Exam (elaborations) ATI RN COMPREHENSIVE EXIT EXAM FLASHCARDS QUIZLET

ATI RN COMPREHENSIVE EXIT EXAM FLASHCARDS QUIZLETATI RN COMPREHENSIVE EXIT EXAM 1,858 terms Pierate Terms in this set (1858) diet for chronic renal failure low protein & potassium DM pt teaching change shoes, wash bfeet w/soap & water pulse pressure subtract systolic value from diastolic value lantus never mix, long lasting, no peak rhogam given @ 28 weeks & 72 hours post delivery when mom is negative & baby positive indication of baby dehydration improving smooth fontannel pt w/orthostatic hypotension put near nursing station cleaning a wound clean to dirty use bulb syringe peripheral arterial disease cramp in leg while walking intermitment claudication seizure precautions supine position 20 weeks gestation, having urinary frequency u/a & c/s report to new nurse @ shift change pt @ xray s/s of hemolytic blood transfusion flank pain ER rape victim priority acess anxiety nutrition carbs 45%, protein 10-15% latex allergy tape up cords first ingredient on a food label most content thoracentesis, & painful w/breathing put pt on UNAFFECTED side for 1 hour or longer pt w/IV sedation check LOC if not responsive help older brother get used to baby get a gift for big brother early decelerations head compressions methergine contraindication HTN delegate to AP I & O HF monitoring weights location for peripheral line radial prioritizing care for multiple pt's low flank pain ativan for seizures med for diabetes insipidus desmopressin radiation tatoo use mild soap & water uric acid stones eat low fat yogurt antigout med decreases uric acid level allopurinol non-pharm relation technique for pain management in labor hypnosis psychotic disorder assessment finding flat affect newborn withdrawal from heroin (opioids) hypertonicity mitral valve location 5th intercostal amniocentesis go pee before procedure total gastrectomy lack b 12 takes 30-60 meal to eat a meal stoma color pink or red is normal MAOI's diet no pepperoni, no tyramine, COTTAGE CHEESE OKJ give iron w/? OJ statins contraindication Grapefruit juice haldol lip smacking mag sulfate decreased urine output decreased respirations decreased pulmonary edema antidote for mag sulfate calcium gluconate clozaril interventions monitor WBC valproic thyroid m aecdid liver function effectiveness weight loss diuretics don't skip doses DIG adverse effects N/V & HA prednisone take with milk hemo/peritoneal dialysis pt teaching medical asepsis cranial nerve 11 shoulder peripheral catheter insertion advance catheter when you see flash back of blood return dispose of insulin needles @ home in coffee container confirmation of ng placement x ray swallowing difficulty referral speech therapy acrabose skip a meal, skip dose, give w/1st bite of food sprains & strains RICE pt DNR-CC & family asking questions related to. therapeutic communication: THERAPEUTIC RESPONSE What did the dr tell you? delegating to AP about skeletal traction: NEEDS MORE TEACHING AP places weight on bed daughter feeling guilty about admitting parent into long-term facility: THERAPEUTIC RESPONSE rephrase what daughter is feeling how good nurse plans her day rechecks her priorities half way through her shift good nurse sets these when she works GOALS pt gets bad dx, & asks you not to tell her spouse:YOUR RESPONSE you have a right to privacy delegate to AP CPR baby in contact precautions in a private room, what would you do to save hospital $? bring formula prn how does a nurse properly manage her time mid-shift? reevaluates goals which psych pt would you see first? hallucinations dementia pt @ ER, w/marks on coccyx & wrist, suspected abuse. what do you do? ask pt. INTERVIEW HIM psych pt yelling in front of group. very agitated, what do you do? isolate pt charge nurse scheduling resolution between nurses nurse listens to both sides respite care gives family a break pt in seclusion documentation what happened prior to seclusion that caused for seclusion parkinson's : pt teaching nutrition- thicken liquids pt