4671023
Beschreibung
Karteikarten von Jamie R Pascual, aktualisiert more than 1 year ago
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Erstellt von Jamie R Pascual
vor mehr als 8 Jahre
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| Frage | Antworten |
| THE NURSING PROCESS | ASSESSMENT (DATA COLLECTION), ANALYSIS (INVESTIGATE), PLANNING, INTERVENTION, EVAULUATION |
| Cyclosporine (Sandimmune) Class: Immunosuppresent Agent Uses: Prevent organ rejection after kidney, heart, or liver transplant. TX psoriasis or severe rheumatoid arthritis. Avoid Grapefruit & grapefruit juice | Evaluate clients understanding of the drug if he/she states "I will need to take the Sandimmune for the rest of my life" |
| What is the sequence of instructions that should be given to a person having chest pain and taking Nitrogylcerin? | Stop all activity, place a tablet under his tongue, Wait 5 min. If chest pain is unrelieved in 5 min, call 911 |
| nifedipine (Adalat) classification: Calcium channel blockers. Relaxes the muscles of your heart and blood vessels. USES: treat hypertension (high blood pressure) and angina (chest pain) | Adalat does cause uterine relaxation by blocking the flow of calcium to the myometrial cells. (Inhibiting uterine contractions by blocking calcium channels. |
| Lasix (furosemide) Classification: Loop diuretic (water pill) Prevents your body from absorbing too much salt, allowing the salt to instead be passed in your urine. Uses: Treats fluid retention (edema) in people with congestive heart failure, liver disease, or a kidney disorder such as nephrotic syndrome. | When prescribed this drug always assess the client for? "Hypokalemia" Lasix, potassium exc retion is increased |
| Appropriate nursing action to administer a Mantoux skin test for tuberculosis (TB)? | "Insert the needle with the bevel up." The TB syringes should be held close to the skin so that the hub of the needle touches it as the needle is introduced bevel up. This reduces the needle angel at the skin surface and facilitates the injection of tuberculin just beneath the surface of the skin in order to form a wheal. |
| For long-term therapy of glucocorticoid therapy for asthma, what should be included in the discharge teaching plan? | Schedule the medication on alternate days to decrease side effects. (Some side effects of long-term glucocorticoid therapy can be avoided by using alternate day therapy. |
| Convert 2 oz, 3 oz, & 3 oz into mL? | Multiply the total ounces by 30mL/oz: 7.5 X 30mL= 225mL |
| bismuth subsalicylate (Pepto-Bismol) is used in the treatment of peptic clcer disease because of its? | "Antimicrobial action" Bismuth subsalicylate is effective in treating peptic ulcer disease when the ulcer is caused by the bacteria, H. Pylori. It also coats the stomach and ulcer providing protection from gastric juices. |
| What should be included in the discharge teaching of a client prescribed warfarin (Coumadin)? | "Carry a medic alert ID card at all times" Client is at an increased risk for bleeding. It is important for any medical personnel to be aware of the clients medical history. |
| A client with Congestive heart failure is being treated with digoxin (Lanoxin). The client feels get his breakfast tray and reports nausea. What action should be taken. | "Check the client's apical pulse" This sign of digoxin (Lanoxin) toxicity needs further assessment. Other signs include slow apical pulse, nausea, diarrhea, feeling weak or dizzy, H/A, weakness, anxiety, depression, mild skin rash. |
| amitriptyline (Elavil) Classification: Tricyclic Antidepressant Uses: Treat symptoms of depression. Client needs further instruction when she states? | "I'm glad this medicine helps me. My husband and I would like to start out family as soon as possible" Tricyclic antidepressants should be avoided during pregnancy, esp during 1st trimester because they are associated with fetal anomalities. |
| Prescribed Diuril 25mg/kg/day PO BID for infant weighing 6.5kg. Available is Diuril 100mg per 5 mL. Calculate the mL that the nurse is to give the child each dose. | Total daily dose (25mg X 6.5kg) = 162.5 Amount per dose (162.5mg/2 doses) = 81.25 or 81.3. Available dose (100mg) Dose needed (81.3mg) Quantity of dose available = 5 mL Equation: (have/quantity = Desire/X) Equation: (100/5mL = 81.3mg/X) Cross Multiply: (100X = 406.5) X = 4.065 mL or 4.1 mL |
