NCLEX PRACTICE QUESTIONS WITH 100% VERIFIED ANSWERS LATEST UPDATE 2024/2025, Exams of Health sciences

Download NCLEX PRACTICE QUESTIONS WITH 100% VERIFIED ANSWERS LATEST UPDATE 2024/2025 and more Exams Health sciences in PDF only on Docsity! NCLEX PRACTICE QUESTIONS WITH 100% VERIFIED ANSWERS LATEST UPDATE 2024/2025 The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply: 1. Applies sterile gloves before performing client care 2. Ensures surgical masks are worn by staff in client's room 3. Requests that the client be assigned to a single-client room 4. Uses alcohol-based sanitizers for hand hygiene 5. Wears a single-use, disposable gown during client care 3, 5 Contact precautions Organisms: - MDR organisms (eg, MRSA, VRE) - Enteric organisms (eg, Clostridium difficile) - Scabies Infection-control measures: -Hand hygiene (soap & water for C difficile) - Nonsterile gloves - Gown - Private room preferred - Use dedicated medical equipment that always stays in the patient's room (Option 1) Clean, rather than sterile, gloves are required during care of a client with C difficile to prevent transmission of infection to other individuals. (Option 2) Surgical masks are required when caring for a client prescribed droplet isolation precautions but are needed only in clients with contact isolation precautions if performing activities with the possibility of body fluid splashing (eg, suctioning, wound care). (Option 4) When caring for clients with C difficile, it is critical to perform hand hygiene with soap and water, rather than alcohol-based sanitizers. Alcohol-based sanitizers are unable to effectively kill spore- forming bacteria (eg, C difficile, anthrax). The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube. Which of the following actions by the nurse are appropriate? Select all that apply: 1. Administers 100% oxygen prior to suctioning the client 2. Applies suction while withdrawing the catheter from the airway 3. Instills sterile normal saline into tracheostomy prior to suctioning 4. Limits suctioning to 20 seconds during each suction pass 5. Uses sterile gloves and technique throughout the procedure 1, 2, 5 Open endotracheal (ET) suctioning is a skill used to clear secretions and maintain airway patency. When performing ET suctioning to reduce the risk of complications (ex. pneumonia, hypoxemia) or tracheal injury (ex. trauma, bleeding), the nurse preoxygenates with 100% oxygen, applies suction only while withdrawing the catheter, uses sterile technique, and limits each suction pass to ≤10 seconds (Option 3) Instilling sterile normal saline solution or sterile water (ie, lavaging) in the client's airway, a practice no longer supported by evidence, greatly increases the risk for infection by potentially transporting bacteria from the upper airway into the lower airways. (Option 4) Suctioning longer than 10 seconds increases risk for collapse of airway structures (eg, alveoli, bronchioles) and hypoxemia (ie, oxygen saturation <90%). The telemetry nurse is reviewing the cardiac monitors of 4 clients. Which cardiac rhythm is the priority for intervention by the nurse? 1. Atrial fibrillation 2. Premature Ventricular Contractionss 3. Ventricular Fibrillation 4. Ventricular tachycardia 3 Ventricular fibrillation (VF) is a lethal arrhythmia characterized by disorganized electrical activity in the heart ventricles. Because of this erratic electrical activity, the heart's muscles lose the ability to contract, resulting in loss of blood flow and pulse (eg, cardiac arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation (Option 3). (Option 1) Atrial fibrillation is a cardiac arrhythmia characterized by disorganized electrical activity in the atria and an irregular pulse rate. Clients may experience this condition chronically or in response to other medical conditions (eg, electrolyte imbalance). However, a client with VF has no pulse and is the priority for care. (Option 2) Premature ventricular contractions are abnormal electrical impulses in the ventricles that may occur spontaneously or in response to heart irritants (eg, stimulant medications, electrolyte alterations, pain). This arrhythmia is typically not harmful but requires monitoring by the nurse. (Option 4) Ventricular tachycardia, a potentially lethal dysrhythmia characterized by organized, rapid firing of electrical activity within the ventricles, may impair perfusion and often leads to cardiac arrest and/or VF. However, clients may have a pulse with ventricular tachycardia, making the client with VF and no pulse the priority. - Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to weakness of the lower eyelid muscle (Option 1) - Flattening of the nasolabial fold on the side of the paralysis (Option 3) - Inability to smile or frown symmetrically (Option 4) - Alteration in the sensory fibers can cause loss of taste on the anterior two-thirds of the tongue. (Options 2 and 5) Electric shock-like pain in the lips and gums and severe pain along the cheekbone are symptoms of trigeminal neuralgia (cranial nerve V). With Bell palsy, the trigeminal nerve may become hypersensitive and cause facial pain, but this is uncommon and typically more indicative of trigeminal neuralgia. The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect? Select all that apply: 1. Blue, cyanotic toes 2. Calf pain 3. Dry, shiny, hairless skin 4. Lower leg warmth and redness 5. Unilateral leg edema 2, 4, 5 Although clients with a DVT may have no symptoms, typical clinical manifestations include unilateral edema, localized pain (eg, calf pain) or tenderness to touch, warmth, erythema, and occasionally low- grade fever (Options 2, 4, and 5). Recognition of a potential DVT is critical because the thrombus can dislodge from the vessel and cause life-threatening pulmonary embolism. (Option 1) Blue, cyanotic toes is an indicator of impaired arterial blood perfusion to the extremity, which may occur with acute arterial occlusion (eg, arterial embolism) or severely reduced blood flow (eg, vasopressor-induced vasoconstriction, atherosclerosis). (Option 3) Dry, shiny, hairless skin are common clinical manifestations of chronic peripheral arterial disease. These characteristic skin alterations occur from long-term impairment of blood flow to the extremity. The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply: 1. Bradycardia 2. Chest pain 3. Dyspnea 4. Hypoxemia 5. Tachypnea 6. Tracheal deviation 2, 3, 4, 5 Pulmonary embolism (PE) is a potentially life-threatening medical emergency occurring when a blood clot, fat or air embolus, or tissue (eg, tumor) travels via the venous system into the pulmonary circulation and obstructs blood flow into the lung. This prevents deoxygenated blood from reaching the alveoli, which leads to hypoxemia due to impaired gas exchange and cardiac strain due to congested blood flow in the pulmonary arteries. Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death). However, many clients initially have mild, nonspecific symptoms that are often misdiagnosed and inadequately managed, greatly increasing the likelihood of progression to shock and/or cardiac arrest. Clinical manifestations of PE include: - Pleuritic chest pain (ie, sharp lung pain while inhaling) (Option 2) - Dyspnea and hypoxemia (Options 3 and 4) - Tachypnea and cough (eg, dry or productive cough with bloody sputum) (Option 5) - Tachycardia - Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis (Option 1) Tachycardia, rather than bradycardia, is expected with PE because the heart attempts to compensate for hypoxemia, right ventricular overfilling, and decreased left ventricular cardiac output. (Option 6) Tracheal deviation is a sign of tension pneumothorax (not PE), which occurs when pressure on the side of the collapsed lung pushes organs toward the unaffected lung. The registered nurse (RN) is discussing care of shared clients with the licensed practical nurse. Which of the following clients require intervention by the RN? Select all that apply: 1. A client receiving a blood transfusion who reports severe anxiety and has blood pressure 90/60 mm Hg and pulse 110/min 2. A client receiving oral metoprolol whose heart rate has decreased to 60/min after administration 3. A client whose blood pressure decreased from 130/80 mm Hg to 110/70 mm Hg following administration of 1 mg hydromorphone IV 4. A client whose blood pressure was 90/65 mm Hg before prescribed oral nifedipine was administered 5. A client whose pulse increased from 70/min to 100/min after albuterol administration 1, 4 Clients receiving blood products are at risk for acute transfusion reactions (eg, hemolytic reaction), which may be life-threatening without prompt recognition and intervention. Clients with symptoms of a blood transfusion reaction (eg, anxiety, hypotension, tachycardia) require immediate assessment (Option 1). Nifedipine is a calcium channel blocker often used to treat hypertension. Administration of nifedipine is contraindicated in clients whose blood pressure is already low (ie, systolic <90 mm Hg), as this may cause potentially life-threatening hypotension. Therefore, the nurse should promptly assess the client with a blood pressure 90/65 mm Hg who received nifedipine for hemodynamic stability (Option 4). The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first? 1. Administer 0.25 mg hydromorphone IV push for pain 2. Draw blood for complete blood count and electrolyte levels 3. Initiate IV access and infused normal saline 4. Obtain urine specimen for urinalysis 2 Appendicitis is inflammation of the appendix and often results from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. When prioritizing care of the client with appendicitis, the nurse should utilize the ABCs (ie, airway, breathing, circulation). Fluid resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed at preventing circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status (Option 3). (Option 1) Pain medications may be administered to promote comfort, but should be administered via IV route to maintain NPO status in case of emergency surgery. However, circulation takes priority over pain medication. (Options 2 and 4) Blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse should prioritize circulatory status over obtaining laboratory specimens. A health care provider prescribes cefuroxime 30 mg/kg/day PO divided in equal doses every 12 hours for a child with a urinary tract infection. The child weighs 34 lb. Based on the available concentration of cefuroxime, how many mL would the nurse administer per dose? Click the exhibit button for additional information. Record your answer using one decimal place. Medication concentration: 250mg/5ml 4.6 To calculate the volume of cefuroxime in milliliters per dose, the nurse should first identify the fracture site. A weight gently and continuously pulls on the leg and hip, helping maintain alignment of the limb. The nurse should ensure that the traction boot is fitted properly and that the limb remains straight in a neutral position (Option 3). Skin traction exerts pressure on nerves, blood vessels, and soft tissue. The nurse should frequently assess neurovascular status (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin integrity in the limb to which the boot is applied (Options 1 and 4). Overall pain level and efficacy of administered pain medications should be monitored closely, as increasing pain in the limb in traction may indicate neurovascular compromise (Option 2). (Option 5) Side-to-side repositioning of the client in Buck traction can cause injury. Side-to-side position changes cause the affected leg to be adducted or abducted, which, when paired with the force of traction, can increase spasm and pain and contribute to neurovascular and orthopedic compromise. The nurse is reinforcing education about home and lifestyle alterations to a client recently diagnosed with HIV. Which of the following statements by the client indicates a need for further education? Select all that apply: 1. "I don't have to use protection if my sexual partner is also HIV positive." 2. "I have to make sure my family knows not to borrow my razors." 3. "I need to avoid eating raw or undercooked meats and eggs." 4. "I started to use lambskin condoms during sex, as I have a latex allergy." 5. "I won't reuse or share any needles or syringes that I use to inject heroin." 1, 4 Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells, resulting in progressive immune system impairment. When educating clients with HIV, the nurse should discuss health promotion and infection transmission prevention strategies, particularly safe sex practices. Unprotected sex increases the risk of transmitting HIV and other sexually transmitted infections (STIs). Protected sex is important even with HIV-positive partners as HIV has multiple strains and coinfection results in HIV superinfection, which may hasten progression to AIDS (Option 1). Clients with HIV should use latex or synthetic condoms and/or dental dams during sexual activity involving mucous membrane exposure (ie, oral, vaginal, anal) to semen or vaginal secretions. Natural barriers (eg, lambskin) do not prevent transmission of STIs due to the presence of small pores (Option 4). (Option 2) Sharing personal hygiene devices that may have been exposed to blood (eg, toothbrushes, razors) increases HIV transmission risk and should be avoided. (Option 3) Immunosuppressed clients should be educated to avoid raw or undercooked foods (eg, eggs, meats, seafood) to avoid foodborne illnesses. (Option 5) To prevent transmission of HIV, hepatitis B virus, and other bloodborne diseases, IV drug users should be taught to avoid reusing or sharing needles or syringes. The nurse is assisting with a vaginal birth at term gestation. Which newborn assessment finding is most important for the nurse to follow-up? 1. Edema of the scalp crossing the suture lines 2. Flat, bluish, discolored area on the buttocks 3. Small tuft of hair at the base of the spine 4. White, waxy substance in the axillae and labial folds 3 Spina bifida, a neural tube defect occurring when spinal vertebrae do not close during fetal development, potentially allows spinal cord contents to protrude through the opening. The mildest formis spina bifida occulta, usually located at the fifth lumbar or first sacral vertebra. The newborn may have no impairments or may experience neurologic disturbances (eg, bowel/bladder incontinence, sensory loss) of varying severity. Manifestations of spina bifida occulta may include a tuft of hair, hemangioma, nevus, or dimple along the base of the spine. The nurse should notify the health care provider because further assessment and surgical repair may be required (Option 3). (Option 1) Caput succedaneum (mnemonic - caput succedaneum = crosses suture), edema of the soft tissue of the scalp due to prolonged pressure of the presenting part against the cervix during labor, resolves in a few days. (Option 2) Flat, bluish, discolored areas on the lower back and/or buttocks indicate the benign finding, congenital dermal melanocytosis (ie, Mongolian spots). (Option 4) Vernix caseosa, a protective substance covering the fetus, is secreted by the sebaceous glands. This white, cheesy/waxy substance is most likely seen in the axillary and genital areas of term newborns. A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? Click on the exhibit button for additional information. 