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Mark k Flashcards

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1
Q

clarifying an order vs questioning

A

one of the answers is INCOMPLETE, NOT WRONG

questioning:

WILL HARM THE PATIENTS

wrong med, dose, route, amount

+

wrong documentation, wrong abbreviation (like QID, TID, qd, BID, 2.0, 2,000)

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2
Q

3 colon areas

A
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3
Q

valve locations 5

A

aoritc: 2nd right of sternal border

pulmonic: 2nd left of sternal border

tricupsid: 4th left of sternal border

mitral/apical pulse: 5th midclavicular

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4
Q

4 food rules for peds

A

NEVER casseroles for children

Don’t mix meds with food

Finger food for TODDLERS

LEAVE PRESCHOOLERS FOOD ALONE – 1 meal good

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5
Q

don and doff PPE

A

don:

gown, mask, goggle, gloves (REVERSE ALPHABETICAL + mask 2nd)

doff:

gloves, goggle, gown, mask (ALPHABETICAL ORDER)

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6
Q

3 expected vs unexpected s.s in sepsis

A

Sepsis EXPECTED s/s:

  • Inc WBC
  • Warm and flushed
  • Hyperglycemia

UNEXPECTED: DIC!!!!!

  • Bleeding
  • Low coag
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7
Q

preg weight gain calculation

A

Number of weeks of gestation minus 9

If within +- 1 or 2 then NORMAL

If within +- 3 then ASSESS patient

If within +- 4 or more – do BIOPHYSICAL PROFILE of fetus

BMI <18 -> 25-40 lbs
BMI 18-25 -> 25-35
BMI 25-30 -> 15-25

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8
Q

when can fundal height be palpated?

A

20-22 weeks when it is midway between the umbilicus and the pubic symphis

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9
Q

4 positive preg signs vs probable

A

positive:
- Fetal skeleton on xray

  • Presence of fetus on ultrasound
  • Auscultation of heart via doppler
  • EXAMINER palpates fetal movement and outline

Maybe signs are:

  • Positive pregnancy test
  • Chadwicks sign (blue cervix, vagina and vulva)
  • Goodells sign (softening of cervix)
  • Hegar sign (softening of uterus)

**these occur in alphabetical order!!!!!!

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10
Q

when first hear the fetal HR

when most likely

when should you

A

1st: 8-12

most: 10

should: by 20

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11
Q

when first notice quickening

when most likely

when should you

A

1st: 16

most likely: 18

should: by 20

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12
Q

prenatal visit frequency

A
  • 1x/month until week 28
  • Every other week between 28 – 36 weeks
  • Once a week after week 36 until delivery (or week 42 if that comes first)

If a woman comes in for her 12th week prenatal checkup, when is her next prenatal visit?

16 weeks

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13
Q

when can a patient be induced for a c section

A

42 weeks

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14
Q

what lab will decrease during pregnancy

A

Hgb - it is concerning if < 9 (need anemia assessment)

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15
Q

education for dyspnea in preg

A

get in a tripod position – hands on knees or surface of table

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16
Q

most reliable sign of labor and birth

A

regular and progressive contractions

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17
Q

labor vs false contractions

A

T: timing that INC in freq, duration, and intensity

R: radiating to abdomen

U: unable to relieve with activity

E: exam changes - cervical dilation

vs

F: fails to cause cervical change

a: activity alleviates contractions

k: keep feeling same area , no radiation

e:erratic timing of contractions

5:1:1

every 5 min, lasting 1 min for more than 1 hour = go to hospital

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18
Q

after birth what constitutes post partum infection

A

> 100.4 for 2 consecutive days

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19
Q

fetal kick count

A

counted 3x/day
If the mother has felt fewer than four movements, she should count for 1 more hour. Fewer than four movements in that hour warrant evaluation

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20
Q

station is

vs engagement

A

the relation of fetal presenting part and the mother’s ischial spines (know

this)—the narrowest part of the pelvis

  1. Engagement is station zero—this means the presenting part is at the ischial spines (smallest diameter part of the pelvis)
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21
Q

Lie

A

relationship of spine of mother and spine of baby

Desired = VERTICAL lie (mother and baby spines are parallel) -> BABY COMIN

NOT desired = TRANSVERSE lie (mother and baby spines are perpendicular (Trouble -> NEED C SECTION)

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22
Q

presentation is

A

part of the baby thats in the canal - usually ROA

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23
Q

estrogen vs oxytocin vs prostaglandin vs relaxin

A
  1. Estrogen -> makes utuerus more susceptible to oxytocin
  2. Oxytocin -> contractions
  3. Prostaglandin -> cervix softening and stretching
  4. Relaxin -> cervix relaxation
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24
Q

for laboring or preg patient who is priority

A

IF question asks what patient to check on first – patient with contractions no longer than 90 seconds and no closer than 2 minutes – STOP PTOCIN

What parameters regarding uterine contraction would make you stop Pitocin?

