1. Food Choices for a Child Who Has Celiac Disease
1.1. Avoid wheat, rye, and barley
1.2. Eat foods that are gluten free
1.2.1. milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh meat and fish, and dried beans
2. Priority Finding to Report for COPD
2.1. productive cough that is most severe in the moring, hypoxemia, crackles and wheezes, rapid and shallow RR, use of accessory muscles, barrel chest or increase chest diameter (emphysema), hyperresonance on percussion
2.1.1. Hypoxemia - PaO2 less than 80 mm Hg
2.1.2. Hypercarbia - increase PaCO2 greater than 45 mm Hg
2.1.3. Increase hematocrit level
2.2. Expected O2 sat levels is 95-100%; should be maintained between 88-92%
3. Care of the Nontunneled Percutaneous Central Venous Catheter
3.1. Confirm placement with Chest X ray
3.2. Sterile dressing should be intact
3.3. Short term use less than 6 weeks
4. Antibiotics Affecting Protein Synthesis: Manifestations of Toxicity
4.1. Hepatotoxicity - leathargy, jaundice
4.2. Doxyceline increase the risk of digoxin toxicity
4.3. Ototoxicity - hearing loss, vertigo, and tinnitus
4.4. Nephrotoxocity - elevated BUN / Creatinine, dilute urine, proteinuria
4.4.1. heamturia and cloudy urine
5. Indications of Magnesium Sulfate Toxicity
5.1. loss of deep tendon reflexes, urinary output less than 30 mL/hr or 100 mL/4 hr, respirations less than 12/min, pulmonary edema, severe hypotension, or chest
5.2. D/C the infusion
5.3. antidote: calcium gluconate or calcium chloride
5.4. Report: blurred vision, headache, nausea, vomiting, or difficulty breathing
6. Contraindication to admin of Methylergonovine
6.1. urine stimulant, promote urine contractins and expel the retained fragments of placenta, postpartum bleeding
6.2. hypertension, heart disease, severe heaptic or renal disease
7. Teaching about Montelukast
7.1. Long term therapy of asthma, prevent exercise induces bronchospasm
7.2. Monitor PT and INR levels
7.3. take 1 hr before or after a meal, avoid taking with food, once daily at bedtime, take 2 hr before exercie
8. Determining the need for the admin of Rh Immune Globulin
8.1. Rh negative clients with newborns who are Rh postive must be given dose within 72 hr of newborn being born
9. Postpartum Adaptations
9.1. Three stages of Lochia
9.1.1. Lochia rubra - dark red, feshy odor, 1-3 days after birth
9.1.2. Lochia serosa - pinkish brown color, small clots, 4-10 after birth
9.1.3. Lochia alba - yellowish white creamy color, fleshy odor, 10 days - 6 weeks postpartum
10. Auscultating Sites for the Heart
10.1. Aoritc - right sternum 2nd ICS
10.2. Pulmonic - left sternum 2nd ICS
10.3. Erb's point - left sternum 3rd ICS
10.4. Tricuspid - left sternum 4th ICS
11. Clinical Judgment
11.1. Medication for a Client in Labor Who is Experiencing Complications
11.1.1. Rh - mom, Rh + baby = Rhogam
11.1.2. Oxytocin = induce labor, cervical priming
11.1.3. Misoprostol and Dinoprostone = soften and then the cervix
11.1.4. Terbutaline = tachsystole
11.2. Generating Solutions for Cognitive and Perceptual Distubances
11.2.1. Delirium
11.2.1.1. hallucinations and illusions
11.2.1.2. level of consciousness altered / rapidly fluctuate
11.2.1.3. treat underlying cause
11.2.1.4. provide memory aids, keep consistent daily rountine, consistent caregivers, cover or remove mirrors, encourage physical activity during the day, and provide adequate lighting at night in the bathroom
11.3. Acute Infectious Gastrointestinal Disorders: Anticipating Provider Prescription
11.3.1. Metronidazole and Tinidazole
11.3.1.1. C.difficile and G. lamblia
11.4. Identifying Manifestations of Labor Complications
11.4.1. Fetal heart rate
11.4.1.1. decelertions indication cord compression, head compression, anemia, or hypoxemia
11.4.2. Maternal vital signs
11.4.2.1. blood pressure and heart rate
11.4.3. Signs of infections
11.4.3.1. heavy or foul smelling lochia
11.4.4. Vaginal bleeding
11.4.4.1. any type of bleeding
11.4.5. Signs of fetal distress
11.4.5.1. cessation of uterine contractions
11.5. Prioritizing Risk Factors for Postoperative Client
11.5.1. Affecting Wound Healing
11.5.1.1. loss of skin turgor, skin fragility, decreased peripheral circulation and oxygenation, slower tissue regneration, decrease in nutrients, decrease in collagen, impaired immune system function, dehydration
11.6. Nursing Actions for a Client in Labor Who Has an Infection
11.6.1. GBS will recieve IV antibiotic
11.6.2. Admin fluids
11.7. Acute Infectious Gastrointestinal Disorders: Actions to take to implement a plan of care
11.7.1. Hydration, rest, diet (BRAT) - bananas, rice, applesauce, and toast, anti - vomiting, diarrhea
12. Managemnet of Care
12.1. Tetralogy of Fallot
12.1.1. cyanosis at birth, systolic murmur, episode of acute cyanosis and hypoxia (blue . tet spells)
12.2. Ventricular spetal defect (VSD)
12.2.1. a hole in the septum between right and left ventricle, loud harsh murmur, heart failure
12.3. Atrial septal defect (ASD)
12.3.1. a hole in the septum between right and left atria, left to right shunt, systolic murmur and fixed spilt seconf heart sound, heart failure
13. Psychosocial Intergrity
13.1. Expected Findings of Schizophrenia
13.1.1. Positve symptoms - hallucinations, delusions, alterations in speech, and bizarre behavior