receiving radiation, what should you wear? lead apron pt suffering from hyperthermia seizure precautions pt refuses last minute for a procedure he already consented for okay to stop procedure s/s of smallpox rash on tongue xerostoma humidifier vagina procedure, cervical cancer place catheter Lyme disease report it lice (pediculodis capitis) can survive on surfaces for up to 48 hours RSV keep stethescope in room (droplet) 16 weeks gestation can get AFP test done bacterial meningitis droplet precautions when can kid return to school for chicken pox when lesions are crusted over kicks a ball: developmental stage 24 months bwarobny gw o/cslteofmt lyip care cuhnatineg ainrmg se &ve pryedrfaoyr mm aRyO leMad to skin irritation after male circumcision apply petroleum jelly w/every diaper change breastfeeding w/hep c don't breast feed if you have cracked nipples contraindication w/oral contraceptives HTN combination contraceptives contraindications pt w/migraines when percussing RUQ, what should we feel dullness dementia pt offer finger foods black males @ great risk for CVA med for alcohol withdrawal disulfiran (antabuse) better nutririon canola oil healthy eating 45 % carbs to prevent neuro tube defects folate prevnting delays of healing protein & o2 pt raped & @ ER assess anxiety pt reports abuse assess pt, check for injuries anorexia 60% refeeding-pre-albumin of 10 telemetry is used for check for dysrythmia do not give mmr to child bearing pt b4 pregnancy test pt w/hx of blood transfusion diet for hf dry spices to flavor food TURP: closed intrermittment irrigation let it drain Cranial nerve XI (hot spot) shoulder Proper lifting technique (picture) bending at knees 24 month old walk up steps Food label greatest weight listed first IV technique advance catheter Refeeding syndrome 60% Low fat diet canola oil instead of vegetable oil Prior to amniocentesis empty bladder Radiation implant limit visitors to 30 minutes Levothyroxine take on empty stomach, in am; increases tsh Metformin contraindication kidney disease, severe infection, shock, hypoxic conditions Mastectomy lay of affected side to promote drainage, support arm on pillow, HOB 30 Circumcision use petroleum jelly with every diaper change Check for NG tube placement in the jejunum X-ray Colostomy care cut the bag Seizure precautions saline lock IV Ethical medical error veracity Early Magn deesicuemle srualtfiaotnes head compressions interventions (select all) calcium gluconate, stop infusion, UO less than 30, RR less than 12, decreased reflexes Thoracentesis causes pneumothorax expected finding not friction rub; tracheal deviation AP's talking in cafeteria tell them to stop talking Safety for parkinson's clear area Warfarin vitamin k for toxicity; INR 2-3; PT 11-12.5 Contraindication of MMR blood transfusion Diabetic foot care (select all) change shoes frequently, wash feet with soap and water Sprains avoid warm compress Expected finding of small pox rash in mouth 16 weeks pregnant alpha protein Psych med lip smacking Where to start IV first (picture) hand PRBC need further teaching start IV on other arm Delegate to AP CPR compressions Delegate to LPN sterile dressing Postural drainage give albuterol, trendelenberg; 1 hour before meals or 2 hours after Dumping syndrome high protein and fat; avoid milk, sweets, and sugar; small, frequent meals DASH diet increase fruit, vegetables, and low Baby with reflux small, frequent meals, thicken form ufalat dwaitirhy ;r ikc,e m cge,r ecal, HOB 30 Cleft palate repair periodic restraints Nephrotic syndrome vitamin K Pernicious anemia schilling's test Peritoneal dialysis report cloudy; monitor glucose; warm solution before Gastric surgery eat 3 meals Gastrectomy small, frequent meals; vitamin B12, D, iron, and folate Statin grapefruit Preventing uric acid stones yogurt RSV have own stethoscope in room Change of shift report orthostatic hypotension by nurses station Confused patient raise 1 side rail Hypoglycemia cool and clammy skin Hyperglycemia thirst Glycosylated blood test HbA1C