Download CDC Guidelines for Isolation Precautions in Hospitals Minnesota

CDC Guidelines for Isolation Precautions in Hospitals
Minnesota Dept. of Health
Yale New Haven Hospital Infection Control Manual
Use Airborne Precautions for patients known or suspected to have serious illnesses transmitted by
airborne droplet nuclei. These include:





Measles (rubeola)
Varicella (chicken pox) – requires Contact Prec. as well
Herpes Zoster (shingles), disseminated – requires contact prec. as well
TB
Severe Acute Repiratory Syndrome (SARS)
Airborne Precautions include personal respiratory protection and special ventilation and air
handling. Airborne transmission occurs through either: airborne droplet nuclei (small particles, 5
micrograms or smaller, of evaporated droplets containing microorganisms that remain suspended in
the air for long periods of time) or dust particles that contain an infectious agent.
Microorganisms carried by the airborne route can be widely dispersed by air currents and may
become inhaled by a susceptible host in the same room or over a long distance form the source
patient – depending on environmental factors such as temperature and ventilation.
Airborne precautions include Standard Precautions plus personal respiratory protection (N95
respirator) or powered air-purifying respirator (PAPR) and airborne infection isolation room (AIIR).
These rooms must, at a minimum, provide negative pressure with a minimum of 6 air exchanges per
hour, and exhaust directly to the outside or through HEPA filtration.
Droplet Precautions: droplets can be transmitted during coughing, sneezing, talking, and during certain
procedures such as suctioning or bronchoscopy. Droplets generally travel no further than 3 feet from
patient. Droplet precautions include Standard Precautions plus surgical mask worn when working within
3 feet of the patient.
In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to
have serious illnesses transmitted by large particle droplets. These include:


Invasive Haemophilus influenza (H.influenza), type b disease, including meningitis, pneumonia,
epiglottitis, and sepsis
Invasive Neisseria meningitides disease, including meningitis, pneumonia, and sepsis
Other serious bacterial respiratory infections spread by droplet transmission, including:





Diptheria (pharyngeal)
Mycoplasma pneumonia
Pertussis
Pneumonic plague
Strep (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children
Serious viral infections spread by droplet transmission, including:





Adenovirus
Influenza
Mumps
Parvovirus B19
Rubella (German Measles)
Contact Precautions
In addition to Standard Precautions, use Contact Precautions for patients known or suspected to
have serious illnesses easily transmitted by direct patient contact or by contact with items in the
patient's environment. Examples of such illnesses include:






Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant
bacteria judged by the infection control program, based on current state, regional, or national
recommendations, to be of special clinical and epidemiologic significance
Enteric infections with a low infectious dose or prolonged environmental survival, including:
o Clostridium difficile
o For diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7,
Shigella, hepatitis A, or rotavirus
Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young
children
Skin infections that are highly contagious or that may occur on dry skin, including:
o Diphtheria (cutaneous)
o Herpes simplex virus (neonatal or mucocutaneous)
o Impetigo
o Major (noncontained) abscesses, cellulitis, or decubiti
o Pediculosis
o Scabies
o Staphylococcal furunculosis in infants and young children
o Zoster (disseminated or in the immunocompromised host)†
Viral/hemorrhagic conjunctivitis
Viral hemorrhagic infections (Ebola, Lassa, or Marburg)
Measles (rubeola) requires Standard Precautions and Airborne Precautions. *No mask required if
immune to measles. *Note: All healthcare workers should have received 2 doses of the measles vaccine
if born after 1957. If born prior to 1957, one is considered immune. Limit transport of patient; if
transporting is necessary, place N-95 mask on patient. Private-Negative Pressure Room Required.
Duration of Precautions: Duration of illness
German Measles (Rubella) requires Standard Precautions and Droplet Precautions. Duration of
Precautions: Until 7 days after onset of rash
Group A and Group B Strep, invasive: requires Standard precautions.
Extrapulmonary Tuberculosis (draining lesion, including scrofula) requires Standard Precautions.
Tuberculous Meningitis requires Standard Precautions.
Note: Patient should be evaluated for evidence of concurrent (active) pulmonary tuberculosis. If
evidence exists for active pulmonary tuberculosis Airborne Precautions are required.
Pulmonary Tuberculosis, confirmed or suspected (including laryngeal disease) requires Standard
Precautions and Airborne Precautions. Wear N-95/ HEPA respirator prior to entering patient's room.
Limit transport of patient; if transporting is necessary, place N-95 mask on patient. Private-Negative
Pressure Room Required. Duration of Precautions: Duration of illness
Chickenpox (Primary Varicella zoster infection) requires Standard precautions, Airborne Precautions
and Contact Precautions. Negative pressure room required. *No mask required if immune to Varicella.
Limit transport of patient; if transporting is necessary, place a N-95 mask on patient; all staff who have
contact with patient during transport must be immune. Contact Precautions: Don and remove gown and
gloves upon entering and exiting pt’s room. Dedicate non-critical pt care equipment. Duration of
Precautions: Maintain precautions until all lesions are crusted. The average incubation period for
varicella is 10 to 16 days, with a range of 10 to 21 days. Place exposed susceptible patients on Airborne
Precautions beginning on the 10th day after exposure and continuing until 21 days after last exposure
(up to 28 days if VZIG has been given).
Anthrax – Cutaneous and Anthrax-Inhalational requires Standard Precautions. Anthrax may
be a disease indicating possible bioterrorism.
Clostridium difficile colitis requires Standard Precautions and Contact Precautions.
Bronchiolitis (infants and young children) requires Standard Precautions and Contact Precautions.
Candidiasis: Standard Precautions
Chlamydia, all types: Standard Precautions
Gastroenteritis, including cholera, e.coli, rotavirus, giardia, etc: requires Standard Precautions *but
requires the use of Contact Precautions for diapered or incontinent patients including children under 6
years of age.
CMV (cytomegalovirus) : Standard Precautions
Croup requires Standard Precautions and Contact Precautions.
Decubitis ulcer - major requires Standard Precautions and Contact Precautions. A major decubitus ulcer
is one that is not contained by a dressing. Duration of Precautions: Until wound heals over and stops
draining. Minor requires Standard Precautions only.
Diptheria – Cutaneous and Diptheria -- Pharyngeal: Standard and Contact. Duration of Precautions:
Until off all antibiotics and until two cultures obtained 24 hours apart are negative.
Arthropod-borne Viral Encephalitis requires Standard Precautions. Examples: West Nile
Encephalitis, Eastern Equine Encephalitis, Western Equine Encephalitis, St. Louis Encephalitis,
California (LaCrosse) Encephalitis
Invasive Hemophilus influenzae disease: ie: H. influenza meningitis, H. influenza epiglottitis: Standard
and Droplet precautions. Duration of Precautions: until 24 hours of effective antimicrobial therapy has
been given.
Epstein-Barr Virus, including mononucleosis: Standard precautions
Fifth’s Disease: Standard and Droplet, *but in an immunocompetent (normal) patient with acute
disease, it is not communicable after onset of rash; thus, Droplet Precautions are not then necessary.
Duration of precautions for others: For an immunocompromised patient with chronic disease--duration
of hospitalization. aplastic crisis or red cell aplasia (e.g. sick cell patients) --maintain Droplet
Precautions for 7 days
Leprosy (Hansen’s Disease): standard precautions.
Hepatitis A, B, C, D, E: standard precautions, except for diapered/incontinent patients and type A.
Impetigo: standard and contact. Duration of precautions: until 24 hours after initiation of effective
therapy.
Kawasaki Syndrome: standard precautions
Legionnaire’s Disease: standard precautions
Meningococcal meningitis (due to Neisseria meningitides): standard and droplet precautions.
Pneumococcal meningitis: standard precautions
Mumps: standard and droplet. Duration of precautions: for 9 days after onset of swelling.
Norwalk viral gastroenteritis: standard precautions *but requires the use of Contact Precautions for
diapered or incontinent patients including children under 6 years of age. Duration of precautions is
duration of illness.
Respiratory Syncytial Virus (RSV): standard and contact precautions. Can be roomed with other RSV pts
as long as there are no other significant organisms present (ie MRSA, VRE, etc)
Smallpox: standard, airborne, and contact precautions. Smallpox is a public health emergency and may
be a disease indicating possible bioterrorism. Linen: All laundry should be placed in biohazard bags and
autoclaved before laundering. Patient transport requires approval of Hospital Epidemiologist or
designee. Duration of Isolation: To be determined by Hospital Epidemiology.
Smallpox vaccination requires Standard Precautions, Airborne Precautions and Contact Precautions if an
individual presents with an acute medical complaint and the scab has not separated from the
inoculation site (usually occurs by day 14-21 post-vaccination).
Typhoid Fever, including Salmonellosis—all salmonella species: standard *but requires the use of
Contact Precautions for diapered or incontinent patients including children under 6 years of age for
duration of illness.
Whooping Cough is Pertussis; requires standard and droplet precautions. Maintain precautions until 5
days after patient is placed on effective therapy.
Re: Anyoone up for random FACT THROWING??
ELECTROLYTES
1. Na- Hypo (Below 135)
Symptom: irritability, apprehension, confusion, postural hypotension, tachycardia, tremors, seizures,
coma
Intervention/Tx: Administer IV saline sol, restrict water intake
Na- Hyper (Above 145)
symptom: thirst, dry mucous mem, restlessness, agitation, postural hypotension, switching, seizures
Intervention/Tx: Administer oral fluids or dextrose 5%, restrict oral sodium intake
2. K- Hypo (Below 3.5)
symptom: thirst, dry mucous mem, restlessness, agitation, postural hypotension, switching, seizures
Intervention/Tx: Administer K
K- Hyper (5.1)
symptom: irritability, anxiety, paresthesias, weaknessof lower extrem, diarrhea, adbominal cramps
Intervention/Tx: eliminate oral and parentheral K intake, administer K wasting diuretics
3. Ca- Hypo (Below 8.6)
symptom: numbness and tingling of fingers and circumoral region, hyperreflexia, muscle cramps,
seizures
Intervention/Tx: Administer ca salts, calcium gluconate, diet high in ca and vit d
Ca- Hyper (10)
symptom: lethargy, weakness, depressed reflexes, anorexia, nausea, vomiting, back pain
Intervention/Tx: prevent with wt bearing exercise, hydration, calcitonin prevents bone resorption
4. Mg- Hypo (Below 1.6)
symptom: muscle tremors. hyperactive deep tensdon reflexes, confusion, seizures, cardiac
dysrhythmias
Intervention/Tx: Administer Mg PO or IV
Mg- Hyper (2.6)
symptom: muscle tremors, hypoactive deep tendon reflexes, decreased rate and depth of respirations,
cardiac arrest
Intervention/Tx: administer, calcium chloride, calcium gluconate to oppose effects on cardiac muscle,
increase fluids
5. PO4- Hypo (Below 2.7)
symptom: confusion, coma, rhadbomyolosis, muscle weakness
Intervention/Tx: oral supplement, diet- high in phosphorous,
PO4- Hyper (4.5)
symptom: muscle problems, tetany, calcium-phosphate precipitates in skin, soft tissue, cornea, blood
vessels
Intervention/Tx: identify and treat underlying cause diet- restrict foods and fluids high in
phosphorous, adequate hydration, phosphate-binding agents
Re: Anyoone up for random FACT THROWING??
ELECTROLYTES
1. Na- Hypo (Below 135)
Symptom: irritability, apprehension, confusion, postural hypotension, tachycardia, tremors, seizures,
coma
Intervention/Tx: Administer IV saline sol, restrict water intake
Na- Hyper (Above 145)
symptom: thirst, dry mucous mem, restlessness, agitation, postural hypotension, switching, seizures
Intervention/Tx: Administer oral fluids or dextrose 5%, restrict oral sodium intake
2. K- Hypo (Below 3.5)
symptom: thirst, dry mucous mem, restlessness, agitation, postural hypotension, switching, seizures
Intervention/Tx: Administer K
K- Hyper (5.1)
symptom: irritability, anxiety, paresthesias, weaknessof lower extrem, diarrhea, adbominal cramps
Intervention/Tx: eliminate oral and parentheral K intake, administer K wasting diuretics
3. Ca- Hypo (Below 8.6)
symptom: numbness and tingling of fingers and circumoral region, hyperreflexia, muscle cramps,
seizures
Intervention/Tx: Administer ca salts, calcium gluconate, diet high in ca and vit d
Ca- Hyper (10)
symptom: lethargy, weakness, depressed reflexes, anorexia, nausea, vomiting, back pain
Intervention/Tx: prevent with wt bearing exercise, hydration, calcitonin prevents bone resorption
4. Mg- Hypo (Below 1.6)
symptom: muscle tremors. hyperactive deep tensdon reflexes, confusion, seizures, cardiac
dysrhythmias
Intervention/Tx: Administer Mg PO or IV
Mg- Hyper (2.6)
symptom: muscle tremors, hypoactive deep tendon reflexes, decreased rate and depth of respirations,
cardiac arrest
Intervention/Tx: administer, calcium chloride, calcium gluconate to oppose effects on cardiac muscle,
increase fluids
5. PO4- Hypo (Below 2.7)
symptom: confusion, coma, rhadbomyolosis, muscle weakness
Intervention/Tx: oral supplement, diet- high in phosphorous,
PO4- Hyper (4.5)
symptom: muscle problems, tetany, calcium-phosphate precipitates in skin, soft tissue, cornea, blood
vessels
Intervention/Tx: identify and treat underlying cause diet- restrict foods and fluids high in
phosphorous, adequate hydration, phosphate-binding agents
6 Readers Gave Kudos
CocoKat jadu1106 JoanieDee, LPN Melinurse nezz621 SWEETDREAMERINSOCAL
6 Readers Gave Kudos
CocoKat jadu1106 JoanieDee, LPN Melinurse nezz621 SWEETDREAMERINSOCAL
Report
BURNS
1st degree burn (superficial partial thickness)
-superficial tissue damage involving epidermis only
-local pain and erythema, blisters are absent for about 24 hrs
-mild to no systemic reponse
-quick healing (3-5 days) without scarring
2nd degree (deep partial thickness)
-tissue damage involving the epidermis and part of the dermis
-skin appearing red to pale and moist
-formation of wet blisters immediatelt after injury is sustained
-intact pain sensory
-healing takes 3-4 weeks with some scarring
3rd degree (full thickness)
-tissue damage involving the epidermis and entire dermis, extending into SQ tissue
-injury appears white, red, sometimes black
-dry, hard leathery appearance due to loss of elasticity
-edema, decreased elasticity
-painless to touch due to destruction of superficial nerve endings in skin
-require skin grafting
Remember for the Rule of Nines: head area and trunk area of an infant is greater in percentage than that
of an adult
My Advice:
1) Don't be your own worst enemy, don't second guess yourself. Think through the questions but
don't second guess yourself. Don't let the difficulty of the question throw you off ! Do your best, reread the question if you're having some difficulty narrowing down, select a choice, click next and start
a new question and a fresh slate.
2) When studying, focus on the less known, less obvious signs and symptoms. For example, we all
know about the pendulous abdomen, striae, moon face, hump back, etc associated with Cushing's but
what about hyperuricemia? polycythemia? psychosis?
3) Content is great but you gotta gotta know your infection control guidelines and what diseases
require what precaution. KNOW the diseases that require standard precautions well. I really would
advise checking out the "Laharti: Priority, Delegation, Assignments" book. It really does something for
your confidence level when, during the exam, you can say to yourself, "Hey, these questions are just
like the ones I saw in that book!"
4) Know EXPECTED outcomes vs UNEXPECTED outcomes. For example, if a pt with ulcerative colitis
has bloody diarrhea, you're not gonna FREAK OUT, cuz it's expected. Now if the pt had s/s of a
COMPLICATION of Ulcerative colitis (s/s of bowel perf, etc) THEN you'd freak out and assign them a
higher priority. So when studying my advice would be to know what is expected, what the
complications are and what the signs and symptoms of the complications are.
Hi, LanePN,
I saw your response to my post about studying. I recently passed my NCLEX-PN and plan in the future
to continue for my RN. I see you are studying for your NCLEX-PN now. After you pass your PN boards
if you want to study RN material together you can PM me.
Best of luck on your NCLEX-PN. Not everyone gets the same NCLEX questions but yes I did have many
disease process, Delegation, Prioritization and Infection Control (which patient to put in which room,
near the nurses station or in the room with another patient or not etc.)
I was too late to receive all of Suzanne's plan but I did study using Saunder's and Suzanne's first tip.
As well as Memory Notebook of Nursing's color pictures and Pneumonics. Suzanne's plan was designed
for 2 months of study. I see you want to take your NCLEX in 3 weeks.
Do lots of NCLEX practice questions and read the rationales for any you get wrong or need more
understanding for. If you know what body systems or disease processes you are weak and strong in,
then begin by doing questions and study in your weak areas, then if you run out of time for studying
your strong areas you will probably be OK for those anyway. Also as you answer NCLEX questions
keep a list of Test Taking Strategies beside you and practice using those strategies until you just start
thinking through the questions that way.
Saunders NCLEX Test Taking Strategies as Questions
Say to yourself
DID I.....
Avoid reading into the question?
Look for key words?
Determine the issue of the question?
Look for a true or false response question?
Look for key words that indicate the need to ptioritize?
Use the ABC's?
Use Maslow's
Use the Nursing Process?
Look for key words that indicate I need to do an assessment?
or if it is an emergency do I need to do an intervention?
Is this an analysis question?
Planning, Implementation, Evaluation
Use therapeutic communication techniques to answer this question?
Eliminate Similar Options?
Eliminate options that Contain Absolute Words?
Look for the Umbrella Option?
Use the guidelines for DELEGATING?
Determine the class of drug by the end of it's name?
Use medical terminology to break down words?
Test Item Check List
Use this handy list to check yourself
every time you answer a question.
Say to yourself
DID I CAREFULLY...
Read the Stem?
Read all of the Options?
Read the stem again?
Look for Key Words?
Eliminate obviously incorrect answers?
During peritoneal dialysis- client suddenly begins to breathe more rapidly, what do you do? Elevate
the HOB! Will decrease the pressure fo the dialysate on the diaphragm and increase the vital capacity
of the lungs, draining the cavity will further decrease the pressure.
Normal platelet = 150,000- 400,000. Decreased platelet= increase risk for bleeding. No IM injections,
use sm. gauge needle to prevent trauma, apply firm pressure to needlestick site for 10 min, soft
bristled toothbrush , do not floss, and no hard fards
Femoral to popliteal bypass graft= report if client becomes clammy. Hypovolemic shock is caused by
an inadequate volume of blood caused by hemorrhage, severe dehyradtion, or burns. skin will be cold
and clammy b/c the body redirects blood from the skin, kidneys, and GI tract to the brain and heart.
Urine output and B/P decreases and pulse increase
Pre-op teaching of extracapsular cataract removal -post-op- activites and restrictions needs to be
taught. Protect eye from ICP that will cause the suture line to rupture. To bend at the knees, avoid
sneezing, coughing, blowing nose, not to strain during a BM, to avoid vomiting, and do not lie down in
an dependent position
Hepatic encaphalopathy occurs with profound liver disease and results from the accumulation of
ammonia in the blood. Low protein and high calorie diet.
mother receiving DES is at risk for development of vag. cancer
cervical cancer risk factor= sex at early age
WHIPPLE PROCEDURE- for pancreatic cancer= removal of head of pancreas, distal portion of common
bile duct, the duodenum, and part of the stomach for tx of cancer. NG tube is connected to
intermittent low suction, assess tub for kinking. Postion client in semi-fowlers. Drainage should be
serosanguineous- pinkish
Post-op radical neck dissectino, detect the presence of stirdor, most probable cause is laryngeal
obstruction! Is identified upon auscultation of the trachea with a stethoscope. A coarse- high pitched
sound can be heard on inspiration d/t edema of the larynx.
Re: Anyoone up for random FACT THROWING??
PRAYERS BEFORE YOU TAKE THE EXAM
Dear God,
Today I will have my examinations. You know how important they are to me. So I am humbly asking
Your gracious help and divine assitance. I pray to you, my dear God, please neve rlet me be at ease
and give my very best. Please never let me guess nor rely on pure luck, but enlighten my mind and let
me think clearly. Please never let me resort to chances nor to dishonesty, but let me work to the
fullest of my ability. I pray for Your guidance that i as i think, I may find the right solutions, I may be
able to correctly answer the questions, I may solve those difficult problems. I ask, O God, Your
intercession, that as I write, I may not be careless nor overconfident, I may not be distracted but be
more concentrated, I may not be in a hurry nor take the exams too lightly. Today, O my Lord, I will
take my examinations Let me, with Your help, give my best effort. Let me, because of You, receive the
best and fruitful results. This I pray in Jesus name. Amen.
My tips:
Stages of Dying:
DABDA
Denial
Anger
Bargaining
Depression
Acceptance
Normal growth and development
Most People Can Get Stuff
BIRTH to 1 year- Mobiles
1-3 years- Push and pull toys
3-5 years - Coloring
6-12 years- Board Games
12-19 years- own Stuff
Diabetic KetoAcidosis (DKA): (5-10% mortality)
– Almost exclusively in Type 1 diabetics
– S/S: Polyuria, dehydration, ab pain, fruity breath, AMS, ↓ Na/Mg/Phos, ↑K (↓ total body), +
following:
• Hyperglycemia (>250)
• Metabolic acidosis (pH <7.3,> 20)
• Ketonuria/Ketonemia
– TX:
• IV insulin bolus (0.1 unit/kg) then IV infusion with same amount per hr AFTER making sure pt is
not ↓ K
– Continue until acidosis corrects then taper
• NS immediately upon diagnosis
– Switch to D5NS when glucose < 250
• Why in the world would I give D5NS when a patient still has high glucose levels? The most important
problem is the acidosis that is occurring. To reverse this we give insulin to drive glucose into the cell.
Remember that K rushes into the cell along with the glucose, and wherever K can go, H+ can go.
Since high levels of H+ in the blood is the cause of the acidosis, we give insulin to drive this H+
intercellularly, thereby reversing acidosis. We can't give insulin if the level of glucose is too low, so we
give D5NS to keep levels around 250 so we can give insulin until the acidosis is gone.
• Add KCl to IV fluids once K < 5; replenish other electrolytes as necessary; Even though K usually
appears high, it most often is total body low and when you give glucose, the K is driven into the cell,
and hypokalemia can develop rapidly.
Hyperosmolar Hyperglycemic nonketotic syndrome (HHNS):
– Severe ↑ Glucose, almost exclusively in Type 2 diabetics
– Similar to DKA but usually have much higher glucose (>600) and NO acidosis or
ketonuria/ketonemia
– Treat with fluids and low dose Insulin infusion
– An important distinction is that DKA usually occurs in Type 1 Diabetics, while HHNS most often
occurs in Type 2 Diabetics. Remember this as it is a common question in the NCLEX world.
Hypoglycemia:
– Patho: When glucose drops to 80 = insulin levels ↓ ; 70 = Glucagon ↑; 50 = epinephrine ↑ along with
s/s such as sweaty, ↑BP, ↑HR, tremors; Also around 50 CNS s/s (drowsy, h/a, confused) begin
– Note: S/S from epinephrine release are absent if pt is on a BB
– TX: If pt is alcoholic give Thiamine before any other treatment to prevent encephalopathy
• Can eat = ↑ sugar food;
• Can Not eat = ½ - 2 amps D50 IV push; (Glucagon alternative option if no IV access is available,
however is of no use in prolonged hypoglycemia because stores of glycogen are depleted)
Points to remember:
– For high sugar (DKA, HHNS) most of the signs and symptoms are from polyuria, so look for
dehydration and electrolyte imbalances...remember High and Dry
– For low sugar most of the signs and symptoms are from the release of epinephrine, so look for
things that would happen when someone was high on adrenaline, such as hypertension, sweating,
tachycardia and tremors.
– Imperative that you can recognize the difference between these two, as you are almost guaranteed
to see a question relating to this difference!
Re: Anyoone up for random FACT THROWING??
PULMONARY EDEMA:TX "MAD DOG"
Morphine
Aminophylline
Digitalis
Diuretics
Oxygen
Gases in blood(ABG'S)
drugs to treat viral respiratory infections
"you'd get a respiratory infection if you shoot an ARO (arrow)
laced with viruses into the lungs
ARO
Re: Anyoone up for random FACT THROWING??
d1206,thanks for the correction
back to facts:
Pnuemothorax symptoms
P-THORAX
Pleuritic pain
Trachea deviation
Hyper resonance
Onset sudden
Reduced breath sounds(dyspnea)
Absent Fremitus
X-ray shows collapse
Hi everyone my simple "PHARMA" facts for today from COMMERCIALS:
1)Sumatriptan (IMITREX)---an NSAID for MIGRAINE
2)Alleve---for muscle pain
3)Advair---COPD, bronchitis, emphysema
4)Lipitor--- to decrease BP, and for CAD
5)Mucinex--- expectorant, can last for 12 hours
6)Zopidem (AMBIEN)---anti-insomnia, taken at bedtime with full glass of water in an empty
stomach (seen this at Saunders Q & A too)
7) Enbrel---for Rheumatoid Arthitis SE: immunosuppression, fever and bruising
Oh and GLUCERNA diet for people with DM.. So far those are the drugs that Ive seen on TV ads. and
1 came up on Saunders Q &A the ambienCR.
ABCDE mnemonic --CAUSE of secondary hypertension
A: Accuracy, Apnea, Aldosteronism
B: Bruits, Bad Kidney
C: Catecholamines, Coarctation of the Aorta, Cushing's Syndrome
D: Drugs, Diet
E: Erythropoietin, Endocrine Disorders
MASLOW'S HIERARCHY examples and
contraindications
by vadee
Updated Oct 08, 2008 at 04:18 PM by vadee
Registered User
Received 162 Kudos from 39 posts
Join Date: Oct 2008
Posts: 70
As we all know, Maslow's hierarchy is important to know and understand. Yet there are examples
where Maslow's hierarchy is contraindicated. With that being said, here is to refresh your memory
on Maslow's hierarchy. PLEASE HELP GIVE EXAMPLES.
--------------------------------------------------------------------------------IMAGINE that this is the pyramid:
1st (most) important (located at the bottom of the pyramid): BASIC PHYISIOLOGICAL NEEDS:
airway, respiratory effort, heart rate, rhythm, and strength of contraction, nutrition, elimination
2nd most important (located above physiological on the pyramid): SAFETY AND SECURITY:
protection from injury, promote feeling of security, trust in nurse-client relationship
PSYCHOSOCIAL NEEDS
3rd most important: LOVE and BELONGING: maintain support systems, protect from isolation, fear
4th: SELF ESTEEM: control, competence, positive regard, acceptance/worthiness
5th (top of the pyramid): SELF ACTUALIZATION: hope, spiritual well-being, enhanced growth.
----------------------------------------------------------------example of when it is contraindicated:
-a dehydrated and extremely suicidal client: safety comes before hydration
-----------------------------------------------------------example of when physiological is more important than safety
-cataract client: disturbed sensory perception (visual) is more important than risk of injury related to
decreased vision
)In myocardial infarction...MORPHINE first BEFORE OXYGEN...
2) In sickle cell crisis...TREAT HYDRATION FIRST BEFORE OXYGEN
in nclex,common sense is a key factor. you always think for the safety of the patient.I choose the
extremely suicidal.For the other one,it only says "dehydrated". Offer some fluids.hehe
apology..i meant to say this CLIENT was dehydrated plus suicidal....you would want to provide safety
first before hydration. i reread my posting and realized that I made it sound like there were two clients
involved rather than one.
thanks and lets keep them coming. =)
cataract client: disturbed sensory perception (visual) is more important than risk of injury
related to decreased vision
hhmmm physiologic need IS more important than safety/security.
that being said, i believe if you can't see, (physiologic) then it'll probably lead you busting your butt
along the way (safety/security)
phyisiologic needs always come before safety, except in psy. When you think about these needs, you
need O2, water, food. Also, think about ABC's then safety
example of when oxygen is not administered first....
a client receiving parenteral nutrition with suspected air embolism.
1. First CLAMP the intravenous catheter (prevents the embolism from going through the heart to the
pulmonary system).
2. Position the client to a LEFT trendelenburg position with the HOB lower (this will trap the air in the
right side of the heart)
3. CONTACT the physician
4. Administer OXYGEN as prescribed
5. Take the VITALS frequently
6. document the occurrence
so what i got from this is that you save the documentation for last. Before administering oxygen, you
need to contact the Physician (remember that administration of oxygen requires Physician's order).
usually you would want to do all that you can first before contacting the Physician. In this case which
is considered an emergency, the vitals is taken after the physician is contacted and oxygen is
administered.
that being said, i believe if you can't see, (physiologic) then it'll probably lead you busting
your butt along the way (safety/security)
yes but risk for is a potential diagnosis and altered sensory perception is an actual diagnosis. Priority
would be a diagnosis that is present not one that has the potential to be.
Just remember that underneath that Maslow's triangle there is an imaginary "additional" line below
the whole thing that is LIFE or DEATH.
In other words, if the "safety" factor is a life or death issue, that takes priority over every other need.
A client being hydrated isn't going to mean a hill of beans if he's dead.
always draw up clear to cloudy when mixing insulin.
2. do not add potassium to the diet of someone who is taking potassium sparing diretics.
3. Give diretics in the am to avoid nocturia.
4. always check for tube placement with 10 cc of air before instilling ANYTHING in an NG tube.
5. An infant should double there birth weight by 6 months old.
mother/baby stuff
1. Rh negative mom gets Rhogam if baby Rh positive. Mom also gets Rhogam after
aminocentesis, ectopic preganancy, or miscarriages.
2. fetus L/S Ratio less than 2= immature lungs......2-3=borderline....greater than
3=good lung maturity dude!! may give dexamethasone to speed up maturity if baby
needs to be delivered soon.
3. prolasped cord position knee chest or trend..call for help!! GET THAT BOTTOM
OFF THE CORD! SUPPORT CORD WITH YA HAND
4. decelerations early vs late----always good to be early but dont ever show up late.
early mirrors the contraction, late comes after the contraction
5. LOCHIA SEQUENCE...lochia rubra- red, clotty....lochia serosa...pink,
brown....lochia alba..white.........SHOULD NEVER HAVE A FOUL ODOR!
VEAL CHOP
Variable deceleration -Cord compression
Early deceleration - Head ompression
Acceleration - O.k
Late deceleration - Position change
Pt with asthma - FIRST give bronchodilators (opens airways) and then stuff them with steroids
2. Antepartum client c/o leg cramps - teach client to dorsiflex foot
3. Pt who had thyroidectomy - assess for signs of hypocalcemia (muscle twitching: positive
Chvostek's/Trousseau's sign, tetany)
4. NORMAL FINDINGS for a 6 month old child - sits up without support
5. DELEGATION/SUPERVISION
RN's can assess (initial for sure, MOST IMPORTANTLY), teach, administer blood products, planning,
evaluation, infusion of IV meds,
LVN's can do dressing changes, administer enemas/antibiotics, oral care and routine observation, perform
fingerstick glucose readings, gathering data and observations: breath sounds and pulse oximetry, set up
equipment for oxygen and suctioning, checking and observing client for signs of infection, irrigating the ear,
reminding client about post-op instructions given by RN, assisting with procedures in stable clients with
predictable outcomes
Nursing assistant's can do VS's, baths, ambulate client, brush/floss client's teeth, record intake and output,
can remind client to perform actions that are already part of the plan of care, weighing the client, taking pulse
and blood pressure, reinforce dietary and fluid restrictions after the RN has explained them to the client
Remember that long-term corticosteroid use causes adrenal atrophy, which will decrease the ability of
the body to withstand stress. Therefore, when a pt is made NPO before surgery, check with the MD
because this medication may still need to be given. Sometimes you may also see the the dosage of a
corticosteroid increased before surgery
Re: Anyoone up for random FACT THROWING??
Burns
Priority = 1-airway (ABCs),
2-Circulation (Fluids & E-lytes)= IV LR
3-Pain,
4-Infection
Percaution= Cap, Gown, Mask, Gloves (use by nurse to  infection.
Wound Care= at least 1/day with carful Aseptic (sterile) techinique if pt with 50% burned.
Meds= Morphine IV (monitor VS)
Analgesic 30 min before wound care
Tx= Silvadene (monitor urine for sulfa crystals) (Tx for psudomonas)
Monitor= adequate fluid replacement check urinary output of 30ml/hr
Lab= Hematocrit male 40-50, female 37-47
Diet=  Calorie  Carb  protein / TPN may be used monitor BS / Sliding Scale for insulin
supplments: Vit B, Vit C, Iron
FyI: Most concern is a burn that does not blanch.
Degree of Burns
1◦ = Pink to red; epidermis damage (superfical) ;uncontrollable painful
2◦ = red to white with blisters and edema; epidermis and dermis (partial thickness) ;
painful
= charred, waxy white and edema; damage skin, nerves, muscle, bones(called deep
thickness burn), painless
3◦ = usually dry darkbrown or has a leathery appearence.
;damage to all the Epidermis and Dermis Skin grafting is recommended.( Full Thickness
Burn)
4◦= The tissue beneath the skin is burned/destroyed. includes the muscles, tendons,
ligaments and bones. Skin grafting is usually needed to close up the areas.
Endocrine Glands
Hypothalamus (Regulator)
Pituitary Gland (Growth, Reproduction, Melanin, F&E)
Pineal Gland (Melatonin, Circadan Rhythms)
Thyroid (Metabolism, Energy, Growth)
Parathyroid (Calcium Regulation)
Thymus (Immune Response)
Adrenal Glands (Stress Response, Metabolism, F&E)
Pancreas (Fat, Protein, Carb Metabolism)
Ovaries (Reproductive System, Sex Organs)
Testes (Reproduction, Muscles, Bones, Skin, Hair)
Hormones
Hypothalmus (Releasing/Inhibiting Hormones)
Ant. Pituitary (TSH, Growth Hormone, LH, FSH, ACTH)
Posterior Pituitary (ADH, MSH, Oxytocin)
Pineal (Melantonin)
Thymus (Thymopoietin)
Thyroid (T4, T3, Calcitonin)
Parathyroids ( PTH)
Adrenal Medulla (Epi, Norepi)
Adrenal Cortex ( Glucocorticoids, Mineralocorticoids)
Pancreas (Insulin, Glucagon)
Addisson’s Disease Assessments
Fatigue
Weakness
Dehydration
Eternal tan
Decreased resistance to stress
Low Sodium
Low Blood Sugar
High Potassium Addisson’s Disease
Implementations
High protein, High carbohydrate, high Sodium, Low potassium diet
Teach life-long hormone replacement
Addisonian Crisis Assessments
• Hypotension
• Extreme weakness
• Nausea vomiting
• Abdominal pain
• Severe hypoglycemia
• Dehydration Addisonian Crisis Implementations
• Administer NaCl IV, vasopressors, hydrocortisone
• Monitor vital signs
• Absolute bedrest
Cushing’s Syndrome Assessments
• Osteoporosis
• Muscle wasting
• Hypertension
• Purple skin striations
• Moon face
• Truncal obesity
• Decreased resistance to infection Cushing’s Syndrome Implementations
• Low Carbohydrate, Low Calorie, High Protein, High Potassium, Low sodium diet
• Monitor glucose level
• Postop care after adrenalectomy or hypophysectomy
Buck's traction is used to immobilize and reduce spasms in a fractured hip.
Prioritizing

Anyone threatening suicide/self-harm should be seen first, followed by anyone hearing
command hallucinations to harm others.

