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HURST review (1)
Terms in this set (164)
prescription for restraints was received at 3am because of combative behavior. on last assessment at 7am, client was still combative. what is the BEST action?
a. continue restraints
b. remove restraints until HCP writes prescription
c. assign UAP to check on client periodically
d. obtain prescription from HCP
obtain prescription from HCP
*periodical checks is not an acceptable time frame (must give specific hours)
how often do you need a prescription for restraints if they are still needed?
every 4 hours
*should include why they require restraint & period for using them (no longer than 24 hours)
post-op care for a thoracentesis:
-check vitals frequently
-examine dressing for bleeding
-listen to and percuss lungs
-palpate around incision site for air under skin
how should a client be positioned post-op for a thoracentesis?
turn them on their unaffected side for at least 1 hour (promote re-expansion of lung and healing of the site)
*do not place with affected lung down
Nurse is caring for a client prescribed vancomycin for MRSA. what nursing intervention is appropriate?
verify the client's BUN and creatinine are in normal range
why would muscle spasms in a client who is 28 weeks pregnant complaining of swollen hands and feet be the biggest concern?
client could have pre-eclampsia and is at risk for seizures
do you need to wear gloves when taking a client's vitals or passing out meal trays?
(not coming into contact with body fluids)
when caring for a client who is immunosuppressed, what precautions are needed?
when is a N95 mask placed on a client?
airborne precautions (ex. TB)
what is a common effect/SE of an SSRI?
*SSRI's may cause temperature dysregulation
*should have a lessening of depressive symptoms within a few weeks
assessment findings common with cirrhosis:
firm, nodular liver
increased ALT and AST levels
bleeding from GI tract
LOW serum albumin levels (sick liver = less proteins)
No pork (bacon, ham, or sausage)
no shellfish (but yes normal fish)
steak must not have any traces of blood
milk is not allowed at same time as meat
Client with gout is being treated with NSAID for acute flare up. what is the expected finding?
dramatic decrease in pain after beginning medications
*patient's with gout usually experience dramatic improvement within 24 hours
*NSAID's do not reduce plasma uric acid levels
are a low-grade fever and rash adverse effects of NSAIDs?
*NSAIDs prevent fever, biggest SE is GI upset
if a client at 32 weeks gestation is admitted to OB unit with BP of 142/90 and 1+ proteinuria, who should the nurse assign her to share a room with?
another client with possibility of preterm delivery (not one with potential emergency)
*room should be kept quiet to decrease stimulus
Why would a post-partum client be a bad choice to share a room with a client who has pre-eclampsia?
newborn would require frequent post-partum assessments and nursing care
*great deal of activity in the room
can an LPN re-insert an NG tube that a client pulled out?
can LPN monitor PCA pump pain medication is being delivered?
(cannot initiate or administer pain meds -just monitor the pump)
can a LPN collect data on a new client?
yes, if the RN verifies and co-signs to complete assessment
what developmental tasks would the nurse expect to see in a young adult
developing meaningful and intimate relationships
giving and sharing with an individual without asking what will be done in return
during what age group do people find a sense of fulfillment that can be found by volunteering in the community?
(finding ways to support others)
what age group must find some way to satisfy and support the next generation?
middle adulthood (parenting task)
what age group do people reflect on their life accomplishments
what is the best instruction for a UPA who is caring for a client with Alzheimer's that keeps walking into other rooms on the unit?
hang a familiar object on the door
(client's with alzheimer's may not recognize their own name or take time to read)
s/s of acute rejection (kidney)
tenderness over the kidney
nurse is planning teaching to a group of assisted living residents (close quarters, ex. dorm) about TB. what should the include?
cover mouth when coughing
proper hand washing
obtain TB skin test
proper disposal of tissues (hygiene measure)
s/e of a client who has received too much levothyroxine:
(replacement hormone for hypothyroidism, would be showing s/s of hyperthyroidsism / CAD)
foot care for diabetics:
check shoes for rough spots
file toenails straight across (instead of cutting)
break in new shoes gradually (30-60 min/day)
avoid self-care for corns/calluses (contact HCP first)
which rhythm change would be a priority for the nurse to assess?
bradycardia --> will decrease CO / perfusion to vital organs
(a fib/a flutter is not as life threatening)
can a UAP collect a stool specimen?
(not urine from catheter, sterile procedure)
can a UPA apply cardiac leads and connect to cardiac monitor?
can a UAP feed a client who is dysphagic?
*risk of aspiration, need an RN present
what tag would a client receive if they had a BP 40, HR 30, and respirations 6?
*nurse would not assess in a disaster
what color tag would a patient with a sucking chest wound and tension pneumothorax receive in a disaster?
