NCLEX Everything! Flashcards
Most common areas affected by scabies
hands and feet
Where should a portable shield be placed for a client with a radioactive implant?
on the hallway side of the client’s bed
not at the foot of the bed
what might you see if there is fecal impaction
oozing liquid stool. can be mistaked for uncontrolled diarrhea.
Interventions when a veteran is having a flashback
maintain a safe environment, protect self. client is in a war zone
What drink should be recommended for a client taking furosemide and digoxin?
Orange Juice- containes 496 mg of potassium
low potassim precipitates dig toxicity
When is glucagon normally used?
If client is a ketoacidosis or coma. They are usually unconscious
2 Types of Drugs that contain tyramine (MAOIs)
Phenelzine, Isocarboxazid,
Metronidazole
(Flagyl)
- *Indication** intra-abdominal infections, gynecoligical infections, septicemia, endocarditis, amebic liver abscess, peptic ulcer
- *Action** inhibits dna and protein synthesis in bacteria
- *Class** anti-infective, antiprotoxoals, antiulcer
- *Nursing Considerations** obtain cultures before therapy, monitor neruologic status, monitor intake and outpus and daily weights. May alter liver enzymes
What fluid and electrolyte imbalance happens with vomiting?
loss of acid in the stomach. Metabolic Alkalosis
Signs of Diabetes insipidus
- cracked lips due to dehydration
- large urine output
- low specific gravity as urine is not concentrated in the kidney
What is a sign of a fat embolism
petechiae
what is a good gift for a patient with parkinson diseaes?
warming tray for food. Keeps it hot and appealing for their slow eating process.
What drugs may lead to agranulocytosis
- Hyperthyroid drugs
- Propylthiorucil
- Methimazole
- Clozapine- 2nd gen antipsychotic
what type of precautions is pertussis
Droplet
tonsilittis, CF, and bronchitis are all standard.
Where is dorsalis pedis artery located
Insulin Long Acting
Detemir, Glargine, Levemir, Lantus
- *Indication** hyperglycemia with diabetes type 1 and type 2, ketoacidosis
- *Action** stimulates uptake of glucose into muscle and fat cells, inhibits production of glucose in the livere, prevents breakdown of fat and protien
Detemir onset 3-4 hr, Peak 3-14hr
Glargine 3-4,, no peak
- *Class** lpancreatics, antidiabetics
- *Nursing Considerations** monitor body weight over time, may cause decreased inorganic phsophates, potassium and mag. Monitor B/S Q6, monitor A1C every 3-6 months
Why is pain med a priority for MI
pain wil increase oxygen demand
Hallmark Signs of Tensions Pneumothoraz
chest pain, muffled heart/lung sounds. medistinal shift, respiratory distress.
Why is it important to assess blood pressure for pt coming off spinal anasthesia?
blocakge of autonomic nervous system may still be presen and cause hypotension. Gradually elevate head of bed.
If pt is experiencing chest pain and nausea and dizziness what lab values should you request
CBC, Cardiac Enzymes. R/t MI or Angina
Tyramine rich foods
aged cheese, wine, tofu, chocolate, lunchmeats, fermented foods, caffeine
Why is a patient with hemophilia at risk for knee and joint deformities
most frequent site of bleeding is in the muscles and joints; repeated bleeding episodes causes changes in bones and muscles
When should PPIs (prazole) be given with regard to mealtime
on an empty stomach BEFORE meals
Signs of Autonomic Dysreflexia
- severe headache
- profuse sweating
- full bladder
- bradycardia
- hypertension
- goosepumps
- nasal congestion
best lab value to confirm diagnosis of MI
Troponin Levels
priority assessment post op
- respiratory highest priority (breathing)
- cardiac status (circulation)
- dressing
- positioning
- check the surgical notes
- monitor incision site
Priorities if a patient has fallen out of bed
- Obtain Vital Signs
- Assist client back to bed (if does not appear injured)
- Call HCP to report Incident
- Incident Report
What action is benefical to prevent hypercalcemia
walking as much as possible keeps the calcium in the bone
What level of training should be assigned to triage
you need at least one experienced RN, an inexperienced RN could be provided training.
This condition may be caused by gallstones, chronic alcohol use, infections, medications, and trauma.
Pancreatitis
tx with IV fluids, antibiotics, pain relievers
Atropine Overdose
Hot as a hare, mad as a hatter, red as a beet, dry as a bone
What are the 5 Stages of grief?
- Denial
- Anger
- Barganing
- Depression
- Acceptance
what is a common occurence with patients with hyperparathyroidism
urinary tract calcui- hematuria is a sign
parathyroid function: increase the concentration of plasma calcium by increasing the release of calcium and phosphate from bone matrix, increasing calcium reabsorption by the kidne
what are WBCs when patient is neutropenic
low
Why is carbazapine used for Trigeminal Neuraglia (tic durex)
for agonizing pain. Inhibits nerve impulses and reduces pain of the condition
Normal therapeutic range for PTT
1.5-2 times normal
Normal: 20-25
Upper: 32-39
A-S-T-H-M-A MGMT
- Albuterol (Adrenergic)
- Steroids
- Theophylline
- Hydration
- Mask
- Antibiotics
When is a patient in coma according to glascow scale
below 8. 15 is the best
Iodine
- *Indication** thyroidectomy, thyrotoxic crisis, radiation exposure
- *Action** inhibits release of thyroid hormones
- *Class** antithyroid agent
- *Nursing Considerations** GI bleed, diarrhea, hypothyroidism, goiter, monitor for hypersensitivity
when is phototherapy for an infant needed?
if bilirubin is greater than 15 mg/dL at 72 hours of age.
What type of pain delivery system is well suited for pts with cancer
SubQ
what could a multipara patient that is requesting to go to the bathroom to have a bowel movement mean?
imment birth, urgent. Do not allow to use the bathroom.
Who is the only employee from a health care organization that can be a lega withness of signing of an advance directive
clinical social worker
Which clients are at greates risk factor for respiratory depression while receiving opioids for analgesia?
elderly, opiate naive, pulmonary disease. Count the risk factors.
What does CSF have in meningitis
high protein, low glucose
What is the general rule with nutrition and renal patients?
decrease proteins because protein increases BUN
chvostek sign location
Lab Values for Metabolic Alkalosis
ph HIGH PCO2, HIGH, HCO3 High
Low Potassium
Why is morphine contraindicated in pancreatitis?
causes spasm of the spincter. Demerol should be given.
First action for chest pain (MI, Angina)
EKG, ST wave will have and issue
What can LVNs never do
assessments or evaluations. but can implement the tasks on the plan of care
What complication is at risk with Kawasaki Disease
Coronary artery aneurysm
Affects mucus membranes, lymph nodes and walls of the blood vessels. Can cause inflammation of the arteries, possible heart attack in child, fever lasting more than 2 weeks.
Methlergonovine
- *Indication** postpartum hemorrhage
- *Action** stimulates uterine muscles causing uterine contraction
- *Class** oxytocic, ergot alkaloids
- *Nursing Considerations** can cause hypertension, cramps, N/V, dyspnea. Monitor BP, HR and uterine response. Assess caclium levels
Lactulose
- *Indication** Constipation, portal systemic encephalopathy
- *Action** draws water into the stool and softens stool, inhibits ammonia passing into the colon
- *Class** osmotic laxative
- *Nursing Considerations** caution with DIabetes, may cause cramps ab distention and hyperglyciema, mental status, ammonial levels , avg 2-3 bowel movement per day
-sartan
ARBs
How high should a pregnant women let her heart rate go?
not above 140 bpm
Bucks traction is for
knee immobility
what type of exercises whould be recommended if a patient is in a cast
isometric exercises.
INR- international normalized Ratio
2 - 3 for standard warfarin therapy
3 - 4.5 for high dose warfarin therapy
Altepase
- Indication MI, Acute ischemis strok, occluded central lines
- Action converts plasminogen to plasmin, degrades fibrin in clots
- Class thrombolytic
- Nursing Considerations Intracranial hemorrhage, bleediing, anaphylaxis, HTN, neuro status
Possible SE of Imipramine (trycyclic antidepress)
sore throat, fever, increased fatigue, N/V, diarrhea
What type of precautions does a patient with mengiococal pneumonia have?
droplet
A harrington rod is used for scoliosis, what do you want to assess
neuro checks b/c of spine
What is assessment is necessary when oxytocin is given
palpate the uterus. Oxytocin stimulates the uterus to contract. Can lead to uterus rupture.
What is a common temporary side effect of Pepto Bismol (Bismuth Subsalicylate)
dark tint of the tongue
Paroxetine
- *Indication** major depressive disorder, OCD, anxiety, PTSD
- *Action** blocks reuptake of CNS
- *Class** antianxiety agent, antidepressant, SSRI
- *Nursing Considerations** neurleptic malignant syndrome, decrease effectiveness of digozin, increase bleeding with warfarin, suicidal thoughts
What could administering morphine do for a critical patient with a head injury
could mask signs of ICP
Examples of selective beta 1s
MEAANe
- Metroprolol
- Exmolol
- Acebutolol
- Atenolol
- Nebivolol
If you see a question with Who, What Where…?
consider the question that asks in a different way.
signs of hemolytic reaction
hypotension, back ache, low back pain, fever, dyspnea
Why should you be worried about a patient taking haloperidol with a fever?
neuroleptic malignant syndrome, lethal side effect
What is the nurse practitioner’s role in short words
perform physical examinations/recommends diagnostic testing
what does a myelogram test?
lumbar puncture with injection of contrast medium. allows visualization of the vertebral canal.
