OK I know this sounds stupid but I have a friend that gets really freaked out before big tests like finals, HESI, NCLEX, and usually we get together and a few days before I start throwing out random facts at her. On 2 different tests she said the only way she got several questions was from the random facts that I threw at her that she never would have thought of!
SOOOOO..... I thought that if yall wanted to do this we could get a thread going and try to throw out 5 random facts or "things to remember". NCLEX is coming and the more I try to review content the more I realize that I have forgotten so......here are my 5 random facts for ya:
OH and BTW these came from rationales in Kaplan or Saunders no made up stuff:
1️⃣ A kid with Hepatitis A can return to school 1 week within the onset of jaundice.
2️⃣ After a patient has dialysis they may have a slight fever...this is normal due to the fact that the dialysis solution is warmed by the machine.
3️⃣ Hyperkalemia presents on an EKG as tall peaked T-waves
4️⃣ The antidote for Mag Sulfate toxicity is ---Calcium Gluconate
5️⃣ Impetigo is a CONTAGEOUS skin disorder and the person needs to wash ALL linens and dishes seperate from the family. They also need to wash their hands frequently and avoid contact.
Oh, ohh, one more...
? Vasopressin is also known as antidiuretic hormone
a medication that a nurse should question with copd would be: propranolol hydrochloride (inderal)(beta-adrenergic blockers).
rational: - beta blocker that blocks beta adrenergic impulses to the bronchial tree that cause bronchodilator resulting in increased bronchoconstriction.
the nurse performs an ice massage - for a client in chronic pain. the nurse is most concerned if which of the following is observed?
ans=
- mottling or graying of the tissue.
rational: - site should be observed every five minutes for:
-signs of tissue intolerance, including blanching, mottling, or graying.
complete heart block - the nurse should question which of the following orders?
ans=
administrer lidocaine (xylocaine)(antiarrhythmic agent) 50 mg iv push for pvcs in excess of six per minute.
rational = in complete heart block, the av node blocks all impulses from the sa node, so the atria and ventricles beat independently, because lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response, cardiac depressants are contraindicated in the presence of complete heart block.
manic phase of bipolar disorder - it is most important for the nurses to offer which of the following meals?
ans=
tuna salad sandwich and orange slices
rational = clients with mania need nutritious finger foods;
foods contain protein, carbs, and vitamin c and fiber.
urinary pattern - the nurse should instruct a patient to do what first?
ans=
keep a record of daily fluid intake.
rational: - client needs to know how much and when he ingests fluid.
ileal conduit 2 days ago - most important for the nurse to take which of the following actions?
ans=
apply a close fitting drainage bag to the stoma.
rational = primary preventative measure to prevent urine from contacting the skin.
note: should be cleaned with soap and water not an antiseptic solution.
intubating a postoperativeclient - most appropriate action to take would be to.
ans=
place the intubation blade in a bag, and arrange for gas sterilization.
rational = sterilization of equipment after exposure to body fluids of a client is protocol.
diet teaching for a client with sci. - the following meal that is best.
ans=
spaghetti with meat sauce and green beans.
rational - high fiber diet is an important part of bowel program, fiber helps prevent the complication of constipation, includes whole-grain foods, bran, fresh and dried fruits, increased fiber will facilitate defecation, especially with reduction in fat intake.
note: i picked a tuna fish sandwich with orange juice due to the fiber
(spaghetti is white flour and is constipating)
note: birth weight should double in 5 months.
client presents with diaphoresis, pallor, and tachycardia
- one hour after receiving 7 u of regular insulin. - action the nurse should take first is
ans=
offer the client milk and crackers.
rational - onset of action for reg. insulin is 30-60 min; assessment indicates a problem with hypoglycemia, foods such as mild and crackers should be given if blood sugar is around 40-60 mg/dl. if orange juice or simple sugaris given, it should befollowed with a meal or with protein intake.
note: it is unnecessary to administer glucagons unless client is unresponsive.
client receiving chlorpromazine (thorazine) (antipsychotics) 400mg/day for four weeks - presents with temp. 105 fsevere rigidity, oculogyric crisis, and severe hypertension. most important for the nurse to take which action?
ans=
hold the chlorpromazine, and notify the medical staff stat. -
rational = client is experiencing neuroleptic malignant syndrome, fatal in about 15 - 20% of cases, is toxic effect of antipsychotic medication.
