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NCLEX: Prioritization, Delegation, And Assignment 5th Edition > Case Study 6, 7, 8, 9 > Flashcards

Case Study 6, 7, 8, 9 Flashcards

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1
Q

COPD Paintent has a 99% Ox Sat with the help of 6L/min nasal canula. What is the nurses first intervention

What is the 2nd intervention

A

Remove oxygen canula

Goal is 90 - 94 Ox Sat in COPD.

Because High Ox can lead to Decreased Respitions which will Increase PCO².

2nd notify HCP

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2
Q

Home health care

Newly referred 70 yr with emphysema will need an initial visit today to evaluate the need for oxygen therapy. Which staff member is best to make initial home visit for the patient.

  1. Experienced LPN 10 years exp with home oxygen therapy
  2. Respiratory therapist who regularly works with homemade oxygen patients
  3. RN usually works Maternal, / child division of public health agency
  4. On-call RN works in home health agency a few days a month in her time off
A
  1. On-call RN works in home health agency a few days a month in her time off

Initial assessment is a job for an RN.

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3
Q

Chemotherapy (decreases / increases) ones ability to have a fetus

A

decreases: Decreased the WBC, so If there is a small fever whole neutral

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4
Q

May an experienced UAP ensure that the flow rate of a nasal canula is 5L/min

A

Yes, they can verify this

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5
Q

Ox Sat drops to 88% and resp is shallow 34/min

First action

A

Call HCP

Respiratory arrest is possible

ET intubation & Mechanical Ventilation required

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6
Q

High pressure alarm goes off on an Endotracheal Tube.

First action

If no actions are successful and alarm continues, what do you do?

A

Suction client of mucus.

Possible ausculate for crackles over trachea, this mean suction is needed.

If not successful: Manually vent while notifying respiratory therapist

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7
Q

Which do you preform before removing an ET tube?

  1. Set up oxygen delivery system
  2. Bring emergency equipment for reintubation to the bedside.
  3. Hyperoxygenate the client
  4. Rapidly deflate the cuff.
  5. Instruct client to cough while the tube is removed
  6. Adminster oxygen by face mask
A
  1. Set up oxygen delivery system
  2. Bring emergency equipment for reintubation to the bedside.
  3. Hyperoxygenate the client
  4. Rapidly deflate the cuff.
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8
Q

Which are in scope of practice of RN student nurse.

  1. Admin 50 mg of IV Ranitinde in 50 mL of NS to prevent gastric ulcers
  2. Monitor traction ropes and weights while the client is repositioned
  3. Assess neurological status for changes in movement & strength
  4. Provide pin site care using hydrogen peroxide & NS
  5. Adding a nursing concern to the care plan for the client at risk of infections
  6. Checking vital signs and oxygen sat
A
  1. Admin 50 mg of IV Ranitinde in 50 mL of NS to prevent gastric ulcers
  2. Provide pin site care using hydrogen peroxide & NS
  3. Checking vital signs and oxygen sat

Admin meds, simple treatments, adn VS

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9
Q

Bethanechol is prescribed for…

A

Urinary retention medication and Saliva production stimulator

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10
Q

Bladder retention training consists of SATA

  1. remove indwelling catheter
  2. Encourage client to limit fluid to 1000mL/day
    3.Gradually increase intervals between Catheterization
  3. Teach patient to initiate voiding by tapping on his bladder every 4 hours
  4. Teach to preform self-catheteruzation if necessary
  5. Adminster bethanechol chloride 20 mg orally 2x daily
A
  1. remove indwelling catheter
  2. Gradually increase intervals between catheterization
  3. Teach the patient to initiate voiding by tapping on his bladder every 4 hours
  4. Teach to perform self-catheteruzation if necessary
  5. Adminster bethanechol chloride 20 mg orally 2x daily
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11
Q

Mr.M is transferred to a rehabilitation facility. Which statement indicates that the client needs additional teaching.

  1. After rehabilitation, I may be able to achieve my goal of bladder function again.
  2. With rehab, I will regain all of my motor function
  3. Rehabilitation will help me to become as independent as possible
  4. After rehabilitation I hope to return to gainful employment.
A
  1. With rehab, I will regain all of my motor function

Read 2 or 3 times on real test.

