Integumentary
A client has come into contact with poison ivy and calls the clinic you work at. How should the nurse respond FIRST?
A. Come to the Emergency Department or you will die
B. Apply calamine lotion
C. Take a shower and rinse off any exposure, being sure to use soap and water multiple times.
D. Don't do anything if you can't see anything on your skin
C. First thing with exposure is safety and to remove the stimulus! The sap is invisible but still remains on the skin. Cleansing removes exposure and reduces the chance of irritation.
What are the treatment options for aortic aneurysms and why
Antihypertensives- decreases BP to prevent rupture and expansion
Surgery with graft
What are some medications that you can see on a patient's eMar that may indicate a history of a clot?
Warfarin
Eliquis
Lovenox
Aspirin
How do fractured ribs present?
A. Slow deep respirations
B. Rapid deep respirations
C. Paradoxical respirations
D. Pain with inspiration
Fractured ribs and trauma include pain and tenderess- causing shallow respirations. Paradoxical movement is flail chest
What is used to check visual acuity?
Snellen chart
A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. What admission assessment finding is the nurse expected to note?
A. Inflammation of the epidermis only
B. A skin infection of the dermis and hypodermis
C. An acute superficial infection of the dermis and lymphatics
D. An epidermal and lymphatic infection caused by Staph
B. Cellulitis is characterized by an infection involving the dermis and hypodermis. Key notes: deep red erythema, no sharp borders, spreads through tissue spaces, edematous, tender.
(The infection is NOT superficial!)
Lifestyle: NO smoking, drinking, drugs, limit caffeine, exercise, frequent BP checks, medication compliance, maintain healthy weight, decrease salt intake
Which is a common symptom of a pulmonary embolism?
A. Hot flushed feeling
B. Sudden chills
C. Sudden chest pain
D. Dyspnea
What is the EARLIEST detectable sign of AHRF and respiratory distress?
A. Cyanosis
B. Hypotension
C. Increased respiratory rate
D. Wheezing
C. Think early- cyanosis is later, hypotension is late, wheezing is asthma. First, the body is going to try to compensate and first is to increase the respiratory rate
The previous notes state a stage II pressure wound in the sacral area. The nurse would expect which of the following:
A. Intact skin
B. Full-thickness skin loss
C. Exposed bone, muscle, and tendon
D. Partial thickness skin loss
50 bonus points for every pressure injury prevention strategy given!!!
D. Stage II is classified as partial-thickness skin loss. Slough may be present. Stage I is intact skin with redness. Stage III is full thickness. Exposed bone, muscle, tendon is stage IV.
Prevention is key!
Herpes Zoster (shingles) is noted on a patient's chart. What is the diagnostic test?
A. Positive patch test
B. Positive culture
C. Abnormal biopsy
D. Wood's lamp examination indicative of an infection
B. Herpes Zoster aka shingles is viral. Viral culture of the lesion is the right answer. A patch test involves an allergen (not a virus), a biopsy is a ctyoogical examination of tissue (not a virus), and a Wood's lamp is used for superficial infections (not a virus).
REMEMBER PRECAUTIONS FOR THIS PATIENT (no pregnant nurses, airborne precautions AND contact precautions, and staff who have been vaccinated or have immunity. Also prevent scratching- secondary skin issues
List symptoms of an aortic aneurysm
Syncope
Dyspnea
Cyanosis
Hoarseness in voice!!! Difficulty swallowing and talking from pressure
Abdominal- pulsating mass
Systolic bruit
Tenderness
What statement needs further education in a patient taking warfarin?
I will avoid alcohol
I will take my pills at the same time every day
I will continue my salads
I will wear a medical alert bracelet
I will continue my aspirin
salads and aspirin are red flags. Leafy greens contain vitamin K which is the antidote for warfarin. Aspirin is also a blood thinner which should not be taken with warfarin
Home instructions for tuberculosis include: (SATA)
A. Resume activities gradually and slowly
B. Avoid contact with others for 6 months
C. Sputum culture every 2-4 weeks
D. No respiratory isolation as families have already been exposed
E. Cover mouth when sneezing or coughing and put used tissues into plastic bags
F. Patient is no longer infectious when 1b sputum culture comes back as negative
A, C, D, E
Medication compliance is needed, after 2-3 weeks on meds the patient is unlikely to be infectious, resume activities gradually, have a well-balanced diet, respiratory isolation is not necessary as familly have already been exposed, put used tissues into new baggies, sputum culture every couple of weeks, 3 sputum cultures needed to be negative before client is no longer infectious
What should be included in a teaching plan for glaucoma?
