flaccid bladder

8/3/2019 Flaccid Bladder

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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 monthBaseline Data must be collected to design an effective behaviormodification program.

Parlodel (bromocriptine) (Antiparkinson Agent) administration: Should be taken with meals to decrease GI upset.

Post op Abdominal surgery low fowlers position 15 degreestakes pressure off of suture line.

Pressure ulcers S&S Blanching or hyperemia that doesntdisappear is a warning sign for pressure ulcers

Late decelerations Stop infusion of pitocin(Oxytocin)(miscOB/GYN Agents)

Abdominal Surgery with complaints of left leg dull achesNursing 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 eradicatethe phobic response by replacing with relaxation responses byusing muscle relaxation techniques with it. (Guided imagery)


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Note: CVP reading measure the pressure in the R ventricles. TheSwan Ganz catheter measures the Pulmonary Artery wedgepressure which is an indirect reading of the pressure in the Lventricle.

Trigeminal Neuralgia (Tic Douloureux) The nursing careshould be directed toward preventing stimuli to the area anddecreasing pain Ex: eat soft warm foods.

DIC Disseminated intravascular coagulation (DIC) - There isoozing 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 weekgestation - Nurse anticipates c-section delivery due to lungsadequately mature there is no need to postpone delivery and c-section is preferred with preterm infants.

Diabetes Type 1 Client states I have a quivering feeling in mystomach is given priority due to the fact that this is a sign ofhypoglycemia.Hypoglycemia signs also include:

-tachycardia-cold clammy-skin,-weakness-pallorNurse: 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 andconsistency.

Appendectomy Following surgery nurse notices large amountof serosanguineous drainage on dressing.Most important for the nurse to obtain is:


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unlikely possibility, but if your child doesnt develop normally, yourpediatrician 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 thatthe consent form has been signed.

Note: surgical consent should be rechecked before going tosurgery.

Note: Assessment for allergies should be done earlier then 1 hourbefore surgery.

Addisons Disease Increased salt should be increased duringperiods of stress.

Note: with decrease in aldosterone, there is an increasedexcretion of sodium: sodium intake should be increased.

Note:The nurse should be concerned with auscultating an S3ventricular 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 Istart itching I need to call you

Note: itching is a common side effect of narcotics used in PCApain management.

Thorazine (Chlorpromazine) (Antipsychotic)Client should reportif they have difficulty urinating.

Note: dry mouth, weight gain and constipation can be resolved athome. Difficulty with urination can become a severe healthproblem unless treated.

Digoxin (lanoxin) (antiarrhythimics)-Theraputic level is 0.5 2.0.If blood level comes back 2.0.


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**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 frequentassessment.

Note: After MI the most common complication following isdysrhythmia, with ventricular types being the most serious.

Cholecystectomy Expected drainage is 500-1000 ml/day,However complaints of sever abdominal pain after surgery couldindicate peritonitis or wound infection

Colonoscopopy

Note:All activities that the client participated in before thecolostomy may be resumed after appropriate healing of the stomaor incisions.

3 year old When assisting a parent on foods it is best to allowfinger foods for this age group.

Note: Child is going through autonomy versus shame and doubt

stage-finger foods allow child the necessary independence for thisstage.

Note: Distended abdomen with splenomegaly Possibility of internal bleeding, life-threatening situation

Acute asthma attack Most concerned if patients respirationrate 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 thephysician regarding pain medication Administer medication Q4around the clock.


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Note: around the clock (ATC) administration of analgesics is moreeffective in maintaining blood levels to alleviate the painassociated with cancer.

Elderly with dementia When planning care it is best to speakslowly in a face to face position.

Note: providing flexibility leads to confusion schedules need to beroutine.

Note: Propranolol (Inderal) (antianginals, antiarrhythmics)decreases the effectiveness of atorvastatin. (Lipitor) (lipid-lowering agents)

Note: patient on lipitor and the following statement made by clientshould be told to the physician I take Inderal.

Droplet precausion A child with pertussis.

Note: bronchitis is the inflammation of large airway, standardprecautions., Tonsillitis standard precaution.

