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NCLEX: NGN > General 2 > Flashcards

General 2 Flashcards

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1
Q

Three Indications for getting a peritoneal dialysis instead of a haemodialysis

A

Difficulty with vascular access
Unstable, infection, HTN, Anticoagulant
Patient is independent, can do treatments on their self

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2
Q

Describe the procedure for peritoneal dialysis.

1st & Subsequent times

A

1st dialysate in (Warm it first) then drain

Subsequent times: Drain first then dialysate

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3
Q

Preprocedure: Peritoneal dialysis

VS, Labs, BS
Dry weight (before dialysate)
________

A

Assess access point

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4
Q

Difference between CAPD & APD peritoneal dialysis

A

CAPD = Daytime
4x - 5x
Gravity feed
Mobile

APD

Nighttime
Machine

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5
Q

(Otitis externa/ media), also known as swimmer’s ear, is an inflammation of the outer ear and ear canal.

(Otitis externa/media) is an inflammation of the middle ear, which is located behind the eardrum

A

Otitis externa, also known as swimmer’s ear (bacteria / Fungus can grow in this fluid)

Otitis media is an inflammation of the middle ear

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6
Q

FHR

A

Fetal heart rate
110 - 160

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7
Q

Decelerations are….

A

temporary decreases in the fetal heart rate (FHR) that can occur during labor.

Three types:
Early, variable, and late.
Early = Normal

Late and variable = Concerning

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8
Q

Early decelerations in FHR (abnormal/normal)

Late decelerations…

Causes

A

Early = normal

Fundal pressure, breech posistion, strong uterine contractions, vaginal examination, placement of internal monitoring equipment

Late = abnormal/ concerning

Hypoxemia due to uteroplacental insufficiency,

Occurs when the placenta doesn’t deliver enough nutrients to the fetus during pregnancy.

This can happen when the placenta doesn’t develop properly or is damaged, or when there’s insufficient blood flow to it.

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9
Q

Early or late decelerations

Breech baby
Fetal Hypoxemia
Strong uterine contractions
Metabolic fetal acidemia
Uteroplacental insufficiency

A

Early decelerations = Normal
Breech baby
Strong uterine contractions

Late decelerations = Concerning
Fetal Hypoxemia
Metabolic fetal acidemia
Uteroplacental insufficiency

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10
Q

During haemodialysis BP drops to 82/54

Nurse preforms the following intervention:

Reduce temperature of dialysate ( Warm fluid in veins causes vasodilation = low BP)

Adjusting rate of dialyzer flow

Place client in Trendelenburg posistion

Administration of: Fluid bolus, albumin, or Mannitol

These interventions don’t work to raise BP

Complete the following sentence:

The client is at Most risk for developing _____ due to ______

Conditions:

Hypoglycemia
Myocardial injury
Infectious disease
Fluid volume imbalance
Disequilibrium syndrome

Potential Causes:
Fluid shifts
DM
Pericardial disease
Frequent blood Transfusion
Rapid reduction of electrolytes

A

Most risk for developing myocardial injury due to pericardial disease

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11
Q

Adverse SE

Increased Intercranial Pressure ICP
Neurotoxicity
Respiratory Despression
Othrostaic HTN
Constipation/ Emesis
Urinary retention

Choose:

Beta Blockers
Nsaids
Opiods

A

Opiods

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12
Q

Myoclonus (sudden, involuntary muscle jerk, shake, or spasm.)

Hyperalgesia: increased sensitivity to pain and an extreme response to pain.

Delirium

Agitation

SE from Opiods

T or F

A

T

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13
Q

Methylnaltrexone
Common brands: Relistor

Is….

When to use…

A

Gut motility stimulator
It can treat constipation caused by narcotic pain medications.

After other Anticonstipation measures taken.

