HESI COMPREHENSIVE PREDICTOR STUDY GUIDE

What can be delegated to Assistive personnel (AP)? - ADLs - bathing - grooming - dressing -
ambulating - feeding (w/o swallow precautions) - positioning - bed making - specimen collection
- I&O - VS (stable clients
A nurse on a med surg unit has recieved change of shift report and will care for 4 clients. Which
of the following clients needs will the nurse assign to an AP?
A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk with a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence
D. Applying a sterile dressing to a pressure ulcer C
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP.
Which of the following info should the nurse share with the AP?
Select all:
A. the roommate is up independently
B. The client ambulates with his slippers on over his antiembolic stockings
C. The client uses a front wheeled walker when ambulating
D. The client had pain meds 30 minutes ago
E. The client is allergic to codeine
F. the client ate 50 % of his breakfast this morning B

An RN is making assignments for client care to an LPN at the beginning of the shift. Which of
the following assignments should the LPN question?
A. Assisting a client who is 24 hr postop to use an incentive spirometer
B. Collecting a clean catch urine specimen from a client who was admitted on the previous shift
C. providing nasopharyngeal suctioning for a client who has pneumonia
D. Replacing the cartridge and tubing on a PCA pump D
A nurse is preparing an inservice program about delegation. Which of the following elements
should she identify when presenting the 5 rights of delegation. Select all:
A. Right client
B. Right supervision/evaluation
C. Right direction/communication
D. Right time
E. Right circumstances B

A nurse manager of a med surg unit is assigning care responsibilities for the oncoming shift. A
client is waiting transfer back to the unit from the PACU following thoracic surgery. To which
staff member should the nurse assign the client?
A. Charge nurse
B. RN
C. LVN
D. AP B
What is the study of conduct and character? Ethics
What are the values and beliefs that guide behavior and decision making? Morals
What is the right to make ones own personal decisions, even tho those decisions might not be in
the persons best interest Autonomy
What are positive actions to help others Beneficience
What is fairness in care delivery and use of resources Justice
What is avoidance of harm or injury Non-maleficence
A nurse is caring for a client who decides not to have surgery despite significant blockages in his
coronary arteries. The nurse understands that this clients choice is an example of what principles?
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificience B
A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands
that this aspect of care delivery is an example of which of the following ethical principles? A.
Fidelity
B. Autonomy
C. Justice
D. Beneficience D
A nurse is instructing a group of nursing students about the responsibilities involved with organ
donation and procurement. When the nurse explains that all clients waiting for a kidney
transplant have to meet the same qualifications, the students should understand that this aspect of
care delivery is an example of which ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmaleficence C
A nurse questions a med prescription as too extreme and light of the clients advanced age and
unstable status. The nurse understands that this action is an example of which ethical principle
A. Fidelity
B. Autonomy
C. Justice
D. Nonmalificence D
Which of the following situations can be identified as an ethical dilemma?
A. A nurse on a med surg unit demonstrates signs of chemical impairment
B. A nurse over hears another nurse telling an older adult client that if he doesnt stay in bed she
will restrain him
C. A family has conflicting feelings about initiation of enteral tube feeding of their father who is
terminally ill

D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney
form C
Most managers can be categorized as authoritative, democratic, and laissez faire
makes decisions of the group motivates by coercion
communication occurs down the chain of command
Work output by the staff is usually high-good for crisis situations and bureaucratic settings
Authoritative
includes the group when decisions are made
Motivates by supporting star achievements
Communication occurs up and down the chain of command
Work output by staff is usually of good quality-good when cooperation and collaboration is
necessary Democratic
makes very few decisions and does little planning
motivation is largely the responsibility of individuals staff members
Communication occurs up and down the chain of command and between group members
Work output is low unless an informal leader evolves from the group
*the use of any of these styles may be appropriate depending on the situation Laissez faire
The nurse should consider the hierarchy of human needs when prioritizing interventions, which
are? - Physiological needs first (oxygen, shelter, food)
- Safety & security needs (physical safety)
- Love and belonging
- Self esteem
- Self actualization
The ABC framework identifies, in order, the three basic needs for sustaining life Airway
Breathing
Circulation
Nurses must follow what code of standards in delegating and assigning tasks ANA codes of
standards
What values would a nurse possess to be a client advocate? - caring
- autonomy
- respect
- empowerment
What do the nurse need to keep in mind about the client when being their advocate?
Client's religion & culture
When should planning discharge process begin?
A. at time of admission
B.2 days after client is admitted
C.whenever the nurse has the time to do planning
D.when the physician has the discharge order A
What is an interdisciplinary team? A group of health care professionals from different
disciplines Fill in the blank:
1. _______ is used by interdisciplinary team to make health care decisions about clients with
multiple problems. 2. ________, which may take place at team meetings, allows the achievement
of results that the participants would be incapable of accomplishing if working alone. 1&2
= collaboration
What is the nurse's contribution to an interdisciplinary team? - knowledge of nursing care
& its management
- a holistic understanding of the client, her/his healthcare needs & healthcare systems.
A four-month-old infant is admitted to the pediatric intensive care unit with a
temperature of 105°F (40.5 °C). The infant is irritable, and the nurse
observes nuchal rigidity. Which assessment finding would indicate an increase
in intracranial pressure?
1. Positive Babinski.
2. High-pitched cry.
3. Bulging posterior fontanelle.
4. Pinpoint pupils. 2
A client is receiving total parenteral nutrition (TPN). To determine the client's
tolerance of this treatment, the nurse should assess for which of the
following?
1. A significant increase in pulse rate.
2. A decrease in diastolic blood pressure.
3. Temperature in excess of 98.6°F (37°C).
4. Urine output of at least 30 cc per hour. 4
The client is exhibiting symptoms of myxedema. The nursing
assessment should reveal 1. increased pulse rate.
2. decreased temperature.
3. fine tremors.
4. increased radioactive iodine uptake level. 2
A nonstress test is scheduled for a client at 34-weeks gestation who developed
hypertension, periorbital edema, and proteinuria. Which of the following
nursing actions should be included in the care plan in order to BEST prepare
the client for the diagnostic test?
1. Start an intravenous line for an oxytocin infusion.
2. Obtain a signed consent prior to the procedure.
3. Instruct client to push a button when she feels fetal movement.
4. Attach a spiral electrode to the fetal head. 3
Which of the following nursing interventions is MOST important for a 45-year-old
woman with rheumatoid arthritis?
1. Provide support to flexed joints with pillows and pads.
2. Position her on her abdomen several times a day.
3. Massage the inflamed joints with creams and oils.
4. Assist her with heat application and ROM exercises. 4 The nurse is caring for a young
adult admitted to the hospital with a severe head injury. The nurse should position the patient
1. with his neck in a midline position and the head of the bed elevated 30°.
2. side-lying with his head extended and the bed flat.
3. in high Fowler's position with his head maintained in a neutral position. 4. in semi-Fowler's
position with his head turned to the side. 1 The nurse is teaching a 40-year-old man
diagnosed with a lower motor neuron disorder to perform intermittent self-catheterization at
home. The nurse should instruct the client to
1. use a new sterile catheter each time he performs a catheterization.
2. perform the Valsalva maneuver(holding breath and bearing down) before doing the
catheterization.
3. perform the catheterization procedure every 8 hours.
4. limit his fluid intake to reduce the number of times a catheterization is needed. 2 A client is
being discharged with sublingual nitroglycerin (Nitrostat).
The client should be cautioned by the nurse to
1. take the medication five minutes after the pain has started.
2. stop taking the medication if a stinging sensation is absent.
3. take the medication on an empty stomach.
4. avoid abrupt changes in posture. 4
A 38-year-old woman is returned to her room after a subtotal thyroidectomy
for treatment of hyperthyroidism. Which of the following, if found by the
nurse at the patient's bedside, is nonessential?
1. Potassium chloride for IV administration.
2. Calcium gluconate for IV administration.
3. Tracheostomy set-up.
4. Suction equipment. 1
A nurse recognizes that an initial positive outcome of treatment for a
victim of sexual abuse by one parent would be that the client 1.
acknowledges willing participation in an incestuous relationship.
2. reestablishes a trusting relationship with his/her other parent.
3. verbalizes that s/he is not responsible for the sexual abuse.
4. describes feelings of anxiety when speaking about sexual abuse. 3
An adolescent client is ordered to take tetracycline HCL (Achromycin) 250 mg
PO bid. Which of the following instructions should be given to this client by
the nurse?
1. "Take the medication on a full stomach, or with a glass of milk."
2. "Wear sunscreen and a hat when outdoors."
3. "Continue taking the medication until you feel better."
4. "Avoid the use of soaps or detergents for two weeks." 2 After a client develops left-sided
hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone.
Which of the following nursing diagnoses would be a priority to include in his care plan?
1. Alteration in mobility related to paralysis.
2. Alteration in skin integrity related to decrease in tissue oxygenation.
3. Alteration in skin integrity related to immobility.
4. Alteration in communication related to decrease in thought processes 2 A client has a
history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ -
4.0 mEq/L. Which nutrient should be restricted in the client's diet?
1. Protein.
2. Fats.
3. Carbohydrates.
4. Magnesium. 1
An extremely agitated client is receiving haloperidol (Haldol) IM every 30 minutes
while in the psychiatric emergency room. The MOST important nursing
intervention is to
1. monitor vital signs, especially blood pressure, every 30 minutes.
2. remain at the client's side to provide reassurance.
3. tell the client the name of the medication and its effects.
4. monitor the anticholinergic effects of the medication. 1
The nurse is caring for clients in the skilled nursing facility. Which of the following
clients require the nurse's IMMEDIATE attention?
1. A client admitted for a cerebral vascular accident (CVA) whose prescription
for warfarin (Coumadin) expired two days ago.
2. A client in pain who was receiving morphine in an acute care institution and
was transferred with a prescription for acetaminophen with codeine. 3. A client
who has dysuria and foul-smelling, cloudy, dark amber urine.
4. An immunosuppressed client who has not received an influenza immunization. 1
The nurse is observing care given to a client experiencing severe to panic levels of
anxiety. The nurse would intervene in which of the following situations?
1. The staff maintains a calm manner when interacting with the client.
2. The staff attends to client's physical needs as necessary.
3. The staff helps the client identify thoughts or feelings that occurred prior to the
onset of the anxiety.
4. The staff assesses the client's need for medication or seclusion if other interventions
have failed to reduce anxiety. 3
A 69-year-old client is undergoing his second exchange of intermittent
peritoneal dialysis (IPD). Which of the following would require an intervention
by the nurse?
1. The client complains of pain during the inflow of the dialysate.
2. The client complains of constipation.
3. The dialysate outflow is cloudy.
4. There is blood-tinged fluid around the intra-abdominal catheter. 3 The clinic nurse is
performing diet teaching with a 67-year-old client with acute gout. The nurse should teach the
client to limit his intake of 1. red meat and shellfish.
2. cottage cheese and ice cream.
3. fruit juices and milk.
4. fresh fruits and uncooked vegetables. 1
A client is scheduled for a left lower lobectomy. The physician has ordered
diazepam (Valium) 2 mg IM for anxiety. The nurse would determine that the
medication is appropriate if the client displays which of the following
symptoms?
1. Agitation and decreased level of consciousness.
2. Lethargy and decreased respiratory rate.
3. Restlessness and increased heart rate.
4. Hostility and increased blood pressure. 3
A 59-year-old woman with bipolar disorder is receiving haloperidol (Haldol)
2 mg PO tid. She tells the nurse, "Milk is coming out of my breasts." Which
of the following responses by the nurse is BEST?
1. "You are seeing things that aren't real."
2. "Why don't we go make some fudge."
3. "You are experiencing a side effect of Haldol."
4. "I'll contact your physician to change your medication." 3
The physician orders ranitidine hydrochloride (Zantac) 150 mg PO qd for
a client. The nurse should advise the client the BEST time to take this
medication is 1. before breakfast.
2. with dinner.
3. with food.
4. at hs. 4
. If a client develops cor pulmonale (right-sided heart failure), the nurse would
expect to observe
1. increasing respiratory difficulty seen with exertion.
2. cough productive of a large amount of thick, yellow mucus.
3. peripheral edema and anorexia.
4. twitching of extremities. 3
The nurse is performing triage on a group of clients in the emergency department.
Which of the following clients should the nurse see FIRST?
1. A 12-year-old oozing blood from a laceration of the left thumb due to cut on a rusty
metal can.
2. A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but
not the place and time.
3. A 49-year-old with a compound fracture of the right leg who is complaining of
severe pain.
4. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of
470 mg/dL. 2
The nurse in the outpatient clinic teaches a client with a sprained right ankle
to walk with a cane. What behavior, if demonstrated by the client, would
indicate that teaching was effective?
1. The client advances the cane 18 inches in front of her foot with each step.
2. The client holds the cane in her left hand.
3. The client advances her right leg, then her left leg, and then the cane. 4. The client holds the
cane with her elbow flexed 60°. 2 A client returns to his room following a myelogram. The
nursing care plan should include which of the following?
1. Encourage oral fluid intake.
2. Maintain the prone position for 12 hours.
3. Encourage the client to ambulate after the procedure.
4. Evaluate the client's distal pulses on the affected side. 1
The nurse is caring for a patient following an appendectomy. The patient
takes a deep breath, coughs, and then winces in pain. Which of the
following statements, if made by the nurse to the patient, is BEST? 1.
"Take three deep breaths, hold your incision, and then cough."
2. "That was good. Do that again and soon it won't hurt as much."
3. "It won't hurt as much if you hold your incision when you cough." 4.
"Take another deep breath, hold it, and then cough deeply 1
A young woman is transferred to a psychiatric crisis unit with a
diagnosis of a dissociative disorder. The nurse knows which of the following comments
by the client is MOST indicative of this disorder?
1. "I keep having recurring nightmares."
2. "I have a headache and my stomach has bothered me for a week."
3. "I always check the door locks three times before I leave home."
4. "I don't know who I am and I don't know where I live." 4 A 23-year-old man is admitted with
a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following
symptoms should the nurse expect to see INITIALLY?
1. Unequal and dilated pupils.
2. Decerebrate posturing.
3. Grand mal seizures.
4. Decreased level of consciousness. 4
. The nursing team includes two RNs, one LPN/LVN, and one nursing
assistant. The nurse should consider the assignments appropriate if the nursing
assistant is assigned to care for
1. a client with Alzheimer's requiring assistance with feeding.
2. a client with osteoporosis complaining of burning on urination.
3. a client with scleroderma receiving a tube feeding.
4. a client with cancer who has Cheyne-Stokes respirations. 1 An elderly client is returned to her
room after an open reduction and internal fixation of the left femoral head after a fracture. It is
MOST important for the nursing care plan to include that the client 1. eat a high-protein, low-
residue diet.
2. lie on her unoperated side.
3. exercise her arms and legs.
4. cough and deep breathe. 4
Which of the following is a correctly stated nursing diagnosis for a client with
abruptio placentae?
1. Infection related to obstetrical trauma.
2. Potential for fetal injury related to abruptio placentae.
3. Potential alteration in tissue perfusion related to depletion of fibrinogen.
4. Fluid volume deficit related to bleeding. 4
An 8-year-old client is returned to the recovery room after a
bronchoscopy. The nurse should position the client 1. in
semi-Fowler's position.
2. prone, with the head turned to the side.
3. with the head of the bed elevated 45° and the neck extended.
4. supine, with the head in the midline position. 1
Which of the following assessment findings would indicate to the nurse the
need for more sedation in a client who is withdrawing from alcohol
dependence?
1. Steadily increasing vital signs.
2. Mild tremors and irritability.
3. Decreased respirations and disorientation.
4. Stomach distress and inability to sleep. 1
The home care nurse is instructing a client recently diagnosed with tuberculosis.
It is MOST important for the nurse to include which of the following as a part
of the teaching plan?
1. During the first two weeks of treatment, the client should cover his mouth and nose
when he coughs or sneezes.
2. It is necessary for the client to wear a mask at all times to prevent transmission of the
disease.
3. The family should support the client to help reduce feeling of low self-esteem and
isolation.
4. The client will be required to take prescribed medication for a duration of 6-9
months. 4
The nurse's INITIAL priority when managing a physically assaultive client
is to
1. restrict the client to the room.
2. place the client under one-to-one supervision.
3. restore the client's self-control and prevent further loss of control. 4. clear the immediate area
of other clients to prevent harm. 3 A client with newly diagnosed type I diabetes mellitus is
being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet,
15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the
client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50
mg/dL. The nurse would expect the client to be
1. confused with cold, clammy skin and a pulse of 110.
2. lethargic with hot, dry skin and rapid, deep respirations.
3. alert and cooperative with a BP of 130/80 and respirations of 12.
4. short of breath, with distended neck veins and a bounding pulse of 96. 1 The nurse is
supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The
nurse determines that the staff's care is appropriate if which of the following is observed?
1. The child is placed in a private room.
2. The staff removes a toy from the child's bed and takes it to the nurse's station.
3. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
4. The staff uses standard precautions. 1
When using restraints for an agitated/aggressive patient, which of the following
statements should NOT influence the nurse's actions during this intervention?
1. The restraints/seclusion policies set forth by the institution.
2. The patient's competence.
3. The patient's voluntary/involuntary status.
4. The patient's nursing care plan. 3
The nurse is caring for an 80-year-old client with Parkinson's disease. Which
of the following nursing goals is MOST realistic and appropriate in planning
care for this client?
1. Return the client to usual activities of daily living.
2. Maintain optimal function within the client's limitations.
3. Prepare the client for a peaceful and dignified death.
4. Arrest progression of the disease process in the client. 2
A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth
I). In planning the discharge teaching, the client should be cautioned by the
nurse about which of the following?
1. Sit up for at least 30 minutes after eating.
2. Avoid fluids between meals.
3. Increase the intake of high-carbohydrate foods.
4. Avoid eating large meals that are high in simple sugars and liquids. 4 A nurse is caring for
a 37-year-old woman with metastatic ovarian cancer admitted for nausea and vomiting. The
physician orders total parenteral nutrition (TPN), a nutritional consult, and diet recall. Which
of the following is the BEST indication that the patient's nutritional status has improved after 4
days?
1. The patient eats most of the food served to her.
2. The patient has gained 1 pound since admission.
3. The patient's albumin level is 4.0mg/dL.
4. The patient's hemoglobin is 8.5g/dL. 3
A 23-year-old woman at 32-weeks gestation is seen in the outpatient clinic.
Which of the following findings, if assessed by the nurse, would indicate a
possible complication?
1. The client's urine test is positive for glucose and acetone.
2. The client has 1+ pedal edema in both feet at the end of the day.
3. The client complains of an increase in vaginal discharge.
4. The client says she feels pressure against her diaphragm when the baby moves. 1 After
abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client
becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which
of the following nursing interventions would be MOST appropriate?
1. Irrigate the nasogastric tube with distilled water.
2. Aspirate the gastric contents with a syringe.
3. Administer an antiemetic medicine.
4. Insert a new nasogastric tube. 2
After sustaining a closed head injury and numerous lacerations and abrasions
to the face and neck, a five-year-old child is admitted to the emergency
room. The client is unconscious and has minimal response to noxious
stimuli. Which of the following assessments, if observed by the nurse three
hours after admission, should be reported to the physician?
1. The client has slight edema of the eyelids.
2. There is clear fluid draining from the client's right ear.
3. There is some bleeding from the child's lacerations.
4. The client withdraws in response to painful stimuli. 2 The nurse is caring for a manic client in
the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which
of the following actions?
1. Take the client to the dining room with 1:1 supervision.
2. Inform the client he may go to the dining room when he controls his behavior.
3. Hold the meal until the client is able to come out of seclusion.
4. Serve the meal to the client in the seclusion room.4
A client is given morphine 6 mg IV push for postoperative pain. Following
administration of this drug, the nurse observes the following: pulse 68,
respirations 8, BP 100/68, client sleeping quietly. Which of the following
nursing actions is MOST appropriate?
1. Allow the client to sleep undisturbed.
2. Administer oxygen via facemask or nasal prongs.
3. Administer naloxone (Narcan).
4. Place epinephrine 1:1,000 at the bedside. 3
What type of infectious diseases are required to be reported to the health department? -
severe cases of Staphylococcus aureus infections including methicillin-resistant Staphylococcus
aureus (MRSA)
What is the process of taking a telephone order from a provider? Patient name, drug, dose,
route, frequency read back for accuracy
A nurse is caring for a client who has tuberculosis. Which of the following actions should the
nurse take? SATA

a) Place the client in a negative pressure room

b) wear gloves when assisting the client with oral care
c) limit each visitor to 2 hr increments
d) wear a surgical mask when providing care
e) Use antimicrobial sanitizer for hand hygiene A
BE
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile.
Which of the following information should the nurse include in the teaching?

a) Assign the client to a room with a negative air-flow system

b) Use alcohol-based hand sanitizer when leaving the clients room
c) clean contaminated surfaces in the clients room with a phenol solution
d) have family members wear a gown and gloves when visiting D
A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines
that the client has developed phlebitis and removes the IV catheter. Which of the following
actions should the nurse take next?

a) place a warm compress over the IV site

b) record the findings in the client's chart
c) notify the client's primary care provider
d) prepare to insert a new IV catheter A
A nurse is caring for a client who has dementia. Which of the following interventions should the
nurse take to minimize the risk for injury for this client?

a) use a bed exit alarm system

b) raise 4 side rails while client is in bed
c) apply one soft wrist restraint
d) dim the lights in the client's room A
A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following
is an appropriate nursing action?

a) implement a regular toileting schedule

b) encourage the client to wear athletic socks when ambulating
c) place all 4 bed rails in the upright position
c) require a family member to remain at the bedside A
Which of the following techniques should the nurse use when performing nasotracheal
suctioning for a client?

a) insert the suction catheter while the client is swallowing

b) apply intermittent suction when withdrawing the catheter
c) place the catheter in a location that is clean and dry for later use
d) hold the suction catheter with the clean, non-dominant hand B
A nurse is caring for a client following an acute myocardial infarction. The client is concerned
that providing self-care will be difficult due to extreme fatigue. Which of the following strategies
should the nurse implement to promote the client's independence?

a) request an occupational therapy consult to determine the need for assistive devices
b) assign assistive personnel to perform self-care tasks for client
c) instruct the client to focus on gradually resuming self-care tasks
d) ask the client if a family member is available to assist with his care C
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the
following is an expected finding?

a) serum albumin level of 3 g/dL

b) HDL level of 90 mg/dL
c) Norton scale score of 18
d) Braden scale score of 20 A
A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following
client statements indicates an understanding of the procedure?

a) "I had a bowel movement, but I was able to save the urine"
b) "I have a specimen in the bathroom from about 30 minutes ago"
c) "I flushed what I urinated at 7 am and have saved the rest since"
d) "I drink a lot, so I will fill up the bottle and complete the test quickly" C
A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the
following should be used to irrigate the tube in order to maintain fluid and electrolyte balance?

a) tap water
b) sterile water
c) 0.9% sodium chloride
d) 0.45% sodium chloride C
A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness.
Which of the following should the nurse include in the teaching?

a) use the cane on the weak side of the body

b) advance the cane and the atrong leg simultaneously
c) maintain two points of support on the floor
d) advance the cane 30 to 45 cm (12-18 in) with each step C
Which of the following should indicate to a nurse the need to suction a client's tracheostomy?

a) irritability
b) hypotension
c) flushing
d) bradycardia A
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following
actions should the nurse take?

a) wear sterile gloves when removing the old dressing

b) warm the irrigation solution to 40.5C (105F)
c) cleanse the wound from the center outwards
d) use a 20 mL syringe to irrigate the wound C
A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse
instruct the client to avoid?

a) lemon-lime sports drinks

b) ginger ale
c) black coffee
d) orange sherbet D
A nurse is caring for a client who is having difficulty voiding following the removal in an
indwelling urinary catheter. Which of the following interventions should the nurse take?

a) assess for bladder distention after 6 hr

b) encourage the client to use a bed pan in the supine position
c) restrict the clients intake of oral fluids
d) pour warm water over the clients perineum D
When caring for the client diagnosed with delirium, which condition is the most important for the
nurse to investigate?
1. Cancer of any kind.
2. Impaired hearing.
3. Prescription drug intoxication. 4. Heart failure. 3
Which of the following is essential when caring for a client who is experiencing delirium?
1. Controlling behavioral symptoms with low-dose psychotropics.
2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to
increase orientation.
4. Decreasing or discontinuing all previously prescribed medications. 2
Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client
with delirium?
1. Explain the experience of having delirium.
2. Resume a normal sleep-wake cycle.
3. Regain orientation to time and place.
4. Establish normal bowel and bladder function. 3
A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To
ensure the client's safety while walking in the halls, the nurse should do which of the following?
1. Administer PRN haloperidol (Haldol) to decrease the need to walk.
2. Assess the client's gait for steadiness.
3. Restrain the client in a geriatric chair.
4. Administer PRN lorazepam (Ativan) to provide sedation. 2
During a home visit to an elderly client with mild dementia, the client's daughter reports that she
has one major problem with her mother. She says, "She sleeps most of the day and is up most of
the night. I can't get a decent night's sleep anymore." Which suggestions should the nurse make
to the daughter? Select all that apply.
1. Ask the client's physician for a strong sleep medicine. 2. Establish a set routine for rising,
hygiene, meals, short rest periods, and bedtime.
3. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the
day.
4. Promote relaxation before bedtime with a warm bath or relaxing music.
5. Have the daughter encourage the use of caffeinated beverages during the day to keep her
mother awake. 2
3
4
The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse
anticipates administering this medication to help decrease which of the following behaviors?
1. Sleep disturbances.
2. Concomitant depression.
3. Agitation and assaultiveness.
4. Confusion and withdrawal. 3
The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client
recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the
family about the use of lorazepam (Ativan). The nurse should instruct the family to report which
of the following significant side effects to the health care provider?
1. Paradoxical excitement.
2. Headache.
3. Slowing of reflexes.
4. Fatigue. 1
When providing family education for those who have a relative with Alzheimer's disease about
minimizing stress, which of the following suggestions is most relevant?
1. Allow the client to go to bed four to five times during the day.
2. Test the cognitive functioning of the client several times a day.
3. Provide reality orientation even if the memory loss is severe.
4. Maintain consistency in environment, routine, and caregivers 4
What are some ways to identify a patient before giving a medication? The Joint
Commission requires 2 client identifiers be used when administering medications.
- clients name
- assigned identification number
- telephone number
- birth date or other personal-specific identifiers. Bar code scanners may be used to identify
clients
What are some things to teach about home safety with elderly patients? - Removing items that
could cause the client to trip, such as throw rugs and loose carpets
- Placing electrical cords and extension cords that against a wall behind furniture
- Making sure that steps and sidewalks are in good repair
- Placing grab bars near the toilet and in the tub or shower and installing a stool riser
- Using a non-skid mat in the tub or shower
- Placing a shower chair in the shower
- Ensuring that lighting is adequate both inside and outside of the home
A nurse is providing discharge instructions to a client who has a prescription for the use of
oxygen in
his home. Which of the following should the nurse teach the client about using oxygen safely in
his home? (Select all that apply.)
A. Family members who smoke must be at least 10 ft from the client when oxygen is in use.
B. Nail polish should not be used near a client who is receiving oxygen.
C. A "No Smoking" sign should be placed on the front door.
D. Cotton bedding and clothing should be replaced with items made from wool. E. A fire
extinguisher should be readily available in the home. B
C
E
A nurse is providing home safety instructions to a group of older adult clients. Match the safety
risk with the appropriate instruction. ____ Passive smoking
____ Carbon monoxide poisoning
____ Food poisoning
A. Have water heaters inspected on an annual basis.
B. Cook all meat at an appropriate temperature.
C. Avoid enclosed areas with others who may be smoking.
C
A
B
When performing nasotracheal suctioning what technique should be used? Sterile asepsis bc the
trachea is considered sterile and prevents infections
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses.
The nurse educator evaluates the teaching as effective when the newly licensed nurse states the
client who has heat stroke will have which of the following?
A. Hypotension
B. Bradycardia
C. Clammy skin
D. Bradypnea A
What do you do when a client has a seizure - lower to bed/floor
- protect head, move nearby furniture, provide privacy, - - put on side with head flexed slightly
forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for
help
-admin meds as ordered
-note duration of seizure and sequence and type of movement
seclusion and restraints -must be ordered
-should be ordered for the shortest duration necessary and only if less restrictive measures are not
sufficient
-a client may voluntarily request temp seclusion
-restraints can be physical or chemical
-if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be
performed and documented every 15-30 min
What position is good to use for a patient who is at high risk for a pressure ulcer 30 degree lateral
position is recommended for clients at risk for pressure ulcers
health promotion (injury prevention-suffocation): infant (birth-1 yr) -avoid plastic bags -
keep balloons out of reach
-ensure crib mattress fits snugly
-ensure crib slats are no more than 6 cm (2.4 in) apart
-remove crib mobiles and gyms by 4-5 months
-do not use pillows in crib
-place infant on back for sleep
-keep toys with small parts out of reach
-remove drawstrings from jackets and other clothing
hypotension is classified with a reading below normal; systolic < 90 mm Hg; can be a result
of fluid depletion, heart failure, or vasodilation
What temperature should pork be cooked at 160 degrees
What is the safest way to thaw out frozen foods In the refrigerator
What are the precautions for vancomycin resistant enterococcus Standard precautions
including hand washing and gloving should be followed
What does a newborns poop look like If your baby is exclusively breastfed, her poop will
be yellow or slightly green and have a mushy or creamy consistency What is appropriate for an
adolescent in the hospital? Puzzles and books
What is the proper nutrition during pregnancy - Folic acid is important for pregnancy, as it
can help to prevent birth defects known as neural tube defects, including spina bifida
- green leafy vegetables and brown rice
What should be avoided during pregnancy Do not take vitamin A supplements, or any
supplements containing vitamin A (retinol), as too much could harm your baby
What is the most appropriate method for contraception for an adolescent IUD or implant If a
patient has anorexia nervosa and works out constantly Allow them to workout and continue their
regimen
What medications can be taken to help with smoking cessation Bupropion hydrochloride is a
medicine for depression, but it also helps people quit smoking. Brand names include Zyban®,
Wellbutrin®, Wellbutrin SR® and Wellbutrin XL® but this medication is also available as a
generic. Varenicline (chantix)
What are the five stages of grief denial
anger bargaining depression acceptance
discrete and applies the letting go of an object or person before the loss as in the case of terminal
illness
individuals have the opportunity to greet before the actual loss anticipatory grief
involves difficult progression through the expected stages of the grieving process
grief work is prolonged and manifestations more severe client may develop suicidal
ideation, intense feelings of guilt and lowered self-esteem somatic complaints persist
for an extended period of time dysfunctional grief
Signs for meningococcemia Vomiting, febrile, petechial rash (unstable)
Levothyroxine effects Used to restore client's metabolic rate
* Toxic effects = heat intolerance, Tachycardia, Weight loss, Hypertension
Multiple Sclerosis Patient Mitoxantrone SE's Mitoxantrone IV every 3 months (chemo drug)
* Report Sore Throat
(greatest risk for client is severe infection due to myelosuppression from mitoxantrone)
* Vomiting = causes dehydration
* Hair Loss = emotional distress
* Amenorrhea = emotional distress
Malnourished COPD patients (1) Limit liquid intake at meal times
(2) Consume foods w/ protein (like eggs)
(3) Maintain an upright position (High Fowler's position) to promote ventilation
(4) Use milk instead of water when making soup
Which grief process is it when Client exhibits increased anxiety + may project anger toward self
+ others
"I don't deserve to die, this isn't fair" Anger stage
Which Grief Process when Client acknowledges the impending loss while remaining hopeful
"If I could just make it through this, I'd never smoke again" Bargaining Stage
How should you respond when client wants to discontinue dialysis "What has changed to make
you decide this?"
= Seek clarification from client to establish mutual understanding while staying therapeutic What
should the nurse do when one member of a support group expresses anger repeatedly?
Focus more on the group members who have a positive outlook
(Speak to group member privately to uncover source of anger)
What immunizations are CONTRAINDICATED for pregnant women + which SHOULD be
given? Contraindicated = Herpes Zoster + Varicella + MMR (measles, mumps, rubella)

