PRACTICE TEST QUESTIONS Downloaded from FILIPINO NURSES CENTRAL {www.filipinonursescentral.wordpress.com}
-->Unlike false labor, true labor produces regular rhythmic contractions,
abdominal discomfort, progressive descent of the fetus, bloody show, and
progressive effacement and dilation of the cervix.
-->To help a mother break the suction of her breast-feeding infant, the nurse
should teach her to insert a finger at the corner of the infant’s mouth.
-->Administering high levels of oxygen to a premature neonate can cause
blindness as a result of retrolental fibroplasia.
-->Amniotomy is artificial rupture of the amniotic membranes.
-->During pregnancy, weight gain averages 25 to 30 lb (11 to 13.5 kg).
-->Rubella has a teratogenic effect on the fetus during the first
trimester. It produces abnormalities in up to 40% of cases without
interrupting the pregnancy.
-->Immunity to rubella can be measured by a hemagglutination inhibition test
(rubella titer). This test identifies exposure to rubella infection and
determines susceptibility in pregnant women. In a woman, a titer greater
than 1:8 indicates immunity.
-->When used to describe the degree of fetal descent during labor, floating
means the presenting part isn’t engaged in the pelvic inlet, but is freely
movable (ballotable) above the pelvic inlet.
-->When used to describe the degree of fetal descent, engagement means
when the largest diameter of the presenting part has passed through the
pelvic inlet.
-->Fetal station indicates the location of the presenting part in relation to the
ischial spine. It’s described as –1, –2, –3, –4, or –5 to indicate the
number of centimeters above the level of the ischial spine; station –5 is at
the pelvic inlet.
-->Fetal station also is described as +1, +2, +3, +4, or +5 to indicate
the number of centimeters it is below the level of the ischial spine; station
0 is at the level of the ischial spine.
-->During the first stage of labor, the side-lying position usually
provides the greatest degree of comfort, although the patient may assume
any comfortable position.
-->During delivery, if the umbilical cord can’t be loosened and slipped from
around the neonate’s neck, it should be clamped with two clamps and cut
between the clamps.
-->An Apgar score of 7 to 10 indicates no immediate distress, 4 to 6
indicates moderate distress, and 0 to 3 indicates severe distress. -->To elicit Moro’s reflex, the nurse holds the neonate in both hands and
suddenly, but gently, drops the neonate’s head backward. Normally, the
neonate abducts and extends all extremities bilaterally and symmetrically,
forms a C shape with the thumb and forefinger, and first adducts and then
flexes the extremities.
]-->Pregnancy-induced hypertension (preeclampsia) is an increase in blood
pressure of 30/15 mm Hg over baseline or blood pressure of 140/95
mm Hg on two occasions at least 6 hours apart accompanied by edema
and albuminuria after 20 weeks’ gestation.
-->Positive signs of pregnancy include ultrasound evidence, fetal heart tones,
and fetal movement felt by the examiner (not usually present until 4
months’ gestation
-->Goodell’s sign is softening of the cervix.
-->Quickening, a presumptive sign of pregnancy, occurs between 16 and 19
weeks’ gestation.
-->Ovulation ceases during pregnancy.
      -->Any vaginal bleeding during pregnancy should be considered a complication until proven      otherwise.
]-->To estimate the date of delivery using Nägele’s rule, the nurse counts
backward 3 months from the first day of the last menstrual period and then adds 7 days to this date.  -3 +7 +1
f]-->At 12 weeks’ gestation, the fundus should be at the top of the
symphysis pubis. ]-->Cow’s milk shouldn’t be given to infants younger than age 1
because it has a low linoleic acid content and its protein is difficult for
infants to digest. ]-->If jaundice is suspected in a neonate, the nurse should examine the infant
under natural window light. If natural light is unavailable, the nurse
should examine the infant under a white light. ]-->The three phases of a uterine contraction are increment, acme,
and decrement.
-->The intensity of a labor contraction can be assessed by the indentability of
the uterine wall at the contraction’s peak. Intensity is graded as mild
(uterine muscle is somewhat tense), moderate (uterine muscle is
moderately tense), or strong (uterine muscle is boardlike).
]-->Chloasma, the mask of pregnancy, is pigmentation of a circumscribed area
of skin (usually over the bridge of the nose and cheeks) that occurs in some
pregnant women.
]-->The gynecoid pelvis is most ideal for delivery. Other types include
platypelloid (flat), anthropoid (apelike), and android (malelike). ]-->Pregnant women should be advised that there is no safe level of alcohol
intake.
]-->The frequency of uterine contractions, which is measured in minutes,
is the time from the beginning of one contraction to the beginning of
the next.
]-->Vitamin K is administered to neonates to prevent hemorrhagic disorders
because a neonate’s intestine can’t synthesize vitamin K.
]-->Before internal fetal monitoring can be performed, a pregnant patient’s
cervix must be dilated at least 2 cm, the amniotic membranes must be
ruptured, and the fetus’s presenting part (scalp or buttocks) must be at
station –1 or lower, so that a small electrode can be attached.
]-->Fetal alcohol syndrome presents in the first 24 hours after birth and
produces lethargy, seizures, poor sucking reflex, abdominal distention, and
respiratory difficulty.
]-->Variability is any change in the fetal heart rate (FHR) from its normal
rate of 120 to 160 beats/minute. Acceleration is increased FHR;
deceleration is decreased FHR.
]-->In a neonate, the symptoms of heroin withdrawal may begin several
hours to 4 days after birth.
]-->In a neonate, the symptoms of methadone withdrawal may begin 7
days to several weeks after birth.
]-->In a neonate, the cardinal signs of narcotic withdrawal include
coarse, flapping tremors; sleepiness; restlessness; prolonged,
persistent, high-pitched cry; and irritability.
]-->The nurse should count a neonate’s respirations for 1 full minute.
]-->Chlorpromazine (Thorazine) is used to treat neonates who are addicted to
narcotics.
]-->The nurse should provide a dark, quiet environment for a neonate who is
experiencing narcotic withdrawal.
]-->In a premature neonate, signs of respiratory distress include nostril
flaring, substernal retractions, and inspiratory grunting.
]-->Respiratory distress syndrome (hyaline membrane disease) develops in
premature infants because their pulmonary alveoli lack surfactant.
]-->Whenever an infant is being put down to sleep, the parent or caregiver
should position the infant on the back. (Remember back to sleep.)
]-->The male sperm contributes an X or a Y chromosome; the female ovum
contributes an X chromosome.
]-->Fertilization produces a total of 46 chromosomes, including an XY
combination (male) or an XX combination (female).
]-->The percentage of water in a neonate’s body is about 78% to 80%.
]-->To perform nasotracheal suctioning in an infant, the nurse positions
the infant with his neck slightly hyperextended in a “sniffing”
position, with his chin up and his head tilted back slightly.
]-->Organogenesis occurs during the first trimester of pregnancy,
specifically, days 14 to 56 of gestation.
]-->After birth, the neonate’s umbilical cord is tied 1" (2.5 cm) from the
abdominal wall with a cotton cord, plastic clamp, or rubber band.
]-->Gravida is the number of pregnancies a woman has had, regardless of
outcome.
]-->Para is the number of pregnancies that reached viability, regardless
of whether the fetus was delivered alive or stillborn. A fetus is considered
viable at 20 weeks’ gestation.
]-->An ectopic pregnancy is one that implants abnormally, outside the uterus. ]-->The first stage of labor begins with the onset of labor and ends
with full cervical dilation at 10 cm.
]-->The second stage of labor begins with full cervical dilation and
ends with the neonate’s birth.
-->The third stage of labor begins after the neonate’s birth and ends
with expulsion of the placenta.
In a full-term neonate, skin creases appear over two-thirds of the neonate’s
feet. Preterm neonates have heel creases that cover less than two-thirds of
the feet.
]-->The fourth stage of labor (postpartum stabilization) lasts up to 4 hours
after the placenta is delivered. This time is needed to stabilize the mother’s
physical and emotional state after the stress of childbirth.
]-->At 20 weeks’ gestation, the fundus is at the level of the umbilicus.
]-->At 36 weeks’ gestation, the fundus is at the lower border of the rib
cage.
]-->A premature neonate is one born before the end of the 37th week of
gestation.
]-->Pregnancy-induced hypertension is a leading cause of maternal death in
the United States.
]-->A habitual aborter is a woman who has had three or more consecutive
spontaneous abortions.
]-->Threatened abortion occurs when bleeding is present without cervical
dilation.
]-->A complete abortion occurs when all products of conception are expelled.
]-->Hydramnios (polyhydramnios) is excessive amniotic fluid (more than
2,000 ml in the third trimester).
]-->Stress, dehydration, and fatigue may reduce a breast-feeding mother’s
milk supply.
]-->During the transition phase of the first stage of labor, the cervix is dilated
8 to 10 cm and contractions usually occur 2 to 3 minutes apart and last for
60 seconds.
]-->A nonstress test is considered nonreactive (positive) if fewer than two
fetal heart rate accelerations of at least 15 beats/minute occur in 20
minutes.
]-->A nonstress test is considered reactive (negative) if two or more fetal
heart rate accelerations of 15 beats/minute above baseline occur in 20
minutes.
-->A nonstress test is usually performed to assess fetal well-being in a
pregnant patient with a prolonged pregnancy (42 weeks or more), diabetes,
a history of poor pregnancy outcomes, or pregnancy-induced hypertension.
]-->A pregnant woman should drink at least eight 8-oz glasses (about 2,000
ml) of water daily.
]-->When both breasts are used for breast-feeding, the infant usually doesn’t
empty the second breast. Therefore, the second breast should be used first
at the next feeding.
]-->A low-birth-weight neonate weighs 2,500 g (5 lb 8 oz) or less at
birth.
]-->A very-low-birth-weight neonate weighs 1,500 g (3 lb 5 oz) or less
at birth.
]-->When teaching parents to provide umbilical cord care, the nurse should
teach them to clean the umbilical area with a cotton ball saturated with
alcohol after every diaper change to prevent infection and promote drying. ]-->Teenage mothers are more likely to have low-birth-weight neonates
because they seek prenatal care late in pregnancy (as a result of denial)
and are more likely than older mothers to have nutritional deficiencies. ]-->Linea nigra, a dark line that extends from the umbilicus to the mons
pubis, commonly appears during pregnancy and disappears after
pregnancy.
-->Implantation in the uterus occurs 6 to 10 days after ovum fertilization. -->Placenta previa is abnormally low implantation of the placenta so that it
encroaches on or covers the cervical os.
-->In complete (total) placenta previa, the placenta completely covers the
cervical os.
-->In partial (incomplete or marginal) placenta previa, the placenta
covers only a portion of the cervical os.
-->Abruptio placentae is premature separation of a normally implanted
placenta. It may be partial or complete, and usually causes abdominal pain,
vaginal bleeding, and a boardlike abdomen.
-->Cutis marmorata is mottling or purple discoloration of the skin. It’s a
transient vasomotor response that occurs primarily in the arms and legs of
infants who are exposed to cold.
-->The classic triad of symptoms of preeclampsia are hypertension, edema,
and proteinuria. Additional symptoms of severe preeclampsia include
hyperreflexia, cerebral and vision disturbances, and epigastric pain.
-->Ortolani’s sign (an audible click or palpable jerk that occurs with thigh abduction) confirms congenital hip dislocation in a neonate.
-->The first immunization for a neonate is the hepatitis B vaccine,
which is administered in the nursery shortly after birth.
-->If a patient misses a menstrual period while taking an oral contraceptive
exactly as prescribed, she should continue taking the contraceptive.
-->If a patient misses two consecutive menstrual periods while taking an
oral contraceptive, she should discontinue the contraceptive and take a
pregnancy test.
-->If a patient who is taking an oral contraceptive misses a dose, she should
take the pill as soon as she remembers or take two at the next scheduled
interval and continue with the normal schedule.
-->If a patient who is taking an oral contraceptive misses two consecutive
doses, she should double the dose for 2 days and then resume her normal
schedule. She also should use an additional birth control method for 1
week.
-->Eclampsia is the occurrence of seizures that aren’t caused by a cerebral
disorder in a patient who has pregnancy-induced hypertension.
-->In placenta previa, bleeding is painless and seldom fatal on the first
occasion, but it becomes heavier with each subsequent episode.
-->Treatment for abruptio placentae is usually immediate cesarean
delivery.
-->Drugs used to treat withdrawal symptoms in neonates include
phenobarbital (Luminal), camphorated opium tincture (paregoric),
and diazepam (Valium).
-->Infants with Down syndrome typically have marked hypotonia,
floppiness, slanted eyes, excess skin on the back of the neck, flattened
bridge of the nose, flat facial features, spadelike hands, short and broad
feet, small male genitalia, absence of Moro’s reflex, and a simian crease on
the hands.
-->The failure rate of a contraceptive is determined by the experience of 100
women for 1 year. It’s expressed as pregnancies per 100 woman-years.
-->The narrowest diameter of the pelvic inlet is the anteroposterior
(diagonal conjugate).
]-->The chorion is the outermost extraembryonic membrane that gives
rise to the placenta.
-->The corpus luteum secretes large quantities of progesterone.
-->From the 8th week of gestation through delivery, the developing cells
are known as a fetus.
-->In an incomplete abortion, the fetus is expelled, but parts of the placenta
and membrane remain in the uterus.
-->The circumference of a neonate’s head is normally 2 to 3 cm greater
than the circumference of the chest.
-->After administering magnesium sulfate to a pregnant patient for
hypertension or preterm labor, the nurse should monitor the
respiratory rate and deep tendon reflexes.
-->During the first hour after birth (the period of reactivity), the neonate is
alert and awake.
-->When a pregnant patient has undiagnosed vaginal bleeding, vaginal
examination should be avoided until ultrasonography rules out placenta
previa.
-->After delivery, the first nursing action is to establish the neonate’s airway. -->Nursing interventions for a patient with placenta previa include positioning
the patient on her left side for maximum fetal perfusion, monitoring fetal
heart tones, and administering I.V. fluids and oxygen, as ordered.
-->The specific gravity of a neonate’s urine is 1.003 to 1.030. A lower
specific gravity suggests overhydration; a higher one suggests
dehydration.
-->The neonatal period extends from birth to day 28. It’s also called the first 4
weeks or first month of life.
-->A woman who is breast-feeding should rub a mild emollient cream or
a few drops of breast milk (or colostrum) on the nipples after each feeding.
She should let the breasts air-dry to prevent them from cracking.
-->Breast-feeding mothers should increase their fluid intake to 2½ to 3 qt
(2,500 to 3,000 ml) daily.
-->After feeding an infant with a cleft lip or palate, the nurse should
rinse the infant’s mouth with sterile water.
-->The nurse instills erythromycin in a neonate’s eyes primarily to
prevent blindness caused by gonorrhea or chlamydia.
-->Human immunodeficiency virus (HIV) has been cultured in breast milk and
can be transmitted by an HIV-positive mother who breast-feeds her infant. -->A fever in the first 24 hours postpartum is most likely caused by
dehydration rather than infection.
-->Preterm neonates or neonates who can’t maintain a skin
temperature of at least 97.6° F (36.4° C) should receive care in an
incubator (Isolette) or a radiant warmer. In a radiant warmer, a heat-
sensitive probe taped to the neonate’s skin activates the heater unit automatically to maintain the desired temperature.
-->During labor, the resting phase between contractions is at least 30
seconds.
-->Lochia rubra is the vaginal discharge of almost pure blood that occurs
during the first few days after childbirth.
-->Lochia serosa is the serous vaginal discharge that occurs 4 to 7 days
after childbirth.
-->Lochia alba is the vaginal discharge of decreased blood and increased
leukocytes that’s the final stage of lochia. It occurs 7 to 10 days after
childbirth.
-->Colostrum, the precursor of milk, is the first secretion from the breasts
after delivery.
-->The length of the uterus increases from 2½" (6.3 cm) before pregnancy to
12½" (32 cm) at term.
-->To estimate the true conjugate (the smallest inlet measurement of the
pelvis), deduct 1.5 cm from the diagonal conjugate (usually 12 cm). A true
conjugate of 10.5 cm enables the fetal head (usually 10 cm) to pass.
-->The smallest outlet measurement of the pelvis is the intertuberous
diameter, which is the transverse diameter between the ischial tuberosities. -->Electronic fetal monitoring is used to assess fetal well-being during labor. If
compromised fetal status is suspected, fetal blood pH may be evaluated by
obtaining a scalp sample.
-->In an emergency delivery, enough pressure should be applied to the
emerging fetus’s head to guide the descent and prevent a rapid change in
pressure within the molded fetal skull.
-->After delivery, a multiparous woman is more susceptible to bleeding than a
primiparous woman because her uterine muscles may be overstretched and
may not contract efficiently.
-->Neonates who are delivered by cesarean birth have a higher incidence of
respiratory distress syndrome.
-->The nurse should suggest ambulation to a postpartum patient who has gas
pain and flatulence.
-->Massaging the uterus helps to stimulate contractions after the placenta is
delivered.
-->When providing phototherapy to a neonate, the nurse should cover the
neonate’s eyes and genital area. -->The narcotic antagonist naloxone (Narcan) may be given to a neonate to
correct respiratory depression caused by narcotic administration to the
mother during labor. -->In a neonate, symptoms of respiratory distress syndrome include
expiratory grunting or whining, sandpaper breath sounds, and seesaw
retractions. -->Cerebral palsy presents as asymmetrical movement, irritability, and
excessive, feeble crying in a long, thin infant. -->The nurse should assess a breech-birth neonate for hydrocephalus,
hematomas, fractures, and other anomalies caused by birth trauma. -->When a patient is admitted to the unit in active labor, the nurse’s first
action is to listen for fetal heart tones. -->In a neonate, long, brittle fingernails are a sign of postmaturity. -->Desquamation (skin peeling) is common in postmature neonates. -->A mother should allow her infant to breast-feed until the infant is satisfied.
The time may vary from 5 to 20 minutes. -->Nitrazine paper is used to test the pH of vaginal discharge to determine the
presence of amniotic fluid. -->A pregnant patient normally gains 2 to 5 lb (1 to 2.5 kg) during the first
trimester and slightly less than 1 lb (0.5 kg) per week during the last two
trimesters. -->Neonatal jaundice in the first 24 hours after birth is known as pathological
jaundice and is a sign of erythroblastosis fetalis. -->A classic difference between abruptio placentae and placenta previa is the
degree of pain. Abruptio placentae causes pain, whereas placenta previa
causes painless bleeding. -->Because a major role of the placenta is to function as a fetal lung, any
condition that interrupts normal blood flow to or from the placenta
increases fetal partial pressure of arterial carbon dioxide and decreases
fetal pH. -->Precipitate labor lasts for approximately 3 hours and ends with delivery of
the neonate. -->Methylergonovine (Methergine) is an oxytocic agent used to prevent and
treat postpartum hemorrhage caused by uterine atony or subinvolution.
-->As emergency treatment for excessive uterine bleeding, 0.2 mg of
methylergonovine (Methergine) is injected I.V. over 1 minute while the
patient’s blood pressure and uterine contractions are monitored.
-->Braxton Hicks contractions are usually felt in the abdomen and don’t cause
cervical change. True labor contractions are felt in the front of the abdomen
and back and lead to progressive cervical dilation and effacement.
-->The average birth weight of neonates born to mothers who smoke is 6 oz
(170 g) less than that of neonates born to nonsmoking mothers.
-->Culdoscopy is visualization of the pelvic organs through the posterior
vaginal fornix.
-->The nurse should teach a pregnant vegetarian to obtain protein from
alternative sources, such as nuts, soybeans, and legumes.
-->The nurse should instruct a pregnant patient to take only prescribed
prenatal vitamins because over-the-counter high-potency vitamins may
harm the fetus.
-->High-sodium foods can cause fluid retention, especially in pregnant
patients.
-->A pregnant patient can avoid constipation and hemorrhoids by adding fiber
to her diet.
-->If a fetus has late decelerations (a sign of fetal hypoxia), the nurse should
instruct the mother to lie on her left side and then administer 8 to 10 L of
oxygen per minute by mask or cannula. The nurse should notify the
physician. The side-lying position removes pressure on the inferior vena
cava.
-->Oxytocin (Pitocin) promotes lactation and uterine contractions.
-->Lanugo covers the fetus’s body until about 20 weeks’ gestation. Then it
begins to disappear from the face, trunk, arms, and legs, in that order.
]-->In a neonate, hypoglycemia causes temperature instability, hypotonia,
jitteriness, and seizures. Premature, postmature, small-for-gestational-age,
and large-for-gestational-age neonates are susceptible to this disorder.
]-->Neonates typically need to consume 50 to 55 cal per pound of body weight
daily.
]-->Because oxytocin (Pitocin) stimulates powerful uterine contractions during
labor, it must be administered under close observation to help prevent
maternal and fetal distress.
]-->During fetal heart rate monitoring, variable decelerations indicate
compression or prolapse of the umbilical cord.
]-->Cytomegalovirus is the leading cause of congenital viral infection.
]-->Tocolytic therapy is indicated in premature labor, but contraindicated in
fetal death, fetal distress, or severe hemorrhage.
]-->Through ultrasonography, the biophysical profile assesses fetal well-being
by measuring fetal breathing movements, gross body movements, fetal
tone, reactive fetal heart rate (nonstress test), and qualitative amniotic
fluid volume.
]-->A neonate whose mother has diabetes should be assessed for
hyperinsulinism.
]-->In a patient with preeclampsia, epigastric pain is a late symptom and
requires immediate medical intervention.
]-->After a stillbirth, the mother should be allowed to hold the neonate to help
her come to terms with the death.
]-->Molding is the process by which the fetal head changes shape to facilitate
movement through the birth canal.
]-->If a woman receives a spinal block before delivery, the nurse should
monitor the patient’s blood pressure closely.
]-->If a woman suddenly becomes hypotensive during labor, the nurse should
increase the infusion rate of I.V. fluids as prescribed.
]-->The best technique for assessing jaundice in a neonate is to blanch the tip
of the nose or the area just above the umbilicus.
]-->During fetal heart monitoring, early deceleration is caused by compression
of the head during labor.
]-->After the placenta is delivered, the nurse may add oxytocin (Pitocin) to the
patient’s I.V. solution, as prescribed, to promote postpartum involution of
the uterus and stimulate lactation.
]-->Pica is a craving to eat nonfood items, such as dirt, crayons, chalk, glue,
starch, or hair. It may occur during pregnancy and can endanger the fetus.
]-->A pregnant patient should take folic acid because this nutrient is required
for rapid cell division.
]-->A woman who is taking clomiphene (Clomid) to induce ovulation should be
informed of the possibility of multiple births with this drug.
]-->If needed, cervical suturing is usually done between 14 and 18 weeks’
gestation to reinforce an incompetent cervix and maintain pregnancy. The
suturing is typically removed by 35 weeks’ gestation.
]-->During the first trimester, a pregnant woman should avoid all drugs unless
doing so would adversely affect her health.
]-->Most drugs that a breast-feeding mother takes appear in breast milk.
]-->The Food and Drug Administration has established the following five
categories of drugs based on their potential for causing birth defects: A, no
evidence of risk; B, no risk found in animals, but no studies have been done
in women; C, animal studies have shown an adverse effect, but the drug
may be beneficial to women despite the potential risk; D, evidence of risk,
but its benefits may outweigh its risks; and X, fetal anomalies noted, and
the risks clearly outweigh the potential benefits.
]-->A patient with a ruptured ectopic pregnancy commonly has sharp pain in
the lower abdomen, with spotting and cramping. She may have abdominal
rigidity; rapid, shallow respirations; tachycardia; and shock.
]-->A patient with a ruptured ectopic pregnancy commonly has sharp pain in
the lower abdomen, with spotting and cramping. She may have abdominal
rigidity; rapid, shallow respirations; tachycardia; and shock.
]-->The mechanics of delivery are engagement, descent and flexion, internal
rotation, extension, external rotation, restitution, and expulsion.
]-->A probable sign of pregnancy, McDonald’s sign is characterized by an ease
in flexing the body of the uterus against the cervix.
]-->Amenorrhea is a probable sign of pregnancy.
]-->A pregnant woman’s partner should avoid introducing air into the vagina
during oral sex because of the possibility of air embolism.
]-->The presence of human chorionic gonadotropin in the blood or urine is a
probable sign of pregnancy.
]-->Radiography isn’t usually used in a pregnant woman because it may harm
the developing fetus. If radiography is essential, it should be performed
only after 36 weeks’ gestation.
]-->A pregnant patient who has had rupture of the membranes or who is
experiencing vaginal bleeding shouldn’t engage in sexual intercourse.
]-->Milia may occur as pinpoint spots over a neonate’s nose.
]-->The duration of a contraction is timed from the moment that the uterine
muscle begins to tense to the moment that it reaches full relaxation. It’s
measured in seconds.
]-->The union of a male and a female gamete produces a zygote, which
divides into the fertilized ovum.
]-->The first menstrual flow is called menarche and may be anovulatory
(infertile).
]-->Spermatozoa (or their fragments) remain in the vagina for 72 hours after
sexual intercourse.
]-->Prolactin stimulates and sustains milk production.
]-->Strabismus is a normal finding in a neonate.
]-->A postpartum patient may resume sexual intercourse after the perineal or
uterine wounds heal (usually within 4 weeks after delivery).
]-->A pregnant staff member shouldn’t be assigned to work with a patient who
has cytomegalovirus infection because the virus can be transmitted to the
fetus.
]-->Fetal demise is death of the fetus after viability.
]-->Respiratory distress syndrome develops in premature neonates because
their alveoli lack surfactant.
]-->The most common method of inducing labor after artificial rupture of the
membranes is oxytocin (Pitocin) infusion.
]-->After the amniotic membranes rupture, the initial nursing action is to
assess the fetal heart rate.
]-->The most common reasons for cesarean birth are malpresentation, fetal
distress, cephalopelvic disproportion, pregnancy-induced hypertension,
previous cesarean birth, and inadequate progress in labor.
]-->Amniocentesis increases the risk of spontaneous abortion, trauma to the
fetus or placenta, premature labor, infection, and Rh sensitization of the
fetus.
]-->After amniocentesis, abdominal cramping or spontaneous vaginal bleeding
may indicate complications.
]-->To prevent her from developing Rh antibodies, an Rh-negative
primigravida should receive Rho(D) immune globulin (RhoGAM) after
delivering an Rh-positive neonate.
]-->If a pregnant patient’s test results are negative for glucose but positive for
acetone, the nurse should assess the patient’s diet for inadequate caloric
intake.
]-->If a pregnant patient’s test results are negative for glucose but positive for
acetone, the nurse should assess the patient’s diet for inadequate caloric
intake.
]-->Rubella infection in a pregnant patient, especially during the first
trimester, can lead to spontaneous abortion or stillbirth as well as fetal
cardiac and other birth defects.
]-->A pregnant patient should take an iron supplement to help prevent
anemia.
]-->Direct antiglobulin (direct Coombs’) test is used to detect maternal
antibodies attached to red blood cells in the neonate.
]-->Nausea and vomiting during the first trimester of pregnancy are caused by
rising levels of the hormone human chorionic gonadotropin.
]-->Before discharging a patient who has had an abortion, the nurse should
instruct her to report bright red clots, bleeding that lasts longer than 7
days, or signs of infection, such as a temperature of greater than 100° F
(37.8° C), foul-smelling vaginal discharge, severe uterine cramping,
nausea, or vomiting.
]-->When informed that a patient’s amniotic membrane has broken, the nurse
should check fetal heart tones and then maternal vital signs.
]-->The duration of pregnancy averages 280 days, 40 weeks, 9 calendar
months, or 10 lunar months.
]-->The initial weight loss for a healthy neonate is 5% to 10% of birth weight. ]-->The normal hemoglobin value in neonates is 17 to 20 g/dl.
]-->Crowning is the appearance of the fetus’s head when its largest diameter
is encircled by the vulvovaginal ring.
]-->A multipara is a woman who has had two or more pregnancies that
progressed to viability, regardless of whether the offspring were alive at
birth.
]-->In a pregnant patient, preeclampsia may progress to eclampsia, which is
characterized by seizures and may lead to coma.
]-->The Apgar score is used to assess the neonate’s vital functions. It’s
obtained at 1 minute and 5 minutes after delivery. The score is based on
respiratory effort, heart rate, muscle tone, reflex irritability, and color.
]-->Because of the anti-insulin effects of placental hormones, insulin
requirements increase during the third trimester.
]-->Gestational age can be estimated by ultrasound measurement of maternal
abdominal circumference, fetal femur length, and fetal head size. These
measurements are most accurate between 12 and 18 weeks’ gestation.
]-->Skeletal system abnormalities and ventricular septal defects are the most
common disorders of infants who are born to diabetic women. The incidence
of congenital malformation is three times higher in these infants than in
those born to nondiabetic women.
]-->Skeletal system abnormalities and ventricular septal defects are the most
common disorders of infants who are born to diabetic women. The incidence
of congenital malformation is three times higher in these infants than in
those born to nondiabetic women.
]-->The patient with preeclampsia usually has puffiness around the eyes or
edema in the hands (for example, “I can’t put my wedding ring on.”).
]-->Kegel exercises require contraction and relaxation of the perineal muscles.
These exercises help strengthen pelvic muscles and improve urine control in
postpartum patients.
]-->Symptoms of postpartum depression range from mild postpartum blues to
intense, suicidal, depressive psychosis.
]-->The preterm neonate may require gavage feedings because of a weak
sucking reflex, uncoordinated sucking, or respiratory distress.
]-->Acrocyanosis (blueness and coolness of the arms and legs) is normal in
neonates because of their immature peripheral circulatory system.
]-->To prevent ophthalmia neonatorum (a severe eye infection caused by
maternal gonorrhea), the nurse may administer one of three drugs, as
prescribed, in the neonate’s eyes: tetracycline, silver nitrate, or
erythromycin.
]-->Neonatal testing for phenylketonuria is mandatory in most states.
]-->The nurse should place the neonate in a 30-degree Trendelenburg position
to facilitate mucus drainage.
]-->The nurse may suction the neonate’s nose and mouth as needed with a
bulb syringe or suction trap.
]-->To prevent heat loss, the nurse should place the neonate under a radiant
warmer during suctioning and initial delivery-room care, and then wrap the
neonate in a warmed blanket for transport to the nursery.
]-->The umbilical cord normally has two arteries and one vein.
]-->When providing care, the nurse should expose only one part of an infant’s
body at a time.
]-->Lightening is settling of the fetal head into the brim of the pelvis.
]-->If the neonate is stable, the mother should be allowed to breast-feed
within the neonate’s first hour of life.
]-->The nurse should check the neonate’s temperature every 1 to 2 hours until
it’s maintained within normal limits.
]-->At birth, a neonate normally weighs 5 to 9 lb (2 to 4 kg), measures 18" to
22" (45.5 to 56 cm) in length, has a head circumference of 13½" to 14" (34
to 35.5 cm), and has a chest circumference that’s 1" (2.5 cm) less than the
head circumference.
]-->In the neonate, temperature normally ranges from 98° to 99° F (36.7° to
37.2° C), apical pulse rate averages 120 to 160 beats/minute, and
respirations are 40 to 60 breaths/minute.
]-->The diamond-shaped anterior fontanel usually closes between ages 12 and
18 months. The triangular posterior fontanel usually closes by age 2
months.
]-->In the neonate, a straight spine is normal. A tuft of hair over the spine is
an abnormal finding.
]-->Prostaglandin gel may be applied to the vagina or cervix to ripen an
unfavorable cervix before labor induction with oxytocin (Pitocin).
]-->Supernumerary nipples are occasionally seen on neonates. They usually
appear along a line that runs from each axilla, through the normal nipple
area, and to the groin.
]-->Meconium is a material that collects in the fetus’s intestines and forms the
neonate’s first feces, which are black and tarry.
]-->The presence of meconium in the amniotic fluid during labor indicates
possible fetal distress and the need to evaluate the neonate for meconium
aspiration.
]-->To assess a neonate’s rooting reflex, the nurse touches a finger to the
cheek or the corner of the mouth. Normally, the neonate turns his head
toward the stimulus, opens his mouth, and searches for the stimulus.
]-->Harlequin sign is present when a neonate who is lying on his side appears
red on the dependent side and pale on the upper side.
]-->Mongolian spots can range from brown to blue. Their color depends on
how close melanocytes are to the surface of the skin. They most commonly
appear as patches across the sacrum, buttocks, and legs.
]-->Mongolian spots are common in non-white infants and usually disappear
by age 2 to 3 years.
]-->Vernix caseosa is a cheeselike substance that covers and protects the
fetus’s skin in utero. It may be rubbed into the neonate’s skin or washed
away in one or two baths.
-->Caput succedaneum is edema that develops in and under the fetal scalp
during labor and delivery. It resolves spontaneously and presents no danger
to the neonate. The edema doesn’t cross the suture line.
]-->Nevus flammeus, or port-wine stain, is a diffuse pink to dark bluish red
lesion on a neonate’s face or neck.
]-->The Guthrie test (a screening test for phenylketonuria) is most reliable if
it’s done between the second and sixth days after birth and is performed
after the neonate has ingested protein.
]-->To assess coordination of sucking and swallowing, the nurse should
observe the neonate’s first breast-feeding or sterile water bottle-feeding. ]-->To establish a milk supply pattern, the mother should breast-feed her
infant at least every 4 hours. During the first month, she should breast-feed
8 to 12 times daily (demand feeding).
]-->To avoid contact with blood and other body fluids, the nurse should wear
gloves when handling the neonate until after the first bath is given.
]-->If a breast-fed infant is content, has good skin turgor, an adequate
number of wet diapers, and normal weight gain, the mother’s milk supply is
assumed to be adequate.
]-->In the supine position, a pregnant patient’s enlarged uterus impairs
venous return from the lower half of the body to the heart, resulting in
supine hypotensive syndrome, or inferior vena cava syndrome.
]-->Tocolytic agents used to treat preterm labor include terbutaline (Brethine),
ritodrine (Yutopar), and magnesium sulfate.
]-->A pregnant woman who has hyperemesis gravidarum may require
hospitalization to treat dehydration and starvation.
]-->Diaphragmatic hernia is one of the most urgent neonatal surgical
emergencies. By compressing and displacing the lungs and heart, this
disorder can cause respiratory distress shortly after birth.
]-->Common complications of early pregnancy (up to 20 weeks’ gestation)
include fetal loss and serious threats to maternal health.
]-->Fetal embodiment is a maternal developmental task that occurs in the
second trimester. During this stage, the mother may complain that she
never gets to sleep because the fetus always gives her a thump when she
tries.
]-->Visualization in pregnancy is a process in which the mother imagines what
the child she’s carrying is like and becomes acquainted with it.
]-->Hemodilution of pregnancy is the increase in blood volume that occurs
during pregnancy. The increased volume consists of plasma and causes an
imbalance between the ratio of red blood cells to plasma and a resultant
decrease in hematocrit.
]-->Mean arterial pressure of greater than 100 mm Hg after 20 weeks of
pregnancy is considered hypertension.
]-->The treatment for supine hypotension syndrome (a condition that
sometimes occurs in pregnancy) is to have the patient lie on her left side. ]-->A contributing factor in dependent edema in the pregnant patient is the
increase of femoral venous pressure from 10 mm Hg (normal) to 18 mm Hg
(high).
]-->Hyperpigmentation of the pregnant patient’s face, formerly called
chloasma and now referred to as melasma, fades after delivery.
