ReMar Quick Facts

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74 terms bruce_rueda_versoza Preview NCLEX 1,074 ter Tiar How do precautions change w/AIDS?Pt. has low CD4 & is at risk for infection: -private room - reverse isolation RN wears gown, goggles, mask when direct contact w/ bodily fluids Causes of acute renal failureInfection, obstruction, shock

• phases of Acute Renal FailureOliguric, Diuretic, Recovery

During the Oliguric phase what will you see?Low urine output, hyperkalemia, HTN, elevated BUN/creatinine, fluid overload, elevated Sodium & Potassium The diuretic phase is 2nd, what will you see?Urine output slowly returns, hypokalemia, hypotension, BUN/ creatinine decreases but still elevated What does recovery phase mean?Kidneys are recovering through a slow process, urine vl & BUN is normal What are nursing interventions for Acute Renal Failure? Daily weights, I&O's,treat the cause & diuretics What is the best diet for a client w/ acute renal failure? High carb & low protein What allergy is contraindicated for contrast?Iodine/Shellfish What are the major complications of having an amputation performed ?Infections, skin breakdown, phantom limb pain, joint contractures What is the positioning for care?AKA-(above the knee) amputation Elevate 1st 24hrs then prone position to prevent hip flexion

What is the positioning for care?BKA-(below the knee) amputation Elevate foot of bed 1st 24hrs then prone position twice daily to prevent hip flexion AneurysmDilation formed at a weak point on the wall of an artery

Aneurysm: what sound would be heard on auscultation? Blowing bruit

What are risk factors for aneurysm?Arteriosclerosis, infection ( syphillis), smoking, HTN Signs of a ruptured Aneurysm?Severe pain, N/V, tachycardia, decreased LOC, hypotension Aneurysm: client teachingAvoid straining, lifting, or exerting take, melds on schedule, Report severe back/ flank pain Appendicitis, commonly seen in what age range? 10-30 Classic sign of appendicitis?Acute Right Lower Abdominal Pain S/S of AppendicitisLoss of appetite, N/V, low grade temp.In appendicitis , localized tenderness is found in? McBurney's point Treatment for AppendicitisImmediate surgery to remove appendix, IV antibiotics, semi-fowlers position, NPO to rest gut General treatment for any acute abdominal pain NPO status, no heat on abdomen, assess abdominal distention, IV fluid therapy

ABG: where are most samples drawn from?Radial artery in wrist

After ABG sample, how long should pressure be applied to the site?

• minutes

Which test should be performed before collecting an ABG on a pt.?Allen's Test AsthmaAn obstructive airway disease caused by spasms and inflammation of the bronchioles.Signs of AsthmaSOB, tachycardia, expiratory wheezes, cough Primary treatment goal of asthmaIdentify the allergen

Asthma: What medications work best for treatment Anti-inflammatory

Corticosteroids Bronchodilators Leukotriene modifiers Metered dose inhalers

Tx-Asthma: What should you give first?

Steroid or Bronchodilator Bronchodilator What are Leukotriene modifiers?Drugs used to block the chemical Leukotriene reduces inflammatory Ex. Montelukast (Singulair) Autonomic Dysreflexia occurs in clients w/ what kind of injury?Spinal cord injury ( T-5 or above) Why is autonomic dysreflexia so serious?Life threatening due to clients becoming extremely hypertensive Signs of autonomic dysreflexiaIncrease in BP 40mm Hg, headache, bradycardia, Blurred vision, sweating

Autonomic dysreflexia: what should be done during an

episode?Place client in High-Fowlers, Check for bladder distention, Loosen restrictive clothing Autonomic dysreflexia: TreatmentRemoval of the stimuli, Pt. needs to void/ bowel movement Bell's Palsy affects which cranial nerve?Cranial nerve #7 What does the client with Bells Palsy suffer from? Temporary facial paralysis that affects chewing, eating, and closing their eyes Treatment for Bell's PalsyWear eye patch @ night Use artificial tears Wear glasses to protect eyes *steroids to reduce edema Benign Prostatic Hyperplasia (BPH)Enlargement of the prostate gland Cause unknown Because the prostate blocks the urethra opening clients will feel and see what when they urinate?Straining to urinate Decreased stream Feeling like they have to go all the time Dribbling Who gets BPH?Men usually >50 What is the best way to assess for BPH?Rectal exam, will feel pea sized nodule What is the common surgical treatment for BPH? Transurethral resection of the Prostate (TURP) How is transurethral resection of the prostate (TURP) performed?Scope goes through the penis and removes parts of the prostate After a TURP procedure what is client at risk for? Bleeding; monitor for hemorrhage Before a TURP, what will all clients get?3way (lumen) Foley catheter

What are the three lumens for in a 3way lumen Foley catheter?Inflating the ballon, inflow of solution, outflow of urine What will the Dr. order to be done afte a TURP? Continuous bladder irrigation (CBI) What is the goal of the bladder irrigation? ( after a TURP )Reduce/prevent blood clot formation What type of fluid is used to irrigate the bladder? Isotonic sterile saline After a TURP , what do you want the urine to be? Light pink During a continuous bladder irrigation, what must the client be monitored for?Bladder distention Fluid overload/ hyponatremia Blood loss After a TURP, if bladder spasms occur give...B&O suppositories or Ditropan Best position for a pt. receiving a TURP, post-op? Lying flat, sitting up puts pressure on the bladder Discharge instructions after TURPDrinking 2-3L of fluids daily No lifting or straining If bright red clots call MD Do kegel exercises What must be received before a transfusion is started? Written consent What is the most common infection spread through blood transfusion?Hepatitis B In order to determine donor compatibility what must be done?Type and cross match What must be done to determine clients baseline before starting the transfusion?Vital Signs For blood administration, what size IV is needed? 18G w/ filter needle How many nurses confirm the unit of blood?Two How long after blood is removed from the banks refrigerator do you have to start it?30 minutes How long must you stay with the client after transfusion is started?15 minutes How many milliliters are in one unit of packed red blood cells About 250 mL