  • No longer than 90 seconds and no closer than 2 minutes

What is uterine hyperstimulation?

  • No longer than 90 seconds and no closer than 2 minutes

What is a sign of uterine tetany?

  • No longer than 90 seconds and no closer than 2 minutes
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25
Q

frequency vs duration vs intensity

A
  1. “Frequency” = beginning of one contraction and beginning of next
  2. “Duration” = beginning of one to end of another
  3. “intensity” = tell her to PALPATE WITH ONE HAND OVER FUNDUS WITH PADS OF FINGERS
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26
Q

painful back labor tx

A

– ROP or AOP (think “Oh pain”) LOW PRIORITY

Tx: POSITION THEN PUSH

  1. Position in knee chest
  2. Push with fist into sacrum to counter pressure
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27
Q

normal FHR - tx for high, low, low baseline variablity, and high baseline variability

A

1 STOP PITOCIN!!!!!!!!! If running

120-160

<110:

L -> left side

I -> IV

O -> oxygen

N –> notify HCP

> 160:

  • document finding
  • take moms temp

“low baseline variability” = BAD

Not changing

L -> left side

I -> IV

O -> oxygen

N –> notify HCP

“high baseline variability” = GOOD

Always changing

-document finding

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28
Q

what to assess post partum

A

EVERY 4-8 HOURs

BUBBLE HEAD

B: breasts

U: UTERINE FUNDUS -> boggy is massage, displaced is cath, HEIGHT of fundus related to UMBILICUS (fundal height should be at umbilicus after delivery and then it is equal to the day post partum) = 4 days = 4th line in the middle of the belly

B/B: bladder and bowel

L: LOCHIA -> vaginal drainage -> rubra (red), serosa (pink), alba (white)

  • Moderate lochia amount = 4-6 inches on pad in 1 hour
  • Excessive = 100% sat in 15 min

E: episiotomy

H/H: hgb/hct

E: EXTEMITY -> look for thrombophlebitis -> measure the bilateral calf circumference

A: affect

D: discomfort

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29
Q

Cephalohematoma vs Caput succedaneum:

A

Cephalohematoma:

  • ONE side of head
  • Over occipital bone
  • Develops within 24-48 hours

Caput Succedaneum:

  • Crosses Sutures and is Symmetrical
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30
Q

Which of the following 4 children will be able to manage his own care?

A 7-year-old with Cystic Fibrosis

b. An 8-year-old with Diabetes Mellitus

c. A 10-year-old with a scraped knee

d. A 13-year-old with Chronic Renal Failure

A

MANAGE not treat

D!!!!!

*** it is not about severity of problem, it is about age

12 OR OLDER!!!!

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31
Q

motor function ages

A
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32
Q

piagets stages of cog

A
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33
Q

congenital Heart defects + education (7)

A

T: trouble defects start with T – except ventricular hypoplastic syndrome

R: shunts blood R to L

B: patient blue

  • Need surgery now
  • Slow development
  • Short life
  • Grief
  • Cardiac monitor
  • Hospital stay
  • Need cardiologist referral
  • ALL DEFECTS WILL HAVE A MUMUR and need an echo
34
Q

4 characterisitics of tetrology of fallot

A
  • Pulmonary artery stenosis
  • RVH (right ventricular hypertrophy)
  • Overriding aorta
  • VSD (ventricular septal defect)
35
Q

ischemic vs hemorrhagic stroke

A
  1. Ischemic:

Caused by an OBSTRUCTION

Give tPA within 3 hours!!!!!

  1. Hemorrhagic:

Caused by HYPERTENSION

NO TPA

36
Q

earliest sign of inc ICP

A

irritability

37
Q

condition with Inc IOP

A

glaucoma (sudden is closed angle, gradual is open angle)

38
Q

3 examples of high pressure alarms

5 actions

s/s

A

increased resistance

Kink in tubing

Condensed water in tube

Mucus plug

High pressure alarm going off?

