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NCLEX Flashcards

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1
Q

Diseases with too much aldosterone

A

Cushings (too much of all steroids), hyperaldosteronism (Conn’s)

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2
Q

too little aldosterone

A

Addisons- Need to ADD steroids- will go into FVD

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3
Q

ANP action

A

in response to atrial stretch (from vol excess) released to cause excretion of sodium and water

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4
Q

goes up with concentration and down in dilution

A

urine specific gravity, sodium and hematocrit

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5
Q

Anti diuretic hormone action (ADH)

A

causes retention of only water- think ADH-H20. ADH from pituitary in head- head injury or sx? increased ICP?

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6
Q

too much ADH

A

SIADH- too many letters, too much water! Na does not follow the water. retain water- FVE. urine concentrated (being retained) and blood dilute

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7
Q

too little ADH

A

DI= Diurese. Lose water, FVD, urine dilute and blood concentrated.

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8
Q

normal CVP

A

2-6 mmHg, or 5-10 cmH20

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9
Q

Fluid retention think

A

heart problems first. Watch the weight on all heart patients.

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10
Q

assessment or evaluation think

A

signs and symptoms

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11
Q

Bed rest induces

A

diureses- blood comes back to core- atrial stretch- ANP and reduction of ADH. Everything thinker- pulmonary secretions (pneumonia), blood (DVT), kidney stones- push fluids unless contraindicated. watch for crackles, edema, weight, BP, CVP

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12
Q

IVF slowly to

A

old, young, hx of heart or kidney problems

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13
Q

polyuria think

A

shock. loss of fluids from anywhere: thoracentesis, paracentesis, vomiting, diarrhea, hemorrhage, third spacing.

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14
Q

sxs FVD

A

decreased weight, BP, UO, skin turgor, dry membranes, increased respiratory rate, concentrated urine (increased specific gravity), cool and clay. SAFETY- risk for ORTHOSTATIC HYPOTENSION, risk for falls and overload

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15
Q

isotonic fluids action

A

increases blood pressure, NS goes with blood products. DO NOT give to HTN, cardiac or renal d/s can cause FVE, HTN, or hypernatremia (ones with sodium)

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16
Q

types isotonic fluids (4)

A

NS, LR, D5W, D5 1/4 NS

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17
Q

hypotonic fluids action and types (3)

A

(hypO= Out of vessel) shifts into cells- rehydrates without causing HTN. For those with hx of HTN, cardiac or renal d/s, to dilute hypernatremia. D2.5W, 1/2 NS, 0.33%NS ALERT- watch for cellular edema/ too much fluid to cells can cause FVD in vascular space and decrease BP

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18
Q

hypertonic fluids action and types

A

(hypEr= Enter the vessel) Volume expanders
for hyponatremia or severe third spacing. ALERT- monitor for FVE- BP, pulse, CVP. D10Wm, 3 or 5%NS, D5LR, D5 1/2NS, D5 NS, TPN

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19
Q

2 types of cancer

A

solid tumors and hematologic malignancies

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20
Q

sarcoma

A

solid tumor in connective tissue- bones, cartilage, tendons

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21
Q

carcinoma

A

solid tumor in epithelial tissues- line organs- and skin! most common type of cancer

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22
Q

hematologic malignancy

A

originate from blood or lymphatic system- leukemia, lymphomas..

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23
Q

metastasis

A

ability to travel- can travel by direct invasion, through blood stream or through lymphatic system

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24
Q

cancer primary prevention

A

no smoking, exercise good nutrition, maintain normal weight, limit or eliminate alcohol, vaccine for viruses, avoid exposure to carcinogens

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25
Q

secondary prevention for cancer (female)

A

screenings to detect early. Breast SE day 7-12, clinical breast exam q3yrs 20-39 and q1yr >40. paps q3yr >21 y/o. mammogram starting at 40 y/o
colonoscopy and fecal occult blood > 50 y/o

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26
Q

secondary prevention for cancer (male)

A

breast self awareness, yearly testicular exam, monthly self exam, (majority ages 15-36!!) teach testical self exam early. Digital rectal example, PSA, and fecal occult blood annually after 50. colonoscopy at 50 and q10yr.

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27
Q

Cachexia

A

extreme wasting and malnutrition (used in cancer)

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28
Q

Cancer symptoms think

A 
Caution
Chang in bowel/bladder habits
A sore that does not heal
Unusual bleeding or discharge
Thickening or lump
Indigestion or difficulty swallowing 
Obvious change in wart or mole
Nagging cough or hoarseness
Also- weight loss, FATIGUE, pain
Fever- first in leukemia and lymphoma (infection!
)
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29
Q

Cancer can invade bone marrow causing (3)

A

Anemia -hypoxia risk
leukopenia- infection risk
thrombocytopenia- bleeding risk

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30
Q

rupture of innominate artery

A

bleeding massively from the trach- call Dr, OR ASAP

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31
Q

sputum specimen

A

get first thing in the morning, sterile technique! sterile specimens. have client rinse out mouth first to decrease mouth bacteria, don’t let mouth touch the sterile cup. if they have a trach- get the sputum specimens from the trach.

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32
Q

total laryngectomy

A

removed vocal cords and epiglottis- have a permanent trach. can use an electrolarynx or Blom- Singer to talk. they cannot whistle, drink through a straw or swim, can smoke through the trach.

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33
Q

suctioning a trach

A

hyper oxygenate before and after, sterile procedure, stop advancing at resistance/ cough, intermittent suction on the way out for no longer then 10 seconds, monitor HR/arrythmias, can stimulate the vegas nerve and cause HR to drop

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34
Q

adjuvant

A

using two complimentary treatments together- like chemo and radiation

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35
Q

neoadjuvant

A

time specific therapies- one is done before the next- like surgery to remove tumor followed by chemo.

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36
Q

Grade of cancer

A

1-4 based off of how different cells are from the original cells- more different- more aggressive.

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37
Q

TNM system

A

cancer staging- TNM

Tumor size, lymph Node involvement, Metastasis?

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38
Q

mastectomy with lymph node removal

A

protect that side for the rest of life- no constriction, no: watch, purse on that side, IV, BP, sunburn, nail biting, elastic blouses, watch small cuts

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39
Q

brachytherapy

A

internal radiation close to cancer. both pts will emit radiation
unsealed- IV or PO, radioactive for 24-48 hrs and radioactive body fluids
sealed or solid- body fluids not radioactive, can be temp or permanent implants
*safe to assume all emit radiation!!!

