nclex review Flashcards

Terms Definitions
hyperopia
farsightedness
RBC/MALES
4.6-6.2
Lithium
0.8-1.5
UTI: Treatment
Antibacterial
Hypermagnesium Cause
antacids
basophils
0.3%; 0-200 cells/mm3
Abdominal Assessment
Inspection
Auscultation
Palpation
Percussion
PROTHROMBIN TIME
<40 SEC
Anorexia
Loss of appetite.
phosphorus
2.7 - 4.5 mg/dL
Glaucoma
Pressure within the eye
Jehovahs witness
No Blood products
Induration
Area of hardened tissue.
Nephrotic syndrome
proteinuria, hypoalbuminemia, hyperlipemia, edema, weight gain, anorexia, pallor
magnesium sulfate
Given to prevent eclampsia
Low potassium levels: Precipitate
digoxin toxicity
Hypothermia: results in
myocardial irritablity
Disrupts conduction system of heart and causes heart to be near fibrillation threshold, especailly ventricular
Clozaril
an atypical antipsychotic, side effects include leukopenia, gram-negative septicemia, drowsiness, tachycardia, and hypotension.
clay colored stools indicates/
biliary obstruction
SERUM ELECTROLYTE

CALCIUM
9.3 - 10.9 MG/DL
Shock
An abnormal physiologic state characterized by reduced cardiac output, circulatory insufficiency, tachycardia, hypotension, restlessness, pallor, and diminished urinary output. Shock may be caused by a variety of conditions, including trauma, infection, h
Bronchoscopy
Visual examination of the tracheobronchial tree using a bronchoscope.
uteroplacental insufficiency during contraction
Abruptio placentae
bupropion HCL(wellbutrin)
SSRI's (selective serotonin reuptake inhibitor)
alendronate (Fosamax)
Used to treat osteoporosis
Which places client at risk for ECT
Should be reported to physician
Addison's Disease: S/S of hyponatremia
Muscle cramps
Fatigue
Hypotension
Cheyne-Stokes
Periods of hyperpnea alternating with periods of apnea
Crescendo breathing
Results from cerebral lesion
Mennigococal Meningitis
Transmission is droplet and contact.

Protect yourself by wearing gloves, gown, mask, and goggles.
normal wbc count
4 - 10k microliters
Normal therapeutic digoxin administration range
0.5 - 2.0
Impetigo
honey-colored crust, vesicles that are reddish macules which appear around the neck.
* It is an infection.
* No isolation is required
Tenting
An indication of decreased skin turgor, as exhibited by a fold of skin remaining or holding in the pinched position after being released.
Apraxia
Complete or partial inability to perform purposeful movements in the absence of sensory or motor impairment.
Stokes-Adams attack
Episode of confusion and light-headedness accompanying syncope with or without seizures due to inadequate cerebral perfusion secondary to heart block.
Cystoscopy
Direct visualization of the urinary tract by inserting a cystoscope in the urethra.
tetany (trousseau's and chvosteks), seizures, confusion, paresthesia, irritability
Hypocalcemia implementation
combines cervical mucus evaluation & basal body temp evaluation, non-prescription/drug
Dilantin
ACE Inhibitor Action
Prevents production of angiotension II, causing systemic vasodilation
Platelet transfusion: Set
Set designed for platelets
Smaller filter
Shorter tubing
Bipolar: Missed Meals
Patient's poor judgement, dehydration and poor nutrition, patient is at risk for injury
metformin (Glucophage): Bitter and metallic tastes/Abdominal cramps
Antidiabetics
Common side effects
Doctor can adjust dose and/or patient take medication with meals
Communication: Feedback
Frequent exchange and feedback is important
When emotions are high, listening decreases and content retention is low
10. The REM sleep cycle occur approximately every ____ minutes?
90
Flail Chest
Caused by fracture of multiple adjacent ribs, causing the chest wall to become unstable and respond paradoxically. The chest on the affected side is pulled inward during inspiration and bulges outward during expiration.
Ulcerative Colitis
this disease causes inflammation and ulceration of the colon and the rectum. It requires a high calorie, high protein, and low residue diet.
what's a catecholamine
compounds with a sympathomimetic action. Some are produced by the body and function as key neurologic chemicals. Others are synthesized as drugs for use in the treatment of such disorders as asthma, shock, and heart failure.
Alcohol abuse warning signs
tremors
incr temp
nocturnal leg cramps
pain intolerance
VITAL SIGNS OF ADULT

CVP
2 - 6 MM/H20
Enteric precautions
A category-specific type of infection precautions established by the Centers for Disease Control and Prevention involving infections transmitted by intestinal secretions. These have since been replaced with standard precautions and transmission-based prec
Hydrotherapy
Treatment involving the use of water, such as tub or shower baths and whirlpools.
Abruption placentae
Premature separation of a normally positioned placenta in a pregnancy of at least 20 weeks' gestation either before labor or during labor but before delivery. This serious complication of pregnancy, occurring in one of every 200 births and often resulting
Tardive dyskinesia A neurological syndrome marked by slow, rhythmical, automatic movements that occur as an adverse effect of extended phenothiazine use.
Venography
A radiographic test using a contrast medium to identify thrombi or obstruction in the veins of the lower extremities or the kidneys.
care for the client with a life-threatening illness or injury first
MAOIs
Western blot test
confirms presence of HIV antibodies
phosphorus foods
fish, organic meats, nuts, pork, beef, chicken, whole-grain breads and cereal
A nurse is provinding discharge instructions to the client with pulmonary sarcoidosis. The nurse determines that the client understands the information if the client verbalizes which early sign of exacerbation?
Shortness of breath
Small bowel follow-through
Small bowel series
Done in conjunction with upper GI series
Encompasses duodneojejunal junction to ileocecal valve
Patient swallows barium sulfate
TB: Combination Medications
To prevent the development of resistant organisms
Take all three medications daily for first eight weeks
After 8 weeks, isoniazid and rifampin for another 4-8 months
SKIN TRACTION
APPLIED BY USING ELASTIC BANDAGES OR ADHESIVES
A highly positive urine myoglobin level following a crush injury to the leg has been noticed. What should the nurse assess the patient for?
Acute tubular necrosis
During low-output stage of Acute Renal Failure, should fluids be limited, or encouraged?
Limit fluids
Vitamin C
This vitamin enhances the synthesis of protein and is essential for the maturation and repair of tissue.
Gestational diabetes
The development of diabetes during pregnancy, usually during the second trimester.
Debridement
Removal of dead or damaged tissue or foreign material from a wound to prevent the growth of microorganisms and further damage and to promote healing.
Pneumothorax
A collection of air in the pleural space; may result from an open chest wound that permits the entrance of air or from the rupture of a vesicle on the surface of the lung. Common types of pneumothorax are open, closed, and tension.
KCL
* always diluted & infused thru a pump*20 to 40 mEq/L*Never IV push --> causes cardiac arrest*dilute wit NS, not dextrose b/c it inc Intracellular K shifting* monitor IV site b/c risk of phlebitis*monitor UO less than 30mL/hr
causes of metabolic alkalosis
diuretics, excessive vomiting or GI suctioning, excessive intake of antacids, hyperaldosteronism, ingestion/parenteral injection of excess sodium bicarbonate, massive transfusion of whole blood
Sources of nutrition: Sodium-Restricted Diet
Aim for ~600mg Na/meal and 200mgNa/Bedtime Snack
Sodium may need to be restricted in the diet for a variety of reasons including congestive heart failure, high blood pressure, and diseases associated with fluid imbalance like kidney and liver diseases
Pain: confused client
Offer pain medication, don't wait for client to ask
Infants: Solitary Play
Interest centered on own activity, but enjoys presence of others
One child digs a hole, another blows bubbles
Central Catheter Insertion
During the insertion you would never instruct a patient to breath deeply it may cause an air embolism, you;d instruct them to perform Valsalva Maneuver to prevent an embolism.
what's considered a full term baby
38 - 42 weeks
Patient on Crutches
which a patient is using crutches assess that the weight of the body is transffered to the hands and the arms. The arms should be bent at a 35 degree angle.
Urinary tract infection (UTI)
A bacterial infection, most commonly caused by Escherichia coli or a species of Klebsiella, Proteus, Pseudomonas, or Enterobacter, affecting one or more parts of the urinary tract.
Anticholinergic
1. Of or relating to blockade of the impulses of parasympathetic or other cholinergic nerve fibers. 2. Any agent with anticholinergic properties.
5Fs: fair, fat, forty, five pregnancies, flatulent(disease can occur in all ages and both sexes)
Hip fractures commonly hemorrhage,
EMOLLIENTS AND MOISTURIZERS
SELF CARE TEACHING FOR A PT WITH PSORIASIS WOULD INCLUDE APPLICATION OF...?
A nurse is gathering data on a client with a diagnosis of TB. The nurse reviews the results of which diagnostic test that will confirm this diagnoisis?
Sputum culture
"Here and Now"
Take care of problem now to prevent harm to client
Do not ask "Why"
Function of Albumin
Albumin is given to pull fluid back into blood vessels, from which diuretics can then promote
excess fluid excretion.
CBI (Continuous Bladder Irrigation) is to:
prevent formation of clots (obstructions) and spasms
DIETS

