What are isolation precautions for a client who has influenza?
Airborne
What are recommended vaccinations for older adult
... [Show More] clients?
Varicella
Pneumococcal
Influenza
Zoster
What are risk factors for deep-vein thrombosis?
Immobility
Surgery
Obesity
Tobacco use
Pregnancy
Central venous catheter
Trauma
Heart failure
Cancer
Contraceptives
What are interventions for preventing complications following a transurethral resection of the prostate?
Monitor for bleeding
Instruct client:
- Avoid heavy lifting, strenuous exercise, sex, and NSAIDs
- Drink 12 8oz glasses of water/day
What are interventions for maintaining proper traction?
- Maintain body alignment
- Avoid lifting/removing weights
- Ensure weights are hanging freely and not on floor
- If weights are displaced, replace weights
- Ensure no knots or kinks in ropes
What are manifestations of hypokalemia?
Weak, irregular pulse
Hypotension
Respiratory distress
Decreased motility
Everything slows
What type of debridement would you do for slough on a wound?
Mechanical
What are indications of a transfusion reaction?
Immediate: chills, fever, low back pain, tachycardia, flushing, hypotension, tachypnea, nausea, anxiety
Anaphylactic: wheezing, dyspnea, cyanosis, hypotension
How do you remove a PICC line?
Sterile procedure
Put patient in trendelenburg position and cover w/ occlusive dressing
How do you care for a central venous access device?
Observe for infection
Change drsg q48-72h
Change IV tubing q24h
Observe for systemic infection
What is client teaching for a patient on Furosemide?
Increase K+
Monitor electrolytes
Weigh daily
What are nursing interventions to prevent acute kidney injury?
Drink 2L fluids/day
Smoking cessation
Maintain healthy weight
Use NSAIDs cautiously
Control diabetes and hypertension
What do you use to control pain after an athroplasty?
Opioids and NSAIDs
How is TPN administered?
Through a central line (PICC)
What lab values do you assess for hepatitis and cirrhosis?
PT: 11-13 seconds
What lab values do you assess for gout?
Increased ESR (0-29)
Increased serum uric acid (>6.5)
Increased BUN (10-20)
Increased creatinine (0.8-1.2)
What tool do you use when monitoring neurological status?
Glasgow coma scale
What is the priority action for Cushing's disease?
Hypervolemia: distended neck veins, edema, SOB, adventitious lung sounds, infection, tachycardia, hypotension, weight, I&O
What is the priority action during the resuscitation phase of a burn victim?
Fluids and airway
What are assessment findings in a client who has right-sided heart failure?
Jugular vein distention
Edema
Fatigue
Polyuria
Abdominal distention
Weight gain
What patient teaching is necessary for someone following a glossectomy?
Alt communication techniques
Elevate HOB
Oral hygiene
Swallowing exercises
Report leakage of fluid from suture
How do you perform an ear irrigation?
Pull ear up/back
Tilt head towards affected side (allow drainage of solution)
When do you administer thrombolytic therapy to a stroke patient?
Within 6hr of symptoms
After MRI
Not for hemorrhagic stroke or for those w/ bleeding risks
How do you teach skin care following radiation treatment?
Wash w/ mild soap and water
Pat dry
Wear soft clothing
What do you clarify on a provider prescription regarding chest tube insertion/monitoring?
Clamp only for specific needs
Do not milk/strip tubing
What are interventions for meningitis?
Isolate: droplet precaution
Cooling blanket
Report infections
Decrease environ. stimuli
Provide quiet environ.
Minimize bright lights
Bed rest
Monitor ICP
Seizure precautions
Replace fluids/electrolytes
Risk for pneumonia
How do you care for a patient with an endotracheal tube?
Have resuscitation equip and face mask at bedside
Monitor vitals
Monitor placement
What assessment findings are present in the early stage of a burn injury?
Breathing and cardiopulmonary problems
Hypovolemia
How do you care for a patient post thyroidectomy?
Keep in semi-Fowler's
Support head/neck w/ pillow
Avoid neck extension
Vitals q15-30min
Deep breathing q30-60min
Suction PRN
Assess dressing
For respiratory distress:
Trach supplies PRN
Humidified O2
Cough/deep breathe
Suction
How do you identify a first degree heart block on an ECG?
Prolonged PR interval
What is the priority action for sinus bradycardia?
Atropine
What is the pharmacological treatment of diabetes insipidus?
Fluid replacement (hypovolemia)
What should you teach a client about thyroid storm?
Notify PCP of fever, increased restlessness, palpitations or chest pain
What is the pathophysiology of Parkinson's?
Overstimulation of basal ganglia by acetylcholine
How do you assess for compartment syndrome?
Pain
Pallor
Pulselessness
Paralysis
Parasthesia
What are clinical manifestations of nephrotic syndrome?
Fluid volume overload [Show Less]