Nclex Flashcards
Glucose
Normal Value
70-110 mg/dL
Glucose
Effects of Imbalance
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.
NA+
Normal Value
135-145 mEq/L
NA+
Effects of Imbalance
High or Low sodium = confusion (change in neuro status) - affected by fluid balance
K+
3.5-5 mEq/L
K+
Effect
High or low dysrhythmia
High: diarrhea, cramping - acidotic states Think: alot of bananas= loose stools
Low: constipation, leg cramps - alkalotic states
Ca+
Lab
8.5-10.5
Ca+
Effects
High: constipation, slowed reflexes, kidney stones
Think: C for constipation= everything is slow Low: tetany, increased reflexes, Chvosteks & trousseau, diarrhea
BUN
Lab
10-20 mg/dL
BUN
Effect
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)
Creatinine
Lab
0.5-1.5 mg/dL
Creatinine
Effect
Specific to kidney function (based on muscle mass)
Level is the same for therapeutic range digoxin and lithium
WBC
Lab
5-10K mm3
WBC
Effects
if extremely low then sepsis (overwhelming will see immature bands or blasts - mature cells have died in the war).
filgrastim increases WBC
Platelets
Lab
150-450K
Platelets
High: clotting (anticoagulants, antiplatelets, hydration, therapeutic phlebotomy)
Low: bleeding (oprelvekin synthetic colony stimulating factor, soft toothbrush, electric razor, fall precautions)
Hgb
Lab
> 10 g/dL (10-15)
More
Hgb
Effect
Low: anemia (sob, lethargic, pallor), pace activities
can give CSF epogen to increase H&H
HCT
Lab
35% or > up 48%
HCT
Effect
Low: anemia - see above High: clotting
affected by fluid balance
Bilirubin
Lab
<1
Less than
Bilirubin
Effect
High: , icterus, abdominal pain, clay stools, , increased risk of bleeding
MRI
Pre
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
MRI
Post
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
CT with contrast
Pre
check for allergies for shellfish or
Hold glucophage the day of the procedure and 48 hours
after
CT with contrast
Pre
check for allergies for shellfish or
Hold glucophage the day of the procedure and 48 hours
after
CT with contrast
Post
Hold glucophage 48hrs after
Increase hydration to excrete dye
Electroencephalogram (EEG)
Pre
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
Electroencephalogram (EEG)
Nothing really post procedure
None
Arterial Blood Gas
Pre
Allen’s test, check bleeding profile
PT/INR, PTT, Liver function) what meds are they on anticoagulants, antiplatelets or any bleeding disorders
Arterial Blood Gas
Post
Hold pressure for 5 minutes
or even longer if on meds that cause bleeding.
Endoscopy
Pre
NPO 4-6 hours before to prevent
aspiration
Endoscopy
Post
Gag reflex before anything
PO
Cardiac Catheterization
Pre
NPO 4-6 hours prior, check
allergies, shellfish, iodine,
consent. Do not shave site, we only trim it
Cardiac Catheterization
Post
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,
Thoracentesis
Pre
remain still, assess their lungs, vital signs prior consent, bleeding time, meds that may increase risk. of bleeding
Thoracentesis
Post
CXR immediately after, assessment of lungs signs immediately, could
cause a pneumothorax, vital could
Nasal Cannula
0.5-6L, tissue damage around ears and nares, humidify if 3-4L or higher
Simple Face Mask
Cannot have less than 5-6 Liters or the client will rebreath their C02 and will have respiratory acidosis and have to be intubated
100% Nonrebreather
fill the reservoir bag with oxygen first before applying to client or will rebreath c02 and become acidotic
Respiratory
Complication
atelectasis, pneumonia
atelectasis
collapsed alveoli
Respiratory
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
Cardiac
Complication
DVT, PE, orthostatic
hypotension
Cardiac
Interventions to Prevent
ambulation, heparin sq or lovenox, sequentials, TEDS, fluids, change positions slowly
GI
Complication
ileus, constipation, N/V
GI
Interventions to Prevent
ambulation, nasogastric tube if vomiting or ileus - NPO until bowel sounds return
GU
GU
Complication
urinary retention, stones if they stay in bed too long, Catheter associated UTI (CAUTI)
GU
Interventions to Prevent
Get them OOB - Gravity, lots of fluids
Integumentary
Complication
pressure ulcers, eviscerate,
dehiscence, wound infection
Integumentary
Interventions to Prevent
Turn q2hs, ambulate, use binder, splint when coughing sterile dressing changes
State 2 differences between an ileostomy and colostomy?