Haloperidol
Indication schisophrenia, mania, aggressive and agitated
Action alters effect of dopamine
Class antipsychotic, butryrophenones
Nursing EPS, caution in QT prolongation. seizures, constipation, dry mouth, agranulosytosis. Assess for hallucinations, Monitor hemodynamics, monitor neurleptic malignant syndrome. CBC with differential
the lower the glascow coma scale indicates
coma.
Maneuver used to asses carpal tunnel syndrome
Phallen’s maneuver. Put the back of hand together and bend both wrists at the same time. Produces parathesia of median nerve
for a forensic inviestigation why should material NOT be placed in a plastic bag?
should be paper, b/c bacteria could destroy DNA evidence if plastic bags are used.
what assessment is MOST important post op knee surgery
neurovascular checks every hour for 12 hours, then every 2-4 hours. Surery may interrupt blood supply to affected extremity and immediate intervention is required.
Med of choice for status epilepticus
valium
The assesssment of flattened neck veins when client is in supine position, goes with what nursing diagnosis
decreased cardiac output related to decreased plasma volume
which method of administration offers the client the longest duration of medication action?
rectal administration
What is the cause of late decelerations
placental insufficiency
Pancrelipase
- *Indication** pancreatic insufficiency, ductal obstruction
- *Action** replacement of pancreatic enzymes: lipase, amylase, protease
- *Class** digestive agent
- *Nursing Considerations** contraindicated in pig products, SOB, rash, assess nutritional status, monitor for steatorrhea, increase uric acid levels, take with meals
What does the nurse need to do after a cast is applied
elevate for first 24-48 hours to minimize swelling.
what are the most life threatening conditions after a cesarean birth?
fluid and electroylte imbalances. Hemorrhage and shock.
Vasopressin
- *Indication** MGMT of diabetes insipidius, Vt/VF, unresponsibe to initial shock, GI hemorrhage
- *Action** increases water permeability of the kidney collecting duct and distal convoluted tubule elading to water retention, also increases peripheral vascular resistance leading to increased BP
- *Class** antidiuretic hormone
- *Nursing Considerations** caution with HF, and CV disease, contraindicated in renal failure, hypersensitivity to pork. Monitor vitals. Monitor urine specific gravity & osmolality. Weight pt and assess for edema. Monitor electrolyte panel. DO NOT USE alcohol
what disease is associatd with glaucoma
diabetes
What should be done if a physician yells at a nurse in front of a client
nurse manager should request an immediate private meeting with HCP and staff nurse
-terol
bronchodilator
Nystatin
- *Indication** Candidiasis (thrush)
- *Action** causes leakge of funcal cell contents
- *Class** antifungal
- *Nursing Considerations** diarrhea, N/V, caution with dentures, assess mucus membranes
What foods should a patient with diverticulitis avoid?
corn, seeds, cucumber, tomatoes, strawberries, figs. These may block diverticula
How long should a client wait before brushing teeth after hypophysectomy
1-2 weeks to allow incision to heal
What type of drug is ethacyrnic acid
loop diuretic (potassium wasting)
How is most pain relieved in orthopedics
elevation, cold packs and analgesics (toherwise something is WRONG)
a push pull toy is good for which age group
18-21 months
HELLP
- Hemolysis
- Elevated
- Liver Function Tests
- Low
- Platelet Count
what position is a client placed for liver biopsy
supine with right arm behind their head
Hallmark signs of emphysema
carrel chest, chronic cough, SOB, wheezing, Weight loss
Best practice for confirming NG tube?
aspirating gastric contents and testing pH (should be below 5)
What is an important intervention to take if you are delivering an IV push medication?
time the med administration with a watch
T wave indicates
ventricular repolarization
Fluticasone (Flovent)
Indication prophylactic asthma treatmt
Action local anti-inflammatory
Class corticosteroid, inhalation, anti-asthmatic
Nursing watch for untreated infectios and suppressed immune function. Can cause headaches, insomnia, bronchospasm, nasal congestion, adrenal suppression. Monitor respiratory status, may lead to decreased bone density. Bronchodilators should be used BEFORE corticosteroids. Stop smoking
dunlap traction is for
skeletal or skin
Montelukast
- *Indication** prevent asthma, manage seasonal allergies, prevent exercise induced bronchoconstriction
- *Action** disrupts the effects of leukotrienes which effect airway edema.
- Class** allergy, cold, cough remedis, bronchodilator. Leukotriene antagonist*
- *Nursing Considerations** assess respiratory status, liver function, does not treat acute asthma
if a client is incontinent w/ frequent UTIs, what is an important intervention
intermitten catheterization for any residual urine volume. Bladder may not empty completely.
Primary clients for C. Difficile
hospitalized, receiving antibiotic therapy- Ampicillin, amoxicillin and cephalosporins (Cephalexin)
what type of socks are recommended for diabetic patient with foot problemts
cotton to absorb moisture
First signs of cystic fibrosis
meconium ileus at birth. Baby is inconsolable, does not eat, not passing meconium.
A client is in the third month of her first pregnancy. During the interview, she tells a nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of these nursing interventions is best at this time?
counsel the woman to consent to HIV screening
10 year old cognitive capabilities
able to think logically in the organization of facts
Guthrie Test
tests PKU, baby should have eaten source of protein first
classic symptoms of guilland barre
respiratory failure, flaccid paralysis, urinary retention
what position for shock, and why not trendelenburg
Elevate lower extremetities, trendenleburg puts too much pressure on throacic cavity which can increase workload on the heart. Lower extremeities iimproves circulation to the brain and vital organs.
- Atrial Fibrillation
- Irregular
- Heart Rate 60
- PRI- n/A
- QRS Interval 0.04 -0.06
what should you expect with perforated bowel
lead to peritonitis, expect surgery
What can a UAP help with
- ADLs
- hygiene
- feeding
- ambulation
- NO nursing judgment
What is a major side effect of INH
peripheral neuropathy
Dexamethasone
Indication cerebral edema, assess for cushing’s dissease
Action suppress inflammation and normal immune response. Used in inflammatory states
Class antiasthmatics, corticosteroids,
Nursing watch liver, avoid in untreated infections, may cause CNS alteration, peptic ulcers, cushings, weight gin, osteoporosis, decrease wound healing, elevated blood sugars, watch lipid and cholesterol
If a patient has and SCI injury at C-5, what is his sexual functioning
sexual functioning may be possible, depends on severity of the injury, age of the client.
What is the symptothermal method
non prescription birth control. Combines cervical mucus and basal body temperature.
what happen is a patient has low serum albumin
third spacing.Pretibilal edema. Albumin prevents plasma from leaking into interstitial fluid
tidine
H2 blocker
Normal Newborn Blood Pressure
50-75
MI & dysrhythmias go together like peas and carrots.
Where can you find standard of care?
institutional policy and procedure documents
when you are obtaining an assessment of a client with a headache, what should be your FIRST assessment
get a description in clients own words of the headache. Usually a symptom and not a disease, can be a result of neurolgical disease, caused by vasodilation or skeletal muscle tension
what is the first symptom of fat embolism
extreme confusion. Obtain blood gases.
What is an emergency situation for a patient with bulimia nervosea
a hoarse vois that is barely audibly. Indicates tracheosophageal fistula. Tear, laryngitis is a danger sign.
Propolol
- *Indication** anaesthia, induction, sedation
- *Action** hypnotic, produces amnesia
- *Class** general anesthetic
- *Nursing Considerations** caution with CVD, lipid disorder, increased ICP, apnea bradycardai, hypotension. Burnign pain at insertion site. Can turn urine green, assess respiraotry status and hemodynamic. Maintain patent airway. Assess level of sedation
A pt with BPH has a distended bladder due to acute urinary retention. What should nurse understand about care of this client
tx includes catheterization (starting w. smallest catheter size). Complete and rapid emptying of the bladder. Bladder irrigation is performed.
when a client is wearing bilateral eye patches, what is a necessary action to take
frequently touch the client while speaking to him.her
The most common healthcare associated infection
caused by staff
adverse reactions to atropine that should be reported to HCP
transient arrhythmias & paradoxical bradycardia.
For a client that received TURP, what is the purpose of continuous bladder irrgation
enables urine to keep flowing and prevent clots
what is a risk factor if membranes have ruptures for more than 24 hours after birth
infection
antihistamine eyedrops side effects
headache, burnig, rhinitis, sinusitis, blurred visions, pruritus,
What is the most important interventions with burn management
fluid replacement, hypoxia is alwasy the priority, hyperkalemia
What could be indicative of peripheral vascular disease
legs throbbing when going for a walk. Requires follow-up
What position should you place a client after a tonsillectomy?
prone or side lying with bed elevated.
What is the rule for UAPs for documentation
they cannot document what they cannot assess
What is fetor
breaths smells like ammonia
Why do daytime activities help clients that are immobilized in bed
it causes them to nap less during the day and provides relief from tension so they can relax at night
What is the first sign of worsening asthma
a fall in peak flow rates. Feeling tired, sneezing, stomach ache, poor appeptite, night time cough.
