Micep Black
Transcript of Micep Black
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Editor Medical Surgical Nursing
Associate Professor of Nursing
University of Nebraska Medical CenterOmaha, NE
CLIENT SAFETY, SECURITY & PRIVACYREQUIREMENTS in MEDICAL-SURGICAL
NURSING PRACTICE
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Test Plan Structure Safe and Effective Environment
Health Promotion/ Maintenance
Psychological Integrity
Physiological Integrity Pharmacological Intervention
Reduction of Risk
Items written based on usual activities ofnurses one year after graduation
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Safe Effective Care Environment Management of Care 13-19%
Safety and Infection Control 8-14%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 13-19% Reduction of Risk Potential 13-19%
Physiological Adaptation 11-17%
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Multiple Choice Single right answer
Multiple Answer More than 1 right answer
The item will indicate that more than one answer is right
Fill in the Blank Usually math
Hot Spot Location of something on a figure
Eg, location of apical pulse Exhibit items
Information contain in documents within the item
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Computer adaptive testing Items chosen for student based on previous
response
The test is designed to decide if you pass or fail
and will continue to test you until it is certain Items delivered one at a time
Test item must be answered or you cannot goto next item
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75 items given one at a time Computer then judges students performance
More items given in areas of poor performance
265 is most questions that it will offer
Time maximum is 5 hours
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I am going to present a test item,
give you a minute to answer
and then discuss the item
and content related to it.
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A. Explain the actual changes that will occur in her
body and then have her sign the consent formB. Delay having the patient sign surgical consent
and ask the surgeon to see her again
C. Allow the patient to sign consent for surgery;
she understands the surgery correctlyD. Tell the surgical staff to inform the surgeon
that the patient may need further informationduring recovery
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Total Hysterectomy is removal of the uterusand ovaries. Menstruation will stop and
menopause will start suddenlywhich itappears that she does not understand
The nurses role is not to explain theoperation, except for minor issues
The nurses signature indicates that thepatient (and not someone else) signed theconsent
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A legal document that provides evidence that thepatient has been given the reason for surgery,the other options (other operations, effect of notoperating, medications instead of surgery) andcomplications of surgery
This discussion must be done by the surgeon
Nurse witnesses the signature
Patient must be awake and not medicated
If the patient needs an operation for which he didnot consent, they have to be awaken foranesthesia and consent to a new procedure Many consent forms indicate options for different
procedures
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A. Higher than the IV dose
B. Lower than the IV dose
C.
The same as the IV dose
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Oral medications have a first pass effectthrough the liver. The liver excretes or bindsa large portion of the medication, makingless available to the patient. Therefore the
dose of oral meds is higher than IV meds.
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To achieve the same level of pain control, 10mg of Morphine IV is equal to: 30 mg of oral morphine
1200 mg of oral codeine
60 mg of oxymorphone
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A. Monitoring hyperalimentation (TPN) infusion
B. Dressing change on a wound the RN sawyesterday
C. Inserting an NG tube and administeringtube feeding
D. Teaching a newly diagnosed diabetic about
insulin injections
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LPN/LVNs cannot: insert NG tubes, they can monitor tube feeding
monitor IV fluids or meds
Teach complex material
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Delegating is assigning a task to another person,while the RN remains accountable
LPN/LVN A 1 year program of study in practical nursing
Very skilled at tasks and procedures Can learn complex assessments on the job
LPN/LVN cannot Insert NG or IVs Administer IV medications
Administer blood Develop care plans
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A. Stage IB. Stage IIC. Stage III
D. Stage IV
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Partial thickness ulcers Full thickness ulcers
Stage I
Stage IIStage IV
Stage III
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Prevention is key Intervene based on risk areas
Use Braden scale to help
Keep skin clean and dry
Turn patient side to side q 2 hrs Often delegated, consider how you will keep track of
patient position
Treatment
Nutrition Wound care
Sleep surface
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A. Pain level now 12/10;screaming
B. Pain level 6/10
C. Pain not present now,but going to PT in 1hour
D. Pain 2/10; keepingpatient from sleeping
E. Pain constant at 8/10
1. Acetaminophen 600 mgpo (Tylenol)
2. Morphine 2 mg IV3. Oxycodone 5 mg with
acetaminophen 500 mgpo4. OxyContin 10 mg po5. Acetaminophen (500
mg) and propoxyphene(50 mg) (Darvocet)
6. Fentanyl 100mg patch
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A. Pain level now 12/10;screaming = 2
B. Pain level 6/10 = 3 or 5
C. Pain not present now,
but going to PT in 1hour = 3 or 5
D. Pain 2/10; keepingpatient from sleeping= 1
E. Pain constant at 8/10= 2 and then 4 or 6
1. Acetaminophen 600 mgpo (Tylenol)
2. Morphine 2 mg IV3. Oxycodone 5 mg with
acetaminophen 500 mgpo4. OxyContin 10 mg po5. Acetaminophen (500
mg) and propoxyphene(50 mg) (Darvocet)
6. Fentanyl 100 mg patch
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Examine degree of pain Examine tolerance of pain
Consider effect of last dose of analgesic
Consider side effects and adverse effects ofdrug
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Ideal for intense pain Best given IV when pain is high
Onset is rapid
Side effects Constipation Tolerance
Adverse Effects Respiratory Depression
Oxygen saturation monitor used Do not turn off alarms!
