NCLEX NOTES Flashcards


Set Details Share
created 10 years ago by lakrf61
1,199 views
updated 10 years ago by lakrf61
show moreless
Page to share:
Embed this setcancel
COPY
code changes based on your size selection
Size:
X
Show:
1

Side effects of corticosteroids

Mood swing, increase hair growth, hump back, hypoglycemia, puffy face

2

Clinical findings typically in child with nephrotic symdrome

Massive proteinuria, hypoproteinemia, hypoalbuminemia, hyperlipidemia, edema

3

Visicants

Chemotherapeutic agents causing severe cellular damage to tissues

4

Side effect of amoxicillin

N/V, diarrhea, headache. Occasionally rash

5

Manifestations of leukemia in child

Anemia, infection, polycythemia, bleeding, bone pain

6

Phimosis

Foreskin of the penis cannot retract

7

S/S of child with epigolitis

Drooling,restless, high fever, no spontaneous cough due to obstruction

8

History of child with intussusception includes

CF, gastrostomy tube, abdominal blunt force trauma, URI and gastroenteritis

9

Gluten-sensitive enteropathy aka

Celiac disease

10

Vesicouretereal reflux

Urine flows backward from bladder to ureter causing UTI

11

Bleeding between the cranium and the dura

epidural hematoma

12

Early closure of cranial sutures

Craniosynostosis

13

Medication to treat multifocal PVC

Lidocaine

14

NI for child with RSV

albuterol (airways), acetaminophen (fever), fluids (hydration)

15

Hemolytic reactions with blood transfusion

fever, pain at injection site, hypotention, renal failutre, tachycardia, ogliuria, shock. Allergic reactions ( rash, hives and respiratory distress)

16

Most common cause for emergency surgery in children

Appendicitis

17

NI for patient with inflammatory bowel disease prescribed TPN

1.Check glucose level
2.Daily weight
3.Assess subclavian line for infection
4.Assess bowel sounds

18

Indication pancreatic enzyme is effective on patient with chronic pancreatitis

Bowel movements are formed, soft, brown

19

Preprocedure intervention for patient scheduled for cardiac catherization

Pedal and posterial tibial pulses

20

Severe abdominal pain, has hard rigid abdomen, temperature of 102 F.

Notify MD immediately - signs of peritonitis (life threatening)

21

PTT, PT, INR levels

PTT
PT
INR 2-3

22

Long term use of cascara sagrada (chronic constipation)

Hypokalemia

23

Favorable pelvic shape for vaginal birth

Anthropoid (long, narrow, oval)

24

Diet for CHF patient on digoxin and furosemide

baked pollack, mash potatoes(high potassium) carrot, raisin salad(low sodium)

25

NI for patient postop internal rotation of fractured right hip

Pillow to keep right leg abducted during turning

26

Neonate response to loud noises

Moro reflex

27

Food high in potassium

Carrot, spinach, apricots

28

S/S of blunt chest wall injury

SOB, chest pain.
Larger pneumothorax - tachypnea, cyanosis, diminished breath sounds, subcutaneous emphasema

29

NI for child with juvenile arthritis

Isometric exercise during painful episodes.
Hot/cold packs, splinting, positioning affected joint in neutral position reduce pain.

30

Early sign of hypovolemic shock

Restlessness, anxiety, agitation.
Late signs: lower BP, diminished perepheral pulses, pallor, cold skin, urine < 30 mL/hr

31

Signs of psychomotor retarded depression

Slowed walking and talking

32

Priority for child with partial/full thickness burns over 35% of body

Foley catheter - accurate urine measure hourly

33

Therapeutic effect of nitrofuratoin sodium (Macrodantin)

Antibacterial for acute UTI or chronic suppressive treatment : absent of dysuria

34

Adverse effect of fluoxetine (Prozac)

N/V, cramping, diarrhea.