You actually got this question wrong

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12
Q

3 major areas of concer for Addisons disease- Adrenal insufficiency

A

Hormone replacement
Hyperkalemia
Hypoglycemia

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13
Q

What action would the RN assign to an experienced LPN

  1. Interpret Ms. B’s lab values
  2. Change Ms B dressing on the right side
  3. Prepare a nursing care plan for Ms B
  4. Adminster IV promethazine for neausa
A
  1. Change Ms B dressing on the right side

IV drug administration is not Always in the LPNs role

But changing bandages is

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14
Q

With adrenal insufficiency (Addisons) HR (increase) 124, tremors, headache. Which action should the nurse take first.

  1. BS level
  2. Serum K
  3. Cardiac monitor
  4. Fluid restrictions
A
  1. BS level

Hypoglycemia

Common with Addisons

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15
Q

Biggest concern for Cushings disease.

  1. HR 102
  2. RR 26
  3. BP 156/88
  4. Temp 101.8
A
  1. Temp 101.8

Cushings = Over production of Cortisol (reduces # of circulating lymphocytes)

Greater risk for infection

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16
Q

Which factor supports Cushings Disease

  1. Cessation of menses at 33
  2. Increased craving for salty foods
  3. Weight loss 25 lbs
  4. Nausea Diarrhea, loss of appetite
A
  1. Cessation of menses at 33
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17
Q

Which happen with Cushings SATA

  1. Truncal obesity
  2. Weight loss
  3. Bruising
  4. Hypertension
  5. Thickened skin
  6. Dependent edema
A
  1. Truncal obesity
  2. Bruising
  3. Hypertension
  4. Dependent edema

Weight loss is expected with Addisons

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18
Q

Which will you find in Cushings (Excessive Cortisol Production) SATA

  1. Elevated serum cortisol
  2. Decreased serum sodium
  3. Elevated serum glucose
  4. Decreased lymphocytes
  5. Increased serum calcium
  6. Decreased urine androgen
A
  1. Elevated serum cortisol
  2. Elevated serum glucose
  3. Decreased lymphocytes
  4. Increased serum calcium

Not
2. Decreased serum sodium
6. Decreased urine androgen

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19
Q

Complete adrenalectomy nurse teachings about Cortisol replacement therapy. Include which key points

  1. Taken medication in 2 doses (1 upon waking & the other at 4 PM)
  2. Take meds on empty stomach to facilitate absorption
  3. Weight self daily
  4. Never skip dose of medication
  5. Call Dr.for persistent nausea, severe diarrhea, or fever
  6. Report any weight gain, round face, fluid retention, or swell to HCP.
A
  1. Taken medication in 2 doses (1 upon waking & the other at 4 PM)
  2. Weight self daily
  3. Never skip dose of medication
  4. Call Dr.for persistent nausea, severe diarrhea, or fever
  5. Report any weight gain, round face, fluid retention, or swell to HCP.
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20
Q

24 hr urine collection for vanillylmandelic acid, metanephrine, and catecholamine for Cushings syndrome

Which is not sure

  1. 2 - 3 day special diet is required before urine collection
  2. No caffeine, citrus fruits, bananas, or chocolate before test
  3. Continue taking all your regular meds, including aspirin & high blood pressure meds
  4. You will discard the first morning urine during the 24 hr urine collection
A
  1. Certain meds like Aspirin & Beta Blockers maybe stopped for the 24 hr urine collection test. BB due to rebound HTN
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21
Q

Which are interventions for Cushings when the candidate cannot receive an adrenalectomy?

  1. Admin spironolactone
  2. Monitor for and report Dry mouth, thirst, lethargy
  3. Avoid / Limit potassium rich food
  4. Gluccorticoid replacement therapy
  5. Instruct to report gynecomastia
  6. Acetaminophen for headache
A
  1. Admin spironolactone
  2. Monitor for and report Dry mouth, thirst, lethargy
  3. Avoid / Limit potassium rich food
  4. Instruct to report gynecomastia
  5. Acetaminophen for headache
  6. Gluccorticoid replacement therapy
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22
Q

Which nonpharmacological intervention for pain management is most appropriate for nephrolithiasis.

