Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NCLEX: NGN > General > Flashcards

General Flashcards

You may prefer our related Brainscape-certified flashcards:
NCLEX-RN® flashcards NCLEX-PN® flashcards
1
Q

What is the priority for a psy patient who is upset, paranoid, angry, potentially violent?

A

Allow them to vent

This may diffuse the situation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Which of the following potential nursing actions would be undertaken with an 11 month old with possible bacterial meningitis

Incentive spirometer q2h
Oxygen via nasal canual
Continous pulse Ox monitoring
Droplet precautions

Seizure precautions
Neurological checks daily

Type & cross match for 2 units of PRBCs
Vital signs every hr
Contact HCP if temp > 102.4
Blood cultures

A

Oxygen via nasal canual
Continous pulse Ox monitoring
Droplet precautions

Seizure precautions

Vital signs every hr
Contact HCP if temp > 102.4
Blood cultures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Select if the findings are consistent with

Acute pancreatitis or Dehydration or Both

Fever
Tachycardia
Ab pain
Hypotension
Vomiting

A

Fever Both
Tachycardia Both
Ab pain Acute pancreatitis
Hypotension Both
Vomiting Acute pancreatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Acute abdominal pain
N/V
Blue-Gray discoloration of umbilicus area

Classic signs of..

A

Acute pancreatitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Risk factors for CKD are…

Chronic Kidney disease

A

Diabetes
HTN
Other risk factors include:
Heart disease
Family history of CKD
Obesity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Pregnancy-related disorder that involves persistent high blood pressure, proteinuria, and poor placental perfusion

A

Preeclampsia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

When can preeclampsia occur?

What are some consequences

A

Pregnancy or after giving birth

Potentially serious.

Liver and kidney damage, and a decrease in platelets

Dangerous to Mother & Child

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

HELLP syndrome AKA

What is it?

A

Also called: hemolysis (RBC breakdown), elevated liver enzymes, low platelet

A serious complication of high blood pressure during pregnancy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Which are immediate concerns for a newborn?

RR 40 - 60
Intermittent expiratory grunting
Fine crackles
Occasional apenic episodes

Arms & legs relaxed
Crying
Relaxed body posture
Diminished reflexes

Skin molted (Reddish-purple streaks, spots)
Axillary temp 96.7
HR 132
Presence of a murmur

A

Expiratory grunting & apenic episode

Relaxed muscles / Posture is abnormal. Possible sign of respiratory compromise

Axillary temp is too low.

Normals
New born RR = 30 - 60

Fine crackles are normal / COURSE CRACKELS ARE NOT

HR = 100 - 160

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

54 yr admitted to ED with severe, watery diarrhea, weakness, occasional muscle twitching. No N/V, A&O X3

Has stage 3 CKD which is well managed by diuretics, diet, fluid restriction. Not receiving Kidney Replacement Therapy.

HR 59 & irregular. ECG Tall peaked T waves, flat P, widened QRS.

Labs
NA 145
K 5.9
Hg 11
Hct 35%
BUN 34
Creatine 2.8

Which findings need immediate follow-up?

A

54 yr admitted to ED with severe, watery diarrhea, weakness, occasional muscle twitching.

HR 59 & irregular. ECG Tall peaked T waves, flat P, widened QRS.

Labs
K 5.9
BUN 34

Low Hg & Hct are expected in stage 3 CKD.

Elevated creatinine is associated Only with Kidney function Not Fluid levels. Elevated is to be expected in Stage 3 CKD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Airway Clearance Therapy is needed in CF patients due to Thick Mucus production that can block bronchi & bronchioles.

Treatments include: (5)

A

Chest physiotherapy
Percussion & postural drainage
PEP Positive Expiratory Therapy
High frequency chest compressions
Exercise

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

CF causes thick mucus to block the pancreas.

What kind of problem will this have on the health

Type of diet for CF

Medications / Supplements needes?

A

Pancreatitic enzymes unable to reach duodenum - fats & protiens will be be properly absorbed

Diet: High protein, high calorie, Unrestricted Fatsneeded?

Meds: Pancreatic Enzymes with food
Multivitamin, esp (A,D,E,K) - Fat soluble

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Why should clients with CF seperate 6’ from other clients with CF?

A

Reduced Infections

The stagent mucus is a Breeding Ground for BACTERIA INFECTIONS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Why is diabetes (CFRD) common with CF?

How is it diagnoses?

A

Reduction in Islets of Langerhan - where beta cells produce Insulin

OGTT

2 hrs after glucose administration 240 BS = Diabetes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

CF patient requires more of this electrolyte?