  1. Unkink
  2. Empty water out of tubing
  3. Turn patient
  4. Ask them to cough, deep breathe
  5. Suction AS NEEDED!!!!!!

Settting is too high = resp. alkalosis (pt panting) -

The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory ALKALOSIS. What would you do next?

IF PATIENT IS ALKALOSIS – THEY CAN BE WEANED OFF

39
Q

low pressure vent alarm

A

decreased resistance

Examples:

MAIN Tube disconnection

O2 sensor tube disconnection

Low pressure alarm going off?

  1. Reconnect the tubing unless tube is on the floor
  2. Bag patient and call resp therapist

Setting too low = resp. acidosis

“respiratory = ventilate” / “acidosis= under”

The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory ACIDOSIS. What would you do next?

NOTIFY HCP BECAUSE THEY ARE NOT READY TO BE WEANED – THEY ARE UNDERVENTILATING

40
Q

high aPTT

high PT

high INR

high d dimer

A

aPTT: high = heparin, DIC

PT: high = DIC, factor deficiency

INR: high = warfarin, LOW vit K

Ddimer: >0.4 blood clot

41
Q

amylase/lipase number lab for pancreatitis

A

> 220

42
Q

normal ESR

A

<20

43
Q

shock s/s

A

cool, moist, pale skin, restless, scant urine

need fluids

44
Q

levels of HTN

A
45
Q

6 risk factors for T2D

A
  • Fam Hx of type 2
  • > 45 years old
  • Obesity BMI>28
  • Dec HDL
  • HTN
  • NOT TYPE 1 !!!!
46
Q

best indicator of long term glucose control

A

HgbA1c

47
Q

functional psychosis

A

***Functional: schizophrenia, major depression, mania, schizoaffective

  • They CAN learn reality and we must teach them

Tx: Acknowledge, present reality, set limits and enforce them

48
Q

dementia based psychosis

A

senile/dementia/stroke

  • They CANNOT learn reality

Tx: Acknowledge, redirect!!! Give them something to do

49
Q

delirium psychosis

A

: SUDDEN AND DRAMATIC EPISODICdue to UTI, thyroid imbalance, adrenal crisis, electrolytes, meds

Tx: Acknowledge, reassure about safety and temporariness of condition

50
Q

tolerance vs dependence

A

tolerance: need higher doses for same effect, NO WITHDRAWAL

dependence: need it to feel normal , YES WITHDRAWAL

51
Q

nurse pt relationship phases

A

Preinteraction: GOALS

Orientation: purpose, time, trust

Working: problem solving

Termination: achieved goals

52
Q

if Q has quotes and all A are quotes -empathy question

A

· Choose the answer that reflects their FEELINGS, not their WORDS -ignore what is said and go with what is felt

I see you feel angry

53
Q

4 features of crutches (one is stairs)

A
  • Length of crutch measured by placing tip on the ground and have 2-3 fingers widths bellow the axillary
  • Tip should point 6 inches side and 6 inches in front
  • Elbow flexion 30 degrees

“up with good leg and down with the bad” + CRUTCHES MOVE WITH BAD LEG

54
Q

types of gaits

A

*even number gait for even number legs affected

*use odd when one leg is affected

*use swing through if both legs affected OR AMPUTATION

  • 2 point gait for mild bilateral weakness= move 1 crutch and opposite foot together
  • 3 point gait – move 2 crutches and bad leg together
  • 4 point gait- move crutch-> move opposite foot -> move wnd crutch -> move opposite foot
  • Swing through for non weight bearing (amputee) -> affected leg never touches the ground
55
Q

A pt affected with early stages of rheumatoid arthritis. What gait should the pt use?

A
  • Both legs affected (because it is a systemic disease)
  • Early stage—mild
  • 2-point gait
56
Q

Pt is first day postop, right knee, partial weight bearing allowed. What gait should the pt use?

A
  • One leg affected
  • Odd-numbered gait
  • 3-point gait
57
Q

Pt is in advanced stages of ALS. What gait should the pt use?

A
  • Bilateral leg weakness (because it is a systemic disease)
  • Even-numbered gait
  • Advanced stages = Severe
  • 4-point gait
58
Q

Pt with left hip replacement, 2nd day postop on non-weight bearing instruction. What gait should

the pt use?

A
  • Non-weight bearing of 1 leg
  • Swing-through gait
59
Q

Pt with bilateral (B/L) total knee replacement first day postop. Weight bearing is allowed. What

gait should the pt use?

