Examverse

A nurse is caring for a client who is postprocedure following lumbar puncture and reports throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.) A. Use the GCS when assessing the pt. B. Assist the client to a supine position C. Administer an opioid medication D. Encourage the client to increase fluid intake E. Instruct the client to perform deep breathing and coughing exercises B. Assist the client to a supine position C. Ad...

When moving lines, which side do you want to move them to? Ventilator side Peripheral IV Line - Hollow line inserted into a peripheral vein - Used for short term administration of medications, fluids, and blood transfusions - Typically seen in UE but may be placed in feet or femoral region Infiltration - Occurs when IV is no longer within the vein and leaks into the tissue - Significant swelling and tenderness above insertion site Promote patient to keep joints near ...

What are 2 major risk factors for stress ulcers? 1. Mechanical ventilation for greater than 48 hours 2. Coagulopathy What's standard initial empiric therapy for HAP/VAP/HCAP Combination antibiotic therapy What is recommended intitial empiric therapy for treatment of candida glabrata infections? Echinocandin When should you narrow antibiotic treatment? Based off culture susceptibility reports What are the 4 FDA approved indications for recombinant Factor VIIa in ...

1 The goal of treatment for cardiogenic shock is to A. Maintain tissue oxygenation and perfusion B. Prevent bradycardia C. Increase afterload D. Increase preload A 2 The nurse notes premature ventricular contractions (PVCs) while suctioning a patient's endotracheal tube. Which action by the nurse is a priority? A. Decrease the suction pressure to 80 mm Hg. B. Document the dysrhythmia in the patient's chart. C. Stop and ventilate the patient with 100% oxygen. D. Give antidysrhy...

Why is first aid important? It is better to know first aid and not need it than to need first aid and not know it First aiders do NOT diagnose Who needs first aid? Intentional and unintentional injuries constitute a major threat to public health and are referred to as the neglected epidemic. 4 Minute delay a delay of as little as XX when a person's heart stops can mean death Value of Self Allows one to care for his or her injuries. Allows one to direct others in pro...

What is the goal of acute care physical treatment? prioritized around what the patient needs to get home safely and independently (or able for a caretaker to take care of them) What does telemetry do? -view of heart electrical activity -continuous pulse ox -intermittent blood pressure When is telemetry used? pt at high risk for cardiac events What do telemetry units provide? -data log of heart function -can alert nurses if a pt is suffering from an acute or dangerous ...

Someone w hemorrhagic stroke, discharge teaching, with pt and family, what is priority Monitor LOC, modify the environment for safety and how they should do that MED surg, cervical collar, spine XRAY taken but not read, what is our plan of action? Restrict patient to a flat position, log roll them (everything moves at same time) Admitted suspected for basilar skull fx, what gives diagnoses? Racoon eyes, periorbital edema, down at temples, battle sign Guillain Barre sharp ...

The nurse is caring for a patient who sustained a knee injury at work. The nurse explains that which diagnostic test best demonstrates soft tissue damage in the area of the injury? A. Knee x-ray B. Electromyography (EMG) C. Computed tomography (CT) D. Magnetic resonance imaging (MRI) D. MRI for soft tissue damage. x-rays and CT are helpful in determining simple and complex bone fractures. EMG is for muscle problems. A 40-year-old patient has a tight cast on the left lower leg. Wh...

The nurse is preparing the patient for a diagnostic procedure to remove a mucus plug. The nurse would prepare the patient for which test? Thoracentesis Bronchoscopy Pulmonary angiography Sputum culture and sensitivity Bronchoscopy Bronchoscopy is a procedure in which the bronchi are visualized through a fiberoptic tube. Bronchoscopy may be used for diagnostic purposes to obtain biopsy specimens and assess results of treatment, and also is used for treatment, such as removing mucu...