Swanz Ganz Catheter or Pulmonary Artery Catheter does what?
inserted into the the right side of the heart thru the groin or neck using conscious sedation (at the bedside). can measure different pressures in the heart and lungs.
What is Kawasaki disease, and what is the demographic?
boys younger than 5 and asian descent. Red eyes (conjuctivitis), rash on the body and genital area, strawberry tongue. Red skin on palms of hands. Last 2-12 wks without treatment
what is considered a positive PPD test
5mm or greater induration
Common findings in mitral valve regurgitation include
heart murmurs, SOB, fatigue, Paroxysmal noctural dyspnea
Coumadin Antidote
Vitamin K
Glucagon
Indication severe hypoglycemia, antidote for beta blockers and calcium channel blockers
Action stimulates production of glucose, relaxes GI tract
Class pancreatic, hormone
Nursing anaphylaxis, hypotensionn. Assess for hypoglycemia, neuro status. Monitor serum glucose. Teach pt signs of hypoglycemia
What can immunoglobulin therapy interfere with?
body’s ability to form appropriate amts of antibodies. Live attenuated immunizations should be delayed.
Medication Antidotes
If a patient with MS is having exacerbations what position should they be in
prone. May minimize spasms of the flexor muscles. If not relieved, contractures could occur and pressure ulcers
what is your most important assessment with gloerulonephritis
blood pressure.
first sign of pyloric stenosis in a baby
mild vomiting that progesses to projectile vomiting.
Meperidine
- *Indication** moderate to severe pain, sedation
- *Action** binds to opiate receptors in the CNS and alters perception of pain, while producing a general depression of the CNS
- *Class** opioid Analgesic
- *Nursing Considerations** altered mentation, hypotension, constipation, N/V. Assess BP, pulse and respriatory rate. Use caution if matient is receiving MAOIs. Narca is the antidote. Can cause seizures. May increase pancreatic enzyme levels. Assess bowel function
If a client is showing early signs of shock, what position
lower head of bed, place client on left side, air rises to right atrium
Do calcium channel blocker effect preload or afterload
afterload
What is the pathogen of peptic ulcer disease
heliobacter pylori
What is important to know for all anti-infective drugs
decrease effectiveness of oral contraceptives
HCO3
22-27 mm Hg
How do you know there is a therapeutic response for patient with edema
weight loss
what are the proper procedures when a neonate is hooked to a warming device
Continuous temperature monitoring using a probe
priority due to skin burns, brain damage
Left CVA impacts
speech
How much water must pt drink prior to ultrasound of urinary bladder
32 ounces
What is the rule for a pancreatitis client
keep stomach empty and dry. Kee client NPO, have NGT to suction, bed rest!
Drugs that are ototocxic?
- Loop diuretics
- Aminoglycoside Antibx (Gent)
- Aspirin
What is the highest schedule drug, not used in a clinical setting
Schedule I.
Potassium
3.5 - 5.0 mEq/L
what does an elevated d-dimer test indicate following aprution of placenta
concern for DIC. Notify HCP right away.
how can you tell if an infant is in pain
- increased pulse rate
- rubbing part of the body and crying
- eyes closed tightly, mouth opened
murphy’s sign
pain with palpation of gall bladder seen with cholecystitis
what is the primary purpose to turn cough and deep breath?
promote ventilation, and prevent respiratory acidosis
The bubbling in a water seal chest tube chamber indicates
lung has not yet re-expanded
Metered Dose Inhaler
What type of communication technique is best for patient with Wernicke’s Aphasi
non verbals, actions, movements, props. Wernicke have no understanding of language. They can speak, but it makes no sense
What type of breathing occurs with metabolic acidosis
deep rapid respirations, hyperpnea
How do you know if pt has toxic effects of aminophylline?
confusion, headache, flushing, tachycardia, seizure, palpitations, nervousness. Notify HCP.
A child with burn is at risk for dehydration, what finding would indicate decrease in status
increased hematocrit and decrease in urine volume
Fentanyl (Sublimaze)
Indication supplement to general anethseia, continuous IV infusion for purpose of analgesia
Action binds to opiate receptors in the CNS altering perception of pain, producing CNS depression
Class opioid analgesic
Nursing watch for ICP, head trauma and adrenal insufficiency. Avoid MAOIs. Can cause apnea, laryngospasm, decreased respiration, bradycardia, hypotension. Do not consume grapfruit juice. Monitor hemodynamics. Assess pain scale
What are signs of strabismus?
seeing double, might close one eye to see.
What is wander band used for
a sensor bracelet allows patients to roam around (dementia pt) trips an alarm system if they decide to leave.
What does crepitus mean?
air in sub q space (usually due to pneumothorax)
Order of operation for instilling eye drops
- Have client sit down, tilt head
- Pull tissue under eye downward
- hold dropper stabilize hand
- have client look up
- Close eye and move it around
- Press on lacrimal duct for 1 full minute
Bicarb
22-29 mEq/L
What is a common complication of nephrotic syndrome
venous thrombosis
major side effects with statin drugs include
must get liver function test and eye exams (will have eye lens opacities)
do not think of blood pressure with this drug
What is a good handoff report technique
- Introduction (yourself)
- Patient name, identifiers,
- Assessment, chief complaint, Vital signs/sx, Dx
- Situation (code status, recent changes, response to tx)
- Safety concerns (lab values, socioeconomic factors, allergies, falls
- Background (comorbidities, currend meds, family hx
- Actions (what did you do)
- Timing (level of urgency and explicit timing, priotixation actions
- Ownerhip (who is responsible)
- Next (blocking discharge, plan)
If a client is hallucinatying, why is it important to ask what they voices are saying?
must assess the nature of command hallucinations
Venturi Mask
- Most accurate oxygen delivery system
- helpful for adminstering low, constant O2 for COPD patients
*
What happens to nitrogen balance in burns, infections, injuries, fever or starvation
negative nitrogen balance. Protein is the body’s only source of nitrogen. Must be balanced by excretion of urea wastes.
What are signs of hypertensive crisis due to ingesting tyramines
headache, nasuea, tachycardia, vomitting.
early signs of hypoxemia
- increased HR
- Resltessness
- Irritability
- Nasal flaring
- cyanosis is a late sign
concentric training
muscle tense while shortening
If nurse makes a medication error, what are the appropriate actions to take?
- Monitor vital signs
- notify HCP
- Document the administration
- Notify nurse manager
what is usually the cause of a bladder infection
e.coli, not r/t glomerulonephritis (streptococcus)
what teaching should be recommended for clients with low back pain?
avoid standing for long periods of time
Fetal Attitude
the relationship of the fetall body part to one another
Fire Rescue plan, what does PRC stand for
Protect clients, Report the Fire, Contain the Fire
Common symptoms of measles
koplik spots
CHAIN OF COMMAND
ALWAYS FOLLOW THIS!
Signs ofr meningitis
Kerniq/Brudinski
What should you be concerned if observed after giving chlordiazepoxie
blurred vision, drowsiness. Anti-anxiety drug.
other SE’s include constipation, slurred speech, anorexia, polyuria, pancytopena, administer meals ro with milk to decrease GI irritation
-dil-
Vasodilator
What are signs of infection in elderly patients?
tachycardia, tachypnea, and confusion (not fever)
Sign of a big risk factor after CABG
chest tube drainage suddenly stops. Hallmark sign of cardiac tamponade
According to Erickson’s Stages, when does a client develop trust
birth - 18 months of age
Bryant’s traction
children
Write down the complications you expect with regard to days after surgery (i.e. 24-48 hours, 72 hours)
If pt has latex allergy, what else do you want to assess?
bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestunuts, tomatoes, peaches
What are signs of toxicity with aspirin
tinnusitis, headache, hyperventilation, diarrhea, confusion, diaphoresis.
What is the action behind morphine for MI
decreases blood return to the right side, and decreases peripheral resistance. Decreases pre load and afterload. Causes vasodilation
Erikson Stages thru Teenager
- 0-18 months– Trust vs Mistrust
- 18-3 years– autonomy vs shame/doubt
- 3-5 years– initiative vs guilt (preschooler)
- 5-13 years– industry vs inferiority
- 13-21 years– identity vs role confusion
Cortisone
Indication adrenal insufficiency, Addison’s Disease
Action suppress inflammation and normal immune response. Adrenal glands exrete steroid, cortisol, blood sugars, metabolism of fat, protein and carbohydrates. decreasing bone formation
Class antiasthmatic, corticosteroids
Nursing watch liver, avoid untreated infections, CNS alteration, peptic ulcers, Cushings, Weight, gain, osteoporosis, decrease wound healing
Methylphenidate
(ritalin)
- *Indication** ADHD, narcolepsy
- *Action** improves attention span
- *Class** CNS stimulatn,
- *Nursing Considerations** sudden death, hypertension, plapitations, anorexia, hyperactivity, insomnia. decreased effects of warfarin and phenytoin. Do not use with MAOIs. Do not consume caffeniated beverages. Monitor for dependence
What does a Swan-Ganz catheter do?
indirectly measures the pressure in the ventricles. Meausures the pulmonary artery wedge pressure.
What intervention is needed for an infant after a cleft lip repair
arm restrains to rpevent rubbing suture line
What do you want from a non stress test
it to be reactive
Why is Z-Track administration utilized
because IM technique is too irritating to the Sub Q tissues.