But measure rate and depth ofrespirations
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Slow release oxycodone Ideal for cancer patients in
escalating pain
High risk of addiction
Do Not Crush these pills Leads to overdose
Do not confuse with Oxytocin
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Indicated for moderate Onset 30-45 minutes
Side effects the same
Adverse effect Hepatotoxicity from acetaminophen over 4000mg
in 24 hours
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A. Elderly ageB. Use of diuretics
C. Use of sedatives
D. Prior fall
E. WeaknessF. Sensory loss
G. Confusion
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Multiple options is a common format in theNCLEX and no partial credit is given for
correct answers
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A. Carefully lift the patient back to bed
B. Ask the patient why he got out of bed
C. Call the physician to examine the patient
D. Leave the patient on the floor and examinehim for signs of fracture
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Moving the patient could further harm afractured limb. Once the probably injury isknown, he may best be moved onto a cart forxrays
Calling the MD will be done, but not first, firstcollect some data
Asking the patient why he got up will provide
data to prevent future falls, but does not helpthis problem
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Most common reason is to use the bathroom High risk patients
Elders, frequent voiding (diuretics), confused
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A. Sharp pain in the hip
B. Internal rotation of the leg
C. Shortening of the leg
D. Bleeding from the hip
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This patient appears tohave a broken left hip.
Fractured bones lead tospasm of the limb Shortens the limb
Deforms the limb
External rotation in the leg
Pain in the limb
Loss of function
Loss of motion
Bleeding is due to tissueinjury, not fracture per se
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A. I will use a chair with arms
B. I will cross my legs gentlyC. I will only lie on my right side
D. I will avoid climbing stairs
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Flexion of the hip, internal rotation andabduction are to be avoiding
Therefore: She cannot cross her legs
She cannot lie on her sides without a pillow toabduct the leg
She must use a chair with arms to avoid hip flexion
Climbing the stairs is OK
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Flexion and extension Abduction and adduction
Internal and external rotation
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A. Maintain NPO status
B. Remove all metal objectsC. Obtain a consent for the procedure
D. Clarify allergies to contrast or shell fish
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Contrast dye, which can contain iodine, isoften used to visualize the vessels
The patient does not need to be NPO
Metal is not a problem with CT, it is aproblem with MRI
CT is noninvasive; no consent is needed
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Magnetic Resonance provides much greater contrast
between soft tissues Magnetic rays align atoms Prep
Sedation prn if claustrophobic
No metal due to magnet
Ear plugs prn due to noise
Computerized (Axial)Tomography scan. T series of cross sectional X-rays computer to put them together
to provide an image Prep
Very rapid, so sedation not used Metal OK
CT scanner requires patient
be still. Claustrophobia maybe a concern with somepatients
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A. An obese middle-aged woman at bedrestafter pelvic surgery
B. An elderly man with a fractured arm uptwice daily
C. A normal weight middle-aged man whosmokes
D. An demented elderly woman with afractured hip; up to the chair
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Her risk factors are immobility, pelvic surgeryand obesity
Moving patients are at less risk
Smoking is a risk factor, but needs to becombined with other risk factors
Fractured hips and elders are at risk,especially when bedridden
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Risk Factors Presentation
Risk factors Sluggish blood movement
Swelling in the pelvis,nonmoving legs
Increased blood clottingtendency Increased platelet count
Injury to vessels in pelvisor legs
Fractures of the hips,pelvis
Presentation Dyspnea
Anxiety
Tachycardia Tachypnea
Decreased O2 sats
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A. It should dissolve it in 4 to 6 hours
B. Because you have taken a lot of vitamin K, itmay be a day or two
C. It will not dissolve the clot, it will prevent newones from forming
D. It will only soften the clot, which makes it easierfor your body to break it down
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Antithrombotics work in 4-6 hours Used in some clients after stroke and MI
Vitamin K does not affect Heparin, vitamin K
affects warfarin It reduces the effectiveness of warfarin
Is used to reverse warfarin
It does not soften the clot, but the body does
breakdown the clot
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Heparin (heparin sodium) Half life 4 hours Reversible with Monitor partial thromboplastin times Given IV or subq
Low molecular weight heparins Given once daily, subq Cannot be monitored by blood studies
Coumadin (warfarin) Given orally Monitor INR (therapeutic 2-3) and prothrombin time (PT)
Can be taken for years Animal heart valves, venous disease
Reversed with vitamin K (Aqua-Mephtyon) Affected by foods with vitamin K
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A. PT
B. INR
C. PTTD. Bleeding Time
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Heparin is monitored by PTT Usually drawn every 4-8 hours
PT (prothrombin time)
Used to monitor Coumadin INR (International Normalized Ratio)
Used to monitor Coumadin Standardized international measure
Allows patients to travel
Bleeding time Used for unusual bleeding diseases
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A. At 12 ml per hour
B. At 25 ml per hour
C. At 50 ml per hour
D. At 250 ml per hour
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250 ml/25,000 units = 100 units/1 ml 250/25000 = 1/100
Therefore 12 ml delivers 1200 units per hour
This is a very common error in medication
delivery and will be tested!!
