Mark Klimek Blue Book Part 1, Question Bank with answers, 2022/2023. NCLEX

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Mark Klimek Blue Book Part 1, Question Bank with answers, 2022/2023. NCLEX 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 painful; bleeding is more voluminous in placenta 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 VS, vaginal bleeding, fetal HR during Abruptio Placenta? - ✔✔Q5-15 minutes for bleeding, maternal VS and continuous fetal monitoring Deliver baby 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? - ✔✔Higher 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 for 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? - ✔✔Hereditary, 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 transmissible through what four routes? - ✔✔blood sexual contact breast feeding across placenta in utero HIV is present in all body fluids? - ✔✔Yes, but it is 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 diarrhea night sweats fever 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. Prolongs life, used prophylactically and 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 weight 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 AIREBORNE 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 do 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 Na+ restriction. Fluid restriction is #2 if edema is severe. What are the urinalysis 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 Late adulthood What is the age range for early adulthood? - ✔✔19 - 35 What is the age range for middle adulthood? - ✔✔35 - 64 What is the age range for late adulthood? - ✔✔64 - 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 live my life just about the same," is an example of __________ __________. - ✔✔Ego Integrity The result of the positive resolution of the final life crisis. Viewed as the key to harmonious personality development; the individual views their whole life with satisfaction and contentment. 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? - ✔✔Remind the patient to straighten their knee constantly while standing To prevent post-op swelling, the stump should be __________ for 12 to 24 hours. - ✔✔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 toe, he is experiencing _____________. - ✔✔phantom limb sensation (which is normal) When will phantom limb sensation subside? - ✔✔In a few months Is it acceptable for the patient to push the stump against a wall? - ✔✔Yes, this is one way to toughen a stump so it will not breakdown due to the wear of the prosthetic leg; hitting it with pillows is another good method. An aneurysm 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, syphillis 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 pulse? - ✔✔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? - ✔✔All signs of shock Decreased LOC (restlessness) Tachycardia Hypotension 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) color temperature pain 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. Angina = nitro and rest relieve the pain MI = nitro and rest DO NOT relieve the pain How many nitroglycerine tablets can you take before you call the doctor? - ✔✔3 tablets How many minutes should lapse between the nitro pills you take? - ✔✔5 minutes - take 1 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? - ✔✔hypotension and headache 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 of anorexia nervosa is made when there is a weight loss of _______% or more of body weight. - ✔✔15 (pt weighs less than 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 1 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 Color The total apgar score can range from - ✔✔0 to 10 The maximum score an 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 is ________ (bad/good). - ✔✔Bad, 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) To score the maximum of 2 points on nueromuscular reflex irritability the infant must ______________. - ✔✔Cry If the neonate ____________, they will score a 1 on neuromuscular irritability. - ✔✔Grimaces To receive a 0 on reflex (neuromuscluar) irritability the neonate must exhibit _______ - ✔✔No response To score a maximum score of 2 on color the child must be ____________. - ✔✔Totally pink If the child's _______ are ______ and the trunk -face abdomen are ________, the child scores 1 on color - ✔✔Extremities are blue (cyanotic), Pink To get a 0 on color the infant is - ✔✔Totally blue, pale Acrocyanosis - ✔✔Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming. Apendicitis is an _________ of the appendix due to __________. - ✔✔inflammation, obstruction Apendicitis occurs most in what age group? - ✔✔15 to 35 What is the most common complication of appendicitis? - ✔✔Peritonitis Peritonitis - ✔✔Inflammation of the peritoneum What is the first sign of appendicitis? - ✔✔RUQ pain What follows the RUQ abdominal pain of appendicitis? - ✔✔N/V Where does the pain of appendicitis finally end up? - ✔✔RLQ What is the name of the RLQ abdominal pain where appendicitis pain finally localizes? - ✔✔McBurney's Point What is present when rebound tenderness is present? - ✔✔Peritoneal inflammation What is the highest that the temp will be in appendicitis? - ✔✔102 F What blood count is elevated in appendicitis? - ✔✔WBC What is the name for an elevated WBC? - ✔✔Leukocytosis What is the only treatment recommended for appendicitis? - ✔✔surgery - appendectomy Before the client with suspected appendicitis sees the physician what should be avoided? - ✔✔Pain meds, enemas, laxatives and food! NPO To lessen the pain, place the client with appendicitis in ___________ position. - ✔✔Fowlers (a sitting position) (also use post op) Never apply __________ to the area of the appendix. - ✔✔Heat (it causes rupture) After appendectomy, document in the nurses notes the return of __________ - ✔✔Bowel sounds (peristalsis) 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 Sucruse is a sugar found in ____________ and _____________. - ✔✔fruits, veggies What is glycogen? - ✔✔It is a stored formed of glucose/energy manufactured by the liver Lactose is a sugar found in ? - ✔✔Milk 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 The nutrient needed most for growth and repair of tissues is _____________. - ✔✔Protein (2nd best is Vitamin C) Proteins provide __________ Kcalories per 1 gram. - ✔✔4 Vitamins and minerals provide energy for the body. (T/F) - ✔✔Fale- 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 in Bell's Palsy. - ✔✔taste Will the patient with Bell's Palsy 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 hesitancy. What does this mean? - ✔✔Difficulty starting to void. Will the man with BPH have enuresis, nocturia or hematuria? - ✔✔Nocturia and maybe hematuria, NOT enuresis 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 continuous bladder irrigation? - ✔✔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 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 bladder 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 Abnormally 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 and don't flow well If a transfusion reaction occurs what should the nurse do first? - ✔✔Stop the blood flow and 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 transufsion reaction is suspected, what two samples are collected and sent to the lab? - ✔✔Urine and 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 transufsion 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 headache low back pain increased pulse and respirations decreasing BP oliguria hematuria What are the signs and symtpoms 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 matchng 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 indentifies 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 rotuine 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 blood transfusion 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 and when should a breast feeding mother cleanse the areola? - ✔✔Plain water, before and after each feeding For a woman who doesnt 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 refrigeratored? - ✔✔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 whern 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 Buerger's Disease? - ✔✔Lower only Which sex does Buerger's Disease 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 on a burn patient? - ✔✔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 the shock phase of burn management, 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 of a burn? - ✔✔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 Neoplasm refers to benign and malignant tumors. (T/F) - ✔✔True Which type of tumor is more malignant? Differentiated or