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NCLEX - MedSurg
NCLEX Review - Medical/Surgical
| Question | Answer |
|---|---|
| List four common symptoms of pneumonia the nurse might note on physical examination. | Tachypnea, fever with chills, productive cough, bronchial breath sounds |
| State four nursing interventions for assisting the client to cough productively. | Encourage deep breathing; increase fluid intake to 3 L/day; use humidity to loosen secretions; suction airway to stimulate coughing. |
| What symptoms of pneumonia might the nurse expect to see in an older client? | Confusion, lethargy, anorexia, rapid respiratory rate |
| How does the nurse prevent hypoxia during suctioning? | Deliver 100% O2 (hyperinflating) before and after each endotracheal suctioning. |
| During mechanical ventilation, what are three major nursing interventions? | Monitor client’s respiratory status and secure connections; establish a communication mechanism with the client; keep airway clear by coughing and suctioning. |
| When examining a client with emphysema, what physical findings is the nurse likely to see? | (Pink Puffer) Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in lung fields |
| What is the most common risk factor associated with lung cancer? | Smoking |
| Describe the preoperative nursing care for a client undergoing a laryngectomy. | Involve family and client in manipulation of tracheostomy equipment before surgery; plan acceptable communication methods; refer to speech pathologist; discuss rehabilitation program. |
| List five nursing interventions after chest tube insertion. | Maintain dry occlusive dressing on chest tube. Keep all tubing connections tight and taped. Monitor clinical status. Encourage the client to breathe deeply periodically. Monitor the fluid drainage, and mark the time of measurement and the fluid level. |
| What immediate action should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus? What should the nurse do if a chest tube is accidentally removed from the client? | Place the end of the tube in a sterile water container at a 2-cm level. Apply an occlusive dressing, and notify health care provider stat. |
| What instructions should be given to a client following radiation therapy? | Do not wash off lines; wear soft cotton garments; avoid use of powders and creams on radiation site. |
| What precautions are required for clients with TB when placed on respiratory isolation? | A mask for anyone entering room; private room; client must wear mask if leaving room. |
| List four components of teaching for the client with tuberculosis. | Cough into tissues and dispose of immediately in special bags. Long-term need for daily medication. Good handwashing technique. Report symptoms of deterioration, e.g., blood in secretions. |
| What should be checked if fluctuations (tidaling) in chest tube fluid ceases | check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client’s position, because expanding lung tissue may be occluding the tube opening. Remember, when external suction is applied, the fluctuations cease. |
| What is a pink puffer | Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe. The person works harder to breathe, but the amount of O2 taken in is adequate to oxygenate the tissues. |
| What is a blue bloater | Insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (cor pulmonale). |
| Differentiate between acute renal failure and chronic renal failure. | Acute renal failure: often reversible, abrupt deterioration of kidney function. Chronic renal failure: irreversible, slow deterioration of kidney function characterized by increasing BUN and creatinine. Eventually dialysis is required. |
| During the oliguric phase of renal failure, protein should be severely restricted. What is the rationale for this restriction? | Toxic metabolites that accumulate in the blood (urea, creatinine) are derived mainly from protein catabolism. |
| Identify two nursing interventions for the client on hemodialysis. | Do not take BP or perform venipuncture on the arm with the AV shunt, fistula, or graft. Assess access site for thrill and bruit. |
| What is the highest priority nursing diagnosis for clients in any type of renal failure? | Risk for imbalanced fluid volume |
| A client in renal failure asks why he is being given antacids. How should the nurse reply? | Calcium and aluminum antacids bind phosphates and help to keep phosphates from being absorbed into bloodstream, thereby preventing rising phosphate levels; must be taken with meals. |