(life threatening injury; but can be helped if care is quick!)
therapeutic serum levels of digoxin:
is performing a postop wound dressing change using clean gloves cost-effective care?
*need sterile gloves, infection is more expensive than gloves
what is an example of cost effective nursing care?
-providing palliative care to a terminally ill client (reduces unnecessary resources)
-beginning discharge planning on admit
-counseling clients to quit smoking
-educating parents on importance of immunizations
why is "pre op diazepam 10.0 mg given PO" not correct documentation?
don't use trailing 0's
(same as not using a leading 0 --> 0.5 not .5)
is "appears to be having abdominal discomfort" correct documentation?
if a client has a Apgar score of 4, 5, or 6 at 5 minutes: what is the nurses priority intervention?
administer "blow-by" oxygen while suctioning
*requires immediate intervention; transferring them to an ICU will delay care (NOT RIGHT)
if a client is admitted for suspected sepsis (temp 102.2 and lethargic) what action is priority?
blood cultures x 2
start an IV/start fluids
*IV can be started at any point
*should get blood cultures before IVF's so blood sample is not affected in any way
should crust be removed from insertion site of Steinmann pins?
yes, but not a priority
"my veins have turned to stone and my heart is solid" is an example of:
*feeling detached to reality, feeling that their parts have changes or sense of seeing oneself from a distance
client with Schizophrenia who is purposelessly imitating movements by others is exhibiting:
invention of new words by psychotic patients is called
normal aPTT level when on an anticoagulant
if a client is on heparin and their aPTT is 110 seconds, what should you do?
Administer protamine sulfate
heparin overdose =
what is monitored in a patient on warfarin?
PT and INR
if a client states "I don't have any help taking care of my baby. I don't feel like I can take care of him anymore. I wish I never had him. maybe then my husband would spend more time at home"
what should you say?
come to the clinic right now
*assume the worst (exhibiting s/s of postpartum psychosis)
*think: suicide or infanticide
patency of AV shunts:
who is at a nutritional risk?
client receiving clear liquids only for > 3 days
how to draw up 2 insulins:
clear (regular) before cloudy (NPH/suspension)
insulin syringes should be stored at:
should an LPN care for a 3 year old admitted with possible septicemia?
*potentially unstable and will probably require IV antibiotics
should a LPN care for a 10 year old transferred from ICU yesterday with head injury?
*need close observation of RN
can a LPN care for a 10 year old paraplegic in for bowel training?
*will need very little RN assistance
is Buck's traction in scope of practice of an LPN?
*skin traction/ long-term (not unstable)
client education: using crutches
-do not alter height of crutches
-body weight should be supported on hand grips
-elbows flexed 30 degrees
-when sitting or standing from a chair, position crutches on the affected side
if a primary HCP asks you to use a container with formalin and you have not handled formalin before, what is the best action?
read about it on the MSDS (material safety data sheet)
*drug handbook will not have details on handling a hazardous material
*calling someone to ask is not reliable
how to determine compressions are deep enough:
presence of carotid pulse with each compression
best way to open a client's airway with suspected head/neck/spinal injury?
jaw thrust maneuver
if a primary HCP orders a medication that you notice is on the client's list of allergies, what should you do? (patient advocate)
-notify primary HCP immediately
-stop the medication on the client's medication administration record
-check the client's allergy band against list of allergies documented in medical record
nervousness, anxiety, increased sweating, exophthalmos
-increased GI motility
which hormone causes amenorrhea?
what substance should NOT be used with oxygen treatment?
petroleum jelly (combustible substance)
client education about peritoneal dialysis:
sweet taste may be experienced when peritoneal dialysis is used
about 2,000-2,500 mL should infuse in about 10 minutes
effluent should be warmed (promote blood flow, cool can cause vasoconstriction)
if all the fluid does not come out, turn from side to side
effluent should come out clear in appearance & drain by gravity
injury to frontal lobe may cause:
*motor control, ability to speak words, memory, and judgement are all controlled by frontal lobe
impaired vision may occur with damage to:
s/s hyperglycemia (fruity breath) = what acid/base imbalance?
*result of DKA (ketoacidosis)
how can you evaluate that a client with Grave's disease and exophthalmos is adhering to the teaching plan?
absence of corneal irritation
what type of hair removal is not recommended before surgery?
shaving with a razor (causes micro-abrasions)
*use clippers or depilatory cream
when should an alcoholic go to an AA meeting?
every single day (whether they feel the need to drink or not)
client presents to ED with fever, cough, and malaise. nurse notices rash of vesicles around face, palms of hands, and soles of feet. what is the priority action?