undifferentiated? - ✔✔Undifferentiated is worse to have (highly differentiated is better to have) When cancer spreads to a distant site it is called? - ✔✔Metastasis The cause of cancer is known. (T/F) - ✔✔False A person should have a yearly work up exam for cancer detection over the age of __________. - ✔✔40 In general, cancer drugs have side effects in which three body systems? - ✔✔GI Hematologic (blood) Integumentary What are the 3 most common chemotherapeutic GI side effects? - ✔✔N/V Diarrhea Stomatitis (oral sores) Clients receiving chemotherapy must be NPO. (T/F) - ✔✔False Is it permissible to give lidocaine viscous ac (before meals) if the patient has chemotherapeutic stomatosis? (T/F) - ✔✔True With what solution should the client with chemotherapeutic stomatitis rinse pc (after meals)? - ✔✔H2O2 - hydrogen peroxide What lubricant can safely be applied to the cracked lips of chemotherapy stomatitis? - ✔✔K-Y Jelly Name the 3 hematologic side effects of chemotherapy. - ✔✔Thrombocytopenia Leukopenia Anemia Which cells are low in thrombocytopenia? - ✔✔Platelets What drug should NOT be given to the patient with chemotherapeutic thrombocytopenia? - ✔✔ASA (aspirin) When should the nurse WITHHOLD IM injections in the client on chemotherapy? - ✔✔Only when their PLATELET count is down. What are the 3 objective symptoms/signs of thrombocytopenia? Hint: P.E.E. - ✔✔Petechiae Epistaxis Ecchymosis What is epitaxis? - ✔✔Nose bleeds What is ecchymosis? - ✔✔Bruising What is petechiae? - ✔✔Small dot like pinpoint hemorrhages on the skin. What blood cell is low in leukopenia? - ✔✔White blood cells When the Absolute Neutrophil Count ANC is below________ the person on chemotherapy will be placed on reverse isolation. - ✔✔500 What is the #1 integumentary side effect of chemotherapy? - ✔✔Alopecia What is alopecia? - ✔✔Hair loss The hair loss due to chemotherapy is usually temporary? (T/F) - ✔✔True Can scalp tourniquets prevent chemotherapy alopecia? - ✔✔In some cases, yes Can ice packs to the scalp prevent chemotherapy alopecia? - ✔✔In some cases, yes CD ranks ________ among the leading cause of maternal death. - ✔✔Fourth What is the #1 cause of CD of pregnancy? - ✔✔Rheumatic heart disease Pregnancy requires a __________ increase in the cardiac output. - ✔✔30-50% What is the #1 cause of maternal death in CD of pregnancy? - ✔✔Decompensation What is meant by decompensation? - ✔✔Failure of the heart to maintain adequate circulation. What will you see when you observe the neck of a client with CD of pregnancy? - ✔✔Distended neck veins -JVD What will you hear when you auscultate the heart of the client with CD of pregnancy? - ✔✔Murmurs What will you hear when you auscultate the lungs of the client with CD of pregnancy? - ✔✔Crackles-rales If the client with CD of pregnancy experiences sudden heart failure what is the MOST common thing you will see? - ✔✔Sudden onset of SOB (dyspnea). What is the #1 treatment of CD during pregnancy? - ✔✔Rest What are the three most common drugs given to women with CD in pregnancy? - ✔✔Diuretics Heparin Digitalis Why are diuretics given to women with CD of pregnancy? - ✔✔To promote diuresis which will: -lower circulating blood volume -decrease preload -decrease the amount of blood the heart pumps. Why are anticoagulants (heparin only) given to women with CD of pregnancy? - ✔✔To prevent thrombophlebitis due to venous congestion, usually in legs. Why is digitalis given to women with CD of pregnancy? - ✔✔To increase the strength of the heart and to decrease the rate, rest the heart while making it more efficient Can a woman with CD of pregnancy be given analgesics during labor? - ✔✔Yes, in fact they should be given analgesics, may get too anxious which is bad for the patient Can morphine be given to a woman with CD during labor? - ✔✔Yes, even though it negatively affects the fetus, remember morphine decreases preload and pain which rests the heart. What is the most common dietary modification for the woman with CD who shows signs of decompensation? - ✔✔Decreased sodium, decreased water (restriction) Is a C-section mandatory for delivery of a woman with CD of pregnancy? - ✔✔No Second to rest, what is very important treatment for CD of pregnancy? - ✔✔Weight control How long must the woman with CD of pregnancy be on bed rest after delivery? - ✔✔At least one week What nutrients should be supplied in the