88 terms


Total Review (step test, entrance test to RN)
How to detect female cancers using Breast Self Examinations
A BSE should not be conducted around the same time of menstrual cycle.
*lay flat on back, using opposite hand to breast with arm raised, use 3 middle fingers in circular motion.
Cerebrovascular Accident; caring for a client who has dysphagia
CVA-opp side is affected. (Ex. Right sided CVA, mean left is affected, so would eat on right side of mouth)
*client needs thickened liquids, sitting upright, eat soft or semi-soft foods, have tv off so won't distract and aspirate
Expected lab value changes with lipitor:
A normal Bilirubin is (0.2-1.2 mg/dl). A slight increase in Bilirubin is expected when taking lipitor.
A liver function test will be ordered, and cholesterol q 3-6 months. LDL level should be below 130mg/dl
Heart Failure: Understanding medication Self Administration
monitor serum potassium level, DECREASED potassium levels increases digoxin toxicity.
*Cardiotonic drugs affect the intracellular calcium levels in the heart= increased cardiac output, renal blood flow, and urine formation. Neg side affect is bradycardia.. MONITOR apical pulse
Postoperative Nursing: Recognizing development of deep vein thrombosis
monitor for soreness or pain when standing or walking, calf tenderness, and skin warmth.
*use compression stockings or foot pump
*give low dose of warfarin
Instructions when giving a client nitro
Store meds in a dark container
*place tablet under tongue
*burning sensation indicates tablet is fresh
*position supine with elevated legs to manage hypotension
Cataracts: Postoperative discharge teaching
*wear eye shield at all times for at least 1-2 weeks
*wash eyelid with cotton pad and warm water, sleep on unoperative side
*do not put head below waist 2-3 days, do not get constipated
* some mucos and tears is normal, some irritation and scratchyness is normal
Immobilizing Interventions: Observing Bucks Extension Traction
*Inspect the skin of the limb in traction (beneath velcro boot) at least once q 8hrs for irritation and inflamation
*Do NOT release the weights of the traction
*No pin care required
*If burning sensation present in foot= NOTIFY PHYSICIAN
Immobilizing Interventions: prioritizing care for a client with a long arm cast
*use sling for arm/cast support,
*keep arm raised above heart for first 48hrs
*raise arm over head throughout day to prevent shoulder stiffness
*monitor skin color and warmth of skin, keep dry and move fingers frenquently
Diabetic Ketoacidosis Causes (severe bloodsugar elevation)
*occurs when not enough circulating insulin
*body forced to breakdown body fats for energy=build up of ketones. This bulild up of ketones turnes blood acidotic= coma/death
*s/s - fatigue, frequent urination, increased thirst, fruity breath, nausea, vomiting, rapid breathing, muscle stiffness
Head Injury: Providing Care for a client with Increased Intracranial Pressure
- monitor v/s closely, accurately and periodically
-maintain airway, if client is not intubated place client on side to decrease possibility of airway occulusion
-watch for coughing when suctioning=can create seizure activity
-administer medications(corticosteroids, dilantin, antibiotics)
_Restrict fluids, and elevate bed to 30 degrees
-maintain normal body temperature
Tuberculosis: Recognizing signs and symptoms
Early sign= slight cough with expectoration of mucus, fever, night sweats
Late sign= bloody productive cough, chest pain, dyspnea, weight loss
Electrolyte Imbalances: Expected findings
low- irrigular heartbeat, confusion, B/P changes, nervous system or bone disorders

high- weakness or twitching of muscles, numbness, fatigue, irregular heartbeat, B/P changes
normal calcium range
4.5-5.5 mEq/l
normal range for potassium
3.5-5.3 mEq/L
normal magnesium range
normal Sodium range
Fluid Imbalances: Recognizing fluid volume Deficit
primarily fluid deficit= (hypertonic)more water than salt is being lost( diuretic use, infections, fever, diabetes inspidus)
*Primarily sodium deficit( hypotonic)= more salt than water is being lost ( diuretics, or salt-wasting renal disease
*combined 50-50= isotonic, (diuretics, prolonged diarrhea or vomiting
Priortizing care for a client experiencing anaphylatic shock
1. if faintness- lie pt. down, if difficult breathing or swelling in throat, keep pt sitting up.
