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127 Cards in this Set

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4 symptoms of pneumonia that maybe be noted on a physical exam:
Tachypnea
fever c chills
productive cough
bronchial breathe sounds
S&Sx of pneumonia expected in older clients:
Confusion
Lethargy
Anorexia
Rapid RR
O2 flow rate for a COPD client:
1 - 2 L per Nasal Cannula (b/c too much O2 may eliminate COPD clients hypoxic stimulus to breathe)
Prevent hypoxia during suctioning by:
Oxygenating 100% before and after each endotrach. suctioning
3 interventions for mech. ventilation:
Monitor resp. status
Establish communication mech
Keep airway clear c coughing and suctioning
Visible S&Sx of Emphysema:
Barrel chest
Cough (dry or productive)
Decreased breath sounds
Dyspnea
Crackles in lung fields
NSG care fo Pre-Op laryngectomy;
Involve pt/fam to manipulate trach. equipment
Plan for communication method
Speech Pathologist referral
Rehab discussion
5 NSG interventions after chest tube insertion:
Dry occlusive dsg
Tight/Taped tubing connections
Monitor Cx status
Encourage periodic deep breathing
Monitor fluid drainage and mark the time of measurement and fluid level
Immediate action to be taken if chest tube becomes d/c from appliance? If d/c from client?
d/c from appliance- place end of tube in sterile water @ 2cm lvl

d/c from client- apply occlusive dsg & notify MD
Instructions to be given following radiation therapy:
Don't wash off lines
Wear soft cotton garments
Avoid powders and creams @ radiation site
Precautions required for TB when placed on respiratory isolation
Private room
Masks for all entering & for pt when exiting
4 components of TB teaching
Cough into tissues & dispose immediately in special bags
Long-Term need for daily meds
Hand washing
Report S&Sx of deterioration
Acute Renal Failure (ARF) vs. Chronic Renal Failure (CRF):
ARF- usually reversible, abrupt kidney fx deterioration

CRF- irreversible, slow kidney fx deterioration
Characterized by ^BUN and CREAT (dialysis required eventually)
Why does protein need to be restricted during the OLIGURIC phase of renal failure?
Toxic metabolites that accumulate in the blood (urea, creatinine) derive mainly from protein catabolism
2 NSG interventions for clients on hemodialysis:
DON'T take BP on A-V shunt / fistula / graft
Assess site for thrill and bruit
Highest priority NSG Dx for any type of Renal Failure?
Risk for imbalanced fluid volume
Why is a renal failure pt given antacids?
Antacids (CA & Al flavor) bind to phosphates to keep them from being absorbed into the blood stream. Eventually preventing rising Phosphate lvls.

**Must be taken with Meals!**
4 essential teaching elements for for clients with frequent UTIs:
Fluid intake of 3L / day
Good hand washing
Void q 2-3 hrs
Take all prescribed meds
Wear cotton under garments
Most important NSG interventions for pts with possible renal calculi:
Straining all urine!!
Other interventions include accurate I&Os
Analgesics PRN
What d/c instructions should be given to a pt who has had urinary calculi:
Maintain fluid intake of 3 - 4 L / day
Follow-up care
Prescribed diet (based on calculi content)
Avoid supine position
How long after a transurethral resection of the prostate gland (TURP) should hematuria subside?
Day 4
3 priority NSG interventions for a TURP pt who just had a urinary catheter removed:
Strict I&O
Observe for Hematuria
Warn that burning and freq may last up to a week
Primary assessments after kidney surgery:
Resp. status (gaurded d/t pain)
Circulatory status
Pain
Urinary Assessment (esp. output)
Pt's description of pain associated to Angina:
Squeezing, heavy, burning, radiating to L arm or shoulder, transient or prolonged
Teaching plan for a pt taking Nitroglycerin:
Taken at the first sign of Anginal pain. take NO MORE than 3, 5 minutes apart. Call for med. attention if pain not relieved in 10 mins.
Parameters for diagnosing HTN:
> 140 / 90
Teaching plan for anti-hypertensive meds:
Explain how, when and why of meds.
Necessity of compliance and follow-up visits.
Need for lab tests.
Vital sign parameters while initiating therapy
Describe intermittent claudication:
Pain r/t peripheral vascular disease (PVD) Occurs c exercise and subsides c rest
D/c instructions for pt PS (post status) venous PVD:
Keep extremities elevated while sitting.
Rest @ first sign of pain.
Keep warm s heat pad
Change position often.
Avoid crossing legs.
Un-restrictive clothing.
Underlying cause of an abdominal aortic aneurysm:
Atherosclerosis
Daily lab values to be monitored daily in a pt c thrombophlebitis undergoing anticoagulant therapy:
PTT, PT, Hbg, Hct, platelets
When do PVCs present a grave danger?
When they occur more >1 in 10 beats, occur in 2s or 3s, land near a T-wave, or take on multiple configurations
L Cardiac Heart Failure (CHF) vs. R CHF:
L CHF = pulmonary congestion d/t back-up of circulation in the L ventricle