diet of the pregnant woman with CD? - ✔✔Iron Folic acid Prevent anemia (anemia always makes the heart work more) What are the two most common subjective complaints of the woman who is decompensating during labor? - ✔✔SOB Palpitations In addition to the things you assess for in every woman during labor, what additional assessment must you make for a woman with CD? - ✔✔You must assess lungs sounds frequently How often must you assess the lung sounds during the first stage of labor? During active labor? During transition labor? - ✔✔Every 30 to 10 minutes In which position should a woman with CD in labor be? - ✔✔Semi recumbent, HOB up The nurse should limit the client's efforts to ________ ______ during labor when CD is present. - ✔✔Bear down What is the big danger to staff when caring for a client with cesium implant? - ✔✔Radiation hazard What are the three principles to protect yourself from radiation hazard? - ✔✔Distance Shielding Time Will the woman with a cesium implant have a foley? - ✔✔Yes From where should the nurse provide care to the client with cesium implant? - ✔✔The head of the bed How can the woman with cesium implant move in bed? - ✔✔Only from side to side What four symptoms in a patient with a cesium implant should be reported to the physician? - ✔✔Profuse vaginal discharge Elevated temp Nausea Vomiting (these indicate infection and perforation) Should pregnant staff care for a client with a cesium implant? - ✔✔No Can the woman with a cesium implant have the HOB elevated? - ✔✔Yes, only 45 degrees maximum From where should the nurse talk to the client? - ✔✔The entrance to the room Is bed rest necessary when a woman has cesium implant in place? - ✔✔Yes, absolute bed rest What type of diet is this woman with a cesium implant on? - ✔✔Low residue (decrease bowel motility ) No nurse should attend the client with a cesium implant more than ____ per day. - ✔✔1/2 hour What would you do if the cesium implant came out? - ✔✔Pick it up with forceps only - never touch with hand even if you are wearing gloves. Should the nurse provide perineal care for the client with a cesium implant? - ✔✔No, risk of radiation hazard What part of your hand do you use to handle a wet cast? - ✔✔The palm Upon what do you support a cast while it dries? - ✔✔Pillows (no plastic covers) How long does it take a cast to dry? - ✔✔24 hours Should you cover a wet cast? - ✔✔No Should you use a heat lamp or hair dryer or fan to help dry a cast? - ✔✔No heat lamp and hair dryer Yes fan What signs or symptoms would you report if they were present after cast application? - ✔✔Numbness Tingling Burning Pallor Unequal or absent pulses Unequal coolness If there is inflammation under a cast, it will be evident in a _______ spot. - ✔✔Hot To prevent irritation of the skin near the edges of a cast the edges should be ____________. - ✔✔Petaled What type of cast causes cast syndrome? - ✔✔A body cast What causes cast syndrome? - ✔✔Anxiety and stress leading to sympathoadrenal shut-down of the bowel What is the #1 symptom of cast syndrome? - ✔✔Nausea and vomiting due to bowel obstruction What is the #1 treatment of cast syndrome? - ✔✔NPO and NG tube for decompression A dry cast is gray or white? - ✔✔White A dry cast is dull or shiny? - ✔✔Shiny A dry cast is dull or resonant to percussion? - ✔✔Resonant Traction is used to _______ and _______ a fracture, relieve ________ _______ and prevent ________. - ✔✔Reduce and immobilize, muscle spasm; deformities Can skin traction be removed for skin care? - ✔✔Yes Can the client be removed from skeletal traction? - ✔✔No Name 3 types of skin traction - ✔✔Bucks Bryants Pelvic Name 3 types of skeletal traction - ✔✔Cranial tongs Thomas splints with Peason attachments 90 degrees to 90 degrees What type of traction is most commonly used for hip fracture in adults? - ✔✔Bucks What type of traction is most commonly used for hip fractures in children? - ✔✔Bryants In what position should the bed be if the patient is in pelvic traction? - ✔✔Semi-fowlers with knee gatched To insure that Bryant's traction is working the child's hip/sacrum should be _________ - ✔✔Off the bed enough to slip a hand between the sacrum and the bed. What is the advantage of balanced counteraction? - ✔✔You can easily move the patient around in bed Patients in Russell's traction are particularly prone to ____________. - ✔✔Thrombophlebitis