By : Yoko
? In a patient with hypokalemia (serum potassium level below 3.5 mEq/L), presenting signs and symptoms include muscle weakness and cardiac arrhythmias.
? During cardiac arrest, if an I.V. route is unavailable, epinephrine can be administered endotracheally.
? Pernicious anemia results from the failure to absorb vitamin B12 in the GI tract and causes primarily GI and neurologic signs and symptoms.
? A patient who has a pressure ulcer should consume a high-protein, high-calorie diet, unless contraindicated.
? The CK-MB isoenzyme level is used to assess tissue damage in myocardial infarction.
? After a 12-hour fast, the normal fasting blood glucose level is 80 to 120 mg/dl.
? A patient who is experiencing digoxin toxicity may report nausea, vomiting, diplopia, blurred vision, light flashes, and yellow-green halos around images.
? Anuria is daily urine output of less than 100 ml.
? In remittent fever, the body temperature varies over a 24-hour period, but remains elevated.
? Risk of a fat embolism is greatest in the first 48 hours after the fracture of a long bone. It’s manifested by respiratory distress.
? To help venous blood return in a patient who is in shock, the nurse should elevate the patient’s legs no more than 45 degrees. This procedure is contraindicated in a patient with a head injury.
? The pulse deficit is the difference between the apical and radial pulse rates, when taken simultaneously by two nurses.
? To reduce the patient’s risk of vomiting and aspiration, the nurse should schedule postural drainage before meals or 2 to 4 hours after meals.
? Blood pressure can be measured directly by intra-arterial insertion of a catheter connected to a pressure-monitoring device.
? A positive Kernig’s sign, seen in meningitis, occurs when an attempt to flex the hip of a recumbent patient causes painful spasms of the hamstring muscle and resistance to further extension of the leg at the knee.
? In a patient with a fractured, dislocated femur, treatment begins with reduction and immobilization of the affected leg.
? Herniated nucleus pulposus (intervertebral disk) most commonly occurs in the lumbar and lumbosacral regions.
? Laminectomy is surgical removal of the herniated portion of an intervertebral disk.
? Surgical treatment of a gastric ulcer includes severing the vagus nerve (vagotomy) to reduce the amount of gastric acid secreted by the gastric cells.
? Valsalva’s maneuver is forced exhalation against a closed glottis, as when taking a deep breath, blowing air out, or bearing down.
? When mean arterial pressure falls below 60 mm Hg and systolic blood pressure falls below 80 mm Hg, vital organ perfusion is seriously compromised.
? Lidocaine (Xylocaine) is the drug of choice for reducing premature ventricular contractions.
? A patient is at greatest risk of dying during the first 24 to 48 hours after a myocardial infarction.
? During a myocardial infarction, the left ventricle usually sustains the greatest damage.
? The pain of a myocardial infarction results from myocardial ischemia caused by anoxia.
? For a patient in cardiac arrest, the first priority is to establish an airway.
? The universal sign for choking is clutching the hand to the throat.
? For a patient who has heart failure or cardiogenic pulmonary edema, nursing interventions focus on decreasing venous return to the heart and increasing left ventricular output. These interventions include placing the patient in high Fowler’s position and administering oxygen, diuretics, and positive inotropic drugs as prescribed.
? A positive tuberculin skin test is an induration of 10 mm or greater at the injection site.
? The signs and symptoms of histoplasmosis, a chronic systemic fungal infection, resemble those of tuberculosis.
? In burn victims, the leading cause of death is respiratory compromise. The second leading cause is infection.
? The exocrine function of the pancreas is the secretion of enzymes used to digest carbohydrates, fats, and proteins.
? A patient who has hepatitis A (infectious hepatitis) should consume a diet that’s moderately high in fat and high in carbohydrate and protein, and should eat the largest meal in the morning.
? Esophageal balloon tamponade shouldn’t be inflated greater than 20 mm Hg.
? Overproduction of prolactin by the pituitary gland can cause galactorrhea (excessive or abnormal lactation) and amenorrhea (absence of menstruation).
? Intermittent claudication (pain during ambulation or other movement that’s relieved with rest) is a classic symptom of arterial insufficiency in the leg.
? In bladder carcinoma, the most common finding is gross, painless hematuria.
? Parenteral administration of heparin sodium is contraindicated in patients with renal or liver disease, GI bleeding, or recent surgery or trauma; in pregnant patients; and in women older than age 60.
? Drugs that potentiate the effects of anticoagulants include aspirin, chloral hydrate, glucagon, anabolic steroids, and chloramphenicol.
? For a burn patient, care priorities include maintaining a patent airway, preventing or correcting fluid and electrolyte imbalances, controlling pain, and preventing infection.
? Elastic stockings should be worn on both legs.
? Active immunization is the formation of antibodies within the body in response to vaccination or exposure to disease.
? Passive immunization is administration of antibodies that were preformed outside the body.
? A patient who is receiving digoxin (Lanoxin) shouldn’t receive a calcium preparation because of the increased risk of digoxin toxicity. Concomitant use may affect cardiac contractility and lead to arrhythmias.
? Intermittent positive-pressure breathing is inflation of the lung during inspiration with compressed air or oxygen. The goal of this inflation is to keep the lung open.
? Wristdrop is caused by paralysis of the extensor muscles in the forearm and hand.
? Footdrop results from excessive plantar flexion and is usually a complication of prolonged bed rest.
? A patient who has gonorrhea may be treated with penicillin and probenecid (Benemid). Probenecid delays the excretion of penicillin and keeps this antibiotic in the body longer.
? In patients who have glucose-6-phosphate dehydrogenase (G6PD) deficiency, the red blood cells can’t metabolize adequate amounts of glucose, and hemolysis occurs.
? On-call medication is medication that should be ready for immediate administration when the call to administer it’s received.
? If gagging, nausea, or vomiting occurs when an airway is removed, the nurse should place the patient in a lateral position with the upper arm supported on a pillow.
? When a postoperative patient arrives in the recovery room, the nurse should position the patient on his side or with his head turned to the side and the chin extended.
? In the immediate postoperative period, the nurse should report a respiratory rate greater than 30, temperature greater than 100° F (37.8° C) or below 97° F (36.1° C), or a significant drop in blood pressure or rise in pulse rate from the baseline.
? Irreversible brain damage may occur if the central nervous system is deprived of oxygen for more than 4 minutes.
? Treatment for polycythemia vera includes administering oxygen, radioisotope therapy, or chemotherapy agents, such as chlorambucil and nitrogen mustard, to suppress bone marrow growth.
? A patient with acute renal failure should receive a high-calorie diet that’s low in protein as well as potassium and sodium.
? Addison’s disease is caused by hypofunction of the adrenal gland and is characterized by fatigue, anemia, weight loss, and bronze skin pigmentation. Without cortisol replacement therapy, it’s usually fatal.
? Glaucoma is managed conservatively with beta-adrenergic blockers such as timolol (Timoptic), which decrease sympathetic impulses to the eye, and with miotic eyedrops such as pilocarpine (Isopto Carpine), which constrict the pupils.
? Miotics effectively treat glaucoma by reducing intraocular pressure. They do this by constricting the pupil, contracting the ciliary muscles, opening the anterior chamber angle, and increasing the outflow of aqueous humor.
? While a patient is receiving heparin, the nurse should monitor the partial thromboplastin time.
? Urinary frequency, incontinence, or both can occur after catheter removal. Incontinence may be manifested as dribbling.
? When teaching a patient about colostomy care, the nurse should instruct the patient to hang the irrigation reservoir 18″ to 22″ (45 to 55 cm) above the stoma, insert the catheter 2″ to 4″ (5 to 10 cm) into the stoma, irrigate the stoma with 17 to 34 oz (503 to 1,005 ml) of water at a temperature of 105° to 110° F (40° to 43° C) once a day, clean the area around the stoma with soap and water before applying a new bag, and use a protective skin covering, such as a Stomahesive wafer, karaya paste, or karaya ring, around the stoma.
? The first sign of Hodgkin’s disease is painless, superficial lymphadenopathy, typically found under one arm or on one side of the neck in the cervical chain.
? To differentiate true cyanosis from deposition of certain pigments, the nurse should press the skin over the discolored area. Cyanotic skin blanches, but pigmented skin doesn’t.
? A patient who has a gastric ulcer is most likely to report pain during or shortly after eating.
? Widening pulse pressure is a sign of increasing intracranial pressure. For example, the blood pressure may rise from 120/80 to 160/60 mm Hg.
? In a burn victim, a primary goal of wound care is to prevent contamination by microorganisms.
? To prevent external rotation in a patient who has had hip nailing, the nurse places trochanter rolls from the knee to the ankle of the affected leg.
? Severe hip pain after the insertion of a hip prosthesis indicates dislodgment. If this occurs, before calling the physician, the nurse should assess the patient for shortening of the leg, external rotation, and absence of reflexes.
? As much as 75% of renal function is lost before blood urea nitrogen and serum creatinine levels rise above normal.
? When compensatory efforts are present in acid-base balance, partial pressure of arterial carbon dioxide (PaCO2) and bicarbonate (HCO3–) always point in the same direction:
? pH PaCO2 HCO3– = respiratory acidosis compensated
? pH PaCO2 HCO3– = respiratory alkalosis compensated
? pH PaCO2 HCO3– = metabolic acidosis compensated
? pH PaCO2 HCO3– = metabolic alkalosis compensated.
? Polyuria is urine output of 2,500 ml or more within 24 hours.
? The presenting sign of pleuritis is chest pain that is usually unilateral and related to respiratory movement.
? If a patient has a gastric drainage tube in place, the nurse should expect the physician to order potassium chloride.
? An increased pulse rate is one of the first indications of respiratory difficulty. It occurs because the heart attempts to compensate for a decreased oxygen supply to the tissues by pumping more blood.
? In an adult, a hemoglobin level below 11 mg/dl suggests iron deficiency anemia and the need for further evaluation.
? The normal partial pressure of oxygen in arterial blood is 95 mm Hg (plus or minus 5 mm Hg).
? Vitamin C deficiency is characterized by brittle bones, pinpoint peripheral hemorrhages, and friable gums with loosened teeth.
? Clinical manifestations of pulmonary embolism are variable, but increased respiratory rate, tachycardia, and hemoptysis are common.
? Normally, intraocular pressure is 12 to 20 mm Hg. It can be measured with a Schiøtz tonometer.
? In early hemorrhagic shock, blood pressure may be normal, but respiratory and pulse rates are rapid. The patient may report thirst and may have clammy skin and piloerection (goose bumps).
? Cool, moist, pale skin, as occurs in shock, results from diversion of blood from the skin to the major organs.
? To assess capillary refill, the nurse applies pressure over the nail bed until blanching occurs, quickly releases the pressure, and notes the rate at which blanching fades. Capillary refill indicates perfusion, which decreases in shock, thereby lengthening refill time. Normal capillary refill is less than 3 seconds.
? Except for patients with renal failure, urine output of less than 30 ml/hour signifies dehydration and the potential for shock.
? In elderly patients, the most common fracture is hip fracture. Osteoporosis weakens the bones, predisposing these patients to fracture, which usually results from a fall.