ATI Fundamentals/Leadership & Mngmt.

/Maternal Newborn/Med-Surg

Question Answer
Joint Commission, State boards of Nursing,
Name the health care regulatory agencies.
& FDA
American Nurses Association (ANA) & National
League of Nursing (NLN) are professional ____ Nursing
organizations?
___ health care involves the provision of
Tertiary
specialized and highly technical care?
What are 3 examples of tertiary care? ICU, Oncology treatment center, Burn center
Cardiac rehabilitation and home health care are
Restorative
both examples of ___ care?
An older adult who states "it is difficult to prepare
nutritional balanced meals at home for just
Social worker
myself", should be referred to which member of
the health care team?
Who can assist clients who have physical
challenges to use adaptive devices or methods to
Occupational therapist (OT)
help the patient to actively participate in self-care
activities?
A registered dietician can help a patient choose
nutritional needs, but they cannot help the patient Physical limitations
with _____ _____?
True or False: CNA's are able to assist the patient
in understanding medication side effects and False
determine pain level.
True or False: CNA's can assist patients with
ADL's such as bathing, toileting and ambulation,
True.
as well as measuring and recording information
such as vital signs and intake and output.
What is the right to make own decisions? Ex.
Autonomy
patient refuses surgery
What is characterized by taking action to help
others? Ex. nurse offers pain med to client before Beneficience
ambulating
What is characterized by fairness in care delivery
and use of resources? Ex. nurse explains all
Justice
clients waiting for kidney transplant must meet
the same criteria
What is the act of avoiding harm or injury? Ex. Nonmaleficence
nurse questions med prescription she believes is
too dangerous for an older adult client
Which tort can make a patient fearful and
apprehensive? Ex. AP tells patient, "If you don't
Assault
stop peeing everywhere, I am going to put a
diaper on you."
The patient can only choose any ___ adult to be
their health care proxy for an Advanced Competent
Directive- does not have to be family member.
True or False: Staff must ask patient if they have
True
an Advanced Directive.
Nurse should provide ________ if a patient does
Written documentation
not have an Advanced Directive.
True or False: A patient must seek provider
False
approval before submitting Advanced Directive.
Making sure the surgeon obtained client consent
and witnessing the client's signature on the form
Informed consent
are the only obligations a nurse has regarding
which legal responsibility?
As required by law, what must a nurse who
notices behavior that could jeopardize client care
Report observations to nurse manager
or could possibly indicate a substance abuse
disorder immediately do?
Any current problems, change, incidence or
consultations that may require modification
What information should be included in a change- of a client's care. Ex. Bone scan scheduled
of-shift report? this afternoon, patient missed PT this
morning, patient dressing falls off when
ambulating out of bed.
Have another nurse listen to telephone
conversation, repeat prescription details back
How to properly receive a provider's prescription
to provider, and obtain provider's written
over the phone?
signature on the actual prescription within 24
hours.
A condom catheter is a ____ procedure and can
Non-invasive
be performed by an AP.
Right supervision, evaluation, direction and
Delegation
communication are a part of the 5 rights of __?
Post-surgery patients must be managed by a(n)? RN
At time of evaluation, the nurse gathers
information about the client and identifies that the
Reasses
desired client outcome (ex. pain relief) is not
successfully met. What is the nurse's next step?
How do you assess/reassess pain? Pain scale
___ data is what the nurse observes and
Objective
measures?
Tachycardia, HTN, and no temperature
increase, patient not adherent/refuses to
What are some patient characteristics that imply perform suggested pain interventions (Ex.
pain management may not be adequate? cough, deep breathe, dangling), & only
accepts pain med either at or over the regular
4 hour PRN interval.
True or False: Easily agitated patients indicate False. This alone is not a single identity of
they are experiencing pain. pain.
Sudden tenderness or swelling of a lower
extremity on a 24 hour post op abdominal surgery
patient likely suggests a new problem, such as Deep vein thrombosis (DVT).
___, and is not an indicator of inadequate pain
relief.
Dysphagia is the greatest risk related to a patient's
nutrition evaluation because it increases the risk Aspiration
for __?
Older Adults (unfamiliar surroundings = fall
Unfamiliar surroundings upon admission to the
risk) Orient the patient to his/her room.
hospital is the greatest risk factor for what age
(before leaving, teach how to use call light
client? What should be the priority NI?
and other equipment at bedside)
Providing information about Advanced Directives
Admission
is done at ___?
When does patient discharge planning start? Admission
True or False: If applicable, a client should be
introduced to their roommate upon admission to True
the hospital to decrease stress.
True or False: You should ask about organ
False. This could instill unnecessary fear.
donation at time of hospital admission.
Cognitive status (LOC) along with needed
information related to patient medications,
alternative therapies, prescribed diets, allergies, or Transfer report
psychological issues pertinent to possible prompt
intervention should be included in the ___ ___?
Where to go for follow-up care & written
instructions for diet/medications (Ex. Names
What should be included in the discharge
and contact information of health care
summary for a patient who is going home? (Ex.
provider and community resources,
Post-op knee arthroplasty)
analgesics or anticoagulants, how to avoid
post-op constipation)
A patient is being discharged from the hospital to Patient diagnosis, last recorded vital signs,
another provider who will then take over client
need for special equipment & advanced
care. (Ex. Long-term facility). What additional
directive status. (Necessary since a new
information should be included in the transfer
provider will be taking over medical care)
report?
