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NS 325 Med Surg > Final > Flashcards

Final Flashcards

1
Q

Liver cirrhosis can lead to?

A

An increase in ammonia levels

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2
Q

High ammonia levels can cause what complication?

A

Encephalopathy (hepatic)

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3
Q

What drug should you expect to administer for encephalopathy and what does it do?

A

Lactulose. Promotes frequent bowel movements to eliminate ammonia

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4
Q

What can happen if a liver cirrhotic pt has constipation

A

Confusion can be caused.

Ammonia gas sits within the colon which can get reabsorbed by the bowel.

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5
Q

High Potassium level what should the nurse expect to administer?

A
  1. Insulin IV
  2. Dextrose 50% IV
  3. Blood draw
    Insulin drives the K+ back into the cell
    Glucose prevents hypoglycemia
    check K levels
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6
Q

How do we initially treat small bowel obstruction?

What if upper GI discomfort

A

Rest the bowel with NPO status.

NGT is inserted to remove UGI contents and gas

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7
Q

What is the nurse most concerned with for Vomiting?

A

Airway management

increasing risk of aspiration if lethargic

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8
Q

What effect does a right hemisphere stroke have?

A

visual spatial deficit
affects left side (neglects left side)
hemiopsia vision

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9
Q

Neuro changes in older adults might be?

A

An evolving stroke

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10
Q

What is highest priority assessment with evolving stroke?

A

Dysphagia

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11
Q

What do you monitor for with a TBI? and what is it?

A

Cushing’s triad
BP - widened pulse pressure
HR decrease (may not be brady)
RR - change in pattern (may be fast or slow)

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12
Q

Nuerogenic Shock Symptoms

A

bradycardia
hypotension
Hypothermia

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13
Q

Trauma Symptoms

A

tachycardia
hypotension
clammy skin

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14
Q

During Shock what is the first nursing action?

A

Administer 100% O2 via nonrebreather mask

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15
Q

Head trauma Symptoms

A

declining neuro status

shown by positive Babinski and low Glasgow

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16
Q

Nurse must monitor for what in a head trauma?

A 
Monitor for signs of increased intracranial pressure
Papilledema
Cushing's triad
Decreases in Glasgow (slurred speech)
Decorticate posture
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17
Q

What is a classic sign of autonomic dysreflexia? and what is a nursing action?

A

Throbbing headache

Nurse should check for bowel or bladder retention

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18
Q

WHat life threatening conditioning mainly affects patients with spinal injuries of T6 or higher?

A

Autonomic dysreflexia

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19
Q

What does spinal cord injury:C5 and above affects?

A

Breathing

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20
Q

Spinal cord injuries are classified by?

A
  1. Mechanism of injury
  2. Level of injury
  3. Degree of injury
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21
Q

What causes stroke patients who have A-fib to be at higher risk of hemorrhagic stroke?

A

Warfarin (Coumadin)

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22
Q

Chronic Pancreatitis is exacerbated by

A

ETOH ingestion

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23
Q

Acute renal failure may be identified from which labs?

A

lab tests with results hyperkalemia and metabolic acidosis

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24
Q

GI bleeds Nurse Considerations

A

Monitor stools for bright red blood per rectum (BRBPR)

monitor for rigid, board-like abdomen (which means large bleeds into abd cavity)

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25
Q

What qualifications are necessary to give pt Altipase (TPA)?

A

Pt presents within 3-4.5 hrs of symptoms
it must be an ischemic stroke (not hemorrhagic)
must have CT scan (to rule out bleeds in brain)

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26
Q

What can cirrhosis pts sequester? What does that causes?

A

Albumin which leads to massive ascites.

fluid would be yellow/ gold in color (albumin rich.

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27
Q

Renal failure may reveal which high electrolyte?

What drug considerations must you monitor?

A

high K+
Let HCP know if pt is on Spirnalactone (K+ sparring meds)
Hold the meds

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28
Q

DIarrhea may cause?

Nurse considerations?

A

electrolyte depletion
Replace electrolytes as ordered
if C-diff let the body continue to purge in order to lessen amount of C-Diff

No immodium to pt

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29
Q

Vtach Nurse considerations

A

assess the patient’s level of consciousness

Defibrillate if unconscious w/ pulseless

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30
Q

Fluid volume overload?
Drug management
Nurse considerations

A

loop diuretic furosemide
Monitor Serum K+ and NA+ levels
Monitor daily weight gain in HF

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31
Q

Monitor for decompensating Heart Failure?
Right Sided HF symptoms
Left Sided HF symptoms

A

R: JVD, pedal edema

L: pulmonary edema, auscultate for crackles

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32
Q

Heart Failure Maintenance care?