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A. The son cannot speak English well
B. The sons breath smells of alcohol
C. The son states his mother does not have
insuranceD. The son is talking on his cell phone while
listening to the discharge plan
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The patient may have an occult (not nowvisible) head injury: Decreasing level of consciousness Pain Vomiting
Pupillary changes Loss of motion or strength in limbs
Being alert is important to recognize thesechanges
The nurse needs to ask him to put the cell
phone down and listen Interpreters can be used to provide information Insurance does not change the standard of care
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Advocacy for patients is a very importantnursing role Especially for those patients who cannot advocate
for themselves Demented, sedated, children, unconscious
Advocacy can mean Asking MDs for information or orders Clarifying orders and information provided to the
patient
Determining the disposition of the patient Who will provide care for patient? Are they competent
to do so?
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1. Patient who needs insulin prior to eatingbreakfast, 0600 blood glucose was 122.
2. Patient who is being dismissed to home todayand needs discharge medication instruction.
3. Patient who has been receiving first unit ofblood since 0400; second unit is needed.
4. Patient who is going to surgery later thismorning and needs consent form signed.
5. Patient who had surgery yesterday and took lastprn oral pain med at 0500.
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3, patient getting blood 5, patient who may been in pain
1, patient who needs insulin
4, patient going to surgery
2, patient going home
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ABCs helpful Patient with these issues seen first Patients at risk for these problems seen first Or patients who might die of the problem if not
seen first
Treatments with time limits Blood cannot infuse over 4 hours
Actual problems over potential problems Except with head injury
Teaching considered low priority in mostcases
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A. Suctioning a tracheostomyB. Turning a patient side to sideC. Calculating intake and outputD. Administering an oral medicationE. Feeding a patient who has had a new stroke
and is at risk of aspirationF. Collecting vital signs on a stable patient
who has had surgery
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Suctioning airways requires sterile technique
Administering oral medications requires alicense
Feeding patients at risk of aspiration requiresassessment skill
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Nurses aides with 6 weeks of training Persons with on the job training Assign them tasks based on:
Task is repetitive and requires little supervision Relatively noninvasive
Assign them to patients who are Medically stable; they do not have assessment
skills beyond what they have learned on their own
Give them specific instructions on what to
report back to you and when
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A. Activate the fire alarm by calling the operatorB. Cover the wound and remove the patient from
the room
C. Place a pillow or blanket over the TV to put the
fire outD. Leave the leg undressed and remove the patient
from the room
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A. The patient is the priority, not infection
controlB. If the fire was small, in a waste basket for
example, it might be able to be contained,but a TV is an electrical
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RACE is the most common acronym Rescue the patient
Activate the Alarms
Contain the Fire
Close the doors
Close the fire doors
Extinguish the Fire
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A. Draw a sample of blood just before the nextdose and at the end of the infusion
B. Draw a sample of blood just before the nextdose and 1 hour after the infusion in complete
C. Obtain a sample of urine just before the nextdose and at the end of the infusion
D. Obtain a sample of urine just before the nextdose and 1 hour after the infusion in complete
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Peak concentrations of medications occur
when the medicine is at its highest level For IV meds, this is when the medication has
completely infuses
For oral medications, it is about 30-45 minutes
after ingestion Trough (low) concentrations occur just before
the next dose
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Medications that have a toxic effect on theliver, kidneys or ears need to be monitored
Patients with liver or kidney disease cannotexcrete the meds and become toxic more
rapidly Therefore doses can be reduced or frequency be
made longer (eg, every 18 hours, every other day)
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A. I drink grapefruit juice every morning.
B. I eat a lot of spinach and kale.
C. I drink milk with every meal.
D. I have changed to K Salt.
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Dark green vegetablescontain vitamin K
Spinach and kalecontain large amountsof vitamin K. Vitamin Kinterferes with theeffect of warfarin andshould not be eaten.
