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
CN XI Test
Shrug shoulders & turn head against resistance
CN XI = Spinal Accessory
CN XII Test
Stick out tounge
Look for fasciculations: Brief, spontaneous contraction or twitch in a muscle.
CN XII = Hypoglossal
Vasculitis aka …..
Describe…
Angitis
Swelling & thickening of blood vessels that causes less blood flow to affected areas.
S/S: fever, fatigue, weight loss, and muscle and joint pain.
Name disease
1st stage: Painless sore on the genitals, rectum, or mouth. (3 - 90 days later)
2nd Rash on trunk, palms, & soles of feet. ( 4 - 10 weeks later)
3rd Brain, nerves, eyes, or heart are severely damaged (3 - 15 yrs later)
Syphilis
Infarction Definition
Tissue death (necrosis) due to inadequate blood supply
Nystagmus is…
Uncontrolled movements of the eyes.
Can lead to balance issues
Highest risk for ischemic stroke
- 76 yr old African American male with A fib & HTN
- 50 yr old White female sleep apena & obese
- 75 yr Black male smoked cigs 15 years
- 54 yr White female Hyperlipidemia & alcohol use disorder.
- 76 yr old African American male with A fib & HTN
Client has 3 non- modifiable risk factors (age, race, gender) & 2 modifible A fib & HTN
Black most likely ischemic stroke
Males more likey than females
Older more likely
- Client has 2 modifable risk factors
- Client 3 non modifible risk factors and 1 modifible (smoking)
- Client 2 modifible risk factors
3 types of strokes
Stroke = interrupted Blood flow to the brain.
Thrombotic- Blood clot forms in artery & obstructs blood flow to brain
Embolic - Blood clot forms in area other than artery (Heart for example) and moves to the brain.
Hemorrhage: Blood vessle ruptures and Blood flow is interrupted
Thrombotic stroke / Embolic stroke
Risk factors
CAD
Air embolism
Atherosclerosis
HTN
Cholesterol >200 / Triglycerides >150
Long bone fractures
Obesity / lack physical exercise
DM
Atrial / Septal defects
A fib
Thrombotic Stroke
CAD
Atherosclerosis
HTN
Cholesterol >200 / Triglycerides >150
Obesity / lack physical exercise
DM
Embolic stroke
Afib
Atrial / Septal Defects (Hole Septum that separates side of heart)
Long bone fractures
Air embolism
Blood thinners or trauma to the head are causes of this type of stroke
Hemorrhagic
Lochia is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue
Describe normal color
- First 2 hrs
- Up to 3 days after delivery
- 4 - 9 days after delivery
- Roughly 10 days after
- Bright Red - First 2 hrs
- Dark Red - Up to 3 days after delivery (locha Rubra)
- Pink Brown - 4 - 9 days after delivery (locha serosa)
- Yellow White - Roughly 10 days after (lochia alba)
Type I DM patient calls clinic and reports n/v & fever. Which of these instructions is best
- Drink 1 glass water every 4 hrs
- Call back if urinary output decreases
- You may need to increase insulin dose
- Check BS every 4 - 6 hrs
- You may need to increase insulin dose
Illness can cause a relase of hormones which will rise BS.
Client MAY require more insulin based on BS
- Client should drink (broth, Gatorade) every 0.5 - 1 hr.
- Client should check BS & ketones every 3-4 hrs
Give an example of Persecutory delusion
Give example Referential delusion
Give example Nihilistic delusion
Give example Grandiose delusion
Persecutory delusion: other people are out to get you
Referential delusion: Believes unrelated circumstances are related to the client ( News is talking directly to them)
Nihilistic Delusion: Major catastrophic will occur
Grandiose delusion: Belief one is powerful or important (I’m a poker god)
Name nursing test to assess for Neisseria meningitis (3)
Nuchal rigidity
Kerrnig sign
The patient lies on their back with their hips and knees flexed, and then passively extends their leg. The test is positive if the extension causes pain.
Brudzinski sign
The patient lies on their back and the examiner flexes their neck forward until their chin touches their chest. The test is positive if the patient involuntarily flexes their hips or knees
Which is most appropriate for client diagnosed with bipolar,currently in manic phase.