3 ways organisms reach lungs 1. Aspiration 2. Inhalation 3. Hematogenous 3 ways to acquire pneumonia 1. Community acquired (CAP) 2. Hospital acquired (HAP) 3. Ventilator acquired / with in the hospital (VAP) Hospital acquired pneumonia is defined as... pneumonia occurring 48hr or longer after hospitalization that wasn't present at the time of admission Ventilator associated pneumonia is defined as... pneumonia that occurs more than 48hr after endotracheal intubation...

What are the modifiable risk factors of CAD? -elevated serum lipids -hypertension -cigarette smoking -pre-diabetes or diabetes -obesity -chronic kidney disease -metabolic syndrome -diet high in saturated fat, cholesterol & calories -physical inactivity -elevated homocysteine level -post menopause What are the principles of primary health care? -public participation -health promotion -appropriate skills and technology -accessibility -intersectoral collaboration what ...

The nurse had taught the client w/ chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse determines that the client has understood the information of the if the client states it will be necessary to control which of the following? a. Diabetes Mellitus b. Alcohol Intake c. Duodenal Ulcers d. Crohn's Disease Alcohol Intake The most significant contributing factor to the development of chronic pancreatitis is alcohol ingestion. This is a st...

A nurse is on a medical-surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has an ulceration of the right heel whose blood glucose is 300 mg/dL B. Client who reports right calf pain and shortness of breath C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D. Client who has dark red coloration of left toes and absent pedal pulse B. Client who r...

A client with end-stage lung cancer and metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this client? A.Checking the restraints every 1 to 2 hours B.Releasing the restraints at least every 2 hours C.Using chemical sedation instead of restraints D.Using the most restrictive devices to prevent falls B.Releasing the rest...

Ch 1: Rapid Response Teams and safety (also called Medical Emergency Team): Team of critical care experts who... ...save lives and decrease the risk of harm by providing care to patients before a respiratory or cardiac arrest occurs. Ch 1: Rapid Response Teams and safety: Made up of... An ICU nurse, RT, Intensivist (MD), hospitalist (MD) Ch 1: Rapid Response Teams and safety: SAFETY includes... ...the incorporation of BEST PRACTICES. Ch 1: Rapid Response Teams and safety:...

What are prevention measures we can take for burns -keep small children out of the kitchen -turn pot handles away from the edge of the stove -Watch out for electrical cords attached to hot items -set your water heater to 120° -keep lighters and matches locked away not just hidden - don't use gasoline for any reason other than filling your gas tank -Don't smoke while using oxygen What is first aid for burns -Stop the burning process stop drop and roll -small burn: put affected ...

Shock What occurs when perfusion of cells and O2 delivery is inadequate? Myocardial, Valve, & Dysrhythmia-related issues What causes cardiogenic shock? Hemorrhage and other fluid losses (vomitting, diarrhea, diaphoresis, intake<output, third spacing) What causes hypovolemic shock? Allergies What causes anaphylactic shock? Sepsis & Neurogenic-related issues (infection & injury to spinal cord/brain) What causes distributive shock? Embolism, Tamponade, & ...

Prioritize evidence-based care for patients with pneumonia 1. Improve gas exchange >oxygen therapy >incentive spirometry 2. Preventive airway obstruction >thinning secretions w/ hydration >thinning secretions w/ medications >manual percussion therapy 3.Prevent sepsis 4.Prevent/manage emphysema (if applicable) Teach adults how to decrease the risk for respiratory infections 1. Avoid crowds (especially in the fall/winter when viruses are prevalent) 2.Avoid people...

What is a critical care pt? Physiologically unstable At risk for serious complications Require intensive and complicated nursing → Turning q2 Support and/or advanced technology What are anxiety indicators? High HR, agitation, high BP, behavior, vitals What are common problems of critical care pts? Anxiety Pain Communication Coping What is pain in critical care pts? Can trigger anxiety Always ask if they are in pain If unable to communicate→ look at their fac...

A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? (Select all that apply). a. Nausea and vomiting b. Hyperthermia c. Bradycardia d. Increased weight e. Decreased serum sodium f. Decreased level of consciousness a,d,e,f A nurse is caring for a child with a diagnosis of meningitis. What clinical findings indicate an increase in intracr...