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NURSING BULLETS _____________ ___________________________________________________________

FUNDAMENTALS OF NURSING
MATERNAL AND CHILD HEALTH NURSING
MEDICAL SURGICAL NURSING
PSYCHIATRIC NURSING
Compiled by:
ROBERT C RE!A" BSN
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NURSING BULLETS _____________ ___________________________________________________________
FUNDAMENTALS OF NURSING
A blood pressure cuff thats too narrow can cause a falsel ele!ated blood pressure read"n#$
%hen prepar"n# a s"n#le "n&ect"on for a pat"ent who ta'es re#ular and neutral prote"n (a#edorn "nsul"n) the nurse should
draw the re#ular "nsul"n "nto the sr"n#e f"rst so that "t does not conta*"nate the re#ular "nsul"n$
Rhonch" are the ru*bl"n# sounds heard on lun# auscultat"on$ The are *ore pronounced dur"n# e+p"rat"on than dur"n#
"nsp"rat"on$
Ga!a#e "s forced feed"n#) usuall throu#h a #astr"c tube ,a tube passed "nto the sto*ach throu#h the *outh-$
Accord"n# to .aslows h"erarch of needs) phs"olo#"c needs ,a"r) water) food) shelter) se+) act"!"t) and co*fort- ha!e the
h"#hest pr"or"t$
The safest and surest wa to !er"f a pat"ents "dent"t "s to chec' the "dent"f"cat"on band on h"s wr"st$
In the therapeut"c en!"ron*ent) the pat"ents safet "s the pr"*ar concern$
/lu"d osc"llat"on "n the tub"n# of a chest dra"na#e sste* "nd"cates that the sste* "s wor'"n# properl$
The nurse should place a pat"ent who has a Sen#sta'en0Bla'e*ore tube "n se*"0/owler pos"t"on$
The nurse can el"c"t Trousseaus s"#n b occlud"n# the brach"al or rad"al arter$ (and and f"n#er spas*s that occur dur"n#
occlus"on "nd"cate Trousseaus s"#n and su##est hpocalce*"a$
/or blood transfus"on "n an adult) the appropr"ate needle s"1e "s 12 to 34G$
Intractable pa"n "s pa"n that "ncapac"tates a pat"ent and cant be rel"e!ed b dru#s$
In an e*er#enc) consent for treat*ent can be obta"ned b fa+) telephone) or other tele#raph"c *eans$
5ec"bel "s the un"t of *easure*ent of sound$
Infor*ed consent "s re6u"red for an "n!as"!e procedure$
A pat"ent who cant wr"te h"s na*e to #"!e consent for treat*ent *ust *a'e an 7 "n the presence of two w"tnesses) such
as a nurse) pr"est) or phs"c"an$
The 80trac' I$.$ "n&ect"on techn"6ue seals the dru# deep "nto the *uscle) thereb *"n"*"1"n# s'"n "rr"tat"on and sta"n"n#$
It re6u"res a needle thats 19 ,3$: c*- or lon#er$
In the e!ent of f"re) the acron* *ost often used "s RA;E$ ,R- Re*o!e the pat"ent$ ,A- Act"!ate the alar*$ ,;- Atte*pt to
conta"n the f"re b clos"n# the door$ ,E- E+t"n#u"sh the f"re "f "t can be done safel$
A re#"stered nurse should ass"#n a l"censed !ocat"onal nurse or l"censed pract"cal nurse to perfor* beds"de care) such as
suct"on"n# and dru# ad*"n"strat"on$
If a pat"ent cant !o"d) the f"rst nurs"n# act"on should be bladder palpat"on to assess for bladder d"stent"on$
The pat"ent who uses a cane should carr "t on the unaffected s"de and ad!ance "t at the sa*e t"*e as the affected
e+tre*"t$
To f"t a sup"ne pat"ent for crutches) the nurse should *easure fro* the a+"lla to the sole and add 39 ,: c*- to that
*easure*ent$
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Assess*ent be#"ns w"th the nurses f"rst encounter w"th the pat"ent and cont"nues throu#hout the pat"ents sta$ The nurse
obta"ns assess*ent data throu#h the health h"stor) phs"cal e+a*"nat"on) and re!"ew of d"a#nost"c stud"es$
The appropr"ate needle s"1e for "nsul"n "n&ect"on "s 3:G and :<=9 lon#$
Res"dual ur"ne "s ur"ne that re*a"ns "n the bladder after !o"d"n#$ The a*ount of res"dual ur"ne "s nor*all :4 to 144 *l$
The f"!e sta#es of the nurs"n# process are assess*ent) nurs"n# d"a#nos"s) plann"n#) "*ple*entat"on) and e!aluat"on$
Assess*ent "s the sta#e of the nurs"n# process "n wh"ch the nurse cont"nuousl collects data to "dent"f a pat"ents actual
and potent"al health needs$
Nurs"n# d"a#nos"s "s the sta#e of the nurs"n# process "n wh"ch the nurse *a'es a cl"n"cal &ud#*ent about "nd"!"dual)
fa*"l) or co**un"t responses to actual or potent"al health proble*s or l"fe processes$
>lann"n# "s the sta#e of the nurs"n# process "n wh"ch the nurse ass"#ns pr"or"t"es to nurs"n# d"a#noses) def"nes short0ter*
and lon#0ter* #oals and e+pected outco*es) and establ"shes the nurs"n# care plan$
I*ple*entat"on "s the sta#e of the nurs"n# process "n wh"ch the nurse puts the nurs"n# care plan "nto act"on) dele#ates
spec"f"c nurs"n# "nter!ent"ons to *e*bers of the nurs"n# tea*) and charts pat"ent responses to nurs"n# "nter!ent"ons$
E!aluat"on "s the sta#e of the nurs"n# process "n wh"ch the nurse co*pares ob&ect"!e and sub&ect"!e data w"th the outco*e
cr"ter"a and) "f needed) *od"f"es the nurs"n# care plan$
Before ad*"n"ster"n# an ?as needed@ pa"n *ed"cat"on) the nurse should as' the pat"ent to "nd"cate the locat"on of the
pa"n$
Aeho!ahs %"tnesses bel"e!e that the shouldnt rece"!e blood co*ponents donated b other people$
To test !"sual acu"t) the nurse should as' the pat"ent to co!er each ee separatel and to read the ee chart w"th #lasses
and w"thout) as appropr"ate$
%hen pro!"d"n# oral care for an unconsc"ous pat"ent) to *"n"*"1e the r"s' of asp"rat"on) the nurse should pos"t"on the
pat"ent on the s"de$
5ur"n# assess*ent of d"stance !"s"on) the pat"ent should stand 34B ,2$1 *- fro* the chart$
/or a #er"atr"c pat"ent or one who "s e+tre*el "ll) the "deal roo* te*perature "s 22C to D2C / ,1=$=C to 3E$EC ;-$
Nor*al roo* hu*"d"t "s F4G to 24G$
(and wash"n# "s the s"n#le best *ethod of l"*"t"n# the spread of *"croor#an"s*s$ Hnce #lo!es are re*o!ed after rout"ne
contact w"th a pat"ent) hands should be washed for 14 to 1: seconds$
To perfor* catheter"1at"on) the nurse should place a wo*an "n the dorsal recu*bent pos"t"on$
A pos"t"!e (o*ans s"#n *a "nd"cate thro*bophleb"t"s$
Electroltes "n a solut"on are *easured "n *"ll"e6u"!alents per l"ter ,*E6<L-$ A *"ll"e6u"!alent "s the nu*ber of
*"ll"#ra*s per 144 *"ll"l"ters of a solut"on$
.etabol"s* occurs "n two phasesI anabol"s* ,the construct"!e phase- and catabol"s* ,the destruct"!e phase-$
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The basal *etabol"c rate "s the a*ount of ener# needed to *a"nta"n essent"al bod funct"ons$ Its *easured when the
pat"ent "s awa'e and rest"n#) hasnt eaten for 1E to 1= hours) and "s "n a co*fortable) war* en!"ron*ent$
The basal *etabol"c rate "s e+pressed "n calor"es consu*ed per hour per '"lo#ra* of bod we"#ht$
5"etar f"ber ,rou#ha#e-) wh"ch "s der"!ed fro* cellulose) suppl"es bul') *a"nta"ns "ntest"nal *ot"l"t) and helps to
establ"sh re#ular bowel hab"ts$
Alcohol "s *etabol"1ed pr"*ar"l "n the l"!er$ S*aller a*ounts are *etabol"1ed b the '"dnes and lun#s$
>etech"ae are t"n) round) purpl"sh red spots that appear on the s'"n and *ucous *e*branes as a result of "ntrader*al or
sub*ucosal he*orrha#e$
>urpura "s a purple d"scolorat"on of the s'"n thats caused b blood e+tra!asat"on$
Accord"n# to the standard precaut"ons reco**ended b the ;enters for 5"sease ;ontrol and >re!ent"on) the nurse
shouldnt recap needles after use$ .ost needle st"c's result fro* *"ssed needle recapp"n#$
The nurse ad*"n"sters a dru# b I$J$ push b us"n# a needle and sr"n#e to del"!er the dose d"rectl "nto a !e"n) I$J$
tub"n#) or a catheter$
%hen chan#"n# the t"es on a tracheosto* tube) the nurse should lea!e the old t"es "n place unt"l the new ones are appl"ed$
A nurse should ha!e ass"stance when chan#"n# the t"es on a tracheosto* tube$
A f"lter "s alwas used for blood transfus"ons$
A four0po"nt ,6uad- cane "s "nd"cated when a pat"ent needs *ore stab"l"t than a re#ular cane can pro!"de$
A #ood wa to be#"n a pat"ent "nter!"ew "s to as') ?%hat *ade ou see' *ed"cal helpK@
%hen car"n# for an pat"ent) the nurse should follow standard precaut"ons for handl"n# blood and bod flu"ds$
>otass"u* ,LM- "s the *ost abundant cat"on "n "ntracellular flu"d$
In the four0po"nt) or alternat"n#) #a"t) the pat"ent f"rst *o!es the r"#ht crutch followed b the left foot and then the left
crutch followed b the r"#ht foot$
In the three0po"nt #a"t) the pat"ent *o!es two crutches and the affected le# s"*ultaneousl and then *o!es the unaffected
le#$
In the two0po"nt #a"t) the pat"ent *o!es the r"#ht le# and the left crutch s"*ultaneousl and then *o!es the left le# and the
r"#ht crutch s"*ultaneousl$
The !"ta*"n B co*ple+) the water0soluble !"ta*"ns that are essent"al for *etabol"s*) "nclude th"a*"ne ,B1-) r"bofla!"n
,B3-) n"ac"n ,BF-) pr"do+"ne ,B2-) and canocobala*"n ,B13-$
%hen be"n# we"#hed) an adult pat"ent should be l"#htl dressed and shoeless$
Before ta'"n# an adults te*perature orall) the nurse should ensure that the pat"ent hasnt s*o'ed or consu*ed hot or
cold substances "n the pre!"ous 1: *"nutes$
The nurse shouldnt ta'e an adults te*perature rectall "f the pat"ent has a card"ac d"sorder) anal les"ons) or bleed"n#
he*orrho"ds or has recentl under#one rectal sur#er$
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In a pat"ent who has a card"ac d"sorder) *easur"n# te*perature rectall *a st"*ulate a !a#al response and lead to
!asod"lat"on and decreased card"ac output$
%hen record"n# pulse a*pl"tude and rhth*) the nurse should use these descr"pt"!e *easuresI MF) bound"n# pulse
,read"l palpable and forceful-N M3) nor*al pulse ,eas"l palpable-N M1) thread or wea' pulse ,d"ff"cult to detect-N and 4)
absent pulse ,not detectable-$
The "ntraoperat"!e per"od be#"ns when a pat"ent "s transferred to the operat"n# roo* bed and ends when the pat"ent "s
ad*"tted to the postanesthes"a care un"t$
Hn the *orn"n# of sur#er) the nurse should ensure that the "nfor*ed consent for* has been s"#nedN that the pat"ent hasnt
ta'en anth"n# b *outh s"nce *"dn"#ht) has ta'en a shower w"th ant"*"crob"al soap) has had *outh care ,w"thout
swallow"n# the water-) has re*o!ed co**on &ewelr) and has rece"!ed preoperat"!e *ed"cat"on as prescr"bedN and that
!"tal s"#ns ha!e been ta'en and recorded$ Art"f"c"al l"*bs and other prostheses are usuall re*o!ed$
;o*fort *easures) such as pos"t"on"n# the pat"ent) rubb"n# the pat"ents bac') and pro!"d"n# a restful en!"ron*ent) *a
decrease the pat"ents need for anal#es"cs or *a enhance the"r effect"!eness$
A dru# has three na*esI #ener"c na*e) wh"ch "s used "n off"c"al publ"cat"onsN trade) or brand) na*e ,such as Tlenol-)
wh"ch "s selected b the dru# co*panN and che*"cal na*e) wh"ch descr"bes the dru#s che*"cal co*pos"t"on$
To a!o"d sta"n"n# the teeth) the pat"ent should ta'e a l"6u"d "ron preparat"on throu#h a straw$
The nurse should use the 80trac' *ethod to ad*"n"ster an I$.$ "n&ect"on of "ron de+tran ,I*feron-$
An or#an"s* *a enter the bod throu#h the nose) *outh) rectu*) ur"nar or reproduct"!e tract) or s'"n$
In descend"n# order) the le!els of consc"ousness are alertness) lethar#) stupor) l"#ht co*a) and deep co*a$
To turn a pat"ent b lo#roll"n#) the nurse folds the pat"ents ar*s across the chestN e+tends the pat"ents le#s and "nserts a
p"llow between the*) "f neededN places a draw sheet under the pat"entN and turns the pat"ent b slowl and #entl pull"n#
on the draw sheet$
The d"aphra#* of the stethoscope "s used to hear h"#h0p"tched sounds) such as breath sounds$
A sl"#ht d"fference "n blood pressure ,: to 14 ** (#- between the r"#ht and the left ar*s "s nor*al$
The nurse should place the blood pressure cuff 19 ,3$: c*- abo!e the antecub"tal fossa$
%hen "nst"ll"n# ophthal*"c o"nt*ents) the nurse should waste the f"rst bead of o"nt*ent and then appl the o"nt*ent fro*
the "nner canthus to the outer canthus$
The nurse should use a le# cuff to *easure blood pressure "n an obese pat"ent$
If a blood pressure cuff "s appl"ed too loosel) the read"n# w"ll be falsel ele!ated$
>tos"s "s droop"n# of the eel"d$
A t"lt table "s useful for a pat"ent w"th a sp"nal cord "n&ur) orthostat"c hpotens"on) or bra"n da*a#e because "t can *o!e
the pat"ent #raduall fro* a hor"1ontal to a !ert"cal ,upr"#ht- pos"t"on$
To perfor* !en"puncture w"th the least "n&ur to the !essel) the nurse should turn the be!el upward when the !essels
lu*en "s lar#er than the needle and turn "t downward when the lu*en "s onl sl"#htl lar#er than the needle$
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To *o!e a pat"ent to the ed#e of the bed for transfer) the nurse should follow these stepsI .o!e the pat"ents head and
shoulders toward the ed#e of the bed$ .o!e the pat"ents feet and le#s to the ed#e of the bed ,crescent pos"t"on-$ >lace
both ar*s well under the pat"ents h"ps) and stra"#hten the bac' wh"le *o!"n# the pat"ent toward the ed#e of the bed$
%hen be"n# *easured for crutches) a pat"ent should wear shoes$
The nurse should attach a restra"nt to the part of the bed fra*e that *o!es w"th the head) not to the *attress or s"de ra"ls$
The *"st "n a *"st tent should ne!er beco*e so dense that "t obscures clear !"sual"1at"on of the pat"ents resp"rator
pattern$
To ad*"n"ster hepar"n subcutaneousl) the nurse should follow these stepsI ;lean) but dont rub) the s"te w"th alcohol$
Stretch the s'"n taut or p"c' up a well0def"ned s'"n fold$ (old the shaft of the needle "n a dart pos"t"on$ Insert the needle
"nto the s'"n at a r"#ht ,O40de#ree- an#le$ /"r*l depress the plun#er) but dont asp"rate$ Lea!e the needle "n place for 14
seconds$ %"thdraw the needle #entl at the an#le of "nsert"on$ Appl pressure to the "n&ect"on s"te w"th an alcohol pad$
/or a s"#*o"doscop) the nurse should place the pat"ent "n the 'nee0chest pos"t"on or S"*s pos"t"on) depend"n# on the
phs"c"ans preference$
.aslows h"erarch of needs *ust be *et "n the follow"n# orderI phs"olo#"c ,o+#en) food) water) se+) rest) and
co*fort-) safet and secur"t) lo!e and belon#"n#) self0estee* and reco#n"t"on) and self0actual"1at"on$
%hen car"n# for a pat"ent who has a naso#astr"c tube) the nurse should appl a water0soluble lubr"cant to the nostr"l to
pre!ent soreness$
5ur"n# #astr"c la!a#e) a naso#astr"c tube "s "nserted) the sto*ach "s flushed) and "n#ested substances are re*o!ed throu#h
the tube$
In docu*ent"n# dra"na#e on a sur#"cal dress"n#) the nurse should "nclude the s"1e) color) and cons"stenc of the dra"na#e
,for e+a*ple) ?14 ** of brown *uco"d dra"na#e noted on dress"n#@-$
To el"c"t Bab"ns'"s refle+) the nurse stro'es the sole of the pat"ents foot w"th a *oderatel sharp ob&ect) such as a
thu*bna"l$
A pos"t"!e Bab"ns'"s refle+ "s shown b dors"fle+"on of the #reat toe and fann"n# out of the other toes$
%hen assess"n# a pat"ent for bladder d"stent"on) the nurse should chec' the contour of the lower abdo*en for a rounded
*ass abo!e the s*phs"s pub"s$
The best wa to pre!ent pressure ulcers "s to repos"t"on the bedr"dden pat"ent at least e!er 3 hours$
Ant"e*bol"s* stoc'"n#s deco*press the superf"c"al blood !essels) reduc"n# the r"s' of thro*bus for*at"on$
In adults) the *ost con!en"ent !e"ns for !en"puncture are the bas"l"c and *ed"an cub"tal !e"ns "n the antecub"tal space$
Two to three hours before be#"nn"n# a tube feed"n#) the nurse should asp"rate the pat"ents sto*ach contents to !er"f that
#astr"c e*pt"n# "s ade6uate$
>eople w"th tpe H blood are cons"dered un"!ersal donors$
>eople w"th tpe AB blood are cons"dered un"!ersal rec"p"ents$
(ert1 ,(1- "s the un"t of *easure*ent of sound fre6uenc$
(ear"n# protect"on "s re6u"red when the sound "ntens"t e+ceeds =E dB$ 5ouble hear"n# protect"on "s re6u"red "f "t e+ceeds
14E dB$
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>rothro*b"n) a clott"n# factor) "s produced "n the l"!er$
If a pat"ent "s *enstruat"n# when a ur"ne sa*ple "s collected) the nurse should note th"s on the laborator re6uest$
5ur"n# lu*bar puncture) the nurse *ust note the "n"t"al "ntracran"al pressure and the color of the cerebrosp"nal flu"d$
If a pat"ent cant cou#h to pro!"de a sputu* sa*ple for culture) a heated aerosol treat*ent can be used to help to obta"n a
sa*ple$
If ee o"nt*ent and eedrops *ust be "nst"lled "n the sa*e ee) the eedrops should be "nst"lled f"rst$
%hen lea!"n# an "solat"on roo*) the nurse should re*o!e her #lo!es before her *as' because fewer patho#ens are on the
*as'$
S'eletal tract"on) wh"ch "s appl"ed to a bone w"th w"re p"ns or ton#s) "s the *ost effect"!e *eans of tract"on$
The total parenteral nutr"t"on solut"on should be stored "n a refr"#erator and re*o!ed F4 to 24 *"nutes before use$
5el"!er of a ch"lled solut"on can cause pa"n) hpother*"a) !enous spas*) and !enous constr"ct"on$
5ru#s arent rout"nel "n&ected "ntra*uscularl "nto ede*atous t"ssue because the *a not be absorbed$
%hen car"n# for a co*atose pat"ent) the nurse should e+pla"n each act"on to the pat"ent "n a nor*al !o"ce$
5entures should be cleaned "n a s"n' thats l"ned w"th a washcloth$
A pat"ent should !o"d w"th"n = hours after sur#er$
An EEG "dent"f"es nor*al and abnor*al bra"n wa!es$
Sa*ples of feces for o!a and paras"te tests should be del"!ered to the laborator w"thout dela and w"thout refr"#erat"on$
The autono*"c ner!ous sste* re#ulates the card"o!ascular and resp"rator sste*s$
%hen pro!"d"n# tracheosto* care) the nurse should "nsert the catheter #entl "nto the tracheosto* tube$ %hen
w"thdraw"n# the catheter) the nurse should appl "nter*"ttent suct"on for no *ore than 1: seconds and use a sl"#ht tw"st"n#
*ot"on$
A low0res"due d"et "ncludes such foods as roasted ch"c'en) r"ce) and pasta$
A rectal tube shouldnt be "nserted for lon#er than 34 *"nutes because "t can "rr"tate the rectal *ucosa and cause loss of
sph"ncter control$
A pat"ents bed bath should proceed "n th"s orderI face) nec') ar*s) hands) chest) abdo*en) bac') le#s) per"neu*$
To pre!ent "n&ur when l"ft"n# and *o!"n# a pat"ent) the nurse should pr"*ar"l use the upper le# *uscles$
>at"ent preparat"on for cholecsto#raph "ncludes "n#est"on of a contrast *ed"u* and a low0fat e!en"n# *eal$
%h"le an occup"ed bed "s be"n# chan#ed) the pat"ent should be co!ered w"th a bath blan'et to pro*ote war*th and
pre!ent e+posure$
Ant"c"pator #r"ef "s *ourn"n# that occurs for an e+tended t"*e when the pat"ent real"1es that death "s "ne!"table$
The follow"n# foods can alter the color of the fecesI beets ,red-) cocoa ,dar' red or brown-) l"cor"ce ,blac'-) sp"nach
,#reen-) and *eat prote"n ,dar' brown-$
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%hen prepar"n# for a s'ull 70ra) the pat"ent should re*o!e all &ewelr and dentures$
The f"#ht0or0fl"#ht response "s a s*pathet"c ner!ous sste* response$
Broncho!es"cular breath sounds "n per"pheral lun# f"elds are abnor*al and su##est pneu*on"a$
%hee1"n# "s an abnor*al) h"#h0p"tched breath sound thats accentuated on e+p"rat"on$
%a+ or a fore"#n bod "n the ear should be flushed out #entl b "rr"#at"on w"th war* sal"ne solut"on$
If a pat"ent co*pla"ns that h"s hear"n# a"d "s ?not wor'"n#)@ the nurse should chec' the sw"tch f"rst to see "f "ts turned on
and then chec' the batter"es$
The nurse should #rade hperact"!e b"ceps and tr"ceps refle+es as ME$
If two ee *ed"cat"ons are prescr"bed for tw"ce0da"l "nst"llat"on) the should be ad*"n"stered : *"nutes apart$
In a postoperat"!e pat"ent) forc"n# flu"ds helps pre!ent const"pat"on$
A nurse *ust pro!"de care "n accordance w"th standards of care establ"shed b the A*er"can Nurses Assoc"at"on) state
re#ulat"ons) and fac"l"t pol"c$
The '"localor"e ,'cal- "s a un"t of ener# *easure*ent that represents the a*ount of heat needed to ra"se the te*perature
of 1 '"lo#ra* of water 1C ;$
As nutr"ents *o!e throu#h the bod) the under#o "n#est"on) d"#est"on) absorpt"on) transport) cell *etabol"s*) and
e+cret"on$
The bod *etabol"1es alcohol at a f"+ed rate) re#ardless of seru* concentrat"on$
In an alcohol"c be!era#e) proof reflects the percenta#e of alcohol *ult"pl"ed b 3$ /or e+a*ple) a 1440proof be!era#e
conta"ns :4G alcohol$
A l"!"n# w"ll "s a w"tnessed docu*ent that states a pat"ents des"re for certa"n tpes of care and treat*ent$ These dec"s"ons
are based on the pat"ents w"shes and !"ews on 6ual"t of l"fe$
The nurse should flush a per"pheral hepar"n loc' e!er = hours ,"f "t wasnt used dur"n# the pre!"ous = hours- and as
needed w"th nor*al sal"ne solut"on to *a"nta"n patenc$
Pual"t assurance "s a *ethod of deter*"n"n# whether nurs"n# act"ons and pract"ces *eet establ"shed standards$
The f"!e r"#hts of *ed"cat"on ad*"n"strat"on are the r"#ht pat"ent) r"#ht dru#) r"#ht dose) r"#ht route of ad*"n"strat"on) and
r"#ht t"*e$
The e!aluat"on phase of the nurs"n# process "s to deter*"ne whether nurs"n# "nter!ent"ons ha!e enabled the pat"ent to
*eet the des"red #oals$
Huts"de of the hosp"tal sett"n#) onl the subl"n#ual and transl"n#ual for*s of n"tro#lcer"n should be used to rel"e!e acute
an#"nal attac's$
The "*ple*entat"on phase of the nurs"n# process "n!ol!es record"n# the pat"ents response to the nurs"n# plan) putt"n# the
nurs"n# plan "nto act"on) dele#at"n# spec"f"c nurs"n# "nter!ent"ons) and coord"nat"n# the pat"ents act"!"t"es$
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NURSING BULLETS _____________ ___________________________________________________________
The >at"ents B"ll of R"#hts offers pat"ents #u"dance and protect"on b stat"n# the respons"b"l"t"es of the hosp"tal and "ts
staff toward pat"ents and the"r fa*"l"es dur"n# hosp"tal"1at"on$
To *"n"*"1e o*"ss"on and d"stort"on of facts) the nurse should record "nfor*at"on as soon as "ts #athered$
%hen assess"n# a pat"ents health h"stor) the nurse should record the current "llness chronolo#"call) be#"nn"n# w"th the
onset of the proble* and cont"nu"n# to the present$
%hen assess"n# a pat"ents health h"stor) the nurse should record the current "llness chronolo#"call) be#"nn"n# w"th the
onset of the proble* and cont"nu"n# to the present$
A nurse shouldnt #"!e false assurance to a pat"ent$
After rece"!"n# preoperat"!e *ed"cat"on) a pat"ent "snt co*petent to s"#n an "nfor*ed consent for*$
%hen l"ft"n# a pat"ent) a nurse uses the we"#ht of her bod "nstead of the stren#th "n her ar*s$
A nurse *a clar"f a phs"c"ans e+planat"on about an operat"on or a procedure to a pat"ent) but *ust refer 6uest"ons
about "nfor*ed consent to the phs"c"an$
%hen obta"n"n# a health h"stor fro* an acutel "ll or a#"tated pat"ent) the nurse should l"*"t 6uest"ons to those that
pro!"de necessar "nfor*at"on$
If a chest dra"na#e sste* l"ne "s bro'en or "nterrupted) the nurse should cla*p the tube "**ed"atel$
The nurse shouldnt use her thu*b to ta'e a pat"ents pulse rate because the thu*b has a pulse that *a be confused w"th
the pat"ents pulse$
An "nsp"rat"on and an e+p"rat"on count as one resp"rat"on$
Eupnea "s nor*al resp"rat"on$
5ur"n# blood pressure *easure*ent) the pat"ent should rest the ar* a#a"nst a surface$ Us"n# *uscle stren#th to hold up
the ar* *a ra"se the blood pressure$
.a&or) unalterable r"s' factors for coronar arter d"sease "nclude hered"t) se+) race) and a#e$
Inspect"on "s the *ost fre6uentl used assess*ent techn"6ue$
/a*"l *e*bers of an elderl person "n a lon#0ter* care fac"l"t should transfer so*e personal "te*s ,such as
photo#raphs) a fa!or"te cha"r) and 'n"c''nac's- to the persons roo* to pro!"de a co*fortable at*osphere$
>ulsus alternans "s a re#ular pulse rhth* w"th alternat"n# wea' and stron# beats$ It occurs "n !entr"cular enlar#e*ent
because the stro'e !olu*e !ar"es w"th each heartbeat$
The upper resp"rator tract war*s and hu*"d"f"es "nsp"red a"r and plas a role "n taste) s*ell) and *ast"cat"on$
S"#ns of accessor *uscle use "nclude shoulder ele!at"on) "ntercostal *uscle retract"on) and scalene and
sternocle"do*asto"d *uscle use dur"n# resp"rat"on$
%hen pat"ents use a+"llar crutches) the"r pal*s should bear the brunt of the we"#ht$
Act"!"t"es of da"l l"!"n# "nclude eat"n#) bath"n#) dress"n#) #roo*"n#) to"let"n#) and "nteract"n# soc"all$
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NURSING BULLETS _____________ ___________________________________________________________
Nor*al #a"t has two phasesI the stance phase) "n wh"ch the pat"ents foot rests on the #round) and the sw"n# phase) "n
wh"ch the pat"ents foot *o!es forward$
The phases of *"tos"s are prophase) *etaphase) anaphase) and telophase$
The nurse should follow standard precaut"ons "n the rout"ne care of all pat"ents$
The nurse should use the bell of the stethoscope to l"sten for !enous hu*s and card"ac *ur*urs$
The nurse can assess a pat"ents #eneral 'nowled#e b as'"n# 6uest"ons such as ?%ho "s the pres"dent of the Un"ted
StatesK@
;old pac's are appl"ed for the f"rst 34 to E= hours after an "n&urN then heat "s appl"ed$ 5ur"n# cold appl"cat"on) the pac' "s
appl"ed for 34 *"nutes and then re*o!ed for 14 to 1: *"nutes to pre!ent refle+ d"lat"on ,rebound pheno*enon- and
frostb"te "n&ur$
The pons "s located abo!e the *edulla and cons"sts of wh"te *atter ,sensor and *otor tracts- and #ra *atter ,refle+
centers-$
The autono*"c ner!ous sste* controls the s*ooth *uscles$
A correctl wr"tten pat"ent #oal e+presses the des"red pat"ent beha!"or) cr"ter"a for *easure*ent) t"*e fra*e for
ach"e!e*ent) and cond"t"ons under wh"ch the beha!"or w"ll occur$ Its de!eloped "n collaborat"on w"th the pat"ent$
>ercuss"on causes f"!e bas"c notesI t*pan ,loud "ntens"t) as heard o!er a #astr"c a"r bubble or puffed out chee'-)
hperresonance ,!er loud) as heard o!er an e*phse*atous lun#-) resonance ,loud) as heard o!er a nor*al lun#-)
dullness ,*ed"u* "ntens"t) as heard o!er the l"!er or other sol"d or#an-) and flatness ,soft) as heard o!er the th"#h-$
The opt"c d"s' "s ellow"sh p"n' and c"rcular) w"th a d"st"nct border$
A pr"*ar d"sab"l"t "s caused b a patholo#"c process$ A secondar d"sab"l"t "s caused b "nact"!"t$
Nurses are co**onl held l"able for fa"l"n# to 'eep an accurate count of spon#es and other de!"ces dur"n# sur#er$
The best d"etar sources of !"ta*"n B2 are l"!er) '"dne) por') sobeans) corn) and whole0#ra"n cereals$
Iron0r"ch foods) such as or#an *eats) nuts) le#u*es) dr"ed fru"t) #reen leaf !e#etables) e##s) and whole #ra"ns) co**onl
ha!e a low water content$
;ollaborat"on "s &o"nt co**un"cat"on and dec"s"on *a'"n# between nurses and phs"c"ans$ Its des"#ned to *eet pat"ents
needs b "nte#rat"n# the care re#"*ens of both profess"ons "nto one co*prehens"!e approach$
Bradcard"a "s a heart rate of fewer than 24 beats<*"nute$
A nurs"n# d"a#nos"s "s a state*ent of a pat"ents actual or potent"al health proble* that can be resol!ed) d"*"n"shed) or
otherw"se chan#ed b nurs"n# "nter!ent"ons$
5ur"n# the assess*ent phase of the nurs"n# process) the nurse collects and anal1es three tpes of dataI health h"stor)
phs"cal e+a*"nat"on) and laborator and d"a#nost"c test data$
The pat"ents health h"stor cons"sts pr"*ar"l of sub&ect"!e data) "nfor*at"on thats suppl"ed b the pat"ent$
The phs"cal e+a*"nat"on "ncludes ob&ect"!e data obta"ned b "nspect"on) palpat"on) percuss"on) and auscultat"on$
%hen docu*ent"n# pat"ent care) the nurse should wr"te le#"bl) use onl standard abbre!"at"ons) and s"#n each entr$ The
nurse should ne!er destro or atte*pt to obl"terate docu*entat"on or lea!e !acant l"nes$
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NURSING BULLETS _____________ ___________________________________________________________
/actors that affect bod te*perature "nclude t"*e of da) a#e) phs"cal act"!"t) phase of *enstrual ccle) and pre#nanc$
The *ost access"ble and co**onl used arter for *easur"n# a pat"ents pulse rate "s the rad"al arter$ To ta'e the pulse
rate) the arter "s co*pressed a#a"nst the rad"us$
In a rest"n# adult) the nor*al pulse rate "s 24 to 144 beats<*"nute$ The rate "s sl"#htl faster "n wo*en than "n *en and
*uch faster "n ch"ldren than "n adults$
Laborator test results are an ob&ect"!e for* of assess*ent data$
The *easure*ent sste*s *ost co**onl used "n cl"n"cal pract"ce are the *etr"c sste*) apothecar"es sste*) and
household sste*$
Before s"#n"n# an "nfor*ed consent for*) the pat"ent should 'now whether other treat*ent opt"ons are a!a"lable and
should understand what w"ll occur dur"n# the preoperat"!e) "ntraoperat"!e) and postoperat"!e phasesN the r"s's "n!ol!edN
and the poss"ble co*pl"cat"ons$ The pat"ent should also ha!e a #eneral "dea of the t"*e re6u"red fro* sur#er to reco!er$
In add"t"on) he should ha!e an opportun"t to as' 6uest"ons$
A pat"ent *ust s"#n a separate "nfor*ed consent for* for each procedure$
5ur"n# percuss"on) the nurse uses 6u"c') sharp tapp"n# of the f"n#ers or hands a#a"nst bod surfaces to produce sounds$
Th"s procedure "s done to deter*"ne the s"1e) shape) pos"t"on) and dens"t of underl"n# or#ans and t"ssuesN el"c"t
tendernessN or assess refle+es$
Ballotte*ent "s a for* of l"#ht palpat"on "n!ol!"n# #entle) repet"t"!e bounc"n# of t"ssues a#a"nst the hand and feel"n# the"r
rebound$
A foot cradle 'eeps bed l"nen off the pat"ents feet to pre!ent s'"n "rr"tat"on and brea'down) espec"all "n a pat"ent who has
per"pheral !ascular d"sease or neuropath$
Gastr"c la!a#e "s flush"n# of the sto*ach and re*o!al of "n#ested substances throu#h a naso#astr"c tube$ Its used to treat
po"son"n# or dru# o!erdose$
5ur"n# the e!aluat"on step of the nurs"n# process) the nurse assesses the pat"ents response to therap$
Bru"ts co**onl "nd"cate l"fe0 or l"*b0threaten"n# !ascular d"sease$
H$U$ *eans each ee$ H$5$ "s the r"#ht ee) and H$S$ "s the left ee$
To re*o!e a pat"ents art"f"c"al ee) the nurse depresses the lower l"d$
The nurse should use a war* sal"ne solut"on to clean an art"f"c"al ee$
A thread pulse "s !er f"ne and scarcel percept"ble$
A+"llar te*perature "s usuall 1C / lower than oral te*perature$
After suct"on"n# a tracheosto* tube) the nurse *ust docu*ent the color) a*ount) cons"stenc) and odor of secret"ons$
Hn a dru# prescr"pt"on) the abbre!"at"on p$c$ *eans that the dru# should be ad*"n"stered after *eals$
After bladder "rr"#at"on) the nurse should docu*ent the a*ount) color) and clar"t of the ur"ne and the presence of clots or
sed"*ent$
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NURSING BULLETS _____________ ___________________________________________________________
After bladder "rr"#at"on) the nurse should docu*ent the a*ount) color) and clar"t of the ur"ne and the presence of clots or
sed"*ent$
Laws re#ard"n# pat"ent self0deter*"nat"on !ar fro* state to state$ Therefore) the nurse *ust be fa*"l"ar w"th the laws of
the state "n wh"ch she wor's$
Gau#e "s the "ns"de d"a*eter of a needleI the s*aller the #au#e) the lar#er the d"a*eter$
An adult nor*all has F3 per*anent teeth$
After turn"n# a pat"ent) the nurse should docu*ent the pos"t"on used) the t"*e that the pat"ent was turned) and the f"nd"n#s
of s'"n assess*ent$
>ERRLA "s an abbre!"at"on for nor*al pup"l assess*ent f"nd"n#sI pup"ls e6ual) round) and react"!e to l"#ht w"th
acco**odat"on$
%hen percuss"n# a pat"ents chest for postural dra"na#e) the nurses hands should be cupped$
%hen *easur"n# a pat"ents pulse) the nurse should assess "ts rate) rhth*) 6ual"t) and stren#th$
Before transferr"n# a pat"ent fro* a bed to a wheelcha"r) the nurse should push the wheelcha"rs footrests to the s"des and
loc' "ts wheels$
%hen assess"n# resp"rat"ons) the nurse should docu*ent the"r rate) rhth*) depth) and 6ual"t$
/or a subcutaneous "n&ect"on) the nurse should use a :<=9 3:G needle$
The notat"on ?AA Q H R F@ "nd"cates that the pat"ent "s awa'e) alert) and or"ented to person ,'nows who he "s-) place
,'nows where he "s-) and t"*e ,'nows the date and t"*e-$
/lu"d "nta'e "ncludes all flu"ds ta'en b *outh) "nclud"n# foods that are l"6u"d at roo* te*perature) such as #elat"n)
custard) and "ce crea*N I$J$ flu"dsN and flu"ds ad*"n"stered "n feed"n# tubes$ /lu"d output "ncludes ur"ne) !o*"tus) and
dra"na#e ,such as fro* a naso#astr"c tube or fro* a wound- as well as blood loss) d"arrhea or feces) and persp"rat"on$
After ad*"n"ster"n# an "ntrader*al "n&ect"on) the nurse shouldnt *assa#e the area because *assa#e can "rr"tate the s"te
and "nterfere w"th results$
%hen ad*"n"ster"n# an "ntrader*al "n&ect"on) the nurse should hold the sr"n#e al*ost flat a#a"nst the pat"ents s'"n ,at
about a 1:0de#ree an#le-) w"th the be!el up$
To obta"n an accurate blood pressure) the nurse should "nflate the *ano*eter to 34 to F4 ** (# abo!e the d"sappearance
of the rad"al pulse before releas"n# the cuff pressure$
The nurse should count an "rre#ular pulse for 1 full *"nute$
A pat"ent who "s !o*"t"n# wh"le l"n# down should be placed "n a lateral pos"t"on to pre!ent asp"rat"on of !o*"tus$
>rophla+"s "s d"sease pre!ent"on$
Bod al"#n*ent "s ach"e!ed when bod parts are "n proper relat"on to the"r natural pos"t"on$
Trust "s the foundat"on of a nurse0pat"ent relat"onsh"p$
Blood pressure "s the force e+erted b the c"rculat"n# !olu*e of blood on the arter"al walls$
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NURSING BULLETS _____________ ___________________________________________________________
.alpract"ce "s a profess"onals wron#ful conduct) "*proper d"schar#e of dut"es) or fa"lure to *eet standards of care that
causes har* to another$
As a #eneral rule) nurses cant refuse a pat"ent care ass"#n*entN howe!er) "n *ost states) the *a refuse to part"c"pate "n
abort"ons$
A nurse can be found ne#l"#ent "f a pat"ent "s "n&ured because the nurse fa"led to perfor* a dut that a reasonable and
prudent person would perfor* or because the nurse perfor*ed an act that a reasonable and prudent person wouldnt
perfor*$
States ha!e enacted Good Sa*ar"tan laws to encoura#e profess"onals to pro!"de *ed"cal ass"stance at the scene of an
acc"dent w"thout fear of a lawsu"t ar"s"n# fro* the ass"stance$ These laws dont appl to care pro!"ded "n a health care
fac"l"t$
A phs"c"an should s"#n !erbal and telephone orders w"th"n the t"*e establ"shed b fac"l"t pol"c) usuall 3E hours$
A co*petent adult has the r"#ht to refuse l"fesa!"n# *ed"cal treat*entN howe!er) the "nd"!"dual should be full "nfor*ed
of the conse6uences of h"s refusal$
Althou#h a pat"ents health record) or chart) "s the health care fac"l"ts phs"cal propert) "ts contents belon# to the
pat"ent$
Before a pat"ents health record can be released to a th"rd part) the pat"ent or the pat"ents le#al #uard"an *ust #"!e
wr"tten consent$
Under the ;ontrolled Substances Act) e!er dose of a controlled dru# thats d"spensed b the phar*ac *ust be accounted
for) whether the dose was ad*"n"stered to a pat"ent or d"scarded acc"dentall$
A nurse cant perfor* dut"es that !"olate a rule or re#ulat"on establ"shed b a state l"cens"n# board) e!en "f the are
author"1ed b a health care fac"l"t or phs"c"an$
To *"n"*"1e "nterrupt"ons dur"n# a pat"ent "nter!"ew) the nurse should select a pr"!ate roo*) preferabl one w"th a door
that can be closed$
In cate#or"1"n# nurs"n# d"a#noses) the nurse addresses l"fe0threaten"n# proble*s f"rst) followed b potent"all l"fe0
threaten"n# concerns$
The *a&or co*ponents of a nurs"n# care plan are outco*e cr"ter"a ,pat"ent #oals- and nurs"n# "nter!ent"ons$
Stand"n# orders) or protocols) establ"sh #u"del"nes for treat"n# a spec"f"c d"sease or set of s*pto*s$
In assess"n# a pat"ents heart) the nurse nor*all f"nds the po"nt of *a+"*al "*pulse at the f"fth "ntercostal space) near the
ape+$
The S1 heard on auscultat"on "s caused b closure of the *"tral and tr"cusp"d !al!es$
To *a"nta"n pac'a#e ster"l"t) the nurse should open a wrappers top flap awa fro* the bod) open each s"de flap b
touch"n# onl the outer part of the wrapper) and open the f"nal flap b #rasp"n# the turned0down corner and pull"n# "t
toward the bod$
The nurse shouldnt dr a pat"ents ear canal or re*o!e wa+ w"th a cotton0t"pped appl"cator because "t *a force ceru*en
a#a"nst the t*pan"c *e*brane$
A pat"ents "dent"f"cat"on bracelet should re*a"n "n place unt"l the pat"ent has been d"schar#ed fro* the health care fac"l"t
and has left the pre*"ses$
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NURSING BULLETS _____________ ___________________________________________________________
The ;ontrolled Substances Act des"#nated f"!e cate#or"es) or schedules) that class"f controlled dru#s accord"n# to the"r
abuse potent"al$
Schedule I dru#s) such as hero"n) ha!e a h"#h abuse potent"al and ha!e no currentl accepted *ed"cal use "n the Un"ted
States$
Schedule II dru#s) such as *orph"ne) op"u*) and *eper"d"ne ,5e*erol-) ha!e a h"#h abuse potent"al) but currentl ha!e
accepted *ed"cal uses$ The"r use *a lead to phs"cal or pscholo#"cal dependence$
Schedule III dru#s) such as pare#or"c and butabarb"tal ,But"sol-) ha!e a lower abuse potent"al than Schedule I or II dru#s$
Abuse of Schedule III dru#s *a lead to *oderate or low phs"cal or pscholo#"cal dependence) or both$
Schedule IJ dru#s) such as chloral hdrate) ha!e a low abuse potent"al co*pared w"th Schedule III dru#s$
Schedule J dru#s) such as cou#h srups that conta"n code"ne) ha!e the lowest abuse potent"al of the controlled substances$
Act"!"t"es of da"l l"!"n# are act"ons that the pat"ent *ust perfor* e!er da to pro!"de self0care and to "nteract w"th
soc"et$
Test"n# of the s"+ card"nal f"elds of #a1e e!aluates the funct"on of all e+traocular *uscles and cran"al ner!es III) IJ) and
JI$
The s"+ tpes of heart *ur*urs are #raded fro* 1 to 2$ A #rade 2 heart *ur*ur can be heard w"th the stethoscope sl"#htl
ra"sed fro* the chest$
The *ost "*portant #oal to "nclude "n a care plan "s the pat"ents #oal$
/ru"ts are h"#h "n f"ber and low "n prote"n) and should be o*"tted fro* a low0res"due d"et$
The nurse should use an ob&ect"!e scale to assess and 6uant"f pa"n$ >ostoperat"!e pa"n !ar"es #reatl a*on# "nd"!"duals$
>ost*orte* care "ncludes clean"n# and prepar"n# the deceased pat"ent for fa*"l !"ew"n#) arran#"n# transportat"on to the
*or#ue or funeral ho*e) and deter*"n"n# the d"spos"t"on of belon#"n#s$
The nurse should pro!"de honest answers to the pat"ents 6uest"ons$
."l' shouldnt be "ncluded "n a clear l"6u"d d"et$
%hen car"n# for an "nfant) a ch"ld) or a confused pat"ent) cons"stenc "n nurs"n# personnel "s para*ount$
The hpothala*us secretes !asopress"n and o+toc"n) wh"ch are stored "n the p"tu"tar #land$
The three *e*branes that enclose the bra"n and sp"nal cord are the dura *ater) p"a *ater) and arachno"d$
A naso#astr"c tube "s used to re*o!e flu"d and #as fro* the s*all "ntest"ne preoperat"!el or postoperat"!el$
>scholo#"sts) phs"cal therap"sts) and ch"ropractors arent author"1ed to wr"te prescr"pt"ons for dru#s$
The area around a sto*a "s cleaned w"th *"ld soap and water$
Je#etables ha!e a h"#h f"ber content$
The nurse should use a tubercul"n sr"n#e to ad*"n"ster a subcutaneous "n&ect"on of less than 1 *l$
/or adults) subcutaneous "n&ect"ons re6u"re a 3:G 19 needleN for "nfants) ch"ldren) elderl) or !er th"n pat"ents) the
re6u"re a 3:G to 3DG S9 needle$
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1E
NURSING BULLETS _____________ ___________________________________________________________
Before ad*"n"ster"n# a dru#) the nurse should "dent"f the pat"ent b chec'"n# the "dent"f"cat"on band and as'"n# the
pat"ent to state h"s na*e$
To clean the s'"n before an "n&ect"on) the nurse uses a ster"le alcohol swab to w"pe fro* the center of the s"te outward "n a
c"rcular *ot"on$
The nurse should "n&ect hepar"n deep "nto subcutaneous t"ssue at a O40de#ree an#le ,perpend"cular to the s'"n- to pre!ent
s'"n "rr"tat"on$
If blood "s asp"rated "nto the sr"n#e before an I$.$ "n&ect"on) the nurse should w"thdraw the needle) prepare another
sr"n#e) and repeat the procedure$
The nurse shouldnt cut the pat"ents ha"r w"thout wr"tten consent fro* the pat"ent or an appropr"ate relat"!e$
If bleed"n# occurs after an "n&ect"on) the nurse should appl pressure unt"l the bleed"n# stops$ If bru"s"n# occurs) the nurse
should *on"tor the s"te for an enlar#"n# he*ato*a$
%hen pro!"d"n# ha"r and scalp care) the nurse should be#"n co*b"n# at the end of the ha"r and wor' toward the head$
The fre6uenc of pat"ent ha"r care depends on the len#th and te+ture of the ha"r) the durat"on of hosp"tal"1at"on) and the
pat"ents cond"t"on$
>roper funct"on of a hear"n# a"d re6u"res careful handl"n# dur"n# "nsert"on and re*o!al) re#ular clean"n# of the ear p"ece
to pre!ent wa+ bu"ldup) and pro*pt replace*ent of dead batter"es$
The hear"n# a"d thats *ar'ed w"th a blue dot "s for the left earN the one w"th a red dot "s for the r"#ht ear$
A hear"n# a"d shouldnt be e+posed to heat or hu*"d"t and shouldnt be "**ersed "n water$
The nurse should "nstruct the pat"ent to a!o"d us"n# ha"r spra wh"le wear"n# a hear"n# a"d$
The f"!e branches of phar*acolo# are phar*aco'"net"cs) phar*acodna*"cs) phar*acotherapeut"cs) to+"colo#) and
phar*aco#nos$
The nurse should re*o!e heel protectors e!er = hours to "nspect the foot for s"#ns of s'"n brea'down$
(eat "s appl"ed to pro*ote !asod"lat"on) wh"ch reduces pa"n caused b "nfla**at"on$
A sutured sur#"cal "nc"s"on "s an e+a*ple of heal"n# b f"rst "ntent"on ,heal"n# d"rectl) w"thout #ranulat"on-$
(eal"n# b secondar "ntent"on ,heal"n# b #ranulat"on- "s closure of the wound when #ranulat"on t"ssue f"lls the defect
and allows reep"thel"al"1at"on to occur) be#"nn"n# at the wound ed#es and cont"nu"n# to the center) unt"l the ent"re wound
"s co!ered$
Lelo"d for*at"on "s an abnor*al"t "n heal"n# thats character"1ed b o!er#rowth of scar t"ssue at the wound s"te$
The nurse should ad*"n"ster proca"ne pen"c"ll"n b deep I$.$ "n&ect"on "n the upper outer port"on of the buttoc's "n the
adult or "n the *"dlateral th"#h "n the ch"ld$ The nurse shouldnt *assa#e the "n&ect"on s"te$
An ascend"n# colosto* dra"ns flu"d feces$ A descend"n# colosto* dra"ns sol"d fecal *atter$
A folded towel ,scrotal br"d#e- can pro!"de scrotal support for the pat"ent w"th scrotal ede*a caused b !asecto*)
ep"d"d*"t"s) or orch"t"s$
%hen #"!"n# an "n&ect"on to a pat"ent who has a bleed"n# d"sorder) the nurse should use a s*all0#au#e needle and appl
pressure to the s"te for : *"nutes after the "n&ect"on$
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>latelets are the s*allest and *ost fra#"le for*ed ele*ent of the blood and are essent"al for coa#ulat"on$
To "nsert a naso#astr"c tube) the nurse "nstructs the pat"ent to t"lt the head bac' sl"#htl and then "nserts the tube$ %hen the
nurse feels the tube cur!"n# at the pharn+) the nurse should tell the pat"ent to t"lt the head forward to close the trachea
and open the esopha#us b swallow"n#$ ,S"ps of water can fac"l"tate th"s act"on$-
/a*"l"es w"th lo!ed ones "n "ntens"!e care un"ts report that the"r four *ost "*portant needs are to ha!e the"r 6uest"ons
answered honestl) to be assured that the best poss"ble care "s be"n# pro!"ded) to 'now the pat"ents pro#nos"s) and to feel
that there "s hope of reco!er$
5ouble0b"nd co**un"cat"on occurs when the !erbal *essa#e contrad"cts the non!erbal *essa#e and the rece"!er "s
unsure of wh"ch *essa#e to respond to$
A non&ud#*ental att"tude d"splaed b a nurse shows that she ne"ther appro!es nor d"sappro!es of the pat"ent$
Tar#et s*pto*s are those that the pat"ent f"nds *ost d"stress"n#$
A pat"ent should be ad!"sed to ta'e asp"r"n on an e*pt sto*ach) w"th a full #lass of water) and should a!o"d ac"d"c foods
such as coffee) c"trus fru"ts) and cola$
/or e!er pat"ent proble*) there "s a nurs"n# d"a#nos"sN for e!er nurs"n# d"a#nos"s) there "s a #oalN and for e!er #oal)
there are "nter!ent"ons des"#ned to *a'e the #oal a real"t$ The 'es to answer"n# e+a*"nat"on 6uest"ons correctl are
"dent"f"n# the proble* presented) for*ulat"n# a #oal for the proble*) and select"n# the "nter!ent"on fro* the cho"ces
pro!"ded that w"ll enable the pat"ent to reach that #oal$
/"del"t *eans loalt and can be shown as a co**"t*ent to the profess"on of nurs"n# and to the pat"ent$
Ad*"n"ster"n# an I$.$ "n&ect"on a#a"nst the pat"ents w"ll and w"thout le#al author"t "s batter$
An e+a*ple of a th"rd0part paer "s an "nsurance co*pan$
The for*ula for calculat"n# the drops per *"nute for an I$J$ "nfus"on "s as followsI ,!olu*e to be "nfused R dr"p factor- T
t"*e "n *"nutes U drops<*"nute
Hn0call *ed"cat"on should be #"!en w"th"n : *"nutes of the call$
Usuall) the best *ethod to deter*"ne a pat"ents cultural or sp"r"tual needs "s to as' h"*$
An "nc"dent report or unusual occurrence report "snt part of a pat"ents record) but "s an "n0house docu*ent thats used for
the purpose of correct"n# the proble*$
;r"t"cal pathwas are a *ult"d"sc"pl"nar #u"del"ne for pat"ent care$
%hen pr"or"t"1"n# nurs"n# d"a#noses) the follow"n# h"erarch should be usedI >roble*s assoc"ated w"th the a"rwa) those
concern"n# breath"n#) and those related to c"rculat"on$
The two nurs"n# d"a#noses that ha!e the h"#hest pr"or"t that the nurse can ass"#n are Ineffect"!e a"rwa clearance and
Ineffect"!e breath"n# pattern$
A sub&ect"!e s"#n that a s"t1 bath has been effect"!e "s the pat"ents e+press"on of decreased pa"n or d"sco*fort$
/or the nurs"n# d"a#nos"s 5ef"c"ent d"!ers"onal act"!"t to be !al"d) the pat"ent *ust state that hes ?bored)@ that he has
?noth"n# to do)@ or words to that effect$
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The *ost appropr"ate nurs"n# d"a#nos"s for an "nd"!"dual who doesnt spea' En#l"sh "s I*pa"red !erbal co**un"cat"on
related to "nab"l"t to spea' do*"nant lan#ua#e ,En#l"sh-$
The fa*"l of a pat"ent who has been d"a#nosed as hear"n# "*pa"red should be "nstructed to face the "nd"!"dual when the
spea' to h"*$
Before "nst"ll"n# *ed"cat"on "nto the ear of a pat"ent who "s up to a#e F) the nurse should pull the p"nna down and bac' to
stra"#hten the eustach"an tube$
To pre!ent "n&ur to the cornea when ad*"n"ster"n# eedrops) the nurse should waste the f"rst drop and "nst"ll the dru# "n
the lower con&unct"!al sac$
After ad*"n"ster"n# ee o"nt*ent) the nurse should tw"st the *ed"cat"on tube to detach the o"nt*ent$