| List four essential elements of a teaching plan for clients with frequent urinary tract infections. | Fluid intake 3 L/day; good handwashing; void every 2 to 3 hours during waking hours; take all prescribed medications; wear cotton undergarments. |
| What are the most important nursing interventions for clients with possible renal calculi? | Straining all urine is the most important intervention. Other interventions include accurate I&O documentation and administering analgesics as needed. |
| What discharge instructions should be given to a client who has had urinary calculi? | Maintain high fluid intake of 3 to 4 L/day. Pursue follow-up care (stones tend to recur). Follow prescribed diet based on calculi content. Avoid supine position. |
| Following transurethral resection of the prostate gland (TURP), hematuria should subside by what postoperative day? | The fourth day |
| After the urinary catheter is removed in the TURP client, what are three priority nursing actions? | Continued strict I&O. Continued observations for hematuria. Inform client burning and frequency may last for a week. |
| After kidney surgery, what are the primary assessments the nurse should make? | Respiratory status (breathing is guarded because of pain); circulatory status (the kidney is very vascular and excessive bleeding can occur); pain assessment; urinary assessment (most important, assessment of urinary output). |
| What is a percutaneous nephrostomy | needle/catheter inserted through skin into calyx of the kidney. stone may be dissolved by percutaneous irrigation with a liquid or by ultrasonic sound waves (lithotripsy) that can be directed to break up the stone, which then can be eliminated. |
| Signs of digoxin toxicity | Signs of toxicity in adults include nausea, vomiting, anorexia, visual disturbances, restlessness, headache, cardiac dysrhythmias, and pulse <60 bpm. |
| What is the major difference between dialysate for hemodialysis and peritoneal dialysis | Peritoneal dialysis dialysate is much higher in glucose. For this reason, if the dialysate is left in the peritoneal cavity too long, hyperglycemia may occur. |
| Normal urine output | 1 mL/kg/hr; 1500-2000 mL/day |
| How do clients experiencing angina describe that pain? | Described as squeezing, heavy, burning, radiates to left arm or shoulder, transient or prolonged |
| Develop a teaching plan for a client taking nitroglycerin. | Take at first sign of anginal pain. Take no more than three, 5 minutes apart. Call for emergency attention if no relief in 10 minutes. |
| List the parameters of BP for diagnosing HTN. | 140/90 |
| Differentiate between essential and secondary HTN. | Essential HTN has no known cause; secondary HTN develops in response to an identifiable mechanism. |
| Develop a teaching plan for a client taking antihypertensive medications. | Explain how and when to take medication, reason for medication, necessity of compliance, need for follow-up visits while on medication, need for certain lab tests, and vital sign parameters while initiating therapy. |
| Describe intermittent claudication. | Pain related to PVD; the pain occurs with exercise and disappears with rest. |
| Describe the nurse’s discharge instructions to a client with venous PVD. | Keep extremities elevated when sitting, rest at first sign of pain, keep extremities warm (but do not use heating pad), change position often, avoid crossing legs, wear unrestrictive clothing. |
| What is often the underlying cause of an abdominal aortic aneurysm? | Atherosclerosis |
| What lab values should be monitored daily in a client with thrombophlebitis who is undergoing anticoagulant therapy? | PTT, PT, Hgb, Hct, platelets |
| When do PVCs present a grave danger? | When they begin to occur more often than once in 10 beats, occur in twos or threes, land near the T wave, or take on multiple configurations |
| Differentiate between the symptoms of left-sided cardiac failure and right-sided cardiac failure. | Left-sided failure results in pulmonary congestion due to backup of circulation in the left ventricle. Right-sided failure results in peripheral congestion due to backup of circulation in the right ventricle. |
| List three symptoms of digitalis toxicity. | Dysrhythmias, headache, nausea, and vomiting |
| What condition increases the likelihood that digitalis toxicity will occur? | Hypokalemia (which is more common when diuretics and digitalis preparations are given together) |