]-->The hormone relaxin, which is secreted first by the corpus luteum and
later by the placenta, relaxes the connective tissue and cartilage of the
symphysis pubis and the sacroiliac joint to facilitate passage of the fetus
during delivery.
]-->Progesterone maintains the integrity of the pregnancy by inhibiting uterine
motility.
]-->Ladin’s sign, an early indication of pregnancy, causes softening of a spot
on the anterior portion of the uterus, just above the uterocervical juncture. ]-->During pregnancy, the abdominal line from the symphysis pubis to the
umbilicus changes from linea alba to linea nigra.
]-->In neonates, cold stress affects the circulatory, regulatory, and respiratory
systems.
      -->Obstetric data can be described by using the F/TPAL system:
-->F/T: Full-term delivery at 38 weeks or longer -->P: Preterm delivery between 20 and 37 weeks
-->A: Abortion or loss of fetus before 20 weeks -->L: Number of children living (if a child has died, further explanation is
needed to clarify the discrepancy in numbers).
-->Parity doesn’t refer to the number of infants delivered, only the number of
deliveries.
      -->Women who are carrying more than one fetus should be encouraged to gain 35 to 45 lb (15.5 to 20.5 kg) during pregnancy.
-->The recommended amount of iron supplement for the pregnant patient is
30 to 60 mg daily.
-->Drinking six alcoholic beverages a day or a single episode of binge drinking
in the first trimester can cause fetal alcohol syndrome.
-->Chorionic villus sampling is performed at 8 to 12 weeks of pregnancy for
early identification of genetic defects.
-->In percutaneous umbilical blood sampling, a blood sample is obtained from
the umbilical cord to detect anemia, genetic defects, and blood
incompatibility as well as to assess the need for blood transfusions.
-->The period between contractions is referred to as the interval, or resting
phase. During this phase, the uterus and placenta fill with blood and allow
for the exchange of oxygen, carbon dioxide, and nutrients.
-->In a patient who has hypertonic contractions, the uterus doesn’t have an
opportunity to relax and there is no interval between contractions. As a
result, the fetus may experience hypoxia or rapid delivery may occur.
-->Two qualities of the myometrium are elasticity, which allows it to stretch
yet maintain its tone, and contractility, which allows it to shorten and
lengthen in a synchronized pattern.
-->During crowning, the presenting part of the fetus remains visible during the
interval between contractions.
-->Uterine atony is failure of the uterus to remain firmly contracted.
-->The major cause of uterine atony is a full bladder.
-->If the mother wishes to breast-feed, the neonate should be nursed as soon
as possible after delivery.
-->A smacking sound, milk dripping from the side of the mouth, and sucking
noises all indicate improper placement of the infant’s mouth over the
nipple.
-->Before feeding is initiated, an infant should be burped to expel air from the
stomach. -->Most authorities strongly encourage the continuation of breast-feeding on
both the affected and the unaffected breast of patients with mastitis. -->Neonates are nearsighted and focus on items that are held 10" to 12" (25
to 30.5 cm) away. -->In a neonate, low-set ears are associated with chromosomal abnormalities
such as Down syndrome. -->Meconium is usually passed in the first 24 hours; however, passage may
take up to 72 hours. -->Boys who are born with hypospadias shouldn’t be circumcised at birth
because the foreskin may be needed for constructive surgery. -->In the neonate, the normal blood glucose level is 45 to 90 mg/dl. -->Hepatitis B vaccine is usually given within 48 hours of birth. -->Hepatitis B immune globulin is usually given within 12 hours of birth. -->HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is
an unusual variation of pregnancy-induced hypertension. -->Maternal serum alpha-fetoprotein is detectable at 7 weeks of gestation and
peaks in the third trimester. High levels detected between the 16th and
18th weeks are associated with neural tube defects. Low levels are
associated with Down syndrome. -->An arrest of descent occurs when the fetus doesn’t descend through the
pelvic cavity during labor. It’s commonly associated with cephalopelvic
disproportion, and cesarean delivery may be required. -->A late sign of preeclampsia is epigastric pain as a result of severe liver
edema. -->In the patient with preeclampsia, blood pressure returns to normal during
the puerperal period. -->To obtain an estriol level, urine is collected for 24 hours. -->An estriol level is used to assess fetal well-being and maternal renal
functioning as well as to monitor a pregnancy that’s complicated by
diabetes. -->A pregnant patient with vaginal bleeding shouldn’t have a pelvic
examination.
-->In the early stages of pregnancy, the finding of glucose in the urine may be
related to the increased shunting of glucose to the developing placenta,
without a corresponding increase in the reabsorption capability of the
kidneys. -->A patient who has premature rupture of the membranes is at significant
risk for infection if labor doesn’t begin within 24 hours. -->Infants of diabetic mothers are susceptible to macrosomia as a result of
increased insulin production in the fetus.
      -->To prevent heat loss in the neonate, the nurse should bathe one part of his body at a time and    keep the rest of the body covered.
-->A patient who has a cesarean delivery is at greater risk for infection than
the patient who gives birth vaginally. -->The occurrence of thrush in the neonate is probably caused by contact with
the organism during delivery through the birth canal. ]-->The nurse should keep the sac of meningomyelocele moist with normal
saline solution. -->If fundal height is at least 2 cm less than expected, the cause may be
growth retardation, missed abortion, transverse lie, or false pregnancy. -->Fundal height that exceeds expectations by more than 2 cm may be caused
by multiple gestation, polyhydramnios, uterine myomata, or a large baby. -->A major developmental task for a woman during the first trimester of
pregnancy is accepting the pregnancy. -->Unlike formula, breast milk offers the benefit of maternal antibodies. -->Spontaneous rupture of the membranes increases the risk of a prolapsed
umbilical cord. -->A clinical manifestation of a prolapsed umbilical cord is variable
decelerations. -->During labor, to relieve supine hypotension manifested by nausea and
vomiting and paleness, turn the patient on her left side. -->If the ovum is fertilized by a spermatozoon carrying a Y chromosome, a
male zygote is formed. -->Implantation occurs when the cellular walls of the blastocyte implants itself
in the endometrium, usually 7 to 9 days after fertilization.
      -->Implantation occurs when the cellular walls of the blastocyte implants itself in the endometrium,      usually 7 to 9 days after fertilization.
-->Heart development in the embryo begins at 2 to 4 weeks and is complete
by the end of the embryonic stage.
-->Methergine stimulates uterine contractions.
-->The administration of folic acid during the early stages of gestation may
prevent neural tube defects.
-->With advanced maternal age, a common genetic problem is Down
syndrome.
]-->With early maternal age, cephalopelvic disproportion commonly occurs.
]-->In the early postpartum period, the fundus should be midline at the
umbilicus.
]-->A rubella vaccine shouldn’t be given to a pregnant woman. The vaccine
can be administered after delivery, but the patient should be instructed to
avoid becoming pregnant for 3 months.
]-->A 16-year-old girl who is pregnant is at risk for having a low-birth-weight
neonate.
]-->The mother’s Rh factor should be determined before an amniocentesis is
performed.
]-->Maternal hypotension is a complication of spinal block.
]-->After delivery, if the fundus is boggy and deviated to the right side, the
patient should empty her bladder.
]-->Before providing a specimen for a sperm count, the patient should avoid
ejaculation for 48 to 72 hours.
]-->The hormone human chorionic gonadotropin is a marker for pregnancy.
]-->Painless vaginal bleeding during the last trimester of pregnancy may
indicate placenta previa.
]-->During the transition phase of labor, the woman usually is irritable and
restless.
]-->Because women with diabetes have a higher incidence of birth anomalies
than women without diabetes, an alpha-fetoprotein level may be ordered at
15 to 17 weeks’ gestation.
]-->To avoid puncturing the placenta, a vaginal examination shouldn’t be
performed on a pregnant patient who is bleeding.
]-->A patient who has postpartum hemorrhage caused by uterine atony should
be given oxytocin as prescribed.
]-->Laceration of the vagina, cervix, or perineum produces bright red bleeding
that often comes in spurts. The bleeding is continuous, even when the
fundus is firm.
]-->Hot compresses can help to relieve breast tenderness after breast-feeding. ]-->The fundus of a postpartum patient is massaged to stimulate contraction
of the uterus and prevent hemorrhage.
endif]-->A mother who has a positive human immunodeficiency virus test
result shouldn’t breast-feed her infant.
]-->Dinoprostone (Cervidil) is used to ripen the cervix.
]-->Breast-feeding of a premature neonate born at 32 weeks’ gestation can be
accomplished if the mother expresses milk and feeds the neonate by
gavage.
]-->If a pregnant patient’s rubella titer is less than 1:8, she should be
immunized after delivery.
]-->The administration of oxytocin (Pitocin) is stopped if the contractions are
90 seconds or longer.
-->For an extramural delivery (one that takes place outside of a normal
delivery center), the priorities for care of the neonate include maintaining a
patent airway, supporting efforts to breathe, monitoring vital signs, and
maintaining adequate body temperature.
]-->Subinvolution may occur if the bladder is distended after delivery. ]-->The nurse must place identification bands on both the mother and the
neonate before they leave the delivery room.
]-->Erythromycin is given at birth to prevent ophthalmia neonatorum. ]-->Pelvic-tilt exercises can help to prevent or relieve backache during
pregnancy.
]-->Before performing a Leopold maneuver, the nurse should ask the patient
to empty her bladder.
• Odynophagia is painful swallowing, in the mouth (oropharynx) or esophagus. It can occur with or without dysphagia, or difficult swallowing • Halitosis, oral malodor (scientific term), breath odor, foul breath, fetor oris, fetor ex ore, or most commonly bad breath are terms used to describe • Pyloroplasty is surgery to widen the opening of the end of the pylorus, which is found in the lower portion of the stomach, • Billroth I = gastroduodenal reconstruction • Billroth II = gastrojejunal reconstruction • ISOTONIC = the muscle shortens to produce contraction • ISOMETRIC = NO CHANGE in muscle length • ISOKINETIC = Involves muscle contraction or tension against a resistance • Measure correct crutch length LYING DOWN Measure from the Anterior Axillary Fold to the HEEL of the foot then: Add 1 inch (Kozier) Add 2 inches (Brunner and Suddarth) • Hyperalgesia—excessive sensitivity to pain • Bruxism- commonly called night teeth-grinding occurring during stage 2 sleep • Somnambulism- “sleepwalking" • POLYSOMNOGRAPHY is the only method that can confirm sleep apnea. • Urticaria - (or hives) is a skin condition, commonly caused by an allergic reaction, that is characterized by raised red skin wheals • Pruritus- is an itch or a sensation that makes a person want to scratch. • CAUTION ---- Mnemonics for early detection for CANCER C- Change in bowel/bladder habits A- A sore that does not heal U- Unusual bleeding T- Thickening or lump in the breast I- Indigestion O- Obvious change in warts N- Nagging cough and hoarseness • Alopecia begins within 2 weeks of therapy. Regrowth within 8 weeks of termination • Tenesmus is a feeling of incomplete defecation. It is experienced as an inability or difficulty to empty the bowel at defecation. • The CONDUCTING SYSTEM OF THE HEART Consists of the 1. SA node- the pacemaker 2. AV node- slowest conduction 3. Bundle of His – branches into the Right and the Left bundle branch 4. Purkinje fibers- fastest conduction • The Heart sounds 1. S1- due to closure of the AV valves 2. S2- due to the closure of the semi-lunar valves 3. S3- due to increased ventricular filling 4. S4- due to forceful atrial contraction
• The lymphatic system also is part of the vascular system and the function of this system is to collect the extravasated fluid from the tissues and returns it to the blood • CARDIAC Proteins and enzymes CK- MB ( creatine kinase). Elevates in MI within 4 hours, peaks in 18 hours and then declines till 3 days • Troponin I and T Troponin I is usually utilized for MI. Elevates within 3-4 hours, peaks in 4-24 hours and persists for 7 days to 3 weeks! Normal value for Troponin I is less than 0.6 ng/mL • Cholesterol= 200 mg/dL • Triglycerides- 40- 150 mg/dL • Ischemic changes may show ST depression and T wave inversion • Nitrates- to dilate the coronary arteries • Aspirin- to prevent thrombus formation • Beta-blockers- to reduce BP and HR • Calcium-channel blockers- to dilate coronary artery and reduce vasospasm • After MI, Patients who are able to walk 3-4 mph are usually ready to resume sexual activities • Infective endocarditis >> Osler’s nodes- painful nodules on fingerpads • Infective endocarditis >> Roth’s spots- pale hemorrhages in the retina • LEFT SIDED CHF 1. Dyspnea on exertion 2. PND 3. Orthopnea 4. Pulmonary crackles/rales 5. cough with Pinkish, frothy sputum 6. Tachycardia 7. Cool extremities 8. Cyanosis 9. decreased peripheral pulses 10. Fatigue 11. Oliguria 12. signs of cerebral anoxia • RIGHT SIDED CHF 1. Peripheral dependent, pitting edema 2. Weight gain 3. Distended neck vein 4. hepatomegaly 5. Ascites 6. Body weakness 7. Anorexia, nausea 8. Pulsus alternans • CARDIOGENIC SHOCK 1. HYPOTENSION 2. oliguria (less than 30 ml/hour)
3. tachycardia 4. narrow pulse pressure 5. weak peripheral pulses 6. cold clammy skin 7. changes in sensorium/LOC 8. pulmonary congestion • CARDIAC TAMPONADE A condition where the heart is unable to pump blood due to accumulation of fluid in the pericardial sac (pericardial effusion) • BECK’s Triad- Jugular vein distention, hypotension and distant/muffled heart sound • ANEURYSM - Dilation involving an artery formed at a weak point in the vessel wall Saccular= when one side of the vessel is affected Fusiform= when the entire segment becomes dilated
RISK FACTORS Atherosclerosis Infection= syphilis Connective tissue disorder Genetic disorder= Marfan’s Syndrome • PERIPHERAL ARTERIAL OCCLUSIVE DISEASE (PAOD) - Refers to arterial insufficiency of the extremities usually secondary to peripheral atherosclerosis • INTERMITTENT CLAUDICATION- the hallmark of PERIPHERAL ARTERIAL OCCLUSIVE DISEASE (PAOD) Intermittent claudication is a clinical diagnosis given for muscle pain (ache, cramp, numbness or sense of fatigue), classically calf muscle • RAYNAUD’S DISEASE - A form of intermittent arteriolar VASOCONSTRICTION that results in coldness, pain and pallor of the fingertips or toes • Cheilosis (also called cheilitis) is a painful inflammation and cracking of the corners of the mouth. It sometimes occurs on only one side of the mouth • APLASTIC ANEMIA - A condition characterized by decreased number of RBC as well as WBC and platelets • Pernicious Anemia - Beefy, red, swollen tongue (Schilling’s test) • Progesterone - maintains the uterine lining for implantation and relaxes all smooth muscles • Relaxin - is the hormone that softens the muscles and joints of the pelvis • Thyroxine - increases basal metabolic rates • Buck's Traction - Skin traction • Skeletal Traction - with Pins • Vit. B2 (riboflavin) deficiency - scaly skin • Vit. A deficiency - Night blindness • Vit. D deficiency - Skeletal Pain • Zinc deficiency - slow wound healing • Selenium deficiency - heart damage • Toxoplasmosis parasite - infection from inadequately cooked meat, eggs, or
milk, ingestion or inhaling the oocyst excreted in feline feces • Sclerotherapy - injecttion of a sclerosing agent into a varicosity. The agent damages the vessels and causes aseptic thrombosis, which result in vein closure. • Deep Tendon Reflex Test 1+ - diminished 2+ - normal 3+ - increased, brisker-than-average 4+ very brisk, hyperactive • Involution is a progressive descent of the uterus into the pelvic cavity that occurse at approx. 1cm per day. • FHR can be first heard with fetoscope at 18 to 20 weeks gestation. 10 weeks with a doppler ultrasound. • Folic acid rich food are peanuts, sunflower seeds and raisins • Variable deceleration = cord compression • Early deceleration = pressure on the fetal head during a contraction • Later deceleration = uteroplacental insufficiency • Cystitis is inflammation of the urinary bladder. • Pyelonephritis is an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney (nephros in Greek). • Partial weightbearing - 30% to 50% of the body weight on the affected limb • Touch-down weight bearing allows the client to let the limb touch the floor but not bear weight. • Thyroid supplements for hypothyroidism should be taken in the morning to avoid insomia. • Croup - dont administer cough syrup and cold medicines because they will dry and thicken secretions. Sips of warm fluid will relax the vocal cords and thin the mucos. • Koplik spots - small bluish-white spots with a red base found on the buccal mucosa • German measles - pinkish-rose maculopapular rash on the face, neck and scalp. Reddish and pinpoint petechiae spots found on the soft palate • Erythema infectiosum (fifth disease) [slapped cheek] - an intense, fiery-red, edematous rash on the cheeks. • Rocky Mountain Spotted Fever (RMSF) - rash on the palm and soles of the feed and on the remainder of the body. Fever, headache, anorexia and restlessness. Meds given is Tetracycline hydrochloride (achromycin) • Thioguanine and thiotepa are antineoplastic medications • Ticlopidine hydrochloride (Ticlid) is a platelet aggregation inhibitor • Erythema marginatum is characterized by red skin lesions that start as flat or slightly raised macules, usually over the trunk and that spread peripherally. • Atrial fibrillation - Auscultating the apical pulse for an irregular rate while palpating the radial pulse for pulse deficit • Triple dye is used for initial cord care because it minimizes bateria and promotes drying. • A low cardiac output will cause the increased build-up of blood in the heart and pulmonary system, causing crackles to be heard in the lung fields.
• S3 heart sounds = ventricular gallop • Trachoesophageal fistual = abdominal distension • 3 stages of separation anxiety are PROTEST, DESPAIR AND DETACHMENT • Anaphylactic shock = fatal allergic reaction • Cardiac Tamponade - assessment findings include tachycardia, distant or muffled heart sounds, jugular vein distention and falling blood pressure accompanied by pulsus paradoxus ( a drop in inspiratory BY by > 10 mmhg) • Spironolactone (Aldactone) > pt. may experience body image changes due to threatened sexual identity. These body image changes are related to decreased libido, gynecomastia in males, and hirsutism in females. • Diabetic ketoacidosis (DKA) - fruity odor to the client's breath • Rhonchi - occur as a result of the passing of air through fluid-filled narrow passages. Rhonchi are sometimes referred to as "gurgles". Diseases with excess mucous product, such as pnemonia are associated with rhonchi. Rhonchi are usually heard on expiration and may clear with a cough. • Urolithiasis is a condition in which crystals in the urine combine to form stones, also called calculi or uroliths • Hodgkin's disease is a type of lymphoma distinguished by the presence of a particular kind of cancer cell called a Reed-Sternberg cell. • Cardiogenic shock (left-sided heart failure) - includes altered sensorium, tachycardia, hypotension, tachypnea, oliguria, and cold, clammy, cyanotic skin • Ovarian cancer symptoms include abdominal discomfort, irreg. menses, flatulence, fullness after a light mean and increase abdominal girth. • Myocardial infarction: -ST segment elevation usually occurs immediately or during the early stages of MI. -The CK-MB isoenzyme begins to rise 3 to 6 hourse after MI. -T wave depression and abnormal Q wave changes occur within several hours to several days after the MI. • Abdominal aortic aneurysm (AAA) symptoms are "heart beating" in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be ausculated over the mass. • Neuroleptic Malignant syndrome experiences an elevated in temperature ( sometimes up to 107 F) and parkinsonian symptoms • Intermittent claudication usually refers to cramplike pains in the legs (usually the calf muscles, but may be in the thigh. • Cholinergic effect includes increase in salivation, lacrimation, urination and defecation, bradycardia, hypotension and increaes muscle weakness • Ventricular tachycardia is characterized by the absense of P waves, wide QRS complexes (usually greater then 0.14 second) and a rate between 100 and 250 impulses per minute. • Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. There are no measurable rate and no visible P waves or QRS complexes. • Inguinal hernia is a common defect that appears as a painless inguinal swelling
when the child cries or strains. • Partial obstruction of the herniated loop of intestine - difficulty in defecating • Phimosis - a dribbling stream, indicating an obstruction in the flow of urine • Cryptorchidism - absense of the testes within the scrotum. • Triamterene (Dyrenium) is a potassium-sparing diuretic. Side effects include frequent urination and polyuria. • Erythroblastosis fetalis is a hemolytic disease of the fetus or newborn resulting in excessive destruction of red blood cells (RBCs) and stimulation of immature erythrocytes. • Glycosylated hemoglobin values of 8% or less are acceptable
 When preparing a single injection for a patient who  takes regular and neutral protein Hagedorn insulin, the nurse should draw the regular insulin into the syringe first so that it does not contaminate the regular insulin.
 Rhonchi are the rumbling sounds heard on lung  auscultation. They are more pronounced during expiration than during inspiration.
 Gavage is forced feeding, usually through a gastric tube  (a tube passed into the stomach through the mouth).
 According to  Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority.
 The safest and surest  way to verify a patient’s identity is to check the identification band on his wrist.
 In the therapeutic environment, the patient’s safety is the  primary concern.
 Fluid oscillation in the tubing of a chest drainage  system indicates that the system is working properly.
 The nurse should  place a patient who has a Sengstaken-Blakemore tube in semi-Fowler position.
 The nurse can elicit Trousseau’s sign by occluding the  brachial or radial artery. Hand and finger spasms that occur during occlusion indicate Trousseau’s sign and suggest hypocalcemia.
 For blood  transfusion in an adult, the appropriate needle size is 16 to 20G.
 Intractable pain is pain that incapacitates a patient and can’t be relieved by drugs.
 In an emergency, consent for treatment can be obtained by fax,  telephone, or other telegraphic means.  Decibel is the unit of measurement  of sound.
 Informed consent is required for any invasive  procedure.
 A patient who can’t write his name to give consent for  treatment must make an X in the presence of two witnesses, such as a nurse, priest, or physician.
 The Z-track I.M. injection technique seals the  drug deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that’s 1" (2.5 cm) or longer.
 In the event of fire,  the acronym most often used is RACE. (R) Remove the patient. (A) Activate the alarm. (C) Attempt to contain the fire by closing the door. (E) Extinguish the fire if it can be done safely.
 A registered nurse should assign a  licensed vocational nurse or licensed practical nurse to perform bedside care, such as suctioning and drug administration.
 If a patient can’t void,  the first nursing action should be bladder palpation to assess for bladder distention.  The patient who uses a cane should carry it on the unaffected  side and advance it at the same time as the affected extremity.
 To fit  a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2" (5 cm) to that measurement.
 Assessment begins with the  nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies.
 The appropriate needle  size for insulin injection is 25G and 5/8" long.
 Residual urine is  urine that remains in the bladder after voiding. The amount of residual urine is normally 50 to 100 ml.
 The five stages of the nursing process are  assessment, nursing diagnosis, planning, implementation, and evaluation.
 Assessment is the stage of the nursing process in which the  nurse continuously collects data to identify a patient’s actual and potential health needs.
 Nursing diagnosis is the stage of the nursing process in  which the nurse makes a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes.
 Planning is the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan.
 Implementation is the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions.
 Evaluation is the stage of the nursing process in which  the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan.
 Before administering any “as  needed” pain medication, the nurse should ask the patient to indicate the location of the pain.
 Jehovah’s Witnesses believe that they shouldn’t  receive blood components donated by other people.
 To test visual  acuity, the nurse should ask the patient to cover each eye separately and to read the eye chart with glasses and without, as appropriate.
 When  providing oral care for an unconscious patient, to minimize the risk of aspiration, the nurse should position the patient on the side.
 During  assessment of distance vision, the patient should stand 20' (6.1 m) from the chart.  For a geriatric patient or one who is extremely ill, the ideal room  temperature is 66° to 76° F (18.8° to 24.4° C).
 Normal room humidity is  30% to 60%.
 Hand washing is the single best method of limiting the  spread of microorganisms. Once gloves are removed after routine contact with a patient, hands should be washed for 10 to 15 seconds.
 To perform  catheterization, the nurse should place a woman in the dorsal recumbent position.
 A positive Homans’ sign may indicate  thrombophlebitis.
 Electrolytes in a solution are measured in  milliequivalents per liter (mEq/L). A milliequivalent is the number of milligrams per 100 milliliters of a solution.
 Metabolism occurs in two  phases: anabolism (the constructive phase) and catabolism (the destructive phase).
 The basal metabolic rate is the amount of energy needed to  maintain essential body functions. It’s measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment.
 The basal metabolic rate is expressed in calories consumed  per hour per kilogram of body weight.
 Dietary fiber (roughage), which  is derived from cellulose, supplies bulk, maintains intestinal motility, and helps to establish regular bowel habits.
 Alcohol is metabolized  primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs.
 Petechiae are tiny, round, purplish red spots that appear on the  skin and mucous membranes as a result of intradermal or submucosal hemorrhage.
 Purpura is a purple discoloration of the skin that’s  caused by blood extravasation.
 According to the standard precautions  recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use. Most needle sticks result from missed needle recapping.
 The nurse administers a drug by I.V. push by using a needle  and syringe to deliver the dose directly into a vein, I.V. tubing, or a catheter.
 When changing the ties on a tracheostomy tube, the nurse  should leave the old ties in place until the new ones are applied.
 A  nurse should have assistance when changing the ties on a tracheostomy tube.
 A filter is always used for blood transfusions.
 A  four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide.
 A good way to begin a patient interview is to  ask, “What made you seek medical help?”
 When caring for any patient,  the nurse should follow standard precautions for handling blood and body fluids.  Potassium (K+) is the most abundant cation in intracellular  fluid.
 In the four-point, or alternating, gait, the patient first moves  the right crutch followed by the left foot and then the left crutch followed by the right foot.
 In the three-point gait, the patient moves two crutches  and the affected leg simultaneously and then moves the unaffected leg.
 In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch simultaneously.
 The vitamin B complex, the water-soluble vitamins that  are essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12).
 When being weighed, an  adult patient should be lightly dressed and shoeless.
 Before taking an  adult’s temperature orally, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the previous 15 minutes.
 The nurse shouldn’t take an adult’s temperature rectally if the patient has a cardiac disorder, anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery.
 In a patient who has a cardiac disorder,  measuring temperature rectally may stimulate a vagal response and lead to vasodilation and decreased cardiac output.
 When recording pulse  amplitude and rhythm, the nurse should use these descriptive measures: +3, bounding pulse (readily palpable and forceful); +2, normal pulse (easily palpable); +1, thready or weak pulse (difficult to detect); and 0, absent pulse (not detectable).
 The intraoperative period begins when a patient is  transferred to the operating room bed and ends when the patient is admitted to the postanesthesia care unit.
 On the morning of surgery, the nurse  should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water), has removed common jewelry, and has received
preoperative medication as prescribed; and that vital signs have been taken and recorded. Artificial limbs and other prostheses are usually removed.
 Comfort measures, such as positioning  the patient, rubbing the patient’s back, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness.
 A drug has three names: generic name, which is used  in official publications; trade, or brand, name (such as Tylenol), which is selected by the drug company; and chemical name, which describes the drug’s chemical composition.
 To avoid staining the teeth, the patient should  take a liquid iron preparation through a straw.
 The nurse should use  the Z-track method to administer an I.M. injection of iron dextran (Imferon).
 An organism may enter the body through the nose, mouth,  rectum, urinary or reproductive tract, or skin.
 In descending  order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma.
 To turn a patient by logrolling, the nurse folds the  patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if needed; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet.
 The diaphragm  of the stethoscope is used to hear high-pitched sounds, such as breath sounds.
 A slight difference in blood pressure (5 to 10 mm Hg) between  the right and the left arms is normal.
 The nurse should place the blood  pressure cuff 1" (2.5 cm) above the antecubital fossa.
 When instilling  ophthalmic ointments, the nurse should waste the first bead of ointment and then apply the ointment from the inner canthus to the outer canthus.
 The  nurse should use a leg cuff to measure blood pressure in an obese patient.
 If a blood pressure cuff is applied too loosely, the reading  will be falsely
elevated.
 Ptosis is drooping of the eyelid.  A tilt  table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position.
 To perform venipuncture  with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle.
 To move a patient to the edge  of the bed for transfer, the nurse should follow these steps: Move the patient’s head and shoulders toward the edge of the bed. Move the patient’s feet and legs to the edge of the bed (crescent position). Place both arms well under the patient’s hips, and straighten the back while moving the patient toward the edge of the bed.
 When being measured for crutches, a patient should wear  shoes.
 The nurse should attach a restraint to the part of the bed frame  that moves with the head, not to the mattress or side rails.
 The mist  in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern.
 To administer heparin  subcutaneously, the nurse should follow these steps: Clean, but don’t rub, the site with alcohol. Stretch the skin taut or pick up a well- defined skin fold. Hold the shaft of the needle in a dart position. Insert the needle into the skin at a right (90-degree) angle. Firmly depress the plunger, but don’t aspirate. Leave the needle in place for 10 seconds. Withdraw the needle gently at the angle of insertion. Apply pressure to the injection site with an alcohol pad.
 For a sigmoidoscopy, the nurse should place the patient in the  knee-chest position or Sims’ position, depending on the physician’s preference.
 Maslow’s hierarchy of needs must be met in the  following order: physiologic (oxygen, food, water, sex, rest, and comfort), safety and security, love and belonging, self-esteem and recognition, and self-actualization.
 When caring for a patient who has a nasogastric  tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness.
 During gastric lavage, a nasogastri c tube is inserted, the stomach is flushed, and ingested substances are removed through the tube.
 In documenting drainage on a surgical dressing, the nurse should  include the size, color, and consistency of the drainage (for example, “10 mm of brown mucoid drainage noted on dressing”).
 To elicit Babinski’s reflex,  the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as a thumbnail.
 A positive Babinski’s reflex is shown by  dorsiflexion of the great toe and fanning out of the other toes.
 When  assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis.
 The  best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours.
 Antiembolism stockings decompress the superficial  blood vessels, reducing the risk of thrombus formation.
 In adults, the  most convenient veins for venipuncture are the basilic and median cubital veins in the antecubital space.
 Two to three hours before beginning a tube  feeding, the nurse should aspirate the patient’s stomach contents to verify that gastric emptying is adequate.
 People with type O blood are considered  universal donors.
 People with type AB blood are considered universal  recipients.
 Hertz (Hz) is the unit of measurement of sound  frequency.
 Hearing protection is required when the sound intensity  exceeds 84 dB. Double hearing protection is required if it exceeds 104 dB.
 Prothrombin, a clotting factor, is produced in the liver.
 If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory request.
 During lumbar puncture, the nurse  must note the initial intracranial pressure and the color of the cerebrospinal fluid.
 If a patient can’t cough to provide a sputum sample for culture,  a heated aerosol treatment can be used to help to obtain a sample.
 If  eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first.
 When leaving an isolation room, the nurse should  remove her gloves before her mask because fewer pathogens are on the mask.
 Skeletal traction, which is applied to a bone with wire pins or  tongs, is the most effective means of traction.
 The total parenteral  nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use. Delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction.
 Drugs aren’t routinely injected  intramuscularly into edematous tissue because they may not be absorbed.
 When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice.
 Dentures should be cleaned in a sink that’s  lined with a washcloth.
 A patient should void within 8 hours after  surgery.
 An EEG identifies normal and abnormal brain waves.
 Samples of feces for ova and parasite tests should be delivered to the laboratory without delay and without refrigeration.
 The autonomic  nervous system regulates the cardiovascular and respiratory systems.
 When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion.
 A low-residue diet includes such foods as roasted chicken,  rice, and pasta.
 A rectal tube shouldn’t be inserted for longer than 20  minutes because it can irritate the rectal mucosa and cause loss of sphincter control.
 A patient’s bed bath should proceed in this order: face, neck,  arms, hands, chest, abdomen, back, legs, perineum.
 To prevent injury  when lifting and moving a patient, the nurse should primarily use the upper leg muscles.
 Patient preparation for cholecystography includes ingestion of  a contrast medium and a low-fat evening meal.
 While an occupied bed is  being changed, the patient should be covered with a bath blanket to promote warmth and prevent exposure.
 Anticipatory grief is mourning that occurs  for an extended time when the patient realizes that death is inevitable.
 The following foods can alter the color of the feces: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown).
 When preparing for a skull X-ray, the patient should remove all  jewelry and dentures.
 The fight-or-flight response is a sympathetic  nervous system response.
 Bronchovesicular breath sounds in peripheral  lung fields are abnormal and suggest pneumonia.
 Wheezing is an  abnormal, high-pitched breath sound that’s accentuated on expiration.
 Wax or a foreign body in the ear should be flushed out gently by irrigation with warm saline solution.
 If a patient complains that his hearing aid is  “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries.
 The nurse should grade hyperactive biceps  and triceps reflexes as +4.
 If two eye medications are prescribed for  twice-daily instillation, they should be administered 5 minutes apart.
 In a postoperative patient, forcing fluids helps prevent constipation.
 A nurse must provide care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy.
 The kilocalorie (kcal) is a unit of energy measurement that  represents the amount of heat needed to raise the temperature of 1 kilogram of water 1° C.
 As nutrients move through the body, they undergo ingestion,  digestion, absorption, transport, cell metabolism, and excretion.
 The  body metabolizes alcohol at a fixed rate, regardless of serum
concentration.
 In an alcoholic beverage, proof reflects the percentage  of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol.
 A living will is a witnessed document that states a patient’s  desire for certain types of care and treatment. These decisions are based on the patient’s wishes and views on quality of life.
 The nurse should flush a  peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency.
 Quality assurance is a method of determining whether nursing actions and practices meet established standards.
 The five rights of medication  administration are the right patient, right drug, right dose, right route of administration, and right time.
 The evaluation phase of the nursing  process is to determine whether nursing interventions have enabled the patient to meet the desired goals.
 Outside of the hospital setting, only  the sublingual and translingual forms of nitroglycerin should be used to relieve acute anginal attacks.
 The implementation phase of the nursing process  involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities.
 The Patient’s Bill of Rights  offers patients guidance and protection by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization.
 To minimize omission and distortion of facts, the  nurse should record information as soon as it’s gathered.
 When  assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present.
 When assessing a patient’s health history, the nurse  should record the current illness chronologically, beginning with the onset of the problem and continuing to the present.
 A nurse shouldn’t give false  assurance to a patient.
 After receiving preoperative medication, a  patient isn’t competent to sign an informed consent form.
 When lifting  a patient, a nurse uses the weight of her body instead of the strength in her arms.
 A nurse may clarify a physician’s explanation about an operation  or a procedure to a patient, but must refer questions about informed consent to the physician.
 When obtaining a health history from an acutely ill or  agitated patient, the nurse should limit questions to those that provide necessary information.
 If a chest drainage system line is broken or  interrupted, the nurse should clamp the tube immediately.
 The nurse  shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse that may be confused with the patient’s pulse.
 An inspiration and  an expiration count as one respiration.
 Eupnea is normal  respiration.
 During blood pressure measurement, the patient should rest  the arm against a surface. Using muscle strength to hold up the arm may raise the blood pressure.
 Major, unalterable risk factors for coronary artery  disease include heredity, sex, race, and age.
 Inspection is the most  frequently used assessment technique.  Family members of an elderly person  in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a comfortable atmosphere.
