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or Evaluation? Next, Decide the Order of Priority INITIAL or FIRST - NURSING PROCESS – assessment? Priority ABC if answers are not Nursing process BEST- DISCRIMINATE out of few correct answers MOST IMPORTANT ABC’s - MASLOW’S hierarchy of needs or REAL problem vs potential prob MOST CONCERNED – there is a complication 3 Implementations one assessment – maybe assessment 2 assessment and 2 implementations verify what the questions asks for First you must decide what part of the nursing process the question is connected with: ANALYSIS--is the process of identifying potential and actual health problems. Most identify pertinent assessment information and assimilate it into the nursing diagnosis. Prioritize the needs that have been identified during analysis. Some common words that are associated with ANALYSIS questions: diagnose; contrast; compare; analyze; order; prioritize; define; classify; catagorize; synthesize; sort; arrange; ASSESSMENT--consists of a collection of data. Baseline information for pre and post procedures is included. Also included the recognition of pertinent signs and symptoms of health problems both present and potential. Verification of data and confirmation of findings are also included. Assess a situation before doing an intervention. Some common words that are associated with ASSESSMENT questions: observe; gather; collect; differentiate; assess; recognize; detect; distinguish; identify; display; indicate; describe; PLANNING--Involves formulating goals and outcomes. It also involves various members of the health care team and the patient's family. All outcome criteria must be able to be evaluated with a specific time frame. Be sure to establish priorities and modify according to question. Some common words that are associated with PLANNING questions: rearrange; reconstruct; determine; outcomes; formulate; include; expected; designate; plan; generate; short/long term goal; develop; IMPLEMENTATION--Addresses the actual/direct care of a patient. Direct care entails pre, intra and postoperative management, preforming procedures, treatments, activities of daily living. Also includes the coordination of care and referral on discharge. It involves documentation and therapeutic response to intervention and patient teaching for health promotion and helping the patient maintain proper health. Some common words that are associated with IMPLEMENTATION questions: document; explain; give; inform; administer; implement; encourage; advise; provide; perform; EVALUATION--Determines if the interventions were effective. Were goals met? Was the care delivered properly? Are modification plans needed. Addresses the effectiveness of patient teaching and understands and determines in proper care was offered. Evaluation can involve documentation, reporting issues, evaluates care given and determine the appropriateness of delegating to others. Most significantly, it finds out the response of the patient to care and the extent to which the goals we met. Some common words that are associated with EVALUATION questions: monitor; expand; evaluate; synthesize; determine; consider; question; repeat; outcomes; demonstrate;
reestablish; After determining what part of the nursing process the question is concerned with, next focus your attention on determining the category of priority: Safe and effective care environment is always first. Patient safety is related to the proper preparation and delivery of nursing techniques and procedures as part of the nursing practice. It relates to every aspect of the delivery of care. Physiologic integrity is the ability to provide competent care Information that may be described as traditionally medical- surgical and pediatric nursing falls into this category. Specific questions in this area can be related to many direct-care aspects of nursing practice. The importance of this area is highlighted because it is one in which planning, implementation and evaluation of care needs can easily be identified and tested. Physiologic integrity is always a slight lower priority than safety unless it involves airway, breathing and circulation. "ABC's" always comes first! Psychosocial integrity tests the knowledge about a patients response to a disease or disorder. An understanding of stress, anxiety and ways to cope are essential. This is a lower priority the physiological integrity. Health maintenance deals with health promotion, health teaching, disease prevention and assessment of risk factors for health problems. Normal growth and development is a major theme in this category. This however, is a low priority. In Summary, when choosing the right answer for you NCLEX exam question 1) ask yourself, "what part of the nursing process is this question dealing with: analysis, assessment, planning, implantation or evaluation? and 2) Remember to prioritize your choices: safety always being first, 2)physiological integrity unless there is ABC 3) psychosocial integrity and health maintenance always has the lowest priority when choosing an answer. Other tidbits: Avoid choices with the answers "all" "always" "never" or "none". Nothing is ever a definite in Science. Look for answers that are different. If three answers say the same thing but in different words, choose the answer that is different. When given choices that are pharmacologically based or non pharmacologically based, choose the non pharmacological intervention. It is more often then not, the correct answer. 4 impl. answers one says wash hands its prob right.