| When should Digitalis be held | Hold the digitalis if the pulse rate is <60 or >120 bpm (<90 bpm in an infant) or has markedly changed rhythm. |
| What lifestyle changes can the client who is at risk for HTN initiate to reduce the likelihood of becoming hypertensive? | Cease cigarette smoking, if applicable; control weight, exercise regularly, and maintain a low-fat, low-cholesterol diet. |
| What immediate actions should the nurse implement when a client is having a myocardial infarction? | Place the client on immediate strict bed rest to lower O2 demands on heart; administer O2 by nasal cannula at 2 to 5 L/min; take measures to alleviate pain and anxiety (administer PRN pain medications and antianxiety medications). |
| What symptoms should the nurse expect to find in a client with hypokalemia? | Dry mouth and thirst, drowsiness and lethargy, muscle weakness and aches, and tachycardia |
| Bradycardia is defined as a heart rate below _____ bpm. Tachycardia is defined as a heart rate above _____ bpm. | 60 bpm; 100 bpm |
| What precautions should clients with valve disease take prior to invasive procedures or dental work? | Take prophylactic antibiotics. |
| What is the difference between synchronous and asynchronous pacemakers | Synchronous, or demand: Pacemaker fires only when the client’s heart rate falls below a rate set on the generator. Asynchronous, or fixed: Pacemaker fires at a constant rate. |
| What is the antagonist for Heparin? | protamine sulfate |
| What lab value determines the efficacy of Heparin? | PTT at 1.5-2.5 times normal |
| What is the atntagonist for warfarin (Coumadin)? | vitamin K |
| What lab value determines the efficacy of warfarin (Coumadin)? | PT at 1.5-2.5 times normal; INR 2:3 |
| Normal BUN | 10 to 20 mg/dL |
| Normal creatinine | 0.6 to 1.2 mg/dL |
| What medications/treatments should be administered with MIs | MONA: morphine, oxygen, nitroglycerin, aspirin. |
| List four nursing interventions for the client with a hiatal hernia. | Sit up while eating and for 1 hour after eating. Eat frequent, small meals. Eliminate foods that are problematic. |
| List three categories of medications used in the treatment of Peptic Ulcer Disease (PUD). | Antacids, H2 receptor blockers, mucosal healing agents, proton pump inhibitors |
| List the symptoms of upper and lower GI bleeding. | common to both: tarry stools; Upper GI: melena, hematemesis; lower GI: bloody stools |
| What bowel sound disruptions occur with an intestinal obstruction? | Early mechanical obstruction: high-pitched sounds; late mechanical obstruction: diminished or absent bowel sounds |
| List four nursing interventions for postoperative care of a client with a colostomy. | Irrigate daily at same time; use warm water for irrigations; wash around stoma with mild soap and water after each ostomy bag change; ensure that pouch opening extends at least ⅛ inch around the stoma. |
| List the common clinical manifestations of jaundice. | Scleral icterus (yellow sclera), dark urine, chalky or clay-colored stools |
| What are the common food intolerances for clients with cholelithiasis? | Fried, spicy, and fatty foods |
| List five symptoms indicative of colon cancer. | Rectal bleeding, change in bowel habits, sense of incomplete evacuation, abdominal pain with nausea, weight loss |
| In a client with cirrhosis, it is imperative to prevent further bleeding and observe for bleeding tendencies. List six relevant nursing interventions. | Avoid injections; use small-bore needles for IV insertion; maintain pressure for 5 minutes on all venipuncture sites; use electric razor; use soft-bristle toothbrush for mouth care; check stools and emesis for occult blood. |
| What is the main side effect of lactulose, which is used to reduce ammonia levels in clients with cirrhosis? | Diarrhea |
| List four groups who have a high risk for contracting hepatitis. | Homosexual males, IV drug users, those who have had recent ear piercing or tattooing, and health care workers |
| How should the nurse administer pancreatic enzymes? | Give with meals or snacks. Powder forms should be mixed with fruit juices. |
| What is fetor hepaticus | distinctive breath odor of chronic liver disease characterized by a fruity or musty odor that results from the damaged liver’s inability to metabolize and detoxify mercaptan, a sulfurous amino acid. |