A
  • Even-numbered gait = Bilateral
  • Weight bearing
  • First day postop = Severe
  • 4-point gait
60
Q

Pt with bilateral total knee replacement 3 weeks postop. What gait should the pt use?

A
  • Even-numbered gait = Bilateral
  • Weight bearing
  • 3 weeks postop = mild
  • 2-point
61
Q

walkers

A

o The walker is on the side of the pt, the pt “Picks it up … Sets it down … Walks to it”

o Once the walker is in front of the pt, the pt “Holds on to chair, Stands up, Then grabs

walker”

***no tennis balls or wheels on a walker

**tie belongings to the SIDE of walkers

62
Q

If patient has fractured femur or pelvic

A

they are at high risk for fat embolism so must assess LOC

63
Q

cervical spinal cord tx

A

A. Cervical – innervates diaphragm and arms

Preop assessment:

  • Assess breathing THEN arm and hand function

Post op assessment:

  • Pneumonia
64
Q

thoracic spine tx

A

A. Thoracic – upper back – innervates gut and abdomen

Preop:

  • Assess cough and bowels

Postop:

  • Pneumonia/paralytic ileus
65
Q

lumbar spine tx

A

A. Lumbar – lower back – innervates bladder and legs

Preop:

  • Urinary retention or last time patient voided then leg functions

Postop:

  • Urinary retention and legs
66
Q

3 nerve root compression s/s

A
  • Pain
  • Parasthesia
  • Paresis
67
Q

post op laminectomy 3 nursing actions

A
  • Do not dangle patient for 10-15 min, get them up and moving
  • Question order for sitting for 1 hour (cannot sit for longer than 30 min)
  • They can walk , lay down without restrictions
68
Q

4 discharge teaching for spinal surgery/laminectomy + 3 PERMENANT restrictions

A
  • Don’t sit longer than 30 min for 6 weeks
  • Lie flat, log roll for 6 weeks
  • Don’t drive for 6 weeks
  • Don’t lift more than 5 lbs for 6 weeks

PERMENANT restrictions:

  • Laminectomy can never bend at waist (they need to use knees) like everyone else
  • Cervical lams cannot lift anything over their head ever for life
  • No horseback riding, biking, jerking around ever for life
69
Q

what is aortic regurgitation

2 features

contraindications

education

A

blood backed up into the L ventricle

· Wide pulse pressure

· Diastolic murmur

· No beta blockers because it decreases diastolic BP

Education: infection prevention because of infective endocarditis

  • Abx before dental procedures
70
Q

what to assess for hypertonic solutions

A

lung sounds

71
Q

3 fludis for shock

A

NS, LR, hypertonic

72
Q

If you see patient itching but NO rash and the patient has asthma

A

this is an attack - give albuterol

73
Q

peak exp rate

A

<50% EMERGENCY / >79% fine

74
Q

apical vs basilar chest tubes

A

· Apical chest tube removes Air

> 80ml/hour NOT EXPECTED

Bubbling EXPECTED

· Basilar chest tube removes Blood or fluid (due to gravity)

200mL/hour EXPECTED

Bubbling NOT EXPECTED

75
Q

chest tube drainage device knocks over

A
  1. -> ask patient to take a deep breath and then set device up and DO NOT CALL HCP
76
Q

water seal of chest tube breaks

A
  1. 1st clamp, 2nd . cut, 3rd . submerge in sterile water , 4th unclamp THIS MUST BE DONE IN 15 SECONDS

aka · FIRST ACTION IS CLAMP, PRIORITY ACTION IS SUBMERGE IN STERILE WATER

77
Q

chest tube pulled from PATIENT

A
  1. 1st cover with gloved hand, best: sterile gauze
78
Q

manipulation vs dependency

A
  • Manipulating: causing harm to victim / illegal
  • Dependency: does not cause harm
79
Q

wernicke and korsakoff

3 characteristics

s/s

tx

A

psychosis caused by Vitamin B1 and Thiamine deficiency

  1. Preventable (can prevent it)
  2. Arrestable (can stop it from getting worse)
  3. IRREVERSIBLE (WILL KILL BRAIN CELLS)

s/s = amnesia and confabulation (making up stories WITHOUT awareness of it)

tx: redirect

80
Q

alc withdrawal vs delirium tremens

A
81
Q

dosage calculation

A

IV drip rates = Volume × Drop factor / Time

  • Micro/Mini drip = 60 drops per mL
  • Macro drip = 10 drops per mL

nclex (3 decks)

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