Name the health care regulatory agencies.

Joint Commission, State boards of Nursing, & FDA

What are 3 examples of tertiary care?

ICU, Oncology treatment center, Burn center

As required by law, what must a nurse who notices behavior that could jeopardize client care or could possibly indicate a substance abuse disorder immediately do?

Report observations to nurse manager

What information should be included in a change-of-shift report?

Any current problems, change, incidence or consultations that may require modification of a client's care. Ex. Bone scan scheduled this afternoon, patient missed PT this morning, patient dressing falls off when ambulating out of bed.

How to properly receive a provider's prescription over the phone?

Have another nurse listen to telephone conversation, repeat prescription details back to provider, and obtain provider's written signature on the actual prescription within 24 hours.

What are some patient characteristics that imply pain management may not be adequate?

Tachycardia, HTN, and no temperature increase, patient not adherent/refuses to perform suggested pain interventions (Ex. cough, deep breathe, dangling), & only accepts pain med either at or over the regular 4 hour PRN interval.

True or False: Easily agitated patients indicate they are experiencing pain.

False. This alone is not a single identity of pain.

Unfamiliar surroundings upon admission to the hospital is the greatest risk factor for what age client? What should be the priority NI?

Older Adults (unfamiliar surroundings = fall risk) Orient the patient to his/her room. (before leaving, teach how to use call light and other equipment at bedside)

True or False: You should ask about organ donation at time of hospital admission.

False. This could instill unnecessary fear.

What should be included in the discharge summary for a patient who is going home? (Ex. Post-op knee arthroplasty)

Where to go for follow-up care & written instructions for diet/medications (Ex. Names and contact information of health care provider and community resources, analgesics or anticoagulants, how to avoid post-op constipation)

A patient is being discharged from the hospital to another provider who will then take over client care. (Ex. Long-term facility). What additional information should be included in the transfer report?

Patient diagnosis, last recorded vital signs, need for special equipment & advanced directive status. (Necessary since a new provider will be taking over medical care)

Nursing intervention for a patient who is about to have a surgical dressing change and is experiencing coughing and sneezing?

Place a mask on the client to limit the spread of pathogens into the wound bed.

A sterile solution should be prepared before or after you put on sterile gloves? Why?

Before. The outside of the bottle itself is considered contaminated; therefore, touching the outside of the bottle once sterile gloves are applied will breach sterile technique.

Which flap on a sterile field should be unfolded first?

The top flap farthest from the body.

Wash hands with soap and water for at least ___? If hands are soiled, wash hands with soap and water for at least ___. What water temperature should be used? Use clean ____ to turn off faucets and dry hands.

15 seconds. 2 minutes. Warm. Paper towel.

What are some actions that are recognized as decontaminating a sterile field and should not be done?

Delayed procedures, nurse moves/looks away from sterile field, hand brushes against 1" borders of sterile field, & dropping or placing a contaminated or non-sterile item on the sterile field (Ex. Cotton ball moistened with sterile normal saline).