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40
Q

nursing internal radiation precautions

A

time, distance, iron shield. rotate assignment daily, nurse should only get one radiation implant pt a shift, private room, film badge, wear gloves with risk of exposure to body fluids, mark room with instructions for specific isotope, prevent dislodgment- bed rest, fiber restriction, cath to prevent bladder distention

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41
Q

internal radiation pt visitors

A

limit, visitors must stay 6 ft away, cannot visit for more than 30 minutes. no visitors who are < 16 years old or pregnant.

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42
Q

after internal radiation precautions

A

client is immunosuppressed. stay 6 ft away from people for up to 10 days, close lid and flush toilet 2-3 times

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43
Q

radiation implant dislodgement

A

gloves, forceps, tongs- put in lead lined container and call radiation dept- leave it in the room

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44
Q

external radiation

A

AKA tele therapy or external beam radio therapy with a cobalt or gamma machine- pt is not radioactive- do not wash off markings or put lotion on them, protect the site from UV for 1 year

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45
Q

sxs from external radiation

A

1 c/o fatigue, location and dose related. erythema, shedding, altered taste, and pancytopenia (all blood components decreased)

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46
Q

calcitonin

A

hormone made by the thyroid gland. it takes ca from blood and puts it back into bones- so it decreases serum calcium. the drug calcitonin is given to pts with osteoporosis. need iodine to make hormones

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47
Q

don’t give beta blockers to

A

asthmatics or diabetics. hides the symptoms of hypoglycemia and can cause an asthma attack

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48
Q

parathyroid think

A

calcium. parathyroid secretes PTH (parathyroid hormone) which pulls calcium from bone and deposited it in the blood- increases serum calcium

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49
Q

hyperparathyroidism=

A

hypercalcemia= hypophosphatemia
too much PTH, serum ca is high and phosphate is low- client is sedated (Ca acts as a sedative) fix with partial parathyroidectomy

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50
Q

pheochromocytoma

A

benign tumors in adrenal medulla (on top of kidneys) that secrete boluses of epi and norepinephrine causing increase BP, pulse, flushing, HA, palpitations- check the catecholamine levels (vanilla test or metanephrine test, 24 urine collection) DO NOT palpate ABN, can cause bolus and severe HTN

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51
Q

4 major actions glucocorticoids

A

adrenal cortex steroid. Think MI-FI Mood, Immunosuppressed, Fat, Insulin
1- change mood
2- alter defense mech- suppress immune system
3- Breakdown fats and proteins -to glucose
4- inhibit insulin- hyperglycemia- monitor glucose
and don’t let them share room with infected b/c of suppressed immune system

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52
Q

Graves

A

hyperthyroid

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53
Q

addisons

A

insufficient steroids/ adrenocorticoids- glucocorticoids, mineralocorticoids (aldosterone), and sex hormones

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54
Q

aldosterone drug name

A

fludrocortisone

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55
Q

glucocorticoid administration

A

prednisone- give twice a day, 2/3 of dose in morning and 1/3 of dose in evening (for addisons disease)

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56
Q

addisons symptoms

A

Think no aldosterone or glucocorticoids. no aldosterone to help retain water and Na, so lose water and Na, retain K, hypotension; no glucocorticoids to make glucose or inhibit insulin, so hypoglycemic, confused, GI probs, fatigue, and skin discolorations- hyper pigment or depigment (vitiligo)

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57
Q

cushings

A

too many steroids- glucocorticoids, mineralocorticoids, sex hormones

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58
Q

magnesium and calcium think

A

sedatives/ muscles, loose, flaccid muscles, arrhythmia, decreased LOC, DTRs, pulse and respirations

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59
Q

normal magnesium

A

1.3-2.1 mEq/L

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60
Q

normal calcium

A

9.0- 10.5 mg/dL

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61
Q

low magnesium or calcium

A

tight rigid muscle tone, risk for seizure, stridor/ laryngospasm, chvosteks and or trousseaus sign, arrhythmia, DTRs increased, swallowing probs

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62
Q

calcium gluconate

A 
given IVP very slowly (max 1.5-2mL/min)
For hypermagnesium (antidote), or hypocalcemia
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63
Q

hypermagnesium causes, tx

A

renal failure or antacids (tums have magnesium) tx: vent if resp depression, dialysis if kidney prob, calcium gluconate antidote

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64
Q

hypercalcemia cause and tx

A

hyperparathyroid (too much PTH), Thiazides (retain Ca), immobilization- bear weight to keep Ca in bones, fluids to prevent kidney stones, DVT, sodium phosphate- inverse relationship, steroids, phosphorous foods, calcitonin, vitamin D

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65
Q

hypomagnesium cause and tx

A

diarrhea, alcoholism- give Mg but monitor kidney fin!, seizure precautions, eat magnesium

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66
Q

foods high in magnesium

A

spinach, mustard greens, summer squash, broccoli, halibut, turnip greens, pumpkin seeds, peppermint, cucumber, green beans, celery, kale, sunflower seeds, sesame seeds, flax seeds

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67
Q

hypocalcemia cause and tx

A

hypoparathyroidism, radical neck dissection, thyroidectomy (all not enough PTH)
Vit D, phosphate binders (sevelamer, calcium acitate), IV Ca- give slowly with pt on heart monitor

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68
Q

Na think

A

Neuro! neuro changes when sodium is high or low

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69
Q

hypernatremia= dehydration cause

A

feeding tube, hyperventilation, heat stroke, DI. give fluids, restrict Na, Daily weights, I&O, lab work

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70
Q

hyponatremia= Dilution cause and tx

A

Replacing fluid with only water, psychogenic polydipsia, D5W, SIADH
client needs salt, not water, give hypertonic saline if having neuro probs- 3 or 5% NS- very dangerous, messes with brain and can throw into FVE

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71
Q

hypernatremia symptoms

A

neuro and dry mouth, thirsty, swollen tongue

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72
Q

hyponatremia symptoms

A

neuro and HA, Seizure, Coma

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73
Q

hyperkalemia cause and tx

A

kidney probs, aldactone (spironolactone-retain K),
dialysis if kidney prob, calcium gluconate for arrhythmia, glucose and insulin, Kayexalate (sodium polystyrene sulfonate)

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74
Q

hyperkalemia ECG changes

A

bradycardia, tall peaked T waves, prolonged PR intervals, flat or absent P wave, widened QRS, conduction blocks, v fib