Complete Blood Count (CBC) Name Normal Result WBC LYMPH LYMPH % MID MID % GRAN GRAN %
4.5-10.5 K/UL 0.6-4.1 K /UL (10.0-58.5 %) (0.0-1.8 K/ UL) (0.1-24.0 %) (2.0-7.8 K/ UL) (37.0-92.0
RBC HGB HCT MCV MCH MCHC RDW PLT MPV
%) (4.04-5.48 M /UL) (12.2-16.2 g /dL) (37.7-47.9 %) (80-97 fL) (27.0-31.2 pG /cell) (31.8-35.4 g /dL) (11.5-14.8 %) (145-450 K /uL) (0.0-99.8 fL)
Coumadin and Warfarin have higher times Name Normal Result PROTIME INR
CHEMISTRY Basic & Comprehensive Metabolic Panels. Name Normal Result BUN CREATININE GLUCOSE CALCIUM SODIUM POTASSIUM CHLORIDE CO2 BUN/CREATININE ANION GAP ALBUMIN
(10.0-26.0 mg/dl) (0.6-1.4 mg/dl) (70.0-100.0 mg/dl) (8.8-10.4 mg/dl) (135.0-145.0 mg/dl ) (3.5-5.0 mg/dl) (94.0-112.0 MEQ/ L) (21.0-32.0 MEQ/L) (8.0-36.0 RATIO) (4.0-34.0 RATIO) (3.5-5.0 G/DL)
TOTAL PROTEIN DIRECT BILI TOTAL BILI ALKALINE PHOS AST/SGOT ALT/SGPT
(6.3-8.1 G/DL) (0.0-0.6 MG/DL) (0.2-1.3 MG/DL) (40.0-150.0 IU/L) (5.0-34.0 IU/L)
Diabetes Our HbA1c method is calibrated using a NGSP DCCT-referenced method. While the 'normal range' is 6.0, the target for a patient with diabetes depends upon their clinical situation. In general, AACE recommends a target for diabetes patientsof 6.5 or less. HbA1c Name Normal Result HbA1c-DCCT Ref (4.00-6.00 %) .
Name CORTISOL Urine Studies
Normal Result (2.50-25.00 ug/dL)
Lab: Urine Protein 24 hr (doesn't include volume) Name T.URINE PROTEIN tputest 24 HR. TP URINE Expected results
This is an internal calculation from our computer that is not relevant (30.00-150.00 mg/24 hr)
Lab: Creatinine Clearance Name CREATININE URINE VOLUME Expected Results (0.6-1.4 mg/dl) (1000-3000 ml/24 hrs)
The urine creatinine concentration varies URINE CREAT significantly depending upon amount of fluid intake This is an internal calculation TV from our computer that is not relevant CREAT (97.0-137.0 mL/min ) CLEARANCE UA Urinalysis dipstick Name 10/25/2007
COLOR CLARITY LEUKOCYTES NITRATE UROBILINOGEN PROTEIN pH BLOOD SPEC. GRAVITY KETONE BILIRUBIN GLUCOSE
YELLO W) (CLEA R) (NEGATI VE ) (NEGATI VE ) (NEGATI VE ) (NEGATI VE ) (5.0 8.5 ) (NEGATI VE ) (1.000 1.030 ) (NEGATI VE ) (NEGATI VE ) (NEGATI VE )
UA Microscopic Add-On to dipstick Name 10/25/2007 (NEGATIVE /HPF WBC ) (NEGATIVE /HPF RBC ) (NEGATIVE /LPF CASTS ) (NEGATIVE CRYSTALS ) (NEGATIVE YEAST ) (NEGATIVE /HPF EPITHELIAL CELL ) (NEGATIVE TRICHOMONAS ) (NEGATIVE BACTERIA )
NCLEX Lab stuff Na 135-145 K 3.5-5.5 Ca 8-10 Mg 1.5-2.0 Platelets 150,000-450,000 ptt 30-60 seconds WBC 5,000-11,000 RBC 4.5-6.0 million Hct 35-45% Hgb 12-16 BUN 7-20 Creatinine 0.5-1.5 Quickening 16 weeks fetal heart tones 20 weeks fetal heart rate 120-160 Litium intial 1.0-1.5, therapeutic 0.6-1.2 Dilantin 10-20 Digoxin 0.8-2.0 Heparin look at ptt and antidote is Protamine Sulfate Coumadin look at INR and antidote is vitamin K Mag Sulfate antidote is Calcium Gluconate narcotic antidote is Narcan Tyenol antidote is Mucomist Insulin: Reg 30-60 min onset, 2-4 hr peak and 5-7 duration NPH 1-3 hr onset, 6-12 hr peak and 18-24 duration Lispro- fast acting and to eat right away pH 7.35-7.45 PaCO2 35-45 PaO2 90-100% HCO3 22-26 Rules of Nines: 9% is head and each arms, 18% is front torso, back torso and each legs and 1% is groin 5 P's with fractures: pain, pallor, pulselessness, paresthesia and paralysis Cranial nerves: Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Acoustic, Glassopharnygeal,