An infant experiencing vomiting and/or diarrhea should be seen before an older child, young
adult, or adult experiencing vomiting/diarrhea.
IRON-DEFICIENCY ANEMIA (IDA)
* Anemia that results when iron supply is inadequate for optimal RBC formation because of excessive
iron loss from bleeding, decreased dietary intake, or malabsorption
Nursing assessment
*
*
*
*
Fatigue and weakness
Shortness of breath
Pallor (ear lobes, palms, and conjunctiva)
Brittle spoonlike nails
* Cheilosis (cracks in the corners of the mouth)
* Smooth, sore tongue
* Dizziness
* Pica (craving to eat unusual substances such as clay or starch)
* Blood sample shows microcytic and hypochromic anemia (small RBC diameter with decreased
pigmentation) and an increase in red cell size distribution width (RDW)
* Decreased MCV, MCH, and MCHC; analyzed only when hemoglobin is low
* Low serum iron level and elevated serum iron-binding capacity or low serum ferritin levels
Therapeutic management
* Examine stools for occult blood; endoscopic examination and other diagnostic procedures may be
performed to detect possible sources of bleeding
* Increase intake of iron-rich foods, such as organ meats, meat, beans, green leafy vegetables,
molasses, and raisins
* Administer iron supplements
* Administer parenteral iron dextran (InFed) by deep IM route via Z-track method
* Determine stool color, consistency, frequency, and amount; may appear greenish black and tarry;
caution client that iron supplements usually cause constipation and client should take preventive
measures (fluids, fiber)
Client teaching
* Take iron on an empty stomach; absorption of iron is decreased with food; ab*sorption may be
enhanced when taken with an acidic beverage (such as one with vitamin C), but avoid grapefruit Mice
* Foods high in iron include organ meats (beef or calf liver, chicken liver), other meats, beans (black,
pinto, and garbanzo), leafy green vegetables, raisins, and molasses
MEGALOBLASTIC ANEMIA
* Vitamin B12, deficiency anemia
* A type of anemia characterized by macrocytic RBCs
Nursing assessment
* Pallor or slight jaundice with a complaint of weakness
* Smooth, sore, beefy red tongue (glossitis), and cheilosis (cracking of lips)
* Diarrhea
* Paresthesias (numbness or tingling in extremities)
* Impaired proprioception (difficulty identifying one's position in space. which may progress to
difficulty with balance)
* Clients with this anemia tend to be fair-haired or prematurely gray Macrocytic (megaloblastic)
anemia (RBC diameter >8) with increase in MCV and MCHC
* Gastric secretion analysis reveals achlorhydria: absence of free hydrochloric acid in a pH maintained
at 3.5
* Twenty-four-hour urine for Schilling test (a vitamin B12 absorption test th indicates if client lacks
intrinsic factor by measuring excretion of orally ad-ministered radionuclide-labeled B12) confirms
diagnosis of pernicious anemia
Therapeutic management
* Medication therapy: parenteral vitamin B12,100 to 1000 mcg subcutaneously daily for 7 days, then
once a week for 1 month, then monthly for lifetime is usually prescribed; a nasal form is now available
also
Client teaching
* Dietary sources of vitamin B12 include dairy products, animal proteins
Folic acid—deficiency anemia
Nursing assessment
* Pallor, progressive weakness, fatigue
* Shortness of breath
* Cardiac palpitations
* GI symptoms are similar to B12 deficiency but usually more severe (glossitis, cheilosis, and
diarrhea)
* Neurological symptoms seen in B12 deficiency are not seen in folic acid deficiency and therefore
assist in differentiating these two types of anemia
* RBC analysis shows macrocytic (megaloblastic) anemia (RBC diameter, high MCV with low
hemoglobin, low serum folate level
Therapeutic management
* Includes dietary counseling and administration of folic acid
Client teaching
* Dietary sources of folic acid such as green leafy vegetables, fish, citrus yeast, dried beans, grains,
nuts, and liver
APLASTIC ANEMIA
Nursing assessment
*
*
*
*
*
*
*
*
*
Pallor and fatigue
Palpitations and exertional dyspnea
Infections of the skin and mucous membranes
Bleeding from gums, nose, vagina, or rectum
Purpura (bruising)
Retinal hemorrhage
Blood counts reveal pancytopenia (decreased RBC, WBC, and platelets)
Decreased reticulocyte count
Bone marrow examination reveals decrease in activity of bone marrow or no cell activity
Therapeutic management
* Institute reverse isolation to protect client from infection
* Monitor for evidence of bleeding
* Avoid invasive procedures including rectal temperatures
Client teaching
* Methods to prevent infection such as avoiding crowds, maintaining good hygiene, hand washing, and
elimination of uncooked foods from the diet
* Methods to prevent hemorrhage such as using a soft toothbrush, avoiding contact sports, and use of
an electric razor
* Avoid drugs that increase bleeding tendency, such as aspirin
Sickle Cell Disease
Nursing assessment
* Pallor and jaundice
* Fatigue and possible irritability
* Large joints and surrounding tissue may become swollen during crisis
* Priapism (abnormal, painful, continuous erection of penis) may occur if penile veins are obstructed
* Severe pain
* Anemia with sickle cells noted on a peripheral smear
* Hemoglobin electrophoresis to detect presence and percentage of hemoglobin is used for a definitive
diagnosis
* Elevated serum bilrubin levels
* Elevated reticulocyte count
Therapeutic management
* Care of client in sickle cell crisis
o Recognize that client may have severe pain and medicate accordingly, usually with opioid analgesics
o Administer 02 to increase oxygenation to cells
o Promote hydration to decrease blood viscosity; provide oral intake of at 6 to 8 quarts daily or IV
fluids of 3 liters daily
o Monitor for complications such as vaso-occlusive disease (thrombosis), hy*poxia, CVA, renal
dysfunction, priapism leading to impotence, acute chest syndrome (fever, chest pain, cough,
pulmonary infiltrates, and dyspnea), an substance abuse
o Manage infection if appropriate
Medication therapy
* Narcotic (opioid) analgesics during the acute phase of sickle cell crisis, often at large doses
Client teaching
* Ways to prevent sickle cell crisis
* Maintain an oral intake of at least 4 to 6 quarts a day; avoid conditions that might predispose to
dehydration
* Avoid high altitudes
* Prevent and promptly treat infections
* Use stress-reduction strategies
* Avoid exposure to cold
* Avoid overexertion
Anemia
* Children with persistent anemia might experience frequent bouts of otitis media and upper
respiratory infections.
Pernicious Anemia
* For the exam, you should know the names for the various B vitamins and realize that they can be
used interchangeably in test items;
* B1 (Thiamine)
* B2 (riboflavin)
* B3 (niancin)
* B6 (pyridoxine)
* B9 (folic acid)
* B12 (cyanocobalamin)
Sikle Cell Anemia
* When multiple transfusions are given, reduce iron overload and hemosiderosis with subcutaneous
chelating injections of deferoxamine (Desferal)
* Morphine is the drug of choice for acute pain in sickle cell anemia. Meperidine is contraindicated due
to the possibility of central nervous system stimulation in these clients that could lead to seizure
activity.
* An easy to remember general nursing care for clients with sickle cell anemia is to remember the
following
* H - heat
* H – hydration
* O – oxygen
* P – pain relief
Polycythemia Vera
This disorder is characterized by thicker than normal blood. There is an increase in the client’s
hemoglobin to levels of 18 g/dL, RBC of 6 million/mm or hematocrit at 55% or greater and increased
platelets)
* With polycythemia, the client is at risk for cerebrovascular accident (CVA), myocardial infarction,
(MI) and bleeding due to dysfunctional platelets.
Hemophilia
* Intracranial bleeding is the major cause of death in clients with hemophilia
* Cryoprecipitates are no longer used for treatment of hemophilia because HIV and hepatitis cannot
be removed.
Transfusion Therapy
* Severe reactions occur during the first 50mL of blood transfused. Stay with the patient for the initial
15-30 min of infusion
Client with Burns
BURN INJURY
* An alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity,
or radiation
* There are several types of burn injury: thermal, chemical, electrical, and radiation
* Thermal burn: results from dry heat (flames) or moist heat (steam or hot liq*uids); is most common
type; causes cellular destruction that results in vascu*lar, bony, muscle, or nerve complications;
thermal burns can also lead to inhalation injury if head and neck area is affected
* Chemical burn: caused by direct contact with either acidic or alkaline agents; alters tissue perfusion
and leads to necrosis
* Electrical burn: severity depends on type and duration of current and amount of voltage; electricity
follows path of least resistance (muscles, bone, blood vessels. and nerves); sources of electrical injury
include direct current, alter*nating current, and lightning
* Radiation burn: usually associated with sunburn or radiation treatment for cancer; usually
superficial; extensive exposure to radiation may lead to tissue damage and multisystem injury
o Nursing assessment: history of injury, estimate burn extent and depth, obtain past medical history
and medication history including date of last tetanus pro*phylaxis; assess for other concurrent injuries
o Systemic effects of severe burns include asphyxia from smoke inhalation that causes edema of
respiratory passages; shock from fluid shifts; renal failure from shock; protein loss from open wound;
potassium excess from tissue destruction and renal failure
o Diagnostic and laboratory test findings: may have elevated hematocrit (Hct) and decreased
hemoglobin (Hgb) caused by fluid shift, decreased sodium (Nat) and increased potassium (K+) caused
by damage to capillary and cell mem*branes, elevated BUN and creatinine caused by dehydration,
myoglobin in urine, and possible deterioration of arterial blood gases (ABGs) and oxygen (02)
saturation readings depending on respiratory status
o Therapeutic management
* First aid: douse flames with water or smother them with a blanket, coat, or other similar object;
cool a scald burn with cool water; flush chemical burns copiously with water or other appropriate
irrigant after dusting away any dry powder if present; remove client from contact with an electrical
source only after current has been shut off
* Priority care is on ABCs: airway, breathing, and circulation; assess for smoke inhalation injury
(singed nares, eyebrows or lashes; burns on face or neck; stridor, increasing dyspnea) and give 02
(up to 100% as prescribed), being prepared for possible intubation and mechanical ventilation if
severe inhala*tion injury or carbon monoxide inhalation has occurred; assess for signs of shock
caused by fluid shifts (increased pulse, falling BP and urine output, pal*lor, cool clammy skin,
deteriorating level of consciousness [LOC])
* Fluid resuscitation: Brooke formula uses 2 mL/kg/% TBSA burned (3/4 crys*talloid plus 1/4 colloid)
plus maintenance fluid of 2,000 mL D5W per
o Medication therapy: analgesics—usually morphine sulfate IV, tetanus booster (> 5-10 years since
last dose), topical antimicrobials, systemic antibiotics
o Acute phase of burn management: begins with start of diuresis (usually 48 to 72 hours postburn)
and ends with closure of burn wound
o Therapeutic management
+ Wound care management includes debridement, dressing changes, hydrother*apy, and possible
escharotomy,
+ Mafenide (Sulfamylon) may be applied in thin layer over open wound and covered with dressing
+ Sulfadiazine (Silvadene) may applied in thin layer over open wound and cov*ered with dressing;
use with caution when impaired renal function exists; must be washed off and reapplied every 8 to 12
hours
+ Skin grafting may need to be done to achieve healing in full-thickness and large, deep partialthickness burns
+ Nutritional therapies (high-calorie, high-protein diet with vitamins and min*erals) and continue to
maintain hydration status
+ Infection control with strict sterile technique
+ Maintain heated environment to prevent chilling
+ Physical therapy as needed
+ Psychosocial support
# Rehabilitative phase of burn management: begins with wound closure and ends when client returns
to highest level of health restoration
# Therapeutic management
* Prevent immobility contractures with exercises or ongoing physical therapy
* Assist in returning to work. family, and social life
* Client education
* Environmental safety: use low temperature setting for hot water heater, en*sure access to and
adequate number of electrical cords/outlets, isolate house*hold chemicals, avoid smoking in bed
* Use of sunscreen to protect healing tissue and other protective skin; measures soft tissue injuries;
or deep chemical or electrical
+ To prevent burns, hot water heaters should be set no higher that 120° Fahrenheit.
Burn Classifications
+ Pain medication is given intravenously to provide quick, optimal relief and to prevent
overmedication as edema subsides and fluid shift is resolving.
+ The cardiac status of a client with electrical burns should be closely monitored for at least 24 hours
following the injury to detect changes in electrical conduction of the heart.
+ Full thickness burns can damage muscles, leading to the development of myoglobinuria in which
urinary output becomes burgundy in color. The client with myoglobinuria require hemodialysis to
prevent tubular necrosis and acute renal failure.
Burn Measurement with TBSA
+ It will be beneficial to review your nursing textbooks for local and systematic reactions to burns
because these injuries affect all body systems and cardiovascular and renal functions in particular.
Nursing Care for Burn Victims
+ The eyes should be irrigated with water immediately if a chemical burn occurs. Follow-up care with
an ophthalmologists is important because burns of the eyes can result in corneal ulceration and
blindness.
+ Important Steps in treating a burn client include the following:
* Treat airway and breathing – Traces of carbon around the mouth or nose, blisters in the roof of the
mouth, or the presence of respiratory stridor, indicate the client has respiratory damage
* Ensure proper circulation – Compromised circulation is evident by a drop in normal blood pressure,
slowed capillary refill, and decreased urinary output. These symptoms signal impending burn shock.
o It is important to remember that the actual burns might not be the biggest survival issue facing burn
clients. Carbon monoxide from inhaled smoke can develop into a critical problem as well. Carbon
monoxide combines with hemoglobin to form carboxyhemoglobin which binds to available hemoglobin
200 times more readily than with oxygen. Carbon monoxide poisoning causes a vasolidating effect
causing the client to have a characteristic cherry red appearance. Interventions for carbon monoxide
poisoning focus on early intubation and mechanical ventilation with 100% oxygen.
The Consensus Formula
o Fluid replacement formulas are calculated from the time of injury rather than from the time of
arrival in the emergency room.
The Intermediate Phase
o Infections represent a major threat to the post-burn client. Bacterial infections (Staphylococcus,
Proteus, pseudomonas, eshcerichia coil, and Klebsiella) are common due to optimal growth conditions
posed by the burn wound; however, the primary source of infection appears to be the client’s own
intestinal tract. As a rule, systemic antibiotics are avoided unless an actual infection exists,
o Enzymatic debridement should not be used for burns greater thatn 10% TBSA, for burns near the
eyes, or for burns involving muscle.
Dressing for Burns
o Dressing for burns include standard wound dressings (sterile gauze) and biologic or biosynthetic
dressings (grafts, amniotic membranes, cultured skin, and artificial skin)
o Biologic dressings are obtained from either human tissue (homograft or allograft) pr animal tissue
(heterograft or xenograft). These dressing which are temporary are used for clients with partial
thickness or granulating full thickness injuries.
o Hemografts and allografts are taken from cadaver donors and obtained through a skin bank. These
grafts are expensive and there is a risk of blood-borne infection. Heterografts and xenografts are
taken from animal sources. The most common heterograft is pig skin (porcine) because of its
compatibility with human skin.
o Muslims and Orthodox Jews are two religious/ethnic groups who might be offended by the use of
porcine grafts since the pig is considered an unclean animal. Christian groups such as Seventh Day
Adventists might also reject the use of procine grafts.
DIAGNOSTIC TEST AND ASSESSMENT
Pulse oximetry
* Monitors arterial or venous oxygen saturation ([percentage of 02] bound to he*moglobin [Hgb]
compared to volume that Hgb is capable of binding); normal is usually 95% or greater in a client with
no lung disease; in clients with lung dis*ease, target oxygen saturation is 90% or greater; may be
measured intermit*tently (such as with vital signs or ambulation) or continuously
* Uses a light spectroscopy probe attached to a finger, earlobe, or nose
* Accuracy is lower with diminished peripheral perfusion, brightly lit environ*ment, acrylic fingernails,
and dark skin color
Laboratory
Sputum analysis: specimen obtained for microbiology (Gram stain, culture and sensitivity) or cytology
* Specimens for acid-fast bacilli (mycobacterium tuberculosis) may be collected
* on three different days; specimen collection following a long sleep period (early morning) is
desirable because of greater concentration; if unable to ob*tain a sputum specimen for acid-fast
bacilli, gastric specimen may be obtained because mycobacterium tuberculosis is not altered by acidic
gastric contents
* Specimen processing: collect specimens in appropriate container and send to laboratory promptly
Skin testing: assesses for allergic reactions to specified antigens (type I hyper- sensitivity), exposure
to tuberculosis-causing organisms (type IV hypersensiti vity), or fungi
* Measure area of induration (if present), not reddened area; read result 48 to 72 hrs after
placement; an uncertain reading at 48 hrs may be reread at 72
* Positive result: individual has been exposed to antigen; does not mean that individual currently has
active disease, only that there has been exposure/ infection
* When performing skin tests to assess for type I allergies, ensure that antihict*amines, which could
interfere with test results, are discontinued 72 hours prior to testing
COMMON NURSING TECHNIQUES AND PROCEDURES
Airway management: goal is to maintain patent airway
1. Head and jaw position
* Open airway by head tilt and anterior chin lift maneuver
* In individuals with suspected neck injury, open airway by anterior chin dis*placement and/or jaw
thrust; do not perform head tilt
* Limit suctioning to 10 seconds per catheter pass (5 in children) to reduce risk of inadequate
oxygenation and cardiac dysrhythmias from hypoxia
Body positioning
* Acute respiratory failure
a. Elevate head at least 45 decrees to increase chest exnansion
* Unilateral lung disease a. Position with unaffected lung in dependent position ("good lung down")
Oxygen (02) administration
Nasal cannula
* Typical 02 flow of 1 to 6 L/min will provide 02 concentrations of 24% to 44%
* Individuals with chronic obstructive pulmonary disease (COPD) should re*ceive low flow oxygen,
about 1 to 2 L/min, to prevent respiratory depression; these clients are used to high CO2 levels and
low 02 levels, so increased 02 (greater than 2 L/min) can cause a loss of respiratory drive
Key ventilator settings
* Rate: number of breaths per minute delivered by ventilator; is a number that is combined with the
mode often in clinical practice (e.g., SIMV of 6/min)
* FiO2: fraction of inspired 02 or 02%; amount of 02 in air inhaled via ventilator; is expressed as a
decimal instead of a percentage (e.g., Fi02 of .40 versus 40%)
* Tidal volume (VT): amount of air delivered with each breath; often expressed in milliliters or liters
(e.g., 700 mL or 0.7 L)
* PEEP: abbreviation for positive end-expiratory pressure; the amount of posi*tive-pressure set in
system at end of exhalation; keeps alveoli open during ex*halation to increase gas exchange; is
expressed in terms of centimeters of pressure (e.g., 5 cm)
Nursing management
* Position client for maximum alveolar ventilation and comfort; maintain soft restraints to avoid
accidental extubation
* Monitor for any changes in respiratory status or effort
* Maintain ventilator settings as ordered and remain knowledgeable about how to troubleshoot
ventilator alarms (high pressure frequently indicates need for suctioning or kinking/compression of ET
tube; low pressure indi*cates leak or disconnection); manually ventilate client if alarms sound
with*out apparent cause
* Monitor arterial blood gases (ABGs) and maintain continuous 02 satura*tion monitoring
* Complete a thorough physical assessment with emphasis on cardiac, neuro*logical, and respiratory
areas
* Administer antibiotics, neuromuscular blocking agents, and sedatives as ordered
* Maintain nasogastric suction to prevent aspiration
* Supply nutritional support as ordered
* Perform frequent oral care and suctioning to maintain airway patency
* Provide emotional support to client and family as well as alternative commu*nication method
Potential complications: pneumothorax, GI stress ulcers, hypotension caused by decreased venous
return from increased intrathoracic pressure, increased in*tracranial pressure, infection
Laryngectomy
Postoperative care
* Maintain patent airway
* Provide pain management
* Provide appropriate nutritional support
* Teach client and family how to care for tracheostomy and feeding tube (if applicable)
* Provide access to communication devices, such as writing supplies, picture or word board, speaking
tracheostomy valve
* Provide emotional sunnort to client and family: make annronriate referrals
Respiratory Isolation
* Droplet precautions (transmission-based precautions)
* In addition to standard precautions, persons should wear mask when near client who has known or
suspected pathogen transmitted by droplet route
* Limit client transport within facility; when transport is necessary, place mask on client
* Limit contamination of equipment and/or environment
* Place client in private room or with a cohort (client with same diagnosis)
NURSING MANAGEMENT OF CLIENT HAVING THORACIC SURGERY
Preoperative period
* Reduce anxiety through preoperative teaching about procedure and postopera*tive course and care
* Assess client's support systems and ability to care for self after surgery
* Administer preoperative medications, such as antibiotics, opioid analgesics, and anti-anxiety agents,
as ordered
* Obtain baseline vital signs, oxygenation status, and cognitive status for compari*son postoperatively
Postoperative period
* Maintain patent airway
* Position client for optimal ventilation and perfusion; note any specific surgeon-s orders for
positioning; be prepared to initiate respiratory support (intubation. emergency tracheostomy,
mechanical ventilation) as needed
* Maintain client safety
* Assess for and report possible surgical complications to maintain oxygenation
* Change in level of consciousness (LOC) ranging from restlessness and agitation to lethargy or
unresponsiveness
* Increase in respiratory rate, unequal chest expansion, decreased breath sounds, and/or use of
accessory muscles for breathing
* Loss of water seal drainage in closed chest drainage system
* Greater than desired volume of chest drainage (75-100 mL drainage over 1 hour is an average
acceptable upper limit); orders should specify volume acceptable chest tube drainage; should
decrease over first 24 hours
Positioning client after lung surgery: orders should specify turning parameters for indvidual client
* Lobectomy: positioning includes lying on back or turned to either side
* Segmental resection: positioning includes lying on back and turned onto nonl erative side;
positioning on operative side may place tension on sutures and mote bleeding
* Pneumonectomy
* Positioning includes lying on back and turned toward operative side
* Avoid complete lateral turning to either side, which changes pressure dynam*ics within chest and
could lead to mediastinal shift
OBSTRUCTIVE PULMONARY DISEASES
Emphysema
a. Progressive destruction of alveoli related to chronic inflammation
Assessment
* "Pink puffer" is a classic clinical description characterized by barrel chest, pursed-lip breathing
(caused by forced exhalation), obvious use of accessory muscles when breathing, and underweight
appearance
* Exertional dyspnea progresses with advancing disease
* Persistent tachycardia is related to inadequate oxygenation
* Overall diminished breath sounds, and possible wheezes or crackles
* ABGs: slightly decreased P02; PCO2 is not elevated until later stages
* Chest x-ray: hyperinflated lungs with a flattened diaphragm; heart size is nor*mal or small
* Pulmonary function tests: low vital capacity and forced expiratory volume (FEVi)
Therapeutic management
* Goals are to improve ventilation and promote patent airway by removing se*cretions
* Remove environmental pollutants and encourage smoking cessation
* Prescribed treatments include bronchodilator therapy, beta-adrenergic ago*nists, corticosteroid
therapy, oxygen and nebulization therapy, chest physio*therapy, intermittent positive-pressure
breathing (IPPB), possibly mechanical ventilation, and possible surgical procedures such as
bullectomy, lung volume reduction surgery, or lung transplantation
* Provide education and referrals for clients with behaviors (such as smoking) that increase risk for
COPD
* Refer clients to a structured pulmonary conditioning program and provide reinforcement as
appropriate
* Teach clients to avoid pulmonary irritants
* Assist clients to develop appropriate nutritional plans to provide ade*quate calories
Chronic bronchitis
A disorder of chronic airway inflammation with a chronic productive cough lasting at least 3 months
during 2 years; is a form of COPD
Assessment
* Frequent cough, occurring during winter season, with foul-smelling sputum
* Frequent pulmonary infections
* Classic appearance of "blue bloater" includes tendency for obesity and bluish-red skin discoloration
from cyanosis and polycythemia
* Dyspnea and activity intolerance occurs as disease progresses
* Increased anterior–posterior chest diameter
* Elevated red blood cell count; hemoglobin and hematocrit elevated in later stages
* Chest x-ray reveals enlarged heart, congested lung fields, and normal or flattened diaphragm
* Pulmonary function indicates increased residual volume, decreased vital capacity, FEVi, and
FEVi/FVC ratio
Therapeutic management
* Includes measures previously described in section on emphysema
* Provide education or referrals to clients with behaviors that increase the risk of developing COPD
* Refer clients to a structured pulmonary conditioning program and provide reinforcement as
appropriate
* Teach clients how to avoid pulmonary irritants
* Assist clients to develop appropriate nutritional plans that provide adequate calories but maintain
ideal weight
* Administer supplemental low-flow 02 as necessary; be prepared to initiate mechanical ventilation
* Surgical interventions include bullectomy, lung volume reduction surgery, lung transplantation
* Medication therapy includes immunization against pneumonia and influenza antibiotics, possible
bronchodilators (beta-adrenergic agonists, anticholiner-minimal client symptoms; air leak may
progress until pressure between thoracic cavity and atmosphere equalizes and client is symptomatic.
* Tension: disruption of chest wall or lungs causes air accumulation in pleural space; pressure on
mediastinum causes pressure on other lung and interrupts venous return to heart; is a medical
emergency that requires emergency placement of chest tube to relieve increasing pressure in thoracic
cavity and restore adequate cardiac output
PNEUMOTHORAX AND HEMOTHORAX
Assessment
*
*
*
*
*
*
*
*
Dyspnea
Tracheal deviation toward unaffected side
Diminished breath sounds on affected side
Percussion dullness on affected side
Unequal chest expansion (reduced on affected side)
Crepitus over chest
Chest x-ray reveals pneumothorax
ABG shows decreased P02
Therapeutic management
* In mild cases, no chest tube is required; if pneumothorax is significant, a chest tube is inserted and
attached to water seal drainage
* Spontaneous pneumothorax: in otherwise healthy client, may resolve without in*vasive treatment
* If spontaneous pneumothorax occurs repeatedly, may require pleurodesis, an in*stillation of an
agent (such as talc or tetracycline) in pleural spaces to allow pleura to adhere together; other
procedures include partial pleurectomy, sta*pling, or laser pleurodesis for pleural sealing
* Care of client with a chest tube:
* Monitor respiratory and oxygenation status
* Provide supplemental oxygen as indicated
* Maintain infection control practices
* Medication therapy: analgesics and antibiotics
ATELECTASIS
* Incomplete expansion or collapse of the lung resulting from obstruction of air*way by secretions or a
foreign body
Assessment
* Low-grade fever
* Breath sounds diminished or absent in affected area
* Diminished rate and depth of respiration
PULMONARY TUBERCULOSIS
* Lung infection caused by Mycobacterium tuberculosis
Assessment
* Frequent cough with copious frothy pink sputum; nonproductive cough devel*ops first as an early
symptom (especially in early morning)
* Night sweats
* Anorexia
* Weight loss
* History may indicate recent exposure to infected individual
* Positive tuberculin skin test (indicates exposure)
* Appearance of characteristic Ghon tubercle on chest x-ray
* Positive acid-fast bacillus sputum cultures (provides definitive diagnosis of infection)
Therapeutic management
* Monitor respiratory and oxygenation status
* Provide adequate nutrition and hydration
* Institute standard precautions (Centers for Disease Control [CDC] Tier 1) and airborne precautions
(Tier 2, transmission-based precautions
* Use a private room with negative air pressure that has 6 to 12 full air exchanges per hour and is
vented to the outside or has its own air filtration system
* Wear specially fitted mask (N95 respirator) whenever entering client's room; fit-test the mask with
each use
* Provide visitors with appropriate masks
* Wear gown and masks if client does not reliably cover mouth during cough*ing or sneezing to
reduce risk of transmission to others
* Provide client with a surgical mask if it is necessary to bring client to another department; choose
shortest and least busy route and alert that department ahead of time about client's status; schedule
tests for least busy times of day
* Administer antimicrobial therapy as prescribed
* Provide supplemental oxygen as indicated
* Obtain periodic sputum cultures following onset of antimicrobial therapy
Client education
* Infection control measures, including handwashing, coughing into tissues disposing of them in a
closed bag
* Teach client, family, and close contacts about mechanisms of transmission antimicrobial therapy,
including need to take medication for full course of apy to prevent recurrence and/or development of
drug-resistant organisrm
PULMONARY EMBOLISM
* Emboli lodge in pulmonary vasculature and impede blood flow through pulmonary capillaries
Assessment
*
*
*
*
*
*
*
*
*
*
Restlessness, anxiety, agitation
Vital signs: tachycardia, tachypnea, hypotension, fever
Chest pain
Hemoptysis
Mental status changes with possible decreasing level of consciousness
Cyanosis
Recent history of thromboembolism and/or long bone fractures
Lung crackles upon auscultation
Atrial fibrillation
Chest x-ray may be normal
Therapeutic management
* Supplemental oxygen therapy; maintain patent airway
* Be prepared to initiate mechanical ventilation
* Maintain IV access and provide circulatory support as needed
* Anticoagulant and/or thrombolytic therapy
* Opioid analgesies and anti-anxiety agents as needed
* Embolectomy
* To prevent future pulmonary emboli, a vena cava filter may be inserted to trap emboli from a known
source
BRONCHOGENIC CARCINOMA
* Lung cancer is leading cause of death from malignancy
Assessment
*
*
*
*
*
*
*
*
*
*
*
*
Symptom onset is often late in course of disease
Persistent cough with or without hemoptysis
Localized chest pain
Dyspnea
Unilateral wheeze upon auscultation
Swallowing difficulty
Anorexia and weight loss
Enlarged neck lymph nodes
Mass visible on chest x-ray
CT scan or MRI of chest may better differentiate mass
Sputum for cytology reveals tumor cells
Bronchoscopy for direct biopsy or washings for cytology reveal tumor cells
Therapeutic management
*
o
o
o
Surgical resection
Pneumonectomy: removal of entire lung
Lobectomy: removal of a lobe of lung
Segmentectomy (segmental resection): removal of a segment or segments of a lung
o
*
*
*
*
Wedge resection: dissection and removal of a defined area in lung
Chemotherapy
Radiation therapy
Laser therapy
Immunotherapy
CANCER OF THE LARYNX
* Most laryngeal tumors are benign
Assessment
* Hoarseness and/or change in voice characteristics
* Palpable jugular nodes
* Pain when swallowing
* Unexplained earache
* Diagnostic test results: laryngeal biopsy findings, x-ray visualization, MRI findings, barium swallow
visualization
Therapeutic management
* Depends on stage of disease and general condition of client
* Radiation therapy or brachytherapy (placement of a radioactive sow next to tumor)
* Chemotherapy
* Laryngectomy
* Radical neck dissection
* Maintain patent airway (tracheostomy performed with laryngectomy)
* Pain management
* Provide adequate hydration and nutrition (temporary or permanent alter route for nutrition)
* Provide alternate means for communication and plan for permanent mea communication (artificial
larynx or esophageal speech)
* Monitor respiratory and oxygenation status
* Provide oxygen supplementation as indicated
* Medication therapy: opioid analgesics and antipyretics
THORACIC TRAUMA
* Alteration of breathing mechanics and/or gas exchange caused by respiratory. system trauma
Assessment
*
*
*
*
*
*
*
Chest pain, may be severe such as with flail chest
Shallow breathing with splinting
Possible unequal chest expansion
Tachycardia, tachypnea, hypotension
Crepitus over chest
Chest x-ray findings show white opacifications
ABGs reveal hypoxemia
Therapeutic management: same as pneumothorax and hemothorax
*
*
*
*
*
Ventilation support
Be prepared to initiate mechanical ventilation
Maintain IV access
Possible placement of chest tube with water seal drainage
Medication therapy: opioid analgesics, patient-controlled or epidural analgesia may be appropriate
CYSTIC FIBROSIS (CF)
* Multisystem disorder of exocrine glands, leading to increased production of
thick mucus in bronchioles, small intestines, and pancreatic and bile ducts
Assessment
* Sweat test (pilocarpine iontophoresis) analyzes Na+ and C1-- content in sw e chloride concentration
greater than 60 meq/L is diagnostic of cystic fibrosis.. ents often report that infants taste salty when
kissed
Therapeutic management
* Respiratory: ensure pulmonary hygiene is performed; auscultate breath sounds before and after
treatments; encourage coughing and deep breath exercises and physical activity as tolerated;
administer prescribed antibiotics and bronchodilator(s)
* Digestive: provide high-calorie (150% above normal recommendations). high protein diet and
snacks; give infants a predigested formula such as pregestnutramigen; administer pancreatic enzymes
with all meals and snacks; indi ize to achieve stools as near normal as possible; administer fat-soluble
vitamins determine food preferences to encourage acceptance of diet; weigh daily: avoid pulmonary
treatments immediately after meals to decrease risk of vomiting
* Medications: antibiotics for treatment of pulmonary infection and purulent cretions, pancreatic
enzymes for fat absorption, vitamin supplementation. immucolytics to decrease viscosity of sputum,
bronchodilators to improve lung function; see Chapter 37 for overview of commonly ordered
respiratory cardiac medications
* High-calorie, high-protein diet is essential; give pancreatic enzymes with all meals and snacks; may
need extra salt in hot weather
BRONCHOPULMONARY DYSPLASIA (BPD)
* A chronic obstructive pulmonary disorder occurring in infants as a sequela to prolonged 02 therapy
and mechanical ventilation
Assessment
* Diagnosed by chest x-ray, which reveals lung changes and air trapping with or without
hyperinflation
* Blood gases reveal hypercapnia (increased CO2) and respiratory acidosis
* Respiratory observations include tachypnea (rapid respirations), tachycardia, in*creased work of
breathing, retractions, wheezing, and barrel chest (rounding of chest caused by trapped air)
* Pallor, activity intolerance, and poor feeding result from chronic hypoxia
Therapeutic management
* Infants with BPD are cared for in intensive care units and require an artificial airway; avoid pressure
or trauma to ET tube and infant's airway
* Suctioning, turning, and weighing is done carefully to ensure adequate 02 sat*uration levels are
maintained
* Monitor respiratory status continuously; infant's condition can worsen in a short period of time
* Monitor for fluid overload; infants are at increased risk for pulmonary edema; weigh daily; maintain
strict I & 0
* Strict handwashing; avoid exposure to respiratory infections
* Cluster nursing care to minimize 02 requirements and caloric expenditure
* Plan quiet stimulation and activities to foster normal infant development and parental bonding with
extended and often repeated hospitalizations of in*fants with BPD
Medications
*
*
*
*
Bronchodilators open airways and increase lung compliance
Corticosteroids reduce airway edema and inflammation
Diuretics remove excess fluid from lungs and help prevent pulmonary edema
Antibiotics may be given prophylactically
LARYNGOTRACHEOBRONCHITIS (LTB)
* Viral infection that causes inflammation, edema, and narrowing of chea, and bronchi; usually LTB is
preceded by a recent upper respira% fection (URI)
Assessment
* Onset is gradual after URI
* Child awakens with low-grade fever, barking cough, and acute stridor; noisy breathing and use of
accessory muscles increase
* Child is agitated, restless, has a frightened appearance, sore throat, and rhinorrhea
* Pulse oximetry is used to detect hypoxemia; anteroposterior (AP) and lateral upper airway x-rays
are ordered
Therapeutic management
* Monitor child's respiratory effort continuously to ensure a patent airway; ob*serve for diminished
breath sounds, circumoral cyanosis, diminishing noisy breathing, and drooling
* Quiet respiratory effort is a sign of physical exhaustion and impending respira*tory failure
* Provide humidity and supplemental 02; IV fluids prevent dehydration and help liquefy secretions
* Assist child to assume upright position or any position of comfort; promote a calm, quiet
environment; keep parents nearby to decrease child's stress and to lessen crying
* Keep emergency intubation equipment available at bedside; readily respond to call bell or requests
for assistance
* Assess parental and child's anxiety level; provide emotional support
* Medications
* Bronchodilators decrease mucosal constriction and laryngeal edema; nebu*lized racemic epinephrine
has a rapid onset with improvement of symptoms, although relapse may occur within 2 hours
* Corticosteroids decrease inflammation and edema
Child and family education
* Cool mist humidifier and parental presence can be initial treatment of crisis; comforting measures
include cuddling, rocking, singing, and any calming mea*sures until breathing becomes easier
* Instruct parents to seek medical attention immediately if breathing becomes la*bored, child seems
exhausted or very agitated, or if symptoms do not improve after cool air humidity treatment
EPIGLOTTITIS
Inflammation and swelling of epiglottis. primarily affecting children ages 2 to 8
Assessments
* Child awakens with sudden onset of high fever (102°F), extremely sore and pain on swallowing
* Child is very anxious, restless, looks ill, and insists on sitting upright legs and arms, with chin thrust
out and mouth open (tripod position)
* Dysphonia (muffled voice), dysphagia (difficulty swallowing), drooling and distressed respiratory
effort are classic signs
* Edematous, cherry-red epiglottis is most reliable diagnostic sign
* Examination of throat is contraindicated, however, unless emergency equipment and trained
personnel are available; physical manipulation of hypersensitive and irritated airway muscles may
result in spasm and a obstruction
* Lateral neck-x-ray confirms an enlarged epiglottis; portable x-rays are completed in examination
room with child on parent's lap to minimize stress maximize child's comfort and calm behavior
* Complete blood count (CBC) and blood cultures are taken once child is - stabilized
Therapeutic management
* Assess continuously for respiratory distress and decrease in respiratory report changes in status
* Never leave child unattended; support child in position of comfort; encourage parents to hug and
cuddle their child
* Keep ET and tracheotomy tubes and suction equipment at bedside; assist emergency ventilation if
needed before child is taken to operating room for airway insertion
* Child is usually intubated for 24 hours; restraints may be necessary to prevent tube dislodgment,
because swelling of epiglottis may prohibit reintubation
* Provide support for child and family and alleviate anxiety; explain all procedures clearly and calmly
* All invasive procedures, including starting an IV infusion, ABGs, and blot surtures are performed in
OR
* Keep child NPO; IV fluids provide hydration; administer antipyretics and antibotics as prescribed
* After extubation, monitor child closely in intensive care unit to ensure ir*ate assessment if
respiratory effort is compromised
* Medications
* Antibiotics treat bacterial infection (usually given for 7 to 10 days); discharged in about 3 days with
oral antibiotics
* Antipyretics treat fever and manage pain of sore throat
* Corticosteroids may be given for 24 hours before extubation
Assessment
* Clinical manifestations include worsening of URI with tachypnea, retractions, low-grade fever,
anorexia, thick nasal secretions, and increasingly labored breathing; older infants may have a
frequent, dry cough
* Auscultation of lungs reveal wheezing or crackles
* Nasopharyngeal washing to obtain respiratory secretions identifies causative virus; chest x-ray may
be normal or indicate hyperinflation or nonspecific inflammation
Therapeutic management
* Assess respiratory status hourly; provide humidified 02 to ease respiratory ef*fort; use pulse
oximetry to assess 02 saturation
* Clear nasal passages with bulb syringe; elevate head of bed
* Cluster nursing care to allow for rest; assess anxiety level of parents and provide support; maintain
a calm environment
* IV fluids may be needed if oral intake is compromised; monitor strict I & 0; weigh daily to assess
fluid loss
* Maintain strict handwashing and contact precautions; caregivers should not care for other high-risk
children
* Medications: bronchodilators and steroids are sometimes used; prevention of bronchiolitis in highrisk children under age 2 may be achieved with use of palivizumab (Synagis) or IV RSV
immunoglobulin
FOREIGN BODY ASPIRATION
* Inhalation of an object into respiratory tract, intentional or otherwise
* The type and shape of object, as well as small diameter of an infant's airway, de*termines severity
of problem; round objects such as hot dogs, round candy, nuts, and grapes do not break apart and
are more likely to occlude airway; latex bal*loons are particularly hazardous; objects with irregular
shapes may irritate air*way and partially obstruct airflow
Assessment
* Sudden coughing and gagging is first sign, and objects in upper airway may be expelled by coughing
* Partial obstruction may cause symptoms of respiratory infection for days or even weeks; child may
have hoarseness, croupy cough, wheezing, and dyspnea
Therapeutic management
* Assess respiratory status to determine severity of problem and degree of ob*struction; continuously
monitor and provide assistance if obstruction worse
* If total airway obstruction occurs, perform back blows and chest thrusts for infants and Heimlich
maneuver in children older than 1 year
* Keep NPO; foreign body is usually removed in surgery
* Position for comfort and to optimize airway; provide emotional support to parents and child and
alleviate anxiety
* After removal of object, assess for additional obstruction that may result from laryngeal edema and
tissue swelling
Asthma
* When both antibiotics and aminophylline are administered intravenously, the nurse should check for
compatibility. If only one IV site is used, the nurse should use the SAS procedure (saline, administer
medication, saline) for administering medications. Administer IV doses using a controller.
* Clinets receiving aminophylline should be maintained or cardiorespiratory monitoring because
aminophylline affects cardia and respiratory rates as well as blood pressure. Because toxicity can
occur rapidly the nurse should monitor the client’s aminophylline level. Symptoms of toxicity are
nausea, vomiting, tachycardia, palpitations, hypotension. In extreme cases, the client could progress
to shock, coma and death.
* The therapeutic range for aminophylline is 10-20 mcg/mL.
Pneumonia
* Some medications used in the treatment of pneumonia require special attention:
* Tetracycline should not be given to women who are pregnant or to small children because of the
damage it can cause to developing teeth and bones
* Garamycin, an aminoglycoside, is both ototoxic and nephrotoxic. It is important to monitor the client
for signs of toxicity. Serum peak and trough levels are obtained according to hospital protocol. Peak
levels for Garamycin are drawn 30 minutes after the third or fourth IV or IM dose. Trough levels for
Garamycin are drawn 30 minutes before the third or fourth IV dose. The therapeutic range for
Garamycin is 4-10mcg/mL.
Pulmonary Embolus
* Remember the three Fs of fat emboli:
o Fat
o Femur
o Football player
* Most fat emboli come from fractured femurs; most fractured femurs occur in young men 18-25, the
age of most football players.
* Streptokinase is made from beta strep; therefore, clients with a history of strep infections might
respond poorly to anticoagulant therapy with streptokinase because they might have formed
antibodies.
* Streptokinase is not clot specific; therefore, the client might develop a tendency to bleed from
incision of injection sites.
Registered User
Received 278 Kudos from 61 posts
Join Date: Jun 2008
Posts: 64
Oct 27, 2008, 02:55 AM
Updated Oct 27, 2008 at 02:59 AM by SWEETDREAMERINSOCAL
Re: Anyoone up for random FACT THROWING??
Here are some things to review:
In a peds patient who has a low h/h the best approach for the nurse to
do is to plan nursing care around lengthy rest periods due to the inability of
rbc’s to carry O2 to the blood.
In a patient with Bulimia a nurse would expect to see a decreased K+ due
to the loss of electrolytes.
A peds patient who is postop placement of ventriculoperitoneal
shunt the nurse needs to assess for abdominal distention because CSF may
cause peritonitis or postop ileus as a complication of distal catheter
placement.
In a malfunctioning ventriculoperitoneal shunt the infant is most likely
to display irritability because of increased ICP.
After a tonsillectomy and adenoidectomy in a peds patient, increased
restlessness should be reported immediately because that is a sign of
hemorrhage as well as increased resp. rate and heart rate.
In a stage two skin ulcer, it is best to apply a hydrocolloid or foam
dressing as evidence shows that these best promote healing.
Tetany and parasthesia are signs of hypocalcemia as well as muscle
cramps and seizures. Hypocalcemia may be secondary to damage to the
parathyroid gland after a thyroidectomy.
Blood urea nitrogen (BUN) should be monitored closely after burns
to the body since the glomerular filtration rate is decreased with fluid shift.
Kidney function should be monitored closely otherwise, renal failure may
occur.
The peak air flow volumes decrease about 24 hours before clinical
manifestations of exacerbation of asthma.
If a woman complaints about painless vaginal bleeding while
pregnant, she should be prepared for an abdominal ultrasound as these are
signs and symptoms of placenta previa and it is diagnosed with an abd us.
A potential complication of renal bx (biopsy)is hemorrhage; therefore,
vital signs should be assessed to determine if this is happening.
Medications
Beta-blockers block the release of epinephrine to the cells therefore
resulting in hypotension which decreases libido and impotence.
Decadron increases the production of HCL acid, causing ulcers;
therefore it should be taken with milk or food.
PT should be monitored with Coumadin therapy; the dosage is ordered
daily based on the PT results. Coumadin affects the Vit K clotting factors.
Signs of digitalis toxicity include nausea, vomiting, abd cramps and halo
vision. K+ levels should be reviewed as low K+ levels lead to digitalis toxicity.
Patient should be taught take adequate K+ intake.
Infusion of a unit of packed RBC’s should be a limited to a max of over 4
hours.
Pancreatic enzymes for a child with cystic fibrosis should be taken with
every meal and every snack to allow for the digestion of all the food that is
eaten.
In a child who has ingested half a bottle of aspirin you would expect to
see epistaxis since the ASA lowers platelet levels and prolongs the bleeding
time.
When a patient is on Lasix, it is essential to include in the shift report the
urine output.
Lactulose will decrease lethargy if given to a patient, since this
removes ammonia from the patient’s body decreasing hepatic encephalopathy
which is lethargy and confusion.
Best site for injection for a 5 year old is the vastus lateralis muscle.
Dilantin causes swollen and tender gums; therefore good oral hygiene
must be maintained.
Signs of tardive dyskenisia include smacking lips, grinding of teeth and
“fly catching” tongue movements.
When administering a suppository the patient should be laying on
their left side. The suppository melts after 10-15 minutes therefore they can
move around.
Administering epinephrine supersedes maintaining airway in the
event of an allergic reaction to the flu shot. This is done when the patient has
not lost consciousness and is normotensive.
Foods and more
Foods rich in Iron include: red meats, fish, egg yolks, green leafy
vegetables, legumes, dried fruit, whole grains.
Sickle cell crisis should be symptom management; management of
pain would be a priority.
Cow milk should not be given to infants younger than 1 year.
Solid food should be added at 4-6 months of age one at a time and
should start with an iron fortified cereal.
NIDDM patients should keep a regular schedule of meals and snacks
and should be taught to read labels and make good choices about food.
Give a diet low in sodium when the patient is minimal change of Nephrotic
syndrome.
When a child has had mild diarrhea for two days they should continue
with regular diet and oral rehydration fluids.
Potato chips have no gluten in them therefore a child with Celiac
Disease should have this as a snack. Corn, rice, soybeans and potatoes
are digestible by persons with celiac disease.
A heart murmur would alert the nurse to a complication of Ineffective
Endocarditis.
A hematocrit of 60 on a patient with Diabetic ketoacidosis would
alert the nurse for immediate action as this means they are severely
dehydrated which all systems are at risk of hypoxia from a lack of or
sluggish circulation.
In the absence of insulin, fats and proteins are broken down by the body
to supply energy ketones, a by-product of fat-metabolism which can
accumulate and cause metabolic acidosis.
Excessive vomiting causes metabolic alkalosis because of the loss of
acid in the stomach and vice versa, diarrhea causes metabolic acidosis
because of the loss of bicarbonate.
Signs of metabolic alkalosis include irritability, increased activity,
hyperactive reflexes, muscle twitching and elevated pulse.
Assessment is the first step of the nursing process.
When a child is injured and appears to have fractured a leg,
assessment and inspection of the child is a priority.
Synthetic casts usually set in 30 minutes and dry in a few hours and the
patient can stand up in 24 hours.
Plaster casts (thicker) take up to 72 hours to dry and set. Both should
be uncovered in the first 24 hours because they give off a lot of heat.
Applying ice can relieve itching.
There is a strong relationship between Group A streptococci and
Rheumatic fever usually occurring within 2-6 weeks.
Live immunizations (MMR) should be delayed for the child with
Kawasaki’s Disease going home with immunoglobulin therapy because this
may interfere with the formation of antibodies.
Tracheoesophageal fistula priority nursing diagnosis would be
ineffective airway clearance and to prevent aspiration.
In asthma attack the airways are narrowed therefore a wheezing sound
results.
Slurred speech or changes in LOC may be indicators of continued
bleeding or extension of stroke in a patient admitted with possible CVA,
therefore slurred speech should be reported immediately for further testing.
In Hep C, findings may show many years later; for example having a
blood transfusion 15 years ago.
In a newborn with neural tube defect, the sac must be kept moist by
applying a moist sterile nonadherent dressing before closure. They
should be changed frequently to prevent drying.
A Milwaukee brace is used to correct curvature of the spine and is
usually long term (1-2 years) during the growing phase of the child.
Pain related to ischemia should be the priority nursing diagnosis in a
patient with a diagnosis of MI. Pain increase BP, pulse, O2 demand to
myocardium and anxiety.
When expiratory wheezes are suddenly absent in one lobe in a
patient with an acute asthma attack, this means an emergency because
the small airways have collapsed.
It is important to monitor hourly urine output on a patient who has
had a pulseless Dysrhythmia since the perfusion to the kidney was
diminished, this caused for the Glomerular perfusion to be diminished which
can lead to pre-renal failure.
If an infant is spitting up frequently and has a lot of gas, this may be
indicative of an allergy to the formula or experiencing GERD. Mucus
production, irritability and restlessness are some of the signs the infant will
display.
In a newly diagnosed Alzheimer’s patient the most helpful
intervention would be for the nurse to help the family find effective
communication strategies since this will help the family enhance their
ability to relate to the patient.
In a patient with Grave’s Disease (Hyperthyroidism), it is important
for the nurse to intervene if noted on the initial nursing assessment if
the patient has exophthalmoses (protruding eye balls). This can lead to
corneal abrasion or damage when the eyelid is not able to complete close over
the eyeball.
Signs of neuroblastoma include irregular abdominal mass the crosses
the midline, weight loss, pallor, irritability, anorexia and weakness.
An infant with respiratory distress syndrome is unable to maintain
alveolar surface tension due to the fact that the lungs did not mature
completely.
A child with Fetal Alcohol Syndrome will most likely display
s/slike deformities in the joints, limbs and fingers, thinned upper lip, small
teeth with faulty enamel and will have delayed development.
A child with pinworm will display s/s like itching in the perianal area,
bed wetting, irritability, poor sleep patterns, and short attention span.
last for today ..study hard
goal
toddlers ages 1-3, separation anxiety is at its peak.
When performing an assessment on a toddler, first approach the toddler with
minimal physical contact to gain his/her cooperation, then proceed slowly with
simple explanations prior to contact; be flexible.
The DTaP immunization is associated to have the most reactions like
crying inconsolably, child feels very warm and shaking spells. The immunization
is contraindicated if the reactions are severe or signs of encephalopathy within 7
days.
In a couple who has experienced a miscarriage, the best therapeutic
communication for the nurse to use is to help the couple begin the grieving process
by sharing their feelings and use support persons.
On the 2nd of a patient who experienced an MI, the focus should be on the
daily needs and what needs to be done that day.
When planning home care for a patient the nurse first needs to assess the
cognitive ability of the patient and the availability of a caregiver.
Animal dander is very common to affect children with asthma therefore
when interviewing the parents it is important to assess the child’s environment for
household pets.
A fracture in the epiphysis may result in retarded bone growth therefore
one leg being shorter than the other one.
Increased amounts of folic acid prevent neural tube defects; therefore
women of child bearing age should increase their consumption in dietary
supplements or diet.
For a four year old, it is best to relate time to a known event like supper,
dinner, breakfast, etc. since they don’t understand time completely.
Telangientatic nevi or stork bites are small salmon patches in that
disappear in 1-2 years of age.
To prevent lead contamination in infants, let tap water run for a few
minutes before filling up the bottle to mix it with formula.
Diagnosis of pediculous capitis may be made by observing whitish oval
specks sticking to the hair. Treatment consists of using of medicated shampoo
for children over 2 years old and meticulous brushing of hair.
The concrete operations stage consists of moral judgment and logical
thinking therefore a child can make the assumption that stealing is wrong.
The best response for the nurse to give to a client who is worried that her
spouse will not come near her after a mastectomy would be “ Are you
worried that the surgery will lead to changes?” since this leaves a channel open for
discussion.
The most effective intervention for a withdrawn patient is to give
opportunities to have interaction with one person since they feel uncomfortable
in social interaction.
The priority in accidental poisoning in children is to empty the child’s
mouth to prevent further ingestion of the substance.
More falls occur in the bedroom than anywhere else in the house, therefore
to prevent falls on elderly patients, night lights should be placed in the bedroom as
a priority intervention.
All healthcare personnel should be aware of balloon allergies since this is
an allergy to latex.
The best way to protect ourselves from a patient suspected of having TB
is to wear a particulate respirator mask.
Giving sips of water to a toddler who has ingested drain cleaner will help
dilute the corrosive substance prior to gastric lavage.
Seclusion should only be used when there is an immediate threat of
violence to staff, other patients or the patient himself. If it is not used
appropriately charges against the nurse may result in unlawful seclusion and
restrain even though the patient cooperated.
If a patient had MRSA and passed away the body should be labeled with
MRSA so contact precautions can be implemented.
The immediate action by a nurse who just got stuck with a needle is to
wash the site vigorously.
A four year old can help with the care of an infant when he is supervised
and helps feel the four year old not left out and encourages bonding with the infant.
A child with severe deep abrasions over 98% of his body is considered to
not survive since the deep abrasions should be thought of as 2nd or 3rd degree
burns. The child is at great risk of both infection and shock.
In accidental poisoning it is most important to identify the substance that
was ingested, then the age and weight of the child to prepare the antidote that is
needed and then the time of ingestion.
If the advance directive is available when a patient comes in and is
unconscious, that should be given the priority to guide the care of the patient.
Employers must provide reasonable accommodations for disabled
individuals based on the Americans with Disabilities Act.
Assertive communication respects the needs of all parties to express
themselves therefore requesting a private meeting with a provider that is
loudly criticizing a nurse and the nurse is the most appropriate thing to do in order
to protect patients and other staff from the display.
Effective time management for a nurse manager is also setting goals and
prioritization of the work.
Nurses are more satisfied with autonomy and control. This improves team
morale.
Patients who were admitted voluntarily can request to be discharge any
time they want in a psychiatric facility as long as they are not a threat to
themselves or others.
If a nurse is reluctant to interact with a patient, she must discuss feelings
with a peer or supervisor so she can discover attitudes and feelings that influence
nurse-client relationship.
The LVN should not have the care of a patient who was newly admitted
and has not had stability established.
When large amounts of fluids are given to a patient in a short period of
time the priority is to Auscultate the patient’s lungs since the fluid overload may
lead in worst cases to heart failure with lung congestion.
In the Glasgow’s Coma Scale, any score less than 13 indicates neurological
impairment.
When a psych patient is sharing his grandiose ideas, the best therapeutic
approach is to listen quietly without commenting on it.
When a patient is depressed and states a desire to not live anymore, the
best approach is to ask about thoughts of hurting themselves.
Repeated actions of OCD are done to relieve anxiety.
Neologism is associated with a thought disorder and it means that the
patient invents new words to describe something that no one else understands.
In a psych setting, the nurse should limit contact to handshaking has
hugging may be interpreted by the patient as sexual advances.
The therapeutic milieu is meant to provide safety and test for grounds for
patterns of new behaviors.
A depressed patient is at highest risk of committing suicide 7-14 days
after they start meds or therapy because that is when they gain the energy to go
on with the plan.
Dental erosion and parotid gland enlargement are signs of bulimia since
the parotid gland enlarges due to the self induced vomiting and the teeth get
damaged by the acid in the stomach.
few more to share:
Flail chest is caused by fracture of multiple
adjacent ribs, causing the chest wall to become
unstable and respond paradoxically. The chest in
the affected side is pulled inward during inspiration
and bulges outward during expiration.
5-digit system (GTPAL)–
1st digit accounts for the # of times the uterus has
been pregnant,
2nd is the # of term deliveries,
3rd is the # of preterm deliveries,
4th is for the # of abortions and
5th is the # of living children.
Hemoglobin A1c –
7% or less indicates good control,
7%-8% indicates fair control and
8% or higher indicates poor control.
This test measures the amount of glucose that has
become permanently bound to the RBC from
circulating glucose.
At the end of 12 weeks gestation th
e sex of the baby can be determined by the
appearance of the external genitalia.
Gynecoid pelvis is a normal female pelvis and is
the most favorable for successful labor and birth.
Android pelvis (resembling a male pelvis) would
not be favorable for labor because of narrow pelvic
planes.
An anthropoid pelvis has an outlet that is
adequate, with platypelloid pelvis (flat pelvis) has
a wide transverse diameter, but the
anteroposterior diameter is short, making the
outlet inadequate.
Ballottement is a technique of palpating a floating
structure by bouncing it gently and feeling it
rebound. In the technique used to palpate the
fetus, the examiner places a finger in the vagina
and taps gently upward causing the fetus to rise.
The fetus then sinks and the examiner feels a
gentle tap on the finger.
12 week gestation the fundal height should be at
the umbilicus
Second stage of labor begins when the cervix is
dilated completely and ends with birth of the
neonate..
12-month-old infant –
RR: 20-40 breaths/min,
HR: 90-130 beats/min,
BP: 90/56 mmHg
Toilet training – bowel control usually is achieved
before bladder control. The child should not be
forced to sit for long periods. The ability to remove
clothing is one of the physical signs of readiness.
The physical ability to control anal and urethral
sphincters is achieved some time after the child is
walking, between 18-24 months.
Ageism is a form of prejudice in which older
adults are stereotyped by characteristics found in
only a few members of their group. Fundamentals
to ageism are the view that older persons are
different from “me” and will remain different from
“me”. Therefore, they are portrayed as not
experiencing the came desire, needs and concerns.
Reye syndrome – decreasing stimuli and
providing rest decreases stress on the brain tissue,
checking for jaundice will assist in identifying the
presence of liver dysfunction that occurs in Reye’s
syndrome. The vomiting that occurs is caused by
cerebral edema and is a symptom of increased
intracranial pressure.
Ventriculoperitoneal shunt – Treatment for
hydrocephalus. If the shunt is broken or
malfunctioning, the fluid from the ventricle part of
the brain will not be diverted to the peritoneal
cavity. The CSF will build up in the cranial area.
The result is increased ICP, which then causes a
high-pitched cry in the infant.
Myringotomy is the insertion of
tympanoplasty tubes into middle ear to
equalize pressure and keep the ear aerated.
Parents should be instructed that the child should
not blow his or her nose for 7 to 10 days.
For children younger than age 3, the auditory
canal is straightened by pulling the lobe down and
back.
For children older than 3, the pinna is pulled up
and back.
Feeding an infant with cleft palate, ESSR –
enlarge the nipple;
stimulate the sucking reflex,
swallow and
rest to allow the infant to finish
swallowing what has been placed in the mouth.
Pertussis is transmitted by direct contact or
respiratory droplets from coughing. The
communicable period occurs primarily during the
convalescent phase.
Proper steps in administering vaccines:
The nurse should first verify the order and then
obtain parental consent. The nurse should also
question the parents about the presence of any
allergies in the child. The nurse should next
prepare the injection and document the lot number
(located on the medication vial) of the vaccination.
The nurse then selects an appropriate site and
administers the vaccination. The nurse then
documents that the vaccination has been
administered and provides an updated
immunization record to the parents.
Psoriasis occurs equally among women and men,
although the incidence is lower in darker skinned
races and ethnic groups. A genetic predisposition
has been recognized in some cases. Emotional
distress, trauma, systemic illness, seasonal
changes, and hormonal changes are linked to
exacerbations.
CUSHING’S SYNDROME - A diet low in
carbohydrates and sodium but ample in protein
and potassium is encouraged for a client with
Cushing’s syndrome. Such a diet promotes
weight loss, reduction of edema and hypertension,
control of hypokalemia, and rebuilding of wasted
tissue.
Asterixis is irregular flapping movements of the
fingers and wrists when the hands and arms are
outstretched, with the palms down, wrists bent up,
and fingers spread. Asterixis is the most common
and reliable sign that hepatic encephalopathy is
developing.
Cranial nerves III (oculomotor), IV
(trochlear), and VI (abducens) have only
motor components and control, in a
coordinated manner, the six cardinal fields of
gaze. This is tested by moving an object in six
directions (involving horizontal and diagonal
movements). Corneal reflex is the function of the
trigeminal nerve (cranial nerve V). Pupillary
response and accommodation is the function of
cranial nerve III (oculomotor) alone.
Individuals at risk for developing a latex
allergy include health care workers, individuals
who work in the rubber industry or those who have
had multiple surgeries, have spina bifida, wear
gloves frequently, such as food handlers,
hairdressers, and auto mechanics, or are allergic to
kiwis, bananas, pineapples, tropical fruits, grapes,
avocados, potatoes, hazelnuts, and water
chestnuts.
To test for Kernig’s sign, the leg is raised with
the knee flexed. Then, the leg is extended at the
knee. If any resistance is noted or pain is felt, the
result is a positive Kernig’s sign. This is a common
finding in meningitis.
Brudzinski’s sign occurs when flexion of the head
causes flexion of the hips and knees.
Chvostek’s sign, seen in tetany, is a spasm of the
facial muscles elicited by tapping the facial nerve
in the region of the parotid gland.
Trousseau’s sign is a sign for tetany in which
carpal spasm can be elicited by compressing the
upper arm and causing ischemia to the nerves
distally.
Late decelerations are correlated with
uteroplacental deficiency.
+ PKU – offer the infant Lofenalac; infant lacks
enzyme necessary to convert phenylalanine to
tyrosine that causes accumulation in the tissues
and leads to mental retardation. Lofenalac is low in
phenylalanine but contains minerals and vitamins
required by the infant.
Codeine phosphate (Paveral) – analgesic used
for moderate to severe pain for Hemophilia A.
Terbutaline (Brethine) – S/E are maternal
tachycardia nervousness, tremors, headache, and
possible pulmonary edema. Fetal S/S includes
tachycardia and hypoglycemia.
Perphenazine (Trilafon) – can cause
extrapyramidal side effects.
Thiothixene (Navane) is an anti-parkinsonian
agent, used to counteract extrapyramidal side
effects.
Procainamide HCL (Pronestyl)– A/E severe
hypotension or bradycardia.
Ketoconazole (Nizoral) – drug of choice for
treatment of candidiasis (mouth pain, difficulty
swallowing and a white discharge in the back of
the throat.
Hyponatremia – headache, apprehension,
lethargy, muscle twitching, convulsions, diarrhea,
fingerprinting of skin.
Right-sided heart failure is manifested by
congestion of the venous system, resulting in
peripheral edema. Also there is congestion of the
gastric veins, resulting in anorexia and eventual
development of ascites.
Gemfibrozil (lopid) – lipid-lowering agents used
with patients with high serum triglyceride levels.
S/E abdominal pain, cholelithiasis; taken 30
minutes before breakfast and supper.
Monitor aspartate aminotransferase (AST) for
liver function. Normal AST 8-20 units/L and
normal ALT 8-20 units/L.
Hydrochloride (Zantac) – taken at hour of sleep.
Hip spica cast – patient complaining of pain,
assessment symptom of circulatory impairment
from cast by pressing nail of great toe to indicate
circulatory function. Compare speed with which
color returns with result on the opposite side.
Sluggish return indicates circulatory impairment;
too rapid return indicates venous congestion.
Addison’s disease – steroid replacement is the
most important information the client needs to
know.
Fluoxetine HCL (Prozac) is an “energizing”
antidepressant; positive response would be an
increased energy level and being able to
participate more in milieu.
Hemolytic reaction of blood transfusion – N/V, pain in
lower back, hematuria. Most dangerous type of reaction.
sympathetic-dilates pupils, inhibits salivation, relaxes bronchi, accelerates heart, inhibits digestive
activity, stimulates glucose released by the liver, secretes epi & norepi from kidney, relaxes bladder,
and contracts rectum.
parasympathetic-constrict pupils, stimulates salivation, inhibits heart, consticts bronchi, stimulates
digestive activity, stimulates gallbladder and contracts bladder, also relaxes the rectum.
They are the opposite of each other. Good luck studying!!!
THERAPEUTIC LEVELS
while i was reading this thread, someone ask to post about the theraputic levels, but a little was
discussed so im just listing some common drugs..
Acetaminophen-------------------------- 5-20 ug/ml
Acetylcysteine-------------------------- 5-20ug/ml
Carbamazepine (Tegretol)---------------- 3-14ug/ml
Cycloserine----------------------------- 25-35ug/ml
Digoxin (Lanoxin)------------------------ 0.5-2ng/ml
Digitoxin (Crystodin)--------------------- 15-25ng/ml
Gentamycin (Garamycin)----------------- 5-10ug/ml
Lidocaine (Xylocaine)-------------------- 1.5-5ug/ml
Lithium (Lithobid)------------------------ 0.5-1.3mEqL
Magnesium So4-------------------------- 4.8-8mg/dL
Phenytoin (Dilantin)---------------------- 10-20mgug/dL
Phenobarbital (Luminal)-------------------10-30ug/ml
Procainamide (Pronestyl)-----------------4-10ug/ml
Propanolol (Inderal)----------------------50-100ng/ml
Salicylate (Aspirin)----------------------100-250 ug/ml
Theophylline (Aminophylline)--------------10-20ug/ml
Vancomycin-----------------------------30-40ug/ml
1. Ritalin should be administered after the child has eaten breakfast
2. Oligohydramnios is associated with intrauterine growth restriction.
3. Varicose Veins predispose the client to thrombophlebitis.
4. Bile drainage for the first 24 hours is 300-500 mL
5. Early Heart failure characteristic = Increased Respiration rate
6. T-tube is not irrigated!
7. Rocker bottom feet is found in infatns born with Trisomy 18
8. ECG should be done before taking imipramine (Tofranil)
9. Antidote to morphine = Naloxone (Narcan)
10. Tinnitus is a common symptom of aspirin toxicity
Hope those are helpful
PRIORITY
Emergent Priority (1st): requires immediate attention and continuous evaluation yet have a high
survival rate
-trauma
-chest pain
-severe respiratory deficits
-chemical splashes to the eyes
Urgent Priority (2nd): injuries non life threatening - .treated within 1-2 hours and are evaluated every
30 to 60 minutes thereafter.
-simple fracture
-asthma without respiratory distress
-fever
-hypertension
-abdominal pain
-renal stone
Nonurgent Priority (3rd): clients can wait several hours before being seen and require 1-2 hours of
evaluated thereafter.
-minor laceration
-sprain
-cold symptoms
So if someone came in with a chest pain because they ate something wrong and another person that
came in with a high blood pressure, do pick the chest pain first.
DELEGATIONS
CNAs
-skin care, feeding, toileting, vital signs (not initials), height, weight, I & O, ROM exercises,
ambulation, transporting, grooming, and hygiene measures of stable clients.
LPNs/LVNs
-physiologically stable clients with predictable outcomes
-dressings, suctioning, urinary catheterization, med administrations (only oral, subcutaneous, and
intramuscular), no rectal or IV meds
RN associated:
-care for individual in a structured health care environment
RN BSN:
-care for individuals, families, groups, and communities in both structured and unstructured health
settings.
RN (all):
-assessment/planning care, initiating teaching, IV meds
RN can not delegate these tasks:
-initial assessments of clients
-evaluation of client data
-nursing judgment
-client/family education/evaluation
-Nursing diagnosis
These are my fives
1) Hypocalcemia < 8.6 mg/dl manifested by prologued ST-interval on EKG and prologued QT-interval.
2) A patient with hypocalcemia has to have a heart monitor and placed on seizure precautions.
3) A patient with hypocalcemia would be positive sign to Chvostek's and Trousseau's sign and would
show hyperactive deep tendon reflexes.
4) ST-interval on the EKG represents ventricular repolarization.
5) QT-interval last 0.32-0.4 secs. it represents the time needed for ventricular depolarization. feliz3
A new nursing graduate is attending an agency orientation regarding the nursing model of
practice implemented in the facility. The nurse is told that the nursing model is a tam
nursing approach. The nurse understands that planning of care delivery will be based on
which characteristic of this type of nursing model of practice?
1.A task approach method is used to provide care to clients
2.A single RN is responsible for providing nursing care to a group of clients
3.Managed care concepts and tools are used in providing client care
4.Nursing personnel are led by an RN leader in providing care to a group of clients.
I need you help! Thank you
!
That's my answer NO. 4. Team nursing model is led by an RN seen this in saunders
Pharmacology Notes:
Librium - antianxiety used to tx symptoms of acute alcohol withdrawal.
Cogentin - used to tx parkinsonian side effects of Thorazine (antipsychotic med)
Methadone Hydrochloride - opiod analgesic; tx for narcotic withdrawal
Procardia - antianginal med (CCB) decreases myocardial O2 demand.
Digoxin - strengthens myocardial contractio0n & slows conduction thru AV node
Coumadin - inhiits prothrombin synthesis
Amicar - antifibrinolytic; prevents recurrence of subarachnoid hemorrhage.
Lithium - tx manic phase of bipolar
Nimodipine - CCB; decreases spasm in cerebral blood vessels
Diltiazem - CCB; inhibits Ca+ influx in vascular smooth muscle; reduces myocardial O2 demand &
decreases force of ventricular contraction
Clotrimazole - antifungal; treats rashes.
Terbutaline (Brethine) and Magnesium Sulfate- treatment for preterm labor
Dilantin can cause gingival hyperplasia, advise good oral hygiene and freq. dental visits, IVPush for
Dilantin should be - 25-50 mg/min (or 2-3 mins)
Pharmacology - any of the –mycin - check for tinnitus or hearing loss
Don’t give beta blockers to anyone with respiratory problems i.e asthma, copd.
Vasopressin is also known as antidiuretic hormone
NEVER NEVER NEVER administer KCl via IV push.
Beta Blockers and ACE Inhibitors are less effective in African Americans than Caucasians.
Vinca Alkaloids (Vincristine) lead to neurotoxicity and can present with numbness and tingling in
the legs or paralytic ileus.
No narcotics to any head injury – won’t be able to accurately assess LOC, so pick the narcotic if you
have an order to question.
Mannitol for ICP
Narcan is given for to reverse respiratory depression...a rate of 8 or less is too low and requires
nursing action.
Celebrex is contraindicted in pts with a history of cirrhosis.
Foscarnet (Foscavir) can be toxic to kidneys so creatinine is monitored.
Calcium isn't an antidote for hypermagnesemia. Renal filtration is how excess Mg is removed-- that or
of course dialysis.
Instead, calcium helps to stabilize the electrical gradients of muscle and nerve cells, which helps to
prevent dysryhthmias.
Hi,
I want to make a few comments about two medications on your list, the first one is magnesium
sulfate which is also an antidysrhythmic that suppress dysrhythmias by inhibiting abnormal pathways
in the electrical conduction system of the heart. This drug also is used as anticonvulsant for seizure
prevention in pregnant women with eclampsia. This antidote to this drug is calcium gluconate. A
person given an infusion of magnesium sulfate needs to have a heart monitor in place, frequent
assessment of respirations, blood pressure and neurological functions. This drug cannot be given with
food because food affects its absorption. It is imperative to monitor respirations when using this drug
because one of the sides effects of it is reduced respiratory rate. This drug is contraindicated if the
patient has a heart block, myocardial damage or renal failure. If the patient has preeclamsia this drug
is continued for the first 12 hours postpartum. High doses of this drug can cause loss of deep tendon
reflexes, heart block, respiratory paralysis and cardiac arrest. You must have calcium gluconate
readily available in case the patient manifests drug toxicity symptoms.
Mannitol(Osmitrol) is another drug used with extreme caution for clients with increased intracraneal
pressure. First, this drug comes in in chrystal form which needs to be dissolved in warm water and the
nurse must use a special filter in the syringe before administering this drug. Must monitor renal
function for diuresis is expected...meaning the patient is going to urinate a lot for this drug draws fluid
from the brain cells. A patient with increased intracraneal pressure must have the head of the bed
eleveted 30 degrees, by the way. feliz3
what does sympathetic and para sympa do to our body?
i messed up ^^ just want to make sure... tnx guys
This is how I remember it...hope it helps you.
p-sympth ( cholinergic)
feed/breed
actelycholine
increase GI, Gu, decrease BP, heart rate, resp, const. pupils
Sympth (adrenergic)
fight/flight
epi, norepi, dopamine
increase BP, heart rate, resp.,decrease GU, GI, dilate pupils
Another thing I want to add concerning Mannitol is that this drug has to have a port of its own,
meaning, it cannot go through the same port with other drugs for there is a risk to form crystals
when in contact with other drugs through the port wall. This fact is true about Dilantin
(anticonvulsant) and Potassium. Potassium cannot be given IVPush or intramuscular injection ever
because Potasium is caustic, and it will burn and possibly colapse the patient's vein. It is imperative to
assess the needle site where potassium is infused for signs of infiltration, phlebitis and cellulites.
Potassium when given IV must be diluted, the patient must have a renal assessment and have
a heart monitor in place. feliz3
Giving in to a child’s temper tantrum is detrimental to the child’s emotional health. It
teaches the child that if they have a tantrum, they will be given what they want. Giving in to
a temper tantrum leads to habitual tantrums that can extend far past three years of age.
When a child has their first tantrum, caregivers can try to soothe and calm the child. If the
child is unresponsive to the attempts made to soothe their frustrations, caregivers should
ignore the tantrum.
When a child realizes that he or she will not be indulged or rewarded for their tantrums,
temper tantrums generally subside.
THERAPEUTIC LEVEL
10-20 mcg/ml
Theophylline
Acetaminophen
Phenytoin
Chloramphenicol
Serum Digoxin - 0.5 - 2 mg/dL
Carbamazepine - 4 - 12 mcg/dL
One is resistant to Vancomycin and the other is resistant to Methicillin.
(Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Staphylococcus
aureus)
Vancomycin as the drug of choice for treatment of methicillin-resistant
Staphylococcus aureus (MRSA) and (VRSA) is susceptible to trimethoprim/sulfamethoxazole,
minocycline,linezolid, and quinupristin/dalfopristin.
Precautions are contact and you can place these patients in rooms together or private
Preop teaching for lobectomy pt - sitting position, the client will take a deep breath,
exhale through the mouth, and cough from deep in the lungs.
Ativan- used for symptoms of severe anxiety: rapid pulse, diaphoresis, tightness in the
chest, and inability to see connections between details.
Patient identification - check the chart against the name and hospital number on the
client’s armband; in the hospital environment the client should not participate in his
identification.
Child with RSV involves contact with a medication (Ribavirin) that is teratogenic and is
classified as Pregnancy Risk Category X
Age 12 months - hepatic metabolism of drugs is similar to an adult.
Most impt cause of adverse drug reaction in older adults - reduced renal excretion
Until the child walks or is 1 year of age, the vastus lateralis muscle is the preferred
injection site.
Robaxin - a muscle relaxant.
Buccal medications - administered by placing the medication between the upper molar
teeth and the cheek; should not be swallowed and should not be administered with water.
An oral syringe or a pediatric medication dispenser is a useful device for measuring small
quantities of medications for infants; it is placed at the side of the mouth.
Nasal drops - position the head back over the edge of the bed or pillow with the head
turned toward the side
Vaginal suppository - should be lubricated with a sterile water-based jelly and inserted
approximately 3 to 4 inches into the vaginal orifice; dorsal recumbent position, not on the
side.
To reduce pain during IM injection - applying pressure at the site of an IM injection may
reduce the pain experienced by the client.
Fluid overload - may experience headache and dizziness from the increase in circulating
volume, which increases cerebral vascular pressure.
Long-term NSAIDs use impairs ability to clot; NSAIDs decrease platelet adhesiveness or
stickiness, which impairs coagulation
Sulfonamides, tetracyclines, phenothiazines - photosensitivity is common to all of these
medications.
Increasing fluid intake - important with sulfonamides to prevent crystalluria.
Unusual bruising - early indication of an untoward effect of phenothiazine, which is
associated with bone marrow depression.
IgG - major antibody against viruses and bacteria. IgG is the principal mediator of the
secondary immune response..
IgA - secretory immunoglobulin found in tears, saliva, and mucous secretions of the lungs
and gastrointestinal tract
IgE - mediates allergic reactions
Oral polio, measles-mumps-rubella, and varicella vaccines - contraindicated in the
immunocompromised client.
Cyclosporine - powerful immunosuppressant and is the drug of choice for preventing organ
rejection after allogenic transplantation. Common s/e are hyperglycemia, infection, tremor.
Valacyclovir (Valtrex) - form of acyclovir, which is indicated in the oral treatment of
herpes zoster and recurrent genital herpes in immunocompetent adults.
Oncological emergencies - life-threatening problems that arise as a result of the tumor or
the treatment. They may be obstructive —superior venal caval syndrome, third space
syndrome, spinal cord compression, or intestinal obstruction; metabolic — SIADH,
hypercalcemia, tumor lysis syndrome, septic shock, and disseminated intravascular
coagulation (DIC); and infiltrative — cardiac tamponade and carotid artery rupture.
both systolic and diastolic blood pressures tend to increase with normal aging, but the elevation of the
sytolic is greater.
-Tachycardia is the major side effect of tocolytic drugs. (brethine, Yutopar)
-Although Flagyl is the treatment of choice for some vaginal infections, it is contraindicated in the first
trimester of pregnancy
-Clients with abruptio placentae or placenta previa should undergo no abdominal or vaginal
manipulations.
-HgB norms for children
Newborn: 14-24
Infant: 10-15
Child: 11-16
-take axillary temp in children with congenital megacolon
-paralytic ileus is a common problem in comatose clients. A gastric tube aids in gastric decompression.
-the body's response to illness and stress is to produce glucose. therefore, any illness results in
hyperglycemia.
-an early sign of colon cancer is rectal bleeding.
-restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload.
-during aortic aneurysm repair, the large arteries are clamped for a period of time, and kidney
damage can result.
-normally, kidneys excrete approximately 1 ml or urine per kg of body weight per hr, which is about 1
or 2 liters in 24 hrs.
-exposure to tobacco smoke is the primary casue of COPD in the US
-the symptoms of anterior MI characteristically last more than 15 min and are more intest than
angina.
-before drawing blood for an ABG, check Allen test to assess collateral circulation.
Pseudomembranous colitis may result from a superinfection with C. difficile during clindamycin
therapy.
Risperidone (Risperdal) has a lower incidence of extrapyramidal effects than do the typical
antipsychotics. Risperdal does produce anticholinergic effects, and neuroleptic malignant syndrome
can occur.
Erythromycin is the drug of choice for treating Legionnaires' disease.
Warfarin is used to prevent clot formation.
Pinworms come out of the intestine through the anus at night to lay eggs, causing perianal itching.
The child wakes up and may begin scratching. Eggs under the fingernails are carried to the mouth if
the child chews on his nails, and the life cycle of the pinworm continues. In addition to teaching
children not to bite their fingernails, parents should keep the nails short and encourage hand washing
before food preparation and eating
Adverse reactions to gentamicin include ototoxicity and nephrotoxicity. The nurse must monitor the
client's hearing and instruct him to report any hearing loss or tinnitus. Signs of nephrotoxicity include
decreased urine output and elevated BUN and creatinine levels
Gentamicin has a therapeutic serum medication level .
therapeutic range= 5-10mcg/ml meaning a serum amount
of this medication beyond that range the nurse must assess
cranial nerve VIII(auditory) and assess for symptoms of kidney
problems, talk to the doctor about a higher drug range than
recommended and document it. Educate patient about side effects
and to report immediately what the patient is experiencing. feliz3
Pernicious Anemia= Vitamin B12 deficiency caused by impaired absorption of Vit. B12. The body will
not make enough red blood cells for lack of vitamin B-12. This type of anemia is seen in patients who
have lost the ability to absorb Vit. B-12, the elderly, alcoholics and in patients with stomach surgery,
or gastritis. Pernicious anemia is due to the lack of a stomach protein which helps in the absortion of
Vit. B-12. This protein is called intrinsic factor which is produced by the gastric cells. Vit. B-12 is
absorbed in the ileum. Patients with problem with the ileum need to be watch for pernicious anemia.
Injections of intrinsic factor are given to patients with Vit. B-12 deficiency, it could be done once a
week or once a month, but they must have that injection, and an insulin syringe used for giving
intrinsic factor shots. Lab tests needed CBC, neurological assessment, lack of vit. B-12 may change
the surface of the tongue and shrink or thin the stomach lining. feliz3
From my previous post clarification when to use this sequence for type of examination Hope
this helps. S
Abdominal Assessment Sequence
Inspection
Auscultation
Percussion
Palpation
In this order because sequence prevents altering bowel sounds. By performing palpation before
auscultation.
BUT for all other assessments
Inspection
Palpation
Percussion
Auscultation
Tidal volume refers to the volume of air inspired and expired with a normal breath.
Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a
forced inspiration.
Forced vital capacity is the vital capacity performed with a maximally forced expiration.
Residual volume is the maximal amount of air left in the lung after a maximal expiration.
According to the American Heart Association,these should be perform during cardiac arrest
1. the nurse should first assess responsiveness.
2.If the client is unresponsive, the nurse should activate the emergency medical system 3.call for a
defibrillator.
4.Next, the nurse should assess breathing by opening the airway and then looking, listening, and
feeling for respirations.
5.If respirations aren't present, the nurse should administer two slow breaths,
6. then assess the pulse.
7.If no pulse is present, the nurse should start chest compressions.
Ketoacidosis early symptoms:
1)thirst or dry mouth
2)frequent urination
3) increased glucose levels
4) increased level of ketones in urine
ketoacidosis late symptoms:
5) constantly feeling tired
6) dry, flushed skin
7) nausea & vomiting
8) short, deep breaths (Kussmal's breathing pattern)
9) fruity breath odor
10) confusion
This is seen in people with diabetes mellitus type and rarely seen in patients with diabetes II---older
people with diabetes II may be the exception. When blood glucose is greater or equal to 240 mg/dl
test urine for ketones every 4-6 hours. An infection and a fever will increase blood sugar levels in
diabetics.
Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) symptoms:
1) blood sugar level greater or equal to 600 mg/dl
2) dry, parched mouth
3) extreme thirst (may gradually disappear)
4) warm, dry skin that does not sweat
5) high fever (greater or equal to 101 F degrees)
6) sleepiness or confusion
7) loss of vision
8) hallucinations
9) weakness on one side of the body
10) dark urine
Prone to happen to patients with diabetes II (non insulin dependent) Usually brought by an illness or
an infection.
feliz3
Marijuana: causes hunger
Boy being evaluated for DM expect: bed wetting (Poyuria).
MVA – unonscious head injury Higest priority: turn patient q 2 hours
Left sacrum posterior= Assess FHR: above ubilicus on mother’s left side
Liver biopsy Exhale hold breath
T Tube 12 hours post cholesectomy of:300 ml drainage good/ok
document
Delay in development in a 9 month old is: child uses a palmar grasp to
hold objects (p234 Prentice Hall) This should have disappeared at 1-3
months
Radium Implant Cervical Cancer nurse should: Keep the used linen in
room till implants are removed
If patient states I can’t feel my toes: Assess by checking skin
temperature of Foot. **NOT ask him to wiggle toes!!
Adrenocortical Insuffciency nurse would expect: Decreased sodium,
glucose, Increased potassium
FHR initally 150, after apex of contraction: The FHR drops to 12; when
contracion is completed the FHR is 130 this is: Late Deceleration
DPT @ 4 wks than again at ?
Infant cutting teeth: has 26 teeth
Women 35 weeks getation (I find unexpected):
Rbc: 4.9
HGB: 15
HCt: 45%
Conversion (Defense Mechanism): Client converts his anziety over
school performance on exams into a physical symptom that interfers
w/ability to perform e.g. “I was unable to take my final B/C I was unable to
write.
Obbssive compulsive ritual: means patient is attempting to achieve:
Avoid severe levels of Anxiety (not exressing anxiety- but strategy to avoid
it)
Calan Verapamil a Ca Chanel blocker (CCB) that depress myocardial
contractions, dialates : used along with otherantihypertensves can cause
HTN,
HRT Failure assess: for peripheral edema
Early Fetal deceleration: a slowing early in the conraction, usually a
normal finding on heart tracings
Myelogram test involves a lumbar puncture: w/ injection of contrast
media alllowing x-ray visual of vertebral canal.
Total hip replacement: Okay for side lying as long as abduction is
maintained
Cuffed Tracheostomy tube in place: purpose of cuff is to  risk of
aspiration intro trachea by the cuff sealing the tracheostomy from the
trachea
ECT