1. Bruising easily, especially on the arms 2. Fatigue 3. Feeling depressed 4. Muscle cramps in the legs 4 Hypokalemia (<3.5 mEq/L [<3.5 mmol/L]) is a common, adverse effect of potassium-wasting diuretics (eg, furosemide, bumetanide) that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia (Option 4). Additional causes of hypokalemia include gastrointestinal losses (eg, vomiting, diarrhea, nasogastric suctioning) and medications (eg, insulin). To combat hypokalemia in clients receiving potassium-wasting diuretics, supplemental potassium and/or a high-potassium diet may be required. (Option 1) Bruising is common with the use of antiplatelet agents (eg, aspirin, clopidogrel). However, the nurse should monitor for and report signs of uncontrolled bleeding, such as bloody stools and signs of stroke (eg, headache, slurred speech). (Option 2) Myocardial infarction and heart failure often cause activity intolerance and fatigue due to decreases in heart muscle function. In addition, fatigue is a common side effect experienced on initiation of beta blocker (eg, metoprolol) therapy, but typically improves over time. (Option 3) Feelings of depression are common after an acute health-related event such as a myocardial infarction. The nurse should further explore and evaluate feelings of depression; however, these symptoms are not immediately life-threatening unless the client exhibits suicidal ideation. The parent of a 5-year-old child calls the clinic to report the recurrence of a nosebleed for which the child was seen a week ago. Which of the following instructions should the nurse reinforce? Select all that apply: 1. Apply a cold cloth to the bridge of the nose 2. Apply continuous pressure to the nose for 10 minutes 3. Attempt to keep the child calm and quiet 4. Have the child lie down and turn to the left side 5. Take the child to the emergency department 1, 2, 3 Epistaxis (nosebleed) is a common and rarely serious nasal condition that can be caused by dry mucous membranes, local injury (eg, nose-picking), insertion of a foreign body, or rhinitis. Epistaxis usually involves the anterior nasal septum and often resolves spontaneously or with simple home management. Home management of epistaxis includes: - Prioritizing application of direct, continuous pressure to the soft, compressible area below the nasal bone for 10 minutes to promote clot formation (Option 2) - Holding a cold cloth or ice pack to the bridge of the nose to induce vasoconstriction and slow bleeding (Option 1) (Option 2) UAP can measure, empty, and document the output of a drain, but the registered nurse is responsible for assessing proper drain function and the type, amount, color, and odor of drainage. (Option 3) With a disgruntled family member, there may be a need for skilled communication to keep the situation from escalating. The visitor should be escorted off the unit by a security officer. The long-term care nurse is caring for a client diagnosed with macular degeneration. Which client statement supports this diagnosis? 1. "I have been seeing small flashes of light." 2. "I have trouble threading my sewing needle. I have to hold it far away to see it." 3. "I notice that my peripheral vision is becoming worse." 4. "I see a blurry spot in the middle of the page when I read." 4 Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact (Option 4). (Option 1) Seeing small flashes of light is associated with retinal detachment. (Option 2) Inability to see things close up, known as presbyopia, occurs when the lens of the eye becomes less elastic with age and therefore unable to adjust to near and far vision. (Option 3) Poor peripheral vision, also called tunnel vision, can result from optic nerve damage seen in glaucoma. The charge nurse is assisting with a nonemergent cardioversion for a client with supraventricular tachycardia. Which action by the primary nurse would cause the charge nurse to intervene? 1. Administers a one-time dose of IV midazolam 2. Disengages the "sync" function on the defibrillator 3. Places defibrillator pads on upper right and lower left chest 4. Turns off the client's oxygen and moves it away from the bed 2 Synchronized cardioversion is a procedure used to convert tachyarrhythmias (eg, supraventricular tachycardia, ventricular tachycardia) with a pulse to stable cardiac rhythms via transcutaneous electrical shock. The shock in cardioversion is timed by the defibrillator ("sync" feature enabled) to be delivered only during the R wave of the QRS complex, when the ventricles depolarize. Accidentally delivering shocks during the T wave, when heart ventricles are repolarizing, causes R-on-T phenomenon, which frequently results in lethal arrhythmias (eg, ventricular fibrillation). The nurse must ensure that the defibrillator's "sync" feature is enabled when preparing to perform synchronized cardioversion. Disabling or failing to enable the "sync" feature may result in a potentially lethal, asynchronous shock being delivered to the client (Option 2). (Option 1) During nonemergent cardioversion of a hemodynamically stable client, a sedative (eg, midazolam) is often administered for client comfort. (Option 3) Defibrillator pads should be placed on the right upper chest next to the sternum and on the left lower chest. (Option 4) Prior to delivery of electrical shock (eg, cardioversion, defibrillation), oxygen should be turned off and moved away. Oxygen is flammable and may explode when subjected to electric currents. The nurse is instructing a female client how to collect a clean catch urine specimen. Place in order the steps indicating that client teaching has been effective. All options must be used. 1. Cleanses vulva from front to back with single-use aseptic towelettes 2. Initiates urinary stream before passing container into stream for collection 3. Performs hand hygiene and removes container lid, with sterile side placed upward 4. Removes specimens container from the stream before stopping urinary flow 5. Spreads labia using index finger and thumb of non-dominant hand 3, 5, 1, 2, 4 A female client performs a clean catch urine specimen by completing hand hygiene and opening the specimen container, spreading the labia using the index finger and the thumb of the nondominant hand, and cleansing the vulva in a front-to-back motion. The client then initiates a urine stream before introducing the container midstream for urine collection. The container is removed when well filled (30- 60 mL) and before urinary flow ends. The nurse in an emergency department is assigned to triage clients coming to the ED for tx on the evening shift. The nurse whorls assign priority to which patient? 