RN Comp Practice 2023 A Flashcards
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Questions and Answers

Which of the following interventions should the nurse include in the plan? (Select all that apply)

  • Place the patient's cane on their left side while ambulating
  • Massage bony prominences on the patient's left side
  • Position the bedside table on the patient's left side
  • Support the patient's left arm on a pillow while sitting (correct)
  • Which instructions should the nurse include for parents of a child who has autism spectrum disorder?

  • Use a reward system to modify the child's behavior (correct)
  • Administer alprazolam PRN to reduce the child's anxiety
  • Maintain a flexible daily schedule for the child
  • Provide a variety of family members to care for the child
  • Which intervention should the nurse use to maintain surgical sterile technique during a sterile dressing change?

  • Maintain sterile objects within the line of vision (correct)
  • Hold hands folded below the waist after donning sterile gloves
  • Pick up and pour solutions with the palm of the hand covering bottle labels
  • Keep sterile items within a 1.3 cm (0.5 in) border of the sterile drape
  • What aPTT value should the nurse expect in a toddler who has hemophilia A?

    <p>45 seconds</p> Signup and view all the answers

    Which action should the nurse manager take first regarding staffing changes?

    <p>Form a committee of staff members to investigate current staffing issues</p> Signup and view all the answers

    Which instruction should the nurse include in the plan of care for a patient with thrombocytopenia?

    <p>Avoid venipunctures when possible</p> Signup and view all the answers

    What should be the first action when implementing an emergency preparedness plan?

    <p>Notify the incident commander</p> Signup and view all the answers

    What should be included in the care plan for an 8-year-old patient with cystic fibrosis?

    <p>Administer high-dose antibiotic therapy</p> Signup and view all the answers

    Which diagnostic test should the nurse expect the provider to order for a child taking valproic acid?

    <p>Serum liver enzyme levels</p> Signup and view all the answers

    What should the nurse say in response to a patient requesting to review their medical record?

    <p>There's a protocol for reviewing your medical record, and I can initiate the process.</p> Signup and view all the answers

    Which lab result should the nurse report for a patient who has ESRD?

    <p>Sodium 148</p> Signup and view all the answers

    What is the nurse's priority assessment for a patient in the fourth stage of labor receiving oxytocin IV?

    <p>Amount of vaginal bleeding</p> Signup and view all the answers

    What intervention should be included in the plan for a patient with mechanical restraints?

    <p>Provide a staff member to stay with the patient</p> Signup and view all the answers

    What assessment findings are consistent with Crohn's disease, ulcerative colitis, or peritonitis?

    <p>Albumin level: 2.4</p> Signup and view all the answers

    What assessment findings can indicate a transfusion reaction in a patient receiving blood?

    <p>Anxiety</p> Signup and view all the answers

    What is the condition diagnosed for a patient who reports palpitations, difficulty breathing, and feelings of faintness?

    <p>Somatic symptom disorder</p> Signup and view all the answers

    What actions should the nurse take when her pediatric patient is exhibiting symptoms of an allergic reaction?

    <p>DC supplemental oxygen</p> Signup and view all the answers

    What five actions should the nurse take with a patient experiencing hallucinations following alcohol withdrawal?

    <p>Administer thiamine, Maintain a low-stimulation environment, Administer chlordiazepoxide, Initiate seizure precautions, Perform a CIWA-Ar</p> Signup and view all the answers

    What is the condition for a post-op patient who is experiencing right lower extremity pain and itching?

    <p>Varicose veins</p> Signup and view all the answers

    Which assessment findings require an immediate follow-up in a patient with schizophrenia?

    <p>Involuntary tongue movement and foot tremor</p> Signup and view all the answers

    Which statement by a parent would prompt a nurse to request a high-frequency chest compression vest for a child with cystic fibrosis?

    <p>My child only has a small amount of mucus after percussion therapy.</p> Signup and view all the answers

    What is the condition for a patient post-op who has abdominal pain and has not had a bowel movement in 5 days?

    <p>Intestinal obstruction</p> Signup and view all the answers

    What is an adverse effect of clonidine that the nurse should inform the patient about?

    <p>Dry mouth</p> Signup and view all the answers

    Which action should the nurse take first when caring for a patient who had a recent stroke?

    <p>Assess the patient for functional limitations.</p> Signup and view all the answers

    What information should the nurse include in the educational session regarding organ donation for children with terminal illnesses?

