Cholinergic Crisis
The client presents with increased muscle weakness and twitching due to administration of tensilon
Stage II Lime Disease
Is characterized by joint pain as well as cardiac and neurological complications. If left untreated it may become chronic and lead to arthritis and peripheral neuropathy.
Correct sequence to respond with a Epi-Pen
1. Inject the pen
2.Remove the stinger
3. Clean with soapy water
4. Apply Ice
5. Get medical help
Adverse effect of Radiation therapy for laryngeal cancer.
Difficulty swallowing (it indicates a swelling of the esophageal tissue and may lead to malnutrition.)
A Possible intervention to Prevent Dumping syndrome post surgery.
Lie in supine position after meals (this will help food to move slower through the intestinal tract)
A decrease in Urine output
This may indicate a change in hepatic function and should be reported to the provider.
Subclavian insertion site for a client for 3-4 weeks.
directly below the clavicle with a triple lumen catheter.
What is the priority assessment for a client with a spinal injury
Peripheral reflex and sensation changes. (The greatest risk to the client is neurological damage and this would manifest )
Priority assessment for a client with status epilepticus having a seizure.
Level of oxygenation. Using the ABCs
Intervention for a client having a tonic-clonic seizure who has become cyanotic
Turn them onto their side. This will provide a patent airway.
Highest priority in a casted patient
Decreased blood flow past the casted area (may be manifested by decreased pulse pressure)
First priority for a client with a fever cough and sweating
Initiate airborne precautions
Priority intervention post any type of transplant
Provide immunosuppressive agents
Post TB treatment instructions
After three negative sputum cultures the client is considered non-infectious.
Teaching for IBS
Increase daily intake of fiber because it helps produce bulky soft stools and establish patterns of bowel relief.
Placement of leads for ECG
Flat surfaces on extremities.
Assessment for a client receiving Heparin
Petechiae (
Teaching for client with a hearing aid
Background noises are often a challenging and will require some adjustment
Teaching for clients with arthritis
Consistency of exercise schedule is important.
Possible complication post Eye surgery
Moderate pain and vomiting (this may represent intraocular pressure or hemorrhage)
Possible complication of a TERP surgery
The client has red colored urine with occasional clots (this could represent arterial bleeding)
A sign of digoxin toxicity
Visual disturbances
Important to report about IV insertion site
Swelling (this could mean infiltration or leakage at the insertion site.)
Adverse side effect of Mannitol
Headache (notify the physician immediately)
This assessment finding signifies Hemolytic transfusion reaction.
low back pain and apprehension.
Ibuprofen common side effect
GI bleending
Acetylcisteine (Mucomyst)
This drug is used to thin secretions in the pulmonary making it easier for the client to cough up stuff.
Common side effect of iron supplement
Constipation (recommend an increase in dietary fiber for this client.)
Placement of client for insertion of subclavian IV catheter.
Trendelenburg position.
A finding of Tension Pneumothorax
Chest asymmetry.
In diabetic keytone acidosis
The blood glucose level is above 300
Nursing intervention post Thyroidectomy
Provide humidified oxygen (this promotes easier breathing and can relieve some muscle and nerve distress)
Treatment for biliary Colic ( spasms)
Anticholinergics. (these are muscle relaxers and will relieve spasms)
This is a positive response to HIV treatment
a decrease in viral load
Proprnolol Hydrochloride is a beta Blocker
non-selective beta blockers cause broncho-constriction especially in clients who have a pre-existing respiratory disorder
High priority for a client that had a left sided CVA
Monitor the clients gag reflex
Burn victim priority assessment
Glasgaow coma scal of 9 that may represent a systemic infection
when assessing a client with a rash you should
first ask what medications they are taking (to check for any allergic reactions to meds)
renal failure puts you at risk for
Digoxin toxicity.