%hen the nurse re*o!es #lo!es and a *as') she should re*o!e the #lo!es f"rst$ The are so"led and are l"'el to conta"n
patho#ens$
;rutches should be placed 29 ,1:$3 c*- "n front of the pat"ent and 29 to the s"de to for* a tr"pod arran#e*ent$
L"sten"n# "s the *ost effect"!e co**un"cat"on techn"6ue$
Before teach"n# an procedure to a pat"ent) the nurse *ust assess the pat"ents current 'nowled#e and w"ll"n#ness to learn$
>rocess record"n# "s a *ethod of e!aluat"n# ones co**un"cat"on effect"!eness$
%hen feed"n# an elderl pat"ent) the nurse should l"*"t h"#h0carbohdrate foods because of the r"s' of #lucose
"ntolerance$
%hen feed"n# an elderl pat"ent) essent"al foods should be #"!en f"rst$
>ass"!e ran#e of *ot"on *a"nta"ns &o"nt *ob"l"t$ Res"st"!e e+erc"ses "ncrease *uscle *ass$
Iso*etr"c e+erc"ses are perfor*ed on an e+tre*"t thats "n a cast$
A bac' rub "s an e+a*ple of the #ate0control theor of pa"n$
Anth"n# thats located below the wa"st "s cons"dered unster"leN a ster"le f"eld beco*es unster"le when "t co*es "n contact
w"th an unster"le "te*N a ster"le f"eld *ust be *on"tored cont"nuouslN and a border of 19 ,3$: c*- around a ster"le f"eld "s
cons"dered unster"le$
A ?sh"ft to the left@ "s e!"dent when the nu*ber of "**ature cells ,bands- "n the blood "ncreases to f"#ht an "nfect"on$
A ?sh"ft to the r"#ht@ "s e!"dent when the nu*ber of *ature cells "n the blood "ncreases) as seen "n ad!anced l"!er d"sease
and pern"c"ous ane*"a$
Before ad*"n"ster"n# preoperat"!e *ed"cat"on) the nurse should ensure that an "nfor*ed consent for* has been s"#ned and
attached to the pat"ents record$
A nurse should spend no *ore than F4 *"nutes per =0hour sh"ft pro!"d"n# care to a pat"ent who has a rad"at"on "*plant$
A nurse shouldnt be ass"#ned to care for *ore than one pat"ent who has a rad"at"on "*plant$
Lon#0handled forceps and a lead0l"ned conta"ner should be a!a"lable "n the roo* of a pat"ent who has a rad"at"on "*plant$
Usuall) pat"ents who ha!e the sa*e "nfect"on and are "n str"ct "solat"on can share a roo*$
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5"seases that re6u"re str"ct "solat"on "nclude ch"c'enpo+) d"phther"a) and !"ral he*orrha#"c fe!ers such as .arbur#
d"sease$
/or the pat"ent who ab"des b Aew"sh custo*) *"l' and *eat shouldnt be ser!ed at the sa*e *eal$
%hether the pat"ent can perfor* a procedure ,pscho*otor do*a"n of learn"n#- "s a better "nd"cator of the effect"!eness of
pat"ent teach"n# than whether the pat"ent can s"*pl state the steps "n!ol!ed "n the procedure ,co#n"t"!e do*a"n of
learn"n#-$
Accord"n# to Er"' Er"'son) de!elop*ental sta#es are trust !ersus *"strust ,b"rth to 1= *onths-) autono* !ersus sha*e
and doubt ,1= *onths to a#e F-) "n"t"at"!e !ersus #u"lt ,a#es F to :-) "ndustr !ersus "nfer"or"t ,a#es : to 13-) "dent"t
!ersus "dent"t d"ffus"on ,a#es 13 to 1=-) "nt"*ac !ersus "solat"on ,a#es 1= to 3:-) #enerat"!"t !ersus sta#nat"on ,a#es 3:
to 24-) and e#o "nte#r"t !ersus despa"r ,older than a#e 24-$
%hen co**un"cat"n# w"th a hear"n# "*pa"red pat"ent) the nurse should face h"*$
An appropr"ate nurs"n# "nter!ent"on for the spouse of a pat"ent who has a ser"ous "ncapac"tat"n# d"sease "s to help h"* to
*ob"l"1e a support sste*$
(perpre+"a "s e+tre*e ele!at"on "n te*perature abo!e 142C / ,E1$1C ;-$
."l' "s h"#h "n sod"u* and low "n "ron$
%hen a pat"ent e+presses concern about a health0related "ssue) before address"n# the concern) the nurse should assess the
pat"ents le!el of 'nowled#e$
The *ost effect"!e wa to reduce a fe!er "s to ad*"n"ster an ant"pret"c) wh"ch lowers the te*perature set po"nt$
%hen a pat"ent "s "ll) "ts essent"al for the *e*bers of h"s fa*"l to *a"nta"n co**un"cat"on about h"s health needs$
Ethnocentr"s* "s the un"!ersal bel"ef that ones wa of l"fe "s super"or to others$
%hen a nurse "s co**un"cat"n# w"th a pat"ent throu#h an "nterpreter) the nurse should spea' to the pat"ent and the
"nterpreter$
In accordance w"th the ?hot0cold@ sste* used b so*e .e+"cans) >uerto R"cans) and other ("span"c and Lat"no #roups)
*ost foods) be!era#es) herbs) and dru#s are descr"bed as ?cold$@
>re&ud"ce "s a host"le att"tude toward "nd"!"duals of a part"cular #roup$
5"scr"*"nat"on "s preferent"al treat*ent of "nd"!"duals of a part"cular #roup$ Its usuall d"scussed "n a ne#at"!e sense$
Increased #astr"c *ot"l"t "nterferes w"th the absorpt"on of oral dru#s$
The three phases of the therapeut"c relat"onsh"p are or"entat"on) wor'"n#) and ter*"nat"on$
>at"ents often e+h"b"t res"st"!e and challen#"n# beha!"ors "n the or"entat"on phase of the therapeut"c relat"onsh"p$
Abdo*"nal assess*ent "s perfor*ed "n the follow"n# orderI "nspect"on) auscultat"on) palpat"on) and percuss"on$
%hen *easur"n# blood pressure "n a neonate) the nurse should select a cuff thats no less than one0half and no *ore than
two0th"rds the len#th of the e+tre*"t thats used$
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%hen ad*"n"ster"n# a dru# b 80trac') the nurse shouldnt use the sa*e needle that was used to draw the dru# "nto the
sr"n#e because do"n# so could sta"n the s'"n$
S"tes for "ntrader*al "n&ect"on "nclude the "nner ar*) the upper chest) and on the bac') under the scapula$
%hen e!aluat"n# whether an answer on an e+a*"nat"on "s correct) the nurse should cons"der whether the act"on thats
descr"bed pro*otes autono* ,"ndependence-) safet) self0estee*) and a sense of belon#"n#$
%hen answer"n# a 6uest"on on the N;LE7 e+a*"nat"on) the student should cons"der the cue ,the st"*ulus for a thou#ht-
and the "nference ,the thou#ht- to deter*"ne whether the "nference "s correct$ %hen "n doubt) the nurse should select an
answer that "nd"cates the need for further "nfor*at"on to el"*"nate a*b"#u"t$ /or e+a*ple) the pat"ent co*pla"ns of chest
pa"n ,the st"*ulus for the thou#ht- and the nurse "nfers that the pat"ent "s ha!"n# card"ac pa"n ,the thou#ht-$ In th"s case)
the nurse hasnt conf"r*ed whether the pa"n "s card"ac$ It would be *ore appropr"ate to *a'e further assess*ents$
Jerac"t "s truth and "s an essent"al co*ponent of a therapeut"c relat"onsh"p between a health care pro!"der and h"s pat"ent$
Benef"cence "s the dut to do no har* and the dut to do #ood$ Theres an obl"#at"on "n pat"ent care to do no har* and an
e6ual obl"#at"on to ass"st the pat"ent$
Non*alef"cence "s the dut to do no har*$
/res AB;5E cascade pro!"des a fra*ewor' for pr"or"t"1"n# care b "dent"f"n# the *ost "*portant treat*ent concerns$
A U A"rwa$ Th"s cate#or "ncludes e!erth"n# that affects a patent a"rwa) "nclud"n# a fore"#n ob&ect) flu"d fro* an upper
resp"rator "nfect"on) and ede*a fro* trau*a or an aller#"c react"on$
B U Breath"n#$ Th"s cate#or "ncludes e!erth"n# that affects the breath"n# pattern) "nclud"n# hper!ent"lat"on or
hpo!ent"lat"on and abnor*al breath"n# patterns) such as Lorsa'offs) B"ots) or ;hene0Sto'es resp"rat"on$
; U ;"rculat"on$ Th"s cate#or "ncludes e!erth"n# that affects the c"rculat"on) "nclud"n# flu"d and electrolte d"sturbances
and d"sease processes that affect card"ac output$
5 U 5"sease processes$ If the pat"ent has no proble* w"th the a"rwa) breath"n#) or c"rculat"on) then the nurse should
e!aluate the d"sease processes) #"!"n# pr"or"t to the d"sease process that poses the #reatest "**ed"ate r"s'$ /or e+a*ple)
"f a pat"ent has ter*"nal cancer and hpo#lce*"a) hpo#lce*"a "s a *ore "**ed"ate concern$
E U E!erth"n# else$ Th"s cate#or "ncludes such "ssues as wr"t"n# an "nc"dent report and co*plet"n# the pat"ent chart$
%hen e!aluat"n# needs) th"s cate#or "s ne!er the h"#hest pr"or"t$
%hen answer"n# a 6uest"on on an N;LE7 e+a*"nat"on) the bas"c rule "s ?assess before act"on$@ The student should
e!aluate each poss"ble answer carefull$ Usuall) se!eral answers reflect the "*ple*entat"on phase of nurs"n# and one or
two reflect the assess*ent phase$ In th"s case) the best cho"ce "s an assess*ent response unless a spec"f"c course of act"on
"s clearl "nd"cated$
Rule ut"l"tar"an"s* "s 'nown as the ?#reatest #ood for the #reatest nu*ber of people@ theor$
E#al"tar"an theor e*phas"1es that e6ual access to #oods and ser!"ces *ust be pro!"ded to the less fortunate b an affluent
soc"et$
Act"!e euthanas"a "s act"!el help"n# a person to d"e$
Bra"n death "s "rre!ers"ble cessat"on of all bra"n funct"on$
>ass"!e euthanas"a "s stopp"n# the therap thats susta"n"n# l"fe$
A th"rd0part paer "s an "nsurance co*pan$
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Ut"l"1at"on re!"ew "s perfor*ed to deter*"ne whether the care pro!"ded to a pat"ent was appropr"ate and cost0effect"!e$
A !alue cohort "s a #roup of people who e+per"enced an out0of0the0ord"nar e!ent that shaped the"r !alues$
Joluntar euthanas"a "s act"!el help"n# a pat"ent to d"e at the pat"ents re6uest$
Bananas) c"trus fru"ts) and potatoes are #ood sources of potass"u*$
Good sources of *a#nes"u* "nclude f"sh) nuts) and #ra"ns$
Beef) osters) shr"*p) scallops) sp"nach) beets) and #reens are #ood sources of "ron$
Intrathecal "n&ect"on "s ad*"n"ster"n# a dru# throu#h the sp"ne$
%hen a pat"ent as's a 6uest"on or *a'es a state*ent thats e*ot"onall char#ed) the nurse should respond to the e*ot"on
beh"nd the state*ent or 6uest"on rather than to whats be"n# sa"d or as'ed$
The steps of the tra&ector0nurs"n# *odel are as followsI
Step 1I Ident"f"n# the tra&ector phase
Step 3I Ident"f"n# the proble*s and establ"sh"n# #oals
Step FI Establ"sh"n# a plan to *eet the #oals
Step EI Ident"f"n# factors that fac"l"tate or h"nder atta"n*ent of the #oals
Step :I I*ple*ent"n# "nter!ent"ons
Step 2I E!aluat"n# the effect"!eness of the "nter!ent"ons
A ("ndu pat"ent "s l"'el to re6uest a !e#etar"an d"et$
>a"n threshold) or pa"n sensat"on) "s the "n"t"al po"nt at wh"ch a pat"ent feels pa"n$
The d"fference between acute pa"n and chron"c pa"n "s "ts durat"on$
Referred pa"n "s pa"n thats felt at a s"te other than "ts or"#"n$
Alle!"at"n# pa"n b perfor*"n# a bac' *assa#e "s cons"stent w"th the #ate control theor$
Ro*ber#s test "s a test for balance or #a"t$
>a"n see*s *ore "ntense at n"#ht because the pat"ent "snt d"stracted b da"l act"!"t"es$
Hlder pat"ents co**onl dont report pa"n because of fear of treat*ent) l"festle chan#es) or dependenc$
No por' or por' products are allowed "n a .usl"* d"et$
Two #oals of (ealth >eople 3414 areI
(elp "nd"!"duals of all a#es to "ncrease the 6ual"t of l"fe and the nu*ber of ears of opt"*al health
El"*"nate health d"spar"t"es a*on# d"fferent se#*ents of the populat"on$
A co**un"t nurse "s ser!"n# as a pat"ents ad!ocate "f she tells a *alnour"shed pat"ent to #o to a *eal pro#ra* at a local
par'$
If a pat"ent "snt follow"n# h"s treat*ent plan) the nurse should f"rst as' wh$
/alls are the lead"n# cause of "n&ur "n elderl people$
>r"*ar pre!ent"on "s true pre!ent"on$ E+a*ples are "**un"1at"ons) we"#ht control) and s*o'"n# cessat"on$
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Secondar pre!ent"on "s earl detect"on$ E+a*ples "nclude pur"f"ed prote"n der"!at"!e ,>>5-) breast self0e+a*"nat"on)
test"cular self0e+a*"nat"on) and chest 70ra$
Tert"ar pre!ent"on "s treat*ent to pre!ent lon#0ter* co*pl"cat"ons$
A pat"ent "nd"cates that hes co*"n# to ter*s w"th ha!"n# a chron"c d"sease when he sas) ?I* ne!er #o"n# to #et an
better$@
Hn not"c"n# rel"#"ous art"facts and l"terature on a pat"ents n"#ht stand) a culturall aware nurse would as' the pat"ent the
*ean"n# of the "te*s$
A .e+"can pat"ent *a re6uest the "nter!ent"on of a curandero) or fa"th healer) who "n!ol!es the fa*"l "n heal"n# the
pat"ent$
In an "nfant) the nor*al he*o#lob"n !alue "s 13 #<dl$
The n"tro#en balance est"*ates the d"fference between the "nta'e and use of prote"n$
.ost of the absorpt"on of water occurs "n the lar#e "ntest"ne$
.ost nutr"ents are absorbed "n the s*all "ntest"ne$
%hen assess"n# a pat"ents eat"n# hab"ts) the nurse should as') ?%hat ha!e ou eaten "n the last 3E hoursK@
A !e#an d"et should "nclude an abundant suppl of f"ber$
A hpoton"c ene*a softens the feces) d"stends the colon) and st"*ulates per"stals"s$
/"rst0*orn"n# ur"ne pro!"des the best sa*ple to *easure #lucose) 'etone) p() and spec"f"c #ra!"t !alues$
To "nduce sleep) the f"rst step "s to *"n"*"1e en!"ron*ental st"*ul"$
Before *o!"n# a pat"ent) the nurse should assess the pat"ents phs"cal ab"l"t"es and ab"l"t to understand "nstruct"ons as
well as the a*ount of stren#th re6u"red to *o!e the pat"ent$
To lose 1 lb ,4$: '#- "n 1 wee') the pat"ent *ust decrease h"s wee'l "nta'e b F):44 calor"es ,appro+"*atel :44 calor"es
da"l-$ To lose 3 lb ,1 '#- "n 1 wee') the pat"ent *ust decrease h"s wee'l calor"c "nta'e b D)444 calor"es ,appro+"*atel
1)444 calor"es da"l-$
To a!o"d shear"n# force "n&ur) a pat"ent who "s co*pletel "**ob"le "s l"fted on a sheet$
To "nsert a catheter fro* the nose throu#h the trachea for suct"on) the nurse should as' the pat"ent to swallow$
J"ta*"n ; "s needed for colla#en product"on$
Hnl the pat"ent can descr"be h"s pa"n accuratel$
;utaneous st"*ulat"on creates the release of endorph"ns that bloc' the trans*"ss"on of pa"n st"*ul"$
>at"ent0controlled anal#es"a "s a safe *ethod to rel"e!e acute pa"n caused b sur#"cal "nc"s"on) trau*at"c "n&ur) labor and
del"!er) or cancer$
An As"an A*er"can or European A*er"can tp"call places d"stance between h"*self and others when co**un"cat"n#$
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The pat"ent who bel"e!es "n a sc"ent"f"c) or b"o*ed"cal) approach to health "s l"'el to e+pect a dru#) treat*ent) or sur#er
to cure "llness$
;hron"c "llnesses occur "n !er oun# as well as *"ddle0a#ed and !er old people$
The tra&ector fra*ewor' for chron"c "llness states that preferences about da"l l"fe act"!"t"es affect treat*ent dec"s"ons$
E+acerbat"ons of chron"c d"sease usuall cause the pat"ent to see' treat*ent and *a lead to hosp"tal"1at"on$
School health pro#ra*s pro!"de cost0effect"!e health care for low0"nco*e fa*"l"es and those who ha!e no health
"nsurance$
;olle#"al"t "s the pro*ot"on of collaborat"on) de!elop*ent) and "nterdependence a*on# *e*bers of a profess"on$
A chan#e a#ent "s an "nd"!"dual who reco#n"1es a need for chan#e or "s selected to *a'e a chan#e w"th"n an establ"shed
ent"t) such as a hosp"tal$
The pat"ents b"ll of r"#hts was "ntroduced b the A*er"can (osp"tal Assoc"at"on$
Abandon*ent "s pre*ature ter*"nat"on of treat*ent w"thout the pat"ents per*"ss"on and w"thout appropr"ate rel"ef of
s*pto*s$
Jalues clar"f"cat"on "s a process that "nd"!"duals use to pr"or"t"1e the"r personal !alues$
5"str"but"!e &ust"ce "s a pr"nc"ple that pro*otes e6ual treat*ent for all$
."l' and *"l' products) poultr) #ra"ns) and f"sh are #ood sources of phosphate$
The best wa to pre!ent falls at n"#ht "n an or"ented) but restless) elderl pat"ent "s to ra"se the s"de ra"ls$
B the end of the or"entat"on phase) the pat"ent should be#"n to trust the nurse$
/alls "n the elderl are l"'el to be caused b poor !"s"on$
Barr"ers to co**un"cat"on "nclude lan#ua#e def"c"ts) sensor def"c"ts) co#n"t"!e "*pa"r*ents) structural def"c"ts) and
parals"s$
The three ele*ents that are necessar for a f"re are heat) o+#en) and co*bust"ble *ater"al$
Sebaceous #lands lubr"cate the s'"n$
To chec' for petech"ae "n a dar'0s'"nned pat"ent) the nurse should assess the oral *ucosa$
To put on a ster"le #lo!e) the nurse should p"c' up the f"rst #lo!e at the folded border and ad&ust the f"n#ers when both
#lo!es are on$
To "ncrease pat"ent co*fort) the nurse should let the alcohol dr before #"!"n# an "ntra*uscular "n&ect"on$
Treat*ent for a sta#e 1 ulcer on the heels "ncludes heel protectors$
Se!enth05a Ad!ent"sts are usuall !e#etar"ans$
Endorph"ns are *orph"ne0l"'e substances that produce a feel"n# of well0be"n#$
>a"n tolerance "s the *a+"*u* a*ount and durat"on of pa"n that an "nd"!"dual "s w"ll"n# to endure$
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NURSING BULLETS _____________ ___________________________________________________________
MATERNAL ' CHILD HEALTH NURSING
Unl"'e false labor) true labor produces re#ular rhth*"c contract"ons) abdo*"nal d"sco*fort) pro#ress"!e descent of the
fetus) blood show) and pro#ress"!e efface*ent and d"lat"on of the cer!"+$
To help a *other brea' the suct"on of her breast0feed"n# "nfant) the nurse should teach her to "nsert a f"n#er at the corner
of the "nfants *outh$
Ad*"n"ster"n# h"#h le!els of o+#en to a pre*ature neonate can cause bl"ndness as a result of retrolental f"broplas"a$
A*n"oto* "s art"f"c"al rupture of the a*n"ot"c *e*branes$
5ur"n# pre#nanc) we"#ht #a"n a!era#es 3: to F4 lb ,11 to 1F$: '#-$
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3F
NURSING BULLETS _____________ ___________________________________________________________
Rubella has a terato#en"c effect on the fetus dur"n# the f"rst tr"*ester$ It produces abnor*al"t"es "n up to E4G of cases
w"thout "nterrupt"n# the pre#nanc$
I**un"t to rubella can be *easured b a he*a##lut"nat"on "nh"b"t"on test ,rubella t"ter-$ Th"s test "dent"f"es e+posure to
rubella "nfect"on and deter*"nes suscept"b"l"t "n pre#nant wo*en$ In a wo*an) a t"ter #reater than 1I= "nd"cates
"**un"t$
%hen used to descr"be the de#ree of fetal descent dur"n# labor) float"n# *eans the present"n# part "snt en#a#ed "n the
pel!"c "nlet) but "s freel *o!able ,ballotable- abo!e the pel!"c "nlet$
%hen used to descr"be the de#ree of fetal descent) en#a#e*ent *eans when the lar#est d"a*eter of the present"n# part has
passed throu#h the pel!"c "nlet$
/etal stat"on "nd"cates the locat"on of the present"n# part "n relat"on to the "sch"al sp"ne$ Its descr"bed as V1) V3) VF) VE) or
V: to "nd"cate the nu*ber of cent"*eters abo!e the le!el of the "sch"al sp"neN stat"on V: "s at the pel!"c "nlet$
/etal stat"on also "s descr"bed as M1) M3) MF) ME) or M: to "nd"cate the nu*ber of cent"*eters "t "s below the le!el of the
"sch"al sp"neN stat"on 4 "s at the le!el of the "sch"al sp"ne$
5ur"n# the f"rst sta#e of labor) the s"de0l"n# pos"t"on usuall pro!"des the #reatest de#ree of co*fort) althou#h the pat"ent
*a assu*e an co*fortable pos"t"on$
5ur"n# del"!er) "f the u*b"l"cal cord cant be loosened and sl"pped fro* around the neonates nec') "t should be cla*ped
w"th two cla*ps and cut between the cla*ps$
An Ap#ar score of D to 14 "nd"cates no "**ed"ate d"stress) E to 2 "nd"cates *oderate d"stress) and 4 to F "nd"cates se!ere
d"stress$
To el"c"t .oros refle+) the nurse holds the neonate "n both hands and suddenl) but #entl) drops the neonates head
bac'ward$ Nor*all) the neonate abducts and e+tends all e+tre*"t"es b"laterall and s**etr"call) for*s a ; shape w"th
the thu*b and foref"n#er) and f"rst adducts and then fle+es the e+tre*"t"es$
>re#nanc0"nduced hpertens"on ,preecla*ps"a- "s an "ncrease "n blood pressure of F4<1: ** (# o!er basel"ne or blood
pressure of 1E4<O: ** (# on two occas"ons at least 2 hours apart acco*pan"ed b ede*a and albu*"nur"a after 34
wee's #estat"on$
>os"t"!e s"#ns of pre#nanc "nclude ultrasound e!"dence) fetal heart tones) and fetal *o!e*ent felt b the e+a*"ner ,not
usuall present unt"l E *onths #estat"on
Goodells s"#n "s soften"n# of the cer!"+$
Pu"c'en"n#) a presu*pt"!e s"#n of pre#nanc) occurs between 12 and 1O wee's #estat"on$
H!ulat"on ceases dur"n# pre#nanc$
An !a#"nal bleed"n# dur"n# pre#nanc should be cons"dered a co*pl"cat"on unt"l pro!en otherw"se$
To est"*ate the date of del"!er us"n# NW#eles rule) the nurse counts bac'ward F *onths fro* the f"rst da of the last
*enstrual per"od and then adds D das to th"s date$
At 13 wee's #estat"on) the fundus should be at the top of the s*phs"s pub"s$
;ows *"l' shouldnt be #"!en to "nfants oun#er than a#e 1 because "t has a low l"nole"c ac"d content and "ts prote"n "s
d"ff"cult for "nfants to d"#est$
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3E
NURSING BULLETS _____________ ___________________________________________________________
If &aund"ce "s suspected "n a neonate) the nurse should e+a*"ne the "nfant under natural w"ndow l"#ht$ If natural l"#ht "s
una!a"lable) the nurse should e+a*"ne the "nfant under a wh"te l"#ht$
The three phases of a uter"ne contract"on are "ncre*ent) ac*e) and decre*ent$
The "ntens"t of a labor contract"on can be assessed b the "ndentab"l"t of the uter"ne wall at the contract"ons pea'$
Intens"t "s #raded as *"ld ,uter"ne *uscle "s so*ewhat tense-) *oderate ,uter"ne *uscle "s *oderatel tense-) or stron#
,uter"ne *uscle "s boardl"'e-$
;hloas*a) the *as' of pre#nanc) "s p"#*entat"on of a c"rcu*scr"bed area of s'"n ,usuall o!er the br"d#e of the nose and
chee's- that occurs "n so*e pre#nant wo*en$
The #neco"d pel!"s "s *ost "deal for del"!er$ Hther tpes "nclude platpello"d ,flat-) anthropo"d ,apel"'e-) and andro"d
,*alel"'e-$
>re#nant wo*en should be ad!"sed that there "s no safe le!el of alcohol "nta'e$
The fre6uenc of uter"ne contract"ons) wh"ch "s *easured "n *"nutes) "s the t"*e fro* the be#"nn"n# of one contract"on to
the be#"nn"n# of the ne+t$
J"ta*"n L "s ad*"n"stered to neonates to pre!ent he*orrha#"c d"sorders because a neonates "ntest"ne cant snthes"1e
!"ta*"n L$
Before "nternal fetal *on"tor"n# can be perfor*ed) a pre#nant pat"ents cer!"+ *ust be d"lated at least 3 c*) the a*n"ot"c
*e*branes *ust be ruptured) and the fetuss present"n# part ,scalp or buttoc's- *ust be at stat"on V1 or lower) so that a
s*all electrode can be attached$
/etal alcohol sndro*e presents "n the f"rst 3E hours after b"rth and produces lethar#) se"1ures) poor suc'"n# refle+)
abdo*"nal d"stent"on) and resp"rator d"ff"cult$
Jar"ab"l"t "s an chan#e "n the fetal heart rate ,/(R- fro* "ts nor*al rate of 134 to 124 beats<*"nute$ Accelerat"on "s
"ncreased /(RN decelerat"on "s decreased /(R$
In a neonate) the s*pto*s of hero"n w"thdrawal *a be#"n se!eral hours to E das after b"rth$
In a neonate) the s*pto*s of *ethadone w"thdrawal *a be#"n D das to se!eral wee's after b"rth$
In a neonate) the card"nal s"#ns of narcot"c w"thdrawal "nclude coarse) flapp"n# tre*orsN sleep"nessN restlessnessN
prolon#ed) pers"stent) h"#h0p"tched crN and "rr"tab"l"t$
The nurse should count a neonates resp"rat"ons for 1 full *"nute$
;hlorpro*a1"ne ,Thora1"ne- "s used to treat neonates who are add"cted to narcot"cs$
The nurse should pro!"de a dar') 6u"et en!"ron*ent for a neonate who "s e+per"enc"n# narcot"c w"thdrawal$
In a pre*ature neonate) s"#ns of resp"rator d"stress "nclude nostr"l flar"n#) substernal retract"ons) and "nsp"rator #runt"n#$
Resp"rator d"stress sndro*e ,hal"ne *e*brane d"sease- de!elops "n pre*ature "nfants because the"r pul*onar al!eol"
lac' surfactant$
%hene!er an "nfant "s be"n# put down to sleep) the parent or care#"!er should pos"t"on the "nfant on the bac'$ ,Re*e*ber
bac' to sleep$-
The *ale sper* contr"butes an 7 or a X chro*oso*eN the fe*ale o!u* contr"butes an 7 chro*oso*e$
/ert"l"1at"on produces a total of E2 chro*oso*es) "nclud"n# an 7X co*b"nat"on ,*ale- or an 77 co*b"nat"on ,fe*ale-$
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3:
NURSING BULLETS _____________ ___________________________________________________________
The percenta#e of water "n a neonates bod "s about D=G to =4G$
To perfor* nasotracheal suct"on"n# "n an "nfant) the nurse pos"t"ons the "nfant w"th h"s nec' sl"#htl hpere+tended "n a
?sn"ff"n#@ pos"t"on) w"th h"s ch"n up and h"s head t"lted bac' sl"#htl$
Hr#ano#enes"s occurs dur"n# the f"rst tr"*ester of pre#nanc) spec"f"call) das 1E to :2 of #estat"on$
After b"rth) the neonates u*b"l"cal cord "s t"ed 19 ,3$: c*- fro* the abdo*"nal wall w"th a cotton cord) plast"c cla*p) or
rubber band$
Gra!"da "s the nu*ber of pre#nanc"es a wo*an has had) re#ardless of outco*e$
>ara "s the nu*ber of pre#nanc"es that reached !"ab"l"t) re#ardless of whether the fetus was del"!ered al"!e or st"llborn$ A
fetus "s cons"dered !"able at 34 wee's #estat"on$
An ectop"c pre#nanc "s one that "*plants abnor*all) outs"de the uterus$
The f"rst sta#e of labor be#"ns w"th the onset of labor and ends w"th full cer!"cal d"lat"on at 14 c*$
The second sta#e of labor be#"ns w"th full cer!"cal d"lat"on and ends w"th the neonates b"rth$
The th"rd sta#e of labor be#"ns after the neonates b"rth and ends w"th e+puls"on of the placenta$
In a full0ter* neonate) s'"n creases appear o!er two0th"rds of the neonates feet$ >reter* neonates ha!e heel creases that
co!er less than two0th"rds of the feet$
The fourth sta#e of labor ,postpartu* stab"l"1at"on- lasts up to E hours after the placenta "s del"!ered$ Th"s t"*e "s needed
to stab"l"1e the *others phs"cal and e*ot"onal state after the stress of ch"ldb"rth$
At 34 wee's #estat"on) the fundus "s at the le!el of the u*b"l"cus$
At F2 wee's #estat"on) the fundus "s at the lower border of the r"b ca#e$
A pre*ature neonate "s one born before the end of the FDth wee' of #estat"on$
>re#nanc0"nduced hpertens"on "s a lead"n# cause of *aternal death "n the Un"ted States$
A hab"tual aborter "s a wo*an who has had three or *ore consecut"!e spontaneous abort"ons$
Threatened abort"on occurs when bleed"n# "s present w"thout cer!"cal d"lat"on$
A co*plete abort"on occurs when all products of concept"on are e+pelled$
(dra*n"os ,polhdra*n"os- "s e+cess"!e a*n"ot"c flu"d ,*ore than 3)444 *l "n the th"rd tr"*ester-$
Stress) dehdrat"on) and fat"#ue *a reduce a breast0feed"n# *others *"l' suppl$
5ur"n# the trans"t"on phase of the f"rst sta#e of labor) the cer!"+ "s d"lated = to 14 c* and contract"ons usuall occur 3 to F
*"nutes apart and last for 24 seconds$
A nonstress test "s cons"dered nonreact"!e ,pos"t"!e- "f fewer than two fetal heart rate accelerat"ons of at least 1:
beats<*"nute occur "n 34 *"nutes$
A nonstress test "s cons"dered react"!e ,ne#at"!e- "f two or *ore fetal heart rate accelerat"ons of 1: beats<*"nute abo!e
basel"ne occur "n 34 *"nutes$
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NURSING BULLETS _____________ ___________________________________________________________
A nonstress test "s usuall perfor*ed to assess fetal well0be"n# "n a pre#nant pat"ent w"th a prolon#ed pre#nanc ,E3
wee's or *ore-) d"abetes) a h"stor of poor pre#nanc outco*es) or pre#nanc0"nduced hpertens"on$
A pre#nant wo*an should dr"n' at least e"#ht =0o1 #lasses ,about 3)444 *l- of water da"l$
%hen both breasts are used for breast0feed"n#) the "nfant usuall doesnt e*pt the second breast$ Therefore) the second
breast should be used f"rst at the ne+t feed"n#$
A low0b"rth0we"#ht neonate we"#hs 3):44 # ,: lb = o1- or less at b"rth$
A !er0low0b"rth0we"#ht neonate we"#hs 1):44 # ,F lb : o1- or less at b"rth$
%hen teach"n# parents to pro!"de u*b"l"cal cord care) the nurse should teach the* to clean the u*b"l"cal area w"th a
cotton ball saturated w"th alcohol after e!er d"aper chan#e to pre!ent "nfect"on and pro*ote dr"n#$
Teena#e *others are *ore l"'el to ha!e low0b"rth0we"#ht neonates because the see' prenatal care late "n pre#nanc ,as
a result of den"al- and are *ore l"'el than older *others to ha!e nutr"t"onal def"c"enc"es$
L"nea n"#ra) a dar' l"ne that e+tends fro* the u*b"l"cus to the *ons pub"s) co**onl appears dur"n# pre#nanc and
d"sappears after pre#nanc$
I*plantat"on "n the uterus occurs 2 to 14 das after o!u* fert"l"1at"on$
>lacenta pre!"a "s abnor*all low "*plantat"on of the placenta so that "t encroaches on or co!ers the cer!"cal os$
In co*plete ,total- placenta pre!"a) the placenta co*pletel co!ers the cer!"cal os$
In part"al ,"nco*plete or *ar#"nal- placenta pre!"a) the placenta co!ers onl a port"on of the cer!"cal os$
Abrupt"o placentae "s pre*ature separat"on of a nor*all "*planted placenta$ It *a be part"al or co*plete) and usuall
causes abdo*"nal pa"n) !a#"nal bleed"n#) and a boardl"'e abdo*en$
;ut"s *ar*orata "s *ottl"n# or purple d"scolorat"on of the s'"n$ Its a trans"ent !aso*otor response that occurs pr"*ar"l
"n the ar*s and le#s of "nfants who are e+posed to cold$
The class"c tr"ad of s*pto*s of preecla*ps"a are hpertens"on) ede*a) and prote"nur"a$ Add"t"onal s*pto*s of se!ere
preecla*ps"a "nclude hperrefle+"a) cerebral and !"s"on d"sturbances) and ep"#astr"c pa"n$
Hrtolan"s s"#n ,an aud"ble cl"c' or palpable &er' that occurs w"th th"#h abduct"on- conf"r*s con#en"tal h"p d"slocat"on "n a
neonate$
The f"rst "**un"1at"on for a neonate "s the hepat"t"s B !acc"ne) wh"ch "s ad*"n"stered "n the nurser shortl after b"rth$
If a pat"ent *"sses a *enstrual per"od wh"le ta'"n# an oral contracept"!e e+actl as prescr"bed) she should cont"nue ta'"n#
the contracept"!e$
If a pat"ent *"sses two consecut"!e *enstrual per"ods wh"le ta'"n# an oral contracept"!e) she should d"scont"nue the
contracept"!e and ta'e a pre#nanc test$
If a pat"ent who "s ta'"n# an oral contracept"!e *"sses a dose) she should ta'e the p"ll as soon as she re*e*bers or ta'e
two at the ne+t scheduled "nter!al and cont"nue w"th the nor*al schedule$
If a pat"ent who "s ta'"n# an oral contracept"!e *"sses two consecut"!e doses) she should double the dose for 3 das and
then resu*e her nor*al schedule$ She also should use an add"t"onal b"rth control *ethod for 1 wee'$
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3D
NURSING BULLETS _____________ ___________________________________________________________
Ecla*ps"a "s the occurrence of se"1ures that arent caused b a cerebral d"sorder "n a pat"ent who has pre#nanc0"nduced
hpertens"on$
In placenta pre!"a) bleed"n# "s pa"nless and seldo* fatal on the f"rst occas"on) but "t beco*es hea!"er w"th each subse6uent
ep"sode$
Treat*ent for abrupt"o placentae "s usuall "**ed"ate cesarean del"!er$
5ru#s used to treat w"thdrawal s*pto*s "n neonates "nclude phenobarb"tal ,Lu*"nal-) ca*phorated op"u* t"ncture
,pare#or"c-) and d"a1epa* ,Jal"u*-$
Infants w"th 5own sndro*e tp"call ha!e *ar'ed hpoton"a) flopp"ness) slanted ees) e+cess s'"n on the bac' of the
nec') flattened br"d#e of the nose) flat fac"al features) spadel"'e hands) short and broad feet) s*all *ale #en"tal"a) absence
of .oros refle+) and a s"*"an crease on the hands$
The fa"lure rate of a contracept"!e "s deter*"ned b the e+per"ence of 144 wo*en for 1 ear$ Its e+pressed as pre#nanc"es
per 144 wo*an0ears$
The narrowest d"a*eter of the pel!"c "nlet "s the anteroposter"or ,d"a#onal con&u#ate-$
The chor"on "s the outer*ost e+trae*bron"c *e*brane that #"!es r"se to the placenta$
The corpus luteu* secretes lar#e 6uant"t"es of pro#esterone$
/ro* the =th wee' of #estat"on throu#h del"!er) the de!elop"n# cells are 'nown as a fetus$
In an "nco*plete abort"on) the fetus "s e+pelled) but parts of the placenta and *e*brane re*a"n "n the uterus$
The c"rcu*ference of a neonates head "s nor*all 3 to F c* #reater than the c"rcu*ference of the chest$
After ad*"n"ster"n# *a#nes"u* sulfate to a pre#nant pat"ent for hpertens"on or preter* labor) the nurse should *on"tor
the resp"rator rate and deep tendon refle+es$
5ur"n# the f"rst hour after b"rth ,the per"od of react"!"t-) the neonate "s alert and awa'e$
%hen a pre#nant pat"ent has und"a#nosed !a#"nal bleed"n#) !a#"nal e+a*"nat"on should be a!o"ded unt"l ultrasono#raph
rules out placenta pre!"a$
After del"!er) the f"rst nurs"n# act"on "s to establ"sh the neonates a"rwa$
Nurs"n# "nter!ent"ons for a pat"ent w"th placenta pre!"a "nclude pos"t"on"n# the pat"ent on her left s"de for *a+"*u* fetal
perfus"on) *on"tor"n# fetal heart tones) and ad*"n"ster"n# I$J$ flu"ds and o+#en) as ordered$
The spec"f"c #ra!"t of a neonates ur"ne "s 1$44F to 1$4F4$ A lower spec"f"c #ra!"t su##ests o!erhdrat"onN a h"#her one
su##ests dehdrat"on$
The neonatal per"od e+tends fro* b"rth to da 3=$ Its also called the f"rst E wee's or f"rst *onth of l"fe$
A wo*an who "s breast0feed"n# should rub a *"ld e*oll"ent crea* or a few drops of breast *"l' ,or colostru*- on the
n"pples after each feed"n#$ She should let the breasts a"r0dr to pre!ent the* fro* crac'"n#$
Breast0feed"n# *others should "ncrease the"r flu"d "nta'e to 3S to F 6t ,3):44 to F)444 *l- da"l$
After feed"n# an "nfant w"th a cleft l"p or palate) the nurse should r"nse the "nfants *outh w"th ster"le water$
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3=
NURSING BULLETS _____________ ___________________________________________________________
The nurse "nst"lls erthro*c"n "n a neonates ees pr"*ar"l to pre!ent bl"ndness caused b #onorrhea or chla*d"a$
(u*an "**unodef"c"enc !"rus ,(IJ- has been cultured "n breast *"l' and can be trans*"tted b an (IJ0pos"t"!e *other
who breast0feeds her "nfant$
A fe!er "n the f"rst 3E hours postpartu* "s *ost l"'el caused b dehdrat"on rather than "nfect"on$
>reter* neonates or neonates who cant *a"nta"n a s'"n te*perature of at least OD$2C / ,F2$EC ;- should rece"!e care "n an
"ncubator ,Isolette- or a rad"ant war*er$ In a rad"ant war*er) a heat0sens"t"!e probe taped to the neonates s'"n act"!ates
the heater un"t auto*at"call to *a"nta"n the des"red te*perature$
5ur"n# labor) the rest"n# phase between contract"ons "s at least F4 seconds$
Loch"a rubra "s the !a#"nal d"schar#e of al*ost pure blood that occurs dur"n# the f"rst few das after ch"ldb"rth$
Loch"a serosa "s the serous !a#"nal d"schar#e that occurs E to D das after ch"ldb"rth$
Loch"a alba "s the !a#"nal d"schar#e of decreased blood and "ncreased leu'octes thats the f"nal sta#e of loch"a$ It occurs
D to 14 das after ch"ldb"rth$
;olostru*) the precursor of *"l') "s the f"rst secret"on fro* the breasts after del"!er$
The len#th of the uterus "ncreases fro* 3S9 ,2$F c*- before pre#nanc to 13S9 ,F3 c*- at ter*$
To est"*ate the true con&u#ate ,the s*allest "nlet *easure*ent of the pel!"s-) deduct 1$: c* fro* the d"a#onal con&u#ate
,usuall 13 c*-$ A true con&u#ate of 14$: c* enables the fetal head ,usuall 14 c*- to pass$
The s*allest outlet *easure*ent of the pel!"s "s the "ntertuberous d"a*eter) wh"ch "s the trans!erse d"a*eter between the
"sch"al tuberos"t"es$
Electron"c fetal *on"tor"n# "s used to assess fetal well0be"n# dur"n# labor$ If co*pro*"sed fetal status "s suspected) fetal
blood p( *a be e!aluated b obta"n"n# a scalp sa*ple$
In an e*er#enc del"!er) enou#h pressure should be appl"ed to the e*er#"n# fetuss head to #u"de the descent and
pre!ent a rap"d chan#e "n pressure w"th"n the *olded fetal s'ull$
After del"!er) a *ult"parous wo*an "s *ore suscept"ble to bleed"n# than a pr"*"parous wo*an because her uter"ne
*uscles *a be o!erstretched and *a not contract eff"c"entl$
Neonates who are del"!ered b cesarean b"rth ha!e a h"#her "nc"dence of resp"rator d"stress sndro*e$
The nurse should su##est a*bulat"on to a postpartu* pat"ent who has #as pa"n and flatulence$
.assa#"n# the uterus helps to st"*ulate contract"ons after the placenta "s del"!ered$
%hen pro!"d"n# phototherap to a neonate) the nurse should co!er the neonates ees and #en"tal area$
The narcot"c anta#on"st nalo+one ,Narcan- *a be #"!en to a neonate to correct resp"rator depress"on caused b narcot"c
ad*"n"strat"on to the *other dur"n# labor$
In a neonate) s*pto*s of resp"rator d"stress sndro*e "nclude e+p"rator #runt"n# or wh"n"n#) sandpaper breath sounds)
and seesaw retract"ons$
;erebral pals presents as as**etr"cal *o!e*ent) "rr"tab"l"t) and e+cess"!e) feeble cr"n# "n a lon#) th"n "nfant$
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3O
NURSING BULLETS _____________ ___________________________________________________________
The nurse should assess a breech0b"rth neonate for hdrocephalus) he*ato*as) fractures) and other ano*al"es caused b
b"rth trau*a$
%hen a pat"ent "s ad*"tted to the un"t "n act"!e labor) the nurses f"rst act"on "s to l"sten for fetal heart tones$
In a neonate) lon#) br"ttle f"n#erna"ls are a s"#n of post*atur"t$
5es6ua*at"on ,s'"n peel"n#- "s co**on "n post*ature neonates$
A *other should allow her "nfant to breast0feed unt"l the "nfant "s sat"sf"ed$ The t"*e *a !ar fro* : to 34 *"nutes$
N"tra1"ne paper "s used to test the p( of !a#"nal d"schar#e to deter*"ne the presence of a*n"ot"c flu"d$
A pre#nant pat"ent nor*all #a"ns 3 to : lb ,1 to 3$: '#- dur"n# the f"rst tr"*ester and sl"#htl less than 1 lb ,4$: '#- per
wee' dur"n# the last two tr"*esters$
Neonatal &aund"ce "n the f"rst 3E hours after b"rth "s 'nown as patholo#"cal &aund"ce and "s a s"#n of erthroblastos"s
fetal"s$
A class"c d"fference between abrupt"o placentae and placenta pre!"a "s the de#ree of pa"n$ Abrupt"o placentae causes pa"n)
whereas placenta pre!"a causes pa"nless bleed"n#$
Because a *a&or role of the placenta "s to funct"on as a fetal lun#) an cond"t"on that "nterrupts nor*al blood flow to or
fro* the placenta "ncreases fetal part"al pressure of arter"al carbon d"o+"de and decreases fetal p($
>rec"p"tate labor lasts for appro+"*atel F hours and ends w"th del"!er of the neonate$
.ethler#ono!"ne ,.ether#"ne- "s an o+toc"c a#ent used to pre!ent and treat postpartu* he*orrha#e caused b uter"ne
aton or sub"n!olut"on$
As e*er#enc treat*ent for e+cess"!e uter"ne bleed"n#) 4$3 *# of *ethler#ono!"ne ,.ether#"ne- "s "n&ected I$J$ o!er 1
*"nute wh"le the pat"ents blood pressure and uter"ne contract"ons are *on"tored$
Bra+ton ("c's contract"ons are usuall felt "n the abdo*en and dont cause cer!"cal chan#e$ True labor contract"ons are
felt "n the front of the abdo*en and bac' and lead to pro#ress"!e cer!"cal d"lat"on and efface*ent$
The a!era#e b"rth we"#ht of neonates born to *others who s*o'e "s 2 o1 ,1D4 #- less than that of neonates born to
nons*o'"n# *others$
;uldoscop "s !"sual"1at"on of the pel!"c or#ans throu#h the poster"or !a#"nal forn"+$
The nurse should teach a pre#nant !e#etar"an to obta"n prote"n fro* alternat"!e sources) such as nuts) sobeans) and
le#u*es$
The nurse should "nstruct a pre#nant pat"ent to ta'e onl prescr"bed prenatal !"ta*"ns because o!er0the0counter h"#h0
potenc !"ta*"ns *a har* the fetus$
("#h0sod"u* foods can cause flu"d retent"on) espec"all "n pre#nant pat"ents$
A pre#nant pat"ent can a!o"d const"pat"on and he*orrho"ds b add"n# f"ber to her d"et$
If a fetus has late decelerat"ons ,a s"#n of fetal hpo+"a-) the nurse should "nstruct the *other to l"e on her left s"de and
then ad*"n"ster = to 14 L of o+#en per *"nute b *as' or cannula$ The nurse should not"f the phs"c"an$ The s"de0l"n#
pos"t"on re*o!es pressure on the "nfer"or !ena ca!a$
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F4
NURSING BULLETS _____________ ___________________________________________________________
H+toc"n ,>"toc"n- pro*otes lactat"on and uter"ne contract"ons$
Lanu#o co!ers the fetuss bod unt"l about 34 wee's #estat"on$ Then "t be#"ns to d"sappear fro* the face) trun') ar*s)
and le#s) "n that order$
In a neonate) hpo#lce*"a causes te*perature "nstab"l"t) hpoton"a) &"tter"ness) and se"1ures$ >re*ature) post*ature)
s*all0for0#estat"onal0a#e) and lar#e0for0#estat"onal0a#e neonates are suscept"ble to th"s d"sorder$
Neonates tp"call need to consu*e :4 to :: cal per pound of bod we"#ht da"l$
Because o+toc"n ,>"toc"n- st"*ulates powerful uter"ne contract"ons dur"n# labor) "t *ust be ad*"n"stered under close
obser!at"on to help pre!ent *aternal and fetal d"stress$
5ur"n# fetal heart rate *on"tor"n#) !ar"able decelerat"ons "nd"cate co*press"on or prolapse of the u*b"l"cal cord$
;to*e#alo!"rus "s the lead"n# cause of con#en"tal !"ral "nfect"on$
Tocolt"c therap "s "nd"cated "n pre*ature labor) but contra"nd"cated "n fetal death) fetal d"stress) or se!ere he*orrha#e$
Throu#h ultrasono#raph) the b"ophs"cal prof"le assesses fetal well0be"n# b *easur"n# fetal breath"n# *o!e*ents) #ross
bod *o!e*ents) fetal tone) react"!e fetal heart rate ,nonstress test-) and 6ual"tat"!e a*n"ot"c flu"d !olu*e$
A neonate whose *other has d"abetes should be assessed for hper"nsul"n"s*$
In a pat"ent w"th preecla*ps"a) ep"#astr"c pa"n "s a late s*pto* and re6u"res "**ed"ate *ed"cal "nter!ent"on$
After a st"llb"rth) the *other should be allowed to hold the neonate to help her co*e to ter*s w"th the death$
.old"n# "s the process b wh"ch the fetal head chan#es shape to fac"l"tate *o!e*ent throu#h the b"rth canal$
If a wo*an rece"!es a sp"nal bloc' before del"!er) the nurse should *on"tor the pat"ents blood pressure closel$
If a wo*an suddenl beco*es hpotens"!e dur"n# labor) the nurse should "ncrease the "nfus"on rate of I$J$ flu"ds as
prescr"bed$
The best techn"6ue for assess"n# &aund"ce "n a neonate "s to blanch the t"p of the nose or the area &ust abo!e the u*b"l"cus$
5ur"n# fetal heart *on"tor"n#) earl decelerat"on "s caused b co*press"on of the head dur"n# labor$
After the placenta "s del"!ered) the nurse *a add o+toc"n ,>"toc"n- to the pat"ents I$J$ solut"on) as prescr"bed) to
pro*ote postpartu* "n!olut"on of the uterus and st"*ulate lactat"on$
>"ca "s a cra!"n# to eat nonfood "te*s) such as d"rt) craons) chal') #lue) starch) or ha"r$ It *a occur dur"n# pre#nanc
and can endan#er the fetus$
A pre#nant pat"ent should ta'e fol"c ac"d because th"s nutr"ent "s re6u"red for rap"d cell d"!"s"on$
A wo*an who "s ta'"n# clo*"phene ,;lo*"d- to "nduce o!ulat"on should be "nfor*ed of the poss"b"l"t of *ult"ple b"rths
w"th th"s dru#$
If needed) cer!"cal sutur"n# "s usuall done between 1E and 1= wee's #estat"on to re"nforce an "nco*petent cer!"+ and
*a"nta"n pre#nanc$ The sutur"n# "s tp"call re*o!ed b F: wee's #estat"on$
5ur"n# the f"rst tr"*ester) a pre#nant wo*an should a!o"d all dru#s unless do"n# so would ad!ersel affect her health$
.ost dru#s that a breast0feed"n# *other ta'es appear "n breast *"l'$
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F1
NURSING BULLETS _____________ ___________________________________________________________
The /ood and 5ru# Ad*"n"strat"on has establ"shed the follow"n# f"!e cate#or"es of dru#s based on the"r potent"al for
caus"n# b"rth defectsI A) no e!"dence of r"s'N B) no r"s' found "n an"*als) but no stud"es ha!e been done "n wo*enN ;)
an"*al stud"es ha!e shown an ad!erse effect) but the dru# *a be benef"c"al to wo*en desp"te the potent"al r"s'N 5)
e!"dence of r"s') but "ts benef"ts *a outwe"#h "ts r"s'sN and 7) fetal ano*al"es noted) and the r"s's clearl outwe"#h the
potent"al benef"ts$
A pat"ent w"th a ruptured ectop"c pre#nanc co**onl has sharp pa"n "n the lower abdo*en) w"th spott"n# and cra*p"n#$
She *a ha!e abdo*"nal r"#"d"tN rap"d) shallow resp"rat"onsN tachcard"aN and shoc'$
A pat"ent w"th a ruptured ectop"c pre#nanc co**onl has sharp pa"n "n the lower abdo*en) w"th spott"n# and cra*p"n#$
She *a ha!e abdo*"nal r"#"d"tN rap"d) shallow resp"rat"onsN tachcard"aN and shoc'$
The *echan"cs of del"!er are en#a#e*ent) descent and fle+"on) "nternal rotat"on) e+tens"on) e+ternal rotat"on) rest"tut"on)
and e+puls"on$
A probable s"#n of pre#nanc) .c5onalds s"#n "s character"1ed b an ease "n fle+"n# the bod of the uterus a#a"nst the
cer!"+$
A*enorrhea "s a probable s"#n of pre#nanc$
A pre#nant wo*ans partner should a!o"d "ntroduc"n# a"r "nto the !a#"na dur"n# oral se+ because of the poss"b"l"t of a"r
e*bol"s*$
The presence of hu*an chor"on"c #onadotrop"n "n the blood or ur"ne "s a probable s"#n of pre#nanc$
Rad"o#raph "snt usuall used "n a pre#nant wo*an because "t *a har* the de!elop"n# fetus$ If rad"o#raph "s essent"al)
"t should be perfor*ed onl after F2 wee's #estat"on$
A pre#nant pat"ent who has had rupture of the *e*branes or who "s e+per"enc"n# !a#"nal bleed"n# shouldnt en#a#e "n
se+ual "ntercourse$
."l"a *a occur as p"npo"nt spots o!er a neonates nose$
The durat"on of a contract"on "s t"*ed fro* the *o*ent that the uter"ne *uscle be#"ns to tense to the *o*ent that "t
reaches full rela+at"on$ Its *easured "n seconds$
The un"on of a *ale and a fe*ale #a*ete produces a 1#ote) wh"ch d"!"des "nto the fert"l"1ed o!u*$
The f"rst *enstrual flow "s called *enarche and *a be ano!ulator ,"nfert"le-$
Sper*ato1oa ,or the"r fra#*ents- re*a"n "n the !a#"na for D3 hours after se+ual "ntercourse$
>rolact"n st"*ulates and susta"ns *"l' product"on$
Strab"s*us "s a nor*al f"nd"n# "n a neonate$
A postpartu* pat"ent *a resu*e se+ual "ntercourse after the per"neal or uter"ne wounds heal ,usuall w"th"n E wee's
after del"!er-$
A pre#nant staff *e*ber shouldnt be ass"#ned to wor' w"th a pat"ent who has cto*e#alo!"rus "nfect"on because the
!"rus can be trans*"tted to the fetus$
/etal de*"se "s death of the fetus after !"ab"l"t$
Resp"rator d"stress sndro*e de!elops "n pre*ature neonates because the"r al!eol" lac' surfactant$
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F3
NURSING BULLETS _____________ ___________________________________________________________
The *ost co**on *ethod of "nduc"n# labor after art"f"c"al rupture of the *e*branes "s o+toc"n ,>"toc"n- "nfus"on$
After the a*n"ot"c *e*branes rupture) the "n"t"al nurs"n# act"on "s to assess the fetal heart rate$
The *ost co**on reasons for cesarean b"rth are *alpresentat"on) fetal d"stress) cephalopel!"c d"sproport"on) pre#nanc0
"nduced hpertens"on) pre!"ous cesarean b"rth) and "nade6uate pro#ress "n labor$
A*n"ocentes"s "ncreases the r"s' of spontaneous abort"on) trau*a to the fetus or placenta) pre*ature labor) "nfect"on) and
Rh sens"t"1at"on of the fetus$
After a*n"ocentes"s) abdo*"nal cra*p"n# or spontaneous !a#"nal bleed"n# *a "nd"cate co*pl"cat"ons$
To pre!ent her fro* de!elop"n# Rh ant"bod"es) an Rh0ne#at"!e pr"*"#ra!"da should rece"!e Rho,5- "**une #lobul"n
,RhoGA.- after del"!er"n# an Rh0pos"t"!e neonate$
If a pre#nant pat"ents test results are ne#at"!e for #lucose but pos"t"!e for acetone) the nurse should assess the pat"ents
d"et for "nade6uate calor"c "nta'e$
If a pre#nant pat"ents test results are ne#at"!e for #lucose but pos"t"!e for acetone) the nurse should assess the pat"ents
d"et for "nade6uate calor"c "nta'e$