A. Avoid overuse of the eyes
B. Decrease salt
C. Lifelong need for medications
D. Decrease fluid intake
C. There is no reversal, only progression management. Steps need to be taken for life to prevent progression
SATA! When assessing a skin lesion for basal cell carcinoma, the nurse most likely expects to note what findings?
A. Irregularly shaped lesion
B. Small papule with dry, rough scales
C. Firm nodule lesion with crust
D. Pearly papule with central crater and waxy border
E. Located in a spot exposed to outdoor sunlight
50 bonus points for every skin cancer prevention strategy stated
D and E. Basal cell carcinoma is a pearly white papule with a cental crater and rolled waxy border. Sunlight is a RISK FACTOR! Melanoma is a irregular papule with various coloration, Actinic keratosis is a small dry scale, squamous cell carcinoma is a firm crusty nodule
You are monitoring a patient with hypertension who is taking propanolol. Which is an adverse reaction?
A. Insomnia
B. Expiratory wheezes
C. BP drop from 150/80 to 138/72 after medication
D. HR 88 BPM down to 72 BPM after medication
B. Audible wheezes indicate a bronchospasm. -olol are beta blockers which induce reactions in patients with COPD and asthma
What are some key assessment items of DVTs?
What are some interventions?
Higher risk of pulmonary embolism!
Calf or groin pain (Homan's sign)
Swelling
Warm skin
Tender to touch
Do NOT massage
Antiembolism stockings
Measure calf
Monitor for SOB
Heparin or antithrombolytic therapy
Check labs
SATA! A nurse is caring for a client hospitalized with acute COPD. The nurse expects to note what findings on this client?
A. low arterial PCo2
B. Hyperinflated chest
C. Decreased oxygen with exercise
D. Wide diaphragm
E. Increased vital capacity
B and C. COPD includes hypoxemia, hypercapnia, dyspnea, desatting during exercise, use of accessory muscles (Barrel chest), and a hyperinfated chest with a flattened diaphragm. Vital capacity will be decreased
Give me an educational speech on Raynaud's Disease
vasospasm of artery
avoid cold and stress
fingers, toes, ears, cheeks
Check pulses
No smoking
Avoid injuries to hands and feet
SATA! Silver sulfadiazine is prescribed to your patient. Which of the following needs follow-up?
A. Glucose 99
B. Platelets 300,000
C. Mag 1.5
D. WBC 3000
E. Stinging on application
F. Grey discoloration of skin
D, E and F! This medication is used for broad spectrum antibacterial for wounds. WBC count is indicative of leukopenia. The medication should also not sting on application, and skin discoloration is abnormal but a side effect of the medication and can lead to it needing to be discontinued.
Your patient has an alteplase drip and suddenly becomes anxious with itching. On assessment, you hear stridor. Which of these interventions is correct?
A. Stop the infusion
B. Raise the HOB
C. Protamine sulfate
D. Diphenhydraming
E. Call RRT
A, D, E
STOP THE INFUSION!!! Remove the stimulus
You will need help so call a Rapid Response
Antihistamines will help urticaria
Raising the HOB can cause further hypotension
Protamine sulfate is the antidote for heparin
Describe to me PAD vs PVD
PAD: tissue damage below level of artery, atheroclerosis most common cause, intermittent claudication, burning or aching pain better in dependent position, loss of hair, dry scaly skin, thic toenais, elevation pallor, decreased peripheral pulses, ulcers. Do NOT elevate above heart- remember gravity rules. Intermittent walking helps, avoid cold exposure, no direct heat, avoid tobacco and caffeine.
PVD: from prolonged venous hypertension (stretches and damages the veins), edema, venous stasis poses risks, ulcers, brown discoloration, edema, leg elevation to return blood to heart, compression stockings, no prolonged sitting, encourage movement
Heart racing is normal
Headache
Dizziness
Dry mouth
Tremors
Nervousness
Tachycardia
Assess lung sounds before AND after
Breathe medication deep into lungs
Avoid caffeine around time of administration
Smoking cessation
Avoid known triggers
What home measures should be included in a patient who just had a cataract extraction with implant?
Scratchiness and eye discomfort normal- take analgesics
If the pain worsens, notify the surgeon immediately
Purulent drainage, redness, decreased visual acuity, notify surgeon
Eye shield for bedtime
No bending over- increases IOP