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Nclex review Blue book
Terms in this set (2000)
Name the five/six essential nutrients
carbs, fats, proteins, vitamins, minerals, water
The major source of energy for the body is
carbs provide ____________ Kcalories per 1 gram
Sucrose is a sugar found in ____________ and _____________.
Lactose is a sugar found in ?
What is glycogen?
It is a stored formed of glucose/energy manufactured by the liver
Is glycogen eaten in foods?
NO! It is a stored form of glucose MANUFACTURED by the liver.
When the body does not receive enough carbs it burns ___________ and _____________.
The most concentrated source of energy for the body is ___________.
Fats provide ___________ Kcalories per 1 gram.
Fats carry vitamins
A,D,E,K (Remember FADE K!)
The nutrient needed most for growth and repair of tissues is _____________.
protein (second best is Vit C)
Proteins provide __________ Kcalories per 1 gram.
Vitamins and minerals provide energy for the body. (T/F)
False- they are necessary for a body's chemical reactions.
Water is present in ALL body tissues. (T/F)
True (even bone)
Water accounts for ________ to ___________% of an adult's total weight?
50 to 60%
Name the four basic food groups
Milk & Cheese, Meat & Legumes, Veggies & Fruits, Bread & Cereal
Water acounts for __________ to _________% of an infant's total weight?
70 to 75%
An individual is overweight if they are ________% above the ideal weight.
An individual is obese if they weigh ________% above the ideal weight.
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?
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 _____________.
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.
Will the patient be able to close their eye on the affected side?
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 ________.
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
In BPH the force of the urinary stream is (increased/decreased).
The man with BPH has a _________-stream of urine
The man with BPH has hesitancey. What does this mean?
Difficulty starting to void
Will the man with BPH have enuresis, nocturia or hematuria?
Enuresis-No, Nocturia-Yes, and Hematuria-Maybe
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?
What does TURP stand for?
Transurethral resection of the prostate
The most radical prostate surgery is the ____________ prostatectomy.
What type of diet is used in BPH?
Acid Ash diet
Decrease pH (makes urine acid)
Chz, eggs, Meat, fish, oysters, poultry, Bread, Cereal, Whole Grains, Pastries, Cranberries, Prunes, Plums, Tomatoes, Peas, Corn, Legumes.
What is the primary purpose of a 3 way continuous bladder irrigation (CBI) after TURP?
To keep the catheter clear of clots and to drain urine
What solution is used for CBI?
Normal saline (0.9 NaCl)
How fast do you run the CBI?
At whatever rate it takes to keep the urine flowing and free of clots
What drug is use to treat bladder spasm?
B&O suppositories (Belladonna & Opiates)
Should you take a rectal temp after prostatectomy? Give stool softeners?
No rectal temperatures, yes stool softeners
You should call the MD after TURP when you see _________ thick ________, _____________ clots, and ____________ urine drainage on the dressing.
Bright thick blood, persistent clots, persistent urine on dressing (don't call MD for transitory clots and urine on dressing.)
If you see an increase in blood content of urine coming out of the catheter, you would first ___________.
Pull carefully on the catheter to apply local pressure on the prostate with the Foley balloon.
If you see clots in the tubing you would first ____________.
Increase the flow-rate.
What exercises should the post prostectomy patient do upon discharge? Why?
Perineal exercises, start and stop stream of urine, because dribbling is a common but temporary problem post op
Will the post prostectomy patient be impotent?
If TURP, no impotence, if perineal prostatectomy, yes impotence
How often should the drainage bag be emptied?
Every 8 hours
What is the most common problem due to catheterization?
What is the most common organism to cause UTI with catheterization?
What is the most common route for organisms to enter the blader when a catheterization is used?
Up through the inside of the catheter in the days following catheterization
Name foods that make acid urine
Cranberry juice, apple juice (avoid citrus juices- they make alkaline urine)
What is important about the level of the urinary drainage bag?
Never have the bag at a higher level than the bladder.
How is the catheter taped in a male client?
To the lateral thigh or abdomen
How is the catheter taped in a female client?
To the upper thigh
What urinary pH prevents UTI?
Acidity, low pH
Should the drainage bag ever touch the floor?
Is it ok to routinely irrigate indwelling catheters?
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?
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.
Which artery is most commonly used to measure blood pressure?
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.
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.
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?
Abnromally high blood pressure is called____________.
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?
Vasoconstriction will ___________ blood pressure.
Vasodilation will ____________ blood pressure.
Shock will ___________ blood pressure.
Increased intracranial pressure will _________ the pulse pressure.
Increase or Widen
If my blood pressure is 190/110, what is my pulse pressure?
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?
With what solution should blood be transfused?
0.9 normal saline
How many nurses are requried to check the blood?
What happens when blood is administered with Dextrose IVs?
The cells clump together & don't flow well
If a transfusion reaction occurs what should the nurse do first?
Stop the blood flow & start running the saline
How long can a unit of blood be on the unit before it must be started?
Less than 1/2 hour
What should the nurse do with the IV line if transfusion reaction is suspected?
Keep it open with saline
If a transfusion reaction is suspected, what two samples are collected and sent to the lab?
Urine & blood
If a unit of blood is infused through a central line it must be__________.
Which of the following are signs of transfusion reaction? Bradycardia, Fever, Hives, Wheezing,
Increased Blood Pressure, Low Back Pain
Low back pain, wheezing, fever, hives
What are three types of transfusion reactions that can occur?
Hemolytic, febrile, allergic
What would you do first if you suspected transfusion reaction?
Stop the blood and start the saline
What are the signs and symptoms of a hemolytic transfusion reaction?
Shivering, HA, low back pain, increased pulse & respirations, decreasing BP, oliguria, hematuria
What are the signs and symptoms of a febrile transfusion reaction?
Low back pain, shaking HA, increasing temperature, confusion, hemoptysis
What are the signs of symptoms of an allergic reaction to a transfusion?
Hives- uticaria, wheezing, pruritus, joint pain, (arthralgia)
Give three reasons for a blood transfusion
Restore blood volume secondary to hemorrhage, maintain hemoglobin in anemia, replace specific blood components
What does blood-typing mean?
Check for surface antigen on the red blood cell
When does typing and cross matching need to be done?
Whenever a client is to get a blood product. It is only good for 24 hours.
What does blood cross matching mean?
Mixing a little of the client's blood with the donor blood and looking for agglutination.
When are hemolytic transfusion reactions likely to occur?
In the first 10 to 15 minutes
When is a febrile reaction likely to occur?
Within 30 minutes of beginning the transfusion
What test identifies Rh factor?
Coombs test detects antibodies to Rh
What is the difference between whole blood and packed cells?
Packed cells don't have nearly as much plasma or volume as whole blood does
What would you do if the client had an increasing temperature and was to get blood?
Call the MD because blood is often held with an elevated temperature
How long should it take for one unit of blood to infuse?
From one hour to three hours
How long should you stay with the patient after beginning a transfusion?
At least 15 to 30 minutes
What blood type is the universal recipient?
What blood type is the universal donor?
What is the routine for vital sign measurement with a transfusion?
Once before administration
Q15 x 2 after administration is begun
Q1 x1 after transfusion has stopped
What IV solution is hung with a blood transfusion?
0.9 normal saline (No glucose)
What gauge needle is used with a blood transfusion?
Large gauge, 18 gauge
What other things are appropriate after a reaction?
Call MD, get a blood sample, get urine sample, monitor vitals, send blood to lab
Can blood be given immediately after removal from refrigeration?
No, it has to be warmed first for only about 20 to 30 minutes.
With what solution & when should a breast feeding mother cleanse the areola?
Plain water, before & after each feeding
For a woman who doesn"t have retracted nipples, is towel drying or air drying better?
Air drying of the nipples is best
The goal is for the infant to breast feed for __________ minutes per side.
How does the mother break the suction of the breast feeding infant?
She inserts her little finger into the side of the infant's mouth
When should the breast feeding infant be burped?
After feeding from each breast
Assuming no mastitis, on which side should the breastfeeding begin?
Begin nursing on the side that the baby finished on the last feeding
How long can breast milk be refrigerated?
How long can breast milk be frozen?
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?
Which two nutrients is breast milk lower in?
Fluoride and iron
What should you tell a breast feeding mother about her milk supply when she goes home from the hospital?
Milk should come in postpartum day 3. Breastrfeed every 2-3 hours to establish good milk supply.
Can a woman on oral contraceptives breastfed?
Should not use OCP during the first 6 weeks after birth because the hormones may decrease milk supply. Estrogen is not recommended. Non-hormonal methods are recommended. Remember, breastfeeding is an unreliable contraceptive.
What is another name for Buerger's disease?
Which extremities are affected by it?
Which sex does it affect the most often?
The group with the highest incidence of Buerger's disease is __________.
Upon walking the patient with Buerger's experiences _______ _________.
What is intermittent claudication?
Pain in calf upon walking
A first degree burn is pale or red?
A first degree burn has vesicles (T/F)?
A second-degree burn is pale or red?
A second-degree burn is dull or shiny?
A second-degree burn has vesicles? (T/F)
A Second degree-burn is wet or dry?
A third-degree burn is white or red?
A third-degree burn is wet or dry?
A third degre burn is hard or soft?
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_______.
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?
Name the 3 phases of burn
Shock, diuretic, recovery
Fluid moves from the___________ to the _______ in the SHOCK phase.
Bloodstream, interstitial space
The shock phase lasts for the first ________ to ________ hours after a burn.
24 to 48 hours
During shock phase of a burn is potassium increased or decreased? Why?
Increased, because of all the cells damaged- the K+ is released from damaged cells.
What acid-base disorder is seen in the shock phase of a burn?
What is the #1 therapy in the shock phase?
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?
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?
The burn patient will be on _______urine output and daily __________.
Silver nitrate cream___________ the ________.
Pain medications should be administered _______ before ________ care.
30 minutes, wound care
When using silver nitrate, the dressings must be kept __________.
What is Curlings ulcer? Why is it a problem in burn patients? What drug prevents it?
It is a stress GI ulcer, you get these with any severe physical stress. Tagamet, Zantac, Pepcid (any H2 receptor antagonist), Protonix Prilosec
In Abruptio Placenta, the placenta _______________ from the uterine wall ____________.
Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________.
Multigravida, 35 (HTN, trauma, cocaine)
How is the bleeding of Abruptio Placenta different from that in placenta previa?
usually pain; bleeding is more voluminous in previa
If you are the nurse starting the IV on the client with Abruptia Placenta, what guage needle should you use?
18 (in preparation to give blood if necessary)
How often should you measure the vital signs, vaginal bleeding, fetal heart rate during Abruptio Placenta>?
Q5-15 minutes for bleeding and maternal VS, continuous fetal monitoring, deliver at earliest sign of fetal distress
How is an infant delivered when Abruptio Placenta is present?
Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa?
In what trimester does Abruptio Placenta most commonly occur?
At what age are accidental poisonings most common?
2 years old
If a child swallows a potentially poisonous substance, what should be done first?
call medical help
Should vomiting be induced after ingestion of gasoline?
No- not for gas or any other petroleum products
When taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER?
the suspected poison
An elderly client is a (high/low) risk for accidental poisoning? What about a school age child?
high - due to poor eyesight, high
What types of chemicals cause burns to oral mucosa when ingested?
Lye, caustic cleaners
Children at highest risk for seizure activity after ingestion are those who have swallowed _____________ and ______________.
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?
What are the 3 causative factors in acne vulgaris?
Heredity, Bacterial, Hormonal
Uncleanliness is a cause of acne?
What is the most common retinoid given to people with acne?
Accutane is an analog of which vitamin?
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?
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?
How often should the client with acne wash his face each day?
twice a day
What instructions do you give to a client taking tetracycline?
Take it on an empty stomach and avoid the sunlight (photosensitivity)
What are comedones?
Blackheads and white heads
What virus causes AIDS?
HIV - Human immunodeficiency virus
The AIDS virus invades helper ____________.
T-lymphocytes (or CD4 cells)
AIDS is trasmissible through what four routs?
blood, sexual contact, breast feeding, across placenta in utero
HIV is present in all body fluids?
Yes, but not transmitted by all, only blood, semen and breast milk
Name the 5 risk groups for AIDS
Homosexual/bisexual men, IV drug users, hemophiliacs, heterosexual partners of infected people, newborn children of infected women
What is the first test for HIV antibodies?
What test confirms the ELISA?
Which test is the best indicator of the progress of HIV disease?
A CD4 count of under __________ is associated with the onset of AIDS-related symptoms.
A CD4 count of under _______ is associated with the onset of opportunistic infections.
Give 6 symptoms of HIV disease.
Anorexia, fatigue, weakness, night sweats, fever, diarrhea
Which 2 classes of drugs are given in combination for HIV sero-positivity?
NRTI's (nucleoside reverse transcriptease inhibitors) and PI's (protease inhibitors)
They prevent viral replication.
