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NCLEX REVIEW > MEDSURG > Flashcards

MEDSURG Flashcards

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NCLEX-RN® flashcards NCLEX-PN® flashcards
1
Q

PICC LINE:

A

Inserted via the basilic or cephalic veins into the SVC.

  • Nurses need to measure and document the external length of the PICC during dressing changes
  • If there is a change in external length –> hold IV meds/fluids, secure the PICC to prevent further movement, and notify HCP
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2
Q

After abdominal surgery, placement of NG tube to decompress the stomach and the absence of bowel sounds for 24-72 hours is expected. T/F

A

TRUE

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3
Q

What is rhabdomyolysis?

A

Occurs when large amounts of muscle tissue break down and is associated with elevated levels of creatine kinase (>15,000)
-Acute kidney injury is a complication of rhabdo –> to prevent this the nurse should IV fluids

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4
Q

Hemodynamic parameters:

A
  • Cardiac output = 4-8L/min
  • Cardiac index = 2.2-4
  • CVP = 2-8
  • MAP = 70-105
  • Pulmonary artery wedge pressure = 6-12
  • Systemic vascular resistance = 800-1200
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5
Q

MAP of at least what is required to perfuse vital organs?

A

60, but above 70 is optimal.

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6
Q

Common causes of a low MAP?

A

-Hypovolemia (hemorrhage, severe dehydration), sepsis, and heart failure

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7
Q

Interventions of a low MAP?

A

Replacing intravascular volume (IV fluids, albumin, blood products) and administering IV meds such as vasopressors (norepi, vasopressin)

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8
Q

The nurse should NOT document that an incident report was filed or refer to the incident report in the medical record. T/F

A

TRUE

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9
Q

SCOPE OF PRACTICE: RN

A
  • Clinical assessment
  • Initial client education
  • Discharge education
  • Clinical judgement
  • Initiating blood transfusion
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10
Q

SCOPE OF PRACTICE: LPN/LVN

A
  • Monitoring RN findings
  • Reinforcing education
  • Routine procedures (catheterization)
  • Most medication administrations
  • Ostomy care
  • Tube patency and enteral feedings
  • Specific assessments
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11
Q

SCOPE OF PRACTICE: UAP

A
  • Activities of daily living
  • Hygiene
  • Linen changes
  • Routine, stable vital signs
  • Documenting input/output
  • Positioning
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12
Q

Signs and symptoms of a PE:

A

Dyspnea, hypoxemia, tachypnea, cough, chest pain, hemoptysis, tachycardia, syncope, and hemodynamic instability.
-Nurse should elevate HOB, administer oxygen, and assess the client

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13
Q

An emergent call is warranted to HCP in the middle of the night if:

A
  • Falls
  • Deteriorates significantly or dies
  • Has critical lab results
  • Needs a prescription that requires clarification
  • Leaves against medical advice or runs away
  • Refuses key treatments in a relevant period
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14
Q

Administration of heparin is normally discontinued prior to surgery due to the increased risk of bleeding and should be clarified with the HCP. T/F

A

TRUE

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15
Q

Advanced directives:

A

Prepared by a client prior to the need to indicate the client’s wishes

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16
Q

A living will:

A

gives instructions about future medical care treatment if the client is unable to communicate

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17
Q

A medical power of attorney:

A

Individual designated to make health care decisions should a client become unable to make an informed decision

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18
Q

Giving oxygen via nasal cannula is NOT a resuscitative measure. T/F

A

TRUE

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19
Q

What is Raynaud’s phenomenon?

A
  • Triggered by cold exposure
  • During an episode, digital arteries (fingers) constrict and blood flow is impaired, causing the skin to turn pale and then blue and to feel cold and numb.
  • As blood flow returns, the skin turns red and then throbbing or tingling sensations are felt
  • Most episodes last 15-20 minutes and are triggered by cold exposure
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20
Q

Symptoms of acute-onset abdominal pain radiating to the back is typically associated with what?