A

moderate tolerable activity.
Stable Na and K intake
Monitor Heart rate
Monitor Body weight

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33
Q

Beta-blocker use Pt education

A

Expect some orthostatic hypotension

change positions slowly (from lying to sitting)

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34
Q

Prior to blood transfusion premedicate patient with

A

Diphenydramine and acetaminophen

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35
Q

Blood Transfusion

Nursing Considerations

A

stay with the client for the first 15 to 30 minutes of infusion via a large bore venous access ( 20 gauge or larger)

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36
Q

Transfusion hemolytic reaction symptoms

Nurse Considerations

A

headache
low back pain becomes apparent w/in 15-30 min.

Immediately stop blood transfusion and infusion NS w/ new tubing

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37
Q

Transfusion access ports

A

PICC and triple lumen catheters have one 20 gauge and one 18 gauge both appropriate for transfusion.

PICC central line can be inserted in the upper extremity.

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38
Q

PICC care includes

A

flushing both lumens daily w/ 10 mls sterile NS to maintain potency

Sterile occlusive dressing needs to be changed weekly

Never advance a catheter that has been pulled out a couple inches

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39
Q

Diabetes Type I Insulin Pump Care

A

Change the needle at least every 3 days

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40
Q

Sick day care for DM I

A

monitor for ketones
monitor serum glucose
continue insulin regimen when sick

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41
Q

DM II Metformin education

A

No hypoglycemia
weight loss of approximately 8 lbs
best taken with evening meal

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42
Q

Hypothyroid maintenance

A

Monitor for symptoms associated w/ decreased metabolism, constipation, always cold

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43
Q

Osteoarthritis: OA

A

affects articulating cartilage
herbeden nodules affect DIPS (distal interphalanges)

Pt joint stiff & has pain on movement but will improve with activity

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44
Q

Multiple sclerosis Presenting symptoms

A

Numbness, weakness

visual impairment/ sudden loss of vision de to optic neuritis

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45
Q

Normal Hgb and Hct

A

Hgb: 13.5 - 17.5
Hct: 41 - 53

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46
Q

Severe anemia requires

A

blood transfusions

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47
Q

Packed red blood cells Considerations

A

only contain red cells, so if 3-5 units are transfused know that they lack clotting factors

Pt needs fresh frozen plasma or clotting factors

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48
Q

Pre-renal failure

Signs and Symptoms

A

low or no urine output due to hypotension/shock

must send urine to lab for specific gravity - which should be high

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49
Q

GI Bleed can result in Anemia

Symptoms

A

Fatigue and/or SOB

low Hgb can decrease oxygen carrying capacity

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50
Q

Why must you monitor Hemoglobin count with anemia?

A

Asses for oxygen carrying capacity of the blood

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51
Q

Must monitor pt on Heparin infusion for

Nursing Considerations

A

must be prolonged range (60-80)

electric razor use is suggested for shaving

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52
Q

In pre-op assessment monitor for

A

medication use and let provider know if use Anticoagulant or NSAID use

Procedures may need to be delayed (w/ anti-coags or NSAIDS use)

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53
Q

Dentist must be aware of which drugs use and what is done?

A

Anticoagulant or NSAID use in order to administer topical clotting agents in dental procedures

dental procedures are scheduled w/o discontinuing med

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54
Q

Thrombocytopenia (what is it and risk)

A

low platelet count

Predisposes the client to bleeding tendencies

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55
Q

Normal Platelet Count

A

150,000 to 400,00

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56
Q

RA :(affects)

A

synovial joints bilaterally

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57
Q

Initial Rx for RA and nursing considerations

A

ASA, Steroids

high risk for GI Bleeds so check w/ Guaiac stools

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58
Q

Stronger Rx for RA and nursing considerations

A

Methotrexate

s/e is decreased WBC (<4000/uL)

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59
Q

Neurologic dysfunction can be expressed as

A

seizures

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60
Q

Antiseizure med Nursing considerations

A

Monitor for drowsiness, ataxia, diplopia

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61
Q

Seizure Nurse consideration Teaching

A

do not restrain limbs
do not stick anything into pt mouth

Educate pt: keep diary of them, can’t drive care, can’t take tub baths

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62
Q

Single most important action to prevent transfusion reactions?