  1. Avoid over or underhydration
  2. Gentle back massage
  3. Darken room and encourage rest
  4. Apply ice pack to affected area
A
  1. Avoid over or underhydration

Balanced fluids makes kidney stones passage the least painful

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23
Q

renal calculi: reports that pain has decreased but is now having other symptoms. Which is most urgent

  1. Painless hematuria with small clots
  2. Dull pain that radiates to groin area
  3. Absence of pain amd scant urine output
  4. Scant urinary urgency
A
  1. Absence of pain amd scant urine output

Scant urine output = possible blocking the urine outflow. Which can damage the kidney

Other symptoms are common with renal calculi

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24
Q

Broken tibia which will relieve pain the most.

  1. Instruct to periodically move toes
  2. Diversional therapy
  3. Elevate injured leg above the heart
  4. Place in high fowler
A
  1. Elevate injured leg above the heart

This will minimize swelling. Swelling will put pressure on the nerves

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25
Q

Best time to activate PCA to receive dose of pain med

  1. When pain is 5 of 10.
  2. 30 min after waking and 30 minutes before bed
  3. As soon as lockout time expires, if pain is still present, even mild.
  4. 10 min before painful procedure (dressing change or PT)
A
  1. 10 min before painful procedure (dressing change or PT)

10 min is aprox time it takes for meds to kick-in.

5 maybe too much pain for an individual

Lockout Time must be explained but instruct patient not to focus dosage based on Lockout time

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26
Q

Tibia fracture. Reports new onset of right abdominal pain, hyperactive bowel sounds, tense abdomin and guarding and exquisite tenderness with palpation. Priority action.

  1. Give PRN pain med
  2. Notify HCP
  3. Take complete set of vitals
  4. Assist him to change posistion
A
  1. Take complete set of vitals

Measure vitals first then report to HCP.

RISK abdominal trauma
These findings represent a change
Status could be from internal bleeding

Assessment is 1st step in nursing process.

SBAR (to HCP) will require this information

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27
Q

After hernia repair surgery the patient is given dose of pain meds. 1 hr later the patient states they are still hurting. What is the first action

  1. Call HCP for a change in medication dose
  2. Initiate NPO incase surgery is needed
  3. Check bladder for distention and last voiding
  4. Reassure the patient that the hernia is not reoccurring
A
  1. Check bladder for distention and last voiding

Maybe experiencing bladder atony (bladder muscles can’t fully contract, difficult to empty the bladder)

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28
Q

What is the TENS unit used for?

A

Transcutaneous electrical nerve stimulation.

Decreases pain

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29
Q

Bacterial pneumonia pain management. Which can be Delegated to UAP?

  1. Clean TENS unit
  2. Notify nurse about patients request for pain meds
  3. Reinforce the use of pillow to splint cough
  4. Observe actions that increase fatigue
  5. Suggest relatives bring comfort items
  6. Assist patient in change posistion q2h
A
  1. Notify nurse about patients request for pain meds
  2. Reinforce the use of pillow to splint cough
  3. Assist patient in change posistion q2h

Not
1. Clean TENS unit (PTs Job)
4. Observe actions that increase fatigue (RNs job)
5. Suggest relatives bring comfort items (RN)

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30
Q

Peripheral inserted central catheter.
Following Meds & Solutions need to be given now.
Vancomycin 1.5 g in 250mL of 5% Dextrose over 90 min
Levofloxacin 750 mg in 150 mL NS over 90 min
5% Dextrose & 0.45% saline 1000mL with 20 mEq potassium at 125mL/hr
IV bolus of 3mg morphine

Priority action

  1. Call HCP & ask if meds times can be staggered
  2. Call pharmacy and inquire about compatibility of meds
  3. Give bolus of morphine first because it takes the least amount of time
  4. Obtain order to establish 2nd Peripheral IV site
A
  1. Call pharmacy and inquire about compatibility of meds

Call pharmacy first.
If not compatible give morphine first due to quick admin time.

If not compatible call HCP and inquire about staggering time or second line

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31
Q

Patient with substance abuse history who has bacterial pneumonia says; My back hurts bad. I need more morphine. Based on the principles of nonmaleficence what is the priority action.

  1. Believe his subjective report and give ordered pain meds.
  2. Contact HCP and request higher dose.
  3. Consider history of addiction, chronic pain, respiratory status and time of last dose.
  4. Offer nonpharmacological measures, ie. Posistion change.
A
  1. Consider history of addiction, chronic pain, respiratory status and time of last dose.

