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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?
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Blood pressure
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If a patient is taking LMWH (heparin) and the INR is 4.5. What would you do?
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give Protamine Sulfate (antidote)
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Which patient is most at risk for PVD?
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African American man with DM
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Which woman is most at risk for CVD?
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Woman with weight in the abdominal region.
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Giving an IM injection need to give 4ml and want to avoid the sciatic nerve. Where do you give?
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Ventrogluteal
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Where would you give an IM injection of iron?
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Dorsogluteal
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Which is NOT correct when giving otic drops to a patient with a perforated ear?
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Using aseptic technique (must be sterile)
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What would be the most important education for a patient in sickle cell crisis?
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Hydrate at least 4,500ml
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What would be the best meal for a patient with vitamin B12 anemia?
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Fried liver and onions, OJ and green leafy vegetables
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What should a patient with iron deficiency anemia eat?
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Steak
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What should a patient with folic acid anemia be given?
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Green leafy vegetables
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Patient has Glossitis what would you suggest they do?
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Eat green leafy vegetables
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What are signs and symptoms of woman with CAD (Left sided MI?) select all that apply:
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indigestion-abdominal fullness-fatigue with rest-anxiety
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RN education for pt taking ACE inhibitor?
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ask for help rising / rising slowly
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Orthostatic hypotension what is it?
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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
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If patient has normal heart rate and rhythm what is true?
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Automaticity of the conduction system is normal.
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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?
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Heredity
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Patient’s heart rate is 40 beats/min what is the problem with the patient’s heart?
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SA node
SA 60-100 AV 40-60 His 20-40 |
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Follow path of a drop of blood starting from the superior vena cava:
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RA, tricuspid valve, RV, pulomonic valve, pulmonary artery, lungs, pulmonary vein, LA, mitral valve, LV, aortic valve
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SOB when lying down in bed?
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Orthopnea
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Essential (primary) hypertension?
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No known cause
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Patient on LMWH what indicates the patient has proper education?
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Call the physician if they notice black tarry stools
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Patient has an order for LMWH and coumadin what would the nurse do?
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give as ordered (if no INR values given)
INR >3 do not give |
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Predictable/expected secondary effect?
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Side Effect
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Patient with CVD (priority Dx for a patient with HF?). What is the most critical nursing diagnosis?
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Impaired gas exchange
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Pt NPO which drugs could be given? (select all that apply)
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SL, PR (also IM, IV, transdermal, SC)
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Pt has clubbing what is the priority assessment?
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check pulse oximetry
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African American patient which do you check for skin changes?
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nail beds
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Which would you tell PAD/PVD patient to do to increase vasodilation?
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Do not smoke
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Patient is taking hydrochlorothiazide and is having muscle cramps what would you advise the patient to do?
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take potassium supplements
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Ischemia to the left ventricle what happens?
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Decrease cardiac output
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Patient comes to the dr. office and blood pressure is (unexpectantly?) elevated what would you do
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check in other arm
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PVD patient what would you advise them?
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Do not bend extremities (leg)
(elevate extremities, avoid tight fitting clothing?) |
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Patient taking ACE inhibitor, Captopril, what would you check?
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Serum potassium levels
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Patient has an order for 5mg morphine Q4H. He had last dose 3 hours ago and is c/o pain. What would you do?
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do not administer (dosage question?)
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Patient has order for Beta Blocker HR less than 60, what would you do?
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do not administer
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How to locate PMI?
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Observe chest for visible pulsations
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Early symptoms of heart failure is?
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Dyspnea (SOB) on exertion (fatigue when climbing stairs)
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Patient with hyperlipidemia what food choice would you pick?
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Skim milk, cereal, banana, and decaf.
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PVD diagnosis who is most at risk?
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middle-age man who smokes
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Sickle cell disease what would the patient state?
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I get fatigued more often.
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What is a sign of edema?
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My shoes feel tighter
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Sickle cell anemia patient what would you do (select all that apply?
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Check pulse ox, Feel for peripheral pulses, Elevate extremities (legs)
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Patient has BP of 138/88 (prehypertension) what would you recommend? Suggest to patient to make dietary and lifestyle changes
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make dietary changes
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Assess cardiac status which would be the most critical?
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Hearing swishing (bruits) sound on either side of the neck
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What would you educate a patient with cardiac problems that is on a nicotine patch for quitting smoking?
