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List four common symptoms of pneumonia
Tachypnea, fever with cills, productive cough, bronchial breath sounds
What symptoms of pneumonia might the nurse expect to see in an older client?
Confusion, lethargy, anorexia, rapid respiratory rate
When examining a client with emphysema, what physical findings is the nurse likely to see?
Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in lung fields "pink puffers"
What instructions should be given to a client following radiation therapy?
Do not wash off lines, wear soft cotton garments, and avoid use of powders and creams on radiaiton site
How much urine do adults produce in a 24 hour period?
Usually 1 to 2 liters
What may be prescribed in potassium is too high?
What foods are high in potassium?
Bananas, avocados, spinach, fish, and salt substitutes
Differentiate between acute renal failure and chronic renal failure
Acute renal failure: often reversible, abrupt deterioration of kidney function. Chronic renal failure: irreversible, slow deterioration of kidney function characterized by increasing BUN and creatine. Eventually dialysis is required.
During oliguric phase of renal failure, protein should be severely restricted. What is the rationale for this restriction?
Toxic metabolites that accumulate in the blood (urea, creatine) are derived mainly from protein catbolism
What are the nursing interventions for the client on hemodialysis?
Do not take BP or perform venipunctures on the arm with the A-V shunt, fistula, or graft. Assess access site for thrill and bruit.
What is the highest priority nursing diagnosis for clients in any type of renal failure?
Risk for imbalanced fluid volume
A client in renal failure asks why he is being given antacids. How should the nurse reply?
Calcium and aluminum antacids bind phophates and help to keep phosphates from being absorbed into blood stream, thereby preventing rising phosphate levels; must be taken with meals
What are the most important nursing interventions for clients with possible calculi?
Straining all urine is the most important intervention. Other interventions include accurate intake and ouput documentation and administering analgesics as needed.
Following transurethral resection of the prostate gland (TURP), hematuria should subside by what postoperative day?
The Fourth day
After the urinary catheter is removed in the TURP client, what are three priority nursing actions?
Continued strict I & O. Continued observations for hematuria. Inform client burning and frequency may last for a week.
After kidney surgery, what are the primary assessments the nurse should make?
- Respiratory status (breathing is guarded b/c of pain)
- Circulatory status (the kidney is very vascular and excessive bleeding can occur)
- Pain assessment
- Urinary assessment (most importantly, assessment of urinary output)
How do clients experiencing angina describe that pain?
Described as squeezing, heavy, burning, radiates to left arm or shoulder, transient or prolonged
What is the bp reading for diagnosing HTN?
Describe intermittent claudication
Pain related to peripheral vascular disease; the pain occurs with exercise and dissapears with rest
Describe the nurse's discharge instructions to a client with venous peripheral vascular disease
Keep extremities elevated when sitting, rest at first sign of pain, keep extremities warm (but do no use heating pad), change positions often, avoid crossing legs, wear unrestrictive clothing
What is often the underlying cause of an abdominal aortic aneurysm
When do PVCs present a grave danger?
Begin to occcur more often than once in 10 beats, occur in twos or threes, land near the T wave, or take on multiple configurations
Differentiate btw symptoms of L sided heart failure and R sided heart failure
- L sided failure resutls in pulmonary congestion due to back up of circulation in the left ventricle.
- R sided failure results in peripheral congestion due to back up of circulation in the right ventricle
List 3 symptoms of digitalis toxicity
Dysrhythmias, HA, nausea & vomitting
What condition increases the likelihood that digitolis toxicity will occur?
Hypokalemia (which is more common when diuretics and digitalis preparations are given together)
What immediate actions should the nurse implement when a client is having a MI?
Place client on immediate strict bed rest to lower o2 demands on heart, admin o2 by nasal cannula at 2-5 L/min, take measures to alleviate pain and anxiety (administer prn pain and anxiety meds)
What symptoms should the nurse expect to find in a client with hypokalemia?
Dry mouth and thirst, drowsiness and lethargy, muscle weakness and aches, and tachycardia
List 3 categories of meds that are used in the treatment of peptic ulcer disease
Antacids, histamine-2 receptor blockers, mucosal healing agents, proton pump inhibitors
List the symptoms of upper and lower GI bleeding
- Upper GI: melena, hematemesis, tarry stools
- Lower GI: bloody stools, tarry stools
- Common to both: tarry stools
What bowel sounds disruptions occur with an intestinal obstruction?
- Early mechanical obstruction: high-pitched sounds
- Late mechanical obstruction: diminished or absent bowel sounds
List 4 nursing interventions for post-op care of a client with a colostomy
irrigate daily at same time; use warm water for irrigations; wash around stoma with mild soap and water after each ostomy bag change; ensure that pouch opening extends at least 1/8 inch around the stoma
List the common clinical manifestations of jaundice
Sclera-icteric (yellow sclera), dark urine, chalky or clay-colored stools
List 5 symptoms indicative of colon cancer
Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abd pain with nausea, weight loss
How should the nurse administer pancreatic enzymes?
give with meals or snacks. powder forms should be mizde with fruit juices
What is the non-surgical management of a client with cholecystitis?
- Low fat diet
- Medications for pain and clotting if required
- Decompression of the stomach via NG tube
When should corticosteroids be taken?
With meals to prevent gastric irritation.
Which type of diabetic always requires insulin replacement?
Type 1, insulin-dependent DM
Which type of diabetic sometimes requires no medication?
Type 2, non-insulin dependent DM
what is the patient at risk for 36 hours after a long bone fracture, fracture of the pelvis, or multiple fractures?