R CHF = peripheral congestion d/t back-up circulation in the R ventricle
4 S&Sx of Digitalis toxicity:
Dysrhythmias, Headache (HA), N / V (Nausea & Vomiting)
What condition increases the likelihood that Digitalis toxicity will occur?
Hypokalemia (<- becomes more common if diuretics and digitalis preparations are given together)
Lifestyle changes a HTN pt can make to reduce the likelihood of becoming hypertensive:
Stop smoking (if applicable)
Control weight
Exercise regularly
Maintain a low-fat / low-cholesterol diet
What immediate actions should the nurse implement for a pt who is having a Myocardial Infarction (MI)?
Strict bed rest (to lower O2 demand to <3)
Admin. O2 via nasal cannula @ 2 - 5 L / min
Meds for pain / anxiety
S&Sx for a client with Hypokalemia:
Dry mouth / thirst
Drowsiness / lethargy
Muscle weakness & aches
Tachycardia
Brady<3 is defined as:

Tachy<3 is defined as:
HR < 60

HR > 100
Clients c valve disease should take what precaution before invasive procedures or dental work?
Prophylactic antibiotics.
4 NSG interventions for pt c hiatal hernia
sit up while eating & for 1 hour after
Eat frequent, small meals.
Eliminate problematic foods.
3 categories of meds used in tx of peptic ulcer dz:
Antacids
Histamine-2 receptor blockers
Mucosal healing agents
Proton pump inhibitors
S&Sx of Upper GI bleed:

S&Sx of Lower GI bleed:
Upper: melena, hematemsis

Lower: bloody stools

BOTH: tarry stools
What bowel sounds disruption occur with an intestinal obstruction?
Early mech. obstruction- high-pitched sounds

Late mech. obstruction- diminished or absent (also occurs c neurogenic obstruction)
4 NSG interventions for post-op care of clients c a colostomy:
Irrigate daily @ same time c warm water
Wash around stoma c mild soap and water after q bag change
Ensure that pouch opening extends at least 1/8 inch around stoma
Clinical manifestations of jaundice:
Sclera-icteric (yellow sclera)
Dark Urine
Chalky / clay-colored stools
Food intolerances for pts c cholelithiasis:
Fried, Spicy & Fatty foods
5 S&Sx indicative of colon cancer:
Rectal bleeding
Change in bowel habits
Sense of incomplete evacuation
Abd pain c nausea
Weight Loss
6 relevant NSG interventions, to prevent further bleeding / observe for bleeding tendencies, for pt c cirrhosis:
Avoid injections
Small bore needles for IV
Maintain pressure for 5 mins on venipuncture sites
Electric razor
Soft-bristle toothbrush
Check stools and emesis for occult blood
Side Fx of Lactulose (used to reduce ammonia levels in cirrhosis):
Diarrhea
4 groups at risk for contracting hepatitis:
Homosexual males
IV drug users
Recent ear piercing / tattooing
Healthcare Workers
How to administer pancreatic enzymes:
With meals or snacks.