 Pulsus alternans is a regular pulse rhythm  with alternating weak and strong beats. It occurs in ventricular enlargement because the stroke volume varies with each heartbeat.
 The upper  respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication.  Signs of accessory muscle use include shoulder  elevation, intercostal muscle retraction, and scalene and sternocleidomastoid muscle use during respiration.
 When patients use axillary crutches,  their palms should bear the brunt of the weight.
 Activities of daily  living include eating, bathing, dressing, grooming, toileting, and interacting socially.
 Normal gait has two phases: the stance phase, in which the  patient’s foot rests on the ground, and the swing phase, in which the patient’s foot moves forward.
 The phases of mitosis are prophase, metaphase,  anaphase, and telophase.
 The nurse should follow standard precautions  in the routine care of all patients.
 The nurse should use the bell of  the stethoscope to listen for venous hums and cardiac murmurs.
 The  nurse can assess a patient’s general knowledge by asking questions such as “Who is the president of the United States?”
 Cold packs are applied for the  first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury.  The pons is located above the medulla and consists of white matter  (sensory and motor tracts) and gray matter (reflex centers).
 The  autonomic nervous system controls the smooth muscles.
 A correctly  written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It’s developed in collaboration with the patient.
 Percussion causes five basic notes: tympany (loud intensity, as heard over a gastric air bubble or puffed out cheek), hyperresonance (very loud, as heard over an emphysematous lung), resonance (loud, as heard over a normal lung), dullness (medium intensity, as heard over the liver or other solid organ), and flatness (soft, as heard over the thigh).
 The optic disk is yellowish  pink and circular, with a distinct border.
 A primary disability is  caused by a pathologic process. A secondary disability is caused by inactivity.
 Nurses are commonly held liable for failing to keep an  accurate count of sponges and other devices during surgery.
 The best  dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals.
 Iron-rich foods, such as organ meats, nuts,  legumes, dried fruit, green leafy vegetables, eggs, and whole grains, commonly have a low water content.
 Collaboration is joint communication and  decision making between nurses and physicians. It’s designed to meet patients’ needs by integrating the care regimens of both professions into one comprehensive approach.
 Bradycardia is a heart rate of fewer than 60  beats/minute.
 A nursing diagnosis is a statement of a patient’s actual  or potential health problem that can be resolved, diminished, or otherwise changed by nursing interventions.
 During the assessment phase of the  nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data.
 The patient’s health history consists primarily of subjective data, information that’s supplied by the patient.
 The physical examination includes  objective data obtained by inspection, palpation, percussion, and auscultation.
 When documenting patient care, the nurse should write  legibly, use only standard abbreviations, and sign each entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines.
 Factors that affect body temperature include time of day, age,  physical activity, phase of menstrual cycle, and pregnancy.
 The most  accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery. To take the pulse rate, the artery is compressed against the radius.
 In a resting adult, the normal pulse rate is 60 to 100  beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults.
 Laboratory test results are an objective  form of assessment data.
 The measurement systems most commonly used in  clinical practice are the metric system, apothecaries’ system, and household system.
 Before signing an informed consent form, the patient should  know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks
involved; and the possible complications. The patient should also have a general idea of the time required from surgery to recovery. In addition, he should have an opportunity to ask questions.
 A patient must sign a  separate informed consent form for each procedure.
 During percussion,  the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds. This procedure is done to determine the size, shape, position, and density of underlying organs and tissues; elicit tenderness; or assess reflexes.
 Ballottement is a form of light palpation involving  gentle, repetitive bouncing of tissues against the hand and feeling their rebound.
 A foot cradle keeps bed linen off the patient’s feet to  prevent skin irritation and breakdown, especially in a patient who has peripheral vascular disease or neuropathy.
 Gastric lavage is flushing  of the stomach and removal of ingested substances through a nasogastric tube. It’s used to treat poisoning or drug overdose.
 During the evaluation  step of the nursing process, the nurse assesses the patient’s response to therapy.
 Bruits commonly indicate life- or limb-threatening vascular  disease.
 O.U. means each eye. O.D. is the right eye, and O.S. is the  left eye.
 To remove a patient’s artificial eye, the nurse depresses the  lower lid.
 The nurse should use a warm saline solution to clean an  artificial eye.
 A thready pulse is very fine and scarcely  perceptible.
 Axillary temperature is usually 1° F lower than oral  temperature.
 After suctioning a tracheostomy tube, the nurse must  document the color, amount, consistency, and odor of secretions.
 On a  drug prescription, the abbreviation p.c. means that the drug should be administered after meals.
 After bladder irrigation, the nurse should  document the amount, color, and clarity of the urine and the presence of clots or sediment.
 After bladder irrigation, the nurse should document the  amount, color, and
clarity of the urine and the presence of clots or sediment.
 Laws regarding patient self-determination vary from state to  state. Therefore, the nurse must be familiar with the laws of the state in which she works.
 Gauge is the inside diameter of a needle: the smaller the  gauge, the larger the diameter.
 An adult normally has 32 permanent  teeth.
 After turning a patient, the nurse should document the position  used, the time that the patient was turned, and the findings of skin assessment.
 PERRLA is an abbreviation for normal pupil assessment  findings: pupils equal, round, and reactive to light with accommodation.
 When percussing a patient’s chest for postural drainage,  the nurse’s hands should be cupped.
 When measuring a patient’s pulse,  the nurse should assess its rate, rhythm, quality, and strength.
 Before  transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels.
 When assessing  respirations, the nurse should document their rate, rhythm, depth, and quality.  For a subcutaneous injection, the nurse should use a 5/8" 25G  needle.
 The notation “AA  & O × 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time).
 Fluid intake includes all  fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or feces, and perspiration.
 After administering an intradermal injection, the  nurse shouldn’t massage the area because massage can irritate the site and interfere with results.
 When administering an intradermal injection,  the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle), with the bevel up.
 To obtain an accurate  blood pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure.
 The nurse should count an irregular pulse for 1 full  minute.
 A patient who is vomiting while lying down should be placed in  a lateral position to prevent aspiration of vomitus.
 Prophylaxis is  disease prevention.
 Body alignment is achieved when body parts are in  proper relation to their natural position.
 Trust is the foundation of a  nurse-patient relationship.
 Blood pressure is the force exerted by the  circulating volume of blood on the arterial walls.
 Malpractice is a  professional’s wrongful conduct, improper discharge of duties, or failure to meet standards of care that causes harm to another.
 As a general rule,  nurses can’t refuse a patient care assignment; however, in most states, they may refuse to participate in abortions.
 A nurse can be found negligent if a  patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform.
 States have enacted  Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from the assistance. These laws don’t apply to care provided in a health care facility.
 A  physician should sign verbal and telephone orders within the time established by facility policy, usually 24 hours.
 A competent adult has the right to  refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of his refusal.
 Although a patient’s  health record, or chart, is the health care facility’s physical property, its contents belong to the patient.
 Before a patient’s health record can be  released to a third party, the patient or
the patient’s legal guardian must give written consent.
 Under the Controlled Substances Act, every dose of a  controlled drug that’s dispensed by the pharmacy must be accounted for, whether the dose was administered to a patient or discarded accidentally.
 A  nurse can’t perform duties that violate a rule or regulation established by a state licensing board, even if they are authorized by a health care facility or physician.
 To minimize interruptions during a patient interview, the  nurse should select a private room, preferably one with a door that can be closed.
 In categorizing nursing diagnoses, the nurse addresses  life-threatening problems first, followed by potentially life-threatening concerns.
 The major components of a nursing care plan are outcome  criteria (patient goals) and nursing interventions.
 Standing orders, or  protocols, establish guidelines for treating a specific disease or set of symptoms.
 In assessing a patient’s heart, the nurse normally finds the  point of maximal impulse at the fifth intercostal space, near the apex.
 The S1 heard on auscultation is caused by closure of the mitral and tricuspid valves.
 To maintain package sterility, the nurse should open a  wrapper’s top flap away from the body, open each side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body.
 The nurse shouldn’t dry a  patient’s ear canal or remove wax with a cotton- tipped applicator because it may force cerumen against the tympanic membrane.
 A patient’s identification  bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises.
 The Controlled  Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse potential.  Schedule I drugs, such  as heroin, have a high abuse potential and have no currently accepted medical use in the United States.
 Schedule II drugs, such as morphine, opium,  and meperidine (Demerol), have a high abuse potential, but currently have accepted medical uses. Their use may
lead to physical or psychological dependence.  Schedule III drugs, such as paregoric and butabarbital  (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both.
 Schedule IV drugs, such as chloral hydrate, have a  low abuse potential compared with Schedule III drugs.
 Schedule V drugs,  such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances.
 Activities of daily living are actions that  the patient must perform every day to provide self-care and to interact with society.
 Testing of the six cardinal fields of gaze evaluates the  function of all extraocular muscles and cranial nerves III, IV, and VI.
 The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with the stethoscope slightly raised from the chest.
 The  most important goal to include in a care plan is the patient’s goal.
 Fruits are high in fiber and low in protein, and should be omitted from a low- residue diet.
 The nurse should use an objective scale to assess and  quantify pain. Postoperative pain varies greatly among individuals.
 Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings.
 The nurse should provide honest answers  to the patient’s questions.
 Milk shouldn’t be included in a clear  liquid diet.
 When caring for an infant, a child, or a confused patient,  consistency in nursing personnel is paramount.
 The hypothalamus  secretes vasopressin and oxytocin, which are stored in the pituitary gland.
 The three membranes that enclose the brain and spinal cord are  the dura mater, pia mater, and arachnoid.
 A nasogastric tube is used to  remove fluid and gas from the small intestine
preoperatively or postoperatively.
 Psychologists, physical therapists, and chiropractors  aren’t authorized to write prescriptions for drugs.
 The area around a  stoma is cleaned with mild soap and water.
 Vegetables have a high fiber  content.
 The nurse should use a tuberculin syringe to administer a  subcutaneous injection of less than 1 ml.
 For adults, subcutaneous  injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle.
 Before administering a  drug, the nurse should identify the patient by checking the identification band and asking the patient to state his name.
 To clean the skin before an  injection, the nurse uses a sterile alcohol swab to wipe from the center of the site outward in a circular motion.
 The nurse should inject heparin deep  into subcutaneous tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation.
 If blood is aspirated into the syringe before  an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure.
 The nurse shouldn’t cut the  patient’s hair without written consent from the patient or an appropriate relative.
 If bleeding occurs after an injection, the nurse should apply  pressure until the bleeding stops. If bruising occurs, the nurse should monitor the site for an enlarging hematoma.
 When providing hair and scalp care,  the nurse should begin combing at the end of the hair and work toward the head.
 The frequency of patient hair care depends on the length and  texture of the hair, the duration of hospitalization, and the patient’s condition.
 Proper function of a hearing aid requires careful handling  during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries.
 The hearing aid  that’s marked with a blue dot is for the left ear; the one with a red dot is for the right ear.
 A hearing aid shouldn’t be exposed to heat or humidity  and shouldn’t be immersed in water.
 The nurse should instruct the  patient to avoid using hair spray while wearing a hearing aid.
 The five  branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy.  The nurse should  remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown.
 Heat is applied to promote vasodilation, which reduces pain  caused by inflammation.
 A sutured surgical incision is an example of  healing by first intention (healing directly, without granulation).
 Healing by secondary intention (healing by granulation) is closure of the wound when granulation tissue fills the defect and allows reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered.  Keloid formation is an abnormality in healing  that’s characterized by overgrowth of scar tissue at the wound site.
 The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site.
 An ascending  colostomy drains fluid feces. A descending colostomy drains solid fecal matter.
 A folded towel (scrotal bridge) can provide scrotal support for  the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis.
 When giving an injection to a patient who has a bleeding  disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection.
 Platelets are the smallest and  most fragile formed element of the blood and are essential for coagulation.
 To insert a nasogastric tube, the nurse instructs the  patient to tilt the head back slightly and then inserts the tube. When the nurse feels the tube curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this
action.)
 Families with loved ones in  intensive care units report that their four most important needs are to have their questions answered honestly, to be assured that the best possible care is being provided, to know the patient’s prognosis, and to feel that there is hope of recovery.
 Double-bind communication occurs when the verbal message  contradicts the nonverbal message and the receiver is unsure of which message to respond to.
 A nonjudgmental attitude displayed by a nurse shows that  she neither approves nor disapproves of the patient.
 Target symptoms  are those that the patient finds most distressing.
 A patient should be  advised to take aspirin on an empty stomach, with a full glass of water, and should avoid acidic foods such as coffee, citrus fruits, and cola.
 For  every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for the problem, and selecting the intervention from the choices provided that will enable the patient to reach that goal.
 Fidelity means loyalty and can  be shown as a commitment to the profession of nursing and to the patient.
 Administering an I.M. injection against the patient’s will and  without legal authority is battery.
 An example of a third-party payer  is an insurance company.
 The formula for calculating the drops per  minute for an I.V. infusion is as follows: (volume to be infused × drip factor) ÷ time in minutes = drops/minute
 On-call medication should be given  within 5 minutes of the call.
 Usually, the best method to determine a  patient’s cultural or spiritual needs is to ask him.
 An incident report  or unusual occurrence report isn’t part of a patient’s record, but is an in-house document that’s used for the purpose of correcting the problem.
 Critical pathways are a multidisciplinary guideline for  patient care.
 When prioritizing nursing diagnoses, the following  hierarchy should be used: Problems associated with the airway, those concerning breathing, and those related to circulation.  The two nursing diagnoses that  have the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern.
 A subjective sign that a  sitz bath has been effective is the patient’s expression of decreased pain or discomfort.
 For the nursing diagnosis Deficient diversional activity to  be valid, the patient must state that he’s “bored,” that he has “nothing to do,” or words to that effect.
 The most appropriate nursing diagnosis for an  individual who doesn’t speak English is Impaired verbal communication related to inability to speak dominant language (English).
 The family of a patient  who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him.
 Before instilling medication into  the ear of a patient who is up to age 3, the nurse should pull the pinna down and back to straighten the eustachian tube.
 To prevent injury to the  cornea when administering eyedrops, the nurse should waste the first drop and instill the drug in the lower conjunctival sac.
 After administering eye  ointment, the nurse should twist the medication tube to detach the ointment.
 When the nurse removes gloves and a mask, she should remove  the gloves first. They are soiled and are likely to contain pathogens.
 Crutches should be placed 6" (15.2 cm) in front of the patient and 6" to the side to form a tripod arrangement.
 Listening is the most effective  communication technique.
 Before teaching any procedure to a patient,  the nurse must assess the patient’s current knowledge and willingness to learn.
 Process recording is a method of evaluating one’s communication  effectiveness.
 When feeding an elderly patient, the nurse should limit  high-carbohydrate foods because of the risk of glucose intolerance.
 When feeding an elderly patient, essential foods should be given first.
 Passive range of motion maintains joint mobility. Resistive exercises increase muscle mass.
 Isometric exercises are performed on an extremity that’s  in a cast.
 A back rub is an example of the gate-control theory of  pain.
 Anything that’s located below the waist is considered unsterile;  a sterile field becomes unsterile when it comes in contact with any unsterile item; a sterile field must be monitored continuously; and a border of 1" (2.5 cm) around a sterile field is considered unsterile.
 A “shift to the  left” is evident when the number of immature cells (bands) in the blood increases to fight an infection.
 A “shift to the right” is evident when  the number of mature cells in the blood increases, as seen in advanced liver disease and pernicious anemia.
 Before administering preoperative  medication, the nurse should ensure that an informed consent form has been signed and attached to the patient’s record.
 A nurse should spend no  more than 30 minutes per 8-hour shift providing care to a patient who has a radiation implant.
 A nurse shouldn’t be assigned to care for more than  one patient who has a radiation implant.
 Long-handled forceps and a  lead-lined container should be available in the room of a patient who has a radiation implant.
 Usually, patients who have the same infection and  are in strict isolation can share a room.
 Diseases that require strict  isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.
 For the patient who abides by Jewish custom, milk and  meat shouldn’t be served at the same meal.
 Whether the patient can  perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps involved in the procedure (cognitive domain of learning).
 According to Erik Erikson, developmental stages are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to age 3), initiative versus guilt (ages 3 to 5), industry versus inferiority (ages 5 to 12), identity versus identity diffusion (ages 12 to 18), intimacy versus isolation (ages 18 to 25), generativity versus stagnation (ages 25 to 60), and ego integrity versus despair (older than age 60).
 When communicating with a hearing impaired  patient, the nurse should face him.
 An appropriate nursing intervention  for the spouse of a patient who has a serious incapacitating disease is to help him to mobilize a support system.
 Hyperpyrexia is extreme elevation in  temperature above 106° F (41.1° C).
 Milk is high in sodium and low in  iron.
 When a patient expresses concern about a health-related issue,  before addressing the concern, the nurse should assess the patient’s level of knowledge.
 The most effective way to reduce a fever is to administer an  antipyretic, which lowers the temperature set point.
 When a patient is  ill, it’s essential for the members of his family to maintain communication about his health needs.
 Ethnocentrism is the universal belief that  one’s way of life is superior to others’.
 When a nurse is communicating  with a patient through an interpreter, the nurse should speak to the patient and the interpreter.
 In accordance with the “hot-cold” system used by some  Mexicans, Puerto Ricans, and other Hispanic and Latino groups, most foods, beverages, herbs, and drugs are described as “cold.”
 Prejudice is a  hostile attitude toward individuals of a particular group.
 Discrimination is preferential treatment of individuals of a particular group. It’s usually discussed in a negative sense.
 Increased gastric motility  interferes with the absorption of oral drugs.
 The three phases of the  therapeutic relationship are orientation, working, and termination.
 Patients often exhibit resistive and challenging behaviors in the orientation phase of the therapeutic relationship.
 Abdominal assessment is  performed in the following order: inspection, auscultation, palpation, and percussion.
 When measuring blood pressure in a neonate, the nurse  should select a cuff that’s no less than one-half and no more than two-thirds the length of the extremity that’s used.
 When administering a drug by  Z-track, the nurse shouldn’t use the same needle that was used to draw the drug into the syringe because doing so could stain the skin.
 Sites for  intradermal injection include the inner arm, the upper chest, and on the back, under the scapula.
 When evaluating whether an answer on an examination  is correct, the nurse should consider whether the action that’s described promotes autonomy (independence), safety, self-esteem, and a sense of belonging.
 When answering a question on the NCLEX examination, the  student should consider the cue (the stimulus for a thought) and the inference (the thought) to determine whether the inference is correct. When in doubt, the nurse should select an answer that indicates the need for further information to eliminate ambiguity. For example, the patient complains of chest pain (the stimulus for the thought) and the nurse infers that the patient is having cardiac pain (the thought). In this case, the nurse hasn’t confirmed whether the pain is cardiac. It would be more appropriate to make further assessments.
 Veracity is truth and is an essential component of a  therapeutic relationship between a health care provider and his patient.
 Beneficence is the duty to do no harm and the duty to do good.  There’s an obligation in patient care to do no harm and an equal obligation to assist the patient.
 Nonmaleficence is the duty to do no harm.
 Frye’s ABCDE cascade provides a framework for prioritizing care by identifying the most important treatment concerns.
 A = Airway. This category  includes everything that affects a patent airway, including a foreign object, fluid from an upper respiratory infection, and edema from trauma or an allergic reaction.
 B = Breathing. This category includes everything that affects  the breathing pattern, including hyperventilation or hypoventilation and abnormal breathing patterns, such as Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.
 C = Circulation. This category includes  everything that affects the circulation, including fluid and electrolyte disturbances and disease processes that affect cardiac output.
 D =  Disease processes. If the patient has no problem with the airway, breathing, or circulation, then the nurse should evaluate the disease processes, giving priority to the disease process that poses the greatest immediate risk. For example, if a patient has terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern.
 E = Everything else. This category includes  such issues as writing an incident report and completing the patient chart. When evaluating needs, this category is never the highest priority.
 When  answering a question on an NCLEX examination, the basic rule is “assess before action.” The student should evaluate each possible answer carefully. Usually, several answers reflect the implementation phase of nursing and one or two reflect the assessment phase. In this case, the best choice is an assessment response unless a specific course of action is clearly indicated.
 Rule  utilitarianism is known as the “greatest good for the greatest number of people” theory.
 Egalitarian theory emphasizes that equal access to goods and  services must be provided to the less fortunate by an affluent society.
 Active euthanasia is actively helping a person to die.
 Brain death is  irreversible cessation of all brain function.
 Passive euthanasia is  stopping the therapy that’s sustaining life.
 A third-party payer is an  insurance company.
 Utilization review is performed to determine whether  the care provided to a patient was appropriate and cost-effective.  A value  cohort is a group of people who experienced an out-of-the-ordinary event that shaped their values.
 Voluntary euthanasia is actively helping a patient  to die at the patient’s request.  Bananas, citrus fruits, and potatoes are  good sources of potassium.
 Good sources of magnesium include fish,  nuts, and grains.
 Beef, oysters, shrimp, scallops, spinach, beets, and  greens are good sources of iron.
 Intrathecal injection is administering  a drug through the spine.
 When a patient asks a question or makes a  statement that’s emotionally charged, the nurse should respond to the emotion behind the statement or question rather than to what’s being said or asked.
 The steps of the trajectory-nursing model are as follows: – Step 1: Identifying the trajectory phase – Step 2: Identifying the problems and establishing goals – Step 3: Establishing a plan to meet the goals – Step 4: Identifying factors that facilitate or hinder attainment of the goals – Step 5: Implementing interventions – Step 6: Evaluating the effectiveness of the interventions
 A Hindu patient is likely to request  a vegetarian diet.
 Pain threshold, or pain sensation, is the initial  point at which a patient feels pain.
 The difference between acute pain  and chronic pain is its duration.
 Referred pain is pain that’s felt at  a site other than its origin.
 Alleviating pain by performing a back  massage is consistent with the gate control theory.
 Romberg’s test is a  test for balance or gait.
 Pain seems more intense at night because the  patient isn’t distracted by daily activities.
 Older patients commonly  don’t report pain because of fear of treatment, lifestyle changes, or dependency.  No pork or pork products are allowed in a Muslim diet.
 Two goals of Healthy People 2010 are: – Help individuals of all ages to increase the quality of life and the number of years of optimal health – Eliminate health disparities among different segments of the population.
 A community nurse is serving as a patient’s advocate if she  tells a malnourished patient to go to a meal program at a local park.
 If a patient isn’t following his treatment plan, the nurse should first ask why.
 Falls are the leading cause of injury in elderly people.
 Primary prevention is true prevention. Examples are immunizations, weight control, and smoking cessation.
 Secondary prevention is early  detection. Examples include purified protein derivative (PPD), breast self-examination, testicular self-examination, and chest X-ray.
 Tertiary prevention is treatment to prevent long-term complications.
 A  patient indicates that he’s coming to terms with having a chronic disease when he says, “I’m never going to get any better.”
 On noticing religious  artifacts and literature on a patient’s night stand, a culturally aware nurse would ask the patient the meaning of the items.
 A Mexican patient may  request the intervention of a curandero, or faith healer, who involves the family in healing the patient.
 In an infant, the normal hemoglobin  value is 12 g/dl.
 The nitrogen balance estimates the difference between  the intake and use of protein.
 Most of the absorption of water occurs  in the large intestine.
 Most nutrients are absorbed in the small  intestine.
 When assessing a patient’s eating habits, the nurse should  ask, “What have you eaten in the last 24 hours?”
 A vegan diet should  include an abundant supply of fiber.
 A hypotonic enema softens the  feces, distends the colon, and stimulates peristalsis.
 First-morning  urine provides the best sample to measure glucose, ketone, pH, and specific gravity values.
 To induce sleep, the first step is to minimize  environmental stimuli.
 Before moving a patient, the nurse should assess  the patient’s physical abilities and ability to understand instructions as well as the amount of strength required to move the patient.
 To lose 1 lb  (0.5 kg) in 1 week, the patient must decrease his weekly intake by 3,500 calories (approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient must decrease his weekly caloric intake by 7,000 calories (approximately 1,000 calories daily).
 To avoid shearing force injury, a patient who is  completely immobile is lifted on a sheet.
 To insert a catheter from the  nose through the trachea for suction, the nurse should ask the patient to swallow.
 Vitamin C is needed for collagen production.
 Only the  patient can describe his pain accurately.
 Cutaneous stimulation creates  the release of endorphins that block the transmission of pain stimuli.
 Patient-controlled analgesia is a safe method to relieve acute pain caused by surgical incision, traumatic injury, labor and delivery, or cancer.
 An  Asian American or European American typically places distance between himself and others when communicating.
 The patient who believes in a  scientific, or biomedical, approach to health is likely to expect a drug, treatment, or surgery to cure illness.
 Chronic illnesses occur in very  young as well as middle-aged and very old people.
 The trajectory  framework for chronic illness states that preferences about daily life activities affect treatment decisions.
 Exacerbations of chronic disease  usually cause the patient to seek treatment and may lead to hospitalization.
 School health programs provide cost-effective health  care for low-income families and those who have no health insurance.
 Collegiality is the promotion of collaboration, development, and interdependence among members of a profession.
 A change agent is an individual who  recognizes a need for change or is selected to make a change within an established entity, such as a hospital.
 The patients’ bill of rights  was introduced by the American Hospital Association.
 Abandonment is  premature termination of treatment without the patient’s permission and without appropriate relief of symptoms.
 Values clarification is a process that  individuals use to prioritize their personal values.
 Distributive  justice is a principle that promotes equal treatment for all.
 Milk and  milk products, poultry, grains, and fish are good sources of phosphate.
 The best way to prevent falls at night in an oriented, but restless, elderly patient is to raise the side rails.
 By the end of the orientation  phase, the patient should begin to trust the nurse.
 Falls in the  elderly are likely to be caused by poor vision.
 Barriers to  communication include language deficits, sensory deficits, cognitive impairments, structural deficits, and paralysis.
 The three elements  that are necessary for a fire are heat, oxygen, and combustible material.
 Sebaceous glands lubricate the skin.
 To check for  petechiae in a dark-skinned patient, the nurse should assess the oral mucosa.
 To put on a sterile glove, the nurse should pick up the first  glove at the folded border and adjust the fingers when both gloves are on.
 To increase patient comfort, the nurse should let the alcohol dry  before giving an intramuscular injection.
 Treatment for a stage 1 ulcer  on the heels includes heel protectors.
 Seventh-Day Adventists are  usually vegetarians.
 Endorphins are morphinelike substances that  produce a feeling of well-being.
 Pain tolerance is the maximum amount  and duration of pain that an individual is willing to endure.
MEDICAL SURGICAL NURSING BULLETS
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.
 Before angiography, the nurse should ask the patient  whether he’s allergic to the dye, shellfish, or iodine and advise him to take nothing by mouth for 8 hours before the procedure.
 During myelography,  approximately 10 to 15 ml of cerebrospinal fluid is removed for laboratory studies and an equal amount of contrast media is injected.
 After  angiography, the puncture site is covered with a pressure dressing and the affected part is immobilized for 8 hours to decrease the risk of bleeding.
 If a water-based medium was used during myelography, the  patient remains on bed rest for 6 to 8 hours, with the head of the bed elevated 30 to 45 degrees. If an oil-based medium was used, the patient remains flat in bed for 6 to 24 hours.
 The level of amputation is determined by  estimating the maximum viable tissue (tissue with adequate circulation) needed to develop a functional stump.
 Heparin sodium is included in the  dialysate used for renal dialysis.
 Paroxysmal nocturnal dyspnea may  indicate heart failure.
 A patient who takes a cardiac glyc oside, such as digoxin, should consume a diet that includes high-potassium foods.
 The nurse should limit tracheobronchial suctioning to 10 to 15 seconds and should make only two passes.
 Before performing tracheobronchial  suctioning, the nurse should ventilate and oxygenate the patient five to six times with a resuscitation bag and 100% oxygen. This procedure is called bagging.
 Signs and symptoms of pneumothorax include tachypnea,  restlessness, hypotension, and tracheal deviation.
 The cardinal sign of  toxic shock syndrome is rapid onset of a high fever.  A key sign of peptic ulcer is hematemesis, which can be bright red or dark red, with the consistency of coffee grounds.
 Signs and symptoms of a perforated peptic ulcer  include sudden, severe upper abdominal pain; vomiting; and an extremely tender, rigid (boardlike) abdomen.
 Constipation is a common adverse reaction to aluminum hydroxide.
 For the first 24 hours after a myocardial infarction, the patient should use a bedside commode and then progress to walking to the toilet, bathing, and taking short walks.
 After a  myocardial infarction, the patient should avoid overexertion and add a
new activity daily, as tolerated without dyspnea.
 In a patient with a  recent myocardial infarction, frothy, blood-tinged sputum suggests pulmonary edema.
 In a patient who has acquired immunodeficiency syndrome, the  primary purpose of drugs is to prevent secondary infections.
 In a  patient with acquired immunodeficiency syndrome, suppression of the immune system increases the risk of opportunistic infections, such as cytomegalovirus, Pneumocystis carinii pneumonia, and thrush.
 A patient with acquired  immunodeficiency syndrome may have rapid weight loss, a sign of wasting syndrome.
 If the body doesn’t use glucose for energy, it metabolizes  fat and produces ketones.
 Approximately 20% of patients with  Guillain-Barré syndrome have residual deficits, such as mild motor weakness or diminished lower extremity reflexes.
 Hypertension and hypokalemia are  the most significant clinical manifestations of primary hyperaldosteronism.
 After percutaneous aspiration of the bladder, the patient’s first void is usually pink; however, urine with frank blood should be reported to the physician.
 A urine culture that grows more than 100,000 colonies of  bacteria per milliliter of urine indicates infection.
 A patient who is  undergoing dialysis should take a vitamin supplement and eat foods that are high in calories, but low in protein, sodium, and potassium.
 In a patient  who has chronic obstructive pulmonary disease, the most effective ways to reduce thick secretions are to increase fluid intake to 2,500 ml/day and encourage ambulation.
 The nurse should teach a patient with emphysema how to  perform pursed-lip breathing because this slows expiration, prevents alveolar collapse, and helps to control the respiratory rate.
 Clubbing of the  digits and a barrel chest may develop in a patient who has chronic obstructive pulmonary disease.
 A stroke (“brain attack”) disrupts the brain’s blood  supply and may be caused by hypertension.
 In a patient who is  undergoing dialysis, desired outcomes are normal weight, normal serum albumin level (3.5 to 5.5 g/dl), and adequate protein intake (1.2 to 1.5 g/kg of body weight daily).
 Intermittent peritoneal dialysis involves performing  three to seven treatments that total 40 hours per week.
 In a patient  with chronic obstructive pulmonary disease, the best way to administer oxygen is by nasal cannula. The normal flow rate is 2 to 3 L/ minute.
 Isoetharine  (Bronkosol) can be administered with a handheld nebulizer or by intermittent positive-pressure breathing.
 Brain death is irreversible cessation  of brain function.
 Continuous ambulatory peritoneal dialysis requires  four exchanges per day, 7 days per week, for a total of 168 hours per week.
 The classic adverse reactions to antihistamines are dry mouth,  drowsiness, and blurred vision.
 Because of the risk of paralytic ileus,  a patient who has received a general anesthetic can’t take anything by mouth until active bowel sounds are heard in all abdominal quadrants.
 The  level of alpha-fetoprotein, a tumor marker, is elevated in patients who have testicular germ cell cancer.
 Clinical manifestations of orchitis caused  by bacteria or mumps include high temperature, chills, and sudden pain in the involved testis.
 The level of prostate-specific antigen is elevated in  patients with benign prostatic hyperplasia or prostate cancer.
 The  level of prostatic acid phosphatase is elevated in patients with advanced stages of prostate cancer.
 Phenylephrine (Neo-Synephrine), a mydriatic, is  instilled in a patient’s eye to dilate the eye.
 To promote fluid  drainage and relieve edema in a patient with epididymitis, the
nurse should elevate the scrotum on a scrotal bridge.
 Fluorescein staining is  commonly used to assess corneal abrasions because it outlines superficial epithelial defects.
 Presbyopia is loss of near vision as a result of  the loss of elasticity of the crystalline lens.
 Transient ischemic  attacks are considered precursors to strokes.
 A sign of acute appendicitis,  McBurney’s sign is tenderness at McBurney’s point (about 2" [5 cm] from the right anterior superior iliac spine on a line between the spine and the umbilicus).
 When caring for a patient with Guillain-Barré syndrome, the  nurse should focus on respiratory interventions as the disease process advances.
 Signs and symptoms of colon cancer include rectal bleeding,  change in bowel habits, intestinal obstruction, abdominal pain, weight loss, anorexia, nausea, and vomiting.
 Symptoms of prostatitis include  frequent urination and dysuria.
 A chancre is a painless, ulcerative  lesion that develops during the primary stage of syphilis.
 During the  tertiary stage of syphilis, spirochetes invade the internal organs and cause permanent damage.
 In total parenteral nutrition, weight gain is the  most reliable indicator of a positive response to therapy.
 The nurse  may administer an I.V. fat emulsion through a central or peripheral catheter, but shouldn’t use an in-line filter because the fat particles are too large to pass through the pores.
 If a patient who has a prostatectomy is using a  Cunningham clamp, instruct him to wash and dry his penis before applying the clamp. He should apply the clamp horizontally and remove it at least every 4 hours to empty his bladder to prevent infection.
 If a woman has signs  of urinary tract infection during menopause, she should be instructed to drink six to eight glasses of water per day, urinate before and after intercourse, and perform Kegel exercises.
 If a menopausal patient experiences a “hot  flash,” she should be
instructed to seek a cool, breezy location and sip a cool drink.
 Cheilosis causes fissures at the angles of the mouth and  indicates a vitamin B2, riboflavin, or iron deficiency.
 Tetany may  result from hypocalcemia caused by hypoparathyroidism.
 A patient who  has cervical cancer may experience vaginal bleeding for 1 to 3 months after intracavitary radiation.
 Ascites is the accumulation of fluid,  containing large amounts of protein and electrolytes, in the abdominal cavity. It’s commonly caused by cirrhosis.
 Normal pulmonary artery pressure is  10 to 25 mm Hg. Normal pulmonary artery wedge pressure is 5 to 12 mm Hg.
 After cardiac catheterization, the site is monitored for bleeding  and hematoma formation, pulses distal to the site are palpated every 15 minutes for 1 hour, and the patient is maintained on bed rest with the extremity extended for 8 hours.
 Hemophilia is a bleeding disorder that’s  transmitted genetically in a sex- linked (X chromosome) recessive pattern. Although girls and women may carry the defective gene, hemophilia usually occurs only in boys and men.
 Von Willebrand’s disease is an autosomal dominant  bleeding disorder that’s caused by platelet dysfunction and factor VIII deficiency.
 Sickle cell anemia is a congenital hemolytic anemia that’s  caused by defective hemoglobin S molecules. It primarily affects blacks.
 Sickle cell anemia has a homozygous inheritance pattern. Sickle  cell trait has a heterozygous inheritance pattern.
 Pel-Ebstein  fever is a characteristic sign of Hodgkin’s disease. Fever recurs every few days or weeks and alternates with afebrile periods.
 Glucose-6-phosphate  dehydrogenase (G6PD) deficiency is an inherited metabolic disorder that’s characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis.
 Preferred sites for bone marrow aspiration are  the posterior superior iliac crest, anterior iliac crest, and sternum.