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.
How often should an ostomy pouch/wafer be changed?
3-10 days or prn if there is a leak. Bag emptied? 2/3rd full
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. hot liquids, knee chest, ambulate, change the wafer, warm shower, massage around it - if nothing needs to be seen = blockage
State 3 reasons a nurse would clamp a chest tube?
Looking for leak (intermittently), changing the drainage container, or getting ready to remove it.
TPN
Equipment/Lines/Tubes required to administer
filtered tubing, central line
TPN Nursing considerations (need to knows to prevent harm)
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
Tube Feedings
Equipment/Lines/Tubes required to administer
tubing set, formula, NGT, GT, JT
Tube Feedings Nursing considerations (need to knows to prevent harm)
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
State 3 factors that increase a client’s risk for falls
Age, medication, previous fall, uses equipment to ambulate (cane, walker), lines
How are crutches measured?
2-3 fingerbreadths below axillary, 20 degree angle wrist pressure on wrists not axillary
A client is being discharged home after hip surgery, what “hip precaution” teaching will you provide?
do not cross legs, do not bend over 90 degrees, chair height (upside down stop light), raised toilet seat. chairs with arms
What do nurses need to know about traction e.g. bucks or cervical?
continuous never release, never change weights
State 2 nursing considerations when communicating with a client who is hearing impaired
quiet environment, face them, lighting, hearing aids in if they have them, set aside enough time to speak with client
A nurse is discharging home a client with a visual deficit. State 3 home safety interventions
no chairs with wheels, no extension cords, or small animals, good lighting, no scatter rugs, paint edges of stairs bright colors
What can be delegated to an LPN?
Anything the nurse cannot EAT (Evaluate, assess or teach), only have stable patients, chronic conditions.
State 3 nursing ethical principles
autonomy, veracity (telling truth), fidelity (doing what you say you will do, keep your word), beneficence (doing good); nonmaleficence (not doing harm)
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?
CXR
A client is at risk for aspiration (difficulty swallowing) what should the nurse instruct the CNA to do when feeding the client?
90 degrees, chin tuck, no straws, speech and swallow
Metoprolol
beta blocker
Metoprolol
Action/Side Adverse
blocks beta 1 receptor on the heart to slow heart rate and decrease blood pressure (blocks sympathetic response)
Metoprolol
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
Accupril
Ace inhibitor -pril
Accupril
Action/Side Adverse Effects
interferes with the Renin-Angiotensin - Aldosterone system
Accupril
Check BP and Potassium levels (could be high because hold onto K+); Umbrella BP protocols ; S/E: hacking cough; Adverse reaction : angioedema
Warfarin
anticoagulant
Warfarin
Action/Side Adverse Effects
interferes with clotting cascade
Warfarin
Nursing Considerations
Parameters/Effectiveness, etc.
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
Digoxin
Classification
Cardiac glycoside
or positive inotrope (increases contractility), negative chronotropic (decreases heart rate)
Digoxin
Action/Side Adverse Effects
increases ventricular contractility to improve cardiac output
Digoxin
Nursing Considerations
Parameters/Effectiveness, etc.
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.
Furosemide
loop diuretic
Furosemide
Action/Side Adverse Effects
increase urine output and potassium (waster)
Furosemide
Check BP, Potassium, fluid balance check weights (daily), effective if ease of breathing, clearer lungs, decreased edema, lowered BP monitor urine output.