Can dissrupt short term memory
Can cause HA
Can cause transiet confusional state
Report “Backache” to MD S/P ECT B/C it’s NOT USUAL AFTER
ECT!
Infant Reflexes
Moro’s Reflex
Dissappears after 3 to 4 months
Suddan jarring extention & abduction of extremities &
Fanning of fingers w/index finger & thumb in C-shape
Tonic Neck Reflex
Disappears 3 to 4 months
When head is turned to side arm & leg extends on that side &
Oppisite arm/leg flexes
Grasp Reflex
Touching palms of hands on soles of feet cause flexion of hands/toes
Palms Grasp
Disspear after 3 mos
Planter Grasp
Lessened by 8 mos.
Babiniski Reflex
Disappears after 12 months
Toes will fan out
Incision line is Red: Complication (swelling under sutures is expected)
Feeding tube feedings:
Rinse bag Change form every 4 hours is approprate B/C there is an
of organisms after 4 hours

growth
Health Promotion & Maintance Safety
Droplet precautions
Meningococcal meningitis = Droplets
Wear: gown
Gloves
Mask
Goggles
**(NOT FOR: Lyme disease (ticks) Pnumonia Carnii)
TB= Droplet
Meningococcal vaccine
High risk group: college students B/C dorms / closed quarters can be viral
or bacterial worse B/C of excudate
Total hip patient: Place in a room with a patient w/blanced suspension
traction (clean with clean)
Sickle Cell Crisis: clean so place in a room with patient with multiple
sclerosis (MS)= (clean also)
Lyme DX: connectient Lyme, connectient
ABT: usually BID
Pottery Cup: Lead poisoning potential
*Toxic Hepatitis : From a medication (commonly Tylenol)…considered
Safe/clean Patient
Cesium implant : for CA of Abdomen- Ok to disgard
Urine /geces
In hospital bathroom
(Does not need biohazard container)
Unidentified contaminent exposed :
Frist- determine the ceontamination that occurred in the field
(doesn’t matter which type of contaminate it was)
Trunk toys= dangerous
Amniocentesis at 16 weeks gestation: Nurse should have patient
void/empty bladder prior to amniocentesis.
Re: Anyoone up for random FACT THROWING??
a couple more facts and I off to bed....
Brain Hemisphere Function
Left hemisphere
-detail
Sequential, logical, analytical
Decodes the sequence and structure of language
Right hemisphere
Processes information
Associated with imagination
Spatial perception
Lobes
Frontal Lobe
Cognition
Memory
Prefrontal ability to concentrate
Gate keeper to judgment and inhibition
Personality and emotional traits
Movement
Motor cortex
Controls voluntary motor activity
Language controls motor speech
Parietal
Processes sensory input sensory discrimination , body orientation
Occipital
Controls primary visual reception area and visual association
Temporal
Controls auditory receptive area and association areas
Controls language and memory.
Re: Anyoone up for random FACT THROWING??
[FONT='Times New Roman','serif']mnemonics[/font]
[FONT='Times New Roman','serif']To remember the clinical findings associated w/UTI think urinary
tract is FULL of infection:
F-frequent urge to void
U-urine that is foul smelling and cloudy
L-low grade fever
L-lethargy
No P No K.
If the patient isn't peeing, they are probably retaining potassium, therefore they shouldn't be
getting it.
Nursing Considerations for renal failure --KIDNEY:
K - Keeping fluid balance
I - Inspecting the skin for Pruritus
D - Dietary Instructions
N - No to Acidosis
E - Electrolyte imbalance maintainance
Y - Your blood counts
ASSESSMENT on dehydration
D=dry skin & mucous membrane
E=eyeball/fontannel sunken
H=hypotension
Y= you feel coolness/mottling of the extremeties
D=delayed capillary filling time
R= response to stimuli/LOC changes
A= absence of tears
T=tachycardia
I=increase urine specific gravity
O=oliguria
N=no/loss skin turgor and elasticity[/font] stomatitis