2. Ensure pt does not choke or vomit, so place client in recovery position.
3.get help promptly
4.shot of adrenaline into muscle side of thigh
5.Intravenous fluids given
6. 6-12 hrs observation
Reinforcing Teaching for External Radiation Therapy:
*obtain inform consent
*inform client not to scrub areas of body marked with ink, so treatment can be applied to same area
*high protein, high carb, low-residue diet
*avoid heat pads, skin creams, keep skin dry, wear loose clothing
*administer antidiarrheal medication (for pelvic radiation)
Fractures: Preventing complications while in skeletal Traction:
*provide pin care, keep crusting around pins to a minimum to prevent infection and unnecessary pulling of skin.( Osteomyelitis most serious complication associated)
*Keep hydrated, follow plan to prevent constipation
*ROM to unaffected extremities, breathing excercises
Iron Deficiency Anemia: Foods that aid in Iron Absorption:
*VITAMIN C aids in absorption- take at meal time with iron enriched foods. (Vitamin C = citrus fruits, strawberries, green leafy veges, bell peppers, califlower)
*AVOID calcium supplements, black or green tea, or coffee
*+++ oysters, prune juice, walnuts, chickpeas, beans, peanuts, lentils, peas+++
Sources of Nutrition: Expected findings in a school age child with vitamin C deficiency:
*Edema, bronchial infections, fatigue, weakness, swollen/bleeding gums, nosebleeds, spontaneous pinpoint hemorrhages can be observed
*stops healing of bone fractures, anemia
Diabetes Mellitus: Reinforce teaching to a school age child:
*most common type I insulin dependent
*a multidose basal-bolus insulin program works well for most= glougine at HS, paired with aspart insulin and using insulin algorithms as a guide for insulin food-activity decisions 4-5x a day.
*frequent BG monitors
Meningitis: Expected findings: (Brainspine Infection)
s/s fever, chills, confusion, nausea, vomiting, sensitivity to light, often SEVERE HEADACHE, stiff neck, may have infection in blood, nose, or ear.
*monitor for DEHYDRATION, maintain dim lighting and assist with ADL'S
cognitive Disorders: Assisting a client who has dementia
*orient client to familiar or pleasurable activities
*precautions for safety measures, wandering, eliminate hazards
*monitor I&O, weight regularly
*nonverbal communication increases, verbal decreases
*communication should include social and historical events from earlier yrs of client's life, using repetition
post op client of pneumonectomy, what adverse finding indicates acute pulmonary edema?
Frothy sputum, dyspnea, cough, crakles, and possibly cynosis
What is nageles Rule to determine expected due date?
1st day of last period, than subtract 3 months, and than add 7 days, than add 1 year
Medications for Rheumatoid Arthritis: Findings to report while taking prednisone (Deltasone)
Risk for osteoporosis, Insomnia, vertigo, adrenal suppression, delayed wound healing
Monamine Oxidase Inhibitors: Adverse Effects of Phenelzine (Nardil)
Orthostatic hypotension, dizziness, HA, fatigue, tremors, weakness, dry mouth, weight gain, constipation
Chemotherapy Agents: Interactions with Tamoxifen (Nolvadex)
Fluoxetine=Don't use warfarin, halperidol, benadryl, bupropion, sertaline, carbamazepine
Oral Hpoglycemics: reinforcing teaching for a client taking Glyburide
monitor when taking aspirin, IBU, tums, & cinnamon
*watch for heartburn, hypoglycemia, nausea, contraindicated for clients with sulfa allergy, type I diabetes, DKA
Organic Nitrates: Proper use of Nitroglycerin (Nitro-Bid) skin Patch
monitor for othostatic hypotension, apply to area with few hairs, and do not apply near the area for defibrillation to avoid skin burns.