Powder forms to be given mixed c fruit juices
Test to determine thyroid activity:
T3, T4
What condition results from all tx of hyperthyroidism?
Hypothyroidism (requiring thyroid replacement)
3 S&Sx of hyperthyroidism:

3 S&Sx of hypothyroidism:
Hyper: weight loss, heat intolerance, diarrhea
Hypo: fatigue, cold intolerance, weight gain
5 teaching aspects for pts who are beginning corticosteroid therapy:
Continue with meds until weaning plan begun by MD
Monitor serum K, glucose, NA
Weigh daily (report gain of >5 lb / wk)
Monitor BP & pulse closely
Teach S&Sx of Cushing syndrome
Physical appearance of pt c Cushing's Dz
Moon face
Obesity in trunk
Buffalo Hump in back
Muscle atrophy
Thin skin
Which type of Diabetes Mellitus requires insulin replacement?
Type 1 insulin-dependent diabetes mellitus (IDDM)
Which type of diabetic sometimes requires no meds?
Type 2 non-insulin-dependentt diabetes mellitus (NIDDM)
5 S&Sx of hyperglycemia:
Polydipsia
Polyuria
Polyphagia
Weakness
Weight loss
5 S&Sx of hypoglycemia:
Hunger
Lethargy
Confusion
Tremors / shakes
Sweating
Important teachings for newly diagnosed diabetic:
Underlying pathology
Mgmt / Tx regimen
Meal planning
Exercise program
Insulin admin
Sick-day mgmt
S&Sx of hyperglycemia (not enough insulin) and hypoglycemia (d/t too much insulin OR too much exercise OR not enough food)
Method of drawing up mixed insulin:
Verify MD order
Store unopened insulin in fridge
Opened insulin kept @ room temp for up to 28 days.
Draw up regular insulin first
Rotate injection sites
May reuse syringe by recapping and storing in fridge
Peak action time of rapid-acting regular insulin:

Immediate-acting insulin:

Long-acting insulin:
Rapid-acting: 2 - 4 hours


Immediate-acting: 6 - 12 hours

Long-acting: 14 - 20 hours
Relationship of glucose balance and...
Stress:
Exercise:
Bedtime Snacking:
Stress: increase glucose production = increased insulin need

Exercise: increases chances of insulin rxn, (always have snack avail to tx hypoglycemia)

Bedtime snacking: maybe prevent insulin rxn while waiting for long-acting insulin to peak
Pt is experiencing HA, nausea, minimal trembling. Has cool, moist hands. What is pt most likely experiencing?
Hypoglycemia / insulin rxn
5 foot care interventions to be taught to a diabetic pt:
Check feet daily, report breaks, scars and blisters to MD
Wear well fitting shoes
Never go barefoot / wear sandals
Don't self remove callouses or blisters
Cut or file nails straight across
Wash feet daily c mild soap and warm water
Rheumatioid arthritis VS degenerative joint disease RE: joint involvement
Rheumatoid: occurs BILATERALLY

DJD: occurs ASYMMETRICALLY
Drug categories commonly used to tx arthritis:
NSAIDS (salicylates are the 'cornerstone' of tx
&
Corticosteroids (for severe arthritis S&Sx)
3 pain-relieving interventions for pts c arthritis:
Warm, moist heat
Diversionary activities
Medications
Preventative measures females should take to prevent osteoporosis:
Estrogen replacement & CA supplement after menopause,
High-CA and Vit D intake (beginning in early adulthood)
Weight- bearing exercise
Common side fx of salicylates:
GI Irritation
Tinnitus
Thrombocytopenia
Mild liver enzyme elevation
Priority NSG intervention for pt on NSAIDS:
Teach pt to take drugs c food or milk
3 most commonly replaced joints:
Hip, Knee, Finger
Post-op residual limb (stump) care (after amputation) for the first 48 hours:
Elevate stump for first 24 hours
Do NOT elevate stump after 48 hours
Keep stump in extended position and turn pt to prone position X3 a day to prevent flexion contracture
NSG care for pt c phantom pain after amputation
Be aware that phantom pain is real and will disappear eventually.
It does respond to pain medication
Pt in traction for long bone fx c slight fever, SOB & restless. They are most likely experiencing:
a Fat embolism. characterized by hypoxemia, respiratory distress, irritability, restlessness, fever & petechiae
Immediate nursing actions if fat embolization is suspect in pt c a fracture or other orthopedic condition:
Notify MD stat
Draw blood gases
Admin O2 according to blood gas results
Assist c endotracheal intubation
Tx of respiratory failure
3 problems associated c immobility:
Venous thrombosis
Urinary calculi
Skin integrity problems
3 NSG interventions for prevention of thromboembolism in immobilized pt c musculoskeletal problems:
Passive ROM
Elastic stockings
Elevate FOB (foot of bed) 25 degrees to ^ venous return
Classifications of the commonly prescribed eye drops for glaucoma:
Parasympathomimetic (for pupillary constriction)
Beta-adrenergic receptor-blocking (inhibit aqueous humor production)
Prostaglandin agonists (^ aqueous humor outflow)
2 types of hearing loss:
Conductive (transmission of sound to inner ear is blocked)
Sensorineural (damage to eighth cranial nerve)
4 NSG interventions for blind person:

4 NSG interventions for deaf person:
Blind: announce presence clearly, call by name, prient carefully to surroundings, guide by walking in front of client with his or her hand in your elbow
Deaf: reduce distraction before beginning conversation, look and listen to pt, give full attention to pt if they are a lip reader
Face pt directly
Glascow Coma Scale:
objective assessment of the lvl of consciousness based on a score of 3 to 15.

A score of 7 or less indicative coma.
4 NSG Dx for comatose pt:
(in order of priority) Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, decreased cardiac output
4 independent NSG interventions to maintain adequate respiration, airway and oxygenation:
Position for maximum ventilation (prone, semi-prone and slightly to one side)
Insert an airway for tongue obstruction
Suction airway
Monitor arterial PO2 & PCO2
Hyperventilate c 100% O2 before suctioning
Who is at risk for cerebral vascular accidents (CVAs)?
pts c HTN, previous TIAs, <3 dz (a-flutter or a-fib), diabetes, oral contraceptive use, elderly
3 NSG interventions to prevent thrombi (which can be r/t immobility):
Frequent ROM exercise, frequent (q2hr) positions changes, avoidance of positions that decrease venous return
4 rationales for the appearance of restlessness in unconscious pts:
Anoxia
Distended bladder
Covert Bleeding
Return to Conciousness
NSG interventions that can prevent corneal drying in a comatose pt:
Irrigation c sterile prescribed solution PRN
Ophthalmic ointment every 8 hours
Close assessment for corneal ulceration or dry
When can a pt on IV hyperalimentation begin to receive tube feedings instead?
When peristalsis returns AEB active bowel sounds, passage of flatus or bowel movement
Most important principle in a bowel management program for a pt c neurologic deficits:
Establishment of regularity
Define cerebral vascular accident:
A disruption of blood supply to part of the brain which results in sudden loss of brain function.
If a pt has a dx of CVA c S&Sx of aphasia & right hemiparesis but no memory or hearing deficit what hemispher has the client suffered a lesion?
Left
S&Sx of spinal shock:
Hypotension, bladder and bowel distension, total paralysis and lack of sensation below lesion
S&Sx of autonomic dysreflexia:
HTN, bladder and bowel distention, exaggerated autonomic responses, HA, sweating, goose bumps, bradycardia
Most important indicator of ^ ICP:
Change in lvl of responsiveness.
VS changes indicative of ^ICP:
^BP, widening pulse pressure, increased or decreased pulse, respiratory irregularities, temperature increase
S&Sx which would indicate a need to go to the ER after being knocked down to the ground:
Vertigo, confusion, subtle behavior change, HA, vomiting, ataxia (imbalance), or seizure.
Activities and situations that increase ICP and should be avoided:
Change in bed position, extreme hip flexion endotracheal suctioning, compression of jugular veins, coughing, vomiting, straining of any kind
Action of hyperosmotic agents (osmotic diuretics) used to tx intracranial pressure:
Dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent re-absorption and by drawing fluid from the extravascular spaces into the plasma
Why should narcotics be avoided c neurologic impairment?
Narcotics mask the level of responsiveness as well as masking pupillary reponses
What characteristics of HA and vomiting should alert the nurse to refer a pt to the neurologist?
HA more severe upon awakening and voiting not associated with nausea are S&Sx of a brain tumor
How should the head of the bed be positioned for postcraniotomy pts c infratentorial lesions?
Supratentorial: elevated