Should give = TDaP (Tetanus, Diphtheria, Pertussis)

Long term effects of NSAIDS (Ibuprofen) Gastric Ulcerations, perforations, hemorrhage,
hypertension
Alcohol Use Manifestations of Withdrawal Body burns 0.5 oz of alcohol per hour
* Withdrawal appears within 4-12 hours
* Irritability + Tremors + Anxiety
* Nausea + Vomiting + HA
* Diaphoresis
* Sleep Disturbances
* TACHYCARDIA + HTN

Use Benzodiazepines = tx
Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium)
When does Discharge planning begin? At Admission
Case Management nursing involves: *Decreasing cost by improving client outcomes
* Providing education to optimize health participation
* Advocating for services + client's rights
What is bipolar disorder? Bipolar disorder is a mood disorder with recurrent episodes of
depression and mania.
What comorbidities may be observed with a patient who is bipolar? Substance use
disorder (experiences more rapid cycling), anxiety disorders, eating disorders, ADHD. What
therapy will be useful for patients with bipolar? Electroconvulsive therapy for the patient
who is suicidal or rapid cycling who HAS taken Lithium and has proven ineffective.
Used to subdue manic behavior.
What kind of medications are indicated for abstinence maintenance of alcohol? Disulfiram
(Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral)
Teaching points for naltrexone (Vivitrol)? Take with meals to supress GI distress. Monthly IM
injections should be suggested for patients who have difficulty to adhering to the medication
regimen.
A nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping
syndrome, the nurse should advise the client to: a) restrict fluid intake to 1 qt (1,000
ml)/day.
b) drink liquids only between meals.
c) don't drink liquids 2 hours before meals.
d) drink liquids only with meals. B
A patient who has undergone colostomy surgery is experiencing constipation. Which of the
following interventions should a nurse consider for such a patient? a) Instruct the patient to
keep a record of food intake
b) Instruct the patient to avoid prune or apple juice
c) Suggest fluid intake of at least 2 L per day
d) Assist the patient regarding the correct diet or to minimize food intake C
A client is admitted with a diagnosis of acute appendicitis. When assessing the abdomen, the
nurse would expect to find rebound tenderness at which location? a) Left lower quadrant
b) Left upper quadrant
c) Right upper quadrant
d) Right lower quadrant D
Which outcome indicates effective client teaching to prevent constipation? a)
The client reports engaging in a regular exercise regimen.
b) The client limits water intake to three glasses per day.
c) The client verbalizes consumption of low-fiber foods.
d) The client maintains a sedentary lifestyle. A
Patients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which of the
following is a sign of potential hypovolemia? a) Hypotension
b) Bradycardia
c) Warm moist skin
d) Polyuria A
The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool,
which of the following characteristics would the nurse be most likely to find? a) Green color
and texture
b) Black and tarry appearance
c) Clay-like quality
d) Bright red blood in stool B
After teaching a group of students about the various organs of the upper gastrointestinal tract and
possible disorders, the instructor determines that the teaching was successful when the students
identify which of the following structures as possibly being affected? a) Large intestine
b) Ileum
c) Stomach
d) Liver C
A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this
client during the first 24 hours after admission? a) Skim milk
b) Nothing by mouth
c) Regular diet
d) Clear liquids B
Bladder retraining for the treatment of urge incontinence: • Use timed voidings to increase
intervals between voidings/decrease voiding frequency.
• Perform pelvic floor (Kegel) exercises.
• Perform relaxation techniques.
• Offer undergarments while the client is retraining.
• Teach the client not to ignore the urge to void.
• Provide positive reinforcement as client maintains continence.
• Eliminate or decrease caffeine drinks.
• Take diuretics in the morning. what are normal creatinine levels?
what are normal BUN levels? 0.8-1.4 mg/dL
8-25 mg/dL
What are total serum protein values (normals) 6-8 g/dL
Describe pre-albumin this is the best tool for evaluating nutrition. it has a half-life of 2 days
which is much shorter than albumin so it is much more accurate. (albumin's half-life is 2-3
weeks) what is normal pre-albumin values? what are normal serum levels of magnesium ?
what is a normal potassium serum level? 17-40 mg/dL
1.5-2.5 mEq/L (less than 1.5 is considered hypomagnesemia) 3.5-5.0 mEq/L (less than 3.5 is
considered hypokalemia) what are good sources of folic acid? Excellent sources of folate
include romaine lettuce, spinach, asparagus, turnip greens, mustard greens, calf's liver, parsley,
collard greens, broccoli, cauliflower, beets, chicken liver and lentils.
Sources of potassium beans, spinach, potatoes, dried apricots, acorn squash, yogurt, salmon,
avocados, mushrooms and bananas what is important about the diet of someone taking ACE
inhibitors? can result in high potassium levels. Limit potassium intake (beans, spinach,
potatoes, dried apricots, acorn squash, yogurt, salmon, avocados, mushrooms and bananas)
Taking Coumadin. Which foods should the client limit? Foods containing Vitamin K. Dark
leafy greens (spinach), brussel sprouts, broccoli, asparagus, cabbage, pickels, prunes what
is a normal hematocrit level in a female?
What are normal Hgb values (female)?
what are normal values for WBCs? 37-48% (male is 42-52%)
12-16 g/dL (male 13-17) 4500-11,000 / uL what foods should you avoid if you have
diverticulitis? avoid hard-to-digest foods such as nuts, corn, popcorn, and seeds, for fear that
these foods would get stuck in the diverticula and lead to inflammation. (Eat foods high in
fiber)
When taking MAOI's, limit your consumption of thyramine--it can cause elevated BP. This is
found in "aged" products such as aged cheeses (swiss), cured meats (pepperoni/salomi),
sauerkraut, soy sauce...Examples of MAOI's are: Isocarboxazid (Marplan), Phenelzine (Nardil),
Selogilive, Emsam, Eldepryl, Zelapar...
At what age does bone loss begin with osteoporotis what
are normal Calcium levels? at age 35 (women)
8.6-10 mg/dL
A positive Chvosteks sign is found in a patient. The nurse would anticipate IV administration of
calcium gluconate (because hypocalcemia causes Chvostek's sign)
What are the S/S of lithium toxicity?
(depakote for bipolar disorder) fine hand tremors, mild GI upset, slurred speech and
muscle weakness
a nurse is obtaining a medication history from a client who is to start a new prescription for
warfarin ( Coumadin) . which of the following over the counter medication should the nurse
instruct the client to avoid Aspirin
a nurse responsible for a client receiving a antihypertensive medication is to teach the
client to change position slowly to avoid dizziness or fainting
a client should receive a dose of flumazenil ( romazicon) to treat symptoms of
benzodiazepine overdose
a nurse is reinforcing teaching to a client who is prescribed diazepam tor anxiety of the following
statement indicated the client understand the teaching I will tell my doctor before I stop
taking the medication a nurse is reinforcing teaching to a client who is starting amitriptyline (
Elavil) for treatment of depression which of the following should the nurse include 1. change
position slowly to minimize dizziness
2. chewing sugarless gum to prevent dry mouth
a client who is start taking lithium carbonate month ago tell the nurse she has just begun taking
multiply daily doses of ibuprofen ( motrin) for tension headache. should the client avoid
ibuprofen. why or why not ? what , if any is the appropriate action for the nurse to take NSAIDS
such as ibuprofen increase the renal reabsorption of lithium carbonate , possibly leading to
lithium carbonate toxicity . therefor this client would avoid NSAIDS . the nurse should notify the
provider of client headache and ibuprofen us a client has prescription for valproic ( Depakote)
which of the following laboratory value should the nurse anticipate monitor for the client taking
this medication thrombocytes, amylase count and liver function test alcohol withdrawal
heroin withdrawal nicotine withdrawal alcohol abstinence
opioid over dose chlordiazeproxide( Librium) methadone( dolophine) bupropion
( wellbutrin) disulfiram ( antabuse) naloxone (narcan) a client who has parkinson's
disease is prescribed levodopa/carbidopa ( sinemet) and pramipexole ( Mirapex) for
which of the following should the nurse monitor this client orthostatic
hypotension
a nurse is preparing to care for a client in the surgical unit who will be receiving lorazapam (
ativan IV) . for what adverse effect should the nurse monitor this client the nurse should
monitor the client respiratory depression a client has a new prescription for spironilactone (
aldactone ) which of the following laboratory value should the nurse recognized as a reason to
withhold the morning dose of the medication and notify the provider serum potassium 5.2
a nurse is caring for a client who prescribed daily dose of both digoxin ( llanoxin ) and
furosemide ( Lasix) . the client potassium level 3.2 mEq/L for which of the following medication
interaction is the client at risk Toxic level of digoxin a nurse is reinforcing a teaching on a client
who has a prescription for verapamil ( calan) which of the following statement by the client
indicated need further teaching i should decrease the amount of calcium in my diet while
taking the medication
A nurse is caring for an older adult client who ahs a new prescription for digoxin and takes
multiple other medications. Concurrent use of which of the following medications places the
client at risk for digoxin toxicity? * Verapamil (Calan)
Adverse effect of Verapamil Avoid grapefruit juice
Interaction of diuretics and ACE inhibitors excessive reduction in blood pressure and
symptomatic hypotension or hyperkalemia
What can prevent MI, stroke, or death in high-risk patients Ramipril
What to monitor for when taking enoxaparin (lovenox) Hyperkalemia

Cases of headache, hemorrhagic anemia, eosinophilia, alopecia, hepatocellular and cholestatic

liver injury reported
What are the therapeutic effects of protamine Antidote to severe heparin overdose +
Reversal of heparin administered during procedures
How to prevent adverse effects of oxycodone can cause respiratory depression.

What is the nursing intervention and/or client education ? Monitor vital signs.
› Stop opioids for respiratory rate less than 12/min, and notify the provider.
› Have naloxone and resuscitation equipment available.
› Avoid use of opioids with CNS depressant medications (barbiturates,
benzodiazepines, consumption of alcohol). opioid agonists can cause
Constipation