A

Sodium.

It is lost in the sweat , parents describe their child as tasting Salty

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Laparotomy vs laparoscopy.

A

Laparotomy: Open exploratory procedure to examine the abdominal organs. Large incision, quicker & easier.

laparoscopy: lighted camera is inserted into the abdomen through a “Key-Hole” to examine the organs in the abdomen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Colectomy is….

Why is it preformed?

A

Surgical procedure that removes part or all of the colont

Cancer, inflammatory disease, or diverticulitis.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Minimum urine voided per hour?

A

30 mL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Atelectasis can occur after surgery due to: Anesthesia, analgesics, or Immobility.

Name (5) S&S

A

Elevated RR
Dyspnea
Fever
Crackles
Productive cough

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Hemorrhage/ Bleeding after surgery due to slipping of suture or dislodged clot

S/S
Hypertension/ Hypotension
Bounding Pulse/ Weak Pulse
Skin: Cool & Clammy / Hot & Dry
RR: Decrease/ Increase

A

Hypotension
Weak Pulse
Skin: Cool & Clammy
RR: Increase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Tamoxifen is this type of medication

Used for…

How does it work

A

Estrogen modulator that blocks estrogen in breast tissue.

Use to treat breast cancer & prevents breast cancer

Works by blocking estrogen receptors Inhibit growth and proliferation of cancer cells

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Tamoxifen blocks the effects of estrogen in breast tissue (Prevent / Treat) breast cancer.

Has the serious adverse side effect

List SE:

A

Cause endometrial cancer

S&S
Hypercalcemia (Bone Pain) / Fractures / Bone Metastasis
Menstrual bleeding post menopause
Pelvic pain
Vaginal discharge
Vasomotor (Hot Flashes)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Chorioamnionitis, also known as intra-amniotic infection …

A

Common pregnancy complication

Inflammation & infection of the fetal membranes and placenta

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

( Gravida / Para)
Number of times a female is or has been pregnant, regardless of the pregnancy outcome.A current pregnancy, if any, is included in this count. A multiple pregnancy (e.g., twins, triplets, etc.) is counted as 1.

(Gravida / Para “Parity”)
Number of births (including live births and stillbirths) where pregnancies reached viable gestational age. A multiple pregnancy (e.g., twins, triplets, etc.) carried to viable gestational age is still counted as 1.

A

Gravida
Number of times a female is or has been pregnant, regardless of the pregnancy outcome.A current pregnancy, if any, is included in this count. A multiple pregnancy (e.g., twins, triplets, etc.) is counted as 1.

Para “Parity”
Number of births (including live births and stillbirths) where pregnancies reached viable gestational age. A multiple pregnancy (e.g., twins, triplets, etc.) carried to viable gestational age is still counted as 1.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Prelabor rupture of membranes (PROM) - Spontaneous rupture of amniotic sac with subsequent leakage of amniotic fluid

Preterm prelabor rupture of membranes (Same as above) but happens < ___ week of pregnancy

Risk Factors include

A

37th

Cigarettes
urinal / gential tract infection, previous Preterm birth
history of cervical cerclage (surgical procedure: Stitches around the cervix to help prevent preterm birth)
Short cervix length
Contractions during pregnancy
Uterine overdistension
Bleeding 2nd / 3rd trimester
Pulmonary disease
Connective tissue disorder
Low BMI
Nutrition deficiency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Placental abruption …

S/S

A

When the placenta becomes dislodged from the uterus (womb) Serious Problem

Bleeding from vagina
Stomach / Back pain
Contractions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Retained placenta ..

A

All or part of the placenta or membranes remain in the uterus during the third stage of labor.

It’s not common, but it can be serious and lead to severe infection or life-threatening blood loss for the mother

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Intrauterine infection, also known as chorioamnionitis…

A

Infection that occurs in the uterus during pregnancy, when the placenta, amniotic fluid, or membranes become infected.

It can also develop after birth, when the lining of the uterus becomes infected

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Umbilical Cord Prolapse

Umbilical cord comes out of the uterus before the baby

Effects on baby:

Factors that cause Umbilical Cord Prolapse

A

Bradycardia <120
Hypoxia

Factors:

Umbilical Cord seen as water breaks
Drop in babies HR
Change in blood pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Pulmonary hypoplasia (PH)
Rare congenital malformation that causes incomplete lung development
Small or abnormally low numbers of alveoli or bronchopulmonary segments.

