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NCLEX: Prioritization, Delegation, And Assignment 5th Edition > Case Study 3, 4, 5 > Flashcards

Case Study 3, 4, 5 Flashcards

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1
Q

Chest pain what is the first intervention

  1. Nitroglycerin 0.6 mg sublingual up to 3x spaced 5 min apart.
  2. Morphine IV 2mg push
  3. Check BP & HR
  4. Lab test fir cardiac markers & daily electrogram
A
  1. Check BP & HR
    (Establish Baseline)

Then

  1. Nitroglycerin 0.6 mg sublingual up to 3x spaced 5 min apart, check VS between doses.

Then if that doest work

  1. Morphine IV 2mg push
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2
Q

Chronic emphysema, feels SOB after walking. What should RN do first

  1. Notify HCP
  2. Increase Ox to 6/L via nasal Cannula
  3. Assess Ox Sat
  4. Remind client to cough and deep breath
A
  1. Assess Ox Sat

Always assess first unless a Loss of Life will occur or serious illness.

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3
Q

Notify HCP immediately

  1. Bilateral pitting edema ankle & calf rated +2
  2. Crackles in lower & middle lungs
  3. Dry peeling skin both feet
  4. Faint but palpable pedal & post-tibial pulse
A
  1. Crackles in lower & middle lungs
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4
Q

107 - 139 Men
87 - 107 Women

Are normal Values associated with 24 hr creatinine clearance.

What do high or low values signify

A

Both signify kidney disease/ damage

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5
Q

Fluid & Food restrictions on Hemodyalsis

A

Fluid 32 - 50 oz daily

Protein, potassium, phosphorus, sdoium

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6
Q

Why can’t a HD shunt placed in the left forearm be used for blood draws.

A

Risk of infections

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7
Q

Which statement will cause the RN supervisor to intervene for a CKD patient recieving hemodyalsis

  1. Sevelamer prevents your body from absorbing phosphate
  2. Take Folic acid after dialysis
  3. Take docusate to prevent Constipation that maybe caused by ferrous Sulfate
  4. Take epoetin alfa 3x weekly PO to treat anemia
A
  1. Take epoetin alfa 3x weekly PO to treat anemia.

Epoetin alfa to stimulate RBC production is given SQ or IV

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8
Q

1 day post-op kidney transplant. Temp 100.4, BP 168/92, Pain around transplant site. Best interpretation of the findings

  1. Hyperacute rejection
  2. Acute rejection
  3. Chronic rejection
  4. Transplant site infection
A
  1. Hyperacute rejection

Hyperacute rejection occurs 48 hrs after transplant surgery.

Acute rejection: occurs within the first few months.

Chronic rejection: happens after a year or at any time beyond.

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9
Q

What intervention is done for a Hyperacute rejection?

  1. Increased dosage of immunosuppressant medications
  2. IV antibiotics
  3. Conservative management including dialysis
  4. Immediate removal of transplanted kidney
A
  1. Immediate removal of transplanted kidney for Hyperacute rejection

Increased dose of immunosuppressant = Acute rejection

Conservative management = Chronic rejection

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10
Q

What is the priority nursing concept to consider when planning the emergency interventions for DKA

  1. Gas exchange
  2. Acid-base imbalance
  3. Fluid & electrolyte imbalance
  4. Adherence
A
  1. Fluid & electrolyte imbalance
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11
Q

Dehydration with DKA

When are the following fluids used.

Potassium supplements
5% Dextrose
0.9 NS

A

0.9 NS first fluid to correct dehydration in DKA

Potassium within 1 or 2 hrs after starting insulin

5% Dextrose when BS is approaching 250

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12
Q

Initially woth DKA potassium levels are _____

After insulin therapy expect _____ levels of potassium

A

Initially woth DKA potassium levels are (Norm / Elevated)

After insulin therapy expect (Low) levels of potassium

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13
Q

19 yr is hospitalized and doesn’t want his parents to know. He states: Please don’t call my mother. If she knows I’m in the hospital she will make me quit school and live with her.”
What is the best therapeutic communication

  1. None of the staff will tell her, but you should
  2. Your mom loves you and is concerned with your well-being
  3. It sounds like you want to be independent & responsible for yourself
  4. You are an adult, you have the right to make your own decisions.
A
  1. It sounds like you want to be independent & responsible for yourself

Acknowledge & Reflect statements is good therapeutic communication

1 & 4 give unsolicited advice
2 is platitude that is not supported by 1st hand knowledge

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14
Q

After treatment with Insulin for DKA in the critical phase the patient has a BS of 150. What should be the first action taken….