A

Pt identification by two RNs

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63
Q

Glomerulonephritis can result from

A
  1. viruses that cause measles or hepatitis
  2. accumulation of antibody-antigen complexes & complement
    ex. Strep
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64
Q

Common cause of Hemolytic jaundice

A

is blood transfusion reaction

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65
Q

Common cause of post-hepatic jaundice

A

gallstone obstructing the common bile duct

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66
Q

Most common cause Hepatic jaundice?

A

cirrhosis or hepatitis

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67
Q

Support care during tonic clonic seizure

A

Rescue position, loosen restrictive clothing, prepare to clear airway

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68
Q

seizure inpatient precautions

A

maintain patent IV access
padded siderails
suction setup

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69
Q

Airborne precautions are used for?

A

Shingles, Herpes Zoster, Chicken Pox

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70
Q

What to do with two patients with acid fast bacilli? Room situation wise?

A

They can room together

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71
Q

Systemic Lupus erythematosis, Nurse Considerations

A

internal organs may be affected as well (Kidneys)

so monitor I&O

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72
Q

SLE Rx and use

A

Prednisone to stop the autoimmune hyperactivity

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73
Q

Postop stress may result in

A

Body retaining fluid so urinary output is decreased.

Day 2 stress response decreases and urinary output increases

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74
Q

S&S of a Transfusion reaction

What is the nursing action?

A

Increased HR, Increased RR, back pain

Stop the transfusion and change to new tubing w/normal saline infusion

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75
Q

Hemodialysis (HD)

First session complication

A

First sessions may be complicated by disequilibrium syndrome
Rapid solute loss from the extracellular fluid causes mild cerebral edema

Pt may complain of nausea and headache

76
Q

Anaphylaxis (What is it and Nurse Considerations)

A

known allergy to bee sting
1st action is to manage airway
1st medication action is to administer Epi-pen (stops histamine release)

77
Q

Nurses first action during post op recovery?

A

Continuous monitoring oxygen saturation.

Auscultate lungs to ensure breath sounds are clear.

78
Q

ITP - idiopathic thrombocytopenic purpura

Nurse considerations

A

bleeding disorder in which the immune system destroys platelets.

Avoid IM or SubQ injections

79
Q

HD education

A

teach the pt to monitor I&O
Take daily weight
Pt diet: limit Na and K+

80
Q

Gall Bladder inflammation

Pt education

A

cholecystitis suffers do not always have GB removed

Education: low fat diet, choose poached or baked proteins, no fried foods, no fat desserts

81
Q

Septic shock presentation

A

hypotension

82
Q

Nursing action with septic shock

A

Administer IV fluids

Administer ordered vasoconstrictor to raise the BP (norepinephrine)

83
Q

Nursing considerations for Septic shock

A

Monitor for target organ perfusion w/ urinary output for >30ml/hr

84
Q

Pressure Ulcers Stage III and Stage IV?

A

Stage III - involves subQ tissue

Stage IV - deeper subQ tissue and also involves underlying fascia

85
Q

Heparin induced thrombocytopenia (HITTS)

What is it and how is it confirmed

A

an immune mediated clinico pathological syndrome initiated by heparin therapy.

Confirm with decreasing activated partial thromboplastin time

86
Q

HD pts at risk for? What S&S?

A

at risk for fluid volume overload (FVO)

Assessment findings for FVO: tachypnea, JVD, bounding peripheral pulses, crackles @ bases of lungs

87
Q

Dysphagia risk and nursing considerations?

A

swallowing disorders carry risk of aspiration

Nurse action: avoid thin liquids (Pt must have thickened diet?

88
Q

Femur Bone Fracture - nurse consideration

A

Assess for Neurovascular issues

Check for decreased sensation below the fracture

89
Q

Osteoporosis - Results in and pt education

A

bones are weakened by loss of substance and loss of density

educate pt to walk every day to give the bones work

90
Q

THA (total hip arthroplasty) Nurse Considerations

A

keep abductor pillow in place
Monitor for DVT

Educate pt when discharge don’t cross legs
don’t bend trunk to reach below waistline
Pt should use elevated toilet seat

91
Q

Nurse consideration for emergency care sprains or fractures?

A
  1. check pulse
  2. stabilize lightly
  3. apply ice to site
92
Q

Assessment and actions are guided by what first?

A

Airway!!!!!!!

