Card Set Information
What is the most lethal complication of a peptic ulcer?
38 yr old pt postop with rod in leg being given an analgesic via PCA. Who is allowed to adjust the PCA?
noone except patient
Pt at clinic to receive allergy injection but missed dose last week. What should nurse do?
ask dr before admin--dosage may need to be adjusted
How do you diagnose AIDS?
CD4+ and leukocytes below 200
Pt getting tranfusion with packed RBCs. What is the important thing for nurse to do before beginning trasfusion?
donor and recipient must match
Pt has had TURP and is having bladder spasms. What should nurse do?
ck drainage system; ck catheter for kinks or obstructions; ck urine for discoloration
Pt has had hemiarthroplasty (bipolar hip repair). What should nurse tell pt?
do not cross legs
Pt had stapedectomy. What is important for nurse to tell pt?
open mouth when blowing nose or coughing to avoid any pressure
Pt had amputation on right leg below knee and is experiencing pain. What do you explain to pt about the pain?
it is phantom pain; brain is still sending nerve signals to leg
Petecchia and ecchymoses are seen in what type of hematological disease?
Pt had anaphylactic reaction and is being monitored. What nursing dx is given?
decreased cardiac output
Pt had Rubin's test done to evaluate patency of fallopian tubes. Pt is experiencing pain in shoulder. What do you tell her?
it is normal; caused by the oxygen used during procedure (diaphragmatic irritation)
Pt is upset about having permanent colostomy. How do you talk to the pt?
ask open-ended questions
What is the most important measure in preventing transmission of pathogens to a pt with depressed bone marrow?
Pt admitted with possible appendicitis. What is contraindicated? What should you give them?
no heat, no laxatives, no enema, NPO til dr orders, measure I&O; give fluid and electrolytes
Before doing a CT scan with contrast what should you ask the pt?
if they are allergic to seafood or iodine
Pt has had allergic reaction to bee sting but is stabilized and being d/c. You talk to pt about prevention of reaction. What stmt would indicate pt needs further teaching?
"I will take corticosteroids to prevent another reaction"
Pt has had ORIF on left ankle. What is the most important thing for nurse to assess?
Pt has a fractured femur with a possible fat embolus. How would you explain this to the pt?
a break in a bone forces fat molecules into the bloodstream
Pt is at health dept and complains of purulent urethral discharge with pain when urinating. What info would you get from pt?
info on sexual hx
When doing lab tests for liver enzymes, what abnormal value would indicate a problem?
Pts with pernicious anemia must receive injections of _______for the rest of their life.
Pt is receiving sulfasalazine for their Crohn's disease, what should you instruct them to do and why?
drink plenty of fluids to avoid crystallization in the kidneys (leading to kidney stones)
Pt with Graves' disease has sx of SOB, tachycardia, and increased temp, blood pressure, respirations....what would this be?
Pt with head injury is restless. What could be the cause?
pain in bladder
Pt with new dx of diabetes. What is the blood test they would use?
What are the primary pathophysiologic features of polycythemia vera?
increased RBCs, hyperviscosity; **poor circulation and low O2
How long can blood be out of the refrigerator?
Pt with urticaria c/o itching. What should you ask them?
"Have you changed your meds"
Pt on on PCN, codeine, has now been given another med. Pt now is itching and gets UTI. What should nurse do?
Stop all meds and call dr
Pt admitted with acute pulmonary edema. How do you give them fluids?
slowly; 30 or less
The cirrhotic liver cannot absorb vitamin K. What would be elevated?
Position most beneficial for pt postop after tracheotomy:
What antiemetic is admin IV over a 5 min period 30 minutes before chemo?
What is the plan of care for a pt with aphasia?
see what degree the aphasia is and adapt communication accordingly
Pt with Type II diabetes has total loss of feeling in his feet. How do you instruct pt to avoid injury?
do not go barefoot; wear shoes with soles
Safety measure for pt receiving first time intradermal injections for allergy testing:
have pt stay in office for 20 min
COPD instructions to help pt to achieve nutrition status would be:
increase protein and calories, eat small frequent meals, **rest 30 minutes before eating
When paracentesis is done, nurse must have pt __________immediately before the procedure to prevent puncture of the bladder.
Pt c/o of chest pain, tachycardia, and dyspnea.....what could this be a sign of?
Lispro acts how quickly?
15 minutes after injection
Why do older adults not adapt to surgery as well?
response to physiological changes
Pt has compound fracture of the femur. What is the first thing the dr orders?
What are nursing interventions for pt receiving external radiation?
instruct pt on markings, no constrictive clothing, no laying on areas where markers are
If initial tx has not been successful for tumor lysis syndrome, what would be the next step?
Pt diagnosed with gouty arthritis. How do you explain this to the pt?
overproduction of uric acid causing Tophi (uric acid crystals)
Pt with DM has diabetic retinopathy and is getting their first photocoagulation therapy. What does this therapy do?
destroys new blood vessels
Lasix affects electrolytes causing ___________, the defiency of the electrolyte can cause weakness, irregular pulse.
hypokalemia; **problems with potassium levels
Pt is treated with an injection of penicillin for strep throat. Even though she has taken it before what should nurse do?
