*NURSING > Test Prep > Exam Bank; Mark Klimek Blue book (ALL) NCLEX (117 pages) Complete Q&A, Updated June 2022. (All)

Exam Bank; Mark Klimek Blue book (ALL) NCLEX (117 pages) Complete Q&A, Updated June 2022.

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(first 20 pages free) Mark Klimek Blue book (ALL) NCLEX Study Guide Test Bank; 2022. Name the five/six essential nutrients - carbs, fats, proteins, vitamins, minerals, water The major source of... energy for the body is - carbs carbs provide ____________ Kcalories per 1 gram - 4 Sucrose is a sugar found in ____________ and _____________. - fruits, veggies Lactose is a sugar found in ? - milk What is glycogen? - It is a stored formed of glucose/energy manufactured by the liver Is glycogen eaten in foods? - NO! It is a stored form of glucose MANUFACTURED by the liver. When the body does not receive enough carbs it burns ___________ and _____________. - protein, fat The most concentrated source of energy for the body is ___________. - fats Fats provide ___________ Kcalories per 1 gram. - 9 Fats carry vitamins - A,D,E,K (Remember FADE K!) The nutrient needed most for growth and repair of tissues is _____________. - protein (second best is Vit C) Proteins provide __________ Kcalories per 1 gram. - 4 Vitamins and minerals provide energy for the body. (T/F) - False- they are necessary for a body's chemical reactions. Water is present in ALL body tissues. (T/F) - True (even bone) Water accounts for ________ to ___________% of an adult's total weight? - 50 to 60% Name the four basic food groups - Milk & Cheese, Meat & Legumes, Veggies & Fruits, Bread & Cereal Water acounts for __________ to _________% of an infant's total weight? - 70 to 75% An individual is overweight if they are ________% above the ideal weight. - 10 An individual is obese if they weigh ________% above the ideal weight. - 20 What solution and material are used to cleanse the eyes of an infant? - Plain water, cotton balls, washcloths Can you use cotton swabs to clean the eyes, nares or ears of an infant? - No, this is dangerous Can you use the same cotton ball/washcloth edge for both eyes? - No, it would cross contaminate Should you cover an unhealed umbilical site with the diaper? - No, fold the diaper down. What temperature is appropriate for the water used to bathe an infant? - 100 to 105 What is the #1 purpose of a tepid sponge bath? - Lower body temperature during fever. How should the temperature of the water be tested if no thermometer is available? - Dropping water on inside surface of your forearm. With which body part do you begin when bathing an infant? - Eyes always When cleansing an infant's eye, cleanse from outer to inner canthus? - No, inner to outer Should you retract the foreskin of a 5 week old male, uncircumcised infant to cleanse the area? - No, not until foreskin retracts naturally and without resistance- then it should be retracted, cleansed and replaced. When sponge-bathing with tepid water the correct temp is _____________. - 98.6 F How long does it take for the umbilical stump to fall off? - 7 to 14 days The primary reason why an infant is draped during the bath is to provide privacy. (T/F) - False, the primary purpose of draping is to prevent chilling. You may use friction to remove vernix caseosa from an infant's skin. (T/F) - False, it causes damage/bruising What solution is commonly used for care of umbilical cord? - 70% alcohol to promote drying (trend is toward soap and water) What cranial nerve is affected in Bell's Palsy? - #7, facial nerve What is the #1 symptom of Bell's Palsy? - One sided (unilateral) facial paralysis Complete recovery from the paralysis of Bell's Palsy should occur in _______ to ______ months. - 4 to 6 In addition to the facial paralysis, the sense of ______ is also affected. - taste Will the patient be able to close their eye on the affected side? - no Give three eye interventions for the client with Bell's Palsy. - Dark glasses, artificial tears, cover eye at night As the prostate enlarges it compresses the ___________ and causes urinary ________. - Urethra, rentention At what age does BPH occur? - men over 50 years of age What does BPH stand for? - Benign Prostatic Hypertrophy IN BPH the man has (increased/decreased) frequency of urination - increased In BPH the force of the urinary stream is (increased/decreased). - decreased The man with BPH has a _________-stream of urine - forked The man with BPH has hesitancey. What does this mean? - Difficulty starting to void Will the man with BPH have enuresis, nocturia or hematuria? - Enuresis-No, Nocturia-Yes, and Hematuria-Maybe Enuresis - inability to control the flow of urine and involuntary urination What is the best way to screen men for BPH? - Digital rectal exam Should fluids be forced or restricted in BPH? - forced What does TURP stand for? - Transurethral resection of the prostate The most radical prostate surgery