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182 Cards in this Set

  • Front
  • Back
There was a stenosis mitral valve problem with a patient. What would you assess first?
Blood pressure
If a patient is taking LMWH (heparin) and the INR is 4.5. What would you do?
give Protamine Sulfate (antidote)
Which patient is most at risk for PVD?
African American man with DM
Which woman is most at risk for CVD?
Woman with weight in the abdominal region.
Giving an IM injection need to give 4ml and want to avoid the sciatic nerve. Where do you give?
Ventrogluteal
Where would you give an IM injection of iron?
Dorsogluteal
Which is NOT correct when giving otic drops to a patient with a perforated ear?
Using aseptic technique (must be sterile)
What would be the most important education for a patient in sickle cell crisis?
Hydrate at least 4,500ml
What would be the best meal for a patient with vitamin B12 anemia?
Fried liver and onions, OJ and green leafy vegetables
What should a patient with iron deficiency anemia eat?
Steak
What should a patient with folic acid anemia be given?
Green leafy vegetables
Patient has Glossitis what would you suggest they do?
Eat green leafy vegetables
What are signs and symptoms of woman with CAD (Left sided MI?) select all that apply:
indigestion-abdominal fullness-fatigue with rest-anxiety
RN education for pt taking ACE inhibitor?
ask for help rising / rising slowly
Orthostatic hypotension what is it?
Decrease of more than 20mm Hg of the systolic pressure or more than 10mm Hg of the diastolic pressure, as well as a 10-20% increase in heart rate
If patient has normal heart rate and rhythm what is true?
Automaticity of the conduction system is normal.
A patient has hyperlipidemia and has decreased the fat in his diet and has started an exercise program. He wants to know why his lipid levels are still high?
Heredity
Patient’s heart rate is 40 beats/min what is the problem with the patient’s heart?
SA node

SA 60-100
AV 40-60
His 20-40
Follow path of a drop of blood starting from the superior vena cava:
RA, tricuspid valve, RV, pulomonic valve, pulmonary artery, lungs, pulmonary vein, LA, mitral valve, LV, aortic valve
SOB when lying down in bed?
Orthopnea
Essential (primary) hypertension?
No known cause
Patient on LMWH what indicates the patient has proper education?
Call the physician if they notice black tarry stools
Patient has an order for LMWH and coumadin what would the nurse do?
give as ordered (if no INR values given)

INR >3 do not give
Predictable/expected secondary effect?
Side Effect
Patient with CVD (priority Dx for a patient with HF?). What is the most critical nursing diagnosis?
Impaired gas exchange
Pt NPO which drugs could be given? (select all that apply)
SL, PR (also IM, IV, transdermal, SC)
Pt has clubbing what is the priority assessment?
check pulse oximetry
African American patient which do you check for skin changes?
nail beds
Which would you tell PAD/PVD patient to do to increase vasodilation?
Do not smoke
Patient is taking hydrochlorothiazide and is having muscle cramps what would you advise the patient to do?
take potassium supplements
Ischemia to the left ventricle what happens?
Decrease cardiac output
Patient comes to the dr. office and blood pressure is (unexpectantly?) elevated what would you do
check in other arm
PVD patient what would you advise them?
Do not bend extremities (leg)

(elevate extremities, avoid tight fitting clothing?)
Patient taking ACE inhibitor, Captopril, what would you check?
Serum potassium levels
Patient has an order for 5mg morphine Q4H. He had last dose 3 hours ago and is c/o pain. What would you do?
do not administer (dosage question?)
Patient has order for Beta Blocker HR less than 60, what would you do?
do not administer
How to locate PMI?
Observe chest for visible pulsations
Early symptoms of heart failure is?
Dyspnea (SOB) on exertion (fatigue when climbing stairs)
Patient with hyperlipidemia what food choice would you pick?
Skim milk, cereal, banana, and decaf.
PVD diagnosis who is most at risk?
middle-age man who smokes
Sickle cell disease what would the patient state?
I get fatigued more often.
What is a sign of edema?
My shoes feel tighter
Sickle cell anemia patient what would you do (select all that apply?
Check pulse ox, Feel for peripheral pulses, Elevate extremities (legs)
Patient has BP of 138/88 (prehypertension) what would you recommend? Suggest to patient to make dietary and lifestyle changes
make dietary changes
Assess cardiac status which would be the most critical?
Hearing swishing (bruits) sound on either side of the neck
What would you educate a patient with cardiac problems that is on a nicotine patch for quitting smoking?
Do not smoke while wearing the patch because it puts you at a greater risk for heart attack
A patient was recently diagnosed with hypertension which dietary would they most need to avoid?
Canned and processed foods
Nurse calculating pack years for smoker who just got diagnosed, nurse intervention?
Try not to be judgmental in questioning.
Patient takes NSAIDS for long time. Nurse preparing patient for pre-op, nurse asks what question to assess:
when did you last take your NSAIDs?
Patient taking Dilaudid. Nurse taking history. What should she ask patient?
when was your last dose?
Nurse student suctioning. What would cause tissue damage?
Do not suction on the way in
Plavix: Adverse Effect
Ecchymosis
Patient couldn’t speak or write, type of aphasia?
Expressive
how to calculate dosage for rTPA?
0.9 x wt (kG), max of 90 kg. give 10% of dose as a bolus over 1 min

