What is a kosher diet? - ✔✔ no shellfish but yes fish with fins and scales; no pork; no mixing meat with milk, ever
woman is post pelvic surgery
... [Show More] and asks why she has a foley catheter inserted, what is your response? - ✔✔ it avoids stress on the incision site/bladder
crutches on what side when rising? when walking? - ✔✔ unaffected side when rising; affected side when walking;
Arms at what degrees when hands on crutch rails while standing? - ✔✔ 30 degrees
What walking gate for stairs? (crutches) - ✔✔ 3 point
Normal stoma findings - ✔✔ moist shiny/pink; mild soap and water, then dry gently and completely, apply paste if used, apply barrier pastes to creases
Cholecystitis diet - ✔✔ no cheese! low fat, low cholesterol (<200), if AST & lipase, any type of bilirubin, WBC, amylase, LDH, are elevate = bad
expect what during latent phase of labor? - ✔✔ (0-3, 5-30, 30-45) 0-3 cm, contractions mild and moderate, 5-30 min apart/30-45 seconds
contractions 3 minutes apart = what phase of labor? - ✔✔ active
variable decelerations = what? intervention? - ✔✔ cord compression! prep for emergency c-section or inducing labor. also can change position, d/c oxytocin, o2 8-10L/min per mask, perform/assist with vaginal exam, assist with amnioinfusion if ordered
Which of the following is the initial nursing action for the nurse to take when late decelerations appear on the fetal monitor?
a - reposition the client in to left-lateral position
b - apply a fetal scalp electrode
c - increase the iv fluid rate
d - perform a vaginal exam to assess dilation - ✔✔ a - reposition the client in to left-lateral positioning
best pain management for 8-10 post open cholecystectomy; demerol, hydromorphine, fentanyl, morphine - ✔✔ DEMEROL NOT morphine or others; morphine can cause biliary spasms
fontanels close when? - ✔✔ posterior 2-3 months; anterior 12-18 months
do you report chlamydia, do you need consent, etc? - ✔✔ mandated reporting to CDC, without verbal or written consent
Empty JP drain when? clean how? - ✔✔ before half full, or every 8-12 hrs, NOT 24 hours. Clean with soap and water, NOT antimicrobials or Dakin's etc.
If JP drainage has doubled in last two hours, possible cause? - ✔✔ hemorrhage. Access, stat CBC, notify physician
What do bananas, avocado and spinach have in common? If patient on what med, these are good foods? - ✔✔ high K+, so good for hypokalemic patients; if patients on thiazide diuretics (Diuril, enduron), may be HYPOKalemic, so give these!
MAOI's/Nardil, avoid what? - ✔✔ Cheese!
Cheese is not good with what? Cheese is good for what and why? - ✔✔ nardil/maoi! good for hyponatremia because high in sodium, high in protein
is drainage at pin sites ok with bucks traction? - ✔✔ drainage ok, note the type/color/odor/amount; leave crust as a barrier, pin care 3x/day
phenytoin, SMZ-TMP, command hallucinations = what? - ✔✔ phenytoin toxicity!
If patient has command hallucinations, withold med? - ✔✔ yes!
methergine risk? what does it do? - ✔✔ treats postpartum hemorrhage by inducing uterine contractions; reducing hemorrhage; HYPERTENSION is a risk, so check bp prior to administration, watch for n/v, headache
high pressure alarm, do what? - ✔✔ assess for kinkds, client bitingg, excess secretions (suction), pulmonary edema, etc. Notify provider
Low pressure alarm do what? - ✔✔ assess for leaks, displacement, if can't find anything wrong, MANUALLY ventilate & call respiratory stat, do NOT leave alone
2 years of age, presentation of arms longer than torso, or round & soft abdomen - ✔✔ round & soft abdomen, NOT arms longer than torso
3 years of age normals; immunization? - ✔✔ 2-3kg/yr, 2.5-3 in/yr, picky eaters, initiative vs guilt, imaginary friends, ride tricycle, jump off bottom step, stand on one foot for a few seconds, DTaP, IPV, MMR, varicella, influenza
first thing to do with a newborn; take temperature, weight, dry... - ✔✔ DRY
terminally ill patient only wants family, not friends with them. Type of grief? - ✔✔ anticipatory, not dysfunctional, normal or disenfranchised
a client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive & unresponsive. The nurse anticipates that which IV solution will most likely be prescribed to increase intravascular volume, replace immediate blood loss volume & increase BP? (5% dextrose in LR, 0.33 NaCl, 0.225% NaCl, 0.45 NaCl) - ✔✔ 5% dextrose in LR
Give what for hypovolemic shock ? - ✔✔ 5% dextrose in LR
Client's family asks you to pray with them. Response? - ✔✔ refer to spiritual services
After a blood transfusion, will you look at hub, hct, BP or HR for changes? - ✔✔ hgb!!! 1-2 pt increase per unit of blood
can you give an antibiotic in a TPN infusion line? what can you add to a TPN infusion line? - ✔✔ NO! Nothing!
change a TPN infusion line every 24 hours or how often? - ✔✔ yes! every 24 hours
can clients family change dressing daily? tie tubing to neck? - ✔✔ no, every 8 hours? yes, square knot with 1-2 finger width
TPN, slow down infusion before endingg, d/c until new bag ready? - ✔✔ no, dont d/c or change rate, don't change flow rate!
hip arthroplasty, what to watch out for? - ✔✔ peripheral pulses! cool & weak, 1+ peripheral pulses, sign to call provider [Show Less]