(hba1c) of 6% - results normal, indicates good control of diabetes.
normal heart rate for a two day infant - 120-160 bpm
-if a 2 day old infant, lying quietly alert,
-heart rate of 185 bpm has tachycardia, and requires further investigation.
graves disease - nurse would intervene if client drinks
ans=
tea.
rational: = stimulant that would increase metabolic rate.
after the anesthesiologist administers an epidural to a woman - highest priority would be to
ans=
obtain the blood pressure.
rational: assessment side effect of an epidural is hypotension from the vasodilation that occurs.
note: assessing the fhr monitor may be done as ongoing management but is not a priority.
ciprofloxacin (cipro) (fluoroquinolones) - most important for the nurse to include when instructing the client about this medication
ans=
" drink plenty of fluids"
rational - prevents crystalluria and stone formation.
spinal anesthesia - the following is an important nursing implication regarding this anesthesia
ans=
adequately hydrated the client
rational = important that the client be well hydrated to prevent hypotensive problems after the spinal anesthesia is initiated.
note: unnecessary for client to be npo for 12 hours
a client is diagnosed with a tumor of the pituitary gland and has a transphenoidal hypophysectomy. the nurse plans care for the patient two days after surgery. it is most important for the nurse to monitor which of the following?
ans=
specific gravity of urine.
note:lack of adh from pituitary will cause diabetes insipidus and diuresis with very low specific gravity.
note: clients on hydrochlorothiazide (hydrodiuril) (diuretic) should be encouraged to eat foods high in potassium - ex. dried apricots, bananas every day due to the diuretic causing loss of potassium.
note:a lpn/lvn with shingles can care for non-high risk clients as long as lesions are covered.
the nurse performs hypertension screening at the local grocery store. it is most important for the nurse to complete which of the following tasks?
ans=
take two readings at least five minutes apart.
note:recognition of adult hypertension should be done after two readings taken at least five minutes apart.
note: to confirm a client stating that he thinks he has an ulcer. nurse should respond by asking " do you have a burning pain in the epigastric region?"
- peptic ulcer pain is often referred to as a "boring pain in the back" or a burning gnawing feeling in the midepigastric area.
the nurse cares for a client immediately after an abdominal aortic aneurysm repair. vital signs and blood pressure 100/70, pulse 120 respirations 24, urine output 75 ml during the past three hours. which of the following is a priority nursing action for this client?
ans=
maintain bedrest, and evaluate for a decrease in cvp readings.
note:client is at increasedrisk for development of hypovolemic shock, vital signs and urine output correlate with the early signs of shock, the nurse should compare the cvp with previous readings.
note: client with a harrington rod due to scoliosis, in preparation for the immediate postoperative care, the nurse should include which of the following in a teaching plan - ans.
take 10 deep breaths every 2 hours.
note: client must be monitored closely for the first 48-72 hours for respiratory problems bowel and urinary problems need to be assessed along with neurological problems in the extremities. client will have a catheter, may have a nasogastric tube connected to low suction,.
no reason to reassign pregnant staff member from taking care of cytomegalovirus patient. - just need standard precautions.
the family members of an 85 year old report to the nurse that they suspect that their father is masturbating. which of the following responses by the nurse is best?
ans=
" this is considered a normal behavior for men"
note:masturbation is an activity performed by some elderly men.
the nurse cares for a patient following a right adrenalectomy. during the immediate postoperative period, it is most important for the nurse to observe for which of the following?
ans=
blood pressure alteration
note: decrease in blood pressure may indicate shock.
when using palpation techniques during the physical assessment of an adult female with abdominal pain, which of the following actions should the nurse take first?
ans=
inform the client to breathe slowly.
note:breathing slowly will enhance relaxation of the abdominal muscles.
note: holding a deep breath is done during palpation of the liver.
note: it is important for the parents to stroke an infant after surgery. the tactile stimulation is imperative for an infant's normal emotional development, after the trauma of surgery; sensory deprivation can cause failure to thrive.
note: on an ekg stripe if there are 8 qrs complexes in 30 large squares for a 6 second strip. the heart rate is calculated by timeing the qrs complexes by 10.
ex (8x10) = 80. 80 is the hr.
an order has been received to obtain a stool specimen and test for occult blood. the nurse is most concerned if the client makes which of the following statements?
ans=
" i take feosol every day"
note: iron supplements can cause color of stool to resemble melena.
a primipara is admitted in early labor, and her membranes rupture. which of the following assessments by the nurse is most important?
ans=
assess for a prolapsed cord.
note: initial assessment is to check for a prolapsed cord.
note:the mother's bp is not affected by rupture of the membranes.
the nurse prepares a client for a laparoscopic cholecystectomy for treatment of cholelithiasis. it is most important for the nurse to ask which of the following questions?
ans=
" who is going to help you at home during the next couple of days?"
note: cleint usually discharged the day of surgery or the next day: ensure that client has help at home for first 24-48 hours.
note: activity helps reduce frequency and degree of phantom pain on an amputee.
an adolescent is seen in the emergency room for an overdose of acetylsalicylic acid (aspirin)( antipyretics, nonopioid analgesics). which of the following actions by the nurse is best?
ans=
determine when the client took the aspirin.
note:charcoal, if given within two hours, will absorb particles of salicylate.
note:pt. withdrawing from pain or noxious stimuli is a sign of deterioration in pt's condition. physicain should be notified.
