NCLEX RN NGN Practice Questions/ NGN NCLEX RN Practice Questions Updated 2023-2024 Latest, Exams of Nursing

Download NCLEX RN NGN Practice Questions/ NGN NCLEX RN Practice Questions Updated 2023-2024 Latest and more Exams Nursing in PDF only on Docsity! NCLEX RN NGN Practice Questions/ NGN NCLEX RN Practice Questions Updated 2023-2024 Latest Version Test Bank 1000+ Questions and Ans Loss of urine is unpredictable & continuous --------- Correct Answer ---------- Total incontinence Voids in increments of less than 50 mL under conditions of increased abdominal pressure. --------- Correct Answer ---------- Stress incontinence Occurs rather predictable times that correspond when certain bladder volume is attained. --------- Correct Answer ---------- Reflex incontinence Earliest symptom is paresthesia (numbness & tingling in fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, pallor & coolness to distal limb. Cyanosis is a late sign. --------- Correct Answer ---------- Compartment syndrome Skin traction often applied after hip fracture before fracture is reduced in surgery. Traction reduces muscle spasms & helps immobilize fracture. --------- Correct Answer --- ------- Buck's (extension) traction Infection & pancytopenia are side/adverse effects. Assess white blood cell counts & platelet counts --------- Correct Answer ---------- Etanercept for treatment of rheumatoid arthritis Encourage drink 3000 mL fluid day. Full effect may take 1 week or longer. Given with, or immediately after, meals or milk. Develops rash, irritation eyes, swelling of lips or mouth;contact HCP because may indicate hypersensitivity. Medication prevents, treats hyperuricemia caused by chemotherapy. May increase effect of Warfarin sodium if this medication was prescribed for client, should verify prescription with HCP --------- Correct Answer ---------- Allopurinol (Zyloprim) Prescribed for gout. Used with caution older adults, debilitated clients, & clients with cardiac, kidney, or GI disease. --------- Correct Answer ---------- Colchicine (Colcrys) Take medication with full glass of water after rising in morning. Not eat or drink anything for 30 minutes following administration --------- Correct Answer ---------- Alendronate (Fosamax) prescribed for osteoporosis Liver damage most serious adverse effect. To reduce risk of liver damage, liver function tests should be performed before treatment & throughout treatment. Administered lowest effective dosage for shortest time necessary. --------- Correct Answer ---------- Dantrolene sodium (Dantrium) Used with caution history of urinary retention, glaucoma, & increased intraocular pressure. --------- Correct Answer ---------- Cyclobenzaprine hydrochloride (Flexeril) Skeletal muscle relaxant. May cause urine to turn brown, black, dark green color. Needs to be told; harmless effect. Medication can cause hypotension & bradycardia. Drowsiness & dizziness can also occur. --------- Correct Answer ---------- Methocarbamol (Robaxin) Autoimmune disease causes blistering in epidermis. Large flaccid blisters (bullae). Blisters are in epidermis, have thin covering of skin & break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. --------- Correct Answer ---------- Pemphigus Health care worker, people who work in rubber industry, or have had multiple surgeries, have spina bifida, wear gloves frequently; food handlers, hairdressers, & auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts. --------- Correct Answer ---------- Individuals at risk for developing a latex allergy Multisystem infection that results from bite by tick carried by several species of deer. Blood to detect performed 4 to 6 weeks following tick bite. Antibody formation takes place in the following manner. Ticks should be removed with tweezers & area washed with an antiseptic. --------- Correct Answer ---------- Lyme disease Prevention; insect repellent on skin & clothes in an area where ticks likely found. Long- sleeved tops & long pants, closed shoes, & hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up & over pant legs to prevent ticks from entering under clothing. --------- Correct Answer ---------- Lyme disease Avoid uncooked eggs & unpasteurized milk. Fruits & vegetables washed before eating. Contact materials possibly contaminated with cat feces; litter boxes, sand boxes, garden soil avoided. Avoid touching mucous membranes mouth or eyes while handling raw meat, wash all kitchen surfaces that come contact with uncooked meat, wash hands after handling raw meat. Symptoms; altered mental status, headache, & cognitive impairment. --------- Correct Answer ---------- Toxoplasmosis Caused by inhalation of spores from bat or bird droppings. An opportunistic infection that affects lungs & can occur in client with HIV infection. Diagnostic tests include chest x-ray, sputum culture, lung biopsy, & bronchoscopy --------- Correct Answer ---------- Histoplasmosis Chronic connective tissue disease. Corticosteroids prescribed treat inflammation. Topical agents may provide some relief from joint pain. Activity encouraged as tolerated Causes constipation, instructed increase fluid intake & bulk (high fiber) in diet. If heart beats fast, HCP notified could indicate overdose. Diarrhea could indicate incomplete intestinal obstruction HCP notified. --------- Correct Answer ---------- Oxazepam (Serax) Cause orthostatic hypotension. Sunlight avoided. Psychotropic med, caution with (driving, other activities requiring alertness) determine if alertness affected. Atypical antipsychotic renal & liver function studies done. --------- Correct Answer ---------- Risperidone (Risperdal) maximum therapeutic effect may not occur for 2-3 weeks after antidepressant therapy initiated. --------- Correct Answer ---------- Imipramine (Tofranil) (MAOI) Avoid foods high in tyramine. Ingestion of these foods could trigger potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; fruits such as avocados, raisins, or figs. --------- Correct Answer ---------- Phenelzine (Nardil); for depression Can occur from use monoamine oxidase inhibitor; hypertension, occipital headache radiating frontally, neck stiffness & soreness, N&V. --------- Correct Answer ---------- Hypertensive crisis Is a process of learning a different culture to adapt to a new or changing environment. -- ------- Correct Answer ---------- Acculturation. It is a subjective perspective of the person's heritage and a sense of belonging to a group --------- Correct Answer ---------- Ethnic identity Include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, & spiritual measures (prayer). --------- Correct Answer ---------- Low-risk therapies: Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans. --------- Correct Answer ---------- High risk of obesity & diabetes mellitus Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products. --------- Correct Answer ---------- Jehovah's Witnesses Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. ------- -- Correct Answer ---------- Orthodox Judaism include whole medical systems, mind-body medicine, biologically based practices, manipulative & body-based practices, & energy medicine. --------- Correct Answer -------- -- Five categories of complementary and alternative medicine (CAM): Focused, maintains strong control, makes decisions, & addresses all problems. Dominates group & commands, rather than seeks suggestions or input. Manager addresses problem (quality improvement) with taff, designs a plan without input, & wants all problems reported directly back to her --------- Correct Answer ---------- Autocratic leader Participative & would likely meet with each staff person individually to determine staff member's perception of problem. Would also speak with the staff about any issues & ask the staff for input with developing a plan. --------- Correct Answer ---------- Democratic leader Passive and nondirective. Would state what the problem was & inform staff that the staff needed to come up with a plan to "fix it." --------- Correct Answer ---------- Laissez-faire leader Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck & hand vein distention, altered LOC, & decreased hematocrit. --------- Correct Answer ------ ---- Overhydration or fluid overload & occurs when fluid intake or fluid retention Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, & tomatoes --------- Correct Answer ---------- Common food sources of potassium: Muscle weakness, increased urinary output, & decreased specific gravity of the urine would be noted --------- Correct Answer ---------- Hyponatremia Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide- based or magnesium-based antacids. Malnutrition is associated with alcoholism. --------- Correct Answer ---------- Hypophosphatemia Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors. Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole grains, & carbonated beverages. --------- Correct Answer ---------- Hyperphosphatemia Vomiting, diarrhea, conditions that increased respiration's or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy. Diuretics, & gastrointestinal suctioning. --------- Correct Answer ---------- Causes of a fluid volume deficit Decreased kidney function, heart failure, hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds & body cavities, & excessive ingestion of sodium. --------- Correct Answer ---------- Causes of overhydration or fluid overload: Trauma, burns, sepsis, or metabolic or respiratory acidosis. --------- Correct Answer ------ ---- Hyperkalemia causes: Cushing's syndrome or colitis & over use of laxatives. --------- Correct Answer ---------- Hypokalemia causes: Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or diarrhea. --------- Correct Answer ---------- Metabolic acidotic Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms experienced would include hypoventilation & tachycardia. --------- Correct Answer -------- -- Metabolic alkalosis Decreased pH and an increased CO2. Hypoventalation & COPD --------- Correct Answer ---------- Respiratory acidotic Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea) occurs. --------- Correct Answer ---------- Respiratory alkalotic Sample for PT & INR level to determine anticoagulation status & risk for bleeding -------- - Correct Answer ---------- Warfarin (Coumadin) aPTT monitors the effects. Anticoagulant used most often during hemodialysis. Monitors extent of anticoagulation checking PTT, which is appropriate measure heparin effect. Protamine sulfate is antidote. --------- Correct Answer ---------- Heparin Dark green leafy vegetables good source iron, oranges are a good source of vitamin C, which enhances iron absorption. --------- Correct Answer ---------- Iron deficiency anemia foods in diet: May lack B12 in diet. --------- Correct Answer ---------- Vegans Include fruits & vegetables --------- Correct Answer ---------- Low sodium foods: Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish & shellfish. Smoked foods, --------- Correct Answer ---------- High Sodium foods: Placed in left Sims position so enema solution can flow by gravity in natural direction of colon. --------- Correct Answer ---------- Cleansing enema Preconventional stage, morals are thought to be motivated by punishment & reward. ---- ----- Correct Answer ---------- Kohlberg's theory of moral development Should not try anticipate newborn infant needs but allow newborn infant to signal needs. If newborn infant is not allowed to signal a need, newborn will not learn how to control environment. Delayed or prolonged response to newborn infant's signal would inhibit development trust & lead to mistrust of others --------- Correct Answer ---------- Erikson's psychosocial development theory Child has the ability to think abstractly and logically. --------- Correct Answer ---------- Formal operations stage of Piaget's cognitive developmental theory Child begins to understand the environment. --------- Correct Answer ---------- Paiget's sensorimotor stage Child is able to classify, order, and sort facts. --------- Correct Answer ---------- Paiget's concrete operational stage Child learns to think in terms of past, present, & future. --------- Correct Answer ---------- Paiget's preoperational stage 20 to 40 breaths/minute --------- Correct Answer ---------- Normal respiratory rate in a 12- month-old 90 to 130 beats/minute --------- Correct Answer ---------- Normal apical heart rate in a 12- month-old 90/56 mm Hg --------- Correct Answer ---------- Average blood pressure in a 12-month- old Diamond-shaped & located on top of head. Soft & flat in normal infant, & it normally closes by 12- 18 months of age --------- Correct Answer ---------- Anterior fontane Decreased lean body mass & age-associated decreased glomerular filtration rate. ------- -- Correct Answer ---------- older client is at risk for medication toxicity because Stand feet together & arms at sides, close eyes & hold position; normally client can maintain posture & balance. Positive Romberg's sign is a vestibular neurological sign found when client exhibits loss balance when closing eyes. --------- Correct Answer ------ ---- Romberg's test Rhythmic respirations with periods of apnea. Periods apnea followed by deep rapid breathing --------- Correct Answer ---------- Cheyne-Stokes respirations Physical obstruction to transmission of sound waves --------- Correct Answer ---------- Conductive hearing loss occurs as result pathological process in inner ear, defect in 8th cranial nerve, or defect of sensory fibers that lead to cerebral cortex. --------- Correct Answer ---------- Sensorineural hearing loss Abnormal heart sound & described as gentle, blowing, swooshing sound. --------- Correct Answer ---------- Heart murmur Described as a scratchy, leathery heart sound. --------- Correct Answer ---------- Pericardial friction rub Tests the six cardinal positions of gaze --------- Correct Answer ---------- Assess for muscle weakness in eyes Visual acuity & cranial nerve II (optic). --------- Correct Answer ---------- Snellen eye chart Close eyes & then lightly touching areas of face & testing corneal reflexes assess cranial nerve V (trigeminal). --------- Correct Answer ---------- Testing sensory function tested insupine position. Flexes head (gently moves head to chest) & there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if passively flexes hip & knee in response to neck flexion & reports pain in vertebral column. --------- Correct Answer ---------- Positive Brudzinski's sign Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned by one umbilical vein. Arteries carry deoxygenated blood & waste products from fetus, umbilical vein carries oxygenated blood & provides oxygen & nutrients to fetus. --------- Correct Answer ---------- Fetal circulation Connects umbilical vein to inferior vena cava --------- Correct Answer ---------- Ductus venosus Is temporary opening between right & left atria. --------- Correct Answer ---------- Foramen ovale Joins the aorta & pulmonary artery --------- Correct Answer ---------- Ductus arteriosus Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement, Braxton Hicks contractions, & positive pregnancy test for presence of HCG. --------- Correct Answer ---------- Probable signs of pregnancy Fetal heart rate detected by electronic device (Doppler transducer), active fetal movements palpable by examiner, & outline fetus by radiography or ultrasonography. --- ------ Correct Answer ---------- Positive signs of pregnancy *Pregnancy avoided for 1-3 months. *Vaccine administered subcutaneous route.