NCLEX General Flashcards
What is minimum urine output? Anything lower than this value may be indicative of what?
30ml/hr, anything less may indicate low vascular volume, low cardiac output, decreased renal perfusion
What is Guillain-Barre syndrome?
Immune disorder in which your body attacks your nerves, initial symptoms include muscle weakness and tingling.. spreads quickly and can result in total body paralysis.
- Most life-threatening element to this disease is neuromuscular respiratory failure!
What IV site is best for reduced risk of infection?
dorsal surface of HAND, most distal upper extremities are the best.
- lower extremities are the last resort.
- the more proximal site on the arm, the higher the risk. Hand is best.
What IV site is best for trauma/emergency pts?
ACF, large gauge IVs in preparation for large fluid boluses or blood transfusions
A patient is ordered a blood transfusion but has no IV access. What gauge and site do you insert an IV?
ACF, #18 gauge
IV Infiltration vs. Extravasation?
Infiltration: IV cannula moves out of the vein and fluid is administered into the tissue surrounding the vein instead of in the vein itself, causing swelling. (INTERSTITIAL)
Extravasation: a vesicant (irritant) is accidentally administered into tissue surrounding a vein, causing severe pain, blanching and tissue damage. IV infusion must be stopped immediately. (INTERSTITIAL WITH IRRITANT)
You are administering norepinephrine through PIV and the client complains of severe pain, the vein is blanching. What is the antidote for extravasation?
EXTRAVASATION: Norepinephrine = Vesicant
- stop infusion immediately, disconnect IV tubing, aspirate IV and remove cannula
- raise effected limb above heart to reduce edema
- contact HCP and get order for PHENTOLAMINE SC in surrounding tissue (vasodilator, antidote for extravasation)
A client has an arrhythmia and has tried many medications to correct it and none have worked. What is the last resort medication for arrhythmia and why is it the LAST resort?
AMIODARONE, higher incident of lung toxicity. S+S: - dyspnea - dry cough - pleuritic chest pain
How to treat hypothermia/frost bite? (3)
DO NOT MASSAGE, injured tissue is easily damaged.
- provide adequate analgesia
- continuous warm water soaks
- elevate effected limb after rewarming as limb can become very edematous and may blister
Two common medications for allergies?
- diphenhydramine (benadryl)
- loratadine (claritin)
Common medications for nausea/emesis? (3)
- dimenhydrinate (gravol)
- ondansetron (zofran)
- metaclopramide (maxeran)
Common medications for bronchospasm/asthma exacerbation? (4)
- ipatropium (atrovent)
- salbutamol (ventolin)
- budoneside (pulmicort)
- corticosteroids
What do you assess for hepatic encephalopathy?
- ammonia levels
- hand tremors with arms extended (asterixis)
- mental status changes
What is asterixis?
flapping hand tremors when arms extended
Signs and symptoms of increased ICP?
N/V Headache restlessness change in mentation seizures
above what level of creatinine would we become concerned about kidney injury?
1.3
what are some factors that increase risk of high Creatinine and kidney injury?
Old age NPO dehydration fluid loss intra-op antibiotics
What is the fastest treatment of severe hyperkalemia?
50ml D5W +10u insulin IV
What are signs of peritonitis?
rebound tenderness
increased WBC
Pt on peritoneal dialysis is having insufficient output.. what would we first assess, why and what is the treatment?
- assess for constipation, listen to bowel sounds, last BM?, cramping, etc.
- Distended intestines block fenestrated catheter.
- Treatment = stool softeners
— **Other causes could be a kink in the tubing.
What does the CKD diet look like?
- low sodium, potassium and phosphorus no dairy (phos), no avocado, banana, coconut, oranges, watermelon.
- apples, pears and berries are good!
What are some major complications of AVF or arteriovenous fistulas?
stenosis thrombosis infection hemorrhage - assess for numbness, tingling
Your patient returns from hemodialysis. 30 minutes later, they complain of a headache rated 8/10 for pain and they are nauseous. What is the nurses priority?
Suspicion of dialysis disequilibrium syndrome (DDS), obtain VS and contact MD immediately.
Dialysis rate will be slowed for this patient for following treatments.
You are a hemodialysis nurse. Prior to connecting pt to dialysis machine, what must be assessed?
- VS
- Pre dialysis weight
- palpate fistula for thrill and listen for bruit
How do you know a AVF (arteriovenous fistula) is patent and healthy?
- no excess redness/swelling/sign of infection
- *****thrill and bruit present .. MOST IMPORTANT!!
