final when you have a pt with a cast what is your priority= circulation,movementand sensation...

. assesscirculationby pulsecheckmovementby movingfingerschecksensationby askingif theycan feel anything when you have a child with a arm cast what is priority >checkperipheralpulsesin affected area invasion of client privacy.. what would be a good example of violating patient privacy a client was brought to er after serious accident needs to go to a procedure needs an informed accident who do you go to ? nevera friendonlyclosefamilymember you are doing rounds, in planning client rounds, which client will you collect the data first? lookfor a pt whowill fall into categoryof ABC- ABCis priority You have a patient who came from surgery the initial nursing action is= (immediately after post op) youractionis ABC(infectiondoesntset in until 72 hrs do not answerthat) your pt has sever headache he was given analgesic how does it give pain release= gait controlmechanism Bilroth I- gastro dudenostomy II- gastro jujenostomy If they have has abdominal surgery what will they come back with? NGT(inorderto removeexcessair you needto add NGTfor first 24-48 hrs after surgery*whichof the physicianordersdo you question?Never irrigatea NGTstatuspost abdomensurgery you have a pt w/ acute gastritis, which medication that you find on your pt chart is contraindicated = NSAIDS(irritateto stomachIbuprofen,aspirin, steroids) acid base- ph-7.35-7.45 paCO2= 35-45 Respiratory pa O2= 80-100% HCO3= 22-28 GI/Kidney (metabolic) (21-26) <---Acidosis ^ Alkalosis---> UGIT- NGT/Vomiting > left with metabolic alkalosis (if it comes out your mouth alkalosis) LGIT- Diarrhea > left with acidosis (comes from your anus is acidosis) Respiratory Acidosis > COPD= Asthma, bronchitis, Pulmonary Emphysema Trap CO2= CO2+H2O> H2CO3- Resp acidosis Chronic bronchitis usually stays with the pt Hyperventilate (RR^ deep rapid) Hypoventilate (RR down shallow) Which diet do you not give to COPD pts?- Carbohydrates

 A pt has fat embolis (from fracture of long bone) clot that has moved... DX: CXR if fat embolis goes into lungs it is called pulmonary fat embois Osteoarthritis- degenerative;older population;unilateral;pain=restpain goesaway RA- inflammatory- no specific age; elderly pts; autoimmune condition; symmetrical; pain-rest pain still there labs: ^ESR (inflammatory condition) measures how fast RBS move; positive rheumatoid factor Herniated slip disk (intervertebral disk) If a pt with a known herniated disk c/o rt/lt buttocks pain is a result of? musclespasmon herniateddisk computation: dr orders medication 0=7.5 mg IM BID S= 10mg/mL 7.5X 1ml = 0.75 ml 10 when you have a pt with AKA= what type of dressing= compressiondressingwhatis immediatenursinginterventionif dressingcomesoff? Rewrapcompressionstocking Compartment syndrome= increased pressure in a muscle compartment= Fasciotomy= opening into fascia do muscles decrease in size decrease in edema > wound care= moist sterile normal saline dressing When giving a flu vaccine first question to ask = ask if they are allergic to eggs pulmonary emphysema- CO2 maximum of 2 liters to patients Systemic lupus- s/sx- butterfly rash; polymyalgia (muscle pain); polyarthalgia (joint pain) If a pt fractures a leg what kind of acute pain will he have= nonseceptive pain- pain 6 months or less what do you do with a cast -- elevate the leg to release edema and swelling; how long do you allow for cast to dry 24-48 hrs; NI- tap on cast for itching or apply cold compresses GI: liver cirrhoses - crackles- pulmonary overload- no flat veins; no increase urine output; no rapid pulse nurse plan of care knowing which of the following american asian- they believe in Yin and Yang albuterol- bronchodilator; tachycardia; asthma; respiratory distress COPD (resp. acidosis) when you have a pt ventilator dependent alarm is going on > What is initial NI when trying to trouble shoot for ventilator that keeps alarming- Use ambubag for patient - ventilator not working Osteoarthritis- pain in the joints; dull aching pain young female pt going for cxr- are you pregnant when you are assisting client going for pulmonary angiogram? are you allergic to sea food what manifestation to indicate you are allergic to contrast medium? Respiratory distress