NRTI (nucleoside reverse transcriptease inhibitors)
an antiviral drug used against HIV (is incorporated into the DNA of the virus and stops the building process; results in incomplete DNA that cannot create a new virus; often used in combination with other drugs)
PI's (Protease inhibitors)
most potent of antiviral meds, inhibit cell protein synthesis that interferes with viral replication, does not cure but slows progression of AIDS and prolongs life, used prophylactically, used in AIDS to decrease viral load and opportunistic infections
What do NRTI's and PI's do?
They prevent viral replication
What does the physician hope to achieve with NRTI's and PI's for HIV?
A delayed onset of AIDS for as long as possible (usually can delay onset for 10-15 years)
What is the most common NRTI used?
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?
The typical pneumonia of AIDS is caused by ___________ ____________.
What type of oral/esophageal infections do AIDS patients get?
What is the #1 cancer that AIDS patients get?
Kaposi's sarcoma is a cancer of the ___________.
T/F: AIDS patients get lymphomas?
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
decrease in wbc, indicated viral infection
Without leukopenia the AIDS patient will be on ____________ precautions.
Standard precautions or blood and body fluid precautions
When the AIDS patient has a low platelet count, what is indicated?
bleeding precautions; No IM's, no rectal temperatures, other bleeding precautions
Does AIDS require a single room?
Yes - if WBC counts are low
When do you need a gown with AIDS?
If you are going to get contaminated with secretions
When do you need a mask with AIDS?
Not usually unless they have an infection caused by an airborne bug
When do you need goggles with AIDS?
Suctioning, central line start, arterial procedures
If an AIDS patient's blood contaminates a counter top, with what di you clean?
1:10 solution of bleach and water
Are all articles used by AIDS patients double-bagged?
no - only those contaminated with secretions
Can AIDS patients leave the floor?
Yes, unless WBC's are very low
Is dietary protein limited in AGN?
Not usually, however if there is severe azotemia then it may be restricted
nitrogenous wastes in the blood (increased creatinine, BUN)
What is the best indicator of renal function?
The serum creatinine
Do people recover from AGN?
Yes, the vast majority of all clients recover completely from it
How can AGN be prevented?
By having all sore throats cultured for strep and treating any strep infections
What is the most important intervention in treating AGN?
Bedrest - they can walk if hematuria, edema and hypertension are gone.
What is the most common dietary restriction for AGN?
Moderate sodium restriction. Fluid restriction is #2 if edema is severe.
What are the urinaysis findings on AGN?
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?
What organism causes acute glomerular nephritis?
Group A beta hemolytic strep
What happens to the kidney in AGN?
It becomes clogged with antigen-antibody complexes which then cause inflammation and loss of function.
How often are vital sign measurements taken in AGN?
Q4 hours with blood pressure
Will the client have hypo or hyper tension with AGN? Why?
Hypertension, because of fluid retention
What are the first signs of AGN?
Puffiness of face, dark urine
What are the three adult stages of development called
early adulthood, middle adulthood and later adulthood
What is the age range for early adulthood?
19 to 35 years of age
What is the age range for middle adulthood?
35 to 64 years of age
What is the age range for late adulthood?
64 years of age to death
What is the developmental task for early adulthood?
Intimacy vs. Isolation
What is the developmental task for middle adulthood?
Generativity vs. stagnation.
Intimacy vs. Isolation
Erikson's stage in which individuals form deeply personal relationships, marry, begin families
Generativity vs. Stagnation
Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service
What is the developmental task for later adulthood?
Ego Integrity vs. Despair
Ego Integrity vs. Despair
(Erikson) People in late adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be relived
"Time is too short to start another life, though I wish I could," is an example of ___________.
"If I had to do it over again, I'd life my life just about the same," is an example of ____ ____________
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 _____________
What will prevent hip flexion contracture after AKA?
Lying prone several times a day
What is the #1 contracture problem after BKA?
Flexion of the knee
How do you prevent flexion contracture of the knee after BKA?
Remide the patient to straighten their knee constantly while standing
To prevent post-op swelling, the stump should be __________.
How long should the stump be elevated to prevent post op swelling?
How often should a stump be washed?
When a stump is wrapped, the bandage should be tightest _____________ and loosest _____________.
distally (far from the center), proximally (neareast to the point)
If after a right BKA, the client c/o pain in his right tow, he is experiencing _____________.
phantom limb sensation (which is normal)
When will phantom limb sensation subside?
in a few months
Name ways to toughen a stump so it will not breakdown due to the wear of the prosthetic leg?
push the stump against the wall, hitting it with a pillow
An aneurysim is an abnormal _______________ of the wall of a(n) artery.
widening (it is also weakening)
What artery is widened in a thoracic aneurysm?
An aneurysm can result from an _____________ and from ____________.
The most common symptom of abdominal aneurysm is:
a pulsating mass above the umbilicus
Which aneurysm is most likely to have no symptoms?
the abdominal is most often "silent"
Which vital signs are most important to measure in clients with aneurysm?
The pulse and blood pressure
An aneurysm will most affect which of the following, the blood pressure or the pusle?
the pulse (many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change.
What activity order is the client with an aneurysm supposed to have?
Bedrest. do not get these people up
If the client with aneurysm is physically unstable, should you encourage turning, coughing and deep breathing?
no, bedrest until the client is stable!
What class of drugs is the client with an aneurysm most likely to be on?
What is the BIG danger with aneurysms of any type?
Rupture, leads to shock and death
If an aneurysm is ruptured how would you know it?
decreased LOC (restlessness), tachycardia, hypotension - all signs of shock
If an aneurysm ruptures what is the #1 priority?
Get them to the operating room ASAP
Is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room?
Yes, if available you can get them into antishock trousers but not if this causes a delay in getting them to the operating room
The post op thoracic aneurysm is most likely to have which type of tube?
Chest tube, because the chest was opened
The post op abdominal aneurysm repair client is most likely to have which type of tube?
NG tube for decompression of bowel
If you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hours?
check the distal extremity (far from center) for color, temperature, pain and PULSE, also MUST document
What causes angina pectoris?
Decreased blood supply to myocardium, resulting in ischemia and pain
Describe the pain of angina pectoris
crushing substernal chest pain that may radiate
What drug treates angina pectoris?
How do you tell if a client has angina or an MI?
the pain of the two is similar, the way to tell the difference is if nitro and rest relieve the pain. For angina, nitro and rest relieve the pain, for MI, nitro and rest do not relieve the pain
How many nitro tabs can you take before you call the doctor?
How many minutes should lapse between the nitro pills you take?
5 minutes - take one nitro tab every 5 minutes 3 times, if no relief, call MD
By what route do you take nitro?
What is the action of nitro?
dilates coronary arteries to increase blood supply (O2 supply) and reduces preload.
What are the top 2 side effects of nitro?
headache and hypotension
What precaution must the nurse take when administering topical nitro paste?
wear gloves, nurse may get a dose of the med
Everyone with angina needs bypass surgery? t/f
Anorexics are usually __________ under the age of _____.
The diagnosis is made when there is a weight loss of _______% or more of body weight.
15 (weigh < 85% of normal body weight), hospitalize if 30% weight loss
A major mental/emotional nursing diagnosis seen in anorexia nervosa is ___________.
Altered body image
The pulse rate of anorexics is tachycardic or bradycardic?
List the most common gynecologic symptom of anorexia nervosa?
What is found over the body of the client with anorexia nervosa?
lanugo (soft downy hair)
What is the top priority in the care of the client with anorexia nervosa?
intake of enough food to keep them alive, have them gain weight
The best goal to evaluate the progress of the client with anorexia nervosa?
an adequate weight gain
What is the apgar scale?
quick objective way to evaluate the vital functions of the newborn
When is apgar scoring performed on infants?
at one minute and again at 5 minutes after the birth
Name the 5 criteria that are recorded on an apgar scale
Cardiac status, respiratory effort, muscle tone, neuromuscular irritability, and color
The total apgar score can range from
0 to 10
The maximum score and infant can receive on any one of the criteria is
A 10 on the apgar means the baby is
in terrific health
A 0 on the apgar means the baby
On heart rate or cardiac status, a 2 means that the HR is above _______ BPM.
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 _________.
A high score of 2 is given for respiratory effort if the newborn_____________.
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 _______________.
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 ______________.
If the neonate ____________, they will score a 1 on neuromuscular irritability.
To receive a 0 on reflex (neuromuscluar) irritability the neonate must exhibit _______
To score a maximum score fo 2 on color the child must be ____________.
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
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 __________.
Apendicitis occurs most in what age group?
15 to 35
What is the most common complication of appendicitis?
inflammation of the peritoneum
What is the first sign of appendicitis?
right upper quadrant pain
What follows the RUQ abd pain of appendicitis?
Where does the pain of appendicitis finally end up?
What is the name of the RLQ abd pain where appendicitis pain finally localizes?
What is present when rebound tenderness is present?
What is the hightes that the temp will be in appendicitis?
What blood count is elevated in appendicitis?
What is the name for an elevated WBC?
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, food! NPO
To lessen pain place the client 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)
What is the primary dietary prescription for calcium nephrolithiasis?
Low calcium diet
For the client with calcium nephrolithiasis the diet should be _________ash.
If the kidney stone is calcium phosphate the diet must be low in _____ too.
The primary diet treatment for uric acid nephrolithiasis is _________ -________.
The client with uric acid nephrolithiasis should have a diet low in ___________.
What is methionine?
The precursor of the amino acid cystine (precursor = material out of which something is made)
Name two foods high in methionine.
Clients with cystine nephrolithiasis should have a (n) _________ ash diet.
Increasing fluids to over 3000 cc per day is more effective in treating renal calculi ( kidney stones) than any dietary modification. (T/F)
True. It's more important to flush the urinary tract than worry about what you're eating.
Neoplasm refers to benign and malignant tumors. (T/F)
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?
The cause of cancer is known. (T/F)
A person should have a yearly work up exam for cancer detection over the age of __________.
In general, cancer drugs have side effects in which three body systems?
What are the 3 most common chemotherapeutic GI side effects?
Stomatitis (oral sores)
Clients receiving chemotherapy must be NPO. (T/F)
Is it permissible to give lidocaine viscous ac (before meals) if the patient has chemotherapeutic stomatosis? (T/F)
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?
Name the 3 hematologic side effects of chemotherapy.
Which cells are low in thrombocytopenia?
What drug should NOT be given to the patient with chemotherapeutic thrombocytopenia?
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.
What is epitaxis?
What is ecchymosis?
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.
What is the #1 integumentary side effect of chemotherapy?
What is alopecia?
The hair loss due to chemotherapy is usually temporary? (T/F)
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.
What is the #1 cause of CD of pregnancy?
Rheumatic heart disease
Pregnancy requires a __________ increase in the cardiac output.
What is the #1 cause of maternal death in CD of pregnancy?
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?
What will you hear when you auscultate the lungs of the client with CD of pregnancy?
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?
What are the three most common drugs given to women with CD in pregnancy?
Why are diuretics given to women with CD of pregnancy?
To promote diuresis which will:
-lower circulating blood volume
-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?
Second to rest, what is very important treatment for CD of pregnancy?
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?
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?
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.
What is the big danger to staff when caring for a client with cesium implant?
What are the three principles to protect yourself from radiation hazard?
Will the woman with a cesium implant have a foley?
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
(these indicate infection and perforation)
Should pregnant staff care for a client with a cesium implant?
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.
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?
Upon what do you support a cast while it dries?
Pillows (no plastic covers)
How long does it take a cast to dry?
Should you cover a wet cast?
Should you use a heat lamp or hair dryer or fan to help dry a cast?
No heat lamp and hair dryer
What signs or symptoms would you report if they were present after cast application?
Unequal or absent pulses
If there is inflammation under a cast, it will be evident in a _______ spot.
To prevent irritation of the skin near the edges of a cast the edges should be ____________.
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?
A dry cast is dull or shiny?
A dry cast is dull or resonant to percussion?
Traction is used to _______ and _______ a fracture, relieve ________ _______ and prevent ________.
Reduce and immobilize, muscle spasm; deformities
Can skin traction be removed for skin care?
Can the client be removed from skeletal traction?
Name 3 types of skin traction
Name 3 types of skeletal traction
Thomas splints with Peason attachments
90 degrees to 90 degrees
What type of traction is most commonly used for hip fracture in adults?
What type of traction is most commonly used for hip fractures in children?
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 ____________.
When a patient is in a Buck's traction they may turn to the _________ side.
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?
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?
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?
What movements are to be avoided after cataract surgery?
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)
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?
Antibiotic drugs (gtts)
What three drugs are given post-operatively for surgical cataract removal?
Analgesics (mild to moderate)
Give five causes of catarcts?
Exposure to heat
Celiac's disease is a __________ disease
The client with celiacs cannot tolerate___________.
Gluten is a __________.
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 _____- _____.
Clients with celiac's disease do not absorb what mineral?