What is a common misconception with hemophilia A
bleeding all the time
what does stable eschar do for skin care?
serves as body’s natural cover
Hep A Precautions
wear gown and gloves during client contact
White Blood Cell Count
4500-11,000 cells/mm3
BUN
8-25 mg/dL
Norepinephrine
- *Indication** tx of severe hypotension and shock
- *Action** increase BP and COutput by stimulating alpha-adrenergic receptors in the blood vessels, demonstrates minor beta activity
- *Class** vasopressor
- *Nursing Considerations** monitor bp every couple minutes, can result in rebound hypotension due to tissue ischemia, monitor EKG and CVP if possible. Instruct pt to report headaches, dizziness, and chest pain
how do you know a woman is in the transition phase of labor?
asks to go to the bathroom. Increases pelvic pressure intense desire to urinate
What are the next steps if child has diarrhea and dehyrdation has stopped?
once rehydration has occured, start to introduce usual diet.
Other than hypertension and mental health. What can beta blockers be used for?
essential tremors
What should you NOT do after amputation
do not elevate after 24 hours. May result in flexion contracture. Expose to air.
What is the priority for cardia dysrthythmias
decreased cardiac output
how far apart should intake and output be from eachother?
200-300ml
what is the MOST importatn to consider when a client is immobile?
skin integrity
In poison control when should you NOt induce vomiting
if contains alkaline or acid agents. I.E. lye, houseehold cleaners, oven cleaner, furniture polish, metal cleaners, battery acids, petroleum products
can neutralize using activated charcoal
Lorazepam
- *Indication** anxiety, sedation
- *Action** general CNS depression
- *Class** anesthetic, antianxiety, sedative hypnotic, bonzo
- *Nursing Considerations** caution with COPD and sleep apnea, avoid alcohol use, antidote is Flumazenil, may cause cardiac arrest, bradycardia, hypotension, administer slowly and dilute to decrease complications
- arone
ex: Amiodarone
antiarrhythmic
If a client has a blood glucose of 175 and reports being hungry and thirsty what should you do?
administer Humulin R- Insulin (short acting, regular). Will work in 30 mintues, pt should wait to eat breaskfost so insulin can begin working
What is the most widely accepted test to examine the presence of tardive dyskinesia
Abnormal involuntary movement scale
SATA questions, what do you need to pay attention to
once a week, daily, once a month
ensure that the timing is appropriate.
What should you do if there is lots of water in a tracheostomy tubing?
empty the fluid, pt at risk for aspriation.
Client with Irritable Bowel Syndrome is having problems with fiber, what should you do
- increase fiber gradually 2 - 3 mg per day, help to reduce gas and bloating
- Dairy products can contribute to gas formation
- small frequent meals to reduce gas
goal is to reduce gas and bloating
What drug is used for autonomic dysreflexia
hydrazaline, fast acting antihypertensive.
Airborne precuations
mask, gloves
Atrial Flutter
250-350 bpm
Prothrombin Time (PT)
9.5 - 11.8 seconds
How often should self breast exams be performed
monthly
What is the most important intervention when body iimage is a factor
touch
Proper actions to take if you administer incorrect dose of medication
- record the dose of med administered
- perform an assessment on the client
- contact the physcian
- chart any adverse reaction
- submit the report to risk manager within 24 hours
Quadrigeminy
PVC after 3 normal QRS
How do you protect against extravasation in vesicant drugs for cancer?
aspirate positive blood return prior to use
femoral pulse is located..
What does justice mean?
fairness
Diazepam
Indication anxiety, pre-op sedation, conscious sedation, tx of seixures, insomnia, mgmt of alcohol withdrawal
Action depress the CNS
Class benzodiazepine, antianxiety, anticonvulsant, skeletal muscle relaxant
Nursing ccontraindicated in hepatic dysfunction, wathc renal impairment, dizziness, drowsiness, lethargy, hypotension, physical dependence, tolerance, caution with alcohol use
What is the preferred site for ABG
radial. Apply firm pressure 5 min prior. Leave oxygen on. Sample should be cold on ice to minimize chemical reaction
What is the primary purpose of a transitional care program
reduce readmissions to the hosptial
Cefaclor
Indication tx of respiratory tract infections, skin infections, otitis media
Action bacteriacidal, binds to bacterial cell wall causing cell death
Class cephalosporin 2nd generation, anti-infective
Nursing contraindicated cephalosporin and penicillin allergies, may lead to seizures, pseudomembranous colitis, diarrhea, phlebitis at iv site, anaphalzis, assess infection and allergies, obtain cultures prior to therapy, monitor bowel function, can lead to super infection
what discomforts should be noted for a laparscopy exam
carbon dioxide is trapped in the abdomen and may cause shoulder pain
findings that indicate elder abuse
- over/undernourished,
- absence of needed dentures and glasses
- poor nutritional status
- dehydration
- urine burns
- excoriation
- pressure ulcers
- bruises
- battering (fractured hip can be osteoporosis)
How can you tell a patient is taking lithium
shaky hands
when does the potestorir fontanelle close?
6 to 8 weeks
what indicates cardiovascular fluid overload
rales and tachycardia
What is a milkwakee brace used for?
scoliosis 1-2 years, during periods of growth
What do insurance companies have a problem with when ordering supplies on discharge?
ordering extra suplies is considered stockpiling and they may refuse to pay the bill
what food should you avoid with chronic kidney disease
high potassium foods, risk for hyperkalemia
Common symptoms of cholera
rice watery stool
What is contraindicated for HEP B vaccine
anaphylactic rx to baker’s yeast
Classic findings of pulmonary stenosis
heaviy brathing, dyspnea, tachycardia, peripheral edema
Common symptoms of leprosy
lioning face
What is the most accurate procedure to rule out interstitial cystitis
cytoscopy procedure
VEAL CHOP
- Variable Cord Compression
- Early Head Compression
- Accelerations Okay
- Late Placental Insufficiency
Nursing Consideration with Fentanyl patch
- slowly absorped thru sub Q tissue, can take up to 12-24 hours before effective analgesia
- short acting opioid can be given for breathrough pain
- the pt can shower/bathe, but should not be exposed to hot tubs or heating pads. Speeds absorption of medication
- throw them away but folding in half, not by cutting in half
Amiodarone
- *Indication** ventricular arrthythmias, SVT, ACLS V-fib, Vtach
- *Action** prolongs action potential, inhibits adrenergic stimulation, decreases peripheral vascular resistance causing vasodilation
- *Class** Antiarrthymic Class III, Potassium channel blocker
- *Nursing Considerations** can cause ARDS, pulmonary toxicity, CHF, bradycardia, hypotension, increases dig levels, increases activity of warfarin, 2 RN check, monitor pulse daily and pt report abnormaility, avoid drinking grapefruit juice
Meniere’s syndrome makes client dizzy what intervention should nurse ensure
do not turn head
cullen’s sign
ecchymosis in umbilical area, seen with pancreatitis
Ketorolac (Toradol)
- *Indication** pain
- *Action** pain relif due to prostaglandin inhibition
- *Class** nonsteroidal antiinflammatory agent, non-opioid analgesics, pyrroziline carboxylic acid
- *Nursing Considerations** Steven Johnson Syndrome, anaphylaxis, drosiness, GI bleed, should not exceed 5 days of tx, increased bleeding risk with garlic, ginger and ginkgo, decrease HTN meds and diuretics
Olanzapine
- *Indication** schizophrenia, mania, depression, anorexia nervosa, N/V, r/t chemo
- *Action** antagonizes dopamine and serotnin
- *Class** antipsychotic, mood stabiilizer, thienbenzodiazioines
- *Nursing Considerations** do not use while breastfeeding, neurlyptic malignant syndrome, seizures, suicidial thoughts, inosmonia, tardive dyskinesia, aggranulocytosis, constipation, tremors, assess mental status, hemodynamics, Blood sugars, intake and output. liver function tests
When should you do an allen’s test?
prior to doing an abg to check for sufficient blood flow
negative test if color return in less than 7 seconds
Chancres, flu-like symptoms, hair loss, palmar rash signs of
syphyillis
Insulin (Short Acting)
- *Indication** hyperglycemia with diabetes type 1 and type 2, ketoacidosis
- *Action** stimulates uptake of glucose into muscle and fat cells, inhibits production of glucose in the livere, prevents breakdown of fat and protien
- IV onset 1-2 hr, Peak 4-12 hr*
- *Class** lpancreatics, antidiabetics
- *Nursing Considerations** monitor body weight over time, may cause decreased inorganic phsophates, potassium and mag. Monitor B/S Q6, monitor A1C every 3-6 months
Responsibilities of UAP
- No scope of practice
- Non-invasive and non-sterile treatments
- bathing, transferring, ambulating, feeding, toileting, Vital signs
when is a very low calorie diet acceptable
an obese client (BMI greater than 30). Need professional monitoring.
What type of diet does a patient with preeclampsia need?
protein. Lie on the left side, adequite fluids. Protein restores osmotic pressure
What is the mneomonic for a client with celiacs
- Barley
- Rye
- Oats
- Wheat
What is BUN
Blood Urea Nitrogen. How much concentration, if highly concentration, kidneys are not functioning properly
Situations where Promethazine would be prescribed.