is the ____________ prostatectomy. - Perineal What type of diet is used in BPH? - Acid Ash Acid Ash diet - Decrease pH (makes urine acid) Chz, eggs, Meat, fish, oysters, poultry, Bread, Cereal, Whole Grains, Pastries, Cranberries, Prunes, Plums, Tomatoes, Peas, Corn, Legumes. What is the primary purpose of a 3 way continuous bladder irrigation (CBI) after TURP? - To keep the catheter clear of clots and to drain urine What solution is used for CBI? - Normal saline (0.9 NaCl) How fast do you run the CBI? - At whatever rate it takes to keep the urine flowing and free of clots What drug is use to treat bladder spasm? - B&O suppositories (Belladonna & Opiates) Should you take a rectal temp after prostatectomy? Give stool softeners? - No rectal temperatures, yes stool softeners You should call the MD after TURP when you see _________ thick ________, _____________ clots, and ____________ urine drainage on the dressing. - Bright thick blood, persistent clots, persistent urine on dressing (don't call MD for transitory clots and urine on dressing.) If you see an increase in blood content of urine coming out of the catheter, you would first ___________. - Pull carefully on the catheter to apply local pressure on the prostate with the Foley balloon. If you see clots in the tubing you would first ____________. - Increase the flow-rate. What exercises should the post prostectomy patient do upon discharge? Why? - Perineal exercises, start and stop stream of urine, because dribbling is a common but temporary problem post op Will the post prostectomy patient be impotent? - If TURP, no impotence, if perineal prostatectomy, yes impotence How often should the drainage bag be emptied? - Every 8 hours What is the most common problem due to catheterization? - UTI What is the most common organism to cause UTI with catheterization? - E. coli What is the most common route for organisms to enter the blader when a catheterization is used? - Up through the inside of the catheter in the days following catheterization Name foods that make acid urine - Cranberry juice, apple juice (avoid citrus juices- they make alkaline urine) What is important about the level of the urinary drainage bag? - Never have the bag at a higher level than the bladder. How is the catheter taped in a male client? - To the lateral thigh or abdomen How is the catheter taped in a female client? - To the upper thigh What urinary pH prevents UTI? - Acidity, low pH Should the drainage bag ever touch the floor? - No Is it ok to routinely irrigate indwelling catheters? - No What agents are best for catheter care? - Soap and water What is the most effective way to decrease UTI with catheters? - Keep the drainage system closed, do not disconnect junction of tubing Give some signs of infection in a Foley catheter - Cloudy urine, foul smelling urine, hematuria Is urinary incontinence an indication for catheterization? - No Give three appropriate indications for bladder catheterization? - Urinary retention, to check for residual, to monitor hourly output What are the top 2 diagnoses for a client with a catheter? Which is #1? - #1- Potential for infection; Potential impairment of urethral tissue integrity What is systole? - The MAXIMAL force of blood on artery walls What is diastole? - The LOWEST force of blood on artery walls Accurate blood pressure is obtained by using a cuff that has width of __________ of the arm. - Two-thirds Which artery is most commonly used to measure blood pressure? - Brachial Can the thigh EVER be used to obtain a blood pressure? - Yes, but this is rare. When pressure is auscultated the first sound heard is the ____________ measurement. - Systolic The change in the character of the sounds is known as the ________ - First diastolic sound The cessation of sounds is known as the _________ - Second diastolic sound When 2 values are given in a blood pressure the first is the __________measurement. - Systolic When 2 values are given in a blood pressue, the bottom number stands for the change in sounds or cessation of sounds? - Cessation of sounds What is the normal adult blood pressure? - 120/80 Abnromally high blood pressure is called____________. - Hypertension What is the pulse pressure? - The difference between the systolic and the diastolic blood pressure If you deflate a cuff TOO SLOWLY, the reading will be too high or low? Why? - High, venous congestion makes the arterial pressure higher (increases resistance) If you use too narrow of a cuff the reading will be too high or low? - High Vasoconstriction will ___________ blood pressure. - Increase Vasodilation will ____________ blood pressure. - Decrease Shock will ___________ blood pressure. - Decrease Increased intracranial pressure will _________ the pulse pressure. - Increase or Widen If my blood pressure is 190/110, what is my pulse pressure? - 80 mmHg What blood test must be done before a transfusion? - Type and cross match