If he’s breathing what is the oxygen saturation

93
Q

Intercranial Pressure (ICP) consist of

A

Pressure inside the skull
Brain tisse
CSF
Blood

94
Q

ICP Pressure normal

95
Q

Nursing interventions for ICP increase

A

Position pt supine with HOB @ 30 degrees

Limit head movements and turning of pt

96
Q

Head injuries can cause?

A

Increase in ICP and Brain Edema

97
Q

Increase of ICP Symptoms

A 
change in Level of Consciousness
increasing Lethargy (ALWAYS REPORT)
98
Q

Normal Sinus Rhythm

Athletes HR

A

Normal 60-100 bpm and regular

Athletes 50 bpm

99
Q

What ECG dysrhythmia is lethal? and Nursing Action

A

V-fib

Shockable rhythm - Grab Crash Card Defib or AED

100
Q

What happens to patient if they have a really fast rate?

A

Pt feels racing n their chest

The cardiac output drops and pt feels faint

101
Q

Cancer - S&S

A

profound fatigue,

increased risk for DVT due to decrease clotting time (make clots fast)

102
Q

Cancer diets

A

should be high in calories and protein

low in fats, low in empty carbs, not too many sweets

103
Q

Hemophiliacs Nurse considerations and Educations

A

Danger of bleeding without knowing they are bleeding internally

Educate pt to seek immediate medical attention if have abdominal pain

104
Q

UTI Teaching

A

Hydration will help physically wash bacteria off the bladder wall and decrease colonization

105
Q

UTI (Cystitis)

What is it and risk to kidney (S&S of kidney)

A

overgrowth of bacteria in the urinary system.

Bacteria can translocate to kidney
Pt may experience flank pain and develop pyelonephritis

106
Q

Stress incontinence

S&S and treatment

A

dribble of urine with sneeze

May be improved with 3 months of pelvic floor exercises

107
Q

Nurse considerations for GERD patients

A

lying patients flat can increase risk of aspiration

Assess lungs

108
Q

Hallmark symptom for hepatitis

109
Q

Hep. A transmission

A

oral fecal route including high fecal count in food

110
Q

Hep. C. transmission

A

Blood to Blood - IV drug use, Transfusion, Hemodialysis - needle stick injuries

111
Q

Ulcerative colitis flairs - Nurse considerations

A

frequent bloody stools require pt to be NPO in order to rest the gut

112
Q

Craniotomy risk and Nurse considerations?

A

Infection (Meningitis)

Monitor for fever, shivering, increased WBC
Monitor for Kernig’s sign
Monitor for 2-3 days

113
Q

How do we diagnose ALS?

A

test reflexes which show abnormal or excessive movement at site or excessive movement seen at other parts of body

114
Q

What happens to muscles due to ALS?

A

Atrophied and weakened

115
Q

How do we diagnose MG?

A

test reflexes

They are depressed and no excessive or involuntary movements

116
Q

Glasgow Coma Scale

A

3-15

15 is normal and highest

117
Q

AIDS diagnosis is made by

A

CD4 with T cell count of <200

118
Q

HIV transmission

A

largely via sex or IV drug paraphernalia sharing

Not transmitted by saliva

119
Q

Functional incontinence and Nursing interventions

A

caused by barriers to toileting when urge presents

Managed by implementing a toileting schedule with assist

120
Q

Irritable Bowel Disease (IBD) Dietary preference

A

Minimize fats

stay away from fats w/ NCLEX

121
Q

Ulcerative colitis - Monitor for?

A

holds potential for GI bleeding or peritonitis

be alarmed by rebound tenderness - call HCP

122
Q

Stones/renal calculi Nurse intervention

A

Pain management
stones may move/irritate tissue
Pain and hematuria may alarm the pt.

123
Q

Guillian Barre Syndrome

Nurse Considerations

A

Ascending Paralysis
Monitor for when it reaches diaphragm
Concern of effective breathing

124
Q

Parkinson’s Disease (PD) S&S

A

Tremors (pill rolling), bradykinesia, limb rigidity

Passive ROM illicits cogwheel rigidity

125
Q

Delirium

What is it and Nurse Teaching

A

confusion r/t illness hospitalization, meds

change in routine can be supported by having family to reassure them

126
Q

Alzheimer’s disease diagnosis

A

Can only be made when other causes of dementia are ruled out
Seek diagnosis as early as possible
so Aricept can be most effective

127
Q

Nurse Consideration for Dementia

A

Reorient to place and time

128
Q

IM injection procedure

A

Inject then Aspirate then inject into muscle

if get blood when aspirate: dispose of needle and med and start whole new process with new med, new syringe, new needle, new alcohol swab, new site

129
Q

OPIOIDS - Nursing considerations

A

Can cause pupil constriction
decrease respiratory drive
decrease peristalsis
increase nausea and vomiting

130
Q

Hormone replacement Therapy (HRT) - Nurse considerations

A

Monitor for safe administration
report complaints of lumb numbness or intense headache and calf pain

HRT increases risk of DVT

131
Q

Thromboembolic elastic stockings used for?