35

Side effect of isopreterenol

Bronchodilator. Tachycardia, HTN, chest pain, dyshrythmias, nervousness, restlessness, headache

36

Position for patient with smoke inhalation and burns to anterior trunk with diagnosis of Impaired gas exchange

Turning, humidified oxygen, IS, suctioning PRN to prevent atelectasis and pneumonia

37

Priority for a child with hypertonic dehydration

Urine output. Not to give potassium if < 1 mL/kg/hr

38

Normal labs

Creatinine 0.6-1.3
BUN 5-20
Calcium 8.6-10
WBC 4500-11000
TSH 0.2-5.4
Magnesium 1.6-2.6

39

S/S of dystocia with patient in labor

High level maternal fear,anxiety.
Fetal distress
Featal failed to descend

40

NI for patient receiving parenteral nutrition with sign of air embolism

Trendelengburg position increase intrathoracic pressure, decreases amount of blood pulled into the vena cava during inspiration

41

Lumbar puncture performed to obtain CSF for analysis. Negative values if CSF is normal

RBC

42

Adverse effect of epoetin alfa

HTN

43

Aluminum hydroxide prescribed for chronic renal failure, to be taken

With meal

44

Efavirenz - antiviral prescribed for HIV patient is best taken

HS due to side effect on the nervous system

45

Bronchial breath sounds can be heard at

Trachea or larynx

46

FSH and LH secreted by

Anterior pituitary gland

47

Labs values for patient with undyalized chronic renal failure
(CRF)

BUN >
Creatinine > 4.5
K > 5.9

48

Administration of dopanmine and nitroprusside IV drips

Dopanmine (vasopressor), nitroprusside (vasodilator) for dilation of coronary vessles. Given SEPARATE SITES

49

S/S if cholecystitis

Pain begin in RUQ of abdomen, radiate to right shoulder and scapula

50

Diet for uncomplicated hyperthyroidism patient

Increase protein + calories, no caffein

51

Diet for stomatitis

Soft, bland, cool food

52

S/S of pelvic inflammatory disease

lower abdominal pain, fever, dysuria

53

carbamazepine (Tegretol)

5-12 mcg/mL

54

digoxin (Lanoxin)

0.5-2 ng/mL

55

gentamicin (Garamycin)

5-10 mcg/mL

56

theophylline

10-20 mcg/mL

57

tobramycin (nebcin)

5-10 mcg/mL

58

Side effects of chemotherapy with doxorubicin

alopecia, cardiotoxity can occure, urine/sweat turn red, stool turn white,severe injury if extravasation occurs ( IV administration )

59

Side effects of phenytoin (Dilantin) - anticonvulsant

Constipation, bleeding gums, hyperglycemia, decreased platelet counts

60

Opisthrotonos

prolonged arching of the back with head and heels bent backward

61

Care plan for child with hepatitis

Low fat, well balance diet. Teach hand washing technique. Caution in giving medication due to liver inability to detoxify/excrete. Jaundice is expected.

62

Toxic effect of cisplatin (Platinol) given to cancer patient

otoxicity, tinnitus, hypokalemia, hyocalcemia, hypomagnesia, nephrotoxity.
Give amifostine before cisplatin to reduce potential renal toxicity

63

Involution of fundus 12 hrs after delivery

rise to level of umbilicus then dececends into the pelvis one fingerbreadth each succeeding day

64

Signs/symtoms of meningitis

Tachycardia, photophobia, red/macular rash, positive Kernig sign

65

Clients are high risk for metabolic acidosis

Diabetes mellitus, renal failure, malnutrion because of increase acids in the body

66

Increase calcium of a client who is lactose intolerant

Tofu, broccoli, sardines, mustard greens

67

NI for hypernatremia

Sodium level >145 . Monitor I/O, VS, reduce sodium, electrolyte levels, increase fluid

68

Data collection for patient with positive Chvostek sign

Indicative of hypocalcemia = tachycardia, hypotention, positive Trousseau's sign, diarrhea, seizures, hypoactive bowel sounds

69

S/S of child with bacterial meningitis

fever, nuchal ridgity, irritability

70

Adverse reaction of magnesium sulfate

flushing, depressed respiration, extreme muscle weakness,

71

Calcium channel blockers are use for

HTN, angina pectoris, cardiac dysrhymias

72

S/S of an infant with Hirshprung's disease

Fever, constipation, FTT, abdominal distention, explosive/watery diarrhea

73

Fetal heart developed and beating

gestational week 5

74

Side effects of rifabutin (Mycobutin) for client with active Mycobacterium avium complex disease and TB

Rash, gastrointestinal disturbances, neutropenia, red/orange body secretions, uvitis (blurred vision or eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, flu-like syndrome.