Clients with celiac's disease don't absorb fats; therefore they don't absorb _____ ______ ______.
Fat soluble vitamins
What are the four fat-soluble vitamins?
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?
Veggies are allowed or not allowed in diet of client with Celiac's disease?
Fruits are allowed or not allowed?
Grains of all kinds are prohibited. (T/F)
What grains are allowed in a gluten-free diet?
Rice and corn
What grains are not allowed in a gluten-free diet?
Are foods made with wheat, oat, or rye flour allowed?
Is milk allowed on a gluten-free diet?
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?
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 diet?
No, for the same reason ice cream isn't.
Which soups are not allowed on a gluten free diet?
Creamed soups- these often have flour
The #1 problem with central lines ___________
How often should central line dressings be changed?
QOD- every other day
What type of dressing is applied to a central line insertion site?
Can drugs be piggybacked into central --TPN?
No, use another lumen.
When changing central line tubing the patient should be told to_________?
Turn his head away from the site, hold breath, and perform the Valsalva maneuver
If a central line is found accidentally open the patient should be positioned on his ______ ______.
A CVA is a __________ of the brain cells due to decreased _____ _____ and ______.
Destruction; blood flow and oxygen
Women have a (higher/lower) incidence of stroke than men?
Name the three types of CVA
Use of oral contraceptives increases the risk of CVA (T/F).
Chronic abuse of alcohol increases risk of CVA. (T/F)
Obesity increases risk of CVA (T/F)
Smoking increases the risk of CVA. (T/F)
Atrial fibrillation increases the risk of CVA (T/F)
True, emboli particularly
What is a TIA?
Transient Ischemic Attack
Warning sign of impending CVA (transient neurologic deficits of any kind can last 30 seconds to 24 hours)
Do patients experiencing a CVA have a headache?
The first sign of CVA is usually a___________.
Change in LOC
The activity order in early management of CVA is __________.
Absolute Bed Rest
The patient with a recent CVA is most likely to have fluids restricted or forced?
How far should the HOB be up after CVA?
Can the stroke victim be turned side-to-side?
How often should the CVA patient be turned or repositioned?
Every 2 hours
The CVA patient should be turned onto his paralyzed side no longer than 2 hours. (T/F)
False, the patient should not be on their paralyzed side for more than 20 minutes.
ROM exercises should occur every 2 hours in CVA patients. (T/F)
False-- every 4 hours or 3 times a day is enough
To prevent urinary incontinence; the CVA patient should be catheterized. (T/F)
False- remember incontinence will never be allowed as a reason for catheterization
Which type of paralysis is typical of CVA- paraplegia, hemiplegia or quadriplegia?
What anatomical fact accounts for the left side of the body being controlled by the right brain?
The motor-pyramidal-tracts cross over to the other side (decussate in the medulla)
If the patient has right hemiplegia, he cannot move his ____ ____ and ____ ____ and the stroke was on the _________ side of the brain.
Right arm and right leg, left
What is hemianopsia?
Not being able to see one half of the field of vision.
The client with hemianopsia should be taught to ____________.
What is scanning?
Moving the head from side to side to see the whole field of vision.
If the client has right homonymous hemaniopsia, the food on the ____ side of the tray may be ignored.
After meals, the nurse must always check _______ of the CVA client for _________.
Mouth (cheek), food
Should a CVA patient have all four side rails up at all times? Should they be restrained?
Side rails yes. Restraints- no, unless they are a danger to themselves or others
When a patient does not understand INCOMING language he is said to have ______ aphasia.
When the CVA client understands your question but can't respond verbally correctly, he is said to have ___________ aphasia.
What is global aphasia?
Both receptive and expressive
Aphasia is most common if the stroke occurred in the (dominant/non-dominant) hemisphere of the brain.
How do you tell which side of the person's brain is dominant?
It is the side that controls their dominant hand, ie, a left handed person has a dominant right hemisphere and conversely a right hand person has a dominant left hemisphere
For which type of aphasia are slow, short, simple directions most useful?
For which type aphasia is careful listening and needs anticipation most useful?
The loss of the ability to perform purposeful, skilled acts, ie brushing teeth, is called __________.
Peripheral neuropathy, constipation, ototoxicity
Peripheral neuropathy (foot drop, numbness and tingling, hoarseness, jaw pain)
constipation (adynamic ileus due to neurotoxicity)
Chemo-therapeutic Agent Toxicities
Toxic to just about every organ except to heart, toxicity made worse with aspirin
The infant fears _________ most when hospitalized.
Separation from love object
The toddler fears _______ most when hospitalized.
Separation from family
The preschooler fears separation as well as _________ when hospitalized.
Mutilation- remember preschoolers have vivid imaginations...fantasy
The toddler and preschooler will think that illness is caused by_____________.
Something they did wrong.
The school-aged hospitalized child is afraid of separation from ___________.
The school-aged child perceives the cause of illness to to be external or internal?
External, she knows that illness is not a result of bad behavior.
The adolescent who is hospitalized fears separation from _________ and loss of ___________.
Preschoolers may require physical restraint during painful procedures. (T/F)
Which age group engages in stalling tactics before painful procedures most?
Which age groups are most likely to physically resist the nurse during procedures?
Toddlers may require physical restraint for painful procedures. (T/F)
The meats that are highest in cholesterol are _________ meats.
liver, heart, brains, kidneys
The meats that are second highest in cholesterol are the ___________
Shell seafood- shrimp, crab, lobster
Egg white is (high/low) in cholesterol?
Egg yolk is (high/low) in cholesterol?
The three meats lowest in cholesterol are _________, _________ and __________.
Chicken, pork, mutton
Milk is (high/low) in cholesterol.
Is cheese high in cholesterol?
Only moderate, not really that high
Which oils are high in cholesterol?
Is cholesterol a triglyceride?
Do plant foods contain any cholesterol?
No, not many
What is otitis media?
Chronic infectious/inflammatory disease of the middle ear
Is otitis a disease of the adult or child?
Usually the child
What part of the ear is involved in otitis media?
What are the 2 common subjective signs of otitis media?
Feeling of fullness in the ear
What are the 2 common objective signs of otitis media?
Drainage from ear
What commonly happens secondary to otitis media?
Perforation of the ear drum
Do all the children with otitis media need tubes in their ears?
What are the two most common medical treatments for otitis media?
Antibiotic ear drops
What is the most severe complication of otitis media?
Meningitis or mastoiditis
What is cholesteatoma?
An epidemial cyst in the ear highly associated with otitis media.
What are the restrictions to be followed when tubes are in a child's ear?
No swimming, no showering, no diving
What is cleft lip?
The lip is open to the nares
What is cleft palate?
The roof of the mouth is open to the nasopharynx.
Is it possible to have only one: cleft lip or cleft palate?
Yes, you can have one or or the other or both
When will the cleft lip be repaired?
Between 10 weeks and 6 months
When is cleft palate repaired?
Between 1 and 5 years of age
Why is cleft lip repaired early?
Feeding is easier after repair and appearance after repair is more acceptable to parents.
Describe the nipples on bottles used to feed babies with cleft lip?
Large-holed, soft nipples
The infant with cleft lip/palate needs more frequent ___________.
Children with cleft lip/palate should be fed in what position?
An almost upright position
What is the #1 complication of cleft lip/palate?
Children with cleft lip and cleft palate have long-term problems _____, _____ and _____.
In how many surgeries is cleft palate repaired?
one at 12 to 18 months
the last at 4 to 5 years
Why is final repair of the palate delayed until 4 to 5 years?
Earlier surgery would interfere with tooth development.
How are cleft lip and cleft palate primarily treated?
Is the infant restrained BEFORE repair?
No, just AFTER repair
Should children with cleft palate BEFORE surgery be allowed to cry? To breast-feed?
Yes, they can cry; may breast feed with simple cleft lip however palate interferes with feeding
AFTER repair of cleft lip is infant allowed to cry? To breast feed?
No, the infant should be held to PREVENT CRYING; the infant is not allowed to breast-feed because sucking is not good after lip repair.
After clep lip repair, what device will the baby wear?
A Logan bow
What is the purpose of a Logan Bow?
To prevent stress on the suture line
With what device will the infant be restrained?
How do you care for an infant with a Logan Bow?
Remove the gauze before feeding and cleanse after feeding with peroxide and saline.
Can cleft lip /palate babies sleep on their backs?
What position is contraindicated after cleft lip repair?
NEVER lie on their abdomen
What will be used to feed the infant after cleft lip repair?
A dropper/syringe with rubber tip to discourage sucking
What must the mother do after feeding the baby who has had cleft lip/palate repair?
Rinse the infant's/child's mouth with water
What is a colostomy?
A surgically created opening of the colon out onto the abdomen wall.
Name the 3 most common reasons for a colostomy.
What is meant by the term "temporary colostomy"?
A colostomy that is not intended to be permanent-- the bowel will be reconnected at a later date and the client will defecate normally
What is meant by the term "double barrel" colostomy?
A procedure where the colon is cut and both ends are brought out onto the abdomen.
Colostomies performed for cancer tend to be (temporary/permanent).
Colostomies performed for a gunshot are usually (temporary/permanent)
In a double-barrel colostomy, from which stoma (barrel) will the stool come out?
A fresh new stoma is _________, __________ and __________.
Red, large, noisy
When a client voices embarrassment over the noises that their colostomy makes on the first post-op day, what would you say?
The noise will go away in a few days to a week.
What behavior on the part of the client is the BEST indicator that they have accepted their stoma?
When they do their own stoma care
By what day post-op should the client begin to take care of their own stoma?
By the 3rd to 4th day, they should be looking at it and asking questions by day 2.
The MORE colon is removed the more _________ the stool.
What technique is used to remove feces and flatus from the bowel through a colostomy?
How many times per day will the client irrigate his colostomy?
Which solution is used to irrigate a colostomy?
How warm should the irrigation solution be?
Warmer than body temperature, ie, 99-100F
In what position should the client be when they irrigate their colostomy?
stool very damaging to the skin
high risk for fluid/electrolyte imbalances
typical stool odor
stool damages the skin
empties several times per day
may or may not be at risk for fluid/electrolytes imbalances
typical stool odor
stool doesn't irrigate unless diarrhea
predictable 2 to 3 times per day emptying
lowest risk for fluid/electrolyte imbalances
CHF can be right-sided, left sided or both-sided. (T/F)
True- left sided usually comes FIRST
What does right sided CHF mean?
Right ventricle has decompensated
Dependent Edema (legs and sacrum)
Jugular venous distention
Anorexia and nausea
Swelling of the fingers and hands
What does left sided CHF mean?
Left ventricle has decompensated
CHF can result from MI. (T/F)
When cardiac output fails, name three ways the heart will try to compensate.
Dilate and heart rate will increase
What is meant by "cardiac decompensation"?
It means that the compensatory mechanisms - hypertrophy, dilation, tachycardia are not working and the heart has failed.
Name the three groups of drugs used to treat CHF?
What is the activity order for clients with CHF?
What special item do clients with CHF have to wear to decrease venous stasis in the legs?
How often should anti-embolism hose (TED) be removed?
When during the day should TED hose be applied?
Before the client gets out of bed
Is it okay to use powder with TED hose?
Should you massage the calves of the client with CHF?
Before you give digitalis, what action must you take?
Measure the apical pulse
If the adult client's apical pulse is below 60, what should you do?
Do not give digitalis
For a child don't give for a pulse under 70
For an infant don't give for a pulse under 90
What daily measurement best indicates the amount of fluid the client is retaining?
Should clients with CHF have a Foley catheter?
Yes, on diuretics and fluid balance is important
What complication is common in CHF?
When the client is taking diuretics, what mineral is the CHF client most likely to lose?
You should tell the client with CHF to immediately report to his/her doctor if he/she gains _____pounds in one week.
Name the four most common toxic effects of digitalis.
N&V-- very common
Should hearing aids be removed before going for surgery?
Yes, but just before surgery
Hearing aids are more useful in sensory or conductive hearing loss?
Some women experience discomfort when wearing contact lenses during pregnancy or menstrual periods. (T/F)
Should a client sleep with the hearing aide in place?
No, a client should not sleep with a hearing aide in place.
What the two most common causes of whistling and squealing of a hearing aid?
What solution should be used to clean a hearing aid?
Soap and water
What solution is best to use if you intend to remove a client's contact lenses?
Hearing aids make sounds more distinct and clear. (T/F)
False, they only amplify--make it louder, they do not clarify
Can you use alcohol on the earmold of a hearing aid?
No, it dries and cracks it
The connecting tube of a hearing aid can be cleansed with__________.
A pipe cleaner
What is the most common complication of malpositioned lenses in the comatose or confused patient?
4 to 5 cc
Cushings syndrome is __________ secretion of _______, _______ and _______ _______ by the _______ _______.
Oversecretion; glucocorticoids, mineralocorticoids, androgenic hormones; adrenal gland
In Cushings the blood sugar is (increased/decreased).