provide and instruct patient on good oral hygieneinspect mouth regularly, use non-alcoholic
mouthwash (e.g.)diluted hydrogen peroxide),removal of ill-fitting dentures, use of soft-brsitled
toothbrush
provide health teachings on the importance of:
o keeping mucous membranes moistlet patients suck on popsicle
o avoidance of hot and spicy foodspasta and tacos
o avoidanceof acidic and/or carbonated food and drinks,cola, orange juice, grapefruit
juice
o keeping food at room temperature or slightly cool
apply water-soluble lubricant such as KY jelly to dry, cracked lips
offer viscous lidocaine before meals to minimize discomfort
more to come later:
A prickling sensation is an indication of compartment syndrome and requires immediate
action by the nurse.
The most important aspects of home care for a child with acute spasmodic croup are
humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate
systemic hydration aids is mucociliary clearance and keeps secretions thin, white, watery,
and easily removed with minimal coughing
This priority intervention prevents pressure caused by pooling of blood, thus minimizing the
pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will
have little effect. Opioid narcotics are given for severe pain.
Cold stress causes increased risk for respiratory distress. The baby delivered in such
circumstances needs careful monitoring. In this situation, the newborn must be warmed
immediately to increase its temperature to at least 97 degrees Fahrenheit (36 degrees
CelsiusAfter delivery.
the high glucose levels which crossed the placenta to the fetus are suddenly stopped.
The newborn continues to secrete insulin in anticipation of glucose. When oral feedings
begin, the newborn will adjust insulin production within a day or two
Aphthous stomatitis refers to a canker sore of the oral soft
tissues, including the lips, tongue, and inside of the cheeks.
A rigid board like abdomen is a sign of: peritonitis, a possible
life-threatening condition.
Epigastric pain occurring 90 minutes to 3 hours after eating:
indicates a duodenal ulcer.
Anorexia and periumbilical pain: are characteristic of
appendicitis.
Appendicitis risk of rupture is minimal with the 24 hours: but
increases significantly after 48 hours.
A client with a large-bowel obstruction: may have ribbionlike
stools.
Cullen’s sign: is evidenced by discoloration at the periumbilical
area. This sign may indicate an underlying subcutaneous
intraperitoneal hemorrhage.
Chvostek’s sign: is a facial nerve spasm and trousseau’s sign is a
carpopedal spasm; both signs occur with hypocalcemia.
Chvostek’s definition: a spasm of the facial muscles elicited by
light taps on the facial nerve. This spasm signals tetany and is seen
in clients with hypocalcemia.
Broca’s area: not sign, is an area within the brain that controls the
motor functions involved in speech.
Esophagogastroduoscopy: Endoscopic examination of the
esophagus, stomach and duodenum; usually performed using a
fiber-optic instrument.
A physician inserts a fiberoptic endoscope via the mouth: to
visualize the esophagus, stomach, and duodenum.
Bleeding:, though rare, signals the complication of perforation.
Sore throat, drooling, and absent gag reflex are: normal
findings after an EGD.
The endoscope can cause the sore throat. Clients my drool until the
gag reflex returns and they’re able to swallow their saliva.
Before performing the Esophagogastroduoscopy, the physician
administers a local anesthetic that inactivates to the gag reflex, so
the reflex may be absent for a period after the procedure.
Black, tarry stools: are a sign of bleeding high in the GI tract, as
form a gastric ulcer, and result from the action of digestive enzymes
on the blood.
Vomitus associated with upper GI Tract bleeding: commonly is
described as coffee-ground-like.
Clay-colored stools are: associated with biliary obstruction.
Bright red stools indicate: lower GI tract bleeding.
The nurse should tell the client that it’s the nurse’s professional
obligation to maintain client privacy and confidentiality.
Promising the client that she won’t tell anyone isn’t a professional
response to the client’s concern.
Telling the client that she can’t lie if asked about the client’s
procedure is an inappropriate response that doesn’t uphold the
client’s right to privacy.
Telling the client that she’ll avoid any questions is an unprofessional
response that doesn’t truly address the client’s concerns.
A client who’s dizzy and anemic: is at risk for injury b/c of his
weakened state.
Assisting him with the bedpan: would best meet his needs at
this time without risking his safety.
The client may fall: if walking to the bathroom, left alone to
urinate, or trying to stand up.
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.
Prothrombin synthesis in the liver: requires vitamin K.
In Cirrhosis, vitamin K is lacking: precluding Prothrombin
synthesis and, in turn, increasing the client’s PT.
An  PT, which indicates clotting time: increases the risk of
bleeding. Therefore, the nurse should expect to administer
phytonadione (Vitamin K1) to promote Prothrombin synthesis.
Spironolactone and Furosemide are diuretics and have no effect on
bleeding or clotting time.
Warfarin: is an anticoagulant that prolongs PT.
The client diagnosed with Clostridum difficle diarrhea:
requires contact isolation.
Contact isolation precautions: require the use of glove and gown
if soiling is likely.
A mask, face shield, & N-95 respirator: aren’t necessary to
maintain contact isolation.
A client with a small- bowel obstruction: can’t tolerate oral
intake, fluid volume deficit may occur and can be life-threatening.
Therefore, maintaining fluid balance is the primary goal.
Pain relief and maintaining body weight: don’t reflect lifethreatening conditions.
The client’s normal bowel pattern: can be reestablished after
fluid volume is stabilized.
Nurse should tell the client to drink 8 to 13-oz glasses of
fluid daily: to replace fluids lost through diarrhea.
Kaolin and pectin mixtures should be taken: after each loose
bowel movement for up to eight doses daily.
The client should avoid self-medication: for longer than 48
hours.
The client should consult physician: if diarrhea persists longer
than 48 hours despite treatment.
The surgeon should collaborate with the enterostomal nurse:
who can address the client’s concerns.
The enterostomal nurse may schedule a visit: with client who
has a colostomy to offer support, to the client.
The clinical educator can provide: information about the
colostomy when the client is ready to learn.
The staff nurse and social worker aren’t specialized in
colostomy care: so they aren’t the best choices for the situation.
The nurse should intervene by providing additional teaching:
if the client reports that he takes antacids.
Antacids can interact with ranitidine (zantac): and interfere
with its absorption.
Ranitidine doesn’t interact with: antibiotics, antipsychotics, or
antiarrhythmics.
The RN must confirm that the LPN has specialized IV
training: before asking her to begin IV therapy for the client.
Initiating IV therapy: is beyond the usual scope of the practice
for an LPN.
Weighing the client, teaching coughing and deep breathing
exercises, an teaching the client how to collect a urine
specimen: are within the scope of LPN practice and don’t require
additional training.
Pseudomembranous colitis: may result from superinfection with
C. Difficle during Chidamycin therapy.
Chidamycin-induced Pseudomembranous colitis isn’t caused:
by S. aureus, B. fragilis or E. coli.
Shock definition: An abnormal physiologic state characterized by
reduced cardiac output, circulatory insufficiency, tachycardia,
hypotension, restlessness, pallor, and diminished urine output.
Shock may be caused b various conditions, including trauma,
infection, hemorrhage, poisoning, myocardial infarction, and
dehydration.
Shock and bleeding must be controlled: before oral intake, so
the client should receive nothing by mouth.
When the bleeding a controlled:, the diet is gradually increased,
starting with ice chips and then clear liquids.
Skim milk shouldn’t be given: b/c it increases gastric acid
production, which could prolong bleeding.
A clear liquid diet: is the first diet offered after bleeding and shock
are controlled.
The nurse should instruct the client to take antacids
(Aluminum-magnesium complex (RIOPAN) with: water B/C
water helps transport an antacid to the stomach.
The client shouldn’t take an antacid with: fruit juice or a food
rich in vitamin C or D B/C the antacid may impair absorption of
important nutrients in the juice or food.
The medical record must include a signed DNR form: so that
all health care team members are aware of the client’s wishes.
The nurse must also act as an advocate: for the client and
support his wishes.
Urging the client to agree to a proposed treatment regimen he
doesn’t want and assuring the family that everything possible will be
done for the client are in opposition to the client’s wishes.
The Health Insurance Portability and Accountability Act:
prevents the nurse from discussing the issue with the family unless
the client has given permission.
Crohn’s Disease: A chronic inflammatory bowel disease of
unknown cause, usually involving the terminal ileum, with scarring
and thickening of the bowel wall.
Signs and symptoms: include frequent episodes of diarrhea,
severe abdominal pain, nausea, fever, chills, anorexia, and weight
loss.
The nurse may not release any confidential information: to
unauthorized individuals, such as the client’s boss.
Telling the client’s boss the diagnosis and asking the boss to come
in to discuss the issue breach client confidentiality.
The client requires further teaching if he suggest: that he
acquired the virus through sexual contact.
Hepatitis A is transmited by: the ORAl-FECAL route or through
ingested food or liquid that’s contamiated with the virus.
Hepatitis A is rarely transmitted: through sexual contact.
Clients with hepatitis A: need to take every effort to avoid
spreading the virus to other members of thir family with precautions
such as preparing food carefully, washing hands often, and taking
medications as ordered.
The correct sequence of abdominal examination is: inspection,
auscultation, percussion, and palpation.
This sequence differs from that used for other body regions:
(inspection, palpation, percussion, and auscultation) B/C palpation
and percussion  intestinal activity, ltering bowel sounds.
Therefore, the nurse shouldn’t palpate or percuss the
abdomen before: auscultatin.
Assessment of any body system or region starts with
inspection: therefore, auscultating or palpating the abdomen first
would be incorrect.
Disseminated herpes zoster Private room, airborne precautions & contact
precautions wear N-95 mask: keep door closed @ all times; remove gown
shoes etc. before leaving room.
Doppler ultrasound device: Hold probe at 45 degree angle to artery being
assessed; move distal to proximal; conductive gel helps sound transmissionok to warm the gel & it’s important to warm the gel to allow vasodilatation
and better sound /ultrasound : mark pulses with water poof pen.(does not
wash off).
Hepatitis A vaccine: indicated if patient is traveling out of country to Africa
also, South America and Asia for example; Hep A spread via Fecal/Oral
route. Also those w/chronic liver disease, hemophilia, who’s receiving
clotting factor
Standard Precautions req’d to care for Hep A patients.
Judaism: Milk/ and Milk products NEVER enter along with meats.
Raise HOB & Stop Infusion: If patient appears restless and c/o of
difficulty breathing- lung sounds noted bibasilar crackles (Rales).
Place Patient in sitting positions FIRST to reduce that high B/P – if
noted with autonomic dysreflexia- (severe rapid HTN), (sever HA), T5 injury,
temperature extremities noxious stimuli  temperature skin pressure
diaphoretic nauseated, brydiacardic, seizures (T-6 and above = Autonomic
dysreflexia)
Phenazopyridine (Pyridium): instruct if skin or sclera develops a yellow
tinge call the physician – indicates drug accumulation due to renal
impairment
Pernicious anemia: requires monthly vitamin B 12 injections; without
them death will occur in 1-3 years
Cane walking: Going upstairs, lead with strong leg and follow with weaker
leg and cane (always hold can in hand opposite of weak leg) (when going
downstairs, lead with the bad leg and then the cane)
Signs/Symptoms impending labor: contractions that continuously for an
hour (e.g. contractions occurring every 5 mins for an hour).
Generally = Labor: in true labor, contractions, are regular with decreasing
intervals between contractions  in intensity and duration, intensity usually
increases with w/ walking, cervix dilates and effaces.
Passing mucous plug is NOT s/sx of labor: as passing mucous plug may
occur up to 2 weeks before onset of labor, client may not notice it!
A contraction 3-4 min apart and bloody show is a sign of Labor: But
may expel blood 24-48 hours before labor onset.
Oxygen in oxygen tent: Most important to intervene if Birthday Candles on
cake for toddler’s are – Oxygen combustible w/ flames/birthday candles.
Propranolol (Inderal) ordered: to a client w/ type I DM (IDDM) Patient
takes NPH & Reg insulin Q morning – instruct:


Inderal may ask symptoms of hypoglycemia, removing your body’s
early warning system.
Question propranolol (Inderal) if ordered for patient w/history
bronchial asthma- may cause bronchospasm.
Dilantin Phenytoin: can cause vitamin D deficiency-  intake of milk,
cantaloupe and Kale.
Extrusion reflex: normal neonate reflex – disappears by 3 months;
extrusion reflex= tongue moving outward when tongue is touched.
ASA Toxicity= tinnitus, HA, hyperventilation, agitation, confusion, diarrhea,
and seating- withhold ASA and all physician.
Re: Anyoone up for random FACT THROWING??
a little more for ya...
Tuberculosis: classic symptoms= c/o dry cough for several weeks
with freq night sweats, low grade fever- place in negative air
pressure room or fit w/ N-95 mask until confirmations made on TB.
Toddlers play with these toys: Pounding board, cloth picture
books
Preschoolers play with these toys: educational computer
programs play clothes for dressing up, tricycle, and skates.
*change peri-pads: every time she uses lavatory and when soiled
(not just when soiled)
Emphysema: client breathless, ashen in color, VS-Temp 98.8 ◦F,
Pulse 114, RR 36, B/P 138/108, 02@2L min via NC.
**What is most concerns nurse? Client’s skin color is pink within
first 20 mins. Of oxygen delivery= BAD (if w/in 1st 30 mins of 02)
– this may be oxygen induced hypoventilation-improving
apnea/Resp arrest
Low back pain secondary to multiple myeloma: Position: in bed
HOB up 45 and hips & knees moderately flexed & knees should be
higher than hips for comfort.
African American hair- use oil application (not shampooshampoo dries makes hair brittle)
Adrenal insufficiency client on Prednisone 5 mg PO bid is going
for surgery- MD will:  dose of prednisone due to surgical stress.Surgery increases demand for corticosteroids (due to stress,
trauma)
Physiological jaundice: baby is jaundiced B/C the liver is unable
to clear bilirubin from the blood caused by Rh-negative mother and
baby is Rh positive also a 2nd pregnancy.
Safety precautions for children:
Blow nose, with both nostrils open: DO NOT occlude one nostril
at a time.
Cotton-tipped applications used: only on outer ears-never push
inside ears.
Never irrigate a foreign object out of an ear, such as a bean,
pasta, peanut, or other vegetable.
Heroin overdose- client gets Narcan- expect: Tachycardia, HTN
due to Opioid withdrawal, nausea, vomiting, restless andabdominal Cramping.
9 month old development (expected): infant sits unsupported;
infant pulls himself to standing position & holds on furniture
compares two cubes (does not build w/blocks until 12 months).
Responds to simple verbal commands-comprehends NO- No! At 9
months.
12 month old development (expected): attempts to build twoblock tower, can say 3-5 words; infant hugs parent upon request at
12 months.
Alcohol withdrawal symptoms: Hyper-alert startles easily, and
anorexia, increased pulse, anxiety, remorse insomnia,
hallucinations.
Narcotic withdrawal symptoms: watery eyes, cramps, and
tremors.
Cannabis withdrawal symptoms: insomnia, hyperactivity and 
appetite
*Malignant Hyperthermia: “I hope they keep the O.R. cool. My
grandpa died during Surgery when he got very hot└>genetic
predisposition- live-threatening complication of general anesthesia –
tachy, Dysrhythmia
Tachypnea hyperthermia hypotension, TX: Dantrolene
(DonTrium).
Client in early labor c/o “not being able to hold my urinenurse should first:

check the pH for the fluid (to determine if a fluid is amniotic
(Alkaline) or urine (acidic).
Normal PTT: 20-45 seconds;
PTT therapeutic level: 1.5 -2.5 times control; maximum PTT is
112 seconds.
*If PTT is >150 seconds: STOP heparin and notify MD (don’t
admin protamine sulfate yet!)
Digoxin: with hold med if infant’s heart rate is below 90-110
excessive slowing of beats may indicate digitalis toxicity.
*Hepatitis A in a child = most likely s/s of hepatitis A in young
children: * ANOREXIA*, malaise, lethargy, easily fatiguing.
Prednisone (Deltasone): B/C a steroid should be taken with
meals- early morning w/breakfast prednisone causes gastric
irritation, ulceration, and w/prednisone! So take w/meals –breakfast
in A.M.!
Theophylline (Aminophylline): for acute respiratory problemswithhold if: Tachycardia & hypotension and nausea & vomiting and
notify physician.
Newborn head circumference: average head circumference =
33-35 cm (increased to 4 cm = hydrocephaly, or IICP)
Hemophilia clients: (Pediatric clients) most at risk for “crippling
knee” – joint deformities”-most frequent site of bleeding (in
hemophiliacs) is into joints and muscles- cause changes in
bone/joints muscles.
*Inhaled chemical takes priority: over swallowed chemical.
* CNA collect sputum culture specimen: for C&S, and also
check blood glucose**
Trifluoperazine (Stelazine) antipsychotic:-excreted in breast
milk-breast feeding is CONTRAINTICATED with Stelazine.
Indocien (Indomethacn) - use w/ caution w/PVD – Indocin is an
NSAID- Risk PVD bleeding!
SLE: sun exposure, working in garden, infection, and joint stress
are problems, skin of patients w/SLE often has discoid lesions and
can become erythematosus on exposure to sunLupus victims should avoid all direct sun exposure: and to lay
UV light, tanning beds – immunosuppressed should NOT work w/
impossible to garden/dig.
ADHD: “When asked to sit, child wanders in hallway; child looks out
window when RN talks to him child repeatedly doesn’t to leave
always on the go interrupts often.
Chronic renal Failure – diet: lean meat, eggs, fish, poultry, high
protein, with CRF (also low Na, Low K+).
Cataracts: form due to –as aging lenses of eyes gradually moisture
and the lenses density increases.
MRI: CONTRINDICATED if suspecting something in his eyes 2 to
an MVA maybe metal
-esp. if patient c/o “something wrong w/my L eye “Be cautious 
safety
Respiratory syncylial Virus RSV: requires “Contact” precautions
-causes bronchiolitis
-Private Room w/sleeping accommodations
Influenza: =Droplet precautions -w/sleeping accommodations
Kawasaki Syndrome: = “Acute Systemic Vasculitis” unknown cause
TX: IV immuneglobulin & Salicylates therapy = Standard Precautions
65 year-old & older – most reliable sign of infection:
=TACHYCARDIA, TACHYPENA, CONFUSION,
(fever may be absent-is absent in 25-30% of clients)
“INFECTION IN ELDERLY” (more than 20% of elderly may present w/out
any leukocytosis)
NGT tube feeding: HOB up 30; warm feeding to RM temperature
(RN measures pH aspirate); infuse no less than 30 mins.
Clamp proximal end of feeding tube at end of feeding: - prevents air
from entering stomach.
*Chronic Alcoholic: c/o tremors, confusion & heart is feeling as if its racing
-chronic alcohol use is most common cause.
-*of Hypomagnesemia (< 1.5 MEq/L) =which may result in Cardiac
Arrest.
-Cardiac Arrest
└> Manifestations: neuromuscular irritability, tremors, tetany, and
seizures.
*IVF in active Labor= Lactated Ringers Solution: (has electrolytes)
even if requesting an epidural for pain!
Begin physical assessment while patient is lying in bed: then, ask
patient to sit on side of bed, transfer to chair, then observe gait.
** myelomeningocele: (Neonate born w/ this) Place in position: on
Abdomen w/face turned to side -prevents pressure onto the sac-like
protrussion on his back- pressure would result in IICP or may rupture sac- or
meningitis, due to infection
-leading to meningitis infection; cover lesion w/most sterile drsg.
CHf if pink-tinged sputum:intervene-may be blood/fluid accumulation in
lungs.
FHR 150-160 at apex of contraction:
FHR is 125:returns to baseline at completion of contraction
-RN should: continue to monitor FHR: (the above indicates early
deceleration- B/C of head compression- this is reassuring fetal heart tone
pattern.
Ileostomy: measure output from the ileostomy
Ileostomy: never use lotions
Conversion reaction: = “Repression” defense mechanism
-instructive drives & their accompanying anxiety are repressed & converted
into a physical symptom.
Sulfaslazine (Azulfidine):
Sulfonamides used to treat inflammatory bowel disease IBD (e.g.
ulcerative Colitis)
└> increases fluids to prevent crystallization in the kidney tubules
└> may turn urine orange-red, temporarily
└> decreases bowel inflammation –take w/food
└>diarrhea is common s/sx ulcerative colitis- continue taking Sulfaslazine
(Azulfidine)
Sulfaslazine (Azulfidine): for IBD Ulcerative Colitis
*If IV set delivers 60 drops per minute: drops per minute equals ml per
hour
Child receiving 40 drips IVF per minute. IV set has drip factor of 60 drops
per ml
At this rate, how many hours will it take nurse to infuse 400ml?
40 drops/min = 40 ml/hr
400 ml = 10 (10 hrs)
40 ml/hr
See First?
19 y/o scheduled for tonsillectomy – not priority
25 y/o scheduled for inguinal hernia repair- stable
32 y/o scheduled for mastoidectomy
-chronic ear infection often cause vertigo Priority client due to safety
39 y/o scheduled for removal of nasal polyp –stable client
Black Colosh – may cause hypotension when used: in comb w/
antihypertensive drugs (Tenormin) (atenolol) (Metorolol)
Dyspareunia (painful intercourse): explore/assess personal menstrual
history.
**Priority side effect surgery on a 2 month old infant:
=“encourage the parents to stroke the infant”
– tactile stimulation is imperative for infants emotional development &
– stimulate post surgery sedation!
Digoxin Toxicity s/sx: confusion & reports of seeing yellow halos
around lights –
Digoxin toxicity is of great concern in  presence of diarrhea
(hypokalemia) or attention of elytes.
*Lithium toxicity early signs:
-Slurred speech,
-muscle weakness
-N/V diarrhea
-thirst,
-polyuria
expected w/lithium=mild thirst
Advanced signs of lithium toxicity = cause hand tremors, in
coordination ,
GI upset, mental confusion
Severe toxicity= Ataxia (definition=which is the unsteady and clumsy motion of the
limbs or torso due to the failure of the coordination of muscle movements.)
Developmental milestones:
13-15 months= walks without help at 13-15.
18 months = builds a tower of 3 to 4 blocks at 18 months
24 months= uses 2 to 3 word sentences at 24 months
30 months= jumps with both feet at 30 months
Chronic CNS disorders assoc with alcoholism
Korsakoff’s psychosis: assess for “confabulation” or memory disturbance
in order to fill in gaps, patient invents elaborate happenings
Wernieke’s syndrome: form of dementia related to thaimine deficiency
– s/sx: nystagmus , diplopia, confusion, atazia, apathy, disorentation.
Polyarterstis nodosa: (inflammation of the small arteries causing
diminished blood) └>* tx w/ “cortisone” now results in a 90 % remission
rate*
**Hyperbilirubinemia- phototherapy lights ( treatment on infant ): s/e
(ok) frequent loose stools & increased urine output.
*eye patches used – must be adequately placed on infant*
-if NOT adequately placed eye ptches: then the jaundice around infant’s
eyes will begin to diminish –This is BAD* indicates eye patches ineffective.
Phototherapy is considered:
total serum bilirubin> 15 mg/dl @ 72 hours of age.
Postpartum mother-instructs:
Call for assistance first time getting up:
( possible othstatic hypotension) = safety
Expect small clots the size of a dime or quarter (normal post
delivery):
golf ball size clot indicating more than anticipated uterine bleeding/
If dry / cracked nipples: may use Lanolin (emolients)
(for breast-feeding mom’s)
Apgar Scores: 2 points given for each of the following (in total) (elvaluated
at 1 and minutes)
1. heart rate = 2 pts WNL’s
2. color = 2 pts (B/C central color is pink, hands blue)
3.
muscle = 2 pts ( B/C moderate flexion of

&
extremities)
4. Respiratory effect = 2 pts WNL’s
5. Reflex immlablity = 1 pt (B/C slight reponse to foot tap)
*10 year-old child SPORTS safety teachings most likely:
(NOT water safety; Water safety more for toddler & preschool)
(Recreational water safety for adolescents)
Ascities management:
FIRST administer: Albumin- to pull back fluids into blood vessesl so
diuretics can remove excess first.
Second administer: spiroaldactone
2 year-old: Provide with finger food,
(2 yr working on autonomy- finger foods provide this independence!)
Instruction moving Patient: supine position to standing position at left
side of bed with walker: (S/P spinal fussion)
Focus on using arms, the left elbow as a pivot w/the left hand grasping
mattress edge & the right hand pushing on the mattress above the
elbow, then slide legs over side of the mattress

- This
maintains spinal alignment & prevents injury; easy to accomplish
spine must be kept straight through out transfeer)
- (entire
- DO
NOT bend knees w/spinal fusion;  swinging legs contraindicated
Too!
-
Prenatal Home Visit to a pregnant client – most important for nurse to
follow-up /intervene is:

