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Nclex Flashcards

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1
Q

Glucose

Normal Value

A

70-110 mg/dL

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2
Q

Glucose

Effects of Imbalance

A

High glucose: 3 p’s (polydipsia: thirst, polyuria, polyphagia: increase hungry)

Low glucose: confusion, irritability, diaphoresis - sympathetic response.

If no tx for either then trajectory is seizure, coma and death.

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3
Q

NA+

Normal Value

A

135-145 mEq/L

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4
Q

NA+

Effects of Imbalance

A

High or Low sodium = confusion (change in neuro status) - affected by fluid balance

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5
Q

K+

A

3.5-5 mEq/L

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6
Q

K+

Effect

A

High or low dysrhythmia

High: diarrhea, cramping - acidotic states Think: alot of bananas= loose stools

Low: constipation, leg cramps - alkalotic states

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7
Q

Ca+

Lab

A

8.5-10.5

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8
Q

Ca+

Effects

A

High: constipation, slowed reflexes, kidney stones

Think: C for constipation= everything is slow Low: tetany, increased reflexes, Chvosteks & trousseau, diarrhea

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9
Q

BUN

Lab

A

10-20 mg/dL

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10
Q

BUN

Effect

A

affected by fluid balance and diet (protein intake - if eat a lot of protein then high if little protein intake then low.) Kidney function but not specific
10-20 is therapeutic drug range for dilantin (phenytoin and theophylline)

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11
Q

Creatinine

Lab

A

0.5-1.5 mg/dL

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12
Q

Creatinine

Effect

A

Specific to kidney function (based on muscle mass)

Level is the same for therapeutic range digoxin and lithium

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13
Q

WBC

Lab

A

5-10K mm3

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14
Q

WBC

Effects

A

if extremely low then sepsis (overwhelming will see immature bands or blasts - mature cells have died in the war).
filgrastim increases WBC

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15
Q

Platelets

Lab

A

150-450K

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16
Q

Platelets

A

High: clotting (anticoagulants, antiplatelets, hydration, therapeutic phlebotomy)
Low: bleeding (oprelvekin synthetic colony stimulating factor, soft toothbrush, electric razor, fall precautions)

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17
Q

Hgb

Lab

A

> 10 g/dL (10-15)

More

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18
Q

Hgb

Effect

A

Low: anemia (sob, lethargic, pallor), pace activities

can give CSF epogen to increase H&H

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19
Q

HCT

Lab

A

35% or > up 48%

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20
Q

HCT

Effect

A

Low: anemia - see above High: clotting

affected by fluid balance

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21
Q

Bilirubin

Lab

A

<1

Less than

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22
Q

Bilirubin

Effect

A

High: , icterus, abdominal pain, clay stools, , increased risk of bleeding

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23
Q

MRI

Pre

A

Make sure there is no metal in the
e.g. welders may have fragments in their eyes and not know it, older pace-makers, rods, etc. Also, are they claustrophobic? May need a benzo before the procedure. If MRA,
Hold glucophage the day of the
procedure and hold for 48 hours after the procedure

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24
Q

MRI

Post

A 
It depends if it’s just a MRI (don’t need to do anything);
a MRA (angiography which requires dye) need to increase fluids to flush out the dye or can cause renal dysfunction
None
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25
Q

CT with contrast

Pre

A

check for allergies for shellfish or
Hold glucophage the day of the procedure and 48 hours
after

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26
Q

CT with contrast

Pre

A

check for allergies for shellfish or
Hold glucophage the day of the procedure and 48 hours
after

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27
Q

CT with contrast

Post

A

Hold glucophage 48hrs after

Increase hydration to excrete dye

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28
Q

Electroencephalogram (EEG)

Pre

A

No lCNS stimulants or depressants
Before EEG e.g. no coffee/ tea: chocolate
hold the client’s seizure
meds (which would depress CNS). May sleep deprive them to increase likelihood of seizure

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29
Q

Electroencephalogram (EEG)

A

Nothing really post procedure

None

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30
Q

Arterial Blood Gas

Pre

A

Allen’s test, check bleeding profile

PT/INR, PTT, Liver function) what meds are they on anticoagulants, antiplatelets or any bleeding disorders

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31
Q

Arterial Blood Gas

Post

A

Hold pressure for 5 minutes

or even longer if on meds that cause bleeding.

