respiratory
A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?
Developing a list of people with whom the client has had contact
What is troponin and what does its presence in the blood signify?
-type of protein found in heart muscle NOT in blood but when heart is damaged, it's sent to bloodstream
-normal: <0.02 (usually a negative #)
-if high, may have had previous heart problem or it's an acute MI
-elevvated 3-5 hours after and last 7-9 days
List common CNS side effects of Famotidine
Hallucinations, confusion, agitation, depression, anxiety, insomnia, convulsion in client with impaired renal functions.
An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?
Use of accessory muscles
After a stroke, a client is admitted to the facility. The client is conscious, has left-sided weakness, and an absent gag reflex. He's incontinent and has a tarry black stool. His blood pressure is 100/60 mm Hg, and his hemoglobin is 100 g/L. Which nursing intervention is a priority for this client? Select one:
a. Checking stools for occult blood
b. Elevating the head of the bed to 30 degrees
c. Performing range-of-motion (ROM) exercises on the left side
d. Keeping skin clean and dry
b. Elevating the head of the bed to 30 degrees
On auscultation, which finding suggests a right pneumothorax?
Absence of breath sounds in the right thorax
what is cardiac cath used for?
removes blockages in the arteries.
purpose of using Naloxone (Narcan) with opioids; know therapeutic actions:
• Competitively blocks the effects of opioids, including CNS and respiratory depression, without producing any agonist (opioid like) effects.
• Reversal of signs of opioid excess.
What is stable angina?
Pain that occurs with exercise or emotional stress and is relieved by rest or nitroglycerin (Nitrostat).
When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the health care provider will order? Select one:
a. Irrigation
b. Culture and sensitivity tests
c. Incision and drainage
d. Debridement to remove necrotic tissue
d. Debridement to remove necrotic tissue
You are assessing a client's potential for pulmonary emboli in his leg. What finding indicates possible deep vein thrombosis?
Pain in the calf
what is MONA?
doesn't matter which is first
-morphine (reducing pain decreases workload), hemodynamic effects is why we use this instead of other pain relievers
-oxygen
-nitroglycerin: can be given 3 times, 1 pill every 5 minutes
-aspirin: 4 baby aspirin-324 mg
*if pt. comes from ambulance or home, have they taken aspirin today? Figure out how much they took and give them the rest
What is Cyanocobalamin
Antianemics, vitamins
Corrects manifestation of pernicious anemia. Corrects vitamin B12 deficiency
what does the nurse do if she sees her patient presenting with Decorticate vs. Decerebrate
Decorticate = "C'
Decerebrate = "E"
The nurse is caring for a client who has a pressure ulcer. The client has a 20-year history of smoking. What effect does smoking have on wound healing? Select one:
a. It decreases the blood supply in fatty tissue.
b. It decreases the supply of nutrients to the injured area.
c. It slows collagen synthesis by fibroblasts.
d. It impedes blood flow to healing areas.
d. It impedes blood flow to healing areas.
A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following?
Pleural effusion
difference between ekg and echocardiagram?
ekg shows underlying rhythms and electrical conduction
provides pictures of the heart's valves and chambers and helps the sonographer evaluate the pumping action of the heart echo or simply an echo, is an ultrasound of the heart. Echocardiography uses standard two-dimensional, three-dimensional, and Doppler ultrasound to create images of the heart and determine the pumping action and ability of the heart
what is Spirolactone
Diuretic, potassium-sparing diuretic
Increase survival in patients with severe heart failure. Weak diuretic
A client is experiencing shortness of breath, fatigue, and jugular vein distention. The nurse auscultates a third heart sound (S3). What should the nurse anticipate as the cause of these signs and symptoms?
Heart failure
Shortness of breath, fatigue, jugular vein distention, and an S3 are signs/symptoms of heart failure resulting from the decreased pumping ability of the heart and increased fluid volume.
A client with newly diagnosed type 2 diabetes asks the nurse what 'type 2' means in relation to diabetes. Which of the following statements is the best response to explain to the client how type 2 diabetes differs from type 1? Select one:
a. "With type 2 diabetes, there are islet cell antibodies and insulin autoantibodies that destroy beta cells in the pancreas."
b. "With type 2 diabetes, there is decreased insulin secretion and/or cellular/tissue resistance to insulin that is produced."
c. "With type 2 diabetes, The body is totally dependent on an outside source of insulin."
d. "With type 2 diabetes, the C-peptide chain of proinsulin secreted by the pancreas cannot be removed by the liver, resulting in a lack of active insulin."
b. "With type 2 diabetes, there is decreased insulin secretion and/or cellular/tissue resistance to insulin that is produced."
What is the reason for chest tubes after thoracic surgery?
Draining secretions, air, and blood from the thoracic cavity is necessary.
left sided heart failure
Results from Myocardial Ischemia
*Blood backs up into the Pulmonary Veins
*Enlarged left ventricle due to increased workload and end diastolic volume
-LV failing and can't push blood to body, so it goes to the lungs...pulmonary congestion, SOB, etc.
What class is Amlodipine
Antihypertensive
Systemic vasodilation resulting in decreased BP. Coronary vasodilation resulting in decreasing frequency and severity of attachs of angina
A nurse is caring for a client in the emergency department who was just admitted with chest pain, possible acute coronary syndrome. Which of the following actions should the nurse take first?
Check pts BP then
Administer sublingual nitroglycerin
A client with type 1 diabetes has received diet instruction as part of his treatment plan. The nurse determines a need for additional instruction when the client makes which following comment? Select one:
a. "I may eat whatever I want as long as I cover the calories with sufficient insulin."
b. "I should eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia."
c. "I may have an occasional alcoholic drink if I include it in my meal plan."
d. "I will need a bedtime snack because I take an evening dose of NPH insulin."
a. "I may eat whatever I want as long as I cover the calories with sufficient insulin."