a cat is sleeping on the windowsill*
(cat= toxoplasmosis RISK to pregnant client & unborn infant)
(this “CAT” is even more priorty than throw rugs on the dam floor)
*FIRST- determine clients needs * (physical needs FIRST)**
Frontal Lobe responsible for:
Personality
Behavior / voluntary activities
Emotions, &
Intellect function
Parietal Lobe responsible for:
Sensation
Temporal Lobe responsible for:
Auditory
Occipital Lobe responsible for:
Visual
Clozapire (Clozaril) – RISK for Agranulocytosis (check WBC’s)
- c/o of sore throat ,cough , fever
- have WBC’s checked
- (if < 2000 WBCs drug will be D/C’d
- Potentially LIFE-THREATENING
Atypical antipsychotic side effect:
- Leukopenia,
- gram-negative
- septicemia,
- Drowsiness,
- Hypotensiton
- Tachycardia,
- Agranulocytosis
Skateboard accident:
Assess what FIRST?
Head injury is PRIORITY
“Did you hit your Head?
“NOT”; “Wear you wearing a helmet?”
Hypothermia rewarming patient :
- Monitor for “ventricular fibillation”
(Due to rewarming & myocardial irrtablity)
Acyclovir (Zovirax): Take with FOOD: may cause N/V
└>Antiviral for Tx: Herpes
*ECT: alert physician if client takes Alendronate (Fosamax): used to
TX: osteoporosis- place client at risk for ECT report Fosamax to M.D.
Strategy:
1 grain= 60mg
gri = 60 mg
grii = 120 mg
grii= 2 grains
Administer:
Phenobarbital (Luminal) grii PO to a 3 year-old child.
Label reads: 160 mg/5 cc
How many cc of pheobarbital should nurse administer?
1gr__ = 2gr X = 120 mg
60mg Xmg
160mg = 120 = 600 = 3.75 cc = 3.8 cc
5 cc Xcc 160x
Absent “RED REFLEX” in newborn BAD: opthalmic emergency
–Light is NOT being:Transmitted to  retina and the early suppression of
optic nerve fucntion which results from the obsturction of the light
causes: blindness
-Notify physician immediately.
Newborn facial drooping = facial paralysis CN VII (Facial): –occurred
in delivary
–usually resolves with in few days to 3 weeks
-can be permanent
Acute Phase of Cerebrovascular Accident-positon client: Supine
w/head of bed elevated 15-30 degrees
(-facilitates venous drainage from brain; ICP,keeps head midline)
Here you go somemore facts:
LTB diagnosis Laryngotracheobronchitis: Inspiratory stridor and
restlessness
Fear of heights = projection and displacement
8 weeks gestation and test positive for VDRL = Must instruct
client the importance of penicillin for the prescribed time
Note:The renal threshold for glucose is elevated in elderly
Ultrasound detects: gestational age
Amniocentesis: determines spinal cord problems and blood
problems
Head lice: must instruct to repeat shampoo in 7 to 10 days
For patient with mental retardation: – Must assess level and
determine client’s comprehension.
Early signs and symptoms of preclampsia:
Facial swelling and Proteinuria
Most likely to observe in IV drug users: Cellulitis
With a CVA nurse can only prevent: corneal abrasion With A
CVA
Nurse CAN Not prevent: inability to talk, loss of gag reflex or
open affected eye.
Play
4 year old : associative play
Infant: solitary play
Toddler: parallel play = toddler
Addisonian crisis:restlessness and rapid weak pulse
Fundus location : umbilicus for palpation in 4th stage of labor
Post – Op patient of cataract surgery: you would caution the
patient from sudden movements and bending over due to causes
pressure on suture lines.
Alcohol problems: Tremors increased temp. nocturnal leg cramps
complaints of joint pain
Dwarfism: Delicate features (appear younger then chronological
age)
Rocephin (cephalosporin): Most important for nurse to monitor,
The surface of tongue (Hairy tongue)
Note: Black Hairy Hairy tongue (lingua villosa) is a common
condition caused by defective desquamation results from a variety
of precipitating factors. Some of these factors include poor oral
hygiene, tooth loss (because a soft diet does not allow for normal
desquamation from rough food scraping the tongue), chronic or
extensive use of antibiotics, and radiation treatments to the head
and neck. Patients with hairy tongue are more often than not coffee
or tea drinkers and often use tobacco.
Read More: http://en.wikipedia.org/wiki/Hairy_tongue
Hypothyroidism: should avoid narcotic sedatives
Clomid (Clomiphene) medication (fertility drug): – induces
ovulation by changing hormonal effects on ovary.
Naprosyn (naproxen)– NSAID (anti-inflammatory): Nurse
should assess: for fluid retention and dizziness
Cortisol Converts: protein and fat into glucose and also an antiinflammatory agent
Note:Cortisol is a steroid hormone released from the adrenal cortex
in response to a hormone called ACTH (produced by the pituitary
gland). It is usually referred to as the "stress hormone" as it is
involved in response to stress 6. It increases blood pressure and
blood sugar, and reduces immune responses.
Read More:http://en.wikipedia.org/wiki/Cortisol
Calan medication: Nurse should check patient’s heart rate
Note: Calan (verapamil) (calcium channel blocker) indicated to treat
supraventricular tachycardias.
Breast feeding mother should increase her calorie intake:
by 500 calories per day.
Note: The fluid in water seal chamber doesn’t fluctuate with
respiration = this indicates no more air leaking into pleural space.
3 month old scheduled for barium swallow: = Should be NPO 3
hours prior to the procedure.
Note: When preparing for cholesterol screening only sip water for
12 hours are permitted for 12 hours before plasma cholesterol
screening to achieve accurate results
Toddler with lead poisoning: The fluid to be encouraged when
given a choice of water, fruit punch, orange juice and milk.
**Milk due to vit – D which optimized deposition of lead in long
bones.
Second stage after denial is Anger:
1st stage= Denial
2nd stage= Anger
3rd stage = bargaining,
4th stage = Depression
5th stage = acceptance
Intravenous pyelogram (IVP): Able to examine the urinary tract
by x-ray. Evaluates the kidney function.
Nephrotic syndrome:
= client teaching for diet is
= adequate protein and low sodium.
Colostomy: Needs to be irrigated at the same time everyday.
Prior to sending client for cardiac cauterization:
= Most important to report if client has an allergy to shellfish
Note: Iodine is uesed. – This will avoid anaphylactic shock during
procedure.
A few more facts for today:
SCI Spinal Cord Injury– assessment findings are – Sever
pounding headache, profuse nasal congestion and
Piloerection(Goose Flesh)
NOTE: Piloerection:Erection of the hair of the skin.
When caring for a child with RSV Respiratory syncytial virus – Gown
and gloves need to be on.
S/SX: resemble the common cold. However, RSV infection can also
result in pneumonia, especially in the very young, the very old or
those with weakened immune systems. Symptoms generally begin
four to six days after exposure. Symptoms generally develop slowly
over a period of several days. The contagious period is usually less
than 10 days after symptoms begin, but occasionally is longer.
Note: Respiratory syncytial virus is a respiratory illness
caused by a virus. It is spread through contact with droplets
from the nose and throat of infected people when they cough
and sneeze. RSV can also spread through dried respiratory
secretions on bedclothes and similar items.
Amniocentesis – Detects blood disorders such as hemolytic
disease
Hemolytic reactions – Hypotension, low back pain, and fever
Graves Disease – Nurse expects weight loss 10 in 3 weeks, also
restless, heat intolerance, reflexes hyperactive.
Reminiscing Group – provides an environment for social
interaction and companionship
Hypocalcemia – Positive for troussear’s sign
Hypercalcemia – Constipation, depressed reflex, decreased muscle
strength.
Radium implant – Most important to chart, date, and time of
removal with total time of implant treatment
Miller Abbott Tube – Reason to remove fluid and gas from small
intestines – provides for intestinal decomporssion, intestinal tube is
often used for treatment of paralytic ileus.
PKU test – (Phenyiketonuria) – specimen should be collected as
close to discharge as possible but not after 7 days.
A common reaction of a husband of a rape victim – Emotionally
distressed and needing assistance
FAS – (fetal alcohol syndrome) of a newborn – Replace vitamins,
depleted –
Note: adequate intake of vit-B complex is necessary for normal
CNS function
Addison’s Disease – Darker skin that is more pigmented
Best to start toilet training at 20 months
TURP – continuous irrigation is used to enable urine to keep flowing
TPN– discontinued abruptly – results in hypoglycemia –
S/SX: are diaphoresis, confusion, and tachycardia.
RML – right middle lobe of lung to auscultate –
Right anterior chest between 4th and 6th intercostals.
Note: Can Not auscultate the RML from the posterior.
Myasthenia Gravis – Client has increased muscle fatigue so nurse
needs to assess muscle groups towards the end of the day.
Meniere’s syndrome – Nurse stands directly in front of patient so
– client doesn’t have to move or turn head to see nurse. Decreasing
movement of head decreases vertigo attacks.
MRI– Takes approx. 90 minutes with no discomfort and no dye is
used for this procedure
IVP – (pyelography) – Nurse should contact physician if client state
that they are on Metformin (Glucophage) –
Note: this should be discontinued 48 hours prior to procedure due
to contrast media can cause life threatening lactic acidosis.
Patient refusing cancer meds – require an RN due to assessment
skills needed for this patient – should not be deligated.
Narcan – short half life and may need to be repeated in 2 to 3
minutes.
Normal Lab Values
K+ - 3.5 to 5.0
Ca+ - 4.5 to 5.3
AST (SGOT) – 8 – 20 U/L
ALT (SGPT) – 8 – 20 U/L
PT – 11 to 15 seconds
Hgb – males 13.5 – 17.5 females 12.1 – 16.0
BUN – 10 20
Creatine – 0.6 – 1.2
WBC – 5,000 – 10,000 per MM3
Iron needs –
* women 15 mg per day : 1,200 – 1,500 Kcal
Cushing's Syndrome= overproduction of cortisol hormone produced in the adrenal cortex which is
part of the adrenal glands which sit on top of the kidneys.
Signs:
1) high blood sugar---makes the patient prone to infections
2) sodium increase---fluid retention---elevated blood pressure
3) watch for Potassium which tends to decrease---heart arrhythmias
4) fat face due to fluid retention
5)truncal obesity
6)buffalo hump (fat accumulation on the back of the neck)
7) exosthalmus ( eyes look "bug out") due to increase level of cortisol
8) extremities appear thin, presence of muscle wasting, leg sores that do not heal
Note this patient is not a good candidate for steroids in general people with high blood sugar as in
diabetic are definitely not good candidates for steroids...but patient need a good antiinflammatory
such as a steroids are known to be. Therefore, if this patient has to on steroids(cortisone0 please
watch for side effects of steroids which are:
a) increase blood sugar---remember this patient has high blood sugar
to begin with as a result of an increased level of cortisol
b) increased risk for infection
c) increased edema
This patient is going to need emotional support for this disease changes the persons appearance
negatively.
Addison Disease= Decreased production of cortisol.
Signs:
1) craving salt---low sodium level, so the patient craves salty foods
2) hyponatremia---watch for low blood pressure
3) hypoglycemia---complains of weakness, tired all the time, low energy
this lack of energy is the most insidious in times of stress
4) anorexia, nausea, vomiting, diarrhea
5) as sodium is low, so is water---remember water follows sodium, so the patient is seriously
dehydrated
6) weight loss---remember, anorexia, the reason for the weight loss
7) skin turned bronzed---due to increased levels melanocite stimulating hormone(MSH)
TX: coticorsteroids---avoid Addisonian Crisis which would be precipitated by a mayor stressor such as
adrenal insufficiency
Signs of Addsinian Crisis:
1) profound weakness---cannot get out of bed-no energy for that
2) severe abdominal, back and leg pain
3) high fever---hypothermia
4) peripheral vascular collapse
5) renal failure
must have a muscle strengthening medication Prostigmin or Mestilon on time.
Sx:
1) dropping eyelids---difficulty moving her face muscles, this patient cannot even open his/her eyes
2) patient does not have sensory deficit, no loss of reflexes or muscle atrophy---the patient can feel
but has a hard time moving the muscles needed to move around even to take in a breath of air
Note: Time is of the essence with this kind of patient. Myasthenia Gravis is a progressive disease
caused by failure in the transmission of nerve impulses by a neurotransmitter called acetylcholine. If
there is no acetylcholine there is no muscle movement remember we use the muscle of the diaphragm
for respiration: no acetylcholine we die for we cannot breathe! This disease is very serious, and on top
of that it is tricky. We need to learn to recognize the difference between a cholinergic crisis (too much
acetylcholine circulating) versus myasthenic crisis ( no acetylcholine at all--I told you what that means
for the poor patient) Tensilon is a drug with a short half life that will strenghten muscle weakness if
the patient is having an myasthenic crisis. If the patient is having a cholinergic crisis Tensilon would
do nothing, but it is a good diagnostic tool for figuring out fast what's wrong with the patient.
Management of Myastenia Gravis:
1) Do not allow the patient to exercise or get an infection of any kind.
2) Must administer medications on time otherwise the patient will end up hooked to a ventilator
3) Must avoid sedatives, tranquilizers, muscle relaxants ( no, kidding...) which cause
respiratory depression
4) During a myasthenic crisis do not give to the patient anything to eat or drink ---high risk for
aspiration--5) after the crisis assess, assess, assess--ability to swallow and if the patient has improved give a
soft diet easy to swallow.
feliz3
must have a muscle strengthening medication Prostigmin or Mestilon on time.
Sx:
1) dropping eyelids---difficulty moving her face muscles, this patient cannot even open his/her eyes
2) patient does not have sensory deficit, no loss of reflexes or muscle atrophy---the patient can feel
but has a hard time moving the muscles needed to move around even to take in a breath of air
Note: Time is of the essence with this kind of patient. Myasthenia Gravis is a progressive disease
caused by failure in the transmission of nerve impulses by a neurotransmitter called acetylcholine. If
there is no acetylcholine there is no muscle movement remember we use the muscle of the diaphragm
for respiration: no acetylcholine we die for we cannot breathe! This disease is very serious, and on top
of that it is tricky. We need to learn to recognize the difference between a cholinergic crisis (too much
acetylcholine circulating) versus myasthenic crisis ( no acetylcholine at all--I told you what that means
for the poor patient) Tensilon is a drug with a short half life that will strenghten muscle weakness if
the patient is having an myasthenic crisis. If the patient is having a cholinergic crisis Tensilon would
do nothing, but it is a good diagnostic tool for figuring out fast what's wrong with the patient.
Management of Myastenia Gravis:
1) Do not allow the patient to exercise or get an infection of any kind.
2) Must administer medications on time otherwise the patient will end up hooked to a ventilator
3) Must avoid sedatives, tranquilizers, muscle relaxants ( no, kidding...) which cause
respiratory depression
4) During a myasthenic crisis do not give to the patient anything to eat or drink ---high risk for
aspiration--5) after the crisis assess, assess, assess--ability to swallow and if the patient has improved give a
soft diet easy to swallow.
feliz3
I added RSV to the droplet precautions, now making the SPIDERMAN look like this:
DROPLET (CONTACT +)
think of SPIDERMAN! (having a runny nose)
(4 Ss, 5 Ps & 3 Ms) (The spider DROPS from the ceiling)
S - Scarlet fever
S - Sepsis
S - Streptococcal pharyngitis
S – Streptococcus, group A
P – Parainfluenza
P - Parvovirus B19
P - Pertussis (whooping cough)
P – Pneumonia (Haemophilus influenzae)
P – Pneumonic plague
I - Influenza
D - Diptheria (pharyngeal)
E – Epiglottitis due to H. influenzae
R – Respiratory Syncytial Virus (RSV)
R - Rubella
M - Mumps
M – Meningitis, bacterial
M - Mycoplasma or meningeal pneumonia
An – Adenovirus
And, according to the CDC website regarding varicella, it should have airborne precautions, at least
until the vesicles have crusts, so now that makes VCHIP change to CHIPS:
* Skin Infections:
CHIPS
C - Cutaneous diptheria
H - Herpes simplex
I – Impetigo (ok to care by pregnant nurse, need to wear gloves and gowns)
P - Pediculosis
S - Scabies, Staphylococcus
And here's the Standard & Airborne. Please correct me if you see anything not up to par!
STANDARD:
Localized Herpes Zoster (cold sore) Standard
Lyme disease (caused by ticks) Standard
AIRBORNE: (Starv)
Avian influenza Airborne, Contact & Droplet (including N95 respirator)
Rubeola (measles) Airborne
Sars Airborne, Contact, Droplet
Smallpox Airborne, Contact, Droplet
Tuberculosis Airborne
Varicella (chickenpox) Airborne
Varicella zoster (herpes zoster, shingles) Airborne
Vesicular rash (at first) Airborne
S = SARS, smallpox (airborner, contact, droplet)
T = Tuberculosis
A = Avian influenza (airborne, contact, droplet)
R = Rubeola
V = Varicella (chickenpox), varicella zoster (shingles); vesicular rash (to begin with -- until vesicles
heal over)
Trendlenburg Test: Used with patients who may have varicose
veins.
Imipramine (Tofranil) Tricyclic antidepressant Nurse Should
-teach a patient to report:
S/E: of sore throat, fever, increased fatigue, vomit and diarrhea.
POC: Having a pt. turn cough and deep breath Q2H
– Promotes ventilation and prevents respiratory acidosis.
Type 1 diabetic: When providing good foot care includes having
feet measured everytime you buy new shoes
Note: feet enlarge with age.
After cast is placed on a preschool child action the nurse should
take next is to elevate arm on two pillows.
Note: (this minimizes swelling)
Cystic Fibrosis: Diet:
-should be high in protein and calories and low in fat.
A cleansing enema is usually ordered before: an IVP.
Pyelogram
When going down stairs:
– lead with crutches and bad leg followed by the good.
When going up stairs:
–lead with good leg and follow with crutches and bad leg.
**remember good girls go up to heaven &
**bad girls go down to
Infant not interested in nursing: either from the mother or
formula. The nursing diagnosis in this case is -Fluid volume deficit
Note: failure to thrive is a medical diagnosis.
Hiatal hernia - classic symptoms / associated with reflux.
Ex: complaints of awakening at night with hearburn.
AIMS – (abnormal involuntary movement scale)
– examination to test for tardive dyskinesia.
IBS – irritable bowel syndrome
– Pattern alternates from diarrhea to constipation.
AKA – above the knee amputation – with an immediate
prosthetic fitting it is most important for the nurse to provide cast
care on affected extremity.
Note: case applied to provide uniform compression, prevent pain
and contractures.
Appropriate Play for a 5 y/o. – Talk on phone imitating father.
Rheumatoid arthritis – When inflammation is sever, decrease the
number of repetitions when exercising.
Tetracycline (anti infectives):
–use max protection sunscreen when out doors and
-never take with milk or antacids.
-Should take with a full glass of water
-1 hr before meals or 2 hrs after.
Cushings Syndrome:
–signs and symptoms include:
-Buffalo hump,
-hyperglycemia,
-hypernatremia.
AKA – above the knee amputation
-an indication of infection are complains of:
-persistent pain at the operation site.
(characteristics of inflammation and infection)
Mechanism of conversion – Pt. says:
-“Unable to take final because unable to write”
–coverts anxiety into physical symptoms.
Obsessive Compulsive Disorder – Rituals are to avoid sever
levels of anxiety.
Note: attempt to avoid or alleviate increasing levels of anxiety.
Guillain Barre:
–S&S are:
-Respiratory failure,
-flaccid paralysis,
-urinary retention.
Note: Early fetal decelerations are usually a normal sign.
Myelogram – Test involves:
-a lumbar puncture with injection of contrast medium,
-allowing x-ray visualization of vertebral canal.
Tracheotomy Cuff:
-seals trachea and
-helps prevent aspiration.
Note: an unexpected affect of ECT: -is a backache.
Confusion and disorientation is an expected outcome.
Babinski Reflex – should be present at 9 months.
-This reflex disappears after 1 year of age.
Acute Hypoparathyroidism – Most important for nurse to have is
a tracheotomy set.
48 hours post-op hernia repair – Findings that indicate possible
complication – incision line is red.
Note: the incision line should be pink, -other BAD indications
would be warmth and tenderness, pain, purulent or odorous
drainage.
Continuous Tube feedings (around the clock) – Rinse bag and
change every 4 hours –
Note: there is an increase in microorganisms.
32 week gestation 4 lb 10oz:
-baby with mottling,
-acrocyanosis
-irregular respiration 60 indicates
–cold stress.
Here is my last one for today...
Burns: Clothing should be removed and they should be wrapped in
a clean sheet. This is best to prevent infections.
Note: should never apply soap or ointments with 2nd or 3rd degree
burns.
DPat – Immuzation shot:
-Low grade fever appears within the first 48 hours.
Trilafon medication (perphenazien) – (antipsychotic)
–Client on this drug now displays:
-head turned side
-neck arched at an angle
-stiffness
-muscle spasms
Nurse should expect to give  Aiperiden (akineton)
(Antiparkinson agent)
-used to counteract extra pyramidal side effects.
Alcohol Withdrawls – Steadily increasing vitals with a client
withdrawing from alcohol is a sign that d.t.’s (Delirium Tremens)
are approaching, can be avoided with additional sedation.
Bronchoscopy – Client recovering from bronchoscopy should be
positioned in semi-fowler’s position.
-Check vitals Q15 min. until stable.
–Assess for respiration difficulties like stridor
-dyspnea results from laryngeal edema
-laryngospasm
Ketoconazole (nizoral) – 200mg daily – drug of choice to treat
candidiasis.
Hyponatremia s/s
– H/A apprehension and
-lethargy
-muscle twitching
-convulsions
-diarrhea finger printing of skin.
Haldol s/sx
–include galactorrhea lactation
(excessive or spontaneous flow of milk)
-gynecomastia – (excessive growth of male mammary glands
Note: must explain to the client that it’s S/E of haldol.
Antiembolism stockings – should be worn the entire hospital stay
only removed for baths and replaced after skin is dry.
MS pt.
–39 weeks gestating with -BP 127/72 -pulse 72 -cervix 4 cm -FHT
124.
-Nurse should anticipate reduction in amount of pain
medication to a MS pt.
Note: there is an overall decrease in pain perception due to Multiple
Sclerosis.
Lumbar Puncture
– To confirm meningitis in a child most important action by the
nurse:
-is to restrain the child.
Note:This prevents trauma during the procedure.
Priority – Client admitted for a CVA
whose prescription for warfarin Coumadin expired 2 days ago takes
priority over -immuno-suppressed patients.
Note: Possible recurence of a stroke.
Salem sump NG tube – HOB elevated 60 to 90 degrees.
(gravity is used to help with placing this tube.)
SLE – should be in remission for at least 5 months prior to trying to
conceive.
Kussmaul Respiration – A sign of hyperglycemia
Diaphoresis and trembling – A sign of hypoglycemia
Informed Consent – From either divorced parent is sufficient.
Resp Rate of 8 – is too low. If morphine was adminstered.
-This sign should necessitate a nurse to administer Narcan
immediately – Respiratory Depression
Child poisoned with – lighter fluid: –should induce vomiting.
However vomiting is contraindicated: with ingestion of
hydrocarbons due to danger of aspiration.
Manic Patient – During meal time if patient is in seclusion – they
should be kept in seclusion and the meal served while remaining in
seclusion for safety.
Aseptic Techniques (sterile) – with 50% burn over body due to
high risk for infection.
Diabetes – When morning self-monitoring of blood glucose (SMBG)
reading shows 214 and 230 and the patient is on regular and NPH
insulin.
-Best action by the nurse: is to adjust NPH by increasing it 3
units.
Never want to eliminate evening snacks completely, only adjust
and encourage exercise is good.
Compazine (prochlorperazine) (anxiolytic) – should be considered
incompatible in a syringe with all other medications.
Nutritional Status – Best indicator is albumin levels 4.09/dl. Note:
weigh gain could be ascites.
Sickle Cell Crisis – Adequate hydration is a priority with sickle cell
crisis.
Billroth 1 – Note: After gastrectomy and vagotomy planning
discharge have client avoid large meals high in simple sugars. To
avoid dumping syndrome.
Glipizide (glucotrol) (antidiabetics)– Is effective for diabetics
who produce minimal amounts of insulin.
Hemophilia A – Best medication for a child with Hemophilia A
=codeine Phosphate (paveral)(Therapeutic)
NOTE: Assess Blood pressure, pulse, RR- assess level of sedation
Terbutaline (brethine) (bronchodilator) – Should be withheld
with heart rate 144.
Note: S/E of this med is tachy, nervousness, tremors, H/A, possible
pulmonary edema.
Hep A – 18 month old with hep A:
-contact precaution
-child is placed in a private room.
Haldol Decanoate (Haloperidol)(antipycotic)
–Should be given in deep large muscle mass with 2” needle 21
gauge – single dose.
NOTE: Patient should lie in recumbent position for 1 hour after
administration of this drug.
PVC’s – Lidocaine (Antiarrhythmic Agent) is the drug of choice for
PVC’s or for consecutive PVC’s.
Note: it is unexpected for a 3 month old to grasp a toy just out of
reach – unexpected until 6 months of age.
Gout Pain – Encourage weight bearing while ambulating.
Note: that ROM may aggravate pain
HIV – Newborn of an HIV+ mother admitted to the nursery should
include (Standard precaution) in POC.
S&S of post infusion phlebitis
– reddened area
-red streaks at the site
Addison’s disease – Most important for nurse to instruct:
-steroid replacement
HX of oliguria:
-HTN
-periph. Edema (with bun 25)
-Nurse should restrict protein in patient’s diet.
Cranial Nerve # 7 – Facial Nerve:
-provides motor activity to facial muscle.
Ex: crooked smile nurse should assess #7.
Priority – During discharge with a client with HIV taking AZT
(Azidothymidine zidovudine) (Nucleoside reverse transcriptase
inhibitor) at home Nurse writes a schedule of when the medicine
should be taken planning and written is more effective for
adherence to time frame.
POC for client - on bed rest to promote evening rest and sleep the
most important is to = encourage daytime activities.
Colon Surgery – An appropriate action to take with a client
returning from colon surgery:
-is to ask the client to lift his head off the pillow
–This assesses if there is remaining effects of neuromuscular
blocking agents
Note: may block ability to breathe deeply.
Penrose Drain – when changing dressing on incision remove one
layer at a time (to avoid dislodging drain)
Developmental Stage of a 40 y/o – Starts to measure life
accomplishments with goals.
Note: Sterile = Aseptic
Clean = Antiseptic
Rheumatoid Arthritis – Most important is:
-assist client with heat application
-ROM exercise
Note: This reduces swelling, increases circulation, diminishes
stiffness while preserving joint mobility.
MYXEDEMA – There is a slowing of all body functions.
Note: Decreased Temperature would be revealed.
Esophageal Speech – Client swallows air and then eructates it
while forming words with his mouth.
Increased ICP – 4 month old with increased ICP
-High pitched cry.
Findings – find a 2 year old with:
-FX femur
-several lacerations
-bruises of unexpected origin
Report finding to CPS.
Reduced oxygen level- Symptoms that indicate reduction of O2
levels –Ex: BP 150/90, pulse 90
-pulling of NG tubing
-picking at bed covers
Ewald Tube – Is large, orogastric tube
-designed for rapid lavage:
Note: insertion often causes gagging and vomiting, suction
equipment must be available.
Oxytocin (Pitocin) (misc OB/GYN Agents) – Important for safe
administration of oxytocin = Palpate the uterus frequently.
Narcotic – With drawl is very much like the flu.
-Runny nose
-yawning
-fever
-muscle and joint pain
-diarrhea.
Battery – Harmful or offensive touching
Here is my send for today..
Flaccid Bladder – You want to produce
-acid urine to minimize risk of UTI.
- produce acid urine:
-prune
-cranberry
-tomato juices
produce alkaline urine:
-Milk
-lemonade produce
Hep B – Vaccines additional injections at
-one month
-six month
Baseline Data – must be collected to design an effective behavior
modification program.
Parlodel (bromocriptine) (Antiparkinson Agent) administration:
– Should be taken with meals to decrease GI upset.
Post op – Abdominal surgery low fowlers position 15 degrees takes
pressure off of suture line.
Pressure ulcers S&S – Blanching or hyperemia that doesn’t
disappear is a warning sign for pressure ulcers
Late decelerations – Stop infusion of pitocin(Oxytocin)(misc
OB/GYN Agents)
Abdominal Surgery – with complaints of left leg dull aches
Nursing Intervention:
– elevate extremities to promote venous return and
-decrease venous pressure to relieve pain and edema.
Systematic Desensitization:
Note:Phobias are a learned response and the goal is to eradicate
the phobic response by replacing with relaxation responses by using
muscle relaxation techniques with it. (Guided imagery)
Detached Retina – Classic signs are:
-bright flashes of light
-client stating that protions of visual field is dark
Impetigo – with a child the nurses 1st priority:
-is to notify the child’s parents first.
Infant with samonella:
–Priority is contact precausion 1st to prevent transmission.
-Then other implementations can be performed.
Note: - Magnesium Sulfate (IV) (Mineral and electrolyte
replacement/supplements) can cause:
-slowing of the respiratory rate in an infant and hyporeflexia.
-The normal resp. rate for an infant is 30 – 60 per min.
-So 18 respiration indicates a problem.
Doxepin hydrochloride (Sinequan)(antianxiety agent,
Antidepressant)
- Is an antidepressant,
- signs of overdose include:
- -excitability
- -tremors
Child age 7:
– Periods of shyness are to be expected
-nightmares are frequently experienced at this age
Decreased RBC – s/sx:
-Fatigue
-pallor
-exertional dyspnea
Rheumatic Fever – Is the most common cause of mitral valve
problems. Ex: mitral stenosis.
Paracentesis – Most important Nurse Intervention in preparing a
client for this procedure to to have them void just before the
procedure.
Swan Ganz – Indirectly measures pressure in the ventricles. Note:
CVP reading measure the pressure in the R ventricles. The Swan
Ganz catheter measures the Pulmonary Artery wedge pressure
which is an indirect reading of the pressure in the L ventricle.
Trigeminal Neuralgia – (Tic Douloureux) – The nursing care
should be directed toward preventing stimuli to the area and
decreasing pain – Ex: eat soft warm foods.
DIC – Disseminated intravascular coagulation (DIC) - There is
oozing blood from the venipuncture site and abdominal incision.
Note: DIC is an acquired clotting disorder from overstimulation,
prolonged oozing from sites of minor trauma first symptom.
Lecithin Sphingomyelin (L/S) ratio = 3:1. – With a 33 week
gestation - Nurse anticipates c-section delivery due to lungs
adequately mature there is no need to postpone delivery and csection is preferred with preterm infants.
Diabetes Type 1 – Client states “ I have a quivering feeling in my
stomach” is given priority due to the fact that this is a sign of
hypoglycemia.
Hypoglycemia signs also include:
-tachycardia
-cold clammy
-skin,
-weakness
-pallor
Nurse: Check BS
-offer milk.
Abdominal Abscess – Drain inserted:
– Assessment that is best made by nurse to report is the character
of the drainage
– Ex: purulent or otherwise major priority over amount and
consistency.
Appendectomy – Following surgery nurse notices large amount of
serosanguineous drainage on dressing.
Most important for the nurse to obtain is:
-“Was tissue drain placed during surgery”
–This is frequently done during surgery to prevent accumulation in
wound,
Dressing should be reinforced.
Third trimester of pregnancy – Nurse most concerned with:
-epigastric pain
–Indicates impeding convulsion
-takes precedence over SOB because this is expected.
Pyloric stenosis – 4 week old – The statement expected from the
mother is “My son is fussy and hungry all the time. Baby becomes
lethargic, dehydrated, and malnourished.
Tagamet – (cimetidine) (anti ulcer agent) – An indication that
further teaching is necessary if client’s statement is
“ My stool may change color while I’m on this medication”.
Note: no change in stool color with cimetidine. Assess patient for
epigastric or abdominal pain and frank or occult blood in the stool,
emesis, or gastric aspirate but no stool color change.
Mononucleosis – S&S include
-sore throat, flu-like symptoms for the previous 2 weeks and
physical exam reveals enlarged lymph nodes.
-Advise family not to share drinking glass or silverware with
anybody.
Note: Mono is spread by direct contact avoid contact with cups
and silverware for about 3 months.
Bulimic – Most therapeutic to analyze a bulimic client’s eating
habits and the circumstances that precipitate the client’s eating
problems –
Note: assigning a Thought Feelings Action (TFA) journal relating to
client’s eating behaviors will be most helpful to the nurse and
therapeutic to the client.
Bacterial Meningitis – Mother is afraid of perminant brain damage
of her child. Most therapeutic communication is : “ It is unlikely
possibility, but if your child doesn’t develop normally, your
pediatrician will help you with any problems”.
Note: Bacterial Meningitis If treated early, good prognosis: may
be complications and long term effects (seizure disorders,
hydrocephalus, impaired intelligence, visual and hearing defects).
Herniorrhaphy – Most important one hour before is confirm that
the consent form has been signed.
Note: surgical consent should be rechecked before going to
surgery.
Note: Assessment for allergies should be done earlier then 1 hour
before surgery.
Addison’s Disease – Increased salt should be increased during
periods of stress.
Note: with decrease  in aldosterone, there is an  increased
excretion of sodium: sodium intake should be increased.
Note:The nurse should be concerned with auscultating an S3
ventricular gallop on a 78 year old woman.
Note: ventricular gallop is an early sign of Heart Failure (HF).
Note: Teaching is effective with a PCA pump when client says” If I
start itching I need to call you”
Note: itching is a common side effect of narcotics used in PCA pain
management.
Thorazine (Chlorpromazine) (Antipsychotic)–Client should report if
they have difficulty urinating.
Note: dry mouth, weight gain and constipation can be resolved at
home. Difficulty with urination can become a severe health problem
unless treated.
Digoxin (lanoxin) (antiarrhythimics)
-Theraputic level is 0.5 –2.0.
If blood level comes back 2.0.
**Medication should be held and physician notified.
Pleur evac –Fluid in the water seal chamber does not fluctuate,
indicates re-expansion of lung. And x-ray will confirm this.
Glasgow coma scale –5 indicates coma, client requires frequent
assessment.
Note: After MI the most common complication following is
dysrhythmia, with ventricular types being the most serious.
Cholecystectomy –Expected drainage is 500-1000 ml/day,
However complaints of sever abdominal pain after surgery could
indicate peritonitis or wound infection
Colonoscopopy–
Note:All activities that the client participated in before the
colostomy may be resumed after appropriate healing of the stoma
or incisions.
3 year old –When assisting a parent on foods it is best to allow
finger foods for this age group.
Note: Child is going through autonomy versus shame and doubt
stage
-finger foods allow child the necessary independence for this stage.
Note: Distended abdomen with splenomegaly
– Possibility of internal bleeding, life-threatening situation
Acute asthma attack – Most concerned if patient’s respiration rate
increases from 86 to 100 beats per minute.
Note: pulse increase is due to decrease in oxygenation of tissues.
Note: pallor is unreliable indicator of deterioration of status.
Demerol 100 mg PO q4h (meperidine)(opioid analgesics) –
Without much relief. Valid suggestion for the nurse to make to the
physician regarding pain medication – Administer medication Q4
around the clock.
Note: around the clock (ATC) administration of analgesics is more
effective in maintaining blood levels to alleviate the pain associated
with cancer.
Elderly with dementia – When planning care it is best to speak
slowly in a face to face position.
Note: providing flexibility leads to confusion schedules need to be
routine.
Note: Propranolol (Inderal) (antianginals, antiarrhythmics)
decreases the effectiveness of atorvastatin. (Lipitor) (lipid-lowering
agents)
Note: patient on lipitor and the following statement made by client
should be told to the physician “ I take Inderal.
Droplet precausion – A child with pertussis.
Note: bronchitis is the inflammation of large airway, standard
precautions., Tonsillitis standard precaution.
Total hip replacement – Most important for the nurse to apply
thigh high TED hose to promote venous return.
Note: use of antiembolic hose and or sequential compression
devices decreases venous stasis and reduces risk of thrombus
formation.
Hip fracture with Buck’s traction – Most important action by the
nurse is to turn the client every 2 hours to the unaffected side.
Immobility is the leading cause of problems with Buck’s traction,
Important to turn client to unaffected side.
Reflux – With infant should be maintained in an upright position:
HOB should be raised at a 30 degree angle.
After an appendectomy. – Patient complains of pain. After
administering analgesics the following action should be to elevate
the HOB 30 to 45 degrees.
Note: This would reduce stress on suture line and provide for
comfort.
Lumbar puncture (LP) - Best to prepare a 5 year old is to - Do a
mock run-through of the procedure.
Note: Excellent method to use with a child because it incorporates
actually “Feeling:” many aspects of the procedure as they are
explained.
Parathyroidectomy – Should be concerned with a client eating
quantities of food from which of the following food groups – Milk
products
Note: Low calcium diet is recommended preoperatively.
-Diet should be high in phosphorus and low in calcium.
Thermal injury – Most concerned with:
-Increased respiratory rate
-decrease BP.
Note: May indicate burn wound sepsis, a life threatening
complications of thermal injury.
Elderly Client – Drinks plenty of fluids however has a diet that
consists of starch. He lives alone with a limited income
– Most important to increase protein intake.
Note: Protein is needed to slow down the degeneration process of
aging.
Test positive for tuberculosis:
–Client placed on isoniazid (INH) 4 weeks ago.
-Nurse is most concered if client has fatigue and dark urine.
Note: This is an initial indications of hepatic dysfunction.
Dx with schizophrenia – Becomes increasingly withdrawn to point
of mutism. Most important action is to - Sit with client for brief
period of time.
Note: nurse should maintain contact with client but not make
demands to communicate or participate in activities.
Wet to dry – dressing for a client of an infected abdominal incision.
The nurse should intervene if client’s spouse wets the old dressing
with sterile saline before removing it.
Note: it is contraindicated – dressing should be removed dry so
wound debris and necrotic tissue are removed with old dressing.
Spina bifida – Of an 2 day old infant in for surgery repair. Mother
is concerned that infant would be confined to a wheelchair. Best
statement by nurse – “ The corrective surgery will not change your
child’s physical disability”
Note: Spinal nerves that are destroyed by the myelomeningocele
cannot be corrected: nothing can return function to portions of the
body that are innervated by the spinal nerves below the site of the
myelomeningocele.
Electrical burns –
Note: electrical burn injuries are typically more injurious to
underlying tissue, such as nerve and vascular tissue, which require
complex and timely treatment.
Child of 5 years old – with Closed head injury
– Best action is to assess orientation to person, place and time
every hour. *Early signs of increased ICP are alterations in
orientation.
Cystic Fibrosis – Statement that indicates parental understanding
about the cause of their newborn’s diagnosis of CF – “ Both of us
carry a recessive trait for cystic fibrosis.
Note: cystic fibrosis is inherited by an autosomal recessive trait.
Right sprained ankle – Learning to walk with a cane. Nurse
should be positioned by standing on the client’s left side and slightly
behind the client.
Note: Stand slightly behind client on strong side.
Note:If resistance is met with trying to flush diluted heparin into a
subclavian triple lumen catheter. Action nurse should take is to
secure the lumen with a luer - lock cap and notify the physician.
Note: streptokinase (Streptase,or Kabbikinase) (thrombolytics)
may be used to dissolve clot. If unsuccessful, lumen is labeled as
clotted off.
Administration of medication to a 4 month old – Most
appropriate is to place the medication in an empty nipple and allow
the infant to suck.
Note: never add to child’s formula feeding.
Note: Nurse should verify the order with a physician about IM
injection of Demerol for pain to a client receiving thrombolytic
therapy.
Note: bleeding can occur with IM injections.
Note:Douching makes Pap smear inaccurate. Have client avoid
douching for 24 hours.
Medication contraindicated – For a patient with hemophilia A =
Oxycodone terephthalate (percodan)(equals oxycodone and aspirin)
(opioid analgesics) – Contraindicated for persons with bleeding
disorder, contains aspirin.
Patient with sickle cell crisis with an infiltrated IV – Is a
priority due to IV fluids are critical to reduce clotting and pain
Questions about peak expiratory flow are in connection with mechanical ventilation, but before
discussing that subject, I want to post facts about lung sounds and where to locate them when using
the stethoscope.
Types of breaths sounds and their location:
1) Bronchial---------------------- trachea and larynx
tracheal, tubular (other names for the same sounds)
2) Broncovesicular--------------- over the major bronchi
3) Vesicular --------------------over the peripheral lung fields where air
enters the bronchi
If you read a question describing broncovesicular sounds, now you know which area of the lungs the
question is talking about.
Tracheal breath sounds
high-pitched, loud, harsh, hollow sounding, equal on inspiration and expiration.
Bronchial breath sounds
High-pitched, blowing, muffled, expiratory sound slightly longer than inspiratory.
Broncovesicular breath sounds
louder and harsher than vesicular sounds, muffled vesicular sound combined with with loud guttural
sound, equal on inspiration and expiration.
Vesicular breath sounds
soft and low-pitched, rustling or breezy, three times longer on inspiration than expiration.
Mechanical ventilation:
Tidal volume=the volume of air the patient receives with each breath, that will be determined by the
doctor and the ventilator would be set according to his orders.
Fraction of inspired oxygen(FiO2)= O2 concentration delivered to the patient which is determined
by the patient's condition and arterial blood gases (ABGs).
Rate=number of ventilator breath delivered per minute.
Sighs= volumes of airthat are 1.5 to 2 times the set tidal volume. The sighs are delivered 6-10 times
per hour. Sighs may be used to prevent atelectasis (collapsed, airless lung).
Peak Airway Inspiratory Airway Pressure= the pressure needed for the ventilator to deliver a set
tidal volume at a given compliance (the elasticity, extensibility and distensibility of the lungs and the
thoracic structures)
Causes of Ventilator Alarm:
Note: Assess your patient first and the ventilator second.
High-Pressure alarm
1) increased secretions
2) wheezing or broncospasm causes decreased airway size,
remember, the ventilator is preset according to certain
compliance (see above definition)
3) Displacement of endotracheal tube
4) Endotracheal tube obstruction due to water or a kink
in the tubbing.
5) patient is anxious or fights the ventilator
Low-Pressure alarm
1) Patient spontaneously breathing--that's nice
2) disconnection or leak in the ventilator or in the patient's
airway cuff occurs
Important Definitions:
Assault= Putting a client in fear of a harmful or offensive contact. The victim fears and believes that
harm will result as a direct consequence from the threat perceived coming from the care giver.
Battery= An intentional touching of a client's body without his/her consent.
Invasion of privacy= Includes violating confidentiality, intruding on private client or family matters
and sharing client information with unauthorized persons.
False Imprisonment= A client is not allowed toleave a health care facility; however, there is no legal
justification for detaining the client. False imprisonment is committed when restraining devises are
used without an appropriate clinical justification.
Defamation= False communication or a careless disregard for the truth that causes damage to
someone's reputation. This could be done in writing(libel) or verbally(slander).
Fraud= Results from a deliberate deception intended to produce unlawful gains.
Negligence=Failure to provide care that a reasonable person ordinarily would use in similar
circumstances.
Malpractice= Failure to met the standards of acceptable care, which results in harm to another
person.
Restrains:
Definition= Devises designed for protecting the client used for limiting the physical activity of a client
or to immobilize him/her or an extremity.
Kinds of restrains:
Physical--restricts client's movements through the application of a physical devise
Chemical--drugs given to a patient for inhibiting a specific behavior or movement, for example a sick
patient in a mechanical ventilator who fights the machine is given vecuroniun bromide, a paralytic
agent which relaxes skeletal muscles so the patient cannot fight the mechanical ventilator. Obviously
that chemical restrain is needed for that patient to breathe. There are specific rules governing the use
of any kind of restrains on a patient:
1) A restrain must have a doctor's order.
2) There cannot be a standing order for a restrain.
3) Physician's order must state
a) the type of restrain
b) identify the behavior for which the restrain is used
c) identify the limit or time frame for use
4) Physician"s orders for restrains must be renewed within a specific time
frame which is usually 24 hours.
5) Restrains are not to be ordered PRN(as needed)
6) The reason for the use of the restrain has to be told to the patient and his/her family and their
permission must be asked.
7) Restrains should not interfere with any treatment given to the patient or affect the patient's health.
8) to secure the restrain a half-bow knot should be used for it is easy to undo and it is safe.
9) The patient must have enough slack to allow movement of the body. Do not secure the restrains to
the bed's side rails, use for that the bed's frame or a chair.
10) Assess the skin integrity, neuromuscular and circulatory status every 30 minutes and remove
the restrain every 2hours to permit muscle exercise and promote circulation. Continually assess
and document the need for restrain.
Note: Not following those rules while restraining a patient is definedby law as false imprisonment.
feliz3
Asian Americans - higher incidence of stomach and liver cancers.
Rape victim - obtaining informed consent for examination is a priority before any
action is taken, including obtaining laboratory specimens and notifying the police. This
is part of process which initiates the chain of custody of the specimens and their
collection.
Hostage response is when victims assume responsibility for the violence inflicted on
them. Victims tend to blame themselves for the abuse and develop a sense of
unworthiness.
Valacyclovir (Valtrex) - a form of acyclovir; indicated in the oral treatment of herpes
zoster and recurrent genital herpes in immunocompetent adults.
Down syndrome - have a high incidence of congenital heart disease, especially atrial
defects.
When assisting in the medical treatment of alcohol withdrawal, the nurse should
encourage intake of fluids providing they are not too somnolent. Alcohol depletes the
body of fluid,
Alcohol withdrawal - anorexia, irritability, nausea, tremulousness, insomnia,
nightmares, hyperalertness, tachycardia, increased blood pressure, diaphoresis, and
anxiety.
Bulimia nervosa - Russell's sign, which is the presence of bruises or calluses on the
thumb or hand, caused by trauma from self-induced vomiting.
Cocaine - can cause seizures, which is one of the most serious side effects of cocaine
use.
Cocaine withdrawal - physical activity will help to dissipate anxiety and decrease the
cravings
Delirium tremens - alcohol withdrawal syndrome, which occurs most often after 24
hours; visual and tactile hallucinations, confusion, tachycardia, and possibly seizures
Dementia - symptoms of confusion are worse at night. This may be referred to as
“sundowning syndrome” in clients with Alzheimer’s disease.
Chlorpromazine (thorazine) - One of the common side effects of antipsychotic
medications is drowsiness; it usually diminishes after the client has taken the
medication for a few days.
Postural hypotension occurs with phenothiazides (chlorpromazine, fluphenazine)
Li toxicity - diarrhea, confusion, ataxia, slurred speech, hypotension, seizures, oliguria,
coma, and death; increased thirst and urination; polydipsia, polyuria, and fine tremors are
some of the very early signs of lithium toxicity
Generalized anxiety - can be managed with either benzodiazepines (Librium) or an
antidepressant.
Donepezil (Aricept) - cholinesterase inhibitor drug indicated for treatment of
Alzheimer's type dementia
Clozapine (Clozaril) - antipsychotic that can cause a potentially fatal blood dyscrasia
characterized by agranulocytosis (decreased WBCs, specifically neutrophils)
Older adult with alcohol withdrawal - Short-acting benzodiazepines, such as Ativan, are
preferred in older clients or when liver damage is suspected, because it is not metabolized
by the liver.
Methotrexate- causes GI tract irritations from toxicity; avoid sunlight and maintain
effective birth control while on the medication.
Sulfamylon (burn cream) - carbonic anhydrase inhibitor, and when systemically
absorbed, can precipitate metabolic acidosis; used to treat bacterial growth under
the eschar; causes a burning or stinging sensation on application, and pain management
should be planned; old ointment should not be removed.
Glaucoma has a strong hereditary tendency; those with a family history of glaucoma
should have intraocular pressure monitored yearly after the age of 30 instead of waiting
until after the age of 40 as would low-risk individuals.
Myringotomy - to promote drainage by making a surgical incision into the tympanic
membrane, which also relieves the pressure, prevents eardrum perforation, and
reduces pain.
Meniere’s Disease - assess the frequency and severity of attacks to plan best for
the client’s safety.
Infants are obligate-nose breathers - nose drops given before feeding promotes
clearance of the nasal 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. Meniere’s disease)
High priority patient who has a cast that complains of a
funny feeling: affected extremity indicates neurovascular
compromise, and requires immediate assessment.
Note: client in early stages of labor with a diagnosis of complete
placenta previa must be prepared for an immediate cesarean
section. Implementation, cannot deliver vaginally.
Note: Patient with epiglottitis who is having an early
complications of hypoxemia: will present with heart rate of 148
beats per minute. The HR correlates with hypoxemia and is an
early finding, along with restlessness.
After stabilizing a client with severe multiple trauma injuries
from a motor vehicle accident, which of the following actions by
the nurse is best? – Ans.
1. Limit visiting hours to promote optimal rest
2. Arrange for a psychologist to visit with the family.
3. Arrange for the family to meet with a social worker to discuss
financial aid.
4. Arrange for clergy to visit with the client and family as
requested.
Should remove nitro-patch before MRI is performed.
If a family member verbalizes that a family member will
closely watch the apnea monitor at all times. Nurse should
be concerned because this indicates a feeling that monitor may
not let them know if their infant stops breathing.
Patient admitted to the hospital with dry mucous membranes and
decreased skin turgor. Vital are BP – 120/70, temp, 101 degrees F,
pulse 88, resp 14. Lab tests indicate the serum sodium is 150
mEq/L and the Hct is 48%. The nurse expects the physician to
order which of the following IV fluids? – Ans.
1. -D5 NS,
2. -0.9 Na Cl
3. -lactated ringer
4. -0.45% Na Cl,
Note: Isotonic solution pushing fluid back to the cells.
Specific to dehydration.
“I should wash my hands before redressing my wound”
– Indicated understanding of asepsis, hallmark is hand washing.
A mother with a 4 year old comes in to confirm her second
pregnancy. The most important action for a nurse to do is identify the client’s general health needs. (Physical Needs)
The priority for a nurse in caring for a client diagnosed with
perforated bowel secondary to a bowel obstruction is to
prepare the client for emergency surgery.
Note: this can lead to peritonitis if not addressed.
A mother brings her 17 month old son to the well baby clinic for a
routine checkup. She confides to the nurse that she is concerned
because her son sucks his thumb, especially at night when he
is put to bed.
Which of the suggestions by the nurse is best?
– Don’t intervene at this time. This behavior usually subsides
after 24 months of age.
Note: Normal behavior, peaks at 18 – 20 months, most prevalent
when child is hungry or tired.
When 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 to
rotate the injection sites. This with prevent tissue damage and
promote tissue absorption of the medicine.
NOTE: dimercaprol (BAL inOil)(antidotes) treatment of acute
poioning with:
-mercury
-Gold
-Arsenic
Used adjunct with edetate calcium disodium in treatment of server
lead poisoning accompaneied by encephalopathy or blood level >
100mcg/dl
Priority question for OB _ Immediate intervention is always given
to a multipara woman at four weeks gestation reporting unilateral ,
dull abdominal pain. This indicates an etopic pregnancy and
needs to be evaluated.
A patient with a thermal injury to the right arm – The observation
that is most important to report to the doctor is – Gastric PH less
than 6.0 –
Note: decrease in gastric PH could indicate hypersecretion of
hydrogen ions,predisposing factor to stress ulcer formation.
Note: situational crisis: priority is to determine how client
coped with crisis in the past and build on client’s coping strategies.
Note: -if oil is placed on a wound it is most important to wash
the burn with soap and water –
Note: cooking fat applied to an open wound increases the
possibility of infection: burns should be rinsed immediately with
tap water to reduce the heat in the burn.
Client with DX of hyperparathyroidism – The most important
symptom to report to the next shift is – Hematuria
Note: Hematuria is a sign of renal calculi: 55% of
hyperparathyroid clients have renal stones.
Note: Dx with multiple sclerosis – most important for the nurse
to include in instructions – Is to avoid overexposure to heat and
cold –
Note: this may cause damage related to the changes in sensation
Several days after a client had a myocardial infarction, the
physician places the client on a 2-gm sodium diet.
Which of the following selections indicates to the nurse an
understanding of the diet? – Ans.
1. Scrambled egg, orange slices, and milk,
2. instant oatmeal, toast and orange juice,
3. poached egg, bacon and milk,
4. biscuit, fruit cup and sausage.
Note: instant oatmeal has sodium added
NOTE: all items are low in sodium with correct answer due to
milk is allowed on a salt restricted diet.
Instruction about the medication is effective when a pt. on
naproxen sodium (Anaprox) (nonopioid analgesics , nonsteroidal
anti-inflammatory agents, antipyretics) States “ I should call my
doctor if my stools turn very dark” –
Note: NSAIDs can cause gastrointestinal bleeding
Note:During a dressing change the old dressing should not be
saturated with sterile saline before it is removed. The
dressing should be removed dry so that wound debris and
necrotic tissue are removed with old dressing.
Note: Most important for nurse to assess for before administering
calcium gluconate 10% 500 mg IV stat – is patency of the
vein. If injected into the extravascular tissues, calcium gluconate
can cause a severe chemical burn.
Note: a child admitted with failure to thrive has just had a positive
sweat test. – Nurse anticipates what change in the child’s POC? –
ans.Administration of replacement enzymes.
Note: positive for sweat test indicate cyctic fibrosis.
Note:Best recommendation during discharge for a patient who
suffered a mild MI and smokes one pack of cigarettes per day– Ans.
Participate in a program such as nicotine avoidance.
A pt. has a Sengstaken-Blakemore tube in place. The nurse
enters the room and finds the pt. in respiratory distress. Which
of the following actions should the nurse take FIRST? – Ans.
Cut the balloon ports and remove the tube.
Note: Scissors always secured at the bedside: remove tube if
observe signs of respiratory distress or airway obstruction
caused by upward displacement of esophageal balloon.
It is most important for the nurse to include which of the following
instruction with prenatal vitamins. – Ans.
Take prenatal vitamins with orange juice at bedtime.
Note:taking the vitamins with something acidic increases the
absorption of iron. Taking them with food at bedtime
decreases the possibility of nausea, as the client will be asleep.
To promote safety in the environment of a client with a
marked depression of T cells, – Ans.
Remove any standing water left in containers or equipment.
Note: Water should not be allowed to stand in containers,
such as respiratory or suction equipment because this could act as
a culture medium.
Note: proper med administration Carafate (Sucralfate) (anti
ulcer agent): should be taken 1 hour ac (before meals) and
the Maalox (aluminum hydroxide with magnesium hydroxide)
(antacids)1 hour pc (after meals).
A client develops severe, crushing chest pain radiating to the
left shoulder and arm – BEST PRN med the nurse should
administer should be – Ans.
Morphine Sulfate IV (Opioid analgesic)
Note:This med reduces pain, anxiety and cardiac workload: reduces
the preload and afterload pressures.
The nurse cares for a client diagnosed with dementia in a long
term care facility. Which of the following actions by the nurse is
BEST? –– Ans.
Direct conversation toward assisting the client to reminisce and
talk about important past events in life.
Note:geriatric client should be encouraged to talk about his life
and important things in the past because he has recent memory
loss.
Which of the following is the FIRST nursing action that should be
implemented for a client after a vaginal delivery? – Ans.
Check the patient’s lochial flow.
Note:Complication of hemorrhage assessed by observing lochial
flow.
Note:When recording client’s chief complaint – It should be
recorded using the client’s own words. – Ans.
“My stomach hurts after dinner every night”
A client comes to the nurse’s station for the prescribed antipsychotic
medication. The nurse notes that the client has torticollis , an
arched back, and rapid movement of the eyes. Which of the
following actions should the nurse take first? – Ans.
Administer the PRN trihexyphenidyl (Artane) (antiparkinson
agents)IM immediately
(torticollis definition: Spasmodic contraction of neck muscles
causing head to tilt to one side and chin pointing to other side
McGraw Hill Nurse’s dictionary 2007)
Note:administer Cogentin (benztropine)(antiparkinson agents). or
Artane(trihexyphenidyl)(antiparkinson agents). – Assessment, no
validation required.
Note: a preschool client’s mother reports that the child has freq.
abouts of gastroenteritis. Most important quest. To ask
“Does the child attend a day care center?” –
Note: environments with increased numbers of children (day care)
more likely to promote infections due to close living conditions and
increased likelihood of disease transmission.
Note:Desired response to fluid replacement with a patent DX with
hypovolemia. – Ans.
CVP reading of 8 cm of water pressure.
Note: Normal range of CVP is 3-12 cm water pressure so 8
indicates desired results.
Note: - HGB 11 gt, HCT 33% indicates hypervolemia.
PH 7.34 indicated acidosis.
Client with elevated vital signs, hallucinations and aggressive
behavior that are possibly on hallucinogenic drugs – Following
action is to decrease environmental stimulation.
Note: symptoms will subside with time and decreased
stimulation.
Note: Early stages of hepatic encephalopathy is – having
difficulty describing what he does at work.
Note: impaired thought processes is early symptoms.
Proper weight gain pregnancy is:
-2-5 lbs in the first trimester,
-0.66- 1.1 weely in 2nd and 3rd trimester.
-So 14 lbs in the fifth month is normal. 5 + 8 = 13.
A young adult comes to the AIDS clinic for treatment of large,
painful, purplish-brown open areas on his right arm and
back. The nurse should instruct the client to take which of the
following actions? – Ans.
Clean the area carefully with soap and warm water every
day, and cover them with a sterile dressing.
Note:Open Kaposi’s sarcoma lesions should be cleaned and dressed
daily to prevent secondary infection.
The nurse assesses an infant who had a repair of a cleft lip and
palate. The respiratory assessment reveals that the infant has
upper airway congestion and slightly labored respirations.
Which of the following nursing actions is MOST appropriate? – Ans.
Position the infant on one side.
Note:will facilitate drainage of mucus from upper airway and will
promote adjustment to breathing through the nose.
Note:Pitocin(Oxytocin) (misc O/B GYN Agents) should always be a
secondary infusion controlled by an IV pump.
A client is admitted with a diagnosis of renal calculi and is
experiencing severe pain. Meperidine (Demerol)(Narcotic
Analgesics) 75 mg IM is given prior to the change of shift. Which of
the following symptoms is MOST important for the nurse to report
to the next shift? – Ans.
Change in the location and character of pain.
Note: Location of the pain depends on location of renal stone:
character of pain changes depending on location or
movement of stone.
Note: -Nursing interventions should involve distracting and
redirecting behaviors for a bipolar disorder patient in the
manic phase.
Note: gown gloves and mask are appropriate for rubella
(German measles) = droplet precaution.
Note: Flagyl shouldn’t be taken with alcohol. It will cause
antabuse (Disulfiram)(alcohol antagonist drug)like reactions. Should
also be taken with food to decrease gastric upset.
Note:4 year old with sickle cell anemia, baby aspirin
(SALICYLATES) (antipyretics, nonopioid analgesics) shouldn’t be
given for complains of pain.
Note: Aspirin(SALICYLATES) (antipyretics, nonopioid analgesics)
can cause a hemorrhage during a sickle cell crisis.
Which of the following findings indicates to the nurse that a client’s
Salem sump tube (nasogastric) was functioning effectively?
– Ans.
The presence of a hissing sound from the blue lumen tube.
Note: Hissing sound is indicative that air is freely exiting the
airway; purpose is to provide continuous steady suction without
pulling gastric mucosa.
The nurse cares for a pt. with deep partial thickness and full
thickness burns. The client receives morphine sulfate 15 mg
IV(Opioid analgesic). The nurse notes a decrease in bowel
sounds and slight abdominal distention which of the
following. Actions, if taken by the nurse, is BEST? – Ans.
Explore alternative pain management techniques.
Note: Morphine (Opioid analgesic)
is drug of choice for burn pain management, when side effect
becomes apparent, exploration of alternative pain management
techniques such as visualization becomes important.
Note:How to obtain a throat culture from a client diagnosed with
pharyngitis. – Ans.
Quickly rub a cotton swab over both tonsillar areas and the
posterior pharynx.
NOTE: height and weight changes in a year
Height: at age 6 – 12 children grow about 2 inches (5 cm) a year
Weight: gain 4.5 – 6.5lb (3 – 3 kg) a year
Height: at age 7 about 44 – 51 inches (111.8 – 129.7cm)
Weight: average 39 – 66.5 lb (17.7 – 30kg)
A mother brings her 7 year old daughter to the outpatient clinic
for a routine check up. The girl weighs 50.25 lb (22.85 kg) and
is 48 inches (121.7 cm) tall. The nurse notes that the child has
gained 2.5 lb and grown 3 inches in the past year. Which of
the following. Responses by the nurse is best?– Ans.
“ Your daughter’s height and weight are within normal
limits.”
NOTE: First 24 hours of TPN – Nurse should evaluate blood
glucose level.
Note: Total parenteral nutrition (TPN), or hyperalimentation, has a
high glucose content important to monitor glucose levels.
The nurse receives a phone call from a nursing assistant who
states that her 5 year old child has developed chickenpox. It
would be MOST important for the nurse to ask which of the
following.– Ans.
“Have you had the chicken pox?”
Note: Need to ascertain if staff has had the disease, if not, Varicella
Zoster Immune Globulin (VZIG) can be given,
-exclude from patient care from the:
10th day after First exposure through the 21st day after last
exposure.
Unless Given than 28th day if VZIG given)
The nurse knows that which of the following.Plans would be a
priority for an infant with a positive PKU blood test? – Ans.
Place the infant on Lofenalac formula.
Note: Guthrie blood test evaluates neonate for phenylketonuria
(PKU).
Note: Lofenalac formula is low in phenylalanine but contains
minerals and vitamins to provide a balanced nutritional formula.
Phenylketonuria definition: Phenylpyruvic acid in the urine. *A
recessive hereditary disease caused by the body's failure to oxidize
an amino acid (phenylalanine) to tyrosine, because of a defective
enzyme.
24 hr after abdominal surgery, which of the following. Plans is a
nursing priority to prevent complication of flatulence? – ans.
Assist the client to walk in the hall every two hours.
Note: Twalking in the hall, this action will increase peristalsis,
decreasing the development of flatus.
A client admitted with metastatic cancer has received
chemotherapy for three months.
Lab values include:
RBC 3.8 millin/mm3,
WBC 3,000/mm3,
Hgb 9.3 g/dl,
platelets 50.000/mm5 .
The nurse expects the patient to exhibit which of the following
symptoms? – Ans.
BP 120/70, pulse 100, respirations 16. –
Note: Increase pulse and respiration are caused by decreased
oxygenation of tissues. – The patient will be pale due to
anemia,
Normal RBC male – 4.3 – 5.9 million/mm3,
female 3.5 – 5.5 mill./mm3
Normal WBC 4,000 – 11,000/mm3,
Normal Hgb male 13,5 – 17.5 g/dl, female 12 – 16 gt/dl
A physician writes an order for an HIV positive infant to receive
Inactivated polio (IPV) immunization. Which of the following.
Nursing actions is MOST appropriate?– Ans.
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 after
surgery. Which of the following foods should the nurse
encourage?– Ans.
Yogurt and acidophilus milk.
Note:These foods will help maintain normal intestinal flora,
which may be altered by the keflex.
Note: A client with AIDS who had a chest tube removed
yesterday and is complaining of crackling under his skin Indicates subcutaneous emphysema, which is indication of
pneumothorax,
observe client for respiratory distress, contact physician.
Note:If nurse enters the room to find a tracheotomy tube
dislodged. The nurse should immediately replace the
tracheotomy tube.
Note:a client with sunken eyeballs and fruity breath
indicates diabetic ketoacidosis,
treatment: with normal saline and regular insulin.
Note: HEP–A: is not infectious within a week or so after the
onset of jaundice, child can return to school. Activity at that
time depends on the child’s energy level.
Which finding indicates to the nurse that a client experiencing
alcohol withdrawal is in need of more sedation to control the
severity of withdrawal symptoms? – Ans.
Elevated pulse rate
Note:pulse rate is a good indicator of client’s progress through
withdrawal, increasingly elevated pulse signals:
impending alcohol withdrawal
delirium requiring more sedation.
A client developed diabetes insipidus following. A craniotomy.
The nurse provides discharge instructions for the client and spouse.
Which of the following statements, if made by the client indicates to
the nurse that further teaching is needed? – Ans.
-“I should weigh myself every day
-drink less fluid if I gain more than 5 lb over a week”.
Note: - desmopressin (DDAVP, Stimate)(hormone) treatment of
Diabetes Insipidus nasally or SQ required for remainder of
life.
During the physical assessment, the nurse determines the need to
perform the bulge test. Which of the following statements, if made
by the nurse is BEST– Ans.
”Please lie down and extend your legs”
Note: Bulge test: confirms presence of fluid in the knee,
client’s leg should be extended and supported on the bed.
Note:Cromolyn Sodium (Intal, NasalCrom) (misc antiallergy
agents) is used to prevent the release of histamine and other
allergy-triggering substances.
– Correct statement would be
“ I will take the medicine before I begin any vigorous exercise”.
Note:favorable results from administration of
medicationlevothyroxine (synthroid) (harmoe) is increased urine
output.
Note: Medication increases metabolic processes of body,
including glomerular filtration, edema will decrease as water is
excreted.
NOTE:- Appropriate action in palpating the uterine contractions
would be to:
place one hand on the abdomen over the fundus, and
with the fingertips presses gently.
A nurse was sued for malpractice but is proved innocent.
Which fact from the case was decisive in determining the outcome?
– Ans.
No harm was actually suffered by the patient.
NOTE: - Required elements of malpractice are:
duty
breach of duty
causation
injury
Glasgow Scale= A method of assessing neurological condition on a scale 1-15. A score < 8
indicates coma. Eye opening is the most important indicator. The highest score is 15 which
is normal.
Levels of Consciousness:
LOC-----------------------Description
Full Awake, alert & oriented, understands & responds
Consciousness accordingly.
Confusion Disoriented first to time, then place, then person.
Memory deficits, restless, difficulties following
commands.
Lethargy Oriented to time, person and place, but
demonstrates slow mental process, sluggish
speech. Sleeps frequently, but weakens to
spoken word or gentle shake. Maintains
wakefulness with sufficient stimulation.
Obtundation Extreme drowsiness, responds with one or two
word when spoken to, follows very simple
commands, requires more vigorous stimulation
to waken, and stays awake only for a few minutes
at a time.
Stupor Minimal movement, responds unintelligibly, and
wakens briefly only to repeated vigorous
stimulation.
Coma Does not respond to verbal stimuli, does not
speak. May have appropriate motor response
(withdraws from noxious stimuli), nonpurposeful
response.
Recognizing a Stroke:
S-- ask your patient to smile Which cranial nerve would you be testing?
T-- ask you patient to Talk and speak a simple sentence coherently
i.e. Today is a beautiful day.
R--ask your patient to raise both hands
Ask your patient to stick his/her tongue out. Which cranial nerve are you testing and what are the
abnormal sign you are watching for?
A medication that a nurse should question with COPD would
be: Propranolol hydrochloride (Inderal)(beta-adrenergic
blockers).
Rational: – Beta blocker that blocks beta adrenergic impulses to
the bronchial tree that cause bronchodilator resulting in increased
bronchoconstriction.
The nurse performs an ice massage – for a client in chronic pain.
The nurse is most concerned if which of the following is observed?
Ans=
– Mottling or graying of the tissue.
Rational: – Site should be observed every five minutes for:
-signs of tissue intolerance, including blanching, mottling, or
graying.
Complete Heart Block – The nurse should question which of the
following orders?
Ans=
Administrer lidocaine (xylocaine)(antiarrhythmic agent) 50 mg IV
push for PVCs in excess of six per minute.
Rational = In complete heart block, the AV node blocks all
impulses from the SA node, so the atria and ventricles beat
independently, because lidocaine suppresses ventricular
irritability, it may diminish the existing ventricular response,
cardiac depressants are contraindicated in the presence of
complete heart block.
Manic phase of bipolar disorder – It is most important for the
nurses to offer which of the following meals?
Ans=
Tuna salad sandwich and orange slices
Rational = clients with mania need nutritious finger foods;
foods contain protein, carbs, and vitamin C and fiber.
Urinary Pattern – The nurse should instruct a patient to do what
first?
Ans=
Keep a record of daily fluid intake.
Rational: – Client needs to know how much and when he ingests
fluid.
Ileal Conduit 2 days ago – Most important for the nurse to take
which of the following actions?
Ans=
Apply a close fitting drainage bag to the stoma.
Rational = Primary preventative measure to prevent urine from
contacting the skin.
Note: should be cleaned with soap and water not an antiseptic
solution.
Intubating a postoperative client – Most appropriate action to
take would be to.
Ans=
Place the intubation blade in a bag, and arrange for gas sterilization.
Rational = Sterilization of equipment after exposure to body
fluids of a client is protocol.
Diet teaching for a client with SCI. – The following meal that is best.
Ans=
Spaghetti with meat sauce and green beans.
Rational – High fiber diet is an important part of bowel program,
fiber helps prevent the complication of constipation, includes
whole-grain foods, bran, fresh and dried fruits, increased fiber will
facilitate defecation, especially with reduction in fat intake.
Note: I picked a tuna fish sandwich with orange juice due to the
fiber
(Spaghetti is white flour and is constipating)
NOTE: BIRTH WEIGHT SHOULD DOUBLE IN 5 MONTHS.
Client presents with diaphoresis, pallor, and tachycardia
– One hour after receiving 7 U of regular insulin. – Action the
nurse should take first is
Ans=
Offer the client milk and crackers.
Rational – Onset of action for reg. insulin is 30-60 min;
assessment indicates a problem with hypoglycemia, foods such as
mild and crackers should be given if blood sugar is around 4060 mg/dl. If orange juice or simple sugaris given, it should
befollowed with a meal or with protein intake.
Note: It is unnecessary to administer glucagons unless client is
unresponsive.
Client receiving chlorpromazine (Thorazine) (antipsychotics)
400mg/day for four weeks – Presents with temp. 105 F severe
rigidity, oculogyric crisis, and severe hypertension. MOST
important for the nurse to take which action?
Ans=
Hold the chlorpromazine, and notify the medical staff stat. –
Rational = Client is experiencing neuroleptic malignant
syndrome, fatal in about 15 – 20% of cases, is toxic effect of
antipsychotic medication.
(HbA1c) of 6% - Results normal, indicates good control of
diabetes.
Normal heart rate for a two day infant – 120-160 BPM
-If a 2 day old infant, lying quietly alert,
-heart rate of 185 bpm has tachycardia, and requires further
investigation.
Graves disease – Nurse would intervene if client drinks
Ans=
TEA.
Rational: = Stimulant that would increase metabolic rate.
After the anesthesiologist administers an epidural to a woman
– HIGHEST priority would be to
Ans=
Obtain the blood pressure.
Rational: assessment side effect of an epidural is hypotension
from the vasodilation that occurs.
Note: Assessing the FHR monitor may be done as ongoing
management but is not a priority.
Ciprofloxacin (CIPRO) (fluoroquinolones) – MOST important for the
nurse to include when instructing the client about this medication
Ans=
“ Drink plenty of fluids”
Rational – Prevents crystalluria and stone formation.
Spinal Anesthesia – The following is an important nursing
implication regarding this anesthesia
Ans=
Adequately hydrated the client
Rational = Important that the client be well hydrated to prevent
hypotensive problems after the spinal anesthesia is initiated.
Note: unnecessary for client to be NPO for 12 hours
A client is diagnosed with a tumor of the pituitary gland and
has a transphenoidal hypophysectomy. The nurse plans care for
the patient two days after surgery. It is MOST important for the
nurse to monitor which of the following?
Ans=
Specific Gravity of Urine.
Note: Lack of ADH from pituitary will cause diabetes insipidus
and diuresis with very low specific gravity.
NOTE: Clients on hydrochlorothiazide (HydroDIURIL) (diuretic)
should be encouraged to eat foods high in potassium – Ex.
Dried apricots, bananas every day due to the diuretic causing loss of
potassium.
NOTE:A LPN/LVN with shingles can care for non-high risk clients
as long as lesions are covered.
The nurse performs hypertension screening at the local grocery
store. It is MOST important for the nurse to complete which of the
following tasks?
Ans=
Take two readings at least five minutes apart.
Note: Recognition of adult hypertension should be done after
two readings taken at least five minutes apart.
NOTE: To confirm a client stating that he thinks he has an ulcer.
Nurse should respond by asking “ Do you have a burning pain in
the epigastric region?”
- Peptic ulcer pain is often referred to as a “boring pain in the
back” or a burning gnawing feeling in the midepigastric area.
The nurse cares for a client immediately after an abdominal aortic
aneurysm repair. Vital signs and blood pressure 100/70, pulse
120 respirations 24, urine output 75 ml during the past three hours.
Which of the following is a priority nursing action for this client?
Ans=
Maintain bedrest, and evaluate for a decrease in CVP readings.
NOTE: client is at increased risk for development of
hypovolemic shock, vital signs and urine output correlate with the
early signs of shock, the nurse should compare the CVP with
previous readings.
Note: Client with a Harrington rod due to scoliosis, in
preparation for the immediate postoperative care, the nurse should
include which of the following in a teaching plan – ans.
Take 10 deep breaths every 2 hours.
Note: Client must be monitored closely for the first 48-72 hours
for respiratory problems bowel and urinary problems need to
be assessed along with neurological problems in the
extremities. Client will have a catheter, may have a nasogastric
tube connected to low suction,.
No reason to reassign pregnant staff member from taking care of
cytomegalovirus patient. – Just need standard precautions.
The family members of an 85 year old report to the nurse that they
suspect that their father is masturbating. Which of the following
responses by the nurse is BEST?
Ans=
“ This is considered a normal behavior for men”
NOTE:Masturbation is an activity performed by some elderly men.
The nurse cares for a patient following a right adrenalectomy.
During the immediate postoperative period, it is MOST important for
the nurse to observe for which of the following?
Ans=
Blood pressure alteration
NOTE: Decrease in blood pressure may indicate shock.
When using palpation techniques during the physical assessment
of an adult female with abdominal pain, which of the following
actions should the nurse take FIRST?
Ans=
Inform the client to breathe slowly.
NOTE: Breathing slowly will enhance relaxation of the
abdominal muscles.
NOTE: holding a deep breath is done during palpation of the liver.
NOTE: It is important for the parents to stroke an infant after
surgery. The tactile stimulation is imperative for an infant’s normal
emotional development, after the trauma of surgery; sensory
deprivation can cause failure to thrive.
NOTE: on an EKG stripe if there are 8 QRS complexes in 30 large
squares for a 6 second strip. The heart rate is calculated by
timeing the QRS complexes by 10.
EX (8X10) = 80. 80 is the HR.
An order has been received to obtain a stool specimen and test
for occult blood. The nurse is MOST concerned if the client makes
which of the following statements?
Ans=
“ I take Feosol every day”
NOTE: Iron supplements can cause color of stool to resemble
melena.
A primipara is admitted in early labor, and her membranes
rupture. Which of the following assessments by the nurse is MOST
important?
Ans=
Assess for a prolapsed cord.
NOTE: Initial assessment is to check for a prolapsed cord.
Note:the mother’s BP is not affected by rupture of the membranes.
The nurse prepares a client for a laparoscopic cholecystectomy
for treatment of cholelithiasis. It is MOST important for the
nurse to ask which of the following questions?
Ans=
“ Who is going to help you at home during the next couple of days?”
NOTE: Cleint usually discharged the day of surgery or the next day:
ensure that client has help at home for first 24-48 hours.
NOTE: Activity helps reduce frequency and degree of phantom pain
on an amputee.
An adolescent is seen in the emergency room for an overdose
of acetylsalicylic acid (Aspirin)( antipyretics, nonopioid analgesics).
Which of the following actions by the nurse is BEST?
Ans=
Determine when the client took the aspirin.
NOTE: Charcoal, if given within two hours, will absorb particles
of salicylate.
NOTE:Pt. withdrawing from pain or noxious stimuli is a sign of
deterioration in pt’s condition. Physicain should be notified.
The nurse evaluates care for a client diagnosed with depression.
The nurse is MOST concerned if which of the following is observed?
Ans=
The LPN?LVN administers flurazepam hydrochloride (Dalmane)
(sedative hypnotics)15 mg hs.
NOTE: Medication that produces dependence should be a last
resort, used only if other nursing measures and antidepressant
meds have not worked and the client is exhausted.
The nurse prepares a client for insertion of a suclavian triple
lumen catheter to be used for administration of total
parenteral nutrition (TPN). The nurse should position the client in
which of the following positions?
Ans=
Supine with the client’s head low and turned away from the
insertion site.
NOTE:Produces dilation of the neck and shoulder vessels, making
entry easier and preventing air embolus.
The nurse cares for a woman with pregnancy-induced
hypertention (PIH) treated with magnesium sulfate. The
nurse is MOST concerned if which of the following is observed?
Ans=
Urine output decreaed from 70 to 30 ml/hr.
NOTE: is metabolized and excreted by the kidneys; decrease in
the urine output can lead to toxicity.
The school nurse interviews an adolescent. The nurse is MOST
concerned if the adolescent states which of the following?
Ans=
“ I’m glad I don’t get as sweaty as my friends when I work out.”
NOTE: Should have increased sweat production due to
hormonal changes.
Which of the following questions BEST aids the nurse in assessing
the orientation of a client on the psychiatric unit?
Ans=
“What is your name?”
NOTE: Some well-oriented people do not know the answer
to(WHO IS THE PRESIDENT OF THE USA?) this question:
-depending upon their age, educational level, etc.
Which of the following statements by an adult client indicates to the
nurse the need for further teaching regarding care of a sigmoid
colostomy?
Ans=
“I’m irrigating my colostomy after each meal.”
NOTE: Irrigation of sigmoid colostomy is not necessary more
than once a day and sometimes every two or three, if at all.
Note:It is possible for many clients to go without a collection bag
by performing routine irrigations.
The nurse assesses a child diagnosed with cystic fibrosis. The
nurse is MOST concerned if which of the following is observed?
Ans=
The child is expectorating thick, yellow mucus.
Note: Thick, yellow mucus is indicative of pneumonia.
Note: exertional dyspnea increases during the day and child
complains about difficulty breathing is not unusual for a child
with cystic fibrosis.
The physician prescribes hydrochlorothiazide (Oretic)
(antihypertensives, diuretics) 50 mg PO daily for a client. The
client also takes dexamethasone (Decaspray) (corticosteroids) 2
sprays in each nostril bid. The nurse should encourage the client to
increase the intake of which of the following foods?
Ans=
Citrus fruits and green, leafy vegetables.
Note: Need to increase intake of potassium rich foods because
of potassium loss from diuretic medications.
NOTE: Client with deep partial thickness and full thickness burns
over 30% of the body. Three days ago it is most important for the
nurse to report which of the following observations to the next shift?
Ans=
Gen. muscle weakness and lethargy.
Note: Muscle weakness and lethargy are signs of hypokalemia,
which can occur on the third day after a burn: hypokalemia is
caused by diuresis.
A client complains of hearing loss. While the nurse is irrigating
the client’s ear to remove cerumen for better observation of the
tympanic membrane, the client complains of dizziness. Which of the
following actions should the nurse take FIRST?
Ans=
Warm the irrigant, and resume the procedure.
Note: water that is too cool can elicit dizziness when it comes
into contact with the tympanic membrane.
NOTE: client with Addison’s disease has hyperkalemia. NO
need to encourage foods rich in potassium. Cortef
(hydrocortisone)(antiasthmatics, corticosteroids)for Addison’s is
best taken in the morning.
If steroids are taken at night, they may cause sleeplessness.
A client returns to the floor following a bronchoscopy. The client
complains of thirst and requests ice chips. The physician left an
order for the patient to resume a regular diet. The nurse should
take which of the following actions?
Ans=
Touch the back of the client’s throat with a tongue depressor.
Note: assessment of patient: a local anesthesia sprayed in throat
may interfere with swallowing. Need to check gag reflex.
The nurse enters the room and discovers that the client has
slurred speech, right-sided paralysis, and unequal pupils.
Which of the following actions should the nurse take FIRST?
Ans=
Assess the respiratory status.
Note: Determining LOC is not as important. Ensuring the client
has an open airway is the appropriate next step.
Further instruction is needed with GoLYTELY (polyethylene
glycolelectrolyte solution)(cathartics/laxatives) if client states:
Ans=
“If I drink it ice cold, it won’t taste as bad.”
Note: Golytely can cause hypothermia due to large quantity
of solution ingested.
In caring for a client with dementia, the nurse should give
highest priority to which of the following goals?
Ans=
Maintain an optimal level of functioning.
NOTE: dementia is characterized by severe, prolonged
impairment, which is often irreversible; main focus of care is to
keep client as healthy as possible for as long as possible.
NOTE: it is normal for a neonate; to have apnea for 10 sec.
If 15 seconds or longer should be reported to a physician.
While checking the patency of a Salem sump tube, the nurse
finds stomach contents draining from the air vent. Which of the
following nursing actions is MOST appropriate? Ans=
Insert 30 ml of air through the air vent.
NOTE: Clearing the air vent with air will re-establish proper
suction in the Salem sump tube.
A 4 month old infant who had a temp. of 103 F following the
last DTaP vaccine is seen in the clinic for another immunization
administration. Prior to the nurse’s administering the DTaP, which of
the following should be the nurse’s priority?
Ans=
Consult the physician about pediatric DT (diphtheria and tetanus)
NOTE: fever over 103 F in first 48 hours after DTaP is a valid
contraindication for pertussis vaccine.
PT with AIDS – Teaching is effective if the patient takes docusate
sodium (Colace) 300 mg once a day.
NOTE: Bowel programs, stool softeners, and laxatives reduce
intestinal stasis and bacterial overgrowth.
The public health nurse cares for a child diagnosed with
impetigo. The nurse is MOST concerned if which of the following is
observed?
Ans=
Periorbital edema.
NOTE: Indicative of poststreptococcal glomerulonephritis, a
possible complication of impetigo periorbital edema.
A client receives prochlorperazine maleate (Compazine)
(antiemetics, antipsychotics)10 mg IM before repair of a hernia
under general anesthesia. The nurse is MOST concerned if which of
the following is observed six hours after surgery?
Ans.
The patient has not voided since surgery.
NOTE: Compazine Urine retention is side effect of medication
and is caused by general anesthesia.
The nurse conducts a class at a senior citizen center on the changes
associated with aging. The nurse is MOST concerned if a client
states which of the following?
Ans=
“I’ve been sleeping with fewer blankets over me lately”
NOTE: Usually becomes intolerant to cold.
NOTE: DX of haemophilus influenzae meningitis – How long child
will need to be in isolation.
Ans=
“Isolation can usually be stopped 24 hours after the start of
antibiotic therapy.”
NOTE:haemophilus influenzae meningitis treated with
penicillin; IV fluids and isolation for 24 hours after the start of
antibiotic therapy to prevent respiratory transmission.
NOTE: fetal heartbeat can be heard at 12 weeks; is a positive
sign of pregnancy.
Best assessment to assist the nurse in determining her expected
date of confinement (EDC)?
Ans=
If client isn’t shure when the last menstruation was.
The nurse cares for a client in hypovolemic shock. Which of the
following indicates a therapeutic response to volume replacement?
Ans=
Urine output increases to 40 ml/hour.
NOTE: hypovolemic shock: primary objective of fluid replacement
is to perfuse vital organs;
-increase in urine output to a normal range indicates that kidneys
are adequately perfused; other major organs are being perfused
also.
Note: CVP is an indicator of fluid balance; CVP of 5 cm water is
in the low range and does not indicate adequate tissue
perfusion.
NOTE: During examination of thyroid:drinking water facilitates
swallowing.
Which nursing action is MOST appropriate when an infant is
admitted for fever, poor feeding, irritability, and a bulging
fontanel?
Ans=
Place the client on droplet precautions.
NOTE: Implementation; classic signs of meningitis; client should
be isolated from other clients.
NOTE: If Dr. orders an analgesic to be administered to a
woman in labor who is 9 cm dilated and is having contractions
every 3 minutes, lasting for 50 seconds. Which of the following
nursing actions is MOST important?
Ans=
Notify the physician regarding the status of contractions.
NOTE: Information indicates that woman is in transition phase;
analgesics should not be administered during transition
phase.
NOTE: Extrusion reflex in an infant usually disappears in 3 to 4
months of age.
NOTE: dexamethasone (Decadron) (antiasthmatics,
corticosteroids)should be taken with breakfast.
Note: Oral steroids have ulcerogenic properties
-need to be administered with meals;
-if ordered daily, administer in morning.
A client with urinary frequency, burning, and a temperature
of 102 F is instructed by the nurse to collect a urine specimen
for culture and sensitivity. The nurse knows that teaching is
successful if the client states which of the following?
Ans=
“I will collect the specimen using an aseptic technique”
NOTE: aseptic technique decreases the possibility of
contamination with organisms.
NOTE:appropriate actvity for a 10 year old female client
recovering from a sickle cell crisis?
Ans=
Collecting pictures of favorite stars from magazines.
NOTE:collecting is an activity that is important to schoolaged children.
NOTE: after a thyroidectomy a nurse is most concerned
with:tension and muscle spasm of the hand when a blood
pressure cuff is applied to the are and inflated. -Positive
Trousseau’s sign :indicates tetany; surgery may damage
parathyroid glands and cause a decrease in serum calcium.
The nurse cares for a client with a bleeding duodenal ulcer. The
nurse is MOST concerned if the patient reported taking which of the
following mediations?
Ans=
Metoclopramide hydrochloride (Reglan)(antiemetics) 15 mg PO.
NOTE: Reglan stimulates motility of upper gastrointestinal
tract, contraindicated with possible hemorrhage of
gastrointestinal tract; used to treat nausea of chemotherapy.
NOTE: heparin(anticoagulants) not transmitted in breast milk;
breast-feeding considered safe.
NOTE: haldol (haloperidol) (antipsychotics)is particularly effective
in reducing assaultive behavior associated with severe anxiety.
Symptoms of a Hypertensive Crisis
1) severe occipital headache radiating frontally
2) neck stiffness and soreness
3) nausea/vomiting
4) chills/fever
5) clammy skin
6) dilated pupils
7) palpitations
8) tachycardia and bradycardia
9) chest pain
Prevention Definition:
1) Primary prevention= measures that include activities that help avoid
a given health care problem. Examples:
a) passive/active immunization, exercise and a balanced diet for
avoiding diabetes type 2 and high blood pressure
b) health protection education such as promoting using a helmet while
riding a motorcycle, use of the passenger seatbelt
Successful primary prevention helps to avoid suffering, cost and
burden of a disease.
2) Secondary Prevention=Identification and treatment of asymptomatic
clients who have already developed the risk factors or pre-clinical
disease, but in whom the condition is not clinically apparent.
3) Tertiary Prevention= Activities involving the care of a client who has
been diagnosed with a disease with the attempt to restore the highest
function. Example, speech therapy for a person who had a stroke.
feliz
Duration: 18-24hrs. Intermediate acting insulin
5) Ultralente (U)=Onset: 30min.-3hrs. Peak: 10-20hrs.
Duration: 20-36hrs. Inject thigh fat tissue
6) Lantus= Onset: 60-90 min. No peak time insulin is delivered at a
steady level. Duration:20-36hrs.
Note: premixed insulins are a combination of specific proportions of intermediate-acting and short-
acting insulin in a bottle or in an insulin pen. The numbers following the brand name indicate the
percentage of each type of insulin. For example Novolin 70/30. The first number is the percentage of
NPH=70, and Regular=30. The second number is 30 which represents the percentage of Regular
Insulin in the bottle.