75

cinoxacin (Cinobac) urinary antiseptic caution

client with renal impairment

76

Functions of amniotic fluid

Allow fetus to move freely, maintain body temperature, measure kidney function, surround+cushion+protect fetus

77

S/S of air embolism

Life threatening - chest pain, coughing, hypotention, cyanosis, hypoxia, churning "windmill" sound on right ventricle

78

S/S of client taking phenytoin (Dilantin) has serum phenytoin level of 30 mcg/mL

Phenytoin level: 10-20 mcg/mL.
CNS depression, lethargy, ataxia, nausea, nystagmus, diplopia, lack of hyperactive reflex

79

S/S of severe pregnancy induced hypertention (PIH)

BP 150/90, urine +3 protein
NI: Monitor renal functioning

80

Common symtom of nephrotic syndrome

decrease urination + appear frothy

81

Diet restrictions for renal failure patient

< 40 g protein daily

82

Medications for long term control of tonic-clonic seizures

gabapentin, ethosuximide, carbamazepine

83

Discharge instruction for patient taking nifedipine (Adalft) for blood pressure

Take pulse daily. Weight at the same time each day. Palpitations may occur in early morning. Be care when rising from sitting to standing

84

Side effects of phenytoin ( Dilantin)

Constipation, bleeding gums, hyperglycemia, blood dyscrasias = decreased platelet + WBC

85

Diet high in calcium for lactose intolerant patient

Tofy, mustard greens, sardines

86

Procedure to administer an enema to an adult patient

Standard precautions. Client in left sims' position (retention of solution). Lubricate + insert tube 4 inches. Enema solution hang 12-18 inches above client's anus. Temperature: 100-105 F. Clamp tube if client is discomfort.

87

NI for pulmonary edema

LV failed to eject sufficient blood = increase pressure in the lung due to accumulated blood.
Administer oxygen. High fowler position. Furosemide. Foley (measure output).IV morphine sulfate (reduces return, decrease anxiety, reduce breathing)

88

Instructions for a client post op total laryngectomy about caring for the stoma

Wash daily with wash cloth. Avoid soap, cotton swabs or tissues. Avoid alcohol. Thin layer of petroleum jelly to skin around stoma(prevent cracking).Protect from water.

89

Care of client post op lumber puncture

Monitor ability to void. Maintain supine position. Monitor ability to move extremities. Inspect puncture site for redness, drainage, swelling

90

S/S of skull fracture following a head injury

Drainage from ear. Bruising around eyes. Pink tinged drainage from nose

91

Discharge instructions for client post op tonsillectomy.

Avoid hot fluid, rough foods. Rest 24 hours

92

Data from client diagnosed with placenta previa

Bright red vaginal bleeding. Soft, relaxed, nontender uterus, Fundal height may be > than gestational age

93

Prescribed interventions for carcinoma of the lung who develops SIADH

Radiation. Chemotherapy. Serum sodieum blood level. Antagonist to ADH. Restrict fluid, increase sodium intake.

94

NI for seizure client on corticosteroids for arthritis. Symtoms: flushed skin, dry mucous membranes, elevated tempt, poor skin tugor. Serum sodium of 172 mEq/L

Monitor I & O. Vital signs. Sodium reduced diet. Electrolyte levels. Increase water intake.

95

S/S of 3 yr old suspected bacterial meningitis

Fever, irritability, nuchal rigidity

96

Advantage of using spinal anesthesia for delivery of a fetus

Immediate onset. Ease of administration. Absence of fetal hypoxia.