the nurse evaluates care for a client diagnosed with depression. the nurse is most concerned if which of the following is observed?
ans=
the lpn?lvn administers flurazepam hydrochloride (dalmane) (sedative hypnotics)15 mg hs.
note: medication that produces dependence should be a last resort, used only if other nursing measures and antidepressant meds have not worked and the client is exhausted.
the nurse prepares a client for insertion of a suclavian triple lumen catheter to be used for administration of total parenteral nutrition (tpn). the nurse should position the client in which of the following positions?
ans=
supine with the client's head low and turned away from the insertion site.
note:produces dilation of the neck and shoulder vessels, making entry easier and preventing air embolus.
the nurse cares for a woman with pregnancy-induced hypertention (pih)treated with magnesium sulfate. the nurse is most concerned if which of the following is observed? ans=
urine output decreaed from 70 to 30 ml/hr.
note: is metabolized and excreted by the kidneys; decrease in the urine output can lead to toxicity.
the school nurse interviews an adolescent. the nurse is most concerned if the adolescent states which of the following?
ans=
" i'm glad i don't get as sweaty as my friends when i work out."
note:should have increased sweat production due to hormonal changes.
which of the following questions best aids the nurse in assessing the orientation of a client on the psychiatric unit?
ans=
"what is your name?"
note: some well-oriented people do not know the answer to(who is the president of the usa?) this question:
-depending upon their age, educational level, etc.
which of the following statements by an adult client indicates to the nurse the need for further teaching regarding care of a sigmoid colostomy?
ans=
"i'm irrigating my colostomy after each meal."
note:irrigation of sigmoid colostomy is not necessary more than once a day and sometimes every two or three, if at all.
note:it is possible for many clients to go without a collection bag by performing routine irrigations.
the nurse assesses a child diagnosed with cystic fibrosis. the nurse is most concerned if which of the following is observed?
ans=
the child is expectorating thick, yellow mucus.
note:thick, yellow mucus is indicative of pneumonia.
note: exertional dyspnea increases during the day and child complains about difficulty breathing is not unusual for a child with cystic fibrosis.
the physician prescribes hydrochlorothiazide (oretic) (antihypertensives, diuretics) 50 mg po daily for a client. the client also takes dexamethasone (decaspray) (corticosteroids) 2 sprays in each nostril bid. the nurse should encourage the client to increase the intake of which of the following foods?
ans=
citrus fruits and green, leafy vegetables.
note:need to increase intake of potassium rich foods because of potassium loss from diuretic medications.
note: client with deep partial thickness and full thickness burns over 30% of the body. three days ago it is most important for the nurse to report which of the following observations to the next shift?
ans=
gen. muscle weakness and lethargy.
note: muscle weakness and lethargy are signs of hypokalemia, which can occur on the third day after a burn: hypokalemia is caused bydiuresis.
a client complains of hearing loss. while the nurse is irrigating the client's ear to remove cerumen for better observation of the tympanic membrane, the client complains of dizziness. which of the following actions should the nurse take first?
ans=
warm the irrigant, and resume the procedure.
note:water that is too cool can elicit dizziness when it comes into contact with the tympanic membrane.
note: client with addison's diseasehas hyperkalemia. no need to encourage foods rich in potassium. cortef (hydrocortisone)(antiasthmatics, corticosteroids)for addison's is best taken in the morning.
if steroids are taken at night, they may cause sleeplessness.
a client returns to the floor following a bronchoscopy. the client complains of thirst and requests ice chips. the physician left an order for the patient to resume a regular diet. the nurse should take which of the following actions?
ans=
touch the back of the client's throat with a tongue depressor.
note: assessment of patient: a local anesthesia sprayed in throat may interfere with swallowing. need to check gag reflex.
the nurse enters the room and discovers that the client has slurred speech, right-sided paralysis, and unequal pupils. which of the following actions should the nurse take first?
ans=
assess the respiratory status.
note: determining loc is not as important. ensuring the client has an open airway is the appropriate next step.
further instruction is needed with golytely (polyethylene glycolelectrolyte solution)(cathartics/laxatives) if client states:
ans=
"if i drink it ice cold, it won't taste as bad."
note:golytely can causehypothermia due to large quantity of solution ingested.
in caring for a client with dementia, the nurse should give highest priority to which of the following goals?
ans=
maintain an optimal level of functioning.
note: dementia is characterized by severe,prolonged impairment, which is often irreversible; main focus of care is to keep client as healthy as possible for as long as possible.
note: it is normal for a neonate; to have apnea for 10 sec.
if 15 seconds or longer should be reported to a physician.
while checking the patency of a salem sump tube, the nurse finds stomach contents draining from the air vent. which of the following nursing actions is most appropriate? ans=
insert 30 ml of air through the air vent.
note:clearing the air vent with air will re-establish proper suction in the salem sump tube.