Nurse considerations

A

For peripheral venous disease to promote circulation

Stockings should be placed before getting out of bed in the morning
Legs should be elevated when not wearing stockings
Must be removed daily for skin check

132
Q

What is given to expand intravascular volume?

A

Isotonic solutions of 0.9% NS or Lactated Ringers

133
Q

Before IV removal Nurse Considerations?

A

Always assess IV site

134
Q

Infusion Care for Peripheral IV site selection

A

Selection in the upper limb
Starting at or close to hand on side that has least complications

Don’t use limb side of dialysis AV shunt or mastectomy site

Nondominant limb more convenient

135
Q

IF IV site vein becomes compromised?

A

Fluids can leak into the surrounding tissue (extravasation) and may require removing catheter

May try flushing the line, temp. of fluid, or pH of infusion may cause intermittent discomfort but nothing is wrong w/ IV catheter

136
Q

Discontinuation of IV site

A

Compare the site to the opposite entry

Put in the New IV before discontinuing initial catheter site

137
Q

Ventricular tachycardia

A

assess pt LOC, if unconscious w/ pulseless vtach

dfib is indicated

138
Q

Pacemaker teaching

A

Teach client to let providers know of pacemaker before procedures

139
Q

Surgical Pre-op Teaching

A

Teach pt about what to expect in OR (drains, dressings, mobility limits, and how long each post op phase will last.

Teach splinting techniques to increase deep breathing and cough

140
Q

Surgery Pre-Op allergy?

A

Identify especially if have iodine/shellfish allergy

141
Q

Post anesthesia nursing Interventions?

A

Promote deep breathing and cough
Blow off CO2
Increase oxygenation

142
Q

Post procedure Monitor which complaints

A

if abnormal VS readings - confirm equipment correctly working

Look at the patient and what is he exhibiting

143
Q

Post op care with angiogram tests that involve catheter being placed in blood vessel

A

Clot may be dislodged to the lungs, heart or brain

monitor for pulmonary embolism or stroke (brain embolism)

144
Q

Gastric hemorrhage suspected

A 
NG tube is inserted to monitor rate of bleed
H2 blocker (ranitidine) decreases acid production
145
Q

Situations of Respiratory distres nurses first action?

A

Always give Oxygen first

do not place in high fowlers first

146
Q

Jackson-Pratt drains care

A

should be compressed after emptying.

Compressing and replacing the cap creates a vacuum that gently draws excess fluid from the site

147
Q

Post-op nausea Nursing Care

A

may result in emesis.
If BP is normal position pt in High Fowlers
if hypotension - position side lying

148
Q

Incisions

A

if edges are aligned we document them as approximated

if sides are pulled apart the wound has eviscerated

149
Q

Evisceration - Nurse Care

A

maintain skin viability by applying sterile-soaked dressings to the wound

150
Q

Osteomyelitis; Drug and Nursing Care

A

Antibiotic treatement of gentamycin requires monitoring for tolerance

Hearing can be ototoxic
Kidney ability for drug clearance must monitor Cr

151
Q

Nutritional status monitoring

A

best by prealbumin level

23-43

152
Q

Total Parenteral Nutrition (TPN)

Nursing care

A

Concentrated glucose infusion w/ elemental electrolytes, vitamins, minerals, and insulin (to counter increased glucose)

Must monitor blood glucose every 4 to 6 hours

Since solution is super sugar administer 50% of goal for first day to allow body to adjust

Cover catheter site w/ occlusive dressing

153
Q

Thoracentesis procedure - Nurse care

A

Provide pain management before the procedure

Instruct the patient to take deep breaths after the procedure

154
Q

Pleuravac Monitoring

A

Chest tube system is properly functioning if the water level is fluctuating in the chamber

fluctuation in water level reflects the client’s respiratory cycle

155
Q

Multidose inhalers Pt education

A

educate pt to wait a minimum of 1 min. between puffs and rinse mouth after use

156
Q

Mechanical Ventilation via endotracheal tube (ETT)