A

AAA

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21
Q

Serosanguineous drainage:

A

Pink drainage and would be expected 2 hours after surgery

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22
Q

Sanguineous =

A

Bright red drainage; a dressing saturated with this indicates excessive blood loss with possible hemorrhage

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23
Q

Only RNs and LPNs can perform trach care. T/F

A

TRUE

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24
Q

TPN should never be discontinued abruptly. T/F

A

TRUE: due to the risk of hypoglycemia

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25
Q

The typical target INR =

A

2-3

  • In some instances, mechanical heart valve = as high as 3.5
  • The higher the INR, the higher the bleeding risk
  • Nurse should NOT administer warfarin if INR is above 4
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26
Q

Flumazenil is the antidote for what?

A

Benzodiazepine overdose

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27
Q

Dextrose is given to prevent what?

A

hypoglycemia

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28
Q

Insulin quickly lowers which electrolyte by pushing it intracellularly?

A

potassium

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29
Q

What is a major complication of infectious mononucleosis?

A

A ruptured spleen; presents with sudden onset of left upper quadrant abdominal pain

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30
Q

Good samaritan laws prevent civil action IF:

A

If a nurse stops to assist after an accident, as long as the nurse acts competently, continues care until another caregiver takes over, and does NOT accept money

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31
Q

Normal calcium levels:

A

8.6-10.2

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32
Q

Normal phosphorus level:

A

2.4-4.4

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33
Q

Opioid-induced sedation scale:

A

If a client falls asleep during conversation:

  • UNACCEPTABLE
  • Monitor respiratory status
  • Notify HCP to decrease sedation
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34
Q

Malignant HYPERthermia:

A

Rare and life-threatening condition precipitated by certain medications used for anesthesia and succinylcholine.
-Early signs include: tachypnea, tachycardia, and a rigid jaw –> as it progresses, client will develop a high fever

TREATMENT: IV dantrolene to reverse the process by slowing metabolism

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35
Q

Etiologies associated with the development of COPD:

A
  • Tobacco smoke
  • Occupational exposure to chemicals and dust
  • Air pollution
  • Genetics
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36
Q

Dialysis disequilibrium syndrome:

A

Rare but potentially life-threatening complication that can occur in clients during the initial stages of HD.

  • It can be prevented by slowing the rate of dialysis
  • Characteristic manifestations include: headache, restlessness, change in mentation, and seizure activity
37
Q

When a foreign body becomes accidentally embedded in the eye, BOTH eyes should be shielded to prevent eye movement and additional injury. T/

A

TRUE

38
Q

Signs of hypovolemia:

A

hypotension, tachycardia, and decreased urinary output

39
Q

Hypercarbia:

A

When you have too much CO2 in your bloodstream

40
Q

The following are at greatest risk for respiratory depression related to opioid use for analgesia:

A
  • The elderly
  • Those with underlying pulmonary disease
  • History of snoring
  • Obesity
  • Smoking
  • Post surgery (first 24 hours)
41
Q

How do you treat pertussis (whooping cough)?

A

Treatment consists of antibiotics and supportive measures

  • Humidified oxygen and adequate fluid intake to help break down secretions
  • Respiratory status should be monitored for obstruction
  • Vaccination against whooping cough is available
  • Client should be positioned on the left side to prevent aspiration if vomiting occurs
42
Q

Clients should be instructed to not take what vitamin supplement along with isotretinoin?

A

Vitamin A

-Blood donation is also prohibited while on this medication

43
Q

Preventing ventilator-associated complications: Sedation and weaning

A
  • Monitor the client’s level of sedation
  • Use the minimum amount of sedation necessary for comfort
  • Perform daily spontaneous awakening trials to determine weaning readiness
44
Q

Preventing ventilator-associated complications: Infection prevention

A
  • Maintain semi-fowler position (30-45 degrees)
  • Perform oral care with chlorhexidine followed by endotracheal suctioning (every 2 hours)
  • Maintain a closed, sterile ventilatory circuit
45
Q

Preventing ventilator-associated complications:

A
  • Initiate enteral feeds dense in calories and protein

- Monitor gastric residual volumes

46
Q

Shingles lesions that are open need what type of precaution?