| hydralazine (Apresoline Classification: Vasodilator Action: Works by relaxing the muscle oin your blood vessels to help them dilate (widen) Uses: Treat high blood pressure (Hypertension) If switched from hydralazine to Lopressor the client would less likely experience what Side Effect? | "Tachycardia" Hydralazine can trigger reflex stimulation of the heart, thereby causing cardiac work and myocardial oxygen demand to increase. Whereas, metroprolol is used to treat reflex tachycardia but blocking beta adrenergic stimulation to the heart. Metroprolol (Lopressor) Classification: Beta-blocker Action: Effects the heart and circulation (blood flow through arteries & veins) |
| If prescribed this drug what should the the client be assessed for routinely? Metro prolol (Lopressor) Classification: Beta-blocker Action: Effects the heart and circulation (blood flow through arteries & veins) | Peripheral edema, dyspnea, rales/crackles, fatigue, weight gain, and jugular venous distention. |
| If prescribed this drug for CHF. What statement requires further teaching? spironolactone (Aldactone) Classification: Potassium-sparing diuretic (water pill) Action: Prevents your body from absorbing too much salt and keeps your potassium levels from getting to low. Uses: Diagnose or treat condition of too much aldosterone (found in kidney: produced by kidney's) Fluid retntion. CHF | "I like to use salt substitute since I am on a sodium restriction" Salt substitutes contain potassium and place the client at risk for hyperkalemia. |
| If taking furosemide (Lasix) what statement demonstrate to the nurse understanding of this medication? Digoxin (Lanoxin) Action: Helps make the heart beat stronger and with a more regular rhythm. Uses: Treat heart failure. TX: Atrial fibrillation Teaching skip next dose if less than 12hr away. Serious Side Effect: Nausea, Vomiting, loss of appetite, fast, slow or uneven HR, bloody or black, tarry stools, blurred vision, yellowed vision, confusion, hallucination, unusual thoughts or behavior | "I will eat fruits and vegetables every day that have a high-potassium content in them" Hypokalemia is an adverse effect of furosemide therapy. Since the client is on digoxin, it is important to maintain the K+ levels between 3.5mg to 5.0 mg/dL to avoid digoxin toxicity. |
| When should digoxin be held? | If their heart rate is below 80/min. A heart rate of (less than 60/min) may signify digoxin toxicity. |
| What should a client be instructed to do when on digoxin? | Weigh himself/herself on a regular basis and report a weight gain of 3 to 5 lb in a week. |
| When should furosemide (Lasix) be prescribed? | In the early morning so that the diuretic effect can take place during the day and not interrupt the sleep cycle at night. |
| Doctors Order: 5mg PO every 4hr PRN pain Available: Codiene 7.5mg/15mL what should the nurse administer? | Dose needed = 5mg, Dose available (7.5mg), Quantity of dose available 15mL Have/Quantity = Desire/X 7.5mg/15 = 15mL/X 7.5mg X = 75 x = 10 |
| buspirone (Buspar) With a history of anxiety client presents a panic attack. Client wants buspar but MD orders diazepam (Valium) What is the disadvantage of Buspar? Classification: Anti-anxiety Action: affects the chemicals in the brian that may be unbalanced in people with anxiety. TX: Symptoms of anxiety (fear, tension, irritability, dizziness, pounding heartbeat) Half-life- 2-4 hours (24hr excreted in the urine) | "Delayed onset of action" Buspirone is an effective nonbenzodiazepine antianxiety drug. It would not be the choice with a client with acute anxiety, such as panic attack, because its effect are not usually evident for 7 to 10 days and may take up to 3 to 4 weeks for therapeutic levels to be achieved. |
| Which of the following behaviors should the nurse caution the client against to prevent lithium toxicity? lithium (Eskalith) Classification: Antimanic or Antipsychotic Uses: Treatment of manic/depressive (bipolar) and depressive disorders. | "Fasting" Crash dieting or fasting can lead to lithium toxicity because the sodium and electrolyte balance would be altered, causing the blood levels of lithium to rise. NOT THE ANSWER: Increased sodium intake: (This leads to excretion of lithium and decreases lithium level. and may cause a relapse of bipolar |
| Can you list some symptoms of manic episodes of manic depression.> | "Hyperactivity, rushed speech, poor judgment, reduced need for sleep, aggression, and anger" |
