NCLEX Flashcards
Hyperglycemia blood glucose range
Greater than 180 mg/dL
Treatment for magnesium toxicity
stop magnesium immediately, administer IV calcium gluconate bolus
Platelet reference range
150,000 to 400,000 mm³
If low expect petechiae, spontaneous bleeding
What are signs and symptoms of magnesium toxicity?
Nausea, Flushing, headache, decreased or absent deep tendon reflexes (DTR’s), hypocalcemia, somnolence, respiratory paralysis, cardiac arrest, decreased urine output, note: mag is eliminated via kidneys
Target blood glucose for a patient on TPN
140 to 180 mg/dL
Action of warfarin/Coumadin
Vitamin K antagonist. Prevents blood clot formation in patients with a fib, artificial valve, history of thrombosis.
Considerations regarding MMR vaccine for childbearing age and pregnant people
MMR is a live attenuated vaccine and therefore contraindicated in pregnancy. If a person is pregnant and found to be not immune, they should be offered the vaccine postpartum period for a non-pregnant person who receives the MMR vaccine pregnancy should be avoided for 1 to 3 months post vaccination.
What are contraindications for administration of thrombolytic agents (-PLASE)
Active bleeding, recent trauma, aneurysm, arterial venous malformation, history of hemorrhagic stroke, uncontrolled hypertension, all contraindicated due to risk of intracerebral hemorrhage. Also do not give to pts with peptic ulcer disease d/t risk of increased ulcer bleeding.
How can peripheral edema in children manifest?
Periorbital edema (puffiness around the eyes)
Hypoglycemia blood glucose range
Less than 70 mg/dL
What are warning signs of lithium toxicity
Excessive urination and increased thirst, nausea and vomiting, extrapyramidal symptoms. Monitor for fluid intaxe output, GI symptoms, neurological symptoms
CD4 plus cell count reference range
Normal range 500 to 1200 mm³
How long should a muscler needle be
1 to 1 1/2 inches
Cows milk is rich in
Calcium and vitamin D
Palpable lymph nodes post mastectomy normal versus abnormal findings
Normal: Palpable, superficial, small (0.5 to 1 cm), mobile, firm, non-tender
Abnormal: Tender, hard, fixed, larger than 1 cm
Nursing considerations/teaching for warfarin/Coumadin
Vitamin K rich foods such as green vegetables (spinach, broccoli), and liver need to be kept CONSISTENT (not decreased/increased) while taking. Need monthly INR draws.
What is the therapeutic range for magnesium sulfate?
4 to 7 mEq/L
Warfarin is also known as
Coumadin
What decreases efficacy of warfarin/Coumadin
Think increased clotting. Rifampin, carbamazepine, oral contraceptives, ginseng, St. John’s wort, vitamin K rich foods.
2.2 pound/1 kg weight gain or loss is equal to how much fluid
1000 mL or 1 L
What increases risk of bleeding with warfarin/Coumadin
Acetaminophen, NSAIDs, ABX, antifungals, Amiodarone, cranberry, ginkgo biloba, vitamin E, omeprazole, thyroid hormone, SSRIs.
Nursing considerations/teaching around carbamazepine
Associated with Leukopenia due to agranulocytosis, Resulting in increased infection risk. Patient should be educated regarding infection prevention and signs and symptoms of infection.
What is the number one priority intervention in a patient with DKA?
Re-hydration with normal saline
What is the most common complication of central lines?
Catheter occlusion
What is the best intervention for a suspected central line occlusion?
See if occlusion is mechanical/non thrombotic –reposition the patient (head, arm), as catheter tip may be against a vessel wall. Then assess for kinks, closed clamps, precipitate in the IV tubing.
What is the appropriate sized flush for central lines?
No smaller than 10 mL. Smaller size increases intraluminal pressure and can damage the line
What is an important nursing consideration for IV vancomycin?
Red man syndrome is a possible side effect and occurs with rapid vancomycin administration. S/sx of RMS = flsuhing, erythema, pruritis, usually on the face, neck, and chest. Muscle pain, spasm, dyspnea, hypotension may also occur. Usually related to rate of infusion NOT an allergic reaction. Vancomycin should be infused at minimum over 60 minutes.
Normal serum calcium range
8.6.-10.2 mg/dL
Complication of thyroidectomy
Hypocalcemia d/t removal of parathyroid glands. Can lead to laryngeal spasm = life threatening.
S/sx of hypocalcemia
Tetany (tingling of hands, toes, circum-oral region) positive trousseau or chvostek signs.
Treatment for hypocalcemia
Calcium gluconate
What is ketorolac?
NSAID –nephrotoxic, avoid in kidney patients
Considerations re: NSAID prescriptions
No more than 1 NSAID should be prescribed at a time, inappropriate for CHF patietns due to sodium retention and resulting increased fluid retention
What is malignant hyperthermia?
Rare, inherited muscle abnormality triggered by inhaled anesthetic agents and succinylcholine (anectine. A depolarizing muscle relaxant) used in general anesthesia. Asking re: family history of reactions of anesthesia is importantant, especially if patient has never undergone anesthesia.
Depth of proper chest compressions
2 - 2.4 inches/5-6 centimeters
Rate of proper chest compressions
100-120 compressions/min
Therapeutic range of lithium
0.6 - 1.2 mEq/L for maintenence
up to 1.5 for acute mania
toxic over 1.5-2
Asterixis
flapping hand tremors in arm extension
What causes asterixis
Elevated serum ammonia levels
Treatment for elevated serum ammonia levels
Lactulose.
Action of albumin
Increases intravascular oncotic pressure = increased intravascular volume, helps prevent hypotension and tachycardia = more stable vital signs.
Normal range serum magnesium
1.5 - 2.5 mEq/L
What are etiology/risks of hypomagnesia
Often associated with excessive EtOH use, results in ventricular arrhythmia –specifically torsades de pointes which looks like a twisting ribbon or a sideways tornado– and neuromuscular excitability –tremors, hyperactive reflexes, positive trousseau and chovstek signs, seizure.
Post operative blood loss normal range
No greater than 100 mL/hr
Normal urine output children vs adults
30 mL/hr or 0.5 mL/kg/hr adults
1 mL/kg/hr children
What is myasthenia gravis?