Nursing intervention for a patient who is about to
Place a mask on the client to limit the spread
have a surgical dressing change and is
of pathogens into the wound bed.
experiencing coughing and sneezing?
Before. The outside of the bottle itself is
A sterile solution should be prepared before or considered contaminated; therefore, touching
after you put on sterile gloves? Why? the outside of the bottle once sterile gloves
are applied will breach sterile technique.
Approximately what length of the sterile drape
1 inch
edges/borders is considered non-sterile?
True or False: The inner wrapping of an item on a
True
sterile field is considered sterile.
True or False: An irrigated syringe on the sterile
True
field is considered non-contaminated/sterile?
Which flap on a sterile field should be unfolded
The top flap farthest from the body.
first?
Wash hands with soap and water for at least ___?
If hands are soiled, wash hands with soap and
water for at least ___. What water temperature 15 seconds. 2 minutes. Warm. Paper towel.
should be used? Use clean ____ to turn off faucets
and dry hands.
Delayed procedures, nurse moves/looks
away from sterile field, hand brushes against
What are some actions that are recognized as
1" borders of sterile field, & dropping or
decontaminating a sterile field and should not be
placing a contaminated or non-sterile item on
done?
the sterile field (Ex. Cotton ball moistened
with sterile normal saline).
Prior to sterile procedure, the nurse prepares any
necessary solutions. Next, a pair of sterile gloves
is applied. After opening gloves and verifying that Non-dominant hand
the glove cuffs are directed toward the body,
which hand is used to apply the first sterile glove?
Stage of infection where acute signs and
Convalescence
symptoms have faded?
Stage of infection where non-specific clinical
Prodromal
manifestations occur?
Stage of infection where specific clinical
Illness
manifestations related to the illness occur?
Patient reporting severe sore throat, pain when Illness
swallowing and swollen lymph nodes is
experiencing which stage of infection?
Linear clusters of fluid-containing vesicles with
Herpes Zoster
some crust is indicative of what?
A pink body rash can indicate ___? Allergic reaction
Red edematous rash bilateral on the cheeks
Systemic lupus eythematosus (SLE)
(butterfly rash) can indicate ___?
False. Full side rails may put the client at
True or False: To decrease fall risk, bed should be
greater risk for fall because he may try to
in lowest position and full side rails should be up.
crawl over the rails.
_____ footwear helps the client from slipping? Non-skid
____ serves as the basis for an individualized plan
of care and is the priority action to determine the Fall-risk assessment
degree of patient's risk for fall?
Family should smoke outside. Do not use
nail polish or other flammable materials. "No
Discharge teaching for using oxygen at home
Smoking" sign on front door and even on
should include?
bedroom door. Wear cotton materials. Have
fire extinguisher ready and available.
Wool and synthetic materials create _____ and
Static electricity
should be avoided with oxygen therapy?
Carbon monoxide poisoning is so dangerous
because it combines with ___ in the body and Hemoglobin
ultimately reduces oxygen perfusion?
Signs and symptoms of a patient who has had a
Hypotension, tachycardia, tachypnea and
heat stroke include what vital sign and
hot, dry skin.
temperature changes?
A patient receiving enteral tube feedings due to
Semi-Fowler's (HOB 30 degrees)
dysphagia should be placed in what position?
Which patient position allows for chest expansion
by sitting on the side of the bed and resting arms Orthopneic
over pillows placed on bedside table?
Request assistance when repositioning client.
Lower center gravity for stability. Bend at
the knees and spread feet apart. Hold lifted
How to prevent injury with staff nurses?
objects as close as possible. Use smooth
movements. Take breaks from every 15-20
minutes from repetitive movement.
When sitting for long periods of time, how should
Slightly above hips.
you position your knees?
A client with appendicitis needs immediate ____ Appendectomy
to prevent rupture of the appendix and subsequent
peritonitis? These patients cannot be discharged
in event of mass casualty or disaster.
Close all client doors, shutters and drapes.
Place blankets over clients who cannot
Nursing intervention in the event of a tornado? ambulate and move all beds away from
windows. Ambulatory clients should be told
to go in to the hallway, away from windows.
Listen for background noises to determine
location of caller. Try to stay on line as long
Nursing intervention in the event of a bomb as you can, asking questions to obtain
threat? information and call-tracing. Do not
announce overhead unless you are an idiot
who wants to stir mass chaos.
Testicular, blood pressure, BMI, & cholesterol
20 years old
tests begin at what age?
Between 40-50 years old, females should have
Mammogram
what annual routine screening?
When the client is able to demonstrate the
appropriate technique, ___ learning has taken Psychomotor
place?
Following a nurse education session, a client
states her previous ideas have changed and she
Affective
will be willing to adjust to suggestions given in
teaching. This is an example of ___ learning?
Rolling from back to front, bearing weight on
legs, and sitting unsupported are expected gross
6-9 months
motor development findings on what infant
age(s)?
Parents should remove gyms and mobiles by what
4 months
age?