a 4 month old infant who had a temp. of 103 f following the last dtap vaccine is seen in the clinic for another immunization administration. prior to the nurse's administering the dtap, which of the following should be the nurse's priority?
ans=
consult the physician about pediatric dt (diphtheria and tetorifice)
note:fever over 103 f in first 48 hours after dtap is a valid contraindication for pertussis vaccine.
pt with aids - teaching is effective if the patient takes docusate sodium (colace) 300 mg once a day.
note:bowel programs, stool softeners, and laxativesreduce intestinal stasis and bacterial overgrowth.
the public health nurse cares for a child diagnosed with impetigo. the nurse is most concerned if which of the following is observed?
ans=
periorbital edema.
note: indicative of poststreptococcal glomerulonephritis, a possible complication of impetigo periorbital edema.
a client receives prochlorperazine maleate (compazine) (antiemetics, antipsychotics)10 mg im before repair of a hernia under general anesthesia. the nurse is most concerned if which of the following is observed six hours after surgery?
ans.
the patient has not voided since surgery.
note: compazineurine retention is side effect of medication and is caused by general anesthesia.
the nurse conducts a class at a senior citizen center on the changes associated with aging. the nurse is most concerned if a client states which of the following?
ans=
"i've been sleeping with fewer blankets over me lately"
note: usually becomes intolerant to cold.
note: dx of haemophilus influenzae meningitis - how long child will need to be in isolation.
ans=
"isolation can usually be stopped 24 hours after the start of antibiotic therapy."
note:haemophilus influenzae meningitis treated with penicillin; iv fluids and isolation for 24 hours after the start of antibiotic therapyto prevent respiratory transmission.
note:fetal heartbeat can be heard at 12 weeks; is a positive sign of pregnancy.
best assessment to assist the nurse in determining her expected date of confinement (edc)?
ans=
if client isn't shure when the last menstruation was.
the nurse cares for a client in hypovolemic shock. which of the following indicates a therapeutic response to volume replacement?
ans=
urine output increases to 40 ml/hour.
note: hypovolemic shock: primary objective of fluid replacement is to perfuse vital organs;
-increase in urine output to a normal range indicates that kidneys are adequately perfused; other major organs are being perfused also.
note: cvp is an indicator of fluid balance; cvp of 5 cm water is in the low range and does not indicate adequate tissue perfusion.
note: during examination of thyroid:drinking water facilitates swallowing.
which nursing action is most appropriate when an infant is admitted for fever, poor feeding, irritability, and a bulging fontanel?
ans=
place the client on droplet precautions.
note: implementation; classic signs of meningitis; client should be isolated from other clients.
note: if dr. orders an analgesic to be administered to a woman in labor who is 9 cm dilated and is having contractions every 3 minutes, lasting for 50 seconds. which of the following nursing actions is most important?
ans=
notify the physician regarding the status of contractions.
note: information indicates that woman is in transition phase; analgesics should not be administered during transition phase.
note:extrusion reflex in an infant usually disappears in 3 to 4 months of age.
note: dexamethasone (decadron) (antiasthmatics, corticosteroids)should be taken with breakfast.
note: oral steroids have ulcerogenic properties
-need to be administered with meals;
-if ordered daily, administer in morning.
a client with urinary frequency, burning, and a temperature of 102 f is instructed by the nurse to collect a urine specimen for culture and sensitivity. the nurse knows that teaching is successful if the client states which of the following?
ans=
"i will collect the specimen using an aseptic technique"
note:aseptic techniquedecreases the possibility of contamination with organisms.
note:appropriate actvity for a 10 year old female client recovering from a sickle cell crisis?
ans=
collecting pictures of favorite stars from magazines.
note:collecting is an activity that is important to school-aged children.
note: after a thyroidectomy a nurse is most concerned with:tension and muscle spasm of the hand when a blood pressure cuff is applied to the are and inflated. -positive trousseau's sign :indicates tetany; surgery may damage parathyroid glands and cause a decrease in serum calcium.
the nurse cares for a client with a bleeding duodenal ulcer. the nurse is most concerned if the patient reported taking which of the following mediations?
note:reglan stimulates motility of upper gastrointestinal tract, contraindicated with possible hemorrhage of gastrointestinal tract; used to treat nausea of chemotherapy.
note: heparin(anticoagulants)not transmitted in breast milk; breast-feeding considered safe.
note:haldol(haloperidol) (antipsychotics)is particularly effective in reducing assaultive behavior associated with severe anxiety.
Apgar Score= The evaluation of an infant's physical condition, usually performed 1 minute after birth and again at 5 minutes after birth. This assessment is based on the rate of five factors: heart rate, respiratory effort, muscle tone, reflex irritability and color. This five factors reflect the infant's ability to adapt to life outside of the uterus. The five scores are totaled at 1 minute after birth and at 5 minutes after birth. The normal score is 9/10 at 1 minute after birth and 10 at 5 minutes after birth.
