NCLEX REVIEW Flashcards
Ventricular Fibrillation Priority Intervention
Defibrillation
What rhythm is this?
Ventrcular Fibrillation
Transcutaneous electrical nerve stimulation unit teaching
Adjust it until the client feels a pins and needles sensation
Tyroid storm is a complication of what disease ?
Hyperthyroidism
With hyperthyroidism everything goes what way :
UP , everything goes high
Thyroid Storm treatment
Dexamethasone : To inhibit conversion of T4 into T3
Propranolol : to reduce HR/BP
Propylthiouracil
Acyclovir Indication
Herpes infection
Phenytoin contraindication
Warfarin
Wernecke’s encephalopathy treatment
Thiamine (Vitamin B )
Bronchovesicular lungs sounds may be ausculted where ?
Posteriorly, Between the scapula
Where can you auscultate the aortic valve ?
Right second intercostal space
Where can you obtain apical pulse and any adventitious sounds S3 , S4 ?
Midclavicular line 5th intercostal space
Where can you ausculate bronchial breath sound ?
Over the trachea
Cilostazol indication
To treat peripheral arterial disease
Cilostazol mechanism of action
Decrease platelet aggregation
Promotes vasodilation
Ambulate without pain
Hypothyroidism signs symptoms
Perioorbital edema
Weight gain
Constipation
Anemia
Increased TSH and decreased T3/T4
Hyperthyroidism signs symptoms
Tachycardia
Weight loss
Heat intolerance
Injected red conjunctiva
Insomnia
Increased systolic blood pressure
Diaphoresis
Hypothyroidism meds
Levothyroxine
Asystole rhythm intervention
CPR then Epinephrine
V Fib and Atrial dysthymia meds
Amiodarone
Sodium carbonate in cardiac arrest
Only use if acidosis is suspected
Early deceleration is caused by
Fetal head compression
Variable deceleration is caused by
Cord compression
Late deceleration is caused by
Reduced blood floor to the placenta
Fat embolism symptoms
Petechiae (red-purple spots)
Fat embolism occurence timeline
Is a severe complication that occur 48 hours following a fracture
Catanonia treatment
Lorazepam
Pulmonary embolism diagnostics test
D-Dimer
CT Scan
Fiberglass cast dries takes how long to dry ?
30 minutes
Variant Angina occur when :
At the same time every day , usually at rest
Stable angina occurs when
After activity
Variant angina treatment
Calcium channel blockers (ine)
Stable angina treatment
Nitroglycerin
Isoniazid (INH) indication
First-line therapy treatment for pulmonary tuberculosis
Major adverse effect of INH
Peripheral neuropathy
Peripheral neuropathy treatment
B complex vitamins
What is narcolepsy ?
Client falling asleep in the middle of normal daily activities
Narcolepsy treatment
Modafinil
Fluoxetine indication
Anxiety and depressive disorders
Engrossment
Intense emotional bonding and attachment that occurs between a parent and a newborn shortly after birth
Binding-in
Is a standard psychosocial process where the mother links the newborn facial features to other family members
Entrainment
Refers to the rhythmic synchronization process where the mother links the newborn facial features to other family members
Detachment
When the bonding process fails and either the infant or parent has no bond with the other
Etanercept teaching
-Etanercept increase the risk for infection
-Before the first dose the client should have a negative purified protein
-After administered, the nurse should perform an assessment of the injection site
Iron teaching
-Take with orange juice
-Drink with with straw to avoid staining teeth
Bell palsy meds
Predsisone
Acyclovir
Sumatriptan indication
To treat migraines headaches
1 ounce = ML
30 ML
Guanfacine indication
To treat ADHD
Rapid acting insulin when should it be administered?
5-10 min before meal or while the client actively eating
Insulin good for how many days after opening ?
28 days at room temperature
Insulin storage
Store insulin in a cool dry place
Protect insulin from direct heat and light
Short acting insulin when to administer?
Administered 20-30 minutes before meals
Rooting reflex
Newborn turn their head to the side on which the cheek is stroked
Babinski reflex
Newborn big toe moves upward toward the top surface of the foot , and the other toes fans out
Grasp reflex
Newborn wrap fingers around examiner when placed in the newborn palms
Moro reflex
Newborn places index fingers and thumbs into a C shape
Fundus is soft and boggy what do you do ?
Massage it until it firm
Enoxaparin adverse effects
Thrombocytopenia
Medication to avoid with polycystic kidney disease?
NSAID
What happen when you take a blood pressure in the leg?
Systolic blood pressure increase by up to 10 to 40 mm Hg
Lochia color in first stage ?
Rubra : red
Lochia color in second stage ?
Serosa : Pink
Lochia color in third stage
Alba : white
Cefoperazone indication
Pseudomonas aeruginosa
Tolvaptan indication
Treat SIADH
Myringotomy procedure purpose
To facilitate drainage from the eardrum
What is preeclampsia ?
Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage of damage to another organ system , most of the liver and kidney.
Preeclampsia manifestations :
Hyperreflexia , headache , epigastric pain
Serotonin syndrome is caused by what type of medication overdose ?
MAOI , SSRI , like paroxetine , citolapram, tramadol , venlafaxine
Common side effects of the DTAP vaccine
Fever
Urticaria type of precautions?
Standard
If patient got placenta previa the nurse should not do what ?
The cervix should not be assessed for dilation
Live attenuated vaccine example ?
Rotavirus , MMR , Varicella
Kosher diet is in what culture?
Orthodox Jewish Faith
Orthodox Jewish practice example:
Unwrap the eating utensils
Furosemide teaching administration time :
Take furosemide early in the day to avoid nocturia
ECT electroconvulsive side effects
Memory Loss
Metoclopramide adverse effects
Dystonic movements of the face
Involuntary movement of the jaw
NIPPV non-invasive positive pressure ventilation , BIPAP, CPAP purpose
To support ventilation, decrease respiratory muscle, improve overall respiratory function.
Misoprostol mechanism of action
Protect the gastric mucosa, decreasing gastric acid secretion, lining the stomach for protection.
Prednisone indictation
RA
Most accessible pulse in an infant
Brachial
Average weight during pregnancy
25-35 LB
Desmopressin indication
Diabetes insipidus / Noctural enuresis
Nasal Cannula delivery amount
1-6 L
24-44%
Venturi Mask delivery amount
4-10 L
24-55 %
Simple Face Mask
5-8 L
40-60%
Simple Face Mask
5-8 L
40-60%
Non-rebreather Mask
100%, and is the only device to provide 100% , and is used for CO poisoning
Visual disturbances is expected is what part of the brain mess up.
Occipital lobe
Magnesium sulfate indication in labor
Prevent seizure activity associated with preeclampsia and eclampsia,
Delay labor progress to prevent preterm labor
In a client with cystic fibrosis how the stool look ?
Bulky, foul-smelling, oily stools
Irregular , and P-Waves is what rhythm ?
Atrial fibrillation
P-Waves and regular what rhytm ?
Sinus Tachycardia
Spirolactone and sodium?
Retain sodium does not lower it
Prednisone decrease what electrolytes?
Potassium
1 cup equal to ?
8 ounces
Simethicone Indication
To treat Excessive flatulence and it’s discomfort
Medications that may cause a prolonged QT :
Azithromycin , haloperidol , Ziprasidone , Ondosetron
Oxybutynin Indication
To treat urinary bladder urgency and incontinence
Sumatriptan adverse effects
Angina
What is cheiloplasty?
Is a procedure to repair a cleft lip
What do the nurse need to have the bed after a patient cheiloplasty ?
Bulb syringe , suction equipment
Earliest sign of digoxin toxicity
Vomiting, report to provider
Deficiency in client with Chronic Alcoholism?
Vitamin B9
Thiamine
Magnesium
What test is needed before starting Isotretinoin ?
Pregnancy test
Beta blocker mechanism of action
Decrease blood pressure by causing vasodilation of the vessels.
Block catecholamines from the beta receptors sites found in the heart and lungs
What medication may cause Stevens-Johnson syndrome?
Lamotrigine
Trans esophageal echocardiogram indication
To derermine if patient have any blood clots in the heart
What meds do we use for dytonic reactions?
Diphenhydramine
Lamotrigine indication
To treat bipolar disorder
Epilepsy
NG tube is correctly placed if PH is ?
Under 5.5
Risperidone adverse effects
Gynecomastia
Guided Imagery
Involves the client creating an image in mind , concentrating on the image and gradually becoming less aware of the offending stimulus.
Bradykinesia
Slow movement , develops by patient with slow movement.
Akinesia
Freezing or no movement, develops with client parkinson disease
Digoxin indication
Used to manage and treat heart failure,
To control ventricular rates in some clients with Atrial fibrillation
Early signs of digoxin toxicity
Anorexia , nausea, vomiting
Neurological abnormalities can also occur early : Fatigue , headache, weakness, depression, drowsiness, nightmares.
Late signs of digoxin toxicity
Facial pain, personality changes , ocular disturbances (photophobia, diplopia, light flashes, halos around bright objects , yellow or green color perception
What happen with hypermagnesemia ?
Neurological manifestations occurs when magnesium elevated : depression, drowsiness, sedation, lethargy, respiratory depression, muscle weakness, areflexia, bradycardia, hypertension
Epiglotttis
Is a serious obstructive inflammatory process that requires immediate intervention and that airway patency is a priority
Epiglottitis nursing intervention
Lateral neck and chest X-ray to determine degree of obstruction.
Sit upright to reduce respiratory distress
Place on oxygen saturation monitor
Tracheostomy or intubation may be necessary if respiratory distress is severe
Epiglottitis contraindications intervetions
Do not examine the throat with a tongue depressor or attempting to obtain a throat culture
Oral contraceptives contraindications
Thrombophlebitis
Thromboembolic disorder
Cardiovascular disease
Cerebrovascular disease
Breast cancer
Estrogen dependent-cancer
Malignant or benign tumor
Impaired liver function
Hypertension
Diabetes mellitus with vascular involvement
What cardiac rhythm is this one ?
Ventricular fibrillation
Ventricular Fibrillation intervention
Defibrillate immediately
If defibrillator is not available, do CPR until defibrillator arrives.
Position to administer an enema ?
Left lateral side lying position with the right knee flexed
Position to administer an enema ?
Left lateral side lying position with the right knee flexed
Words that indicate the need to prioritize
Words that reflects assessment
Additional Strategic words
Normal temperature value
97.8- 99.5
Hypovolemia earliest sign
Restlessness, followed by increase heart rate and decreased blood pressure
Digoxin teaching
If pulse rate drops less than 60 notify your cardiologist…….
Maslow hierarchy
Physiological
Safety and security needs
Love and belonging
Self-esteem
Self-actualization
Contact precaution equipment
Gown and Gloves
Face shield if splashing is anticipated
Beta blocker end with what prefix
Lol
Angiotensin-converting enzyme inhibitors (ACE) end with what prefix , and what their indication
‘’Pril’’
Use for Hypertension
Pharmocology rules
-Do not take antacid with medication because the antacid will affect the absorption of the medication.