True or False: Make sure balloons are fully False. Toddlers should not play with
inflated for a toddler. balloons at all.
Building simple models is an appropriate play
School-aged children
activity for what age group?
Both playing and looking at books and filling and
empyting containers are appropriate play Toddlers (1-3 years old)
activities for what age group?
When should a children switch from whole milk
2 years old
to low-fat or fat free milk?
A child who builds a 2- block tower and uses a
cup well are expected fine motor skill findings of 15 months
what age?
Rule of thumb: ___ tbsp. of solid food is given 1 (Ex. 2 tbsp. for a 2 year old)
per year of age?
Pretend play helps children determine difference
between reality and fantasy and is commonly Preschool (4-5 years old)
observed with what age group?
Preschoolers enjoy mastering tasks they can
Ask child if they want to help with received
perform independently. What is a NI related to
care (Ex. mealtime activites). Parents can aid
decreasing fear of the hospital? What can parents
by bringing a favorite toy from home.
do to help?
True or False: When providing care to the False. The nurse should try to avoid
preschool patient, the nurse should cluster clustering invasive procedures. Preschoolers
invasive procedures and only assign staff have less anxiety than toddlers, so no need to
members that the client prefers. prioritize this intervention.
Modeling with clay is an appropriate play
Preschooler (4-5 years old)
intervention for what age child?
___ is developed in school-age children? Privacy
What is the lateral curvature of the spine which in
most cases, has no apparent cause? Most common
in what gender? What age is the complication Scoliosis. Females. Adolescents.
most noticeable, therefore urging recommended
screenings?
Provide non-violent videos to watch. Allow
Appropriate interventions for an adolescent with
flexibility in schedule. Allow patient to
multiple fractures?
perform his own morning care.
Where is the first sign of sexual maturation in
Enlarged testes & scrotum.
boys located?
Wear helmet while skiing. Have a carbon
What are some safety precautions for young
monoxide detector in the home. Secure
adults (20-35 years old)?
firearms in a safe location.
In middle adulthood, ___ vision declines? Near (Presbyopia)
Metabolism declines and weight gain is likely
Middle adulthood (35-65 years old)
with what age group?
In middle adulthood, secretions of bicarbonate
and gastric mucus begin to decrease and persist
Peptic ulcer disease (PUD)
into older adult. This increases the risk for a
person to develop ___?
Middle adults focus on searching and developing
Intimate
____ relationships?
Subjective data related to older adult patient's Eat alone, new medication(s), 24 hr. recall,
recent weight loss changes includes? & fixed income. (Ex. "Do you eat alone or
with somebody?", "Have you started any
new medication over the last 6 months?",
"What foods have you eaten in the last 24
 hours?", "Are you on a fixed income?")
Lower iron required (after menstruation),
increase fluid intake (prevent dehydration
Nutritional/supplemental teaching for an older and constipation). increase calcium (prevent
adult patient should include? osteoporosis), limit sodium intake (prevent
edema and HTN), & increase fiber (prevent
constipation).
When a nurse is introducing herself in the first
step of a comprehensive physical examination, "What do you prefer to be called/answer to?"
what question should the nurse ask the patient?
Use a mix of open and close-ended
What strategies should a nurse use after questions, reduce noise to promote a calm
introducing herself in the initial phase of a and quiet environment, and perform the
comprehensive physical examination? general survey before the examination
portion.
Obtain _____ before initiating antimicrobial
Culture specimens
medication?
Obtain culture specimen before initiating
Patient is restless and skin is warm. VS indicate
antimicrobial medications. Encourage the
increased temperature, tachycardia and tachypnea.
client to limit activity and rest. Assist patient
What are appropriate nursing interventions?
with frequent PO hygiene.
Patient with low platelet count has an increased
Bleeding
risk for ____?
A patient with a fractured femur has a blood
pressure reading of 140/94 with no history of Ask patient if they are in pain.
HTN. NI?
True or False: An LPN can obtain VS on a patient
who is 2 hours post-op following a cardiac True
catheterization.
What should the RN do if newly hired AP have Ask the AP's if they need help completing
not calculated I&O on several clients? I&O records.
What provides the most relevant information
Variance/ Incident report
regarding the effectiveness of a procedure?
What strategy is used if a manager does not
Avoidance
intervene even when conflict escalates?
Patient states he is going to leave hospital. Should
No, not immediately.
the nurse notify risk manager immediately?
If patient leaves without discharge, what should Client left facility "against medical advice"
the nurse document? (AMA).
True or False: Most facilities do not have a form
for patients to sign if they choose to leave before False
discharge.
Acceptable or Unacceptable: Reviewing health
Unacceptable
care record of client assigned to another nurse.
Acceptable or Unacceptable: Making a copy of
Unacceptable
lab values to give to provider during rounds.
Acceptable or Unacceptable: Providing
information about a client's condition to a hospital Unacceptable
clergy.
Acceptable or Unacceptable: Discussing client
condition over the phone with an individual who Acceptable
has provided the client's information code.
Acceptable or Unacceptable: Participate in
walking rounds that involve exchange of client Unacceptable
related information outside the patient's room.
In regards to advances directives, what should the
Contact a representative to talk with the
nurse do if a client states he is too young to worry
client about advanced directives and offer
about life-sustaining measures and does not need
additional information.
the information?