*Exposure immunosuppressed individuals avoided. *Hypersensitivity reaction can occur if client has allergy to eggs. --------- Correct Answer ---------- Rubella virus vaccine Postpartum Three classic signs are hypertension, generalized edema, & proteinuria. --------- Correct Answer ---------- Classic signs of preeclampsia Can trigger disseminated intravascular coagulation (DIC). Evidence of bleeding, such as in gums, petechiae, & purpura should be reported to HCP if noted on assessment. ------- -- Correct Answer ---------- Severe preeclampsia Considered a risk factor for disseminated intravascular coagulation (DIC). --------- Correct Answer ---------- Dead fetus syndrome Isoniazid plus rifampin (Rifadin) will be required for 9 months. --------- Correct Answer --- ------- Pregnant client tuberculosis is suspected; sputum culture obtained & identifies Mycobacterium tuberculosis When the cervix is dilated completely & ends with birth of the neonate. --------- Correct Answer ---------- Second Stage of Labor begins Occur if umbilical cord becomes compressed, reducing blood flow between placenta & the fetus. --------- Correct Answer ---------- Variable decelerations Result from pressure on fetal head during a contraction. --------- Correct Answer ---------- Early decelerations Fetal heart rate assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Minimal vaginal examinations would be done because of risk of infection. --------- Correct Answer ---------- Assessment finding following an amniotomy should be conducted first Acute abdominal pain present. Uterine tenderness with abruption, especially central abruption & trapped blood behind placenta. Abdomen feels hard/boardlike on palpation as blood penetrates myometrium & causes uterine irritability. Premature separation placenta from uterine wall after 20th week gestation, before fetus delivered. Associated conditions; hypertension, smoking, alcohol/ cocaine abuse. Overdistention uterus; multiple gestation, polyhydramnios. In addition, short umbilical cord, physical trauma, increased maternal age & parity are risk factors. Painful vaginal bleeding, abdominal pain, & back pain identify signs/symptoms of abruptio placentae. --------- Correct Answer ---------- Abruptio placentae Classified as antidote for acute iron toxicity. --------- Correct Answer ---------- Deferoxamine (Desferal) Early sign slight change LOC, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late sign ICP include significant decrease LOC, bradycardia, decreased motor & sensory responses, alterations pupil size & reactivity, posturing, Cheyne-Stokes respirations, & coma. --------- Correct Answer ---------- Symptom of increased ICP Confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate & biopsy. --------- Correct Answer ---------- Leukemia Malignancy lymph nodes. Presence of giant, multinucleated cells (Reed-Sternberg cells) is classic characteristic of this disease. --------- Correct Answer ---------- Hodgkin's disease Never be administered in the presence of oliguria or anuria. Checks amount urine output before administration. --------- Correct Answer ---------- potassium chloride Also known as congenital aganglionosis or megacolon. Pellet or ribbon-like stools: foul- smelling is clinical manifestation of disorder. Delayed passage or absence of meconium stool in neonatal period also a sign. Bowel obstruction in neonatal period, abdominal pain & distention, & failure to thrive also clinical manifestations. --------- Correct Answer - --------- Hirschsprung's disease Projectile vomiting, irritability, hunger & crying, constipation, & signs dehydration including decrease urine output. --------- Correct Answer ---------- Pyloric stenosis Invagination of section of intestine into distal bowel. Most common cause of bowel obstruction children aged 3 months to 6 years. Severe abdominal pain; crampy & intermittent, child draw in knees to chest. Vomiting may be present, but not projectile. Bright red blood & mucus passed through rectum & commonly described as currant jelly-like stools --------- Correct Answer ---------- Intussusception Preoperative period, child observed presence loose teeth to decrease risk aspiration during surgery. Bleeding during surgery controlled via packing & suction as needed. Frequent swallowing, restlessness, fast/thready pulse, & vomiting bright red blood are signs of bleeding. Bad mouth odor normal after tonsillectomy & may be relieved by drinking more liquids. --------- Correct Answer ---------- Tonsillectomy (Surgical removal tonsils) condition eyes not aligned because lack coordination of extraocular muscles. May in child when complains frequent headaches, squints, tilts head to see. Other manifestations include crossed eyes, closing one eye to see, diplopia, photophobia, loss of binocular vision, or impairment of depth perception. --------- Correct Answer ---------- Strabismus Decreased wheezing in child with asthma may be interpreted incorrectly as positive sign when may actually signal inability move air. "Silent chest" is an ominous sign during an asthma episode. --------- Correct Answer ---------- Child with asthma Highly communicable disorder. Not transmitted airborne route. Usually transferred by hands. Use contact & standard precaution during care (wearing gloves & gown) reduce nosocomial transmission of RSV. Isolated private room or room with another infant with RSV infection. Cool humidified oxygen delivered relieve dyspnea, hypoxemia, & insensible water loss from tachypnea. --------- Correct Answer ---------- Respiratory syncytial virus (RSV) Acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, & enlargement cervical lymph nodes. Subacute stage, cracking lips & fissures, desquamation skin on tips of fingers & toes, joint pain, cardiac manifestation, & thrombocytosis. Convalescent stage, appear normal, but signs inflammation may be present. --------- Correct Answer ---------- Kawasaki disease Narrowing or stricture of aortic valve. Signs of exercise intolerance, chest pain, & dizziness when standing for long periods. --------- Correct Answer ---------- Aortic stenosis Failure fetal ductus arteriosus (artery connecting aorta & pulmonary artery) to close. Characteristic machinery-like murmur is present, & infant may show signs of heart failure --------- Correct Answer ---------- Patent ductus arteriosus Abnormal opening between the atria --------- Correct Answer ---------- Atrial septal defect Abnormal opening between the right and left ventricles. --------- Correct Answer ---------- Ventricular septal defect Gross hematuria & proteinuria: urine may be small in volume, specific gravity elevated, & urine may appear dark & smoky; cola-colored/brown-colored. Foamy urine from proteinuria. Hypertension common. Blood urea nitrogen levels may be elevated. Moderately elevated high urinary specific gravity. Common experiences excess fluid volume & fatigue. Intervention; fluid restriction, monitoring weight, I&O. Diet high calorie but low protein. Placed bed rest, encouraged rest, because direct correlation between proteinuria & hematuria & increased activity level. --------- Correct Answer ---------- Glomerulonephritis Symptoms include increased serum lipids, edema, increased excretion of protein in the urine, & decreased serum albumin levels. Kidney disorder characterized massive proteinuria, hypoalbuminemia (hypoproteinemia), & edema. Child with edema from nephrotic syndrome high risk skin breakdown. Skin surfaces cleaned & separated with clothing to prevent irritation & resultant skin breakdown. Child will be anorexic. --------- Correct Answer ---------- Nephrotic syndrome Weight gain; periorbital & facial edema most prominent in morning; leg, ankle, labial, or scrotal edema; decreased urine output & urine dark & frothy; abdominal swelling; blood pressure normal or slightly decreased. Massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, & pallor. --------- Correct Answer ---------- Nephrotic syndrome Condition which one or both testes fail descend through inguinal canal into scrotal sac. Surgical correction may be necessary. Vigorous activities restricted 2 weeks after surgery help healing & prevent injury. --------- Correct Answer ---------- Cryptorchidism: orchiopexy surgery Congenital defect involving abnormal placement urethral orifice of penis. Urethral orifice located below glans penis along ventral surface. Should not be circumcised because dorsal foreskin tissue used for surgical repair of hypospadias. --------- Correct Answer --- ------- Hypospadias Congenital defect abnormal placement urethral orifice of penis. Urethral opening located anywhere on dorsum of penis. Anatomical characteristic facilitates entry bacteria into urine. --------- Correct Answer ---------- Epispadias Chronic disability characterized by impaired muscle movement & posture --------- Correct Answer ---------- Cerebral palsy Inflammation brain occurs as a result of viral illness or central nervous system infection. --------- Correct Answer ---------- Encephalitis Infectious process central nervous system. --------- Correct Answer ---------- Meningitis Congenital condition results in moderate to severe retardation. More likely to develop acute leukemia than average child --------- Correct Answer ---------- Down syndrome Not able extend leg when thigh is flexed anteriorly at hip. Raise child's leg with knee flexed & then extend the leg at knee & assess for pain; resistance is noted or pain is felt, result is positive Kernig's sign. --------- Correct Answer ---------- Kernig's sign Neck flexion causes adduction & flexion movements lower extremities children & adolescents --------- Correct Answer ---------- Brudzinski's sign (extension) posturing characterized: rigid extension & pronation of arms & legs. Abnormal extension upper extremities with internal rotation of upper arms & wrists & extension of lower extremities with some internal rotation. Indicates damage in diencephalon, midbrain, or pons --------- Correct Answer ---------- Decerebrate posturing (flexion) posturing; Abnormal flexion of upper extremities & extension of lower extremities with possible plantar flexion of feet. Indicates lesion in cerebral hemisphere Acute, life-threatening condition occurs in uncontrollable hyperthyroidism. Systolic hypertension, tachycardia, diarrhea, & fever as high as 106° F, abdominal pain, dehydration, extreme vasodilation, stupor rapidly progressing to coma, atrial fibrillation, & cardiovascular collapse. Fever, nausea, tremors. As condition progresses they become confused. Restless, anxious & experiences tachycardia. --------- Correct Answer ---------- Thyroid storm Incretin mimetic used for type 2 diabetes mellitus only. Not recommended clients taking insulin. --------- Correct Answer ---------- Exenatide (Byetta) Rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals approximately 30 minutes before meals & should be withheld if client does not eat. Hypoglycemia is a side effect of repaglinide & client should always be prepared by carrying a simple sugar with her or him at all times. ------- -- Correct Answer ---------- Repaglinide(Prandin) Oral hypoglycemic given combination repaglinide, works decreasing hepatic glucose production. Common side effect metformin is diarrhea. Used with caution; kidney/liver disease, heart failure, chronic lung disease, history heavy alcohol consumption. --------- Correct Answer ---------- Metformin (Glucophage) Insomnia, weight loss, & mild heat intolerance side effects. Taken on empty stomach enhance absorption. Dosing morning before breakfast. --------- Correct Answer ---------- levothyroxine sodium (Synthroid) Treat hyperthyroidism, or Graves' disease. Excessive dosing may convert hyperthyroid state to hypothyroid state. If this occurs, dosage should be reduced. Adverse effect of PTU is agranulocytosis. Early signs adverse effect; fever & sore throat. --------- Correct Answer ---------- Propylthiouracil (PTU) may decrease effect oral hypoglycemics, insulin, diuretics, & potassium supplements. -- ------- Correct Answer ---------- Prednisone Severe & unrelenting, located epigastric area & radiating to back. NPO (nothing by mouth) status decrease activity of pancreas. Pain management typically administration opioids patient-controlled analgesia. Morphine or hydromorphone (Dilaudid) are typically used. Nasogastric tube insertion is done to provide suction secretions & administer medications as necessary. --------- Correct Answer ---------- Acute pancreatitis Avoid chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, & alcohol --------- Correct Answer ---------- Gastroesophageal reflux disease (GERD Inability absorb vitamin B12. This leads to development of pernicious anemia. --------- Correct Answer ---------- Chronic gastritis Nonbloody diarrhea usually not more than four to five stools daily. Over time, diarrhea episodes increase in frequency, duration, & severity. --------- Correct Answer ---------- Crohn's disease Irregular flapping movements fingers & wrists when hands & arms are outstretched, with palms down, wrists bent up, & fingers spread. --------- Correct Answer ---------- Asterixis Pain relieved by food intake. Burning, heavy, sharp, or "hungry" pain that often localizes in mid-epigastric area. 90 minutes to 3 hours after eating & often awakens client at night. --------- Correct Answer ---------- Duodenal ulcer Weight loss or nausea & vomiting. exacerbated by intake of food. Pain occurs 30-60 minutes after meal & rarely occurs at night --------- Correct Answer ---------- Gastric ulcer Bowel protrudes through stoma, causing elongated & swollen appearance to stoma ----- ---- Correct Answer ---------- Prolapsed stoma Sunken & hidden stoma (Sinking in of stoma) --------- Correct Answer ---------- Stoma retraction Frequent complication that occurs is fluid & electrolyte imbalance. I & O monitored. ------ --- Correct Answer ---------- Ileostomy Narrow opening --------- Correct Answer ---------- Stenosed Stoma Early manifestation occur 5- 30 mins after eating. Symptoms; vertigo, tachycardia, syncope, sweating, pallor, palpitations, & desire to lie down. Instruct maintain low Fowler position while eating & lie down for 30 mins after eating. Small, frequent meals best & avoid liquids with meals. Avoiding high-carbohydrate food sources also assist. --- ------ Correct Answer ---------- Dumping syndrome Immunomodulator that reduces degree inflammation in colon, reducing diarrhea --------- Correct Answer ---------- Infliximab (Remicade): Used in Crohn's disease antiemetic treat postoperative nausea/vomiting, also N&V associated with chemotherapy. --------- Correct Answer ---------- Ondansetron (Zofran) Pancreatic enzyme used as digestive aid for pancreatitis. Reduce amount fatty stools (steatorrhea). Also help improve nutritional status --------- Correct Answer ---------- Pancrelipase (Pancrease MT) Gastric protectant administered 1 hour before meals & bedtime. Timed to allow it to form protective coating over ulcer before food intake stimulates gastric acid production & mechanical irritation. --------- Correct Answer ---------- Sucralfate (Carafate) Antiulcer agent. Intended effect is relief of pain from gastric irritation, often called heartburn by clients --------- Correct Answer ---------- Omeprazole (Prilosec) Promote carbon dioxide elimination; facilitates maximal expiration with obstructive lung disease. Allows better expiration by increasing airway pressure that keeps air passages open during exhalation. --------- Correct Answer ---------- Pursed-lip breathing preoxygenate before suction & limit suction pass to 10 seconds --------- Correct Answer ---------- Suctioning Paradoxical chest movement --------- Correct Answer ---------- Suffered flail chest earliest sign is increased respiratory rate, can begin from 1 to 96 hours after initial insult to body. Followed by increasing dyspnea, air hunger, retraction accessory muscles, & cyanosis. --------- Correct Answer ---------- Acute respiratory distress syndrome Common initial symptom chest pain; sudden in onset. Next common symptom dyspnea, accompanied by increased respiratory rate. Other symptoms PE include apprehension, restlessness, tachycardia, cough, & cyanosis. --------- Correct Answer ---------- Pulmonary embolism Sitting up & leaning on overbed table, sitting up & rest elbows on knees, standing & leaning against wall. --------- Correct Answer ---------- Emphysema positions that help breathing First pulmonary manifestations cough with expectoration mucoid sputum. Sputum cultures performed every 2-4 weeks after initiation drug therapy. Return work when three sputum cultures are negative; considered noninfectious at that point. --------- Correct Answer ---------- Tuberculosis Antitubercular medication. Side effect peripheral neuritis. Symptoms; numbness, tingling, paresthesias in extremities. Minimized w/pyridoxine (vitamin B6) intake. Report yellow eyes/skin immediately. Hepatotoxic. Monitor liver enzyme first 3 months therapy. Children HIV infection who demonstrate positive Mantoux tuberculin skin test result, minimum 12 months treatment recommended. --------- Correct Answer ---------- Isoniazid Used caution impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or history seizures. Medication may increase blood glucose levels. ----- ---- Correct Answer ---------- Terbutaline: is an bronchodilator Treat bronchial asthma. Used with caution impaired hepatic function. Liver function laboratory tests should be performed and monitored with treatment. --------- Correct Answer ---------- Zafirlukast (Accolate) administered empty stomach unless it causes GI upset, & then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before. Rifampin causes Diuretic & expected outcome increased urine output, decreased crackles, & decreased weight. Can be used for client who needs diuresis. --------- Correct Answer ---------- Bumetanide Antidote is protamine sulfate; readily available to use if excessive bleeding or hemorrhage should occur. --------- Correct Answer ---------- Heparin Vitamin K is an antidote --------- Correct Answer ---------- Warfarin sodium Contraindicated number of preexisting conditions in which there is risk uncontrolled bleeding. Also contraindicated severe uncontrolled hypertension because risk cerebral hemorrhage. --------- Correct Answer ---------- Thrombolytic therapy Check patency fistula by palpating for presence of a thrill or auscultating for a bruit. ------ --- Correct Answer ---------- arteriovenous fistula for hemodialysis Symptoms: Dysuria & penile discharge. In male often results from chlamydial infection & characterized: dysuria accompanied by clear to mucopurulent discharge. Because disorder often coexists with gonorrhea, diagnostic tests done for both & include culture & rapid assays --------- Correct Answer ---------- Urethritis Symptoms: scrotal pain & edema, accompanied by fever, nausea & vomiting, chills. Often caused by infection, although sometimes by trauma. Common interventions; bed rest with bathroom privileges, elevation scrotum, ice packs, sitz baths, analgesics, & antibiotics. --------- Correct Answer ---------- Epididymitis Signs: Pallor, diminished pulse, & pain in left hand --------- Correct Answer ---------- Arterial steal syndrome from left arm fistula Creatinine level frequently used laboratory test determine renal function. Increases when at least 50% of renal function is lost. --------- Correct Answer ---------- Renal function disorder often occurs first 2 weeks after transplantation. Manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, & deteriorating renal function. --------- Correct Answer ---------- Acute rejection occurs gradually over period of months to years. --------- Correct Answer ---------- Chronic rejection characterized headache, mental confusion, decreased LOC, nausea, vomiting, twitching, & possible seizure activity. Disequilibrium syndrome is caused by rapid removal solutes from body during hemodialysis. --------- Correct Answer ---------- Disequilibrium syndrome urinary retention can be triggered by decongestants, anticholinergics, & antidepressants. Should be questioned about use of these medications if has urinary retention. Retention also precipitated by other factors, such as alcoholic beverages, infection, bed rest, & becoming chilled. --------- Correct Answer ---------- history of benign prostatic hyperplasia with an inability to void Administered with full glass of water; maintain high fluid intake. Medication is more soluble in alkaline urine. --------- Correct Answer ---------- Sulfamethoxazole May be administered IV infusion; not mixed with any other medications or solutions. Infused over 60-90 minutes, & bolus infusion or rapid infusions must be avoided. Early sign/symptom blood disorders that can occur; sore throat, fever, pallor, & instructed notify (HCP) if these occur. --------- Correct Answer ---------- Trimethoprim- sulfamethoxazole Because risk anaphylaxis during administration IV route, epinephrine & oxygen must be immediately available for use. Nephrotoxicity evaluated by monitoring elevated BUN & serum creatinine levels. Adverse effects; are nephrotoxicity, infection, hypertension, tremors, & hirsutism. Nephrotoxicity & infection are most serious. --------- Correct Answer ---------- Cyclosporine (Sandimmune) grapefruit juice inhibits metabolism. As result, consumption grapefruit juice can raise cyclosporine levels by 50% to 100%, greatly increasing risk of toxicity. --------- Correct Answer ---------- Cyclosporine (Sandimmune) Used for urinary tract infection. Imparts harmless brown color to urine --------- Correct Answer ---------- Nitrofurantoin (Furadantin) Reverse anemia associated with chronic kidney disease. Therapeutic effect seen hematocrit between 30% & 33% (Treat anemia) Medication administer subcutaneously or intravenously as prescribed. --------- Correct Answer ---------- Epoetin alfa (Epogen) Severe pain or pain accompanied by nausea is indicator increased intraocular pressure & should be reported to HCP immediately --------- Correct Answer ---------- Cataract extraction Reveals red, dull, thick, immobile tympanic membrane, with/without perforation. Postauricular lymph nodes tender & enlarged. Low-grade fever, malaise, anorexia, swelling behind ear, pain with minimal movement of head. --------- Correct Answer ------- --- Otoscopic examination with mastoiditis Painless blurring central vision is chief clinical manifestation. Early symptom include slightly blurred vision & decrease in color perception. --------- Correct Answer ---------- early stages of cataract formation Surgical removal eyeball. Presence bright red drainage on dressing,reported to HCP, indicates hemorrhage. --------- Correct Answer ---------- enucleation Sensorineural hearing loss that occurs with aging. --------- Correct Answer ---------- Presbycusis Right eye tested, then left eye, & then both eyes tested. Visual acuity measured with or without corrective lenses & at distance 20 feet from chart. --------- Correct Answer -------- -- Snellen chart Vision 20/20 normal; client able read from 20 feet what person with normal vision can read from 20 feet. Visual acuity 20/60 can read distance of 20 feet what person with normal vision can read at 60 feet. --------- Correct Answer ---------- Snellen chart Wash hands & put gloves on. Tilt head backward, open eyes, & look up. Nurse pulls lower lid down against cheekbone & holds bottle like pencil with tip downward. Nurse gently rests wrist of hand on cheek & squeezes bottle gently to allow drop to fall into conjunctival sac. Instructed close eyes gently & not to squeeze eyes shut to prevent loss of medication. --------- Correct Answer ---------- Administer eye medications Steps Contraindicated for gastrointestinal bleeding & potentially ototoxic. Mild intoxication with acetylsalicylic acid (aspirin) called salicylism. Tinnitus (ringing in the ears) is most frequent effect noted with intoxication --------- Correct Answer ---------- Acetylsalicylic acid (aspirin) Nail bed pressure tests --------- Correct Answer ---------- Unconscious patient test client's peripheral response to pain Tested using sternal rub, placing upward pressure orbital rim, or squeezing clavicle or sternocleidomastoid muscle. --------- Correct Answer ---------- Unconscious patient Cerebral responses to pain Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure --------- Correct Answer ---------- Vital signs if the intracranial pressure is rising weakness one side body may occur after stroke. Involves weakness face, tongue, arm, & leg on one side. Also aphasic: unable to discriminate words & letters. Generally cautious & anxious when attempting new task. Right-sided hemiparesis has weakness right arm, leg & needs assistance with feeding, bathing, & ambulating. --------- Correct Answer ---------- Hemiparesis Loss of half visual field. Objects placed in intact field vision, & also should approach from intact side. Instructs to scan environment to overcome visual deficit & client teaching from within intact field vision. Encourage use personal eyeglasses, if available. --------- Correct Answer ---------- Homonymous hemianopsia Tricyclic antidepressant treat obsessive-compulsive disorder. Sedation sometimes occurs. Weight gain & tachycardia side /adverse effects of medication. --------- Correct Answer ---------- Clomipramine (Anafranil); treats OCD Seizure activity can occur taking dosage greater 450 mg daily. Weight gain occasional side effect, constipation common side effect. --------- Correct Answer ---------- Bupropion (Wellbutrin); antidepressive agent Excitement, euphoria, hyperactivity, excessive energy, decreased need sleep, impaired ability concentrate or complete single train of thought. Mood predominantly elevated, expansive, or irritable. Nonstop physical activity & poor nutritional intake problem. -------- - Correct Answer ---------- Mania Treat hypoglycemia because it increases blood glucose levels. Family instructed how to administer. Unconscious client, arousal usually occurs within 20 min glucagon injection. When consciousness regained, oral carbohydrates should be given. --------- Correct Answer ---------- Glucagon Mild cognitive deficits to severe, life-threatening alteration neurological function. Confabulation or fabrication events/experiences fill in memory gaps not unusual. Lack inhibitions first indication something "wrong" to significant others. As progresses; difficulty sleeping & episodes wandering/sun downing --------- Correct Answer ---------- Dementia Desire please others. Need to be correct or perfect interferes with rational decision- making processes. Moralistic. Rules & rituals help manage anxiety. Observe rigid rules/regulations --------- Correct Answer ---------- Anorexia nervosa Best absorbed taken empty stomach with water or vitamin C containing juice. Iron supplements usually cause constipation. Meats excellent source iron. Pregnant client take iron supplements regardless of food intake --------- Correct Answer ---------- Iron supplementation If taken with Warfarin sodium; decreased dosage of warfarin. --------- Correct Answer ---- ------ Levothyroxine (Synthroid); prescribed for Hypothyroidism Head neutral, midline position. Head of bed raised to 30 to 45 degrees. Avoid flexing or extending neck or turning head from side to side. --------- Correct Answer ---------- Basilar skull fracture risk Increase ICP. Place in which positions? Operative positioned elevated on pillow & not exceeding shoulder elevation. Promotes optimal drainage from limb, without impairing circulation to arm. --------- Correct Answer ---------- After undergoing right mastectomy. Place right arm in which position? Acts more rapidly than regular insulin, shorter duration action. Effect begin 25 minutes after subcutaneous injection, peak 0.5 to 1.5 hours, & duration action 5 hours. Because rapid onset, administered 15 minutes to immediately before eating. --------- Correct Answer ---------- Lispro insulin (Humalog) Onset action is 1.5 hours, peaks 4 to 12 hours, & duration action 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time. --------- Correct Answer ------ ---- Humulin N is an intermediate-acting insulin Discontinue wearing contacts until infection cleared completely. New contact lenses eliminate chance reinfection from contaminated contact lenses & would lessen risk corneal ulceration. --------- Correct Answer ---------- Conjunctivitis & use of contact lenses Endoscopic procedure surgically remove pituitary tumor through incision in the sphenoid sinus. Brushing teeth not be permitted for at least 2 weeks after surgery to prevent disruption of surgical site. --------- Correct Answer ---------- Transsphenoidal hypophysectomy Sometimes age has to do with decision for radiation therapy. Usually delayed until child 8 years old, whenever possible, prevent retardation of bone growth & soft tissue development. --------- Correct Answer ---------- Radiation therapy Achieved by Ace wraps, boots, & slings that apply direct force on skin. Traction maintained with 5 to 8 lb of weight, & this type of traction can cause skin breakdown. ---- ----- Correct Answer ---------- Skin traction Person puts another person in fear of harmful or offensive contact & victim fears & believes that harm will result as a result of threat. --------- Correct Answer ---------- Assault Most common side effect GI disturbances, including decreased appetite, nausea, & diarrhea. These generally subside over time. May lose average of 7-8 lb because medication causes nausea & decreased appetite. --------- Correct Answer ---------- Metformin (Glucophage); Type II Diabetes Nocturia, incontinence, & enlarged prostate characteristics & need to be assessed all male clients over 50 years of age. Nocturnal emissions are commonly associated with prepubescent males. --------- Correct Answer ---------- Benign prostatic hyperplasia For hypothyroidism; Achieve normal thyroid hormone levels --------- Correct Answer ----- ----- Levothyroxine (Synthroid) Early menarche, Family history breast cancer, High-dose radiation exposure to chest, Previous cancer of breast, uterus, or ovaries --------- Correct Answer ---------- Risk factors for breast cancer Most common form nonmechanical obstruction, Inability to pass flatus, pain usually manifests as more constant generalized discomfort. --------- Correct Answer ---------- Paralytic ileus Respiratory rate & depth increase to compensate. Headache; restlessness; mental status changes, drowsiness & confusion. Visual disturbances; diaphoresis; cyanosis as hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; & dysrhythmias ------ --- Correct Answer ---------- Respiratory acidosis Elevates head of bed maintain airway patency & prevent aspiration. Apply pressure over bleeding site & call HCP immediately. Monitors airway & vital signs. --------- Correct Answer ---------- Hemorrhage from surgical site after radical neck dissection Decreased metabolism low levels of thyroid hormone. Interventions replace hormone. Cold intolerance, requires warm environment. Well-balanced diet low in fat for weight reduction & high in fluids & high-fiber foods to prevent constipation. Notify HCP chest pain because could indication overreplacement thyroid hormone. --------- Correct Answer ---------- Hypothyroidism Provide warm environment, consume low-fat diet, well balanced diet, thyroid replacement therapy will be needed. --------- Correct Answer ---------- Hypothyroidism Hypertension, cardiovascular disease, diabetes mellitus, & obesity associated with development --------- Correct Answer ---------- Glaucoma Labs do not establish diagnosis but often an elevation white blood cell count (leukocytosis) with shift to left (increased number of immature white blood cells). Sudden relief pain; suspected appendicitis is commonly indicative of ruptured appendix. Risk for peritonitis & shock. HCP notified immediately because need begin IV antibiotics to prevent further complication. NPO in anticipation of surgery. --------- Correct Answer -- -------- Appendicitis Decrease amount of food taken at each sitting, eat in semirecumbent position, eliminate ingesting fluids with meals, & avoid consumption of high-carbohydrate meals. --------- Correct Answer ---------- Chronic dumping syndrome Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, (NSAIDs), caffeine, alcohol, & stress. Certain medical conditions; Crohn's disease, Zollinger-Ellison syndrome, & hepatic & biliary disease can increase risk. ------- -- Correct Answer ---------- Peptic ulcer disease risk factors Inflammatory disease large colon. Symptom: diarrhea, 10-20 liquid bloody stools per day, weight loss, anorexia, fatigue, increase WBC count, increase erythrocyte sedimentation rate, dehydration, hyponatremia, & hypokalemia. Because loss of blood, decreased hemoglobin & hematocrit levels. Rebound tenderness may indicate peritonitis; report to HCP. --------- Correct Answer ---------- Ulcerative colitis Appearance jaundice & associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, & clay-colored stools --------- Correct Answer ---------- Three stages associated with viral hepatitis. Second (icteric) stage Jaundice decreases & colors of urine & stool return to normal. --------- Correct Answer -- -------- Three stages associated with viral hepatitis. Third (posticteric) stage Contraindicated patient with renal impairment (Renal disease) --------- Correct Answer -- -------- Nitrofurantoin (Macrobid With food can cause N&V. Avoid problem, oral dose administered 1 hour before meals or 2 hours after meals. --------- Correct Answer ---------- Bethanechol chloride (Urecholine) Painless vision changes & "tunnel vision. --------- Correct Answer ---------- Primary open- angle glaucoma (POAG) Vitamin C (ascorbic acid) increases absorption iron by body. (Orange Juice) --------- Correct Answer ---------- Oral iron supplements Enhances reabsorption sodium & chloride ions distal tubules of kidney & excretion potassium & hydrogen ions. Promote water retention. --------- Correct Answer ---------- Fludrocortisone acetate (Florinef); prescribed for Addison's disease Communicable period 4 days before to 5 days after rash appears. Small blue-white spots with red base may appear in mouth; Koplik's spots. Respiratory symptoms; profuse runny nose, cough, & fever occur before rash. Rash usually begins on face & spreads downward toward feet --------- Correct Answer ---------- Rubeola (measles) Transmitted direct contact with or droplet spread from infected person. Droplet precautions indicated during period communicability (immediately before & after swelling begins) --------- Correct Answer ---------- Mumps Transmitted direct contact, droplet (airborne) spread, & contaminated objects. Communicable period for 1 to 2 days before onset rash to 6 days after first crop of vesicles, when crusts have formed. --------- Correct Answer ---------- Chickenpox Pastia's sign, White strawberry tongue, Edematous & beefy-red pharynx. --------- Correct Answer ---------- Scarlet fever Positive antibody test child younger 18 months age indicates only mother infected because maternal antibodies persist infants for 6-9 months &, in some cases, as long as 18 months. Positive ELISA does not indicate true HIV infection or development AIDS, nor does it indicate that newborn will develop AIDS later in life --------- Correct Answer -- -------- Enzyme-linked immunosorbent assay (ELISA) Treat developmental dysplasia hip. Provides support & stability hips. Worn 16-23 hours day; removed only check skin & for bathing. Infant may be moved when out of harness, but hips & buttocks should be supported carefully. Harness does not need to be removed for diaper changes or feedings. --------- Correct Answer ---------- Pavlik harness Activity limited, most children because of fatigue, voluntarily restrict their activities during active phase of disease. Catheterization may cause infection. Child should be allowed to express feelings with play. Visitors limited to allow for adequate rest. --------- Correct Answer ---------- Acute glomerulonephritis Bladder exposed & external to body through a defect in lower abdominal wall . Highest priority impaired tissue integrity related to exposed bladder mucosa. --------- Correct Answer ---------- Bladder exstrophy Medication treat lead poisoning. Renal function (BUN & creatinine) is monitored closely during administration chelation therapy because excreted via kidneys. --------- Correct Answer ---------- Succimer (Chemet) Bowel herniates through defect abdominal wall to right of umbilical cord. No membrane covering exposed bowel. Surgical repair done as soon as possible because risk infection in unprotected bowel. Highest risk immediately after delivery is infection --------- Correct Answer ---------- Gastroschisis Antiviral respiratory medication used mainly for hospitalized children with severe RSV. Administration via hood, face mask, or oxygen tent. --------- Correct Answer ---------- Ribavirin (Virazole) Involves history & physical exam limited to specific problem, client complaint & most often used in walk-in clinic or ED --------- Correct Answer ---------- Focused assessment Assessment finding include difficulty walking/sitting; torn, stained, bloody underclothing; pain, swelling, itching of genitals; & bruises, bleeding, lacerations in genital or anal area. --------- Correct Answer ---------- Sexually abused child Consist twitching of extremity, face, or neck, or sensation of twitching or numbness in extremity or face or neck --------- Correct Answer ---------- Simple partial seizures Brief random contractions of muscle group that can occur on one or both sides of body. --------- Correct Answer ---------- Myoclonic seizure Brief episodes altered awareness or momentary LOC. No muscle activity occurs except eyelid fluttering or twitching. Blank facial expression. Seizures last only 5 to 10 seconds, but may occur one after another several times a day --------- Correct Answer ---------- Absence seizures Decreased stomach-emptying time & lowered basal metabolic rate cause constipation. Adequate dietary fiber aid bowel function. Dietary fiber increases fecal weight & water content & accelerates transit fecal mass through GI tract. Retention of water by fiber has ability soften stools & promote regularity. Fluid intake & exercise facilitate bowel elimination. --------- Correct Answer ---------- Older client has an increased tendency to experience constipation Magnesium sulfate is anticonvulsant, goal of care directed preventing eclampsia (seizures). --------- Correct Answer ---------- woman with preeclampsia is receiving magnesium sulfate Surfactant replacement exogenous surfactant preparation instilled into lungs through endotracheal tube. --------- Correct Answer ---------- Respiratory distress syndrome diagnosed, surfactant replacement therapy prescribed. Route used to administer this medication? Place newborn flat surface. Striking surface or making loud, abrupt noise startle newborn. Assumes sharp extension & abduction of arms with thumbs & forefingers in a