When does this happen on fetal development

A

<20 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

32 yr old G²P¹
First delivery unremarkable
History of mitral valve stenosis, monitored
No medication

Post delivery
Peripad soaked with blood
Abdominal cramps
Fundus is soft & 4 fingerbreaths above the umbilicus, devianted right.

HR: 120
BP 98/ 62
RR: 24
SpO²: 92% RA

The nurse would immediately plan for (1.) _______ and (2.) _____

1.
Uterine massage
Rapid administration of blood
Administration of methylergonovine
Manual exploration if Uterine cavity

  1. Hysterectomy
    Uterine tamponade
    Oxygen administration
    IV infusion of oxytocin
A

The nurse would immediately plan for Uterine massage and IV infusion of Oxytocin

Initial interventions for excessive postpartum bleeding = Contract the uterus & stop bleeding

Immediate interventions (Uterine Atony) Firm massage of fundus, expression of clots in uterus, Elimination of bladder distention, Continous IV Oxytocin.

Methylergonovine admin IM produces sustained Uterine Contractions, However, it is contradicted with HTN or Cardiovascular disease due to vasoconstriction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Methylergonovine is used for what?

A

admin IM
Sustained Uterine Contractions

Contradicted with HTN or Cardiovascular disease due to vasoconstriction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

uterine balloon tamponade

Stops post-partum hemorrhage due to a ________.

It’s inserted inside the uterus, filled with fluid and works by compressing the bleeding vessels

A

Relaxed uterus

34
Q

Postpartum hemorrhage

First: Massage Fundus (if it is soft)
Admin Oxytocin IM
Admin methylergonovine

If bleeding continues

PHCP will perform….

If this is ineffective, then….

A

Manual explanation of uterine cavity for retained clots or placental fragments

Uterine tamponade/ Surgical Management

Hysterectomy maybe needed

35
Q

Which of the following are indicated directly following an ischemic stroke

Complete swallow screen
Allow thickened liquids only
Administer fibrinolytic therapy
Obtain electronic infusion pump
Perform cardiovascular assessment
Insert indwelling urinary catheter
Admin IV Antihypertensive meds (BP = 152 / 84)
Perform frequent neurological assessment

A

Complete swallow screen
Administer fibrinolytic therapy
(break up blood clots)
Obtain electronic infusion pump
(Used to deliver fibrinolytic therapy / must be 2 RN check)
Perform cardiovascular assessment
Perform frequent neurological assessment

Ischemic Stoke BP of 150/100 is needed to maintain Cerebral perfusion

Ischemic stroke is caused by a blockage of a cerebral or carotid artery.

Fibrinolytic therapy No Invasive tubes placed 24 hrs or until stable (bleed risk)

36
Q

Exclusion for this therapy include

> 4.5 hrs from onset of symptoms
80 yrs
Anticoagulant use
Ischemic injury to > 1/3 of brain
Significant neurological impairment
History both Stroke & DM

A

Fibrinolytic therapy

37
Q

Evisceration is most common 5 - 10 days after surgery in obese, diabetic, malnourished, immune deficit, steroid using clients.

What nursing actions will be taken: (5)

A

Cover with sterile,warm saline soaked dressing

Stay with patient & notify rapid response team

Place supine HOB 15 - 20 °

Assess VS q10min

Prepare for surgery

38
Q

3 month old with heart failure due to Ventricular Septal Defect

Prescribed: digoxin, enalapril, carvedilol, furosemide

RR: 64
HR: 164
T: 97.8
BP: 78/ 48
SPO² 91% RA

Which intervention would the nurse plan for this baby

Maintain fluid restrictions
Admin Sodium Bicarbonate
Admin K supplements
Plan feeding around infants sleep schedule
Allow baby to cry for 5 minutes before feeding
Monitor for Bradycardia, Bradypenea, HTN

A

Plan feeding around sleep schedule

Metabolic needs are higher in infants with Heart Failure and require more calories

K level will probably be fine

Even though furosemide (K wasting diuretic) is given
ACE inhibitors blocks Aldosterone, blocking of Aldosterone leads to Hyperkalemia

39
Q

The Modified Early Warning Score (MEWS) is a bedside scoring system that evaluates a patient’s physiological state using six vital parameters: (Name Them)

Critical MEWS score

A

systolic blood pressure, heart rate, respiratory rate, axillary temperature, mental status, and urine output

For a critical total MEWS score of ≥5 or a single physiological parameter score of 3

40
Q

In the following patient 80 F, UTI. MEWS preformed to monitor warning signs of Sepsis