What does a type and cross match indicate? - Whether the client's blood and donor blood are compatible. What should the nurse measure before starting a transfusion? - Vital signs With what solution should blood be transfused? - 0.9 normal saline How many nurses are requried to check the blood? - 2 nurses What happens when blood is administered with Dextrose IVs? - The cells clump together & don't flow well If a transfusion reaction occurs what should the nurse do first? - Stop the blood flow & start running the saline How long can a unit of blood be on the unit before it must be started? - Less than 1/2 hour What should the nurse do with the IV line if transfusion reaction is suspected? - Keep it open with saline If a transfusion reaction is suspected, what two samples are collected and sent to the lab? - Urine & blood If a unit of blood is infused through a central line it must be__________. - Warmed Which of the following are signs of transfusion reaction? Bradycardia, Fever, Hives, Wheezing, Increased Blood Pressure, Low Back Pain - Low back pain, wheezing, fever, hives What are three types of transfusion reactions that can occur? - Hemolytic, febrile, allergic What would you do first if you suspected transfusion reaction? - Stop the blood and start the saline What are the signs and symptoms of a hemolytic transfusion reaction? - Shivering, HA, low back pain, increased pulse & respirations, decreasing BP, oliguria, hematuria What are the signs and symptoms of a febrile transfusion reaction? - Low back pain, shaking HA, increasing temperature, confusion, hemoptysis What are the signs of symptoms of an allergic reaction to a transfusion? - Hives- uticaria, wheezing, pruritus, joint pain, (arthralgia) Give three reasons for a blood transfusion - Restore blood volume secondary to hemorrhage, maintain hemoglobin in anemia, replace specific blood components What does blood-typing mean? - Check for surface antigen on the red blood cell When does typing and cross matching need to be done? - Whenever a client is to get a blood product. It is only good for 24 hours. What does blood cross matching mean? - Mixing a little of the client's blood with the donor blood and looking for agglutination. When are hemolytic transfusion reactions likely to occur? - In the first 10 to 15 minutes When is a febrile reaction likely to occur? - Within 30 minutes of beginning the transfusion What test identifies Rh factor? - Coombs test detects antibodies to Rh What is the difference between whole blood and packed cells? - Packed cells don't have nearly as much plasma or volume as whole blood does What would you do if the client had an increasing temperature and was to get blood? - Call the MD because blood is often held with an elevated temperature How long should it take for one unit of blood to infuse? - From one hour to three hours How long should you stay with the patient after beginning a transfusion? - At least 15 to 30 minutes What blood type is the universal recipient? - AB What blood type is the universal donor? - O What is the routine for vital sign measurement with a transfusion? - Once before administration Q15 x 2 after administration is begun Q1 x1 after transfusion has stopped What IV solution is hung with a blood transfusion? - 0.9 normal saline (No glucose) What gauge needle is used with a blood transfusion? - Large gauge, 18 gauge What other things are appropriate after a reaction? - Call MD, get a blood sample, get urine sample, monitor vitals, send blood to lab Can blood be given immediately after removal from refrigeration? - No, it has to be warmed first for only about 20 to 30 minutes. With what solution & when should a breast feeding mother cleanse the areola? - Plain water, before & after each feeding For a woman who doesn"t have retracted nipples, is towel drying or air drying better? - Air drying of the nipples is best The goal is for the infant to breast feed for __________ minutes per side. - 20 How does the mother break the suction of the breast feeding infant? - She inserts her little finger into the side of the infant's mouth When should the breast feeding infant be burped? - After feeding from each breast Assuming no mastitis, on which side should the breastfeeding begin? - Begin nursing on the side that the baby finished on the last feeding How long can breast milk be refrigerated? - 24 hours How long can breast milk be frozen? - 6 months In what type of container should breast milk be stored? - Sealed plastic bags Can you microwave frozen breast milk in order to warm/thaw it? - Never Which two nutrients is breast milk lower in? - Fluoride and iron What should you tell a breast feeding mother about her milk supply when she goes home from the hospital? - Milk should come in postpartum day 3. Breastrfeed every 2-3 hours to establish good milk supply. Can a woman on oral contraceptives breastfed? - Should not use OCP during the first 