C position; followed by flexion & adduction to an "embrace" position (legs follow a similar pattern). Moro reflex present at birth & absent by 6 months age if neurological maturation is not delayed. Persistent response lasting more than 6 months may indicate a neurological abnormality. --------- Correct Answer ---------- The Moro reflex Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, & shoulder dystocia can place at risk --------- Correct Answer ---------- Traumatic uterine rupture Expulsion placenta with fetal side presenting first. --------- Correct Answer ---------- Schultz presentation Type cutaneous stimulation involving light stroking abdomen used before transition promote relaxation & relieve mild to moderate pain. Effleurage also provides tactile stimulation to fetus. Massaging abdomen during contractions, using both hands in circular motion. --------- Correct Answer ---------- Effleurage Clear & maintain open airway. first action during seizure (eclampsia) is to ensure patent airway --------- Correct Answer ---------- If progresses from preeclampsia to eclampsia, nurse should take which first action? Leafy green vegetables are rich in folate (folic acid) --------- Correct Answer ---------- Identifying food highest in folic acid. Monitoring only; fetus is not challenged or stressed by uterine contractions. Ultrasound transducer records fetal heart activity secured over abdomen, Fetal heart activity & movements are recorded. --------- Correct Answer ---------- Nonstress test Short nipple on bottle, & give baby food or baby food mixed with water. Straws, pacifiers, spoons, fingers must be kept away from mouth 7-10 days after surgery. Pacifier not used 2 weeks following repair. Avoid taking oral temperatures. --------- Correct Answer ---------- Child with cleft palate repair Treat Scabies; can penetrate intact skin & cause seizures if absorbed in sufficient quantities. Preexisting seizure disorder at high risk. Not be used pediatric client unless safer medications failed control infection --------- Correct Answer ---------- Lindane Medication used to treat known or suspected ethylene glycol (antifreeze) intoxication. Administered IV route. Diluted in at least 100 mL 0.9% normal saline or 5% dextrose in water & administered over 30-min period. --------- Correct Answer ---------- Fomepizole (Antizol) Angiotensin II type 1 receptor antagonist. Used for hypertension. --------- Correct Answer ---------- Irbesartan (Avapro) Palliative treatment advanced breast cancer postmenopausal woman with disease progression after treatment with antiestrogen therapy. --------- Correct Answer ---------- Letrozole (Femara) Treat idiopathic parkinsonian syndrome. Normally administered three times day to treat client. --------- Correct Answer ---------- Ropinirole hydrochloride (Requip) Relieve mild/moderate manifestations that occur in benign prostatic hypertrophy. Also improves urinary flow rates. Treat Urinary obstruction. Administered 30 minutes after meals. --------- Correct Answer ---------- Tamsulosin hydrochloride (Flomax) Vomit contains sour undigested food without bile, & constipation --------- Correct Answer ---------- Pyloric stenosis Therapeutic range 4-8 mg/dL. Signs toxicity include CNS depression. Maintain respiratory rate at or greater 16 bpm (or agency protocol), maintain presence deep tendon reflexes, & urinary output greater 30 mL/hour. Toxic effects may cause loss of deep tendon reflexes, heart block, respiratory paralysis, & cardiac arrest. Antidote magnesium sulfate is Calcium Gluconate. --------- Correct Answer ---------- Magnesium sulfate Produces flushing/sweating owing to decreased peripheral blood pressure. Decreases central nervous system activity, acting as anticonvulsant, & decreases frequency & duration uterine contractions. Decreases acetylcholine, blocking neuromuscular transmission. --------- Correct Answer ---------- Magnesium sulfate Assesse five parameters fetal activity: fetal heart rate, fetal breathing movement, gross fetal movemens, fetal tone, amniotic fluid volume. Each five parameters contribute 0-2 points, 8 considered normal, 10 perfect. Result available immediately. --------- Correct Answer ---------- Biophysical profile Calcium present in dark green leafy vegetables, broccoli, legumes, nuts, & dried fruits. - -------- Correct Answer ---------- Pregnant client lactose intolerance manifests with bleeding with odor, cervical dilation, and fever. Cramping may or may not be present. --------- Correct Answer ---------- Septic Abortion Termination pregnancy that cannot be prevented. Moderate/severe bleeding with mild cramping & cervical dilation noted in this type of abortion. --------- Correct Answer -------- -- Inevitable abortion Heavy bleeding, severe cramping, cervical dilation, & passage large clots. --------- Correct Answer ---------- Incomplete abortion Slight/moderate bleeding, intermittent cramping without dilation. --------- Correct Answer ---------- Threatened abortion Maternal infection; syphilis, toxoplasmosis, & rubella are causes. --------- Correct Answer ---------- Spontaneous abortion Nursing care: Preventing/identifying hypovolemic shock & controlling pain. Elevated pulse rate; indicator shock. β-hCG present but at lower levels --------- Correct Answer --- ------- Ectopic pregnancy Increase Risk factor; obesity (more than 198 pounds, depending on height), chronic hypertension, family history DM, previous birth large infant (greater 4000 g), & gestational diabetes previous pregnancy. Glucose crosses placenta; insulin does not. High fetal demands glucose, combined with insulin resistance caused by hormonal changes last half pregnancy, result elevation maternal blood glucose levels. Increases demand for insulin. Referred to as diabetogenic effect pregnancy. --------- Correct Answer ---------- Gestational diabetes Symptom; vaginal bleeding, excessive N&V, larger-than-normal uterus for gestational age, elevated levels hCG, failure detect fetal heart activity even with sensitive instruments, early development gestational hypertension. Fetal activity not noted. -------- - Correct Answer ---------- Gestational trophoblastic disease (Hydatidiform mole) Infant: Trust versus Mistrust Toddler: Autonomy versus Shame & Doubt stage. Develops sense control over self & bodily functions. . Preschool age: Initiative versus Guilt. school-aged child: Industry versus Inferiority --------- Correct Answer ---------- Erikson's psychosocial stages of development Homes older than 25 years may have lead paint & will most likely have lead pipes, which can contribute to lead poisoning. --------- Correct Answer ---------- Lead poisoning Remove toys with sharp edges that may cause injury from play area. Wear a helmet and elbow pads during activities that could cause injury. Activities should be monitored. --------- Correct Answer ---------- Child hemophilia; safe environment Condition after childbirth; uterus does not return to normal size. Retained placental fragments & infection primary cause. When either of these processes present, uterus will have difficulty contracting. --------- Correct Answer ---------- Subinvolution Green leafy vegetables, whole grains, fruits, liver, dried peas, & beans. --------- Correct Answer ---------- Folic acid food items Two arteries carry blood from embryo to chorionic villi & one vein that returns blood to embryo. --------- Correct Answer ---------- Umbilical cord Crackers, Melba toast, dry cereal at bedside; eat before getting up in morning; eating smaller more frequent meals; decreasing fats; & consuming adequate fluid between meals but not with meals. High-carbohydrate diet could increase episodes nausea. ------ --- Correct Answer ---------- Decreasing morning nausea in pregnancy Antispasmodic medications; used as treatment for Bladder spasm after prostatectomy. - -------- Correct Answer ---------- Oxybutynin (Ditropan) Problem with constipation; result of fluid restriction, fatigue that limits exercise, dietary restrictions. Also phosphate-binding antacids such as aluminum hydroxide gel cause constipation as side effect. Weight gain between dialysis treatments ideally no more than 1 to 1.5 kg. Potentially life-threatening outcomes associated with hyperglycemia, hyperkalemia, & hypocalcemia, they are most relevant to nursing management of client with CKD --------- Correct Answer ---------- Chronic kidney disease (CKD) Risk factors; DM, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities urinary tract, presence urinary stones, & presence indwelling urinary catheter or frequent catheterization. --------- Correct Answer ---------- Pyelonephritis Refrigeration preserves elements of urine. If stands room temperature, warmth causes bacteria & WBCs to decompose. Also, urea breaks down to ammonia & becomes more alkaline. pH decreases in an acidic condition. --------- Correct Answer ---------- Urine specimen put in lab refrigerator because? Start test empty bladder. Collected urine refrigerated or placed on ice to prevent change in urine. Fifteen mins before end collection time, should be asked to void, & this specimen added to collection. --------- Correct Answer ---------- 24 hour urine Neutropenia most serious adverse effect. Baseline (CBC) count with differential performed. Neutropenia occurs often first 3 months therapy; CBC with differential recommended every 2 weeks during first 3 months. If diagnosis neutropenia determined, will be withdrawn from therapy. Used prevent stroke & not contraindicated in hypertension. GI disturbances can occur & instruct take with food to minimize these side effects. --------- Correct Answer ---------- Ticlopidine (Ticlid) Symptoms; delay uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, temp elevation up to 104° F. Intrauterine infection may lead to further maternal complications. infections; fallopian tubes, ovaries, & blood (sepsis). Care; Maintaining adequate hydration (3000-4000 mL/day), bed rest Fowler's position facilitate drainage & lessen congestion, provide appropriate analgesia lessen pain, & administering antibiotics prescribed. --------- Correct Answer ---------- Postpartum endometritis Early signs; Nocturia, decreased force urinary stream, & difficulty initiating urinary stream. --------- Correct Answer ---------- Prostatic hyperplasia (BPH) Humulin R drawn up before Humulin N insulin, & can be drawn into same syringe. Usually administered 15-30 mins before meal. To mix Humulin N insulin suspension, vial should be gently rotated. Shaking introduces air bubbles into solution. --------- Correct Answer ---------- Insulin Inside container is sterile. Fingers touching inside container, cause container to become unsterile. Meatus cleansed front to back (toward anus). Labia should remain open during procedure. If allowed to close, tissue will have to be cleansed again with antiseptic pads. Should void small amount intoilet before urinating into specimen container allow some of organisms near meatus to leave area. --------- Correct Answer -- -------- Midstream urine specimen Antidepressant treatment of major depression. --------- Correct Answer ---------- Paroxetine hydrochloride (Paxil) Removal of gallbladder. Teach coughing & deep breathing exercises afterwards because respiration tend to be shallow because deep breathing painful as result location for surgical procedure. --------- Correct Answer ---------- Cholecystectomy First 4-6 weeks after colostomy formation, should consume low-fiber diet. After this period, should eat high-carbohydrate, high-protein diet. Also instruct add new foods, including those with fiber, one at a time to determine tolerance to that food. --------- Correct Answer ---------- New colostomy Prescribed diet; low fiber & does not include milk. Help reduce frequency of diarrhea. --- ------ Correct Answer ---------- Acute ulcerative colitis caused decreased absorption vitamin K in intestine with decreased production prothrombin by liver. --------- Correct Answer ---------- Prolonged prothrombin time ET tube suctioned first, & then cuff is deflated & tube is removed. --------- Correct Answer ---------- Removal endotracheal (ET) tube Water or a kink in tubing, biting on ET tube, increased secretions airway, wheezing or bronchospasm, displacement ETl tube, or fighting ventilator. --------- Correct Answer ----- ----- Causes high-pressure ventilator alarm Disconnection or leak in system & ceasing to spontaneously breathe --------- Correct Answer ---------- Causes low-pressure ventilator alarm Adverse effects include; cyanosis, excessively rapid/slow heart rate, & sudden development bloody secretions. If any of these signs observed, immediately stop suctioning & report adverse effect to HCP. Coughing normal response suctioning ,with intact cough reflex & does not indicate cannot tolerate procedure. --------- Correct Answer ---------- Nasotracheal suctioning Suction equipment kept bedside of unconscious client, regardless if artificial airway used. Auscultates breath sounds every 2-4 hours, or more frequently. Hyperoxygenated before, during, & after suctioning minimize cerebral hypoxia. Intermittent suction applied while catheter withdrawn. Suctioning not performed longer than 10 seconds at one time; prevent cerebral hypoxia & rise in intracranial pressure. --------- Correct Answer ---------- Suctioning unconscious client with tracheostomy Integrase inhibitor & acts by inhibiting human immunodeficiency virus (HIV) replication. Side effects include itching, nausea & diarrhea, headache, & fatigue. Temperature of 101.2° F indicative potential infection, adverse effect of this medication. --------- Correct Answer ---------- Raltegravir (Isentress) Family member/others close contact client TB placed on prophylactic therapy; isoniazid 6-12 months. Client usually not contagious after taking med 2-3 consecutive weeks. Must take full course therapy (6 month or longer) prevent reinfection/drug-resistant tuberculosis. Signs & symptoms that have been present for weeks or even months. Include fatigue, lethargy, chest pain, anorexia & weight loss, night sweats, low-grade fever, & cough with mucoid or blood-streaked sputum. --------- Correct Answer ---------- Tuberculosis (Antihistamine)Side effect; drowsiness/sedation, blurred vision, hypertension & sometimes hypotension, dry mouth, constipation, urinary retention, & sweating --------- Correct Answer ---------- Brompheniramine maleate (BroveX) Signs opioid withdrawal; increase temp & BP, abdominal cramping, vomiting, restlessness. Time onset few minutes to few hours after admin of naloxone hydrochloride, depending on opioid involved, degree of dependence, & dose of naloxone. Should be titrated every 2 to 5 minutes according to client response. --------- Correct Answer ---------- Naloxone hydrochloride (Narcan) Administered 1 hour before or 2 hours after meals; food can hamper absorption. Normal dosage 400 mg orally twice daily for 7 to 10 days for mild infections or 10 to 21 days for severe infections. --------- Correct Answer ---------- Norfloxacin (Noroxin) Treats UTI; under acidic conditions, decomposes into ammonia & formaldehyde. Formaldehyde denatures bacterial proteins, causing death of organism. --------- Correct Answer ---------- Methenamine (Mandelamine) Adverse effect hypertension. Occasionally tachycardia may occur. Medication may cause improved sense well-being. Takes 2-6 weeks therapy before significant increase hematocrit observed. Not intended client require immediate correction severe anemia, & not substitute for emergency blood transfusions. Administered parenterally by intravenous or subcutaneous route. Should be refrigerated at all times. --------- Correct Answer ---------- Epoetin alfa (Epogen, Procrit) Aluminum-containing antacids constipating, take stool softener or additional bulk-type laxatives relieve side effect. Chew tablets thoroughly & follow with 4 oz of water. --------- Correct Answer ---------- Aluminum hydroxide (Amphojel) Iron supplement treat anemia. Constipation; side effect associated with administration oral iron supplements. Stool softeners prescribed prevent constipation. Instructed to take medication with orange juice or tomato juice. --------- Correct Answer ---------- Ferrous sulfate (Feosol) Alternative med to cyclosporine (Sandimmune) prevention organ rejection after transplantation. More effective than cyclosporine but more toxic. Concurrent use Prednisone; glucocorticoids recommended during administration. --------- Correct Answer ---------- Tacrolimus (Prograf) Immunosuppressant. Potentially fatal anaphylactic reactions can occur. Manifestations; pulmonary edema, cardiovascular collapse, & cardiac or respiratory arrest. Assessing lung sounds priority. --------- Correct Answer ---------- muromonab-CD3 (Orthoclone OKT3) Cannot maintain hands supinated position with arms extended & eyes closed. Assessment may be done to detect small changes muscle strength that might not otherwise be noted. --------- Correct Answer ---------- Pronator drift Presence involuntary rapid eye movements. Abnormal finding that may occur as result of disease or as a side effect of some medications. --------- Correct Answer ---------- Nystagmus Excessive reflex action. --------- Correct Answer ---------- Hyperreflexia Must inspect environment for safety hazards. Avoiding prolonged sitting & standing. Loosen brace during meals & for 30 minutes after each meal. May have difficulty eating if brace too tight. Loosening brace after each meal will allow adequate nutritional intake & promote comfort. --------- Correct Answer ---------- Spinal fusion & wearing a brace Medication prescribed; Lactulose hyperosmotic laxative agent has adjunct benefit lowering serum ammonia levels. --------- Correct Answer ---------- Hepatic encephalopathy Use 500 to 1000 mL warm tap water. Suspended 18 inches above stoma. Cone is inserted 2-4 inches into stoma but never be forced. Cramping occurs, decrease flow rate irrigant as needed by closing irrigation clamp. --------- Correct Answer ---------- Procedure colostomy irrigation When receiving ribavirin, exposure precautions observed. Anyone entering room wear a gown, mask, gloves, & hair covering. Pregnant or considering pregnancy & anyone with history respiratory