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Foods may alter absorption or bind with themedication Common problems:
Grapefruit juiceis metabolized by the same enzyme thatmetabolizes medications Antibiotics, Antihypertensives (calcium channel blockers),
Antiarrhythmics, Hormone Replacements, Cholesterol Blockers Tyramine with MAOs for psychiatric disease leads to
hypertensive crisis Tyramine found in beer, red wine, cheese, processed meats,
fruit, chocolate and nuts Milk or food and antibiotics
Delay absorption Potassium salt is substituted for NaCl
Very bitter and Much more salty Use with caution with kidney failure
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A. Hold the drug and notify the pharmacistB. Substitute a cephalosporin of equal strength
C. Explain that IV allergies do not cross over tooral allergies
D. Ask the patient to describe what happenedlast time she took Penicillin
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Some patients will report being allergicwhen they are not. They believe that havingan upset stomach is an allergy
The pharmacist will not be able to change the
order Allergies are not route dependent
The nurse cannot independently change the
drug from what is ordered
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Hives of theface and neck Skin rash is common
Several types Mild localized rash
Systemic effects
Anaphylaxis
Airway and facial edema
Occur with a secondexposure Immune system is set to
trigger a second response
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A. The ability of the patient to swallowB. Previous allergies to this medication or
PenicillinC. What other medications the patient
routinely takesD. The ability of the patient to adhere to the
TID drug regimine
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Augmentin pills are large and strep throatmay prevent swallowing them
Augmentin contains Penicillin and a crossover allergy is possible
Other medications, such as birth control pills,may interaction
Adherence to a TID regimen may be difficult
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Patients can take 20 ormore pills in one day
NSAID Sulfa Macrolides
- mycin antibiotics Quinolones
ciprofloxacin, enoxacin,norfloxacin, and ofloxacin Phenytoin
Quinolones
ACE inhibitors Potassium replacements
Spironolactone
Digoxin Amiodarone
Verapamil
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A. Jaundice
B. Oliguria
C. CandidiasisD. Gastric Bleeding
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Candidiasis (vaginal is very common) occurswhen the bacterial flora are altered andCandida grows unchecked Presentation is vaginal itching and pain, and a white
cheese-like drainageJaundice, oliguria and gastric bleeding is not
due to antibiotic Buy if present should be reported to the MD
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Proliferation(growth) oforganisms not killedby the antibiotic
Vaginal - vaginitis Bowel -- diarrhea
Oral -- thrush
Prevention with
probiotics? Lactobacillus in yogurt
can restore balance
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A. Avoid alcoholB. Limit fluids to 1000 ml per day
C. Avoid exposure to the sunlight
D. Limit consumption of milk products
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All the sulfa drugs can lead tophotosensitivity
Alcohol is avoided with Flagyl (metronidazole)
Milk delays absorption, it does not interfere
with this drug actions
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A. An elderly woman who lives in a nursinghome
B. A middle aged woman who has just gotten ahead cold
C. A young nurse with an allergy to eggs
D. An elderly woman who had a reaction to theflu vaccine last year
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High risk patients for influenza are: The elderly The institutionalized Persons with respiratory disease Health care providers
Influenza vaccine is contraindicatedin:
Persons with febrile illness Persons with egg allergy Persons who have had a prior reaction
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Natural = Nonspecific immunity From intact skin and white blood cells
Acquired Immunity = Antibodies Active = have the disease
Active = have an immunization
Passive = borrow the antibodies from others ormother
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A. YesB. No
C. I have no idea!
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Thrombolytics are used to dissolve the clot Drug names end in ase
However they dissolve all clots Not used with bleeding strokes, other sources of
bleeding
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Left sided stroke Right sided weakness
Language, mathematical and analytic processesimpaired
Right sided stroke Left sided weakness
Visual and spatial loss and loss of proprioception
Awareness of body in space Neglect of left side of body
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A.
Daily oral care with flossing will be neededB. Take the medication each morning with milk
C. The medication should be used until he isseizure free for 1 year
D. Limit alcohol consumption to 2 glasses ofwine daily
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Phenytoin has a narrowtherapeutic range
Gingival hyperplasiafrom poor oral care
Phenytoin is notabsorbed with milk ortube feeding
It needs to be taken forlife
Alcohol reduces itsabsorption Increases risk of seizures
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Digoxin (digitalis)
Phenytoin (Dilantin)
Warfarin (Coumadin)
Gentamicin Phenobarbital
Quinine
Patients quicklybecome toxic
Blood levels are drawnwhen doses arechanged
Nurses need tomonitor for signs andsymptoms of toxicity
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A. Heart failure
B. Asthma
C. DiabetesD. Dementia
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Propranolol is a nonselective Alpha and Betablocker, therefore will causebronchoconstriction
It should be used cautiously in diabetics May mask hypoglycemia
It is used for the treatment of heart failure
It has no contraindications in dementia
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Alpha 1 receptors are in the arterioles When stimulated lead sympathetic response
Flight or fight
Peripheral vasoconstriction to shunt blood
Tachycardia
Beta 1 receptors When stimulated lead to increased heart rate and increased
myocardial contraction
Beta 2 receptors
When stimulated lead to vasodilation, bronchodilation, musclecontraction
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A. Potassium 2.3B. Potassium 5.5
C. Sodium 135
D. Sodium 145
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Furosemide is a potassium wasting diuretic Loop diuretic
Normal values of potassium are 3 or 3.5 to 5or 5.5
Sodium range is 135-145 If this patients sodium is trending higher, MD
should be asked, patient may be becomingdehydrated
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You must memorize Sodium - 135-145
Potassium 3-5.5
Calcium 7-9
