NCLEX Review Questions Flashcards
Best practice for confirming NG tube?
aspirating gastric contents and testing pH (should be below 5)
Procedure for neutropenic precautions
- PPE
- private room
- visitor restriction
- no raw vegetable or fruits
- bathe daily
Team Nursing
- Most common delivery system
- team of nursing personnel provides total care to a group of clients
What endocrine disorder leads to dry scaly skin, muscle cramps, tingling of the lips, fingers and toes
Hypoparathyroidism
First Stage of Labor Transitional Phase lasts for
10-15 minutes
What medication is the only FDA approved med to treat PTSD
SSRIs
What is a priority for a patient after orchiectomy?
removll of testis for prostate cancer. PAIN MGMT
Diet for crohn’s disease
increased protien increase calorie. Low fat, Low Residue (fiber)
Hallmark Signs of tonsillitis
viral or bacterial. Difficulty swallowing, ear pain, fever/chills, headache, sore throat
What is the septum
a wall between the ventricles, there should be no opening
Which age range is at increased risk for poisoning?
Toddlers age 1-3 years b/c increasing mobility
Activity Lifestyle changes after MI
decrease physical activites. Need Cardiac Rehab
When is glucagon normally used?
If client is a ketoacidosis or coma. They are usually unconscious
What is the primary purpose of a transitional care program
reduce readmissions to the hosptial
What is always a concern with mysathenia gravis
airway
If a mother is RH negative and rbeastfeeding exclusively, what is a concern
hyperbilirubemia
What is the role of the MDS coordinator
interacts with health care staff to coordinate care processes of client assessment and care planning. Usually an RN
What type of diet does a patient with preeclampsia need?
protein. Lie on the left side, adequite fluids. Protein restores osmotic pressure
What patient is good to put next to a depressed patient
another depressed paitent or someone who’s condition is more stable. Matching roommates ages as closely as possible
If a patient has and SCI injury at C-5, what is his sexual functioning
sexual functioning may be possible, depends on severity of the injury, age of the client.
What is the algorithm for safe client handling and repositioning in bed
- Use 2-3 Caregivers for a client that can partially assist & weights less tah 200 lbs
- Use a friction reducing device
- Move bed into flat position at comfortable height for caregivers
What is the glabellar reflex
tap the bridge of ose and baby will close both eyes
When a patient has a spinal cord injury what is the biggest risk
immobility. place client on pressure reducing support surface.
Heberden’s nodes are characteristic of
osteoarthritis nodules. Strongly inherited.
What is a major side effect of INH
peripheral neuropathy
Where is the apical pulse heard? (apex/mitral area)
4-5th intercostal space midclavicular line
PPE for Contact Precautions
Gown, Gloves
This GI issue Pain localizes to the right upper quadrant, but may radiate to the right shoulder or scapula
Cholecystitis
What is the 3rd stage of labor
placental separation and expulsions. Lasts 5-30 minutes
Therapeutic range for lithium
0.8 - 1.2 mEq/L
Why type of solution is lactated ringers?
isotonic
Fetal Attitude
the relationship of the fetall body part to one another
What is placenta previa
placenta is abnormally implanted in the lower uterine segment. No vaginal exams, IVs to restore blood volume.
Bright flashes of light; blurred vision; “floaters” in the eye
Retinal detachment
Procedures for after a newborn is delivered
- Asses infant’s airway and breating
- perform bulb suctioning if excessive mucus
- assess infants heart rate
- place id bands on mother and infant
- administer vit k
Priority action for pt with preeclmapsia
have the client turn to the left side
Who establihed the Standards of Practice
the nursing profession (ANA)
How is Scope of Practice determines
Stat’es nurse practice act
TB treatment
medication is taken daily with monthly visits to the clinic
Infectious diseaseas that require contact precautions
meningitis, Varicella (Gown, Gloves)
arrett’s esophagus is a complication of this condition
GERD
Things the nurse CANNOT delegate
- assessment
- evaluation of client date
- nursing judgment
- teaching and evaluation
- nursing dx, or care planning
Fetal station means
the relationship between the presenting part of the baby with the mother’s pelvis
Why can’t a CNA shave a client after surgery
they probably have taken anticoagulants only an electric shaver can be used.
The most common healthcare associated infection
caused by staff
How much radiation in mammography is it equivalent to?
one hour of sun exposure
Foods to avoid if low WBCs
raw fruits and vegetables, undercooked meats, moldy cheeses, luch meat, salads things from the deli counter, brewed teas.