97

S/S of client with positive Chvostek's sign

Tetany.Diarrhea. Possible seizure. Positive Trousseau's sign

98

Toxic effect of cancer patient taking cisplatin (Platinol)

Tinnitus. Ototoxicity. Nephrotoxicity. Hypomagnesemia

99

Platelets

150,000-400,000

100

Prothrombin time and International normalized ratio (INR)

PT: 2 seconds.
INR: (Male) 9.6-11.8 seconds (Female) 9.5-11.3 seconds
1.5-2 lab value - oral anticoagulants
2-3 for standard warfarin therapy

101

Iron

Male: 65-175 Female: 50-170

102

Hematocrit

Male: 42-52 Female: 35-47

103

Cardiac markers

Troponin I: <0.6 >1.5 = MI
Troponin T: >0.1-0.2 = MI
Myoglobin > 90 = MI

104

Creatine kinase (CK)

26-174

105

RBC

Male: 4.5-6.2 million
Female: 4.0-5.5 million

106

Hemoglobin

Male: 14-16 g/dL Female: 12-15 g/dL

107

Activated partial thromboplastin time (aPTT)

1.5-2.5 times normal for heparin

108

WBC

4500-11000

109

thyroid-stimulating homrone (TSH)

0.2-5.4

110

magnesium

1.6-2.6

111

calcium

8.6-10

112

BUN

5-20

113

Serum creatinine

0.6-1.3

114

Medications for treatment of HF

Diuretics, cardiac glycosides, PDE inhibitors, Ace inhibitors

115

Respiratory Acidosis ( pH <7.35 PCO2 > 45 )

Cause: Asthma, atlectasis, brain trauma, bronchiectasis, bronchitis, CNS depression, emphasyma, hypoventilation, medications, pneumonia, PE, repiratory failure
S/S: Headache, restlessness, drowsiness, confusion, visual disturbances, diaphoresis, cyanosis, hyperkalemia, tachycardia, dysrhythmias -> V fib

116

Respiratory Alkalosis ( pH > 7.45 PCO2 < 35)

Cause: Anxiety, fever, hyperventilation, hypoxia, hysteria, overventilation by mechanical ventilators, pain
S/S: Headache, vertigo, lower LOC, paresthesia, hypokalemia, hypocalcemia, tetany, convulsions

117

Metabolic Acidosis ( pH <7.35 HCO3 <22 )

Cause: DM, ecessive acetylsalicylic acid, gastrointestinal fistulas, high fat diet, insufficient metabolism of carbohydrates, lactic acidosis, malnutrition, RF, severe diarrhea, starvation.
S/S: Headache, N/V, diarrhea, fruity smelling breath, CNS depression, hypotension, hyperkalemia

118

Matabolic Alkalosis ( pH > 7.45 HCO3 >27)

Cause: Diuretics, excessive vomiting or gastrointestinal suctioning, excessive intake of antacids, hyperaldosteronism, excess sodium bicarbonate, massive transfusion of whole blood
S/S: N/V, dizziness, parathesia, hypokalemia, hypocalcemia, disrhythmia, tachycardia.

119

Adverse effect of ergotamine (Ergostat)

HTN, parathesias, N/V

120

Lab results confirms meningitis

Reduce glucose level, pressure > 200, protein >15, cloudy,increase WBC

121

Food high in riboflavin

Milk

122

Indication of low protein intake

Albumin <3.5
Normal 3.5-5

123

ABG results of respiratory failure client

PaO2 <50 PaCO2 >50

124

Major adverse effects of dantrolene sodium (Dantrium)

Drowsiness, diarrhea, hepatotoxicity

125

Risk factor for endometrial cancer

Estrogen replacement therapy

126

Side effects of Rifabutin (Mycobutin) for treatment of TB and MAC disease

Rash, gastrointestinal disturbances, neutropenia, red-orange body secretions, uveitis, myositis, arthralgia, hepatitis, chest pain, dyspnea, flu-like syndrome.