Have pt stay for 20 minutes in case of allergic reaction this time.
Pt has cerebral aneurysm and has ICP. What is contraindicated with ICP?
no sneezing or coughing to avoid any additional pressure
What is agnosia?
total or partial loss of ability to recognize familiar objects or people
What is the immediate medical management for any fracture?
splint and elevate
Pt has sore tongue and fatigue. What test would be done to check B12?
Schillings test--shows malabsorption of B12--test for pernicious anemia
What is the best prevention of HIV in infants and children?
do not get pregnant
When should/shouldn't you do a sputum collection?
do not collect after meals
An illness that occurs when the body tissues are attacked by its own immune system.
Pt teaching for female with genital herpes:
use condoms even when sx are not present
Pt presents with partial and full-thickness burns and smoke inhalation. What would you check for? What does this do to the pts hemoglobin?
carbon monoxide poisoning; the carbon dioxide binds with the hemoglobin instead of the oxygen
What is DIC?
an acquired hemorrhagic syndrome; **pt can bleed out
After having influenza pt has chills, small peticchia in mouth and a heart murmur is detectable. What could this be?
Pt has pain in the thoracic cavity. What structure is not in the thoracic cavity?
Asterixis is a hand flapping tremor in which the pt stretches out an arm and hyperextends the wrist with the fingers separated, relaxed, and extended. This occurs in the pt with ________ ________.
A/P repair of cystocele....you would expect pt to return to the PACU with a ___________.
catheter in place
First priority for a pulmonary embolus is to administer _________.
In a pt with pneumothorax, what would chest auscultation reveal?
unequal breath sounds and no sounds over affected area
What lab value is most indicative of iron deficiency anemia?
low hematocrit and **low hemoglobin
Pt has aplastic anemia....how would you explain this to the pt?
the activity of their bone marrow is depressed (area of RBC production)
Pt having anaphylactic reaction to bee sting. What would you administer?
Pt c/o of gonorrhea sx but says he doesn't think his parter had it and doesn't understand how he could've gotten it. What do you tell the pt?
Most women are asymptomatic and don't even know they have it
How are the tissues and cells affected when a pt has anemia?
insufficient amount of O2 causing ischemia
Pt is being treated for chlamydia and has a hx of recurrent herpes. What is a nursing intervention?
counsel pt about her sexual and drug use hx, risk reductor measures, and do HIV test
Pt has compartment syndrome. Look for s/s of what?
Volkmann's contracture (with clawhand, flexion of wrist and fingers and atrophy of forearm)
Describe care for a pt with a head injury that has drainage from the nose and ears:
wipe but don't blow nose; do not place anything in nose
What is the first s/s of hemorrhage postop?
How would nurse know that pt with HIV now has AIDS?
CD4+ below 200, pos HIV, hx of opportunistic diseases
Pt with cancer of the prostate now has cachexia. What does this mean?
profound state of illness and malnutrition, marked by weakness, poor health, wasting
Long-term complication of DM:
Pt has enlarged lymph nodes, irritability, fatigue as well as pain in joints and bones. Bone aspiration will show:
Depressed level of consciousness type of anesthesia:
How does HIV cause AIDS?
it attacks the immune system that protects the body from foreign invaders, making unable to protect the body from organisms that cause diseases
What medication is contraindicated in pts with pancreatitis and would it cause?
morphine; may cause spasms of the sphincter of Oddi
Pt with burns to the upper chest and singed nose hair....what would you assess for?
HIV pt is advised to have good nutrition. Why?
to improve immune function
Pt has fatigue, large painless lymph nodes. What are these sx of and what type of cells would you look for to confirm?
Hodgkins lymphoma; **Reed-Sternberg cells
Pt with Meneire's disease would be treated with what?
Pt had cholecystectomy. After surgery wound dehisced....what is this?
separation of surgical incision; rupture
Why is a foley inserted prior to a laparoscopy?
decompress bladder for open view
Pt is getting chemo for breast cancer. A pt with leukopenia needs a special nursing intervention...what would this be?
protect from pathogens; monitor for infection
If a pt has ICP or suspected ICP, what test should not be done?
What causes epididymitis?
infection of the testicle; *thrombus
Pt has thermal burn. Infection is the most common cause of death after what period of time?
Dyspnea, wheezing, urticaria of arms and face post bee sting....what are these s/s of?
What is the most common cause of cardiomyopathy in young adults?
What are nursing interventions for epistaxis?
head forward, Fowlers position
Ulcer that occurs as a complication of burns 8 to 14 days after injury is:
Pt is pregnant and has AIDS. She is concerned and says her baby is not safe. What instructions would nurse give her?
use standard precautions, avoid direct contact with any body fluids
Pt has esophageal cancer. Radiation therapy can cause aspiration from a _______________.
After an MI, cardiac enymes will be evaluated. What lab values would be off?
LDH, AST, SGOT, CPK-MB and troponin 1
Exam done to check percentages of WBCs:
differential WBC count
Pt is told she is going to have palliative surgery. What is the purpose of this?
it is designed to relieve uncomfortable sx, but that does not produce a cure