Flaccid Bladder 52206q

Flaccid Bladder – You want to produce -acid urine to minimize risk of UTI. - produce acid urine: -prune -cranberry -tomato juices produce alkaline urine: -Milk -lemonade produce Hep B – Vaccines additional injections at -one month -six month Baseline Data – must be collected to design an effective behavior modification program. Parlodel (bromocriptine) (Antiparkinson Agent) istration: – Should be taken with meals to decrease GI upset. Post op – Abdominal surgery low fowlers position 15 degrees takes pressure off of suture line. Pressure ulcers S&S – Blanching or hyperemia that doesn’t disappear is a warning sign for pressure ulcers Late decelerations – Stop infusion of pitocin(Oxytocin)(misc OB/GYN Agents) Abdominal Surgery – with complaints of left leg dull aches Nursing Intervention: – elevate extremities to promote venous return and -decrease venous pressure to relieve pain and edema. Systematic Desensitization: Note:Phobias are a learned response and the goal is to eradicate the phobic response by replacing with relaxation responses by using muscle relaxation techniques with it. (Guided imagery)

Detached Retina – Classic signs are: -bright flashes of light -client stating that protions of visual field is dark Impetigo – with a child the nurses 1st priority: -is to notify the child’s parents first. Infant with samonella: –Priority is precausion 1st to prevent transmission. -Then other implementations can be performed. Note: - Magnesium Sulfate (IV) (Mineral and electrolyte replacement/supplements) can cause: -slowing of the respiratory rate in an infant and hyporeflexia. -The normal resp. rate for an infant is 30 – 60 per min. -So 18 respiration indicates a problem. Doxepin hydrochloride (Sinequan)(antianxiety agent, Antidepressant) - Is an antidepressant, - signs of overdose include: - -excitability - -tremors Child age 7: – Periods of shyness are to be expected -nightmares are frequently experienced at this age Decreased RBC – s/sx: -Fatigue -pallor -exertional dyspnea Rheumatic Fever – Is the most common cause of mitral valve problems. Ex: mitral stenosis. Paracentesis – Most important Nurse Intervention in preparing a client for this procedure to to have them void just before the procedure. Swan Ganz – Indirectly measures pressure in the ventricles.

Note: CVP reading measure the pressure in the R ventricles. The Swan Ganz catheter measures the Pulmonary Artery wedge pressure which is an indirect reading of the pressure in the L ventricle. Trigeminal Neuralgia – (Tic Douloureux) – The nursing care should be directed toward preventing stimuli to the area and decreasing pain – Ex: eat soft warm foods. DIC – Disseminated intravascular coagulation (DIC) - There is oozing blood from the venipuncture site and abdominal incision. Note: DIC is an acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom. Lecithin Sphingomyelin (L/S) ratio = 3:1. – With a 33 week gestation - Nurse anticipates c-section delivery due to lungs adequately mature there is no need to postpone delivery and csection is preferred with preterm infants. Diabetes Type 1 – Client states “ I have a quivering feeling in my stomach” is given priority due to the fact that this is a sign of hypoglycemia. Hypoglycemia signs also include: -tachycardia -cold clammy -skin, -weakness -pallor Nurse: Check BS -offer milk. Abdominal Abscess – Drain inserted: – Assessment that is best made by nurse to report is the character of the drainage – Ex: purulent or otherwise major priority over amount and consistency. Appendectomy – Following surgery nurse notices large amount of serosanguineous drainage on dressing. Most important for the nurse to obtain is:

-“Was tissue drain placed during surgery” –This is frequently done during surgery to prevent accumulation in wound, Dressing should be reinforced. Third trimester of pregnancy – Nurse most concerned with: -epigastric pain –Indicates impeding convulsion -takes precedence over SOB because this is expected. Pyloric stenosis – 4 week old – The statement expected from the mother is “My son is fussy and hungry all the time. Baby becomes lethargic, dehydrated, and malnourished. Tagamet – (cimetidine) (anti ulcer agent) – An indication that further teaching is necessary if client’s statement is “ My stool may change color while I’m on this medication”. Note: no change in stool color with cimetidine. Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate but no stool color change. Mononucleosis – S&S include -sore throat, flu-like symptoms for the previous 2 weeks and physical exam reveals enlarged lymph nodes. -Advise family not to share drinking glass or silverware with anybody. Note: Mono is spread by direct avoid with cups and silverware for about 3 months. Bulimic – Most therapeutic to analyze a bulimic client’s eating habits and the circumstances that precipitate the client’s eating problems – Note: asg a Thought Feelings Action (TFA) journal relating to client’s eating behaviors will be most helpful to the nurse and therapeutic to the client. Bacterial Meningitis – Mother is afraid of perminant brain damage of her child. Most therapeutic communication is : “ It is