A

Notify HCP & infuse 10% glucose

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15
Q

Signs of hypokalemia

  1. Fatigue
  2. Cold, clammy skin
  3. Muscle weakness
  4. Hypotension
  5. Weak Pulse
  6. Shallow respirations
A
  1. Fatigue
  2. Muscle weakness
  3. Hypotension
  4. Weak Pulse
  5. Shallow respirations
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16
Q

Acute cholecystitis and a brief/ incomplete hand-off report. What is the priority question for the receiving nurse

  1. What are her vital signs
  2. Is she going to surgery or radiology this AM
  3. Is she still in pain
  4. Does she need any morning medications
A
  1. Is she going to surgery or radiology this AM

This will alter way you take care of her

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17
Q

Bowel obstruction HCP has dose of Psyllium prescribed standing order. The nurse want to give this med. But before doing so ask another nurse what she thinks. Which is the best response

1.Call HCP & verify if the standing order applies for this patient

  1. Give Psyllium accordingly to standing orders

3 Laxatives can cause bowel perforation if there is bowel perforation

  1. Client can’t be constipated they are on NPO
A

3 Laxatives can cause bowel perforation if there is bowel perforation

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18
Q

Bowel obstruction patient feels weak, confused. Her NG drainage container has large amounts of watery bile-colored fluid. Which lab value should be checked first

  1. BUN & Creatinine
  2. Platelets & WBC
  3. NA, K, pH
  4. Bilirubin, hematocrit, hemoglobin
A
  1. NA, K, pH

NG suction causes loss of NA / K.
Results = Metabolic Alkalosis

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19
Q

UC which situation needs immediate investigation

  1. Senna given yesterday AM
  2. One dose Atropine Sulfate was given yesterday
  3. IV infusion infliximab 5mg/kg
  4. IV hydrocortisone 100 mg
A
  1. Senna given yesterday AM

Laxatives are generally n9t given to UC patients

Atropine sulfate = Antidiarrheal (use sparingly)

Infliximab & hydrocortisone Both reduce inflammation

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20
Q

Sulfasalazine (Anti-inflammatory)
Which would you report immediately

  1. Decreased appetite
  2. N/V
  3. Decreased urine output
  4. Headache
A
  1. Decreased urine output

Nephron toxic

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21
Q

Acute pancreatitis: Develops dry cough, left-sided chest pain, SOB, low grade fever. Which complication does the nurse suspect

  1. Hypovolemic shock
  2. Pleural effusion
  3. Paralytic ileus
  4. Acute Respiratory Distress Syndrome
A
  1. Pleural effusion
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22
Q

Acute pancreatitis small amount of blood oozing from insertion site & palm shapped bruises on anterior lateral humerus. First action

  1. Remove IV line and restart at different site
  2. Remind UAP to handle clients gently
  3. Assess for other signs of obvious or Occult bleeding
  4. Obtain order for coagulation studies

Why is this a major concern

A
  1. Assess for other signs of obvious or Occult bleeding

Acute pancreatitis can lead to Disseminated intravascular coagulation DIC which can be fatal

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23
Q

Which is better for RA in the AM

Warm shower

Or

Bath

A

Shower

It is hard to get in and out of bath

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24
Q

New nurse tells team leader that she cannot find documentation that shows the time of Mr. GreenJeans last pain medication. What action should the team lead do?

1.Help the new nurse look it up in the MAR
2. Tell the new nurse to ask the night nurse before she leaves.
3. Speak to the night shift nurse about documentation
4. Have new nurse ask the patient

A
  1. Tell the new nurse to ask the night nurse before she leaves.

As a team lead attempt to have staff figure things out between themselves

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25
Q

Long-term opiod use to control pain from multiple myeloma. Which side effect is of major concern.

  1. Constipation
  2. Respiration
  3. N/V
  4. Sedation
A
  1. Constipation

Constipation is the only SE that one does not build a tolerance to.

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26
Q

End stage multiple myeloma medication list. Which one would you question

  1. Naltrexone
  2. Fentanyl
  3. Morphine
  4. Acetaminophen
A
  1. Naltrexone

Narcan (Naltrexone) is an opiod Antagonist

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27
Q

Match

Naproxex, Doxepin, Lorazepam, Dicyclomime

Anxiolytic, NSAID, Depression/ Neuropathic Pain, Muscle Spasms

A

Naproxex: NSAID
Doxepin: Neuropathic Pain
Lorazepam: Anxiolytic
Dicyclomime: Muscle Spasms

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28
Q

ED patient arrives stating vomited bright red blood 2x in last 6 hrs. Which task would the nurse perform first

  1. Draw blood for cbc & type cross match
  2. Establish 2 peripheral IV lines with 16 gauge catheters
  3. Insert NG tube and observe gastric contents
  4. Repeat vital signs and apply pulse ox
A
  1. Establish 2 peripheral IV lines with 16 gauge catheters

Hypovolemia due to blood loss is the concern.