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ATI Fundamentals

ATI Fundamentals/Leadership & Mngmt./Maternal Newborn/Med-Surg

Question	Answer
Name the health care regulatory agencies.	Joint Commission, State boards of Nursing, & FDA
American Nurses Association (ANA) & National League of Nursing (NLN) are professional ____ organizations?	Nursing
___ health care involves the provision of specialized and highly technical care?	Tertiary
What are 3 examples of tertiary care?	ICU, Oncology treatment center, Burn center
Cardiac rehabilitation and home health care are both examples of ___ care?	Restorative
An older adult who states "it is difficult to prepare nutritional balanced meals at home for just myself", should be referred to which member of the health care team?	Social worker
Who can assist clients who have physical challenges to use adaptive devices or methods to help the patient to actively participate in self-care activities?	Occupational therapist (OT)
A registered dietician can help a patient choose nutritional needs, but they cannot help the patient with _____ _____?	Physical limitations
True or False: CNA's are able to assist the patient in understanding medication side effects and determine pain level.	False
True or False: CNA's can assist patients with ADL's such as bathing, toileting and ambulation, as well as measuring and recording information such as vital signs and intake and output.	True.
What is the right to make own decisions? Ex. patient refuses surgery	Autonomy
What is characterized by taking action to help others? Ex. nurse offers pain med to client before ambulating	Beneficience
What is characterized by fairness in care delivery and use of resources? Ex. nurse explains all clients waiting for kidney transplant must meet the same criteria	Justice
What is the act of avoiding harm or injury? Ex. nurse questions med prescription she believes is too dangerous for an older adult client	Nonmaleficence
Which tort can make a patient fearful and apprehensive? Ex. AP tells patient, "If you don't stop peeing everywhere, I am going to put a diaper on you."	Assault
The patient can only choose any ___ adult to be their health care proxy for an Advanced Directive- does not have to be family member.	Competent
True or False: Staff must ask patient if they have an Advanced Directive.	True
Nurse should provide ________ if a patient does not have an Advanced Directive.	Written documentation
True or False: A patient must seek provider approval before submitting Advanced Directive.	False
Making sure the surgeon obtained client consent and witnessing the client's signature on the form are the only obligations a nurse has regarding which legal responsibility?	Informed consent
As required by law, what must a nurse who notices behavior that could jeopardize client care or could possibly indicate a substance abuse disorder immediately do?	Report observations to nurse manager
What information should be included in a change-of-shift report?	Any current problems, change, incidence or consultations that may require modification of a client's care. Ex. Bone scan scheduled this afternoon, patient missed PT this morning, patient dressing falls off when ambulating out of bed.
How to properly receive a provider's prescription over the phone?	Have another nurse listen to telephone conversation, repeat prescription details back to provider, and obtain provider's written signature on the actual prescription within 24 hours.
A condom catheter is a ____ procedure and can be performed by an AP.	Non-invasive
Right supervision, evaluation, direction and communication are a part of the 5 rights of __?	Delegation
Post-surgery patients must be managed by a(n)?	RN
At time of evaluation, the nurse gathers information about the client and identifies that the desired client outcome (ex. pain relief) is not successfully met. What is the nurse's next step?	Reasses
How do you assess/reassess pain?	Pain scale
___ data is what the nurse observes and measures?	Objective
What are some patient characteristics that imply pain management may not be adequate?	Tachycardia, HTN, and no temperature increase, patient not adherent/refuses to perform suggested pain interventions (Ex. cough, deep breathe, dangling), & only accepts pain med either at or over the regular 4 hour PRN interval.
True or False: Easily agitated patients indicate they are experiencing pain.	False. This alone is not a single identity of pain.
Sudden tenderness or swelling of a lower extremity on a 24 hour post op abdominal surgery patient likely suggests a new problem, such as ___, and is not an indicator of inadequate pain relief.	Deep vein thrombosis (DVT).
Dysphagia is the greatest risk related to a patient's nutrition evaluation because it increases the risk for __?	Aspiration
Unfamiliar surroundings upon admission to the hospital is the greatest risk factor for what age client? What should be the priority NI?	Older Adults (unfamiliar surroundings = fall risk) Orient the patient to his/her room. (before leaving, teach how to use call light and other equipment at bedside)
Providing information about Advanced Directives is done at ___?	Admission
When does patient discharge planning start?	Admission
True or False: If applicable, a client should be introduced to their roommate upon admission to the hospital to decrease stress.	True
True or False: You should ask about organ donation at time of hospital admission.	False. This could instill unnecessary fear.
Cognitive status (LOC) along with needed information related to patient medications, alternative therapies, prescribed diets, allergies, or psychological issues pertinent to possible prompt intervention should be included in the ___ ___?	Transfer report
What should be included in the discharge summary for a patient who is going home? (Ex. Post-op knee arthroplasty)	Where to go for follow-up care & written instructions for diet/medications (Ex. Names and contact information of health care provider and community resources, analgesics or anticoagulants, how to avoid post-op constipation)
A patient is being discharged from the hospital to another provider who will then take over client care. (Ex. Long-term facility). What additional information should be included in the transfer report?	Patient diagnosis, last recorded vital signs, need for special equipment & advanced directive status. (Necessary since a new provider will be taking over medical care)
Nursing intervention for a patient who is about to have a surgical dressing change and is experiencing coughing and sneezing?	Place a mask on the client to limit the spread of pathogens into the wound bed.
