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Pt w/Genital herpes what will be a sign that an out-brake is imminent?
genital puritis (itching)
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Mantoux test what should the angel of the needle be?
10-15 degree angle
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What problem will increase the risk of suicide?
Teen with depression over recent breakup w/a friend
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Kidney surgery what will give the Nx immediate concern?
do to post-operative bleeding hemorrhage --->can cause hypovolemic shock
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Pt. has renal failure what is the s/s?
Anemia
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(SATA) Partial thickness burns
- Painful open are when blisters brake
- Injury to deeper portions of the dormas
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Burn pt. TBSA is 40% his weights 132 lbs (4cc/1kg)
What is his weight in kilograms?
60 Kg
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How many cc's of fluid will be infuse in 24 hrs?
kg x 4cc x 40 / 24 = 400cc
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How many cc's in the first 8 hrs?
kg x 4cc x 40 / 8 = 1,200 cc
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How many millimiters should the pump be set for the next 16 hrs?
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If a macrodrip is used how many drops per min. should the pump be set for 16 hrs?
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The following consideration for a burn pt's are the following except?
Cool the burn w/ice
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What will you find for a pt. that has been diagnosed with bulimia?
erosion of the dental amal (teeth)
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When doing tracheostomy at home, what technique should the pt use?
Medically aseptic (as clean as possible)
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(SATA) Warning signs of suicide:
- Withdrawer
- Apathetic
- Angry outburst
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(Write-in) In your own words give me 5 things to considered for an interview?
- Dress appropriately
- Eye contact
- Promptness
- Firm hand shake
- Stay calm
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A mother is breast feeding and she wants to know how to do a breast examination, what should the Nx suggest to the pt?
you should do the BSE after the infant empties the breast
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Pt is brought in with 2nd degree burn in his left arm and left anterior leg what will be the percentage according to the rule of nine?
9 left arm + 9 left anterior leg = 18%
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A batter wife needs help, which community will provide assistance to this pt?
Women shelter
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(SATA) Pt with alcohol withdraw syndrome is ready to enter a rehab facility which of the following actions will be appropriate for this pt?
- Talk to his family
- Alcoholic anonymous
- Promote participation in a treatment program
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Which of the following nursing diagnosis is properly worded?
Related to and because of
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Which of the following actions is correct in performing tracheal suction?
Limit suction w/in 10 sec.
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Pt has HIV which of the following indicates that the pt needs intubation?
PO2 is less than 80%
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Nx diagnosis where no problem exist, the pt desire a higher level of wellness.. what kind of dx would u give the pt?
a wellness diagnosis
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Pt w/ alcohol withdraw is pulling from his central venus catheter what should the Nx do for this pt?
Protect the client from harm
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The Nx suspects that the pt is experiencing alcohol withdraw syndrome what nursing action is appropriate?
Ask pt about his drinking
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Anxiety details are distorted, what level of anxiety will this be?
Panic
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The pt who needs the highest possible concentration of oxygen, which mask will be the best delivery system?
Venturi Mask
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(SATA) Cystoscopy
- Helps identify the signs of hematuria incontinence in urine retention
- Allows the collection of tissue samples, cell washing and urine samples
- Uses a light source to visualize the internal instruction
- Requires no surgical incision
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Opportunistic disease HIV/AIDS
Pneumocystis carinii
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Pt is intubated has a ET tube and is coughing secretion what intervention is a priority for this pt?
Suctioning
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A nursing student is working with a Nx on pt's w/ AIDs the student does not suction the pt what should the Nx do?
Talk to the student
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Which is an example of subjected data?
The clients feelings and statements about health problems
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Pt w/ Chronic renal failure, what action is appropriate?
Weight pt daily before breakfast
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Where should the Nx place an oximeter for proper measurement?
apply to the clients finger
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Pt w/alcohol withdraw what will be a complication of de-toxicity?
seizures
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Post-menopose pt wants to know how to prevent Osteoporosis what should the Nx suggest to the pt?
Weight barring exercise
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Pt has a problem of pH of 7.52 also PaCO2 of 28 and bicarbonate of 24 what is the pt's problem?
Respiratory alkalosis
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Immediately after the distillate solution the Nx should?
Clamp the tubing from the infusion
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Pt w/ Toracocentesis is in an up-right position why is this pt on this position?
fluid accumulates at the bases
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(Fill-in) ______ it is a step in the nursing process where the Nx establishes outcomes and actions to achieve the overall goal
Planing
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(SATA) which of the following reproductive system problems requiers identification of sexual partner
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Pt w/ a bronchoscopy what will tell the Nx that the pt understand the procedure?
I will not eat or drink starting mid-night till the procedure is done
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Which of the following pt's will be at risk for impaired tissue integrity?
Client having reconstructive breast surgery
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Everything is true about Laissez faire except?
Communication is mutual back and forward
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The nurse does a breast examination laying down
Standing up in front of a mirror
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(Fill-in) ________ is transferring to competent individual the authority to perform selective nursing task in a selected situation while retaining accountability for the delegation
Delegation
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Which statement by the pt shows that she understand the ideal time to perform a breast examination?
1 wk after their mensis
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Pt w/ mastectomy on the left breast and an IV on the lower right arm where should the Nx take the B/P?
On the leg
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For the Heimlich maneuver where should the Nx position her hands?
below the sternum
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(Fill-in) _______ a graph obtained from diseased humans
Allograft
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What diagnostic test is an indicator for kidney disease?
Syrum Creatinine level
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Nx should teach a pt who has a catheter how to prevent bladder infection?
encourage showers rather than baths
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What is the significance of a positive Tuberculosis TB test?
Antibodies are presence
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Oliguric stage of renal failure. Oliguria scanty urine, how many ml in a day would you expect?
100-500 ml/day
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The social theory of causation that has to do with anorexia
Sign of pain w/in the whole family system
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Alcohol dependence the pt has been admitted, what indication tells the Nx that the pt is using rationalization?
"I always remember what happens the next day"
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Pt w/ Anorexia nervosa during the initial exam what is the Nx most likely to assess?
Growth of fine body hair (lanugo)
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Which of the pt's common indicates that he is ready for a rehab center?
"I am powerless over alcohol and need help"
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A pt has been sexually assaulted a police officer comes w/this lady which of the following intervention should the Nx do?
trying to bring pts anxiety down from panic to modorate
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Dealing w/ a suspected family violence problem what approach should the Nx use?
Support
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(Fill-in) ______ is the ulcer acquiring during burns
Curling's ulcer
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Which assessment for Peritoneal dialysis should the pt do before and after to see if the dialysis worked?
Weight themselves
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Incentive spirometer
It helps the pt visualize deep breathing
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Pt has a phobic condition he has been treated with behavior therapy how does this work?
systemic desensitization
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Which substance transmits HIV?
blood
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Nx is manually assessing AV fist, what would you expect to notice?
a thrill
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Nx is removing an indwelling catheter what is the following appropriate thing to do?
Document the time of the removal
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(SATA) Nutrition in a burn pt:
- Enteral feedings can reduce nausea and vomiting
- Carbohydrates
- Need to increase vitamins & minerals
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Pt w/Substance abuse what should the Nx include in his plan of care?
Participate in support groups like alcoholic anonymous (AA)
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