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32
Q

Endoscopy

Pre

A

NPO 4-6 hours before to prevent

aspiration

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33
Q

Endoscopy

Post

A

Gag reflex before anything

PO

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34
Q

Cardiac Catheterization

Pre

A

NPO 4-6 hours prior, check
allergies, shellfish, iodine,
consent. Do not shave site, we only trim it

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35
Q

Cardiac Catheterization

Post

A

HOB less 30 degrees.
Depends on closure device, maintain pressure, check site q15 minutes and distant pulses, bp/hr for internal bleeding. Hydration to remove dye from body,

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36
Q

Thoracentesis

Pre

A

remain still, assess their lungs, vital signs prior consent, bleeding time, meds that may increase risk. of bleeding

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37
Q

Thoracentesis

Post

A

CXR immediately after, assessment of lungs signs immediately, could
cause a pneumothorax, vital could

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38
Q

Nasal Cannula

A

0.5-6L, tissue damage around ears and nares, humidify if 3-4L or higher

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39
Q

Simple Face Mask

A

Cannot have less than 5-6 Liters or the client will rebreath their C02 and will have respiratory acidosis and have to be intubated

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40
Q

100% Nonrebreather

A

fill the reservoir bag with oxygen first before applying to client or will rebreath c02 and become acidotic

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41
Q

Respiratory

Complication

A

atelectasis, pneumonia

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42
Q

atelectasis

A

collapsed alveoli

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43
Q

Respiratory

A

TCDB q2h, ISE 10x hour while awake, pickle or accapella (blow into to loosen secretions), ambulate or at least sit up in chair, chest physiotherapy, hydration to thin secretions

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44
Q

Cardiac

Complication

A

DVT, PE, orthostatic

hypotension

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45
Q

Cardiac

Interventions to Prevent

A

ambulation, heparin sq or lovenox, sequentials, TEDS, fluids, change positions slowly

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46
Q

GI

Complication

A

ileus, constipation, N/V

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47
Q

GI

Interventions to Prevent

A

ambulation, nasogastric tube if vomiting or ileus - NPO until bowel sounds return
GU

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48
Q

GU

Complication

A

urinary retention, stones if they stay in bed too long, Catheter associated UTI (CAUTI)

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49
Q

GU

Interventions to Prevent

A

Get them OOB - Gravity, lots of fluids

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50
Q

Integumentary

Complication

A

pressure ulcers, eviscerate,

dehiscence, wound infection

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51
Q

Integumentary

Interventions to Prevent

A

Turn q2hs, ambulate, use binder, splint when coughing sterile dressing changes

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52
Q

State 2 differences between an ileostomy and colostomy?

A

​a. Consistency: Ileostomy watery, continuous output. Colostomy is more formed- not continuous
​b. Location: ileocecal (right lower quadrant - ileostomy); colostomy ascending, transverse, descending can irrigate colostomy but not ileostomy.

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53
Q

How often should an ostomy pouch/wafer be changed?

A

3-10 days or prn if there is a leak. Bag emptied? 2/3rd full

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54
Q

A client calls the clinic stating they have not had any output from their ileostomy for 2hrs. What is the best response by the nurse? State at least 2 things the nurse should tell the client.

A

a. hot liquids, knee chest, ambulate, change the wafer, warm shower, massage around it - if nothing needs to be seen = blockage

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55
Q

State 3 reasons a nurse would clamp a chest tube?

A

Looking for leak (intermittently), changing the drainage container, or getting ready to remove it.

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56
Q

TPN

Equipment/Lines/Tubes required to administer

A

filtered tubing, central line

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57
Q 
TPN 
Nursing considerations (need to knows to prevent harm)
A

daily labs, 2 nurses, monitor infection, check glucose levels, must change tubing q24hrs. Run out of TPN? dextrose 10-20% at same rate to prevent hypoglycemia, Monitor fluid balance

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58
Q

Tube Feedings

Equipment/Lines/Tubes required to administer

A

tubing set, formula, NGT, GT, JT

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59
Q 
Tube Feedings 
Nursing considerations (need to knows to prevent harm)
A 
NGT placement CXR before using.
check blood glucose q6h
check residuals q4h
change the set q24h
make sure enough free water
Head of the bed 30 degrees or higher to prevent aspiration
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60
Q

State 3 factors that increase a client’s risk for falls

A

​Age, medication, previous fall, uses equipment to ambulate (cane, walker), lines

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61
Q

How are crutches measured?

A

2-3 fingerbreadths below axillary, 20 degree angle wrist pressure on wrists not axillary

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62
Q

A client is being discharged home after hip surgery, what “hip precaution” teaching will you provide?

A

do not cross legs, do not bend over 90 degrees, chair height (upside down stop light), raised toilet seat. chairs with arms

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63
Q

What do nurses need to know about traction e.g. bucks or cervical?

A

continuous never release, never change weights

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64
Q

State 2 nursing considerations when communicating with a client who is hearing impaired

A

quiet environment, face them, lighting, hearing aids in if they have them, set aside enough time to speak with client

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65
Q

A nurse is discharging home a client with a visual deficit. State 3 home safety interventions

A

no chairs with wheels, no extension cords, or small animals, good lighting, no scatter rugs, paint edges of stairs bright colors

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66
Q

What can be delegated to an LPN?

A

Anything the nurse cannot EAT (Evaluate, assess or teach), only have stable patients, chronic conditions.

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67
Q

State 3 nursing ethical principles

A

autonomy, veracity (telling truth), fidelity (doing what you say you will do, keep your word), beneficence (doing good); nonmaleficence (not doing harm)

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68
Q

A client has a nasogastric tube for decompression. The nurse will set the suction gauge at 40-60 mmHg
​What is the gold standard for NTG placement?