What is the nursing intervention and/or client education ? Advise the client to increase
fluid/fiber intake and physical activity.
› Administer a stimulant laxative such as bisacodyl (Dulcolax) to counteract
decreased bowel motility, or a stool softener such as docusate sodium (Colace) to
prevent constipation.
Adverse effects of ferrous sulfate constipation;
upset stomach; black or dark-colored stools; or.
temporary staining of the teeth.
Baclofen (Lioresal) therapeutic outcome: Decrease the frequency and severity of muscle
spasms (MS).
What is the difference between respiratory acidosis and respiratory alkalosis? Acidosis
refers to an excess of acid in the blood that causes the pH to fall below 7.35, and alkalosis refers
to an excess of base in the blood that causes the pH to rise above 7.45.
Bowel elimination how to get a specimen collection Collect stool specimens for serial fecal
occult blood (guaiac) testing 3 times from 3 different defecations. Stool samples should come
from fresh stools that are not contaminated with water or urine.
Identifying manifestations of transient ischemic attacks symptoms r/t afffected area. Rapid
onset of weakness, numbness, aphasia, visual field cuts. 1-2 clusters before stroke.
Musculoskeletal congenital disorders Monitor skin for breakdown areas and prevent pressure
sores.
The nurse caring for a child in Buck's skin traction will keep the: Child pulled up in bed Where
should the cath bag be placed when urinary catheterization Make sure the catheter bag/system is
at a level below the client's bladder to avoid reflux.
What are the signs and symptoms of fluid volume deficit loss of total body Na. Causes include
vomiting, excessive sweating, diarrhea, burns, diuretic use, and kidney failure. Clinical features
include diminished skin turgor, dry mucous membranes, tachycardia, and orthostatic
hypotension.
What is the nursing action for dehiscence Cover with a sterile towel moistened with sterile
saline; Have patient flex knees slightly and put in Fowler's .
Which of these instructions should a nurse include in the teaching plan for a client who had
removal of a cataract in the left eye?
a. "Forcefully cough and take deep breaths every two hours to keep your airway clear."
b. "Perform the prescribed eye exercises each day to strengthen your eye muscles."
c. "Rinse your eyes with saline each morning to prevent postoperative infection."
d. "Take the prescribed stool softener to avoid increasing intraocular pressure." d. "Take the
prescribed stool softener to avoid increasing intraocular pressure."
A client vomits during a continuous nasogastric tube feeding. A nurse should stop the feeding
and take which of these actions? a. Suction the nasogastric tube.
b. Flush the tube with 30 mL of sterile water.
c. Remove the nasogastric tube.
d. Check the residual volume. d. Check the residual volume.
Which of these actions best demonstrates cultural sensitivity by a nurse? a.
The nurse talks in a slow-paced speech.
b. The nurse asks clients about their beliefs and practices toward pregnancy.
c. The nurse uses charts and diagrams when teaching pregnant clients.
d. The nurse can speak several different languages. b. The nurse asks clients about their beliefs
and practices toward pregnancy.
Which of these manifestations should a nurse expect to observe in a 3-month-old infant who is
diagnosed with dehydration? a. Hyperreflexia.
b. Tachycardia.
c. Bradypnea.
d. Agitation. b. Tachycardia.
When assessing a client's risk of developing nosocomial infection, a nurse plans to determine
potential entry portals, which include: a. the urinary meatus.
b. vomitus.
c. contaminated water.
d. sexual intercourse. a. the urinary meatus.
A client who is on the inpatient psychiatric unit has a history of violence. Which of these actions
should a nurse take if the client is agitated?
a. Encourage the client to verbalize feelings.
b. Lock the client in a secluded room.
c. Ask the other clients to give feedback regarding the client's behavior.
d. Ignore the client's inappropriate behavior. a. Encourage the client to verbalize feelings. Which
of these measures should a nurse include when planning care for a school-aged child during a
sickle cell crisis episode?
a. Monitoring for signs of bleeding.
b. Providing pain relief.
c. Administering cool sponge baths to reduce fevers.
d. Offering a high calorie diet. b. Providing pain relief.
Which of these instructions should a nurse include in the plan of care for a 32-week gestation
client who had an amniocentesis today?
a. "Drink at least six glasses of fluids during the next six hours after the test."
b. "Call the clinic if you experience any abdominal cramps."
c. "Don't be concerned if you have some vaginal spotting in the next 12 hours."
d. "When you get home, stay on bed-rest for the next 48 hours." b. "Call the clinic if you
experience any abdominal cramps."
An adolescent has a nursing diagnosis of fatigue related to inadequate intake of iron-rich foods.
Selection of which of these lunches by the client indicates a correct understanding of foods high
in iron content?
a. Peanut butter and jam sandwich.
b. Chicken nuggets with rice.
c. Tuna salad sandwich.
d. Beefburger with cheese. d. Beefburger with cheese.
A client has been admitted with acute pancreatitis. Which of these laboratory test results supports
this diagnosis?
a. Elevated serum potassium level.
b. Elevated serum amylase level.
c. Elevated serum sodium level.
d. Elevated serum creatinine level. b. Elevated serum amylase level.
Which of these manifestations, if assessed in a client who is two-hours postoperative after
abdominal surgery, should a nurse report immediately? a. Vomiting and a pulse rate of
106/minute.
b. Respiratory rate of 12/minute and urine dribbling.
c. Blood pressure of 100/60 mm Hg and wound discomfort.
d. Urine output of 100 mL/hr and flushed skin. a. Vomiting and a pulse rate of 106/minute.
Which of these observations of a student nurse's behavior while interacting with a client who
is crying indicates a correct understanding of therapeutic communication? a. The student
maintains continuous eye contact with the client.
b. The student places one arm around the client's shoulder?
c. The student sits quietly next to the client.
d. The student leaves the room to provide privacy for the client. c. The student sits quietly
next to the client.
Which of these actions should a nurse take initially if a client who is diagnosed with diabetes
mellitus develops tremors and ataxia?
a. Measure the client's blood sugar level.
b. Administer a concentrated form glucose to the client.
c. Administer a prn dose of insulin.
d. Measure the client's urine for ketones. a. Measure the client's blood sugar level.
An elderly client is at increased risk of developing drug toxicity to prescribed medications due to
declining hepatic and renal functioning. Which of these strategies should a nurse plan to decrease
this risk?
a. Increasing the time interval between medication doses.
b. Limiting the client's oral fluid intake.
c. Administering the medications with meals.
d. Encouraging the client to void every three to four hours. a. Increasing the time interval
between medication doses.
A client has persistent paranoid delusions that the food on the unit is poisoned. Which of these
measures should a nurse include in the client's care plan? a. Explaining that staff does not
poison clients.
b. Focusing on how the hospital staff helps clients.
c. Allowing the client to eat food from sealed containers.
d. Telling the client that not eating the food that is served will result in privilege restrictions.
 c. Allowing the client to eat food from sealed containers.
Thrombophlebitis is a complication that may result due to surgery. Which of these actions should
a nurse take in the operating room to prevent this complication from occurring?
a. Gatch the knee of the bed.
b. Administer anticoagulants preoperatively.
c. Apply sequential compression devices.
d. Maintain the legs in a dependent position. c. Apply sequential compression devices. When
discussing weigh gain during pregnancy, a nurse should recommend that the total weight gain
for a pregnant client who is at ideal body weight for her height is: a. at least 15 pounds.
b. 15 to 20 pounds.
c. 25 to 35 pounds.
d. at least 45 pounds. c. 25 to 35 pounds.
Which of these manifestations, if reported by a client who is 10-weeks-pregnant, supports the
diagnosis of ruptured tubal pregnancy. a. Sharp unilateral abdominal pain.
b. Uncontrollable vomiting.
c. Marked abdominal distention.
d. Profuse vaginal bleeding. a. Sharp unilateral abdominal pain.
Which of these assignments, if made by a nurse to a nursing assistant, indicates that the nurse
needs additional instructions regarding the principles of delegation?
a. "Please bathe the client in room 12, and then bring the client to the dining room for
breakfast by 9 A.M."
b. "Please bathe the client in room 10, administer a back rub, and then evaluate if the back
rub eased the client's discomfort."
c. "Please measure the intake and output for the client's in rooms 8. 9. and 10, and record
each on the intake/output sheets by 2 P.M."
d. "Please toilet the clients in rooms 11, 12, and 13 mid-morning and after lunch." b. "Please
bathe the client in room 10, administer a back rub, and then evaluate if the back rub eased the
client's discomfort."
A client has the following order for regular insulin (Humulin R) on a sliding scale:
Blood sugar 150-180 mg: Give 2 units regular insulin
Blood sugar 181-200 mg: Give 4 units regular insulin
Blood sugar 201-220 mg: Give 6 units of regular insulin
Blood sugar above 220 mg: Call MD
At 11 A.M., a nurse obtains a finger stick glucose of 198 mg. The only syringe is a three
milliliter one. Regular insulin is available as 100 units per milliliter. How many milliliters should
the nurse administer? a. 0.04
b. 0.4
c. 4
d. 40 a. 0.04
Which of these nursing diagnosis is the priority for a client who is one-hour postoperative after
extensive abdominal surgery?
a. Risk for impaired physical mobility.
b. Risk for deficient fluid volume.
c. Risk for ineffective airway clearance.
d. Risk for infection. c. Risk for ineffective airway clearance.
A nurse should recognize that which of these occupations increases a person's risk of developing
hepatitis B?
a. Sanitation worker.
b. Nursery school teacher.
c. Hemodialysis nurse.
d. Fish market sales person. c. Hemodialysis nurse.
Which of these assessments is the priority for a client who sustained second-degree burns of the
face and neck?
a. Respiratory status.
b. Renal function.
c. Level of pain.
d. Signs of infection. a. Respiratory status.
A nurse should place a child who is two hours post-tonsillectomy and adenoidectomy in which
of these positions? a. Supine, flat.
b. Orthopneic.
c. Trendelenberg.
d. Side-lying. d. Side-lying.
Which of these instructions should a nurse include in the discharge teaching for a client who has
diabetes mellitus?
a. "Soak your feet in hot water once a day."
b. "Cut your toenails in an oval shape weekly."
c. "Avoid using any soap on your feet."
d. "Apply lotion to your feet each day." d. "Apply lotion to your feet each day." A nurse
inadvertently administers an incorrect medication to a client. Which of these actions should
the nurse take first? a. Assess the client.
b. Notify the physician.
c. Contact the nurse manager.
d. Complete an incident report. a. Assess the client.
An elderly client who is receiving a blood transfusion develops a rapid bounding pulse and an
elevated blood pressure. Which of these actions should a nurse take? a. Add a 5% dextrose
solution to the line.
b. Raise the head of the bed.
c. Stop the transfusion.
d. Measure the client's temperature. c. Stop the transfusion. When caring for a client who has
hepatitis B, a nurse should wear: a. gloves when administering oral medications to the client.
b. a gown when changing the client's position.
c. gloves when removing the intravenous cannula.
d. a gown when emptying the client's used bath water. c. gloves when removing the
intravenous cannula.
Which of these outcome criteria is appropriate for a client who has a nursing diagnosis of
ineffective airway clearance?
a. Absence of wheezing throughout the lung fields.
b. Clear lung sounds on auscultation.
c. Pulse oximetry level of 80%.
d. Frequent coughing throughout the day. b. Clear lung sounds on auscultation.
A doctor prescribes liquid oral iron medication for a 4-year-old child. Which of these questions
should a nurse ask the child's mother to determine if the medication is being administered
correctly?
a. "Are you using a straw to administer the medicine?"
b. "Has your child been urinating more frequently?"
c. "Have you increased your child's milk intake each day?"
d. "Is there a change in the color of your child's skin?" a. "Are you using a straw to
administer the medicine?"
Which of these assessment findings, if present in a 4-month-old infant who has severe diarrhea,
should a nurse recognize as suggestive that the infant is dehydrated? a. Bulging anterior
fontanel.
b. Pulse rate of 120/minute.
c. Decreased urine output.
d. Cyanosis of the mucus membrane. c. Decreased urine output.
Which of these instructions should be included in the teaching plan for the parents of a 10month-
old infant who is admitted to the hospital for failure to thrive?
a. Advise the mother to make sure the infant drinks the entire bottle at each feeding.
b. Encourage the mother to feed the infant slowly in a quiet environment.
c. Teach the mother to position the infant on the abdomen following feedings.
d. Instruct the mother to play actively with the infant during bottle feedings. b. Encourage
the mother to feed the infant slowly in a quiet environment.
When a newborn is 48 hours old, a nurse notes that the child is jaundiced. The nurse should
recognize which of these conditions as a probable cause of the newborn's jaundice? a.
Dehydration.
b. Liver immaturity.
c. ABO incompatibility.
d. Gallbladder immaturity. b. Liver immaturity.
Which of these items should a nurse removed from the food tray of a client who is on a
sodiumrestricted diet?
a. Packet of a salt substitute.
b. Grapefruit juice.
c. Container of jelly.
d. Ketchup. d. Ketchup.
Which of these statements, if made by a client who had a total hip replacement, would indicate a
correct understanding of the postoperative instructions?
a. "I will stoop carefully to pick up items from the floor."
b. "I will use a raised toilet seat in the bathroom."
c. "I will bend forward when tying my shoes."
d. "I will put my leg through the full range of motion each day." b. "I will use a raised toilet
seat in the bathroom."
Which of these measures should a nurse include when planning care for an 88-year-old client
who is admitted to the hospital with pneumonia?
a. Restricting visitors to the client's immediate family members.
b. Limiting the client care activities to no more than five minutes each.
c. Allowing the client to perform self-care as tolerated.
d. Providing the client with a non-stimulating environment. c. Allowing the client to perform
self-care as tolerated.
A client, who is newly diagnosed with cancer says to anurse, "I suppose I need to complete all
unfinished business as soon as possible." Which of these responses is appropriate? a. "Yes,
you should do this immediately.
b. "Don't you think you should stay focused on your treatment for now?
c. "Exactly what things are you talking about?"
d. "It sounds like you are concerned with your diagnosis." d. "It sounds like you are concerned
with your diagnosis."
Which of these interventions should plan for a child who is receiving chelation therapy for lead
poisoning?
a. Keeping an accurate record of intake and output.
b. Instituting measures to prevent skeletal fractures.
c. Maintaining isolation precautions.
d. Maintaining strict bed rest. a. Keeping an accurate record of intake and output.
A nurse obtains these vital signs on an adult client. Which finding should the nurse follow-up
first?
a. Heart rate, 60/minute and regular.
b. Respiration, 30/minute and deep.
c. Temperature, 97.1 °F (36.2 °C)
d. Blood pressure, 136/86 mm Hg b. Respiration, 30/minute and deep.
When determining the duration of a uterine contraction, a nurse should measure the contraction
from the:
a. beginning of one contraction to the end of that contraction.
b. end of one contraction to the beginning of the next contraction.
c. beginning of one contraction to the beginning of the next contraction.
d. strongest point of one contraction to the strongest point of the next contraction. a. beginning of
one contraction to the end of that contraction.
A nurse should recognize which of these signs is a probably sign of pregnancy? a.
Frequency of urination.
b. Positive pregnancy test.
c. Nausea in the morning.
d. Abdominal distention. b. Positive pregnancy test.
All of these clients are on bed rest. Which one is the most at risk to develop skin breakdown? a.
An 82-year-old client who bathes once a week.
b. An 83-year-old client who applies powder after drying the skin.
c. An 84-year-old client who has been NPO for four days.
d. An 85-year-old client who has coronary artery disease. c. An 84-year-old client who has
been NPO for four days.
A client diagnosed with type 1 diabetes mellitus has a glycosylated hemoglobin A1c of 4.2%. A
nurse should interpret this to mean that the client has: a. had a period of sustained
hyperglycemia.
b. been non-compliant with home management.
c. been in relatively good diabetic control.
d. eaten a high carbohydrate snack just prior to testing. c. been in relatively good diabetic
control.
A nurse is caring for a client with burns and in reverse isolation. Which measures should the
nurse include?
a. Wearing disposable gloves when chaging the dressings.
b. Having the client wear goggles when staff is in the room.
c. Wearing a gown, mask, and gloves when providing care to the client.
d. Disposing of the client's soiled laundry in a red bag. c. Wearing a gown, mask, and gloves
when providing care to the client.
A physician has ordered 100 mg of Amoxicillin po for a child. The available liquid amoxicillin is
250 mg/5 mL. How many milliliters should a nurse administer? a. 1.0
b. 1.5.
c. 2.0
d. 2.5 c. 2.0
A nurse charts on all assigned clients at 2:00 P.M. The nurse then remembers something that
happened at 9:00 A.M. to a client who was not charted. Which of these actions should the nurse
take?
a. Include the 9:00 A.M. scenario in the shift report.
b. Enter the scenario after the original 2:00 P.M. charting and mark it as a "late entry".
c. Put the information in the margin and indicate the accurate time placement by drawing an
arrow.
d. Draw a line through the previous charting with "error" and then re-record everything,
including the new information. b. Enter the scenario after the original 2:00 P.M. charting
and mark it as a "late entry".
While giving a bath to a client, a nurse notices that the client's back appear reddened. Which of
these interpretations and additional assessments should the nurse make?
a. The client's skin is sensitive to touch; lightly rub the client's chest area.
b. The client has decreased circulation; palpate the peripheral pulses.
c. The client is showing signs of pressure; press on the skin and observe for a return of color.
d. The client is allergic to the soap; check the extremities for discoloration. c. The client is
showing signs of pressure; press on the skin and observe for a return of color.
A newborn is placed under fluorescent light as part of the treatment for physiologic jaundice.
During the duration of the newborn's treatment, a nurse should: a.
cover the newborn's closed eyes with patches.
b. measure the newborn's pulse and respirations every two hours.
c. keep the newborn under the light at all times, even during the feedings.
d. notify the physician if the newborns stools become greenish yellow. a. cover the newborn's
closed eyes with patches.
Which of these symptoms should a nurse expect to assess in a client who develops
hypoglycemia?
a. Fruity breath odor.
b. Polyuria.
c. Diaphoresis.
d. Flushed skin. c. Diaphoresis.
A client is eight hours postoperative after a transurethral resection of the prostate (TURP).
Which of these observations, if noted by a nurse, indicates a complication? a.
Hourly urine output of 90 mL.
b. Reports of bladder spasms.
c. BP 92/60 mm Hg, pulse rate 118/minute.
d. Pink-tinged urine output. c. BP 92/60 mm Hg, pulse rate 118/minute.
A nurse should assess a child who has diabetes mellitus (type 1) for symptoms of hyperglycemia,
which include:
a. flushed skin and thirst.
b. irritability and hunger.
c. sweating and jitteriness.
d. lethargy and tremors. a. flushed skin and thirst.
Which of these laboratory test results should a nurse monitor for a client who is receiving
intravenous heparin therapy at a rate of 1,500 units per hour for the treatment of an acute
pulmonary embolism?
a. Partial thromboplastin time.
b. Clot retraction time.
c. Platelet levels.
d. Bleeding time. a. Partial thromboplastin time.
Which of these techniques should a nurse use to assess for correct placement of a nasogastric
tube prior to administering a feeding?
a. Aspirate 10 mL contents and measure the pH.
b. Slowly inject 50 mL of saline and observe for resistance.
c. Inject 20 mL of water and listen for gurgling sounds.
d. Observe for bubbles after submerging the end of the tube in a cup of water. a. Aspirate 10
mL contents and measure the pH.
A client has shortness of breath when lying down and usually assumes an upright or sitting
position in order to breathe more comfortably. A nurse should document this observation as: a.
dyspnea.
b. bradypnea.
c. orthopnea.
d. apnea. c. orthopnea.
Which of these instructions should a nurse give to a client when collecting a sputum specimen?
a. "Take a deep breath, then cough and spit into this container."
b. "Gargle with antiseptic mouthwash before you spit into this container.
c. "Spit whatever sputum you have in your mouth into this container."
d. "Drink some fluids to loosen your secretions and the spit into this container." a. "Take a
deep breath, then cough and spit into this container."
A client who is receiving radiation therapy has a nursing diagnosis of imbalanced nutrition: less
than body requirements related to diminished taste perception and nausea. Which of these
additional nursing diagnoses should a nurse consider for the client? a. Risk for aspiration.
b. Ineffective protection.
c. Risk for deficient fluid volume.
d. Altered tissue perfusion. c. Risk for deficient fluid volume.
Which of these menus, if chosen by a parent of a child who has celiac disease, would indicate to
a nurse that the parent understands the teaching about a gluten-free diet? a. Broiled steak, baked
potato, and spinach.
b. Pork chop, egg noodles, and green peas.
c. Fried chicken, white roll, and mixed vegetables.
d. Baked macaroni with cheddar cheese and corn. a. Broiled steak, baked potato, and spinach.
Which of these statements, if made by a nurse, is non-therapeutic because it disregards a
client's feelings and concerns?
a. "You appear anxious and tense."
b. "Everything will be okay."
c. "I notice you're biting your nails."
d. "I'm not sure I understand what you're saying." b. "Everything will be okay."
A client tells a nurse, "I am so scared about the interview tomorrow. I just know I will say the
wrong thing and not get the job." Which of these responses, if made by the nurse, will create a
communication barrier?
a. "Would you like to practice the interview?"
b. "Have you thought about some possible questions that may be asked in the interview?"
c. "Tell me more about your concerns."
d. "You need to relax, and everything will be fine." d. "You need to relax, and everything will be
fine."
A young healthy adult, who has been exercising in hot weather, has fatigue, loss of appetite, and
lightheadedness. Which of these assessments should a nurse make? a. Determine the client's
preferred diet.
b. Measure the client's body temperature.
c. Auscultate the lungs.
d. Ascertain the client's typical sleep pattern. b. Measure the client's body temperature.
Which of these nursing measures is the priority for a child who has hemophilia and who sustains
a leg injury?
a. Ensuring adequate hydration for the child.
b. Soaking the child's injured leg in warm water.
c. Administering the missing factor VIII to the child.
d. Transfusing one unit of whole blood to the child. c. Administering the missing factor VIII to
the child.
Which of these outcomes should a nurse focus on for a client who had a bronchoscopy two hours
ago?
a. Preventing hemorrhage.
b. Preventing pneumonia.
c. Preventing aspiration.
d. Preventing dehydration. c. Preventing aspiration.
A client who had a coronary artery bypass graft four days ago suddenly develops sinus
tachycardia and reports shortness of breath and dizziness. Which of these interpretations and
actions should a nurse take?
a. This is an expected occurrence following bypass surgery; continue to monitor the client.
b. This indicates normalization of the blood pressure; hold all anti-hypertensive medications.
c. This may be an early sign of heart failure; notify the physician.
d. This indicates hypoxia; administer oxygen at 5/L per minute. c. This may be an early sign
of heart failure; notify the physician.
Which of these lunch selections, if made by a client who has congestive heart failure, should a
nurse recognize as indicative of a need for additional instructions?
a. Cottage cheese with fresh fruit salad, whole wheat bread, and herbal tea.
b. Baked chicken with brown rice, mixed green salad, and iced coffee.
c. Egg salad sandwich with mayonnaise, pickles, and seltzer water.
d. Beef tenderloin, carrots, mashed potatoes, and a baked apple. c. Egg salad sandwich with
mayonnaise, pickles, and seltzer water.
Which of the statements if made by a client who is take furosemide (Lasix), supports a nursing
diagnosis of knowledge deficit?
a. "This medication will increase the amount and frequency of my urination."
b. "This medication must be taken, even on days when I fell well."
c. "I will need to add more salt to my diet because this medication will increase its excretion."
d. "I should change my position slowly to avoid dizziness related to this medication." c. "I
will need to add more salt to my diet because this medication will increase its excretion."
Which of these statements, if made by a client who has chronic obstructive pulmonary disease,
indicates improvement?
a. "I hope to attend my grandson's graduation next month."
b. "I can now walk one more block than I could last month."
c. "I take several quick breaths when I begin to cough."
d. "I do my breathing exercises in the evening after I eat dinner." b. "I can now walk one more
block than I could last month."
An 8-month-old infant is admitted to the hospital because of failure to thrive. Which of these
actions should a nurse plan?
a. Limit the parents' interactions with the infant.
b. Consistently assign the care of the infant to the same staff.
c. Rotate assignments so that all staff can evaluate the infant.
d. Limit the infant's activity until the cause of the problem is identified. b. Consistently assign
the care of the infant to the same staff.
Which of these actions should a nurse include to enhance the effectiveness of client teaching
sessions?
a. Include all content in one session so as not to overwhelm the client.
b. Initially demonstrate and explain the procedure to the client.
c. Avoid repetition of content.
d. Include all clients on the unit in the sessions. b. Initially demonstrate and explain the
procedure to the client.
Which of these laboratory test results is more important for a nurse to assess for a client who
reports chest pain? a. WBC count.
b. PTT level.
c. Troponin level.
d. Hemoglobin. c. Troponin level.
A nurse should explain to a primigravida that urine tests will be done at each prenatal visit
throughout the pregnancy to measure:
a. specific gravity and pregnancy hormones.
b. culture and white blood cell count.
c. glucose and protein.
d. bacteria and red blood cell count. c. glucose and protein.
Which of these manifestations should a nurse expect to observe in a client who is diagnosed with
paranoid schizophrenia? a. Regression.
b. Suspiciousness.
c. Catatonia.
d. Hyperactivity. b. Suspiciousness.
Which of these measures should an emergency room nurse include when speaking with a family
experiencing the loss of an infant from Sudden Infant Death Syndrome (SIDS)? a. Explaining to
the parents how SIDS could have been predicted.
b. Discouraging the parents from viewing the infant's body.
c. Encouraging the parents to take the opportunity to say goodbye.
d. Interviewing the parents in-depth about the circumstances of the infants death. c. Encouraging
the parents to take the opportunity to say goodbye.
Which of these assessments is the priority for a client who is admitted with recurrent depression?
a. Previous episodes of depression.
b. Compliance with prescribed medications.
c. Presence of a suicide plan.
d. Problems with communication. c. Presence of a suicide plan.
Which of these changes in the assessment data of a child who has congestive heart failure should
a nurse recognize as indicative of a therapeutic response to prescribed medication therapy? a.
Increased weight.
b. Increased urine output.
c. Increased respiratory rate.
d. Increased heart size. b. Increased urine output.
Which of these assignments, if delegated to unlicensed assistive personnel (UAP) by a nurse, is
appropriate?
a. The UAP is assigned to measure a client's intake and output.
b. The UAP is assigned to assess a client's lung sounds.
c. The UAP is assigned to teach a client about diet restrictions.
d. The UAP is assigned to change a client's postoperative wound dressing. a. The UAP is
assigned to measure a client's intake and output.
A client who has a history of asthma develops an acute asthma attack. Which of these questions
should a nurse ask when assessing the etiology of this attack? a. "Have you eaten any new foods
recently?"
b. "How many hours did you sleep last night?"
c. "Are you exercising every day?"
d. "Have you reduced your fluid intake recently?" a. "Have you eaten any new foods recently?"
Which of these foods should a nurse suggest that a client who is diagnosed with iron-
deficiency anemia choose for dinner?
a. Cooked dry beans, green leafy vegetables, and dried fruits.
b. Raw cabbage, tomato juice, and cantaloupe.
c. Fresh fish, peanut butter, and oatmeal.
d. Cheddar cheese, enriched bread, and yellow vegetables. a. Cooked dry beans, green leafy
vegetables, and dried fruits.
A nurse in a prenatal clinic performs Leopold's maneuvers on a client who is 8-months-pregnant
primarily to:
a. turn the fetus in the uterus.
b. ease the fetus into the true pelvis.
c. assessment of the location of the placenta.
d. determine the fetal presentation. d. determine the fetal presentation.
A child is brought to the clinical for serum lead screening because of ingestion of lead-based
paint. Which of these manifestations, if present in the child, would indicate early signs of lead
toxicity?
a. Convulsive seizures.
b. Behavior changes.
c. Bleeding tendencies.
d. Low-grade fever. b. Behavior changes.
Which of these recommendations should a nurse make when teaching a client who is to start
taking oral prednisone (Deltasone)?
a. "Take this medicine at bedtime, on an empty stomach."
b. "Take this medicine with a hot beverage in the evening."
c. "Take this medicine in the morning, one hour before breakfast."
d. "Take this medicine in the morning with food or milk." d. "Take this medicine in the morning
with food or milk."
Which of these actions should a nurse take prior to initiating prescribed antibiotic therapy for a
client who has a urinary tract infection? a. Measure the body temperature.
b. Cleanse the perineum.
c. Weigh the client.
d. Obtain a urine culture specimen. d. Obtain a urine culture specimen.
When caring for a client who is receiving oxygen therapy via nasal cannula, a nurse should
instruct the client:
a. to inhale through the mouth.
b. to breathe through the nose.
c. to hold the catheter when coughing.
d. to take quick, shallow breaths. b. to breathe through the nose.
Each of these clients has impaired mobility related to knee surgery. Which client should a nurse
assess first?
a. A 20-year-old who has a sports-related injury.
b. A 37-year-old who reports limited mobility.
c. A 59-year-old who has a history of hypertension.
d. A 70-year-old who has bilateral cataracts. c. A 59-year-old who has a history of hypertension.
The mother of a 2-month-old tells a nurse that the baby is consuming six ounces of plain
commercial formula seven times a day, plus one ounce of cereal in the morning and at
bedtime.
Based on this information, the nurse should conclude that the baby's diet is: a.
too high in calories.
b. too high in iron content.
c. deficient in calcium.
d. insufficient for the baby's age and weight. c. A 59-year-old who has a history of hypertension.
A nurse plans to assess a client's recent memory. Which of these questions should the nurse
include?
a. "Who is your closest friend?"
b. "What was the name of the school you attended?"
c. "What day were you admitted to the unit?"
d. "What did you have for breakfast?" d. "What did you have for breakfast?"
A client who has a breast tumor says to a nurse, "I am so anxious. Why did I have to get sick
now?" Which of these responses, if made by the nurse, is therapeutic?
a. "You will need to find someone to talk over your fears on a regular basis."
b. "What do you think is making you feel so anxious now?"
c. "Are you aware that there are newer, more effective treatments for breast cancer?"
d. "Tell me more about your concerns." d. "Tell me more about your concerns."
Which of these actions, if taken by a nurse who is transferring a client from the bed to the chair,
is correct?
a. The bed is raised to a comfortable working height for the nurse.
b. The wheelchair is placed perpendicular to the bed.
c. The nurse stands behind the client during the transfer.
d. The nurse supports the client in an upright standing position for a few moments. d. The
nurse supports the client in an upright standing position for a few moments.
A nurse should assist a pregnant client who is in the first trimester to achieve the developmental
task of this stage of pregnancy, which is: a. accepting the fact that she is pregnant.
b. accepting the fact that the fetus is a separate being.
c. accepting that she will soon deliver the child.
d. accepting that her body image has changed. a. accepting the fact that she is pregnant.
When interacting with a client who is paranoid, a nurse should: a.
use touch to place the client at ease.
b. maintain a caring facial expression.
c. stand close to the client.
d. maintain a professional attitude towards the client. d. maintain a professional attitude
towards the client.
Which of these tasks is appropriate for a nurse to delegate to a nursing assistant in an acute care
unit?
a. Feeding a client who was admitted with a stroke yesterday.
b. Ambulating a client who was admitted with a myocardial infarction yesterday.
c. Measure the blood pressure of a client who was admitted with an asthma attack yesterday.
d. Suctioning the tracheostomy that was performed on a client yesterday. c. Measure the blood
pressure of a client who was admitted with an asthma attack yesterday.
Which of these techniques should a nurse plan to use with a client who is delusional? a.
Explore the delusion so the client will know it is false.
b. Explain clearly why the client's belief is incorrect.
c. Focus on reality-based topics.
d. Avoid speaking with the client when he/she is delusional. c. Focus on reality-based
topics.
Which of the following manifestations should a nurse recognize as suggestive of right-sided
heart failure?
a. Cool extremities and frothy sputum.
b. Jugular vein distention and pedal edema.
c. Orthopnea and frequent cough at night.
d. Weight loss and lower calf pains. b. Jugular vein distention and pedal edema.
Which of these statements, if made by a nursing student prior to a sterile dressing change, is
correct?
a. "I understand that if objects touch other objects on the sterile field they are considered
contaminated."
b. "I understand that sterile objects that are below my waist are considered contaminated."
c. "I understand that all objects in the sterile field must be dry."
d. "I understand that contaminated objects can be used if rinsed with an antimicrobial solution."
b. "I understand that sterile objects that are below my waist are considered
contaminated."
A nurse reviews a client's prenatal record and notes that the client's last menstrual period (LMP)
was on September 18th. Using the Naegele's rule, the nurse should calculate that the client's
expected date of delivery (EDD) will be: a. May 11th.
b. May 25th.
c. June 11th.
d. June 25th. d. June 25th.
Which of these instructions should a nurse give to a client who has venous insufficiency
regarding the use of elastic stockings (TEDs)?
a. "Bunch the TEDs up and pull them on like socks."
b. "Lower the TEDs to your ankles if your legs ache."
c. "Keep the TEDs on at all times."
d. "Put the TEDs on before you get up in the morning." d. "Put the TEDs on before you get
up in the morning."
A nurse assesses a client who is scheduled for a total abdominal hysterectomy at 10:00 A.M.
WHich of the factors should the nurse recognize as most likely to influence the outcome of the
surgery?
a. The client has voided two times since 5:00 A.M.
b. The client is not able to demonstrate leg exercises because of osteoarthritis.
c. The client takes one acetylsalicylic acid (baby Aspirin) daily.
d. The client reports mouth dryness. c. The client takes one acetysalicylic acid (baby Aspirin)
daily.
A client's urine output is 500 mL in 24 hours. Which of these actions should a nurse take? a.
Report the findings to the physician.
b. Obtain an order for a diuretic.
c. Encourage the client to limit fluid intake.
d. Record the finding and continue to monitor the client. a. Report the findings to the
physician.
A nurse should question an order for a potassium chloride intravenous infusion for which of
these clients?
a. A client who has hypoxia.
b. A client who is obese.
c. A client who has anuria.
d. A client who is congested. c. A client who has anuria.
A 22-year-old college student has a heart rate that is 48/minute and regular during a routine
physical examination. Which of these questions should a nurse consider when analyzing this
heart rate?
a. Is this student an athlete?
b. Does this student smoke?
c. How much alcohol does this student drink?
d. Is this student feeling anxious? a. Is this student an athlete?
Which of the following clients should a nurse recognize is most likely to develop diabetic
ketoacidosis?
a. A 23-year-old who has type 1 diabetes mellitus and is being treated for a tooth abscess.
b. A 31-year-old gestational diabetic who has occasional bout of nausea.
c. A 55-year-old who has type 2 diabetes mellitus and is adjusting well to the lifestyle changes.
d. A 72-year-old who has type 2 diabetes mellitus and is managed with diet and exercise. a. A
23-year-old who has type 1 diabetes mellitus and is being treated for a tooth abscess. Which of
these postoperative complications in the first hour after surgery requires immediate
intervention?
a. Serous draining on the dressing.
b. Swelling of an extremity under a cast.
c. Vomiting.
d. Dehiscence of a wound. d. Dehiscence of a wound.
Which of these assessments should a nurse make of a client who had a knee replacement this
morning?
a. Pain.
b. Signs of infection.
c. Bowel movement frequency.
d. Range of motion. a. Pain.
Which of these actions should a nurse take prior to assisting an elderly client to shave his face? a.
Have the client sign a consent form.
b. Determine what medications the client takes.
c. Soften the client's skin by applying lotion.
d. Cleanse the face with a bactericidal solution. b. Determine what medications the client takes.
Which of these factors should a nurse consider when delegating tasks to unlicensed assistive
personnel (UAP)?
a. The UAP's relationship with clients.
b. The UAP's willingness to perform tasks.
c. The UAP's previous experiences on the unit.
d. The UAP's duration of employment on the unit. c. The UAP's previous experiences on the
unit.
Which of these nursing diagnoses is the priority for a young adult client who has first-degree
burns of the legs and smoke inhalation from a fire in the home? a. Pain.
b. Risk for infection.
c. Impaired gas exchange.
d. Body image disturbance. c. Impaired gas exchange.
A child who has cystic fibrosis is receiving pancrelipase (Pancrease MT) with meals and snacks.
To determine if the desired effects of the Pancrease are achieved, a nurse should consider which
of these questions?
a. Is the child's blood sugar level within normal limits?
b. Has the child's appetite improved with the medications?
c. Are the child's stools of normal consistency?
d. Does the child report increased belching and flatus? c. Are the child's stools of normal
consistency?
When assessing a group of children, a nurse should recognize which child is at increased risk of
developing acute glomerulonephritis?
a. A 3-year-old who has multiple urinary tract anomalies.
b. A 4-year-old who had a streptococcal infection a week ago.
c. A 5-year-old who has recurrent enuresis at night.
d. A 6-year-old who had chicken pox infection two weeks ago. b. A 4-year-old who had a
streptococcal infection a week ago.
A client says to a nurse, "I am Alexander the Great. I am a world leader and must return to my
kingdom. I am not taking any medications. I do not want anyone to come near me. I need to
protect myself if they do." Which of these problems should the nurse focus on first? a. Risk
for violence.
b. Delusions of grandeur.
c. Disturbed personal identity.
d. Risk for noncompliance. a. Risk for violence.
When a client who has a diagnosis of depression is taking a monoamine oxidase (MAO)
inhibitor, which of these dieatry instructions should a nurse give to the client? a.
"Increase your intake of foods that are high in vitamin C, such as oranges."
b. "Avoid foods that contain tyramine, such as aged cheeses."
c. "Increase your intake of foods high in tryptophan, such as fish."
d. "Restrict foods high in sodium, such as canned soups." b. "Avoid foods that contain
tyramine, such as aged cheeses."
Which of these strategies should a nurse plan for a client who is manic and has lost 30 pounds? a.
Nutritious finger foods.
b. Low-protein diets.
c. Limiting fluids in between meals.
d. Daily weights. a. Nutritious finger foods.
A 15-year-old child who has type I diabetes mellitus receives an injection of regular insulin 5
units and isophane (NPH) insulin 15 units subcutaneously at 7:00 A.M. before eating breakfast.
At 10:30 A.M., the child tells the school nurse, "I am sweating and feel weak." Which of these
actions should the nurse take first? a. Measure the blood sugar.
b. Determine what the child ate for breakfast.
c. Give a simple carbohydrate.
d. Contact the physician. a. Measure the blood sugar.
A client who has a head injury is drowsy and lethargic, and has clear nasal discharge. Which of
these actions should a nurse take?
a. Obtain a specimen of the drainage for culture and sensitivity.
b. Test the drainage for glucose.
c. Cover the nares with sterile gauze.
d. Cleanse the nostrils with sterile saline solution. b. Test the drainage for glucose.
Which of these actions, if taken by a nursing assistant, should a nurse recognize as increasing the
client's risk of developing a nosocomial infection?
a. Wearing non-sterile gloves while emptying the Foley drainage bag.
b. Taping a paper bag to the side rail for tissue disposal.
c. Placing the Foley catheter drainage bag on the bed while transferring the client.
d. Using the same cuff to measure the blood pressures of all the clients on the unit. c.
Placing the Foley catheter drainage bag on the bed while transferring the client.
A nurse is preparing a client for a vaginal examination. Which of these statements should the
nurse make?
a. "Go into the bathroom and empty your bladder."
b. "Cleanse your perineal area with betadine solution."
c. "Hold your breath while the speculum remains in place."
d. "Push down as the doctor inserts the speculum." a. "Go into the bathroom and empty your
bladder."
A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should
the nurse assess first?
a. A 25-year-old client who is terminally ill with metastatic testicular cancer.
b. A 37-year-old client who has second-degree burns on both feet.
c. A 49-year-old client who has an acute myocardial infarction related to cocaine ingestion.
d. A 68-year-old client who is bed bound related to severe Parkinson's disease. c. A 49-
yearold client who has an acute myocardial infarction related to cocaine ingestion.
Which of these preventative measures should a nurse manager in a long-term care facility plan to
institute to decrease clients' risks for falls?
a. Monitoring clients frequently for evidence of activity intolerance.
b. Placing all client personal items in the bedside drawers.
c. Raising the side rails for all clients who have memory impairment.
d. Maintaining all client beds in the highest position. a. Monitoring clients frequently for
evidence of activity intolerance.
Which of these assessment findings, if present in a primigravida, indicates that the client is
experiencing true labor?
a. The pains are felt in the lower abdomen, back, and groin.
b. The Braxton-Hicks contractions have become stronger and more frequent.
c. There is an increased amount of white mucus discharge.
d. There is a progressive increase in effacement and cervical dilatation. d. There is a
progressive increase in effacement and cervical dilatation.
A client is admitted for opiate detoxification for the fifth time. Which of these statements, if
made by a staff member, indicates a biased view of the client? a. "I feel so frustrated when
clients are re-admitted."
b. "Addicts relapse because they don't try hard enough."
c. "I think this client needs to consider long-term placement after detoxification."
d. "The team really needs to discuss this client's treatment plan." b. "Addicts relapse because
they don't try hard enough."
Which of these women, each of whom is in labor, should a nurse recognize as in need of
immediate attention?
a. A woman who is having contractions every 6 to 8 minutes of mild to moderate intensity.
b. A woman who is receiving oxytocin augmentation and who has contractions lasting 60 to 70
seconds.
c. A woman who is in the active phase of labor and who insists she needs to use the bedpan to
have a bowel movement.
d. A woman whose uterine contractions frequency is every two to give minutes. c. A woman
who is in the active phase of labor and who insists she needs to use the bedpan to have a bowel
movement.
A nurse has received a report on these assigned clients. Which client should the nurse follow-up
first?
a. A client, admitted with acute diverticulitis, who has a white blood cell count (WBC) of 10,000
mm3.
b. A client, admitted with acute pancreatitis, who has a fasting serum glucose of 130 mg/dL
today, and had a reading of 160 mg/dL yesterday.
c. A client, admitted with hepatitis, who has jaundice and tea-colored urine.
d. A client who is currently receiving cancer chemotherapy and who has a white blood cell count
of 500 mm3 today. d. A client who is currently receiving cancer chemotherapy and who has a
white blood cell count of 500 mm3 today.
Which of these statements, if made by a client who is taking a diuretic, should a nurse recognize
as indicative of the need for additional instructions?
a. "I take all of my medications at bedtime so I don't forget them."
b. "I eat one or two bananas every day."
c. "I weigh myself every day in the morning."
d. "I will call my doctor if I have muscle weakness." a. "I take all of my medications at bedtime
so I don't forget them."
A nurse is monitoring a client who had a cystoscopy six hours ago. The nurse should inform the
physician of which these manifestations? a. The client has pink-tinged urine.
b. The client reports burning on urination.
c. The client's white blood cell count is 15,000 mm3.
d. The client appears drowsy. c. The client's white blood cell count is 15,000 mm3. Which of
these actions should a nurse perform prior to a client's scheduled hemodialysis? a. Administer
prophylactic antibiotics.
b. Weigh the client.
c. Give the client normal saline solution to drink.
d. Measure the urine specific gravity. b. Weigh the client.
Which of these behaviors, if taken by a staff nurse on a psychiatric unit, indicates a correct
understanding of therapeutic techniques?
a. A nurse smiles when speaking with clients who are manic.
b. A nurse uses touch to communicate concern with a depressed client.
c. A nurse sets consistent limits with manipulative clients.
d. A nurse shares own anxiety reduction techniques with a client who has panic attacks. c. A
nurse sets consistent limits with manipulative clients.
A client has been in bed for the past three days. Which of these measures should a nurse include
before assisting the client out of bed?
a. Having the client drink a glass of water.
b. Raising the head of the bed.
c. Flexing the client's knees.
d. Assessing the lung sounds. b. Raising the head of the bed.
A client who has insulin-dependent diabetes mellitus asks a nurse, "What should I do when I feel
nervous, sweaty, and hungry?" The nurse should give the client which of these instructions? a.
"Lie down and rest."
b. "Eat a carbohydrate snack."
c. "Take your prn dose of insulin."
d. "Add a slice of bread to your next meal." b. "Eat a carbohydrate snack."
Which of these tasks should a licensed practical nurse (LPN) delegate to a nursing assistant? a.
Checking the 11 A.M. blood sugar for a client who has ketoacidosis.
b. Measuring the pulse oximetry level for a client who has status asthmaticus.
c. AMbulating a client who had a hip replacement three days ago.
d. Changing the dressing for a client who had wound debridement last week. c. AMbulating
a client who had a hip replacement three days ago.
A 36-week-pregnant woman awakens to find she is having profuse, red vaginal bleeding. A
nurse should prepare the woman to have an immediate sonogram to determine the: a.
location of the placenta.
b. uterine response to labor.
c. the fetus's current weight.
d. condition of the uterine vascular bed. a. location of the placenta.
A nurse is planning to interview a client who speaks limited English. Which of these strategies
should the nurse include?
a. Smile frequently during the interview interview to reduce the client's anxiety.
b. Observe the client for indicators of confusion or not understanding questions.
c. Maintain constant eye contact throughout the interview.
d. Keep the interview short to decrease the client's fatigue. b. Observe the client for indicators of
confusion or not understanding questions.
A nurse takes the weight of a normal 2-year-old child who comes in to the pediatric clinic for a
well-child visit. If the child weighted 7 lbs, 2 oz. at birth, how much should the nurse expect the
child to weight at this visit? a. 14 lbs, 2 oz.
b. 18 lbs, 6 oz.
c. 28 lbs, 8 oz.
d. 45 lbs, 10 oz. c. 28 lbs, 8 oz.
A nurse has been discussing the nutritional needs of children with a group of parents in a clinic.
Which of these statements, if made by the parent of a 2-year-old child, should the nurse follow
up?
a. "I give my child slices of cheese as an afternoon snack."
b. "I give my child a cup of skim milk as an afternoon snack."
c. "I give my child some popcorn as an afternoon snack."
d. "I give my child some yogurt as an afternoon snack." c. "I give my child some popcorn as
an afternoon snack."
Which of these client care situations has the greatest potential for presenting an ethical dilemma
for a nurse?
a. Participating in pregnancy termination procedures.
b. Counseling a client who is terminally ill with AIDS.
c. Discussing contraception options with adolescents.
d. Caring for a client who is from a different culture than the nurse. a. Participating in pregnancy
termination procedures.
Which assessment information should a nurse obtain first when a pregnant woman and her
husband arrive at the Labor and Delivery Unit?
a. Whether the couple attended birthing classes.
b. The frequency and intensity of labor contractions.
c. The number of previous pregnancies and outcomes.
d. The amount and time of the client's last food intake. b. The frequency and intensity of
labor contractions.
A client who has Parkinson's disease has been identified as being at risk for falls. Which of these
actions by a nurse is most likely to reduce the client's risk of falling? a. Monitor the client's blood
pressure after ambulation.
b. Ensure the client wears socks when ambulating.
c. Encourage frequent weight-bearing exercise.
d. Assign an assistant to remain with the client when ambulating. d. Assign an assistant to remain
with the client when ambulating.
A nurse determines that the therapeutic effectiveness of magnesium sulfate (MgSO4) for client
who has preeclampsia is achieved when there is increased: a. urinary output.
b. blood pressure.
c. respiratory rate.
d. uterine movement. a. urinary output.
Which of these assessments is the initial priority of a client who is one-hour postoperative after
an exploratory laparotomy?
a. The appearance of the client's surgical incision.
b. The client's level consciousness.
c. The adequacy of the client's respiratory function.
d. The client's fluid and electrolyte status. c. The adequacy of the client's respiratory function.
Which of these client reports should a nurse recognize as suggestive of hypothyroidism? a.
"My hands shake whenever I reach for anything."
b. "I feel cold and tired all the time."
c. "I sweat whenever I walk more than one block."
d. "My head aches each evening." b. "I feel cold and tired all the time."
A nurse is monitoring a client who is taking acetylsalicylic acid (Aspirin) 975 mg daily for
adverse effects, which include: a. loss of joint mobility.
b. increased serum calcium levels.
c. increasing heart failure.
d. occult blood in the stools. d. occult blood in the stools.
Which of these rationales explains the purpose of nasogastric tube with suction for a client who
had abdominal surgery?
a. Prevention of gastric decompression.
b. Removal of secretions from the stomach.
c. Provision of postoperative nutrition.
d. Promotion of abdominal distention. b. Removal of secretions from the stomach. A 75-
year-old client who is newly admitted to a long-term care facility has all these nursing
diagnoses. Which one is the priority? a. Risk of injury.
b. Anxiety.
c. Sleep pattern disturbance.
d. Chronic. a. Risk of injury.
A 12-month-old child is playing with the father. Which of these behaviors indicates that the child
is demonstrating object permanence?
a. The child transfers a toy to the other hand when given another one.
b. The child returns a block to the same spot on the table.
c. The child looks for a toy that the father has hidden under the table.
d. The child recognizes that a ball of clay is the same when flattened out. c. The child looks for a
toy that the father has hidden under the table.
A nurse should recognize that a client's selection of which of these foods demonstrates a correct
understanding of a high-fiber diet for colon cancer prevention? a. Corn muffin.
b. Bran flakes.
c. Raising muffin.
d. Green salad.b. Bran flakes.
Which of these discharge instructions should a nurse include for a client who has a ruptured
tympanic membrane that occurred during a fall?
a. "No showers or washing of the hair for the next month."
b. "Avoid yawning or holding your head down."
c. "Do not allow any water to enter the ear until healing is confirmed by direct visualization."
d. "Avoid swallowing and coughing until your ear has healed." c. "Do not allow any water to
enter the ear until healing is confirmed by direct visualization."
Which of these nursing measures is appropriate for a client who has recurrent renal calculi? a.
Weighing the client daily before breakfast.
b. Measuring the blood pressure every four hours.
c. Encouraging a daily intake of three liters of fluids.
d. Testing the urine for protein each shift. c. Encouraging a daily intake of three liters of
fluids.
When auscultating the lungs of a woman who is admitted for severe pregnancy-induced
hypertension, a nurse notes the presence of crackles and moist respirations. These assessment
findings most likely indicate which of these complications? a. A convulsion is imminent.
b. Pulmonary edema has developed.
c. Bilateral lobar pneumonia is present.
d. Respiratory failure is evident. b. Pulmonary edema has developed.
A licensed practical nurse (LPN) is assigned to care for all of these clients. Which client should
the nurse assess first?
a. A client who is eight-hours postoperative after a hip replacement.
b. A client who is drowsy after falling out a third story window.
c. A client who is four hours post-colonoscopy and polyp removal.
d. A client who is dysphasic after a transient ischemic attack. b. A client who is drowsy
after falling out a third story window.
Which of these clients is at the highest risk of developing osteoporosis? a.
An obese African-American adolescent who does not exercise.
b. A pregnant Asian client who is a vegetarian.
c. A middle-aged Native-American male who is quadriplegic.
d. A thin, elderly Caucasian female who lives alone. d. A thin, elderly Caucasian female who
lives alone.
A nurse is obtaining the health history of a client who is admitted for surgical repair of an
inguinal hernia. Which of these factors should the nurse recognize as having the greatest impact
on the outcome of the surgery?
a. The client takes several acetylsalicylic acid (Aspirin) tablets daily for knee pain.
b. The client drinks one glass of beer every evening with dinner.
c. The client had a knee replacement six months prior to this admission.
d. The client is allergic to all penicillin-type antibiotics. a. The client takes several
acetylsalicylic acid (Aspirin) tablets daily for knee pain.
A nurse should recognize that a client who has chronic obstructive pulmonary disease (COPD),
needs additional instructions if the client makes which of these statements? a. "I will try to take
slow, deep breaths when I feel short of breath."
b. "I will use the albuterol (Proventil) nebulizer before I eat.
c. "I will drink most of my fluids between meals."
d. "I will turn up the oxygen flow rate if I have difficulty breathing." d. "I will turn up the
oxygen flow rate if I have difficulty breathing."
A woman is treated in the emergency room for a broken arm and multiple facial bruises caused
by her spouse. Which of these statements, if made by a nurse, is therapeutic? a. "You should
leave this relationship now or you will be sorry."
b. "Are you aware that women who remain in abusive relationships eventually are killed?"
c. "This type of abuse typically recurs after a period of remorse by the abuser."
d. "Can you think of what you did to cause this abuse?" c. "This type of abuse typically
recurs after a period of remorse by the abuser." Which is a presumptive sign of pregnancy?