Rubella "nfect"on "n a pre#nant pat"ent) espec"all dur"n# the f"rst tr"*ester) can lead to spontaneous abort"on or st"llb"rth
as well as fetal card"ac and other b"rth defects$
A pre#nant pat"ent should ta'e an "ron supple*ent to help pre!ent ane*"a$
5"rect ant"#lobul"n ,d"rect ;oo*bs- test "s used to detect *aternal ant"bod"es attached to red blood cells "n the neonate$
Nausea and !o*"t"n# dur"n# the f"rst tr"*ester of pre#nanc are caused b r"s"n# le!els of the hor*one hu*an chor"on"c
#onadotrop"n$
Before d"schar#"n# a pat"ent who has had an abort"on) the nurse should "nstruct her to report br"#ht red clots) bleed"n# that
lasts lon#er than D das) or s"#ns of "nfect"on) such as a te*perature of #reater than 144C / ,FD$=C ;-) foul0s*ell"n#
!a#"nal d"schar#e) se!ere uter"ne cra*p"n#) nausea) or !o*"t"n#$
%hen "nfor*ed that a pat"ents a*n"ot"c *e*brane has bro'en) the nurse should chec' fetal heart tones and then *aternal
!"tal s"#ns$
The durat"on of pre#nanc a!era#es 3=4 das) E4 wee's) O calendar *onths) or 14 lunar *onths$
The "n"t"al we"#ht loss for a health neonate "s :G to 14G of b"rth we"#ht$
The nor*al he*o#lob"n !alue "n neonates "s 1D to 34 #<dl$
;rown"n# "s the appearance of the fetuss head when "ts lar#est d"a*eter "s enc"rcled b the !ul!o!a#"nal r"n#$
A *ult"para "s a wo*an who has had two or *ore pre#nanc"es that pro#ressed to !"ab"l"t) re#ardless of whether the
offspr"n# were al"!e at b"rth$
In a pre#nant pat"ent) preecla*ps"a *a pro#ress to ecla*ps"a) wh"ch "s character"1ed b se"1ures and *a lead to co*a$
The Ap#ar score "s used to assess the neonates !"tal funct"ons$ Its obta"ned at 1 *"nute and : *"nutes after del"!er$ The
score "s based on resp"rator effort) heart rate) *uscle tone) refle+ "rr"tab"l"t) and color$
Because of the ant"0"nsul"n effects of placental hor*ones) "nsul"n re6u"re*ents "ncrease dur"n# the th"rd tr"*ester$
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FF
NURSING BULLETS _____________ ___________________________________________________________
Gestat"onal a#e can be est"*ated b ultrasound *easure*ent of *aternal abdo*"nal c"rcu*ference) fetal fe*ur len#th)
and fetal head s"1e$ These *easure*ents are *ost accurate between 13 and 1= wee's #estat"on$
S'eletal sste* abnor*al"t"es and !entr"cular septal defects are the *ost co**on d"sorders of "nfants who are born to
d"abet"c wo*en$ The "nc"dence of con#en"tal *alfor*at"on "s three t"*es h"#her "n these "nfants than "n those born to
nond"abet"c wo*en$
S'eletal sste* abnor*al"t"es and !entr"cular septal defects are the *ost co**on d"sorders of "nfants who are born to
d"abet"c wo*en$ The "nc"dence of con#en"tal *alfor*at"on "s three t"*es h"#her "n these "nfants than "n those born to
nond"abet"c wo*en$
The pat"ent w"th preecla*ps"a usuall has puff"ness around the ees or ede*a "n the hands ,for e+a*ple) ?I cant put *
wedd"n# r"n# on$@-$
Le#el e+erc"ses re6u"re contract"on and rela+at"on of the per"neal *uscles$ These e+erc"ses help stren#then pel!"c *uscles
and "*pro!e ur"ne control "n postpartu* pat"ents$
S*pto*s of postpartu* depress"on ran#e fro* *"ld postpartu* blues to "ntense) su"c"dal) depress"!e pschos"s$
The preter* neonate *a re6u"re #a!a#e feed"n#s because of a wea' suc'"n# refle+) uncoord"nated suc'"n#) or resp"rator
d"stress$
Acrocanos"s ,blueness and coolness of the ar*s and le#s- "s nor*al "n neonates because of the"r "**ature per"pheral
c"rculator sste*$
To pre!ent ophthal*"a neonatoru* ,a se!ere ee "nfect"on caused b *aternal #onorrhea-) the nurse *a ad*"n"ster one
of three dru#s) as prescr"bed) "n the neonates eesI tetraccl"ne) s"l!er n"trate) or erthro*c"n$
Neonatal test"n# for phenl'etonur"a "s *andator "n *ost states$
The nurse should place the neonate "n a F40de#ree Trendelenbur# pos"t"on to fac"l"tate *ucus dra"na#e$
The nurse *a suct"on the neonates nose and *outh as needed w"th a bulb sr"n#e or suct"on trap$
To pre!ent heat loss) the nurse should place the neonate under a rad"ant war*er dur"n# suct"on"n# and "n"t"al del"!er0
roo* care) and then wrap the neonate "n a war*ed blan'et for transport to the nurser$
The u*b"l"cal cord nor*all has two arter"es and one !e"n$
%hen pro!"d"n# care) the nurse should e+pose onl one part of an "nfants bod at a t"*e$
L"#hten"n# "s settl"n# of the fetal head "nto the br"* of the pel!"s$
If the neonate "s stable) the *other should be allowed to breast0feed w"th"n the neonates f"rst hour of l"fe$
The nurse should chec' the neonates te*perature e!er 1 to 3 hours unt"l "ts *a"nta"ned w"th"n nor*al l"*"ts$
At b"rth) a neonate nor*all we"#hs : to O lb ,3 to E '#-) *easures 1=9 to 339 ,E:$: to :2 c*- "n len#th) has a head
c"rcu*ference of 1FS9 to 1E9 ,FE to F:$: c*-) and has a chest c"rcu*ference thats 19 ,3$: c*- less than the head
c"rcu*ference$
In the neonate) te*perature nor*all ran#es fro* O=C to OOC / ,F2$DC to FD$3C ;-) ap"cal pulse rate a!era#es 134 to 124
beats<*"nute) and resp"rat"ons are E4 to 24 breaths<*"nute$
The d"a*ond0shaped anter"or fontanel usuall closes between a#es 13 and 1= *onths$ The tr"an#ular poster"or fontanel
usuall closes b a#e 3 *onths$
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NURSING BULLETS _____________ ___________________________________________________________
In the neonate) a stra"#ht sp"ne "s nor*al$ A tuft of ha"r o!er the sp"ne "s an abnor*al f"nd"n#$
>rosta#land"n #el *a be appl"ed to the !a#"na or cer!"+ to r"pen an unfa!orable cer!"+ before labor "nduct"on w"th
o+toc"n ,>"toc"n-$
Supernu*erar n"pples are occas"onall seen on neonates$ The usuall appear alon# a l"ne that runs fro* each a+"lla)
throu#h the nor*al n"pple area) and to the #ro"n$
.econ"u* "s a *ater"al that collects "n the fetuss "ntest"nes and for*s the neonates f"rst feces) wh"ch are blac' and tarr$
The presence of *econ"u* "n the a*n"ot"c flu"d dur"n# labor "nd"cates poss"ble fetal d"stress and the need to e!aluate the
neonate for *econ"u* asp"rat"on$
To assess a neonates root"n# refle+) the nurse touches a f"n#er to the chee' or the corner of the *outh$ Nor*all) the
neonate turns h"s head toward the st"*ulus) opens h"s *outh) and searches for the st"*ulus$
(arle6u"n s"#n "s present when a neonate who "s l"n# on h"s s"de appears red on the dependent s"de and pale on the upper
s"de$
.on#ol"an spots can ran#e fro* brown to blue$ The"r color depends on how close *elanoctes are to the surface of the
s'"n$ The *ost co**onl appear as patches across the sacru*) buttoc's) and le#s$
.on#ol"an spots are co**on "n non0wh"te "nfants and usuall d"sappear b a#e 3 to F ears$
Jern"+ caseosa "s a cheesel"'e substance that co!ers and protects the fetuss s'"n "n utero$ It *a be rubbed "nto the
neonates s'"n or washed awa "n one or two baths$
;aput succedaneu* "s ede*a that de!elops "n and under the fetal scalp dur"n# labor and del"!er$ It resol!es
spontaneousl and presents no dan#er to the neonate$ The ede*a doesnt cross the suture l"ne$
Ne!us fla**eus) or port0w"ne sta"n) "s a d"ffuse p"n' to dar' blu"sh red les"on on a neonates face or nec'$
The Guthr"e test ,a screen"n# test for phenl'etonur"a- "s *ost rel"able "f "ts done between the second and s"+th das after
b"rth and "s perfor*ed after the neonate has "n#ested prote"n$
To assess coord"nat"on of suc'"n# and swallow"n#) the nurse should obser!e the neonates f"rst breast0feed"n# or ster"le
water bottle0feed"n#$
To establ"sh a *"l' suppl pattern) the *other should breast0feed her "nfant at least e!er E hours$ 5ur"n# the f"rst *onth)
she should breast0feed = to 13 t"*es da"l ,de*and feed"n#-$
To a!o"d contact w"th blood and other bod flu"ds) the nurse should wear #lo!es when handl"n# the neonate unt"l after the
f"rst bath "s #"!en$
If a breast0fed "nfant "s content) has #ood s'"n tur#or) an ade6uate nu*ber of wet d"apers) and nor*al we"#ht #a"n) the
*others *"l' suppl "s assu*ed to be ade6uate$
In the sup"ne pos"t"on) a pre#nant pat"ents enlar#ed uterus "*pa"rs !enous return fro* the lower half of the bod to the
heart) result"n# "n sup"ne hpotens"!e sndro*e) or "nfer"or !ena ca!a sndro*e$
Tocolt"c a#ents used to treat preter* labor "nclude terbutal"ne ,Breth"ne-) r"todr"ne ,Xutopar-) and *a#nes"u* sulfate$
A pre#nant wo*an who has hpere*es"s #ra!"daru* *a re6u"re hosp"tal"1at"on to treat dehdrat"on and star!at"on$
5"aphra#*at"c hern"a "s one of the *ost ur#ent neonatal sur#"cal e*er#enc"es$ B co*press"n# and d"splac"n# the lun#s
and heart) th"s d"sorder can cause resp"rator d"stress shortl after b"rth$
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NURSING BULLETS _____________ ___________________________________________________________
;o**on co*pl"cat"ons of earl pre#nanc ,up to 34 wee's #estat"on- "nclude fetal loss and ser"ous threats to *aternal
health$
/etal e*bod"*ent "s a *aternal de!elop*ental tas' that occurs "n the second tr"*ester$ 5ur"n# th"s sta#e) the *other *a
co*pla"n that she ne!er #ets to sleep because the fetus alwas #"!es her a thu*p when she tr"es$
J"sual"1at"on "n pre#nanc "s a process "n wh"ch the *other "*a#"nes what the ch"ld shes carr"n# "s l"'e and beco*es
ac6ua"nted w"th "t$
(e*od"lut"on of pre#nanc "s the "ncrease "n blood !olu*e that occurs dur"n# pre#nanc$ The "ncreased !olu*e cons"sts
of plas*a and causes an "*balance between the rat"o of red blood cells to plas*a and a resultant decrease "n he*atocr"t$
.ean arter"al pressure of #reater than 144 ** (# after 34 wee's of pre#nanc "s cons"dered hpertens"on$
The treat*ent for sup"ne hpotens"on sndro*e ,a cond"t"on that so*et"*es occurs "n pre#nanc- "s to ha!e the pat"ent l"e
on her left s"de$
A contr"but"n# factor "n dependent ede*a "n the pre#nant pat"ent "s the "ncrease of fe*oral !enous pressure fro* 14 **
(# ,nor*al- to 1= ** (# ,h"#h-$
(perp"#*entat"on of the pre#nant pat"ents face) for*erl called chloas*a and now referred to as *elas*a) fades after
del"!er$
The hor*one rela+"n) wh"ch "s secreted f"rst b the corpus luteu* and later b the placenta) rela+es the connect"!e t"ssue
and cart"la#e of the s*phs"s pub"s and the sacro"l"ac &o"nt to fac"l"tate passa#e of the fetus dur"n# del"!er$
>ro#esterone *a"nta"ns the "nte#r"t of the pre#nanc b "nh"b"t"n# uter"ne *ot"l"t$
Lad"ns s"#n) an earl "nd"cat"on of pre#nanc) causes soften"n# of a spot on the anter"or port"on of the uterus) &ust abo!e
the uterocer!"cal &uncture$
5ur"n# pre#nanc) the abdo*"nal l"ne fro* the s*phs"s pub"s to the u*b"l"cus chan#es fro* l"nea alba to l"nea n"#ra$
In neonates) cold stress affects the c"rculator) re#ulator) and resp"rator sste*s$
Hbstetr"c data can be descr"bed b us"n# the /<T>AL sste*I
/<TI /ull0ter* del"!er at F= wee's or lon#er
>I >reter* del"!er between 34 and FD wee's
AI Abort"on or loss of fetus before 34 wee's
LI Nu*ber of ch"ldren l"!"n# ,"f a ch"ld has d"ed) further e+planat"on "s needed to clar"f the d"screpanc "n nu*bers-$
>ar"t doesnt refer to the nu*ber of "nfants del"!ered) onl the nu*ber of del"!er"es$
%o*en who are carr"n# *ore than one fetus should be encoura#ed to #a"n F: to E: lb ,1:$: to 34$: '#- dur"n#
pre#nanc$
The reco**ended a*ount of "ron supple*ent for the pre#nant pat"ent "s F4 to 24 *# da"l$
5r"n'"n# s"+ alcohol"c be!era#es a da or a s"n#le ep"sode of b"n#e dr"n'"n# "n the f"rst tr"*ester can cause fetal alcohol
sndro*e$
;hor"on"c !"llus sa*pl"n# "s perfor*ed at = to 13 wee's of pre#nanc for earl "dent"f"cat"on of #enet"c defects$
In percutaneous u*b"l"cal blood sa*pl"n#) a blood sa*ple "s obta"ned fro* the u*b"l"cal cord to detect ane*"a) #enet"c
defects) and blood "nco*pat"b"l"t as well as to assess the need for blood transfus"ons$
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NURSING BULLETS _____________ ___________________________________________________________
The per"od between contract"ons "s referred to as the "nter!al) or rest"n# phase$ 5ur"n# th"s phase) the uterus and placenta
f"ll w"th blood and allow for the e+chan#e of o+#en) carbon d"o+"de) and nutr"ents$
In a pat"ent who has hperton"c contract"ons) the uterus doesnt ha!e an opportun"t to rela+ and there "s no "nter!al
between contract"ons$ As a result) the fetus *a e+per"ence hpo+"a or rap"d del"!er *a occur$
Two 6ual"t"es of the *o*etr"u* are elast"c"t) wh"ch allows "t to stretch et *a"nta"n "ts tone) and contract"l"t) wh"ch
allows "t to shorten and len#then "n a snchron"1ed pattern$
5ur"n# crown"n#) the present"n# part of the fetus re*a"ns !"s"ble dur"n# the "nter!al between contract"ons$
Uter"ne aton "s fa"lure of the uterus to re*a"n f"r*l contracted$
The *a&or cause of uter"ne aton "s a full bladder$
If the *other w"shes to breast0feed) the neonate should be nursed as soon as poss"ble after del"!er$
A s*ac'"n# sound) *"l' dr"pp"n# fro* the s"de of the *outh) and suc'"n# no"ses all "nd"cate "*proper place*ent of the
"nfants *outh o!er the n"pple$
Before feed"n# "s "n"t"ated) an "nfant should be burped to e+pel a"r fro* the sto*ach$
.ost author"t"es stron#l encoura#e the cont"nuat"on of breast0feed"n# on both the affected and the unaffected breast of
pat"ents w"th *ast"t"s$
Neonates are nears"#hted and focus on "te*s that are held 149 to 139 ,3: to F4$: c*- awa$
In a neonate) low0set ears are assoc"ated w"th chro*oso*al abnor*al"t"es such as 5own sndro*e$
.econ"u* "s usuall passed "n the f"rst 3E hoursN howe!er) passa#e *a ta'e up to D3 hours$
Bos who are born w"th hpospad"as shouldnt be c"rcu*c"sed at b"rth because the fores'"n *a be needed for
construct"!e sur#er$
In the neonate) the nor*al blood #lucose le!el "s E: to O4 *#<dl$
(epat"t"s B !acc"ne "s usuall #"!en w"th"n E= hours of b"rth$
(epat"t"s B "**une #lobul"n "s usuall #"!en w"th"n 13 hours of b"rth$
(ELL> ,he*ols"s) ele!ated l"!er en1*es) and low platelets- sndro*e "s an unusual !ar"at"on of pre#nanc0"nduced
hpertens"on$
.aternal seru* alpha0fetoprote"n "s detectable at D wee's of #estat"on and pea's "n the th"rd tr"*ester$ ("#h le!els
detected between the 12th and 1=th wee's are assoc"ated w"th neural tube defects$ Low le!els are assoc"ated w"th 5own
sndro*e$
An arrest of descent occurs when the fetus doesnt descend throu#h the pel!"c ca!"t dur"n# labor$ Its co**onl
assoc"ated w"th cephalopel!"c d"sproport"on) and cesarean del"!er *a be re6u"red$
A late s"#n of preecla*ps"a "s ep"#astr"c pa"n as a result of se!ere l"!er ede*a$
In the pat"ent w"th preecla*ps"a) blood pressure returns to nor*al dur"n# the puerperal per"od$
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NURSING BULLETS _____________ ___________________________________________________________
To obta"n an estr"ol le!el) ur"ne "s collected for 3E hours$
An estr"ol le!el "s used to assess fetal well0be"n# and *aternal renal funct"on"n# as well as to *on"tor a pre#nanc thats
co*pl"cated b d"abetes$
A pre#nant pat"ent w"th !a#"nal bleed"n# shouldnt ha!e a pel!"c e+a*"nat"on$
In the earl sta#es of pre#nanc) the f"nd"n# of #lucose "n the ur"ne *a be related to the "ncreased shunt"n# of #lucose to
the de!elop"n# placenta) w"thout a correspond"n# "ncrease "n the reabsorpt"on capab"l"t of the '"dnes$
A pat"ent who has pre*ature rupture of the *e*branes "s at s"#n"f"cant r"s' for "nfect"on "f labor doesnt be#"n w"th"n 3E
hours$
Infants of d"abet"c *others are suscept"ble to *acroso*"a as a result of "ncreased "nsul"n product"on "n the fetus$
To pre!ent heat loss "n the neonate) the nurse should bathe one part of h"s bod at a t"*e and 'eep the rest of the bod
co!ered$
A pat"ent who has a cesarean del"!er "s at #reater r"s' for "nfect"on than the pat"ent who #"!es b"rth !a#"nall$
The occurrence of thrush "n the neonate "s probabl caused b contact w"th the or#an"s* dur"n# del"!er throu#h the b"rth
canal$
The nurse should 'eep the sac of *en"n#o*elocele *o"st w"th nor*al sal"ne solut"on$
If fundal he"#ht "s at least 3 c* less than e+pected) the cause *a be #rowth retardat"on) *"ssed abort"on) trans!erse l"e) or
false pre#nanc$
/undal he"#ht that e+ceeds e+pectat"ons b *ore than 3 c* *a be caused b *ult"ple #estat"on) polhdra*n"os) uter"ne
*o*ata) or a lar#e bab$
A *a&or de!elop*ental tas' for a wo*an dur"n# the f"rst tr"*ester of pre#nanc "s accept"n# the pre#nanc$
Unl"'e for*ula) breast *"l' offers the benef"t of *aternal ant"bod"es$
Spontaneous rupture of the *e*branes "ncreases the r"s' of a prolapsed u*b"l"cal cord$
A cl"n"cal *an"festat"on of a prolapsed u*b"l"cal cord "s !ar"able decelerat"ons$
5ur"n# labor) to rel"e!e sup"ne hpotens"on *an"fested b nausea and !o*"t"n# and paleness) turn the pat"ent on her left
s"de$
If the o!u* "s fert"l"1ed b a sper*ato1oon carr"n# a X chro*oso*e) a *ale 1#ote "s for*ed$
I*plantat"on occurs when the cellular walls of the blastocte "*plants "tself "n the endo*etr"u*) usuall D to O das after
fert"l"1at"on$
I*plantat"on occurs when the cellular walls of the blastocte "*plants "tself "n the endo*etr"u*) usuall D to O das after
fert"l"1at"on$
(eart de!elop*ent "n the e*bro be#"ns at 3 to E wee's and "s co*plete b the end of the e*bron"c sta#e$
.ether#"ne st"*ulates uter"ne contract"ons$
The ad*"n"strat"on of fol"c ac"d dur"n# the earl sta#es of #estat"on *a pre!ent neural tube defects$
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NURSING BULLETS _____________ ___________________________________________________________
%"th ad!anced *aternal a#e) a co**on #enet"c proble* "s 5own sndro*e$
%"th earl *aternal a#e) cephalopel!"c d"sproport"on co**onl occurs$
In the earl postpartu* per"od) the fundus should be *"dl"ne at the u*b"l"cus$
A rubella !acc"ne shouldnt be #"!en to a pre#nant wo*an$ The !acc"ne can be ad*"n"stered after del"!er) but the pat"ent
should be "nstructed to a!o"d beco*"n# pre#nant for F *onths$
A 120ear0old #"rl who "s pre#nant "s at r"s' for ha!"n# a low0b"rth0we"#ht neonate$
The *others Rh factor should be deter*"ned before an a*n"ocentes"s "s perfor*ed$
.aternal hpotens"on "s a co*pl"cat"on of sp"nal bloc'$
After del"!er) "f the fundus "s bo## and de!"ated to the r"#ht s"de) the pat"ent should e*pt her bladder$
Before pro!"d"n# a spec"*en for a sper* count) the pat"ent should a!o"d e&aculat"on for E= to D3 hours$
The hor*one hu*an chor"on"c #onadotrop"n "s a *ar'er for pre#nanc$
>a"nless !a#"nal bleed"n# dur"n# the last tr"*ester of pre#nanc *a "nd"cate placenta pre!"a$
5ur"n# the trans"t"on phase of labor) the wo*an usuall "s "rr"table and restless$
Because wo*en w"th d"abetes ha!e a h"#her "nc"dence of b"rth ano*al"es than wo*en w"thout d"abetes) an alpha0
fetoprote"n le!el *a be ordered at 1: to 1D wee's #estat"on$
To a!o"d punctur"n# the placenta) a !a#"nal e+a*"nat"on shouldnt be perfor*ed on a pre#nant pat"ent who "s bleed"n#$
A pat"ent who has postpartu* he*orrha#e caused b uter"ne aton should be #"!en o+toc"n as prescr"bed$
Lacerat"on of the !a#"na) cer!"+) or per"neu* produces br"#ht red bleed"n# that often co*es "n spurts$ The bleed"n# "s
cont"nuous) e!en when the fundus "s f"r*$
(ot co*presses can help to rel"e!e breast tenderness after breast0feed"n#$
The fundus of a postpartu* pat"ent "s *assa#ed to st"*ulate contract"on of the uterus and pre!ent he*orrha#e$
A *other who has a pos"t"!e hu*an "**unodef"c"enc !"rus test result shouldnt breast0feed her "nfant$
5"noprostone ,;er!"d"l- "s used to r"pen the cer!"+$
Breast0feed"n# of a pre*ature neonate born at F3 wee's #estat"on can be acco*pl"shed "f the *other e+presses *"l' and
feeds the neonate b #a!a#e$
If a pre#nant pat"ents rubella t"ter "s less than 1I=) she should be "**un"1ed after del"!er$
The ad*"n"strat"on of o+toc"n ,>"toc"n- "s stopped "f the contract"ons are O4 seconds or lon#er$
/or an e+tra*ural del"!er ,one that ta'es place outs"de of a nor*al del"!er center-) the pr"or"t"es for care of the neonate
"nclude *a"nta"n"n# a patent a"rwa) support"n# efforts to breathe) *on"tor"n# !"tal s"#ns) and *a"nta"n"n# ade6uate bod
te*perature$
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NURSING BULLETS _____________ ___________________________________________________________
Sub"n!olut"on *a occur "f the bladder "s d"stended after del"!er$
The nurse *ust place "dent"f"cat"on bands on both the *other and the neonate before the lea!e the del"!er roo*$
Erthro*c"n "s #"!en at b"rth to pre!ent ophthal*"a neonatoru*$
>el!"c0t"lt e+erc"ses can help to pre!ent or rel"e!e bac'ache dur"n# pre#nanc$
Before perfor*"n# a Leopold *aneu!er) the nurse should as' the pat"ent to e*pt her bladder$
MEDICAL SURGICAL NURSING
In a pat"ent w"th hpo'ale*"a ,seru* potass"u* le!el below F$: *E6<L-) present"n# s"#ns and s*pto*s "nclude *uscle
wea'ness and card"ac arrhth*"as$
5ur"n# card"ac arrest) "f an I$J$ route "s una!a"lable) ep"nephr"ne can be ad*"n"stered endotracheall$
>ern"c"ous ane*"a results fro* the fa"lure to absorb !"ta*"n B13 "n the GI tract and causes pr"*ar"l GI and neurolo#"c s"#ns
and s*pto*s$
A pat"ent who has a pressure ulcer should consu*e a h"#h0prote"n) h"#h0calor"e d"et) unless contra"nd"cated$
The ;L0.B "soen1*e le!el "s used to assess t"ssue da*a#e "n *ocard"al "nfarct"on$
After a 130hour fast) the nor*al fast"n# blood #lucose le!el "s =4 to 134 *#<dl$
A pat"ent who "s e+per"enc"n# d"#o+"n to+"c"t *a report nausea) !o*"t"n#) d"plop"a) blurred !"s"on) l"#ht flashes) and
ellow0#reen halos around "*a#es$
Anur"a "s da"l ur"ne output of less than 144 *l$
In re*"ttent fe!er) the bod te*perature !ar"es o!er a 3E0hour per"od) but re*a"ns ele!ated$
R"s' of a fat e*bol"s* "s #reatest "n the f"rst E= hours after the fracture of a lon# bone$ Its *an"fested b resp"rator d"stress$
To help !enous blood return "n a pat"ent who "s "n shoc') the nurse should ele!ate the pat"ents le#s no *ore than E: de#rees$
Th"s procedure "s contra"nd"cated "n a pat"ent w"th a head "n&ur$
The pulse def"c"t "s the d"fference between the ap"cal and rad"al pulse rates) when ta'en s"*ultaneousl b two nurses$
To reduce the pat"ents r"s' of !o*"t"n# and asp"rat"on) the nurse should schedule postural dra"na#e before *eals or 3 to E
hours after *eals$
Blood pressure can be *easured d"rectl b "ntra0arter"al "nsert"on of a catheter connected to a pressure0*on"tor"n# de!"ce$
A pos"t"!e Lern"#s s"#n) seen "n *en"n#"t"s) occurs when an atte*pt to fle+ the h"p of a recu*bent pat"ent causes pa"nful
spas*s of the ha*str"n# *uscle and res"stance to further e+tens"on of the le# at the 'nee$
In a pat"ent w"th a fractured) d"slocated fe*ur) treat*ent be#"ns w"th reduct"on and "**ob"l"1at"on of the affected le#$
(ern"ated nucleus pulposus ,"nter!ertebral d"s'- *ost co**onl occurs "n the lu*bar and lu*bosacral re#"ons$
La*"necto* "s sur#"cal re*o!al of the hern"ated port"on of an "nter!ertebral d"s'$
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NURSING BULLETS _____________ ___________________________________________________________
Sur#"cal treat*ent of a #astr"c ulcer "ncludes se!er"n# the !a#us ner!e ,!a#oto*- to reduce the a*ount of #astr"c ac"d
secreted b the #astr"c cells$
Jalsal!as *aneu!er "s forced e+halat"on a#a"nst a closed #lott"s) as when ta'"n# a deep breath) blow"n# a"r out) or bear"n#
down$
%hen *ean arter"al pressure falls below 24 ** (# and sstol"c blood pressure falls below =4 ** (#) !"tal or#an perfus"on
"s ser"ousl co*pro*"sed$
L"doca"ne ,7loca"ne- "s the dru# of cho"ce for reduc"n# pre*ature !entr"cular contract"ons$
A pat"ent "s at #reatest r"s' of d"n# dur"n# the f"rst 3E to E= hours after a *ocard"al "nfarct"on$
5ur"n# a *ocard"al "nfarct"on) the left !entr"cle usuall susta"ns the #reatest da*a#e$
The pa"n of a *ocard"al "nfarct"on results fro* *ocard"al "sche*"a caused b ano+"a$
/or a pat"ent "n card"ac arrest) the f"rst pr"or"t "s to establ"sh an a"rwa$
The un"!ersal s"#n for cho'"n# "s clutch"n# the hand to the throat$
/or a pat"ent who has heart fa"lure or card"o#en"c pul*onar ede*a) nurs"n# "nter!ent"ons focus on decreas"n# !enous return
to the heart and "ncreas"n# left !entr"cular output$ These "nter!ent"ons "nclude plac"n# the pat"ent "n h"#h /owlers pos"t"on
and ad*"n"ster"n# o+#en) d"uret"cs) and pos"t"!e "notrop"c dru#s as prescr"bed$
A pos"t"!e tubercul"n s'"n test "s an "ndurat"on of 14 ** or #reater at the "n&ect"on s"te$
The s"#ns and s*pto*s of h"stoplas*os"s) a chron"c sste*"c fun#al "nfect"on) rese*ble those of tuberculos"s$
In burn !"ct"*s) the lead"n# cause of death "s resp"rator co*pro*"se$ The second lead"n# cause "s "nfect"on$
The e+ocr"ne funct"on of the pancreas "s the secret"on of en1*es used to d"#est carbohdrates) fats) and prote"ns$
A pat"ent who has hepat"t"s A ,"nfect"ous hepat"t"s- should consu*e a d"et thats *oderatel h"#h "n fat and h"#h "n
carbohdrate and prote"n) and should eat the lar#est *eal "n the *orn"n#$
Esopha#eal balloon ta*ponade shouldnt be "nflated #reater than 34 ** (#$
H!erproduct"on of prolact"n b the p"tu"tar #land can cause #alactorrhea ,e+cess"!e or abnor*al lactat"on- and a*enorrhea
,absence of *enstruat"on-$
Inter*"ttent claud"cat"on ,pa"n dur"n# a*bulat"on or other *o!e*ent thats rel"e!ed w"th rest- "s a class"c s*pto* of
arter"al "nsuff"c"enc "n the le#$
In bladder carc"no*a) the *ost co**on f"nd"n# "s #ross) pa"nless he*atur"a$
>arenteral ad*"n"strat"on of hepar"n sod"u* "s contra"nd"cated "n pat"ents w"th renal or l"!er d"sease) GI bleed"n#) or recent
sur#er or trau*aN "n pre#nant pat"entsN and "n wo*en older than a#e 24$
5ru#s that potent"ate the effects of ant"coa#ulants "nclude asp"r"n) chloral hdrate) #luca#on) anabol"c stero"ds) and
chlora*phen"col$
/or a burn pat"ent) care pr"or"t"es "nclude *a"nta"n"n# a patent a"rwa) pre!ent"n# or correct"n# flu"d and electrolte
"*balances) controll"n# pa"n) and pre!ent"n# "nfect"on$
Elast"c stoc'"n#s should be worn on both le#s$
Act"!e "**un"1at"on "s the for*at"on of ant"bod"es w"th"n the bod "n response to !acc"nat"on or e+posure to d"sease$
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NURSING BULLETS _____________ ___________________________________________________________
>ass"!e "**un"1at"on "s ad*"n"strat"on of ant"bod"es that were prefor*ed outs"de the bod$
A pat"ent who "s rece"!"n# d"#o+"n ,Lano+"n- shouldnt rece"!e a calc"u* preparat"on because of the "ncreased r"s' of
d"#o+"n to+"c"t$ ;onco*"tant use *a affect card"ac contract"l"t and lead to arrhth*"as$
Inter*"ttent pos"t"!e0pressure breath"n# "s "nflat"on of the lun# dur"n# "nsp"rat"on w"th co*pressed a"r or o+#en$ The #oal of
th"s "nflat"on "s to 'eep the lun# open$
%r"stdrop "s caused b parals"s of the e+tensor *uscles "n the forear* and hand$
/ootdrop results fro* e+cess"!e plantar fle+"on and "s usuall a co*pl"cat"on of prolon#ed bed rest$
A pat"ent who has #onorrhea *a be treated w"th pen"c"ll"n and probenec"d ,Bene*"d-$ >robenec"d delas the e+cret"on of
pen"c"ll"n and 'eeps th"s ant"b"ot"c "n the bod lon#er$
In pat"ents who ha!e #lucose020phosphate dehdro#enase ,G2>5- def"c"enc) the red blood cells cant *etabol"1e ade6uate
a*ounts of #lucose) and he*ols"s occurs$
Hn0call *ed"cat"on "s *ed"cat"on that should be read for "**ed"ate ad*"n"strat"on when the call to ad*"n"ster "ts rece"!ed$
If #a##"n#) nausea) or !o*"t"n# occurs when an a"rwa "s re*o!ed) the nurse should place the pat"ent "n a lateral pos"t"on
w"th the upper ar* supported on a p"llow$
%hen a postoperat"!e pat"ent arr"!es "n the reco!er roo*) the nurse should pos"t"on the pat"ent on h"s s"de or w"th h"s head
turned to the s"de and the ch"n e+tended$
In the "**ed"ate postoperat"!e per"od) the nurse should report a resp"rator rate #reater than F4) te*perature #reater than
144C / ,FD$=C ;- or below ODC / ,F2$1C ;-) or a s"#n"f"cant drop "n blood pressure or r"se "n pulse rate fro* the basel"ne$
Irre!ers"ble bra"n da*a#e *a occur "f the central ner!ous sste* "s depr"!ed of o+#en for *ore than E *"nutes$
Treat*ent for polcthe*"a !era "ncludes ad*"n"ster"n# o+#en) rad"o"sotope therap) or che*otherap a#ents) such as
chlora*buc"l and n"tro#en *ustard) to suppress bone *arrow #rowth$
A pat"ent w"th acute renal fa"lure should rece"!e a h"#h0calor"e d"et thats low "n prote"n as well as potass"u* and sod"u*$
Add"sons d"sease "s caused b hpofunct"on of the adrenal #land and "s character"1ed b fat"#ue) ane*"a) we"#ht loss) and
bron1e s'"n p"#*entat"on$ %"thout cort"sol replace*ent therap) "ts usuall fatal$
Glauco*a "s *ana#ed conser!at"!el w"th beta0adrener#"c bloc'ers such as t"*olol ,T"*opt"c-) wh"ch decrease s*pathet"c
"*pulses to the ee) and w"th *"ot"c eedrops such as p"locarp"ne ,Isopto ;arp"ne-) wh"ch constr"ct the pup"ls$
."ot"cs effect"!el treat #lauco*a b reduc"n# "ntraocular pressure$ The do th"s b constr"ct"n# the pup"l) contract"n# the
c"l"ar *uscles) open"n# the anter"or cha*ber an#le) and "ncreas"n# the outflow of a6ueous hu*or$
%h"le a pat"ent "s rece"!"n# hepar"n) the nurse should *on"tor the part"al thro*boplast"n t"*e$
Ur"nar fre6uenc) "ncont"nence) or both can occur after catheter re*o!al$ Incont"nence *a be *an"fested as dr"bbl"n#$
%hen teach"n# a pat"ent about colosto* care) the nurse should "nstruct the pat"ent to han# the "rr"#at"on reser!o"r 1=9 to 339
,E: to :: c*- abo!e the sto*a) "nsert the catheter 39 to E9 ,: to 14 c*- "nto the sto*a) "rr"#ate the sto*a w"th 1D to FE o1
,:4F to 1)44: *l- of water at a te*perature of 14:C to 114C / ,E4C to EFC ;- once a da) clean the area around the sto*a w"th
soap and water before appl"n# a new ba#) and use a protect"!e s'"n co!er"n#) such as a Sto*ahes"!e wafer) 'araa paste) or
'araa r"n#) around the sto*a$
The f"rst s"#n of (od#'"ns d"sease "s pa"nless) superf"c"al l*phadenopath) tp"call found under one ar* or on one s"de of
the nec' "n the cer!"cal cha"n$
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NURSING BULLETS _____________ ___________________________________________________________
To d"fferent"ate true canos"s fro* depos"t"on of certa"n p"#*ents) the nurse should press the s'"n o!er the d"scolored area$
;anot"c s'"n blanches) but p"#*ented s'"n doesnt$
A pat"ent who has a #astr"c ulcer "s *ost l"'el to report pa"n dur"n# or shortl after eat"n#$
%"den"n# pulse pressure "s a s"#n of "ncreas"n# "ntracran"al pressure$ /or e+a*ple) the blood pressure *a r"se fro* 134<=4
to 124<24 ** (#$
In a burn !"ct"*) a pr"*ar #oal of wound care "s to pre!ent conta*"nat"on b *"croor#an"s*s$
To pre!ent e+ternal rotat"on "n a pat"ent who has had h"p na"l"n#) the nurse places trochanter rolls fro* the 'nee to the an'le
of the affected le#$
Se!ere h"p pa"n after the "nsert"on of a h"p prosthes"s "nd"cates d"slod#*ent$ If th"s occurs) before call"n# the phs"c"an) the
nurse should assess the pat"ent for shorten"n# of the le#) e+ternal rotat"on) and absence of refle+es$
As *uch as D:G of renal funct"on "s lost before blood urea n"tro#en and seru* creat"n"ne le!els r"se abo!e nor*al$
%hen co*pensator efforts are present "n ac"d0base balance) part"al pressure of arter"al carbon d"o+"de ,>a;H3- and
b"carbonate ,(;HFV- alwas po"nt "n the sa*e d"rect"onI
p( >a;H3 (;HFV U resp"rator ac"dos"s co*pensated
p( >a;H3 (;HFV U resp"rator al'alos"s co*pensated
p( >a;H3 (;HFV U *etabol"c ac"dos"s co*pensated
p( >a;H3 (;HFV U *etabol"c al'alos"s co*pensated$
>olur"a "s ur"ne output of 3):44 *l or *ore w"th"n 3E hours$
The present"n# s"#n of pleur"t"s "s chest pa"n that "s usuall un"lateral and related to resp"rator *o!e*ent$
If a pat"ent has a #astr"c dra"na#e tube "n place) the nurse should e+pect the phs"c"an to order potass"u* chlor"de$
An "ncreased pulse rate "s one of the f"rst "nd"cat"ons of resp"rator d"ff"cult$ It occurs because the heart atte*pts to
co*pensate for a decreased o+#en suppl to the t"ssues b pu*p"n# *ore blood$
In an adult) a he*o#lob"n le!el below 11 *#<dl su##ests "ron def"c"enc ane*"a and the need for further e!aluat"on$
The nor*al part"al pressure of o+#en "n arter"al blood "s O: ** (# ,plus or *"nus : ** (#-$
J"ta*"n ; def"c"enc "s character"1ed b br"ttle bones) p"npo"nt per"pheral he*orrha#es) and fr"able #u*s w"th loosened
teeth$
;l"n"cal *an"festat"ons of pul*onar e*bol"s* are !ar"able) but "ncreased resp"rator rate) tachcard"a) and he*opts"s are
co**on$
Nor*all) "ntraocular pressure "s 13 to 34 ** (#$ It can be *easured w"th a Sch"Yt1 tono*eter$
In earl he*orrha#"c shoc') blood pressure *a be nor*al) but resp"rator and pulse rates are rap"d$ The pat"ent *a report
th"rst and *a ha!e cla** s'"n and p"loerect"on ,#oose bu*ps-$
;ool) *o"st) pale s'"n) as occurs "n shoc') results fro* d"!ers"on of blood fro* the s'"n to the *a&or or#ans$
To assess cap"llar ref"ll) the nurse appl"es pressure o!er the na"l bed unt"l blanch"n# occurs) 6u"c'l releases the pressure)
and notes the rate at wh"ch blanch"n# fades$ ;ap"llar ref"ll "nd"cates perfus"on) wh"ch decreases "n shoc') thereb
len#then"n# ref"ll t"*e$ Nor*al cap"llar ref"ll "s less than F seconds$
E+cept for pat"ents w"th renal fa"lure) ur"ne output of less than F4 *l<hour s"#n"f"es dehdrat"on and the potent"al for shoc'$
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NURSING BULLETS _____________ ___________________________________________________________
In elderl pat"ents) the *ost co**on fracture "s h"p fracture$ Hsteoporos"s wea'ens the bones) pred"spos"n# these pat"ents to
fracture) wh"ch usuall results fro* a fall$
Before an#"o#raph) the nurse should as' the pat"ent whether hes aller#"c to the de) shellf"sh) or "od"ne and ad!"se h"* to
ta'e noth"n# b *outh for = hours before the procedure$
5ur"n# *elo#raph) appro+"*atel 14 to 1: *l of cerebrosp"nal flu"d "s re*o!ed for laborator stud"es and an e6ual
a*ount of contrast *ed"a "s "n&ected$
After an#"o#raph) the puncture s"te "s co!ered w"th a pressure dress"n# and the affected part "s "**ob"l"1ed for = hours to
decrease the r"s' of bleed"n#$
If a water0based *ed"u* was used dur"n# *elo#raph) the pat"ent re*a"ns on bed rest for 2 to = hours) w"th the head of the
bed ele!ated F4 to E: de#rees$ If an o"l0based *ed"u* was used) the pat"ent re*a"ns flat "n bed for 2 to 3E hours$
The le!el of a*putat"on "s deter*"ned b est"*at"n# the *a+"*u* !"able t"ssue ,t"ssue w"th ade6uate c"rculat"on- needed to
de!elop a funct"onal stu*p$
(epar"n sod"u* "s "ncluded "n the d"alsate used for renal d"als"s$
>aro+s*al nocturnal dspnea *a "nd"cate heart fa"lure$
A pat"ent who ta'es a card"ac #lcos"de) such as d"#o+"n) should consu*e a d"et that "ncludes h"#h0potass"u* foods$
The nurse should l"*"t tracheobronch"al suct"on"n# to 14 to 1: seconds and should *a'e onl two passes$
Before perfor*"n# tracheobronch"al suct"on"n#) the nurse should !ent"late and o+#enate the pat"ent f"!e to s"+ t"*es w"th a
resusc"tat"on ba# and 144G o+#en$ Th"s procedure "s called ba##"n#$
S"#ns and s*pto*s of pneu*othora+ "nclude tachpnea) restlessness) hpotens"on) and tracheal de!"at"on$
The card"nal s"#n of to+"c shoc' sndro*e "s rap"d onset of a h"#h fe!er$
A 'e s"#n of pept"c ulcer "s he*ate*es"s) wh"ch can be br"#ht red or dar' red) w"th the cons"stenc of coffee #rounds$
S"#ns and s*pto*s of a perforated pept"c ulcer "nclude sudden) se!ere upper abdo*"nal pa"nN !o*"t"n#N and an e+tre*el
tender) r"#"d ,boardl"'e- abdo*en$
;onst"pat"on "s a co**on ad!erse react"on to alu*"nu* hdro+"de$
/or the f"rst 3E hours after a *ocard"al "nfarct"on) the pat"ent should use a beds"de co**ode and then pro#ress to wal'"n#
to the to"let) bath"n#) and ta'"n# short wal's$
After a *ocard"al "nfarct"on) the pat"ent should a!o"d o!ere+ert"on and add a new act"!"t da"l) as tolerated w"thout
dspnea$
In a pat"ent w"th a recent *ocard"al "nfarct"on) froth) blood0t"n#ed sputu* su##ests pul*onar ede*a$
In a pat"ent who has ac6u"red "**unodef"c"enc sndro*e) the pr"*ar purpose of dru#s "s to pre!ent secondar "nfect"ons$
In a pat"ent w"th ac6u"red "**unodef"c"enc sndro*e) suppress"on of the "**une sste* "ncreases the r"s' of
opportun"st"c "nfect"ons) such as cto*e#alo!"rus) >neu*ocst"s car"n"" pneu*on"a) and thrush$
A pat"ent w"th ac6u"red "**unodef"c"enc sndro*e *a ha!e rap"d we"#ht loss) a s"#n of wast"n# sndro*e$
If the bod doesnt use #lucose for ener#) "t *etabol"1es fat and produces 'etones$
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NURSING BULLETS _____________ ___________________________________________________________
Appro+"*atel 34G of pat"ents w"th Gu"lla"n0BarrZ sndro*e ha!e res"dual def"c"ts) such as *"ld *otor wea'ness or
d"*"n"shed lower e+tre*"t refle+es$
(pertens"on and hpo'ale*"a are the *ost s"#n"f"cant cl"n"cal *an"festat"ons of pr"*ar hperaldosteron"s*$
After percutaneous asp"rat"on of the bladder) the pat"ents f"rst !o"d "s usuall p"n'N howe!er) ur"ne w"th fran' blood should
be reported to the phs"c"an$
A ur"ne culture that #rows *ore than 144)444 colon"es of bacter"a per *"ll"l"ter of ur"ne "nd"cates "nfect"on$
A pat"ent who "s under#o"n# d"als"s should ta'e a !"ta*"n supple*ent and eat foods that are h"#h "n calor"es) but low "n
prote"n) sod"u*) and potass"u*$
In a pat"ent who has chron"c obstruct"!e pul*onar d"sease) the *ost effect"!e was to reduce th"c' secret"ons are to "ncrease
flu"d "nta'e to 3):44 *l<da and encoura#e a*bulat"on$
The nurse should teach a pat"ent w"th e*phse*a how to perfor* pursed0l"p breath"n# because th"s slows e+p"rat"on)
pre!ents al!eolar collapse) and helps to control the resp"rator rate$
;lubb"n# of the d"#"ts and a barrel chest *a de!elop "n a pat"ent who has chron"c obstruct"!e pul*onar d"sease$
A stro'e ,?bra"n attac'@- d"srupts the bra"ns blood suppl and *a be caused b hpertens"on$
In a pat"ent who "s under#o"n# d"als"s) des"red outco*es are nor*al we"#ht) nor*al seru* albu*"n le!el ,F$: to :$: #<dl-)
and ade6uate prote"n "nta'e ,1$3 to 1$: #<'# of bod we"#ht da"l-$
Inter*"ttent per"toneal d"als"s "n!ol!es perfor*"n# three to se!en treat*ents that total E4 hours per wee'$
In a pat"ent w"th chron"c obstruct"!e pul*onar d"sease) the best wa to ad*"n"ster o+#en "s b nasal cannula$ The nor*al
flow rate "s 3 to F L< *"nute$
Isoethar"ne ,Bron'osol- can be ad*"n"stered w"th a handheld nebul"1er or b "nter*"ttent pos"t"!e0pressure breath"n#$
Bra"n death "s "rre!ers"ble cessat"on of bra"n funct"on$
;ont"nuous a*bulator per"toneal d"als"s re6u"res four e+chan#es per da) D das per wee') for a total of 12= hours per
wee'$
The class"c ad!erse react"ons to ant"h"sta*"nes are dr *outh) drows"ness) and blurred !"s"on$
Because of the r"s' of paralt"c "leus) a pat"ent who has rece"!ed a #eneral anesthet"c cant ta'e anth"n# b *outh unt"l
act"!e bowel sounds are heard "n all abdo*"nal 6uadrants$
The le!el of alpha0fetoprote"n) a tu*or *ar'er) "s ele!ated "n pat"ents who ha!e test"cular #er* cell cancer$
;l"n"cal *an"festat"ons of orch"t"s caused b bacter"a or *u*ps "nclude h"#h te*perature) ch"lls) and sudden pa"n "n the
"n!ol!ed test"s$
The le!el of prostate0spec"f"c ant"#en "s ele!ated "n pat"ents w"th ben"#n prostat"c hperplas"a or prostate cancer$
The le!el of prostat"c ac"d phosphatase "s ele!ated "n pat"ents w"th ad!anced sta#es of prostate cancer$
>henlephr"ne ,Neo0Snephr"ne-) a *dr"at"c) "s "nst"lled "n a pat"ents ee to d"late the ee$
To pro*ote flu"d dra"na#e and rel"e!e ede*a "n a pat"ent w"th ep"d"d*"t"s) the nurse should ele!ate the scrotu* on a scrotal
br"d#e$
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NURSING BULLETS _____________ ___________________________________________________________
/luoresce"n sta"n"n# "s co**onl used to assess corneal abras"ons because "t outl"nes superf"c"al ep"thel"al defects$
>resbop"a "s loss of near !"s"on as a result of the loss of elast"c"t of the crstall"ne lens$
Trans"ent "sche*"c attac's are cons"dered precursors to stro'es$
A s"#n of acute append"c"t"s) .cBurnes s"#n "s tenderness at .cBurnes po"nt ,about 39 [: c*\ fro* the r"#ht anter"or
super"or "l"ac sp"ne on a l"ne between the sp"ne and the u*b"l"cus-$
%hen car"n# for a pat"ent w"th Gu"lla"n0BarrZ sndro*e) the nurse should focus on resp"rator "nter!ent"ons as the d"sease
process ad!ances$
S"#ns and s*pto*s of colon cancer "nclude rectal bleed"n#) chan#e "n bowel hab"ts) "ntest"nal obstruct"on) abdo*"nal pa"n)
we"#ht loss) anore+"a) nausea) and !o*"t"n#$
S*pto*s of prostat"t"s "nclude fre6uent ur"nat"on and dsur"a$
A chancre "s a pa"nless) ulcerat"!e les"on that de!elops dur"n# the pr"*ar sta#e of sph"l"s$
5ur"n# the tert"ar sta#e of sph"l"s) sp"rochetes "n!ade the "nternal or#ans and cause per*anent da*a#e$
In total parenteral nutr"t"on) we"#ht #a"n "s the *ost rel"able "nd"cator of a pos"t"!e response to therap$
The nurse *a ad*"n"ster an I$J$ fat e*uls"on throu#h a central or per"pheral catheter) but shouldnt use an "n0l"ne f"lter
because the fat part"cles are too lar#e to pass throu#h the pores$
If a pat"ent who has a prostatecto* "s us"n# a ;unn"n#ha* cla*p) "nstruct h"* to wash and dr h"s pen"s before appl"n#
the cla*p$ (e should appl the cla*p hor"1ontall and re*o!e "t at least e!er E hours to e*pt h"s bladder to pre!ent
"nfect"on$
If a wo*an has s"#ns of ur"nar tract "nfect"on dur"n# *enopause) she should be "nstructed to dr"n' s"+ to e"#ht #lasses of
water per da) ur"nate before and after "ntercourse) and perfor* Le#el e+erc"ses$
If a *enopausal pat"ent e+per"ences a ?hot flash)@ she should be "nstructed to see' a cool) bree1 locat"on and s"p a cool
dr"n'$
;he"los"s causes f"ssures at the an#les of the *outh and "nd"cates a !"ta*"n B3) r"bofla!"n) or "ron def"c"enc$
Tetan *a result fro* hpocalce*"a caused b hpoparathro"d"s*$
A pat"ent who has cer!"cal cancer *a e+per"ence !a#"nal bleed"n# for 1 to F *onths after "ntraca!"tar rad"at"on$
Asc"tes "s the accu*ulat"on of flu"d) conta"n"n# lar#e a*ounts of prote"n and electroltes) "n the abdo*"nal ca!"t$ Its
co**onl caused b c"rrhos"s$
Nor*al pul*onar arter pressure "s 14 to 3: ** (#$ Nor*al pul*onar arter wed#e pressure "s : to 13 ** (#$
After card"ac catheter"1at"on) the s"te "s *on"tored for bleed"n# and he*ato*a for*at"on) pulses d"stal to the s"te are palpated
e!er 1: *"nutes for 1 hour) and the pat"ent "s *a"nta"ned on bed rest w"th the e+tre*"t e+tended for = hours$
(e*oph"l"a "s a bleed"n# d"sorder thats trans*"tted #enet"call "n a se+0l"n'ed ,7 chro*oso*e- recess"!e pattern$ Althou#h
#"rls and wo*en *a carr the defect"!e #ene) he*oph"l"a usuall occurs onl "n bos and *en$
Jon %"llebrands d"sease "s an autoso*al do*"nant bleed"n# d"sorder thats caused b platelet dsfunct"on and factor JIII
def"c"enc$
S"c'le cell ane*"a "s a con#en"tal he*olt"c ane*"a thats caused b defect"!e he*o#lob"n S *olecules$ It pr"*ar"l affects
blac's$
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NURSING BULLETS _____________ ___________________________________________________________
S"c'le cell ane*"a has a ho*o1#ous "nher"tance pattern$ S"c'le cell tra"t has a hetero1#ous "nher"tance pattern$
>el0Ebste"n fe!er "s a character"st"c s"#n of (od#'"ns d"sease$ /e!er recurs e!er few das or wee's and alternates w"th
afebr"le per"ods$
Glucose020phosphate dehdro#enase ,G2>5- def"c"enc "s an "nher"ted *etabol"c d"sorder thats character"1ed b red blood
cells that are def"c"ent "n G2>5) a cr"t"cal en1*e "n aerob"c #lcols"s$
>referred s"tes for bone *arrow asp"rat"on are the poster"or super"or "l"ac crest) anter"or "l"ac crest) and sternu*$
5ur"n# bone *arrow har!est"n#) the donor rece"!es #eneral anesthes"a and E44 to =44 *l of *arrow "s asp"rated$
A butterfl rash across the br"d#e of the nose "s a character"st"c s"#n of sste*"c lupus erthe*atosus$
Rheu*ato"d arthr"t"s "s a chron"c) destruct"!e colla#en d"sease character"1ed b s**etr"c "nfla**at"on of the sno!"u*
that leads to &o"nt swell"n#$
Screen"n# for hu*an "**unodef"c"enc !"rus ant"bod"es be#"ns w"th the en1*e0l"n'ed "**unosorbent assa$ Results are
conf"r*ed b the %estern blot test$
The ;L0.B "soen1*e le!el "ncreases E to = hours after a *ocard"al "nfarct"on) pea's at 13 to 3E hours) and returns to
nor*al "n F das$
E+cess"!e "nta'e of !"ta*"n L *a s"#n"f"cantl anta#on"1e the ant"coa#ulant effects of warfar"n ,;ou*ad"n-$ The pat"ent
should be caut"oned to a!o"d eat"n# an e+cess"!e a*ount of leaf #reen !e#etables$
A l*ph node b"ops that shows Reed0Sternber# cells pro!"des a def"n"t"!e d"a#nos"s of (od#'"ns d"sease$
Bells pals "s un"lateral fac"al wea'ness or parals"s caused b a d"sturbance of the se!enth cran"al ,fac"al- ner!e$
5ur"n# an "n"t"al tubercul"n s'"n test) lac' of a wheal after "n&ect"on of tubercul"n pur"f"ed prote"n der"!at"!e "nd"cates that the
test dose was "n&ected too deepl$ The nurse should "n&ect another dose at least 39 ,: c*- fro* the "n"t"al s"te$
A tubercul"n s'"n test should be read E= to D3 hours after ad*"n"strat"on$
In read"n# a tubercul"n s'"n test) erthe*a w"thout "ndurat"on "s usuall not s"#n"f"cant$
5eath caused b botul"s* usuall results fro* delaed d"a#nos"s and resp"rator co*pl"cat"ons$
In a pat"ent who has rab"es) sal"!a conta"ns the !"rus and "s a ha1ard for nurses who pro!"de care$
A febr"le nonhe*olt"c react"on "s the *ost co**on transfus"on react"on$
(po'ale*"a ,abnor*all low concentrat"on of potass"u* "n the blood- *a cause *uscle wea'ness or parals"s)
electrocard"o#raph"c abnor*al"t"es) and GI d"sturbances$
Ber"ber") a ser"ous !"ta*"n B1 ,th"a*"ne- def"c"enc) affects alcohol"cs who ha!e poor d"etar hab"ts$ Its ep"de*"c "n As"an
countr"es where people subs"st on unenr"ched r"ce$ Its character"1ed b the phrase ?I cant)@ "nd"cat"n# that the pat"ent "s too
"ll to do anth"n#$
E+cess"!e sedat"on *a cause resp"rator depress"on$
The pr"*ar postoperat"!e concern "s *a"ntenance of a patent a"rwa$
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NURSING BULLETS _____________ ___________________________________________________________
