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final

when you have a pt with a cast what is your priority= circulation, movementand

sensation... assesscirculationby pulse checkmovementby movingfingerschecksensationby

askingif they can feel anything

when you have a child with a arm cast what is priority >checkperipheralpulsesin affected

area

invasion of client privacy.. what would be a good example of violating patient privacy-

a client was brought to er after serious accident needs to go to a procedure needs an

informed accident who do you go to ? never a friendonly closefamily member

you are doing rounds, in planning client rounds, which client will you collect the data

first? look for a pt who will fall into categoryof ABC-- ABCis priority

You have a patient who came from surgery the initial nursing action is= (immediately

after post op) your action is ABC(infectiondoesntset in until 72 hrs do not answerthat)

your pt has sever headache he was given analgesic how does it give pain release=

gait control mechanism

Bilroth I- gastro dudenostomy II- gastro jujenostomy If they have has abdominal

surgery what will they come back with? NGT(inorder to removeexcessair you needto add

NGTfor first 24-48 hrs after surgery*whichof the physicianordersdo you question?Never

irrigatea NGTstatuspost abdomensurgery

you have a pt w/ acute gastritis, which medication that you find on your pt chart is

contraindicated = NSAIDS(irritate to stomachIbuprofen,aspirin, steroids)

acid base- ph-7.35-7.45

paCO2= 35-45 Respiratory pa O2= 80-100%

HCO3= 22-28 GI/Kidney (metabolic)

(21-26)

UGIT- NGT/Vomiting > left with metabolic alkalosis (if it comes out your mouth

alkalosis)

LGIT- Diarrhea > left with acidosis (comes from your anus is acidosis)

Respiratory Acidosis > COPD= Asthma, bronchitis, Pulmonary EmphysemaTrap CO2= CO2+H2O> H2CO3- Resp acidosis

Chronicbronchitis usually stays with the pt

Hyperventilate (RR^ deep rapid)

Hypoventilate (RR down shallow)

Which diet do you not give to COPD pts?- Carbohydrates

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A pt has fat embolis (from fracture of long bone) clot that has moved... DX: CXR if fat

embolis goes into lungs it is called pulmonary fat embois

Osteoarthritis- degenerative;older population;unilateral; pain=restpain goesaway

RA- inflammatory- no specific age; elderly pts; autoimmune condition; symmetrical;

pain-rest pain still there labs: ^ESR (inflammatory condition) measures how fast RBS

move; positive rheumatoid factor Herniated slip disk (intervertebral disk) If a pt with a known herniated disk c/o rt/lt

buttocks pain is a result of? musclespasmon herniateddisk

computation: dr orders medication

0=7.5 mg IM BID

S= 10mg/mL

7.5X 1ml = 0.75 ml

10

when you have a pt with AKA= what type of dressing= compressiondressingwhat is

immediatenursinginterventionif dressingcomesoff? Rewrapcompressionstocking

Compartment syndrome= increased pressure in a muscle compartment= Fasciotomy=

opening into fascia do muscles decrease in size decrease in edema > wound care=

moist sterile normal saline dressing

When giving a flu vaccine first question to ask = ask if they are allergic to eggs

pulmonary emphysema- CO2 maximum of 2 liters to patients

Systemic lupus- s/sx- butterfly rash; polymyalgia (muscle pain); polyarthalgia (joint

pain)

If a pt fractures a leg what kind of acute pain will he have= nonseceptive pain- pain 6

months or less

what do you do with a cast -- elevate the leg to release edema and swelling; how long

do you allow for cast to dry 24-48 hrs; NI- tap on cast for itching or apply cold

compresses

GI: liver cirrhoses - crackles- pulmonary overload- no flat veins; no increase urine

output; no rapid pulse

nurse plan of care knowing which of the following american asian- they believe in Yin

and Yang

albuterol- bronchodilator; tachycardia; asthma; respiratory distress

COPD (resp. acidosis) when you have a pt ventilator dependent alarm is going on >

What is initial NI when trying to trouble shoot for ventilator that keeps alarming- Use

ambubag for patient - ventilator not working

Osteoarthritis- pain in the joints; dull aching pain

young female pt going for cxr- are you pregnant

when you are assisting client going for pulmonary angiogram? are you allergic to sea

food

what manifestation to indicate you are allergic to contrast medium? Respiratory

distress

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if you have a pt w/ a fx and cant feel anything on lt finger and slow capillary refill and

decrease pulses what do you do first? Call physician because it is life threatening

If a pt has pulmonary TB what are not manifestations? Mark all that apply- no stridor,

no fever; non productive cough, chills, anorexia, wt loss, night sweats

if you have a pt who went for ORIF of hip- when trying to turn pt do not cross legs use

abduction pillow (away from mid-line)

compartment syndrome- from a severe fx pt asks how did he develop compartment

syndrome? Swelling in muscle unable to expand. increase pressure

pt w/ multiple trauma admitted to hosp w/ fx and placed a cast, in positioning leg w/

cast what do you do? elevate legs continuosly for 24 hours to decrease presence of

edema

what is this diformity- pt goes to er for lower leg, injured leg looks shorter and smaller

than other leg; painful and ecchymosis? Contusion fracture

SPrain- joint

STrain- muscle

skin traction- use bandages

skeletal traction- pins goes into bones

Pt asking nurse why do you need box extension traction (example of skin traction)

before going too surgery, what is the purpose? to decreasemusclespasms

pt w/ pulmonary TB- DX = sputum culture-

Imodium- anti-diarrrhea

Pt has chest tube- monitor for Subcutaneous emphysema> crepitus secondary to

emphysema> refers to air

pt went for sx, pt diet changed from NPO to clear liquids, what should pt have before

giving clear liquids? bowel sounds; normal BS is 4-32 pt went for EGD, what is highest priority for this client? GAG reflex (any procedure that

goes through the throat)

if a pt goes for chemo what is sx: nausea, anemia, neutropenia, depressed bone

marrow= decreased RBC, WBC, Platelets, (-penia is decreased) which of the

following will you not expect for chemotherapy

if your patient has chronic gastritis (stomach) what do you have to absorb vitamin B12