Malignant Hyperthermia is manifested by
a rapid heart rate
Priority finding in a patient with Hyperthyroidism
a blood pressure above 170 mm Hg (This signifies a thyroid storm)
The anticoagulant in heparin
presents a risk of bleeding
Abnormal finding post hemodialysis
Decreased LOC
Intervention for Left Sided Heart Failure
Auscultate the lungs. (pulmonary edema is a clinical manifestation of Left sided heart failure)
What should you do to prevent irritation of the skin around an illeostomy
Instruct the client to use a skin barrier to prevent skin breakdown
This is an adverse effect of Furosemide
A depletion of sodium below 135
These signs are idicative of Increased intracranial pressure
Papilledema, Cushings trian, slurred speech, and Decorticate Posturing
Viagra is a vaso-dialator
So it should not be used with other vaso-dialators or there is a risk of hypotension
This is a poor finding in a patient being treated for heart failure
Weight gain
Finding that the Pneumothorax chest tube is fuctioning properly
the water level is fluctuating in the chamber (the water should rise and fall with the clients breaths)
Priority intervention for a client post operative with an evisceration.
Apply a sterile saline soaked towel to protect the innards
What client history requires a nurse to interven for a client that needs a CT scan with Iodine
A shellfish allergy
One of the first signs of hemorrhage is
an increased heart rate
Medications that are time released
should not be opened
Puffs with a prednisone inhaler
should be spaced 1 minute apart
In Bucks Traction
the weights should always hang freely
Sequential treatment for a client that has Hemorrhagic Shock
1.Administer oxygen
2.Initiate IV Therapy
3.Insert NG tube
4.Administer rantadine
When a pulse oximeter provides you with an abnormal reading what is the first intervention
check the pulse oximeter and take it again
When administering medication IM and you aspirate blood you should
dispose of the medication and start over at a new site
How do you verify the placement of an NG tube that was inserted a week ago
Check the PH of the aspirated fluid
Non-Pharmacological intervention for Rheumatoid Arthritis
Alternately apply heat and cold to the affective joints.
A hemoglobin blood test is conducted to check
the oxygen carrying capacity of the blood
When presented with a bacterial infection who should you room the client with
with someone with a similar infection (Ex. Acid-fast bacilli and tuberculosis)
Common side effects of Morphine are
Nausea and vomiting (so the nurse should be prepared to administer an antiemetic)
How do JP drains work
they are compressed and create negative pressure to remove fluid from drain sites
During peritoneal dialysis what is an appropriate intervention if the fluid is draining to slow
turn the patient on their side
it is standard to stay with a client for the first 30 min of a RBC transfusion because
most transfusion reactions happen during this time and during the first 50-100ml of blood product
What should be done to prevent injury to the pharnageal mucosa during suctioning
suction intermittently when removing the suction catheter
What should you do for a client using mechanical ventilation and is anxious and restless
tell them to let the machine breathe for you
To prevent infection while administering TPN via IV
the nurse should place an occlusive dressing over the insertion site
Low prealbumin places the client at risk for what
skin breakdown (normal prealbumin 23-43)
Proper teaching for a client with an ICD (defibrilator)
Notify all care providers
Positive result of an albuterol nebulizer
an increase in SaO2 above 92%
Ibuprofen is an anticoagulant
and should be reported to the surgeon before any operations
Lack of consciousness
indicates that a client is unstable and requires defirilation
When should a nurse stop suctioning an endotracheal tube
when the clients pulse rate drops (this means you are stimulating the vagal nerve)
A good intervention for heat stroke is
placement of a cooling blanket
During chemotherapy it is important to monitor
the stools for blood because this can be a sign of bone marrow suppression and thrombocytopenia
An increase in external catheter length means
that the catheter has become dislodged.
Shingles patients should be isolated becuase
they are an airborne pathogen
When a patient has a history of seizures it is important to
keep a patent IV access in case the client needs to be administered Seizure halting medications
When should metformin be taken
in the evening with meals PO to slow the release of the medication.
a bad indication of the placement of a nephrostomy tube is
back pain (it signifies dislodgement or a clogged tube)
What should a patient with a cast report to a physician
pain not relieved by analgesics (this could signify compartment syndrome