NCLEX 3 Flashcards
IV gauges?
24 G = infant/peds and temporary access
22 G = Peds, IV contrast, med/surg, and easily blown veins
20 G = most adults, CT angiography, and blood transfusions
18 G = massive trauma, codes, and RRTs (increased risk for mechanical phlebitis)
kids under 5 yo, inflammation of blood vessels throughout body.
Kawasaki Disease
S/S: strawberry tongue, fever, rash, conjunctivitis, oral mucosa changes, and swollen lymph nodes
Addison’s disease S/S?
hair loss, hyperpigmentation (tan), wt loss, GI upset, fatigue, hypoglycemia, postural hypotension, and weak
Adrenal crisis – extreme fatigue, dehydration, fever, hypotension, renal shut down, increased serum K+, and decreased serum Na+
Lumbar puncture?
spinal needle inserted into subarachnoid space to collect CSF sample
pt fetal side lying position (stay still)
post: keep pt flat for several H, monitor for comp. (increased ICP), and encourage increase fluid intake
Acute glomerulonephritis?
secondary to many conditions/ infection processes (strep, mono, hepatitis)
clinical feat. – oliguria, fatigue, fluid retention, proteinuria, hematuria, and increased BP.
Prevent FVO, no fluids, Na+, and K+, monitor I&O, wt, and BP
most common heart anomaly
CoA
monitor – VS, BP, HR, and O2, reg assess peripheral pulses, cap refill, skin color, and temp
Help w/ feeding – poor heart output and resp compromised = poor feeding, monitor I&O
potential causes of late decels?
uteroplacental insufficiency, maternal hypotension, uterine hyperstimulation, and maternal hypoxemia
anaphylactic shock treatment?
epi
corticosteroids
bronchodilators
neurogenic shock treatment?
spinal cord injury
cooling
supportive care
septic shock treatment?
systemic RTX cause release of inflammatory cytokines
IV ABX
IV fluids
preterm labor causes?
dehydration
infection
sex
exercise (strenuous)
activities
stress
environmental factors
neurogenic shock CM?
hypotension
bradycardia
hypothermia
tachypnea
decreased U/O
anxiety
significant peripheral vasodilation, inhibition of baroreceptor response, and impaired thermoregulation
hyperthyroidism S/S?
tremor
HR drop
fatigue
restless
oligomenorrhea and amenorrhea
intolerant to heat
diarrhea
irritable
sweat
muscle wasting and wt loss
DKA?
factors: infection, stress, inadeq. insulin dose
S/S: ketosis, kussmaul resp, rotting fruit breath, nausea, and abd pain
serum glucose: >300
serum ketones: yes, increased anion gap >12
ABGs: acidosis
more likely to occur in DMT1
HHS?
factors: infection, stress, poor fluid intake
S/S: dehydration and altered LOC
serum glucose: >600
serum ketones: no
ABGs: metabolic alkalosis
heart auscultation?
Aortic: 2nd ICS to R of sternal border
Pulmonic: 2nd ICS to L of sternal border
Erbs point: 3rd ICS to L of sternal border
Tricuspid: 4-5th ICS to lower L of sternal border
Mitral: 5th ICS at midclavicular line (Apex)
Liver Biopsy?
post-procedure position pt R side w/ pillow under site, observe for bleeding 2-4 H post procedure
calf pain at dorsiflexion of foot, DVT
Homans sign
pt lies on back and leg = extended, painful and leg cannot be fully extended, meningitis
Kernings sign
hip and knee flex when neck = flexed, meningitis
Brudzinskis sign
blue discolor of umbilicus, pancreatitis
cullens sign
blue discolor of flanks, pancreatitis
grey turners sign
CV tamponade treatment?
pericardiocentesis (needle inset to aspirate the pericardial fluid in U/S guided procedure)
+ pressure vent complications?
barotrauma
vent associated injury
neurodynamic effect
what is the priority for V-Fib?
defib and then high quality CPR
inflammation of bone caused by bacterial infection
osteomyelitis
dangerous S/S of a concussion?
one pupil larger
drowsy/not able to wake
HA that gets worse
slurred speech
weak
numb
decreased coordination
repeated N/V
convulsions
restless
agitated
LOC
fear of wt gain w/ distorted body image, BMI < 18.5 kg
anorexia
recurrent of unconscious binge eating, vomit, laxatives, diuretics, or inappropriate exercise, excessive concern on body wt, and shape, and normal to low BMI
bulimia
what treat varicella?
antiviral meds – acyclovir and valacyclovir
what is normal ICP?
10-15 mmHg
herd therapy?
ginkgo: memory increase and SE = bleeding
ginseng: mental performance and SE = bleeding
saw palmetto: benign prostatic hyperplasia and SE = bleeding
St. Johns Wort: depression and insomnia and SE = HTN, decreased anticoagulant effect, interacts with antidepressants, steroids, and digoxin
licorice extract: ulcers and bronchitis and SE = HTN and hypokalemia
corticosteroid SE?
cataracts
up all night
suppressed immune
HTN
infection
necrosis
wt gain
striae
bone loss (osteoporosis)
acne
hyperglycemia
myopathy
depression/emotional change
hypernatremia management?
free H2O admin
loop diuretics
agent causing (remove)
give IVF
HTN treatment?
ACEs
Beta-blockers
CCB
Diuretics
parkinsons S/S?
tremor
rigidity
akinesia (absent movement)
ataxia (poor muscle control)
postural instability
GCS rating?
eye response 1-4
verbal response 1-5
motor response 1-6
less than 8 = intubate
L sided heart failure S/S?
fatigue
orthopnea
rales/restless
cyanosis/confused
extreme weak
dyspnea
cardiogenic shock meds?
vasodilator
epi (adrenergic)
inotropes
nor-epi (vasopressor)
what do you do when there are variable decels and umbilical cord is protruding through the vagina?
apply pressure to lift presenting fetal part
stay w/ pt and call for help
pt in trendelenburg
O2 via face mask
prepare for immediate c-section
what is cardiogenic shock?
pump failure, heart cannot pump adeq. blood to the body
unable tp pump blood, despite normal blood volume, due to heart emergency
blood pools in L vent and backs up into lungs – pulm edema and decreased CO
lack of blood to tissues – inadeq. O2 – impaired cellular metabolism
S/S: hypotension, tachycardia, weak/rapid pulse, tachypnea, shallow/fast breathing, diaphoresis and cool/clammy skin, and arrhythmias and JVD
S/S of transfusion reaction?
rash
elevated temp
anxiety/apprehension
chills
tachypnea
increased pulse
oliguria and hemoglobinuria
nausea
spermatic cord twist, decreased blood flow to the testicles, surgery, emergency.
testicular torsion
s/s: sudden severe scrotal pain, swell, and nausea
Rh factor?
inherited protein attached to surface of RBCs
positive = can receive pos or neg blood
negative = can only receive neg blood
What are common drug classes for ABX?
aminoglycosides (-mycin/-micin)
cephalosporins (cef-/ceph-)
fluoroquinolones (-floxacin)
glycopeptides (-in (mycin))
macrolides (-thromycin)
penicillins (-cillin)
tetracyclines (-cycline)
percussion sound over hallow organs, small intestine, and colon
tympathy
sound heard when tapping on chest
hyperresonance
low pitched hallow sound heard over healthy lung tissue
resonance
replaces resonance when fluid or solid tissue replaces air containing lung tissues, pneumonia, tumors, or pleural effusions
dullness
early and late CM of increased ICP?
early: decreased LOC, behavior change (restless, irritable, and confused), HA, and N/V (possible projectile)
late: cushing’s triad, and abnormal posture
