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127 Cards in this Set
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4 symptoms of pneumonia that maybe be noted on a physical exam:
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Tachypnea
fever c chills productive cough bronchial breathe sounds |
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S&Sx of pneumonia expected in older clients:
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Confusion
Lethargy Anorexia Rapid RR |
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O2 flow rate for a COPD client:
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1 - 2 L per Nasal Cannula (b/c too much O2 may eliminate COPD clients hypoxic stimulus to breathe)
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Prevent hypoxia during suctioning by:
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Oxygenating 100% before and after each endotrach. suctioning
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3 interventions for mech. ventilation:
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Monitor resp. status
Establish communication mech Keep airway clear c coughing and suctioning |
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Visible S&Sx of Emphysema:
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Barrel chest
Cough (dry or productive) Decreased breath sounds Dyspnea Crackles in lung fields |
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NSG care fo Pre-Op laryngectomy;
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Involve pt/fam to manipulate trach. equipment
Plan for communication method Speech Pathologist referral Rehab discussion |
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5 NSG interventions after chest tube insertion:
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Dry occlusive dsg
Tight/Taped tubing connections Monitor Cx status Encourage periodic deep breathing Monitor fluid drainage and mark the time of measurement and fluid level |
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Immediate action to be taken if chest tube becomes d/c from appliance? If d/c from client?
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d/c from appliance- place end of tube in sterile water @ 2cm lvl
d/c from client- apply occlusive dsg & notify MD |
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Instructions to be given following radiation therapy:
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Don't wash off lines
Wear soft cotton garments Avoid powders and creams @ radiation site |
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Precautions required for TB when placed on respiratory isolation
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Private room
Masks for all entering & for pt when exiting |
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4 components of TB teaching
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Cough into tissues & dispose immediately in special bags
Long-Term need for daily meds Hand washing Report S&Sx of deterioration |
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Acute Renal Failure (ARF) vs. Chronic Renal Failure (CRF):
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ARF- usually reversible, abrupt kidney fx deterioration
CRF- irreversible, slow kidney fx deterioration Characterized by ^BUN and CREAT (dialysis required eventually) |
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Why does protein need to be restricted during the OLIGURIC phase of renal failure?
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Toxic metabolites that accumulate in the blood (urea, creatinine) derive mainly from protein catabolism
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2 NSG interventions for clients on hemodialysis:
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DON'T take BP on A-V shunt / fistula / graft
Assess site for thrill and bruit |
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Highest priority NSG Dx for any type of Renal Failure?
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Risk for imbalanced fluid volume
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Why is a renal failure pt given antacids?
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Antacids (CA & Al flavor) bind to phosphates to keep them from being absorbed into the blood stream. Eventually preventing rising Phosphate lvls.
**Must be taken with Meals!** |
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4 essential teaching elements for for clients with frequent UTIs:
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Fluid intake of 3L / day
Good hand washing Void q 2-3 hrs Take all prescribed meds Wear cotton under garments |
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Most important NSG interventions for pts with possible renal calculi:
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Straining all urine!!
Other interventions include accurate I&Os Analgesics PRN |
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What d/c instructions should be given to a pt who has had urinary calculi:
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Maintain fluid intake of 3 - 4 L / day
Follow-up care Prescribed diet (based on calculi content) Avoid supine position |
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How long after a transurethral resection of the prostate gland (TURP) should hematuria subside?
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Day 4
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3 priority NSG interventions for a TURP pt who just had a urinary catheter removed:
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Strict I&O
Observe for Hematuria Warn that burning and freq may last up to a week |
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Primary assessments after kidney surgery:
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Resp. status (gaurded d/t pain)
Circulatory status Pain Urinary Assessment (esp. output) |
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Pt's description of pain associated to Angina:
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Squeezing, heavy, burning, radiating to L arm or shoulder, transient or prolonged
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Teaching plan for a pt taking Nitroglycerin:
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Taken at the first sign of Anginal pain. take NO MORE than 3, 5 minutes apart. Call for med. attention if pain not relieved in 10 mins.
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Parameters for diagnosing HTN:
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> 140 / 90
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Teaching plan for anti-hypertensive meds:
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Explain how, when and why of meds.
