Nclex Review Final Flashcards
The B in the SBAR technique is
Background, what the clients treatments are
SBAR stands for
Situation
Background
Assessment
Recommendation
If a UAP who usually works on a different unit, is assigned to your unit what is the first question you should ask
What type of care did they provide
If a client has breakfast around the time he prays or meditates, and he doesnt want to be interrupted what is the best thing to do
Talk with the client to work out a plan
What task should be given to a UAP on a client with severe hyperglycemia
Vital Sign checks
90 year olds coming back to the hospital 2 weeks after they have been let go, what are 3 common reasons for this
Family preferences
Clients Health status
Poor communication among providers
Which client should be taken care of first
A - 70 year old male with history of heart failure, who reported going to the bathroom too much after taking a diuretic
B - 81 year old female with a history of coronary artery disease reporting dyspnea, nausea, and unusual discomfort in back
C - 86 year old male diagnosed with hypertension, whose last recorded B/P was 180/90 after learning a close friend was hospitalized
D - 94 year old female diagnosed with Peripheral artery disease reporting cramp like pains in both calf muscles following physical therapy
B
History of coronary artery disease, and client reproting dyspnea, nausea, and unusual discomfort , can be signs of what
Myocardial Infarction
What do you tell a 75 year old clients son, when the son says “ i do not understand the need for a living will”
Health Care decisions can be made based on clients wishes
What is a living will
a written statement detailing a person’s desires regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive.
What nursing practice best reduces the chance of communication errors that might otherwise lead to negative client outcomes
Use standardized forms for client handoffs
An 80-year old client is hospitalized for a chronic condition, The client informs family members that a living will has been prepared and client wants no life-prolonging measures performed. The client becomes unresponsive and deteriorates. What is your first action
Notify the attending physician
Even if you are not using the clients name or any identifiers before discussing something outside of work what should you do
Nothing you can be fired for breaching confidentiality
If a nurse becomes attracted to one of there patients what should happen
The nurse transfers the care of the client to another nurse
The overall goal of CQI is
improve quality of health care
A client with a diagnosis of bipolar disorder has been ordered to a halfway house to be considered for placement. A social worker telephones the hospital unit and asks for information about the clients mental status and adjustment. What must the nurse understand before releasing any information
Make sure there is written consent from the client
A child is newly diagnosed with hepatitis A, what teaching instructions would the nurse reinforce with childs parents
Wash hands with soap and water after contact with child
If a radioactive bomb goes off in a shopping area what should a corresponding nurse instruct everyone to do first
cover mouth and nose
Why should a newly diagnosed patient with Active Tuberculosis be reported to health department
Contacts needs to be traced and screened
What is a very important patient teaching to a patient just prescribed oral solution of radioactive iodine.
Urine and saliva will be radioactive for 24 hours after ingestion
How should we transfer a patient who can only partially bear weight on a casted leg
Two caregivers must use a Stand-pivot technique and wide base of support when transferring
What action is priority for a 2 month old post op cleft lip and cleft palate repair
Bilateral elbow restraints must be used continuously
What should you do right after being accidentally stuck with a needle while changing linens
Wash hands vigorously
A child at home just swallowed poison and wants to know if they should induce vomiting what is your response
Vomiting should never be induced unless the poison control center tells you, just tell them to empty mouth of any remains
Adolescent hemophiliacs should be aware that contact sports can cause
Bleeding
rare bleeding disorder in which the blood doesn’t clot normally
Hemophilia
Older adults are at greater risk for experiencing adverse effects from medications because of what two things
Decrease in total body water and increase in fat
A nurse observes a newborn whose apgar score is 8 and then 9 at 5 minute evaluation. these scores would be more commonly related to what abnormality
Color
The most common apgar score deduction is
Acrocyanosis (color)
A parent asks what should i say to my child who asks where do babies come from, what should you tell them to say
Give a simple answer
What finding in newborns is due to maternal hormones
Enlargement of breasts
Short term memory loss is commonly mistaken for
Hearing loss
What is important to do when discussing a matter with an adolescent
Leave presence of guardians
A home health nurse is making an initial visit to a 70 year old client what is the first action
Identify learning needs
When a client is unconscious and involuntary forgetting painful events, ideas, conflicts this is called
Repression
When a client is conscious and forgetting voluntarily this is called
Supression
When a client blames someone else for a situation this is called
Projection
A newly diagnosed cancer patient tells you that you are stupid what should you do
a - Accept the clients statement
b - make no comment
c- tell the client that is is inappropriate
d - explore what is going on with the client
D
What are the only two FDA approved medications for treatment of Post traumatic stress disorder
Zoloft and Paxil
When a client says he refuses to eat because the food is cold what should you do
Ask client what foods are acceptable
A drunk driver got into an accident and 12 hours after admission is diaphoretic, tremulous, and irritable, b/p elevated. Client says i have to get out of here. what does this suggest
Client is in early stage of alcohol withdrawal
Caring for a client with an unstable spinal cord injury at the T-7 level, which nursing intervention should be priority for this client
Place client on pressure reducing mattress
For a child with atopic dermatitis, what is something we should enforce
Have child wear mittens and socks to prevent scratching
Children with celiac disease follow what kind of diet.