*applied once a day, in am, sites rotated
*HEADACHE is most common side affect
Neuromuscular Blocking Agents: Effects of Atropine
Ataxia, coma, confusion, dizziness, HA, headache, insomnia, tachycardia, hypotension, pulmonary edema, delayed gastric emptying
radiation for prostate cancer
proper skin care includes COLD PACKS
Intracavitary radiation for cancer of the cervix, what is # 1 risk
postpartum client has developed thrombophlebitis, what should nurse do?
*place patient in trendelenburgs position.
* To prevent thrombophlebitis, get client ambulating early!!
A client is prepared to receive elective cardioversion to treat atrial fibrillation
*Remove all oxygen from client to prevent fire/combustion
Substance Abuse: Use of Support Groups
*active participation= better chance of maintaining abstinence, first step is formal treatment, than mutual support groups
Suicide :Theraputic Response:
*1st response identify clients psychosocial assessment (an accurate assessment so that the client's psychological and emotional needs are identified)
*gain trust and permission from client, use a welcoming environment, make yourself completely tuned into the client
*assess events leading up to suicidal thoughts
*establish a human to human connection, non judgemental
Bipolar disorder: understanding the disease:
*Mania stage= irrational behavior, racing thoughts, acting extremely irresponsible, or participating in dangerous activities
*flucuates between mania stage and depressed stage.
*starts between ages 15-24, therapy revolves around solving the relationship between thoughts, behaviors, and emotions
ACE inhibitor
ends in "pril"
Beta Blocker
ends in "lol"
hypertension =
B/P above 140/90
Digoxin Toxicity
*DECREASED POTASSIUM levels increases digoxin toxicity.
* s/s = nausea, vomiting, anorexia, bradycardia, depression, yellow halos in visual field, hyperkalemia, photophobia, diplopia
Furosemide (lasix)
used to manage edema associated with heart failure & hepatic or renal disease to control hypertension
acts as a vasoconstrictor increasing BP and renal perfusion (urine flow)
stimulates heart after heart attack or during surgery.
Hematoma (lab signs)
elevated temp and decreased hematocrit
hypovolemia (lab signs)
increased hemtocrit and hemoglobin
thromboembolism s/s
fever, dyspnea, chest pain, cough, signs of shock
# 1 sign of surgically induced hypothyroidism
progressive weight gain
client who is immediate post gastroscopy period, what would be included in the plan of care
assess gag reflex prior to administration of fluids, due to anestetic that would been sprayed in throat prior
After billroth II surgery, the client develops dumping syndrome, what does the nurse not want the client to do?
Do not have client sit up for at least 30 min after meals
*Sitting upright will produce or promote dumping syndrome. Client needs to lie down after meals.
What instructions should a client be given before undergoing a paracentesis?
Client must empty bladder prior to procedure.
why use a protein restricted diet for advanced liver disease?
The liver can not rid the body of ammonia that is made by the breakdown of protein. A protein restricted diet will therefore decrease ammonia production.
What is considered adequate urinary output for perfusion of kidney, heart, and brain?
A rate of 30ml/hr is considered adequate.
client is diagnosed with Graves disease, why does client need to take propanolol (Inderal)
propanolol blocks the cardiovascular symptoms of graves disease
Eating Disorders : Understanding Bulemia:
s/s Repeatedly eating large amounts of food in a short amount of time
-purging, fasting, exercising to much, misusing laxatives, diuretics, &enemas
-feeling ashamed of how much your eating, hides food, does not eat around others, irregular menstrual cycles
*low levels of potassium, dry skin, tooth decay, mouth sores, bloating, BUT= stay with in normal weight range
Nursing Care of Newborn: Safety precautions
*main focus- monitor VS, keep baby warm
-baby's respirations may not stabilize for about 2hrs after birth, at this point its abnormal for respiratory rate to be greater than 60 breaths per min.
-leave kelly clamp on till after plastic umbilical cord clamp has been applied
-remove secretions from mouth& nose with gloved finger or sm. syringe
Meeting the nutritional needs of newborns: Formula feeding
-once removed from fridge, needs to be used or thrown with in 2hrs.
-once feeding occurs, any remaining formula should be tossed 1hr after start of feeding.