6 weeks after birth because the hormones may decrease milk supply. Estrogen is not recommended. Non-hormonal methods are recommended. Remember, breastfeeding is an unreliable contraceptive. What is another name for Buerger's disease? - Thromboangiitis obliterans Which extremities are affected by it? - Lower only Which sex does it affect the most often? - Males The group with the highest incidence of Buerger's disease is __________. - Smokers Upon walking the patient with Buerger's experiences _______ _________. - Intermittent Claudication What is intermittent claudication? - Pain in calf upon walking A first degree burn is pale or red? - Red A first degree burn has vesicles (T/F)? - False A second-degree burn is pale or red? - Red A second-degree burn is dull or shiny? - Shiny A second-degree burn has vesicles? (T/F) - True A Second degree-burn is wet or dry? - Wet A third-degree burn is white or red? - White A third-degree burn is wet or dry? - Dry A third degre burn is hard or soft? - Hard Of first, second and third degree burns which has less pain? Why? - Third degree burns, nerve damage has occured For what purpose do you use the rule of nines? - To estimate the percentage of body surface burned; is NOT used for children. In the rule of nines, the head and neck receive _______: each arm receives_______. - 9%, 9% In the rule of nines, the front trunk gets_____, the posterior trunk gets_____, each leg gets ______ and the genitalia gets________. - 18%, 18%, 18%, 1% What is the only IM given to a burn patient? - Tetanus toxoid- if they had a previous immunization; tetanus antitoxin- if they have never been immunized before (or immune globulin) In the emergent phase do you cover burns? (in the field) - Yes, with anything clean and dry. Should you remove adhered clothing? - No Name the 3 phases of burn - Shock, diuretic, recovery Fluid moves from the___________ to the _______ in the SHOCK phase. - Bloodstream, interstitial space The shock phase lasts for the first ________ to ________ hours after a burn. - 24 to 48 hours During shock phase of a burn is potassium increased or decreased? Why? - Increased, because of all the cells damaged- the K+ is released from damaged cells. What acid-base disorder is seen in the shock phase of a burn? - Metabolic Acidosis What is the #1 therapy in the shock phase? - Fluid replacement/resuscitation What is the simple formula for calculating fluid replacement needs in the first 24 hours? - 3cc X Kg X % burned per day If the MD orders 2,800 cc of fluid in the first 24 hours after a burn, one-_____ of it must be infused in the first 8 hours. - Half (or 1,400 cc) What blood value will dictate IV flow rate? - The hematocrit How will you know the patient has entered the fluid mobilization or diuretic phase? - The urine output will increase How long does the fluid mobilization or diuretic phase of a burn last? - 2 to 5 days In the diuretic phase, K+ levels fall or rise? - Fall- remember diuresis always causes hypokalemia If the nurse accidentally runs the IVs at the shock phase rate during the diuretic phase the patient will experience? - Pulmonary edema The burn patient will be on _______urine output and daily __________. - Hourly, weight Sulfamyon cream__________. - Burns Silver nitrate cream___________ the ________. - Stains, skin Pain medications should be administered _______ before ________ care. - 30 minutes, wound care When using silver nitrate, the dressings must be kept __________. - Wet What is Curlings ulcer? Why is it a problem in burn patients? What drug prevents it? - It is a stress GI ulcer, you get these with any severe physical stress. Tagamet, Zantac, Pepcid (any H2 receptor antagonist), Protonix Prilosec In Abruptio Placenta, the placenta _______________ from the uterine wall ____________. - Separates, prematurely Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________. - Multigravida, 35 (HTN, trauma, cocaine) How is the bleeding of Abruptio Placenta different from that in placenta previa? - usually pain; bleeding is more voluminous in previa If you are the nurse starting the IV on the client with Abruptia Placenta, what guage needle should you use? - 18 (in preparation to give blood if necessary) How often should you measure the vital signs, vaginal bleeding, fetal heart rate during Abruptio Placenta>? - Q5-15 minutes for bleeding and maternal VS, continuous fetal monitoring, deliver at earliest sign of fetal distress How is an infant delivered when Abruptio Placenta is present? - Usually C-section Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa? - Highter In what trimester does Abruptio Placenta most commonly occur? - Third At what age are accidental poisonings most common? - 2 years old If a child swallows a potentially poisonous substance, what should be done first? - call medical help Should vomiting be induced after ingestion of gasoline? - No- not for gas or any other petroleum