-Do not crush enteric-coated or sustained release tablets, also capsules should not be opened
-Never adjust or change a medication dose or abruptly stop taking the medication
-Avoid taking OTC or herbal supplements unless prescribed by provider
TURP (Transurethral resection of the prostate) expected symptoms :
Pink urine (normal assessment)
Legal Criteria for involuntary admission
-Individual is unable to adequately meet basic needs (food,clothing,shelter,medical care, personal safety)
-Individual appears to be imminent danger to self or others
Veracity
Tell the truth and avoid dishonesty
Scope of UAP
-Activities of daily living
-Hygiene
-Linen change
-Routine, Stable vital signs
-Documenting intake & output
-Positioning
Signs of intracranial pressure in Children
-Bulging fontanelles
-Increased head circumference
-Sunset eyes, sclera visible above the iris, setting-sun sign
-Prominent scalp veins
Normal diaper rate change in children
6-10 diaper / day
Babinki reflex
Toes fan out and big toes dorsiflexes when plantar surface is stroked
Morphine assessment time following
30 minutes after administration
Gastric bypass surgery intervention
-Should be treated with antiemetic if Postoperative nausea, vomiting , dry heaving occur to avoid wound dehiscence , and evisceration
Ventricular Septal defect what is it ?
Opening between the ventricles that results in shunting of oxygenated blood from left to right ventricle
Ventricular Septal defect may lead to :
Heart failure
Grunting during feeding in patient with ventricular septal defect indicate :
Heart failure
Patent Ductus arteriosus PDA is :
When the ductus arteriousus remains open causing blood to shunt from the aorta to the pulmonary artery.
Loud, machine,like murmur is expected
Coartation of the aorta
Narrowing of the descending aorta, which results in increased blood flow to the upper extremities (bounding radial pulses ) , and decreased blood flow to the lower extremities.
LPN scope of practice
-Monitoring RN findings
-Reinforcing education
-Routines procedures
-Most medication administration m
-Ostomy care
-Tube patency and enteral feeding
Limited assessment than an LPN can do :
Lungs sounds
Bowel sounds
Neurovascular checks
ICP (Intrahepatic cholestasis of pregnancy ) is a :
Liver disorder exclusive to pregnancy that typically occurs during the third trimester and causes generalized pruritus that is worse on the hand and feet , however no rash is present
Signs of cardiac tamponade
Tachycardia
Muffled heart sounds
Jugular veins distentions
Decreased BP
Vaginal delivery may be contraindicated if client got
Genital herpes , taking antiviral like acyclovir
Nonmaleficience
Do no harm
Paternalism
Client being treated as children
Oxygen level that would be concerning on Nclex
Below 93%
Blood glucose range within first 24 hours after birth
40-60 mg/dl
Criteria to call provider in middle of the night
-Falls
-Deteriorates significantly or dies
-Has critical laboratory results
-Needs prescription that requires clarification
-Leaves against AMA
-Refuses key treatment in a relevant period
Glascow coma scale <7 means
Client in a coma
APTT normal value
46-70 seconds
1.5 - 2 times normal
Peak flow emergency value
<50%
Hydrocephalus is an :
Increase in an intracranial pressure that results from obstruction of cerebrospinal fluid.
Intracranial pressure can lead to:
Death , brain damage
Signs of hydrocephalus (intracranial pressure) in children
-Bulging fontanelles
-Increased head circumference
-Sunset eyes (sclera visible above the iris )
Vomiting
PVC (Premature ventricular contraction) rhythm
Intrahepatic cholestasis of pregnancy (ICP) is a :
Is a liver disorder exclusive to pregnancy that typically occurs during the 3rd trimester and causes generalized pruritus that is worse on the hands and feet , however no rash is present.
Intrahepatic cholestasis of pregnancy (ICP) is a :
Is a liver disorder exclusive to pregnancy that typically occurs during the 3rd trimester and causes generalized pruritus that is worse on the hands and feet , however no rash is present.
Signs and symptoms of cardiac tamponade
-Tachycardia
-Muffled heart sound
-Jugular vein distention
-Decrease in systolic blood pressure
-hypotension
Speech Therapy deal with :
-Communicating
-Swallowing
-Eating
Social worker deal with :
-Coping
-Connecting to resources
Genital herpes is caused by what virus ?
Herpes simplex virus (HSV)
Characteristic of HSV
Painful , vesicular lesions that form ulcers that cross over.
Headache
Low grade fever
Malaise
Paresthesia
Itching at the site
Meds for HSV
Acyclovir (antiviral)
Pregnant Women with HSV need to have what delivery method
Cesarean birth
Patient with Alcoholic cirrhosis is at risk for :
Hemorrhage due to esophageal varices and coagulation disorders
Normal respiratory for infant
30-60 min
Normal temperature for infant
97.7-99.7
Pulses Spot
What’s an aura ?
Is a sensory warning that a complex or generalized seizure will occur
Tyroid Storm symptoms
Tachycardia , fever , hypotension, CHF, nausea, vomiting , diarrhea, altered mental status
Green amniotic fluid indicate what ?
Fetus has passed it first stool in utero
Infant botulism is a
Food poisoning that occurs after consuming clostridium botulinum, which is a bacteria in soil and animal
Infants botulism signs and symptoms
Constipation , decreased head control , diminished tendon reflexes
Botulism put on at risk for :
Respiratory failure and arrest
Postion for client with hypovolemic shock
-Maintaining head of bed <=30 to allow venous return , increase cardiac output, perfusion
Assault is an :
Act that threatens the client and cause the client to fear arm, but without the client being touched
Battery
Involve making physical contact with the client without permission
Is the intentional touching of a person that is legally defined or occurs without the person consent
Breast cancer appearance
Red, warm, peau d’orange breast tissue, breast mass
SABA (albuterol) adverse effects
Palpitation
Peak flow meter value and intervention
Green zone >=80% no intervention needed.
Yellow zone 50-79% SABA albuterol
Red zone <50% emergency medical care
Hypothyroidism signs and symptoms
Constipation , weakness , peripheral edema
Serotonine syndrome is cauused by what type of meds
SSRI ( Paroxetine )
Serotonin syndrome signs and symtoms
-Altered mental status (agitation,confusion, hallucinations)
-Neuromuscular excitement (Jitters, tremors, shivering)
-Automatic symptoms (high fever, diaphoresis, diarrhea)
Brain cancer risk factor
Early menarche
Late menaupause
Long use of menopausal therapy , estrogen, progestin pills
Do not administer live vaccine to :
Compromised immune system client
Immunosuppresed client
Live vaccine Example
MMR
Varicella zoster (chickenpox)
Rotavirus
Yellow fever
Polio
Client that fall in the category low immune system and to not administer live vaccine
Cancer
Chemo / radiation
Methotrexate
Immunoglobulins therapy
Pregnant client
JVD distention assessment angle
30-45 degree angle
True labor signs
Contraction
Pain in lower back, radiates to abdomen
Increase cervical dilation and effacement
Red meat increase risk for :
Cancer
Vaccine to not administer to pregnant women
HPV
MMR
Live attenuated vaccine
Varicella
Postmature , posterm newborn clinical finding
Deep plantar creases
Dry cracked and peeling skin
Abundant scalp hair and long fingernails
Minimal or absent vernix caseosa
Recurrent chlamydial infection and pelvic inflammatory disease may lead to :
Infertility
Total weight gain during pregnancy
25-35 LB
To prevent neural tube defects a pregnant client needs to take:
Folic acid ( cereals, breads, pastas, green leafy vegetables, brocolli asparagus
B-Complex vitamins
Daily folic acid for pregnant women
400 mcg supplement
Bishop score
Is a system for the assessment and rating of cervical favoribility and readiness for induction of labor
Normal Bishop score
Score of 6-8 in nulliparous women means successful induction and subsequent vaginal birth
Infant weight at 6-12 months
Double by age of 6 months
Triple by age of 12 months
Posterior fontanel fuses at
2-3 months
Anterior fontanel fuses at
18 months
Recommendations for constipation during pregnancy
Regular moderate intensity exercise
Increase intake of high fiber (raw fruit and vegetables)
Drink adequate fluid
Influenza Vaccine can be given to baby at what age ?
> =6 months
Molar pregnancy , hydatiform mole teaching
Avoid pregnancy during follow up care while the health care provider monitor human chorionic gonadotropin levels to ensure that gestational trophoblastic neoplasia does not develop
Fundal height is measured from
The symphisis pubis to the top of the uterine fundus
Fundal height is at the symphysis pubis at when:
12 weeks
Reaches the umbilicus at : 20-22 weeks
At the xiphoid : 36 weeeks
GTPAL
G=> Gravidity : number of times a person has been pregnant, regardless of pregnancy outcome.
T=> Term : number of birth at 37 weeks 0 gestation and beyond
P=> Preterm : Number of birth at 20 weeks 0 days to 36 weeks 6 days gestation
A=> Abortion : number of pregnancy ending before 20 weeks 0 days gestation.
L=> Living children
Normal mole finding measurements
<5 mm
In chidren less than <3 you should pull the pinna :
Down and back
Second trimester starts at. :
14 weeks 6 days gestation
Quickening starts at ?
What sensation ?
16-20 weeks
Described as flutter in the abdomen
Screening for gestational diabetes for pregnant client starts
24-48 weeks
Weight gain in second trimester
1 lb per week
Risk factor for pelvic inflammatory disease
Multiple sexual partners
History of chlamydia and gonorrhea
Partner with STI
Age 15-25
Lack of consistent barrier contraception use
Lead poisoning occurs from :
Lead exposure , either via ingestion of lead-based paints, or water from lead pipes, or by inhalation of contaminated dust or soil around older homes
Lead poisoning teaching
Home environment should be inspected
Wash hand before eating
Return for follow up lead level
Use hot tap water
Cystic fibrosis facts
Both parents must be carrier of the abnormak genes for offspring to get the disorder
Right occiput position intervention
Apply counterpressure to the client sacrum during contraction
HPV can be transmitted through :
Skin to skin
Sexual contact vaginal anal or oral
HPV put you at risk for what type of cancer
Cervical cancer
Hpv vaccine age
9-26
Breast engorgement comforts measure
Application of ice pack and chilled
Fresh cabbage leaves
Analgesic
Firm breast support
Menaupause teaching
Have cholesterol level monitored
Engage in weight bearing exercise
Consume dietary calcium, green leafy vegetables, low fat diary products
Vacuum assisted vaginal birth caused damage to :
Brachial plexus nerve roots that connect neck and arms.