gluten-free
What is the expected urine output of children per hour
1 ml / kg / hour
For a patient with osteoporosis what should we ask them to perform
weight bearing activities
Chalky white to yellowish staining and pitting of the enamel are signs of what
excessive fluoride intake (fluorosis)
When performing manual fecal impaction removal, what is one thing we must know
patient can experience bradycardia during removal
Patients with Coronary artery disease should be eating how
small frequent meals.
avoid large heavy meals
What is common side effect of Pepto-bismol
Black tongue
What is a side effect of Nifedipine (Procardia)
Facial Flushing
Xanax taken for 3 days, what response should nurse see in patient
tranquilization, numbing of emotions
What is important to tell a patient taking bactrim, septra, and sulfatrim for UTI
Drink at least 8 glasses of water a day
What finding shows clients is no accepting Gentamicin correctly
Borderline renal function
Humalog is a _________ insulin and so it onsets in _____
Rapid-acting
10-15 minutes
Antihistamines may cause what in older patients
Confusion
For a client taking Tylenol 3 what is common side effect seen after 3 days
No bowel movement
Why might a nurse receive an order for a deep injection
Prevents medication from tissue irritation
Deep injection is also known as
Z track
A nurse is preparing a client scheduled for a Intravenous pyelogram (IVP) what is the most important information to collect prior
Allergy history
What can we expect in a 16 year old with a femur fracture 14 hours after surgery, Tachycardia, increased shortness of breath, a temperature of 100.1, feelings of anxiety, and a SaO2 of 88%
Fat embolism
Whats the most important data to collect after following an episode of Epilepticus
Level of Consciousness
If a nurse detects blood tinged fluid leaking from the nose and ears of a client diagnosed with trauma what should we do
Apply bulky, loose sterile dressings to the nose and ears
Which finding should nurse report immediately to charge nurse in 1 month old infant
A - inspiratory grunting
B - Increased heart rate with crying
C - Abdominal respirations
D - Irregular breathing rate
A
What is an important nursing action to a patient complaining of discomfort, after below the knee amputation
elevate stump
What is common to expect with a patient with portal hypertension
Ascites
What acronym should we use when determining priority in emergency situations
Airway
Breathing
Circulation
What does I PASS the BATON stand for
I = introduction (introduce yourself and your role/job) P = patient (name, identifiers, age, gender, location) A = assessment (presenting chief complaint, vital signs and symptoms and diagnosis) S = situation (current status/circumstances, including code status, recent changes, response to treatment) S = safety concerns (critical lab values/reports, socio-economic factors, allergies, alerts such as falls, isolation, etc.) B = background (co-morbidities, previous episodes, current medications, family history) A = actions (what actions were taken or are required and provide brief rationale) T = timing (level of urgency and explicit timing, prioritization of actions) O = ownership (who is responsible - nurse/doctor/team and patient/family responsibilities) N = next (what will happen next? anticipated change? what is the PLAN? what is the contingency plan?)
What does CUS stand for
C = concern ("I am concerned...")
U = uncomfortable ("I am uncomfortable...")
S = safety ("this is unsafe...")Because UAP’s are unlicensed they have
No scope of practice
What are the 5 rights of delegation
✓Right Task ✓Right Circumstances ✓Right Person ✓Right Direction/Communication ✓Right Supervision/Evaluation
What are the 4 C’s of communication
- Clear - Does the team member understand what I am saying?
- Concise - Have I confused the direction by giving too much unnecessary information?
- Correct - Is the direction given according to policy, procedures, job description, and the law?
- Complete - Does the delegatee have all the information necessary to complete the task?
What does ADPIE stand for
A = Assessment D = Diagnosis P = Planning I = Implementation E = Evaluation
COACTS for documentation stand for
Confidential Organized (chronologically) Accurate Complete Timely Subjective and objective data
What does SOAP stand for
S = subjective; what client tells you O = objective; what you observe, see, etc. A = assessment; what you think is going on based on the data P = plan; what you are going to do
What does DAR stand for
D = data - collecting information about a problem A = action - the task to be completed about the problem R = response - the client's response to the problem
True or False
A nurse has a legal duty to provide good samaritan care at the site of a traffic accident.
False - Nurses are protected from legal liability when they provide good samaritan care, but are not legally required to provide it.
True or False
A nurse has a legal duty to prove that he or she was not the “proximate cause” of damage to a client.
False - It is the plaintiff who must prove that the nurse was the proximate cause of damage; if accused, nurses must defend against the charge.
True or false
A nurse has a legal duty to encourage the client to sign the consent form if the nurse believes the procedure will really benefit the client.
False - The nurse should not try to influence the client, but should explain the procedure, its risks and benefits, and its alternatives.
True or false
A nurse has a legal duty to use the most secure form of restraint if the provider orders restraints.
False - The nurse should use the least restrictive form of restraint.
The health care provider has written an order for “morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain” for a 75 year-old client in an extended care facility. The licensed practical nurse (LPN) in charge has no other licensed persons working that shift. Which action should the LPN take first?