VS: RR: 12, HR: 110, Systolic BP: 92, Temp 100.5, A&Ox3

Indicated or Contradicted

Hourly VS, I&O, neurological, and cardiopulmonary

Admin prescribed BP meds

Administration of Ibuprofen for fever

Administration prescribed antibiotics

Notify physician of increases MEWS score

A

Hourly VS, I&O, neurological, and cardiopulmonary

Administration prescribed antibiotics

Notify physician of increases MEWS score

Contradicted:

Admin prescribed BP meds
Systolic BP = 90, THIS WILL GIVE HYPOTENSION

Administration of Ibuprofen for fever.
Increase likelihood of Shock (NSAID)

41
Q

Right sided cerebral stroke will cause weakness on which side of the body?

What field of vision will be diminished?

A

Right side stroke = left side weakness / paralysis

Left field of vision in both eyes

42
Q

Right cerebral stroke

Which of the statements demonstrates UNDERSTANDING or FURTHER TEACHING

  1. Client places right arm into shirt first when dressing
  2. Spouse states “ it will help if vision if I approach him from the right side”
  3. Spouse “ I will talk to the home aids and be sure they get all the care done in the first hour after arrival “
  4. Client turns head to the left & right before taking on an activy.
  5. I know that I will need help to use the bathroom
  6. I can skip the stool softener if I have a BM
  7. Picks up washcloths with left hand to wash face.
A
  1. Client places right arm into shirt first when dressing FURTHER TEACH
    (Affected side should be used first)
  2. Spouse states “ it will help if vision if I approach him from the right side”
    UNDERSTOOD: Approach from UNAFFECTED SIDE
  3. Spouse “ I will talk to the home aids and be sure they get all the care done in the first hour after arrival.”
    FURTHER TEACHING (Task should be broken into steps- Inability to concentrate after stroke)
  4. Client turns head to the left & right before taking on an activity. UNDERSTOOD (Scanning will help to see the environment)
  5. I know that I will need help to use the bathroom UNDERSTOOD
  6. I can skip the stool softener if I have a BM FURTHER TEACHING
  7. Picks up washcloths with left hand to wash face. UNDERSTOOD
    (Always use weak side for ADL and assist with strong side)
43
Q

It is normal and expected that a new born have elevated bilirubin levels.

Levels must exceed ___ before jaundice is observed.

“Normal” levels are 0.2 - 1.4

A

5

44
Q

New born will urinate up to ___ times daily due to bladder involuntarily empties at 15 mL

A

20

45
Q

Transitional stools appear by the 3rd day in new borns initial feeding and are Greenish brown to Yellowish Brown, thin, and less sticky then ______ (1st Poop) - describe

A

Meconium

Composed of materials ingested during the time the infant spends in the uterus: intestinal epithelial cells, lanugo (Soft hair that can cover a new born), mucus, amniotic fluid, bile, and water.

Meconium, unlike later feces, is viscous and sticky like tar – its color usually being a very dark olive green and it is almost odorless

46
Q

Normal temperature for a new born

A

97.7 - 98 Axillary

47
Q

Apical HR newborn

A

120 - 140

48
Q

RR for a new born

A

30 - 60

49
Q

A change in drainage from darker red to brighter red is a positive sign that healing is improving.

T or F

A

F

It could mean a fresh bleed

Contact Surgeon

50
Q

Purpose of the water seal chamber in a drainage collection system?

A

Prevent air from reentering

51
Q

What does intermittent bubbles in the water seal chamber signify

A

Air is leaving the pleural space

Good thing

52
Q

Water level stops “tidling” going up and down in waterseal chamber

What 2 things can this mean

A
  1. Displaced chest tube - Xray confirm
  2. Lung has reexpanded
53
Q

Continous bubbling in water seal chamber

2 reasons

A
  1. Leak in system
  2. Pneumothorax
54
Q

Constant bubbling in air chamber

How does nurse determine cause of the bubbling?

Which nursing interventions do you perform with these findings

Leak from placement
Leak from tubing / device

A
  1. Clamp tube closest to patient insertion site. If bubbling stops then bubbling is due to improper insertion of chest tube. Bubbling continues faulty tube,connection, device.

Intervention:

Improper Placement:
Check for subcutaneous crepitus (Snap, Crackles, Pop undernskin)

Put 3 sided petroleum gauze over insert point.

System problem;

Replace system

When disconnecting system put tube underwater

55
Q

Air leaks in chest tubes need to be resolved due to possible pneumothorax which can lead to this heart condition

A

Cardiac Tamponade

Fluid filled sac surrounding the heart compresses it.