| Solve. 100mg/kg/day to be given in 4 divided doses. Client Weight 33lb. Available 125mg/5mL? | 2.2lb/1kg = Clients weigh in lb x=15 Daily dose = 100mg x 15kg = 1500mg Amt per dose: 1500/4 doses = 375mg Have/quantity = Desire/X 125mg/5mL = 375mg 125X = 1875X = 15mL |
| School-aged child with asthma. What medication should the nurse anticipate on prescribing as a rescue inhalor? | "Albuterol (Proventil)" Albuterol is a beta 2 adrenergic agonist that is used to provide immediate relief for an acute asthma attack. |
| What is this mediation used for? Fluticasone HFA aerosol inhaler Fluticasone propionate (Flovent) Classification: Corticosteroid Uses: Preventing or reducing the frequency and seriousness of asthma attacks. | "It's used for long-term prophylaxis of asthma. " Other meds used for long-term management of asthma: Cromolyn sodium (Intal) mast cell stabilizer with inflammatory action: Montelukast (Singular) leukotriene modifier Fast fact: Will NOT help or stop an asthma attack once one starts Notify doctor is white patches in the mouth and throat appear. Symptoms of overdose: Darkening of skin, fainting, loss of appetite, mental depression, unusual tiredness or weakness. |
| What instructions should the nurse give the client to ensure understanding regarding the removal of a chest tube? | "Exhale and bear down gently" A gentle Valsalva maneuver is recommended to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space. Avoid taking too large an inspiration during actual removal as this would allow air entry into the pleural space and may result in a pneumothorax. |
| Client has a history of congestive heart failure. What should the nurse monitor for that is a manifestation of left-sided heart failure? | "Dyspnea with a cough that is worse at night" Left-sided heart failure causes blood to back up in the heart and lungs with decreased distribution of blood throughout the body. |
| Name some manifestations of Right-sided Heart failure? | Swelling of the fingers and hands, Jugular neck vein distension, 3+ ankle edema. |
| What is the highest priority when a client has an acute exacerbation of rheumatoid arthritis? | "Impaired physical mobility" When setting priorities for care, physiological needs should be addressed first according to Manslow's Hierarchy of needs. Reducing the client's pain will help with other needs, such as hygiene and grooming. |
| Name the Manslows 2nd Hierarchy of needs for the following: Body-image disturbance | Psychological comfort need. |
| Client with Hypoparathyroidism. What should the nurse observe the client for as evidence of a potential electrolyte disturbance? | "Involuntary muscle spasm" A decreased in parathormone secretion leads to hypocalcemia (decreased serum calsium levels), which may cause tetany. Involuntary muscle spasm The electrolyte that impacts hypertension is sodium. The parathyroid has no role in sodium regulation. |
| Platelet count of 18,000 cells/mL. What is an appropriate nursing intervention? | "Avoid intramuscular injections" (IM) Platelet count is dangerously low indicating thrombocytopenia (decreased platelet count). Any invasive procedure, can precipitate hemorrhage that may be difficult to stop. Bleeding precautions are necessary. |
| Name two client identifiers when administering medication required by Joint Commission. | Compare the medical record number and the name on the MAR with the cient's identification band. |
| Which is the "most important benefit" of breastfeeding a "newborn" during the "fourth stage of labor"? | "Oxytocin secretion is stimulated causing uterine contractions" R: Production & secretion of oxytocin causes the uterus to contract, thus promoting involution and decreasing the risk for maternal hemorrhage and blood loss. |
| Client in "balanced skeletal traction" with a "femur fracture" Nursing intervention | "Offering the client a diet high in fluid and fiber" R-An immobilized client is at risk for constipation. The nurse should encourage a diet high in fluid & fiber to promote gastrointestinal function. |
| Parent's of a "4-month old infant" about normal growth & development. Which comment made by the parent indicate to the nurse a "need for further teaching"? | "My baby loves to play with the musical mobile in the crib." R: "Crib mobiles should be removed from the crib at 4 months. Infants at this age are beginning to reach for objects and pull on them. The crib mobile could fall and become a choking or strangulation hazard." |
| What should be assessed when a cleint's abdominal aortic aneurysm is extending? | "Abdominal pain with the onset of back pain" |