Nothing because IV Push is not under LPN scope of practice
A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action the nurse should take?
Remember, the collection of additional data is typically the initial approach when problems arise. Although the client has the right to refuse the medication, it’s possible that the herbal preparation does not have the intended purpose of the prescribed medication or may even have unintended side effects.
What does race stand for
Rescue or remove clients
Activate fire alarm system
Contain fire by closing doors and windows
Extinguish flames (with fire extinguisher)
If someone becomes poisoned in a nursing home what two things will stop us from inducing vomiting
alkaline or acid agents. Such poisons include lye, household cleaners, oven cleaner, furniture polish, metal cleaners, battery acids, or petroleum products.
FRAIL MOM & DAD stands for
Falls Relative or caregiver strain Activities of daily living Incontinence Living situation
Memory Impairment
Oculo-otic impairment (visual and auditory problems)
Malnutrition
Drugs
Advance directives
Depression
When handling and moving clients how high or low should bed be
at waist level
What are the 6 steps in chain of infection
Causative agent (Pathogen) Reservoir Portal of Exit Transmission Route Portal of Entry Susceptible host
The precaution we use for all clients for care is called
Standard Precautions
With patients with C.diff why must we wash our hands and not use hand sanitizer
because hand sanitizer does not kill C difficile spores
What do we wear for transmission based precautions
gown and gloves
What do we wear for droplet precautions
gown, gloves, surgical mask
What do we wear for airborne precautions
Respiratory protection with N95 respirator
what do we wear for neutropenic precautions
health care workers will wear gowns, masks, gloves when providing care
What must we avoid giving patients that are on neutropenic precautions
Must avoid giving raw fruits and vegetables
Immunity that is obtained by the development of antibodies resulting from an attack of infectious disease
naturally acquired immunity
Immunity that is obtained by vaccination
artificially acquired immunity
Immunity that is obtained by the transmission of antibodies from the mother through the placenta to the fetus or to the infant through the colostrum
naturally acquired immunity
Difference between passive and active immunity is
In active we produce our own antibodies
Passive is not permanent
Bacillus anthracis also known as ________ usually comes from
Anthrax
Farm animals
What is the drug of choice for Anthrax
ciprofloxacin hydrochloride (Cipro), drug of choice
Yersinia pestis also known as ______ usually comes from
Plague
Rodents or Fleas
What are the 4 drugs of choice for Plague
streptomycin
gentamycin (Garamycin)
doxycycline (Vibramycin)
ciprofloxacin hydrochloride (Cipro)
Variola virus also known as ________ usually comes from
Small pox
other exposed individuals
What is the drug of choice for smallpox
no drug for it
used to describe a severe multisystem syndrome caused by four different families of viruses, including arenaviruses, filoviruses, bunyaviruses, and flaviviruses
Viral hemorrhagic fever
What are two antidotes for Sarin GB Gas
Atropine pralidoxime chloride (2-PAM chloride)
a protein-based medication which promotes the growth of white blood cells
filgrastim (Neupogen)
medication commonly used to increase white blood cells and prevents subsequent infections
pegfilgrastim (Neulasta)
True or False
Assistive devices are used when a caregiver is required to lift more than 35 lbs (15.9 kg).
True
A client with a draining wound that tests positive for Staphylococcus aureus is placed on
Contact precautions
True or false
Newborns are fitted with tamper-proof security sensors around their ankles during their stay in the hospital.
True
It is important to remember that when you are taking off contaminated clothing you must
Not pull it over your head
The health care team is planning discharge for a 90 year-old client diagnosed with musculoskeletal weakness. Which intervention would be the priority for helping to prevent falls in the home?
Night lights
The nurse is caring for a client diagnosed with hepatitis C. When reviewing the client’s health history, which of the following findings does the nurse recognize as the most likely cause for developing hepatitis C?
a - Recent travel to Central America
b - Receiving blood product transfusions prior to 1992
c - Eating raw shellfish last week
d - Getting a tattoo three months ago at a licensed tattoo parlor
b - Receiving blood product transfusions prior to 1992
Four clients are admitted to an adult medical unit on the same shift. The nurse should expect to implement airborne precautions for the client with which of the following diagnoses?
a - Advanced carcinoma of the lung
b - Confirmed AIDS with cytomegalovirus (CMV)
c - Suspected viral pneumonia
d - Positive Mantoux test with an abnormal chest x-ray
d - Positive Mantoux test with an abnormal chest x-ray
A child is admitted with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first?
a - Droplet precautions
b - Monitor and record vital signs every 30 minutes
c - Seizure precautions
d - Notify of changes in neurologic status
a - Droplet precautions
The nurse is discussing safety precautions with the parents of a child. Which activity would be most hazardous to an 18 month-old child?
a - Riding in a car
b - Jumping on a bed
c - Eating whole peanuts
d - Playing around electrical outlets
a - Riding in a car
Leading cause of deaths to infants
The 4 year-old needs to have several vaccines prior to starting kindergarten. However, the nurse determines that the MMR vaccine should not be given. What is the best reason why the MMR should not be given to this child?