Asymmetric arm movement while testing the moro reflex on client with vaccum assisted vaginal birth may indicate :
Fracture or brachial plexus injury
Average newborn head circumference
13-14 in
33-35 cm
Infection that causes abnormalities during pregnancy
TORCH ( Toxoplasmosis, Rubella, Cytomegalovirus, Herpex simplex virus )
Pregnant woman who is allergic to penicilin should get
Penicilin desensitization
Nitrazine PH test help differentiate what :
Alkaline amniotic fluid and vaginal secretion or urine
Nitrazine PH color test meaning :
Yellow or Green : suggest that amniotic membrane are intact
Bluish color : probable rupture of membrane
Presence of blood or semen may result in false positive
Factors that causes peripheral artery disease
Smoking
Hypertension
Diabetes mellitus
Hyperlipidemia
Risk factor for hyperbilirubinemia
Preterm gestational age <37 weeks
Older sibling had it
Maternal blood group incompatibility
Exclusive breast feeding
Murmurs description sound
Loud blowing , musical or swooshing sounds
Anaphylactic treatment
Epinephrine
Indirect combs test screens for
RH sensitization in client who are RH negative
RH immune globulin is given at
28 weeks gestation, or within 72 hours postpartum
Fetal vertex position
Occipicut posterior
Back of the head is located posteriorly
Right occipicut
Back of the fetal head is facing neither anterior nor posterior
Right occipicut transverse
When the back of the fetal head is facing neither anterior or posterior and is facing the right side of the maternal pelvis
Breech position
Occurs when the fetal sacrum is the presenting part
Transition phase of labor dilation
8-10 cm
Hyperemesis gravidarum signs and symptoms
Ketonuria
Weight loss
Hypokalemia
Dehydration
Tachycardia
Pinprick test is a :
Test involve applying pressure to an area to assess client sensation
How to assess pulsus paradoxus
Is the difference between the pressure heard at the first korotkoff sound during expiration and the korotkoff sound heard throughout inspirations and expiration
Fetal alcohol syndrome signs and symptoms
Intellectual disability
Developmental delay
Distinct facial characteristics (indistinct philtrum,thin upper lip, epicanthal fold, flat midface , short palpebral fissures)
Pregnant women can breastfeed with hepatis B
True/False
True
Dyplasia of the hips manifestation
Presence of extra gluteal folds on the affected side of the
Examination of skin lesion
A : asymmetric
B : Border irregularity
C : Color change
D: Diameter ( size of a nickel)
E: Evolving appearance
B12 deficiency symptoms
Peripheral neuropathy
Neuromotor impairment
Memory loss
Varicella vaccine provide protection against :
Varicella zoster virus
Varicella vaccine side effects
Low grade fever
Swelling and erythema
Irritability
Rash
Aspirin in infant may cause :
Reye syndrome
Warning signs of cancer
C : change in bowels or bladder habits
A : A sore that does not heal
U : unusual bleeding or discharge from a body orifice
T: Thickening lump in the breast or elsewhere
I : Indigestion or difficulty swallowing
O : Obvious change in wart or mol
N : Nagging cough or hoarseness
Normal respiratory rate for newborn
30-60 min
Suicide risk factors
-Psychiatric disorders, prior suicide attempts
-Hopelessness
-Never married, divirced, separated
-Living alone
-Unemployed or unskilled
-Physical Illness
-Family history of suicide, family discord
-Access to firearms
-Substance abuse, impulsivity
Protective factors for suicide
Social support
Family connectedness
Parenthood
Religion and participation in religious activities
Assessment finding of child abuse should be documented in :
Body map, to provide written record of the injuries , include a detailed description of each
Aphasia
Impairments or loss of language comprehension
Anorexia nervosa clinical manifestation
Amenorrhea
Lanugo : fine, downy hair
Fluid and electrolyte imbalance
Fear of weight gain
Decreased metabolic rate : hypotension, bradycardia, cold intolerance, decreased body temperature
BMI weight loss in anorexia nervosa
<18.5 kg/m2
Neonatal abstinence syndrome or Opioid withdrawal ( same thing) clinical manifestations
CNS : irritability’s, restlessness, high pitched crying
Nasal congestion, sweating , sneezing
Poor feeding , diarrhea
Precipiting factors for delirium
Hypoxia
Acute infection
Fever
Electrolyte imbalance
Sleep deprivation
Dehydration and malnutrition
Metabolic disorders (hypoglycemia)
Opiods and benzodiazepines
Therapeutic communication
Show empathy or feelings
Sharing hope or humor
Providing information
Focusing or clarifying
Asking relevant information
Summarize or paraphrase
Delirium tremens manifestations
Fever, hypertension, tachycardia, hallucinations, diaphoresis
Parralel play age
1-3 years
Transference
Patient displaces feelings and behaviors from the patient past onto the nurse
Counter transference
Occurs when the nurse direct feelings about another person onto the client
Opioids withdrawal signs and symptoms
Anxiety, restlessness, nausea , vomiting , pupillary dilation, tachycardia
Displacement
Defense mechanism that involves redirecting uncomfortable thoughts or behaviors from their original source onto an object or individual.
Projection
Involves subconsciously assigning uncomfortable feelings to someone else of the appearance of others to cover up one’s own insecurities
Rationalization
Avoild guilt by using excuses to logically justify behavior
Reaction formation
Replacing an unpleasant impulse with its opposite impulse
Infant starts to roll at the age of :
4 months
Thiamine is given to alcohol abuse client to prevent
Wernicke encephalopathy
Paranoid personality disorder
Characterized by pervasive suspiciousness and distrust of others
Narcissistic personality disorder
Characterized by a recurrent pattern of grandiosity, need for admiration, or lack of empathy
Narcissistic personality disorder often have :
Fear of abandonment
Extreme fragile self esteem
Schizophrenia signs and symptoms
Hallucinations
Delusions
Apathy
Alogia
Anhedonia
Avolition
Lithium action
Help regulate mood and improve acute manic symptoms
Quetiapine
Decrease symptoms of schizophrenia
SSRI ( sertraline )
Elevated mood in client
Serotonin-norepinephrine reuptake inhibitor (duloxetine )
Elevated mood in client
Buprorion treat
Major Depressive disorder
ADHD
Cholinesterase inhibitors (donepezil)
Used to treat Alzheimer and improve cognitive function by increasing the amount of acetylcholine in the brain
Methylphenidate used to treat
ADHD
Alzheimer disease agitation intervention
Acknowledge the client emotions
Reassurance (kept the client from harm)
Distraction (to divert the client attention
Redirection to simple task
Agoraphobia
Is an intense fear and anxiety about being certain situations or spaces and unable to escape
Acrophobia
Fear of heights
ADHD manifestation
Hyperactivity, distractibility, impulsivity
ADHD intervention
Provide a structured, organized, and consistent environment with a daily schedule
Associative looseness
Is a form of disorganized thinking characterized by rapid , shifting ideas with little or no connection
Concrete thinking
Difficult with abstract thinking
Tangentiality
Involves transitioning from one topic to the next without getting to the point of the original idea or topic
Neologism
Are invented words that hold meaning for the client but are meaningless to others
Pursed lip breathing help with :
Reducing respiratory rate
Lessen dyspnea
Improve airflow by providing pressure that prolongs exhalation and expel trap air from the alveoli
Irritable bowel syndrome is :
A condition in children characterized by abdominal discomfort, diarrhea, constipation
Irritable bowel syndrome cure
No cure
How to improve irritable bowel syndrome
Adding probiotic supplement to the diet
Add moderate amount of fiber
Developing healthy coping skills
Exercise regularly
Avoid substance that may exacerbate IBS like high fat food , caffeinated, beverages
Myastenia gravis is
Autoimmune neuromuscular disease that involves the attack of acetylcholine receptors by autoantibodies at the neuromuscular junction
Lack of acetylcholine causes :
Fluctuating skeletal muscle weakness
Myastenia gravis clinical manifestations
Difficulty speaking, swallowing, chewing
Ptsosis ( eyelid drops
Diplopia (double vision)
Fatigue
Breathing difficulty
Meningis type of precaution?
Droplet
Meniere disease is :
Excess fluid accumulation in the inner ear
Meniere disease manifestations
Vertigo , tinnitus, hearing loss
Meniere disease self care
Low sodiun diet
Avoid stimuli (flickering light, tv)
Take antiemetic, antihistamine, sedative)
Vestibular rehabilitation
Ventricular tachycardia rhythm
Aphasia
Impairment verbal and written language comprehension
Pneumonia intervention
Chest physiotherapy
Huff coughing
Hydration
Position head of bed 45-60 degrees
Radiation contamination affect
Proliferating cell first such as oral mucosa, GI tract , bone marrow
Benign prostatic hyperplasia treatment
Transurethral resection of the prostate (TURP)
During continuous bladder irrigation (CBI) if urine output is less than CBI input this is an indicator for :
Obstruction and require immediate follow up
Position to put client in with air embolism
Left lateral trendelenburg
Genital herpes care
Use sitz bath and oatmeal bath to provides comfort and relief of itching and burning.
Avoid sex when lesion are present as the virus spread via contact
Always condoms during sex even the lesions are not present
Cranial nerve 9 and 10 injuries may cause :
Impair swallowing
Client with homonymous hemianopsia
Will not see
Object on the affected side
Primary adrenal insufficiency ( Addison disease ) manifestations
Bronze skin pigmentations
Hypovolemia
Hypertension
Hyponatremia
Hyperkalemia
Vitiligo
Appropriate intervention for asystole
Chest compression
Bag valve mask
Epinephrine
Anaphylactic shock management
Epinephrine
Elevale legs
Bronchodilator (albuterol)
Antihistamine
Corticosteroids
Ventilator associated pneumonia prevention
Elevating head of the bed
Provide oral care with antiseptic solution
Performing scheduled daily sedation vacation
Practicing strict hygiene
Measles type of precautions
Airborne precaution
Measle isolation precautions
Negative pressure room
N95
Post mastectomy position
Semi-fowler position to promote ease breathing
Arm and hand on the affected side should be placed on elevated pillow to promote drainage and prevent lymphatic pooling
Choking intervention for client <1
Back slaps and chest thrusts
Choking intervention for children > 1
Abdominal thrust
Intussusception manifestations
Abdominal pain
Current jelly stools
Sausage shaped abdominal mass
Intracranial pressure manifestation
Decreased level of consciousness, muscle flaccidity, projectile vomiting , cushing triad
Esophageal atresia / tracheoesophageal fistula is :
Esophagus and trachea do not properly develop
Hypothyroidism manifestation
Fatigue , weight gain , cold intolerance, decreased gastrointestinal motility, menstrual irregularities.
BNP protein function
Is a protein made by the ventricle in response to stretching caused by increased blood volume and extracellular fluid that accompany heart failure
BNP causes :
Natriuses : sodium elimation
Normal BNP
<100
People with heart failure have an :
Elevated BNP
Clinical manifestations of hypothyroidism in infants
Dry skin
Hoarse cry
Difficulty awakening
Bacterial meningitis manifestation in newborn
Seizures
High pitch cry
Poor feeding
Nuchal rigidity
Bulging fontanelles
SIADH manifestation
Sodium level slightly decrease
Decreased urine output
Water retention result in weight gain
High urine specific gravity
Low serum osmolarity
Higher urine osmolarity
Burn degree
Normal uterine contractions during first stage of labor
Brocca Aphasia is caused by damage to :
Frontal lobe
Tracheotomy suctioning techniques
Preoxygenate with 100% oxygen
Use strictly sterile techniques
Suction only while withdrawing the catheter from the tracheostomy tube
Limit suction to 10-15 seconds
P Wave represents
Atrial depolarization
QRS complex represents
Ventricular depolarization
Atrial pacemaker should displayed
Pacemaker spike before the P wave
Hip fracture manifestation
External rotation
Abduction
Muscle spasm
Shortening of the affected extremities
Hypoalbuminemia lead to
Pitting edema
Ascites
Purse lib breathing how do you do it ?