13.1.2. Negative symptoms - blunt or flat affectm alogia (poverty of thought or speech), anergia (lack of energy), anhedonia (lack of pleasure or joy), avolition (lack of motivation in activities and hygiene)
14. Speaking to a Client Who Has a Hearing Impairment
14.1. sit and face the client, avoid covering mouth while speaking, encourage hearing devices, speak slowly and clearly, lowering vocal pitch before increasing volume, write down what the client does not understand
15. Care for a New Cast
15.1. Neurovascular Assessment
15.1.1. Sensation (numbness and tingling), skin temp (should be warm), skin color (check distal to injury and pigmentation), Cap refill, pulses, and movement
15.1.2. 5 P's
15.1.2.1. Pain, Paralysis, Paresthesia, Pallor, and Pulselessness
15.2. Elevate the casted area with pillow during the first 24-48 hr to prevent swelling
15.3. Ice for the first 24 hr
15.4. Plaster cast
15.4.1. use the palm of hands to avoid denting
16. Caring for a client in Buck's Traction
16.1. Assess neuro status every hour for 24 hr and the every 4 hour
16.2. Check placement every 8-12 hr
16.3. Report unrelieved severe pain and muscle spasms with medicaitons
17. Food recommendation for a client who has Osteoporosis
17.1. Foods that increase in calcium
17.1.1. Minerals
17.2. Foods that increase in vitamin D
18. Kosher Dietary Practice
18.1. How the animal is slaughtered; so that no blood is consumed
18.2. No alcohol
18.3. No pork
18.4. Might not eat meat and dairy products at the same time
18.5. Fasting is done during Ramadan
19. Discharge Teaching for Antipsychotic Medicaitons
19.1. Observe for indication of infections
19.1.1. fever, sore throat
19.1.2. WBC less than 3,000
19.2. Antichloinergics effects
19.2.1. dry mouth, blurred vision, urinary retention, constipation, tachycardia
19.2.1.1. sugarless gum, sip water, wear sunglasses outdoors, foods high in fiber, 2-3 L/day of fluid intake, voiding before medicaiton
19.3. Extrapyramidal Adverse Effects
19.3.1. Acute Dystonia
19.3.1.1. spasm of the tongue, neck, face and back
19.3.1.2. treat with benztropine
20. Identifying theapeutic effects of Buspirone
20.1. Anitanxiety med
20.2. panic disorder, social anxiety disorder, OCD, PTSD, generalized anxiety disorder, and bruxism (grinding of teeth)
21. Contraindicaiton for MMR Immunization
21.1. Pregnancy, severe allergic reaction to previous MMR, immunodeficiencym active illness, recent blood products, TB, and corticosteriods for 14 days or more
22. Identifying Client Understanding of Newborn Care
22.1. newborns should be breastfeed every 2-3 hr; every 3 hr during the day; every 4 hr during the night
22.1.1. should be done 8-12 times within 24 hr
22.2. should void 6-8 diapers per day
23. Expected finding for a client who has Cataracts
23.1. decreased visual acuity, blurred vision, and dipllopia (double vision)
23.2. progressive and painless vision loss, visible opacity, and absent red relex
24. Safety and Infection Control
24.1. Newborn Complications: Phototherapy for Hyperbilirubinemia
24.1.1. remove every 4 hr anc check eyes for inflammation or injury
24.1.2. repositon every 2 hours
24.1.3. newborn should be placed 18 in from lamp
24.2. Staff Education Regarding Antiobiotic-Resistant Infections
24.2.1. proper antibiotic use, good hand hygiene, standard precautions
24.3. Priority Action for a Client Who is Agitated
24.3.1. staying calm, acknowledge the client feelinfs, ask open ended questions, non-threatening body posture
24.4. Seizures: finding indicating need for a home safety modification
24.4.1. pad side rails, keep bed free of injury, have suction and oxygen equipment
24.5. Common manifestation of a food allergy
24.5.1. nausea, vomiting, diarrhea, abdominal distention, and pain
24.6. Evaluating Teaching about Car Seat Safety
24.6.1. rear-facing at 45 degree angle, straps should be at or below the child shoulders, chest clip should be at nipple level
24.7. Action for Anthraz Exposure
24.7.1. isolation, decontamination, disposal (double bag), report, antibiotics, vaccine, and stockpile
25. Reduction of Risk Potential
25.1. Inflammatory Disorders: Priority Findings in a Client Who Has Pericarditis
25.1.1. widespread ST elevation or PR depression, elevated ESR and CRP, low grade fever
25.2. Categorizing Pitting Edema
25.2.1. 1+ = trace, 2 mm, rapid skin response
25.2.2. 2+ = mild, 4 mm, 10-15 sec skin response
25.2.3. 3+= moderate, 6 mm, prolonged skin response
25.2.4. 4+ = severe, 8 mm, prolonged skin response
26. Physiological Adaption
26.1. Teaching About Legg-Calve-Perthes Disease
26.1.1. impaired circulation to femoral head that results in aseptic necrosis
26.1.2. Nursing Care
26.1.2.1. admin NSAIDs, maintain rest and limited weight bearing, advance to active range of motion as prescribed
26.1.2.2. Client education
26.1.2.2.1. important to attend school and perform other approriate activities
26.2. Order of Nursing Actions Following Laparotomy
26.2.1. assess airway and breathing, vital signs, manage pain, check site for bleeding or drainage, bowel sounds, adequate fluid hydration, and early mobilization
26.3. Manifestations of Decreased Cardiac Output
26.3.1. shortness of breath, fatigue, edema (legs, feet, or ankles), low blood pressure, weak pulse, cool extremities, decreased urine output, and altered mental status