a - Previous life-threatening allergic reaction to the antibiotic neomycin
b - Known allergy to peanuts
c - Low-grade temperature and a runny nose
d - The child is too old for the second dose of the MMR
a - Previous life-threatening allergic reaction to the antibiotic neomycin
A client who has a diagnosis of dementia tends to wander from the assigned room. The nurse can best ensure the safety of this client by using which approach?
a - Repeatedly remind the client of the time and place
b - Explain the risks of becoming lost to the client
c - Assign one staff member to check the client every 30 minutes
d - Attach a WanderGuard® sensor band to the client’s wrist
d - Attach a WanderGuard® sensor band to the client’s wrist
The nurse is attending an in-service about healthcare-associated infections (HAIs). Which factor is identified as the most common cause of HAIs in the acute care setting?
a - Existence of an intravenous access device
b - Presence of an indwelling urinary catheter
c - Inadequate fluid intake over 72 hours
d - Decreased mobility for a week or longer
b - Presence of an indwelling urinary catheter
What is the most common HAI
Catheter-associated urinary tract infections is the most common HAI in the acute care hospital setting. Surgical site infections, bloodstream infections and pneumonia are the other categories of infections.
What does activated charcoal do ?
Activated charcoal binds with the poison to limit absorption from the digestive tract
The parents of a toddler ask, “How long will our child have to sit in a car seat when riding in a car?” What would be the best response by the nurse?
Until the child is about 2 years-old
A 76 year-old client is admitted to the unit after reportedly falling at home. The client begins to seize and loses consciousness. What action by the nurse is appropriate to do next?
a - Collect pillows and pad the side rails of the bed
b - Place an oral airway in the mouth and suction the mouth
c - Announce a cardiac arrest and assist with intubation
d - Stay with client and observe for airway obstruction
d - Stay with client and observe for airway obstruction
Parents of a 7 year-old child call a clinic nurse because their child was sent home from school due to a rash. The child, seen the day before by the health care provider, was diagnosed with fifth disease (erythema infectiosum) and is otherwise in good health. What would be the appropriate action by the nurse?
a - Inform the school that the child is receiving antibiotics for the rash
b - Refer the school officials to printed materials about this viral illness
c - Tell the parents to bring the child to the clinic for further evaluation
d - Explain that this rash is no longer contagious and does not require isolation
d - Explain that this rash is no longer contagious and does not require isolation
Are children with fifth disease, (erythema infectiosum) contagious ?
No they are not
Women of child bearing age should have an average of how much folic acid per day
400 mcg
What is Nageles rule and what is it used for
N plus 7 days, minus 3 months, plus 1 year. For pregnancy
the relationship between the presenting part of the baby with the mother’s pelvis
Fetal Station
the relationship between the head to tailbone axis for both the fetus and the mother
Fetal Lie
the relationship of the fetal body parts to one another
Fetal Attitude
portion of the fetus that enters the pelvic inlet first (cephalic, breech, shoulder)
Fetal Presentation
to prevent erythroblastosis fetalis we administer Rh immune globulin to RH _________ women
negative
The 5 P’s of labor are
passageway, passenger, powers, position and psyche
vaginal part of cervix progressively shortens and its walls thin, is measured in %
effacement
progressive enlargement of the cervical os from less than 1 centimeter to 10 centimeters
dilation
stimulates milk production when nipples stimulated
prolactin
stimulates uterine contraction and milk letdown reflex
oxytocin
What does bubble assessment stand for
B = Breasts U = Uterus B = Bowels B = Bladder L = Lochia E = Episiotomy/C-section incision
E—can also stand for maternal emotions about the outcomes of the birth and the new baby
What does APGAR score stand for
Activity Pulse Grimace Appearance Respiration
New born Vitals Temp Apical Heart Rate Blood Pressure Respirations
97.9-99.7
110-160
50-75
30-60
True or False
Fetal movement count during the third trimester should be at least 5 movements per day.
False
In the third trimester, an awake, healthy fetus should move at least 3 times per hour. If the baby does not move, the mother should drink a glass of juice and then start a new count.
True or False
The fourth stage of labor is placental separation and expulsion.
False
The third stage of labor is placental separation and expulsion and lasts about 5 to 30 minutes. The fourth stage of labor is maternal adaptation, occurring 1 to 2 hours after birth.
True or False
When the fetus is active, its heart rate should increase by about 15 beats per minute.
True
When the fetus is active, its heart rate will accelerate by about 15 beats per minute above the baseline. Average fetal heart rate is about 130 BPM when near term.
True or False
One of the first signs of pregnancy is Chadwick’s sign, which is the softening of the cervix.
False
There are several findings of pregnancy during the first trimester. Increased vascularity in vagina is called Chadwick’s sign; the increased vascularization and softness of uterine isthmus is Hegar’s sign; and the softening of the cervix is Goodell’s sign.
True or False
The nurse will give Rh immune globulin (RhoGAM) to a Rh negative women after a miscarriage (spontaneous abortion).
True
RhoGAM is administered to Rh negative women after any possible exposure to fetal blood, such as after each ectopic pregnancy, miscarriage, abortion, or amniocentesis.
