O GUIDE Flashcards
Where is the bronchial breath sounds located, what is the characteristic of the lung sound?
A. low pitch located in upper diaphragm
B. Loud, harsh high pitch heard over the trachea(between clavicle and midsternum)
C. Blowing sound heard in the posterior chest between the scapulae in the center part of the chest
D. Soft , breezy low pitched sound heard over most of the lung fields and peripheral lung area
B. Loud, harsh high pitch heard over the trachea(between clavicle and midsternum)
Where is the bronchovesicular breathe sounds , what is the characteristic of the lung sound?
A. low pitch located in upper diaphragm
B. Loud, harsh high pitch heard over the trachea(between clavicle and midsternum)
C. Blowing sound heard in the posterior chest between the scapulae in the center part of the chest
D. Soft , breezy low pitched sound heard over most of the lung fields and peripheral lung area
C. Blowing sound heard in the posterior chest between the scapulae in the center part of the chest
Where is the vesicular breathe sounds , what is the characteristic of the lung sound?
A. low pitch located in upper diaphragm
B. Loud, harsh high pitch heard over the trachea(between clavicle and midsternum)
C. Blowing sound heard in the posterior chest between the scapulae in the center part of the chest
D. Soft , breezy low pitched sound heard over most of the lung fields and peripheral lung area
D. Soft , breezy low pitched sound heard over most of the lung fields and peripheral lung area
Your client has been admitted due to jaundice and epitaxis. The doctor has ordered lab draws and his ALT levels are 70(4-36). Which of the following drugs do you suspect has caused his liver function test to be elevated?
A. Acetominpophen
B. Ampicillin
C. Phenytoin
D. Lithium
E. Valproic Acid
E. Valproic Acid
A. Acetominpophen
C. Phenytoin
Where is the location of the aortic Valve?
A. right 2nd intercoastal space
B. Left 2nd intercoastal place
C. left 3 intercoastal space
D. left 4th intercoastal space lower left sternal boarder
E. the 5th intercoastal space midclavicular line
A. right 2nd intercoastal space
Where is the location of the Pulmonic valve
A. right 2nd intercoastal space
B. Left 2nd intercoastal place
C. left 3 intercoastal space
D. left 4th intercoastal space lower left sternal boarder
E. the 5th intercoastal space midclavicular line
B. Left 2nd intercoastal place
Where is the location of Erbs point
A. right 2nd intercoastal space
B. Left 2nd intercoastal place
C. left 3 intercoastal space
D. left 4th intercoastal space lower left sternal border
E. the 5th intercoastal space midclavicular line
C. left 3 intercoastal space
Where is the location of Tricuspid valve
A. right 2nd intercoastal space
B. Left 2nd intercoastal place
C. left 3 intercoastal space lower left sternal border
D. left 4th intercoastal space
E. 5 the intercoastal space midclavicular line
D. left 4th intercoastal space
Where is the location of Mitral Valve
A. right 2nd intercoastal space
B. Left 2nd intercoastal place
C. left 3 intercoastal space
D. left 4th intercoastal space lower left sternal border
E. The left 5th intercoastal space midclavicular line
E. The 5th intercoastal space midclavicular line
You as the nurse is administering a phospate with gravity to a client with fecal impaction. The client is complaining of stomach cramps. What is the best action by the nurse?
A. Increase the height of the gravity enema
B. Insist the client hold his buttocks together
C. Decrease the height of the gravity enema to reduce the speed of the flow
D. Stop the enema transfusion
C. Decrease the height of the gravity enema to reduce the speed of the flow
Which of the following signs and symptoms are associated with intusseception for a neonate?
A. currant jelly stool
B. Olive mass on abdomen
C. Ribbon like stool
D. bilious vomitting
A. currant jelly stool
s/s Intense abdominal pain
Abdominal swelling or distension
Currant jelly stools**
Bilious vomit
Lethargy
Shallow breathing
*Tender distended abdomen, possibly with a palpable sausage-shaped mass in the upper right
quadrant
Your client with intucceston is a preparing for surgery. What finding should you report to the Health Care. Provider immediately?