problems or airway disease should not care for or visit receiving ribavirin. Hand washing absolutely necessary before leaving room prevent spread of germs. --------- Correct Answer ---------- Infant respiratory syncytial virus infection receiving ribavirin (Virazole) Swelling occurs when infant cries or strains. --------- Correct Answer ---------- Inguinal hernia Normal sugar in the blood. Use glycosylated hemoglobin assay to measure glucose molecules that attach to the hemoglobin A molecules & remain there for life of red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Glycosylated hemoglobin (hemoglobin A1c) --------- Correct Answer --------- - Euglycemia Humidifier help liquefy secretions & promote drainage. Consumption large amounts fluids important to help liquefy secretions. Sleeping head of bed elevated to 45-degree angle will assist in promoting drainage. Apply heat in form of wet packs over affected sinuses to promote comfort & help resolve the infection. --------- Correct Answer ---------- Acute sinusitis Advance diet from cool clear liquids to full liquids. Hot fluids & carbonated beverages avoided because irritating to throat. Milk & milk products (pudding) avoided because they may cause to cough; could cause pain at surgical site. Raw fruits or vegetables, avoided for 10 days protect operative site & prevent bleeding. Instructed to rest in bed or on couch for 24 hours after & gradually resume full activity. --------- Correct Answer --- ------- After tonsillectomy Avoid cigarette smoking, alcohol consumption, exposure airborne carcinogens, & vocal abuse. Schedule routine physical examinations. Seek medical care if difficulty swallowing, persistent hoarseness, enlarged lymph nodes in neck, or unexplained weight loss occurs. --------- Correct Answer ---------- Laryngeal cancer Informed consent; procedure is invasive. Test take 15 to 60 minutes. No dietary restrictions after test. Encouraged consume fluids. Bed rest after test. During procedure fetal position. After procedure flat positio for at least 2 hours.n. If able prone position with pillow under abdomen best position. Helps reduce cerebrospinal fluid leakage & decreases likelihood of post-lumbar puncture headache. Liberal fluid intake encouraged replace cerebrospinal fluid removed, unless contraindicated by client's condition. Checks puncture site for redness & drainage & assesses ability to void & move extremities. --------- Correct Answer ---------- Lumbar puncture Purpose of test is provide information about blood vessels. --------- Correct Answer ------- --- Digital subtraction angiography study Flat position 45 to 60 minutes. Painless test & contrast dye may or may not be used. No dietary restrictions necessary. May damage items such as credit cards & watches & jewelry & hair clips cause artifacts. These should be removed before test. --------- Correct Answer ---------- Magnetic resonance imaging (MRI) Ice applied affected joint; pain & swelling, & analgesics administered as prescribed. Avoid excessive use of joint for several days, elevate knee while sitting, avoid twisting knee, & return for suture removal in 7 days. --------- Correct Answer ---------- Arthroscopy of knee Skeletal muscle relaxant & can cause liver damage; Monitor results liver function studies. Discontinued if no relief spasticity achieved in 6 weeks. --------- Correct Answer ---------- Dantrolene (Dantrium) Gold preparation given orally rather than injection. (GI) reaction including diarrhea, abdominal pain, nausea, & loss of appetite common early therapy but subside first 3 months. Early signs & symptoms toxic reactions; rash, purple blotches, pruritus, mouth lesions, & metallic taste in mouth. Signs & symptoms toxic reactions reported HCP. ----- ---- Correct Answer ---------- Auranofin (Ridaura) Skeletal muscle relaxant. Acts at spinal cord level decrease frequency & amplitude of muscle spasms in clients with spinal cord injuries or diseases or with multiple sclerosis. Can cause urinary retention. Constipation is an adverse effect. Fatigue is CNS effect most intense during early phase therapy & diminishes with continued medication use. --- ------ Correct Answer ---------- Baclofen (Lioresal) Treat scabies, Massaged into skin entire body, starting with chin & work downward. Head & face are treated only if needed. Special attention should given skin folds & creases. Contact eyes, mucous membranes, & any region inflammation should be avoided. Second application made 24 hours after first. Cleansing bath shouldtaken 48 hours after second application; if needed, treatment can be repeated 7 days. --------- Correct Answer ---------- Crotamiton (Eurax) Diispensed as powder reconstituted IV administration & slow IV infusion over 1 hour. To minimize risk renal damage, should be hydrated during infusion & for 2 hours after infusion. Common adverse reaction are phlebitis & inflammation at IV site, reversible nephrotoxicity, evidenced by elevated serum creatinine & BUN can occur. Ccause of nephrotoxicity is deposition of acyclovir in renal tubules. Risk renal injury is increased by dehydration & use of other nephrotoxic medications --------- Correct Answer ---------- Acyclovir (Zovirax) by (IV) route Active against RSV, influenza virus types A & B, & herpes simplex virus. Administered oral inhalation. Absorbed from lungs & achieves high concentrations respiratory tract secretions & erythrocytes. --------- Correct Answer ---------- Ribavirin (Virazole) Administered empty stomach with full glass water (1 hour before or 2 hours following ingestion of food). --------- Correct Answer ---------- Erythromycin (E-mycin). Can produce a cholinergic reaction & antidote for this type reaction is atropine sulfate. -- ------- Correct Answer ---------- Bethanechol chloride Atropine sulfate should be available because it is antidote --------- Correct Answer -------- -- Enlon (Tensilon) test Antidote for cholinergic crisis. Anticholinergic ; Causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, & urinary retention. Monitors for any of these effects in immediate postoperative period. --------- Correct Answer ---------- Atropine sulfate Target range therapeutic serum level of phenytoin between 10 & 20 mcg/mL. Below 10 mcg/mL too low control seizures. Above 20 mcg/mL, signs toxicity appear. IV admin performed slowly (no faster 50 mg/min) rapid administration can cause cardiovascular collapse. Monitors CBC because hematological effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, & thrombocytopenia. (Antiseizure medication (specifically phenytoin) taken during pregnancy is known risk factor in development of cleft lip & cleft palate) --------- Correct Answer ---------- Phenytoin (Dilantin) Naloxone (Narcan) opioid antagonist used treat opioid overdose. --------- Correct Answer ---------- Morphine sulfate Stop ongoing migraine attack; & treat cluster headaches. --------- Correct Answer --------- - Ergotamine tartrate (Cafergot) Client on bed rest who requires range-of-motion (ROM) exercises every 4 hours --------- Correct Answer ---------- Registered nurse is planning client assignments for day. Which is most appropriate assignment for the unlicensed assistive personnel (UAP)? Contraindicated clients glaucoma. Mydriatic medications dilate pupil & cause increased intraocular pressure in eye. --------- Correct Answer ---------- Atropine sulfate Tuning fork needed to perform test --------- Correct Answer ---------- Weber test Used treatment of cardiogenic shock; most effective instituted early. Contraindicated with aortic insufficiency & thoracic & abdominal aneurysms. --------- Correct Answer ------ ---- Intra-aortic balloon pump (IABP) therapy Found to be protein marker detection myocardial infarction, & assay for this protein used some institutions to aid in diagnosis of myocardial infarction. --------- Correct Answer ---------- Cardiac troponin T or cardiac troponin I Late sign increased ICP & consists of widening pulse pressure (systolic pressure rises faster than diastolic pressure) & bradycardia. --------- Correct Answer ---------- Cushing's reflex Contraindications performing test; cervical-level spinal cord injuries & severely increased intracranial pressure. Unconscious client, eye movements indication brainstem activity, doll's-eyes maneuver intact, eyes move opposite direction when head turned. Abnormal responses; movement eyes same direction as for head & maintenance midline position of eyes when head turned. Abnormal response indicates disruption processing information through brainstem. --------- Correct Answer ---------- Oculocephalic response (doll's-eyes maneuver) Results from long-term alcohol abuse --------- Correct Answer ---------- Laennec's cirrhosis Prescribed for portosystemic encephalopathy. Broad-spectrum antibiotic destroys normal bacteria found in bowel, decreasing protein breakdown & ammonia production. - -------- Correct Answer ---------- Oral neomycin Prescribed hepatic encephalopathy reduce bacterial breakdown protein in bowel. Desired effect is two or three soft stools per day with an acid fecal pH. Creates acid environment in bowel & causes ammonia leave bloodstream & enter colon. Ammonia becomes trapped in bowel. Lactulose has laxative effect allows elimination of ammonia. Diarrhea may indicate excessive administration of medication. --------- Correct Answer -- -------- Lactulose (Chronulac) Tachypnea & dyspnea first clinical manifestations. Blood-tinged frothy sputum would present later sign, after development pulmonary edema. Breath sounds in early stages ARDS usually are clear. --------- Correct Answer ---------- Acute respiratory distress syndrome (ARDS) Hematuria & flank or lumbar pain; colicky in nature or dull & aching. Proteinuria, calculi, uremia, palpable kidney masses & Hypertension other common findings. --------- Correct Answer ---------- Polycystic kidney disease Risk low cardiac output owing to loss of atrial kick. Assesse for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, & distended neck veins. --------- Correct Answer ---------- Uncontrolled atrial fibrillation with ventricular rate greater than 100 beats/min Encouraged drink large amounts water 24-48 hours to facilitate urinary excretion radioisotope. --------- Correct Answer ---------- Bone scan Assess for allergy egg yolks. --------- Correct Answer ---------- Fat emulsion (Intralipids) Represents time takes cardiac impulse spread from atria to ventricles. Normal range PR interval 0.12 to 0.20 second. --------- Correct Answer ---------- PR interval Intermediate-acting insulin onset action 3-4 hours, peak action 4-12 hours, & duration action of 16-20 hours. Hypoglycemic reaction most likely to occur at peak time --------- Correct Answer ---------- Humulin N insulin Rapid-acting insulin. Onset of action 15 minutes; peaks in 1-3 hours, & its duration of action 3-5 hours. Hypoglycemic reactions are most likely to occur during peak time. ----- ---- Correct Answer ---------- Aspart insulin (NovoLog) Heat loss occurs when infant is on cold surface, such as a table --------- Correct Answer ---------- Conduction Heat from body surface radiates to surrounding environment. --------- Correct Answer --- ------- Radiation Air moving across infant's skin transfers heat to air. --------- Correct Answer ---------- Convection Moisture from wet body surface dissipates heat along with moisture. --------- Correct Answer ---------- Evaporation Monitor results liver function studies & ammonia level determinations. --------- Correct Answer ---------- Divalproex sodium (Depakote) Tidaling stops when lung reexpanded or chest drainage tubes are kinked or obstructed. --------- Correct Answer ---------- Closed chest drainage system fluctuation (tidaling) in water-seal compartment has stopped One-side facial paralysis cause; compression facial nerve. Signs; facial droop from paralysis facial muscles; increased lacrimation; painful sensations eye, face, or behind ear; speech or chewing difficulties. Facial drooping associated with Bell's palsy makes it difficult to close eyelid on affected side. Widening of palpebral fissure (opening between eyelids) & asymmetrical smile are seen. --------- Correct Answer ---------- Bell's palsy Complete fracture across shaft bone, with splintering bone into fragments --------- Correct Answer ---------- Comminuted fracture Fracture of bone across entire shaft with some possible displacement, but without breaking skin --------- Correct Answer ---------- Simple fracture Incomplete fracture, which occurs through part cross-section of bone-one side bone fractured, & other side bent. --------- Correct Answer ---------- Greenstick fracture Also called open or complex fracture, is one in which skin or mucous membrane; broken & resulting wound extends to depth of fractured bone. --------- Correct Answer ---------- Compound fracture Abnormal lateral curvature in any area spine. Region most commonly affected is right thoracic area, where it results in rib prominence --------- Correct Answer ---------- Scoliosis Right arm is equal to 9%. Leg is equal to 18%. Anterior thorax equal to 18% Posterior thorax is equal to 18%. Head equal to 9% & perineum is equal to 1% --------- Correct Answer ---------- Rule of nines Surgical procedure will allow fluid to drain from middle ear & may be necessary to treat acute otitis media. --------- Correct Answer ---------- Myringotomy (Stye); application warm compresses 15 mins four times day & instillation ophthalmic antibiotic ointment for causative infectious organism & prevent spread infection surrounding lid glands. Warm compresses promote comfort & aid bringing purulent contents to head, causing rupture with drainage. --------- Correct Answer ---------- Hordeolum Provide activities involv use of hands & gross motor movements; volleyball, finger- painting, drawing, & working with clay. Provide way to discharge motor tension. --------- Correct Answer ---------- Bipolar disorder experiencing psychomotor agitation Does not occur suddenly. In few days or hours preceding thrombotic stroke, experience transient loss of speech, hemiparesis, or paresthesias on one side of body. Signs; include dizziness, cognitive changes, or seizures. --------- Correct Answer ---------- Cerebral thrombosis (thrombotic stroke) Spasms pain, start suddenly, last seconds to minutes. Pain described stabbing, similar electric shock. Accompanied by spasm facial muscles that cause twitching of parts of face or mouth, closure of eye. Symptoms; triggered by pressure; washing face, brushing Anxiolytic medication. Side effects; Dizziness, nausea, headaches, nervousness, lightheadedness, & excitement. Not addicting, tolerance does not develop, & not sedating. --------- Correct Answer ---------- Buspirone hydrochloride (BuSpar) Treatment chronic alcoholism maintaining enforced sobriety. Abstain from alcohol at least 12 hours before initial dose, most important assessment is when last alcoholic intake was consumed. Use cautiously: hypothyroidism, diabetes mellitus, epilepsy, cerebral damage, nephritis, & hepatic disease. Contraindicated; severe heart disease, psychosis, or hypersensitivity to medication. --------- Correct Answer ---------- Disulfiram (Antabuse) Humulin N bottle rotated at least 1 min between both hands resuspend insulin & warm medication. Humulin R insulin drawn before Humulin N. Insulin can be stored room temperature. Additional bottles insulin for future use stored in refrigerator. --------- Correct Answer ---------- Mix Humulin R & Humulin N insulin in the same syringe Inject air into Humulin N bottle equal to amount of insulin prescribed. Next inject amount of air equal to amount of prescribed insulin into Humulin R bottle. Regular insulin then withdrawn, followed by Humulin N insulin. Contamination regular insulin with Humulin N insulin will convert part of Humulin R insulin into longer-acting form. --------- Correct Answer ---------- Mixture of Humulin N & Humulin R insulin. Antiemetic & used to treat nausea. --------- Correct Answer ---------- Droperidol (Inapsine) Laxative, causes nausea & abdominal cramps most frequent side effects. Hypokalemia can result from long-term use. --------- Correct Answer ---------- Cascara sagrada Treatment of constipation, It increases peristalsis. --------- Correct Answer ---------- Senna (Senokot) Antidiarrheal; administered for loose stools. Treat both acute diarrhea & chronic diarrhea from disorders such as inflammatory bowel disease. Also used reduce volume of drainage from an ileostomy. --------- Correct Answer ---------- Loperamide (Imodium) Antiemetic agent used for relief of nausea & vomiting --------- Correct Answer ---------- Trimethobenzamide (Tigan) Antiemetic relief postoperative nausea & vomiting. Nausea & vomiting associated with chemotherapy --------- Correct Answer ---------- Ondansetron (Zofran) Available as an oral solution & should be served chilled to make it more palatable -------- - Correct Answer ---------- Magnesium citrate Antiemetic & antipsychotic agent. Side effect; blurred vision, constipation, dry mouth, & dry eyes. --------- Correct Answer ---------- Prochlorperazine Most common side effect; confusion. Less common CNS side effects; headache, dizziness, drowsiness, & hallucinations. --------- Correct Answer ---------- Cimetidine (Tagamet) Blood pressure is monitored during administration; can cause severe & sudden hypotension, even with single dose. Supine while receiving medication, & resuscitation equipment should be available. --------- Correct Answer ---------- Pentamidine (Pentam 300) Antituberculosis med given in conjunction with other TB meds. May be discontinued by HCP if sputum cultures become negative. --------- Correct Answer ---------- Pyrazinamide (Pyrazinamide) topical antifungal agent; treatment of cutaneous fungal infections. Used on fungal rash - -------- Correct Answer ---------- Clotrimazole (Lotrimin) Ringing ears & vertigo two symptoms ototoxicity. Frequent adverse effect of therapy with use of aminoglycosides & could result permanent hearing loss. --------- Correct Answer ---------- Tobramycin sulfate (Tobrex) Antidysrhythmic treat life-threatening ventricular dysrhythmias. Requires continuous cardiac monitoring, with infusion