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58 Cards in this Set
- Front
- Back
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List four common symptoms of pneumonia the nurse might note on physical exam |
Tachpnea, fever with chills, productive cough, bronchial breath sounds |
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State four nursing interventions for assisting the client to cough productively |
Deep breathing, fluid intake increase to 3 liters per day, use humidity to loosen secretions, airway to stimulate coughing |
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What symptoms of pneumonia might the nurse expect to see in an older client |
Confusion, lethargic, anorexia, rapid respiratory rate |
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How does the nurse prevent hypoxia during suctioning |
Deliver a hundred percent oxygen before and after each endotracheal suctioning |
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During mechanical ventilation, what are three major nursing interventions |
One of your clients respiratory status and secure connections, establish a communication mechanisms with the client, keep airway clear by coughing and suctioning |
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When examining a client with emphysema, what physical findings is the nurse likely to see |
Barrel chest, dry or productive cough, decreased breath sounds, dyspenia, crackles in lung fields |
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What is the most common risk factors associated with lung cancer |
Smoking |
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Describe the preoperative nursing care for a client undergoing a laryngectomy |
Involve family / client in manipulation of tracheostomy equipment before surgery, plan acceptable communication method, refer to speech pathologist, discuss rehabilitation program |
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List five nursing interventions to implement after chest tube insertion |
Maintain a dry occlusive dressing to chest tube site at all times. Keeping all tubing connections tight and taped, monitor clients clinical status. Encourage the client to breathe deeply periodically. Monitor the fluid drainage and mark the time of measurement and fluid level |
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What immediate action should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus what should the nurse do if a chest tube is accidentally removed from the client |
Place the end of the tube in a sterile water container at 2 centimeter level. Applying an occlusive dressing and notify healthcare provider STAT |
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What instructions should be given to a client after radiation therapy |
Do not wash off lines; wear soft cotton garments ;avoid use of powders / creams on radiation site |
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What precautions are required for clients with TB when place on respiratory isolation |
Mask for anyone entering room, private room, client must wear mask if leaving room |
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List four components of teaching for the client with tuberculosis |
Cough into tissues and dispose immediately into special bags. Long-term need for daily medication. Good hand washing technique. Report symptoms of deterioration, such as blood in secretions |
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Differentiate between acute renal failure and chronic renal |
Acute renal face: often reversible, abrupt deterioration of kidney function. Chronic renal failure: irreversible, slow deterioration of kidney function characterized by increased BUN and creatinine |
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During the oliguric phase of renal failure, protein should be severely restricted. What is the rationale for this restriction |
Toxic metabolites that accumulate in the blood ( urea, creatinine ) are derived mainly from protein catabolism |
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Identify two nursing interventions for the client on hemodialysis |
Do not take blood pressure or perform venipunctures on the arm with the AV shunt, fistula ,or graft. Assess sites for thrill & bruit |
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What is the highest priority nursing diagnosis for clients in any type of renal failure |
Risk for imbalance fluid volume |
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A client in renal failure asks why he is being given antacids. How should the nurse reply |
Calcium and aluminum antacids bind phosphates and help to keep phosphate from being absorbed into the bloodstream thereby preventing rising phosphate levels and must be taken with meals |
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List four essential elements of a teaching plan for clients with frequent urinary tract infections |
Fluid intake 3 liters / day, good hand washing, void every 2 to 3 hours during waking hours, take all prescribed medications, wear cotton undergarments |
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What discharge instructions should be given to a client who has had urinary calculi |
Maintain high fluid intake of 3 to 4 liters per day. Follow up care. Follow prescribed diet based on calculi content. Avoid supine position |
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What are the most important nursing interventions for clients with possible renal calculi |
Straining all urine is the most important intervention. Other interventions include accurate intake and output documentation and administering analgesics as needed |
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Following transurethral resection of the prostate gland (TURP), hematuria should subside by what post operative day |
Fourth day |
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After the urinary catheter is removed in the TURP client, what are three priority nursing actions to be taken |
Continued strict I&O's. Continued observations of hematuria. Inform client that burning and frequency may last for a week |
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After kidney surgery, what are the primary assessments the nurse should make |
Respiratory status (breathing is guarded because of pain), circulatory status (the kidney is very vascular, and excessive bleeding can occur), pain assessment, urinary assessment (most importantly, assess of urinary output) |
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How do client experiencing angina describe the pain |
Squeezing, heavy, burning, radiates to left arm or shoulder, transient, or prolonged |
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Teaching plan for the client taking nitroglycerin |
Take at first sign of angina pain. Take no more than 3, 5 minutes apart. Call for emergency attention if no relief in 10 minutes |
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Parameters for hypertension |
140 / 90 |
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Differentiate between essential and secondary hypertension |