1. A pt complaining of muscle aches, a headache, history of seizures 2. Twisted ankle when rollerblading, requesting pain meds 3. Minor laceration on index finger sustained while cutting eggplant 4. Chest pain who just ate pizza made with a very spicy sauce 4 Patients with trauma, chest pain, severe respiratory distress or cardiac arrest, limb amputation, and acute neurological deficits or who have sustained chemical splashes to eyes, are classified as emergent.. Tornado protocol? Select all that apply 1. Open doors to pt rooms 2. Move beds away from windows 3. Close window shades and curtains 4. Place blankets over pts who are confined to bed 5. Relocate ambulatory pts from hallways back into room 2, 3, 4 Focus on what can protect pts from flying debris. Ambulatory pts should be moved into hallways from their rooms, away from windows. When do you give Rhogam? If mom isn't Rh sensitized (neg. Coombs (antibody) test to prevent antibody formation within 72 hours of birth Dietary restrictions for patients receiving hemodialysis Renal diet: low sodium, low potassium (avoid raw carrots, tomatoes, OJ), low phosphorus (chicken, turkey, dairy), low protein (0.6-0.8 g/kg/day), fluid intake monitoring Which telemetry pt is the priority for the nurse to assess first? 1. Adolescent pt with coarctation of the aorta and diminished femoral pulses 2. Infant with ventricular septal defect with reported grunting during feeding 3. Newborn pt with patent ductus arteriosus and a loud machinery-like systolic murmur 4. Preschool pt with tetralogy of Fallot who has finger clubbing and irritability 2 VSD places the pt at risk of CHF because the defect causes a septal opening and left to right shunting leading to excess blood flow to the lungs. This places the patient at risk for congestive heart failure and pulmonary hypertension. CM include systolic murmur near the 3rd or 4th intercostal space and CHF signs (diaphoresis, tachypnea, dyspnea). COA - elevated pulse pressure in upper extremities, diminished in lower TOF - cyanotic, congenital heart defect (CM: irritability, clubbing of fingers) Priority action in providing care for PTSD pt Encourage the pt to talk about their trauma at their own pace, listen actively to build trust, and allow pts to vent Which assessments are essential for clopidogrel, prasugrel, and ticagrelor? Monitor for bruising, sx of bleeding (ex. tarry stools, hematuria) and decreased platelet counts - It's a misconception that bed bugs are only drawn to dirty environments. They can inhabit any environment and spread easily in clothing, bags, furniture and bedding. - They don't pose significant harm, but can cause an uncomfortable rash. - The entire house should be exterminated since just washing a single pillowcase or blanket won't stop the infestation and all family members and pets can be affected. - Minimize itching to prevent secondary infections. Pursed lip breathing technique for COPD pts Relax neck and shoulders. Inhale for 2 second through nose keeping mouth closed. Exhale for 4 seconds through pursed lips. How? Pursed lips create pressure which prolongs expiration and decreased SOB Pts should practice 5-10 minutes 4 times daily Administration of IV hydromorphone - Slowly over 2-3 minutes - With stool softener to prevent constipation - Reasses pain and sedation level every 15-30 minutes - Helps with deep breathing exercised when pt is in pain A pt who is 6 cm dilated with recurrent variable decelerations gets an IUPC placed and is prescribed an amnioinfusion, what finding should be reported to the HCP immediately? Uterine resting baseline tone above 20 mmHg and minimal to absent fluid return. Why? Indication of uterine overdistension b/c of too much fluid infused. Pause infusion and notify HCP. Normal contraction frequency and duration Every 2-3 minutes or 3-5 contractions/10 minutes lasting 45-80 seconds during active labor - Intensity: 25-50 mmHg - Resting tone: should not exceed 20 mmHg SHOULD NOT EXCEED 90 SECONDS Normal fetal heart rate baseline 110-160/min Priority follow-up for Sulfasazline prescribed for pt with IBD Elevated urine specific gravity (norm. 1.003-1.030) bc IBD pts are at risk of dehydration and sulfa can crystalize in the kidney if dehydrated Expected findings: elevated erythrocyte sedimentation rate, C-reactive protein, and WBC, mild-moderate anemia, yellow-orange discoloration of pt's skin and urine is expected SE Normal Hgb Men: 14-18 Women: 12-16 How is effectiveness for TB treatment determined? 3 negative sputum cultures and chest X-ray Entire course of therapy must be completed (6-9 months) Side effects of TB treatment Rifampin: hepatotoxicity, red-orange discoloration of body fluids, increased metabolism of some drugs Isoniazid: hepatotoxicity and peripheral neuropathy Ethambutol: ocular toxicity A pt is hypertensive, tachycardic, and has low central venous pressure, what does this indicate? Hypovolemic shock Normal central venous pressure 2-8 mm Hg Tx for hypovolemic shock Fluid resuscitation - isotonic fluids (LR, NS) What should be done if the pt remains hypotensive after a fluid bolus? Vasopressor or isotropic medications (norepinephrine, dopamine) should be initiated. Circulatory fluid volume must be restored first Digoxin education - Held for pulse <90-110/min for infants + younger children or <70/min for an older child - Oral liquid is administered in side/ back of mouth - Do not mix w/ food or liquids - Never give extra doses (vomiting = toxicity) - Give water/brush teeth after to remove sweetened liquid Reasons for prophylactic antibiotics pre-dental op to prevent infective endocarditis? - Prosthetic heart valve - Previous hx of IE - Unrepaired cyanotic congenital heart defect - Cardiac transplant Normal Hct Males: 42-52% Females: 37-47% Meds for open fracture - Cefazolin (ABX) - Cyclobenzaprine (musc. relaxant) - Tetanus/diptheria toxoid (immunization if not up to date) - Ketorolac (NSAID) - Opioids Why give heparin/enoxaparin/aspirin 24 hrs before and after surgery? Reduce risk of venous thromboembolism (validate if Hgb and Hct are low) CM of neurogenic shock Bradycardia Preventions of SIDS - Alt. position of infant's head - ALWAYS supine when sleeping - Tummy time 30-60 min/day Sx of blood dyscrasia unblanchable small red pinpoint rash (severe drug response - systemic) Oropharyngeal candidiasis tx Nystatin (antifungal) Folliculitis - Due to staph in moist areas with friction - Tx: medicated soap, topical ABX, warm compress Leg swelling and calf pain from 15-hour flight 2 days ago DVT -> PE Pt who smokes has intermittent leg pain worsens w/ walking, eases w/ rest Intermittent claudication Tx for dog bite resulting in pain, edema, and redness Iron-rich foods - Eggs - Green leafy veggies - Meats - Shellfish Eating w/ foods rich in vit. C (citrus, potatoes, tomatoes, green veggies) enhances iron absorption (coffee & tea interferes) Unstageable pressure injury Slough/eschar preventing visualization of wound base - debridement necessary Stage 2 pressure injury shallow, partial-thickness skin loss Stage 3 pressure injury full thickness skin loss, may see subq fat deep tissue injury purple or maroon, intact, caused by pressure Fetal station +1> below maternal ischial spines N/V & trembling/shivering Colonoscopy prep 1. Clear liquid day before 2. NPO 8-12 hrs before exam 3. Bowel cleansing agent day before (cathartic, enema, or polyethylene glycol) Pediculosis Capitis education - Launder in hot H2O -Items that can't be washed/dry cleaned- sealed plastic bag for 14 days to kill lice -Vacuuming ASA (aspirin) toxicity tx 1ST - Activated charcoal (inhibits absorption) THEN