A) More frequent urination

B) Goodell sign (cervix)
C) Chadwick sign
D) Fetal movement palpable

Subject: Maternity More frequent urination.

List the presumptive signs of pregnancy?

Subject: Maternity 1. Missed menstrual period.

2. Breast change: nipples tingle, fuller, darker.
3. More frequent urination.
4. Morning sickness.
5. Skin change: chloasma, linea nigra, striae.
What does 'Presumptive Signs' of pregnancy mean?

Subject: Maternity What the mother first notices when she may be pregnant.
What does 'Probable Signs' of pregnancy mean?

Subject: Maternity What an objective examiner first notices.

List the probable signs of pregnancy.

Subject: Maternity 1. Uterus is enlarged. Hegar sign.

2. Goodell sign (cervix)
3. Chadwick sign (vagina)
4. Von Fernwald sign
5. Lab tests: pregnancy test (home test)
6. Braxton-Hicks contractions
7. Ballottement
Which is a probable sign of pregnancy?

A) Darkened areolas
B) Fetal movement felt at 20 weeks
C) Von Fernwald sign
D) Hearing FHT (Fetal Heart Tones)

Subject: Maternity Von Fernwald sign What

does 'Positive Signs' of pregnancy mean?

Subject: Maternity An examiner is 100% positive that the woman is pregnant through
examination.
List all the positive signs of pregnancy.

Subject: Maternity 1. Can feel fetal parts through palpitation.

2. Electronic Doptone scope (audible at 8-11 weeks)
3. Sonogram (at 12 weeks)
4. Fetoscope or Leff stethoscope
5. Ultrasonographic (echographic) 6. Fetal movement palpable after 20 weeks Which is a
positive sign of pregnancy?

A) Home pregnancy test is positive. B)

Chloasma
C) The examiner can feel fetal parts through palpitation.
D) Frequent urination.

Subject: Maternity The examiner can feel fetal parts through palpitation.
What is Nagele's rule and how do you use it to determine the due date of birth?

Subject: Maternity Nagele's rule is a standard way of calculating the due date of a pregnancy
(EDC). The process is adding 9 months and 7 days to the first day of the last menstrual period
(LMP).
Calculate Nagele's rule for the first day of LMP of March 2, 2015.

Subject: Maternity December 9, 2015

Calculate Nagele's rule for the first day of LMP of July 12, 2012.

Subject: Maternity April 19, 2013

Calculate Nagele's rule for the first day of LMP of April 1, 2013.

Subject: Maternity January 8, 2014 Determine

Gravidity and Parity:
A woman is pregnant for the 3rd time. She had one son born at 42 weeks gestation, another son
at 40 weeks gestation.
What does 'gravida' mean in GTPAL? Gravida indicates the number of times the woman
has been pregnant, regardless of whether these pregnancies were carried to term. What is
'parity' mean in GP? Parity, or "para" indicates the number of >20-week births (including
viable and non-viable; i.e., stillbirths). Pregnancies consisting of multiples, such as twins or
triplets, count as one birth.
What does 'abortus' mean in GTPAL? Abortus is the number of pregnancies that were lost
for any reason, including induced abortions or miscarriages. The abortus term is sometimes
dropped when no pregnancies have been lost. Stillbirths are not included.
What does 'living' mean in GTPAL? How many children are living.
What does 'term' mean in GTPAL? Term means how many were giving birth after 37 weeks.
What are the appropriate episode findings for a client with bipolar experiencing mania?
Inappropriate affect
Inappropriate dress
Inability to sleep or eat
Becomes angry quickly
Pressured speech
Presecutory delusion
What are the appropriate episode findings for a client with bipolar experiencing depression?
Inability to make decisions
Lack of energy
Lack of self-confidence
Describe isolation in mental health. A child who was physically abused by her uncle, but shows
no emotion when speaking about him.
Describe identification in mental health. A client, admitted, with epilepsy, and now wants to
become a nurse.
Describe conversion in mental health. A college freshman who is having difficulty
organizing her workload and develops irritable bowel syndrome.
Describe displacement in mental health. A client who is angry with a physician, but yells at
the RN.
Describe regression in mental health. A 3-year old hospitalized for leukemia only wants to be fed
with a bottle while being held by his mother.
Describe intellectualization in mental health. A wife who talks about the love of her family, but
doesn't demonstrate love towards them.
Describe projection in mental health. A client yells at the nurse saying she is fearful and
withdrawn and should not be a nurse.
Describe rationalization in mental health. A client who is being treated for drug abuse says
she can't stop because "her husband verbally abuses her and she takes the drugs to get through
the painful experience."
Describe suppression in mental health. An adolescent who was involved in a drunk driving
accident in which his best friend died, says he doesn't remember drinking and driving, even
though he gave a report of the incident to the police.
Describe reaction formation in mental health. A client is angry about all aspects of care,
but acts nice to all health care personnel.
Describe sublimation in mental health. A father who lost his son after binge drinking joins
organizations to educate others about alcohol on college campuses.
Re-educative therapy Involves learning new ways of perceiving and behaving.
Self-control therapy Uses combination of cognitive and behavioral approaches to dealing with.
Gestalt therapy Emphasis is on "here and now".
Aversion therapy Negative reinforcement is used.
Cognitive therapy Active, directive, time limited, structured approach.
Supportive therapy Reinforcement of client's existing coping mechanisms.
ReconstructiveEmotional/cognitive restructuring takes place.
Desensitization therapy Repeated exposure to stimulus which gradually reduces intense
reaction.
Behavior therapy Belief is that most behaviors are learned.
Transactional analysis Goal is that individuals in group will communicate from proper ego
states/responses of others.
What is the key finding for Rubeola? Koplik spots.
What is the key finding for Rubella? Petechial spots on soft palate.
What is the key finding for Roseola? Rose-pink macules that blanche on pressure. What
is the key finding for Mumps? Parotid gland swelling.
What is the key finding for Varicella? Vesicles.
What is the key finding for Pertussis? Paroxysmal coughing episodes.
What is the key finding for Diptheria? Gray membrane on tonsils/pharnyx.
What is the key finding for Poliomyelitis? Stiffness progressing to flaccid paralysis.
What is the key finding for Scarlet fever? Strawberry tongue.
What is the key finding for fifth disease? Slapped face rash appearance.
What is the key finding for mononucleosis? Hepatosplenomegaly.
What is the key finding for Rocky Mountain Spotted Fever? Maculopapular rash on
ankles/wrists.
What is the function of the pituitary gland? It's the master gland. Controls everything.
What is the function of the Adrenal gland? Sodium/electrolyte balance/SNS response.
What is the function of the thyroid gland Basal metabolic rate/growth rate.
What is the function of the parathyroid gland? Calcium/phosphorus metabolism.
What is the function of the pancreas? Carbohydrate/fat/protein metabolism.
What is the function of the ovaries? Progesterone/estrogen production.
What is the function of the testes? Development secondary sex characteristics.
What types of airborne diseases require a negative pressure room and N-95 fitted masks?
Rubeola, Vericella and Tuberculosis
What types of diseases require droplet precautions? Streptococcal pharyngitis or pneumonia,
haemophilus influenza type B, scarlet fever, pertussis, mumps, meningococcal meningitis.
Where do you place droplet precautions clients? Best is in a private room or can be placed in
a room with others that have the same condition.
What type of diseases are placed in contact precautions? Enteric diseases caused by micro
organisms, wound infection, herpes simplex, scabies, multidrug resistant organisms.
Caradioversion should be initially set to? 50-100 joules
What is cardiac output? heart rate x stroke volume
What is a kosher diet? no shellfish but yes fish with fins and scales; no pork; no mixing meat
with milk, ever
woman is post pelvic surgery and asks why she has a foley catheter inserted, what is your
response? it avoids stress on the incision site/bladder
crutches on what side when rising? when walking? unaffected side when rising; affected side
when walking;
Arms at what degrees when hands on crutch rails while standing? 30 degrees
What walking gate for stairs? (crutches) 3 point
Normal stoma findings moist shiny/pink; mild soap and water, then dry gently and
completely, apply paste if used, apply barrier pastes to creases
Cholecystitis diet no cheese! low fat, low cholesterol (<200), if AST & lipase, any type of
bilirubin, WBC, amylase, LDH, are elevate = bad
expect what during latent phase of labor? (0-3, 5-30, 30-45) 0-3 cm, contractions mild and
moderate, 5-30 min apart/30-45 seconds
contractions 3 minutes apart = what phase of labor? active variable decelerations = what?
intervention? cord compression! prep for emergency c-section or inducing labor. also can change
position, d/c oxytocin, o2 8-10L/min per mask, perform/assist with vaginal exam, assist with
amnioinfusion if ordered
Which of the following is the initial nursing action for the nurse to take when late decelerations
appear on the fetal monitor? a - reposition the client in to left-lateral position b - apply a fetal
scalp electrode c - increase the iv fluid rate d - perform a vaginal exam to assess dilation a -
reposition the client in to left-lateral positioning best pain management for 8-10 post open
cholecystectomy; demerol, hydromorphine, fentanyl, morphine DEMEROL NOT morphine
or others; morphine can cause biliary spasms
fontanels close when? posterior 2-3 months; anterior 12-18 months
do you report chlamydia, do you need consent, etc? mandated reporting to CDC, without verbal
or written consent
Empty JP drain when? clean how? before half full, or every 8-12 hrs, NOT 24 hours. Clean
with soap and water, NOT antimicrobials or Dakin's etc.
If JP drainage has doubled in last two hours, possible cause? hemorrhage. Access, stat
CBC, notify physician
What do bananas, avocado and spinach have in common? If patient on what med, these are good
foods? high K+, so good for hypokalemic patients; if patients on thiazide diuretics (Diuril,
enduron), may be HYPOKalemic, so give these!
MAOI's/Nardil, avoid what? Cheese!
Cheese is not good with what? Cheese is good for what and why? nardil/maoi! good for
hyponatremia because high in sodium, high in protein
is drainage at pin sites ok with bucks traction? drainage ok, note the
type/color/odor/amount; leave crust as a barrier, pin care 3x/day phenytoin,
SMZ-TMP, command hallucinations = what? phenytoin toxicity!
If patient has command hallucinations, withold med? yes! methergine risk? what
does it do? treats postpartum hemorrhage by inducing uterine contractions; reducing
hemorrhage; HYPERTENSION is a risk, so check bp prior to administration, watch for
n/v, headache
high pressure alarm, do what? assess for kinkds, client bitingg, excess secretions
(suction), pulmonary edema, etc. Notify provider
Low pressure alarm do what? assess for leaks, displacement, if can't find anything wrong,
MANUALLY ventilate & call respiratory stat, do NOT leave alone
2 years of age, presentation of arms longer than torso, or round & soft abdomen round
& soft abdomen, NOT arms longer than torso
3 years of age normals; immunization? 2-3kg/yr, 2.5-3 in/yr, picky eaters, initiative
vs guilt, imaginary friends, ride tricycle, jump off bottom step, stand on one foot for a few
seconds, DTaP, IPV, MMR, varicella, influenza
first thing to do with a newborn; take temperature, weight, dry... DRY
terminally ill patient only wants family, not friends with them. Type of grief? anticipatory,
not dysfunctional, normal or disenfranchised a client involved in a motor vehicle crash presents
to the emergency department with severe internal bleeding. The client is severely hypotensive
& unresponsive. The nurse anticipates that which IV solution will most likely be prescribed to
increase intravascular volume, replace immediate blood loss volume & increase BP? (5%
dextrose in LR, 0.33 NaCl, 0.225% NaCl,
0.45 NaCl) 5% dextrose in LR
Give what for hypovolemic shock ? 5% dextrose in LR
Client's family asks you to pray with them. Response? refer to spiritual services
After a blood transfusion, will you look at hub, hct, BP or HR for changes? hgb!!! 1-2 pt
increase per unit of blood can you give an antibiotic in a TPN infusion line? what can you add
to a TPN infusion line?
NO! Nothing!
change a TPN infusion line every 24 hours or how often? yes! every 24 hours can clients
family change dressing daily? tie tubing to neck? no, every 8 hours? yes, square knot
with 1-2 finger width
TPN, slow down infusion before endingg, d/c until new bag ready? no, dont d/c or change rate,
don't change flow rate!
hip arthroplasty, what to watch out for? peripheral pulses! cool & weak, 1+ peripheral
pulses, sign to call provider
mom engorged, don't do what? dont self express milk; ice packs, support bra all ok
Rifampin, isoniazid, phenytoin, what's up? INH/Isoniazid increases phenytoin toxicity, meaning
ataxia and hallucinations may present; decrease phenytoin dosage; hepatotoxicity possible with
rifampin
Palpate fontanels by 2-3 years? No! bulging fontanels could mean increased ICP,
meiningitis
first priority for DKA patients? establish venous access, before anything
DKA patient drops glucose from 450-250; do what? measure glucose, temp, what and how
often? measure glucose & potassium hourly, provide IV glucose at 250 to prevent hypoglycemia
patient has l1-l2 paralysis, lives with spouse, bathroom & bedroom on 2nd floor. Needs PT,
respite, speech therapy and what? needs occupational and physical therapy, but social
services is number one for help with home adapation highest risk to patient is bed tray left in
room, tray table at end of bed, restraints tied to bed rails?
restraints tied to bed rails, this is inappropriate
infant has scaly spots, erythemic papillae, and something on lips. Report which to physician/
lips
a woman comes in to you and says she is on contraception and wants to get pregnant. waht is she
at risk for? if IUD, then ectopic pregnancy. infant has substernal heaves, expect what?
o2, suction, survanta for surfactant, vent support aPTT normal level 25-35 platelets
normal 150-400
aPTT 30 and platelets 200, what's wrong? nothing
can you delegate an LPN to check NG tube placement? can they provide first feeding after CVA?
yes, according to book; not clear; but assume no beause high risk scenario
ventricular tachycardia/vtach=what ECG widened QRS what can a 3 month old eat? carrots,
grapes, graham crackers or popcorn graham crackers dehydration = what v/s low bp, high
hr, metabolic acidosis (low ph, high bicarb), postural hypotension, h&h, BUN, elevated glucose
reaches 250 on insulin, give what? isotonic, hypotonic, hypertonic, dextrose? dextrose to
prevent hypoglycemia bend at waist to pick up, or tuck pelvis and flex abs?flex & tuck, never
bend at waist! give patient cooling blanket when febrile, what is sign of adverse
reaction?shivering can digoxin toxicity occur with 3.2 potassium? yes
130/86 BP, severe headache, what would you report in preterm labor to provider? severe
headache; hypertensive crisis s/s of magnesium toxicity? 2 main interventions urine
output <30, rr <12, no deep patellar tendon reflexes, decreased LOC, cardiac dysrhythmia,
immmmmmediately d/c, give calcium glucanate
tuna good for what? bad for what? high in protein and potassium; so watch out if anemic,
increase or decrease milk and give iron or no? decrease milk as it interferes with iron
absorption, and they need iron; give iron!
report what after a craniotomy? aphasia, because this means increased ICP r/t increased
bleeding, which is the highest risk. keep HOB at 30
prednisone 10 months ok? watch for what? long term not recommended, never change dosage,
watch for osteoporosis, avoid large crowds due to increased risk for infection; nurse is educating
on losing one pound a week; how many calories? 500 calories/day bad sign with a mother
with newborn? disapproval diet for glomerulonephritis? low sodium, water restriction
pediatric patient dehydrated, after initial oral rehydration, give water, juice or ginger ale? none!
postoperative are for a client following a colon resection for colorectal cancer includes which of
the following? SATA;
1: report to the provider that the stoma is red in color and has serosanguineous discharge 2:
monitor and treat pain & evaluate pain-relief measures
3: start a full liquid diet upon return to medical unit
4: provide wound care using surgical aseptic technique
5: advise the client to use stool softners to prevent straining 2, 4, 5 naegeles
rule -3+7
boggy uterus, do what? massage the fundus
vertebrae related to paralysis below or above l1-l2 = paralysis priority
infection for amniotomy fever/infection
patient has stairs, has had a stroke, and has trouble communicating - priority therapy? speech
/ ABCs
best to orient what? what not? follow nurse, not skills checklist
what can grant informed consent? parent of minor, spouse or closest relative granted power of
attorney, court-ordered rep, legal guardian impaired nurse, do what? report to charge nurse
med error is what trait? (fidelity, veracity, beneficence?) veracity patient up & walking, pain 8,
need what type of pain management? PCA pump, prn morphine singulair prevent exercise-
induced bronchospasm, and for long-term use; take ONCE DAILY AT BED TIME
take peak gentamicin (amino glycoside) when? trough? 30 min after giving IM, or 30 min after
IV has finished; trough immediately before giving next dose lithium levels 0.4-1
s/s of early lithium toxicity slurred speech, nvd, thirst, polyuria, muscle weakness whats up
with central lines and pushing meds with resistance ? dont do it! may be dislodging a
thrombosis if you run out of TPN, do what? hang dextrose have client do what with anthrax?
strip down
asthma & beta blockers don't give lol's/beta blockers to asthma patient's ace-inhibitors? dry
cough
how does dopamine work, by vasodilating or increasing cardiac output? increasing cardiac
output
thorazine hold if shuffling
fentanyl patch changing time 72 hours, 48 if intolerant long term effect of corticosteroids losing
hair on legs chronic emphysema ABG? RESP, acid (low ph, low co2) increase PAWP
means what? reference? 4-12, increased means left sided heart failure a patient is
experiencing umbilical cord prolapse - intervention? put hand up vagina and hold it there
GERD s/s atypical chest pain, SOB
reglan extrapyramidal side effects (twitching, facial spasms, give anthihistamine to help)
iron deficiency anemia lab results hgb <12, hct <33 ateriovenous fistula fact dont
measure bp on this side
with oxygen toxicity, will you see hypo or hyperventilation? hypoventilation and
bradypnea
explain irrigating with solution hold 1 inch above
wound has dehisced, do what? put saline soaked sterile gauze over what
is histrionic personality disorder? flirty & seductive
expected findings of schizo? memory deficit, difficulty concentrating, disordered thinking, poor
problem solving and decision-making what test for breast cancer vs ovarian cancer? HER2
(her 2 boobs) gene = breast AFTER biopsy but BRCA1 (bra) is for detecting breast cancer w/o
biopsy.. ca-125 (clit area) for ovarian cancer appropriate post-op care for diabetes/ vitamin c
flush a central line with how many mL? 10! 3 if peripheral what does abnormal pap smear
indicate? cervical cancer what to tell woman if trying to get pregnant after stops, may take
awhile
treatment for chlamydia, both mom & baby? timing for baby? zithromax, amoxicillin and
erthromycin for both mom & baby; immmmmmmediately following delivery decontamination
for radiation? soap and water & disposable towels
insulin, rotate sites or no? do not rotate site valproic
acid liver failure, jaundice
first thing for implementing staff changes? investigate staffing issues with task force no
consent from ed to do surgery, do what? get official interpreter heavy lochia, boggy
fundus, do what give oxytocin autism ati lack of responsiveness frequent variable decels
turn on left side first post EGD, what to watch for? cool/clammy skin, sign of
perforation cytoxan for neuroblastomas in toddlers hydrate liberally risk for diabetes
inspidus monitor for polyuria postpartum, immediate action? boggy uterus, massage
fundus cushings disease, 2 things moon face and increased cortisol memory loss ICP
equation for calculating a pulse pressure sbp - dbp = pp
when should a trough level be scheduled for a once daily dosing of gentamycin? 1 hr prior to
next dose
when should a peak level be drawn for divided doses of gentamycin? 30 m after admin of
med or infusion has finished
when should a trough level be drawn for divided doses of gentamycin? right before next dose
s/s dehydration hyperthermia, tachycardia, thready pulse, hypoTN, orthostatic
hypotension, decreased CVP, tachypnea, dizziness, cool/clammy skin, diaphoresis, sunken
eyeballs
s/s overhydration tachycardia, bounding pulse, HTN, tachypnea, increased CVP, confusion,
muscle weakness, wt gain, ascites, dyspnea, crackles
s/s hyponatremia hypothermia, tachycardia, rapid thready pulse, hypoTN, ortho hypo,
headache, confusion, decreased DTR's, hyperactive bowel sounds
s/s hypernatremia hyperthermia, tachycardia, rapid thready pulse, ortho hypo, restlessness,
irritability, muscle twitching, reduced to absent DTR's, hyperactive bowel sounds s/s
hypokalemia hyperthermia, weak irregular pulse, hypotn, resp distress, muscle cramping,
pvc's, bradycardia, decreased mobility
s/s hyperkalemia slow/irregular pulse, hypotn, restlessness, irritability, weakness with
ascending flaccid paralysis, n/v/d, hyperactive bowel sounds
complications following hypophysectomy (removal of pituitary gland) monitor for bleeding
and nasal drainage for possible csf leak, assess neurological condition every hour for first 24 h
and every 4h after;
nursing intervention for preventing delays in healing encourage fluid intake of 2-3L;
increase protein, keep serum albumin levels above 3.5 meds for sinus tachy amiodarone,
adenosine, verapamil, synchronized cardioversion s/s hyperglycemia bg >250; thirst,
frequency in urination, hunger, warm/dry/flushed skin, weakness, malaise, rapid/weak pulse,
hypotension, deep rapid respirations
complications of pericarditis cardiac tamponade (hypotension, muffled heart sounds, JVD,
pardoxical pulse)
pericarditis commoly follows a respiratory infection
s/s of pericarditis chest pressure/pain, FRICTION RUB, SOB, pain relieved when sitting
and leaning forward
fasting blood glucose post pone admin of antidiabetic med until after levels are drawns, ensure
patient has fasted for 8 hours prior to blood drawn oral glucose tolerance test fasting blood
glucose level drawn at start then pt consumes a specified amount of glucose; blood glucose
levels drawn every 30 m for 2 hrs, instruct client to consume balanced diet for 3d prior then
fast 10-12 hr
glycosylate hemoglobin best indicator for average blood glucose level for the past 120d,
normal range is 4-6%, diabetic range is 6.5-8% evaluating proper placement of NG tube
aspirate to collect gastric contents & test pH (4 or less), x-ray, injecting air into tube to listen
over abdomen is NOT an acceptable practice IV urography used to detect obstruction; assess
for a parenchymall mass, and assess size of kidney
before an IV urography procedure the nurse should check if patient is allergic to iodine &
check creatinine levels b/c dye can cause renal failure complications of chest tube insertion air
leaks - monitor the water seal chamber for continuous bubbling (air leak); tension pneumothorax
- sucking chest wounds, prolonged clamping of the tubing, kinks in the tubing, or obstructing can
cause this pt teaching for external radiation therapy gently wash skin over the irradiated area w/
mild soap/water, DONT remove radiation tattoos, DONT apply powders or lotions, wear soft
clothing over irradiated area, avoid tight clothing, DON'T expose area to sun or heat
how infectious mono is spread saliva incubation
period for infectious mono 4-6 weeks
s/s of infections mono fever, sore throat, swollen lymph glands, increased WBC, atypical
lymphocytes, splenomegaly, enlarged liver
transmission precautions for infectious mono standard contact complications
of infections mono ruptured spleen
nursing interventions for patient who has HSV-2 monitor fetal well being, fetal consequences
include miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible
c-section of lesions present during labor early s/s of cold stress in infants axillary temp <97.7,
increase rr, increased hr, mottled skin late s/s of cold stress in infants apneic episodes,
bradycardia, acrocyanosis, decreased activity
indications for use of cardioversion atrial dysrhythmia, SVT, ventricular tachycardia w/ pulse, tx
of choice for pt who are symptomatic
s/s of hypoglycemia shakiness, diaphoresis, anxiety, nervousness, chills, nausea, headache,
weakness, confusion tx for hypoglycemia 4 oz or 2 oz grape juice or 8 oz milk, recheck bg in 15
min if still low (<70) give 15 g more carbs, recheck in 15 min, if w/n normal limits eat 1g protein
(peanut butter, cheese) nursing interventions for increased ICP keep HOB at 30, avoid
extreme flextion, extension or rotation of the head & maintain in midline neutral position; keep
body aligned to avoid hip flextion/extentio, minimize endotracheal suctioning; instruct pt to
avoid coughing or blowing nose
s/s of bacterial vaginosis vaginal odor, discharge, dysuria nursing interventions for boggy
uterus massage the fundus then administer oxytocin what acid base imalance w/ a pt with
chronic emphysema most likely have respiratory acidosis; compensatory metaboli alkalosis
calcium 8.5-10 chloride
95-105 glucose 70-110
potassium 3.5-5 na 135-
145 BUN 12-20 creatinine 0.7-
14 specific gravity 1.015-1.030
hgb 12-18 hct 40 wbc
5000-10000 rbc 4-6
uric acid 3.5-7.5
Cranial nerve XI (hot spot) shoulder
Proper lifting technique (picture) bending at knees
24 month old walk up steps
Food label greatest weight listed first
IV technique advance catheter
Refeeding syndrome 60%
Low fat diet canola oil instead of vegetable oil
Prior to amniocentesis empty bladder
Radiation implant limit visitors to 30 minutes
Levothyroxine take on empty stomach, in am; increases tsh
Metformin contraindication kidney disease, severe infection, shock, hypoxic conditions
Mastectomy lay of affected side to promote drainage, support arm on pillow, HOB 30
Circumcision use petroleum jelly with every diaper change
Check for NG tube placement in the jejunum X-ray
Colostomy care cut the bag
Seizure precautions saline lock IV
Ethical medical error veracity
Early decelerations head compressions
Magnesium sulfate interventions (select all) calcium gluconate, stop infusion, UO less than
30, RR less than 12, decreased reflexes
Thoracentesis causes pneumothorax expected finding not friction rub; tracheal deviation
AP's talking in cafeteria tell them to stop talking
Safety for parkinson's clear area
Warfarin vitamin k for toxicity; INR 2-3; PT 11-12.5
Contraindication of MMR blood transfusion
Diabetic foot care (select all) change shoes frequently, wash feet with soap and water
Sprains avoid warm compress
Expected finding of small pox rash in mouth
16 weeks pregnant alpha protein
Psych med lip smacking
Where to start IV first (picture) hand
PRBC need further teaching start IV on other arm
Delegate to AP CPR compressions
Delegate to LPN sterile dressing
Postural drainage give albuterol, trendelenberg; 1 hour before meals or 2 hours after
Dumping syndrome high protein and fat; avoid milk, sweets, and sugar; small, frequent meals
DASH diet increase fruit, vegetables, and low fat dairy; k, mg, ca
Baby with reflux small, frequent meals, thicken formula with rice cereal, HOB 30
Cleft palate repair periodic restraints
Nephrotic syndrome vitamin K
Pernicious anemia schilling's test
Peritoneal dialysis report cloudy; monitor glucose; warm solution before
Gastric surgery eat 3 meals
Gastrectomy small, frequent meals; vitamin B12, D, iron, and folate
Statin grapefruit
Preventing uric acid stones yogurt
RSV have own stethoscope in room
Change of shift report orthostatic hypotension by nurses station
Confused patient raise 1 side rail
Hypoglycemia cool and clammy skin
Hyperglycemia thirst
Glycosylated blood test HbA1C
Priority for patient in seclusion document
Buddhist patient vegetarian
Positive TB hard raised bump
Heart murmur sound blowing or swishing
Dehydration oliguria
NST
PAD pain/cramping when walking, calf muscle atrophy, shiny cool extremities; elevate legs
Cast with white extremity compartment syndrome
Alcohol withdrawal expected finding n&v, tachycardia, diaphoresis, tremors, seizures
Varicella scabs okay
Hyperthermia not blanket or ice
Purpose of ice decrease inflammation
Sexual assault assess anxiety
THA avoid flexion greater than 90
Beta blocker teaching don't stop abruptly; avoid in asthma; take with food
Combination contraceptives increase BP
Myelosuppression flu shot
Glucocorticoidincrease dose in DM; take with meals; avoid NSAIDs; Addison's crisis if stopped
abruptly
Extreme focus mild anxiety
Good diet 30% carbs
Family concern what has the doctor told you
Adolescent 1300 mg of calcium
Lyme disease report to health department
Organize workload goals for the day
Intervene pacing around wife
Renal failure decrease protein, K, Na, increase carbs, strict I&O
Preeclampsia proteinuria
Urine frequency in pregnancy urine sensitivity test
Lice can live for 48 hours on surfaces
Chest tube complications bubbling in water seal
Elderly abuse ask privately
Informed consent signed willingly
Sibling bonding offer gift each time sibling gets one
TURP complication hematuria
African american over Caucasian heart disease
Sickle cell priority hydration
Sickle cell complication SOB
Respite care give caretaker break
Acarbuse take with first bite of each meal
Hallucination I understand you are scared
Fire extinguisher PASS
Advanced directive don't need a lawyer
Breastfeeding and hepatitis c as long as you don't have cracked nipples
ICP keep HOB midline
Long term use of proton pump inhibitors osteoporosis
Diabetes insipidus polyuria
Difficulty voiding warm water
ACE inhibitors cough
What do you hear when you palpate abdomen resonance
Negotiation strategy understand both sides
Dying patient wants to be alone depression or dysfunctional
Wife progressing quickly can you tell me more
Pregnant non-pharmacological pain management aromatherapy, breathing techniques,
imagery, music, use of focal points, subdued lighting
Hypnosis purpose alter perception of pain
Complication of conscious sedation with RR 6 stop infusion or give something
Major depression, OCD give fluoxetine
What causes constipation iron
Patient can't sleep don't drink caffeine before bed
Collecting urine culture on baby straight cath
Electrolytes Na - 136-145
K - 3.5-5
Ca - 9-10.5
Mg - 1.3-2.1
P - 3-4.5
Cl - 98-106
Hypervolemia bounding, JVD, edema, confusion, increase everything
Anorexia prealbumin 10
Dehydration improving baby flat fontanelle
Unsaturated fat coconut oil
Priority abdominal pain and went away
Opioid agonist naloxone (Narcan)
COPD increase calories and protein
Needle disposal at home coffee container on top shelf
Give RhoGAM in second pregnancy protect future pregnancy
Swallow problem refer to speech therapist
Nutrition for heart failure Decrease Na, increase fluids, increase fiber; increase K with
diuretic
Adverse affects of dogoxin Bleeding gums, bloody urine and stools, arrhythmias, petichiae NG
nutrition Increase K
Methotrexate adverse affect High blood pressure
Most common cause of hyperthyroidism Grave's Disease
S/S of thyroid storm hyperthermia, HTN, delirium, vomiting, abdominal pain, hyperglycemia,
tachydysrhythmias
Antidote for Valium intoxication Flumazenil (Romazicon)
Valium, monitor for what? decreased respirations
Appropriate actions for bacterial meningitis droplet precautions, decrease environmental stimuli,
maintain best rest w/ HOB at 30, seizure precautions, replace fluid and electrolytes position
crutches on affected or unaffected side when sitting or rising from chair? unaffected side 2-3
finger widths
Crutches no weight bearing
Tripod position weight on UNAFFECTED side.
advance both crutches and affected extremity move
unaffected forward (beyond crutches) advance
both crutches then affected extremety continue
sequence (steps equal length)
Crutches with weight bearing move crutches forward about 1 step length move AFFECTED leg
forward level with crutches move unaffected leg forward continue sequence (steps equal length)
Intervention for sprain(PRINCE) Protect, Rest, Ice, NSAIDs, Compress, Elevate
Airborne Precautions Used to protect against droplet infections smaller than 5 mcg (measles,
varicella, pulmonary or laryngeal tuberculosis). Airborne precautions require:
- A private room
- Masks/ respiratory protection devices for caregivers and visitors
-Negative pressure airflow exchange in the room of at least six exchanges per hour.
Droplet Precautions Protect against droplets larger than 5 mcg (streptococcal pharyngitis or
pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma, pneumonia, meingococcal
pneumonia/sepsis, pneumonic plague). Droplet precautions require:
- A private room or a room with other clients with the same infectious disease -Masks
Contact Precautions MRS WEE) Multidrug resistant organism, respiratory infection, skin
infection (varicella, diphteria, shingle, impetigo, scabies), wound infection, enteric infection
(cdiff), eye infection