Fat embolism- initial symptom is confusion due to hypoxemia (check blood gases for Po2)
What is the most common complication in client's with hip fractures?
thromboembolism- prevention includes PROM, elastic stockings, elevation of foot of bed 25 degrees to increase venous return, and low dose heparin therapy
Identify categories of drugs commonly used to treat arthritis
NSAIDS (salicylates most common) and corticosteroids
What are the common side effects of salicylates?
GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation
What is the priority nursing intervention used with clients taking NSAIDS?
Administer or teach client to take drugs with food or milk
Describe postop residual limb (stump) care after amputation for the first 48 hours
- Elevate risefual limb (stump) for the first 24 hours
- Do not elevate residual limb (stump) after 48 hours
- Keep residual limb (stump) in extended position and tunr client to prone position three times a day to prevent flexion contracture
A nurse discovers that a client is in traction for a long bone fracture has a slight fever, is short of breath, and is restless. What does the client most likely have?
A fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness, fever, and petechiae
What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition?
notify physician stat, draw blood gases, adminster o2 according to blood gas results, assist with endotracheal intubation and treatment of respiratory failure
List 3 nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems
Passive ROM exercises, elastic stockings, and elevation of foot of bed 25 degrees to increase venous return
State four nursing interventions to maintain adequate respiration, airway, and oxygenation in the unconscious client
- Position for maximum ventilation (prone of semiprone and slightly to one side)
- Insert airway if tongue is obstructing
- Suction airway efficiently
- Monitor arterial Po2 and Pco2
- Hyperventilate with 100% o2 before suctioning
List four rationales for the appearance of restlessness in the unconscious client
Anoxia, distended bladder, covert bleeding, or a return to consciousness
A client with a dx of CVA presents with symptoms of aphasia and right hemiparesis but no memory or hearing deficit. In what hemisphere has the client sufered a lesion?
What are the symptoms of spinal shock?
hypotension, bladder and bowel distention, total paralysis, lack of sensation below lesion
what are the symptoms of autonomic dysreflexia
hypertension, bladder and bowel distention, exaggerated autonomic responsess, headache, sweating, goose bumps, and bradycardia
what is the most important indicator of increased ICP
level of responsiveness
What vital sign changes are indicative of increased ICP?
- increased BP
- widening pulse pressure
- Incereased or decreased pulse
- respiratory irregularities
- Temperature increase
How should the head of the bed be positioned for postcraniotomy clients with infratorial lesions?
- infratorial lesions: flat
- Supratentorial lesions: elevated
What types of drugs are used in the treatment of myasthenia gravis?
Anticholinesterase drugs, which inhibit the action of cholinesterase at the nerve endings to promote the accumulation of acetylcholine at receptor sites; this should improve neuronal transmission to muscles
What foods need to be eaten in the client with anemia?
- Iron (red meats, organ meats, whole wheat products, spinach, carrots)
- Folic acid (green vegetables, liver, citrus fruits)
- Vitamin B12 (glandular meats, yeast, green leafy vegetables, milk, and cheese)
List 3 potential causes of anemia
- Diet lacking in iron, folate, or vitamin B12
- Use of salicylates, thiazides, diuretics
- Exposure to toxic agents, such as lead or insecticides
What is the only IV fluid compatible with blood products?
What actions should the nurse take if a hemolytic transfusion reaction occurs?
- Turn off transfusion.
- Take temperature
- Send blood being transfused to lab
- Obtain urine sample
- Keep vein patent with normal saline
Name 3 food sources of vitamin B12
Glandular meats (liver), milk, green leafy vegetables
Describe the use of leucovorin
Leucovorin is used as an antidote with methotrexate to prevent toxic reactions
Describe the method for collecting trough and peak blood levels of antibiotics
- Collection of trough: draw blood 30 minutes prior to admin of antibiotics
- Collection of peak: draw blood 30 minutes after administration of antibiotics
What is the characteristic cell found in Hodgkin disease?
What are the indications for a hysterectomy in a client who has fibromas?
- Severe menorrhagia leading to anemia
- Severe dysmenorrhea requiring narcotic analgesics
- Severe uterine enlargement causing pressure on other organs
- Severe low back and pelvic pain
List the symptoms and conditions assocaited with cystocele
Symptoms include incontenence or stress inctoninence, urinary retention, and recurrent bladder infections. Conditions associated with cystocele include multiparity, trauma in childbirth, and aging
What are the most important nursing intervetnions for the postoperative client who has had a hysterectomy with an A & P repair?
Avoid taking rectal temps and rectal manipulaiton, manage pain, and encourage early ambulation
What screening tool is used to detect cervical cancer? What are the american cancer society's recommendations for women ages 30-70 with three consecutive normal results?
- Pap smears
- Women ages 30-70 with three consecutive normal results may have pap smears every 2-3 years (screening for HPV)
What are the 3 most important tools for early detection of breat cancer? How often should these tools be used?
- Breast self exam monthly
- Mammogram baseline at age 35, followed every 1 to 2 years in 40s and every year after age 50
- Physical examination by a professional skilled in examination of the breast
What is the most common cause of nongonococcal urethritis?
What is the causative organism of syphilis?
Malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD?
Which STD is characterized by remissions and exacerbations in both males and females?
Herpes simplex type II
Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of the burned client
- Stage I (emergent phase): replacement of fluids is titrated to urine output
- Stage II (acute phase): patent infusion site is maintained in case supplemental IV fluids are needed; saline lock is helpful; colloids may be used
- Stage III (rehabilitation phase): no extra fluids are needed, but high-protein dirnks are recommended
Why is the burned client allowed no "free" water?
water may interfere with electrolyte balance. Client needs to ingest food products with highest biologic value
Describe an autograft
use of client's own skin for grafting