- no numbness tingling in hand
What does a creatinine of 4.3 indicate?
Critical Cr level, major kidney injury
- the kidneys are not able to clear creatinine as they should. Poor clearance of Cr increases its levels in the blood
You are discharging a hemodialysis patient who has a healed AVF. What would you include in their discharge teaching?
- no BP OR BLOOD DRAW taken on AVF arm
- no sleeping on effected arm
- no restricting clothing or jewelry
- no heavy lifting
- do strength exercises with effected hand!! Helpful for circulation and strength.
- if any sign of infection or numbness and tingling in effected arm, notify MD immediately or go to ER.
A nurse is caring for a child with acute glomerulonephritis. Frequent monitoring of what is a priority and why?
blood pressure
- severe HTN is a common complication, control it to prevent further injury to kidney
4 characteristics of nephrotic injury?
- hypoalbuminemia
- hyperlipidemia
- edema (r/t low albumin)
- proteinuria
What does albumin do in the body? What happens when its LOW?
When it is HIGH, what is the indication?
Albumin = protein made by the liver.
keeps fluids in the bloodstream as to not leak into the tissue, so when it is LOW.. you get edema.
HIGH albumin would indicate dehydration.
A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. The client’s skin is pale around the fistula’s arm and hand. What does this mean and what should you do as their nurse?
- arterial steal syndrome, the vein is likely “stealing” too much of the arterial blood from the fistula point. Contact MD when this is suspected, as leads to ischemia then necrosis of limb.
A client is to go to CT with iodine contrast in the morning. What medication should be withheld if they are taking it and why?
METFORMIN. A side effect is lactic acidosis.. if the pt develops kidney injury from the contrast dye, acidosis will worsen.
Iodinized contrast is hard on the ____.
kidneys, should not be used if already compromised.
> ____mL of residual urine noted in the bladder should be reported to MD.
100mL as sign of urinary retention
What is VERY important with a Wilms tumour?
DO NOT PALPATE
A pt is prescribed an enteric coated potassium supplement. What teaching should be given related to this medication?
Do not crush.
Take with plenty of water and sit upright for 30-1hr after because of esophageal irritation risk.
Which prescription will immediately protect the client from experiencing dysrhythmias associated with hyperkalemia?
CALCIUM GLUCONATE!!! Stabilizes ECG changes and then safe to admin insulin and dextrose.
You are asessing a client during the dwelling stage of peritoneal dialysis. What assessment finding would require immediate intervention??
crackles in the base of the lungs, high risk of resp distress. dialysate was likely infused too quickly or at a volume too high
The nurse is assessing a heterosexual female client diagnosed with tuberculosis who started taking rifapentine a week ago. it would be of importance to mention what about oral contraceptives and this drug?
Rifapentine increases the metabolism of oral contraceptives making them uneffective. Non hormonal contraceptives methods would be better
Why do we supply thiamine supplements to alcoholic patients?
To prevent Wernickes encephalopathy, memory loss and increased confusion d/t thiamine deficiency directly related to alcohol abuse
What is theophylline?
A drug for respiratory disorders, bronchodilates, etc
What is something that must be known about theophylline?
it has a narrow therapeutic index, toxic if above 30.
Also CANNOT take ciprofloxacin or cimentidine d/t rxn where it dramatically increases drug level.
What is the therapeutic range of phenytoin? what are signs of toxicity?
10-20
- decreased mentation
- ataxia (involuntary muscle spasms)
- slurred speech
What drugs are the BEST for calming your heart down if tachycardic, tachyrhythmic?
calcium channel blockers
CCBs are ___ inotropic, chronotropic, dromotropic?
NEGATIVE, therefore A DEPRESSANT
S+S of DVT?
Unilateral leg pain
one leg larger than other
local warmth
erythema (redness of skin)
How to calculate MAP?
sys+(dias x2) / 3
What factors may precipitate angina pectoris? (4)
those that increase o2 demand:
- sexual intercourse
- cigarette smoking
- amphetamine use
- cold exposure
How soon after MI recovery can someone return to sexual activity?
after you can successfully walk up 2 flights of stairs w/o symptoms
Auscultation of a new S3 sound indicates what?
Heart failure or cardiogenic shock, VOLUME OVERLOAD
Normal CVP?
2-8mmHg
Normal MAP? needs to be above____???
70-105mmHg
needs to be at least 60 for cerebral perfusion
Normal cardiac output?
4-8litres/minute
The nurse admits an 81-year-old client with gastroenteritis. Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min. Pulse oximetry shows 88%. The nurse suspects which of the these factors may be affecting accuracy of the pulse oximetry reading?
hypotension. Low BP effects what the pulse oximeter can measure.