Vagus, Spinal Accessory and Hypoglossal Fetal Heart strips: VEAL CHOP (Variable is cord, early is head, accelerations is ok and late is placental insuffenciency) Cancer: CAUTION signs starve a gastric ulcer, feed a duo ulcer 200-300 ml blood loss with vaginal birth, 500 ml with c-section, over is hemorrhage Addison's (AD-Aldosteron Deficiency to remember) disease- ↓NA and ↑ K, HYPOGLYCEMIA. Remember – if there is low/absent NA+ in the body, than nothing holds H2O in. Thus, ↑ Urine output, Hypotension +, Hypovolumia, dehydration and ↓ CO. Major function of Aldosterone – is to keep NA+ in & K+ out of the body . Cushing’s (too much glucocorticoids) syndrome is opposite to Addison’s. Adrenal hypersecretion of glucocorticoids. ↑ NA ↓K and Ca, HYPERGLYCEMIA. When assessing think of the cushion (moon face, buffalo hump, truncal obesity). Pheochromocytoma - HTN is a hallmark. Urine specific gravity: 1.010-1.030 Diabetes Insipidus: â ADH, á UO (dehydration), â urine specific gravity, á serum Na SIADH: á ADH, â UO á urine specific gravity, â serum Na, HHNKS: glucose > 800, no ketones, acidosis Total cholesterol: optimal <200. borderline 200-230. high > 239. LDL: optimal <139. borderline 140-160. high >160. AST: 10-40 ALT: 5-35 Serum albumin: 3.5-5.5 Hemophilia a: no asa, nsaids Blood type O = universal donor. Blood type AB = universal recipient CVP: nl 3-12. >12: hypervolemia, <3: hypovolemia Isotonic: 0.9% NaCl, LR, D5W Hypotonic: 0.45% NaCal Hypertonic: D10-15W, 3% NaCl 60mg=1grain Carbamazepine: therapeutic 5-12 Antabuse: avoid otc cough/cold-contain alcohol 24-34wks: fundal height correlates with wks gestation No grapefruit juice: cyclosporine, carbamazepine, buspar, zocor, verapamil OD benzodiazepines – antidote: flumazenil (romazicon) KAPLAN missed Q - Cranial nerve VII – asymmetry of face - Cranial Nerve IX – swallowing problems - Cranial Nerve I – loss of smell - Cranial nerve III – Ptosis - Older client – hydration – check BP - Older client - sudden confusion – infection - Hemophilia is sex linked disorder - Mother to son
- Insert suction catheter until resistance, than withdraw and apply intermittent suctioning twirling motion. - Fear of height – projection and displacement - Dilaudid – narcotic analgesic - measure for hypotension and respiratory distress - Older – renal glucose is elevated in their urine – false negative reading - Enema – left side lying position - Laryngotracheobronchitis – early sympt.- inspiratory stridor and restlessness - Extrapyramidal side effects – Akathisia – motor restlessness - Dystonias – protrusion of tongue, abnormal posturing - Pseudoparkinsonism – tremors, rigidity - Dyskinesia – stiff neck, difficult swallowing Early preeclampsia – facial swelling and proteinuria CVA – facial paralysis – protect eye from corneal abrasion Lithium toxicity – early fine tremors, nausea, vomiting, diarrhea Infant – solid food – rice cereal – start around4-5 months Solitary play – infant Parallel play – toddler Associative play – preschool Addisonian crisis – restlessness, rapid weak pulse 4th stage of labor – fundus – palpable at umbilicus Alcohol problem – symptoms are tremors, ↑ temp., nocturnal leg cramps… Antibiotic ( Rocephin) – watch for overgrowth of organisms on tongue or mouth Rinne test – fork next to mastoid bone than front auditory canal Clomiphene (Clomid) – induces ovulation by changing hormones in ovary Naproxene (Naprosyn) – NSAID – SE HA, dizziness, GI, pruritus and rash Cortisol – anti-inflammatory agent Verapamil – check Heart rate Blood transfusion – allergic reaction – respiratory wheezing, urticaria (hives), facial flushing, and epiglottal edema. Pacemaker purpose is – increase the cardiac output by regulating cardiac rhythm. Plasma cholesterol screening instruct client to only sip water 2 hrs before the procedure Lead poisoning – best fluids milk – vit. D helps remove lead from bones Stages of terminal illness – 1 – denial, isolation 2 – anger 3 – bargaining 4 – depression 5 – acceptance. Intravenous pyelogram IVP – examines by x-ray of urinary tract evaluates kidney function SHARE is a group who supports parents