Nursing Considerations:
A low 1 minute score after birth requires immediate intervention including administration of Oxygen, clearing of the nasopharynx and transfer to NICU.
A baby who has a low score that persists at 5 minutes after birth, requires expert care such as:
1) assisted ventilation
2) umbilical catherization
3) cardiac massage
4) blood gas evaluation
5) correction of acid-base deficit
6) medications to reverse the effect on the baby of medications taken by the mother during gestation.
Rubella vaccine is made from live attenuated (weakened) virus. This vaccine is potentially teratogenic(harmful to the fetus) in the organogenesis phase of fetal development. Women must avoid becoming pregnant for 2-3 months after vaccination.
A priority for a pregnant woman with a dx of preeclasia or eclampsia receiving magnesium sulfate is to assess for Deep Tendon Reflexes.
Symptoms of a Hypertensive Crisis
1) severe occipital headache radiating frontally
2) neck stiffness and soreness
3) nausea/vomiting
4) chills/fever
5) clammy skin
6) dilated pupils
7) palpitations
8) tachycardia and bradycardia
9) chest pain
Prevention Definition:
1) Primary prevention= measures that include activities that help avoid
a given health care problem. Examples:
a) passive/active immunization, exercise and a balanced diet for
avoiding diabetes type 2 and high blood pressure
b) health protection education such as promoting using a helmet while
riding a motorcycle, use of the passenger seatbelt
Successful primary prevention helps to avoid suffering, cost and
burden of a disease.
2) Secondary Prevention=Identification and treatment of asymptomatic
clients who have already developed the risk factors or pre-clinical
disease, but in whom the condition is not clinically apparent.
3) Tertiary Prevention= Activities involving the care of a client who has
been diagnosed with a disease with the attempt to restore the highest
function. Example, speech therapy for a person who had a stroke.
Now, my facts will be about Insulins...must know that Regular Insulin is the only one of the Insulins that isclear and that can be givenintravenously. Only Regular Insulin can be given intravenously.
1) Regular ®= onset: 30-1hr. Peak: 2-5hrs. Duration: 5-8hrs. Where to inject it? belly area fat tissue and fat tissue around the hip. Short acting insulin covers insulin needs for meals eaten within 30-60 minutes.
2) Humalog= onset: 5-30 minutes. Peak:30 min. to 2 and a half hr.
Duration: 3-5hrs. Fast acting insulin. Inject the same place as Regular
6) Lantus= Onset: 60-90 min. No peak time insulin is delivered at a
steady level. Duration:20-36hrs.
Note: premixed insulins are a combination of specific proportions of intermediate-acting and short-acting insulin in a bottle or in an insulin pen. The numbers following the brand name indicate the percentage of each type of insulin. For example Novolin 70/30. The first number is the percentage of NPH=70, and Regular=30. The second number is 30 which represents the percentage of Regular Insulin in the bottle. feliz3
3) Any activity that increases blood pressure or impedes
venous return to from the brain is strictly prohibited.
ABSOLUTELY NO!
a) pushing
b) pulling
c) sneezing
d) coughing
e) straining---may have to be given a stool softener for
avoiding effort of bowel movement--document this--
4) stimulants such as caffeine, nicotine---prohibited
5) visitors, radio, TV and reading material---limited or prohibited.
The purpose is to avoid increase in intracranial pressure.
Signs of infiltrated IV:
1) pallor
2) coolness
3) swelling--IV fluid deposited in subcutaneous tissue
4) IV stops when the pressure of the fluid deposited in the tissue
exceeds the pressure in the tubbing.
Phlebitis, thrombosis and infection cause the affected skin to feel warm to the touch.
Dilantin(phenytoin) is an anticonvulsive that causes gum bleeding and hyperplastic gingivitis (inflammation and enlargement of the gums caused by an increase in the number of cells). An assessment of the mouth while the patient is taking this drug and educating the patient about the importance of using a soft toothbrush is a must for a patient taking Dilantin. feliz3
Never administer concentrated potassium chloride without firstdiluting it
Potassium chloride (KCL) preparation available in a premixed form a KCL preparation greater than 60mEq/L should not be given in a peripheral vein...what do you think it will happen to the peripheral vein?
Administer potassium at an infusion rate than does not exceed 10-20mEq/L
For extreme hypokalemia, infusion rates should be no more than 40mEq/hr while the patient is hooked to an EKG. Must monitor cardiac activity.
Potassium is excreted by the kidneys, assess kidney function before administering Potassium
Use an infusion pump to control the infusion flow rate
Infiltrated KCL (KCL going into the subcutaneous tissue instead of the blood circulation system--extravasation causes tissuenecrosis-- :uhoh21:). KCL is extremely irritating as Potassium is a caustic substance.