Nonmalifence means doing no harm to patient.

Consider factors such as Respitory Status with his bacterial pneumonia

Addiction is not a reason to withhold medicine, infact he may get a higher dose because of it.

Always review time of last dose given

Opiods are not typically first-line medication fir back pain.

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32
Q

Hospice patient son states: Assessment shows that patient has rapid shallow breathing and reports pain over right lateral ribs. What is priority action

  1. Take vitals / pulse ox and inform HCP
  2. Apply oxygen and raise HOB
  3. Obtain order and start IV for bolus morphine
  4. Be calm, stay with patient, encourage Pursed lip breathing.
A
  1. Apply oxygen and raise HOB

PRN oral morphine is typically prescribed for End-of-life care hospice patients

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33
Q

Hospice patients son complains that mother is not recieving enough pain meds. The HCP says “I’ll be in tomorrow. Just tell the son to deal with it.” Best action

  1. Call another HCP
  2. Continue with current orders
  3. Advise son to call HCP
  4. Notify unit manager
A
  1. Notify unit manager

Move up chain of command.

Calling another HCP is not appropriate

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34
Q

Nursing student brings flowers into a neutropenic patients room. The student then realizes the error and tells the RN. What should the RN do first?

  1. Direct student to read isolation precautions before entering room
  2. Call the nursing instructor and report student for making an error
  3. Acknowledge & praise student for taking responsibility for the mistake.
  4. Write an incident report and have instructor & student sign it.
A
  1. Acknowledge & praise student for taking responsibility for the mistake.

It is Vital that students and staff feel comfortable with self-reporting mistakes for PATIENT SAFETY

35
Q

Patient is on is recieving chemotherapy. Which order will the RN question.

  1. Adminster Filgrastim 5 mcg/kg SQ qday
  2. Catheterization to obtain urine specimen
  3. Flush IV saline lock every shift
  4. Monitor VS q4h
A
  1. Catheterization to obtain urine specimen

Increased risk for infection

Clean catch method is sufficient

36
Q

Best practice for hand hygine a neutropenic patient.

A

Wash hands upon entering room and before touching patient

37
Q

Aprepitant, a 5-HT3 receptor antagonist, and dexamethasone is recommended for…..

A

Reducing emisis associated with chemotherapy

38
Q

Match

Chemotherapy induced peripheral neuropathy, VT, Peripheral arterial insufficiency

Pain,Pallor, Pulselessness, paresthesia, paralysis, poikilothermy (coolness)

Calf / groin tenderness, sudden onset unilateral swelling, induration (hardening) along blood vessels, warmth, edema

Numbness, tingling, Neuropathic pain

A

Peripheral arterial insufficiency
Pain,Pallor, Pulselessness, paresthesia, paralysis, poikilothermy (coolness)

Venus Thrombosis (VT)
Calf / groin tenderness, sudden onset unilateral swelling, induration (hardening) along blood vessels, warmth, edema

Chemotherapy induced peripheral neuropathy
Numbness, tingling, Neuropathic pain

39
Q

Priority for post tracheostomy and partial laryngectomy

A

Aspiration

40
Q

Which assessment Findings post tracheostomy would be of most concern

  1. Pulsation of tracheostomy tube in synchrony with heart
  2. Increased secretions in and around the tracheostomy
  3. Increased coughing, with difficulty in expectorating secretions
  4. Presence of food particles in tracheal secretions
A
  1. Pulsation of tracheostomy tube in synchrony with heart

Medical emergency

Misplaced pushing against innominate artery

41
Q

Which is most important piece of equipment for a tracheostomy and partial laryngeal to have at bedside.

  1. Adult-sized Endotracheal Tube
  2. Laryngeal scope with blades of several sizes.
  3. Bag-valve mask with extension tubing
  4. Tracheostomy insertion tray.
A
  1. Bag-valve mask with extension tubing

Ambu bag: Used first if problem with tracheostomy equipment or respiratory effort.

With tracheostomy no need for Endotracheal Tube or laryngeal scope

Insertion tray is probably unessary, site will mature within 72 hrs

42
Q

Chemotherapy medication. What is the most important to prevent extravastion.

  1. Careful monitoring of access site during adminstion
  2. Hold med until implant port or central line Is established.
  3. Ensure chemotherapy nurse is assigned to care for patient
  4. Call pharmacy to verify if medication is vesicant
A
  1. Careful monitoring of access site during adminstion

Close monitoring will prevent leaks from becoming large and causing a problem.