A. Bilious vomit
B. Sausage shape mass in upper right quadrant
C. Olive shaped mass
D. passing of brown stool
D. passing of brown stool
Passage of a normal brown stool
usually indicates that the
intussusception has reduced
itself
he parent of a 4-year-old child tells the pediatric nurse that the child’s abdomen seems to be swol- len. During further assessment, the parent tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms’ tumor, would plan to avoid which during the physical assessment?
- Palpating the abdomen for a mass
- Assessing the urine for the presence of hematuria
- Monitoring the temperature for the presence of fever
- Monitoring the blood pressure for the presence of hypertension
- Palpating the abdomen for a mass
(-also known as nephroblastoma - unilateral kidney tumor)
Nursing considerations , do not palapate
, monitor BP
s/s
Painless, firm mass in abdomen, deep in flank
area
Confined to one side
Weight loss
Fever
Hypertension (occasionally)
Anemia
Lymphadenopathy (swelling of lymph nodes)
- Swelling or mass within the abdomen (mass is
characteristically firm, nontender, confined to one side, and deep within the flank) - Urinary retention or hematuria, or both
- Anemia (caused by hemorrhage within the tumor)
- Pallor, anorexia, and lethargy (resulting from anemia)
- Hypertension (caused by secretion of excess amounts of renin by the tumor) 6. Weight loss and fever
Your client’s Total Parental Nutrition has been delayed due to manufacture issues. Which order from the nurse should she recommend the Health Care provider to prescribe?
A. Dextrose 10%
B. 0.45% NS
C. 0.9% NS
D. Sodium Chloride 3%
A. Dextrose 10%
TPN requires two nurses to verify
-if TPN IS LATE DO NOT SPEED INFUSION(DELIVER AT RATE PRESCRIBED YOU ARE NOT THE DOCTOR)
Your client with sickle cell is cureently in crisis. What order(s) would you suspect the physican to order?
A. Furosemide
B. 0.9% NS
C. Lithium
D. Morphine
E. O2 Nasal cannula 3L/min
B. 0.9% NS
D. Morphine
E. O2 Nasal cannula 3L/min
What is the nursing intervention for a new born with Jaundice?
A. Adminster vitamin K
B. Phototherapy
C. Assess sclera
D. Assess feet
B. Phototherapy
Your baby may have jaundice if their urine is yellow(a newborn baby’s urine should be colourless) or their poo is pale (it should be yellow or orange).
What should a new born always have on if recieving phototherapy? SELECT ALL THAT APPLY
A. eye covers
B sunscreen
C. Head covering
D. Diaper
D. Diaper
A. eye covers
Should the bay be front facing or rear facing when in a car seat?
A. Rear
B. Front
- Always place your baby in an approved car safety seat when traveling in a motor vehicle (car, truck, bus, van), train, or airplane.
- Your baby should be in a rear-facing infant car safety seat from birth for as long as possible until exceeding the car seat’s limits for height and weight. The car safety seat should be in the back seat of the car (see Fig. 23.21).
Which of the following is a warrants immediate attention after your client has recieved a brochoscopy?
A. Positive gag relex
B. Esophageal soreness
C. Mild pain
D. bloody sputum
D. bloody sputum
Which of the following is the correct teaching for your client who has a hearing aid?
A. Clean the hearing aid with hydrogen peroxide
B. Increase the volume of the hearing aid unil you hear echos
C. Keep the hearing aid as far away fro your bedside table
D. Turn the volume until hearing is established
D. Turn the volume until hearing is established
-Clean with mild soap and water
Your client has been taking long term antiacids due to a history of peptic ulcer disease. Which acid base disorder would you suspect your client to have?
A. metabolic acidosis
B. metabolic alkalosis
C. restipratory acidosis
D. respiratory alkalosis
B. metabolic alkalosis
Your client has been using excessive laxative due to a history of Bulimia Nervosa. Which acid base disorder would you suspect your client to have?
A. metabolic acidosis
B. metabolic alkalosis
C. restipratory acidosis
D. respiratory alkalosis
A. metabolic acidosis
Is Amtriptiline cardiotoxic?
A. no
B. yes
B. yes
You client with major depression disorder has called the clinic due to an unsuccesful suicide attempt. He explains to you he ingested his weekly prescription of Amtriptiline in one sitting and is having palpitations. What is the nurses best response?