Infiltration(extravasation) Protocol:
Signs and Sx
1) coolness to the skin
2) taut skin
3) dependent edema
4) backflow of blood absent
5) infusion rate slowing
Tx
1) assess for inflitration and notify physician
2) discontinue catheter
3) apply cool compresses
4) inject, depending on the drug given, an antidote to the site
May vary from state to state, these laws were passed by the state legislatures to encourage health care professional to assist in emergency situations without fear of being sued for the care given. These laws limit liability and offer legal immunity during an emergency, provided that the health care professional gives reasonable care and receives no compensation, monetary or otherwise for the care given. Immunity from a law suit applies only when the health care provided complies with the state conditions for protecting the health care provider and the care given is not intentionally negligent.
Negligence=failure to provide care that any reasonable person ordinarily would use in a similar situation.
That in a nutshell is the Good Samaritan laws. I hope this helps, feliz3
oral contraceptives: most effective if i take it at the same time each day
use a diaphragm or other or other barrier (condom): for first 3 weeks of oral contraception therapy.
if upper gi series and lower gi series ordered: do lower gi series first- b/c to avoid barium from upper gi -traveling to lower gi & interfering with results.
s/sx irritable bowel syndrome: ha, epigastric pain reieved by food, anorexia, n&v , and periods of both constipation and diarrhea
pain 4/10 after total abdominal hysterectomy:
administer narcotic pain meds, as ordered
-b/c there is a "known" etiology for pain... surgury !
not repostion for comfort just b/c pain is 4/10...
-look at pain management s/p !
regular insulin:
onset: ½ hr (30 mins)
peak: 2.5 to 5 hours
nph insulin:
onset: 1 ½ hours
peak: 4 ro 12 hours
iron (intramuscula): iron dextran
- add 0.2 ml of air to syringe after drawing up iron med.
-ensures an air-lock which which clears excess medicine from the needle
-dose to prevent medication irritation and/or
-"staining" from leaking in subcutanous tissues & skin surface either or
-injection or
-withdrawl of needle.
- pull the skin and subcutaneous tissue 1 inch to one side of intended injection site & hold it there while inecting iron = z track method
- wait 10 secounds after injectin the med (iron)
-before removing needle,
-aspirate first (1m);
- never massage
- z-track in adult must always dorsal gluteal:
-never deltoid with z-track
c/o red-haze in his viaual field:
ask "have you ben see by an opthamologist?"
-should be evaluated by opthamologist
-"red haze" = vitreous hemorrhage -may be absorbed spontenusly if it does not resolve this way, may need surgury
asthma preventive care (child):
- do not let child sleep on bottem bunk- have asthmatics sleep on top bunk to avoid dust mites!
- do not sleep or lie down on upholsterd furniture
- sleep on foam pillow & foam mattress- ok with asthmatics
- remove child from room & have wear mask when vacuming carpets.
suspension of amoxicillin trihydrate (amoxil) for a 2 month old infant:
-shake med before giving it never put in formula;
-give an empty tummy -for maxmuim absorption.
rotating insuling injection sites:
if nurses/ patient are not rotating injection sites...
glucose levels rise temporarily
-b/c poor absorption of insulin lends to óincrease blood sugar.
** post-op patients are "clean" ...
-s/p right pnumonectomy (clean)
-contraindicated to be placed with copder (dirty)
epoetin alpha (procrit) (antianemics): report to m.d.
-if hematocrit rises more than 4% in two weeks
(flu-like symptoms normal at first)
(ie; from 28% to 33%
-contact m.d. to decrease procrit
-b/c ó increase risk of htn & seizures)
fundus- palpate (where) after 8 hours post delivery:
-level of umbilicus
(fundus will be here 6 to 12 hrs post
(beginning with day 1, fundus descends
~ 1 fingerbreadth per-day
tpn completion: hang 10% dextrose in water
-hypertonic dxtrose to wean patient, & is similar to tpn!
basal body temperature method:
(to determine if patient is ovulating)
-client takes temperature every morning before rising
-if patient ovulates there ill be a slight drop, and
-then rise in temperature b/c of progesterone influence,
-temperature will be ó increase during second-half of cycle.
lumpectomy-of breast?
do notexpose to: hot or cold; no sunshine exposure;
no tape, no creams,lotions, deoderants
-wear a loose-fitting bra made of 100% cotton; assess skin for redness, cracking
***wheezing upon inspiration (18 month-old infant):
**know: wheezing usually occurs on expiration**
**-thus, ask :"was child eating a hotdog or nuts, beans, seeds, chewing gum, " immediately before
thanks for your posts which is helpful to all of us. which books or cds you refer to prepare for nclex? please reply me. i want to write exam in january.