Holding med is not appropriate however the nurse may advocate for a central line placement

43
Q

Cancer patient has been receiving 10 mg IV morphine for pain. HCP switches to oral Hydromorphone 5mg. Nurse checks the equianalgesic dose table and sees that 10mg morphine = 7.5 Hydromorphone. What should the nurse do?

  1. Call pharmacy and double check that equianalgesic dose is actually 7.5
  2. Recognize that variable cross-tolerence necessitates upward titration for safety
  3. Question the HCP because the client deserves adequate pain relief
  4. Wait until the change of meds occurs and monitor clients response.
A
  1. Recognize that variable cross-tolerence necessitates upward titration for safety

Cross-tolerance of opiods can vary. It is potential that an equal dose could produce stronger effects.

Start low and titrate upwards is safe

44
Q

Bacillus Calmette-Guerin (BCG) delivered via a catheter to…

A

is a type of immunotherapy drug and vaccine that’s used to treat early-stage, non-muscle invasive bladder cancer (NMIBC)

45
Q

What precaution must be taken with urine collected after Bacillus Calmette-Guerin (BCG)

A

Clean toilet with bleach solution for atleast 6 hrs after each void

Bacillus Calmette-Guerin (BCG)

a vaccine and immunotherapy medicine for Tuberculosis (TB) and bladder cancer:

46
Q

How long should it take until normal voiding patter (pain-free symptom-free) take to resume after removal of catheter adminstration of Bacillus Calmette-Guerin (BCG)

A

With in 3 days.

First 3 days patient will experience dysuria, urgency, and frequency

47
Q

But in order of seriousness

  1. Bladder cancer reports dysuria
  2. Chest drainage system tipped over
  3. Neutropenic with fever of 101
  4. Tracheostomy needs suctioning
  5. Bowel resection, has swollen, tender, red calf
A
  1. Tracheostomy needs suctioning
  2. Chest drainage system tipped over
  3. Neutropenic with fever of 101
  4. Bowel resection, has swollen, tender, red calf
  5. Bladder cancer reports dysuria
48
Q

Can a CNA empty colostomy bag and measure contents

A

Yes

49
Q

Which method of admin of pain medication is the nurse most likely to question

  1. Oral
  2. IV
  3. Rectal
  4. IM
A

IM

It is painful and dispereces unevenly

50
Q

What is the probably reason a patient with non- Hodgkin lymphoma is having Dysrhthmias

A

Chemotherapy leading to cell lysis. Hyperkalemia due to K coming outta the cell

51
Q

65 yr Male 40 pack year smoker HTN. Tachycardia, pain abdominal and back, N/V. Upon Ausculation nurse hears a Bruit (whooshing sound) & sees pulsaciones Left Lower quadrant. What is the best first action

  1. Measure abdominal girth
  2. Place in high fowler position
  3. Notify HCP
  4. Administer pain meds
A
  1. Notify HCP

Abdominal Aortic Aneurysm maybe expanding & risk for rupture.

Don’t place in high fowler posistion. This will put pressure and worsen

52
Q

CT reveals 7.5 cm diameter AAA which preop tasks can be Delegated to student nurse

  1. Teaching about cough & deep breathing
  2. Assessing peripheral pulses for postop comparison
  3. Admin bowel prep of magnesium Sulfate PO
  4. Draw blood for lab typing and screening
  5. Discuss reasons for surgery
  6. Pack patients belongings for transfer to SICU
A
  1. Teaching about cough & deep breathing
  2. Assessing peripheral pulses for postop comparison
  3. Admin bowel prep of magnesium Sulfate PO
  4. Pack patients belongings for transfer to SICU

Not
5. Discuss reasons for surgery
(Reasons for surgery RN can discuss this)
4. Draw blood for lab typing and screening

53
Q

BP 198/94 which is priority action

  1. Assign LPN give furosemide & Enalapril now.
  2. Instruct UAP to get patient back into bed now.
  3. Tell UAP to recheck BP q15m
  4. Send LPN to recheck vital signs
A