A

Both air and contact precautions. Also requires a negative airflow room

*Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions

47
Q

Prevention of ventilator-associated pneumonia:

A
  • Hand hygiene
  • Noninvasive ventilation when possible
  • Daily sedation and weaning protocols
  • HOB 30-45
  • Suctioning of subglottic secretions
  • Endotracheal tube cuff pressure >20 cm
  • Oral antiseptics w/ chlorhexidine
  • Routine prophylaxis not recommended
  • Avoid proton pump inhibitors and histamine receptor-blocking agents
48
Q

Gastric lavage:

A
  • Performed through an orogastric tube to remove ingested toxins and irrigate the stomach
  • Intubation and suction supplies should always be at bedside
  • Clients should be placed on their side or with the head of the bed elevated to minimize aspiration risk
  • GL should be initiated within one hour of overdose
49
Q

DASH Diet focuses on:

A
  • Including fresh fruits and veggies, and whole grains in the daily diet
  • Choosing fat-free or low-fat dairy products
  • Choosing meats lower in cholesterol and alternative protein sources instead of red meats
  • Limiting intake of sweets, food high in sodium, and sugary beverages to an occasional treat
50
Q

24 hour urine is needed for what??

A

creatinine clearance

51
Q

Clean catch or midstream urine sample is used when:

A

Urinalysis, urine culture, and sensitivity testing

52
Q

Primary open-angle glaucoma:

A

Tunnel vision; peripheral vision loss

53
Q

Retina detachment:

A

Sudden onset of light flashes, floaters, cloudy vision, curtain appearing in vision

54
Q

Cataracts:

A

Cloudiness

55
Q

Age related-macular degeneration:

A

Gradual loss of central vision

56
Q

Exophthalmos: complication of hyperthyroidism –> at risk for dryness, injury, and infection

A

Nursing care:

  • Maintain HOB in a raised position
  • Use artificial tears or other similar products to moisten the eyes to prevent corneal drying
  • Taping the client’s eyelids shut during sleep if they dont close on their own
  • Regular visits to eye doc
  • Smoking cessation
  • Restrict salt intake
  • Use dark glasses
  • Perform intraocular muscle exercises
57
Q

Treatment of frostbite:

A
  • Remove clothing and jewelry to prevent constriction
  • Do not massage, rub, or squeeze the area involved
  • Immerse the affected area in water heated to 98.6-102.2
  • Avoid heavy blankets or clothing
  • Provide analgesia
  • Elevate the injured area
  • Keep wounds open, no dressings
  • Monitor for compartment syndrome
58
Q

Copper IUDs:

A

clients should anticipate heavier bleeding and increased cramping during menses
-IUD strings should be checked each month

59
Q

Normal urine SG:

A

1.003-1.030

60
Q

Receptive aphasia:

A

Impairment of verbal and written language comprehension; visual aids and hand gestures are better to educate with

61
Q

PPV in a NEWBORN begins at:

A

when the HR is less than <100/min

62
Q

Phlebostatic axis:

A

4th ICS, at the midway point of the AP diameter of the chest wall

63
Q

Manifestations of septic shock:

A
  • Fever OR hypothermia (>100.4/<96.8)
  • Hypotension: SBP <90, or MAP <65
  • Prolonged cap refill time >3-4 seconds
  • Tachycardia
  • WBC >12000
64
Q

Hodgkin lymphoma and NHL:

A

HL: malignant Reed-Sternberg cells must be found in the lymphatic tissue
-HL tends to follow a predictable path of metastasis, whereas NHL tends to be more widely disseminated.

65
Q

The most common clinical manifestation of ANY form of lymphoma is:

A
  • Presence of at least one painless, enlarged lymph node; often in the neck, underarm, or groin
  • Clients may also develop a fever
  • Weight loss
  • Night sweats
  • Itching, fatigue
  • Poor prognosis
66
Q

Clients in DKA require what?

A

IV normal saline as PRIORITY due to severe dehydration.

  • Once fluids are given as a bolus, insulin is initiated.
  • Clients with insulin deficiency frequently have increased potassium levels
67
Q

A nurse suspects a DVT in a client–> what is the next move?

A

Thorough neurovascular assessment of the extremities

68
Q

Interventions to manage lymphedema:

A
  • Decongestive therapy (massage technique to mobilize fluid)
  • Compression sleeves or intermittent pneumatic compression sleeve
  • Elevation of arm above the heart
  • Isometric exercises
  • Avoidance of venipunctures
69
Q

Common complications of total hip replacements:

A

BLEEDING, prosthesis dislocation, DVT, and infection

-Nursing priority after initial hour should be the amount of drainage in the suction drainage device.