Sit upright and inhale deeply , before performing a quick forceful exhalation that creates an audible huff sounds
Pursed lips during exhalation should be performing during pursed lip breathing
Rate of respiration is regulated by
Medulla Oblongata
Speech is controlled by
Frontal lobe
Touch , sensation is controlled by
Parietal lobe
Vision is controlled by
Occipital lobe
Ball palsy in an inflammation of what cranial nerve
Cranial nerve 7
Tracheostomy care position
Semi fowler position
Frosbite intervention
No massaging or rubbing
Provide warm water soak
analgesia , and report increasing pain
Elevated injury area above the level of the heart
Apply loose , nonadherent , sterile dressing, monitoring for compartment syndrome
Tetanus immunization
Assess for compartment syndrome
Arteriography to evaluate perfusion
Amputation may be required due to those develop gangrene or compartment syndrome
Emergency treatment for autonomic dysreflexia
Check for bowel distention
Removing tight clothing
Raising head of the bed
Ectopic pregnancy signs and symptoms
Hypotension, tachycardia, dizziness, shoulder pain , pelvic pain, vaginal bleeding, positive pregnancy test
Ptosis is an injury to what cranial nerve
Cranial nerve 3
Retinoblastoma make pupils appears
White
Anticoagulants are contraindicated in client with
Hemorrhagic stroke
Bed position for hip replacement
<60
Spirometer use indication
Sitting or high fowler position
Raise the piston to preset goal marker
Spirometer should be used 5-10 times every hours
Hold breath 2-6 seconds after inhalation
Macular degeneration manifestations
Blurry spot in the middle
Anemia is characterized by
Low hemoglobin level
Neutropenia is characterized by
Low wbc count
Thrombocytopenia is characterized by
Decreased platelets count
Septic shock signs and symptoms
Fever
Hypothermia
Hypotension
Tachycardia
Leukocytosis
Client with hemophilia should not take
NSAID
Normal heart rate (1-12 month)
100-160 min
Normal respiratory rate (1-12 month)
30-60 min
Polycythemia vera is:
Too much RBC produced causing increased blood viscosity, venous stasis , and increased risk for thrombus formation
Polycythemia vera management:
Therapeutic phlebotomy
Low dose of aspirin
Increase fluid intake
Elevating legs while sitting
Antihistamine cream
Tuberculosis signs and symptoms
Low grade fever
Night sweats
Anorexia and weight loss
Fatigue
Cough
Purulent or blood tinged sputum
SOB
Poorly controlled diabetes in pregnancy lead to
Polycythemia (elevated hematocrit)
Pertussis type of precautions
Droplet precautions
Green Vomit represents
Bile from instestine which indicate bowel obstruction
Marfan syndrome causes
Sudden death in athletes due to cardiac abnormalities
Wound irrigation process
Administer analgesics
Fill a 30-60 ml sterile irrigation
Attach 18-19 gauge needle and hold it 1 inch above the wound
Use continuous pressure to flush the wound , repeat until drainage is clear
Dry the surrounding wound area to prevent skin breakdown
Clean from the least contaminated area
Diabetes insipidus treatment
Desmopressin
Anaphylaxis symptoms
Respiratory compromise (oral and airway, swelling, stridor, wheezing, chest tightness,
Shock ( dizziness, loss of consciousness)
Infants cardiac arrest intervention
Check the infant pulse no longer than 10 seconds
Provide 2 minutes of CPT till at rate of at least 100 compression
Trachea deviated from midline is a sign of
Tension pneumothorax
Pneumonia signs and symptoms
Crackles
Pleuritic chest pain
Bronchial breath sound
Unequal chest expansion
Dullness
Myastenia gravis intervention
Vaccination
Eating soft food
Taking acetylcholine inhibitors (pyrisdostigminr) 45-60 min before meal
Planning for precipitating factors like pregnancy
Epidural anesthesia may lead to
Hypotension
Non pharmacological invertion for SVT
Vagal manoeuvers : place ice bag to the client face and instruct client to hold their breath while bearing down
Hypoglycemia signs and symptoms
Diaphoresis
Pallor , paresthesia
Trembling
Palpitations
Anxiety
Restlessness
Blurred vision
Cool and clammy skin
Acute pancreatitis manifestation
Left upper quadrant pain radiating to the back
Ronchi is heard in client with
Bronchitis
Rules of 9
Chest tube >100 ML /hr
Is sign of hemorrhage
Magnesium toxicity antidote
Calcium gluconate
Hemophilia treatment
Administer IV factor VIII
Signs of ectopic pregnancy
Hypotension
Tachycardia
Shoulder pain
Venous ulcer management
Elevate leg 20-30 // 3-4 times daily
Consume diet in high protein Vitamin C, Vitamin A, Zinc
Apply compression stocking
Apply fragrance free moisturizer
Peritonitis manifestation
Fever
Abdominal rigidity
Guarding
Rebound tenderness
Acute thyrotoxicosis ( thyroid storm )
Life threatening conditions that occur in response to stress
Ulcerative colitis management
Take vitamin and oral supplements
Use a skin barrier cream for perianal irritation
Drinking at least 2000-3000 ml
Continuously taking sulfasalazine after symptoms resolve
Duchenne Muscular dystrophy manifestation
Gower sign: placing hand on thigh to push up to stand
Enlarged calves
Walking on tiptoe
Frequent tripping or falling
Acute closure glaucoma manifestation
Severe eyes pain
Reduced central vision
Blurred vision
Ocular redness
Halos around the light
Blood transfusion intervention
Stop the transfusions
Initiate normal saline to maintain IV access and prevent hypotension and vascular collapse
Signs of blood transfusions reaction
Chills
Fever
Low back pain
Itching
Blood transfusions reaction intervention
Stop transfusion immediately and disconnect tubing
Maintain IV access with normal saline
Notify HCP
Monitor vital signs
Recheck labels, numbers , and client blood type
Treat client symptoms according to HCP prescriptions
Collect blood and urine specimen to evaluate for hemolysis
Return blood and tubing set to the blood bank for additional testing
Complete necessary facility paperwork to document the reaction
Hyperkalemia treatment
May give calcium gluconate
HHS Hyperosmolar hyperglycemic state manifestation
Neurological manifestations (blurry vision , lethargy, coma )
Severe hyperglycemia
Herpes Zoster (shingles ) signs symptoms
Vesicular rash has a characteristic of linear dermatomal distribution and can present with severe pain
Nonrebreather mask
Is used in emergency, delivers high concentrations of oxygen (up to 90-95 % ) requires a tight face seal.
Simple face mask
Delivers a higher concentrations of oxygen 40-60%
Venturi mask
Used to deliver a guaranteed oxygen concentration to client
Head tilt-chin manoeuver is used to
Open airway
Oropharyngeal airway
Is a temporary artificial airway used to prevent tongue displacement and tracheal obstruction in client who are sedated or unconscious
Oropharyngeal airway teaching
Should never be taped in place because of the risk for choking and aspiration
Right sided heart failure manifestions
Peripheral edema
Jugular vein distention
Increased abdominal girth
Ascites
Aspirin in children lead to :
Reye syndrome
Crackles at lung based indicate
Pulmonary edema
Bronchial breath sound indicates
Pneumonia
Stridor indicate
Laryngospasm or edema of the upper airway
Pulmonary edema manifestation
Pink frothy sputum
Acute onset dyspnea
Cough productive
Toxic epidermal necrolysis intervention
Provide cotton blankets
Administering lubricating eye drops
Oral candiasis manifeststation
White patches on the oral mucosa, palate, and tongue
Difficulty sucking or feeding
What rhythm is this one ?
Atrial fibrillation
Burn fluid resuscitation
Lactated ringer
SIADH manifestation
Dark Amber urine
Diabetes insipidus manifestation
High serum osmolarity
Low urine specific gravity
Dehydration
Polydipsia
Pheochrocytoma management
Prepare for surgical removal of the tumor
Administration of IV hypertension
Initiating 24 hr urine collection
Pleural effusion manifestations
Dyspnea
Pain with respiratory
Diminished breath sounds with dullness to percussion over the area
Symptoms of paralytic ileus
Abdominal discomfort , distention
Nausea, vomiting
Lispro
Given within 15 minutes before eaten
Peak 30 min - 3hrs
Client with peptic ulcer disease should avoid :
NSAIDS
Smoking
Excess use of alcohol or caffeine
Wound evisceration position
Low fowler position with knees bent to reduce tension on the open wound
Hirschsprung disease manifestation
Difficulty tolerating feeding
Bilious emesis
Distended abdomen
No passage of meconium for 48 hours
First line of treatment for torsades de pointe
IV Magnesium
Maslow hierarchy of needs
Tripod position
Helps ease work of breathing in client with COPD
Tradelenburg position
Helps to increase venous return in client with shock
Right lateral position
Used in client with pneumonia
SVT initial treatment
Vagal manoeuvers ( bearing down as if having a bowel movement
Risk factors for oral candiasis
Immunosuppressant (HIV) antibiotic therapy
Fat embolism manifestation
Respiratory issues
Petechiae
Neurologic impairment
Preterm labor intervention
Administer glucocorticoids (bethamethasone , dexamethasone ) to stimulate lung maturity
Administration of antibiotics
Initiated magnesium sulfate
Give to tocolytics ( nifedipine , indomethacin ) to suppress uterine uterine activity
Yellow zone on peak flow meter
Indicates symptoms are worsening, and the client need to take rescue meds
If level return to green , no changes are necessary to daily meds
Angiotensin converting enzyme inhibitors ( pril) and angiotensin receptors blockers ( tan) are contraindicated
In pregnant women
Position to put a baby with cleft lip palate
Upright supine position
Left to right cardiac shunt ( patent ductus arteriosus, atrial septal defect, ventricular septal defect ) manifestation
Heart murmur
Poor weight gain
Diaphoresis
Signs of heart failure
Peritonitis manifestation
Low grade fever
Tachycardia
Cloudy outflow
Carpal spasm ( trousseau)
Signs of hypocalcemia
How to use adult AED( adult external defibrillator) on kids
One pad is placed on the chest
The other pad is placed on the back
Hepatis nursing intervention
Rest
Adequate nutrition ( adequate carbohydrates and protein intake, low fat small frequent meals)
Diabetes insipidus clinical manifestations
Polyuria
Polydipsia
Hypernatremia
Increased serum osmolarity
Decreased urine specific gravity
Hyperthyroidism nutrition
High protein
Carbohydrates
Vitamin
Minerals
Cushing syndrome clinical manifestations
Weight gain
Truncal obesity
Moon face
Skin Atrophy
Muscle weakness
Hypertension
Hyperglycemia
Pursed lip technique
Inhale 2 seconds through my nose , keeping my mouth close
Exhale 4 seconds through purse lips
Otitis media manifestation
Purulent drainage
Red and bulging tympanic membrane
Restlessness and irritability
Pulling on the ear
Refusal to eat
Phases of seizure
Prodromal phase: period with warning signs that precede the seizure
Aural phase : period before the seizure where client may experience visual or other sensory changes
Ictal phase : is the period of active seizure
Postical phase: recovery, client may experience confusion
Adult AED should be used by the age of
8
Sjogren syndrome teaching
Use artificial tears and saliva
Pulseless client intervention
2 minutes of CpR in cycles of 30 high quality chest compression to 2 rescue breath ,
followed by activating the emergency response and obtaining an AED
Poison Ivy intervention
Wash the area
Transcuder placement for BP reading
4th intercostal space at the midaxillary line