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75
Q

hypokalemia ECG changes

A

U waves, PVCs, v tach

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76
Q

hyperkalemia symptoms other than ECG

A

first muscle twitching, then weakness, then flaccid paralysis- then life threatening arrythmia

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77
Q

hypokalemia symptoms (not ECG)

A

muscle cramps and weakness then life threatening arrythmias

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78
Q

hypokalemia cause and tx

A

vomiting, NG suction, diuretics, not eating

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79
Q

potassium supps

A

GI upset with PO- give with food. IV always on a pump, mix well- settles, never IVP, burns during infusion, Assess kidneys/ urinary output before giving

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80
Q

potassium and metabolic A/B imbalance

A

metabolic acidosis= hyperkalema

metabolic alkalosis= hypokalemia

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81
Q

rule of 9s

A

head and neck-9
each arm-9
each leg-18
front-18, back-18

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82
Q

consensus formula

A

aka parkland formula
4mL LR X Kg X % burned= total for 24 hours
1st 8 hours- 1/2
next 16 hours- 1/2
titrate to 0.5mL/kg/hr urinary output (1mL for kids)

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83
Q

prealbumin

A

most sensitive indicator for nutritional status/ nitrogen balance

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84
Q

diet for burns

A

protein and vitamin C- always for max nutrition

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85
Q

meds to prevent GI stress ulcer

A

curlings ulcer
antacids= HYDROXIDE (a base!)-aluminum hydroxide, mag hydroxide (milk of magnesia). liquid on empty stomach at bedtime, when stomach empty more risk of acid on the ulcer, protects overnight.
H2 antagonist= DINEs, ranitidine, famotidine..-take at night to inhibit acid secretion
proton pump inhibitors= ZOLE- pantoprazole, esomeprazole..take before first meal
Sucralfate- barrier over ulcer. 1 hr b4 meals and at bedtime, empty stomach, with glass of water- no other meds at same time.

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86
Q

tetanus toxoid

A

booster- takes 2-4 weeks for body to make antibodies- active immunity. give with burns unless overdue for booster or don’t know- then give immune globulin (antibodies)-passive immunity

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87
Q

circumferential burn

A

circulatory checks- pulse, color, temp, cap refill

if bad- escharotomy or fascitomy to relieve pressure

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88
Q

brown or red urine post burn

A

myoglobin from damaged tissues- can clog kidney- call dr. may give Mannitol to flush (diuretic) also given for increased ICP. EXCEPTION- normally want to give fluids not diuretics to burn pt- trying to save kidneys

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89
Q

burns and potassium

A

tissue damaged- k leaks out of cells, hyperkalemia

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90
Q

enzymatic debridement

A

sutilains or collagenase- eat dead tissue

not for face, if PG, over large nerves or if area is opened to a body cavity.

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91
Q

mycin drugs

A

cause nephrotoxicity and ototoxicity- monitor BUN, creatinine and hearing

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92
Q

autograft

A

(burns) graft from own skin, dressing at donor site until stops bleeding, then open to air, can re harvest from same donor site every 12-14 days in healthy pt

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93
Q

electrical burn

A

heart monitor for 24 hours, at risk for v fib, c collar until cervical fracture is r/o

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94
Q

Cardiac output assessment

A

focused assessment- do anytime a hear rhythm change!

LOC, Chest pain?, wet lungs, skin cold and clammy or warm and dry?, Urinary output, peripheral pulses

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95
Q

what is coronary artery disease

A

broad term that includes chronic stable angina and acute coronary syndrome (MI and unstable angina)

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96
Q

drugs for chronic stable angina

A

nitro- dilates all vessels, decreased BP, ASA
and BLOCK from happening again (prevention) with BB and CCB!
beta blockers (prevention)- decrease BP, pulse and contractility
ca channel blockers (prevention)- dilates arteries, including coronary arteries and decreases BP
don’t leave a hypotensive client- unstable!

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97
Q

given to protect kidneys from iodine dye

A

acetylcysteine preprocedure; iodine based dye makes them feel warm and flushed and palpitations are normal- cardiac cath uses dye!

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98
Q

Triad MI symptoms

A

in women with MI- indigestions/ abdominal fullness, chronic fatigue and SOB. women also c/o pain btwn shoulders, aching jaw or choking sensation

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99
Q

1 sign MI in elderly

A

SOB. they may faint or have a behavior change

anytime ELDERLY + BEHAVIOR CHANGE = PROBLEM could be UTI, but r/o life threatening causes first

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100
Q

MI labs

A

troponin most sensitive and specific- elevates 3-4 hours and remains elevated for 3 weeks
myoglobin increases within one hour and peaks in 12 hours- not specific for diagnosis, but can be used to R/O

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101
Q

troponin levels

A

troponin T < 0.10 ng/ml

troponin I < 0.03 ng/ml

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102
Q

digoxin

A

normal level- 0.5-2 ng.ml
increases contractility and decreases heart rate (check apical pulse) =increase CO
toxicity GI probs then arrhythmia and vision change

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103
Q

apical pulse location

A

5th intercostal , left midclavicular

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104
Q

fluid retention, think

A

heart problems (heart failure) report weight gain of 2-3 lbs (1-2 kg)

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105
Q

loss of capture

A

when pacemaker fires but does not result in a heart contraction

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106
Q

failure to sense

A

when pacemaker fires at inappropriate times when it is not needed

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107
Q

cardiac tamponade

A

blood fluid or exudates have leaked into pericardial sac resulting in compression of heart. hallmark signs: INCREASING CVP with DECREASING BP. NARROWED Pulse Pressure=CARDIAC TAMPONADE
WIDENED PP= INCREASED ICP
decreased CO= worry shock
TX- pericardiocentesis

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108
Q

Pulse pressure

A

difference btwn SBP and DBP.
Narrowed= Cardiac Tamponade
Widened= Increased ICP
these are changes from baseline

109
Q

depression nursing interventions

A

help with self care during acute stage. help them experience accomplishments
no compliments, thoughts slowed- slow communication or give silence
prevent isolation- Seek them out! Interaction helps

110
Q

manic interventions

A

decrease stimulation, no group- one on one, brief frequent contact with staff, writing activity good. walk with them during meals- use finger foods. weigh daily, don’t get manipulated, set limits and remove hazards