If canos"s occurs c"rcu*orall) subl"n#uall) or "n the na"l bed) the o+#en saturat"on le!el ,Sao 3- "s less than =4G$
A rap"d pulse rate "n a postoperat"!e pat"ent *a "nd"cate pa"n) bleed"n#) dehdrat"on) or shoc'$
Increased pulse rate and blood pressure *a "nd"cate that a pat"ent "s e+per"enc"n# ?s"lent pa"n@ ,pa"n that cant be e+pressed
!erball) such as when a pat"ent "s reco!er"n# fro* anesthes"a-$
L"doca"ne ,7loca"ne- e+erts ant"arrhth*"c act"on b suppress"n# auto*at"c"t "n the >ur'"n&e f"bers and ele!at"n# the
electr"cal st"*ulat"on threshold "n the !entr"cles$
;ullens s"#n ,a blu"sh d"scolorat"on around the u*b"l"cus- "s seen "n pat"ents who ha!e a perforated pancreas$
5ur"n# the postoperat"!e per"od) the pat"ent should cou#h and breathe deepl e!er 3 hours unless otherw"se contra"nd"cated
,for e+a*ple) after cran"oto*) cataract sur#er) or throat sur#er-$
Before sur#er) a pat"ents resp"rator !olu*e *a be *easured b "ncent"!e sp"ro*etr$ Th"s *easure*ent beco*es the
pat"ents postoperat"!e #oal for resp"rator !olu*e$
The postoperat"!e pat"ent should use "ncent"!e sp"ro*etr 14 to 13 t"*es per hour and breathe deepl$
Before a*bulat"n#) a postoperat"!e pat"ent should dan#le h"s le#s o!er the s"de of the bed and perfor* deep0breath"n#
e+erc"ses$
5ur"n# the pat"ents f"rst postoperat"!e a*bulat"on) the nurse should *on"tor the pat"ent closel and ass"st h"* as needed
wh"le he wal's a few feet fro* the bed to a stead cha"r$
(po!ole*"a occurs when 1:G to 3:G of the bods total blood !olu*e "s lost$
S"#ns and s*pto*s of hpo!ole*"a "nclude rap"d) wea' pulseN low blood pressureN cool) cla** s'"nN shallow
resp"rat"onsN ol"#ur"a or anur"aN and lethar#$
Acute per"card"t"s causes sudden se!ere) constant pa"n o!er the anter"or chest$ The pa"n "s a##ra!ated b "nsp"rat"on$
S"#ns and s*pto*s of sept"ce*"a "nclude fe!er) ch"lls) rash) abdo*"nal d"stent"on) prostrat"on) pa"n) headache) nausea) and
d"arrhea$
Roc' .ounta"n spotted fe!er causes a pers"stent h"#h fe!er) nonp"tt"n# ede*a) and rash$
>at"ents who ha!e under#one coronar arter bpass #raft should sleep 2 to 14 hours per da) ta'e the"r te*perature tw"ce
da"l) and a!o"d l"ft"n# *ore than 14 lb ,E$: '#- for at least 2 wee's$
;laud"cat"on pa"n ,pa"n on a*bulat"on- "s caused b arter"al "nsuff"c"enc as a result of athero*atous pla6ue that obstructs
arter"al blood flow to the e+tre*"t"es$
>ace*a'ers can be powered b l"th"u* batter"es for up to 14 ears$
The pat"ent shouldnt !o"d for 1 hour before percutaneous suprapub"c bladder asp"rat"on to ensure that suff"c"ent ur"ne
re*a"ns "n the bladder to *a'e the procedure successful$
Left0s"ded heart fa"lure causes pul*onar con#est"on) p"n'0t"n#ed sputu*) and dspnea$ ,Re*e*ber L for left and lun#$-
The current reco**ended blood cholesterol le!el "s less than 344 *#<dl$
%hen car"n# for a pat"ent who "s ha!"n# a se"1ure) the nurse should follow these #u"del"nesI ,1- A!o"d restra"n"n# the pat"ent)
but help a stand"n# pat"ent to a l"n# pos"t"on$ ,3- Loosen restr"ct"!e cloth"n#$ ,F- >lace a p"llow or another soft ob&ect under
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the pat"ents head$ ,E- ;lear the area of hard ob&ects$ ,:- 5ont force anth"n# "nto the pat"ents *outh) but *a"nta"n a patent
a"rwa$ ,2- Reassure and reor"ent the pat"ent after the se"1ure subs"des$
G"n#"!al hperplas"a) or o!er#rowth of #u* t"ssue) "s an ad!erse react"on to phento"n ,5"lant"n-$
%"th a#"n#) *ost *arrow "n lon# bones beco*es ellow) but "t reta"ns the capac"t to con!ert bac' to red$
;l"n"cal *an"festat"ons of l*phede*a "nclude accu*ulat"on of flu"d "n the le#s$
Afterload "s !entr"cular wall tens"on dur"n# sstol"c e&ect"on$ Its "ncreased "n pat"ents who ha!e septal hpertroph)
"ncreased blood !"scos"t) and cond"t"ons that cause bloc'a#e of aort"c or pul*onar outflow$
Red blood cells can be stored fro1en for up to 3 earsN howe!er) the *ust be used w"th"n 3E hours of thaw"n#$
/or the f"rst 3E hours after a*putat"on) the nurse should ele!ate the stu*p to pre!ent ede*a$
After hsterecto*) a wo*an should a!o"d se+ual "ntercourse for F wee's "f a !a#"nal approach was used and 2 wee's "f the
abdo*"nal approach was used$
>ar'"nsons d"sease character"st"call causes pro#ress"!e *uscle r"#"d"t) a'"nes"a) and "n!oluntar tre*or$
Ton"c0clon"c se"1ures are character"1ed b a loss of consc"ousness and alternat"n# per"ods of *uscle contract"on and
rela+at"on$
Status ep"lept"cus) a l"fe0threaten"n# e*er#enc) "s a ser"es of rap"dl repeat"n# se"1ures that occur w"thout "nter!en"n#
per"ods of consc"ousness$
The "deal donor for '"dne transplantat"on "s an "dent"cal tw"n$ If an "dent"cal tw"n "snt a!a"lable) a b"olo#"cal s"bl"n# "s the
ne+t best cho"ce$
Breast cancer "s the lead"n# cancer a*on# wo*enN howe!er) lun# cancer accounts for *ore deaths$
The sta#es of cer!"cal cancer are as followsI sta#e 4) carc"no*a "n s"tuN sta#e I) cancer conf"ned to the cer!"+N sta#e II) cancer
e+tend"n# beond the cer!"+) but not to the pel!"c wallN sta#e III) cancer e+tend"n# to the pel!"c wallN and sta#e IJ) cancer
e+tend"n# beond the pel!"s or w"th"n the bladder or rectu*$
Hne *ethod used to est"*ate blood loss after a hsterecto* "s count"n# per"neal pads$ Saturat"n# *ore than one pad "n 1
hour or e"#ht pads "n 3E hours "s cons"dered he*orrha#"n#$
Transurethral resect"on of the prostate "s the *ost co**on procedure for treat"n# ben"#n prostat"c hperplas"a$
In a chest dra"na#e sste*) the water "n the water0seal cha*ber nor*all r"ses when a pat"ent breathes "n and falls when he
breathes out$
Sp"nal fus"on pro!"des sp"nal stab"l"t throu#h a bone #raft) usuall fro* the "l"ac crest) that fuses two or *ore !ertebrae$
A pat"ent who rece"!es an tpe of transplant *ust ta'e an "**unosuppressant dru# for the rest of h"s l"fe$
Incent"!e sp"ro*etr should be used : to 14 t"*es an hour wh"le the pat"ent "s awa'e$
In wo*en) pel!"c "nfla**ator d"sease "s a co**on co*pl"cat"on of #onorrhea$
Scol"os"s "s lateral S0shaped cur!ature of the sp"ne$
S"#ns and s*pto*s of the secondar sta#e of sph"l"s "nclude a rash on the pal*s and soles) eros"on of the oral *ucosa)
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NURSING BULLETS _____________ ___________________________________________________________
alopec"a) and enlar#ed l*ph nodes$
In a pat"ent who "s rece"!"n# total parenteral nutr"t"on) the nurse should *on"tor #lucose and electrolte le!els$
Unless contra"nd"cated) on ad*"ss"on to the postanesthes"a care un"t) a pat"ent should be turned on h"s s"de and h"s !"tal s"#ns
should be ta'en$
Ede*a "s treated b l"*"t"n# flu"d "nta'e and el"*"nat"n# e+cess flu"d$
A pat"ent who has had sp"nal anesthes"a should re*a"n flat for 13 to 3E hours$ J"tal s"#ns and neuro*uscular funct"on should
be *on"tored$
A pat"ent who has *aple srup ur"ne d"sease should a!o"d food conta"n"n# the a*"no ac"ds leuc"ne) "soleuc"ne) and ls"ne$
A se!ere co*pl"cat"on of a fe*ur fracture "s e+cess"!e blood loss that results "n shoc'$
To prepare a pat"ent for per"toneal d"als"s) the nurse should as' the pat"ent to !o"d) *easure h"s !"tal s"#ns) place h"* "n a
sup"ne pos"t"on) and us"n# asept"c techn"6ue) "nsert a catheter throu#h the abdo*"nal wall and "nto the per"toneal space$
If *ore than F L of d"alsate solut"on return dur"n# per"toneal d"als"s) the nurse should not"f the phs"c"an$
(e*od"als"s "s the re*o!al of certa"n ele*ents fro* the blood b pass"n# hepar"n"1ed blood throu#h a se*"per*eable
*e*brane to the d"alsate bath) wh"ch conta"ns all of the "*portant electroltes "n the"r "deal concentrat"ons$
Gan#rene usuall affects the d"#"ts f"rst) and be#"ns w"th s'"n color chan#es that pro#ress fro* #ra0blue to dar' brown or
blac'$
L"dne funct"on "s assessed b e!aluat"n# blood urea n"tro#en ,nor*al ran#e "s = to 34 *#<dl- and seru* creat"n"ne ,nor*al
ran#e "s 4$2 to 1$F *#<dl- le!els$
A we"#ht0bear"n# transfer "s appropr"ate onl for a pat"ent who has at least one le# thats stron# enou#h to bear we"#ht) such
as a pat"ent w"th he*"ple#"a or a s"n#le0le# a*putat"on$
H!erflow "ncont"nence ,!o"d"n# of F4 to 24 *l of ur"ne e!er 1: to F4 *"nutes- "s a s"#n of bladder d"stent"on$
The f"rst s"#n of a pressure ulcer "s reddened s'"n that blanches when pressure "s appl"ed$
Late s"#ns and s*pto*s of s"c'le cell ane*"a "nclude tachcard"a) card"o*e#al) sstol"c and d"astol"c *ur*urs) chron"c
fat"#ue) hepato*e#al) and spleno*e#al$
A *echan"cal !ent"lator) wh"ch can *a"nta"n !ent"lat"on auto*at"call for an e+tended per"od) "s "nd"cated when a pat"ent
cant *a"nta"n a safe >aH3 or >a;H3 le!el$
Two tpes of *echan"cal !ent"lators e+"stI ne#at"!e0pressure !ent"lators) wh"ch appl ne#at"!e pressure around the chest
wall) and pos"t"!e0pressure !ent"lators) wh"ch del"!er a"r under pressure to the pat"ent$
An#"na pector"s "s character"1ed b substernal pa"n that lasts for 3 to F *"nutes$ The pa"n) wh"ch "s caused b *ocard"al
"sche*"a) *a rad"ate to the nec') shoulders) or &awN "s descr"bed as !"sel"'e) or constr"ct"n#N and *a be acco*pan"ed b
se!ere apprehens"on or a feel"n# of "*pend"n# doo*$
The d"a#nos"s of an acute *ocard"al "nfarct"on "s based on the pat"ents s"#ns and s*pto*s) electrocard"o#ra* trac"n#s)
tropon"n le!el) and card"ac en1*e stud"es$
The #oal of treat*ent for a pat"ent w"th an#"na pector"s "s to reduce the hearts wor'load) thereb reduc"n# the *ocard"al
de*and for o+#en and pre!ent"n# *ocard"al "nfarct"on$
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N"tro#lcer"n decreases the a*ount of blood that returns to the heart b "ncreas"n# the capac"t of the !enous bed$
The pat"ent should ta'e no *ore than three n"tro#lcer"n tablets "n a 1:0*"nute per"od$
(e*od"als"s "s usuall perfor*ed 3E hours before '"dne transplantat"on$
S"#ns and s*pto*s of acute '"dne transplant re&ect"on are pro#ress"!e enlar#e*ent and tenderness at the transplant s"te)
"ncreased blood pressure) decreased ur"ne output) ele!ated seru* creat"n"ne le!el) and fe!er$
After a rad"cal *astecto*) the pat"ents ar* should be ele!ated ,w"th the hand abo!e the elbow- on a p"llow to enhance
c"rculat"on and pre!ent ede*a$
>ostoperat"!e *astecto* care "ncludes teach"n# the pat"ent ar* e+erc"ses to fac"l"tate l*ph dra"na#e and pre!ent
shorten"n# of the *uscle and contracture of the shoulder &o"nt ,fro1en shoulder-$
After rad"cal *astecto*) the pat"ent should help pre!ent "nfect"on b *a'"n# sure that no blood pressure read"n#s)
"n&ect"ons) or !en"punctures are perfor*ed on the affected ar*$
/or a pat"ent who has under#one *astecto* and "s suscept"ble to l*phede*a) a pro#ra* of hand e+erc"ses can be#"n
shortl after sur#er) "f prescr"bed$ The pro#ra* cons"sts of open"n# and clos"n# the hand t"#htl s"+ to e"#ht t"*es per hour
and perfor*"n# such tas's as wash"n# the face and co*b"n# the ha"r$
S"#ns and s*pto*s of theophll"ne to+"c"t "nclude !o*"t"n#) restlessness) and an ap"cal pulse rate of *ore than 344
beats<*"nute$
The nurse shouldnt "nduce !o*"t"n# "n a person who has "n#ested po"son and "s ha!"n# se"1ures or "s se*"consc"ous or
co*atose$
;entral !enous pressure ,;J>-) wh"ch "s the pressure "n the r"#ht atr"u* and the #reat !e"ns of the thora+) "s nor*all 3 to =
** (# ,or : to 13 c* (3H-$ ;J> "s used to assess r"#ht0s"ded card"ac funct"on$
;J> "s *on"tored to assess the need for flu"d replace*ent "n ser"ousl "ll pat"ents) to est"*ate blood !olu*e def"c"ts) and to
e!aluate c"rculator pressure "n the r"#ht atr"u*$
To pre!ent deep !e"n thro*bos"s after sur#er) the nurse should ad*"n"ster :)444 un"ts of hepar"n subcutaneousl e!er = to
13 hours) as prescr"bed$
Hral ant"coa#ulants) such as warfar"n ,;ou*ad"n- and d"cu*arol) d"srupt natural blood clott"n# *echan"s*s) pre!ent
thro*bus for*at"on) and l"*"t the e+tens"on of a for*ed thro*bus$
Ant"coa#ulants cant d"ssol!e a for*ed thro*bus$
Ant"coa#ulant therap "s contra"nd"cated "n a pat"ent who has l"!er or '"dne d"sease or GI ulcers or who "snt l"'el to return
for follow0up !"s"ts$
The nurse can assess a pat"ent for thro*bophleb"t"s b *easur"n# the affected and unaffected le#s and co*par"n# the"r s"1es$
The nurse should *ar' the *easure*ent locat"ons w"th a pen so that the le#s can be *easured at the sa*e place each da$
5ra"na#e of *ore than F)444 *l of flu"d da"l fro* a naso#astr"c tube *a su##est "ntest"nal obstruct"on$ Xellow dra"na#e
that has a foul odor *a "nd"cate s*all0bowel obstruct"on$
>reparat"on for s"#*o"doscop "ncludes ad*"n"ster"n# an ene*a 1 hour before the e+a*"nat"on) war*"n# the scope "n war*
water or a ster"l"1er ,"f us"n# a *etal s"#*o"doscope-) and drap"n# the pat"ent to e+pose the per"neu*$
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NURSING BULLETS _____________ ___________________________________________________________
Treat*ent for a pat"ent w"th bleed"n# esopha#eal !ar"ces "ncludes ad*"n"ster"n# !asopress"n ,>"tress"n-) #"!"n# an "ce water
la!a#e) asp"rat"n# blood fro* the sto*ach) us"n# esopha#eal balloon ta*ponade) pro!"d"n# parenteral nutr"t"on) and
ad*"n"ster"n# blood transfus"ons) as needed$
A trau*a !"ct"* shouldnt be *o!ed unt"l a patent a"rwa "s establ"shed and the cer!"cal sp"ne "s "**ob"l"1ed$
After a *astecto*) l*phede*a *a cause a feel"n# of hea!"ness "n the affected ar*$
A d"n# pat"ent shouldnt be told e+actl how lon# hes e+pected to l"!e) but should be told so*eth"n# *ore #eneral such as
?So*e people l"!e F to 2 *onths) but others l"!e lon#er$@
After ee sur#er) a pat"ent should a!o"d us"n# *a'eup unt"l otherw"se "nstructed$
After a corneal transplant) the pat"ent should wear an ee sh"eld when en#a#"n# "n act"!"t"es such as pla"n# w"th ch"ldren or
pets$
After a corneal transplant) the pat"ent shouldnt l"e on the affected s"te) bend at the wa"st) or ha!e se+ual "ntercourse for 1
wee'$ The pat"ent *ust a!o"d #ett"n# soapsuds "n the ee$
A ."lwau'ee brace "s used for pat"ents who ha!e structural scol"os"s$ The brace helps to halt the pro#ress"on of sp"nal
cur!ature b pro!"d"n# lon#"tud"nal tract"on and lateral pressure$ It should be worn 3F hours a da$
Short0ter* *easures used to treat sto*al retract"on "nclude stool softeners) "rr"#at"on) and sto*al d"latat"on$
A pat"ent who has a colosto* should be ad!"sed to eat a low0res"due d"et for E to 2 wee's and then to add one food at a t"*e
to e!aluate "ts effect$
To rel"e!e postoperat"!e h"ccups) the pat"ent should breathe "nto a paper ba#$
If a pat"ent w"th an "leosto* has a bloc'ed lu*en as a result of und"#ested h"#h0f"ber food) the pat"ent should be placed "n
the 'nee0chest pos"t"on and the area below the sto*a should be *assa#ed$
5ur"n# the "n"t"al "nter!"ew and treat*ent of a pat"ent w"th sph"l"s) the pat"ents se+ual contacts should be "dent"f"ed$
The nurse shouldnt ad*"n"ster *orph"ne to a pat"ent whose resp"rator rate "s less than 13 breaths<*"nute$
To pre!ent dr"n# of the *ucous *e*branes) o+#en should be ad*"n"stered w"th hdrat"on$
/la!o+ate ,Ur"spas- "s class"f"ed as a ur"nar tract spas*olt"c$
(potens"on "s a s"#n of card"o#en"c shoc' "n a pat"ent w"th a *ocard"al "nfarct"on$
The predo*"nant s"#ns of *echan"cal "leus are cra*p"n# pa"n) !o*"t"n#) d"stent"on) and "nab"l"t to pass feces or flatus$
/or a pat"ent w"th a *ocard"al "nfarct"on) the nurse should *on"tor flu"d "nta'e and output *et"culousl$ Too l"ttle "nta'e
causes dehdrat"on) and too *uch *a cause pul*onar ede*a$
N"tro#lcer"n rela+es s*ooth *uscle) caus"n# !asod"lat"on and rel"e!"n# the chest pa"n assoc"ated w"th *ocard"al "nfarct"on
and an#"na$
The d"a#nos"s of an acute *ocard"al "nfarct"on "s based on the pat"ents s"#ns and s*pto*s) electrocard"o#ra* trac"n#s)
and seru* en1*e stud"es$
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NURSING BULLETS _____________ ___________________________________________________________
Arrhth*"as are the predo*"nant proble* dur"n# the f"rst E= hours after a *ocard"al "nfarct"on$
;l"n"cal *an"festat"ons of *alabsorpt"on "nclude we"#ht loss) *uscle wast"n#) bloat"n#) and steatorrhea$
Aspara#"nase) an en1*e that "nh"b"ts the snthes"s of deo+r"bonucle"c ac"d and prote"n) "s used to treat acute l*phoct"c
leu'e*"a$
To rel"e!e a pat"ents sore throat thats caused b naso#astr"c tube "rr"tat"on) the nurse should pro!"de anesthet"c lo1en#es) as
prescr"bed$
/or the f"rst 13 to 3E hours after #astr"c sur#er) the sto*ach contents ,obta"ned b suct"on"n#- are brown$
After #astr"c suct"on"n# "s d"scont"nued) a pat"ent who "s reco!er"n# fro* a subtotal #astrecto* should rece"!e a clear l"6u"d
d"et$
The descend"n# colon "s the preferred s"te for a per*anent colosto*$
Jal!ular "nsuff"c"enc "n the !e"ns co**onl causes !ar"cos"t$
A pat"ent w"th a colosto* should restr"ct fat and f"brous foods and should a!o"d foods that can obstruct the sto*a) such as
corn) nuts) and cabba#e$
A pat"ent who "s rece"!"n# che*otherap "s placed "n re!erse "solat"on because the wh"te blood cell count *a be depressed$
S*pto*s of *"tral !al!e stenos"s are caused b "*proper e*pt"n# of the left atr"u*$
>ers"stent bleed"n# after open heart sur#er *a re6u"re the ad*"n"strat"on of prota*"ne sulfate to re!erse the effects of
hepar"n sod"u* used dur"n# sur#er$
The nurse should teach a pat"ent w"th heart fa"lure to ta'e d"#o+"n and other dru#s as prescr"bed) to restr"ct sod"u* "nta'e) to
restr"ct flu"ds as prescr"bed) to #et ade6uate rest) to "ncrease wal'"n# and other act"!"t"es #raduall) to a!o"d e+tre*es of
te*perature) to report s"#ns of
The nurse should chec' and *a"nta"n the patenc of all connect"ons for a chest tube$ If an a"r lea' "s detected) the nurse
should place one Lell cla*p near the "nsert"on s"te$ If the bubbl"n# stops) the lea' "s "n the thorac"c ca!"t and the phs"c"an
should be not"f"ed "**ed"atel$ If the lea' cont"nues) the nurse should ta'e a second cla*p) wor' down the tube unt"l the lea'
"s located) and stop the lea'$
In two0person card"opul*onar resusc"tat"on) the rescuers ad*"n"ster 24 chest co*press"ons per *"nute and 1 breath for
e!er : co*press"ons$
."tral !al!e stenos"s can result fro* rheu*at"c fe!er$
Atelectas"s "s "nco*plete e+pans"on of lun# se#*ents or lobules ,clusters of al!eol"-$ It *a cause the lun# or lobe to
collapse$
The nurse should "nstruct a pat"ent who has an "leal condu"t to e*pt the collect"on de!"ce fre6uentl because the we"#ht of
the ur"ne *a cause the de!"ce to sl"p fro* the s'"n$
A pat"ent who "s rece"!"n# card"opul*onar resusc"tat"on should be placed on a sol"d) flat surface$
Bra"n da*a#e occurs E to 2 *"nutes after card"opul*onar funct"on ceases$
;l"*acter"c "s the trans"t"on per"od dur"n# wh"ch a wo*ans reproduct"!e funct"on d"*"n"shes and #raduall d"sappears$
After "nfratentor"al sur#er) the pat"ent should re*a"n on h"s s"de) flat "n bed$
In a pat"ent who has an ulcer) *"l' "s contra"nd"cated because "ts h"#h calc"u* content st"*ulates secret"on of #astr"c ac"d$
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NURSING BULLETS _____________ ___________________________________________________________
A pat"ent who has a pos"t"!e test result for hu*an "**unodef"c"enc !"rus has been e+posed to the !"rus assoc"ated w"th
ac6u"red "**unodef"c"enc sndro*e ,AI5S-) but doesnt necessar"l ha!e AI5S$
A co**on co*pl"cat"on after prostatecto* "s c"rculator fa"lure caused b bleed"n#$
In r"#ht0s"ded heart fa"lure) a *a&or focus of nurs"n# care "s decreas"n# the wor'load of the heart$
S"#ns and s*pto*s of d"#o+"n to+"c"t "nclude nausea) !o*"t"n#) confus"on) and arrhth*"as$
An asth*a attac' tp"call be#"ns w"th whee1"n#) cou#h"n#) and "ncreas"n# resp"rator d"stress$
In a pat"ent who "s reco!er"n# fro* a tons"llecto*) fre6uent swallow"n# su##ests he*orrha#e$
Ileosto*"es and (art*anns colosto*"es are per*anent sto*as$ Loop colosto*"es and double0barrel colosto*"es are
te*porar ones$
A pat"ent who has an "leosto* should eat foods) such as sp"nach and parsle) because the act as "ntest"nal tract deodor"1ers$
An adrenalecto* can decrease stero"d product"on) wh"ch can cause e+tens"!e loss of sod"u* and water$
Before ad*"n"ster"n# *orph"ne ,5ura*orph- to a pat"ent who "s suspected of ha!"n# a *ocard"al "nfarct"on) the nurse
should chec' the pat"ents resp"rator rate$ If "ts less than 13 breaths<*"nute) e*er#enc e6u"p*ent should be read"l
a!a"lable for "ntubat"on "f resp"rator depress"on occurs$
A pat"ent who "s reco!er"n# fro* supratentor"al sur#er "s nor*all allowed out of bed 1E to E= hours after sur#er$ A pat"ent
who "s reco!er"n# fro* "nfratentor"al sur#er nor*all re*a"ns on bed rest for F to : das$
After a pat"ent under#oes a fe*oral0popl"teal bpass #raft) the nurse *ust closel *on"tor the per"pheral pulses d"stal to the
operat"!e s"te and c"rculat"on$
After a fe*oral0popl"teal bpass #raft) the pat"ent should "n"t"all be *a"nta"ned "n a se*"0/owler pos"t"on to a!o"d fle+"on of
the #raft s"te$ Before d"schar#e) the nurse should "nstruct the pat"ent to a!o"d pos"t"ons that put pressure on the #raft s"te unt"l
the ne+t follow0up !"s"t$
Hf the f"!e senses) hear"n# "s the last to be lost "n a pat"ent who "s enter"n# a co*a$
;holel"th"as"s causes an enlar#ed) ede*atous #allbladder w"th *ult"ple stones and an ele!ated b"l"rub"n le!el$
The ant"!"ral a#ent 1"do!ud"ne ,Retro!"r- successfull slows repl"cat"on of the hu*an "**unodef"c"enc !"rus) thereb
slow"n# the de!elop*ent of ac6u"red "**unodef"c"enc sndro*e$
Se!ere rheu*ato"d arthr"t"s causes *ar'ed ede*a and con#est"on) sp"ndle0shaped &o"nts) and se!ere fle+"on defor*"t"es$
A pat"ent w"th ac6u"red "**unodef"c"enc sndro*e should ad!"se h"s se+ual partners of h"s hu*an "**unodef"c"enc !"rus
status and obser!e se+ual precaut"ons) such as abst"nence or condo* use$
If a rad"oact"!e "*plant beco*es d"slod#ed) the nurse should retr"e!e "t w"th ton#s) place "t "n a lead0sh"elded conta"ner) and
not"f the rad"olo# depart*ent$
A pat"ent who "s under#o"n# rad"at"on therap should pat h"s s'"n dr to a!o"d abras"ons that could eas"l beco*e "nfected$
5ur"n# rad"at"on therap) a pat"ent should ha!e fre6uent blood tests) espec"all wh"te blood cell and platelet counts$
The nurse should ad*"n"ster an alu*"nu* hdro+"de antac"d at least 1 hour after an enter"c0coated dru# because "t can cause
pre*ature release of the enter"c0coated dru# "n the sto*ach$
Ac"d0base balance "s the bods hdro#en "on concentrat"on) a *easure of the rat"o of carbon"c ac"d to b"carbonate "ons ,1
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part carbon"c ac"d to 34 parts b"carbonate "s nor*al-$
A*otroph"c lateral scleros"s causes pro#ress"!e atroph and wast"n# of *uscle #roups that e!entuall affects the resp"rator
*uscles$
.etabol"c ac"dos"s "s caused b abnor*al loss of b"carbonate "ons or e+cess"!e product"on or retent"on of ac"d "ons$
(e*"anops"a "s defect"!e !"s"on or bl"ndness "n one0half of the !"sual f"eld of one or both ees$
Sste*"c lupus erthe*atosus causes earl0*orn"n# &o"nt st"ffness and fac"al erthe*a "n a butterfl pattern$
After total 'nee replace*ent) the pat"ent should re*a"n "n the se*"0/owler pos"t"on) w"th the affected le# ele!ated$
In a pat"ent who "s rece"!"n# transplor"c feed"n#s) the nurse should watch for du*p"n# sndro*e and hpo!ole*"c shoc'
because the sto*ach "s be"n# bpassed$
If a total parenteral nutr"t"on "nfus"on *ust be "nterrupted) the nurse should ad*"n"ster de+trose :G "n water at a s"*"lar rate$
Abrupt cessat"on can cause hpo#lce*"a$
Status ep"lept"cus "s treated w"th I$J$ d"a1epa* ,Jal"u*- and phento"n ,5"lant"n-$
5"se6u"l"br"u* sndro*e causes nausea) !o*"t"n#) restlessness) and tw"tch"n# "n pat"ents who are under#o"n# d"als"s$ Its
caused b a rap"d flu"d sh"ft$
An "nd"cat"on that sp"nal shoc' "s resol!"n# "s the return of refle+ act"!"t "n the ar*s and le#s below the le!el of "n&ur$
(po!ole*"a "s the *ost co**on and fatal co*pl"cat"on of se!ere acute pancreat"t"s$
In a pat"ent w"th sto*at"t"s) oral care "ncludes r"ns"n# the *outh w"th a *"+ture of e6ual parts of hdro#en pero+"de and
water three t"*es da"l$
In ot"t"s *ed"a) the t*pan"c *e*brane "s br"#ht red and lac's "ts character"st"c l"#ht refle+ ,cone of l"#ht-$
In pat"ents who ha!e per"card"ocentes"s) flu"d "s asp"rated fro* the per"card"al sac for anals"s or to rel"e!e card"ac
ta*ponade$
Urt"car"a "s an earl s"#n of he*olt"c transfus"on react"on$
5ur"n# per"toneal d"als"s) a return of brown d"alsate su##ests bowel perforat"on$ The phs"c"an should be not"f"ed
"**ed"atel$
An earl s"#n of 'etoac"dos"s "s polur"a) wh"ch "s caused b os*ot"c d"ures"s$
>at"ents who ha!e *ult"ple scleros"s should !"suall "nspect the"r e+tre*"t"es to ensure proper al"#n*ent and freedo* fro*
"n&ur$
Asp"rated red bone *arrow usuall appears rust0red) w"th !"s"ble fatt *ater"al and wh"te bone fra#*ents$
The 5"c' test detects scarlet fe!er ant"#ens and "**un"t or suscept"b"l"t to scarlet fe!er$ A pos"t"!e result "nd"cates no
"**un"tN a ne#at"!e result "nd"cates "**un"t$
The Sch"c' test detects d"phther"a ant"#ens and "**un"t or suscept"b"l"t to d"phther"a$ A pos"t"!e result "nd"cates no
"**un"tN a ne#at"!e result "nd"cates "**un"t$
The reco**ended adult dosa#e of sucralfate ,;arafate- for duodenal ulcer "s 1 # ,1 tablet- four t"*es da"l 1 hour before
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*eals and at bedt"*e$
A pat"ent w"th fac"al burns or s*o'e or heat "nhalat"on should be ad*"tted to the hosp"tal for 3E0hour obser!at"on for delaed
tracheal ede*a$
In add"t"on to pat"ent teach"n#) preparat"on for a colosto* "ncludes w"thhold"n# oral "nta'e o!ern"#ht) perfor*"n# bowel
preparat"on) and ad*"n"ster"n# a cleans"n# ene*a$
The phs"olo#"c chan#es caused b burn "n&ur"es can be d"!"ded "nto two sta#esI the hpo!ole*"c sta#e) dur"n# wh"ch
"ntra!ascular flu"d sh"fts "nto the "nterst"t"al space) and the d"uret"c sta#e) dur"n# wh"ch cap"llar "nte#r"t and "ntra!ascular
!olu*e are restored) usuall E= to D3 hours after the "n&ur$
The nurse should chan#e total parenteral nutr"t"on tub"n# e!er 3E hours and the per"pheral I$J$ access s"te dress"n# e!er D3
hours$
A pat"ent whose carbon *ono+"de le!el "s 34G to F4G should be treated w"th 144G hu*"d"f"ed o+#en$
%hen "n the roo* of a pat"ent who "s "n "solat"on for tuberculos"s) staff and !"s"tors should wear ultraf"lter *as's$
%hen pro!"d"n# s'"n care "**ed"atel after p"n "nsert"on) the nurses pr"*ar concern "s pre!ent"on of bone "nfect"on$
After an a*putat"on) *o"st s'"n *a "nd"cate !enous stas"sN dr s'"n *a "nd"cate arter"al obstruct"on$
In a pat"ent who "s rece"!"n# d"als"s) an "nternal shunt "s wor'"n# "f the nurse feels a thr"ll on palpat"on or hears a bru"t on
auscultat"on$
In a pat"ent w"th !"ral hepat"t"s) the parench*al) or Lupffers) cells of the l"!er beco*e se!erel "nfla*ed) enlar#ed) and
necrot"c$
Earl s"#ns of ac6u"red "**unodef"c"enc sndro*e "nclude fat"#ue) n"#ht sweats) enlar#ed l*ph nodes) anore+"a) we"#ht
loss) pallor) and fe!er$
%hen car"n# for a pat"ent who has a rad"oact"!e "*plant) health care wor'ers should sta as far awa fro* the rad"at"on
source as poss"ble$ The should re*e*ber the a+"o*) ?If ou double the d"stance) ou 6uarter the dose$@
A pat"ent who has >ar'"nsons d"sease should be "nstructed to wal' w"th a broad0based #a"t$
The card"nal s"#ns of >ar'"nsons d"sease are *uscle r"#"d"t) a tre*or that be#"ns "n the f"n#ers) and a'"nes"a$
In a pat"ent w"th >ar'"nsons d"sease) le!odopa ,5opar- "s prescr"bed to co*pensate for the dopa*"ne def"c"enc$
A pat"ent who has *ult"ple scleros"s "s at "ncreased r"s' for pressure ulcers$
>"ll0roll"n# tre*or "s a class"c s"#n of >ar'"nsons d"sease$
/or a pat"ent w"th >ar'"nsons d"sease) nurs"n# "nter!ent"ons are pall"at"!e$
/at e*bol"s*) a ser"ous co*pl"cat"on of a lon#0bone fracture) causes fe!er) tachcard"a) tachpnea) and an+"et$
.etrorrha#"a ,bleed"n# between *enstrual per"ods- *a be the f"rst s"#n of cer!"cal cancer$
.ann"tol "s a hperton"c solut"on and an os*ot"c d"uret"c thats used "n the treat*ent of "ncreased "ntracran"al pressure$
The class"c s"#n of an absence se"1ure "s a !acant fac"al e+press"on$
."#ra"ne headaches cause pers"stent) se!ere pa"n that usuall occurs "n the te*poral re#"on$
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A pat"ent who "s "n a bladder retra"n"n# pro#ra* should be #"!en an opportun"t to !o"d e!er 3 hours dur"n# the da and
tw"ce at n"#ht$
In a pat"ent w"th a head "n&ur) a decrease "n le!el of consc"ousness "s a card"nal s"#n of "ncreased "ntracran"al pressure$
Er#ota*"ne ,Er#o*ar- "s *ost effect"!e when ta'en dur"n# the prodro*al phase of a *"#ra"ne or !ascular headache$
Treat*ent of acute pancreat"t"s "ncludes naso#astr"c suct"on"n# to deco*press the sto*ach and *eper"d"ne ,5e*erol- for
pa"n$
S*pto*s of h"atal hern"a "nclude a feel"n# of fullness "n the upper abdo*en or chest) heartburn) and pa"n s"*"lar to that of
an#"na pector"s$
The "nc"dence of cholel"th"as"s "s h"#her "n wo*en who ha!e had ch"ldren than "n an other #roup$
Aceta*"nophen ,Tlenol- o!erdose can se!erel da*a#e the l"!er$
The pro*"nent cl"n"cal s"#ns of ad!anced c"rrhos"s are asc"tes and &aund"ce$
The f"rst s*pto* of pancreat"t"s "s stead ep"#astr"c pa"n or left upper 6uadrant pa"n that rad"ates fro* the u*b"l"cal area or
the bac'$
So*na*bul"s* "s the *ed"cal ter* for sleepwal'"n#$
Ep"nephr"ne ,Adrenal"n- "s a !asoconstr"ctor$
An untreated l"!er lacerat"on or rupture can pro#ress rap"dl to hpo!ole*"c shoc'$
Hbst"pat"on "s e+tre*e) "ntractable const"pat"on caused b an "ntest"nal obstruct"on$
The def"n"t"!e test for d"a#nos"n# cancer "s b"ops w"th ctolo#"c e+a*"nat"on of the spec"*en$
Arthro#raph re6u"res "n&ect"on of a contrast *ed"u* and can "dent"f &o"nt abnor*al"t"es$
Bro*ptons coc'ta"l "s prescr"bed to help rel"e!e pa"n "n pat"ents who ha!e ter*"nal cancer$
A sarco*a "s a *al"#nant tu*or "n connect"!e t"ssue$
Alu*"nu* hdro+"de ,A*pho&el- neutral"1es #astr"c ac"d$
Sublu+at"on "s part"al d"slocat"on or separat"on) w"th spontaneous reduct"on of a &o"nt$
Barb"turates can cause confus"on and del"r"u* "n an elderl pat"ent who has an or#an"c bra"n d"sorder$
In a pat"ent w"th arthr"t"s) phs"cal therap "s "nd"cated to pro*ote opt"*al funct"on"n#$
So*e pat"ents who ha!e hepat"t"s A *a be an"cter"c ,w"thout &aund"ce- and lac' s*pto*s) but so*e ha!e headaches)
&aund"ce) anore+"a) fat"#ue) fe!er) and resp"rator tract "nfect"on$
(epat"t"s A "s usuall *"ld and wont ad!ance to a carr"er state$
In the pre"cter"c phase of all for*s of hepat"t"s) the pat"ent "s h"#hl conta#"ous$
Enter"c precaut"ons are re6u"red for a pat"ent who has hepat"t"s A$
;holecsto#raph "s "neffect"!e "n a pat"ent who has &aund"ce as a result of #allbladder d"sease$ The l"!er cells cant transport
the contrast *ed"u* to the b"l"ar tract$
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In a pat"ent who has d"abetes "ns"p"dus) dehdrat"on "s a concern because d"abetes causes polur"a$
In a pat"ent who has a reduc"ble hern"a) the protrud"n# *ass spontaneousl retracts "nto the abdo*en$
To pre!ent purple #lo!e sndro*e) a nurse shouldnt ad*"n"ster I$J$ phento"n ,5"lant"n- throu#h a !e"n "n the bac' of the
hand) but should use a lar#er !essel$
5ur"n# sta#e III of sur#"cal anesthes"a) unconsc"ousness occurs and sur#er "s per*"tted$
Tpes of re#"onal anesthes"a "nclude sp"nal) caudal) "ntercostal) ep"dural) and brach"al ple+us$
The f"rst step "n *ana#"n# dru# o!erdose or dru# to+"c"t "s to establ"sh and *a"nta"n an a"rwa$
Resp"rator parals"s occurs "n sta#e IJ of anesthes"a ,to+"c sta#e-$
In sta#e I of anesthes"a) the pat"ent "s consc"ous and tran6u"l$
5spnea and sharp) stabb"n# pa"n that "ncreases w"th resp"rat"on are s*pto*s of pleur"s) wh"ch can be a co*pl"cat"on of
pneu*on"a or tuberculos"s$
Jert"#o "s the *a&or s*pto* of "nner ear "nfect"on or d"sease$
Loud tal'"n# "s a s"#n of hear"n# "*pa"r*ent$
A pat"ent who has an upper resp"rator tract "nfect"on should blow h"s nose w"th both nostr"ls open$
A pat"ent who has had a cataract re*o!ed can be#"n *ost nor*al act"!"t"es "n F or E dasN howe!er) the pat"ent shouldnt
bend and l"ft unt"l a phs"c"an appro!es these act"!"t"es$
S*pto*s of corneal transplant re&ect"on "nclude ee "rr"tat"on and decreas"n# !"sual f"eld$
Gra!es d"sease ,hperthro"d"s*- "s *an"fested b we"#ht loss) ner!ousness) dspnea) palp"tat"ons) heat "ntolerance)
"ncreased th"rst) e+ophthal*os ,bul#"n# ees-) and #o"ter$
The four tpes of l"poprote"n are chlo*"crons ,the lowest0dens"t l"poprote"ns-) !er0low0dens"t l"poprote"ns) low0dens"t
l"poprote"ns) and h"#h0dens"t l"poprote"ns$ (ealth care profess"onals use cholesterol le!el fract"onat"on to assess a pat"ents
r"s' of coronar arter d"sease$
If a pat"ent who "s ta'"n# a*photer"c"n B ,/un#"1one- bladder "rr"#at"ons for a fun#al "nfect"on has sste*"c cand"d"as"s and
*ust rece"!e I$J$ flucona1ole ,5"flucan-) the "rr"#at"ons can be d"scont"nued because flucona1ole treats the bladder "nfect"on
as well$
>at"ents w"th adult resp"rator d"stress sndro*e can ha!e h"#h pea' "nsp"rator pressures$ Therefore) the nurse should
*on"tor these pat"ents closel for s"#ns of spontaneous pneu*othora+) such as acute deter"orat"on "n o+#enat"on) absence of
breath sounds on the affected s"de) and crep"tus be#"nn"n# on the affected s"de$
Ad!erse react"ons to cclospor"ne ,Sand"**une- "nclude renal and hepat"c to+"c"t) central ner!ous sste* chan#es
,confus"on and del"r"u*-) GI bleed"n#) and hpertens"on$
Hsteoporos"s "s a *etabol"c bone d"sorder "n wh"ch the rate of bone resorpt"on e+ceeds the rate of bone for*at"on$
The hall*ar' of ulcerat"!e col"t"s "s recurrent blood d"arrhea) wh"ch co**onl conta"ns pus and *ucus and alternates w"th
as*pto*at"c re*"ss"ons$
Safer se+ual pract"ces "nclude *assa#"n#) hu##"n#) bod rubb"n#) fr"endl '"ss"n# ,dr-) *asturbat"n#) hand0to0#en"tal
touch"n#) wear"n# a condo*) and l"*"t"n# the nu*ber of se+ual partners$
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I**unosuppressed pat"ents who contract cto*e#alo!"rus ,;.J- are at r"s' for ;.J pneu*on"a and sept"ce*"a) wh"ch
can be fatal$
Ur"nar tract "nfect"ons can cause ur"nar ur#enc and fre6uenc) dsur"a) abdo*"nal cra*ps or bladder spas*s) and urethral
"tch"n#$
.a**o#raph "s a rad"o#raph"c techn"6ue thats used to detect breast csts or tu*ors) espec"all those that arent palpable
on phs"cal e+a*"nat"on$
To pro*ote earl detect"on of test"cular cancer) the nurse should palpate the testes dur"n# rout"ne phs"cal e+a*"nat"ons and
encoura#e the pat"ent to perfor* *onthl self0e+a*"nat"ons dur"n# a war* shower$
>at"ents who ha!e thalasse*"a *"nor re6u"re no treat*ent$ Those w"th thalasse*"a *a&or re6u"re fre6uent transfus"ons of red
blood cells$
A h"#h le!el of hepat"t"s B seru* *ar'er that pers"sts for F *onths or *ore after the onset of acute hepat"t"s B "nfect"on
su##ests chron"c hepat"t"s or carr"er status$
Neuro#en"c bladder dsfunct"on "s caused b d"srupt"on of ner!e trans*"ss"on to the bladder$ It *a be caused b certa"n
sp"nal cord "n&ur"es) d"abetes) or *ult"ple scleros"s$
H+#en and carbon d"o+"de *o!e between the lun#s and the bloodstrea* b d"ffus"on$
To #rade the se!er"t of dspnea) the follow"n# sste* "s usedI #rade 1) shortness of breath on *"ld e+ert"on) such as
wal'"n# up stepsN #rade 3) shortness of breath when wal'"n# a short d"stance at a nor*al pace on le!el #roundN #rade F)
shortness of breath w"th *"ld da"l act"!"t) such as sha!"n#N #rade E) shortness of breath when sup"ne ,orthopnea-$
A pat"ent w"th ;rohns d"sease should consu*e a d"et low "n res"due) f"ber) and fat) and h"#h "n calor"es) prote"ns) and
carbohdrates$ The pat"ent also should ta'e !"ta*"n supple*ents) espec"all !"ta*"n L$
In the three0bottle ur"ne collect"on *ethod) the pat"ent cleans the *eatus and ur"nates 14 to 1: *l "n the f"rst bottle and 1: to
F4 *l ,*"dstrea*- "n the second bottle$ Then the phs"c"an perfor*s prostat"c *assa#e) and the pat"ent !o"ds "nto the th"rd
bottle$
/"nd"n#s "n the three0bottle ur"ne collect"on *ethod are "nterpreted as followsI pus "n the ur"ne ,pur"a- "n the f"rst bottle
"nd"cates anter"or urethr"t"sN bacter"a "n the ur"ne "n the second bottle "nd"cate bladder "nfect"onN bacter"a "n the th"rd bottle
"nd"cate prostat"t"s$
S"#ns and s*pto*s of aort"c stenos"s "nclude a loud) rou#h sstol"c *ur*ur o!er the aort"c areaN e+ert"onal dspneaN
fat"#ueN an#"na pector"sN arrhth*"asN low blood pressureN and e*bol"$
Elect"!e sur#er "s pr"*ar"l a *atter of cho"ce$ It "snt essent"al to the pat"ents sur!"!al) but "t *a "*pro!e the pat"ents
health) co*fort) or self0estee*$
Re6u"red sur#er "s reco**ended b the phs"c"an$ It *a be delaed) but "s "ne!"table$
Ur#ent sur#er *ust be perfor*ed w"th"n 3E to E= hours$
E*er#enc sur#er *ust be perfor*ed "**ed"atel$
About =:G of arter"al e*bol" or"#"nate "n the heart cha*bers$
>ul*onar e*bol"s* usuall results fro* thro*b" d"slod#ed fro* the le# !e"ns$
The consc"ous "nterpretat"on of pa"n occurs "n the cerebral corte+$
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To a!o"d "nterfer"n# w"th new cell #rowth) the dress"n# on a donor s'"n #raft s"te shouldnt be d"sturbed$
A se6uela "s an abnor*al cond"t"on that follows and "s the result of a d"sease) a treat*ent) or an "n&ur$
5ur"n# s"c'le cell cr"s"s) pat"ent care "ncludes bed rest) o+#en therap) anal#es"cs as prescr"bed) I$J$ flu"d *on"tor"n#) and
thorou#h docu*entat"on of flu"d "nta'e and output$
A pat"ent who has an "leal condu"t should *a"nta"n a da"l flu"d "nta'e of 3)444 *l$
In a closed chest dra"na#e sste*) cont"nuous bubbl"n# "n the water seal cha*ber or bottle "nd"cates a lea'$
>alp"tat"on "s a sensat"on of heart pound"n# or rac"n# assoc"ated w"th nor*al e*ot"onal responses and certa"n heart d"sorders$
/at e*bol"s* "s l"'el to occur w"th"n the f"rst 3E hours after a lon#0bone fracture$
/ootdrop can occur "n a pat"ent w"th a pel!"c fracture as a result of peroneal ner!e co*press"on a#a"nst the head of the f"bula$
To pro*ote !enous return after an a*putat"on) the nurse should wrap an elast"c banda#e around the d"stal end of the stu*p$
%ater that accu*ulates "n the tub"n# of a !ent"lator should be re*o!ed$
The *ost co**on route for the ad*"n"strat"on of ep"nephr"ne to a pat"ent who "s ha!"n# a se!ere aller#"c react"on "s the
subcutaneous route$
The nurse should use /owlers pos"t"on for a pat"ent who has abdo*"nal pa"n caused b append"c"t"s$
The nurse shouldnt #"!e anal#es"cs to a pat"ent who has abdo*"nal pa"n caused b append"c"t"s because these dru#s *a
*as' the pa"n that acco*pan"es a ruptured append"+$
The nurse shouldnt #"!e anal#es"cs to a pat"ent who has abdo*"nal pa"n caused b append"c"t"s because these dru#s *a
*as' the pa"n that acco*pan"es a ruptured append"+$
As a last0d"tch effort) a barb"turate co*a *a be "nduced to re!erse unrelent"n# "ncreased "ntracran"al pressure ,I;>-) wh"ch
"s def"ned as acute I;> of #reater than E4 ** (#) pers"stent ele!at"on of I;> abo!e 34 ** (#) or rap"dl deter"orat"n#
neurolo#"c status$
The pr"*ar s"#ns and s*pto*s of ep"#lott"d"t"s are str"dor and pro#ress"!e d"ff"cult "n swallow"n#$
Sal"!at"on "s the f"rst step "n the d"#est"on of starch$
A pat"ent who has a de*and pace*a'er should *easure the pulse rate before r"s"n# "n the *orn"n#) not"f the phs"c"an "f
the pulse rate drops b : beats<*"nute) obta"n a *ed"cal "dent"f"cat"on card and bracelet) and resu*e nor*al act"!"t"es)
"nclud"n# se+ual act"!"t$
Trans!erse) or loop) colosto* "s a te*porar procedure thats perfor*ed to d"!ert the fecal strea* "n a pat"ent who has
acute "ntest"nal obstruct"on$
Nor*al !alues for erthrocte sed"*entat"on rate are 4 to 1: **<hour for *en oun#er than a#e :4 and 4 to 34 **<hour for
wo*en oun#er than a#e :4$
A ;L0.B le!el thats *ore than :G of total ;L or *ore than 14 U<L su##ests a *ocard"al "nfarct"on$
>ropranolol ,Inderal- bloc's s*pathet"c ner!e st"*ul" that "ncrease card"ac wor' dur"n# e+erc"se or stress) wh"ch reduces
heart rate) blood pressure) and *ocard"al o+#en consu*pt"on$
After a *ocard"al "nfarct"on) electrocard"o#ra* chan#es ,ST0se#*ent ele!at"on) T0wa!e "n!ers"on) and P0wa!e
enlar#e*ent- usuall appear "n the f"rst 3E hours) but *a not appear unt"l the :th or 2th da$
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NURSING BULLETS _____________ ___________________________________________________________
;ard"o#en"c shoc' "s *an"fested b sstol"c blood pressure of less than =4 ** (#) #ra s'"n) d"aphores"s) canos"s) wea'
pulse rate) tachcard"a or bradcard"a) and ol"#ur"a ,less than F4 *l of ur"ne per hour-$
A pat"ent who "s rece"!"n# a low0sod"u* d"et shouldnt eat cotta#e cheese) f"sh) canned beans) chuc' stea') chocolate
pudd"n#) Ital"an salad dress"n#) d"ll p"c'les) and beef broth$
("#h0potass"u* foods "nclude dr"ed prunes) water*elon ,1:$F *E6< port"on-) dr"ed l"*a beans ,1E$: *E6<port"on-)
sobeans) bananas) and oran#es$
Luss*auls resp"rat"ons are faster and deeper than nor*al resp"rat"ons and occur w"thout pauses) as "n d"abet"c 'etoac"dos"s$
;hene0Sto'es resp"rat"ons are character"1ed b alternat"n# per"ods of apnea and deep) rap"d breath"n#$ The occur "n
pat"ents w"th central ner!ous sste* d"sorders$
(per!ent"lat"on can result fro* an "ncreased fre6uenc of breath"n#) an "ncreased t"dal !olu*e) or both$
Apnea "s the absence of spontaneous resp"rat"ons$
Before a thro"decto*) a pat
ent *a rece"!e potass"u* "od"de) ant"thro"d dru#s) and propranolol ,Inderal- to pre!ent thro"d stor* dur"n# sur#er$
The nor*al l"fe span of red blood cells ,erthroctes- "s 114 to 134 das$
J"sual acu"t of 34<144 *eans that the pat"ent sees at 34B ,2 *- what a person w"th nor*al !"s"on sees at 144B ,F4 *-$
Ur"nar tract "nfect"ons are *ore co**on "n #"rls and wo*en than "n bos and *en because the shorter urethra "n the fe*ale
ur"nar tract *a'es the bladder *ore access"ble to bacter"a) espec"all Escher"ch"a col"$
>en"c"ll"n "s ad*"n"stered orall 1 to 3 hours before *eals or 3 to F hours after *eals because food *a "nterfere w"th the
dru#s absorpt"on$
."ld react"ons to local anesthet"cs *a "nclude palp"tat"ons) t"nn"tus) !ert"#o) apprehens"on) confus"on) and a *etall"c taste "n
the *outh$
About 33G of card"ac output #oes to the '"dnes$
To ensure accurate central !enous pressure read"n#s) the nurse should place the *ano*eter or transducer le!el w"th the
phlebostat"c a+"s$
A pat"ent who has lost 3)444 to 3):44 *l of blood w"ll ha!e a pulse rate of 1E4 beats<*"nute ,or h"#her-) d"spla a sstol"c
blood pressure of :4 to 24 ** (#) and appear confused and lethar#"c$
Arter"al blood "s br"#ht red) flows rap"dl) and ,because "ts pu*ped d"rectl fro* the heart- spurts w"th each heartbeat$
Jenous blood "s dar' red and tends to oo1e fro* a wound$
Hrthostat"c blood pressure "s ta'en w"th the pat"ent "n the sup"ne) s"tt"n#) and stand"n# pos"t"ons) w"th 1 *"nute between each
read"n#$ A 140** (# decrease "n blood pressure or an "ncrease "n pulse rate of 14 beats< *"nute su##ests !olu*e deplet"on$
A pneu*at"c ant"shoc' #ar*ent should be used caut"ousl "n pre#nant wo*en and pat"ents w"th head "n&ur"es$
After a pat"ents c"rculat"n# !olu*e "s restored) the nurse should re*o!e the pneu*at"c ant"shoc' #ar*ent #raduall) start"n#
w"th the abdo*"nal cha*ber and followed b each le#$ The #ar*ent should be re*o!ed under a phs"c"ans super!"s"on$
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NURSING BULLETS _____________ ___________________________________________________________
.ost he*olt"c transfus"on react"ons assoc"ated w"th *"s*atch"n# of ABH blood tpes ste* fro* "dent"f"cat"on nu*ber
errors$
%ar*"n# of blood to *ore than 14DC / ,E1$DC ;- can cause he*ols"s$
;ard"ac output "s the a*ount of blood e&ected fro* the heart each *"nute$ Its e+pressed "n l"ters per *"nute$
Stro'e !olu*e "s the !olu*e of blood e&ected fro* the heart dur"n# sstole$
Total parenteral nutr"t"on solut"on conta"ns de+trose) a*"no ac"ds) and add"t"!es) such as electroltes) *"nerals) and !"ta*"ns$
The *ost co**on tpe of neuro#en"c shoc' "s sp"nal shoc'$ It usuall occurs F4 to 24 *"nutes after a sp"nal cord "n&ur$
After a sp"nal cord "n&ur) per"stals"s stops w"th"n 3E hours and usuall returns w"th"n F to E das$
To+"c shoc' sndro*e "s *an"fested b a te*perature of at least 143C / ,F=$=C ;-) an erthe*atous rash) and sstol"c blood
pressure of less than O4 ** (#$ /ro* 1 to 3 wee's after the onset of these s"#ns) des6ua*at"on ,espec"all on the pal*s and
soles- occurs$
The s"#ns and s*pto*s of anaphla+"s are co**onl caused b h"sta*"ne release$
The *ost co**on cause of sept"c shoc' "s #ra*0ne#at"!e bacter"a) such as Escher"ch"a col") Llebs"ella) and >seudo*onas
or#an"s*s$
Bru"ts are !ascular sounds that rese*ble heart *ur*urs and result fro* turbulent blood flow throu#h a d"seased or part"all
obstructed arter$
Ur"ne p( "s nor*all E$: to =$4$
Ur"ne p( of #reater than =$4 can result fro* a ur"nar tract "nfect"on) a h"#h0al'al" d"et) or sste*"c al'alos"s$
Ur"ne p( of less than E$: *a be caused b a h"#h0prote"n d"et) fe!er) or *etabol"c ac"dos"s$
Before a percutaneous renal b"ops) the pat"ent should be placed on a f"r* surface and pos"t"oned on the abdo*en$ A sandba#
"s placed under the abdo*en to stab"l"1e the '"dnes$
Nephrot"c sndro*e "s character"1ed b *ar'ed prote"nur"a) hpoalbu*"ne*"a) *"ld to se!ere dependent ede*a) asc"tes) and
we"#ht #a"n$
Underwater e+erc"se "s a for* of therap perfor*ed "n a (ubbard tan'$
.ost wo*en w"th tr"cho*on"as"s ha!e a *alodorous) froth) #reen"sh #ra !a#"nal d"schar#e$ Hther wo*en *a ha!e no
s"#ns or s*pto*s$
Jo"d"n# cstourethro#raph *a be perfor*ed to detect bladder and urethral abnor*al"t"es$ ;ontrast *ed"u* "s "nst"lled b
#entle sr"n#e pressure throu#h a urethral catheter) and o!erhead 70ra f"l*s are ta'en to !"sual"1e bladder f"ll"n# and
e+cret"on$
;stourethro#raph *a be perfor*ed to "dent"f the cause of ur"nar tract "nfect"ons) con#en"tal ano*al"es) and