A

CXR

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69
Q

A client is at risk for aspiration (difficulty swallowing) what should the nurse instruct the CNA to do when feeding the client?

A

90 degrees, chin tuck, no straws, speech and swallow

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70
Q

Metoprolol

A

beta blocker

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71
Q

Metoprolol

Action/Side Adverse

A

blocks beta 1 receptor on the heart to slow heart rate and decrease blood pressure (blocks sympathetic response)

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72
Q

Metoprolol

A

Heart rate <60 & BP (SBP<90)
People with respiratory disorders because it affects beta 2 receptors causing bronchoconstriction
Diabetics - check blood glucose more frequently - masks hypoglycemia
change positions slowly, do not stop abruptly, do not overheat yourself

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73
Q

Accupril

A

Ace inhibitor -pril

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74
Q

Accupril

Action/Side Adverse Effects

A

interferes with the Renin-Angiotensin - Aldosterone system

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75
Q

Accupril

A

Check BP and Potassium levels (could be high because hold onto K+); Umbrella BP protocols ; S/E: hacking cough; Adverse reaction : angioedema

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76
Q

Warfarin

A

anticoagulant

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77
Q

Warfarin

Action/Side Adverse Effects

A

interferes with clotting cascade

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78
Q

Warfarin

Nursing Considerations
Parameters/Effectiveness, etc.

A

careful with NSAIDS increased risk of bleeding. Antidote: Vitamin K or Aquamephyton, Fresh Frozen Plasma (FFP). Teaching: Do not drastically change your diet; soft toothbrush, electric razor, no contact sports, report excessive bleeding or bruising. Lab: PT/INR if A-fib 2-3, if mechanical valve 2.5-3.5 or 4

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79
Q

Digoxin

Classification

A

Cardiac glycoside

or positive inotrope (increases contractility), negative chronotropic (decreases heart rate)

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80
Q

Digoxin

Action/Side Adverse Effects

A

increases ventricular contractility to improve cardiac output

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81
Q

Digoxin

Nursing Considerations
Parameters/Effectiveness, etc.

A

Therapeutic range: 0.5-1.5 (if near 2 then patient will have symptoms of toxicity) visual disturbances green/yellow halos,
N/V Check at the bedside: Apical pulse for 1 minute if <60 hold
Also check potassium - if low can cause toxicity. How do you determine effectiveness? clearer lungs, decreased edema, no SOB or improved breathing, energy.

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82
Q

Furosemide

A

loop diuretic

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83
Q

Furosemide

Action/Side Adverse Effects

A

increase urine output and potassium (waster)

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84
Q

Furosemide

A 
Check BP, Potassium, fluid balance
check weights (daily), effective if ease of breathing, clearer lungs, decreased edema, lowered BP monitor urine output.
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85
Q

Aspirin

A

antiplatelet, antipyretic, NSAID

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86
Q

Aspirin

A

Anti-platelet - makes them less sticky - effects the platelet for the life of the platelet which is 10 days

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87
Q

Aspirin

A

No one under 18 or Reye syndrome (liver failure)
Take with food - gastric distress and ulcers
Toxicity: tinnitus - ringing in the ears

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88
Q

Phenytoin

A

anti-seizure/

anti-epileptic

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89
Q

Phenytoin

Action/Side Adverse Effects

A

seizure threshold - increase to prevent seizures

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90
Q

Phenytoin

A

Therapeutic range: 10-20
Causes birth defects
Decreases effectiveness of oral contraceptives - use barrier
Gingival hyperplasia, good oral care
pink urine is normal, Tube feedings hold 1 hour before and after
If given IV no dextrose or it will crystallize

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91
Q

Dexamethasone

A

steroids (-asone or one)

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92
Q

Dexamethasone

A

antiinflammatory

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93
Q

Dexamethasone

A

Do not stop abruptly or cause an adrenal crisis. Must taper the drug.
Long term: Moon Face, truncal obesity, thin extremities, buffalo hump, cataracts, osteoporosis, hirsutism, weight gain, fluid retention
As soon as take the medication - early signs: hyperglycemia, risk for infection, slow wound healing.

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94
Q

Cardizem

A

calcium channel blocker

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95
Q

Cardizem

A

ion influx

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96
Q

Cardizem

A

At bedside check: Heart Rate & Blood Pressure, prolong QT interval on ECG
Umbrella for drugs that lower BP

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97
Q

Simvastatin

A

anti cholesterol medications

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98
Q

Simvastatin

A

works directly on the liver to slow production of cholesterol

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99
Q

Simvastatin

A

Given night because the liver is more active at night.
LFT before starting medication and monitor LFTs
Adverse reaction: rhabdomyolysis
Do not ingest grapefruit juice.
Report abdominal pain, jaundice, icterus, dark urine, clay stools
Monitor cholesterol: Total = <200
HDL>60
LDL<100

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100
Q

Lorazepam

A

benzodiazepine

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101
Q

Lorazepam

A

works on CNS

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102
Q

Lorazepam

A

works on CNS

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103
Q

Lorazepam

A 
antidote: flumazenil or romazicon
monitor respiratory rate
safety precautions
highly addictive
tolerance and withdrawal
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104
Q

Morphine sulfate

A

Opioid pain medication

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105
Q

Morphine sulfate

A

CNS

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Perfectly
106
Q

Morphine sulfate

A

Antidote: naloxone/narcan
monitor Respirations hold if <12
tolerance/dependence

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107
Q

What is the maximum score on the Glasgow Coma Scale?