 During bone marrow harvesting, the donor receives general anesthesia and 400 to 800 ml of marrow is aspirated.
 A butterfly rash across the bridge of  the nose is a characteristic sign of systemic lupus erythematosus.
 Rheumatoid arthritis is a chronic, destructive collagen disease characterized by symmetric inflammation of the synovium that leads to joint swelling.
 Screening for human immunodeficiency virus antibodies begins with the enzyme-linked immunosorbent assay. Results are confirmed by the Western blot test.
 The CK-MB isoenzyme level increases 4 to 8 hours after a  myocardial infarction, peaks at 12 to 24 hours, and returns to normal in 3 days.
 Excessive intake of vitamin K may significantly antagonize the anticoagulant effects of warfarin (Coumadin). The patient should be cautioned to avoid eating an excessive amount of leafy green vegetables.
 A lymph  node biopsy that shows Reed-Sternberg cells provides a definitive diagnosis of Hodgkin’s disease.
 Bell’s palsy is unilateral facial weakness or  paralysis caused by a disturbance of the seventh cranial (facial) nerve.
 During an initial tuberculin skin test, lack of a wheal  after injection of tuberculin purified protein derivative indicates that the test dose was injected too deeply. The nurse should inject another dose at least 2" (5 cm) from the initial site.
 A tuberculin skin test should be read  48 to 72 hours after administration.
 In reading a tuberculin skin test,  erythema without induration is usually not significant.
 Death caused by  botulism usually results from delayed diagnosis and respiratory complications.
 In a patient who has rabies, saliva contains the virus  and is a hazard for nurses who provide care.
 A febrile nonhemolytic  reaction is the most common transfusion reaction.
 Hypokalemia  (abnormally low concentration of potassium in the blood) may
cause muscle weakness or paralysis, electrocardiographic abnormalities, and GI disturbances.
 Beriberi, a serious vitamin B1 (thiamine) deficiency,  affects alcoholics who have poor dietary habits. It’s epidemic in Asian countries where people subsist on unenriched rice. It’s characterized by the phrase “I can’t,” indicating that the patient is too ill to do anything.
 Excessive sedation may cause respiratory depression.
 The primary postoperative concern is maintenance of a patent airway.
 If  cyanosis occurs circumorally, sublingually, or in the nail bed, the oxygen saturation level (Sao 2) is less than 80%.
 A rapid pulse rate in a  postoperative patient may indicate pain, bleeding, dehydration, or shock.
 Increased pulse rate and blood pressure may indicate that a  patient is experiencing “silent pain” (pain that can’t be expressed verbally, such as when a patient is recovering from anesthesia).
 Lidocaine  (Xylocaine) exerts antiarrhythmic action by suppressing automaticity in the Purkinje fibers and elevating the electrical stimulation threshold in the ventricles.
 Cullen’s sign (a bluish discoloration around the umbilicus)  is seen in patients who have a perforated pancreas.
 During the  postoperative period, the patient should cough and breathe deeply every 2 hours unless otherwise contraindicated (for example, after craniotomy, cataract surgery, or throat surgery).
 Before surgery, a patient’s respiratory  volume may be measured by incentive spirometry. This measurement becomes the patient’s postoperative goal for respiratory volume.
 The postoperative  patient should use incentive spirometry 10 to 12 times per hour and breathe deeply.
 Before ambulating, a postoperative patient should dangle his  legs over the side of the bed and perform deep-breathing exercises.
 During the patient’s first postoperative ambulation, the nurse should monitor the patient closely and assist him as needed while he walks a few feet from the
bed to a steady chair.
 Hypovolemia occurs when 15% to 25% of the body’s  total blood volume is lost.
 Signs and symptoms of hypovolemia include  rapid, weak pulse; low blood pressure; cool, clammy skin; shallow respirations; oliguria or anuria; and lethargy.
 Acute pericarditis causes sudden  severe, constant pain over the anterior chest. The pain is aggravated by inspiration.
 Signs and symptoms of septicemia include fever, chills,  rash, abdominal distention, prostration, pain, headache, nausea, and diarrhea.
 Rocky Mountain spotted fever causes a persistent high fever,  nonpitting edema, and rash.
 Patients who have undergone coronary artery  bypass graft should sleep 6 to 10 hours per day, take their temperature twice daily, and avoid lifting more than 10 lb (4.5 kg) for at least 6 weeks.
 Claudication pain (pain on ambulation) is caused by arterial insufficiency as a result of atheromatous plaque that obstructs arterial blood flow to the extremities.
 Pacemakers can be powered by lithium batteries for up to  10 years.
 The patient shouldn’t void for 1 hour before percutaneous  suprapubic bladder aspiration to ensure that sufficient urine remains in the bladder to make the procedure successful.
 Left-sided heart failure  causes pulmonary congestion, pink-tinged sputum, and dyspnea. (Remember L for left and lung.)
 The current recommended blood cholesterol level is less  than 200 mg/dl.
 When caring for a patient who is having a seizure, the  nurse should follow these guidelines: (1) Avoid restraining the patient, but help a standing patient to a lying position. (2) Loosen restrictive clothing. (3) Place a pillow or another soft object under the patient’s head. (4) Clear the area of hard objects. (5) Don’t force anything into the patient’s mouth, but maintain a patent airway. (6) Reassure and reorient the patient after the seizure subsides.
 Gingival hyperplasia, or overgrowth of gum  tissue, is an adverse reaction to
phenytoin (Dilantin).
 With aging,  most marrow in long bones becomes yellow, but it retains the capacity to convert back to red.
 Clinical manifestations of lymphedema include accumulation  of fluid in the legs.
 Afterload is ventricular wall tension during  systolic ejection. It’s increased in patients who have septal hypertrophy, increased blood viscosity, and conditions that cause blockage of aortic or pulmonary outflow.
 Red blood cells can be stored frozen for up to 2  years; however, they must be used within 24 hours of thawing.
 For the  first 24 hours after amputation, the nurse should elevate the stump to prevent edema.
 After hysterectomy, a wom an should avoid sexual intercourse for 3 weeks if a vaginal approach was used and 6 weeks if the abdominal approach was used.
 Parkinson’s disease characteristically causes progressive muscle  rigidity, akinesia, and involuntary tremor.
 Tonic-clonic seizures are  characterized by a loss of consciousness and alternating periods of muscle contraction and relaxation.
 Status epilepticus, a life-threatening  emergency, is a series of rapidly repeating seizures that occur without intervening periods of consciousness.
 The ideal donor for kidney  transplantation is an identical twin. If an identical twin isn’t available, a biological sibling is the next best choice.
 Breast cancer is the  leading cancer among women; however, lung cancer accounts for more deaths.
 The stages of cervical cancer are as follows: stage 0,  carcinoma in situ; stage I, cancer confined to the cervix; stage II, cancer extending beyond the cervix, but not to the pelvic wall; stage III, cancer extending to the pelvic wall; and stage IV, cancer extending beyond the pelvis or within the bladder or rectum.
 One method used to estimate blood loss  after a hysterectomy is counting perineal pads. Saturating more than one pad in 1 hour or eight pads in 24 hours is considered hemorrhaging.
 Transurethral resection of the prostate is the most common procedure for
treating benign prostatic hyperplasia.
 In a chest drainage system, the  water in the water-seal chamber normally rises when a patient breathes in and falls when he breathes out.
 Spinal fusion provides spinal stability  through a bone graft, usually from the iliac crest, that fuses two or more vertebrae.
 A patient who receives any type of transplant must take an  immunosuppressant drug for the rest of his life.
 Incentive spirometry  should be used 5 to 10 times an hour while the patient is awake.
 In  women, pelvic inflammatory disease is a common complication of gonorrhea.
 Scoliosis is lateral S-shaped curvature of the  spine.
 Signs and symptoms of the secondary stage of syphilis include a  rash on the palms and soles, erosion of the oral mucosa, alopecia, and enlarged lymph nodes.
 In a patient who is receiving total parenteral nutrition,  the nurse should monitor glucose and electrolyte levels.
 Unless  contraindicated, on admission to the postanesthesia care unit, a patient should be turned on his side and his vital signs should be taken.
 Edema is  treated by limiting fluid intake and eliminating excess fluid.
 A  patient who has had spinal anesthesia should remain flat for 12 to 24 hours. Vital signs and neuromuscular function should be monitored.
 A patient  who has maple syrup urine disease should avoid food containing the amino acids leucine, isoleucine, and lysine.
 A severe complication of a femur  fracture is excessive blood loss that results in shock.
 To prepare a  patient for peritoneal dialysis, the nurse should ask the patient to void, measure his vital signs, place him in a supine position, and using aseptic technique, insert a catheter through the abdominal wall and into the peritoneal space.
 If more than 3 L of dialysate solution return during peritoneal  dialysis, the nurse should notify the physician.
 Hemodialysis is the  removal of certain elements from the blood by passing heparinized blood through a semipermeable membrane to the dialysate bath, which contains all of the important electrolytes in their ideal concentrations.
 Gangrene usually  affects the digits first, and begins with skin color changes that progress from gray-blue to dark brown or black.
 Kidney function is assessed by  evaluating blood urea nitrogen (normal range is 8 to 20 mg/dl) and serum creatinine (normal range is 0.6 to 1.3 mg/dl) levels.
 A weight-bearing  transfer is appropriate only for a patient who has at least one leg that’s strong enough to bear weight, such as a patient with hemiplegia or a single-leg amputation.
 Overflow incontinence (voiding of 30 to 60 ml of urine  every 15 to 30 minutes) is a sign of bladder distention.
 The first sign  of a pressure ulcer is reddened skin that blanches when pressure is applied.
 Late signs and symptoms of sickle cell anemia include  tachycardia, cardiomegaly, systolic and diastolic murmurs, chronic fatigue, hepatomegaly, and splenomegaly.
 A mechanical ventilator, which can  maintain ventilation automatically for an extended period, is indicated when a patient can’t maintain a safe PaO2 or PaCO2 level.
 Two types of  mechanical ventilators exist: negative-pressure ventilators, which apply negative pressure around the chest wall, and positive-pressure ventilators, which deliver air under pressure to the patient.
 Angina pectoris is  characterized by substernal pain that lasts for 2 to 3 minutes. The pain, which is caused by myocardial ischemia, may radiate to the neck, shoulders, or jaw; is described as viselike, or constricting; and may be accompanied by severe apprehension or a feeling of impending doom.
 The diagnosis of an acute  myocardial infarction is based on the patient’s signs and symptoms, electrocardiogram tracings, troponin level, and cardiac enzyme studies.
 The goal of treatment for a patient with angina pectoris is to reduce the heart’s workload, thereby reducing the myocardial demand for oxygen and preventing myocardial infarction.
 Nitroglycerin decreases the amount of  blood that returns to the heart by increasing the capacity of the venous bed.
 The patient should take no more than three nitroglycerin  tablets in a 15-minute period.
 Hemodialysis is usually performed 24  hours before kidney transplantation.
 Signs and symptoms of acute kidney  transplant rejection are progressive enlargement and tenderness at the transplant site, increased blood pressure, decreased urine output, elevated serum creatinine level, and fever.
 After a radical mastectomy, the  patient’s arm should be elevated (with the hand above the elbow) on a pillow to enhance circulation and prevent edema.
 Postoperative mastectomy care  includes teaching the patient arm exercises to facilitate lymph drainage and prevent shortening of the muscle and contracture of the shoulder joint (frozen shoulder).
 After radical mastectomy, the patient should help prevent  infection by making sure that no blood pressure readings, injections, or venipunctures are performed on the affected arm.
 For a patient who has  undergone mastectomy and is susceptible to lymphedema, a program of hand exercises can begin shortly after surgery, if prescribed. The program consists of opening and closing the hand tightly six to eight times per hour and performing such tasks as washing the face and combing the hair.
 Signs  and symptoms of theophylline toxicity include vomiting, restlessness, and an apical pulse rate of more than 200 beats/minute.
 The nurse shouldn’t  induce vomiting in a person who has ingested poison and is having seizures or is semiconscious or comatose.
 Central venous pressure (CVP),  which is the pressure in the right atrium and the great veins of the thorax, is normally 2 to 8 mm Hg (or 5 to 12 cm H2O). CVP is used to assess right-sided cardiac function.
 CVP is monitored to assess the need for fluid  replacement in seriously ill patients, to estimate blood volume deficits, and to evaluate circulatory pressure in the right atrium.
 To prevent deep vein  thrombosis after surgery, the nurse should administer 5,000 units of heparin subcutaneously every 8 to 12 hours, as prescribed.
 Oral anticoagulants,  such as warfarin (Coumadin) and dicumarol, disrupt natural blood clotting mechanisms, prevent thrombus formation, and limit the extension of a formed thrombus.
 Anticoagulants can’t dissolve a formed thrombus.
 Anticoagulant therapy is contraindicated in a patient who has liver or kidney disease or GI ulcers or who isn’t likely to return for follow-up visits.
 The nurse can assess a patient for thrombophlebitis by  measuring the affected and unaffected legs and comparing their sizes. The nurse should mark the measurement locations with a pen so that the legs can be measured at the same place each day.
 Drainage of more than 3,000 ml of  fluid daily from a nasogastric tube may suggest intestinal obstruction. Yellow drainage that has a foul odor may indicate small-bowel obstruction.
 Preparation for sigmoidoscopy includes administering an enema 1 hour before the examination, warming the scope in warm water or a sterilizer (if using a metal sigmoidoscope), and draping the patient to expose the perineum.
 Treatment for a patient with bleeding esophageal varices includes administering vasopressin (Pitressin), giving an ice water lavage, aspirating blood from the stomach, using esophageal balloon tamponade, providing parenteral nutrition, and administering blood transfusions, as needed.
 A trauma victim shouldn’t  be moved until a patent airway is established and the cervical spine is immobilized.
 After a mastectomy, lymphedema may cause a feeling of  heaviness in the affected arm.
 A dying patient shouldn’t be told  exactly how long he’s expected to live, but should be told something more general such as “Some people live 3 to 6 months, but others live longer.”
 After eye surgery, a patient should avoid using makeup until  otherwise instructed.
 After a corneal transplant, the patient should  wear an eye shield when engaging in activities such as playing with children or pets.
 After a corneal transplant, the patient shouldn’t lie on the  affected site, bend at the waist, or have sexual intercourse for 1 week. The patient must avoid getting soapsuds in the eye.
 A Milwaukee brace is  used for patients who have structural scoliosis. The brace helps to halt the progression of spinal curvature by providing longitudinal traction and lateral pressure. It should be worn 23 hours a day.
 Short-term measures used to  treat stomal retraction include stool softeners, irrigation, and stomal dilatation.
 A patient who has a colostomy should be advised to eat a  low-residue diet for 4 to 6 weeks and then to add one food at a time to evaluate its effect.
 To relieve postoperative hiccups, the patient should  breathe into a paper bag.
 If a patient with an ileostomy has a blocked  lumen as a result of undigested high-fiber food, the patient should be placed in the knee-chest position and the area below the stoma should be massaged.
 During the initial interview and treatment of a patient with  syphilis, the patient’s sexual contacts should be identified.
 The nurse  shouldn’t administer morphine to a patient whose respiratory rate is less than 12 breaths/minute.
 To prevent drying of the mucous membranes, oxygen  should be administered with hydration.
 Flavoxate (Urispas) is  classified as a urinary tract spasmolytic.
 Hypotension is a sign of  cardiogenic shock in a patient with a myocardial infarction.
 The  predominant signs of mechanical ileus are cramping pain, vomiting, distention, and inability to pass feces or flatus.
 For a patient with a myocardial  infarction, the nurse should monitor fluid intake and output meticulously. Too little intake causes dehydration, and too much may cause pulmonary edema.
 Nitroglycerin relaxes smooth muscle, causing vasodilation and  relieving the
chest pain associated with myocardial infarction and angina.
 The diagnosis of an acute myocardial infarction is based on the  patient’s signs and symptoms, electrocardiogram tracings, and serum enzyme studies.
 Arrhythmias are the predominant problem during the first 48  hours after a myocardial infarction.
 Clinical manifestations of  malabsorption include weight loss, muscle wasting, bloating, and steatorrhea.
 Asparaginase, an enzyme that inhibits the synthesis of  deoxyribonucleic acid and protein, is used to treat acute lymphocytic leukemia.
 To relieve a patient’s sore throat that’s caused by  nasogastric tube irritation, the nurse should provide anesthetic lozenges, as prescribed.
 For the first 12 to 24 hours after gastric surgery, the  stomach contents (obtained by suctioning) are brown.
 After gastric  suctioning is discontinued, a patient who is recovering from a subtotal gastrectomy should receive a clear liquid diet.
 The descending colon is  the preferred site for a permanent colostomy.
 Valvular insufficiency in  the veins commonly causes varicosity.
 A patient with a colostomy should  restrict fat and fibrous foods and should avoid foods that can obstruct the stoma, such as corn, nuts, and cabbage.
 A patient who is receiving  chemotherapy is placed in reverse isolation because the white blood cell count may be depressed.
 Symptoms of mitral valve stenosis are caused by  improper emptying of the left atrium.
 Persistent bleeding after open  heart surgery may require the administration of protamine sulfate to reverse the effects of heparin sodium used during surgery.
 The nurse should teach a  patient with heart failure to take digoxin and other drugs as prescribed, to restrict sodium intake, to restrict fluids as prescribed, to get adequate rest, to increase walking and other activities gradually, to avoid extremes of temperature, to report signs of  The nurse should check and maintain the  patency of all connections for a chest tube. If an air leak is detected, the nurse should place one Kelly clamp near the insertion site. If the bubbling stops, the leak is in the thoracic cavity and the
physician should be notified immediately. If the leak continues, the nurse should take a second clamp, work down the tube until the leak is located, and stop the leak.
 In  two-person cardiopulmonary resuscitation, the rescuers administer 60 chest compressions per minute and 1 breath for every 5 compressions.
 Mitral  valve stenosis can result from rheumatic fever.
 Atelectasis is  incomplete expansion of lung segments or lobules (clusters of alveoli). It may cause the lung or lobe to collapse.
 The nurse should instruct a patient  who has an ileal conduit to empty the collection device frequently because the weight of the urine may cause the device to slip from the skin.
 A  patient who is receiving cardiopulmonary resuscitation should be placed on a solid, flat surface.
 Brain damage occurs 4 to 6 minutes after  cardiopulmonary function ceases.
 Climacteric is the transition period  during which a woman’s reproductive function diminishes and gradually disappears.
 After infratentorial surgery, the patient should remain on  his side, flat in bed.
 In a patient who has an ulcer, milk is  contraindicated because its high calcium content stimulates secretion of gastric acid.
 A patient who has a positive test result for  human immunodeficiency virus has been exposed to the virus associated with acquired immunodeficiency syndrome (AIDS), but doesn’t necessarily have AIDS.
 A common complication after prostatectomy is circulatory failure  caused by bleeding.
 In right-sided heart failure, a major focus of  nursing care is decreasing the workload of the heart.
 Signs and  symptoms of digoxin toxicity include nausea, vomiting, confusion, and arrhythmias.
 An asthma attack typically begins with wheezing, coughing,  and increasing respiratory distress.
 In a patient who is recovering  from a tonsillectomy, frequent swallowing suggests hemorrhage.
 Ileostomies and Hartmann’s colostomies are permanent stomas. Loop colostomies and double-barrel colostomies are temporary ones.
 A patient who has an  ileostomy should eat foods, such as spinach and parsley, because they act as intestinal tract deodorizers.
 An adrenalectomy can decrease steroid  production, which can cause extensive loss of sodium and water.
 Before  administering morphine (Duramorph) to a patient who is suspected of having a myocardial infarction, the nurse should check the patient’s respiratory rate. If it’s less than 12 breaths/minute, emergency equipment should be readily available for intubation if respiratory depression occurs.
 A patient who is recovering from supratentorial  surgery is normally allowed out of bed 14 to 48 hours after surgery. A patient who is recovering from infratentorial surgery normally remains on bed rest for 3 to 5 days.
 After a patient undergoes a femoral-popliteal bypass graft,  the nurse must closely monitor the peripheral pulses distal to the operative site and circulation.
 After a femoral-popliteal bypass graft, the  patient should initially be maintained in a semi-Fowler position to avoid flexion of the graft site. Before discharge, the nurse should instruct the patient to avoid positions that put pressure on the graft site until the next follow-up visit.
 Of the five senses, hearing is the last to be lost in  a patient who is entering a coma.
 Cholelithiasis causes an enlarged,  edematous gallbladder with multiple stones and an elevated bilirubin level.
 The antiviral agent zidovudine (Retrovir) successfully slows  replication of the human immunodeficiency virus, thereby slowing the development of acquired immunodeficiency syndrome.
 Severe rheumatoid arthritis  causes marked edema and congestion, spindle- shaped joints, and severe flexion deformities.
 A patient with acquired immunodeficiency syndrome should  advise his sexual partners of his human immunodeficiency virus status and observe sexual precautions, such as abstinence or condom use.
 If a  radioactive implant becomes dislodged, the nurse should retrieve it with tongs, place it in a lead-shielded container, and notify the radiology department.
 A patient who is undergoing radiation therapy should pat  his skin dry to avoid abrasions that could easily become infected.  During  radiation therapy, a patient should have frequent blood tests, especially white blood cell and platelet counts.
 The nurse should administer an aluminum  hydroxide antacid at least 1 hour after an enteric-coated drug because it can cause premature release of the enteric-coated drug in the stomach.
 Acid-base balance is the body’s hydrogen ion concentration, a measure of the ratio of carbonic acid to bicarbonate ions (1 part carbonic acid to 20 parts bicarbonate is normal).
 Amyotrophic lateral sclerosis causes  progressive atrophy and wasting of muscle groups that eventually affects the respiratory muscles.
 Metabolic acidosis is caused by abnormal loss of  bicarbonate ions or excessive production or retention of acid ions.
 Hemianopsia is defective vision or blindness in one-half of the visual field of one or both eyes.
 Systemic lupus erythematosus causes early-morning  joint stiffness and facial erythema in a butterfly pattern.
 After total  knee replacement, the patient should remain in the semi-Fowler position, with the affected leg elevated.
 In a patient who is receiving transpyloric  feedings, the nurse should watch for dumping syndrome and hypovolemic shock because the stomach is being bypassed.
 If a total parenteral nutrition  infusion must be interrupted, the nurse should administer dextrose 5% in water at a similar rate. Abrupt cessation can cause hypoglycemia.
 Status  epilepticus is treated with I.V. diazepam (Valium) and phenytoin (Dilantin).
 Disequilibrium syndrome causes nausea, vomiting,  restlessness, and twitching in patients who are undergoing dialysis. It’s caused by a rapid fluid shift.
 An indication that spinal shock is resolving is  the return of reflex activity in the arms and legs below the level of injury.
 Hypovolemia is the most common and fatal complication of severe  acute pancreatitis.
 In a patient with stomatitis, oral care includes  rinsing the mouth with a mixture of equal parts of hydrogen peroxide and water three times daily.
 In otitis media, the tympanic membrane is bright red  and lacks its characteristic light reflex (cone of light).
 In patients  who have pericardiocentesis, fluid is aspirated from the pericardial sac for analysis or to relieve cardiac tamponade.
 Urticaria is an early sign of  hemolytic transfusion reaction.
 During peritoneal dialysis, a return of  brown dialysate suggests bowel perforation. The physician should be notified immediately.
 An early sign of ketoacidosis is polyuria, which is caused  by osmotic diuresis.
 Patients who have multiple sclerosis should  visually inspect their extremities to ensure proper alignment and freedom from injury.
 Aspirated red bone marrow usually appears rust-red, with  visible fatty material and white bone fragments.
 The Dick test detects  scarlet fever antigens and immunity or susceptibility to scarlet fever. A positive result indicates no immunity; a negative result indicates immunity.
 The Schick test detects diphtheria antigens and immunity  or susceptibility to diphtheria. A positive result indicates no immunity; a negative result indicates immunity.
 The recommended adult dosage of  sucralfate (Carafate) for duodenal ulcer is 1 g (1 tablet) four times daily 1 hour before meals and at bedtime.
 A patient with facial burns or smoke  or heat inhalation should be admitted to the hospital for 24-hour observation for delayed tracheal edema.
 In addition to patient teaching,  preparation for a colostomy includes withholding oral intake overnight, performing bowel preparation, and administering a cleansing enema.
 The  physiologic changes caused by burn injuries can be divided into two stages: the hypovolemic stage, during which intravascular fluid shifts into the interstitial space, and the diuretic stage, during which capillary integrity and intravascular volume are restored, usually 48 to 72 hours after the injury.
 The nurse should change total parenteral nutrition tubing every  24 hours and the peripheral I.V. access site dressing every 72 hours.
 A  patient whose carbon monoxide level is 20% to 30% should be treated with 100% humidified oxygen.
 When in the room of a patient who is in isolation  for tuberculosis, staff and visitors should wear ultrafilter masks.
 When providing skin care immediately after pin insertion, the nurse’s primary concern is prevention of bone infection.
 After an amputation, moist  skin may indicate venous stasis; dry skin may indicate arterial obstruction.
 In a patient who is receiving dialysis, an  internal shunt is working if the nurse feels a thrill on palpation or hears a bruit on auscultation.
 In a patient with viral hepatitis, the  parenchymal, or Kupffer’s, cells of the liver become severely inflamed, enlarged, and necrotic.
 Early signs of acquired immunodeficiency  syndrome include fatigue, night sweats, enlarged lymph nodes, anorexia, weight loss, pallor, and fever.
 When caring for a patient who has a  radioactive implant, health care workers should stay as far away from the radiation source as possible. They should remember the axiom, “If you double the distance, you quarter the dose.”
 A patient who has Parkinson’s disease  should be instructed to walk with a broad-based gait.
 The cardinal  signs of Parkinson’s disease are muscle rigidity, a tremor that begins in the fingers, and akinesia.
 In a patient with Parkinson’s disease, levodopa  (Dopar) is prescribed to compensate for the dopamine deficiency.
 A  patient who has multiple sclerosis is at increased risk for pressure ulcers.
 Pill-rolling tremor is a classic sign of Parkinson’s  disease.
 For a patient with Parkinson’s disease, nursing interventions  are palliative.
 Fat embolism, a serious complication of a long-bone  fracture, causes fever, tachycardia, tachypnea, and anxiety.
 Metrorrhagia (bleeding between menstrual periods) may be the first sign of cervical cancer.
 Mannitol is a hypertonic solution and an  osmotic diuretic that’s used in the treatment of increased intracranial pressure.
 The classic sign of an absence seizure is a vacant facial  expression.
 Migraine headaches cause persistent, severe pain that  usually occurs in the temporal region.
 A patient who is in a bladder  retraining program should be given an opportunity to void every 2 hours during the day and twice at night.
 In a patient with a head injury, a decrease  in level of consciousness is a cardinal sign of increased intracranial pressure.
 Ergotamine (Ergomar) is most effective when taken during the  prodromal phase of a migraine or vascular headache.
 Treatment of acute  pancreatitis includes nasogastric suctioning to decompress the stomach and meperidine (Demerol) for pain.
 Symptoms of hiatal hernia include a  feeling of fullness in the upper abdomen or chest, heartburn, and pain similar to that of angina pectoris.
 The incidence of cholelithiasis is higher  in women who have had children than in any other group.
 Acetaminophen  (Tylenol) overdose can severely damage the liver.
 The prominent  clinical signs of advanced cirrhosis are ascites and jaundice.
 The  first symptom of pancreatitis is steady epigastric pain or left upper quadrant pain that radiates from the umbilical area or the back.
 Somnambulism is  the medical term for sleepwalking.
 Epinephrine (Adrenalin) is a  vasoconstrictor.
 An untreated liver laceration or rupture can progress  rapidly to hypovolemic shock.
 Obstipation is extreme, intractable  constipation caused by an intestinal obstruction.
 The definitive test  for diagnosing cancer is biopsy with cytologic examination of the specimen.
 Arthrography requires injection of a contrast medium and can  identify joint abnormalities.
 Brompton’s cocktail is prescribed to help  relieve pain in patients who have terminal cancer.
 A sarcoma is a  malignant tumor in connective tissue.
 Aluminum hydroxide (Amphojel)  neutralizes gastric acid.
 Subluxation is partial dislocation or  separation, with spontaneous reduction of a joint.
 Barbiturates can  cause confusion and delirium in an elderly patient who has an organic brain disorder.
 In a patient with arthritis, physical therapy is indicated to  promote optimal functioning.
 Some patients who have hepatitis A may be  anicteric (without jaundice) and lack symptoms, but some have headaches, jaundice, anorexia, fatigue, fever, and respiratory tract infection.
 Hepatitis A is usually mild and won’t advance to a carrier state.
 In  the preicteric phase of all forms of hepatitis, the patient is highly contagious.
 Enteric precautions are required for a patient who has  hepatitis A.
 Cholecystography is ineffective in a patient who has  jaundice as a result of gallbladder disease. The liver cells can’t transport the contrast medium to the biliary tract.
 In a patient who has diabetes  insipidus, dehydration is a concern because diabetes causes polyuria.
 In a patient who has a reducible hernia, the protruding mass spontaneously retracts into the abdomen.
 To prevent purple glove syndrome, a nurse  shouldn’t administer I.V. phenytoin (Dilantin) through a vein in the back of the hand, but should use a larger vessel.
 During stage III of surgical  anesthesia, unconsciousness occurs and surgery is permitted.
 Types of  regional anesthesia include spinal, caudal, intercostal, epidural, and brachial plexus.
 The first step in managing drug overdose or drug toxicity is to  establish and maintain an airway.
 Respiratory paralysis occurs in stage  IV of anesthesia (toxic stage).
 In stage I of anesthesia, the patient  is conscious and tranquil.
 Dyspnea and sharp, stabbing pain that  increases with respiration are symptoms of pleurisy, which can be a complication of pneumonia or tuberculosis.
 Vertigo is the major symptom of inner ear  infection or disease.
 Loud talking is a sign of hearing  impairment.
 A patient who has an upper respiratory tract infection  should blow his nose with both nostrils open.
 A patient who  has had a cataract removed can begin most normal activities in 3 or 4 days; however, the patient shouldn’t bend and lift until a physician approves
these activities.
 Symptoms of corneal transplant rejection include eye  irritation and decreasing visual field.
 Graves’ disease  (hyperthyroidism) is manifested by weight loss, nervousness, dyspnea, palpitations, heat intolerance, increased thirst, exophthalmos (bulging eyes), and goiter.
 The four types of lipoprotein are chylomicrons (the  lowest-density lipoproteins), very-low-density lipoproteins, low-density lipoproteins, and high-density lipoproteins. Health care professionals use cholesterol level fractionation to assess a patient’s risk of coronary artery disease.
 If a patient who is taking amphotericin B (Fungizone) bladder  irrigations for a fungal infection has systemic candidiasis and must receive I.V. fluconazole (Diflucan), the irrigations can be discontinued because fluconazole treats the bladder infection as well.
 Patients with adult  respiratory distress syndrome can have high peak inspiratory pressures. Therefore, the nurse should monitor these patients closely for signs of spontaneous pneumothorax, such as acute deterioration in oxygenation, absence of breath sounds on the affected side, and crepitus beginning on the affected side.
 Adverse reactions to cyclosporine (Sandimmune) include renal and  hepatic toxicity, central nervous system changes (confusion and delirium), GI bleeding, and hypertension.
 Osteoporosis is a metabolic bone disorder  in which the rate of bone resorption exceeds the rate of bone formation.
 The hallmark of ulcerative colitis is recurrent  bloody diarrhea, which commonly contains pus and mucus and alternates with asymptomatic remissions.
 Safer sexual practices include massaging,  hugging, body rubbing, friendly kissing (dry), masturbating, hand-to-genital touching, wearing a condom, and limiting the number of sexual partners.
 Immunosuppressed patients who contract cytomegalovirus (CMV) are at risk for CMV pneumonia and septicemia, which can be fatal.
 Urinary tract infections  can cause urinary urgency and frequency, dysuria, abdominal cramps or bladder spasms, and urethral itching.
 Mammography is a radiographic technique  that’s used to detect breast cysts or tumors, especially those that aren’t palpable on physical examination.
 To promote early detection of  testicular cancer, the nurse should palpate the testes during routine physical examinations and encourage the patient to perform monthly self-examinations during a warm shower.
 Patients who have thalassemia minor require no  treatment. Those with thalassemia major require frequent transfusions of red blood cells.
 A high level of hepatitis B  serum marker that persists for 3 months or more after the onset of acute hepatitis B infection suggests chronic hepatitis or carrier status.
 Neurogenic bladder dysfunction is caused  by disruption of nerve transmission to the bladder. It may be caused by certain spinal cord injuries, diabetes, or multiple sclerosis.
 Oxygen and  carbon dioxide move between the lungs and the bloodstream by diffusion.
 To grade the severity of dyspnea, the following system is used: grade 1, shortness of breath on mild exertion, such as walking up steps; grade 2, shortness of breath when walking a short distance at a normal pace on level ground; grade 3, shortness of breath with mild daily activity, such as shaving; grade 4, shortness of breath when supine (orthopnea).
 A patient with  Crohn’s disease should consume a diet low in residue, fiber, and fat, and high in calories, proteins, and carbohydrates. The patient also should take vitamin supplements, especially vitamin K.
 In the three-bottle urine collection  method, the patient cleans the meatus and urinates 10 to 15 ml in the first bottle and 15 to 30 ml (midstream) in the second bottle. Then the physician performs prostatic massage, and the patient voids into the third bottle.
 Findings in the three-bottle urine collection method are  interpreted as follows: pus in the urine (pyuria) in the first bottle indicates anterior urethritis; bacteria in the urine in the second bottle indicate bladder infection; bacteria in the third bottle indicate prostatitis.
 Signs and  symptoms of aortic stenosis include a loud, rough systolic murmur over the aortic area; exertional dyspnea; fatigue; angina pectoris; arrhythmias; low blood pressure; and emboli.
 Elective surgery is primarily a matter of  choice. It isn’t essential to the patient’s survival, but it may improve the patient’s health, comfort, or self-esteem.
 Required surgery is  recommended by the physician. It may be delayed, but is inevitable.
 Urgent surgery must be performed within 24 to 48 hours.
 Emergency  surgery must be performed immediately.
 About 85% of arterial emboli  originate in the heart chambers.
 Pulmonary embolism usually results  from thrombi dislodged from the leg veins.
 The conscious interpretation  of pain occurs in the cerebral cortex.
 To avoid interfering with new  cell growth, the dressing on a donor skin graft site shouldn’t be disturbed.
 A sequela is any abnormal condition that follows and is the  result of a disease, a treatment, or an injury.
 During sickle cell  crisis, patient care includes bed rest, oxygen therapy, analgesics as prescribed, I.V. fluid monitoring, and thorough documentation of fluid intake and output.
 A patient who has an ileal conduit should maintain a daily  fluid intake of 2,000 ml.
 In a closed chest drainage system, continuous  bubbling in the water seal chamber or bottle indicates a leak.
 Palpitation is a sensation of heart pounding or racing associated with normal emotional responses and certain heart disorders.
 Fat embolism is likely  to occur within the first 24 hours after a long-bone fracture.
 Footdrop  can occur in a patient with a pelvic fracture as a result of peroneal nerve compression against the head of the fibula.
 To promote venous return  after an amputation, the nurse should wrap an elastic bandage around the distal end of the stump.
 Water that accumulates in the tubing of a ventilator  should be removed.