(decrease b12=pernicious anemia) ? IF (intrensic factor)

what is your NI priority if your patient has multiple myeloma (bone marrow)? increase

fluid intake (proper hydration)

characteristic myeloma- dumping syndrome- rapid emptying of stomach contents from duodenum; what are

manifestations= pale; sweating;pallor(no dry skin, bradycardia, no double vision)

What are you going to tell pt after a CT scan w/ dye? warmflushingsensationas you

inject into body,fluids will not be restricted, not painful, test does not take 2-3 hrs

pt w/ acute pancreatitis what 2 enzymes will be affected? Amylase and Lipase; what

position do you avoid= supine (flat)

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Zantac (ranitidine) what is best time to give Zantac? At bed time

pt on prolonged bed rest to prevent GI complication? fluids if not contraindicated

Respiratory complication on prolonged bed rest?

youre taking care of a pt what do you do to monitor

Prilosec- medications for GERD Pt has taking meds for 4 wks how would you know if

pt has received optimal intended effect? preventheart burn

TENS unit- transcutaneouselectrical nervestimulation; which statement from pt does he

need more teaching? Needles need to be inserted into skin

You have an older female pt that you would like to join group therapy in facility what

nursing action would you consider doing first before going to that group? Changediaper

pt went for pneumoectomy what is >> pink frothysputum(pulmonaryedema)

anaphylaxis- severe allergic reaction- what is priority for severe allergic reaction=

airway

Decrease immune system- infectionprevention

pt has Lupus defined as inflammatorycollagen if the dr orders you to give an IM injection of 400,000 units H/S=300,000 units per mm

how many mL do you give

when inserting NGT position in high fowlers(90 degree)

if pt had AKA RT leg how would you position pt?

w/ pt has evicersation - sterile saline dressing,assessfor shock, call nurseinstruct pt to

remaincalmand quiet, preparept for sx

if your clients doesnt speak english and has pain what chart does he use to describe

pain? WongBaker

mark all that apply- a pt went for surgery you are monitoring for signs of complication

which of the following would you expect to find in an immediate post op pt?less than 3 capillaryrefill; homanssign (-); hypoactiveBS;

if vital sign of pt comes back from sx and bp is 100/60 p: 90 resp: 20 bpm what do you

do? Nothing- normalranges

lung infection turns into- pneumonia

chest compression- 1/2-2 inchesfor adults

what lab results will tell you a sx needs to be rescheduled? HGB

incentive spirometer teaching that pt doesnt understand- I can use in any positionI want

pt is verbally abusive and confused; has headache and asking for analgesic nurse

says she cannot: says she was going to put in restraints: what is that considered:

Abuse

Ethnocentrism- tendency to view your culture as the best; stem: which statement is

lack of understanding?

hypercalcemia- when you have increased high calcium levels - muscleweakness

how would u know client is benefitting from platelet transfusion- decreasedbleeding

chills and rashes-

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prevent DVT on pulmonary embolism- ROMexercises

a piece of lungs removed what are expected findings when pt has chest tube

draining? middlejar fluctuatingup and down;if you have 50cc-100 is normalof draining-

dressingyou use is occlusive- petrolatumdressing;drainiagesystemshouldbe under bed; no

bubbling-leak in system;whenyou removechest tube tell pt to hold breath(valsalva)

when you have medication PRN what does it mean= as needed

if pt has cancer pain how do you give ? aroundthe clock

broth, jello, tea (clear liquid is anything u can see through)

when feeding a GT patient place in - fowlersposition

if pt has ucer and taking tums how do you know pt - heart burn is gone

Zolfran-anit nausesand anti vomiting

A pt w/ GERDpprescribedReglan- 30 minutesbeforeeach meal

Bisulfan (Myeleran) drug of choice for Leukemia; Give Allaperinol(anti-gout) medication

pt has NGT low suction- pt has metabolicakalosis

in gastroesophagia disease- which substances will increase lower dysophagia spincterpressure? non-fat milk (do not give fatty acids, tea, or coffee)

pancreatitis- what is major complication in paralytic ileus? do not havegas

what is associated w/ Crohn's disease? malabsorption

why do you stage lung cancer? to identify best treatment

If you are giving pt Kayexalade (K to K) drug of choice to bring downpotassiumlevel

(chooselowestpotassiumlevel)

If you are supervising nursing student who is doing suctioning how do you know if

student is performing it wrong: whenyou notice she is applyingsuctionuponinsertion

Aspirin toxic- ringing in the airs

Always remember HCT %= women normal level 42-46 male is 48-53;When you aredehydrated (hct increases)? 48