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188 Cards in this Set
- Front
- Back
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child safety |
dont over protect. keep the guns and ammo in different lockers |
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dislodged trach tube |
extend the clients neck |
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ileostomy stoma |
area should be cleaned with warm water and dried. DONT GIVE LAXATIVE to a stoma patient and avoid enteric coated medications |
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post antiobiotics |
client may develop c diff after antibiotics, place on contact precautions. |
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sinemet |
take with low protein diet |
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urine sample |
into sterile container not clean |
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kosher |
no meat or poultry given at the same time as dairy |
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hemovac drain |
similar to jackson pratt. surgical drain
note: nurse should never ever change the md dose |
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bilateral yellow exudate |
colustrium. is a normal finding |
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moderate facial edema |
facial edema during pregnancy indicates pre ecclampsia |
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muscle spasms during traction |
if spasms increase, patient is recieving too much traction |
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narcotics |
assess oxygen first before looking for signs of overdose |
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vfib |
v tach - lidocaine v fib - shock asystole - compressions |
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client depressed or chemo not eating |
ask what your favorite foods/ here and now. normal daily intake falls under long term assessment |
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nclex and abuse |
need to report signs of abuse . don't make assessment yourself, use the chain of command. note in scope of practice? |
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crushing headache |
could be a migraine. assess a burn to the face first because it could involve and airway problem, especially if the client RR is out of range |
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stroke patient |
at risk for aspiration or respiratory assess. ALWAYS ASSESS AIRWAY. potential vs actual always |
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chicken pox |
isolate for 6 days |
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observed nurse using drug |
dont confront the observed nurse, this is confrotational. report directly to the supervisor |
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irregular periods |
normal for the first 2 years |
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chlorodiazepoxiide |
librium is a benzooo. given to help with withdrawal. lpn can stay with agressive client
different from antabuse or disulfram which makes it impossible for the client to drink. not given until 12 hrs after the client had the last drink. |
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dumping syndrome and pernicous anemia |
can occur. client gets vitamin b 12 shots once a month |
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metform before invasive procedure |
hold for 48 hours |
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lumbar laminectomy |
like a lumbar punture, client has to lay flat. |
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risk of hyponatremia |
neurological depression with risk of seizure. takes priority over fluid retention. fluid retention is a potential problem, hyponatremia is an actual problem. |
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normal spoken voice |
normal voice is a good indicator of the ability for the client to talk. a client will able to swallow before they can talk, therefore talking is a better indication of a patent airway. also children that are able to cry. |
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do you have chest pain |
always the answer. nicotine is a vasoconstrictor, contra indicated in client with circulation problems |
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trach cuff pressure |
should be below 20. cuff is there to prevent aspiration |
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alzheimers patient |
needs to be stimulated, dont put down a hallway and leave them. upper respiratory is contact, semi private room |
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ace inhibitor and cough |
dry non productive cough seen with ace inhibitors only |
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carbamazepine |
is tegretol. anti seizure, tetragenic to infant |
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normal ALT and AST |
10 - 20 |
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psych patient election |
can vote from hospital by absentee ballet. who cares tho |
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inactivated polio vaccine IPV |
can be given to hiv patient |
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PN therapy |
vitals every 4 hours, has a high level of glucose. its important to take sugar levels with PN nutrition |
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syphillis |
has 4 stages involved. primary concern is safe sex |
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infant vitals |
take the RR while they are still sleeping |
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placenta previa |
must deliver c section, do not deliever a previa vaginally |
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PTSD client |
place them in a support group first before allowing them to densistise |
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braxton hicks |
occur before 38 weeks and are normal. hot flashes and chills arent normal |
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sterile gauze with jelly |
circumcision. |
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psychotic patient |
treat in ascending order. all try the less invasive first. |
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apnea monitor |
doesnt have to watched at all times |
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head injury |
assess every 3-4 hrs |
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jackson pratt |
attach to the clients cloth, not the bed |
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bulge test |
indicates prescence of fluid in the knee. client should lay lay and extend knee |
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celiac |
RYE, WHEATS, OATS AND BARLEY. apperantly no carrot or celery |
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stool specimen |
collected over period of 3 days. 3 stools in 3 days |
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mri |
patient must remove a nitro patch |
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renal failure |
usually caused by hypovolemia |
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which observation is most important to report to the next shift |
LOOK FOR AN EXPECTED OUTCOME OF THE MEDICATIONNNN. |
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first trimest |
white vaginal discharge is expected |
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UTI |
WBC AND RBCS are expected |
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hepatitic encephalopathy |
difficulty describing what they do, diffficult sleeping, writing changes |
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sensitive breast |
cold pack and tight bra |
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imaginary friend |
normal for a 4-6 year, allow client to play. explaining the friend will increase anxiety |
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burn |
elevated hematocrit is normal . pH below 5 isnt normal |
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psych patient |
rules change. set limits, can say that i feel uncomfortanle. |
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burns and pain |
must give narcotics, but when they experience the expected side effects its time to explore alternative routes of administration |