Malignant hyperthermia treatment
Dantrolene
Mechanical ventilation intervention
Maintain head of bed 30-45%
Pause sedation to assess weaning
With hyperkalemia on ECG the nurse should monitor
Tall, peaked T waves on the ECG
Addison disease primary treatment
Costicosteroid (end in sone )
Long term used of corticosteroids may mask signs of
Infection , so report sign of infection to HCP asap
Report signs of hyperglycemia
Statins adverse effect
Myopathy ( generalized by muscle aches and weakness )
Muscle injury
Hepatic dysfunction
Anticholinergic meds adverse effects
Urinary retention
Vancomycin administration time
Over 60 minutes to prevent VIR
Isotretinoin contraindications
Vitamin A
Tetracycline
Clopidogrel should not be given in client with
Peptic ulcer disease
Before administering beta blocker the nurse should monitor
Blood pressure
Heart rate
Before administering ace inhibitors the nurse should monitor
Potassium
Blood pressure
Aspirin requires monitoring
Platelets levels
Sign of bleeding
Statins require monitoring
Muscle pain before administering
Scopolamine patch is placed :
Behind the ear
Antacids should not be administered with
Misoprotol
What to monitor when child receiving methylphenidate
Height / Weight / Blood Pressure
Phenytoin indication
Partial seizures
Phenytoin toxicity signs and symptoms
Neurological manifestations
Ataxia
Nystagmus
Nausea
Vomiting
Levetiracetam indication
Treat seizures
Signs of hypokalemia
Muscle weakness, cramps
Mannitol indication
Treat cerebral edema
Acute glaucoma
Live attenuated influenza vaccine should not be given to :
Immunocompromised
Pregnant
Less than 2 years of age
Metoclopramide puts patients at risk for :
Tardive dyskinesia (uncontrollable lip smacking , hand wringing, rocking
Ace inhibitors adverse effects
Angioedema (swelling of the lips , tongue , throat, face , larynx)
Erythropoietin alfa contraindications
Uncontrolled blood pressure
Benzodiazepines (pam) antidote
Flumazenil
Topical capsaicin teaching
Wait 30 minutes before washing the affected area
Carbidopa/ levodopa teaching
Urine and saliva may turn reddish brown but this is not harmful
Site of injection in newborn
Vastus lateralis
TB induration positive if
Induration >=15
Immunocompromised >=5
Long term used of Proton pump inhibitors (prazole)
Put patient at risk for clostridium difficile associated with diarrhea, decreased bone density, pneumonia, hypomagnesemia
Statins drugs teaching
Report any muscle aches or weakness as these can lead to rhambolysis
Methylphenidate teaching
Take in the morning
Ferrous sulfate indication
Treat iron deficiency anemia
Ferrous sulfate teaching
Administer 1 hr or 2 before or after meals
Antacids or calcium decrease absorption of iron if administered with or within 1hr of sulfate
Proton Pump inhibitor put patient at risk for
Osteoporosis
Bones fractures from decreased calcium absorption
IUD teaching
Mild discomfort ,cramping, spotting is associated with IUD insertion
Heavier bleeding
Check on IUD string at least every month
Benzodiazepines withdrawal symptoms
Tremor
Seizures
Tachycardia
Nausea
Vomiting
Medications that are contraindicated during pregnancy
Doxycycline
Ace inhibitors (pril)
Isotretinoin
Levothyroxine teaching
Take on empty stomach preferably in the morning
Hyperkalemia (ECG peaked T waves) treatment
Calcium gluconate to prevent life threatening dysrhythmias
After calcium gluconate meds to correct potassium level is administered
Pain management during second stage of labor :
Epidural anesthesia
Nitrous oxide
Pudental nerve block
Corticosteroids ( sone ) risk
Increase the risk for conversion of latent TB to active TB
SSRI and MAOI contraindicated
Should never be taken together
Enema administration
Put patient in left lateral position with knee flexed
Hang the enema no more than 12 inches (30 cm) above the rectum to avoid overly rapid administration
Lubricants the enema tubing tip and insert 3-4 inches (7.5-10 cm ) into the rectum
Insert the tubing tip directed toward the umbilicus
Encourage client to retain the enema (5-10 minutes )
Opening the roller clamp on the tubing to allow the solution to flow by gravity
Stop if report abdominal cramps
Simvastatin teaching
Take in the evening at bedtime
Digoxin teaching
Check pulse , Heart rate
Report GI ( anorexia , nausea, abdominal pain)
Report visual changes ( alterations in color vision, scotomas, blindness)
Neurological changes ( lethargy, fatigue, weakness, confusion, dizzy , lightheaded)
Methylergonovine contraindication
Contraindicated for clients with hypertension due to the risk of seizures or stroke
Recommended rate for infusion of potassium chloride
No greater than 10 mEq/hr (10 mmol/hr
Low sodium diet can precipitate
Lithium toxicity
Allopurinol teaching
Take medication with a full glass of water with each dose
Increase fluid intake
Sulfasazaline indication
Rheumatoid arthritis
Inflammatory bowel disease
Sulfasalazine adverse effects
Crytalluria
Yellow orange skin
Urine discoloration
Photosensitivity
Duloxetine , pregabalin , amitryptyline indication
Pain relieving effects
Depression
Potassium chloride teaching
Take it with a full glass of water and stay sitting upright
Contraindicated with oliguria
Elevated TSH level interventions
Increase levothyroxine dose
Dabigatran teaching
No routine lab check required
Hold digoxin in children if
Heart rate <90-110 in infants and young children
Heart rate <70 in older children
Misoprostol contraindications
Cesarean Birth
Abnormal fetal heart rate
Urine tachysystole
History of renal failure
Insertion of central venous access device in femoral vein should be avoided due to
High risk for central line- associated bloodstream infection
Sulfonylyrea (glyburide) adverse effects
Hypoglycemia, Weight gain
Methotrexate teaching
Increase dietary intake of folic acid
Isoniazid teaching
Take pyridoxine vitamin B6 to prevent neuropathy
Avoid aluminum containing antacids
Report hepatotoxicity jaundice dark urine
Report numbness
Polystyrene sulfonate enema
Kayexalate retention enema
Indication
For client with high serum potassium levels
Omeprazole indication
To prevent stress ulcers from developing during surgery or a major illness
Anticholinergic (Benztropine , trihexyphenidyl) contraindicarion
Client with glaucoma , urinary retention or benign hyperplasia
Methylphenidate teaching
Causes insomnia do not administer the last dose no later than 6pm to precent disruption
Indimethacin teaching
Indomethacin increase the risk for bleeding when used concurrently with apixaban therapy
Lithium toxicity intervention teaching
Drinking at least 8-12 cups of fluid
Receiving routine blood test
IV iodine teaching
Metformin should be discontinued 24-48 hours before administration of iodined contrast
Avoid in client with renal impairment
Ear drop teaching
Pull pinna up and back to straighten the ear canal in clients >4 years old and adults
Pull the pinna down and back <3 years old
Signs of magnesium toxicity
Absent or diminished tendon reflexes
Decreased respiratory rate
Somnolence
Sertraline may cause :
Sexual dysfunction
TLS tumor lysis syndrome may cause
Severe electrolyte imbalance
Desmopressin teaching
Desmopressin will lower urinary output and cause the specific gravity to increase
Amoxicillin / clavulanate teaching
Take with food
Shake well before administering
Medication that we don’t administer via NG tube
Enteric coated
Extended release
Sustained release
Asthma exacerbation management
Short acting beta agonist (Albuterol , Ipratopium )
Corticosteroids ( methylprenisolone )
Oxygen saturation maintains >90%
Nitroglycerin teaching
It should be stored in the original container at room temperature to protect from degradation
Warfarin teaching
Warfarin must be taken same time every day to maintain therapeutic INR
Antibiotics can affect INR value
Stimulant meds like Methylphenidate adverse effects
Weight loss
Hypertension
Exacerbation of vocal / motor tics
Excess brain stimulation
Abuse potential
Suppository meds administration teaching
Suppository must be inserted past both the external and internal sphincter
Tetracycline teaching
Take 1 hour before or 2 hr after meals with water
Take with dairy products or withing 2 hours of taking antacids
Use sunblock due to photosensitivity
Acronym to assess stroke
FAST
F : facial dropping (numbness or droopiness on one side of the face)
A : Arm weakness ( weakness or drifting of one arm when raised shoulder level)
S : Speech difficulties (slurring speech , incomprehensible speech , inability to understand others
T: Notation of the time of symptoms onset, which is critical for guiding treatment
Pavlik harness care :
Assess skin 2-3 times daily for redness , breakdown, under the straps
Dress child in a shirt and knee socks
Apply diapers underneath the straps
Leave harness on at all times
Peripheral venous access device insertion site
Cephalic vein
Elevated BNP is indicative of
Heart failure
Neonate resting pulse
110-160
Electroencephalogram teaching
Wash hair
Avoid caffeine beverages
ECG is painless
Valsava manoeuver is contraindicated in clients
With intracranial pressure
Stroke
Head injury
Heart disease
Cataract surgery
Positioning
Tradelenburg : for air embolism
Side lying with head, back, knees flexed : lumbar puncture
Arm raised above the head on the affected side : chest tube
Descending stairs using a cane
1.Cane , 2.affected leg 3.unaffected leg
Going up a stairs with cane
1.Step up with the stronger let
- Move cane next while bearing weight on the stronger leg
- Finally move the weaker leg up
Stress incontinence
Involuntary leakage of small amounts of urine when intraabdominal pressure is increased
Herpes Zoster precautions
Private room with negative airflow
Protective gown and gloves
Airborne precautions N95
Parovirus B19 may cause
Fetal abnormalities
Stillbirth
Romberg test teaching
Stand with feet together and hand at the sides of the body , then ask to close their eyes
Loss of balance indicates ataxia is sensory
Normal glascow score
15
Abdominal examination order
1.Inspections 2. Auscultation 3. Percussion 4.Palpitations
Normal Pupils
3-5 mm
Mnemonic for metabolic syndrome
We Better Think High Glucose
Waist circumference
Blood pressure
Triglycerides
HDL
Glucose
Salem Pump intervention
Semi fowler position
Mouth care every 4 hours
Turn off suction briefly every 4 hours
Turn off suction briefly during auscultation
Priority goal after mastectomy
Elevate the affected arm
Boston Brace teaching
Proper skin care
Wear a cotton t-shirt under the brace
Adherence to wearing the brace
Position to prevent aspiration pneumonia
Side lying position
Polycythemia vera teaching
Elevate leg and feet while sitting
Wearing support stocking
Increase fluid intake during exercise and hot wearing
Report sign of DVT , swelling, tenderness
Infant with bacterial meningitis may develop
Hydrocephalus
And ICP
So bulging fontanels and increasing head circumference are important indicators of bacterial meningitis may
Uterine tachysystole occurs when
Contraction are too frequent >5 contraction in 10 min
Osteoporosis may lead to
Kyphosis
Having client to track object through 6 cardinal’s point if vision is testing what cranial nerve
3 , 4 , 6
What lab values liver cirrhosis causes to be elevated
Bilirubin
Ammonia
Coagulation studies
Hyponatremia and hypoalbuminea are to be expected
Lithium level and time lab
0.8-1.2
Draw lithium level 12 hours after last dose.