of medication by intravenous pump. --------- Correct Answer ---------- Amiodarone (Cordarone) Orally or nasogastric tube treat acetaminophen overdose. Inhalation for use as mucolytic. Before administration medication as antidote, ensure that stomach is empty through emesis or gastric lavage. Solution is diluted in cola, water, or juice to make more palatable --------- Correct Answer ---------- Acetylcysteine (Mucomyst) When umbilical cord protruding, actions immediately directed at reducing cord compression & facilitating delivery fetus. Cord wrapped loosely in sterile towel saturated warm normal saline, prevent from drying out & becoming compressed. Placed extreme Trendelenburg's or modified Sims' position or knee-chest position to reduce compression. --------- Correct Answer ---------- Prolapsed cord Characterized by decreased iron-binding capacity & increased transferrin saturation. Best sources dietary iron: red meat, liver & other organ meats; blackstrap molasses; & oysters. Kidney beans, whole wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, & apricots. --------- Correct Answer ---------- Iron deficiency anemia Classic sign; weakness, mild diarrhea, & smooth, sore, red tongue. May also have nervous system signs & symptoms; paresthesias, difficulty with balance, & occasional confusion. The Schilling test used determine cause vitamin B12 deficiency, which leads to pernicious anemia --------- Correct Answer ---------- Pernicious anemia Three enemas may be given when prescription for enemas until clear. If more than three necessary, should call HCP (or act according to agency policy). Excessive enemas could cause fluid & electrolyte depletion. --------- Correct Answer ---------- Prescription for enemas until clear Severe anemia predominantly affects African Americans. Characterized by presence of Hgb S. Must have two abnormal genes encoding Hgb S to have sickle cell disease. Increased reticulocyte count, & presence nucleated red blood cells. Reticulocyte counts increased in children with sickle cell disease because life span of their sickled red blood cells is shortened. --------- Correct Answer ---------- Sickle cell anemia Most common sites in adult are iliac crest & sternum. Areas rich in bone marrow & easily accessible for testing. --------- Correct Answer ---------- Bone marrow aspiration Avoid infections, can increase metabolic demand & cause dehydration, precipitating a crisis. Fluids important prevent dehydration, which could lead to crisis. Warm weather & mild exercise not need to be avoided; should take measures avoid dehydration during these conditions. Priorities management are hydration therapy & pain relief. Given IV fluids promote hydration & reverse agglutination of sickled cells in small blood vessels. Opioid analgesics may be given relieve pain. Oxygen administered according individual need. --------- Correct Answer ---------- Sickle cell crisis Experience shortness of breath & fatigue because of decreased ability of blood to carry oxygen to tissues to meet metabolic demands. Tachycardia result efforts by body compensate for effects of anemia. --------- Correct Answer ---------- Anemia that developed as a result of blood loss after a traumatic injury check restraints, circulatory status, & skin integrity every 30 minutes. ]Removed at least every 2 hours to permit muscle exercise & promote circulation. Restraints not secured bedrails because this could cause injury if rails are lowered. Agency guidelines regarding the use of restraints should always be followed. --------- Correct Answer -------- -- hand restraints Blood cells that destroy bacteria. With fewer than 10,000 cells/L circulating granulocytes, risk infection increases significantly --------- Correct Answer ---------- Granulocytes With vitamin B6 & B12 deficiencies, iron deficiency, chronic infection, bone marrow depression, multiple myeloma, leukemia, hemolytic anemia, & pernicious anemia. Decrease RBC count also may be noted in older client. --------- Correct Answer ---------- Decreased RBC counts occur Immature RBC. Count increased any time there is accelerated production of RBCs. Decreased when bone marrow has slowed production of RBCs. --------- Correct Answer ---------- Reticulocyte Forgetfulness begins interfere with daily routine. Difficulty concentrating & difficulty learning new material --------- Correct Answer ---------- Early-stage Alzheimer's disease Antiparkinsonian medication. Increases dopaminergic action, assisting reduction tremor, akinesia, & rigidity of parkinsonism --------- Correct Answer ---------- Selegiline hydrochloride (Eldepryl) Early symptoms; restlessness, forgetfulness, clumsiness, falls, balance & coordination problems, altered speech, & altered handwriting. Difficulty swallowing occurs in later stages --------- Correct Answer ---------- Huntington's disease If bacterial infection CSF present, findings; reduced glucose level, protein level greater 15 mg/dL, increased WBC, cloudy appearance CSF, & CSF pressure greater than 200 mm H2O. --------- Correct Answer ---------- Bacterial meningitis diagnosis made by a polymerase chain reaction (PCR) test. Test rapid & noninvasive. -- ------- Correct Answer ---------- Herpes simplex encephalitis. Antispasmodic relieve symptoms urinary urgency, frequency, nocturia, & incontinence clients uninhibited or reflex neurogenic bladder. Expected effects; improved urinary control & decreased urinary frequency, incontinence, & nocturia. --------- Correct Answer ---------- Oxybutynin (Ditropan XL) Neglects affected side of body. May ignore presence of affected side (often creating safety hazard as result of potential injuries) or may state that involved arm or leg belongs to someone else --------- Correct Answer ---------- Anosognosia Condition affected person has few language skills as result extensive damage left hemisphere. Speech is nonfluent & associated with poor comprehension & limited ability to name objects or repeat words. --------- Correct Answer ---------- Global aphasia Difficulty repeating words spoken by another, & speech characterized by literal paraphasia with intact comprehension. --------- Correct Answer ---------- Conduction aphasia Exhibit a rambling type of speech. --------- Correct Answer ---------- Wernicke's aphasia Early signs include changes mental status & impaired respiratory function result of impaired perfusion distal to site of embolus. Dyspnea, petechiae, and chest pain are signs of fat embolism. Cardiovascular & renal impairment likely secondary to impaired respiratory function. Suspected fat embolism, position sitting (Fowler's) position relieve dyspnea. Supplemental oxygen reduce signs of hypoxia. HCP notified --------- Correct Answer ---------- Fat embolism Informed consent form is required. Shaves & surgically cleans anticipated entry site. Procedure is explained, asked about allergies to shellfish or contrast media. Oral ingestion except for sips of water avoided for 4-6 hours before test. x-ray imaging blood vessels of lungs after injection of contrast material --------- Correct Answer ---------- Pulmonary angiography Symptoms; weakness, hypotension, fever, & mental status changes --------- Correct Answer ---------- Adrenal insufficiency after adrenalectomy Observe for clear nasal drainage; constant swallowing; & severe, persistent, generalized, frontal headache. Symptoms indicate cerebrospinal fluid leak into sinuses. Clear drainage noted after procedure, HCP notified. --------- Correct Answer ---------- Transsphenoidal hypophysectomy Neck circumference monitored every 4 hours assess occurrence postoperative edema. Upright position facilitate air exchange. Monitor dressing closely & should loosen dressing if necessary. Assist with deep breathing exercises, but coughing minimized prevent tissue damage & stress to incision. After surgery may experience temporary calcium imbalance. Assess for Chvostek's & Trousseau's signs. Treatment is administration of calcium gluconate or calcium lactate. --------- Correct Answer ---------- Thyroidectomy Regular insulin intravenous route treatment choice for DKA. Short-acting insulin only insulin that can be given intravenously because it can be titrated to blood glucose levels. Expect to note blood glucose levels between 350 & 1500 mg/dL, ketonuria, serum pH less than 7.35, & serum bicarbonate less than 15 mEq/dL. --------- Correct Answer ---------- Diabetic ketoacidosis (DKA) Antimicrobial agent used treat urinary tract infections caused P. aeruginosa --------- Correct Answer ---------- Ciprofloxacin (Cipro) Involve epidermis, full dermis, & some of subcutaneous fat layer. Burn appears tan or fawn color, with skin hard, dry, & inelastic. Edema severe, & accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings damaged, & area may be insensitive to touch, with little or no pain. --------- Correct Answer ---------- Full-thickness burn Has a flat shape --------- Correct Answer ---------- Platypelloid pelvis Has an oval shape --------- Correct Answer ---------- Anthropoid pelvis Is heart-shaped --------- Correct Answer ---------- Android pelvis Is a normal female pelvis --------- Correct Answer ---------- Gynecoid pelvis Classic symptom; high fever (temperature 101º F or higher), vomiting, & severe diarrhea. Other symptoms; headache, myalgia, chills, abdominal pain, dizziness, lethargy, possible confusion, & agitation. --------- Correct Answer ---------- Toxic shock syndrome (TSS) Symptoms; reduced force & size of urinary stream, intermittent stream, hesitancy beginning flow of urine, inability stop urinating, sensation of incomplete bladder emptying after voiding, postvoid dribbling of urine, & increase in episodes of nocturia. --- ------ Correct Answer ---------- Prostatism Topical medication treat mild to moderate acne. --------- Correct Answer ---------- Topical azelaic acid (Azelex) Blindness in half visual field. Taught scan environment. Allows client take in entire visual field, necessary for proper functioning in environment & helps prevent injury to client ---- ----- Correct Answer ---------- Hemianopsia Responsible for visual acuity. Tested using Snellen chart assess distant vision. Another item used evaluate optic nerve function is Rosenbaum card; evaluate near vision. Hand- held card used test visual acuity. Records smallest line seen as well as distance that card is held from client --------- Correct Answer ---------- Cranial nerve II (the optic nerve) Pink or red without any blistering. Skin blanches to touch, may be edematous & painful, & heals on its own, usually within 1 week. --------- Correct Answer ---------- Superficial burns Topical antifungal agent treatment of cutaneous fungal infections. Monitors effectiveness by noting presence or absence of skin rash, which is characteristic of this infection. --------- Correct Answer ---------- Clotrimazole (Lotrimin AF) Antidiabetic med administered alone or conjunction with another antidiabetic med. Contraindicated; significant renal dysfunction, inflammatory bowel disease, colonic ulceration, or partial intestinal obstruction. --------- Correct Answer ---------- Acarbose (Precose) Maintain low-fiber diet 1-3 days before test. Clear liquids or water allowed 12-24 hours before test. Laxatives & enemas prescribed before test to cleanse bowel. Encouraged drink liquids after procedure to facilitate passage of barium. --------- Correct Answer ------ ---- Barium enema Test performed 1 minute after birth & again 5 minutes after birth. --------- Correct Answer ---------- Apgar score Method measuring IOP using calibrated instrument that indents or flattens corneal apex. Pressures between 10-21 mm Hg are considered to be within normal range. Increased IOP indicative of glaucoma. --------- Correct Answer ---------- Tonometry test severe pain usually indicate complications. Encourage drink large amounts water for 24- 48 hours flush radioisotope from system. --------- Correct Answer ---------- Bone biopsy symptom; pain, loss of function in area, deformity, shortening of extremity, crepitus, swelling, & ecchymosis. --------- Correct Answer ---------- Fracture Results from pulling force on muscle, resulting soreness & pain with muscle use --------- Correct Answer ---------- Strain Injury ligament caused by wrenching or twisting motion & manifested by pain, swelling, & inability to use joint or bear weight normally. --------- Correct Answer ---------- Sprain If result of ELISA is positive, Western blot is done to confirm findings. If the result of Western blot is positive, then considered to be seropositive for infection & to be infected with virus. --------- Correct Answer ---------- Human immunodeficiency virus (HIV) infection --------- Correct Answer ---------- Impetigo JIA twice as likely to occur in girls than in boys. Clinical manifestations of JIA include morning stiffness & painful, stiff, swollen joints. Most often occurs before age of 16. Complication of JIA is iridocyclitis. --------- Correct Answer ---------- Juvenile idiopathic arthritis (JIA) Also called innate inherited or innate-native immunity, is that immunity with which person is born. Does not require previous exposure to antigen. --------- Correct Answer - --------- Natural resistance Includes all antigen-specific immunities that person develops during a lifetime. --------- Correct Answer ---------- Acquired immunity Lasts much longer & more effective at preventing subsequent infections than passive immunity. Active immunity lasts for years & can be easily reactivated by booster dose of antigen. Protection from active immunity takes 5-14 days to develop after first exposure to antigen & 1-3 days after subsequent exposures. --------- Correct Answer ---------- Active immunity Most likely cause is activation of an autoimmune response.Test for rheumatoid factor detects presence of unusual antibodies of IgG & IgM type, which develop in a number of connective tissue diseases. --------- Correct Answer ---------- Rheumatoid arthritis Measuring ESR can confirm inflammation or infection anywhere in body. ESR useful for connective tissue disease because value directly correlates with degree inflammation & later with severity of the disease. ESR value of 30 to 40 mm/hr indicates mild inflammation, 40 to 70 mm/hr indicates moderate inflammation, & 70 to 150 mm/hr indicates severe inflammation. --------- Correct Answer ---------- Erythrocyte sedimentation rate (ESR) Epidermal blistering & sloughing precipitated by lateral finger pressure, commonly is present in pemphigus vulgaris --------- Correct Answer ---------- Nikolsky's sign Bone pain most common symptom & may manifest in areas close to a joint. Pain related to progressive enlargement & deformity of bone. Hearing loss, numbness face, or (more rarely) blindness can occur when thickened bone of Paget's disease compresses vital nerves in skull. Fatigue or difficulty with ambulation may occur but would not be most common symptom. --------- Correct Answer ---------- Paget's disease Stage I carcinoma strictly confined to cervix. Stage II, carcinoma has extended beyond cervix but has not extended to pelvic wall. Stage III carcinoma has extended to pelvic wall at lower third of vagina, & in stage IV, carcinoma has extended beyond true pelvis or has clinically involved mucosa of bladder or rectum. --------- Correct Answer ---------- Papanicolaou smear (PAP), test for cancer produces GH, LH, and FSH --------- Correct Answer ---------- Anterior pituitary gland ADH & oxytocin are synthesized by hypothalamus & stored in posterior pituitary gland -- ------- Correct Answer ---------- Posterior pituitary gland Produces Epinephrine & norepinephrine --------- Correct Answer ---------- Adrenal medulla Produces cortisol, androgens, & aldosterone --------- Correct Answer ---------- Adrenal cortex Bone infection & may be caused by direct contamination of bone through open wound. Bacteria invade bone tissue & produce inflammation. Ischemia & necrosis of bone tissue may follow if not treated. --------- Correct Answer ---------- Osteomyelitis Narrowing this valve will impede circulation blood through the Left atrium to left ventricle --------- Correct Answer ---------- Mitral stenosis Failure of aortic valve to close completely allows blood to flow retrograde through the Aorta to left ventricle --------- Correct Answer ---------- aortic regurgitation Primary effect decrease blood pressure is reduced blood flow to myocardium. This decreases oxygenation of cardiac tissue. Cardiac tissue likely to become excitable or irritable in presence of hypoxia. Heart rate is likely to increase in response to change. Effects of tissue ischemia lead to decreased contractility over time. --------- Correct Answer ---------- Decrease in blood pressure The left coronary artery supplies right atrium & right ventricle with blood --------- Correct Answer ---------- coronary arteries Early decreases fluid volume compensated for by increase in pulse rate. Although BP will decrease, it is not the earliest indicator. --------- Correct Answer ---------- Earliest indication of new decreases in fluid volume Normal cardiac output for adult can range from 4-8 L/min & varies greatly with body size. Heart normally pumps 5 L of blood every minute. --------- Correct Answer ---------- Cardiac output Bifurcates from left main coronary artery to supply anterior wall of left ventricle & a few other structures --------- Correct Answer ---------- Left anterior descending coronary artery (LAD) Bifurcates from left coronary artery & supplies left atrium & lateral wall of left ventricle --- ------ Correct Answer ---------- Circumflex coronary artery Supplies right side of heart, including right atrium & right ventricle. --------- Correct Answer ---------- Right coronary artery (RCA Supplies posterior wall of the heart. --------- Correct Answer ---------- Posterior descending coronary artery (PDA) Inserted too far into trachea, tube will enter right main bronchus. Occurs because right bronchus is shorter & wider than left & extends downward in more vertical plane. If tube not inserted far enough, no chest expansion at all will occur. --------- Correct Answer ----- ----- Endotracheal tube Use specific positions; vary depending on affected (Lobe or Lobes). Usually place head lower than affected lung segments facilitate drainage of secretions. Postural drainage often done in conjunction chest percussion for maximum effectiveness. --------- Correct Answer ---------- Postural drainage Inflammation visceral & parietal pleurae. Inflammation prevents parietal & visceral pleural surfaces from gliding over each other with respiration. Experiences pain, especially with inspiration. Pleural friction rub auscultated early in course of pleurisy before pleural fluid accumulates. Once fluid accumulates in inflamed area, friction between visceral & parietal lung surfaces decreases, & pleural friction rub disappears. -- ------- Correct Answer ---------- Pleurisy Cartilaginous ridge separates opening two main (right & left) bronchi. Endotracheal tube inserted past carina, tube will enter right main bronchus as result natural curvature of airway. Hazardous because only right lung will be ventilated. --------- Correct Answer ---- ------ The carina IV catheter used should be at least 18 or 20 gauge. Large enough to prevent damage to blood cells. --------- Correct Answer ---------- Transfuse red blood cells Throat suspected epiglottitis not examined/cultured stimulation with tongue depressor or culture swab could cause laryngospasm, thus completing airway obstruction. Humidified oxygen & antipyretics are components management. Axillary rather than oral temperatures taken to avoid stimulation & resultant laryngospasm. If suspected, priorities are maintain patent airway & obtain chest radiograph to confirm diagnosis. If present, child taken promptly to operating room for tracheal intubation or immediate placement of surgical airway. --------- Correct Answer ---------- Epiglottitis --------- Correct Answer ---------- Ménière's disease 1. Place in semi-Fowler's position 2. Turn on suction device & set regulator at 80 mm Hg. 3. Apply gloves & attach suction tubing to suction catheter. 