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RN > charge nurse > nursing supervisor > chief nurse
What is the correct nursing hierarchy in reporting a situation?
Droplet precaution
A client is diagnosed with AIDS. He then had an opportunistic infection of pneumocystis jeroveci. What precaution should you implement?
150,000-400,00/mL
normal platelet count
"How do you feel about the lifestyle changes you are planning to make?"
You are trying to determine client's adjustment to his new diagnosis. What question would elicit the most useful info from client?
- Open capsule & sprinkle into orange juice
- Ask pharmacy for liquid form of med
- Give med w/ soft foods
- Crush meds and mix with water
An 88 yr old client has difficulty swallowing. What nursing actions are appropriate in administering tablets by mouth?
Shakiness, cold, clammy skin
Orange juice is needed if what symptoms develop?
Calf pain
Tenderness
Increased girth of leg
Homan's sign
Signs of DVT
Brudzinki's sign
A positive sign of meningitis, in which there is an involuntary flexion of the HIP & KNEE when the patient's NECK is passively flexed
Sweaty skin
Client is diagnosed w/ Graves' dss. What manifestation will you expect?
Imbalanced nutrition: less than body requirements r/t hypermetabolism
What is an approp nursing diagnosis for hyperthyroidism?
hepatosplenomegaly
Client has pulmonic stenosis. What symptom will you expect?
Wear long-sleeved clothing when going outside (antipsychotics = hypothermia)
What health teaching should you include for a client on neuroleptic ttt?
"Tell me when you feel anxious"
You observe that the px is agitated. What is an appropriate therapeutic communication?
"How do you feel about having a male nurse?"
Client states, "I've never had a male nurse before". How should you respond?
88-92%
normal COPD O2 sat
Manage joint pain and fatigue to perform ADLs
What is an appropriate expected outcome for px with rheumatoid arthritis?
Client does not drink water DURING meals
What assessment finding indicates effective mgmt of client w/ anorexia nervosa?
Steamed mix veggies, lean beef, rice
What should chronic renal failure patient's diet be?
N&V
Hypertension
Dizziness
Client underwent hemodialysis for the first time. What s/s suggest disequilibrium syndrome?
Low sodium, high K, high protein
A client is receiving Prednisone. What should his diet be?
Raisins
Banana
Watermelon
Papaya
Tomatoes
Orange juice
Which foods are high in potassium?
Apple/pineapple
Strawberries
Which fruits are low in potassium?
Taping tube to the bridge of the nose
What is your last step in inserting NGT?
inspection, palpation, percussion, auscultation
order of physical assessment
Px is able to attend conference on time
What indicates effectiveness of lithium?
endocardial cushion defect
cardiac abnormality that is commonly observed in children with Down Syndrome (trisomy 21)
Terminal
At which stage of the natural history of dss is tertiary prevention required?
2-8 C
appropriate storage temp of DPT
hemophilus influenzae
microorganism responsible for the most common type of meningitis in children aged 2 mos to 3 years
morbillivirus
etiological agent of Rubeola (Measles) "9-day Measles"
RA 7160
= Local Government Code of 1991
= law that devolved basic health services to LGUs
Amebic dysentery
identified by the presence of blood and/or mucus in the stool
giardiasis
characterized by fat malabsorption, resulting in the production of oily stools (steatorrhea)
severe dehydration
Which of the ff severe conditions may not always require urgent referral to a hospital?
IV fluid therapy
Oresol or NGT
Hospital referral
What is the mgmt for severe dehydration?
myoglobin elevation
early indicator of myocardial damage
Creatine Phosphokinase (CPK), Troponin T & I, myoglobin
Which laboratory studies evaluate myocardial damage?
t-wave inversion
You reviewed the ECG of a px during an episode of chest pain. You find out he has myocardial ischemia. How is this displayed in an ECG?
increased QRS duration
You reviewed the ECG of a px during an episode of chest pain. You find out he has a bundle-branch block. How is this displayed in an ECG?
shortened PR interval
You reviewed the ECG of a px during an episode of chest pain. You find out he has a junctional rhythm. How is this displayed in an ECG?
pathological q waves
You reviewed the ECG of a px during an episode of chest pain. You find out he has a myocardial infarction. How is this displayed in an ECG?
hemorrhagic shock
Patient who is 4 hrs PP has weak and thready pulse of 100 bpm. This may indicate __.
amount of lochia (determine the extent of uterine bleeding)
Patient who is 4 hrs PP has weak and thready pulse of 100 bpm. What do you check for?
due to dehydrating effects of labor
Why is high temp normal after birth?
community of solution
If a nurse chooses to volunteer in a community of indigenous people and help them lobby against environmental degradation of their ancestral land, the nurse is part of a?
Epidemiological surveillance
What public health function according to WHO focuses on CONTROL OF COMMUNICABLE DSS?
PHC Strategy
= made by the World Health Organization
= adopted in the PH by virtue of Letter of Instruction No. 949 by President Marcos
= defined by Alma Ata Declaration as "essential health care at a cost that the community CAN AFFORD"
PHC Strategy
= health services made available to all age groups
= socially acceptable, scientifically sound services of healthcare given to the poor
= a strategy of healthcare delivery among developing & first-world countries
Alma Ata Declaration
= made on Sept. 6-12, 1978 in Union of Soviet Socialist Republics (USSR)
= defines PHC strategy as "essential health care at a cost that the community CAN AFFORD"
= listed 8 essential health services to achieve the goal of "health for all"
Report the situation to the nursing supervisor
Incoming male RN smells of alcohol. What is your most appropriate action?
Do not eat raw food
Practice handwashing before & after using bathroom
Avoid crowded places
Avoid refrigerated foods
Avoid exposure to cold & dampness
Px has a WBC count of 3,000/cumm. What would you give as health teachings?
glycosylated hemoglobin
most accurate lab test for the diagnosis of DM
Prothrombin time
Lab test for client receiving Warfarin (Coumadin)
Position the elbows flexed at 30-degree angle at the crossbar of the crutches
What should you tell the px regarding use of crutches after his knee amputation?
20/15 vision (the lower the R number, the more farsighted)
Px is diagnosed with hyperopia. What do you expect to note in his Snellen's chart test?
Kussmaul's breathing
What breathing pattern do you observe in a px with diabetic ketoacidosis?
Apple (has low potassium)
A patient has a serum K level of 5.8 mEq/L. Which fruit can be included in his diet based on this finding?
70-110 mg/dL
normal fasting blood glucose
10-20 mg/dL
Normal BUN levels
3.5-5.0 mEq/L
normal potassium levels
below 1.010 (diluted)
A patient has diabetes insipidus. The nurse would expect to find that his specific gravity is __.
respiratory acidosis
Patient has the ff arterial blood gas results: pH 7.32, PaCO2 50mmHg, HCO3 26 mEq/L. His results indicated __.
Inform charge nurse about suspected child abuse
A 3 yr old child was brought to ER for limb fractures. His mother is uncooperative in giving info. What is your next action?
Suctioning for 15-20 secs (should be
When suctioning a client with tracheostomy, what will be an inappropriate action?
Palpate pedal artery of affected leg
How will you assess neurovascular status of an extremity casted from ankle to thigh?
SOB
Client is receiving blood transfusion. What symptom indicates that client is experiencing Transfusion Reaction Acute Lung Injury (TRALI)?
Urinary bag is full
Client is diagnosed with ruptured intervertebral discs T6 to T12. What assessment finding will concern you the most several hrs after surgery?
He is eating green salad
What observation in an immunocompromised patient requires health teaching?
Client who is HIV positive
Client has AIDS. What client can be safely roomed-in with client?
"I know this is frightening for you, but I don't see any bugs crawling in your skin."
Client has tactile hallucinations due to Delirium Tremens. He states, "There are bugs crawling under my skin!" What's your most appropriate response?
Prone
Best position for a child with myelomeningocele
Sitting upright leaning forward
Position for thoracentesis
Lithotomy
Position for cystoscopy
Prone
Position for renal biopsy
Tetralogy of Fallot
congenital malformation involving four distinct heart defects
patent ductus arteriosus (PDA)
passageway (ductus arteriosus) between the aorta and the pulmonary artery remains open (patent) after birth
Can perform personal self-care activities with no chest pain
What is an appropriate expected outcome for px with MI on her second day hospitalization?
inspection, auscultation, percussion, palpation
order of abdominal assessment
headache (increased ICP)
What finding is most concerning for a px who will undergo lumbar puncture?
The client's spouse turns on the TV 1 hour in the afternoon & 2 hrs in the evening
Px has closed head injury. What situation needs intervention by the nurse?
Wear long sleeve shirt (antipsychotics = hypothermia)
A client is taking Chlorpromazine (Thorazine). What should you include in the health teaching before letting client walk?
Measles
Which illness has been declared as the target for eradication in the PH through Presidential Proclamation no. 4?
early in the morning
Appropriate time for scheduling a stool specimen to confirm the diagnosis of a px suspected of having pinworms
total popu x 3%
How do we estimate the num of infants in a popu?
Tertiary prevention
= prevention that involves rehab, prevention of permanent disability and disability limitation
= for convalescents, disabled, complicated cases, and terminally ill
buccal mucosa
You know that the presence of Koplik's spots is a definitive sign of measles. These spots can be observed at what part of the body?
DPT (diphtheria, pertussis, tetanus)
= vaccine used in the Expanded Program Immunization (EPI) that should NOT BE STORED IN A FREEZER
= aka pentavalent vax
pentavalent vaccine
vaccine that protects against five potential killers: Diptheria, Tetanus, Pertusis, Hib, and Hepatitis B
rural health unit
As a new BSN graduate aspiring to be a public health nurse, where do you submit your application?
copious amount of watery stools
primary symptom of cholera
Oresol
oral rehydration solution for use to correct dehydration caused by diarrhea or correct fluid imbalance in dengue
Assess further because this may be a sign of infection
The client reports that his cast has a foul odor. How should you respond?
name, address, gender, info about living will, durable power of attorney for healthcare, location of advance directive
You need to collect the px's biographic details. What are examples of these data?
Info related to chief complaint, past health hx, hx of immunizations
You need to assess a patient's health and illness patterns. What info do you need?
flat sign of electrocardiogram
What health status indicates death of px?
lochia
After observing a PP client with temp of 101.4F, a tender uterus upon palpation, a uterus that remains unusually large and not descending as expected, what should you assess next?
Recognize this as normal first period of reactivity
After birth, you observe that the male newborn has an RR of 78, HR of 160, nostril flaring, mild intercostal retractions, and grunting. What action will you take next?
fractured clavicle
If infant has asymmetrical Moro reflex response, what do you assess for next?
Community
a group of people, a territory, with interaction and common issues
8 midwives (40,000/5,000=8)
According to the DOH, if a certain municipality has 40,000 population, how many midwives does the nurse expect that she will work with?