UAP can do VS Not necessary for nurse to do it

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29
Q

ED client arrived having vomited blood 2x in last 6 hrs. Which finding should be immediately reported

  1. Melena stools
  2. History of NSAID use
  3. Tense & rigid abdomen
  4. Risk factors for HIV
A
  1. Tense & rigid abdomen

Tense & rigid abdomen signals perforation, peritonitis, or worsening hemorrhage

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30
Q

Uncooperative states they will leave if you put a NG tube in their nose. What should nurse do first

  1. Physically restrain and insert tube
  2. Explain the AMA form
  3. Notify nursing supervisor & patient advocate
  4. Page HCP & document attempt
A
  1. Page HCP & document attempt

HCP can order restraints if patient cannot make safe decisions.

HCP may try to convince or have them sign AMA form.

Nursing supervisor & advocate can be notified if situación escalates

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31
Q

NG tube inserted. Which is greatest cause for concern

  1. Reports tube is irritating nose and throat feels sore
  2. Gastric contents have a coffee-ground appearance
  3. Patient coughs frequently and connect speak clearly
  4. Gastric fluid is bright red & small clots
A
  1. Patient coughs frequently and connect speak clearly

Tube was inserted in trachea. Remove immediately.

Findings of blood should be reported but are less urgent than a tube in the trachea

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32
Q

Lab informs nurse that phlebotomist may have mislabeled or drawn sample from other patient in a STAT order. What should the nurse do first.

  1. Call phlebotomist to come back
  2. Draw a new blood sample and lable it.
  3. Report the phlebotomist to their supervisor
  4. Ask phlebotomist to explain what happened
A
  1. Draw a new blood sample and lable it.

STAT order needs to be done STAT

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33
Q

Blood Transfusion. IRN is 2.5 what action should be taken next

  1. No action this is within normal findings for GI bleeding
  2. HCP notified for possible prescription of FFP Fresh Frozen Plasma
  3. Laboratorio findings should be reevaluated at completion of treatment
  4. Contact Blood bank for additional units of packed RBC
A

HCP notified for possible prescription of FFP Fresh Frozen Plasma

FFP contains coagulation factors that will clot the blood.

IRN should normally be <1.1

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34
Q

Describe the following values on the Glassgow Coma Scale

13 to 15:
9 to 12:
3 to 8:

A

15 is Best possible score

13 - 15 Mild traumatic brain injury (mTBI). Also known as a concussion.

9 - 12 Moderate TBI

3 - 8 Severe TBI

3 is No response at all

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35
Q

Decorticate Posturing/ Decerebrate Posturing

Both describe abnormal body posistions associated with Injury / Disease to brain

(Stiff legs held out straight, Arms bent to chest wrist & fingers bent, Toes pointed downward, Fist clenched, arched backward head, unresponsiveness)

(Arms held to side of body with palms away from body and fingers curled, Toes pointed downward and inward, head arched backwards)

A

Decorticate Posturing

Stiff legs held out straight, Arms bent to chest wrist & fingers bent, Toes pointed downward, Fist clenched, arched backward head, unresponsive

Decerebrate posturing
Arms held to side of body with palms away from body and fingers curled, Toes pointed downward and inward, head arched backwards

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36
Q

Babinski sign is used to check for damage to brain or spinal cord. Describe the process

A

Stroke the sole of the foot

Positive Babinski sign is when the big toe extends upward and the other toes fan out.

A normal response is when the toes curl downward and bow

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37
Q

Increases ICP in ED. Which nurse is best for primary care

  1. RN from temp agency with extensive previous emergency care who has been working on the ED for 3 days
  2. LPN with 10 years experience in ED who is in last semester of RN program
  3. RN who worked in ED for the past 5 years after transferring from the mother baby unit.
  4. RN with 12 years ICU experience and floated to ED today.
A
  1. RN who worked in ED for the past 5 years after transferring from the mother baby unit.

Familiarity with location of equipment and organization of care in ED

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38
Q

Patient fell from 2nd story. Fixed & dilated pupils, widened pulse pressure 190/ 40, and Bradycardia are all causes by increasing pressure on brainstem and indicate she is at risk for…

A

Brainstem herniation (results in brain death)

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39
Q

MAP 80 - ICP 22 = CPP 58

What does this represent

A

Mean arterial pressure (Mean pressure of arteries: MAP = 0.42×SBP + 0.58× 64

Minus

ICP = Norm range (0 - 15)

EQUALS

Cerebral Perfusion Pressure

(Amount of blood Perfusion to brain)
60 - 80 Normal Range

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40
Q

Which intervention will keep CPP at 60 mm Hg or higher.

  1. Keep HOB 30°
  2. Check pupil reaction to light
  3. Reposition client q2h
  4. Perform Endotracheal suction PRN
  5. Check Glasgow coma scale q1h
  6. Administer Mannitol 100 mg IV if ICP >20
  7. Titrate norepinephrine drip maintain MAP >80 mmHg
A
  1. Keep HOB 30°
  2. Administer Mannitol 100 mg IV if ICP >20
  3. Titrate norepinephrine drip maintain MAP >80 mmHg

Mannitol decreases ICP on TBI

30° Reduces cerebral edema by promoting Venous drainage.