| Jugular vein distention and peripheral edema are manifestations of what? | "Right-sided heart failure" slide needs |
| Chest pain radiating to the left arm suggests what? | "Myocardial infarction" |
| Infant had a "Ventriculoperitoneal shunt placed" "Teaching was effictive" if parent says? | "A new shunt will probably be needed in a couple of years" R: Tube will be longer than needed to allow for growth. In preschool the child will outgrow the tubing length and require a revision of the original shunt. |
| Client taking "warfarin (Coumadin)". Which LAB value indicates an "effective" response? | "INR of 3.0" R: Therapeutic INR range is 2.5-3.0 If INR is greater than 4.0 may resul result in an increased risk for bleeding. Anticoagulant: used to prevent thrombus formation. |
| What LABS should be checked to verify effectiveness of Heparin? | Activated partial thromboplastin time (aPTT) of 35 secs. R: An aPTT of 30 to 45 sec is normal prothrombin time |
| What does Hct (Hematocrit) & Hgb (Hemogloblin) Lab used to check for? | The hematocrit test is often used to check for anemia, usually along with a hemoglobin test or as part of a complete blood count (CBC). The test may be used to screen for, diagnose, or monitor a number of conditions and diseases that affect the proportion of the blood made up of red blood cells (RBCs). |
| Parents son new Dx of "Asperger's syndrome" What "comment" indicates adequate learning? | "It will help our child if we keep a structured daily routine" R: High functioning form of autism spectrum disorder: typically the child will have high cognitive skills. Structured environment can help to minimize the problems these children experience with sudden schedule changes, socialization requirements, and the preference for ritualistic behavior. |
| "Postoperative client" "Hip arthroplasty" w/Hx of "Chronic obstructive pulmonary disease (COPD). What O2 delievery system is appropriate? | "Nasal Canula" R: A nasal canula delivers precise concentrations of oxygen: therefore, it is an appropriate device for a client with COPD who requires a precise percentage of inspired oxygen. |
| "66 year old". "Does not have old medication or immunization records" available. Should the client recieve "pneumococal vaccine" if client is unsure? | "The client should receive the pneumococcal vaccine" cdc recommends a one-time revaccination for clients age 65 or older. If less than 65yr CDC recommends a one-time revaccination. |
| Client "diagnosed with depression" What "Nursing intervention" would foster a therapeutic environment for the client? | "Build trust with the client by sitting quietly with him" R:"Building trust with the client will give him the idea that the nurse is interested in his issues. establishing client trust encourages him to speak more openly about issues and concerns." |
| Caring for an infant with dehydration. What is the "most accurate way to determine hydration status?" | "Obtain daily weights" R: daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical in children under 2 years of age because a greater portion of body weight is composed of fluid. |
| What is the best example the nurse educator should use to best illustrate a suspicious finding of possible child abuse? | "Arm cast for spiral fracture of the forearm" R: Spiral fractures can only occur from twisting of an appendage, in this case the arm. They are treated by casting the involved limb from the joint below the fracture to limit mobility and allow healing. In most instances, spiral fractures of the arm are cited as an example of an abusive injury children, adults, and older adults. |
| "Early stages" of Alzheimer's disease. What "Action" to improve client's "level of orientation"? | "Post a large calendar on the bullentin board" |
| Can you name some interventions, activites & safety for early stage Alzheimer patience | Encourage client to participate in group activities, Have a client attend daily reminiscence therapy sessions, Place a wander alert electronic alarm bracelet on the client's wrist. |
| What LAB data suggests "systemic lupus erythematosus (SLE)? | "Erythrocyte sedimentation rate (ESR)" R: SLE is a chronic systemic autoimmune disesase |
| What adverse effect happens when a client takes too much levothyroxine sodium (Synthroid) for hypothyroism? | "Chest pain" as a result of too much levothyroxine. |
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