An autoimmune disease affecting the neuromuscular junction. Acetylcholine is unable to bind to the receptors. Results in fluctuating muscle weakness in skeletal muscles related to eyes and eylid movements, speaking, swallowing, breathing. Tx. is anticholinesterase drugs like pyridostigmine (Mestinon) which increases acetylcholine binding and increases muscle strength. Meds are given prior to meals to maximize swallow ability during eating. Semi-solid foods should be provided.
What are etiology and symptoms of myasthenic crisis?
Stress, infection, undermedication.
S/sx = oropharyngeal and respiratory muscle weakness and respiratory failure.
First step in management of someone who has been impaled with an object
Stabilization of the impaling object (then assessment, IV and blood draws, fluids, etc)
Amiodarone toxic side effects
Antiarrhythmia drug used only when other tx have failed because it has toxic adverse effects like pulmonary toxicity which manifests as a dry cough, pleuritic chest pain, and dyspnea. Requires urgent follow up.
What is uterine tachysystole and what is the treatment?
Due to pitocin augmentation in labor. More than 5 contractions in 10 minutes over 30 minutes. Tx = turn off pitocin, place pt in side lying position, provide O2 8-10 L/min, give IV fluid bolus, prepare to administer terbutaline, notify provider.
What causes diabetes inspidius?
ADH insufficiency. Sometimes due to pituitary manipulation.
S/sx of diabetes insipidus
Increased thirst (polydipsia), excessive urination (polyuria). Fluid volume deficit = can lead to weight loss, HYPERnatremia, HIGH serum osmolality, copious DILUTE urine with low specific gravity.
What are side effects and teaching considerations of sulfa drugs
Can cause kidney damage (client should drink lots of water), photosensitivity (client should wear sunscreen), folic acid deficit (client should take folate), agranulocytosis, stevens-johnson syndrome (teach client to d/c meds if rash appears), may cause orange-yellow skin and urine which will normalize when drug is stopped
Key steps of chest tube removal
Pre-medicate patient, have patient Valsalva during removal, it is a sterile procedure, and a sterile, airtight occlusive dressing is applied to wound after removal. A follow up chest x-ray is indicated 2-24 hours after removal.
Where are the most ideal PIV sites?
Hand or forearm
What are the classic signs of Duchenne Muscular Dystrophy
Falls frequently, pushes up on thighs to stand, walks on tiptoes, big calves.
Early sign of pneumothorax
Drop in O2 sat
Before starting TNF (tumor necrosis factor) drugs what must be ruled out? What must be monitored when taking TNF drugs?
TB –pt must be cleared or treated for latent TB prior to starting TNF. WBC must be monitored because TNF causes immunosuppression and elevated white count may indicate active infection. Pts with active infection, or taking antibiotics for an infection, should not take TNF.
ABG ranges
pH 7.35 - 7.45
PaCO2 45 - 35 (represents respiratory system)
HC03 22 - 26 (represents metabolic/renal system)
PaO2 80 -100 mm Hg
What does full compensation look like in ABGs?
pH is normal but less than 7.40 is acidotic and more than 7.0 is alkalotic
what does partial compensation look like in ABGs?
All values are out of range (neither PaC02 and HC03 are in normal range)
What does uncompensated look like in ABGs?
PaCo2 or HC03 are in normal range
What is high fowlers position
HOB up at 45 degrees or higher
What is Sim’s position
flat and side lying
What is the action of lactulose?
It decreases intestinal absorption of ammonia
Is a positive pg test a probable or diagnostic sign of pg?
It is probable –a gestational trophoblastic disease can also cause positive serum HcG
Normal range urine specific gravity
1.003 - 1.030
Procedure for 24 hour urine
Time is marked as start, urine is voided and discarded so time coincides with an emtpy bladder. Dark jug with power is provided for urine collection, refrigerated or kept on ice when not in use. If ANY void is missed, must start test again.
Loop diuretics can cause or worsen…
loop diuretics (like furosemide and bumetanide) can worsen hypokalemia unless they are K sparing
Elevated liver enzymes in a TB patient may indicate
drug induced hepatitis
Vanco therapeutic range
10-20 mg/L
Why is a vanco trough run? What else is checked?
To assess for nephrotoxicity. If trough is higher than therapeutic range, contact HCP. Also assessing BUN and creatinine. If either is high, also consider nephrotoxicity and contact HCP.
Normal creatinine range
0.6 - 1.3 mg/dL. Best indicator of kidney function. Elevated not that exciting unless on a nephrotoxic drug or a dye procedure in the morning.
Normal BUN
6 -20 mg/dL
If elevated, assess for dehydration
BUN stands for
Blood Urea Nitrogen
Most common drugs used to treat C. Diff are?
Metronidazole and oral Vancomycin. IV vancomycin is not effective.
Signs of digoxin toxicity, monitoring
N/V, slow HR, change in color perception. Digoxin is secreted by the kidney so creatinine and BUN are monitored. Elevation can indicate kidney injury, which means digoxin may accumulate = toxicity risk. Pt should report GI symptoms, neurological symptoms (lethargy, confusion, fatigue), visual changes, symptoms of cardiac block (dizziness, lightheadedness)
Chest tube bubbling normal vs abnormal
Gentle, continuous bubbling in suction control unit is normal
Bubbling in leak gauge or in water seal chamber is not normal UNLESS the pt has pneumothorax in which case gentle intermittent bubbling in water seal chamber is expected until lung has fully expanded
Polycythemia
An increase in RBCs. A compensatory response to chronic low blood O2 levels. Can lead to clots/stroke. Defined as hemoglobin >22 g/dL or hematocrit >65%
Interventions for anaphylaxis
High flow O2 via non-rebreather IM epinephrine can be repeated very 5 -15 min as needed --this is the MAIN Treatment while symptoms present, all others are supportive Elevated legs IV fluid resuscitation Albuterol/bronchodilator Antihistamine Corticosteroids
People with hemophilia are at increased risk for
joint destruction due to frequent bleeding into joint spaces
What does a positive Romberg test indicate?
Pt stands up straight and closes their eyes. If they fall over, that is a positive Romberg test. Indicates impaired proprioception/sensory ataxia.
Normal range for potassium
3.5 - 5.3 mmol/L
if low, prepare to give KCl, call provider.
If elevated (5.4 - 5.9) hold all KCl, assess heart, call provider , give kayexsolate and regular insulin and D5W.
