QT6 1/8

Question 1

correct height of elbows with walker

Answer 1

30 degree angle

Question 2

What kind of fluid is given for dehydration?

Answer 2

hypotonic solution, shifts fluid into intracellular space to correct dehydratio

Question 3

significant side effect of sublingual nitroglycerin?

Answer 3

hypotension

BP should be closely observed to ensure that it does not continue to decrease

Question 5

What is a high priority regarding IM injections?

Answer 5

highest priority is to prevent tissue damage and promote tissue absorption of the medicine, accomplished through rotation of the injection sites

Question 6

How long does it take MAOIs to work?

Answer 6

tranylcypromine sulfate

takes three to four weeks to work

Question 7

What is hematuria a sign of in a pt with hyperparathyroidism?

Answer 7

hematuria is a sign of renal calculi; 55% of hyperparathyroid clients have renal stones

Question 8

radical mastectomy of the right breast

correct position?

Answer 8

Position the client in semi-Fowler’s position with the right arm elevated

Question 9

pt teaching regarding risperidone

Answer 9

• causes weight gain
• drug impairs body temperature regulation
• causes photosensitive reactions (should wear long sleeves in the sun)
• orthostatic hypotension

Question 10

TB pt have to take isoniazid for 6mo. What is a side effect that shoud be reported?

Answer 10

may cause peripheral neuropathy indicated by tingling,

may also see nausea

Question 11

prepares the client for a lumbar puncture

Answer 11

• “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

Question 12

early stages of hepatic encephalopathy

Answer 12

• 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

Question 13

late stages of hepatic encephalopathy

Answer 13

• 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

Question 14

appropriate pregnancy weight gain

Answer 14

weight gain 2–5 lb (2.5 kg) first trimester,

0.66–1.1 lb (0.5 kg) weekly in second and third trimester

Question 15

edema is a result of…

Answer 15

a result of sodium and fluid retention

Question 16

normal range for fetal heart tones

Answer 16

120 to 160 beats per minute

Question 17

If bismuth subsalicylate is taken, how should other meds be dosed?

Answer 17

bismuth subsalicylate absorbs PO meds, separate administration of other meds and take 1hr after bismuth

Question 18

Which finding indicates to the nurse that the client’s Salem sump tube (nasogastric) is functioning effectively?

Answer 18

hissing sound is indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa

Question 19

throat culture from the client diagnosed with pharyngitis

Answer 19

Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx

Question 20

How much height and weighth increase is expected for school-age child?

Answer 20

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)

Question 21

What should be given to the infant with a positive PKU blood test?

Answer 21

Place the infant on Lofenalac formula.

Question 22

what changes occur for pt after a total laryngectomy?

Answer 22

• 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

Question 23

When RBC are low and pt has increased pulse and respirations, why is this occurring?

Answer 23

increased pulse and respirations are caused by decreased oxygenation of tissues

Question 24

How often should ostomy bag be changed?

Answer 24

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

Question 26

bronchoscopy

Answer 26

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*

Question 27

When giving antibiotics, what is altered?

Answer 27

normal intestinal flora

yogurt and Acidophilus milk can help maintain intestinal flora

Question 28

subcutaneous emphysema

Answer 28

crackling under his skin

which is indication of pneumothorax

Question 29

What does constant bubbling is observed in the water seal chamber indicate?

Answer 29

would indicate an air leak, would not allow negative pressure to be re-established and would hinder complete resolution of the pneumothorax

Question 30

What physiological changes occur in stage four Parkinson’s disease?

Answer 30

stage four Parkinson’s disease, client is immobile

ROM exercise to all extremities four times a day.

Question 31

guaiac test

Answer 31

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.

Question 32

What must the nurse always do before a pt goes for a intravenous pyelogram (IVP)?

Answer 32

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