Verifying that a client understands what is done
during a cardiac catheterization, informing health
care team members about a DNR status and
Advocacy
reporting failure of fellow staff members to
provide care are examples of which nursing role
of?
____ is a document that addresses and outlines
Patient Care Partnership
clients' rights when receiving care?
What resource should a newly licensed nurse
access to review procedure and standards prior to Institutional policy and procedure manual
inserting IV catheter on a patient?
Use a ____ knot to tie restraints to the bed frame? Quick-release
Ensure that the restraint is loose enough for ROM
2
and can fit ___ fingers between device and client?
History of previous fall. Reduced vision.
What factors can increase a patient's risk for falls?
Impaired memory. House slippers. Kyphosis.
Patient brought back to unit after total hip Apply arm and leg restraints immediately.
arthroplasty. Confused, moving leg in ways that Get order from provider. Have family
could cause dislocation with multiple attempts to member sign restraint consent form. Use a
get out of bed. What actions should the nurse quick-release knot tied at bed frame. 2
take? fingers can fit between client and device.
True or False: A description of the incident
should be documented in the client's health care True
record.
Incident reports should/should not be shared with Should not
the client?
___ includes a description of the incident and
Incident report
actions taken?
Who investigates the incident/incident report? Risk management department
A hollow, drum or bell-like sound that is
commonly auscultated over a pneumothorax or a Tympany
distended abdomen?
Tympany over a pneumothorax is heard if the
Free air
chest contains ___ ___?
When auscultating at the apex of the heart, the
nurse understands she is hearing S1 sounds,
Tricuspid and mitral valve
which is also identified by the closing of which
two valves?
Bruits are indicative of what unexpected finding? Narrowed blood vessels
What sound results from the rubbing together of
Friction rub
inflamed peritoneum layers?
True or False: Capillary refill <2 second, thick
skin on the soles of the feet and numerous light
True
brown macule on the face are normal skin
findings.
An abnormal color finding of nail beds indicative
Pale
of anemia and/or impaired circulation is ___?
What are some explanations for finding
Loss of adipose tissue, dehydration &
significant skin tenting over an older adult's
diminished skin elasticity.
forearm?
A form of therapeutic communication used that
focuses back on the patient? Ex. A client states, "I Reflecting Ex. In response, the nurse says,
have to check with my wife and see what she "How do you feel about going home today?"
thinks about be being discharged today."
How should the nurse sit to facilitate effective
At eye level facing the patient.
communication?
True or False: The nurse should not talk about
True
family to the interpreter while family is present.
True or False: When involving an interpreter, the
nurse should look at the family and ask one True
question at a time using lay terms.
True or False: It is ok for the nurse to interrupt
conversation between the interpreter and the False
patient.
A Jehova's Witness desperately needs a blood Involve the patient's religious and spiritual
transfusion but based on religious and spiritual leaders. Discuss alternative forms of blood
motives, he will not accept the treatment. How products and try to compromise with an
should the nurse respond to this? acceptable plan for all.
Highest priority nursing intervention to prevent Frequently clean the client's perineal area
infection with indwelling urinary catheter? and provide catheter care.
Inspect feet daily, use moisturizing lotion-
Patient teaching related to diabetes foot care NOT between the toes, wash with lukewarm
should include what important criteria? water, dry thoroughly, check shoes for any
foreign objects, avoid any OTC medications.
Brush the dentures with a toothbrush and
How should the nurse care for dentures?
denture cleaner.
Periods of ___ warrant a prompt referral for
Apnea
diagnostic sleep studies?
A ____ diet consists of foods that are low in fiber
and easy to digest. What are some appropriate Low-residue. Dairy products & eggs.
food examples?
Nursing interventions to reduce the risk of
thrombus development include applying ____ Elastic stockings. Change position.
____ and assisting client to ____ ____ often?
What is a cardiac complication related to
Orthostatic hypotension
immobility?
A respiratory complication related to immobility
is decreased respiratory movement. As a result,
Atelectasis & Hypotension pneumonia
this can progress in to two severe respiratory
complications known as _____ and _____?
Universal symptoms commonly indicative of pain
Nausea & Vomiting
include ____ and ____?
A nurse is monitoring a patient receiving opioiod
Nausea, vomiting, bradypnea (respiratory
analgesia for adverse effects. What adverse
depression), urinary retention, constipation,
effects should the nurse anticipate? Hint:
orthostatic hypotension (dizzy, light-headed)
Symptoms effect GI, GU and cardiac systems.
True or False: Massage therapy and therapeutic
True
touch require special licensure or certification.
What are 3 complementary and alternative
therapies that a nurse should encourage nursing Guided imagery, meditation & music therapy
students to use while providing patient care?
What are expected findings for a patient who has Dehydration resulting in hypotension, fever,
had prolonged diarrhea? and poor skin turgor; tachycardia
Losing control of urine whenever coughing,
laughing or sneezing is indicative of which type Stress
of incontinence?
What should the nurse instruct the patient to avoid
in an effort to control/eliminate stress Avoid caffeine and alcohol.
incontinence?
Should the Crede maneuver be used to manage No. This is used for reflex incontinence
stress incontinence? (involuntary loss).
