AND ANSWERS
Depression0-0ans✔Express0long0term0goals0is0a0good0thing
At0first0normal0to0feel0more0energy
peripheral0arterial0disease0(PAD)0-
0ans✔Described0by0decreased0perfusion0which0indicates0poor0healing,0need0adequate
0nutrients0for0healing
Pressure0injuries0stages0-
0ans✔Stage01:0Intact0skin,0non0blanchable0with0localized0redness
Stage02:0Shallow,0open0ulcer,0pink-0red0wound0
Stage03:0Full0thick0skin0loss0with0visible0SQ0fat
Stage04:0Full0thick,0exposed0bone,0tendon,0muscle
Unstageable:0Full0thick0skin0loss,0slough,0eschar
Ventricular0Trigeminy0(PVC)0-
0ans✔Every03rd0beat0is0a0PVC0,0check0the0labs0potassium0might0need0to0be0supplem
ented
Respiredone0-0ans✔Atypical0antipsychotic,0watch0for0EPS!!0no0shaking
hyperglycemia0-0ans✔30Ps0
Polyphagia
Polyuria
Polydipsia
ACE0-0ans✔angiotensin-converting0enzyme
Angioedema,0Cough,0Elevated0Potassium
Example:0Lisinopril
A0ostomy0bag0should0be0changed0-0ans✔Every05-100days
Before0administering0intermittent0NG0feeds0-0ans✔1.0Elevate0HOB035-45
2.0Check0tube0placement0marking
3.0Confirm0tube0placement0(x0ray0and0aspirate)
4.0Bowel0sounds
,5.0Flush0with0300mL
6.0If0cramping0occurs0,0slow0the0feed0(fast0or0cold)
preeclampsia0-
0ans✔HTN,0proteinuria,0HA,0blurred0vision,0facial0edema,0oliguria,0hyperactive0DTR
Naloxone0(Narcan)0-
0ans✔opiate0antagonist,0reverses0opioid0induced0resiratory0depression
In0hospice0,0ethical0issue0because0reversing0the0effects0can0cause0severe0pain.0Asse
s0patient0to0see0AAO
tPA0(tissue0plasminogen0activator)0C/I0-0ans✔-0Give03-
4.50hours0from0onset0of0symptoms0
-0<0100,0000platelets
-0coagulation0disorder0
-0any0major0surgery0within0140days
Ezetimibe0(Zetia)0-0ans✔Zaps0away0cholesterol
Celecoxib0(Celebrex)0-0ans✔NSAID,0increases0risk0of0thrombus
Lithium0toxicity0-0ans✔Therapeutic0window00.6-1.2
QUESTION0doctors0order0for0hydrochlorothiazide0(diuretic)0,0lithium0must0have0a0bala
nce0of0water0and0sodium,0water0depletion0can0cause0lithium0to0bind0to0sodium0excess
ively0=0toxic,0watch0for0blurred0vision
Hearing0Impaired0-0ans✔-0repeat0back
-0well0lit0room
-0sit0in0front0of0client0
-0use0printed0materials
Placebo0-
0ans✔NEVER0GIVE,0if0patient0is0not0getting0pain0relief0then0notify0health0provider
Adverse0Event0-
0ans✔Something0that0is0wrong,0like0mislabeling0a0specimen,0giving0the0wrong0medicat
ion
40year0old0(preschool)0-0ans✔-0draw0a0circle
-0use0spoon0and0fork
-0walk0up0and0down0stairs
Lispro0(fast0acting0insulin)0-0ans✔Onset:0150min
Peak:0300min
Duration:030hours
Give0WITH0meals!
,SEVERE0hypoxemia0-0ans✔PaO20<0600mmHg,0report0to0the0HCP
Petechiae0on0dark0skin0-0ans✔Buccal0mucosa0and0conjunctiva
Emphysema0-0ans✔hyperinflation0of0air0sacs0with0destruction0of0alveolar0walls0—
>0lung0become0hyper0inflated0=0hyperressonance,0prolonged0expiration,0barrel0chest
**0STRIDOR0should0not0be0expected0it0indicates0respiratory0distress0and0is0a0MED0E
MERGENCY
Potassium0-0ans✔3.5-5.0
NEVER0IV0PUSH
If0given0through0a0pump0should0not0be0>0100mEq/hr
Second0degree0heart0block0(0Wenckebach)0-
0ans✔Irregular0rhythm,0increasing0PR0intervals0followed0by0a0P0wave0without0a0QRS0
complex.
NEED0transcutaneous0pacemaker
Initial0interventions0for0substernal0chest0pain0-0ans✔-0vitals
-012-lead
-0cardiac0markers,0electrolytes
-0preparation
Mechanical0valves0-
0ans✔Pt0needs0to0be0on0lifetime0anticoagulant0therapy0to0avoid0thromboembolism
Risk0for0infective0endocarditis
Need0antibiotics0for0dental0procedures
Bumetadine0-0ans✔Bumex,0loop0diuretic
"Water0pill"0give0for0pulmonary0edema
Guafenesin0(Mucinex)0-0ans✔expectorant
TORCH0-0ans✔Pregnant0women0AVOID
Toxoplasmosis,0other,0rubella,0cytomegalovirus,0herpes
ICP0-0ans✔Do0not0over0elevate0the0head,0decreases0venous0return0to0the0head
Maintain0body0in0midline
Suction0only0when0ABSOLUTELY0necessary0
NO0pillows0for0ICP
Reduce0dyspnea0in0terminally0ill0-0ans✔-opioids
-0low0flow0O2
-0comfort
-0relieve0anxiety
, Postprocedural0angina0-0ans✔**0Thrombosis0or0stent0occlusion
Restraints0-0ans✔Every0hour0keep0assessing0for0the0need0to0keep0restraints
DO0NOT0remove0because0family0is0in0the0room
Renew0order0every024
Check0CMS
WHY0do0I0need0to0do0this?0-
0ans✔Contact0provider0to0repeat0explanation0before0having0patient0sign0the0consent
Dabigatran0-0ans✔Pradaxa
-0Watch0for0signs0of0excess0bleeding
Expected0finding0of0G-tube0-0ans✔Moves00.20in0when0patient0coughs
TB0PPD0induration0-0ans✔>010mm0if0immigrant0=0ask0about0vaccine0and0x-ray
>015mm0if0no0issues
New0S30heart0sound0-0ans✔Sign0of0volume0overload,0possible0CHF
Newborn0expected0-0ans✔Respiratory0rate030-60
Glucose0<70-1000but0over040
VSD0is0not0expected0but0it0is0not0TRouBle
Hypoxia0in0toddler0-0ans✔Irritability
Vaginal0Hematoma0-
0ans✔A0client0that0just0delivered0a0term0infant0reports0persistent,0severe0vaginal0pain0
&0a0feeling0of0fullness.0What0does0the0nurse0suspect?
What0can0help0appetite?0-0ans✔Brushing0teeth0before0meals
If0patient0is0dizzy0when0walking0to0the0bathroom0-
0ans✔PRIORITY0is0assisting0patient0to0a0sitting0position
Somatic0symptom0disorder0-
0ans✔psychological0disorder0in0which0the0symptoms0take0a0somatic0(bodily)0form0with
out0apparent0physical0cause
**0limit0discussing0signs0and0symptoms
Long0acting0nitrate0-0ans✔Good0sign0is0able0to0perform0ADLs0without0chest0pain
Torsades0de0pointes0-
0ans✔Multiple0PVC's0with0rotating0ventricular0ectopic0pacemakers0(above)0are0called0
Give0Mag0IV**