If 6 or greater, emergent: ECG, hold all KCl, assess heart, call provider , give kayexsolate and regular insulin and D5W, do not leave pt side
P wave represents
atrial contraction/depolarization
QRS complex represents
ventricular contraction/depolarization
T wave represents
re-polarization of ventricles
Typical “ideal” length of EKG strip
6 seconds
Tiny boxes in EKG represent how much time
0.04 seconds
A big box in EKG represents how much time
0.20 seconds
Prolonged PR interval is how long
greater than 0.20 seconds (more than 5 little boxes)
What are the sinus rhythms
Sinus brady, normal sinus, sinus tach
All are regular rhythms, with P for every QRS and QRS for every P and regular P to P intervals, but different rates.
Hydrocele
Fluid filled testicular mass typically painless/bilatera. Usually resolves by pt’s first birthday.
Acrocyanosis
blue hands/feet
Neonatal “normal” RR
30-60 breaths per minute
Therapeutic INR range
2-3 but up to 3.5 for heart valve disease. Anything over 4 is concerning but not emergent.
Chillblains or Pernio definition and tx
Frost bite. Redness and swelling and blanched areas of skin due to cold exposure/injury. Rewarm in warm water (104 F) for approx 30 minutes or until areas of blanching are pink again. Areas unable to be submerged in water can be rewarmed with warm compresses. After rewarming, elevate extremeties to reduce swelling, do not apply occlusive dressings, do not massage.
Serotonin syndrome
A risk when SSRIs are used in combination with MAOIs. If a pt has been on MAOIs, must wait 14 days before starting SSRIs.
Aortic stenosis typical subjective and objective findingd
Dyspnea on exertion, chest pain, syncope, weak pulses, soft of absent S2, systolic murmur over right sternal border.
Peak expiratory flow rate
measures max exhalation, indicates amount of airway obstruction. Increasing peak expiratory flow rate value = more exhalation = less obstruction.
Connection between heart failure patients and expected findings re sodium levels
Dilutional hyponatremai is expcted in heart failure patients due to excess fluid. Signs and symptoms are fatigue and headache. Na levels below 130 mEq/L is cause for concern but borderline low (low 130s) is not emergent.
Risk to congential heart disease/syntheic materials repair, and prosthetic valve patients in relation to dental work
Risk for infective endocarditis due to oral surgery and some dental procedures. They need prophylactic antibiotics prior to procedures.
Intussusception
An intestinal obstruction due to bowel folds (like a telescope) causing increase in bowel pressure, vomiting due to pyloric muscle spasms (but NOT projectile vomiting). Produces blood and mucus in stool, looks like red jelly, a sausage shaped right sided mass on palpation is expected. Anticipate air enema (pneumatic enema) or hydrostatic (saline) enema to relieve obstruction/diagnose. Risk of peritonitis (life threatening): fever, abdominal ridigity and guarding, rebound tenderness.
Steatorrhea
Oily or bulky, foul-smelling stool due to excess fat in stool. Results from malabsorbtion of fat may be due to pancreatic insufficiency, cystic fibrosis, celiac disease.
Hirschsprung’s disease
congenital aganglionic megacolon, causes internal sphincter to remain rigid/not relax resulting in bowel obstruction and causes thin, ribbon-like stools or inability to pass stool in newborns first 48 hours, produces bilious vomit. Potentially fatal complication is enterocolitis which can lead to sepsis, presents as fever, lethargy, explosive foul-smelling diarrhea, and worsening distension of abdomen.
Neurogenic shock symptoms
Hypotension and bradycardia due to massive vasodilation
Thyroid storm symptoms
Rapid increase in temp, HR, BP due to stress/trauma in Grave’s patients (hyperthyroid)
Proper administration of a nasal spray medication
High fowlers position with head slightly bowed, occlude opposite nostril, point spray tip away from center of nose, spray and inhale deeply, breathe through mouth, repeat on opposite side. Blot nose secretions but do not blow nose for several minutes post administration,
Normal PR interval
0.12 - 0.2 seconds
Normal QRS interval
0.6 - 0.11 seconds
Name the cranial nerves
I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Vestibulocochlear IX Glossopharangeal X Vagus XI Accessory XII Hypoglossal
What type of nerve is Cranial Nerve I, what is it responsible for? How is it tested?
CN I Olfactory is a sensory nerve, responsible for sense of smell. Have patient close eyes and identify a scent.
What type of nerve is Cranial Nerve II, what is it responsible for? How is it tested?
CN II Optic is a sensory nerve responsible for vision. One eye at a time, test peripheral vision and test reading vision on chart.
What type of nerve is Cranial Nerve III, what is it responsible for? How is it tested?
CN III Oculomotor is a motor nerve, responsible for eyeball movement and pupillary dilation/constriction. Tested together with CN IV and
CN VI. Tested by holding pen light to make figure H in air, shining pen light into eyes from each side, and bring penlight toward nose from further away.
What type of nerve is Cranial Nerve IV, what is it responsible for? How is it tested?
CN IV Trochlear is a motor nerve, moves eyeball down and laterally. Tested together with CN III, CN VI.
What type of nerve is Cranial Nerve V, what is it responsible for? How is it tested?
CN V Trigeminal is a sensory and motor nerve, responsible for mandibular and maxillary and opthalmic areas (example chewing). Tested by opening mouth against resistance.
What type of nerve is Cranial Nerve VI, what is it responsible for? How is it tested?
CN VI Abducens is a motor nerve, is responsible for side to side eye movement. Tested with CN III and IV.
What type of nerve is Cranial Nerve VII, what is it responsible for? How is it tested?
CN VII Facial is a sensory and motor nerve, responsible for facial movement and expression, helps control secretion of saliva and tears, taste. Tested by asking pt to close eyes tightly, open eyes wide, puff out cheeks, smile and frown.
What type of nerve is Cranial Nerve VIII, what is it responsible for? How is it tested?
CN VIII Vestibulococchlear is a sensory nerve, responsible for hearing and equilibrium. Tested by rubbing fingers next to ears.
What type of nerve is Cranial Nerve IX, what is it responsible for? How is it tested?
CN IX Glossopharyngeal is a sensory and motor nerve, responsible for taste, swallowing/gag, speech, saliva excretion, tested together with CN X. Tested by asking pt to open wide and say ah and observing uvula moving up, can also test gag by sticking something in back of pt’s throat.
