RN MILESTONE EXAM 2 NSG 0200-7 2024 UPDATE
-Chemo Side Effects - ANSo Nausea/vomiting (24-48 hr, can be delayed up to 1
week)
24 hour- Jaundice - ANSPhysiologic jaundice occurs from a normal reduction in red
blood cells. Pathologic jaundice occurs within first 24 hours of life OR persists
beyond 7 days
A client with anorexia has her friend bring her several cookbooks so she can plan a
party when she is discharged. What nursing intervention is appropriate in
addressing this behavior? - ANSDiscuss activities that don't involve food that can
take place after discharge. Discuss the cookbooks with the treatment team, and if
the treatment plan so indicates, take the books from the client.
A nurse is preparing a client for the termination phase of the nurse-client
relationship. The nurse prepares to implement which nursing task appropriate for
this phase? - ANSMaking appropriate referrals
ABG findings - ANSpH: 7.35 - 7.45
PCO2: 35 - 45 mmHg
HCO3: 22 - 26 mmHg
Acute Pancreatitis assessment - ANSHistory, ETOH abuse, severe LUQ pain, tachy,
restless, decrease bowel, jaundice, grey turner or Cullen signs, increase serum
amylase/lipase or WBC, hyperlipidemia
Acute renal failure priority - ANSo Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ANSo Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and
bronchial obstruction)
Addison's Crisis Hypoglycemia S/S - ANS- weakness
- fatigue
- severe hypotension
- nausea/vomiting
- dehydration
- dysrhythmias
- shock
ADHD Exam/Assessment - ANS- failure to listen/follow direction
- difficulty playing quietly/sitting still
- disruptive, impulsive behavior
- distractibility to external stimuli
- excessive talking
- shifting from one unfinished task to another
Aggression response - ANS5-phase cycle= Triggering (event), Escalation (movement
toward a loss of control), Crisis (loss of control), Recovery (regain control), Postcrisis
,(reconciliation)
***Hx = likely to occur again
Alcohol withdrawal - ANS- Needs to be done under medical supervision b/c can be
deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
, - Tremors, nausea, vomiting
Alcoholic hepatis teaching - ANS- low sodium diet
- small frequent meals
- no alcohol
Anxiety Suicide Risks: - ANSRestless, difficulty concentrating, irritability
- "Have you had any suicidal thoughts since starting bupropion?"
Arterial Insufficency - ANS- mostly men
- legs mostly affected
arterial insufficiency symptoms - ANS-weak pedal pulses
-shiny and cool skin
-intermittent claudication
- aching/cramping
- induced fatigue
Asthma Triggers: - ANSDust, mites, roaches, cloth, pets, horses, detergents, soaps,
food, mold, pollens, seasonal
Bizarre social behavior - ANS- assess physical needs, suicide risk, ensure safety at
all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
Boggy Uterus Actions - ANS- massage and administer uterotonic to increase uterine
contraction.
- give oxytocin
Cancer intractable pain plan of care - ANSo Pain, other symptoms and side effects
are managed based on the best available evidence, with attention to disease-
specific pain and symptoms, which are skillfully and systematically applied. ??????
Cardiomyopathy care plan - ANS○ Medications- digoxin, diuretics, antidysrhythmic,
antihypertensive medications
○ Surgery- septal myectomy, septal ablation, implanted devices (CRT, ICD,
LVAD, pacemaker), heart transplantation
Chronic Kidney Disease = metabolic acidosis - ANSkidneys fail, no longer reabsorb
HCO3 (bicarb), serum bicarbonate decrease = acidosis occurs
** sodium bicarb administration
Cirrhosis ascites dyspnea- S/S -
ANSencephalopathy portal hypertension
esophageal varices
hemorrhage
Compartment Syndrome S/S -
ANSPain Paresthesia
Paralysis
Pallor
Pulse-lessness
Hard/swollen
Muscle
-Chemo Side Effects - ANSo Nausea/vomiting (24-48 hr, can be delayed up to 1
week)
24 hour- Jaundice - ANSPhysiologic jaundice occurs from a normal reduction in red
blood cells. Pathologic jaundice occurs within first 24 hours of life OR persists
beyond 7 days
A client with anorexia has her friend bring her several cookbooks so she can plan a
party when she is discharged. What nursing intervention is appropriate in
addressing this behavior? - ANSDiscuss activities that don't involve food that can
take place after discharge. Discuss the cookbooks with the treatment team, and if
the treatment plan so indicates, take the books from the client.
A nurse is preparing a client for the termination phase of the nurse-client
relationship. The nurse prepares to implement which nursing task appropriate for
this phase? - ANSMaking appropriate referrals
ABG findings - ANSpH: 7.35 - 7.45
PCO2: 35 - 45 mmHg
HCO3: 22 - 26 mmHg
Acute Pancreatitis assessment - ANSHistory, ETOH abuse, severe LUQ pain, tachy,
restless, decrease bowel, jaundice, grey turner or Cullen signs, increase serum
amylase/lipase or WBC, hyperlipidemia
Acute renal failure priority - ANSo Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings - ANSo Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and
bronchial obstruction)
Addison's Crisis Hypoglycemia S/S - ANS- weakness
- fatigue
- severe hypotension
- nausea/vomiting
- dehydration
- dysrhythmias
- shock
ADHD Exam/Assessment - ANS- failure to listen/follow direction
- difficulty playing quietly/sitting still
- disruptive, impulsive behavior
- distractibility to external stimuli
- excessive talking
- shifting from one unfinished task to another
Aggression response - ANS5-phase cycle= Triggering (event), Escalation (movement
toward a loss of control), Crisis (loss of control), Recovery (regain control), Postcrisis
,(reconciliation)
***Hx = likely to occur again
Alcohol withdrawal - ANS- Needs to be done under medical supervision b/c can be
deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
, - Tremors, nausea, vomiting
Alcoholic hepatis teaching - ANS- low sodium diet
- small frequent meals
- no alcohol
Anxiety Suicide Risks: - ANSRestless, difficulty concentrating, irritability
- "Have you had any suicidal thoughts since starting bupropion?"
Arterial Insufficency - ANS- mostly men
- legs mostly affected
arterial insufficiency symptoms - ANS-weak pedal pulses
-shiny and cool skin
-intermittent claudication
- aching/cramping
- induced fatigue
Asthma Triggers: - ANSDust, mites, roaches, cloth, pets, horses, detergents, soaps,
food, mold, pollens, seasonal
Bizarre social behavior - ANS- assess physical needs, suicide risk, ensure safety at
all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
Boggy Uterus Actions - ANS- massage and administer uterotonic to increase uterine
contraction.
- give oxytocin
Cancer intractable pain plan of care - ANSo Pain, other symptoms and side effects
are managed based on the best available evidence, with attention to disease-
specific pain and symptoms, which are skillfully and systematically applied. ??????
Cardiomyopathy care plan - ANS○ Medications- digoxin, diuretics, antidysrhythmic,
antihypertensive medications
○ Surgery- septal myectomy, septal ablation, implanted devices (CRT, ICD,
LVAD, pacemaker), heart transplantation
Chronic Kidney Disease = metabolic acidosis - ANSkidneys fail, no longer reabsorb
HCO3 (bicarb), serum bicarbonate decrease = acidosis occurs
** sodium bicarb administration
Cirrhosis ascites dyspnea- S/S -
ANSencephalopathy portal hypertension
esophageal varices
hemorrhage
Compartment Syndrome S/S -
ANSPain Paresthesia
Paralysis
Pallor
Pulse-lessness
Hard/swollen
Muscle