products When taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER? - the suspected poison An elderly client is a (high/low) risk for accidental poisoning? What about a school age child? - high - due to poor eyesight, high What types of chemicals cause burns to oral mucosa when ingested? - Lye, caustic cleaners Children at highest risk for seizure activity after ingestion are those who have swallowed _____________ and ______________. - drugs, insecticides Can impaired skin integrity ever be an appropriate nursing diagnosis when poisoning has occurred? - Yes, when lye or caustic agents have been ingested What is the causative organism of acne? - P. acnes (propionibacterium acnes) What structures are involved in acne vulgaris? - The sebaceous glands Name 3 drugs given for acne? - Vitamin A, Antibiotics, Retinoids Dietary indiscretions and uncleanliness are causes of acne? - False What are the 3 causative factors in acne vulgaris? - Heredity, Bacterial, Hormonal Uncleanliness is a cause of acne? - False What is the most common retinoid given to people with acne? - Accutane Accutane is an analog of which vitamin? - Vitamin A What is the most common side effect of accutane? And what is most important in health teaching in adminstration? - Inflammation of the lips; Causes birth defects What is the antibiotic most commonly given to clients with acne? - Tetracycline How long will it take for the person to see results when acne is being treated? - 4 to 6 weeks Does stress make acne worse? - yes How often should the client with acne wash his face each day? - twice a day What instructions do you give to a client taking tetracycline? - Take it on an empty stomach and avoid the sunlight (photosensitivity) What are comedones? - Blackheads and white heads What virus causes AIDS? - HIV - Human immunodeficiency virus The AIDS virus invades helper ____________. - T-lymphocytes (or CD4 cells) AIDS is trasmissible through what four routs? - blood, sexual contact, breast feeding, across placenta in utero HIV is present in all body fluids? - Yes, but not transmitted by all, only blood, semen and breast milk Name the 5 risk groups for AIDS - Homosexual/bisexual men, IV drug users, hemophiliacs, heterosexual partners of infected people, newborn children of infected women What is the first test for HIV antibodies? - ELISA What test confirms the ELISA? - Western Blot Which test is the best indicator of the progress of HIV disease? - CD4 count A CD4 count of under __________ is associated with the onset of AIDS-related symptoms. - 500 A CD4 count of under _______ is associated with the onset of opportunistic infections. - 200 Give 6 symptoms of HIV disease. - Anorexia, fatigue, weakness, night sweats, fever, diarrhea Which 2 classes of drugs are given in combination for HIV sero-positivity? - NRTI's (nucleoside reverse transcriptease inhibitors) and PI's (protease inhibitors) They prevent viral replication. NRTI (nucleoside reverse transcriptease inhibitors) - an antiviral drug used against HIV (is incorporated into the DNA of the virus and stops the building process; results in incomplete DNA that cannot create a new virus; often used in combination with other drugs) PI's (Protease inhibitors) - most potent of antiviral meds, inhibit cell protein synthesis that interferes with viral replication, does not cure but slows progression of AIDS and prolongs life, used prophylactically, used in AIDS to decrease viral load and opportunistic infections What do NRTI's and PI's do? - They prevent viral replication What does the physician hope to achieve with NRTI's and PI's for HIV? - A delayed onset of AIDS for as long as possible (usually can delay onset for 10-15 years) What is the most common NRTI used? - AZT (zidovudine) What is the most challenging aspect of combination of drug therapy for HIV disease? - The number of pills that must be taken in 24 hours can be overwhelming. The frequency also makes it hard to remember-an alarm wristwatch is used. Clients with AIDS (gain/lose) weight? - lose The typical pneumonia of AIDS is caused by ___________ ____________. - Pneumocystic carinii What type of oral/esophageal infections do AIDS patients get? - Candida What is the #1 cancer that AIDS patients get? - Kaposi's sarcoma Kaposi's sarcoma is a cancer of the ___________. - skin T/F: AIDS patients get lymphomas? - True What lab findings are present in AIDS? - Decreased RBC's, WBC's and platelets If the AIDS patient has leukopenia they will be on _____________ ________________. - protective (reverse) isolation Define Leukopenia - decrease in wbc, indicated viral infection Without leukopenia the AIDS patient will be on ____________ precautions. - Standard precautions or blood and body fluid precautions When the AIDS patient has a low platelet count, what is indicated? - bleeding precautions; No IM's, no rectal temperatures, other bleeding precautions Does AIDS require a