What type of nerve is Cranial Nerve X, what is it responsible for? How is it tested?
CN X Vagus is a sensory and motor nerve, responsible for taste, swallowing/gag, cough, speaking, senses aortic blood pressure, slows heart rate, simulates digestive organs –tested together with CN IX. Tested by observing speech –able to talk without hoarsenss, and observing ability to swallow.
What type of nerve is Cranial Nerve XI, what is it responsible for? How is it tested?
CN XI Accessory is a motor nerve, responsible for head, shoulder and neck movement. Controls trapezius and sternocleomastoid, controls swallow movements. Tested by asking pt to move head side to side, up and down, and shrug against resistance.
What type of nerve is Cranial Nerve XII, what is it responsible for? How is it tested?
CN XII Hypoglossal is a motor nerve, responsible for tongue movement, speech and swallowing. Have pt. stick out tongue and move it side to side. Should be midline when not moving side to side.
What is atrial flutter? What does it look like?
Atrial flutter is a self perpetuating loop of conduction, usually in the right atrium. The atrial rate is REGULAR and RAPID with a BPM of 250 - 400. Ventricular rate is 1/3 slower due to the AV node blocking some of the atrial impulses. Ventricular rate is usually regular but can also be irregular. Characterized on ECG by absense of normal p-wave and instead “flutter waves” or f-waves/ a sawtooth pattern prior to the QRS complex.
What is atrial fibrillation? What does it look like?
Atrial fibrillation is due to multiple electrical impulses from many ectopic sites in and around the atria, often near pulmonary vein roots. The impulses are unsynchronized and random causing atria to quiver (fibrillate) rather than contract. Most impulses do not pass to the ventricles. Atrial rate can be very fast. Ventricular rate is IRREGULAR, ranging from less than 60 to more than 100 BPM. Characterized on ECG by absent P-waves and narrow, irregular QRS complexes. Baseline may be flat or appear undulating. Flat indicates MORE conduction impulses from atria.
What is ventricular tachycardia? What does it look like?
V-tach is due to a single strong firing site/circuit in one of the ventricles. Usually occurs in people with structural heart problems such as scarring from a prior MI or heart muscle abnormalities. Impulses originating in the ventricles produce premature ventricular contractions that are REGULAR and FAST ranging from 100-250 BPM. Characterized on ECG with no P-wave and wide, undulating QRS complexes – it looks like large, regular humps. Sustained V-tach longer than 30 seconds requires immediate intervention to prevent cardiac arrest. It can quickly progress to V Fib
What is ventricular fibrillation?
V-fib is caused by multiple weak ectopic impulses in the ventricles causing them to fibrillate/quiver rather than contract. This means no blood is being pumped out of the heart. Quickly leads to cardiac arrest . Characterized on ECG as irregular, random wave forms with no identifiable waves or complexes.
What are the medical/electric treatments for bradycardia
Atropine and isoproterenol
Pacemaker
What are the medical/electric treatments for A-fib, SV-tach, and V-tach with pulse?
Amiodarone, adenosine, verapamil
Synchronized cardioversion
What are the medical/electric treatments for pulseless v-tach, ventricular fibrillation?
Amiodarone, lidocaine, epinepherine
Defibrillation
Hypoglycemia range and interventions for neonates
<40-45 mg/dL is considered the hypoglycemic range for neonates
<35 mg/dL in neonates ages 4-24 hours if asymptomatic, first line is to feed (breast or formula)
What is VSD
Ventricular septal defect. LEFT TO RIGHT SHUNT –A septal opening between ventricles causing left to right shunt and excess blood flow to the lungs and increased risk of CHF and pulmonary HTN. Causes pulmonary congestion, increased work of breathing, decreased lung compliance.
What are signs/symptoms of VSD
systolic murmur at sternal border at 3rd or 4th intercostal space, diaphoresis, tachypnea, dyspnea,poor weight gain. ACYANOTIC
Over how long should a blood transfusion be administered?
2-4 hours
What is the priority medication in EToH intoxication?
IV thiamine before or with IV glucose to prevent Wernike Encephalopathy
What is a consideration re: HR and beta blockers?
Beta blockers (-LOL) can sometimes worsen HF and shouldn’t be given to a patient with low BP, and left sided HF symptoms
Aspirin is contraindicated when
there is evidence of bleeding
Statins are contraindicated when
there is evidence of sever liver injury or muscle injury
Metronidazole can cause what urinary side effect
Dark urine
If air embolism is suspected in a central line, what position should the patient be in
Trendelenberg (supine with feet elevated above head) to allow air to rise and trap in right atrium.
During injection cap and tubing changes what should the patient do
Turn head away from field, and hold breath or valsalva in order to prevent air entering line/air embolism.
Sjogren’s Syndrome
Auto immune condition causing inflammation of the exocrine glands (lacrimal, salivary) –causes dry eyes, dry mouth. Pt needs to avoid drying things (no decongestions, harsh soaps, excessively hot water, acidic drinks , other mucosal/oral irritants like coffee, etoh, nicotine), receive regular oral care.
Possible side effects/interactions of St. John’s wort
Increases effect of warfarin/coumadin, can cause serotonin syndrome if taken with anti-depressants, can lessen iron absorption, can cause photosensitivity
Treatment for acetylsalicylic acid toxicity
Activated charcoal followed by IV sodium bicarbonate.
Sinusoidal FHR pattern
repetitive wave-like fluctuations in HR with absent variability and no response to UCs. An ominous finding requiring immediate intervention
Variable decels
ABRUPT decrease (less than 30 seconds from onset to nadir) and at least 15 beats below baseline for 15 or more seconds up to 2 minutes. Usually due to cord compression, maternal position change indicated and can often correct.
Early decels
Mirror UCs, with apparent and gradual decrease in FHR over 30 seconds or more from onset to nadir. Indicates head compression, normal finding.
Late decels
Follow UCs, with apparent and gradual decrease in FHR over 30 seconds or more from onset to nadir. Indicates placental insufficiency and fetal hypoxia, indication to turn pt to left side-lying and administer O2
VEAL CHOP
variable - cord
early - head
accelerations -okay!
late - placental
After cleft palate repair what precaution should be taken?
