QT 6

cdunbar4's version from 2017-09-22 21:05

Section 1

Question Answer
butorphanol tartrate narcotic pain reliever, causes sedation; monitor VS for respirations depth/rate
tx for discomfort after immunization for infantsantipyretics (not salicylates) can be used; cool compress to decrease pain for temp. intervention; decrease movement of extremity
Early signs of hypoxemia in 4 year oldIncreased HR; throwing toys and kicking in bed; nasal flaring with activity
Later signs of hypoxemia in 4yo?bluish discoloration of skin (cyanosis); bluish discoloration around mouth (circumoral cyanosis)
CI to administer IPV immunization to infant who is HIV positive?No. CI include anaphylactic rxn to neomycin, streptomycin or polymyxin B. Also, if child has had a seizure w/in 3 days of DTP
Client has torticollis, arched back and rapid movement of eyesClient is experiencing EPS, do NOT give haloperidol (will only exacerbate symptoms); administer PRN trihexyphenidyl IM immediately or benztropine
"clergy" spiritual support during a crisis
incorrect blood glucose testingmilking finger after sticking it (forces interstitial fluid with blood and dilutes it)
RSV infant; young child with infected wound s. aureus...precautions?contact, no mask
teen with TSS precautions?standard
rubella (German measles) precautionsdroplet; gown, gloves, mask
D/C teaching client with M.S.ambulate as tolerated every day; avoid overexposure to heat; perform ROM/stretching/strengthening exercises; participate in social activities
Priority for post op thyroidectomy surgerymonitor signs resp. distress every hour as swelling can occur
What would you observe from a client post thyroidectomy if they had post op hemorrhaging?frequent swallowing
terbutaline used to delay delivery in preterm labor
client diagnosed with placenta previaget ready for immediate c section
Common post op total laryngectomy nutritional support for about 10 days until wound heals, then gradually resumes oral intake; will require tube to prevent scar tissue contracture; will not be able to sing, whistle or laugh using laryngeal communication
Curling's ulcerclient is at risk for it 24 hours after a severe burn; gastric pH is acidic (1-5)
Appropriate weight gain for first trimester2-5 lb.
Appropriate weight gain for 2nd and third trimester0.66-1.1 lb. weekly
Bulge test confirms presence of fluid in the knee
how to perform bulge testlie down with extended legs
Normal timeframe of thumb suckingpeaks at 18-20months, persists til about 24 months...this is it usually subsides
prenatal vitamins should be taken withsomething acidic, increases absorption of iron; taking them with food decreases possibility of nausea since client will be asleep
transition phase breathing techniquepant with pursed lips-allows patient to control pain and promotes adequate oxygenation of fetus

Section 2

Question Answer
plan of care for positive sweat testrefer to social services/multi disciplinary care is required for children with this diagnosis; unrestricted fat diet due to the malabsorption of fat; enzyme replacement therapy
manic phase nursing caredistract client with light physical activities; remind client about the rules concisely
correct method of palpating contractionsplace one hand on abdomen over fundus, and with fingertips, press gently
chlorpromazine administration times to reduce daytime sedationused to treat psychosis, change times to 100mg in morning, 100mg after dinner and 100mg at hs
fluid volume deficit/dehydrationcan cause dizziness (notify pcp); use a measuring cup to measure amount client drinks throughout day; drink fluids throughout day
between ages 6-12, children grow about how many inches per year?2 inches
Age 7 average weight/height39-66.5lb and 44-51inches
Common misconception of diet increases for pregnant womento double their calories; women should increase caloric intake by 300 for fetal growth, maternal tissues and the placenta
Risperidone pt. teachingcan cause weight gain, ortho hypoTN (change positions slowly), impairs body temp regulation (avoid extreme temps), causes photosensitive reactions
Braxton Hicks contractionscan occur and feel like abdomen relax/contract when hand is placed on it
unilateral, dull abdominal pain of client at 4 wks gestationneeds to be evaluated for ectopic pregnancy; unstable, unexpected, circulatory, real
moderate cramping and bright red bleedingthreatened abortion: unstable, unexpected, circulation, potential, moderate bleeding
light vaginal spotting, mild crampingspontaneous abortion
whitish vaginal secretions during first trimester of pregnancyexpected
morphine given to pt. for crushing chest pain radiating to left shoulder and arm. How does morphine help to relieve this pain?reduces cardiac workload, pain and anxiety; reduces preload and afterload
what would indicate an air leak in a chest tube?constant bubbling in water seal chamber
treatment to help with exopthalmos in hyperthyroidismopthalmic eye drops
sputum characteristics indicating a decrease in pneumoniarespirations 20 with moderate amount of thin, white sputum, denies dyspnea
proper administration of sucralatebest on an empty stomach, take 1 hour before meals and aluminum hydroxide 1 hour after meals
Salem sump tube (NG) is effectivelypresence of hissing sound from blue lumen tube
numbness in hand after cardiac cathnotify pcp, could indicate problem with circulation; anticoagulants and vasodilators may be ordered
hyperparathyroidism55% of pts develop renal calculi, hematuria is a sign of urinary tract calculi, important to report to next nurse
isoniaized may causeperipheral neuropathy (tingling in peripheries), can also cause nausea
client has decided to bottle feed, actions r/t breast milk productionuse acetaminophen as directed ; apply cool packs around outside of each breast (will decrease milk production); supportive bra; engorgement/milk will resolve in 5-7 days