- Apply soft wrist & ankle restraints
- Admin tranquilizer
- Provide frequent reality orientation
- Provide high calorie finger foods
- Provide high calorie finger foods
Maslows - Physical comes first
- Reality reorient is appropriate for schizophrenia
Long time Heroin addict reports using heroine 8 hrs ago. Which would the nurse expect to see.
- HR 50
- Slurred speech
- Drowsiness
- Hyperreflexia
- BP 90/60
- Meiosis
- Hyperreflexia
He is in withdrawal. So everything will be increased
Which would nuse question with osteomyelitis.
- Support extremity with pillows
- Apply heat
- Provide high protein diet
- Avoid exercise
- Apply heat
Osteomyelitis = bone infection
Which requires immediate unsynchronized defibrillation?
- Rate 0 beats/min absence of QRS complexes
- Rate 30 beats/min; normal P wave, normal PR intervals, normal QRS complexes
- Rate 130 beats/min, fibrillatory waves noted
- Rate not measurable; irregular wave forms of varying shape & amplitude
Correct
4. V fib - Immediate unsynchronized defib & CPR
- Rate 0 beats/min absence of QRS complexes = Asystole (Immediate CPR)
- Sinus Bradycardia - IV Atropine or Transcutaneous pacing (artificial pacemaker, isa noninvasive procedure that temporarily regulates a patient’s heart rate and cardiac output during a medical emergency)
- A fib - CCB or possibly synchronized Cardioversion
Presence of a U wave indicates this electrolyte problem
Hypokalemia
Nausea is common in SATA
Asthma, MI, GERD
MI
Which statement indicates that more Teaching is needed for a patient who is new prescribed Lisinopril
- I will change posistions slowly
- I will report non-productive cough to HCP
- I will eat potassium rich foods
- I will need to stop taking Lisinopril if I become pregnant
- I will eat potassium rich foods
Hyperkalemia is a side effect of Lisinopril and potassium rich foods sound be avoided
Fetal death can occur if pregant
Can a UAP preform nail care on a client?
Yes, unless they have DM or other circulatory problems
Adult male client with malignant lymphoma recieves a prescription for Vincristine Sulfate (oncolytic drug)
Which is most concerning
- WBC 2,500
- Platelet 75,000
- Sodium 132
- Hemoglobin 5.5
All are low due to the SE of Vincristine Sulfate
Hemoglobin is most concerning because it carries oxygen
Bitten by a snake. Nurse observes petechiae & purpura on clients chest. Which finding should be reported immediately
- BP 170/90
- Glucose 170
- PT 16 seconds
- 100.2 °
- PT 16 seconds
Normal PT is 9.5 - 12 seconds
Presence of petechiae & purpura after a snake bite suggest DIC.
Elevated PT also suggest this.
- Hypotension not Hypertension would be associated with DIC
Fetal heart rate falls below baseline close to the beginning of the contraction
What action does the nurse take?
- Provide emotional support to the client
- Posistion client in side laying Posistion
- Increase oxygen flow rate
- Stop infusion of Oxytocin
- Provide emotional support to the client
A fetal heart rate that falls below baseline close to the beginning of the contraction describes Early Deceleration, Normal Finding.
- Side-laying is appropriate posistion for late decelerations
- Increasing oxygen rate is appropriate for late decelerations
- Stopping an infusion of Oxytocin is appropriate for late decelerations
For Ménière disease which order would the nurse question?
- Meclizine 25 mg
- Sodium restrictions to 3,000 mg
- Bed rest during acute phase
- Diazepam 10 mg PO
- Sodium restrictions to 3,000 mg
Sodium restriction will be 2,000 mg daily. 2,300 mg is normal
Meniere Disease is caused by inner ear problems, Vertigo, sensoral hearing loss, N/V, Tinnitus
Meclizine (Antihystimine - treats Motion Sickness & Vertigo) is commonly prescribed.
As well as antimetics Metoclopramide (Reglan), Ondansetron (Zofran), Dimenhydrinate (Dramamine).