- going on a cruise
- preoperative sedation or surgery
- enhancing pain med after surgery due to sedation
anti-emetic, drowsiness
If a mother is RH negative and rbeastfeeding exclusively, what is a concern
hyperbilirubemia
How much radiation in mammography is it equivalent to?
one hour of sun exposure
what drugs are used for gout
colchicine, allopurinol, probenecid
how often should trach be cleaned
every 4 hours
S2 Auscultation
- closing of the aortic valve
- after short systolic pause, before long diastolic pause
- heard best over aorta, secon right interspace
- high pitched dull in quality
Hydralazine
Indication Hypertension
Action arterial vasodilator
Class anti hypertensive, vasodilator
Nursing tachycardia, sodium retention, dysrthymias, angina. Use caution with MAOIs. Monitor BP. Instruct pt on how to take BP
What are minors known as if they are married
emancipated minors through marriage, pregnancy, high school graduation, independet living or service in the military (have the legal capacity of an adult)
Sucralfate
- *Indication** GI ulcers, GI injury prevention form high dose aspirin, NSAID tx
- *Action** reacts with gastric acid to form a paste that dheres to ulcer
- *Class** antiulcer, GI protectant
- *Nursing Considerations** caution in renal failure, concurrent use of antacids may decrease the effect of sucralfate. Administer 30 min before or after. Adminsiter on empty stomch 1 hour before meals
Signs Symptoms of Buerger’s disease
vasculitis of blood vessels in upper and lower extremities. Digital sensitivity to cold
principle of safe assignments of nurse has never done a procedure before
change the assignment. Match the skills with the tasks.
CNS infection examples
meningiits, encephalitis
Oxytocin
- *Indication** labor induction, postpartum bleeding
- *Action** stimulates uterine smooth muscle
- *Class** hormone, oxytocics
- *Nursing Considerations** ICH in fetus, asphyxia in fetus, may cause coma and seizures in mother. Monitor blood pressure, assess maternal electrolytes. Uterine Tetany
what drug is given for myesthenia gravis
neostigmine. before eating will hep with chewing and swallowing.
What is a problem an infant could have if mother has diabetes?
hypoglycemia due to increased output of insulin
Terbutaline
- *Indication** asthma, COPD, preterm leabor
- *Action** prdouces bronchodilation
- *Nursing Considerations** nervousness, restlessness, tremors, assess respiratory status. monitor for hypoglycemia, may cause decreased potassium level.
Common symptoms of pneumonia
rusty sputum
Care after myelogram
- drink lots of clear liquids
- remain in bed for 8 hours, slightly elevated
- resume regular diet and meds
- avoid alcohol for 24 hours
- no strenuous activity for 48 hours.
What procedures should be implemented following a broncoscopy
semi-fowlers position, vitals q15. assess respiratory difficulty
What do you need to know about DIC
always secondary to something else
What is the maximum dose of IM injection for infants and toddlers
1mL
CABs in CPR stand for
compressions, airway, breathing
Trimethroprim/Sulfamethoxazole
- *Indication** bronchitis, UTI, diarrhea, pneumonia, multiple types of infection
- *Action** bacteriacidal by preventing metabolism of folic acid
- *Class** folat antagonist, antiinfective, antiprotozoal
- *Nursing Considerations** renal damage, steven johnson syndrome, agranulocytosis, aplastic anemia, phlebitis, drink 8-10 glasses of water
When you see coffee brown emesis what should you think
peptic ulcer
What is buck’s traction used for
to immobilize, position and align the lower extremity.
5-7 lbs is recommended for skin traction
Primary Nursing
- Primary nurse designs, implements and is accountable for nursing care of clients during entire stay on the unit
- continuity of care, not feasible with varying schedules
- greater nurse satisfaction, more personalized care, less turn over
- fewer negative outcomes for patients
Carbamazepine
Indication seizure, DM neruopathy, pain associated with trigeminal neuralgia
Action affects sodium channels in neurons leading to decreased synaptic transmission
Class anticonvulsant
Nursing interferes with oral contraceptives, do not use with MAOIs, suicidal thoughts, Steven Johnson syndrom, agranylocytosis, aplastic anemia, thrombocytopenia, No grapefruit juice, monitor CBC and platelets, monitor blood levels
What is penatmidine isethoionate used for and how do you know if it is affective?
prevent pneumocystitis, (AIDS), drug should decrease crackles and dyspnea.
What is the normal range for prothrombin time?
What is the normal range for Warfarin
10-14 seconds
20-28 seconds
Symptoms of Myasthenia Gravis
- muscle weakness that improves with rest
- ptosis- drooping eyelids
- impaired speech
- dysphagia
- double vision (diplopia)
Findings of Endocarditis
- Red spots on palms/soles (Janeway lesions)
- Red painful sores on fingetips and tes (Osler’s Nodes)
- fever, night sweats muscle aches.
Feeding an infant with a cleft lip
rubber tip syringe, prevent sucking on the tubing, Tend to swallow excessive amounts of air, require frequent bubbling.
Verapamil
- *Indication**hypertension, angina, SVT, migrain
- *Action** prevents tranport of calcium, leading to decreased contraction, decreases SA and AV node conduction
- *Class** antianginal, antiarrthymic, antihtn, vascular headache. CA blocker
- *Nursing Considerations** dont use with 2nd 3rd degree block. can cause anxiety, confusion, cough, dypsnea, CHF, bradycardia, hypotension, elevated liver enzymes, Steven’s Johnson sydrome. Hyperglycemia, gingival hyperplasia. grapefruit can increase effects. Can increase levels of diozin. assess angina.
pregnancy and type 1 insulin requirements
increase during pregnancy and decrease after delivery
Magnesium Sulfate
- *Indication** HTN, hypomagnesameia, preterm labor, torsade de pointes, asthma, anticonvulant with eclampsia
- *Action** magnesium plays a role in muscle excitability
- *Class** mineral/electrolytes
- *Nursing Considerations** caution with renal insufficiency, decreased respiratory rate, dysrthymias, hypotension, muscle weakness. Monitor EKG and repsiratory status. Monitor Mg levels. 2 practictioner check
Nursing considerattions with Vincristin (Oncovin)
- Used for ALL (Acute Lymphocytic Leukemia)
- IV use only
- Intrathetcal admin can be fatal
- Vesicant can cause local damage if extravasation occurs
- Tx includes warm compresses
- Peripheral neuropathy is a major side effect
- monitor for decreased hepatic functining b/c gets metabolized in the liver
Activity Lifestyle changes after MI
decrease physical activites. Need Cardiac Rehab
which is worse, inhaling a chemical or swallowing it?
inhaling. Immediate absorption and can impair oxygen exchange
what std is reportable
Gonorrhea
What is most valuable tool for school aged children and physical assessment
weight and heigh compared to standard tables
Cold vs Hot for pain
Cold for acute pain, heat for chornic pain (RA)
Why would a patient with hypertension have increased renin levels
increases serum aldosterone levels, increasing kidney reabsroption of soidum and water. Increases blood pressure
where are eye drops placed for a child?
in the conjuctival sac as the lower lid is pulled down
Foods to avoid if low WBCs
raw fruits and vegetables, undercooked meats, moldy cheeses, luch meat, salads things from the deli counter, brewed teas.
What needs to happen to prep a client for iv pyelogram
- clean out gi tract
- NPO 8-12 hours
- administer laxative the evening before
- enema morning of the test
Precautions to take with RSV
no contact lenses or pregnant nurses in rooms where ribavirin is being administered by hood, tent, etc.
What is a major side effect of terbutaline when used for women in labor?
tachycardia, withhold the medication. Fetus may have tachycardia and hypoglycemia. Minimal effects aon blood pressure thought.
Dobutamine
Indication short term mgmt of heart failure
Action positive inotropic effects, little effect on heart rate. Stimulates beta receptors in the heart
Class inotropic, adrenergic
Nursing hemodynapics, hypertension, increase HR, PVCs, skin reactions, beta blockers may negate therapeutic effects, montior CO, watch peripheral pulses, do not confuse with dopamine
What type of breathing occurs with pneumothorax?
rapid respirations/ tachypnea
Procedure for neutropenic precautions
- PPE
- private room
- visitor restriction
- no raw vegetable or fruits
- bathe daily
Heberden’s nodes are characteristic of
osteoarthritis nodules. Strongly inherited.
Metoclopramide
(Reglan)
- *Indication** prevention of N/V hiccups, migrains, gastric stasis
- *Action accelerates gastric emptying by stimulating motility**
- *Class** anti-emetic
- *Nursing Considerations** do not use with GI obstruction. Can cay extrapyramidal reaction, Neurolyptic malignant syndrome, Tardive dyskinesia, dysrithymias, BP alterations, hematologic alteration, facila movements, sedation. Can decrease effects of levodopa. Monitor liver function
-perone
antianxiety agent
Demerol contraindication
sickle cell crisis
Indications of Intenstinal obstruction
abdominal distention, chills fever (toxic megacolon), fitula formation
What are the 3 Ps of hyperglycemia?
Polyuria, polydipsia, polyphasia
he client is informed that the ultrasound suggests the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. What causes this change?
maternal hypertension. Common cause of late pregnancy fetal growth restriction. Vasoconstriction reduces placental exchange of oxygen and nutrients.