feliz3
Aneurism Precautions:
1) Bed rest in a quiet setting is a must for a patient with this condition.
2) Minimize environmental stimuli--keep lights dimmed
3) Any activity that increases blood pressure or impedes
venous return to from the brain is strictly prohibited.
ABSOLUTELY NO!
a) pushing
b) pulling
c) sneezing
d) coughing
e) straining---may have to be given a stool softener for
avoiding effort of bowel movement--document this-4) stimulants such as caffeine, nicotine---prohibited
5) visitors, radio, TV and reading material---limited or prohibited.
The purpose is to avoid increase in intracranial pressure.
Signs of infiltrated IV:
1) pallor
2) coolness
3) swelling--IV fluid deposited in subcutaneous tissue
4) IV stops when the pressure of the fluid deposited in the tissue
exceeds the pressure in the tubbing.
Phlebitis, thrombosis and infection cause the affected skin to feel warm to the touch.
Dilantin(phenytoin) is an anticonvulsive that causes gum bleeding and hyperplastic
gingivitis (inflammation and enlargement of the gums caused by an increase in the number
of cells). An assessment of the mouth while the patient is taking this drug and educating the







patient abouNEVER give potassium IV push because it is fatal.
Never administer concentrated potassium chloride without first diluting it
Potassium chloride (KCL) preparation available in a premixed form a KCL preparation greater
than 60mEq/L should not be given in a peripheral vein...what do you think it will happen to
the peripheral vein?
Administer potassium at an infusion rate than does not exceed 10-20mEq/L
For extreme hypokalemia, infusion rates should be no more than 40mEq/hr while the patient
is hooked to an EKG. Must monitor cardiac activity.
Potassium is excreted by the kidneys, assess kidney function before administering
Potassium
Use an infusion pump to control the infusion flow rate
Infiltrated KCL (KCL going into the subcutaneous tissue instead of the blood circulation
system--extravasation causes tissue necrosis-). KCL is extremely irritating as Potassium
is a caustic substance.
Infiltration(extravasation) Protocol:
Signs and Sx
1) coolness to the skin
2) taut skin
3) dependent edema
4) backflow of blood absent
5) infusion rate slowing
Tx
1)
2)
3)
4)
assess for inflitration and notify physician
discontinue catheter
apply cool compresses
inject, depending on the drug given, an antidote to the site
Prevention:
1) Stabilize the catheter
2) Place the catheter in appropriate site
3) avoid antecubital fossa...why?
for a patient taking Dilantin.
feliz3
feliz3 t the importance of using a soft toothbrush is a must
If upper Gi series and lower Gi series ordered: DO lower GI
series first- B/C to avoid barium from upper GI –traveling to lower
Gi & interfering with results.
S/SX irritable bowel syndrome: HA, epigastric pain reieved by
food, anorexia, N&V , and periods of both constipation and diarrhea
Pain 4/10 after total abdominal hysterectomy:
Administer narcotic pain meds, as ordered
-B/C there is a “known” etiology for pain… Surgury !
NOT repostion for comfort just B/C pain is 4/10…
-Look at pain management S/P !
Regular insulin:
Onset: ½ hr (30 mins)
Peak: 2.5 to 5 hours
NPH insulin:
Onset: 1 ½ hours
Peak: 4 ro 12 hours
Iron (intramuscula): Iron Dextran
Add 0.2 ml of air to syringe after drawing up iron med.
-ensures an air-lock which which clears excess medicine from the
needle
-dose to prevent medication irritation and/or
-“staining” from leaking in subcutanous tissues & skin surface either
or
-injection or
-withdrawl of needle.
Pull the skin and subcutaneous tissue 1 inch to one side of
intended injection site & hold it there while inecting iron = Z Track
method
Wait 10 secounds after injectin the med (iron)
-before removing needle,
-aspirate first (1M);
NEVER massage
Z-track in ADULT must ALWAYS DORSAL GLUTEAL:
-NEVER DELTOID with Z-Track
C/O Red-Haze in his viaual field:
Ask “Have you ben see by an Opthamologist?”
-should be evaluated by opthamologist
-“Red Haze” = vitreous hemorrhage -may be absorbed spontenusly
if it does not resolve this way, may need surgury
Asthma preventive care (child):
DO NOT let child sleep on bottem bunk- have asthmatics
sleep on top bunk to avoid dust mites!
DO NOT sleep or lie down on upholsterd furniture
Sleep on foam pillow & foam mattress- OK with asthmatics
Remove child from room & have wear mask when vacuming
carpets.
Suspension of amoxicillin trihydrate (Amoxil) for a 2 month
old infant:
-shake med before giving it NEVER PUT IN FORMULA;
-give an empty tummy –for maxmuim absorption.
Rotating Insuling injection sites:
if nurses/ patient are not rotating injection sites…
Glucose levels rise temporarily
-B/C poor absorption of insulin lends to increase Blood
Sugar.
** Post-OP patients are “clean” …
-S/P Right pnumonectomy (clean)
-contraindicated to be placed with COPDer (dirty)
Epoetin Alpha (Procrit) (antianemics): Report to M.D.
-if hematocrit rises more than 4% in two weeks
(flu-like symptoms normal at first)
(ie; from 28% to 33%
-Contact M.D. to decrease Procrit
–B/C  increase risk of HTN & seizures)
Fundus- palpate (where) after 8 hours post delivery:
-Level of umbilicus
(fundus will be here 6 to 12 hrs post
(beginning with day 1, fundus descends
~ 1 fingerbreadth per-day
TPN completion: hang 10% dextrose in water
-hypertonic dxtrose to wean patient, & is similar to TPN!
Basal Body Temperature Method:
(to determine if patient is ovulating)
–client takes temperature every morning before rising
-if patient ovulates there ill be a slight drop, and
-then rise in temperature B/C of progesterone influence,
-temperature will be  increase during second-half of cycle.
Lumpectomy-of breast?
DO NOT EXPOSE TO: HOT or COLD; NO SUNSHINE exposure;
NO TAPE, NO CREAMS,LOTIONS, DEODERANTS
–wear a loose-fitting bra made of 100% cotton; assess skin for
redness, cracking
***Wheezing upon inspiration (18 month-old infant):
**Know: wheezing usually occurs on expiration**
**-Thus, ask :”was child eating a hotdog or nuts, beans, seeds,
chewing gum, “ immediately before
-developing (inspiratory wheezing) breathing problems?
toddlers (18 months to 3 years)
-in DANGER of aspirating large pieces of meat (hotdog),
seeds, nuts, beans,
chewing gum etc.)
Insertion of Central venous catheter:
-instruct client to turn her head to the left until the procedure is
complete
-shave skin at insertion site the right before to allow healing of
minor irritations
-inform client she will be positioned with her head down
(Trendelenberg) during insertion procedure of central venous
catheter
-Instruct to perform VALSALVA MANEUVER – to prevent
EMBOLISM
(DO NOT DEEP BREATH) (instead hold breath & bear down
Question: Does anybody knows how to create a table in this thread?...this information I'm sending
looks better written on a table for clarification purposes, but I have no idea what keys I need to use in
order to create a table.
feliz3
Normal Blood gas Values:
pH----7.35---7.45
Pco2--35-45 mmHg
HCO3--22-27 mEq/L
Po2----80-100 mmHg
O2 sat--95%-100%
Note: CO2 is the acidic component of this buffer system
HCO3 is the base component of this buffer system
Base=Alkaline
Buffer= a substance than maintains a given pH
A lot of acid in a solution will lower the pH of a solution: acid solution
A lot of alkaloids in a solution will increase the pH of a solution: alkaline
solution.
Metabolic Acidosis:
Condition:
metabolic acidosis---pH: low
---Paco2: Normal
---HCO3: low
Compensated metabolic acidosis---pH: low
---Paco2: low
---HCO3: low
How the body compensates for metabolic acidosis:
The lungs hyperventilate
to blow off excess of CO2
and conserve HCO3.
Causes of Metabolic Acidosis:
1)Diabetes Mellitus or diabetic ketoacidosis
2) Excessive ingestion of of acetylsalicylic acid = ASA = aspirin
3) Severe diarrhea
4) High fat diet
5) Insufficient metabolism of carbohydrates
6) Renal insufficiency or renal failure
7) Malnutrition: Improper metabolism of nutrients causes fat
catabolism (breakdown) leading to an excess of ketones (by-product
of fat metabolism)
Assessment:
1) The lungs blowing off the CO2 build up and compensate
for the acidosis, hyperepnea or hyperventilating
(respiratory rate > 20 breaths/min) with Kussmaul's breathing
pattern.
Kussmaul's breathing=deep breathing pattern and when it is due to
metabolic acidosis, the rate could be fast, slow or normal.
2) headache
3) nausea/vomiting/diarrhea
4) fruity-smelling breath resulting from improper fat metabolism
5) CNS depression: mental dullness, drowsiness, stupor and coma
6) Twitching, convulsions
7) Hyperkalemia--must know this in connection with metabolic
acidosis
This is it for now, but I will continue discussing the body's reactions
to acid-base imbalances, later.
feliz3
Fall prevention:
Exercise, Tai-chi,
-prevents falls or decrease chances of falling
-Tai-chi improves balance & coordination
-Avoid shoes with thin, nonslip soles are SAFEST
-Avoid slippers
-Avoid athletic shoes with deep treads!!
-Go to eye doctor
-Have vision checked
-Buy New, Bight Lamps/ lights for home
-Remove throw rugs
Q bank # 15
TB skin testing with PPD:
**10 mm in duration: POSITIVE PPD in otherwise healthy patient.
**5 mm in duration: Positive PPD in HIV Positive client and other
immunocompromised clients
Allergies to sulfa drugs/sulfonamides: if *skin develops a yellow crust*
(Jaundice is a sign of liver involvement (may signal metastasis- of cancer cells)
Morphine sulfate (MS04)  will DECREASE blood return to right side of heart, and
decrease peripheral resistance
-decreases preload & after load pressures and cardiac workload
- Vasodialtes; provides anxiety relief too.
-SQ or IM – Wow! Even SQ! Even continuous IV morphine infusion ..ESP if on
Hospice.
Captopril (Capoten) (ACE inhibitor): Take 1 hour before or 2 hours after meals
(NEVER with meals for Captopril always separate!)
-Take Captopril at same time every day
-Ace inhibitor Treatment for HTN
-change position slowly to prevent orthostatic hypotension
-S/E: dry hacking cough
- Hypotension
-taste disturbances (metallic)
-Protienuria
-DO NOT increase potassium
-DO NOT use salt substitute
-DO NOT double dose if missed dose
-Avoid potassium foods
-No Apricots
-No Bananas on Captopril
Decreased variability: This FHR pattern:..
-will occur if Meperidine (Demerol) 50mg IV is given to client in Labor
-irregular fluctuations in the baseline of FHR;
-Demerol crosses the placenta &
-is a CNS depressant; FHR variability is affected by Narcotic Administration.
Early decelerations = occur before peak of contraction
–result from fetal head compression (NORMAL)
Late decelerations = occur after peak of contraction
-from uteroplacental insufficiency (ABNORMAL)
Variable declarations = occur any time during uterine contraction
-result from cord compression (ABNORMAL)
“Casts” in urine = “Renal Disease”
Specific Gravity = 1.010 to 1.030 (normal)
Blood Urea Nitrogen (BUN) = 10 to 30 mg/ml (normal)
Serum creatinine = 0.5-1.5 mg/dl (normal)
Permanent Pacemaker: MOST IMPORTANT “Take your pulse every day”
-a change in heart rhythm or rate can signal a malfunction of the pacemaker
-take pulse x 1 full minute
-same time each day & record it in a journal;
-also, take pulse if feeling any symptoms!!
Acute Glomerulonephritis:
-C/O of sore throat,
-fever
Culture
-group A beta-hemolytic streptococcus infection
Urinalysis
-large amount of protein and
-Large # of red blood cells will be found in urinalysis
-Instruct client to make an appointment
-before leaving the country to determine client’s renal status
Anorexia Nervosa:
-BEST INDICATOR that goal of balanced nutrition has been met to meet metabolic
demand;
“MENSTRUAL PERIOD” has returned and is REGULAR” = Balanced nutrition
-NOT ideal body weight has been attained…
-B/C NO guarantee that underlying metabolism disturbances been corrected.
Postpartum Hemorrhage: GREATEST RISK hemorrhage is with:
-DISTENEDED BLADDER can cause hemorrhage
-this distended bladder will likely displace the uterus to the:
LEFT or RIGHT & interferes with uterine contraction
*-Episiotomy is NOT a risk for hemorrhage! But can cause discomfort.
Abusing Spouse: most appropriate therapy=Group therapy
UTI’s : -repeated UTI’s and incontinent -uninhibited bladder:
-Perform an intermittent catheterization for residual urine volume
-bladder may not empty completely
“residual urine can cause UTI”
B/C it sits in there and causes infection!
First stage of labor (3 phases)
Latent Phase:
= 0-3 cm;
Contractions :
10-30 secs &
Contractions 5-30 minutes apart
-Mild to moderate
Active Phase:
=4-7 cm;
Contractions:
40-60 secs &
Contractions 3-5 mins apart
-moderate to strong
***Transition Phase: 8-10 cm
Contractions:
45-90 secs &
1 ½ to 2 mins apart
Strong ***intense desire to urinate***
-in this phase even ask for help to go to the bathroom!
40 year-old:
-client compares life’s accomplishments
-against goals
(potential mid-life-crisis at 40 yr-old)
**Enteral line gets disconnected:
-patient restless, C/O difficulty breathing
-nurse locks the Central Catheter
position patient
* On left side in Trendelenberg;
-institute Oxygen therapy &
-Notify Physician
** S/SX:
-Air embolism DO NOT place in high fowlers
-may go to brain
Battery Acid to the eyes:
-continue to irrigate his eyes until the pH is within normal limits
–removal of acid is imperative
-checking pH helps verify if chemical/acid has been removed
-this falls within the L.V.N.’s scope of practice!
-DO NOT interrupt rinsing of eyes
Older client with Emphysema:
-becomes restless &
-confused
-encourage client do “Pursed-Lip Breathing”
-B/C prevents collapse of lungs-helps patient control rate/depth of breathing
Term Infant
Extremities flexed at rest
Lanugo (fine-hair over body)
Lanugo greatest @ 28 wk gestation
Elbow creases contain vernix
Nipple bud measures 0.5 to 1 cm
Pre-term infant
extremities are in extension (preterm)
Restraints:
-reevaluate the need for restraints every 4 hours
-order for restraints are time-limited to 4 hours
Prednisone (cortisone)-Long-term use ( 3 yrs. Or more)
-leads to osteoporosis
S/SX
-weakness
-muscle wasting
-depression,
-alopecia
-buffalo hump (Cushing Syndrome)
-Obesity
-Mood swings
-slow wound healing
Phobia:
-e.g. fear of elevators:
FIRST allow patient to avoid elevator
(NOT encourage to discuss his fear)
Nasal decongestant spray:
-close one nostril while you breathe in and squeeze the spray into the other
-be seated with head erect or
-head slightly tilted backward
-Tip of spray bottle SHOULD actually be inserted into the nostril!
-DO NOT blow nose after spraying medication into nose!
-B/C Need to retain the nasal medication!
*NEVER label IV bags directly onto PLASTIC with a Permanent Marking
Pens
-BEST on label instead!
-B/C ink can penetrate into IV Solution BAD



Suzanne's plan
30 minutes studying Infection Control (from this site, the CDC web site, and another site listed
on this forum, also the You Tube flash card review on Infection Control
75 questions on the NCLEX 3500 site -- quite different than my other NCLEX review CD



Several pages in my Delegating, Prioritization & Assigning book
30 minutes studying rationales that I had copied & pasted from NCLEX review-type questions
from a CD & the NCLEX 3500 site
30 minutes studying medications
30 minutes (minimum) going over the Facts Throwing site
THROWING??

