Terms in this set (61)
What is a kosher Diet?
Fish with fins and scales is okay
no mixing meat with milk -- EVER!!
Woman is post pelvic surgery and asks why she has a foley catheter inserted, what is your response?
It avoids stress on the incision site/bladder
Crutches on which side when rising? Walking?
Unaffected side when rising, affected side while walking.
What walking gate for stairs?
What degree should the arms be when hands on crutches while standing?
Normal stoma findings?
Moist, shiny, pink
Wash with mild soap and water
Dry gently and completely
Apply barrier cream
Low fat, low cholesterol (<200)
If AST and lipase, any type of bilirubin, WBC, amylase, LDH, are elevated, bad.
What to expect during latent phase of labor?
(0-3, 5-30, 30-45)
Contractions mild and moderate, 5-30min. apart
Lasting 30-45 seconds.
What phase of labor when contractions are 3 minutes apart?
What to do for Variable Decelerations?
Cord compression! Prep for emergency c-section or inducing labor.
Also can change position, d/c oxytocin, O2 8-10L/min per mask, perform/assist with vaginal exam, assist with amnioinfusion if ordered
Best pain management for 8-10 post-open cholecystectomy?
Morphine can cause biliary spasms
When do fontanels close?
Posterior: 2-3 months
Sunken if dehydrated
Do you report chlamydia?
Mandating reporting to CDC without verbal or written consent
JP Drain (when to drain and how to clean)
Before half full, or every 8-12 hours, NOT 24 hours.
Clean with soap and water, NOT antimicrobials or Dakin's etc.
What if JP doubles in last 2 hours?
Hemorrhage. So assess, stat CBC, notify physician.
What do bananas, avocado and spinach have in common? If patient on what med, these are good foods?
K+, so good for hypokalemic patients.
If patients on thiazide diuretics (Diuril, Enduron), may be HYPOkalemic, so give these
MAOI's/Nardil, avoid what?
Creamed, Aged, Processed meat
Cheese good for what?
Hyponatremia because high in sodium
Also high in potassium
Drainage at pin sites for Buck's Traction
Drainage ok, note the type, odor, color and amount. Leave crust as a barrier, pin care 3x/day
Methergine risk? What does it do?
Treats postpartum hemorrhage by inducing uterine contractions, reducing hemorrhage.
HYPERTENSION is a risk, so CHECK BP prior to administration, watch for n/v, headache,
High pressure alarm, do what?
Assess for kinks, client biting, excess secretions (suction), pulmonary edema, etc. Notify provider
Low Pressure alarms, do what?
Assess for leaks, displacement. If can't find anything wrong, MANUALLY VENTILATE AND CALL RESPIRATORY STAT, do NOT LEAVE ALONE
2 years of age, presentation of arms longer than torso, or round and soft abdomen?
Round and soft abdomen, NOT arms longer than torso
3 years of age normals; immunizations?
initiative vs. guilt
jump off bottom step
stand on one foot for few seconds.
DTaP, IPV, MMR, varicella, influenza
First thing to do with a newborn: Take temperature, weigh, dry...
Terminally ill patient only wants family, not friends with them. Type of grief?
not dysfunctional, normal, or disenfranchised.
A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which IV solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume, and increase BP? 1. 5% dextrose in lactated Ringer's 2. 0.33% sodium chloride (1/3 normal saline) 3. 0.225% sodium chloride (1/4 normal saline) 4. 0.45% sodium chloride (1/2 normal saline)
5% dextrose in LR
LR = volume expander
Give what for hypovolemic shock
Client's family asks you to pray with them. Response?
Refer to Spiritual Services
After a blood infusion, will you look at hGb, hct, BP, or HR for changes?
Hgb! 1-2 point increase per unit of blood.
Can you give an antibiotic in a TPN infusion line? What can you add to a TPN infusion line?
Cannot add anything
Lipids only thing that can go with it
Change a TPN infusion line every 24 hours, or how often?
Every 24 hours
TPN, slow down infusion before ending, d/c until new bag ready?
No, don't d/c or change rate, don't change flow rate!
Can add 10% Dextrose until new bag arrives
Can client's family change dressing daily? Tie tubing to neck?
No, every 8 hours! Yes, square knot with 1-2 finger widths,
Hip arthroplasty, what to watch out for?
Peripheral pulses! So cool and weak, 1+ peripheral pulses, sign to call provider.
Mom engorged, don't do what?
Don't self express milk! Ice packs, support bra all ok.
Rifampin, isoniazid, phenytoin, what's up?
INH/Isoniazid increases phenytoin toxicity, meaning ataxia and hallucinations may present. Decrease phenytoin dosage. Hepatotoxicity possible with rifampin.
Palpate fontanels by 2-3 years?
Bulging fontanels could mean ^ ICP, meningitis.
First priority for DKA patients
ESTABLISH VENOUS ACCESS, before ANYTHING.
DKA patient drops glucose from 450 to 250, do what? Measure glucose, temp, what, and how often?
Measure glucose & potassium hourly, provide IV glucose at 250 to prevent hypoglycemia.
Patient has L1-L2 paralysis, lives with spouse, bathroom and bedroom on 2nd floor. Needs PT, respite, speech therapy, what?
Needs occupational and physical therapy, but social services is number one for help with home adaptation!
Highest risk to patient is bed tray left in room, tray table at end of bed, restraints tied to bed rails?
Restraints to bed rails! This is inappropriate.
Infant has scaly spots, erythemic papillae, and something on lips. Report which to physician?
A woman comes in to you and says she is on contraception and wants to get pregnant. What is she at risk for?
If IUD, then ectopic pregnancy!
Infant has substernal heaves, expect what?
O2, suction, Survanta for surfactant, vent. support
aPTT 30 and platelets 200, what's wrong?
Can you delegate an LPN to check NG tube placement? Can they provide first feeding after CVA?
Yes, according to book; not clear, but assume no, because high risk scenario
Ventricular tachycardia/Vtach = what ECG?
What can a 3-month old eat, carrots, grapes, graham crackers, or popcorn?
Dehydration = what v/s
Low BP, high HR, metabolic acidosis (low pH, high bicarb). postural hypotension, H&H, BUN and other elevated
Glucose reaches 250 on insulin, give what? Isotonic, hypotonic, hypertonic, dextrose?
Dextrose to prevent hypoglycemia.
Bend at waist to pick up, or tuck pelvis and flex abs?
Flex and tuck, NEVER bend at waist
Give patient cooling blanket when febrile, what is sign of adverse reaction?
Can digoxin toxicity occur with 3.2 potassium?
130/86 BP, severe headache, what would you report in preterm labor to provider?
Severe headache!! HYPERTENSIVE CRISIS
S/S of magnesium sulfate toxicity? 2 main interventions
urine output < 30,
RR < 12
No deep patellar tendon reflexes
IMMEDIATELY D/C, give CALCIUM GLUCONATE
Tuna good for what, bad for what?
High in protein AND potassium, so watch out.
If anemic, increase or decrease milk, and give iron or no?
Decrease milk as it interferes with iron absorption, and they need iron; give iron!
Report what after a craniotomy?
Aphasia, because this means increased ICP r/t increased bleeding which is the highest risk. Keep HOB at 30
Prednisone 10 months, ok? Watch for what?
Long term not recommend, never change dosage, watch for osteoporosis, AVOID LARGE CROWDS due to ^ risk for infection
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