127

Positioning for a patient with insertion of MIller Abbott tube

Right side to faciliate passage through pylorus of stomach into small intestine

128

Medication prescribe for a child with spina bifida

sulfisoxazole (Gantrisin)

129

Phallic stage of Sigmund Freud's theory of personality development

Recognition of differences between sexes

130

Adverse effects of scopolamine (TransdermScop)

Dry mouth, urinary retention, dilation of pupils

131

Diagnostic study for carcinoma of the larynx patient taking bleomycin sulfate (Blenoxane)

Pulmonary function. Monitor for dyspnea (pulmonary toxicity) - discontinue med

132

Neologism

Created new word by combining syllables of other words

133

Medication commonly use for opioid intoxication

Nalorphine (Nalline)

134

S/S of Meningeal irritation

Positive Brudzinski and Kernig's signs, nuchal rididity, restlessness, severe headache

135

S/S of otitis media

Fever (4

136

Plan of care for patient diagnosed with dystocia

Characteristics of contractions (prolonged labor = fetal distress)

137

Herbal therapies used as antispasmodic

Angelica, Chamomile, Peppermint oil

138

Highest priority in caring of a child with nephrotic syndrome

Dipstick the urine for protein Q 4 hrs

139

Lab results for a child with iron deficiency anemia

Low hemoglobin levels + microcytic/hypochronic RBC

140

Toxic effects related to Oxybutynin chloride (Ditropan)

nervousness, restlessness, irrability, hypo/hypertention, confusion, tachycardia, flushed face, respiratory depression

141

Best information for recovery from spinal shock

Reflexes

142

Lab values for a child with sickle cell disease

Decreased Hbg + Hmat + Platelets. Increased reticulocyte counts (short RBC life span)

143

S/S of spinal shock of a patient with C5 spinal cord injury

Absent B/S, distended abdomen, respiratory diminished

144

S/S of inhalation injury with carbon monoxide

5-10% = impaired visual
11-20% = flushing/headache
21-30% = nausea/impaired dexterity
31-40% = vomiting, dizziness, synecope
41-50% = tachypnea, tachycardia
>50% = coma/death

145

Therapy that involves pairing a stimulus attractive to the client with an unpleasant event

Aversion therapy (negative reinforcement)

146

Test which determines continuation of pyrazinamide therapy

Positive sputum culture

147

Adverse effect of demopressin (DDAVP)

Water intoxication + hyponatremia = drowsiness, listlessness, headache

148

Nervous, lethargic, memory loss

Korsakoff psychosis - result from chronic alcoholism

149

S/S of chronic glomerulonephritis (CGN

Fixed specific gravity of urine, increased BUN + creatinine

150

S/S of renal caculi of patient with multiple fractures in an auto accident

Renal calculi = imobility = decalcification of bones

151

NI for a child during acute phase of glomerulonephritis

Assess appearance for signs of cerebral complications

152

Priority NI for post op insisional cholecystectomy patient

Hypostatic pneumonia (painful to cough)

153

Newborn whose mother had ruptured of membranes 23 hrs before delivery is at risk for

Neonatal sepsis = infection from organisms in the vaginal tract

154

S/S associated with Addison's diease

Elevated Adrenalcorticotropic hormone ( ACTH) and Meloncyte-stimulating hormone (MSH) = hyperpigmentation

155

Client receiving furosemide IV push. Possible complication?

Tachycardia

156

Pt. with PE, notes petechiea on chest and abdomen. Priority?

Contact physician

157

Rationale for diabetic pt to use diaphragm as method of contraception instead of pills

Noninvasive that will not alter blood glucose levels

158

Teaching to diabetic pt with a cold regarding insulin needs

Infect = alteration/increase insulin needs. Check Q 4 hr

159

Complication of Grave's disease

SOB

160

TB patient ask how long he have to take INH

Approx. 1 year and reevaluated

161

MRSA pt receiving Vanomycin IV. If client experience "red man" syndrome, nurse should

Slow infusion and monitor BP

162

Expected finding in normal newborn

Acrocyanosis

163

Intervention for Pt with radical mastectomy

Arranging visit from a member of Reach for Recovery

164

2 medications to be given IM. Nurse should

Determine whether medications can be combined

165

Finding consistent with an acute inflammatory reaction of a MVA pt with 4 in laceration on left lower leg