single room? - Yes - if WBC counts are low When do you need a gown with AIDS? - If you are going to get contaminated with secretions When do you need a mask with AIDS? - Not usually unless they have an infection caused by an airborne bug When do you need goggles with AIDS? - Suctioning, central line start, arterial procedures If an AIDS patient's blood contaminates a counter top, with what di you clean? - 1:10 solution of bleach and water Are all articles used by AIDS patients double-bagged? - no - only those contaminated with secretions Can AIDS patients leave the floor? - Yes, unless WBC's are very low Is dietary protein limited in AGN? - Not usually, however if there is severe azotemia then it may be restricted Define azotemia? - nitrogenous wastes in the blood (increased creatinine, BUN) What is the best indicator of renal function? - The serum creatinine Do people recover from AGN? - Yes, the vast majority of all clients recover completely from it How can AGN be prevented? - By having all sore throats cultured for strep and treating any strep infections What is the most important intervention in treating AGN? - Bedrest - they can walk if hematuria, edema and hypertension are gone. What is the most common dietary restriction for AGN? - Moderate sodium restriction. Fluid restriction is #2 if edema is severe. What are the urinaysis findings on AGN? - Hematuria Proteinuria +3 to +4 Specific gravity Up How long after strep infection does AGN develop? - 2 to 3 weeks after initial infection How do you assess fluid excess in the child with AGN? - Daily weight What organism causes acute glomerular nephritis? - Group A beta hemolytic strep What happens to the kidney in AGN? - It becomes clogged with antigen-antibody complexes which then cause inflammation and loss of function. How often are vital sign measurements taken in AGN? - Q4 hours with blood pressure Will the client have hypo or hyper tension with AGN? Why? - Hypertension, because of fluid retention What are the first signs of AGN? - Puffiness of face, dark urine What are the three adult stages of development called - early adulthood, middle adulthood and later adulthood What is the age range for early adulthood? - 19 to 35 years of age What is the age range for middle adulthood? - 35 to 64 years of age What is the age range for late adulthood? - 64 years of age to death What is the developmental task for early adulthood? - Intimacy vs. Isolation What is the developmental task for middle adulthood? - Generativity vs. stagnation. Intimacy vs. Isolation - Erikson's stage in which individuals form deeply personal relationships, marry, begin families Generativity vs. Stagnation - Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service What is the developmental task for later adulthood? - Ego Integrity vs. Despair Ego Integrity vs. Despair - (Erikson) People in late adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be relived "Time is too short to start another life, though I wish I could," is an example of ___________. - despair "If I had to do it over again, I'd life my life just about the same," is an example of ____ ____________ - Ego Integrity What does AKA mean? - Above the knee amputation What does BKA mean? - Below the knee amputation If the patient had an AKA they should lie ____________ several times per day. - prone (to prevent flexion contracture) The #1 contracture problem in AKA is ____________ of the _____________ - flexion, hip What will prevent hip flexion contracture after AKA? - Lying prone several times a day What is the #1 contracture problem after BKA? - Flexion of the knee How do you prevent flexion contracture of the knee after BKA? - Remide the patient to straighten their knee constantly while standing To prevent post-op swelling, the stump should be __________. - elevated How long should the stump be elevated to prevent post op swelling? - 12-24 hours How often should a stump be washed? - daily When a stump is wrapped, the bandage should be tightest _____________ and loosest _____________. - distally (far from the center), proximally (neareast to the point) If after a right BKA, the client c/o pain in his right tow, he is experiencing _____________. - phantom limb sensation (which is normal) When will phantom limb sensation subside? - in a few months Name ways to toughen a stump so it will not breakdown due to the wear of the prosthetic leg? - push the stump against the wall, hitting it with a pillow An aneurysim is an abnormal _______________ of the wall of a(n) artery. - widening (it is also weakening) What artery is widened in a thoracic aneurysm? - the aorta An aneurysm can result from an _____________ and from ____________. - infection, syphilis The most common symptom of abdominal aneurysm is: - a pulsating mass above the umbilicus Which aneurysm is most likely to have no symptoms? - the abdominal is most often "silent" Which vital signs are most important