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Stack #4632738
| Question | Answer |
|---|---|
| #separator:tab | |
| #html:false | |
| Bronchoscopy what do you do? | Check gag reflex post-op immediately before any food Assess for bleeding, infection, or hypoxemia post-op Notify provider if bleeding or fever |
| To prevent aspiration for a pt? | Have suction available in room Turn pt on their side when vomiting Check for gag reflex before resuming diet |
| Inhaler use: | Shake well before use, breathe out slowly before & after medication, rinse out mouth after adminsitration |
| Long-acting beta agonist does____ relieve symtpoms | NOT |
| Corticosteroids | if oral lesions presents, rinse after medication, NO culture is needed yet |
| For oxygen therapy always use this first | 2-4 L/min via nasal cannula then 40% via venturi mask for better o2 precision |
| What order would you question for a COPD patient with a trach? | Suction every 2-3 hrs |
| Chest tube management: | Do not strip tube, use a hand-over-hand milking motion Keep drainage system lower than pt chest Water seal chamber is expected to have a rise with inhalation & fall with exhalation Notify surgeon or RRT |
| Notify surgeon or RRT of chest tube S/S? | Tracheal deviation Sudden onset of dyspnea O2 sat < 90% Drainage stops Visible eyelets on chest tube = tube coming out If chest tube falls out of pts chest or disconnect from drainage → cover with dry sterile gauze & tape down; dry sterile |
| TB | 3 negative sputum cultures to be non-infectious Usually no longer contagious after 2-3 weeks of consecutive drug therapy |
| HbA1C is the best indicator of? | average BGL (blood glucose levels) |
| HOLD metformin for what pts? | cannot have IV contrast due to lactic acidosis |
| After insulin injection | monitor for hypoglycemic reactions at insulin peak times |
| Rotate injection sites to prevent what? | lipohyoertrophy |
| If we encounter a unconscious pt. | administer IV 50% dextrose or glucagon |
| Conscious pt we give? | 15-20g SIMPLE CARB (orange juice, milk, honey) |
| Continue to take insulin if ill T/F? | TRUE |
| Pt. education to diabetic regarding eyes? | yearly eyes exams by ophthalmologist |
| If a pt on TPN solution is running low, what is the appropriate nursing action? | Infuse Dextrose 10% if TPN is unavailable |
| The nurse is assessing a pt. diagnosed w/T1DM. the pt has acute confusion, diaphoretic, and clammy. Which should the nurse administer first? | 2% Milk 4 oz |
| The nurse administers regular humlin insulin at 0600, when should the nurse expect a therapeutic response | 0630 |
| If there is indication of a latex allergy NOTIFY ? | doctor |
| What is needed to be available with a pt. with history of malignant hyperthermia? | Dantrolene |
| A pt had abdominal surgery is coughing, nauseated, and vomiting. What is the nurses priority? | Auscultate lung sounds |
| After any immobilizing surgery we encourage what? | use of incentive spirometer to promote pulmonary status |
| • Protein in the urine is the best indicator of? | reduced kidney function |
| If a pt is on opioids monitor for what? | monitor respiratory depression |
| Nurses are NOT responsible for detailed procedure info | "verify pt name and medical ID # or FIN" |
| When the pt is unconscious, consent should be given by? | a medical power of attorney |
| If pt has not initialed correct surgical site before transfer, notify who? | surgeon |
| Insulin will be determined administration before/after surgery? | BEFORE |
| NGT used for decompression of gastric pressure? | green aspirate = placed in the stomach (lookinto) |
| A client comes from surgery 2 hrs ago and additional bleeding is seen on dressing, what is the appropriate nursing action? | Reinforce dressing and document |
| A pt has intestine protruding out of incision, what is the immediate nursing action? | Raise HOB and have pt. flex their knees (evisceration position) |
| Chronic respiratory acidosis common in what pts? | common for COPD → metabolic alkalosis to compensate |
| Water seal chamber is | expected |
| TB usually no longer contagious after how many weeks of consecutive drug therapy? | 2-3 weeks |
| Rapid Insulin Peak Time? | 30min -1.5hr |
| Short Insulin Peak Time? | 2-5 Hrs |
| Rapid Insulin Onset Time? | 15 min |
| Short Insulin Onset Time? | 30 min |
| Monitor for hypoglycemic rx | [sweating, weakness, dizziness, confusion, headache, tachycardia/palpitations, slurred speech, blurred vision] at insulin peak time |
| Hypoglycemia (<70 mg/dL) | - Mild shakiness - Mental confusion - Sweating - Palpitations - Headache - Lack of coordination - Blurred vision - Seizures - Coma |
| Rapid drop | tachycardia, diaphoresis, nervousness |
| Gradual drop | headache, confusion, fatigue/drowsy |
| If unconscious, place pt in? | lateral position to prevent aspiration, administer glucagon subq or IM & notify provider, repeat in 10 minutes if still unconscious |
| Recheck glucose 15 min following | 15-20 g of simple carb (4/6 oz of OJ, 6-10 hard candies, 1 tbsp of honey) |
| Cold & clammy skin | needs some candy!!! |
| if a pt is sick they should stop or continue insulin therapy? | CONTINUE |
| The nurse is assessing a pt diagnosed w/ type 1 DM the pt has acute confusion, diaphoretic, and clammy. Which should the nurse administer first? (same type of question) | 2% milk 4 oz |
| HbA1c: greater than 6.5%. | best indicator of average blood glucose level within 120 days |