"ncont"nence$ It also "s used to assess for prostate lobe hpertroph "n *en$
(erpes s"*ple+ "s character"1ed b recurrent ep"sodes of bl"sters on the s'"n and *ucous *e*branes$ It has two !ar"at"ons$
In tpe 1) the bl"sters appear "n the nasolab"al re#"onN "n tpe 3) the appear on the #en"tals) anus) buttoc's) and th"#hs$
.ost pat"ents w"th ;hla*d"a tracho*at"s "nfect"on are as*pto*at"c) but so*e ha!e an "nfla*ed urethral *eatus) dsur"a)
and ur"nar ur#enc and fre6uenc$
The hpothala*us re#ulates the autono*"c ner!ous sste* and endocr"ne funct"ons$
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NURSING BULLETS _____________ ___________________________________________________________
A pat"ent whose chest e+curs"on "s less than nor*al ,F9 to 29 [D$: to 1: c*\- *ust use accessor *uscles to breathe$
S"#ns and s*pto*s of to+"c"t fro* thro"d replace*ent therap "nclude rap"d pulse rate) d"aphores"s) "rr"tab"l"t) we"#ht
loss) dsur"a) and sleep d"sturbance$
The *ost co**on aller#"c react"on to pen"c"ll"n "s a rash$
An earl s"#n of asp"r"n to+"c"t "s deep) rap"d resp"rat"ons$
The *ost ser"ous and "rre!ers"ble conse6uence of lead po"son"n# "s *ental retardat"on) wh"ch results fro* neurolo#"c
da*a#e$
To assess dehdrat"on "n the adult) the nurse should chec' s'"n tur#or on the sternu*$
/or a pat"ent w"th a pept"c ulcer) the tpe of d"et "s less "*portant than "nclud"n# foods "n the d"et that the pat"ent can tolerate$
A pat"ent w"th a colosto* *ust establ"sh an "rr"#at"on schedule so that re#ular e*pt"n# of the bowel occurs w"thout sto*al
d"schar#e between "rr"#at"ons$
%hen us"n# rotat"n# tourn"6uets) the nurse shouldnt restr"ct the blood suppl to an ar* or le# for *ore than E: *"nutes at a
t"*e$
A pat"ent w"th d"abetes should eat h"#h0f"ber foods because the blunt the r"se "n #lucose le!el that nor*all follows a *eal$
Au#ular !e"n d"stent"on occurs "n pat"ents w"th heart fa"lure because the left !entr"cle cant e*pt the heart of blood as fast as
blood enters fro* the r"#ht !entr"cle) result"n# "n con#est"on "n the ent"re !enous sste*$
The lead"n# causes of bl"ndness "n the Un"ted States are d"abetes *ell"tus and #lauco*a$
After a thro"decto*) the pat"ent should re*a"n "n the se*"0/owler pos"t"on) w"th h"s head ne"ther hpere+tended nor
hperfle+ed) to a!o"d pressure on the suture l"ne$ Th"s pos"t"on can be ach"e!ed w"th the use of a cer!"cal p"llow$
>re*enstrual sndro*e *a cause abdo*"nal d"stent"on) en#or#ed and pa"nful breasts) bac'ache) headache) ner!ousness)
"rr"tab"l"t) restlessness) and tre*ors$
Treat*ent of deh"scence ,patholo#"c open"n# of a wound- cons"sts of co!er"n# the wound w"th a *o"st ster"le dress"n# and
not"f"n# the phs"c"an$
%hen a pat"ent has a rad"cal *astecto*) the o!ar"es also *a be re*o!ed because the are a source of estro#en) wh"ch
st"*ulates tu*or #rowth$
Atrop"ne bloc's the effects of acetlchol"ne) thereb obstruct"n# "ts !a#al effects on the s"noatr"al node and "ncreas"n# heart
rate$
Sal"clates) part"cularl asp"r"n) are the treat*ent of cho"ce "n rheu*ato"d arthr"t"s because the decrease "nfla**at"on and
rel"e!e &o"nt pa"n$
5eep) "ntense pa"n that usuall worsens at n"#ht and "s unrelated to *o!e*ent su##ests bone pa"n$
>a"n that follows prolon#ed or e+cess"!e e+erc"se and subs"des w"th rest su##ests *uscle pa"n$
The *a&or he*odna*"c chan#es assoc"ated w"th card"o#en"c shoc' are decreased left !entr"cular funct"on and decreased
card"ac output$
Before thro"decto*) the pat"ent should be ad!"sed that he *a e+per"ence hoarseness or loss of h"s !o"ce for se!eral das
after sur#er$
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NURSING BULLETS _____________ ___________________________________________________________
Acceptable ad!erse effects of lon#0ter* stero"d use "nclude we"#ht #a"n) acne) headaches) fat"#ue) and "ncreased ur"ne
retent"on$
Unacceptable ad!erse effects of lon#0ter* stero"d use are d"11"ness on r"s"n#) nausea) !o*"t"n#) th"rst) and pa"n$
After a cran"oto*) nurs"n# care "ncludes *a"nta"n"n# nor*al "ntracran"al pressure) *a"nta"n"n# cerebral perfus"on pressure)
and pre!ent"n# "n&ur related to cerebral and cellular "sche*"a$
/ol"c ac"d and !"ta*"n B13 are essent"al for nucleoprote"n snthes"s and red blood cell *aturat"on$
I**ed"atel after "ntracran"al sur#er) nurs"n# care "ncludes not #"!"n# the pat"ent anth"n# b *outh unt"l the #a# and
cou#h refle+es return) *on"tor"n# !"tal s"#ns and assess"n# the le!el of consc"ousness ,LH;- for s"#ns of "ncreas"n#
"ntracran"al pressure) and ad*"n"ster"n# anal#es"cs that dont *as' the LH;$
;hest phs"otherap "ncludes postural dra"na#e) chest percuss"on and !"brat"on) and cou#h"n# and deep0breath"n# e+erc"ses$
;ush"n#s sndro*e results fro* e+cess"!e le!els of adrenocort"cal hor*ones and "s *an"fested b fat pads on the face
,*oon face- and o!er the upper bac' ,buffalo hu*p-) acne) *ood sw"n#s) h"rsut"s*) a*enorrhea) and decreased l"b"do$
To pre!ent an add"son"an cr"s"s when d"scont"nu"n# lon#0ter* predn"sone ,5eltasone- therap) the nurse should taper the
dose slowl to allow for *on"tor"n# of d"sease flare0ups and for the return of hpothala*"c0p"tu"tar0adrenal funct"on$
>ulsus parado+us "s a pulse that beco*es wea' dur"n# "nsp"rat"on and stron# dur"n# e+p"rat"on$ It *a be a s"#n of card"ac
ta*ponade$
Substances that are e+pelled throu#h portals of e+"t "nclude sal"!a) *ucus) feces) ur"ne) !o*"tus) blood) and !a#"nal and
pen"le d"schar#es$
A *"croor#an"s* *a be trans*"tted d"rectl) b contact w"th an "nfected bod or droplets) or "nd"rectl) b contact w"th
conta*"nated a"r) so"l) water) or flu"ds$
A post*enopausal wo*an who rece"!es estro#en therap "s at an "ncreased r"s' for #allbladder d"sease and breast cancer$
The appro+"*ate o+#en concentrat"ons del"!ered b a nasal cannula are as followsI 1 L U 3EG) 3 L U 3=G) F L U F3G) E LU
F2G) and : L U E4G$
;ard"nal features of d"abetes "ns"p"dus "nclude pold"ps"a ,e+cess"!e th"rst- and polur"a ,"ncreased ur"nat"on to : L<3E
hours-$
A pat"ent w"th low spec"f"c #ra!"t ,1$441 to 1$44:- *a ha!e an "ncreased des"re for cold water$
5"abet"c co*a can occur when the blood #lucose le!el drops below 24 *#<dl$
/or a pat"ent w"th heart fa"lure) the nurse should ele!ate the head of the bed =9 to 139 ,34 to F4 c*-) pro!"de a beds"de
co**ode) and ad*"n"ster card"ac #lcos"des and d"uret"cs as prescr"bed$
The pr"*ar reason to treat streptococcal sore throat w"th ant"b"ot"cs "s to protect the heart !al!es and pre!ent rheu*at"c
fe!er$
A pat"ent w"th a nasal fracture *a lose consc"ousness dur"n# reduct"on$
(oarseness and chan#e "n the !o"ce are co**onl the f"rst s"#ns of larn#eal cancer$
The lun#s) colon) and rectu* are a*on# the *ost co**on cancer s"tes$
The *ost co**on preoperat"!e proble* "n elderl pat"ents "s lower0than0nor*al total blood !olu*e$
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NURSING BULLETS _____________ ___________________________________________________________
.ann"tol ,Hs*"trol-) an os*ot"c d"uret"c) "s ad*"n"stered to reduce "ntraocular or "ntracran"al pressure$
%hen a stro'e "s suspected) the nurse should place the pat"ent on the affected s"de to pro*ote lun# e+pans"on on the
unaffected s"de$
/or a pat"ent who has had chest sur#er) the nurse should reco**end s"tt"n# upr"#ht and perfor*"n# cou#h"n# and deep0
breath"n# e+erc"ses$ These act"ons pro*ote e+pans"on of the lun#s) re*o!al of secret"ons) and opt"*al pul*onar
funct"on"n#$
5ur"n# e!er sleep ccle) the sleeper passes throu#h four sta#es of nonrap"d0ee0*o!e*ent sleep and one sta#e of rap"d0
ee0*o!e*ent sleep$
A pat"ent who "s ta'"n# calc"fed"ol ,;alderol- should a!o"d conco*"tant use of preparat"ons that conta"n !"ta*"n 5$
A pat"ent should be#"n and end a 3E0hour ur"ne collect"on per"od w"th an e*pt bladder$ /or e+a*ple) "f the phs"c"an orders
ur"ne to be collected fro* 4=44 Thursda to 4=44 /r"da) the ur"ne !o"ded at 4=44 Thursda should be d"scarded and the
ur"ne !o"ded at 4=44 /r"da should be reta"ned$
In a pat"ent who "s rece"!"n# d"#o+"n ,Lano+"n-) a low potass"u* le!el "ncreases the r"s' of d"#o+"n to+"c"t$
Blood urea n"tro#en !alues nor*all ran#e fro* 14 to 34 *#<dl$
/lura1epa* ,5al*ane- to+"c"t "s *an"fested b confus"on) halluc"nat"ons) and ata+"a$
A s"lent *ocard"al "nfarct"on "s one that has no s*pto*s$
Ad!erse react"ons to !erapa*"l ,Isopt"n- "nclude d"11"ness) headache) const"pat"on) hpotens"on) and atr"o!entr"cular
conduct"on d"sturbances$ The dru# also *a "ncrease the seru* d"#o+"n le!el$
%hen a rectal tube "s used to rel"e!e flatulence or enhance per"stals"s) "t should be "nserted for no lon#er than 34 *"nutes$
Xellow"sh #reen d"schar#e on a wound dress"n# "nd"cates "nfect"on and should be cultured$
S"c'le cell cr"s"s can cause se!ere abdo*"nal) thorac"c) *uscular) and bone pa"n alon# w"th pa"nful swell"n# of soft t"ssue "n
the hands and feet$
Hral cand"d"as"s ,thrush- "s character"1ed b crea*0colored or blu"sh wh"te patches on the oral *ucous *e*brane$
Treat*ent for a pat"ent w"th cst"c f"bros"s *a "nclude dru# therap) e+erc"ses to "*pro!e breath"n# and posture) e+erc"ses
to fac"l"tate *ob"l"1at"on of pul*onar secret"ons) a h"#h0salt d"et) and pancreat"c en1*e supple*ents w"th snac's and
*eals$
>ancreat"c cancer *a cause we"#ht loss) &aund"ce) and "nter*"ttent dull0to0se!ere ep"#astr"c pa"n$
.etastas"s "s the spread of cancer fro* one or#an or bod part to another throu#h the l*phat"c sste*) c"rculat"on sste*)
or cerebrosp"nal flu"d$
The *ana#e*ent of pul*onar ede*a focuses on open"n# the a"rwas) support"n# !ent"lat"on and perfus"on) "*pro!"n#
card"ac funct"on"n#) reduc"n# preload) and reduc"n# pat"ent an+"et$
/actors that contr"bute to the death of pat"ents w"th Al1he"*ers d"sease "nclude "nfect"on) *alnutr"t"on) and dehdrat"on$
(od#'"ns d"sease "s character"1ed b pa"nless) pro#ress"!e enlar#e*ent of cer!"cal l*ph nodes and other l*pho"d t"ssue
as a result of prol"ferat"on of Reed0Sternber# cells) h"st"octes) and eos"noph"ls$
(unt"n#tons d"sease ,chorea- "s a hered"tar d"sease character"1ed b de#enerat"on "n the cerebral corte+ and basal #an#l"a$
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NURSING BULLETS _____________ ___________________________________________________________
A pat"ent w"th (unt"n#tons d"sease *a e+h"b"t su"c"dal "deat"on$
At d"schar#e) an a*putee should be able to de*onstrate proper stu*p care and perfor* stu*p0tou#hen"n# e+erc"ses$
Acute tubular necros"s "s the *ost co**on cause of acute renal fa"lure$
;o**on co*pl"cat"ons of "ce water la!a#e are !o*"t"n# and asp"rat"on$
/oods h"#h "n !"ta*"n 5 "nclude fort"f"ed *"l') f"sh) l"!er) l"!er o"l) herr"n#) and e## ol'$
/or a pel!"c e+a*"nat"on) the pat"ent should be "n the l"thoto* pos"t"on) w"th the buttoc's e+tend"n# 3S9 ,2$E c*- past the
end of the e+a*"nat"on table$
If a pat"ent cant assu*e the l"thoto* pos"t"on for a pel!"c e+a*"nat"on) she *a l"e on her left s"de$
A *ale e+a*"ner should ha!e a fe*ale ass"stant present dur"n# a !a#"nal e+a*"nat"on for the pat"ents e*ot"onal co*fort and
the e+a*"ners le#al protect"on$
;er!"cal secret"ons are clear and stretch before o!ulat"on and wh"te and opa6ue after o!ulat"on$ There nor*all odorless
and dont "rr"tate the *ucosa$
A pat"ent w"th an "leosto* shouldnt eat corn because "t *a obstruct the open"n# of the pouch$
L"!er dsfunct"on affects the *etabol"s* of certa"n dru#s$
Ede*a that acco*pan"es burns and *alnutr"t"on "s caused b decreased os*ot"c pressure "n the cap"llar"es$
(ponatre*"a "s *ost l"'el to occur as a co*pl"cat"on of naso#astr"c suct"on"n#$
In a *an who has co*plete sp"nal cord separat"on at SE) erect"on and e&aculat"on arent poss"ble$
The earl s"#ns of pul*onar ede*a ,dspnea on e+ert"on and cou#h"n#- reflect "nterst"t"al flu"d accu*ulat"on and decreased
!ent"lat"on and al!eolar perfus"on$
.ethlpredn"solone ,Solu0.edrol- "s a f"rst0l"ne dru# used to control ede*a after sp"nal cord trau*a$
/or the pat"ent who "s reco!er"n# fro* an "ntracran"al bleed) the nurse should *a"nta"n a 6u"et) restful en!"ron*ent for the
f"rst few das$
Neurosph"l"s "s assoc"ated w"th w"despread da*a#e to the central ner!ous sste*) "nclud"n# #eneral pares"s) personal"t
chan#es) slapp"n# #a"t) and bl"ndness$
A wo*an who has had a sp"nal cord "n&ur can st"ll beco*e pre#nant$
In a pat"ent who has had a stro'e) the *ost ser"ous co*pl"cat"on "s "ncreas"n# "ntracran"al pressure$
A pat"ent w"th an "ntracran"al he*orrha#e should under#o arter"o#raph to "dent"f the s"te of the bleed"n#$
/actors that affect the act"on of dru#s "nclude absorpt"on) d"str"but"on) *etabol"s*) and e+cret"on$
Before prescr"b"n# a dru# for a wo*an of ch"ldbear"n# a#e) the prescr"ber should as' for the date of her last *enstrual per"od
and as' "f she *a be pre#nant$
Ac"dos"s *a cause "nsul"n res"stance$
A pat"ent w"th #lucose020phosphate dehdro#enase def"c"enc *a ha!e acute he*olt"c ane*"a when #"!en a sulfona*"de$
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The f"!e bas"c act"!"t"es of the d"#est"!e sste* are "n#est"on) *o!e*ent of food) d"#est"on) absorpt"on) and defecat"on$
S"#ns and s*pto*s of acute pancreat"t"s "nclude ep"#astr"c pa"n) !o*"t"n#) blu"sh d"scolorat"on of the left flan' ,Gre
Turners s"#n-) blu"sh d"scolorat"on of the per"u*b"l"cal area ,;ullens s"#n-) low0#rade fe!er) tachcard"a) and hpotens"on$
A pat"ent w"th a #astr"c ulcer *a ha!e #naw"n# or burn"n# ep"#astr"c pa"n$
To test the f"rst cran"al ner!e ,olfactor ner!e-) the nurse should as' the pat"ent to close h"s ees) occlude one nostr"l) and
"dent"f a non"rr"tat"n# substance ,such as pepper*"nt or c"nna*on- b s*ell$ Then the nurse should repeat the test w"th the
pat"ents other nostr"l occluded$
Sal' and Sab"n "ntroduced the oral pol"o !acc"ne$
A pat"ent w"th a d"sease of the cerebellu* or poster"or colu*n has an ata+"c #a"t thats character"1ed b sta##er"n# and
"nab"l"t to re*a"n stead when stand"n# w"th the feet to#ether$
In trau*a pat"ents) "*pro!ed outco*e "s d"rectl related to earl resusc"tat"on) a##ress"!e *ana#e*ent of shoc') and
appropr"ate def"n"t"!e care$
To chec' for lea'a#e of cerebrosp"nal flu"d) the nurse should "nspect the pat"ents nose and ears$ If the pat"ent can s"t up) the
nurse should obser!e h"* for lea'a#e as the pat"ent leans forward$
Loc'ed0"n sndro*e "s co*plete parals"s as a result of bra"n ste* da*a#e$ Hnl the ees can be *o!ed !oluntar"l$
Nec' d"ssect"on) or sur#"cal re*o!al of the cer!"cal l*ph nodes) "s perfor*ed to pre!ent the spread of *al"#nant tu*ors of
the head and nec'$
A pat"ent w"th cholecst"t"s tp"call has r"#ht ep"#astr"c pa"n that *a rad"ate to the r"#ht scapula or shoulderN nauseaN and
!o*"t"n#) espec"all after eat"n# a hea! *eal$
Atrop"ne "s used preoperat"!el to reduce secret"ons$
Seru* calc"u* le!els are nor*all E$: to :$: *E6<L$
Suppressor T cells re#ulate o!erall "**une response$
Seru* le!els of aspartate a*"notransferase and alan"ne a*"notransferase show whether the l"!er "s ade6uatel deto+"f"n#
dru#s$
Seru* sod"u* le!els are nor*all 1F: to 1E: *E6<L$
Seru* potass"u* le!els are nor*all F$: to :$4 *E6<L$
A pat"ent who "s ta'"n# predn"sone ,5eltasone- should consu*e a salt0restr"cted d"et thats r"ch "n potass"u* and prote"n$
%hen perfor*"n# cont"nuous a*bulator per"toneal d"als"s) the nurse *ust use ster"le techn"6ue when handl"n# the catheter)
send a per"toneal flu"d sa*ple for culture and sens"t"!"t test"n# e!er 3E hours) and report s"#ns of "nfect"on and flu"d
"*balance$
%hen wor'"n# w"th pat"ents who ha!e ac6u"red "**unodef"c"enc sndro*e) the nurse should wear #o##les and a *as'
onl "f blood or another bod flu"d could splash onto the nurses face$
Blood sp"lls that are "nfected w"th hu*an "**unodef"c"enc !"rus should be cleaned up w"th a 1I14 solut"on of sod"u*
hpochlor"te :$3:G ,household bleach-$
Ranauds pheno*enon "s "nter*"ttent "sche*"c attac's "n the f"n#ers or toes$ It causes se!ere pallor and so*et"*es
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paresthes"a and pa"n$
Intussuscept"on ,prolapse of one bowel se#*ent "nto the lu*en of another- causes sudden ep"#astr"c pa"n) sausa#e0shaped
abdo*"nal swell"n#) passa#e of *ucus and blood throu#h the rectu*) shoc') and hpotens"on$
Bence Aones prote"n occurs al*ost e+clus"!el "n the ur"ne of pat"ents who ha!e *ult"ple *elo*a$
Gauchers d"sease "s an autoso*al d"sorder thats character"1ed b abnor*al accu*ulat"on of #lucocerebros"des ,l"p"d
substances that conta"n #lucose- "n *onoctes and *acroctes$ It has three for*sI Tpe 1 "s the adult for*) tpe 3 "s the
"nfant"le for*) and tpe F "s the &u!en"le for*$
A pat"ent w"th colon obstruct"on *a ha!e lower abdo*"nal pa"n) const"pat"on) "ncreas"n# d"stent"on) and !o*"t"n#$
;olch"c"ne ,;olsal"de- rel"e!es "nfla**at"on and "s used to treat #out$
So*e people ha!e #out as a result of hperur"ce*"a because the cant *etabol"1e and e+crete pur"nes nor*all$
A nor*al sper* count "s 34 to 1:4 *"ll"on<*l$
A f"rst0de#ree burn "n!ol!es the stratu* corneu* laer of the ep"der*"s and causes pa"n and redness$
Sheehans sndro*e "s hpop"tu"tar"s* caused b a p"tu"tar "nfarct after postpartu* shoc' and he*orrha#e$
%hen car"n# for a pat"ent who has had an asth*a attac') the nurse should place the pat"ent "n /owlers or se*"0/owlers
pos"t"on$
In elderl pat"ents) the "nc"dence of nonco*pl"ance w"th prescr"bed dru# therap "s h"#h$ .an elderl pat"ents ha!e
d"*"n"shed !"sual acu"t) hear"n# loss) or for#etfulness) or need to ta'e *ult"ple dru#s$
Tuberculos"s "s a reportable co**un"cable d"sease thats caused b "nfect"on w"th .cobacter"u* tuberculos"s ,an ac"d0fast
bac"llus-$
/or r"#ht0s"ded card"ac catheter"1at"on) the phs"c"an passes a *ult"lu*en catheter throu#h the super"or or "nfer"or !ena ca!a$
After a fracture) bone heal"n# occurs "n these sta#esI he*ato*a for*at"on) cellular prol"ferat"on and callus for*at"on) and
oss"f"cat"on and re*odel"n#$
A pat"ent who "s scheduled for pos"tron e*"ss"on to*o#raph should a!o"d alcohol) tobacco) and caffe"ne for 3E hours before
the test$
In a stro'e) decreased o+#en destros bra"n cells$
A pat"ent w"th #lauco*a shouldnt rece"!e atrop"ne sulfate because "t "ncreases "ntraocular pressure$
The nurse should "nstruct a pat"ent who "s hper!ent"lat"n# to breathe "nto a paper ba#$
5ur"n# "nter*"ttent pos"t"!e0pressure breath"n#) the pat"ent should b"te down on the *outhp"ece) breathe nor*all) and let
the *ach"ne do the wor'$ After "nsp"rat"on) the pat"ent should hold h"s breath for F or E seconds and e+hale co*pletel
throu#h the *outhp"ece$
/le+"on contractures of the h"ps *a occur "n a pat"ent who s"ts "n a wheelcha"r for a lon# t"*e$
Nsta#*us "s rap"d hor"1ontal or rotat"n# ee *o!e*ent$
After *elo#raph) the pat"ent should re*a"n recu*bent for 3E hours$
The treat*ent of spra"ns and stra"ns cons"sts of appl"n# "ce "**ed"atel and ele!at"n# the ar* or le# abo!e heart le!el$
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An ant"chol"nesterase a#ent shouldnt be prescr"bed for a pat"ent who "s ta'"n# *orph"ne because "t can potent"ate the effect
of *orph"ne and cause resp"rator depress"on$
.op"a "s nears"#htedness$ (perop"a and presbop"a are two tpes of fars"#htedness$
The *ost effect"!e contracept"!e *ethod "s one that the wo*an selects for herself and uses cons"stentl$
To perfor* %ebers test for bone conduct"on) a !"brat"n# tun"n# for' "s placed on top of the pat"ents head at *"dl"ne$ The
pat"ent should perce"!e the sound e6uall "n both ears$ In a pat"ent who has conduct"!e hear"n# loss) the sound "s heard "n
,lateral"1es to- the ear that has conduct"!e loss$
In the R"nne test) bone conduct"on "s tested b plac"n# a !"brat"n# tun"n# for' on the *asto"d process of the te*poral bone
and a"r conduct"on "s tested b hold"n# the !"brat"n# tun"n# for' S9 ,1$F c*- fro* the e+ternal aud"tor *eatus$ These tests
are alternated) at d"fferent fre6uenc"es) unt"l the tun"n# for' "s no lon#er heard at one pos"t"on$
After an a*putat"on) the stu*p *a shr"n' because of *uscle atroph and decreased subcutaneous fat$
A pat"ent who has deep !e"n thro*bos"s "s #"!en hepar"n for D to 14 das) followed b 13 wee's of warfar"n ,;ou*ad"n-
therap$
After pneu*onecto*) the pat"ent should be pos"t"oned on the operat"!e s"de or on h"s bac') w"th h"s head sl"#htl ele!ated$
To reduce the poss"b"l"t of for*at"on of new e*bol" or e+pans"on of e+"st"n# e*bol") a pat"ent w"th deep !e"n thro*bos"s
should rece"!e hepar"n$
Atheroscleros"s "s the *ost co**on cause of coronar arter d"sease$ It usuall "n!ol!es the aorta and the fe*oral) coronar)
and cerebral arter"es$
>ul*onar e*bol"s* "s a potent"all fatal co*pl"cat"on of deep !e"n thro*bos"s$
;hest pa"n "s the *ost co**on s*pto* of pul*onar e*bol"s*$
The nurse should "nfor* a pat"ent who "s ta'"n# phena1opr"d"ne ,>r"d"u*- that th"s dru# colors ur"ne oran#e or red$
>neu*othora+ "s a ser"ous co*pl"cat"on of central !enous l"ne place*entN "ts caused b "nad!ertent lun# puncture$
>neu*ocst"s car"n"" pneu*on"a "snt cons"dered conta#"ous because "t onl affects pat"ents who ha!e a suppressed "**une
sste*$
To enhance dru# absorpt"on) the pat"ent should ta'e re#ular erthro*c"n tablets w"th a full #lass of water 1 hour before or 3
hours after a *eal or should ta'e enter"c0coated tablets w"th food$ The pat"ent should a!o"d ta'"n# e"ther tpe of tablet w"th
fru"t &u"ce$
Tr"s*us) a s"#n of tetanus ,loc'&aw-) causes pa"nful spas*s of the *ast"cator *uscles) d"ff"cult open"n# the *outh) nec'
r"#"d"t and st"ffness) and dspha#"a$
The nurse should place the pat"ent "n an upr"#ht pos"t"on for thoracentes"s$ If th"s "snt poss"ble) the nurse should pos"t"on the
pat"ent on the unaffected s"de$
If #ra!"t flow "s used) the nurse should han# a blood ba# FB ,1 *- abo!e the le!el of the planned !en"puncture s"te$
The nurse should place a pat"ent who has a closed chest dra"na#e sste* "n the se*"0/owler pos"t"on$
If blood "snt transfused w"th"n F4 *"nutes) the nurse should return "t to the blood ban' because the refr"#erat"on fac"l"t"es on
a nurs"n# un"t are "nade6uate for stor"n# blood products$
Blood thats d"scolored and conta"ns #as bubbles "s conta*"nated w"th bacter"a and shouldnt be transfused$ /"ft percent of
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pat"ents who rece"!e conta*"nated blood d"e$
/or *ass"!e) rap"d blood transfus"ons and for e+chan#e transfus"ons "n neonates) blood should be war*ed to O=$DC / ,FDC ;-$
A chest tube per*"ts a"r and flu"d to dra"n fro* the pleural space$
A handheld resusc"tat"on ba# "s an "nflatable de!"ce that can be attached to a face *as' or an endotracheal or tracheosto*
tube$ It allows *anual del"!er of o+#en to the lun#s of a pat"ent who cant breathe "ndependentl$
.echan"cal !ent"lat"on art"f"c"all controls or ass"sts resp"rat"on$
The nurse should encoura#e a pat"ent who has a closed chest dra"na#e sste* to cou#h fre6uentl and breathe deepl to help
dra"n the pleural space and e+pand the lun#s$
Tracheal suct"on re*o!es secret"ons fro* the trachea and bronch" w"th a suct"on catheter$
5ur"n# colosto* "rr"#at"on) the "rr"#at"on ba# should be hun# 1=9 ,E:$D c*- abo!e the sto*a$
The water used for colosto* "rr"#at"on should be 144C to 14:C / ,FD$=C to E4$2C ;-$
An arter"al e*bol"s* *a cause pa"n) loss of sensor ner!es) pallor) coolness) parals"s) pulselessness) or paresthes"a "n the
affected ar* or le#$
Resp"rator al'alos"s results fro* cond"t"ons that cause hper!ent"lat"on and reduce the carbon d"o+"de le!el "n the arter"al
blood$
."neral o"l "s contra"nd"cated "n a pat"ent w"th append"c"t"s) acute sur#"cal abdo*en) fecal "*pact"on) or "ntest"nal
obstruct"on$
%hen us"n# a X0tpe ad*"n"strat"on set to transfuse pac'ed red blood cells ,RB;s-) the nurse can add nor*al sal"ne solut"on
to the ba# to d"lute the RB;s and *a'e the* less !"scous$
Autotransfus"on "s collect"on) f"ltrat"on) and re"nfus"on of the pat"ents own blood$
>repared I$J$ solut"ons fall "nto three #eneral cate#or"esI "soton"c) hpoton"c) and hperton"c$ Isoton"c solut"ons ha!e a solute
concentrat"on thats s"*"lar to bod flu"dsN add"n# the* to plas*a doesnt chan#e "ts os*olar"t$ (poton"c solut"ons ha!e a
lower os*ot"c pressure than bod flu"dsN add"n# the* to plas*a decreases "ts os*olar"t$ (perton"c solut"ons ha!e a h"#her
os*ot"c pressure than bod flu"dsN add"n# the* to plas*a "ncreases "ts os*olar"t$
Stress "ncont"nence "s "n!oluntar lea'a#e of ur"ne tr"##ered b a sudden phs"cal stra"n) such as a cou#h) snee1e) or 6u"c'
*o!e*ent$
5ecreased renal funct"on *a'es an elderl pat"ent *ore suscept"ble to the de!elop*ent of renal calcul"$
The nurse should cons"der us"n# shorter needles to "n&ect dru#s "n elderl pat"ents because these pat"ents e+per"ence
subcutaneous t"ssue red"str"but"on and loss "n areas) such as the buttoc's and delto"d *uscles$
Ur#e "ncont"nence "s the "nab"l"t to suppress a sudden ur#e to ur"nate$
Total "ncont"nence "s cont"nuous) uncontrollable lea'a#e of ur"ne as a result of the bladders "nab"l"t to reta"n ur"ne$
>rote"n) !"ta*"n) and *"neral needs usuall re*a"n constant as a person a#es) but calor"c re6u"re*ents decrease$
/our !al!es 'eep blood flow"n# "n one d"rect"on "n the heartI two atr"o!entr"cular !al!es ,tr"cusp"d and *"tral- and two
se*"lunar !al!es ,pul*on"c and aort"c-$
An elderl pat"ents he"#ht *a decrease because of narrow"n# of the "nter!ertebral spaces and e+a##erated sp"nal cur!ature$
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;onst"pat"on *ost co**onl occurs when the ur#e to defecate "s suppressed and the *uscles assoc"ated w"th bowel
*o!e*ents re*a"n contracted$
Gout de!elops "n four sta#esI as*pto*at"c) acute) "ntercr"t"cal) and chron"c$
;o**on postoperat"!e co*pl"cat"ons "nclude he*orrha#e) "nfect"on) hpo!ole*"a) sept"ce*"a) sept"c shoc') atelectas"s)
pneu*on"a) thro*bophleb"t"s) and pul*onar e*bol"s*$
An "nsul"n pu*p del"!ers a cont"nuous "nfus"on of "nsul"n "nto a selected subcutaneous s"te) co**onl "n the abdo*en$
A co**on s*pto* of sal"clate ,asp"r"n- to+"c"t "s t"nn"tus ,r"n#"n# "n the ears-$
A frostb"tten e+tre*"t *ust be thawed rap"dl) e!en "f def"n"t"!e treat*ent *ust be delaed$
A pat"ent w"th Ranauds d"sease shouldnt s*o'e c"#arettes or other tobacco products$
Ranauds d"sease "s a pr"*ar arter"ospast"c d"sorder that has no 'nown cause$ Ranauds pheno*enon) howe!er) "s caused
b another d"sorder such as scleroder*a$
To re*o!e a fore"#n bod fro* the ee) the nurse should "rr"#ate the ee w"th ster"le nor*al sal"ne solut"on$
%hen "rr"#at"n# the ee) the nurse should d"rect the solut"on toward the lower con&unct"!al sac$
E*er#enc care for a corneal "n&ur caused b a caust"c substance "s flush"n# the ee w"th cop"ous a*ounts of water for 34
to F4 *"nutes$
5ebr"de*ent "s *echan"cal) che*"cal) or sur#"cal re*o!al of necrot"c t"ssue fro* a wound$
Se!ere pa"n after cataract sur#er "nd"cates bleed"n# "n the ee$
A b"!al!e cast "s cut "nto anter"or and poster"or port"ons to allow s'"n "nspect"on$
After ear "rr"#at"on) the nurse should place the pat"ent on the affected s"de to per*"t #ra!"t to dra"n flu"d that re*a"ns "n the
ear$
If a pat"ent w"th an "ndwell"n# catheter has abdo*"nal d"sco*fort) the nurse should assess for bladder d"stent"on) wh"ch *a
be caused b catheter bloc'a#e$
;ont"nuous bladder "rr"#at"on helps pre!ent ur"nar tract obstruct"on b flush"n# out s*all blood clots that for* after
prostate or bladder sur#er$
The nurse should re*o!e an "ndwell"n# catheter when bladder deco*press"on "s no lon#er needed) when the catheter "s
obstructed) or when the pat"ent can resu*e !o"d"n#$ The lon#er a catheter re*a"ns "n place) the #reater the r"s' of ur"nar
tract "nfect"on$
In an adult) the e+tent of a burn "n&ur "s deter*"ned b us"n# the Rule of N"nesI the head and nec' are counted as OGN each
ar*) as OGN each le#) as 1=GN the bac' of the trun') as 1=GN the front of the trun') as 1=GN and the per"neu*) as 1G$
A deep part"al0th"c'ness burn affects the ep"der*"s and der*"s$
In a pat"ent who "s ha!"n# an asth*a attac') nurs"n# "nter!ent"ons "nclude ad*"n"ster"n# o+#en and bronchod"lators as
prescr"bed) plac"n# the pat"ent "n the se*"0/owler pos"t"on) encoura#"n# d"aphra#*at"c breath"n#) and help"n# the pat"ent to
rela+$
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>rostate cancer "s usuall fatal "f bone *etastas"s occurs$
A str"ct !e#etar"an needs !"ta*"n B13 supple*ents because an"*als and an"*al products are the onl source of th"s !"ta*"n$
Re#ular "nsul"n "s the onl tpe of "nsul"n that can be *"+ed w"th other tpes of "nsul"n and can be #"!en I$J$
If a pat"ent pulls out the outer tracheosto* tube) the nurse should hold the tracheosto* open w"th a sur#"cal d"lator unt"l
the phs"c"an pro!"des appropr"ate care$
The *edulla oblon#ata "s the part of the bra"n that controls the resp"rator center$
/or an unconsc"ous pat"ent) the nurse should perfor* pass"!e ran#e0of0*ot"on e+erc"ses e!er 3 to E hours$
A t"*ed0release dru# "snt reco**ended for use "n a pat"ent who has an "leosto* because "t releases the dru# at d"fferent
rates alon# the GI tract$
The nurse "snt re6u"red to wear #lo!es when appl"n# n"tro#lcer"n pasteN howe!er) she should wash her hands after
appl"n# th"s dru#$
Before e+cretor uro#raph) a pat"ents flu"d "nta'e "s usuall restr"cted after *"dn"#ht$
A sod"u* polstrene sulfonate ,Lae+alate- ene*a) wh"ch e+chan#es sod"u* "ons for potass"u* "ons) "s used to decrease
the potass"u* le!el "n a pat"ent who has hper'ale*"a$
If the color of a sto*a "s *uch l"#hter than when pre!"ousl assessed) decreased c"rculat"on to the sto*a should be
suspected$
.assa#e "s contra"nd"cated "n a le# w"th a blood clot because "t *a d"slod#e the clot$
The f"rst place a nurse can detect &aund"ce "n an adult "s "n the sclera$
Aaund"ce "s caused b e+cess"!e le!els of con&u#ated or uncon&u#ated b"l"rub"n "n the blood$
.dr"at"c dru#s are used pr"*ar"l to d"late the pup"ls for "ntraocular e+a*"nat"ons$
After ee sur#er) the pat"ent should be placed on the unaffected s"de$
%hen ass"#n"n# tas's to a l"censed pract"cal nurse) the re#"stered nurse should dele#ate tas's that are cons"dered beds"de
nurs"n# care) such as ta'"n# !"tal s"#ns) chan#"n# s"*ple dress"n#s) and #"!"n# baths$
5eep calf pa"n on dors"fle+"on of the foot "s a pos"t"!e (o*ans s"#n) wh"ch su##ests !enous thro*bos"s or thro*bophleb"t"s$
Ultra0short0act"n# barb"turates) such as th"opental ,>entothal-) are used as "n&ect"on anesthet"cs when a short durat"on of
anesthes"a "s needed such as outpat"ent sur#er$
Atrop"ne sulfate *a be used as a preanesthet"c dru# to reduce secret"ons and *"n"*"1e !a#al refle+es$
/or a pat"ent w"th "nfect"ous *ononucleos"s) the nurs"n# care plan should e*phas"1e str"ct bed rest dur"n# the acute febr"le
sta#e to ensure ade6uate rest$
5ur"n# the acute phase of "nfect"ous *ononucleos"s) the pat"ent should curta"l act"!"t"es to *"n"*"1e the poss"b"l"t of
ruptur"n# the enlar#ed spleen$
5a"l appl"cat"on of a lon#0act"n#) transder*al n"tro#lcer"n patch "s a con!en"ent) effect"!e wa to pre!ent chron"c an#"na$
The nurse *ust wear a cap) #lo!es) a #own) and a *as' when pro!"d"n# wound care to a pat"ent w"th th"rd0de#ree burns$
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The nurse should e+pect to ad*"n"ster an anal#es"c before bath"n# a burn pat"ent$
The passa#e of blac') tarr feces ,*elena- "s a co**on s"#n of lower GI bleed"n#) but also *a occur "n pat"ents who ha!e
upper GI bleed"n#$
A pat"ent who has a #astr"c ulcer should a!o"d ta'"n# asp"r"n and asp"r"n0conta"n"n# products because the can "rr"tate the
#astr"c *ucosa$
%h"le ad*"n"ster"n# che*otherap a#ents w"th an I$J$ l"ne) the nurse should d"scont"nue the "nfus"on at the f"rst s"#n of
e+tra!asat"on$
A low0f"ber d"et *a contr"bute to the de!elop*ent of he*orrho"ds$
A pat"ent who has abdo*"nal pa"n shouldnt rece"!e an anal#es"c unt"l the cause of the pa"n "s deter*"ned$
If sur#er re6u"res ha"r re*o!al) the reco**endat"on of the ;enters for 5"sease ;ontrol and >re!ent"on "s that a dep"lator
be used to a!o"d s'"n abras"ons and cuts$
/or nasotracheal suct"on"n#) the nurse should set wall suct"on at :4 to O: ** (# for an "nfant) O: to 11: ** (# for a ch"ld)
or =4 to 134 ** (# for an adult$
After a *ocard"al "nfarct"on) a chan#e "n pulse rate and rhth* *a s"#nal the onset of fatal arrhth*"as$
Treat*ent of ep"sta+"s "ncludes nasal pac'"n#) "ce pac's) cauter w"th s"l!er n"trate) and pressure on the nares$
>all"at"!e treat*ent rel"e!es or reduces the "ntens"t of unco*fortable s*pto*s) but doesnt cure the causat"!e d"sorder$
>lac"n# a postoperat"!e pat"ent "n an upr"#ht pos"t"on too 6u"c'l *a cause hpotens"on$
Jerapa*"l ,;alan- and d"lt"a1e* ,;ard"1e*- slow the "nflow of calc"u* to the heart) thereb decreas"n# the r"s' of
supra!entr"cular tachcard"a$
After card"opul*onar bpass #raft) the pat"ent w"ll perfor* turn"n#) cou#h"n#) deep breath"n#) and wound spl"nt"n#) and
w"ll use ass"st"!e breath"n# de!"ces$
A pat"ent who "s e+posed to hepat"t"s B should rece"!e 4$42 *l<'# I$.$ of "**une #lobul"n w"th"n D3 hours after e+posure
and a repeat dose at 3= das after e+posure$
The nurse should ad!"se a pat"ent who "s under#o"n# rad"at"on therap not to re*o!e the *ar'"n#s on the s'"n *ade b the
rad"at"on therap"st because the are land*ar's for treat*ent$
The *ost co**on s*pto* of osteoarthr"t"s "s &o"nt pa"n thats rel"e!ed b rest) espec"all "f the pa"n occurs after e+erc"se
or we"#ht bear"n#$
In adults) ur"ne !olu*e nor*all ran#es fro* =44 to 3)444 *l<da and a!era#es between 1)344 and 1):44 *l<da$
5"rectl appl"ed *o"st heat softens crusts and e+udates) penetrates deeper than dr heat) doesnt dr the s'"n) and "s usuall
*ore co*fortable for the pat"ent$
Tetraccl"nes are seldo* cons"dered dru#s of cho"ce for *ost co**on bacter"al "nfect"ons because the"r o!eruse has led to
the e*er#ence of tetraccl"ne0res"stant bacter"a$
Because l"#ht de#rades n"tropruss"de ,N"tropress-) the dru# *ust be sh"elded fro* l"#ht$ /or e+a*ple) an I$J$ ba# that
conta"ns n"tropruss"de sod"u* should be wrapped "n fo"l$
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NURSING BULLETS _____________ ___________________________________________________________
;ephalospor"ns should be used caut"ousl "n pat"ents who are aller#"c to pen"c"ll"n$ These pat"ents are *ore suscept"ble to
hpersens"t"!"t react"ons$
If chlora*phen"col and pen"c"ll"n *ust be ad*"n"stered conco*"tantl) the nurse should #"!e the pen"c"ll"n 1 or *ore hours
before the chlora*phen"col to a!o"d a reduct"on "n pen"c"ll"ns bacter"c"dal act"!"t$
The erthrocte sed"*entat"on rate *easures the d"stance and speed at wh"ch erthroctes "n whole blood fall "n a !ert"cal
tube "n 1 hour$ The rate at wh"ch the fall to the botto* of the tube corresponds to the de#ree of "nfla**at"on$
%hen teach"n# a pat"ent w"th *asthen"a #ra!"s about pr"dost"#*"ne ,.est"non- therap) the nurse should stress the
"*portance of ta'"n# the dru# e+actl as prescr"bed) on t"*e) and "n e!enl spaced doses to pre!ent a relapse and *a+"*"1e
the effect of the dru#$
If an ant"b"ot"c *ust be ad*"n"stered "nto a per"pheral hepar"n loc') the nurse should flush the s"te w"th nor*al sal"ne
solut"on after the "nfus"on to *a"nta"n I$J$ patenc$
The nurse should "nstruct a pat"ent w"th an#"na to ta'e a n"tro#lcer"n tablet before ant"c"pated stress or e+erc"se or) "f the
an#"na "s nocturnal) at bedt"*e$
Arter"al blood #as anals"s e!aluates #as e+chan#e "n the lun#s ,al!eolar !ent"lat"on- b *easur"n# the part"al pressures of
o+#en and carbon d"o+"de and the p( of an arter"al sa*ple$
The nor*al seru* *a#nes"u* le!el ran#es fro* 1$: to 3$: *E6<L$
>at"ent preparat"on for a total cholesterol test "ncludes an o!ern"#ht fast and abst"nence fro* alcohol for 3E hours before the
test$
The fast"n# plas*a #lucose test *easures #lucose le!els after a 130 to 1E0hour fast$
Nor*al blood p( ran#es fro* D$F: to D$E:$ A blood p( h"#her than D$E: "nd"cates al'ale*"aN one lower than D$F: "nd"cates
ac"de*"a$
5ur"n# an ac"d perfus"on test) a s*all a*ount of wea' hdrochlor"c ac"d solut"on "s "nfused w"th a nasoesopha#eal tube$ A
pos"t"!e test result ,pa"n after "nfus"on- su##ests reflu+ esopha#"t"s$
Nor*all) the part"al pressure of arter"al carbon d"o+"de ,>a;H3- ran#es fro* F: to E: ** (#$ A >a;H3 #reater than E:
** (# "nd"cates ac"de*"a as a result of hpo!ent"lat"onN one less than F: ** (# "nd"cates al'ale*"a as a result of
hper!ent"lat"on$
Red cell "nd"ces a"d "n the d"a#nos"s and class"f"cat"on of ane*"a$
Nor*all) the part"al pressure of arter"al o+#en ,>ao 3- ran#es fro* =4 to 144 ** (#$ A >ao 3 of :4 to =4 ** (# "nd"cates
resp"rator "nsuff"c"enc$ A >ao 3 of less than :4 ** (# "nd"cates resp"rator fa"lure$
The wh"te blood cell ,%B;- d"fferent"al e!aluates %B; d"str"but"on and *orpholo# and pro!"des *ore spec"f"c
"nfor*at"on about a pat"ents "**une sste* than the %B; count$
An e+erc"se stress test ,tread*"ll test) e+erc"se electrocard"o#ra*- cont"nues unt"l the pat"ent reaches a predeter*"ned tar#et
heart rate or e+per"ences chest pa"n) fat"#ue) or other s"#ns of e+erc"se "ntolerance$
Alterable r"s' factors for coronar arter d"sease "nclude c"#arette s*o'"n#) hpertens"on) h"#h cholesterol or tr"#lcer"de
le!els) and d"abetes$
The *ed"ast"nu* "s the space between the lun#s that conta"ns the heart) esopha#us) trachea) and other structures$
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NURSING BULLETS _____________ ___________________________________________________________
.a&or co*pl"cat"ons of acute *ocard"al "nfarct"on "nclude arrhth*"as) acute heart fa"lure) card"o#en"c shoc')
thro*boe*bol"s*) and left !entr"cular rupture$
The s"noatr"al node "s a cluster of hundreds of cells located "n the r"#ht atr"al wall) near the open"n# of the super"or !ena
ca!a$
/or one0person card"opul*onar resusc"tat"on) the rat"o of co*press"ons to !ent"lat"ons "s 1:I3$
/or two0person card"opul*onar resusc"tat"on) the rat"o of co*press"ons to !ent"lat"ons "s :I1$
A pat"ent who has pulseless !entr"cular tachcard"a "s a cand"date for card"o!ers"on$
Echocard"o#raph) a non"n!as"!e test that d"rects ultra0h"#h0fre6uenc sound wa!es throu#h the chest wall and "nto the heart)
e!aluates card"ac structure and funct"on and can show !al!e defor*"t"es) tu*ors) septal defects) per"card"al effus"on) and
hpertroph"c card"o*opath$
Ata+"a "s "*pa"red ab"l"t to coord"nate *o!e*ents$ Its caused b a cerebellar or sp"nal cord les"on$
Hn an electrocard"o#ra* str"p) each s*all bloc' on the hor"1ontal a+"s represents 4$4E second$ Each lar#e bloc' ,co*posed
of f"!e s*all bloc's- represents 4$3 second$
Starl"n#s law states that the force of contract"on of each heartbeat depends on the len#th of the *uscle f"bers of the heart
wall$
The therapeut"c blood le!el for d"#o+"n "s 4$: to 3$: n#<*l$
>ancrel"pase ,>ancrease- "s used to treat cst"c f"bros"s and chron"c pancreat"t"s$
Treat*ent for *"ld to *oderate !ar"cose !e"ns "ncludes ant"e*bol"s* stoc'"n#s and an e+erc"se pro#ra* that "ncludes
wal'"n# to *"n"*"1e !enous pool"n#$
An "nto+"cated pat"ent "snt cons"dered co*petent to refuse re6u"red *ed"cal treat*ent and shouldnt be allowed to chec' out
of a hosp"tal a#a"nst *ed"cal ad!"ce$
The pr"*ar d"fference between the pa"n of an#"na and that of a *ocard"al "nfarct"on "s "ts durat"on$
Gneco*ast"a "s e+cess"!e *a**ar #land de!elop*ent and "ncreased breast s"1e "n bos and *en$
;lass"c s*pto*s of Gra!es d"sease are an enlar#ed thro"d) ner!ousness) heat "ntolerance) we"#ht loss desp"te "ncreased
appet"te) sweat"n#) d"arrhea) tre*or) and palp"tat"ons$
General"1ed *ala"se "s a co**on s*pto* of !"ral and bacter"al "nfect"ons and depress"!e d"sorders$
J"ta*"n ; and prote"n are the *ost "*portant nutr"ents for wound heal"n#$
A pat"ent who has portal hpertens"on should rece"!e !"ta*"n L to pro*ote act"!e thro*b"n for*at"on b the l"!er$ Thro*b"n
reduces the r"s' of bleed"n#$
The nurse should ad*"n"ster a sedat"!e caut"ousl to a pat"ent w"th c"rrhos"s because the da*a#ed l"!er cant *etabol"1e
dru#s effect"!el$
Beta0he*olt"c streptococcal "nfect"ons should be treated a##ress"!el to pre!ent #lo*erulonephr"t"s) rheu*at"c fe!er) and
other co*pl"cat"ons$
The *ost co**on nosoco*"al "nfect"on "s a ur"nar tract "nfect"on$
The nurse should "*ple*ent str"ct "solat"on precaut"ons to protect a pat"ent w"th a th"rd0de#ree burn thats "nfected b
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NURSING BULLETS _____________ ___________________________________________________________
Staphlococcus aureus$
A pat"ent who "s under#o"n# e+ternal rad"at"on therap shouldnt appl crea* or lot"on to the treat*ent s"te$
The *ost co**on !ascular co*pl"cat"on of d"abetes *ell"tus "s atheroscleros"s$
Insul"n def"c"enc *a cause hper#lce*"a$
S"#ns of >ar'"nsons d"sease "nclude drool"n#) a *as'l"'e e+press"on) and a propuls"!e #a"t$
I$J$ cholan#"o#raph "s contra"nd"cated "n a pat"ent w"th hperthro"d"s*) se!ere renal or hepat"c da*a#e) tuberculos"s) or
"od"ne hpersens"t"!"t$
."rrors should be re*o!ed fro* the roo* of a pat"ent who has d"sf"#ur"n# wounds such as fac"al burns$
A pat"ent who has #out arthr"t"s should "ncrease flu"d "nta'e to pre!ent calcul" for*at"on$
An+"et "s the *ost co**on cause of chest pa"n$
A pat"ent who "s follow"n# a low0salt d"et should a!o"d canned !e#etables$
Bananas are a #ood source of potass"u* and should be "ncluded "n a low0salt d"et for pat"ents who are ta'"n# a loop d"uret"c
such as furose*"de ,Las"+-$
The nurse should encoura#e a pat"ent who "s at r"s' for pneu*on"a to turn fre6uentl) cou#h) and breathe deepl$ These
act"ons *ob"l"1e pul*onar secret"ons) pro*ote al!eolar #as e+chan#e) and help pre!ent atelectas"s$
The nurse should not"f the phs"c"an whene!er a pat"ents blood pressure reaches 1=4<144 ** (#$
Buc's tract"on "s used to "**ob"l"1e and reduce spas*s "n a fractured h"p$
/or a pat"ent w"th a fractured h"p) the nurse should assess neuroc"rculator status e!er 3 hours$
%hen car"n# for a pat"ent w"th a fractured h"p) the nurse should use p"llows or a trochanter roll to *a"nta"n abduct"on$
Hrthopnea "s a s*pto* of left0s"ded heart fa"lure$
Althou#h a f"ber#lass cast "s *ore durable and dr"es *ore 6u"c'l than a plaster cast) "t tp"call causes s'"n "rr"tat"on$
In an "**ob"l"1ed pat"ent) the *a&or c"rculator co*pl"cat"on "s pul*onar e*bol"s*$
To rel"e!e ede*a "n a fractured l"*b) the pat"ent should 'eep the l"*b ele!ated$
I$J$ ant"b"ot"cs are the treat*ent of cho"ce for a pat"ent w"th osteo*el"t"s$
Blue de "n c"*et"d"ne ,Ta#a*et- can cause a false0pos"t"!e result on a fecal occult blood test such as a (e*occult test$
The nurse should suspect elder abuse "f wounds are "ncons"stent w"th the pat"ents h"stor) *ult"ple wounds are present) or
wounds are "n d"fferent sta#es of heal"n#$
I**ed"atel after a*putat"on) pat"ent care "ncludes *on"tor"n# dra"na#e fro* the stu*p) pos"t"on"n# the affected l"*b)
ass"st"n# w"th e+erc"ses prescr"bed b a phs"cal therap"st) and wrapp"n# and cond"t"on"n# the stu*p$
A pat"ent who "s prone to const"pat"on should "ncrease h"s bul' "nta'e b eat"n# whole0#ra"n cereals and fresh fru"ts and
!e#etables$
In the pel!"c e+a*"nat"on of a se+ual assault !"ct"*) the speculu* should be lubr"cated w"th water$ ;o**erc"al lubr"cants
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NURSING BULLETS _____________ ___________________________________________________________
retard sper* *ot"l"t and "nterfere w"th spec"*en collect"on and anals"s$
/or a ter*"nall "ll pat"ent) phs"cal co*fort "s the top pr"or"t "n nurs"n# care$
5ors"fle+"on of the foot pro!"des "**ed"ate rel"ef of le# cra*ps$
After card"ac sur#er) the pat"ent should l"*"t da"l sod"u* "nta'e to 3 # and da"l cholesterol "nta'e to F44 *#$
Bleed"n# after "ntercourse "s an earl s"#n of cer!"cal cancer$
Hral ant"d"abet"c a#ents) such as chlorpropa*"de ,5"ab"nese- and tolbuta*"de ,Hr"nase-) st"*ulate "nsul"n release fro* beta
cells "n the "slets of Lan#erhans of the pancreas$
%hen !"s"t"n# a pat"ent who has a rad"at"on "*plant) fa*"l *e*bers and fr"ends *ust l"*"t the"r sta to 14 *"nutes$ J"s"tors
and nurses who are pre#nant are restr"cted fro* enter"n# the roo*$
;o**on causes of !a#"nal "nfect"on "nclude us"n# an ant"b"ot"c) an oral contracept"!e) or a cort"costero"dN wear"n# t"#ht0
f"tt"n# pant hoseN and ha!"n# se+ual "ntercourse w"th an "nfected partner$
A pat"ent w"th a rad"at"on "*plant should re*a"n "n "solat"on unt"l the "*plant "s re*o!ed$ To *"n"*"1e rad"at"on e+posure)
wh"ch "ncreases w"th t"*e) the nurse should carefull plan the t"*e spent w"th the pat"ent$
A*on# cultural #roups) Nat"!e A*er"cans ha!e the lowest "nc"dence of cancer$
The '"dnes f"lter blood) select"!el reabsorb substances that are needed to *a"nta"n the constanc of bod flu"d) and e+crete
*etabol"c wastes$
To pre!ent stra"n"n# dur"n# defecat"on) docusate ,;olace- "s the la+at"!e of cho"ce for pat"ents who are reco!er"n# fro* a
*ocard"al "nfarct"on) rectal or card"ac sur#er) or postpartu* const"pat"on$
After prostate sur#er) a pat"ents pr"*ar sources of pa"n are bladder spas*s and "rr"tat"on "n the area around the catheter$
To+oplas*os"s "s *ore l"'el to affect a pre#nant cat owner than other pre#nant wo*en because cat feces "n the l"tter bo+
harbor the "nfect"n# or#an"s*$
Good food sources of fol"c ac"d "nclude #reen leaf !e#etables) l"!er) and le#u*es$
The Glas#ow ;o*a Scale e!aluates !erbal) ee) and *otor responses to deter*"ne the pat"ents le!el of consc"ousness$
The nurse should place an unconsc"ous pat"ent "n low /owlers pos"t"on for "nter*"ttent naso#astr"c tube feed"n#s$
La]nnecs ,alcohol"c- c"rrhos"s "s the *ost co**on tpe of c"rrhos"s$
