ATI RN
- ANS-Bone marrow suppression (myelosuppression) leads to anemia and thrombocytopenia. ■
Nursing Actions for Anemia
☐
Keep an eye out for signs of exhaustion, pallor, dizziness, and trouble breathing. ☐
Help the client manage anemia-related fatigue by scheduling activities with rest periods in
between employing energy-saving strategies (sitting during ADLs and showers) and ☐
Give antianemic and erythropoietic medications like Epogen (epoetin alpha). medications such
as ferrous sulfate (Feosol) as prescribed.
☐
Monitor Hgb values to determine response to medications. Be prepared to administer blood
if it is required. - ANS-Mucositis, also known as stomatitis, is an inflammation of the gums,
tongue, roof, and other tissues in the mouth. floor of the mouth, and inside the lips and cheeks.
■
Nursing Actions
☐
Examine the client's mouth several times a day, and inquire about the presence of oral lesions.
☐
Document the location and size of lesions that are present. It is important to culture lesions
and reported to the provider.
☐
Glycerin-based mouthwashes and swabs should be avoided. Anesthetic, non-alcoholic
mouthwashes are recommended.
☐
Before eating, administer a topical anesthetic. ☐
Discourage consumption of salty, acidic, or spicy foods.
☐
Offer oral hygiene before and after each meal. Make use of agents that lubricate or moisturize
to combat mouth dryness. ■
Client Education
☐
Encourage the client to rinse mouth with a solution of half 0.9% sodium chloride and half
peroxide at least twice a day, and to brush teeth using a soft-bristled toothbrush.
☐
Instruct client to take medications to control infection as prescribed (nystatin [Mycostatin],
acyclovir [Zovirax]).
☐
Encourage the client to eat soft, bland foods and supplements that are high in calories
(mashed potatoes, scrambled eggs, cooked cereal, milk shakes, ice cream, frozen yogurt,
bananas, and breakfast mixes)
,- ANS-Nausea and vomiting/anorexia
■
Numerous chemotherapy medications are emetogenic (cause or induce vomiting) or anorexia
as well as an altered taste in the mouth.
■
Ondansetron (Zofran), a serotonin blocker, has been shown to be effective and is frequently
administered with corticosteroids, phenothiazines, and antihistamines.
■
Nursing Actions
☐
Administer antiemetic medications at times that are appropriate for a chemotherapeutic agent
(prior to treatment, during treatment, after treatment).
☐
Administer antiemetic medications for several days after each treatment as needed.
☐
Remove vomiting cues, such as odor and supplies associated with nausea.
☐
Implement nonpharmacological methods to reduce nausea (visual imagery, relaxation,
acupuncture, distraction).
☐
Calculate calorie intake by counting calories. Provide nutritional liquid supplements as needed.
Add protein powders to food or tube feedings.
☐
Administer megestrol (Megace) to increase the appetite if prescribed.
☐
Examine for signs of dehydration or an imbalance in fluid and electrolytes. ☐
Perform mouth care prior to serving meals to enhance the client's appetite
Encourage the use of plastic eating utensils, sucking on hard candy, and avoiding red meats
to prevent or reduce the sensation of metallic taste
- ANS-Nursing Actions for Thrombocytopenia
☐
Monitor for petechiae, ecchymosis, bleeding of the gums, nosebleeds, and occult or frank
blood in the feces, urine, or vomit ☐
Institute bleeding precautions (avoid IVs and injections, apply pressure for approximately
10 min after blood is obtained, handle client gently and avoid trauma).
☐
Administer thrombopoietic medications such as oprelvekin (Interleukin 11, Neumega)
to encourage the production of platelets. Monitor platelet count, and be prepared to administer
platelets if the count falls below 30,000/mm
3
.
■
Client Education
☐
, Instruct the client and family how to manage active bleeding.
☐
Explain to the client how to stop bleeding, including how to use an electric razor and a
soft-bristled toothbrush, avoid blowing nose vigorously, ensure that dentures fit appropriately).
☐
Instruct the client to avoid the use of NSAIDs.
☐
Teach the client to prevent injury when ambulating (wear closed-toes shoes, remove
tripping hazards in the home) and apply cold if injury occurs
- Nursing-related ANS Considerations ☐ Always ask clients whether they are allergic to sulfa.