No hard objects in mouth (pacifiers, instruments, tongue depressors, etc)
Reassuring fetal movement frequency
4/hour or 10/2 hours
Sustained fetal bradycadia/tachycardia
<110 BPM or >160 BPM for more than 10 minutes
Ranges for immunocompromise in children
<750 in infants up to 12 months,
<500 in children ages 1- 5,
<200 children 5 and older
Consideration for immunocompromised people and vaccines
People showing signs of immunocompromise (i.e. CD4+ count) should not receive live-attenuated vaccines (varicella, MMR)
signs and symptoms of tardive dyskinesia
Uncontrollable/involuntary movements in: Mouth -lip smacking/puckering, tongue protrusion/curling Facial grimacing Brow twitching/furrowing Excessive blinking Foot tapping Hand wringing Tremor/shaking Rocking Torticollis (persistent neck flexion/extension)
Neuroleptic malignancy syndrome (NMS)
Altered mental status, muscle rigidity, fever, autonomic instability (diaphoresis, tachypnea, htn, tachycardia, dysrhythmia). A rare condition most often seen with “typical” anti-psychotics (haloperidol, fluphenazine) but can also be seen in “atypical” antipsychotics (clozapine, risperidone, olanzapine). Tx: d/c antipsychotic, request HCP follow up.
Teaching to avoid lithium toxicity
Drink 2-3 L H20 daily, avoid diuretics like coffee, tea, soda, maintain normal sodium intake (no low sodium diet), avoid NSAIDs
Rescue breaths
If Pt has pulse but no/abnormal respiratory effort, rescue breaths should be administered every 5-6 seconds = 10-12 breaths/min for 2 minutes before reassessing. If rescue breaths have been administered and the pulse is less than 60 and there is signs (i.e. grey/blue skin) that perfusion is not happening, begin chest compressions
Compression to breath ratio in CPR
30:2
If alone and pt is pulseless, how long to administer CPR
Administer 2 minutes of CPR before leaving to activate EMS and get defibrillator
Survival expectancy cut off for full thickness burns
Pts with full thickness burns greater than 60% of body are not expected to survive
OTC meds which can increase BP
Should be avoided in pts with HTN: high sodium antacids, appetite suppressants, cold and sinus preparations
SIADH
syndrome of inappropriate antidiuretic hormone, often caused by ectopic secretion of ADH from a malignant lung tumor. Causes an increase in water absorption, excessive intra and extra cellular fluid, HYPERvolemia, and dilutional HYPOnatremia.
SIADH appropriate tx
Requires HYPERtonic solition eg. 3% NaCl in small quantities to help fluid shift and correct hyponatremia
Examples of isotonic solutions
0.9% NaCl, lactated ringers
Used to replace intravascular fluid, losses associated with vomiting, diarrhea, burns, trauma.
Examples of hypertonic solutions
3% NaCl (or more % saline)
Examples of hypotonic solutions
0.45% NaCl (or less % saline) or 5% dextrose solution
First degree heart block
Look at space between P and QRS. If it longer than 1/2 a big box, consider a 1st degree
“if the R is far from P, then you have a first degree” –in first degree block, the PR interval is longer than 0.20 seconds
Second degree heart block type I
“longer, longer, longer, drop! Then you have a Wenkebach” –in Mobitz Type I, the PR interval progressively lengthens until a beat is dropped, and then the process resumes again.
“March out” the P waves –they’re regular because the atrial rate is regular but the P to QRS interval lengthens and then occasionally the QRS drops out entirely
Second degree heart block type II
“If some Ps don’t get through, then you have a Mobitz II” –in Mobitz Type II, the PR interval remains constant/no lengthening but occasionally, the QRS complex doesn’t happen. Look for multiple Ps in a row with no QRS complex.
Third degree heart block
LETHAL RHYTHM “If Qs and Ps do not agree, then you have a third degree” –Atrial signals are not getting through, ventricle is generating escape impulse independently of atria, so atria is beating 60-100 BPM and ventricles beating 30-45 BPM asynchronously. Looks like a weird P-QRST with occasional long intervals between complexes. This is a high priority finding due to risk of decompensation into cardiogenic shock or periods of asystole. Tx atropine and temp pacing until permanent pacemaker can be placed.
Ps might be hidden behind Ts making them a little larger collectively, Ps are regular.
QRS are also regular. March out both to notice where the Ps are hidden behind the Ts. The atrial and ventricular rates are not coordinated at all.
Note: easy to confuse with 1st degree
Congenital dermal melanocytosis AKA
mongolian spots. Fade over first 1-2 years of life, document size and location so they are not confused with bruising.
Linezolid (Zyvox)
Oxazolidinone antibiotic for vancomycin and methicillin resistant bacteria, pneumonia, and skin infections. Cannot be used with SSRIs or food/drink containing tyramine because of the drug’s MAOI-type properties which increase risk of serotonin syndrome. SSRIs and tyramine containing foods can be started again 24 hours after stopping linezolid.
Considerations for gentamycin
Like vancomycin, gentamycin should be monitored for s/sx of nephrotoxicity and ototoxicity. Check BUN and creatinine and measure urine output.
Age range for cervical cancer screening
Screen all cervix-having people between ages 21-65 regardless of age at onset of sexual activity. Screen every 3 years ages 21-29
What drugs necessitate monitoring for Stevens-Johnson syndrome
Allopurinol, anticonvulsants (like carbamazepine, lamotrigine, phyenytoin), and sulfa drugs
S/sx of epiglottis in 3-7 year olds
acute respiratory distress, toxic appearance (sitting up, leaning forward, drooling), stridor, and high fever, tachycardia and tachypnea. This is a pediatric emergency requiring endotracheal intubation and possible tracheostomy.
Normal, non-therapeutic INR range
0.75 - 1.25 –mildly elevated in cirrhosis pts is to be expected due to liver damage
Opioid agonist-antagonist meds used in labor
Butorphanol tartrate (stadol) and Nalbuphrine hydrochloride (nubain) are appropriate for clients in active labor, not wishing to ambulate, and no contraindications (imminent birth, opioid dependence). Can result in respiratory depression of newborn because these drugs cross placental barrier. Peaks 30-60 min after administration, and lasts 2-4 hours.
Bell Palsy
Unilateral peripheral facial paralysis due to inflammation of the facial nerve (CN VII) in absence of a stroke or other cause. S/sx inability to completely close eye on affected side, alteration in tear production (excessive or absent), flattened nasolabial fold on nose, inability to smile/frown symmetrically, loss of taste on anterior 2/3 of tongue.