Necessity of compliance and follow-up visits. Need for lab tests. Vital sign parameters while initiating therapy |
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Describe intermittent claudication:
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Pain r/t peripheral vascular disease (PVD) Occurs c exercise and subsides c rest
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D/c instructions for pt PS (post status) venous PVD:
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Keep extremities elevated while sitting.
Rest @ first sign of pain. Keep warm s heat pad Change position often. Avoid crossing legs. Un-restrictive clothing. |
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Underlying cause of an abdominal aortic aneurysm:
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Atherosclerosis
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Daily lab values to be monitored daily in a pt c thrombophlebitis undergoing anticoagulant therapy:
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PTT, PT, Hbg, Hct, platelets
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When do PVCs present a grave danger?
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When they occur more >1 in 10 beats, occur in 2s or 3s, land near a T-wave, or take on multiple configurations
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L Cardiac Heart Failure (CHF) vs. R CHF:
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L CHF = pulmonary congestion d/t back-up of circulation in the L ventricle
R CHF = peripheral congestion d/t back-up circulation in the R ventricle |
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4 S&Sx of Digitalis toxicity:
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Dysrhythmias, Headache (HA), N / V (Nausea & Vomiting)
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What condition increases the likelihood that Digitalis toxicity will occur?
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Hypokalemia (<- becomes more common if diuretics and digitalis preparations are given together)
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Lifestyle changes a HTN pt can make to reduce the likelihood of becoming hypertensive:
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Stop smoking (if applicable)
Control weight Exercise regularly Maintain a low-fat / low-cholesterol diet |
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What immediate actions should the nurse implement for a pt who is having a Myocardial Infarction (MI)?
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Strict bed rest (to lower O2 demand to <3)
Admin. O2 via nasal cannula @ 2 - 5 L / min Meds for pain / anxiety |
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S&Sx for a client with Hypokalemia:
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Dry mouth / thirst
Drowsiness / lethargy Muscle weakness & aches Tachycardia |
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Brady<3 is defined as:
Tachy<3 is defined as: |
HR < 60
HR > 100 |
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Clients c valve disease should take what precaution before invasive procedures or dental work?
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Prophylactic antibiotics.
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4 NSG interventions for pt c hiatal hernia
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sit up while eating & for 1 hour after
Eat frequent, small meals. Eliminate problematic foods. |
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3 categories of meds used in tx of peptic ulcer dz:
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Antacids
Histamine-2 receptor blockers Mucosal healing agents Proton pump inhibitors |
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S&Sx of Upper GI bleed:
S&Sx of Lower GI bleed: |
Upper: melena, hematemsis
Lower: bloody stools BOTH: tarry stools |
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What bowel sounds disruption occur with an intestinal obstruction?
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Early mech. obstruction- high-pitched sounds
Late mech. obstruction- diminished or absent (also occurs c neurogenic obstruction) |
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4 NSG interventions for post-op care of clients c a colostomy:
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Irrigate daily @ same time c warm water
Wash around stoma c mild soap and water after q bag change Ensure that pouch opening extends at least 1/8 inch around stoma |
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Clinical manifestations of jaundice:
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Sclera-icteric (yellow sclera)
Dark Urine Chalky / clay-colored stools |
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Food intolerances for pts c cholelithiasis:
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Fried, Spicy & Fatty foods
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5 S&Sx indicative of colon cancer:
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Rectal bleeding
Change in bowel habits Sense of incomplete evacuation Abd pain c nausea Weight Loss |
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6 relevant NSG interventions, to prevent further bleeding / observe for bleeding tendencies, for pt c cirrhosis:
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Avoid injections
Small bore needles for IV Maintain pressure for 5 mins on venipuncture sites Electric razor Soft-bristle toothbrush Check stools and emesis for occult blood |
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Side Fx of Lactulose (used to reduce ammonia levels in cirrhosis):
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Diarrhea
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4 groups at risk for contracting hepatitis:
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Homosexual males
IV drug users Recent ear piercing / tattooing Healthcare Workers |
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How to administer pancreatic enzymes:
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With meals or snacks.
Powder forms to be given mixed c fruit juices |
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Test to determine thyroid activity:
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T3, T4
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What condition results from all tx of hyperthyroidism?