A. “Why would you do this?”
B. “I would advice you to think about the consequences of your actions.”
C. “I am glad you called I will send an ambulance to reach you”
D. “Do you have a family history of depression”
C. “I am glad you called I will send an ambulance to reach you”
What is the priory action for your client with Hyperosmolor HyperglycemicState?
A. Administer sodium chloride 3%
B. Administer Long Acting Insulin
C. Administer 0.9% NS
D. Administer Atropine
C. Administer 0.9% NS
What is a clinical finding of Placenta Previa
A. dark painful vaginal bleeding
B. fetal heart rate 130
C. fetal kicks has increased from 4 to 7 her hour
D. painless brightred bleeding
D. painless brightred bleeding
1.Sudden onset of painless, bright red vaginal bleeding occurs in the last half of pregnancy.
2. Uterus is soft, relaxed, and nontender.
3. Fundal height may be more than expected for
gestational age.
What is a clinical finding of Abruptio Placentae
A. dark painful vaginal bleeding
B. fetal heart rate 130
C. fetal kicks has increased from 4 to 7 her hour
D. painless brightred bleeding
A. dark painful vaginal bleeding
Dark red vaginal bleeding. If the bleeding is high
in the uterus or is minimal, there can be an ab-
sence of visible blood.
2. Uterine pain or tenderness or both
3. Uterine rigidity
4. Severe abdominal pain
5. Signs of fetal distress
6. Signs of shock if bleeding is excessive
Your client with a histrty of Retinal detachment in the left eye has enetered the clinic due to loss of central vision in his right eye. Which condition or clinical finding do you expect this client to have?
A. macular degeneration
B. floating dark spots
C. loss of peripheral vision
D. cloudy lens
A. macular degeneration
Diverticulosis
High fiber, low residence
Diverticulitis
low fiber high protein, high calorie
proper technique for mixing insulin , know the steps
10-14 asses for scoliosis
recheck liver biopsy -lpn
restraint - q24 remove q2 q20 bathroom, -continous monitoring
magnesium toxicity s/s for vital signs
vitamin b6
1-3ml/kg/hr urine output baby
low pressure , high pressure mechanical vent, alarm goes off manually O2 bag valve mask
chest tube assessment, report to provider
boggy fundus first nursing action- massage fundus
3 y/o knows a 1000 words
maybe dawn and smoygi
stoma dark red and dry- call doctor
kid comes with bruises- assess background story of bruises
normal changes for elder adults
donn and doff - outside of room
know abg ph , hcow pa02
DKA VS HHS S/s potassium-hhs
TX FOR DKA VS HHS
priority questionssss- acute client
appendicits priority- relief of pain ?? indication of appendix rupture=peritonitis medical emergency, peritoneal cavity is sterile
clozapine- flu like
Paranoid personality disorder encourage them to eat (they are suspicious and distrustful) - use pre packaged food
know defense mechanisms
A
D
P
I
E
(
M
A
S
L
O
W
Know reflexes
know erikson stages
opiod narcotics while pregnant- neonate will have hyperreflexia
Asthma further teaching , prescribed propronalol
nitro follow up ,(take out container only good for 3 months) is good 5-6 months
burn patient- urine output
PARKLAND FORMULA
BURN PERCENTAGE
singe nares- monitory respiration and airways
signs of elder abuse -malnutrition, pressume ulcers,
IM injection
z track
post op turp- monitor h and h
cbi-continius bladder irrigation;
phlebitis intervention, remove iv and insert a new one in another location
Ostomy
Ileostomy - empty the ileostomy 30 minuttes after eating , yogurt to decrease gas and smell (no asparagas)
When do you empty- colostomy bag 1/3 full
No urine output for cather - manually irrigate catheter
wrong teaching for HOSPICE- no life saving procedures
CPR
defib
no antibiotics- no pic lines
ethical dilemma- hospice patient getting a pic line
Your client is prescribed 5mg/5ml of Morphine IV. The pharmacy only has 10mg/10ml vials available. What is the proper action by the nurse?