Total hip replacement Most important for the nurse to applythigh high TED hose to promote venous return.

Note: use of antiembolic hose and or sequential compressiondevices decreases venous stasis and reduces risk of thrombusformation.

Hip fracture with Bucks traction Most important action bythe nurse is to turn the client every 2 hours to the unaffected side.Immobility is the leading cause of problems with Bucks 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. Afteradministering analgesics the following action should be to elevatethe HOB 30 to 45 degrees.

Note: This would reduce stress on suture line and provide for


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comfort.

Lumbar puncture (LP) - Best to prepare a 5 year old is to - Do amock run-through of the procedure.

Note: Excellent method to use with a child because it incorporatesactually Feeling: many aspects of the procedure as they areexplained.

Parathyroidectomy Should be concernedwith a client eatingquantities of food from which of the following food groups Milkproducts

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 threateningcomplications of thermal injury.

Elderly Client Drinks plenty of fluids however has a diet thatconsists 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 ofaging.

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 topoint of mutism. Most important action is to - Sit with client forbrief period of time.

Note: nurse should maintain contact with client but not makedemands to communicate or participate in activities.


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Wet to dry dressing for a client of an infected abdominalincision. The nurse should intervene if clients spouse wets the olddressing with sterile saline before removing it.

Note: it is contraindicated dressing should be removed dry sowound debris and necrotic tissue are removed with old dressing.

Spina bifida Of an 2 day old infant in for surgery repair. Motheris concerned that infant would be confined to a wheelchair. Beststatement by nurse The corrective surgery will not change yourchilds physical disability

Note: Spinal nerves that are destroyed by the myelomeningocelecannot be corrected: nothing can return function to portions of the

body that are innervated by the spinal nerves below the site of themyelomeningocele.

Electrical burns

Note: electrical burn injuries are typically more injurious tounderlying tissue, such as nerve and vascular tissue, which requirecomplex 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 ICP are alterations inorientation.

Cystic Fibrosis Statement that indicates parental understandingabout the cause of their newborns diagnosis of CF Both of uscarry 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 clients left side andslightly behind the client.

Note: Stand slightly behind client on strong side.

Note:If resistance is met with trying to flush diluted heparin into asubclavian triple lumen catheter. Action nurse should take is to


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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.Administration of medication to a 4 month old Mostappropriate is to place the medication in an empty nipple and allowthe infant to suck.

Note: never add to childs formula feeding.

Note: Nurse should verify the order with a physician about IMinjection of Demerol for pain to a client receiving thrombolytictherapy.

Note: bleeding can occur with IM injections.

Note:Douching makes Pap smear inaccurate. Have client avoiddouching for 24 hours.

Medication contraindicated For a patient with hemophilia A =Oxycodone terephthalate (percodan)(equals oxycodone andaspirin) (opioid analgesics) Contraindicated for persons withbleeding disorder, contains aspirin.

Patient with sickle cell crisis with an infiltrated IV Is apriority due to IV fluids are critical to reduce clotting and pain.

Hope this helps with your studies... Remember:

Goal for today is to study!!! Goal is

more in a while...:typing

S

No. 2271

fromsh08

Nov 12, 2008, 01:58 PM
http://allnurses.com/members/291816/http://allnurses.com/members/291816/


11/29

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 pass

No. 2272

fromfeliz3

Nov 12, 2008, 03:06 PM

Originally Posted byRachi321

i got alot of questions on peak expiratory flow rate on my last test that i didn't understandand 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 forage and stuff idk im just worried about it showing it up again.

Questions about peak expiratory flow are in connection with mechanical ventilation, but beforediscussing 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 larynxtracheal, tubular (other names for the same sounds)

2) Broncovesicular--------------- over the major bronchi

3) Vesicular --------------------over the peripheral lung fields where airenters the bronchiIf you read a question describing broncovesicular sounds, now you know which area of the lungs thequestion is talking about.