(in test the answer was 0.9 x 60= 54 x 10%= 5.4)
Older adult, respiratory system changes with age?
decrease in elastic recoil, decrease in alveolar surface area
Patient with stroke, How to decrease risk of VAP?
continuously suction subglottic secretions
Incentive Spirometer how to use
Exhale, Inhale, Breath 5 secs
Pt. with flexion posturing...
Decorticate
GCS- Incomprehensible/ no eye movement/ : no motor movement
score 4
High risk for nosocomial pneumonia?
ventilator/mechanical
High risk for CAP?
Smoker
Pt in Coma due to brain attack, what to ask family in ED?
Ask family about drug alcohol abuse
Partial rebreather mask, which would a nurse intervene?
oxygen at 2L

cannula 1-6, simple 5-8, prb 6-10 nrb 10-15 (with 2/3 full res)
Patient with thrombotic stroke, aphasia
Ask if patient has had 2 episodes of speech impairment with in the past month (slow onset)
Patient with aphasia, cant communicate. How to help communicate?
Use picture board
Which surgery would a patient have 10/10 pain?
Abdominal surgery
Patient pulse ox at 92% dropped to 85%, 1st priority?
Reassess and apply oxygen
Patient has 2 oz. of clear thin sputum in early morning, Initial intervention?
Monitor sputum and watch amount
Patient with embolic stroke, at risk associated with what disease process?
AF
Patient had Tylenol 4g/ day, what should be checked?
Liver function test (LFT)

(max is 4g/d)
Patient on morphine, while sleeping HR drops to 8, what should be done first
Arouse patient from sleep
27. What drug to administer for embolic stroke?
rTPA (not for hemorrhagic)
Normal therapeutic INR level?
2-3 (normal is .8-1.2, therapeutic is 1.5-2x that value)
Patient was on hydro morphine, not working anymore. What happened?
Patient developed tolerance
Patient just admitted into ER with a CVA, what do you do?
elevate HOB to 30 degrees
Pneumonia, not a normal sign
WBC 8,000