-Do not put in fridge or heat up to reuse
Newborn Assessment:Head
-general apperance, facial bruising is caused by birth trauma and should be noted.
-norm shape- flattened over forhead, raises to a point
-norm circumference- between 33& 38 cm
-Fontanelle size- the posterior fontanelle can be already closed at birth= NOT ABNORMAL, should feel soft yet spongy
-sunken fontanelle= dehydration
-over riding suture lines is a normal finding
-widely spaced suture lines=RED FLAG
reason for vitamin K IM to be given to newborn at birth
to prevent hemorrhagic disorders
Care of newborn: Purpose of prophylactic eye care:
-purpose fights against gonorrhea conjunctivitis or opthalmia neonatorum, which can be passed through the vaginal canal through delivery.
-Its applied over lower lids of both eyes, than manipulate eyelids to spread medication over eyes
-silver nitrate or erythromycin (most popular) are used
Assessment & management of Newborn complications: Hyperbilirubinemia:
-Jaundice (yellow discoloration of skin, whites of the eyes) first in the face.
s/s- hard to wake up infant, shrill cry, irritable, arches neck or body backwards
-treatment= phototherapy & encourage feeding
newborn abnormal cries at birth
-high pitch cry= abnormal
-to stimulate a cry- rub soles of feet. Trendelenburg or side laying position
mood stabilizers: Reinforcing Teaching about Taking Lithium Carbonate (Eskalith)
-antimania drug used to treat schizoaffective disorder
-increase risk of seizure
-amount of salt in body influences the effects of medicine, this can increase salt loss from body
-drink lots of fluids, avoid caffeine, don't get overheated
-take after meals, No to low salt diet
-#1 side affect= blurred vision confusion
Cystic Fibrosis: Reinforcing Teaching about pancrelipase (pancrease)
its a combination of lipase, amylase, and protease, which are enzymes needed for digestion of fats, carbohydrates and proteins. these are normally produced in pancreas, but people with cystic fibrosis do not excrete them. Pancrelipase products are made from enzymes taken from pigs.
-take before meals, and not if allergic to pork, never crush or chew or store in fridge
Methylzanthines: Adverse Effects of Theophylline (Theo-Dur)
-Methylxanthines are known to stimulate peptic acid secretion
-caution in patients with active peptic ulcerdisease.
-cautiously in patients with impaired renal function
-Severe Potential Hazard= Seizures, Head Injury, Cerebral Vascular Disorder,Gastroesophageal Reflux Disease,
-Theophylline is removed by hemodialysis, so don't give to dialysis pt
-Toxicity is most likely to occur when levels exceed 20 mcg/mL.
Client Rights: Refusing Treatment
arguement among family, or doubt on healthcare team, treatment must be given until case is resolved in court.
-Only time a person does not have right to make decision to refuse treatment is when greater public interest would be in danger
Abdomen: Auscultating Bowel sounds
-dilates with gas and fluid, the bowel sounds become high pitched
-Vascular bruits are the audible manifestation of turbulent blood flow( organ moves against the serosal surface), swishing sounds
-rubs are the result of inflamed peritoneal surfaces grating on each other during respiration.(usually rare, but found norm over the liver or spleen)
-absence of bowel sounds indicators of intra-abdominal infection
Ergonomic Principles: Reinforcing Teaching about the use of a Standartized Walker
-check for correct height. Have client stand inside of walker with arms at their sides. Walker handles should be even with client's wrists
-used with client's that have unilateral or bilateral weakness or an inability to bear weight on one leg
-it requires arm strength and balance
Immobilizing Interventions:Findings to Report with a client in traction
Provide care to client in traction (check the weights are hanging freely, observe skin for irritation and site of skeletal traction insertion for signs of infection; use aseptic technique when cleaning the site of insertion)
Gastroenteral Feedings: Inserting an NG tube
passed through the nares (nostril), down the esophagus and into the stomach. This type of feeding tube is generally used for short term feeding, usually only 2 weeks maximum
-prior to feeding assess the bowel sounds and residual content
-Check tube placement= Introduce 5-20ml of air into tube & auscultate to hear gurgling. Aspirate gastric content, immerse tip of tube into water, no bubbles must be produced.