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Do not smoke while wearing the patch because it puts you at a greater risk for heart attack
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A patient was recently diagnosed with hypertension which dietary would they most need to avoid?
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Canned and processed foods
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Nurse calculating pack years for smoker who just got diagnosed, nurse intervention?
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Try not to be judgmental in questioning.
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Patient takes NSAIDS for long time. Nurse preparing patient for pre-op, nurse asks what question to assess:
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when did you last take your NSAIDs?
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Patient taking Dilaudid. Nurse taking history. What should she ask patient?
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when was your last dose?
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Nurse student suctioning. What would cause tissue damage?
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Do not suction on the way in
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Plavix: Adverse Effect
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Ecchymosis
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Patient couldn’t speak or write, type of aphasia?
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Expressive
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how to calculate dosage for rTPA?
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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) |
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Older adult, respiratory system changes with age?
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decrease in elastic recoil, decrease in alveolar surface area
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Patient with stroke, How to decrease risk of VAP?
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continuously suction subglottic secretions
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Incentive Spirometer how to use
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Exhale, Inhale, Breath 5 secs
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Pt. with flexion posturing...
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Decorticate
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GCS- Incomprehensible/ no eye movement/ : no motor movement
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score 4
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High risk for nosocomial pneumonia?
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ventilator/mechanical
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High risk for CAP?
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Smoker
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Pt in Coma due to brain attack, what to ask family in ED?
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Ask family about drug alcohol abuse
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Partial rebreather mask, which would a nurse intervene?
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oxygen at 2L
cannula 1-6, simple 5-8, prb 6-10 nrb 10-15 (with 2/3 full res) |
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Patient with thrombotic stroke, aphasia
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Ask if patient has had 2 episodes of speech impairment with in the past month (slow onset)
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Patient with aphasia, cant communicate. How to help communicate?
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Use picture board
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Which surgery would a patient have 10/10 pain?
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Abdominal surgery
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Patient pulse ox at 92% dropped to 85%, 1st priority?
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Reassess and apply oxygen
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Patient has 2 oz. of clear thin sputum in early morning, Initial intervention?
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Monitor sputum and watch amount
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Patient with embolic stroke, at risk associated with what disease process?
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AF
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Patient had Tylenol 4g/ day, what should be checked?
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Liver function test (LFT)
(max is 4g/d) |
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Patient on morphine, while sleeping HR drops to 8, what should be done first
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Arouse patient from sleep
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27. What drug to administer for embolic stroke?
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rTPA (not for hemorrhagic)
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Normal therapeutic INR level?
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2-3 (normal is .8-1.2, therapeutic is 1.5-2x that value)
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Patient was on hydro morphine, not working anymore. What happened?
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Patient developed tolerance
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Patient just admitted into ER with a CVA, what do you do?
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elevate HOB to 30 degrees
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Pneumonia, not a normal sign
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WBC 8,000
(expected: chest pain, myalgia, malaise). WBC should be greater than 10K |
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Patient left hemisphere injury, Good indicator patient understands own limitations?
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Patient used unaffected side to do ROM exercises on the affected side
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Why patient should go to rehab?
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To get patient to highest level of functioning
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Patient previous hemorrhagic stroke, headache, nausea , vomiting, a sign of
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Aneurysm is re bleeding
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Hemorrhagic stroke , onset?
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Abrupt onset
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Who is the most likely to be under treated for pain?
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ELDERLY gentleman with r. arthritis
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Pt had stroke 24 hrs ago. RN nursing diagnosis?
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inadequate tissue perfusion
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Pt with expressive deficit, has an injury in what area of the brain?
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Broca's area
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Which is sign of physical addiction?
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Stomach cramping
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Pt with MI has left shoulder pain but denies chest pain. This is an example of…..
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referred pain
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Stroke Pt. area affected was weirnekes. What would you expect to see in this pt.
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Inability to comprehend spoke and written language
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Pt. brought to ER he had a motor vehicle accident and suffer head injury. Priority assessment.
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assess respiratory status
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Pt. had pain med 1 hour ago. She complains of severe pain. Nurse first action?
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believe the pt.
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Pt. had a minor hemorrhagic stroke about 1 week ago. Comes to hospital complaining of headache and vomiting. This is a sign of
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re-bleeding aneurysm
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How would you RX hyperkalemia?
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-sodium bicarbonate
-kaexolate -regular insulin (NOT NPH) -calcium gluconate |
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What instructions to give pt. with mild hypernatremia?