IV sodium bicarb (excretes salicylate) Pavlik Harness for DDH - Usually worn for 3-5 mos - Most successful started during 1st 6 mos of life - Shirt, knee socks, & diaper under straps (skin protection) - Avoid lotions & powders (excess moisture) - Lightly massage skin under straps qday (circ.) - Should stay in place for diaper changes - Straps should be assessed q1-2 wks by HCP, NEVER ADJUSTED BY PARENTS - Assess skin 2-3x daily Cervical Cancer risk factors #1: HPV - STIs - oral contraceptive use - multiple sexual partners - sexual activity <18 - weakened immunity Acute Appendicitis Sx - excruciating pain in lower abd. above r hip (McBurney's point) - N/V, anorexia - rebound tenderness & guarding - r leg flexed to decrease pain Diverticulitis Sx - pain in lower l quadrant (sigmoid) - palpable, tender mass - systemic sx of infection Acute Cholecystitis Sx - pain in r upper quadrant of abd referred to r scapula - indigestion, N/V, restlessness - fever, leukocytosis HIV education - always use protection even w/ HIV+ partner (multiple strains - coinfection - superinfection) - latex/synthetic condoms/dental dams - NO lambskin Marfan Syndrome education #1: NO competitive/contact sports (risk for cardiac injury & sudden death: aortic root disease is major cause of death) - monitor for scoliosis - annual eye exams - preventive ABX may be needed New-onset anemia for 50 yo Screening colonoscopy for colon cancer + annual fecal occult blood test Pt w/ splenectomy reporting headache & chills - Needs immediate intervention: minor infections w/o functioning spleen can become life-threatening - Cultures, imaging, ABX Immune thrombocytopenia purpura - platelets <150,000/mm3 - petechiae is common Polycythemia Vera - chronic disease: bone marrow overproduces RBCs, WBCs, & platelets - Increased Hct >53%, blood volume, enhanced blood viscosity & abnormal clotting is normal Factors that influence bone healing nutrition, adequate circulation, age (overwt BMI puts pt @ risk for fractures but doesn't impact healing) Home Safety hazards - open wood burning stove - built pre-1978 (lead paint) What should you do if chest tube dislodges? Firmly cover insertion site with palm of clean, gloved hand - sterile occlusive dressing is better aka PETROLEUM GAUZE (prevent pneumothorax) Pts who undergo coronary intervention & stent placement are at risk for... Retroperitoneal hemorrhage Sx: hypotension, back pain, flank ecchymosis, hematoma, diminished distal pulses Expectant Triage - Pulselessness - Apnea - Severe Neuro Trauma - Burns to >60% TBSA Emergent Triage - HOB 30-45 degrees - Assess tube marking - Confirm tube placement (gastric aspirate - return to stomach) - Auscultate BS - If cramps, slow feeding - Flush tube w/ 30 mL of H2O pre & post feeding Fall risk precautions w/ altered mental status - Bed alarm - Room close to station - Bedside commode close to bed - Well-lit room - No restraints initially, will only increase agitation Skeletal traction interventions - WTS SHOULD NOT BE REMOVED unless prescribed by HCP - Intake of >/= 2L of clear fluids - Wts hang freely - Monitoring pin insertion sites, freq. neuro checks, inspect rope DNR but HCP writes prescription for life-saving intervention Can provide comfort measures but cannot give life-saving intervention, must advocate for pt's wishes Pt receiving blood transfusion gets new prescription for Amphotericin B Wait 1 hr after transfusion finishes before administering Amphotericin B (similar SEs) Foods high in potassium - Green leafy veggies - Melons, bananas, strawberries - Milk - Beef, fish, & shellfish - Whole grains tPA ( tissue plasminogen activator - thrombolytic therapy) - MUST be given 3-4.5 hrs from onset of ischemic stroke - Contraindications: recent surgery (14 days), thrombocytopenia (<100,000/mm3), coag. disorders NSAIDs Risk (naproxen, ibuprofen, celecoxib) #1: increase risk of thrombotic events ex. MI, stroke (esp. w/ cardiovascular disease) Pt reports headache after nitroglycerin Document & administer acetaminophen (expected finding b/c vasodilator) Lithium Narrow therapeutic index 0.6-1.2 - Interaction w/ #1: thiazide diuretics, NSAIDs, & antidepressants Priority for pregnant pt @38 wks w/ contractions, severe abd. pain, & dark vag. bleeding #1: Palpate abd. & apply FHR monitor -- indicates placental abruption (can interrupt fetal O2 & cause maternal hemorrhage) - then IV for fluids & blood, possible C-section Placenta previa Sx: painless, bright red vaginal bleeding RISK FOR HEMORRHAGE -- VAGINAL EXAMS CONTRAINDICATED, pelvic rest recommended, C/S after 36 wks Afib Ineffective atrial contraction - Increased risk for clots (could cause stroke or PE) First degree heart block Prolonged PR - Asymptomatic (usually) PVCs Wide distorted QRS - Usually in response to stimulants (caffeine, nicotine, alc, electrolyte imbalances) STEMI >=1 of coronary arteries supplying blood to myocardium is occluded PROMPT Tx: thromolytics, percutaneous coronary intervention Pediculosis Pubis Tx "Crabs" aka pubic lice - Use lice tx shampoo (1% permethrin) - Remove nits w/ fine-toothed nit comb, fingernails, or tweezers - Wash & dry clothes w/ hot H2O & hot dryer setting - Sexual partners should also receive tx - May be passed through close contact & sharing linens - ALL HOUSEHOLD MEMBERS are @ risk Incident Reporting Should be filed when action results in harm OR has potential to cause harm to pt, visitor, or employee ex. falls, mislabeled specimens, med. & communication errors Rapid-acting insulin peak 30 minutes - 3 hrs - given in pt will eat within 15 mins - can be scheduled prandial (prevent unless BS <70) or correctional (unless BS<150) Regular insulin peak 2-5 hrs Long-acting insulin peak (Detemir) 3-14 hrs Insulin NPH peak 4-12 hrs ABG concern for COPD PaO2 <60 mmHg (sig. hypoxemia requiring intervention) Sx precipitating seizure activity (eclampsia) in preeclamptic pts Hyperreflexia, clonus (assessed by dorsiflexing foot & observing rhythmic, jerking "beats" as foot is released) Reactive Nonstress Test (NST) - Baseline 110-160/min - Moderate variability (6-25/min) - >=2 accelerations in 20 mins, each peaking >= 15/min above baseline lasting >= 15 s Emphysema CM due to loss of elasticity in lungs due to permanently enlarged alveoli -- hyperinflation of lungs - Activity intolerance, anxiety - Barrel chest - Hyper-resonance on percussion - Prolonged expiration Stridor Harsh or high-pitched breathing due to obstruction or constriction of airway - indicates LIFE THREATENING AIRWAY COMPROMISE - Drier mucous membranes - Decrease in # & motility of cilia HPV education - HPV increases risk of genital warts & cerv. cancer - Warts that have been treated can reoccur @ any time - Teens & HAs should be vaccinated - Women should receive cervical cancer screening @ age 21 - Barrier methods can reduce risk but don't eliminate it 2nd degree AV block intervention (consistent PR intervals & dropped QRS complexes) Transcutaneous pacemaker IMMEDIATELY Cushing's Triad r/t increased ICP Early sx: LOC changes Late sx: 1.bradycardia, 2. increased systolic blood pressure, widening pulse pressure (diff. btw systolic & diastolic), 3. irregular resp. Intoxicated pt found lying on sidewalk when admitted has LOC changes, bradycardia, increased BP & widening pulse pressure - action? CT to rule out intracranial bleed Priority hypothermia interventions - Warm blankets - Warm IV fluids - Cardiac monitor (as core temp. decreases, prone