111
Q

schizophrenia interventionsq

A

decrease stimuli, observe frequently w/o looking suspicious, orient frequently, keep conversations real world, they have concrete thinking and lots of communication probs (echolalia, neologism, word salad) “i don’t understand” may be LOA X4 and still have delusions or hallucinations

112
Q

paranoid

A

trust issues- be reliable, be honest, build trust. ID meds, don’t mix, don’t be overly friendly/ touching. consistent nurses, no competitive activities- they have an abnormal anger response- tantrums- hypersensitive. all consuming jealousy- everyone has it better

113
Q

alcohol withdrawal intervention

A

DTs (stage 2 and 3 delirium) keep the lights on
stage 1 and 2- walk and talk to them- keep reorienting
give anxiolytics- may have a tolerance q2h. thiamine injections, multivitamins and magnesium

114
Q

alcoholic signs and symptoms

A

peripheral neuritis/impotence (kills nerves- low B vit effects)
kills GI- liver and pancreas probs, gastritis
diurese- lose mg and K
complications- korsakoffs (time disorientation- confabulate), wernickes (moody, tire easily)

115
Q

panic attack

A

stay 6 feet away and use simple words. symptoms will peak within 10 minutes. have clients journal to reduce anxiety and identify triggers, peaks and valleys.

116
Q

hallucinations interventions

A

warn before you touch, don’t say they, involve in an activity- out of hallucination and into real world. elevate HOB, turn off TV, and offer reassurance

117
Q

ECT pre and post procedure

A

for severe depression and manic
NPO, void, atropine to dry secretions, succinylcholine chloride to relax muscles, baseline injuries
post- on side, don’t aspirate, stay with client, assure family temporary memory loss is expected, reorient over and over, involve in day’s activities ASAP

118
Q

amount of fluid replacement in glomerullonephritis

A

24 hour loss + 500 mLs for insensible loss

kidney damaged so not excreting, careful of FVE

119
Q

anasarca- when happens and patho

A

total body edema- seen in nephrotic syndrome-
inflammatory response produces large holes in kidneys lose large amount of proteins. no protein in the blood so blood goes into tissues, bp decreases. the only kidney patient will increase protein intake in

120
Q

fixed specific gravity

A

seen in renal failure- kidney lose ability to concentrate and dilute urine. do a Fluid Challenge- give bolus of 250 or more NS and the specific gravity will not change.

121
Q

acute renal failure oliguric phase- worry about

A

FVE and hyperkalemia- retaining fluid and potassium. UO is decreasing to 100-400mL/24 hrs

122
Q

acute renal failure diuretic phase- worry about

A

FVD and hypokalemia. sudden increase in UO, excreting fluid and potassium

123
Q

assessing patency of dialysis access

A

palpate a thrill and auscultate a bruit

feel thrill- can purr, hear bruit- turbulent blood flow

124
Q

symptoms of peritonitis from peritoneal dialysis

A

abdominal pain and cloudy effluent— cloudy effluent with any peritoneal dialysis= infection! should be clear, stat color

125
Q

diet for client on peritoneal dialysis

A

fiber- abdominal fluid is decreasing peristalsis

protein- lose protein in exchange bc holes in peritoneum are large

126
Q

CCRT

A

continuous renal replacement therapy- done in ICU, never > 80 ml fluid out of body at one time- less stress on cardiovascular system. for pt with fragile cardiovascular status and acute renal failure

127
Q

urolithiasis

A

means stone in ureter- renal calculi
symptoms: pain with N/V, WBC in urine, hematuria- urine test for RBC
tx with ketorolac, ondansetron and hydromorphone, increase fluids

128
Q

extracorporeal lithotripsy

A

extracorporeal shock wave lithotripsy (ESWL) high energy shock wave to break kidney stones into sand- will come back with foley, want to see sediment in bottom of bag.

129
Q

Glasgow coma scale- 3 responses

A

measures LOC
Eye opening, motor response, verbal response. 0 means no response. total can be 3-15, anything less than 13 bad, requires full neuro assessment hourly

130
Q

Babinski reflex

A

normal for children under 1 year/ not walking, is fanning toes
plantar (curled toes) normal for adult

131
Q

documenting reflex

A

(0) absent, (2+) normal, (4+) hyperactive. must have denominator to show scale used. so normal= 2+/4+

132
Q

CT

A

computerized tomography - may use die (consent), picture slices/ layers, keep head still and no talking

133
Q

MRI

A

magnetic resonance imaging- better than CT, not usually a dye, uses a magnet. no jewelry, pacemaker, credit cards, old tattoos may have lead, can’t talk or hear others in tube. teeth fillings okay

134
Q

Cerebral Angiography

A

angiography- DYE (consent), x ray of cerebral perfusion
iodine based dye- hydrate, void, peripheral pulses, groin prepped, watch BUN, retaining, output hold metformin, warmth in face and metallic taste
after- bed rest 4-6 hours, monitor femoral bleed, possible embolus,

135
Q

ECG

A

electroencephalography- records electrical activity of brain to dx seizure d/o, screen for coma/brain death, and to dx sleep d/o. no caffeine, no sedatives- but normal breakfast so no blood sugar drop. baseline EEG lying quietly- then hyperventilate or stimulate coma patient

136
Q

lumbar puncture

A

to obtain spinal fluid to analyze for blood, infection, and tumor cells or measure pressure with manometer, admin drugs. position over bedside table with head down. CSF should be clear and colorless
after- lie flat or prone for 2-3 hrs, increase fluids, HA is common- increases with increase HOB, for HA: bed rest, fluids, pain med and blood patch- do not do puncture if known increased ICP

137
Q

normal ICP

A

0-15 mm Hg

138
Q

early symptoms of increased ICP

A

earliest- change in LOC, slurred slowed speech, delay in response to verbal suggestion, slow to respond to command, increased drowsiness, confusion and may have HA, vomiting, pupil changes

139
Q

late signs of increased ICP

A

worse change in LOC progressing to stupor and coma

Cushing’s Triad, posturing and may have HA, vomiting,and or pupil changes

140
Q

Cushing’s triad

A

changes in vital signs seen with increasing ICP
Systolic HTN with widening pulse pressure, slow, full, bounding pulse, irregular respirations- change in pattern like cheyenne stokes or ataxic (containing apnea)

141
Q

posturing types

A

response to painful/ noxious stimuli when motor response centers are compromised
deCORticate- towards the CORE, arms flexed inward and bent in toward body, legs extended
Decerebrate- all 4 extremities in rigid extension- really bad and burning calories

142
Q

complications of increased ICP

A

brain herniation- obstructs blood flow to brain

DI and SIADH (with head injury)

143
Q

Tx of increased ICP

A

maintain O2, isotonic saline, inotropic agents (dobutamine and norepinephrine), monitor BP and HR closely, want to decrease ICP without decreasing cerebral perfusion. keep temp < 100, elevate HOB, keep head in midline to promote drainage from head, monitor ICP when turning, avoid straining (restraints, no blowing, hep flexion, bowl or bladder distention) limit suctioning, space out nursing interventions, monitor Glasgow coma, cushing triad, phenobarbital to decrease cerebral metabolism, osmotic diuretic (mannitol) steroids to decrease cerebral edema

144
Q

ICP monitoring

A

ventricular catheter monitor or subarachnoid screw

risk for infection, no loose connections, keep dressings dry to decrease bacterial ability to travel through

145
Q

neuro- when thinking intubate?