Why is it important for a patient with an acute episode of pancreatitis to maintain bedrest
decreases the metabolic rate and the secretion of pancreatic enzymes; bathroom priveledges are not allowed.
by 6 months of age, what are the immunizations a child will have received?
- 3 doses of diptheria
- tetanus
- pertussis
Heparin
Indication venous trhomboembolism, prophylaxis and tx. Low dose used to ensure patency of IV catheters
Action increases the inhibitory effect of antithrombin on factor Xa
Class anticoagulant, antithrombotic
Nursing monitor signs of bleeding, platelet count, hyperkalemia, pt report signs of bleeding
liver biopsy prep
administer vit k, npo 6-12 before. Teach pt will need to hold breath for 5-10 secs, supine position, lateral with upper arms elevated. Post- position on rt side, frequent vs. Report severe ab pain stat. No heavy lifting for 1 wk
Guaifenesin (Robitussin)
Indication cough suppression
Action decreases viscosity of and mobilizes secretions
Class allergy, cold, cough remedy, expectorant
Nursing avoid OTC meds, assess lung sounds. Adequate fluid intake
Amoxicillin
- *Indication** skin ifections, respiratory infections, sinusitis, endocarditis prophylaxis, lime disease
- *Action** linhibits synthesis of bacterial cell wall leadting to cell death
- *Class** antiinfective, antiulcer, aminopenicillins
- *Nursing Considerations** contraindicated w/ penicillin allergy, seizures, rash anaphylaxis, excreted by kidneys-monitor renal albs, monitor pt for diarrhea, bloddy stool should be reported immediately
-cef
cephlosporin
When is handwashing a requirement?
- prior to eating
- after cleaning a wound
- after contact with inanimate object
- before having direct contact with a client
- C.Diff/soiled hands
what is a complication of impetigo
poststreptococcal glomerulonephritis, watch for periorbital edema.
Which adverse affect of ACE inhibitors need to be reported to the HCP
persistent cough, common reason to change to another medication.
(accumulation of bradykinin)
When does a pregnant women need to increase insulin dosage
during first 3 months of pregnancy
What medication is the only FDA approved med to treat PTSD
SSRIs
russells traction is for
femur or lower leg
What symptom from a diabetic patient should be reported immediately?
profusion perspiration, sx of hypoglycemia. (numbness and tingling are expected findings)
What is the reasoning of why an OCD patient performs rituals
to avoid severe levels of anxiety
what is a controversial seizure precaution
padded side railes, may embarras the client and family.
What are you worried about with neuroleptic malignant syndrome
very high temperature
What type of diet does a patient with chronic kidney disease need?
increase pasta and bready. Helps maintain energy requirements
Risk factors for CT scan with contrast
- history of asthma
- positive pregnancy
- Poor renal function
- Beta blockers
- heart, kidney, thyroid disease
What hormone causes a womens period to stop
progesterone
Epinephrine
Indication adrenalin, asthma, COPD exacerbations, allergic, cardiac arrest, anesthesia adjunct
Action both beta 1 and beta 2, alpha agonist properties. Bronchodilation, increases HR and BP
Class antiasthmatic, bronchodilator, vasopressor, adrenergic
Nursing angina, tachycardia, hytpertension, restlessness, nervouseness, hyperglycemia, MAOIs can lead to hypertensive crisis, do not use stimulants, hemodynamics, chest pain, adequate fluid intake, rinse after inhalation, beta blockers negate effects, increased blood sugar
Priority action for pt with preeclmapsia
have the client turn to the left side
What is the antidote for metformin
acetylcestein (24-48 hrs after contrast)
characteristics of hyperkalemia
muscle cramps, bradycardia, v,fib
What is important to note when planning debridement of a deep partilal thickness burn
need adequate time and emotional support
Warfarin
- *Indication** venous thrombosis, pumonary embolism, afib, myocardial infarction
- *Action** disrupts liver synthesis of Vitamin K dependent clotting
- *Class** anticoagulatn, coumarins
- *Nursing Considerations** contraindicated with bleeding, severe hypertension. Azole and anitfungals increase effects. Obtain full hx of supplements and herbsl. Large amounts of Vit K may antagonize effects of warfarin. Therapeutic level PT 1.3-1.5, INR 2.5-3.5/ No alcohol. Monitor bleeding times
-itis is always associated with
fever, inflammation, infection
Captopril
Indication hypertension
Action block angiotensin I to angiotensin II, Increases renin levels and decreases aldosterone. Vasodilation
Class ACE inhibitor, antihtn
Nursing neurtopenia, watch potassium, watch diuretics, 1 hr before meals, watch weight and fluid status, renal profile, monitor CBC
Proper technique for administering TPN thru Central Line
- Confirm the order
- check solution for cloudiness
- select and flusht the correct tubing and filter
- Thread IV tubing thru infusion pup
- use aseptic technique for handling injection cap
- connect to central line
- Set infusion pump at prescribed rate.
Med of choice for SVT
adenosine or adenocard
Butorphanol
Indication severe pain, labor pain, sedation
Action alters perception and response to pain by biding to opiate receptors in the CNS
Class opioid analgesic, agonists
Nursing caution with MAOIs, may cause confusion, hallucination, sedation, Monitor CNS depression, assess BP, pulse and respirations, aminister slowly through IV line
What should clients expect after transurethral resection of the prostate
3 way indwelling has a large diamtere, will continuously feel the urge to void for 24-48 hours
What does unstable chronic angina indicate
impending heart attack
Common symptoms of asthma
wheezon on expiration
How is anthrax spread
contact with infected animal hair and hides
standard precautions
Contact Precautions Mrs. WEE
- Multidrug resistant organism
- respiratory infections
- skin infections
- wound infection
- entereic infetion- c.diff
- eye infection- conjuctivitis
What could be a cause at home for a child to have an astma attack
new pillow
Drugs that alter electrolytes
- diuretics
- Thiazides- hold on to Ca & Uric Acid
- ACE- hyperkalemia
- Steroids- hypokalemia
Characterstics of hyponatremia
Nausea, confusion, muscle twitching, ICP, muscle cramps
When should you withold a calcium channel block (-dipine)
bradycardia
other than clearing the bowels, what else does IVP require
radiopaque dye, allergy to iodine can be life threatening
Fetal Lie
the relationship between the head to tailbone axis for both the fetus and the mother
Where is pain in diverticulitis
Left Lower Quadrant
Mannitol
- *Indication** increased ICP, oliguric renal failure, edema introcular pressure
- *Action** reeabsorption of water and electrolytes by increasing osmotic pressure excreted by the kidneys
- *Nursing Considerations** phlebitis at IV site. Dehydration, F/E imbalance. Monitor neuro status
How might restrains without consent or sufficient justification be interpreted?
false imprisonment
When is a child ready for toilet training
when myelinationf of the spinal cord is completed this is when voluntary control of sphincter muscles occurs. (between 18 and 24 months). Child has to be walking without holdingo n.
What will a patient experience with placenta previa
painless vaginal bleeding (painful bleeding indicated abruptio placenta)
Procedure for dressing change of burn
- administer morphine
- debride the wound of eschar using gauze
- obtain wound cultures
- apply silvadene ointment
- cover wound with sterile gauze dressing
In a math equation requiring dilution factor, what should you watch for as potential trick
don’t get confused by the quantitiy of diluent. only the final concentration directs your answer
what does percocet have with it?
oxycodone with acetaminophen
Infant milestones
Name an example of a hypotonic solution
0.45% sodium chloride
LPN/LVN and blood
cannot handle
Common cause of aortic stenosis
aging heart, or rheumatic fever
- Atrial Flutter
- Regular Rate
- QRS 0.06
Infectious Diseaseas that are droplet
rubella, meningitis
why should metformin be taken with meals?
to reduce side effects such as N/V, anorexia, ab cramps, fatigue.
What is a contraindication for receiving influenza vaccine
allergy to egg proteins b/c grown on egg embryos
precautions with a fistula
never take blood pressure or draw blood from arm with fistula
Fetal adaptions during labor
- engagement
- descent
- flexion
- internal rotation
- extension
- external rotation
- expulsion
What is lateral communication
between staff members i.e. coordinate activities
What can cause false positive result on fecal occult test
- eating red meat
- NSAIDS
- steroid use
- bleeding gums
Cardiopa/Levodopa
Indication parkinson’s disease
Action levodopa converts to dopamine and works as a neurotransmitter and carbidopa prevents destruction of levodopa
Class dopamine agonist, antiparkinson agent
Nursing orthostatic hypotension, dark urine, takes weeks to effect, no MAOIs, no with glaucoma/melanoma
Indomethacin
Indication inflammaotry disorders when pts do not respond to other meds.
Action decrease pain and inflammation by inhibiting prostaglandin synthesis
Class antirheumatic, ductus arteriosis patency, nonsteroidal antiinflammatory agent
Nursing monitor hepatitis and GI bleed, dizziness, drowsiness and headache. Assess for anaphylactic reaction. Aspirin may decrease effectiveness. Monitor renal labs. Shake supension before administration. Pt should wear sunscreen and protective clothing to protect against photosensitivity.
