Nclex Flashcards
Total knee arthroplasty (TKA) understanding or no understanding of the teaching provided.
understanding:
“I’ll call my surgeon if my incision gets red or has drainage.”
“I’m allowed to bear weight on my right leg.”
“I can probably drive in a few months
no understanding
“I can stop taking my blood thinner when I get home.”
“I’ll have physical therapy for about a week.”
Massive bleeding from gastric or duodenal ulcers
presents as hematemesis
minimal bleeding from these ulcers can present as
melena
massive upper GI bleeding occurs, the client may experience
dizziness
hypotension
and tachycardia
Massive bleeding from gastric or duodenal ulcers
The nurse would administer
oxygen
respiratory support as needed,
start two large-bore intravenous lines for isotonic fluids
and blood replacement,
monitor vital signs,
hematocrit,
and oxygenation saturation.
Warfarin
Anticoagulant
Atrial fibrillation
Ibuprofen
Nonsteroidal anti-inflammatory drug
Chronic back pain
Famotidine
H2 antagonist
Gastric acid reflux
Trimethoprim / sulfamethoxazole
Anti-infective agent
Urinary tract infection
Verapamil
Calcium channel blocker
Angina pectoris
Assessing a client for complications of a deep vein thrombosis,
The nurse recognizes
shortness
signs of pulmonary embolism,
hematuria
ecchymosis
signs of hemorrhage, which can occur as a result of heparin therapy.
Urinary catheter obstruction
Assess the three-way urinary catheter for kinks and blood clots.
Bladder spasm
Keep the three-way urinary catheter attached to the client’s thigh and encourage the client to relax his bladder muscles.
Postoperative TURP (transurethral resection of the prostate)
Immobility
Help the client to get out of bed, ambulate, and sit in a chair as soon as permitted after surgery.
Urine blood clots (Postoperative TURP)
Maintain the rate of continuous bladder irrigation to keep the urine clear.
Pain
Assess for pain every 2 hours and administer pain medication as needed.
atorvastatin
HMG-CoA reductase inhibitor
Management of hyperlipidemia
carvedilol
Beta-adrenergic blocker
Management of hypertension and heart failure
digoxin
Cardiac glycoside
Increase myocardial contractile force
lisinopril
Angiotensin-converting enzyme inhibitor
Management of heart failure
diagnosis of sickle cell disease, the nurse is aware
Acute vaso-occlusive episodes
Stroke,
Acute kidney injury,
and Sepsis.
Hydroxyurea ( sickle cell disease (SCD)
Be sure to follow up on all lab testing because the drug can lower your red blood cell and platelet count.”
“Because the drug can cause birth defects, be sure to use contraception to prevent pregnancy.”
“Try to avoid people with infection and public places where there are large crowds.”
“Hydroxyurea has been known to cause several types of cancer, so be sure to follow up with your medical appointments.”
Acute pulmonary edema
Administer furosemide 20 mg intravenous push.
Exacerbation of heart failure.
discharge instructions will the nurse provide
A “Weigh yourself each day at the same time on the same scale to monitor for fluid retention.”
B “Contact your primary health care provider if you experience cold symptoms lasting more than 3 days.”
D “Notify your primary health care provider if you experience shortness of breath or chest pain while resting.”
E “Do not use table salt, avoid salty foods, and read labels on all food items to ensure your diet is low in sodium.”
Secondary to severe weakness in his lower extremities.recent echocardiogram indicates moderate heart failure with an ejection fraction (EF) of 38%. Prescribed aspirin and a variety of cardiac medications. The nurse’s initial client assessment findings are listed
Blurred vision
Sinus rhythm with preventricular contractions
Bilateral basilar crackles
Creatinina kinase 1200 U/L
Potassium 5.2mg
The client is diagnosed with rhabdomyolysis. Prescriptions to place a large-bore intravenous catheter and administer normal saline 0.9% at 125 mL/hr are received.
Information missing
Client who has left ventricular dysfunction, the nurse assesses for COMFUSION.
CHEST PAIN related to inadequate myocardium perfusion.
OLIGURIArelated to inadequate renal perfusion.
Manifestations of pulmonary congestion include dyspnea, crackles, and tachypnea.
Place the client in a sitting position and administer supplemental oxygen and furosemide intravenous push.
Sickle cell disease is preparing for discharge to home with her parents.
nurse is planning health teaching to help the client prevent a sickle cell crisis
“Avoid overly strenuous physical activities.”
“Avoid temperatures that are extremely hot or cold.”
“Engage in low-impact, low-energy exercise three or four times a week.”
“Eat a healthy diet that is rich in fruits and vegetables.”
“Avoid high altitudes, such as mountainous areas.”
“Avoid smoking and tobacco use, including vaping.”
“Dress appropriately for the temperature that you are in.”
Echocardiogram results indicate moderate heart failure with an ejection fraction (EF) of 38%. The client’s wife provides a list of his current medications.