True or False
The fetus receives more oxygenated blood when the laboring mother lies on her side.
True
Positioning the laboring mother on her (left) side usually results in a higher fetal oxygen saturation. Other measures to increase fetal oxygenation (and placental perfusion) include administering oxygen to the laboring woman.
True or False
A gravida 3, para 3 woman should be rushed to the delivery room once engagement has occurred.
False
Engagement means that the baby’s head no longer floats freely, but has dropped down into the pelvis. In a multipara, engagement normally occurs about two weeks before birth.
Gravida is
of pregnancies
Para is
of pregnancies that have lasted past 20 weeks
True or False
About 5 days after delivery, lochia is pink-brown in color.
True
Normal bleeding and discharge should be more watery and pink-brown colored (lochia serosa) about 3 to 5 days after delivery. It may take up to 2 to 4 weeks for discharge to taper off completely.
True or False
A woman cannot become pregnant when she is breastfeeding.
False
Pregnancy can occur with unprotected intercourse at the first menstrual cycle after birth. Nurses should caution women to avoid pregnancy for the first three months after delivery.
True or false
The safest time for the fetus is to give the mother analgesia when her cervix is dilated 8 to 10 centimeters.
False
The safest time to offer analgesia is when dilation is between 4 to 7 centimeters.
Stages of Labor with Measurements
Latent 0-3
Active 4-7
Transitional 8-10
Baby growth _____ after 6 months and ______ after 1 year
doubles
triples
Posterior Fontanel closes at
6-8 weeks
Anterior fontanel closes at
12-18 months
Primary =
Secondary =
Tertiary =
Prevent
Screen
Treat
True or False
When you examine the mouth, you see that the soft palate is moist and pink with whitish spots. These are normal findings
False
The soft palate should be reddish pink; spots are a possible sign of infection.
You examine this client’s breast and see a cluster of very tiny dimples near one nipple. Are these normal findings?
No. There should be no dimples; in fact “orange peel” skin is a late sign of breast cancer.
What test is used to test Rh factor
Coombs test
Parents are asking for information about how they will know if their toddler is ready for toilet training. What should the nurse understand before reinforcing information about toilet training?
a - Neuronal impulses are interrupted at the base of the ganglia
b - The toddler can understand cause and effect
c - Myelination of the spinal cord is completed during the toddler years
d - The child learns voluntary sphincter control through repetition
C - Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, which occurs sometime between the ages of 18 to 24 months. The other options are incorrect. Notice that both the question and the correct option has the word “toddler” in them.
The clinic nurse is performing the intake assessment for a 74 year-old male. The client has a history of benign prostatic hypertrophy (BPH) and reports having trouble voiding. After the client uses the bathroom to void, how would the nurse practitioner best assess bladder distention?
a - Look for rounded swelling above the pubis
b - Scan the bladder using a portable ultrasound scanner
c - Insert an intermittent urinary catheter
d - Check for rebound tenderness
b - Urinary retention and incomplete bladder emptying can result from urethral obstruction, as seen in BPH. The nurse can palpate the area from the umbilicus towards the symphysis pubis; an empty bladder rests behind the symphysis pubis and should not be palpable. The nurse can also percuss this area; a urine-filled bladder produces a dull sound. But a bladder ultrasound scanner is usually more effective than manual palpation since it registers bladder volume digitally. Routine catheterization to check for post void residual is not recommended; but if bladder distention is greater than 200 mL, the client may need to be catheterized.
During an initial check on a newborn after a birth by a breech delivery, a nurse suspects hip dislocation. Which finding is most suggestive of this abnormality?
a - Flexion of lower extremities
b - Negative Ortolani response
c - Lengthened leg of affected side
d - Irregular hip symmetry
d - Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation. The leg is shortened on the affected side. One check for hip dislocation is the Ortolani click; if it is found, it is called a positive response.
A nurse is observing children playing in the hospital playroom. The nurse should expect to see 4 year-old children playing in which manner?
a - Alone with hand-held computer games
b - Cooperatively with other preschoolers
c - Competitive board games with older children
d - With their own toys alongside with other children
b - Cooperative or associative play is typical of the preschool period. School-age children would play board games, toddlers engage in side-by-side or parellel play, and adolescents would be more likely to play the hand-held computer games.
The school nurse is observing a group of children. The nurse should be aware that which of these psychosocial needs are more commonly found in adolescents?
a - Attention, competition, being right
b - Social competencies, respect, sense of humor
c - Independence, confidence, narcissism
d - Privacy, autonomy, peer interaction
d - Adolescents display the need for privacy, autonomy, and peer interaction concurrent with an evolving sense of identity.
A 75 year-old client is admitted with the diagnosis of possible dehydration. The nurse should understand that older adults are at risk for dehydration due to which of the following factors?
a - Reduced gastric emptying
b - Weakened urinary sphincter
c - Decreased sensation of thirst
d - Reduction in lean body mass
c - Older adults do not drink because they do not feel as thirsty as younger people. Other risk factors for minimal ingestion of fluids in older adults may include fear of incontinence, inability to drink fluids independently or it’s simply too painful to get up from a chair.