A

15 (lowest is 3)

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108
Q

Which nerve is affected in Bell’s Palsy?

A

CN VII (know all CN and how they are tested)

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109
Q

What is Cushing’s triad?

A

IICP widened pulse pressure, bradycardia, irregular respirations

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110
Q

Where is a ventriculostomy drain leveled to?

A

forman monroe, tragus of the ear

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111
Q

Which eye disorder has a loss of central vision?

A

macular degeneration no treatment (retinal detachment - curtain; glaucoma= loss peripheral only one that causes pain treated with medications; cataracts opaque vision)

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112
Q

Which type of cerebrovascular bleed requires immediate surgery (lucid then deteriorates quickly)?

A

Epidural bleed

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113
Q

What part of the brain controls balance?

A

cerebellum (C for coordination); frontal (Be Expressive - personality , expressive aphasia - Brocas); temporal (hearing, receptive aphasia, wernickes); parietal is sensation; occipital is vision

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114
Q

State 2 interventions you would do if clear drainage was observed draining from the nares of a client with a basilar skull fracture? (state 2)

A
  1. halo test; mustache dressing. High risk for CNS infection = nuchal rigidity
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115
Q

What are the cardinal signs of Parkinson’s Disease?

A

TRAPI

Tremors, rigidity, akinesia (bradykinesia slow movement), Postural instability

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116
Q

How is autonomic dysreflexia treated? Who is at risk?

A

T6 spinal injury or above, high bp caused by a stimulus below the injury usually bladder distention or constipation or tight clothing. Sit them up, look for the problem. If SBP >170 give BP medication

117
Q

State 2 things a nurse needs to know about traction (Gardner wells or Bucks)

A
  1. continuous traction and 2. do not change weights
118
Q

State 2 vasopressors

A

a. epinephrine, norepinephrine, dopamine, dobutamine, vasopressin
vasodilators: Nitroglycerin, nitroprusside

119
Q

Where is the phlebostatic axis located?

A

right atrium (4th ICS mid axillary)

120
Q

What is it?

A

VTach___________________Treatment: __Check for pulse if have one then cardiovert; if pulseless treat as VFib - defibrillate ASAP, CPR until defibrillator is obtained.

121
Q

What is it?

A

SVT__Treatment: vagal maneuvers (stimulate parasympathetic system) bear down, cough, blow through a straw, put face in ice water; doctor can carotid massage; adenosine 6, 12, 12 = 30 mg rapid iv push followed 20 mL of saline

122
Q

What are signs and symptoms of pericarditis?

A

friction rub, pain relieved if leaning forward, and NSAIDS

123
Q

Which type of valve replacement requires life-long anticoagulants?

A

mechanical (biological do not, but need to get a new biological every 8-10 years whereas mechanical is for life)

124
Q

arterial ulcer

A

In arterial disease there is not enough blood, blood is warm and it carries all the nutrients. So decreased blood flow to lower extremities will not have edema, will be cool (lack of the warm blood), scarce hair and thick toenails because lack of nutrients, wounds are deep and edges are well circumscribed, weak pulses

125
Q

venous ulcer

A

Venous insufficiency is just the opposite, no problem getting to the feet but blood pools in the feet due to incompetent valves make it difficult for the blood to return to the right side of the heart so edema, warm feet, good pulses, toenails are fine and hair is not patchy. Wounds are shallow with irregular borders

126
Q

What medication(s) would you use to lower systemic vascular resistance?

A

vasodilators, antihypertensives

127
Q

Interpret the following ABG:

pH 7.20, pC02 32, Hc03 18, Pa02 70

A

Metabolic Acidosis, partial compensation, hypoxemia

128
Q

What would cause a low pressure alarm on a ventilator?

A

disconnected, pneumothorax, leak, tracheostomy cuff is down.

​High pressure alarm: stiff non compliant lungs, increased secretions in tube, biting the tube, kink in the tube

129
Q

What is the cardinal sign of ARDs?