Acetazolamide is a sulfa-based medication
___ lung expansion with age - ANS-decreased
_____ seconds is/are measured in each large box on ECG graph paper? - ANS-0.20
HSV safety precautions - ANS-contact ◯ Client Education:
■ Avoid UV and sun exposure.
■ Use mild protein shampoo and avoid harsh hair treatments.
■ Use steroid creams for skin rash.
ANS: Avoid crowds and people who are sick, as illness can precipitate an exacerbation, and
promptly report peripheral and periorbital edema and signs of infection related to
immunosuppression. ■ Educate client of childbearing age regarding risks of pregnancy with
lupus and
treatment medications.
1 cup, or 8 ounces 1 g (gram) - ANS-1000 mg
1 kg - ANS-2.2 lbs
1 oz - ANS-30 mL
1 pint - ANS-2 cups
1 quart - ANS-2 pints
1 tsp - ANS-5 mL
16 weeks gestation - ANS-can get AFP test done
16 weeks pregnant - ANS-alpha protein
17 year old having an emergency surgery. What type of consent is best to intervene? -
ANS-Verbal
1st Degree Heart Block Causes - ANS-May be normal variant; inferior wall MI; drugs: verapamil
or digoxin
1st Degree Heart Block Treatment - ANS-Monitor; Observe for symptoms
2 - Hyperglycemia
Administer sliding scale insulin or
plan for insulin to be added to the
TPN solution.
Monitor blood glucose - ANS-3 - Hypoglycemia
Inform the provider and plan to give
additional dextrose.
Monitor frequent blood glucose.
20 weeks gestation, having urinary frequency - ANS-u/a & c/s
, 24 month old - ANS-walk up steps
2nd Degree Heart Block Causes - ANS-organic heart disease, MI, Dig Toxicity, Beta and
Calcium Blockers
2nd Degree Heart Block Treatment - ANS-Monitor HR, Atropine, Temp Pacemaker, Avoid meds
that decrease conductivity
3-4 cups of milk a day for a child? - ANS-NO too much milk can reduce the intake of other
nutrients especially iron. Watch for ANEMIA
3rd Degree Heart Block - ANS-Regularity: Regular
Rate: 40-60 bpm if junctional; 20-40 bpm if focus is ventricular.
P Wave: upright and uniform; more p waves than QRS complexes
PRI: no relationship between p waves and QRS complexes
QRS: < .12 seconds if junctional; > .12 seconds if ventricular
3rd Degree Heart Block Causes - ANS-Organic Heart Disease, MI, Drugs, Electrolyte
Imbalance, Excess Vagal Tone
3rd Degree Heart Block Signs & Symptoms - ANS-Extreme Dizziness, Hypotension, Syncope,
Decrease CO, Altered Mental Status
3rd Degree Heart Block Treatment - ANS-Pacemaker (temporary or permanent)
6-8 wet diapers a day indicates? - ANS-effective breastfeeding
89% oxygen postoperative: what to do... - ANS-Change oxygen to another finger
A "twisting" polymorphic ventricular tachycardia that is observed in situations where the QT
interval has been prolonged - ANS-torsades de pointes
A 17-year-old boy is referred to a cardiologist by a primary care physician for evaluation of
recurrent spells of dizziness. During the episodes, he feels intense anxiety with palpitations and
breathlessness. He doesn't show any symptoms between episodes; he doesn't have any h/o
chest pain or syncope. Physical examination:
No abnormalities detected
Lab:
EKG: Short PR interval; wide QRS with a slurred upstroke.
Blood: Normal; Chest X ray: Normal - ANS-Wolff-Parkinson-White syndrome
A 44-year-old male complains of occasional palpitations, shortness of breath, dizziness and
chest discomfort.
Physical examination:
Pulse: Irregularly irregular
JVP: no waves with an "a" Heart sounds: variable intensity S1 with occasional S3
Lab:
EKG: Variable ventricular rate (90-190); Irregular RR intervals.
Blood: CK-MB normal
Normal ANS-atrial fibrillation on the chest x-ray A 46-year-old woman presented to the
emergency room with symptoms of lightheadedness, shortness of breath, and sudden onset of
palpitations. These symptoms began approximately 2 hours previously.