(expected: chest pain, myalgia, malaise). WBC should be greater than 10K
Patient left hemisphere injury, Good indicator patient understands own limitations?
Patient used unaffected side to do ROM exercises on the affected side
Why patient should go to rehab?
To get patient to highest level of functioning
Patient previous hemorrhagic stroke, headache, nausea , vomiting, a sign of
Aneurysm is re bleeding
Hemorrhagic stroke , onset?
Abrupt onset
Who is the most likely to be under treated for pain?
ELDERLY gentleman with r. arthritis
Pt had stroke 24 hrs ago. RN nursing diagnosis?
inadequate tissue perfusion
Pt with expressive deficit, has an injury in what area of the brain?
Broca's area
Which is sign of physical addiction?
Stomach cramping
Pt with MI has left shoulder pain but denies chest pain. This is an example of…..
referred pain
Stroke Pt. area affected was weirnekes. What would you expect to see in this pt.
Inability to comprehend spoke and written language
Pt. brought to ER he had a motor vehicle accident and suffer head injury. Priority assessment.
assess respiratory status
Pt. had pain med 1 hour ago. She complains of severe pain. Nurse first action?
believe the pt.
Pt. had a minor hemorrhagic stroke about 1 week ago. Comes to hospital complaining of headache and vomiting. This is a sign of
re-bleeding aneurysm
How would you RX hyperkalemia?
-sodium bicarbonate
-kaexolate
-regular insulin (NOT NPH)
-calcium gluconate
What instructions to give pt. with mild hypernatremia?
read labels on processed
pt. has 20/10 vision. What does this mean?
they see at 20 feet what other see at 10
pt. has presbyopia. Wants corrective lenses. What is an appropriate response by the nurse?
You will need glasses for reading and upclose work
pt. has mydriasis. What does this mean?
pupils dilated
pt has myopia, this means?
need glasses for distance.
pt has miosis, this mean?
pupils constricted
pt. has dyscoria, one pupil 2mm bigger than the other. What is the nurses priority action?
ask how long this has been occurring
pt. has cataract in the right eye. Pt. states “I shouldn’t have waited so long.” What is the nurses response?
it can be corrected with surgery
pt. puts in eye drops. What signifies further teaching is needed?
tip of the dropper bottle hits the eye
pt. discussing ways to keep IOP down. What signifies further teaching is needed?
putting arms over head (or sex)
pt. complains of photopsia and floating dark spots. What does this signify?
retinal detachment (also painless)
pt. wants to avoid getting meniere’s disease. What is best advice from the nurse?
(SMOKING)
How to decrease vertigo when suffering a meniere’s disease attack?
lay down for 10 min when vertigo starts
diet for pt. with hypokalemia?
sausage, toast, raisins, milk
meal suggestion for pt. with hyperkalemia?
poached egg
pt. arm bends at wrist when taking blood pressure. What is the nurses priority action?
deflate cuff and oxygenate (Trouseua's sign - hypocalcemia)
what shows that a pt. needs further teaching when cleaning ears?
put q tips in ears after swimming to get the excess water out
Normla lab values: K, Na, Mg, Ca, Ph, Cl
K 3.5-5
Na 136-145
Mg 1.2-2.1
Ca 9-10.5
Ph 4-5.5
Cl 98-106
pt. complains of burning in arm with a potassium IV. No signs of swelling, redness, or heat. What is the nurses priority action?
slow the infusion rate and check back in 15 minutes
pt. vision drastically changes in one eye from one day to the next. What is the nurses priority action?
perform a detailed assessment
pt has severe visual disturbance. What is an appropriate nursing diagnosis?
risk for injury
Order for 60 meq of potassium. Have 20 meq per tab. How many tabs do you give?
do not give med
Order for 40 meq of potassium. Have 20 meq per tab. How many tabs do you give?
2 tabs
order for magnesium IM. How much do u give?
do not give med
tx for hypophasphatemia?
increase phosphate, decrease calcium
what is expected with normal aging when dealing with vision?
pupils are more able to dilate
pt. taking beta blocking eye drops. How to prevent hypotension.
press on inner eye
what is not true about primary open angle glaucoma?
least common
what is true about primary open angle glaucoma?
most common
which of the following is not a cause of epistaxis?
marijuana use
which statements signifies that pt. needs further teaching about administration of ear drops?
lay on back with chin up
pt. with hypocalcemia. How do you check for positive chvostek sign?
tap facial nerves for muscle contraction
who is more susceptible for hypocalcemia?
pt with alcoholism and malnutrition
who is more susceptible for hyperalcemia?
pt with hyperparathyroidism, immobile.
priority teaching for hypocalcemia?
shave with an electric razor
signs of fluid and electrolyte imbalance?
stops drinking fluids at 5pm so they wont have to rise to use restroom
signs of fluid and electrolyte imbalance?
rings are tight on fingers
which of the following shows appropriate accommodation?
