tracheoesophageal Fistula with Esophageal Atresia
TX: NIPPA
167
Client taking NSAIDs develops blood in stool/vomit, Heartburn, NV and Anemia.
Diagnosis?
Gastritis
TX: NIPPA- BUN & Creatinine
Misoprostol - Vitamin B12
168
Client with joint pain upon awakening, ulnar deviation, morning sickness & tissue swelling & instructed to take a warm shower/bath upon awakening.
Diagnoses ?
Rheumatoid Arthritis
TX: MIM
- Methotrexate
-Isoniazid
- Metronidazole
(If prescribed Methotrexate, STOP if pregnant & double folic acid dose. Can terminate pregnancies)
169
Client presents with a molar butterfly rash, arthritis, ulcers and renal issues.
Diagnoses ?
Lupus
Treated with immunosuppressants (PAM)
-Prednisone
-Azothioprine
-Methotrexate
170
OBESE Client presents with inflammation of Big Toe (Podagia), swelling of joints, & dysuria.
Diagnosis?
GOUT
- Avoid or decrease organ meats
-Avoid or decrease ETOH
-Dont Smoke
-MED: Colchicine
-: MED: Allopurinol...Prevent build up of Purines
RF: Obesity, Organ meats, DM, ETOH, Poor Diet, Sardines, Increased BUN/Creatinine.
171
Client wit drooping eyelids, double vision, difficulty with breathing & swallowing with hoarse voice and trouble talking. Weakness & fatigue.
Diagnosis?
Myasthenia Gravis
- Eat small foods/meal to protect airway
-Flu vaccine >6 mos year old & pneumonia Vaccine
MED: Pyridostigmine (take before meals)
172
Indications of Dialysis in client with acute kidney injury? (AEIOU)
- Acid (Metabolic)
-Electrolyte Imbalance (K+)
-Intoxication Overdose
-Overload of Fluid
-Uremia (encepholopy-Pericarditis)
**Restrict Na & K+
**INcrease Phosphophus: Yogurt, cheese, etc.
173
Nursing Interventions for Hemodialysis?
HOLD MEDS until client return
Before & After Dialysis:
- Check Vitals
-Monitor BUN/Creatinine
-Check weight & last Dialysis weight
-Check thrill /Brui in AV Fistula
- Monitor for Bleeding (Heparin is added to bag)
174
What is the concern in Client with Peritoneal Dialysis?
Infection is the concern
-Use STERILE procedures when spiking & attaching bag with effluent
- Drainage bag below abdomen
- If fluid is Cloudy- FOA!! (Infection) -- Peritonitis
175
Client is guarding of abdomen, abdomen is hard and rigid with rebound tenderness.
Diagnosis?
Peritonitis
** Do a culture and sensitivity 1st!
