signs and symptoms of hypoglycemia - reduced cognition, tremors, diaphoresis, weakness, hunger, headache, irritability, seizure, clammy skin,
... [Show More] blurred/double vision, shallowed respirations
Signs and symptoms of hyperglycemia - polyuria, polydipsia, polyphagia, nausea/vomiting, abdominal pain, constipation, drowsiness, headaches, flushed/dry skin, fruity breath odor, weak rapid pulse, urine positive for glucose and acetone, blood glucose above 200
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
A) administer penicillin G 2.4 million units IM to client
B) instruct the client to schedule an annual pelvic examination
C) tell the client she will start medication for HIV immediately after delivery
D) report the clients condition to the local Heath department - D) report the clients condition to the local health department
HIV is one of the conditions on the nationally notifiable infections conditions that is required to be reported
When does treatment begin for pregnant women with HIV? And what type of treatment is used? - Treatment for HIV will be during the prenatal and perinatal periods. Treatment with anti-retroviral prophylaxis such as Zidovudine, triple drug antiretroviral therapy (ART), or highly active antiretroviral therapy (HAART) during pregnancy have been reported to decrease transmission of HIV to the newborn.
What medication would be given IM for a client who has syphillis and is pregnant? - Penicillin G
Major adverse affect of combined oral contraceptives? - Depression.
Other common adverse affects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?
A) "I can administer oxytocin 4 hours after the insertion of the medication"
B) "you will need a full bladder prior to insertion of the medication
C) "remain in a side lying position for 15 minutes after the medication is inserted"
D) "an antacid will be given 20 minutes prior to the insertion of the medication - A) "I can administer oxytocin 4 hours after the insertion of the medication"
The nurse can administer oxytocin no sooner than four hours after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.
How long should a patient stay in a side lying position after insertion of misoprostol? - 30-40 minutes after insertion
What medications (class) should you avoid giving with misoprostol? - Avoid administering aluminum hydroxide and magnesium containing antacids with misoprostol
A nurse is caring for A prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?
A) administer antiviral medication
B) schedule and ultrasound examination
C) administer haemophilus influenzae type b vaccine
D) schedule an indirect Coombs test - B) schedule and ultrasound examination
The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect a possible development of fetal hydrops. Also the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.
What is a indirect Coombs test used for? - This test determines whether the client has antibodies to the Rh antigen. The titer determines the prenatal clients sensitization and if there is RH incompatibility.
What is another name for parvovirus B19, and what does it affect? Is it transmissible from a pregnant woman to her baby? - This virus spreads through respiratory secretions such as saliva, sputum, or nasal mucus when an infected person coughs or sneezes. Another name for this virus is fifths disease. The virus can also spread through blood or blood products therefore a pregnant woman who is infected with the virus can pass the virus to her baby. There are currently no vaccinations to protect against fifth disease.
A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect a provider to prescribe?
A) kleihaur-Betke test
B) progesterone serum level
C) lecithin/sphingomyelin (L/S) ratio
D) maternal alpha-fetoprotein (AFP) - A) Kleihaur-Betke test
The nurse should expect the provider to prescribe a kleihauer-betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if RHo- (D) immune globulin therapy should be administered to a client who is rh-negative.
What is the Kleihauer-Betke test? - Blood test used to detect the amount of fetal blood (hemoglobin) transferred from a fetus to a mothers bloodstream
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. So which of the following complication should the nurse assess?
A) abruptio placenta
B) placenta previa
C) preeclampsia
D) maternal bradycardia - A) abruptio placenta
Cocaine use increases the risk for vasoconstriction and possible abruptio placenta
A nurse is planning care for a client who had a single lumen nasogastric tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply)
A) set the suction machine at 120mmHg
B) provide oral hygiene frequently
C) measure the amount of drainage from the NG tube every shift
D) secure the NG tube to the clients gown
E) apply petroleum jelly to the clients nares - B, D, C
A. Is incorrect because single lumen NG tubes are used for intermittent suction, and the machine is set at 80-100 mmHg. Higher suction can traumatize the gastric lining.
E. Is incorrect because the client could aspirate an oil based lubricant like petroleum jelly into the lungs, which could result in lipid pneumonia. A water-soluble lubricant should be applied to the nares to help prevent or relieve dry skin
What is the appropriate mmHG amount of suction used for a single lumen NG tube? - 80-100mmHg
Higher suction can traumatize the gastric lining
A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the clients risk of aspiration?
A) irrigate the tubing with 30ml of sterile water
B) Elevate the head of the bed to 30-45°
C) suggest changing the feeding to lactose free formula
D) warm the enteral formula to room temperature before feeding - B) elevate head of bed to 30-45°
Should you warm up enteral feeding formulas to room temperature before giving to client? Why? - YES! This can help reduce abdominal cramping and discomfort from cold formula ingestion.
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?
A) redness at the Infusion site
B) edema at the infusion site
C) warmth at the infusion site
D) oozing of blood at the infusion site - B) edema at the infusion site
Edema due to fluid entering subcutaneous tissue is an indication of infiltration.
What is a cholecystectomy? - surgical removal of the gallbladder
A nurse is changing the dressings for a client who is 3 days post operative following a cholecystectomy. The nurse observes yellow thick drainage on the dressing. The nurse should document this finding at which of the following types of drainage?
A) sanguineous exudate
B) serous exudate
C) serosanguineous exudate
D) purulent exudate - D) purulent exudate
Purulent exudate is yellow, green, or brown, and usually indicates would sloughing or infection
What does sanguineous drainage look like and mean? - Bright red is color, indicates accumulation of RBCs from the plasma
What does serous exudate look like and mean? - Appears watery and clear to light yellow in color, indicates plasma from the blood
What does serosanguineous exudate look like and mean? - Appears pale yellow to blood-tinged, watery drainage may also be evident. Indicates plasma mixed with light bloody drainage
A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the clients medical record?
A) the client refused to take medication today
B) the client stated "I will not take this pill"
C) the client seemed angry and hostile
D) the client threw the medication at the floor - D) the client threw the medication at the floor [Show Less]