Trigeminal neuralgia
Affecting CN V, shock-like pain in lips, gums, severe pain along cheek bone
Weight loss over what percentage of birthweight in first 5 days requires follow up?
More than 7%
Tet spell
Hypercyanotic episode in infants or children with tetrology of fallot. Infants should be placed in knee chest position, children will often get into squatting position. This provides relief of dyspnea by reducing volume of blood being shunte through the overriding aorta and VSD.
Serious side effects of tamoxifen
Tamoxifen is a selective estrogen receptor modulator used in treatment/prevention of estrogen-positive breast caner. Serious side effects include thromboembolic events and endometrial cancer.
What is trousseau’s sign and how is it elicited?
An early sign of hypocalcemia, observed by placing a BP cuff on the arm and inflating it to above the most recent systolic pressure. Leave on for 3 minutes. This obstructs the brachial artery and induces a spasm of hand and forearm muscles if hypocalcemic.
What is Chovstek’s sign and how is it elicited.
A sign of hypocalcemia, oberved by tapping face at the angle of the jaw and observing for facial contraction.
IV catheter gauge
14g for administration of fluids/meds in emergency/field settings and hypovolemic shock
18g for blood or large qty fluids in adults
20/22g for general IV and meds. 20 is acceptable for blood but not ideal.
24g children and elderly pts with small fragile veins
Suddent onset of left upper quadrant pain can indicate
Spleen rupture –a possible complication of Epstein Barr (mononucleosis) infection
Abrupt cessation of central acting alpha2 agonists or -beta blockers can cause what?
Abrupt stop of clonidine or methyldopa (CAA2A) or -olol (beta blockers) can lead to rebound hypertension. Drugs should be tapered down, not stopped abruptly.
High levels of PEEP can lead to what complications?
High PEEP (10-20 cm H20) can cause barotrauma of the lung (overdistension or rupture of alveoli) leading to pneumothorax or subcutaneous emphysema. Decreased venous return can also cause hypotension.
1 TBSP = ? mL
15 mL in 1 TBSP
If a question asks whether an ABG is compensated or NOT compensated and the ABG is partially compensated what is the correct answer?
Not compensated, because it is not FULLY compensated
Hypertonic total enteral feeds can cause what complication? What is the treatment?
hypertonic TEF can cause N/V/D due to higher osmolality, similar to dumping syndrome. Slow the rate of administration and it will usually correct, and then you can taper up the rate to the goal rate.
What is crutch paralysis
Muscle weakness/sensory symptoms of forearm/wrist/hand caused by continuous/prolonged excessive pressure on axillae and radial nerve damage due to use of crutches that are too long/not ambulating correctly on the crutches.
Rhythms appropriate for defibrillation
Ventricular fibrillation and pulseless ventricular tachycardia, SVT if not responsive to adenosine
Rhythms NOT appropriate for defibrillation
Asystole
Ryhthms appropriate for synchronized cardioversion
Supraventricular tachycardia, ventricular tachycardia with pulse, atrial fibrillation with RVR
Ideal contraction strength
25 -50 mm Hg, should never exceed 80 mm Hg
Resting uterine tone in mm Hg
average 10 mm Hg should never exceed 20 mm Hg. After amnioinfusion, expect resting tone to remain equal to or greater than 20 mmHg and observe for fluid leaking, otherwise suspect uterine overdistension.
Proper technique for cane walking, up/down stairs
Cane always moves before the bad leg: cane, bad leg, good leg for flat surfaces.
Stairs: Up with the good and down with the bad –cane, good, bad for up stairs, cane, bad, good, for down stairs.
What are considerations re: IVPB Potassium?
it should NEVER be given by gravity –must be provided by pump. It is a vessicant so must monitor site. Monitor renal labs and function (urine output). Max PIV rate is 10 mEq/hr and max concentration is 40 mEq/L otherwise needs to be given via central line.
Typical developmental milestones by age 1
Can sit from standing without assistance, birth weight should have roughly tripled, pincer grasp.
Presbyopia
Inability to see close objects clearly
In elderly patients what is considered febrile?
Lower body temp means lower febrile cut off. 37.8 C / 100.2 F is considered febrile
Appropriate fluid resuscitation for burn victims
Lactated Ringers
Rheumatic fever
RF is an acute inflammatory disease of the heart, occurs 2-3 weeks after a streptococcal pharyngitis (strep throat) due to delayed onset of autoimmune reaction
Tumor lysis syndrome
Oncologic emergency, causes HYPERkalemia, HYPERuricemia, HYPERphosphatemia, HYPOcalcemia. Requires aggressive rehydration, electrolyte correciton (loop diruetics and phosphate binders) and hypouricemic agents (like allopurinol)
TB test reading
Positive: induration greater than or equal to 15 mm in a healthy person, greater than or equal to 10 mm in a potential risk person or with mild immunosuppression, greater than or equal to 5 mm in a high risk person. If positive, ask about bacille Calmette-Guerin vaccine which lessens receptivity to TB but causes false positive results.
1000 mcg =
1 mg
1000 mg =
1 g
Rapid acting insulins and OPD
Rapid = “logs” humalog, novolog. Onset 15 min, peak 1 hour, duration 3 hours. Give WITH meals.
Short acting insulins and OPD
Short = regular = R. Onset 30 min, peak 2 hours, duration 8 hours. Can be run in IV.
Intermediate acting insulins and OPD
Intermediate = NPH. Humulin. “N” Onset 2 hours, peak 8 hours, duration 16 hours. Never put anything cloudy in a bag.
Long acting insulins and OPD
Long = Levemir, lantus. Glargine. Onset 2 hours, peak NONE, duration 24 hours. Never mix with other insulins. Can be given at same time, as separate injecton. The only insulin safe to give at bedtime.
Neonatal abstinence syndrome s/sx
withdrawal from opiates: irritability, hypertonia, jittery, seizures, diarrhea, vomiting, feeding intolerance, sweating, sneezing, pupillary dilation
Drug to reverse benzodiazapine overdose
Flumazenil
Normal central venous pressure
2-8 mm Hg. If elevated can indicate R ventricular failure or fluid volume overload
Normal MAP
70 -105 mm Hg
Normal systemic vascular resistance
800-1200 dynes/sec/cm-5
Most severe complication of acute glomerulonephritis
Severe hypertension
Narrowing pulse pressure is a sign of
hypovolemic shock
Chronic mitral valve regurgitation consideration
Often asymptomatic but can develop into heart failure so s/sx of heart failure should be monitored for: pulmonary edema due to L to R backflow, causing dyspnea and orthopnea. Fatigue due to decreased cardiac output. Atrial fibrillations/palpations due to enlargement of L atria.