Tracheal breath sounds

high-pitched, loud, harsh, hollow sounding, equal on inspiration and expiration.Bronchial breath soundsHigh-pitched, blowing, muffled, expiratory sound slightly longer than inspiratory.Broncovesicular breath soundslouder and harsher than vesicular sounds, muffled vesicular sound combined with with loud guttural

sound, equal on inspiration and expiration.Vesicular breath soundssoft 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 bythe 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 6-10times 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 aset tidal volume at a given compliance (the elasticity, extensibility and distensibility of the lungs andthe thoracic structures)Causes of Ventilator Alarm:

Note: Assess your patient first and the ventilator second.
http://allnurses.com/members/233186/http://allnurses.com/nclex-discussion-forum/anyoone-up-random-308584-post3241327.html#post3241327http://allnurses.com/members/233186/


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High-Pressure alarm1) increased secretions2) wheezing or broncospasm causes decreased airway size,remember, the ventilator is preset according to certaincompliance (see above definition)

3) Displacement of endotracheal tube4) Endotracheal tube obstruction due to water or a kinkin the tubbing.5) patient is anxious or fights the ventilatorLow-Pressure alarm

1) Patient spontaneously breathing--that's nice2) disconnection or leak in the ventilator or in the patient's

airway cuff occurs

I hope this information helps. feliz3 :typing

No. 2273

fromfeliz3

Nov 12, 2008, 06:59 PM

Originally Posted bysh08

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

Congratulations on taking the exam! feliz3

No. 2274

fromfeliz3

Nov 12, 2008, 10:10 PM

Important Definitions:Assault= Putting a client in fear of a harmful or offensive contact. The victim fears and believesthat 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 familymatters and sharing client information with unauthorized persons.False Imprisonment= A client is not allowed toleave a health care facility; however, there is nolegal justification for detaining the client. False imprisonment is committed when restraining devisesare used without an appropriate clinical justification.

Defamation= False communication or a careless disregard for the truth that causes damage tosomeone'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 similarcircumstances.Malpractice= Failure to met the standards of acceptable care, which results in harm to another
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person.

Restrains:Definition= Devises designed for protecting the client used for limiting the physical activity of aclient or to immobilize him/her or an extremity.Kinds of restrains:

Physical--restricts client's movements through the application of a physical deviseChemical--drugs given to a patient for inhibiting a specific behavior or movement, for example asick patient in a mechanical ventilator who fights the machine is given vecuroniun bromide, aparalytic 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 rulesgoverning the use ofany 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 statea) the type of restrainb) identify the behavior for which the restrain is usedc) identify the limit or time frame for use4) Physician"s orders for restrains must be renewed within a specific timeframe 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 theirpermission must be asked.7) Restrains should not interfere with any treatment given to the patient or affect the patient'shealth.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 restrainsto 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 removethe restrain every 2hours to permit muscle exercise and promote circulation. Continually assessand document the need for restrain.

Note: Not following those rules while restraining a patient is definedby law as false imprisonment.

feliz3

No. 2275

fromisobelle5287

Nov 13, 2008, 05:30 AM

St Johns 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


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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 Alzheimers 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."


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- Chinese Proverb

No. 2276

fromisobelle5287

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


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perforation, and reduces pain.

Menieres Disease - assess the frequency and severity of attacks to plan

best for the clients safety.

Infants are obligate-nose breathers - nose drops given before feeding

promotes clearance of the nasal passages; 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. Menieres disease)

13 days to go... :typing ... ...

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

- Chinese Proverb

No. 2277

fromSWEETDREAMERINSOCAL

Nov 13, 2008, 12:14 PMUpdated 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 afunny feeling: affected extremity indicates neurovascularcompromise, and requires immediate assessment.

Note: client in early stages of labor with a diagnosis ofcomplete

placenta previa must be prepared for an immediatecesarean section. Implementation, cannot deliver vaginally.

Note:Patient with epiglottitis who is having an earlycomplications of hypoxemia: will present with heart rate of 148beats per minute. The HR correlates with hypoxemia and is an


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early finding, along with restlessness.

After stabilizing a client with severe multiple traumainjuries from a motor vehicle accident, which of the following

actions by the nurse is best? Ans.1. Limit visiting hours to promote optimal rest2. Arrange for a psychologist to visit with the family.3. Arrange for the family to meet with a social worker to discussfinancial aid.4. Arrange for clergy to visit with the client and family asrequested.