Fluid / Fiber
Senna - Stimulants
Docusate - Stool Softener
Lactulose or Sodium phosphate

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14
Q

Which 5 interventions would the nurse include in the plan of care for a client to maintain good seal during NPWT

  1. ID air leaks using stethoscope
  2. Shave hair around would
  3. Ensure periwound skin surface is dry
  4. Avoid wrinkles when applying transparent film
  5. Fill uneven skin surfaces with barrier skin product
  6. Frame the periwound area with hydrocolloid dressing
  7. Cut transparent film to extend 1/2 inch beyond wound perimeter
  8. Use as many dressing layers as needed
A
  1. ID air leaks using stethoscope
  2. Ensure periwound skin surface is dry
  3. Avoid wrinkles when applying transparent film
  4. Fill uneven skin surfaces with barrier skin product
  5. Frame the periwound area with hydrocolloid dressing
  6. Cut transparent film to extend 1/2 inch beyond wound perimeter
  7. Use as many dressing layers as needed for prevent air leaks.

Wrong:
2. Shave hair around would.
Use clippers not “shave”

  1. Cut transparent film to extend 1/2 inch beyond wound perimeter

Transparent film should extend 1 or 2 “ beyond wound perimeter

  1. Use as many dressing layers as needed for prevent air leaks.

1 or 2 layers only.
Multiple layers prevent moisture vapor transmission causing Maceration

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15
Q

Which of the following would a nurse do to help a client with a Negative Self-Imag3

  1. Set realistic goals for behavior modification
  2. Reward client for practicing new behaviors
  3. Provide positive regard for adaptive behavior only
  4. Encourage the client to practice behavior modification
  5. Help client ID Negative qualities & Experiences
  6. Help client ID own behavior needing change
  7. Reinforce self-worth with time and attention by giving one-on-one time
A
  1. Set realistic goals for behavior modification
  2. Reward client for practicing new behaviors
  3. Encourage the client to practice behavior modification
  4. Help client ID Negative qualities & Experiences
  5. Help client ID own behavior needing change
  6. Reinforce self-worth with time and attention by giving one-on-one time

Incorrect:

  1. Provide positive regard for adaptive behavior (Social or practical competence to live in society)

Nurse will give unconditional positive regard & avoid reinforcement of Negative behaviors

  1. Help client ID Negative qualities & Experiences

Instead, recognize positive qualities & accomplishments

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16
Q

Conditioner where a client will need TPN (total parental nutrition) (4)

A

Highly Stressed Neurological States

Burns
Sepsis
Head Trauma
No able to digest / absorb foods

17
Q

TPN can’t be stopped Abruptly

If TPN bags is empty & another isn’t ready, what does the nurse do?

A

Infuse 10% glucose solution

18
Q

Risk factors for TPN are

Hypoglycemia or Hyperglycemia

A

Both

Be prepared to treat both conditions

Insulin & Glucagon ready

19
Q

DM patient feels: Hunger, irritated, shaky and weak

Which would the nurse suggest to help with these symptoms of hypoglycemia

6 saltine crackers
3 Graham crackers
120 mL of fruit juice
240 mL skim milk
6 - 10 hard candie
4 tbl honey
120 mL of diet soda
Decrease carb intake
Admin insulin on sliding scale base

A

6 saltine crackers
3 Graham crackers
120 mL of fruit juice
240 mL skim milk
6 - 10 hard candies

Wrong

4 tbl honey = Too Much, 1 tbl is needed

120 mL of diet soda
Decrease carb intake
Admin insulin on sliding scale base

20
Q

79 yr old client returned home from hospital for heart failure.

The client started walking 3x weekly but has stopped the routine due to being tired.

VS:

HR 68
RR 20
SpO² 92% RA
BP 112 / 68

COMPELETE THE SENTENCE

The nurse would 1. ___________ because 2. ___________

  1. Advise the client to slow down on the exercise program

Inform the client to maintain the same exercise regimen

Instruct client to check ankel edema before exercising

The heart needs to contract efficiently, and exercise is one treatment measure to accomplish this.