| What are the recommendations for early detection of colon cancer? | digital rectal exam yearly after 40; stool blood test yearly after 50; and colonscopy or sigmoidoscopy exam every 10 years after 50 |
| What diagnostic test is used to determine thyroid activity? | T3, T4 |
| What condition results from all treatments for hyperthyroidism? | Hypothyroidism, requiring thyroid replacement |
| State three symptoms of hyperthyroidism and three symptoms of hypothyroidism. | Hyperthyroidism: weight loss, heat intolerance, diarrhea; Hypothyroidism: fatigue, cold intolerance, weight gain |
| List five important teaching aspects for clients who are beginning corticosteroid therapy. | Continue medication until weaning plan is begun by physician; monitor serum potassium, glucose, and sodium frequently; weigh daily, and report gain of >5 lb/wk; monitor BP and pulse closely; teach symptoms of Cushing syndrome. |
| Describe the physical appearance of clients who have Cushing syndrome. | Moon face, obesity in trunk, buffalo hump in back, muscle atrophy, and thin skin |
| Which type of diabetes always requires insulin replacement? | Type 1 |
| Which type of diabetes sometimes requires no medication? | Type 2 |
| List five symptoms of hyperglycemia. | Polydipsia, polyuria, polyphagia, weakness, weight loss |
| List five symptoms of hypoglycemia. | Hunger, lethargy, confusion, tremors or shakes, sweating |
| Name the necessary elements to include in teaching a client newly diagnosed with diabetes. | The underlying pathophysiology; its management; meal planning; exercise program; insulin admin; sick-day management; symptoms of hyperglycemia (not enough insulin) and of hypoglycemia (too much insulin, too much exercise, not enough food); foot care |
| In fewer than 10 steps, describe the method of drawing up a mixed dose of insulin (regular with NPH). | Draw up regular insulin first; rotate injection sites; may reuse syringe by recapping and storing in refrigerator. |
| Identify the peak action time of the following types of insulin: rapid-acting regular insulin; intermediate-acting insulin; long-acting insulin. | Rapid-acting regular insulin: 2 to 4 hours; immediate-acting insulin: 6 to 12 hours; long-acting insulin: 14 to 20 hours |
| When preparing a client with diabetes for discharge, the nurse teaches the client the relationship between stress, exercise, bedtime snacking, and glucose balance. State the relationships among each of these. | Stress usually increases glucose production and insulin need. Conversely, exercise may increase the chance of hypoglycemic reaction; therefore, the client should always carry a fast-acting source of carbohydrate, when exercising. |
| When making rounds at night, the nurse notes that a client prescribed insulin is complaining of a headache, slight nausea, and minimal trembling. The client’s hand is cool and moist. What is the client most likely experiencing? | Hypoglycemia/insulin reaction |
| Identify five foot-care interventions that should be taught to a client with diabetes. | Check feet daily, report any breaks, sores, or blisters to provider; wear well-fitting shoes; never go barefoot or wear sandals; never personally remove corns or calluses; cut or file nails straight across; wash feet daily with mild soap and warm water. |
| Why do clients with diabetes have trouble with wound healing? | High glucose contributes to damage of the capillaries which causes permanent scarring, inhibiting normal activity. This causes disruption of capillary elasticity and promotes problems. |
| What is Addison crisis | Addison crisis is a medical emergency. It is brought on by sudden withdrawal of steroids or a stressful event (trauma, severe infection) or exposure to cold, overexertion, or decrease in salt intake. |
| What tests are performed for hypocalcemia? | Chvostek sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. Trousseau sign is a carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes. |
| Normal serum calcium | 9.0 to 10.5 mEq/L. |
| What antithyroid drugs are used to treat thyroid storm? | Propylthiouracil (PTU) and methimazole (Tapazole) |
| Differentiate between rheumatoid arthritis and OA in terms of joint involvement. | Rheumatoid arthritis occurs bilaterally. OA occurs asymmetrically. |
| Identify the categories of drugs commonly used to treat arthritis. | NSAIDs, of which salicylates are the cornerstone of treatment, and corticosteroids (used when arthritic symptoms are severe) |
