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99 Cards in this Set
- Front
- Back
Which measure should the nurse plan for a patient with thrombocytopenia resulting from cancer chemo?
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Apply pressure to the venipuncture site for five minutes
Rationale: Thrombocytopenia= depletion of platelets places the patient at increased risk for bleeding. Applying pressure is an appropriate measure against this risk. |
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which pt with an ileal conduit displays a need for additional teaching?
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secures face plate with tape
Rationale: Tape is used around skin barrier, never on the pouch |
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Which disorder places a pt at an increased risk of cancer?
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Down Syndrome
Rationale: These pt have an increased risk of leukemia |
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In assessing a pt with oral lesions s/t chemo, nurse should also assess?
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perianal area
rationale:r/for infection is related to pathogen entry site such as mucous membranes, IV sites. |
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A nurse must recommend which of the following for a pt. with anticipated alopecia?
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Acquire a wig which matches hair color prior to chemo.
rationale: selecting a wig before hair falls out make for matching texture and color. |
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A childs with Wilms Tumor should not be palpated where?
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On the abdomen
Rationale: palpating will increase seeding of tumor |
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A pt with stage 4 adenocarcinoma of right lung has a regualr resp. rate, circumoral cyanosis, small amount of yellow mucus when coughing, which is an appropriate diagnosis?
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Impaired Gas Exchange
Rationale: Tumor has metastisized. Gas exchange is impaired as amount of can cer grows. |
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How do we prevent lymphedema?
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pt avoid dangling arm, sleep on unaffected side, wear loos fitting clothes, wear gloves when working with strong acids or detergents, Do not cut cuticles rather use lotion.
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A pt with a radical mastectomy has had blood samples and blood pressure drawn on the unaffected arm, WHY?
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To decrease risk of infection
rationale:both procedures require constriction of the arm which if affected arm placing the pt at an increased risk of infection |
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A toddler with leukemia has stomatitis, which statement declares teaching has been effective?
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I can prepare my childs favorite foods such as mash potatoes & chocolate milk
rationale: these foods are bland and easy to chew. |
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Which statement made by a pt should alert the nurse to provide addt. teaching regarding breast ca.?
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Thank god I can just examine one breast!
rationale: BSE should include the entire chest wall and axilla. |
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Pt with ca. is in a state of cachexia, what should the nurse include in the care plan?
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Eat six small meals per day & report any weight loss
rationale: a pt. with cachexia needs addtional nutrition. small frequent meals work best with these pt. |
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What is appropriate for visitors of a pt receiving internal radiation therapy?
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Maintain distance of 6 feet from isotope source
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when preparing a plan to meet learning needs of pt with cancer, who is undergoing chemo, the nurse should include which instruction?
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Use recommended antiemetic drug prior to therapy
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A pt with a colostomy is disharged, what do we include in discharge instructions?
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pouch opening 1/8 inch bigger than stoma, clean with mild soap and pat dry, change bag when 1-3rd full . change bag q 3-7 days
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Which measure should the nurse plan for a patient with thrombocytopenia resulting from cancer chemo?
|
Apply pressure to the venipuncture site for five minutes
Rationale: Thrombocytopenia= depletion of platelets places the patient at increased risk for bleeding. Applying pressure is an appropriate measure against this risk. |
|
which pt with an ileal conduit displays a need for additional teaching?
|
secures face plate with tape
Rationale: Tape is used around skin barrier, never on the pouch |
|
Which disorder places a pt at an increased risk of cancer?
|
Down Syndrome
Rationale: These pt have an increased risk of leukemia |
|
In assessing a pt with oral lesions s/t chemo, nurse should also assess?
|
perianal area
rationale:r/for infection is related to pathogen entry site such as mucous membranes, IV sites. |
|
A nurse must recommend which of the following for a pt. with anticipated alopecia?
|
Acquire a wig which matches hair color prior to chemo.
rationale: selecting a wig before hair falls out make for matching texture and color. |
|
A childs with Wilms Tumor should not be palpated where?
|
On the abdomen
Rationale: palpating will increase seeding of tumor |
|
A pt with stage 4 adenocarcinoma of right lung has a regualr resp. rate, circumoral cyanosis, small amount of yellow mucus when coughing, which is an appropriate diagnosis?
|
Impaired Gas Exchange
Rationale: Tumor has metastisized. Gas exchange is impaired as amount of can cer grows. |
|
How do we prevent lymphedema?