who lost a newborn or had miscarriage. Fluid balance in older – maintain an accurate intake and output Early stage of nephritic syndrome – adequate protein intake and low sodium Colostomy irrigation should be initiated at same time each day for normal pattern Ataxia – supervise ambulation Amniocentesis – detect hemolytic disease of the newborn Blood transfusion – hemolytic reaction – chills, headache, backache, dyspnea, cyanosis, chest pain, tachycardia, hypotension. Sputum culture – collect in the morning, cough deeply and expectorate Radiology department is responsible for handling radium implant Sodium VS Lithium Fetal alcohol Syndrome – replace vitamins – poor maternal diet Radical mastectomy – first - care for patient’s pain Tetrahydrozoline (Visine) – no for closed-angle glaucoma, caution in hypertension Methenamine (Mandelamine) – avoid alkaline foods and fluids such as milk Estrogen - side effect – nausea Exploratory laparotomy – intestinal obstruction – distended abdomen with pain Hyperparathyroidism – Highest Cardiac dysrythmias Reactive depression – most physical and psychic energy in the morning Young adult – Erickson’s intimacy versus isolation Pt. with gastric ulcer have pain – ½ hr to 1 hr after a meal Diabetes insipidus – dry lips, ↑urinary output, low specific gravity 1.004 - N(1.010-1.030) Narcan is used when respiratory depression cause by Opiates – can be repented in 2-3 minutes. Abdominal muscles help support lumbar spine Who should nurse see first think ABC Compazine – controls nausea and vomit Epidural used for pain relief monitor for urinary incontinence, hypotension, respiratory depression, nausea and vomiting
Right cataract surgery – do not place on R side, do not put a pressure on the surgery. Fetus produces ↑ amount of insulin to match mothers increased glucose levels, after birth infant has increased insulin and ↓ level of glucose… Cystic fibrosis - ↑ protein, ↑ calories ↓ fat PSA and phosphatase test for prostatic cancer Biopolar – combative behavior – gain control with physically aggressive – administer sedatives and mood stabilizing meds. Hiatal hernia – hallmark – awakening at night with heartburn Captopril – antihypertensive measure BP Pneumonia infection – cellulitis infection ↑ temperature – body compensatory - ↑ respiratory, tachycardia, ↑ pulse rate Irritable bowel syndrome – diarrhea and constipation 5 years – boy talk on a toy phone and imitates father 6 months old – DTP, 15 months – MMR 2-4-12-18 months polio, chickenpox and smallpox not recommended Pain = inflammation and infection Obsessive compulsive rituals help avoid anxiety Guillain-Barre Syndrome – diagnosis – respiratory failure, flaccid paralysis (paralysis of the muscles) urinary retention (loss of sensation) Propranolo Inderal – se – airways – wheezing, shortness of breath, Bronchospasm – nonproductive cough Draining abscess – contact precautions – gown and gloves Prosthetic hip implant - side-lying affected hip in abduction, Cuffed tracheostomy tube – seals trachea helps prevent aspiration Electroconvulsive therapy – call physician when backache present Babinski reflex gone 1 year, Moro’s gone 3-4 months, Tonic neck reflex – 3-4 months, Palmar grasp gone 3 months and Plantar gone by 8 months Best nursing action – assess bf implementing (ask yourself if assessment was done and if its enough if not assess) Hypoparathyroidism – risk for laryngospasm – have tracheostomy set Naegele’s rule add 7 days to first day of menstrual period and subtract three months Question 86
• • • •
Parietal lobe (A)-primary center for sensation Temporal lobe (B)-auditory reception area Frontal lobe (C)-CORRECT-involved with personality, behavior, emotions, and intellectual function Occipital lobe (D)-primary visual receptor center