Protect visitors and caregivers against direct client/ environmental contact infections(respiratory
syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes
simplex, scabies, multi-resistant organisms). Contact precautions require: - A private room or a
room with other clients with the same infection - Gloves and gowns worn by the caregivers and
visitors.
- Disposal fo infectious dressing material into a single, nonporous bag without touching the
outside of the bag.
use of restraints provider must rewrite order every 24h, Toileting and ROM exercises and
assessment of neurovascular and neurosensory status q2h, tie to bed frame (loose knots that are
easily removed)
Care for Pt who has clostridium difficile contact precautions, encourage increased fluid
intake, antiemetics, antimicrobial therapy clinical manifestations of smallpox high fever,
fatigue, sever headache, rash (starts centrally and spreads outward) that turns to pus-filled
lesions, vomiting, delirium, excessive bleeding sealed radiation implant pt in private room,
nurse should wear dosimeter film badge, visitors limited to 30m visits and maintain distance of
6ft, visitors who are pregnant or under 16yrs. should not contact Pt, lead container in room,
instruct pt to call nurse for assistance with elimination
Latent phase of labor 1st part of the 1st stage of labor, lasts 4-6h, cervix 0-3cm, contractions
irregular, mild to mod frequency 5-30m and duration of 30-45s, some dilation and effacement, pt
talkative and eager Use slow/ deep breathing
Periodic FHR Changes Variable Cord Compression Move client
Early Head Compression Identify progress
Acceleration Other (Okay) No action needed Late
Placental Insufficiency Execute action fast
equation for calculating due date 1st day of last period + 1yr - 3 months + 7d = due date
grains per day 6 oz whole grains (cereals , rice, pasta) 1 oz = one slice of bread, 1 cup cereal 1/2
cup cooked pasta
veggies per day 2.5 cups (raw, cooked, or juice) broccoli, carrots dry beans and peas, corn,
potatoes, tomatoes
fruits per day 2 cups (1 small banana, orange, 1/4 cup dried apricots) milk
per day 3 cups (2% milk, yogurt, cheese)
protein per day 5.5oz (one small chicken breast 3 oz, one egg 1 oz, 1/4 cup dried cooked
beans 1oz
nutrients for healthy nervous system B complex vitamins (thiamine, niacin, B6 & B12, Ca, and
Na
Oils 6 tsp (canola, corn, olive, nuts, olives and some fish)
Lab Results of an MI elevated troponin, CK-mb enzymes, elevated LDH
daily % calories from protein 10% daily % calories from carbs 45-
65% daily % calories from fat 20-35%
expected physiological changes of aging decreased EVERYTHING (skin turgor, wt, chest
wall movement, senses, ht, subQ fat) measures to prevent injury with osteoporosis Ca
supplementation, adequate amounts of protein, mag, vit. K, Vit D, wt-bearing exercises,
remove throw rugs, provide adequate lighting, clear walkways, mark thresholds, doorways and
steps
African American women are at increased risk for what? cervical cancer
African Americans are at increased risk for what? heart disease and stroke
What populations are at greater risk for diabetes? American Indians, Alaskan natives, African
Americans & Hispanics
Discharge teaching on breast engorgement Nonlactating Clients: avoid nipple stimulation &
apply cold compresses 15m on and 45m off, cabbage leaves placed inside bra, pain meds,
supportive bra.
Lactating Clients: manually express some milk, frequent feeding or pumping, warm shower,
beast massage, supportive bra, maternal meds after feed to avoid cross-over to breast milk.
to lose 1 lb of body fat per week, an adult must have an energy deficit of ____ cals/day 500 or
3,500 cal/wk
Positive symptoms of schizophrenia hallucinations, delusions, alterations in speech, bizarre
behavior
Negative symptoms of schizophrenia flat, blunt affect; algoia (poverty of thought/speech);
avolition (lack of motivation); anhedonia (lack of pleasure/joy); anergia (lack of energy) Nursing
interventions for domestic partner abuse help Pt develop a safety plan, identify behaviors and
situations that might trigger violence and provide information regarding safe places to live;
encourage participation in support groups
Nursing interventions for Pt who is manic decrease stimulation, frequent rest periods, observe
for escalating behavior, provide outlets for physical activity, provide portable nutritious food, use
a calm, matter-of-fact approach, give concise explanations
Nursing interventions for alcohol withdrawal syndrome self-assess ones own feelings
regarding abuses; use open-ended questions, close/one-on-one observation; low-stimulation
enviro, encourage attendance of self-help groups
Nursing interventions for Pt with PTSD provide safety and comfort, remain w/ Pt through
episode, give reassurance, group/family therapy is best, assist client to eval. coping mechanisms
that work, assist Pt in determining triggers
Nursing interventions for dementia reinforce reality, orientation to Person Place Time, encourage
reminiscence about happy times, talk about familiar things, minimize need for decision making
and abstract thinking to avoid frustration
Ileostomy Care apply skin barriers to stoma, empty bag when it is 1/3 full, assess for fluid
and electrolyte imbalances
Normal post-op output for an ileostomy is what? 1 L/day; may be bile colored and liquid;
normal to see small amounts of blood
Stoma appearance should normally look pink or red and moist/red and beefy
Steps in performing closed intermittent irrigation clamp catheter w/ injection port and
extension tubing, cleanse port
slowly inject syringe w/ irrigant into catheter remove
syringe and unclamp
allow irrigant to drain into drainage bag
Benefits of applying ice to extremity decreases inflammation, bleeding, fever, swelling, muscle
spasms and pain
Kosher foods animals which chew cud and have split hooves (cattle, sheep, goats, & deer),
seafood with fins and scales, NO PORK (hotdogs, sausage, gelatin), and no meats mixed with
milk
Nutritional needs for Hepatic Encephalopathy high carb, high cal,
low to mod fat, and low to mod protein; small, frequent meals;
supplement w/ vitamins (B complex), folic acid, and iron
Nursing intrvetions for Pt receiving TPN monitor serum and urine glucose, monitor
for "cracking" of solution,
use sterile technique when changing central line, bag
and tubing should be changed q24h
TPN fluid overload is evidenced by what? weight gain > 1kg/day and edema
Interventions for chronic renal failure diet high in carbs and mod. fat,
control protein intake, restrict Na, K, Ph, and Mg
Sleep promotion bedtime routine, min number of times pt is awakened, assist w/ personal
hygiene or back rub, exercise 2hr before bed, limit fluids 2-4hr before bed
Intermittent tube feedings HOB @ 45 degrees feed and 1hr after feeding, admin.
solution at room temp,
formula is administered q4-6h in equal portions of 200-300mL over a 30m-60m time frame
Flush 30mL every 4 hours
Bariatric surgeries Dietary planning limited to liquids or pureed foods for first 6wks, meal size
shouldn't exceed 1c, vit & min supplements
Foods that can cause odor for ostomyfish, eggs, asparagus, garlic, beans, and dark green leafy
veggies
Foods that can cause gas for ostomy pt dark green leafy veggies, beer, carbonated
beverages, dairy products, and corn
What type of diet should a client who has dysphasia be on? Pureed or mechanical soft diet
Contraindications for the use of Isosorbide Mononitrate (IMDUR)
For Angina Headache hypersensitivity to nitrates, traumatic head injury b/c med can increase
ICP, use cautiously in Pt taking Hypotension: antiHTN meds or have renal or liver dysfucntion
If Pt develops reflex tachycardia from taking Imdur give what? metoprolol (Lopressor)
Atorvastatin (lipitor) purpose decrease manufacture of LDL and VLDL and increase HDLs;
promotes vasodilation, decreased plaque site inflammation, and decreased risk of
thromboembolism
S/E of Atorvastatin (Lipitor) Hepatotoxicity (liver fxn tests after 12wks then q6m); myopathy
(obtain baseline CK levels); peripheral neuropathy (notify provider)
Teaching for Atorvastatin (Lipitor) don't take with grapefruit juice, take in evening S/E
of Metoclopramide (Reglan)
For Heartburn (antiematic) EPS (bradykinesia, tremor, rigidy)
(notify Ph, admin benadryl), hypotension, sedation, anticholinergic effects
Doxazosin (Cardura)
For HTN and BPH venous & arterial dilation, smooth muscle relaxation of prostatic capsule
and bladder neck
Teaching and S/E of Alpha Blockers
Doxazosin (Cardura) or Prazosin (Minipress) 1st dose orthostatic hypotension (syncope,
dizzy or faint)

take 1st dose at night and monitor BP 2hr after 1st dose, avoid activities requiring mental
alertness for first 12-24h, instruct pt to change position slowly, take with food
Clozapine (Clozaril) Chlorpromazine
(Neg and Pos s/s Schizophrenia)
S/E What to do? neg and pos s/s of schizophrenia, relief of psychotic symptoms

DRINK FLUIDS AVOID SUNLIGHT

New onset diabetes/loss of glucose control (report s/s of increased thirst, urination, appetite), wt
gain, hypercholesterolemia, orthostatic hypotension, anticholinergic effects, symptoms of
agitation, dizziness, sedation, and sleep disruption, mild EPS such as tremor, risk for
dyslipidemia, risk for fatal agranulocytosis (baseline & wkly monitor of WBC, notify of S/S of
infection) Stop med for signs of neuroleptic malignant syndrome
Therapeutic effect of Levothyroxine (Synthroid) For Hypothyroidism: decreased TSH 0.33.0,
normal T4 levels, absence of hypothyroidism symptoms (depression, wt gain, bradycardia,
anorexia, cold intolerance, dry skin, menorrhagia); takes several wks to notice a therapeutic
effect
Long-term adverse effects of Haloperidol (Haldol) Tardive dyskinesia (involuntary movements
of tongue and face, lip smacking, involuntary movments of arms, legs, and trunk)
Effectiveness of Allopurinal (Zyloprim) is evidenced by Improvement in pain caused by gout
attack (decreased joint swelling, redness), decreased number of gout attacks, decreased uric acid
levels
Leukotrien Modifiers
Montelukast (Singulair) suppress inflammation, bronchoconstriction, airway edema, and
mucus production

long-term therapy for asthma and to prevent exercise-induced bronchospasm

Take once daily at bedtime

Assessment of DI Decreased urine specific gravity and osmolality
Hypernatremia
Hypokalemia
Increased urinary output
Dehydration, weight loss and dry skin
Desmopressin (DDAVP)
For Diabetes Insipidus promote absorption of water within the kidneys; cause
vasoconstriction; tx of diabetes insipidus
Effectiveness of DDAVP is evidenced by: reduction in the large volumes of urine output
associated with diabetes insipidus to normal levels
Contraindications to MMR Immunization pregnancy, allergy to gelatin and neomycin, hx of
thrombocytopenia, immunosuppression, recent blood transfusion; common cold NOT a
contraindication
Administration of Enoxaparin (Lovenox)
Anticoagulant subq q12h for 2-8d; use 20-22G needle to draw up; 25-26G needle to admin;
admin in abdomen at least 2" away from umbilicus; apply pressure for 1-2m after injection;
DON'T RUB
Teaching about iron supplements take with orange juice on empty stomach; may cause
constipation, N/V/D, can turn stool a dark green/black color
Furosemide (Lasix)
Purposes of Use block reabsorption of Na and chloride and prevent reabsorption of water;
cause extensive diuresis

Used for: pulmonary edema caused by HF, emergent need for rapid mobilization of fluid
S/E of Furosemide (Lasix) dehydration, hypoNa, hypoCl, hypoTN, hypoK
OTOTOXICITY
Teaching on Lasix avoid admin late in day, report significant wt loss, lightheadedness,
dizziness, GI distress, and general weakness, observe for signs of low Mg levels such as muscle
twitching and tremors Sedative/ Hypnotic Medications
Eszopiclone (Lunesta) Temazepam (Restoril)
Zolpidem tartrate (Ambien) Use cautiously with mental depression avoid with alcohol and
medications with CNS depression
S/E Dry mouth, decreased libido, respiratory depression
Opioids (relief and sedation) Duragesic, Dilaudud, Morphine, Demerol, Codeine, oxycodone
Opioid antagonist nalaxone (Narcan) used for respiratory depression
Ace Inhibitors (end in "pril") Used for: HTN, HF, MI, diabetic neuropathy
Monitor potassium levels K+ persistent
non-productive cough
SSRI (Duloxetine, Fluoxetine, Escitalopram, Fluvoxamine, Paroxetine, Sertraline) Teaching
Avoid alcohol, do not discontinue abruptly, monitor for agitation, confusion and halluciations
within the first 72 hours. S/E Weight gain, sexual dysfunction, fatigue, drowsiness

May cause serotonin syndrome (2-72 hrs after start of treatment): tremors, agitation, confusion,
anxiety and hallucinations
When should admin RhoGAM when mom is Rh-negative and had Rh-positive infant;
admin w/n 28 weeks (3rd trimeter) and 72h after birth
Spontaneous abortion, amneoscentesis
Does does Magnesium Sulfate do? relaxes smooth muscle of the uterus and inhibits uterine
activity by suppressing contractions What are s/s of Mag sulfate toxicity?

What is the antidote for Mag Sulfate? loss of Deep Tendon Reflexes, urinary output <
30ml/hr, resp depression, pulmonary edema, and/or chest pain

Calcium Gluconate to fix!

What are the contraindications for Mag sulfate? active vagninal bleeding, dilation of cervix
is > 6cm, chorioamnionitis, > 34 wks gestation, acute fetal distress, severe pregnancy induced
HTN or eclampsia
Indications to withhold Propranolol (inderal)
Beta Blocker bradycardia, SOB, edema, fatigue, AV block, Pt has asthma
ANGINA Containdications for vasodilators
Nitros CLIENTS WITH A HEAD INJURY
Hypotensive risk with antihypertensive meds
Erectile dysfunction meds (life threatening hypotension)
Uses for methadone (Dolophine) relief of mod to severe pain; sedation; reduction of bowel
motility
Equation for calculating pulse pressure systolic - diastolic = pulse pressure
120-80=40
When should a trough level be scheduled for a once daily dosing of Gentamycin? 1hr prior to
next dose
When should a peak level be drawn for divided doses of Gentamycin? 30m after admin of
med or infusion has finished
When should a trough level be drawn for divided doses of Gentamycin? right before next dose
S/S of dehydration hyperthermia, tachycardia, thready pulse, hypoTN, orthostatic
hypotension, decreased CVP, tachypnea, dizziness, cool clammy skin, diaphoresis, sunken
eyeballs
S/S for overhydration tachycardia, bounding pulse, HTN, tachypnea, increased CVP, confusion,
muscle weakness, wt gain, ascites, dyspnea, crackles
S/S of hyponatremia hypothermia, tachycardia, rapid thready pulse, hypoTN, ortho hypo,
headache, confusion, decreased DTRs, hyperactive bowel sounds
S/S of hypernatremia hyperthermia, tachycardia, rapid thready pulse, ortho hypo, restlessness,
irritability, muscle twitching, reduced to absent DTRs, hyperactive bowel sounds S/S of
hypokalemia hyperthermia, weak irregular pusle, hypoTN, resp. distress, muscle cramping,
hypoactive DTRs, PVCs, bradycardia, decreased motility
S/S of hyperkalemia slow, irregular pulse; hypoTN, restlessness, irritability, weakness with
ascending flaccid paralysis, N/V/D, hyperactive bowel sounds
S/S of hypocalcemia muscle twitches/tetany, hyperactive DTRs, positive Chvostek's sign
(tapping on the facial nerve triggering facial twitching), positive Trousseau's sign (hand/finger
spasms with sustained blood pressure cuff inflation), seizures
S/S of hypomagnesaemia hyperactive DTRs, muscle tetany, positive Chvostek's and
Trousseau's signs, hypoactive bowel sounds, paralytic ileus
Complications following a hypophysectomy (removal of pituitary gland) monitor for bleeding
and nasal drainage for possible CSF leak (assess drainage for glucose or halo sign); assess
neurological condition every hour for first 24h and every 4h after
Nursing Interventions for preventing delays in healing encourage an intake of 2-3L of
fluid/d, increase protein, keep serum albumin levels above 3.5 Meds
for Sinus Tachycardia amiodarone, adenosine, and verapmil;
synchronized cardioversion
S/S of hyperglycemia BG > 250, thirst, freq. urination, hunger; warm, dry flushed skin;
weakness; malaise; rapid, weak pulse; hypoTN, deep rapid respirations
Complication of pericarditis cardiac tamponade (hypoTN, muffled heart sounds, JVD,
paradoxical pulse)
Pericarditis commonly follows a respiratory infection
S/S of pericarditis chest pressure/pain, friction rub, SOB, pain relieved when sitting and leaning
forward
Fasting blood glucose post pone admin of antidiabetic med until after levels are drawn; ensure pt
has fasted for 8hr prior to blood draw
Oral glucose tolerance test fasting blood glucose level drawn at start then pt consumes a
specified amount of glucose. Blood glucose levels drawn every 30m for 2hrs; instruct client to
consume balanced diet for 3d prior then fast 10-12hr
Glycosylate hemoglobin (HgA1c) best indicator for average blood glucose level for the past
120d; normal range is 4-6%, diabetic range is 6.5-8%
Evaluating proper placement of NG tube aspirate to collect gastric contents and test pH (4 or
less) before feeding. Hold if residual is >100 mL,
X-Ray
Injecting air into tube to listen over abdomen is NOT an acceptable practice
IV Urography Procedure used to detect obstruction, assess for a parenchymal mass, and
assess size of kidney

Before procedure check allergy to iodine and check creatinine levels because dye can cause renal
failure.
Complications of chest tube insertion air leaks - monitor the water seal chamber for continuous
bubbling (air leak); tension pneumothorax - sucking chest wounds, prolonged clamping of the
tubing, kinks in the tubing, or obstruction may cause this

Tidaling in water seal chamber is normal!

Pt teaching for external radiation therapy gently wash skin over the irradiated area w/ mild
soap and water, DON'T remove radiation tattoos, DON'T apply powders or lotions, wear soft
clothing over irradiated area, avoid tight clothing, DON'T expose area to sun or heat
Infectious Mononucleosis Spread? saliva
Transmission Precautions? Standard Contact
Incubation Time? 4-6 Weeks

S/S: fever, soar throat, swollen lymph glands, increased WBC, atypical lymphocytes,
splenomegaly, enlarged liver

Complication: ruptured spleen

Nursing Interventions for Pt who has HSV-2 monitor fetal well-being, fetal consequences
include miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible c
section if lesions present during labor
Early S/S of cold stress in infant auxiliary temp < 97.7, increased resp. rate, increased HR,
mottled skin
Late S/S of cold stress in infant apneic periods, bradycardia, acrocyanosis, decreased
activity
Indications for use of cardioversion Atrial dysrhythmias, SVT, vent. tachy w/ pusle & tx of
choice for pt who are symptomatic
S/S of Hypoglycemia shakiness, diaphoresis, anxiety, nervousness, chills, nausea, headache,
weakness, confusion
Tx for Hypoglycemia 4oz OJ or 2 oz grape juice or 8 oz milk recheck
BG in 15m
if still low (<70) give 15g more carbs
recheck BG in 15m, if w/n norm limits eat 1g protein (peanut butter, cheese)
Nursing Interventions for increased ICP Keep HOB at 30 degrees, avoid extreme flexion,
extension, or rotation of the head and maintain in midline neutral position; keep body aligned
avoid hip flextion/extension; minimize endotracheal or oral suctioning; instruct pt to avoid
coughing or blowing nose
S/S of Bacterial Vaginosis vaginal odor, discharge, dysuria
Nursing Interventions for Boggy Uterus Postpartum massage first then administer oxytocin what
acid-base imbalances w/ a pt with chronic emphysema most likely have? resp. acidosis and
compensatory metabolic alkalosis
Respiratory Syncytial Virus Transmission Precautions Contact Precautions
PPE: Gloves, Gown (mask and goggles as needed)
Private Room
Gloves and gown by visitors
Disposal of infectious dressing material into nonporous bag
Dedicated equipment to room or disinfect

Droplet Precautions
PPE: Mask when 3 feet of the client
Private room
Keep door closed

In Baby: Maintain normal body temperature

Care at Birth Vital signs should be checked on admission/birth and every 30 min x 2, every 1 hr
x 2, and then every 8 hr.
Weight should be checked daily at the same time, using the same scale.
Inspect the newborn's umbilical cord. Observe for any bleeding from the cord, and ensure that
the cord is clamped securely to prevent hemorrhage.
In the first 6 to 8 hr of life as body systems stabilize and pass through periods of adjustment,
observe for periods of reactivity.
First period of reactivity - The newborn is alert, exhibits exploring activity, makes sucking
sounds, and has a rapid heart rate and respiratory rate. Heart rate may be as high as 160 to
180/min, but will stabilize at a baseline of 100 to 120/min during a period that lasts 15 to 30
min after birth. Period of relative inactivity - The newborn will become quiet and begin to rest
and sleep. The heart rate and respirations will decrease, and this period will last from 30 min to
2 hr
after birth.
Second period of reactivity - The newborn reawakens, becomes responsive again, and often gags
and chokes on mucus that has accumulated in his mouth. This period usually occurs 2 to 8 hr
after birth and may last 10 min to several hours.
Intervening to Promote Bonding Facilitate the bonding process by placing the infant skin-
toskin in the en face position with the client immediately after birth.
Promote rooming-in as a quiet and private environment that enhances the family bonding
process.
Promote early initiation of breastfeeding, and encourage the client to recognize infant readiness
cues. Offer assistance as needed.
Teaching the client about infant care facilitates bonding as the client's confidence improves.
Encourage the parents to bond with their infant through cuddling, bathing, feeding, diapering,
and inspection.
Provide frequent praise, support, and reassurance to the client as she moves toward independence
in caring for her infant and adjusting to her maternal role.
Encourage the client/parents to express their feelings, fears, and anxieties about caring for their
infant
Combination Oral Contraceptives Contradictions 1. Are smokers and over the age of 35.
2. Have a history of thrombophlebitis and cardiovascular events.
3. Have a family history or risk factors for breast cancer.
4. Are experiencing abnormal vaginal bleeding.
5. Use cautiously in clients who have hypertension, diabetes mellitus, gall bladder disease,
uterine
leiomyoma, seizures, and migraine headaches
Left Sided Heart Failure Dyspnea, orthopnea (shortness of breath while lying down),
nocturnal dyspnea
Fatigue
Displaced apical pulse (hypertrophy)
S3 heart sound (gallop)
Pulmonary congestion (dyspnea, cough, bibasilar crackles)
Frothy sputum (can be blood-tinged)
Altered mental status
Manifestations of organ failure, such as oliguria (decrease in urine output
Right Sided Heart Failure Jugular vein distention
Ascending dependent edema (legs, ankles, sacrum)
Abdominal distention, ascites
Fatigue, weakness
Nausea and anorexia
Polyuria at rest (nocturnal)
Liver enlargement (hepatomegaly) and tenderness
Weight gain
Cardiomyopathy (leading to heart failure)
Compartment Syndrome 1. Compartment syndrome (ACS) is assessed by using the five P's
(pain, paralysis, paresthesia, pallor, and pulselessness).
2. Increased pain unrelieved with elevation or by pain medication.
3. Intense pain when passively moved.
4. Paresthesia or numbness, burning, and tingling are early signs.
5. Paralysis, motor weakness, or inability to move the extremity indicate major nerve damage
and are late signs.
6. Color of tissue is pale (pallor), and nail beds are cyanotic.
7. Pulselessness is a late sign of compartment syndrome.
8. Palpated muscles are hard and swollen from edema.
9. If untreated, tissue necrosis can result. Neuromuscular damage occurs within 4 to 6 hr.
Surgical treatment is a fasciotomy.
Vitamin to prevent neural defects Folate is a B-vitamin found in spinach and leafy green
vegetables, dried beans, liver, and citrus fruits. In
vitamin supplements and fortified foods such as breakfast cereal, it is usually found in the form
"folic acid."
Disposing of insulin syringes at home Coffee container on a high shelf
Status Epilepticus Meds Lorazepam (Ativan) Drug of choice
Diazepam (Valium)
Phenytoin (Dilantin) (IV Slowly)
Fosphenytoin (Cerebyx)
Brachytherapy (Radiation) Radiation source is within the client who emits radiation and is a
hazard to those around for a period of time.
Varicella/ Chickenpox Direct contact and airborne precautions. 2-3 week incubation.
Contagious until all lesions have scabbed. Pregnant women should not be in contact.
Amount of calcium needed daily 1,000-1,200 mg a day. 600 mg at a time.
Refeeding Syndrome Potassium, magnesium, and phosphate move intracellularly during enteral
nutrition, electrolyte disturbances can result. Patients who are severely malnourished are at high
risk for refeeding syndrome and require careful management of fluid and electrolytes when
tubefed. For patients who are severely ill or malnourished, provide feedings at 50% of estimated
requirements and increase gradually over 24 to 48 hours if careful monitoring does not suggest
clinical or biochemical abnormalities. Circulatory collapse that occurs when a client's completely
compromised cardiac system is overwhelmed by a replenished vascular system after normal fluid
intake resumes.
Anorexia Abnormal Lab Values 1. Hypokalemia
2. Serum Albumin less than 3.5 (malnutrition)
3. Anemia and leukopenia with lymphocytosis
4. Possible impaired liver function, shown by increased enzyme levels
5. Possible elevated cholesterol
6. Abnormal thyroid function tests.
7. Elevated carotene levels, which cause skin to appear yellow.
8. Decreased bone density
9. Abnormal blood glucose level
10. ECG changes
Cranial nerve XI (Spinal accessory) Function of the nerve: Motor - Turning head, shrugging
shoulders
System: Head and neck
Mother's Tests at 12 weeks Ultrasound
chorionic villi sampling
NT Down Syndrome
Amniocentesis Performed at 14-16 weeks
assess fetal lung maturity and well being
Rh-negative mothers get Rhogam
Complications are bleeding, contractions, signs and symptoms of infection peripherally inserted
central catheter (PICC) catheter used for long-term intravenous access and inserted in the
basilic or cephalic vein just above or below the antecubital space with the tip of the catheter
resting in the superior vena cava
Needs an informed consent
How to access a venous access port (port a cath) don a mask-use surgical asepsis- don sterile
glove
-prime access cap, extension tubing and non coring needle with pre filled NS syringe
-cleanse the site with chlorahexadine for 30 seconds
-immoblize the device with non dominant hand forming a U with index and thumb -insert
non-coring, non-barbed (Huber) needle with dominant hand in a 90 degree angle Most
facilities' policies allow access to the implanted port with the same needle for 7 days.
Does Port need flushing? -open ended= require heparin flushing
-valved= does not require heparin
Vancomycin Precautions Causes: Ototoxicity and nephrotoxicity
Monitor creatinine and BUN
Peak and Trough Levels
Therapeutic Range 20-40 mcg/dL
Infusion reactions (rash, flushing, tachycardia, hypotension)
Thrombophlebitis
DON'T TAKE WITH LOOP DIURETICS (OTOTOXICITY)
Who Cannot Give Consent kids less than 18
intoxicated- blood alcohol level of .08 client
with a dose of morphine
a nurse is caring for a client with a hx of agression, the client is playing cards and throws them at
other patients- what should you do ask the client how he is feeling (therapeutic cmcn) not take
the cards away (this will increase aggression)
explaining unit rules will not help either
Cocaine/Amphetamines Dilated pupils, tachycardia, elevated BP, impaired judgement,
grandiosity, paranoia with delusions
Opiates (Heroin, fentanyl) Constricted pupils, decreased respirations, decreased BP, initial
euphoria followed by dysphoria
Dialysis Teaching Pt needs to report: muscle cramps, headache, nausea, or dizziness
(hypotension)
Total Gastrectomy is total removal of the stomach; long term complication include dumping
syndrome- undigested food rapidly enters the duodenum or jejunum usually 5-30 minutes after
eating, epigastric pain with cramping, loud hyperactive bowel sounds- managed primarily with
smaller and more frequent meals- no liquids with meals- increase in protein and fats- reduce
carbs; Anemia may also be problem after gastric surgery due to decreased iron absorption;
intrinsic factor is also lost so B12 cant be absorbed; folic acid deficiency, poor absorption of
nutrients
Gastrectomy Medications Needed Vitamin B12 is absorbed in the stomach and must be
supplemented with regular injections by patients who underwent a total gastrectomy. Absorption
may be impaired in those who still have part of their stomach, so it is necessary to have B12
levels checked periodically. Supplementation with folate, iron, and calcium may also be
necessary to correct deficiencies caused by the surgery.
Purpose of Telemetry Detects the ability of cardiac cells to generate a spontaneous and repetitive
electrical impulse through the heart muscle
Gestational Hypertension 20 weeks of pregnancy
Seizure Precautions Rescue equipment at bedside
Establish IV Site
Position seizing pt to ground, stay with them
Protect Head
If in bed, pad side-rails
Side lie with head flexed and slightly forward
Loosen restrictive clothing
Document time, behavior, aura, etc.
Report seizure to the provider
In Case of Fire Rescue Pull
Alarm Aim
Contain Squeeze
Extinguish Sweep
Bacterial Meningitis sign of ICP Nuchal Ridgidy, Kernig's Sign

Sign of ICP: Memory Loss

To Promote Wound Healing Protein and Vit A
Digoxin Toxicity Diarrhea, Nausea and Muscle Weakness 0.8-2.0
Theophyline Toxicity Hypotension, Albuminuria, Tachycardia and Anorexia 10-20
Valporic Acid for Seizure Control Hepatotoxic, report jaundice
Warfarin Do not take with acetaminophen report dark stools
Signs of Peritonitis Rigid, Board Like Abdomen
Absent Bowel Sounds
Fever
High WBCs
Rheumatoid Arthritis Use cold to edematous joints
Suctioning Airway Use surgical asepsis
No more than three consecutive times When
resistance is met, retract 1-2cm Dumping
Syndrome No liquids or carbs!
Right CVA Minimizes problems
Short attention span
Impaired judgement and time
Impulsive
Left CVA Impaired speech and comprehension
Slow and depressed
HGB 12-18
Hit 37%-52%
gtt Volume/time * gtt = gtt 1 min