PE: BP 95/70 mm Hg
Her rest of her physical examination is unremarkable, with a heart rate of 170 beats per minute
on average. EKG: abnormal P waves; P-R intervals are within normal limits; normal QRS
complexes - ANS-supraventricular tachycardia
- ANS-Bone marrow suppression (myelosuppression) leads to anemia and thrombocytopenia. ■
Nursing Actions for Anemia
☐
Keep an eye out for signs of exhaustion, pallor, dizziness, and trouble breathing. ☐
Help the client manage anemia-related fatigue by scheduling activities with rest periods in
between employing energy-saving strategies (sitting during ADLs and showers) and ☐
Give antianemic and erythropoietic medications like Epogen (epoetin alpha). medications such
as ferrous sulfate (Feosol) as prescribed.
☐
Monitor Hgb values to determine response to medications. Be prepared to administer blood
if it is required. - ANS-Mucositis, also known as stomatitis, is an inflammation of the gums,
tongue, roof, and other tissues in the mouth. floor of the mouth, and inside the lips and cheeks.
■
Nursing Actions
☐
Examine the client's mouth several times a day, and inquire about the presence of oral lesions.
☐
Document the location and size of lesions that are present. It is important to culture lesions
and reported to the provider.
☐
Glycerin-based mouthwashes and swabs should be avoided. Anesthetic, non-alcoholic
mouthwashes are recommended.
☐
Before eating, administer a topical anesthetic. ☐
Discourage consumption of salty, acidic, or spicy foods.
☐
Offer oral hygiene before and after each meal. Make use of agents that lubricate or moisturize
to combat mouth dryness. ■
Client Education
☐
Encourage the client to rinse mouth with a solution of half 0.9% sodium chloride and half
peroxide at least twice a day, and to brush teeth using a soft-bristled toothbrush.
☐
Instruct client to take medications to control infection as prescribed (nystatin [Mycostatin],
acyclovir [Zovirax]).
☐
Encourage the client to eat soft, bland foods and supplements that are high in calories
(mashed potatoes, scrambled eggs, cooked cereal, milk shakes, ice cream, frozen yogurt,
bananas, and breakfast mixes)
,- ANS-Nausea and vomiting/anorexia
■
Numerous chemotherapy medications are emetogenic (cause or induce vomiting) or anorexia
as well as an altered taste in the mouth.
■
Ondansetron (Zofran), a serotonin blocker, has been shown to be effective and is frequently
administered with corticosteroids, phenothiazines, and antihistamines.
■
Nursing Actions
☐
Administer antiemetic medications at times that are appropriate for a chemotherapeutic agent
(prior to treatment, during treatment, after treatment).
☐
Administer antiemetic medications for several days after each treatment as needed.
☐
Remove vomiting cues, such as odor and supplies associated with nausea.
☐
Implement nonpharmacological methods to reduce nausea (visual imagery, relaxation,
acupuncture, distraction).
☐
Calculate calorie intake by counting calories. Provide nutritional liquid supplements as needed.
Add protein powders to food or tube feedings.
☐
Administer megestrol (Megace) to increase the appetite if prescribed.
☐
Examine for signs of dehydration or an imbalance in fluid and electrolytes. ☐
Perform mouth care prior to serving meals to enhance the client's appetite
Encourage the use of plastic eating utensils, sucking on hard candy, and avoiding red meats
to prevent or reduce the sensation of metallic taste
- ANS-Nursing Actions for Thrombocytopenia
☐
Monitor for petechiae, ecchymosis, bleeding of the gums, nosebleeds, and occult or frank
blood in the feces, urine, or vomit ☐
Institute bleeding precautions (avoid IVs and injections, apply pressure for approximately
10 min after blood is obtained, handle client gently and avoid trauma).
☐
Administer thrombopoietic medications such as oprelvekin (Interleukin 11, Neumega)
to encourage the production of platelets. Monitor platelet count, and be prepared to administer
platelets if the count falls below 30,000/mm
3
.
■
Client Education
☐
, Instruct the client and family how to manage active bleeding.
☐
Explain to the client how to stop bleeding, including how to use an electric razor and a
soft-bristled toothbrush, avoid blowing nose vigorously, ensure that dentures fit appropriately).
☐
Instruct the client to avoid the use of NSAIDs.
☐
Teach the client to prevent injury when ambulating (wear closed-toes shoes, remove
tripping hazards in the home) and apply cold if injury occurs
- Nursing-related ANS Considerations ☐ Always ask clients whether they are allergic to sulfa.
