Practice Test Flashcards
Pneumonia patient is receiving Gentamicin. What are the most important nursing interventions
Ototoxic & Nephrotoxic (Monitor BUN & Creatinine)
Draw Peak 1 hr after IM & 30 min - 1hr after IV finish
Draw trough just before next dose
______ treats angina pectoris to reduce ischemia and relieve pain by decreasing myocardial oxygen consumption.
Maybe applied to skin in a proximal non-hairy area.
Nitroglycerin
How does defibrillation work to return to normal rhythm.
Causes asystole and allows the SA node to recapture being the pacemaker
Which is at highest risk for tb
- Immigrant from Germany
- Productive cough & smoking history
- Immunosuppressant taking post kidney transplant
- Stage 2 Breast cancer & start chemotherapy next week
- Immunosuppressant taking post kidney transplant
Immunosuppressants, IV drugs, live in institución, close contact with someone who has TB are risk factors
Match
Condylomata acuminata (Genital Warts)
Chlamydia
Genital Herpes
Painful, Vesicular Genital lesions
Foul-smelling, thick, yellow vaginal discharge
Cauliflower-like lesions on perineum & vagina
Genital Herpes
Painful, Vesicular Genital lesions
Chlamydia
Foul-smelling, thick, yellow vaginal discharge-Pelvic pain, painful menses, Male client: Dysuria, frequent urination, watery discharge
Condylomata acuminata (gen warts)
Cauliflower-like lesions on perineum & vagina
Cauliflower-like lesions on perineum & vagina
Which are characteristics is complications of Immobility
- Slow wound healing
- Asymmetrical chest wall movement
- Increased pulse
- Joint contractures
- Hypoactive bowels
- Decreased urine
- Slow wound healing - difficulties with eating Protein
- Asymmetrical chest wall movement : Atelectasis causes asymmetrical chest wall movements
- Increased pulse: Recumbent posistion increases HR
- Joint contractures
- Hypoactive bowels
- Decreased urine: Inadequate intake of fluids
Stable V Tach with pulse will get this type of intervention
IV Amiodarone (Antiarrhythmic), Procainamide (Antiarrhythmic), Sotalol (Antiarrhythmic)
Client has V Tach and no pulse treatment.
Client has V Tach and pulse treatment
V Tach no pulse
Chest compressions (30:2) until shockable rhythm
Shock when able (according to defib machine)
After continue CPR & Shocks
After 3 sets administer 1 milligram of adrenaline/vasopressor and 300 milligrams of amiodarone (Antiarrhythmic)
Antidysrhythmic therapy
Intravenous (IV) procainamide, amiodarone, or sotalol can restore
Match
Cardiogenic Shock, Obstructive, Distributive, Hypovolemic
Pulmonary embolism, Tumors, tension pneumothorax, high ventilador pressure, superior vena cava syndrome.
Secondary to vasodilation and loss of vasomotor tone. Sepsis & Spinal cord injuries
When the heart is unable to pump properly: MI, Dysrhthmias, HF, Cardiac Arrest, Cardiomyopathy, Myocardial Contusion, Valvular Heart Disease
Blood volume is inadequate to maintain circulation: hemorrhage, GI losses, burns, diaphoresis
Obstructive
Blood flow to and from the heart is stopped
Pulmonary embolism, Tumors, tension pneumothorax, high ventilador pressure, superior vena cava syndrome.
Distributive Shock
Blood vessels dilate leading to loss of perfusion. Sepsis & Spinal cord injuries
Distributive
Secondary to vasodilation and loss of vasomotor tone. Sepsis & Spinal cord injuries
Cardiogenic
When the heart is unable to pump properly: MI, Dysrhthmias, HF, Cardiac Arrest, Cardiomyopathy, Myocardial Contusion, Valvular Heart Disease
Hypovolemic
Blood volume is inadequate to maintain circulation: hemorrhage, GI losses, burns, diaphoresis
Calcium Gluconate is used to correct Hyperkalemia, which is more likely to occur in ( DKA or HHS ) “Hyperglycemic Hyperosmolar syndrome”
DKA
In acidosis, the H is pumped into cells to Raise the pH.