A

when glasgow coma is less than 8, think intubate

146
Q

meningitis

A

inflammation of spinal cord or brain
bacterial- transmitted through respiratory system-DROPLET PRECAUTIONS, very contagious, very deadly- immunize before college
Viral transmitted by feces and requires CONTACT PRECAUTIONS seen more in infants and children

147
Q

symptoms of meningitis

A

chills/ fever, severe HA, N/V, nuchal rigidity (stiff neck), photophobia

148
Q

meningitis tx

A

steroids, antibiotics (bacterial), analgesics
DROPLET PRECAUTION- Bacterial
CONTACT PRECAUTION- Viral

149
Q

generalized seizure

A

AKA non focal- involves entire brain and initial manifestation is Loss of Consciousness

150
Q

Partial seizure

A

AKA focal- involves a local area of brain- symptoms vary widely. simple means no loss of consciousness, complex means impaired consciousness, confused, unable to respond

151
Q

tonic- clonic

A

AKA grand mal
tonic- lose consciousness and completely rigid
clonic- jerking, muscles tense and relax

152
Q

myoclonic seizure

A

sudden, brief contractions of a muscle or group of muscles

153
Q

absence seizure

A

AKA petit mal characterized by brief loss of consciousness

154
Q

anticonvulsants for seizure

A

rapid acting- lorazepam
long acting- phenytoin or phenobarbital, have toxic SE so used smallest effective dose, monitor drug levels for tox through lab values, abrupt withdrawal can cause seizure

155
Q

autonomic dysreflexia

A

upper spinal cord injury (above T6), aka hyperreflexia. characterized by severe HTN and HA, bradycardia, nasal stuffiness, flushing, sweating, blurred vision, anxiety- can cause stroke
sit client up to decrease BP, put in catheter for distended bladder, removed impaction (constipation), look for skin pressure/ pain, cold draft…

156
Q

where would you see bleeding with basal skull fracture

A

EENT, ears, eyes, nose, throat

157
Q

difference in open/ closed skull fracture

A

whether the dura was torn

surgery for depressed skull fractures (skull depressed into brain), don’t normally need surgery for non depressed

158
Q

NO Smoking when?

A

Anytime NPO. smoking increases stomach secretions- increase risk for aspiration. Also increases stomach motility- will effect an Upper GI series test- which you are NPO for as well (after midnight) also no gum or mints

159
Q

go lytely

A

polyethylene glycol, put in freezer to make extra cold- can tolerate better, no straw (air), causes nausea- antiemetic- used for colon prep, colonoscopy

160
Q

McBurney’s Point

A

Lower right quadrant -location of appendix and pain with appendicitis (initially generalized pain, eventually localizes here with rebound tenderness, N/V (after abdominal pain), anorexia)

161
Q

clotting times

A

therapeutic INR 2-3
aPTT 30-40, >110 need antidote- protamine sulfate
normal PT 11-13 seconds, therapeutic is 1.5-2.5X normal

162
Q

D dimer

A

blood test that increases in presence of blood clots. look at to dx pulmonary embolism, but if had surgery will be increased from clotting at incision site- VQ scan best to dx PE

163
Q

crutches with stairs

A

up with good leg, down with bad leg

164
Q

cane

A

use on strong side of body

165
Q

LVN/ LPN delegation

A

Cannot plan or assess independently or care for unstable pt, but do not assign them anything a UA can do. they can reinforce teach

166
Q

full chemo precautions

A

chemo/ isolation gown, 2 pairs of chemo gloves, goggles and or mask if splashing or inhalation can occur (with drugs or body fluids) YELLOW waste container or waste bag. excretion 3-7 days

167
Q

PPE order

A

mask, gown, gloves, goggles

168
Q

vesicant

A

type of chemo drug that causes extravasation if infiltrates. stay with any client receiving vesicant drug, if extravasation happens, stop infusion, cold pack, follow extravasation protocols

169
Q

infection prevention cancer pt

A

private room, limit visitors, change dressings and IV tubing daily, cough and deep breathe, no fresh plants, bathe moist areas twice/day, wash hands after touching person or pet, avoid or wash really well fresh fruits and vegetables, drink only fresh water (can be out only 15 minutes), teach come to hospital with temp >100.4

170
Q

ANC

A

absolute neutrophils count. watch on cancer patients, indicates how well they can handle an infection. normal is 2200-7700

171
Q

Neutrophenic precautions

A

infection prevention + V/S q4h, private room with closed door and posted sign, antimicrobial soap for HH, no invasive tx (IM injection, rectal exam/meds, indwelling caths, NG (when possible)), limit acetaminophen

172
Q

CMV

A

cytomegalovirus- very common herpes virus, dormant/ asymptomatic in healthy people. blood products for immunosuppressed is tested for it, they need CMV negative blood or CMV “safe”= blood with CMV goes through leukoreduction

173
Q

patient has symptoms of being pregnant is called

A

presumptive signs- ex: amenorrhea, N/V, urinary frequency or breast tenderness. signs that can be observed by the Dr are probable sings- unless they are positive signs like a heartbeat

174
Q

can hear baby heartbeat on doppler at ? weeks

A

10-12 weeks

fetoscope at 17-20 weeks

175
Q

Gravida Parida

A

Gravida- number of pregnancies

parida- pregnancies when fetus reaches 20 weeks- not viable

176
Q

viability

A

24 weeks

177
Q

TPAL

A

term, preterm, abortion (spontaneous or elective), living children

178
Q

naegele’s rule

A

due date estimator, first day of LMP, add 7 days, subtract 3 days, add 1 year. accurate within 2 weeks