Prevents proper filling

Low BP, SOB, lightheadedness

56
Q

Non alcoholic steatohepatitis (NASH) an aggressive form of: Non alcoholic Fatty Liver Disease
(Too much fat is stored in the liver)

S/S liver inflammation leads to Cirrhosis & liver failure.
Tired,weak,weight loss & yellowing of skin & eyes, Web-like clusters of enlarged blood vessels under skin & Itching.

If NASH results in Cirrhosis what will be the S/S (4)

A

Fluid retention
Internal bleeding
Muscle wasting
Confusion

57
Q

Risk factors for fatty liver disease (5)

A

Obesity, (pre)DM, >cholesterol & triglyceride levels, HTN

58
Q

Liver biopsy shows:

Fat present, No inflammation/tissue damage

A

NAFLD nonalcoholic fatty liver disease
Fat present, No inflammation/tissue damage

NASH nonalcoholic steatohepatitis
Fat, Inflammation, Liver damage

Scar tissue (fibrosis) present
Cirrhosis

59
Q

Can liver damage reverse itself

A

Yes

60
Q

After birth

Fundus should be : Firm,midline, & involute 1 cm daily. If it is soft, boggy, or higher than expected this could mean… (this problem)

A

Uterine Atony

Uterus doesn’t contract enough after giving birth.

Most common cause of postpartum hemorrhage

61
Q

Lochia is…

A

lochiais thevaginal dischargeafter giving birth, containingblood,mucus, anduterinetissue.[1]Lochia discharge typically continues for four to eight weeks after

62
Q

Describe time frame and changes of lochia

1 - 3

4 - 10

> 10

A

1 - 3
Lochia rubra: Dark Red

4 - 10
Lochia Serosa: brownish red to pink

> 10
Lochia alba
Yellowish white

63
Q

Over distended bladder post partum can lead to (3)

A

Fundal displacement
Uterine Atony
Excessive Locha

64
Q

Is peripheral edema an expected finding post partum

A

Yes, lower extremities

65
Q

Acute Post Streptococal glomerulonephritis happens 1 or 2 weeks post Strep Throat or 3 - 6 weeks post skin infection.

Give S&S of this disease

A

Facial puffiness - Morning, spreads to other areas of body.
Periorbital edema
Anorexia
Decreased urine output
BP elevated
Cola colored urine
Hematuria & Proteuria
NO BACTERIA PRESENT in Urine

66
Q

Autonomic reflexia is…..

caused by…

Found in these patients…

Intervention….

A

Potentially life-threatening condition in which noxious visceral cause Sudden, Massive sympathetic reflex arch

Causes: Bladder distention, UTI, epididymitis, bowel distention/ obstruction

Found in: High level spinal cord injury patients

Interventions: ID noxious source & remove it.

Sit patient up right

Remove tight clothes

Monitor BP

67
Q

Type of shock attributed to severe CNS damage

Hypotension
Bradycardia
Peripheral vasodilation

A

Neurogenic shock

68
Q

Post partum

Scant amount of lochia is <2”

Excessive amount is soak pad in <____min

A

15

69
Q

How long after post partum is the uterus not palpable

A

2 weeks

70
Q

Day ___ the fundus is halfway way between the umbilicus & symposis process

A

6

71
Q

Post partum

The fundus decends ___ cm daily

A

1 cm

72
Q

12 hours after delivery, describe the fundus posistion

A

Firm, midline, and @ level of umbilicus

73
Q

Fundus is laterally shifted

Which intervention would nurse take to correct this

A

Have client empty bladder

Less to most invasive means

74
Q

Why does breastfeeding stop post partum hemorrhage

A

Baby suckling on nipples release oxytocin

Oxytocin contracts uterus

75
Q

(Pre) eclampsia can happen during this window of time

A

Pregnancy

> 20wks - 6 weeks post partum

76
Q

Eclampsia differs from pre-eclampsia how?

A

Eclampsia involves seizures

77
Q

(Pre) eclampsia defining characteristics

A

New onset HBP

&

Protein urea

78
Q

Severe pre-eclampsia >160/>110 can have these 2 serious side effects

A
  1. Hemorrhagic Stroke
  2. Detached placental abruption
79
Q

During (Pre) eclampsia thrombin formations in blood vessels will cause hemolysis of RBCs.

Which condition has destruction of RBC, elevated liver enzymes, low platelet count

A

HELLP

80
Q

How can (Pre) eclampsia be treated?

A

Delivery of baby & placenta

NCLEX: NGN (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions