Sample Tests Flashcards
if a client becomes combative and hits personnel, you want to
inform client behavior is unacceptable to set limits
sending people out of the room gives client power. speak calmly to client to help them regain control
reporting behavior first to the provider is passing the buck
a client in a balanced suspension traction for a compound fracture reports that their hands, feet and nose is cold. you want to assess for
dependent edema-
in recumbent position, cardiac workload increases and if the heart can’t keep up, then the peripheral areas of the body will be colder
holding breath causes the ______ maneuver, which increases the workload on the heart.
Valsalva
to prevent this occurrence, teach the immobilized clients about exhaling when moving about in bed
an older adult client reports muscle weakness and drowsiness. nurse observes decreased deep tendon reflexes and hypotension. nurse should ask if the client has taken ______
antacids
increased intake of magnesium containing antacids and laxatives can cause hypermagnesemia (>2.1). this depresses the CNS and cardiac impulse transmission.
D/C oral Mag, support ventilation as needed, administer loop diuretics of IV calcium, and educate
Chvostek signs is seen with
hypocalcemia
to elicit the sign, tap the face just below and anterior to the ear to trigger facial twitching on that side of the face
remaining 800mL of dialyslate remaining in peritoneal cavity. what is an important question to ask?
when was your last BM?
full colon can interfere with emptying process
shoulder pain can occur during _____ of peritoneal diasylate
intake
what foods are cross contaminated with latex?
apple, avocado, banana, carrot, celery, chestnut, kiwi, melon, papaya, raw potato, and tomato
if a client taking citalopram notices a fever, what should they do?
notify provider immediately
could be serotonin syndrome
don’t take tylenol
citalopram is an SSRI used to treat depression
S&S of serotonin syndrome
abdominal pain, fever, sweating, tachycardia, HTN, delirium, myoclonus, irritability, mood changes, may result in death
a child has a sore throat, fever and sudden drooling. what could be going on?
acute epiglottis
life threatening
drooling occurs d/t difficulty swallowing. child may become apprehensive or anxious. the child should be transported to hospital in sitting upright position to aid in breathing
take to ED immediately!!
don’t inspect the through unless immediate intubation can be performed if needed. touching the back of the throat may cause spasms cutting off the ability to breathe
normal bilirubin levels day 3-5 of life
13-15
if an infant with a congenital heart disease becomes easily fatigued during feedings, the nurse should first
feed the infant soon after awakening, every three hours, make nipple wider.
increasing caloric content of feeding requires provider prescription, takes time to implement. and should only increase by 2 kcal/oz/day
regular formulas provide ____ kcal/oz
20
muscular weakness produces by repeated movements that soon disappear following rest describes
myasthenia gravis
6 month old with rotavirus with severe diarrhea and dehydration requires ____ precautions
contact precautions (fecal-oral) required since child is incontinent/diapered
private room necessary
primipara client is in labor, cervix is 5cm dilated 100% effaced, fetal head at -1 station. membranes rupture and fluid is clear. what do you do next?
*encourage the client to void every 1-2 hours to facilitate descent of fetal presenting part; and take temperature every hour because of the ruptured membranes (infection risk?)
no ambulating client, could cause cord prolapse
too early to deliver
IV and electronic fetal monitor is probably already in place
impetigo is caused by untreated staphylococcus and can cause
acute glomerulonephritis
periorbital edema is a good indicator of
acute glomerulonephritis (poststreptococcal)
chlordiazepoxide is an anti-anxiety and sedative/hypnotic medication used to treat
anxiety and alcohol withdrawal
medication causes drowsiness and sedation
patient comes in with a severe headache and has a cervical spinal injury. what action does the nurse take first?