Criteria for leaving AMA:
- they are NOT a threat to themselves or others
- they are competent to understand the risks
- they are NOT under the influence of drugs/alcohol
Normal fetal hr
120-160
What is naegele’s rule?
estimation of due date:
LMP - 3MONTHS + 7DAYS
Fetal hr can be detected at ___wks
10-12
An infant has a cleft palate and is awaiting operation. In the mean time, how can we best promote oral intake until palate can be repaired?
burp often
feed in upright position
use a specialy bottle/nipple
What are some risk factors for pelvic inflammatory disease?
- multiple sexual partners
- history of PID/Chlamydia/gonorrhoea
- lack of contraception use
- age 15-25
What is pelvic inflammatory disease?
infection of the upper reproductive system (FEMALE)
Expected weight gain during pregnancy is determined by the woman’s prepregnancy ___
BMI
- The lower the BMI, the more weight should be put on.. no more than 30lbs usually.
Birth is imminent. The woman is complaining of severe perineal pressure and requires a analgesic intervention that can be administered quickly and has little maternal/baby side effects. What analgesic procedure is this?
pudendal nerve block.
3 things a nurse should assess during an amniotomy to induce labour?
- characteristics of amniotic fluid
- maternal temp check q2h
- assess fetal hr before and after procedure
When a child is diagnosed with “failure to thrive”, what does that mean?
weight less than 80% of ideal for their age
A healthy 2yo should have the vocabulary of about __words.
300
What age may separation anxiety begin to develop?
6months
How can we reduce separation anxiety while caring for a peds pt in hospital?
- allow parents to stay in room during procedures
- adhere to their home regimen as much as possible
- promote a quiet environment with reduced stimuli
- give the child a parents shirt to hold during procedures
What is a nitrazine test?
A test done to determine whether a pregnant woman’s “water has broken”
- a BLUE strip indicates a pH greater than 6 and is more likely fluid from ruptured membranes
What can result in a false positive from a nitrazine test?
contamination with
- semen
- fingerprints
- cervical mucus
Amniotic fluid is ___. Vaginal fluids or urine are ___. (acidic, alkaline)
amniotic: ALKLALINE
vaginal/urine: ACIDIC
- How to tell if your water broke or not. nitrazine test
Shoulder dystocia is detected, the nurse should:
push mothers legs back against the abdomen and apply pressure above the symphysis pubis
Client at 34wks begins to develop intense itching on the hands and feet with no rash. What is likely dx?
intrahepatic cholestasis, dangerous for mom and baby, increased bile production by liver and high concentration in blood
EC pills should be taken within ___hrs of unprotected sex to be effective.
72hrs or 3 days
Why is oxytocin a high alert medication?
because of the risk of tachysystole.
What is tachysystole?
excessive uterine contractions (>5/10mins), decrease placental perfusion which leads to decreased fetal oxygenation
At what point must the nurse begin massaging the fundus?
AFTER the placenta is expelled to decrease bleeding and promote uterine tone
When a baby is not placed skin-to-skin or warmed after birth they are likely to experience cold stress which can lead to
hypoglycemia and respiratory distress
What is lanugo?
fine hair on body of preterm newborns
Measles-mumps-rubella (MMR) vaccine is a live or inactive vaccine?
LIVE, therefore contraindicated in pregnancy and immunosuppressed pts.
Why are pregnant women at higher risk of heartburn?
progesterone relaxes sm muscle therefore relaxes the esophageal sphincter.
How to reduce heartburn?
avoid fried/fatty food
eat sm. regular meals
sit upright after meals
What is normal WBC count?
4,000-11,000
Signs of infection following a long birth:
- tachycardia
- febrile/fever
- foul smelling lochia
Moms group B streptococcus status is unknown. Prophylactic antibiotics are given if meets the following qualifications?
- preterm gestation
- febrile mom
- over 18hrs since rupturing of membranes
The FHR monitor shows recurrent, variable decelerations in fetal HR w/ contractions. What does the nurses suspect is happening and what is the treatment?
umbilical cord compression during uterine contraction. Will be treated with amnioinfusion. Monitor for uterine overdistension
What population is at a higher risk of vitamin B12 deficiency and why?
Vegan, because VitB12 is found only in animal foods
prazole vs azole meds?
prazole: PPI, protects stomach
azole: antifungals/antibiotics
Warfarin MUST be held if INR>__?
3.5
Symptomatic bradycardia is treated with?
atropine
normal CVP?
2-8