Dehydration can lead to false positives Values are higher than true numbers
Overhydration can lead to false negatives Dilutional effects
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A. Calcium 8.5
B. Chloride 100
C. Potassium 3.0
D. Sodium 122
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Sodium is the majorextracellular ion
When patient is dehydrated Fluid is lost
Sodium is not The portion of sodium is larger
More concentrated
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A. Chew on hard candy for dry mouthB. Take the medication on an empty stomach
C. Increase the amount of calcium taken daily
D. Increase the amount of fluid and fiber takendaily
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Calcium channel blockers increaseconstipation Smooth muscle in the colon does not work as well
They do not need to be taken on an empty
stomach They do not lead to dry mouth
They do not require that calcium intake bechanged
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End in the suffix pril inhibit depolarization-
induced Ca2+ entry intosmooth and cardiac
muscle cells in thecardiovascular system Smooth muscle in
arterioles where BP is
controlled
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A. 1 liter per minuteB. 2 liters per minute
C. 3 liters per minute
D. 4 liters per minute
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Oxygen therapy is provided in % by facemasks Each 4 percent = I liter by nasal cannula
Room air is 20%, so
24% = 1 liter 28% = 2 liters
32% = 3 liters
36% = 4 liters
Maximum oxygen by NC is 6 liters
At this rate, it dries the nasal mucosa and leads tobleeding
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Titrated to oxygen saturation in blood Measured by probe on finger or ear
Normal % is over 92%
Use lowest level of oxygen to meet O2 needs
Use of oxygen in patients with emphysema Drive to breath is hypoxia (not hypercapnia)
So if oxygen given, drive to breathe can be suppressed
Usually given only1-2 liters of oxygen
Venturi masks can deliver oxygen at specificpercentage
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A. Less coughing
B. O2 sats > 95%
C. Respiratory rate of 28/bpm
D. Fewer crackles in the chest
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The purpose of suctioning is to removesecretions from the tube and upper airways Suction catheters do not reach alveoli
Lung sounds will not improve until the patient
coughs Suctioning will cause reflex coughing
Respiratory rate should decrease
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A. I will stop using the inhaler if I get handtremors after using it.
B. I should use the inhaler as a rescue drug ifmy chest feels tight.
C. I should stop using the inhaler when I amtaking steroids.
D. I will take this inhaler daily to keep myasthma in control.
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Albuterol is an inhaled bronchodilator usedfor acute care of bronchospasm.
It can lead to tachycardia and tremorsbecause it is an alpha 1 agonist.
It is often used in combination with steroidsfor the treatment of acute asthma.
It is not a daily drug or a routine drug;inhaled steroids are used for this purpose.
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Asthma presentationPeak flow is key tomonitoring
Allergic response Inflammation
Airway swells and spasmsclosed
Presentation
Wheezing Dyspnea
Decreased peak flow
Measured by patient
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A. Presence of gag reflex
B. Color and amount of sputum
C. Ability to turn head side to side
D. Chest pain that worsens with inspiration
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The airway is numbed for the procedure Gag reflex is blocked for up to 2 hours
Do not feed the patient until gag reflex returns
Aspiration could develop
Assessment of sputum is not unique in thiscase
Injury to the neck from hyperextension couldoccur, but rare
Pneumothorax could occur, but rare and notunique to this procedure
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Examination of the bronchiwith a lighted tube Remove mucus
Biopsy airway tumors/masses
Remove foreign objects Patient is sedated
Airway is numbed
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A. Blood in the
collectionchamber
B. Air bubbling inthe air seal
C. Air bubbling inthe suctioncontrol chamber
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A. Blood in thecollection chamber
A. From thehemothorax
B. Air bubbling in theair seal
A. From thepneumothorax
C. Air bubbling inthe
suction controlchamber
A. From the wall suction
Fluid collection
Water seal
Suctioncontrol
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Placed into the pleural space Upper chest to remove air Lower chest to remove fluid
If system opens Air reenters pleural space and lung can collapse
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A. Ondansetron (Zofran)
B. Metoclopramide (Reglan)C. Prochlorperazine (Compazine)
D. Dimenhydrinate (Dramamine)
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Ondansetron (Zofran) works on the vomitingcenter in the brain
Metoclopramide (Reglan) is a GI stimulant andbest used for nausea after surgery
Prochlorperazine (Compazine) can lead toextrapyramidal effects Tremor, restlessness, uncontrollable speech
Dimenhydrinate (Dramamine) Commonly used for motion sickness
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Chemoreceptor trigger zone area of the brain which receives inputs from blood-
born drugs or hormones, and communicates withthe nearby vomiting center to initiate vomiting
Treat nausea prior to chemotherapy Treat nausea prior to surgery
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A. Let the patient take the medsB. Review the Medication Administration
Record and let her take the important onesC. Do not let her take the medications, report
the error and notify the MD
D. Do not let her take the medications andnotify the charge nurse
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The patient cannot take the meds, too muchtime has past and the nurse may have thesame meds for 0900
The MD may need to change the prescription
to replace the missing medications;something that the charge nurse cannot do
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Right drug Know how to correctly
compute dose
Check your work 3 times
Right dose Know algebra and how to
compute doses based onbody weight
Right patient Check ID band Have patient state his/her
name
Right time Know schedule for QD,
BID, TID, Q 6 hrs, beforeand after meals
Right route Know incompatibilities
with IV meds Know drug-drug, drug-
food interactions Right documentation
Chart only after the med
is given
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A. Discontinue the IV
B. Change the IV tubing
C. Slow the infusion rate
D. Apply a hot pack to the IV site
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The IV has infiltrated and needs to bestopped. The fluid is infusing into the tissuesnot the vein.
IV tubing is changed every 48 to 72 hours
routinely Slowing the infusion rate will not stop the
infiltration
Hot packs can be applied after the IV catheter
is out to help with fluid reabsorption
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IVs are often started by RNs
3 attempts is the usual maximumnumber of triesUsually started first in the handThen future sites are movedproximal in the arm
IV site complicationsInfiltration needle has
slipped and fluid is going into
tissuesExtravasation toxic meds
going into tissues
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A. Dyspnea
B. Polyuria
C. Confusion
D. IV site infiltration
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The IV fluid may have been deposited in hislungs when in fluid overload.
Polyuria would be great, it would mean thathis kidneys are excreting the fluids.
Confusion may be a concern, it may indicatehe has developed cerebral edema.
IV site infiltration would be worrisome, if thefluid is now in his arm, but not the most
severe problem.
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Sterile fluids infused into thebody through a catheter in a vein
Used to replace fluids in thevascular space (vessels)
Types of fluids Isotonic saline, D5W, LR
Hypertonic combinations of NS andglucose and Lactated Ringers
Hypotonic less than NS (.2, .45 NS
without glucose) Prescribed at hourly rates
Adult rates range from 75-125 ml/hr
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A. Remove the catheter and attempt to reinsertit into the urethra
B. Leave the catheter in the vagina and attemptto insert a new catheter into the urethra
C. Ask the patient to use the bedpan so thatthe urethra is open
D. Examine the perineum more closely andattempt to identify the urethra
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Common problems includeimproper exposure and poorlightening
Do not reuse the samecatheter
Leaving the old catheter in thevagina is not a bad idea; itprovides a marker
Using the bedpan will not
open the urethra long enoughfor you to see it
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Sterile items only remain sterile if they touchother sterile items
A sterile field is not sterile if you turn yourback to it
Exposure the perineum with yournondominant hand; so that your gloved handremains sterile
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A. I bought a good moisturizer for my feet.
B. I will use a mirror to check my feet every
night.C. I have found a place to buy shoes that have
a broad toe space.
D. I will use a hot baths every night to
increase blood flow to my feet.
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Diabetics develop neuropathy and cannot feelpain. Therefore hot water could burn thepatient.
Keeping the skin moist prevents fissures andcracks
Broad toe in a shoe is idea
Examining the skin on the feet with a mirroris critical for finding skin problems early
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After 10 years of diabetes, especiallyif poorly controlled blood glucose Retinopathy
Loss of vision Nephropathy
Loss of kidney function
May need dialysis Neuropathy
Dense numbness of the legs Easily injured Very slow to heal open wounds May lead to amputation
Autonomic neuropathy Slowed digestion Blood pressure problems (low or high)
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A. Consent to be Treated
B. Advance Directives
C. Patients Bill of Rights (Patient Partnerships)
D. Consent for Surgery
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Tumor? Impaction?
Hematoma?
Abdominal aortic aneurysm?
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Cues: pulsatile, sudden onset Likely treatment: either surgery or allow it to
rupture without treatment to end her life
Surgery
Likelihood of living is low So, confirming Advanced Directives is very
important
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Living Will The patients desires for treatments that prolong
life
DNR, tube feeding, intubation, CPR, cardiac meds
Durable Power of Attorney A person who can make decisions about life, death,
treatments on behalf of the patient
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A. Plan to do CPR if his heart stops
B. Contact the physician now for an updatedDNR order
C. Place a note on the chart for the physicianto renew the DNR
D. Ask the patient what he wants done if hisheart stops today and do what he wants
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Patients condition is deteriorating and hemay die soon
No assumptions can be made about preferredDNR status
Patient has to be in right mind or sane tomake this decision You could ask and give this information to the MD
Morphine clouds judgement
Once CPR starts, even if on a DNR patient bymistake, it must continue
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Orders written by MD after discussion withpatient or family
In some states, a DNR expires after 6 months Assuming the patients condition may have
improved
If no DNR is present on the record, all
resusitation takes place
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A. Allow him to leave as he intendsB. Validate that he understands the possible
consequences of his decision
C. Have him sign a leaving against medical advice
document before leavingD. Ask security to detain him until someone can sign
consent to be treated for him
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Angina can be due to occlusion of thecoronary arteries
Angina can precede a fatal myocardial
infarction The MD has to be notified, but if the patient
is left alone he may leave as he intends
Security cannot retain him, this could be seenas false imprisonment
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All patients have the right to refuse care
They must know and be able to comprehend theconsequences of this decision Demented patients cannot refuse carethey cannot
understand the consequences
Documentation of the conversations must be verycomplete Law suits can occur if patient suffers the consequences
and it is not clear that he was fully informed
Leaving against medical advice (AMA) Legal document that protects hospital from law suits If patient is at risk of harm to self or others may need to
be commitment to a mental health facility
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A. Ambulate upon return from the study
B. Assess puncture site for hematomaC. Avoid antiplatelet medications
D. Restrict oral and IV fluids
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The femoral artery is often the access siteand can quickly develop hematoma or bleed
The patient will be at bedrest with a pressuredevice on the groin (sandbag, pressure
gauge) Antiplatelet meds (Clopidogrel [Plavix],
aspirin, low molecular weight heparin) aregiven
Oral of IV fluids are pushed to remove thecontrast and prevent kidney injury
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Dye study of thecoronary arteries Invasive need consent
Dye check allergies toiodine or shellfish
Indications Chest pain
Unstable angina with STsegment changes
Confirmation of theextent of heart disease
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A. The exact location of the pain
B. If the pain radiates and to where
C. What makes the pain better and worseD. Does taking a deep breath cause pain
E. Vital signs and oxygen saturation
F. Color of the skin, diaphoresis
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Angina and MI
Pulmonary Embolus Some pain, more
tachycardia, tachypnea,decreased O2 sats, anxiety
Pleurisy Pain is worse with
breathing and sharp
Gastric distress/ulcers Pain related to diet
Pain better with food
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A. Medicate him for pain and splint the chestB. Suction his airway to remove the secretions
C. Increase his FIO2 to reduce his need tocough
D. Increase his fluid intake to thin thesecretions
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Incisional pain is made worse with coughing,so analgesics will help
His oxygen needs to be kept over 93-95% but
it is not to reduce the need to cough Suctioning him would be traumatic and would
make him violently cough
Fluids are often restricted after heart surgeryto avoid fluid overload
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Priorities of care Rhythm management
Edema and trauma tofibers
BP management
Hypotension may causegrafts to collapse
Hypertension maycause bleeding fromgrafts
Chest care Congestion common
Pain management
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A. Nothing
B. Administer sublingual nitroglycerin
C. Call a cardiac arrest, and begin CPR
D. Determine if the patient is conscious, if
not proceed with CPR
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A. Nothing, continue to monitor
B. Administer sublingual nitroglycerin
C. Call a cardiac arrest, and begin CPR
D. Determine if the patient is conscious, ifnot proceed with CPR
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A. Nothing
B. Administer sublingual nitroglycerin
C. Call a cardiac arrest, and begin CPR
D. Determine if the patient is conscious, if
not proceed with CPR
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A. Nothing
B. Administer sublingual nitroglycerin
C. Call a cardiac arrest, and begin CPR
D. Determine if the patient is conscious, ifnot proceed with CPR
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V fibrillation
V tachy (cardia)
Asystole
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A. I will take my water pill (furosemide) atnight.
B. I will take my heart rhythm pill (digoxin)when my pulse gets to 60.
C. I will have my blood (warfarin) tested weeklywhile I take this blood thinner.
D. I only need to take this blood pressure pill(Captopril) weekly.
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PT and INR is monitored weekly
at first to make dose changes Impacted by vitamin K intake
Furosemide is taken in the AM
Digoxin reduces heart rate
Pulse needs to be taken for aminute
Toxicity includes seeing yellowrings, fatigue, weakness, confusionand anorexia
BP meds are taken daily BP should be monitored
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A. Push 40 mEq of KCl into a central lineB. Push 20 mEq of KCl into a peripheral line
C. Infuse diluted KCl at 20 mEq per hourthrough a peripheral line
D. Infuse diluted KCl at 20 mEq per hourthrough a central line
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Never, never, ever give undiluted potassium
It stops the heart and the heart cannot befixed!
Diluted potassium is given
10 mEq through a peripheral line 20 mEq through a central line
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Peripheral lines are inthe arms and hands
Central lines are placed byMDs into subclavian andother large vessels
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A. Cred maneuvers
B. Kegel exercisesC. Increased calcium intake
D. Limit oral intake of fluids
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Kegel exercises strengthen the pelvic floor
Cred maneuvers is tapping over the bladder used by spinal cord injured to relax the bladder
Calcium has no impact
Oral fluids should not be restricted Other suggestions
Limit alcohol and caffeine
Used prescribed hormone therapy
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Stress Occurs with laughing, jumping, coughing
Mainly in women, follow child birth
Urge Seen with urinary infections
Functional Cannot reach the toilet in time or cannot remove
clothing in time
Total Unaware of need to void
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A. Furosemide 20 mg IV statB. IV NS 1000 ml bolus over 1 hour
C. Irrigate the catheter with 30 ml NS
D.
