General NCLEX Knowledge Flashcards
What is the ideal SPO2% for someone with COPD?
88-92%
Rule of 9’s%?
- Head
- Arms (anterior and posterior)
- Back
- Chest
- Legs (anterior and posterior)
- Genitalia
Head: 9%
Arms: 9% EACH, anterior 4.5% and posterior 4.5%
Back: 18%
Chest: 18%
Legs: 18% EACH, anterior 9% and posterior 9%
Genitalia: 1%
Definition of isotonic solution?
Fluid that goes into the vascular space and stays there.
Example of isotonic solution?
0.9% NS,D5W, Lactated ringers
What is hypotonic solutions?
Used if isotonic solutions are contraindicated (ie. renal disease or cardiovascular disease). Causes water to go into vascular space and enter into cells to rehydrate.
Examples of hypotonic solutions?
0.45% NS, 0.33% NS
What are hypertonic solutions?
CONCENTRATED solutions (high alert medications). Water is REMOVED from cells back into the vascular space.
Example of hypertonic solutions?
3%NS, TPN, albumin, D10W, D5W, D5LR.
What are we concerned about with severe diarrhea and vomiting?
Electrolyte imbalances.
What foods contain phosphorus?
Fish, pumpkin, nuts, PROTEIN, dairy, whole grains.
What foods contain magnesium?
Leafy greens, wheat, peanut butter, PROTEIN, potatoes, dairy.
What foods contain calcium?
Dairy, leafy greens, sardines, tofu.
What foods contain potassium?
Fruits & veggies, PROTEIN.
What foods contain sodium?
Processed canned foods, dairy, bread, bacon.
Positive trousseau’s and positive chvostek’s indicate what?
Low calcium.
What is the MAX potassium allowed to give per hour?
10mEq
What electrolytes have an inverse relationship?
Sodium + potassium
Calcium + phosphorus
Magnesium + phosphorus
What electrolytes have similar relationships?
Magnesium + calcium
Magnesium + potassium
What does the RR do in acidosis?
Increases to excrete acids.
What does RR do in alkalosis?
Decreases to retain acids.
What can cause metabolic alkalosis?
GI suctioning or severe vomiting.
What can cause respiratory alkalosis?
Overstimulation of respiratory system = hyperventilation, hysteria, over ventilation.
Formula for medication dosages?
Desired dose/dose on hand x mL
Formula for flow rate?
(Total volume x drop factor) divided by time in minutes = drops per a minute.
Formula for mL per hour?
Total volume in mL divided by number of hours.
Infusion time formula?
Total volume to be infused divided by mL per hour
What are the steps of the nursing process?
- Assess: collect data
- Diagnosis: what is the problem?
- Planning: how can we best manage the problem?
- Implementing: put the plan into action.
- evaluating: did the plan work?
What blood type can anyone get?
0-
What blood type can receive ALL blood?
AB+
Rh- patient should NEVER receive what type of blood?
Rh +
S+S of blood transfusion reaction?
Fever, chest pain/tightness, SOB, anxiety, back pain, hypotension, tachycardia.
If blood transfusion reaction occurs - what do we do?
Stop transfusion, change IV tubing at IV site and admin NS, notify MD + blood bank, stay with patient to monitor s+s.
What do we do for the first 15 minutes of a blood transfusion?
STAY WITH PATIENT to monitor for transfusion reaction.
What can cause crackles in the lungs?
Pneumonia, heart failure, pulmonary oedema, fluid overload.
What can cause wheezing in the lungs?
Asthma.
What can relieve wheezing in lungs?
Broncodilator ie. albuterol
What can cause rhonchi in lungs?
Chronic bronchitis.
What can cause stridor sounds in lungs?
Aspiration of foreign objects, epiglottis, anaphylaxis.
What is a life threatening adventitious lung sounds?
STRIDOR = means obstruction in upper airway.
What position do we put patients in for SOB?
High fowlers
Position for MI?
Semi-fowlers
Position for head injury?
Elevate HOB 30 degrees
Position for AFTER total hip replacement?
DO NOT sleep on affected side, DO NOT flex hips more than 45-60 degrees, do NOT elevate HOB >45degrees.
**MAINTAIN hip adduction by separating thighs with pillow.
How do we position infant with spina bifida?