What loop diuretic can cause ototoxicity (hearing
Furosemide (Lasix)
loss) and blurred vision?
Always keep hearing aids dry. Clean molds
A client who just started wearing hearing aids with soap and water. Keep volume on the
requires education. What should be included with lowest effective setting. Take batteries out of
hearing aid instructions? hearing aids when removing at night to
conserve battery power.
____ is the best medication choice for rapid onset
of pain because it is immediately absorbed into
IV Morphine
the bloodstream and provides immediate
response?
It is recommended to administer irritating meds
with what, to assist in prevention of N/V and
Small amounts of food.
ability to retain the medication and achieve its
therapeutic effect?
Window allotted for administering medication? 30 minute window
Cool, pale, swollen skin. IV rate slows or
What will you see if IV has infiltrated?
stops. Damp IV dressing. Pain.
Warm, red, swollen skin. Pain, chills and
What will you see if IV has phlebitis/cellulitis? "does not feel well". Induration and red
streak on arm near the IV site.
Basic signs and symptoms of FVE? Tachycardia, HTN, SOB & edema.
Proper needle angle for starting an IV? 10-30 degrees
Nursing intervention if patient IV has
Stop infusion & remove catheter.
phlebitis/cellulitis?
Antipsychotic used to treat schizophrenia? What haloperidol (Haldol). Extrapyramidal
is a serious side effect of this medication? symptoms (EPS).
Examples of extrapyramidal symptoms (EPS) Fine motor tremors, acute dystonia,
include? uncontrollable restlessness, drooling
Priority assessment prior to giving new
Allergies
medication?
True or False: To promote adherence with
medication administration to older adult clients, True
pills should be placed in daily pill holders.
To promote adherence with medication
administration to older adult clients, ___ forms
Liquid
should be provided if patient has difficulty
swallowing?
True or False: To promote adherence with True
medication administration to older adult clients,
relatives can be asked to assist periodically.
To promote adherence with medication
administration to older adult clients, medication Easy
containers should be ____ to open?
Diuretics, Corticosteroids and Antipsychotics can
Glucose
cause the body to have an elevated ____ level?
What are 3 key factors to assess patient's ability to
Finger dexterity, visual acuity and
learn self-monitoring of blood glucose using a
demonstration ability.
glucometer?
Restlessness, confusion, pallor, tachycardia,
Early signs of hypoxemia?
tachypnea, & HTN.
Stupor, cyanosis, bradycardia, bradypnea,
Late signs of hypoxemia?
hypotension & cardiac dysrhythmias.
While withdrawing catheter. No routine
Guidelines to endotracheal suctioning. When to
suctioning. Sterile technique. Use new
apply suction? Routine suctioning? Asepsis used?
catheter for each suction attempt (limited to
When to use a catheter?
2-3 attempts).
True or False: Petroleum jelly should be applied
False
for patient with oxygen therapy via nasal cannula.
True or False: Remove nasal cannula at meal
False
times with oxygen therapy?
Diabetes Mellitus places a client at risk for Impaired circulation & immune system
impaired ____ & ____? function
Emesis and transmission from a client's
contaminated hands are identified as ____ Direct contact (person-to-person)
contact?
Urinary incontinence, acute confusion and
agitation are atypical signs and symptoms of ____ Infection
in an older adult patient?
Constant HA, nuchal rigidity, photophobia,
Signs and symptoms of bacterial meningitis?
fever, chills, altered LOC, red macular rash,
What precautions are taken with these clients?
elevated WBC count. Droplet precautions.
What diagnostic(s) identify IICP? CT or MRI
Adrenal insufficiency, DKA and ascites are all
Hypovolemic
risk factors for ___ shock?
Heart failure is a risk factor for ___ shock? Hypervolemic
Cool, clammy skin, hypotension,
Expected findings with hypovolemia?
tachycardia, decreased skin turgor, syncope
Determine decreased/increased lab results that Increased Hct, Increased serum osmolality,
indicate dehydration: Hct, Serum osmolarity, Increased sodium, Increased urine specific
Sodium, Urine specific gravity and Creatinine gravity & Increased creatinine.
What fluids should be administered to a patient
Hypotonic fluids
with hypernatremia?
What medication is given for the treatment of
sodium polystyrene sulfonate (Kayexelate)
hyperkalemia?
A patient with hypercalcemia is at risk for ____
Pathologic fractures
____?
Nursing intervention for patient receiving enteral
Decrease the rate of feeding.
feeding with diarrhea?
Goal of managing dumping syndrome is to slow
Peristalsis
the rate of ____?
A client with a chest tube reports a burning
sensation/pain in his chest, indicating that the
Occluded.
chest tube is resting against tissues and has
become ___?
To move the tip of a chest tube away from the
tissues (occlusion) what should be the nurses Assist the client to a side-lying position.
priority intervention?
What is the therapeutic serum lithium level? This
medication is given to treat what mental health 0.8-1.4. Bipolar disorder.
disorder?
To reduce the risk of painful stimuli, how should
Warmed to room temperature.
ear drops be prepared prior to administration?
It is important to remember that the ear is
Temperature
sensitive to extremities in ___?
