MATH
The physician orders 2 tablespoons of liquid acetaminophen for a child.
How many milliliters should the nurse administer?
30 mL
1 tablespoon = 15 mL
15 x 2 = 30 mL
what is the normal ICP level?
5 - 15 mmHG
which lifestyle factor increases pressure in the legs and is a common risk factor for developing varicose veins
prolonged sitting or standing
T / F - viral meningitis is a more mild infection than bacterial & rarely fatal
true
the nurse is aware that the most dangerous complication of a patient with a DVT is ...
PE or pulmonary embolism
The physician orders 250 mg of amoxicillin for a child. The pharmacy supplies amoxicillin 125 mg per 5 mL.
How many milliliters should the nurse administer?
10 mL
a patient has just been admitted to the ER with trauma to the skull / head. the nurse should keep in mind that an ICP over _____ mmHG requires intermediate intervention
anything over 20 mmHg = can cause brain damage
These non-invasive tests are often used to assess blood flow and valve function in patients with varicose veins
doppler / duplex ultrasound & clinical examination
a nurse is conducting an education session on meningitis. the nurse should mention which populations are more at risk for contracting bacterial meningitis?
those living in close quarters such as dorms / prisons
This classic triad of risk factors is known as Virchow’s Triad?
venous stasis
endothelial injury
hypercoagulability
The physician orders Dextrose 5% in 0.9% NaCl 1,000 mL to run over 8 hours.
At how many milliliters per hour (mL/hr) should the nurse set the IV pump?
125 mL
an ICU nurse is caring for a patient with ICP. over the past 15 minutes she notes the following vital signs which are indicative of what ?
bp : 178 / 67
HR : 45 bmp
11 breaths / min irregular
cushing's triad
- indicative of severe rise in ICP & can signify impending herniation and then death
A 58-year-old nurse reports to the clinic with swollen, bulging veins in her lower legs, complains of heaviness and aching at the end of her shifts, and notes that symptoms worsen when standing for long periods.
What 3 nursing intervention would be most appropriate to relieve her symptoms and prevent progression?
encouraging leg elevation
wearing compression stockings
avoiding prolonged standing
a patient is admitted to the hospital with possible bacterial meningitis. the nurse questions the patient about a recent history of what?
A. mosquito / tick bites
B. chickenpox / measles
C. cold sores / fever blisters
D. an upper respiratory infection
D. an upper respiratory infection
a patient with a VTE is receiving therapy with Heparin and asks the nurse whether the drug will dissolve the clot in her leg. which response by the nurse is best?
A. this drug will break up & dissolve the clot so blood flow can be restored
B. heparin will prevent growth of the clot of formation of new clots where circulation is slowed
C. heparin will not dissolve the clot but it will inhibit the inflammation around the clot to delay development of new clots
D. heparin will dilate the vein, preventing turbulence of blood flow around the clot that may cause it to break off and travel to the lungs
B. heparin will prevent growth of the clot of formation of new clots where circulation is slowed
heparin is an anticoagulant it will NOT dissolve clot but will prevent formation of new clots
clot dissolvers = thrombolytics
The physician orders 0.9% NaCl 750 mL to run over 5 hours. The IV tubing has a drip factor of 20 gtt/mL.
How many drops per minute (gtt/min) should the nurse set?
50 gtt/min
which events cause an increase in ICP? SATA
A. vasodilation
B. necrotic cerebral tissue
C. blood vessel compression
D. edema from initial brain insult
E. brainstem compression & herniation
A B D
blood vessel compression, brainstem compression & herniation occur because of ICP but are not a contributing cause
A patient with varicose veins asks why they should walk daily even though their legs hurt after long periods of standing.
how should the nurse respond?
walking and light exercise help calf muscles pump blood back to the heart & reduce venous stasis
what are the three typical manifestations of meningitis?
fever
headache
nuchal rigidity
what care could the RN delegate to the AP for a patient with a VTE?
A. assess use of herbs
B. measure patient for elastic compression stockings
C. remind patient to flex & extend legs q2h while in bed
D. teach patient to call emergency response system within signs of pulmonary embolism
C. remind patient to flex & extend legs q2h while in bed
The physician orders dopamine at 5 mcg/kg/min for a patient who weighs 176 lbs. The IV solution contains 400 mg dopamine in 250 mL D5W.
What rate (mL/hr) should the nurse set the IV pump?
15 mL/hr
a patient with a head injury has bloody drainage from the ear. what would the nurse do to determine if CSF is present in the drainage?
A. examine tympanic membrane for a tear
B. test fluid for a halo sign on a white dressing
C. test fluid with a glucose stick / strip
D. collect 5mL of fluid in a test tube and send it to the laboratory for analysis
B. test fluid for a halo sign on a white dressing
CSF has glucose however with blood present it will not give you a reading so next best thing is to drip it onto a white cloth / towel and observe for formation of a yellow halo
A patient with varicose veins is concerned about developing ulcers around the ankles. They ask the nurse what they can do at home to protect their skin and prevent complications.
which teaching points should be provided?
3/4
inspect legs daily
keep skin clean
wear compression stockings as prescribed
report any signs of infection or ulcer formation immediately
if vigorous control of a fever in a patient with meningitis is needed to prevent complications of increased ICP, seizures, and neurological damage what is the most important parameter that should be monitored?
monitor LOC
a nurse notices a patient with a DVT has intermittent compression devices on. as the nurse is taking them off the patient, he proceeds to ask why they are being taken off. the nurse proceeds to respond with ...
SCD's and / or intermittent compression devices shouould not be applied to patients with DVT because it can compress and mimic a massage, potentially dislodging the clot causing it to turn into a PE