1. The nurse checks for placement of a nasogastric tube before beginning tube feeding for a client. Which of the following results would indicate to the RN that the tube feeding can begin? The PH of the contents removed from the NG tube is 3 (stomach acid contents are acidic) 2. The nurse in an outpatient clinic teaches a client with right-sided weakness to walk down stairs using a cane. What behavior would indicate by the client that teaching was successful? The client leads with the cane, followed by her right leg and then her left leg 3. A client is admitted with IRS. The RN would anticipate that the client’s hx reflect which of the following? Pattern of alternating diarrhea and constipation. 4. The nurse is teaching nutrition classes at the community center. Which of the following foods would the nurse encourage a low-income diet to eat to satisfy essential protein needs? Legumes – cheap and rich in protein 5. The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the RN emphasize to facilitate regular bowel elimination? Eat more foods with increased bulk – whole grains, legumes, veggies, fruits, seeds, nuts, bulk promotes peristalsis Regular exercise Normal fluid intake of 1,500 cc/day Laxatives are used as last resort b/c they are habit forming 6. A mother brings her 9 month old child to the pediatrician’s office with complaints of a fever of 102.2 and frequent vomiting. The nurse would expect the following reflex to still be present? Babinski’s reflex – stroking outer sole of foot upwards causes toes to hyperextend and fan and great toe to doriflex, disappears after one year of age. 7. A client with an irregular pulse of 81 and a K level of 3.0 mEq/L has digoxin (lanoxin) ordered. Which of the following actions if taken by the RN IS BEST? Notify the physician – hypokalemia can precipitate digoxin toxicity, Doctor should be called to obtain
PPE, Assessment, Sterile Gloving, and Vital Signs (Pulse/Blood Pressure)
Hypoxemia- reduced oxygen in the blood
Airway obstruction- tongue, secretions (jaw thrust forward, oral airway if unconscious)
Hypoventilation- not breathing well (pain, drugs)
Secretions-trachea damaged and more mucus secreted
Vomit-tilt head to side, lower head of bed, suction, basin
Yonkers-suctioning equipment specific to mouth suctioning
Position- semi fowler….
| |Criteria licensure: criteria for licensure in the state of ten. States that only |
| |graduate of approved schools of nursing are eligible to take the national council |
| |licensure examination (NCLEX). Associates’ degree, Baccalaureate Degree, Master’s |
| |degree and doctoral degree all take the NCLEX. You must also pass a background check |
| |and pay money.….
1. George Brown, 72 years of age, is a male patient who is admitted with the diagnosis of acute pulmonary edema secondary to acute left ventricular heart failure. The patient has a history of coronary artery disease that has been treated medically. The patient is anxious, pale, cold, clammy, and dyspneic. The vital signs are: blood pressure 88/50 mm Hg, heart rate 110 bpm, respiratory rate 32 breaths/min, and temperature 97°F. There are bubbling crackles and wheezing throughout the lung fields and….
Focus Questions #1
1. Relate each client’s current manifestations to the pathophysiology of shock to determine what type of shock the client could be experiencing.
Shock is a syndrome characterized by decreased tissue perfusion and impaired cellular metabolism. The patient Richard Tanner has been admitted to the CCU for r/o myocardial infarction. The patient has not prior history of cardiac problems though he has been treated for the last 5 years for cholesterol totaling 285 (HDL 35, LDL 212)….
* Disturbances in automaticity – initiation of impulse is altered
* Disturbances in conduction – alteration in the speed the impulse travels
* Reentry of impulses – cardiac tissue is depolarized multiple times by the same impulse
* Speed, distance and location can be changed or affected (blockages cause change in heart rhythm)
* Risk factors
* Cardiovascular disease, MI
* MI – death of tissue – no electricity….
BT is a 95 year old Caucasian female that lives with her husband and has spent 39 years working as a missionary. She presented to the emergency room at Milford Memorial Hospital on March 17, 2012 complaining of diarrhea for the past 6 days, up to 5 times a day. She also reported loss of appetite and weakness; upon admission to the emergency room she vomited once and verbalized cramping in the upper abdominal region. She was admitted with acute infectious colitis, acute renal failure, and dehydration….
MEDICAL SURGICAL NURSING
MEDICAL SURGICAL NURSING
List 4 common symptoms of pneumonia the Tachypnea, fever with chills, productive cough,
nurse might note on a physical exam.
bronchial breath sounds.
State 4 nursing interventions for assisting Deep breathing, fluid intake increased to 3 liters/
the client to cough productively.
day, use humidity to loosen secretions, suction
airway to stimulate coughing.
What symptoms of pneumonia might the
nurse expect to see….
Ch. 56-61 (cont)
-trauma to head, including chg in LOC
-traumatic brain injury= incr potential for poor outcome
-immediately after, 2h after, 3 wk after, death common
-*abnormal motor reflex, alt eye mvmt, hypotension= hypoxia= decr O2 in brain, incr ICP greater than 20
GCS measures speech, eye, motor
-if greater than 8= 90% chance recov
-if less than 8= 30-70% chance recov
Scalp lac- most common type, profuse bld, complication is infx
-skull fx- linear, depressed, simple….
The nurse has admitted a patient with a new diagnosis of pneumonia and explained to the patient that together they will plan the patient’s care and set goals for discharge. The patient says, “How is that different from what the doctor does?” Which response by the nurse is most appropriate?
“In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health.”
This response is consistent with the American Nurses Association….
Recent Surgeries ____LEFT HIP REPLACEMENT, VERICOSE VEIN STRIPPING________________________
Chief Complaint _____LEFT LEG PAIN__________________________________________________________
____GW is a 56 year old male, admitted from a nursing home 3/25/14. He was complaining of left leg pain of his infected leg and was diagnosed with Cellutitis and infected ulcer wound of the left leg. He is a full code, NKA, and AO x 3. He is….