to dysrhythmias) -- handle gently: could go into spontaneous Vfib - Anticipate defibrillation Rhythms for cardioversion 1. Supraventricular tachycardia 2. Ventricular tachycardia w/ pulse 3. Afib w/ rapid ventricular response MUST BE ABLE TO SYNC W/ R WAVE Suctioning Technique - Apply suction no longer than 5-10 sec. - Wait 1-2 mins btw suction passes - Should be set at medium pressure (adults: 100-120 mmHg, kids: 50-75 mmHg) Painful genital lesions can be indicative of... Significance for pregnant women & tx Herpes Simplex Virus - Neonatal HSV has serious morbidity & mortality Tx: IMMEDIATE ANTIVIRAL THERAPY ex. acyclovir & C/S What should never be done during an operative vaginal birth with vacuum extractor or forceps? NEVER PUSH ON FUNDUS - may cause uterine rupture Measuring fundal ht 12 wks: just above symphysis pubis 16 wks: halfway btw symphysis pubis & umbilicus 20 wks: at level of umbilicus 36 wks: diploid process After 20 wks, fundal ht is measured in cm from symphysis pubis to top of funds Most concerning lab values for pt w/ systemic lupus erythematous - Serum Creatinine: >1.3 - BUN >20 - Abnormal UA can indicate presence of lupus nephritis (inflammation of kidney - can lead to serious kidney injury) Nitrazine test for ROM Probable rupture - Blue (amniotic fluid is alkaline) Probably intact membranes - Yellow (vaginal fluids are acidic) NOTE: PRESENCE OF BLOOD OR SEMEN CAN RESULT IN FALSE POS. (alk) What questions should be asked with birth is imminent? - Recent meds or illicit drug use - Current preg. dx & how many babies - Color of amniotic fluid - Due date How parents can help w/ hospitalization of toddler - Follow home routines - Stay with kid (including overnight) - Using playroom Trach care steps 1. Gather supplies & pos. pt in semi-Fowler's 2. Don PPE 3. Remove soiled dressing & clean gloves 4. Don sterile glove; remove old cannula & replace 5. Clean around stoma w/ sterile H2O, dry & replace gauze Elevated TSH indicates... Tx? Hypothyroidism (insufficient T3 & T4) - Tx: increase levothyroxine Adequate urine output @ least 30 mL/hr or 0.5 mL/kg/hr Aminoglycosides and serious rxns Ex. gentamicin, tobramycin, amikacin OTOTOXICITY & NEPRHOTOXICITY 18 month old is consuming small amounts of food Physiologic anorexia: NORMAL - decreased metabolic needs: very high demands of infant slow to keep pace w/ moderate growth of toddlerhood- intake over several days meets nutritional & energy needs IV vancomycin nursing actions - Infuse for @ least 60 mins - Monitor BP (for hypotension) - Assess for hypersensitivity - Monitor for anaphylaxis - Observe IV site q 30 mins - Draw prescribed trough level (10-20 mg/dL) Linezolid teaching SSRIs are contraindicated (increased risk of serotonin syndrome) Liver biopsy complication & sx to look for Internal bleeding (highly vast. organ) - watch for tachycardia Fever, vomiting, irritability, high-pitched cry may indicate... Pt w/ pleural effusion normal finding Absent breath sounds in base of lung b/c of fluid collecting in pleural space preventing lung from expanding Trismus Inability to open mouth due to tonic contraction of muscles (sx of peritonsillar or retropharygneal abscess - implication of tonsillitis) Complication of endoscopic retrograde cholangiopancreatogrophy Appendicitis manifesting as epigastric of l upper quadrant pain often radiating to back & rapid rise in pancreatic enzymes (amylase, lipase) Barium contrast education May make stool white for up to 3 days (should be encouraged to drink fluids to assist in expulsion of contrast) Why is enteral nutrition preferred? Maintain integrity of gut, prevent stress ulcers, prevent translocation of bacteria into bloodstream Education for pts w/ asthma who exercise Inhaled bronchodilator should be taken 20 mins before athletic activity Acute pancreatitis complications Pancreatic abscess/necrosed pancreas: high fever, leukocytosis, increasing abd. pain - TX IMMEDIATELY W/ ABX TO PREVENT SEPSIS Most important lab value to report abt pt with DM type I Elevated serum creatinine (@ risk for diabetic nephropathy) Normal serum fasting blood glucose 70-99 mg/dL What amount of residual urine in the bladder should be reported? > 100 mL Abnormal urine culture results >10,000 organisms/mL indicates UTI What vaccines can be administered to a pregnant pt @ 30 wks gestation Inactivated vaccines: - Influenza injection regardless of trimester during flu season - Tetanus, diphtheria, and pertussis (provides newborns w/ passive immunity against whooping cough) Live virus vaccines are contraindicated 68 yo M had laparoscopic cholecystectomy 8 hrs ago & has not urinated since surgery Help pt OOB to help with normal position for urinating - if unable to urinate, use bladder scanner Pt education for postop pain after invasive MIDCAB grafting Overall recovery time is expected to be shorter, but initial postop pain can actually be higher b/c incisions were made btw ribs After turning pt w/ chest tube 125 mL of dark bloody drainage rushes out Document & continue to monitor drainage - Immediately following thoracotomy, chest tube drainage (50-500 mL for first 24 hrs) is expected to be sanguineous for sev. hrs then change to serosanguineous followed by serous over a period of a few days - Not concerning - most likely r/t retained blood b/c of partial tube blockage Complication of PEEP Barotrauma (from high levels: 10-20 cm H2O) can lead to pneumothorax & decreased venous return can cause hypotension Small bowel obstruction CM & nursing actions - Rapid onset of N/V - Colicky intermittent abd. pain - Abd. distension Nursing actions: - NPO -NG - IV fluids - Pain control Large bowel obstruction - Gradual onset of sx - Absolute constipation (later) - Lack of flatus (later) Pain during defecation Rectal problem: inflammation, anal fissure, or thromboses hemorrhoids CBT components 1. Education abt specific disorder 2. Self-observation & monitoring 3. Relaxation techniques 4. Desensitization activities 5. Changing neg. thoughts How to help pt experiencing auditory hallucinations Provide earphones & a DVD player and have pt sing along w/ music (increasing amp of external sound makes it easier to ignore hallucinations) Meds contraindicated for HF NSAIDs ex. ibuprofen (contributes to sodium retention, therefore fluid retention) HF pt management - Weigh self daily @ same time, same amt of clothing, same scale - Avoid meals with Na >400 mg/serving - Take diuretics in morning - Encourage cardiac rehabilitation (exercise plan) - Avoid NSAIDs Grapefruit + CCB (VND) Severe hypotension Grapefruit + statins possible myopathy Cardiac tamponade sx requiring immediate intervention - Muffled/distant heart tones - Narrowed pulse pressure - JVD - Pulsus paradoxus - Dyspnea, tachypnea - Tacycardia Complication of pericardial effusion Cardiac tamponade Cardiac tamponade tx Emergency pericardiocentesis 30 month old wt gain since birth Miconazole 3-7 days - refrain from sex for duration of tx - partner does not need to be tested Hypothyroidism CM - Bradycardia - Wt gain, constipation - Fatigue/muscle aches, joint pains - Lethargy/apathy, forgetfulness, depression - Decreased libido - Cold intolerance, dry & thick skin, brittle nails & hair, hair loss, facial & generalized interstitial edema - Anemia (pallor) Adenosine administration - 6 mg IV rapidly over 1-2 seconds followed by 20 mL saline flush - For SVT - Half life <5 sec. - Repeat boluses of 12 mg may be given 2x