Nanay Mo PDF

1. 2. 3. 4. 5. SATA: A. congenital cardiac problem B. infant with cystic fib C. late stage cancer Breath sounds are silent throughout the chest Place the infant in supine position My child may need another shunt in couple yrs RN completed discharge instructions for kid who have leukemia.Which statem...

1. 2. 3. 4. 5. SATA: A. congenital cardiac problem B. infant with cystic fib C. late stage cancer Breath sounds are silent throughout the chest Place the infant in supine position My child may need another shunt in couple yrs RN completed discharge instructions for kid who have leukemia.Which statement from parent indicates learning has occurred- treat our child the same as her siblings 6. White reflex in the eye 7. Cerebral palsy causes non progressive brain dmg 8. Projectile vomiting 9. 186.7 10. Lets work together to plan your day along 11. Lear to trust and relate to each pother differently 12. That u for sharing now lets hear what others are thinking 13. Common precursors to mental illness in adults 14. Suggest family therapy for both son and mom 15. RN caring for pt with hallucinations. Which intervention is most therapeutic- distract pt attention 16. Risperidone- delusion 17. RN assessing pt with delusional disorder with paranoia. What is the BEST initial communication by the nurse- You seem to be having trouble trusting the staff 18. SATA: RN giving chlorpromazine to pt. What potential side effects? a. Tardive dyskinesia, b. NMS, c. Acute dystonia, d. akathisia 19. Benztropine 20. RN talking with family. Husband and wife fighting a lot. Husband having an affair with secretary. This dynamic is example of- Triangulation 21. RN completed family assessment. Primary goal for family should include- assisting the fam in learning about differentiation 22. SATA a. educated , rich people are not victims of abuse b. Woman causes the beating c. If the abuser apologizes the abuser will not report the abuser 23. Interview the pt alone to assess for abuse 24. Tell me more about how your child hurt herself today 25. Early detection and management 26. Ondansetron 27. Monitoring plt count 28. SATA: RN received in report that pt is receiving chemo have severe neutropenia. Which action should RN implement- Inspect skin and mucous membrane, assess fever every 4hrs, monitor wbc count 29. SATA: Pt on oncology unit who is receiving chemo begin to experience difficulty swallowing with painful sores. Which interventions should be implemented- rinse 2% viscous lidocaine, examine for blisters, provide soft sponge or soft bristle 30. The pt’s pain rating 31. SATA a. Difficult swallowing b. Change in bowel or bladder c. Sore throat doesnt heal d. Unusual discharge 32. Cd4+ T cell count less than 200 cells /mm3 33. It is intended to keep the virus from developing 34. Provide 15g of simple carb 35. Don’t take metformin 48hrs before 36. Pt with CKD receiving epoetin. Which lab results indicate therapeutic effect- HCT 35% 37. When taking admission of pt with right heart failure. RN should expect the pt to complain of- dyspnea, fatigue, edema 38. Which nursing action is PRIORITY for the pt who experience generalized tonic clonic seizure- keep the pt in side lying position 39. Decrease oxygen sat w/ mild activity 40. Reduces air trapping by increased expiration 41. Tracheostomy tray 42. Heart rate increased from 50-70 43. Distended abdomen 44. Reduction of steatorrhea 45. Rn caring pt with hepatic encephalopathy and the fam expresses distress that the pt’s protein intake has been reduce. What response by rn is appropriate- less protein in diet will help prevent confusion associated with liver failure 46. During assessment of pt with cirrhosis which data the nurse should be concerned- blood noted in vomitus 47. Age younger than 40 48. Smoking cessation 49. Annual mammo 50. Administer oxygen 51. Crackles 52. I don’t need my walker to get to the bathroom 53. RN caring pt following mastectomy. Which rn interventions should assist in preventing lymphedema of affected arm- encouraging early arm exercise 54. Consistent use of standard precaution 55. RN caring a pt with hx of dm reviews lab results that include hgba1c of 5.9%. How should rn interpret this finding- pt has maintained good glycemic control 56. I will avoid going bare foot 57. The nurse is preparing a patient newly diagnosed with diabetes about home glucose monitoring. Which blood glucose measurement indiactes impending hypoglycemia? - 50 58. Diabetes cause blindness so I should see ophthalmologist 59. Instruct the pt to move to another injection site location 60. Chest pain 61. Patient is placed on fluid restrictions because of CKD. Which assessment finding should alert the nurse that the patient’s fluid balance is stable at this time? - No adventitious lungs sounds 62. Medication w/ dirt changes lowers blood pressure and can slow progression of disease 63. Pt with kussmaul respirations 64. Control htn 65. This pill will reduce the swelling in my body 66. Vitamin k 67. Cardiac nurse is teaching a client diagnosed with CHF. Which teaching interventions should the nurse discuss with the client? SATA a. Notify the healthcare provider if client gains more than 2 lbs in 1 day b. Keep the head of the bed elevated when sleeping c. Teaching client which foods are high in sodium and should be avoided d. Perform isotonic exercises like walking or swimming at least once a day 68. Pain and cramping w/ exercise & relieved with rest 69. Reorient to person and current events 70. Inability to recall the word car 71. Rigidity with ambulation 72. Risk for falls 73. Bilateral joint pain 74. A 52 year old in a tripod position 75. A nurse evaluates the following VS result for a pt with COPD, HR 110, RR 12, BP 145/65, O2 76% - Initiate oxygen therapy to increase saturation 76. Night sweats 77. SATA: a. dyspnea, b. cough, c. wheezing 78. What health teaching by the nurse is important for clients diagnosed with systemic lupus erythematosus? SATA a. Take frequent rest periods to prevent fatigue b. Avoid over exposure to the sun c. Report fever to your healthcare provider immediately d. Use a mild soap for bathing to prevent skin irritation 79. Sputum culture 80. Rust colored sputum 81. The pt who uses iv drug 11mm 82. Potassium 6.2 83. At the end of a day a nice hot bath may relieve 84. The nurse caring for the patient with exacerbation of ulcerative colitis should expect to implement which nursing interventions? SATA a. Monitor for bleeding b. Administer antidiarrheal med c. Help pt identify dietary triggers d. Administer aminosalicylates 85. Limit physical activity 86. Hips and knees 87. Administer levothyroxine 88. I am always feeling so cold 89. The nurse is reviewing the record of a patient with Crohn's disease. Which stool characteristic should the nurse expect to see documented? - non bloody diarrhea 90. A-fib 91. Hypokalemia 92. Check pts status and leads 93. Creatinine of 2.7 94. Ask the pt to extend arms 95. The nurse is reviewing trigger factors that can cause a seizure with a patient newly diagnosed with generalized seizures. Which of the following would the nurse include in this review (SATA) a. Avoid overwhelming fatigue b. Remove caffeine products from diet c. Limit exposure to flashing lights 96. SATA a. Hypotension b. Hypoglycemia c. Hyperkalemia 97. Nurse is analyzing the lab results of a patient with leukemia who has received a regimen of chemotherapy. Which value does the nurse specifically note is a result of massive cell destruction that occurred with chemotherapy - increased potassium 98. Rn is assessing a patient with Cushing’s disease. Which of the following assessment findings is the priority? - Weight gain 99. Rn is caring for a pt who is taking prednisone for an exacerbation of inflammatory bowel disease. Which assessment finding does the nurse recognize as a priority? - pt has elevated body temp 100. An inverted t wave