A

refractory hypoxemia needs mechanical ventilation and high PEEP

130
Q

Bronchitis

Causes/
Physiology

A

smoking, pollution

131
Q

Bronchitis

S&S

A

Blue bloater
increased H&H d/t constant release of erythropoietin
eventually right-sided HF (Cor Pulmonale)
02 sats 88-91%

132
Q

Bronchitis

Tests/ Procedures/
Treatment

A 
pulmonary function tests
inhalers (beta 2 agonists - terol; anticholinergics - tropium; and inhaled steroids - cort or asone)
mucolytics
low dose steroids
low oxygen via NC
133
Q

Bronchitis

Education

A

stop smoking
teach about medications: what order to take inhalers,
do not stop steroids abruptly (if they are taking them)
Pursed lip breathing (helps keep alveoli open longer for better gas exchange)

134
Q

Emphysema

Causes/
Physiology

A

smoking, pollution or genetic (do not have alpha 1 antitrypsin)

135
Q

Emphysema

S&S

A

Pink puffer - able to oxygenate themselves but using accessory muscles
02 sats 88-91%

136
Q

Emphysema

Tests/ Procedures/
Treatment

A

Pulmonary function tests
inhalers (same as bronchitis above)
low dose steroids
low oxygen via NC

137
Q

Emphysema

Education

A

Same as above for Bronchitis

Also, diaphragmatic breathing (largest muscle- less 02 use when using diaphragm instead of accessory muscle to breath)

138
Q

Asthma

Causes/
Physiology

A

allergens

genetic

139
Q

Asthma

S&S

A

wheezing due to

bronchoconstriction

140
Q

Asthma

A

wheezing due to

bronchoconstriction

141
Q

Asthma

A

Peak flow meter
Green is good
yellow need to change med regime
red take rescue inhaler and call 911

142
Q

Asthma

A

take medications as prescribed, how to use the peak flow meter, should be used everyday, try to avoid triggers

143
Q

Tuberculosis

A

underdeveloped populations, crowded living conditions, immunocompromised

144
Q

Tuberculosis

S&S

A

Night sweats, weight loss, hemoptysis

145
Q

Tuberculosis

Tests/ Procedures/
Treatment

A

Positive sputum culture Acid Fast Bacilli, CXR

146
Q

Tuberculosis

Education

A

Must wear surgical mask when out in public or around people, take meds as prescribed (ethambutol, INH, Rifampin or Streptomycin) after 3 negative sputum cultures then they can stop taking the meds

147
Q

Pneumothorax

Causes/
Physiology

A

Tall thin young males are at high risk for spontaneous pneumothorax, pple with COPD have blebs on their lungs puts them at risk, a client on a ventilator that has noncompliant lungs or trauma

148
Q

Pneumothorax

S&S

A

absent or dim lung sounds (if small); tracheal shift to the unaffected side if large

149
Q

Pneumothorax

Tests/ Procedures/
Treatment

A

Chest tube needs to be placed to restore negative pressure and re-expansion of the lung

150
Q

Pneumothorax

Education

A

Pain control with PCA, about chest tube - when ambulating etc.
TCDB (pulmonary toileting)

151
Q

Hyperglycemia

A

insulin

152
Q

Hypoglycemia

A

15’s (15 grams of simple carbohydrate, recheck blood glucose in 15 min, another 15 grams of simple carbs if not in range but if in range then 7.5 g of complex carbohydrate so blood sugar does not plummet)

if confused or not conscious then give glucagon sq or IM or Dextrose 50% IVP if they have an IV - never give PO if not fully conscious - will aspirate

153
Q

Rapid (Lispro, Aspartate) (-logs)

Onset

A

5-15min

154
Q

Rapid (Lispro, Aspartate) (-logs)

Peak

A

1.5 (1-2)

155
Q

Regular Insulin (-lin)

Onset

A

30

156
Q

Regular Insulin (-lin)

Peak

A

3 (2-4)

157
Q

NPH

Onset

A

60

158
Q

NPH

Peak

A

6 (4-8)

159
Q

Long acting

A

60

160
Q

Long acting

Peak

A

No peak - basal rate

161
Q

State the 2 differences between HHNKS and DKA:

A

a. Hyperglycemia hyperosmotic nonketotic syndrome - no acidosis, no ketones - type II diabetics (Blood glucose 600-1000)
b. DKA acidosis, ketones, Type I 400-600

162
Q

What labs would the nurse expect for a client admitted with adrenal crisis?

A 
adrenal cortex (think of the hormones aldosterone, cortisol and sex hormones):
aldosterone:  holds onto NA & water gets rid of potassium - so what if no aldosterone?
​get rid of NA+ and water and hold onto K+= hyponatremia, hypotension, hyperkalemia

Cortisol: if present have increase in glucose; if don’t have cortisol = hypoglycemia

Adrenal crisis= hyperkalemic, hyponatremic, hypotension, hypoglycemic

163
Q

What are the complications (emergency) of hypothyroid and hyperthyroid?