___ precautions include placing the client either
in a private room or with other clients who have
Droplet (Ex. rubella)
the same disease, as well as using of a mask when
providing care?
Sickle cell anemia patients often have ___ Hct
Low
levels?
A sickle cell pain crisis patient displays slurred
speech. The nurse understands this is a medical
emergency because the blockage of blood vessels CVA
in the brain by sickle cells results in ___, which
ultimately leads to neurological impairment?
___ is the bronchodilator medication that should
be administered first to open the airways of a Albuterol
patient diagnosed with asthma?
True or False: A written prescription from the
provider is necessary to legally change the client's True
code status to a DNR.
What is a decrease in neutrophils, resulting in a Agranulocytosis. Decreased WBC count.
reduced ability to fight infection and can cause
death? This adverse effect can be seen in what lab
value?
What are three adverse effects seen across Seizures, agranulocytosis & orthostatic
Antipsychotics? (Ex. clozapine (Clozaril)) hypotension.
Abdominal distention present at birth is indicative
Tumor or an abdominal wall defect.
of a ____?
A patient with an NG tube to suction is at
Hypokalemia
increased risk for which electrolyte imbalance?
A nurse should teach a client scheduled for a
lumbar puncture that a post-procedure Headache
complication is ___?
Initial HIV symptoms are often similar to the
Flu
___?
What should be the nurse's priority goal if abuse
Protect patient from further abuse.
is suspected?
Condoms are used which what type of lubricants? Water-soluble
Contraceptive patches are replaced how often? Once a week
How often should spermicide be applied? Every time that the patient has sex.
What are some common side effects of oral
Amenorrhea, weight gain, breast tenderness,
contraceptives that usually subside after a few
mild HTN & headache.
months of use?
An IUD can cause irregular vaginal bleeding and
Ectopic pregnancy
increases the risk for what complication?
True or False: A change in the length of the string
of an IUD may indicate expulsion and should be True
reported to the provider.
An adverse effect of medroxyprogesterone (Depo-
Provera) is loss of ___ ___? To prevent, the
Bone density. Calcium and Vit-D.
patient should be instructed to also take what 2
things?
True or False: A male patient who has a
vasectomy is a permanent contraceptive method. False. Sexual function is not impaired.
Sexual function will be slightly altered.
A prenatal client who does not like milk inquires
about other potential foods she could eat to
Dark green, leafy vegetables
consume a good source of calcium . What should
the nurse recommend?
Maternal HTN, blunt abdominal trauma, cocaine
and cigarette use are risk factors associated with Abruptio placenta
what maternal-nb complication?
____ is manifested by lower quadrant pain with or Ectopic pregnancy
without bleeding in a prenatal patient?
To promote lung maturity when delivery is
Why is Betamethasone (Celestone) given?
anticipated.
What medication is prescribed for the client
Methylergonovine (Methergine)
experiencing postpartum bleeding?
Contraindications for pregnant woman with HIV+ Episiotomy, vacuum extraction, forceps, and
include? internal fetal monitoring.
What are 3 risk factors for hyperemesis Obesity, multifetal pregnancy & migraine
gravidarum? HA
RR <12, UO <30 mL/hr, absent patellar deep
Signs of magnesium sulfate toxicity?
tendon reflex, & decreased LOC.
What is the antedote for magnesium sulfate? Calcium gluconate
True or False: Magnesium sulfate is used for
False
dilation > 6 cm.
True or False: Magnesium sulfate is used for
True
preterm labor.
True or False: Magnesium sulfate is used for
True
severe gestational HTN.
True or False: Magnesium sulfate is used for
False
vaginal bleeding.
True or False: Magnesium sulfate is used for
False
acute fetal distress.
A prenatal client with premature rupture of
membranes should be instructed to keep a daily Fetal kick counts
record of ___?
What stage and phase of labor is a patient in who
has contractions lasting 30-45 seconds apart and Stage 1- Latent Phase
appear relaxed, eager and talkative?
Stage 1 active labor is determined by dilation of
___ cm. and contractions lasting 40-70 seconds 4-7 cm.
apart?
Stage 1 transition phase of labor is a patient who
is dilated 8-10 cm. and has contractions lasting for 45-90 seconds apart
how long?
What phase of labor shows signs of irritability
Transition phase
and rectal pressure?
The second stage of labor is characterized by
Expulsion of the fetus.
what?
A nurse determines a large gush of blood from a Umbilical cord prolapse.
patient's vagina is amniotic fluid. The nurse
knows the priority intervention is to monitor the
FHR for signs of distress because the greatest risk
to both the mother and fetus at this time is ___?
A prenatal client with ruptured membranes and
leaking fluid for over 24 hours is a great risk for Infection
___?
____ ____ to the lower back relieves the pressure
exerted on the pelvis and spinal nerves by the Sacral counter-pressure
fetus in persistent posterior position?
Maternal hypotension can occur following an
epidural block and can be offset by administering IV fluids
______?
Lidocaine (Xylocaine) is administered to a patient
expected to deliver in 20 minutes for pain relief,
episiotomy, and expulsion of the fetus. The nurse Pudenal block
understands this type of regional anesthesia is a
____ block?
____ blocks are administered during labor and
allow the client to participate in the second stage Epidural
while remaining comfortable?