179
Q

increase calories and protein by how much during pregnancy

A

increase calories by 300/day AFTER first tri (500 if adolescent). 500 calories during breastfeeding
increase protein from 40-45 (normal) to 60
expect to gain 4 lbs in first tri

180
Q

to prevent neural tube defects in baby

A

take 400 msg/day of folic acid. spina bifida is an example of neural tube defects

181
Q

exercise rule during pregnancy

A

do not let your HR > 140. your CO and uterine perfusion will decrease. no high impact exercise- rec walking and swimming

182
Q

fetal HR

A

120-160, 110-120 worry, <110 panic

183
Q

need RBC when H and H

A

hgb of 8 and Hct of 24%

184
Q

lightening

A

sign of labor- about 2 weeks before term, presenting part of fetus descends into pelvis, pt can breathe easier and is less congested but urinary frequency (last had in 1st tri) returns

185
Q

engagement

A

largest presenting part in pelvic INLET. will block the cord from prolapse when membranes rupture. ROM- check fetal heart tones!!!

186
Q

fetal stations measures

A

measured in cm and measures relationship of presenting part of the fetus to the ischial spines of the mom

187
Q

labor- when go to hospital

A

5 minutes apart or ROM

188
Q

Non stress test

A

(NST) want to see 2+ accelerations of 15+ WITH FETAL MOVEMENT (pt push button when feel mvmt). acceleration is abrupt increase from baseline that lasts 15+ seconds and come back to base within 2 minutes. recorded for 20 minutes

189
Q

biophysical profile test (BPP)

A

done by U/S, each parameter counts as 2 pts- want 8-10/10. done in last tri or earlier in high risk, also high risk may do every 1-2 wks in 3rd tri. measures over 30 minutes: reactive NST, muscle tone (1 flex/extend), movement (3 times), breathing (1 mvmt), amniotic fluid adequate

190
Q

contraction stress test

A

CST. oxytocin challenge test. oxytocin is very dangerous- one on one observation. determines if baby can handle stress of contraction, want non reactive. do not want to see late deceleration= uterine/placenta insufficiency. want a negative test, rarely done before 28 wks and RESULTS GOOD FOR ONE WEEK, positive= hospitalization

191
Q

three types of decelerations

A

Early- okay- hypoxia from fetal head compression
late- bad- uteroplacental insufficiency
variable- bad- umbilical cord compression- move patient

192
Q

epidural complication

A

Can have acute severe hypotension. give bolus 1000mL NS or LR before epidural and monitor BP- put in semi fowlers on side to prevent compression to vena cava.

193
Q

when to turn off oxytocin

A

contractions too frequent or too long (want 1 every 2-3 minutes lasting 60seconds), or any signs of fetal distress- like late decels. TURN OFF not down

194
Q

post partum lochia

A

Dark red (RUBRA) 3-4 DAYS
Pink/brown (SEROSA) 4-10 days
white/ (ALBA)- 10-28 days or up to 6 weeks anything abnormal (amount, color, smell) decrease activity and call doctor. goes backward to rubra, call 911
close no larger than a nickel

195
Q

peripad rule

A

do not saturate more than 1 peripad per hour. more think hemorrhage

196
Q

kangaroo care

A

should be done for 1 hour at least 4 times a week. bonding for baby: stabilizes HR, improves O2 sats, regulates temp, conserves calories

197
Q

dx of early post part hemmorrhage

A

more than 500 mL blood loss in first 24 hours AND 10% drop in hematocrit from admission. late is anytime after 24 hours to 6 weeks.
meds: oxytocin, methylergonovine maleate, carboprost

198
Q

mastitis tx

A

usually 2-4 wks pp from staphylococcus
bed rest, support bra, feed frequently from affected side first, heat and pain meds, penicillin drug of choice- allergy? erythromycin. take antibiotic after feeding

199
Q

apgar

A

done at 1 and 5 minutes look at HR respirations, reflex irritability, color. want at least an 8

200
Q

drugs at birth

A

erythromycin drops or ointment for eye prophylaxis from gonococcus and chlamydia, phytonadione (vit k) for clotting factors to vastus laterals

201
Q

pathologic jaundice

A

jaundice within the first 24 hours of life. usually means Rh/ ABO incompatibility. after 24 hours is physiological jaundice (hyperbilirubinemia) normal hemolysis of excess RBCs, liver immaturity

202
Q

Rh sensitization or Rh factor occurs when?

A

only with Rh (-) mom and Rh (+) baby, get exposed with first baby and develop antibodies (become sensitized) with subsequent pregnancies babies will have increased immature RBCs (making more because getting attacked- this is called Erythroblastosis fetalis)

203
Q

Coombs

A

indirect coombs- test to mom measures antibodies for Rh
Direct Coombs- done on cord blood to count antibodies on RBCs.
with Rh + baby and sensitized mom will do frequent ultrasounds and deliver when baby stops growing.

204
Q

Rho (D) immune globulin (RhoGAM) RULE

A

must give before antibodies form. given at 28 wks (just in case any mixing of blood, protects current baby) and anytime bleeding episode/ ANY chance mixing of blood. also given within 72 hours after birth (protects future baby) give after car wreck, before abortion or amniocentesis, ectopic pg, percutaneous cord blood

205
Q

cystic fibrosis

A

usually discovered by salty kiss to baby or meconium illeus. losing salt, have steatorrhea. causes thick sticky mucus everywhere, need pulmonary txs, pancreatic enzymes get stuck, need enzymes with food (don’t digest fat well), need water soluble vitamins, autosomal recessive d/o (BOTH parents).

206
Q

celiac d/s diet

A

lifelong genetic malabsorption d/o to gluten. canNOT eat BROW Barley, Rye, Oats and When
Can have rice, corn and soy.