100ml/20min * 10gtt 50 gtt 1 min

If given hours multiply by 60

Fontella Closing on Newborn (Anterior and Posterior) Anterior: 12-18 months
Posterior: 1-2 months
Best time to perform bladder scan. Immediate after void
Cholecystitis (inflammation of gallbladder) Diet -Increase fruits, vegetables, whole grains.
Ex: Melon
-Avoid greasy/fatty foods
Moro Reflex (one of many reflexes present at birth) -Startled (arms out sideways, palms up,
thumb flexed).
Ex: strike surface next to newborn.
Position for suppository or enema administration. -Sim's/left lateral/Rt. knee to chest
Varicella contraindication Corticosteroids
DTAP contraindication Hx of inconsolable crying
Newborn Car Seat Safety Snug harness across axillary. Not across abdomen or neck.
Ileostomy what pt expect on appearance. -Initial drainage: dark green, odorless.
-Some initial bleeding normal
-Pink or red stoma color normal
-Initial swelling; decreases 2-3 weeks later
Ileostomy care and education *-Empty pouch: 1/3 to 1/2 full.
-Clean pouch 1-2 times daily.
-Pouch change every 4-6 weeks.
-Wafer size 1/8 to 1/4 larger than stoma -Avoid
high fiber foods to prevent blockage.
Delirium (occurs quickly) Simple orientation and low stimuli environment
Hep B contraindication Baker's yeast
MMR contraindication -Pregnancy, recent blood transfusion....
Anorexia Nervosa Electrolytes increasing: Sodium, Potassium, Chloride, BUN, Liver
function, Cholesterol.
Bulimia Therapeutic Nursing Care offer small and frequent meals
89% oxygen postoperative: what to do... Change oxygen to another finger
Non-Rebreather Mask Ensure two "flaps" open during exhalation/close during inhalation.
Venturi Mask Ensure reservoir bag 2/3 full during inspiration and expiration.
Thoracentesis position sitting position, arms raised and resting overbed table.
Chlorpromazine (med for psychoses)
-Adverse Effects and given treatment -Severe Spasms/Tremors
Tx: benzotropine (Cogentin), diphenhydramine (Benadryl).
Contraction Stress Test (CST).
Description, Purpose, normal range. -Brush palm across nipple for 2-3min to release natural
oxytocin that produce contractions.
-Determine how fetus will tolerate stress of labor.
-3 contractions, 10 min period, duration 40-60 secs.
What is most likely to happen during variable deceleration? Cord compression
What is most likely to happen during early deceleration? Fetal Head Compression
Cystic Fibrosis (Respiratory Disorder)
-Diagnostic Test
-Possible Medication Administration -DNA mutant gene identification.
-Open capsule sprinkle on food (Enzyme: Pancrease).
Levothyroxine (Synthroid) -What is it?
-What patients should use this medication with caution?
-Best way to take? -Thyroid hormone; treats hypothyroidism.
-Cardiac pts; aggrevates tachy and anxiety
-Take in the morning, on empty stomach
Levothyroxine (Synthroid)
-Signs of Toxicity *Cardiac: anxiety, chest pain, tachy, htn.
Buck's Traction
-Goal
-Following conservative measurements
-Skin integrity/Neuro -Immobilization
-Follow RX orders: type of traction, weights, whether it can be removed.
-Reposition every 2 hrs, provide pin care, neuro checks
Amputation
-Patient education Apply prosthetic before ambulating.
Ferrous Sulfate (Feosol)
-Purpose
-Reporting symptoms
-Administration
-How to monitor effectiveness -Treats iron deficiency -
GI distress: nausea, constipation, heartburn.
-Take on empty stomach, drink with straw and rinse to prevent staining.
- Increase Hgb of 2g/dL, Hct
Orientation Phase Introduce, Discuss confidentiality, Set goals
Working Phase Problem Solve
Terminal Phase Evaluation (evaluate goals, experience, feelings)
Chadwick's Sign Purplish vulva during pregnancy
Patient is having a hysterectomy and states, "I can possibly plan a pregnancy". What needs to be
reinforced? Outcome
Vaginal Flush Complications Preterm Labor: Ruptured membranes, signs of infection
Sucralfate for PUD coats stomach to prevent formation of ulcer and aids with healing existing
ulcers
17 year old having an emergency surgery. What type of consent is best to intervene? Verbal
Insulins not to mix garglarine and determis
Malfunctioning IV machine mark as defected and get new one
What is the best recommendation for a newly diagnosed diabetic 2 patients that lives
independently? Refer to support group
Circumcision post op care: cleaning -Change diaper every 4 hrs.
-Clean penis with each change.
-Apply petroleum jelly for at least 24 hrs after circumcision (prevent adhering).
-Fan fold diaper (prevent pressure). -Avoid
wrapping penis (impairs circulation) -
Washing: trickle warm water over penis.
-Do not clean yellowish mucus that appears by day 2.
-Do not use moistened towelettes.
-Healing: a couple of weeks.
TB precautions and care -private room/negative pressure
-N95 masks
-pt wear mask when transported out of room or in any public place.
-Medications: may be taking up to 4 meds at a time; up to 6-12 months
-Test exposed family members
-Sputum culture every 2-3 weeks; 3 negatives results in noninfectious.
Vaginal discharge during early pregnancy Leukorrhea
MRSA Contact Precautions -keep distance within 3 ft of client
-Private room or share with someone with similar infection (wound infection, herpes simplex) -
double bag dressing gauze.
-PPE: Gloves and Gowns.
Metformin most common side effect Renal (kidney) failure
Drawing up Insulin? Regular vs. NPH First Regular (clear), then NPH (cloudy) Interaction
between SSRI (e.g. fluoxetine) and St. John's Worts Hypertension and Increased HR;
may be life-threatening.
Diabetic Foot Care -Nailcare: Podiatrist, cut nail straight across.
-Wear Clean Cotton Socks/Closed Shoes
-Do not soak feet or wear ointments
Used Opioid overdose Naloxone (Narcan)
Contraindication During Alcohol Withdrawal Delirium, accompanied by hallucinations.
Patient education for Amniocentesis. -Position: supine or rolled towel under right hip
-Continue breathing normally when inserting needle -Rest 30 mins after procedure.
-Increase fluids for next 24 hrs.
Indications of Fluid Volume Depletion (Hypovolemia) -Thready pulse/Hypotensive -Tachy
-Increased Respiration
-Cool, Clammy, Diaphoretic
-Decreased Urine Output
-Thirst
Type Stomas: Appearance
-Single
-Loop
-Divided
-Double-Barrel -Single (one stoma); brought through onto anterior abd wall.
-Loop (two openings); proximal (active) and distal (inactive).
-Divided (two separate stomas); proximal (digestive) and distal (secretes mucus).
-Double-Barrel (distal and proximal sutured together are both brought up onto abd wall).
Documentation for Ostomy Care (Stool) Amount Consistency
Color
Priority for Panic Disorder Breathing Technique
Education on meds for Kidney Disease
1.Digoxin (Lanoxin)
2.Sodium plystyrene (Kayexalate)
3.Epoetin alfa (Epogen)
4.Ferrous sulfate (Feosol)
5.Aluminum hydroxide gel (Amphojel)
6.Furosemide (Lasix) 1. Take within 2 hrs of meal, monitor signs of toxicity, apical pulse for 1
min.

2. Monitor hypokalemia, restrict sodium intake.

3. blood twice a week, monitor HTN.

4. administer following dialysis with stool softner, take with food.

5. avoid pts with GI disorders, take 2 hrs before or after Digoxin.

6. Monitor I&O, bp, weight. Report thirst, cough.

Newborn Water and Room Temp Water: 120F or lower
Room: 97.9-99 F
Bathing Newborn technique Bathe from cleanest to dirtiest
-Eyes
-Face
-Head
-Chest
-Arms
-Legs
-Groin (last)
Newborn reflex shown on day 1 hear voice
Immunization is recommended for postexposure protection Hep A (fecal route)
Arthroplasty pt education
-How to avoid contractures, dislocations; prevent DVT's.
-Non-pharmalogical treatment -Do not bend at waist. -Use
abductor pillow in between legs.
-Perform Continuous Passive Motion
-Ice pack
COPD
-conservative measurements
-Rapid relief med -High Fowler position
-Increase fluids to liquify mucous
-Albuterol
Dementia Living Coordination Home health Agency>Assisted Living>Nursing Home
Need for Sterile Gloves Inserting Catheter
Discomforts During Pregnancy -Nausea
-Fatigue
-Backache
-Constipation
-Varicose Veins
-Hemoroids
-Heartburn
-Nasal stuffiness
-Dyspnea
-Leg Cramps
-Edema lower extremities
Acute Mania Interventions -Decrease stimuli and one to one observation if necessary. Bulimia
Plan of Care when meal planning closely monitor the client during and after meals to prevent
purging
Reinforcing Teaching About Oppositional Defiant Disorder Set clear limits on unacceptable
behaviors and be consistent. Reward system for acceptable behavior.
Osteoarthritis Alternate: Heat Therapy for Pain and Cold Therapy for Inflammation
-Use assistive devices (raised toilet to help not straining)
What to do before bolus feeding or administration of medication Check for residuals (60 mL
syringe)
What to do when pt complains of cramping during tube feeding? Decrease infusion rate
Ideal location for drainage bag of catheters Hang on bedframe below level of the bladder.
Ventilator Alarms
-Low Pressure
-High Pressure -Low: disconnection
-High: suction for possible secretions, kinks.
Glasgow Coma Scale (head injuries)
(eyes, verbal, motor) highest number 15, good.
lowest number 3, severe. Pressure Ulcer
Strategies
-Reposition time (bed/chair)
-Incontinent Pt. -Bed every 2hr, chair every hour. -Apply
barrier cream and moisture absorbing pad.
Immunization: booster every 10 years DTP
HPV vaccination doses 3 doses
How to measure Fundal Height top of symphysis pubis to top of fundus
How to calculate due date: LMP 8/2/15 -subtract 8-3=5
-add 7 + 2= 9

May 9, 2016
Contraindicated Immunizations During Pregnancy -Varicella
-Zoster
-MMR
True Labor vs False Labor Abdominal Discomfort true: low back and abdominal false:
abd and groin
Types of Decelerations: <120 fhr
-early
-late
-variable -early: head compression
-late: uteroplacental insufficiency
-variable: cord compression
Nursing Interventions during late or variable deceleration left lateral position, oxygen, csection
Normal Fetal HR 120-160
Nursing Care for Boggy Uterus Ask pt to void; if still boggy massage top of fundus with
fingers and reassess every 15 mins.
Nursing Care for Engorgement Apply moist heat for 5 min before breastfeeding.
Ice compresses after feeding to reduce discomfort and swelling.
Nursing Care for Mastitis Continue breastfeeding and take antibiotics as prescribed.
Narcotic antidote Naloxone (narcan) What is wrong with the script? gentamicin 50
mg po every 4 hours #30 Drug name: Gentamicin (capital G)
Anemia lab RBC 4.20-4.87
BUN/Creatinine normal values (for kidney function)
7-20/0.8-1.4
WBC normal values (for infection)
4,000-10,000
Sodium 136-144
Potassium 3.5-5.5
Chloride 96-106
Be ready to administer ____ for Magnesium sulfate toxicity Calcium gluconate
Sign of mag sulfate toxicity (4) 1. Absent deep tendon reflexes
2.Resp rate < 12
3. Urine output < 30
4.Mag levels above 8 Understanding
Rh.
Administration of antibody and time. Mother Rh negative.
Fetus Rh positive.

Rhogam at 28 weeks, then 72 hrs after birth.

Stroke eating precautions -check gag reflex
-thickened fluids/puree
-Sit upright/flexed neck forward
Dehydration S&S (hypovolemia) -pulse; weak and thready. hypotension
-tachy
-confused
-decreased urine output
-skin and mucous membranes dry
Urine Specificity increased
Urine Specific Normal Values and Significance Decreased hypervolemia. Increased
hypovolemia.
1.001-1.029
JVD. What side of heart? Right
Adverse effect of ACE inhibitor (pril's) ACE inhibitors, such as captopril, increase
potassium levels (hyperkalemia) Buddhism diet -some are vegetarians
-may avoid alochol and tobacco
-may fast on holy days
-chanting is common
-brain death is not considered a a requirement for death christianity
-some avoid alcohol, tobacco, caffeine
-fast during lent
hinduism -some are vegetarians
-do not prolong life
-want to lie on floor while dying
-thread is placed around neck/wrist
-pours water into mouth
-bathes body -cremated
islam -avoid alcohol and pork
-fast during ramadan
-faces mecca
-confesses sins during dying
-white cloth washes body
-prayer is said
jehovah's witness -no blood
-avoid foods having or prepared with blood
judiasm -kosher diet-cannot have dairy and meat in the same meal and veggies and meat
have to be cooked in different parts of the kitchen mormonism -avoid alcohol, tobacco and
caffeine
conflict resolution strategies -open communication amont staff is needed -de-
escalate the situation with open communication and problem-solving strategies -use
"I" statements
-listen carefully to what other people are saying, try to understand their perspective
-move conflict that is escalating to private location
-share ground rules
steps of problem solving -ID problem
-discuss possible solutions
-analyze ID solutions
-select solution
-implement solution
-evaluate scabies -itchy,
especially at night -rash,
especially between fingers
-thin, pencil mark lines on skin
-most common head, neck, shoulders, palms, soles (young kids)
-older kids- most common on hands, wrists, genitals, ab
Pediculosis capitis- head lice -intense itching
-small, red bumps on the scalp
-nits (white specks) on the hair shaft
newborn assessment -expected head circumference (32-36 cm)
-expected chest circumference (30-33 cm)
-length 18-22 in
for clients who are hearing imparied -sit and face client
-avoid covering mouth while speaking
-encourage use of hearing devices
-speak slowly and clearly
-do not shout
-try lowering vocal pitch before increasing volume
-use brief sentences with simple words
-write down what clients do not understand
-minimize background noise
-ask for sign language interpreter if needed
use of three way indwelling catheter continuous bladder irrigation prostate
issues
gentamicin otoxicity (tinnitus, HA, hearing loss, nausea, dizziness, vertigo) nephrotoxicity
hypersensitivity- rash, pruritus
dietary prevention nephrolithiasis -avoid oxalates- rhubarb, spinach, beets
-avoid excessive intake of protein, sodium and calcium monitor
for these in Levodopa -NV, drowsiness
-dyskinesias (head bobbing, tics, grimacing, tremors)- decrease dose
-orthostatic hypotension
-CV effects- tachycardia, palpitations, irregular heartbeat
-psychosis
-discoloration of sweat and urine- normal -activation of
malignant melanoma ileal conduit -continuous drainage
into external pouch -monitor peristomal skin for redness,
excoriation or infection
-teach them how to care for the drains and their insertion site during the 3-6 weeks before
removal
-clean the insertion sites gently with water and then apply dry sterile dressing
-intially catheterize stoma= emtpy pouch every 2-3 hours and irrigate pouch in the morning and
evening
-later they can cath every 4 hours while away or more often if they sense fullness
-clean reusable catheter tip with warm soap and water, rinse it thoroughly and can use it for up to
a month
ventriculoperitoneal shunt post op for infant with hydrocephalus report what to provider
irritability when being held
early detection of men's prostate cancer annual measurement of prostate specific antigen
(PSA) should be performed for men over 50
method to evaluate nurse's time management skills maintain regular notes about the nurse's time
management skills
after receiving report assess who first? post op client with abdominal distention and no
bowel sounds because of paralytic ileus
nurses documents dressing change that was not performed what should charge nurse do first?
gather more info about staff nurse's actions ASSESSSSS
assessing newborn immediate intervention grunting, tachypnea, nasal flaring proper
steps of crutches while climbing stairs 1) stand in tripod position
2) place body weight on crutches
3) place unaffected e.g. on stair
4) move affected leg and crutches up to the stair antisocial personality disorder lack of
remorse thrombocytopenia instruct nurse to avoid what nose blowing estradiol monitor and
report what to provider headaches, hypertension client with depression which if most
important finding to report to an interdisciplinary conference the client's appetite has
diminished over the last week
12 yr old bacterial meningitis which finding indicates client is experiencing increased intracranial
pressure (ICP) Memory Loss
nurse assisting with thoracentesis for a client who has pleurisy nurse should plan to do what
instruct the client to avoid deep breathing during procedure
appropriate action for client who will need physical therapy involve client in selection of pt
provider
nursing action for a client who is receiving continuous passive motion (CPM) following a total
knee arthroplasty turn off the CPM mating during meal time
urine output 15 ml/hr what additional assessment data is indicative of fluid volume deficit
orthostatic hypotension! inc bun, tachy,
nurse difficulty staffing weekend shifts. which actions should nurse manager take first to
successfully implement staffing changes form a staff task force to investigate current staffing
issues
mental client becoming increasingly loud and belligerent nurse action use calm and clear
statements to set limits teaching for peripheral artery disease apply lubricating lotion to the feet
to pre even cracting of the skin. don't elevate feet above heart
esophagogastroduodenoscopy (EGD) findings to report cool, clammy skin
digoxin toxicity nausea!!! diarrhea failure to thrive develop a
structured routine epinephrine adverse effects report of chest pain!
client to see first? older client who is confused and attempting to pull on IV valproic acid
(Depakote) which side effects should nurse monitor and report? Jaundice!!
pulmonary edema
crohns disease decrease what in diet? fiber
18 hr post op client following cesarean birth, highest priority finding unilateral tenderness
of the left lower extremity
fractured ankle ice applied every 20 min report what finding to provider? cyanosis of nail beds
appropriate action for early decelerations continue observing the fetal heart rate active labor
receiving oxytocin. fur shows variability with accelerations. nursing action? document
and continue to monitor
community mental health clinic which group is appropriate for nurse to lead? medication
education group
risk for osteoporosis sedentary lifestyle
15 min immediate postpartum period requires immediate action by nurse? bobby uterus who
should receive rhogam an o- woman following spontaneous abortion
first trimester routine prenatal exam when checking if fetal heart can be detected nurse should
place scope midline just above the symphysis pubis and apply firm pressure appropriate action
for intravenous pyelogram for next day administer laxative, npo, econurage fluids
Pacreatitis -- Upper left quadrant pain (abdominal pain)
Priority Finding: *Absent bowel sounds* (indicative of paralytic ileus.
*Expected findings:*
(H) amylase + (H) Lipase
Liver enzymes elevated
Glucose may be elevated - (L) insulin
N/V, jaundice, (H) WBC
Hepatitis A Contaminated Food
Lab values
(Per ATI) *BUN*: 10-20
*Cr*: 0.6-1.2
*Creatinine Clearance*: 80-139
*Na*: 135-145
*K*: 3.5-5
*Ca*: 9-11
*Cl*: 98-106
*Mg*: 1.3-2.1
*Albumin*: 3.5-5 (slow changes in protein)
*Prealbumin*: 23-43 (better indication of malnutrition - for acute changes in protein)
*Urine Specific Gravity*: 1.010-1.025
*Fasting Glucose*: <110
*Oral glucose tolerance test*: <140
*HbA1c*: <5%; pre-diabetes: 5.7-6.4%; DM: >6.5%
*ICP*: 10-15 mm Hg
*pH*: 7.35-7.45
*O2*: 95-100%
*PaCO2*: 35-45 mm Hg
*HCO3*: 22-26
*CO*: 4-7 L/min
*D-dimer*: 0.43-2.33 mcg/mL (elevated = clot formation occurred--> pulmonary embolism
occurred)
*CK-MB*: 0% (30-170 units/L); elevated 4-6 hrs; lasts 3 days
*Troponin I*: <0.03 ng/L; elevated @ 3hrs; lasts 7-10 days
*Troponin T*: <0.2 ng/L; elevated @3-5hrs; lasts 14-21 days
*Cholesterol*: <200 mg/L
*HDL*: 35-80 (female): 35-65 (male) -- High Desirable
*LDL*: >130 mg/dL -- Low Desirable (up to 70% of total cholesterol)
*Triglycerides*: 40-160 (males); 35-135 (females); 55-220 (older adults) -- Evaluates
Atherosclerosis
*RBC*: 4.2-5.4 (female); 4.7-6.1 (male)
*WBC*: 5,000-10,000
*Platelets*: 150,000-400,000
*Hgb*: 12-16 (females); 14-18 (males)
*Hct*: 37-47 (females); 42-52 (males) (3x Hgb)
*PT*: 11-12.5 -- See clotting & vit. K
*aPTT*: 30-40 seconds -- Monitor for Heparin; increased if DIC, liver disease
*INR*: 2-3 on warfarin (checked with PT) Magnesium Sulfate Adverse
effects:
Respiratory paralysis (serious)
Depressed or absent reflexes
Hypotension
Depressed cardiac function
Prednisone inhaler Wait 20-30 seconds between puffs Exhale
with pursed lips
Rinse mouth afterwards (to decrease chance of infection) hold
breath for 10 seconds
Detached Retina "feels like a *curtain* is pulled over my eye"
Hypothyroidism Causes constipation (due to decreased metabolism)
Hyperthyroidism Increase nutritional intake with meals. (due to increased metabolism using
up protein, lipid, and carbohydrate stores)
*Priority finding*: Increased BP
Chest Tubes Keep collection chamber below lungs
Weight applied to skin traction should be 5-10 lbs max to prevent skin injury
Ileostomy bag "Apply skin barrier" to protect skin from enzyme & bile salts
Non-tunneled percutaneous central venous catheter Place client in trendelenburg position to
provide easier access to vessels & decrease risk of air embolus
Newly diagnosed Heart Failure patient Try to walk at least 3 times a week for exercise
Arterial lines Need pressure bag around the solution, because pressure form an artery is greater
than that of the line
Iron supplements -should be taken with high-fiber foods to prevent constipation
-avoid taking with milk because it interferes with absorption
Propanolol (-lol meds - Beta Blockers) can cause bronchoconstriction
Morphine (opiods) Adverse Effect:
nausea and vomiting
Mastectomy Expect presence of one or more surgical drains
Blood transfussions OK to use 0.9% sodium chloride.
--5% dextrose & Ringer's lactate will cause clots
--0.45% cannot use because it's hypotonic

Adverse reaction: Low back pain. Stop transfusion immediately.

Burns Priorities:
--Resuscitation Phase (first 48 hrs): Fluid balance & maintain Electrolyte balance.
--Acute phase (36-48 hrs): Have adequate nutrition to maintain weight, including increased
caloric intake.
--Rehabilitative phase: encourage use of affected extremity to maintain maximal limb function.
Erythrocyte Sedimentation Rate (ESR) Inflammation marker test.
Another inflammation test is: C-Reactive Protein.
Inflammation markers --Increase Erythrocyte Sedimentation Rate (ESR)
--Increase WBC
--Decreased Serum complement level
--Increased Globulin level
Diabetic Ketoacidosis Glucose reading <300 mg/dL is improvement
Above the knee amputation and temporary prosthesis --Have firm mattress (avoid soft
mattress)
--Wear compression bandage at all times
--Keep residual limb in extension
Tension Pneumothorax Look for chest asymmetry
Type 1 diabetes & acute disease --*Continue to take insulin at regular intervals regardless of
meal*
--Monitor blood glucose Q4h --Call
provider if glucose >250 mg/dL --
Notify provider if ketones present.
Elasticized bandages Keep toes and fingers open to check for blood circulation
Fluid overload --Crackles in lungs
--Distended neck veins
Irrigating a granulating wound Use 30 mL syringe
Rheumatoid Arthritis Apply heat and cold to decrease joint inflammation and pain. Left-sided
heart failure Sign: Oliguria during the day from decreased blood flow to kidneys
Right-sided heart failure --Distended abdomen
--Jugular vein distention
--Dependent edema
Sildenafil discontinue if pt taking Isosorbide Mononitrate.
Can cause severe hypotension
Gentamicin Like many antibiotics are nephrotoxic.
Look at kidney functions tests
Lyme disease Stage II experience: joint pain, cardiac and neurologic complications.
If not treated at this stage becomes chronic and causes arthritis, peripheral neuropathy, vasculitis,
and myocarditis.
HIV treatment Effectiveness shows decreased viral load.
Right Hemisphere stroke Affects visual and spatial awareness and proprioception (sense of
our body's position) --Impulsive behavior
--one-sided neglect syndrome
--loss of depth perception
--poor judgement
--left hemiplegia or hemiparesis
--visual changes
Left hemisphere stroke Affects language, mathematic skills, & analytic thinking
--Anxiety concerning the future
--Feelings of guilt
--Expressive aphasia
--Agnosia, Alexia (reading difficulty), agraphia (writing difficulty)
--depression, anger, & quickly frustrated
--visual changes
Diabetes Type I and traveling --Change shoes often to decrease risk of blisters and sores.
--Limit physical activity if blood glucose <65 mg/dL
--carry insulin in insulated tote bag to protect against temperature changes
--Drink water every 2 hrs to reduce risk of dehydration
Increase ICP (signs and symptoms) --JVD,
--Glasgow Coma Scale <15
--sleepiness or difficulty arousing patient
--Wide BP
--Decerebrate and decorticate posturing
Oxycodone Side effect: Constipation
Bilateral pneumonia & PaO2 at 80 mm Hg Administer oxygen per nasal cannula BEFORE
High Fowler's position
Guaifenesin Mucolytic medication.
removes thick mucus secretions from COPD patients w/ SOB, cough, and fatigue.
COPD patients considerations If hypoxic, deliver O2 to 90%.
--sit up in orthopneic position, with arms resting over bed table to facilitate breathing.
Suctioning a tracheostomy patient --Preoxygenate at least 30 seconds
--Suction pass 10-15 seconds
--Set pressure between 80-120 mm Hg --Suction
up to three times.
Transurethral Resection of Prostate (TURP) - 12-hr post procedure Priority Finding:
Concentrated red urine with intermittent clots indicates client at greatest risk for hemorrhage.
Hormone Replacement Therapy Adverse Effects:
--Calf pain = DVT
--Numbness in arms & intense headaches= Cerebrovascular problems
Hypocalcemia --Muscle cramps
--Tingling sensation
Digoxin --Don't miss a dose
--Antiacids reduce absorption
--Adverse Effect = N/V
--Check pulse rate before each dose
Cholinergic Crisis Exhibits increased muscle weakness and twitching
Postpartum, resume sexual activity --Use water soluble gel for lubrication to prevent
discomfort
--May resume sexual activity 2-4 weeks after
Cocaine use during pregnancy Risk for Abruptio Placenta
Hyperemesis gravidarum Eat to taste
-Some food better than none
Pregnancy Lab tests --Group B Strep (GBS) @ 35-37 wks
--3-hr glucose tolerance @ 28 wks
--Rubella Titer @ initial consult
Contraceptives and Hx of Osteoporosis Avoid Medroxyprogesterone
Contraceptives and Hx Cardio, breast cancer, and poor liver function Avoid: Combined
estrogen-progestin oral contraceptive
Pregnant woman, water breaks Monitor Fetal HR
Betamethasone & preterm labor Administered to stimulate fetal lung maturity & prevent
respiratory distress
Infant safety Set water heater <120 F
Vaginal deliver & breastfeeding mom Needs additional 330 calories/day while
breastfeeding
Contraction stress test Negative: (Normal finding) within 10 min period, three uterine
contractions & no decels.
Positive: (Abnormal finding) persistent and consistent decelerations on more than half the
contractions. Cord or fetal head compression present. Newborn expected findings --Breast
nodule <10mm apart
--Posterior fontanel smaller than anterior
--overlapping suture lines
--Lanugo over the shoulders
--No yellow on skin
Newborn considerations --Void once within 24 hrs; 6-10 times/day post 4th day.
--Erythromycin in eyes within 1 hr from birth
--Vit K for clotting
--Hep B (birth + 1 mo + 6 mo) (NOT same thigh as Vit K)
Newborn complications Cold stress - leads to hypoxia, acidosis, and hypoglycemia (due to
use of energy to establish respirations and maintain body heat)

Tx: Cold: warm slowly across 2-4 hrs; Hypoglycemia: breastfeed or formula feed.
Hypoxia: Oxygen
Epigastric pain in pregnancy Indicator of hepatic involvement and clinical manifestation of
severe preeclampsia
Biophysical profile for mother in 3rd trimester Includes Amniotic fluid index
Neonatal sepsis signs --Temperature instability
--Tachypnea
--Hypotonia
--Lethargy
--Nasal flaring
--Irritability
Gonorrhea during pregnancy Risk for Premature rupture of membranes
Preeclampsia during pregnancy Risk for Proteinuria Late
Decelerations during labor at 38 weeks.
Specify order of steps to follow A. Reposition client on her side
B. Elevate her legs
C. Increase maintenance IV fluids
D. Palpate uterus to assess tachysystole
E. Administer Oxygen via face mask @ 8L/min Terbutaline Adverse Effects:
--Hyperglycemia
--Hypokalemia
--Hypotension
Client in labor and reports back pain with right occiput posterior position Apply sacral
counterpressure
Hypoglycemia signs in newborn Jitteriness, twitching, weak high-pitched cry, irregular
respiratory effort, cyanosis, lethargy, eye rolling, seizures, blood glucose level <40 Mastitis
Sudden onset of fever, chills, body aches, and unilateral breast pain with tenderness
Cefazolin Nurse notices urticaria, dyspnea, anxiety, and SOB

Administer Epinephrine to induce vasoconstriction & bronchodilation

Ergotamine sublingual for migraine headaches Take one table at onset of migraine. Up
to 3 tablets/day
Methotrexate Immunosuppressant
--Monitor signs of infection such as fever
Flumazenil Reversal agent for Benzodiazepine Toxicity
Narcan & Naloxone Reversal agent for Opioid toxicity
Atropine Reversal agent for inhibitor overdose
Neostigmine Reversal agent for neuromuscular blocker overdose
Salmeterol Long-acting Bronchodilator
Graves disease Difficulty focusing
Carbamazepine Interferes with oral contraceptives
Reversal agents *Flumazelin* --> Benzodiazepines

*Narcan & Naloxone* --> Opioids

*Atropine* --> Inhibitor overdose

*Vitamin K* --> Warfarin

*Protamine Sulfate* --> Heparin

*Calcium gluconate* --> Magnesium sulfate toxicity

*Acetylcysteine* --> acetaminophen toxicity

*Digibind* --> Digoxin toxicity (prevent absorption)

*Sodium Polystyrene* --> High levels of K in body Urticaria

Hives
Tinnitus Indication of ototoxicity.
withhold aspirin
Sucralfate Forms a protective barrier over ulcers
Atorvastatin (statins medications) Monitor CK (due to muscle breakdown)
Projection Attributing faults to others
Displacement Transfer of feelings to a less threatening person
Splitting A primitive ego defense mechanism that places people and not Arvad categories
Ventricular septal defect vSD Most common congenital heart defect irritability and restlessness
our clinical manifestations Coarctation of the aorta Narrowing of aortic arch that
causes increased resistance bloodflow between the proximal and distal aorta the resulting
physiologic change is an increased pressure in the proximal area the upper distal extremities
and decrease pressure in the lower extremities Hydatidiaform Mole Called gestational
trophoblastic disease. The trophoblastic cells become fluid filled and the embryo fails to grow
fetal loss usually occurs a 16 weeks and rarely is fetus carried to term
Left Sided Heart Failure Sx Symptoms Weakness, fatigue, anxiety, depression, dyspnea,
shallow respirations up to 32-40 min, Paroxysymal Nocturnal Dyspnea, Orthopnea (SOB in
recumbent position, dry hacking cough, nocturia, frothy pink tinged sputum (advanced
pulmonary edema)
Left Sided Heart Failure Left ventricle heaves,
Pulsus alternans, (alternating pulses, strong weak), Increased heart rate, PMI displaced inferiorly
and posteriorly. (LV hypertrophy),

decreased PaO2, slight increase in PaCO2, (poor O2 exchange),

Crackles, pulmonary edema

s3 and s4 heart sounds

Pleural effusion

Changes in mental status

Restlessness, confusion
Right sided Heart failure Sx Symtpoms fatigue, anxiety depression, dependent bilateral edema,
right upper quadrant pain, anorexia and GI bloating, nausea
Right sided heart failure Right ventricle heaves

Murmurs

Jugular venous distention

Edema (e.g. pedal scrotum, sacrum,)

weight gain
increase heart rate

ascites
Anasarca (massive generalized body edema)

Hepatomegaly (liver enlargement)