4. Hyperoxygenate client. 5. Insert catheter into tracheostomy until resistance is met, & then pull it back 1 cm. 6. Apply intermittent suction & slowly withdraw catheter while rotating it back & forth ----- ---- Correct Answer ---------- Suction airway tracheostomy tube Used control shivering hyperthermic states. --------- Correct Answer ---------- Chlorpromazine (Thorazine) Use a 25- to 26-gauge, ⅝-inch needle. --------- Correct Answer ---------- Subcutaneous injection of heparin sodium Dissolve any clots in coronary arteries. --------- Correct Answer ---------- Streptokinase (Streptase) Bed placed semi-Fowler's with knee gatch raised sufficiently flex knees. Relaxes muscles of lower back & relieves pressure on spinal nerve root. --------- Correct Answer ---------- Williams' position Tachycardia & hypotension, confusion, tachypenia --------- Correct Answer ---------- Signs of hypovolemic shock Anticholinergic medication & used treat Parkinson's disease. Common GI side effects include constipation, dry mouth, & nausea. Adverse effect is ileus. --------- Correct Answer ---------- Benztropine (Cogentin) Characterized by chronic joint pain, variable intensity, more severe on rising in morning. Age onset most common between 30-50 years. (Early symptoms; Fatigue & morning stiffness, generalized weakness, anorexia, & weight loss) may appear before joint manifestation --------- Correct Answer ---------- Rheumatoid arthritis (RA) Instructing to do what client fears &, if possible, exaggerate outcome of this exposure to point of humor --------- Correct Answer ---------- Paradoxical intention Assess for an allergy to Sulfa drugs --------- Correct Answer ---------- Acetazolamide (Diamox Sequels) Child will exhibit elevated ASO titer, elevated ESR, leukocytosis, & positive result on CRP determination. Initial diagnosis is made by noting presence of Aschoff's bodies. ---- ----- Correct Answer ---------- Rheumatic fever Maintenance patent airway, oxygen administration, assessment of vital signs & LOC, & dysrhythmia detection. Airway highest priority. --------- Correct Answer ---------- Cardioversion Inability identify well-known objects & people --------- Correct Answer ---------- Agnosia Altered motor function; Disturbance in gait. --------- Correct Answer ---------- Ataxia Difficulty finding right word to use. Loss of a previously held ability to speak or understand spoken or written language. ----- ---- Correct Answer ---------- Aphasia Inability to perform familiar skilled activities, perform purposeful movements or use objects appropriately --------- Correct Answer ---------- Apraxia Limit insertion & suctioning time to 5 seconds to prevent hypoxia. --------- Correct Answer ---------- Suctioning a tracheostomy in infant Young child, ages 3 to 6 years, max volume medication safely injected into ventral gluteal muscle is 1.5 mL. --------- Correct Answer ---------- Intramuscular (IM) injection in young child Lead shield kept bedside use when providing direct care to prevent exposure radiation. Visitors limited, & women who are pregnant or who may be pregnant should not enter room. Visitation allowed older 16 years of age. Must have warning sign posted on closed door & on chart (per agency policy) alert staff & visitors radiation therapy is in process. In private room. --------- Correct Answer ---------- Cervical-uterine radiation implant Also known as DVT, exhibits redness or warmth of affected leg, tenderness at site, possibly dilated veins (if superficial), low-grade fever, edema distal to obstruction, & increased calf circumference affected extremity. Management DVT includes possible bed rest 5-7 days, limb elevation; relief discomfort; warm, moist heat, analgesics as needed; anticoagulant therapy; & monitor for signs PE. Ambulation contraindicated increases likelihood dislodgement tail of thrombus, which could travel to lungs as PE. (Ask about pain in calf area) --------- Correct Answer ---------- Thrombophlebitis Used irrigating & cleaning necrotic or purulent wounds. Can be used for packing necrotic wounds but cannot be used pack purulent wound because solution inactivated by copious pus. --------- Correct Answer ---------- Sodium hypochlorite (Dakin's) Long-term management consists measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, & maintain tissue integrity (foot care & nutrition). --------- Correct Answer ---------- Peripheral arterial disease (PAD) --------- Correct Answer ---------- Fracture types Begin right lower quadrant, ileocecal valve area; normally bowel sounds are always present there. --------- Correct Answer ---------- Auscultate bowel sound Used treat metastatic breast cancer that is resistant to other therapy. Also used to treat colon cancer. Contraindication to use; severe renal impairment such as that which occurs in chronic kidney disease. Bone marrow depression can occur from use; CBC & blood chemistry studies should be done periodically --------- Correct Answer ---------- capecitabine (Xeloda) Physiological responses; normal blood pressure, heart rate, & respiratory rate, along with normal pupils & dry skin --------- Correct Answer ---------- Chronic pain Causes increased blood pressure (initially), increased pulse & respiratory rate, dilated pupils, & perspiration --------- Correct Answer ---------- Acute pain Older adults should not meperidine hydrochloride because prolonged half-life accumulates with repeated dosing; can lead to life-threatening seizures. Because physical changes of aging, older clients excrete this medication slowly, leading to risk for cerebral irritation & seizures. --------- Correct Answer ---------- Meperidine hydrochloride (Demerol) Low-grade toxicity characterized; ringing in ears, generalized pruritus (which may be severe), headache, dizziness, flushing, tachycardia, hyperventilation, sweating, & thirst. Marked toxicity manifested; hyperthermia, restlessness, abnormal breathing pattern, seizures, respiratory failure, and coma. High doses can produce GI bleeding or gastric mucosal lesions. --------- Correct Answer ---------- Acetylsalicylic acid (ASA) Treat hypercholesterolemia & hypertriglyceridemia. Decreases LDL cholesterol & plasma triglycerides & increases HDL cholesterol (good cholesterol). Contraindications; include active liver disease, unexplained elevated liver function tests, pregnancy, & lactation. Frequent side effect; headache. Adverse effects; photosensitivity & potential for developing cataracts. --------- Correct Answer ---------- Atorvastatin (Lipitor) Incomplete dislocation of joint surfaces. --------- Correct Answer ---------- Subluxation Disruption of a joint to extent that articulating surfaces are no longer in contact. --------- Correct Answer ---------- Dislocation Muscle or ligament used beyond limit of its functional ability. Characterized by overstretching of muscle or ligament & also could involve tearing if strain is more severe (i.e., second- or third-degree strain versus first-degree strain). --------- Correct Answer --- ------- Strain Soft tissue injury that results in hemorrhage into involved tissue. --------- Correct Answer ---------- Contusion Point at which ureters enter bladder. Juncture, ureter runs obliquely for 1.5 to 2 cm through bladder wall before opening into bladder. Anatomical pathway prevents reflux urine back into ureter &, acts as a valve to prevent urine from traveling back into ureter & up to kidney. --------- Correct Answer ---------- Ureterovesical junction Because hydrogen ions contribute to acidosis in the body, the kidneys retain hydrogen ions in alkalosis to restore acid-base balance --------- Correct Answer ---------- Metabolic alkalosis Do not manufacture adequate amounts of erythropoietin --------- Correct Answer ---------- Chronic kidney disease Stimuli ADH release; increased plasma osmolality, decreased blood volume, hypotension, pain, dehydration from nausea, vomiting, or diarrhea, & stress. --------- Correct Answer ---------- Antidiuretic hormone (ADH) Potassium-retaining diuretic. Potassium-retaining diuretics decrease reabsorption of sodium & water & inhibit excretion of potassium in renal collecting ducts. Avoid eating bananas. --------- Correct Answer ---------- Triamterene (Dyrenium) Fiber responsible skin's toughness & resiliency & plays important role in healing process. --------- Correct Answer ---------- Collagen Outermost layer, Stratum corneum. Which contains the horny or cornified cells. --------- Correct Answer ---------- Skin cells that slough off loss of hair. --------- Correct Answer ---------- Alopecia Dry skin --------- Correct Answer ---------- Xerosis Excessive hair growth --------- Correct Answer ---------- Hirsutism Excessive sweating. --------- Correct Answer ---------- Hyperhidrosis Blotchy brown macules across cheeks & forehead. Condition caused by hormonal influences on melanin production. --------- Correct Answer ---------- Melasma Resemble a net in appearance --------- Correct Answer ---------- Reticular skin lesions Ring-shaped. --------- Correct Answer ---------- Annular lesions Shaped like an arc. --------- Correct Answer ---------- Arciform lesions Can be caused by vasodilation from high environmental temperatures, fever, or inflammation --------- Correct Answer ---------- Erythema (or redness) of the skin Occurs with increasing age & has no clinical significance. Appears assmall, round, bright red lesion on trunk or extremities --------- Correct Answer ---------- Cherry angioma Results from increased pressure in veins, usually in lower legs, & has irregularly shaped bluish center with radiating branches. --------- Correct Answer ---------- Venous star Bright red center with legs that radiate outward. Commonly seen in liver disease & vitamin B deficiency, although they occasionally can occur without underlying pathology. --------- Correct Answer ---------- Spider angiomas Fungal infection; results inflammation nail fold, with separation fold from nail plate. Affected area generally is tender to touch & has purulent drainage. --------- Correct Answer ---------- Paronychia Purpuric lesion also known as a bruise --------- Correct Answer ---------- Ecchymosis Used detect MI & decreased myocardial blood flow, & determine left ventricular function. Radioisotope injected intravenously; therefore a signed informed consent is necessary. --------- Correct Answer ---------- Technetium 99m ventriculography (multigated acquisition [MUGA] scan CO2 acts as an acid in body. Rise in blood CO2 will result in a fall in blood pH. --------- Correct Answer ---------- Retaining carbon dioxide (CO2) Are cations that contribute to a state of acidosis in body. --------- Correct Answer ---------- Hydrogen ions 1. Close the roller clamp on the IV tubing. 2. Spike the IV bag & half-fill drip chamber. 3. Open roller clamp & fill the tubing. 4. Uncap the distal end of the tubing 5. Attach distal end of the tubing to the client --------- Correct Answer ---------- Prepares solution & IV tubing; Arrange actions in order 1. Check compatibility phenytoin with IV solution. 2. Draw up medication in a 3-mL syringe. 3. Check client's identification (ID) bracelet. 4. Pinch off IV tubing above injection port. 5. Inject the medication. 6. Document medication was administered. --------- Correct Answer ---------- Prescription administer phenytoin (Dilantin) by intravenous push (IVP) throughIV line infusing 1000 mL of 0.9% sodium chloride. Arrange actions in order Injection cap should be discarded & new one applied whenever blood is drawn from lumen. --------- Correct Answer ---------- Multilumen central venous catheter Symptoms of watery diarrhea, flatus, abdominal distention, pain, & fever. Diagnostic tests include stool culture with bowel biopsy. --------- Correct Answer ---------- Cryptosporidiosis Measures titer antibodies that destroy nuclei cells & cause tissue death. When fluorescent method used, test sometimes referred to as FANA. Test is positive value greater than 1:8 will be present. --------- Correct Answer ---------- Fluorescent antinuclear antibody titer (FANA) Tests for presence unusual antibodies of IgG & IgM types, which develop in some connective tissue diseases. --------- Correct Answer ---------- Rheumatoid factor assay tests Confirm presence inflammation or infection in body. Useful for management of connective tissue disease because rate measured directly correlates with degree of inflammation & later with severity of disease. Normal ESR range 0 to 30 mm/hr Mild inflamation; 30 to 40 mm/hr Moderate inflamation; 40 to 70 mm/hr Severe inflammation; 70 to 150 mm/hr --------- Correct Answer ---------- Erythrocyte sedimentation rate (ESR) Diagnostic tests include viral culture & gross examination. Manifests painful, vesicular lesions that rupture & cause ulcers on tongue, lips, & buccal mucosa. --------- Correct Answer ---------- Herpes simplex Observes for signs of bleeding, may cause swelling & compression of adjacent tissues. Laryngeal stridor results from compression of trachea & is a harsh, high-pitched sound heard on inspiration & expiration. Laryngeal stridor is acute emergency, necessitating immediate attention to avoid complete obstruction airway. --------- Correct Answer -------- -- Parathyroidectomy Absence of P waves, presence of wide & bizarre QRS complexes, & compensatory pause that follows ectopy. (Premature beats followed by a compensatory pause) --------- Correct Answer ---------- Premature ventricular contractions (PVCs) (Prone toe-in position) will promote internal rotation of hips, which will relax muscle, thereby making injection less painful. --------- Correct Answer ---------- Administering (IM) injection gluteal muscle, position to best relax the muscle. Ipsilateral paralysis & loss of touch, pressure, vibration, & proprioception. Contralaterally, pain & temperature sensation are lost because these fibers decussate after entering cord. --------- Correct Answer ---------- Brown-Séquard syndrome Positioned supine head of bed elevated at a 45- to 60-degree angle. Places heart close proximity to chest wall for easier insertion of needle into pericardial sac. --------- Correct Answer ---------- Pericardiocentesis to treat cardiac tamponade Anticoagulant. An adverse effect anticoagulant therapy is bleeding. Question about symptoms that could indicate bleeding: bleeding gums, bruising, hematuria, or dark tarry stools. --------- Correct Answer ---------- Enoxaparin (Lovenox) Indicates increased number of immature neutrophils, an increased number of bands. Signals presence of an acute infectious process. --------- Correct Answer ---------- Left shift Represents increased number mature neutrophils --------- Correct Answer ---------- Right shift Occurs most often in alcoholics. Abstinence alcohol important to prevent from developing chronic pancreatitis. Usually experience malabsorption with weight loss. Limit fat in diet & take in small meals, will reduce amount of carbohydrates & protein that client must digest at any one time. --------- Correct Answer ---------- Chronic pancreatitis Potentially hepatotoxic. Use of this medication investigated with symptoms compatible with liver disease (such as ascites & jaundice) acetylcysteine (Mucomyst) is antidote. To administered mix medication in flavored ice drink & allowing drink the medicine. Drink though straw also will minimize contact with mouth due to unpleasant taste. --------- Correct Answer ---------- Acetaminophen (Tylenol) Experiences involuntary loss of urine soon after experiencing urgency. --------- Correct Answer ---------- Urge incontinence Because compromise respiration leading cause death cervical cord injury, respiratory assessment highest priority. Assessment temperature & strength can be done after adequate oxygenation is ensured --------- Correct Answer ---------- C4 spinal cord injury Erythema on face, giving a "slapped cheeks" appearance --------- Correct Answer -------- -- Erythema infectiosum (fifth disease) Obtained using sterile gloves & sterile container. After obtaining specimen, stool is sent immediately to laboratory --------- Correct Answer ---------- Stool smear specimen If experience chills, fever, flushing face/trunk, tachycardia, syncope, tingling, & an unpleasant taste in mouth; Manifestations of what is called "red neck syndrome." Corrective