General Med surg
client taking warfarin has an INR of 5.2 and reports bleeding gums.
What is the priority intervention?
A. Administer vitamin K
B. Hold the warfarin
C. Increase green leafy vegetables
D. Prepare for blood transfusion
What is hold the warfarin?
Before administering digoxin, the nurse must assess this.
what is assess apical heart rate?
Pre-op teaching for incentive spirometer is to prevent:
A. Atelectasis
B. DVT
C. Infection
D. Bleeding
What is atelectasis?
What vaccine is given at birth?
What is the hepatitis B vaccine?
This isolation precaution requires a negative pressure room.
what is airborne precautions?
This IV solution is considered isotonic and commonly used for fluid resuscitation.
What is 0.9% normal saline?
A client on ACE inhibitors develops facial swelling and difficulty breathing. This reaction is occurring.
what is angioedema?
A post-op client suddenly becomes restless, tachycardic, and dyspneic. This life-threatening complication is suspected.
What is pulmonary embolism?
At 2 months, infants typically receive this combination vaccine that protects against diphtheria, tetanus, and pertussis
What is Dtap?
Which lab value is most concerning?
A. Sodium 138
B. Potassium 2.8
C. Glucose 150
D. Hgb 12
What is potassium value of 2.8?
A client with atrial fibrillation is at highest risk for developing this complication.
What is stroke?
The antidote for heparin overdose.
what is protamine sulfate?
The nurse has 4 post-op clients. Who should be seen first?
A. Client with urine output 40 mL/hr
B. Client with O2 sat 92% on 2L
C. Client with sudden calf pain and swelling
D. Client requesting pain medication
What is sudden calf pain and swelling? (Possible DVT)
This live vaccine is given subcutaneously and protects against measles, mumps, and rubella.
What is MMR?
A client taking warfarin should avoid this vitamin in large amounts?
what is vitamin K?
The priority intervention for a client with magnesium level of 6.5 mEq/L is this medication
What is calcium gluconate?
A client taking lithium has vomiting, tremors, and confusion. The nurse suspects this.
what is lithium toxicity?
74 year old male went for laparoscopic cholecystectomy. patient returns to the unit 5 hours later and become acutely confused, hypertensive, tachycardia, and complains of lower abdominal pressure and the urge to urinate. what is the nursing intervention?
This vaccine should NOT be given to immunocompromised children because it is live.
what is varicella or MMR?
The nurse receives report on 4 clients. Who should be assessed first?
A. COPD with O2 sat 89% on 2L
B. Post-cardiac cath with cool extremity
C. New onset confusion after hip surgery
D. Blood glucose 68 mg/dL
What is post-cardiac cath with cool extremity? (Possible arterial occlusion)
This is a classic assessment finding in a client with pneumothorax.
What are absent breath sounds on the affected side?
Which medications increase potassium levels? Select all that apply.
Spironolactone
B. Furosemide
C. Lisinopril
D. Insulin
E. Potassium chloride
What are spironolactone, lisinopril, and potassium chloride?
patient has the following vital signs s/p appendectomy POD #2:
Temp: 37.3
BP: 88/53
HR: 115
RR: 23
SPO2: 94% on RA
WBC: 21,000
sepsis is suspected. what is the priority nursing interventions to be expected in a traditional sepsis bundle.
what is: broad spectrum antibiotics, fluid resuscitation 30cc/kg of isotonic fluid, oxygen, notify provider.
The HPV vaccine series is recommended to begin at this age.
what is 11-12?
A child with Tetralogy of Fallot experiences a cyanotic spell. The nurse should place the child in this position.
What is knee to chest position?