Should remove nitro-patchbefore MRI is performed.

If a family member verbalizes that a family member willclosely watch the apnea monitor at all times. Nurse shouldbe concerned because this indicates a feeling that monitor maynot let them know if their infant stops breathing.

Patient admitted to the hospital with dry mucous membranes anddecreased skin turgor. Vital are BP 120/70, temp, 101 degreesF, pulse 88, resp 14. Lab tests indicate the serum sodium is 150mEq/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 Cl3. -lactated ringer4. -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 ofasepsis, hallmark is handwashing.

A mother with a 4 year old comes in to confirm her secondpregnancy. The most important action for a nurse to do is -identify the clients general health needs. (Physical Needs)


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The priority for a nurse in caring for a client diagnosed withperforated bowelsecondary to a bowel obstruction is toprepare the client for emergency surgery.

Note: this can lead toperitonitis if not addressed.A mother brings her 17 month old son to the well baby clinic fora routine checkup. She confides to the nurse that she is concernedbecause her son sucks his thumb, especially at night when heis put to bed.Which of the suggestions by the nurse is best? Dont intervene at this time. This behavior usuallysubsides after 24 months of age.

Note: Normal behavior, peaks at 18 20 months, most prevalentwhen child is hungry or tired.

When administering Calcium EDTA (edetate calcium disodium)

(antidotes) and dimercaprol (BAL inOil)(antidotes) for elevated

blood lead levels the action that has the highest priority is torotate the injectionsites. This with prevent tissue damage andpromote tissue absorption of the medicine.

NOTE: dimercaprol (BAL inOil)(antidotes) treatment of acute

poioning with:-mercury-Gold-ArsenicUsed adjunct with edetate calcium disodium in treatment of serverlead 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 reportingunilateral , dull abdominal pain. This indicates an etopicpregnancy and needs to be evaluated.

A patient with a thermal injury to the right arm Theobservation that is most important to report to the doctor is Gastric PH less than 6.0


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Note:decrease in gastric PH could indicate hypersecretion ofhydrogen ions,predisposing factor tostress ulcer formation.

Note:situational crisis: priority is to determine how client

coped with crisis in the past and build on clients copingstrategies.

Note: -if oil is placed on a wound it is most important to washthe burn with soap and water

Note:cooking fat applied to an open wound increases thepossibility ofinfection: burns should be rinsed immediately withtap water to reduce the heat in the burn.

Client with DX of hyperparathyroidism The most importantsymptom to report to the next shift is Hematuria

Note: Hematuria is a sign of renal calculi:55% ofhyperparathyroid clients have renal stones.

Note:Dx with multiple sclerosis most important for the nurseto include in instructions Is to avoid overexposure to heatand cold

Note: this may cause damage related to the changes in sensationSeveral days after a client had a myocardial infarction, thephysician places the client on a 2-gm sodium diet.Which of the following selections indicates to the nurse anunderstanding 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 dueto milk is allowed on a salt restricted diet.

Instruction about the medication is effective when a pt. on


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naproxen sodium (Anaprox) (nonopioid analgesics,nonsteroidal anti-inflammatory agents, antipyretics) States Ishould call my doctor if my stools turn very dark

Note: NSAIDs can cause gastrointestinal bleedingNote:During a dressing change the old dressing should notbesaturated with sterile saline before it is removed. Thedressing should be removed dryso that wound debris andnecrotic tissue are removed with old dressing.

Note: Most important for nurse to assess for beforeadministering calcium gluconate 10% 500 mg IV stat ispatency of the vein. If injected into the extravascular tissues,

calcium gluconate can cause a severe chemical burn.Note: a child admitted with failure to thrive has just had apositive sweat test. Nurse anticipates what change in thechilds POC? ans.Administration of replacement enzymes.

Note: positive for sweat test indicate cyctic fibrosis.

Note:Best recommendation during discharge for a patient whosuffered a mild MI and smokes one pack of cigarettes per dayAns.

Participate in a program such as nicotine avoidance.