A sterile solution should be prepared before or after you put on sterile gloves? Why?	Before. The outside of the bottle itself is considered contaminated; therefore, touching the outside of the bottle once sterile gloves are applied will breach sterile technique.
Approximately what length of the sterile drape edges/borders is considered non-sterile?	1 inch
True or False: The inner wrapping of an item on a sterile field is considered sterile.	True
True or False: An irrigated syringe on the sterile field is considered non-contaminated/sterile?	True
Which flap on a sterile field should be unfolded first?	The top flap farthest from the body.
Wash hands with soap and water for at least ___? If hands are soiled, wash hands with soap and water for at least ___. What water temperature should be used? Use clean ____ to turn off faucets and dry hands.	15 seconds. 2 minutes. Warm. Paper towel.
What are some actions that are recognized as decontaminating a sterile field and should not be done?	Delayed procedures, nurse moves/looks away from sterile field, hand brushes against 1" borders of sterile field, & dropping or placing a contaminated or non-sterile item on the sterile field (Ex. Cotton ball moistened with sterile normal saline).
Prior to sterile procedure, the nurse prepares any necessary solutions. Next, a pair of sterile gloves is applied. After opening gloves and verifying that the glove cuffs are directed toward the body, which hand is used to apply the first sterile glove?	Non-dominant hand
Stage of infection where acute signs and symptoms have faded?	Convalescence
Stage of infection where non-specific clinical manifestations occur?	Prodromal
Stage of infection where specific clinical manifestations related to the illness occur?	Illness
Patient reporting severe sore throat, pain when swallowing and swollen lymph nodes is experiencing which stage of infection?	Illness
Linear clusters of fluid-containing vesicles with some crust is indicative of what?	Herpes Zoster
A pink body rash can indicate ___?	Allergic reaction
Red edematous rash bilateral on the cheeks (butterfly rash) can indicate ___?	Systemic lupus eythematosus (SLE)
True or False: To decrease fall risk, bed should be in lowest position and full side rails should be up.	False. Full side rails may put the client at greater risk for fall because he may try to crawl over the rails.
_____ footwear helps the client from slipping?	Non-skid
____ serves as the basis for an individualized plan of care and is the priority action to determine the degree of patient's risk for fall?	Fall-risk assessment
Discharge teaching for using oxygen at home should include?	Family should smoke outside. Do not use nail polish or other flammable materials. "No Smoking" sign on front door and even on bedroom door. Wear cotton materials. Have fire extinguisher ready and available.
Wool and synthetic materials create _____ and should be avoided with oxygen therapy?	Static electricity
Carbon monoxide poisoning is so dangerous because it combines with ___ in the body and ultimately reduces oxygen perfusion?	Hemoglobin
Signs and symptoms of a patient who has had a heat stroke include what vital sign and temperature changes?	Hypotension, tachycardia, tachypnea and hot, dry skin.
A patient receiving enteral tube feedings due to dysphagia should be placed in what position?	Semi-Fowler's (HOB 30 degrees)
Which patient position allows for chest expansion by sitting on the side of the bed and resting arms over pillows placed on bedside table?	Orthopneic
How to prevent injury with staff nurses?	Request assistance when repositioning client. Lower center gravity for stability. Bend at the knees and spread feet apart. Hold lifted objects as close as possible. Use smooth movements. Take breaks from every 15-20 minutes from repetitive movement.
When sitting for long periods of time, how should you position your knees?	Slightly above hips.
A client with appendicitis needs immediate ____ to prevent rupture of the appendix and subsequent peritonitis? These patients cannot be discharged in event of mass casualty or disaster.	Appendectomy
Nursing intervention in the event of a tornado?	Close all client doors, shutters and drapes. Place blankets over clients who cannot ambulate and move all beds away from windows. Ambulatory clients should be told to go in to the hallway, away from windows.
Nursing intervention in the event of a bomb threat?	Listen for background noises to determine location of caller. Try to stay on line as long as you can, asking questions to obtain information and call-tracing. Do not announce overhead unless you are an idiot who wants to stir mass chaos.
Testicular, blood pressure, BMI, & cholesterol tests begin at what age?	20 years old
Between 40-50 years old, females should have what annual routine screening?	Mammogram
When the client is able to demonstrate the appropriate technique, ___ learning has taken place?	Psychomotor
Following a nurse education session, a client states her previous ideas have changed and she will be willing to adjust to suggestions given in teaching. This is an example of ___ learning?	Affective
Rolling from back to front, bearing weight on legs, and sitting unsupported are expected gross motor development findings on what infant age(s)?	6-9 months
Parents should remove gyms and mobiles by what age?	4 months
True or False: Make sure balloons are fully inflated for a toddler.	False. Toddlers should not play with balloons at all.
Building simple models is an appropriate play activity for what age group?	School-aged children
Both playing and looking at books and filling and empyting containers are appropriate play activities for what age group?	Toddlers (1-3 years old)
When should a children switch from whole milk to low-fat or fat free milk?	2 years old
A child who builds a 2- block tower and uses a cup well are expected fine motor skill findings of what age?	15 months
Rule of thumb: ___ tbsp. of solid food is given per year of age?	1 (Ex. 2 tbsp. for a 2 year old)
Pretend play helps children determine difference between reality and fantasy and is commonly observed with what age group?	Preschool (4-5 years old)
Preschoolers enjoy mastering tasks they can perform independently. What is a NI related to decreasing fear of the hospital? What can parents do to help?	Ask child if they want to help with received care (Ex. mealtime activites). Parents can aid by bringing a favorite toy from home.