In Cushings the sodium level is (increased/decreased)
In Cushings syndrome, the client develops __________ face.
In Cushings syndrome, the trunk is ________ and the extremities are _________.
What is seen on the abdomen of the patient with Cushings?
Striae--purple horizontal lines
Men with Cushings develop______________.
What is gynecomastia?
Women with Cushings develop?
What is hirsuitism?
Hair where you don't want it
The Cushings syndrome patient will have a _________ on their upper back.
The patient with Cushings Syndrome will have (increased/decreased) blood pressure.
Increased, remember retaining water and sodium
The Cushings syndrome patient will have ________ natremia, _________kalemia and _______glycemia.
Hyper; hypo; hyper
Cushings clients will have (increased/decreased) resistance to infection.
Chronic _____________therapy imitates Cushings.
Cushings Man aka Cush Man
moon face with infection
buffalo hump on back
keeps glucose and salt
has striations on abdomen and breasts
Is CF hereditary?
What glands are affected in CF?
What is the appearance of the stool in a client with CF?
remember the 4 Fs
What are the top 2 nursing diagnoses for a client with CF?
Decreased airway clearance Alteration in nutrition or absorption
What is the classic test for CF?
Iontophoresis - sweat test
In which two systems/organs are the most problems in CF?
How does the client evaluate the activity of their pancreas?
Observe stools for steatorrhea
What is the typical diet for CF client?
The major problem in CF is _______________.
Increased viscosity of the secretions of exocrine glands lead to obstruction.
The most common intervention for the CF client with a diagnosis of decreased airway clearance is _________________.
What vitamins need to be replaced in CF?
Fat soluble in water soluble form -- A,D,E,K
What do CF clients need to do (ingest) in hot weather?
Take NaCl tablets
The child with the diagnosis of CF probably had a history of _________ ________ at birth.
Meconium ileus-- bowel obstruction due to the thickness of the stool.
Why is the child with CF receiving pancreas/viokase/pancreatin?
They are enzymes which aid absorption of nutrients.
When should the child with CF take his pancreatin/viokase/pancreas?
With meals, so it is in the gut while the food is present, the whole purpose is to increase absorption of ingested food.
Direct visualization of the urethra and bladder through a cystoscope.
What would you do if the client had any one of the following after cystoscopy: bladder spasm, burning, frequency?
Record it but no need to call the MD
What would you do if the client's urine was pink-tinged after cystoscopy?
Record it in the notes, no need to call the MD.
Is the client NPO before cystoscopy?
No, not unless a child with a general anesthetic-- in fact with adults you should encourage fluids.
Are enemas required before cystoscopy?
No, but may be ordered.
Should you encourage fluids after cystoscopy?
Is a signed informed consent required for cystoscopy?
What vital sign changes are most ominous after cystoscopy?
A fall in the blood pressure and increase in the pulse-- increasing hemorrhage
Is the client sedated for a cystoscopy?
It is done under LOCAL anesthesia. General anesthesia may be used for a child.
What drugs are most commonly given before cystoscopy?
Valium or demerol
Increasing dietary fiber lowers the risk of ___________ of the __________.
Foods lose some or all of their fiber when they are ___________. ___________,____________ or__________.
Processed, cooked, peeled, refined
Whole grains and grain products are (high/low) in fiber.
Fruits are (high/low) in fiber.
Veggies are (high/low) in fiber.
Milk and milk products are (high/low) in fiber.
Meats are (high/low) in fiber.
Nuts, seeds, and legumes are (high/low) in fiber.
Which has highest fiber? Grains, fruits, veggies, nuts.
Grains, especially bran
When a person increases fiber in the diet they should do so____________.
Side effects of a high fiber diet include__________ and malabsorption of ____________.
Gas (flatus), minerals
Of milled bread, enriched bread, fortified bread and whole grain bread; which is highest in fiber?
What structures in the brain are most affected in Parkinson's?
The neurotransmitter imbalance that causes Parkinson's is a ______ in ______ ______.
Decrease, dopamine activity
What drugs can cause a Parkinson-like syndrome?
Haldol, major tranquilizers -- drugs that end in -azine
What is the classic motor manifestation of Parkinson's?
Pill-rolling and tremors
What type of rigidity is typical of Parkinson's?
Parkinson's patients move fast or slow?
What type of gait is seen in Parkinson's?
Shuffling slow gait
Patient's with Parkinson's have ______ speech.
Patients with Parkinson's tend to have constipation or diarrhea?
Name four drugs used to treat Parkinson's.
Levodopa, Sinement, Symmetrol, Cogentin, Artane, Parlodel
In what type of chair should Parkinson's patients sit?
What time of day can be particularly dangerous for the Parkinson's patient?
Mealtime, due to choking
When a patient is taking Levodopa he should have assistance getting out of bed because...
Of orthostatic hypotension
What vitamin should patients on Levodopa avoid?
Levodopa should be given with or without food?
What might Levodopa do to patients urine?
Make it very dark
The tremors of Parkinson's will get better or worse when they purposefully move or perform a task?
Better, they tremor more when not performing an action
The client on a PCA pump is less likely to have post-operative complications than the client without a PCA pump. (T/F)
True, because the comfortable patient moves around more and is less likely to get thrombophlebitis, pulmonary embolus, fatigue, ileus and pneumonia
Clients with COPD are not good candidates for PCA pumps. (T/F)
True, due to the effects of narcotics on central respiratory control
Name the three most common uses of PCA techniques.
Post-operative pain, cancer pain, sickle-cell crisis pain
PCA pumps allow a more constant level of serum drug than conventional analgesia. (T/F)
A major disadvantage of PCA pump is that the client can take too much medication. (T/F)
False, it is not possible for the client to overdose due to the lock-out feature
Clients on PCA pumps use more medication than those receiving IM injections. (T/F)
False, they use less
A disadvantage of PCA pumps is that the client does not ambulate as early due to the machine. (T/F)
False, PCA clients ambulate earlier and they pull their machine with them.
When discontinuing a PCA infusion it is acceptable to discard the drug cartridge. (T/F)
False, the whole cartridge system must be returned to the pharmacy due to federal narcotic control laws.
Comfort range or relative humidity is...
Which patients should be forbidden to smoke? Smoke alone?
Those with oxygen in the room, confused, sleepy, drugged clients
When applying restraints remember to...
Avoid bruising skin, cutting off circulation, accidental entangling
List ways to ensure privacy...
Use drapes and screens during care in semi-private rooms
Plastic pillow cases are ______. (disadvantages)
Hot and slippery
When using restraints with clients who object, don't forget about _____- _____.
Individuals who are ill are ________ sensitive to noise than individuals who are well.
When you are not at the bedside the bed should always be...
In the lowest position
Can nurses be held liable for an accident resulting from a client not being told how to use the call light?
Dangers associated with drafts are...
Circulation of micro-organisms on air currents
The first thing a nurse should do when a client objects to side rails is...
Explain why they are being used.
The comfort range of temperature is...
68 to 74 degrees
Is having the client verbally identify himself considered adequate safety?
No, only identification bands are acceptable.
Bed side rails should be up for the following individuals...
Elderly clients, unconscious, babies, young children, restless, confused
The symptoms of sensory overload and sensory deprivation are...
Fear, panic, depression, inability to concentrate, restlessness, agitation
If a family member asks to have the side rails down while they are in the room you should...
Remember that you are responsible for the client's safety-- not his family, it might be unwise to permit this
Pillows are sterilized between uses. (T/F)
What is the common name for pediculosis?
What is the common finding with pediculosis pubis?
Reddish-brown dust in the underwear
What common household solution is used to remove nits?
Vinegar. Nits are the eggs of lice that adhere to the hair shaft
What shampoo is used for lice?
Where are head lice most commonly found?
At the back of the head and behind the ears
On what do lice feed?
After treatment how long do you have to inspect for lice?
Inspect for 2 weeks to be sure that they are all gone
What is the most common symptom of lice?
What is the most dangerous toxicity of Kwell?
What is the typical of the lesions of pemphigus?
Foul-smelling, blisters break easily, seen in the elderly, cause unknown
What is the characteristic lesion of pemphigus?
Large vesicular bullae
What are bullae?
What chemical is added to the bath water of a client with pemphigus?
What precaution must be taken with potassium permanganate?
Be careful that no undissolved crystals touch the client; it will burn the skin
What is the typical skin care of pemphigus?
Cool wet dressing
What unusual nursing diagnosis is high priority in pemphigus?
Alteration in fluid and electrolyte balance
What are the top three nursing interventions in pemphigus?
Oral care, protection from infection, encouraging high fluid intake
What kinds of fluids will clients with pemphigus drink best?
What drugs are most commonly used?
Should steroids be given with meals?
What is the #1 cause of death in pemphigus?
An acute or chronic disease of adults, characterized by occurence of successive crops of bullae that appear suddenly or apparently normal skin and disappear, leaving pigmented spots. It may be attended by itching and burning and constitutional disturbance. The disease if untreated is usually fatal. A characteristic finding is a positive Nikolsky sign: When pressure is applied tangential to the surface of affected skin, the outer layer of epidermis will detach from the lower layer. (Probably autoimmune)
Peritoneal Dialysis (PD)
The removal of wastes, electrolytes and fluids from the body using peritoneum as dialysis membrane
When PD is being used the client must be on heparin. (T/F)
False, you do not need to be heparinized for peritoneal, but you do need to be heparinized for hemodialysis
How long does one episode/course of PD last?
Could be 10 hours
With PD there is a high/low risk of peritonitis?
When fluid accumulates in the abdomen during PD what problem does the client experience first?
Dyspnea - SOB or difficulty breathing, due to the inability of the diaphragm to descend
What nutrient is lost in highest amounts during PD?
Can a client who had recent bowel surgery get PD?
Should a client who is having breathing problems receive PD?
What body surface must be punctured to administer PD?
The solution introduced into the peritoneum during PD is called...
Before allowing the dialysate to flow into the peritoneal cavity it must be _____ to _____ temperature.
Before PD it is important the client be...
Weighed, to assess water loss or gain
What force is used to introduce the dialysate into the peritoneum?
Gravity only, no pumps
How fast does the dialysate usually flow into the peritoneum?
In 10 minutes
How long is the dialysate allowed to remain in the peritoneum before it is drained out?
How long does it usually take for the dialysate to drain out of the peritoneum?
10 minutes: (10 minutes flow in, 30 minutes in abdominal cavity, 10 minutes flow out = total of 50 minutes)
If the dialysate does not drain out well, you would first...
Have them turn side to side
What color is the dialysate when it comes out?
Straw-colored - clear
Should you raise the HOB to increase drainage of the dialysate?
How often do you measure vital signs during PD?
Every 15 minutes during the first cycle and every hour thereafter
Can a client on PD: Sit in a chair? Eat? Urinate? Defacate?
Yes to all
If too much fluid is removed during PD, the client will experience...
Decreased blood pressure (hypotension)
If the client absorbs too much of the dialysate the client will experience...
Increased blood pressure (circulatory overload)
If the client complains of dyspnea during PD you would first __________, then __________.
Slow the flow, elevate HOB
If the client complains of abdominal pain during PD you would first...
Encourage them to move about
Cloudy drainage in the dialysate commonly means...
Peritonitis (Not good, call MD)
What would you do if you noticed a small amount of blood come out in the first few bottles that were infused?
Nothing, this is normal: the blood is due to the initial puncture of the abdomen
What precautions are important in the care of the client receiving PD?
Safety, because they get dizzy.
Is I&O important to record during PD?
How high should the dialysate bag be when its infused?
What factor do clients with pernicious anemia lack?
Intrinsic factor. It has no other name.
What vitamin is not absorbed in a patient with pernicious anemia?
What is another name for Vitamin B-12?
Why isn't Vitamin B-12 absorbed in pernicious anemia?
Because these patients lack intrinsic factor
What happens when patients with pernicious anemia don't absorb Vitamin B-12?
Their RBC's do not mature and they become seriously anemic.
What other disease can be confused with pernicious anemia?
What are some classic and unique signs of pernicious anemia?
Beefy red tongue
Numbness and tingling of the hands
Sores in the mouth
What is the medical treatment for pernicious anemia?
IM injections of Vitamin B-12
How long must the client receive this medical treatment?
For the rest of life
Can we cure pernicious anemia?
No, just treat the symptoms.
What unique urine test is done to diagnose pernicious anemia?
The Schilling test
Is it okay to give B12 orally to a client with pernicious anemia?
No, it will never be absorbed due to a lack of intrinsic factor
What neurologic test do they do for this anemia?
The Romberg test (a test for balance), in normal people this test is negative, in the client with pernicious anemia this test becomes positive
What is conservation? In what stage does it develop?
When the child realized that number, weight, volume remain the same even when outward appearances change; Concrete Operational
What is the age range of formal operation thinking?
What is the sensori-motor stage of intellectual development?