A

a. Hypothyroid emergency/complication:_myxedema coma - give synthroid (thyroid hormone)
b. Hyperthyroid emergency/complication: thyroid storm - treat symptoms High BP, High temperature-

164
Q

Using the rule of nines and Parkland formula calculate fluid resuscitation for first 8 hours:

A

Burns to the face, entire right arm, entire chest and abdomen, entire right leg and groin. Client weighs 68kg

face: 4.5, 9, 18, 18 1= 50.5 x 4mL x 68= 13,736/2 = 6868 first 8hrs (has to be infused within 8hrs of the when the burn occurred e.g. if burned at 1000, then it must be infused by 1800) then the rest over the next 16 hours
6868/8= 858.5

165
Q

Hepatitis

Risk Factors

A 
Know ABC
Immunoglobulins
vaccinations
body fluids
contaminated water/feces
166
Q

Hepatitis

S&S

A

liver dysfunction

167
Q

Hepatitis

Treatment

A

immunoglobulin

vaccinations

168
Q

Cholecystitis

Risk Factors

A

female, fair fat, forty and fertile

169
Q

Cholecystitis

S&S

A

right up quad/shoulder/back pain after fatty/spicy meal, N/V

170
Q

Cholecystitis

Treatment

A

diet, cholecystectomy

171
Q

Acute Pancreatitis

Risk Factors

A

alcoholism or stone is lodged in common bile duct, smoke

172
Q

Acute Pancreatitis

S&S

A

acute abdominal pain, n/v , increased lipase and amylase

173
Q

Acute Pancreatitis

Treatment

A

rest the stomach, nasogastric tube, stop drinking and smoking
or removal of the stone

174
Q

Compare and contrast Glomerulonephritis and Nephrotic Syndrome - how are they similar and how are they different?

A

strep infection undetected/not treated - damaged kidneys, more permeable losing large cells albumin and red blood cells. Low albumin look like pillsbury dough boy (edema) frothy coca cola urine (frothy album and coca cola is red blood cells) ; red blood cells anemic. - treat glomerulonephritis antibiotic, go slow with replacing albumin.

If glomerulonephritis is not treated properly then they will develop nephrotic syndrome - irreversible chronic renal failure - go ahead and replace albumin.

175
Q

What are the 3 phases of acute renal failure?

A

1) anuric/oliguric, 2) diuresis 3) recovery

176
Q

What are 3 types (causes) of acute renal failure?

A

pre-renal (volume); intrarenal (drugs aminoglycoside); post-renal (enlarged prostate or stone)

177
Q

Hemodialysis

A

3 days a week for few hours

hypotension

178
Q

Hemodialysis

Complications that might occur

A

hypotension

disequilibrium syndrome (too fast removal of BUN) slow the rate

use heparin= so risk of bleeding

179
Q

Peritoneal Dialysis

A

several exchanges a day

with dwell times

180
Q

Peritoneal Dialysis

Complications that might occur

A

peritonitis

fluid overload

181
Q

Rheumatoid Arthritis

A 
symmetrical joint destruction/deformities
swan neck, boutonniere
Rheumatoid factor (RF), ANA (antinuclear antigen)
stiff when joints not used e.g. waking up in the morning - feel better with movement
182
Q

Rheumatoid Arthritis

A 
DMARDs
Disease modifying antirheumatic drugs
plaquenil
steroids
methotrexate
183
Q

Osteoarthritis

A

unilateral
wear and tear

pain occurs with use of the joints

184
Q

Osteoarthritis

A

unilateral
wear and tear

pain occurs with use of the joints

185
Q

Osteoarthritis

Treatment

A

steroids
surgery
OTC: chondroitin

186
Q

Gout

A

build up of uric acid in the small joints can be in fingers and toes
(usually great toe)
very painful inflamed
Exacerbated by dehydration

187
Q

Gout

A

prophylactic use of
Probenecid (helps excrete (pee) out the uric acid)
Allopurinol (decreases the production of uric acid

Colchicine for acute episodes
Indomethacin

188
Q

PPN

Equipment Needed

A

peripheral line

189
Q

PPN

Complications

A

hyperglycemia

fluid overload

190
Q

PPN

Nursing
Interventions to
Prevent
Complications

A 
daily labs
glucose checks
change tubing/bag
q24
dedicated lines
D10-D20% if no
feeding on hand
191
Q

Isotonic

A

volume to increase BP

192
Q

Hypotonic

A

cellular dehydration- never give this to
someone with a cerebral edema will
worsen it.

193
Q

Hypertonic

A

brain swelling

194
Q

Lumbar puncture

Pre

A

contraindicated
for lICP, consent, labs,

keep patient still, calm

195
Q

Lumbar puncture

A 
dark room, hydrate,
supine position to
prevent spinal ha, but if
develop a spinal ha then
blood patch
196
Q

Computed
Tomography
Angiography

A

dye allergy,
metformin hold

metallic taste

197
Q

Computed
Tomography
Angiography

A

hydrate to clear dye

198
Q

Barium enema

A

instill enema
do enema
before barium swallow

nothing specific

199
Q

Barium enema

A

fluids, laxatives

200
Q

Tracheostomy mask

A

always humidified

201
Q

24hr urine collection

A

pt void then start time

202
Q

24hr urine collection

A

if tissue or feces gets in or miss a void, start over Keep on ice

203
Q

24hr urine collection

A

add last void, return to lab

204
Q

Pyelography

Pre

A

allergies to
iodine/shellfish.
metformin hold

205
Q

Pyelography

Post/

A

hydrate to clear dye

206
Q

Sickle Cell

Pre

A

african american,
hemoglobin S
carrier

207
Q

Sickle Cell

During

A 
pain, extremities,
chest due to poor
perfusion (sickling
blocks off small
capillaries)
208
Q

Sickle Cell

Post

A

fluids, oxygen,
morphine,
hydroxyurea
prophylactically

209
Q

Pernicious

Pre

A

gastric bypass

210
Q

Tell me about the chain of infection.

A

microorganism present, portal of entry, susceptible host

211
Q

What is the difference between medical asepsis and surgical asepsis?

A

MEDICAL ASEPSIS REDUCES THE AMOUNT OF MICROORGANISMS (CLEAN TECHNIQUE) AND SURGICAL ASEPSIS REMOVES ALL MICROORGANISMS (STERILE)

212
Q

State 3 interventions a nurse can do to improve pulmonary function.

A

turn, cough, deep breath, ambulate, incentive spirometry, hydrate

213
Q

Tell me about 3 therapeutic communication techniques.

A 
active listening
no why questions
offering self
CLARIFYING/RESTATING
OPEN-ENDED
CLOSE-ENDED
214
Q

Foley Catheter

A

neurogenic bladder, surgery,
irritation

infection prevention, aseptic
technique

215
Q

Straight catheter

A

no void after 6 hrs

infection prevention

216
Q

Ostomy

A

bladder cancer

sterile technique, infection
prevention

217
Q

Nephrostomy

A

blockage below kidney

infection prevention

218
Q

What teaching would you provide to a client who has just been prescribed 3 inhalers (Ipratropium, Salmeterol and Azmacort)

A

-Terol first a beta 2 agonist, -tropium next and inhaled anticholinergic, steroids are last - rinse mouth and mouth piece to prevent thrush after using steroid inhalers. If you develop thrush use Nystatin swish and swallow - swish as long as you can in your mouth then swallow because thrush will travel through the entire GI tract

219
Q

State 3 reasons a nurse would clamp a chest tube?

A

a. checking for leaks (start at the patient) b. changing the drainage container c. to determine if the chest tube is ready to be removed.
b. If the chest tube becomes disconnected from the drainage container. - take the end of the tube and put in sterile water/saline - in the room should clamps, sterile saline/water, gauze dressing and an occlusive vaseline dressing.
c. The chest tube is pulled out of the patient - it was newly placed - use gauze and tape 3 sides
d. if it was a chest tube that was pulled out and it was ready to come out - put vaseline occlusive
dressing on the incision site.

220
Q

What should a stoma look like?

A

pink, beefy red - not blue, pale or black. Shrinks after surgery

221
Q

A client calls the clinic stating they have not had any output from their ileostomy for 2hrs. What is the best response by the nurse?

A

VERY CONCERNING! Means there is a blockage. Knee to chest, drink warm fluids, prune juice, take warm shower, ambulate, massage around the site, replace the wafer - go to ER or clinic immediately.

222
Q

Diltiazem

Class

A

Calcium Channel Blocker

223
Q

Diltiazem Action

A

slows heart rate and decreases blood pressure

224
Q

Diltiazem Parameters

A

HR <60 & SBP <90

225
Q

Diltiazem Side/Adverse Effects

A

Hypotension, bradycardia, dizziness

226
Q

Diltiazem Client Teaching

A

Change positions slowly, do not discontinue abruptly, do not over heat yourself

227
Q

Digoxin Class

A

Cardiac Glycoside/Positive Inotropic

228
Q

Digoxin Action

A

Increases contractility of the ventricles

229
Q

Digoxin Parameters

A

Apical Pulse for 1 minute <60

230
Q

Digoxin Side/Adverse Effects:

A

Bradycardia, green/yellow halos, n/v

Increased risk of toxicity if low K+
•Therapeutic range: 0.5-1.5

231
Q

enalapril Class

A

ACE inhibitor

232
Q

enalapril Action

A

works on Renin-Angiotension Aldosterone System blocks angiotensin 2 and prevents release of aldosterone

233
Q

enalapril Parameters

A

Fluid balance, BP, and Potassium

234
Q

enalapril Side/Adverse Effects:

A

hypotension, hyperkalemia, angioedema, hacking cough, birth defects/morbidity/mortality

235
Q

enalapril Client Teaching

A

Monitor fluid balance, weight, daily same scale, cloths, time, edema, BP, change positions slowly, don’t overheat yourself, report difficulty swallowing, tongue

236
Q

Heme

A

Oprelvikin

Filgrastim

Epogen

237
Q

Oprelvikin Class

A

Colony stimulating factor

238
Q

Oprelvikin action

A

increase platelet count

239
Q

Oprelvikin Parameters

A

monitor platelet count (150-450K)

240
Q

Oprelvikin Side/Adverse Effects

A

could develop clots if too many platelets, increased blood pressure. Bone pain is side-effect

241
Q

Oprelvikin Client Teaching

A

Take Tylenol for bone pain

242
Q

Filgrastim Class

A

Colony Stimulating Factor

243
Q

Filgrastim Action

A

Increases WBC

244
Q

Filgrastim Parameters

A

Monitor WBC

245
Q

Filgrastim Side/Adverse Effects:

A

leukocytosis (too many WBC), bone pain

246
Q

Filgrastim Client Teaching

A

bone pain is common, take Tylenol. Avoid people with infections.