Priority for patient in seclusion document Buddhist patient vegetarian Positive TB hard raised bump Heart murmur sound blowing or swishing Dehydration oliguria NST ... PAD pain/cramping when walking, calf muscle atrophy, shiny cool extremities; elevate legs Cast with white extremity compartment syndrome Alcohol withdrawal expected finding n&v, tachycardia, diaphoresis, tremors, seizures Varicella scabs okay Hyperthermia not blanket or ice Purpose of ice decrease inflammation Sexual assault assess anxiety THA avoid flexion greater than 90 Beta blocker teaching don't stop abruptly; avoid in asthma; take with food Combination contraceptives increase BP Myelosuppression flu shot Glucocorticoid increase dose in DM; take with meals; avoid NSAIDs; Addison's crisis if stopped abruptly Extreme focus mild anxiety Good diet 30% carbs Family concern what has the doctor told you Adolescent 1300 mg of calcium Lyme disease report to health department Organize workload goals for the day Intervene pacing around wife Renal failure decrease protein, K, Na, increase carbs, strict I&O PUrreineec lfaremqpuseiancy in proteinuria pregnancy urine sensitivity test Lice can live for 48 hours on surfaces Chest tube complications bubbling in water seal Elderly abuse ask privately Informed consent signed willingly Sibling bonding offer gift each time sibling gets one TURP complication hematuria African american over Caucasian heart disease Sickle cell priority hydration Sickle cell complication SOB Respite care give caretaker break Acarbuse take with first bite of each meal Hallucination I understand you are scared Fire extinguisher PASS Advanced directive don't need a lawyer Breastfeeding and hepatitis c as long as you don't have cracked nipples ICP keep HOB midline Long term use of proton pump inhibitors osteoporosis Diabetes insipidus polyuria Difficulty voiding warm water AWChEa ti ndhoib yitoour shear when cough you palpate abdomen resonance Negotiation strategy understand both sides Dying patient wants to be alone depression or dysfunctional Wife progressing quickly can you tell me more Pregnant nonpharmacological pain management aromatherapy, breathing techniques, imagery, music, use of focal points, subdued lighting Hypnosis purpose alter perception of pain Complication of conscious sedation with RR 6 stop infusion or give something Major depression, OCD give fluoxetine What causes constipation iron Patient can't sleep don't drink caffeine before bed Collecting urine culture on baby straight cath Electrolytes Na - 136-145 K - 3.5-5 Ca - 9-10.5 Mg - 1.3-2.1 P - 3-4.5 Cl - 98-106 Hypervolemia bounding, JVD, edema, confusion, increase everything Anorexia prealbumin 10 Dehydration improving baby flat fontanelle Unsaturated fat coconut oil Priority abdominal pain and went away Opioid agonist naloxone (Narcan) COPD increase calories and protein Needle disposal at home coffee container on top shelf Give RhoGAM in second pregnancy protect future pregnancy Swallow problem refer to speech therapist Nutrition for heart failure Decrease Na, increase fluids, increase fiber; increase K with diuretic Adverse affects of dogoxin Bleeding gums, bloody urine and stools, arrhythmias, petichiae NG nutrition Increase K Methotrexate adverse affect High blood pressure I.M. site for children VASTUS LATERALIS or antelolateral thigh is the site for IM injections in children < 2 yrs. of age Peak Levels show the highest concentration Time for drawing Peak levels: Oral Intake 1 to 2 hour after administration Time for drawing Peak levels: I.M. 1 hour after administration Time for drawing Peak levels: I.V. 30 minutes after administration Trough Levels show the lowest concentration or residual level, usually obtained within 15 minutes before next dose. Do not administer until confirmed. Can meds be administered through blood tubing? NO. Never administer meds through tubing being used for blood administration How long should fluids be infused? Fluids should be infused within 24 hours, discard unused potion, to prevent