HEART HEALTHY DIET
LOW FAT (LESS THAN 30% OF CALORIES SHOULD BE FROM FAT
Tension pneumothorax
A condition in which air enters the pleural space through a tear in lung tissue but can't exit through the same vent, thereby trapping air in the pleural space with each inspiration and producing positive pleural pressure. This in turn causes the ipsilate
congenitalabd. placment of urethral orifice of penis
risk entry of bateria into urine
Peripheral arterial insufficiency: Hot bath
Can result in burning because vascular problems result in decreased sensation of lower extremities
If an anorexic client said &quot;My firends and I went out to lunch today&quot; would this be positive or negative?
Positive, shows signs of improvement
Digoxin is used for which dysrhythmias / disease?
CHF, A-Fib, A-flutter, paroxysmal atrial tachycardia
Autonomic neuropathy
6. You are taking the history of a 14 year old girl who has a (BMI) of 18. The girl reports inability to eat, induced vomiting and severe constipation. Which of the following would you most likely suspect?
Care of the older Adult Client: Temperature changes
-Diminished ability to sense temp changes may occur with aging, check water w/ wrist before immursing older adults in it.
-older adults don't bathe as frequent due to diminished perspiration
-normal temp for elderly 36 deg.c
(normal temp of young adult would be possibly a fever to an elderly adult
Normal Blood Gas Values
pH= 7.35 to 7.45
pCO2= 35 to 34 mmHg
HCO3= 22 to 26 mEq/L
PO2= 80 to 100mm Hg
what is trousseau's sign &amp; it's indication?
hypocalcemia; carpopedal spasm when bp cuff is higher than sbp
HTN inc workload of left ventricle, b/c i has to pump the stroke volume against increased resistance (afterload) in major bl. vessels.(LV empties into great vessels). this leads to LV failure, leading to S/Sx of Heart failure
Left-sided heart failure - pulmonary s/sx b/c lungs lie behind left sie of the heart from perspective of circulation
Will a young child with cancer get radiation therapy or chemotherapy?
chemo because radiation can cause retardation of bone growht and soft tissue development in kids younger than 8 years of age
A client at the family planning clinic is diagnosed with primary dysmenorrhea. Which of the following should be included in the nurse's teaching plan for non-pharmacological comfort measures?
c - balanced meals and adequate rest
A client at the family planning clinic is diagnosed with primary dysmenorrhea. Which of the following should be included in the nurse's teaching plan for non-pharmacological comfort measures?
a - initiation of oral contraception.
b - application of cold to the abdomen
c - balanced meals and adequate rest
d - regular emotional counseling
5. A thirty five year old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect?
A. Atherosclerosis B. Diabetic nephropathy C. Autonomic neuropathy D. Somatic neuropathy
When can HIV be passed from a mother to her infant
during the antenatal, intrapartal, or postpartum periods. THrough breast feeding.
Which of the following statement from a client receiving treatment for Chlamydia would alert the nurse that further teaching is indicated.
c I will be glad to resume sexual activity now that my treatment has begun
Which of the following statement from a client receiving treatment for Chlamydia would alert the nurse that further teaching is indicated.
a. I must avoid intercourse for at least 7 days while I'm taking my medication.
b. My partner will need to take the same medicine that I am taking.
c. I will be glad to resume sexual activity now that my treatment has begun
d. If I were pregnant, this infection might cause my baby to develop an eye infection.
put on NPO status to rest pancreas & supprest GI secretions
sidelying with HOB elevated 45Turning, coughing, Deep breatheAntacids/anticholinergics meds
The nurse evaluates a client's correct understanding of ovulation based on the cervical mucu methods when the client states:
d. The mucus will be clear, thin, and stretchable
The nurse evaluates a client's correct understanding of ovulation based on the cervical mucu methods when the client states:
a. there will bed a lot of thick, white mucus with a strong odor.
b. the mucus will be dark and maybe blood tinged.
c. the mucus will be thick and sticky
d. the mucus will be clear, thin and stretchable
Amanda states that her menstrual cycle occurs every 20 days. What additional data should the nurse gather?
a - the amount of flow per cycle
Amanda states that her menstrual cycle occurs every 20 days. What additional data should the nurse gather?
a - the amount of flow per cycle
b - type of protection used
c - age her mother went through menopause
d - number of sexual partners
SODIUM
135-145
PACO2
35-45
FHR
120-160BPM
"Clean"patient
Post-op patient
Calcium
9.3-10.9 mg/dl
lymphocytes
34%; 1000-4800 cells/mm3
NG: Not inserted
PRN
Polydipsia
Chronic, excessive thirst.
METHOTREXATE
USED IN SEVERE PSORIASIS
Cause of Headache: Medications
Antihypertensives
Diuretics
Anti-inflammatories
GLIDING
SLIDE OVER ONE ANOTHER
abbreviation for both eyes
ou
Echolalia
Parrotlike and inappropriate repetition of another's words.
Antiarrhythmics Adverse Effects
Bradycardia, tachycardia, hypotension
Impending delivery
Crowning of fetal head
TB: ethambutol: S/E
Optic neuritis
Skin rash
carbamazepine (Tegretol): Action
Anticonvulsants
Inhibits nerve impulses and reduces pain
RSV
Respiratory synctial virus, causes bronchiolitis and requires contact precaution which includes gown, gloves, but no mask.
* Keep in mind the best providers of care are parents, provide sleeping accommodation's for them when assigning rooms.
Calcium levels (normal)
8.6 - 10.0
ABG VALUES

HCO3
24 - 26 MEQ/L
Lymphangiography
A diagnostic radiographic evaluation of lymphatic system filling after injection of a contrast medium into a lymphatic vessel of each foot or hand.
high--> renal failure
inc hemoglobin from
fluoxetine (Prozac)
SSRI's (selective serotonin reuptake inhibitor)
Isotonic solution: Fluid replacement, increase plasma vol.
0.9% NaCL
Diabetes: Nursing education
Reduce calories
Maintain low-fat diet
Exercise regularly
Laminectomy: Rocking
Can be stressful to spine
Hypophosphatemia S/S
weakness, deep tendon reflexes, irritability, seizures, decreased CO
s/sx of meningitis
nuchal rigidity, fever, headache
Tegretol
control seizures that have not responded to other anticonvulsants
Chylamydia
Purulent discharge from the cervix, urthera or Bartholin's gland is associated with several STD such as chlyamydia.
Clarification
Communication technique used to help the client identify inconsistencies in his statements.
Compartment syndrome
A neurovascular complication commonly associated with fractures of the limb; constricting or occlusive dressings, sutures, or casts; poor positioning; and any injury causing ischemia, swelling, or bleeding into the tissues that ultimately can lead to perm
Scoliosis
An appreciable lateral curvature of the spine resulting from numerous causes, including congenital malformations of the spine, muscle paralysis, poliomyelitis, sciatica, and unequal leg length.
hypermagnesemia implementations
discontinue PO/IV mag, support ventilation, IV Calcium gluconate, monitor rhythm
bulging fontanel & dilated scalp veins
nausea
Suicide :Theraputic Response:
*1st response identify clients psychosocial assessment (an accurate assessment so that the client's psychological and emotional needs are identified)
*gain trust and permission from client, use a welcoming environment, make yourself completely tuned into the client
*assess events leading up to suicidal thoughts
*establish a human to human connection, non judgemental
Narcotic Pain Administration
Known etiology for pain (surgery)
Appropriate to provide immediately for moderate
Fetal distress
Fetus in trouble
Correlated with fetal tachycardia, bradycardia, and various decelerations and fetal heart rate patterns
Peripheral vascular disease: smoking
Causes vasoconstriction of extremities
Emotional stress and caffeine also cause vasoconstriction
Peripheral arterial occlusion: S/S
Pain, pulselessness, pallor, parethesia paralysis
Client can't distinguish between sharp and dull pressure on leg
14. Which of the following best describes a person that is completely awake falling asleep spontaneously?
cataplexy
Serum Lipase
Normal Value = 10 to 140
Hypertonic IV Fluids
5% D1/2NS
5% D/NS
10% D/W
5% LR

*chronic malnutrition, chronic illness
what is tb
tuberculosis
An acute or chronic infection from exposure to Mycobacterium tuberculosis or another strain of mycobacteria characterized by pulmonary infiltrates and formation of granulomas with caseation, fibrosis, and cavitation.
propanolol
Monitor HR &amp; BP
Assess for SOB, wheezing
Assess for insomnia, dizz