True or False: When providing care to the preschool patient, the nurse should cluster invasive procedures and only assign staff members that the client prefers.	False. The nurse should try to avoid clustering invasive procedures. Preschoolers have less anxiety than toddlers, so no need to prioritize this intervention.
Modeling with clay is an appropriate play intervention for what age child?	Preschooler (4-5 years old)
___ is developed in school-age children?	Privacy
What is the lateral curvature of the spine which in most cases, has no apparent cause? Most common in what gender? What age is the complication most noticeable, therefore urging recommended screenings?	Scoliosis. Females. Adolescents.
Appropriate interventions for an adolescent with multiple fractures?	Provide non-violent videos to watch. Allow flexibility in schedule. Allow patient to perform his own morning care.
Where is the first sign of sexual maturation in boys located?	Enlarged testes & scrotum.
What are some safety precautions for young adults (20-35 years old)?	Wear helmet while skiing. Have a carbon monoxide detector in the home. Secure firearms in a safe location.
In middle adulthood, ___ vision declines?	Near (Presbyopia)
Metabolism declines and weight gain is likely with what age group?	Middle adulthood (35-65 years old)
In middle adulthood, secretions of bicarbonate and gastric mucus begin to decrease and persist into older adult. This increases the risk for a person to develop ___?	Peptic ulcer disease (PUD)
Middle adults focus on searching and developing ____ relationships?	Intimate
Subjective data related to older adult patient's recent weight loss changes includes?	Eat alone, new medication(s), 24 hr. recall, & fixed income. (Ex. "Do you eat alone or with somebody?", "Have you started any new medication over the last 6 months?", "What foods have you eaten in the last 24 hours?", "Are you on a fixed income?")
Nutritional/supplemental teaching for an older adult patient should include?	Lower iron required (after menstruation), increase fluid intake (prevent dehydration and constipation). increase calcium (prevent osteoporosis), limit sodium intake (prevent edema and HTN), & increase fiber (prevent constipation).
When a nurse is introducing herself in the first step of a comprehensive physical examination, what question should the nurse ask the patient?	"What do you prefer to be called/answer to?"
What strategies should a nurse use after introducing herself in the initial phase of a comprehensive physical examination?	Use a mix of open and close-ended questions, reduce noise to promote a calm and quiet environment, and perform the general survey before the examination portion.
Obtain _____ before initiating antimicrobial medication?	Culture specimens
Patient is restless and skin is warm. VS indicate increased temperature, tachycardia and tachypnea. What are appropriate nursing interventions?	Obtain culture specimen before initiating antimicrobial medications. Encourage the client to limit activity and rest. Assist patient with frequent PO hygiene.
Patient with low platelet count has an increased risk for ____?	Bleeding
A patient with a fractured femur has a blood pressure reading of 140/94 with no history of HTN. NI?	Ask patient if they are in pain.
True or False: An LPN can obtain VS on a patient who is 2 hours post-op following a cardiac catheterization.	True
What should the RN do if newly hired AP have not calculated I&O on several clients?	Ask the AP's if they need help completing I&O records.
What provides the most relevant information regarding the effectiveness of a procedure?	Variance/ Incident report
What strategy is used if a manager does not intervene even when conflict escalates?	Avoidance
Patient states he is going to leave hospital. Should the nurse notify risk manager immediately?	No, not immediately.
If patient leaves without discharge, what should the nurse document?	Client left facility "against medical advice" (AMA).
True or False: Most facilities do not have a form for patients to sign if they choose to leave before discharge.	False
Acceptable or Unacceptable: Reviewing health care record of client assigned to another nurse.	Unacceptable
Acceptable or Unacceptable: Making a copy of lab values to give to provider during rounds.	Unacceptable
Acceptable or Unacceptable: Providing information about a client's condition to a hospital clergy.	Unacceptable
Acceptable or Unacceptable: Discussing client condition over the phone with an individual who has provided the client's information code.	Acceptable
Acceptable or Unacceptable: Participate in walking rounds that involve exchange of client related information outside the patient's room.	Unacceptable
In regards to advances directives, what should the nurse do if a client states he is too young to worry about life-sustaining measures and does not need the information?	Contact a representative to talk with the client about advanced directives and offer additional information.
Verifying that a client understands what is done during a cardiac catheterization, informing health care team members about a DNR status and reporting failure of fellow staff members to provide care are examples of which nursing role of?	Advocacy
____ is a document that addresses and outlines clients' rights when receiving care?	Patient Care Partnership
What resource should a newly licensed nurse access to review procedure and standards prior to inserting IV catheter on a patient?	Institutional policy and procedure manual
Use a ____ knot to tie restraints to the bed frame?	Quick-release
Ensure that the restraint is loose enough for ROM and can fit ___ fingers between device and client?	2
What factors can increase a patient's risk for falls?	History of previous fall. Reduced vision. Impaired memory. House slippers. Kyphosis.
Patient brought back to unit after total hip arthroplasty. Confused, moving leg in ways that could cause dislocation with multiple attempts to get out of bed. What actions should the nurse take?	Apply arm and leg restraints immediately. Get order from provider. Have family member sign restraint consent form. Use a quick-release knot tied at bed frame. 2 fingers can fit between client and device.
True or False: A description of the incident should be documented in the client's health care record.	True
Incident reports should/should not be shared with the client?	Should not
___ includes a description of the incident and actions taken?	Incident report
Who investigates the incident/incident report?	Risk management department
A hollow, drum or bell-like sound that is commonly auscultated over a pneumothorax or a distended abdomen?	Tympany