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diabetes |
excessive thirst and weight loss |
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daily weights |
normal for over hydration, not necc in fluid volume deficit. |
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bottle feed |
different from breast feed. use cold packs, well fitting bra, can use tylenol po, be patient. do not massage the breast or milk with pump |
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labor |
pushing should be discouraged until the 2nd phase of labor. during transition phase of labor, use pursed lip breathing. |
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kaposi sarcoma lesions |
appear purple or brown and are open areas on the arms and back, upper. should clean with soap and water and then leave them uncovered |
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HPV |
nothing can be done, except pap smear in 6 months? |
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after vaginal delivery |
check the lochia flow immediatly, takes priorty. |
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cleft lip in an infant |
position the client on ONE side. dont suction and dont elevate the head of the bed |
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masectomy |
place the client in low fowlers position with the affected arm elevated. AFFECTED ARM MUST BE ELEVATED |
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hep a child |
can return to school right away. |
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milk |
low sodium. |
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chief complaint |
reported in the clients own words |
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isonazid |
CAUSES PERIPHRAL NEUROPATHY. see tingling fingers |
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weight gain |
2-5 pounds per week first trimester, 1 pound a week after |
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dehyrdation |
give a hypotonic solution, not an isotonic. |
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sagenmore blake tube |
used for esphogeal varices. if the client is having trouble breathing, remove the tube first. always have sissors by the bed. |
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flexor |
flexing muscles are stronger than extrensor muscles, thts why paralysed patients get flexures. |
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nasogastric tube |
hissing sound means the pump is funtioning |
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DI following craniotomy |
will need to take replacemtn hormones for life. |
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normal cvp |
3 - 12 |
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heat in cast |
a sign of pressure . |
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withdrawn cancer patient in pain |
give pain meds first . makes it easier for them to talk |
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hyperparathyroid |
leads to high calcium levels. highest priority for the patient is assessing for kidney stones, done by looking for hematuria. |
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pain and incentive spirometer |
when a patients pain decreases, there use of the incentive spirometer will improve. |
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ms patient |
ambulate as tolerated, avoid heat and cold, include strength and stretch excercise, participate in social activites. |
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neccessary activites of ADL |
comb hair, brush teeth and eat. |
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thumb sucking |
is normal until 18-20 months of age. will subside after 24 mnths. |
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elevated pulse in alcohol |
elevated pulse is an indication of worsening alcohol withdrawal |
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thin white sputum |
means pneumonia is getting better |
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assessment of newborn |
edema scalp is normal initially, circumoral cyanosis is the oral cavity and not normal, |
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fat on burn |
increased risk of infection. can wash with soap and water to remove |
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internal radiation |
3 hrs a day, must roate staff, dont need lead apron for all care just limit time, |
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frequent swolling in tonsilectomy |
can indicate hemmorage. ok to check rr q1hr for thyroidecomy |
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prenatal vitamins |
take with orange juice at bedtime |
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ostomy bag |
change once a week |
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lost central line |
lower the head of the bed and place on the left side |
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pku |
give lofenalac |
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new hip replacement |
needs home care assessment |
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malpractice |
duty to act, breach of duty, causation and injury |
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bowel obstruction |
semi fowlers, immediate surgery |
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postural drainage |
positioning the patient so that mucus is expelled |
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thick yellow mucus |
indicative of pneumonia. look out for in a client that has cystic fibrosis |
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psych patient |
indicate the wrong action and tell them how to fix it |
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cholecytitis |
right upper abdominal pain is expected. if the client experiences jaundice it is a bad sign |
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osteoporosis |
need calcium and vitamin D equally. encourage weight bearing excercises |
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oxytocin |
sustained contractions can lead to rupture of the uterus. no longer than 90 seconds |
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meds and confused |
even the elderly confused client has the right to have their meds checked again |
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inseruton of a subclavian cather |
patient should lay supine with head looking away |
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i think i have an ulcer |
do you have mid epigastric pain |
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palpate the abdomen |
have the client breathe slowly to relax the abdomen |
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full liquid |
orange juice is considered a full liquid, apple juice isnt |
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patient with hyper emesis |
NPO to rest the stomach, start an iv, need input and output every 4 hrs, need to check weight and put them on bed rest. |
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h flu menigitis |
need antiobiotics and isolation for 24 hrs after they are started |
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kidney stones |
drink alot of water, eat diet low in sodium to keep water, limit coffee |
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visiting hours |
a nurse is a patient advocate and can adjust the visitng hours |
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4 year old |
cant write a letter yet |
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normal ammonia levels |
15 - 45 |
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hydrochlorothiazide |
should be taken with food because it upsets the stomach |
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cyclophosphamide |
anti cancer, will cause alopecia. |
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hip fracture |
can cause a fat embolism. |
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right adrenalectomy |
client can go into shock . monitor for blood pressure alterations |
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young children in the family |
involve in the plan of care. give a reason and a soultuon for care of the family |