May cause bradycardia, decr B/P, bronchospasm
MATERNITY NORMALS

FAB9
FOLIC ACID= B9
B STANDS FOR BRAIN
(DECREASES NEURAL TUBE DEFECTS)
THE CLIENT SHOULD BEGIN THREE MONTHS PRIOR TO BECOMING PREGNANT
Ectopic pregnancy
Implantation of the fertilized ovum outside the uterine cavity. Types of ectopic pregnancy are abdominal pregnancy, interstitial pregnancy, and tubal pregnancy.
Addisonian crisis
An emergency situation occurring with adrenal hypofunction and exposure to trauma, surgery, or other severe physiologic stress that exhausts the body's stores of glucocorticoids.
Reflection
A technique in which the listener interprets the feelings of the client and repeats them back to the client; encourages the client to clarify his feelings.
Vesicle
1. Any small anatomic sac that contains liquid. 2. A small blister that contains clear fluid.
Private room- neg.pressure c 6-12 air exchanges/hr, mask, N95 for TB, Door keep closed.
Droplet
biopsy
confirms if tumor is benigh or malignant
calcium foods
cheese, collard greens, milk and soy milk, rhubarb, sardines, spinach, tofu, yogart
A nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. What equipment would the nurse plan to have at the bedside when the client returns from surgery?
Obturator
Bowel Obstruction: S/S
Frequent small amounts of watery diarrhea
Abdominal pain and nausea
Can be life-threatening if bowel perforates
amphotericin B (Amphotec, Fungizone)
Antifungal
Often given to leukemic patients
Can cause severe reactions
Do not administer with transfusion, unable to tell what is causing reaction
Pt. refuses chemotherapy
Assess whether client is experiencing any side effects
Thrombolytic therapy: Contraindications
Trauma in last two months
Active internal bleeding
Hx of hemorrhagic stroke
Intracranial or intraspinal surgery
Intracranial neoplasm
Atriovenous malformation
Aneurysm
Severe uncontrolled hypertension
Anthropoid pelvis
Pelvis type that is characterized by an oval shaped inlet.
What is case management?
case management represents an interdisciplinarly health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of client care
Head lice shampoo directions:
repeat 7-10 days
Kwell is toxic;
Risk factor for Cataracts
Prolonged use of Steriodal Anti-inflammatory agents is a risk fact for catarcts
Fantasy play
Type of play involving imaginary playmates typically associated with preschoolers.
pressure on fetal head during a contraction
Late deceleration
INTRAVASCULAR DEHYDRATION
RATIONALE BEHIND ADM IV FLUIDS TO A BURNT PATIENT IS...
A nurse is reading the results of a Mantoux skin test on a client woth no documentad health problems. The site has no induration an a 1-mm area of ecchymosis. The nurse interprets that the result is:
Negative
Esophageal intubation in stomach: in stomach: No airway
Remove immediately
Hyperventilate pt to prevent hypoxia
Attempt another intubation with a new sterile tube
Nursing assistant: Appropriate delegation of heat and cold
Appropriate to delegate to UAP application of heat or cold to a closed inflamed or painful area
Platelet transfusion: Reaction
Occurs in first 30 minutes, often 10-15
Febrile most common with platelet, WBC, or plasma
CVA patient: Feeding
Head should be midline and flexed slightly forward t facilitate swallowing and to prevent aspiration
Nagele's Rule
Add seven days to the last menstrual period, then count forward nice months.
what's the 4th stage of labor
recovery (post placental delivery)
Primary Syphilis
It will display as a papule like lesion in the vaginal area. Chancre develops iwthin two to six weeks; appears at point of entry; starts as small papule, develops into painless ulcer.
Vastus lateralis
The largest of the four muscles that make up the quadriceps femoris; located on the outside of the thigh, extending from the hip joint to the common quadriceps tendon and inserted in the patella; extends the leg.
Sx of Deficient fluid volume
Inc respirations/HRDec central venous pressure (normal CVP: 4-11cmH20)weight loss, poor skin turgordry mucous membranesdec. urine outputinc specific gravityinc. hematocritaltered LOC
Diabetic Ketoacidosis Causes (severe bloodsugar elevation)
*occurs when not enough circulating insulin
*body forced to breakdown body fats for energy=build up of ketones. This bulild up of ketones turnes blood acidotic= coma/death
*s/s - fatigue, frequent urination, increased thirst, fruity breath, nausea, vomiting, rapid breathing, muscle stiffness
Respiratory= Opposite:
pH is high above 7.45, PCO2 is down below 35 (Alkalosis).
pH is low below 7.35, PCO2 is up above 45 (Acidosis).
Hip Replacement: Prevent dislocation
Maintain leg in position of abduction for 2-3 months
Signs of an Air Embolism
* Apprehension
* Chest Pain
* Loud Churning sound heard over the pericardium
* Dyspnea
* Hypotension
* Rapid and Weak Pulse
Positive Trousseau's sign is indicative of:
HypOcalcemia; BP cuff inflated 1-4 mins causes hand &amp; fingers to undergo spasm &amp; flexion
Acquired immunodeficiency syndrome (AIDS)
A disorder of the immune system characterized by an inability to mount a successful defense against infection such as by organisms that usually aren't pathogenic (opportunistic infections). The syndrome is caused by infection with the human immunodeficien
NG TUBE INSERTION
WHAT WOULD THE NURSE PREPARE TO DO FOR THE CLIENT WHO IS 6HR POST BURN AND HAS ABSENT BOWEL SOUNDS AND ABD DISTENTION?
Chickenpox vaccine
Given to people over age of 13 if they have not had disease
What are common manifestations of Addison's disease
postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and irritability
Order of Developmental Milestones for an Infant
1. Doll eye's reflex disappears
2. begins drooling
3. Responds to own name
4. Takes deliberate steps when standing
5. Picks up bite-size pieces of cereal
take 1-2 hrs after other oral meds
Symptothermal method fo birth control
Cerebrovascular Accident; caring for a client who has dysphagia
CVA-opp side is affected. (Ex. Right sided CVA, mean left is affected, so would eat on right side of mouth)
*client needs thickened liquids, sitting upright, eat soft or semi-soft foods, have tv off so won't distract and aspirate
How can you avoid aspiration in patients being fed through tube feedings?
Elevate the HOB 30-45 degrees following a bolus tube feeding. Put the person in the right lateral position.
what are the actions of narcotics (6)
reduce pain perception. induce mental changes. promote deep sleep. depress respirations. constrict pupils. decrese GI motility.
high K+ level - massive cell destruction conditions
trauma, burns, sepsis, metabolic or respiratory acidosis.
What are common symptoms of a brain tumor?
projectile vomiting occuring in the morning and a positive babniski sign
Marie and her husband are planning pregnancy. She suffers from premenstrual syndrome and asks the nurse which relief measure would be appropriate. The nurse's best response is:
d - increase intake of complex carbohydrates
Marie and her husband are planning pregnancy. She suffers from premenstrual syndrome and asks the nurse which relief measure would be appropriate. The nurse's best response is:
a - zoloft
b - increase foods containing methylxanthines
c - low dose oral contraceptives
d - increase intake of complex carbohydrates
troponin higher than 0.1 to 0.2 ng/mL --> Myocardial infarction
Creatinine level (0.6 - 1.2 mg/dL)
The nurse working on the sexual assault response team (SART) will begin acquisition of medical and forensic data by first:
c. obtain a detailed hx of the event
The nurse working on the sexual assault response team (SART) will begin acquisition of medical and forensic data by first:
a. photograph any physical injuries
b. scrape under the victim's fingernails
c. obtained a detailed hisotry of the event
d. mark clothing and seal in an airtight bag
Wet to Dry Dressing: Apply moist gauze
Apply moist gauze in a single layer to the wound
Absorbs drainage and adheres to wound
Cover moist dressing with dry sterile dressing
When teaching a client to use the calendar method of contraception, which of the following should the nurse include in her teaching plan?
B.Ovulation occurs around day 14 of the menstrual cycle, sperm are viable up to five days, and ovum live for 24 hours.
When teaching a client to use the calendar method of contraception, which of the following should the nurse include in her teaching plan?
A. Ovulation occurs around day 10 of the menstrual cycle, sperm are viable up to 3 days and ovum live for 2 hours.
B. Ovulation occurs around day 14 of the menstrual cycle, sperm are viable up to five days, and ovum live for 24 hours
C. Ovulation occurs around day 18 of the menstrual cycle, sperm are viable up to 2 days, and ovum live for 4 hours
D. Ovulation occurs around day 11 of the menstrual cycle, sperm are viable up to 4 days and ovum live for 48 hours
A client's total parenteral nutrition is 6 hours behind schedulel. The nurse would
D. Check the blood glucose level.
A client's total parenteral nutrition is 6 hours behind schedulel. The nurse would
A. Run the fluid at a rate to make up for the lost time.
B. Report the situation to the physician.
C. Run the IV at the prescribed site.
D. Check the blood glucose level.
ZIDE
DIURETICS
HCO3
22-26
PaO2
80%-100%
loperamide (Imodium)
Antidiarrheal
Potassium
3.5-5.5 mEq/L
eosinophils
2.7%; 0-450 cells/mm3
metformin (Glucophage): S/E
Antidiabetics
Nausea
Vomiting
Anorexia
Abdominal cramps
Fatigue
Tend to be mild and resolve as therapy continues
Mg
1.6 to 2.6
BUN
7 to 18
hypovolemia
decrease in fluid volume
theophylline (Theobid):Therapeutic range
Bronchodilator, xanthine-derivative
10-20 mcg/dL
Toxicity occurs over 20 mcg/dL
MEATUS
SHORT CHANNEL OR PASSAGEWAY
abbreviation for both ears
au
Irritability
Excitability or excessive responsiveness to a stimulus.
normal range for potassium
3.5-5.3 mEq/L
Late decelerations
Correlated with uteroplacental deficiency
Cushing's Syndrome
hypercortisolism causes hyperglycemia other symptoms of the disease include fatigue, weakness, osteoporosis, cramps, edema, hypertension, decreased resistance to infection, truncal obesity, buffalo hump, and moon face.
Magnesium levels (normal)
1.6 - 2.6
CHEMISTRY VALUES

BUN
7 - 22 MG/DL
Asepsis
The absence of living, disease-producing organisms. Medical asepsis refers to the removal or destruction of disease organisms or infected material. Surgical asepsis refers to protection against infection before, during, or after surgery by means of steril
sitting position(elevate HOB) first before any other implementation
Shock
imipramine (Tofranil)
TCA's (tricycline anti- depressant )
Dupuytren contracture
Slow progressive contracture of plantar fascia
Fourth and fifth fingers are contracted onto palm
Compartment syndrome: S/S
Pain after taking medication
TB: rifampin S/E
Hepatitis
Febrile reactions
Nausea and vomiting
flurazepam (Dalmane)
Sedative /hypnotic
Used for short-term management of insomnia
S/E: Confusion, daytime drowsiness, blurred vision
Atrophy
Lesion that is shiny and translucent
Myelomeningocele: At risk
Infection (takes priority)
For impaired circulation of CSF
Contractures
Pneumococcal vaccine
Prevent pneumonia
Highest risk is older adults
Hypotonic IV Fluids
0.45% NS

*DKA, perspirations, ESRD,diarrhea
what does tachycardia indicate
decreased cardiac output
Decerebrate positioning
rigid extension, arms extended, foreearms pronated , wrists and fingers flexed

