Nursing Process
A patient's respiratory rate is 10 breaths/minute. He is scheduled to receive hydrocodone 5/325 mg now. What action should the nurse take?
Hold this opioid medication due to respiratory depression.
The primary goal for pain control when caring for a client who is terminally ill is?
To block pain without suppressing level of consciousness.
What is the best description of a Stage 3 decubitus ulcer?
A shallow crater that extends to the subcutaneous tissue becoming a full-thickness loss of tissue with adipose tissue visible. Relatively painless.
What food should be restricted to avoid excessive accumulation of uric acid?
Purine-rich foods.
(Organ meats, steak, shellfish, sardines)
What blood test (lab) MUST be done prior to a percutaneous liver biopsy?
PT/INR
(Coagulation studies)
Wheezes
A client is prescribed a miotic eye medication for the treatment of glaucoma. What action does a miotic eye medication have on the eye?
Constricts the pupil
What intervention can a nurse perform immediately if a patient has an SpO2 of 85%?
Raise the head of the bed.
A Living Will
A Five Wishes Document
A Durable Power of Attorney for Healthcare
Examples of a client's end-of-life care choices in written form.
What are the two medications most commonly used to treat herpes zoster (Shingles)?
Acyclovir (anti-viral) and Prednisone (corticosteroid)
This condition occurs due to aging and results in disntegration of cartilage in joints.
What is osteoarthritis.
Avoid heavy lifting and strenuous exercise.
Avoid constipation.
How to wear a truss.
Nurse teaching for prevention of an inguinal hernia recurrence.
Avoid carbonated fluids and fluids high in citrus content.
Monitor client for bloody drainage from mouth or frequent swallowing
Apply ice collar as orders for pain or swelling.
Encourage client to gently gargle with warm saline three to four times daily.
Gradually increase fluids then, add soft foods.
Client teaching following a Tonsillectomy and adenoidectomy
Atropine (an anti-cholingeric) is contraindicated in which eye condition?
Glaucoma
A nurse is setting up medications for a home health geriatric patient and notices polypharmacy. What diagnostic study should the nurse anticipate after reporting this to the provider?
Liver Function Studies
(LFTs)
This vital sign is considered the Fifth (5th) vital sign and must be checked when performing an assessment.
What is a pain assessment.
Which of the following pharmacologic therapies would the nurse anticipate for a client after ortho surgery to prevent complications?
Antineoplastic
Antianginal
Antidysrhythmic
Anticoagulant
What nurse teaching will you give to a client who is prescribed Ibuprofen for arthritis pain? Why?
Take this medication with food. It may cause GI bleeding.
Recombinant interferon alfa-2b in combination with Ribavirin is given to clients with hepatitis B, C, and D. What teaching must be given to clients of childbearing age?
They must use strict birth control methods due to side effects of birth defects.
What medication will the nurse administer for a client during an acute asthma attack?
A bronchodilator
It's okay to use the same side of a wash cloth to wipe each eye? True or False
False
Prior to a lung scan with the use of radioisotopes, a nurse must first assess for this allergy in patients.
What is iodine allergy.
What should a nurse strongly recommend for a client who is prescribed opioids for chronic pain?
Follow a bowel regimen.
(Prevent constipation)
What is Psoriasis.
When a patient is prescribed a corticosteroids for her arthritis pain, what is important for the nurse to teach the patient?
The dose must be tapered down when discontinuing this medication.
A complication that may follow a bowel perforation that presents with a board-like, rigid abdomen and absent bowel sounds.
What is peritonitis.
Aspiration
Infection
Injury to the laryngeal nerve
What are complications of a tracheostomy.
Keratitis is treated with topical anesthetics, mydriatics, and local and systemic antibiotics. What action do mydriatic eye drops have on the pupils?
They dilate the pupil.
Salicylate toxicity for too much aspirin use can present with what major symptom?
Ringing in the ears (tinnitus)
To instill antibiotic ear solution into an adult with otitis media, how will the nurse pull the auricle of the ear?
Pull the auricle upward and back to instill the medication.
Careful pin site care must be done to prevent infection on what type of procedure to treat fractures?
External Fixation
This fracture involves the skin or mucous membranes.
What is a Compound fracture.
Initial symptoms of this disorder include right upper abdominal discomfort, nausea, and frequent belching, especially after a high fat meal.
Cholelithiasis (Gall Stones)
A nurse is caring for a client who just completed pulmonary angiography. What will the nurse notify the physician of it it occurs?
Absent distal pulse
Cool skin temperature in the affected limb
Poor capillary refill
Complaints of numbness/tingling
Bleeding or hematoma
During this examination using a tuning fork, if a client begins to sway, lose balance, or their arms drift, it indicates a balance problem. What is the name of this test?
A Romberg Test.
What teaching will the nurse provide to a patient for the use of antibiotics?
Complete the prescription even if the infection appears to resolve.
Abrupt change in mental status (confusion/disorientation), fever, increased respiratory rate, and increased blood pressure in an otherwise oriented adult may indicate what?
Delirium caused by possible infection.
A nurse may place this side of their hand on the surface of a patient's skin to detect skin temperature.
What is the dorsum or dorsal of their hand.
When providing care for a client with osteoporosis, what dietary recommendation will you provide for them?
Eat a well-balanced diet, high in calcium.
What dietary recommendation can a nurse provide to a patient who is constipated?
Increase dietary fiber.
What lab test BEST provides data on a potential impairment in ventilation?
Ishihara polychromatic plates are a diagnostic tool for what?
To determine color vision.
Which of the following nursing diagnosis is the HIGHEST priority for a client who receives Morphine for pain?
Risk for Injury
Risk for Impaired Gas Exchange
Risk for Fluid Imbalance
Decreased Mobility
Infection control measures taken when caring for ALL clients, regardless of diagnosis or infection status
What are Standard Precautions.
On a burn victim, an escharotomy may be performed? What does this procedure do?
It relieves tissue constriction that is causing impaired circulation.
Eschar will not allow new skin to grow and can harbor potential for infection if left in place.
Which of the following must be done prior to ortho surgery to prevent excessive bleeding?
Withhold aspirin.
Reduce antacids.
Encourage a large meal with steak.
Avoid excess fluid.
How will the nurse recognize a client has passed all of the barium swallow?
The stool will no longer be white or clay colored.
After the initial X-Ray to confirm placement of an nasogastric (NG) tube, what is the most reliable way to assess placement before giving the patient medications via the NG tube?
Measure pH of aspirates (stomach contents)
The eyelid margins are inflamed, patchy flakes cling to the eyelashes and are visible, purulent drainage may be present. What eye disorder is described?
Blepharitis