Lab is also drawn to determine if you develop hypothyroidism
Refeeding syndrome characterized by
Mnemonic : PPM
Decline serum phosphate , potassium, magnesium
Mcg to ml
1ml =1000 mcg
Peak intermediate insulin (Humulin)
6-14 hours
Most common side effects of diabetes
GI disturbances
Triage
Airborne Precautions
UAP , LPN RN scope of practice
Maslow hierarchy
Central venous Catheter (CVC) vein insertion
Central vein => subclavian , internal jugular vein , femoral vein
Central venous catheter is used to :
Administer fluid
Administer meds
Parenteral nutrition
Hemodynamic
Central venous catheter teaching
Proper hand hygiene
Non sterile gloves
Catheter hubs always be handled aseptically, always allow aseptic to dry before using the hub/port
CVC are used to administer incompatible drugs simultaneously
Enteral nutrition is given through
A feeding tube , orally
Syringe size to flush a CVC
10 ML
Push pause method CVC
Slowly injecting normal saline into the cvc and stopping for any resistance, injecting against resistance may cause embolism, malfunction
Most CVC require heparin flushing for what :
To maintain patency and prevent clotting when not in use
Standard heparin dose to flush a CVC
Doses of 2-3 ml of 10 units/ml or 100 units/ml
Doses of 1000-10000 units are given in case of venous thromboembolism
Distal port of cvc is used to monitor:
Central venous pressure (right atrium monitoring)
Distal end of the CVC is located where :
In the superior vena cava vein , closest to the right atrium of the heart
Catheter (CVC) occlusion intervention
Repositioning the client m
Assessing for IV tubing , clamps, kinks or precipitate
If occlusion remain contact HCP, for alteplase
How to prevent infection when discontinuing a CVC
Supine position
Bear down or exhale
Air occlusive dressing
Pull the line cautiously
Vein to insert a peripheral venous access device
Cephalic vein
Central line dressing change technique
Sterile technique , wearing sterile gloves , mask
Central line dressing change teaching
Tell client to turn head away from the picc line
Tell client to hold breath , or perform valsalva manoeuver to prevent air entering the line
How to perform valsalva manoeuver
Hold the breath while bearing down and contracting muscle
Valsalva manoeuver contraindications
Intracranial pressure
Stroke
Head injury
Heart disease
Cataract surgery
Liver cirrhosis
What is thoracentesis
Needle inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes
Thoracentesis position
Upright sitting position on the side of the bed , leaning forward over the bedside table with arms supported on pillows
Lumbar puncture position
Fetal position
What to monitor after thoracentesis
Level of alertness
Lungs sounds
O2 saturation
Respiratory pattern
PICC line should be changed every
7 days
Thoracentesis needle insertion location
Intercostal space
What is phototherapy
Used of fluorescent light to treat hyperbilirubinemia or jaundice in newborn clients.
Convert bilirubin into water soluble form that is excreted through urine and stools
Phototherapy intervention
Fully exposed except for diaper and eye shields when placed under the phototherapy lights
No lotion or ointment
Monitor for skin breakdown and temperature changes
May removes clients for feeding and bonding
Phototherapy immediate intervention
Meconium (sticky, thick , black/dark green stool) may worsen hyperbilirubinemia
How to verify endotracheal tube placement
Capnography
Type of feeding when a client is on mechanical ventilation
Continuous feeding , no bolus
Ventilator associated pneumonia manifestation
Positive sputum culture
Leukocytosis
Elevated temperature
New or progressive infiltration on xray
How to prevent aspiration in client with ventilator
Assess abdominal distention every 4hrs , assess for GI intolerance feeding
Keep head of bed at >=30 degreees
Keep endotracheal cuff inflated
Suction any secretion
Use caution when using sedation
Avoid bolus
High positive end expiratory pressure may cause
Barotrauma
Hypotension
Avoid suction before
ABG draw
When should you suction patient with ICP ?
When O2 drops because of respiratory secretions
Ventilator asssociated pneumonia intervention
Oral care chlorhexidine every 2 hous
Reposition side to side every 2 hours
Long term complications with mechanical ventilator
Stress ulcers , so give H2 blockers or PPI
Extubation intervention
Use warm humidifier oxygen via facemask
Oral care
NPO
High fowler position
Wound dehiscence intervention
Stool softener (docusate) to prevent straining and constipation
Antimetics (ondosetron) to prevent straining with nausea
Abdominal binder to provide homeostasis, support the incision, and reduce mechanical stress on the wound
Monitor blood glucose
Splint the abdomen by holding a pillow or folded against the wound for support when coughing and moving
How often do you empty the jackson pratt
Empty device 4-12 hours unless it is 1/2 to 2/3 full
Normal expected serosanguineous drainage after 24 hours
80-120 ml in the firsr 24 hours , if more notify the provider
Wound irrigation intervention
Administer analgesics 30-60 minutes before the procedure to decrease discomfort
Fill a 30-60 ml sterile irrigation syringe with the prescribed irrigation solution
Attach 18-19 gauge needle to the syringe and hold it 1 inch(2.5 cm ) qbove the wound
Use continuous pressure to flush the wound
Dry the surrounding area to prevent skin breakdown and irritation
Venous leg ulcer management
Elevating the legs for 20-30 min 3-4 times days
Consume vitamin A and Zinc
Apply compression stocking
Fragance free moisturizer
Identify the part of this chest tube A B C D
Section A : suction Control chamber
Section B : Part of water seal chamber
Section C : water seal chamber
Section D : collection chamber
Presence of air leak is indicated by
Continuous bubbling of fluid at the base of the water seal chamber Section
Continuous, gentle bubbling in suction chamber indicate
Drainage system is working properly
Chest tubes drainage that should be reported to the provider
Drainage >3ml for 3 consecutive hours should be reported immediately to the provider
Chest tube hemothorax value to he reported
Drainage of >100 ml or sudden changes in quality should be reported to the HCP
Vein use for arteriovenus fistula
Cephalic or basilic vein
Teaching for client with fistula
Avoid sleeping on the arm
Avoid lifting heavy object , however can use a squeezing soft ball or sponge
Check the function of vascular access by feeling for vibration (thrill) to assess AVF patency
Avoid rectrictive clothing
Monitor for signs of bleeding or infection after dialysis
Signs of peritonitis due to peritoneal dialysis complications
Cloudy outflow
Low grade fever
Tachycardia
Abdominal pain
Rebound tenderness
Peritoneal insufficient outflow intervention
Assess for abdominal distention and constipation
Examin the catheter for kink or obstruction
Place the client in side-lying position
Expected color of stoma
Pink to red that is moist
Abnormal stoma color
Dusky , pale, dark colored may indicate vascular compromise and should be reported to HCP
Ascending colon care
Clarifying enteric-coated meds
Identify food that cause excess gas and odor => brocolli , cauliflower, dried beans
Finding that indicate needs to suction
Adventitious breath sounds (rhonhi, wheezes, crackles)
Altered mental status ( irritability, lethargy)
Decreased O2
Increased respiratory rate
Increased work of breathing ( flared nostrils, use of accessory muscle )
Pallor, mottling , cyanosis of the skin
Client with single chamber pacemaker will show
Pacemaker spike before the P wave
What rhythm is this :
Ventricular pacing
How to use spirometry
Sitting high fowler
Seal lips around mouthpiece before slowly inhaling
Hold breath 2-6 seconds
Coughing to promote expectoration
Meds to avoid during pregnancy
NSAIDs =>. Remember NSAIK =>
N= Naproxen
S=Salicyclic acid
A= Aspirin
I=Ibuprofen, Indomethacin
K= Ketorolac
———————————————————
Ace and Arbs => pril , sartan
———————————————————
Doxycycline and tetracycline ( cycling dangerous during pregnancy
———————————————————
Carbamazepine => seizures
Varicella vaccine teaching
Return for a second dose 4-8 weeks
Use contraception for 1 month to avoid pregnancy
Normal weight to maintain during pregnancy
18.5 - 24.9 kg
Diet and vitamin during pregnancy
Folic acid 400 mcg / day to prevent neural tube defects
Calcium 500 mg daily
Iron rich foods meat and dried fruit
Iron supplements ( ferrous sulfate) to prevent anemia
Iron teaching
Take on empty stomach
Risk for constipation
Increase vitamin c to aid absorption
Food rich with calcium , iron , B vitamins
Grilled chicken
Greens peanut butter
Juice
Protein contains foods vegetarians client
Dried beans
Seeds
Peanut butter
Peas
Sources of calcium
Dark green , leafy vegetables
Sources of folic acid
Cereal , bread , pastas
Gastric lavage is performed through what ?
Orogastric tube
Gastric lavage purpose
To remove ingested toxins and irrigate the stomach
Gastric lavage risk complications
Aspirations
Esophageal or gastric perforation
Dysrhythmia
Gastric lavage indication :
When overdose is lethal or can be initiated within 1 hour of the overdose
Standard treatment for overdose
Activated charcoal administration but it is ineffective in some drugs (lithium, iron, alcohol.
Gastric lavage teaching
Intubation and suction supplies should always be available at bedside in case aspiration, or respiratory distress
Pyelonephritis infection symptoms
Dull flank pain, extended towards the umbilicus
Major depressive disorder meds
SSRI : fluoxetine , escitalopram
Multiple sclerosis meds
Corticosteroids to reduce inflammation and accelerate neurological symptoms recovery
NMS is a complication of what meds
Olanzapine
Antipasmodic (tolterodine, oxybutynin) are used to :
Reduce the frequency of bladder spasms
Rheumatoid arthritis meds
Methotrexate
Communicable disease
Snellen chart teaching
Child age of 6 and older should stand 10 feet away
Electroconvulsive therapy facts
Client feel no pain , anesthesia and muscle relaxation are administered during ECT
Furosemide adverse effects
Ototoxic
Agoraphobia
Fear of leaving the house or being in public due to the anxiety and fear of having future attacks in situations that may be embarrassing or incapacitating
Opioid withdrawal symptoms
Nausea, vomiting, diarrhea, abdominal cramping, myalgia
Alcohol withdrawal meds
Benzodiazepine ( diazepam , lorazepam, chlordiazepoxide )
Vitamins ( thiamine, folic acid)
Hold lithium if sodium
Is low , hyponatremia
Lithium teaching
Consume adequate dietary sodium because low sodium diet precipitates sodium toxicity
Lithium take at least one for manic effects to subside and at least 2 weeks for the full therapeutic of the medication to be seen
Limit intake of soda, tea, coffee
Drink 2-3 liter of fluid each day to maintain normal sodium level and prevent toxicity
Loop diuretic ( furosemide) adverse effects :
Ototoxic
Furosemide teaching
Admister slowly to prevent Ototoxicity
Dabigatran indication
To reduce the risk for thromboembolism and stroke in client with AFIb
Dabigatran indication
To reduce the risk for thromboembolism and stroke in client with AFIb
Dabigatran teaching
Implement measure to prevent bleeding
Dabigatran capsules should be swallowed not crushed, chewed , or opened
Beta adrenergic blockers ( atenolol , metoprolol , propranolol ) indication
To reduce symptoms of thyrotoxicosis (thyroid storm?