In decort"cate postur"n#) the pat"ents ar*s are adducted and fle+ed) w"th the wr"sts and f"n#ers fle+ed on the chest$ The le#s
are e+tended st"ffl and rotated "nternall) w"th plantar fle+"on of the feet$
;and"dates for sur#er should rece"!e noth"n# b *outh fro* *"dn"#ht of the da before sur#er unless cleared b a
phs"c"an$
.eper"d"ne ,5e*erol- "s an effect"!e anal#es"c to rel"e!e the pa"n of nephrol"th"as"s ,ur"nar calcul"-$
An "n&ured pat"ent w"th thro*boctopen"a "s at r"s' for l"fe0threaten"n# "nternal and e+ternal he*orrha#e$
The Trendelenbur# test "s used to chec' for un"lateral h"p d"slocat"on$
As soon as poss"ble after death) the pat"ent should be placed "n the sup"ne pos"t"on) w"th the ar*s at the s"des and the head on
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NURSING BULLETS _____________ ___________________________________________________________
a p"llow$
Jascular res"stance depends on blood !"scos"t) !essel len#th and) *ost "*portant) "ns"de !essel d"a*eter$
A below0the0'nee a*putat"on lea!es the 'nee "ntact for prosthes"s appl"cat"on and allows a *ore nor*al #a"t than abo!e0the0
'nee a*putat"on$
;erebrosp"nal flu"d flows throu#h and protects the four !entr"cles of the bra"n) the subarachno"d space) and the sp"nal canal$
Sod"u* re#ulates e+tracellular os*olal"t$
The heart and bra"n can *a"nta"n blood c"rculat"on "n the earl sta#es of shoc'$
After l"*b a*putat"on) narcot"c anal#es"cs *a not rel"e!e ?phanto* l"*b@ pa"n$
A pat"ent who rece"!es *ult"ple blood transfus"ons "s at r"s' for hpocalce*"a$
Sph"l"s "n"t"all causes pa"nless chancres ,s*all) flu"d0f"lled les"ons- on the #en"tals and so*et"*es on other parts of the
bod$
E+posure to a rad"oact"!e source "s controlled b t"*e ,l"*"t"n# t"*e spent w"th the pat"ent-) d"stance ,fro* the pat"ent-) and
sh"eld ,a lead apron-$
Aaund"ce "s a s"#n of dsfunct"on) not a d"sease$
Se!ere &aund"ce can cause bra"n ste* dsfunct"on "f the uncon&u#ated b"l"rub"n le!el "n blood "s ele!ated to 34 to 3: *#<dl$
The pat"ent should ta'e c"*et"d"ne ,Ta#a*et- w"th *eals to help ensure a cons"stent therapeut"c effect$
%hen car"n# for a pat"ent w"th &aund"ce) the nurse should rel"e!e prur"tus b pro!"d"n# a sooth"n# lot"on or a ba'"n# soda
bath and should pre!ent "n&ur b 'eep"n# the pat"ents f"n#erna"ls short$
Tpe B hepat"t"s) wh"ch "s usuall trans*"tted parenterall) also can be spread throu#h contact w"th hu*an secret"ons and
feces$
Insul"n "s a naturall occurr"n# hor*one thats secreted b the beta cells of the "slets of Lan#erhans "n the pancreas "n
response to a r"se "n the blood #lucose le!el$
5"abetes *ell"tus "s a chron"c endocr"ne d"sorder thats character"1ed b "nsul"n def"c"enc or res"stance to "nsul"n b bod
t"ssues$
A d"a#nos"s of d"abetes *ell"tus "s based on the class"c s*pto*s ,polur"a) polpha#"a) we"#ht loss) and pold"ps"a- and a
rando* blood #lucose le!el of *ore than 344 *#<dl or a fast"n# plas*a #lucose le!el of *ore than 1E4 *#<dl when tested on
two separate occas"ons$
A pat"ent w"th nonV"nsul"n0dependent ,tpe 3- d"abetes *ell"tus produces so*e "nsul"n and nor*all doesnt need e+o#enous
"nsul"n supple*entat"on$ .ost pat"ents w"th th"s tpe of d"abetes respond well to oral ant"d"abet"c a#ents) wh"ch st"*ulate the
pancreas to "ncrease the snthes"s and release of "nsul"n$
A pat"ent w"th "nsul"n0dependent ,tpe 1- d"abetes *ell"tus cant produce endo#enous "nsul"n and re6u"res e+o#enous "nsul"n
ad*"n"strat"on to *eet the bods needs$
Rap"d0act"n# "nsul"ns are clearN "nter*ed"ate0 and lon#0act"n# "nsul"ns are turb"d ,cloud-$
Rap"d0act"n# "nsul"ns be#"n to act "n F4 to 24 *"nutes) reach a pea' concentrat"on "n 3 to 14 hours) and ha!e a durat"on of
act"on of : to 12 hours$
The best t"*es to test a d"abet"c pat"ents #lucose le!el are before each *eal and at bedt"*e$
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NURSING BULLETS _____________ ___________________________________________________________
Inter*ed"ate0act"n# "nsul"ns be#"n to act "n 1 to 3 hours) reach a pea' concentrat"on "n E to 1: hours) and ha!e a durat"on of
act"on of 33 to 3= hours$
Lon#0act"n# "nsul"ns be#"n to act "n E to = hours) reach a pea' concentrat"on "n 14 to F4 hours) and ha!e a durat"on of act"on
of F2 hours or *ore$
If the results of a nonfast"n# #lucose test show abo!e0nor*al #lucose le!els after #lucose ad*"n"strat"on) but the pat"ent has
nor*al plas*a #lucose le!els otherw"se) the pat"ent has "*pa"red #lucose tolerance$
Insul"n re6u"re*ents are "ncreased b #rowth) pre#nanc) "ncreased food "nta'e) stress) sur#er) "nfect"on) "llness) "ncreased
"nsul"n ant"bod"es) and so*e dru#s$
Insul"n re6u"re*ents are decreased b hpothro"d"s*) decreased food "nta'e) e+erc"se) and so*e dru#s$
(po#lce*"a occurs when the blood #lucose le!el "s less than :4 *#<dl$
An "nsul"n0res"stant pat"ent "s one who re6u"res *ore than 344 un"ts of "nsul"n da"l$
(po#lce*"a *a occur 1 to F hours after the ad*"n"strat"on of a rap"d0act"n# "nsul"n) E to 1= hours after the ad*"n"strat"on
of an "nter*ed"ate0act"n# "nsul"n) and 1= to F4 hours after the ad*"n"strat"on of a lon#0act"n# "nsul"n$
%hen the blood #lucose le!el decreases rap"dl) the pat"ent *a e+per"ence sweat"n#) tre*ors) pallor) tachcard"a) and
palp"tat"ons$
Hb&ect"!e s"#ns of hpo#lce*"a "nclude slurred speech) lac' of coord"nat"on) sta##ered #a"t) se"1ures) and poss"bl) co*a$
A consc"ous pat"ent who has hpo#lce*"a should rece"!e su#ar "n an eas"l d"#ested for*) such as oran#e &u"ce) cand) or
lu*p su#ar$
An unconsc"ous pat"ent who has hpo#lce*"a should rece"!e an S$;$ or I$.$ "n&ect"on of #luca#on as prescr"bed b a
phs"c"an or :4G de+trose b I$J$ "n&ect"on$
A pat"ent w"th d"abetes *ell"tus should "nspect h"s feet da"l for calluses) corns) and bl"sters$ (e should also use war* water
to wash h"s feet and tr"* h"s toena"ls stra"#ht across to pre!ent "n#rown toena"ls$
The earl sta#e of 'etoac"dos"s causes polur"a) pold"ps"a) anore+"a) *uscle cra*ps) and !o*"t"n#$ The late sta#e causes
Luss*auls resp"rat"ons) sweet breath odor) and stupor or co*a$
An aller#en "s a substance that can cause a hpersens"t"!"t react"on$
A correct"!e lens for nears"#htedness "s conca!e$
;hron"c untreated hpothro"d"s* or abrupt w"thdrawal of thro"d *ed"cat"on *a lead to *+ede*a co*a$
S"#ns and s*pto*s of *+ede*a co*a are lethar#) stupor) decreased le!el of consc"ousness) dr s'"n and ha"r) delaed
deep tendon refle+es) pro#ress"!e resp"rator center depress"on and cerebral hpo+"a) we"#ht #a"n) hpother*"a) and
hpo#lce*"a$
Nears"#htedness occurs when the focal po"nt of a ra of l"#ht fro* an ob&ect thats 34B ,2 *- awa falls "n front of the ret"na$
/ars"#htedness occurs when the focal po"nt of a ra of l"#ht fro* an ob&ect thats 34B awa falls beh"nd the ret"na$
A correct"!e lens for fars"#htedness "s con!e+$
Refract"on "s cl"n"cal *easure*ent of the error "n ee focus"n#$
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NURSING BULLETS _____________ ___________________________________________________________
Adhes"ons are bands of #ranulat"on and scar t"ssue that de!elop "n so*e pat"ents after a sur#"cal "nc"s"on$
The nurse should *o"sten an ee patch for an unconsc"ous pat"ent because a dr patch *a "rr"tate the cornea$
A pat"ent who has had ee sur#er shouldnt bend o!er) co*b h"s ha"r !"#orousl) or en#a#e "n act"!"t that "ncreases
"ntraocular pressure$
%hen car"n# for a pat"ent who has a penetrat"n# ee "n&ur) the nurse should patch both ees loosel w"th ster"le #au1e)
ad*"n"ster an oral ant"b"ot"c ,"n h"#h doses- and tetanus "n&ect"on as prescr"bed) and refer the pat"ent to an ophthal*olo#"st for
follow0up$
S"#ns and s*pto*s of colorectal cancer "nclude chan#es "n bowel hab"ts) rectal bleed"n#) abdo*"nal pa"n) anore+"a) we"#ht
loss) *ala"se) ane*"a) and const"pat"on or d"arrhea$
%hen cl"*b"n# sta"rs w"th crutches) the pat"ent should lead w"th the un"n!ol!ed le# and follow w"th the crutches and
"n!ol!ed le#$
%hen descend"n# sta"rs w"th crutches) the pat"ent should lead w"th the crutches and the "n!ol!ed le# and follow w"th the
un"n!ol!ed le#$
%hen sur#er re6u"res eelash tr"**"n#) the nurse should appl petroleu* &ell to the sc"ssor blades so that the eelashes
w"ll adhere to the*$
>a"n after a corneal transplant *a "nd"cate that the dress"n# has been appl"ed too t"#htl) the #raft has sl"pped) or the ee "s
he*orrha#"n#$
A pat"ent w"th ret"nal detach*ent *a report float"n# spots) flashes of l"#ht) and a sensat"on of a !e"l or curta"n co*"n#
down$
I**ed"ate postoperat"!e care for a pat"ent w"th ret"nal detach*ent "ncludes *a"nta"n"n# the ee patch and sh"eld "n place
o!er the affected area and obser!"n# the area for dra"na#eN *a"nta"n"n# the pat"ent "n the pos"t"on spec"f"ed b the
ophthal*olo#"st ,usuall) l"n# on h"s abdo*en) w"th h"s head parallel to the floor and turned to the s"de-N a!o"d"n# bu*p"n#
the pat"ents head or bedN and encoura#"n# deep breath"n#) but not cou#h"n#$
A pat"ent w"th a cataract *a ha!e !"s"on d"sturbances) such as "*a#e d"stort"on) l"#ht #lar"n#) and #radual loss of !"s"on$
%hen tal'"n# to a hear"n#0"*pa"red pat"ent who can l"p0read) the nurse should face the pat"ent) spea' slowl and enunc"ate
clearl) po"nt to ob&ects as needed) and a!o"d chew"n# #u*$
;l"n"cal *an"festat"ons of !enous stas"s ulcer "nclude he*os"der"n depos"ts ,!"s"ble "n fa"r0s'"nned "nd"!"duals-N dr) crac'ed
s'"nN and "nfect"on$
The fluorescent trepone*al ant"bod absorpt"on test "s a spec"f"c serolo#"c test for sph"l"s$
To reduce fe!er) the nurse *a #"!e the pat"ent a spon#e bath w"th tep"d water ,=4C to OFC / [32$DC to FF$OC ;\-$
%hen co**un"cat"n# w"th a pat"ent who has had a stro'e) the nurse should allow a*ple t"*e for the pat"ent to spea' and
respond) face the pat"ents unaffected s"de) a!o"d tal'"n# 6u"c'l) #"!e !"sual clues) supple*ent speech w"th #estures) and
#"!e "nstruct"ons cons"stentl$
The *a&or co*pl"cat"on of Bells pals "s 'erat"t"s ,corneal "nfla**at"on-) wh"ch results fro* "nco*plete ee closure on the
affected s"de$
I**unosuppressants are used to co*bat t"ssue re&ect"on and help control auto"**une d"sorders$
After a un"lateral stro'e) a pat"ent *a be able to propel a wheelcha"r b us"n# a heel0to0toe *o!e*ent w"th the unaffected
le# and turn"n# the wheel w"th the unaffected hand$
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/"rst0*orn"n# ur"ne "s the *ost concentrated and *ost l"'el to show abnor*al"t"es$ It should be refr"#erated to retard
bacter"al #rowth or) for *"croscop"c e+a*"nat"on) should be sent to the laborator "**ed"atel$
A pat"ent who "s reco!er"n# fro* a stro'e should al"#n h"s ar*s and le#s correctl) wear h"#h0top snea'ers to pre!ent
footdrop and contracture) and use an e## crate) flotat"on) or pulsat"n# *attress to help pre!ent pressure ulcers$
After a fracture of the ar* or le#) the bone *a show co*plete un"on ,nor*al heal"n#-) delaed un"on ,heal"n# that ta'es
lon#er than e+pected-) or nonun"on ,fa"lure to heal-$
The *ost co**on co*pl"cat"on of a h"p fracture "s thro*boe*bol"s*) wh"ch *a occlude an arter and cause the area "t
suppl"es to beco*e cold and canot"c$
;hloral hdrate suppos"tor"es should be refr"#erated$
;ast appl"cat"on usuall re6u"res two personsN "t shouldnt be atte*pted alone$
A plaster cast reaches *a+"*u* stren#th "n E= hoursN a snthet"c cast) w"th"n F4 *"nutes because "t doesnt re6u"re dr"n#$
Se!ere pa"n "nd"cates the de!elop*ent of a pressure ulcer w"th"n a castN the pa"n decreases s"#n"f"cantl after the ulcer
de!elops$
Ind"cat"ons of c"rculator "nterference are abnor*al s'"n coolness) canos"s) and rubor or pallor$
5ur"n# the postoperat"!e phase) "ncreas"n# pulse rate and decreas"n# blood pressure *a "nd"cate he*orrha#e and
"*pend"n# shoc'$
Hrthoped"c sur#"cal wounds bleed *ore than other sur#"cal wounds$ The nurse can e+pect 344 to :44 *l of dra"na#e dur"n#
the f"rst 3E hours and less than F4 *l each = hours for the ne+t E= hours$
A pat"ent who has had h"p sur#er shouldnt adduct or fle+ the affected h"p because fle+"on #reater than O4 de#rees *a
cause d"slocat"on$
The (oer l"ft) a hdraul"c de!"ce) allows two persons to l"ft and *o!e a nona*bulator pat"ent safel$
A pat"ent w"th carpal tunnel sndro*e) a co*ple+ of s*pto*s caused b co*press"on of the *ed"an ner!e "n the carpal
tunnel) usuall has wea'ness) pa"n) burn"n#) nu*bness) or t"n#l"n# "n one or both hands$
The nurse should "nstruct a pat"ent who has had heatstro'e to wear l"#ht0colored) loose0f"tt"n# cloth"n# when e+posed to the
sunN rest fre6uentlN and dr"n' plent of flu"ds$
A consc"ous pat"ent w"th heat e+haust"on or heatstro'e should rece"!e a solut"on of S teaspoon of salt "n 134 *l of water
e!er 1: *"nutes for 1 hour$
An I$J$ l"ne "nserted dur"n# an e*er#enc or outs"de the hosp"tal sett"n# should be chan#ed w"th"n 3E hours$
After a tep"d bath) the nurse should dr the pat"ent thorou#hl to pre!ent ch"lls$
The nurse should ta'e the pat"ents te*perature F4 *"nutes after co*plet"n# a tep"d bath$
Shower or bath water shouldnt e+ceed 14:C / ,E4$2C ;-$
5"latat"on and curetta#e "s w"den"n# of the cer!"cal canal w"th a d"lator and scrap"n# of the uterus w"th a curette$
%hen not "n use) all central !enous catheters *ust be capped w"th adaptors after flush"n#$
;are after d"latat"on and curetta#e cons"sts of bed rest for 1 da) *"ld anal#es"cs for pa"n) and use of a ster"le pad for as lon#
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as bleed"n# pers"sts$
If a pat"ent feels fa"nt dur"n# a bath or shower) the nurse should turn off the water) co!er the pat"ent) lower the pat"ents head)
and su**on help$
A pat"ent who "s ta'"n# oral contracept"!es shouldnt s*o'e because s*o'"n# can "ntens"f the dru#s ad!erse card"o!ascular
effect$
The use of soft restra"nts re6u"res a phs"c"ans order and assess*ent and docu*entat"on of the pat"ent and affected l"*bs)
accord"n# to fac"l"t pol"c$
A !est restra"nt should be used caut"ousl "n a pat"ent w"th heart fa"lure or a resp"rator d"sorder$ The restra"nt can t"#hten
w"th *o!e*ent) further l"*"t"n# resp"rator funct"on$ To ensure pat"ent safet) the least a*ount of restra"nt should be used$
If a p"##bac' sste* beco*es d"slod#ed) the nurse should replace the ent"re p"##bac' sste* w"th the appropr"ate solut"on
and dru#) as prescr"bed$
The nurse shouldnt secure a restra"nt to a beds s"de ra"ls because the *"#ht be lowered "nad!ertentl and cause pat"ent
"n&ur or d"sco*fort$
The nurse should assess a pat"ent who has l"*b restra"nts e!er F4 *"nutes to detect s"#ns of "*pa"red c"rculat"on$
The ;enters for 5"sease ;ontrol and >re!ent"on reco**ends us"n# a needleless sste* for p"##bac'"n# an I$J$ dru# "nto
the *a"n I$J$ l"ne$
If a #own "s re6u"red) the nurse should put "t on when she enters the pat"ents roo* and d"scard "t when she lea!es$
%hen chan#"n# the dress"n# of a pat"ent who "s "n "solat"on) the nurse should wear two pa"rs of #lo!es$
A d"sposable bedpan and ur"nal should re*a"n "n the roo* of a pat"ent who "s "n "solat"on and be d"scarded on d"schar#e or at
the end of the "solat"on per"od$
.coses ,fun#al "nfect"ons- *a be sste*"c or deep ,affect"n# the "nternal or#ans-) subcutaneous ,"n!ol!"n# the s'"n-) or
superf"c"al ,#row"n# on the outer laer of s'"n and ha"r-$
The n"#ht before a sputu* spec"*en "s to be collected b e+pectorat"on) the pat"ent should "ncrease flu"d "nta'e to pro*ote
sputu* product"on$
A sa*ple of feces for an o!a and paras"te stud should be collected d"rectl "nto a waterproof conta"ner) co!ered w"th a l"d)
and sent to the laborator "**ed"atel$ If the pat"ent "s bedr"dden) the sa*ple can be collected "nto a clean) dr bedpan and
then transferred w"th a ton#ue depressor "nto a conta"ner$
%hen obta"n"n# a sputu* spec"*en for test"n#) the nurse should "nstruct the pat"ent to r"nse h"s *outh w"th clean water)
cou#h deepl fro* h"s chest) and e+pectorate "nto a ster"le conta"ner$
Tono*etr allows "nd"rect *easure*ent of "ntraocular pressure and a"ds "n earl detect"on of #lauco*a$
>ul*onar funct"on tests ,a ser"es of *easure*ents that e!aluate !ent"lator funct"on throu#h sp"ro*etr"c *easure*ents-
help to d"a#nose pul*onar dsfunct"on$
After a l"!er b"ops) the pat"ent should l"e on the r"#ht s"de to co*press the b"ops s"te and decrease the poss"b"l"t of
bleed"n#$
A pat"ent who has c"rrhos"s should follow a d"et that restr"cts sod"u*) but pro!"des prote"n and !"ta*"ns ,espec"all B) ;) and
L) and folate-$
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NURSING BULLETS _____________ ___________________________________________________________
If 13 hours of #astr"c suct"on dont rel"e!e bowel obstruct"on) sur#er "s "nd"cated$
The nurse can puncture a n"fed"p"ne ,>rocard"a- capsule w"th a needle) w"thdraw "ts l"6u"d) and "nst"ll "t "nto the buccal
pouch$
%hen ad*"n"ster"n# whole blood or pac'ed red blood cells ,RB;s-) the nurse should use a 12 to 34G needle or cannula to
a!o"d RB; he*ols"s$
("rsut"s* "s e+cess"!e bod ha"r "n a *ascul"ne d"str"but"on$
Hne un"t of whole blood or pac'ed red blood cells "s ad*"n"stered o!er 3 to E hours$
Scur! "s assoc"ated w"th !"ta*"n ; def"c"enc$
A !"ta*"n "s an or#an"c co*pound that usuall cant be snthes"1ed b the bod and "s needed "n *etabol"c processes$
>ul*onar e*bol"s* can be caused when thro*boe*bol"s* of fat) blood) bone *arrow) or a*n"ot"c flu"d obstructs the
pul*onar arter$
After *a+"llofac"al sur#er) a pat"ent whose *and"ble and *a+"lla ha!e been w"red to#ether should 'eep a pa"r of sc"ssors or
w"re cutters read"l a!a"lable so that he can cut the w"res and pre!ent asp"rat"on "f !o*"t"n# occurs$
Rap"d "nst"llat"on of flu"d dur"n# colon"c "rr"#at"on can cause abdo*"nal cra*p"n#$
A collaborat"!e relat"onsh"p between health care wor'ers helps shorten the hosp"tal sta and "ncreases pat"ent sat"sfact"on$
/or elderl pat"ents "n a health care fac"l"t) pred"ctable ha1ards "nclude n"#htt"*e confus"on ,sundown"n#-) fractures fro*
fall"n#) "**ob"l"t0"nduced pressure ulcers) prolon#ed con!alescence) and loss of ho*e and support sste*s$
Resp"rator tract "nfect"ons) espec"all !"ral "nfect"ons) can tr"##er asth*a attac's$
H+#en therap "s used "n se!ere asth*a attac's to pre!ent or treat hpo+e*"a$
5ur"n# an asth*a attac') the pat"ent *a prefer nasal pron#s to a Jentur" *as' because of the *as's s*other"n# effect$
;hron"c obstruct"!e pul*onar d"sease usuall de!elops o!er a per"od of ears$ In O:G of pat"ents) "t results fro* s*o'"n#$
An earl s"#n of chron"c obstruct"!e pul*onar d"sease ,;H>5- "s slow"n# of forced e+p"rat"on$ A health person can e*pt
the lun#s "n less than E secondsN a pat"ent w"th ;H>5 *a ta'e 2 to 14 seconds$
;hron"c obstruct"!e pul*onar d"sease e!entuall leads to structural chan#es "n the lun#s) "nclud"n# o!erd"stended al!eol"
and hper"nflated lun#s$
;ellul"t"s causes local"1ed heat) redness) swell"n# and) occas"onall) fe!er) ch"lls) and *ala"se$
Jenous stas"s *a prec"p"tate thro*bophleb"t"s$
Treat*ent of thro*bophleb"t"s "ncludes le# ele!at"on) heat appl"cat"on) and poss"bl) ant"coa#ulant therap$
A suct"on"n# *ach"ne should re*a"n at the beds"de of a pat"ent who has had *a+"llofac"al sur#er$
/or a bedr"dden pat"ent w"th heart fa"lure) the nurse should chec' for ede*a "n the sacral area$
In pass"!e ran#e0of0*ot"on e+erc"ses) the therap"st *o!es the pat"ents &o"nts throu#h as full a ran#e of *ot"on as poss"ble to
"*pro!e or *a"nta"n &o"nt *ob"l"t and help pre!ent contractures$
In res"stance e+erc"ses) wh"ch allow *uscle len#th to chan#e) the pat"ent perfor*s e+erc"ses a#a"nst res"stance appl"ed b the
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therap"st$
In "so*etr"c e+erc"ses) the pat"ent contracts *uscles a#a"nst stable res"stance) but w"thout &o"nt *o!e*ent$ .uscle len#th
re*a"ns the sa*e) but stren#th and tone *a "ncrease$
I*pet"#o "s a conta#"ous) superf"c"al) !es"copustular s'"n "nfect"on$ >red"spos"n# factors "nclude poor h#"ene) ane*"a)
*alnutr"t"on) and a war* cl"*ate$
After card"opul*onar resusc"tat"on ,;>R- be#"ns) "t shouldnt be "nterrupted) e+cept when the ad*"n"strator "s alone and
*ust su**on help$ In th"s case) the ad*"n"strator should perfor* ;>R for 1 *"nute before call"n# for help$
The ton#ue "s the *ost co**on a"rwa obstruct"on "n an unconsc"ous pat"ent$
/or adult card"opul*onar resusc"tat"on) the chest co*press"on rate "s =4 to 144 t"*es per *"nute$
A pat"ent w"th ulcers should a!o"d bedt"*e snac's because food *a st"*ulate nocturnal secret"ons$
In an#"oplast) a blood !essel "s d"lated w"th a balloon catheter thats "nserted throu#h the s'"n and the !essels lu*en to the
narrowed area$ Hnce "n place) the balloon "s "nflated to flatten pla6ue a#a"nst the !essel wall$
A full l"6u"d d"et suppl"es nutr"ents) flu"ds) and calor"es "n s"*ple) eas"l d"#ested foods) such as apple &u"ce) crea* of wheat)
*"l') coffee) stra"ned crea* soup) h"#h0prote"n #elat"n) cranberr &u"ce) custard) and "ce crea*$ Its prescr"bed for pat"ents
who cant tolerate a re#ular d"et$
A pureed d"et *eets the pat"ents nutr"t"onal needs w"thout "nclud"n# foods that are d"ff"cult to chew or swallow$ /ood "s
blended to a se*"sol"d cons"stenc$
A soft) or l"#ht) d"et "s spec"f"call des"#ned for pat"ents who ha!e d"ff"cult chew"n# or tolerat"n# a re#ular d"et$ Its
nutr"t"onall ade6uate and cons"sts of foods such as oran#e &u"ce) crea* of wheat) scra*bled e##s) enr"ched toast) crea* of
ch"c'en soup) wheat bread) fru"t coc'ta"l) and *ushroo* soup$
A re#ular d"et "s pro!"ded for pat"ents who dont re6u"re d"etar *od"f"cat"on$
A bland d"et restr"cts foods that cause #astr"c "rr"tat"on or produce ac"d secret"on w"thout pro!"d"n# a neutral"1"n# effect$
A clear l"6u"d d"et pro!"des flu"d and a #radual return to a re#ular d"et$ Th"s tpe of d"et "s def"c"ent "n all nutr"ents and
should be followed for onl a short per"od$
>at"ents w"th a #astr"c ulcer should a!o"d alcohol) caffe"nated be!era#es) asp"r"n) and sp"c foods$
In act"!e ass"stance e+erc"ses) the pat"ent perfor*s e+erc"ses w"th the therap"sts help$
>en"c"ll"nase "s an en1*e produced b certa"n bacter"a$ It con!erts pen"c"ll"n "nto an "nact"!e product) "ncreas"n# the
bacter"as res"stance to the ant"b"ot"c$
Battles s"#n "s a blu"sh d"scolorat"on beh"nd the ear "n so*e pat"ents who susta"n a bas"lar s'ull fracture$
;rac'les are non*us"cal cl"c'"n# or rattl"n# no"ses that are heard dur"n# auscultat"on of abnor*al breath sounds$ The are
caused b a"r pass"n# throu#h flu"d0f"lled a"rwas$
Ant"b"ot"cs arent effect"!e a#a"nst !"ruses) proto1oa) or paras"tes$
.ost pen"c"ll"ns and cephalospor"ns produce the"r ant"b"ot"c effects b cell wall "nh"b"t"on$
%hen assess"n# a pat"ent w"th an "n#u"nal hern"a) the nurse should suspect stran#ulat"on "f the pat"ent reports se!ere pa"n)
nausea) and !o*"t"n#$
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>h"*os"s "s t"#htness of the prepuce of the pen"s that pre!ents retract"on of the fores'"n o!er the #lans$
A*"no#lcos"des are natural ant"b"ot"cs that are effect"!e a#a"nst #ra*0ne#at"!e bacter"a$ The *ust be used w"th caut"on
because the can cause nephroto+"c"t and ototo+"c"t$
Hn scrotal e+a*"nat"on) !ar"coceles and tu*ors dont trans"llu*"nate) but sper*atoceles and hdroceles do$
A hordeolu* ,eel"d ste- "s an "nfect"on of one or *ore sebaceous #lands of the eel"d$
A chala1"on "s an eel"d *ass thats caused b chron"c "nfla**at"on of the *e"bo*"an #land$
5ur"n# ophthal*oscop"c e+a*"nat"on) the absence of the red refle+ "nd"cates a lens opac"t ,cataract- or a detached ret"na$
Resp"rator ac"dos"s "s assoc"ated w"th cond"t"ons such as dru# o!erdose) Gu"lla"n0BarrZ sndro*e) *asthen"a #ra!"s)
chron"c obstruct"!e pul*onar d"sease) p"c'w"c'"an sndro*e) and 'phoscol"os"s$ Bullets
Resp"rator al'alos"s "s assoc"ated w"th cond"t"ons such as h"#h fe!er) se!ere hpo+"a) asth*a) and pul*onar e*bol"s*$
.etabol"c ac"dos"s "s assoc"ated w"th such cond"t"ons as renal fa"lure) d"arrhea) d"abet"c 'etos"s) and lact"c 'etos"s) and w"th
h"#h doses of aceta1ola*"de ,5"a*o+-$
Gastrecto* "s sur#"cal e+c"s"on of all or part of the sto*ach to re*o!e a chron"c pept"c ulcer) stop he*orrha#e "n a
perforated ulcer) or re*o!e a *al"#nant tu*or$
.etabol"c al'alos"s "s assoc"ated w"th naso#astr"c suct"on"n#) e+cess"!e use of d"uret"cs) and stero"d therap$
J"t"l"#o ,a ben"#n) ac6u"red s'"n d"sease- "s *ar'ed b star' wh"te s'"n patches that are caused b the destruct"on and loss of
p"#*ent cells$
H!erdose or acc"dental o!er"n#est"on of d"sulf"ra* ,Antabuse- should be treated w"th #astr"c asp"rat"on or la!a#e and
support"!e therap$
The causes of abdo*"nal d"stent"on are represented b the s"+ /sI flatus) feces) fetus) flu"d) fat) and fatal ,*al"#nant-
neoplas*$
A pos"t"!e .urphs s"#n "nd"cates cholecst"t"s$
S"#ns of append"c"t"s "nclude r"#ht abdo*"nal pa"n) abdo*"nal r"#"d"t and rebound tenderness) nausea) and anore+"a$
Asc"tes can be detected when *ore than :44 *l of flu"d has collected "n the "ntraper"toneal space$
/or a pat"ent w"th or#an"c bra"n sndro*e or a sen"le d"sease) the "deal en!"ron*ent "s stable and l"*"ts confus"on$
In a pat"ent w"th or#an"c bra"n sndro*e) *e*or loss usuall affects all spheres) but be#"ns w"th recent *e*or loss$
5ur"n# card"ac catheter"1at"on) the pat"ent *a e+per"ence a thudd"n# sensat"on "n the chest) a stron# des"re to cou#h) and a
trans"ent feel"n# of heat) usuall "n the face) as a result of "n&ect"on of the contrast *ed"u*$
Sl"#ht bubbl"n# "n the suct"on colu*n of a thorac"c dra"na#e sste*) such as a >leur0e!ac un"t) "nd"cates that the sste* "s
wor'"n# properl$ A lac' of bubbl"n# "n the suct"on cha*ber "nd"cates "nade6uate suct"on$
Nutr"t"onal def"c"enc "s a co**on f"nd"n# "n people who ha!e a lon# h"stor of alcohol abuse$
In the pat"ent w"th !ar"cose !e"ns) #raduated co*press"on elast"c stoc'"n#s ,F4 to E4 ** (#- *a be prescr"bed to pro*ote
!enous return$
Non!"ral hepat"t"s usuall results fro* e+posure to certa"n che*"cals or dru#s$
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NURSING BULLETS _____________ ___________________________________________________________
Substant"al ele!at"on of the seru* transa*"nase le!el "s a s*pto* of acute hepat"t"s$
Nor*al card"ac output "s E to 2 L<*"nute) w"th a stro'e !olu*e of 24 to D4 *l$
E+cess"!e !o*"t"n# or re*o!al of the sto*ach contents throu#h suct"on can decrease the potass"u* le!el and lead to
hpo'ale*"a$
As a hepar"n anta#on"st) prota*"ne "s an ant"dote for hepar"n o!erdose$
If a pat"ent has a pos"t"!e react"on to a tubercul"n s'"n test) such as the pur"f"ed prote"n der"!at"!e test) the nurse should
suspect current or past e+posure$ The nurse should as' the pat"ent about a h"stor of tuberculos"s ,TB- and the presence of
earl s"#ns and s*pto*s of TB) such as low0#rade fe!er) we"#ht loss) n"#ht sweats) fat"#ue) and anore+"a$
S"#ns and s*pto*s of acute rheu*at"c fe!er "nclude chorea) fe!er) card"t"s) *"#rator polarthr"t"s) erthe*a *ar#"natu*
,rash-) and subcutaneous nodules$
Before under#o"n# an "n!as"!e dental procedure) the pat"ent who has a h"stor of rheu*at"c fe!er should rece"!e
prophlact"c pen"c"ll"n therap$ Th"s therap helps to pre!ent conta*"nat"on of the blood w"th oral bacter"a) wh"ch could
*"#rate to the heart !al!es$
After a *ocard"al "nfarct"on) *ost pat"ents can resu*e se+ual act"!"t when the can cl"*b two fl"#hts of sta"rs w"thout
fat"#ue or dspnea$
Elderl pat"ents are suscept"ble to orthostat"c hpotens"on because the baroreceptors beco*e less sens"t"!e to pos"t"on
chan#es as people a#e$
/or the pat"ent w"th suspected renal or urethral calcul") the nurse should stra"n the ur"ne to deter*"ne whether calcul" ha!e
been passed$
The nurse should place the pat"ent w"th asc"tes "n the se*"0/owler pos"t"on because "t per*"ts *a+"*u* lun# e+pans"on$
/or the pat"ent who has "n#ested po"son) the nurse should sa!e the !o*"tus for anals"s$
The earl"est s"#ns of resp"rator d"stress are "ncreased resp"rator rate and "ncreased pulse rate$
In adults) #astroenter"t"s "s co**onl self0l"*"t"n# and causes d"arrhea) abdo*"nal d"sco*fort) nausea) and !o*"t"n#$
;ard"ac output e6uals stro'e !olu*e *ult"pl"ed b the heart rate per *"nute$
In pat"ents w"th acute *en"n#"t"s) the cerebrosp"nal flu"d prote"n le!el "s ele!ated$
%hen a pat"ent "s suspected of ha!"n# food po"son"n#) the nurse should not"f publ"c health author"t"es so that the can
"nter!"ew pat"ents and food handlers and ta'e sa*ples of the suspected conta*"nated food$
The pat"ent who "s rece"!"n# a potass"u*0wast"n# d"uret"c should eat potass"u*0r"ch foods$
A pat"ent w"th chron"c obstruct"!e pul*onar d"sease should rece"!e low0le!el o+#en ad*"n"strat"on b nasal cannula ,3 to
F L<*"nute- to a!o"d "nterfer"n# w"th the hpo+"c dr"!e$
In *etabol"c ac"dos"s) the pat"ent *a ha!e Luss*auls resp"rat"ons because the rate and depth of resp"rat"ons "ncrease to
?blow off@ e+cess carbon"c ac"ds$
In wo*en) #onorrhea affects the !a#"na and fallop"an tubes$
After trau*at"c a*putat"on) the #reatest threats to the pat"ent are blood loss and hpo!ole*"c shoc'$ In"t"al "nter!ent"ons
should control bleed"n# and replace flu"d and blood as needed$
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Ep"nephr"ne "s a s*patho*"*et"c dru# that acts pr"*ar"l on alpha) beta1) and beta3 receptors) caus"n# !asoconstr"ct"on$
Ep"nephr"nes ad!erse effects "nclude dspnea) tachcard"a) palp"tat"ons) headaches) and hpertens"on$
A card"nal s"#n of pancreat"t"s "s an ele!ated seru* a*lase le!el$
("#h colon"c "rr"#at"on "s used to st"*ulate per"stals"s and reduce flatulence$
Bleed"n# "s the *ost co**on postoperat"!e proble*$
The pat"ent can control so*e colosto* odors b a!o"d"n# such foods as f"sh) e##s) on"ons) beans) and cabba#e and related
!e#etables$
%hen parals"s or co*a "*pa"rs or erases the corneal refle+) fre6uent ee care "s perfor*ed to 'eep the e+posed cornea
*o"st) pre!ent"n# ulcerat"on and "nfla**at"on$
Inter!ent"ons for the pat"ent w"th ac6u"red "**unodef"c"enc sndro*e "nclude treat"n# e+"st"n# "nfect"ons and cancers)
reduc"n# the r"s' of opportun"st"c "nfect"ons) *a"nta"n"n# ade6uate nutr"t"on and hdrat"on) and pro!"d"n# e*ot"onal support
to the pat"ent and fa*"l$
S"#ns and s*pto*s of chla*d"al "nfect"on are ur"nar fre6uencN th"n) wh"te !a#"nal or urethral d"schar#eN and cer!"cal
"nfla**at"on$
;hla*d"al "nfect"on "s the *ost pre!alent se+uall trans*"tted d"sease "n the Un"ted States$
The p"tu"tar #land "s located "n the sella turc"ca of the spheno"d bone "n the cran"al ca!"t$
.asthen"a #ra!"s "s a neuro*uscular d"sorder thats character"1ed b "*pulse d"sturbances at the *oneural &unct"on$
.asthen"a #ra!"s) wh"ch usuall affects oun# wo*en) causes e+tre*e *uscle wea'ness and fat"#ab"l"t) d"ff"cult chew"n#
and tal'"n#) strab"s*us) and ptos"s$
(pother*"a "s a l"fe0threaten"n# d"sorder "n wh"ch the bods core te*perature drops below O:C / ,F:C ;-$
S"#ns and s*pto*s of hpop"tu"tar"s* "n adults *a "nclude #onadal fa"lure) d"abetes "ns"p"dus) hpothro"d"s*) and
adrenocort"cal "nsuff"c"enc$
Re"ters sndro*e causes a tr"ad of s*pto*sI arthr"t"s) con&unct"!"t"s) and urethr"t"s$
/or pat"ents who ha!e had a part"al #astrecto*) a carbohdrate0restr"cted d"et "ncludes foods that are h"#h "n prote"n and fats
and restr"cts foods that are h"#h "n carbohdrates$ ("#h0carbohdrate foods are d"#ested 6u"c'l and are read"l e*pt"ed fro*
the sto*ach "nto the duodenu*) caus"n# d"arrhea and du*p"n# sndro*e$
A wo*an of ch"ldbear"n# a#e who "s under#o"n# che*otherap should be encoura#ed to use a contracept"!e because of the
r"s' of fetal da*a#e "f she beco*es pre#nant$
>ern"c"ous ane*"a "s !"ta*"n B13 def"c"enc thats caused b a lac' of "ntr"ns"c factor) wh"ch "s produced b the #astr"c
*ucosal par"etal cells$
To perfor* pursed0l"p breath"n#) the pat"ent "nhales throu#h the nose and e+hales slowl and e!enl a#a"nst pursed l"ps
wh"le contract"n# the abdo*"nal *uscles$
A pat"ent who "s under#o"n# che*otherap should consu*e a h"#h0calor"e) h"#h0prote"n d"et$
Ad!erse effects of che*otherap "nclude bone *arrow depress"on) wh"ch causes ane*"a) leu'open"a) and thro*boctopen"aN
GI ep"thel"al cell "rr"tat"on) wh"ch causes GI ulcerat"on) bleed"n#) and !o*"t"n#N and destruct"on of ha"r foll"cles and s'"n)
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wh"ch causes alopec"a and der*at"t"s$
The he*o#lob"n electrophores"s test d"fferent"ates between s"c'le cell tra"t and s"c'le cell ane*"a$
The ant"b"ot"cs erthro*c"n) cl"nda*c"n) and tetraccl"ne act b "nh"b"t"n# prote"n snthes"s "n suscept"ble or#an"s*s$
The nurse ad*"n"sters o+#en as prescr"bed to the pat"ent w"th heart fa"lure to help o!erco*e hpo+"a and dspnea$
S"#ns and s*pto*s of s*all0bowel obstruct"on "nclude decreased or absent bowel sounds) abdo*"nal d"stent"on) decreased
flatus) and pro&ect"le !o*"t"n#$
The nurse should use both hands when !ent"lat"n# a pat"ent w"th a *anual resusc"tat"on ba#$ Hne hand can del"!er onl E44
cc of a"rN two hands can del"!er 1)444 cc of a"r$
5osa#es of *ethl+anth"ne a#ents) such as theophll"ne ,Theo05ur- and a*"nophll"ne ,A*"nophll"n-) should be
"nd"!"dual"1ed based on seru* dru# le!el) pat"ent response) and ad!erse react"ons$
The pat"ent should appl a transder*al scopola*"ne patch ,Transder*0Scop- at least E hours before "ts ant"e*et"c act"on "s
needed$
Earl "nd"cat"ons of #an#rene are ede*a) pa"n) redness) dar'en"n# of the t"ssue) and coldness "n the affected bod part$
Ipecac srup "s the e*et"c of cho"ce because of "ts effect"!eness "n e!acuat"n# the sto*ach and relat"!el low "nc"dence of
ad!erse react"ons$
Hral "ron ,ferrous sulfate- *a cause #reen to blac' feces$
>olcthe*"a !era causes prur"tus) pa"nful f"n#ers and toes) hperur"ce*"a) plethora ,redd"sh purple s'"n and *ucosa-)
wea'ness) and eas fat"#ab"l"t$
Rheu*at"c fe!er "s usuall preceded b a #roup A beta0he*olt"c streptococcal "nfect"on) such as scarlet fe!er) ot"t"s *ed"a)
streptococcal throat "nfect"on) "*pet"#o) or tons"ll"t"s$
A thro"d stor*) or cr"s"s) "s an e+tre*e for* of hperthro"d"s*$ Its character"1ed b hperpre+"a w"th a te*perature of
up to 142C / ,E1$1C ;-) d"arrhea) dehdrat"on) tachcard"a of up to 344 beats<*"nute) arrhth*"as) e+tre*e "rr"tab"l"t)
hpotens"on) and del"r"u*$ It *a lead to co*a) shoc') and death$
Tard"!e ds'"nes"a) an ad!erse react"on to lon#0ter* use of ant"pschot"c dru#s) causes "n!oluntar repet"t"!e *o!e*ents of
the ton#ue) l"ps) e+tre*"t"es) and trun'$
Asth*a "s bronchoconstr"ct"on "n response to aller#ens) such as food) pollen) and dru#sN "rr"tants) such as s*o'e and pa"nt
fu*esN "nfect"onsN weather chan#esN e+erc"seN or #astroesopha#eal reflu+$ In the Un"ted States) about :G of ch"ldren ha!e
chron"c asth*a$
Blood cultures help "dent"f the cause of endocard"t"s$ An "ncreased wh"te blood cell count su##ests bacter"al "nfect"on$
In a pat"ent who has acute aort"c d"ssect"on) the nurs"n# pr"or"t "s to *a"nta"n the *ean arter"al pressure between 24 and 2:
** (#$ A !asod"lator such as n"tropruss"de ,N"tropress- *a be needed to ach"e!e th"s #oal$
/or a pat"ent w"th heart fa"lure) one of the *ost "*portant nurs"n# d"a#noses "s decreased card"ac output related to altered
*ocard"al contract"l"t) "ncreased preload and afterload) and altered rate) rhth*) or electr"cal conduct"on$
/or a pat"ent rece"!"n# per"toneal d"als"s) the nurse *ust *on"tor bod we"#ht and blood urea n"tro#en) creat"n"ne) and
electrolte le!els$
An#"otens"n0con!ert"n# en1*e "nh"b"tors) such as captopr"l ,;apoten- and enalapr"l ,Jasotec-) decrease blood pressure b
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"nterfer"n# w"th the ren"n0an#"otens"n0aldosterone sste*$
A pat"ent who has stable !entr"cular tachcard"a has a blood pressure and "s consc"ousN therefore) the pat"ents card"ac output
"s be"n# *a"nta"ned) and the nurse *ust *on"tor the pat"ents !"tal s"#ns cont"nuousl$
An#"otens"n0con!ert"n# en1*e "nh"b"tors "nh"b"t the en1*e that con!erts an#"otens"n I "nto an#"otens"n II) wh"ch "s a
potent !asoconstr"ctor$ Throu#h th"s act"on) the reduce per"pheral arter"al res"stance and blood pressure$
In a pat"ent who "s rece"!"n# a d"uret"c) the nurse should *on"tor seru* electrolte le!els) chec' !"tal s"#ns) and obser!e for
orthostat"c hpotens"on$
Breast self0e+a*"nat"on "s one of the *ost "*portant health hab"ts to teach a wo*an$ It should be perfor*ed 1 wee' after the
*enstrual per"od because thats when hor*onal effects) wh"ch can cause breast lu*ps and tenderness) are reduced$
>ost*enopausal wo*en should choose a re#ular t"*e each *onth to perfor* breast self0e+a*"nat"on ,for e+a*ple) on the
sa*e da of the *onth as the wo*ans b"rthda-$
The d"fference between acute and chron"c arter"al d"sease "s that the acute d"sease process "s l"fe0threaten"n#$
%hen prepar"n# the pat"ent for chest tube re*o!al) the nurse should e+pla"n that re*o!al *a cause pa"n or a burn"n# or
pull"n# sensat"on$
Essent"al hpertens"!e renal d"sease "s co**onl character"1ed b pro#ress"!e renal "*pa"r*ent$
.ean arter"al pressure ,.A>- "s calculated us"n# the follow"n# for*ula) where S U sstol"c pressure and 5 U d"astol"c
pressureI .A> U [,5 R 3- M S\ T F
S*pto*s of sup"ne hpotens"on sndro*e are d"11"ness) l"#ht0headedness) nausea) and !o*"t"n#$
An "**unoco*pro*"sed pat"ent "s at r"s' for Lapos"s sarco*a$
5olls ee *o!e*ent "s the nor*al la# between head *o!e*ent and ee *o!e*ent$
Th"rd spac"n# of flu"d occurs when flu"d sh"fts fro* the "ntra!ascular space to the "nterst"t"al space and re*a"ns there$
;hron"c pa"n "s an pa"n that lasts lon#er than 2 *onths$ Acute pa"n lasts less than 2 *onths$
The *echan"s* of act"on of a phenoth"a1"ne der"!at"!e "s to bloc' dopa*"ne receptors "n the bra"n$
>at"ents shouldnt ta'e b"sacodl) antac"ds) and da"r products all at the sa*e t"*e$
Ad!"se the pat"ent who "s ta'"n# d"#o+"n to a!o"d foods that are h"#h "n f"ber) such as bran cereal and prunes$
A pat"ent who "s ta'"n# d"uret"cs should a!o"d foods that conta"n *onosod"u* #luta*ate because "t can cause t"#hten"n# of
the chest and flush"n# of the face$
/urose*"de ,Las"+- should be ta'en 1 hour before *eals$
A pat"ent who "s ta'"n# #r"seoful!"n ,Gr"so!"n />- should *a"nta"n a h"#h0fat d"et) wh"ch enhances the secret"on of b"le$
>at"ents should ta'e oral "ron products w"th c"trus dr"n's to enhance absorpt"on$
Ison"a1"d should be ta'en on an e*pt sto*ach) w"th a full #lass of water$
/oods that are h"#h "n prote"n decrease the absorpt"on of le!odopa$
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A pat"ent who "s ta'"n# tetraccl"ne shouldnt ta'e "ron supple*ents or antac"ds$
A pat"ent who "s ta'"n# warfar"n ,;ou*ad"n- should a!o"d foods that are h"#h "n !"ta*"n L) such as l"!er and #reen leaf
!e#etables$
The nor*al !alue for cholesterol "s less than 344 *#<dl$ The nor*al !alue for low0dens"t l"poprote"ns "s 24 to 1=4 *#<dlN
for h"#h0dens"t l"poprote"ns) "ts F4 to =4 *#<dl$
The nor*al card"ac output for an adult who we"#hs 1:: lb ,D4$F '#- "s : to 2 L<*"nute$
A pul*onar arter pressure catheter ,Swan0Gan1- *easures the pressure "n the card"ac cha*bers$
Se!ere chest pa"n thats a##ra!ated b breath"n# and "s descr"bed as ?sharp)@ ?stabb"n#)@ or ?'n"fel"'e@ "s cons"stent w"th
per"card"t"s$
%ater0ha**er pulse "s a pulse thats loud and bound"n# and r"ses and falls rap"dl$ It can be caused b e*ot"onal e+c"te*ent
or aort"c "nsuff"c"enc$
>atholo#"c spl"tt"n# of S3 "s nor*all heard between "nsp"rat"on and e+p"rat"on$ It occurs "n r"#ht bundle0branch bloc'$
>"n') froth sputu* "s assoc"ated w"th pul*onar ede*a$ /ran' he*opts"s *a be assoc"ated w"th pul*onar e*bol"s*$
An aort"c aneurs* can be heard &ust o!er the u*b"l"cal area and can be detected as an abdo*"nal pulsat"on ,bru"t-$
(eart *ur*urs are #raded accord"n# to the follow"n# sste*I #rade 1 "s fa"nt and "s heard after the e+a*"ner ?tunes "n@N
#rade 3 "s heard "**ed"atelN #rade F "s *oderatel loudN #rade E "s loudN #rade : "s !er loud) but "s heard onl w"th a
stethoscopeN and #rade 2 "s !er loud and "s heard w"thout a stethoscope$
;lot for*at"on dur"n# card"ac catheter"1at"on "s *"n"*"1ed b the ad*"n"strat"on of E)444 to :)444 un"ts of hepar"n$
.ost co*pl"cat"ons that ar"se fro* card"ac catheter"1at"on are assoc"ated w"th the puncture s"te$
Aller#"c s*pto*s assoc"ated w"th "od"ne0based contrast *ed"a used "n card"ac catheter"1at"on "nclude urt"car"a) nausea and
!o*"t"n#) and flush"n#$
To ensure that blood flow hasnt been co*pro*"sed) the nurse should *ar' the per"pheral pulses d"stal to the cutdown s"te to
a"d "n locat"n# the pulses after the procedure$
The e+tre*"t used for the cutdown s"te should re*a"n stra"#ht for E to 2 hours$ If an antecub"tal !essel was used) an
ar*board "s needed$ If a fe*oral arter was used) the pat"ent should re*a"n on bed rest for 2 to 13 hours$
If a pat"ent e+per"ences nu*bness or t"n#l"n# "n the e+tre*"t after a cutdown) the phs"c"an should be not"f"ed "**ed"atel$
After card"ac catheter"1at"on) flu"d "nta'e should be encoura#ed to a"d "n flush"n# the contrast *ed"u* throu#h the '"dnes$
In a pat"ent who "s under#o"n# pul*onar arter catheter"1at"on) r"s's "nclude pul*onar arter "nfarct"on) pul*onar
e*bol"s*) "n&ur to the heart !al!es) and "n&ur to the *ocard"u*$
>ul*onar arter wed#e pressure "s a d"rect "nd"cator of left !entr"cular pressure$
>ul*onar arter wed#e pressure #reater than 1= to 34 ** (# "nd"cates "ncreased left !entr"cular pressure) as seen "n left0
s"ded heart fa"lure$
%hen *easur"n# pul*onar arter wed#e pressure) the nurse should place the pat"ent "n a sup"ne pos"t"on) w"th the head of
the bed ele!ated no *ore than 3: de#rees$
>ul*onar arter pressure) wh"ch "nd"cates r"#ht and left !entr"cular pressure) "s ta'en w"th the balloon deflated$
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>ul*onar arter sstol"c pressure "s the pea' pressure #enerated b the r"#ht !entr"cle$ >ul*onar arter d"astol"c pressure
"s the lowest pressure "n the pul*onar arter$
Nor*al adult pul*onar arter sstol"c pressure "s 1: to 3: ** (#$
Nor*al adult pul*onar arter d"astol"c pressure "s = to 13 ** (#$
The nor*al o+#en saturat"on of !enous blood "s D:G$
;entral !enous pressure "s the a*ount of pressure "n the super"or !ena ca!a and the r"#ht atr"u*$
Nor*al adult central !enous pressure "s 3 to = ** (#) or F to 14 c* (3H$
A decrease "n central !enous pressure "nd"cates a fall "n c"rculat"n# flu"d !olu*e) as seen "n shoc'$
An "ncrease "n central !enous pressure "s assoc"ated w"th an "ncrease "n c"rculat"n# !olu*e) as seen "n renal fa"lure$
In a pat"ent who "s on a !ent"lator) central !enous pressure should be ta'en at the end of the e+p"rator ccle$
To ensure an accurate basel"ne central !enous pressure read"n#) the 1ero po"nt of the transducer *ust be at the le!el of the
r"#ht atr"u*$
A blood pressure read"n# obta"ned throu#h "ntra0arter"al pressure *on"tor"n# *a be 14 ** (# h"#her than one obta"ned
w"th a blood pressure cuff$
In .^nc'eber#s scleros"s) calc"u* depos"ts for* "n
he *ed"al laer of the arter"al walls$
The s*pto*s assoc"ated w"th coronar arter d"sease usuall dont appear unt"l pla6ue has narrowed the !essels b at least
D:G$
S*pto*s of coronar arter d"sease appear onl when there "s an "*balance between the de*and for o+#enated blood and
"ts a!a"lab"l"t$
>ercutaneous translu*"nal coronar an#"oplast "s an "n!as"!e procedure "n wh"ch a balloon0t"pped catheter "s "nserted "nto a
bloc'ed arter$ %hen the balloon "s "nflated) "t opens the arter b co*press"n# pla6ue a#a"nst the arters "nt"*al laer$
Before percutaneous translu*"nal coronar an#"oplast "s perfor*ed) an ant"coa#ulant ,such as asp"r"n- "s usuall
ad*"n"stered to the pat"ent$ 5ur"n# the procedure) the pat"ent "s #"!en hepar"n) a calc"u* a#on"st) or n"tro#lcer"n to reduce
the r"s' of coronar arter spas*s$
5ur"n# coronar arter bpass #raft sur#er) a bloc'ed coronar arter "s bpassed b us"n# the saphenous !e"n fro* the
pat"ents th"#h or lower le#$
%hen a !e"n "s used to bpass an arter) the !e"n "s re!ersed so that the !al!es dont "nterfere w"th blood flow$
5ur"n# a coronar arter bpass #raft procedure) the pat"ents heart "s stopped to allow the sur#eon to sew the new !essel "n
place$ Blood flow to the bod "s *a"nta"ned w"th a card"opul*onar bpass$
5ur"n# an an#"nal attac') the cells of the heart con!ert to anaerob"c *etabol"s*) wh"ch produces lact"c ac"d as a waste
product$ As the le!el of lact"c ac"d "ncreases) pa"n de!elops$
>a"n thats descr"bed as ?sharp@ or ?'n"fel"'e@ "s not cons"stent w"th an#"na pector"s$
An#"nal pa"n tp"call lasts for : *"nutesN howe!er) attac's assoc"ated w"th a hea! *eal or e+tre*e e*ot"onal d"stress *a
last 1: to 34 *"nutes$
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A pattern of ?e+ert"on0pa"n0rest0rel"ef@ "s cons"stent w"th stable an#"na$
Unl"'e stable an#"na) unstable an#"na can occur w"thout e+ert"on and "s cons"dered a precursor to a *ocard"al "nfarct"on$
A pat"ent who "s scheduled for a stress electrocard"o#ra* should not"f the staff "f he has ta'en n"trates$ If he has) the test
*ust be rescheduled$
E+erc"se e6u"p*ent) such as a tread*"ll or an e+erc"se b"'e) "s used for a stress electrocard"o#ra*$ Act"!"t "s "ncreased unt"l
the pat"ent reaches =:G of h"s *a+"*u* heart rate$
In pat"ents who ta'e n"tro#lcer"n for a lon# t"*e) tolerance often de!elops and reduces the effect"!eness of n"trates$ A 130
hour dru#0free per"od "s usuall *a"nta"ned at n"#ht$
Beta0adrener#"c bloc'ers) such as propranolol ,Inderal-) reduce the wor'load on the heart) thereb decreas"n# o+#en
de*and$ The also slow the heart rate$
;alc"u* channel bloc'ers "nclude n"fed"p"ne ,>rocard"a-) wh"ch "s used to treat an#"naN !erapa*"l ,;alan) Isopt"n-) wh"ch "s