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Hypothyroidism (requiring thyroid replacement)
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3 S&Sx of hyperthyroidism:
3 S&Sx of hypothyroidism: |
Hyper: weight loss, heat intolerance, diarrhea
Hypo: fatigue, cold intolerance, weight gain |
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5 teaching aspects for pts who are beginning corticosteroid therapy:
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Continue with meds until weaning plan begun by MD
Monitor serum K, glucose, NA Weigh daily (report gain of >5 lb / wk) Monitor BP & pulse closely Teach S&Sx of Cushing syndrome |
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Physical appearance of pt c Cushing's Dz
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Moon face
Obesity in trunk Buffalo Hump in back Muscle atrophy Thin skin |
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Which type of Diabetes Mellitus requires insulin replacement?
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Type 1 insulin-dependent diabetes mellitus (IDDM)
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Which type of diabetic sometimes requires no meds?
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Type 2 non-insulin-dependentt diabetes mellitus (NIDDM)
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5 S&Sx of hyperglycemia:
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Polydipsia
Polyuria Polyphagia Weakness Weight loss |
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5 S&Sx of hypoglycemia:
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Hunger
Lethargy Confusion Tremors / shakes Sweating |
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Important teachings for newly diagnosed diabetic:
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Underlying pathology
Mgmt / Tx regimen Meal planning Exercise program Insulin admin Sick-day mgmt S&Sx of hyperglycemia (not enough insulin) and hypoglycemia (d/t too much insulin OR too much exercise OR not enough food) |
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Method of drawing up mixed insulin:
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Verify MD order
Store unopened insulin in fridge Opened insulin kept @ room temp for up to 28 days. Draw up regular insulin first Rotate injection sites May reuse syringe by recapping and storing in fridge |
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Peak action time of rapid-acting regular insulin:
Immediate-acting insulin: Long-acting insulin: |
Rapid-acting: 2 - 4 hours
Immediate-acting: 6 - 12 hours Long-acting: 14 - 20 hours |
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Relationship of glucose balance and...
Stress: Exercise: Bedtime Snacking: |
Stress: increase glucose production = increased insulin need
Exercise: increases chances of insulin rxn, (always have snack avail to tx hypoglycemia) Bedtime snacking: maybe prevent insulin rxn while waiting for long-acting insulin to peak |
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Pt is experiencing HA, nausea, minimal trembling. Has cool, moist hands. What is pt most likely experiencing?
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Hypoglycemia / insulin rxn
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5 foot care interventions to be taught to a diabetic pt:
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Check feet daily, report breaks, scars and blisters to MD
Wear well fitting shoes Never go barefoot / wear sandals Don't self remove callouses or blisters Cut or file nails straight across Wash feet daily c mild soap and warm water |
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Rheumatioid arthritis VS degenerative joint disease RE: joint involvement
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Rheumatoid: occurs BILATERALLY
DJD: occurs ASYMMETRICALLY |
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Drug categories commonly used to tx arthritis:
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NSAIDS (salicylates are the 'cornerstone' of tx
& Corticosteroids (for severe arthritis S&Sx) |
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3 pain-relieving interventions for pts c arthritis:
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Warm, moist heat
Diversionary activities Medications |
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Preventative measures females should take to prevent osteoporosis:
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Estrogen replacement & CA supplement after menopause,
High-CA and Vit D intake (beginning in early adulthood) Weight- bearing exercise |
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Common side fx of salicylates:
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GI Irritation
Tinnitus Thrombocytopenia Mild liver enzyme elevation |
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Priority NSG intervention for pt on NSAIDS:
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Teach pt to take drugs c food or milk
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3 most commonly replaced joints:
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Hip, Knee, Finger
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Post-op residual limb (stump) care (after amputation) for the first 48 hours:
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Elevate stump for first 24 hours
Do NOT elevate stump after 48 hours Keep stump in extended position and turn pt to prone position X3 a day to prevent flexion contracture |
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NSG care for pt c phantom pain after amputation
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Be aware that phantom pain is real and will disappear eventually.