when finger brought to nose, pupils constrict
pt is hypokalemic. What is appropriate action by the nurse?
administer potassium at 5 meq/hr IV
pt has burning with 60 meq/hr of potassium..what is the nurses priority action
stop infusion
pt. is dehydrated. When would you administer oxygen?
115 beats/min
pt. asks why she need to get her pressure checked every year in her eyes? What is correct response by the nurse?
high IOP blocks blood flow to the eye
41. pt. is hypokalemic and grip strength has gone down since last assessment two hours ago. What is the nurses priority?
administer oxygen
psychosocial condition for pt with hyponatremia?
confusion
pt. is hyperkalemic. On D50 with insulin.. pt is confused, sweaty. What is the nurses priority action?
check blood sugar
Foods low in sodium?
Chicken, carrots, bread, butter
(no cheese!)
What signs that hyponatremia is getting worse?
Hyperactive bowel sounds
Sign of hypocalcemia in a Pt?
Cramps in legs
pt with hypokalemia, what indicates a therapeutic effect?
pt now has a bowel movement daily
what indicates a patient needs more education regarding their hypokalemia?
I will drink more fluids if I am constipated (will become even more dilute)
Renal assessment with abdominal assessment, what do you do first?
Auscultate
pt having a Urography, what is the nursing priority to ask the pt?
Seafood allergy
normal Urinalysis results?
Ph 6, spec gravity 1.015, no sugar, no bilirubin
pt has an indwelling catheter and cyctitis, whats a nursing diagnosis?
Risk for infection
Difference between Stress & urge incontinence?
Stress-weak pelvic wall muscles / urge-contractions (neurological)
Incontinence sign that further education is needed?
I will limit fluids
Who is not ideal for Bladder training?
Confused elderly patient
Confused pt with functional incontinence, family wants catheter, what is the nurses response?
Use pads to reduce smells and prevent leaks
stress incontinence priority?
Keep diary to record activities, times
which form of incontinence can result from a difficult vaginal delivery?
Stress incontinence
Sign of acute pyelonephritis versus the UTI?
Fever and chills
Pt with diabetes mellitus who has comes to the hospital with their 3rd pyelonephritis, what education should the nurse give to prevent further episodes?
Drink more water/empty bladder on schedule
Just had abdominal surgery and now has no bowel sounds?
Document (normal)- because absent bowel sounds are normal post surgery
CT w/barium, patient education postop?
Drink lots of fluids for the next couple days
Endoscopy which is an indication that the pt needs further teaching?
(Take coumadin with a sip of water tomorrow morning—no coumadin because of possible perforation during exam and Pt should be kept NPO)
What is the reason for obstructive jaundice being itchy?
Bile salts accumulate in skin
sign of chronic cholecystitis chronic v acute?
Clay colored stool and dark colored urine
suspect for pt with rigid abdomen?
Peptic ulcer Perforation with peritonitis
viral gastroenteritis dietary instruction?
Drink water to prevent dehydration
(not clear fluids)
Crohns assessment will have?
Hyperactive bowel
stoma teaching on how to dress/clean it?
Begin teaching when pt is ready to look at it ( not have everything ready at bedside or premedicate first)
Crohns colonic strictures complication?
Abdomen distended- this will note possible bleeding and is emergency
Crohns teaching?
Colonoscopy every few years
Motor vehicle accident ecchymotic abdomen – what do you assess?
Guarding/rigidity
risk for gastritis?
Pt taking Naproxen (NSAIDS)/
PUD vomits undigested food?
NG tube (obstruction)
. Billroth II-beefy red tongue, what should the nurse include in assessment?
Have you been taking you Multivitamin daily? (B12)
How do you know it is a stomach ulcer vs dudenal?
Pt is Underweight
pt comes into ER, unconscious w/GI bleed, whats nurses priority action?
Intubate with ET
NG tube placement, upon checking, the pH is 6 (which is above normal,) what’s nurses response?
Xray( to confirm placement
Billroth diaphoretic, sweaty?
Avoid sugar (dumping syndrome)
Getting TPN and has dry mouth, dizziness and frequent urination? (DKA)
Check blood sugar
rantidine/zantac why taking while in the hospital?
To Prevent stress ulcer from forming while in the hospital
PUD labs- what not to do?
Monitor I&O, H&H, Stool for occult blood--- (don’t percuss)
Sleep deprivation, pt will be? Select all that apply
Irritability, expansiveness
what assessment for pt on Ativan
check respirations
giving 2 mL of med to avoid sciatic?
Give in ventrogluteal—because too many ml for deltoid
which is not an Effect on immobility?
Muscular hypertrophy
H. pylori, what medication to give?
Give amoxicillin
pt instructions for antacids?
Wait 1-2 hrs after other meds
. pt has a new ileostomy and also had a NGT?
Check placement with xray confirmation\
Pt comes in with hard rigid abd?
Prepare for emergency surgery