Aspirin
antiplatelet, antipyretic, NSAID
Aspirin
Anti-platelet - makes them less sticky - effects the platelet for the life of the platelet which is 10 days
Aspirin
No one under 18 or Reye syndrome (liver failure)
Take with food - gastric distress and ulcers
Toxicity: tinnitus - ringing in the ears
Phenytoin
anti-seizure/
anti-epileptic
Phenytoin
Action/Side Adverse Effects
seizure threshold - increase to prevent seizures
Phenytoin
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
Dexamethasone
steroids (-asone or one)
Dexamethasone
antiinflammatory
Dexamethasone
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.
Cardizem
calcium channel blocker
Cardizem
ion influx
Cardizem
At bedside check: Heart Rate & Blood Pressure, prolong QT interval on ECG
Umbrella for drugs that lower BP
Simvastatin
anti cholesterol medications
Simvastatin
works directly on the liver to slow production of cholesterol
Simvastatin
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
Lorazepam
benzodiazepine
Lorazepam
works on CNS
Lorazepam
works on CNS
Lorazepam
antidote: flumazenil or romazicon monitor respiratory rate safety precautions highly addictive tolerance and withdrawal
Morphine sulfate
Opioid pain medication
Morphine sulfate
CNS
Morphine sulfate
Antidote: naloxone/narcan
monitor Respirations hold if <12
tolerance/dependence
What is the maximum score on the Glasgow Coma Scale?
15 (lowest is 3)
Which nerve is affected in Bell’s Palsy?
CN VII (know all CN and how they are tested)
What is Cushing’s triad?
IICP widened pulse pressure, bradycardia, irregular respirations
Where is a ventriculostomy drain leveled to?
forman monroe, tragus of the ear
Which eye disorder has a loss of central vision?
macular degeneration no treatment (retinal detachment - curtain; glaucoma= loss peripheral only one that causes pain treated with medications; cataracts opaque vision)
Which type of cerebrovascular bleed requires immediate surgery (lucid then deteriorates quickly)?
Epidural bleed
What part of the brain controls balance?
cerebellum (C for coordination); frontal (Be Expressive - personality , expressive aphasia - Brocas); temporal (hearing, receptive aphasia, wernickes); parietal is sensation; occipital is vision
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)
- halo test; mustache dressing. High risk for CNS infection = nuchal rigidity
What are the cardinal signs of Parkinson’s Disease?
TRAPI
Tremors, rigidity, akinesia (bradykinesia slow movement), Postural instability
How is autonomic dysreflexia treated? Who is at risk?
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
State 2 things a nurse needs to know about traction (Gardner wells or Bucks)
- continuous traction and 2. do not change weights
State 2 vasopressors
a. epinephrine, norepinephrine, dopamine, dobutamine, vasopressin
vasodilators: Nitroglycerin, nitroprusside
Where is the phlebostatic axis located?
right atrium (4th ICS mid axillary)
What is it?
VTach___________________Treatment: __Check for pulse if have one then cardiovert; if pulseless treat as VFib - defibrillate ASAP, CPR until defibrillator is obtained.
What is it?
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
What are signs and symptoms of pericarditis?
friction rub, pain relieved if leaning forward, and NSAIDS
Which type of valve replacement requires life-long anticoagulants?
mechanical (biological do not, but need to get a new biological every 8-10 years whereas mechanical is for life)
arterial ulcer
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
venous ulcer
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
What medication(s) would you use to lower systemic vascular resistance?
vasodilators, antihypertensives
Interpret the following ABG:
pH 7.20, pC02 32, Hc03 18, Pa02 70
Metabolic Acidosis, partial compensation, hypoxemia
What would cause a low pressure alarm on a ventilator?
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
What is the cardinal sign of ARDs?
