1.Fill in the Blank: Clients with MG have a marked reduction of _______.

**** Clients with MG have a reduction of neurotransmitter – Acetylcholine) Prevent

inactivation of Ach by cholinesterase. Intensify the effects of Ach released from motor neurons -
increases muscle strength in successive action potentials. The injection of
edrophonium; marked improvement in muscle strength in the client does not show signs of
muscle improvement in the client's strength.
2.What are some triggering factors for myasthenia gravis?
*** The triggering factors of myasthenia gravis were:
-infection
-stress
-Fatigue
-cathartics (laxatives)
-Heat - saunas, hot tub, sunbathing
3.Compare/contrast Myasthenic crisis and Cholinergic crisis.
To help differentiate between a myasthenic crisis (a worsening of the disease that
necessitates therapy with anticholinesterase drugs)and a cholinergic crisis (caused by an
overdose of anticholinesterase drugs). Both conditions are marked by severe muscle
weakness and breathing difficulty.
Cholinergic Crisis
How does it happen? It happens due to excessive stimulation at the neuromuscular junction by
acetylcholine (too much ACh available) which leads to overdrive in cholinergic response.
Causes: overmedication of anticholinesterase medication given in myasthenia gravis
Why? these medications stop the breakdown of acetylcholine, so there is MORE available
at the neuromuscular junction. This is great for treating myasthenia gravis, but too much of the
medication can cause cholinergic crisis and overstimulates the muscle fiber where it will
eventually quit contracting.
Signs and Symptoms:
Muscle fibers have had enough of the stimulation so they quit responding to the impulse
which will lead to:
Respiratory failure
Muscle weakness
However, other signs and symptoms that will present are similar to parasympathetic
stimulation (the “rest and digest” system), but in OVERDRIVE!!
 GI issues: vomiting, diarrhea, cramping
 Pupil constriction
 Increase salivation and tear production….blurred vision and increase respiratory
secretions
 Muscle fasciculation/twitching…from overstimulation eventually paralysis
 Low blood pressure and heart rate
So, other than the symptoms how are these conditions diagnosed?
Tensilon Test: Edrophonium is given, which is an anticholinesterase inhibitor, and this will
cause the patient to experience even more weakness (adding more ACh at the site…it is not
needed because there is already enough ACh at the neuromuscular junction site causing
overstimulation). The patient’s signs and symptoms will not respond but become worsen
finding: NEGATIVE result
Treatment: HOLD anticholinesterase medication and administer atropine (antidote) per MD
order.

Myasthenic Crisis
How does it happen? It happens due to low to no stimulation at the neuromuscular junction by
acetylcholine (receptors are not available to do their job because of antibodies attacking the
receptors), which leads to severe muscle weakness.
Causes: insufficient amounts of anticholinesterase drug or an illness (respiratory infection) stress
etc. that has created exacerbation of the disease myasthenia gravis.
Signs and Symptoms:
Remember no receptors are available to receive the ACh so there is NO stimulation of the muscle
fiber, which leads to NO contraction but flaccidity.
(note: both conditions will have):
Respiratory failure
Muscle weakness
However, signs and symptoms will affect all voluntary muscles making them flaccid (from eyes
to bowels):
 pupils dilated
 tachycardia/HTN
 no cough or gag
 aspiration (can’t swallow or cough)
 incontinence (no muscle strength) of both bowel and bladder
How to tell the difference other than symptoms:
Tensilon Test: Edrophonium is given, which is an anticholinesterase inhibitor, and this will
cause the patient to experience IMPROVED muscle strength (adding more ACh at the
neuromuscular junction because it inhibits the breakdown of ACh)….signs and
symptoms temporarilydiminish…..findings: POSITIVE result

4.You are caring for a client who has just arrived into the emergency department with a
greenstick fracture. What nursing interventions would you provide for this client?

Greenstick fracture is a Non-accidental injury more commonly causes spiral

(twisting) fractures but a blow on the forearm or shin could cause a green stick fracture. The
fracture usually occurs in children and teens because their bones are flexible,
unlike adults whose more brittle bones usually break.
For this procedure, you may be given pain medication or sedatives, or occasionally
general anesthesia, as the procedure can be quite painful. Most greenstick fractures are treated
with a cast. This helps not only to keep the bones in place as they heal, but also to prevent further
breakage of the already damaged bone.
5. The nurse is caring for a client with a traumatic injury to the right ankle. The client has
an unstable fracture with only a temporary splint in place. The client is having increased
pain that is unresolved with IV narcotics and has 4+ edema, pallor, and uselessness of the
right foot. What should the nurse suspect and what interventions should be taken?

**** Any suspected fracture (broken bone) or dislocation should be splinted, immobilized, or
both. An effective splint helps to prevent further injury and to provide substantial pain
relief. Splints can be ready-made or can be made from basic materials. Cutaneous edema is
 referred to as "pitting" when, after pressure is applied to a small area, the indentation persists
after the release of the pressure. Non-pitting edema is observed when the indentation does not
persist. It is associated with such conditions as lymphedema, lipedema, and myxedema.
Clear fluid blisters have separated within the epidermis, and hemorrhagic blisters separate at the
dermal-epidermal junction. The clinical difference is healing time; clear blisters take about 12
days and hemorrhagic blisters heal in about 16 days.
To reduce pain and swelling:
1. Sit with your foot elevated higher than your knee at least 4 times a day.
2. Apply an ice pack 20 minutes of every hour you are awake for the first 2 days.
3. After 2 days, use the ice pack for 10 to 20 minutes, 3 times a day as needed.
6.A client has a new diagnosis of genital herpes. Which of the following medications should
the nurse expect to see prescribed?
**** A. Acyclovir (Zovirax),
A. Acyclovir
B. Podophyllin
C. AZT
D. Isoniazid

7.A nurse administers erythromycin ointment (0.5%) to the eyes of a newborn infant, and
the mother asks the nurse why this is performed. The best response by the nurse would be
that it is to:

A. Prevent cataracts in the newborn infant born to a woman who is susceptible to rubella.
B. Protect the newborn infant’s eyes from possible infections acquired while hospitalized.
C. Minimize the spread of micro-organisms to the newborn infant from invasive
procedures during labor.
D. Prevent ophthalmia neonatorum from occurring after delivery in a newborn infant born
to a woman with an untreated gonococcal infection.
**** D. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a
newborn born to a woman with an untreated gonococcal infection.

Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for

ophthalmia neonatorum, which is caused by the bacterium Neisseria gonorrhoeae. Preventive
treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes for
administering this medication to a newborn infant.
8.What are the complications of Sexually Transmitted Infections (STIs)?
**** Anyone who is sexually active risks exposure to a sexually transmitted infection to some
degree. Factors that may increase that risk include: Having unprotected sex.Vaginal or anal
penetration by an infected partner who isn't wearing a latex condom significantly increases the
risk of getting an STI.
9.Interpret the ABG: pH 7.34 (low), PaCO2 60 mmHg (high), HCO-3 21 mEq/L (normal),
PaO2 80 mmHg (normal).
*** Unable to determine disorders

Normal Arterial Blood Gas Values

pH 7.35-7.45
PaCO2 35-45 mm Hg
PaO2 80-95 mm Hg
HCO3 22-26 mEq/L
O2 Saturation 95-99%
BE +/- 1

10.Interpret the ABG: pH 7.50 (high), PaCO2 30 mmHg (low), HCO-3 24 mEq/L (normal),
PaO2 90 mmHg (normal).
acute respiratory alkalosis
11.Interpret the ABG: pH 7.31 (Low) , PaCO2 30 mmHg (low), HCO-3 18 mEq/L (low),
PaO2 60 mmHg (low).
Partly compensated metabolic acidosis
12.Interpret the ABG: pH 7.45 (normal), PaCO2 50 mmHg (high), HCO-3 30 mEq/L
(high), PaO2 65 mmHg (low).
 Compensated Respiratory Acidosis
13.The nurse has just received an order to transfuse 1 unit of Packed RBCs. What are the
next steps in the process?
**** Change in vital signs during the transfusion from the baseline may indicate that a
transfusion reaction is occuring. This is why nurse assesses vital signs before the procedure and
again after 15 mintues. The other options do not identify assessment that are required just before
beginning a transfusion.
14. During bedside report the oncoming nurse notes that the client is receiving a unit of
Packed RBCs that are type A-. The client’s chart reveals that the client is blood type AB+.
What should the nurse’s next action be?
*** When a transfusion is given, it is preferable for patients to receive blood and plasma of the
same ABO and RhD group. However if the required blood type is unavailable, a patient may be
given a product of an alternative but compatible group as shown below.
Blood Compatibility

Patient Type Compatible Red Cell Types Compatible Plasma Types

(FFP & Cryoprecipitate)

A A, O A, AB

B B, O B, AB

O O O, A, B, AB

AB AB, A, B, O AB

RhD Positive RhD Positive

RhD Positive
RhD Negative RhD Negative

RhD Positive
RhD Negative RhD Negative
RhD Negative

Note that Group O RhD negative (O negative) red cells have neither ABO nor RhD
antigens on their surface. O RhD negative red cells are issued in emergency situations where life
saving transfusion is required prior to completion of a crossmatch. Both RCH and RWH blood
banks maintain a reserve of 5 emergency O RhD Negative red cells. (Click here for further
information on emergency blood release). Group O is often referred to as the universal red cell
donor.
Group AB individuals have neither anti-A nor anti-B antibodies in their plasma. Group
AB plasma can therefore be given to patients of any ABO blood group and is often referred to as
the universal plasma donor.

15.The nurse is caring for a client that is receiving a unit of Fresh Frozen Plasma after a
significant burn. The client start to complain of itching, feeling flushed, and difficulty
breathing. Explain the priority nursing interventions.
*** According to the Infusion Nurses Society and "Core Curriculum for Infusion Nursing"
PRBC's may infused over 1-2 hours but must be infused within 4 hours. FFP should
be administered at 200 mL/hr or slower if potential for overload. Platelets as fast as tolerated by
patient.
Each unit contains between 200 and 250 ml of plasma and will raise plasma factor levels
by 3-5%. Cross-matching is not required for transfusion, but type-specific or ABO-compatible
plasma must be selected. Plasma can be transfused as FFP for 24 hours after thawing.
Fresh frozen plasma (FFP) is a blood product made from the liquid portion of whole blood.
It is used to treat conditions in which there are low blood clotting factors (INR>1.5) or low levels
of other blood proteins.
 Pre-medicate with antihistamine per order;
 if it occurs, stop infusion & give diphenhydramine (Benadryl);
 you may restart infusion per order if reaction is mild.