infection Complications associated with IV infusion infiltration, extravasation, phlebitis, thrombophlebitis, hematoma, venous spasm Preventing Infiltration use smallest catheter for prescribed therapy, stabilize portaccess, assess blood return Treatment of Infiltration stop, remove, cold compress, elevate extremity, insert new cath in opposite extremity Preventing Extravasation know vesicant potential before giving medication Treatment of Extravasation stop, discontinue, aspirate med if possible, cold compress, document Preventing Phlebitis & Thrombophlebitis rotate sites every 72 to 96 hrs, secure catheter, aseptic technique for PICC lines, limit activity with extremity Treatment of Phlebitis & Thrombophlebitis stop, remove, heat compress, insert new cath in opposite extremity Preventing Hematoma avoid veins not easily seen or palpated, obtain hemostasis after insertion Treatment of Hematoma remove, apply pressure, monitor for signs of phlebitis and treat Preventing Venous Spasm allow time for vein diameter to return after tourniquet removed, infuse fluids at room temp Treatment of Venous Spasm temporarily slow infusion rate, warm compress TPN hypertonic solution, contains dextrose, proteins, electrolytes, minerals, trace elements, and insulin prescribed, administered via central venous device like PICC line, subclavian, or internal jugular vein Care for TPN verify with another nurse, use infusion pump, monitor daily weights, I & O, fluid balance, serum glucose q4 to 6 hrs, infection, change dressing q48 to 72 hrs, change tubing and fluid q24 hours, if TPN is unavailable, administer dextrose 10% in water to prevent hypoglycemia Complications of central venous catheters pneumothorax during insertion, air embolism, lumen occlusion, bloodstream infection Pneumothorax during insertion use ultrasound to locate veins, avoid subclavian insertion when possible, treat with O2, assist with chest tube insertion Air Embolism have client lie flat when changing administration set or needleless connectors, ask client to perform Valsava maneuver, treat by placing client in left lateral trendelenberg, and O2 Lumen Occlusion flush promptly with NS between, before, and after each med, treat with 10 cc syringe with pulsing motion Bloodstream Infection maintain sterile technique, treat by changing entire infusion system, notify MD, obtain cultures, and administer antibiotics Antidote for Acetaminophen Acetylcysteine, Mucomyst Antidote for Benzodiazepine Flumazenil, romazicon Antidote for Curare Cyanide edrophonium, tensilon Poisoning methylene blue Antidote for Digitalis digoxin immune FAB, Digibind Antidote for ethylene poisioning fomepizole, antizol Antidote for Heparin and enoxaparin or Lovenox Protamine Sulfate Antidote for Iron Deferoxamine, desferal Antidote for Magnesium Sulfate calcium gluconate 10%, kalcinate Antidote for Narcotics naloxone, narcan Antidote for Warfarin phytonadione, vitamin K aminophylline 10 to 20 mcg/ml carbamazepine 5 to 12 mcg/ml digoxin 0.8 to 2.0 mcg/ml gentamicin 0.5 to 0.8 mcg/ml lidocaine 1.5 to 5.0 mcg/ml lithium 0.4 to 1.4 mcg/ml magnesium sulfate 4 to 8 mcg/ml phenobarbital 10 to 30 mcg/ml phenytoin 10 to 20 mcg/ml quinidine 2 to 5 mcg/ml salicylate 100 to 250 mcg/ml theophylline 10 to 20 mcg/ml taocbertamyincoinphen toxicity >5 2to5 010 mcg/ml aminophylline toxicity > 20 amitriptyline toxicity > 500 digoxin toxicity > 2.4 gentamicin toxicity > 12 lidocaine toxicity > 5 lithium toxicity > 2.0 magnesium sulfate toxicty > 9 methotrexate toxicity > 10 over 24 hours phenobarbital toxicity > 40 phenytoin toxicity > 30 quinidine toxicity > 10 salicylate toxicity > 300 theophylline toxicity > 20 tobramycin toxicity > 12 PRIL ace inhibitors, captopril, enalapril VIR antivirals, acyclovir, valacylovir AZOLE anti fungals, fluconazole, variconazole STATIN antilipidemics, atorvastatin, simvastatin SARTAN angiotensin 2 receptor blockers, ARBS, valsartan, losartan OLOL beta blockers, metoprolol, nadolol DIPINE calcium channel blockers, amlodipine, nifedipine AFIL