NCLEX 2 Flashcards
preeclampsia triad?
proteinuria, rising BP, and edema
(increased BP, wt gain, puffy face, pedal edema)
Cushing’s syndrome?
thin hair
moon face
increased facial hair
red cheeks and acne
wt gian
pendulous abd
stretch marks
thin skin
buffalo humo
increased neck fat
easy bruise
CNS instability
fluid retention
osteoporosis
thin extremities
slow heal
What labs are drawn for Heparin and Warfarin?
Heparin = PTT
Warfarin = PT
Asthma triggers?
allergens
sports, smoking
temp changes
hazards
microbes
anxiety
VEAL CHOP?
V = variable decels –> Cord compression
E = early decels –> head compression
A = accels –> OKAY!
L = late decels –> placental insufficiency
heart failure tx?
upright position
nitrates
lasix
O2
ACEs
Digoxin
decreased fluids
decrease afterload
decrease Na+
test: dig level, ABG, and K+
hypoglycemia S/S?
sleepy, sweating, pallor, hunger, lack of coordination, and irritable
Insulin types w/ onset, peak, duration?
Rapid acting (aspart), onset 15 M, peak 1-3 H, duration 3-5 H
Rapid acting (lispro), onset 15 M, peak 30-90 M, duration 5 H
Short acting (regular), onset 30 M, peak 2-4 H, duration 5-12 H
Intermediate acting (NPH), onset 1-4 H, peak 4-12 H, duration 10-24+ H
Long acting (glargine), onset 2-4, peak none, duration 24 H
Opioid SE?
miosis (pupil constriction), mood changes
out of it
resp depression, decreased salivation
pruritus, pneumonia (aspiration)
hypotension, HA
infreq. elimination (constipation, urine retention)
nausea, nervous
emesis
Adrenal crisis?
emergency, severe dehydrations, hyponatremia, hypoglycemia, and hyperkalemia; triggered by sudden cessation of corticosteroids or Addisons that is unresponsive to the need for additional steroids bc of stressful event
priority treat – IV hydrocortisone (admin with NS or D5W)
HbA1C?
7.5% (DMT2)
5.7-6.4% (preDM)
6.5% (DM DX)
<7% treatment goal for DM
intervening b4 a person has a health problem
edu, immunizations, and modify risky behavior
primary prevention
early ID of the disease and early intervention
screening, health fairs, reg BP check, referral to specialist
secondary prevention
treat the disease and prevent further complications
nutritional edu for chronic illness, outpatient therapy, support groups
tertiary prevention
CPR compression rate?
100-120/M, pulse assess no more than 10 seconds
infant pulse = brachial
child and adult pulse = carotid artery
primitive protection motor reflex, slight drop, sudden movement, or loud noise
moro reflex
Immunizations?
Hep B (birth, 1-2 mos, 6-18 mos)
rotavirus (2 mos, 4 mos, 6 mos)
DTap (2 mos, 4 mos, 6 mos, 15-18 mos, 4-6 yo)
HIB (2 mos, 4 mos, 6 mos, 12-15 mos)
polio (2 mos, 4 mos, 6-18 mos, 4-6 yo)
MMR (12-15 mos, 4-6 yo)
Varicella (12-15 mos, 4-6 yo)
flu (starts at 6 mos)
lung collapsed due to collection of fluid in the pleural space
pleural effusion
lung collapsed due to collection of blood in the pleural space
hemothorax
lung collapsed due to collection of air in the pleural space
pneumothorax
pneumothorax comp., opening of the pleural space creates a 1 way valve, air collects in lungs and cannot escape (increased pressure)
tension pneumothorax
less blood pumped out of ventricles, left = fluid to lungs, S3 gallop
Systolic heart failure
less blood fills up in the ventricles, right = fluid into body, S4 gallop
Diastolic heart failure
Heart unable to pump adeq. O2 rich blood through body, result in poor perfusion of tissues and organs
heart failure
primary goal = maintain heart output
secondary goal = decrease venous pressure to decrease edema
avoid NSAIDS and CCB (can exacerbate heart failure)
Maslow’s?