Re: Anyoone up for random FACT
Hello guys,
So heres some stuff i worked on, and hope it will help you guys. It's random facts. Feel free to
correct any mistakes...
Food ok to give to infant during first year of life
0-4 mos - breast milk or formula
4-6 mos - pureed fruits, rice cereal, strained veg., ground meat
1 yr - whole milk may be introduced
Post-op care for a pt underwent surgical repair of Detached retina
- approach pt from left side (to avoid startling the pt)
- discourage bending down, coughing and deep breathing
- orient pt to his environment
-administer stool softener to discourage straining during defacation leads to
increase IOP
- Pt should lie on his back or on the unaffected side to decrease IOP on the affected
side
LEFT SIDED HEART FAILURE
- backward failure of the LEFT ventricle causes congestion of the pulmonary
vasculature.
S/S - dyspnea on exertion (in severe case dyspnea at rest)
- rales or crackles
- pleural effusion
- pulmonary edema
- orthopnea
- dizziness
- confusion
- cool extremeties at rest
- gallop rythm
- heart murmur
RIGHT SIDED HEART FAILURE
- backward failure of the RIGHT ventricle leads to congestion of systemic capillaries.
S/S - peripheral edema
- jugular vein distention
- hepatomegaly
- ascites
- hepatojugular reflux
- nocturia
Tx for both left and right sided
failure is focused on improving symptoms and
preventing progression of the dse.
ST JOHN'S WORT (SJW)- most widely known as herbal treatment for
major depression.
- extracts are usually in tablet or capsule form
it can also be in teabags or tincture form.
SJW is is generally well tolerated but has some adverse effects like :
- dizziness
- GI symptoms
- confusion
- tiredness and sedation
- in some cases hair loss also has been noted
Note: SJW may interact with birth control pills and may reduce the effectiveness of
oral contraceptives by 50%.
St John's wort may also contribute to serotonin syndrome in combination with other
drugs which may elevate serotonin levels in the CNS.
Drugs which may contribute to serotonin syndrome with St John's
wortClassDrugsantidepressantsMAOIs, TCAs, SSRIs, mirtazapine, venlafaxineopioidstramadol,
pethidineCNS stimulantsphentermine, diethylpropion, amphetamines, sibutramine5-HT1
agoniststriptansillicit drugsmethylenedioxymethamphetamine (MDMA), lysergic acid
diethylamide (LSD), cocaineothersse
legiline, tryptophan, buspirone, lithium, linezolid, dextromethorphan, 5-HTP
ERYTHEMA INFECTIOSUM ( 5th disease)
- also called as slapped cheek syndrome
- 5th dse derived its classification as the 5th of the classical skin rashes on children
called exanthems.
Note: in japan it is called " apple disease or ringo- byou "
S/S
- bright red cheeks ( defining sign that there may an infection)
- red lacy rashes on the rest of the body
- rash can last up to 2 days (in some cases can last up to
several weeks)
- pts are no longer infectious once the rash has appeared.
Note: In pregnant women - infection had been linked to
hydrops fetalis causing spontaneous abortion.


Re: Anyoone up for random FACT THROWING??
This one is going to be short and sweet for I am preparing for Susanne's plan which is actually
quite good...I am having fun with it. feliz3
Scale measuring Pulse Strength:
0 = Absent
1+ = Pulse is diminished, barely palpable, easily to obliterate
2+ = Easily palpable, normal pulse
3+ = Full pulse, incresed
4+ = Strong, bounding pulse, cannot be obliterated
Lung conditions and Expected Sounds:
Type: Description:
Pneumonia & consolidation = Broncovesicular or bronchial breaths
sounds over the affected area. Rales
may be present on late inspiration.
Rales/crackles = Discontinuous
bubbling noises heard on auscultation
of the lungs during inspiration.
Pneumothorax = Decreased or absent breaths sounds.
No adventitious sounds present.
Adventitious sounds = a breath sound that s not
normally heard such as a rale/crackle, gurgle or a
wheeze. It may be superimposed on normal breaths
sounds.
Tumor = Decreased or absent breath sounds over an area
the lungs.
Emphysema = Bronchial breaths sounds with prolonged expiration and
and decreased intensity. Fine rales often present during
late inspiration; occasional rhonchi.
Rhonchi = an abnormal sound heard during the
auscultation of an airway obstructed by thick secretions,
muscular spasm, neoplasm (abnormal cell growth) or
external pressure. This is like a continuous rumbling
sounds which are more pronounced during expiration and
clears on coughing. The person with emphysema coughs
a lot an easily get out of air.
Pleural effusion = Decreased or absent breaths sounds. A pleural friction
rub may be heard.
Pleural friction rub = pleuropericardial rub
An abnormal coarse, grating sound heard on
auscultation of the lungs during late inspiration and
early expiration.
Asthma = Broncovesicular breaths sounds. Wheezes or sibilant rhonchi
usually present.
Atelectasis = Vesicular breaths sounds. rales may be heard in late
inspirations.
Bronchitis = Vesicualr breaths sounds. Rales and sibilant rhonchi
(wheezes) present.
Best, feliz3


Re: Anyoone up for random FACT THROWING??
Atropine - cyclopegic - temporary paralysis of the muscles of
accommodation to maintain pupillary dilatation.
Exopthalmos - fluid and fat accumulation in the areas behind the eyeballs
forces the eyes forward, out of their sockets.
SIADH – d/t extracellular fluid expansion, serum osmolality decreases;
sodium levels decline (as a result of being diluted), leading to hyponatremia.
Cold insulin - increases tissue hypertrophy; all extra bottles may be stored
in the refrigerator, but the bottle currently being used should remain at
room temperature, and the insulin should be injected at room temperature.
Non-insulin-dependent diabetes mellitus (NIDDM), or type 2 diabetes, - is
due to insulin resistance, insulin deficiency, and inappropriate glucose
production by the liver
RAI uptake - increases in hyperthyroidism and decreases in hypothyroidism
Diabetic foot care - no foot soaks; macerate the skin and can increase the
risk of breaks in the skin.
Diabetes - leading cause of end-stage renal disease (ESRD), the result of
chronic kidney disease; in both type 1 and type 2 diabetes, the first sign of
deteriorating kidney function is the presence of small amounts of albumin in
the urine, a condition called microalbuminuria
Addisonian crisis – an acute episode adrenal insufficiency, which can be a
life-threatening emergency; weakness, often accompanied by pain in the
back, abdomen, or legs, along with severe manifestations of glucocorticoid
and mineralocorticoid deficiency including hypotension (particularly
postural), tachycardia, dehydration, hyponatremia, hyperkalemia,
hypoglycemia, hyperpyrexia, and confusion
Immed post-op of diabetic clients - the blood sugar frequently fluctuates,
therefore, insulin sliding scale is used
Post ablation therapy (RAI) - it frequently takes several weeks before the
production of thyroid is sufficiently decreased for the blood pressure to
return to normal so that beta adrenergic blockers are used to maintain the
client’s blood pressure and pulse rate until the RAI has sufficiently
decreased the output of the thyroid hormone.
Regular insulin (a short-acting insulin) peaks in 2 to 4 hours
NPH insulin (an intermediate-acting insulin) peaks in 6 to 12 hours.
Metformin (Glucophage) - taken with meals to minimize gastrointestinal
effects; adverse effects are abdominal bloating, diarrhea, nausea, vomiting,
and an unpleasant metallic taste
SILICOSIS - is a chronic fibrotic pulmonary dse caused by inhalation of silica dust
(crystalline silicon dioxide particles).
Exposure to silica and silicates occurs in almost all mining , quarrying and tunneling
operations.
S/S - hypoxemia
- severe airflow obstruction
- right sided
failure
- edema may occur because of the cardiac failure
Management:
- Theres is no specific Tx for silicosis, because the fibrotic process in the lung is
irreversible.
- Supportive therapy is directed at managing complications and preventing infection.
- Testing is performed to rule out other lung dses like TB,
LUNG CANCER AND SARCOIDOSIS.
Note: If TB is present , it is agressively treated and additional therapy might include
OXYGEN, DIURETICS, INHALED BETA-ADRENERGIC AGONISTS, ANTICHOLINERGICS,
and
BRONCHODILATOR THERAPY.
TEACHING PTS SELF-CARE FOR CARDIAC PT's
The most effective way to increase the probability that the pt will comply with selfcare regimen after discharge is to provide adequate education about the dse process
and to facilitate the pt's involvement with the cardiac rehabilitation program.
EXPECTED OUTCOMES
- experiences relief of pain
- shows no signs of respiratory difficulties
- maintains adequate tissue perfusion
- is less anxious
- complies with self care program
- avoids complications

Levothyroxine (Synthroid) – toxicity include cardiovascular collapse, dysrhythmias,
and tachycardias; should not to take the medication if pulse is greater than 100
beats/min and to notify their physician of headaches, nervousness, chest pain,
palpitations, or any unusual symptoms.
Glipizide (Glucotrol) - sulfonylureas reduce the blood glucose level by stimulating
insulin release from the pancreas.
PTU – (for hyperthyroidism) report fever, sore throat which are earliest
indications of agranulocytosis; most serious toxic effect of the medication.
Addison’s disease - should always wear a medical alert ID bracelet and should
carry an emergency kit, which should include 100 mg of IM dexamethasone and
directions for its injection; the physician’s phone number; and the client’s diagnosis
and medication schedule
Sliding scale - with the blood sugar level at 200 mg/dl, no additional regular insulin
needs to be given.
Thyrotoxic crisis, or thyroid storm - an acute condition that can be life
threatening; treated with high doses of potassium iodide or strong iodine solution,
which inhibits the synthesis of triiodothyronine and thyroxine (T3 & T4) and blocks
the release of these hormones in the circulation
Somatrem (Protropin) – growth hormone; given at bedtime
Vitamin D toxicity - nausea, vomiting, poor appetite, constipation, weakness, and
weight loss; raises blood levels of calcium, causing mental status changes such as
confusion.
Glyburide (Micronase) – is a second-generation sulfonylurea whose primary action
is to stimulate the release of insulin from the pancreatic islet cells
According to the American Diabetic Association, it is acceptable practice to reuse
disposable needles and syringes.
Rapid-acting insulins - lispro (Humalog) and insulin aspart (NovoLog), - usually
administered within 15 minutes of beginning a meal.
Glipizide (Glucotrol) – sulfonylureas; may increase sensitivity to sunlight, resulting
in sunburn.; wear sunscreen and to avoid excessive exposure to sunlight
Intermediate-acting insulin - Lente, should be given 30 to 60 minutes before a
meal.
Uptake of fat soluble vitamins - decreased in children with Cystic Fibrosis.
Digoxin - increases ventricular irritability and increases the risk of ventricular
fibrillation following cardioversion.
Chlamydial infections - one of the most frequent causes of salpingitis or pelvic
inflammatory disease.
leaking cuff on ET tube - a leak in the cuff would allow air to pass through the
trachea and vocal cords, allowing the client to make a noise — to speak.
major purpose of oxygen therapy is to decrease the workload of the heart in
clients with chronic pulmonary diseases and to assist in preventing right heart
failure.
croup - causes upper airway obstruction, inspiratory stridor is a predominant
symptom.
autosomal recessive inheritance pattern occurs with cystic fibrosis; parents are
not affected, but each parent carries the trait; there is a 25% chance that with
each pregnancy the child will have the condition.
Flail chest care - turning, coughing, and deep breathing represent the most
appropriate airway care.
Acute asthma attack - doing a slow, prolonged exhalation will allow the client to
exhale a greater volume and this will facilitate increased oxygenation.
CF diet modification - the lack of pancreatic enzymes leads to malabsorption of
fats and therefore deficits of the fat-soluble vitamins; these vitamins are
administered to the client in a water-soluble form.
clavicle puffy and “crackling”noise upon palpation - after thoracic trauma, air
in the pleural space (pneumothorax) dissects through soft tissue, causing
subcutaneous emphysema; air in the tissues causes the crackling noise.
paradoxical respirations may occur with multiple rib fractures.
Re: Anyoone up for random FACT THROWING??
OK, this is another short one, dear friends,
Dysfunction:
... it is about the Assessment of Thyroid Gland
Hyperthyroidism:



















increased body metabolism
nervousness/restlessness
tachycardia HR >100 bpm and bounding heart sounds
increased blood pressure
reduced vital capacity
skin warm, moist, and smooth
hair fine, nails soft
weakness and fatigue
demineralization of the bones
hypercalcemia---if calcium is high what do you think would be phosphorous level?
brisk reflexes
increased appetite and weight loss
muscle wasting
diabetes worsens
increased stools
increased libido
decreased fertility-no period for women
higher body temperature
exosphtalmus (bug out eyes)--- Graves Disease is a result of hyperthyroidism
Thyroidectomy: Removal of a hyperactive thyroid gland








post-op critical for patient may BLEED
often blood collects behind the neck being pulled by
gravity if the patient is lying on his/her back
place patient in semi-Fowler's position for avoiding tensionon the suture line
assess airway due to potential swelling from the wound
vocal chords may be swollen
assess frequently for noisy breathing and increased restlessness---very important
assess for vocal changes: increased hoarseness--may be indicative of laryngeal edema
assess for normal wound healing--avoid infection
Note: A patient with this type of surgery gets into trouble, he/she can lose the airway fast. Have a
TRACHEOTOMY SET readily available for opening the airway, pronto. Swelling occludes the
airway, so frequent assessment for that is a must.
Lab value that must be watched carefully:
a) calcium levels--parathyroids glands may have been accidentally removed with the thyroid. As you
know, parathyroid glands help in maintaining the blood calcium concentration, low levels of calcium
will trigger another medical emergency. Therefore, it is necessary to have calcium gluconate readily
available in case the serum calcium level goes below its normal limits.
Best, feliz3
Early clubbing: -Seen in client with:
pallor,
fatigue,
weakness &
dyspnea on exertion
 angle between the nail plate &
Proximal nail fold is straightened to 180 degrees (normal is 160 degrees)
└ indicates “early” clubbing”
- sign of hypoxia
- “nail base” is also “spongy” on palpation
- There is normally a 160 degree angle between nail plate & proximal nail fold, &
nails shape is normally convex (straightening or flattening beyond 180 degrees=
late clubbing)
Halo vest traction-MOST CONCERN if:
“It hurts when I chew”
-If pain occurs with jaw movement in halo traction,
-24-48 hours after halo traction has been applied,
-it may indicate that skull pins have slipped onto the thin temporal plate
-notify physician immediately
(Halo vest its normal to have a headache)
Acute pancreatitis:
-use Meperidine HCL (Demerol)
- is drug of choice
[Contraindicated is MSO4—B/C it causes spasms of sphincter of Oddi]
Intravenous pyelogram: X-ray taken at intervals after dye is injected;
-requires bowel perquisite;
-NPO after Mid-Night;
**Assess for allergies to:
-Shellfish, (shrimp)
iodine,
chocolate,
eggs,
milk
(B/C potential Anaphylaxis!)
chronic lung disease - decreased breath sounds caused by the decrease in air movement
through the lung fields; increase in the A-P diameter of the chest and there is a prolonged
expiratory phase
chronic lung disease – most common complication is pneumonia
pulmonary embolus - priority is to relieve chest pain and restore oxygenation.
chronic bronchitis - history of productive cough and dyspnea.
Acute respiratory distress syndrome - a form of pulmonary edema that is characterized
by labored respirations and low pO2 in spite of a high Fi02; consistent decline in the p02,
regardless of the Fi02
cystic fibrosis - stools are large, bulky, and foul smelling (steatorrhea)
low pressure alarm sounds – begin manual mechanical ventilation; the first priority is to
ensure that the client is receiving adequate ventilation; usually, the low-pressure alarm
sounds when the machine cannot deliver the tidal volume because of a leak or break in the
system
Important indication of how clients with cystic fibrosis are doing is appetite; poor
appetite and weight loss are indications that an infectious process may be occurring
three normal breath sounds - vesicular, bronchovesicular, and bronchial
Vesicular breath sounds - soft, low-pitched, gentle, rushing sounds that are heard in all of
the lung areas, except the major bronchi.
Bronchovesicular breath sounds - medium pitch and are heard anteriorly over the main
stem bronchi on either side of the sternum and posteriorly between the scapulae.
Flail chestproduces paradoxical respirations, which means the affected or flail part of the
lung will be sucked in during inspiration (mediastinal shift to uninjured side) and bulge out
on expiration (mediastinal shift to the injured side).
Chronic bronchitis – teach client to use diagphragmatic breathing to increase lung
expansion and maximize ventilation
ARDS - PEEP is used to increase Pa02 without raising Fi02; allows lower Fio2 below 60%.
Adrenalin - vasoconstriction is a primary effect; throbbing headache, tremor, and increase
in blood pressure also occur.
Theophylline - N is 10 to 20 mcg/ml; restlessness, tachycardia, insomnia, nausea, and
vomiting are indicative of side effects of theophylline at a toxic level.
Albuterol (Proventil) by metered-dose inhaler - to be most effective, there needs to be
a 1-minute time lapse between the two puffs of medication; the first puff will open the
upper airways & will allow more effective penetration of the lower tract with the second
puffof medication








Processed fruits and vegetables have a higher sodium content than fresh fruits and
vegetables.
The salicylic acid contained in aspirin and ibuprofen is strong enougho irritate the gastric
mucosa, especially in patients diagnosed with peptic ulcer disease.
The elderly have a decreased need for calories due to decreased activity.
After abdominal surgery, expect bowel sound to return with 12-24 hours.
Before a barium enema study, the patient's large intestine must be completely cleaned for a
clear view of the colon.
During a nasogastric tube feeding the head of the bed needs to be elevated for 30 minutes for
facilitation of the absorption process.
Drainage from a chest tube should not exceed 100 ml/hour, if the drainage is more than that,
or if the drainage becomes bright red or increases, suddenly--call the doctor
When to call the doctor:
a) if the patient has been injured
b) if the patient suddenly experiences adverse effects or an
unexpected turn for the worse
c) when the patient experiences a negative side effect from a
medication
d) if the patient refuses a prescribed treatment
e) if the prescribed medication is not working

When urine output from urethral or nephrostomy tubes is < 30ml/hr or there is no urine
output for 15 minutes, call the doctor immediately. Best, fel


Re: Anyoone up for random FACT THROWING??
Hi to all of you from sunny California!

I want to start a new thread related to Fact Throwing, but is specific to a particular situation. I
want to call it: "You call the doctor when"... and we all share our contributions about
legitimate reasons to call the doctor. I want to do this because while preparing for the NCLEX
some of the questions more often than not there is one alternative "call the physician" and
actually that has been the wrong answer for several scenarios presented that I would have
chosen to call the MD. It will work like this:
You call the doctor when...
questioning the safety of a prescription given such as prescribing
a dextrose solution to a diabetic
the prescription order is illegible or needs clarification on the
particular dosage to be given and or the route
If you agree to this please follow the format or any other you prefer.
Thanks, feliz3
Description of COPD:
a) slowly progressive dyspnea
b) relatively mild cough later
c) increased dyspnea upon exertion
d) dyspnea is relieved by rest though it may become persistent
e) cough with scant mucoid sputum
Note: The drive to breathe for a COPD patient is not getting rid
of CO2 as people with healthy oxygen exchange do.
COPD patients drive to breathe is apnea.
Therefore, a COPD patient cannot be given more than 2-3 liters
of Oxygen during an apnea episode.
Giving a COPD patient more than 2-3 liters of O2 would
affect his center of respiratory reflexes (medulla oblongata)
in the brain. Giving a COPD patient O2 at higher rates
will knock down the COPD patient's ability to breathe.
Best, feliz3Condition
pH
PaCo2
HCO3
How the body compensates?
Metabolic acidosis
low
normal
low
With compensation
low
low
low
Hyperventilation to blow off excess CO2 and conserve HCO3
Metabolic alkalosis
high
normal
high
With compensation
high
high
high
Hypoventilation to increase CO2
Kidneys keep H+ and excrete HCO3
Respiratory acidosis
low
high
normal
With compensation
low
high
high
Kidneys conserve HCO3
And eliminate H+ to increase pH
Respiratory alkalosis
high
low
normal
With compensation
high
low
low
Kidneys eliminate H+ to decrease pH

Post aortic femoral bypass graft - after ambulation, it is important to determine
the continued integrity of the graft, which is done by checking the pedal pulse of
affected leg
severe forms of chronic venous disorders - lower extremity edema is the usual
initial complaint; pitting edema may be seen at first, but as the edema becomes
more chronic, the skin and subcutaneous tissues are replaced by fibrous tissues,
resulting in thick, hardened contracted skin.
chronic venous insufficiency - leathery, brawny appearance from erythrocyte
extravasation to the extremity, persistent edema, stasis dermatitis, and pruritus.
venous stasis ulcers - characteristically form near the ankle on the medial aspect
with wound margins that are irregularly shaped with tissue that is a ruddy color.
Gangrenous wounds and diminished peripheral pulses are associated with arterial
occlusive disease.
first few hours after femoral bypass graft surgery - greatest risk for graft
occlusion; a dramatic increase in the level of pain; loss of a palpable pulse or pulses
distal to the operative site; extremity pallor or cyanosis; decreasing ankle-brachial
index measurements; numbness, tingling, or a cold extremity temperature may
indicate occlusion of the bypass graft and should be reported immediately; pulses
have usually returned to normal strength in the operating room after
revascularization
ankle-brachial index (ABI) – normal resting is 1 or 1.1. ; means that the blood
pressure at the ankle is the same as or greater than the pressure at the arm and
indicates that there is no significant narrowing or blockage of blood flow.
Shock progresses – narrowing pulse pressure
Inderal - primary action is to slow the cardiac rate, therefore decrease in cardiac
output; effective in the treatment of hypertension or dysrhythmias that result in
tachycardia
Low therapeutic dose dopamine - support renal perfusion when administered in low
doses in the initial stages of shock by dilatation of renal arteries
“statin” drugs - for hyperlipidemia are hepatotoxic; liver enzyme levels should be
determined as a baseline before administration of the drug is started and
periodically throughout therapy.
Mannitol – increased tubular excretion of water; is an osmotic diuretic
Dopamine IV - increases blood pressure to increase the adequacy of cardiac
output; will increase renal perfusion and increase the urinary output.
Dopamine (Intropin) - at low doses increases renal perfusion; at intermediate
doses, it increases myocardial contractility, which increases cardiac output and
oxygen delivery; at high doses, it causes vasoconstriction and ventricular
dysrhythmias.
Dobutamine (Dobutrex) - usually given in conjunction with dopamine because it has
a vasodilation effect, improves cardiac output, and is less likely to cause
dysrhythmias.
Hypovolemic pt should receive adeq fluid replacemt first - before the initiation of a
potent vasopressor, such as Levophed; otherwise the intense vasoconstriction
effect will lead to a further reduction in tissue perfusion
Condition
pH
PaCo2
HCO3
Metabolic acidosis
With
compensation
low
low
normal
low
low
low
Metabolic
alkalosis
With
compensation
high
normal
high
high
high
high
How the body
compensates?
Hyperventilation
to blow off excess
CO2 and conserve
HCO3
Hypoventilation to
increase CO2
Kidneys keep H+
and excrete HCO3
Respiratory
acidosis
With
compensation
low
high
normal
low
high
high
Respiratory
alkalosis
With
compensation
high
low
normal
high
low
low
Kidneys conserve
HCO3
And eliminate H+
to increase pH
Kidneys eliminate
H+ to decrease pH
Cor pulmonale - jugular vein distention with the client in a sitting position, or with a
45-degree head elevation, is indicative of an increase in the central venous pressure.
First-degree heart block - can only be evaluated with an ECG or monitor tracing
because the distinguishing factor is a prolonged P-R interval
PVCs - irritable foci occurring in the ventricles, which are indicators of cardiac
irritability; frequently precede the development of ventricular tachycardia
pulmonary artery diastolic pressure increase – strongly suggests left-sided heart
failure
central venous pressure increase - would indicate right-sided heart failure
MAP & CR - increased in heart failure
Post central line insertion – check for bil breath sounds to determine whether a
pneumothorax has occurred as a complication of the insertion procedure
Pedal edema – weigh client to det fluid retention
Femoral arteriogram – local anesthetic given to lessen discomfort
acute rheumatic fever - carditis, fever, chorea, migratory polyarthritis, erythema
marginatum (rash), and subcutaneous nodules.
Sinus or atrial tachycardia - heart rate at or above 100 beats/min, the presence of P
waves for each QRS complex, a PR interval below 0.20, the T wave should be present
after each QRS complex, and the rhythm should be regular
cyanotic heart defect – cyanosis, irritability, clubbing of the digits, shortness of
breath, crouching or squatting, heart murmur, respiratory tract infections that recur
excessively, and stunted growth
Nitroglycerin – vasodilator; dilates the coronary arteries, thereby increasing
myocardial blood supply
PVCs – drug of choice: lidocaine
Diltiazem (Cardizem) - calcium channel blocker; reducing heart rate, which will
decrease chest pain as well as decrease and blood pressure in the treatment of
hypertension
Normally, functional closure of the ductus arteriosus occurs by about 15 hours of life
in healthy infants born at term. IV indomethacin (Indocin) was the conventional
therapy to promote closure of PDA in preemies, but indomethacin affects blood flow to
organs such as the kidneys and so may lead to complications such as renal failure
Ibuprofen -(the active ingredient in Advil, Motrin, Medipren, and Nuprin) has been
found to work as well as indomethacin in treating PDA in preterm infants with
respiratory distress syndrome and is less likely to impair kidney function
appendicitis – position of comfort is on the side with the legs flexed against the
abdomen; the head of the bed should remain slightly elevated to decrease the upward
spread of infection in case the appendix ruptures
continent Kock’s ileostomy - catheter is placed in the stoma during surgery and is
irrigated every 2 to 4 hours postoperatively; catheter may be left in place for about 46 days; client is taught how to catheterize his stoma every 2 to 4 hours to remove any
drainage or urine
Creutzfeldt-Jakob disease (CJD) is a very rare and incurable degenerative neurological
dse. that is mostly fatal.
Among the types of transmissible spongiform encephalopathy found in humans it is the
most common.
S/S
- rapidly progressive dementia that leads to memory loss
- personality changes and hallucinations
- speech impairment
- jerky movements (myoclonus)
- balance and coordination dysfunction (ataxia)
- changes in gait
- rigid posture
- seizures
Note: The duration of the dse varies sporadic CJD can be fatal within months or even
weeks .
Some pt's sypmtoms can continue for years.
It usually affects people aged 45–75, most commonly appearing in people between the
ages of 60–65. The exception to this is the more recently-recognised 'variant' CJD
(vCJD), which occurs in younger people.
INFECTION CONTROL
CONTACT PRECAUTION:
MRSA
Croup
Hepatitis A
Imetigo
C. Diff.
DROPLET PRECAUTION:
Adenovirus
Influenza
Parvovirus B19
Streptococcus
pharyngitis
Diptheria
STANDARD PRECAUTION:
Lyme dse.
Herpes zozter (localized)
Meningococcal pneumonia
Non contained cellulitis
Haemophilus Influenza pneumonia
AIRBORNE PRECAUTION:
Varicella
Tuberculosis
Measles
This is it for now guys
have a lovely weekend
pls. feel free to correct any mistakes ....
Gastric Ca - achlorhydria, an absence of free hydrochloric acid in the stomach
Peritonitis - abdominal pain & distention caused by fluid leaking into the peritoneal
cavity, fever, nausea, vomiting, and altered bowel habits (inability to pass gas and
feces)
Pyloric stenosis - infant should be weighed daily and placed on his or her right side to
prevent aspiration after feeding
TEF - elevate infant's head 30 degrees decreases gastric reflux into the trachea.
Post cleft palate repair - on the side with head slightly elevated to prevent pooling of
secretions in the oropharynx; positioning on the back can lead to aspiration of pooling
secretions; repair is begun at 6 to 18 months, after some development of the affected
area has occurred.
Cleft Lip repair – done at 3 mos
If w/ s/s of appendicitis - should avoid ambulation so that peristalsis is prevented or
activities that increase pain, such as walking; and activity would increase risk of
rupture
NGT post colon resection or colostomy - to prevent abdominal distention in the client
who has had bowel surgery until after peristalsis has returned, bowel sounds are
evident, and the colostomy begins to function
PUD - “gnawing, burning, or boring” pain
right shoulder pain - describes diaphragmatic irritation, most often caused by free
air in the abdominal cavity, which is a common postoperative complication
perforation- usually preceded by sudden sharp abdominal pain
indigestion - heartburn and substernal discomfort
bowel obstruction - bowel sounds proximal to the obstruction are frequently
hyperactive; bowel sounds distal to the obstruction will be hypoactive
Bowel sounds are considered absent if they are not detected after listening to all four
quadrants for a total of 5 minutes.
placement of a central line - very easy to cause a pneumothorax; immediate
evaluation of the breath sounds is important. A chest x-ray film should also be
obtained after the procedure is completed; the placement of the line should be
verified before beginning administration of the hyperalimentation solution
Daily irrigations are not indicated for an ileostomy and would cause a loss of digestive
enzymes, fluid, and electrolytes.
Misoprostol (Cytotec) - protects the lining of the stomach by stimulating the
secretion of mucous and increasing the bicarbonate production; a gastric antisecretory
agent
Metoclopramide - is a GI stimulant and should not be given in situations where an
intestinal obstruction is suspected
severe hepatic disease – diet aimed in reducing ammonia levels through consumption of
low-protein foods and simple carbohydrates
Referred shoulder pain - common response after a laparoscopic cholecystectomy. The
laparoscopic procedure uses carbon dioxide to expand the peritoneal cavity for better
visibility, while the gallbladder is removed through a tiny incision; activity and walking
will help to absorb the carbon dioxide
Referred Pain = Pain perceived as coming from an area different from that in which the pathology
is occurring. An example of this would be the perception of left arm or jaw pain in a person having
a myocardial infarction.
This is the attachment...I put some notes on picture for guiding me
feliz3
Please, click on the picture to see bigger. Thanks, feliz 3
PS this would not have been possible without the kind assistance of super moderator
Silverdragon102. I want to thank her publicly.
I do not know why is so hard just to put a simple attachment on this page. Please, bear with me I
just sent a message to silverdragon102, supermoderator about having difficulties attaching the
picture.
feliz3
Levodopa – (parkinsons) first side effect to be noticed may be gastrointestinal
problems like anorexia, N&V. ; taking medication with meals may alleviate these
symptoms.
Most CSF leaks resolve spontaneously; child should be maintained on bed rest until
drainage ends.
early symptom of Parkinson’s disease - slowness of movements in all normal activities
of daily living
Parkinson’s – mood fluctuations
Irritability and vomiting are common signs of increased intracranial pressure in the
infant; the symptoms are often delayed in the infant because of the open fontanels
Done to pts w/ increased ICP - hyperventilation causes respiratory alkalosis, which
results in cerebral vasoconstriction; this decreases the circulating cerebral blood
volume and thus decreases intracranial pressure
MS early signs - include difficulty with fine motor movement, especially of the head
and neck; often, visual disturbance / diplopia is the most ominous sign
Tonic-clonic or generalized seizure - loss of consciousness and involvement of all the
major motor muscles
cerebral palsy – in infant, feeding difficulties because of poor sucking ability and
persistent tongue thrust
cerebral palsy - often occurs as a result of hypoxia during labor and delivery; it is
more likely with a premature, small child (1500 gm) or with a difficult labor and
delivery
(C5) level of injury - intercostal muscles and diaphragm can be affected; high risk for
development of respiratory compromise
Pupillary checks - pupils are checked for the reaction to light and accommodation,
which is controlled by cranial nerve III (oculomotor)
post lumbar puncture - increase oral intake to facilitate the body’s replacement of
the cerebrospinal fluid that withdrawn
MS - prevention of constipation and urinary tract problems is important in the health
promotion; keeping cool, not warm, is associated with improvement of neurological
function
bed to a wheelchair transfer - should move his upper body to the wheelchair first
and then move his legs from the bed to the wheelchair
myelogram- sensation of flushing is a typical response to radiopaque dye when it is
injected intravenously
simple partial seizure - unilateral paresthesia, numbness and tingling, and spastic
movement of the extremities (old term is Jacksonian seizure); no loss of consciousness
or incontinence of bowel or bladder
myasthenic crisis - respiratory muscles are affected and aspiration is a concern;
compromises respirations and may result in infections, aspiration and respiratory
insufficiency
myelomeningocele usual complication – hydrocephalus; rapid increase in head size
(increase in frontal occipital circumference), irritability, suture line separation, and
bulging fontanels; eyes appear to look downward only, with the cornea prominent over
the iris (sunset sign)
osteoarthritis - gradual onset and affects weight-bearing joints with pain that is more
pronounced after exercise
herniated lumbar disk pre-op - movement and sensation should be evaluated before
surgery to have as a base for evaluation during the postoperative recovery period
balanced suspension traction with a Thomas splint - check the groin area where the
thigh is supported
Osteoarthritis and gouty arthritis – unilateral
Crepitus - associated with osteoarthritis.
hip dysplasia - help stabilize the hip, a Pavlik harness is used
Denis Browne - splint is used to correct talipes equinovarus
Harrington rods - surgically inserted to treat scoliosis
post lumbar laminectomy - bladder dysfunction may occur after surgery because of
impaired innervation to the bladder from the lumbar area; client should be checked
every 2 to 4 hours for bladder distention.
menopausal or post menopausal women, prolonged steroid intake and hyperthyroid
intake have all been associated with the development of osteoporosis
Pickup Walker use - arms are flexed 30° when standing in the walker, the walker is
advanced and the client steps into the walker with the affected leg first, bearing
weight on the walker as the client moves forward
Acetylsalicylic acid (aspirin) - DOC and is the most effective in the early treatment
of rheumatoid arthritis
H2 blockers – like Zantac, are not effective in preventing ulcerations caused by
nonsteroidal antiinflammatory drugs (NSAIDs); if the client is using NSAIDs to
control the pain from arthritis, the nurse should notify the health care provider to
consider changing the medications
First sign of toxic shock syndrome - rapid onset of high fever
TX for wernicke's encephalopathy - thiamine IV
Pap smear classification of CIN grade III - highly suggestive of malignancy
post abdominal hysterectomy – observe for decreased UO; low back pain and
decreased urine output are serious symptoms that may indicate accidental
intraoperative cutting of the ureter
Gonorrhea in men - urethritis, dysuria, and purulent drainage
fluorescent treponemal antibody absorption test - identifies the spirochete treponema
pallidum, which causes syphilis
Up to 100 ml of serosanguineous fluid would be an acceptable amount of drainage over a
24-hour period in a client who has had a mastectomy.
BPH complication - flank pain and hematuria may be indicative of an infection or a
ureteral obstruction causing increased pressure on the renal pelvis
postcoital bleeding - common symptom of cervical cancer
Depo provera - irregular menses and edema are common; administered by IM injection
every 3 months
tetracyclines and ampicillins - may decrease the effectiveness of the oral
contraceptives
serious side effects of OCs - thromboembolic problems; increased risk for a stroke,
an MI, or a pulmonary embolism
Rapid instillation and removal of dialysate fluid along with accumulation of the fluid
under the diaphragm can lead to pain and discomfort
indications for dialysis - volume overload, weight gain, hyperkalemia, metabolic
acidosis, and rising BUN (normal is 8-25 mg/dl) and serum creatinine (normal is 0.6-1.3
mg/dl) levels, along with decreased urinary creatinine clearance
disequilibrium syndrome - decrease in blood pressure, confusion, and sometimes
seizures
OHAs - not usually recommended for breast-feeding mothers
RhoD - given to all Rh-negative women in the twenty-eighth week of gestation
negative rubella titer (serologically a titer of 1:8 or enzyme immunoassay [EIA] level
of 0.8) - indication that the woman needs to be vaccinated; women must understand
that they must practice contraception to avoid pregnancy for 2 to 3 months after
being vaccinated because of risks associated with side effects and teratogenic effects
of the live vaccine
ruptured fallopian tube - causes a sharp, sudden, stabbing pain. Symptoms of shock
(decreased BP, increased pulse, and respirations) occur as the client’s condition quickly
becomes a surgical emergency
Board-like abdominal rigidity is often noted with abruptio placentae.
In the last two trimesters of pregnancy, the insulin needs should steadily increase as a
result of the insulin antagonism from the placenta and the fetus; lack of an increased
need for insulin may be a sign of placental insufficiency
Women over 35 years old - routinely scheduled for amniocentesis to determine
presence of fetal genetic defects
Post amniocentesis - damage to the membranes is a possibility and a high-priority
situation; without the protective barrier of the amniotic membrane, the mother and
the baby are susceptible to infection; should refrain from sexual intercourse because
of the possibility of introduction of pathogens; bathing would also be a hazard because
of the possibility of contracting an infection from the bath water
diaphragm - predisposes many women to UTIs; some women are sensitive to the
contraceptive cream or jelly; has been associated with toxic shock syndrome; hence, its
use should be avoided during menses, and it should not be left in place longer than 6-8
hours
Depo-Provera - frequently associated with menstrual cycle changes; irregular bleeding
is the most commonly cited reason for discontinuation
RhoGAM or RhoD - given with and after each pregnancy, including an abortion of an Rh
positive fetus
Chorionic villi sampling - performed at 8 to 12 weeks' gestation to detect genetic
disease; performed early to give the client the option of terminating the pregnancy if
genetic defects are present
Re: Anyoone up for random FACT THROWING??
Hegar’s sign - (softening of the lower uterine isthmus) may be present at 6 to
8 weeks' gestation, along with Chadwick’s sign, a bluish-purple discoloration of
the vaginal walls
When a laboring client is at +3, delivery is imminent
priority nursing measure to correct a variable deceleration - to change the
mother’s position; problem may be caused by pressure on the umbilical cord, and
a position change will help to relieve it
abruptio placentae - prone to the development of disseminated intravascular
coagulation after delivery, which is characterized by abnormal fibrinogen and
coagulation studies
Epidural anesth- left lateral (Sims') position with legs flexed and shoulders
parallel to readily expose the lumbar spaces; or the client may be in a sitting
position with her shoulders resting on the bedside table
Urine retention - common cause of uterine atony and can lead to postpartum
hemorrhage; urine retention causes a distended bladder to displace the uterus
above the umbilicus and to the side, which prevents the uterus from contracting
nurse should assess an episiotomy for presence of edema and approximation of
the incision; swelling in the perineal area causes more tension on the suture line
and increases pain; although the perineal sutures may be difficult to visualize,
the suture line should be intact
contraction of 60 seconds in duration and occurring every 2 minutes is too
strong and too frequent; pitocin infusion must be either stopped or slowed to
prevent uterine rupture
Before the administration of magnesium sulfate, the total urine output should
be above 30 ml per hour, respiratory rate should be >12 breaths/min, and deep
tendon reflexes should be 2+
Close monitoring of frequency (q15mins) and length of contractions is critical
for a client receiving oxytocin before delivery; FHR should be monitored on an
almost a continuous basis in clients receiving oxytocin
Within 12 hours, the fundus may be approximately 1 cm above the level of the
umbilicus
Post cleft lip repair – supine head turned to side; it is important that the child
be positioned in such a manner that he does not traumatize the incisional area
and that the airway is maintained
It is not necessary to cover the neonate’s eyes with use of the fiberoptic
blanket; feedings and fluids should be encouraged to promote excretion of the
bilirubin
Post circumcision - whitish-yellowish exudate around the glans penis is
granulation tissue and is normal; it will usually disappear within 2 to 3 days; it is
not an infection
Grunting creates a “back-pressure” in an attempt to keep alveoli from
collapsing; if the alveoli are kept open, the functional residual capacity will
increase, the lungs will be better ventilated, and the Po2 will increase
Post cicumcision - petroleum jelly should be applied as a moisture barrier to
the head of the penis; this should be done after each diaper change; a dry
dressing should not be used