What are the 5 stages of grief
Denial Anger Bargaining Depression Acceptance
Stress mobilizes which system
sympathetic nervous system (norepinephrine and epinephrine) and the endocrine system (especially the pituitary gland).
True or False
The nurse should write everything down for the client with Wernicke’s aphasia.
False
People with Wernicke’s aphasia may have no understanding of language in any modality - spoken or written. They can speak, but what they say makes no sense. Communication may be more effective using non-verbal techniques, such as actions, movements, props, and gestures.
What is the drug of choice for depression in the elderly
Zoloft
What is the drug of choice for depression in children
PROzac
The only FDA-approved type of medications used to treat this disorder are SSRIs.
Sertraline (Zoloft) and paroxetine (Paxil) are FDA-approved to treat PTSD. Other medications may be used off-label or as adjunct treatment. For example, prazosin (Minipress) may be used to decrease nightmares.
Electroconvulsive therapy (ECT) is used to treat a severe form of this disorder.
Depressive disorder
For severe depression and when medication does not ease the symptoms of clinical depression, ECT can be used. ECT can also be used to treat people with symptoms of delusions, hallucinations or suicidal thoughts.
Russell’s sign is observed with this disorder.
A person who repeatedly self-induces vomiting will have scraped or raw areas on the knuckles. Bulimia nervosa is a type of feeding and eating disorder.
A person with this disorder recognizes their behavior is excessive and unreasonable but cannot stop the behavior.
People with OCD cannot control their obsessions and/or compulsions, even though they recognize that they are unreasonable or excessive.
A “drug holidays” are sometimes used in the management of this disorder.
A drug holiday refers to the deliberate interruption of pharmacotherapy for a defined period and for a specific clinical purpose. Sometimes a clinician will give the child with ADHD a “vacation” from medications on weekends or during summer break from school.
the therapeutic lab values for the mood stabilizer, lithium carbonate (Lithane) are
0.8 to 1.2 mEq/L
A client talks about being upset after electroconvulsive therapy (ECT) because of the side effect of confusion. In the post ECT phase, the client reports losing money and an inability to remember telephone numbers. What would be the most therapeutic response by the nurse?
a - “I can understand that the confusion is upsetting to you.”
b - “Your illness indicates that you needed the treatments.”
c - “We will develop a plan to prevent money and memory loss.”
d - “The confusion will clear up within 48 to 72 hours each time.”
a - Communicating caring and empathy while acknowledging the client’s feelings is the most appropriate and therapeutic response. Developing a plan for dealing with the effects of memory loss can be done later if it is agreed upon by the client.
The nurse is caring for a client who has a history of heavy alcohol use. Which behaviors would indicate the client is experiencing delirium tremens (DTs)?
a - Tremors or jerking movements caused by rapidly contracting muscles or tremors
b - A generalized shaking of the body accompanied by repetitive thoughts and movements
c - Disorganized thinking and feelings of terror with non purposeful behaviors
d - An excited state accompanied by disorientation, hallucinations and tachycardia
d - Delirium tremens (DTs) is a severe form of alcohol withdrawal that usually occurs within 72 hours after the last drink. During DTs, the person experiences both physical and mental hyperexcitability. Common findings include agitation, confusion, disorientation and hallucinations. The physical component of DTs includes diaphoresis, tachycardia, hypertension, tremors, fever, and eventually, if not treated, grand mal seizures, severe dehydration and death.
The nurse is caring for a client who is being treated for major depressive disorder. During which period of time would the nurse expect the client to be at the highest risk for attempting suicide?
a - When the client refuses to participate in group therapy sessions while hospitalized
b - After an angry outburst with family members over some insignificant issue
c - Within one to two weeks after initiation of antidepressant medication and psychotherapy
d - Within 72 hours after admission, while in one-to-one observation
c - As the findings of depression decrease due to treatment, the client may acquire the energy to develop a plan and follow through with a suicide attempt. Sudden changes in behavior, such as excessive happiness, are indicators that a client may have decided on a suicide plan.
How many wet diapers should a newborn have per day
6-8 wet diapers
What are the fat soluble vitamins
ADEK
Water accounts for how much of our body
60%
what is the recommended intake of water per day
2-3 liters
normal lab value for chloride
95-105 mEq/L
normal serum phosphate level
2.8-4.5 mg/dL
normal lab value for sodium
135-145 mEq/L
normal lab value for potassium
3.5-5 mEq/L
low levels of serum sodium 125 mEq/L or less result in
mental confusion, hostility, hallucinations
excess levels of serum sodium may result in
hypertension or generalized edema, called anasarca
Which vitamin is needed to help with calcium absorption
Vitamin D
What are some Dietary Approaches to Stop Hypertension
low in saturated fat, cholesterol, and total fat
diet for for renal disease such as pyelonephritis, uremia, kidney failure
low protein, meats and other foods high in protein such as legumes, fish, dairy
diet for for conditions such as burns, anemia, malabsorption syndromes, ulcerative colitis
High protein
diet for clients with gout
low purine diet
A cane should be on the strong side or weak side
strong side
The thirst center is located in the
hypothalamus
Nasogastric tubes should be no faster than
300mg/dl
normal value for Bicarbonate
22 - 29 mEq/L
The nurse is caring for a client who is paralyzed. What observation of the client would indicate the probable presence of a fecal impaction?
a - Semisoft to liquid stools
b - Continuous rumbling flatulence
c - Absence of bowel movements
d - Oozing liquid stool
D - When the bowel is impacted with hardened feces, there is often a frequent seepage of brownish liquid around the obstruction. This is often mistaken for uncontrolled diarrhea. Be careful to report only the objective facts; for example, the the client is oozing brownish liquid from the rectum.
