-
What is the treatment for V-tach? With a pulse and with no pulse.
- Pulse: O2, amiodarone, lidocaine, cardioversion
- No pulse: CPR and DEFIBRILLATION
-
What is the treatment for F-vib?
- CPR
- Defibrillation
- Epinephrine
- Shock
- Amiodarone
-
What are 3 symptoms associated with cardiac tamponade?
- JVD
- muffled heart tones
- Hypotension
-
What is the main presenting symptom of pancreatitis?
Abdominal pain!!
-
What disorder is suspected in a client who presents with pain, jaundice, and clay-colored stools?
Cholelithiasis
-
What can you teach the client to do to prevent dumping syndrome?
- Avoid sugar, salt, and milk
- Eat a high protein, high fat, low card diet
- Eat small meals and avoid consuming fluids with meals
- Lie down after meals
- Take antispasmodic medications
-
Which disease would u suspect in a client that expierences dull, gnawing pain in the mid-epigastrum or radiating pain to the back that is relieved by eating or taking antacids?
PUD
-
Bloody diarrhea, abdominal pain and tenderness are signs of what?
Ulcerative colitis
-
Cobblestone granuloma, diarrhea 3-5x a day is indicative of what?
Crohn's disease (regional enteritis)
-
What do you hang when you run out of TPN?
10% dextrose
-
Which type of nutrtion is preferred?
Enteral (maintains gut, fewer complications)
-
What are the signs of bowel perforation and peritonitis?
- Guarding of the abdomen
- Increased fever and chills
- Pallor
- Progressive abdominal distention and abdominal pain
- Restlessness
- Tachycardia and tachypnea
-
The client with chronic pancreatitis needs to limit which item in the diet?
Fat
-
Dysfunction of the lower motor neuron pathways result in:
Flaccidity
-
Hyperventilation is recommended if there is any indication of increased ICP. This intervention decreases ICP by:
lowering CO2, which results in vasoconstriction
-
What type of solution would you likely hang in a patient with brain trauma?
Hypertonic
-
What are the 3 signs/symptoms of cushing's triad?
Hypertension, bradycardia, bradypnea
-
You are caring for a patient with a brainstem injury, what is your priority assessment?
Respiratory rate and rhythm
-
Client with laryngeal cancer has undergone radiation to the head and neck, what adverse effects of external radiation would you monitor for?
- Xerostoma (dry mouth)
- Stomatitis
- Dysgeusia (distortion of taste)
-
What is allopurinal used for?
Reduces the amount of uric acid hte bdoy makes (chemo)
-
Myelosuppression (bone marrow suppression) includes what 3 problems? And what are you at risk for?
- Anemia (decreased RBC's)
- Thrombocytopenia (decreased PLT's)
- Neutropenia (decreased production of granulocytes)
Risk for --> Infection and bleeding
-
What are neutropenic precautions?
- Use of gloves!
- No fresh fruit or flowers
-
How do we assess thrombocytopenia?
Decreased PLT count
-
What are two electrolyte involved oncologic emergencies?
- Hyponatremia
- Hypercalcemia
-
Patient with thrombocytopenia is at risk for what?
Bleeding!
-
What ulcer is a common complication in burn injuries?
- Culring's Ulcer
- Curling's ulcer is a common complication secondary to hypersecretion of gastric acid--look for pain, occult bleeding, hematemesis
-
Tracheal deviation, unilateral absence of breath sounds, and neck vein distension are symptoms associated with:
Tension pneumothorax
-
Tumor lysis syndrome is manifested by what finding?
elevated uric acid
-
A client with multiple sclerosis is prescribed Balcofen for what reason?
relieve muscle spasms
-
What is the best choice of airway maintenance in an unconsious trauma victim?
Oropharyngeal airway
-
Which sign/ symptom alerts the nurse to a serious complication of a pelvic fracture?
Gross Hematuria
-
The primary nursing goal for a myasthnia gravis patient is
maintaining respiratory function
-
What is cranial nerve 9? What does it do?
Glossopharyngeal- gag reflex- risk for aspiration
-
The nurse is planning care for an adult man who is admitted with severe flame burns. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn care is characterized by:
fluid shift from plasma to interstitial spaces
-
Which classification of medications is used most often to combat the most frequent side effect of chemotherapy?
antiemetics
-
Which nursing actions assists the client to have adequate ABG values after a head injury?
Manually hyperventilating with 100% oxygen for 60 seconds before suctioning
-
To detect a common adverse (potentially life-threatening) effect of chemotherapy the nurse should assess the client for the development of which symptom?
Fever
-
What vital sign changes are seen with increased ICP?
- Increased temp and BP
- Decreased pulse and respirations
-
A client's platelet count is 95,000/ul. The nurse concludes that the client understands instructions to avoid potential complications when the client states to do what?
Avoid aspirin and aspirin (salicylate)-containing products
-
A nurse is caring for a client with metastatic bone disease. The client complains to the nurse of irritability, confusion, and weight gain. The nurse determines that these findings are indicative of:
- SIADH
- (SIADH causes water retention)
-
A long term goal for a client with multiple sclerosis is to prevent:
- Contractures!