Acetazolamide is a sulfa-based medication
___ lung expansion with age - ANS-decreased
_____ seconds is/are measured in each large box on ECG graph paper? - ANS-0.20
HSV safety precautions - ANS-contact ◯ Client Education:
■ Avoid UV and sun exposure.
■ Use mild protein shampoo and avoid harsh hair treatments.
■ Use steroid creams for skin rash.
ANS: Avoid crowds and people who are sick, as illness can precipitate an exacerbation, and
promptly report peripheral and periorbital edema and signs of infection related to
immunosuppression. ■ Educate client of childbearing age regarding risks of pregnancy with
lupus and
treatment medications.
1 cup, or 8 ounces 1 g (gram) - ANS-1000 mg
1 kg - ANS-2.2 lbs
1 oz - ANS-30 mL
1 pint - ANS-2 cups
1 quart - ANS-2 pints
1 tsp - ANS-5 mL
16 weeks gestation - ANS-can get AFP test done
16 weeks pregnant - ANS-alpha protein
17 year old having an emergency surgery. What type of consent is best to intervene? -
ANS-Verbal
1st Degree Heart Block Causes - ANS-May be normal variant; inferior wall MI; drugs: verapamil
or digoxin
1st Degree Heart Block Treatment - ANS-Monitor; Observe for symptoms
2 - Hyperglycemia
Administer sliding scale insulin or
plan for insulin to be added to the
TPN solution.
Monitor blood glucose - ANS-3 - Hypoglycemia
Inform the provider and plan to give
additional dextrose.
Monitor frequent blood glucose.
20 weeks gestation, having urinary frequency - ANS-u/a & c/s
, 24 month old - ANS-walk up steps
2nd Degree Heart Block Causes - ANS-organic heart disease, MI, Dig Toxicity, Beta and
Calcium Blockers
2nd Degree Heart Block Treatment - ANS-Monitor HR, Atropine, Temp Pacemaker, Avoid meds
that decrease conductivity
3-4 cups of milk a day for a child? - ANS-NO too much milk can reduce the intake of other
nutrients especially iron. Watch for ANEMIA
3rd Degree Heart Block - ANS-Regularity: Regular
Rate: 40-60 bpm if junctional; 20-40 bpm if focus is ventricular.
P Wave: upright and uniform; more p waves than QRS complexes
PRI: no relationship between p waves and QRS complexes
QRS: < .12 seconds if junctional; > .12 seconds if ventricular
3rd Degree Heart Block Causes - ANS-Organic Heart Disease, MI, Drugs, Electrolyte
Imbalance, Excess Vagal Tone
3rd Degree Heart Block Signs & Symptoms - ANS-Extreme Dizziness, Hypotension, Syncope,
Decrease CO, Altered Mental Status
3rd Degree Heart Block Treatment - ANS-Pacemaker (temporary or permanent)
6-8 wet diapers a day indicates? - ANS-effective breastfeeding
89% oxygen postoperative: what to do... - ANS-Change oxygen to another finger
A "twisting" polymorphic ventricular tachycardia that is observed in situations where the QT
interval has been prolonged - ANS-torsades de pointes
A 17-year-old boy is referred to a cardiologist by a primary care physician for evaluation of
recurrent spells of dizziness. During the episodes, he feels intense anxiety with palpitations and
breathlessness. He doesn't show any symptoms between episodes; he doesn't have any h/o
chest pain or syncope. Physical examination:
No abnormalities detected
Lab:
EKG: Short PR interval; wide QRS with a slurred upstroke.
Blood: Normal; Chest X ray: Normal - ANS-Wolff-Parkinson-White syndrome
A 44-year-old male complains of occasional palpitations, shortness of breath, dizziness and
chest discomfort.
Physical examination:
Pulse: Irregularly irregular
JVP: no waves with an "a" Heart sounds: variable intensity S1 with occasional S3
Lab:
EKG: Variable ventricular rate (90-190); Irregular RR intervals.
Blood: CK-MB normal
Normal ANS-atrial fibrillation on the chest x-ray A 46-year-old woman presented to the
emergency room with symptoms of lightheadedness, shortness of breath, and sudden onset of
palpitations. These symptoms began approximately 2 hours previously.
PE: BP 95/70 mm Hg
Her rest of her physical examination is unremarkable, with a heart rate of 170 beats per minute
on average. EKG: abnormal P waves; P-R intervals are within normal limits; normal QRS
complexes - ANS-supraventricular tachycardia