refractory hypoxemia needs mechanical ventilation and high PEEP
Bronchitis
Causes/
Physiology
smoking, pollution
Bronchitis
S&S
Blue bloater
increased H&H d/t constant release of erythropoietin
eventually right-sided HF (Cor Pulmonale)
02 sats 88-91%
Bronchitis
Tests/ Procedures/
Treatment
pulmonary function tests inhalers (beta 2 agonists - terol; anticholinergics - tropium; and inhaled steroids - cort or asone) mucolytics low dose steroids low oxygen via NC
Bronchitis
Education
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)
Emphysema
Causes/
Physiology
smoking, pollution or genetic (do not have alpha 1 antitrypsin)
Emphysema
S&S
Pink puffer - able to oxygenate themselves but using accessory muscles
02 sats 88-91%
Emphysema
Tests/ Procedures/
Treatment
Pulmonary function tests
inhalers (same as bronchitis above)
low dose steroids
low oxygen via NC
Emphysema
Education
Same as above for Bronchitis
Also, diaphragmatic breathing (largest muscle- less 02 use when using diaphragm instead of accessory muscle to breath)
Asthma
Causes/
Physiology
allergens
genetic
Asthma
S&S
wheezing due to
bronchoconstriction
Asthma
wheezing due to
bronchoconstriction
Asthma
Peak flow meter
Green is good
yellow need to change med regime
red take rescue inhaler and call 911
Asthma
take medications as prescribed, how to use the peak flow meter, should be used everyday, try to avoid triggers
Tuberculosis
underdeveloped populations, crowded living conditions, immunocompromised
Tuberculosis
S&S
Night sweats, weight loss, hemoptysis
Tuberculosis
Tests/ Procedures/
Treatment
Positive sputum culture Acid Fast Bacilli, CXR
Tuberculosis
Education
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
Pneumothorax
Causes/
Physiology
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
Pneumothorax
S&S
absent or dim lung sounds (if small); tracheal shift to the unaffected side if large
Pneumothorax
Tests/ Procedures/
Treatment
Chest tube needs to be placed to restore negative pressure and re-expansion of the lung
Pneumothorax
Education
Pain control with PCA, about chest tube - when ambulating etc.
TCDB (pulmonary toileting)
Hyperglycemia
insulin
Hypoglycemia
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
Rapid (Lispro, Aspartate) (-logs)
Onset
5-15min
Rapid (Lispro, Aspartate) (-logs)
Peak
1.5 (1-2)
Regular Insulin (-lin)
Onset
30
Regular Insulin (-lin)
Peak
3 (2-4)
NPH
Onset
60
NPH
Peak
6 (4-8)
Long acting
60
Long acting
Peak
No peak - basal rate
State the 2 differences between HHNKS and DKA:
a. Hyperglycemia hyperosmotic nonketotic syndrome - no acidosis, no ketones - type II diabetics (Blood glucose 600-1000)
b. DKA acidosis, ketones, Type I 400-600
What labs would the nurse expect for a client admitted with adrenal crisis?
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
What are the complications (emergency) of hypothyroid and hyperthyroid?
a. Hypothyroid emergency/complication:_myxedema coma - give synthroid (thyroid hormone)
b. Hyperthyroid emergency/complication: thyroid storm - treat symptoms High BP, High temperature-
Using the rule of nines and Parkland formula calculate fluid resuscitation for first 8 hours:
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
Hepatitis
Risk Factors
Know ABC Immunoglobulins vaccinations body fluids contaminated water/feces
Hepatitis
S&S
liver dysfunction
Hepatitis
Treatment
immunoglobulin
vaccinations
Cholecystitis
Risk Factors
female, fair fat, forty and fertile
Cholecystitis
S&S
right up quad/shoulder/back pain after fatty/spicy meal, N/V
Cholecystitis
Treatment
diet, cholecystectomy
Acute Pancreatitis
Risk Factors
alcoholism or stone is lodged in common bile duct, smoke
Acute Pancreatitis
S&S
acute abdominal pain, n/v , increased lipase and amylase
Acute Pancreatitis
Treatment
rest the stomach, nasogastric tube, stop drinking and smoking
or removal of the stone
Compare and contrast Glomerulonephritis and Nephrotic Syndrome - how are they similar and how are they different?
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.
What are the 3 phases of acute renal failure?