It does respond to pain medication |
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Pt in traction for long bone fx c slight fever, SOB & restless. They are most likely experiencing:
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a Fat embolism. characterized by hypoxemia, respiratory distress, irritability, restlessness, fever & petechiae
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Immediate nursing actions if fat embolization is suspect in pt c a fracture or other orthopedic condition:
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Notify MD stat
Draw blood gases Admin O2 according to blood gas results Assist c endotracheal intubation Tx of respiratory failure |
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3 problems associated c immobility:
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Venous thrombosis
Urinary calculi Skin integrity problems |
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3 NSG interventions for prevention of thromboembolism in immobilized pt c musculoskeletal problems:
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Passive ROM
Elastic stockings Elevate FOB (foot of bed) 25 degrees to ^ venous return |
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Classifications of the commonly prescribed eye drops for glaucoma:
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Parasympathomimetic (for pupillary constriction)
Beta-adrenergic receptor-blocking (inhibit aqueous humor production) Prostaglandin agonists (^ aqueous humor outflow) |
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2 types of hearing loss:
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Conductive (transmission of sound to inner ear is blocked)
Sensorineural (damage to eighth cranial nerve) |
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4 NSG interventions for blind person:
4 NSG interventions for deaf person: |
Blind: announce presence clearly, call by name, prient carefully to surroundings, guide by walking in front of client with his or her hand in your elbow
Deaf: reduce distraction before beginning conversation, look and listen to pt, give full attention to pt if they are a lip reader Face pt directly |
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Glascow Coma Scale:
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objective assessment of the lvl of consciousness based on a score of 3 to 15.
A score of 7 or less indicative coma. |
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4 NSG Dx for comatose pt:
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(in order of priority) Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, decreased cardiac output
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4 independent NSG interventions to maintain adequate respiration, airway and oxygenation:
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Position for maximum ventilation (prone, semi-prone and slightly to one side)
Insert an airway for tongue obstruction Suction airway Monitor arterial PO2 & PCO2 Hyperventilate c 100% O2 before suctioning |
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Who is at risk for cerebral vascular accidents (CVAs)?
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pts c HTN, previous TIAs, <3 dz (a-flutter or a-fib), diabetes, oral contraceptive use, elderly
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3 NSG interventions to prevent thrombi (which can be r/t immobility):
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Frequent ROM exercise, frequent (q2hr) positions changes, avoidance of positions that decrease venous return
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4 rationales for the appearance of restlessness in unconscious pts:
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Anoxia
Distended bladder Covert Bleeding Return to Conciousness |
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NSG interventions that can prevent corneal drying in a comatose pt:
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Irrigation c sterile prescribed solution PRN
Ophthalmic ointment every 8 hours Close assessment for corneal ulceration or dry |
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When can a pt on IV hyperalimentation begin to receive tube feedings instead?
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When peristalsis returns AEB active bowel sounds, passage of flatus or bowel movement
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Most important principle in a bowel management program for a pt c neurologic deficits:
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Establishment of regularity
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Define cerebral vascular accident:
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A disruption of blood supply to part of the brain which results in sudden loss of brain function.
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If a pt has a dx of CVA c S&Sx of aphasia & right hemiparesis but no memory or hearing deficit what hemispher has the client suffered a lesion?
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Left
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S&Sx of spinal shock:
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Hypotension, bladder and bowel distension, total paralysis and lack of sensation below lesion
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S&Sx of autonomic dysreflexia:
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HTN, bladder and bowel distention, exaggerated autonomic responses, HA, sweating, goose bumps, bradycardia
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Most important indicator of ^ ICP:
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Change in lvl of responsiveness.
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VS changes indicative of ^ICP:
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^BP, widening pulse pressure, increased or decreased pulse, respiratory irregularities, temperature increase
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S&Sx which would indicate a need to go to the ER after being knocked down to the ground:
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Vertigo, confusion, subtle behavior change, HA, vomiting, ataxia (imbalance), or seizure.
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Activities and situations that increase ICP and should be avoided:
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Change in bed position, extreme hip flexion endotracheal suctioning, compression of jugular veins, coughing, vomiting, straining of any kind
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Action of hyperosmotic agents (osmotic diuretics) used to tx intracranial pressure:
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Dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent re-absorption and by drawing fluid from the extravascular spaces into the plasma
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Why should narcotics be avoided c neurologic impairment?