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read labels on processed
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pt. has 20/10 vision. What does this mean?
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they see at 20 feet what other see at 10
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pt. has presbyopia. Wants corrective lenses. What is an appropriate response by the nurse?
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You will need glasses for reading and upclose work
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pt. has mydriasis. What does this mean?
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pupils dilated
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pt has myopia, this means?
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need glasses for distance.
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pt has miosis, this mean?
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pupils constricted
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pt. has dyscoria, one pupil 2mm bigger than the other. What is the nurses priority action?
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ask how long this has been occurring
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pt. has cataract in the right eye. Pt. states “I shouldn’t have waited so long.” What is the nurses response?
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it can be corrected with surgery
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pt. puts in eye drops. What signifies further teaching is needed?
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tip of the dropper bottle hits the eye
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pt. discussing ways to keep IOP down. What signifies further teaching is needed?
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putting arms over head (or sex)
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pt. complains of photopsia and floating dark spots. What does this signify?
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retinal detachment (also painless)
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pt. wants to avoid getting meniere’s disease. What is best advice from the nurse?
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(SMOKING)
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How to decrease vertigo when suffering a meniere’s disease attack?
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lay down for 10 min when vertigo starts
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diet for pt. with hypokalemia?
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sausage, toast, raisins, milk
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meal suggestion for pt. with hyperkalemia?
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poached egg
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pt. arm bends at wrist when taking blood pressure. What is the nurses priority action?
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deflate cuff and oxygenate (Trouseua's sign - hypocalcemia)
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what shows that a pt. needs further teaching when cleaning ears?
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put q tips in ears after swimming to get the excess water out
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Normla lab values: K, Na, Mg, Ca, Ph, Cl
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K 3.5-5
Na 136-145 Mg 1.2-2.1 Ca 9-10.5 Ph 4-5.5 Cl 98-106 |
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pt. complains of burning in arm with a potassium IV. No signs of swelling, redness, or heat. What is the nurses priority action?
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slow the infusion rate and check back in 15 minutes
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pt. vision drastically changes in one eye from one day to the next. What is the nurses priority action?
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perform a detailed assessment
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pt has severe visual disturbance. What is an appropriate nursing diagnosis?
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risk for injury
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Order for 60 meq of potassium. Have 20 meq per tab. How many tabs do you give?
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do not give med
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Order for 40 meq of potassium. Have 20 meq per tab. How many tabs do you give?
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2 tabs
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order for magnesium IM. How much do u give?
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do not give med
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tx for hypophasphatemia?
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increase phosphate, decrease calcium
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what is expected with normal aging when dealing with vision?
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pupils are more able to dilate
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pt. taking beta blocking eye drops. How to prevent hypotension.
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press on inner eye
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what is not true about primary open angle glaucoma?
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least common
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what is true about primary open angle glaucoma?
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most common
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which of the following is not a cause of epistaxis?
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marijuana use
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which statements signifies that pt. needs further teaching about administration of ear drops?
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lay on back with chin up
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pt. with hypocalcemia. How do you check for positive chvostek sign?
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tap facial nerves for muscle contraction
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who is more susceptible for hypocalcemia?
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pt with alcoholism and malnutrition
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who is more susceptible for hyperalcemia?
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pt with hyperparathyroidism, immobile.
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priority teaching for hypocalcemia?
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shave with an electric razor
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signs of fluid and electrolyte imbalance?
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stops drinking fluids at 5pm so they wont have to rise to use restroom
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signs of fluid and electrolyte imbalance?
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rings are tight on fingers
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which of the following shows appropriate accommodation?
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when finger brought to nose, pupils constrict
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pt is hypokalemic. What is appropriate action by the nurse?
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administer potassium at 5 meq/hr IV
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pt has burning with 60 meq/hr of potassium..what is the nurses priority action
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stop infusion
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pt. is dehydrated. When would you administer oxygen?
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115 beats/min
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pt. asks why she need to get her pressure checked every year in her eyes? What is correct response by the nurse?
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high IOP blocks blood flow to the eye
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41. pt. is hypokalemic and grip strength has gone down since last assessment two hours ago. What is the nurses priority?
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administer oxygen
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psychosocial condition for pt with hyponatremia?
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confusion
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pt. is hyperkalemic. On D50 with insulin.. pt is confused, sweaty. What is the nurses priority action?
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check blood sugar
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Foods low in sodium?