1) anuric/oliguric, 2) diuresis 3) recovery
What are 3 types (causes) of acute renal failure?
pre-renal (volume); intrarenal (drugs aminoglycoside); post-renal (enlarged prostate or stone)
Hemodialysis
3 days a week for few hours
hypotension
Hemodialysis
Complications that might occur
hypotension
disequilibrium syndrome (too fast removal of BUN) slow the rate
use heparin= so risk of bleeding
Peritoneal Dialysis
several exchanges a day
with dwell times
Peritoneal Dialysis
Complications that might occur
peritonitis
fluid overload
Rheumatoid Arthritis
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
Rheumatoid Arthritis
DMARDs Disease modifying antirheumatic drugs plaquenil steroids methotrexate
Osteoarthritis
unilateral
wear and tear
pain occurs with use of the joints
Osteoarthritis
unilateral
wear and tear
pain occurs with use of the joints
Osteoarthritis
Treatment
steroids
surgery
OTC: chondroitin
Gout
build up of uric acid in the small joints can be in fingers and toes
(usually great toe)
very painful inflamed
Exacerbated by dehydration
Gout
prophylactic use of
Probenecid (helps excrete (pee) out the uric acid)
Allopurinol (decreases the production of uric acid
Colchicine for acute episodes
Indomethacin
PPN
Equipment Needed
peripheral line
PPN
Complications
hyperglycemia
fluid overload
PPN
Nursing
Interventions to
Prevent
Complications
daily labs glucose checks change tubing/bag q24 dedicated lines D10-D20% if no feeding on hand
Isotonic
volume to increase BP
Hypotonic
cellular dehydration- never give this to
someone with a cerebral edema will
worsen it.
Hypertonic
brain swelling
Lumbar puncture
Pre
contraindicated
for lICP, consent, labs,
keep patient still, calm
Lumbar puncture
dark room, hydrate, supine position to prevent spinal ha, but if develop a spinal ha then blood patch
Computed
Tomography
Angiography
dye allergy,
metformin hold
metallic taste
Computed
Tomography
Angiography
hydrate to clear dye
Barium enema
instill enema
do enema
before barium swallow
nothing specific
Barium enema
fluids, laxatives
Tracheostomy mask
always humidified
24hr urine collection
pt void then start time
24hr urine collection
if tissue or feces gets in or miss a void, start over Keep on ice
24hr urine collection
add last void, return to lab
Pyelography
Pre
allergies to
iodine/shellfish.
metformin hold
Pyelography
Post/
hydrate to clear dye
Sickle Cell
Pre
african american,
hemoglobin S
carrier
Sickle Cell
During
pain, extremities, chest due to poor perfusion (sickling blocks off small capillaries)
Sickle Cell
Post
fluids, oxygen,
morphine,
hydroxyurea
prophylactically
Pernicious
Pre
gastric bypass
Tell me about the chain of infection.
microorganism present, portal of entry, susceptible host
What is the difference between medical asepsis and surgical asepsis?
MEDICAL ASEPSIS REDUCES THE AMOUNT OF MICROORGANISMS (CLEAN TECHNIQUE) AND SURGICAL ASEPSIS REMOVES ALL MICROORGANISMS (STERILE)
State 3 interventions a nurse can do to improve pulmonary function.
turn, cough, deep breath, ambulate, incentive spirometry, hydrate
Tell me about 3 therapeutic communication techniques.
active listening no why questions offering self CLARIFYING/RESTATING OPEN-ENDED CLOSE-ENDED
Foley Catheter
neurogenic bladder, surgery,
irritation
infection prevention, aseptic
technique
Straight catheter
no void after 6 hrs
infection prevention
Ostomy
bladder cancer
sterile technique, infection
prevention
Nephrostomy
blockage below kidney
infection prevention
What teaching would you provide to a client who has just been prescribed 3 inhalers (Ipratropium, Salmeterol and Azmacort)
-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
State 3 reasons a nurse would clamp a chest tube?
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.
What should a stoma look like?
pink, beefy red - not blue, pale or black. Shrinks after surgery
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?
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.