1 Assign LPN give furosemide & Enalapril now.

Assessment is done
Time for action

54
Q

Raynaud’s disease which teachings will be helpful

  1. Avoid exposure to cold
  2. Nifedipine (CCB) will help decrease your symptoms
  3. The problems you experience are caused by vasodilation
  4. Keep home comfortability warm
  5. Stress reduction tech can help prevent symptoms
  6. Warm beverages (coffee /tea) will help decrease symptoms
A
  1. Avoid exposure to cold
  2. Nifedipine will help decrease your symptoms
  3. The problems you experience are caused by vasodilation
  4. Keep home comfortability warm
  5. Stress reduction tech can help prevent symptoms

Not
6. Warm beverages will help decrease symptoms (AVOID CAFFEINE)

55
Q

How does nifedipine (CCB) help with Raynaud’s disease

A

It causes vasodilation and decreases vasospasms that cause pain

56
Q

Taking nifedipine (CCB) for Raynaud’s disease, which of the following teachings are appropriate

  1. Avoid exposure to cold
  2. Nifedipine will help decrease your symptoms
  3. The problems you experience are caused by vasodilation
  4. Keep home comfortability warm
  5. Stress reduction tech can help prevent symptoms
  6. Warm beverages will help decrease symptoms
A
  1. Avoid exposure to cold
  2. Nifedipine will help decrease your symptoms
  3. The problems you experience are caused by vasodilation
  4. Keep home comfortability warm
  5. Stress reduction tech can help prevent symptoms

Not
6. Warm beverages will help decrease symptoms (Avoid Caffeine)

57
Q

Taking nifedipine (CCB) for Raynaud’s
Which teachings are appropriate

  1. SE include facial flushing & headaches
  2. Monitor RR before taking
  3. Get out of bed slowly
  4. Consume potassium rich foods
  5. Avoid grapefruit
  6. Take OTC calcium daily
A
  1. SE include facial flushing & headaches
  2. Get out of bed slowly
  3. Avoid grapefruit

Not
2. Monitor RR before taking
6. Take OTC daily
4. Consume potassium rich foods

58
Q

DVT which interventions are appropriate

  1. Bed rest
  2. Elevate leg
  3. Compression stocking
  4. Massage of affected leg
  5. SQ LMWH
A
  1. Bed rest
  2. Elevate leg
  3. Compression stocking
  4. SQ LMWH
59
Q

Buerger disease is…

Risk for development…

A

Recurring progressive inflammation and thrombosis (clotting) of small and medium arteries and veins of the hands and feet.

Risk Tobacco

60
Q

Buerger disease

Patient has pain in arch of left foot. Which are appropriate interventions

  1. Assess pain
  2. Admin nifedipine
  3. Place in supine posistion & elevate foot
  4. Lower room temperature
  5. Instruct to avoid cold environment
  6. Check toes for signs of Gangrene or ulcers
A
  1. Assess pain
  2. Admin nifedipine
  3. Instruct to avoid cold environment
  4. Check toes for signs of Gangrene or ulcers

Not
3. Place in supine posistion & elevate foot (Slows arterial blood supply & increase pain)
4. Lower room temperature (Avoid cold)

61
Q

LDL healthy level
HDL healthy level

A

LDL < 100
HDL >60

62
Q

Which are from arterial ulcers

  1. Claudication absent
  2. Rest pain present
  3. Ulcers occur at end of and between toes
  4. Brown pigment often present
  5. Pallor is seen when raising the extremity and dependent rubor is seen when lowering it.
  6. Treatments involve damp-to-dry dressing changes.
A
  1. Rest pain present
  2. Ulcers occur at end of and between toes
  3. Pallor is seen when raising the extremity and dependent rubor is seen when lowering it.

Not
1. Claudication absent (Claudication Presnt)
4. Brown pigment often present (Venous ulcers)
6. Treatments involve damp-to-dry dressing changes.

63
Q

Treatment for arterial ulcers
Treatment for venous ulcers

A

Arterial = surgical revascularuzation
Venous = long-term wound care (Unaboot & damp-to-dry dressing)

64
Q

Postop for AAA how long until bowel sounds return?