R sided Heart Failure occurs when the right ventricle fails to contract effectively. right sided
heart failure causes a backup of blood into the right atrium and venous circulation. Venous
congestion in the systemic circulation results in jugular venous distention, hepatomegaly,
splenomegaly, vascular congestion of the gastrointestinal tract, and peripheral edema. Right
sided heart failure may result from an acute condition sich as right ventricle infarction or
pulmonary embolism. Cor Pulmonale (right ventricular dilation and hypertrophy caused by
pulmonary disease) can also cause right sided HF. Thr primary cause of heart failure is left sided
heart failure. In this situation, left sided heart failure results in pulmonary congestionand
increased pressure in the blood vessels of the lung (pulmonary hypertension). Eventually,
chronic pulmonary hypertension (increased right ventricular afterload) results in right sided
hypertrophy and HF.
L sided heart failure Pathophysiology the most common form of heart failure is left sided. Left
sided HF results from left ventricular dysfunction. This prevents normal, forward blood flow and
causes blood to back up into the left atrium and pulmonary veins. The increased pulmonary
pressure causes fluid leakage from the pulmonary capillary bed into the interstitium and then the
alveoli. this manifests as pulmonary congestion and edema. Doxazosin teaching stay with
patient orthostatic hypotension thyroid therapeutic effect weight loss no depression no
bradycardia no anorexia no cold intolerance no dry skin no menorrhagia no decreased TSH
levels desmopressin monitor *hypertension* hr
fluid & electrolyte
weight I
&O
specific gravity
Im injection vastus lateralis
NG aspirate
diet dysphagia oatmeal phototherapy
child protect eyes
dumping syndrome S&S nausea, distension, cramping pains, diarrhea within 15 minutes after
eating cancer treatment monitor platelets sinus tachy picture? mononucloesisfever sore throat
swollen lymph nodes increased WBC atypical lymphocytes
spleanomegaly enlarged liver cleft
palate remove restraints calcium
gluconate antidote mag
increased ICP intervenstions head 30 degrees avoid flexion
sneezing coughing minimize suction body in alignment
priority w/ a cast compartment
pain paralysis parathesia pallor
pulselessness fat embolism hot
spot increased drainage
warm to touch
odor immobility
SOB
skin breakdown constipation
HSV2 and pregnant watch for active lesions
interventions with kid with gastroenteritis skin barrier 241 comp iv
urography allergic reaction swollen lips gastric bypass protein first
rhogam 72 hours after baby comes out
early deceleration head compression advance
directives power of attorney
restraints rom q. 2 hr
doc rewrite 1. 24 hrs dont
tie to bed rails tie frame
bed
crutches good side
small pox high fever fatigue severe
headache rash center out pus lesions chills
vomitting delirium propofol allergy eggs,
egg products, soy
iv pump incident report iv pump malfunction ice
num
antiinflammatory rsv
contact radiation use
dosimeter o2 sat move q. 4
hrs
gardening double glove
stem falls of when dry do nothing
old ppl decreased taste sensation
due date 0711
osteoporosis weight bearing lactose
intolerant replace calcium spinach cabs
how much of diet 45-65%
AWS diazepam
lorezepam tegretol
catapress
osteosarcoma pain give morphine
reaction formation ocer compensation or demnostrating the opposite behacior of what is felt
dementia orient with calendar closed intermitten irrigation clamp cath
clense injection port
insert irrigant unclamp
allopurinol liver function test
ileostomy continuous output
chronic kidney disease check GFR
nutritional needs for patient with hepatic encephalopathy decreased protein, increased
ammonia lvl
contra isorbide monitrate hypersensitive to nitrates head
injury
carefull liver renal tpn
change q. 24 glucose q. 4 lipid
dc 12.
iv pump incident report
sprain compress blood
spill bleach
reportable diseases report lyme disease resspiratory
synictal virus contact
meningitis appropriate actions droplet mask until 24 hrs after with antibiotics or if culture comes
back negative stump keep dry early decel head compression latent phase 2cm dilated talkative
bipolar disorders for manic quiet area, not isolated
give finger food alcohol keep safe, orient time and
place ptsd assessment lost of interest
withdrawal things they enjoy kosher
milk and meat seperate
nutrition and oral hydration to report albumin 3.5-5 tpn
monitoring glucose q. 4 hrs
contraindications of statin medications lipitor hepatitis
haldol se tardive dyskinesia
lip smacking vasoconstriction
heroin
montelukast maintanence, not rescue inhaler
iron replacement drink oj
contra to MMR blood transfusion
calculating pulse systolic - diastolic
S&S hyperglycemia pee alot
thirsty nasuea abdominal pain flush
dry skin fruity breath pericardidtis
pulses paradoxes ausculating heart
valve top left chest tube
bubbling continuous
NG tube proper function aspirate residual
cancer treatment for radiation loose clothing
wash mild soap + water, protect from sun
bacterial vaginosis odor
discharge dysuria
manifestations cold stress mottled skin
apneic temp lower 97.7 respiration
increased HR increased acrocynanosis
decreased activity
cardioversion indication Vtach
Vacuum-assisted Birth; Possible complications Cervical Laceration; rare but can include
perineal, vaginal, or cervical lacerations
15 minutes postpartum; Requires immediate action by the RN: Boggy Uterus; indicates
greatest risk for uterine atony. Immediately massage the fundus to prevent blood loss.
Two different Eye Drops; Pt Education: Close eyes for 1 minute following administration of
each eye medication; wait 10-15 minutes between each medication to prevent dilution of the med
NS w/ new script for cefazolin (over 30 min): Piggy back cefazolin into the NS.
Assessment: Following Vaginal Delivery; Heacy lochia and a boggy fundus. Med to administer:
Oxytocin
CVA; Prior to transferring: Assess the clients functional limitations
Theophylline Toxicity; Expected Finding: Anorexia
Prevent breast engorgement: Place ice packs on the breasts for 15 min 3-4 times daily
chlorpromazine: tx: hallucinations
Ed: Sip water frequently and minimize exposure to the sun
New Born Reflex Assessments: Babinki- Foot
Palmer- Hands
Rooting & Sucking- Cheek
Nurse Manager observing New RN's Time Mgmt Skills: maintain notes
New Born HR Assessment: auscultate the apical pulse and count beats for 1 full minute CVA
pt transferred to rehab; Address Family's concerns: Interdisciplinary conference for family at
new facility
pH 7.30, PaO2 56mmHg, PaCO2 54mmHg, HCO3 26mEq/L, SaO2 87% Uncompensated Resp
Acidosis
Fluid Volume Overload: Delegate to AP Measure I&O
Pt wants to see info in Chart: "There is a protocol for reviewing your chart and I can initiate the
process"
cyclophosphamide to toddler w/ neuroblastoma; RN intervention: maintain hydration with
liberal fluid intake; prevents hemorrhagic cystitis SIDS No correlation between DTP and
SIDS.
Exposure to cigarette smoke increases the risk of SIDS.
Breastfeeding decreases risk of SIDS.
Sleep on Back with Firm Mattress.
E.D: Child with fever and fluid-filled vesicles on the trunk and extremities; RN priority:
Implement transmission-based precautions
1200mL NS for 6 hours. How many mL/hr? 200mL/hr
Asthma: Encourage children to stay active

Avoid extreme temp changes, get the flu vaccine, use peek flow meter at the same time daily
Wound Evisceration steps: Stay with Pt/Call for Help
Saline-soaked gauze
Hips and Knees bent
Take Vitals
RN Suspects Abuse; RN's legal responsibility: Contact proper legal authority Pt has
Catheter and Incision: Change gloves between wound care and cath care erythromycin
ointment; mother refuses: Have mother sign the refusal form and document form
completion.
Clang Association Rhyming words or words that all start with the same letter; "Big Bad Box
Bouncing Back"
Echopraxia Repeating what someone else is saying
Neologisms Makes up and uses words that have no meaning except to the speaker
Blocking Suddenly stops speaking for no reason
Ovarian Cancer; Pt Education Clinical manifestations are vague in the early stages
estradiol; Report: Headaches
FHR pattern shows variability with accelerations; RN to: document and continue to monitor
Late decels & variable decels: DC oxytocin
Verify NG tube placement: Aspirate contents from tube and test pH content
Disaster Plan; RN to: triage incoming victims to determine the priority of care
Stg II pressure ulcer: Partial-thickness skin loss
Pt teaching; Wound Care at Home: High protein diet
Variable Decels; 1st action: Turn pt on Left Side
Pt transferring to another unit, necessary to include in transfer report: Last time pt had pain meds
0.5mg/kg/dose PO; Pt weighs 33lbs; Available is 15mg/mL. How many mL/dose? 2.5mL
ranitidine 50mg IV bolus; available is 50mg in 100mL D5W to infuse over 30 min. How many
mL/hr? 200mL/hr
Cane Place on unaffected side of the body. 6-12"
in front of the body prior to stepping forward Step
forward with affected leg 1st.
RN to see 1st: Older client confused and trying to pull IV
PTSD; Effective Tx response: Recognizes the personal effects of the traumatic experience
Delirium Fluctuating LOC throughout the day.
Aware of cognitive changes.
Acute memory deficit.
More pronounced agitation in the evening.
Promote circulation following an episiotomy: warm sitz baths
RA; Managing Symptoms: Apply Cold Therapy
Depression; most important to report: diminished appetite over the past week Depression;
joking about committing suicide, RN to ask: "Do you have a plan to hurt yourself"
FHR monitoring for: PROM, decreased fetal movement, pt with gestational HTN
Assessment; 18hr post of C-Section during breastfeeding: unilateral tenderness of the LLE;
potential DVT
Valproic Acid: May cause hepatic toxicity; undergo lab tests to assess liver function
Warfarin Report changes in stool color (may indicate GI bleed)
Continuous passive motion following a TKA: Turn machine off during meal time
(promotes comfort and dietary intake)
iron-deficiency anemia and elevated cholesterol Black Beans (high iron, low fat) aplastic
anemia
RN to see 1st: Post op with abd distention and no bowel sounds
Indication of Increased ICP: Memory Loss
Manifestations of Bacterial Meningitis: Nuchal rigidity & Kerig's signs
Failure to Thrive (toddler); POC: Develop a structured routine
Moving pt up in bed: Lower side rails, bed in high position, as pt to flex knees and push if
possible, DO NOT GRAB UNDER ARMS
1st Stg of Labor
2nd Stg of Labor
3rd Stg of Labor
4th Stg of Labor
Early Decels: Associated with the progression of labor and are benign; Continue to Observe if
seen
Late Decels: Variables:

Staffing Issues: Find out what the issue is before implementing changes Quality
Improvement DOES NOT: Promote individual accomplishments.
Digoxin: Nausea is a manifestation of toxicity
TB Pt to wear a mask when being transported
Med given in error; Document: Time med was given
EDB: Minus 3 months + 7 days
Vitamin K routinely given to newborns to prevent bleeding PAD: Applies lotion
to the feet to prevent cracking skin infant w/ hydrocephalus 6hrs post op following a
venticularperitoneal shunt; Report: Irritability when being held indicates increased
ICP
mild preeclampsia Report swelling of hands/feet, rest in a side-lying position, report
decreased urinary output, and perform daily fetal kick count
Coworkers discussing pt info in public: Tell them to stop the conversation
Thoracentisis avoid deep breathing during the procedure
Infant Pulse Brachial pulse is used because it is most easily accessible.
Crohn's Diet: Low Fiber
Rh D Immune globulin: O- mother after abortion may have been carrying an Rh-positive
fetus and should receive the injection
BP check in 10 min: AP who is helping a pt to bed will be done on time.
Fractured Ankle; Report: Cyanotic Nail Beds
Chronic Anorexia w/ enteral tube feedings. What lab value indicates additional need for
nutrients: Albumin level of less than 3.5g/dL
Organ Donor: Notify Organ Team,
Collect Specimens,
Remove all Tubes,
Cleanse Body,
Tag Body
Prostate Cancer: Prostate Specific Antigen (PSA) levels should be performs for men over 50.
CG tells CN that pt is not being cared for properly; CN to: Get specific concerns from CG
Ok to be DC in event of disaster: Cellulitis receiving oral antibiotics
Time-mgmt. strategies: Group activities,
Get equipment before entering room, delegate
to AP,
Develop a schedule that prioritizes client care
Diabetes Insipidus Indication:Increased urine output (polyuria)
MH patient is becoming loud and belligerent: Set clear limits (be calm)
Dehydration (Therapeutic Lab Values): Sodium: 136-145mEq/L Urine
Specific Gravity:
Crutches (stairs): Tripod position, Transfer wt to crutches, unaffected then affected leg
Crutches: Make sure rubber tips are secure
AIDS (D/C Teaching): Exposure to soil increases risk for infection Preparing
for an In-service: What do they know first
emotional crisis: assist the client in identifying the cause of the issue
Med Error Documentation Do not document in MAR if IV med was given orally
Narcotic: RN to waste remainder of Med w/ another RN
fluoxetine; report: Tremors
Abduct: Away from body
Adduct: To Body
Sign of Autism in a Toddler: Lack of responsiveness
Pt needs PT after DC: Let pt chose who they want to use
X-ray of Femur; RN to: Cover pelvic area with a lead shield
"I don't know what to do without my wife. Life is just not worth living." "You seem to be
having a difficult time right now."
Post surgical (ruptured appendix); Report: Rigid, board-like abdomen,
Absent bowel sounds,
102.6,
WBC of 21,500
RN intervention; toddler tonsillectomy: administer pain meds on a regular schedule 1st day post
op
Mannitol; Therapeutic Effects: Increased diuresis
Cushing's Disease Moon Face is expected; HTN
Spanish speaking patient: have an official interpreter provide translation
Buck's Traction; AP can NOT adjust the pt's hanging weights
IV pyelogram; RN action: administer a laxative; check for allergies (seafood, milk, eggs or
chocolate)
AP delegation: Arranging the lunch tray for a client with a hip fracture
STI must be reported to the health dept: Explain the purpose of the legal requirement to the pt
Osteoporosis; risk factors: sedentary lifestyle
Insulin Self-administration: pinch skin before injecting
Limited knowledge re: chest tubes; Charge Nurses Action: Ask the nurse about her knowledge
Surgical aseptic technique: Keep sterile objects in the line of vision, hands
above waist, 1" border of sterile drape
Epinephrine; A/E: Chest pain
Stroke pt: withhold meds until a swallow study is done
Blood Transfusion: Verify the pt and blood product with another RN
Lymphocytic leukemia; Labs to report: WBC 1,000
Inappropriate prescription: Rn to tell charge nurse
Advanced Directives: Designates spouse
Toddler scheduled for surgery: encourage parents to bring toys from home
Incident Report: IV pump delivers inadequate dose of meds
Following esophagogastroduodenoscopy (EGD); Report: Cool, clammy skin
tracheostomy tube suctioning: pass the catheter no more than three consecutive times
Blood transfusion; indications of a hemolytic reaction: Low back pain, tachycardia,
hypotension
Immobile Pt POC: maintain correct body alignment with use of trochanter rolls Triage:
which requires immediate nursing intervention: a middle adult client who has a
sucking chest wound
Have infection rates decreased following a policy revision? Outcome
thrombocytopenia; avoid: nose blowing; increases the risk of bleeding and hemorrhaging
Hand Rolls: maintains a functional position
antisocial personality disorder: Lack of remorse
Valproic acid for seizure control; A/E to report: jaundice (liver damage) community mental
health clinic; RN to lead which therapy group: Medication Education Group dry, shiny red skin
over the clients neck and clavicular area; RN education regarding skin care:
Wash with mild soap and water
Breach of client safety: BP cuff used on two different clients
Infertility Clinic Offer support group info
Foods that contain tyramine; Avoid w/ MAOI's: Smoked meat, cheeses and ripe avacados
amitriptyline Anticholinergic; monitor for dry mouth and constipation (CNS effects) band w/
bead that applies pressure to the P6 meridian on her wrist: to relieve nausea
thrombocytopenia; POC: avoid venipuncture if possible
Domestic Violence: discuss escape plan
Staff nurse documents dressing change but doesn't do it: gather info about it alternate
communication methods postop laryngectomy pt use a pad and pencil to write
requests
seizure precautions suction nearby
TKA 1 day post op; report: drsg saturated w/ sanguineous drainage
Bonding behaviors tells visitors baby looks like family members aPPT
value w/ hemophilia A 45
Newborn Assessment; Report: grunting,
tachypnea, nasal flaring
FHR detection: place the scope midline just above the symphysis pubis and apply firm
pressure
NG tube: avoid Blue Dye
Newborn w/ Resp Distress syndrome maintain a normal body temp
Change-of-shift report: level of assistance needed from bed o wheelchair
Symptom that is indicative of Fluid Volume Deficit: Orthostatic hypotension
impaired vision: mark steps with colorful tape
Hospice: care and tx will be provided to control symptoms and make me comfortable
Interdisciplinary Care Conference: Reoccurring hospitalizations
If client decides to leave the facility without a discharge order, the nurse notifies the provider and
discusses with the client __________ Potential risks associated with leaving
What is the purpose of advance directives? To communicate a client's wishes regarding end-
oflife care should the client become unable to do so.
What are the two components of an advance directive? A living will and the durable power
of attorney for health care
What is a living will? Legal document that expresses the client's wishes regarding medical
treatment in the event the client becomes incapacitated and is facing end-of-life issues. What
types of treatment are often addressed in a living will? Those that have the capacity to
prolong life. Ex: cardiopulmonary resucitation, mechanical ventilation, feeding by artificial
means.
What is a Durable Power of Attorney for Health Care? A legal document that designates a health
care proxy, who is an individual authorized to make health care decisions for a client who is
unable. The person who serves in the role of health care proxy to make decisions for the client
should be very familiar with the client's wishes.
Battery Intentional and wrongful physical contact with a person that involves
an injury or of
fensive contact (restraining a client and administering an injection
against his wishes). Physical contact without a person's consent
Assault The conduct of one person makes another person fearful and apprehensive
(thr
eatening to place a nasogastric tube in a client who is
refusing to eat)
False Inprisonment A person is confined or restrained against his will (using restraints on a
competent client to prevent his leaving the health care facility). Physical or chemical restraints.
Malpractice (professional negligence) A nurse administers a large dose of medication due
to a calculation error. The client has a cardiac arrest and dies.
Negligence A nurse fails to implement safety measures for a client who has been identified as
a risk for falls
Doxazosin teaching stay with patient orthostatic hypotension
thyroid therapeutic effect weight loss no depression no
bradycardia no anorexia no cold intolerance no dry skin no
menorrhagia no decreased TSH levels desmopressin monitor
*hypertension* hr
fluid & electrolyte
weight I
&O
specific gravity
Im injection vastus lateralis
NG aspirate
diet dysphagia oatmeal phototherapy
child protect eyes
dumping syndrome S&S nausea, distension, cramping pains, diarrhea within 15 minutes after
eating cancer treatment monitor platelets sinus tachy picture? mononucloesisfever sore throat
swollen lymph nodes increased WBC atypical lymphocytes spleanomegaly enlarged liver
cleft palate remove restraints
calcium gluconate antidote mag
increased ICP intervenstions head 30 degrees avoid flexion
sneezing coughing minimize suction body in alignment
priority w/ a cast compartment
pain paralysis parathesia pallor
pulselessness fat embolism hot
spot increased drainage
warm to touch
odor immobility
SOB
skin breakdown constipation
HSV2 and pregnant watch for active lesions
interventions with kid with gastroenteritis skin barrier 241 comp iv
urography allergic reaction swollen lips gastric bypass protein first
rhogam 72 hours after baby comes out
early deceleration head compression advance
directives power of attorney
restraints rom q. 2 hr
doc rewrite 1. 24 hrs dont
tie to bed rails tie frame
bed
crutches good side
small pox high fever
fatigue severe
headache rash
center out pus
lesions
chills vomitting delirium propofol allergy
eggs, egg products, soy
iv pump incident report iv pump malfunction ice
num
antiinflammatory rsv contact
radiation use dosimeter o2 sat
move q. 4 hrs
gardening double glove
stem falls of when dry do nothing
old ppl decreased taste sensation
due date 0711
osteoporosis weight bearing lactose
intolerant replace calcium spinach cabs
how much of diet 45-65%
AWS diazepam
lorezepam tegretol
catapress
osteosarcoma pain give morphine
reaction formation ocer compensation or demnostrating the opposite behacior of what is felt
dementia orient with calendar closed intermitten irrigation clamp cath
clense injection port
insert irrigant unclamp
allopurinol liver function test
ileostomy continuous output
chronic kidney disease check GFR
nutritional needs for patient with hepatic encephalopathy decreased protein, increased
ammonia lvl
contra isorbide monitrate hypersensitive to nitrates head
injury
carefull liver renal tpn
change q. 24 glucose q. 4 lipid
dc 12.
iv pump incident report
sprain compress blood spill bleach
reportable diseases report lyme disease
resspiratory synictal virus contact
meningitis appropriate actions droplet mask until 24 hrs after with antibiotics or if culture comes
back negative stump keep dry
early decel head compression latent
phase 2cm dilated talkative
bipolar disorders for manic quiet area, not isolated
give finger food alcohol keep safe, orient time and
place ptsd assessment lost of interest withdrawal
things they enjoy kosher milk and meat seperate
nutrition and oral hydration to report albumin 3.5-5
tpn monitoring glucose q. 4 hrs
contraindications of statin medications lipitor hepatitis
haldol se tardive dyskinesia
lip smacking vasoconstriction
heroin
montelukast maintanence, not rescue inhaler
iron replacement drink oj
contra to MMR blood transfusion
calculating pulse systolic - diastolic
S&S hyperglycemia pee alot
thirsty nasuea abdominal pain flush dry skin
fruity breath pericardidtis pulses paradoxes
ausculating heart valve top left chest tube
bubbling continuous NG tube proper function
aspirate residual cancer treatment for radiation
loose clothing wash mild soap + water, protect
from sun
bacterial vaginosis odor
discharge dysuria
manifestations cold stress mottled skin
apneic temp lower 97.7 respiration
increased HR increased acrocynanosis
decreased activity
cardioversion indication Vtach
TPN When TPN is getting low, and you do not have another bag, initiate 500ml of 10%
dextrose solution.
Do not decrease infusion rate or stop, or admin NS because it will lower BG
Unilateral swelling Think of DVT
Post-Op Cholecystectomy Sanguineous drainage 2 hours post op is expected finding.
Trach Suctioning Suction pass: 10-15 sec
Preoxygenate: 30 sec to 30 min 100% O2
Pressure: 80-120 mmHg
Suction up to 3 times
Sildenafil Viagra
Monitor when taking Isosorbide Mononitrate
S/S Hypoglycemia Cool, clammy skin
S/S Hyperglycemia Kussmaul Respirations, Increased UOP, Abdominal Cramping Promotes
good wound healing Foods high in Vitamin A, high in protein, do not use
povidone-iodine to clean wounds- it is TOXIC!, Avoid heat Valproic
Acid Watch for Jaundice- liver damage.
Fetal Tachycardia; Variable decels FHR Administer O2 8-10 L/min via a mask.
Fetal bradycardia, late deceleration of the FHR, decrease or loss of FHR variability, and variable
deceleration of FHR Place the client in a side-lying position. For late or variable - can also DC
the oxytocin.
Radiation Exposure Med Potassium Iodide (Pima)
Blocks the thyroid gland's uptake of radioactive iodine and thus could reduce the risk of thyroid
CAs
Inhalation Anthrax Give Cipro
Smallpox Transmission Bodily fluids, contaminated objects, inhalation of droplets Classic
S/S of MI Epigastric and LUE pain, diaphoresis, N/V, dizziness, chest pain, anxiety and
feelings of doom
Ipratropium Atrovent
ImmunizationsPrimary Prevention
Cipro Teaching Wear large-brim hat and long sleeves (phototoxicity), limit intake of
coffee, tea or colas, do not take with milk or other products, do not take with an antacid.
Amblyopia Unilateral central blindness occurs as a result of another condition, such as
strabismus.
Strabismus muscle weakness allows one eye to wander so that the child cannot focus on an
object with both eyes at the same time. Will result in central blindness if not treated by 6 y/o.
Patch the eye.
Mydriatic Eye Drops Administered for ophthalmic examinations
LASIK May still need reading glasses
Post Thyroidectomy Have Trach Tray available for airway disruption Low
Pressure Alarm A leak within the ventilator circuitry.
Either the tubing has come apart or that client has become disconnected from the ventilator
tubing.
Almost all low-pressure alarms are the result of a malfunction or displacement of connections
somewhere between the endotracheal or tracheostomy tube and the ventilator.
High Pressure alarm Indicates an increase in resistance each time the ventilator administers a
breath to the client.
Excessive airway secretions, decreased lung compliance (COPD), client is coughing or
attempting to talk.
Body Mechanics Knees kept at hip level, sit with back supported, wrist and forearms
parallel to the ground, arms kept closely to the body, head level when looking at screen SLE
Findings Increased ESR- SLE chronic system autoimmune disease that causes skin, heart, lung,
and kidney inflammation. Usually die from ESRD.
Dx: Hx and serologic tests
Decreased RBCs; Anemia (Low Hct and Hgb)
Detached retina Curtain pulled over the visual area with occasional flashes of light.
Medical emergency
Manifestations: sudden onset of decreased peripheral or central vision, dark floaters, flashes of
light, and a shadow or curtain over a part of the visual field.
Addison's Disease Adrenal Gland Hypofunction; inadequate production of glucocorticoids.
Acute adrenal insufficiency can be a life-threatening event- severe fluid and electrolyte
imbalances.
Sodium levels will fall, potassium levels will increase.
Rapid infusion of IV fluids (NS), high dose corticosteroids (Solu-Cortef)- are started as soon as
venous access is established.
So Hyponatremic, Hyperkalemic, Hypoglycemic
Breastfeeding during 4th stage of labor is most important bc Production and secretion of
oxytocin cause the uterus to contract.
Promotes involution and decrease risk for maternal hemorrhage and blood loss.
Peripheral Vascular Disease Leg cramps and leg restlessness
TB Airborne precautions
Age appropriate toys for a 2 -year old Puzzles, large crayons, blocks, picture books,
pushpull toys, finger paints, modeling clay, and musical toys.
Allow for manipulation and exploration and meet the child's developmental and diversional
activity needs. Want interactive.
No dolls bc of choking hazard (better for Preschooler or school-aged child)
Doxycycline (Vibramycin) Watch for photosensitivity
Tetracycline ABX
GI Distress: A/N/V/D
Aminoglycosides or Minocycline (Minocin) Watch for ototoxicity; think mycin- Gentamicin C
Diff think hand hygiene!
Lactose Intolerant Recommend collard greens; contain lactose-free calcium.
Otitis Media Ask about smoking- allergies to common irritants; not contagious. Otitis Externa
could could from water exposure. Candidiasis Opportunistic infection
Affects oral cavity of infants, diabetics, or other clients with immature or compromised immune
systems.
Often the initial opportunistic infection noted in an HIV + child who is developing AIDS Fluid
Balance Most sensitive indicator is daily weights.
Especially critical in children under 2 y/o- greater body weight of fluid
Dialysis Disequilibrium Syndrome (DDS) Occurs in patients new to dialysis- rapid removal of
solutes and changes in blood pH levels.
S/S: HA, nausea, disorientation, restlessness, blurred vision, and asterixis.
Zidovudine (AZT) Not as toxic to the liver
Used in Pneumocystis Carinii Pneumonia
Monitor Hgb Hct- can cause severe anemia; monitor CBC- closely for first 2 weeks.
Does not affect renal system.
Trendelenburg Head is lower than feet
Hypocalcemia Prolonged QT interval; Tingling, numbness, tetany, seizures, abdominal cramps,
hypoTN
Causes of Prolonged QT Parathyroid function, chronic renal disease, massive blood
transfusions, and diarrhea
Helps with Orientation Calendar on the wall
St. John's Wort Do not take with Zoloft
SIADH Tx: Fluid restriction plus hypertonic sodium chloride and Furosemide
Water intoxication caused by the inappropriate, continuous secretion of ADH by the posterior
pituitary gland, causing hypervolemia and hyponatremia.
S/S Hypovolemia Weak pulse, hypoTN, decreased CVP, decreased CO, elevated BUN and
serum osmolality, increased urine sp gravity and osmolality, decreased UOP, hematocrit elevated
Celiac Disease Foul, fatty stools (steatorrhea); malabsorption syndrome
Signs of abuse Spiral fractures
Ethambutol AE: loss of red/green color discrimination
Equation for calculating pulse pressure SBD-DBP = PP
When should a trough level be scheduled for a once daily dosing of Gentamicin? 1st hour prior
to next dose
When should a peak level be drawn for divided doses of Gentamicin? 30 min after admin of
med or infusion has finished
When should a trough level be drawn for divided doses of Gentamicin? right before next dose
S/S of dehydration - hyperthermia
- tachycardia
- thready pulse
- hypotension
- orthostatic hypotension
- decreased CVP
- tachypnea
- dizziness
- cool clammy skin
- diaphoresis
- sunken eyeballs
S/S of overhydration - tachycardia
- bounding pulse
- HTN
- tachypnea
- increased CVP
- confusion
- muscle weakness
- weight gain
- ascites
- dyspnea
- crackles
S/S of hyponatremia - hypothermia
- tachycardia
- rapid thready pulse
- hypotension
- orthostatic hypotension
- headache
- confusion
- decreased deep tendon reflexes
- hyperactive bowel sounds
S/S of hypernatremia - hyperthermia
- tachycardia
- rapid thready pulse
- orthostatic hypotension
- restlessness
- irritability
- muscle twitching
- reduced to absent DTRs
- hyperactive bowel sounds
S/S of hypokalemia - hyperthermia
- weak irregular pulse
- hypotension
- restlessness
- irritability
- weakness with ascending flaccid paralysis
- N/V
- diarrhea
- hyperactive bowel sounds
S/S of hypocalcemia - muscle twitches/tetany
- hyperactive DTRs
- positive Chvostek's sign (tapping on the facial nerve triggering facial twitching)
- positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation) -
seizures
S/S of hypomagnesaemia - hyperactive DTRs
- muscle tetany
- positive Chvostek's and Trousseau's signs
- hypoactive bowel sounds
- paralytic ileus
Chvostek's sign tapping on the facial nerve triggers facial twitching
Trousseau's sign hand/finger spasms with sustained blood pressure cuff inflation
Nutrition for preventing delays in healing encourage intake of 2-3L of fluid per day; increase
protein, keep serum albumin levels above 3.5
Complications following a hypophysectomy monitor for bleeding and nasal drainage for possible
CSF leak (assess drainage for glucose of halo sign); assess neurological condition every hour for
first 24 hours and every 4 hours after
meds of sinus tachycardia amiodarone, adenosine, and verapmil; synchronized cardioversion
S/S of hyperglycemia - Blood glucose level >250
- thirst
- frequent urination
- hunger
- warm, dry flushed skin
- weakness
- malaise
- rapid, weak pulse
- hypotension
- deep rapid respirations
Complications of pericarditis cardiac tamponade: hypotension, muffled heart sounds, JVD,
paradoxical pulse
What does pericarditis commonly follow? respiratory infection
S/S of pericarditis - chest pressure/pain
- friction rub
- SOB
- pain relieved when sitting and leaning forward
Fasting blood glucose postpone administration of anti-diabetic medication until after blood
glucose levels are drawn; ensure patient has fasted for 8 hours prior to blood draw Oral glucose
tolerance test fasting blood glucose level drawn at start then pt consumes a specified amount of
glucose; blood glucose levels drawn every 30min for 2hours; instruct client to consume
balanced diet for 3 days prior to test, then fast for 10 to 12 hours
Glycosylate hemoglobin best indicator for average blood glucose level for the past 120
days; normal range is 4-6%, diabetic range is 6.5-8%
Evaluating proper placement of NG tube - aspirate gastric contents and test pH (4 or less) - X-
ray
- note: injecting air into tube to listen over abdomen is NOT an acceptable practice IV urography
used to detect obstruction, assess for a parenchyma mass, and assess size of kidney
what should the nurse check before an IV urography procedure allergy to iodine and check
creatinine levels because dye can cause renal failure
complications of chest tube insertion air leaks - monitor the water seal chamber for continuous
bubbling;
tension pneumothorax - sucking chest wounds, prolonged clamping of the tube; kinks
in the tubing, or obstruction may cause this
Pt teaching for external radiation therapy gently wash skin over the irradiated area with mild
soap and water;
DO NOT remove radiation tattoos, DO NOT apply powders or lotions, wear soft clothing over
irritated area, avoid tight clothing, DO NOT expose area to sun or heat
how is infectious mononucleosis spread? saliva
incubation period for infection mononucleosis 4-6 weeks
S/S of infectious mononucleosis fever, sore throat, swollen lymph glands, increased WBCs,
atypical lymphocytes, splenomegaly, enlarged liver
tranmission precautions for infectious mononucleosis ruptured spleen
Nutrition for pt who has HSV-2 monitor fetal well-being, fetal consequences - include
miscarriage, preterm labor, and intrauterine growth restriction, obtain cultures, possible Csection
of lesions present during labor
Early S/S of cold stress in infant axillary temp < 97.7, increased respiration rate, increased
HR, mottled skin
Late S/S of cold stress in infant apneic periods, bradycardia, acrocyanosis, decreased
activity
Indications for use of cardioversion atrial dysrhythmias, SVT, ventricular tachycardia with pulse
& treatment of choice for patients who are symptomatic
S/S of hypoglycemia - shakiness
- diaphoresis
- anxiety
- nervousness
- chills
- nausea
- headache
- weakness
- confusion
Treatment for hypoglycemia 4oz orange juice, 2 oz grape juice, 8 oz milk, glucose tablets;
recheck blood glucose in 15 minutes if still low (<70), give 15g more carbs; recheck blood
glucose in 15 minutes, if within normal limits eats 1g protein (peanut butter, cheese) Nutrition
for increased ICP keep HOB at 30 degrees, avoid extreme flexion, extension or rotation
of the head and maintain in midline neutral position keep body aligned, avoid hip
flexion/extension; minimize endotracheal or oral suctioning; instruct pt to avoid coughing or
blowing nose
S/S of bacterial vaginosis vaginal oder, discharge, dysuria
Nutrition of boggy uterus postpartum massage first then administer oxytocin
What acid-base imbalance with a pt with chronic emphysema most likely have? respiratory
acidosis and compensatory metabolic alkalosis Normal Calcium levels 8.5 - 10.9 mg/dL
Normal Chloride levels 95 - 105
Normal Glucose levels 70 - 110
Normal K levels 3.5 - 5.5
Normal Na levels 135 - 145 mEq/L
Normal BUN levels 7 - 22
Normal creatinine levels 0.6 - 1.35
Specific gravity 1.010 - 1.030
Normal total protein levels 6.2 - 8.1 g/L
Normal albumin levels 3.4 - 5 g/L
Hgb 12-16
Hct for females 37 - 47
Hct for males 40 - 54
WBC 5.2 - 12.4
5,000 - 10,000
Normal phosphorus 2.5 - 4.5 Normal
magnesium 1.5 - 2.5 platelets
200,000 to 400,000
RBCs 4.5 - 5 million LDH
100 - 190 U/L
CPK 21 - 232 U/L
Uric acid 3.5 - 7.5
Triglyceride 40 - 50
Total cholesterol 130 - 200
Bilirubin < 1.o mg/dL
Bicarb (CO3) 24 - 26
CO2 25 - 45
PaO2 80 - 100%
SaO2 > 95% pH
7.35 - 7.45
PT 10 - 12 sec
PTT 30 - 45 sec
aPTT 23 - 31 INR
0.9 - 1.2
therapeutic lithium level 0.8 - 1.1
S/S of hypothryoidism - persistent lethargy
- feeling cold
- puffiness of the face - loss of body hair
proper use of crutches: going down the stairs crutches and affected leg down, followed by
unaffected leg
The nurse has given a client instructions about crutch safety. Which client statement indicates
that the client understands the instructions? - "I should not use someone else's crutches."
- "I need to remove any scatter rugs at home" - "I
need to have spare crutches and tips available"
proper three-point gait use of crutches client moves both crutches forward, along with the
affected leg, and then moves the unaffected leg forward
how should patients place crutches when standing on crutches? 6" to the front and side of the
toes
Nurse is giving a client with a left leg cast crutch-walking instructions using the tree-point gait.
The client is allowed touch-down of the affected leg. The nurse should tell the client to perform
which action? Advance the crutches along with the left leg, and then advance the right leg A
client has slight weakness in the right leg. On the basis of this assessment finding, the nurse
determines that the client would benefit most from the use of which item? A straight leg cane
Baby from mom w/ gestational diabetes at risk for low Ca & Mg & glycemia. high bili
Suction for trach pressure not to exceed 120 Hg
Clozapine side effect weight gain, hypotension and hyperglycemia
radical masectomy excersise 24 hr post op, 1 or more drains,
prevent heat loss in infant via conduction paper on scale when
giving blood transfusion give with NaCl
findings w/ severe preeclampsia oliguria, proteinuria, blurred vision, facial edema blood
glucose monitoring what to do first wash patients hands to stimulate blood flow &
decrease infection
steps to take when child is hypoglycemic OJ, wait 15 min, recheck glucose, give crackers &
cheese
AP to assist with meals Alzeimers patient demonstrating aphasia
hyperthyroid tremors
hypothyroid coarse hair, bradycardia, periorbital edema
how many mls in an ounce 30
gastric lavage lay patient on left side, instill 2-300 ml sterile water pt
should sign consent when accurately describes upcoming procedure
total hip going home teaching install raised toilet seat
TB patient precautions wear N95 mask, neg pressure room,
3 days post op aka move to prone position q 4 hr to prevent flexion contracture, don't elevate
for 48 hr, wrap limb distal to promimal to prevent restriction of blood flow case manager with
mental patients arrange transportation to appointments agitated and confused pt with head
injury pulling iv put on mittens and watch
insert catheter in male cath tray on bedside table waist height
pt had cva 6 yrs ago, decrease ICP how? quiet environment, HOB no more than 30 degrees
PICC, prior to starting initial infusion check chest xray
infant with CP getting enteral feeding, intervene when allowing to run for 8 min med
admin what is risk too frequently
strip with no p waves a fib
adult at risk for pressure ulcer 30 degree lateral position in bed client in crisis
safety, relationship, development, coordinate, plan and provide 24 hrs post op,
won't ambulate. nurse to do first ask pt to rate his pain
cardiac tamponade pulsus paradoxus
hypermagnesiumemia monitor for cardiac dysrhythmias
status epilepticus give diazepam
pt not going to have surgery clarify, notify, AMA, Document nurse manager
changing scheduling provide info about sched issues to staff student nurse doing
assessment, what was wrong detailed notes of assessment adverse reaction
propanolol coughing at night
#gtt/min 13
prone to urinary calculi, include in diet... oranges
home care instructions for pacemaker I will be able to take showers and baths
adverse effect of fluoxetine h/a...also urinary freq, hypotension child
to see first waiting appendectomy has sudden relief of pain
infant with apnea monitoring remove leads, ensure alarm can be heard, avoid cosleeping
3 hr oral glucose test fast the night before
potential food and med interaction MAOI wants cheeseburger what
to look for for cataracts cloudy lens with blurred vision
noncompliance with adv directives scenario tube feeding for alzeimers patient admit
with DKA, first... get vitals
pt gets codeine, statement that needs further teaching urinary freq
pt with TB is discharged take meds for at least 6 mo side effect of
ECT short term memory loss older adult with pneumonia acute
confusion
pt recovering from cva, nurse should... id community resources, contact home health,
verify med equip, coordinate OT tape test for pinworms collect in plastic bag short leg cast
for fractured fibula 3 point gait misoprostal and nsaids get pregnancy test
Do not delegate What you can EAT E-evaluate A-assess T-teach
Addison's & Cushings Addison's = down down down up down
Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia
Better peripheral perfusion? EleVate Veins, DAngle Arteries
APGAR Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
Airborne precautions MTV or My chicken hez tb measles, chickenpox (varicella) Herpes
zoster/shingles TB
Airborne precautions protective equip private room, neg pressure with 6-12 air
exchanges/hr mask & respirator N95 for TB
Droplet precautions spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus,
pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)
Contact precaution MRS WHISE
protect visitors & caregivers when 3 ft of the pt.
Multidrug-resistant organisms
RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by
micro-organisms (C diff),