|
pt avoid dangling arm, sleep on unaffected side, wear loos fitting clothes, wear gloves when working with strong acids or detergents, Do not cut cuticles rather use lotion.
|
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A pt with a radical mastectomy has had blood samples and blood pressure drawn on the unaffected arm, WHY?
|
To decrease risk of infection
rationale:both procedures require constriction of the arm which if affected arm placing the pt at an increased risk of infection |
|
A toddler with leukemia has stomatitis, which statement declares teaching has been effective?
|
I can prepare my childs favorite foods such as mash potatoes & chocolate milk
rationale: these foods are bland and easy to chew. |
|
Which statement made by a pt should alert the nurse to provide addt. teaching regarding breast ca.?
|
Thank god I can just examine one breast!
rationale: BSE should include the entire chest wall and axilla. |
|
Pt with ca. is in a state of cachexia, what should the nurse include in the care plan?
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Eat six small meals per day & report any weight loss
rationale: a pt. with cachexia needs addtional nutrition. small frequent meals work best with these pt. |
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What is appropriate for visitors of a pt receiving internal radiation therapy?
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Maintain distance of 6 feet from isotope source
|
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when preparing a plan to meet learning needs of pt with cancer, who is undergoing chemo, the nurse should include which instruction?
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Use recommended antiemetic drug prior to therapy
|
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A pt with a colostomy is disharged, what do we include in discharge instructions?
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pouch opening 1/8 inch bigger than stoma, clean with mild soap and pat dry, change bag when 1-3rd full . change bag q 3-7 days
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when teaching BSE to adults what is the best indication learning has occurred?
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return demonstration
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A pt with cancer asks if there are alternative treatments for ca, nurse response?
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Describe therapies you want to explore
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Chemotherapy should be witheld when?
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when bone marrow suppression occurs
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when a pt with ca. develops pain what is an accurate inital nursing action?
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ask pt. to rate severity of pain on a scale
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A pt with neutropenia is put in a private room why?
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minimize risk of infection
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which findings in a pt with neuroblastoma in the abdomen indicate distant metastasis?
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periorbital edema indicates distant metastasis, bone pain & weakness, weight loss & anorexia are linked to generalized metastasis
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Pt. with a mastectomy is one day postop. what is the greatest risk at this time?
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pulmonary complications
rationale: due to location of surgery |
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A pt with colorectal ca. develops stomatitis r/t chemo which is a dietary intervention?
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increase fluids to maintain electrolyte balance & promote excretion of waste
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which intervention should be included for a pt with multiple myeloma
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good hydration
rationale: hypercalcemia is a common complication of myeloma. maintaining hydration is important |
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a pt had a radical modified mastectomy what should be included immediately post op?
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maintain cont. elevation of right arm on pillow
rationale: elevation helps relieve pain after mastectomy |
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how can prostate ca be diagnosed?
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yearly DRE
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which indicates a need for further teaching for a home care pt with leukemia?
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I keep fresh cut clowers in my room
rationale:live plants/flowers pose a risk for infection |
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a pt will qualify for hospice if -
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life expectancy 6 months or less, spouse works full time, receives palliative therapy, pt resides in LTC facility or elsewhere
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two different chemotherapy drugs are administered why?
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increase numbers of tumor cells killed
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a pt with a laryngectomy can attend which support group?
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Lost chord club
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a family is diagnosed with dysfunctional grieving r/t pt. advanced vaginal ca. What is a primary nursing goal?
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have family members deal feelings of guilt, fear, anger in a supportive setting
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what are s/s of myelosuppresion?
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elevated temp. & gingival bleeding
rationale:these are signs of bone marrow suppression and pose a risk for infection |
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Hodgkins Diet?
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High protein High carb, low residue
Rationale: diet should be nutritious and not irritating to GI tract (low fiber) |
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What color should a stoma be after colostomy surgery?
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light pink to red
dark red or black indicates infection or necrosis |
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what is tumor lysis syndrome?
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when contents of cells destroyed by chemo are released into body causes electrolyte imbalance. Increasing fluids help the body rid excess fluid.
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After abdominal perineal resection for rectal ca. what is an intervention?
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a sidelying position
rationale: it will be less uncomfortable while wound is healing |
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a pt with a bone marrow transplant must report all of the following
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intermittent claudication (indicates vein obstruction), constipation (increases risk of bleeding), rash (transplant rejection
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a pt. with ca. is receiving morphine what diet is appropriate?