erectile dysfunction meds, DINE histamine 2 receptor block esrids,e rnaanfiitli,d tiandea, lfaafmil otidine PRAZOLE proton pump inhibitors, pantoprazole CAINE anesthetics PAM, LAM benzodiazepine ASONE, SOLONE corticosteroid CILLIN penecillin IDE oral hypoglycemic ASE thromolytic AZINE anti emetic PHYLLINE bronchodilator ARIN anticoagulant TIDINE anti ulcer ZINE anti histamine CYCLINE antibiotic MYCIN aminoglycoside FLOXACIN antibiotic TYLINE tryciclic antidepressant PRAM, INE SSRI anti hypertensives assess weight, VS, hydration, ortho BP, renal function, coagulation, educate to take same time each day, avoid hot tubs and saunas, do not discontinue abruptly ACE inhibitors (angiotensin converting enzyme) block the conversion of angiotensin 1 to angiotensin 2 Angiotensin 2 Receptor Blockers selectively block the binding of angiotensin 2 to angiotensin 1 receptors found in tissues ACE Inhibitors captopril or capoten, enalapril or vasotec, enalaripat or vasotec IV, fosinopril or monopril, lisinopril or prinivil ARBs losartan or cozaar, valsartan or diovan, irbesartan or avapro ACE inhibitors and ARBs for HTN, heart failure, MI, and diabetic nephropathy, monitor potassium, use with caution if diuretic therapy is in use ACE inhibitors and ARBs side effects persistent non productive cough with ACE inhibitors, angio edema, hypotension, contra for 2nd and 3rd trimester in pregnancy ACE inhibitors and ARBs nursing interventions captopril should be taken 1 hr before meals, monitor BP, monitor for angio edema and promptly administer epinephrine 0.5 ml of 1:1000 solution sub q Calcium Channel Blockers slows movement of calcium into smooth muscle cells, resulting in arterial dilation and decreased BP, examples are nifedipine/adalat/procardia, verapamil/calan, dilitiazem/cardizem, amlodipine/norvasc Calcium Channel Blockers Use for angina, HTN, veripamil and diltiazem may be used for A Fib, A flutter, or SVT Calcium Channel Blockers Precautions use cautiously in clients taking digoxin and beta blockers, contra for client who have heart failure, heart block, or bradycardia, avoid grapefruit juice (toxic) Calcium Channel Blockers side effects constipation, reflex tachycardia, peripheral edema, toxicity Calcium Channel Blockers nursing interventions do not crush or chew sustained release tablets, administer IV injection over 2 to 3 mins, slowly taper dose if discontinuing, monitor HR and BP Alpha Adrenergic Blockers (symphatholytics) selectively inhibit alpha, adrenergic receptors, resulting in peripheral arterial and venous dilation that lowers BP, esamples are Alpha Adrenergic Blockers (symphatholytics) Use for primary HTN, cardura may be used in treatment of BPH Alpha Adrenergic Blockers (symphatholytics) Precautions increased risk of hypotension and syncope if given with other anti hypertensives, beta blockers, or diuretics, NSAIDs may decrease effect of prazosin Alpha Adrenergic Blockers (symphatholytics) side effects dizziness, fainting Alpha Adrenergic Blockers (symphatholytics) nursing interventions monitor HR and BP, take meds at bed time to minimize effects of hypotension, advise to notify prescriber immediately about adverse reactions, consult prescriber before taking any OTC meds. Lorazepam antidote flumazenil Fluid overload dyspnea s/s, back up of fluid in pulm system Rheumatoid arthritis pain freq rest during the day case mgr arranges for transportation to health care appts w/mental health Total hip install raised toilet seat at home verapamil and grapefruit causes hypotension, g. increases blood levels of v. by inhibiting metabolism vaso occlusive crisis in sickle cell start iv fluids 1st to promote hydration and circulation Do not increase this if pt has COPD exaserbation O2 hemianopsia hemi=half, an=without, opsia=seeing *use scanning tequnique when ambulating narrow QRS complex, irregular 170 bpm, no p waves a fib N/V will cause what lab value to elevate? urine specific gravity-dehydration enoxaparin aka lovenox blowing bubbles to make the "hurt go away" is an example of