- (Major complications associated with MS include contractures, decubitus ulcers, and respiratory complications)
-
The nurse should assess a client in the emergent phase of a burn injury for:
hyperkalemia
-
The major stimulus to acute glomerulonephritis is:
Group A streptococcal infection
-
A patient presents with difficulty starting urination and voiding several times during the night, which disease is the pt most likely suffering from?
BPH
-
UTI and Pyelonephritis are usually caused by which organism?
E. coli
-
The major manifestation of nephrotic syndrome is:
EDEMA
-
A clinical diagnosis of nephrotic syndrome is consistent with an exceedingly high level of:
Protein in the urine
-
What is the leading cause of ESRD?
Diabetes mellitus
-
Female reports loss of urine when she jogs, what type of incontinence is this?
Stress incontinence
-
The nurse would assess the client with urolithiasis for what symptom?
Flank pain
-
Which type of incontinence occurs from a sudden increase in intra-abdominal pressure?
Stress incontinence
-
Type of incontinence that occurs from loss of sensation (paraplegia)
Reflex incontinence
-
Type of incontinence preceded by UTI, tumors, or neurologic dysfunction
Urge incontinence
-
What side effects do clients often experience from dialysis?
Hypotension and muscle cramping
-
What is the first most common clinical manifestation of acute renal failure?
Oliguria
-
Clients with acute glomerulonephritis exhibit what clinical manifestations? (3)
- Hematuria
- Proteinuria
- Tea colored urine
-
What is the purpose of intestinal decompression?
remove fluid and gas build up above level of obstruction, to prevent nausea/vomiting and decrease risk of aspiration.
-
Client has been prescribed a renal diet, which selection would indicate understanding of the prescribed diet?
- Toast, grits, eggs, coffee.
- *High in carbs, low in protein*
-
A client with Ulcerative Colitis should follow what sort of diet?
High in protein, low in residue.
-
The function of the three lumens in a triple lumen catheter is:
continuous inflow and outflow of the irrigation solution
-
What is the most life threatening effect of renal failure?
Retention of potassium
-
What are the signs of a UTI in an elderly client?
Fatigue and observable cognitive changes
-
The nurse is teaching a client that is about to undergo a fistula creation, what should the nurse tell the client?
a vein and an artery in your arm will be attached surgically
-
What nursing intervention is important when monitoring a patient with BPH?
Assess for bladder distention after voiding
-
The nurse teaching a client about chronic renal failure, should instruct the client to restrict what foods?
Potatoes, tomato sauce, and dried figs (foods high in potassium)
-
What is kayexalate used for?
To lower potassium levels (exchanges potassium ions with sodium ions)
-
What dialysis therapy is best for a hemodynamically unstable client?
Continuous venovenous hemodialysis (CWHD)
-
Before hypertonic glucose, insulin infusion, and sodium bicarb are administered, the nurse should:
Assess lab data (these meds are given for high potassium levels)
-
To reduce to the risk of infection in a client with a transplanted kidney, it is imperative that the nurse:
wash hands frequently
-
What would be most beneficial for a client who has ulcerative colitis and has lost 12 pounds?
TPN
-
A client with BPH has a distended bladder and experiences involuntary loss of urine, what type of inctontinence is he experiencing?
Overflow incontinence
-
Why are steroids prescribed to the client with ulcerative colitis?
Steroids are used in acute flare ups b/c they can decrease the incidence of bleeding (steroids decrease inflammation which decerase the bleeding from ulcerations)
-
An elemental diet is prescribed to a client with inflammatory bowel to promote:
nutrient absorption within the upper GI tract
-
When should prevacid be taken?
Before meals
-
What clinical finding should the nurse look for in a client with chronic renal failure?
Uremia
-
Are grafts or fistulas able to be used sooner?
- Grafts
- AV graft 2-3 weeks, fistual 4-6 weeks
-
The client has developed peritonitis r/t a perforated ulcer. During the nusing assessment, what would the nurse most likely find?
Rigid abdomen
-
What is needed after a gastrectomy for gastric cancer?
Monthly B12 injections
-
What assessment findings would be present in a client with a small bowel obstruction?
- Projectile vomiting
- Hyperactive bowel sounds
- Tachycardia, hypotension, and dehydration
-
When teaching a client about the purpose of cimethidine, an H2 antagonist, the nurse should explain that it will:
inhibit gastric acid formation
-
The nurse suspects upper GI bleed, when she observes stool that is:
tarry and black
-
TPN is tapered before discontinuing to prevent what complication?
Rebound hypoglycemia
-
Clients experiencing malabsorption will exhibit what manifestations?
- Easy bruising
- Prolonged INR when taking coumadin
- Anemia
- Osteoporosis
-
Which foods need to be avoided with GERD and esophagitis?
Caffiene, alcohol, and chocolate
-
A client has undergone a radical neck dissection, post-op what needs to be assessed?
- Breath sounds!
- (assess for stridor!!)
-
In preparing a client for a barium enema, the nurse can expect that the client will be:
placed on a low residue diet 1-2 days before the test
|
|