207
Q

normal infant heart rate and blood sugar

A

infant HR 30-60

bs 40-60

208
Q

intussusception

A

bowl folds inside itself and obstructs- 3-36 months old, inconsolable, knees to chest, currant jelly stools with blood and mucus. is an emergency

209
Q

number 1 sign MI in elderly

A

SOB, may faint, change in behavior

210
Q

food high in both potassium and magnesium

A

CHoice Should Both Mag And K

cucumbers, spinach, broccoli/ banana, halibut, mustard greens, avocado, kale

211
Q

hypoglycemia sxs and tx

A

cool, clammy, confusion, shaky, HA, nervous, nausea, increased pulse- give simple sugar (soda, milk, juice) then give complex carb with protein like crackers with cheese. AVOID fat- it delays absorption of sugars-

212
Q

drugs to treat nephrotic syndrome

A

Diuretics to remove excess fluids
ACE Inhibitors - to block aldosterone (being excreted bc low fluid vol in vascular spaces- third spacing)
Prednisone to decrease inflammation and shrink holes in kidneys to stop losing protein
Lipid lowering drugs (cholesterol and lipids increased due to liver making albumin to replace whats lost
Anticoagulation therapy for 6 months- loss of plotting factors
increase protein- losing it.
common is albumin to pull fluid out of tissues with lasix to flush it out.

213
Q

how is protein metabolized, what happens if liver broken?

A

protein is broken down into ammonia, the liver converts the ammonia to urea and the kidneys excrete the urea. so in liver failure ammonia builds up in blood- - decrease protein and salt in diet, lactulose and cleansing enemas to get rid of GI bleed and ammonia- protein in the blood is getting turned into ammonia…

214
Q

hypothyroid looks like? sxs?

A

hypothyroid looks like depression. no energy, fatigue, no expression, depressed mood, slow/slurred speech, weight gain, GI slow, always cold, amenorrhea. may be immobile. tend to have coronary artery d/s (CAD)

215
Q

hydatidiform mole Dx, tx/follow up

A

uterus grows too fast, no FHT, bleeding- confirm with U/S, D&C to remove. follow up- will do chest X-rays to determine metastasis, will measure hCG weekly until normal and then every 2-4 weeks, then q1-2 months for 6 mos to a year- do not get pregnant during this time!

216
Q

leading cause of neonatal death

A

group b strep. give penicillin or clyndamycin

217
Q

what is HELLP syndrome

A

severe pre-eclampsia. Hemolysis, Elevated Liver enzymes, Low Platelet sxs- RUQ pain, N/V malaise

218
Q

cystic fibrosis think, electrolyte? dx test?

A

thick sticky mucus everywhere- main probs respiratory and GI, sweat sodium chloride, hyponatremia. test is sweat chloride test. newborn doesn’t pass first stool (meconium illeus) is first sign- too thick and sticky. high fat, calorie, protein diet and water soluble vitamins (ADEK)

219
Q

CDU intermittent/ continuous bubbling, what is okay and what is not?

A

continuous gentle bubbling expected in suction chamber. water seal chamber can have intermittent bubbling, but never continuous bubbling in water seal chamber- leak, call dr.

220
Q

heart failure tx- meds, diet monitor

A

standard is ACE I’s and ARBS (watch K), will go home on ACEI and/or Beta B. Also, Dig, diuretics, lo(

221
Q

pulmonary edema cause and tx

A

heart, kidney prob and/or rapid fluid admin. have pink frothy sputum (like TB). keep O2>90%, diuretics, nitro, morphine, nesiritide (bnp), upright position

222
Q

nephrotic syndrome tx (diet, 5 meds)

A

diet- low sodium, high protein (even though kidney problem, losing too much protein)
Give albumin to pull fluid back into vessels and diuretic to get rid of the excess fluid, ACEI to block the aldosterone that is causing retention, prednisone reduce inflammation and hopefully shrink hole too small for protein leak, lipid lowering drugs for hyperlipidemia, anticoagulation therapy for up to 6 months. dialysis

223
Q

signs and symptoms of nephrotic syndrome (urine, blood)

A

proteinuria, hypoalbumineia, anasarca, hyperlipidemia, prone to clots

224
Q

catheter for peritoneal dialysis

A

tenckhoff catheter

225
Q

types of peritoneal dialysis

A

continuous ambulatory - 4 times a day, everyday

continuous cycle- at night

226
Q

miscellaneous signs of increasing ICP

A

head injury/ problem with HA. changes in pupil and pupil response (fixed, dilated), projectile vomiting- pressure in vomiting center of the brain

227
Q

Increased ICP Tx

A

maintain O2, maintain adequate perfusion so don’t allow hypotension or bradycardia, isotonic saline and inotropic agents, keep temp below 100 F (increased temp increases metabolism- maybe cooling blanket, hypothermia to decrease cerebral edema), elevate HOB, head midline position avoid anything that could increase ICP or cerebral metabolic demand- maybe barbiturate induced coma, mannitol, steroids, ventricular cath or subarachnoid screw

228
Q

sxs of pancreatitis

A

pain that increases with eating- mass (swollen pancreas) in upper middle to left side, abdominal distention /ascities- losing protein rich fluids and blood- rigid board like abdm with culling sign or gray turns sign, fever, N/V, Jaundice. hypotension (bleeding/3rd spacing!)

229
Q

pancreatitis dx blood work

A

lipase and amylase increase
WBC increase, blood sugar increase (pancreas makes insulin!), liver enzymes increase so now bleeding times increase and bilirubin increase. h/h may go up or down- bleeding/ dehydrated

230
Q

long term use of steroids can cause

A

DM or cushings

231
Q

treatment for pancreatitis (5 meds)

A

NPO, NG to suction and bed rest
control pain- PCA narcotics/ fentanyl patches
steroids for inflammation, anticholinergics to dry up, GI protectants (dines, zoles, antacids (hydroxides), insulin, maintain F&E balance and nutritional status= start with TPN, daily weights, no alcohol and AA (unless the cause is gallbladder d/s)

232
Q

4 functions of the liver

A

detox the body,
helps blood clot
metabolizes drugs and proteins
synthesizes albumin

233
Q

cirrhosis patho and symptoms- blood work

A

liver scarring causes hepatic portal hypertension
firm nodular liver, abdominal pain, ascites, change in bowel habits, chronic dyspepsia (GI upset), splenomegaly, jaundice
Blood- elevated liver enzymes, low albumin (not synthesizing), anemia (not clotting)
worry about BLEEDING

234
Q

how is cirrosis dx, how is the procedure done?

A

first U/S, CT, and/or MRI
liver biopsy to confirm- worry about bleeding!
pre procedure VS and clotting times, position supine, no pillow, right arm behind head
tell to exhale and hold breath to get diaphragm out of the way
lie on right side post procedure and VS

235
Q

cirrosis tx

A

antacids, vitamins, diuretics, I&O, daily weight, rest (tired from toxins), bleeding precautions, measure abdominal girth and maybe paracentesis for the ascites, skin care for jaundice, avoid narcotics- can’t metabolize, low protein diet and low salt

236
Q

hepatic coma caused by

A

too much ammonia- damaged liver cannot convert the ammonia to urea or make albumin.