An additional dose of the prescribed diuretic needs to be taken before exercising

Tolerance to increased activity needs to be built up and takes time

A

The nurse would 1.Advise the client to slow down on the exercise program because 2.Tolerance to increased activity needs to be built up and takes time

21
Q

The umbilical Cord is protruding through the vagina after a patient’s “water broke “

Tell which interventions will be
INDICATED or CONTRAINDICATED

1.Administer Oxygen

2.Notify HCP

3.Monitor FHR continuous

  1. Increase rate flow of Oxytocin
  2. Gently push the cord into the vagina towards the cervix

6.Posistion client with HOB @ 30°

  1. Wrap cord in sterile towel saturated with warm normal saline
  2. Glove the hands insert 2 fingers into the vagina and exert pressure against the presenting part.
A

1.Administer Oxygen

2.Notify HCP

3.Monitor FHR continuous

  1. Wrap cord in sterile towel saturated with warm normal saline
  2. Glove the hands insert 2 fingers into the vagina and exert pressure against the presenting part.

(This will relieve pressure on the cord)

22
Q

T or F

In Umbilic Cord Prolapse the nurse would put client in a semi fowler position and leave client to contact the HCP

A

F

Extreme Trendelenburg
Modified left-lateral
Knee- chest posistion

Stay with patient and summon help

23
Q

5 yr old with asthma attack
Brought to ED
wheezes bilateral
Retractions noted
SpO² 90% RA
HR 112
RR 24
BP 124 / 82

Which actions would the nurse take

  1. Start IV line
  2. Obtain ABG
  3. Administer quick relief medicine
  4. Assist child into left lateral posistion
  5. Ask parents to wait in ED waiting room.
  6. Oxygen nasal Cannula 2L/m
  7. Place on continous cardiorespiratory & pulse Ox monitoring
  8. Obtain blood specimens for electrolytes, CBC, renal function test
A
  1. Start IV line
  2. Obtain ABG
  3. Administer quick relief medicine
  4. Place on continous cardiorespiratory & pulse Ox monitoring
  5. Obtain blood specimens for electrolytes, CBC, renal function test

Wrong:

Face Maks instead of Nasal Cannula (Cannula will dry out membranes)

24
Q

After applying pressure to hand with severed fingers

Why wouldn’t you check to see if bleeding has stopped after 10 minutes?

A

Checking could dislodge clot and make bleeding start again

25
Q

Fingers severed

Which actions do you take.

  1. Call 911
  2. Elevate affected hand above the heart
  3. Place fingers in waterproof bag
  4. Check victim for A,B,C
  5. Place waterproof bag with fingers on ice
  6. Apply direct pressure to amputation site with layers of dry gauze.
  7. Remove gauze after 10 minutes to check bleeding status
  8. Ensure fingers are transported to hospital
A
  1. Call 911
  2. Elevate affected hand above the heart
  3. Place fingers in waterproof bag
  4. Check victim for A,B,C
  5. Apply direct pressure to amputation site with layers of dry gauze.
  6. Ensure fingers are transported to hospital

Wrong:

  1. Place waterproof bag with fingers on ice. PLACE THEM IN ICE WATER 1PART ICE & 3 PARTS WATER
  2. Remove gauze after 10 minutes to check bleeding status

DONT REMOVE GAUZE. THIS CAN DISLODGE THE BLOODCLOT THAT FORMED.

26
Q

Medication Safety

To promote Medication Administration safety & prevent med errors, the nurse checks atleast (1.) _____ client ID, reads the medication lable at least (2.) ______ times, and documents medication administration (3.) ________

Option 1.
1,2,3,4

Option 2.
1,2,3,4

Option 3

As soon as medication is given

Immediately before medications are given

After medications are given and after leaving the room

Before removing the medication from the system.

A

Nurse checks at least 2 client ID, reads medication lables at least 3 times and documents medication administration as soon as medications are given

27
Q

ACE Inhibitor

Used for which diseases

Examples/ Names:

Cautions / SE

A

Diseases:

HTN
Coronary artery disease
Heart failure
Diabetes
Certain chronic kidney diseases
Heart attacks
Scleroderma

Names: (pril)
Captopril, Cilazapril, Enalapril, Fosinopril

Don’t take when pregnant
SE: ANGIOEDEMA / Dry Cough

28
Q

Amiodarone
Common brands: Pacerone, Nexterone

Type of medication

Used to treat:

SE:

Avoid:

A

Antiarrhythmic

Treats: Afib

SE: Serious lung problems, liver problems, worsening irregular heart rate.