| Identify pain relief interventions for clients with arthritis. | Warm, moist heat (compresses, baths, showers); diversionary activities (imaging, distraction, self-hypnosis, biofeedback); and medications |
| What measures should the nurse encourage female clients to take to prevent osteoporosis? | Possible estrogen replacement after menopause, high calcium and vitamin D intake beginning in early adulthood, calcium supplements after menopause, and weight-bearing exercise |
| What are the common side effects of salicylates? | GI irritation, tinnitus, thrombocytopenia, mild liver enzyme elevation |
| What is the priority nursing intervention used with clients taking NSAIDs? | Administer or teach client to take drugs with food or milk. |
| List three of the most common joints that are replaced. | Hip, knee, finger |
| Describe postoperative residual limb (stump) care (after amputation) for the first 48 hours. | Elevate residual limb (stump) for first 24 hours. Do not elevate residual limb (stump) after 48 hours. Keep residual limb (stump) in extended position, and turn client to prone position three times a day to prevent flexion contracture. |
| Describe nursing care for the client who is experiencing phantom pain after amputation. | Be aware that phantom pain is real and will eventually disappear. Administer pain medication; phantom pain responds to medication. |
| A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is short of breath, and is restless. What does the client most likely have? | A fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness, fever, and petechiae |
| What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition? | Notify physician stat, draw blood gases, administer O2 according to blood gas results, assist with endotracheal intubation and treatment of respiratory failure. |
| List three problems associated with immobility. | Venous thrombosis, urinary calculi, skin integrity problems |
| List three nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems. | Passive ROM exercises, elastic stockings, and elevation of foot of bed 25 degrees to increase venous return |
| What differentiates lupus erythematosus from other connective-tissue disorders | avoiding sunglight is key in the management of lupus erythematosus |
| What are the classifications of the commonly prescribed eye drops for glaucoma? | Parasympathomimetic for pupillary constriction; beta-adrenergic receptor-blocking agents to inhibit formation of aqueous humor; carbonic anhydrase inhibitors to reduce aqueous humor production; and prostaglandin agonists to increase aqueous humor outflow |
| Identify two types of hearing loss. | Conductive (transmission of sound to inner ear is blocked) and sensorineural (damage to eighth cranial nerve) |
| Write four nursing interventions for the care of the blind person and four nursing interventions for the care of the deaf person. | blind: announce presence, call by name, orient carefully to surroundings, guide by walking in front of client with his or her hand in your elbow. deaf: reduce distraction, look and listen, give client full attention if lip reader, face client directly. |
| Describe the Glasgow Coma Scale. | An objective assessment of the level of consciousness based on a score of 3 to 15, with scores of 7 or less indicative of coma |
| List four nursing diagnoses for the comatose client in order of priority. (Remember Maslow’s Hierarchy of Needs to help determine priorities.) | Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, and decreased cardiac output |
| State four independent nursing interventions to maintain adequate respiration, airway, and oxygenation in the unconscious client. | Position for maximum ventilation (prone or semiprone and slightly to one side); insert airway if tongue is obstructing; suction airway efficiently; monitor arterial PO2 and PCO2; and hyperventilate with 100% O2 before suctioning. |
| Who is at risk for stroke? | Persons with histories of HTN, previous TIAs, cardiac disease (atrial flutter or fibrillation), diabetes, or oral contraceptive use; and older adults |
| Complications of immobility include the potential for thrombus development. State three nursing interventions to prevent thrombi. | Frequent range-of-motion exercises, frequent (every 2 hours) position changes, and avoidance of positions that decrease venous return. |
| List four rationales for the appearance of restlessness in the unconscious client. | Anoxia, distended bladder, covert bleeding, or a return to consciousness |
