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When you keep a neonate's head in the "sniff" position, how do you do it and what is the purpose of this?
Extend the neck slightly. Purpose is to open airway
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If you have a wound contaminated with soil that may contain animal excrement & has completed the full childhood tetanus immunization given, do you need to take another dose of tetanus vaccine?
If you have received tetanus toxoid within the last 3 years, you don't have to
If your most recent dose was administered 3 or more years earlier, then you need to get a dose!
*REMEMBER # 3!
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The fourth heart sound (S4) indicates:
A failure of the ventricle to eject all blood during systole
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S3 heart sound indicates
Decreased myocardial contractility
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The patient has a complete T5 spinal cord injury (this is a distractor, ignore it).
Assessment: flushed skin, diaphoresis above T5, BP 162/96. Severe pounding headache
Is it OK to elevate HOB 90 degrees?
Fan to reduce diaphoresis?
Yes, it's necessary to elevate HOB to 90 degrees and place extremeties in dependent position to decrease venous return to the heart and increase venous return to the brain. HIGH BP is the most life-threatening condition
NO! No fan because cold drafts may trigger Autonomic Dysreflexia
Also, this is s/s of autonomic dysreflexia therefore remove tactile stimuli (remove constrictive clothing, assess for bowel impaction and bladder distention). Correct any problems. Give antihypertensive meds b/c elevated BP is the most life-threatening complication!!!
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Early postpartum hemorrhage. Which intervention requires revision?
1. Insert an indwelling cath
2. Fundal massage
3. administration of oxytocics
4. pad count
By the time client is hemorrhage, PAD COUNT is no longer appropriate.
Indwelling cath to eliminate the possibility that a full bladder maybe contributing to the hemorrhage.
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What is phentolamine (Regitine). MOA, class, what's for.
- Class: Alpha-adrenergic (receptors that target catecholamines)
- MOA: Antagonizes the body's response to circulating epinephrine and norepinephrine, reducing BP quickly and effectively.
- For: Usually give IV bolus or drip for pheochromocytoma
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After transphenoidal hypophsectomy, what sign most likely indicates hemorrhage?
Frequent swallowing since fluid or blood leaking from the sinuses into the oropharynx.
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Basilar skull fracture. What's a sign indicate hemorrhage?
Bloody drainage from ear
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After an AIR-contrast study, what position should we place the patient in?
Supine with head lower than trunk. (Trendelenburg)
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After blood is removed from fridge, it should be administered within how many hours?
4 hours.
If blood is administered too rapidly (within 1-2 hrs), fluid overload.
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What type of agent is Venlafaxine (Effexor)?
Second-generation antidepressant agent. SNRI
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Patient is experiencing PAT (Paroxysmal Atrial Tachycardia).
Adenosine, an antiarrhythmic is usually ordered
Acts on the AV node to slow conduction and inhibit reentry pathways, convert PAT to sinus rhythm.
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Atropine sulfate is usually used to treat...
Symptomatic bradycardia
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Intravesical instillation of BCG (for bladder cancer) usually causes what kind of adverse effect?
HEMATURIA, urinary frequency and dysuria.
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Patient with compound fracture, highest priority nursing diagnosis should be:
1. risk for infxn r/t effects of trauma
2. Impaired physical mobility r/t trauma
3. activity intolerance r/t weight-bearing limitations
RISK FOR INFXN!!!
It's life threatening! The other 2 sound the same
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Mother calls: her child is fussy, fever, rash started from neck spread to rest of body. Child was exposed to chickenpox 3 weeks ago. Should nurse:
1. Bring child in immediately so dx can be confirmed
2. treat child's sx and use Benadryl for itching
3. be sure child stays quiet, limit amt of TV
BONUS: When can child return to school
2. Most likely explanation is chickenpox, no need to bring in clinic for confirmation unless child is severely ill or has comlications. Acetaminophen for fever & fussiness, oatmeals and Benadryl for itching.
BONUS: Child will need to stay out of day care until the lesions of the rash are crusted over
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Patient is prescribed with a bunch of antacids. Also, order to administer frequently. Why?
Because short duration of action, frequent doses of antacids are needed. Antacids usually rovide a raid immediate onset of action, and aren't highly metabolized.
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A woman having her second baby can anticipate a labor about _________ as long as her first labor
HALF
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Umbilical cord care DO's and DONTs
- DO
- Keep diaper below umbilical cord
- Only sponge bathe the neonate until umbilical cord falls off.
- Entire umbilical cord should be cleaned with alcohol, using a cotton swab or another appropriate method
- DON'T:
- Apply abx ointment it is CONTRAININDICATED unless there are signs of infxn
- Wash umbilical cord with mild soap and water
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SCHIZOPHRENIA pt tells nurse (who is preparing to d/c him) that he has no home and family and has been living on the street. Appropriate action should be
*Just b/c he was a schizophrenic does not mean he's having delusional and making things up right now. Besides, he's getting discharged so that means what he's saying is true and he's not having a delusion
Ask the physician to refer the client to social services.
- Offering client the names and #s of shelters maybe helpful,
- but nurse isn't in the position to f/u after d/c.
Ask the atient to discuss his feelings maybe therapeutic but there's a need at this point for direct intervention!
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HIV mom given birth to neonate. Nurse most likely to detect what when assessing neonate?
HEPATOSPLENOMEGALY, distinctive facial dysmorphism, interstitial pneumonia, recurrent infxn, behaviorial deviations, neurologic abnormalities
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DKA. BG: 450, K: 2.5, NA: 140, URINE S. GRAVITY: 1.025.
2 IV lines: NS infusing through both.
Only 50ml U.O over past 4 hours. Which order should nurse question:
1. infuse 500 ml of NS over 1 hr
2. hold insulin for 30 min
3. add 40 meq KCl to infusion of 1/2 NS . Infuse at 10meq/hr
4. Change second IV solution to dextrose 5% in water
4.
Assessment shows pt is dehydrated: high-end specific gravity, low u.o, so 500 ml of NS until BG goes down to 250 and fluid status goes up
Hold insulin to administer K
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Grandmother ask why 2-mos-old infant hasn't started eating solid foods. Nurse should tell grandma
1. baby is gaining weight and doing well. No need for solid food yet.
2. we've found babies can't digest solid food properly until they're 3-4 mos
2. Stating that babies can't digest solid food proerly is correct because infants younger than 3-4 months lack enzymes needed to digest complex carbs.
Saying there's no need for solid food doesn't address grandma's question directly
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redness, swelling, and INDURATION at wound site can indicate...
Infection
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8 year old HR range
70-120
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