 if you have a pt w/ a fx and cant feel anything on lt finger and slow capillary refill and decrease pulses what do you do first? Call physician because it is life threatening If a pt has pulmonary TB what are not manifestations? Mark all that apply- no stridor, no fever; non productive cough, chills, anorexia, wt loss, night sweats if you have a pt who went for ORIF of hip- when trying to turn pt do not cross legs use abduction pillow (away from mid-line) compartment syndrome- from a severe fx pt asks how did he develop compartment syndrome? Swelling in muscle unable to expand. increase pressure pt w/ multiple trauma admitted to hosp w/ fx and placed a cast, in positioning leg w/ cast what do you do? elevate legs continuosly for 24 hours to decrease presence of edema what is this diformity- pt goes to er for lower leg, injured leg looks shorter and smaller than other leg; painful and ecchymosis? Contusion fracture SPrain- joint STrain- muscle skin traction- use bandages skeletal traction- pins goes into bones Pt asking nurse why do you need box extension traction (example of skin traction) before going too surgery, what is the purpose? to decreasemusclespasms pt w/ pulmonary TB- DX = sputum culture Imodium- anti-diarrrhea Pt has chest tube- monitor for Subcutaneous emphysema> crepitus secondary to emphysema> refers to air pt went for sx, pt diet changed from NPO to clear liquids, what should pt have before giving clear liquids? bowel sounds; normal BS is 4-32 pt went for EGD, what is highest priority for this client? GAG reflex (any procedure that goes through the throat) if a pt goes for chemo what is sx: nausea, anemia, neutropenia, depressed bone marrow= decreased RBC, WBC, Platelets, (-penia is decreased) which of the following will you not expect for chemotherapy if your patient has chronic gastritis (stomach) what do you have to absorb vitamin B12 (decrease b12=pernicious anemia) ? IF (intrensic factor) what is your NI priority if your patient has multiple myeloma (bone marrow)? increase fluid intake (proper hydration) characteristic myeloma dumping syndrome- rapid emptying of stomach contents from duodenum; what are manifestations= pale; sweating;pallor (no dry skin, bradycardia, no double vision) What are you going to tell pt after a CT scan w/ dye? warmflushingsensationas you inject into body, fluids will not be restricted, not painful, test does not take 2-3 hrs pt w/ acute pancreatitis what 2 enzymes will be affected? Amylase and Lipase; what position do you avoid= supine (flat)

Zantac (ranitidine) what is best time to give Zantac? At bedtime pt on prolonged bed rest to prevent GI complication? fluids if not contraindicated Respiratory complication on prolonged bed rest? youre taking care of a pt what do you do to monitor Prilosec- medications for GERD Pt has taking meds for 4 wks how would you know if pt has received optimal intended effect? preventheart burn TENS unit- transcutaneouselectricalnervestimulation; which statement from pt does he need more teaching? Needles need to be inserted into skin You have an older female pt that you would like to join group therapy in facility what nursing action would you consider doing first before going to that group? Changediaper pt went for pneumoectomy what is >> pinkfrothysputum(pulmonaryedema) anaphylaxis- severe allergic reaction- what is priority for severe allergic reaction= airway Decrease immune system- infectionprevention pt has Lupus defined as inflammatorycollagen if the dr orders you to give an IM injection of 400,000 units H/S=300,000 units per mm how many mL do you give when inserting NGT position in highfowlers(90 degree) if pt had AKA RT leg how would you position pt? w/ pt has evicersation - sterile salinedressing,assessfor shock,call nurseinstructpt to remaincalmand quiet, preparept for sx if your clients doesnt speak english and has pain what chart does he use to describe pain? WongBaker mark all that apply- a pt went for surgery you are monitoring for signs of complication which of the following would you expect to find in an immediate post op pt? less than3 capillaryrefill; homanssign(-); hypoactiveBS; if vital sign of pt comes back from sx and bp is 100/60 p: 90 resp: 20 bpm what do you do? Nothing- normalranges lung infection turns into- pneumonia chest compression- 1/2-2 inchesfor adults what lab results will tell you a sx needs to be rescheduled? HGB incentive spirometer teaching that pt doesnt understand- I can use in any positionI want pt is verbally abusive and confused; has headache and asking for analgesic nurse says she cannot: says she was going to put in restraints: what is that considered: Abuse Ethnocentrism- tendency to view your culture as the best; stem: which statement is lack of understanding? hypercalcemia- when you have increased high calcium levels - muscleweakness how would u know client is benefitting from platelet transfusion- decreasedbleeding chills andrashes

 prevent DVT on pulmonary embolism- ROMexercises a piece of lungs removed what are expected findings when pt has chest tube draining? middlejar fluctuatingup and down;if you have50cc-100 is normalof drainingdressingyou use is occlusive- petrolatumdressing;drainiagesystemshouldbe underbed; no bubbling-leak in system;whenyou removechesttubetell pt to hold breath(valsalva) when you have medication PRN what does it mean= as needed if pt has cancer pain how do you give ? aroundthe clock broth, jello, tea (clear liquid is anything u can see through) when feeding a GT patient place in - fowlersposition if pt has ucer and taking tums how do you know pt - heart burnis gone Zolfran-anit nausesand anti vomiting A pt w/ GERDpprescribedReglan- 30 minutesbeforeeachmeal Bisulfan (Myeleran) drug of choice for Leukemia; GiveAllaperinol(anti-gout) medication pt has NGT low suction- pt has metabolicakalosis in gastroesophagia disease- which substances will increase lower dysophagia spincter pressure? nonfat milk (do not give fatty acids, tea, or coffee) pancreatitis- what is major complication in paralytic ileus? do not havegas what is associated w/ Crohn's disease? malabsorption why do you stage lung cancer? to identifybest treatment If you are giving pt Kayexalade (K to K) drug of choice to bringdownpotassiumlevel (chooselowestpotassiumlevel) If you are supervising nursing student who is doing suctioning how do you know if student is performing it wrong: whenyou noticeshe is applyingsuctionuponinsertion Aspirin toxic- ringing in the airs Always remember HCT % = women normal level 42-46 male is 48-53; When you are dehydrated (hct increases)? 48