A. Administer 10mg/10ml to the patient
B. Waste the remaining medication after adminstration.
C. Waste medication with another nurse BEFORE administration
D. Call the pharmacy to change the order to 2mg/1ml.
C. Waste medication with another nurse BEFORE administration
Patient with Gerd proper teaching - use a wedge pillow for sleeping(head elevated)
PRIORITY PATIENT- Follow up patient taking steroids- patient with high glucose or cushings
side effects of Antibiotics-
allergy to cephalasporin do not administer cillin drugs - allergy complication
Neglicence example- nurse doesnt report accident from the morning until the afternoon
Negligence- fail to use proper care resulting in damage/injury Medical error
Failure to obtain informed consent
Incorrect medication
-Enter documentation accurately, completely and in a timely manor chart in real time (it is a form of negligence delayed)
polycystic kidney disease PRIORITY - gross hematuria. assess patient first
GTPAL
Naegals rule
Parkland formula-4mL x kg x TBSA%=total amount needed for fluid resuscitation 1/ 2 given over the first 8 hours
1/2 given over the final 16 hours
vena cava syndrome s/s tachycardia, diaphoresis, nausea, vomiting, pallor, weakness, lightheadedness, and dizziness.-tx turn them on the side
burn patient room setting- increase room temperature to regulate temp, Keep client warm and NPO
Myastenia Gravis S/s
-Weakness that increases with activity and improves with rest
-Lean forward to swallow to prevent aspiration.
s/s
diplopia and ptosis
-dysphagia
post stroke what requires follow up from family - lean backwards when eating< INCORRECT TEACHING (LEAN FORWARD WHEN EATING < CORRECT TEACHING)
PRE Ventricular Contraction- assess potassium levels Check peripheral pulses Monitor potassium
Pace maker teaching- do not put phone in shirt pocket,(maybe sitting in recliner) Notify security that you have a pacemaker,Keep cell phone 6 inches away from pacemaker, scanning guns do not use on arm where pace maker is, shower with water running on back, do not lift warms 2 weeks after surgery
cast care fiber glass-Ice 1-2 hours after for 1-2 days(fiber glass cast) Elevate after application
Monitor for symptoms of compartment syndrome (pulseless, pallor, paresthesia)
VP shut with ICP Children have shrill screams and irriitated. first action- Raise HOB 15 degrees
Raise HOB 15 degrees
Measure head circumference
glaucoma surgey post op teaching- do. not bend at waist, bend at knees
timolol treats glaucoma, apply pressure on inner canthus to prevent systemic effects
post mortem care- before family visitation close eyes, if investigated is iniiated keep iv lines in patient
The body is placed in a supine position (on the back) in normal anatomic position, to prevent abnormal pooling of the blood.
* Arms at side (palms down) or across the abdomen * Head/shoulders elevated on one pillow (to prevent
discoloration of the face secondary to blood pooling)
Dentures and or other prosthetics are inserted if available to maintain normal anatomic appearance.
Close the eyes and hold them closed for several seconds so that they remain shut.
-clean technique
A patient family decided to go through an autopsy for the patient due to a complicated loss and unexpected death in the hospital. What is the priority action of the nurse and health care team?
A. keep all invasive tubes or lines
B. remove all lines and invasive tubes
C. instruct patients family to remove lines
D. instruct UAP to remove lines and invasive tubes
A. keep all invasive tubes or lines
if an autopsy is going to be performed as required by law or family request, any invasive tubes or lines must remain in the body. Such devices include intravenous (IV) lines, nasogastric (NG) tubes, tracheostomy appliances, endotracheal tubes, Foley catheters, drainage tubes, and any other invasive device that was used before death.
Drug antidotes
Ethanol and Benzodiazepines-flumazenil
Opioid-Naloxone
Warfarin-Vitamin K
Digoxin-Digilbind
Acetaminophen-Acetylcysteine
Magnesium sulfate-Calcium gluconate
Heparin-protamine sulfate
hypermagseium or magnesium adverse effect decreased respications
Warm flushed appearance, Decreased deep tendon reflexes, Weakness, Bradycardia, LOW BP, Respiratory Arrest.
mass triage, clients in red are priority
Red
-Shock
-Cardiac arrest
-Pulseless fractures
-Chest pain
private room airborne
Airborne-Private room with negative pressure, N95, keep door closed and keep dedicated equipment in the room.