In clients diagnosed with gouty arthritis, encourage intake of large amounts of water (2,5003,000) to prevent the precipitation of ureate(uric acid salts) in the kidneys.




validation is the process of double checking questionable findings during assessment, for
example double-checking an unusually high blood pressure before writing it down on the
progress notes.
Compartment syndrome results from accumulation of fluid within a muscle compartment,
which decreases the blood flow to tissues and can lead to neuromuscular deficiency and tisue
death. It is usually seen in long bone fractures.
HgbAIc provides useful information about how well diabetes has being controlled for the past
3 months. The normal valueof Hgb A1c is 7.5 or less.
A mild transient fever is expected after a surgery. A high sustained fever indicates
complications such as atelectasis(collapse of a lung area) within the first 48 hours after
surgery; infection of the wound withing 1 week; urinary tract infection within 5 days and
thrombophlebitis within the first week. What to do? insentive spirometry 5-10 every hour-atelectasis; carefull assessment of wound and strict handwashing--infection and for
thrombophlebitis support stockings. Best, feliz3
Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and
immobile tympanic membrane, with or without perforation
From 24-34 weeks gestation, fundal height correlates with # of weeks of
gestation. Example: At 26 weeks gestation, fundal height measures approximately
26 cm.
If an immunocompromised child who has not had chickenpox is exposed to someone
with varicella, the child should receive varicella zoster immune globulin within 96
hours of exposure.
Psoriasis - occurs equally among women and men, although the incidence is lower in
darker skinned races and ethnic groups
Epididymitis from urinary tract infection should decrease intake of acidic foods
and increase fluid intake to flush the urinary system. Because organisms can be
forced into the vas deferens and epididymis from strain or pressure during voiding,
the client should limit the force of the stream
Blurred central visionoccurs with macular degeneration; changes in peripheral
visual acuity most often occurs with glaucoma; glare from bright lights is a common
complaint in the client with a cataract
post pneumonectomy - client should be instructed to perform arm and shoulder
exercises two or three times a day; should expect soreness in the chest and
shoulder and an altered feeling of sensation around the incision site for several
weeks
Black cohosh produces estrogen-like effects.
Zinc stimulates the immune system and is used for its antiviral properties.
Echinacea stimulates the immune system and ginger is used for nausea and
vomiting.
Total nutrient admixture (TNA) is a solution that combines dextrose, amino acids,
and lipids in one solution; 1.2-µm filter or larger filter should be used because the
lipid particles are too large to pass through a smaller (0.22- or 0.10-µm) filter;
0.22-µm filter is used for 2-in-1 solutions containing only dextrose and amino acids
Parenteral nutrition solution should be changed every 24 hours because the PN
solution is a high-concentrate glucose solution and is a medium for bacterial
growth. Infection control is also aided by use of aseptic technique with bag and
tubing changes. Most agencies recommend that tubing be changed every 24 hours
along with the bag
Optimal weight gain on PN is 1 to 2 lb/week
If the client has a temperature higher than 100° F, the unit of blood should not be
hung until the physician is notified and has the opportunity to give further orders.
post surgery - temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F)
and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered
reportable immediately
AKA - amputated limb is supported on pillows for the first 24 hours following
surgery to promote venous return and decrease edema; after the first 24 hours,
the amputated limb usually is placed flat on the bed to reduce hip contracture
Residual amounts more than 100 mL require holding the feeding
Obturator and a Kelly clamp are kept at the bedside of a client with a
tracheostomy.
Pitocin - goal of labor augmentation is to achieve three good-quality contractions
(appropriate intensity and duration) in a 10-minute period; uterus should return to
resting tone between contractions, and there should be no evidence of fetal
distress
hydrocephalus - if the infant is not repositioned frequently, pressure ulcers can
occur on the back and side of the head. An egg crate mattress under the head is
also a nursing intervention that can help prevent skin breakdown
Acute otitis media -child is positioned on his or her affected side to facilitate
drainage; a soft diet is recommended during the acute stage to avoid pain that can
occur with chewing.
Status asthmaticus - inhaled aerosolized short-acting β2 agonists are quick relief
medications and recommended for clients with status asthmaticus after
epinephrine has been administered
aortic stenosis - shows signs of exercise intolerance, chest pain, and dizziness
when standing for long periods of time
early signs of congestive heart failure (CHF) - include tachycardia, tachypnea,
profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory
distress
Intussusception - sausage-shaped mass at RUQ
Complication after surgical treatment of scoliosis is superior mesenteric artery
syndrome - is caused by mechanical changes in the position of the child’s
abdominal contents, resulting from lengthening of the child’s body; results in a
syndrome of emesis and abdominal distention similar to that which occurs with
intestinal obstruction or paralytic ileus
During painful episodes of juvenile idiopathic arthritis, hot or cold packs and
splinting and positioning the affected joint in a neutral position help reduce the
pain; although resting the extremity is appropriate, beginning simple isometric or
tensing exercises as soon as the child is able is important; these exercises do not
involve joint movement
Petechial red, pinpoint spots occurring on the soft palate are characteristic of
rubella (German measles).
Coal tar - used to treat psoriasis and other chronic disorders of the skin;
suppresses DNA synthesis, mitotic activity, and cell proliferation; has an
unpleasant odor, frequently stains the skin and hair, and can cause phototoxicity
Mafenide acetate - a carbonic anhydrase inhibitor and can suppress renal
excretion of acid, thereby causing acidosis;clients receiving this treatment should
be monitored for signs of an acid-base imbalance (hyperventilation); if this occurs,
the medication should be discontinued for 1 to 2 days
A side effect specific to etoposide is orthostatic hypotension; should be
administered slowly over 30 to 60 minutes to avoid hypotension; blood pressure is
monitored during the infusion
Water intoxication (overhydration) or hyponatremia is an adverse reaction to
desmopressin; early signs include drowsiness, listlessness, and headache
Oral doses of levothyroxine (Synthroid) should be taken on an empty stomach to
enhance absorption; dosing should be done in the morning before breakfast
The client who is taking an antihypocalcemic medication should be instructed to
avoid eating too much spinach, rhubarb, bran, or whole-grain cereals because they
decrease calcium absorption
Foods that help thicken the stool of the client with an ileostomy include pasta,
boiled rice, and low-fat cheese
Propantheline bromide - antimuscarinic anticholinergic medication that decreases
gastrointestinal secretions; should be administered 30 minutes before meal
Magnesium citrate - available as an oral solution and is used commonly as a laxative
in preparation for or after certain studies of the gastrointestinal tract.
Magnesium citrate should be served chilled and not be allowed to stand for
prolonged periods, which would reduce the carbonation and make the solution even
less palatable
Prochlorperazine is a phenothiazine - type antiemetic and antipsychotic; assess the
client for blurred vision as a frequent side effect of prochlorperazine; other
frequent side effects include dry eyes, dry mouth, and constipation
TB - one of the first pulmonary symptoms is a slight cough with the expectoration
of mucoid sputum
Carbon dioxide narcosis - condition that results from extreme hypercapnia, with
carbon dioxide levels in excess of 70 mm Hg
With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete
bicarbonate ions at the same rate. The client can experience rebound
metabolic alkalosis, with resulting seizure activity
Pulmonary sarcoidosis - can lead to cor pulmonale (or failure of the right side of
the heart), characterized by distended neck veins, elevated central venous
pressure, full bounding pulse, weight gain, engorged liver, and peripheral edema
Terbutaline (Brethine) - bronchodilator and is contraindicated in clients with
hypersensitivity to sympathomimetics; should be used with caution in clients with
impaired cardiac function, diabetes mellitus, hypertension, or hyperthyroidism, and
a history of seizures; may increase blood glucose levels
Zafirlukast - used with caution in clients with impaired hepatic function; liver
function laboratory tests should be performed
client taking adrenergic bronchodilators may experience paradoxical
bronchospasm, which is evidenced by the client’s wheezing; this can occur with
excessive use of inhalers; further medication should be withheld, and the physician
should be notified
Thiazide diuretics such as hydrochlorothiazide - sulfa-based medications, and a
client with a sulfa allergy is at risk for an allergic reaction; WOF risk for
hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia
Post renal biopsy - if pain originates at the biopsy site and begins to radiate to
the flank area and around the front of the abdomen, bleeding should be suspected
trimethoprim (TMP)-sulfamethoxazole (SMZ) (Bactrim) - should be informed
about early signs of blood disorders that can occur from this medication such as
sore throat, fever, and pallor, and the client should be instructed to notify the
physician if these symptoms occur
Bethanecol Cl (Urecholine) - toxicity (overdose) produces manifestations of
excessive muscarinic stimulation such as salivation, sweating, involuntary urination
and defecation, bradycardia, and severe hypotension
Amphotericin B deoxycholate, erythromycin, and ketoconazole can elevate
cyclosporine levels; when any of these medications is combined with cyclosporine,
the dosage of cyclosporine must be reduced to prevent accumulation to toxic levels
Epoetin alfa (Epogen, Procrit) - client should be instructed not to shake the
bottle; should be refrigerated at all times; should not be frozen
Parkinson’s disease - should exercise in the morning when energy levels are
highest; should avoid sitting in soft deep chairs because they are difficult to get
up from; can rock back and forth to initiate movement; should buy clothes with
Velcro fasteners and slide-locking buckles to support the ability to dress self
Stress ulcer - can be detected by Hematest-positive nasogastric tube aspirate or
stool
Baclofen - a skeletal muscle relaxant and frequently causes drowsiness, dizziness,
weakness, and fatigue; also can cause nausea, constipation, and urinary retention
Pentam 300 - frequent side effects of this medication include leukopenia,
thrombocytopenia, and anemia; should be monitored routinely for signs and
symptoms of infection
adverse effect of PTU - agranulocytosis; needs to be informed of the early signs
of this adverse effect, which include fever and sore throat
Post cervical radiation - foul-smelling vaginal discharge is expected and will occur
for some time following removal of a cervical radiation implant
Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile
tympanic membrane, with or without perforation
From 24-34 weeks gestation, fundal height correlates with # of weeks of gestation.
Example: At 26 weeks gestation, fundal height measures approximately 26 cm.
If an immunocompromised child who has not had chickenpox is exposed to someone with
varicella, the child should receive varicella zoster immune globulin within 96 hours of
exposure.
Psoriasis - occurs equally among women and men, although the incidence is lower in darker
skinned races and ethnic groups
Epididymitis from urinary tract infection should decrease intake of acidic foods and
increase fluid intake to flush the urinary system. Because organisms can be forced into
the vas deferens and epididymis from strain or pressure during voiding, the client should
limit the force of the stream
Blurred central visionoccurs with macular degeneration; changes in peripheral visual
acuity most often occurs with glaucoma; glare from bright lights is a common complaint in
the client with a cataract
post pneumonectomy - client should be instructed to perform arm and shoulder exercises
two or three times a day; should expect soreness in the chest and shoulder and an altered
feeling of sensation around the incision site for several weeks
Black cohosh produces estrogen-like effects.
Zinc stimulates the immune system and is used for its antiviral properties.
Echinacea stimulates the immune system and ginger is used for nausea and vomiting.
Total nutrient admixture (TNA) is a solution that combines dextrose, amino acids, and
lipids in one solution; 1.2-µm filter or larger filter should be used because the lipid
particles are too large to pass through a smaller (0.22- or 0.10-µm) filter; 0.22-µm filter is
used for 2-in-1 solutions containing only dextrose and amino acids
Parenteral nutrition solution should be changed every 24 hours because the PN solution
is a high-concentrate glucose solution and is a medium for bacterial growth. Infection
control is also aided by use of aseptic technique with bag and tubing changes. Most
agencies recommend that tubing be changed every 24 hours along with the bag
Optimal weight gain on PN is 1 to 2 lb/week
If the client has a temperature higher than 100° F, the unit of blood should not be hung
until the physician is notified and has the opportunity to give further orders.
post surgery - temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a
falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable
immediately
AKA - amputated limb is supported on pillows for the first 24 hours following surgery to
promote venous return and decrease edema; after the first 24 hours, the amputated limb
usually is placed flat on the bed to reduce hip contracture
Residual amounts more than 100 mL require holding the feeding
Obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy.
Pitocin - goal of labor augmentation is to achieve three good-quality contractions
(appropriate intensity and duration) in a 10-minute period; uterus should return to resting
tone between contractions, and there should be no evidence of fetal distress
hydrocephalus - if the infant is not repositioned frequently, pressure ulcers can occur on
the back and side of the head. An egg crate mattress under the head is also a nursing
intervention that can help prevent skin breakdown
Acute otitis media -child is positioned on his or her affected side to facilitate drainage;
a soft diet is recommended during the acute stage to avoid pain that can occur with
chewing.
Status asthmaticus - inhaled aerosolized short-acting β2 agonists are quick relief
medications and recommended for clients with status asthmaticus after epinephrine has
been administered
aortic stenosis - shows signs of exercise intolerance, chest pain, and dizziness when
standing for long periods of time
early signs of congestive heart failure (CHF) - include tachycardia, tachypnea, profuse
scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress
Intussusception - sausage-shaped mass at RUQ
Complication after surgical treatment of scoliosis is superior mesenteric artery syndrome
- is caused by mechanical changes in the position of the child’s abdominal contents,
resulting from lengthening of the child’s body; results in a syndrome of emesis and
abdominal distention similar to that which occurs with intestinal obstruction or paralytic
ileus
During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and
positioning the affected joint in a neutral position help reduce the pain; although resting
the extremity is appropriate, beginning simple isometric or tensing exercises as soon as
the child is able is important; these exercises do not involve joint movement
Petechial red, pinpoint spots occurring on the soft palate are characteristic of rubella
(German measles).
Coal tar - used to treat psoriasis and other chronic disorders of the skin; suppresses
DNA synthesis, mitotic activity, and cell proliferation; has an unpleasant odor, frequently
stains the skin and hair, and can cause phototoxicity
Mafenide acetate - a carbonic anhydrase inhibitor and can suppress renal excretion of
acid, thereby causing acidosis;clients receiving this treatment should be monitored for
signs of an acid-base imbalance (hyperventilation); if this occurs, the medication should be
discontinued for 1 to 2 days
A side effect specific to etoposide is orthostatic hypotension; should be administered
slowly over 30 to 60 minutes to avoid hypotension; blood pressure is monitored during the
infusion
Water intoxication (overhydration) or hyponatremia is an adverse reaction to
desmopressin; early signs include drowsiness, listlessness, and headache
Oral doses of levothyroxine (Synthroid) should be taken on an empty stomach to enhance
absorption; dosing should be done in the morning before breakfast
The client who is taking an antihypocalcemic medication should be instructed to avoid
eating too much spinach, rhubarb, bran, or whole-grain cereals because they decrease
calcium absorption
Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice,
and low-fat cheese
Propantheline bromide - antimuscarinic anticholinergic medication that decreases
gastrointestinal secretions; should be administered 30 minutes before meal
Magnesium citrate - available as an oral solution and is used commonly as a laxative in
preparation for or after certain studies of the gastrointestinal tract. Magnesium citrate
should be served chilled and not be allowed to stand for prolonged periods, which would
reduce the carbonation and make the solution even less palatable
Prochlorperazine is a phenothiazine - type antiemetic and antipsychotic; assess the client
for blurred vision as a frequent side effect of prochlorperazine; other frequent side
effects include dry eyes, dry mouth, and constipation
TB - one of the first pulmonary symptoms is a slight cough with the expectoration of
mucoid sputum
Carbon dioxide narcosis - condition that results from extreme hypercapnia, with carbon
dioxide levels in excess of 70 mm Hg
With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete
bicarbonate ions at the same rate. The client can experience rebound metabolic
alkalosis, with resulting seizure activity
Pulmonary sarcoidosis - can lead to cor pulmonale (or failure of the right side of the
heart), characterized by distended neck veins, elevated central venous pressure, full
bounding pulse, weight gain, engorged liver, and peripheral edema
Terbutaline (Brethine) - bronchodilator and is contraindicated in clients with
hypersensitivity to sympathomimetics; should be used with caution in clients with impaired
cardiac function, diabetes mellitus, hypertension, or hyperthyroidism, and a history of
seizures; may increase blood glucose levels
Zafirlukast - used with caution in clients with impaired hepatic function; liver function
laboratory tests should be performed
client taking adrenergic bronchodilators may experience paradoxical bronchospasm,
which is evidenced by the client’s wheezing; this can occur with excessive use of inhalers;
further medication should be withheld, and the physician should be notified
Thiazide diuretics such as hydrochlorothiazide - sulfa-based medications, and a client with
a sulfa allergy is at risk for an allergic reaction; WOF risk for hypokalemia, hyperglycemia,
hypercalcemia, hyperlipidemia, and hyperuricemia
Post renal biopsy - if pain originates at the biopsy site and begins to radiate to the flank
area and around the front of the abdomen, bleeding should be suspected
trimethoprim (TMP)-sulfamethoxazole (SMZ) (Bactrim) - should be informed about
early signs of blood disorders that can occur from this medication such as sore throat,
fever, and pallor, and the client should be instructed to notify the physician if these
symptoms occur
Bethanecol Cl (Urecholine) - toxicity (overdose) produces manifestations of excessive
muscarinic stimulation such as salivation, sweating, involuntary urination and defecation,
bradycardia, and severe hypotension
Amphotericin B deoxycholate, erythromycin, and ketoconazole can elevate cyclosporine
levels; when any of these medications is combined with cyclosporine, the dosage of
cyclosporine must be reduced to prevent accumulation to toxic levels
Epoetin alfa (Epogen, Procrit) - client should be instructed not to shake the bottle;
should be refrigerated at all times; should not be frozen
Parkinson’s disease - should exercise in the morning when energy levels are highest;
should avoid sitting in soft deep chairs because they are difficult to get up from; can rock
back and forth to initiate movement; should buy clothes with Velcro fasteners and slidelocking buckles to support the ability to dress self
Re: Anyoone up for random FACT THROWING??
Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and
immobile tympanic membrane, with or without perforation
From 24-34 weeks gestation, fundal height correlates with # of weeks of
gestation. Example: At 26 weeks gestation, fundal height measures
approximately 26 cm.
If an immunocompromised child who has not had chickenpox is exposed to
someone with varicella, the child should receive varicella zoster immune
globulin within 96 hours of exposure.
Psoriasis - occurs equally among women and men, although the incidence is lower
in darker skinned races and ethnic groups
Epididymitis from urinary tract infection should decrease intake of acidic foods
and increase fluid intake to flush the urinary system. Because organisms can be
forced into the vas deferens and epididymis from strain or pressure during
voiding, the client should limit the force of the stream
Blurred central visionoccurs with macular degeneration; changes in peripheral
visual acuity most often occurs with glaucoma; glare from bright lights is a
common complaint in the client with a cataract
post pneumonectomy - client should be instructed to perform arm and
shoulder exercises two or three times a day; should expect soreness in the
chest and shoulder and an altered feeling of sensation around the incision site
for several weeks
Black cohosh produces estrogen-like effects.
Zinc stimulates the immune system and is used for its antiviral properties.
Echinacea stimulates the immune system and ginger is used for nausea and
vomiting.
Total nutrient admixture (TNA) is a solution that combines dextrose, amino
acids, and lipids in one solution; 1.2-µm filter or larger filter should be used
because the lipid particles are too large to pass through a smaller (0.22- or
0.10-µm) filter; 0.22-µm filter is used for 2-in-1 solutions containing only
dextrose and amino acids
Parenteral nutrition solution should be changed every 24 hours because the
PN solution is a high-concentrate glucose solution and is a medium for bacterial
growth. Infection control is also aided by use of aseptic technique with bag and
tubing changes. Most agencies recommend that tubing be changed every 24
hours along with the bag
Optimal weight gain on PN is 1 to 2 lb/week
If the client has a temperature higher than 100° F, the unit of blood should not
be hung until the physician is notified and has the opportunity to give further
orders.
post surgery - temperature higher than 37.7°C (100°F) or lower than 36.1°C
(97°F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually
considered reportable immediately
AKA - amputated limb is supported on pillows for the first 24 hours following
surgery to promote venous return and decrease edema; after the first 24
hours, the amputated limb usually is placed flat on the bed to reduce hip
contracture
Residual amounts more than 100 mL require holding the feeding
Obturator and a Kelly clamp are kept at the bedside of a client with a
tracheostomy.
Pitocin - goal of labor augmentation is to achieve three good-quality
contractions (appropriate intensity and duration) in a 10-minute period; uterus
should return to resting tone between contractions, and there should be no
evidence of fetal distress
hydrocephalus - if the infant is not repositioned frequently, pressure ulcers
can occur on the back and side of the head. An egg crate mattress under the
head is also a nursing intervention that can help prevent skin breakdown
Acute otitis media -child is positioned on his or her affected side to facilitate
drainage; a soft diet is recommended during the acute stage to avoid pain that
can occur with chewing.
Status asthmaticus - inhaled aerosolized short-acting β2 agonists are quick
relief medications and recommended for clients with status asthmaticus after
epinephrine has been administered
aortic stenosis - shows signs of exercise intolerance, chest pain, and dizziness
when standing for long periods of time
early signs of congestive heart failure (CHF) - include tachycardia,
tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain,
and respiratory distress
Intussusception - sausage-shaped mass at RUQ
Complication after surgical treatment of scoliosis is superior mesenteric
artery syndrome - is caused by mechanical changes in the position of the
child’s abdominal contents, resulting from lengthening of the child’s body;
results in a syndrome of emesis and abdominal distention similar to that which
occurs with intestinal obstruction or paralytic ileus
During painful episodes of juvenile idiopathic arthritis, hot or cold packs and
splinting and positioning the affected joint in a neutral position help reduce the
pain; although resting the extremity is appropriate, beginning simple isometric
or tensing exercises as soon as the child is able is important; these exercises do
not involve joint movement
Petechial red, pinpoint spots occurring on the soft palate are characteristic of
rubella (German measles).
Coal tar - used to treat psoriasis and other chronic disorders of the skin;
suppresses DNA synthesis, mitotic activity, and cell proliferation; has an
unpleasant odor, frequently stains the skin and hair, and can cause phototoxicity
Mafenide acetate - a carbonic anhydrase inhibitor and can suppress renal
excretion of acid, thereby causing acidosis;clients receiving this treatment
should be monitored for signs of an acid-base imbalance (hyperventilation); if
this occurs, the medication should be discontinued for 1 to 2 days
A side effect specific to etoposide is orthostatic hypotension; should be
administered slowly over 30 to 60 minutes to avoid hypotension; blood pressure
is monitored during the infusion
Water intoxication (overhydration) or hyponatremia is an adverse reaction to
desmopressin; early signs include drowsiness, listlessness, and headache
Oral doses of levothyroxine (Synthroid) should be taken on an empty stomach
to enhance absorption; dosing should be done in the morning before breakfast
The client who is taking an antihypocalcemic medication should be instructed to
avoid eating too much spinach, rhubarb, bran, or whole-grain cereals because
they decrease calcium absorption
Foods that help thicken the stool of the client with an ileostomy include pasta,
boiled rice, and low-fat cheese
Propantheline bromide - antimuscarinic anticholinergic medication that
decreases gastrointestinal secretions; should be administered 30 minutes
before meal
Magnesium citrate - available as an oral solution and is used commonly as a
laxative in preparation for or after certain studies of the gastrointestinal
tract. Magnesium citrate should be served chilled and not be allowed to stand
for prolonged periods, which would reduce the carbonation and make the
solution even less palatable
Prochlorperazine is a phenothiazine - type antiemetic and antipsychotic; assess
the client for blurred vision as a frequent side effect of prochlorperazine;
other frequent side effects include dry eyes, dry mouth, and constipation
TB - one of the first pulmonary symptoms is a slight cough with the
expectoration of mucoid sputum
Carbon dioxide narcosis - condition that results from extreme hypercapnia,
with carbon dioxide levels in excess of 70 mm Hg
With a rapid drop in carbon dioxide levels, the kidneys are unable to
excrete bicarbonate ions at the same rate. The client can experience
rebound metabolic alkalosis, with resulting seizure activity
Pulmonary sarcoidosis - can lead to cor pulmonale (or failure of the right side
of the heart), characterized by distended neck veins, elevated central venous
pressure, full bounding pulse, weight gain, engorged liver, and peripheral edema
Terbutaline (Brethine) - bronchodilator and is contraindicated in clients with
hypersensitivity to sympathomimetics; should be used with caution in clients
with impaired cardiac function, diabetes mellitus, hypertension, or
hyperthyroidism, and a history of seizures; may increase blood glucose levels
Zafirlukast - used with caution in clients with impaired hepatic function; liver
function laboratory tests should be performed
client taking adrenergic bronchodilators may experience paradoxical
bronchospasm, which is evidenced by the client’s wheezing; this can occur with
excessive use of inhalers; further medication should be withheld, and the
physician should be notified
Thiazide diuretics such as hydrochlorothiazide - sulfa-based medications, and a
client with a sulfa allergy is at risk for an allergic reaction; WOF risk for
hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia
Post renal biopsy - if pain originates at the biopsy site and begins to radiate
to the flank area and around the front of the abdomen, bleeding should be
suspected
trimethoprim (TMP)-sulfamethoxazole (SMZ) (Bactrim) - should be informed
about early signs of blood disorders that can occur from this medication such
as sore throat, fever, and pallor, and the client should be instructed to notify
the physician if these symptoms occur
Bethanecol Cl (Urecholine) - toxicity (overdose) produces manifestations of
excessive muscarinic stimulation such as salivation, sweating, involuntary
urination and defecation, bradycardia, and severe hypotension
Amphotericin B deoxycholate, erythromycin, and ketoconazole can elevate
cyclosporine levels; when any of these medications is combined with
cyclosporine, the dosage of cyclosporine must be reduced to prevent
accumulation to toxic levels
Epoetin alfa (Epogen, Procrit) - client should be instructed not to shake the
bottle; should be refrigerated at all times; should not be frozen
Parkinson’s disease - should exercise in the morning when energy levels are
highest; should avoid sitting in soft deep chairs because they are difficult to
get up from; can rock back and forth to initiate movement; should buy clothes
with Velcro fasteners and slide-locking buckles to support the ability to dress
self
Stress ulcer - can be detected by Hematest-positive nasogastric tube aspirate
or stool
Baclofen - a skeletal muscle relaxant and frequently causes drowsiness,
dizziness, weakness, and fatigue; also can cause nausea, constipation, and
urinary retention
Pentam 300 - frequent side effects of this medication include leukopenia,
thrombocytopenia, and anemia; should be monitored routinely for signs and
symptoms of infection
adverse effect of PTU - agranulocytosis; needs to be informed of the early
signs of this adverse effect, which include fever and sore throat
Post cervical radiation - foul-smelling vaginal discharge is expected and will
occur for some time following removal of a cervical radiation implant
This I attached chart helps to find the right answer NCLEX –PN, I am practicing based on this
chart it is helped me, good critical thinking practice
1SEFETY
All answer
must be implementations
Try to answer based on knowledge if you cant
What will cause the client the least amount of harm
2-MASELOW
Recognize the answer are both physical & psychosocial
Eliminate psychosocial answers
“Does this make sense?”
ABC
3-THERAPEUTIC
COMMUNICATION
Eliminate don’t worry’
Eliminate ‘explore answer
Don’t ask “why?”
Eliminate “authoritarian” answer
Eliminate “focus on the nurse” answer
4-COLLECT DATA
Vs IMPLEMENT
Recognize both data collection and implementation answers
Read stem to decide whether to collect data or implement.
Select best data collection or implementation
5-EXPECTED
OUTCOME
What is expected out come?
What is the best action for expected out come.
6-REAL WORLD
Don’t use the real world experience to answer NCLEX-PN exam questions.
You have time the staff and the equipment
Take care of the client first
The NCLEX –PN exam tests the LPN judgment
7-POSITIONING
Are you try to prevent or promote
What are you trying to prevent or promote
Think A&P
8-QUESTION
Read the stem one time
Read answer choice for clues to topic
Reword question using clues from answer choices.
9-ANSWERS
Read the stem
Identity the topic
Read the answer choices
Identify the nursing concept contained in answer choice.
Idiopathic thrombocytopenic purpura (ITP) is having low platelet count (thrombocytopenia) of no
known cause (idiopathic). Although most cases are asymptomatic, very low platelet counts can lead to
bleeding diathesis and purpura. Usually, ITP patients suffer from bruising; petechiae, nosebleeds and
bleeding gums may occur if the platelet count really low.
Not Ready, Ready Now":
Air into NPH
Air into Regular
Draw up Regular
Draw up NPH
If it is help
Urinary incontinence is associated with a risk for, fractures, pressure ulcers, and depression. When skin
break dowen related with incontinence, the care giver implied,
Keep the skin clean and dry,
Assess for signs of breakdown,
Apply protective barrier creams and implement bladder retraining program.
Signs of Aspiration:







sudden onse of coughing and shortness of breath (SOB) while eating, drinking or regurgitation
tachypnea, dyspnea, cyanosis, decreased breath sounds
tachycardia, bradycardia
crackles and rhonchi (usually on the right lung, but it could be bilateral)
altered mental status
fever
chest pain(pleuritic)
Immediate Intervention:





elevate the head of the bed (HOB) to upright position and help the client to expectorate
provide supplemental Oxygen
suction oropharynx
encourage coughing
when client is out of danger call the doctor and document doctor's response to the report
given
Focused Assessment:






assess client's ability to clear airway and effort to breathe
assess airway for secretions or foreign objects
assess effectiveness of measures to clear the airway
assess oxygenation status: level of consciousness(LOL), Oxygen saturation, presence of
circumoral (area around the mouth) and nailbed cianosis
assess hear rate, blood pressure, respiration rate, rhythm, effort and work of breathing
auscultate lung fields
Note: Continue to monitor airway and respiratory function.
Symptoms of Dehydration:



increased respirations
increased heart rate
decreased central venous pressure (CVP)
normal CVP = 4-11 cm water





weight loss
poor skin turgor
dry mucous membranes
decreased urine volume
increased specific gravity
normal specific gravity = 1.016-1.022 (depending on laboratory)
CVP= the pressure under which blood is returned to the superior vena
cava and right atrium
Specific Gravity = Urine test that measures the kidney's ability to
concentrate urine.
Note: Decreased specific gravity occurs with increased fluid
retention. Could you guess, why?
feliz3
Hi you all,
I want to add more information to the subject of dehydration. Now I want to add the possible Causes
of Deficient Fluid Volume (another name for good old dehydration) feliz3
Causes of Dehydration:
1) diarrhea
2) conditions that cause increased respiration such as vigorous exercising
3) conditions that cause increased urine output such as diabetes insipidous
4) insufficient IV fluid replacement
5) draining fistulas
6) ileostomy
6) colostomy
7) use of hypertonic fluid for replacing isotonic fluid loses--do you know why is this? Why you cannot
replace fluid for isotonic dehydration with a hypertonic fluid? think about it, and if you do not come up
with the right answer lets discuss it if you like to do so.
Hypertonic Fluids:
NS= Normal Saline
NACL = Sodium Choride
a) 5% Dextrose in Lactated Ringer's solution
b) 5% Dextrose in 45% NS
c) 5% Dextrose in 9% NS
d) 10% Dextrose in Water
e) 3% NACL
USING THESE CAN INCREASE BLOOD SUGAR:
"TOTE BAG"
T -THIAZIDES/DIURETICS
O -ORAL CONTRACEPTIVES
T -THYROID MEDS
E -ESTROGEN
B -BRONCHODILATORS
A -ADRENALINE
G -GLUCOCORTICOIDS
feliz3
USING THESE CAN DECREASE BLOOD SUGAR:
"MATABA" (that means fat in Tagalog)
M -MAOI
A -ANTICOAGULANTS
T -TETRACYCLINE
A -ASA (ASPIRIN)
B -BETA BLOCKERS
A –ALCOHOL Treatment For Chf
U-upright Position ( 45 To 90)
N-nitrates ( Dilates Vessels, Stops Pain)
L-lasix ( Check Potassium)
O- Oxygen
A-aminophylline (dilates)
D-digoxin (acute)
F- Fluids (decrease)
A-afterload ( Decrease)
S- Sodium Restriction ( Decrease)
T- Test ( Dig. Level, Abg's, Potassium Level)
Unload Fast
Re: Anyoone up for random FACT THROWING??
Thank you for everyone!
I love this thread. Here are some of mine to you:
The adverse effects of ANTI-phschotics can be remembered using this: SHANCE
S-SUNLIGHT SENSITIVITY(use hat and sunscreen)
H-HEPATOTOXICITY(monitor LFT)
A-AGRANULOCYTOSIS(characterised by fever and sore throat)
N-NEUROLEPTIC MALIGNANT SYNDROME(characterised by fever and musclar rigidity)
C-CIRCULATORY PROBLEMS(leukopenia and orthostatic hypotension)
E-EXTRA PYRAMIDAL SYMPTOMS(administer anticholinergics and antiparkinsonian agents)









An endotracheal tube cuff should not be inflated > 20 mmHg
fluid oscillation in the tubing of a chest drainage system indicates that the system is working
properly
a positive tuberculin skin test is an induration of 10mm or greater at the injection site, if the
patient is HIV+ it is less than 10mm.
Intermittent claudication (pain during ambulation or other movement that is relieved by rest)
is a classic symptom of arterial insufficiency in the leg.
Passive immunization is the administration of antibodies that were preformed outside the
body.
Active immunization is the formation of antibodies within the body in response to vaccination
or exposure to a disease, and the length of immunity is longer than at passive immunity.
When a patient is having bleeding esophageal varices, pressure against the esophageal veins
must be applied in order to control the bleeding.
If the client has ulcerations in the esophagus, necrosis or has had previous esophageal
surgery, then pressure against the esophageal veins is contraindicated.
A client who has a Sengstaken-Blakemore tube (a triple lumen gastric tube with an inflatable
gastric balloon) should be placed on Fowler's position (upright) in preparation for the incertion
of the tube. The gastric balloon compressess the esophageal varices, and the balloon should
be inflated to 25-45mmHg.
Metabolic Acidosis occurs in conditions such as
1)
2)
3)
4)
5)
6)
7)
8)
diabetes mellitus
diabetic ketoacidosis
Excessive ingestion of aspirin(ASA)
high fat diet
insufficient metabolism of carbohydrates
malnutrion
renal insufficiency or renal failure
severe diarrhea
Metabolic Alkalosis occurs in conditions such as:
1)
2)
3)
4)
5)
6)
7)
diuretics
excessive vomiting
excessive gastrointestinal suctioning
hyperaldosteronism
excessive ingestion of bicarbonate
excessive infusion of bicarbonate (HCO3)
massive transfusion of whole blood
Respiratory Acidosis occurs in diseases that cause obstruction of the airway or a defect in the lung
function such as:
1) asthma (spasm resulting fr)om allergens, irritants or emotions)
2) atelectasis (collapsed alveolar sacs)
3) brain trauma
4) bronchiectasis(dilated bronchi as a result of inflammation)
5) CNS depressants (opioids, sedatives and anesthetics)
6) emphysema (loss of elasticity of alveolar sacks)
7) hypoventilation (retention of CO2)
8) pulmonary edema( extracellular fluid accumulated in pulmonary tissue)
9) pneumonia( excess mucus production and lung congestion)
10) pulmonary emboli (undissolved material that causes an obstruction in the lungs)
Respiratory Alkalosis occurs in conditions that cause overstimulation of the respiratory system
such as:
1)
2)
3)
4)
5)
6)
fever
hyperventilation
hypoxia
hysteria
pain
overventilation by mechanical ventilators
Allen's Test is done prior to the collection of an arterial blood gas specimen for determining the
presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the
presence of adequate collateral circulation could result in severe ischemic injury to the client's hand if
damage to the radial artery occurs with the arterial pucture.
A nurse who fails to perform the Allen's test and as result of that action the client develops tissue
necrosis... is an example of negligence or malpractice? You tell me...felix3
Before performing the Allen's test assess the factors that may affect the accuracy of the results such
as:
1) changes in the Oxygen settings
2) suctioning within the last 20 minutes
3) client's activities
Usually is the Respiratory Therapists who draws the arterial blood, but the nurse performs the Allen's
test and assists with the specimen draw by preparing a heparinized syringe. After the blood is taken
must apply pressure to the puncture site for 5 minutes if the client is on anticoagulants, then it
must be for 10 minutes.
Allen's Test:
1) Apply direct over the client's ulnar (directcly below the last finger) and radial ( directly below the
first finger) arteries simultaneously.
2) While applying pressure ask the client ask the client to open and close the hand repeatedly. The
hand should blanch.
3) Release pressure from the ulnar artery while compressing the radial artery and assess the color of
the extremity distal to the pressure point.
4) If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial
artery should not be used for obtaining an arterial blood specimen. Best, feliz3