Also treat symptoms like tachycardia, hypertension, irritability, tremors, nervousness in hyperthyroidism
Antipsychotics (haloperidol ) meds adverse effects
Neuroleptic malignant syndrome that occurs 1-3 days after initiation of rapid dose
If neuroleptic malignant syndrome is suspected the nurse should :
Hold the dose and notify the healthcare provider
NMS signs and symptoms
Muscle rigidity
Autonomic dysfunction (tachycardia, fluctuations blood pressure , Diaphoresis)
Mental status changes
Hyperthermia
Hyperglycemia
Overweight ( abdominal obesity)
Hypertension
Meds for older adults to avoids
Antidepressants (amitriptyline)
First generation antihistamines ( diphenhydramine )
Benzodiazepine ( diazepam
Thrombolytics ( Tissue plasminogen indication)
To lyse thrombi
To restore perfusion for client having ischemic stroke
Thrombolytics ( tissue plasminogen activator tpa) contraction :
Surgery
Stroke
Head trauma
Sulfonamide antibiotic ( trimethoprim-sulfamethoxazole ) teaching
Should be assessed for for allergie to sulfonurea meds ( glyburide) due to potential cross sensitivity
Common finding in dying client who is unresponsive and no longer able to manage secretions
Loud , wet respiratory
Intervention for this finding = > Anticholinergic ( sublingual atropine , scopolamine)
Corticosteroids teaching
Monitor for infection , low grade fever
Client receiving radioactive iodine should avoid :
Pregnant women and children
Use seperate toilet and disposable tableware
Sleep in separate bed
Isolate personal laundry
Effective treatment of albumin indication
Blood pressure and heart rate within normal limits
Albumin indication
Increase intravascular oncotic pressure
Increase fluid volume in client with ascites
Codeine adverse effects prevention interventions
Increase fluid
Increase bulk diet
Increase laxative
Take meds with food
Changing positions slowly
Acetylcysteine may worsen
Bronchospasm
Bismuth subsalicylate contain
Aspirin / salicylates, and aspirin causes reye syndrome in children so , avoid administering in children
Client taking enoxaparin with platelets less than ? Indicate ?
Less than <150000 indicate thrombocytopenia
Ace inhibitor should be avoided in:
Pregnant client
Adverse effects of nitroglycerin
Severe hypertension, like systolic blood pressure <90
INR > 50 poses risk for
Bleeding
NSAIDs (indomethacin, ibuprofen, naproxen ) causes
GI toxicity
Kidney injury
Exacerbation of fluid overload
Hypertension
Bleeding
NSAIDs should be taken with
Food
NSAIDs should be taken with
Food
Albuterol adverse effects
Tachycardia
Palpitations
Insomnia
Mild tremor
Vomiting
Carbidopa / levodopa indication
To treat bradykinesia in parkinson disease
To improve tremor and rigidity to some extent
Carbidopa / levodopa teaching
Should never be stopped abruptly
Before administering sodium polystyrene the nurse should assess
Bowel sounds
Review medical record of stools
Lactulose is effective if :
Improve in mental status
Lactulose indication
To decrease serum ammonia level
Phenazopyridine (pyridium) turn
Urine orange red color
Client experiencing anxiety may be given
Lavender , aromatherapy
Clonazepam contraindications
Valerian root
Kava
Melatonin
Benzodiazepines
Statins assessment prior administering
Assess dietary intake
Liver function test
Pregnancy status
Meds that decrease heart rate
Beta blocker ( metoprolol , timolol )
Calcium channel blocker ( diltiazem , verapamil
Dehydration and sodium loss may precipitate
Lithium toxicity
Miconazile indication
To treat vaginal candidiasis
Micinazole is best to administer
At bedtime
Vaginal candidiasis teacing
Wear loose-fitting cotton underwear
Refrain from swxual intercourse
Client receiving rapid acting insulin should eat :
Within 15 minutes of administration
Rapid acting insulin example
Aspart
Lispro
Glulisine
Isotretinoin teaching
Use 2 form of contraception consistently
Opioid agonist-antagonist ( butorphanol) indication
Can safely administer in client in active labor who is likely to give birth at least in 2-4 hours after opioid administration
Hypotonic dehydration signs and symptoms in client receiving furosemide
Decrease BP
Increase pulse rate
Output greater than intake
Hypernatremia
Low K
Influenza age appropriate
2-49 , but do not give to immunocompromised or less than 2 years child
Do not give to immunocompromised
Do not give to pregnant client
Sulfasalazine ( Azulfidine ) indication
For mild moderate chronic RA
For inflammatory disease
Meds associated with orthostatic hypertension
Most hypertensive
Most antipsychotic, depressant
Volume depleting agent
Levothyroxine ( synthroid ) therapeutic expectation
Elevated mood
Greater energy level
Heart rate within normal limit
Isoniazid (INH) side effects
Hepatotoxicity (jaundice, vomiting , dark urine, fatigue )
Peripheral neuropathy ( numbness, tingling of extremities)
Isoniazid teaching
Avoid alcohol
Avoid aluminum antacids
Taximofen indication
To treat and prevent receptor-positive breast cancer
Tamoxifen side effects
Deep vein (thromboembolic events)
Endometrial cancer
Ethambutol teaching
Watch for vision changes
Potassium supplement or salt substitute should not be given to client taking
Ace inhibitors
Angiotensin receptor blocker
Sucralfate teaching
Must be given with meals
Form thick layer of paste that adhere to the ulcer surface to prevent further damage and promoting healing
Quinolone should not be given with
Antacids
Thrombolytic therapy (alteplase ) contraindications
Active bleeding
Recent trauma
Surgery
Hemorrhagic stroke
Uncontrollable hypertension
Alteplase are used for
Acute thrombolytic events
Elevated liver enzymes in client receiving Isoniazid ( antetubercular) indicate
Development of drug induce hepatitis
Client with infection should not take
Adalimumab ( tumor necrosis factor TNS )
Kayexalate retention enema indication
For client with high serum potassium levels , to remove excess potassium in the body
What to monitor when receiving glucocorticoid
Glucose level
Nyastin teaching
Shake bottle before measuring the dose
Swish the suspension in the mouth before swallowing
Avoid eating at least 30 min after administration
Monitor oral mucus membranes for signs of irritation ( redness , swelling)
Methotrexate adverse effects
Bone marrow suppression
Hepatotoxicity
GI irritation
Lipsse inhibitor ( orlistat ) teaching :
Taken with or within 1 hour of meals that contain fat.
If a meal does not contain fat , then the dose may be skipped
NSAIDs can cause
MI
Stroke
Exacerbation of heart failure
NSAIDs can cause
MI
Stroke
Exacerbation of heart failure
NSAIDs decrease the effectiveness of
Diuretics
Antihypertensive
What client should avoid taking NSAIDs
Cardiovascular disease
Hypertension
Levothyroxine starts to work after
3-4 weeks
ARBS and. ACE are used to :
Treat hypertension, heart failure
But ARBS are prescribed to client who can’t tolerate the chronic cough caused by ace
Clozapine indication
To treat schizophrenia in client who have not improved with other meds
Clozapine teaching
Monitor for signs of infection
Monitor follow up lab because clozapine may cause neutropenia
Clozapine may cause
Agranulocytosis
Myocarditis
Sialorrhea
Weight gain
Epinephrine teaching
Injecting into the outer thigh at 90 angle at symptoms onset
Seeking immediate medical care after device use
Storing in a dark place at room temperature
Palpitations, tachycardia, dizziness may occur after injection
Hypokalemia may lead to
Ventricular dysrhythmia
Theophylline toxicoty most lethal
Seizure
Cardiac dysrythmia
Phenytoin teaching
Hold entering feeding for 1-2 hours before and after administering phenytoin
Establish cardiac monitoring when administering phenytoin
Ectopic pregnancy means
Fertilized eggs implants begin to grow outside of uterus often in the fallopian tubes
Ectopic pregnancy results in
Hemorrhage, so it requires surgery
Postpartum hemorrhage blood loss amount
Postpartum hemorrhage is a total blood loss >=1000 ml
Accompanied by hypovolemia that can be life threatening
Postpartum hemorrhage risk factors
Uterine over distended
Oxytocin
Magnesium sulfate
Prolonged labor
Precipitous birth
Hepatis B and hepatitis immoglobulin is administered at what age to newborn
Within 12 hours of birth
Large gestional age(>90th percentile) newborn intervention
Assess for birth injuries
Monitor blood glucose
Encourages feeding every 2-3 hours
Report capillaries blood reading <40
Cervical cerclage can prevent :
Preterm birth in clients with cervical insufficiency
Preterm labor signs and symptoms
Low back pain
Discomfort
Regular contraction that intensify
Pelvic pressure
Zika infection in pregnant women may cause
Birth defects and developmental dysfunction
So avoid travel to zika areas
Newborn safety
Use of sleep sack
Supine sleep positioning
Proper car seat use : snuggly fitted harness, rear facing , back seat placement
Posterm newborn clinical findings
Minimal to absent vernix caseosa
Dry cracked
Peeling skin
Deep plantar creases ,
Long fingernail
Scalp hair
Fetal demise put client at risk for
DIC
Shoulder dystocia what to document
Timing of the event
Verbalizing passing time
Perform McRobert manoeuver
Apply suprapubic pressure
Absent moro reflex indicate :
Brain or spinal cord underdevelopment or damage
Newborn of mothers with diabetes melitus commonly experienced
Polycythemia ( hematocrit >65 %
Abnormal finding in newborn
Decreased muscle tone
Sacral dimple
Single artery
What condition is this ? And what is the appropriate intervention?
Congenital dermal melanocytosis
So measure and document the size and location of the markings
The only adequate treatment for syphilis during pregnancy is :
Penicillin, so if allergic penicillin desensitization is necessary
Acrocyanosis is a :
Normal finding , bluish discoloration of the newborn hands and feet
Acrocyanosis intervention
Placing newborn skin to skin with the parent
Parents teaching for umbilical cord
Keep umbilical area dry
No antiseptic to the stump
Report signs of infection
Priority action for placental accreta
Presence of at least two large bore iv
Available blood product
Priority intervention for postpartum endometriosis
Administer antibiotics
Oxytocin administration teaching
Require precise administration so administer via secondary IV line
Titrate oxytocin
Postpartum thrombus intervention
Early ambulation
Perform leg exercises
Maintain sequential compression device
Pica lab to monitor
Hemoglobin and hematocrit
Palpation of the anterior fontanel on cervical examination indicates
Fetus is in cephalic presentation
Miscarriage teaching
Avoid sexual intercourse and tub baths two weeks to prevent infection.