Grapefruit juice

29
Q

How does Amiodarone help against Afib?

Se

A

Vasodilation

SE: Hypotension/ dizziness

30
Q

Beta Blockers: Examples / Names

Treats:

SE

A

(olol)

Treats:
High blood pressure
Chest pain (angina)
Abnormal heart rate (arrhythmia)
Congestive heart failure
Heart attacks

SE: Dizzy,tired, hypotension

31
Q

Oxytocin has a SE of antidiuretic effect.

This will cause (Dehydration/ Water Intoxication)

A

Water intoxication

32
Q

Uterine Rupture can happen with oxytocin.

Give 3 symptoms of this outcome

Give a risk for Uterine Rupture with Oxytocin use

A

Sudden pain between contractions
Excessive vaginal bleeding
Decelerations on fetal monitor

Risk Factor = High Parity (numerous pregnancies)

33
Q

CORRECRT

In dehydration what happens to K & Na levels

A

K = Down
Na = Up

34
Q

Pacemaker

Complications include: (3)

A

Pericardial effusion: Build up of fluid around heart. Not putting pressure on heart

Cardiac Tamponade (Fluid collects in sac around heart. Puts Pressure on the heart and keeps it from filling properly. Drop in blood pressure that can be fatal)

Diaphragmatic pacing

Malposistioned pace maker effects the diaphragm by electrical impulses to stimulate the diaphragm to help people breathe

35
Q

The following are unexpected in a patient who just had a biventricular Pacemaker placed in right subclavian area.

  1. Client reports pain at diaphragm level
  2. Hiccups that last long than normal
  3. Dressing is clean & dry
  4. Client uses left ear for talking on cell phone
  5. Client preforms right shoulder ROM exercise
  6. Client avoids lifting more than 10 lb
  7. Implantation site is clear and free of redness, swelling, drainage.
  8. Muscle contractions are noted over the diaphragm that correspond to HR
A
  1. Client reports pain at diaphragm level
  2. Hiccups that last long than normal
  3. Client preforms right shoulder ROM exercise
    (Avoid lifting arm overhead)
  4. Muscle contractions are noted over the diaphragm that correspond to HR
    (Diaphragmatic pacing- bad positioning of pacemaker / lead is dislodged

Correct:

Talk on cell phone on oppsite side of which pacemaker is located.

*Avoid electromagnetic fields & telecommunications transmitters

36
Q

65 yr Female
First assessment Post Op (open reduction with internal fixation of the left hip)

Mark the normal direct Post Op Findings

RR 8 BPM
SpO² 93% on 3/L min NC
Lung sounds clear to ausculation bilaterally

BP 90/ 56
HR 120 BPM
Peripheral pulses 2+ bilaterally

Drowsy, arousable and responsive to stimuli
PERRLA
Sensation in tact bilateral lower extremities

Bowel sounds hypoactive x4 quad
Urine output 20mL p/h

Surgical dressing saturated with bright red blood
No redness over pressure point
No petechiae or rashes throughout skin

A

SpO² 93% on 3/L min NC
Lung sounds clear to ausculation bilaterally (92 - 100 Normal postop)

Peripheral pulses 2+ bilaterally

Drowsy, arousable and responsive to stimuli
PERRLA
Sensation in tact bilateral lower extremities

Bowel sounds hypoactive x4 quad

No redness over pressure point
No petechiae or rashes throughout skin

ABNORMAL

BP = >120/ 80 due to patient pain
Tachycardia

37
Q

Describe

Breech posistion (Describe Types)

A

Baby is born bottom end first.

3 types

Frank breech: Buttocks are down, Legs are straight up near their head

Complete breech: Buttocks are down, legs are bent at the knee, feet near their buttocks.

Footling breech: One or both of the baby’s feet are down

NCLEX: NGN (3 decks)

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