NCLEX 1 Flashcards
UAP scope of practice?
assist with ROM, ambulate, hygiene, and ADLS
feed and PO care on stable pts
routine VS and I&O
position and linen changes
transport
report concerns to RN/LPN
LPN scope of practice?
monitor RN findings
gather data on stable pts
maintain and remove PIVS
basic care
report pts status to RN/HCP
care for stable pts with predictable outcomes
reinforce RN edu
What is the lab value to evaluate the IVF’s efficacy with septic shock?
serum lactic acid
treatment goals with sepsis shock?
optimal perfusion demonstrated by a MAP > 65
norm – RR, HR, temp, o2 sat, U/O
clearance of lactic acid, decrease lactic
Contact precautions?
MRSA
VRE
RSV
Herpes
Conjunctivitis
Diphtheria
Lice
Scabies
Human metapneumovirus
Staph
Polio
C. Diff
Norovirus
Rotavirus
Droplet Precautions?
Flu
Pertussis
Mumps
Rhino
Adenovirus
Rubella
Epiglottitis
Diphtheria (pharyngeal)
Bacterial meningitis (not viral)
HIB
RSV (+contact)
Airborne Precautions?
TB
Rubeola virus (Measles)
Chicken pox
SARS
Smallpox
Disseminated varicella zoster virus (VZV)
Positioning for cord prolapse?
knee to chest and exaggerated sims position
low predictive value for the presence or absence of DVT
Homans sign
reliable DVT signs?
pain, swell, and warmth
Hyponatremia S/S?
LOC (altered)
weak muscles
osmolarity low
ortho hypotension
seizures
diarrhea
increased ICP
urine osmolarity high
hyperactive bowel sounds
Presumptive signs of preg?
amenorrhea
N/V
fatigue
urine freq.
quickening (slight flutter movement between 16-20 weeks gestation)
Probable signs of preg?
goodells sign (soften of cervix)
braxton hicks ctx
chadwicks sign (blue appearance of cervix)
hegars sign (soften of isthamus of cervix)
pos. preg test
palp of fetal outline
ballottement (sudden tap on cervix during the vag exam may cause fetus to rise in the amniotic fluid and then rebound to OG position)
Positive signs of preg?
fetal movement detected by examiner
auscultation of fetal heart sounds
visual of embryo or fetus
what heart sound is expected during preg?
S3 heart sound bc of increased bld volume
Hypernatremia S/S?
fever
restless and agitation
increased fluid retention
edema
dry mouth
skin flush
altered LOC and confused
low U/O
thirst
BP increased
decreased energy
What is expected for a K+ level over 5.0?
altered heart rhythm, tall peaked T waves with shortened QTI are the 1st finding
Chest tube findings?
Suction control: no tidal, replace with sterile H2O PRN, gentle bubble, connect to suction
H2O seal: fluid level moves up and down (tidal), intermittent bubble
Drainage: no tidal, connected to pt, pink drainage, no bubble
Injection angles?
IM: 90
SUBQ: 45
IV: 25
Intradermal: 5-15, epidermis
What is increased with GOUT?
uric acid
RhoGam?
given at 26-28 weeks and 72 H after delivery
what happens with cold stress?
poor muscle tone
weak/jittery
metabolic acidosis
HTN care?
daily wt
I&O
U/O
response of BP
electrolytes
take pulses
ischemic episodes
complications
Correct order for a stroke?
assess and stabilize w/in 10 M
neuro eval. w/in 25 M
obtain CT of head with no contrast w/in 45 M
ischemic = tPA
admin tPA w/in 60 M (w/in 4-5 H of onset)
admin to stroke unit w/in 3 H of entry to ED
Ischemic stroke?
permissive HTN
tPA (60 M)
surgical removal of clot (percutaneous thrombectomy)
hemorrhagic stroke?
get bleeding under control
aneurysm? coling and clipping
craniotomy
EVD
What is Digoxin?
mainstay for heart failure
treat systolic heart failure and A Fib
low K+ and mg levels may increase risk of toxicity
What interacts with grapefruit juice?
CCB and anticoagulants
what interacts with tyramine foods?
MAOIs
What are the 5 p’s of compartment syndrome?
pain
pallor
pulseless
paresthesia
pressure
what is ARDS cm?
hypoxemia (PaO2 less than 80)
norm PaO2 = 80-100
unconscious suppression of unwanted thoughts or info from consciousness
repression
attributing ones own feelings, thoughts, behavior, or motives
projection
revert to behavior from early stage of development in response to stress
regression
channel neg. emotions or socially unacceptable impulses into socially acceptable behavior
sublimation
Pre-op ABX?
give 1 H b4 surgical incision
Elicited by tapping on face just below and in front of ear to trigger facial twitch of 1 side of the mouth, nose, and cheek
Chvostek sign
elicited by place BP cuff around arm, inflate cuff to greater than pts SBP, and keep inflated for 1-4 M
Trousseaus sign
ABGs?
resp alk = pH increased, PaCO2 decreased, HCO3 norm
resp acid = pH decreased, PaCO2 increased, HCO3 norm
meta alk = pH increased, PaCO2 norm, HCO3 increased
meta acid = pH decreased, PaCO2 norm, HCO3 decreased
Inflammation of peritoneum, abd distension, pain increased w/ cough and movement, pain decreased when bend R hip, rigid, board like abd
peritonitis
PP hemorrhage risk?
polyhydramnios (increase amniotic fluid), prolonged labor
antepartum HTN
recent bleeding HX
twins
uterine fibroids
multi-parity
HTN management?
diet modify
exercise
anti HTN meds
smoking cessation
lifestyle modify
Hypercalcemia S/S?
weak, flaccid, decreased DTR
bradycardia, cyanosis, DVT
fatigue and decreased LOC
decreased peristalsis, hypoactive BS, abd pain, N/V, constipation, and kidney stones
ABX admin, nursing care?
monitor for super-infections
eval. liver and renal function
diarrhea manage
inform HCP if taking other meds
cultures B4 admin
no alc.
take entire course
eval. cultures, WBC, CRP, and temp
walking with a cane?
cane
opposite
affected
leg
what are the 5 rights of delegation?
task, circumstance, person, direction and comm, and supervision and eval.
Lithium?
therapeutic level: 0.6-1.2
bipolar disorder
efficacy in 1-2 weeks
fine hand tremors, wt gain, acne, and hair loss = common
avoid: ACE, NSAIDS, and diuretics
vomit, ataxia, confused, vision blurred = toxic
labs to monitor: thyroid panel, creatinine, NA+, lithium levels, daily fluids intake (1-2L)
Bells Palsy S/S?
blink reflex abdnormal
earache/ eyes roll up
lower corner of mouth and eyelids
loss of taste and brow movement
sudden onset (H-days)
paralysis unilateral (facial nerve: VII)
Management styles?
autocratic: manager makes all decisions
democratic: decisions made by group w/ manager support
laissez-faire: little structure or support by manager
transactional: reward well work, consequence for poor work
Non-Stress Test?
fetal NST eval. if changes in the FHR occur w/ movement
non-reactive = NOT GOOD!
