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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 surge 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?

C. Reapplying a condom catheter for a client who has urinary incontinence

 

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:

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

 

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?

D. Replacing the cartridge and tubing on a PCA pump

 

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:

B. Right supervision/evaluation

C. Right direction/communication

E. Right circumstances

 

A nurse manager of a med surge 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?

B. RN

 

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 an agreement to keep promises-Fidelity

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

 

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?

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

C. Justice

 

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

D. Nonmalificence

 

Which of the following situations can be identified as an ethical dilemma?

C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill

 

Most managers can be categorized as-authoritative, democratic, and laissez faire

Authoritative

§  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-

Democratic

§  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-

Laissez faire

§  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-

 

 

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?- CARE

-       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

 

What is an interdisciplinary team?-

§  A group of health care professionals from different disciplines

 

Fill in the blank:

1.    collaboration is used by interdisciplinary team to make health care decisions about clients with multiple problems.

2.     collaboration, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone

 

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?

2. High-pitched cry.

 

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?

4. Urine output of at least 30 cc per hour.-4

 

The client is exhibiting symptoms of myxedema. The nursing assessment should reveal

2. decreased temperature.

 

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?

3. Instruct client to push a button when she feels fetal movement.

 

Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis?

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°.

 

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

2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization.

 

A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to

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.

 

A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client

3. verbalizes that s/he is not responsible for the sexual abuse.

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?

2. "Wear sunscreen and a hat when outdoors."

 

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?

2. Alteration in skin integrity related to decrease in tissue oxygenation.

 

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.

 

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.

 

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.

 

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?

3. The staff helps the client identify thoughts or feelings that occurred prior to the

onset of the anxiety.

 

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?

3. The dialysate outflow is cloudy.

 

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.

 

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?

3. Restlessness and increased heart rate.

 

 

 

 

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?

3. "You are experiencing a side effect of Haldol."

 

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

4. at hs.-4 (HOURS OF SLEEP)

 

If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe

3. peripheral edema and anorexia.

 

The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST?

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.

 

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?

2. The client holds the cane in her left hand.

 

A client returns to his room following a myelogram. The nursing care plan should include which of the following?

1. Encourage oral fluid intake.

 

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."

 

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?

4. "I don't know who I am and I don't know where I live."

 

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?

4. Decreased level of consciousness.

 

 

 

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.

 

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

4. cough and deep breathe.-4

 

Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?

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.

 

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.

 

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?

4. The client will be required to take prescribed medication for a duration of 6-9 months.-

 

The nurse's INITIAL priority when managing a physically assaultive client is to

3. restore the client's self-control and prevent further loss of control.

 

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.

 

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.

 

 

 

When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse's actions during this intervention?

3. The patient's voluntary/involuntary status.

 

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?

2. Maintain optimal function within the client's limitations.

 

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?

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?

3. The patient's albumin level is 4.0mg/dL.

 

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.

 

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?

2. Aspirate the gastric contents with a syringe.

 

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?

2. There is clear fluid draining from the client's right ear.

 

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?

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?

3. Administer naloxone (Narcan).

 

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

e) Use antimicrobial sanitizer for hand hygiene

 

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?

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

 

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

 

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

 

Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?

b) apply intermittent suction when withdrawing the catheter

 

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?

c) instruct the client to focus on gradually resuming self-care tasks

 

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

 

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?

c) "I flushed what I urinated at 7 am and have saved the rest since"

 

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?

c) 0.9% sodium chloride

 

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?

c) maintain two points of support on the floor

 

Which of the following should indicate to a nurse the need to suction a client's tracheostomy?

a) irritability

 

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

c) cleanse the wound from the center outwards

 

A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid?

d) orange sherbet

 

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?

d) pour warm water over the clients perineum

 

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate?

3. Prescription drug intoxication.

 

Which of the following is essential when caring for a client who is experiencing delirium?

2. Identifying the underlying causative condition or illness.

 

Which of the following is a realistic short-term goal to be accomplished in 2 to 3 days for a client with delirium?

3. Regain orientation to time and place.

 

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?

2. Assess the client's gait for steadiness.

 

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.

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.

 

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?

3.    Agitation and assaultiveness.

 

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.

 

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?

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.)

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.

E. A fire extinguisher should be readily available in the home

 

A nurse is providing home safety instructions to a group of older adult clients. Match the safety risk

with the appropriate instruction.

__C__ Passive smoking

__A__ Carbon monoxide poisoning

 __B__ 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
 

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

 

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 cut

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[Solved] ATI Comprehensive Predicter STUDY THIS ONE quizlet

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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 surge 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? C. Reapplying a condom catheter for a client who has urinary incontinence 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: 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 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? D. Replacing the cartridge and tubing on a PCA pump 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: B. Right supervision/evaluation C. Right direction/communication E. Right circumstances A nurse manager of a med surge 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? B. RN 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 an agreement to keep promises-Fidelity 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 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? 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 C. Justice 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 D. Nonmalificence Which of the following situations can be identified as an ethical dilemma? C. A family has conflicting feelings about the initiation of enteral tube feedings of their father who is terminally ill Most managers can be categorized as-authoritative, democratic, and laissez faire Authoritative  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- Democratic  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- Laissez faire  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- 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?- CARE - 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 What is an interdisciplinary team?-  A group of health care professionals from different disciplines Fill in the blank: 1. collaboration is used by interdisciplinary team to make health care decisions about clients with multiple problems. 2. collaboration, which may take place at team meetings, allows the achievement of results that the participants would be incapable of accomplishing if working alone 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? 2. High-pitched cry. 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? 4. Urine output of at least 30 cc per hour.-4 The client is exhibiting symptoms of myxedema. The nursing assessment should reveal 2. decreased temperature. 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? 3. Instruct client to push a button when she feels fetal movement. Which of the following nursing interventions is MOST important for a 45-year-old woman with rheumatoid arthritis? 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°. 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 2. perform the Valsalva maneuver(holding breath and bearing down) before doing the catheterization. A client is being discharged with sublingual nitroglycerin (Nitrostat). The client should be cautioned by the nurse to 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. A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client 3. verbalizes that s/he is not responsible for the sexual abuse. 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? 2. "Wear sunscreen and a hat when outdoors." 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? 2. Alteration in skin integrity related to decrease in tissue oxygenation. 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. 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. 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. 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? 3. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety. 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? 3. The dialysate outflow is cloudy. 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. 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? 3. Restlessness and increased heart rate. 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? 3. "You are experiencing a side effect of Haldol." 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 4. at hs.-4 (HOURS OF SLEEP) If a client develops cor pulmonale (right-sided heart failure), the nurse would expect to observe 3. peripheral edema and anorexia. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? 2. A 19-year-old with a fever of 1...
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