Airway
A nurse is caring for a client who is experiencing respiratory distress. What is a early manifestation of hypoxemia?
Pale skin
Hypertension
LATE: Bradycardia, Hypotension
ATI chapter 16
A client is wearing a continuous cardiac monitor which begins to sound it alarm at the nurses station. What nursing intervention takes top priority at this time.
Check the client's status and lead placement
Saunder's Cardiovascular
What is the most important nursing intervention to uphold when a patient is having a seizure?
Safety
Brunner and Saunders Neurological
When instilling eye medication for a patient, what is the first step in the application process?
Washing hands
Put on glovesPull the lower lid down against the cheekbone
Instill
Brunner, ATI, and Saunders (Eyes and Ear Medication)
smooth, thick, red tongue
Same as B12: Beefy, red tongue
ATI, Brunner and Saunders
A nurse is caring for a client who has been dx with PN (pneumonia). Objective data: 100 F oral, 30 RR, 100 AP, even/regular, 130/76 BP R, sitting, and 91% O2 RA. The PT has a harsh, productive cough. What is the best nursing intervention to perform at this time?
Apply supplemental oxygen
ATI chapter 17
How many times can a patient take nitroglycerin before calling 911?
3
What type of tremors do patients with Parkinson's experience?
Resting
They are slow rhythmic and start in one foot, hand, or head.
Saunders : Neuro and Brunner/PPWhat is a clinical manifestation of cataract?
Gradual, painless blurring of central vision. Can lead to a decrease in color perception
When a patient first contracts HIV what types of symptoms may they present with?
Flu-like
Brunner (PP)
What should be present in the chest tube water chamber?
Consistent bubbling
No bubbling is occluded chest tube
Constant bubbling is an air leak
Why would the nurse encourage a high fiber diet for a patient who experiences low blood pressures and/or orthostatic hypotension?
Bearing down can cause the patient to vasovagal down...causes even lower BP and PT can code/pass out/hit head, etc
What is 1 characteristic of a right-sided hemiparesis from a stroke?
Aphasic
Weakness on the right side
Weakness on the right side of the face
Neurological: Saunders
What is a Snellen test?
An eye chart that measures visual acuity
Can HSV-1 transfer to the genital region?
Yes and will show up on a pap smear.
Brunner
When a patient is having difficulty breathing what position is best?
High fowler's position
What are 5 typical signs and symptoms of an acute MI?
Diaphoretic, pale, jaw pain, shoulder pain, and chest pain
Can also include SOB and GI upset
Brunner Cardiovascular
What does homonymous hemianopsia mean?
Loss of half of the visual field
Place objects in front of patient on the "intact" side. Approach patient on the "intact" side.
Saunders : Neuro
How long will a patient with glaucoma need to administer eye medication?
For life/forever
Eye drops are a critical component of the treatment plan for the client with glaucoma.
What is a sign of tetany?
Carpal spasm when a BP cuff applied
Tingling around the mouth and limbs.
Hypocalcemia
Brunner and ATI
The nurse is assessing a client after a car accident. The client is at risk for developing acute respiratory distress syndrome. What is an early sign of ARDS?
Increased RR
Then dyspnea, air hunger, retractions, and cyanosis.Saunders book Respiratory System
The nurse is watching the cardiac monitor when a client's cardiac rhythm suddenly changes. There appears to be no P wave and an irregular rhythm. What cardiac rhythm is the client presenting with?
Atrial fibrillation
no P wave and irregular rate
Saunders Cardiovascular
What is unilateral neglect?
Unaware of the affected side
Common in right cerebral hemisphere. They are unaware of their left side. Place cane on the right. ADLs will be affected. Teach them to attend to the affected side first.
Saunders : neurological
Brunner
What is a characteristic manifestation of retinal detachment?
A shadow or curtain in the visual field.
Sauders: eye and ear disorders
What nursing diagnosis can alert the nurse that a patient is at risk for abuse?
Caregiver role strain
Interrupted family process
What else can you identify as a risk factor for abuse?
Brunner