70
Q

Increased WBC =

A

> 11000

71
Q

TB symptoms:

A
  1. Low grade fever
  2. Night sweats
  3. Anorexia and weight loss
  4. Fatigue
    Pulmonary TB includes:
    -Cough
    -Purulent or blood-tinged sputum
    -SOB
72
Q

A normal hemoglobin A1C is ______ in clients without diabetes.

A

4-6%

  • The goal is to keep the level <7% in clients with diabetes
  • Measures blood glucose control over a period of 2-3 months
73
Q

How to assist a falling client?

A
  • Step slightly behind the client and place the arms under the armpit or around the clients waist
  • Place feet wide apart with knees bent
  • Place one foot behind the other and extend the front leg
  • Let the client slide down the extended leg to the floor
74
Q

Enemas:

A
  • Hang the enema bag no more than 12 in (30 cm) above the rectum to avoid overly rapid administration
  • Direct the tubing tip toward the umbilicus
75
Q

How to remove PPE:

A
  1. Gloves
  2. Goggles
  3. Gown
  4. Mask or respirator
76
Q

How to bathe clients with MRSA:

A

Use pre-packaged and pre-moistened cloths containing chlorhexidine (If patient is unable to walk into shower)

77
Q

When descending stairs, the client should:

-Client should hold cane on the stronger side

A
  1. Lead with the cane
  2. Bring the weaker leg down next
  3. Finally step down with the stronger leg
78
Q

When ascending the stairs, the client should:

A
  1. Step up with the stronger leg first
  2. Move the cane next, while bearing weight on the stronger leg
  3. Finally move the weaker leg
79
Q

To reduce the risk of complications and injury during ETt suctioning, the nurse should:

A
  1. Pre-oxygenate with 100% oxygen
  2. Suction only while withdrawing the cath from the airway
  3. Use strict sterile technique - 10 seconds
80
Q

After a cardiac cath procedure, how should the client lay?

A

Place clients flat or in low fowlers w/ the affected extremity straight for 4-6 hours

81
Q

Drugs not to take before surgery!!!

A
  • Clopidogrel (Plavix) is an antiplatelet medication that should be discontinued for 5-7 days before surgery
  • NSAIDs (naproxen) should be discontinued 7 days before scheduled surgery
  • Acetaminophen can be taken to control pain up until surgery
82
Q

When caring for a client in restraints, the nurse should do what:

CHECK IN EVERY 2 HOURS

A
  1. Provide skin care and ROM exercises; ensure basic needs are met
  2. Assess skin integrity and NV status of restrained extremities; pad bony prominences under restraints
  3. Determine the need for continued restraint
83
Q

Trach cuff:

A
  • Used in clients who are at risk for aspiration
  • Inflated cuffs are uncomfortable for clients who are awake because it is difficult to swallow or talk –> the cuff is deflated when the client is improving
84
Q

Assessment findings that indicate a need for suctioning:

A
  • Decreased O2 sats
  • AMS
  • Increased HR
  • Increased RR
  • Increased work of breathing
  • Adventitious breathing sounds
  • Pallor, mottled, or cyanotic skin coloring
85
Q

Ebola precautions:

A

standard, contact, droplet, and airborne precautions

  • Visitors are prohibited
  • Log is made of people who must enter the room
  • Door is kept CLOSED
86
Q

Contact precautions:

A
  1. MDR organisms (MRSA, VRE)
  2. Enteric organisms (C. diff)
  3. Scabies

-Hand hygiene, nonsterile gloves, gown, private room preferred

87
Q

Blood products have to be transfused within how many hours?

A

4!!!!!

*O-neg blood can be given to someone with AB positive blood

88
Q

Allen test:

A
  • Test is done to determine the patency of the ulnar artery
  • If Allens test is positive –> ABGs can be drawn
  • If negative, and the palm doesnt turn pink –> brachial artery or femoral artery must be used

NCLEX REVIEW (12 decks)

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