Nursing Care and Monitoring

A

Suctioning can stimulate the vagus nerve and drops the heart rate
if Hr drops while suctioning –>STOP and manually oxygenate the client w/ ambu bag

157
Q

What to do when pt “fights the ventilator” mechanical ventilation via ETT

A

We try to “talk them down” with explanations for them to relax and allow the ventilator to work for them

158
Q

Suction pressure

A 
80-120 mmHg (green zone)
Insert catheter w/o suction 
initiate cough
suction for 20 seconds
use intermittent suction while withdrawing catheter
159
Q

Asthma

Treatment and S&S

A

Constricted airways will result in decreased forced expiratory volume (FEV) by 20%
forced vital capacity decrease
increased respiratory rate and decreased pulse ox.

Treatment - rescue albuterol
When the bronchodilator relaxes the constriction and improves measurements

160
Q

COPD Nursing Considerations

A

low oxygen support (2L/min)
3000 ml/day to liquify secretions
give gauifenesin to mobilize secretions
Place pt in High fowlers position

161
Q

TB diagnosis

A

Sputum is positive for acid fast bacilli

when ruling out TB; pt is placed respiratory isolation and may be cohorted w/ another patient positive for acid fast bacilli sputum

162
Q

Acute renal failure (monitor what serum level)

A

associated w/ hyperkalemia

163
Q

Dialysis (hemo) care post procedure must monitor

A

level of consciousness

164
Q

Dialysis (peritoneal) nurse care

A

in drain phase, monitor for drainage

monitor patient position for tube patency (no kinks)

165
Q

Nephrectomy

Nursing Considerations

A

removal of kidney
immediate post-op monitor for hemorrhage
compensatory tachycardia due to blood loss
hypovolemic shock

166
Q

Nephrostomy tube care

A

patient will have low grade fever (<100.4)
urine may be blood-tinged
urinary output is increased
Call HCP if pt reports back pain

167
Q

Erectile dysfunction (Contraindication)

A

Nitrates,

systemic venodilation can cause severe hypotension

168
Q

Stress incontinence Education

A

instruct that adequate fluid intake is needed
It is dangerous to become dehydrated

Kegel exercises for at least a month may strengthen the pelvic floor

169
Q

Irritable Bowel Diet

A

Promote 30 grams of fiber into daily diet

170
Q

How do we check Bedside NGT placement?

A

NGT verified with pH that is <5

171
Q

Immediate Burn Care

A

Manage airway,

Administer aggressive IV fluids to support circulation

172
Q

Stoma Skin Care

A

Surrounding skin can be protected from enzymes and bile salts in GI drainage

use skin barrier product before refitting pouch system

173
Q

Hyperkalemia Signs

A

peaked T waves on ECG

174
Q

Hypocalcemia S&S

A

muscle twitching, muscle spasms

175
Q

Hypermagnesemia S&S

A

leads to depressed or absent deep tendon reflexes

176
Q

High ammonia can result in

A

hepatic encephalopathy

177
Q

Initial Nursing action with Heat Stroke

A

Initially must cool the patient

178
Q

Initial Nursing action for Motor vehicle accident (MVA)

A

apply cervical collar to stabilize spinal column, spinal cord

179
Q

Initial nursing action for Anxiety attack?

A

Must administer non-rebreather mask without oxygen and stay with patient

180
Q

When pt complains of increasing pain in cast what should be nursing action?

A

Immediately Call Provider!!!
could be misalignment or development of compartment syndrome

poor circulation distal to fracture

181
Q

Most concerning assessment in regard to cast care?

A

Pt complaint of tingling and numbness because it reflects changes to circulation and nerve function

182
Q

Traction nursing care

A

log roll
maintain skin integrity
Weights must hang freely
Never place weights on floor

183
Q

Rheumatoid arthritis (RA) non pharmacologic pain management

A

Can include alternating heat and cold to decrease joint inflammation

184
Q

Hip replacement

Anticipated finding and drug administration

A

site undergoes healing may be warm and red

Administer anticoagulant therapy due to high risk for DVT

185
Q

Anticoagulant dose is appropriate when INR range is?

A

2.5-3.0

PTT 2 times normal value

186
Q

Sign of inappropriate blood clotting?

A

May be petechiae on the trunk

NS 325 Med Surg (1 decks)

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