When a patient is in a Buck's traction they may turn to the _________ side. - ✔✔Unaffected Define cataract - ✔✔Opacity of the crystalline lens Is surgery done immediately upon diagnosis of cataract? - ✔✔No, they usually wait until it interferes with ADLs . What three most common visual defects occur with cataract? - ✔✔Cloudiness Diplopia (double vision) Photophobia (sensitivity to light) What are the two common treatments of cataract? - ✔✔Laser, surgical removal. Surgery called intraocular or extraocular lens extraction What does the eye look like when a client has cataracts? - ✔✔Cloudy, milky-white pupil What will the client be wearing after cataract surgery? - ✔✔A protective patch/shield on the operative eye for 24 hours, then a metal shield (AT NIGHT only) for 3 weeks When the client asks about the use of glassess or contacts after cataract surgery what would you say? - ✔✔If an introcular lens is implanted they will NOT need glasses. If no lens is implanted, then contacts will be fitted for 3 months post-op, temporary thick glasses given immediately but will get a different prescription in 2 to 3 months What will be a high priority nursing diagnosis for a client post cataract surgery? - ✔✔Safety Should the client ambulate independently after cataract surgery? - ✔✔No the patient should not ambulate independently, depth perception is altered. What positions are to be avoided after cataract surgery? - ✔✔Lying face down. Also, do not lie on operative side for a month. What are the post-operative signs of hemorrhage into the eye? - ✔✔Severe pain Restlessness What movements are to be avoided after cataract surgery? - ✔✔Coughing Sneezing Bending at the waist Straining at stool Rubbing or touching eyes Rapid head movements What positions are okay after cataract surgery? - ✔✔Do not lie on operative side; do not lie on back Should you use talcum powder with a post-operative cataract client? - ✔✔No, it may cause sneezing; also should avoid pepper. What are the three signs of increased intraocular pressure? - ✔✔Pain (moderate to severe) Restlessness Increased pulse rate What is the major objective in caring for a client after surgical cataract removal? - ✔✔To prevent pressure in or on the eyes When the lens is to be extracted for cataracts, what drugs are given preoperatively? - ✔✔Mydriatics Dilators Antibiotic drugs (gtts) What three drugs are given post-operatively for surgical cataract removal? - ✔✔Stool softeners Antiemetics Analgesics (mild to moderate) Give five causes of catarcts? - ✔✔Injury Congenital Exposure to heat Heredity Age Celiac's disease is a __________ disease - ✔✔Malabsorption The client with celiacs cannot tolerate___________. - ✔✔Gluten Gluten is a __________. - ✔✔Protein What does gluten do to the intestines of the client with celiac's disease? - ✔✔It destroys the lining of the intestine. The stools of a client with celiac's disease are ______, ______ and _____- _____. - ✔✔Large Greasy Foul-smelling Clients with celiac's disease do not absorb what mineral? - ✔✔Iron Clients with celiac's disease don't absorb fats; therefore they don't absorb _____ ______ ______. - ✔✔Fat soluble vitamins What are the four fat-soluble vitamins? - ✔✔A,D,E,K Malabsorption of which vitamin leads to bleeding disorder? - ✔✔Vitamin K, remember do not mix up potassium with Vitamin K What will the abdomen of clients with celiac's disease look like? - ✔✔Distended with flatus What is the #1 treatment of celiac's disease? - ✔✔Gluten-free diet Veggies are allowed or not allowed in diet of client with Celiac's disease? - ✔✔Allowed Fruits are allowed or not allowed? - ✔✔Allowed Grains of all kinds are prohibited. (T/F) - ✔✔False What grains are allowed in a gluten-free diet? - ✔✔Rice and corn What grains are not allowed in a gluten-free diet? - ✔✔Wheat Oats Rye Alfalfa Barley Are foods made with wheat, oat, or rye flour allowed? - ✔✔No Is milk allowed on a gluten-free diet? - ✔✔Yes Are meats allowed on a gluten-free diet? - ✔✔Yes, but watch for breaded meats and hot dogs/lunch meats- may have grain in them and are not allowed Are eggs allowed on a gluten-free diet? - ✔✔Yes Is commercial ice cream allowed on a gluten-free diet? - ✔✔No, even though it is a milk product, commercial ice cream has GRAIN in it. Are puddings allowed on a gluten-free [Show More]

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