| What nursing interventions prevent corneal drying in a comatose client? | Irrigation of eyes PRN with sterile prescribed solution, application of ophthalmic ointment every 8 hours, close assessment for corneal ulceration or drying |
| When can a comatose client on IV hyperalimentation begin to receive tube feedings instead? | When peristalsis resumes as evidenced by active bowel sounds, passage of flatus or bowel movement |
| What is the most important principle in a bowel management program for a client with neurologic deficits? | Establishment of regularity |
| Define stroke. | A disruption of blood supply to a part of the brain, which results in sudden loss of brain function |
| A client with a diagnosis of stroke presents with symptoms of aphasia and right hemiparesis but no memory or hearing deficit. In what hemisphere has the client suffered a lesion? | Left |
| What behavior differences are seen in strokes involving the right hemisphere vs. the left hemisphere | Right: impulsive, unaware, confabulates, euphoric, smiling, impaired humor; Left: slow, cautios, anxious when attempting new tasks, depression/catastrophic repsonse to illness, sense of guild, worthlessness, worried, quick to anger |
| Ehsy drugs are administered to Parkinson patients to control symptoms | The pathophysiology involves an imbalance between acetylcholine and dopamine, so symptoms can be controlled by administering a dopamine precursor (levodopa). |
| What are the symptoms of spinal shock? | Hypotension, bladder and bowel distention, total paralysis, lack of sensation below lesion |
| What are the symptoms of autonomic dysreflexia? | HTN, bladder and bowel distention, exaggerated autonomic responses, headache, sweating, goose bumps, and bradycardia |
| What is the most important indicator of increased ICP? | A change in the level of responsiveness |
| What vital sign changes are indicative of increased ICP? | Increased BP, widening pulse pressure, increased or decreased pulse, respiratory irregularities, and temperature increase |
| A neighbor calls the neighborhood nurse stating that he was knocked hard to the floor by his very hyperactive dog. He is wondering what symptoms would indicate the need to visit an emergency department. What should the nurse tell him to do? | Call his physician now and inform him or her of the fall. Symptoms needing medical attention would include vertigo, confusion or any subtle behavioral change, headache, vomiting, ataxia (imbalance), or seizure. |
| What activities and situations that increase ICP should be avoided? | Change in bed position, extreme hip flexion, endotracheal suctioning, compression of jugular veins, coughing, vomiting, and straining of any kind |
| What is the action of hyperosmotic agents (osmotic diuretics) used to treat ICP? | They dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent reabsorption, and by drawing fluid from the extravascular spaces into the plasma. |
| Why should narcotics be avoided in clients with neurologic impairment? | Narcotics mask the level of responsiveness and pupillary responses. |
| Headache and vomiting are symptoms of many disorders. What characteristics of these symptoms would alert the nurse to refer a client to a neurologist? | Headache that is more severe upon awakening, and vomiting not associated with nausea are symptoms of a brain tumor. |
| How should the head of the bed be positioned for postcraniotomy clients with infratentorial lesions? | Supratentorial: elevated; infratentorial: flat |
| Is multiple sclerosis thought to occur because of an autoimmune process? | Yes |
| Is paralysis always a consequence of spinal cord injury? | No |
| What types of drugs are used in the treatment of myasthenia gravis? | Anticholinesterase drugs, which inhibit the action of cholinesterase at the nerve endings to promote the accumulation of acetylcholine at receptor sites; this should improve neuronal transmission to muscles. |
| Define Apraxia | inability to perform purposeful movements in the absence of motor problems |
| Define Dysarthria | difficulty articulating |
| Define Dysphasi | impairment of speech and verbal comprehension |
| Define Aphasia | loss of the ability to speak |
| Define Agraphia | loss of the ability to write |
| Define Alexia | loss of the ability to read |
| Define Dysphagia | dysfunctional swallowing |