Question: Does anybody knows how to create a table in this thread?...this information I'm sending looks better written on a table for clarification purposes, but I have no idea what keys I need to use in order to create a table. feliz3
Normal Blood gas Values:
pH----7.35---7.45
Pco2--35-45 mmHg
HCO3--22-27 mEq/L
Po2----80-100 mmHg
O2 sat--95%-100%
Note: CO2 is the acidic component of this buffer system
HCO3 is the base component of this buffer system
Base=Alkaline
Buffer= a substance than maintains a given pH
A lot of acid in a solution will lower the pH of a solution: acid solution
A lot of alkaloids in a solution will increase the pH of a solution: alkaline
solution.
Metabolic Acidosis:
Condition:
metabolic acidosis---pH: low
---Paco2: Normal
---HCO3: low
Compensated metabolic acidosis---pH: low
---Paco2: low
---HCO3: low
How the body compensates for metabolic acidosis:
The lungs hyperventilate
to blow off excess of CO2
and conserve HCO3.
Causes of Metabolic Acidosis:
1)Diabetes Mellitus or diabetic ketoacidosis
2) Excessive ingestion of of acetylsalicylic acid = ASA = aspirin
3) Severe diarrhea
4) High fat diet
5) Insufficient metabolism of carbohydrates
6) Renal insufficiency or renal failure
7) Malnutrition: Improper metabolism of nutrients causes fat
catabolism (breakdown) leading to an excess of ketones (by-product
of fat metabolism)
Assessment:
1) The lungs blowing off the CO2 build up and compensate
for the acidosis, hyperepnea or hyperventilating
(respiratory rate > 20 breaths/min) with Kussmaul's breathing
pattern.
Kussmaul's breathing=deep breathing pattern and when it is due to
metabolic acidosis, the rate could be fast, slow or normal.
2) headache
3) nausea/vomiting/diarrhea
4) fruity-smelling breath resulting from improper fat metabolism
5) CNS depression: mental dullness, drowsiness, stupor and coma
6) Twitching, convulsions
7) Hyperkalemia--must know this in connection with metabolic
acidosis
This is it for now, but I will continue discussing the body's reactions
feliz3
feliz3
feliz3
feliz3
SWEETDREAMERINSOCAL
64 Posts
:typing here is my send for today
a medication that a nurse should question with copd would be: propranolol hydrochloride (inderal)(beta-adrenergic blockers).
rational: - beta blocker that blocks beta adrenergic impulses to the bronchial tree that cause bronchodilator resulting in increased bronchoconstriction.
the nurse performs an ice massage - for a client in chronic pain. the nurse is most concerned if which of the following is observed?
ans=
- mottling or graying of the tissue.
rational: - site should be observed every five minutes for:
-signs of tissue intolerance, including blanching, mottling, or graying.
complete heart block - the nurse should question which of the following orders?
ans=
administrer lidocaine (xylocaine)(antiarrhythmic agent) 50 mg iv push for pvcs in excess of six per minute.
rational = in complete heart block, the av node blocks all impulses from the sa node, so the atria and ventricles beat independently, because lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response, cardiac depressants are contraindicated in the presence of complete heart block.
manic phase of bipolar disorder - it is most important for the nurses to offer which of the following meals?
ans=
tuna salad sandwich and orange slices
rational = clients with mania need nutritious finger foods;
foods contain protein, carbs, and vitamin c and fiber.
urinary pattern - the nurse should instruct a patient to do what first?
ans=
keep a record of daily fluid intake.
rational: - client needs to know how much and when he ingests fluid.
ileal conduit 2 days ago - most important for the nurse to take which of the following actions?
ans=
apply a close fitting drainage bag to the stoma.
rational = primary preventative measure to prevent urine from contacting the skin.
note: should be cleaned with soap and water not an antiseptic solution.
intubating a postoperative client - most appropriate action to take would be to.
ans=
place the intubation blade in a bag, and arrange for gas sterilization.
rational = sterilization of equipment after exposure to body fluids of a client is protocol.
diet teaching for a client with sci. - the following meal that is best.
ans=
spaghetti with meat sauce and green beans.
rational - high fiber diet is an important part of bowel program, fiber helps prevent the complication of constipation, includes whole-grain foods, bran, fresh and dried fruits, increased fiber will facilitate defecation, especially with reduction in fat intake.
note: i picked a tuna fish sandwich with orange juice due to the fiber
(spaghetti is white flour and is constipating)
note: birth weight should double in 5 months.
client presents with diaphoresis, pallor, and tachycardia
- one hour after receiving 7 u of regular insulin. - action the nurse should take first is
ans=
offer the client milk and crackers.
rational - onset of action for reg. insulin is 30-60 min; assessment indicates a problem with hypoglycemia, foods such as mild and crackers should be given if blood sugar is around 40-60 mg/dl. if orange juice or simple sugaris given, it should befollowed with a meal or with protein intake.
note: it is unnecessary to administer glucagons unless client is unresponsive.
client receiving chlorpromazine (thorazine) (antipsychotics) 400mg/day for four weeks - presents with temp. 105 f severe rigidity, oculogyric crisis, and severe hypertension. most important for the nurse to take which action?
ans=
hold the chlorpromazine, and notify the medical staff stat. -
rational = client is experiencing neuroleptic malignant syndrome, fatal in about 15 - 20% of cases, is toxic effect of antipsychotic medication.