- Diazepam is commonly prescribed to treat Vertigo with meniere disease
Which will be present with Wernicke encephalopathy
- Confusion
- Anisocoria
- Prescribed thiamine
- Horizontal Nystagmus
- Progession into Korsakoff syndrome
- Confusion - characterized by confusion from years of alcohol abuse
- Anisocoria - uneven pupil size, pupils will also have dulled reaction time.
- Prescribed thiamine - 3x for 1 or 2 wks. Helps with poor nutrition
- Horizontal Nystagmus - also lateral orbital palsy, gaze palsy are characteristics of Wernicke
(Not all clients will progress into Korsakoff)
5. Progession into Korsakoff syndrome
Healthy people
A positive result is generally considered to be an induration of ____ mm or more.
High-risk groups
An induration of ___ or more may be considered positive for people who live or work in high-risk environments, such as hospitals, nursing homes, or correctional facilities. It may also be positive for people who recently immigrated from countries with a high prevalence of TB, children under 4, or people who use injected drugs.
Healthy >15mm
High Risk Group >10mm
Which requires intervention
- Client places cane forward 6 – 10” when walking
- Holds cane on stronger side
- Advances weaker keg past can while walking
- Cane length is = to level of greater trochanter
- Advances weaker keg past can while walking
Tension pneumothorax which signs will the nurse see.
- Paradoxical chest wall movement
- Tracheal deviation away from affected side
- Absent breath sounds on unaffected side
- Dullness to percussion
- Hypertension
- Muffled, distant heart sounds
- Tracheal deviation away from affected side
All other incorrect
- Paradoxical chest wall movement is seen with flail chest (fracture of 2 or more adjacent ribs in 2 or more places with loss of chest wall stability)
- Dullness will be heard with hemothorax or any condition with fluid in lungs.
Pneumothorax = hyperresonance
- Pneumothorax = Hypotension (Occurs as result of shifting heart & great vessels)
- Muffled distant heart sound = cardiac tamponade (Fluid filled sac surrounds the heart and puts Pressure on it. Symptoms include low blood pressure, shortness of breath, and lightheadedness.)
Characteristics of placenta previa
- Painful vaginal bleeding.
- Placental location in upper uterine segment
- Detachment of the placenta from the uterus
- Bright red vaginal bleeding
- Disseminated intravascular coagulation
- Bright red vaginal bleeding - Nonpainful
When the placenta covers the opening in the mother’s cervix.
- Painful vaginal bleeding occurs with placental abruption, aka abruptio placenta.
- Location: Upper uterine segment = placental abruption ( Placental abruption happens when the placenta separates from the inner wall of the womb, also called the uterus)
Lower uterine segment = placenta previa
- Placental abruption is characterized by Detachment of the placenta from the uterus
- Coagulopathy (DIC) is absent in placenta previa but frequently occurs in grade 3 placental abruption (sever separation >50%)
Which electrolyte imbalance is characterized by
Absent P
Wide QRS
ST Depression
Peak T waves
- Hypokalemia
- Hyperkalemia
- Hypocalcemia
- Hypercalcemia
- Hyperkalemia - V fib or Ventricular standstill can occur
- Hypokalemia = flattened T waves, Prominent U waves, ST depression, prolonged PR interval
Atrioventricular Septal Defect is found in 40% of Downs Syndrome cases. (Downs = 3 copies of the 21st chromosome “trisomy”)
Tell which symptom is due to Downs or ASD
Failure to thrive
GERD
Crackles in all lobes
163 pulse
Similar creases
Epicanthal folds
Poor muscle tone
Failure to thrive: Both
GERD: Down
Crackles in all lobes: AVD
163 pulse: AVD
Simian creases: DOWN
Epicanthal folds: DOWN
Poor muscle tone: DOWN
Simian creases = Single line in palm
Epicanthal folds = Skin folds that cover the inner corner of the eye, usually on the upper eyelid. Normal in Asian people
Failure to thrive (FTT), also known as …
weight faltering
Condition in which a child doesn’t gain weight or grow at the expected rate
Cardioversion (Synchronized Shocks) or Medications (amiodarone Afib /Adenosine, verapamil, diltiazem, metoprolol for supraventricular tachycardia ) to the QRS complex are used for these types of heart issues.
Irregular / Tachycardia
A fib,atrial flutter, atrialtachycardia and ventricular tachycardia.