A nurse is providing care to a 75 year-old adult client diagnosed with bilateral pneumonia. Which intervention will best promote the client’s comfort?
a - Encourage visits from family and friends
b - Keep conversations short
c - Increase oral fluid intake
d - Monitor vital signs frequently
B - Keeping conversations short will promote the older adult client’s comfort by decreasing the demands on the client’s breathing and energy. Increased intake of fluids is not related to comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the client’s rest. Monitoring vital signs is an important assessment but not related to promoting the client’s comfort.
The client is diagnosed with Ménière’s disease. The nurse should reinforce that the client modify the diet by avoiding foods high in which substance?
a - Calcium
b - Fiber
c - Sodium
d - Carbohydrates
C - The client with Meniere’s disease has an excess accumulation of fluid in the inner ear. A low sodium diet will aid in reduction of the fluid. If you are not sure about which answer to select, look at the “similar/dissimilar” options; in this case, it’s the two minerals: calcium and sodium. Then you should consider which mineral is typically restricted in diets: calcium or sodium?
The client is diagnosed with cystic fibrosis. What type of diet would the nurse expect for a client with this diagnosis?
a - High in carbohydrates and proteins
b - Dairy-free
c - Low calorie, low fat
d - Sodium-restricted
A - These clients need a high-energy diet with increased carbohydrates, protein and fat (possibly as high as 40%). To help answer this question, remember that people with cystic fibrosis need a lot of energy to breathe because they have thick pulmonary secretions. Look for the response that provides the most energy. Also, you will notice that three of the options involve “restrictions.” The correct option involves increasing something in the diet.
All drugs that end in PRILS are
ACE inhibitors (enalapril, lisinopril)
All drugs that end in SARTANS are
angiotensin receptor blockers (losartan, valsartan)
All drugs that end in TRIPTANS are
treatment of acute migraine headache
All drugs that end in STATINS are
lower LDL cholesterol (simvastatin, rosuvastatin)
All drugs that end in DIPINES are
calcium channel blockers (amlodipine, nifedipine)
All drugs that end in PRAZOLES are
proton pump inhibitors (omeprazole)
All drugs that end in AZOLES are
antifungals (miconazole)
What are the 4 common IM injection sites
ventrogluteal, dorsogluteal, vastus lateralis, and deltoid
Describe phlebitis signs of
regional pain and swelling
red streak along vein line
leakage, infiltration, or impaired infusion rate
Describe infiltration signs of
swollen
cool to touch
infusion rate slowing or stopping
Describe infection signs of
warmth redness swelling drainage tenderness or pain
In a child younger than age 3 how do we administer ear drops
pull the lobe down and back
In a child older than 3 years how do we administer ear drops
pull the pinna up and back
What are the 5 rights of administering meds
Dose Time Route Drug Client
Common signs of hyperglycemia
nausea, weakness, thirst, headache, tachypnea
Common signs of hypoglycemia
diaphoresis, tachycardia, hunger, trembling, confusion
True or False
The nurse will apply mild pressure to the inner canthus of the eye after instilling eye drop medication.
True
Applying pressure to the inner aspect of the eye for about a minute or so helps decrease systemic absorption of the medication.
True or False
Lactated ringer’s (LR) solution is a hypotonic fluid.
False
Lactated ringers is an isotonic fluid solution used in many different clinical situations, including fluid resuscitation. An example of a hypotonic fluid is 0.45% sodium chloride.
True or False
The nurse infuses 1 liter of 5% dextrose solution over 8 hours at 17 gtts/min; the IV has a drip factor of 15 gtts/mL.
False
1000 mL / 8 hours X 1 hr / 60 min = 15000 gtts / 480 ml = 31.25 gtts/min
True or False
The nurse can crush the oral medication disopyramide CR (Norpace CR) and mix it with applesauce.
False
CR means ‘controlled release’ and this medication must not be crushed. Do not crush any oral medication that ends in the following letters: CR, CD, LA, SR, XL, XR, XT.