K is pumped out of the cell into the blood vessel HYPERKALEMIA
(DKA / HHS)
Fruity-smelling breath
Fatigue
Rapid breathing
Dry skin and mouth
Flushed face
Headaches
Muscle stiffness or aches
(DKA / HHS)
Malaise, or a general feeling of illness
Weakness
Dehydration
Neurological signs and symptoms, such as hallucinations, drowsiness, loss of vision, or coma
DKA
Fruity-smelling breath
Fatigue
Rapid breathing
Dry skin and mouth
Flushed face
Headaches
Muscle stiffness or aches
HHS
Malaise, or a general feeling of illness
Weakness
Dehydration
Neurological signs and symptoms, such as hallucinations, drowsiness, loss of vision, or coma
Which requires an incident (variance) report?
- Client declines prescribed medication
- Client reports near fall
- Client despite receiving pain meds rates pain 8/10
- Electric IV pump malfunctions
- Electric IV pump malfunctions
Close falls do get incident reports
Client : “My doctor prescribed cephalexin to treat my infection.” The nurse will intervene if the client previously bad an anaphylaxic reaction to which antibiotics?
- Ciprofloxacin
- Piperacillin-tazobactam
- Sulfamethoxazole-trimethoprim
- Doxycycline
- Piperacillin-tazobactam - Penicillin antibiotic (Penicillin allergy = possible Cephlosporin allergy)
- Ciprofloxacin = fluoroquinolone antibiotic - No interaction with cephlosporin
- Sulfamethoxazole-trimethoprim
Sulfonamide antibiotic No interaction with cephlosporin - Doxycycline: Tetracycline antibiotic No cross interaction
Which should be seen first in the ER
- Client who states “It would be better if I wasn’t here.
- Client who reports chills for last 3 days.
- Client taking rifampin who states “ My urine is a reddish orange color “
- Client 8 weeks of gestation who doesn’t feel fetal movement
- Client who states “It would be better if I wasn’t here.
Immediate risk of suicide
Quickening (first recognition of fetal movement) cannot be detected in nulliparous until ___ week & in multipurpose by this week _____
Quickening is felt in
Nulliparous 18th week
Multiparous by 14th or 16th week
Onward old orcs toward the argonoth for a great villian slays hobbits
Onward - 1. Olfactory
old - 2. Optic
orcs - 3. Oculomotor
toward - 4. Trochlear
the - 5. Trigeminal
argonoth - 6. Abducens
for - 7. Facial
A - 8. Auditory
great - 9. Glossalpharyngeal
villains - 10. Vagus
Slays- 11. Spinal Accessory
hobbits - 12. Hypoglossal
CN 1. Test
Give something to smell
Olfactory
CN II Test
Vision
Snelling chart 20 ft
Jager Rosebbaum Chart 14 “
Color vision
Visual fields & Reflexes
Fundoscopy aka ophthalmoscopy,
Eye exam that allows a doctor to see the inside of the eye’s fundus, or back
CN II Vision
CN III, IV, VI Test Check together
Eye movements - Ask look up, down, sideways
Pupil dilation / constriction - Shine Pen Light
Acomodation (Pupils Dilate = far / Constrict = close) - move Pen Close & Away from their face
III Oculomotor
IV Trochlear - Down & Inward Movements - Obseve for Nystagmus (Rapid Movement)
VI Abducens - Side to side movement - Observe for Nystagmus
CN V Test
Facial sensation
Palpate TMJ Temporal Mandibular Joint
Muscles of head & neck also CN XI
Innervation of ear also CN VIII
V = Trigeminal
CN XI Test
Muscles of head and neck
CN XI = Accessory
CN VII Test
- important to check often damaged with injuries
Change facial expression
Taste Anterior 2/3 of tongue
CN VII = Facial
CN VIII Test
Rinne Test (Sensoral hearing) / Webber Conductive Hearing
CN VIII = Vestibulorcochlear (Acoustic)
CN IX & X Test
Pharynx raises when client says “Ah”
Gag reflex 9 & 10
Speaking 10
CN IX = Glossopharyngeal
CN X = Vagus