Mark Klimek Blue Book | Complete NCLEX Study Guide & Test Bank

Mark Klimek Blue Book | Complete NCLEX Study Guide & Test Bank Can you microwave frozen breast milk in order to warm/thaw it? - ansNever Which two nutrients is breast milk lower in? - ansFluoride and iron What should you tell a breast feeding mother about her milk supply when she goes home from the hospital? - ansMilk should come in postpartum day 3. Breastrfeed every 2-3 hours to establish good milk supply. Can a woman on oral contraceptives breastfed? - ansShould not use OCP during the first 6 weeks after birth because the hormones may decrease milk supply. Estrogen is not recommended. Non-hormonal methods are recommended. Remember, breastfeeding is an unreliable contraceptive. What is another name for Buerger's disease? - ansThromboangiitis obliterans Which extremities are affected by it? - ansLower only Which sex does it affect the most often? - ansMales The group with the highest incidence of Buerger's disease is __________. - ansSmokers Upon walking the patient with Buerger's experiences _______ _________. - ansIntermittent Claudication What is intermittent claudication? - ansPain in calf upon walking A first degree burn is pale or red? - ansRed A first degree burn has vesicles (T/F)? - ansFalse A second-degree burn is pale or red? - ansRed A second-degree burn is dull or shiny? - ansShiny A second-degree burn has vesicles? (T/F) - ansTrue A Second degree-burn is wet or dry? - ansWet A third-degree burn is white or red? - ansWhite A third-degree burn is wet or dry? - ansDry A third degre burn is hard or soft? - ansHard Of first, second and third degree burns which has less pain? Why? - ansThird degree burns, nerve damage has occured For what purpose do you use the rule of nines? - ansTo estimate the percentage of body surface burned; is NOT used for children. In the rule of nines, the head and neck receive _______: each arm receives_______. - ans9%, 9% In the rule of nines, the front trunk gets_____, the posterior trunk gets_____, each leg gets ______ and the genitalia gets________. - ans18%, 18%, 18%, 1% What is the only IM given to a burn patient? - ansTetanus toxoid- if they had a previous immunization; tetanus antitoxin- if they have never been immunized before (or immune globulin) How should the temperature of the water be tested if no thermometer is available? - ansDropping water on inside surface of your forearm. With which body part do you begin when bathing an infant? - ansEyes always When cleansing an infant's eye, cleanse from outer to inner canthus? - ansNo, inner to outer Should you retract the foreskin of a 5 week old male, uncircumcised infant to cleanse the area? - ansNo, not until foreskin retracts naturally and without resistance- then it should be retracted, cleansed and replaced. When sponge-bathing with tepid water the correct temp is _____________. - ans98.6 F How long does it take for the umbilical stump to fall off? - ans7 to 14 days The primary reason why an infant is draped during the bath is to provide privacy. (T/F) - ansFalse, the primary purpose of draping is to prevent chilling. You may use friction to remove vernix caseosa from an infant's skin. (T/F) - ansFalse, it causes damage/bruising What solution is commonly used for care of umbilical cord? - ans70% alcohol to promote drying (trend is toward soap and water) What cranial nerve is affected in Bell's Palsy? - ans#7, facial nerve What is the #1 symptom of Bell's Palsy? - ansOne sided (unilateral) facial paralysis Complete recovery from the paralysis of Bell's Palsy should occur in _______ to ______ months. - ans4 to 6 In addition to the facial paralysis, the sense of ______ is also affected. - anstaste Will the patient be able to close their eye on the affected side? - ansno Give three eye interventions for the client with Bell's Palsy. - ansDark glasses, artificial tears, cover eye at night As the prostate enlarges it compresses the ___________ and causes urinary ________. - ansUrethra, rentention At what age does BPH occur? - ansmen over 50 years of age What does BPH stand for? - ansBenign Prostatic Hypertrophy IN BPH the man has (increased/decreased) frequency of urination - ansincreased In BPH the force of the urinary stream is (increased/decreased). - ansdecreased The man with BPH has a _________-stream of urine - ansforked The man with BPH has hesitancey. What does this mean? - ansDifficulty starting to void Will the man with BPH have enuresis, nocturia or hematuria? - ansEnuresis-No, Nocturia-Yes, and Hematuria-Maybe Enuresis - ansinability to control the flow of urine and involuntary urination What is the best way to screen men for BPH? - ansDigital rectal exam Should fluids be forced or restricted in BPH? - ansforced What does TURP stand for? - ansTransurethral resection of the prostate The most radical prostate surgery is the ____________ prostatectomy. - ansPerineal What type of diet is used in BPH? - ansAcid Ash Acid Ash diet - ansDecrease pH (makes urine acid) Chz, eggs, Meat, fish, oysters, poultry, Bread, Cereal, Whole Grains, Pastries, Cranberries, Prunes, Plums, Tomatoes, Peas, Corn, Legumes. What is the primary purpose of a 3 way continuous bladder irrigation (CBI) after TURP? - ansTo keep the catheter clear of clots and to drain urine What solution is used for CBI? - ansNormal saline (0.9 NaCl) How fast do you run the CBI? - ansAt whatever rate it takes to keep the urine flowing and free of clots What drug is use to treat bladder spasm? - ansB&O suppositories (Belladonna & Opiates) Should you take a rectal temp after prostatectomy? Give stool softeners? - ansNo rectal temperatures, yes stool softeners You should call the MD after TURP when you see _________ thick ________, _____________ clots, and ____________ urine drainage on the dressing. - ansBright thick blood, persistent clots, persistent urine on dressing (don't call MD for transitory clots and urine on dressing.) If you see an increase in blood content of urine coming out of the catheter, you would first ___________. - ansPull carefully on the catheter to apply local pressure on the prostate with the Foley balloon. If you see clots in the tubing you would first ____________. - ansIncrease the flow-rate. What exercises should the post prostectomy patient do upon discharge? Why? - ansPerineal exercises, start and stop stream of urine, because dribbling is a common but temporary problem post op Will the post prostectomy patient be impotent? - ansIf TURP, no impotence, if perineal prostatectomy, yes impotence How often should the drainage bag be emptied? - ansEvery 8 hours What is the most common problem due to catheterization? - ansUTI What is the most common organism to cause UTI with catheterization? - ansE. coli What is the most common route for organisms to enter the blader when a catheterization is used? - ansUp through the inside of the catheter in the days following catheterization Name foods that make acid urine - ansCranberry juice, apple juice (avoid citrus juices- they make alkaline urine) What is important about the level of the urinary drainage bag? - ansNever have the bag at a higher level than the bladder. How is the catheter taped in a male client? - ansTo the lateral thigh or abdomen How is the catheter taped in a female client? - ansTo the upper thigh What urinary pH prevents UTI? - ansAcidity, low pH Should the drainage bag ever touch the floor? - ansNo Is it ok to routinely irrigate indwelling catheters? - ansNo What agents are best for catheter care? - ansSoap and water What is the most effective way to decrease UTI with catheters? - ansKeep the drainage system closed, do not disconnect junction of tubing Give some signs of infection in a Foley catheter - ansCloudy urine, foul smelling urine, hematuria Is urinary incontinence an indication for catheterization? - ansNo Give three appropriate indications for bladder catheterization? - ansUrinary retention, to check for residual, to monitor hourly output What are the top 2 diagnoses for a client with a catheter? Which is #1? - ans#1- Potential for infection; Potential impairment of urethral tissue integrity What is systole? - ansThe MAXIMAL force of blood on artery walls