What are two common side effects of Antihypertensives
orthostatic hypotension, fluid and electrolyte imbalance
What are 3 common side effects of Anticholinergic agents
dry mouth, constipation, blurred vision
What is a common side effect of Anticoagulants
bleeding
What are 3 common side effects of Anti-convulsants
CNS depression, myelosuppression: infection and bleeding
Nitroglycerin is classified as a ____________ and is used for
Antianginal, used for management of angina (chest pain)
Nitroglycerin PO is given how and in what intervals
3 tablets sublingually in 5 min intervals
Nitrates are commonly used for, and what do they do
Chest pain angina, relaxes smooth muscles in arterial and venous
Warfarin, coumadin is classified as a, and is used for
Anticoagulant, reverse vitamin k, helps unclot
lidocaine (Xylocaine) is classified as a, and is used for
Sodium channel blocker, dysrhytmias
atropine is classified as a, and is used for
Anticholinergic agent, bradycardia
enalapril (Vasotec) and lisinopril (Prinivil, Zestril) are classified as, and are used for
angiotensin-converting enzyme (ACE) inhibitors ,used for hypertension
What are the blood pressure guidelines for hypertension, pre hypertension etc. (4 stages)
Normal = systolic < 120 mm Hg and diastolic < 80 mm Hg
Prehypertension = systolic 120-139 mm Hg… or diastolic 80-89 mm Hg
Hypertension (Stage 1) = systolic 140-159 mm Hg… or diastolic 90-99 mm Hg
Hypertension (Stage 2) = systolic ≥ 160 mm Hg… or diastolic ≥ 100 mm Hg
amlodipine (Norvasc) is classified as a, and is used for
calcium channel blocker (CCB), hypertension
atenolol (Tenormin) and metoprolol succinate (Toprol), are classified as,and are used for
beta-adrenergic blocking agents (antagonists) (aka beta blockers), used for slow heart rate, tachycardia, hypertension
atorvastatin (Lipitor) and rosuvastatin (Crestor) are classified as, and are used for
Type: HMG-CoA reductase inhibitors (statins), used for cholesterol
aspirin (ASA) is classified as a, and is used for
antiplatelet agents, used for pain/fever
digoxin (Lanoxin) is classified as a, and is used for
cardiac glycoside, used for heart failure
DOPamine (generic) and norepinephrine (Levophed are classified as, and are used for
vasopressors, used for increases heart rate, vasoconstricts peripheral vessels to increase blood pressure
True or False
Naloxone (Narcan) is used to counteract the respiratory depression seen with barbiturate overdose.
False
Naloxone is used to reverse the effects of narcotic (opioid) depression. It is not effective in counteracting depression due to barbiturates, tranquilizers or other non-narcotic anesthetics or sedatives.
True or False
Oral administration of potassium chloride (KCl) with a full glass of water may reduce life-threatening risks associated with IV therapy.
True
Oral administration of KCl with a full glass of water allows slow absorption of KCl into the system. This helps to avoid serious complications of KCl therapy including tissue necrosis, ventricular dysrhythmias, cardiac standstill and death that may occur with rapid infusions.
epinephrine (Adrenalin) and albuterol (VoSpire ER) are classified as, and are used for
adrenergic agonist and is used for, acute bronchospasm, anaphylaxis, asthma, chronic bronchitis, COPD,
prophylaxis for exercise-induced asthma
What are some adverse effects of anticholinergics
dry mouth, constipation, and blurred vision, which are similar to the effects of anticholinergic agents
Phenytoin Dilantin is used for
Seizures
What is the Steven Johnson Syndrome
rare, serious disorder of your skin and mucous membranes. It’s usually a reaction to a medication or an infection. Often, Stevens-Johnson syndrome begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. Then the top layer of the affected skin dies and sheds.
When should synthroid be taken
Synthroid should be taken on an empty stomach, 30-60 minutes before breakfast. Levothyroxine is a thyroid hormone used to treat hypothyroidism.
Haldol, Thorazine are for
Mental disorders
Why should clients taking thorazine, chlorpromazine avoid extreme weather conditions
Chlorpromazine impairs body temperature regulation, so the client should avoid temperature extremes (exercise, hot weather, hot baths, showers, saunas).
True or False
To help reduce stomach upset, a client can take an antacid at the same time as almost any other oral medication.
False
Antacids can reduce the absorption of many medications. It is recommended to take an antacid at least 1 hour before or 2 hours after taking other medications.
True or False
The client uses a dry-powder inhaler as rescue therapy during acute asthma attacks.
Dry-powder inhalers are contraindicated for acute asthma attacks because they do not deliver rapidly acting medication for bronchodilation. Rescue therapy may include albuterol (Ventolin) or epinephrine (Adrenalin).
True or False
5% dextrose in water is the only IV solution used to administer regular insulin.
False
Normal saline is used to infuse IV insulin. Regular insulin is the only insulin that can be given intravenously.
True or False
The nurse should expect to hear bowel sounds when assessing the client who is one day post op following colostomy surgery.
False
It may take three or four days for the bowel to return to normal function after a colostomy.
True or False
The nurse should frequently suction the airway of clients with pneumonia and bronchitis.
False
Suctioning should only be done when clinically necessary and when the client is physically unable to cough up secretions on his or her own. Clinical indicators for suctioning include coarse breath sounds, noisy breathing, increased or decreased pulse, increased or decreased respiration, and prolonged expiratory breath sounds.
True or False
Human urine normally contains small amounts of glucose and protein.
False
Normal human urine is negative for both glucose and protein.