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Narcotics mask the level of responsiveness as well as masking pupillary reponses
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What characteristics of HA and vomiting should alert the nurse to refer a pt to the neurologist?
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HA more severe upon awakening and voiting not associated with nausea are S&Sx of a brain tumor
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How should the head of the bed be positioned for postcraniotomy pts c infratentorial lesions?
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Supratentorial: elevated
Infratentorial: flat |
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Is multiple sclerosis thought to occur because of an autoimmune process?
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Yes
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Is paralysis always a consequence of spinal cord injury?
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No
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What types of drugs are used to tx myasthenia gravis?
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Anticholinesterase drugs that inhibit the cholinesterase at never endings to promote the accumulation of the acetylcholine at receptor sites, this should improve neuronal transmission to muscles
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3 potential causes of anemia:
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Diet lacking in iron, folate of vitamin B12
Use of salicylates, thiazides, diuretics Exposure to toxic agents (such as lead or insecticides) |
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2 NSG dx for client suffering from anemia:
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Activity intolerance and ineffective tissue perfusion
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The only IV fluid compatible with blood products:
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Normal Saline (b/c Sugar ^ blood clotting = bad)
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If a hemolytic transfusion rxn occurs:
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Turn off transfusion.
Take temperature. Send blood being transfused to lab. Urine sample. Keep vein open (KVO) c normal saline |
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3 interventions for pts c tendency to bleed:
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Use soft toothbrush.
Avoid salicylates (they inhibit platelet aggregation). Do not use suppositories. |
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2 sites to be assess for infection in immunosuppressed pts:
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Oral cavity and genital area.
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3 food sources of vitamin b12
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Green leafy vegetables.
Liver (Glandular meats) Milk |
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Describe care of invasive catheters and lines:
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ASEPTIC TECHNIQUE
Change dsgs 2-3x / wk (or when soiled) Caution when piggybacking drugs Check purpose of line and drug to be infused When possible use lines to obtain blood samples to avoid "sticking" client |
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3 safety precautions for administering antineoplastic chemotherapy:
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Double check order c another nurse.
Aspirate to assure administration isn't in tissue. New IV site daily for peripheral chemo. Wear gloves. Dispose of waste in special containers. |
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Leucovorin is used for:
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an antidote with methotrexate to prevent toxic rxns
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Method of collecting peak and trough blood levels of antibiotics:
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Peak : draw blood 30 minutes after administration
Trough: draw blood 30 minutes before administration |
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Characteristic cell found in Hodgkin dz:
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Reed-Sternberg
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4 NSG interventions for care of pt c Hodgkin dz (malignancy of lymphoid system):
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Protect from infection.
Observe for anemia. Encourage high-nutrient foods. Emotional support to pt and family (b/c career development often interrupted for tx. men become sterile, sperm back before tx if desired) |
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4 topics to cover when teaching immunosuppressed pts about infection control:
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Handwashing technique
Avoid infected persons / crowds. Daily hygiene to prevent microorganism spread. |
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Indication for hysterectomy in pt c fibromas:
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Severe menorrhagia l/t anemia.
Severe dysmenorrhea requiring narcotic analgesics Sever uterine enlargement causing pressure to other organs. Severe low back and pelvic pain. |
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S&Sx associated c cystocele:
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Incontinence or stress incontinence
Urinary retention Recurrent bladder infections Conditions assoc c cystocele - multiparity, trauma in childbirth, aging |
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Impt NSG interventions, post-op a hysterectomy c A&P repair:
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Avoid rectal temp / manipulation
Manage pain Encourage early ambulation |
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Priority NSG care for pt c radiation implants:
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Pregnant visitors / caretakers aren't permitted.
Small children visits are discouraged. Confine pt to room Nurse must wear radiation badge & limit time in room. Supplies and equipment should remain within pt's reach |
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Screening tool used to detect cervical cancer? American Cancer Society recommendation for women ages 3o - 7o with three consecutive normal results:
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Pap smear. For women 3o - 7o, after three consecutive normal pap smears may have pap smears every 2 - 3 years
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2 NSG Dx for pt undergoing a hysterectomy for cervical cancer:
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Altered body image r/t uterine removal.
Pain r/t post-op incision |