Scleroderma
Collagen overproduction causing tightening/hardening of the skin and connective tissues. Progressive disease with no cure –management of complications is only option. Renal crisis is a possible complication causing malignant hypertension –life threatening
Desmopressin in DM
Increased risk of water intoxication and hyponatremia. Symptoms: headache, change in LOC, muscle weakness.
Expected labs in cirrhosis
Elevated: ammonia, bilirubin, PTT
Decreased: albumin and sodium
3500 calories =
1 lb gain/loss
Chest pain is always considered
cardiac until proven otherwise –trumps a suspected DVT in prioritization
Anemia of CKD treatment
erythropoietin
Considerations in administration of erythropoietin
BP must be checked prior to administration as an adverse effect of erythropoetin is hypertension. Uncontrolled HTN is a contraindication of administration. Also held if Hgb is greater than 11
How is erythropoetin administered
subcu or IV
Elevted AST/ALT indicates what and is caused by?
hepatic cell injury (hepatitis). Can be due to EtOH use, OTC meds like acetaminophen, herbal/dietary supplements, IV drug use (due to Hep B and C)
Priapism
Prolonged, painful erection. An emergency.
WBC normal range
4,500 - 11,000/mL
Side lying in pneumonia/lung patients
Side-lying on the GOOD side decreases hypoxia by increasing perfusion to the healthy lung, but does NOT increase secretion clearance.
Gastric pH measurement from NG tube purpose
confirms correct placement prior to feed
Von Willebrand disease
Genetic bleeding disorder that decreases coagulation due to inadequate von Willebrand factor. Must monitor for signs/symptoms of bleeding and avoid medications that exacerbate bleeding (aspirin, NSAIDs)
Bronchodilator respiratory medications
BAM
Beta2 agonists -terols
Anticholinergics -pium (decrease mucus production)
Methyxanthines -phylline (increase heart rate, expand lungs, like caffeine)
Anti-inflammatory respiratory medications
SLM
Steroids -sone must taper off!
Leukast, Leukotrine receptor agonists. Leukotrines stablized so bronchi and bronchioles relax. example Singulair -montelukast sodium (Luke likes to sing)
Mast cell stabilizers -stabilizes mast cells to reduce swelling. Example Cromolyn. Think “Mass of chrome”
Sodium polystyrene sulfonate
Kayexolate. Helpful for mild to moderate hyperkalemia. Has risk for intestinal necrosis, requires regular bowel function assessment.
Supraventricular tachycardia
Looks like a regular tachycardia but with narrow QRS and shortened PR interval and possibly hidden P –look for combined P and T with fast rate. If I have something tachy and can’t distinguish P from T = SVT. Can be caused by stimulants or heart disease.
Diseases appropriate for droplet precautions
N. Meningitidis, Influenza B, Diptheria, Mumps, Rubella, Pertussis, Group A strep (strep throa), viral influenza
What precautions are taken for droplet precautions
Surgical mask and private room, gown, gloves, googles/face shield used if risk for splash/body fluid contact
Aceytlcysteine
Loosens/liquifies respiratory secretions in CF or other respiratory patients. Has no effect on smooth muscle and can cause/worsen bronchospasm = contraindicated in asthma patients
Significant increase in BP in pregnancy
Equal to or greater than 30 mmHg systolic or equal to or greater than 15 mmHg diastolic. even in the absense of HTN/symptoms, assess proteinuria, HA, RUQP.
Abdominal aortic aneurysm
Bulge in abdominal aorta due to increased pressure. Can manifest as a pulsative periumbilical mass. Risks: male, over 65, CAD, PVD, HTN, smoking hx, family history, Manifests as acute onset abdominal pain radiating to the back, drop in systolic pressure, increase in pulse, weak pulse, pallor. Life threatening emergency.
Thiazide diuretics and spironolactone
Spironolactone when combined with a thiazide diuretic prevents hypokalemia in pts with normal K levels
Anticholinergics
Benztropine, trihexyphenidyl, used to treat Parkinsons and other diseases but can cause urinary retention and can precipitate acute glaucoma and should not be used in patients with BPD or glaucoma.
Pyloric stenosis
Hypertrophy of pyloric muscle causes postprandial projectile vomiting due to obstruction at gastric outlet. Palpate olive shaped mass to the right of the umbilicus. Vomiting is non-bilious (whatever is eaten is vomited) and leads to progressive dehydration and results in hypokalemic metabolic alkalosis. Hemoconcentration due to dehydration results in elevated hematocrit and BUN.
Hydroclorothiazide can cause
Thiazides are potassium wasting diuretics, and can cause hypokalemia
Physiologic compensation for metabolic acidosis
Rapid breathing to blow off more CO2
Loction of injury, classic symptoms and intervention for neurogenic shock
T6 and higher thoracic and cervical injuries can result in neurogenic shock which presents as hypotension, bradycardia, pink dry skin due to massive vasodilation. Treat with isotonic solution to maintain perfusion to organs, especially kidneys.
signs of cardiac tamponade
Becks triad: low BP, especially large decrease in systolic pressure in short period of time, JVD, quiet heart sounds. Also narrowed pulse pressure, pulsus paradoxus, dyspnea, tachypnea, tachycardia.
Location of the phlebostatic axis
Level of atria at 4th ICS, 1/2 anterior-posterior diameter (midaxillary line)
Locations of heart sounds
Aortic –2nd intercostal space, pt’s right sternal border
Pulmonic –2nd intercostal space, pt’s left sternal border
Erb’s point –3rd intercostal space, pt’s left sternal border
Tricuspid –4th intercostal space, pt’s left sternal border
Mitral –5th intercostal space, mid clavicular line –this is the APEX/place for APICAL pulse/point of maximal impulse (PMI)
How is elevated BNP is used
BNP >100 pg/ml is used to distinguish cardiac cause of dyspnea from respiratory causes
Tinea corporis and tinea capitis
Ring worm. highly contagious fungal infection
Corporis – body
Capitis –scalp
Mnemonic for cranial nerve functions
I Some (sensory) II Say (sensory) III Marry (motor) IV Money (motor) V But (both) VI My (motor) VII Brother (both) VIII Says (sensory) IX Bad (both) X Business (both) XI Marry (motor) XII Money (motor)
What precautions are appropriate for varicella zoster
N95 and gloves and gown, negative pressure room until lesions are dry and crusted (no longer contagious at that point)
ACE inhibitors side effects
dry unproductive cough. Cough stops with med discontinuation. Hypotension, tachycardia, angioedema, hyperkalemia.