41
Q

Postcraniotomy care plan. Which of the following would be assigned to LPN SATA

  1. Check gastric pH q4h
  2. Assess breath sounds
  3. Performing neurological status exam q2h
  4. Turning the client side to side q2h
  5. Monitor Is & Os
  6. Sending urine specimen to check specific gravity
A
  1. Check gastric pH q4h
  2. Monitor Is & Os
  3. Sending urine specimen to check specific gravity

RN
2. Assess breath sounds
3. Performing neurological status exam q2h
4. Turning the client side to side q2h (Increases Risk for ICP & Must be evaluated by RN after posistion)

42
Q

Post decompressive craniectomy (DC)
for ICP the client output was 1200mL pale yellow urine. Best action for nurse to take.

  1. Instruct LPN to monitor urine output hourly
  2. Send specimen to lab to check for specific gravity
  3. Notify HCP & anticipate increase IV rate.
  4. Assess clients neurological status for signs of increased irritation
A
  1. Notify HCP & anticipate increase IV rate.

DI diabetes insipidus is a common complication of intracranial surgery

DI can lead to dehydration IV fluid most be increased

43
Q

Post intracranial surgery for ICP the patient is started on omeprazole. Which is the reason for this new medicine for the client.

  1. Lower chance of aspiration
  2. Decrease incidence of gastric stress ulcers.
  3. Reduce risk of gastroesophageal reflux
  4. Prevent gastric irritation causes by the orogastric tube
A
  1. Decrease incidence of gastric stress ulcers.

Gastric stress ulcers are common with head injuries unless histamine ² blockers (Famotidine) or PPI (Omeprazole) are administered prophylactically

44
Q

Post intracranial surgery. 20 minutes after being positioned on right side clients ICP increases to 30 mm Hg. Which action next

  1. Adminster PRN Mannitol 100mg IV
  2. Assess alignment of head and neck
  3. Elevate HOB 45°
  4. Check pupil response to light
A
  1. Assess alignment of head and neck

Due to recent reposición ICP increase is due to poor posistion.

Neck flexion can cause venous obstruction & increase ICP

45
Q

Post fractured leg surgery. 2nd day
The clients left leg is pale, swollen, and very firm to palpation, pulses are faintly audible using doppler. Most appropriate action

  1. Call orthopedic surgeon & communicate assessment
  2. Elevate leg on pillow to decrease swelling
  3. Continue to monitor left legs, appearance & pedal pulse.
  4. Assess client for indicators of pain, such as Restlessness
A
  1. Call orthopedic surgeon & communicate assessment

Assessment Data suggest compartment syndrome. Which in 4 - 6 hrs will lead to permanent neuromuscular damage

Elevating leg will only lessen blood flow to the leg

46
Q

Which type of oxygen delivery mask can deliver close to 100% which is needed for severely hypoxic patients

A

Nonrebreather

Need to know types of masks and their uses

47
Q

Surviving Sepsis Guidelines

Temp:
HR & RR
PaCo²
WBC

When patients have 2 or more of the above criteria and known or suspected infection

Sepsis is Diagnosed

A

Temp: <96.8 or >100.4
HR & RR 90 & 20
PaCo² 32
WBC <4000 or > 12,000

48
Q

Normal lactate levels

What do elevated levels suggest

A

Norm <2

2 - 4 critically ill
>4 immediate ICU

Sepsis is most commonly associated with high lactate levels
Also,
hepatic disease
trauma
hypothermia
seizures
bowel ischemia

Meds: Albuterol & Epinephrine

49
Q

Surviving Sepsis Guidelines

A

Measure Lactate level
Obtain cultures
Admin broadspectrum antibiotics
Infusion crystalloid solution NS

Norepinephrine will be admin if BP stays low after rapid fluid Infusion

50
Q

When Infusioning NS MOST important evaluation for an adverse reaction to rapid fluid Infusion.

  1. Palpating for any peripheral edema
  2. Monitoring urine output
  3. Listen to lung sounds
  4. Jugular vein distention
A
  1. Listen to lung sounds

Too rapid infusion will create Volume Overload (HF) The most rapid SS is backup of fluid into pulmonary capillaries then alveoli

51
Q

How would a nurse know there is
Extravasation of norepinephrine from IV line?

First action….

An injection of Phentolamine will do what?

A

SS Pallor & coolness at insertion site.

First action stop IV pump

Phentolamine (Vasodilator) will treat the SS

52
Q

Low central venous pressure (CVP) Blood volume too low.

Normal value in supine posistion

A

2 - 8

53
Q

What happens to K levels when insulin is given

A

They lower.

The K goes back into the cell with the glucose

54
Q

When should a trough be drawn for Vancomycin.

A

Immediately before Scheduled Dose

55
Q

Nonrebreather mask 100%. Pulse ox = 88 - 89%. Considering very recent history of ruptured appendix, increased WBC & Fever.

Nurse is scares patient is dev ARDS & sepsis.