247
Q

Epogen Class

A

Colony stimulating factor

248
Q

Epogen Action

A

Increase RBC count

249
Q

Epogen Parameters

A

monitor H&H

250
Q

Epogen Side/Adverse Effects

A

too many RBC increase BP and increased risk of clots.

251
Q

Epogen Client Teaching

A

Bone pain is common s/e take Tylenol. Improvement in s&s of anemia

252
Q

Heparin class

A

parenteral anticoagulant

253
Q

Heparin Action

A

prevent clots from forming or extending

254
Q

Heparin Parameters

A

aPTT (Heparin IV drip 50 to 70 seconds) q6h we’re gonna draw an aPTT

255
Q

Heparin Antidote

A

Protamine Sulfate

256
Q

Heparin Side/Adverse Effects

A

Bleeding (VS: HR and BP), HIT (Heparin Induced Thrombocytopenia)
Complete Blood Cell Count (CBC): H&H, Platelets.

257
Q

Heparin Client Teaching

A

electric razor, soft tooth brush, report excessive bruising or bleeding, report dizziness.

258
Q

Methotrexate Class

A

Chemotherapeutic

259
Q

Methotrexate Action

A

Cancer

260
Q

Methotrexate Parameters

A

suppresses cancer metastases/improvement, decreased

261
Q

Methotrexate Side/Adverse Effects

A

Monitor CBC – causes pancytopenia (decrease blood cell count – RBC, WBC and Platelets)
•RBC < anemia (sob, lethargy, pallor)
•WBC < at risk for infection
•Platelets < risk for bleeding
•Stomatitis, alopecia
•GI issues (NVD)

262
Q

Methotrexate

A

•Client Teaching: do not take colony stimulating factors before chemotherapy, take it after chemo. Talk about alopecia, stomatitis, GI (diarrhea, nausea and vomiting)

•Antidote: leucovarin

263
Q

Infiltration

A

Remove. Elevate. apply warm compress

264
Q

Air embolus

A

Left lateral trendelenberg

265
Q

Extravasation

A

Aspirate drug, inject antidote

266
Q

Hematoma

A

Apply light pressure

267
Q

Phlebitis

A

Remove apply warm/cool compress

268
Q

Acetaminophen antidote

A

N- acetylcysteine (mucomyst)

269
Q

Benzodiazepine

A

Flumazenil (romazicon)

270
Q

Cyanide poisoning

A

Methylene blue

271
Q

Digitalis

A

Digoxin immune FAB (digibind

272
Q

Heparin/enoxaparin

A

Protamine sulfate

273
Q

Iron

A

deferoxamine

274
Q

Lead

A

succimer

275
Q

Magnesium sulfate

A

Calcium gluconate

276
Q

Narcotics

A

naloxone

277
Q

Warfarin

A

Phytonadione (vitamin k, aquamethyton, fresh frozen plasma)
worksheet

278
Q

Gingko

A

treating blood disorders and memory issues

279
Q

Ginkgo people should not take

A

Blood thinner

280
Q

saw palmetto

A

saw palmetto

281
Q

saw palmetto

A

headache, nausea, diarrhea, and dizziness

282
Q

Who should not take saw palmetto

A

taken by children, during pregnancy or breastfeeding, or by those with hormone-sensitive cancers.

283
Q

St. John’s Wort

A

for depression, menopausal symptoms, attention-deficit hyperactivity disorder (ADHD), somatic symptom disorder

284
Q

Who should avoid St John’s wort?

A

major depression because increase mania

285
Q
A

Who should avoid St John’s wort?

286
Q

HEAD TRAUMA

A

Strokes/Bleeds:
o Thrombotic/embolic (clot/blockage) thrombolytics (protocol <3hrs) or
anticoags
o Hemorrhagic (broken vessel)
▪ fast=epidural (meningeal artery/awake, alert then suddenly
declines- EMERGENCY) or slow=subdural (venous bleed)
▪ NO thrombolytics/anticoags!

287
Q

Ventricular tachycardia
Medication to treat

A

antiarrhythmic medication

288
Q

Duodenal ulcer happens after

A

2-3 hours after meal
And night

Relieved by eating

289
Q

Gastric ulcers

A

Occurs 30 minutes after eating

Nclex Review Notes (3 decks)

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