What is a major side effect to be noted with mag
decreased urine output, oliguria
What is the ONLY insulin that can be given IV push
short acting
Purpose of a tracheostomy
- when patient is unable to maintain airway
- unable to cough productively
- Permits Use of Positive Pressure Ventilation
- Prevents aspiration of secretions in unconcsious/paralyzed
Calcium Acetate
Indication hypocalcemia, menopausal osteoporosis, hypokalemia,
Action maintains cell membranes, muscle contraction, nerve impulses, blood formation and coagulation
Class antacids, minerl/electrolyte replacement
Nursing cardiac arrest and arrhythmias, phlebitis at insertion, hypotension, bradycardia, hypercalcemia, dig toxicity, watch parathyroid hormone
Alendronate
- *Indication** osteoporosis
- *Action** linhibits osteoclast activity leading to inhibition of resorption of bone
- *Class** bone resorption inhibitor, biphophnates
- *Nursing Considerations** take first thing in the morning w/ water 30 min prior to eating, assess calcium, may cause muscle pain
What is Creatinine
by product of muscle breakdown. our body tries to filter this out.
Why might you not put liquid medication down a gastrostomy tube?
may contain sorbitol. If client has an allrgy can cause diarrhea.
What are contraindications for a halo crown
skull fractures, chest trauma, obesity and avadanced age
on the nclex what is important to watch for if client has COPD or emphysema?
Should NOT increase oxygen.
primary goal of managed care is to..
reduce health care costs
Bubbling in a suction control chamber vs bubbling in water seal chamber?
Suction control bubbling is expected
Water seal, indicates air leak
notify HCP if draining is more than 100mL/hr
Common side effects of sulfonamides?
Urticaria/Rash
What is an example of behavioral therapy
using positive and negative reinforcement. Assertiveness trainsing and desensitiization.
good for phobias, sexual dysfunction, eating disorders, etc.
What is always an intervention when puncturing the spine
need fluids
Losartan (Cozaar)
- *Indication** HTN, DM neuropathy, CHF
- *Action** inhibits vasoconstrictive properties of angiotensin II
- *Class** angiotensin I receptor antagonist
- *Nursing Considerations** hypotension, tachycardia, angioedema, hyperkalemia. May increase digoxin levels. Asses BP and Heart rate. Assess fluids. Monitor dail weights with CHF. Monitor renal and liver.
PO2
80-100%
Diphemhydramine (Benadryl)
Indication allergy, anaphylaxis, sedation, motion sickness, antitussive
Action antagonizes effects of histamine, CNS depression
Class allergy, cold and cough, antihistamine, antitussive
Nursing drowsiness, anorexia, dry mouth, nausea, chest tightness, thick secreations, hypotension, blurred vision, headache, anticholinergic effects, monitor cough and lung sounds, avoid otc meds.
Trasmission based precaution for C.diff
contact precautions
Glipizide
Indication type 2 diabetes mellitus
Action stimulate release and sensitivity to insulin to lower blood glucose
Class anti-diabetic, sulfonylureas
Nursing aplastic anemias, hypoglycemia, photosensitivity, dizziness, drowiness, headache, diarrhea. Monitor CBC, assess for allergy to sulfonamides. Beta blockers may creat signs of hypoglycemia. Instruct patient on how to check blood sugars. Carry source of sugar in case of hypoglycemia
What are signs of ectoptic pregnanct
unilateral, dull abodminal pain
- Aystole
Major serious symptom of ectopic pregnancy
left lower quadrant pain
Hydrochlorothiazide
Indication hypertension, CHF, renal dysfunction, Cirrhosis, glucocorticoid therapy
Action selectively inhibits reuptake serotonin
Class anti hypertensive, diuretics, thiazide diuretic
Nursing dizziness, hypokalemia, hyponatremia, hypophosphatemia, hypomagnesemia, dehydration. hypokalemai can increase risk for dig toxicity. Monitor BP and I/Os. Monitor electrolyte levels. Take same time each day. How to take BP.
how should pain med be administered for a cancer patient with chronic pain
around the clock is more affective with cancer
What is an issue with infants who have a diabetic mother?
congential anomalies
What is the leading cause of skin breakdown?
decrease in tissue perfusion
Things the nurse CANNOT delegate
- assessment
- evaluation of client date
- nursing judgment
- teaching and evaluation
- nursing dx, or care planning
- admission/discharge
in a psychiatric unit, which client should you see first typically
auditory hallucination, make sure they are not telling the lcient o harm self or others
RACE stands for
Rescue, Alarm, Confine, Evacuate
What could a patient who is 27 weeks gestation with vaginal bleeding during intercourse.
could mean lots of things. could be placenta previa– more serious.
For a patient who is receiving chemotherapy, which laboratory result is of particular importance?
WBC, b/c chemo can decrease wbcs (neutropenia). Leaves the patient vulnerable to infection.
How can you tell the difference between Cerbro Spinal Fluid and other drainage?
Halo test, CSF will be + for glucose. When present there will be a halo around the blood spot
Med of choice for Vtach?
lidocaine
what pelvic inflammatory disease is frequently caused by what infectious disease
chlamydia and gonorrhea
Renal Encephalopathy signs pt with hemodlialysis
confusion irritability, elevated BUN and Creatnine
Gross Motor Skills
2-3 years
- balance on one foot for 3 seconds
- catch a ball
- pedals tricycle
when does discharge planning start?
upon admission
what is the most practical way to communicate with a patient that has a trach
yes/no question (nod, shake)
What is very important with pateitns with sickle cell disease
hydration and anlagesics
What is the most serious complication following gastric bypass surgery (bariatric surgery)
anastomotic leak. Monitor for back, shoulder, abdominal pain, restlessness, unexplained tachycardia, oliguria. Immediately report to surgeon. Do not manipulate NG tube. Elevate HOB.
what toxin needs to be monitored when giving nitroprusside
metabolism involved the production of cyanide.
Amitryptiline
- *Indication** depression, anxiety, insomnia
- *Action** increases effect of serotonin and norepinephrine in the CNS, exhibits antichoinergic effects
- *Class** Antidepressant, tricyclic
- *Nursing Considerations** contraindicated in MI, heart failure, glaucoma, risk for suicidal ideation, arrthythmias, hypotension EKG, alter BG levels, lethargy, do not use with MAOIs, take exactly as instructed, orthostatic hypotension, photosensitivity, may turn urine blue/green
How do you relieve flatus from a patient with an ostomy pouch
open the bottom of the pouch in privacy will cause odor.
Fluoxetine (Prozac)
Indication depressive disorder, PCD, bulimia, panic, bipolar, ADHD, DM neuropathy, obesity
Action inhibits reuptake of serotonin,
Class antidepressant, SSRI
Nursing contraindicated wtih MAOI, citallrpan use, may cause suididal thoughts, insomnia, diarrhea, nausea, serotonin syndrome, QT prolongation, monitor nutrition, good oral hygiene. 4-6 weeks for full affect to take place
Right CVA affects
impulsive behavior
What is the safe action for removing an NG tube
ask the client to hold breath until tube is completely out. Closes the epiglottis and helps prevent aspiration. When inserting it is easier of the pt swallows.
What is a major side effect of antineoplastic drugs
ototoxciity
Ranitidine
- *Indication** duodenal ulcers, GERD, heartburn esophagitis, GI bleed
- *Action** inhibits action of histamine in gastric pareital cells, decreases gastric acid secretion
- *Class** antiulcer agent, H2 blocker
- *Nursing Considerations** dysrthmias, agranulocytosis, aplastic anemia, confusion. Ab pain, monitor for blood in stool. monitor CBC
Digoxin
Indication CHF, Afib, Aflutter
Action ipositive inotropic effect, increases force of Myocardial contraction, prolongs refractiory period, decrease conduction through SA and AV nodes. Increases CO and slow Rate
Class antiarrhythmic, inotropics, digitalis glycosides
Nursing contraindicated with uncontrolled ventricular arrhthmias, hypokalemia increase risk for toxicity, hypercalcemia increase risk for toxic, caution with diuretic, watch for bradycardia, toxciity= vision changes, yellow green vision, montior pulse rate for 1 full minute
Interventions for patient with flail chest
- paradoxical respirations
- monitor vital signs for shock
- (Pler-evac is for pneumothorax)
- Very painful, need pain meds
- Turn Cough Deep Breath, lung expansion
- Monitor ABGs
- No need for surgery
eccentric training
muscle tenses while lengthening
Where my patient report pain if they have pancreatitis?
sharp pain in the epigastric area, above the belly button. Pt might report upper back pain, nurse needs to assess correct location regardless of how the client identifies it verbally.
Abnormal vital sigs and taking fish oil garlic and naproxen
all thos medication increase risk for bleeding. check color of bowel, bruising, frequency of medication use
arrett’s esophagus is a complication of this condition
GERD
if a client denies pain after surgery, how do you validate their pain
uses the faces pain scale. another assessment besides 1-10
If you notice a mass in the umbilica area, which assessment should you NOT perform?
palpate/percuss b/c risk of rupture. Auscultate, bruit would confirm an aneurysm
PPE for Contact Precautions
Gown, Gloves
Digoxin antidote
digiband
Contraindications for IPV (Inactivated polio vaccine)
anaphylactic rx to neomycin, streptomycin or polymyxin B
Even HIV are eligible for this
Phenazopyridine
- *Indication** urological pain
- *Action** analgesia to Urinary tract mucosa
- *Class** non opioid analgesic
- *Nursing Considerations** urine will turn red orange. headache, vertigo, heaptic toxicity, monitor renal function
What does an elevated ST segment mean?
client is having a heart attack. Get them to the cath lab for PCI in less than 90 minutes
worry about this client
What is the term when a nurse causes unintended harm to a patient?