- Take the cholestyramine (Questran) with meals- appropriate action; never take powder dry because it will cause esophageal irritation Increase intake of whole grain cereals.- side effect is constipation; increase intake of fiber and fluids Walk for 30 min, 3-4 times per week. - cholestyramine (Questran) is an antilipemic; regular exercise will prevent atherosclerosis - Hypokalemia - A patient diagnosed with multiple sclerosis receiving prednisone 200 mg PO- corticosteroids cause hypokalemia
A patient diagnosed with systemic scleroderma receiving total parenteral nutrition.-TPN causes hypokalemia A patient diagnosed with acute ulcerative colitis preparing for an ileostom -diarrhea causes hypokalemia
- Hypokalemia - Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not a characteristic of hypokalemia - Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia. Diltiazem is a calcium channel blocker that inhibits calcium movement across cell membranes of cardiac and smooth muscle. It dilates coronary arteries and peripheral arteries and arterioles. Diltiazem decreases the heart rate and slows SA and AV conduction. The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel. The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5 hours - Kawasaki disease - In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present. Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain. - Rifampin – TB - Soft contact lenses may be permanently damaged by the orange discoloration in body fluids caused by rifampin. Any sign of possible jaundice (yellow-colored skin) should always be reported. If rifampin is not tolerated on an empty stomach, it may be taken with food. The client may be on the medication for 12 months even if cultures give negative results. Peyer patches are lymphoid nodules located in the small intestine where T cells congregate. - The therapeutic phenytoin (Dilantin) level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) appears. At a level higher than 30 mcg/mL, ataxia and slurred speech occur. If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity, location, duration, and quality. Although options 1, 3, and 4 all may be components of the assessment, none of these questions would be the initial assessment question in this client. - BuSpar should relieve rapid heartbeat, or anxiety. Buspirone (BuSpar) is not recommended for the treatment of drug or alcohol withdrawal, thought disorders, or schizophrenia. Buspirone hydrochloride most often is indicated for the treatment of anxiety. Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience adverse effects that includes depressed respiratory rate (below 12 breaths/min), severe hypotension, and absent deep tendon reflexes (DTRs). Risk factors for PUD include Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), caffeine, alcohol, and stress. Ibuprofen is an NSAID, and when taken as often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical conditions such as Crohn’s disease, Zöllinger-Ellison syndrome, and hepatic and biliary disease also can increase
risk for PUD by changing the amount of gastric and biliary acids produced. Ulcer disease in a first-degree relative also is associated with increased risk for an ulcer. Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction, which drains serosanguineous fluid. In the first 24 hours after surgery, the drainage may total 80 to 120 Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Atropine sulfate must be available in the event of systemic toxicity. Pindolol is a β blocker. Naloxone hydrochloride is an opioid antagonist used to reverse narcotic-induced respiratory depression. Protamine sulfate is the antidote for heparin. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A “silent chest” is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child’s condition is improving. Shunting occurs when a portion of the lung area has adequate capillary perfusion but is not being ventilated. As a result, no gas exchange occurs. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs. A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance to the stoma. A retracted stoma is characterized by sinking of the stoma. Ischemia of the stoma would be associated with a dusky or bluish color. A stoma with a narrow opening is described as being stenosed. Tamsulosin hydrochloride FLOMAX is used to relieve mild-to-moderate manifestations that occur in benign prostatic hypertrophy. The medication also improves urinary flow rates. Somatotropin (Humatrope) should not be administered during or after epiphyseal closure. Efficacy of therapy declines as the client grows older and is usually lost entirely by age 20 to 24 years. Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. Ergotamine CAFERGOT produces vasoconstriction by stimulating α-adrenergic receptors, which suppresses vascular headaches when the medication is given in the therapeutic dose range. The nurse periodically assesses for hypertension, cool, numb fingers and toes, muscle pain, and nausea and vomiting. Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convulsions, hypokalemia, and hypocalcemia Nesiritide NATRECOR is a recombinant version of human B-type natriuretic peptide, which vasodilates arteries and veins. It is used for the treatment of decompensated heart failure, increases renal glomerular filtration, and increases urine output. Salicylate compounds such as sulfasalazine (Azulfidine) act by inhibiting prostaglandin synthesis and reducing inflammation. The nurse teaches the client to take the medication with a full glass of water and to increase fluid intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation. A quad cane may be used by the client requiring greater support and stability than is provided by a straight leg cane. The quad cane provides a four-point base of support and is indicated for use by clients with partial or complete hemiplegia. The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts. High-pressure alarm would sound if present of mucous plug, kinks in the ventilator tubing, excessive secretions Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.
PRECAUTIONS The nurse observes that staff members enter patient rooms wearing a mask, gown, and gloves, and the doors to the patient rooms remain open A patient diagnosed with influenza.-staff member is following droplet precautions; acute viral respiratory infection that is spread by droplets - A patient with a draining abscess that is uncovered. abscess with no dressing requires contact precautions - A patient diagnosed with bronchitis-inflammation of large airway; standard precautions - A patient diagnosed with Hantavirus pulmonary syndrome- cardiopulmonary illness caused by a virus transmitted by direct or indirect contact with rodents; standard precautions
- A patient diagnosed with tonsillitis-inflammation of large airway; standard precautions - A patient diagnosed with respiratory syncytial virus-acute viral infection causing bronchiolitis; contact precautions - A patient diagnosed with cystic fibrosis- hereditary dysfunction of exocrine glands causing obstruction because of flow of thick mucus; standard precautions.
contact precautions gown and glowes
a mask, gown, and gloves, and the doors to the patient rooms remain open 3 feet space bt pt and visitors. rubella requiring an IM injection acute viral respiratory infection influenza Pertussis-private room, spatial separation 3 feet between visitors and pt.