unlikely possibility, but if your child doesn’t develop normally, your pediatrician will help you with any problems”. Note: Bacterial Meningitis If treated early, good prognosis: may be complications and long term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects). Herniorrhaphy – Most important one hour before is confirm that the consent form has been signed. Note: surgical consent should be rechecked before going to surgery. Note: Assessment for allergies should be done earlier then 1 hour before surgery. Addison’s Disease – Increased salt should be increased during periods of stress. Note: with decrease  in aldosterone, there is an  increased excretion of sodium: sodium intake should be increased. Note:The nurse should be concerned with auscultating an S3 ventricular gallop on a 78 year old woman. Note: ventricular gallop is an early sign of Heart Failure (HF). Note: Teaching is effective with a PCA pump when client says” If I start itching I need to call you” Note: itching is a common side effect of narcotics used in PCA pain management. Thorazine (Chlorpromazine) (Antipsychotic)–Client should report if they have difficulty urinating. Note: dry mouth, weight gain and constipation can be resolved at home. Difficulty with urination can become a severe health problem unless treated. Digoxin (lanoxin) (antiarrhythimics) -Theraputic level is 0.5 –2.0. If blood level comes back 2.0.

**Medication should be held and physician notified. Pleur evac –Fluid in the water seal chamber does not fluctuate, indicates re-expansion of lung. And x-ray will confirm this. Glasgow coma scale –5 indicates coma, client requires frequent assessment. Note: After MI the most common complication following is dysrhythmia, with ventricular types being the most serious. Cholecystectomy –Expected drainage is 500-1000 ml/day, However complaints of sever abdominal pain after surgery could indicate peritonitis or wound infection Colonoscopopy– Note:All activities that the client participated in before the colostomy may be resumed after appropriate healing of the stoma or incisions. 3 year old –When assisting a parent on foods it is best to allow finger foods for this age group. Note: Child is going through autonomy versus shame and doubt stage -finger foods allow child the necessary independence for this stage. Note: Distended abdomen with splenomegaly – Possibility of internal bleeding, life-threatening situation Acute asthma attack – Most concerned if patient’s respiration rate increases from 86 to 100 beats per minute. Note: pulse increase is due to decrease in oxygenation of tissues. Note: pallor is unreliable indicator of deterioration of status. Demerol 100 mg PO q4h (meperidine)(opioid analgesics) – Without much relief. Valid suggestion for the nurse to make to the physician regarding pain medication – ister medication Q4 around the clock.

Note: around the clock (ATC) istration of analgesics is more effective in maintaining blood levels to alleviate the pain associated with cancer. Elderly with dementia – When planning care it is best to speak slowly in a face to face position. Note: providing flexibility leads to confusion schedules need to be routine. Note: Propranolol (Inderal) (antianginals, antiarrhythmics) decreases the effectiveness of atorvastatin. (Lipitor) (lipidlowering agents) Note: patient on lipitor and the following statement made by client should be told to the physician “ I take Inderal. Droplet precausion – A child with pertussis. Note: bronchitis is the inflammation of large airway, standard precautions., Tonsillitis standard precaution. Total hip replacement – Most important for the nurse to apply thigh high TED hose to promote venous return. Note: use of antiembolic hose and or sequential compression devices decreases venous stasis and reduces risk of thrombus formation. Hip fracture with Buck’s traction – Most important action by the nurse is to turn the client every 2 hours to the unaffected side. Immobility is the leading cause of problems with Buck’s traction, Important to turn client to unaffected side. Reflux – With infant should be maintained in an upright position: HOB should be raised at a 30 degree angle. After an appendectomy. – Patient complains of pain. After istering analgesics the following action should be to elevate the HOB 30 to 45 degrees. Note: This would reduce stress on suture line and provide for

comfort. Lumbar puncture (LP) - Best to prepare a 5 year old is to - Do a mock run-through of the procedure. Note: Excellent method to use with a child because it incorporates actually “Feeling:” many aspects of the procedure as they are explained. Parathyroidectomy – Should be concerned with a client eating quantities of food from which of the following food groups – Milk products Note: Low calcium diet is recommended preoperatively. -Diet should be high in phosphorus and low in calcium. Thermal injury – Most concerned with: -Increased respiratory rate -decrease BP. Note: May indicate burn wound sepsis, a life threatening complications of thermal injury. Elderly Client – Drinks plenty of fluids however has a diet that consists of starch. He lives alone with a limited income – Most important to increase protein intake. Note: Protein is needed to slow down the degeneration process of aging. Test positive for tuberculosis: –Client placed on isoniazid (INH) 4 weeks ago. -Nurse is most concered if client has fatigue and dark urine. Note: This is an initial indications of hepatic dysfunction. Dx with schizophrenia – Becomes increasingly withdrawn to point of mutism. Most important action is to - Sit with client for brief period of time. Note: nurse should maintain with client but not make demands to communicate or participate in activities.