Essential has no known cause, or secondary hypertension develops in response to N identifiable mechanism |
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Teaching plan for the client taking antihypertensive medication |
Explain how and when to take medication, reason for medication, necessity of compliance, need for follow up visit while on medication need for certain lab test, vital sign parameters while initiating therapy |
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Describe intermittent claudication |
Pain related to peripheral vascular disease occurring with exercise and disappearing with rest |
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Describe the nurse's discharge instructions to a client with a venous peripheral vascular disease |
Keep extremities elevated when sitting, rest at first sign of pain, keep extremities warm, change position often, avoid crossing legs, wear unrestrictive clothing |
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What is often the underlying cause of abdominal aortic aneurysm |
Atherosclerosis |
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What lab values should be monitored daily for the client with thrombophlebitis who is undergoing anticoagulant therapy |
PTT, PT, Hgb, HCT, and platelets |
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When do PVCs premature ventricular contractions prevent a grave danger |
When they begin to occur more often than once in 10 beats, occur in twos or threes, land near the T wave, or take on multiple configurations |
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Differentiate between the symptoms of left sided cardiac failure and right sided cardiac failure |
Left sided failure result in pulmonary congestion due to back up of circulation in the left ventricle. right sided failure results in peripheral congestion due to back up of circulation in the right ventricle, lower extremities |
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List three symptoms of digitalis toxicity |
Dysrhythmias, headache, nausea, and vomiting |
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What condition increases the likelihood of digitalis toxicity occurring |
When the client is hypokalemia which is more common when diuretics and digitalis preparations are given together. |
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What lifestyle changes can the client who is at risk for hypertension initiate to reduce the likelihood of becoming hypertensive |
Cease cigarette smoking if applicable, control weight, exercise regularly, and maintain low fat / low cholesterol diet |
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What immediate action should the nurse implement when a client is having a myocardial infraction |
Please client on immediate strict bed rest to lower oxygen demands of heart, administer oxygen by nasal cannula at 2 to 5 liters per minute, take measures to alleviate pain and anxiety , administer PRN pain medications and exactty medications |
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What symptoms should the nurse expect to find in the client with hypokalemia |
Dry mouth and thirst, drowsiness and lethargic, muscle weakness and eggs, and tachycardia |
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What is bradycardia |
Below 60 bpm |
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What is tachycardia |
Above 100 bpm |
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What precautions should clients with valve disease who have the highest risk for adverse outcomes from the infective bacterial, endocarditis take before invasive procedures or dental work |
Take prophylactic antibiotics |
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List four nursing interventions for the client with a hiatal hernia |
Sit up while eating and for 1 hour after eating. Eat small, frequent meals. Eliminate foods that are problematic |
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List three categories of meds used in the treatment of peptic ulcer disease |
Antacids, histamine 2 receptor blockers, mucosal healing agents, proton pump inhibitors |
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What bowel sound disruptions occur with an intestinal obstructions |
Early mechanical obstruction:high pitched sounds; late mechanical obstruction:diminished or absent bowel sounds |
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List 4 nursing intervention fir postoperative care of the client with a colostomy |
Irrigate daily at same time; use warm water for irritations; wash around soma with mild soap and water after each ostomy bag change; pouch opening should extend at least 1/8 inch around the stoma |
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List the common clinical manifestations of jaundice |
Icteric sclerae or scleral icterus (yellow sclera),dark urine, chalky or clay colored stools |
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What are the common food intolerances for clients with cholelithiasis |
Fried, spicy, and/our fatty foods |
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List 3 classic initial signs of colorectal cancer |
Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain with nausea, weight loss |
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In a client with cirrhosis, it is imperative to prevent further bleeding and observe fir bleeding tendencies. List six relevant nursing interventions |
Avoid injections, use small bore needles for IV insertion, maintain pressure for 5 minutes on all venipuncture sites, use electric razor, use soft bristle toothbrush for mouth care, check stools and emesis for occult blood |
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What is the main side effect of lactulose,which is used to reduce ammonia levels in clients with cirrhosis |
Diarrhea |
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List four groups who have a high risk of contracting hepatitis |
Homosexual males, IV drug users, those with recent piercing or tattooing, and health care workers |
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How should the nurse administer pancreatic enzyme |
Give with meals or snacks. Powder forms should be mixed with fruit juices |
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What diagnostic test is used to determine thyroid activity |
T3, t4 |
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What condition results from all treatments from hyperthyroidism |
Hypothyroidism , requiring thyroid replacement |
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State three symptoms of hyperthyroidism and three symptoms of hypothyroidism |
Hyperthyroidism: weight loss, heat intolerance,diarrhea . Hypothyroidism: fatigue, cold intolerance, weight gain |
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List five important teaching aspect for clients who are beginning corticosteroids therapy |
Continue medication until weaning plan is begun by physician, monitor serum potassium , glucose, and sodium frequency, weigh daily and report gain of more than 5 lbs / wk, monitor BP and pulse closely, teach symptoms of Cushing syndrome |