A

2 or 3 days

65
Q

AAA postop discharge teachings.
Which are correct

  1. Stair climbing is initially strictly limited
  2. Bedside commode is required even if there is first floor bathroom
  3. Heavy lifting >15lbs is avoided
  4. Caution with pulling, pushing, straining.
  5. Expect to experience abdominal fullness, chest pain, and SOB
  6. Driving a car will be strictly restricted for several weeks
A
  1. Stair climbing is initially strictly limited
  2. Heavy lifting >15lbs is avoided
  3. Caution with pulling, pushing, straining.
  4. Driving a car will be strictly restricted for several weeks

Not
2. Bedside commode is required even if there is first floor bathroom
5. Expect to experience abdominal fullness, chest pain, and SOB (Contact HCP if these symptoms occur)

66
Q

When applying a splint, assess for the 6 p’s

The 6th is poikilothermia, what does poikilothermia mean?

A

Pain, Pulse, Pallor, Paresthesia, Paralysis

Poikilothermia (Coolness)

67
Q

Woman at children’s clinic arrives with a very dirty,skinny child with broken arm and bruises consistent with hand marks.

Social worker informs lady that Child Protective Services has been summoned. Lady threatens to leave. Nurses priority action

  1. Obtain AMA form & have her sign it.
  2. Notify pediatrician of mother’s intent.
  3. Inform mother if they leave the police will be called
  4. Encourage the mother to stay and express feelings and fears
A
  1. Encourage the mother to stay and express feelings and fears

This isn’t the “real-world” and the correct answer is usually the one that relat3s to the material

68
Q

CF patient 6 yrs has specks of blood in sputum. Most likely cause

  1. Pulmonary infection
  2. Gastric irritation
  3. Bronchial remodeling
  4. Gastrointestinal bleeding
A
  1. Pulmonary infection

Hemoptysis is sign of pulmonary infection which erodes the blood vessels.

69
Q

CF has poor air way clearance. Most important intervention.

  1. Increased fluids
  2. Inhaled corticosteroids
  3. Oxygen therapy
  4. Flutter Valve with huffing
A

Slightly big breath through nose and exhale into Flutter®. You may feel vibrations on your chest wall. Repeat 8 -10.

After, huffing and coughing to clear any sputum.

70
Q

CF child is consistently in the 5th percentile of BMI. Which colaborativa intervention is most likely when planning teaching.

  1. Prepare family & child for possible gastronomy tube placement
  2. Focus on increasing intake of protein & calories
  3. Suggest increase dose of pancreatic enzymes
  4. Prepare child & family for potential total parenteral nutrition
A
  1. Prepare family & child for possible gastronomy tube placement

Low BMI in CF children is associated with poor pulmonary function.

Consistent low BMI 5th percentile is a case for alternative feeding such as gastronomy tube.

TPN is not suitable for long-term nutritional defects

71
Q

Which lab value is consistent with clubbing of fingers & toe nails

  1. Elevated WBC
  2. Elevated RBC
  3. Decreased hematocrit
  4. Decreased mean corpuscular volume
A
  1. Elevated RBC

The body will produce more RBC in an attempt to transport more oxygen

Decreased hematocrit is the opposite of what will happen

Decreased mean corpuscular volume is associated with disease that affect formation of RBC (microscopic anemia resulting in iron deficiency)

72
Q

This condition that causes inflammation in the walls of some blood vessels in the body.

It’s most common in infants and young children.

Early stages include a rash and fever.

Symptoms include high fever and peeling skin.

In late stages, there may be inflammation of medium size blood vessels (vasculitis).

It also affects lymph nodes, skin, and mucous membranes, such as inside the mouth.

Name the disease and the treatments

A

Kawasaki disease is usually treatable.

Initial treatments include aspirin and intravenous immunoglobulin therapy given in a medical facility.

73
Q

4 yr admitted with Kawasaki disease. 7th day of fever
Labs:
C-reactive protein 3.1
WBC 17,000

Which is priority
1. Obtain rectal temperature
2. Ausculate lungs
3. Obtain BP
4. Ausculate heart

A
  1. Ausculate heart

One of most common causes of vasculitis in children may result in cardiac complications.

Early indicators Tachycardia that is disproportionate to fever & gallop rhythm.