Usually associated with a worse outcome
Blood Expanders
Lactated Ringers

D5 in Water

Normal Saline
Cirrhosis
A chronic, degenerative liver disease in which the lobes are covered with fibrous tissue, the liver parenchyma degenerates, and the lobules are infiltrated with fat.
Calcium gluconate (PO/IV), caution with pts on dig, seizure precautions, Airway (laryngeal stridor), safety (confusion), Inc diet calcium, exercise
Hypercalcemia s/s
Aortic stenosis
exercise intolerance, chest pain, dizziness when standing too long
Dobutamine
stimulates heart after heart attack or during surgery.
Hip replacement: Report
Leg is outwardly rotated
Indicates dislocation of prosthesis
May also see shortening of extremity, inability to move it, altered alignment, abnormal rotation, increased pain
Toddler: Erickson
Autonomy vs. Shame
3 years of age
15. Which of the following best describes a person that is unable to tell you were there hand or foot is?
autottopagnosia
Latex Allergies
patients with latex allergy should avoid cross reactive foods like apricots, cherries, grapes, kiwis, passion fruit, bananas, avocados, chestnuts, tomatoes and peaches.
Hyponatremia Cause
diaphoresis, wound drainage, NPO, RF, CHF, hyperglycemia
respiratory alkalosis
Caused by both respiratory and nonrespiratory factors, this condition is marked by decreased partial pressure of arterial carbon dioxide, decreased hydrogen-ion concentration, and increased blood pH. Extreme anxiety can precipitate hyperventilation associated with respiratory alkalosis.
Autonomic NS divided into ...
Sympathetic--fight of flight

parasympathetic-- normal body functioning
TREATMENT FOR SPIDER BITES AND BLEEDING?
RICE
REST
ICE
COMPRESSION
ELEVATE EXTREMITY
Epilepsy
A group of neurologic disorders marked by uncontrolled electrical discharge from the cerebral cortex and typically manifested by seizures with clouding of consciousness. Epilepsy is most commonly of unknown cause (idiopathic) but is sometimes associated w
Hydramnios
Presence of an excess volume of amniotic fluid during pregnancy.
Suspension
A liquid that contains solid particles that aren't dissolved; stirring or shaking the liquid maintains the dispersal.
Peritoneal dialysis
A procedure performed to remove toxins, drugs, or other wastes normally excreted by the kidney; transfers these substances across the peritoneum by intermittently introducing and removing a dialysate from the peritoneal cavity.
Osmolarity
The osmotic pressure of a solution expressed in osmoles of solute per liter of solution.
calcium gluconate
tx hypocalcemic tetany(notify Dr. if tingling around mouth, fingertips/toes, muscle spasms, twitching.)
most accurate oxygen concentration
pulmonary embolism s/sx
causes of metabolic acidosis
diabetes mellitus or diabetic ketoacidosis, excessive ingestion of aspirin (acetylsalicylic acid), high fat diet, insuficient metabolism of carbs, lactic acidosis, malnutrition, renal insufficiency or renal failure, severe diarrhea, starvation...... the pH is less than 7.35 and the HCO3 level is less than 22 mEq/L
bacterial infection
s/s occurs within min <24 hrs tachycardia, hypotension, fever, chills, shock NC antibioitcs, vasopressors, steroids
Fluid Volume Overload: Treatment
Elevate head of bed
Stop infusion
Pulmonic area
Second intercostal space just to the left of the sternum
Auscultate for S2
Caused by closure of semilunar valves
Ways infants lose body heat
Conduction, convection, radiation, evaporation
The community health nurse discusses with a client how her husband makes her feel like a servant. The client states that her husband demands all childcare and housework be done completely by her with no help whatsoever from him. The nurse understands her
A. Psychological abuse
The community health nurse discusses with a client how her husband makes her feel like a servant. The client states that her husband demands all childcare and housework be done completely by her with no help whatsoever from him. The nurse understands her
a. psychological abuse
b. physical abuse
c. sexual abuse
d. sociological abuse
Ketones will be evident in which diabetes?
Type I or Type II
Type I
Post-Op Hemorrchoidectomy Care
After this procedure the potential complication is urinary retention manifested by lower abdomen enlargement and sounds dull on percussion. This occurs because of closeness of bladder to the surgical site and occurence of rectal spasms and anorectal tenderness; catheterize to empty bladder.
An increase in the seriousness of a disease or disorder or in its signs and symptoms.
Diabetes insipidus
A metabolic disorder marked by extreme polyuria and polydipsia and resulting from deficient secretion or production of antidiuretic hormone (ADH) or inability of the renal tubules to respond to ADH. (Rarely, excessive water intake causes signs and symptom
Paget's disease
A common bone disease that usually affects middle-aged and elderly people. It’s marked by inflammation of the bones, softening and thickening of the bones, excessive bone destruction, and unorganized bone repair; the result is bowing of the long bones. Th
Laminectomy
Surgical removal of the bony arches of one or more vertebrae; performed to relieve spinal cord compression or to remove a displaced intervertebral disk.
Causes of EXCESS fluid volume
dec kidney functioncongestive HFhypotonic fluids to replace isotonic fluid lossesexcessive irrigation of woundsexcessie ingestion of sodium
RISK FOR INFECTION
HIGHEST PRIORITY FOR AN ELDERLY CLIENT DX WITH HERPES ZOSTER IS?
Which of the following identifies the route of transmission of TB?
The airbourne route
Wet to Dry Dressing: Observe
Observe appearance of wound
Inspect for color, character of drainage, and presence of drains
Hypercalcemia
this may occur as a results of bone destruction by the tumors, elevated levels, affect mental status and can negatively affect multiple organ systems.
Early Decelerations
this occurs before the peak of the contraction, it results from fetal head compression.
Spinal shock
Loss of autonomic reflex, motor, and sensory activity below the level of a lesion. Signs of spinal shock include flaccid paralysis, loss of deep tendon and perianal reflexes, and loss of motor and sensory function.
Bacterial meningitis
Inflammation of the meninges of the brain and spinal cord caused by bacteria such as Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, or Escherichia coli.
Causes of Deficient fluid volume
Vomiting, diarrhea, conditions that causes inc respirations/inc urinary output, insufficient IV fluid replacement, draining fistulas, ileostomy/colostomy
Nutrition for infants: introducing solid foods
-should start at about 6months,some start as early as 4months
Metabolic= Equal:
pH is high above 45, HCO3 is high above 26 (Alkalosis).
pH is low below 7.35, HCO3 is low below 22 (Acidosis).
Raynaud Syndrome: Core temperature
Heating of core of body prevents chilling and consequential shunting of blood to trunk from extremities
Signs and Symptoms of Lithium Toxicity
* Diarrhea
* Over sedation
* Tinnitus
* Ataxia
* Slurred Speech
* Muscle Weakness/Twitching
Thorazine S/E: Antipsychotic, tranquilizer, antiemetic
may be used for restlessness &amp; apprehension B4 surgery
SE = HOTN; May cause tardive dyskinesia
Antisocial personality disorder
A disorder that manifests after age 15 as a pervasive disregard for and violation of the rights of others.
client who is immediate post gastroscopy period, what would be included in the plan of care
assess gag reflex prior to administration of fluids, due to anestetic that would been sprayed in throat prior
Labor: Transition phase S/S
Woman asks for help to go to bathroom
Transition phase cervix is 8-10 cm dilated with complete effacement
Increased pressure in pelvis causes intense desire to urinate
What is sandostatin used for?
to reduce growth hormone levels in clients with acromegaly
Late Stage of Cirrhosis
Late stage of cirrhosis is hypoxia due to fluid in the lungs and weak chest expansion.
Venous disorder, legs are
elevated above level of the heart to assist with return of venous blood to the heart.
Expected lab value changes with lipitor:
A normal Bilirubin is (0.2-1.2 mg/dl). A slight increase in Bilirubin is expected when taking lipitor.
A liver function test will be ordered, and cholesterol q 3-6 months. LDL level should be below 130mg/dl
What does Levothyroxine do in relation to blood clotting?
It accelerates the degradation of vitamin K-dependent clotting factors. Warfarin should be reduced if someone is taking that and synthroid.
To diagnose developmental dysplasia of the hip perform what assessment:
Ortolani's sign.
An audible click on hip manipulation
bowel herniates thru a defect in abd. wall to rt of umbilical cord.
Risk of infection after delivery
A client has recurrent episodes of bacterial vaginosis. What further data should the nurse gather?
a. frequency and method of vaginal douching
A client has recurrent episodes of bacterial vaginosis. What further data should the nurse gather?
a frequency and method of vaginal douching
b. hygiene practices
c sexual orientation
d employment history
Autonomic dysreflexia in spinal cord clients
Nurse elevates HOB & then examines the source of noxious stimuli.
A radioactive implant is being used to treat a client with cancer of the prostate. The implant is found on the floor near the patient. The nurse should:
B. Place the implant in a radiation-proof container, using forceps
A radioactive implant is being used to treat a client with cancer of the prostate. The implant is found on the floor near the patient. The nurse should:
A. Replace the implant, using forceps.
B. Place the implant in a radiation-proof continaer, using forceps.
C. Leave the implant for the radiation safety officer.
D. Place a lead shield between the nurse and the implant.
Does a diabetic need to purchase special foods?
NO, the diabetic just needs to eat a balanced meal
Peak of Regular insulin:

Peak of NPH insulin:
Regular: 2.5 - 5 hr

NPH: 4 - 12 hr
A nurse assess an intravenous site of a client and finds it red, swollen, and painful; there is no blood return. The nurse should:
A. Remove the IV at once
A nurse assess an intravenous site of a client and finds it red, swollen, and painful; there is no blood return. The nurse should:
A. Remove the IV at once.
B. Watch to see if the swelling gets worse
C Report it to the physician
D. Apply an antibiotic ointment to the site.
Amylase
Lipase
60-160
0-160
Gentamicinneomycinstreptomycintobramycin
Cephalosporins
DONE
OPIOD ANALGESICS
Miotics
Constrict pupils
Orange juice
Restores potassium
Normal WBC Level
5000-10000
Vibramycin, Minocin, Panmycin
anticonvulsants
plasma
straight line give quickly
Sterile Field: Below Waist
Contaminated
Hypomagnesium Cause
malnutrition,diarrhea, vomitting, celiac and chrohns disease, hyperglycemia
CN XII
Hypoglossal- tongue movement
3.5 to 5.0
hypokalemia s/s
Battery
Any intentional touching without client's permission
Nurse slaps a patient's face
Heat Stroke: S/S
Hypotension, tachypnea, tachycardia
Temperature of 105 or above
Skin is hot and dry
Behavior is bizarre, confused, delirious or comatose
Wheezes
Squeaky sounds
Heard during inspiration and expiration
OTHER WORDS ASSOC. WITH IMPLEMENTATION
DOCUMENT,EXPLAIN,GIVE,INFORM,ADMINISTER,ENCOURAGE,ADVISE,PROVIDE,PERFORM.
Hypernatremia Cause
Cushings, corticosteroids, NPO, diet
Pre-eclampsia early S/S:

Treatment:
facial swelling
proteinuria
HTN

Treatment: delivery
CHEMISTRY VALUES

TRIGLYCERIDE
40 - 50 MG/DL
atenolol (Tenormin)propanolol (Inderal)metoprolol (Lopressor)
Calcium channel blockers
Sepsis (s/sx)
fever, chills, general malaise
mirtazapine (Remeron)
TCA's (tricycline anti- depressant )
Ketones
Ketones result from fatty acid metabolism
Usually are completely metabolized by liver
Jugular vein distention: S/S of
Cardiac tamponade
SPRAIN
AN EXCESSIVE STRETCHING OF A LIGAMENT
ABG Norms:
pH
paO2
paCO2
HCO3
O2 Saturation
pH 7.35-7.45
paO2 80-100
paCO2 35-45
HCO3 22-26
O2 Saturation 95-100
Cushing syndrome affects blood glucose &amp; sodium which way? (-ER or -O)
HypERglycemia
HypERatremia
Cranial nerve VII
Facial- taste, facial movement
TREATMENT FOR SICKLE CELL CRISES?
HHOP
HEAT
HYDRATION
OXYGEN
PAIN MEDICATIONS
Myalgia
Diffuse muscle pain or tenderness associated with many infectious diseases.
Paraplegia
An abnormal condition characterized by the loss of sensation and motor function in the lower limbs, which may result in either complete or incomplete paralysis.
Endocarditis
An abnormal condition of the endocardium and heart valves marked by vegetations on the valves and endocardium. It may occur as a primary disorder or arise in association with another disease.
Advance directive
Documented written or verbal instructions by the client about his wishes for life-sustaining medical care in the event he becomes incapacitated (for example, living wills, durable powers of attorney for health care, or any document that states the client'
lie flat c legs elevated
After Myringotomy
sodium foods
bacon, butter, canned foods, cheese (american or cottage cheese), hot dogs, lunch meats, ketchup, milk, mustard, processed foods, snack foods, soy sauce, table salt, white and whole-wheat bread
Secondary glaucoma
caused by trauma or optic neoplasm.
Syphilis: Treatment
Penicillin G IM
Erythromycin for 10-15 days if allergic to penicillin
Meningitis vaccine
Currently not required for college students, but information should be given out to dorms, residence halls, etc.
DIATHROSIS
SYNOVIAL JOINTS ARE THOSE THAT MOVE FREELY, AKA..
Halo Vest
the halo vest provided immobilization and allows early ambulation for clients diagnosed with cervical spinal injury.
Acromaegaly- hyperpituitaryism
large feet and hands, arthritc changes, deep voice, organomegaly, rough skin
s/sx of hypocalcemia
parasthesias, muscle spasms, perif numbness
Pericardial Effusion
Diagnostic tests for this is echocardiography which records pericardial effusion with signs of right ventricular and atrial compression.
MATERNITY NORMALS

CONTRACTIONS
NORMAL FREQUENCY = 2-5 MIN APART

DURATION = &lt;90 SEC

INTENSITY = &lt;100 MM/HG
Hospice
A system of family-centered care using a multidisciplinary approach designed to assist the chronically ill person to maintain a satisfactory lifestyle through the terminal phases of dying.
Atopic dermatitis
A skin inflammation occurring in individuals with a genetic predisposition to allergies, characterized by intense itching, maculopapular lesions, and excoriation (rash pattern varies with age but usually occurs on the face).
Cyanotic
Referring to the bluish or bluish black discoloration of the skin and mucous membranes that results from excessive concentration of unoxygenated hemoglobin in the blood.
Sickle cell crisis
Episode of widespread cellular sickling in which the client's red blood cells containing hemoglobin S are exposed to conditions in which oxygen supply to the cells is decreased. This leads to cellular contraction and piling within the cell, altering the s
Transdermal
Method or route of topical drug administration; provides continuous drug delivery through the skin to achieve a constant, steady blood concentration level.
Pulmonary edema
An abnormal condition in which extravascular fluid is accumulated in lung tissues and alveoli.
Compensation occurs when
pH returns to normal value
Dark-skinned--> inner canthus of eyes & heard palate of mouth
Venturi mask
TOURNIQUET EFFECT
REMOVING JEWELRY FROM AN AFFECTED BURN SITE HELPS IN PREVENTING...
Pecans and raisins
Food add calories and are nutritious
Right Sided Heart Failure: S/S
Dependent edema
Distended jugular veins
Weight gain
Group Therapy
Allows exploration with a therapist to set appropriate limits on member's behaviors
ACE Inhibitors
they block the release of aldosterone, which promotes potassium retention clients should avoid foods high in potassium such as broccoli, and bananas.
Common types of pneumothorax are
open, closed, and tension.
Mini Mental Status Exam
Assessment tool for determining severity of aggression;
THERAPUTIC LEVEL
IT IS IMPORTANT TO MAINTAIN THE BLEEDING TIME SLIGHTLY PROLONGED SO THAT CLOTTING WILL NOT OCCURE; THEREFORE, THE BLEEDING TIME WITH MEDICINE SHOULD BE 1 1/2 TO 2 TIMES THE CONTROL. THE CONTROL IS THE PREMEDICATION BLEEDING TIME.
Autosomal recessive disorder
Genetic disorder involving two expressed abnormal autosomal genes (not expressed in the parents) in which the individual affected receives one copy of the altered gene from each parent; thus the individual is homozygous for that trait.
Celiac disease
A chronic disease in which an individual can’t tolerate foods containing gluten or wheat protein. Signs and symptoms include abdominal distention, vomiting, diarrhea, muscle wasting, and extreme lethargy.
Transsphenoidal hypophysectomy
Microsurgery in which an incision is made at the junction of the gums and upper lip. A surgical microscope is advanced and a special surgical instrument is used to excise all or part of the pituitary gland.
Hypertonic
1. A solution that has greater osmotic pressure compared to another solution; a fluid in which cells shrink. 2. In reference to muscles or arteries, having a greater than normal degree of tension.
high protein, high carbs, high sodium, low potassium; medic bracelet; infection!; hypoglycemia, hyponatremia;
Addisonian Crisis
pregnancy risk category D, investitgate if pregnant before giving this med
Transcutaneous electrical nerve stimulation (TENS)
Methylzanthines: Adverse Effects of Theophylline (Theo-Dur)
-Methylxanthines are known to stimulate peptic acid secretion
-caution in patients with active peptic ulcerdisease.
-cautiously in patients with impaired renal function
-Severe Potential Hazard= Seizures, Head Injury, Cerebral Vascular Disorder,Gastroesophageal Reflux Disease,
-Theophylline is removed by hemodialysis, so don't give to dialysis pt
-Toxicity is most likely to occur when levels exceed 20 mcg/mL.
Third heart Sound (S3)
Found in Left sided heart failure
Heimlich maneuver
Embrace client from behind and with a fist quickly thrust upward into her abdomen
Mild level of anxiety
Reinforce client to share problems with the group and attend meeting
Abdominal aortic aneurysm (AAA): Constipation
Increases intraabdominal pressure and risk of rupture
Toddler: Bedtime
"After we read story, we go to sleep"
Ritual
The expression of ____ is known to be a normal response to impending loss.
Anger
verapamil (Calan) is a:
CCB
When used w/other HTNsives can caust HOTN &amp; HF
Positioning to promote gastric emptying.
Lying on the RIGHT side
Otorrhea
A discharge from the ear, which may be serous, sanguineous, or purulent if the external or middle ear is infected.
Paralytic ileus
A decrease in or absence of bowel motility that may occur following abdominal surgery or may be caused by numerous other conditions, most commonly by peritonitis.
constant bubbling in water seal chamber
leak in the system
Assessment & management of Newborn complications: Hyperbilirubinemia:
-Jaundice (yellow discoloration of skin, whites of the eyes) first in the face.
s/s- hard to wake up infant, shrill cry, irritable, arches neck or body backwards
-treatment= phototherapy & encourage feeding
Bell's palsy
Okay to use heat on affected side of face
Do not go out when there is a cold wind, due to sensitivity of nerve endings
Place eye shield over affected eye to prevent corneal irritation
Use artificial tears
CABG: Normal post op
C/O sharp localized pain over sternum, treat with pain meds
Hypothermia is usual, induced during surgery and heat loss from chest
Various types of rape
Date rape, virgin rape, blitz rape, acquaintance rape, power rape, anger rape, sadistic rape, gang rape.
How is iodine toxicity treated
with gastric lavage and then administration of sodium thiosulfate to reduce iodine to iodide
Increase of Tactile Fremitus
This is usually present when the client has pneumonia.
Fundus
The base of an organ; the portion of a hollow organ farthest from its mouth, such as the fundus of the uterus.
femur fractures are at risk for fat emboli
For hospital triage
Cystic Fibrosis: Reinforcing Teaching about pancrelipase (pancrease)
its a combination of lipase, amylase, and protease, which are enzymes needed for digestion of fats, carbohydrates and proteins. these are normally produced in pancreas, but people with cystic fibrosis do not excrete them. Pancrelipase products are made from enzymes taken from pigs.
-take before meals, and not if allergic to pork, never crush or chew or store in fridge
Cataract surgery: post op care
Nursing Assistant raises head of bed 35 degrees
Prevents significant sustained increased intraocular pressure
A client diagnosed with insulin-dependent diabetes mellitus becomes irritable and confused; the skin is cool and clammy, and the pulse rate is 110. The first action of the nurse would be to
A. Give a half-cup of orange juice.
A client diagnosed with insulin-dependent diabetes mellitus becomes irritable and confused; the skin is cool and clammy, and the pulse rate is 110. The first action of the nurse would be to
A. Give a half-cup or orange juice
B. Check the serum glucose
C. Administer regular insulin
D. Call the physician
Early Signs of Myasthenia Gravis
These include Ptosis and Dipolpa. Late signs include dysphagia, and respiratory distress occur later.
Position after Cataract surgery
sleep on unaffected side with a night shield for 1-4 weeks.
red pack blood cells
give 2-4 hrs, 0.9 ns mix cells every 20-30 min
A client is on chemotherapy for acute myelogenous leukemia. The nurse assesses the following laboratory test daily:
A. Complete blood count
A client is on chemotherapy for acute myelogenous leukemia. The nurse assesses the following laboratory test daily:
A. Complete blood count.
B. Electrolyte panel
C. Prothrombin Time
D. Blood urea nitrogen and creatinine
Post Op care for Tonsillecectomy
Patient should not swallow, there is a high risk for bleeding/hemmorhaging.`
Head Injury: Providing Care for a client with Increased Intracranial Pressure
- monitor v/s closely, accurately and periodically
-maintain airway, if client is not intubated place client on side to decrease possibility of airway occulusion
-watch for coughing when suctioning=can create seizure activity
-administer medications(corticosteroids, dilantin, antibiotics)
_Restrict fluids, and elevate bed to 30 degrees
-maintain normal body temperature
The diabetic pt who deals with frequent episodes of Vulvovaginal Candidiasis asks the nurse if there is anything she can do to help prevent these infections. What would be an appropriate nursing response?
a. choose cotton underwear and avoid douching
The diabetic pt who deals with frequent episodes of Vulvovaginal Candidiasis asks the nurse if there is anything she can do to help prevent these infections. What would be an appropriate nursing response?
a. Choose cotton underwear and avoid douching
b. taking a daily antibiotic may assist you in avoiding this infection
c. wear nylon underwear and douche daily with a scented product
d. avoid sexual intercourse during ovulation
How is apgar score counted
0 for absent, 1 for decreased, 2 for strong
How to detect female cancers using Breast Self Examinations
A BSE should not be conducted around the same time of menstrual cycle.
*lay flat on back, using opposite hand to breast with arm raised, use 3 middle fingers in circular motion.
A 45-year old client is receiving heparin sodium for a pulmonary embolus. The nurse evaluates which of the following laboratory reports of partial thromboplastin time as indicative of effective heparin therapy?
C. Two to 2.5 times the control (normal) value.
A 45-year old client is receiving heparin sodium for a pulmonary embolus. The nurse evaluates which of the following laboratory reports of partial thromboplastin time as indicative of effective heparin therapy?
A. Within nomral range
B. One to 1.5 times the control (normal) value
C. Two to 2.5 times the control (normal) value
D. Three times the control (normal) value.
A 45-year-old male returned to his room an hour ago following a bronchoscopy. He is requesting some water. The nurse must:
C. Check the gag and swallowing reflexes.
A 45-year-old male returned to his room an hour ago following a bronchoscopy. He is requesting some water. The nurse must:
A. Keep the client NPO until an order is written.
B. Check the vital signs first.
C. Check the gag and swallowing reflexes.
D. Encourage coughing and deep breathing.
After billroth II surgery, the client develops dumping syndrome, what does the nurse not want the client to do?
Do not have client sit up for at least 30 min after meals
*Sitting upright will produce or promote dumping syndrome. Client needs to lie down after meals.
Carol, age 20 reports to the nurse about her menstrual flow. Which of the following statements made by the client would be cause for further investigaion.
b - I had to change my maxipad at least 14 times today
Carol, age 20 reports to the nurse about her menstrual flow. Which of the following statements made by the client would be cause for further investigaion.
a - i've saturated one tampon today.
b. I had to change my maxipad at least 14 times today
c. A panty liner is sufficient to maintain my flow
d. I always wear tampons because they are easier to use
PLATELETS
150,000-450,000/MM3
Testes
testosterone
"Dirty" patient
COPD
Normal BUN
6-20
Albumin
plasma expander
phenytoin (Dilantin)
Anticonvulsants, anti-arrhythmic
Metabolized and excreted by liver
Elderly clients have some degree of liver impairment and are at high risk for problems
TOTAL BILIRUBIN
0-1.5 MG/DL
ABG VALUES