Tympany over a pneumothorax is heard if the chest contains ___ ___?	Free air
When auscultating at the apex of the heart, the nurse understands she is hearing S1 sounds, which is also identified by the closing of which two valves?	Tricuspid and mitral valve
Bruits are indicative of what unexpected finding?	Narrowed blood vessels
What sound results from the rubbing together of inflamed peritoneum layers?	Friction rub
True or False: Capillary refill <2 second, thick skin on the soles of the feet and numerous light brown macule on the face are normal skin findings.	True
An abnormal color finding of nail beds indicative of anemia and/or impaired circulation is ___?	Pale
What are some explanations for finding significant skin tenting over an older adult's forearm?	Loss of adipose tissue, dehydration & diminished skin elasticity.
A form of therapeutic communication used that focuses back on the patient? Ex. A client states, "I have to check with my wife and see what she thinks about be being discharged today."	Reflecting Ex. In response, the nurse says, "How do you feel about going home today?"
How should the nurse sit to facilitate effective communication?	At eye level facing the patient.
True or False: The nurse should not talk about family to the interpreter while family is present.	True
True or False: When involving an interpreter, the nurse should look at the family and ask one question at a time using lay terms.	True
True or False: It is ok for the nurse to interrupt conversation between the interpreter and the patient.	False
A Jehova's Witness desperately needs a blood transfusion but based on religious and spiritual motives, he will not accept the treatment. How should the nurse respond to this?	Involve the patient's religious and spiritual leaders. Discuss alternative forms of blood products and try to compromise with an acceptable plan for all.
Highest priority nursing intervention to prevent infection with indwelling urinary catheter?	Frequently clean the client's perineal area and provide catheter care.
Patient teaching related to diabetes foot care should include what important criteria?	Inspect feet daily, use moisturizing lotion- NOT between the toes, wash with lukewarm water, dry thoroughly, check shoes for any foreign objects, avoid any OTC medications.
How should the nurse care for dentures?	Brush the dentures with a toothbrush and denture cleaner.
Periods of ___ warrant a prompt referral for diagnostic sleep studies?	Apnea
A ____ diet consists of foods that are low in fiber and easy to digest. What are some appropriate food examples?	Low-residue. Dairy products & eggs.
Nursing interventions to reduce the risk of thrombus development include applying ____ ____ and assisting client to ____ ____ often?	Elastic stockings. Change position.
What is a cardiac complication related to immobility?	Orthostatic hypotension
A respiratory complication related to immobility is decreased respiratory movement. As a result, this can progress in to two severe respiratory complications known as _____ and _____?	Atelectasis & Hypotension pneumonia
Universal symptoms commonly indicative of pain include ____ and ____?	Nausea & Vomiting
A nurse is monitoring a patient receiving opioiod analgesia for adverse effects. What adverse effects should the nurse anticipate? Hint: Symptoms effect GI, GU and cardiac systems.	Nausea, vomiting, bradypnea (respiratory depression), urinary retention, constipation, orthostatic hypotension (dizzy, light-headed)
True or False: Massage therapy and therapeutic touch require special licensure or certification.	True
What are 3 complementary and alternative therapies that a nurse should encourage nursing students to use while providing patient care?	Guided imagery, meditation & music therapy
What are expected findings for a patient who has had prolonged diarrhea?	Dehydration resulting in hypotension, fever, and poor skin turgor; tachycardia
Losing control of urine whenever coughing, laughing or sneezing is indicative of which type of incontinence?	Stress
What should the nurse instruct the patient to avoid in an effort to control/eliminate stress incontinence?	Avoid caffeine and alcohol.
Should the Crede maneuver be used to manage stress incontinence?	No. This is used for reflex incontinence (involuntary loss).
What loop diuretic can cause ototoxicity (hearing loss) and blurred vision?	Furosemide (Lasix)
A client who just started wearing hearing aids requires education. What should be included with hearing aid instructions?	Always keep hearing aids dry. Clean molds with soap and water. Keep volume on the lowest effective setting. Take batteries out of hearing aids when removing at night to conserve battery power.
____ is the best medication choice for rapid onset of pain because it is immediately absorbed into the bloodstream and provides immediate response?	IV Morphine
It is recommended to administer irritating meds with what, to assist in prevention of N/V and ability to retain the medication and achieve its therapeutic effect?	Small amounts of food.
Window allotted for administering medication?	30 minute window
What will you see if IV has infiltrated?	Cool, pale, swollen skin. IV rate slows or stops. Damp IV dressing. Pain.
What will you see if IV has phlebitis/cellulitis?	Warm, red, swollen skin. Pain, chills and "does not feel well". Induration and red streak on arm near the IV site.
Basic signs and symptoms of FVE?	Tachycardia, HTN, SOB & edema.
Proper needle angle for starting an IV?	10-30 degrees
Nursing intervention if patient IV has phlebitis/cellulitis?	Stop infusion & remove catheter.
Antipsychotic used to treat schizophrenia? What is a serious side effect of this medication?	haloperidol (Haldol). Extrapyramidal symptoms (EPS).
Examples of extrapyramidal symptoms (EPS) include?	Fine motor tremors, acute dystonia, uncontrollable restlessness, drooling
Priority assessment prior to giving new medication?	Allergies
True or False: To promote adherence with medication administration to older adult clients, pills should be placed in daily pill holders.	True
To promote adherence with medication administration to older adult clients, ___ forms should be provided if patient has difficulty swallowing?	Liquid
True or False: To promote adherence with medication administration to older adult clients, relatives can be asked to assist periodically.	True
To promote adherence with medication administration to older adult clients, medication containers should be ____ to open?	Easy
Diuretics, Corticosteroids and Antipsychotics can cause the body to have an elevated ____ level?	Glucose
What are 3 key factors to assess patient's ability to learn self-monitoring of blood glucose using a glucometer?	Finger dexterity, visual acuity and demonstration ability.
Early signs of hypoxemia?	Restlessness, confusion, pallor, tachycardia, tachypnea, & HTN.
Late signs of hypoxemia?	Stupor, cyanosis, bradycardia, bradypnea, hypotension & cardiac dysrhythmias.
Guidelines to endotracheal suctioning. When to apply suction? Routine suctioning? Asepsis used? When to use a catheter?	While withdrawing catheter. No routine suctioning. Sterile technique. Use new catheter for each suction attempt (limited to 2-3 attempts).
True or False: Petroleum jelly should be applied for patient with oxygen therapy via nasal cannula.	False
True or False: Remove nasal cannula at meal times with oxygen therapy?	False
Diabetes Mellitus places a client at risk for impaired ____ & ____?	Impaired circulation & immune system function
Emesis and transmission from a client's contaminated hands are identified as ____ contact?	Direct contact (person-to-person)
Urinary incontinence, acute confusion and agitation are atypical signs and symptoms of ____ in an older adult patient?	Infection
Signs and symptoms of bacterial meningitis? What precautions are taken with these clients?	Constant HA, nuchal rigidity, photophobia, fever, chills, altered LOC, red macular rash, elevated WBC count. Droplet precautions.
What diagnostic(s) identify IICP?	CT or MRI
Adrenal insufficiency, DKA and ascites are all risk factors for ___ shock?	Hypovolemic
Heart failure is a risk factor for ___ shock?	Hypervolemic
Expected findings with hypovolemia?	Cool, clammy skin, hypotension, tachycardia, decreased skin turgor, syncope
Determine decreased/increased lab results that indicate dehydration: Hct, Serum osmolarity, Sodium, Urine specific gravity and Creatinine	Increased Hct, Increased serum osmolality, Increased sodium, Increased urine specific gravity & Increased creatinine.
What fluids should be administered to a patient with hypernatremia?	Hypotonic fluids
What medication is given for the treatment of hyperkalemia?	sodium polystyrene sulfonate (Kayexelate)
A patient with hypercalcemia is at risk for ____ ____?	Pathologic fractures
Nursing intervention for patient receiving enteral feeding with diarrhea?	Decrease the rate of feeding.
Goal of managing dumping syndrome is to slow the rate of ____?	Peristalsis
A client with a chest tube reports a burning sensation/pain in his chest, indicating that the chest tube is resting against tissues and has become ___?	Occluded.
To move the tip of a chest tube away from the tissues (occlusion) what should be the nurses priority intervention?	Assist the client to a side-lying position.
What is the therapeutic serum lithium level? This medication is given to treat what mental health disorder?	0.8-1.4. Bipolar disorder.
To reduce the risk of painful stimuli, how should ear drops be prepared prior to administration?	Warmed to room temperature.
It is important to remember that the ear is sensitive to extremities in ___?	Temperature
___ precautions include placing the client either in a private room or with other clients who have the same disease, as well as using of a mask when providing care?	Droplet (Ex. rubella)
Sickle cell anemia patients often have ___ Hct levels?	Low
A sickle cell pain crisis patient displays slurred speech. The nurse understands this is a medical emergency because the blockage of blood vessels in the brain by sickle cells results in ___, which ultimately leads to neurological impairment?	CVA
___ is the bronchodilator medication that should be administered first to open the airways of a patient diagnosed with asthma?	Albuterol
True or False: A written prescription from the provider is necessary to legally change the client's code status to a DNR.	True
What is a decrease in neutrophils, resulting in a reduced ability to fight infection and can cause death? This adverse effect can be seen in what lab value?	Agranulocytosis. Decreased WBC count.
What are three adverse effects seen across Antipsychotics? (Ex. clozapine (Clozaril))	Seizures, agranulocytosis & orthostatic hypotension.
Abdominal distention present at birth is indicative of a ____?	Tumor or an abdominal wall defect.
A patient with an NG tube to suction is at increased risk for which electrolyte imbalance?	Hypokalemia
A nurse should teach a client scheduled for a lumbar puncture that a post-procedure complication is ___?	Headache
Initial HIV symptoms are often similar to the ___?	Flu
What should be the nurse's priority goal if abuse is suspected?	Protect patient from further abuse.
Condoms are used which what type of lubricants?	Water-soluble
Contraceptive patches are replaced how often?	Once a week
How often should spermicide be applied?	Every time that the patient has sex.
What are some common side effects of oral contraceptives that usually subside after a few months of use?	Amenorrhea, weight gain, breast tenderness, mild HTN & headache.
An IUD can cause irregular vaginal bleeding and increases the risk for what complication?	Ectopic pregnancy
True or False: A change in the length of the string of an IUD may indicate expulsion and should be reported to the provider.	True
An adverse effect of medroxyprogesterone (Depo-Provera) is loss of ___ ___? To prevent, the patient should be instructed to also take what 2 things?	Bone density. Calcium and Vit-D.
True or False: A male patient who has a vasectomy is a permanent contraceptive method. Sexual function will be slightly altered.	False. Sexual function is not impaired.
A prenatal client who does not like milk inquires about other potential foods she could eat to consume a good source of calcium . What should the nurse recommend?	Dark green, leafy vegetables
Maternal HTN, blunt abdominal trauma, cocaine and cigarette use are risk factors associated with what maternal-nb complication?	Abruptio placenta
____ is manifested by lower quadrant pain with or without bleeding in a prenatal patient?	Ectopic pregnancy
Why is Betamethasone (Celestone) given?	To promote lung maturity when delivery is anticipated.
What medication is prescribed for the client experiencing postpartum bleeding?	Methylergonovine (Methergine)
Contraindications for pregnant woman with HIV+ include?	Episiotomy, vacuum extraction, forceps, and internal fetal monitoring.
What are 3 risk factors for hyperemesis gravidarum?	Obesity, multifetal pregnancy & migraine HA
Signs of magnesium sulfate toxicity?	RR <12, UO <30 mL/hr, absent patellar deep tendon reflex, & decreased LOC.
What is the antedote for magnesium sulfate?	Calcium gluconate
True or False: Magnesium sulfate is used for dilation > 6 cm.	False
True or False: Magnesium sulfate is used for preterm labor.	True
True or False: Magnesium sulfate is used for severe gestational HTN.	True
True or False: Magnesium sulfate is used for vaginal bleeding.	False
True or False: Magnesium sulfate is used for acute fetal distress.	False
A prenatal client with premature rupture of membranes should be instructed to keep a daily record of ___?	Fetal kick counts
What stage and phase of labor is a patient in who has contractions lasting 30-45 seconds apart and appear relaxed, eager and talkative?	Stage 1- Latent Phase
Stage 1 active labor is determined by dilation of ___ cm. and contractions lasting 40-70 seconds apart?	4-7 cm.
Stage 1 transition phase of labor is a patient who is dilated 8-10 cm. and has contractions lasting for how long?	45-90 seconds apart
What phase of labor shows signs of irritability and rectal pressure?	Transition phase
The second stage of labor is characterized by what?	Expulsion of the fetus.
A nurse determines a large gush of blood from a patient's vagina is amniotic fluid. The nurse knows the priority intervention is to monitor the FHR for signs of distress because the greatest risk to both the mother and fetus at this time is ___?	Umbilical cord prolapse.
A prenatal client with ruptured membranes and leaking fluid for over 24 hours is a great risk for ___?	Infection
____ ____ to the lower back relieves the pressure exerted on the pelvis and spinal nerves by the fetus in persistent posterior position?	Sacral counter-pressure
Maternal hypotension can occur following an epidural block and can be offset by administering ______?	IV fluids
Lidocaine (Xylocaine) is administered to a patient expected to deliver in 20 minutes for pain relief, episiotomy, and expulsion of the fetus. The nurse understands this type of regional anesthesia is a ____ block?	Pudenal block
____ blocks are administered during labor and allow the client to participate in the second stage while remaining comfortable?	Epidural
Spinal blocks are administered in the late second stage but most commonly preceding what?	Cesarean birth
A client in labor and delivery is using patterned breathing and reports numbness and tingling of the fingers. The nurse understand the patient is experiencing hyperventilation and should should perform what following action?	Place oxygen mask over the client's nose and mouth or have client breathe into paper bag.
A patient in labor experiencing incomplete uterine relaxation between hypertonic contractions results in ___ ___?	Fetal hypoxia
True or False: Inadequate uterine relaxation occurs with prolonged labor.	False. Precipitous labor.
What position can the patient assume to help the fetus rotate from a posterior to an anterior position?	Hands and knees
The supine position with a rolled towel under one hip can assist in preventing what?	Vena cava syndrome
What is a potential complication for a fetus in a breech presentation?	Prolapsed umbilical cord
True or False: Breech presentation is more likely to cause prolonged labor.	True
True or False: A postterm neonate is at increased risk for hyperglycemia.	False. Hypoglycemia.
True or False: A postterm neonate is at increased risk for aspiration of meconium.	True
True or False: A postterm neonate is at increased risk for polyhydramnios.	False. Oligohydramnios.
The monitor reveals a FHR of 80-85 bpm. The nurse performs a vaginal examination and notices clear fluid and a pulsing loop of umbilical cord in the client's vagina. What should the nurse do immediately?	Call for help.
A nurse is caring for a client and observes meconium-stained amniotic fluid upon rupture of the client’s membranes. What actions should the nurse take if respiratory efforts are strong and FHR is >100 bpm?	Suction the infant's mouth and nose using a bulb syringe.
A nurse is caring for a client and observes meconium-stained amniotic fluid upon rupture of the client’s membranes. What actions should the nurse take if respiratory efforts are depressed and FHR is <100 bpm?	Suction below the vocal cords using endotracheal tube before spontaneous breaths occur.
What medication is given to a patient with DVT? What lab value(s) are measured?	Heparin- PTT Warfarin (Coumadin)- PT & INR
What is the earliest indication of hypovolemia caused by hemorrhage?	Increasing pulse rate and decreasing blood pressure.
What is a late indication of hypovolemia caused by hemorrhage?	Altered mental status and level of consciousness.
Precipitous delivery, lacerations, uterus inversion and retained placental fragments are risk factors for ____?	Postpartum bleeding
True or False: A patient with DVT will report nausea.	False
True or False: A patient with DVT will report calf tenderness to palpation.	True
True or False: A patient with DVT will not have an elevated temperature.	False
When giving care to a patient with thrombophlebitis, the nurse should measure ___ circumference?	Leg
When giving care to a patient with thrombophlebitis, the nurse should apply what temperature compress to affected extremity?	Cold
True or False: Clients with thrombophlebitis should be encouraged to ambulate to prevent further complications.	False. Adequate rest should be encouraged at this time.
____ is an extreme complication that may occur secondary to a client with preeclampsia?	Disseminated Intravascular Coagulation (DIC)
What is the difference between thrombophlebitis and deep vein thrombosis (DVT)?	Thrombophlebitis occurs closer to the surface of the skin. Swelling present. Pain may vary from discomfort to cramping but gradually subsides. DVT is far more dangerous and more difficult to diagnose. May be asymptomatic.
DVT is most commonly in the __, but may occur anywhere in the leg up to the groin?	Calf
What is the greatest life-threatening concern for a patient diagnosed with deep vein thrombosis (DVT)? How does this occur?	Pulmonary Embolism. Clot in the leg dislodges and travels through the circulatory system to the lungs, causing SOB and chest pain.
True or False: Thrombophlebitis is rarely associated with DVT and does not seem to be a risk factor for a pulmonary embolism (PE).	True
___ is the inflammation to the lining of the uterus occurring 2-5 days after delivery and is the most common post-partal (puerperal) infection? It is characterized by uterine tenderness/enlargment and dark, malodorous lochia.	Endometritis
Staph, e.coli, and strep are usually the infecting agents that enter the breast due to sore or cracked nipples, resulting in ___?	Mastitis
Patient teaching for a urinary tract infection (UTI)?	Peri-care and pad application should be done from front to back. Drink cranberry juice, prune juice and large amounts of fluid. Continue breastfeeding on antibiotic. Tylenol PRN.
Patient teaching for a patient who is breastfeeding with mastitis?	Provide frequent on demand feeding. Continue feeding on both breasts. Completely empty each breast after feeding or use a pump. Wear a good fitting bra- not too tight.
What are the signs and symptoms of Post-partal Depression?	Crying, fatigue, insomnia, anorexia, flat affect & feeling let down.
True or False: PPD occurs within 6 months and often goes away without intervention.	False. PPD does occur within 6 months, but usually will not reside without intervention and treatment.
Monitoring mood and encouraging bonding with the infant are two important nursing interventions when caring for a patient with ___?	PPD
Percentage for appropriate gestational age is ___?	10-90%
True or False: A newborn who has a low birthweight would weigh less than 2,500 g.	True
The ___ reflex is stimulated by holding the newborn in a semi-sitting position and then allowing the head and trunk to fall backwards?	Moro
True or False: Periods of apnea <15 seconds and obligatory nose breathing are expected newborn findings.	True
Normal heart rate for newborn?	100-160
Loss of consciousness for how long is a clinical finding of an absence seizure?	10-15 seconds
At what age do absence seizures stop happening?	Puberty
Daydreaming and dropping held objects are signs and symptoms of what type of seizure?	Absence seizure
Falling to the floor, contraction of entire body, loss of consciousness, possible piercing cry and loss of swallowing reflex are all indicative of a _____ seizure?	Tonic-clonic
What information should the nurse document prior to, during, and following a seizure?	Onset, duration, findings & observations. (Ex. LOC, apnea, cyanosis, motor activity & incontinence)
Children who have CF excrete an abnormal amount of ___ & ___ in their sweat?	Sodium & chloride
CF children need antibiotics because they have __ infections?	Antibiotics (ex. Tobramycin)
CF children have difficulty absorbing __, therefore they need to a vitamin supplement?	Fat (fat-soluble vitamins- KADE)
CF have mucus plugs, therefore they need a ___ & an ___?	Bronchodilator (Albuterol) & an expectorant (Dornase-alfa)
True or False: Wheezing is a sign of CF.	True
What are two late manifestations of CF?	Clubbed fingers and toes & barrel-shaped chest
CF have ___ insufficiency and should receive an enzyme 30 minutes within eating meals and snacks?	Pancreatic
Apply ___ to the edges of a spica cast?	Moleskin
What is most essential to administer to revert Addison's crisis?	Parenteral hydrocortisone
What is the cause of Cushing's syndrome?	Chronic corticosteroid administration.
Cushing's diet should include?	Decreased sodium + Vit-D and Calcium consumption
Focus during emergent phase of burn patient? (At time of injury-restoration of capillary permeability)	Preserve vital organ functioning.
A _____ is indicated by the absence of bowel sounds?	Paralytic ileus
Singed nasal hairs, circumoral burns, hoarseness and sooty bloody sputum are indicative of what type of burn?	Inhalation burn
What mutual symptom is found in both CF and celiac disease?	Steatorrhea
What fracture is indicative of abuse?	Spiral
Cirrhosis patients should be on a ___ protein diet?	Low
If burn is around the mouth, you should prepare for what?	Intubation
Initiate IV access with what kind of catheter for burn patients?	Large-bore catheter
Isotonic crystalloid solutions (NS or LR) are used during the __ stage of burn recovery.	Early
Fluid replacement for a burn patient is most important when?	During the first 24 hours.
What vitamins/minerals to give for wound healing?	Vit-A, Vit-C & zinc.
A nurse should do what to stop the burn for a patient with a superficial partial thickness burn?	Apply a cool, wet compress to the affected area.
Active and passive ROM are recommended to the affected burn area to prevent ___?	Contractures
If a hypoglycemic patient is unconscious or unable to swallow, administer ____ SQ or IM and notify provider?	Glucagon
What types of IV fluids and in what order should you administer to DKA patient?	First, administer NS (isotonic) Second, administer 1/2NS (hypotonic)
What should the nurse do if a patient's blood glucose level approaches 250? Why is this done?	Add glucose (Regular insulin 0.1 unit/kg) as a bolus to IV fluids and followed by continuous IV infusion of Regular insulin 0.1 unit/kg/hr to minimize the RF cerebral edema.
Make sure ___ is adequate before administering K+?	Urine output
With insulin therapy, monitor for what electrolyte imbalance?	Hypokalemia
True or False: Capillary refill will be increased with septic shock.	True
True or False: Urinary output and bowel sounds will increase with septic shock.	False
What to administer to a major burn patient with severe pain?	Morphine sulfate IV continuous
What traction do weights hang freely in?	Skin traction (Russell, Bryant)
Sick day management for a child with T1DM should include?	Frequent blood glucose monitoring. Don't stop taking insulin. Drink fluids without sugars. Test urine for ketones to assist in early detection of DKA. Notify provider if levels become >240.
Patient education for a child with T1DM?	Eat three meals a day with snacks. Don't skip meals! Draw up regular before intermediate.
A child with T1DM who is feeling irritable should drink ___?	Milk. (15g carbohydrates)
True or False: Cornstarch should be avoided on feet for patients with diabetes.	False. Aids in moisture absorption.
Signs of dehydration are indicated in which blood glucose level shift?	Hyperglycemia
How to administer immunizations for 6 month old?	Provide sucrose on pacifier.
Varicella vaccine is contraindicated with what medication?	Steroids
What vaccine is contraindicated if patient has a history of encephalopathy?	DTaP
Hep B vaccine is contraindicated in patients who are hypersensitive to ___?	Yeast
What is a complication of OME?	Transient hearing loss
What clinical manifestations are observed in an infant who has acute otitis media?	Increased pain related to fluid and pressure in ear, rolling head to side, loss of appetite, decreased sensitivity to sound, crying & irritability.
Positioning for a child with ear infection?	Position upright

Created by: pndineen

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