Nursing 2 final exam review
Examples of passive immunity:
Breast milk colostrum from mother to child, and placenta.
Delegations, priority… on our own.
HIV –
When CD4 count is less than 200 AIDS is diagnosed, and high risk of developing serious illness.
When PT CD4 drops below 200 or below 500 with opportunistic infection. Treatment beings
with counts drop below 500. When there is fever, night sweats, severe cough and this client
CD4+cellcount is low, he or she may have anergy, or the inability to mount an immune response
to TB test. The nurse should first place the client on Airborne Precautions to prevent the spread
of TB if is present. Next the nurse notifies the provider about the low CD4+ count and
requests alterative testing for TB. Client with pneumocystic carrini, should pace activities and
allow for adequate rest.
Opportunistic disease for HIV.
toxoplasma gondii: use standard precaution consistently. (2) pneumonitis carinii or Jiroveci –
lab value CD4+ less than 200, low platelet and low sodium. (3) HIV wasting syndrome.
Treatment for type 1 allergies- anaphylactic reaction is (select all that apply ) –
EpiPen, and stay with the person always. When on IV antihistamine patient should not get up
without help because it causes drowsiness. After a patient has been stabilized after anaphylactic
reaction and still wheezing give albuterol.
Establish/maintain airway!! Raise feet and legs – tundenbug position Prevent spread of allergen,
0.3mL epinephrine IM, intubation kit – tracheostomy. Recumbent position, elevate legs, warm
patient, support respirations with O2,BP maintained with IV fluids , Benadryl, steroid.
Indication of albuterol:
used for wheezing as a bronchodilator.
DKA S/S:
DYHYDRATION, KAUSSMAUL BREATH, ABDOMINAL PAIN, FRUITY BREATH
.Hyperglycemia, Tachycardia, Orthostatic Hypotension, Ketones In The Urine, An Increased
Rate And Depth Of Respiration.
Illness, Undiagnosed And Untreated And Decreased Insulin.
ABGs for DKA
Metabolic Acidosis. Labs: glucose greater than 300 -600, PH less than 7.35, HNO3 15, PCO2
28, PO2 98, BUN more than 30, Creatine more than 1.5. Ketones in urine.
, Other Causes – PT Error, Intentional Skipping Of Insulin. Type 1 Diabetes. DKA with Kussmaul
respiration give IV insulin. A glass of wine is okay with meals and counted as two fat exchanges.
Medical Management of DKA:
Rehydrate with normal saline then .45% NaCl D5 .45NS, restore electrolytes, ECGs, hourly
blood sugars, IV insulin, avoid bicarb (it affects K).
Types of hypersensitivity reactions –
Type 1 (anaphylactic -Hypersensitivity – immediate reaction). Through contact, inhalation,
ingestion, or injection of allergen. Allergic reaction mediated by IgE antibodies, release of
histamine from cells, causing local or systemic reaction. Examples: Anaphylaxis, hay fever,
atopic eczema, drug allergy, latex allergy!
Type 2 (Blood transfusions – Hypersensitivity – Cytotoxic reaction)– Antibody is directed
against an individual’s own cells or foreign body, can be life threatening. Blood transfusions,
myasthenia gravis, autoimmune hemolytic anemia, good pasture syndrome.
EAR DROP TEACHING: Warm bottle of drops between hands before administration (rolling),
store in room temperature.do not expose to light, remove cerumen, do not use cotton tip swab.
massage the ear for absorption. Pull up &back for adult, and down and back for children.
BACTERIAL CONJUCTIVITIES TEACHING: Hand washing, keep hands away from eyes,
do not share wash cloth or towels, replace eye cosmetics and do not share, do not wear contact
lens until resolve, avoid rubbing eyes, instill eye drops/ointment correctly without touching tip of
container with eye or eyelashes. Two different bottles of the same medication to avoid cross
contamination.
NURSING INTERVENTION FOR MENIERE’S DISEASE: tell patient to be on low sodium
diet. Stop smoking, avoid caffeine. Client needs to be in bed with side rails up due to vertigo.
Avoid sudden position change, will need help out of bed. Monitor fluid intake and output. Menu
will be broiled chicken breast, and green herbal tea with meals.
Medications are Chlorpromazine, hydrochloride (Thorazine), Diphenhydramine (Benadryl) and
Meclizine(Antivert).
TIMOLOL TEACHING FOR GLAUCOMA: do not administer when pulse/HR is less than
60. Always check HR before administration. It lowers HR & IOP. Check BG.
EFFECTIVENESS OF HEALING FOR GLAUCOMA:
Reduces IOP.
PHOTOS DYNAMIC THERAPY FOR MACULAR DEGENERATION TEACHING:
Verteporfin for photo dynamic therapy. Teaching is to avoid sun exposure or bright indoor light
for 5 days postoperatively.
How to perform Rhine test, equipment: *The Rinne test is normal if air conduction is twice as
long as bone conduction. Rinne test: (air/bone)
Examples of passive immunity:
Breast milk colostrum from mother to child, and placenta.
Delegations, priority… on our own.
HIV –
When CD4 count is less than 200 AIDS is diagnosed, and high risk of developing serious illness.
When PT CD4 drops below 200 or below 500 with opportunistic infection. Treatment beings
with counts drop below 500. When there is fever, night sweats, severe cough and this client
CD4+cellcount is low, he or she may have anergy, or the inability to mount an immune response
to TB test. The nurse should first place the client on Airborne Precautions to prevent the spread
of TB if is present. Next the nurse notifies the provider about the low CD4+ count and
requests alterative testing for TB. Client with pneumocystic carrini, should pace activities and
allow for adequate rest.
Opportunistic disease for HIV.
toxoplasma gondii: use standard precaution consistently. (2) pneumonitis carinii or Jiroveci –
lab value CD4+ less than 200, low platelet and low sodium. (3) HIV wasting syndrome.
Treatment for type 1 allergies- anaphylactic reaction is (select all that apply ) –
EpiPen, and stay with the person always. When on IV antihistamine patient should not get up
without help because it causes drowsiness. After a patient has been stabilized after anaphylactic
reaction and still wheezing give albuterol.
Establish/maintain airway!! Raise feet and legs – tundenbug position Prevent spread of allergen,
0.3mL epinephrine IM, intubation kit – tracheostomy. Recumbent position, elevate legs, warm
patient, support respirations with O2,BP maintained with IV fluids , Benadryl, steroid.
Indication of albuterol:
used for wheezing as a bronchodilator.
DKA S/S:
DYHYDRATION, KAUSSMAUL BREATH, ABDOMINAL PAIN, FRUITY BREATH
.Hyperglycemia, Tachycardia, Orthostatic Hypotension, Ketones In The Urine, An Increased
Rate And Depth Of Respiration.
Illness, Undiagnosed And Untreated And Decreased Insulin.
ABGs for DKA
Metabolic Acidosis. Labs: glucose greater than 300 -600, PH less than 7.35, HNO3 15, PCO2
28, PO2 98, BUN more than 30, Creatine more than 1.5. Ketones in urine.
, Other Causes – PT Error, Intentional Skipping Of Insulin. Type 1 Diabetes. DKA with Kussmaul
respiration give IV insulin. A glass of wine is okay with meals and counted as two fat exchanges.
Medical Management of DKA:
Rehydrate with normal saline then .45% NaCl D5 .45NS, restore electrolytes, ECGs, hourly
blood sugars, IV insulin, avoid bicarb (it affects K).
Types of hypersensitivity reactions –
Type 1 (anaphylactic -Hypersensitivity – immediate reaction). Through contact, inhalation,
ingestion, or injection of allergen. Allergic reaction mediated by IgE antibodies, release of
histamine from cells, causing local or systemic reaction. Examples: Anaphylaxis, hay fever,
atopic eczema, drug allergy, latex allergy!
Type 2 (Blood transfusions – Hypersensitivity – Cytotoxic reaction)– Antibody is directed
against an individual’s own cells or foreign body, can be life threatening. Blood transfusions,
myasthenia gravis, autoimmune hemolytic anemia, good pasture syndrome.
EAR DROP TEACHING: Warm bottle of drops between hands before administration (rolling),
store in room temperature.do not expose to light, remove cerumen, do not use cotton tip swab.
massage the ear for absorption. Pull up &back for adult, and down and back for children.
BACTERIAL CONJUCTIVITIES TEACHING: Hand washing, keep hands away from eyes,
do not share wash cloth or towels, replace eye cosmetics and do not share, do not wear contact
lens until resolve, avoid rubbing eyes, instill eye drops/ointment correctly without touching tip of
container with eye or eyelashes. Two different bottles of the same medication to avoid cross
contamination.
NURSING INTERVENTION FOR MENIERE’S DISEASE: tell patient to be on low sodium
diet. Stop smoking, avoid caffeine. Client needs to be in bed with side rails up due to vertigo.
Avoid sudden position change, will need help out of bed. Monitor fluid intake and output. Menu
will be broiled chicken breast, and green herbal tea with meals.
Medications are Chlorpromazine, hydrochloride (Thorazine), Diphenhydramine (Benadryl) and
Meclizine(Antivert).
TIMOLOL TEACHING FOR GLAUCOMA: do not administer when pulse/HR is less than
60. Always check HR before administration. It lowers HR & IOP. Check BG.
EFFECTIVENESS OF HEALING FOR GLAUCOMA:
Reduces IOP.
PHOTOS DYNAMIC THERAPY FOR MACULAR DEGENERATION TEACHING:
Verteporfin for photo dynamic therapy. Teaching is to avoid sun exposure or bright indoor light
for 5 days postoperatively.
How to perform Rhine test, equipment: *The Rinne test is normal if air conduction is twice as
long as bone conduction. Rinne test: (air/bone)