A pt. has a Sengstaken-Blakemore tube in place. The nurseenters the room and finds the pt. in respiratory distress. Whichof 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 ifobserve signs ofrespiratory distress or airway obstructioncaused by upward displacement of esophageal balloon.

It is most important for the nurse to include which of thefollowing instruction with prenatal vitamins. Ans.Take prenatal vitamins with orange juice at bedtime.

Note:taking the vitamins with something acidic increases theabsorption of iron. Taking them with food at bedtime


21/29

decreases the possibility of nausea, as the client will beasleep.

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 actas a culture medium.

Note: proper med administration Carafate (Sucralfate) (antiulcer 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 theleft shoulder and arm BEST PRN med the nurse shouldadminister 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 longterm care facility. Which of the following actions by the nurse isBEST? Ans.Direct conversation toward assisting the client to reminisce andtalk about important past events in life.

Note:geriatric client should be encouraged to talk about his lifeand important things in the past because he has recentmemory loss.

Which of the following is the FIRST nursing action that should beimplemented for a client after a vaginal delivery? Ans.Check the patients lochial flow.

Note:Complication ofhemorrhage assessed by observinglochial flow.


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Note:When recording clients chief complaint It should berecorded using the clients own words. Ans.

My stomach hurts after dinner every night

A client comes to the nurses station for the prescribedantipsychotic medication. The nurse notes that the client hastorticollis , an arched back, and rapid movement of theeyes. Which of the following actions should the nurse take first? Ans.

Administer the PRN trihexyphenidyl (Artane) (antiparkinsonagents)IM immediately

(torticollis definition: Spasmodic contraction of neck musclescausing head to tilt to one side and chin pointing to other sideMcGraw Hill Nurses dictionary 2007)

Note:administer Cogentin(benztropine)(antiparkinson agents).

or Artane(trihexyphenidyl)(antiparkinson agents). Assessment,no validation required.

Note: a preschool clients mother reports that the child has freq.abouts ofgastroenteritis. 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 andincreased likelihood of disease transmission.

Note:Desired response to fluid replacement with a patent DX withhypovolemia. Ans.CVP reading of 8 cm of water pressure.

Note:Normal range of CVP is 3-12 cm water pressure so 8indicates desired results.

Note: - HGB 11 gt, HCT 33% indicates hypervolemia.PH 7.34 indicated acidosis.

Client with elevated vital signs, hallucinations and aggressive


23/29

behavior that are possibly on hallucinogenic drugs Followingaction is to decrease environmental stimulation.

Note: symptoms will subside with time and decreased

stimulation.Note: Early stages of hepatic encephalopathy is havingdifficulty 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 oflarge,painful, purplish-brown open areas on his right arm andback. The nurse should instruct the client to take which of thefollowing actions? Ans.

Clean the area carefully with soap and warm water everyday, and cover them with a sterile dressing.

Note:Open Kaposis 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 andpalate. The respiratory assessment reveals that the infant hasupper 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 admitted with a diagnosis ofrenal calculi and isexperiencing severe pain. Meperidine (Demerol)(Narcotic


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Analgesics) 75 mg IM is given prior to the change of shift. Whichof the following symptoms is MOST important for the nurse toreport 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 ormovement of stone.

Note: -Nursing interventions should involve distracting andredirecting behaviors for a bipolar disorder patient in themanic phase.

Note:gown gloves and mask are appropriate for rubella

(German measles) = droplet precaution.Note: Flagylshouldnt be taken with alcohol. It will causeantabuse (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) shouldnt begiven 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 clientsSalem 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 exitingthe airway; purpose is to provide continuous steady suctionwithout pulling gastric mucosa.

The nurse cares for a pt. with deep partial thickness and fullthickness burns. The client receives morphine sulfate 15 mgIV(Opioid analgesic). The nurse notes a decrease in bowel

sounds and slight abdominal distention which of thefollowing. Actions, if taken by the nurse, is BEST? Ans.


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Explore alternative pain management techniques.

Note: Morphine (Opioid analgesic)

is drug of choice forburn pain management, when side effect

becomes apparent, exploration of alternative pain managementtechniques such as visualization becomes important.