Diltiazem
Class
Calcium Channel Blocker
Diltiazem Action
slows heart rate and decreases blood pressure
Diltiazem Parameters
HR <60 & SBP <90
Diltiazem Side/Adverse Effects
Hypotension, bradycardia, dizziness
Diltiazem Client Teaching
Change positions slowly, do not discontinue abruptly, do not over heat yourself
Digoxin Class
Cardiac Glycoside/Positive Inotropic
Digoxin Action
Increases contractility of the ventricles
Digoxin Parameters
Apical Pulse for 1 minute <60
Digoxin Side/Adverse Effects:
Bradycardia, green/yellow halos, n/v
Increased risk of toxicity if low K+
•Therapeutic range: 0.5-1.5
enalapril Class
ACE inhibitor
enalapril Action
works on Renin-Angiotension Aldosterone System blocks angiotensin 2 and prevents release of aldosterone
enalapril Parameters
Fluid balance, BP, and Potassium
enalapril Side/Adverse Effects:
hypotension, hyperkalemia, angioedema, hacking cough, birth defects/morbidity/mortality
enalapril Client Teaching
Monitor fluid balance, weight, daily same scale, cloths, time, edema, BP, change positions slowly, don’t overheat yourself, report difficulty swallowing, tongue
Heme
Oprelvikin
Filgrastim
Epogen
Oprelvikin Class
Colony stimulating factor
Oprelvikin action
increase platelet count
Oprelvikin Parameters
monitor platelet count (150-450K)
Oprelvikin Side/Adverse Effects
could develop clots if too many platelets, increased blood pressure. Bone pain is side-effect
Oprelvikin Client Teaching
Take Tylenol for bone pain
Filgrastim Class
Colony Stimulating Factor
Filgrastim Action
Increases WBC
Filgrastim Parameters
Monitor WBC
Filgrastim Side/Adverse Effects:
leukocytosis (too many WBC), bone pain
Filgrastim Client Teaching
bone pain is common, take Tylenol. Avoid people with infections.
Epogen Class
Colony stimulating factor
Epogen Action
Increase RBC count
Epogen Parameters
monitor H&H
Epogen Side/Adverse Effects
too many RBC increase BP and increased risk of clots.
Epogen Client Teaching
Bone pain is common s/e take Tylenol. Improvement in s&s of anemia
Heparin class
parenteral anticoagulant
Heparin Action
prevent clots from forming or extending
Heparin Parameters
aPTT (Heparin IV drip 50 to 70 seconds) q6h we’re gonna draw an aPTT
Heparin Antidote
Protamine Sulfate
Heparin Side/Adverse Effects
Bleeding (VS: HR and BP), HIT (Heparin Induced Thrombocytopenia)
Complete Blood Cell Count (CBC): H&H, Platelets.
Heparin Client Teaching
electric razor, soft tooth brush, report excessive bruising or bleeding, report dizziness.
Methotrexate Class
Chemotherapeutic
Methotrexate Action
Cancer
Methotrexate Parameters
suppresses cancer metastases/improvement, decreased
Methotrexate Side/Adverse Effects
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)
Methotrexate
•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
Infiltration
Remove. Elevate. apply warm compress
Air embolus
Left lateral trendelenberg
Extravasation
Aspirate drug, inject antidote
Hematoma
Apply light pressure
Phlebitis
Remove apply warm/cool compress
Acetaminophen antidote
N- acetylcysteine (mucomyst)
Benzodiazepine
Flumazenil (romazicon)
Cyanide poisoning
Methylene blue
Digitalis
Digoxin immune FAB (digibind
Heparin/enoxaparin
Protamine sulfate
Iron
deferoxamine
Lead
succimer
Magnesium sulfate
Calcium gluconate
Narcotics
naloxone
Warfarin
Phytonadione (vitamin k, aquamethyton, fresh frozen plasma)
worksheet
Gingko
treating blood disorders and memory issues
Ginkgo people should not take
Blood thinner
saw palmetto
saw palmetto
saw palmetto
headache, nausea, diarrhea, and dizziness
Who should not take saw palmetto
taken by children, during pregnancy or breastfeeding, or by those with hormone-sensitive cancers.
St. John’s Wort
for depression, menopausal symptoms, attention-deficit hyperactivity disorder (ADHD), somatic symptom disorder
Who should avoid St John’s wort?
major depression because increase mania
Who should avoid St John’s wort?
HEAD TRAUMA
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!
Ventricular tachycardia
Medication to treat
antiarrhythmic medication
Duodenal ulcer happens after
2-3 hours after meal
And night
Relieved by eating
Gastric ulcers
Occurs 30 minutes after eating