NCLEX position on HIV positive mothers breastfeeding
they should not in developed countries where formula is available
Cephalosporin administration in pts with penicillin allergies
e.g. cephalexin. Can have a cross allergic reaction. If hx of anaphalaxis d/t penicillin, cephalosporin should not be administered. If reaction was rash or other mild reaction to penicillin, HCP may decide to administer cephalosporin anyway.
Maximum time a bottle of solution can be open and used before it needs to be discarded
24 hours
Decerebrate and decorticate position
Decerebrate –the more serious of the two. Arms and legs straight out and toes pointed down, head/neck arched back
Decorticate –bent arms, clenched fists, arms bent in toward body, legs out straight
DKA treatment parameters
NS fluid bolus. Rehydration with normal saline and IV insulin to bring down blood glucose. IV insulin is titrated down as the blood glucose returns to an acceptable range and may be discontinued when it is below 200 mg/dl. IV potassium will be administered even if normokalemic to prevent common complication of hypokalemia d/t insulin causing shift of K from intravascular to cellular space and resulting life threatening arrythmias that can result.
Risks for fat embolism
Long bone fracture –look for dypnea/confusion/decreased Sp02, petichiae on trunk
Calcium channel blockers ending and common side effects
-ipine –vasodilators so cause decrease in blood pressure and can result in dizziness, flushing, headache, peripheral edema, and constipation. Can initially cause orthostatic hypotension so pt teaching should include slow position changes.
Tetracyclines teaching
Take on an empty stomach, avoid iron supplements, dairy and antacids, take with a full glass of water and remain upright after taking to reduce chances of pill induced stomach upset (i.e. don’t take at bedtime), can cause photosensitivity, and it decreases the effectiveness of oral contraceptives so another method must be used while taking.
Upward progressing abdominal pain
is a bad sign, warrants reporting to HCP
Parkland formula
4 ml x body weight in kg x percentage of body burned = 24 hours fluids. 50% is given in the first 8 hours and 50% over the next 16 hours so pay attention to the question wording.
Rule of 9s
9% head and neck 18% anterior torso 18% posterior torso (36% total trunk) 9% right arm 9% left arm 1% genitals 18% right leg 18% left leg
Hospice vs palliative care
Palliative focuses on quality of life and managemnet of symptoms. Can be given even with curative or life-extending treatment in the setting of a terminal diagnosis. Involves a multidisciplinary care team for the pt and family. Hospice is started when treatment is discontinued. Palliative is not limited to a specific time frame re: life expectancy.
Considerations re: treatment of syphilis in pregnancy
IV penicillin is the only acceptable treatment in pregnancy. If pt is allergic, penicillin desensitization must be anticipated.
Crepitus
Grating noise/sensation heard or palpated with movement due to bone and cartilage fragments in joint space
Kussmaul breathing
Compensatory respiratory pattern for metabolic acidosis –think “MAcKussmaul”
If pt on ventilator and respiratory alkalosis what does that mean?
Respirator ventilation is set too high and they are being over-ventilated
If pt on ventilator and respiratory acidosis what does that mean?
Respirator ventilation is set too low and they are being under-ventilated
Calcium channel blockers are like
valium for the heart –calms things down. Good for tachycardia, tachy-arrhythmia,
Anything called “neg x-otrophic” =
Cardiac depressants. Calm the heart down. For the A, AA, and AAA: Antihypertensive, antianginal, anti-atrial arrythmias
Anything called “pos x-otrophic”
Cardiac stimulants
-dipine ending
Calcium channel blocker –“dipping in the calcium channel”
What must be measured/what parameters considered prior to Ca Channel blocker?
Measure BP, hold if systolic lower than 100. Cardizem can be given continuous IV drip and must be titrated to keep systolic BP above 100 so BP must be taken regularly.
Periodic wide QRS =
PVCs
Look like a normal rhythm then a sudden wide QRS complex without a P.
Unifocal –look the same (from a single ectopic source)
Multifocal –look different (from multiple ectopic sources)
Collection of PVCs =
short run of V-tach
PVCs are a low priority except when
more than 6/min or more than 6 in a row or it PVC calls on T before (R on T), then MODERATE priority. NEVER high priority. PVCs AFTER an MI is GOOD.
Ventricular arrythmia meds
(old) = lidocaine. Think V = L.
(new) = amniodarone. Think V = A
Atrial arryhtmia meds
ABCDs (Adena-Beta-Calca-Dig)
A -Adenocard/adenosine (FAST push of 1-2 seconds followed by 20 mL saline flush)
B -Beta blockers (lols) –neg x-otrophics. SE: hypotension and headahce
C -Calcium channel blockers
D -digitalis/digoxin/lanoxin
V-Fib treatment
D-fib
Asystole treatment
Epinephrine then atropine (think AsystolE, reversed)
Chest tube placements
High = air (apical)
Low = blood (basilar)
Assume chest surgery or trauma is UNILATERAL unless otherwise specified
If something compromises chest tube, what are appropriate steps
Clamp, cut if necessary, place in sterile water, unclamp. NEVER clamp for longer than 15 seconds without an order.
Bubbling in water seal appropriate/inappropriate
Intermittent = good (document) Continuous = bad (leak --needs tape)
Bubbling in suction control appropriate/inappropriate
Intermittent = bad (suction too low, increase it) Continuous = good (document)
Congenital heart defects
All are TRouBLe or no trouble
T -all defects starting in T = trouble
RL –right to left = trouble
B –blue = cyanotic
4 defects of tetrology of fallot
VarieD PictureS Of A RancH
or
Valentines Day Pick Someone Out A Red Heart
Vendricular Defect
Pulmonary Stenosis
Overriding Aorta
Right Hypertrophy