-triage client as emergent
-place client in negative pressure room
*these are s/s of smallpox (protect others from exposure)
where does pain radiate to if the phrenic nerve is irritated?
who oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client?
what should the nurse teach a client diagnosed with Hep B to do to ensure proper nutrition?
eat several small meals a day (largest at breakfast)
*patient may be anorexic (gets worse throughout the day)
what is often the first s/s of acute pulmonary edema
*often caused by IV fluid overload
anxiety / restlessness
what type of medication is tranylcypromine?
what type of foods should clients avoid when taking an MAOI?
cured meats, pickled/ fermented/ smoked foods
*cause hypertensive crisis
client education with nitroglycerin SL:
-do not swallow
-keep in a dark, dry place
-medication may burn when taken
-sit or lie down when taking (hypotension may occur)
-headache is most common side effect
s/s infection with a burn:
is bleeding a s/s of infection?
s/s left sided CHF:
s/s of right sided CHF:
hepatomegaly (venous stasis in liver)
anorexia (venous engorgement in abdominal organs)
client presents to ED with vomiting for 3 days. what imbalances should you expect?
hypokalemia / hypomagnesemia
first thing to do if a client with DM reports "numb feet"
assess client's feet for signs of injury
what interventions should the nurse initiate for a client post-liver biopsy?
apply direct pressure immediately after needle is removed
assess puncture site every 15 mins for 1 hour
advice client that right shoulder pain may occur after anesthetic wears off
anyone with a liver biopsy is at a high risk for:
normal CVP reading
CVP below 2=
fluid volume deficit
CVP > 6 =
fluid volume excess/ overload
Nadolol is prescribed to a patient with stable angina. what are expected outcomes?
relief of chest pain
*bradycardia would be an adverse effect
client was exposed to inhaled anthrax. what assessment findings are expected?
abrupt onset of dyspnea and fever
S/S of cutaneous anthrax
manifests as papules resembling an insect bite --> progresses to depressed black (necrotic) ulcers
client is taking an NSAID. what lab value alerts the nurse of a GI bleed, chronically losing small amounts of blood?
elevated reticulocyte count (indicates increased production of RBC's)
paradoxical chest wall movement =
client with esophageal varices has a Blakemore tube in place. what should you have at the bedside?
*if balloon gets dislodged and occludes airway, balloon must be cut
client education for amitriptyline:
wear long sleeves and hat when outside
*tricyclic antidepressants make the client sensitive to sunburn
what statement is MOST indicative of a gallbladder disease?
"when i ate a hamburger and fries, my stomach really hurt"
*gallbladder aids in digestion of fat
what medication is MOST commonly associated with GI upset and constipation?
*can be decreased if the med is taken with food
when client stops talking about suicide, what does it mean?
what test result should you check before administering etanercept, a tumor necrosis factor?
TB skin test
*the immunosuppression can reactivate latent TB
child admitted with suspected pyloric stenosis would have what lab value??
hematocrit of 57%
*concentrated blood would indicate dehydration from the vomiting
*pH would be > 7.45 (metabolic alkalosis from vomiting)
you should notify the HCP for a chest tube drainage amount of:
> 100 in first hour
Burn dressing technique
medicate client with pain meds
wash hands and apply clean gloves
set up sterile field and open packages
remove old dressing and discard
wash hands and apply sterile gloves
clean burn and place sterile dressign
What should you do to decrease risk of pesticide ingestion?
wash with scrub brush and water
hepatitis B =
transmitted via blood!
*don't share razors or needles etc.
*wash bathrooms and kitchen areas with a bleach solution
what type of precautions does measles need?
food poisoning in chicken is probably:
how to decrease swelling in cellulitis:
warm moist compresses
*question order to apply ice packs
PPE for contact precautions
gloves and gown
PRIMARY intervention for any client in traction =
precautions for operating heavy machinery (client education)
wear heavy gloves
stand with feet apart
wear unbreakable goggles
wear closed toe shoes (steel toe boots not necessary)
use ear covers and plugs
wear tight fitting clothing; nothing loose
what indicates that a 3 way irrigation catheter is going too fast after a TURP?
*urine is regulated so it is free of cloths and slightly pink (clear means its not getting rid of clots effectively)
what would indicate that the nurse needs to INCREASE the rate of a 3 way irrigation catheter?
client education: transsphenoidal hypophysectomy
avoid drinking from straw
HOB at 30 degrees
after surgery, UO will be monitored
use a sponge when going oral care (incision is just above the gumline)
what indicates infection with a cast
S&S of cholinergic crisis
increased salivation, lacrimation, and urinary output
what food type is not a good option for a client with dysphagia?