Increased pain caused by release of histamine

166

Food for client lack sufficient protein

Peas and beans

167

Intervention for client receiving a water enema if complain of abdominal cramp

Lower height of enema container

168

Best method for pt with fractured femur in crutch to manipulate stairs

Start up the stairs with unaffected leg first

169

Assessing of a dark-skinned client with anemia

Hard palate

170

Patient's Bill of Rights

The right to advanced directives concerning treatment

171

What is the host according to agent-host model in a toxic chemical spill

Residence living in the area

172

Nurse first time applying dressing. Reading manual, ask another nurse, skill level of the nurse is

Novice

173

Foley catheter for a male client should be inserted

7-9 in

174

Position to move a pt up the bed with 2 care givers

Opposite side of bed at chest level

175

Typical finding of client with fractured hip

Disalignment of affected extremity

176

Pt with sudden hearing loss who just broke up with fiance. This is example of

Conversion reaction

177

Pt receiving Nipride D5W IV.IV fluid has light brownish tint

Expected color of solution

178

Best position for pt with right total hip replacement

With right hip flexed 35 degree

179

An overly aggressive football player who are known as quiet and brooding

Sublimation

180

15 mo old turns his cup upside down, shakes milk from spout

Manipulation of objects in their environment enables toddler to learn about spatial relationships

181

Female pt with chlamydia, before she leaves clinic, nurse should

Obtain name and addresses of client's sexual contacts

182

Infant in need of additional growth assessment

Baby girl 4 months, BW 7 lbs 6 oz, present weight 14 lbs 14 oz

183

Assess for pt on assisted ventilation developed right sided tension pneumothorax.

Left sided tracheal deviation

184

Post op assessment of elderly pt with total hip repair. Sign of severe discomfort

Decreased heart rate

185

Lab finding confirm that pt is bothered by sensory disturbance related to being in ICU.

Increased urine catecholamines

186

Pt with AKA of the right leg refuses to look at the operative site

...

187

What action by the nurse predisposes pt to hyperkalemia while administering transfusion of whole blood

Filling the drip chamber below level of the filter

188

Lab value indicates complication of NG suction

K 3.4 mEq/L

189

Correct wound healing statement

Healing by second intention results in excessive scar formation

190

Statement indicate needs for further teaching of bladder management of pt with paraplegia

I need to eat plenty of citrus fruits to prevent bladder infections

191

Assessment for jaundice in dark-skinned pt with hepatitis

Hard palate

192

Middle East patient

Take time for prayer during the day

193

Sarcoma pt being treated with Adriamycin

Nurse implements isolation precautions

194

Activities best tolerated with muscular dystrophy

Swimming

195

Appearance of area post-op of pt with basal cell carcinoma on the ear

Swollen, tender, blistered

196

Culture taken of a lesion suspected of being herpes

Pack on ice

197

Lesion < 0.5 cm in diameter on pt back

Papules

198

6 months old with multiple bruises, decreased ROM of right leg has fracture of right femur. Statement by mother indicate child abuse

She hurt her leg while she was crawling

199

Pt with pyloric obstruction has persistent vomiting, blood gases expected

pH 7.47, PCO2 40mm Hg

200

Acute leukemia has oral ulcerations. How to increase pt comfort

Cleanse teeth and mouth with lemon and glycerin swabs

201

Gastric ulcer losing significant amount of blood via NG tube, pulse weak, hypotensive.Continuous irrigation of NS ordered. Patient position

Left side lying

202

Pre op teaching of client scheduled for a transphenoidal hypophysectomy for removal of a pituitary tumor

You will not be able to brush your teeth for a week after surgery

203

Symptoms of pt diagnosed of pheochromocytoma NOT EXPECTED

Bradycardia

204

Teaching for pt suspected Addison's disease scheduled for rapid corticotrophin stimulation test

Need for periodic blood samples

205

Lab values expected in pt with Addison's

BUN 22

206

Position of pt with acute pelvic inflammatory disease

Semi folwer's

207

Pt with C6 spinal injury complaint of severe headache. BP 190/100 and diaphoretic.

Make sure Foley catheter is patent

208

Snacks permitted for a child with acute renal failure

Marshmallows

209

Activities suitable for 10 yrs old with asthma

Swimming

210

Musical instrument for teen with asthma

Clarinet

211

Post-op suprapubic prostatectomy has bright red urine with clots.