Continue to monitor for another hour
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The patient is dehydrated, he needs fluidsand quickly to prevent renal failure
Furosemide will create urine, but worsendehydration
The catheter does not appear to be plugged Plugged catheters produce no urine
Monitoring for another hour does not fix theproblem
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Prerenal renal failure Lack of blood getting to the kidneys
Seen in hemorrhage, edema (burns), dehydration
Treated with fluids
Intrarenal renal failure Diseases of the kidney Seen with nephrotic syndrome, diabetes, infection, meds
Treatment of the disease
Postrenal renal failure
Obstruction to flow past the kidneys Seen with prostate disease, kinked of plugged catheters
Treatment is remove the obstruction
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A. Give him 1-2 units of Lispro SQ
B. Notify the dietician to deliver his food traynow
C. Recheck his blood glucose first then givehim 15 g of glucose
D. Give him 15 g of glucose and recheck hisblood glucose in 15 minutes
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Normal blood glucose is 70-100 (110)
Hypoglycemia is serious and needs immediatetreatment
Lispro is rapid acting insulin---would make theproblem worse
There is no point in rechecking the reading; he islethargic, it is probably right Little error in treating
Getting his tray of food wont help; he cant eat it
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Hypoglycemia Below 70, treat with 15 g of glucose
Below 60, start with 15g and recheck glucose
Below 50, add a long acting sugar (eg crackers)
Below 40, use glucagonpatient usually
nonresponsive
Hyperglycemia Treat with short acting insulin, called sliding scale
Based on blood glucose reading
Replace fluids lost with diuresis
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A. None, this is a normal finding
B. Irrigate the ileostomy
C. Increase the patients activity
D. Notify the surgeon of the bowel obstruction
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Ileostomy does not have output for about 3days after surgery. The initial output is mucus
Irrigation would be contraindicated The suture sites are too new
The output is fluid
Activity could be increased for other reasons,but it would not change bowel output
There is no obstruction present
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Resection of bowelResidual stoma produces the type
of stool based on where it was priorto surgery
Stoma should be pink and abovethe skin level, so that appliancecan be attached
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A. Brownies with ice creamB. Pasta with marinara sauce
C. Strawberries with sugar
D. Poached eggs on toast
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High fat foods with stimulate the gall bladderto contract leading to pain
All the foods with sugar or starch or proteinare fine
Pain from gallbladder disease presents as Shoulder blade pain after eating fatty diet
Nausea, belching
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Cholecystectomy (not colostomy)
Done with scope Laparoscopic cholecystectomy
Smaller incision
Shorter hospital stay
Pain from air used in case
Diet afterwards can include
Fats
Bile is released continuosly
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A. Vomiting and abdominal pain
B. BP 122/83 lying and 92/66 standingC. Bluish discoloration around the umbilicus
D. Serum amylase 4 times higher than normal
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This patient is dehydrated and needs IV fluids
Periumbilical blueness (called Cullens sign),elevated amylase, pain and vomiting areexpected findings
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Serum enzymes are elevated whenever cellsare destroyed Amylase and lipase normally in the pancreas are
elevated with pancreatitis
Creatinine kinase and troponin elevated with
myocardial injury Creatinine kinase also elevated with muscle injury
Nurses expected to know which lab values arechanged in various diseases and notify MDs
when abnormal and unexpected findings arepresent
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A. Long acting insulin is used
B. Blood glucose is checked dailyC. MD orders are needed for TPN daily
D. Clean technique is used when changing TPNtubing or bags
l b d d l
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Hyperalimentation is prescribed daily Bags are hung to last 24 hours
If delivery falls behind or is ahead of schedule, it isnot made up
Blood glucose is checked 4 times a day and
treated with sliding scale regular insulin
Sterile technique is used with TPN Given through central lines
d f fl d d l
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Administration of fluids, protein and caloriesthrough a vein. Fats are also commonly givenin a separate infusion
Indications unable to absorb nutrients through the intestinal
tract
severe vomiting, diarrhea, or intestinal disease
Also called parenteral nutrition, totalparenteral nutrition, and TPN.
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C t t k l d f
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Content you know now was learned for a
specific test Create a study plan for review
You need to be able to recall informationpresented randomly Study information in sets to see relationships
E.g., heart disease
Make yourself recall it randomly Make cards to test yourself at odd times
Meet with friends to quiz each other on random topics
Mix up the material Add priority setting to heart disease, add it to OB, etc
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Eli i b i
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Eliminate obvious wrong answers
This exam does not have obvious errors Answer C is not always right
Longest answer is not always right
OK to guess if you have a sense it is right Do not run through the exam at the end and
guess on all unanswered items
S l t t
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Sample test www.4tests.com/exams
www.nclextestnaswers.com
Daily test items online Google to find sites
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