It is the intellectual stage of children from birth to 2 years
What is the age range of concrete operational thinking?
What is the age range of pre-operational thinking? Hint: Think of PRE-schoolers.
What is the classic pattern in formal operational thinking?
What is egocentricity? In what stage is it found?
The child views everything from his frame of reference, common in pre-operational thinking
In Placenta Previa the placenta is implanted _______ than it should be and lays over the ________ ________.
Lower, cervical os
What is the classic symptom of Placenta Previa?
Painless 3rd trimester bleeding (hint: Painless Placenta Previa)
In whom is Placenta Previa most likely to occur? Primigravida's or multigravida's?
What is meant when the physician/nurse use the terms total (complete) or partial (incomplete) in reference to placenta previa?
Total or complete: placenta covers whole cervical opening
Partial or incomplete: placenta covers only part of the cervical opening
What are the 3 complications of placenta previa?
What is the best and safest way to confirm placenta previa?
Should a woman with placenta previa be hospitalized?
Yes, always if bleeding
If a surgeon delays doing a C-section for Placenta Previa it is due to: (reason for delay).
Immaturity of the fetus (they will want the child to mature)
As soon as Placenta Previa is diagnosed, most pregnancies will be terminated via C-section if the fetus is mature. (T/F)
If a woman is admitted with active bleeding with Placenta Previa you should monitor fetal heart tones _________.
Continuously via fetal monitor
It is not necessary to use electronic fetal monitoring when there is active bleeding in Placenta Previa. (T/F)
False, infant must always be monitored
Will a woman with active bleeding in Placenta Previa be given any systemic pain relief during labor?
No, they don't want to depress the fetus
If you were told to start the IV on the woman admitted for Placenta Previa, what gauge needle would you use?
18 gauge, or any other large enough to administer blood
Pneumonia is an ______ in the ______ of the ______.
Infection, alveoli, lungs
Pneumonia is only caused by bacteria. (T/F)
False, it can be caused by viruses and aspiration.
Which blood gas disorder is most common in pneumonia?
Respiratory alkalosis, because the hyperventilation blows off more CO2, than the consolidation traps in the blood
What is polycythemia vera?
A blood disease in which there is an increase in erythrocytes, leukocytes and platelets
What is the typical complexion of a client with polycythemia vera?
Ruddy red, almost purple
What procedure is done to relieve symptoms in polycythemia vera?
What is phlebotomy?
Drain off 200-500 cc of blood from body (opposite of transfusion).
What type of diet will people with polycythemia vera be on?
What are three signs of polycythemia vera?
Is hemoglobin increased or decreased in this disease?
What oral problem will people with polycythemia vera have?
Bleeding mucous membranes
What organ will be enlarged in polycythemia vera?
The spleen, because it is destroying the excessive RBC's.
Due to increased destruction of RBC's seen in polycythemia vera what blood level will be increased?
Uric acid levels will be high (remember - uric acid levels are always high when cells are being destroyed as in hemolysis, chemotherapy or radiation therapy)
What drug is most commonly used in polycythemia vera?
Myleran -- (this is usually used for bone marrow cancer)
How often should the client cough and deep breath post-operatively?
Every 2 hours
How often should the post-operative patient turn?
Every 2 hours
How often should the patient use the incentive spirometer?
Every 1-2 hours
How often should the nurse auscultate the lung sounds post-operatively?
Every 4 hours
How often should the bedridden post-operative patient do leg exercises?
Every 2 hours
The post-operative patient should void by _____hours post-operatively or you must call the MD.
6 to 8
Will the typical post-operative client have lung sounds? Bowel sounds? Increased temperature?
Lung - yes; bowel sounds - no; Low grade temperature - yes
Unless contraindicated the patient should be out of bed no later than ______ hours post-operatively.
Deep vein thrombosis is most common in what type of surgery?
Low abdominal or pelvic
The most common complication of deep vein thrombosis _______ ________.
The best way to prevent thrombophlebitis is TED hose. (T/F)
False, ambulation/exercise are the best ways.
What is paralytic ileus?
Paralysis of the bowel due to surgery (common --especially in abdominal surgery)
If a post-operative patient complains of gas and cramping you should first _______ then ________.
Assess then ambulate
The typical post-operative inflammatory temperature elevation is in the range of ________.
99.8 to 101 degrees
The onset of post operative infection is on the ______ or ______ day post-operative day.
2nd or 3rd, never before that (remember elevated temperatures earlier than the 2nd post-operative day is NOT infection)
Separation of the incisional edges
Protrusion of abdominal contents through a dehiscence.
What do you do for dehiscence?
Decrease HOB (but not flat); cover with sterile gauze moistened with sterile saline, call MD
What do you do, in order, for evisceration?
Decrease HOB (but not flat); cover with sterile gauze moistened with sterile saline, call MD
Before in time or place (ie. "antepartal - before giving birth)
"Not" or "into"
Throughout, completely, a large amount
Out from, away from, outside
A combining form meaning 'equal'
Pregnancy (decreases/increases) the body's insulin requirements.
Can pregnancy convert a non-diabetic woman into a diabetic?
What name is is given to diabetes that is brought on by pregnancy?
Diabetes with pregnancy is (more/less) common as the woman ages.
What is the #1 cause of infant illness when the mother has diabetes?
When is infant hypoglycemia most likely to occur during labor and delivery?
In the hours immediately following delivery
Hormones of pregnancy work against insulin. (T/F)
A sign of gestational diabetes is excessive (weight gain/weight loss)
(Obese/very thin) women are most likely to become diabetic during pregnancy.
In gestational diabetes the client experiences a (decrease/increase) in thirst
In gestational diabetes the client experiences a (decrease/increase) in urine output.
Gestational diabetes is associated with what OB history?
Previous large baby (over 9 lbs), unexplained stillbirth, miscarriage, congenital anomalies
Women who have gestational diabetes tend to deliver infants who are (small/large).
Large for gestational age
Gestational diabetics tend to get ________ infections.
What test confirms the diagnoses of gestational diabetes?
3 hour glucose tolerance test
What are the two main treatment methods in gestational diabetes?
How often should a woman visit the doctor prenatally if diabetes is present?
Twice a month, then once per week in the 3rd trimester
How many pounds per week is the diabetic allowed to gain the 2nd and 3rd trimesters?
1 pound a week
Is severe carbohydrate restriction required in gestational diabetics?
No, it could lead to ketosis
Of protein, fat, and carbohydrates, which ones (percent-wise) increase in the diet of gestational diabetics?
When is insulin used in the treatment of gestatinal diabetes?
When dietary control does not keep the blood sugar within normal limits
If insulin is used, the dose is the same in all 3 trimesters. (T/F)
False, it varies
Oral hypoglycemics should never be used during pregnancy. (T/F)
True, they cause birth defects (teratogenic)
When should a diabetic be delivered?
Between 37 and 39 weeks
What IV solution is used during labor for the diabetic?
The mother's insulin requirements will (fall/rise) markedly after delivery.
During pregnancy what complications is most dangerous for the fetus of a diabetic?
If ketosis is a big problem for the baby during pregnancy what the big problem after delivery?
Why is hypoglycemia such a dangerous problem?
Brain cells die without glucose, brain damage
(Multi/prima) gravida clients are most likely to get PIH.
Which age group(s) are most likely to experience PIH?
Patients under 18 and over 35
When does pre-eclampsia usually begin in pregnancy (week)?
After 20 weeks
Name the three symptoms of PIH.
Hypertension, weight gain (edema), proteinuria
If pre-eclampsia is mild will the woman be hospitalized?
No, just rest at home
What type of diet is indicated for a woman with pre-eclampsia?
Increased protein/normal salt intake (no restriction typically)
What measurement must the woman with pre-eclampsia make every day?
She must weigh herself
What is the activity order for a woman with severe pre-eclampsia?
Left side lying
What is the dietary order for the woman with severe pre-eclampsia?
Low salt, high protein
Are diuretics used for women with pre-eclampsia?
When a woman is hospitalized for severe pre-eclampsia the nurse should test...
#1 reflexes, the urine for protein
When pre-eclampsia gets worse the deep tendon reflexes will be (hyper/hypo) reflexia.
Pre-eclampsia makes the neuromuscular system more or less irritable?
What vision problem do women with pre-eclampsia have?
What types of precautions will be in effect for a woman with severe pre-eclampsia?
Name 5 things included in seizure precations.
Suction machine in room O2 in room
Padded rails up X 4
Must stay on unit
Ambulation with supervision only
No More than 1 pillow
When is pre-eclampsia called eclampsia?
Once convulsions have occured
In eclamptic client what ominous sign almost always precedes a seizure?
Severe epigastric pain
What are the three major treatment objectives in eclampsia?
Decrease blood pressure
The urine output of the eclamptic client will (decrease/increase).
How would you palpate the uterus to see if the eclamptic woman was having contractions?
Place the hand flat on the abdomen over the fundus with fingers apart and press lightly
Premature rupture of membranes (PROM) is a ________ break in the amniotic sac __________ the _________ of contractions.
Spontaneous, before, onset
Usually labor starts within ________hours of rupture membranes.
What is the danger with PROM?
How would you tell if the woman with PROM had an infection?
Foul smelling vaginal discharge
To test amniotic fluid the nurse should check the ________ of the fluid.
Amniotic fluid is (acidic/alkaline)
Being alkaline means have a (high/low) pH
Amniotic fluid turns nitrazine paper deep _________ (color).
When PROM occurs, the age of the fetus must be determined. The best way to assess lung maturity is to check the ________ ratio.
An L/S ratio greater than _______indicates lung maturity.
If labor does not begin within ________ hours after PROM, labor will likely be induced.
If PROM occurs before viability, what is the typical management?
Termination of pregnancy
If PROM occurs after viability but before 36 weeks, what is the typical management?
Hospitalize, watch for infection, try to gain time for the infant to mature
If there are any signs of infection after PROM, what must occur immediately?
Delivery of fetus
PROM always occurs in a gush of fluid. (T/F)
The woman must avoid sexual intercourse if PROM has occurred. (T/F)
What does self-disclosure mean?
When the nurse tells the patient personal information about self.
Is it always bad for the nurse to self-disclose?
No, you can self-disclose as long as you do it cautiously and you are 100% sure it is therapeutic.
If the nurse uses self-disclosure it should be ______ and the conversation should be...
Short, quickly refocused back on the patient
Insight means the ability of the patient to ________his problem.
During what phase should the nurse examine his/her own feelings?
Flight of ideas is when the patient changes topics of conversation______.
The basis for a therapeutic nurse/patient relationship begins with the ______, self______ and ______ _______.
Nurse's, awareness, self understanding
What are the steps of the nurse/patient therapeutic relationship?
Should the nurse self-disclose if the patient asks the nurse to?
No, not unless it is specifically therapeutic.
The nurse should introduce information about the end of the nurse/patient relationship during the _____phase.
Termination phase begins in the _______phase.
Pulmonary edema is accumulation of _______in the lung.
Pulmonary edema is a common complication of ______disorders.
Pulmonary edema usually results from ______ failure.
What force causes the pulmonary edema in left ventricular failure?
Increased hydrostatic pressure in the pulmonary capillaries
Can letting IVs run too fast cause pulmonary edema?
Yes in the client with poor cardiovascular function
What are the four classic signs of pulmonary edema?
Dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, coughing
What is meant by dyspnea on exertion?
Shortness of breath when active.
What is meant by paroxysmal nocturnal dyspnea?
Sudden episodes of difficulty breathing
What is meant by orthopnea?
Shortness of breath when lying flat
Is heart rate fast or slow in pulmonary edema?
What will the nurse auscultate over the lungs when pulmonary edema occurs?
When pulmonary edema is severe what does the sputum look like?
Bloody and frothy
What drug is used in pulmonary edema to reduce fluid in the lungs?
A diuretic (Lasix)
What drug is used to increase ventilation in clients with pulmonary edema?
Is O2 given in pulmonary edema?
Since pulmonary edema is caused by left ventricular failure what drug is given?
Why is morphine given to clients with pulmonary edema?
To decrease apprehension and decrease preload, this rests the heart
If your client suddenly goes into pulmonary edema what would you do first?
Elevate the HOB, then increase O2, then call the MD
Pulmonary embolus is an obstruction of the pulmonary ______ bed by a dislodged _______ or foreign substance.
Where do the emboli that cause pulmonary embolus usually come from?
Besides a thrombus what else can cause an embolus in the lung?
Air, fat, tumor cells
What treatment modality can lead to pulmonary embolus?
What class of drugs can lead to pulmonary embolus?
What heart problem can lead to pulmonary embolus?
Atrial fibrillation (RIGHT atrial fibrillation casues pulmonary embolus; LEFT atrial fibrillation causes cerebral embolus)
What genetic disorder can lead to pulmonary embolus?
Sickle cell anemia
What is the first sign of pulmonary embolus?
The dyspnea of pulmonary embolus is accompanied by ____ _____.