| What are the features of Parkinson disease | tremors (a coarse tremor of fingers and thumb on one hand that disappears during sleep and purposeful activity; also called “pill rolling”), rigidity, hypertonicity, and stooped posture. |
| Drug therapy for MS clients | ACTH, cortisone, cyclophosphamide (Cytoxan), and other immunosuppressive drugs. Nursing implications for administration of these drugs should focus on the prevention of infection. |
| Craniotomy preoperative medications | Corticosteroids to reduce swelling; Agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate [Robinul]); gents to reduce seizures (phenytoin);Prophylactic antibiotics |
| The presence of ______ mL of residual in an adult usually indicates poor gastric emptying, and the feeding should be withheld. | 100 mL |
| List three potential causes of anemia. | Diet lacking in iron, folate, or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic agents, such as lead or insecticides |
| Write two nursing diagnoses for the client suffering from anemia. | Activity intolerance and ineffective tissue perfusion |
| What is the only IV fluid compatible with blood products? | Normal saline |
| What actions should the nurse take if a hemolytic transfusion reaction occurs? | Turn off transfusion. Take temperature. Send blood being transfused to lab. Obtain urine sample. Keep vein patent with normal saline. |
| List three interventions for clients with a tendency to bleed. | Use a soft toothbrush, avoid salicylates, do not use suppositories. |
| Identify two sites that should be assessed for infection in immunosuppressed clients. | Oral cavity and genital area |
| Name three food sources of vitamin B12. | Glandular meats (liver), milk, green leafy vegetables |
| Describe care of invasive catheters and lines. | Use strict aseptic technique. Change dressings two or three times per week or when soiled. Use caution when piggybacking drugs; check purpose of line and drug to be infused. When possible, use lines to obtain blood samples to avoid “sticking” client. |
| List three safety precautions for the administration of antineoplastic chemotherapy. | Double-check order with another nurse. Check for blood return. Use a new IV site daily for peripheral chemotherapy. Wear gloves when handling the drugs, and dispose of waste in special containers to avoid contact with toxic substances. |
| Describe the use of leucovorin. | Leucovorin is used as an antidote with methotrexate to prevent toxic reactions. |
| Describe the method of collecting the trough and peak blood levels of antibiotics. | Collection of trough: draw blood 30 minutes prior to administration of antibiotic. Collection of peak: Draw blood 30 minutes after administration of antibiotic. |
| List four nursing interventions for care of the client with Hodgkin disease. | Protect from infection. Observe for anemia. Encourage high-nutrient foods. Provide emotional support to client and family. |
| List four topics you would cover when teaching an immunosuppressed client about infection control. | Handwashing technique. Avoid infected persons. Avoid crowds. Maintain daily hygiene to prevent spread of microorganisms. |
| What are the indications for a hysterectomy in a client who has fibromas? | Severe menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics, severe uterine enlargement causing pressure on other organs, severe low back and pelvic pain |
| List the symptoms and conditions associated with a cystocele. | Symptoms include incontinence or stress incontinence, urinary retention, and recurrent bladder infections. Conditions associated with cystocele include multiparity, trauma in childbirth, and aging. |
| What are the most important nursing interventions for the postoperative client who has had a hysterectomy with an A&P repair? | Avoid taking rectal temperatures and rectal manipulation; manage pain; and encourage early ambulation. |
| Describe the priority nursing care for a client who has had radiation implants. | Do not permit pregnant visitors or pregnant caretakers in room. Discourage visits by small children. Confine client to room. Nurse must wear radiation badge. Nurse limits time in room. Keep supplies and equipment within client’s reach. |
| What screening tool is used to detect cervical cancer? What are the American Cancer Society’s recommendations for women ages 30 to 70 with three consecutive normal results? | Pap smear. Women ages 30 to 70 with three consecutive normal results may have Pap smears every 2 to 3 years (screening for HPV). |