Wet to dry – dressing for a client of an infected abdominal incision. The nurse should intervene if client’s spouse wets the old dressing with sterile saline before removing it. Note: it is contraindicated – dressing should be removed dry so wound debris and necrotic tissue are removed with old dressing. Spina bifida – Of an 2 day old infant in for surgery repair. Mother is concerned that infant would be confined to a wheelchair. Best statement by nurse – “ The corrective surgery will not change your child’s physical disability” Note: Spinal nerves that are destroyed by the myelomeningocele cannot be corrected: nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele. Electrical burns – Note: electrical burn injuries are typically more injurious to underlying tissue, such as nerve and vascular tissue, which require complex and timely treatment. Child of 5 years old – with Closed head injury – Best action is to assess orientation to person, place and time every hour. *Early signs of increased I are alterations in orientation. Cystic Fibrosis – Statement that indicates parental understanding about the cause of their newborn’s diagnosis of CF – “ Both of us carry a recessive trait for cystic fibrosis. Note: cystic fibrosis is inherited by an autosomal recessive trait. Right sprained ankle – Learning to walk with a cane. Nurse should be positioned by standing on the client’s left side and slightly behind the client. Note: Stand slightly behind client on strong side. Note:If resistance is met with trying to flush diluted heparin into a subclavian triple lumen catheter. Action nurse should take is to

secure the lumen with a luer - lock cap and notify the physician. Note: streptokinase (Streptase,or Kabbikinase) (thrombolytics) may be used to dissolve clot. If unsuccessful, lumen is labeled as clotted off. istration of medication to a 4 month old – Most appropriate is to place the medication in an empty nipple and allow the infant to suck. Note: never add to child’s formula feeding. Note: Nurse should the order with a physician about IM injection of Demerol for pain to a client receiving thrombolytic therapy. Note: bleeding can occur with IM injections. Note:Douching makes Pap smear inaccurate. Have client avoid douching for 24 hours. Medication contraindicated – For a patient with hemophilia A = Oxycodone terephthalate (percodan)(equals oxycodone and aspirin) (opioid analgesics) – Contraindicated for persons with bleeding disorder, contains aspirin. Patient with sickle cell crisis with an infiltrated IV – Is a priority due to IV fluids are critical to reduce clotting and pain. Hope this helps with your studies... : Goal for today is to study!!! Goal is more in a while...:typing S No. 2271 from

sh08

Nov 12, 2008, 01:58 PM

thanks everyone @ this thread for great info and ur time . i took nclex this morning it shut down @ 75.i think i did pretty good or the exam was too easy. i don't know hope i No. 2272 from

feliz3

Nov 12, 2008, 03:06 PM Originally Posted by Rachi321

i got alot of questions on peak expiratory flow rate on my last test that i didn't understand and ive been looking it up and have found little information about it, does anybody have any info that is easy to understand, i can't really find normal values, cuz they differ for age and stuff idk im just worried about it showing it up again. Questions about peak expiratory flow are in connection with mechanical ventilation, but before discussing that subject, I want to post facts about lung sounds and where to locate them when using the stethoscope. Types of breaths sounds and their location: 1) Bronchial---------------------- trachea and larynx tracheal, tubular (other names for the same sounds) 2) Broncovesicular--------------- over the major bronchi 3) Vesicular --------------------over the peripheral lung fields where air enters the bronchi If you read a question describing broncovesicular sounds, now you know which area of the lungs the question is talking about. Tracheal breath sounds high-pitched, loud, harsh, hollow sounding, equal on inspiration and expiration. Bronchial breath sounds High-pitched, blowing, muffled, expiratory sound slightly longer than inspiratory. Broncovesicular breath sounds louder and harsher than vesicular sounds, muffled vesicular sound combined with with loud guttural sound, equal on inspiration and expiration. Vesicular breath sounds soft and low-pitched, rustling or breezy, three times longer on inspiration than expiration. Mechanical ventilation: Tidal volume=the volume of air the patient receives with each breath, that will be determined by the doctor and the ventilator would be set according to his orders. Fraction of inspired oxygen(FiO2)= O2 concentration delivered to the patient which is determined by the patient's condition and arterial blood gases (ABGs). Rate=number of ventilator breath delivered per minute. Sighs= volumes of airthat are 1.5 to 2 times the set tidal volume. The sighs are delivered 6-10 times per hour. Sighs may be used to prevent atelectasis (collapsed, airless lung). Peak Airway Inspiratory Airway Pressure= the pressure needed for the ventilator to deliver a set tidal volume at a given compliance (the elasticity, extensibility and distensibility of the lungs and the thoracic structures) Causes of Ventilator Alarm: Note: Assess your patient first and the ventilator second.

High-Pressure alarm 1) increased secretions 2) wheezing or broncospasm causes decreased airway size, , the ventilator is preset according to certain compliance (see above definition) 3) Displacement of endotracheal tube 4) Endotracheal tube obstruction due to water or a kink in the tubbing. 5) patient is anxious or fights the ventilator Low-Pressure alarm 1) Patient spontaneously breathing--that's nice 2) disconnection or leak in the ventilator or in the patient's airway cuff occurs I hope this information helps. feliz3 :typing No. 2273 from

feliz3

Nov 12, 2008, 06:59 PM Originally Posted by sh08

thanks everyone @ this thread for great info and ur time . i took nclex this morning it shut down @ 75.i think i did pretty good or the exam was too easy. i don't know hope i

Congratulations on taking the exam!

feliz3

No. 2274 from

feliz3

Nov 12, 2008, 10:10 PM Important Definitions: Assault= Putting a client in fear of a harmful or offensive . The victim fears and believes that harm will result as a direct consequence from the threat perceived coming from the care giver. Battery= An intentional touching of a client's body without his/her consent. Invasion of privacy= Includes violating confidentiality, intruding on private client or family matters and sharing client information with unauthorized persons. False Imprisonment= A client is not allowed toleave a health care facility; however, there is no legal justification for detaining the client. False imprisonment is committed when restraining devises are used without an appropriate clinical justification. Defamation= False communication or a careless disregard for the truth that causes damage to someone's reputation. This could be done in writing(libel) or verbally(slander). Fraud= Results from a deliberate deception intended to produce unlawful gains. Negligence=Failure to provide care that a reasonable person ordinarily would use in similar circumstances. Malpractice= Failure to met the standards of acceptable care, which results in harm to another

person. Restrains: Definition= Devises designed for protecting the client used for limiting the physical activity of a client or to immobilize him/her or an extremity. Kinds of restrains: Physical--restricts client's movements through the application of a physical devise Chemical--drugs given to a patient for inhibiting a specific behavior or movement, for example a sick patient in a mechanical ventilator who fights the machine is given vecuroniun bromide, a paralytic agent which relaxes skeletal muscles so the patient cannot fight the mechanical ventilator. Obviously that chemical restrain is needed for that patient to breathe. There are specific rules governing the use of any kind of restrains on a patient: 1) A restrain must have a doctor's order. 2) There cannot be a standing order for a restrain. 3) Physician's order must state a) the type of restrain b) identify the behavior for which the restrain is used c) identify the limit or time frame for use 4) Physician"s orders for restrains must be renewed within a specific time frame which is usually 24 hours. 5) Restrains are not to be ordered PRN(as needed) 6) The reason for the use of the restrain has to be told to the patient and his/her family and their permission must be asked. 7) Restrains should not interfere with any treatment given to the patient or affect the patient's health. 8) to secure the restrain a half-bow knot should be used for it is easy to undo and it is safe. 9) The patient must have enough slack to allow movement of the body. Do not secure the restrains to the bed's side rails, use for that the bed's frame or a chair. 10) Assess the skin integrity, neuromuscular and circulatory status every 30 minutes and remove the restrain every 2hours to permit muscle exercise and promote circulation. Continually assess and document the need for restrain. Note: Not following those rules while restraining a patient is definedby law as false imprisonment. feliz3 No. 2275 from

isobelle5287

Nov 13, 2008, 05:30 AM

St John’s wort - used for self-treatment of depression. Diabetes - higher rate of occurrence in African Americans Asian Americans - higher incidence of stomach and liver cancers. Rape victim - obtaining informed consent for examination is a priority before any action is taken, including obtaining laboratory specimens and notifying the police. This is part of process which initiates the chain of custody of the

specimens and their collection. Hostage response is when victims assume responsibility for the violence inflicted on them. Victims tend to blame themselves for the abuse and develop a sense of unworthiness. Valacyclovir (Valtrex) - a form of acyclovir; indicated in the oral treatment of herpes zoster and recurrent genital herpes in immunocompetent adults. Down syndrome - have a high incidence of congenital heart disease, especially atrial defects. When assisting in the medical treatment of alcohol withdrawal, the nurse should encourage intake of fluids providing they are not too somnolent. Alcohol depletes the body of fluid, Alcohol withdrawal - anorexia, irritability, nausea, tremulousness, insomnia, nightmares, hyperalertness, tachycardia, increased blood pressure, diaphoresis, and anxiety. Bulimia nervosa - Russell's sign, which is the presence of bruises or calluses on the thumb or hand, caused by trauma from self-induced vomiting. Cocaine - can cause seizures, which is one of the most serious side effects of cocaine use. Cocaine withdrawal - physical activity will help to dissipate anxiety and decrease the cravings Delirium tremens - alcohol withdrawal syndrome, which occurs most often after 24 hours; visual and tactile hallucinations, confusion, tachycardia, and possibly seizures Dementia - symptoms of confusion are worse at night. This may be referred to as “sundowning syndrome” in clients with Alzheimer’s disease. Chlorpromazine (thorazine) - One of the common side effects of antipsychotic medications is drowsiness; it usually diminishes after the client has taken the medication for a few days. :typing

"A journey of a thousand miles begins with a single step."

- Chinese Proverb No. 2276 from

isobelle5287

Nov 13, 2008, 05:45 AM

Postural hypotension occurs with phenothiazides (chlorpromazine, fluphenazine) Li toxicity - diarrhea, confusion, ataxia, slurred speech, hypotension, seizures, oliguria, coma, and death; increased thirst and urination; polydipsia, polyuria, and fine tremors are some of the very early signs of lithium toxicity Generalized anxiety - can be managed with either benzodiazepines (Librium) or an antidepressant. Donepezil (Aricept) - cholinesterase inhibitor drug indicated for treatment of Alzheimer's type dementia Clozapine (Clozaril) - antipsychotic that can cause a potentially fatal blood dyscrasia characterized by agranulocytosis (decreased WBCs, specifically neutrophils) Older adult with alcohol withdrawal - Short-acting benzodiazepines, such as Ativan, are preferred in older clients or when liver damage is suspected, because it is not metabolized by the liver. Methotrexate- causes GI tract irritations from toxicity; avoid sunlight and maintain effective birth control while on the medication. Sulfamylon (burn cream) - carbonic anhydrase inhibitor, and when systemically absorbed, can precipitate metabolic acidosis; used to treat bacterial growth under the eschar; causes a burning or stinging sensation on application, and pain management should be planned; old ointment should not be removed. Glaucoma has a strong hereditary tendency; those with a family history of glaucoma should have intraocular pressure monitored yearly after the age of 30 instead of waiting until after the age of 40 as would low-risk individuals. Myringotomy - to promote drainage by making a surgical incision into the tympanic membrane, which also relieves the pressure, prevents eardrum

perforation, and reduces pain. Meniere’s Disease - assess the frequency and severity of attacks to plan best for the client’s safety. Infants are obligate-nose breathers - nose drops given before feeding promotes clearance of the nasal ages; limit use of it once a day Conductive hearing loss - may result from acute otitis media, perforation of the eardrum, and obstruction of the ear canal, as by cerumen Stapedectomy - experience dizziness, vertigo, and nystagmus from changes in endolymph fluid; observe fall precautions Hydrochlorothiazide - is a diuretic that may be used to decrease the lymph fluid buildup in the ear (i.e. Meniere’s disease) 13 days to go... :typing ...

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"A journey of a thousand miles begins with a single step." - Chinese Proverb No. 2277 from

SWEETDREAMERINSOCAL

Nov 13, 2008, 12:14 PM Updated Nov 13, 2008 at 12:27 PM by SWEETDREAMERINSOCAL

Here is my send for today... :typing High priority patient who has a cast that complains of a funny feeling: affected extremity indicates neurovascular compromise, and requires immediate assessment. Note: client in early stages of labor with a diagnosis of complete placenta previa must be prepared for an immediate cesarean section. Implementation, cannot deliver vaginally. Note: Patient with epiglottitis who is having an early complications of hypoxemia: will present with heart rate of 148 beats per minute. The HR correlates with hypoxemia and is an

early finding, along with restlessness. After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is best? – Ans. 1. Limit visiting hours to promote optimal rest 2. Arrange for a psychologist to visit with the family. 3. Arrange for the family to meet with a social worker to discuss financial aid. 4. Arrange for clergy to visit with the client and family as requested. Should remove nitro-patch before MRI is performed. If a family member verbalizes that a family member will closely watch the apnea monitor at all times. Nurse should be concerned because this indicates a feeling that monitor may not let them know if their infant stops breathing. Patient itted to the hospital with dry mucous membranes and decreased skin turgor. Vital are BP – 120/70, temp, 101 degrees F, pulse 88, resp 14. Lab tests indicate the serum sodium is 150 mEq/L and the Hct is 48%. The nurse expects the physician to order which of the following IV fluids? – Ans. 1. -D5 NS, 2. -0.9 Na Cl 3. -lactated ringer 4. -0.45% Na Cl, Note: Isotonic solution pushing fluid back to the cells. Specific to dehydration. “I should wash my hands before redressing my wound” – Indicated understanding of asepsis, hallmark is hand washing. A mother with a 4 year old comes in to confirm her second pregnancy. The most important action for a nurse to do is identify the client’s general health needs. (Physical Needs)

The priority for a nurse in caring for a client diagnosed with perforated bowel secondary to a bowel obstruction is to prepare the client for emergency surgery. Note: this can lead to peritonitis if not addressed. A mother brings her 17 month old son to the well baby clinic for a routine checkup. She confides to the nurse that she is concerned because her son sucks his thumb, especially at night when he is put to bed. Which of the suggestions by the nurse is best? – Don’t intervene at this time. This behavior usually subsides after 24 months of age. Note: Normal behavior, peaks at 18 – 20 months, most prevalent when child is hungry or tired. When istering Calcium EDTA (edetate calcium disodium) (antidotes) and dimercaprol (BAL inOil)(antidotes) for elevated blood lead levels the action that has the highest priority is to rotate the injection sites. This with prevent tissue damage and promote tissue absorption of the medicine. NOTE: dimercaprol (BAL inOil)(antidotes) treatment of acute poioning with: -mercury -Gold -Arsenic Used adjunct with edetate calcium disodium in treatment of server lead poisoning accompaneied by encephalopathy or blood level > 100mcg/dl Priority question for OB _ Immediate intervention is always given to a multipara woman at four weeks gestation reporting unilateral , dull abdominal pain. This indicates an etopic pregnancy and needs to be evaluated. A patient with a thermal injury to the right arm – The observation that is most important to report to the doctor is – Gastric PH less than 6.0 –

Note: decrease in gastric PH could indicate hypersecretion of hydrogen ions,predisposing factor to stress ulcer formation. Note: situational crisis: priority is to determine how client coped with crisis in the past and build on client’s coping strategies. Note: -if oil is placed on a wound it is most important to wash the burn with soap and water – Note: cooking fat applied to an open wound increases the possibility of infection: burns should be rinsed immediately with tap water to reduce the heat in the burn. Client with DX of hyperparathyroidism – The most important symptom to report to the next shift is – Hematuria Note: Hematuria is a sign of renal calculi: 55% of hyperparathyroid clients have renal stones. Note: Dx with multiple sclerosis – most important for the nurse to include in instructions – Is to avoid overexposure to heat and cold – Note: this may cause damage related to the changes in sensation Several days after a client had a myocardial infarction, the physician places the client on a 2-gm sodium diet. Which of the following selections indicates to the nurse an understanding of the diet? – Ans. 1. Scrambled egg, orange slices, and milk, 2. instant oatmeal, toast and orange juice, 3. poached egg, bacon and milk, 4. biscuit, fruit cup and sausage. Note: instant oatmeal has sodium added NOTE: all items are low in sodium with correct answer due to milk is allowed on a salt restricted diet. Instruction about the medication is effective when a pt. on

naproxen sodium (Anaprox) (nonopioid analgesics , nonsteroidal anti-inflammatory agents, antipyretics) States “ I should call my doctor if my stools turn very dark” – Note: NSAIDs can cause gastrointestinal bleeding Note:During a dressing change the old dressing should not be saturated with sterile saline before it is removed. The dressing should be removed dry so that wound debris and necrotic tissue are removed with old dressing. Note: Most important for nurse to assess for before istering calcium gluconate 10% 500 mg IV stat – is patency of the vein. If injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn. Note: a child itted with failure to thrive has just had a positive sweat test. – Nurse anticipates what change in the child’s POC? – ans.istration of replacement enzymes. Note: positive for sweat test indicate cyctic fibrosis. Note:Best recommendation during discharge for a patient who suffered a mild MI and smokes one pack of cigarettes per day– Ans. Participate in a program such as nicotine avoidance. A pt. has a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the pt. in respiratory distress. Which of the following actions should the nurse take FIRST? – Ans. Cut the balloon ports and remove the tube. Note: Scissors always secured at the bedside: remove tube if observe signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon. It is most important for the nurse to include which of the following instruction with prenatal vitamins. – Ans. Take prenatal vitamins with orange juice at bedtime. Note:taking the vitamins with something acidic increases the absorption of iron. Taking them with food at bedtime

decreases the possibility of nausea, as the client will be asleep. To promote safety in the environment of a client with a marked depression of T cells, – Ans. Remove any standing water left in containers or equipment. Note: Water should not be allowed to stand in containers, such as respiratory or suction equipment because this could act as a culture medium. Note: proper med istration Carafate (Sucralfate) (anti ulcer agent): should be taken 1 hour ac (before meals) and the Maalox (aluminum hydroxide with magnesium hydroxide) (antacids)1 hour pc (after meals). A client develops severe, crushing chest pain radiating to the left shoulder and arm – BEST PRN med the nurse should ister should be – Ans. Morphine Sulfate IV (Opioid analgesic) Note:This med reduces pain, anxiety and cardiac workload: reduces the preload and afterload pressures. The nurse cares for a client diagnosed with dementia in a long term care facility. Which of the following actions by the nurse is BEST? –– Ans. Direct conversation toward assisting the client to reminisce and talk about important past events in life. Note:geriatric client should be encouraged to talk about his life and important things in the past because he has recent memory loss. Which of the following is the FIRST nursing action that should be implemented for a client after a vaginal delivery? – Ans. Check the patient’s lochial flow. Note:Complication of hemorrhage assessed by observing lochial flow.

Note:When recording client’s chief complaint – It should be recorded using the client’s own words. – Ans. “My stomach hurts after dinner every night” A client comes to the nurse’s station for the prescribed antipsychotic medication. The nurse notes that the client has torticollis , an arched back, and rapid movement of the eyes. Which of the following actions should the nurse take first? – Ans. ister the PRN trihexyphenidyl (Artane) (antiparkinson agents)IM immediately (torticollis definition: Spasmodic contraction of neck muscles causing head to tilt to one side and chin pointing to other side McGraw Hill Nurse’s dictionary 2007) Note:ister Cogentin (benztropine)(antiparkinson agents). or Artane(trihexyphenidyl)(antiparkinson agents). – Assessment, no validation required. Note: a preschool client’s mother reports that the child has freq. abouts of gastroenteritis. Most important quest. To ask “Does the child attend a day care center?” – Note: environments with increased numbers of children (day care) more likely to promote infections due to close living conditions and increased likelihood of disease transmission. Note:Desired response to fluid replacement with a patent DX with hypovolemia. – Ans. CVP reading of 8 cm of water pressure. Note: Normal range of CVP is 3-12 cm water pressure so 8 indicates desired results. Note: - HGB 11 gt, HCT 33% indicates hypervolemia. PH 7.34 indicated acidosis. Client with elevated vital signs, hallucinations and aggressive

behavior that are possibly on hallucinogenic drugs – Following action is to decrease environmental stimulation. Note: symptoms will subside with time and decreased stimulation. Note: Early stages of hepatic encephalopathy is – having difficulty describing what he does at work. Note: impaired thought processes is early symptoms. Proper weight gain pregnancy is: -2-5 lbs in the first trimester, -0.66- 1.1 weely in 2nd and 3rd trimester. -So 14 lbs in the fifth month is normal. 5 + 8 = 13. A young adult comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back. The nurse should instruct the client to take which of the following actions? – Ans. Clean the area carefully with soap and warm water every day, and cover them with a sterile dressing. Note:Open Kaposi’s sarcoma lesions should be cleaned and dressed daily to prevent secondary infection. The nurse assesses an infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Which of the following nursing actions is MOST appropriate? – Ans. Position the infant on one side. Note:will facilitate drainage of mucus from upper airway and will promote adjustment to breathing through the nose. Note:Pitocin(Oxytocin) (misc O/B GYN Agents) should always be a secondary infusion controlled by an IV pump. A client is itted with a diagnosis of renal calculi and is experiencing severe pain. Meperidine (Demerol)(Narcotic

Analgesics) 75 mg IM is given prior to the change of shift. Which of the following symptoms is MOST important for the nurse to report to the next shift? – Ans. Change in the location and character of pain. Note: Location of the pain depends on location of renal stone: character of pain changes depending on location or movement of stone. Note: -Nursing interventions should involve distracting and redirecting behaviors for a bipolar disorder patient in the manic phase. Note: gown gloves and mask are appropriate for rubella (German measles) = droplet precaution. Note: Flagyl shouldn’t be taken with alcohol. It will cause antabuse (Disulfiram)(alcohol antagonist drug)like reactions. Should also be taken with food to decrease gastric upset. Note:4 year old with sickle cell anemia, baby aspirin (SALICYLATES) (antipyretics, nonopioid analgesics) shouldn’t be given for complains of pain. Note: Aspirin(SALICYLATES) (antipyretics, nonopioid analgesics) can cause a hemorrhage during a sickle cell crisis. Which of the following findings indicates to the nurse that a client’s Salem sump tube (nasogastric) was functioning effectively? – Ans. The presence of a hissing sound from the blue lumen tube. Note: Hissing sound is indicative that air is freely exiting the airway; purpose is to provide continuous steady suction without pulling gastric mucosa. The nurse cares for a pt. with deep partial thickness and full thickness burns. The client receives morphine sulfate 15 mg IV(Opioid analgesic). The nurse notes a decrease in bowel sounds and slight abdominal distention which of the following. Actions, if taken by the nurse, is BEST? – Ans.

Explore alternative pain management techniques. Note: Morphine (Opioid analgesic) is drug of choice for burn pain management, when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important. Note:How to obtain a throat culture from a client diagnosed with pharyngitis. – Ans. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx. NOTE: height and weight changes in a year Height: at age 6 – 12 children grow about 2 inches (5 cm) a year Weight: gain 4.5 – 6.5lb (3 – 3 kg) a year Height: at age 7 about 44 – 51 inches (111.8 – 129.7cm) Weight: average 39 – 66.5 lb (17.7 – 30kg) I will share another later today... study .....

keep going... study:typing...goal

S No. 2278 from

SWEETDREAMERINSOCAL

Nov 13, 2008, 01:57 PM :typing

Hello again just sharing my latest facts... A mother brings her 7 year old daughter to the outpatient clinic for a routine check up. The girl weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that the child has gained 2.5 lb and grown 3 inches in the past year.

Which of the following. Responses by the nurse is best?– Ans. “ Your daughter’s height and weight are within normal limits.” NOTE: First 24 hours of TPN – Nurse should evaluate blood glucose level. Note: Total parenteral nutrition (TPN), or hyperalimentation, has a high glucose content important to monitor glucose levels. The nurse receives a phone call from a nursing assistant who states that her 5 year old child has developed chickenpox. It would be MOST important for the nurse to ask which of the following.– Ans. “Have you had the chicken pox?” Note: Need to ascertain if staff has had the disease, if not, Varicella Zoster Immune Globulin (VZIG) can be given, -exclude from patient care from the: 10th day after First exposure through the 21st day after last exposure. Unless Given than 28th day if VZIG given) The nurse knows that which of the following.Plans would be a priority for an infant with a positive PKU blood test? – Ans. Place the infant on Lofenalac formula. Note: Guthrie blood test evaluates neonate for phenylketonuria (PKU). Note: Lofenalac formula is low in phenylalanine but contains minerals and vitamins to provide a balanced nutritional formula. Phenylketonuria definition: Phenylpyruvic acid in the urine. *A recessive hereditary disease caused by the body's failure to oxidize an amino acid (phenylalanine) to tyrosine, because of a defective enzyme. 24 hr after abdominal surgery, which of the following. Plans is a nursing priority to prevent complication of flatulence? – ans.

Assist the client to walk in the hall every two hours. Note: Twalking in the hall, this action will increase peristalsis, decreasing the development of flatus. A client itted with metastatic cancer has received chemotherapy for three months. Lab values include: RBC 3.8 millin/mm3, WBC 3,000/mm3, Hgb 9.3 g/dl, platelets 50.000/mm5 . The nurse expects the patient to exhibit which of the following symptoms? – Ans. BP 120/70, pulse 100, respirations 16. – Note: Increase pulse and respiration are caused by decreased oxygenation of tissues. – The patient will be pale due to anemia, Normal RBC male – 4.3 – 5.9 million/mm3, female 3.5 – 5.5 mill./mm3 Normal WBC 4,000 – 11,000/mm3, Normal Hgb male 13,5 – 17.5 g/dl, female 12 – 16 gt/dl A physician writes an order for an HIV positive infant to receive Inactivated polio (IPV) immunization. Which of the following. Nursing actions is MOST appropriate?– Ans. ister the immunization. Note: Inactivated polio (IPV) appropriate, contraindications include: • anaphylactic reaction to neomycin, • streptomycin, or • polymyxin- B. A client is placed on cephalexin monohydrate (Keflex) (cephalosporins, First Generation) prophylactically after surgery. Which of the following foods should the nurse encourage?– Ans.

Yogurt and acidophilus milk. Note:These foods will help maintain normal intestinal flora, which may be altered by the keflex. Note: A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin Indicates subcutaneous emphysema, which is indication of pneumothorax, observe client for respiratory distress, physician. Note:If nurse enters the room to find a tracheotomy tube dislodged. The nurse should immediately replace the tracheotomy tube. Note:a client with sunken eyeballs and fruity breath indicates diabetic ketoacidosis, treatment: with normal saline and regular insulin. Note: HEP–A: is not infectious within a week or so after the onset of jaundice, child can return to school. Activity at that time depends on the child’s energy level. Which finding indicates to the nurse that a client experiencing alcohol withdrawal is in need of more sedation to control the severity of withdrawal symptoms? – Ans. Elevated pulse rate Note:pulse rate is a good indicator of client’s progress through withdrawal, increasingly elevated pulse signals: • impending alcohol withdrawal • delirium requiring more sedation. A client developed diabetes insipidus following. A craniotomy. The nurse provides discharge instructions for the client and spouse. Which of the following statements, if made by the client indicates to the nurse that further teaching is needed? – Ans. -“I should weigh myself every day -drink less fluid if I gain more than 5 lb over a week”. Note: - desmopressin (DDAVP, Stimate)(hormone) treatment

of Diabetes Insipidus nasally or SQ required for remainder of life. During the physical assessment, the nurse determines the need to perform the bulge test. Which of the following statements, if made by the nurse is BEST– Ans. ”Please lie down and extend your legs” Note: Bulge test: confirms presence of fluid in the knee, client’s leg should be extended and ed on the bed. Note:Cromolyn Sodium (Intal, NasalCrom) (misc antiallergy agents) is used to prevent the release of histamine and other allergy-triggering substances. – Correct statement would be “ I will take the medicine before I begin any vigorous exercise”. Note:favorable results from istration of medicationlevothyroxine (synthroid) (harmoe) is increased urine output. Note: Medication increases metabolic processes of body, including glomerular filtration, edema will decrease as water is excreted. NOTE:- Appropriate action in palpating the uterine contractions would be to: • place one hand on the abdomen over the fundus, and • with the fingertips presses gently. A nurse was sued for malpractice but is proved innocent. Which fact from the case was decisive in determining the outcome? – Ans. No harm was actually suffered by the patient.