Aspirin
325 mg orally once a day Salicylate Prevention of platelet aggregation.
Atorvastatin
20 mg orally once a day HMG CoA reductase inhibitor Management of hyperlipidemia.
Carvedilol
12.5 mg orally twice a day / Beta-adrenergic blocker / Management of hypertension and heart failure.
Digoxin
0.125 mg orally once a day Cardiac glycoside Increase myocardial contractile force
Lisinopril
2.5 mg orally once a day
Angiotensin-converting enzyme inhibitor
Management of heart failure
18-year-old African-American female client reports shortness of breath, chest discomfort, fatigue, and fever for the past 3 days. She is admitted to the medical-surgical nursing unit with pneumonia and probable sickle cell disease
nursing actions are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Non-Essential (makes no difference or not necessary) for the client’s care at this time.
States she has had no shortness of breath since hospital discharge: INDICATE
Has 21 pitting edema in both ankles and feet : NO ESENCIAL.
Blood pressure = 134/76 mm Hg : INDICATE
Has had no chest pain since hospital discharge.
Contraindicated
Reports feeling like she has more energy now when compared with before her hospital stay.
Contraindicated
Has new-onset fungal skin infection: INDICATE
Nursing action is appropriate for each potential heart failure complication.
Acute pulmonary edema
Administer furosemide 20 mg intravenous push.
Fatigue
Consult a cardiac rehabilitation specialist.
Hypokalemia
Administer potassium supplements.
Cardiac dysrhythmias
Monitor electrocardiogram, oxygen saturation, and serum electrolyte levels.
Hypoxemia
Administer oxygen therapy.
sickle cell disease (SCD) Additional assessment finding that require follow-up by the nurse.
Report shortness of breath, chest discomfort, fatigue, and fever for the last 3 days
Both parent are SCD carriers. but the client has had no symptoms of the disease.
Reports feeling “lightheaded” at time.
Hemoglobin 11.4
Hematocritos 36%
Red blood cell 3.2
WBC 15000
Oral temp 101.6
Blood pressure 98/48
Exacerbation of heart failure chronic renal insufficiency, and coronary artery disease including a myocardial infarction and coronary artery bypass surgery 22 years ago.
For each assessment finding, indicate whether the interventions were Effective (helped to meet expected outcomes), Ineffective (did not help to meet expected outcomes), or Unrelated (not related to the expected outcomes).
States she has had no shortness of breath since hospital discharge: EFFECTIVE
Has 21 pitting edema in both ankles and feet
Blood pressure = 134/76 mm Hg: INEFFECTIVE
Has had no chest pain since hospital discharge:
EFFECTIVE
Reports feeling like she has more energy now when compared with before her hospital stay: EFFECTIVE
Has new-onset fungal skin infection: Unrelated
The primary health care provider prescribes hydroxyurea to prevent or reduce sickling or painful events caused by SCD. Which health teaching by the nurse about hydroxyurea is important to include?
“Be sure to follow up on all lab testing because the drug can lower your red blood cell and platelet count.”
“Because the drug can cause birth defects, be sure to use contraception to prevent pregnancy.”
“Try to avoid people with infection and public places where there are large crowds.”
“Hydroxyurea has been known to cause several types of cancer, so be sure to follow up with your medical appointments.”
Result of the client’s diagnosis of sickle cell disease, the nurse is aware that she could have multiple complications including acute severe pain periods known as
Severe pain periods known as Acute vaso-occlusive episodes.
monitors for other major SCD complications such as Stroke, Acute kidney injury, and Sepsis.
Diagnosed with a right lower extremity deep vein thrombosis (DVT) after surgery. Five days later the heparin infusion is discontinued and the nurse prepares to discharge the client on warfarin.
teaching will the nurse include as part of discharge planning
“Elevate your legs on a couple of pillows when in bed.”
“Wear knee-high graduated compression stockings.”
“Apply prolonged pressure over cuts and nosebleeds.”
“Increase your activity slowly and rest when needed.”
“Keep your scheduled appointment at the Coumadin (Warfarin) clinic.”
“Contact your primary health care provider if your stool is black and tarry.”
“Monitor your heart rate and blood pressure daily.
Diagnosed with a small bowel obstruction, received general anesthesia yesterday during an exploratory laparotomy, experienced a difficult recovery after surgery, and has been on bedrest since admission. Venous duplex ultrasonography of her lower extremities and laboratory studies are completed. Results from these diagnostic tests include the following data:
Apply sequential compression devices to bilateral lower extremities. CONTRAINDICATE
Teach the client to avoid foods high in vitamin K. Non-Essential
Plan to check the client’s platelet count in the morning. INDICATE
Use ice packs and massage techniques to decrease leg swelling and pain. CONTRAINDICATE
Assess for hematuria and blood in the client’s stool. INDICATE
Place client’s legs in a dependent position when sitting in a chair. CONTRAINDICATE
Monitor the client’s intake and urinary output. INDICATE