 The most common route for the  administration of epinephrine to a patient who is having a severe allergic reaction is the subcutaneous route.
 The nurse should use Fowler’s  position for a patient who has abdominal pain caused by appendicitis.
 The nurse shouldn’t give analgesics to a patient who has abdominal pain caused by appendicitis because these drugs may mask the pain that accompanies a ruptured appendix.
 The nurse shouldn’t give analgesics to a patient who  has abdominal pain caused by appendicitis because these drugs may mask the pain that accompanies a ruptured appendix.
 As a last-ditch effort, a  barbiturate coma may be induced to reverse unrelenting increased intracranial pressure (ICP), which is defined as acute ICP of greater than 40 mm Hg, persistent elevation of ICP above 20 mm Hg, or rapidly deteriorating neurologic status.
 The primary signs and symptoms of epiglottiditis are stridor  and progressive difficulty in swallowing.
 Salivation is the first step  in the digestion of starch.
 A patient who has a demand pacemaker should  measure the pulse rate before rising in the morning, notify the physician if the pulse rate drops by 5 beats/minute, obtain a medical identification card and bracelet, and resume normal activities, including sexual activity.
 Transverse, or loop, colostomy is a temporary procedure that’s performed to divert the fecal stream in a patient who has acute intestinal obstruction.
 Normal values for erythrocyte sedimentation rate are 0 to  15 mm/hour for men younger than age 50 and 0 to 20 mm/hour for women younger than age 50.
 A CK-MB level that’s more than 5% of total CK or more than  10 U/L suggests a myocardial infarction.
 Propranolol (Inderal) blocks  sympathetic nerve stimuli that increase cardiac work during exercise or stress, which reduces heart rate, blood pressure, and myocardial oxygen consumption.
 After a myocardial infarction, electrocardiogram changes  (ST-segment elevation, T-wave inversion, and Q-wave enlargement) usually appear in the first 24 hours, but may not appear until the 5th or 6th day.
 Cardiogenic shock is manifested by systolic blood pressure of less than 80 mm Hg, gray skin, diaphoresis, cyanosis, weak pulse rate, tachycardia or bradycardia, and oliguria (less than 30 ml of urine per hour).
 A  patient who is receiving a low-sodium diet shouldn’t eat cottage cheese, fish, canned beans, chuck steak, chocolate pudding, Italian salad dressing, dill pickles, and beef broth.
 High-potassium foods include dried prunes,  watermelon (15.3 mEq/ portion), dried lima beans (14.5 mEq/portion), soybeans, bananas, and oranges.
 Kussmaul’s respirations are faster and deeper  than normal respirations and occur without pauses, as in diabetic ketoacidosis.
 Cheyne-Stokes respirations are characterized by  alternating periods of apnea and deep, rapid breathing. They occur in patients with central nervous system disorders.
 Hyperventilation can result from  an increased frequency of breathing, an increased tidal volume, or both.
 Apnea is the absence of spontaneous  respirations.
 Before a thyroidectomy, a patient may receive  potassium iodide, antithyroid drugs, and propranolol (Inderal) to prevent thyroid storm during surgery.
 The normal life span of red blood cells  (erythrocytes) is 110 to 120 days.
 Visual acuity of 20/100 means that  the patient sees at 20' (6 m) what a person with normal vision sees at 100' (30 m).
 Urinary tract infections are more common in girls and women than in  boys and men because the shorter urethra in the female urinary tract makes the bladder more accessible to bacteria, especially Escherichia coli.
 Penicillin is administered orally 1 to 2 hours before meals or 2 to 3 hours after meals because food may interfere with the drug’s absorption.
 Mild  reactions to local anesthetics may include palpitations, tinnitus, vertigo, apprehension, confusion, and a metallic taste in the mouth.
 About 22%  of cardiac output goes to the kidneys.
 To ensure accurate central  venous pressure readings, the nurse should place the manometer or transducer level with the phlebostatic axis.
 A patient who has lost  2,000 to 2,500 ml of blood will have a pulse rate of 140 beats/minute (or higher), display a systolic blood pressure of 50 to 60 mm Hg, and appear confused and lethargic.
 Arterial blood is bright red, flows rapidly, and (because  it’s pumped directly from the heart) spurts with each heartbeat.
 Venous  blood is dark red and tends to ooze from a wound.
 Orthostatic blood pressure is taken with the patient in the supine, sitting, and standing positions, with 1 minute between each reading. A 10-mm Hg decrease in blood pressure or an increase in pulse rate of 10 beats/ minute suggests volume depletion.
 A pneumatic antishock garment should be used cautiously in  pregnant women and patients with head injuries.
 After a patient’s  circulating volume is restored, the nurse should remove the pneumatic antishock garment gradually, starting with the abdominal chamber and followed by each leg. The garment should be removed under a physician’s supervision.
 Most  hemolytic transfusion reactions associated with mismatching of ABO blood types stem from identification number errors.
 Warming of blood to more than  107° F (41.7° C) can cause hemolysis.
 Cardiac output is the amount of  blood ejected from the heart each minute. It’s expressed in liters per minute.
 Stroke volume is the volume of blood ejected from the heart  during systole.
 Total parenteral nutrition solution contains dextrose,  amino acids, and additives, such as electrolytes, minerals, and vitamins.
 The most common type of neurogenic shock is spinal shock. It  usually occurs 30 to 60 minutes after a spinal cord injury.
 After a  spinal cord injury, peristalsis stops within 24 hours and usually returns within 3 to 4 days.
 Toxic shock syndrome is manifested by a temperature of at  least 102° F (38.8° C), an erythematous rash, and systolic blood pressure of less than 90 mm Hg. From 1 to 2 weeks after the onset of these signs, desquamation (especially on the palms and soles) occurs.  The signs and  symptoms of anaphylaxis are commonly caused by histamine release.
 The  most common cause of septic shock is gram-negative bacteria, such as Escherichia coli, Klebsiella, and Pseudomonas organisms.
 Bruits are vascular sounds  that resemble heart murmurs and result from turbulent blood flow through a diseased or partially obstructed artery.
 Urine pH is normally 4.5 to  8.0.
 Urine pH of greater than 8.0 can result from a urinary tract  infection, a high- alkali diet, or systemic alkalosis.
 Urine pH of less  than 4.5 may be caused by a high-protein diet, fever, or metabolic acidosis.
 Before a percutaneous renal biopsy, the patient should be  placed on a firm surface and positioned on the abdomen. A sandbag is placed under the abdomen to stabilize the kidneys.
 Nephrotic syndrome is  characterized by marked proteinuria, hypoalbuminemia, mild to severe dependent edema, ascites, and weight gain.
 Underwater exercise is a form of  therapy performed in a Hubbard tank.
 Most women with trichomoniasis  have a malodorous, frothy, greenish gray vaginal discharge. Other women may have no signs or symptoms.
 Voiding cystourethrography may be performed to  detect bladder and urethral abnormalities. Contrast medium is instilled by gentle syringe pressure through a urethral catheter, and overhead X-ray films are taken to visualize bladder filling and excretion.
 Cystourethrography may be performed to identify the cause of urinary tract
infections, congenital anomalies, and incontinence. It also is used to assess for prostate lobe hypertrophy in men.
 Herpes simplex is characterized  by recurrent episodes of blisters on the skin and mucous membranes. It has two variations. In type 1, the blisters appear in the nasolabial region; in type 2, they appear on the genitals, anus, buttocks, and thighs.
 Most patients  with Chlamydia trachomatis infection are asymptomatic, but some have an inflamed urethral meatus, dysuria, and urinary urgency and frequency.
 The  hypothalamus regulates the autonomic nervous system and endocrine functions.
 A patient whose chest excursion is less than normal (3" to  6" [7.5 to 15 cm]) must use accessory muscles to breathe.
 Signs and  symptoms of toxicity from thyroid replacement therapy include rapid pulse rate, diaphoresis, irritability, weight loss, dysuria, and sleep disturbance.
 The most common allergic reaction to penicillin is a rash.
 An early  sign of aspirin toxicity is deep, rapid respirations.
 The most serious  and irreversible consequence of lead poisoning is mental retardation, which results from neurologic damage.
 To assess dehydration in the adult, the  nurse should check skin turgor on the sternum.
 For a patient with a  peptic ulcer, the type of diet is less important than including foods in the diet that the patient can tolerate.
 A patient with a colostomy  must establish an irrigation schedule so that regular emptying of the bowel occurs without stomal discharge between irrigations.
 When using  rotating tourniquets, the nurse shouldn’t restrict the blood supply to an arm or leg for more than 45 minutes at a time.
 A patient with diabetes should  eat high-fiber foods because they blunt the rise in glucose level that normally follows a meal.
 Jugular vein distention occurs in patients with heart  failure because the left
ventricle can’t empty the heart of blood as fast as blood enters from the right ventricle, resulting in congestion in the entire venous system.
 The leading causes of blindness in the United States are  diabetes mellitus and glaucoma.
 After a thyroidectomy, the patient  should remain in the semi-Fowler position, with his head neither hyperextended nor hyperflexed, to avoid pressure on the suture line. This position can be achieved with the use of a cervical pillow.
 Premenstrual syndrome may  cause abdominal distention, engorged and painful breasts, backache, headache, nervousness, irritability, restlessness, and tremors.
 Treatment of  dehiscence (pathologic opening of a wound) consists of covering the wound with a moist sterile dressing and notifying the physician.
 When a patient has  a radical mastectomy, the ovaries also may be removed because they are a source of estrogen, which stimulates tumor growth.
 Atropine blocks the effects  of acetylcholine, thereby obstructing its vagal effects on the sinoatrial node and increasing heart rate.
 Salicylates, particularly aspirin, are  the treatment of choice in rheumatoid arthritis because they decrease inflammation and relieve joint pain.
 Deep, intense pain that usually  worsens at night and is unrelated to movement suggests bone pain.
 Pain  that follows prolonged or excessive exercise and subsides with rest suggests muscle pain.
 The major hemodynamic changes associated with cardiogenic  shock are decreased left ventricular function and decreased cardiac output.
 Before thyroidectomy, the patient should be advised that he may  experience hoarseness or loss of his voice for several days after surgery.
 Acceptable adverse effects of long-term steroid use include  weight gain, acne, headaches, fatigue, and increased urine retention.
 Unacceptable adverse effects of long-term steroid use are dizziness on rising, nausea, vomiting, thirst, and pain.
 After a craniotomy, nursing care  includes maintaining normal intracranial pressure, maintaining cerebral perfusion pressure, and preventing injury related
to cerebral and cellular ischemia.
 Folic acid and vitamin B12 are essential for nucleoprotein  synthesis and red blood cell maturation.
 Immediately after intracranial  surgery, nursing care includes not giving the patient anything by mouth until the gag and cough reflexes return, monitoring vital signs and assessing the level of consciousness (LOC) for signs of increasing intracranial pressure, and administering analgesics that don’t mask the LOC.
 Chest  physiotherapy includes postural drainage, chest percussion and vibration, and coughing and deep-breathing exercises.
 Cushing’s syndrome results from  excessive levels of adrenocortical hormones and is manifested by fat pads on the face (moon face) and over the upper back (buffalo hump), acne, mood swings, hirsutism, amenorrhea, and decreased libido.
 To prevent an addisonian  crisis when discontinuing long-term prednisone (Deltasone) therapy, the nurse should taper the dose slowly to allow for monitoring of disease flare-ups and for the return of hypothalamic-pituitary- adrenal function.
 Pulsus  paradoxus is a pulse that becomes weak during inspiration and strong during expiration. It may be a sign of cardiac tamponade.
 Substances that are  expelled through portals of exit include saliva, mucus, feces, urine, vomitus, blood, and vaginal and penile discharges.
 A microorganism may be  transmitted directly, by contact with an infected body or droplets, or indirectly, by contact with contaminated air, soil, water, or fluids.
 A  postmenopausal woman who receives estrogen therapy is at an increased risk for gallbladder disease and breast cancer.
 The approximate oxygen  concentrations delivered by a nasal cannula are as follows: 1 L = 24%, 2 L = 28%, 3 L = 32%, 4 L= 36%, and 5 L = 40%.
 Cardinal features of diabetes  insipidus include polydipsia (excessive thirst) and polyuria (increased urination to 5 L/24 hours).
 A patient with low specific  gravity (1.001 to 1.005) may have an increased desire for cold water.
 Diabetic coma can occur when the blood glucose level drops below 60 mg/dl.
 For a patient with heart failure, the nurse should elevate the  head of the bed 8" to 12" (20 to 30 cm), provide a bedside commode, and administer cardiac glycosides and diuretics as prescribed.
 The primary  reason to treat streptococcal sore throat with antibiotics is to protect the heart valves and prevent rheumatic fever.
 A patient with a nasal  fracture may lose consciousness during reduction.
 Hoarseness and change  in the voice are commonly the first signs of laryngeal cancer.
 The  lungs, colon, and rectum are among the most common cancer sites.
 The  most common preoperative problem in elderly patients is lower-than- normal total blood volume.
 Mannitol (Osmitrol), an osmotic diuretic, is administered  to reduce intraocular or intracranial pressure.
 When a stroke is  suspected, the nurse should place the patient on the affected side to promote lung expansion on the unaffected side.
 For a patient who has had chest  surgery, the nurse should recommend sitting upright and performing coughing and deep-breathing exercises. These actions promote expansion of the lungs, removal of secretions, and optimal pulmonary functioning.
 During every sleep  cycle, the sleeper passes through four stages of nonrapid- eye-movement sleep and one stage of rapid-eye-movement sleep.
 A patient who is taking  calcifediol (Calderol) should avoid concomitant use of preparations that contain vitamin D.
 A patient should begin and end a 24-hour urine collection  period with an empty bladder. For example, if the physician orders urine to be collected from 0800 Thursday to 0800 Friday, the urine voided at 0800 Thursday should be discarded and the urine voided at 0800 Friday should be retained.
 In a patient who is receiving digoxin (Lanoxin), a low  potassium level increases
the risk of digoxin toxicity.
 Blood urea  nitrogen values normally range from 10 to 20 mg/dl.
 Flurazepam  (Dalmane) toxicity is manifested by confusion, hallucinations, and ataxia.
 A silent myocardial infarction is one that has no  symptoms.
 Adverse reactions to verapamil (Isoptin) include dizziness,  headache, constipation, hypotension, and atrioventricular conduction disturbances. The drug also may increase the serum digoxin level.
 When  a rectal tube is used to relieve flatulence or enhance peristalsis, it should be inserted for no longer than 20 minutes.
 Yellowish green discharge on a  wound dressing indicates infection and should be cultured.
 Sickle cell  crisis can cause severe abdominal, thoracic, muscular, and bone pain along with painful swelling of soft tissue in the hands and feet.
 Oral candidiasis  (thrush) is characterized by cream-colored or bluish white patches on the oral mucous membrane.
 Treatment for a patient with cystic  fibrosis may include drug therapy, exercises to improve breathing and posture, exercises to facilitate mobilization of pulmonary secretions, a high-salt diet, and pancreatic enzyme supplements with snacks and meals.
 Pancreatic  cancer may cause weight loss, jaundice, and intermittent dull-to- severe epigastric pain.
 Metastasis is the spread of cancer from one organ or  body part to another through the lymphatic system, circulation system, or cerebrospinal fluid.
 The management of pulmonary edema focuses on  opening the airways, supporting ventilation and perfusion, improving cardiac functioning, reducing preload, and reducing patient anxiety.
 Factors  that contribute to the death of patients with Alzheimer’s disease include infection, malnutrition, and dehydration.
 Hodgkin’s disease is  characterized by painless, progressive enlargement of cervical lymph nodes and other lymphoid tissue as a result of proliferation of Reed-Sternberg cells, histiocytes, and eosinophils.
 Huntington’s disease (chorea) is a  hereditary disease characterized by degeneration in the cerebral cortex and basal ganglia.
 A patient with Huntington’s disease may exhibit suicidal  ideation.
 At discharge, an amputee should be able to demonstrate proper  stump care and perform stump-toughening exercises.
 Acute tubular  necrosis is the most common cause of acute renal failure.
 Common  complications of ice water lavage are vomiting and aspiration.
 Foods  high in vitamin D include fortified milk, fish, liver, liver oil, herring, and egg yolk.
 For a pelvic examination, the patient should be in the  lithotomy position, with the buttocks extending 2½" (6.4 cm) past the end of the examination table.
 If a patient can’t assume the lithotomy position for  a pelvic examination, she may lie on her left side.
 A male examiner  should have a female assistant present during a vaginal examination for the patient’s emotional comfort and the examiner’s legal protection.
 Cervical secretions are clear and stretchy before ovulation and white and opaque after ovulation. They’re normally odorless and don’t irritate the mucosa.
 A patient with an ileostomy shouldn’t eat corn because it may  obstruct the opening of the pouch.
 Liver dysfunction affects the  metabolism of certain drugs.
 Edema that accompanies burns and  malnutrition is caused by decreased osmotic pressure in the capillaries.
 Hyponatremia is most likely to occur as a complication of  nasogastric suctioning.
 In a man who has complete spinal cord  separation at S4, erection and ejaculation aren’t possible.
 The early  signs of pulmonary edema (dyspnea on exertion and coughing) reflect interstitial fluid accumulation and decreased ventilation and alveolar perfusion.
 Methylprednisolone (Solu-Medrol) is a first-line drug used to control edema after spinal cord trauma.
 For the patient who is recovering  from an intracranial bleed, the nurse should maintain a quiet, restful environment for the first few days.
 Neurosyphilis is associated with  widespread damage to the central nervous system, including general paresis, personality changes, slapping gait, and blindness.
 A woman who has had  a spinal cord injury can still become pregnant.
 In a patient who has  had a stroke, the most serious complication is increasing intracranial pressure.
 A patient with an intracranial hemorrhage should undergo  arteriography to identify the site of the bleeding.
 Factors that affect  the action of drugs include absorption, distribution, metabolism, and excretion.
 Before prescribing a drug for a woman of childbearing age,  the prescriber should ask for the date of her last menstrual period and ask if she may be pregnant.
 Acidosis may cause insulin resistance.
 A  patient with glucose-6-phosphate dehydrogenase deficiency may have acute hemolytic anemia when given a sulfonamide.
 The five basic activities of  the digestive system are ingestion, movement of food, digestion, absorption, and defecation.
 Signs and symptoms of acute pancreatitis include epigastric  pain, vomiting, bluish discoloration of the left flank (Grey Turner’s sign), bluish discoloration of the periumbilical area (Cullen’s sign), low-grade fever, tachycardia, and hypotension.
 A patient with a gastric ulcer may have  gnawing or burning epigastric pain.
 To test the first cranial  nerve (olfactory nerve), the nurse should ask the patient to close his eyes, occlude one nostril, and identify a nonirritating substance (such as peppermint or cinnamon) by smell. Then the nurse should repeat the test with the patient’s other nostril occluded.
 Salk and Sabin introduced the oral polio  vaccine.
 A patient with a disease of the cerebellum or posterior column  has an ataxic gait that’s characterized by staggering and inability to remain steady when standing with the feet together.
 In trauma patients,  improved outcome is directly related to early resuscitation, aggressive management of shock, and appropriate definitive care.
 To check for  leakage of cerebrospinal fluid, the nurse should inspect the patient’s nose and ears. If the patient can sit up, the nurse should observe him for leakage as the patient leans forward.
 Locked-in syndrome is complete paralysis as a  result of brain stem damage. Only the eyes can be moved voluntarily.
 Neck dissection, or surgical removal of the cervical lymph nodes, is performed to prevent the spread of malignant tumors of the head and neck.
 A  patient with cholecystitis typically has right epigastric pain that may radiate to the right scapula or shoulder; nausea; and vomiting, especially after eating a heavy meal.
 Atropine is used preoperatively to reduce  secretions.
 Serum calcium levels are normally 4.5 to 5.5  mEq/L.
 Suppressor T cells regulate overall immune  response.
 Serum levels of aspartate aminotransferase and  alanine aminotransferase show whether the liver is adequately detoxifying drugs.
 Serum sodium levels are normally 135 to 145 mEq/L.
 Serum potassium levels are normally 3.5 to 5.0 mEq/L.
 A patient who is  taking prednisone (Deltasone) should consume a salt-
restricted diet that’s rich in potassium and protein.
 When performing continuous ambulatory  peritoneal dialysis, the nurse must use sterile technique when handling the catheter, send a peritoneal fluid sample for culture and sensitivity testing every 24 hours, and report signs of infection and fluid imbalance.
 When  working with patients who have acquired immunodeficiency syndrome, the nurse should wear goggles and a mask only if blood or another body fluid could splash onto the nurse’s face.
 Blood spills that are infected with human  immunodeficiency virus should be cleaned up with a 1:10 solution of sodium hypochlorite 5.25% (household bleach).
 Raynaud’s phenomenon is  intermittent ischemic attacks in the fingers or toes. It causes severe pallor and sometimes paresthesia and pain.
 Intussusception (prolapse of one  bowel segment into the lumen of another) causes sudden epigastric pain, sausage-shaped abdominal swelling, passage of mucus and blood through the rectum, shock, and hypotension.
 Bence Jones protein occurs almost  exclusively in the urine of patients who have multiple myeloma.
 Gaucher’s disease is an autosomal disorder that’s  characterized by abnormal accumulation of glucocerebrosides (lipid substances that contain glucose) in monocytes and macrocytes. It has three forms: Type 1 is the adult form, type 2 is the infantile form, and type 3 is the juvenile form.
 A patient with colon obstruction may have lower abdominal pain,  constipation, increasing distention, and vomiting.
 Colchicine  (Colsalide) relieves inflammation and is used to treat gout.
 Some  people have gout as a result of hyperuricemia because they can’t metabolize and excrete purines normally.
 A normal sperm count is 20 to 150  million/ml.
 A first-degree burn involves the stratum corneum layer of  the epidermis and causes pain and redness.
 Sheehan’s syndrome is  hypopituitarism caused by a pituitary infarct after postpartum shock and hemorrhage.
 When caring for a patient who has had an asthma attack, the  nurse should place the patient in Fowler’s or semi-Fowler’s position.
 In elderly patients, the incidence of noncompliance with prescribed drug therapy is high. Many elderly patients have diminished visual acuity, hearing loss, or forgetfulness, or need to take multiple drugs.
 Tuberculosis is a  reportable communicable disease that’s caused by infection with Mycobacterium tuberculosis (an acid-fast bacillus).
 For right-sided cardiac  catheterization, the physician passes a multilumen catheter through the superior or inferior vena cava.
 After a fracture, bone healing occurs in  these stages: hematoma formation, cellular proliferation and callus formation, and ossification and remodeling.
 A patient who is scheduled for  positron emission tomography should avoid alcohol, tobacco, and caffeine for 24 hours before the test.
 In a stroke, decreased oxygen destroys brain  cells.
 A patient with glaucoma shouldn’t receive atropine sulfate  because it increases intraocular pressure.
 The nurse should instruct a  patient who is hyperventilating to breathe into a paper bag.
 During  intermittent positive-pressure breathing, the patient should bite down on the mouthpiece, breathe normally, and let the machine do the work. After inspiration, the patient should hold his breath for 3 or 4 seconds and exhale completely through the mouthpiece.
 Flexion contractures of the hips may  occur in a patient who sits in a wheelchair for a long time.
 Nystagmus  is rapid horizontal or rotating eye movement.
 After myelography, the  patient should remain recumbent for 24 hours.
 The treatment of sprains  and strains consists of applying ice immediately and elevating the arm or leg above heart level.
 An anticholinesterase agent shouldn’t be prescribed  for a patient who is taking morphine because it can potentiate the effect of morphine and cause respiratory depression.
 Myopia is nearsightedness.  Hyperopia and presbyopia are two types of farsightedness.
 The most  effective contraceptive method is one that the woman selects for herself and uses consistently.
 To perform Weber’s test for bone conduction, a  vibrating tuning fork is placed on top of the patient’s head at midline. The patient should perceive the sound equally in both ears. In a patient who has conductive hearing loss, the sound is heard in (lateralizes to) the ear that has conductive loss.
 In the Rinne test, bone conduction is tested by  placing a vibrating tuning fork on the mastoid process of the temporal bone and air conduction is tested by holding the vibrating tuning fork ½" (1.3 cm) from the external auditory meatus. These tests are alternated, at different frequencies, until the tuning fork is no longer heard at one position.
 After an amputation, the stump may shrink because of muscle atrophy and decreased subcutaneous fat.
 A patient who has deep vein thrombosis is  given heparin for 7 to 10 days, followed by 12 weeks of warfarin (Coumadin) therapy.
 After pneumonectomy, the patient should be positioned on the  operative side or on his back, with his head slightly elevated.
 To  reduce the possibility of formation of new emboli or expansion of existing emboli, a patient with deep vein thrombosis should receive heparin.
 Atherosclerosis is the most common cause of coronary artery disease. It usually involves the aorta and the femoral, coronary, and cerebral arteries.
 Pulmonary embolism is a potentially fatal complication of deep vein thrombosis.
 Chest pain is the most common symptom of pulmonary  embolism.
 The nurse should inform a patient who is taking  phenazopyridine (Pyridium) that this drug colors urine orange or red.
 Pneumothorax is a serious complication of central venous line placement; it’s caused by inadvertent lung puncture.
 Pneumocystis carinii pneumonia  isn’t considered contagious because it only affects patients who have a suppressed immune system.
 To enhance drug absorption, the patient  should take regular erythromycin tablets with a full glass of water 1 hour before or 2 hours after a meal or should take enteric-coated tablets with food. The patient should avoid taking either type of tablet with fruit juice.
 Trismus, a sign of tetanus (lockjaw), causes painful spasms of the masticatory muscles, difficulty opening the mouth, neck rigidity and stiffness, and dysphagia.
 The nurse should place the patient in an upright position  for thoracentesis. If this isn’t possible, the nurse should position the patient on the unaffected side.
 If gravity flow is used, the nurse should hang  a blood bag 3' (1 m) above the level of the planned venipuncture site.
 The nurse should place a patient who has a closed chest drainage system in the semi-Fowler position.
 If blood isn’t transfused within 30 minutes, the  nurse should return it to the blood bank because the refrigeration facilities on a nursing unit are inadequate for storing blood products.
 Blood that’s  discolored and contains gas bubbles is contaminated with bacteria and shouldn’t be transfused. Fifty percent of patients who receive contaminated blood die.
 For massive, rapid blood transfusions and for exchange  transfusions in neonates, blood should be warmed to 98.7° F (37° C).
 A chest tube permits air and fluid to drain from the  pleural space.
 A handheld resuscitation bag is an inflatable device  that can be attached to a face mask or an endotracheal or tracheostomy tube. It allows manual delivery of oxygen to the lungs of a patient who can’t breathe independently.
 Mechanical ventilation artificially controls or assists  respiration.
 The nurse should encourage a patient who has a closed  chest drainage system to cough frequently and breathe deeply to help drain the pleural space and expand the lungs.
 Tracheal suction removes secretions  from the trachea and bronchi with a suction catheter.
 During colostomy  irrigation, the irrigation bag should be hung 18" (45.7 cm) above the stoma.
 The water used for colostomy irrigation should be 100° to 105° F  (37.8° to 40.6° C).
 An arterial embolism may cause pain, loss of  sensory nerves, pallor, coolness, paralysis, pulselessness, or paresthesia in the affected arm or leg.
 Respiratory alkalosis results from conditions  that cause hyperventilation and reduce the carbon dioxide level in the arterial blood.
 Mineral oil is contraindicated in a patient with appendicitis,  acute surgical abdomen, fecal impaction, or intestinal obstruction.
 When using a Y-type administration set to transfuse packed red blood cells (RBCs), the nurse can add normal saline solution to the bag to dilute the RBCs and make them less viscous.
 Autotransfusion is collection,  filtration, and reinfusion of the patient’s own blood.
 Prepared I.V.  solutions fall into three general categories: isotonic, hypotonic, and hypertonic. Isotonic solutions have a solute concentration that’s similar to body fluids; adding them to plasma doesn’t change its osmolarity. Hypotonic solutions have a lower osmotic pressure than body fluids; adding them to plasma decreases its osmolarity. Hypertonic solutions have a higher osmotic pressure than body fluids; adding them to plasma increases its osmolarity.
 Stress incontinence is involuntary leakage of urine triggered by a sudden physical strain, such as a cough, sneeze, or quick movement.
 Decreased  renal function makes an elderly patient more susceptible to the development of renal calculi.
 The nurse should consider using shorter needles to  inject drugs in elderly patients because these patients experience subcutaneous tissue redistribution and loss in areas, such as the buttocks and deltoid muscles.
 Urge incontinence is the inability to suppress a sudden urge  to urinate.
 Total incontinence is continuous, uncontrollable leakage of  urine as a result of the bladder’s inability to retain urine.
 Protein,  vitamin, and mineral needs usually remain constant as a person ages, but caloric requirements decrease.
 Four valves keep blood flowing in one direction  in the heart: two atrioventricular valves (tricuspid and mitral) and two semilunar valves (pulmonic and aortic).
 An elderly patient’s height may  decrease because of narrowing of the intervertebral spaces and exaggerated spinal curvature.
 Constipation most commonly occurs when the  urge to defecate is suppressed and the muscles associated with bowel movements remain contracted.
 Gout develops in four stages: asymptomatic, acute,  intercritical, and chronic.
 Common postoperative complications include  hemorrhage, infection, hypovolemia, septicemia, septic shock, atelectasis, pneumonia, thrombophlebitis, and pulmonary embolism.
 An insulin pump  delivers a continuous infusion of insulin into a selected subcutaneous site, commonly in the abdomen.
 A common symptom of salicylate (aspirin)  toxicity is tinnitus (ringing in the ears).
 A frostbitten extremity  must be thawed rapidly, even if definitive treatment must be delayed.
 A  patient with Raynaud’s disease shouldn’t smoke cigarettes or other tobacco products.
 Raynaud’s disease is a primary arteriospastic disorder that  has no known cause. Raynaud’s phenomenon, however, is caused by another disorder such as scleroderma.
 To remove a foreign body from the eye, the nurse  should irrigate the eye with sterile normal saline solution.
 When  irrigating the eye, the nurse should direct the solution toward the lower conjunctival sac.
 Emergency care for a corneal injury caused by a  caustic substance is flushing the eye with copious amounts of water for 20 to 30 minutes.
 Debridement is mechanical, chemical, or surgical  removal of necrotic tissue from a wound.
 Severe pain after cataract  surgery indicates bleeding in the eye.
 A bivalve cast is cut into  anterior and posterior portions to allow skin inspection.
 After ear  irrigation, the nurse should place the patient on the affected side to permit gravity to drain fluid that remains in the ear.
 If a patient with an  indwelling catheter has abdominal discomfort, the nurse should assess for bladder distention, which may be caused by catheter blockage.
 Continuous bladder irrigation helps prevent urinary tract obstruction by flushing out small blood clots that form after prostate or bladder surgery.
 The nurse should remove an indwelling catheter when bladder  decompression is no longer needed, when the catheter is obstructed, or when the patient can resume voiding. The longer a catheter remains in place, the greater the risk of urinary tract infection.
 In an adult, the extent of a burn  injury is determined by using the Rule of Nines: the head and neck are counted as 9%; each arm, as 9%; each leg, as 18%; the back of the trunk, as 18%; the front of the trunk, as 18%; and the perineum, as 1%.
 A deep  partial-thickness burn affects the epidermis and dermis.
 In a patient  who is having an asthma attack, nursing interventions include administering oxygen and bronchodilators as prescribed, placing the patient in the semi-Fowler position, encouraging diaphragmatic breathing, and helping the patient to relax.
 Prostate cancer is usually fatal if bone metastasis  occurs.
 A strict vegetarian needs vitamin B12 supplements because  animals and animal products are the only source of this vitamin.
 Regular insulin is the only type of insulin that can be mixed with other types of insulin and can be given I.V.
 If a patient pulls out the outer  tracheostomy tube, the nurse should hold the tracheostomy open with a surgical dilator until the physician provides appropriate care.
 The medulla  oblongata is the part of the brain that controls the respiratory center.
 For an unconscious patient, the nurse should perform passive  range-of-motion exercises every 2 to 4 hours.
 A timed-release drug  isn’t recommended for use in a patient who has an ileostomy because it releases the drug at different rates along the GI tract.
 The nurse isn’t  required to wear gloves when applying nitroglycerin paste; however, she should wash her hands after applying this drug.
 Before excretory urography, a  patient’s fluid intake is usually restricted after midnight.
 A sodium  polystyrene sulfonate (Kayexalate) enema, which exchanges sodium ions for potassium ions, is used to decrease the potassium level in a patient who has hyperkalemia.
 If the color of a stoma is much lighter than when  previously assessed, decreased circulation to the stoma should be suspected.
 Massage is contraindicated in a leg with a blood  clot because it may dislodge the clot.
 The first place a nurse can  detect jaundice in an adult is in the sclera.
 Jaundice is caused by  excessive levels of conjugated or unconjugated bilirubin in the blood.
 Mydriatic drugs are used primarily to dilate the pupils for intraocular examinations.
 After eye surgery, the patient should be placed on the  unaffected side.
 When assigning tasks to a licensed practical nurse,  the registered nurse should delegate tasks that are considered bedside nursing care, such as taking vital
signs, changing simple dressings, and giving baths.
 Deep calf pain on dorsiflexion of the foot is a positive Homans’  sign, which suggests venous thrombosis or thrombophlebitis.
 Ultra-short-acting barbiturates, such as thiopental (Pentothal), are used as injection anesthetics when a short duration of anesthesia is needed such as outpatient surgery.
 Atropine sulfate may be used as a preanesthetic  drug to reduce secretions and minimize vagal reflexes.
 For a patient  with infectious mononucleosis, the nursing care plan should emphasize strict bed rest during the acute febrile stage to ensure adequate rest.
 During the  acute phase of infectious mononucleosis, the patient should curtail activities to minimize the possibility of rupturing the enlarged spleen.
 Daily  application of a long-acting, transdermal nitroglycerin patch is a convenient, effective way to prevent chronic angina.
 The nurse must wear a cap,  gloves, a gown, and a mask when providing wound care to a patient with third-degree burns.
 The nurse should expect to administer an analgesic  before bathing a burn patient.
 The passage of black, tarry feces  (melena) is a common sign of lower GI bleeding, but also may occur in patients who have upper GI bleeding.
 A patient who has a gastric ulcer should  avoid taking aspirin and aspirin- containing products because they can irritate the gastric mucosa.
 While administering chemotherapy agents with an  I.V. line, the nurse should discontinue the infusion at the first sign of extravasation.
 A low-fiber diet may contribute to the development of  hemorrhoids.
 A patient who has abdominal pain shouldn’t receive an  analgesic until the cause of the pain is determined.
 If surgery  requires hair removal, the recommendation of the Centers for Disease Control and Prevention is that a depilatory be used to avoid skin abrasions and cuts.
 For nasotracheal suctioning, the nurse should set wall suction at  50 to 95 mm
Hg for an infant, 95 to 115 mm Hg for a child, or 80 to 120 mm Hg for an adult.
 After a myocardial infarction, a change in pulse rate and  rhythm may signal the onset of fatal arrhythmias.
 Treatment of  epistaxis includes nasal packing, ice packs, cautery with silver nitrate, and pressure on the nares.
 Palliative treatment relieves or reduces the  intensity of uncomfortable symptoms, but doesn’t cure the causative disorder.