Spinal blocks are administered in the late second
Cesarean birth
stage but most commonly preceding what?
A client in labor and delivery is using patterned
breathing and reports numbness and tingling of
Place oxygen mask over the client's nose and
the fingers. The nurse understand the patient is
mouth or have client breathe into paper bag.
experiencing hyperventilation and should should
perform what following action?
A patient in labor experiencing incomplete uterine
relaxation between hypertonic contractions results Fetal hypoxia
in ___ ___?
True or False: Inadequate uterine relaxation
False. Precipitous labor.
occurs with prolonged labor.
What position can the patient assume to help the
fetus rotate from a posterior to an anterior Hands and knees
position?
The supine position with a rolled towel under one
Vena cava syndrome
hip can assist in preventing what?
What is a potential complication for a fetus in a
Prolapsed umbilical cord
breech presentation?
True or False: Breech presentation is more likely
True
to cause prolonged labor.
True or False: A postterm neonate is at increased
False. Hypoglycemia.
risk for hyperglycemia.
True or False: A postterm neonate is at increased
True
risk for aspiration of meconium.
True or False: A postterm neonate is at increased
False. Oligohydramnios.
risk for polyhydramnios.
The monitor reveals a FHR of 80-85 bpm. The
nurse performs a vaginal examination and notices
clear fluid and a pulsing loop of umbilical cord in Call for help.
the client's vagina. What should the nurse do
immediately?
A nurse is caring for a client and observes
meconium-stained amniotic fluid upon rupture of
Suction the infant's mouth and nose using a
the client’s membranes. What actions should the
bulb syringe.
nurse take if respiratory efforts are strong and
FHR is >100 bpm?
A nurse is caring for a client and observes
meconium-stained amniotic fluid upon rupture of Suction below the vocal cords using
the client’s membranes. What actions should the endotracheal tube before spontaneous breaths
nurse take if respiratory efforts are depressed and occur.
FHR is <100 bpm?
What medication is given to a patient with DVT? Heparin- PTT Warfarin (Coumadin)- PT &
What lab value(s) are measured? INR
What is the earliest indication of hypovolemia Increasing pulse rate and decreasing blood
caused by hemorrhage? pressure.
What is a late indication of hypovolemia caused Altered mental status and level of
by hemorrhage? consciousness.
Precipitous delivery, lacerations, uterus inversion
and retained placental fragments are risk factors Postpartum bleeding
for ____?
True or False: A patient with DVT will report
False
nausea.
True or False: A patient with DVT will report calf
True
tenderness to palpation.
True or False: A patient with DVT will not have
False
an elevated temperature.
When giving care to a patient with
thrombophlebitis, the nurse should measure ___ Leg
circumference?
When giving care to a patient with
thrombophlebitis, the nurse should apply what Cold
temperature compress to affected extremity?
True or False: Clients with thrombophlebitis False. Adequate rest should be encouraged at
should be encouraged to ambulate to prevent this time.
further complications.
____ is an extreme complication that may occur Disseminated Intravascular Coagulation
secondary to a client with preeclampsia? (DIC)
Thrombophlebitis occurs closer to the
surface of the skin. Swelling present. Pain
What is the difference between thrombophlebitis may vary from discomfort to cramping but
and deep vein thrombosis (DVT)? gradually subsides. DVT is far more
dangerous and more difficult to diagnose.
May be asymptomatic.
DVT is most commonly in the __, but may occur
Calf
anywhere in the leg up to the groin?
Pulmonary Embolism. Clot in the leg
What is the greatest life-threatening concern for a
dislodges and travels through the circulatory
patient diagnosed with deep vein thrombosis
system to the lungs, causing SOB and chest
(DVT)? How does this occur?
pain.
True or False: Thrombophlebitis is rarely
associated with DVT and does not seem to be a True
risk factor for a pulmonary embolism (PE).
___ is the inflammation to the lining of the uterus
occurring 2-5 days after delivery and is the most
common post-partal (puerperal) infection? It is Endometritis
characterized by uterine tenderness/enlargment
and dark, malodorous lochia.
Staph, e.coli, and strep are usually the infecting
agents that enter the breast due to sore or cracked Mastitis
nipples, resulting in ___?
Peri-care and pad application should be done
from front to back. Drink cranberry juice,
Patient teaching for a urinary tract infection
prune juice and large amounts of fluid.
(UTI)?
Continue breastfeeding on antibiotic. Tylenol
PRN.
Provide frequent on demand feeding.
Continue feeding on both breasts.
Patient teaching for a patient who is breastfeeding
Completely empty each breast after feeding
with mastitis?
or use a pump. Wear a good fitting bra- not
too tight.
What are the signs and symptoms of Post-partal Crying, fatigue, insomnia, anorexia, flat
Depression? affect & feeling let down.
False. PPD does occur within 6 months, but
True or False: PPD occurs within 6 months and
usually will not reside without intervention
often goes away without intervention.
and treatment.
Monitoring mood and encouraging bonding with PPD
the infant are two important nursing interventions
when caring for a patient with ___?
Percentage for appropriate gestational age is ___? 10-90%
True or False: A newborn who has a low
True
birthweight would weigh less than 2,500 g.
