QT6 1/8 Flashcards
correct height of elbows with walker
30 degree angle
What kind of fluid is given for dehydration?
hypotonic solution, shifts fluid into intracellular space to correct dehydratio
significant side effect of sublingual nitroglycerin?
hypotension
BP should be closely observed to ensure that it does not continue to decrease
What is a high priority regarding IM injections?
highest priority is to prevent tissue damage and promote tissue absorption of the medicine, accomplished through rotation of the injection sites
How long does it take MAOIs to work?
tranylcypromine sulfate
takes three to four weeks to work
What is hematuria a sign of in a pt with hyperparathyroidism?
hematuria is a sign of renal calculi; 55% of hyperparathyroid clients have renal stones
radical mastectomy of the right breast
correct position?
Position the client in semi-Fowler’s position with the right arm elevated
pt teaching regarding risperidone
- causes weight gain
- drug impairs body temperature regulation
- causes photosensitive reactions (should wear long sleeves in the sun)
- orthostatic hypotension
TB pt have to take isoniazid for 6mo. What is a side effect that shoud be reported?
may cause peripheral neuropathy indicated by tingling,
may also see nausea
prepares the client for a lumbar puncture
- “You will remain flat in bed for eight hours after the test.”
- to prevent a post-lumbar puncture headache
- “You may feel discomfort in your leg when the needle is inserted.”
- nerve endings may be touched when performing the procedure
- “You can have analgesics after the procedure if you have a headache.”
- headaches or discomfort may be experienced after the procedure
early stages of hepatic encephalopathy
- The client has difficulty describing what he does at work.
- impaired thought processes is early symptom
- The client states difficulty sleeping through the night.
- insomnia and sleep disturbances are signs of grade 0
- The client’s spouse notes a change in the client’s handwriting.
- Writing changes and hand tremors are grade 0; early signs
late stages of hepatic encephalopathy
- asterixis: flapping of the hands after extension is grade 3 and above; is late symptom
- lethargy and extended sleep patterns are signs of grade 3; late signs
appropriate pregnancy weight gain
weight gain 2–5 lb (2.5 kg) first trimester,
0.66–1.1 lb (0.5 kg) weekly in second and third trimester
edema is a result of…
a result of sodium and fluid retention
normal range for fetal heart tones
120 to 160 beats per minute
If bismuth subsalicylate is taken, how should other meds be dosed?
bismuth subsalicylate absorbs PO meds, separate administration of other meds and take 1hr after bismuth
Which finding indicates to the nurse that the client’s Salem sump tube (nasogastric) is functioning effectively?
hissing sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa
throat culture from the client diagnosed with pharyngitis
Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx
How much height and weighth increase is expected for school-age child?
between ages 6–12, children grow about 2 inches (5 cm)/year and
gain 4.5–6.5 lb (2–3kg)/year;
at age 7 average 39–66.5 lb (17.7–30 kg) and 44–51 inches (111.8–129.7 cm)
What should be given to the infant with a positive PKU blood test?
Place the infant on Lofenalac formula.
what changes occur for pt after a total laryngectomy?
- will communicate in writing initially, then by artificial larynx or esophageal speech
- requires nutritional support for 10 days until wound heals, then gradually resumes oral intake
- will require laryngectomy tube to prevent scar tissue contracture
- develop some difficulty with taste and smell after the surgery
- will not be able to sing, whistle, or laugh using laryngeal communication
When RBC are low and pt has increased pulse and respirations, why is this occurring?
increased pulse and respirations are caused by decreased oxygenation of tissues
How often should ostomy bag be changed?
ostomy bags should be changed at least once a week (or when seal around stoma is loose or leaking); good time for stoma to be closely inspected
bronchoscopy
Depressed gag reflex- must return before giving fluids
Sputum streaked with blood- common for a few days
sore throat expected
ASSESS FOR RESPIRATORY DISTRESS FROM SWELLING!!!!
- tachypnea, tachycardia, respiratory stridor, and retractions*
When giving antibiotics, what is altered?
normal intestinal flora
yogurt and Acidophilus milk can help maintain intestinal flora
subcutaneous emphysema
crackling under his skin
which is indication of pneumothorax
What does constant bubbling is observed in the water seal chamber indicate?
would indicate an air leak, would not allow negative pressure to be re-established and would hinder complete resolution of the pneumothorax
What physiological changes occur in stage four Parkinson’s disease?
stage four Parkinson’s disease, client is immobile
ROM exercise to all extremities four times a day.
guaiac test
The stool guaiac test or guaiac fecal occult blood test (gFOBT) is one of several methods that detect the presence of fecal occult blood (FOB) which is blood in the feces that cannot be seen.
What must the nurse always do before a pt goes for a intravenous pyelogram (IVP)?
ask for list of the client’s allergies.
IVP involves injection of radiopaque dye, used to identify lesions and assess function; allergy to iodine is life threatening