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dissociative disorder |
client is suffering from a major levels of anxiety |
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dtap and fever of 103 |
do not give to the client |
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adult tubing |
15 drops/ min |
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h2 blockers |
taken 1 hr before meals |
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iron |
must be given with vit c or negligence |
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psych patients |
maintain civil rights. can vote and mail letters to whomever they want |
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turp w/ cbi |
should not leave the bed |
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estrogen |
changes libido, increase sry eyes, should stop smoking |
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comfortable come off alcohol |
chloroepoxide aka librium . a benzo |
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htn and temp |
a htn client is usually 1 degree lower in temp |
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pregnant women |
can excercise normally but should rest |
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arm red and warm |
infection , stop. if extravasation then give cold? |
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perotoneal dialysis |
turn client side to side before checking for kinks in the tubing? |
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complete heart block |
dont give lidocaine |
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VTE |
warm moist packs are correct, stockings on both legs, once heparin therapy is started they should be encouraged to ambulate. |
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vitamin k |
easy bruising. check after using the blood pressure cuff. |
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normal urine |
30 ml / hour is expected |
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polyethylene |
can not make cold. drink up to 4 liters of water |
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impetigo |
caused by strep. can cause periorbital edema |
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diverticulitis |
client can not have seeds |
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peritoneal dialsis |
semi fowlers |
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teens |
ok to fall over own feet. should have increased sweat due to hormone production |
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fetal heartbeat |
can be heard aroudn 12 weeks. definite sign of pregnancy. |
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radium inplant |
every 8 hours, low residue diet, strict bed rest, high fluids with radium, take anti nausea |
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alzheimers |
do not forcefully restrain the client unless they are actively a threat. |
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heparin and new mother |
can breastfeed a baby while the mother is on heparin |
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manic phase |
will not sit down to eat. provide with only healthy finger foods. |
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psych patient |
safe enviroment first before assessing the patient |
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annoying elderly client |
may feel vulnerable. interact at reg intervals |
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onset of labor |
decreased fetal movement, feel gush of fluid, bloody show, low back ache, contrational are normal even but not always |
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pn |
monitor blood glucose, q6hr. check electryolytes several times a weeek |
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Non stress test |
is a presumptive emasure, not done with oxytocin. tell the doctor. |
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pregnancy and analgesic |
can not be given during transition phase of labor or active labor |
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heptatitis b and liver |
can affect pt and ptt. should check before the client goes to surgery |
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bronchoscopy |
assess for swallow reflex before given ice chips, even if ordered |
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cytomegaly virus |
standard precautions |
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mechanical ventialtion |
needs someone there with them to care for it |
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tylenol |
liver toxic. dont give to patient with impaire dliver. |
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dishcarge home |
who is going to help you when you get home takes priority over sleeping and weight. think right now |
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shingles |
can work aslong as lesions are covered. avoid preggo and immunocompromised |
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bucks traction |
ELASTIC BANDAGE |
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harrington rod |
must monitor respiratory status for 48 hrs. asesss bowel and urinary also. take 10 deep breathes every 2 hrs. |
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ivp |
normal to feel flushed and will need a complete bowel prep. no desire to cough |
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intubation equipment |
place the blade in a bag and give gas sterilization |
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iron |
with vit c, not antacids, stools normally turn black |
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TOF |
knee chest position |
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myelogram |
bedrest 24 hrs 30 degress, fluids needs before and after test. fluids are most important to flush dye. |
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addison |
steriods cause fluid retention, steriods taken in the morning |
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mag sulfate |
decreased urine can lead to toxicity, if blood pressure goes up dont have enough magnesium. |
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pacemaker |
pulse should never be below the set rate on the pace maker |
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isonazid |
urine will not turn burn. see periphral neuropathy and alterated liver funtion |
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viral pink eye |
highly contagious. out of school for 3 - 10 days. |
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muscle weakness and lethargy |
hypokalemia. |
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adult htn |
2 readings 5 minutes apart |
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sigmoid colostomy |
irrigate once a day. can go without a patch |
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ssri |
gi bleeding |
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tegretol |
do not give to a patient who is pregnant. assess when the last period was. |
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gas pain |
ambulate frequent, position on right side, give laxative suppository. |
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water in ear |
cold water can cause dizziness, should warm the solution. |
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pitutary |
affects adh, affect urine output. must monitor. |
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ekg |
count qrs in a 6 second strip and multiply by 10 |
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soapsuds enema |
allowed to be 105, insert 3-4 inches, irritation held 8-12 inches above rectum. |
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pleurevac comes out |
place in sterile saline |
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tylenol overdose |
charcoal within 2 hrs, need abg's, acdosis and the temp. |
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cholesterol |
should be under 200. f over 250, needs meds. |
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descrbes feelings to the nurse |
trusting behaviors! |
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extrusion reflex |
disapears at 3-4 months, |