The ___ reflex is stimulated by holding the
newborn in a semi-sitting position and then Moro
allowing the head and trunk to fall backwards?
True or False: Periods of apnea <15 seconds and
obligatory nose breathing are expected newborn True
findings.
Normal heart rate for newborn? 100-160
Loss of consciousness for how long is a clinical
10-15 seconds
finding of an absence seizure?
At what age do absence seizures stop happening? Puberty
Daydreaming and dropping held objects are signs
Absence seizure
and symptoms of what type of seizure?
Falling to the floor, contraction of entire body,
loss of consciousness, possible piercing cry and
Tonic-clonic
loss of swallowing reflex are all indicative of a
_____ seizure?
Onset, duration, findings & observations.
What information should the nurse document
(Ex. LOC, apnea, cyanosis, motor activity &
prior to, during, and following a seizure?
incontinence)
Children who have CF excrete an abnormal
Sodium & chloride
amount of ___ & ___ in their sweat?
CF children need antibiotics because they have __
Antibiotics (ex. Tobramycin)
infections?
CF children have difficulty absorbing __,
Fat (fat-soluble vitamins- KADE)
therefore they need to a vitamin supplement?
CF have mucus plugs, therefore they need a ___ Bronchodilator (Albuterol) & an expectorant
& an ___? (Dornase-alfa)
True or False: Wheezing is a sign of CF. True
Clubbed fingers and toes & barrel-shaped
What are two late manifestations of CF?
chest
CF have ___ insufficiency and should receive an
enzyme 30 minutes within eating meals and Pancreatic
snacks?
Apply ___ to the edges of a spica cast? Moleskin
What is most essential to administer to revert
Parenteral hydrocortisone
Addison's crisis?
What is the cause of Cushing's syndrome? Chronic corticosteroid administration.
 Decreased sodium + Vit-D and Calcium
Cushing's diet should include?
consumption
Focus during emergent phase of burn patient? (At
time of injury-restoration of capillary Preserve vital organ functioning.
permeability)
A _____ is indicated by the absence of bowel
Paralytic ileus
sounds?
Singed nasal hairs, circumoral burns, hoarseness
and sooty bloody sputum are indicative of what Inhalation burn
type of burn?
What mutual symptom is found in both CF and
Steatorrhea
celiac disease?
What fracture is indicative of abuse? Spiral
Cirrhosis patients should be on a ___ protein diet? Low
If burn is around the mouth, you should prepare
Intubation
for what?
Initiate IV access with what kind of catheter for
Large-bore catheter
burn patients?
Isotonic crystalloid solutions (NS or LR) are used
Early
during the __ stage of burn recovery.
Fluid replacement for a burn patient is most
During the first 24 hours.
important when?
What vitamins/minerals to give for wound
Vit-A, Vit-C & zinc.
healing?
A nurse should do what to stop the burn for a Apply a cool, wet compress to the affected
patient with a superficial partial thickness burn? area.
Active and passive ROM are recommended to the
Contractures
affected burn area to prevent ___?
If a hypoglycemic patient is unconscious or
unable to swallow, administer ____ SQ or IM and Glucagon
notify provider?
What types of IV fluids and in what order should First, administer NS (isotonic) Second,
you administer to DKA patient? administer 1/2NS (hypotonic)
Add glucose (Regular insulin 0.1 unit/kg) as
a bolus to IV fluids and followed by
What should the nurse do if a patient's blood
continuous IV infusion of Regular insulin 0.1
glucose level approaches 250? Why is this done?
unit/kg/hr to minimize the RF cerebral
edema.
Make sure ___ is adequate before administering
Urine output
K+?
With insulin therapy, monitor for what electrolyte Hypokalemia
imbalance?
True or False: Capillary refill will be increased
True
with septic shock.
True or False: Urinary output and bowel sounds
False
will increase with septic shock.
What to administer to a major burn patient with
Morphine sulfate IV continuous
severe pain?
What traction do weights hang freely in? Skin traction (Russell, Bryant)
Frequent blood glucose monitoring. Don't
stop taking insulin. Drink fluids without
Sick day management for a child with T1DM
sugars. Test urine for ketones to assist in
should include?
early detection of DKA. Notify provider if
levels become >240.
Eat three meals a day with snacks. Don't skip
Patient education for a child with T1DM?
meals! Draw up regular before intermediate.
A child with T1DM who is feeling irritable
Milk. (15g carbohydrates)
should drink ___?
True or False: Cornstarch should be avoided on
False. Aids in moisture absorption.
feet for patients with diabetes.
Signs of dehydration are indicated in which blood
Hyperglycemia
glucose level shift?
How to administer immunizations for 6 month
Provide sucrose on pacifier.
old?
Varicella vaccine is contraindicated with what
Steroids
medication?
What vaccine is contraindicated if patient has a
DTaP
history of encephalopathy?
Hep B vaccine is contraindicated in patients who
Yeast
are hypersensitive to ___?
What is a complication of OME? Transient hearing loss
Increased pain related to fluid and pressure
What clinical manifestations are observed in an in ear, rolling head to side, loss of appetite,
infant who has acute otitis media? decreased sensitivity to sound, crying &
irritability.
Positioning for a child with ear infection? Position upright