used pr"*ar"l as an ant"arrhth*"cN and d"lt"a1e* ,;ard"1e*-) wh"ch co*b"nes the effects of n"fed"p"ne and !erapa*"l
w"thout the ad!erse effects$
A pat"ent who has an#"nal pa"n that rad"ates or worsens and doesnt subs"de should be e!aluated at an e*er#enc *ed"cal
fac"l"t$
;ard"ac cells can w"thstand 34 *"nutes of "sche*"a before cell death occurs$
5ur"n# a *ocard"al "nfarct"on) the *ost co**on s"te of "n&ur "s the anter"or wall of the left !entr"cle) near the ape+$
After a *ocard"al "nfarct"on) the "nfarcted t"ssue causes s"#n"f"cant P0wa!e chan#es on an electrocard"o#ra*$ These
chan#es re*a"n e!"dent e!en after the *ocard"u* heals$
The le!el of ;L0.B) an "soen1*e spec"f"c to the heart) "ncreases E to 2 hours after a *ocard"al "nfarct"on and pea's at 13
to 1= hours$ It returns to nor*al "n F to E das$
>at"ents who sur!"!e a *ocard"al "nfarct"on and ha!e no other card"o!ascular patholo# usuall re6u"re 2 to 13 wee's for a
full reco!er$
After a *ocard"al "nfarct"on) the pat"ent "s at #reatest r"s' for sudden death dur"n# the f"rst 3E hours$
After a *ocard"al "nfarct"on) the f"rst 2 hours "s the cruc"al per"od for sal!a#"n# the *ocard"u*$
After a *ocard"al "nfarct"on) "f the pat"ent cons"stentl has *ore than three pre*ature !entr"cular contract"ons per *"nute)
the phs"c"an should be not"f"ed$
After a *ocard"al "nfarct"on) "ncreas"n# !ascular res"stance throu#h the use of !asopressors) such as dopa*"ne and
le!arterenol) can ra"se blood pressure$
;l"n"cal *an"festat"ons of heart fa"lure "nclude d"stended nec' !e"ns) we"#ht #a"n) orthopnea) crac'les) and enlar#ed l"!er$
R"s' factors assoc"ated w"th e*bol"s* are "ncreased blood !"scos"t) decreased c"rculat"on) prolon#ed bed rest) and "ncreased
blood coa#ulab"l"t$
Ant"e*bol"s* stoc'"n#s should be worn around the cloc') but should be re*o!ed tw"ce a da for F4 *"nutes so that s'"n
care can be perfor*ed$
Before the nurse puts ant"e*bol"s* stoc'"n#s bac' on the pat"ent) the pat"ent should l"e w"th h"s feet ele!ated 29 ,1:$3 c*-
for 34 *"nutes$
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5resslers sndro*e "s 'nown as late per"card"t"s because "t occurs appro+"*atel 2 wee's to 2 *onths after a *ocard"al
"nfarct"on$ It causes per"card"al pa"n and a fe!er that lasts lon#er than 1 wee'$
In phase I after a *ocard"al "nfarct"on) for the f"rst 3E hours) the pat"ent "s 'ept on a clear l"6u"d d"et and bed rest w"th the
use of a beds"de co**ode$
In phase I after a *ocard"al "nfarct"on) on the second da) the pat"ent #ets out of bed and spends 1: to 34 *"nutes "n a cha"r$
The nu*ber of t"*es that the pat"ent #oes to the cha"r and the len#th of t"*e he spends "n the cha"r are "ncreased depend"n#
on h"s endurance$ In phase II) the len#th of t"*e that the pat"ent spends out of bed and the d"stance to the cha"r are "ncreased$
After transfer fro* the card"ac care un"t) the post0*ocard"al "nfarct"on pat"ent "s allowed to wal' the halls as h"s endurance
"ncreases$
Se+ual "ntercourse w"th a 'nown partner usuall can be resu*ed E to = wee's after a *ocard"al "nfarct"on$
A pat"ent under card"ac care should a!o"d dr"n'"n# alcohol"c be!era#es or eat"n# before en#a#"n# "n se+ual "ntercourse$
The a*bulat"on #oal for a post0*ocard"al "nfarct"on pat"ent "s 3 *"les "n 24 *"nutes$
A post0*ocard"al "nfarct"on pat"ent who doesnt ha!e a strenuous &ob *a be able to return to wor' full0t"*e "n = or O
wee's$
Stro'e !olu*e "s the a*ount of blood e&ected fro* the heart w"th each heartbeat$
Afterload "s the force that the !entr"cle *ust e+ert dur"n# sstole to e&ect the stro'e !olu*e$
The three0po"nt pos"t"on ,w"th the pat"ent upr"#ht and lean"n# forward) w"th the hands on the 'nees- "s character"st"c of
orthopnea) as seen "n left0s"ded heart fa"lure$
>aro+s*al nocturnal dspnea "nd"cates a se!ere for* of pul*onar con#est"on "n wh"ch the pat"ent awa'ens "n the *"ddle
of the n"#ht w"th a feel"n# of be"n# suffocated$
;l"n"cal *an"festat"ons of pul*onar ede*a "nclude breathlessness) nasal flar"n#) use of accessor *uscles to breath) and
froth sputu*$
A late s"#n of heart fa"lure "s decreased card"ac output that causes decreased blood flow to the '"dnes and results "n ol"#ur"a$
A late s"#n of heart fa"lure "s anasarca ,#eneral"1ed ede*a-$
5ependent ede*a "s an earl s"#n of r"#ht0s"ded heart fa"lure$ Its seen "n the le#s) where "ncreased cap"llar hdrostat"c
pressure o!erwhel*s plas*a prote"n) caus"n# a sh"ft of flu"d fro* the cap"llar beds to the "nterst"t"al spaces$
5ependent ede*a) wh"ch "s *ost not"ceable at the end of the da) usuall starts "n the feet and an'les and cont"nues upward$
/or the recu*bent pat"ent) ede*a "s usuall seen "n the presacral area$
S"#ns of ur"nar tract "nfect"on "nclude fre6uenc) ur#enc) and dsur"a$
In tert"ar0"ntent"on heal"n#) wound closure "s delaed because of "nfect"on or ede*a$
A pat"ent who has had supratentor"al sur#er should ha!e the head of the bed ele!ated F4 de#rees$
An ac"d0ash d"et ac"d"f"es ur"ne$
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J"ta*"n ; and cranberr &u"ce ac"d"f ur"ne$
A pat"ent who ta'es probenec"d ,;olbene*"d- for #out should be "nstructed to ta'e the dru# w"th food$
If wound deh"scence "s suspected) the nurse should "nstruct the pat"ent to l"e down and should e+a*"ne the wound and
*on"tor the !"tal s"#ns$ Abnor*al f"nd"n#s should be reported to the phs"c"an$
8oster "**une #lobul"n "s ad*"n"stered to st"*ulate "**un"t to !ar"cella$
The *ost co**on s*pto*s assoc"ated w"th co*part*ental sndro*e are pa"n thats not rel"e!ed b anal#es"cs) loss of
*o!e*ent) loss of sensat"on) pa"n w"th pass"!e *o!e*ent) and lac' of pulse$
To help rel"e!e *uscle spas*s "n a pat"ent who has *ult"ple scleros"s) the nurse should ad*"n"ster baclofen ,L"oresal- as
orderedN #"!e the pat"ent a war*) sooth"n# bathN and teach the pat"ent pro#ress"!e rela+at"on techn"6ues$
A pat"ent who has a cer!"cal "n&ur and "*pa"r*ent at ;: should be able to l"ft h"s shoulders and elbows part"all) but has no
sensat"on below the cla!"cle$
A pat"ent who has cer!"cal "n&ur and "*pa"r*ent at ;2 should be able to l"ft h"s shoulders) elbows) and wr"sts part"all) but
has no sensat"on below the cla!"cle) e+cept a s*all a*ount "n the ar*s and thu*b$
A pat"ent who has cer!"cal "n&ur and "*pa"r*ent at ;D should be able to l"ft h"s shoulders) elbows) wr"sts) and hands
part"all) but has no sensat"on below the *"dchest$
In&ur"es to the sp"nal cord at ;F and abo!e *a be fatal as a result of loss of "nner!at"on to the d"aphra#* and "ntercostal
*uscles$
S"#ns of *en"n#eal "rr"tat"on seen "n *en"n#"t"s "nclude nuchal r"#"d"t) a pos"t"!e Brud1"ns'"s s"#n) and a pos"t"!e Lern"#s
s"#n$
Laborator !alues that show pneu*o*en"n#"t"s "nclude an ele!ated cerebrosp"nal flu"d ,;S/- prote"n le!el ,*ore than 144
*#<dl-) a decreased ;S/ #lucose le!el ,E4 *#<dl-) and an "ncreased wh"te blood cell count$
Before under#o"n# *a#net"c resonance "*a#"n#) the pat"ent should re*o!e all ob&ects conta"n"n# *etal) such as watches)
underw"re bras) and &ewelr$
Usuall food and *ed"c"ne arent restr"cted before *a#net"c resonance "*a#"n#$
>at"ents who are under#o"n# *a#net"c resonance "*a#"n# should 'now that the can as' 6uest"ons dur"n# the procedureN
howe!er) the *a be as'ed to l"e st"ll at certa"n t"*es$
If a contrast *ed"u* "s used dur"n# *a#net"c resonance "*a#"n#) the pat"ent *a e+per"ence d"ures"s as the *ed"u* "s
flushed fro* the bod$
The T1anc' test "s used to conf"r* herpes #en"tal"s$
(epat"t"s ; "s spread pr"*ar"l throu#h blood ,for e+a*ple) dur"n# transfus"on or "n people who wor' w"th blood products-)
personal contact and) poss"bl) the fecal0oral route$
The best *ethod for soa'"n# an open) "nfected) dra"n"n# wound "s to use a hot0*o"st dress"n#$
Sputu* culture "s the conf"r*at"on test for tuberculos"s$
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NURSING BULLETS _____________ ___________________________________________________________
5e+a*ethasone ,5ecadron- "s a stero"dal ant"0"nfla**ator thats used to treat adrenal "nsuff"c"enc$
S"#ns of "ncreased "ntracran"al pressure "nclude alterat"on "n le!el of consc"ousness) restlessness) "rr"tab"l"t) and pup"llar
chan#es$
The pat"ent who has a lower l"*b a*putat"on should be "nstructed to assu*e a prone pos"t"on at least tw"ce a da$
5ur"n# the f"rst 3E hours after a*putat"on) the res"dual l"*b "s ele!ated on a p"llow$ After that t"*e) the l"*b "s placed flat to
reduce the r"s' of h"p fle+"on contractures$
A tourn"6uet should be "n full !"ew at the beds"de of the pat"ent who has an a*putat"on$
An e*er#enc tracheosto* set should be 'ept at the beds"de of a pat"ent who "s suspected of ha!"n# ep"#lott"t"s$
Roc' .ounta"n spotted fe!er "s spread throu#h the b"te of a t"c' harbor"n# the R"c'etts"a or#an"s*$
A pat"ent who has ac6u"red "**unodef"c"enc sndro*e shouldnt share ra1ors or toothbrushes w"th others) but there are no
spec"al precaut"ons for d"nnerware or laundr ser!"ces$
Because ant"fun#al crea*s *a sta"n cloth"n#) pat"ents who use the* should use san"tar nap'"ns$
An ant"fun#al crea* should be "nserted h"#h "n the !a#"na at bedt"*e$
A pat"ent who "s ha!"n# a se"1ure usuall re6u"res protect"on fro* the en!"ron*ent onlN howe!er) anone who needs a"rwa
*ana#e*ent should be turned on h"s s"de$
Status ep"lept"cus "s treated w"th I$J$ d"phenlhdanto"n$
A +eno#raft "s a s'"n #raft fro* an an"*al$
The ant"dote for *a#nes"u* sulfate "s calc"u* #luconate 14G$
Aller#"c react"ons to a blood transfus"on are flush"n#) whee1"n#) urt"car"a) and rash$
A pat"ent who has a h"stor of basal cell carc"no*a should a!o"d sun e+posure$
%hen potent) n"tro#lcer"n causes a sl"#ht st"n#"n# sensat"on under the ton#ue$
A pat"ent who appears to be ?f"#ht"n# the !ent"lator@ "s hold"n# h"s breath or breath"n# out on an "nsp"rator ccle$
An ant"neoplast"c dru# thats used to treat breast cancer "s ta*o+"fen ,Nol!ade+-$
Ad!erse effects of !"ncr"st"ne ,Hnco!"n- are alopec"a) nausea) and !o*"t"n#$
Increased ur"ne output "s an "nd"cat"on that a hpertens"!e cr"s"s "s nor*al"1"n#$
If a pat"ent who "s rece"!"n# I$J$ che*otherap has pa"n at the "nsert"on s"te) the nurse should stop the I$J$ "nfus"on
"**ed"atel$
E+tra!asat"on "s lea'a#e of flu"d "nto surround"n# t"ssue fro* a !e"n thats be"n# used for I$J$ therap$
;l"n"cal s"#ns of prostate cancer are dr"bbl"n#) hes"tanc) and decreased ur"nar force$
;ard"ac #lcos"des "ncrease card"ac contract"l"t$
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Ad!erse effects of card"ac #lcos"des "nclude headache) hpotens"on) nausea and !o*"t"n#) and ellow0#reen halos around
l"#hts$
A T tube should be cla*ped dur"n# pat"ent *eals to a"d "n fat d"#est"on$
A T tube usuall re*a"ns "n place for 14 das$
5ur"n# a !ert"#o attac') a pat"ent who has .Zn"_res d"sease should be "nstructed to l"e down on h"s s"de w"th h"s ees
closed$
%hen *a"nta"n"n# a Aac'son0>ratt dra"na#e sste*) the nurse should s6uee1e the reser!o"r and e+pel the a"r before recapp"n#
the sste*$
The *ost co**on s*pto* assoc"ated w"th sleep apnea "s snor"n#$
("sta*"ne "s released dur"n# an "nfla**ator response$
%hen deal"n# w"th a pat"ent who has a se!ere speech "*ped"*ent) the nurse should *"n"*"1e bac'#round no"se and a!o"d
"nterrupt"n# the pat"ent$
/e!er and n"#ht sweats) hall*ar' s"#ns of tuberculos"s) *a not be present "n elderl pat"ents who ha!e the d"sease$
A su"table dress"n# for wound debr"de*ent "s wet0to0dr$
5r"n'"n# war* *"l' at bedt"*e a"ds sleep"n# because of the natural sedat"!e effect of the a*"no ac"d trptophan$
The "n"t"al step "n pro*ot"n# sleep "n a hosp"tal"1ed pat"ent "s to *"n"*"1e en!"ron*ental st"*ulat"on$
Before *o!"n# a pat"ent) the nurse should assess how *uch e+ert"on the pat"ent "s per*"tted) the pat"ents phs"cal ab"l"t)
and h"s ab"l"t to understand "nstruct"on as well as her own stren#th and ab"l"t to *o!e the pat"ent$
A pat"ent who "s "n a restra"nt should be chec'ed e!er F4 *"nutes and the restra"nt loosened e!er 3 hours to per*"t ran#e of
*ot"on e+erc"ses for the e+tre*"t"es$
Ant"b"ot"cs that are #"!en four t"*es a da should be #"!en at 2 a$*$) 13 p$*$) 2 p$*$) and 13 a$*$ to *"n"*"1e d"srupt"on of
sleep$
Sundowner sndro*e "s seen "n pat"ents who beco*e *ore confused toward the e!en"n#$ To counter th"s tendenc) the nurse
should turn a l"#ht on$
/or the pat"ent who has so*na*bul"s*) the pr"*ar #oal "s to pre!ent "n&ur b pro!"d"n# a safe en!"ron*ent$
/or the pat"ent who has so*na*bul"s*) the pr"*ar #oal "s to pre!ent "n&ur b pro!"d"n# a safe en!"ron*ent$
Nalo+one ,Narcan- should be 'ept at the beds"de of the pat"ent who "s rece"!"n# pat"ent0controlled anal#es"a$
(pnot"c dru#s decrease rap"d ee *o!e*ent sleep) but "ncrease the o!erall a*ount of sleep$
A sudden wa!e of o!erwhel*"n# sleep"ness "s a s*pto* of narcoleps$
A d"abet"c pat"ent should be "nstructed to bu shoes "n the afternoon because feet are usuall lar#est at that t"*e of da$
If sur#er "s scheduled late "n the afternoon) the sur#eon *a appro!e a l"#ht brea'fast$
A hear"n# a"d "s usuall left "n place dur"n# sur#er to per*"t co**un"cat"on w"th the pat"ent$ The operat"n# roo* tea*
should be not"f"ed of "ts presence$
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The nurse should *on"tor the pat"ent for central ner!ous sste* depress"on for 3E hours after the ad*"n"strat"on of n"trous
o+"de$
In the postanesthes"a care un"t) the proper pos"t"on of an adult "s w"th the head to the s"de and the ch"n e+tended upward$ The
S"*s pos"t"on also can be used unless contra"nd"cated$
After a pat"ent "s ad*"tted to the postanesthes"a care un"t) the f"rst act"on "s to assess the patenc of the a"rwa$
If a pat"ent "s ad*"tted to the postanesthes"a care un"t w"thout the pharn#eal refle+) hes pos"t"oned on h"s s"de$ The nurse
stas at the beds"de unt"l the #a# refle+ returns$
In the postanesthes"a care un"t) the pat"ents !"tal s"#ns are ta'en e!er 1: *"nutes rout"nel) or *ore often "f "nd"cated) unt"l
the pat"ent "s stable$
In the postanesthes"a care un"t) the T tube should be uncla*ped and attached to a dra"na#e sste*$
After the pat"ent rece"!es anesthes"a) the nurse *ust obser!e h"* for a drop "n blood pressure or e!"dence of labored
breath"n#$
If a pat"ent be#"ns to #o "nto shoc' dur"n# the postanesthes"a assess*ent) the nurse should ad*"n"ster o+#en) place the
pat"ent "n the Trendelenbur# pos"t"on) and "ncrease the I$J$ flu"d rate accord"n# to the phs"c"ans order or the pol"c of the
postanesthes"a care un"t$
Tpes of ben"#n tu*ors "nclude *+o*a) f"bro*a) l"po*a) osteo*a) and chondro*a$
.al"#nant tu*ors "nclude sarco*a) basal cell carc"no*a) f"brosarco*a) osteosarco*a) *+osarco*a) chondrosarco*a) and
adenocarc"no*a$
/or a cancer pat"ent) pall"at"!e sur#er "s perfor*ed to reduce pa"n) rel"e!e a"rwa obstruct"on) rel"e!e GI obstruct"on)
pre!ent he*orrha#e) rel"e!e pressure on the bra"n and sp"nal cord) dra"n abscesses) and re*o!e or dra"n "nfected tu*ors$
A pat"ent who "s under#o"n# rad"at"on "*plant therap should be 'ept "n a pr"!ate roo* to reduce the r"s' of e+posure to
others) "nclud"n# nurs"n# personnel$
After total 'nee replace*ent sur#er) the 'nee should be 'ept "n *a+"*u* e+tens"on for F das$
>art"al we"#ht bear"n# "s allowed appro+"*atel 1 wee' after total 'nee replace*ent$ %e"#ht bear"n# to the po"nt of pa"n "s
allowed at 3 wee's$
S&^#rens sndro*e "s a chron"c "nfla**ator d"sorder assoc"ated w"th a decrease "n sal"!at"on and lacr"*at"on$ ;l"n"cal
*an"festat"ons "nclude drness of the *outh) ees) and !a#"na$
Nor*al !alues of cerebrosp"nal flu"d "nclude the follow"n#I prote"n le!el) 1: to E: *#<144 *lN fast"n# #lucose) :4 to =4
*#<144 *lN red blood cell count) 4N wh"te blood cell count) 4 to :<`lI p() D$FN potass"u* "on !alue) 3$O **ol<LN chlor"de) 134
to 1F4 *E6<L$
The follow"n# *ne*on"c de!"ce can be used to "dent"f whether a cran"al ner!e "s a *otor ner!eI I So*e a II Sa a III .arr a
IJ .one) a J but a JI . a JII Brother a JII Sas a I7 Bad a 7 Bus"ness a 7I .arr a 7II .one$
To "nterpret the *ne*on"c de!"ceI If the word be#"ns w"th an S) "ts a sensor ner!eN "f "t starts w"th an .) "ts a *otor ner!eN
and "f "t starts w"th a B) "ts both a sensor and a *otor ner!e$
The Glas#ow ;o*a Scale e!aluates le!el of consc"ousness) pup"l react"on) and *otor act"!"t$ A score between F and 1: "s
poss"ble$
%hen assess"n# a pat"ents pup"ls) the nurse should re*e*ber that an"socor"a) une6ual pup"ls of 1 ** or lar#er) occurs "n
appro+"*atel 1DG of the populat"on$
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(o*on*ous he*"anops"a "s a !"sual defect "n wh"ch the pat"ent sees onl one0half of the !"sual f"eld w"th each ee$
Therefore) the pat"ent sees onl one0half of a nor*al !"sual f"eld$
>ass"!e ran#e0of0*ot"on e+erc"ses are co**onl started 3E hours after a stro'e$ There perfor*ed four t"*es per da$
In treat"n# a pat"ent w"th a trans"ent "sche*"c attac') the #oal of *ed"cal *ana#e*ent "s to pre!ent a stro'e$ The pat"ent "s
ad*"n"stered ant"hpertens"!e dru#s) ant"platelet dru#s or asp"r"n and) "n so*e cases) warfar"n ,;ou*ad"n-$
A pat"ent who has an "ntraper"toneal shunt should be obser!ed for "ncreased abdo*"nal #"rth$
5"#est"on of carbohdrates be#"ns "n the *outh$
5"#est"on of fats be#"ns "n the sto*ach) but occurs predo*"nantl "n the s*all "ntest"ne$
5"etar sources of *a#nes"u* are f"sh) #ra"ns) and nuts$
A rou#h est"*ate of seru* os*olar"t "s tw"ce the seru* sod"u* le!el$
In deter*"n"n# ac"dVbase proble*s) the nurse should f"rst note the p($ If "ts abo!e D$E:) "ts a proble* of al'alos"sN "f "ts
below D$F:) "ts a proble* of ac"dos"s$ The nurse should ne+t loo' at the part"al pressure of arter"al carbon d"o+"de ,>a;H3-$
Th"s "s the resp"rator "nd"cator$ If the p( "nd"cates ac"dos"s and the >a;H3 "nd"cates ac"dos"s as well ,#reater than E: **
(#-) then theres a *atch) and the source of the proble* "s resp"rat"on$ Its called resp"rator ac"dos"s$ If the p( "nd"cates
al'alos"s and the >a;H3 also "nd"cates al'alos"s ,less than F: ** (#-) then theres a *atch) and the source of the proble* "s
resp"rat"on$ Th"s "s called resp"rator al'alos"s$ If the >a;H3 "s nor*al) then the nurse should loo' at the b"carbonate
,(;HFV-) wh"ch "s the *etabol"c "nd"cator) and note whether "ts ac"d"c ,less than 33 *E6<L- or al'al"ne ,#reater than 32
*E6<L-$ 5eter*"ne wh"ch !alue the p( *atchesN "t w"ll deter*"ne whether the proble* "s *etabol"c ac"dos"s or *etabol"c
al'alos"s$ If both the >a;H3 and (;HFV are abnor*al) then the bod "s co*pensat"n#$ If the p( has returned to nor*al) the
bod "s "n full co*pensat"on$
The Tens"lon ,edrophon"u* chlor"de- test "s used to conf"r* *asthen"a #ra!"s$
A *as'l"'e fac"al e+press"on "s a s"#n of *asthen"a #ra!"s and >ar'"nsons d"sease$
Albu*"n "s a collo"d that a"ds "n *a"nta"n"n# flu"d w"th"n the !ascular sste*$ If albu*"n were f"ltered out throu#h the
'"dnes and "nto the ur"ne) ede*a would occur$
Ede*a caused b water and trau*a doesnt cause p"tt"n#$
5ehdrat"on "s water loss onlN flu"d !olu*e def"c"t "ncludes all flu"ds "n the bod$
The pr"*ar act"on of an o"l retent"on ene*a "s to lubr"cate the colon$ The secondar act"on "s soften"n# the feces$
A pat"ent who uses a wal'er should be "nstructed to *o!e the wal'er appro+"*atel 139 ,F4$: c*- to the front and then
ad!ance "nto the wal'er$
Brad'"nes"a "s a s"#n of >ar'"nsons d"sease$
Lordos"s "s bac'ward arch"n# cur!ature of the sp"ne$
Lphos"s "s forward cur!ature of the sp"ne$
In a pat"ent w"th anore+"a ner!osa) a pos"t"!e response to therap "s susta"ned we"#ht #a"n$
The dru# "n d"alsate "s hepar"n$
An auto#raft "s a #raft thats re*o!ed fro* one area of the bod for transplantat"on to another$
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S"#ns of cer!"cal cancer "nclude *"d*enses bleed"n# and postco"tal bleed"n#$
After prostatecto*) a catheter "s "nserted to "rr"#ate the bladder and 'eep ur"ne straw0colored or l"#ht p"n') to put d"rect
pressure on the operat"!e s"de) and to *a"nta"n a patent urethra$
If a rad"at"on "*plant beco*es d"slod#ed) but re*a"ns "n the pat"ent) the nurse should not"f the phs"c"an$
The best *ethod to reduce the r"s' for atelectas"s "s to encoura#e the pat"ent to wal'$
Atelectas"s usuall occurs 3E to E= hours after sur#er$
>at"ents who are at the #reatest r"s' for atelectas"s are those who ha!e had h"#h abdo*"nal sur#er) such as cholecstecto*$
A pers"stent decrease "n o+#en to the '"dnes causes erthropo"es"s$
Rhonch" and crac'les "nd"cate "neffect"!e a"rwa clearance$
%hee1"n# "nd"cates bronchospas*s$
;l"n"cal s"#ns and s*pto*s of hpo+e*"a are restlessness ,usuall the f"rst s"#n-) a#"tat"on) dspnea) and d"sor"entat"on$
;o**on ad!erse effects of op"o"ds are const"pat"on and resp"rator depress"on$
5"suse osteoporos"s "s caused b de*"neral"1at"on of calc"u* as a result of prolon#ed bed rest$
The best wa to pre!ent d"suse osteoporos"s "s to encoura#e the pat"ent to wal'$
A cane should be carr"ed on the unaffected s"de and ad!anced w"th the affected e+tre*"t$
Stero"ds shouldnt be used "n pat"ents who ha!e ch"c'enpo+ or sh"n#les because the *a cause ad!erse effects$
Serocon!ers"on occurs appro+"*atel F to 2 *onths after e+posure to hu*an "**unodef"c"enc !"rus$
Therap w"th the ant"!"ral a#ent 1"do!ud"ne "s "n"t"ated when the ;5EM T0cell count "s :44 cells<`l or less$
In a l"#ht0s'"nned person) Lapos"s sarco*a causes a purpl"sh d"scolorat"on of the s'"n$ In a dar'0s'"nned person) the
d"scolorat"on "s dar' brown to blac'$
After an esopha#eal balloon ta*ponade "s "n place) "t should be "nflated to 34 ** (#$
A pat"ent who has Lapos"s sarco*a should a!o"d ac"d"c or h"#hl seasoned foods$
The treat*ent for oral cand"d"as"s "s a*photer"c"n B ,/un#"1one- or flucona1ole ,5"flucan-$
A s"#n of resp"rator fa"lure "s !"tal capac"t of less than 1: *l<'# and resp"rator rate of #reater than F4 breaths<*"nute or
less than = breaths< *"nute$
/or left0s"ded card"ac catheter"1at"on) the catheter "s threaded throu#h the descend"n# aorta) aort"c arch) ascend"n# aorta)
aort"c !al!e) and left !entr"cle$
/or r"#ht0s"ded card"ac catheter"1at"on) the catheter "s threaded throu#h the super"or !ena ca!a) r"#ht atr"u*) r"#ht !entr"cle)
pul*onar arter) and pul*onar cap"llar"es$
Ane*"a can be d"!"ded "nto four #roups accord"n# to "ts causeI blood loss) "*pa"red product"on of red blood cells ,RB;s-)
"ncreased destruct"on of RB;s) and nutr"t"onal def"c"enc"es$
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NURSING BULLETS _____________ ___________________________________________________________
Asp"r"n) "buprofen) phenobarb"tal) l"th"u*) colch"c"ne) lead) and chlora*phen"col can cause aplast"c ane*"a$
After a pat"ent under#oes bone *arrow asp"rat"on) the nurse should appl d"rect pressure to the s"te for F to : *"nutes to
reduce the r"s' of bleed"n#$
/resh fro1en plas*a "s thawed to O=$2C / ,FDC ;- before "nfus"on$
S"#ns of thro*boctopen"a "nclude petech"ae) ecch*oses) he*atur"a) and #"n#"!al bleed"n#$
A pat"ent who has thro*boctopen"a should be tau#ht to use a soft toothbrush and use an electr"c ra1or$
S"#ns of flu"d o!erload "nclude "ncreased central !enous pressure) "ncreased pulse rate) d"stended &u#ular !e"ns) and
bound"n# pulse$
A pat"ent who has leu'open"a ,or an other pat"ent who "s at an "ncreased r"s' for "nfect"on- should a!o"d eat"n# raw *eat)
fresh fru"t) and fresh !e#etables$
To pre!ent a se!ere #raft0!ersus0host react"on) wh"ch "s *ost co**onl seen "n pat"ents older than a#e F4) the donor *arrow
"s treated w"th *onoclonal ant"bod"es before transplantat"on$
The four *ost co**on s"#ns of hpo#lce*"a reported b pat"ents are ner!ousness) *ental d"sor"entat"on) wea'ness) and
persp"rat"on$
>rolon#ed attac's of hpo#lce*"a "n a d"abet"c pat"ent can result "n bra"n da*a#e$
Act"!"t"es that "ncrease "ntracran"al pressure "nclude cou#h"n#) snee1"n#) stra"n"n# to pass feces) bend"n# o!er) and blow"n#
the nose$
Treat*ent for bleed"n# esopha#eal !ar"ces "ncludes !asopress"n) esopha#eal ta*ponade) "ced sal"ne la!a#e) and !"ta*"n L$
(epat"t"s ; ,also 'nown as blood0transfus"on hepat"t"s- "s a parenterall trans*"tted for* of hepat"t"s that has a h"#h
"nc"dence of carr"er status$
The nurse should be concerned about flu"d and electrolte proble*s "n the pat"ent who has asc"tes) ede*a) decreased ur"ne
output) or low blood pressure$
The nurse should be concerned about GI bleed"n#) low blood pressure) and "ncreased heart rate "n a pat"ent who "s
he*orrha#"n#$
The nurse should be concerned about #eneral"1ed *ala"se) cloud ur"ne) purulent dra"na#e) tachcard"a) and "ncreased
te*perature "n a pat"ent who has an "nfect"on$
In a pat"ent who has ede*a or asc"tes) the seru* electrolte le!el should be *on"tored$ The pat"ent also should be we"#hed
da"lN ha!e h"s abdo*"nal #"rth *easured w"th a cent"*eter tape at the sa*e locat"on) us"n# the u*b"l"cus as a chec'po"ntN
ha!e h"s "nta'e and output *easuredN and ha!e h"s blood pressure ta'en at least e!er E hours$
Endo#enous sources of a**on"a "nclude a1ote*"a) GI bleed"n#) catabol"s*) and const"pat"on$
E+o#enous sources of a**on"a "nclude prote"n) blood transfus"on) and a*"no ac"ds$
The follow"n# h"stolo#"c #rad"n# sste* "s used to class"f cancersI #rade 1) well0d"fferent"atedN #rade 3) *oderatel well0
d"fferent"atedN #rade F) poorl d"fferent"atedN and #rade E) !er poorl d"fferent"ated$
The follow"n# #rad"n# sste* "s used to class"f tu*orsI T4) no e!"dence of a pr"*ar tu*orN TIS) tu*or "n s"tuN and T1) T3)
TF) and TE) accord"n# to the s"1e and "n!ol!e*ent of the tu*orN the h"#her the nu*ber) the #reater the "n!ol!e*ent$
>heochro*octo*a "s a catechola*"ne0secret"n# neoplas* of the adrenal *edulla$ It causes e+cess"!e product"on of
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ep"nephr"ne and norep"nephr"ne$
;l"n"cal *an"festat"ons of pheochro*octo*a "nclude !"sual d"sturbances) headaches) hpertens"on) and ele!ated seru*
#lucose le!el$
The pat"ent shouldnt consu*e an caffe"ne0conta"n"n# products) such as cola) coffee) or tea) for at least = hours before
obta"n"n# a 3E0hour ur"ne sa*ple for !an"lll*andel"c ac"d$
A pat"ent who "s ta'"n# ;olBene*"d ,probenec"d and colch"c"ne- for #out should "ncrease h"s flu"d "nta'e to 3)444 *l<da$
A *"ot"c such as p"locarp"ne "s ad*"n"stered to a pat"ent w"th #lauco*a to "ncrease the outflow of a6ueous hu*or) wh"ch
decreases "ntraocular tens"on$
The dru# thats *ost co**onl used to treat streptococcal pharn#"t"s and rheu*at"c fe!er "s pen"c"ll"n$
A pat"ent w"th #out should a!o"d pur"ne0conta"n"n# foods) such as l"!er and other or#an *eats$
A pat"ent who under#oes *a#net"c resonance "*a#"n# l"es on a flat platfor* that *o!es throu#h a *a#net"c f"eld$
Laborator !alues "n pat"ents who ha!e bacter"al *en"n#"t"s "nclude "ncreased wh"te blood cell count) "ncreased prote"n and
lact"c ac"d le!els) and decreased #lucose le!el$
.ann"tol "s a hperton"c os*ot"c d"uret"c that decreases "ntracran"al pressure$
The best *ethod to debr"de a wound "s to use a wet0to0dr dress"n# and re*o!e the dress"n# after "t dr"es$
The #reatest r"s' for resp"rator co*pl"cat"ons occurs after chest wall "n&ur) chest wall sur#er) or upper abdo*"nal sur#er$
Secondar *ethods to pre!ent postoperat"!e resp"rator co*pl"cat"ons "nclude ha!"n# the pat"ent use an "ncent"!e
sp"ro*eter) turn"n# the pat"ent) ad!"s"n# the pat"ent to cou#h and breathe deepl) and pro!"d"n# hdrat"on$
A character"st"c of aller#"c "nsp"rator and e+p"rator whee1"n# "s a dr) hac'"n#) nonproduct"!e cou#h$
The "ncubat"on per"od for Roc' .ounta"n spotted fe!er "s D to 1E das$
."cona1ole ,.on"stat- !a#"nal suppos"tor should be ad*"n"stered w"th the pat"ent l"n# flat$
The nurse should place the pat"ent who "s ha!"n# a se"1ure on h"s s"de$
S"#ns of h"p d"slocat"on are one le# thats shorter than the other and one le# thats e+ternall rotated$
Ant"chol"ner#"c *ed"cat"on "s ad*"n"stered before sur#er to d"*"n"sh secret"on of sal"!a and #astr"c &u"ces$
E+trapra*"dal sndro*e "n a pat"ent w"th >ar'"nsons d"sease "s usuall caused b a def"c"enc of dopa*"ne "n the
substant"a n"#ra$
In a burn pat"ent) the order of concern "s a"rwa) c"rculat"on) pa"n) and "nfect"on$
(per'ale*"a nor*all occurs dur"n# the hpo!ole*"c phase "n a pat"ent who has a ser"ous burn "n&ur$
Blac' feces "n the burn pat"ent are co**onl related to ;url"n#s ulcer$
In a pat"ent w"th burn "n&ur) "**ed"ate care of a full0th"c'ness s'"n #raft "ncludes co!er"n# the s"te w"th a bul' dress"n#$
The donor s"te of a s'"n #raft should be left e+posed to the a"r$
Lea'"n# around a T tube should be reported "**ed"atel to the phs"c"an$
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A pat"ent who has .Zn"_res d"sease should consu*e a low0sod"u* d"et$
In an postoperat"!e pat"ent) the pr"or"t of concern "s a"rwa) breath"n#) and c"rculat"on) followed b self0care def"c"ts$
The s*pto*s of *asthen"a #ra!"s are *ost l"'el related to ner!e de#enerat"on$
S*pto*s of sept"c shoc' "nclude cold) cla** s'"nN hpotens"onN and decreased ur"ne output$
N"net0f"!e percent of wo*en who ha!e #onorrhea are as*pto*at"c$
An ad!erse s"#n "n a pat"ent who has a Ste"n*anns p"n "n the fe*ur would be erthe*a) ede*a) and pa"n around the p"n s"te$
S"#ns of chron"c #lauco*a "nclude halos around l"#hts) #radual loss of per"pheral !"s"on) and cloud !"s"on$
S"#ns of a detached ret"na "nclude a sensat"on of a !e"l ,or curta"n- "n the l"ne of s"#ht$
To+"c le!els of strepto*c"n can cause hear"n# loss$
A lon#0ter* effect of rheu*at"c fe!er "s *"tral !al!e da*a#e$
Laborator !alues noted "n rheu*at"c fe!er "nclude an ant"streptols"n0H t"ter) the presence of ;0react"!e prote"n)
leu'octos"s) and an "ncreased erthrocte sed"*entat"on rate$
;ra*p pa"n "n the r"#ht lower 6uadrant of the abdo*en "s a cons"stent f"nd"n# "n ;rohns d"sease$
;ra*p pa"n "n the left lower 6uadrant of the abdo*en "s a cons"stent f"nd"n# "n d"!ert"cul"t"s$
In the "cter"c phase of hepat"t"s) ur"ne "s a*ber) feces are cla0colored) and the s'"n "s ellow$
S"#ns of osteo*el"t"s "nclude patholo#"c fractures) shorten"n# or len#then"n# of the bone) and pa"n deep "n the bone$
The laborator test that would best reflect flu"d loss because of a burn would be he*atocr"t$
A pat"ent who has acute pancreat"t"s should ta'e noth"n# b *outh and under#o #astr"c suct"on to deco*press the sto*ach$
A *"st tent "s used to "ncrease the hdrat"on of secret"ons$
A pat"ent who "s rece"!"n# le!odopa should a!o"d foods that conta"n pr"do+"ne ,!"ta*"n B2-) such as beans) tuna) and beef
l"!er) because th"s !"ta*"n decreases the effect"!eness of le!odopa$
A pat"ent who has a transact"onal "n&ur at ;F re6u"res pos"t"!e !ent"lat"on$
The act"on of phento"n ,5"lant"n- "s potent"ated when #"!en w"th ant"coa#ulants$
;erebral pals "s a nonpro#ress"!e d"sorder that pers"sts throu#hout l"fe$
A co*pl"cat"on of ulcerat"!e col"t"s "s perforat"on$
%hen a pat"ent who has *ult"ple scleros"s e+per"ences d"plop"a) one ee should be patched$
A dan#er s"#n after h"p replace*ent "s lac' of refle+es "n the affected e+tre*"t$
A cl"n"cal *an"festat"on of a ruptured lu*bar d"s' "ncludes pa"n that shoots down the le# and ter*"nates "n the popl"teal
space$
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The *ost "*portant nutr"t"onal need of the burn pat"ent "s I$J$ flu"d w"th electroltes$
The pat"ent who has sste*"c lupus erthe*atosus should a!o"d sunsh"ne) ha"r spra) ha"r color"n# products) and dust"n#
powder$
The best pos"t"on for a pat"ent who has low bac' pa"n "s s"tt"n# "n a stra"#ht0bac'ed cha"r$
;l"n"cal s"#ns of ulcerat"!e col"t"s "nclude blood) purulent) *uco"d) and water feces$
A pat"ent who has a prote"n sste*"c shunt *ust follow a l"felon# prote"n0restr"cted d"et$
A pat"ent who has a h"atal hern"a should *a"nta"n an upr"#ht pos"t"on after eat"n#$
A suct"on apparatus should be 'ept at the beds"de of a pat"ent who "s at r"s' for status ep"lept"cus$
The lead"n# cause of death "n the burn pat"ent "s resp"rator co*pro*"se and "nfect"on$
In pat"ents who ha!e herpes 1oster) the pr"*ar concern "s pa"n *ana#e*ent$
The treat*ent for Roc' .ounta"n spotted fe!er "s tetraccl"ne$
Strawberr ton#ue "s a s"#n of scarlet fe!er$
If a pat"ent has he*"anops"a) the nurse should place the call l"#ht) the *eal tra) and other "te*s "n h"s f"eld of !"s"on$
The best pos"t"on for the pat"ent after a cran"oto* "s se*"0/owler$
S"#ns of renal trau*a "nclude flan' pa"n) he*ato*a and) poss"bl) blood "n the ur"ne and decreased ur"ne output$
/lan' pa"n and he*ato*a "n the bac' "nd"cate renal he*orrha#e "n the trau*a pat"ent$
Natural d"uret"cs "nclude coffee) tea) and #rapefru"t &u"ce$
;entral !enous pressure of 1= c* (3H "nd"cates hper!ole*"a$
Sal*onellos"s can be ac6u"red b eat"n# conta*"nated *eat such as ch"c'en) or e##s$
Good sources of *a#nes"u* "nclude f"sh) nuts) and #ra"ns$
>at"ents who ha!e low blood urea n"tro#en le!els should be "nstructed to eat h"#h0prote"n foods) such as f"sh and ch"c'en$
The nurse should *on"tor a pat"ent who has Gu"lla"n0BarrZ sndro*e for resp"rator co*pro*"se$
A heat"n# pad *a pro!"de co*fort to a pat"ent who has pel!"c "nfla**ator d"sease$
After supratentor"al sur#er) the pat"ent should be placed "n the se*"0/owler pos"t"on$
To pre!ent deep !e"n thro*bos"s) the pat"ent should e+erc"se h"s le#s at least e!er 3 hours) ele!ate the le#s abo!e the le!el
of the heart wh"le l"n# down) and a*bulate w"th ass"stance$
After bronchoscop) the pat"ents #a# refle+ should be chec'ed$
In a pat"ent w"th *ononucleos"s) abdo*"nal pa"n and pa"n that rad"ates to the left shoulder *a "nd"cate a ruptured spleen$
/or a s'"n #raft to ta'e) "t *ust be autolo#ous$
Untreated ret"nal detach*ent leads to bl"ndness$
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14F
NURSING BULLETS _____________ ___________________________________________________________
A pat"ent who has f"brocst"c breast d"sease should consu*e a d"et thats low "n caffe"ne and salt$
A foul odor at the p"n s"te of a pat"ent who "s "n s'eletal tract"on "nd"cates "nfect"on$
A *uscle rela+ant thats ad*"n"stered w"th o+#en *a cause *al"#nant hperther*"a and resp"rator depress"on$
>a"n that occurs on *o!e*ent of the cer!"+) to#ether w"th adne+al tenderness) su##ests pel!"c "nfla**ator d"sease$
The #oal of cr"s"s "nter!ent"on "s to restore the person to a precr"s"s le!el of funct"on"n# and order$
Nephrot"c sndro*e causes prote"nur"a) hpoalbu*"ne*"a) and ede*a) and so*et"*es he*atur"a) hpertens"on) and a
decreased #lo*erular f"ltrat"on rate$
Bowel sounds *a be heard o!er a hern"a) but not o!er a hdrocele$
S1 "s decreased "n f"rst0de#ree heart bloc'$ S3 "s decreased "n aort"c stenos"s$
Gas "n the colon *a cause t*pan "n the r"#ht upper 6uadrant) obscure l"!er dullness) and lead to falsel decreased
est"*ates of l"!er s"1e$
In ata+"a caused b loss of pos"t"on sense) !"s"on co*pensates for the sensor loss$ The pat"ent stands well w"th the ees
open) but loses balance when there closed ,pos"t"!e Ro*ber# test result-$
Inab"l"t to reco#n"1e nu*bers when drawn on the hand w"th the blunt end of a pen su##ests a les"on "n the sensor corte+$
5ur"n# the late sta#e of *ult"ple *elo*a) the pat"ent should be protected a#a"nst patholo#"cal fractures as a result of
osteoporos"s$
Tr"ccl"c ant"depressants such as a*"tr"ptl"ne ,Ela!"l- shouldnt be ad*"n"stered to pat"ents w"th narrow0an#le #lauco*a)
ben"#n prostat"c hpertroph) or coronar arter d"sease$
>ul*onar e*bol"s* "s character"1ed b a sudden) sharp) stabb"n# pa"n "n the chestN dspneaN decreased breath soundsN and
crac'les or a pleural fr"ct"on rub on auscultat"on$
;l"n"cal *an"festat"ons of card"ac ta*ponade are hpotens"on and &u#ular !e"n d"stent"on$
To a!o"d further da*a#e) the nurse shouldnt "nduce !o*"t"n# "n a pat"ent who has swallowed a corros"!e che*"cal) such as
o!en cleaner) dra"n cleaner) or 'erosene$
A br"ll"ant red refle+ e+cludes *ost ser"ous defects of the cornea) a6ueous cha*ber) lens) and !"treous cha*ber$
Hral hpo#lce*"c a#ents st"*ulate the "slets of Lan#erhans to produce "nsul"n$
To treat wound deh"scence) the nurse should help the pat"ent to l"e "n a sup"ne pos"t"onN co!er the protrud"n# "ntest"ne w"th
*o"st) ster"le) nor*al sal"ne pac'sN and chan#e the pac's fre6uentl to 'eep the area *o"st$
%h"le a pat"ent "s rece"!"n# an I$J$ n"tro#lcer"n dr"p) the nurse should *on"tor h"s blood pressure e!er 1: *"nutes to detect
hpotens"on$
An tpe of flu"d loss can tr"##er a cr"s"s "n a pat"ent w"th s"c'le cell ane*"a$
The pat"ent should r"nse h"s *outh after us"n# a cort"costero"d "nhaler to a!o"d stero"d res"due and reduce oral fun#al
"nfect"ons$
A pat"ent w"th low le!els of tr""odothron"ne and thro+"ne *a ha!e fat"#ue) lethar#) cold "ntolerance) const"pat"on) and
decreased l"b"do$
5ur"n# a s"c'le cell cr"s"s) treat*ent "ncludes pa"n *ana#e*ent) hdrat"on) and bed rest$
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14E
NURSING BULLETS _____________ ___________________________________________________________
A pat"ent who "s hper!ent"lat"n# should rebreathe "nto a paper ba# to "ncrease the retent"on of carbon d"o+"de$
;horea "s a *a&or cl"n"cal *an"festat"on of central ner!ous sste* "n!ol!e*ent caused b rheu*at"c fe!er$
;horea causes constant &er') uncontrolled *o!e*entsN f"d#et"n#N tw"st"n#N #r"*ac"n#N and loss of bowel and bladder
control$
Se!ere d"arrhea can cause electrolte def"c"enc"es and *etabol"c ac"dos"s$
To reduce the r"s' of hpercalce*"a "n a pat"ent w"th *etastat"c bone cancer) the nurse should help the pat"ent a*bulate)
pro*ote flu"d "nta'e to d"lute ur"ne) and l"*"t the pat"ents oral "nta'e of calc"u*$
>a"n assoc"ated w"th a *ocard"al "nfarct"on usuall "s descr"bed as ?pressure@ or as a ?hea!@ or ?s6uee1"n#@ sensat"on "n
the *"dsternal area$ The pat"ent *a report that the pa"n feels as thou#h so*eone "s stand"n# on h"s chest or as thou#h an
elephant "s s"tt"n# on h"s chest$
;alc"u* and phosphorus le!els are ele!ated unt"l hperparathro"d"s* "s stab"l"1ed$
The pa"n assoc"ated w"th carpal tunnel sndro*e "s caused b entrap*ent of the *ed"an ner!e at the wr"st$
>ancreat"c en1*e replace*ent enhances the absorpt"on of prote"n$
La*"necto* w"th sp"nal fus"on "s perfor*ed to rel"e!e pressure on the sp"nal ner!es and stab"l"1e the sp"ne$
A transect"on "n&ur of the sp"nal cord at an le!el causes parals"s below the le!el of the les"on$
/or pulseless !entr"cular tachcard"a) the pat"ent should be def"br"llated "**ed"atel) w"th 344 &oules) F44 &oules) and then
F24 &oules #"!en "n rap"d success"on$
>leural fr"ct"on rub "s heard "n pleur"s) pneu*on"a) and plural "nfarct"on$
%hee1es are heard "n e*phse*a) fore"#n bod obstruct"on) and asth*a$
Rhonch" are heard "n pneu*on"a) e*phse*a) bronch"t"s) and bronch"ectas"s$
;rac'les are heard "n pul*onar ede*a) pneu*on"a) and pul*onar f"bros"s$
The electrocard"o#ra* of a pat"ent w"th heart fa"lure shows !entr"cular hpertroph$
A decrease "n the potass"u* le!el decreases the effect"!eness of card"ac #lcos"des) "ncreases the poss"b"l"t of d"#o+"n
to+"c"t) and can cause fatal card"ac arrhth*"as$
A 130lead electrocard"o#ra* read"n# should be obta"ned dur"n# a *ocard"al "nfarct"on or an an#"nal attac'$
The pr"*ar d"fference between an#"na and the s*pto*s of a *ocard"al "nfarct"on ,.I- "s that an#"na can be rel"e!ed b
rest or n"tro#lcer"n ad*"n"strat"on$ The s*pto*s of an .I arent rel"e!ed w"th rest) and the pa"n can last F4 *"nutes or
lon#er$
;alc"u* channel bloc'ers "nclude !erapa*"l ,;alan-) d"lt"a1e* hdrochlor"de ,;ard"1e*-) n"fed"p"ne ,>rocard"a-) and
n"card"p"ne hdrochlor"de ,;ardene-$
After a *ocard"al "nfarct"on) electrocard"o#raph chan#es "nclude ele!at"ons of the P wa!e and ST se#*ent$
Ant"arrhth*"c a#ents "nclude 6u"n"d"ne #luconate ,Pu"na#lute-) l"doca"ne hdrochlor"de) and proca"na*"de hdrochlor"de
,>ronestl-$
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14:
NURSING BULLETS _____________ ___________________________________________________________
An#"otens"n0con!ert"n# en1*e "nh"b"tors "nclude captopr"l and enalapr"l *aleate ,Jasotec-$
After a *ocard"al "nfarct"on) the pat"ent should a!o"d stressful act"!"t"es and s"tuat"ons) such as e+ert"on) hot or cold
te*peratures) and e*ot"onal stress$
Ant"hpertens"!e dru#s "nclude hdrala1"ne hdrochlor"de ,Apresol"ne- and *ethldopa ,Aldo*et-$
Both parents *ust ha!e a recess"!e #ene for the offspr"n# to "nher"t the #ene$
A do*"nant #ene "s a #ene that onl needs to be present "n one parent to ha!e a :4V:4 chance of affect"n# each offspr"n#$
Bronchod"lators d"late the bronch"oles and rela+ bronch"olar s*ooth *uscle$
The pr"*ar funct"on of aldosterone "s sod"u* reabsorpt"on$
The #oal of pos"t"!e end0e+p"rator pressure "s to ach"e!e ade6uate arter"al o+#enat"on w"thout us"n# a to+"c le!el of
"nsp"red o+#en or co*pro*"s"n# card"ac output$
/urose*"de ,Las"+- "s a loop d"uret"c$ Its onset of act"on "s F4 to 24 *"nutes) pea' "s ach"e!ed at 1 to 3 hours) and durat"on "s
2 to = hours for the I$.$ or oral route$
>re#nanc) *ocard"al "nfarct"on) GI bleed"n#) bleed"n# d"sorders) and he*orrho"ds are contra"nd"cat"ons to *anual re*o!al
of fecal "*pact"on$
A*bulat"on "s the best *ethod to pre!ent postoperat"!e atelectas"s$ Hther *easures "nclude "ncent"!e sp"ro*etr and turn"n#)
cou#h"n#) and breath"n# deepl$
The blood urea n"tro#en test and the creat"n"ne clearance test *easure how effect"!el the '"dnes e+crete these respect"!e
substances$
The f"rst s"#n of resp"rator d"stress or co*pro*"se "s restlessness$
The ant"dote for *a#nes"u* sulfate o!erdose "s calc"u* #luconate 14G$
The ant"dote for hepar"n o!erdose "s prota*"ne sulfate$
An aller#"c react"on to a blood transfus"on *a "nclude flush"n#) urt"car"a) whee1"n#) and a rash$ If the pat"ent has an of
these s"#ns of a react"on) the nurse should stop the transfus"on "**ed"atel) 'eep the !e"n open w"th nor*al sal"ne) and not"f
the phs"c"an$
A pat"ent ta'"n# d"#o+"n and furose*"de ,Las"+- should call the phs"c"an "f he e+per"ences *uscle wea'ness$
A pat"ent w"th basal cell carc"no*a should a!o"d e+posure to the sun dur"n# the hottest t"*e of da ,between 14 a$*$ and F
p$*$-$
A cl"n"cal *an"festat"on of acute pa"n "s d"aphores"s$
Gardnerella !a#"n"t"s "s a tpe of bacter"al !a#"nos"s that causes a th"n) water) *"l'l"'e d"schar#e that has a f"sh odor$
A pat"ent who "s ta'"n# /la#l ,*etron"da1ole- shouldnt consu*e alcohol"c be!era#es or use preparat"ons that conta"n
alcohol because the *a cause a d"sulf"ra*0l"'e react"on ,flush"n#) headache) !o*"t"n#) and abdo*"nal pa"n-$
5ur"n# the ad*"n"strat"on of transcutaneous electr"cal ner!e st"*ulat"on) the pat"ent feels a t"n#l"n# sensat"on$
In pat"ents w"th #lauco*a) the head of the bed should be ele!ated "n the se*"0/owler pos"t"on or as ordered after sur#er to
pro*ote dra"na#e of a6ueous hu*or$
>ostoperat"!e care after per"pheral "r"decto* "ncludes ad*"n"ster"n# dru#s ,stero"ds and cclople#"cs- as prescr"bed to
decrease "nfla**at"on and d"late the pup"ls$
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142
NURSING BULLETS _____________ ___________________________________________________________
Ret"nopath refers to chan#es "n ret"nal cap"llar"es that decrease blood flow to the ret"na and lead to "sche*"a) he*orrha#e)
and ret"nal detach*ent$
Le#el e+erc"ses are reco**ended after sur#er to "*pro!e the tone of the sph"ncter and pel!"c *uscles$
Hne of the treat*ents for tr"cho*on"as"s !a#"nal"s "s *etron"da1ole ,/la#l-) wh"ch *ust be prescr"bed for the pat"ent and
the pat"ents se+ual partner$
A co**on s*pto* after cataract laser sur#er "s blurred !"s"on$
A pat"ent w"th acute open0an#le #lauco*a *a see halos around l"#hts$
An As"an pat"ent w"th d"abetes *ell"tus usuall can dr"n' #"nsen# tea$
To pre!ent ot"t"s e+terna) the pat"ent should 'eep the ears dr when bath"n#$
>at"ents who rece"!e prolon#ed h"#h doses of I$J$ furose*"de ,Las"+- should be assessed for t"nn"tus and hear"n# loss$
The treat*ent for to+"c shoc' sndro*e "s I$J$ flu"d ad*"n"strat"on to restore blood !olu*e and pressure and ant"b"ot"c
therap to el"*"nate "nfect"on$
In pat"ents w"th #lauco*a) beta0adrener#"c bloc'ers fac"l"tate the outflow of a6ueous hu*or$
A *an who loses one test"cle should st"ll be able to father a ch"ld$
Nat"!e A*er"cans are part"cularl suscept"ble to d"abetes *ell"tus$
Blac's are part"cularl suscept"ble to hpertens"on$
%o*en w"th the #reatest r"s' for cer!"cal cancer are those whose *others had cer!"cal cancer) followed b those whose
fe*ale s"bl"n#s had cer!"cal cancer$
A post*enopausal wo*an should perfor* breast self0e+a*"nat"on on the sa*e da each *onth) for e+a*ple) on the sa*e
da of the *onth as her b"rthda$
."ddle0ear hear"n# loss usuall results fro* otoscleros"s$
After test"cular sur#er) the pat"ent should use an "ce pac' for co*fort$
A pat"ent w"th chron"c open0an#le #lauco*a has tunnel !"s"on$ The nurse *ust be careful to place "te*s d"rectl "n front of
h"* so that he can see the*$
;l"n"cal s"#ns of bacter"al pneu*on"a "nclude sha'"n#) ch"lls) fe!er) and a cou#h that produces purulent sputu*$
;l"n"cal *an"festat"ons of fla"l chest "nclude parado+"cal *o!e*ent of the "n!ol!ed chest wall) dspnea) pa"n) and canos"s$
R"#ht0s"ded card"ac funct"on "s assessed b e!aluat"n# central !enous pressure$
A pat"ent w"th a pace*a'er should "**ed"atel report an "ncrease "n the pulse rate or a slow"n# of the pulse rate of *ore
than E to : beats<*"nute$
5"11"ness) fa"nt"n#) palp"tat"on) h"ccups) and chest pa"n "nd"cate pace*a'er fa"lure$
Leu'e*"a causes eas fat"#ab"l"t) #eneral"1ed *ala"se) and pallor$
After card"ac catheter"1at"on) the puncture) or cutdown) s"te should be *on"tored for he*ato*a for*at"on$
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14D
NURSING BULLETS _____________ ___________________________________________________________