to measure in clients with aneurysm? - The pulse and blood pressure An aneurysm will most affect which of the following, the blood pressure or the pusle? - the pulse (many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change. What activity order is the client with an aneurysm supposed to have? - Bedrest. do not get these people up If the client with aneurysm is physically unstable, should you encourage turning, coughing and deep breathing? - no, bedrest until the client is stable! What class of drugs is the client with an aneurysm most likely to be on? - Antihypertensives What is the BIG danger with aneurysms of any type? - Rupture, leads to shock and death If an aneurysm is ruptured how would you know it? - decreased LOC (restlessness), tachycardia, hypotension - all signs of shock If an aneurysm ruptures what is the #1 priority? - Get them to the operating room ASAP Is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room? - Yes, if available you can get them into antishock trousers but not if this causes a delay in getting them to the operating room The post op thoracic aneurysm is most likely to have which type of tube? - Chest tube, because the chest was opened The post op abdominal aneurysm repair client is most likely to have which type of tube? - NG tube for decompression of bowel If you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hours? - check the distal extremity (far from center) for color, temperature, pain and PULSE, also MUST document What causes angina pectoris? - Decreased blood supply to myocardium, resulting in ischemia and pain Describe the pain of angina pectoris - crushing substernal chest pain that may radiate What drug treates angina pectoris? - Nitroglycerine How do you tell if a client has angina or an MI? - the pain of the two is similar, the way to tell the difference is if nitro and rest relieve the pain. For angina, nitro and rest relieve the pain, for MI, nitro and rest do not relieve the pain How many nitro tabs can you take before you call the doctor? - 3 How many minutes should lapse between the nitro pills you take? - 5 minutes - take one nitro tab every 5 minutes 3 times, if no relief, call MD By what route do you take nitro? - sublingual What is the action of nitro? - dilates coronary arteries to increase blood supply (O2 supply) and reduces preload. What are the top 2 side effects of nitro? - headache and hypotension What precaution must the nurse take when administering topical nitro paste? - wear gloves, nurse may get a dose of the med Everyone with angina needs bypass surgery? t/f - False Anorexics are usually __________ under the age of _____. - females, 25 The diagnosis is made when there is a weight loss of _______% or more of body weight. - 15 (weigh < 85% of normal body weight), hospitalize if 30% weight loss A major mental/emotional nursing diagnosis seen in anorexia nervosa is ___________. - Altered body image The pulse rate of anorexics is tachycardic or bradycardic? - Bradycardic List the most common gynecologic symptom of anorexia nervosa? - amenorrhea What is found over the body of the client with anorexia nervosa? - lanugo (soft downy hair) What is the top priority in the care of the client with anorexia nervosa? - intake of enough food to keep them alive, have them gain weight The best goal to evaluate the progress of the client with anorexia nervosa? - an adequate weight gain What is the apgar scale? - quick objective way to evaluate the vital functions of the newborn When is apgar scoring performed on infants? - at one minute and again at 5 minutes after the birth Name the 5 criteria that are recorded on an apgar scale - Cardiac status, respiratory effort, muscle tone, neuromuscular irritability, and color The total apgar score can range from - 0 to 10 The maximum score and infant can receive on any one of the criteria is - 2 A 10 on the apgar means the baby is - in terrific health A 0 on the apgar means the baby - is stillborn On heart rate or cardiac status, a 2 means that the HR is above _______ BPM. - 100 On the HR criteria an infant scores a "1" if their HR is _________ than 0 and ____________ 100 - greater, less than In order to score a 0 on HR the infant must have a rate of _________. - Zero A high score of 2 is given for respiratory effort if the newborn_____________. - Cries vigorously An infant is given a score of 1 if their respirations are _______ or ________. - Slow or irregular An infant is given a score of 0 for respiratory effort if __________. - They do not breathe In order to get a score of 2 on muscle tone the infant must_________________. - Move spontaneously (actively) To get a score of 1 on the APGAR for muscle tone the newborn must place their extremities in _______________. - Flexion A newborn receives a score of 0 on muscle tone when there is__________ - No movement (limp) [Show More]

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