what? nonpharm visualization for pain mgmt w/kids hypoglycemia irritability hyperglycemia polyuria One or more surgical drains after? masectomy, exercise after 24 hrs TB meds ___ or longer 6 mo If client is disorientated and combative during the night, what should Rn do? move client closer to Rn station Wash clients hand with soap/water prior to? CBG Changing this is final step in trach care trach ties Diazepam (benzo) should be given for? status epileptcus HA is adverse effect of? fluoxetine, Use ventrogluteal site hypotension too with these patients for IM obese Clonidine side affect dry mouth Clozapine side affect wt gain Unstable vs are immediate threat to life? t/f true! TPN pt's need this monitored frequently blood glucose, 24 hr TPN at first then 8-12 hrs per day once stable ECT can cause short term memory loss Nurse should use __ with transfusion 0.9% sodium chloride to prevent clotting, **not D5W Expected finding in cardiac tamponade pulsus paradoxus-drop in bp during inspiration Nonmaleficence duty to do no harm autonomy informed consent pattern paced breathing during this phase of labor transition position client who is at risk for pressure ulcer at this level 30 degree lateral position in bed Pt with femur fracture highest prioroty upper chest petechiae-risk for fat embolism syndrome Tremors can indicate hyperthyroidism Cloudiness with blurred vision cataracts this med will help reduce icp mannitol-osmotic ___ lung expansion with age decreased __precautions with hsv contact Occupational therapy for difficulty performing personal hygeine Have pt lie on this side during gastric levage for NG tube left-prevents aspiration Celiac diet gluten free-chicken and wild rice to decrese icp put in quiet env quick notes during h-t assessment Diaphram should be removed how long after intercourse? 6 hrs or more intervention to prevent heat loss with infant pad scale with paper Pt admitted with dka, first priority? vs If INR is 1.8 and ptt is 98 hold heparin infusion 6-8 wet diapers a day indicates? effective breastfeeding Brat diets are contraindicated with diarrhea Ask this if pt refuses to ambulate after surgery pain Review chest x-ray report prior to initiating infusion in picc LPN can insert NG pt with this needs private room with negative air pressure pulm tb if pt is unconsious and needs er help proceed without consent opioid side effect u. retention Use 1:100 chlorine solution to clean kitchen surfaces with this illness hep A make referral for social services for pt with this terminal illness serum magnesium of 2.5 initiate continuous cardiac monitoring Cold therapy for these patients Rheumatoid arthritis to relieve inflammed joints fluoxetine SSRI antidepressant-watch for tremors since this can cause serotonin syndrome w/in 2-72 stage II pressure ulcer partial thickness skin loss stage III pressure ulcer visible sq tissue stage IV muscle damage, tendon exposure Cyclophosphamide treats cancer, drink 1-1.5x h2o to prevent hemmoragic cystitis and prevent dehydration Valporic acid treats seizures-can cause hepatic toxicity digoxin toxicity sign nausea estradiol (estrace) side effect HA Report findings for pt post ruptured appendix 48 hr ago rigid, board like abdomen absent bowel sounds elevated temp elevated wbc (could be indication of peritonitis) Chlorpromazine antipsychotic to decrease hallucinations Theophylline toxicity bronchodilator-can cause anorexia Check this pulse with an infant during cpr brachial Client is in active labor and receiving oxytocin. FHR shows variability w/accelerations. What is correct response? Document and continue to monitor. This is a reassuring pattern indicating intact fetal CNS and healthy placental/fetal exchange of oxygen. Indication of oxygen toxicity Bradypnea-hypoxic drive is removed Advance Directives 2 components of an advance directive are the living will, and a durable power of attorney. Legal documents that allow people to choose what kind of medical care they wish to have if they cannot make those decisions themselves. Nsg