237
Q

sxs of hepatic coma

A

minor mental and motor probs, difficult to arouse
asterisks (flapping hands), handwriting change, reflexes decrease (sedative), EEG is slow, fetter (ammonia breath) liver problem pts tend to be GI bleeders (hepatic portal HTN- increase pressure along whole GI tract) and protein in blood will increase ammonia

238
Q

tx for hepatic coma

A

lactulose, cleansing enema (get the GI bleeding blood out), decreased protein diet, monitor serum ammonia

239
Q

treatment for esophageal varices

A

replace blood, VS, CVP, oxygen (anemic/bleeding)
Octreotide (reduces hepatic HTN)
Ballon Tamponade to put pressure on site (Blakemore- scissors at bedside),
cleansing enema to get rid of blood, lactulose to decrease ammonia, aline lavage to get blood out of stomach

240
Q

gastroscopy

A

EGD, endoscopy- used to dx peptic ulcer
NPO 8 hrs before, sedated, NPO until gag reflex returns (tickle back of throat), watch for perforation- pain, bleeding, having trouble swallowing- check temp q15-30 mins for 1-2 hrs- sudden spike=perforation.
warm saline gargle for soar throat

241
Q

upper GI series

A

looks at esophagus and stomach with dye- also used to dx peptic ulcer, NPO after midnight

242
Q

client teaching peptic ulcer

A

decrease stress, stop smoking, eat what you can tolerate- avoid temp extremes, spicy, caffeine. need to be followed by a dr for 1 year, takes a long time to heal.

243
Q

gastric ulcer vs duodenal ulcer

A

gastric- malnourished, pain 0.5-1 hr after meals, food doesn’t help but vomiting does- vomit blood
duodenal- well nourished, night time pain common, pain 2-3 hours after meal, eating helps, blood in stools

244
Q

hiatal hernia

A

hole in diaphragm too large stomach moves up-
sxs- heartburn, fullness after eating, regurgitation, dysphagia (diff swallow)
tx- small frequent meals, sit up for 1 hour after eating, elevate HOB (at home too), surgery- lose weight most important! lifestyle changes, healthy diet

245
Q

foods that empty stomach fast

A

carbs and electrolytes- avoid foods high in them with dumping syndrome- eat in semi recumbent position and lay on left side after

246
Q

painful breathing like from cracked ribs causes what imbalance

A

respiratory acidosis- taking shallow breaths

hyperventilation- respiratory alkalosis

247
Q

rebound tenderness seen in

A

means peritoneal inflammation- peritonitis

ulcerative colitis, crohn’s d/s, appendicitis

248
Q

one side pneumonia

A

lie good lung down

249
Q

call rrt

A 
acute one of HR <40 or >130
SBP<90
RR <8 or >28
O2 <90% with supportive O2
U/O<50 mL in 4 hours
LOC change
250
Q

venturi mask

A

for COPD pts guaranteed amount of O2

251
Q

Hold epoetin (ESA) when

A

HTN or Hgb> 11- normal is 12-17

252
Q

upper right quad pain could be

A

HELLP, gallbladder or pancreas

253
Q

Guillain Barre synd

A

acute rapidly progressing ascending symmetrical paralysis- starts 1-3 wks after an upper respiratory or GI infection- can have full recovery with PT, prevent clots- ROMs and immunglobulin

254
Q

phenylkentouria

A

PKU- rare inherited d/o can’t breakdown phenylanine- in all things protein- must follow diet for life with special supplements

255
Q

cervical spine injury

A

cervical C1 highest through C8 lowest.

around 4/5 make difference in ability to breath, speak, some arm movements

256
Q

thoracic spine injury

A

T1-T12, T5 above is paraplegia, arms and hands okay- trunk down paralysis. T6-12, can control trunk

257
Q

Lumbar

A

Hip and leg probs, may be able to walk with braces or may need wheelchair- sacral below this

258
Q

thrombotic thrombocytopenia purpura

A

hemolytic anemia with fragmentation of erythrocytes, hemolysis, thrombocytopenia, decreased kidney fxn, and fever- worry about bleeding- especially brain bleed! Bleeding and clotting, clots in capillaries. caused by autoimmune d/o, cyclosporine, clopidegrel, oral contraceptives

259
Q

pyelonephritis

A

UTI in kidneys- causing dull flank pain, N/V, fever

260
Q

rhabdomyolosis

A

myoglobin released from trauma or intense exercise, heat stroke, STATIN drugs! (A/E)- too much, overwhelm kidneys- get dark, maybe bloody urine, oliguria, fatigue. give fluid boluses to flush and protect kidneys

261
Q

hemolytic uremic syndrome

A

can be caused by e.coli diarrhea- RBC being attached, damaged RBCs clog kidneys. uremic acid builds up (uremia) and low platelet count

262
Q

DKA tx

A

IV insulin (reg?) ECG, hourly BS and I&O, RAPID fluids- NS until BS reaches 300 or less then switch to D5W and when labs show potassium low or normal may add potassium

263
Q

if you have an stony, don’t eat:

A

CABBAGE! onions, alcohol, garlic, fish asparagus- trying to limit smell, gas, diarrhea- beans, carbonated beverages, strong cheese. obstructions: raw veg, seeds popcorn, nuts, raisons

264
Q

stridor

A

high pitch rub or wine on inspiration, this is the one to worry about, sign of resp distress

265
Q

when use cardioversion

A

supra ventricular tachycardia, a fib, a flutter, v. tach with a pulse. this synchronized on R wave- NPO 8 hours before, stop dig 48 hours before, pt awake, stable, with midazolam for sedation

266
Q

iron foods

A

Liver and muscle meat, egg, dried fruit, legumes, dark leafy veg, potato, whole grain/ enriched bread and cereal

267
Q

microblastic/cytic anemia

A

from Vit B12 or folic acid deficiency- usually strict Vegan vegetarians

268
Q

priapism

A

sustained erection, can happen with sickle cell anemia- tx with fluids pain meds, nifedipine- if still prob urologist with dilute epi

269
Q

pneumococcal vaccine

A

against S. pneumonia- for anyone high risk or over the age of 65, need to repeat 1 time in 5 years

NCLEX (6 decks)

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