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Chicken, carrots, bread, butter
(no cheese!) |
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What signs that hyponatremia is getting worse?
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Hyperactive bowel sounds
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Sign of hypocalcemia in a Pt?
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Cramps in legs
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pt with hypokalemia, what indicates a therapeutic effect?
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pt now has a bowel movement daily
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what indicates a patient needs more education regarding their hypokalemia?
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I will drink more fluids if I am constipated (will become even more dilute)
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Renal assessment with abdominal assessment, what do you do first?
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Auscultate
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pt having a Urography, what is the nursing priority to ask the pt?
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Seafood allergy
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normal Urinalysis results?
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Ph 6, spec gravity 1.015, no sugar, no bilirubin
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pt has an indwelling catheter and cyctitis, whats a nursing diagnosis?
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Risk for infection
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Difference between Stress & urge incontinence?
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Stress-weak pelvic wall muscles / urge-contractions (neurological)
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Incontinence sign that further education is needed?
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I will limit fluids
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Who is not ideal for Bladder training?
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Confused elderly patient
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Confused pt with functional incontinence, family wants catheter, what is the nurses response?
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Use pads to reduce smells and prevent leaks
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stress incontinence priority?
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Keep diary to record activities, times
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which form of incontinence can result from a difficult vaginal delivery?
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Stress incontinence
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Sign of acute pyelonephritis versus the UTI?
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Fever and chills
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Pt with diabetes mellitus who has comes to the hospital with their 3rd pyelonephritis, what education should the nurse give to prevent further episodes?
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Drink more water/empty bladder on schedule
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Just had abdominal surgery and now has no bowel sounds?
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Document (normal)- because absent bowel sounds are normal post surgery
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CT w/barium, patient education postop?
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Drink lots of fluids for the next couple days
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Endoscopy which is an indication that the pt needs further teaching?
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(Take coumadin with a sip of water tomorrow morning—no coumadin because of possible perforation during exam and Pt should be kept NPO)
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What is the reason for obstructive jaundice being itchy?
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Bile salts accumulate in skin
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sign of chronic cholecystitis chronic v acute?
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Clay colored stool and dark colored urine
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suspect for pt with rigid abdomen?
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Peptic ulcer Perforation with peritonitis
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viral gastroenteritis dietary instruction?
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Drink water to prevent dehydration
(not clear fluids) |
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Crohns assessment will have?
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Hyperactive bowel
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stoma teaching on how to dress/clean it?
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Begin teaching when pt is ready to look at it ( not have everything ready at bedside or premedicate first)
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Crohns colonic strictures complication?
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Abdomen distended- this will note possible bleeding and is emergency
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Crohns teaching?
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Colonoscopy every few years
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Motor vehicle accident ecchymotic abdomen – what do you assess?
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Guarding/rigidity
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risk for gastritis?
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Pt taking Naproxen (NSAIDS)/
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PUD vomits undigested food?
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NG tube (obstruction)
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. Billroth II-beefy red tongue, what should the nurse include in assessment?
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Have you been taking you Multivitamin daily? (B12)
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How do you know it is a stomach ulcer vs dudenal?
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Pt is Underweight
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pt comes into ER, unconscious w/GI bleed, whats nurses priority action?
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Intubate with ET
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NG tube placement, upon checking, the pH is 6 (which is above normal,) what’s nurses response?
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Xray( to confirm placement
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Billroth diaphoretic, sweaty?
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Avoid sugar (dumping syndrome)
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Getting TPN and has dry mouth, dizziness and frequent urination? (DKA)
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Check blood sugar
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rantidine/zantac why taking while in the hospital?
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To Prevent stress ulcer from forming while in the hospital
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PUD labs- what not to do?
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Monitor I&O, H&H, Stool for occult blood--- (don’t percuss)
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Sleep deprivation, pt will be? Select all that apply
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Irritability, expansiveness
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what assessment for pt on Ativan
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check respirations
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giving 2 mL of med to avoid sciatic?
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Give in ventrogluteal—because too many ml for deltoid
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which is not an Effect on immobility?
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Muscular hypertrophy
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H. pylori, what medication to give?
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Give amoxicillin
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pt instructions for antacids?
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Wait 1-2 hrs after other meds
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. pt has a new ileostomy and also had a NGT?
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Check placement with xray confirmation\
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Pt comes in with hard rigid abd?
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Prepare for emergency surgery
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