responsibilities are-providing info regaurding advance dir,documenting status of advance dir, ensuring they are current, and reflect pt. status. Recognizing they take prioritiy for the pt. Ensuring that all healthcare team members are aware. Upgrade to remove ads Only $1/month living will legal document that expresses client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues. Ex. cpr, mechanical ventilation, and feeding by artificial means. durable power of attorney enables patient (called the "principal" in the power of attorney document) to appoint an "agent," such as a trusted relative or friend, to handle healthcare decisions on behalf of patient. advocacy supporting pts. by ensuring that they are properly informed, that their rights are respected, and that they are receiving the proper level of care. Nurses must act as advocates even when they disagree with pts. wishes. Nurses are the pts. voice when healthcare system is not acting in pt. best interest. Assigning the process of transferring authority, accountability, responsibility of pt, care to another health care member. delegating The process of transferring authority and responsibility to another team member to complete a task while retaining accountability. supervising Process of directing monitoring and evaluating performance of tasks by another member of the health care team. case management a methodology for moving a patient through the healthcare system while streamlining costs and maintaining quality, Explore resources available to assist with the pt. in achieving or maintaining independence. airway 1st Identify airway concern( obstruction,stridor) Establish a patent airway recognize that 3-5 mins without o2 is irreversible brain damage 2ndary to cerebral anoxia. Breathing 2nd Access effectiveness of pt. breathing(apnea,depressed, respiratory rate, Intervene as appropriate(reposition, administer narcan). circulation 3rd Identify circulation concern (hypotension ,dysrhythmia, inadequate cardiac output, compartment syndrome) identify ways to minimize or reverse circulatory alteration). disability 4th Access for current evolving disability (neurological deficits stroke evolution) Implement actions to slow down disability. Pt. Rights Nurses role Be informed about all aspects of care and take an active role in decision making process. Accept refuse or request a modification to a plan of care. Receive care that is delivered by a competent individual. Prioritize systemic before local. (life before limb) prioritize interventions for a pt. in shock over interventions for a pt. with a localized limb injury. Prioritize acute before chronic Care of pts. with new injuries/illness( confusion, chest pain) over acute exacerbation of a previous illness, over the care over a pt. with a long-term chronic illness. prioritize actual problems before future potential problems. prioritize administration of medication to a pt. experiencing acute pain over a pt. ambulating and at risk for thrombophlebitis. Hypoglycemia risk factors for Newborns, Blood glucose <40 in term newborn, <25 in preterm newborn POST TERM, IUGR, ASPHYXIA, COLD STRESS, Maternal diabetes, Gestational hypertension, Tocolytic therapy, Prematurity, LGA, SGA, Perinatal hypoxia, Infection, Hypothermia Prioritizing care in clients with hyperthyroidism Alternate periods of activity with rest provide calm environment access mental status increased calories and protein monitor intake and output, wt pt. eye protection for pt. with exophthalmos report a degree of 1 or more to MD prepare for thyroidectomy if meds become unresponsive. Pt. education r/t hyperthyroidism medications, methimazole (tapazole) and (PTU) propylthiouracil. These inhibit the production of thyroid hormone. report fever, sore throat, or bruising to md report any jaundice or dark urine follow md instructions about daily intake of iodine. dysphagia ... Latex allergies must use latex free equipment, gloves and supplies. Risk Factors of Diabetes being African American, Hispanic, or Asian obesity