if rapid rhythm persists - Brief systole can be common - Flushing from vasodilation is frequent Best place to apply pressure if bleeding occurs 1 inch above puncture site Complications of placenta accreta (placenta adheres to myometrium instead of endometrium) LIFE-THREATENING HEMORRHAGE & SHOCK Prevent: 2 large 18-gauge IVs, blood type & crossmatch in case blood transfusion is needed Priority dx for schizophrenic pt Risk for dehydration & malnutrition St. John's wort interactions - Depression meds: TCAs, SSRIs/SNRIs, MAOIs Time needed for heparin bridge to transfer to warfarin 5 day overlap Pre-op assessment for open abd. aneurysm repair Peripheral pulses (to determine if graft becomes occluded post-op) Clopidogrel concern for surgery DISCONTINUE 5-7 days before surgery (same w/ NSAIDs, anticoags, anti platelets, herbal drugs) Foul-smelling lochia post- prolonged vag. delivery of term infant Endometrial infection Other sx: fever, achy, uterine pain/tenderness Note: WBC is normally elevated during first 24 hrs postpartum up to 30,000/mm3 Pt receiving vancomycin reports discomfort at IV site Phlebitis: IMMEDIATELY REMOVE catheter to prevent thrombophlebitis, emboli, or bloodstream infection How often should continuous IV tubing be changed ? - No earlier than every 72 hours unless contaminated - Intermittent & hypertonic infusions ex TPN, propofol, blood require changes 4-24 hrs immunosenescence age-related decline of immune responses that increases older pts risk of infection & sepsis ATYPICAL SX OF INFECTION (ex. hypothermia, altered mental status, leukopenia) should be reported immediately Ovarian cancer sx Often vague: bloating, early satiety, urinary urgency/frequency, pelvic pressure, abd/back/leg pain, GI disturbances Priority when pt has acute change in VS or staff member is worried abt pt's condition Call rapid response team Sx of VP shunt malfunction Vomiting, headaches, changes in vision & mental status (same sx as increased ICP) Best position for newborn resuscitation Neck slightly extended (not hyperextended) + blanket or towel under newborn's shoulders Best assessment indication that bladder irrigation flow is productive after TURP Urine is light pink, no clots Buck's traction nursing actions - Supine/semi-Fowler's position (MAXL 20-30 degrees) - Assess neurovasc. status q30min - Wts should be free-hanging at all times (never placed on bed or floor) How does it work? Skeletal traction is applied directly to bone with metal wire or pin to immobilize, position, or align a fracture when continuous traction is needed and skin traction is not possible WTS SHOULD NEVER BE REMOVED, can cause serious injury Systemic lupus erythematosus pt education - Avoid situations that cause physical & emotional stress - Avoid sun exposure & UV light when possible - Notify HCP if you have fever Most important nursing action for pt with UTI and sx of agitation, confusion, and disorientation One-on-one supervision & freq. reorientation IUD pt education Notify HCP if string feels longer or shorter after menses (assess weekly for first 4 wks & then after each menses - Report PAINS sx (period abnormalities, abd. pain, infection, not feeling well, strings length) IUDs & length of contraception Copper - 10 yrs Levonorgestrel - 3 of 5 yrs Anorexia Nervosa sx - Amenorrhea - Fluid & electrolyte imbalances - Wt loss 25% norm. - Cold intolerance -Lengthy & vigorous exercise - Lanugo in extreme cases Morning sickness interventions - Several small meals during day (high in protein or carbs & low in fat) - Drinking fluids (clear, cold, carbonated) btw rather than during meals - High protein snack before bed & on awakening - Ginger - B6 (nuts, seeds, legumes) Norm. Mg levels 1.5-2.5 mEq/L Normal Albumiin levels 3.5-5.0 g/dL Skin cancer risk factors - Family hx - High # of moles - Immunosuppressants - Outdoor occupation - Aging - Celtic ancestry traits (ex. light skin, red/blonde hair, blue/green eyes, many freckles) Normal aPTT & aPTT with heparin aPTT: 25-35 seconds Heparin aPTT: 46-70 seconds Vitamin K-rich foods - Decrease anticoagulant effects of warfarin - Ex. green leafy veggies & liver - Note: Don't confuse K+ w/ vitamin K Acute glomerulonephritis CM - Complex immune disease commonly induced by GABHS infection - Latent period of 2-3 wks and sx - Sx: periorbital & facial/generalized edema, SEVERE HTN, oliguria, tea-colored urine bc of protein & blood in urine - MONITOR BP Pt has chest pain and transdermal nitroglycerin patch peeled off Tx acute angina: rapid-acting sublingual nitroglycerin (Transdermal patches have delayed onset & are used prophylactically) Priority post-op concern Post-op hypotension (could indicate bleeding, hypovolemia, sepsis) Most concerning for pt w/ blurred vision & reduced visual fields Extreme eye pain (acute angle-closure glaucoma) can lead to permanent blindness from IOP Other CM: sudden onset of severe eye pain, reduced central vision, blurred vision, ocular redness, report of seeing halos around lights Priority for pt w/ alc. intoxication IV thiamine (vitamin B1) before or with IV glucose to prevent Wernicke encephalopathy. Note: untreated WE can lead to death or neurologic morbidity (Korsakoff psychosis) Why shouldn't parents put their kids to bed with a bottle of milk? Can lead to extensive and rapid dental caries in developing teeth aka baby bottle tooth decay (carbohydrate-rick fluid pools around teeth and nourishes decay producing bacteria) Parent education for feeding kids - Chopped whole fruit instead of juice (b/c fiber) - H2O btw meals - Space introducing new foods by ~a wk Breastfeeding Education - Breastfeed: q2-3h, "on demand" when newborn exhibits hunger cues - Position "tummy to tummy" with mouth in front of nipple & head in alignment w/ body - Ensure proper latch (nipple & areola) - At least 15-20mins each breast or until newborn appears satisfied - Insert clean finger beside gums to break suction - Alternate which breast is offered at each feeding When might postmortem care be delayed or not performed? - Family has certain cultural or religious beliefs OR - The death is considered to be non-natural, traumatic, or associated w/ criminal activity How to measure cane length & pt education Greater trochanter to floor - Hold cane on stronger side - Place cane several in. in front of and to side - Move weaker leg forward - 2 points of support on floor at all times Isotonic fluid therapy Tx: extracellular fluid deficits ex. dehydration - gastroenteritis Hypertonic fluid therapy Tx: cerebral swelling: increased ICP, hyponatremia Priority monitoring for dopamine VS for dangerous tachycardia and tachyarrhythmias Normal systemic vascular resistance 800-1200 dynes Normal MAP 70-105 mmHg Toilet training 18-24 months - When able to communicate urge to go and follow simple commands like pulling clothing up and down & walking to and sitting on toilet Dressing change for surgical incision Clean gloves when removing existing dressing changing to sterile gloves when applying new dressing First action for pt w/ suspected meningitis Place pt on droplet precautions Normal temp 96.8-100.4 F (36-38 C) Sumatriptan contraindications Coronary artery disease and ischemic uncontrolled HTN Best action to visualize airway w/ extensive injuries to head & upper back Jaw-thrust maneuver in supine position on backboard when there's any suspicion of spinal injury (Head-tilt chin-lift doesn't stabilize alignment of head and