Does the heart rate increase or decrease in pulmonary embolus?
With severe pulmonary embolus the client will look as though they are __________.
What are the two major treatments of pulmonary embolus?
Name the anitcoagulant given for immediate anticoagulation by IV or SQ route.
A drug for long term anticoagulation in any disorder would be?
What two lab tests monitor coumadin therapy?
Prothrombin time (PT) and the INR
When coumadin is therapeutic, the INR should be between _______ and _______.
2.0 and 3.0
What is lovenox?
It is a low-dose Heparin used for anticoagulation in POST-OP THROMBOPHLEBITIS PREVENTION NOT USED FOR PULMONARY EMBOLUS
Heparin therapy is monitored by daily measurement of the _______.
PTT (partial thromboplastin time)
Effective heparin therapy rises the PTT to approximately _______ times normal.
Clients on heparin should use an electric razor or safety razor?
What is the best way to prevent pulmonary embolus in post-operative patients?
Is it appropriate to massage the legs of the client to preven pulmonary embolus?
Heparin is used in the acute phase of pulmonary embolus. What drug is used for 6 months after pulmonary embolus?
Coumadin therapy is monitored by what daily test?
PT (prothrombin time)
What is pyelonephritis?
A bacterial infection of the kidneys
Which organism causes pyelonephritis?
Name the symptoms that pyelonephritis and cystitis have in common?
Frequency, urgency, burning, cloudy, foul smelling urine
What medical intervention is necessary in pyelonephritis?
IV antibiotics for one to two weeks, must get urine culture 2 weeks after antibiotic therapy is over
How does pyelonephritis differ from cystitis in meaning?
Cystitis means bladder infection; pyelonephritis means an infection of kidney pelvis
What causes or precedes pyelonephritis?
Cystitis always does
Will the client with pyelonephritis have daily weights?
Yes, as would any client with kidney problem
Name the five signs/symptoms that pyelonephritis has that cystitis does not have?
Fever, flank pain, chills, increased WBC, malaise
What is the BIG danger with pyelonephritis?
Permanent scarring and kidney damage
How is pyelonephritis prevented?
By preventing or treating all cystitis (UTI's)
Will the client with pyelonephritis have hematuria?
It is common but not always present
The patient with pyelonephritis will have (hypertension/hypotention)?
Where is the pyloric sphincter?
At the distal (duodenal) end of the stomach
What does stenosis mean?
What is done to correct pyloric stenosis?
In what position should the child with Pyloric Stenosis be during feeding?
The feedings for an infant with pyloric stenosis should be thick or thin?
What test is done to confirm a diagnosis of pyloric stenosis?
Upper GI series (barium swallow)
These infants are prone to develop ______ and failure to ______.
Why does the pyloric valve become stenosed in pyloric stenosis?
In what position should a child with pyloric stenosis be after a feeding?
Right side with HOB up
The infant with pyloric stenosis appears ______ even after vomiting.
What do you see during and after feeding?
Peristaltic waves from left to right
Is vomiting projectile or non-projectile in patients with pyloric stenosis? Is the vomiting bile-stained or not bile-stained?
Projectile, not bile-stained
What assessment finding is found under the right rib cage?
An olive sized bulge (the hypertrophied pylorus)
The symptoms of pyloric stenosis mostly commonly appear at age ______ to _____.
4 to 6 weeks
Describe the typical child with pyloric stenosis.
Firstborn, full term, white, boys
For what reason are Montgomery straps used?
Permit you to remove & replace dressings without using tape (protects the skin)
Sutures in general are removed by the ___ day.
Leaving a would open to air decease infection by eliminating what 3 environmental conditions?
Dark, warm, moist
To remove tape always pull (toward/away) from the wound.
Toward (this way you don't put pressure/pull on the suture line.)
Removal of necrotic tissue from a wound.
What is the purpose of a wound drain?
Remove secretions from the area so healing occurs.
To prevent germs from getting into or out of a wound you should use what type of dressing?
An occlusive dressing
What solution is put onto the skin to protect it from the irritating effects of the tape?
Tincture of benzoin
With what is a round closed in first intention?
Sutures or steri-strips, staples
What is another name of second intention?
When swabbing an incision you would start at the incision or 1 Inch away from the incision?
Start at the incision and move outward.
After you remove soiled dressings and before you put on the sterile dressing you must....
Wash your hands and put on sterile gloves
What is meant be the phrase "advance the drain 1 inch"?
You pull the drain out 1 inch.
After advancing a Penrose drain you (should/should not) cut off the excess drain?
When a dressing saturated, germs can enter the wound from the outside. (T/F)
True, by a process called capillary action
When is a bad time to change dressings?
Scoliosis is a ______ curvature of the ______.
Scoliosis is MOST common in the _______ and
______ sections of the spinal column.
Thoracic and lumbar
Scoliosis in the thoracic spine is usually convex to the
Scoliosis in the lumbar spine is usually convex to the (left/right).
Left (*Hint: curve Left in Lumbar)
With which other two spine deformities is scoliosis
Kyphosis (humpback), Lordosis (swayback)
What is Kyphosis?
Humpback in the thoracic area
What is Lordosis?
Swayback in the lumbar region (Lumbar, Lordosis)
What is the difference between structural and
Structural-you are born with; Functional-you get from bad posture
What age group should be routinely screened for
What are the 3 subjective complaints of clients with scoliosis?
Back pain, dyspnea, fatigue
What test/exam CONFIRMS the diagnosis of
X-rays of the spine
What type of brace is most commonly used for
Name 4 exercises used to treat mild scoliosis.
Heel lifts; sit-ups; hyperextension of the spine; breathing exercises
What kind of treatment is done for severe scoliosis?
Surgical fusion with rod insertion
What type of cast is used post-operatively?
What kind of rod is used to "fix" curvature?
Scoliosis MOST commonly affects _____ _____
(type of clients).
How many hours a day should the client wear a
What solution should be used on the skin where the
Tincture of benzoin or alcohol,no lotions of ointments-you want to toughen the skin not soften it
Clients with a Milwaukee brace should avoid vigorous
After corrective SURGERY how is the client turned?
Log rolled (in a body cast)
How often should the neurovascular status of the
extremities of a client in a Risser cast be measured? Fresh post-operatively?
Every 2 hours
What is a common complication of a client in a body
cast (like a Risser cast)?
What is cast syndrome?
Nausea, vomiting and abdominal distention that can result in intestinal obstruction
What group of people get cast syndrome?
ANYONE in a body cast
What is the treatment of for cast syndrome?
Removal of the cast, NG tube to decompress, NPO
How would you, the nurse, assess for developing
Ask the client if they are experiencing any abdominal symptoms-keep track of bowel movements & passing flatus (if not having BMs or passing flatus, cast syndrome is suspected)
What causes cast syndrome, specifically in a Risser
Hyperextension of the spine by a body cast: the hyperextension interrupts the nerve & blood supply to the gut
The inheritance pattern of sickle-cell anemia is _____
What does heterozygous mean?
It means you only have 1 defective gene from 1 parent.
People who are (hetero/homo) have sickle cell
What does homozygous mean?
It means you have the defective gene from both parents.
People who are (hetero/homo)zygous have sickle cell
People with sickle cell TRAIT only carry the disease,
they DO NOT have symptoms. (T/F)
True-usually it has occurred that in times of SEVERE stress, the TRAIT does cause some symptoms but not usually.
What are the #1 and #2 causes of sickle cell crisis?
The most common type of crisis that occurs is a
In vaso-occlusive crisis the vessels become
occluded with ______ ______.
The abnormal hemoglobin produced by people with
sickle cell anemia is called Hgb ______.
Hgb S-it "sickles"
What shape does Hgb S make the RBC's?
Why do the crescent-shaped RBCs cause occlusion
of the vessels?
They clump together and create a sludge.
What are the top 3 priorities in care of the client with
Oxygenation, hydration, and PAIN control
What activity order will the client with sickle cell
Or Tylenol, Morphine, Demoral, Aspirin which is
NEVER given to a sickle-cell patient?
Aspirin-it can cause acidosis which makes the crisis and sickling worse
At what age is death most likely in sickle cell anemia?
Sickle-cell anemia symptoms do not appear before
the age of ____ months due to the presence of _____ ______.
6; fetal hemoglobin
Sickle cell anemia is most commonly seen in
Should a child in sickle-cell crisis wear tight clothes?
No, it can occlude vessels even more.
Spinal cord injuries are more common in males. (T/F)
In what age range is spinal cord injury most common?
15 to 25
The #1 goal in emergency treatment of spinal cord
Immobilization of the spine
When halo traction is being used to immobilize the
spinal cord the client is allowed to _______.
When the patient with spinal cord injury is in tongs or
on a stryker frame or on a circoelectric bed they are on......
Absolute bed rest
The 2 most common surgeries used to treat spinal
cord injury are ____ and ______.
Laminectomy and spinal fusion
What is spinal shock?
It is a common occurrence in spinal cord injury in which the spinal cord swells above and below the level in injury
When does spinal shock occur?
Immediately or within 2 hours of injury
How long does spinal shock last?
5 days to 3 months
When the spinal cord injury is at level of _____ to
_____ the patient will be a quadriplegic.
C1 to C8
When the spinal cord injury is between _____ and
_____, there is permanent respiratory paralysis.
C1 and C4
Can the patient with spinal cord injury at C7 level have
Yes, because even thought his injury was below C4, spinal shock can lead to loss function above the level, however the will not be permanently ventilator dependent-he will breath on when once spinal shock goes away.
Spinal cord injury in the thoracic/lumbar regions result
If airway obstruction occurs at the accident site and
you suspect spinal cord injury, what maneuver is used to open the airway?
Modified jaw thrust
In spinal cord injury never ______ the neck.
How should you change the position of the spinal cord
injury patient after he has an order to be up? Why?
Slowly, because of severe orthostatic hypotension (they use a tilt table)
For the patient with neurogenic bladder you should
straight catheterize every ____ hours.
Every 6 hours
The patient with spinal cord injury will have
Name 3 drugs used to treat spasms.
Valium, Baclofen, Dantrium
What is automatic dysflexia or hyperreflexia?
A common complication of quadriplegics in response to a fulle bladder or bowel.
What are the vital sign changes seen in autonomic
Sweating, headache, nausea & vomiting, gooseflesh, and severe HYPERtension
What do you do first for the client experiencing
What do you do secondfor the client experiencing
Check the bladder, check the bowel
Do you need to call the doctor for autonomic
No, only call the doctor if draining the bladder & removing impaction does not work
What is the #1 treatment for autonomic dysreflexia?
Drain the bladder, empty the bowel
What is the purpose of restricting activity after spinal
To prevent headache due to CSF loss
Should the client drink after a spinal tap?
Yes, encourage fluids to replace CSF
Do you need an informed consent for a spinal tap?
Should CSF contain blood?
Does the client have to be NPO before a spinal tap?
What is the normal color of cerebrospinal fluid?
Into what space is the needle inserted during a spinal
Can the client turn side-to-side after a spinal tap?
In what position should the client be during a spinal tap?
Lateral decubitus (on their side) position and knees to chest
Identify the activity restriction necessary after lumbar puncture?
Lie flat for 6 to 12 hours
What are the 2 purposes of a spinal tap?
To measure or relieve pressure and obtain a CSF sample
Does the client have to be sedated before a spinal tap?
A drug that destroys or inhibits growth of micro-organisms
Absence of organisms causing disease
A substance used to destroy or inhibit the growth of pathogens but not necessarily their spores (in general safe to use on persons)
A substance used to destroy pathogens but not necessarily their spores (in general not intended for use on persons)
Substance capable of destroying micro-organisms but not necessarily their spores
Substance that prevents or inhibits the growth of micro-organisms
Micro-organisms that do not require free oxygen to live
Micro-organisms requiring free oxygen to live
Micro-organism that causes disease
Clean technique (Define)
Practices that help reduce the number & spread of micro-organisms (synonym for medical asepsis)
An item on which all micro-organism have been destroyed
Process that thickens or congeals a substance
An animal or a person upon which or in which micro-organisms live
Portal of entry (Define)
Part of the body where organisms enter
To make something unclean or unsterile
Surgical asepsis (Define)
Practices that render & keep objects & areas free from all micro-organisms (synonym for sterile techniques)
Medical asepsis (Define)
Practices that help reduce the number & spread of micro-organisms (synonym for clean techniques)
A cell produced by a micro-organism which develops into active micro-organisms under proper conditions.
Which hand should hold the suction catheter? Which
should hold the connecting tube?
The dominant, the non-dominant
The nurse should use (medical/surgical) asepsis
during airway suction?
Surgical asepsis (sterile technique)
What kind of lubricant should be used on the suction
Should the suction be continuous or intermittent?
Intermittent to prevent mucosal damage
For how long should suction be applied during any
one entry of the catheter?