SAO2
&gt; 95%
surgical emergency
Duodenal ulcer
Amount of amniotic fluid
500-1200ml
HEMATOLOGY VALUES

PLT
200,OOO - 400,000
HHNK
rehydrategive regular insulin only
Laryngectomy patient
Postop complications include respiratory difficulties
Early ambulation
Helps client pass flatus
Bronchial
Loud coarse, blowing
Heard over trachea
Normal WBC
4500 to 11,000 cells/uL
bandage technique for joints
figure 8
Homan's Sign
this sign indicated DVT.
MATERNITY NORMALS

FHR
120M - 160 BPM
Dyspnea
Shortness of breath, difficulty breathing, or labored breathing resulting from certain heart conditions, anxiety, or strenuous exercise.
Increased motor activity, tachycardia
Alcohol withdrawal
Dopamine
acts as a vasoconstrictor increasing BP and renal perfusion (urine flow)
Best way to kill germs
WASH HANDS
Addison's Disease: S/S
Symptoms of dehydration
"eternal tan"
Diabetes: Risk Factors
>45 years old
Native American
Obesity
Family Hx
Lasix
this is a potassium-wasting diuretic. Clients need to increase their intake of K+
Diuretics
Decrease water/sodium from loop of henley
Strabismus presents with:
Crossed eyes,
double vision
child covers one eye to see
Vasopressin
After hypophysectomy, or removal of the pituitary gland, the body can synthesize ADH. Vasopressin is given post operatively to replace ADH normally secreted from the pituitary.
Thrombophlebitis
Inflammation of a vein, often involving clot formation. Common causes include chemical irritation, blood hypercoagulability, immobilization, infection, postoperative venous stasis, prolonged sitting or standing, trauma to the vessel wall, or a long period
Extrapyramidal
1. Describing the tissues and structures of the brain located outside the pyramidal tract and not running through the medullary pyramid -- excluding the motor neurons, motor cortex, and corticospinal and corticobulbar tracts. 2. Of or relating to the func
Skin turgor
Skin characteristic determined by pinching a small area of skin on the medial arm or anterior chest and noting how quickly it returns to its position when released.
fatigue, weakness, dehydration, hypoTN, eternal tan, dec resistance to stress, alopecia, wt loss, pathological fractures
Addison's Disease tx
continuous gental bubling in the suction control chamber
approriate
CANDIDA
WHITE MILKY PLAQUE ON TONGUE THAT DEVELOPS AS A RESULT OF OVERGROWTH OF BACTERIA AFTER ATBS
Diagnostic test using dyes: Contraindication
Allergies to shellfish
Infant: Erickson
Trust vs. Mistrust
Birth to 18 months
Potential Disturbed Family
Threatening abandonment will destroy child's trust in family
Removing PPC
Waist ties are fist untied
Gloves off
Neck ties untied
Gown fall forward, and folded away from body
Remove mask
GLYCOSOLATED HEMOGLOBIN
5% (UP TO 7% IN DIABETIC)
Crohn's disease
Chronic inflammatory disorder of the intestinal tract. Characteristics include deep ulcerations, fistula formation, narrow, thick bowels, lymphocytic infiltration. Often occurs in 20's 30's. Symptoms diarrhea, abdominal pain and discomfort, and weight loss ranging from 5-20 lbs. Potential for abdominal masses, perirectal , bladder, skin, vaginal fistulas. Hemorrhage is often associated.
Primigravidae
In the first pregnancy, the progress of labor is cervial effacement, followed by descent and dilation, normal progress of labor at 1 to 1.2 cm per hour for a primigravida.
yellow sclera is an early sign of
jaundice
One S/S of esophageal varices' bleeding:
distended abdomen
VITAL SIGNS OF ADULT

HR
80 - 100 BPM
Active immunity
Acquired immunity caused by the production of antibodies, either after infection or as a result of vaccination.
Tachycardia
A condition characterized by a regular but accelerated action of the heart, usually l00 to 150 beats per minute.
tachycardia, muffled heart sounds, JVD, falling BP, pulsus paradoxus,
Right sided HF
Hodgkin's disease
painless, firm, movable adenopathy in cervical/supraclavicular. presence of Reed-Sterberg cells, involved lymnh nodes, spleen, liver. weight loss
Monamine Oxidase Inhibitors: Adverse Effects of Phenelzine (Nardil)
Orthostatic hypotension, dizziness, HA, fatigue, tremors, weakness, dry mouth, weight gain, constipation
See red haze
Vitreous hemorrhage may be absorbed spontaneously
May require surgery if doesn't
See ophthalmologist
Stethoscope: Palpate abdomen
Used to decrease ticklishness and voluntary guarding that results
Warm stethoscope, when fingers drift over edge, can palpate without causing ticklishness
TRACTION
AN EXERTION OF A PULLING FORCE APPLIED BY TWO DIRECTIONS TO REDUCE AND IMMOBILIZE A FX
Signs of Opioid Withdrawal
* Nausea
* Vomiting
* Restlessness
* Abdominal Cramping
Hep A is infectious in what body outputs:
Feces
Saliva
Blood
Diagnosing TB
Bronchoscopy can help diagnose TB and obtain specimens while clearing the bronchial tree of secretions.
Esophageal atresia
A congenital anomaly involving closure of the esophagus at some point, often ending in a blind pouch.
before ABG by applying pressure to radial artery to determine adequate bl.flow
INH (Isoniazid)
anti-inflammatory for rheumatoid arthritis- decreases joint pain
First Fetal movement (Quickening) starts
Neuromuscular Blocking Agents: Effects of Atropine
Ataxia, coma, confusion, dizziness, HA, headache, insomnia, tachycardia, hypotension, pulmonary edema, delayed gastric emptying
Hip replacement: Flexion
Limited to 60 degrees for 6-7 days
Then limited to 90 degrees for 2-3 months
Instruct patient not to stand or sit for long periods
Do not cross leg beyond mid-line of body
Use assistive device to put on shoes and socks
Transmission based precautions
Related to nature of client's illness, not staff's
PET scan
The priority for patients care is to ensure that the patient will be comfortable and able to lie still through out the procedure, that may last as long as 2 hours.
The nurse researcher is gathering data about the types of rape. She is interviewing clients who were recently raped. A 65-year old woman describes her rapist is extremely violent. She states that the rapist continually screamed, &quot;this is what you get
c. anger rape
The nurse researcher is gathering data about the types of rape. She is interviewing clients who were recently raped. A 65-year old woman describes her rapist is extremely violent. She states that the rapist continually screamed, &quot;this is what you get
1. sadistic rape
2. confidence rape
3. anger rape
4. blitz rape
brudzinskis sign
clients hips and knees flex when lying supine with head lifted toward chest