*too bland and thin, hard to swallow (thicken liquids)
*use ice to stimulate swallowing
how to do ostomy care
remove ostomy bag & old flange
wash stoma with warm soapy water
apply skin protectant and allow drying
cut center of new flange to fit stoma
place stoma adhesive onto new flange
press flange into place and attach bag
*burp bag & clam end securely (dont want stool to leak)
# 1 thing for the nurse to do in the acute phase of SLE:
monitor intake and output and daily weights
when is the tensilon test done?
if the HCP suspects myasthenia gravis
what is it? client will be asked to perform a repetitive movement to test their muscles
ventilation perfusion scans would be used for?
what should you do if a patient receiving feedings reports nausea & has 200mL of residual?
give the residual back and stop the feeding (re-asses in 1 hour)
*do not slow the feeding rate, not in your scope of practice! it's a prescription.
diet for a patient with CF:
high calorie, high fat
cheyne stokes respirations =
heparin = what lab value?
aPTT normal range
60-80 on heparin therapy
normal platelet range
below 150,000 = bleeding precautions!
what action CANNOT be initiated by a nurse?
administering prescriptions as prescribed
*DEPENDENT action; depends on primary HCP's actions first.
what is your FIRST action if you suspect cardiogenic shock?
*Post CABG, decreased BP, increased HR & RR. Decreased UO =
administer 100% oxygen via mask
after ROM, fetal heart rate has sharp decreases with speedy recovery between contractions.
what is the priority action of the RN?
place client in the knee to chest position
*variable decels, sign of prolapsed cord! release pressur!
s/s associated with bulemia nervosa?
muscle cramps, tingling of lips, constipation
what is a good position for clients with lower limb amputation patients?
lay prone several times a day
*avoid sitting in a chair for ? 1 hour
(prevent hip flexion contractures)
Limb care (post-amputation)
clean limb daily with soap and warm water
inspect for s/s infection (redness) and areas of skin breakdown
keep limp socks, wraps, and prostheses clean and dry
perform daily ROM exercises
what should you dot put on a stump?
potential irritants (alcohol, lotion, powders)
if WBC and glucose are elevated in a client with MRSA & patient is on Vanc, what needs to be done?
nothing; hyperglycemia and increased WBC counts are an expected finding in a client with an infection
*do NOT need to notify provider before administering drug
death rattle can be treated with:
*anticholinergic medication to dry up secretions!
where is pain during cholecystitis?
RUQ & referred pain to right shoulder/scapula
what type of food triggers cholelithiasis & cholecystitis?
when should clients taking ferrous sulfate have dairy?
1 hour before or 2 hours after taking iron
what type of vomit is a s/s of emergency in a newborn?
green vomit (stomach bile; indicates an obstruction)
*okay to see minimal blood
*common to vomit through nose
Reye syndrome =
aspirin + virus (like influenza)
what to monitor for clozapine?
CBC and absolute neutrophil count
*risk for agranulocytosis
ages for parallel play
ages for cooperative play (build a castle together)
what age are children playing together by borrowing blocks from eachother without directing others
ages 3-6 (preschool)
where should a cane be measured from on a client?
*waist is too high
immunosuppressant used to treat RA (chemo type drug, causes infection, anemia, and thrombocytopenia)
*educate about high risk of infection!! most important!
what is a common therapeutic procedure post-MI if the client stays comatose?
induction of therapeutic hypothermia
FIRST thing to do if a client reports s/s of DVT:
complete neurovascular assessment on lower extremities
what should you decrease in PV (polycythermia vera)?
*already have too many RBCs / hemoglobin production
a newborn who was born following maternal diabetes with poorly controlled blood sugar will probably have:
elevated hematocrit level
*hyperclycemia = increased insulin = increased oxygen consumption = increased RBCS! (hematocrit)
a baby with a shrill cry and frequent yawning is most likely experiencing:
neonatal abstinence syndrome
*maternal drug use
what feature is a characteristic of fetal alcohol syndrome
smooth philthrum, thin upper lip, and palpebral fissures
most important vital to monitor in a child with glomerulonephritis:
*severe HTN can do more damage than fluid overload in this child
what should you do before giving a client with an NG tube phenytoin?
stop the tube feeding for 1-2 hours
*may contain antacids or calcium that can interfere with the drug
are microwaves safe to use with a pacemaker?
*avoid security at airports & MRI's
leading 2 STI's of PID and infertility:
gonorrhea and chlamydia
client with low BP, low HR, decreased respirations and decreased O2 rate:
exhibiting s/s of hypothyroidism (myxedema coma)
*priority: prepare for intubation!!
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