top: self actualization – fulfillment needs
middle: esteem and belonging/love needs
bottom: safety and physiological needs (priority)
hypothyroidism S/S?
memory loss
obesity
flushed cheeks
slow sluggish speech
onset gradual
skin dry
thin hair
intolerant to cold
decreased energy and appetite
enlarged thyroid
depression
sudden, brief jerk ctx of a muscle or muscles group, found in ankle or wrist, often seen with seizures
clonus
venous thromboembolism prevention?
early ambulation
compression
anticoagulants
ROM
polymorphic ventricular tachycardia – prolonged QTI, rapid, irregular QRS appear to twist around the EKG baseline = sign of arrhythmia
torsades de pointes
rare acute inflammation disorder, affects axons, and/or myelin of the PNS, muscle weak (ascending) or paralysis
guillian barre syndrome
monitor: RR, depth, effort, O2 sat, and breath sounds, resp distress, increased WOB, decreased O2
hemolysis, elevated liver enzymes, and low platelets
HELLP syndrome
renal diet?
low in K+, phosphorus, protein, Na+
may include fluid restrictions
Emergent burn phase?
1st 24-48 H post-injury
increased hypovolemic shock risk, electrolyte imbalance, renal failure
fluids = priority (parkland burn formula)
Acute burn phase?
36-48 H post injury, until wounds heal
focus on healing – prevent infection, decrease pain, nutrition, and wound care
Rehab burn phase?
burn = healed, may take months - years
regain mental and physical function, psychosocial care, ADL assist, PT and OT, and cosmetic correction
Pregnancy terms?
term = 37 weeks or greater
preterm = 20-37 weeks
abortions = any spontaneous or induced b4 20 weeks
Heart block?
1st degree = far away from “P”
wenckebach = longer than drop (type 1)
2nd degree = drop randomly (type 2)
3rd degree = beat independently
decrease or interruption in bile flow from liver to the small intestine
cholestasis
liver function test, bilirubin test, meds, induction of labor if condition = severe or if gestational age is greater or near to term
blood admin?
med rights
2 RNs must check for compatibility and correct order
pt have active type and screen
admin with special blood tubing
NS to infuse w/ after blood
VS b4, during, and after
monitor pt 1st 30 M for signs of transfusion reaction
epiglottitis S/S?
most common cause = bacterial infection (HIB)
airway inflammation
increased pulse
restlessness
retractions
anxious
inspiratory stridor
drooling
what is not a s/s of decreased CV output in neonates?
Bradycardia
pt invents words or phrases that only have meaning to them
neologism
decreased speech w/ short word replies
alogia
CTX stress test?
positive = abnormal
late decels on FHR monitor for more than 50% of CTX.
negative = normal
no late decels or variable decels present during CTX.
CHF risks?
HTN, CAD, DM, obesity, smoking, and alc/drug abuse
Burn care?
breathing, body image
U/O monitor
rule of 9’s, resuscitation of fluids
nutrition, no IM injections
shock, silvadene
neonate heat loss types?
conduction: loss of body heat from direct skin contact w/ a cooler solid object
evaporation: loss of heat through moisture
convection: like conduction, but heat decrease aided by surrounding air currents
radiation: loss of heat to cooler solid objects in the environment that are not in direct contact w/ body
CF complications?
pneumonia
pneumothorax
DM
depression
failure to thrive
vitamin deficiencies
osteoporosis
pancreatitis
infertility
UAP yes and no?
yes: ambulate, turning, linen change, bathe, wts, toilet, feed, PO care, VS, and I & O
no: meds, IVs, assess, or delegation
pancreatitis causes?
gallstones
ethanol
trauma
steroids
mumps
autoimmune diseases
scorpion sting
hyperlipidemia and hypercalcemia
ERCP procedure
drugs