indication of meningitis
Status asthmaticus
A severe and prolonged asthma attack in which bronchospasm fails to respond to oral medication, sometimes resulting in hypoxia, cyanosis, and unconsciousness.
Puerperal
1. Of or pertaining to the period from the end of childbirth until involution of the uterus is complete (usually 3 to 6 weeks). 2. Of or pertaining to a woman (puerpera) who has just given birth to an infant.
a leak or break in system...check all connectors and cuff.
Trochanter roll
Fluid Overload
Inc BP, pulse rate, pulse rate, neck vein distention, shifting of fluid into alveoli
An emergency room nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign, if noted in the client, would indicate the presence of pneumothorax?
Shortness of breath
Right sided heart failure
Caused by failure of right ventricle
Results in back up of circulation
Increased Cranial Pressure
Nursing care should be spaced out to minimize elevation of the ICP, patients are sensitive to sudden and or noxious stimuli such as toughing, jarring, loudness, and bright lights which can increase ICP.
Dietary considerations for pts with ascites
Low sodium 200-300 mmol NA
ABNORMALITIES IN THE OBSTETRIC CLIENT

VARIABLE DECELERATIONS
VARIABLE
CAN OCCUR ANY TIME DURING MONITORING OF THE FETUS AND ARE V SHAPED.

CAUSED BY CORD COMPRESSION

INTERVENTION FOR HYPOTENSION
S=STOP PITOCIN IF INFUSING
T=TURN CLIENT ON LEFT SIDE
O=OXYGEN ADMINISTRATION
P=PUSH IV FLUIDS
Delusions of grandeur
Distorted or false idea or belief that one has exceptional powers, wealth, skill, influence, or destiny.
when Ventriculoperitoneal Shunt broken/malfunction
fluid from ventricle of brain will divert to peritoneal cavitiy so cerebrospinal fluid build up in cranial area --> result Inc. ICP --> causes high-pitched cry in infant
Influenza vaccine: Given to
> 50 years of age
Clients with chronic conditions
Persons traveling to foreign countries
Coombs Test is used for:
used for blood typing
The direct test detects the presence of antibodies against RBCs that may be attached to a person's RBCs. Although healthy people can make these antibodies, in certain diseases (systemic lupus erythematosus, mononucleosis, lymphomas) these antibodies are directed against the client's own RBCs. The presence of these antibodies usually causes a hemolytic anemia.

The indirect Coombs' test detects the presence of circulating antiglobulins. The test is used to determine whether the client has serum antibodies to the type of RBCs that he or she is about to receive by blood transfusion.
Sensorineural hearing loss
Hearing loss caused by a defect or lesion of the inner ear or the acoustic nerve resulting in a distortion of sound that makes discrimination difficult.
Nursing Care of Newborn: Safety precautions
*main focus- monitor VS, keep baby warm
-baby's respirations may not stabilize for about 2hrs after birth, at this point its abnormal for respiratory rate to be greater than 60 breaths per min.
-leave kelly clamp on till after plastic umbilical cord clamp has been applied
-remove secretions from mouth& nose with gloved finger or sm. syringe
Attributes of a battered woman
Women feel they have failed as a mother, wife, or caregiver and accept abuse as a normal healthy relationship. Do not have close family relationships or friendships. Display low self esteem. Show lack of independence in decision making. Display fear related to confronting or upsetting the abuser. Battered women are often abusers themselves of their children.
what's fantasy play &amp; who does it?
imaginary playmates by preschoolers (3 - 5). like magic
Distended bladder--> most frequent cause. Also Constipation/fecal impaction.
*Always check foley make sure no kinks in tubing & to maintain regular bowel.
Rules on Autologous Blood Donations
Patient may only donate blood up to 5 weeks prior to the surgery.
A client has developed depression of the bone marrow from antineoplastic drugs. The nurse states the nursing diagnosis of highest priority as:
D. High risk for infection
A client has developed depression of the bone marrow from antineoplastic drugs. The nurse states the nursing diagnosis of highest priority as:
A. Fluid volume deficit
B. High risk for aspiration
C. Ineffective thermoregulation
D. High risk for infection
Onset 5 to 15 minAdverse Rxn Midmorning
Regular (Humulin R, Novolin R, Iletin II Regular)Short Acting
If someone has chronic lower back pain, what positions should they avoid?
any positions that place a strain on the lower back.
A client is placed on seizure precautions. The nurse knows that an appropriate intervention for a grand mal seizure is:
D. Place the head in a lateral position.
A client is placed on seizure precautions. The nurse knows that an appropriate intervention for a grand mal seizure is:
A. Insert a tongue blade between the teeth to prevent biting the tongue.
B. Apply restraints to prevent injury to the self.
C. Place the client in a supine position.
D. Place the head in a lateral position.
Spiderman S-Sepsis S-Scarlet Fever S-Streptococcal Pharyngitis P-Parvovirus B19 P-pneumonia P-Pertussis I- Influenza D- Diptheria (pharyngeal) E- epiglottitis R- Rubella M-Mumps M- Meningitis M-Mycoplasma or meningeal pneumonia AN- Adenoviru
Private room or cohort , mask, maintain 3 ft separated wit visitors, door may be open
During the evening following a partial gastrectormy, a client's oral temperature is 100F. Other data include a blood pressure of 134/68, a pulse of 88, and a respiratory rate of 18. The nurse should:
B. Take the temp every hour until it is normal.
During the evening following a partial gastrectormy, a client's oral temperature is 100F. Other data include a blood pressure of 134/68, a pulse of 88, and a respiratory rate of 18. The nurse should:
A. Notify the physician immediately
B. Take the temp every hour until it is normal.
C. Perform a thorough Respiratory assessment.
D. Remove the dressing and check the operative site.
A client admitted to the er for a broken leg confides to the nurse that her boyfriend pushed her down the stairs. The client asks the nurse, &quot;why would he bo so cruel to me?&quot; The nurse's best response would be:
c. men who abuse women are insecure and feel powerless
A client admitted to the er for a broken leg confides to the nurse that her boyfriend pushed her down the stairs. The client asks the nurse, &quot;why would he bo so cruel to me?&quot; The nurse's best response would be:
a. i guess you did something to provoke him and he overreacted.
b. i bet this is a family trend for you. were you battered as a child?
c. men who abuse women are insecure and feel powerless
d. was your boyfriend drinking? alcohol causes domestic violence.
RBC/FEMALES
4.2/5.4
SaO2
&gt;95%
Cardiac Assessment
Inspection
Palpation
Percussion
Auscultation
hypoparathyoid
hypocalcemia/ hyperphospatemia
neutrophils
56%; 1800-7800 cell/mm3
Pneumocystis carinii: Precautions
Standard
BLEEDING TIME
4-7 MIN
Sublingual
Under the tongue.
Kawasaki
give immune globulin
hydroxyzine (Vistaril)
Antianxiety, Antihistamines, Sedative/Hypnotics
Normal Glucose Level
70-110 mg
Purulent
Containing or forming pus.
fluid/electrolyte imbalance, constant monitoring of I/OLosses require replacement
Pancreatitis
MS: S/S
Numbness or tingling sensation
Decreased sensitivity to pain, facial pain
Decreased temperature perception
Trigeminal neuralgia: Medications
carbamazepine (Tegretol)
agonizing pain may result in severe depression and suicide
Meningitis
Symptoms include nuchal rigidity (stiff neck), and photophobia.
* Requires droplet precaution until diagnosis is confirmed.
common bile duct obstruction causes
jaundice
Opportunistic Infections
Opportunisitic infection associated with AIDS like PCP causes progressive hypoxemia and cyanosis.
Tetany
Hyperexcitability of nerves and muscles as a result of a lessened concentration of extracellular ionized calcium; symptoms include convulsions, muscle twitching and cramps, and sharp flexion of the wrist and ankle joints.
Polyneuritis
Degeneration of peripheral nerves primarily supplying the distal muscles of the extremities. It results in muscle weakness, with sensory loss and atrophy, and decreased or absent deep tendon reflexes.
Troponin
protein found in striated muscle.
hypovolemia (lab signs)
increased hemtocrit and hemoglobin
Peristalsis
Not controlled by motor nerve fibers
Intestinal obstruction not see in MS
Vaginal infection
Don't wear nylon pantyhose
Sanitary pads may be used to protect clothing and replace tampons
Cotton underwear helps create a clean healthy environment
Cardioversion: Used to treat
Atrial flutter
Atrial fibrillation
Supraventricular tachycardial synchronizes shock with R wave
GTPAL
Gr avidity, Term, Pre-term, Abortion, Live
common side effect of cushing's syndrome
depression
Lopressor - Beta blocker S/E:
laryngospam
bradycardia
cardiac arrest
CVP
Measures fluid volume.
Normal Value is 3 to 12
Tonic-clonic seizure
Paroxysmal, uncontrolled discharge of central nervous system neurons extending to the entire brain and characterized by stiffening (tonic phase) and then rapid synchronous muscle jerking and hyperventilation (clonic phase). Also called a major or grand ma
Hyperphosphatemia
Elevated serum level of phosphorus above 2.6 mEq/L or 4.5 mg/dl.
Hallucinations
Sensory perceptions that don't result from external stimuli and that occur during wakefulness.
Standard precautions
Infection control guidelines established by the Centers for Disease Control and Prevention requiring all health care personnel to use gloves, gowns, and goggles to prevent contact with a client's blood or body fluids and to adhere to strict safety measure
over 60 years 8 to 20
ABG's
Hypomagnesium EKG
tall T waves, depressed ST
DECREASED SODIUM
INCREASED POTASSIUM
WHAT ELECTROLYTE ABNORMALITIES WOULD THE NURSE EXPECT TO OCCUR WHILE WORKING WITH A PATIENT WITH PARTIAL AND FULL THICKNESS BURNS?
Myelogram: Position
Must remain flat for 12-14 hours
Inspect injection site
lithium carbonate (Eskalith): Early s/s of toxicity
Nausea and vomiting
Diarrhea
Thirst
Polyuria
Slurred speech
Muscle weakness
Regression
Return to earlier level of development and comfort measures associated with that level of functioning
Which of the following matches the definition: attributing of our own unwanted trait onto another person?
projection
Delirium tremens
A potentially fatal withdrawal from ethanol ( alcohol). Symptoms may begin within a few hours after cessation but may not peak until 48 to 72 hours. When ethanol is withdrawn a functional decrease is seen in the inhibitory neurotransmitter GABA. Seizures occur 6-48 hours after the last drink. Symptoms, tremors, irritability, nausea vomiting, hallucinations, confusion, sever agitation seizure.
Systemic Lupus Erythematous
Proteinuria and Hyperlipidemia are common signs and symptoms.
implication of high serum k+
life threatening arrhythmia
S/E of Dilaudid 15 mg IM:
photosensitivity, constipation
or
HypOtension, resp depression
HypOtension
respiratory depression
VITAL SIGNS OF ADULT