Use ibuprofen to alleviate cramping
Reports foul smelling vaginal discharge , bleeding, severe pain
Spina bifida manifestations
Tuft of hair
Hemangioma
Nevus
Dimple along the base of the spine
Neonatal abstinence syndrome manifestations
Minimize environmental stimuli
Provide comfort swaddling
Gently rocking newborn
Gestational diabetes melitus complications
Fetal macrosomia
Shoulder dystocia
Polyhydramnios
How to collect blood on heel stick on newborn
Warm the heel
Select location on the lateral or medial aspect of the heel puncture with an automatic lancet ( never use needle )
Cleanse area with alcohol pad
Wipe the first drop of blood to prevent false reading
Myelomeningocele (spini bifida) complications
Dysplasia
Hydrocephalus
Neurogenic bladder
Infection
Delirium tremens occurs when ?
After 48-96 hours following last drink
Dash diet
Low sodium and fat
High calcium , potassium, fiber
Lab hypo hyper manifestations
Myopia is :
Reduced visual acuity when viewing objects at a distance
Clients with myopia need to hold objects near their face or sit near objects to see clearly
Myopia may lead to :
Headache, dizziness, decreased school performance from eye strain
Pinworm symptoms
Perineal itching
Restlessness
Disturbed sleep
Noctural enuresis
Rotavirus spread how
Via fecal route by touching contaminated objects
Rotavirus put you at risk for :
Dehydration
Scarlet fever is a complication of
Streptococcal infection
Scarlet fever is characterized by
Distinctive red rash
Diagnostic procedure for scarlet fever
Throat culture
Rapid streptococcal antigen
Varicella vaccine how many doses
2
Varicella adverse reactions
Low grade fever
Swelling and erythema
Irritability
Rash up 1 month after injection
Infants can eat solid food at what age
4-6 months
Otitis media intervention
Ask for help restraining the client arm stabilizing the head
Pull down and back on the pinna
Insert speculum no further than the outer external auditory canal
Insoect tympanic membrane for infection
First sign of puberty in male
Testicular enlargement
Atrial septal defect expected findings
Heart murmur on auscultation
MMR is administered at what age
12-15 months
Scoliosis is
Deformity characterized by lateral curvature of the spine
First dental visit of a child should occur
Within 6 months of the appearance of the first tooth
Formula teaching for baby
Unused , prepared formula should be stored in the refrigerator, if unused discarded after 24 hours
Allergic rhinitis prevention
Installing high-efficiency particulate air filter
Applying hypoallergenic pillow and mattress covers
Moping floors and damp-dusting furniture frequently
Keep windows closed
Hemophilia teaching
Strategy to reduce risk of bleeding
Ensure medical bracelet wear at all times
Encourage participation in noncontact sports
Hemophilia teaching
Strategy to reduce risk of bleeding
Ensure medical bracelet wear at all times
Encourage participation in noncontact sports
Developmental dysplasia of the hip expected finding
Asymmetrical or extra gluteal fold on the affected side
Cystic fibrosis intervention
Aerobic exercise
Chest physiotherapy
Increase fluid intake
High fat and calories
Social services
Cleft palate repair intervention
Elevete head of bed
Implement pain reduction
Remove elbow restraints
Hip fracture manifestation
External rotation
Abduction
Muscle spasm
Shortening of the affected extremities
Continuous bladder irrigation pain may be caused by
Kinked blocked catheter
Bladder spasm
Postoperative pain
Third degree AV heart block intervention
Temporay of permanent pacemaker
Prepare client for temporary transcutaneous pacing
Parkland formula
4 ml X body weight x % total body surface area
Menaupause teaching
Have cholesterol level monitored
Consume calcium rich food
Weight bearing exercise
Seek support emotional
Otic medication administration
Position the client side lying with the affected ear up
Pull pinna up and back
Instruct client remain side lying 2-3 minutes
Place cotton ball loosely in the outer ear for 15 minutes
Intramuscular injection can be given where
Deltoid
Vastus lateralis
Ventrogluteal
Ketorolac teaching
Used for pain relief but short term due to the risk of bleeding
Z-Track method is used
Use 1-10 1/2 inn needle
Ketorolac teaching
Used for pain relief but short term due to the risk of bleeding
Z-Track method is used
Use 1-10 1/2 inn needle
Client with varicella require what precautions
Airborne and contact : both
Urinary carheter insertion teaching
Use non dominant hand to spread the labia majora and minora before cleansing the urinary meatus
Low back pain intervention
Application of hot and cold compresses
Nsaid / acetaminophen
Sleeping in side lying position or supine
Clonidine patch teaching
Put on dry , hairless area on the upper arm or chest
Sputum collection teaching
Take in the morning
Rinse mouth with water
Site upright and inhale deeply , several times , and cough prior to expectoring
Methicillin staphylococcus aureus intervention
Use package pre-moistened cloths containing chlorhexidine to bathe the client to reduce the spread of infection
Administering enteral feeding intervention
Check gastric residual volume
Place client in high fowler position
Verify the gastric PH is <5, return aspirated GRV to the stomach
Flush tube before and after feeding
Fentanyl patches are placed for how long ?
72 hours
Palliative care focuses on
Quality of life and symptoms management
Palliative cate is provide by a multidisciplinary team
Palliative care provide relief symptoms associated with chronic illness
Postmortem care
Maintain standard or isolation precautions in place at time of the death
Gently closed the client eyes
Removes tube and dressing
Straighten and wash the body
Pad under the perineum
Place pillow under the head
Remove equipment and soiled linen in the room
Give client belongings to a family member or send them with the body
Steps to use fire extinguishers
P : pull the pin
A. : Aim the spray
S : squeze the handle
S. : sweep spray
Hypovolic shock position
Elevating legs
Maintain head of bef =<30 degree
INR therapeutic level
2-3
Complication for infectious mononucleosis
Sudden onset of severe abdominal pain in the left upper quadrant
Acceptable abbreviations include
Ac
Pc
Qid
Cm
Phlebitis is
In a inflammation of a vein that occur as complication of IV therapy
Signs of phlebitis
Pain
Warmth
Swelling
Aortic dissection manifestations
Ripping back pain
Rhabdomyolysis occurs when
Tissue is damaged and myoglobin is released into the blood
Rhabdomyolysis manifestations
Dark colored urine
Elevated creatine kinase
Normal range Mean arterial pressure (MAP)
70 - 105 mm Hg
Anticholinerguc meds adverse effects
Dry mouth
Urge incontinence management
Loss excess weight
Anticholinergic meds ( oxybutynin)
Avoidance of bladder irritants
Pelvic floor exercises
Bladder training
Unilateral face paralysis teaching
Manually close the eyelid after applying artificial tears
Tape the eyelid shut to prevent excessive drying of the eye
Eat soft , high calorie food on the unaffected side to prevent choking
Use warm , moist compress for pain relief
Diabetic ketoacidisis intervention
Administer 1L sodium chloride IV bolus
Initiate continuous iv insulin infusion
Obtain serum blood glucose
Initiate cardiac monitoring
Adrenal crisis meds
Hydrocortisone
Chronic venous insufficiency manifestation
Varicose vein
Edema and brown
Hardened skin on the lower extremities
Head tilt-chin lift manoeuver is performed to :
Open airway
Preventive care for client with HIV
Routine vaccination
Avoid raw/undercooked food
Carpal tunnel syndrome teaching
Wear wrist immobilization splint
Huff coughing how to perform
Sit upright and inhale deeply before forcefully exhaling
Huff coughing how to perform
Sit upright and inhale deeply before forcefully exhaling
Huff coughing is used to :
Loosen and clear secretions for clients with COPD
Total hip arthroplasty teaching
Applying sequential compression device
Placing abductors pillow between the leg
Maintain head of bed <60
Diverticulosis teaching
Prevent constipation ( high fiber , increase fluid intake , regular exercise)
Regular exercise
NPO
NG suction
Best rest
Antibiotics, analgesics
Osteoarthritis manifestation
Pain by weight bearing
Morning stiffness subsiding within 30 minutes
Decreased joint mobility
Range of motion
Atrophy and supporting muscle
Pericarditis manifestation
Pleuritic chest pain that is sharp aggravated during inspirations and coughing
Herpes zoster can occur in client with
History of chickenpox
Primary open glaucoma is characterized by
Intraocular pressure
Gradual loss of peripheral vision
Management acute pancreatitis
Maintain NPO
Opioid analgesia for pain
IV fluid administration
Management acute pancreatitis
Maintain NPO
Opioid analgesia for pain
IV fluid administration
Cast care teaching
Report foul odors or hot area in cast
Prevent cast from getting wet
Elevate the extremity above heart level for the first 48 hours
Regularly exercising the affected extremity
Report symptoms of impair circulation (numbness, tingling, pallor , coolness)
Never insert object under the cast
Aortic dissection intervention
Iz beta blocker to maintain normal pressure in aorta
Influenza transmission period
Highest period transmission usually occur 1 day before symptoms begin and continue for at least 5-7 days after the illness stage begins
Dopamine is used
To improve hemodynamic status in clients with shock and heart failure
Dopamine increase
Heart rate
Blood pressure
Cardiac output
Urine output
Torsade de point meds
Amiodarone
Amitriptyline
Ondansetron
Torsade de pointes causes
Prolinged QT interval , causes by hypomagnesemia
Sjogren syndrome manifestation
Dry eyes and mouth
So use artificial tears and saliva
Overflow incontinence teaching
Implement fixed voiding schedule
Teach technique to emptying bladder (valsa manoeuver , Credé manoeuver, double voiding )
Monitor for perineal skin breakdown
Measure postvoid residual volume
Pessary is used to prevent
Pelvic organ prolapse
Cirrhosis causes what lab to elevated
Ammonia
Biliburin
Prothrombin time
SVT intervention
Perform vagal manoeuver ( bear down if having bowel movement
Cerebellum regulate
Posture and balance
Expected serosanguineous in a jackson pratt
80-120 ml for first 24 hours
Cardiac catheterization intervention
Bed rest with affected extremity straightening
Head of bed <=30
Wound evisceration position
Low fowler position
Labs and laboratory values 1
Lab and laboratory values 2
Stage 1 pressure ulcer characteristics
Intact skin with non-blanchable redness
Stage 2 pressure ulcer characteristics
Partial thickness skin loss, presenting as shallow open ulcer or blister
Stage 3 pressure ulcers
Full thickness skin loss with extensive tissue damage including muscle , bone , or supporting structures
Stage 4 pressure ulcers characterized
Full thickness skin loss with extensive tissue damage including muscle, bone , or supporting structure
Unstageable pressure ulcer characteristics
Full thickness skin loss with the base of the ulcer covered by slough or eschar
SBAR
Intervention to prevent febrile reaction after blood transfusions
Leukocyte-reduced blood product
Status epileptic is defines by
Seizure longer than 5 minutes
Repeated seizure over 30 minutes
Status epileptic intervention
Place client on their side
Loosen any restrictive clothes
Parenteral benzodiazepines (lorazepam) or barbiturates
Meds that leads to nephrotoxicify
Furosemide
Vancomycin
Ibuprofen
Enalapril