 Placing a postoperative patient in an upright  position too quickly may cause hypotension.
 Verapamil (Calan) and  diltiazem (Cardizem) slow the inflow of calcium to the heart, thereby decreasing the risk of supraventricular tachycardia.
 After cardiopulmonary bypass  graft, the patient will perform turning, coughing, deep breathing, and wound splinting, and will use assistive breathing devices.
 A patient who is  exposed to hepatitis B should receive 0.06 ml/kg I.M. of immune globulin within 72 hours after exposure and a repeat dose at 28 days after exposure.
 The nurse should advise a patient who is undergoing radiation therapy not to remove the markings on the skin made by the radiation therapist because they are landmarks for treatment.
 The most common symptom of osteoarthritis is  joint pain that’s relieved by rest, especially if the pain occurs after exercise or weight bearing.
 In adults, urine volume normally ranges from 800 to  2,000 ml/day and averages between 1,200 and 1,500 ml/day.
 Directly  applied moist heat softens crusts and exudates, penetrates deeper than dry heat, doesn’t dry the skin, and is usually more comfortable for the patient.
 Tetracyclines are seldom considered drugs of choice for most common bacterial infections because their overuse has led to the emergence of tetracycline- resistant bacteria.
 Because light degrades nitroprusside  (Nitropress), the drug must be shielded from light. For example, an I.V. bag that contains nitroprusside sodium should be wrapped in foil.
 Cephalosporins should be used cautiously in patients who are allergic to penicillin. These patients are more susceptible to hypersensitivity reactions.
 If chloramphenicol and penicillin must be administered  concomitantly, the nurse should give the penicillin 1 or more hours before the chloramphenicol to avoid a reduction in penicillin’s bactericidal activity.
 The erythrocyte sedimentation rate measures the distance and  speed at which erythrocytes in whole blood fall in a vertical tube in 1 hour. The rate at which they fall to the bottom of the tube corresponds to the degree of inflammation.
 When teaching a patient with myasthenia gravis about  pyridostigmine (Mestinon) therapy, the nurse should stress the importance of taking the drug exactly as prescribed, on time, and in evenly spaced doses to prevent a relapse and maximize the effect of the drug.
 If an antibiotic  must be administered into a peripheral heparin lock, the nurse should flush the site with normal saline solution after the infusion to maintain I.V. patency.
 The nurse should instruct a patient with angina to take a  nitroglycerin tablet before anticipated stress or exercise or, if the angina is nocturnal, at bedtime.
 Arterial blood gas analysis evaluates gas  exchange in the lungs (alveolar ventilation) by measuring the partial pressures of oxygen and carbon dioxide and the pH of an arterial sample.
 The  normal serum magnesium level ranges from 1.5 to 2.5 mEq/L.
 Patient  preparation for a total cholesterol test includes an overnight fast and abstinence from alcohol for 24 hours before the test.
 The  fasting plasma glucose test measures glucose levels after a 12- to 14-hour fast.
 Normal blood pH ranges from 7.35 to 7.45. A blood pH higher than  7.45 indicates alkalemia; one lower than 7.35 indicates acidemia.
 During an acid perfusion test, a small amount of weak hydrochloric acid
solution is infused with a nasoesophageal tube. A positive test result (pain after infusion) suggests reflux esophagitis.
 Normally, the partial pressure  of arterial carbon dioxide (PaCO2) ranges from 35 to 45 mm Hg. A PaCO2 greater than 45 mm Hg indicates acidemia as a result of hypoventilation; one less than 35 mm Hg indicates alkalemia as a result of hyperventilation.
 Red cell  indices aid in the diagnosis and classification of anemia.
 Normally,  the partial pressure of arterial oxygen (Pao 2) ranges from 80 to 100 mm Hg. A Pao 2 of 50 to 80 mm Hg indicates respiratory insufficiency. A Pao 2 of less than 50 mm Hg indicates respiratory failure.
 The white blood cell (WBC)  differential evaluates WBC distribution and morphology and provides more specific information about a patient’s immune system than the WBC count.
 An exercise stress test (treadmill test, exercise  electrocardiogram) continues until the patient reaches a predetermined target heart rate or experiences chest pain, fatigue, or other signs of exercise intolerance.
 Alterable risk factors for coronary artery disease include  cigarette smoking, hypertension, high cholesterol or triglyceride levels, and diabetes.
 The mediastinum is the space between the lungs that  contains the heart, esophagus, trachea, and other structures.
 Major  complications of acute myocardial infarction include arrhythmias, acute heart failure, cardiogenic shock, thromboembolism, and left ventricular rupture.
 The sinoatrial node is a cluster of hundreds of cells located  in the right atrial wall, near the opening of the superior vena cava.
 For one-person cardiopulmonary resuscitation, the ratio of compressions to ventilations is 15:2.
 For two-person cardiopulmonary resuscitation, the  ratio of compressions to ventilations is 5:1.
 A patient who has  pulseless ventricular tachycardia is a candidate for cardioversion.
 Echocardiography, a noninvasive test that directs ultra-high-frequency sound
waves through the chest wall and into the heart, evaluates cardiac structure and function and can show valve deformities, tumors, septal defects, pericardial effusion, and hypertrophic cardiomyopathy.
 Ataxia is impaired ability  to coordinate movements. It’s caused by a cerebellar or spinal cord lesion.
 On an electrocardiogram strip, each small block on the  horizontal axis represents 0.04 second. Each large block (composed of five small blocks) represents 0.2 second.
 Starling’s law states that the force of  contraction of each heartbeat depends on the length of the muscle fibers of the heart wall.
 The therapeutic blood level for digoxin is 0.5 to 2.5  ng/ml.
 Pancrelipase (Pancrease) is used to treat cystic fibrosis and  chronic pancreatitis.
 Treatment for mild to moderate varicose veins  includes antiembolism stockings and an exercise program that includes walking to minimize venous pooling.
 An intoxicated patient isn’t considered  competent to refuse required medical treatment and shouldn’t be allowed to check out of a hospital against medical advice.
 The primary difference  between the pain of angina and that of a myocardial infarction is its duration.
 Gynecomastia is excessive mammary gland development and  increased breast size in boys and men.
 Classic symptoms of Graves’  disease are an enlarged thyroid, nervousness, heat intolerance, weight loss despite increased appetite, sweating, diarrhea, tremor, and palpitations.
 Generalized malaise is a common symptom of viral and  bacterial infections and depressive disorders.
 Vitamin C and protein  are the most important nutrients for wound healing.
 A patient who has  portal hypertension should receive vitamin K to promote active thrombin formation by the liver. Thrombin reduces the risk of bleeding.
 The  nurse should administer a sedative cautiously to a patient with cirrhosis
because the damaged liver can’t metabolize drugs effectively.
 Beta-hemolytic streptococcal infections should be treated aggressively to prevent glomerulonephritis, rheumatic fever, and other complications.
 The most common nosocomial infection is a urinary tract infection.
 The nurse should implement strict isolation precautions to protect a patient with a third-degree burn that’s infected by Staphylococcus aureus.
 A  patient who is undergoing external radiation therapy shouldn’t apply cream or lotion to the treatment site.
 The most common vascular complication of  diabetes mellitus is atherosclerosis.
 Insulin deficiency may cause  hyperglycemia.
 Signs of Parkinson’s disease include drooling, a  masklike expression, and a propulsive gait.
 I.V. cholangiography is  contraindicated in a patient with hyperthyroidism, severe renal or hepatic damage, tuberculosis, or iodine hypersensitivity.
 Mirrors should be  removed from the room of a patient who has disfiguring wounds such as facial burns.
 A patient who has gouty arthritis should increase fluid intake  to prevent calculi formation.
 Anxiety is the most common cause of chest  pain.
 A patient who is following a low-salt diet should avoid canned  vegetables.
 Bananas are a good source of potassium and should be  included in a low-salt diet for patients who are taking a loop diuretic such as furosemide (Lasix).
 The nurse should encourage a patient who is at risk  for pneumonia to turn frequently, cough, and breathe deeply. These actions mobilize pulmonary secretions, promote alveolar gas exchange, and help prevent atelectasis.
 The nurse should notify the physician whenever a patient’s  blood pressure reaches 180/100 mm Hg.
 Buck’s traction is used to  immobilize and reduce spasms in a fractured hip.
 For a patient with a  fractured hip, the nurse should assess neurocirculatory status every 2 hours.
 When caring for a patient with a fractured hip, the nurse should  use pillows or a trochanter roll to maintain abduction.
 Orthopnea is a  symptom of left-sided heart failure.
 Although a fiberglass cast is more  durable and dries more quickly than a plaster cast, it typically causes skin irritation.
 In an immobilized patient, the major circulatory  complication is pulmonary embolism.
 To relieve edema in a fractured  limb, the patient should keep the limb elevated.
 I.V. antibiotics are  the treatment of choice for a patient with osteomyelitis.
 Blue dye in  cimetidine (Tagamet) can cause a false-positive result on a fecal occult blood test such as a Hemoccult test.
 The nurse should suspect elder abuse if  wounds are inconsistent with the patient’s history, multiple wounds are present, or wounds are in different stages of healing.
 Immediately after  amputation, patient care includes monitoring drainage from the stump, positioning the affected limb, assisting with exercises prescribed by a physical therapist, and wrapping and conditioning the stump.
 A patient who is  prone to constipation should increase his bulk intake by eating whole-grain cereals and fresh fruits and vegetables.
 In the  pelvic examination of a sexual assault victim, the speculum should be lubricated with water. Commercial lubricants retard sperm motility and interfere with specimen collection and analysis.
 For a terminally ill patient,  physical comfort is the top priority in nursing care.
 Dorsiflexion of  the foot provides immediate relief of leg cramps.
 After cardiac  surgery, the patient should limit daily sodium intake to 2 g and
daily cholesterol intake to 300 mg.
 Bleeding after intercourse is an early  sign of cervical cancer.
 Oral antidiabetic agents, such as  chlorpropamide (Diabinese) and tolbutamide (Orinase), stimulate insulin release from beta cells in the islets of Langerhans of the pancreas.
 When  visiting a patient who has a radiation implant, family members and friends must limit their stay to 10 minutes. Visitors and nurses who are pregnant are restricted from entering the room.
 Common causes of vaginal infection  include using an antibiotic, an oral contraceptive, or a corticosteroid; wearing tight-fitting panty hose; and having sexual intercourse with an infected partner.
 A patient with a radiation implant should remain in isolation  until the implant is removed. To minimize radiation exposure, which increases with time, the nurse should carefully plan the time spent with the patient.
 Among cultural groups, Native Americans have the lowest  incidence of cancer.
 The kidneys filter blood, selectively reabsorb  substances that are needed to maintain the constancy of body fluid, and excrete metabolic wastes.
 To prevent straining during defecation, docusate  (Colace) is the laxative of choice for patients who are recovering from a myocardial infarction, rectal or cardiac surgery, or postpartum constipation.
 After prostate surgery, a patient’s primary sources of  pain are bladder spasms and irritation in the area around the catheter.
 Toxoplasmosis is more likely to affect a pregnant cat owner than other pregnant women because cat feces in the litter box harbor the infecting organism.
 Good food sources of folic acid include green leafy  vegetables, liver, and legumes.
 The Glasgow Coma Scale evaluates  verbal, eye, and motor responses to determine the patient’s level of consciousness.
 The nurse should place an unconscious patient in low  Fowler’s position for intermittent nasogastric tube feedings.
 Laënnec’s  (alcoholic) cirrhosis is the most common type of cirrhosis.
 In  decorticate posturing, the patient’s arms are adducted and flexed, with the wrists and fingers flexed on the chest. The legs are extended stiffly and rotated internally, with plantar flexion of the feet.
 Candidates for  surgery should receive nothing by mouth from midnight of the day before surgery unless cleared by a physician.
 Meperidine (Demerol) is an effective  analgesic to relieve the pain of nephrolithiasis (urinary calculi).
 An  injured patient with thrombocytopenia is at risk for life-threatening internal and external hemorrhage.
 The Trendelenburg test is used to check for  unilateral hip dislocation.
 As soon as possible after death, the  patient should be placed in the supine position, with the arms at the sides and the head on a pillow.
 Vascular resistance depends on blood viscosity,  vessel length and, most important, inside vessel diameter.
 A  below-the-knee amputation leaves the knee intact for prosthesis application and allows a more normal gait than above-the-knee amputation.
 Cerebrospinal  fluid flows through and protects the four ventricles of the brain, the subarachnoid space, and the spinal canal.
 Sodium regulates  extracellular osmolality.
 The heart and brain can maintain blood  circulation in the early stages of shock.
 After limb amputation,  narcotic analgesics may not relieve “phantom limb” pain.
 A patient who  receives multiple blood transfusions is at risk for hypocalcemia.
 Syphilis initially causes painless chancres (small, fluid-filled lesions) on the genitals and sometimes on other parts of the body.
 Exposure to a  radioactive source is controlled by time (limiting time spent with the patient), distance (from the patient), and shield (a lead apron).
 Jaundice is a  sign of dysfunction, not a disease.
 Severe jaundice can cause brain  stem dysfunction if the unconjugated bilirubin level in blood is elevated to 20 to 25 mg/dl.
 The patient should take cimetidine (Tagamet) with meals to  help ensure a consistent therapeutic effect.
 When caring for a patient  with jaundice, the nurse should relieve pruritus by providing a soothing lotion or a baking soda bath and should prevent injury by keeping the patient’s fingernails short.  Type B hepatitis, which is usually transmitted  parenterally, also can be spread through contact with human secretions and feces.
 Insulin is a naturally occurring hormone that’s secreted by the  beta cells of the islets of Langerhans in the pancreas in response to a rise in the blood glucose level.
 Diabetes mellitus is a chronic endocrine  disorder that’s characterized by insulin deficiency or resistance to insulin by body tissues.
 A diagnosis of diabetes mellitus is based on the classic  symptoms (polyuria, polyphagia, weight loss, and polydipsia) and a random blood glucose level of more than 200 mg/dl or a fasting plasma glucose level of more than 140 mg/dl when tested on two separate occasions.
 A patient with  non–insulin-dependent (type 2) diabetes mellitus produces some insulin and normally doesn’t need exogenous insulin supplementation. Most patients with this type of diabetes respond well to oral antidiabetic agents, which stimulate the pancreas to increase the synthesis and release of insulin.
 A patient  with insulin-dependent (type 1) diabetes mellitus can’t produce endogenous insulin and requires exogenous insulin administration to meet the body’s needs.
 Rapid-acting insulins are clear; intermediate- and long-acting  insulins are turbid (cloudy).
 Rapid-acting insulins begin to act in 30  to 60 minutes, reach a peak concentration in 2 to 10 hours, and have a duration of action of 5 to 16 hours.
 The best times to test a diabetic patient’s  glucose level are before each meal and at bedtime.
 Intermediate-acting insulins begin to act in 1 to 2 hours, reach a peak concentration in 4 to 15 hours, and have a duration of action of 22 to 28 hours.
 Long-acting insulins begin to act in 4 to 8 hours, reach a peak  concentration in 10 to 30 hours, and have a duration of action of 36 hours or more.
 If the results of a nonfasting glucose test show above-normal  glucose levels after glucose administration, but the patient has normal plasma glucose levels otherwise, the patient has impaired glucose tolerance.
 Insulin requirements are increased by growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some drugs.
 Insulin requirements are decreased by hypothyroidism, decreased  food intake, exercise, and some drugs.
 Hypoglycemia occurs when the  blood glucose level is less than 50 mg/dl.
 An insulin-resistant patient  is one who requires more than 200 units of insulin daily.
 Hypoglycemia  may occur 1 to 3 hours after the administration of a rapid-acting insulin, 4 to 18 hours after the administration of an intermediate-acting insulin, and 18 to 30 hours after the administration of a long-acting insulin.
 When the  blood glucose level decreases rapidly, the patient may experience sweating, tremors, pallor, tachycardia, and palpitations.
 Objective signs of  hypoglycemia include slurred speech, lack of coordination, staggered gait, seizures, and possibly, coma.
 A conscious patient who has  hypoglycemia should receive sugar in an easily digested form, such as orange juice, candy, or lump sugar.
 An unconscious patient who has  hypoglycemia should receive an S.C. or I.M. injection of glucagon as prescribed by a physician or 50% dextrose by I.V. injection.
 A patient with  diabetes mellitus should inspect his feet daily for calluses, corns, and blisters. He should also use warm water to wash his feet and trim his toenails straight across to prevent ingrown toenails.
 The early stage of  ketoacidosis causes polyuria, polydipsia, anorexia, muscle cramps, and vomiting. The late stage causes Kussmaul’s respirations, sweet breath odor, and stupor or coma.
 An allergen is a substance that can cause a hypersensitivity  reaction.
 A corrective lens for nearsightedness is concave.
 Chronic untreated hypothyroidism or abrupt withdrawal of thyroid medication may lead to myxedema coma.
 Signs and symptoms of myxedema coma are  lethargy, stupor, decreased level of consciousness, dry skin and hair, delayed deep tendon reflexes, progressive respiratory center depression and cerebral hypoxia, weight gain, hypothermia, and hypoglycemia.
 Nearsightedness  occurs when the focal point of a ray of light from an object that’s 20' (6 m) away falls in front of the retina.
 Farsightedness occurs when the focal  point of a ray of light from an object that’s 20' away falls behind the retina.
 A corrective lens for farsightedness is convex.
 Refraction is clinical measurement of the error in eye focusing.
 Adhesions are bands of granulation and scar tissue that develop in some patients after a surgical incision.
 The nurse should moisten an eye patch for an  unconscious patient because a dry patch may irritate the cornea.
 A  patient who has had eye surgery shouldn’t bend over, comb his hair vigorously, or engage in activity that increases intraocular pressure.
 When caring  for a patient who has a penetrating eye injury, the nurse should patch both eyes loosely with sterile gauze, administer an oral antibiotic (in high doses) and tetanus injection as prescribed, and refer the patient to an ophthalmologist for follow-up.
 Signs and symptoms of colorectal cancer include changes in  bowel habits, rectal bleeding, abdominal pain, anorexia, weight loss, malaise, anemia, and constipation or diarrhea.
 When climbing stairs with  crutches, the patient should lead with the uninvolved leg and follow with the crutches and involved leg.
 When descending stairs with crutches, the  patient should lead with the crutches and the involved leg and follow with the uninvolved leg.
 When surgery requires eyelash trimming, the nurse  should apply petroleum jelly to the scissor blades so that the eyelashes will adhere to them.
 Pain after a corneal transplant may indicate that the  dressing has been applied too tightly, the graft has slipped, or the eye is hemorrhaging.
 A patient with retinal detachment may report  floating spots, flashes of light, and a sensation of a veil or curtain coming down.
 Immediate postoperative care for a patient with retinal  detachment includes maintaining the eye patch and shield in place over the affected area and observing the area for drainage; maintaining the patient in the position specified by the ophthalmologist (usually, lying on his abdomen, with his head parallel to the floor and turned to the side); avoiding bumping the patient’s head or bed; and encouraging deep breathing, but not coughing.
 A patient with a cataract may have vision disturbances, such  as image distortion, light glaring, and gradual loss of vision.
 When  talking to a hearing-impaired patient who can lip-read, the nurse should face the patient, speak slowly and enunciate clearly, point to objects as needed, and avoid chewing gum.
 Clinical manifestations of venous stasis ulcer  include hemosiderin deposits (visible in fair-skinned individuals); dry, cracked skin; and infection.
 The fluorescent treponemal antibody absorption  test is a specific serologic test for syphilis.
 To reduce fever, the  nurse may give the patient a sponge bath with tepid water (80° to 93° F [26.7° to 33.9° C]).
 When communicating with a patient who has had a stroke,  the nurse should allow ample time for the patient to speak and respond, face the patient’s unaffected side, avoid talking quickly, give visual clues, supplement speech with gestures, and give instructions consistently.
 The major  complication of Bell’s palsy is keratitis (corneal inflammation), which results from incomplete eye closure on the affected side.
 Immunosuppressants are used to combat tissue rejection and help control autoimmune disorders.
 After a unilateral stroke, a patient may be able  to propel a wheelchair by using a heel-to-toe movement with the unaffected leg and turning the wheel with the unaffected hand.
 First-morning urine is  the most concentrated and most likely to show abnormalities. It should be refrigerated to retard bacterial growth or, for microscopic examination, should be sent to the laboratory immediately.
 A patient who is recovering from  a stroke should align his arms and legs correctly, wear high-top sneakers to prevent footdrop and contracture, and use an egg crate, flotation, or pulsating mattress to help prevent pressure ulcers.
 After a fracture of the arm  or leg, the bone may show complete union (normal healing), delayed union (healing that takes longer than expected), or nonunion (failure to heal).
 The most common complication of a hip fracture is  thromboembolism, which may occlude an artery and cause the area it supplies to become cold and cyanotic.
 Chloral hydrate suppositories should be  refrigerated.
 Cast application usually requires two persons; it  shouldn’t be attempted alone.
 A plaster cast reaches maximum strength  in 48 hours; a synthetic cast, within 30 minutes because it doesn’t require drying.
 Severe pain indicates the development of a pressure ulcer  within a cast; the pain decreases significantly after the ulcer develops.
 Indications of circulatory interference are abnormal skin  coolness, cyanosis, and rubor or pallor.
 During the postoperative  phase, increasing pulse rate and decreasing blood pressure may indicate hemorrhage and impending shock.
 Orthopedic surgical wounds bleed more  than other surgical wounds. The nurse can expect 200 to 500 ml of drainage during the first 24 hours and less than 30 ml each 8 hours for the next 48 hours.
 A patient who has had hip surgery shouldn’t adduct or flex the  affected hip because flexion greater than 90 degrees may cause dislocation.
 The Hoyer lift, a hydraulic device, allows two persons to  lift and move a nonambulatory patient safely.
 A patient with carpal  tunnel syndrome, a complex of symptoms caused by compression of the median nerve in the carpal tunnel, usually has weakness, pain, burning, numbness, or tingling in one or both hands.
 The nurse should instruct a patient who has had  heatstroke to wear light- colored, loose-fitting clothing when exposed to the sun; rest frequently; and drink plenty of fluids.
 A conscious patient  with heat exhaustion or heatstroke should receive a solution of ½ teaspoon of salt in 120 ml of water every 15 minutes for 1 hour.
 An I.V. line  inserted during an emergency or outside the hospital setting should be changed within 24 hours.
 After a tepid bath, the nurse should dry the patient  thoroughly to prevent chills.
 The nurse should take the patient’s  temperature 30 minutes after completing a tepid bath.
 Shower or bath  water shouldn’t exceed 105° F (40.6° C).
 Dilatation and curettage is  widening of the cervical canal with a dilator and scraping of the uterus with a curette.
 When not in use, all central venous catheters must be capped  with adaptors after flushing.
 Care after dilatation and curettage  consists of bed rest for 1 day, mild analgesics for pain, and use of a sterile pad for as long as bleeding persists.
 If a patient feels faint during a  bath or shower, the nurse should turn off the water, cover the patient, lower the patient’s head, and summon help.
 A patient who is taking oral  contraceptives shouldn’t smoke because smoking can intensify the drug’s adverse cardiovascular effect.
 The use of soft restraints requires a  physician’s order and assessment and documentation of the patient and affected limbs, according to facility policy.
 A vest restraint should be used  cautiously in a patient with heart failure or a respiratory disorder. The restraint can tighten with movement, further limiting respiratory function. To ensure patient safety, the least amount of restraint should be used.
 If a piggyback system becomes dislodged, the nurse should  replace the entire piggyback system with the appropriate solution and drug, as prescribed.
 The nurse shouldn’t secure a restraint to a bed’s side  rails because they might be lowered inadvertently and cause patient injury or discomfort.
 The nurse should assess a patient who has limb restraints  every 30 minutes to detect signs of impaired circulation.
 The Centers for Disease Control and Prevention recommends using a needleless system for piggybacking an I.V. drug into the main I.V. line.
 If a gown  is required, the nurse should put it on when she enters the patient’s room and discard it when she leaves.
 When changing the dressing of a patient who  is in isolation, the nurse should wear two pairs of gloves.
 A  disposable bedpan and urinal should remain in the room of a patient who is in isolation and be discarded on discharge or at the end of the isolation period.
 Mycoses (fungal infections) may be systemic or deep (affecting  the internal organs), subcutaneous (involving the skin), or superficial (growing on the outer layer of skin and hair).
 The night before a sputum  specimen is to be collected by expectoration, the patient should increase fluid intake to promote sputum production.
 A sample of feces for an ova and  parasite study should be collected directly into a waterproof container, covered with a lid, and sent to the laboratory immediately. If the patient is bedridden, the sample can be collected into a clean, dry bedpan and then transferred with a tongue depressor into a container.
 When obtaining a sputum specimen for  testing, the nurse should instruct the patient to rinse his mouth with clean water, cough deeply from his chest, and expectorate into a sterile container.
 Tonometry allows indirect measurement of intraocular  pressure and aids in early detection of glaucoma.
 Pulmonary function  tests (a series of measurements that evaluate ventilatory function through spirometric measurements) help to diagnose pulmonary dysfunction.
 After  a liver biopsy, the patient should lie on the right side to compress the biopsy site and decrease the possibility of bleeding.
 A patient who has  cirrhosis should follow a diet that restricts sodium, but provides protein and vitamins (especially B, C, and K, and folate).
 If 12 hours of gastric  suction don’t relieve bowel obstruction, surgery is indicated.
 The  nurse can puncture a nifedipine (Procardia) capsule with a needle, withdraw its liquid, and instill it into the buccal pouch.
 When administering whole  blood or packed red blood cells (RBCs), the nurse should use a 16 to 20G needle or cannula to avoid RBC hemolysis.
 Hirsutism is excessive body hair in  a masculine distribution.
 One unit of whole blood or packed red blood  cells is administered over 2 to 4 hours.
 Scurvy is associated with  vitamin C deficiency.
 A vitamin is an organic compound that usually  can’t be synthesized by the body and is needed in metabolic processes.
 Pulmonary embolism can be caused when thromboembolism of fat, blood, bone marrow, or amniotic fluid obstructs the pulmonary artery.
 After  maxillofacial surgery, a patient whose mandible and maxilla have been wired together should keep a pair of scissors or wire cutters readily available so that he can cut the wires and prevent aspiration if vomiting occurs.
 Rapid instillation of fluid during colonic irrigation can cause abdominal cramping.
 A collaborative relationship between health care  workers helps shorten the hospital stay and increases patient satisfaction.
 For elderly patients in a health care facility,  predictable hazards include nighttime confusion (sundowning), fractures from falling, immobility-induced pressure ulcers, prolonged convalescence, and loss of home and support systems.
 Respiratory tract infections, especially  viral infections, can trigger asthma
attacks.
 Oxygen therapy is used in  severe asthma attacks to prevent or treat hypoxemia.
 During an asthma  attack, the patient may prefer nasal prongs to a Venturi mask because of the mask’s smothering effect.
 Chronic obstructive pulmonary disease usually  develops over a period of years. In 95% of patients, it results from smoking.
 An early sign of chronic obstructive pulmonary disease (COPD)  is slowing of forced expiration. A healthy person can empty the lungs in less than 4 seconds; a patient with COPD may take 6 to 10 seconds.
 Chronic  obstructive pulmonary disease eventually leads to structural changes in the lungs, including overdistended alveoli and hyperinflated lungs.
 Cellulitis causes localized heat, redness, swelling and, occasionally, fever, chills, and malaise.
 Venous stasis may precipitate  thrombophlebitis.
 Treatment of thrombophlebitis includes leg elevation,  heat application, and possibly, anticoagulant therapy.
 A suctioning  machine should remain at the bedside of a patient who has had maxillofacial surgery.
 For a bedridden patient with heart failure, the nurse  should check for edema in the sacral area.
 In passive range-of-motion  exercises, the therapist moves the patient’s joints through as full a range of motion as possible to improve or maintain joint mobility and help prevent contractures.
 In resistance exercises, which allow muscle length to  change, the patient performs exercises against resistance applied by the therapist.
 In isometric exercises, the patient contracts muscles  against stable resistance, but without joint movement. Muscle length remains the same, but strength and tone may increase.
 Impetigo is a contagious,  superficial, vesicopustular skin infection. Predisposing factors include poor hygiene, anemia, malnutrition, and a warm climate.
 After  cardiopulmonary resuscitation (CPR) begins, it shouldn’t be interrupted, except when the administrator is alone and must summon help. In this case, the administrator should perform CPR for 1 minute before calling for help.
 The tongue is the most common airway obstruction in an unconscious patient.
 For adult cardiopulmonary resuscitation, the chest compression  rate is 80 to 100 times per minute.
 A patient with ulcers should avoid  bedtime snacks because food may stimulate nocturnal secretions.
 In  angioplasty, a blood vessel is dilated with a balloon catheter that’s inserted through the skin and the vessel’s lumen to the narrowed area. Once in place, the balloon is inflated to flatten plaque against the vessel wall.
 A full liquid diet supplies nutrients, fluids, and  calories in simple, easily digested foods, such as apple juice, cream of wheat, milk, coffee, strained cream soup, high-protein gelatin, cranberry juice, custard, and ice cream. It’s prescribed for patients who can’t tolerate a regular diet.
 A pureed diet meets the patient’s nutritional needs  without including foods that are difficult to chew or swallow. Food is blended to a semisolid consistency.
 A soft, or light, diet is specifically  designed for patients who have difficulty chewing or tolerating a regular diet. It’s nutritionally adequate and consists of foods such as orange juice, cream of wheat, scrambled eggs, enriched toast, cream of chicken soup, wheat bread, fruit cocktail, and mushroom soup.
 A regular diet is provided for patients  who don’t require dietary modification.
 A bland diet restricts foods  that cause gastric irritation or produce acid secretion without providing a neutralizing effect.
 A clear liquid diet provides fluid and a gradual  return to a regular diet. This type of diet is deficient in all nutrients and should be followed for only a short period.
 Patients with a gastric  ulcer should avoid alcohol, caffeinated beverages, aspirin, and spicy foods.
 In active assistance exercises, the patient performs exercises  with the therapist’s help.
 Penicillinase is an enzyme produced by  certain bacteria. It converts penicillin into an inactive product, increasing the bacteria’s resistance to the antibiotic.
 Battle’s sign is a bluish  discoloration behind the ear in some patients who sustain a basilar skull fracture.
 Crackles are nonmusical clicking or rattling noises  that are heard during auscultation of abnormal breath sounds. They are caused by air passing through fluid-filled airways.
 Antibiotics aren’t effective  against viruses, protozoa, or parasites.
 Most penicillins and  cephalosporins produce their antibiotic effects by cell wall inhibition.
 When assessing a patient with an inguinal hernia, the nurse  should suspect strangulation if the patient reports severe pain, nausea, and vomiting.
 Phimosis is tightness of the prepuce of the penis that  prevents retraction of the foreskin over the glans.
 Aminoglycosides are  natural antibiotics that are effective against gram-negative bacteria. They must be used with caution because they can cause nephrotoxicity and ototoxicity.
 On scrotal examination, varicoceles and tumors don’t  transilluminate, but spermatoceles and hydroceles do.
 A hordeolum  (eyelid stye) is an infection of one or more sebaceous glands of the eyelid.
 A chalazion is an eyelid mass that’s caused by chronic  inflammation of the meibomian gland.
 During ophthalmoscopic  examination, the absence of the red reflex indicates a lens opacity (cataract) or a detached retina.
 Respiratory acidosis is associated with  conditions such as drug overdose, Guillain-Barré syndrome, myasthenia gravis, chronic obstructive pulmonary disease, pickwickian syndrome, and kyphoscoliosis. Bullets
 Respiratory alkalosis is associated with conditions  such as high fever, severe hypoxia, asthma, and pulmonary embolism.
 Metabolic acidosis is associated with such conditions as renal failure, diarrhea, diabetic ketosis, and lactic ketosis, and with high doses of acetazolamide (Diamox).
 Gastrectomy is surgical excision of all or part  of the stomach to remove a chronic peptic ulcer, stop hemorrhage in a perforated ulcer, or remove a malignant tumor.
 Metabolic alkalosis is associated  with nasogastric suctioning, excessive use of diuretics, and steroid therapy.
 Vitiligo (a benign, acquired skin disease) is marked by stark  white skin patches that are caused by the destruction and loss of pigment cells.
 Overdose or accidental overingestion of disulfiram (Antabuse)  should be treated with gastric aspiration or lavage and supportive therapy.
 The causes of abdominal distention are represented by the six  F’s: flatus, feces, fetus, fluid, fat, and fatal (malignant) neoplasm.
 A positive Murphy’s sign indicates cholecystitis.
 Signs of appendicitis  include right abdominal pain, abdominal rigidity and rebound tenderness, nausea, and anorexia.
 Ascites can be detected when more than 500 ml of fluid  has collected in the intraperitoneal space.
 For a patient with organic  brain syndrome or a senile disease, the ideal environment is stable and limits confusion.
 In a patient with organic brain syndrome, memory  loss usually affects all spheres, but begins with recent memory loss.
 During cardiac catheterization, the patient may experience a thudding sensation in the chest, a strong desire to cough, and a transient feeling of heat, usually in the face, as a result of injection of the contrast medium.
 Slight  bubbling in the suction column of a thoracic drainage system, such as a Pleur-evac unit, indicates that the system is working properly. A lack of bubbling
in the suction chamber indicates inadequate suction.
 Nutritional deficiency is a common finding in people who have a long history of alcohol abuse.
 In the patient with varicose veins, graduated  compression elastic stockings (30 to 40 mm Hg) may be prescribed to promote venous return.
 Nonviral hepatitis usually results from exposure to  certain chemicals or drugs.
 Substantial elevation of the serum  transaminase level is a symptom of acute hepatitis.
 Normal cardiac  output is 4 to 6 L/minute, with a stroke volume of 60 to 70 ml.
 Excessive vomiting or removal of the stomach contents through suction can decrease the potassium level and lead to hypokalemia.
 As a heparin  antagonist, protamine is an antidote for heparin overdose.
 If a patient  has a positive reaction to a tuberculin skin test, such as the purified protein derivative test, the nurse should suspect current or past exposure. The nurse should ask the patient about a history of tuberculosis (TB) and the presence of early signs and symptoms of TB, such as low-grade fever, weight loss, night sweats, fatigue, and anorexia.  Signs and symptoms of acute rheumatic fever  include chorea, fever, carditis, migratory polyarthritis, erythema marginatum (rash), and subcutaneous nodules.
 Before undergoing any invasive dental  procedure, the patient who has a history of rheumatic fever should receive prophylactic penicillin therapy. This therapy helps to prevent contamination of the blood with oral bacteria, which could migrate to the heart valves.
 After a myocardial infarction, most patients can resume sexual activity when they can climb two flights of stairs without fatigue or dyspnea.
 Elderly patients are susceptible to orthostatic hypotension because the baroreceptors become less sensitive to position changes as people age.
 For the patient with suspected renal or urethral calculi, the nurse should strain the urine to determine whether calculi have been passed.
 The  nurse should place the patient with ascites in the semi-Fowler position because it permits maximum lung expansion.
 For the patient who has ingested  poison, the nurse should save the vomitus for
analysis.
 The earliest  signs of respiratory distress are increased respiratory rate and increased pulse rate.
 In adults, gastroenteritis is commonly self-limiting and causes  diarrhea, abdominal discomfort, nausea, and vomiting.
 Cardiac output  equals stroke volume multiplied by the heart rate per minute.
 In  patients with acute meningitis, the cerebrospinal fluid protein level is elevated.
 When a patient is suspected of having food poisoning, the  nurse should notify public health authorities so that they can interview patients and food handlers and take samples of the suspected contaminated food.
 The patient who is receiving a potassium-wasting diuretic should  eat potassium-rich foods.
 A patient with chronic obstructive pulmonary  disease should receive low-level oxygen administration by nasal cannula (2 to 3 L/minute) to avoid interfering with the hypoxic drive.
 In metabolic  acidosis, the patient may have Kussmaul’s respirations because the rate and depth of respirations increase to “blow off” excess carbonic acids.
 In  women, gonorrhea affects the vagina and fallopian tubes.
 After  traumatic amputation, the greatest threats to the patient are blood loss and hypovolemic shock. Initial interventions should control bleeding and replace fluid and blood as needed.
 Epinephrine is a sympathomimetic drug that  acts primarily on alpha, beta1, and beta2 receptors, causing vasoconstriction.
 Epinephrine’s adverse effects include dyspnea,  tachycardia, palpitations, headaches, and hypertension.
 A cardinal sign  of pancreatitis is an elevated serum amylase level.
 High colonic  irrigation is used to stimulate peristalsis and reduce flatulence.
 Bleeding is the most common postoperative problem.
 The patient can  control some colostomy odors by avoiding such foods as fish, eggs, onions, beans, and cabbage and related vegetables.
 When paralysis or coma  impairs or erases the corneal reflex, frequent eye care is performed to keep the exposed cornea moist, preventing ulceration and inflammation.
 Interventions for the patient with acquired immunodeficiency syndrome include treating existing infections and cancers, reducing the risk of opportunistic infections, maintaining adequate nutrition and hydration, and providing emotional support to the patient and family.
 Signs and symptoms of  chlamydial infection are urinary frequency; thin, white vaginal or urethral discharge; and cervical inflammation.
 Chlamydial infection is the most  prevalent sexually transmitted disease in the United States.
 The  pituitary gland is located in the sella turcica of the sphenoid bone in the cranial cavity.
 Myasthenia gravis is a neuromuscular disorder that’s  characterized by impulse disturbances at the myoneural junction.
 Myasthenia gravis, which usually affects young women, causes extreme muscle weakness and fatigability, difficulty chewing and talking, strabismus, and ptosis.
 Hypothermia is a life-threatening disorder in which the body’s  core temperature drops below 95° F (35° C).
 Signs and symptoms of  hypopituitarism in adults may include gonadal failure, diabetes insipidus, hypothyroidism, and adrenocortical insufficiency.
 Reiter’s syndrome  causes a triad of symptoms: arthritis, conjunctivitis, and urethritis.
 For patients who have had a partial gastrectomy, a carbohydrate-restricted diet includes foods that are high in protein and fats and restricts foods that are high in carbohydrates. High-carbohydrate foods are digested quickly and are readily emptied from the stomach into the duodenum, causing diarrhea and dumping syndrome.
 A woman of childbearing age who is undergoing chemotherapy  should be encouraged to use a contraceptive because of the risk of fetal damage if she becomes pregnant.
 Pernicious anemia is vitamin B12 deficiency  that’s caused by a lack of intrinsic factor, which is produced by the gastric mucosal parietal cells.
 To perform pursed-lip breathing, the patient  inhales through the nose and exhales slowly and evenly against pursed lips while contracting the abdominal muscles.
 A patient who is undergoing  chemotherapy should consume a high-calorie, high-protein diet.
 Adverse  effects of chemotherapy include bone marrow depression, which causes anemia, leukopenia, and thrombocytopenia; GI epithelial cell irritation, which causes GI ulceration, bleeding, and vomiting; and destruction of hair follicles and skin, which causes alopecia and dermatitis.
 The hemoglobin electrophoresis  test differentiates between sickle cell trait and sickle cell anemia.
 The antibiotics erythromycin, clindamycin, and tetracycline act by inhibiting protein synthesis in susceptible organisms.
 The nurse administers  oxygen as prescribed to the patient with heart failure to help overcome hypoxia and dyspnea.
 Signs and symptoms of small-bowel obstruction include  decreased or absent bowel sounds, abdominal distention, decreased flatus, and projectile vomiting.
 The nurse should use both hands when  ventilating a patient with a manual resuscitation bag. One hand can deliver only 400 cc of air; two hands can deliver 1,000 cc of air.
 Dosages of  methylxanthine agents, such as theophylline (Theo-Dur) and aminophylline (Aminophyllin), should be individualized based on serum drug level, patient response, and adverse reactions.
 The patient should apply a transdermal  scopolamine patch (Transderm-Scop) at least 4 hours before its antiemetic action is needed.
 Early indications of gangrene are edema, pain, redness,  darkening of the tissue, and coldness in the affected body part.
 Ipecac  syrup is the emetic of choice because of its effectiveness in evacuating the stomach and relatively low incidence of adverse reactions.
 Oral iron  (ferrous sulfate) may cause green to black feces.
 Polycythemia vera  causes pruritus, painful fingers and toes, hyperuricemia, plethora (reddish purple skin and mucosa), weakness, and easy fatigability.
 Rheumatic  fever is usually preceded by a group A beta-hemolytic streptococcal infection, such as scarlet fever, otitis media, streptococcal throat infection, impetigo, or tonsillitis.
 A thyroid storm, or crisis, is an extreme form of  hyperthyroidism. It’s characterized by hyperpyrexia with a temperature of up to 106° F (41.1° C), diarrhea, dehydration, tachycardia of up to 200 beats/minute, arrhythmias, extreme irritability, hypotension, and delirium. It may lead to coma, shock, and death.
 Tardive dyskinesia, an adverse reaction to  long-term use of antipsychotic drugs, causes involuntary repetitive movements of the tongue, lips, extremities, and trunk.
 Asthma is bronchoconstriction  in response to allergens, such as food, pollen, and drugs; irritants, such as smoke and paint fumes; infections; weather changes; exercise; or gastroesophageal reflux. In the United States, about 5% of children have chronic asthma.
 Blood cultures help identify the cause of endocarditis. An  increased white blood cell count suggests bacterial infection.
 In a  patient who has acute aortic dissection, the nursing priority is to maintain the mean arterial pressure between 60 and 65 mm Hg. A vasodilator such as nitroprusside (Nitropress) may be needed to achieve this goal.
 For a  patient with heart failure, one of the most important nursing diagnoses is decreased cardiac output related to altered myocardial contractility, increased preload and afterload, and altered rate, rhythm, or electrical conduction.
 For a patient receiving peritoneal dialysis, the nurse must  monitor body weight and blood urea nitrogen, creatinine, and electrolyte levels.
 Angiotensin-converting enzyme inhibitors, such as captopril  (Capoten) and enalapril (Vasotec), decrease blood pressure by interfering with the renin- angiotensin-aldosterone system.
 A patient who has stable  ventricular tachycardia has a blood pressure and is conscious; therefore, the patient’s cardiac output is being maintained, and the nurse must monitor the patient’s vital signs continuously.
 Angiotensin-converting enzyme  inhibitors inhibit the enzyme that converts angiotensin I into angiotensin II, which is a potent vasoconstrictor. Through this action, they reduce peripheral arterial resistance and blood pressure.
 In a patient who is  receiving a diuretic, the nurse should monitor serum electrolyte levels, check vital signs, and observe for orthostatic hypotension.
 Breast  self-examination is one of the most important health habits to teach a woman. It should be performed 1 week after the menstrual period because that’s when hormonal effects, which can cause breast lumps and tenderness, are reduced.
 Postmenopausal women should choose a regular time each month  to perform breast self-examination (for example, on the same day of the month as the woman’s birthday).
 The difference between acute and chronic  arterial disease is that the acute disease process is life-threatening.
 When preparing the patient for chest tube removal, the nurse should explain that removal may cause pain or a burning or pulling sensation.
 Essential  hypertensive renal disease is commonly characterized by progressive renal impairment.
 Mean arterial pressure (MAP) is calculated using the  following formula, where S = systolic pressure and D = diastolic pressure: MAP = [(D × 2) + S] ÷ 3
 Symptoms of supine hypotension syndrome are  dizziness, light-headedness, nausea, and vomiting.
 An immunocompromised  patient is at risk for Kaposi’s sarcoma.
 Doll’s eye movement is the  normal lag between head movement and eye movement.
 Third spacing of  fluid occurs when fluid shifts from the intravascular space to the interstitial space and remains there.
 Chronic pain is any pain that lasts longer  than 6 months. Acute pain lasts less than 6 months.  The mechanism of action  of a phenothiazine derivative is to block dopamine receptors in the brain.
 Patients shouldn’t take bisacodyl, antacids, and dairy products  all at the same time.
 Advise the patient who is taking digoxin to avoid  foods that are high in fiber, such as bran cereal and prunes.
 A patient  who is taking diuretics should avoid foods that contain monosodium glutamate because it can cause tightening of the chest and flushing of the face.
 Furosemide (Lasix) should be taken 1 hour before meals.
 A patient who  is taking griseofulvin (Grisovin FP) should maintain a high-fat diet, which enhances the secretion of bile.
 Patients should take oral iron products  with citrus drinks to enhance absorption.
 Isoniazid should be taken on  an empty stomach, with a full glass of water.
 Foods that are high in  protein decrease the absorption of levodopa.
 A patient who is taking  tetracycline shouldn’t take iron supplements or antacids.
 A patient who  is taking warfarin (Coumadin) should avoid foods that are high in vitamin K, such as liver and green leafy vegetables.
 The normal value for  cholesterol is less than 200 mg/dl. The normal value for low-density lipoproteins is 60 to 180 mg/dl; for high-density lipoproteins, it’s 30 to 80 mg/dl.
 The normal cardiac output for an adult who weighs 155 lb (70.3  kg) is 5 to 6 L/minute.
 A pulmonary artery pressure catheter  (Swan-Ganz) measures the pressure in the cardiac chambers.
 Severe chest  pain that’s aggravated by breathing and is described as “sharp,” “stabbing,” or “knifelike” is consistent with pericarditis.
 Water-hammer pulse is a  pulse that’s loud and bounding and rises and falls rapidly. It can be caused by emotional excitement or aortic insufficiency.
 Pathologic splitting of  S2 is normally heard between inspiration and expiration. It occurs in right bundle-branch block.
 Pink, frothy sputum is associated with pulmonary  edema. Frank hemoptysis may be associated with pulmonary embolism.
 An  aortic aneurysm can be heard just over the umbilical area and can be detected as an abdominal pulsation (bruit).
 Heart murmurs are graded according to  the following system: grade 1 is faint and is heard after the examiner “tunes in”; grade 2 is heard immediately; grade 3 is moderately loud; grade 4 is loud; grade 5 is very loud, but is heard only with a stethoscope; and grade 6 is very loud and is heard without a stethoscope.
 Clot formation during cardiac  catheterization is minimized by the administration of 4,000 to 5,000 units of heparin.
 Most complications that arise from cardiac catheterization are  associated with the puncture site.
 Allergic symptoms associated with  iodine-based contrast media used in cardiac catheterization include urticaria, nausea and vomiting, and flushing.
 To ensure that blood flow hasn’t  been compromised, the nurse should mark the peripheral pulses distal to the cutdown site to aid in locating the pulses after the procedure.  The  extremity used for the cutdown site should remain straight for 4 to 6 hours. If an antecubital vessel was used, an armboard is needed. If a femoral artery was used, the patient should remain on bed rest for 6 to 12 hours.
 If a  patient experiences numbness or tingling in the extremity after a cutdown, the physician should be notified immediately.
 After cardiac  catheterization, fluid intake should be encouraged to aid in flushing the contrast medium through the kidneys.
 In a patient who is undergoing  pulmonary artery catheterization, risks include pulmonary artery infarction, pulmonary embolism, injury to the heart valves, and injury to the myocardium.
 Pulmonary artery wedge pressure is a direct indicator of  left ventricular pressure.
 Pulmonary artery wedge pressure greater than  18 to 20 mm Hg indicates increased left ventricular pressure, as seen in left-sided heart failure.
 When measuring pulmonary artery wedge  pressure, the nurse should place the patient in a supine position, with the head of the bed elevated no more than 25 degrees.
 Pulmonary artery pressure,  which indicates right and left ventricular pressure, is taken with the balloon deflated.
 Pulmonary artery systolic pressure is the peak pressure  generated by the right ventricle. Pulmonary artery diastolic pressure is the lowest pressure in the pulmonary artery.
 Normal adult pulmonary artery  systolic pressure is 15 to 25 mm Hg.
 Normal adult pulmonary artery  diastolic pressure is 8 to 12 mm Hg.
 The normal oxygen saturation  of venous blood is 75%.
 Central venous pressure is the amount of  pressure in the superior vena cava and the right atrium.
 Normal adult  central venous pressure is 2 to 8 mm Hg, or 3 to 10 cm H2O.
 A decrease  in central venous pressure indicates a fall in circulating fluid volume, as seen in shock.
 An increase in central venous pressure is associated with an  increase in circulating volume, as seen in renal failure.
 In a patient  who is on a ventilator, central venous pressure should be taken at the end of the expiratory cycle.
 To ensure an accurate baseline central venous  pressure reading, the zero point of the transducer must be at the level of the right atrium.
 A blood pressure reading obtained through intra-arterial  pressure monitoring may be 10 mm Hg higher than one obtained with a blood pressure cuff.
 In Mönckeberg’s sclerosis, calcium deposits form in the  medial layer of the arterial walls.
 The symptoms associated with  coronary artery disease usually don’t appear until plaque has narrowed the vessels by at least 75%.
 Symptoms of coronary artery disease appear  only when there is an imbalance between the demand for oxygenated blood and its availability.
 Percutaneous transluminal coronary angioplasty is an  invasive procedure in which a balloon-tipped catheter is inserted into a blocked artery. When the
balloon is inflated, it opens the artery by compressing plaque against the artery’s intimal layer.
 Before percutaneous transluminal  coronary angioplasty is performed, an anticoagulant (such as aspirin) is usually administered to the patient. During the procedure, the patient is given heparin, a calcium agonist, or nitroglycerin to reduce the risk of coronary artery spasms.
 During coronary artery bypass graft surgery, a blocked coronary  artery is bypassed by using the saphenous vein from the patient’s thigh or lower leg.
 When a vein is used to bypass an artery, the vein is reversed so  that the valves don’t interfere with blood flow.
 During a coronary  artery bypass graft procedure, the patient’s heart is stopped to allow the surgeon to sew the new vessel in place. Blood flow to the body is maintained with a cardiopulmonary bypass.
 During an anginal attack, the cells of  the heart convert to anaerobic metabolism, which produces lactic acid as a waste product. As the level of lactic acid increases, pain develops.
 Pain  that’s described as “sharp” or “knifelike” is not consistent with angina pectoris.
 Anginal pain typically lasts for 5 minutes; however, attacks  associated with a heavy meal or extreme emotional distress may last 15 to 20 minutes.
 A pattern of “exertion-pain-rest-relief” is consistent with  stable angina.
 Unlike stable angina, unstable angina can occur without  exertion and is considered a precursor to a myocardial infarction.
 A  patient who is scheduled for a stress electrocardiogram should notify the staff if he has taken nitrates. If he has, the test must be rescheduled.
 Exercise equipment, such as a treadmill or  an exercise bike, is used for a stress electrocardiogram. Activity is increased until the patient reaches 85% of his maximum heart rate.
 In patients  who take nitroglycerin for a long time, tolerance often develops and reduces the effectiveness of nitrates. A 12-hour drug-free period is usually
maintained at night.
 Beta-adrenergic blockers, such as propranolol (Inderal), reduce  the workload on the heart, thereby decreasing oxygen demand. They also slow the heart rate.
 Calcium channel blockers include nifedipine (Procardia),  which is used to treat angina; verapamil (Calan, Isoptin), which is used primarily as an antiarrhythmic; and diltiazem (Cardizem), which combines the effects of nifedipine and verapamil without the adverse effects.
 A  patient who has anginal pain that radiates or worsens and doesn’t subside should be evaluated at an emergency medical facility.
 Cardiac cells can  withstand 20 minutes of ischemia before cell death occurs.
 During a  myocardial infarction, the most common site of injury is the anterior wall of the left ventricle, near the apex.
 After a myocardial infarction, the  infarcted tissue causes significant Q-wave changes on an electrocardiogram. These changes remain evident even after the myocardium heals.
 The level  of CK-MB, an isoenzyme specific to the heart, increases 4 to 6 hours after a myocardial infarction and peaks at 12 to 18 hours. It returns to normal in 3 to 4 days.
 Patients who survive a myocardial infarction and have no other  cardiovascular pathology usually require 6 to 12 weeks for a full recovery.
 After a myocardial infarction, the patient is at greatest  risk for sudden death during the first 24 hours.
 After a myocardial  infarction, the first 6 hours is the crucial period for salvaging the myocardium.
 After a myocardial infarction, if the patient consistently  has more than three premature ventricular contractions per minute, the physician should be notified.
 After a myocardial infarction, increasing vascular  resistance through the use of vasopressors, such as dopamine and levarterenol, can raise blood pressure.
 Clinical manifestations of heart failure  include distended neck veins, weight gain, orthopnea, crackles, and enlarged liver.
 Risk factors associated with embolism are increased blood  viscosity, decreased circulation, prolonged bed rest, and increased blood coagulability.
 Antiembolism stockings should be worn around the clock,  but should be removed twice a day for 30 minutes so that skin care can be performed.
 Before the nurse puts antiembolism stockings back on the  patient, the patient should lie with his feet elevated 6" (15.2 cm) for 20 minutes.
 Dressler’s syndrome is known as late pericarditis because it  occurs approximately 6 weeks to 6 months after a myocardial infarction. It causes pericardial pain and a fever that lasts longer than 1 week.
 In  phase I after a myocardial infarction, for the first 24 hours, the patient is kept on a clear liquid diet and bed rest with the use of a bedside commode.
 In phase I after a myocardial infarction, on  the second day, the patient gets out of bed and spends 15 to 20 minutes in a chair. The number of times that the patient goes to the chair and the length of time he spends in the chair are increased depending on his endurance. In phase II, the length of time that the patient spends out of bed and the distance to the chair are increased.
 After transfer from the cardiac care unit, the  post-myocardial infarction patient is allowed to walk the halls as his endurance increases.
 Sexual intercourse with a known partner usually can be  resumed 4 to 8 weeks after a myocardial infarction.
 A patient under  cardiac care should avoid drinking alcoholic beverages or eating before engaging in sexual intercourse.
 The ambulation goal for a post-myocardial  infarction patient is 2 miles in 60 minutes.
 A post-myocardial  infarction patient who doesn’t have a strenuous job may be able to return to work full-time in 8 or 9 weeks.
 Stroke volume is the amount of blood  ejected from the heart with each heartbeat.
 Afterload is the force that  the ventricle must exert during systole to eject the stroke volume.
 The  three-point position (with the patient upright and leaning forward, with the
hands on the knees) is characteristic of orthopnea, as seen in left-sided heart failure.
 Paroxysmal nocturnal dyspnea indicates a severe form of  pulmonary congestion in which the patient awakens in the middle of the night with a feeling of being suffocated.
 Clinical manifestations of  pulmonary edema include breathlessness, nasal flaring, use of accessory muscles to breath, and frothy sputum.  A late sign of heart failure is decreased  cardiac output that causes decreased blood flow to the kidneys and results in oliguria.
 A late sign of heart failure is anasarca (generalized  edema).
 Dependent edema is an early sign of right-sided heart failure.  It’s seen in the legs, where increased capillary hydrostatic pressure overwhelms plasma protein, causing a shift of fluid from the capillary beds to the interstitial spaces.
 Dependent edema, which is most noticeable at the  end of the day, usually starts in the feet and ankles and continues upward.
 For the recumbent patient, edema is usually seen in the  presacral area.
 Signs of urinary tract infection include frequency,  urgency, and dysuria.
 In tertiary-intention healing, wound closure is  delayed because of infection or edema.
 A patient who has had  supratentorial surgery should have the head of the bed elevated 30 degrees.
 An acid-ash diet acidifies urine.
 Vitamin C and  cranberry juice acidify urine.
 A patient who takes probenecid  (Colbenemid) for gout should be instructed to take the drug with food.
 If wound dehiscence is suspected, the nurse should instruct the patient to lie down and should examine the wound and monitor the vital signs. Abnormal findings should be reported to the physician.
 Zoster immune globulin is  administered to stimulate immunity to varicella.
 The most  common symptoms associated with compartmental syndrome are pain that’s not relieved by analgesics, loss of movement, loss of sensation, pain with passive movement, and lack of pulse.
 To help relieve muscle spasms in a patient  who has multiple sclerosis, the nurse should administer baclofen (Lioresal) as ordered; give the patient a warm, soothing bath; and teach the patient progressive relaxation techniques.
 A patient who has a cervical injury  and impairment at C5 should be able to lift his shoulders and elbows partially, but has no sensation below the clavicle.
 A patient who has cervical  injury and impairment at C6 should be able to lift his shoulders, elbows, and wrists partially, but has no sensation below the clavicle, except a small amount in the arms and thumb.
 A patient who has cervical injury and impairment  at C7 should be able to lift his shoulders, elbows, wrists, and hands partially, but has no sensation below the midchest.
 Injuries to the spinal cord at  C3 and above may be fatal as a result of loss of innervation to the diaphragm and intercostal muscles.
 Signs of meningeal irritation seen in  meningitis include nuchal rigidity, a positive Brudzinski’s sign, and a positive Kernig’s sign.
 Laboratory values that show pneumomeningitis include an  elevated cerebrospinal fluid (CSF) protein level (more than 100 mg/dl), a decreased CSF glucose level (40 mg/dl), and an increased white blood cell count.
 Before undergoing magnetic resonance imaging, the patient should  remove all objects containing metal, such as watches, underwire bras, and jewelry.
 Usually food and medicine aren’t restricted before  magnetic resonance imaging.
 Patients who are undergoing magnetic  resonance imaging should know that they can ask questions during the procedure; however, they may be asked to lie still at certain times.
 If a contrast  medium is used during magnetic resonance imaging, the patient may experience diuresis as the medium is flushed from the body.
 The Tzanck test is  used to confirm herpes genitalis.
 Hepatitis C is spread primarily  through blood (for example, during transfusion
or in people who work with blood products), personal contact and, possibly, the fecal-oral route.
 The  best method for soaking an open, infected, draining wound is to use a hot- moist dressing.
 Sputum culture is the confirmation test for  tuberculosis.
 Dexamethasone (Decadron) is a steroidal anti-inflammatory  that’s used to treat adrenal insufficiency.
 Signs of increased  intracranial pressure include alteration in level of consciousness, restlessness, irritability, and pupillary changes.
 The patient who has  a lower limb amputation should be instructed to assume a prone position at least twice a day.
 During the first 24 hours after amputation, the residual  limb is elevated on a pillow. After that time, the limb is placed flat to reduce the risk of hip flexion contractures.
 A tourniquet should be in  full view at the bedside of the patient who has an amputation.
 An  emergency tracheostomy set should be kept at the bedside of a patient who is suspected of having epiglottitis.
 Rocky Mountain spotted fever is  spread through the bite of a tick harboring the Rickettsia organism.
 A  patient who has acquired immunodeficiency syndrome shouldn’t share razors or toothbrushes with others, but there are no special precautions for dinnerware or laundry services.
 Because antifungal creams may stain clothing,  patients who use them should use sanitary napkins.
 An antifungal cream  should be inserted high in the vagina at bedtime.
 A patient who is  having a seizure usually requires protection from the environment only; however, anyone who needs airway management should be turned on his side.
 Status  epilepticus is treated with I.V. diphenylhydantoin.
 A xenograft is a  skin graft from an animal.
 The antidote for magnesium sulfate is  calcium gluconate 10%.
 Allergic reactions to a blood transfusion are  flushing, wheezing, urticaria, and rash.
 A patient who has a history of  basal cell carcinoma should avoid sun exposure.
 When potent,  nitroglycerin causes a slight stinging sensation under the tongue.
 A  patient who appears to be “fighting the ventilator” is holding his breath or breathing out on an inspiratory cycle.
 An antineoplastic  drug that’s used to treat breast cancer is tamoxifen (Nolvadex).
 Adverse effects of vincristine (Oncovin) are alopecia, nausea, and vomiting.
 Increased urine output is an indication that a hypertensive  crisis is normalizing.
 If a patient who is receiving I.V. chemotherapy  has pain at the insertion site, the nurse should stop the I.V. infusion immediately.
 Extravasation is leakage of fluid into surrounding tissue  from a vein that’s being used for I.V. therapy.
 Clinical signs of  prostate cancer are dribbling, hesitancy, and decreased urinary force.
 Cardiac glycosides increase cardiac contractility.
 Adverse effects of  cardiac glycosides include headache, hypotension, nausea and vomiting, and yellow-green halos around lights.
 A T tube should be clamped during  patient meals to aid in fat digestion.
 A T tube usually remains in  place for 10 days.
 During a vertigo attack, a patient who has Ménière’s  disease should be instructed to lie down on his side with his eyes closed.
 When maintaining a Jackson-Pratt drainage system, the nurse  should squeeze the reservoir and expel the air before recapping the system.
 The most common symptom associated with sleep apnea is  snoring.
 Histamine is released during an inflammatory  response.
 When dealing with a patient who has a severe speech  impediment, the nurse should minimize background noise and avoid interrupting the patient.
 Fever and night sweats, hallmark signs of tuberculosis,  may not be present in elderly patients who have the disease.
 A suitable  dressing for wound debridement is wet-to-dry.
 Drinking warm milk at  bedtime aids sleeping because of the natural sedative effect of the amino acid tryptophan.
 The initial step in promoting sleep in a hospitalized  patient is to minimize environmental stimulation.
 Before moving a  patient, the nurse should assess how much exertion the patient is permitted, the patient’s physical ability, and his ability to understand instruction as well as her own strength and ability to move the patient.
 A patient who is in a  restraint should be checked every 30 minutes and the restraint loosened every 2 hours to permit range of motion exercises for the extremities.
 Antibiotics that are given four times a day should be given at 6 a.m., 12 p.m., 6 p.m., and 12 a.m. to minimize disruption of sleep.
 Sundowner syndrome  is seen in patients who become more confused toward the evening. To counter this tendency, the nurse should turn a light on.
 For the patient who has  somnambulism, the primary goal is to prevent injury by providing a safe environment.
 For the patient who has somnambulism, the primary goal is  to prevent injury by providing a safe environment.
 Naloxone (Narcan)  should be kept at the bedside of the patient who is receiving patient-controlled analgesia.  Hypnotic drugs decrease rapid eye movement sleep, but increase  the overall
amount of sleep.
 A sudden wave of overwhelming sleepiness  is a symptom of narcolepsy.
 A diabetic patient should be instructed to  buy shoes in the afternoon because feet are usually largest at that time of day.
 If surgery is scheduled late in the afternoon, the surgeon may  approve a light breakfast.
 A hearing aid is usually left in place  during surgery to permit communication with the patient. The operating room team should be notified of its presence.
 The nurse should monitor the  patient for central nervous system depression for 24 hours after the administration of nitrous oxide.
 In the postanesthesia care unit, the  proper position of an adult is with the head to the side and the chin extended upward. The Sims’ position also can be used unless contraindicated.
 After a patient is admitted to the postanesthesia care unit, the first action is to assess the patency of the airway.
 If a patient is admitted to the  postanesthesia care unit without the pharyngeal reflex, he’s positioned on his side. The nurse stays at the bedside until the gag reflex returns.
 In  the postanesthesia care unit, the patient’s vital signs are taken every 15 minutes routinely, or more often if indicated, until the patient is stable.
 In the postanesthesia care unit, the T tube should be unclamped  and attached to a drainage system.
 After the patient receives  anesthesia, the nurse must observe him for a drop in blood pressure or evidence of labored breathing.  If a patient begins to go into shock during the  postanesthesia assessment, the nurse should administer oxygen, place the patient in the Trendelenburg position, and increase the I.V. fluid rate according to the physician’s order or the policy of the postanesthesia care unit.
 Types  of benign tumors include myxoma, fibroma, lipoma, osteoma, and chondroma.
 Malignant tumors include sarcoma, basal cell carcinoma,  fibrosarcoma, osteosarcoma, myxosarcoma, chondrosarcoma, and adenocarcinoma.
 For a cancer patient, palliative surgery is performed  to reduce pain, relieve airway obstruction, relieve GI obstruction, prevent hemorrhage, relieve pressure on the brain and spinal cord, drain abscesses, and remove or drain infected tumors.
 A patient who is undergoing radiation  implant therapy should be kept in a private room to reduce the risk of exposure to others, including nursing personnel.
 After total knee replacement  surgery, the knee should be kept in maximum extension for 3 days.
 Partial weight bearing is allowed approximately 1 week after total knee replacement. Weight bearing to the point of pain is allowed at 2 weeks.
 Sjögren’s syndrome is a chronic inflammatory disorder associated with a decrease in salivation and lacrimation. Clinical manifestations include dryness of the mouth, eyes, and vagina.
 Normal values of cerebrospinal fluid include  the following: protein level, 15 to 45 mg/100 ml; fasting glucose, 50 to 80 mg/100 ml; red blood cell count, 0; white blood cell count, 0 to 5/µl: pH, 7.3; potassium ion value, 2.9 mmol/L; chloride, 120 to 130 mEq/L.
 The  following mnemonic device can be used to identify whether a cranial nerve is a motor nerve: I Some | II Say | III Marry | IV Money, | V but | VI My | VII Brother | VII Says | IX Bad | X Business | XI Marry | XII Money.
 To  interpret the mnemonic device: If the word begins with an S, it’s a sensory nerve; if it starts with an M, it’s a motor nerve; and if it starts with a B, it’s both a sensory and a motor nerve.
 The Glasgow Coma Scale evaluates  level of consciousness, pupil reaction, and motor activity. A score between 3 and 15 is possible.
 When assessing a patient’s pupils, the nurse should  remember that anisocoria, unequal pupils of 1 mm or larger, occurs in approximately 17% of the population.
 Homonymous hemianopsia is a visual  defect in which the patient sees only one- half of the visual field with each eye. Therefore, the patient sees only one-half of a normal visual field.
 Passive range-of-motion exercises are commonly started 24 hours  after a stroke. They’re performed four times per day.
 In treating a  patient with a transient ischemic attack, the goal of medical management is to prevent a stroke. The patient is administered antihypertensive drugs, antiplatelet drugs or aspirin and, in some cases, warfarin (Coumadin).
 A patient who has an intraperitoneal shunt should be observed for increased abdominal girth.
 Digestion of carbohydrates begins in the  mouth.
 Digestion of fats begins in the stomach, but occurs  predominantly in the small intestine.
 Dietary sources of magnesium are  fish, grains, and nuts.
 A rough estimate of serum osmolarity is twice  the serum sodium level.
 In determining acid–base problems, the nurse  should first note the pH. If it’s above 7.45, it’s a problem of alkalosis; if it’s below 7.35, it’s a problem of acidosis. The nurse should next look at the partial pressure of arterial carbon dioxide (PaCO2). This is the respiratory indicator. If the pH indicates acidosis and the PaCO2 indicates acidosis as well (greater than 45 mm Hg), then there’s a match, and the source of the problem is respiration. It’s called respiratory acidosis. If the pH indicates alkalosis and the PaCO2 also indicates alkalosis (less than 35 mm Hg), then there’s a match, and the source of the problem is respiration. This is called respiratory alkalosis. If the PaCO2 is normal, then the nurse should look at the bicarbonate (HCO3–), which is the metabolic indicator, and note whether it’s acidic (less than 22 mEq/L) or alkaline (greater than 26 mEq/L). Determine which value the pH matches; it will determine whether the problem is metabolic acidosis or metabolic alkalosis. If both the PaCO2 and HCO3– are abnormal, then the body is compensating. If the pH has returned to normal, the body is in full compensation.
 The Tensilon (edrophonium chloride) test is used to  confirm myasthenia gravis.
 A masklike facial expression is a sign of  myasthenia gravis and Parkinson’s disease.
 Albumin is a colloid that  aids in maintaining fluid within the vascular system. If albumin were filtered out through the kidneys and into the urine, edema would occur.
 Edema  caused by water and trauma doesn’t cause pitting.
 Dehydration is  water loss only; fluid volume deficit includes all fluids in the
body.
 The primary action of an oil retention enema is to lubricate the colon. The secondary action is softening the feces.
 A patient who uses a walker  should be instructed to move the walker approximately 12" (30.5 cm) to the front and then advance into the walker.
 Bradykinesia is a sign of Parkinson’s  disease.
 Lordosis is backward arching curvature of the spine.
 Kyphosis is forward curvature of the spine.
 In a patient with anorexia  nervosa, a positive response to therapy is sustained weight gain.
 The  drug in dialysate is heparin.
 An autograft is a graft that’s removed  from one area of the body for transplantation to another.
 Signs of  cervical cancer include midmenses bleeding and postcoital bleeding.
 After prostatectomy, a catheter is inserted to irrigate the bladder and keep urine straw-colored or light pink, to put direct pressure on the operative side, and to maintain a patent urethra.
 If a radiation implant becomes  dislodged, but remains in the patient, the nurse should notify the physician.
 The best method to reduce the risk for atelectasis is to  encourage the patient to walk.
 Atelectasis usually occurs 24 to 48  hours after surgery.
 Patients who are at the greatest risk for  atelectasis are those who have had high abdominal surgery, such as cholecystectomy.
 A persistent decrease in oxygen to the kidneys  causes erythropoiesis.
 Rhonchi and crackles indicate ineffective airway  clearance.
 Wheezing indicates bronchospasms.
 Clinical  signs and symptoms of hypoxemia are restlessness (usually the first sign), agitation, dyspnea, and disorientation.
 Common adverse effects of  opioids are constipation and respiratory depression.
 Disuse  osteoporosis is caused by demineralization of calcium as a result of prolonged bed rest.
 The best way to prevent disuse osteoporosis is to encourage  the patient to walk.
 A cane should be carried on the unaffected side  and advanced with the affected extremity.
 Steroids shouldn’t be used in  patients who have chickenpox or shingles because they may cause adverse effects.
 Seroconversion occurs approximately 3 to 6 months after  exposure to human immunodeficiency virus.
 Therapy with the antiviral  agent zidovudine is initiated when the CD4+ T-cell count is 500 cells/µl or less.
 In a light-skinned person, Kaposi’s sarcoma causes a purplish  discoloration of the skin. In a dark-skinned person, the discoloration is dark brown to black.
 After an esophageal balloon tamponade is in place, it  should be inflated to 20 mm Hg.
 A patient who has Kaposi’s sarcoma  should avoid acidic or highly seasoned foods.
 The treatment for  oral candidiasis is amphotericin B (Fungizone) or fluconazole (Diflucan).
 A sign of respiratory failure is vital capacity of less  than 15 ml/kg and respiratory rate of greater than 30 breaths/minute or less than 8 breaths/ minute.
 For left-sided cardiac catheterization, the  catheter is threaded through the descending aorta, aortic arch, ascending aorta, aortic valve, and left ventricle.
 For right-sided cardiac  catheterization, the catheter is threaded through the superior vena cava, right atrium, right ventricle, pulmonary artery, and
pulmonary capillaries.