BP
110-120 (SYSTOLIC)
60-90 (DIASTOLIC)
110/60 - 120/90
Gastroenteritis
Inflammation of the lining of the stomach and intestines that accompanies numerous GI disorders; characterized by anorexia, weakness, abdominal pain, nausea, and diarrhea.
Autoimmune disorder
A disorder resulting from an inappropriate immune response that is directed against the self. Antigens normally found in the internal cells stimulate the development of antibodies; these antibodies can’t distinguish antigens of the internal cells from ext
Abuse
1. Behavior toward another that is offensive, harmful, or injurious. 2. Misuse or particularly excessive use of a substance, service, or equipment; commonly refers to improper use of a drug or similar substance.
Clubfoot
A congenital foot deformity in which the foot is twisted out of shape or position.
(S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) --> turn pt to left side and lower the head of the bed.
After Lumbar puncture
Tracheoesophagea fistula
3 C's - coughing, choking, cyanosis
causes of respiratory acidosis
asthma, atelectasis, brain trauma, bronchiectasis, bronchitis, CNS depression, emphysema, hypoventilation, medications, pneumonia, pulmonary edema, respiratory failure or depression........ the pH is less than 7.35 and the partial pressure of CO2 (PCO2) is greater than 45 mm Hg
Chemotherapy Agents: Interactions with Tamoxifen (Nolvadex)
Fluoxetine=Don't use warfarin, halperidol, benadryl, bupropion, sertaline, carbamazepine
Genital herpes
Cluster of painful blisters on genital area
May have difficulty voiding
Recurrence during times of stress, infection, menses
SYNTHARTHROSIS
FIBROUS JOINTS ARE THOSE THAT ARE NOT MOVEABLE...AKA..
Epiglottitis
Never insert a tongue blade into the mouth of a child diagnosed with epiglottis, gag reflex can cause complete obstruction of the airway.
hemolytic reaction to blood transfusion
HOTN
backache
low back pain
fever
Pulmonary Artery Pressure
the pulmonary capillary wedge pressure is the reflection of the pressure in the left ventricle at rest, which is end diastole.
Febrile seizure
Typically, a tonic-clonic seizure of relatively short duration (usually less than 1 minute) occurring with an acute illness and fever.
Cardiac catheterization
A diagnostic procedure in which a cardiac catheter is inserted into a large vein (usually of an arm or leg) and then threaded through the vein to the client's heart.
Rh incompatibility
In hematology: two blood groups that are antigenically different and, therefore, aren't compatible because one group lacks the Rh factor.
on bedrest while implant in place
Autonomic Dysreflexia/Hyperreflexia (S&S: pounding Ha, profuse sweating, nasal congestion, goose flesh, bradycardia, HTN)
applies sterile gauze over site & calls physician
Leflunomide (Arava)
Oral Hpoglycemics: reinforcing teaching for a client taking Glyburide
monitor when taking aspirin, IBU, tums, & cinnamon
*watch for heartburn, hypoglycemia, nausea, contraindicated for clients with sulfa allergy, type I diabetes, DKA
May be seen during entire labor
Flushed and diaphoretic
Contractions are more frequent
Fluid Volume Deficit: S/S
Increased pulse rate with thready quality
Decreased BP
Fever
Increases rate and depth of respirations
Complications with TPN
The high glucose concentration in TPN places the client at risk for hyperglycemia. Signs include excessive thirst, fatigue, restlessness, Kaussmaul's Respirations, and Diuresis.
frank (bright red) blood in stools indicate/s
lower GI bleed
Autonomic nervous system controls....
automatic body functions such as breathing and heartbeat......
Stroke
A condition of sudden onset in which a cerebral blood vessel is occluded by an embolus or cerebrovascular hemorrhage. The resulting ischemia of brain tissue that is normally perfused by the affected vessel may lead to permanent neurologic damage.
bilirubin levels are greater than 13-15 mg/dl
PVD - arterial- appearance
hematocrit
adult male = 42% -52% ; adult female = 35%-47%
A nurse is caring for a client with emphysema who is recieving oxygen. The nurse checks the oxygen flow rate to ensure that it does not exceed:
2 L/minute
Gastric Ulcer: S/S
45 years or older
Pain 1 hour after meals or when fasting
Pain relieved by vomiting,
Food doesn't help with pain
Hematemesis
"Which came first, pain or n/v?"
Pain = Appendicitis
N/V = Gastroenteritis
Rules with Chest Tube
Bubbling in the water seal chamber indicated an air leaking in the chest tube.
decelerations: early vs late
Early are normal; occurs in response to compression of fetal head; does not indicate fetal distress
WHAT IS THE TREATMENT FOR HYPOTENSION AFTER AN EPIDURAL ANESTHETIC?
STOP

S=STOP PITOCIN IF INFUSING
T=TURN CLIENT ON LEFT SIDE
O=OXYGEN ADMINISTRATION
P=PUSH IV FLUIDS
Cardiogenic shock
A condition of low cardiac output that results from heart pump failure, such as in acute myocardial infarction, heart failure, or severe cardiomyopathy.
Jaundice- in skin/mucous membranes
light skinned--> first seen in sclera of the eyes, later in skin
Central Venous Catheter: Insertion
Turn head to left
Skin needs to be free of hair, shave night before to allow healing of minor skin irritations
Place in Trendelenburg position to dilate veins
Breathing: Should not deep breathe
Indicators of Disseminated Intravascular Coagulation (DIC)
there is blood at a venipuncture site and around or on IV catheter.
Cardiac glycosides (digoxin)
Don't use in what heart dysrhythmias?
V-Tach, V-Fib, 2nd &amp; 3rd heart block
Evaporation
The change of a liquid to a vapor at a temperature below the boiling point of the liquid. Evaporation occurs at the surface of the liquid, hastened by an increase in temperature and a decrease in atmospheric pressure.
Cataracts: Postoperative discharge teaching
*wear eye shield at all times for at least 1-2 weeks
*wash eyelid with cotton pad and warm water, sleep on unoperative side
*do not put head below waist 2-3 days, do not get constipated
* some mucos and tears is normal, some irritation and scratchyness is normal
Peripheral Intravenous: Sites to Aviod
* Edematous extremity
* An Arm that is weak, traumatized or paralyzed.
* The arm on the same side as a mastectomy
* An arm that has an arteriovenous fistula or shunt for dialysis.
what is Colles' fracture
fx of distal radius usu r/t fall on outstretched hand
Bloody or clear drainage from nasal or auditory canal after trauma indicate
cerebrospinal fluid leak--> notify MD
What is a major side effect of PTU?
agranulocytosis resulting in fever and sore throat
2. You are responsible for reviewing the nursing unit's refrigerator. If you found the following drug in the refrigerator it should be removed from the refrigerator's contents?
A. Corgard B. Humulin (injection) C. Urokinase D. Epogen (injection)
What should a health care provider do to encourage pain managment in filipinos?
offer pain meds and encourage it because they see pain as a part of living an honorable life.
Why both Coumadin & Heparin administer together
b/c Coumadin workds in the liver & inhibit synthesis of 4 vitamin K depedent clotting factors, but it takes 34 days before therapeutic effect
The nurse needs to obtain a clean catch urine specimen from a client who presented to this women's health clinic with symptoms of gonorrhea. What instructions will the nurse give?
a. place a cotton ball into your vagina prior to obtaining the urine specimen
The nurse needs to obtain a clean catch urine specimen from a client who presented to this women's health clinic with symptoms of gonorrhea. What instructions will the nurse give?
a. place a cotton ball into your vagina prior to obtaining the urine specimen.
b. obtain the 1st stream of urine as the specimen
c. you will have to drink one pint of fluid prior to collection of the specimen
d. the catheter will be removed as soon as I gather the specimen
Following a health class on birth control methods, the nurse knows that more teaching is needed when the 16 year old male student states:
a. if I have sex several times in one night, the quantity of my sperm decreases and I'm less likely to get a girl pregnant
Following a health class on birth control methods, the nurse knows that more teaching is needed when the 16 year old male student states:
a. if I have sex several times in one night, the quantity of my sperm decreases and I'm less likely to get a girl pregnant.
b. The fluid prior to ejactulation may contain some sperm and this could cause a pregnancy.
c. withdrawing prior to ejactulation might not be easy to do.
d. I could still catch a sexually transmitted infection from a girl even if I don't get her pregnant.
/ 604
Term:
Definition:
Definition:

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