| Cite two nursing diagnoses for a client undergoing a hysterectomy for cervical cancer. | Altered body image related to uterine removal; pain related to postoperative incision |
| What are the three most important tools for early detection of breast cancer? How often should these tools be used? | Breast self-examination monthly; mammogram baseline at age 35, followed by exams every 1 to 2 years in 40s and every year after age 50; physical examination by a professional skilled in examination of the breast |
| Describe three nursing interventions to help decrease edema postmastectomy. | Position arm on operative side on pillow. Avoid BP measurements, injections, and venipunctures in operative arm. Encourage hand activity and use. |
| Name three priorities to include in a discharge plan for a client who has had a mastectomy. | Arrange for Reach to Recovery visit. Discuss the grief process with the client. Have physician discuss with client the reconstruction options. |
| What is the most common cause of nongonococcal urethritis? | Chlamydia trachomatis |
| What is the causative organism of syphilis? | Treponema pallidum (spirochete bacteria) |
| Malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD? | Trichomonas vaginalis |
| Which STD is characterized by remissions and exacerbations in both males and females? | Herpes simplex type II |
| Outline a teaching plan for a client with an STD. | Signs and symptoms of STD; mode of transmission; avoiding sex while infected; providing concise written instructions regarding treatment, and requesting a return verbalization to ensure that the client understands; teaching safer sex practices |
| A client comes into the clinic with a chancre on his penis. What is the usual treatment? | IM dose of penicillin (such as benzathine penicillin G, 2.4 million units). Obtain a sexual history, including the names of his sex partners, so that they can receive treatment. |
| What is the anatomic significance of a prolapsed uterus? | When the uterus is displaced, it impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can protrude through the vaginal wall. |
| List four categories of burns. | Thermal, radiation, chemical, electrical |
| Burn depth is a measure of severity. Describe the characteristics of superficial partial-thickness, deep partial-thickness, and full-thickness burns. | Superficial partial-thickness, first degree: pink to red skin (e.g., sunburn), slight edema, and pain relieved by cooling; Deep partial-thickness, second degree: destruction of epidermis and upper layers of dermis; white or red, very edematous, sensitive |
| Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of the burned client. | Stage I (emergent phase): Replacement of fluids is titrated to urine output.; Stage II (acute phase): Patent infusion site is maintained in case supplemental IV fluids are needed; saline lock is helpful; colloids may be used.; Stage III (rehabilitation ph |
| Describe pain management of the burned client. | Administer pain medication, especially prior to dressing wound. Teach distraction and relaxation techniques. Teach use of guided imagery. |
| Outline admission care of the burned client. | Provide a patent airway because intubation may be necessary. Determine baseline data. Initiate fluid and electrolyte therapy. Administer pain medication. Determine depth and extent of burn. Administer tetanus toxoid. Insert NG tube. |
| Nutritional status is a major concern when caring for a burned client. List three specific dietary interventions used with burned clients. | High-calorie, high-protein, high-carbohydrate diet; medications with juice or milk; no “free” water; tube feeding at night. Maintain accurate, daily calorie counts. Weigh client daily. |
| Describe the method of extinguishing each of the following burns: thermal, chemical, and electrical. | Thermal: Remove clothing, immerse in tepid water. Chemical: Flush with water or saline. Electrical: Separate client from electrical source. |
| List four signs of an inhalation burn. | Singed nasal hairs, circumoral burns; sooty or bloody sputum, hoarseness, and pulmonary signs, including asymmetry of respirations, rales, or wheezing |
| Why is the burned client allowed no “free” water? | Water may interfere with electrolyte balance. Client needs to ingest food products with highest biologic value. |
| Describe an autograft. | Use of client’s own skin for grafting. |
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