Luss*auls breath"n# "s assoc"ated w"th d"abet"c 'etoac"dos"s$
If the nurse not"ces water "n a !ent"lator tube) she should re*o!e the water fro* the tube and reconnect "t$
Ta*o+"fen "s an ant"neoplast"c dru# thats used to treat breast cancer$
The ad!erse effects of !"ncr"st"ne ,Hnco!"n- "nclude alopec"a) nausea) and !o*"t"n#$
E*phse*a "s character"1ed b destruct"on of the al!eol") enlar#e*ent of the d"stal a"r spaces) and brea'down of the al!eolar
walls$
To 'eep secret"ons th"n) the pat"ent who has e*phse*a should "ncrease h"s flu"d "nta'e to appro+"*atel 3$: L<da$
The cl"n"cal *an"festat"ons of asth*a are whee1"n#) dspnea) hpo+e*"a) d"aphores"s) and "ncreased heart and resp"rator
rate$
E+tr"ns"c asth*a "s an ant"#enVant"bod react"on to aller#ens) such as pollen) an"*al) dander) feathers) foods) house dust) or
*"tes$
After endoscop "s perfor*ed) the nurse should assess the pat"ent for he*opts"s$
Increased ur"ne output "s an "nd"cat"on that a hpertens"!e cr"s"s has resol!ed$
After rad"cal *astecto*) the pat"ent should be pos"t"oned w"th the affected ar* on p"llows w"th the hand ele!ated and
al"#ned w"th the ar*$
After pneu*onecto*) the pat"ent should perfor* ar* e+erc"ses to pre!ent fro1en shoulder$ BulletsBullets
Left0s"ded heart fa"lure causes crac'les) cou#h"n#) tachcard"a) and fat"#ab"l"t$ ,Th"n' of L to re*e*ber Left and Lun#s$-
Bullets
;ard"ac #lcos"des "ncrease contract"l"t and card"ac output$
R"#ht0s"ded heart fa"lure causes ede*a) d"stended nec' !e"ns) noctur"a) and wea'ness$
Ad!erse effects of card"ac #lcos"des "nclude card"ac d"sturbance) headache) hpotens"on) GI s*pto*s) blurred !"s"on) and
ellow0#reen halos around l"#hts$
A pat"ent who "s rece"!"n# ant"coa#ulant therap should ta'e aceta*"nophen ,Tlenol- "nstead of asp"r"n for pa"n rel"ef$
Ade6uate hu*"d"f"cat"on "s "*portant after larn#ecto*$ At ho*e) the pat"ent can use pans of water or a cool *"st
!apor"1er) espec"all "n the bedroo*$
Late s*pto*s of renal cancer "nclude he*atur"a) flan' pa"n) and a palpable *ass "n the flan'$
(epar"n "s #"!en subcutaneousl) usuall "n the lower abdo*"nal fat pad$
In a pat"ent w"th s"c'le cell ane*"a) war* pac's should be used o!er the e+tre*"t"es to rel"e!e pa"n$ ;old pac's *a
st"*ulate !asoconstr"ct"on and cause further "sche*"a$ The e+tre*"t"es should be placed on p"llows for co*fort$
S"c'le cell cr"s"s causes seps"s ,fe!er #reater than 143C / [F=$OC ;\) *en"n#eal "rr"tat"on) tachpnea) tachcard"a) and
hpotens"on- and !aso0occlus"!e cr"s"s ,se!ere pa"n- w"th hpo+"a ,part"al pressure of arter"al o+#en of less than D4 **
(#-$
Ad!erse effects of d"#o+"n "nclude headache) wea'ness) !"s"on d"sturbances) anore+"a) and GI upset$
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14=
NURSING BULLETS _____________ ___________________________________________________________
To perfor* a tuberculos"s test) a 320#au#e needle "s used w"th a 10*l sr"n#e$
Resp"rator fa"lure occurs when *ucus bloc's the al!eol" or the a"rwas of the lun#s$
The pat"ent should be "nstructed not to cou#h dur"n# thoracentes"s$
The pat"ent should be "nstructed not to cou#h dur"n# thoracentes"s$
A pat"ent who has thro*bophleb"t"s should be placed "n the Trendelenbur# pos"t"on$
S*pto*s of >neu*ocst"s car"n"" pneu*on"a "nclude dspnea and nonproduct"!e cou#h$
To counteract !"ta*"n B1 def"c"enc) a pat"ent who has pern"c"ous ane*"a should eat *eat and an"*al products$
A pat"ent who "s on a !ent"lator and beco*es restless should under#o suct"on"n#$
Autolo#ous bone *arrow transplantat"on doesnt cause #raft0!ersus0host d"sease$
A pat"ent who has *"ld thro*bophleb"t"s "s l"'el to ha!e *"ld cra*p"n# on e+ert"on$
If the f"rst atte*pt to perfor* colosto* "rr"#at"on "s unsuccessful) the procedure "s repeated w"th nor*al sal"ne solut"on$
Breast enlar#e*ent) or #neco*ast"a) "s an ad!erse effect of estro#en therap$
In a pat"ent who has leu'e*"a) a low platelet count *a lead to he*orrha#e$
After rad"cal nec' d"ssect"on) the "**ed"ate concern "s resp"rator d"stress as a result of tracheal ede*a$
After rad"cal *astecto*) the pat"ents ar* should be ele!ated to pre!ent l*phede*a$
(po!ent"lat"on causes resp"rator ac"dos"s$
The h"#h /owler pos"t"on "s the best pos"t"on for a pat"ent who has orthopnea$
A trans"ent "sche*"c attac' affects sensor and *otor funct"on and *a cause d"plop"a) dspha#"a) aphas"a) and ata+"a$
After *astecto*) the pat"ent should s6uee1e a ball w"th the hand on the affected s"de$
;holestra*"ne ,Puestran-) wh"ch "s used to reduce the seru* cholesterol le!el) *a cause const"pat"on$
Glucocort"co"d) or stero"d) therap *a *as' the s"#ns of "nfect"on$
.elano*a "s *ost co**onl seen "n l"#ht0s'"nned people who wor' or spend t"*e outdoors$
A pat"ent who has a pace*a'er should ta'e h"s pulse at the sa*e t"*e e!er da$
A pat"ent who has sto*at"t"s should r"nse h"s *outh w"th *outhwash fre6uentl$
An ad!erse effect of theophll"ne ad*"n"strat"on "s tachcard"a$
The treat*ent for larn#otracheobronch"t"s "ncludes postural dra"na#e before *eals$
After rad"cal nec' d"ssect"on) a h"#h pr"or"t "s pro!"d"n# a *eans of co**un"cat"on$
A h"#h0fat d"et that "ncludes red *eat "s a contr"but"n# factor for colorectal cancer$
After a *od"f"ed rad"cal *astecto*) the pat"ent should be placed "n the se*"0/owler pos"t"on) w"th the ar* placed on a
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14O
NURSING BULLETS _____________ ___________________________________________________________
p"llow$
Ln"fel"'e) stabb"n# pa"n "n the chest *a "nd"cate pul*onar e*bol"s*$
Esopha#eal cancer "s assoc"ated w"th e+cess"!e alcohol consu*pt"on$
A pat"ent who has panctopen"a and "s under#o"n# che*otherap *a e+per"ence he*orrha#e and "nfect"on$
A #rade I tu*or "s encapsulated and #rows b e+pans"on$
;ancer of the pancreas causes anore+"a) we"#ht loss) and &aund"ce$
>rolon#ed #astr"c suct"on"n# can cause *etabol"c al'alos"s$
To *easure the a*ount of res"dual ur"ne) the nurse perfor*s stra"#ht catheter"1at"on after the pat"ent !o"ds$
5e+a*ethasone ,5ecadron- "s a stero"dal ant"0"nfla**ator a#ent thats used to treat bra"n tu*ors$
Lon#0ter* reduct"on "n the del"!er of o+#en to the '"dnes causes an "ncrease "n erthropo"es"s$
A pat"ent who subs"sts on canned foods and canned f"sh "s at r"s' for sod"u* "*balance ,hpernatre*"a-$
;l"n"cal s"#ns and s*pto*s of hpo+"a "nclude confus"on) d"aphores"s) chan#es "n blood pressure) tachcard"a) and
tachpnea$
Red *eat can cause a false0pos"t"!e result on fecal occult blood test$
;arbon *ono+"de replaces he*o#lob"n "n the red blood cells) decreas"n# the a*ount of o+#en "n the t"ssue$
Al'al"ne ur"ne can result "n ur"nar tract "nfect"on$
Bladder retra"n"n# "s effect"!e "f "t len#thens the "nter!als between ur"nat"on$
;he"los"s "s caused b r"bofla!"n def"c"enc$
The concentrat"on of o+#en "n "nsp"red a"r "s reduced at h"#h alt"tudes$ As a result) dspnea *a occur on e+ert"on$
A pat"ent who "s rece"!"n# enter"c feed"n# should be assessed for abdo*"nal d"stent"on$
Th"a*"ne def"c"enc causes neuropath$
A pat"ent who has abdo*"nal d"stent"on as a result of flatus can be treated w"th a car*"nat"!e ene*a ,(arr"s flush-$
>ern"c"ous ane*"a "s caused b a def"c"enc of !"ta*"n B13) or cobala*"n$
After a bar"u* ene*a) the pat"ent "s #"!en a la+at"!e$
The appropr"ate I$J$ flu"d to correct a hpo!ole*"c) or flu"d !olu*e) def"c"t "s nor*al sal"ne solut"on$
Seru* albu*"n def"c"enc co**onl occurs after burn "n&ur$
Before #"!"n# a #astrosto* feed"n#) the nurse should "nspect the pat"ents sto*a$
The *ost co**on "ntest"nal bacter"a "dent"f"ed "n ur"nar tract "nfect"on "s Escher"ch"a col"$
(ponatre*"a *a occur "n a pat"ent who has a h"#h fe!er and dr"n's onl water$
/ol"c ac"d def"c"enc causes *uscle wea'ness as a result of hpo+e*"a$
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5ehdrat"on causes "ncreased resp"rat"on and heart rate) followed b "rr"tab"l"t and fuss"ness$
Glucocort"co"ds can cause an electrolte "*balance$
A decrease "n potass"u* le!el decreases the effect"!eness of card"ac #lcos"des) "ncreases poss"ble d"#o+"n to+"c"t) and can
cause fatal card"ac arrhth*"as$
5"ures"s can cause decreased absorpt"on of !"ta*"ns A) 5) E) and L$
>rote"n deplet"on causes a decrease "n l*phocte count$
To pre!ent paraph"*os"s after the "nsert"on of a /ole catheter) the nurse should replace the prepuce$
Loop d"uret"cs) such as furose*"de ,Las"+-) decrease plas*a le!els of potass"u* and sod"u*$
After pelo#raph) the pat"ent should dr"n' plent of flu"ds to pro*ote the e+cret"on of de$
>otass"u* should be ta'en w"th food and flu"ds$
>roper *easure*ent of a naso#astr"c tube "s fro* the corner of the *outh to the ear lobe to the t"p of the sternu*$
/ull a#on"st anal#es"cs "nclude *orph"ne) code"ne) *eper"d"ne ,5e*erol-) propo+phene ,5ar!on-) and hdro*orphone
,5"laud"d-$
Buprenorph"ne ,Buprene+- "s a part"al a#on"st anal#es"c$
>oor s'"n tur#or "s a cl"n"cal *an"festat"on of d"abetes "ns"p"dus$
A pat"ent who has Add"sons d"sease and "s rece"!"n# cort"costero"d therap *a be at r"s' for "nfect"on$
To assess a pat"ent for he*orrha#e after a thro"decto*) the nurse should roll the pat"ent onto h"s s"de to e+a*"ne the s"des
and bac' of the nec'$
A pat"ent who "s rece"!"n# hor*one therap for hpothro"d"s* should ta'e the dru# at the sa*e t"*e each da$
(perprote"ne*"a *a contr"bute to the de!elop*ent of hepat"c encephalopath$
To *"n"*"1e bleed"n# "n a pat"ent who has l"!er dsfunct"on) s*all0#au#e needles are used for "n&ect"ons$
A pat"ent who has c"rrhos"s of the l"!er and asc"tes should follow a low0sod"u* d"et$
Before an e+cretor uro#raph) the nurse *ust as' the pat"ent whether hes aller#"c to "od"ne or shellf"sh$
A buffalo hu*p "s an abnor*al d"str"but"on of ad"pose t"ssue that occurs "n ;ush"n#s sndro*e$
Le!othro+"ne ,Snthro"d- "s used as replace*ent therap "n hpothro"d"s*$
Le!othro+"ne ,Snthro"d- treats) but doesnt cure) hpothro"d"s* and *ust be ta'en for the pat"ents l"fet"*e$ It shouldnt
be ta'en w"th food because food *a "nterfere w"th "ts absorpt"on$
I*"pra*"ne ,Tofran"l- w"th conco*"tant use of barb"turates *a result "n enhanced ;NS depress"on$
A pat"ent who "s rece"!"n# le!othro+"ne ,Snthro"d- therap should report tachcard"a to the phs"c"an$
The s"#ns and s*pto*s of hper'ale*"a "nclude *uscle wea'ness) hpotens"on) shallow resp"rat"on) apath) and anore+"a$
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In a pat"ent w"th well0controlled d"abetes) the 30hour postprand"al blood su#ar le!el *a be 1FO *#<dl$
A pat"ent who has d"abetes *ell"tus should wash h"s feet da"l "n war* water and dr the* carefull) espec"all between the
toes$
Acute pancreat"t"s causes constant ep"#astr"c abdo*"nal pa"n that rad"ates to the bac' and flan' and "s *ore "ntense "n the
sup"ne pos"t"on$
5"abet"c neuropath "s a lon#0ter* co*pl"cat"on of d"abetes *ell"tus$
>ortal !e"n hpertens"on "s assoc"ated w"th l"!er c"rrhos"s$
After thro"decto*) the nurse should assess the pat"ent for larn#eal da*a#e *an"fested b hoarseness$
The pat"ent w"th hpoparathro"d"s* has hpocalce*"a$
A pat"ent who has chron"c pancreat"t"s should consu*e a bland) low0fat d"et$
A pat"ent w"th hepat"t"s A should be on enter"c precaut"ons to pre!ent the spread of hepat"t"s A$
The pat"ent who has l"!er d"sease "s l"'el to ha!e &aund"ce) wh"ch "s caused b an "ncreased b"l"rub"n le!el$
An ad!erse effect of phento"n ,5"lant"n- ad*"n"strat"on "s hperplas"a of the #"n#"!a$
(e*ate*es"s "s a cl"n"cal s"#n of esopha#eal !ar"ces$
/at destruct"on "s the che*"cal process that causes 'etones to appear "n ur"ne$
The #lucose tolerance test "s the def"n"t"!e d"a#nost"c test for d"abetes$
Atelectas"s and deh"scence are postoperat"!e cond"t"ons assoc"ated w"th re*o!al of the #allbladder$
After l"!er b"ops) the pat"ent should be pos"t"oned on h"s r"#ht s"de) w"th a p"llow placed underneath the l"!er border$
;ate#or"1ed
Bullets
Lu#ols solut"on "s used to de!ascular"1e the #land before thro"decto*$
;holecst"t"s causes low0#rade fe!er) nausea and !o*"t"n#) #uard"n# of the r"#ht upper 6uadrant) and b"l"ar pa"n that
rad"ates to the r"#ht scapula$
Earl s*pto*s of l"!er c"rrhos"s "nclude fat"#ue) anore+"a) ede*a of the an'les "n the e!en"n#) ep"sta+"s) and bleed"n#
#u*s$
The cl"n"cal *an"festat"ons of d"abetes "ns"p"dus "nclude pold"ps"a) polur"a) spec"f"c #ra!"t of 1$441 to 1$44:) and h"#h
seru* os*olal"t$
The cl"n"cal *an"festat"ons of d"abetes "ns"p"dus "nclude pold"ps"a) polur"a) spec"f"c #ra!"t of 1$441 to 1$44:) and h"#h
seru* os*olal"t$
(pertens"on "s a s"#n of re&ect"on of a transplanted '"dne$
Lactulose "s used to pre!ent and treat portal0sste*"c encephalopath$
E+tracorporeal and "ntracorporeal shoc' wa!e l"thotr"ps "s the use of shoc' wa!es to perfor* non"n!as"!e destruct"on of
b"l"ar stones$ Its "nd"cated "n the treat*ent of s*pto*at"c h"#h0r"s' pat"ents who ha!e few noncalc"f"ed cholesterol stones$
5ecreased consc"ousness "s a cl"n"cal s"#n of an "ncreased a**on"a le!el "n a pat"ent w"th '"dne fa"lure or c"rrhos"s of the
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l"!er$
The pa"n *ed"cat"on thats #"!en to pat"ents who ha!e acute pancreat"t"s "s *eper"d"ne ,5e*erol-$
>rochlorpera1"ne ,;o*pa1"ne-) *ecl"1"ne) and tr"*ethoben1a*"de ,T"#an- are used to treat the nausea and !o*"t"n# caused
b cholecst"t"s$
Hbese wo*en are *ore suscept"ble to #allstones than an other #roup$
.etabol"c ac"dos"s "s a co**on f"nd"n# "n acute renal fa"lure$
/or a pat"ent who has acute pancreat"t"s) the *ost "*portant nurs"n# "nter!ent"on "s to *a"nta"n h"s flu"d and electrolte
balance$
After thro"decto*) the pat"ent "s *on"tored for hpocalce*"a$
In end0sta#e c"rrhos"s of the l"!er) the pat"ents a**on"a le!el "s ele!ated$
In a pat"ent who has l"!er c"rrhos"s) abdo*"nal #"rth "s *easured w"th the super"or "l"ac crest used as a land*ar'$
The s*pto*s of Al1he"*ers d"sease ha!e an "ns"d"ous onset$
/racture of the s'ull "n the area of the cerebellu* *a cause ata+"a and "nab"l"t to coord"nate *o!e*ent$
Seru* creat"n"ne "s the laborator test that pro!"des the *ost spec"f"c "nd"cat"on of '"dne d"sease$
A pat"ent who has b"lateral adrenalecto* *ust ta'e cort"sone for the rest of h"s l"fe$
>ortal !e"n hpertens"on causes esopha#eal !ar"ces$
S"#ns and s*pto*s of hpo+"a "nclude tachcard"a) shortness of breath) canos"s) and *ottled s'"n$
The three tpes of e*bol"s* are a"r) fat) and thro*bus$
Assoc"at"ons for pat"ents who ha!e had larn#eal cancer "nclude the Lost ;ord ;lub and the New Jo"ce ;lub$
Before d"schar#e) a pat"ent who has had a total larn#ecto* *ust be able to perfor* tracheosto* care and suct"on"n# and
use alternat"!e *eans of co**un"cat"on$
The un"!ersal blood donor "s H ne#at"!e$
The un"!ersal blood rec"p"ent "s AB pos"t"!e$
.ucus "n a colosto* ba#
"nd"cates that the colon "s be#"nn"n# to funct"on$
After a !asecto*) the pat"ent "s cons"dered ster"le "f he has no sper* cells$
/at"#ue "s an ad!erse effect of rad"at"on therap$
To pre!ent du*p"n# sndro*e) the pat"ents consu*pt"on of h"#h0carbohdrate foods and l"6u"ds should be l"*"ted$
;roprec"p"tate conta"ns factors JIII and 7III and f"br"no#en and "s used to treat he*oph"l"a$
Inso*n"a "s the *ost co**on sleep d"sorder$
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11F
NURSING BULLETS _____________ ___________________________________________________________
Bru+"s* "s #r"nd"n# of the teeth dur"n# sleep$
Elderl pat"ents are at r"s' for osteoporos"s because of a#e0related bone de*"neral"1at"on$
The cl"n"cal *an"festat"ons of local "nfect"on "n an e+tre*"t are tenderness) loss of use of the e+tre*"t) erthe*a) ede*a)
and war*th$
;l"n"cal *an"festat"ons of sste*"c "nfect"on "nclude fe!er and swollen l*ph nodes$
An "**ob"le pat"ent "s pred"sposed to thro*bus for*at"on because of "ncreased blood stas"s$
Urea "s the ch"ef end product of a*"no ac"d *etabol"s*$
.orph"ne and other op"o"ds rel"e!e pa"n b b"nd"n# to the ner!e cells "n the dorsal horn of the sp"nal cord$
Tr"cho*onas and ;and"da "nfect"ons can be ac6u"red nonse+uall$
>resbcus"s "s pro#ress"!e sensor"neural hear"n# loss that occurs as part of the a#"n# process$
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11E
NURSING BULLETS _____________ ___________________________________________________________
PSYCHIATRIC NURSING
Accord"n# to Lbbler0Ross) the f"!e sta#es of death and d"n# are den"al) an#er) bar#a"n"n#) depress"on) and acceptance$
/l"#ht of "deas "s an alterat"on "n thou#ht processes thats character"1ed b s'"pp"n# fro* one top"c to another) unrelated
top"c$
La belle "nd"ffZrence "s the lac' of concern for a profound d"sab"l"t) such as bl"ndness or parals"s that *a occur "n a
pat"ent who has a con!ers"on d"sorder$
.oderate an+"et decreases a persons ab"l"t to perce"!e and concentrate$ The person "s select"!el "nattent"!e ,focuses
on "**ed"ate concerns-) and the perceptual f"eld narrows$
A pat"ent who has a phob"c d"sorder uses self0protect"!e a!o"dance as an e#o defense *echan"s*$
In a pat"ent who has anore+"a ner!osa) the h"#hest treat*ent pr"or"t "s correct"on of nutr"t"onal and electrolte
"*balances$
A pat"ent who "s ta'"n# l"th"u* *ust under#o re#ular ,usuall once a *onth- *on"tor"n# of the blood l"th"u* le!el
because the *ar#"n between therapeut"c and to+"c le!els "s narrow$ A nor*al laborator !alue "s 4$: to 1$: *E6<L$
Earl s"#ns and s*pto*s of alcohol w"thdrawal "nclude an+"et) anore+"a) tre*ors) and "nso*n"a$ The *a be#"n up to
= hours after the last alcohol "nta'e$
Al0Anon "s a support #roup for fa*"l"es of alcohol"cs$
The nurse shouldnt ad*"n"ster chlorpro*a1"ne ,Thora1"ne- to a pat"ent who has "n#ested alcohol because "t *a cause
o!ersedat"on and resp"rator depress"on$
L"th"u* to+"c"t can occur when sod"u* and flu"d "nta'e are "nsuff"c"ent) caus"n# l"th"u* retent"on$
An alcohol"c who ach"e!es sobr"et "s called a reco!er"n# alcohol"c because no cure for alcohol"s* e+"sts$
Accord"n# to Er"'son) the school0a#e ch"ld ,a#es 2 to 13- "s "n the "ndustr0!ersus0"nfer"or"t sta#e of pschosoc"al
de!elop*ent$
%hen car"n# for a depressed pat"ent) the nurses f"rst pr"or"t "s safet because of the "ncreased r"s' of su"c"de$
Echolal"a "s parrotl"'e repet"t"on of another persons words or phrases$
Accord"n# to pschoanalt"c theor) the e#o "s the part of the psche that controls "nternal de*ands and "nteracts w"th the
outs"de world at the consc"ous) preconsc"ous) and unconsc"ous le!els$
Accord"n# to pschoanalt"c theor) the supere#o "s the part of the psche thats co*posed of *orals) !alues) and eth"cs$
It cont"nuall e!aluates thou#hts and act"ons) reward"n# the #ood and pun"sh"n# the bad$ ,Th"n' of the supere#o as the
?supercop@ of the unconsc"ous$-
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NURSING BULLETS _____________ ___________________________________________________________
Accord"n# to pschoanalt"c theor) the "d "s the part of the psche that conta"ns "nst"nctual dr"!es$ ,Re*e*ber " for
"nst"nctual and d for dr"!e$-
5en"al "s the defense *echan"s* used b a pat"ent who den"es the real"t of an e!ent$
In a psch"atr"c sett"n#) seclus"on "s used to reduce o!erwhel*"n# en!"ron*ental st"*ulat"on) protect the pat"ent fro* self0
"n&ur or "n&ur to others) and pre!ent da*a#e to hosp"tal propert$ Its used for pat"ents who dont respond to less
restr"ct"!e "nter!ent"ons$ Seclus"on controls e+ternal beha!"or unt"l the pat"ent can assu*e self0control and helps the
pat"ent to re#a"n self0control$
Tra*"ne0r"ch food) such as a#ed cheese) ch"c'en l"!er) a!ocados) bananas) *eat tender"1er) sala*") bolo#na) ;h"ant"
w"ne) and beer *a cause se!ere hpertens"on "n a pat"ent who ta'es a *onoa*"ne o+"dase "nh"b"tor$
A pat"ent who ta'es a *onoa*"ne o+"dase "nh"b"tor should be we"#hed b"wee'l and *on"tored for su"c"dal tendenc"es$
If the pat"ent who ta'es a *onoa*"ne o+"dase "nh"b"tor has palp"tat"ons) headaches) or se!ere orthostat"c hpotens"on) the
nurse should w"thhold the dru# and not"f the phs"c"an$
;o**on causes of ch"ld abuse are poor "*pulse control b the parents and the lac' of 'nowled#e of #rowth and
de!elop*ent$
The d"a#nos"s of Al1he"*ers d"sease "s based on cl"n"cal f"nd"n#s of two or *ore co#n"t"!e def"c"ts) pro#ress"!e
worsen"n# of *e*or) and the results of a neuropscholo#"cal test$
.e*or d"sturbance "s a class"c s"#n of Al1he"*ers d"sease$
Thou#ht bloc'"n# "s loss of the tra"n of thou#ht because of a defect "n *ental process"n#$
A co*puls"on "s an "rres"st"ble ur#e to perfor* an "rrat"onal act) such as wal'"n# "n a cloc'w"se c"rcle before lea!"n# a
roo* or wash"n# the hands repeatedl$
A pat"ent who has a chosen *ethod and a plan to co**"t su"c"de "n the ne+t E= to D3 hours "s at h"#h r"s' for su"c"de$
The therapeut"c seru* le!el for l"th"u* "s 4$: to 1$: *E6<L$
>hob"c d"sorders are treated w"th desens"t"1at"on therap) wh"ch #raduall e+poses a pat"ent to an an+"et0produc"n#
st"*ulus$
5sfunct"onal #r"e!"n# "s absent or prolon#ed #r"ef$
5ur"n# phase I of the nurse0pat"ent relat"onsh"p ,be#"nn"n#) or or"entat"on) phase-) the nurse obta"ns an "n"t"al h"stor and
the nurse and the pat"ent a#ree to a contract$
5ur"n# phase II of the nurse0pat"ent relat"onsh"p ,*"ddle) or wor'"n#) phase-) the pat"ent d"scusses h"s proble*s)
beha!"oral chan#es occur) and self0defeat"n# beha!"or "s resol!ed or reduced$
5ur"n# phase III of the nurse0pat"ent relat"onsh"p ,ter*"nat"on) or resolut"on) phase-) the nurse ter*"nates the therapeut"c
relat"onsh"p and #"!es the pat"ent pos"t"!e feedbac' on h"s acco*pl"sh*ents$
Accord"n# to /reud) a person between a#es 13 and 34 "s "n the #en"tal sta#e) dur"n# wh"ch he learns "ndependence) has an
"ncreased "nterest "n *e*bers of the oppos"te se+) and establ"shes an "dent"t$
Accord"n# to Er"'son) the "dent"t0!ersus0role confus"on sta#e occurs between a#es 13 and 34$
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Tolerance "s the need for "ncreas"n# a*ounts of a substance to ach"e!e an effect that for*erl was ach"e!ed w"th lesser
a*ounts$
Su"c"de "s the th"rd lead"n# cause of death a*on# wh"te teena#ers$
.ost teena#ers who '"ll the*sel!es *ade a pre!"ous su"c"de atte*pt and left telltale s"#ns of the"r plans$
In Er"'sons sta#e of #enerat"!"t !ersus despa"r) #enerat"!"t ,"n!est*ent of the self "n the "nterest of the lar#er
co**un"t- "s e+pressed throu#h procreat"on) wor') co**un"t ser!"ce) and creat"!e endea!ors$
Alcohol"cs Anon*ous reco**ends a 130step pro#ra* to ach"e!e sobr"et$
S"#ns and s*pto*s of anore+"a ner!osa "nclude a*enorrhea) e+cess"!e we"#ht loss) lanu#o ,f"ne bod ha"r-) abdo*"nal
d"stent"on) and electrolte d"sturbances$
A seru* l"th"u* le!el that e+ceeds 3$4 *E6<L "s cons"dered to+"c$
>ubl"c Law OE03ED ,;h"ld Abuse and Ne#lect Act of 1ODF- re6u"res report"n# of suspected cases of ch"ld abuse to ch"ld
protect"on ser!"ces$
The nurse should suspect se+ual abuse "n a oun# ch"ld who has blood "n the feces or ur"ne) pen"le or !a#"nal d"schar#e)
#en"tal trau*a that "snt read"l e+pla"ned) or a se+uall trans*"tted d"sease$
An alcohol"c uses alcohol to cope w"th the stresses of l"fe$
The hu*an personal"t operates on three le!elsI consc"ous) preconsc"ous) and unconsc"ous$
As'"n# a pat"ent an open0ended 6uest"on "s one of the best was to el"c"t or clar"f "nfor*at"on$
The d"a#nos"s of aut"s* "s often *ade when a ch"ld "s between a#es 3 and F$
5efense *echan"s*s protect the personal"t b reduc"n# stress and an+"et$
Suppress"on "s !oluntar e+clus"on of stress0produc"n# thou#hts fro* the consc"ousness$
In pschodra*a) l"fe s"tuat"ons are appro+"*ated "n a structured en!"ron*ent) allow"n# the part"c"pant to recreate and
enact scenes to #a"n "ns"#ht and to pract"ce new s'"lls$
>schodra*a "s a therapeut"c techn"6ue thats used w"th #roups to help part"c"pants #a"n new percept"on and self0
awareness b act"n# out the"r own or ass"#ned proble*s$
A pat"ent who "s ta'"n# d"sulf"ra* ,Antabuse- *ust a!o"d "n#est"n# products that conta"n alcohol) such as cou#h srup)
fru"tca'e) and sauces and soups *ade w"th coo'"n# w"ne$
A pat"ent who "s ad*"tted to a psch"atr"c hosp"tal "n!oluntar"l loses the r"#ht to s"#n out a#a"nst *ed"cal ad!"ce$
?>eople who l"!e "n #lass houses shouldnt throw stones@ and ?A roll"n# stone #athers no *oss@ are e+a*ples of pro!erbs
used dur"n# a psch"atr"c "nter!"ew to deter*"ne a pat"ents ab"l"t to th"n' abstractl$ ,Sch"1ophren"c pat"ents th"n' "n
concrete ter*s and *"#ht "nterpret the #lass house pro!erb as ?If ou throw a stone "n a #lass house) the house w"ll
brea'$@-
S"#ns of l"th"u* to+"c"t "nclude d"arrhea) tre*ors) nausea) *uscle wea'ness) ata+"a) and confus"on$
A lab"le affect "s character"1ed b rap"d sh"fts of e*ot"ons and *ood$
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11D
NURSING BULLETS _____________ ___________________________________________________________
A*nes"a "s loss of *e*or fro* an or#an"c or "nor#an"c cause$
A person who has borderl"ne personal"t d"sorder "s de*and"n# and &ud#*ental "n "nterpersonal relat"onsh"ps and w"ll
atte*pt to spl"t staff b po"nt"n# to d"screpanc"es "n the treat*ent plan$
5"sulf"ra* ,Antabuse- shouldnt be ta'en concurrentl w"th *etron"da1ole ,/la#l- because the *a "nteract and cause a
pschot"c react"on$
In rare cases) electrocon!uls"!e therap causes arrhth*"as and death$
A pat"ent who "s scheduled for electrocon!uls"!e therap should rece"!e noth"n# b *outh after *"dn"#ht to pre!ent
asp"rat"on wh"le under anesthes"a$
Electrocon!uls"!e therap "s nor*all used for pat"ents who ha!e se!ere depress"on that doesnt respond to dru# therap$
/or electrocon!uls"!e therap to be effect"!e) the pat"ent usuall rece"!es 2 to 13 treat*ents at a rate of 3 to F per wee'$
5ur"n# the *an"c phase of b"polar affect"!e d"sorder) nurs"n# care "s d"rected at slow"n# the pat"ent down because the
pat"ent *a d"e as a result of self0"nduced e+haust"on or "n&ur$
/or a pat"ent w"th Al1he"*ers d"sease) the nurs"n# care plan should focus on safet *easures$
After se+ual assault) the pat"ents needs are the pr"*ar concern) followed b *ed"cole#al cons"derat"ons$
>at"ents who are "n a *a"ntenance pro#ra* for narcot"c abst"nence sndro*e rece"!e 14 to E4 *# of *ethadone
,5oloph"ne- "n a s"n#le da"l dose and are *on"tored to ensure that the dru# "s "n#ested$
Stress *ana#e*ent "s a short0ran#e #oal of pschotherap$
The *ood *ost often e+per"enced b a pat"ent w"th or#an"c bra"n sndro*e "s "rr"tab"l"t$
;reat"!e "ntu"t"on "s controlled b the r"#ht s"de of the bra"n$
.ethohe+"tal ,Bre!"tal- "s the #eneral anesthet"c thats ad*"n"stered to pat"ents who are scheduled for electrocon!uls"!e
therap$
The dec"s"on to use restra"nts should be based on the pat"ents safet needs$
5"phenhdra*"ne ,Benadrl- rel"e!es the e+trapra*"dal ad!erse effects of pschotrop"c dru#s$
In a pat"ent who "s stab"l"1ed on l"th"u* ,Es'al"th- therap) blood l"th"u* le!els should be chec'ed = to 13 hours after the
f"rst dose) then two or three t"*es wee'l dur"n# the f"rst *onth$ Le!els should be chec'ed wee'l to *onthl dur"n#
*a"ntenance therap$
The pr"*ar purpose of pschotrop"c dru#s "s to decrease the pat"ents s*pto*s) wh"ch "*pro!es funct"on and "ncreases
co*pl"ance w"th therap$
.an"pulat"on "s a *aladapt"!e *ethod of *eet"n# ones needs because "t d"sre#ards the needs and feel"n#s of others$
If a pat"ent has s*pto*s of l"th"u* to+"c"t) the nurse should w"thhold one dose and call the phs"c"an$
A pat"ent who "s ta'"n# l"th"u* ,Es'al"th- for b"polar affect"!e d"sorder *ust *a"nta"n a balanced d"et w"th ade6uate salt
"nta'e$
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A pat"ent who constantl see's appro!al or ass"stance fro* staff *e*bers and other pat"ents "s de*onstrat"n# dependent
beha!"or$
Alcohol"cs Anon*ous ad!ocates total abst"nence fro* alcohol$
.ethlphen"date ,R"tal"n- "s the dru# of cho"ce for treat"n# attent"on def"c"t hperact"!"t d"sorder "n ch"ldren$
Sett"n# l"*"ts "s the *ost effect"!e wa to control *an"pulat"!e beha!"or$
J"olent outbursts are co**on "n a pat"ent who has borderl"ne personal"t d"sorder$
%hen wor'"n# w"th a depressed pat"ent) the nurse should e+plore *ean"n#ful losses$
An "llus"on "s a *"s"nterpretat"on of an actual en!"ron*ental st"*ulus$
An+"et "s nonspec"f"cN fear "s spec"f"c$
E+trapra*"dal ad!erse effects are co**on "n pat"ents who ta'e ant"pschot"c dru#s$
The nurse should encoura#e an an#r pat"ent to follow a phs"cal e+erc"se pro#ra* as one of the was to !ent"late
feel"n#s$
5epress"on "s cl"n"call s"#n"f"cant "f "ts character"1ed b e+a##erated feel"n#s of sadness) *elanchol) de&ect"on)
worthlessness) and hopelessness that are "nappropr"ate or out of proport"on to real"t$
/ree0float"n# an+"et "s an+"ousness w"th #eneral"1ed apprehens"on and pess"*"s* for un'nown reasons$
In a pat"ent who "s e+per"enc"n# "ntense an+"et) the f"#ht0or0fl"#ht react"on ,alar* refle+- *a ta'e o!er$
;onfabulat"on "s the use of "*a#"nar e+per"ences or *ade0up "nfor*at"on to f"ll *"ss"n# #aps of *e*or$
%hen start"n# a therapeut"c relat"onsh"p w"th a pat"ent) the nurse should e+pla"n that the purpose of the therap "s to
produce a pos"t"!e chan#e$
A bas"c assu*pt"on of pschoanalt"c theor "s that all beha!"or has *ean"n#$
;athars"s "s the e+press"on of deep feel"n#s and e*ot"ons$
Accord"n# to the pleasure pr"nc"ple) the psche see's pleasure and a!o"ds unpleasant e+per"ences) re#ardless of the
conse6uences$
A pat"ent who has a con!ers"on d"sorder resol!es a pscholo#"cal confl"ct throu#h the loss of a spec"f"c phs"cal funct"on
,for e+a*ple) parals"s) bl"ndness) or "nab"l"t to swallow-$ Th"s loss of funct"on "s "n!oluntar) but d"a#nost"c tests show
no or#an"c cause$
;hlord"a1epo+"de ,L"br"u*- "s the dru# of cho"ce for treat"n# alcohol w"thdrawal s*pto*s$
/or a pat"ent who "s at r"s' for alcohol w"thdrawal) the nurse should assess the pulse rate and blood pressure e!er 3 hours
for the f"rst 13 hours) e!er E hours for the ne+t 3E hours) and e!er 2 hours thereafter ,unless the pat"ents cond"t"on
beco*es unstable-$
Alcohol deto+"f"cat"on "s *ost successful when carr"ed out "n a structured en!"ron*ent b a support"!e) non&ud#*ental
staff$
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The nurse should follow these #u"del"nes when car"n# for a pat"ent who "s e+per"enc"n# alcohol w"thdrawalI .a"nta"n a
cal* en!"ron*ent) 'eep "ntrus"ons to a *"n"*u*) spea' slowl and cal*l) ad&ust l"#ht"n# to pre!ent shadows and #lare)
call the pat"ent b na*e) and ha!e a fr"end or fa*"l *e*ber sta w"th the pat"ent) "f poss"ble$
The therapeut"c re#"*en for an alcohol"c pat"ent "ncludes fol"c ac"d) th"a*"ne) and *ult"!"ta*"n supple*ents as well as
ade6uate food and flu"ds$
A pat"ent who "s add"cted to op"ates ,dru#s der"!ed fro* popp seeds) such as hero"n and *orph"ne- tp"call e+per"ences
w"thdrawal s*pto*s w"th"n 13 hours after the last dose$ The *ost se!ere s*pto*s occur w"th"n E= hours and decrease
o!er the ne+t 3 wee's$
React"!e depress"on "s a response to a spec"f"c l"fe e!ent$
>ro&ect"on "s the unconsc"ous ass"#n"n# of a thou#ht) feel"n#) or act"on to so*eone or so*eth"n# else$
Subl"*at"on "s the channel"n# of unacceptable "*pulses "nto soc"all acceptable beha!"or$
Repress"on "s an unconsc"ous defense *echan"s* whereb unacceptable or pa"nful thou#hts) "*pulses) *e*or"es) or
feel"n#s are pushed fro* the consc"ousness or for#otten$
(pochondr"as"s "s *orb"d an+"et about ones health assoc"ated w"th !ar"ous s*pto*s that arent caused b or#an"c
d"sease$
5en"al "s a refusal to ac'nowled#e feel"n#s) thou#hts) des"res) "*pulses) or e+ternal facts that are consc"ousl "ntolerable$
React"on for*at"on "s the a!o"dance of an+"et throu#h beha!"or and att"tudes that are the oppos"te of repressed "*pulses
and dr"!es$
5"splace*ent "s the transfer of unacceptable feel"n#s to a *ore acceptable ob&ect$
Re#ress"on "s a retreat to an earl"er de!elop*ental sta#e$
Accord"n# to Er"'son) an older adult ,a#e 2: or older- "s "n the de!elop*ental sta#e of "nte#r"t !ersus despa"r$
/a*"l therap focuses on the fa*"l as a whole rather than the "nd"!"dual$ Its *a&or ob&ect"!e "s to reestabl"sh rat"onal
co**un"cat"on between fa*"l *e*bers$
%hen car"n# for a pat"ent who "s host"le or an#r) the nurse should atte*pt to re*a"n cal*) l"sten "*part"all) use short
sentences) and spea' "n a f"r*) 6u"et !o"ce$
R"tual"s* and ne#at"!"s* are tp"cal toddler beha!"ors$ The occur dur"n# the de!elop*ental sta#e "dent"f"ed b Er"'son
as autono* !ersus sha*e and doubt$
;"rcu*stant"al"t "s a d"sturbance "n assoc"ated thou#ht and speech patterns "n wh"ch a pat"ent #"!es unnecessar) *"nute
deta"ls and d"#resses "nto "nappropr"ate thou#hts that dela co**un"cat"on of central "deas and #oal ach"e!e*ent$
Idea of reference "s an "ncorrect bel"ef that the state*ents or act"ons of others are related to oneself$
Group therap pro!"des an opportun"t for each #roup *e*ber to e+a*"ne "nteract"ons) learn and pract"ce successful
"nterpersonal co**un"cat"on s'"lls) and e+plore e*ot"onal confl"cts$
Lorsa'offs sndro*e "s bel"e!ed to be a chron"c for* of %ern"c'es encephalopath$ Its *ar'ed b halluc"nat"ons)
confabulat"on) a*nes"a) and d"sturbances of or"entat"on$
A pat"ent w"th ant"soc"al personal"t d"sorder often en#a#es "n confrontat"ons w"th author"t f"#ures) such as pol"ce)
parents) and school off"c"als$
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A pat"ent w"th parano"d personal"t d"sorder e+h"b"ts susp"c"on) hper!"#"lance) and host"l"t toward others$
5epress"on "s the *ost co**on psch"atr"c d"sorder$
Ad!erse react"ons to tr"ccl"c ant"depressant dru#s "nclude tachcard"a) orthostat"c hpotens"on) hpo*an"a) lowered
se"1ure threshold) tre*ors) we"#ht #a"n) proble*s w"th erect"ons or or#as*s) and an+"et$
The ."nnesota .ult"phas"c >ersonal"t In!entor cons"sts of ::4 state*ents for the sub&ect to "nterpret$ It assesses
personal"t and detects d"sorders) such as depress"on and sch"1ophren"a) "n adolescents and adults$
Hr#an"c bra"n sndro*e "s the *ost co**on for* of *ental "llness "n elderl pat"ents$
A person who has an IP of less than 34 "s profoundl retarded and "s cons"dered a total0care pat"ent$
Refra*"n# "s a therapeut"c techn"6ue thats used to help depressed pat"ents to !"ew a s"tuat"on "n alternat"!e was$
/luo+et"ne ,>ro1ac-) sertral"ne ,8oloft-) and paro+et"ne ,>a+"l- are seroton"n reupta'e "nh"b"tors used to treat depress"on$
The earl sta#e of Al1he"*ers d"sease lasts 3 to E ears$ >at"ents ha!e "nappropr"ate affect) trans"ent parano"a)
d"sor"entat"on to t"*e) *e*or loss) careless dress"n#) and "*pa"red &ud#*ent$
The *"ddle sta#e of Al1he"*ers d"sease lasts E to D ears and "s *ar'ed b profound personal"t chan#es) loss of
"ndependence) d"sor"entat"on) confus"on) "nab"l"t to reco#n"1e fa*"l *e*bers) and nocturnal restlessness$
The last sta#e of Al1he"*ers d"sease occurs dur"n# the f"nal ear of l"fe and "s character"1ed b a blan' fac"al e+press"on)
se"1ures) loss of appet"te) e*ac"at"on) "rr"tab"l"t) and total dependence$
Threaten"n# a pat"ent w"th an "n&ect"on for fa"l"n# to ta'e an oral dru# "s an e+a*ple of assault$
Ree+a*"nat"on of l"fe #oals "s a *a&or de!elop*ental tas' dur"n# *"ddle adulthood$
Acute alcohol w"thdrawal causes anore+"a) "nso*n"a) headache) and restlessness and escalates to a sndro*e thats
character"1ed b a#"tat"on) d"sor"entat"on) !"!"d halluc"nat"ons) and tre*ors of the hands) feet) le#s) and ton#ue$
In a hosp"tal"1ed alcohol"c) alcohol w"thdrawal del"r"u* *ost co**onl occurs F to E das after ad*"ss"on$
;onfrontat"on "s a co**un"cat"on techn"6ue "n wh"ch the nurse po"nts out d"screpanc"es between the pat"ents words and
h"s non!erbal beha!"ors$
/or a pat"ent w"th substance0"nduced del"r"u*) the t"*e of dru# "n#est"on can help to deter*"ne whether the dru# can be
e!acuated fro* the bod$
Treat*ent for alcohol w"thdrawal *a "nclude ad*"n"strat"on of I$J$ #lucose for hpo#lce*"a) I$J$ flu"d conta"n"n#
th"a*"ne and other B !"ta*"ns) and ant"an+"et) ant"d"arrheal) ant"con!ulsant) and ant"e*et"c dru#s$
The alcohol"c pat"ent rece"!es th"a*"ne to help pre!ent per"pheral neuropath and Lorsa'offs sndro*e$
Alcohol w"thdrawal *a prec"p"tate se"1ure act"!"t because alcohol lowers the se"1ure threshold "n so*e people$
>araphras"n# "s an act"!e l"sten"n# techn"6ue "n wh"ch the nurse restates what the pat"ent has &ust sa"d$
A pat"ent w"th Lorsa'offs sndro*e *a use confabulat"on ,*ade up "nfor*at"on- to co!er *e*or lapses or per"ods of
a*nes"a$
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>eople w"th obsess"!e0co*puls"!e d"sorder real"1e that the"r beha!"or "s unreasonable) but are powerless to control "t$
%hen w"tness"n# psch"atr"c pat"ents who are en#a#ed "n a threaten"n# confrontat"on) the nurse should f"rst separate the
two "nd"!"duals$
>at"ents w"th anore+"a ner!osa or bul"*"a *ust be obser!ed dur"n# *eals and for so*e t"*e afterward to ensure that the
dont pur#e what the ha!e eaten$
Transse+uals bel"e!e that the were born the wron# #ender and *a see' hor*onal or sur#"cal treat*ent to chan#e the"r
#ender$
/u#ue "s a d"ssoc"at"!e state "n wh"ch a person lea!es h"s fa*"l"ar surround"n#s) assu*es a new "dent"t) and has a*nes"a
about h"s pre!"ous "dent"t$ ,Its also descr"bed as ?fl"#ht fro* h"*self$@-
In a psch"atr"c sett"n#) the pat"ent should be able to pred"ct the nurses beha!"or and e+pect cons"stent pos"t"!e att"tudes
and approaches$
%hen establ"sh"n# a schedule for a one0to0one "nteract"on w"th a pat"ent) the nurse should state how lon# the con!ersat"on
w"ll last and then adhere to the t"*e l"*"t$
Thou#ht broadcast"n# "s a tpe of delus"on "n wh"ch the person bel"e!es that h"s thou#hts are be"n# broadcast for the world
to hear$
L"th"u* should be ta'en w"th food$ A pat"ent who "s ta'"n# l"th"u* shouldnt restr"ct h"s sod"u* "nta'e$
A pat"ent who "s ta'"n# l"th"u* should stop ta'"n# the dru# and call h"s phs"c"an "f he e+per"ences !o*"t"n#) drows"ness)
or *uscle wea'ness$
The pat"ent who "s ta'"n# a *onoa*"ne o+"dase "nh"b"tor for depress"on can "nclude cotta#e cheese) crea* cheese) o#urt)
and sour crea* "n h"s d"et$
Sensor o!erload "s a state "n wh"ch sensor st"*ulat"on e+ceeds the "nd"!"duals capac"t to tolerate or process "t$
S*pto*s of sensor o!erload "nclude a feel"n# of d"stress and hperarousal w"th "*pa"red th"n'"n# and concentrat"on$
In sensor depr"!at"on) o!erall sensor "nput "s decreased$
A s"#n of sensor depr"!at"on "s a decrease "n st"*ulat"on fro* the en!"ron*ent or fro* w"th"n oneself) such as
dadrea*"n#) "nact"!"t) sleep"n# e+cess"!el) and re*"n"sc"n#$
The three sta#es of #eneral adaptat"on sndro*e are alar*) res"stance) and e+haust"on$
A *aladapt"!e response to stress "s dr"n'"n# alcohol or s*o'"n# e+cess"!el$
(peralertness and the startle refle+ are character"st"cs of posttrau*at"c stress d"sorder$
A treat*ent for a phob"a "s desens"t"1at"on) a process "n wh"ch the pat"ent "s slowl e+posed to the feared st"*ul"$
S*pto*s of *a&or depress"!e d"sorder "nclude depressed *ood) "nab"l"t to e+per"ence pleasure) sleep d"sturbance)
appet"te chan#es) decreased l"b"do) and feel"n#s of worthlessness$
;l"n"cal s"#ns of l"th"u* to+"c"t are nausea) !o*"t"n#) and lethar#$
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As'"n# too *an ?wh@ 6uest"ons "elds scant "nfor*at"on and *a o!erwhel* a psch"atr"c pat"ent and lead to stress
and w"thdrawal$
Re*ote *e*or *a be "*pa"red "n the late sta#es of de*ent"a$
Accord"n# to the 5S.0IJ) b"polar II d"sorder "s character"1ed b at least one *an"c ep"sode thats acco*pan"ed b
hpo*an"a$
The nurse can use s"lence and act"!e l"sten"n# to pro*ote "nteract"ons w"th a depressed pat"ent$
A psch"atr"c pat"ent w"th a substance abuse proble* and a *a&or psch"atr"c d"sorder has a dual d"a#nos"s$
%hen a pat"ent "s read*"tted to a *ental health un"t) the nurse should assess co*pl"ance w"th *ed"cat"on orders$
Alcohol potent"ates the effects of tr"ccl"c ant"depressants$
/l"#ht of "deas "s *o!e*ent fro* one top"c to another w"thout an d"scern"ble connect"on$
;onduct d"sorder "s *an"fested b e+tre*e beha!"or) such as hurt"n# people and an"*als$
5ur"n# the ?tens"on0bu"ld"n#@ phase of an abus"!e relat"onsh"p) the abused "nd"!"dual feels helpless$
In the e*er#enc treat*ent of an alcohol0"nto+"cated pat"ent) deter*"n"n# the blood0alcohol le!el "s para*ount "n
deter*"n"n# the a*ount of *ed"cat"on that the pat"ent needs$
S"de effects of the ant"depressant fluo+et"ne ,>ro1ac- "nclude d"arrhea) decreased l"b"do) we"#ht loss) and dr *outh$
Before electrocon!uls"!e therap) the pat"ent "s #"!en the s'eletal *uscle rela+ant succ"nlchol"ne ,Anect"ne- b I$J$
ad*"n"strat"on$
%hen a pschot"c pat"ent "s ad*"tted to an "npat"ent fac"l"t) the pr"*ar concern "s safet) followed b the establ"sh*ent
of trust$
An effect"!e wa to decrease the r"s' of su"c"de "s to *a'e a su"c"de contract w"th the pat"ent for a spec"f"ed per"od of
t"*e$
A depressed pat"ent should be #"!en suff"c"ent port"ons of h"s fa!or"te foods) but shouldnt be o!erwhel*ed w"th too *uch
food$
The nurse should assess the depressed pat"ent for su"c"dal "deat"on$
5elus"onal thou#ht patterns co**onl occur dur"n# the *an"c phase of b"polar d"sorder$
Apath "s tp"call obser!ed "n pat"ents who ha!e sch"1ophren"a$
.an"pulat"!e beha!"or "s character"st"c of a pat"ent who has pass"!eV a##ress"!e personal"t d"sorder$
%hen a pat"ent who has sch"1ophren"a be#"ns to halluc"nate) the nurse should red"rect the pat"ent to act"!"t"es that are
focused on the here and now$
%hen a pat"ent who "s rece"!"n# an ant"pschot"c dru# e+h"b"ts *uscle r"#"d"t and tre*ors) the nurse should ad*"n"ster
an ant"par'"nson"an dru# ,for e+a*ple) ;o#ent"n or Artane- as ordered$
A pat"ent who "s rece"!"n# l"th"u* ,Es'al"th- therap should report d"arrhea) !o*"t"n#) drows"ness) *uscular wea'ness) or
lac' of coord"nat"on to the phs"c"an "**ed"atel$
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The therapeut"c seru* le!el of l"th"u* ,Es'al"th- for *a"ntenance "s 4$2 to 1$3 *E6<L$
Hbsess"!e0co*puls"!e d"sorder "s an an+"et0related d"sorder$
Al0Anon "s a self0help #roup for fa*"l"es of alcohol"cs$
5esens"t"1at"on "s a treat*ent for phob"a) or "rrat"onal fear$
After electrocon!uls"!e therap) the pat"ent "s placed "n the lateral pos"t"on) w"th the head turned to one s"de$
A delus"on "s a f"+ed false bel"ef$
G"!"n# awa personal possess"ons "s a s"#n of su"c"dal "deat"on$ Hther s"#ns "nclude wr"t"n# a su"c"de note or tal'"n# about
su"c"de$
A#oraphob"a "s fear of open spaces$
A person who has parano"d personal"t d"sorder pro&ects host"l"t"es onto others$
To assess a pat"ents &ud#*ent) the nurse should as' the pat"ent what he would do "f he found a sta*ped) addressed
en!elope$ An appropr"ate response "s that he would *a"l the en!elope$
After electrocon!uls"!e therap) the pat"ent should be *on"tored for post0shoc' a*nes"a$
A *other who cont"nues to perfor* card"opul*onar resusc"tat"on after a phs"c"an pronounces a ch"ld dead "s show"n#
den"al$
Trans!est"s* "s a des"re to wear clothes usuall worn b *e*bers of the oppos"te se+$
Tard"!e ds'"nes"a causes e+cess"!e bl"n'"n# and unusual *o!e*ent of the ton#ue) and "n!oluntar suc'"n# and chew"n#$
Tr"he+phen"dl ,Artane- and ben1trop"ne ,;o#ent"n- are ad*"n"stered to counteract e+trapra*"dal ad!erse effects$
To pre!ent hpertens"!e cr"s"s) a pat"ent who "s ta'"n# a *onoa*"ne o+"dase "nh"b"tor should a!o"d consu*"n# a#ed
cheese) caffe"ne) beer) east) chocolate) l"!er) processed foods) and *onosod"u* #luta*ate$
E+trapra*"dal s*pto*s "nclude par'"nson"s*) dston"a) a'ath"s"a ,?ants "n the pants@-) and tard"!e ds'"nes"a$
Hne theor that supports the use of electrocon!uls"!e therap su##ests that "t ?resets@ the bra"n c"rcu"ts to allow nor*al
funct"on$
A pat"ent who has obsess"!e0co*puls"!e d"sorder usuall reco#n"1es the senselessness of h"s beha!"or but "s powerless to
stop "t ,e#o0dston"a-$
In help"n# a pat"ent who has been abused) phs"cal safet "s the nurses f"rst pr"or"t$
>e*ol"ne ,;lert- "s used to treat attent"on def"c"t hperact"!"t d"sorder ,A5(5-$
;lo1ap"ne ,;lo1ar"l- "s contra"nd"cated "n pre#nant wo*en and "n pat"ents who ha!e se!ere #ranuloctopen"a or se!ere
central ner!ous sste* depress"on$
Repress"on) an unconsc"ous process) "s the "nab"l"t to recall pa"nful or unpleasant thou#hts or feel"n#s$
>ro&ect"on "s sh"ft"n# of unwanted character"st"cs or shortco*"n#s to others ,scape#oat-$
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13E
NURSING BULLETS _____________ ___________________________________________________________
(pnos"s "s used to treat pscho#en"c a*nes"a$
5"sulf"ra* ,Antabuse- "s ad*"n"stered orall as an a!ers"on therap to treat alcohol"s*$
In#est"on of alcohol b a pat"ent who "s ta'"n# d"sulf"ra* ,Antabuse- can cause se!ere react"ons) "nclud"n# nausea and
!o*"t"n#) and *a endan#er the pat"ents l"fe$
I*pro!ed concentrat"on "s a s"#n that l"th"u* "s ta'"n# effect$
Beha!"or *od"f"cat"on) "nclud"n# t"*e0outs) to'en econo*) or a reward sste*) "s a treat*ent for attent"on def"c"t
hperact"!"t d"sorder$
/or a pat"ent who has anore+"a ner!osa) the nurse should pro!"de support at *ealt"*e and record the a*ount the pat"ent
eats$
A s"#n"f"cant to+"c r"s' assoc"ated w"th clo1ap"ne ,;lo1ar"l- ad*"n"strat"on "s blood dscras"a$
Ad!erse effects of haloper"dol ,(aldol- ad*"n"strat"on "nclude drows"nessN "nso*n"aN wea'nessN headacheN and
e+trapra*"dal s*pto*s) such as a'ath"s"a) tard"!e ds'"nes"a) and dston"a$
(per!"#"lance and dZ&c !u are s"#ns of posttrau*at"c stress d"sorder ,>TS5-$
A ch"ld who shows d"ssoc"at"on has probabl been abused$
;onfabulat"on "s the use of fantas to f"ll "n #aps of *e*or$
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13: