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Xerostomia , what is it & how do you treat it = feeling of oral dryness-treat w/ sugarless candy or gum Labs to check for pernicious anemia = B12 Contraindication for the use of combination oral c... ontraceptives = HYPERtension (↑ BP) Sign of mild anxiety = Extreme focus What is remote memory loss = Inability to remember things from YEARS ago Heart failure dietary teaching = Low sodium & fluid restriction Diverticu litis dietary teaching = Low fiber Diverticu losis dietary teaching = High fiber IBS dietary teaching = High fiber Urine Culture on baby = straight catheter Parents are nervous about how their 3-year-old will act when newborn arrives. What can they do = Provide gift from the infant to the sibling Methylprednisolone sodium succinate lab to watch for? Serum glucose (because glucocorticoids cause hyperglycemia) At 14 weeks' gestation, what should the patient report to the MD = Swelling of the face (sign of preeclampsia) A patient is 14 weeks pregnant , where do you check to find the FHR = below the pubs symphysis area. Change of shift report should include = The blood lost Patient teaching for colostomy care = patient doesn't need to change the bag every day (only needs to be changed every 4-7 days) Scoliosis manifestation = Lateral curvature of the spin & asymmetrical hips/ribs Lab values that are elevated for Cushing's disease = ↑ Cortisol, ↑sodium, ↑ glucose Cushing disease Sx: Moon face Administering medications through an NG tube = * Administer meds separately * DO NOT mix with enteral feedings * Dissolve crushed tablets in 15-30mL of water * Flush tubing before & after each medication with 10-30mL of water Tobramycin adverse reaction = Ototoxicity (hearing damage & loss of balance) & Cloudy/bloody urine (nephrotoxicity Anorexia expected finding = pre-albumin 10 (normal is 3.5-5) Amniocentesis patient teaching = empty bladder before the procedure (S/E: can cause contractions) Expected finding during cardiac catheterization = Patient will feel warmth and flushed when dye is inserted Downloaded by Alex Hernandez ([email protected]) lOMoARcPSD|7225888 2 Retinoblastoma = white eye reflex What action should you instruct the patient to do prior to postural drainage? Administer a bronchodilator or nebulizer prior to treatment, postural drainage should be done 1 hour before meals or two hours after meals (perform twice daily) IV phlebitis =Discontinue IV & apply a warm/moist compress IV is infiltrated = Discontinue IV & apply a cool compress Female is to undergo an NST = Doppler transducer placed around abdomen When a patient is receiving mannitol , what should the nurse monitor for = Hypovolemia Co-worker is impaired , what do you do = Report it to the charge nurse Fine hair is a result of this disease = HYPERthyroidism How do you draw blood out of a PICC line = Draw 10mL of blood and discard it, then draw another 10mL of blood for sample, and then flush with 10mL of 0.9% sodium chloride Crohn’s disease = LOW fiber diet latex allergy if they have a sensitivity to what food = Bananas Buddhist patient = vegetarians Food Label = greatest weight is listed first. Child with positional plagiocephaly = Child will wear a molded helmet for 23 hours a day Pregnant women should eat more of what to prevent neural defects = Folate/folic acid A caregiver states they are becoming tired when caring for their parent with Alzheimer's disease , what can the nurse suggest = Respite care (care to give caregivers a break) Cleft palate teaching for feeding = don’t use a spoon, Position infant upright while cradling head & burp them frequently A wound that would heal by primary intention = A surgical incision Sign of glaucoma is loss of = Peripheral vision loss Baby w/reflux = small frequent meals, thicken formula with rice cereal, HOB 30 Radiation implant precautions = * Private room with radiation sign * Wear dosimeter film badge * Limit visitors to 30 min and to remain 6ft away from the patient * Keep lead container in room and tongs * No pregnant ladies or anyone under the age of 16 should come into contact with the patient Discharge teaching for a patient who is going home with HIV/AIDS = * Good hygiene & frequent hand washing * Avoid crowds * Avoid cleaning litter boxes Downloaded by Alex Hernandez ([email protected]) lOMoARcPSD|7225888 3 * Avoid raw foods such as veggies or meats Adolescent nutrition = 1300mg of calcium Priority nursing care for a patient who has been sexually assaulted = Assess their anxiety Identifying a need for hearing evaluation = * Absence of talking by 7 months * Uses gestures rather than talking by 15 months * Speaks in monotone * Speaks loudly for the situation Compartment syndrome = client with cast and has white extremity (6 P’s assessment) NG placement in the Jejunum = X-ray How should you confirm the placement of an NG tube = Aspirate gastric contents (pH less than 4) Methylphenidate patient teaching = It's Ritalin, so take once daily in the morning Simvastatin reaction that you report to the MD = Muscle aches/pain (rhabdomyolysis) Diabetic foot care patient teaching = Cut toe nails straight across, No lotion between toes, wear clean socks made of cotton or wool Where should you insert a peripheral catheter = Distal veins in the non-dominant hand Who receives Rhogam = an O- women following a spontaneous abortion Losartan adverse effect = Angioedema Patient teaching for dabigatran = Report bleeding (it's an anticoagulant) Pacemaker teaching = Take pulse at same time each day & report if HR is less than 5bpm below the pacemaker rate, Report dizzy, fatigue, hiccups or palpitations EKG that has no P wave , has a wavy baseline and increased HR = Atrial fibrillation Newborn genetic screening = Heel-stick test done 24 hours after birth and the infant must be fed within those 24 hours for accurate results Acupuncture contradiction: Herpes Zoster What medication is given for an ectopic pregnancy = Methotrexate Washing hands for a patient who is immunosuppressed = use chlorohexidine Betamethasone causes HYPERglycemia in the mom & HYPOglycemia in the neonate Betamethasone = used to promote fetal lung maturity NG Tube feeding = suction gas residuals every 4 hours. A client who has a history of domestic abuse = discuss an escape plan Cleansing a radiation area = Clean with mild soap or water, Avoid use of powders/lotions/creams Downloaded by Alex Hernandez ([email protected]) lOMoARcPSD|7225888 4 Furosemide & gentamicin drug interaction causes = Kidney problems & dehydration What can you expect after ECT treatments = Temporary short term memory loss When a group strep B culture is obtained during the 35-36 week of gestation and is positive , what do you do = Administer penicillin every 4 hours during labor List some ways to prevent or treat supine hypotension syndrome = Left-lateral side lying, Semi-fowlers, Wedge under one hip while supine Long term use of Protein Pump Inhibitors causes = osteoporosis Magnesium Sulfate = Is an anticonvulsant, Reduces the seizure threshold, Secondary effect - lowers BP*** Administering Magnesium Sulfate = Restrict fluids to 100-125mL/hour, Maintain urine output of 30mL/hour S/S of Magnesium Sulfate Toxicity: C - Cardiac dysrhythmias O - Output less than 30mL/hour R - Respirations less than 12/min A - Absent deep tendon reflexes (HYPOREFLEXIA) L - LOC is decreased Prednisone adverse reaction = Infection, Fluid retention, Hyperglycemia SIDS Prevention = Place babies on their backs to sleep, Pacifier when sleeping, Breastfeeding Sumatriptan is used for = Migraines Pregnant adolescent with no financial help = refer to case manager Absence Seizure = Brief sudden lapse in attention, patient may appear to be day dreaming or staring into space Valporic Acid levels to watch for = This med can cause hepatic toxicity - monitor serum liver enzymes Kidney donor contraindication = Diabetes Situational Crisis example = Lost a grandparent in a MVC (unexpected event) Coarctation of the aorta symptoms = Diminished pulses in extremities (weak femoral pulses) Cocaine patient Signs/Sx = ↑ Temp Patient teaching for parents taking child home after circumcision = Petroleum jelly with diaper changes (change diaper every 4 hrs) Screening test done at 16 weeks' gestation = alpha-fetoprotein (AFP) 3-year-old child can do what? = ride a tricycle Stimulant withdrawal symptom = fatigue Patient teaching for patient with peripheral artery disease = apply lotion to feet to prevent dry, cracked skin. Patient experiencing mania = give a PB&J for a portable snack Patient has diarrhea with enteral feeding , what should you do = administer at slower rate (admin. at room Downloaded by Alex Hernandez ([email protected]) lOMoARcPSD|7225888 5 temperature) When a patient is taking phenelzine what foods should be removed from their meal tray = Caffeinated beverages, Chocolate, Fava beans, Ginseng Lab test for pernicious anemia = Schilling test Sign of hypervolemia = Bounding pulses To ↓cardiac demand in an infant = feed infant when awake or crying Tidaling in water chamber of a chest tube is = Normal (bubbling is NOT) Narcissistic personality disorder expected behavior = infatuated with weight/appearance Clozapine lab contraindication = WBC 2900 (normal is 5,000-10,000) Anterior fontanelle closes = 12-18 months Confused patient = raise 1 side rail Posterior fontanelle closes = 2-3 months Acupuncture contraindication = Herpes zoster Chronic kidney disease hemodialysis patient teaching = 1g/kg of protein a day & ↑K Metoprolol report to MD = bradycardia Pregnant lady exercising teaching = drink lots of water Patient experiencing mania what should you encourage = encourage time in the day room Gentamicin adverse effect = creatinine 2.7 Sertraline adverse effect = dry cough Biofeedback is.... = a technique used to learn