Which action should be taken first

  1. Bilevel positive airway pressure (BiPAP)
  2. Arrange for transfer to ICU
  3. Admin Nebulized Albuterol q4h PRN
  4. Blood, urine, abdominal drainage samples for culture
A
  1. Bilevel positive airway pressure (BiPAP)

Other actions are correct but done after BiPAP

56
Q

Best way to confirm placement of ET tube

A

Use Continous Waveform Capnography

57
Q

BP 100/45
HR 124
OX 90
CVP 3
RR 24
TEMP 102.1

Admitted with ruptures appendix 3 days post op

Based on VS which interventions would you anticipate

  1. Increased IV to 150mL/hr
  2. Admin furosemide 40 mg IV
  3. Start norepinephrine infusion
  4. Give diltiazem 15 mg IV
  5. Admin high calorie enteral feeding 25 mL/ hr
A
  1. Increased IV to 150mL/hr
  2. Admin high calorie enteral feeding 25 mL/ hr

Incorrect
2. Admin furosemide 40 mg IV
3. Start norepinephrine infusion
4. Give diltiazem 15 mg IV

58
Q

Which tech will cause immediate intervention in tracheal suctioning

  1. Fio² to 100% for 5 minutes before suctioning
  2. Using open-suction technique
  3. Admin 2mg IV morphine before suctioning
  4. Applying suction to the catheter while inserting into ET tube
A
  1. Applying suction to the catheter while inserting into ET tube

You knew this answer. Becareful because questions can be worded strangely.

59
Q

Intubated client on mech ventilation
Which to assign to LPN

  1. Oral care chlorhexidine q4h
  2. Place in prone posistion 10 hrs daily
  3. Assess breath sounds
  4. Check Axillary or tympanic temp
A
  1. Oral care chlorhexidine q4h
  2. Check Axillary or tympanic temp
  3. Suction ET as needed
  4. Teach client & family about routine nursing care

LPN should provide oral care and monitor VS in unstable patients instead of UAP.

Not

  1. Place in prone posistion 10 hrs daily
  2. Assess breath sounds
  3. Suction ET as needed
  4. Teach client & family about routine nursing care

If unstable RN preforms the above functions

60
Q

High pressure alarm sounds on a trach/ ventilador patient.
Agitated, RR 40, Pulse Ox 81, Sinus Tach 142

Which action taken first

  1. Listen to breath sounds
  2. Increase Fi0² setting 100%
  3. Check ventilador settings & readout
  4. Suction ET tube after hyperoxygenating him.
A
  1. Listen to breath sounds

When alarm sounds first action is to assess the client.
Breath sounds
Chest movement
Respiratory effort

Helps determine which Respiratory complications client is experiencing.

61
Q

No breaths sounds on right side
Right side doesn’t expand much with inspiration. ET tube still at 23- cm mark at clients teeth.
Which complications of mechanical positive-pressure ventilation is most likely

  1. Aspiration pneumonia
  2. Inadvertent extubation
  3. Tension pneumothorax
  4. ET tube displacement
A
  1. Tension pneumothorax
62
Q

HCP inserts chesttube into right anterior chest @ 2nd intercostal space to reestablish negative pressure and allow reexpansion of tension pneumothorax.

After connecting chest tube to the collection device, which finding is most important to report HCP.

  1. Client indicates pain with each ventilador-assisted inspiration
  2. Large # of air bubbles appear in water-seal chamber during expiration
  3. Continous bubbling occurs in suction chamber during entire resp cycle.
  4. 100mL of blood drains into collection chamber quickly after chest tube insertion.
A
  1. 100mL of blood drains into collection chamber quickly after chest tube insertion.

With tension pneumothorax only a few mm of blood typically occur. 100mL indicates trauma to lung during chest tube insertion

63
Q

Sepsis, dehydration, use of Vancomycin can produce a BUN level of 52

What type of serious problem can happen with this?

A

Acute Kidney Injury

64
Q

9 month arrives at clinic for immunizations. Child is fussy with rhinorrhea, Axillary temp 100.4. Diagnosed with nasopharyngitis
Priority action

  1. Admin half immunization and reschedule for other half.
  2. Advise mother fever is Contradiction for immunization and reschedule
  3. Admin acetaminophen to reduce fever and apply anesthetic cream to injection site.
  4. Advise mother that child will need antibiotics and reschedule appointment.
A
  1. Admin acetaminophen to reduce fever and apply anesthetic cream to injection site.

Fever & minor illness are not Contradictions for Receiving vaccines

Nasopharyngitis is a virus (Antibiotics won’t work)

65
Q

18 month old. Greatest concern after fall and hit head

  1. Swelling size of golf ball
  2. 2 episodes of vomiting small amount of undigested food
  3. Continous crying for 2 hrs, comfort measure ineffective
  4. Gaping 1.5 “ laceration, bleeding controlled by pressure
A
  1. Continous crying for 2 hrs, comfort measure ineffective

Could signify ICP

Vomiting can also signify ICP but under 3 episodes is usually minor.

66
Q

Asmatic child presents to the clinic. Which is the most alarming.

  1. Alert & irritated, lying recumbent on exam table
  2. Awake and nervous, sitting up right, crying, skin pale and dry.
  3. Agitated, sweating, and sitting upright with shoulders hunched forward.
  4. Asleep in sidelaying posistion breathing through open mouth
A
  1. Agitated, sweating, and sitting upright with shoulders hunched forward.

Agitation & sweating are signs of respiratory distress. Tripod posistion is the give-away

67
Q

Client with suspected asthma
Which requires immediate notify HCP

  1. Sudden increase of RR & decreases breath sounds
  2. Rattling cough productive of frothy, clear, gelatinous sputum
  3. Crackles ausculated on inspiration in lower lung field
  4. Restlessness &, Wheezing ausculated at end of expiration
A
  1. Sudden increase of RR & decreases breath sounds

Suggestive of impending Respitory Arrest

Productive cough could produce mucus plugs & bronchial spasms.

Crackles suggestive of pneumonia

Respitory-Arrest is the only life-threatening situation

68
Q

Child has sore throat, difficulty swallowing, fever, Flushed, anxious, drooling. Thick muffled quality to voice, slow quiet breathing.

What is the problem….

What is the priority
1. Fever
2. Drooling
3. Sore Throat
4. Flushing

A

Epiglottitis

Priority = 2. Drooling (Airway obstruction)

69
Q

Fluoxetine (SSRI) prescribed for depression. What instruction related to fluoxetine is is charge nurse most likely to give to PNA?

  1. Watch for and report mild nausea
  2. Assist patient to stand due to Orthostatic Hypotension
  3. Offer fluids and oral hygine for dry mouth
  4. Perform hygine in afternoon due to morning Sedation
A
  1. Watch for and report mild nausea

SSRI SE: Sexual Dysfunction, mild nausea, headache, nervousness, insomnia, anxiety.

Tricyclic antidepressants/ monoamine oxidase inhibitors SE:
Sedation
Orthostatic Hypotension
Anticholinergic
Cardiotoxicity

70
Q

Daughter who is tired of waiting for mother to be transferred to geropsychiatric unit states that she will be taking her mother home today. What is the priority

  1. Obtain AMA form and explain consequences, have daughter sign form
  2. Notify HCP & encourage daughter to call HCP
  3. Encourage daughter to wait and reassure her that transfer will happen soon.
  4. Verify AMA policy and check status of the patient’s transfer, explan findings to daughter
A
  1. Verify AMA policy and check status of the patient’s transfer, explan findings to daughter

It is possible that patient leaving AMA will delay the process

71
Q

Milieu

A

person’s social environment.
“he grew up in a military milieu”

72
Q

HCP directs charge nurse to seclude a manic patient for several hours because they were “belligerent & argumentative” Nurse request that order be given in writing and HCP refuses because “it’s temporary & I already explained the consequences” Best approach?

  1. Assess patient for signs of aggression/ dangerous behavior and discuss findings and concerns with HCP
  2. Refuse to follow verbal orders it is a violation of patients rights if there are no written orders
  3. Recognize settings limits & enforcement are part of the treatment plan, seclude & monitor
  4. Document situation, seclude patient, provide patient care, emotional support.
A
  1. Assess patient for signs of aggression/ dangerous behavior and discuss findings and concerns with HCP

If seclusion is punitive it could be a violation of rights.

Limit settings & boundaries must be in least restrictive manner

73
Q

Why is a 125 sodium level a concern if patient is taking Lithium

A

Low sodium levels body retains Lithium which can be toxic

Mild 1.5 to 2.5
Moderate toxicity: 2.5 to 3.5
Severe toxicity: Higher than 3.5

74
Q

Mild Lithium Toxicity SE:

Moderate Lithium Toxicity SE:

A

Mild Lithium Toxicity SE:
Hand tremors, N/V, Diarrhea, polyuria, lethargy, slurred speech, muscle weakness

Moderate Lithium Toxicity SE:
Excessive Sedation
Decreased urine output
Gait abnormalities
Loss muscle control

75
Q

Non med compliant Manic Bipolar patient. What to do first to promote medication adherence

  1. Review pharmacologic action and reassure that addiction is not an issue
  2. Tell the family to assume responsibility for med adherence
  3. Give written instructions about dosage & frequency
  4. Ask patient to outline steps they use when they take their medication
A
  1. Ask patient to outline steps they use when they take their medication

First, assess for successful attempts with medication adherence.

This gives positive feedback & ID factors that contributed to success.

76
Q

Borderline personality disorder (female patient) accused male nursing student of flirting, trying to kiss her & touched her breast. Student denies but says “ She asked me if I thought she was attractive and I said yes” Best way to handle situation

  1. Advise student this behavior is typical of this patient, suggest he contacts his professor and fills out an incident report
  2. Tell student this was a learning experience and to consider their words more carefully with psych patients
  3. Go with student and confront the patient so details will be clarified then write report
  4. Tell student that incident will have to be reported to board of nursing but nothing is likely to come of it
A
  1. Advise student this behavior is typical of this patient, suggest he contacts his professor and fill out incident report
77
Q

group treatment method for mental health issues. It involves using everyday activities and a conditioned environment to help people with interaction in community settings.

Flexible treatment intervention that may work together with other treatment methods.

A

Milieu therapy

78
Q

Disorganized schizophrenia says: I am God Jesus God. I will pray pray, say pray,say pray day a pray for you. Most therapeutic response

  1. Thank you Jesus I need all the prayers I can get
  2. Praying is a good thing but your not Jesus
  3. Let’s talk about something else
  4. Your offer to pray for me is kind a generous
A
  1. Your offer to pray for me is kind a generous

Acknowledge the underlying healthy intent of the gesture

Expressing delusion of grandeur and religiosity with Clang associations.

After Acknowledge, re-direct to here and now topics

79
Q

Best way to start therapeutic communication with a schizophrenic (thought disorder, word salad (schizophasia), inappropriate giggling, loose associations.

  1. Come join us for a card game. We would enjoy your company
  2. My name is ____. I am a nursing student. What is your name?
  3. I have 15 minutes. Would you like to sit down and talk for awhile?
  4. I heard you were found on the floor in a library. What do you remember about it?
A
  1. My name is ____. I am a nursing student. What is your name?

Thought disorder use short, simple questions that are easy to understand and respond to.

The other option would be unlikely because higher level of concentration is required

80
Q

Clozapine

Class
Use
SE & Serious SE
Contradictions
Special precautions

A

Antipsychotic
Treats schizophrenia esp when other meds were ineffective
SE:
Common Side Effects (SE):

Drowsiness
Dizziness
Increased heart rate
Weight gain
Constipation
Excessive salivation

SERIOUS SIDE EFFECTS

Agranulocytosis: Sever reduction in WBC.

Seizures
Myocarditis
Orthostatic Hypotension

Special precautions: Must monitor WBC often when first starting medication

81
Q

Suicidal patient is started on Fluoxtine 2 days ago. Develops agitation, confusion, disorientated, anxiety, poor concentration. Which adverse medication effects does the nurse suspect?

  1. Neuroleptic malignant syndrome
  2. Withdrawal syndrome
  3. Extrapyrmidal SE
  4. Serotonin syndrome
A
  1. Serotonin syndrome

Begins 2 - 72 hrs after stating SSRI & stop when Discontinued

NMS: Fever, altered mental status, muscle rigidity, Dysrhthmias, autonomic instability (more likely with 1st gen Antipsychotics Haloperidol/ Loxapine)

82
Q

Paranoid schizophrenia, pacing with fist clenched yelling at empty chair. Priority action

  1. Quickly step between him & near by patients
  2. Gather staff members for show of force & unity
  3. Admin PRN Anxiolytic
  4. Use calm clear tone of voice to give simple, concrete instructions
A
  1. Use calm clear tone of voice to give simple, concrete instructions

“I guess priority means “first”

83
Q

Med nurse suggest contact with HCP to increase a patient’s Antipsychotic Medication due to them “pacing & being agitated” Best rational to assess further before contact with HCP

  1. Nurse would want to collect complete SBAR before calling
  2. Akathisia (pacing & squirming) SE of Antipsychotic meds, increase dose will worsen situation
  3. Patient was just started on meds and not enough time has passed to known if dose is sufficient
  4. Other nonpharmacological therapies should be tried first
A
  1. Akathisia (pacing & squirming) SE of Antipsychotic meds, increase dose will worsen situation
84
Q

Paranoid schizophrenic is at risk to harm self or others. Which task can be Delegated to a UAP

  1. Observe interactions and behaviors towards others in day room
  2. Following him around when he is pacing to ensure safety
  3. Serving his food tray and pointing out all the food sealed in original packaging
  4. Checking his personal belongings for items that are potentially life-threatening.
A
  1. Serving his food tray and pointing out all the food sealed in original packaging

Following him will make him more suspicious

Observing interactions & checking belongings should be preformed by RN

85
Q

New nurse calls in 30 minutes before her shift. She says she is sick. What should the charge nurse do first?

  1. Tell her 30 minutes is insufficient for call-in, and ask if she understands the call in policy.
  2. Instruct her to call team members to cover her shift
  3. Document in her file that she failed to give adequate notice for calling in sick
  4. Tell oncoming charge nurse that there was a call in and we will be short.
A
  1. Tell her 30 minutes is insufficient for call-in, and ask if she understands the call in policy.
86
Q

Captopril to manage BP. Which requires immediate nursing action

  1. Urinary output 300mL within 4 hrs
  2. Patient has persistent, dry cough
  3. ECG shows tall peaked t waves
  4. Patient has negative Chvostek’s sign
A
  1. ECG shows tall peaked t waves

ACE inhibitors cause Hyperkalemia

87
Q

Ingestion of ethylene glycol. Which medication needs to be readily available

  1. Acetylcysteine
  2. Naloxone
  3. Deferoxamine
  4. Fomepizole
A

Fomepizole

Deferoxamine (Iron antidote)
Remember Deferoxamine has “fe” in it like irons chemical symbol Fe

Ethylene glycol is found in antifreeze

88
Q

Heart failure taking Digoxin & Furosemide. Which increases risk of Digoxin toxicity

  1. Mag 1.8
  2. K 3
  3. BUN 15
  4. Albumin 5
A
  1. K 3

Hypokalemia is risk for Digoxin Toxicity.

Digoxin slows down heart to make it beat more effective

Albumin norm 3.4 - 5.4 same as K

89
Q

Warfin at 1900 for a fib. IRN level 6 what do you do

  1. Admin as scheduled
  2. Double dose
  3. INR doesn’t matter with Warfarin
  4. Hold and notify HCP
A
  1. Hold and notify HCP

IRN & pT both measures Warfarin
Norm >1 reg
2 - 3 on Warfarin Therapeutic level

pTT is measurement of Heparin

90
Q

Are flu shots recommended for pregnant women

A

Yeppers

91
Q

What if any negative outcomes is chlamydia associated with in terms of a new borns health?

Can a preggers woman take Azithromycin during pregant to stop chlamydia infection

A

Chlamydia is associated with preterm labor / birth and neonatal infection

Yes pregant women can and should take Azithromycin when pregant if they have chlamydia

92
Q

Priority educación for a pregant woman.

  1. Cannot fast for a 3 hr glucose tolerance test
  2. Refer to a social worker because their increased stress can be a risk factor for preterm birth
  3. Gential HPV infection can be treated with a colposcopy
  4. HPV present at time of labor will require a cesarean section
A
  1. Refer to a social worker because their increased stress can be a risk factor for preterm birth
93
Q

Correct Order of action

  1. Apply fetal monitor and measure vital signs
  2. Obtain a thorough history from the client
  3. Notify HCP
  4. Instruct disruptive boyfriend to wait in waiting area and notify security
  5. Call social worker for consult
A
  1. Instruct disruptive boyfriend to wait in waiting area and notify security
  2. Apply fetal monitor and measure vital signs
  3. Notify HCP
  4. Obtain a thorough history from the client
  5. Call social worker for consult
94
Q

Purpose of Betamethasone & Nifedipine in pregnancy

A

Betamethasone: Helps lungs mature and decrease neonatal death, necrotizing enterocolitis, cerebral vascular hemorrhage.

Nifedipine: Used as a tocolytic to reduce uterine contractions

95
Q

Which task be Delegated to UAP

  1. Teaching signs of preterm labor
  2. Discussing nutrition, smoking cessation, stress reduction
  3. Calling prenatal clinic to schedule next prenatal appointment within 1 week
  4. Calling a social worker and discuss plan of care given history of domestic violence
A
  1. Calling prenatal clinic to schedule next prenatal appointment

UAP are allowed to schedule a follow-up appointment

Collaboration with social worker is an RN job

96
Q

Which is not true

  1. Iron may cause Constipation
  2. Iron should be taken with milk
  3. Iron may cause darkening of stools
  4. Iron doesn’t take the place of a high Iron diet needed in pregnancy
A
  1. Iron should be taken with milk
    Slows absorption
97
Q

Requires immediate Go To The Hospital

  1. Contractions are extremely painful
  2. Vaginal bleeding 1 pad per hr
  3. Vaginal bleeding with lots of mucous
  4. My baby is moving a lot today
A
  1. Vaginal bleeding 1 pad per hr
98
Q

Infant born with meconium in the streaking the body, limp, and pale. Which is the correct order

  1. Provide positive-pressure ventilation to infant
  2. Provide the infant warmth
  3. Open infants airway
  4. Provide tactical stimulation
  5. Suction infants mouth and nose if excessive mucus or fluids are present
A
  1. Provide the infant warmth
  2. Open infants airway
  3. Suction infants mouth and nose if excessive mucus or fluids are present
  4. Provide tactical stimulation
  5. Provide positive-pressure ventilation to infant

First move to prewarmed table.

99
Q

Place in correct order. Immediate care of a healthy new born

  1. Place ID bracelets
  2. Administer Vitamin K
  3. Assess airway/breathing
  4. Perform bulb suctioning if mucus is present
  5. Assess infants heart rate
A
  1. Assess airway/breathing
  2. Perform bulb suctioning if mucus is present
  3. Assess infants heart rate
  4. Place ID bracelets
  5. Administer Vitamin K

NCLEX: Prioritization, Delegation, And Assignment 5th Edition (26 decks)

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