| Hold metformin for | any procedure/surgery that may require IV contrast to prevent acute kidney injury |
| hypoglycemic reactions at peak times | sweating, weakness, dizziness, confusion, headache |
| Diabetic Retinopathy (blindness) | recommend diabetic pts. to have yearly eye exams by ophthalmologist |
| hypoglycemia for unconcious pt | place pt. in lateral position to prevent aspiration! administer glucagon sub-q or IM, notify the provider, repeat in 10 mins. if still unconscious |
| If conscious but CANNOT swallow hypoglycemic | give glucagon or IV 50% dextrose |
| If conscious and CAN swallow hypoglycemia | give 15-20g of simple carb (4-6 oz. of OJ, 6-10 hard candies, 1 tbsp of honey) Recheck glucose 15 mins. If still hypoglycemic; administer a second simple carbohydrate (crackers, juice, milk) |
| Keep taking insulin even if still sick Y/N? | YES |
| TPN should it be stopped suddenly? Y/N? | NO! TPN should be follow more TPN or DEXTROSE 10% (only if there is no more TPN |
| Dyspnea & Stridor can cause? | ncreased chest diameter (1:1 AP to lateral) |
| Bronchoscopy | Check for gag reflex post-op immediately before any food Assess for bleeding, infection or hypoxemia post-op Notify provider if bleeding or fever (small bleeding is okay, but not a lot) |
| To prevent aspiration? | have suction available in room, turn pt. to the side when vomiting, check for gag reflex before resuming diet |
| you will most likely see what ABG in patients with COPD? | chronic respiratory acidosis |
| Apply oxygen flow rate of 2-4L then ?% via venturi mask for better O2? | 40% |
| Suction only AS NEEDED. You should question any order if it says? | “continuous suction 2-3 hrs” |
| Long-acting beta2-agonists (bronchodilator): Arformoteral (Brovana) | Take as prescribed even if you feel better, DO NOT MISS A DOSE does not relieve acute symptoms |
| Anti-Inflammatories: Corticosteroids | Side effect: thrush, increased blood sugar, immunosuppression. They can cause stomach ulcers, so they should never be given on an empty stomach and should be taken with food |
| Breathing Techniques for drug therapy: | Shake well before use→breathe out slowly before/after medication→rinse out mouth after |
| water seal chamber is _______ to have a rise with inhalation & fall with exhalation | expected |
| Chest tube complications to look for/notify surgeon or RRT | • Tracheal deviation • Sudden onset of dyspnea (AKA shortness of breath) • O2 sat <90% • Drainage >70mL/hr • Visible eyelet from the tube = chest tube coming out • Chest tube falling out of pts. chest or disconnected from drainage • Chest tube disco |
| DO NOT strip tube because it increases pressure inside lungs | okay to milk the tube (hand over hand) to get out clots →keep drainage system lower than patients chest |
| Patient is usually no longer contagious after ? weeks of consecutive drug therapy | 2-3 weeks |
| Need to have _____ consecutive sputum tests to be considered non-infectious | 3 negative |
| TIA- Transient Ischemic Attack | its brief 30-60 min attack its reversable but is a sign of a stoke coming soon |
| Ischemic Stroke (Most Common)---- Thrombotic | Caused by atherosclerosis (build up of plaque) SLOW and GRADUAL |
| Ischemic Stroke (Most Common)---- Embolic | Clots that break off and travel to the cerebral arteries SUDDEN AFIB is the culprit |
| Hemorrhagic Stroke | Interrupted vessel integrity leads to bleeding in brain tissue or surrounding spaces (subarachnoid/subdural) Primary Risk Factor: Uncontrolled Hypertension SUDDEN and NO TPA bc they will worsen the bleed |
| Non-Contrast CT Scan | The first test performed to rule out hemorrhage before starting any anticoagulant or fibrinolytic therapy. |
| MRI: | More sensitive for detecting early ischemic changes or small strokes. |
| Rapid Recognition: BE FAST | F (Face): Facial drooping. A (Arm): Arm weakness/drift. S (Speech): Slurred speech or difficulty speaking. T (Time): Call 911/Code Stroke immediately; note the last known well time |
| Aphasia | Expressive: Difficulty producing speech/writing. Receptive: Difficulty understanding spoken/written language. Care: Use short, simple sentences; face the client; use picture/communication boards; avoid yes/no questions to prevent frustration . |
| Dysphagia | Priority: Maintain NPO status until a swallow screen/study is passed. Safety: Position patient upright; assess gag reflex; place food in the back of the mouth on the unaffected side; monitor for coughing/choking |
| Unilateral Neglect | Patient is unaware of the affected side |
| Right Hemisphere Stroke | Unilateral Neglect |
| Hemiplegia | Support the affected limb; collaborate with PT/OT for safe transfers (e.g., using a hemi-walker). |
| Increased Intracranial Pressure (ICP) S/S | Decreased LOC, restlessness, irritability, headache, and projectile vomiting |
| ICP Nursing Actions | Elevate HOB to 30 degrees. Maintain head in midline position. Avoid clustering activities and maintain a quiet, low-light environment |
| Generalized Seizures (Tonic-Clonic) | Involves both hemispheres |
| Partial (Focal) Seizures | Begins in a specific area Can be Simple (conscious) or Complex (impaired consciousness) |
| Epilepsy | Two or more unprovoked, chronic seizures |
| Status Epilepticus (Medical Emergency) | Seizure lasting more than 5 minutes or repeated seizures without regaining consciousness |
| Status Epilepticus treatment | Establish airway administer oxygen call Rapid Response IV Lorazepam (Ativan) or Diazepam (Valium) . |
Created by:
llmartinz