Check vital signs and notify physician

212

Teaching for pt taking calcium suppliments

Can use calcium based antacids to supplement diet

213

Pt with electrical burn, area sustained greatest degree of injury

Muscles supporting long bones

214

Organs most like to suffer permanent damage from shock

Kidneys

215

Pt to receive 8000 mL solution of Lactated Ringer begins at 7:30 am. Use Parkland formula, how much solution received by 11:30 pm

6000 mL

216

Drug of choice for status epilepticus

Diazepam (Valium)

217

Electrolyte must be maintain for pt receiving lithium

Sodium

218

Pt receiving colchicines for gout should report symptom

Diarrhea

219

Child with ventriculoperitoneal shunt has clear drainage from incision

Check dressing for presence of glucose with Dexrostik

220

Lung cancer pt advised to increase protein in diet

Crackers, cheese, fruit yogurt

221

14 months old receiving Digoxin and Lasix Q2 daily, assess for

Hypokalemia

222

Pt with seizure disorder to receive phenytoin and Phenobarbital. Nurse should be aware

Larger dose of Phenobarbital might be required because of increase in metabolism

223

If pre-op pt is allergic to shellfish

Physician need to alter type of skin preparation used

224

Lab value of pt in pre-op need immediate attention

PT of 1 minute 20 seconds

225

6 mos old pt with acute diarrhea. Rationaled for diet to include Isomil instead of Similac formula

Lactose intolerance after a diarrheal illness

226

Colostomy pt feel irrigation solution is not drained completely.

Massage abdomen gently

227

Pt with Miller-Abbot tube inserted to decompress the bowel, priority is

Advancing tube 3-4 in as ordered

228

Presence of Cullen's sign of pt in MVA suggestive of

Retroperitoneal bleeding

229

Pt with chronic pancreatitis receiving Pancreatin. Observations most indicative of drug achieved desired effect

Client's stools contain less fat + occur less frequency

230

Pt receiving aminophylline IV feeling nervous and shaky

CNS stimulation

231

Primary purpose pt with fractured hip in Buck's traction

Decrease muscle spasm

232

28 yr old primigravida with pregestional diabetes. Statement indicates understanding of teaching on her insulin needs

Changes in hormone levels will make my body more resistant to insulin, so I will need more as my pregnancy progress

233

Position best for pt with preeclampsia in labor

Left Sims

234

Primary physiological alteration in development of asthma is

Spasm of bronchiolar smooth muscle

235

Intervention to help manic pt maintain sufficient nourishment

Serve high calorie foods she can carry with her

236

Sign suggestive of impaired hearing in an infant

Absence of babbling by age 7 moths

237

Pt receiving Garamycin has order for a peak drawn. Priority

Blood draw 30 minutes after infusion

238

Teaching for pt receiving vincristine

Cause change in taste

239

Essential interventions for pt receiving cyclophosphamide

Urine output

240

Critical intervention for AIDS pt has lesions from herpes simplex virus, receiving acyclovir.

Fluids

241

First sign of graft-host disease following bone marrow transplantation

Rash

242

Medication orders should be questioned for client getting myelogram

Seconal 400 mg PO q 4 hours PRN for headache

243

Primary reason for maintain hyperventilation for MVA pt

Promote cerebral vasoconstriction + decrease cerebral blood flow

244

Finding consistent of stroke pt with receptive aphasia

Damage of temporal lobe

245

Finding considered abnormal of lumbar puncture pt

WBC 100/cu/100 mm

246

Interventions appropriate for pt lost function of cranial nerve V on left side

Helping client select foods easier to swallow

247

Priority following CT scan with contrast medium

Forcing fluids

248

Reddish-purple discoloration on AIDS pt eyelid

Kaposi's sarcoma

249

Elderly pt has difficulty with colors. Which colors often misinterpreted

Violet

250

Ability to remain continent depends on

Sympathetic nervous system (SNS)

251

Teaching for pt with history of renal calculi

Increase intake of meat, eggs, fish, plums, cranberries

252

Client at highest risk for Sarcodosis

30 yr old African American who is pregnant