Infratentorial: flat
Is multiple sclerosis thought to occur because of an autoimmune process?
Yes
Is paralysis always a consequence of spinal cord injury?
No
What types of drugs are used to tx myasthenia gravis?
Anticholinesterase drugs that inhibit the cholinesterase at never endings to promote the accumulation of the acetylcholine at receptor sites, this should improve neuronal transmission to muscles
3 potential causes of anemia:
Diet lacking in iron, folate of vitamin B12
Use of salicylates, thiazides, diuretics
Exposure to toxic agents (such as lead or insecticides)
2 NSG dx for client suffering from anemia:
Activity intolerance and ineffective tissue perfusion
The only IV fluid compatible with blood products:
Normal Saline (b/c Sugar ^ blood clotting = bad)
If a hemolytic transfusion rxn occurs:
Turn off transfusion.
Take temperature.
Send blood being transfused to lab.
Urine sample.
Keep vein open (KVO) c normal saline
3 interventions for pts c tendency to bleed:
Use soft toothbrush.
Avoid salicylates (they inhibit platelet aggregation).
Do not use suppositories.
2 sites to be assess for infection in immunosuppressed pts:
Oral cavity and genital area.
3 food sources of vitamin b12
Green leafy vegetables.
Liver (Glandular meats)
Milk
Describe care of invasive catheters and lines:
ASEPTIC TECHNIQUE
Change dsgs 2-3x / wk (or when soiled)
Caution when piggybacking drugs
Check purpose of line and drug to be infused
When possible use lines to obtain blood samples to avoid "sticking" client
3 safety precautions for administering antineoplastic chemotherapy:
Double check order c another nurse.
Aspirate to assure administration isn't in tissue.
New IV site daily for peripheral chemo.
Wear gloves.
Dispose of waste in special containers.
Leucovorin is used for:
an antidote with methotrexate to prevent toxic rxns
Method of collecting peak and trough blood levels of antibiotics:
Peak : draw blood 30 minutes after administration

Trough: draw blood 30 minutes before administration
Characteristic cell found in Hodgkin dz:
Reed-Sternberg
4 NSG interventions for care of pt c Hodgkin dz (malignancy of lymphoid system):
Protect from infection.
Observe for anemia.
Encourage high-nutrient foods.
Emotional support to pt and family (b/c career development often interrupted for tx. men become sterile, sperm back before tx if desired)
4 topics to cover when teaching immunosuppressed pts about infection control:
Handwashing technique
Avoid infected persons / crowds.
Daily hygiene to prevent microorganism spread.
Indication for hysterectomy in pt c fibromas:
Severe menorrhagia l/t anemia.
Severe dysmenorrhea requiring narcotic analgesics
Sever uterine enlargement causing pressure to other organs.
Severe low back and pelvic pain.
S&Sx associated c cystocele:
Incontinence or stress incontinence
Urinary retention
Recurrent bladder infections

Conditions assoc c cystocele - multiparity, trauma in childbirth, aging
Impt NSG interventions, post-op a hysterectomy c A&P repair:
Avoid rectal temp / manipulation
Manage pain
Encourage early ambulation
Priority NSG care for pt c radiation implants:
Pregnant visitors / caretakers aren't permitted.
Small children visits are discouraged.
Confine pt to room
Nurse must wear radiation badge & limit time in room.
Supplies and equipment should remain within pt's reach
Screening tool used to detect cervical cancer? American Cancer Society recommendation for women ages 3o - 7o with three consecutive normal results:
Pap smear. For women 3o - 7o, after three consecutive normal pap smears may have pap smears every 2 - 3 years
2 NSG Dx for pt undergoing a hysterectomy for cervical cancer:
Altered body image r/t uterine removal.
Pain r/t post-op incision