action administer medication more slowly. --------- Correct Answer ---------- Vancomycin (Vancocin) Necrosis & inflammation are seen in muscle fibers & myocardial fibers. --------- Correct Answer ---------- Polymyositis --------- Correct Answer ---------- Thyroidectomy May require bedrest prevent embolization of thrombus, anticoagulation to prevent thrombus extension & allow for thrombus autodigestion, fluids for hemodilution & decrease blood viscosity, & elastic stockings to reduce peripheral edema & promote venous return. Prevents complications of immobility encouraging coughing & deep breathing. Venous return important maintain because it is contributing factor DVT. Avoids providing foods rich in vitamin K; dark green, leafy vegetables, because this vitamin can interfere with anticoagulation. Not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action & can disrupt an existing thrombus, leading to pulmonary embolism. --------- Correct Answer ---------- Deep vein thrombosis (DVT) Droplet precautions required because this type of pneumonia transmitted by droplet nuclei larger than 5 mm. Nurse wears mask while in room. --------- Correct Answer ------- --- Mycoplasmal pneumonia Short-term parenteral IV infusion. Client who is not tolerating medications orally (N&V) & has seizure disorder would need anticonvulsant administered parenteral route. (If client is unable to keep anticonvulsants down orally, this medication would be given) --------- Correct Answer ---------- Fosphenytoin sodium (Cerebyx) Two thirds of distance between the antecubital fossa and the shoulder --------- Correct Answer ---------- Blood pressure school-age child. Obtain accurate measurement, how should nurse position blood pressure cuff? All inanimate objects are given living meaning. (Piaget's theory) --------- Correct Answer ---------- Animism Child talks just for fun & cannot see another's point of view. --------- Correct Answer ------ ---- Egocentric speech Means that if any part of object or situation changes, whole thing has changed. --------- Correct Answer ---------- Global organization Realization that something out of sight still exists, occurs in later phases of sensorimotor stage of development. --------- Correct Answer ---------- Object permanence Opioid analgesic that can precipitate withdrawal symptoms in opioid-dependent client. Contraindicated if client history of opioid dependency. Client in labor may be given parenteral analgesia during first stage of labor, up to 2-3 hours before anticipated delivery --------- Correct Answer ---------- Butorphanol tartrate Pain, helplessness, panicking, & fear of losing control are possible behaviors --------- Correct Answer ---------- Transition phase of first stage of labor Usually have head of bed elevated 30 degrees (Semi-Fowler's) reduce intracranial pressure that can occur from hemorrhage. Head should be in midline, neutral position; facilitate venous drainage from brain. --------- Correct Answer ---------- Hemorrhagic stroke Head of bed usually kept flat ensure adequate blood flow & thus oxygenation to brain. -- ------- Correct Answer ---------- Ischemic stroke Head of bed kept 30 degrees (Semi-Fowlers) promote venous outflow through jugular veins --------- Correct Answer ---------- Supratentorial craniotomy Greater risk post operation complications; history alcohol abuse risk for liver disease, including altered metabolism & elimination of medications, impaired wound healing, & clotting & bleeding abnormalities. Client with this risk factor also would be at risk for experiencing alcohol withdrawal during postoperative period. --------- Correct Answer ---- ------ Alcohol abuse Medication used to treat iron overload --------- Correct Answer ---------- Deferoxamine Central line inserted upper arm. Flexible catheter that terminates in superior vena cava of heart. Placement verified by x-ray. PICCs intended long-term intravenous catheter placement. Reasonable cost; do not need routine replacements; reliable. Less likely result in infiltration & can be used for administration of number different types medications without extravasation. --------- Correct Answer ---------- Peripherally inserted central catheter (PICC) Most likely occur within first 6 to 8 hours after abrupt cessation; however, it can occur over next several days. --------- Correct Answer ---------- Alcohol withdrawal Hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, & diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, & coma; twitching; & Consists of three phases: follicular, ovulatory, & luteal. --------- Correct Answer ---------- The ovarian cycle Also known as uterine cycle, & Consists of three phases; menstruation, proliferative phase, & secretory phase. --------- Correct Answer ---------- Endometrial cycle. Treated same way ventricular fibrillation with measures that include defibrillation, CPR & medication therapy, with agents such as vasopressin, epinephrine, amiodarone, lidocaine, & magnesium sulfate. --------- Correct Answer ---------- Pulseless ventricular tachycardia Oxygen & metoprolol (to slow ventricular response) are appropriate. Echocardiogram will help to assess heart valve function because mitral valve disease can lead to atrial fibrillation. Bolus of intravenous heparin followed by a continuous infusion to prevent thrombus. --------- Correct Answer ---------- Atrial fibrillation the ventricles Can perform tasks that (UAP) can (skin care, range-of-motion exercises, grooming, ambulation, hygiene measures) as well as dressing changes, endotracheal suctioning, urinary catheterization, & medication administration (oral, subcutaneous, intramuscular, some piggy-back medications). *Oral medication administration. *Data collection, cannot assess. *Urinary catheterization *Endotracheal suctioning *Intramuscular medication administration *Subcutaneous medication administration --------- Correct Answer ---------- Licensed practical nurse (LPN) (Non-invasive) *Range-of-motion (ROM) exercise *Cleaning a client's dentures *Ambulating a postoperative client *Taking vital signs on clients *Assist client with urinary drainage catheter into chair *A client needing a bed bath *A client needing to ambulate *A client requiring assistance with feeding *A client needing to use bedside commode *Providing distraction for client by engaging him/her in a board game *Client admitted dehydration on strict I&O *Client who requires turning every 2 hours *Confused older client who requires feeding *Client 4 days postoperative exploratory laparotomy require ambulation 4 times day *Measuring client's height & weight *Monitoring oral intake & urinary output --------- Correct Answer ---------- Unlicensed assistive personnel (UAP) Immunosuppressive therapy & management of organ transplant patients. Dispense oral liquid into glass container using a specially calibrated pipette. Should not use any other type of dropper to calibrate amount of prescribed medication. --------- Correct Answer --- ------- Cyclosporine (Sandimmune) Narrows perceptual field & selective inattentiveness occurs. --------- Correct Answer ----- ----- Moderate anxiety Significant somatic complaints, ineffective functioning, loud or rapid speech, & purposeless activity. (Hyperventilation, pacing, rapid speech, & headache) --------- Correct Answer ---------- Severe anxiety Associated with feeling dread & terror & sense of impending doom. If prolonged, panic can lead to exhaustion & death. --------- Correct Answer ---------- Panic State in which person's mental capacity recognize reality, communicate, & relate to others is impaired, interfering with person's ability to deal with life's demands. --------- Correct Answer ---------- Psychosis Portable & client controls system for relieving pain & reducing need for analgesics. Attached to skin of body by electrodes. Hospitalization is not required. --------- Correct Answer ---------- Transcutaneous electrical nerve stimulation (TENS) Cough is most frequent early symptom lung cancer, begins as nonproductive & hacking, & progresses to productive. In smoker who already has a cough,change in character & frequency of cough usually occurs. --------- Correct Answer ---------- Lung cancer 1 oz = 30 ml --------- Correct Answer ---------- Total intake Calculation Located midway between right anterior superior iliac crest & umbilicus. Usually location of greatest pain in child with appendicitis. --------- Correct Answer ---------- McBurney's point Assessment; neurological depression, drowsiness & lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, & hypotension. --------- Correct Answer -- -------- Hypermagnesemia Assessment; Tetany, twitches, & positive Trousseau's sign. Tall T waves & depressed ST segment would be observed. --------- Correct Answer ---------- Hypomagnesemia Used for treatment of hyperkalemia. Releases sodium ions primarily in exchange for potassium ions. Therapeutic effect occurs 2-12 hours after oral administration & longer after rectal administration. --------- Correct Answer ---------- Sodium polystyrene sulfonate (Kayexalate) 5% dextrose in water (D5W) 0.9% saline (NS) 5% dextrose in 0.225% saline (5% D/¼ NS) --------- Correct Answer ---------- Isotonic solution 0.45% saline (½ NS) --------- Correct Answer ---------- Hypotonic solution 10% dextrose in water (D10W) 5% dextrose in 0.9% saline (5% D/NS) 5% dextrose in 0.45% saline (5% D/½ NS) --------- Correct Answer ---------- Hypertonic solutions Ingests large amount; risk for developing metabolic acidosis 24 hours after poisoning. Metabolic acidosis occurs, may exhibit hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity-smelling breath because of improper fat metabolism, CNS depression, twitching, convulsions, & hyperkalemia. Shortly after aspirin overdose, may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours post-overdose, however, compensatory mechanism fails and the client reverts to metabolic acidosis. --------- Correct Answer ---------- Aspirin (acetylsalicylic acid) Risk for developing hyperkalemia. Potassium-sparing diuretic; results in excretion sodium, chloride, & water & retention of potassium & phosphate. --------- Correct Answer ---------- Spironolactone (Aldactone) Precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, & hypervolemia. --------- Correct Answer ----- ----- Heart failure ST segment elevation or depression observed. --------- Correct Answer ---------- Myocardial ischemia described as Pao2 of 60 mm Hg or lower & Paco2 of 50 mm Hg or higher in client with no history of respiratory disease. --------- Correct Answer ---------- Respiratory failure --------- Correct Answer ---------- Pulmonary embolism Oxygen used cautiously & should not exceed 2 L/min. Because long-standing hypercapnia that occurs in emphysema, respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels. --------- Correct Answer ---------- Emphysema with chronic hypercarbia & receiving oxygen Stimulates motility upper GI track. Used to stimulate gastric emptying, for treatment of gastroparesis & treat gastroesophageal reflux disease. May also be prescribed to relieve nausea & vomiting --------- Correct Answer ---------- Metoclopramide (Reglan) 1. Maintain a patent airway 2. Assess breath sounds by auscultation 3. Obtain oxygen saturation level using pulse oximetry. 4. Insert intravenous line for fluid administration. 5. Obtain an axillary temperature 6. Administer an antipyretic. --------- Correct Answer ---------- Epiglottitis suspected. Which order of priority would nurse implement actions? Will receive the diphtheria, tetanus, acellular pertussis vaccine, IPV, MMR, and varicella vaccine. --------- Correct Answer ---------- Vaccines at age 4 Relationship between brain levels dopamine & symptoms of schizophrenia. Prognosis is negatively affected when onset of symptoms occurs during adolescent years. Although medication compliance is a strong factor in minimizing recurrence of relapses, it is not only factor that has an effect. Schizophrenia has an effect on reasoning & perception, likelihood of experiencing difficulty in school is not certain. (Limit caffeine) Caffeine can inhibit action of psychotropic medications. Most clients will require continuous medication therapy to manage their symptoms. Although medication compliance is strong factor in minimizing reoccurrence of relapses, relapse could occur. --------- Correct Answer ---------- Schizophrenia Males more likely to be alcohol abusers. Alcohol abuser high risk self-inflected injury, & simultaneous use of more than one substance common. Few of those abusing alcohol receive needed treatment. Alcoholics are found at all economic strata & occur equally among married & single clients. --------- Correct Answer ---------- Alcohol abuser Central nervous system (CNS) depressants, major cause of fatal drug overdoses. Abuse of barbiturates results in both physical & psychological dependency --------- Correct Answer ---------- Barbiturates Abuse causes vasoconstriction, resulting commonly in poor wound healing & hypertension. --------- Correct Answer ---------- Methamphetamine Flashbacks, recurrence perceptual distortions; unique to use of hallucinogenic drugs. --- ------ Correct Answer ---------- Hallucinogenic drug High-pressure alarms triggered by increased airway resistance caused by excess secretions inairway, biting tube, coughing, bronchospasm, kinked ventilatory circuit, or excess condensation of water in ventilator tubing. Excess water should be emptied from tubing. Alarms should never be silenced until cause has been identified & corrected. ---- ----- Correct Answer ---------- Continuous mechanical ventilation (CMV) Low pressure alarm can be caused by disconnected tubing, ETT cuff leak, or apnea. ---- ----- Correct Answer ---------- Continuous mechanical ventilation (CMV) Formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. --------- Correct Answer ---------- Parkland (Baxter) formula Heart rate less 120 beats/min, urine output at least 30 mL/hr, peripheral pulses are +2 or better, & client oriented to client, place, & time. --------- Correct Answer ---------- Fluid resuscitation is adequate (Burn client) Presence rhonchi; indication there are secretions in large airways. Require suction if he/she cannot expectorate them. --------- Correct Answer ---------- Rhonchi Motor response points are as follows: Obeys a simple response = 6 Localizes painful stimuli = 5 Normal flexion (withdrawal) = 4 Abnormal flexion (decorticate posturing) = 3 Extensor response (decerebrate posture)= 2 No motor response to pain = 1. Verbal response points are as follows: Oriented = 5 Confused conversation = 4 Inappropriate words = 3 Respond with incomprehensible sounds = 2 No verbal response = 1 Eye opening points are as follows: Spontaneous = 4 In response to sound = 3 In response to pain = 2 No response, even to painful stimuli = 1 --------- Correct Answer ---------- Glasgow Coma Scale (GCS) Assessment vital signs, level of consciousness, & patency IV lines are priority parameters --------- Correct Answer ---------- Transferring a client to another unit or area Proximal port used because usually port with largest lumen. Blood cultures, initial specimen used for sample, line not flushed before. Turn off infusion for 1 min prevent contaminating sample with IV solution. --------- Correct Answer ---------- When drawing blood from double-lumen central venous catheter Cleaned antiseptic swab & allowed dry completely. Lateral side of finger because central tip contains more nerves & may be more painful. Hold finger dependent position improves blood flow to puncture site. Gentle pressure may be needed to obtain adequate amount blood for test strip --------- Correct Answer ---------- Blood glucose monitor Anticholinergic- Therapy overactive bladder. Side effects; dry mouth, constipation, tachycardia, urinary hesitancy, urinary retention, mydriasis, blurred vision, & dry eyes --- ------ Correct Answer ---------- Oxybutynin Treat migraine headaches. Constricts blood vessels around brain & reduces substances in body that can trigger headache pain. --------- Correct Answer ---------- Sumatriptan (Imitrex) One adverse effect is hepatotoxicity. --------- Correct Answer ---------- Gemfibrozil (Lopid) Require less hand-to-lung coordination, deliver more medication to the lungs, do not require propellant, they are not risk to environment --------- Correct Answer ---------- Dry powder inhaler (DPI) For prophylaxis & maintenance therapy of asthma, maximal effects develop within 24 hours of first dose & maintained with once-daily dosing in evening. (Not for rescue) ------ --- Correct Answer ---------- Montelukast (Singulair) Prevent or treat osteoporosis. Taken in morning at same time, on empty stomach is a priority, remain upright 30 mins after ingestion, --------- Correct Answer ---------- Alendronate (Fosamax) Disorder bone marrow, Excessive production WBC, red blood cells, & platelets. More likely form blood clots that can cause thrombi, strokes, myocardial infarctions, & abnormal bleeding. Hypertensive --------- Correct Answer ---------- Polycythemia vera Clinical manifestations; Dyspnea at rest, Clubbed fingers, Muscle retractions, & Prolonged expiratory breathing phase. Oxygen desaturation with exercise; use accessory respiratory muscles; & prolonged exhalation. Chest x-ray results indicate a hyperinflated chest & may indicate flattened diaphragm --------- Correct Answer ---------- Chronic obstructive pulmonary disease (COPD) Inflammation of mucous lining in the mouth. --------- Correct Answer ---------- Stomatitis Distorted sense of taste --------- Correct Answer ---------- Dysgeusia Dry mouth --------- Correct Answer ---------- Xerostomia Mydriatic medicationsused preoperatively in client with cataract. These medications act by dilating pupils; also constrict blood vessels. --------- Correct Answer ---------- Cataract surgery Sudden burst of black spots or floaters indicates that bleeding has occurred as a result of detachment --------- Correct Answer ---------- Detached retina 1. Raise the head of the bed. 2. Loosen tight clothing on the client. 3. Check for bladder distention. 4. Contact the health care provider 5. Administer antihypertensive medication.