(hba1c) of 6% - results normal, indicates good control of diabetes.
normal heart rate for a two day infant - 120-160 bpm
-if a 2 day old infant, lying quietly alert,
-heart rate of 185 bpm has tachycardia, and requires further investigation.
graves disease - nurse would intervene if client drinks
ans=
tea.
rational: = stimulant that would increase metabolic rate.
after the anesthesiologist administers an epidural to a woman - highest priority would be to
ans=
obtain the blood pressure.
rational: assessment side effect of an epidural is hypotension from the vasodilation that occurs.
note: assessing the fhr monitor may be done as ongoing management but is not a priority.
ciprofloxacin (cipro) (fluoroquinolones) - most important for the nurse to include when instructing the client about this medication
ans=
" drink plenty of fluids"
rational - prevents crystalluria and stone formation.
spinal anesthesia - the following is an important nursing implication regarding this anesthesia
ans=
adequately hydrated the client
rational = important that the client be well hydrated to prevent hypotensive problems after the spinal anesthesia is initiated.
note: unnecessary for client to be npo for 12 hours
a client is diagnosed with a tumor of the pituitary gland and has a transphenoidal hypophysectomy. the nurse plans care for the patient two days after surgery. it is most important for the nurse to monitor which of the following?
ans=
specific gravity of urine.
note: lack of adh from pituitary will cause diabetes insipidus and diuresis with very low specific gravity.
note: clients on hydrochlorothiazide (hydrodiuril) (diuretic) should be encouraged to eat foods high in potassium - ex. dried apricots, bananas every day due to the diuretic causing loss of potassium.
note:a lpn/lvn with shingles can care for non-high risk clients as long as lesions are covered.
the nurse performs hypertension screening at the local grocery store. it is most important for the nurse to complete which of the following tasks?
ans=
take two readings at least five minutes apart.
note: recognition of adult hypertension should be done after two readings taken at least five minutes apart.
note: to confirm a client stating that he thinks he has an ulcer. nurse should respond by asking " do you have a burning pain in the epigastric region?"
- peptic ulcer pain is often referred to as a "boring pain in the back" or a burning gnawing feeling in the midepigastric area.
the nurse cares for a client immediately after an abdominal aortic aneurysm repair. vital signs and blood pressure 100/70, pulse 120 respirations 24, urine output 75 ml during the past three hours. which of the following is a priority nursing action for this client?
ans=
maintain bedrest, and evaluate for a decrease in cvp readings.
note: client is at increased risk for development of hypovolemic shock, vital signs and urine output correlate with the early signs of shock, the nurse should compare the cvp with previous readings.
note: client with a harrington rod due to scoliosis, in preparation for the immediate postoperative care, the nurse should include which of the following in a teaching plan - ans.
take 10 deep breaths every 2 hours.
note: client must be monitored closely for the first 48-72 hours for respiratory problems bowel and urinary problems need to be assessed along with neurological problems in the extremities. client will have a catheter, may have a nasogastric tube connected to low suction,.
no reason to reassign pregnant staff member from taking care of cytomegalovirus patient. - just need standard precautions.
the family members of an 85 year old report to the nurse that they suspect that their father is masturbating. which of the following responses by the nurse is best?
ans=
" this is considered a normal behavior for men"
note:masturbation is an activity performed by some elderly men.
the nurse cares for a patient following a right adrenalectomy. during the immediate postoperative period, it is most important for the nurse to observe for which of the following?
ans=
blood pressure alteration
note: decrease in blood pressure may indicate shock.
when using palpation techniques during the physical assessment of an adult female with abdominal pain, which of the following actions should the nurse take first?
ans=
inform the client to breathe slowly.
note: breathing slowly will enhance relaxation of the abdominal muscles.
note: holding a deep breath is done during palpation of the liver.
note: it is important for the parents to stroke an infant after surgery. the tactile stimulation is imperative for an infant's normal emotional development, after the trauma of surgery; sensory deprivation can cause failure to thrive.
note: on an ekg stripe if there are 8 qrs complexes in 30 large squares for a 6 second strip. the heart rate is calculated by timeing the qrs complexes by 10.
ex (8x10) = 80. 80 is the hr.
an order has been received to obtain a stool specimen and test for occult blood. the nurse is most concerned if the client makes which of the following statements?
ans=
" i take feosol every day"
note: iron supplements can cause color of stool to resemble melena.
a primipara is admitted in early labor, and her membranes rupture. which of the following assessments by the nurse is most important?
ans=
assess for a prolapsed cord.
note: initial assessment is to check for a prolapsed cord.
note:the mother's bp is not affected by rupture of the membranes.
goal... study.... share:typing.... goal to be ...
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