BP: Shock is a risk with kawasaki but it’s a late risk and tachypnea & gallop will come first

74
Q

4 yr admitted with Kawasaki disease. 7th day of fever
Labs:
C-reactive protein 3.1
WBC 17,000

Which pharmacological intervention should the nurse anticipate

  1. IV methylprednisolon
  2. IV immunoglobulin
  3. IV ibuprofen
  4. IV infliximab
A
  1. IV immunoglobulin

First line treatment for children with Kawasaki (Reduces incidents of coronary artery aneurysm)

Methylprednisolone & infliximab for refractory Kawasaki disease

Ibuprofen maybe administered for fever but not via IV

75
Q

Post appendectomy what is the purpose of an NG tube

A

Decompression of the stomach

76
Q

6 year old 21 kg post appendectomy rates pain at 4/10 which is the appropriate medicine

  1. 200 mg ibuprofen
  2. 5 mg hydrocodone
  3. 100 mg acetaminophen
  4. 10 mg codeine
A
  1. 200 mg ibuprofen

4/10 is moderate pain
Ibuprofen dose is correct. Therapeutic dose = 4 - 10 mg / kg / dose

Hydrocodone is for severe pain and may reduce bowel functions, Contradicted after appendectomy

Acetaminophen dose = too low

Proper 10 - 15 mg/kg/ dose

Codeine should not be used for pain. It’s affects vary from No effect - Very sensitive

77
Q

Appears groggy & confused. 3 of 5 muscle strength upper & lower.
NG tube drained 120mL over 12 hrs.
Temp 99
HR 80
RR 17

How should the following values appear

  1. K ( Low / High )
  2. Cl (Low / High )
  3. pH (Low / High)
A
  1. K Low low 3
  2. Cl Low < 95 (Norm 96- 106)
  3. pH High > 7.45
78
Q

After placenta is delivered patient is bleeding profusely. Oxytocin 20 U in 1000 mL is infusing. HCP also prescribes carbon carboprost 250 mcg IM. Which is a Contradiction to carboprost.

  1. Temp 101
  2. BP 148/ 96
  3. History asthma
  4. Allergy to penicillin
A
  1. History asthma

Carboprost used to stop postpartum hemorrhage. Potential to cause bronchospasms.

Misoprostol will be prescribed instead

79
Q

Which actions most important to prevent further hemorrhage in postpartum.

  1. Monitor VS
  2. Assess and massage uterine fundus q15m
  3. Ensure that the bladder is empty
  4. Assist Ms N into left lateral posistion
  5. Provide lunch tray with high iron foods.
A
  1. Assess and massage uterine fundus q15m
  2. Ensure that the bladder is empty

(Full bladder will prevent effective contractions of uterus - leading to uterine atony and blood loss.)

Massage fundus will contract uterus firmly, decreasing rapid blood loss with uterine atony

80
Q

Which statements by a student nurse would cause the charge nurse to intervene. Patient is 2 days postpartum & diagnosed with Endometriosis

  1. Endometriosis is an infection of the uterus.
  2. Reason for antibiotics is to kill bacteria causing the infection
  3. Because your fever, the baby will need to be moved to the nursery
  4. The baby will formula feed while away from you
  5. The antibiotics your receiving (clindamycin & gentamycin) are Contradicted during breast feeding.
A

Incorrect Statements

  1. Because your fever, the baby will need to be moved to the nursery
  2. The baby will formula feed while away from you
  3. The antibiotics your receiving (clindamycin & gentamycin) are Contradicted during breast feeding.

Correct/ True Statement

  1. Endometriosis is an infection of the uterus.
  2. Reason for antibiotics is to kill bacteria causing the infection
81
Q

What is Mastitis

Treatment

A

Possible causes are a blocked milk duct or bacteria entering the breast. It usually occurs within the first three months of breast-feeding.

Symptoms include breast pain, swelling, warmth, fever, and chills.

Antibiotics are required. Mild pain relievers can help with discomfort.

82
Q

5 day old new born lost 5% of body weight. This is a normal finding. How long should it take to regain the weight?

A

7 - 14 days

83
Q

How long for a new borns umbilical Cord stump to detach from navel.

A

7 - 14 days

84
Q

Are either of the following true about subdermal hormonal contraceptive implant etonogestrel 68 mg, which last 3 years.

  1. It is compatible with breast feeding
  2. Irregular vaginal bleeding is common SE
  3. Associated with increased risk of infertility for 5 yrs after removing
A

True

  1. It is compatible with breast feeding
  2. Irregular vaginal bleeding is common SE

False
3. Associated with increased risk of infertility for 5 yrs after removing

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

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