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High fluid High Fiber diet
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what foods can cause cancer?
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smoked foods, salted foods
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how does a radical prostactectomy affect sex?
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causes impotence
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A child with CF has certain dietary needs what are they?
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Good hydration, pancreatic enzymes mixed with food
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what s/s of HPS?
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projectile vomiting, palpable epigastric mass
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Galactesomia?
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Intolerance to lactose, do not give milk or lactose containing products due to infant missing enzyme GALT which is necessary in body to break down galactose into glucose
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a mentally challenged child is about to undergo surgery, what is an nursing action to meet childs need?
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Ask parents what childs use for words
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which factor affects children with CP
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feeding difficulties r/t abnormal postures and decrease in muscle tone
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Infant with Hydrocephalus what is a priority diagnosis?
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altered cerebral perfusion r/t ICP
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which toys help a CF toddler attain goals of therapy?
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push=pull toys
rationale: stimulates mucus secretion |
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a 25 month old toddler can sit up with support but does not walk, what is an important nursing measure?
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refer child to developmental testing
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s/s of Down Syndrome
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protruding tongue, palmar crease
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goal for infant with neurogenic bladdr r/t meningomyelocele?
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preserving renal function
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which statement indicates teaching was effective for a pt discharged regarding prevention of reoccurence of Rheumatic fever
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I will take precuations the rest of my life
rationale: this disease poses risk to heart and joints and has lifelong consequences. |
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a pt taking an ACE inhibitor may experience?
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orthopnea and cough,must be taken prior to meals.
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which statement by a pt taking sub. NTG indicates the need for additonal teaching?
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I repeat dosage q 30 mins. NTG is given repeatedly q 5 mins up to 3 doses if no relief of cp see er/md
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which action for a pt. with SC Anemia indicates need for more teaching?
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restricts fluids
rationale:dehydration is common |
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Schilling test?
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urine collected for 24 hours
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what is indicative of dig. toxicity?
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abdominal pain, yellow halos, hypokalemia
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what physiological change is expected in an adult
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atrial irritability; enlarged left atrium
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s/s of iron deficiency anemia
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smooth sore red tongue, brittle nails & hair; ferritin levels low;H * H low
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a pt expresses powerlessness r/t chronic disease, what intervention can a nurse provide?
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provide a choice of foods for breakfast meal
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Sinoatrial arrest, bradydysrhythmias,AV block may be treated with what drug?
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atropine
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Epinephrine used for?
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Asystole
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Lidocaine used for?
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PVC
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s/s of DVT
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pain in affected area and unilateral edema
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a pt with angina should avoid?
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extreme temperatures
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which indicates successful treatment of CHF?
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cardiac output of 4-7 l/min, central venous presure 0-8 mm hg, systemic vascular resistance 800-1500 dynes/sec, pulmonary artery wedge pressure 4-12mmhg
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common side effects of digitalis
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reduces edema, nausea
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lab results indicative of DIC
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PT & PTT increased, fibrinogen decreased, fibrin split products are increased
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what does a pacemaker do?
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provide electric stimulus to the heart
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A pt has an abdominal aortic aneursysm, what is an emergent s/s?
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severe back pain
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Phase 1 rehabiliation is started when?
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When the pt. is hemodynamically stable
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PE is treated with?
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Digoxin & Lasix
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Dressler Syndrome is treated with?
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NSAID
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Third Degree AV Block treated with?
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Atropine
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Cardiogenic Shock treated with?
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NTG and Dopamine
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which assesment data validate a diagnosis of excess fluid volume r/t right sided heart failure
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pedal edema
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Why take Cromolyn?
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helps pt tolerate activity (asthma)
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A pt with bronchospams may experience what complication?
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respiratory arrest
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Cyanosis is indicative of what?
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impaired circulation or impaired airway patency
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what cause the abnormal ABG in lobar pneumonia?
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exudate infiltrates the alveoli
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bubbling must be cont. in suction chamber
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occasional bubbles in suct chamber indicate problem
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intermittent or absent bubbling in water seal chamber are correct
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cont. bubbling in water seal chamber indicate a problem
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What does Incentive Spirometry do?
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maximizes the amount of air inhaled while maintaining relatively low airway pressure
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s/s of LTB
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stridor on inspiration, low grade fever
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s/s of epiglottitis
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croupy cough, drooling, agitation
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