NCLEX Review Flashcards
What do you do first if a patient has a purulent wound?
Place on precautions
Lymphadenopathy best indicates what?
An infection
Airborne precautions
MTV=Measles, Tuberculosis, Varicella
Varicella aka
Chicken pox
Droplet precautions spacing
3 feet distance and open door is okay
WBC
5,000-10,000
Serum Creatinine
0.5-1.5
AST
10-40
AST indicates
Measures amount of damage to the liver and heart
How to remove a mask with loops?
By the loops
How to remove a mask with ties?
Remove top ties, hold. Remove bottom ties.
What needs to be done when gloves are removed?
Handwashing.
Incubation period
Time between when a person gets infected and when actual symptoms occur.
Who is at risk for latex allergy?
A patient with spinal bifida due to many procedures
What foods can contribute to eczema?
Milk, wheat, and egg whites
Epinephrine can be given through what route?
IM, Subcutaneous
What is more a priority, an artificial airway or epinephrine?
Epinephrine
What is agranulocytosis?
An extreme decrease in WBC
What is urticaria?
Hives
Agranulocytosis symptoms within 2-3 days?
Sore throat, fever, fatigue, and weak rapid pulse
What foods are highly allergenic for infants?
Eggs and meats
When should egg and meat be introduced?
Close to 9 months of age
What organs are part of the immune system?
Spleen and thymus
A Schilling is what type of test?
A 24 hour urine test. The 24 hours start after discarding the first urine. Time and date info recorded before and after. Urine stored in fridge/ice.
What happens in percutaneous anemia?
Vitamin B12 cannot be absorbed due to a lack of an intrinsic factor, therefore it must be given parentally.
What is a priority for a bone marrow biopsy?
Apply pressure to the biopsy site.
What are two big sources of iron?
Eggs and spinach
What is the most common type of anemia?
Iron-deficiency anemia
Why is someone with a total gastrectomy at a high risk for percutaneous anemia?
Loss of mucosal surface that secretes intrinsic factor
Can cooking with iron utensils increase iron in the food?
Yes
What types of food contain iron?
Dried fruit, dark leafy greens, green beans, and raspberries.
How long will someone with percutaneous anemia need B12 injections for?
May need lifelong injections.
What type of gastric problem can cause percutaneous anemia?
Gastric ulcer
What causes pallor in severe anemia?
Shunting of blood to heart and brain.
Which food is rich in folic acid?
Spinach
B12 Intake does what?
Increase RBC maturation
What does the Schilling test measure?
The amount of vitamin B12 in the urine after the client ingests radioactive vitamin B12
Why is intrinsic factor important?
It is needed for B12 absorption
What exam is needed to confirm percutaneous anemia?
Schilling test
What are risk factors for percutaneous anemia?
Family history and autoimmune disease.
How to give iron?
After food, diluted, provide lots of water.
What can iron supplements cause?
Constipation and stained teeth
Hemophilia is what type of trait?
It is an x-linked recessive trait found primarily in males.
What is the priority for injured hemophilia clients?
Apply ice and elevate
What happens during a hemolytic reaction?
Destruction of blood cells occur
S/S of a hemolytic reaction
Kidney pain, hematuria, cyanosis
What is the primary presenting feature of acute glomerulonephritis?
Microscopic or macroscopic (gross) hematuria
Glomerular damage causes what?
RBC and protein plugs or casts to be eliminated in the urine. This makes the pee look cola-colored or reddish-brown.
Dyspnea indicates what in a blood transfusion?
Circulatory overload
The nurse is most concerned if what is observed during a blood transfusion?
Hematuria occurs (Indicates a blood incompatibility)
Therapy for hemophilia
Antihemophilic factor (AHF)
Hemophilia A factor
VIII
Hemophilia B factor
IX
Hemophilia C factor
XI
Hemophilia B aka
Christmas disease
Hematocrit measures what?
Ratio of red blood cells to fluid volume
Oatmeal bath helps what
Relief itching
Blood should run no faster than what for the first 15 minutes
5mL/min
Blood should be infused within how long of refrigeration?
Four hours
What do you do for every unit of blood?
Change the entire IV system
Severe blood reactions occur when
Within the first 50mL of blood
What treatment is controversial with DIC?
Anticoagulation with heparin
What medication should be administered with DIC?
Oxygen
What medication route should be avoided with hemophilia?
IM
Heparin does what?
Provides immediate anticoagulation when manifestations of thrombosis occur
What data should the nurse collect from a patient with hemophilia
ROM (pain might indicate hemorrhage)
How to communicate with someone with AIDS dementia?
Simple instructions
What needs to be avoided if diarrhea?
Nutritional supplements due to dairy.
Can assisting someone brushing their teeth spread HIV?
No
What CD4 count puts someone at risk for developing pneumocystis pneumonia?
Less than 200
What helps prevent pneumocystis pneumonia?
Chemoprophylaxis
Can people with AIDS still have sex?