Negligence
What is the most accurate way of determining proper NG tube placement?
measure hte pH of aspirated gastric contents
Spironolactone
- *Indication** potassium loss, hypertension, edema CHF
- *Action** inhibits sodium reabsorption while sparing potassium and hydrogen
- *Class** diuretic
- *Nursing Considerations** contraindicated with hyperkalemia, monitor I/O, BP, potassium and renal panel
deep partial thickness burns think
blisters are present
red, edema, pain!
Ferrous Sulfate
Indication prevention of iron deficiency anemia
Action iron is needed for hemoglobin, myoglobin and enzymes. It is transported to organs where it becomes part of iron stores
Class anti-anemic, iron supplement
Nursing seizures, hypotension, constipation, epigastric pain, diarrhea, skin staining, anaphylaxis. Asses nutrtional status, bowel function. Monitor hemoglobin, hematocrin. May cause eleved liver enzymes. Should take on an empty stomach to increase absorptio (vit c helps). Use z-track for IM injections.
anticoagulants/narcotics and LPNs
can be administered to stabled clients. But these are HIGH alert medications that should be given by RN to unstable client.
Gabapentine
Indication seizures, peripheral neuropathy, neuropathic pain, prevention of migraines
Action exact method of action is unknown
Class anticonvulsant, mood stabilizer
Nursing suicidal thoughts, confusion, depression, drowsiness, ataxia, facial edema, HTN. Monitor pt closely for changes in behavior and dpression. Asses seizure activity, pain. Take as prescribed
Client with a VTE should be on bed rest because
prevent pulmonary embolism. elevate legs, apply warm moist packs, monitor perippheral pulses, administer anticoagulants.
1 tblsp - how many mls
15 mls
Hallmark Signs of Severe Acute Respiratory Distress Syndrome
cough, difficulty breathing, fatigue, fever > 100.4, headache, myalgia.
compressions per breath for a 5 year old
same as adult 30/2
What is the main cause of glomerulonephriits?
strep. Treat my getting rid of strep
if you see the word immobilize 95% of the time think…
turn 2 hours, skin breakdown!
if a patient takes prednisone for adrenal insufficiency before surgery. What should you modify for the surgery
increase the dosae, because surgery increases the demand. Monitor vs, check for infection and bleeding
Right Sided Heart Failure
- dependent edema
- distended neck veins
- weight gain
Nursing Considerations regarding colestipol
antilipemic agent. Need Fat Soluble vitamins. Used for high cholestorerl and treat digitalis toxicity, biliary obstruction.
cause of GERD, location
lower esophageal sphincter.
What is the best indicator of dehydration
weight
What is the best indicator of an alcohol problem in a patient
tremors, elevated temp, nocturnal leg cramps, complaints of pain
Hydrocodone/Acetominiphen (Norco)
Indication moderate to severe pain
Action alters perception and reaction to pain by binding to opiate receptors in the CNS. Suppresses the cough reflex.
Class opioid analgesic, allergy, cold and cough remedy.
Nursing hypotension, monitor hemodynamics and respirations. May increase ICP. Narcan is the antidote for OD. Do not exceed 4g of acetominophen per day
What is Most important to note while a patient is having a seizure
observe the sequence and types of movements
Potassium antidote
insulin, NaHCO3, Kayexalate, Albuterol
what oral medication can be given to a type 2 diabetic
glipizide
What does downward communication mean?
used to relate organizationl policy such as position description and rules and regulations
symptoms of meningitis?
nuchal rigidity (neck), photophobia, DROPLET
Can CNAs collect urin specimens
yes
What drug should not be given with Lithium
diuretics (furosemide)
additional side effects include polyuria, polydipsia
Gastric vs Duodenal Ulcer
- G: laboring person, malnourished, pain AFTER eating. Food does NOT help. Vomiting does,
- D: Executives, well nourished. Pain after couple hours of eating. food helps
When is an electronic blood pressure machine contraindicated?
irregular HR, peripheral vascular disease, seizure, tremors, and shivering
What reason could a child have frequent bouts of gastroenteritis?
daycare, increased number children prone to infections
what happens to a patient taking cyclophasphamide for MS
develop alopecia 4-5weeks after starting treatment
SPIDERMAN acroydmn for droplet precautans
- Sepsis
- Scarlet fever
- Streptococcal pharyngitis
- parvovirus
- pneumonia
- pertussis
- influenza
- diptheria
- epiglottitis
- rubella
- mumps
- meningitis
- mycoplasma or menigeal pneumonia
- Adenovirus
if you see the word discharge for delegation its always the..
RN!!
how high should irrigation bag be held for an enema
12-18 inches
What is the patho behind MS
demyelination of spinal cord white matter. Can lead to parastesias. Difficulty swalling, impaired speech. Provide warm baths and packs. wide based walk. Bladder training.
Aspirin
- *Indication** rheumatoid arthritis, osteoarthritis, ischemic stroke and MI prophylaxis
- *Action** inhibits production of prstaglandins which leads to rreductiono fever and inflammation, decreases platelet aggregation leading to a decrease in ischemic diseases
- *Class** antipyretic, non opioid analgesic, salicylates
- *Nursing Considerations** bleeding, chronic alcohol use, Steven Johnson syndrome, laryngeal edema, anaphylaxis, increass risk for bleeding with warfarin, heparin, and clopdiogrel, increased risk for GI bleeding w. NSAID, liver function tests
what should you watch for with a patient that has myelonmeingocele?
elevated temp, irritability, lethargy. At risk to develop meningitis. Change dressing ever 2-4 hours using aseptic technique.
What happens to WBCs & RBCs with UTIs
- WBC: inflammation irritation of urethra
- RBC: bladder mucosa irritated and bleeding
what does theophylline do to digoxin toxicity?
increases risk, decreases effects of lithium and dilantin
How should you control a patient in a wheelchair in an elevator
back into the elevator, allows patient control
What is the safest laxative to administer?
Bulk-forming- Psyllium Hydrophilic mucilloid.
What could be a risk factor for malignant hyperthermia r/t general anesthetic
muscle cramps, or unexplained death of a relative with a febrile condition.
How long does an MRI procedure take
90 mintues
Prior to a CAT scan what is most important to assess?
problem client may have with enclosed spaces?
Propanolol
- *Indication** hypertension, angina, arrthymias, cardiomyopathy, alcohol withdrawal, anziety
- *Action** blocks Beta 1 & 2
- *Class** antianginal, antiarrthymic, antihypertensive, headache suppressant, beta blocker
- *Nursing Considerations** pulmonary edema, contraindicated with CHF, cardiogenic shock, bradycardia, heart block. Masks symptoms associated with diabetes mellitus. Advise physician if difficulty breathing
What is the drug of choice for frequent premature ventricular contractions?
lidocain
Metformin
- *Indication** mgmt of type II DM
- *Action** decreases glucose production inthe liver, decrease absorption, increases ellular insulin sensitivity
- *Class** antidiabetic, Biguanide
- *Nursing Considerations** do not use with renal dysfunction, metabolic acidosis. May cause diarrhea, N/V, lactic acidosis. D/C if acidotic.
Which age range is at increased risk for poisoning?
Toddlers age 1-3 years b/c increasing mobility
What will be elevated in glomerulonephritis?
Antistreptolysin (ASO)
Common EKG changes with Hypokalemia
- ST segment depression
- Inverted T waves
- Prominent U waves
- Heart Block
When are hemovac or jackson pratt’s removed after total kneww surgery
the morning after
Post op Thyroidectromy
- Have suction, oxygen, trach available
- monitor repsirations
- Semi Fowler’s position
- laryngeal nerve damage
- hypocalcemia
- thyroid storm
CABG
CABG intersted proximally and distally
vtach
Math Conversions
where is the pulmonic area located?
Afib, No Pwave, & Irregular
300-650 bpm
what is a senstaken blakemore tube used for
inserted thru the nose/mouth. MGMT of GI hemorrhage due to esophageal varices.
- Ventricular Tachycardia
- HR 160
- Regular Rate
What is the septum
a wall between the ventricles, there should be no opening
Where is the mitral area
5th ICS, midclavicular line. Apex of the Heart. Asucultate S1
Where is the Right Middle Lobe located?
right anterior chest between fourth and 6th ntercostal space
Ventricular Fibrillation
Buck’s Traction Care
- remove foam boot 3x per day to inspect skin
- turn client to unaffected side
- back care every 2 hours to prevent pressure sores
- dorsiflex the foot on the affected leg. Asses function of peroneal nerve
- elevate the foot of the client’s bed to provide counter traction
Respiratory Opposite Metabolic Equal
Tricupsid Area Location
fifthe intercostal space lower left sternal border
where do you place the tuning forks for a rinne test?
behind the ear
log roll
- Atrial Pacemaker
- Regular Rate
- PRI 0.20
- QRS 0.09-0.10
- HR 60
Explain Use of a Partial/Non Rebreather Mask
- short term thereapy
- 60-90%, 10-15L/min
Left Sided Heart Failure
- Dyspnea
- S3
- Dry non productive cough
Contracture- the result of a stiffness or constriction in your muscles, joints, tendons, ligaments, or skin that restricts normal movement.
trochanter roll