    <p>The family can have the child in an open casket without fearing that the organ donation might disfigure the child's body.</p> Signup and view all the answers

    Which patient condition is nationally notifiable?

    <p>An adolescent patient who has foodborne botulism</p> Signup and view all the answers

    What action should the nurse plan for a patient with rheumatoid arthritis experiencing moderate to severe pain?

    <p>Allow for frequent rest periods throughout the day.</p> Signup and view all the answers

    What physiological change causes vision loss in patients with cataracts?

    <p>Increased opacity of the lens</p> Signup and view all the answers

    Which finding should indicate to the nurse that a patient is hemorrhaging after a colonoscopy?

    <p>Rapid decrease in blood pressure</p> Signup and view all the answers

    How should the nurse assess an infant's rooting reflex?

    <p>Stroke the infant's cheek</p> Signup and view all the answers

    Which finding indicates oxygen toxicity in a preschooler receiving oxygen therapy?

    <p>Substernal pain</p> Signup and view all the answers

    What medication should be administered for a patient experiencing respiratory distress after receiving lorazepam?

    <p>Flumazenil</p> Signup and view all the answers

    What response should the nurse make to a patient grieving the loss of a partner?

    <p>You seem to be having a difficult time right now.</p> Signup and view all the answers

    What adverse effect should a nurse monitor for a patient taking estradiol?

    <p>Headaches</p> Signup and view all the answers

    What should the nurse prioritize for a patient with bipolar disorder who is becoming increasingly restless?

    <p>Move the patient to a quiet place away from others.</p> Signup and view all the answers

    What should the nurse do during the second stage of labor when early decelerations are observed?

    <p>Continue observing the FHR.</p> Signup and view all the answers

    Study Notes

    Crohn's Disease, Ulcerative Colitis & Peritonitis

    • Temperature elevation (100F) occurs in Crohn's disease, ulcerative colitis (UC), and peritonitis due to inflammation or infection.
    • Unintentional weight loss (-9.7 lbs) indicates potential malabsorption in Crohn's and UC.
    • Frequent loose stools are typical in Crohn's disease; blood in stools suggests ulcerative colitis.
    • Elevated WBC (14) suggests inflammation or infection present in all three conditions.
    • Heart rate of 105 indicates tachycardia associated with peritonitis, due to infection or dehydration.
    • Albumin level (2.4) is low in Crohn's and UC because of inadequate protein absorption; abdominal pain in the RLQ is common in Crohn's.

    Transfusion Reaction Indicators

    • Symptoms of a transfusion reaction include back pain, headache, and anxiety alongside potential fever, chills, chest pain, tachycardia, dyspnea, and hypotension.
    • Vital signs may initially remain stable but require careful monitoring.

    Somatic Symptom Disorder

    • Characterized by somatic symptoms linked to psychological issues, such as difficulty breathing, palpitations, and joint pain.
    • Interventions include monitoring vital signs and assessing for secondary gains related to the illness.

    Allergic Reaction Actions in Pediatrics

    • Immediate actions include administering 0.9% NS IV and epinephrine IM, due to their critical role in anaphylactic reactions.
    • Frequent monitoring of vital signs is essential for detecting shock.

    Alcohol Withdrawal Management

    • Thiamine administration prevents Wernicke syndrome; chlordiazepoxide and a low-stimulation environment help manage withdrawal symptoms.
    • Initiate seizure precautions as withdrawal seizures may occur within 12-24 hours post cessation of alcohol.

    Varicose Veins Assessment

    • Assessment reveals bilateral lower extremity warmth and distended veins.
    • Management includes elevating the affected extremity and applying compression stockings.

    Schizophrenia Assessment Follow-up

    • Tardive dyskinesia is indicated by involuntary tongue movements and foot tremors.
    • Increased agitation and frequency of urination may also require immediate follow-up.

    Cystic Fibrosis and Airway Clearance

    • The need for a high-frequency chest compression vest arises if percussion therapy is ineffective, indicated by minimal mucus production.
    • Teaching nebulizer administration to the child is also crucial.

    Post-Operative Complications

    • Abdominal pain and hypoactive bowel sounds may suggest intestinal obstruction, especially with a lack of bowel movement over 5 days.
    • Semi-Fowler's positioning and IV fluids are indicated to alleviate distention.

    Clonidine Adverse Effects

    • Monitor for dry mouth as a common adverse effect; other potential side effects include constipation, dry eyes, and rashes.

    Stroke Patient Transfer

    • Assessing the patient's functional limitations prior to transfer is essential for safe mobilization strategies.

    Education on Organ Donation

    • Clear communication regarding organ donation's non-disfiguring nature to the family helps facilitate decision-making during end-of-life care.

    Notifiable Infectious Conditions

    • Botulism in adolescents is nationally notifiable and should be reported to CDC due to its potential severity and need for intervention.

    Rheumatoid Arthritis Pain Management

    • Frequent rest periods should be incorporated while allowing patient autonomy in ADLs fosters independence and mobility.

    Cataracts and Visual Acuity

    • Increased opacity of the lens characterizes cataracts, leading to decreased visual acuity; not to be confused with other ocular conditions such as glaucoma.

    Hemorrhaging Post-Colonoscopy

    • A rapid decrease in blood pressure signals possible hemorrhage, while an expected feeling of fullness following the procedure is normal.

    Infant Reflex Assessment

    • The rooting reflex can be assessed by stroking the infant's cheek, prompting a turn towards the side touched.

    Oxygen Toxicity in Cystic Fibrosis

    • Substernal pain indicates potential oxygen toxicity in patients receiving prolonged oxygen therapy.

    Lorazepam Overdose Management

    • Flumazenil is the anticipated medication to reverse lorazepam effects during respiratory distress.

    Grief Responses

    • Acknowledging the patient’s difficulty is a therapeutic communication technique to encourage expression of grief.

    Estradiol Monitoring

    • Headaches should be monitored and reported as they may indicate serious complications such as thromboembolic events.

    Bipolar Disorder Management

    • Moving a restless patient to a quiet space is crucial to prevent harm to others during a manic episode.

    Labor Monitoring

    • Early decelerations during labor are normal; continued FHR monitoring is essential unless other concerning signs emerge.

    Stroke Recovery Care

    • Supporting the affected arm on a pillow prevents injury and subluxation due to weakness following a stroke.

    Autism Spectrum Disorder Care

    • Employing a reward system for behavior modification effectively provides structure and predictability for children with autism.### Surgical Asepsis
    • Sterile items must remain in direct sight to ensure they are untainted.
    • Maintain sterile technique by positioning hands away from the body and above waist level.
    • Items should be kept at least 2.5 cm (1 inch) from the edge of the sterile field.

    Hemophilia A

    • Normal activated partial thromboplastin time (aPTT) values range from 30-40 seconds.
    • Expect aPTT value of 45 seconds for a toddler with hemophilia A, indicating prolonged clotting time.

    Staffing Challenges in Long-Term Care

    • First action for a nurse manager facing staffing difficulties is to form a committee to investigate staffing issues.
    • Understanding the current needs is crucial before implementing changes, representing the assessment stage of the nursing process.

    Care Plan for Thrombocytopenia

    • Instruct patients to avoid venipunctures to minimize bleeding risk due to decreased platelet counts.
    • Neutropenic precautions apply to low white blood cell counts, including restricting visitors and prohibiting fresh flowers.

    Emergency Preparedness Plan

    • Notify the incident commander first when implementing an emergency plan to establish command hierarchy and maintain order.

    Cystic Fibrosis Management

    • Administer high-dose antibiotic therapy due to the rapid metabolism of antibiotics in children with cystic fibrosis.
    • Implement contact precautions and ensure a high-calorie, high-protein diet with included activities of daily living (ADLs).

    Monitoring Patients on Valproic Acid

    • Serum liver enzyme levels should be monitored due to the potential for hepatic toxicity associated with valproic acid.

    Patient's Right to Access Medical Records

    • Patients have the right to access and review their medical records, which is a legal obligation for healthcare facilities under HIPAA.

    Reporting Lab Values in ESRD

    • Report elevated sodium levels (148) to the healthcare provider, indicating hypernatremia in a patient with end-stage renal disease.

    Fourth Stage of Labor Priorities

    • The priority assessment is the amount of vaginal bleeding, as patients are at risk for hemorrhage post-delivery.

    Management of Patients in Mechanical Restraints

    • Continuous observation by a staff member is required for patients in restraints to prevent injury.
    • Restraints should not be removed until the patient can follow commands and is calm. Document assessments regularly, and ensure prescription renewal every four hours for adults.

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    Test your knowledge on assessment findings related to Crohn's disease, ulcerative colitis, and peritonitis with these flashcards. Gain a deeper understanding of symptoms, lab values, and nursing considerations through interactive practice. Perfect for nursing students preparing for their exams!

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