Note:How to obtain a throat culture from a client diagnosed withpharyngitis. Ans.Quickly rub a cotton swab over both tonsillar areas and theposterior pharynx.

NOTE: height and weight changes in a yearHeight: at age 6 12 children grow about 2 inches (5 cm) a

yearWeight: 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

fromSWEETDREAMERINSOCAL

Nov 13, 2008, 01:57 PM

:typingHello again just sharing my latest facts...

A mother brings her 7 year old daughter to the outpatientclinic for a routine check up. The girl weighs 50.25 lb (22.85kg) and is 48 inches (121.7 cm) tall. The nurse notes that thechild has gained 2.5 lb and grown 3 inches in the past year.


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Which of the following. Responses by the nurse is best? Ans. Your daughters height and weight are within normallimits.

NOTE: First 24 hours of TPN Nurse should evaluate bloodglucose level.

Note: Total parenteral nutrition (TPN), or hyperalimentation, has ahigh glucose content important to monitor glucose levels.

The nurse receives a phone call from a nursing assistant whostates that her 5 year old child has developed chickenpox. Itwould be MOST important for the nurse to ask which of thefollowing. 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 lastexposure.

Unless Given than 28th day if VZIG given)

The nurse knows that which of the following.Plans would be apriority 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 containsminerals and vitamins to provide a balanced nutritional formula.

Phenylketonuria definition: Phenylpyruvic acid in the urine. *Arecessive hereditary disease caused by the body's failure to oxidizean amino acid (phenylalanine) to tyrosine, because of a defectiveenzyme.

24 hr after abdominal surgery, which of the following. Plans is anursing priority to prevent complication of flatulence? ans.


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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 admitted with metastatic cancer has receivedchemotherapy 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 toexhibit which of the followingsymptoms? Ans.

BP 120/70, pulse 100, respirations 16.

Note:Increase pulse and respiration are caused bydecreased oxygenation of tissues. The patient will be paledue to anemia,

Normal RBC male 4.3 5.9 million/mm3,female 3.5 5.5 mill./mm3Normal WBC 4,000 11,000/mm3,

Normal Hgb male 13,5 17.5 g/dl, female 12 16 gt/dlA physician writes an order for an HIV positive infant to receiveInactivated polio (IPV) immunization. Which of the following.Nursing actions is MOST appropriate? Ans.Administer 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 aftersurgery. Which of the following foods should the nurseencourage? Ans.


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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 removedyesterday and is complaining ofcrackling under his skin -Indicates subcutaneous emphysema, which is indication ofpneumothorax,observe client for respiratory distress, contact physician.

Note:If nurse enters the room to find a tracheotomy tubedislodged. The nurse should immediately replace thetracheotomy tube.

Note:a client with sunken eyeballs and fruity breathindicates diabetic ketoacidosis,treatment: with normal saline and regular insulin.

Note: HEPA: is not infectiouswithin a week or so after theonset ofjaundice, child can return to school. Activity at thattime depends on the childs energy level.

Which finding indicates to the nurse that a client experiencingalcohol 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 clients progress throughwithdrawal, 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 clientindicates 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


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of Diabetes Insipidus nasally or SQ required for remainderof life.

During the physical assessment, the nurse determines the need to

perform the bulge test. Which of the following statements, ifmade by the nurse is BEST Ans.Please lie down and extend your legs

Note: Bulge test: confirms presence offluid in the knee,clients leg should be extended and supported on the bed.

Note:Cromolyn Sodium (Intal, NasalCrom) (misc antiallergyagents) is used to prevent the release of histamine and otherallergy-triggering substances.

Correct statement would be I will take the medicine before I begin any vigorous exercise.

Note:favorable results from administration ofmedicationlevothyroxine (synthroid) (harmoe) is increasedurine

output.

Note: Medication increases metabolic processes of body,including glomerular filtration, edema will decrease as water isexcreted.

NOTE:- Appropriate action in palpating the uterinecontractions 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 theoutcome? Ans.No harm was actually suffered by the patient.

flaccid bladder

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