place client in sitting position
pounding headache and perfuse sweating are signs of autonomic hyperreflexia experienced by client with spinal injury
placing client in sitting position immediately decreases BP to head reducing risk of cerebral hemorrhage
partial thromboplastin time monitors the effectiveness of
heparin
therapeutic level 1.5-2 times the control
oral anticoag therapy (warfarin) must be instituted ______ before d/c heparin therapy
4-5 days
warfarin interferes with the hepatic synthesis of
vitamin-K dependent clotting factors
GERD patients should consume diets low in
fat and acid
examples: broiled chicken, cream of broccoli soup, rice pudding, apple juice
things to avoid:
- oil in salad dressing, cheese, chocolate are high in fat
- tomato, caffeine lemonade and mint could exacerbate GERD
aminophylline is used to prevent and treat
wheezing, shortness of breath, and difficulty breathing caused by asthma, chronic bronchitis, emphysema, and other lung diseases. It relaxes and opens air passages in the lungs, making it easier to breathe.
aminophylline AE
tachycardia, palpiations, dysrhythmias, N/V/D, nervousness, dizziness, seizures
administer with full glass of water or food if taking orally
decrease intake: colas, coffee, chocolate (xanthine containing foods) that increases AE
encourage fluid intake 2000mL/day to decrease viscosity of airway secretions
ER –> who do you see first?
- ecchymosis and facial lacerations
- SOB + chest pressure
- BP 90/60 + apical pulse 120 bpm
- dizzy + nervousness
- BP 90/60 + apical pulse 120 bpm
* indicates shock, most unstable
a verbally abusive client to staff becoming increasingly more agitated must be seen ____ a client’s family threatening to sue the hospital if concerns aren’t met immediately
before
who do you see first?
- very sleepy infant who refused feedings for 8 hours
- preschool child who is flushed and has a 101.9 temp
- school age child reporting sore throat and had two episodes of vomiting today
- very sleepy infant who refused feedings for 8 hours
the infant has significant risk for dehydration and acidosis. an infants rate of fluid exchange is significantly higher than adult’s. acid forms more rapidly in infants and may lead to acidosis. kidneys are are not mature at this age and cannot adequately concentrate urine to conserve water
5-fluorouracil is a ____ drug
chemo
more immunosuppressed. must be seen first with risk of infection
normal calcium levels
8.2-10.2 mg/dL
fluoxetine is an
SSRI
chlorpropamide is an
oral hypoglycemic
AE: diarrhea, GI upset, hypoglycemia
must be administered in divided doses to relieve GI upset
tonometer reading is used to measure
intraocular pressure
test used to diagnose glaucoma
normal IOP= 10-21
before a CT, you want to make sure the patient isn’t allergic to
seafood, iodine or dye
joint pain with hemophilia indicates
bleeding!
needs to be addressed ASAP
tx: factor VIII, RICE (rest, ice, compression, elevation)
a client taking clozapine is experiencing flu-like symptoms, fever, sore throat, and lethargy. what is going on?
agranulocytosis, severe side effect placing client at risk for infections
clozapine is an antipsychotic
valproic acid is an
anticonvulsant
methylphenidate is a
stimulant used for ADHD
can cause decreased appetite- monitor client’s weight
who do you see first?
- unresponsive with intermittent limb movement
- muscle tone in all four limbs is flaccid
- unresponsive but follows staff with eyes
- immediately withdraws from painful stimuli
- muscle tone in all four limbs is flaccid
indicative of serious, irreversible brain impairment. this client is the most unstable
stage I kidney failure
diminished kidney reserve
kidney function is reduced, but the healthier kidney is able to compensate. since the kidney cannot concentrate urine, the client has polyuria and nocturia
stage II kidney failure
kidney damage
oliguria and swelling occurs
stage V (ESRD)
dialysis required
kidney is no longer functioning
fundal heights
**height correlates with weeks of pregnancy
10-12 weeks- slightly above symphysis pubis
16 weeks- 1/2 way between symphysis pubis and umbilicus
20-22 weeks- level of umbilicus
26 weeks= 26”
28 weeks- 3 fingerbreaths above umbilicus
36 weeks- fundus is just below sternum cartilage
after ___ hours of ABX therapy, strep throat is no longer contagious
24 hours
GERD risk factors
female, over age 45, obese, NG, smoking, caucasian
levothyroxine should be taken before breakfast to prevent
insomnia