Pneumocystis carinii pneumonia with an elevated temperature opportunistic infection of HIV cancer complaining of a sore mouth Candida herpes zoster with an ophthalmic infection Kawasaki Disease Toxic Shock Syndrome Lyme’s Disease Infectious Mononucleosis bronchitis-inflammation of large airway Hantavirus pulmonary syndrome- cardiopulmonary illness caused by a virus transmitted by direct or indirect contact tonsillitis-inflammation of large airway cystic fibrosis- hereditary dysfunction of exocrine glands causing obstruction because of flow of thick mucus Bronchitis – inflammations of large airways
tuberculosis requiring administration of rifampin
Respiratory Syncytial Virus draining abscess that is uncovered. abscess with no dressing Salmonella - bacterium mononucleosis
Wound with S Aureus
Risk to develop a pulmonary embolism - A 16-year-old boy with a fractured left femur due to a sledding accident. -fat emboli is sequelae of fracture of long bones; among pediatric-aged patients, adolescents are most likely to have pulmonary emboli because of nature of their injuries - A 42-year-old obese postpartum woman who is gravida 5, para 5. -pregnancy, obesity, increased maternal age, and high parity are predisposing factors for developing DVT - A 72-year-old man taking a 3-day car trip from Missouri to California. -prolonged sitting causes venous stasis, which predisposes to the development of DVT - An 80-year-old man diagnosed with lung cancer and a history of deep vein thrombosis. lung cancer causes hypercoagulability; advancing age and history of DVT are also predisposing factors Bromocriptine (Parlodel) – take with meals to lower GI upset Decelerations of FHR while having IV oxytocin – stop oxytocin to increase FHR (it will decrese contractions and remove uterine pressure from a child) Cushing syndrome – respirations priority, client prone to fluid overload and CHF due to sodium and water retension.
Detached retina – photophobia – bright flashes, loss of a portion of visual field – dark Magnesium sulfate can slow respirations, can cause hyporeflexia, Newborn RR 30-60 min Doxepin hydrochloride (sinequan) – report change theraphy when developes tremors, and is excitable (overdose) Cardiac cath. – bed rest 8-12 hrs and pressure dressing over cath insertion Peripheral pulses checked q 15 min for 1st hr, 30 min for 2hrs, next q4 hrs, NPO midnight before procedure Mitral stenosis and CHF can be caused by rheumatic fever cause carditis (valves) Swan-Ganz cathether measures pulmonary artery wedge pressure indirect reading of the pressure in the left ventricle Hypoglycemia – tachycardia, cold clammy skin, weakness and pallor, check blood sugar offer milk Low platelets (150,000-400,000) decrease causes problems with blood clotting – risk for injury Post-op abdominal abscess had drain inserted – what to assess? – character of the drain – purulent or other? Pregnancy – epigastric pain – impending convulsion Hypoglycemia – cool, clammy skin, diaphoresis, nervousness, weakness, hunger, confusion, HA, slurred speech, come Relaxed uterus – put infant to the breast – cause natural oxytocin release to contract uterus Addison’s during stress pt needs more sodium – increase sodium intake S3 ventricular gallop is earliest sign of CHF PCA if itching its SE of narcotics Trifluoperazine (Stelazine) – notified nurse if difficult urinating MASLOW safety nr 1 unless there is ABC as an option Digoxin level 0.5-2 ng/ml Three chamber water seal drainage (Pleur-evac) – no fluid fluctuation noted what to do – fluctuations stopped lungs might be re-expanding, take x-ray to confirm RN- head injured client with Glasgow come nr 5 Appendectomy – H in protein, H in calories H in vit C Cholestyramine (Questran) – sprinkle on food or drink, let it stand than stir Pharatjyroidectomy – preop diet - low-calcium diet Isoniazid (INH) – report if fatigue and dark urine seen – hepatic dysfunction Baby aspirin overdose symptoms – tinnitus and gastric distress Hemophilia A – oxycodone (Percodan) can cause bleeding contains aspirin MRI remove nitroglycerine patch bf the procedure Dehydration give give hypotonic