neck, can cause spinal damage) First action for pt in VT Assess for pulse (can be pulseless or have a pulse) If unstable: synchronized cardioversion If stable: anti arrhythmic meds ex. amiodarone Alzheimer Pt Management - Acknowledgement - Reassurance Intentional touching w/o the person's consent even w/o physical injury Assault Threat of battery Peritonitis rebound tenderness, birdlike abd. rigidity, shallow breathing Billroth II surgery education - Lie down after eating to avoid dumping syndrome - Avoid fluids w/ eating to delay (@ least 30 mins before/after meals Infant feeding education - Held in semi-reclining position - Meds given in small ants directed toward back and inside of cheek - Open mouth by applying gentle pressure to chin or cheeks - One hand holds infants free arm Actions for pt w/ nystatin oral suspension - soak dentures in nystatin oral suspension - assess affected area frequently - instruct pt to swish suspension in mouth for several minutes and then SWALLOW - shake before - continued for at least 48 hrs Priority for pt w/ ineffective airway clearance r/t pain Give pain meds before performing coughing exercises so exercises are more effective Best time to take statin drugs - With evening meal (to lower cholesterol since most is synthesized at night) Heparin flush for CCV lumen 2-3 mL containing 100 units/mL using a 10 mL syringe (smaller syringes create more pressure, more potential for damage) Phenytoin therapeutic range and sx of toxicity 10-20 mcg/mL Toxicity sx: horizontal nystagmus, gait unsteadiness, slurred speech, decreased alertness, ataxia Fondaparinux administration NOT administered until more than 6 hours after any surgery and NOT w/ epidural catheter Pt's radiation implant has dislodged, what do you do? Use long-handled forceps to secure implant in a lead container Sickle cell crisis pain management if previous interventions have been ineffective Contact HCP for PCA at higher dose (morphine or hydromorphone aka Dilaudid) NO MEPERIDINE - can cause tremors resulting in seizure Causes of trace amounts of proteinuria - Fever - Strenuous exercise - Prolonged standing Phalen's manuver Dx for carpel tunnel Heel-to-shin test Assesses cerebellar function Normal Calcium levels 8.6-10.2 mg/dL <8.6 hypocalcemia is complication of parathyroidectomy - Check for Trousseau's and Chvostek's sx Radiation contamination monitoring Anywhere with rapidly proliferating cells ex. oral mucosa, GI tract, bone marrow Allergic rhinitis interventions - HEPA filters - Keeping windows closed - Hypoallergenic pillow and mattress covers - Eliminating carpet - Mopping and vacuuming regularly w/ HEPA filter system - Damp-dusting furniture frequently Priority for burn pt 150 mL/hr of IV LR continuously to STABILIZE CIRCULATION Retinal detachment sx - Lightning flashes - Floaters - Curtain-like/gnats/hairnet/cobweb effect could result in permanent blindness w/o intervention Palifermin prevents oral mucositis, doesn't help w/ pain (lidocaine does) DKA protocol 1. Rehydration (NS) 2. Insulin Psychomotor retardation decreased movement, inability/decreased ability to talk, impaired cog. function Syphillis in pregnancy w/ penicillin allergy Penicillin desensitization Detection of FHR 10-12 wks Nagle's Rule LMP +7 days -3 months +1 yr Why are beta blockers given to pts w/ thyrotoxicosis? Tx symptoms ex. tachycardia, HTN IM newborn and infant injections 1 in needle in anterolateral thigh in VASTUS LATERALIS When should the ventrogluteal area be used for injections & what size needle should be used? At least age 3 1 1/2 in. needle 6 mo. crying and grabbing intermittently at abd. w/ red, currant jelly appearance Give air (pneumatic) enema Tx for constipation during infancy 2 oz of pear or apple juice added to diet + high-fiber foods When is a hem occult test performed? 2. Liver biopsy 3. Catheterization via femoral artery 4. Enema 5 Lumbar puncture 1. Upright (Semi-high Fowler's) 2. Right side-lying position 3. Flat or low-Fowler's position w/ affected extremity straight ~4-6hrs 4. Sims 5. Fetal or hunched for procedure (supine for 4-12 hrs in bed ) Neuro assessment requiring immediate follow-up - Can't flex chin toward chest (meningitis) - New onset of arm drift - Pupils >8mm in diameter bilaterally Normal pupils 3-5mm in diameter Interventions for pt w/ bipolar disorder w/ acute manic episode - Private room - Choose clothing for pt - Physical exercise - One-on-one interactions -High-protein, high-cal meals and easy to eat snacks Most important health hx info for pt w/ bladder cancer Tobacco use Most common sx: painless hematuria Pericardial friction rub High-pitched scratchy sound @ apex of heart Which CVC placement has highest possibility for infection? Femoral (inguinal) Most important lab value to monitor w/ Vancomycin administration Creatinine levels (can cause nephrotoxicity) Malignant hyperthermia sx and tx Sx: tacycardia, tachypnea, rigid jaw/generalized rigidity, fever later Tx: IV DANTROLENE - Discontinue succinylcholine - Cooling blankets - Tx high potassium levels (triggered by certain drugs used for anesthesia) Priority for pt w/ new trach Checking tightness, allowing 1 finger to fit under ties Priority sx to report for pt taking rituximab Bronchospasm, dyspnea, tachypnea, hypotension, angioedema Priority for accidental eye exposure Immediately flush eye w/ water or saline for @ least 10 minutes Weaning from breastfeeding - Exclusive breastfeeding for first 6 months - Introduction of pureed foods @ 6 months + breast milk - Introduction of cow's milk @ 1 yr Priority for craniotomy w/ wound drainage saturating the incision Notify HCP of color and amt of drainage Reasons for returning blood to blood bank - Green, black, white, or dusky discoloration - Accumulation of air - Evidence of clotting - Malodor Malfunctioning BP machine Take out of service to prevent pt injury & measure manually Best action for suspected frostbite Thaw in warm water bath 98.6-102.2F and administer analgesics (Manual friction is contraindicated as it could damage the tissue) Frostbite - vasoconstriction restricts blood flow, intracellular fluid freezes and cell membranes rupture Critical value for potassium >5.5 mEq/L What increases likelihood of pt to experience atypical sx of MI? - Female gender - Advanced age - Diabetes/neuropathy When can pregnant women feel fetal movement (quickening)? 18-20 wks Stevens-Johnson syndrome Immune-mediated rxn triggered by certain classes of drugs (sulfonamide ABX, allopurinol, anticonvulsants Sx: blistered lesions on face, trunk, and palms (MAY BE FATAL IF LEFT UNTREATED) Cyclosporine education - Avoid large crowds bc it's an immunosuppressant - Monitor or SE, incidence of secondary malignancies ex. skin cancer, lymphoma is increased in these pts - Can cause hirsutism, associated w/ HTN and nephrotoxicity Preventing skin breakdown in infants - Raise HOB <= 30 degrees to reduce pressure and prevent sliding - Moisture barriers - Pulse ox sites should be changed q4h Priority for pt w/ memory loss post ECT Document (expected finding) Priority for sickle cell pt who received blood transfusion w/ pain all over, anxiety, SOB, and crackles in bilateral lower lobes - Administer prescribed diuretics due to circulatory overload and provide additional resp. support - Slow infusion rate and pt should be put in sitting position Tumor lysis syndrome sx - Hyperkalemia - Hyperuricemia - Hyperphosphatemia Priority sx post CVA