Nclex Flashcards
C.A.U.T.I.O.N.
Cancer
C: Change in bowel or bladder habits
A: A sore that does not heal
U: Unusual bleeding or discharge
T: Thickening or lump in the breast or elsewhere
I: Indigestion or difficulty in swallowing
O: Obvious change in a wart or mole
N: Nagging cough or hoarseness
NPO
General
Upper or Lower CT & Xray
Upper & Lower (scope)
OLOL
Lowers Heart Rate
ACE
PRIL
HyperKalemia
Tachy
STATIN
Cholestrol
Rhabdomyolysis
Nurse managed medication
Heparin
Insulin (sliding scale)
Cohort
Post-op = CLEAN
no infection or at risk for infection pt.
Acute Pericarditis
ST elevation is expected
Incentive Spirometer
Post operative
Lung Sounds
Crackles
Fine - Pulmonary Edema
Coarse- Pneumonia
Lung Sounds
Wheezing
Asthma
Lung Sounds
Stridor
high pitched
obstruction- airway risk
Lung Sounds
Friction rubs
Pneumonia
Pleuritis
TPN
50% dextrose
Hyperglycemia
Infections
Blood administration
Hypersensitivity
Rash - Slow down rate and obtain order for antihistamine or diphenhydramine = Hypersensitivity 1
Rash, Wheezing, Dyspnea- Stop the flow, Run NS and Call HCP= Hypersensitivity 1
Fever & Flank pain STOP! = Hypersensitivity type 2: Cytotoxic
S.I.C.K.
Sugars
Insulin
Carbohydrates
Ketones
*need to keep eating
check sugars more
check urine DKA?
B.G. level of someone sick
140-180
Energy to fight
Water Intoxication
Low levels of Na Risk for seizures, stop breathing, death Brain can swell or shrink -Pad side rails Na: 120 = risk
Hives
Urticaria
Medication
take on an empty stomach
Antacid
Iron
Tetracycline
Levothyroxine
Sucralfate
take before food
IV insitu
72hrs
Photosensitivity
Lupus & Tetracycline
Contraindication to breastfeeding
HIV
Sickle Cell
Circulatory is priority
Testicular torsion
twisting of the testicles
MED EMERGENCY
Sudden, severe pain in the scrotum — the loose bag of skin under your penis that contains the testicles
Swelling of the scrotum
Abdominal pain
Nausea and vomiting
A testicle that’s positioned higher than normal or at an unusual angle
Painful urination
Fever
Glomerulonephritis signs
HTN, Edema, Proteinuria
inflammation of the tiny filters in your kidneys
Dangle vs Elevate
dAngle= Arteries
eleVate=Veins
ADPIE
ASSESS first
Ask why? not just fix it
Be sure the answer will work
Petechiae
Pinpoint red
Early sign of bleeding
Purpura
Large purple spots
Early sign of bleeding
Diabetes Insipidus
Patient urinates a lot
Bad urine tricks specific gravity that you are hydrated
**low specific gravity
Simple Sugars
Honey, Orange Juice
Dysphagia
- No OTC medications because codeine can suppress the sensation of the back of the throat
- Downward motion of the head to swallow
- A straw will not allow the patient to feel the food
Cold and Clammy
Shock
RACE & PASS
Rescue
Alarm
Contain
Extinguish
Pull
Aim
Squeeze
Sweep
The 5 W’s of Post-Op Fever / Infection
Wind
- 2 - 4 days
- Pneumonia
- Deep breathing and IS (prevent atelectasis)
- VAP
- HOB 30 degrees
- Frequent oral care q4hr
- Pantoprazole (PPI)
Water -3 - 5 days -UTI CAUTI -Frequent perineal care -Pull it out ASAP -Rotate it 72 hours
Walking
- 3 - 5 days
- DVT / Thrombophlebitis
Wound
Wonder Drugs
4 Hyperthermic Medical Emergencies / Muscle Rigidity
Neuroleptic Malignant Syndrome
Malignant Hyperthermia
Autonomic Dysreflexia
Serotonin Syndrome
ABGs
Metabolic Acidosis
Respiratory compensation
DKA
Kussmaul Breathing (deep and fast)
Respiratory Problem
Metabolic COmpensation
Regulate pH
Respiratory
Metabolic
Metabolic Acidosis - decrease in HCO3
Metabolic Alkalosis - increase in HCO3
Respiratory Acidosis - increase in CO2
Compensate by increasing the HCO3
Respiratory Alkalosis - decrease in CO2
Compensatory by decreasing the HCO3
Braden Scale for Pressure Ulcer Risk
Mobility
Sensation
Activity
Nutrition
Continuous medication
CANNOT stop
Dopamine, Dobutamine, Epinephrine, Norepinephrine, Phenylephrine
Types of Pacing
Magnets - big no no, shuts off the pacemaker
No blunt trauma
Transcutaneous Pacing Symptomatic Bradycardia 2nd and 3rd HB Sedate the patient Setting on the defibrillator machine (Zoll) Transfemoral Pacing Feed an electrode through the femoral artery and up to the right atrium Little shocks Permanent Pacing
Defibrillation V. TACH or V. FIB Synchronized Cardioversion SVT Pacing
Mg
Chronic alcohol abuser - hypomagnesemia
Loss of electrolytes
Hypomagnesemia
The other direction (increased reactivity)
Hypermagnesemia
Loss of deep tendon reflexes
Anaphylaxis
Airway closure Vasodilate the vasculature → BP tanks Secondary allergic symptoms Hives (urticaria) Pruritis (itching)
Vitamin B3 (niacin)
Antihyperlipidemic
Used in conjunction w a statin / fenofibrate
Vitamin B6 (pyridoxine)
Used for deficiencies, due to pt. On isoniazid therapy for TB
Vitamin B12 (cobalamin)
Pernicious anemia
Vitamin C (ascorbic acid)
Immune
Vitamin K
Stops bleeding
Injection in newborns
Vitamin D
Help calcium and bone growth
Sun
Black Cohosh
relieve menopause symptoms such as hot flashes
St. Johns Wart
Depression
Interacts with everything
Saw Palmetto
BPH in men
Ginseng
Memory / Cognition
Licorice
digestive system complaints
Licorice
digestive system complaints
first dressing change Post-Op
first assessment is always performed by the surgical team
* how exactly do you propose visualizing and assessing the incision, if you cannot even see it?*
Assess the dressing for drainage.
Within 24 hours. - they will assess it.
Patient is post-op 36 hours, you can ASSUME the surgical team has looked it.