Prone to avoid sac rupture.
Position for after lumbar puncture?
SUPINE to avoid CSF leakage.
Position to prevent dumping syndrome?
Eat in low fowlers position, lie supine 20-30 minutes after meals.
Position after ABOVE knee amputation?
Elevate affected leg for 24 hours on pillow, position prone daily for hip extension.
Position after BELOW knee amputation?
Foot of bed elevated for 24 hours, position prone dail
Position for infant with cleft lip?
Supine to prevent trauma to suture line.
Position for chest tube insertion?
Arm raised above head.
Position for prolapsed cord?
Trendelenburg OR knee to chest position.
Position for NGT placement?
High fowlers
Position for hypotension?
Trendelenburg
Position for women in labour with not great FHR?
Left lateral
Position for tube feeding with decreased LOC?
Right lateral + elevated HOB
Position for epidural puncture?
Lateral
Position during lumbar puncture?
Whatever helps to ROUND spine.
Position after thyroidectomy?
Low or semi-fowlers
Position for enema?
SIMS position
Position for autonomic dysreflexia?
High fowlers
Position for paracentesis?
High fowlers
Position after liver biopsy?
Lie on right side for two hours then supine.
Position after myringotomy?
Position on side of affected ear after surgery.
What is included in neutropenic precautions?
Hand hygiene, visits have NO illness, private room, avoid sources of potential infection (raw fruit + veggies, flowers).
When do we use contact precautions (Mrs.WEE)?
M:ultidrug resistant organism R: respiratory infection S:kin infections (viracella, cutaneous diphtheria, herpes, simplex, impetigo, scabies). W:ound infection E:nteric infections: C.DIFF E:ye infections = conjunctivitis.
When do we use droplet precautions (SPIDERMAN)?
S:epsis, scarlet fever & strep pharyngitis P:arovirus B19, pneumonia, pertussis I:nfluenza D:iptheria pharyngeal E:piglottits R:ubella M:umps, meningitis, mycoplasma or meningeal pneumonia, AN: adenovirus
When do we use airborne precautions (MTV)
Measles, TB and varicella zoster.
What do we use for contact precautions?
Gloves, gown
What do we use for PPE for droplet ?
Gloves, gown, face mask and eye shield.
What do we use for PPE for airborne infections?
Gloves & N95 mask.
What can we do to prevent falls?
Orient to room, teach how and when to use call bell, bed in lowest position, raise 3/4 side rails, lock wheels, keep floor dry and free of cords, wear slip resistant footwear, stay with patient during shower.
What is RACE
rescue patient in danger, activate alarm, contain fire, extinguish if small fire.
How do you ambulate with a cane?
the cane ALWAYS moves before the weak leg.
- up stairs = strong leg, cane, weak leg.
- downstairs: cane, weak leg, strong leg.
How do we position for pulmonary embolism?
Trendelenburg & left sided lying.
What considerations do we use for the visually impaired client?
Knock on door, introduce self, use clear and simple sentences, orient patient to room, explain unusual noises, inform location of food for meals using 12clock, walk slightly in front of patient when ambulating and allow them to hold your arm.
What are the 5P’s assessment of fractures?
Pain, pallor, pulselesness, paresthesia and polar (cold).
What do we monitor for with PICCs?
Monitor for infection, embolism and occlusion.
Antidote for warfarin?
Vitamin K
Antidote for heparin?
Protamine sulphae
Antidote for opioid overdose?
Naloxone
Antidote for dioxin?
Digibind
Antidote for magnesium?
Calcium gluconate
Antidote for Tylenol?
N-acetylcysteine
Antidote for benzodiazepines?
Flumazenil
Antidote for insulin?
Glucose
Antidote for cholinergic crisis?
Atropine sulphate
What is included in a full liquid diet versus a clear liquid diet?
Full liquid: plain ice cream, Herbert, milk, fruit juices, pudding.
Clear liquid: Water, bouillon, clear broth, carbonate beverages, gelatine, ice pop, lemonade.
What contains high fats?
Think dairy & protein foods.
What can a LPN NOT do?
No nursing assessments, or IV medications.
What do you never delegate as the RN?
Anything you EAT (evaluate, assess or teach).