 Anemia can be divided into four groups according to its cause: blood loss, impaired production of red blood cells (RBCs), increased destruction of RBCs, and nutritional deficiencies.
 Aspirin, ibuprofen, phenobarbital,  lithium, colchicine, lead, and chloramphenicol can cause aplastic anemia.
 After a patient undergoes bone marrow aspiration, the nurse  should apply direct pressure to the site for 3 to 5 minutes to reduce the risk of bleeding.
 Fresh frozen plasma is thawed to 98.6° F (37° C) before  infusion.
 Signs of thrombocytopenia include petechiae, ecchymoses,  hematuria, and gingival bleeding.
 A patient who has thrombocytopenia  should be taught to use a soft toothbrush and use an electric razor.
 Signs of fluid overload include increased central venous pressure, increased pulse rate, distended jugular veins, and bounding pulse.
 A  patient who has leukopenia (or any other patient who is at an increased risk for infection) should avoid eating raw meat, fresh fruit, and fresh vegetables.
 To prevent a severe graft-versus-host reaction, which is  most commonly seen in patients older than age 30, the donor marrow is treated with monoclonal antibodies before transplantation.
 The four most common  signs of hypoglycemia reported by patients are nervousness, mental disorientation, weakness, and perspiration.
 Prolonged attacks of  hypoglycemia in a diabetic patient can result in brain damage.
 Activities that increase intracranial pressure include coughing, sneezing, straining to pass feces, bending over, and blowing the nose.
 Treatment  for bleeding esophageal varices includes vasopressin, esophageal tamponade, iced saline lavage, and vitamin K.
 Hepatitis C (also known as  blood-transfusion hepatitis) is a parenterally transmitted form of hepatitis that has a high incidence of carrier status.
 The nurse should be  concerned about fluid and electrolyte problems in the patient who has ascites, edema, decreased urine output, or low blood pressure.
 The nurse should  be concerned about GI bleeding, low blood pressure, and increased heart rate in a patient who is hemorrhaging.
 The nurse should be concerned about  generalized malaise, cloudy urine, purulent drainage, tachycardia, and increased temperature in a patient who has an infection.
 In a patient  who has edema or ascites, the serum electrolyte level should be monitored. The patient also should be weighed daily; have his abdominal girth measured with a centimeter tape at the same location, using the umbilicus as a checkpoint; have his intake and output measured; and have his blood pressure taken at least every 4 hours.
 Endogenous sources of ammonia include azotemia, GI bleeding,  catabolism, and constipation.
 Exogenous sources of ammonia include  protein, blood transfusion, and amino acids.
 The following histologic  grading system is used to classify cancers: grade 1, well-differentiated; grade 2, moderately well-differentiated; grade 3, poorly differentiated; and grade 4, very poorly differentiated.
 The following grading system is used to  classify tumors: T0, no evidence of a primary tumor; TIS, tumor in situ; and T1, T2, T3, and T4, according to the size and involvement of the tumor; the higher the number, the greater the involvement.
 Pheochromocytoma is a  catecholamine-secreting neoplasm of the adrenal medulla. It causes excessive production of epinephrine and norepinephrine.
 Clinical  manifestations of pheochromocytoma include visual disturbances, headaches, hypertension, and elevated serum glucose level.
 The patient shouldn’t  consume any caffeine-containing products, such as cola, coffee, or tea, for at least 8 hours before obtaining a 24-hour urine sample for vanillylmandelic acid.
 A patient who is taking ColBenemid (probenecid and colchicine)  for gout should increase his fluid intake to 2,000 ml/day.
 A miotic  such as pilocarpine is administered to a patient with glaucoma to increase the outflow of aqueous humor, which decreases intraocular tension.
 The drug  that’s most commonly used to treat streptococcal pharyngitis and rheumatic fever is penicillin.
 A patient with gout should avoid purine-containing  foods, such as liver and other organ meats.
 A patient who undergoes  magnetic resonance imaging lies on a flat platform that moves through a magnetic field.
 Laboratory values in patients who have bacterial meningitis  include increased white blood cell count, increased protein and lactic acid levels, and decreased glucose level.
 Mannitol is a hypertonic osmotic  diuretic that decreases intracranial pressure.
 The best method to  debride a wound is to use a wet-to-dry dressing and remove the dressing after it dries.
 The greatest risk for respiratory complications occurs after  chest wall injury, chest wall surgery, or upper abdominal surgery.
 Secondary methods to prevent postoperative respiratory complications include having the patient use an incentive spirometer, turning the patient, advising the patient to cough and breathe deeply, and providing hydration.
 A  characteristic of allergic inspiratory and expiratory wheezing is a dry, hacking, nonproductive cough.
 The incubation period for Rocky Mountain  spotted fever is 7 to 14 days.
 Miconazole (Monistat) vaginal  suppository should be administered with the patient lying flat.
 The  nurse should place the patient who is having a seizure on his side.
 Signs of hip dislocation are one leg that’s shorter than the other and one leg that’s externally rotated.
 Anticholinergic medication is administered  before surgery to diminish secretion
of saliva and gastric juices.
 Extrapyramidal syndrome in a patient with Parkinson’s disease is usually caused by a deficiency of dopamine in the substantia nigra.
 In a burn patient,  the order of concern is airway, circulation, pain, and infection.
 Hyperkalemia normally occurs during the hypovolemic phase in a patient who has a serious burn injury.
 Black feces in the burn patient are commonly  related to Curling’s ulcer.
 In a patient with burn injury, immediate  care of a full-thickness skin graft includes covering the site with a bulky dressing.
 The donor site of a skin graft should be left exposed to the  air.
 Leaking around a T tube should be reported immediately to the  physician.
 A patient who has Ménière’s disease should consume a  low-sodium diet.
 In any postoperative patient, the priority of concern  is airway, breathing, and circulation, followed by self-care deficits.
 The symptoms of myasthenia gravis are most likely related to nerve degeneration.
 Symptoms of septic shock include cold, clammy skin;  hypotension; and decreased urine output.
 Ninety-five percent of women  who have gonorrhea are asymptomatic.
 An adverse sign in a patient  who has a Steinmann’s pin in the femur would be erythema, edema, and pain around the pin site.
 Signs of chronic glaucoma include halos around lights,  gradual loss of peripheral vision, and cloudy vision.
 Signs of a  detached retina include a sensation of a veil (or curtain) in the line of sight.
 Toxic levels of streptomycin can cause hearing loss.
 A  long-term effect of rheumatic fever is mitral valve damage.
 Laboratory  values noted in rheumatic fever include an antistreptolysin-O titer, the presence of C-reactive protein, leukocytosis, and an increased erythrocyte sedimentation rate.
 Crampy pain in the right lower quadrant of the  abdomen is a consistent finding in Crohn’s disease.
 Crampy pain in the  left lower quadrant of the abdomen is a consistent finding in diverticulitis.
 In the icteric phase of hepatitis, urine is amber,  feces are clay-colored, and the skin is yellow.
 Signs of osteomyelitis  include pathologic fractures, shortening or lengthening of the bone, and pain deep in the bone.
 The laboratory test that would best reflect fluid  loss because of a burn would be hematocrit.
 A patient who has acute  pancreatitis should take nothing by mouth and undergo gastric suction to decompress the stomach.
 A mist tent is used to increase the hydration  of secretions.
 A patient who is receiving levodopa should avoid  foods that contain pyridoxine (vitamin B6), such as beans, tuna, and beef liver, because this vitamin decreases the effectiveness of levodopa.
 A patient  who has a transactional injury at C3 requires positive ventilation.
 The  action of phenytoin (Dilantin) is potentiated when given with anticoagulants.
 Cerebral palsy is a nonprogressive disorder that  persists throughout life.
 A complication of ulcerative colitis is  perforation.
 When a patient who has multiple sclerosis experiences  diplopia, one eye should be patched.
 A danger sign after hip  replacement is lack of reflexes in the affected extremity.
 A  clinical manifestation of a ruptured lumbar disk includes pain that shoots
down the leg and terminates in the popliteal space.
 The most important  nutritional need of the burn patient is I.V. fluid with electrolytes.
 The patient who has systemic lupus erythematosus should avoid sunshine, hair spray, hair coloring products, and dusting powder.
 The best position  for a patient who has low back pain is sitting in a straight- backed chair.
 Clinical signs of ulcerative colitis include bloody, purulent,  mucoid, and watery feces.
 A patient who has a protein systemic shunt  must follow a lifelong protein- restricted diet.
 A patient who has a  hiatal hernia should maintain an upright position after eating.  A suction  apparatus should be kept at the bedside of a patient who is at risk for status epilepticus.
 The leading cause of death in the burn patient is  respiratory compromise and infection.
 In patients who have herpes  zoster, the primary concern is pain management.
 The treatment for Rocky  Mountain spotted fever is tetracycline.
 Strawberry tongue is a sign of  scarlet fever.
 If a patient has hemianopsia, the nurse should place the  call light, the meal tray, and other items in his field of vision.
 The  best position for the patient after a craniotomy is semi-Fowler.
 Signs  of renal trauma include flank pain, hematoma and, possibly, blood in the urine and decreased urine output.
 Flank pain and hematoma in the back  indicate renal hemorrhage in the trauma patient.
 Natural diuretics  include coffee, tea, and grapefruit juice.
 Central venous pressure of  18 cm H2O indicates hypervolemia.
 Salmonellosis can be acquired by  eating contaminated meat such as chicken, or eggs.
 Good sources of  magnesium include fish, nuts, and grains.
 Patients who have low blood  urea nitrogen levels should be instructed to eat high-protein foods, such as fish and chicken.
 The nurse should monitor a patient who has  Guillain-Barré syndrome for respiratory compromise.
 A heating pad  may provide comfort to a patient who has pelvic inflammatory disease.
 After supratentorial surgery, the patient should be placed in the semi-Fowler position.
 To prevent deep vein thrombosis, the patient should exercise  his legs at least every 2 hours, elevate the legs above the level of the heart while lying down, and ambulate with assistance.
 After bronchoscopy, the  patient’s gag reflex should be checked.
 In a patient with  mononucleosis, abdominal pain and pain that radiates to the left shoulder may indicate a ruptured spleen.
 For a skin graft to take, it must be  autologous.
 Untreated retinal detachment leads to blindness.
 A  patient who has fibrocystic breast disease should consume a diet that’s low in caffeine and salt.
 A foul odor at the pin site of a patient who is in  skeletal traction indicates infection.
 A muscle relaxant that’s  administered with oxygen may cause malignant hyperthermia and respiratory depression.
 Pain that occurs on movement of the cervix, together with  adnexal tenderness, suggests pelvic inflammatory disease.
 The goal of  crisis intervention is to restore the person to a precrisis level of functioning and order.
 Nephrotic syndrome causes proteinuria, hypoalbuminemia, and  edema, and sometimes hematuria, hypertension, and a decreased glomerular filtration rate.
 Bowel sounds may be heard over a hernia, but  not over a hydrocele.
 S1 is decreased in first-degree heart block. S2  is decreased in aortic stenosis.
 Gas in the colon may cause tympany in  the right upper quadrant, obscure liver dullness, and lead to falsely decreased estimates of liver size.
 In ataxia caused by loss of position sense,  vision compensates for the sensory loss. The patient stands well with the eyes open, but loses balance when they’re closed (positive Romberg test result).
 Inability to recognize numbers when drawn on the hand with the  blunt end of a pen suggests a lesion in the sensory cortex.
 During the  late stage of multiple myeloma, the patient should be protected against pathological fractures as a result of osteoporosis.
 Tricyclic  antidepressants such as amitriptyline (Elavil) shouldn’t be administered to patients with narrow-angle glaucoma, benign prostatic hypertrophy, or coronary artery disease.
 Pulmonary embolism is characterized by a sudden, sharp,  stabbing pain in the chest; dyspnea; decreased breath sounds; and crackles or a pleural friction rub on auscultation.
 Clinical manifestations of  cardiac tamponade are hypotension and jugular vein distention.
 To avoid  further damage, the nurse shouldn’t induce vomiting in a patient who has swallowed a corrosive chemical, such as oven cleaner, drain cleaner, or kerosene.
 A brilliant red reflex excludes most serious defects of the  cornea, aqueous chamber, lens, and vitreous chamber.
 Oral hypoglycemic  agents stimulate the islets of Langerhans to produce insulin.  To treat  wound dehiscence, the nurse should help the patient to lie in a supine position; cover the protruding intestine with moist, sterile, normal saline packs; and change the packs frequently to keep the area moist.
 While a patient is  receiving an I.V. nitroglycerin drip, the nurse should monitor
his blood pressure every 15 minutes to detect hypotension.
 Any type of fluid loss  can trigger a crisis in a patient with sickle cell anemia.
 The patient  should rinse his mouth after using a corticosteroid inhaler to avoid steroid residue and reduce oral fungal infections.
 A patient with low levels of  triiodothyronine and thyroxine may have fatigue, lethargy, cold intolerance, constipation, and decreased libido.
 During a sickle cell crisis,  treatment includes pain management, hydration, and bed rest.
 A patient  who is hyperventilating should rebreathe into a paper bag to increase the retention of carbon dioxide.
 Chorea is a major clinical manifestation  of central nervous system involvement caused by rheumatic fever.
 Chorea  causes constant jerky, uncontrolled movements; fidgeting; twisting; grimacing; and loss of bowel and bladder control.
 Severe diarrhea can cause  electrolyte deficiencies and metabolic acidosis.
 To reduce the risk of  hypercalcemia in a patient with metastatic bone cancer, the nurse should help the patient ambulate, promote fluid intake to dilute urine, and limit the patient’s oral intake of calcium.
 Pain associated with a  myocardial infarction usually is described as “pressure” or as a “heavy” or “squeezing” sensation in the midsternal area. The patient may report that the pain feels as though someone is standing on his chest or as though an elephant is sitting on his chest.
 Calcium and phosphorus levels are elevated  until hyperparathyroidism is stabilized.
 The pain associated with  carpal tunnel syndrome is caused by entrapment of the median nerve at the wrist.
 Pancreatic enzyme replacement enhances the absorption of  protein.
 Laminectomy with spinal fusion is performed to relieve  pressure on the spinal nerves and stabilize the spine.
 A transection  injury of the spinal cord at any level causes paralysis below the level of the lesion.
 For pulseless ventricular tachycardia, the patient should be  defibrillated immediately, with 200 joules, 300 joules, and then 360 joules given in rapid succession.
 Pleural friction rub is heard in pleurisy,  pneumonia, and plural infarction.
 Wheezes are heard in emphysema,  foreign body obstruction, and asthma.
 Rhonchi are heard in pneumonia,  emphysema, bronchitis, and bronchiectasis.
 Crackles are heard in  pulmonary edema, pneumonia, and pulmonary fibrosis.
 The  electrocardiogram of a patient with heart failure shows ventricular hypertrophy.
 A decrease in the potassium level decreases  the effectiveness of cardiac glycosides, increases the possibility of digoxin toxicity, and can cause fatal cardiac arrhythmias.
 A 12-lead  electrocardiogram reading should be obtained during a myocardial infarction or an anginal attack.
 The primary difference between angina and the  symptoms of a myocardial infarction (MI) is that angina can be relieved by rest or nitroglycerin administration. The symptoms of an MI aren’t relieved with rest, and the pain can last 30 minutes or longer.
 Calcium channel  blockers include verapamil (Calan), diltiazem hydrochloride (Cardizem), nifedipine (Procardia), and nicardipine hydrochloride (Cardene).
 After  a myocardial infarction, electrocardiograph changes include elevations of the Q wave and ST segment.
 Antiarrhythmic agents include quinidine gluconate  (Quinaglute), lidocaine hydrochloride, and procainamide hydrochloride (Pronestyl).
 Angiotensin-converting enzyme inhibitors include captopril  and enalapril maleate (Vasotec).
 After a myocardial infarction, the  patient should avoid stressful activities and situations, such as exertion, hot or cold temperatures, and emotional stress.
 Antihypertensive drugs  include hydralazine hydrochloride (Apresoline) and methyldopa (Aldomet).
 Both parents must have a recessive gene for the offspring to  inherit the gene.
 A dominant gene is a gene that only needs to be  present in one parent to have a 50–50 chance of affecting each offspring.
 Bronchodilators dilate the bronchioles and relax bronchiolar  smooth muscle.  The primary function of aldosterone is sodium  reabsorption.
 The goal of positive end-expiratory pressure is to  achieve adequate arterial oxygenation without using a toxic level of inspired oxygen or compromising cardiac output.
 Furosemide (Lasix) is a loop  diuretic. Its onset of action is 30 to 60 minutes, peak is achieved at 1 to 2 hours, and duration is 6 to 8 hours for the I.M. or oral route.
 Pregnancy, myocardial infarction, GI bleeding, bleeding disorders, and hemorrhoids are contraindications to manual removal of fecal impaction.
 Ambulation is the best method to prevent postoperative atelectasis. Other measures include incentive spirometry and turning, coughing, and breathing deeply.
 The blood urea nitrogen test and the creatinine clearance test  measure how effectively the kidneys excrete these respective substances.
 The first sign of respiratory distress or compromise is  restlessness.
 The antidote for magnesium sulfate overdose is calcium  gluconate 10%.
 The antidote for heparin overdose is protamine  sulfate.
 An allergic reaction to a blood transfusion may include  flushing, urticaria, wheezing, and a rash. If the patient has any of these signs of a reaction, the nurse should stop the transfusion immediately, keep the vein open with normal saline, and notify the physician.
 A patient taking  digoxin and furosemide (Lasix) should call the physician if he experiences muscle weakness.
 A patient with basal cell carcinoma should avoid  exposure to the sun during the hottest time of day (between 10 a.m. and 3 p.m.).  A clinical manifestation of acute pain is diaphoresis.
 Gardnerella vaginitis is a type of bacterial vaginosis that causes a thin, watery, milklike discharge that has a fishy odor.
 A patient who is  taking Flagyl (metronidazole) shouldn’t consume alcoholic beverages or use preparations that contain alcohol because they may cause a disulfiram-like reaction (flushing, headache, vomiting, and abdominal pain).
 During the  administration of transcutaneous electrical nerve stimulation, the patient feels a tingling sensation.
 In patients with glaucoma, the head of the bed  should be elevated in the semi- Fowler position or as ordered after surgery to promote drainage of aqueous humor.
 Postoperative care after peripheral  iridectomy includes administering drugs (steroids and cycloplegics) as prescribed to decrease inflammation and dilate the pupils.
 Retinopathy  refers to changes in retinal capillaries that decrease blood flow to the retina and lead to ischemia, hemorrhage, and retinal detachment.
 Kegel  exercises are recommended after surgery to improve the tone of the sphincter and pelvic muscles.
 One of the treatments for trichomoniasis vaginalis is  metronidazole (Flagyl), which must be prescribed for the patient and the patient’s sexual partner.
 A common symptom after cataract laser surgery  is blurred vision.
 A patient with acute open-angle glaucoma may see  halos around lights.
 An Asian patient with diabetes mellitus usually  can drink ginseng tea.
 To prevent otitis externa, the patient  should keep the ears dry when bathing.
 Patients who receive prolonged  high doses of I.V. furosemide (Lasix) should be assessed for tinnitus and hearing loss.
 The treatment for toxic shock syndrome is I.V. fluid  administration to restore blood volume and pressure and antibiotic therapy to eliminate infection.
 In patients with glaucoma, beta-adrenergic  blockers facilitate the outflow of aqueous humor.
 A man who loses one  testicle should still be able to father a child.
 Native Americans are  particularly susceptible to diabetes mellitus.
 Blacks are particularly  susceptible to hypertension.
 Women with the greatest risk for cervical  cancer are those whose mothers had cervical cancer, followed by those whose female siblings had cervical cancer.
 A postmenopausal woman should  perform breast self-examination on the same day each month, for example, on the same day of the month as her birthday.
 Middle-ear hearing loss usually  results from otosclerosis.
 After testicular surgery, the patient should  use an ice pack for comfort.
 A patient with chronic open-angle glaucoma  has tunnel vision. The nurse must be careful to place items directly in front of him so that he can see them.
 Clinical signs of bacterial pneumonia  include shaking, chills, fever, and a cough that produces purulent sputum.
 Clinical manifestations of flail chest include paradoxical  movement of the involved chest wall, dyspnea, pain, and cyanosis.
 Right-sided cardiac function is assessed by evaluating central venous pressure.
 A patient with a pacemaker should immediately report an  increase in the pulse rate or a slowing of the pulse rate of more than 4 to 5 beats/minute.
 Dizziness, fainting, palpitation, hiccups, and chest pain  indicate pacemaker failure.
 Leukemia causes easy fatigability,  generalized malaise, and pallor.
 After cardiac catheterization, the  puncture, or cutdown, site should be monitored for hematoma formation.
 Kussmaul’s breathing is associated with diabetic  ketoacidosis.
 If the nurse notices water in a ventilator tube, she  should remove the water from the tube and reconnect it.
 Tamoxifen is an  antineoplastic drug that’s used to treat breast cancer.
 The adverse  effects of vincristine (Oncovin) include alopecia, nausea, and vomiting.
 Emphysema is characterized by destruction of the alveoli,  enlargement of the distal air spaces, and breakdown of the alveolar walls.
 To keep secretions thin, the patient who has emphysema should  increase his fluid intake to approximately 2.5 L/day.
 The clinical  manifestations of asthma are wheezing, dyspnea, hypoxemia, diaphoresis, and increased heart and respiratory rate.
 Extrinsic asthma is an  antigen–antibody reaction to allergens, such as pollen, animal, dander, feathers, foods, house dust, or mites.
 After endoscopy is  performed, the nurse should assess the patient for hemoptysis.
 Increased urine output is an indication that a hypertensive crisis has resolved.
 After radical mastectomy, the patient should be positioned  with the affected arm on pillows with the hand elevated and aligned with the arm.
 After pneumonectomy, the patient should perform arm exercises to  prevent frozen shoulder. BulletsBullets
 Left-sided heart failure causes  crackles, coughing, tachycardia, and fatigability. (Think of L to remember Left and Lungs.) Bullets
 Cardiac glycosides increase contractility and  cardiac output.
 Right-sided heart failure causes edema, distended neck  veins, nocturia, and weakness.
 Adverse effects of cardiac glycosides  include cardiac disturbance, headache, hypotension, GI symptoms, blurred vision, and yellow-green halos around lights.
 A patient who is receiving  anticoagulant therapy should take acetaminophen (Tylenol) instead of aspirin for pain relief.
 Adequate humidification is important after laryngectomy.  At home, the patient can use pans of water or a cool mist vaporizer, especially in the bedroom.
 Late symptoms of renal cancer include hematuria, flank  pain, and a palpable mass in the flank.
 Heparin is given  subcutaneously, usually in the lower abdominal fat pad.
 In a patient  with sickle cell anemia, warm packs should be used over the extremities to relieve pain. Cold packs may stimulate vasoconstriction and cause further ischemia. The extremities should be placed on pillows for comfort.  Sickle  cell crisis causes sepsis (fever greater than 102° F [38.9° C], meningeal irritation, tachypnea, tachycardia, and hypotension) and vaso-occlusive crisis (severe pain) with hypoxia (partial pressure of arterial oxygen of less than 70 mm Hg).
 Adverse effects of digoxin include headache, weakness, vision  disturbances, anorexia, and GI upset.
 To perform a tuberculosis test, a  26-gauge needle is used with a 1-ml syringe.
 Respiratory failure occurs  when mucus blocks the alveoli or the airways of the lungs.
 The patient  should be instructed not to cough during thoracentesis.
 The patient  should be instructed not to cough during thoracentesis.
 A patient who  has thrombophlebitis should be placed in the Trendelenburg position.
 Symptoms of Pneumocystis carinii pneumonia include dyspnea and nonproductive cough.
 To counteract vitamin B1 deficiency, a patient who has  pernicious anemia should eat meat and animal products.
 A patient who is  on a ventilator and becomes restless should undergo suctioning.
 Autologous bone marrow transplantation doesn’t cause graft-versus-host disease.
 A patient who has mild thrombophlebitis is likely to have mild  cramping on exertion.
 If the first attempt to perform colostomy  irrigation is unsuccessful, the procedure is repeated with normal saline solution.
 Breast enlargement, or gynecomastia, is an adverse effect of  estrogen therapy.
 In a patient who has leukemia, a low platelet  count may lead to hemorrhage.
 After radical neck dissection, the  immediate concern is respiratory distress as a result of tracheal edema.
 After radical mastectomy, the patient’s arm should be elevated  to prevent lymphedema.
 Hypoventilation causes respiratory  acidosis.
 The high Fowler position is the best position for a patient  who has orthopnea.
 A transient ischemic attack affects sensory and  motor function and may cause diplopia, dysphagia, aphasia, and ataxia.
 After mastectomy, the patient should squeeze a ball with the hand on the affected side.
 Cholestyramine (Questran), which is used to reduce the  serum cholesterol level, may cause constipation.
 Glucoco rticoid, or steroid, therapy may mask the signs of infection.
 Melanoma is most  commonly seen in light-skinned people who work or spend time outdoors.
 A patient who has a pacemaker should take his pulse at the same time every day.
 A patient who has stomatitis should rinse his mouth with mouthwash frequently.
 An adverse effect of theophylline administration is  tachycardia.
 The treatment for laryngotracheobronchitis includes  postural drainage before meals.
 After radical neck dissection, a high  priority is providing a means of communication.
 A high-fat diet  that includes red meat is a contributing factor for colorectal cancer.
 After a modified radical mastectomy, the patient should be placed in the semi- Fowler position, with the arm placed on a pillow.
 Knifelike,  stabbing pain in the chest may indicate pulmonary embolism.
 Esophageal  cancer is associated with excessive alcohol consumption.
 A patient who  has pancytopenia and is undergoing chemotherapy may experience hemorrhage and infection.
 A grade I tumor is encapsulated and grows by  expansion.
 Cancer of the pancreas causes anorexia, weight loss, and  jaundice.
 Prolonged gastric suctioning can cause metabolic  alkalosis.
 To measure the amount of residual urine, the nurse performs  straight catheterization after the patient voids.
 Dexamethasone  (Decadron) is a steroidal anti-inflammatory agent that’s used to treat brain tumors.
 Long-term reduction in the delivery of oxygen to the kidneys  causes an increase in erythropoiesis.
 A patient who subsists on canned  foods and canned fish is at risk for sodium imbalance (hypernatremia).
 Clinical signs and symptoms of hypoxia include confusion, diaphoresis, changes in blood pressure, tachycardia, and tachypnea.
 Red meat can cause a  false-positive result on fecal occult blood test.
 Carbon monoxide  replaces hemoglobin in the red blood cells, decreasing the amount of oxygen in the tissue.  Alkaline urine can result in urinary tract infection.
 Bladder retraining is effective if it lengthens the intervals between urination.
 Cheilosis is caused by riboflavin deficiency.
 The  concentration of oxygen in inspired air is reduced at high altitudes. As a result, dyspnea may occur on exertion.
 A patient who is receiving  enteric feeding should be assessed for abdominal distention.
 Thiamine  deficiency causes neuropathy.
 A patient who has abdominal distention as  a result of flatus can be treated with a carminative enema (Harris flush).
 Pernicious anemia is caused by a deficiency of vitamin B12, or  cobalamin.
 After a barium enema, the patient is given a  laxative.
 The appropriate I.V. fluid to correct a hypovolemic, or fluid  volume, deficit is normal saline solution.
 Serum albumin deficiency  commonly occurs after burn injury.
 Before giving a gastrostomy feeding,  the nurse should inspect the patient’s stoma.
 The most common  intestinal bacteria identified in urinary tract infection is Escherichia coli.
 Hyponatremia may occur in a patient who has a high fever and  drinks only water.
 Folic acid deficiency causes muscle weakness as a  result of hypoxemia.
 Dehydration causes increased respiration and heart  rate, followed by irritability and fussiness.
 Glucocorticoids can  cause an electrolyte imbalance.
 A decrease in potassium level decreases  the effectiveness of cardiac glycosides, increases possible digoxin toxicity, and can cause fatal cardiac arrhythmias.
 Diuresis can cause decreased  absorption of vitamins A, D, E, and K.
 Protein depletion causes a  decrease in lymphocyte count.
 To prevent paraphimosis after the  insertion of a Foley catheter, the nurse should replace the prepuce.
 Loop diuretics, such as furosemide (Lasix), decrease plasma levels of potassium
and sodium.
 After pyelography, the patient should drink plenty of  fluids to promote the excretion of dye.
 Potassium should be taken with  food and fluids.
 Proper measurement of a nasogastric tube is from the  corner of the mouth to the ear lobe to the tip of the sternum.
 Full  agonist analgesics include morphine, codeine, meperidine (Demerol), propoxyphene (Darvon), and hydromorphone (Dilaudid).
 Buprenorphine (Buprenex) is a  partial agonist analgesic.
 Poor skin turgor is a clinical manifestation  of diabetes insipidus.
 A patient who has Addison’s disease and is  receiving corticosteroid therapy may be at risk for infection.
 To  assess a patient for hemorrhage after a thyroidectomy, the nurse should roll the patient onto his side to examine the sides and back of the neck.
 A  patient who is receiving hormone therapy for hypothyroidism should take the drug at the same time each day.
 Hyperproteinemia may contribute to the  development of hepatic encephalopathy.
 To minimize bleeding in a  patient who has liver dysfunction, small-gauge needles are used for injections.
 A patient who has cirrhosis of the liver and ascites should  follow a low-sodium diet.
 Before an excretory urography, the nurse must  ask the patient whether he’s allergic to iodine or shellfish.
 A buffalo  hump is an abnormal distribution of adipose tissue that occurs in Cushing’s syndrome.
 Levothyroxine (Synthroid) is used as replacement therapy in  hypothyroidism.
 Levothyroxine (Synthroid) treats, but doesn’t cure,  hypothyroidism and must be taken for the patient’s lifetime. It shouldn’t be taken with food because food
may interfere with its absorption.
 Imipramine (Tofranil) with concomitant use of barbiturates may result in enhanced CNS depression.
 A patient who is receiving levothyroxine  (Synthroid) therapy should report tachycardia to the physician.
 The  signs and symptoms of hyperkalemia include muscle weakness, hypotension, shallow respiration, apathy, and anorexia.
 In a patient with well-controlled  diabetes, the 2-hour postprandial blood sugar level may be 139 mg/dl.
 A  patient who has diabetes mellitus should wash his feet daily in warm water and dry them carefully, especially between the toes.
 Acute pancreatitis  causes constant epigastric abdominal pain that radiates to the back and flank and is more intense in the supine position.
 Diabetic neuropathy is a  long-term complication of diabetes mellitus.
 Portal vein hypertension  is associated with liver cirrhosis.
 After thyroidectomy, the nurse  should assess the patient for laryngeal damage manifested by hoarseness.
 The patient with hypoparathyroidism has  hypocalcemia.
 A patient who has chronic pancreatitis should consume a  bland, low-fat diet.
 A patient with hepatitis A should be on enteric  precautions to prevent the spread of hepatitis A.
 The patient who has  liver disease is likely to have jaundice, which is caused by an increased bilirubin level.
 An adverse effect of phenytoin (Dilantin)  administration is hyperplasia of the gingiva.
 Hematemesis is a clinical  sign of esophageal varices.
 Fat destruction is the chemical process  that causes ketones to appear in urine.
 The glucose tolerance test is  the definitive diagnostic test for diabetes.
 Atelectasis and dehiscence  are postoperative conditions associated with removal of the gallbladder.
 After liver biopsy, the patient should be positioned on  his right side, with a pillow placed underneath the liver border.
 Categorized  Bullets
 Lugol’s solution is used to devascularize the  gland before thyroidectomy.  Cholecystitis causes low-grade fever, nausea  and vomiting, guarding of the right upper quadrant, and biliary pain that radiates to the right scapula.
 Early symptoms of liver cirrhosis  include fatigue, anorexia, edema of the ankles in the evening, epistaxis, and bleeding gums.
 The clinical manifestations of diabetes insipidus  include polydipsia, polyuria, specific gravity of 1.001 to 1.005, and high serum osmolality.
 The clinical manifestations of diabetes insipidus include  polydipsia, polyuria, specific gravity of 1.001 to 1.005, and high serum osmolality.
 Hypertension is a sign of rejection of a transplanted  kidney.
 Lactulose is used to prevent and treat portal-systemic  encephalopathy.
 Extracorporeal and intracorporeal shock wave  lithotripsy is the use of shock waves to perform noninvasive destruction of biliary stones. It’s indicated in the treatment of symptomatic high-risk patients who have few noncalcified cholesterol stones.
 Decreased  consciousness is a clinical sign of an increased ammonia level in a patient with kidney failure or cirrhosis of the liver.
 The pain medication that’s  given to patients who have acute pancreatitis is meperidine (Demerol).
 Prochlorperazine (Compazine), meclizine, and trimethobenzamide (Tigan) are used to treat the nausea and vomiting caused by cholecystitis.
 Obese women  are more susceptible to gallstones than any other group.
 Metabolic  acidosis is a common finding in acute renal failure.
 For a  patient who has acute pancreatitis, the most important nursing intervention is to maintain his fluid and electrolyte balance.
 After thyroidectomy, the  patient is monitored for hypocalcemia.
 In end-stage cirrhosis of the  liver, the patient’s ammonia level is elevated.
 In a patient who has  liver cirrhosis, abdominal girth is measured with the superior iliac crest used as a landmark.
 The symptoms of Alzheimer’s disease have an insidious  onset.
 Fracture of the skull in the area of the cerebellum may cause  ataxia and inability to coordinate movement.
 Serum creatinine is the  laboratory test that provides the most specific indication of kidney disease.
 A patient who has bilateral adrenalectomy must take cortisone  for the rest of his life.
 Portal vein hypertension causes esophageal  varices.
 Signs and symptoms of hypoxia include tachycardia, shortness  of breath, cyanosis, and mottled skin.
 The three types of embolism are  air, fat, and thrombus.
 Associations for patients who have had  laryngeal cancer include the Lost Cord Club and the New Voice Club.
 Before discharge, a patient who has had a total laryngectomy must be able to perform tracheostomy care and suctioning and use alternative means of communication.
 The universal blood donor is O negative.
 The  universal blood recipient is AB positive.
 Mucus in a colostomy bag  indicates that the colon is beginning to function.
 After a vasectomy,  the patient is considered sterile if he has no sperm cells.
 Fatigue is  an adverse effect of radiation therapy.
 To prevent dumping syndrome,  the patient’s consumption of high-carbohydrate foods and liquids should be limited.
 Cryoprecipitate contains factors VIII and XIII and fibrinogen  and is used to treat hemophilia.
 Insomnia is the most common sleep  disorder.
 Bruxism is grinding of the teeth during sleep.
 Elderly patients are at risk for osteoporosis because of age-related bone demineralization.
 The clinical manifestations of local infection in an  extremity are tenderness, loss of use of the extremity, erythema, edema, and warmth.
 Clinical manifestations of systemic infection include fever and  swollen lymph nodes.
 An immobile patient is predisposed to thrombus  formation because of increased blood stasis.
 Urea is the chief end  product of amino acid metabolism.
 Morphine and other opioids relieve  pain by binding to the nerve cells in the dorsal horn of the spinal cord.
 Trichomonas and Candida infections can be acquired  nonsexually.
 Presbycusis is progressive sensorineural hearing loss that  occurs as part of the aging process.