solution 0.45% NaCL 10 year old draw the pictures bf cardiac cath. Nitroglycerin – watch for Decreasing BP Piperacillin (Pipracil) check for allergis Sucking tumb – normal behavior for 17 months and disappears 24 moths of age Tranylcypromine sulfate (Parnate) avoid foods with tyramine to prevent hypertensive crisis Hydralazine Apresoline BP is 90/60 do not adnminister any extra dose due to low BP, check with DR Hyperparathyroism report if hematuria due to renal calculi over 50% have renal stones Discharge teaching multiple sclerosis – avoid heat and cold – damage to sensation Naproxen sodium (Anaprox) – NSAIDS can cause GI bleeding – stool turns dark – call doctor Transitional stage of labor active labor – use pursed lips to breath – control pain and help to oxygenate fetus Cystic fibrosis – [positive sweat test – replace enzymes Sengstaken-Blakemore tube in place – women in respiratory distress – cut the balloon ports and remove tube Sucralfate Carafate – best on empty stomach Vaginal delivery – check pt’s lochial flow for hemorrhage (First nursing action) Circulation Isoniazid (INH) – may cause peripheral neuropathy – hands and feet tingle also nausea Lumbar puncture – stay flat in bed after the proc for 8 hrs. Hepatic encephalopathy – early symptoms – impaired thought process Oxytocin (Pitocin) – always a secondary infusion controlled by an IV pump Mtronizadole (Flagyl) – no alcochol can cause Antabuse like reaction nausea, vomiting, HA, cramps, flushing. Aspirin – sickle cell crisis - hemorrhage Magnesium sulfate CNS depressant SE is oliguria (decrease UO) Humulin R is clear drawn up first than Humulin N (cloudy) Butorphanol (stadol) – check VS (med decreases Rate and depth or respirations) pH increased and CO2 increased pt is hyperventilating due to alkalosis – breath to paper bag Polio vaccine – life virus no immunocompromised Chloropromazine hydrochloride (Thorazine) – give medication evening time if possible to reduce daytime sedation Bronchoscopy – assess pt for symptoms of respiratory distress from swelling due to procedure like tachypnea, tachycardia, respiratory stridor, and retractions Cephalexin monohydrate (Keflex) good foods are to help maintain normal intestinal flora Keflex destroids it… Tracheostomy tube out quick replace the tracheostomy tube to secure the airway Head circumference N is 32-36 increased indicate hydrocephaly or IICP Meglumine Diatrizoate (Gastrografin)
Remember 5 rights of medication administration – if there is a medication and you gave 1 medication impl. Right it might be correct…..??? Neostigmine bromide Prostigmin – delay in taking the med may cause difficulty in swallowing, diffucult in taking medication Problem with a chest tube – constant bubbling in the water seal chamber due to an air leak Disoriented client keep side rails up SAFETY Question asks about a drug which is Diuretic look for an answer desired for what diuretic does – look for urine output or clear lungs etc… Hep A communicable for 2-3 weeks bf jaundice and 1 week after jaundice. child can return to school 1 week af jaundice Alcohol withdraw delirium – need more sedation if pulse rate is Increased Bulge test – checks for fluid in the knee, extend legs Expected Embolism in lungs position patient on her left side and Lower the HOB – air bubbles stay away Haemophilus Influenzae (meningitis) droplet precautions for 24 hrs after antibiotics therapy Pneumonia - therapeutic response – RR regular no dyspnea, moderate amount of white sputum Cromolyn sodium (Intal) for asthma - lowers allergic triggers take before vigorous exercise Fluid excess orthopnea, dyspnea, crackles, decrease IV fluids Labor FHR is 59 what to do – fetal bradycardia might be cord compression or separation of placenta its fetal distress L side reduces compression of Vena Cava and aorta – turn L side give O2 by NC start IV Stage four Parkinson’s disease pt is immobile do ROM to 4 extremities 4 times per day Element of MALPRACTICE are duty, breach of duty, causation, and injury to be sued and win all elements must to match if not nurse is innocent
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