Yes
What degrades condoms?
Petroleum jelly
A person with AIDs is at risk for developing what skin problem?
Kaposi sarcoma
What test helps confirm an HIV diagnosis
Western blot
What puts an HIV patient at risk for opportunistic infections?
Decreased T cell or CD4 cell count
What should be decreased if a patient with HIV has diarrhea?
Decrease roughage in the diet like fatty and caffeinated foods.
What should the nurse recommend if a client with HIV experiences fatigue?
Sit while preparing meals
What kills people who have aids?
AIDS virtually cripples the body’s normal protective immune response.
What type of medication is sulfasalazine?
sulfonamide and DMARD
What is sulfasalazine used for?
Mild or moderate chronic RA and inflammatory bowel disease like ulcerative colitis
What are some sulfa medications?
trimethoprim and sulfamethoxazole
Most sulfa drugs have what side effects?
Crystalluria (Drink water), Photosensitivity, Folic acid deficiency, agranulocytosis, and Steven’s Johnson syndrome
Is a dust allergy the same as animal dander?
No
Hydroxychloroquine is what type of medication?
Antimalarial drug
What must a client with SLE due when taking hydroxychloroquine?
Have an ophthalmic examination every 6-12 months
Does hydroxychloroquine work fast?
No, it can take several months
Hydroxychloroquine severe adverse drug reactions?
Retinal toxicity and visual disturbances
What might hydroxychloroquine be prescribed for?
SLE and joint inflammation
When might a tonsillectomy be indicated?
Tonsillitis, peritonsillar abscess, or obstructive sleep apnea
What should the nurse anticipate after a tonsillectomy?
Ear pain (give Tylenol) and bad breath
Halitosis meaning
bad breath
What should someone not do after a tonsilectomy?
Drink with a straw, since it can increase pressure and increase the risk for bleeding.
Can someone after a tonsillectomy be suctioned?
No
What position should someone not be in during an NG feeding?
Supine
Side effects of anticholinergic medications?
Blurred vision, dried mouth, decrease in pee and poop
What medication is given for torsades de pointes?
Magnesium
What is amiodarone?
An antiarrhythmic
When is amiodarone given?
After epinephrine in V-Fib and V-tach
What is vassopressin?
A medication that can increase blood pressure
When is atropine given?
Bradycardia
How to make a cast dry completely?
Reposition the limb every two hours
Do all visitors need to be restricted for an internal radiation implant?
No
What needs to be done for an internal radiation implant?
Donning gloves when emptying the client’s bedpan. Wearing a lead apron when providing direct care. Keeping all linens in the room until the implant is removed.
Which element regarding age of blood cells is important to check?
Expiration date
What happens to the skin when pressed upon in acrocyanosis?
Color returns quickly after blue area is blanched.
What is the range for each category in the apgar score?
0-2
What is an apgar score of 0 in HR
Less than 60 BPM
What is an apgar score of 1 in HR
60-100 BPM
What is an apgar score of 2 in HR
More than 100
If patient is suspected to be abused, then you do what?
REPORT!!!
Is it safe to reduce the volume of ringers and pagers?
Yes
Benign tumors can cause what to the tissue?
Destruction by size and location in the body
What is performance improvement?
The creation of projects after seeing clinical issues. Research findings are used to fix issue.
Signs and symptoms of thyrotoxicosis in someone with Grave’s disease.
Fever, Excessive sweeting, Tachycardia
What is atraumatic care?
Causing little to no trauma
Serum Calcium Level
8.6-10.2
Ionized Calcium Level
4.5-5.1
What food is high in calcium?
Almonds
What food has no calcium?
Asparagus
What lab must be checked if pancreatitis is suspected?
Serum amylase
What does creatinine kinase evaluate?
Muscle function
What does creatinine and BUN evaluate?
Renal function
If platelets are low, what assessment must be done?
Neuro checks to assess for possible brain bleed
What are the 6 vasopressors?
Norepinephrine.
Epinephrine.
Vasopressin (Vasostrict)
Dopamine.
Phenylephrine.
Dobutamine.
What needs to be done before a vasopressor is given?
Adequate fluid volume must be achieved, since they vasoconstrict.
What type of line dopamine is best administered?
Central line
What are the 5 p’s of compartment syndrome?
Pain, pulse, pallor, paresthesia, paralysis
What are the 5 p’s of compartment syndrome?
Pain, pulse, pallor, paresthesia, paralysis
Epiglottitis aka
Obstruction
Any drooling is a —
Priority and might indicate an obstruction
What causes duodenal ulcerations?
With Helicobacter pylori (H. pylori), the bacteria penetrate the intestinal mucosa, altering the function and consistency, leading to ulcerations. (The bacteria enters the intestine and alters the lining.)
radical retropubic prostatectomy priority
Kegel exercises
Measles is the same thing as
Rubeola
What do stations in OB mean?
The relationship of the presenting fetal parts to the ischial spines
utilization review
identifies and eliminates the overuse of diagnostic and treatment services prescribed by health care providers caring for clients on Medicare.