-Height of feeding =12 in. above pt point of insertion
-position fowlers or sitting
Care of the older Adult Client: Temperature changes
-Diminished ability to sense temp changes may occur with aging, check water w/ wrist before immursing older adults in it.
-older adults don't bathe as frequent due to diminished perspiration
-normal temp for elderly 36 deg.c
(normal temp of young adult would be possibly a fever to an elderly adult
Hypertension: Adverse Effects of Captopril (Capoten)
- captopril is an ACE inhibitor used for the treatment of hypertension
-cough being the most common ADR(due to elevated levels of bradykinin)
-rash and taste disturbances (metallic or loss of taste)
-short half-life necessitates 2-3 times daily dosing
-postural hypotension ,Hyperkalemia
Diabetic Ketoacidosis: Discharge Teaching
-Signs and symptoms may include fast, deep breathing, increased urination, fruity-smelling breath, or weakness and confusion. The high sugar level, ketones, and acid can cause you to become very sick. High sugar levels also can lead to dehydration (loss of body fluids and salts)
Hemodialysis and Peritoneal Dialysis: Monitoring for complications
-hemo= monitor for hemmorraging, hepatitis, air embolism, sepis, muscle cramps.
- peritoneal= monitor for fever, abdl tenderness, n&v, peritonitis (cloudy outflow,bleeding)
-Also with peritoneal, increase fiber to prevent constipation, and weigh before and after
Tracheostomy Care
-tie new trache tie before removing old tie to prevent accidental dislodgment
-use precut guaze
-soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well
cerebrovascular accident: priority Interventions
-A CT scan will determine if the client is having a stroke(hemorrhagic or ischemic accident)
-if a stroke was determined to be hemorrhagic, rt-PA is contraindicated
-The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours
-Controlling the blood pressure is critical, why= intracerebral hemorrhage is the major adverse effect of thrombolytic therapy.
- crucial to monitor pupil size & pupillary response to indicate changes around the cranial nerves
vascular Access: Treating IV infiltration
-infusing fluids stopped immediately and the cannula removed.
-elevating the edematous limb or at least making sure the site is non-dependent and no pressure is applied
-Pain control measures may be appropriate
Leukemia:providing oral Hygiene
-The mouth is especially affected because its cells are replaced at a high rate. Chemotherapy and radiation therapy affect the ability of cells to divide - which creates big problems for the normal tissue repair process in the mouth.
-Oral mucositis may appear from 4 to 7 days after the initiation of chemotherapy
-Fungal (candida) infections of the oral mucosa
-spontaneous oral bleeding when the platelet count goes below 20,000
-hypomature enamel.
Sickle Cell Anemia:Preventing a sickle Cell Crisis
A sickle cell crisis happens when sickled red blood cells block small blood vessels that carry blood to your bones. This causes pain that can begin suddenly and last several hours to several days.
Normal Physiological changes of pregnancy:Pyrosis
pyrosis=heartburn, experienced in mid to late part of pregnancy
Nutrition for infants: introducing solid foods
-should start at about 6months,some start as early as 4months
renal disorders: Managing Elevated Phosphorus levels
The kidneys help regulate the level of phosphorus in your blood. If your kidney function is impaired, eventually you'll likely have elevated phosphorus levels (hyperphosphatemia). In turn, the elevated phosphorus decreases the level of calcium in your blood, which can lead to bone disease.
Sources of nutrition: Sodium-Restricted Diet
Aim for ~600mg Na/meal and 200mgNa/Bedtime Snack
Sodium may need to be restricted in the diet for a variety of reasons including congestive heart failure, high blood pressure, and diseases associated with fluid imbalance like kidney and liver diseases
Sources of nutrition:managing potassium level
Most of the extra potassium eaten in the diet is removed by the kidneys
-healthy kidneys take in at least 4.7 grams of potassium each day.
-kidney disease (not on dialysis) take in 2 to 4 grams of potassium per day
-SAFE range of blood potassium levels is 3.5-5.0 mEq/L.