to control you body's functions Antisocial personality disorder can be characterized by = Lack of remorse Methadone withdrawal in newborn symptoms = hypertonicity Patient in ventricular tachycardia is found to be pulseless , what do you do = defibrillate Small pox expected finding = rash in mouth Preventing uric acid stones = YOGURT! Client in need of PT = Nurse should include client in selection of provider for PT. Organizing workload (time management question) = goals for the day Sign/Symptom of preeclampsia = proteinuria Advanced directives = do not need a lawyer Sickle cell priority (during crisis) = HYDRATION/FLUIDS Downloaded by Alex Hernandez ([email protected]) lOMoARcPSD|7225888 6 Pregnant woman has hepatitis C , can she breastfeed = yes, as long as she doesn't have cracked nipples Albumin is an indicator of = being well nourished Needles disposal at home = coffee container on top shelf Dehydration improving in baby sign = flat fontanelle Methotrexate adverse effect = high blood pressure NG tube nutrition = ↑ vitamin K 24-month old should be able to = walk up steps Pregnant woman should get what vaccine = flu shot To ↑ iron absorption , take with = vitamin C (orange juice) When scheduling when to take trough levels = take the level 30 minutes before the next dose is given Burn patient fluid/electrolyte imbalance = metabolic Acidosis EEG patient teaching = clean hair, no conditioner or gel/hairspray in it Parkinson Med - levodopa report = dark urine & monitor for HYPOtension Prostate cancer radiation therapy = wash irradiated area with mild soap & water Hepatitis A cleaning solution = 1:100 chloride solution Acarbuse is taken = with the first bite of each meal (diabetes med) Pregnant woman having late decelerations , what do you do = position the patient in left-lateral position STD that must reported to the CDC = chlamydia Side effect of ACE Inhibitors = Cough Justice = nurse treating a homeless person the same as anyone else Hypnosis intent = to alter the perception of pain African American = ↑ risk for heart disease Patient scheduled for an IV Pyelogram = administer a laxative High pressure alarm sounds on the vent, what do you assume is the cause = kinks, patient biting tubing Low pressure alarm sound on the vent, what do you assume is the cause = air leaks, displacement Patient arrives to ED after MVC, they are hypotensive & unresponsive. What solution will prescribed to increase intravascular volume & replace blood loss & increase BP ?: = 5% dextrose in LR Patient's family asks you to pray with them, what is your response = refer them to spiritual services IUD puts women at risk for = having an ectopic pregnancy Downloaded by Alex Hernandez ([email protected]) lOMoARcPSD|7225888 7 IV is infiltrated = discontinue and apply cold compress IV phlebitis has occurred = discontinue and apply warm/moist compress Patient asks the nurse to see his medical records = you have a right to see your records, let me initiate the process Adverse reaction of giving a patient a cooling blanket = SHIVERING Increase in PAWP means = left-sided heart failure Valproic acid adverse effects = LIVER failure, jaundice Frequent variable decelerations in FHR, what do you do = turn patient on left side Patient is in v. tach and pulseless , what do you do = defibrillate Threatening to insert an NG tube for a patient who refuses to eat is a sign of = assault Thrombocytopenia , you should avoid = blowing nose (wipe nose, not blow) Prior to liver biopsy , patient should have labs for = prothrombin time (PTT) Test for PKU = Guthrie test When should you take pancreatic enzymes = with each meal Contraindication of MMR = blood transfusion Gastric surgery , patient should eat = 3 meals/day What is true of lice = it can live for 48 hours on surfaces What do you hear when you palpate the abdomen = resonance Dying patient wants to be alone, what type of grieving = depression/dysfunctional Accessing a PICC line you need what type of needle = noncoring needle Care plan for a patient who has an indwelling urinary catheter = perineal care after defecation Hyperparathyroidism precaution = fall precaution (due to muscle weakness) Patient is experiencing diarrhea while receiving intermittent feeding, what nursing intervention should be done = administer at a slower rate PICC line understanding of teaching for a newly licensed nurse = informed consent is needed Epinephrine possible side effects = chest pain Amitriptyline adverse reaction to monitor for = urinary retention Group therapy for families adapting to loss of family members is do = determine roles First step to perform when a patient says they want to have a family home visit = clarify the source Referral that should be made for a patient who has a non-healing ulcer = dietitian referral Home safety for an older adult = install grab bars in the tub [Show More]

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