Nurse-sensitive indicators
client outcomes and nursing workforce characteristics that are directly related to nursing care, such as changes in clients’ symptom experiences, functional status, safety, total nursing hours per client day, and costs.
If there seems to be no indication for bleeding, do you check the surgery site or assess for pain?
Assess for pain
Guided Imagery
visualize images and focus on relaxing to reduce pain.
A client can use yoga to
learn how to perform exercises that will improve circulation, promote relaxation, and alleviate pain.
biofeedback
control physiological responses of the body, such as pain, using electronic equipment to evaluate specific responses.
Music therapy
induce distraction and relaxation, thus reducing pain.
How far away should a heparin injection be?
At least two inches away from umbilicus
Are heparin injections aspirated?
No
Is massaging indicated after subcutaneous injection?
No
Rugs
Teach family members to use throw rugs sparingly.
For fall risk, should a patient be advised to avoid walking if unsteady?
No
What should you do if a patient has low calcium levels?
Initiate seizure precautions
Why might a doctor not perform a splenectomy?
The spleen is important in immune function, and without it the chance of overwhelming infection becomes high.
Glipizide medication type
Second-generation sulfonylurea
What type of medication is metformin?
biguanide
Repaglinide medication type and for?
Meglitinide and for diabetes
Miglitol medication type and for?
alpha-glucosidase inhibitor and for diabetes
What does miglitol do?
This delays carbohydrate digestion after meals slowing glucose entry into the systemic circulation.
What is rhabdomyolysis?
A breakdown of muscle tissue that releases a damaging protein into the blood.
Rhabdomyolysis leads to what and what are nursing considerations?
myoglobinuria, which can put the kidneys at risk for acute renal injury. Keep the client hydrated and a urine output of 200 to 300 ml per hour.
A MAP of what is adequate to perfuse organs?
> 60
Fresh frozen plasma is often used for what?
volume expansion caused by fluid and blood loss.
What must the nurse do when faxing to a facility?
Confirm that fax numbers are correct before sending. Use a cover sheet with the name of the recipient printed. Fax the information that is required for immediate needs. A fax can be sent any time with the identifiers.
What is associated with a risk of fetal macrosomia?
Maternal obesity and gestational diabetes
What is fetal macrosomia?
A large fetus
Dependent personality disorder?
Clingy behavior
What abbreviation does JCO want to be avoided
U, cc, OS
Qid
Four times a day
O.D.
Right eye
O.S.
Left eye
O.U.
Both eyes
What is more important, pH or PaCO2?
PaCO2
What is not needed if a charge nurse?
Incident report
Huff cough
a forced expiratory technique that mobilizes secretions from the small airways for easier expectoration.
What are early signs of digitalis toxicity?
Nausea, anorexia, and vomiting
Normal calcium levels
9.0 to 10.5 mg/dL
Normal hemoglobin levels
12 to 18 mg/dL
Normal creatinine levels
0.5 to 1.2 mg/dL
Normal phosphate levels
3.0 to 4.5 mg/dL
In chronic kidney disease, will phosphate be high or low?
High
What technique to use if pain is coming from the kidneys?
Blunt percussion.
The hooking technique is used for what?
Palpate the edges of the liver
Blunt percussion is used for what?
over the costovertebral angle to assess for kidney tenderness.
What is a characteristic of generation X?
Individuals in this generation have a tendency to want work-life balance.
Generation X years
1965 to 1980
What is a characteristic of generation Y?
Wanting to be rewarded for time spent at work
What year is generation Y?
1982 and 1994
How often should meticulous perineal care be done?
Every day
Normal BNP
Less than 100
ESR for males over 50
Less than 20
ESR for males less than 50
Less than 15
ESR for females less than 50
Less than 25
ESR for females over 50
Less than 30
Normal C-reactive protein (CRP)
1 mg/L
Normal INR
2 to 3.5
A high BNP indicates what?
congestive heart failure
An elevated sedimentation rate indicates what?
indicates an inflammatory process
What does a high CPR indicate
inflammation, tissue injury, infection, or atherosclerosis
Conjunctival icterus
Yellowing of the white of the eye
What s/s can indicate a liver rejection?
Light/clay colored stools,dark colored urine, high AST/ALT, CONJUNCTIVAL ICTERUS
AST
10-40
What is Fondaparinux?
anticoagulant that inhibits factor Xa
Fondaparinux is excreted through what?
The kidneys, creatinine level should be monitored periodically, and the drug stopped in clients who develop unstable kidney function or severe renal impairment.
Energy level of defib
For an initial defibrillation for a client experiencing ventricular fibrillation, the nurse sets the defibrillator at 120 to 200, not 80 to 100, Joules for biphasic machines.
How to reduce the risk for falling
The nurse should instruct the client to avoid attempting to do anything beyond reach to reduce the risk for falling.
Hastens
To be quick to do something