How often should the nurse clear the tubing during
After each pass/entry/removal
Which way would you turn the client hear to suction
the right mainstem bronchus? The left mainstem bronchus?
To the left, to the right
The best client position during airway suctioning is _______.
The suction should be delivered while
(inserting/removing) the catheter.
While removing the catheter
What outcomes would indicate that suctioning was
Clear even lung sounds, normal vital signs
How often should the client's airway be suctioned?
When it needs to be, for example moist lung sounds, tachycardia, restlessness (hypoxia), ineffective cough
The unconscious client should assume what position
Side-lying, facing nurse
If not contraindicated, what action by the nursing
before suctioning would most likely reduce hypoxia during suctioning?
Administer a few breaths at 100% oxygen before beginning
What solution should be used to clear the tubing
With what size catheter should an adult's airway be
12 to 16 French
How much suction should be used for an infant?
Less than 80 mm Hg
How much suction should be used for a child?
80 to 100 mm Hg
How much suction should be used for an adult?
120 to 150 mm Hg
Do you assess for suicide potential whenever a
patient makes any statement about wanting to die or kill self?
Yes, in fact whenever a patient makes a statement about wishing or wanting to die or kill self you must ALWAYS AND FIRST assess for suicide potential*-stop everything and assess for suicide patient (except CPR, or course)
Children are at _____ risk for suicide.
Adolescents are (low/high) risk for suicide.
Young adults are (low/high) risk for suicide.
High to moderate
People between 25 and 50 years are (low/moderate
/high) risk for suicide.
Low to moderate
People over 50 year are (low/high) risk for suicide.
The patient who has a definite plan is (low/high) risk
Moderate to high, depends upon feasibility and ease of plan
The use of pills makes the patient (low/moderate/high) risk for suicide.
The patient who has NO definite plan is (low/high) risk
The use of _____, _______, and ______ to kill self,
make high risk suicide.
Guns, ropes, knives
Who is at higher risk for suicide, a man or a woman?
Of: married, divorced, and separated, which marital status is highest risk for suicide? Lowest risk of suicide?
Highest-separated then divorced
The goal of action while the suicidal patient is still of
the phone is to get _______ person _______ the ______.
Another person on the scene (then immediately decreases risk) Remember: people who are alone are always high risk
What are the four classic suicide precautions?
Search personal belongings for drugs & alcohol, remove any sharp objects, remove any device for hanging or strangling; must be on constant one-to-one observation (NEVER out of sight)
Once the patient is admitted for attempted suicide should you ever discuss the attempt with them?
No, you should not focus on the attempt, focus on the present and future.
Lack, deficiency of
Plastic surgery on a specified part
Hardening of a tissue by: inflammation, deposition of mineral salt; an infiltration of connective tissue fibers
A perforation or puncture
Produce, originate, become
Fixation of something
Condition of occlusion
Combining form meaning a tumor or swelling or a cavity
Joining in a seam, suturation
Instrument for observation
Indicates condition, process
Study of; knowledge, science
Surgical removal of
Crushing of something by a surgical instrument
Used in naming enzymes
Syphilis is sexually transmiteed. (T/F)
Syphilis first infects the _____ ______.
What are the stages of syphilis?
Primary, secondary, latent, late
Syphilis is a fatal disease if untreated. (T/F)
What organism causes syphilis?
What is the lesion like in primary syphilis?
The chancre (pronounced shanker)
The chancres of syphilis are (painful/painless).
Chancres disappear without treatment. (T/F)
Late syphilis attacks which 3 body organs?
Liver, heart, brain
What test CONFIRMS the presence of syphilis?
Dark-field illumination of the treponema palladium
What is the treatment of choice for syphilis?
Why is penicillin administered with Procaine?
Procaine makes the shot less painful; Probenecid blocks the excretion of penicillin
What is the most common sign of neurosyphillis?
Ataxia (gait problems)
Mastitis and breast engorgement are more likely to occur in (primipara/multipara).
Where does the organism that causes mastitis come from?
The infant's nose or mouth
Which organism most commonly causes mastitis?
Prolonged intervals between breast-feeding (decrease/increase) the incidence of mastitis.
Can too tight bras lead to mastitis?
Yes, preventing emptying of ducts
Mastitis usually occurs at least _______days after delivery.
When mastitis is present the breasts are ________, _________, and __________.
Hard, swollen, warm
Mastitis is accompanied by a fever over _________.
If mastitis is caused by an organism, what causes breast engorgement?
Temporary increase in vascular and lymph supply to the breast in preparation for milk production
If mastitis occurs 1+ weeks after delivery, when does breast engorgement occur?
2 to 5 days after delivery
Does breast engorgement interfere with nursing?
Yes, the infant has a difficult time latching on (getting nipple in its mouth)
What class of drugs is used to treat mastitis?
Antibiotics are used to treat breast engorgment? (T/F)
Application of (warm H2O compress/ice packs) is the preferred treatment for breast engorgement.
Ice packs to decrease swelling
The mother with mastitis should stop breast feeding. (T/F)
False, the mother must keep breast feeding. (Offer unaffected breast first)
If the mother has an open abscess on her breast, must not breast-feed. (T/F)
For breast engorgement, the non-breastfeeding mother should be told to express breast milk. (T/F)
No, that would increase milk production and would make the problem worse (warm compresses or warm shower to let milk "leak" is okay- Ice is best)
What is the best treatment for breast engorgement?
Breast-feeding - it will balance supply and demand
What is mastoiditis?
Inflammation/infection of the mastoid process
What is the most common cause of mastoiditis?
Chronic otitis media
What are 4 signs and symptoms of mastoiditis?
Drainage from ear, high fever, headache and ear pain, tenderness over mastoid process
What unusual post-operative complication can result from mastoidectomy?
Facial nerve paralysis due to accidental damage during surgery (law suit time!)
What should you do to assess for facial nerve paralysis post-mastoidectomy?
Have the patient smile and wrinkle forehead.
What is the medical treatment for mastoiditis?
What is the surgery for mastoiditis called?
Simple or radical mastoidectomy
Will a simple mastoidectomy worsen hearing?
No, a radical mastoidectomy may
Should the nurse change the post-mastoidectomy dressing?
No, reinforce it. Physician changes first post op dressing
What is a common side effect of mastoidectomy?
What is a major nursing diagnosis post-mastoidectomy?
In the chain of infection, hand washing breaks the mode of ____________.
The best way to decrease nosocomial infection is sterile technique. (T/F)
False, hand washing is the best way.
Sterile gloved hands must always be kept above the waist. (T/F)
When putting on the second of a set of sterile gloves, you should grasp the cuff. (T/F)
False, reach under the cuff with the tip of the gloved fingers.
When putting on the first glove of a set of sterile gloves, you should grasp the cuff. (T/F)
When putting on the second glove of a set of sterile gloves, you must not use the thumb of the first hand. (T/F)
Airborne microorganisms travel on ________ or ______particles.
Dust or water
Another name for medical asepsis is...
Sensitivity (susceptibility) means...
The susceptibility of an organism to the bacterial action of a particular agent
When unwrapping a sterile pack how should you unfold the top point?
Away from you
Ability of an organism to produce disease
Another name for surgical asepsis is...
What is the best location in a client's room to set up a sterile field?
On the over-bed table
Medical aseptic technique are aimed at reducing the number of organisms (T/F)
True, doesn't eliminate all of it just decreases the number
What does bacteriostatic mean?
Having the capability to stop growth of the bacteria
What does bacteriocidal mean?
Having the capability to kill bacteria.
What does nosocomial infection mean?
Infection acquired through contact with contamination in the hospital
When pouring liquid onto a sterile field you should pour from a height of _____ to _____ inches above sterile field.
6 to 8
When you plan to use gloves for a procedure you do not need to wash hands before it. (T/F)
False, always wash even if you plan to use gloves
Growing colony of organisms, usually for the purpose of identifying them
Surgical aseptic techniques render and keep articles free from all organisms. (T/F)
You must never turn your back to a sterile field. (T/F)
What must you do if you reach across a sterile field?
Consider the area contaminated and not use the articles in the area
Micro-organisms grow best in a _______, _______, _______place.
Warm, dark, moist
It is common practice to regard the edges of any sterile field as contaminated. (T/F)
True, the outer 1 inch is considered contaminated. You must not touch it with your sterile gloves.
Immediately after opening a bottle of sterile water, can you pour it directly into a sterile basin?
No, you must pour a few cc's out of the bottle into a waste container before you pour into the sterile basin. (This is called "lipping" the bottle)
Which is the best method for identifying clients accurately?
By ID name-band
An emulsion is a mixture of ______ and ______.
Oil and H2O
Syrups and elixirs are of particular concern to diabetic clients because....
they contain sugars
Oral medications have a (faster/slower) onset of action that IM drugs.
Oral medications have a (shorter/longer) duration of action than IM medications.
How should drugs that stain teeth be administered?
By a straw
A drug given by a parenteral route acts outside the GI tract. (T/F)
Name the four most common parenteral routes of administrations.
SQ, IM, IV, ID (intradermal)
When blood is administered by IV, the needle/catheter should be ________gauge.
You can administer up to ____ cc of a drug per site by IM injection in adults.
Children should receive no more than _______ cc per site by IM injection.
The preferred IM injection site for children under 3 is the _________ ___________.
Why is the dorsogluteal site not recommended for IM injection the children less than 3 years of age?
Because the muscle is not well developed yet.
Can 3 cc of fluid be administered per IM into the deltoid of an adult?
No, maximum of 1 cc
The #1 danger when using the dorsogluteal site for IM injection is___________.
Damage to the sciatic nerve
The preferred angle of injection to to be used for IM administration is___________.
The preferred length of needle to administer an IM injection is...
1 to 2 inch
The preferred gauge of needle for IM injection is...
21 to 22 gauge
Which type of medications are given by Z-track injection?
How long is the needle kept inserted during Z-track injection?
What must be done to the equipment before injecting by Z-track method?
Change the needle
When giving a Z-track injection, the overlying skin is pulled (up/down/medially/laterally).
Subcutaneous injection must be given at 45 degrees. (T/F)
True (for boards), false- whatever angle gets it SQ without going IM
The preferred gauge of needle for injection for SQ injection___________.
The preferred length of needle for SQ injection is_________.
The intradermal route is primarily used for ________ _________.
Name the two sites used for intradermal injection.
In general, the nurse should wear gloves when applying skin preparations such as lotions. (T/F)
After using nose drops, the client should remain ______ for _______ minutes.
Strict aseptic techniques is required when administering a vaginal medication. (T/F)
False-- only "clean" technique or medical asepsis is necessary
Before administering vaginal medications the client is more comfortable if you ask them to _________ .
After administration of a vaginal durg the client should remain _____ for______ minutes.
Rectal suppositories with an oil base should be kept refrigerated. (T/F)
Strict sterile technique is required when administering a drug per rectum. (T/F)
False, clean or medical asepsis
The best way to ensure effectiveness of a rectal suppository is to...
Push the suppository against the wall of the rectum
A rectal suppository is inserted ______ inches in an adult and ________ inches in a child.
The client should remain supine for 5 minutes after having received a rectal suppository. (T/F)
False-- they should be lying on their side for 5 minutes, not supine
A suppository given rectally must be lubricated with a water soluble lubricant. (T/F)
True, lubricant fingers also
Eye medications can be given directly over the cornea. (T/F)
False, into the conjunctival sac, never the cornea; hold the dropper 1/2 inch above the sac
Eye drops should be placed directly into the _______ _______.
To prevent eye medications from getting into the systemic circulation you apply pressure to the _______ for ______ seconds.
Nasolacrimal sac, 10 (press between the inner canthus and the bridge of the nose)
The eye should be irrigated so that the solution flows from outer to inner canthus. (T/F)
False, it must flow from inner canthus to outer (alphabetical: I to O)
If ear medications are not given at room temperature the client may experience...
To straighten the ear canal in the ADULT, the nurse should pull the pinna______ and ________.
Up and back
To straighten the ear canal in the young CHILD under 3 the pinna should be pulled _______ and ________.
Down and back
After receiving ear drops the client should remain in ________position for ________minutes.
Side lying, 5
How far above the ear canal should you hold the dropper while administering ear drops?
Liquid doses of medications should be prepared at _______level.
Liquid drugs should be poured out of the side (opposite of/the same as) the label.
It is safe practice to administer drugs prepared by another nurse. (T/F)
In order to leave drugs at the bedside you must have a physician's order. (T/F)
Young infants accept medication best when given with a _______.
It is safe practice to recap needles after injection. (T/F)
False, Never re-cap
What do you do if you get blood in the syringe upon aspiration?
Remove the syringe immediately and apply pressure; you must discard the syringe and redraw medication in a new syringe
Give with meals, remember Zantac does not have to be given with meals
Give on empty stomach, one hour before meals (antihypertensive)
Given with meals (antihypertensive)
Iron with nausea
Give with meals
Take with LOTS OF WATER regardless of whether you give it at mealtime or not -- Bactrim, Septra, Gantricin, ie, used to treat UTI
Take with lots of water rergardless of meals -- to prevent constipation
Give on empty stomach I hour ac and hs
Give with 200-300 cc water-- not related to mealtime -- this is an emetic (to make you vomit after ingestion of poisons -- don't give if the poisons were caustic, or petroleum based)
Give on empty stomach (anti-tuberculosis) remember Rifampin causes red urine
Non-steroidal anti-inflammatory drugs
Give with food (for arthrosis)
Give with meals (K--sparing diuretic)
Iron (without nausea)
Give on empty stomach with orange juice to increase absorption
Give on empty stomach
Give on empty stomach (antibiotics)
Take with lots of water regardless of mealtim
Give with meals-- especially high fat meals (anti-fungal)
Do not give with milk products, do not give to pregnant women or children before age 8 or damage to tooth enamel occurs
Give with meals, ie, Aminophylline, Theodur (anti-asthmatic bronchodilator)
Give with meals-- remember taper the patient off these drugs slowly
Pancreas pancreatin isozyme
Give with meals-these are oral enzymes used with children with cystic fibrosis to increase the absorption of the food they eat
Para-amino salicylate sodium (PAS)
Give with meals/food-- anti tuberculosis
Give with meals -- anti gout, remember if diarrhea develops, stop the drug
Take with LOTS OF WATER regardless of meals to prevent constipation.
All drugs that end in "-zine" are major tranquilizers that also cause Psuedo Parkinson's or extra-pyramidal effects.
Carafate and sulcrafate
Give on empty stomach 1 hour before meals and at bedtime -- remember these coat the GI tract and interfere with the absorption of other medications (give them by themselves)
Give with meals and give with lots of water--anti uric acid--- used to treat gout and the purine build up seen in chemotherapy for cancer
Define Meniere's Disease
An increase in endolymph in the inner ear, causing severe vertigo.
What is the famous triad of symptoms in Meniere's?
Paroxysmal whirling vertigo -- sensorineural hearing loss--tinnitus (ringing in the ears)
Does Meniere's occur more in men or women?
What should the client do if they get an attack?
What safety measures should be followed with Meniere's?
Side rails up x 4, ambulate only with assistance
What age group in Meniere's highest in?
40 to 60
What can PREVENT the attacks of Meniere's?
Avoid sudden movements
What electrolyte is given to people with Meniere's?
What is the surgery done for Meniere's?
What disease often follows labyrinthectomy?
Bell's palsy-- facial paralysis, will go away in a few months
What is the activity order after labyrinthectomy?
When surgery is performed for Meniere's, what are the consequences?
Hearing is totally lost in the surgical ear
What should the client avoid after labyrinectomy?
Sudden movements and increased Na food
What type of diet is the client with Meniere's on?
What two classes of drugs are given in Meniere's?
Antihistamines and diuretics (Diamox)
Meningitis is an inflammation of the _______ of the _______ and spinal ___________.
Linings, brain , cord
Meningitis can be caused by _______, _____, and _____.
Viruses, bacteria, chemicals
The four most common organisms that cause meningitis are...
The child with meningitis is most likely to be (lethargic/irritable) at first.
What visual symptom will the patient with meningitis have?
Photophobia (over-sensitivity to light)
What is the most common musculo-skeletal symptom of meningitis?
Stiff neck- nuchal rigidity
Will the patient with meningitis have a headache?
Kernig's sign is positive when there is pain in the _____ when attempting to straighten the leg with ____ flexed.
What type of vomiting is present in meningitis?
What is the definitive diagnostic test for meningitis?
Lumbar puncture with culture of CSF (cerebro-spinal fluid)
If the patient has meningitis, the CSF shows _______ pressure, _____ WBC, ______ protein, ______ glucose.
Increased, increased, increased, decreased
On what type of isolation will the patient with meningitis be?
Contact and respiratory precautions
How long will the patient with meningitis be on these precautions?
Until they have been on an antibiotic for 48 hours
The room of a patient with meningitis should be _______ and ______.
Dark and quiet
The client with meningitis can develop________.
What is opisthotonos?
Arching of back (entire body) from hyperextension of the neck and ankles, due to severe meningeal irritation.
If a patient has opisthotonos, in what position would you place them?
Average duration of menstrual flow is _____. The normal range is _____ to ______ days.
5 days, 3 to 6
Average blood loss during menstruation is _____cc.
50 to 60 cc
Name the two phases of ovarian cycle.
Follicular phase (first 14 days)
Luteal phase (second 14 days)
In the menstrual cycle, day 1 is the day on which...
Menstrual discharge begins
How long does an ovarian cycle last?
Average of 28 days
How many days after ovulation does menstruation begin?
What hormones are active during follicular phase?
FSH and Estrogen
During the luteal phase of the ovarian cycle, which of the following hormones increase: estrogen, progesterone or LH?
Progesterone and LH
What is the major function of the luteal phase of the ovarian cycle?
To develop and maintain the corpus luteum which produces progesterone to maintain pregnancy until placenta is established.
If an ovum is fertilized during the luteal phase what hormone will be secreted?
HCG (human chorionic gonadotropin)
During menstruation, the average daily loss of iron is _____ mg.
0.5 to 1.0 mg
What occurs during the follicular phase of the ovarian cycle?
It accomplishes maturation of the graafian follicle which results in ovulation
What type of environmental modification is best for a migraine?
Dark and quiet environment
The long term treatment of migraine focuses upon...
Assessing things that bring on stress and then planning to avoid them.
What type of pain is typical of migraines?
Are migraines more or less common in men?
Besides pain, people with migraines complain of what other symptoms?
Nausea, vomiting and visual disturbances
What are the processes occurring in migraines?
Reflex constriction then dilation of cerebral arteries.
Where is the pain of migraine most likely located?
Name a drug given to treat migraine?
Sansert (methsergide), Cafergot
Are migraine headaches usually unilateral or bilateral?
When Inderal is given in migraine headache, it is used to prevent or treat an attack?
To prevent. It DOES NOT treat.
MS is a progressive _____ disease of the CNS.
Myelin promotes _____, _____ _____ of nerve impulses.
Fast, smooth conduction
MS affects men more than women. (T/F)
What age group usually gets MS?
20 to 40
MS usually occurs in (hot/cool) climates .
What is the first sign of MS?
Blurred or double vision
MS can lead to urinary incontinence. (T/F)
MS can lead to impotence in males. (T/F)
Patients with MS should be taught to walk with a ____-____ gait.
Why are Adrenocorticotropic Hormone (ACTH) and prednisone given during acute MS?
To decrease edema in the demyelination process
For acute exacerbations of MS _______ per IV is often used.
What drug can be given to treat urinary retention in MS?
Will the muscles of MS clients be spastic or flaccid?
What three drugs can be given for muscle spasms?
Valium, Baclofen (Lioresal), Dantrium
Baclofen causes (constipation/diarrhea)
Dantrium causes (constipation/diarrhea)
Diarrhea (hint: D's go together, Dantrium and Diarrhea)
Patient's with MS should have (increased/restricted) fluids.
Increased to dilute urine and reduce incidence of UTI.
The diet of a patient with MS should be ____--ash.
What major sense is affected most in MS (besides vision)?
Tactile (touch)-- they burn themselves easily
Which will bring on a MS exacerbation: over-heating or chilling?
Both will; but they tend to do better in cool weather (summer will always be a bad time for MS patients)
In Myasthenia Gravis (MG) there is a disturbance in transmission of impulses at the _____ _____.
The #1 sign of MG is ______ ______ _____.
Severe muscle weakness
What is the unique adjective given to describe the early signs of MG?
The early signs (difficulty swallowing, visual problems) are referred to a BULBAR signs.
MG affects men more than women. (T/F)
False, affects women more than men
When women get MG they are usually old or young?
When men get MG they are usually old or young?
What neurotransmitter is problematic in MG?
What class of drugs is used to treat MG?
What ending do anticholinesterases have?
Are anticholinesterases sympathetic or parasympathetic?
Anticholestinesterases will have (sympathetic/cholinergic) side effects.
Cholinergic (they will mimic the parasympathetic nervous system)
What surgery CAN be done for MG?
Thymectomy (removal of thymus)
The severe muscle weakness of MG gets better with exercise. (T/F)
False, it is worse with activity
What will the facial appearance of a patient with MG look like?
Mast-like with a snarling smile (called a myasthenic smile)
If a patient has MG, what will be the results of the Tensilon Test?
The patient will show a dramatic sudden increase in muscle strength
Besides the Tensilon Test, what other diagnostic tests confirm a diagnosis of MG?
What is the most important thing to remember about giving Mestinon and other anticholestinerases?
They must be given EXACTLY ON TIME; at home, they might need to set their alarm
Do you give anticholestinerases with or without food?
With food, about 1/2 hour ac; giving ac helps strengthen muscles of swallowing
What type of diet should the patient with MG be on?
What equipment should be at the bedside of an MG patient?
Suction apparatus (for meals), tracheostomy/endotube (for ventilation)
Name the two types of crises that a MG patient can have.
Cholinergic (too much Mestinon)
Myasthenic (not enough Mestinon)
The #1 danger in both Myasthenic and Cholinergic crisis is _____ ______.
What words will the client use to describe the pain of an MI?
Crushing, heavy, squeezing, radiating to left arm, neck , jaw, shoulder
What is an MI?
Either a clot, spasm or plaque that blocks the coronary arteries causing loss of blood supply to the heart and myocardial cell death
What is the #1 symptom of an MI?
Severe chest pain unrelieved by rest and nitroglycerine
Males are more likely to get an MI than females. (T/F)
Due to MI occurs within _____ of symptom onset in 50% of all patients.
What pain medication is given for the pain of a MI (Give three).
Morphine, Demerol, Nitroglycerine
What is the reason for giving post MI patients ASA?
To prevent platelets from forming clots in the coronary arteries
Name a new drug with anti-platelet activity.
The three most common complications after MI are ____ _____,_____, and _______.
Cardiogenic shock, arrhythmia, CHF
Give another name for an MI.
What will the activity order be for the post-MI client?
Bed rest with bedside commode
What is the most common arrhythmia after a MI?
Premature ventricular contractions (PVCs)
What cardiac enzymes indicate an MI?
Elevated CPK, LDH, SGOT
What serum protein rises soonest after myocardial cell injury?
Do people without cell damage have troponin in their blood?
No it is only present when myocardial cells are damaged.
How soon after cell damage does troponin increase?
As soon as 3 hours (can remain elevated for 7 days)
When will the client with an MI be allowed to engage in sexual intercourse after an MI?
6 weeks after discharge
Will fluid resuscitation (administering large amounts of IV fluid) treat cardiogenic shock?
No, you must use cardiac drugs (giving IVs and blood will not help this kind of shock)
Will the client with a MI be nauseated?...diaphoretic?
What will the extremities of the client with a MI feel like?
What is the permanent EKG change seen post MI?
ST wave changes
Of CPK and LDH which rises earliest?
What drug will be used to treat PVCs of MI?
Will the client with a MI need 100% O2 for their entire stay in the hospital?
No, just moderate flow (42% or 3 to 6 liters for first 48 hours)
What information does the measurement of skin fold thickness yield?
The amount of body fat
In general, males have a higher risk of heart disease than females. (T/F)
Post-menopausal females have a lower risk of heart disease than males aged 25-40. (T/F)
False. They have a higher risk.
Family history of diabetes increases the risk fo heart disease. (T/F)
Family history of liver disease increases the risk of heart disease. (T/F)
Cigarette smoking increases the risk of heart disease. (T/F)
Oral contraceptives decrease the risk of heart disease. (T/F)
False, use increases the risk
Routine exercise decreases the risk of heart disease. (T/F)
What is done in a graft for hemodialysis?
A blood vessel is sutured between an artery and a vein.
What is done in an AV fistual?
A surgical anastomosis is made between the artery and a vein.
Does anything exit the skin in an AV fistula?
How long can an AV fistula be used?
Who is the most likely to receive a graft for dialysis?
People with diabetes mellitus.
How often do clients with renal failure undergo dialysis?
3 times per week
Is hemodialysis short term or long term?
Both- but most short term dialysis is achieved by hemodialysis
How long does the average dialysis last?
4 to 6 hours
What are 3 ways to gain access to the circulation in hemodialysis?
What is the most common site for an AV shunt?
Radial artery to radial vein
What should be avoided in the arm of the client with an AV shunt?
No venipuncture or blood pressure allowed in the arm with a shunt, graft or fistula.
What syndrome results when too much fluid is exchanged during hemodialysis too quickly?
What are the symptoms of disequilibrium syndrome?
Change in LOC
Does anything exit the skin in an AV shunt?
Yes, the plastic tube that connects the artery and vein outside the arm
How long can AV shunt be used?
Just for a few weeks
Hemophilia is a ___________ disorder.
Hemophilia A is a deficiency of Factor # __________.