-Varicella (shingles patient)
-Measles
-Tb
Contact-Private room; Gown and gloves before entering
Contact-Private room; Gown and gloves before entering
MRSA
VRE
cDiff
Hep A
Herpes zoster Lice
Scabies
Droplet-Private room or shared room with same pathology
Droplet-Private room or shared room with same pathology
Surgical mask on patient if leaving rom Covid
Pneumonia
Pertussis
Influenza
Epiglottitis
RSV
Measles, Mumps and Rubella Rubella
14 month cannot hold cup- requires follow up-developmental question
atherosclerosis further teaching - no eggs
sterile technique guide-Open flap away from body
Clean gloves to open outer packaging Sterile gloves to open inner packaging 1 inch border
Open flap away from body
Maintain waist level
Never turn back to field
Hands never go below waist or above chest
priority patient -asthma pattient previous wheezing then it stops
umbilicord follow up-falls off before 14 days at rissk and hemmohage
Arteries
Vein
Arteries
Digoxin teaching - foods high in potassium
hyokalemia=dig toxicity
Education
T-ake HR for 1 full minute
-Hold if less than 60/minute
-Report irregular pulse Foods high in potassium
early cirrhosis=high protein diet
late cirrhosis=low protein diet
pancrecritis complication- pain on inspiration
Enoxaparin/ Lovenox Anticoagulation teaching -NEVER expel air bubble or aspirate
Enoxaparin/ Lovenox Anticoagulation
Administration
2 inches above umbilicus No massaging site
NEVER expel air bubble or aspirate
ciproflaxin report - muscle tendermess
mass cauulity incident disscharge- discharge pt on oral meds
what meds can causase thrush- fluticason asthma meds
steroids-formoterol, albuterol
stop from giving vaccine- fever within 24 hrs(febrile illness), low wbc
triage 60% burn patient-black tag .Fixed dilated pupils ,Burns over 60% ,Exposed grey matter
toys for appropriate ages
child who is resting hr should not be high
child who is playing heart rate should not be low
vital signs for all ages
vitals on benzo do not continue to give flumenazil -contact healthcare provider
bucks tractions - does not pin care- (keep the feet elevated)
pin care for skeletal traction
change in BP 20mmhg is a priority patient(orthostatic hypotension)
VEAL CHOP Interventions
sustaining hr is a sign of fetal heart compromise during labor should be variables
Heart rate should be between 110-160 Hyper/hypoactivity
BADDDDD
Consistent heartrate is bad
Meconium stained amniotic fluid
V.E.A.L C.H.O.P
V- Variations = C-cord Compression
Interventions
Turn mother to left side Administer 02
E-Early Decelerations = Head compression Interventions
Vaginal exam to ensure proper dialation A-accelerations = increased 02
Interventions None-this is good
L-late Decels = Placental insuficency Interventions – in this order
Stop oxytocin Turn mom to side Notify PCP Delivery
Posterior fontanel closes by 8 weeks
Anterior fontanel closes by 18 months
Birth weight doubled by 6 months
Birth weight tripled by 12 months
CAR SEAT SAFETY
-Rear facing in back middle seat until 2 years
Safety belt under armpits for babies
-The harness should be snug, and the retainer clip should be placed at the level of the infant’s armpits, not on the abdomen or neck area.
6-7 months
Sits, waves bye bye
12-13 Months
Drink from a cup
24 MONTHS 300 WORDS
SUTURE REMOVAL - SKIP 1 AT A TIME
nitro- throw out q3months not q6 months
patients can change advance directatives anytime
when consent is signed by patient - the patient is ok with going through with the procedure(does not mean patient understands(
kidney transplant 1 degree temp increase requires follow up
patient came back from surgery nurse first action- VERIFY PATIENT ID WHEN COMING BACK FROM PACU!!!
priority patient- BURN PATIENT WITH LOW O2!!!
*HIGH-RISK: SPINA BIFIDA PATIENT RECEIVING MULTIPLE SURGIERIES!!!