Gloves and gowns worn by the caregivers and visitors

Disposal of infectious dressing material into a single, nonporous bag without touching the
outside of the bag

PMGG= Private room/ share same illness, mask, gown and gloves
Skin infection VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis Scabies
Air or Pulmonary Embolism S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of
impending doom. (turn pt to LEFT side and LOWER the head of bed.)
Woman in labor (un-reassuring FHR) (late decels, decreased variability, fetal bradycardia,
etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids!
Tube feeding with decreased LOC Pt on Right side (promotes emptying of the stomach) Head
of bed elevated (prevent aspiration)
After lumbar puncture and oil based myelogram pt is flat SUPINE (prevent headache and
leaking of CSF)
Pt with heat stroke flat with legs elevated during Continuous Bladder Irrigation (CBI)
catheter is taped to the thigh. leg must be kept straight.
After Myringotomy position on the side of AFFECTED ear, allows drainage. After
Cateract surgery pt sleep on UNAFFECTED side with a night shield for 1-4 weeks after
Thyroidectomy low or semi-fowler's position, support head, neck and shoulders.
Infant with Spina Bifida Prone so that sac does not rupture
Buck's Traction (skin) elevate foot of bed for counter traction
After total hip replacement don't sleep on side of surgery, don't flex hip more than 45-60
degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating
thighs with pillows.
Prolapsed cord Knee to chest or Trendelenburg
oxygen 8 to 10 L
Cleft Lip position on back or in infant seat to prevent trauma to the suture line. while
feeding hold in upright position.
To prevent dumping syndrome (post operative ulcer/stomach surgeries) eat in reclining
position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and
fiber diet. small, frequent meals.
AKA (above knee amputation) elevate for first 24 hours on pillow. position prone daily to
maintain hip extension.
BKA (below knee amputation) foot of bed elevated for first 24 hours. position prone to
provide hip extension.
detached retina area of detachment should be in the dependent position administration
of enema pt should be left side lying (Sim's) with knee flexed.
After supratentorial surgery (incision behind hairline on forhead) elevate HOB 30-40 degrees
After infratentorial surgery (incision at the nape of neck) position pt flat and lateral on either
side.
During internal radiation on bed rest while implant in place
Autonomic Dysreflexia/Hyperreflexia S/S pounding headache, profuse sweating, nasal
congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB)
FIRST!
Shock bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated
(modified Trendelenberg)
Head Injury elevate HOB 30 degrees to decrease ICP
Peritoneal Dialysis (when outflow is inadequate) turn pt from side to side BEFORE checking
for kinks in tubing
Lumbar Puncture After the procedure, the pt should be supine for 4-12 hours as prescribed.
Myesthenia Gravis worsens with exercise and improves with rest
Myesthenia Gravis a positive reaction to Tensilon---will improve symptoms
Cholinergic Crisis Caused by excessive medication ---stop giving Tensilon...will make it
worse.
Liver biopsy (prior) must have lab results for prothrombin time
Myxedema/ hypothyroidism slowed physical and mental function, sensitivity to cold, dry skin
and hair.
Grave's Disease/ hyperthyroidism accelerated physical and mental function. Sensitivity to
heat. Fine/soft hair.
Thyroid storm increased temp, pulse and HTN
Post-Thyroidectomy semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside
Hypo-parathyroid CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased
calcium) give high calcium, low phosphorus diet
Hyper-parathyroid fatigue, muscle weakness, renal calculi, back and joint pain (increased
calcium) give a low calcium high phosphorous diet
Hypovolemia increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety.
Urine specific gravity >1.030
Hypervolemia bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine
specific gravity <1.010. semi fowler's
Diabetes insipidus (decreased ADH) excessive urine output and thirst, dehydration, weakness,
administer Pitressin
SIADH (increased ADH) change in LOC, decreased deep tendon reflexes, tachycardia. N/V
HA administer Declomycin, diuretics
hypokalemia muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges,
beans, potatoes, carrots, celery)
Hyperkalemia MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased
cardiac contractility, ECG changes, reflexes
Hyponatremia nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give
osmotic diuretics (Mannitol) and fluids
Hypernatremiaincreased temp, weakness, disorientation, dilusions, hypotension, tachycardia.
give hypotonic solution.
Hypocalcemia CATS Convulsions, Arrythmias, Tetany, spasms and stridor
Hypercalcemia muscle weakness, lack of coordination, abdominal pain, confusion, absent
tendon reflexes, shallow respirations, emergency!
Hypo Mg Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig
toxicity)
Hyper Mg depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep
tendon reflexes, shallow respirations. EMERGENCY
Addison's Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress
fx, alopecia, weight loss. GI stress.
Cushings Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness,
edema, HTN, hirsutism, moonface/buffalo hump
Addesonian crisis N/V confusion, abdominal pain, extreme weakness, hypoglycemia,
dehydration, decreased BP
Pheochromocytoma hypersecretion of epi/norepi. persistent HTN, increased HR,
hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks,
avoid cold and stimulating foods (surgery to remove tumor)
Tetrology of Fallot DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas,
Pulmonary stenosis)
Autonomic Dysreflexia (potentially life threatening emergency!) HOB elevate 90 degrees,
loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer
antihypertensives (may cause stroke, MI, seizure) FHR patterns for OB Think VEAL CHOP!
V-variable decels; C- cord compression caused
E-early decels; H- head compression caused
A-accels; O-okay, no problem
L- late decels; P- placental insufficiency, can't fill what to check with pregnancyNever
check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to
fetal heart tones with stethoscope.
Position of the baby by fetal heart sounds Posterior --heard at sides
Anterior---midline by unbilicus and side Breech-
high up in the fundus near umbilicus Vertex- by
the symphysis pubis.
Ventilatory alarms HOLD
High alarm--Obstruction due to secretions, kink, pt cough etc
Low alarm--Disconnection, leak, etc
ICP and Shock ICP- Increased BP, decreased pulse, decreased resp
Shock--Decreased BP, increased pulse, increased resp
Cor pumonae Right sided heart failure caused by left ventricular failure (edema, jugular vein
distention)
Heroin withdrawal neonate irritable, poor sucking
brachial pulse pulse area on an infant lead poisoning test at
12 months of age Before starting IV antibiotics obtain
cultures! pt with leukemia may have epistaxis due to low
platelets
when a pt comes in and is in active labor first action of nurse is to listen to fetal heart
tones/rate
for phobias use systematic desensitization
NCLEX answer tips choose assessment first! (assess, collect, auscultate, monitor, palpate) only
choose intervention in an emergency or stress situation. If the answer has an absolute, discard it.
Give priority to the answers that deal with the patient's body, not machines, or equipment.
ARDS and DIC are always secondary to another disease or trauma
In an emergency patients with a greater chance to live are treated first
Cardinal sign of ARDS hypoxemia
Edema is located in the interstitial space, not the cardiovascular space (outside of the
circulatory system) the best indicator of dehydration? weight---and skin turgor
heat/cold hot for chronic pain; cold for accute pain (sprain etc) When pt is in
distress....medication administration is rarely a good choice pneumonia fever and chills
are usually present. For the elderly confusion is often present. before IV antibiotics? check
allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose.
COPD and O2 with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must
be low because high O2 concentration takes away the pt's stimulation to breathe. Prednisone
toxicity Cushings (buffalo hump, moon face, high blood sugar, HTN)
Neutropenic pts no fresh fruits or flowers
Chest tubes are placed in the pleural space
Preload/Afterload Preload affects the amount of blood going into Right ventricle. Afterload
is the systemic resistance after leaving the heart.
CABG Great Saphenous vein in leg is taken and turned inside out (because of valves inside) .
Used for bypass surgery of the heart. Unstable
Angina not relieved by nitro PVC's can
turn into V fib.
1 tsp 5 mL
1 oz 30 mL
1 cup 8 oz
1 quart 2 pints
1 pint 2 cups
1 g (gram) 1000 mg
1 kg 2.2 lbs I lb
16 oz
centigrade to Fahrenheit conversion F= C+40 multiply 5/9 and subtract 40
C=F+40 multiply 9/5 and subtract 40
Angiotenson II In the lungs...potent vasodialator, aldosterone attracts sodium.
Iron toxicity reversal deferoxamine
S3 sound normal in CHF. Not normal in MI
After endoscopy check gag reflex TPN
given in subclavian line pain with
diverticulitis located in LLQ appendicitis
pain located in RLQ
Trousseau and Chvostek's signs observed in Hypocalcemia
never give K+ in IV push
DKA is rare in DM II (there is enough insulin to prevent fat breakdown) Glaucoma
patients lose peripheral vision.
Autonomic dysreflexia patients with spinal cord injuries are at risk for developing
autonomic dyreflexia (T-7 or above)
Spinal shock occurs immediately after injury multiple sclerosis myelin sheath destruction.
disruptions in nerve impulse conduction Myasthenia gravis decrease in receptor sites for
acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for
aspiration.
Gullian -Barre syndrome ascending paralysis. watch for respiratory problems.
TIA transient ischemic attack....mini stroke, no dead tissue.
CVA cerebriovascular accident. brain tissue dies.
Hodgkin's disease cancer of the lymph. very curable in early stages
burns rule of Nines head and neck 9% each upper ext 9% each lower
ext 9% front trunk 18% back trunk 18% genitalia 1%
birth weight doubles by 6 months triples
by 1 year
if HR is <100 (children) Hold Dig
early sign of cystic fibrosis meconium in ileus at birth
Meningitis--check for Kernig's/ brudinski's signs wilm's tumor
encapsulated above kidneys...causes flank pain hemophilia is
x linked passed from mother to son when phenylaline
increases brain problems occur buck's traction knee
immobility; dont adjust weights russell traction femur or
lower leg dunlap traction skeletal or skin
bryant's traction children <3 y <35 lbs with femur fx eclampsia
is a seizure
perform amniocentesis before 20 weeks to check for cardiac and pulmonary abnormalities Rh
mothers receive Rhogam to protect next baby
anterior fontanelle closes by...posterior by.. 18 months, 6-8 weeks
caput succedaneum diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes
within 1 to 3 days pathological jaundice occurs:
physiological jaundice occurs: before 24 hours (lasts 7 days)
after 24 hours placenta previa s/s
placental abrution s/s there is no pain, but there is bleeding
there is pain, but no bleeding (board like abd) bethamethasone
(celestone) surfactant. premature babies milieu therapy taking
care of pt and environmental therapy
cognitive therapy counseling five
interventions for psych patients safety
setting limits
establish trusting relationship
meds
least restrictive methods/environment SSRI's
take about 3 weeks to work
patients with hallucinations patients with
delusions redirect them
distract them
Thorazine and Haldol can cause EPS
Alzheimer's 60% of all dementias, chronic, progressive degenerative cognitive disorder. draw
up regular and NHP? Air into NHP, air into Regular. Draw regular, then NHP
Cranial nerves S=sensory M=motor B=both
Oh (Olfactory I) Some
Oh (Optic II ) Say
Oh (Oculomotor III) Marry
To (trochlear IV) Money
Touch (trigeminal V) But
And (Abducens VI ) My
Feel (facial VII) Brother
A (auditory VIII) Says
Girl's (glossopharyngeal IX) Big
Vagina (vagus X) Bras
And (accessory XI) Matter
Hymen (Hypoglossal XII) More
HypernatremiaS (Skin flushed)
A (agitation)
L (low grade fever )
T (thirst)
Developmental 2-3 months: turns head side to side
4-5 months: grasps, switch and roll
6-7 months: sit at 6 and waves bye bye
8-9 months: stands straight at 8
10-11 months: belly to butt
12-13 months: 12 and up, drink from a cup
Hepatitis A Ends in a vowel, comes from the bowel
Hepatitis b B= blood and body fluids (hep c is the same)
Apgar measures HR RR Muscle tone, reflexes, skin color.
Each 0-2 points. 8-10 ok, 0-3 resuscitate
Glasgow coma scale eyes, verbal, motor
Max- 15 pts, below 8= coma Addison's
disease:
Cushing's syndrome: "add" hormone have
extra "cushion" of hormone
Dumping syndrome increase fat and protein, small frequent meals, lie down after meal to
decrease peristalsis. Wait 1 hr after meals to drink Disseminated herpes zoster
localized herpes zoster Disseminated herpes=airborne precautions
Localized herpes= contact precautions. A nurse with localized may take care of patients as long
as pts are not immunosuppressed and the lesions must be covered!
Isoniazid causes peripheral neuritis
Weighted NI (naso intestinal tubes) Must float from stomach to intestine. Don't tape right away
after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate
movement through pyloris Cushings ulcers r/t brain injury
Cushing's triad r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure)
Thyroid storm HOT (hyperthermia)
Myxedema coma COLD (hypothermia)
Glaucoma No atropine
Non Dairy calcium Rhubarb sardines collard greens
Koplick's spots prodomal stage of measles. Red spots with blue center, in the mouth-think
kopLICK in the mouth
INH can cause peripheral neuritis Take vitamin B6 to prevent. Hepatotoxic
pancreatitis pts put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC,
they are probably going to get TPN/Lipids
Murphy's sign Pain with palplation of gall bladder (seen with cholecystitis)
Cullen's sign ecchymosis in umbilical area, seen with pancreatitis
Turner's sign Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis
McBurney's point Pain in RLQ with appendicitis
LLQ Diverticulitis
RLQ appendicitis watch for peritonitis
Guthrie test Tests for PKU. Baby should have eaten protein first shilling
test Test for pernicious anemia
Peritoneal dialysis Its ok to have abd cramps, blood tinged outflow and leaking around site if
the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok Hyper reflexes
absent reflexes upper motor neuron issue (your reflexes are over the top)
Lower motor neuron issue
Latex allergies assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit,
avocados, chestnuts, tomatoes and peaches
Tensilon used in myesthenia gravis to confirm diagnosis
ALS (amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower
motor neuron systems
Transesophageal fistula esophagus doesn't fully develop. This is a surgical emergency (3
signs in newborn: choking, coughing, cyanosis) MMR is given SQ not IM
codes for pt care Red- unstable, ie.. occluded airway, actively bleeding...see first
Yellow--stable, can wait up to an hour for treatment
Green--stable can wait even longer to be seen---walking wounded
Black--unstable, probably will not make it, need comfort care
DOA--dead on arrival
Contraindication for Hep B vaccine anaphylactic reaction to baker's yeast what
to ask before flu shot allergy to eggs what to ask before MMR allergy to
eggs or neomycin when on nitroprusside monitor: cyanide. normal value
should be 1. William's position semi Fowler's with knees flexed to reduce
low back pain
S/S of hip fx External rotation, shortening adduction
Fat embolism blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis.
Hypocalcemia, increased serum lipids. complications of mechanical
ventilation pneumothorax, ulcers Paget's disease tinnitus, bone
pain, elnargement of bone, thick bones with allopurinol no
vitamin C or warfarin! IVP requires bowel prep so bladder can be
visualized
acid ash diet cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
alk ash diet milk, veggies, rhubarb, salmon orange tag in psych is emergent
psych
thyroid med side effects insomnia. body metabolism increases
Tidal volume is 7-10 ml/kg
COPD patients and O2 2LNC or less. They are chronic CO2 retainers expect sats to be
90% or less
Kidney glucose threshold 180
Stranger anxiety is greatest at what age? 7-9 months..separation anxiety peaks in toddlerhood
when drawing an ABG put in heparinized tube. Ice immediately, be sure there are no
bubbles and label if pt was on O2
Munchausen syndrome vs munchausen by proxy Munchausen will self inflict injury or illness
to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by
proxy mother or other care taker fabricates illness in child
multiple sclerosis motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness,
tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia
hungtington's 50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements
of face, limbs and body. no cure
WBC left shift pt with pyelo. neutrophils kick in to fight infections
pancreatic enzymes are taken with each meal! infants IM site
Vastus lateralis
Toddler 18 months+ IM site Ventrogluteal
IM site for children deltoid and gluteus maximus
Thoracentesis: position pt on side or over bed table. no more than 1000 cc removed at a time.
Listen for bilateral breath sounds, V.S, check leakage, sterile dressing
Cardiac cath NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire
to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr
Cerebral angio prep well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for
1214 hr. check site, pulses, force fluids. lumbar puncture fetal position. post-neuro assess
q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache.
ECG no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before.
may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after
the procedure.
Myelogram NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants
withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment
q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids.
assess for distended bladder. Inspect site
Liver biopsy administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to
expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated.
Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk
Paracentesis semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated
temp. watch for hypovolemia
laparoscopy CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease
CO2 buildup
PTB low grade afternoon fever
pneumonia rusty sputum; when percuss-will hear dull sounds
asthma wheezing on expiration emphysema barrel chest
kawasaki syndrome strawberry tongue pernicious anemia
red beefy tongue
downs syndrome protruding tongue
cholera rice watery stool
malariastepladder like fever--with chills
typhoid rose spots on the abdomen diptheria
pseudo membrane formation measles
koplick's spots
sle (systemic lupus) butterfly rash pyloric stenosis
olive like mass Addison's bronze like skin
pigmentation Cushing's moon face, buffalo hump
hyperthyroidism/ grave's disease exophthalmos
myasthenia gravis descending musle weakness
gullian-barre syndrome ascending muscle weakness
angina crushing, stabbing chest pain relieved by nitro MI
crushing stabbing chest pain unrelieved by nitro cystic
fibrosis salty skin
DM polyuria, polydipsia,polyphagia
DKA kussmal's breathing (deep rapid)
Bladder CA painless hematuria BPH
reduced size and force of urine
retinal detachment floaters and flashes of light. curtain vision
glaucoma painful vision loss. tunnel vision. halo
retino blastoma cat's eye reflex
increased ICP hypertension, bradypnea,, bradycarday (cushing's triad)
shock Hypotension, tachypnea, tachycardia Lymes disease bullseye rash intraosseous infusion
often used in peds when venous access can't be obtained. hand drilled through tibia where
cryatalloids, colloids, blood products and meds are administered into the marrow. one med that
CANNOT be administered IO is isoproterenol, a beta agonist. sickle cell crisis two
interventions to prioritize: fluids and pain relief. glomuloneprhitis the most important
assessment is blood pressure children 5 and up should have an explanation of what will
happen a week before surgery Kawasaki disease (inflammation of blood vessles, hence the
strawberry tongue) causes coronary artery aneurysms. ventriculoperitoneal shunt watch for
abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging
fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position
is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30
degrees
3-4 cups of milk a day for a child? NO too much milk can reduce the intake of other nutrients
especially iron. Watch for ANEMIA
MMR and varicella immunizaions after 15 months!
cryptorchidism undescended testicles! risk factor for testicular cancer later in life. Teach
self exam for boys around age 12--most cases occur in adolescence
CSF meningitis HIGH protein LOW glucose
Head injury or skull fx no nasotracheal suctioning otitis media feed upright to avoid
otitis media! positioning for pneumonia lay on affected side, this will splint and reduce pain.
However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a
stuffy nose and you lay with that side up, it clears!)
for neutropenic pts no fresh flowers, fresh fruits or veggies and no milk
antiplatelet drug hypersensitivity bronchospasm
bowel obstruction more important to maintain fluid balance than to establish a normal bowel
pattern (they cant take in oral fluids)
Basophils reliease histamine during an allergic response
Iatragenic means it was caused by treatment, procedure or medication
Tamoxifen watch for visual changes--indicates toxicity
post spelectomy pneumovax 23 is administered to prevent pneumococcal sepsis
Alkalosis/ Acidosis and K+ ALKalosis=al K= low sis. Acidosis (K+ high) No
phenylalanine to a kid with PKU. No meat, dairy or aspartame never give potassium to a
pt who has low urine output! nephrotic syndrome characterized by massive proteinuria
caused by glomerular damage. corticosteroids are the mainstay
the first sign of ARDS increased respirations! followed by dyspnea and tachypnea
normal PCWC (pulmonary capillary wedge pressure) is 8-13 readings 18-20 are
considered high
first sign of PE sudden chest pain followed by dyspnea and tachypnea
Digitalis increases ventricular irritability ----could convert a rhythm to v-fib following
cardioversion
Cold stress and the newborn biggest concern resp. distress
Parathyroid relies on vitamin D to work
Glucagon increases the effects of? anticoagulants
Sucking stab wound cover wound and tape on 3 sides to allow air to escape. If you cover and
occlude it--it could turn into a closed pneumo or tension pneumo!
chest tube pulled out? occlusive dressing
PE Needs O2!
DKA acetone and keytones increase! once treated expect postassium to drop! have K+ ready
Hirschprung's diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the
classic ribbon-like/foul smelling stools
Intussusception Common in kids with CF. Obstruction may cause fecal emesis, current
jelly stools. enema---resolution=bowel movements laboring mom's water breaks? first thing--
worry about prolapsed cord!
Toddlers need to express independence!
Addison's causes sever hypotension!
pancreatitis first pain relief, second cough and deep breathe CF chief concern?
Respiratory problems a nurse makes a mistake? take it to him/her first then take up
the chain nitrazine paper turns blue with alkaline amniotic fluid. turns pink with other
fluids up stairs with crutches? down stairs with crutches? good leg first followed by
crutches(good girls go to heaven) crutches with the injured leg followed by the good leg.
dumping syndrome? use low fowler's to avoid. limit fluids
TB drugs are hepatotoxic! clozapine, Clozaril
antipsychotic
anticholinergic
clozapine s/e weight gain, hypotension, hyperglycemia, agranulocytosis dehydration
-hypovolemia
- elevated urine specific gravity
flumazenil, Romazicon benzo overdose
umbilical cord compression reposition side to side or knee-chest
short cord discontinue pictocin
TB A positive Mantoux test indicates pt developed an immune response to TB.
Acid-fast bacilli smear and culture:(+suggests an active infection) the diagnosis is CONFIRM by
a positive culture for M TB
A chest x-ray may be ordered to detect active lesions in the lungs
QuantiFERON-TB Gold: DIAGNOSTIC for infection, whether it is active or latent
Battery performing procedure without consent
Assault Threatening to give pt. medication putting another
person in fear of a harmful or an offensive contact. Imprisonment
Telling the client you cannot leave the hospital Defamation is a
false communication or careless disregard for the truth that causes
damage to someone's reputation. in writing(Libel) or
Verbally(Slander)
Sprain or Strain RICE
Rest
Ice
Compress Elevate quad cane place of unaffected
side of body place it 6-12 in in front of the body
before walking steps forward with affected leg first
bring the unaffected leg as well, bringing the foot past the cane
hand roll in each hand maintains functional position
Fluoxetine (Prozac) report tremors, agitation, confusion, anxiety, hallucinations=serotonin
syndrome (risk in the first 2-72 hrs after given first time); client will stop the meds; weight
gain/diabetes/ hyperglicemia
asthma kid should participate in sports, inhaler prior to sports, stay inside when cold, use
peak flow meter every day same time, annual influenta vaccine important