Common cause of aortic stenosis
aging heart, or rheumatic fever
What vegetarian foods are rich in
cereals and dried froot
What complication is at risk with Kawasaki Disease
Coronary artery aneurysm
Affects mucus membranes, lymph nodes and walls of the blood vessels. Can cause inflammation of the arteries, possible heart attack in child, fever lasting more than 2 weeks.
In a math equation requiring dilution factor, what should you watch for as potential trick
don’t get confused by the quantitiy of diluent. only the final concentration directs your answer
What is the rule for UAPs for documentation
they cannot document what they cannot assess
Responsibilities of UAP
- No scope of practice
- Non-invasive and non-sterile treatments
- bathing, transferring, ambulating, feeding, toileting, Vital signs
What are minors known as if they are married
emancipated minors through marriage, pregnancy, high school graduation, independet living or service in the military (have the legal capacity of an adult)
A pt with BPH has a distended bladder due to acute urinary retention. What should nurse understand about care of this client
tx includes catheterization (starting w. smallest catheter size). Complete and rapid emptying of the bladder. Bladder irrigation is performed.
Total Client Care Case Method
- RN is responsible for ALL aspects of care
- May be seen in Critical care or PACU
Procedures with a patheint with bronchiolitis to RSV
- Assess for respiratory distress
- promote tissue ogyenation
- institute droplet isolation precautions
- administer medication
- promote desired fluid intake
- provide family teaching
What is the most common cause of diverticular disease
eating a low fiber diet
Pathophysiology of Pernicious Anemia
parietal cells of stomach fail to excrete intrinsic factor which is necessary for absorption of vitamin B12
sx: sore tongue(beefy red), anorexia, nausea, vomiting, diarrhea, abdominal pain
Clinical indicators for suctioning
- course breath sounds
- noisy breathing
- increased/decreased pulse
- increased/decreased respiration
- prolonged expeiratory breath sounds
How many times should the fetus move per hour during 3rd trimester?
3x per hour. If it doesn,t drink a glass of juice and then start a new count
What are the 5 Stages of grief?
- Denial
- Anger
- Barganing
- Depression
- Acceptance
Procedure for child with ingestion of toxic substance
- Stabilize the child (ABCs)
- Start IV infusion (large bore needle)
- Obtain history of ingestion
- reverse or eliminate toxic substance
What is the most accuarete oxygen delivery method
venture mask mixes RA with 100% oxgyen max of 55%
Signs of Chronic Kidney Disease
Ecchymoses, hyperpigmentation, pruritus
What are you worried about with neuroleptic malignant syndrome
very high temperature
If a client has a blood glucose of 175 and reports being hungry and thirsty what should you do?
administer Humulin R- Insulin (short acting, regular). Will work in 30 mintues, pt should wait to eat breaskfost so insulin can begin working
Renal Encephalopathy signs pt with hemodlialysis
confusion irritability, elevated BUN and Creatnine
Nursing Consideration with Fentanyl patch
- slowly absorped thru sub Q tissue, can take up to 12-24 hours before effective analgesia
- short acting opioid can be given for breathrough pain
- the pt can shower/bathe, but should not be exposed to hot tubs or heating pads. Speeds absorption of medication
- throw them away but folding in half, not by cutting in half
What type of pain delivery system is well suited for pts with cancer
SubQ
What could be a cause at home for a child to have an astma attack
new pillow
What is the most important intervention when body iimage is a factor
touch
What is buck’s traction used for
to immobilize, position and align the lower extremity.
5-7 lbs is recommended for skin traction
What is a milkwakee brace used for?
scoliosis 1-2 years, during periods of growth
Who is the only employee from a health care organization that can be a lega withness of signing of an advance directive
clinical social worker
A child with burn is at risk for dehydration, what finding would indicate decrease in status
increased hematocrit and decrease in urine volume
In poison control when should you NOt induce vomiting
if contains alkaline or acid agents. I.E. lye, houseehold cleaners, oven cleaner, furniture polish, metal cleaners, battery acids, petroleum products
can neutralize using activated charcoal
What is the most accurate way of determining proper NG tube placement?
measure hte pH of aspirated gastric contents
Pediculosis capitis, signs
whitish oval specks sticking to the hair shaft. (Head lice)
When is a child ready for toilet training
when myelinationf of the spinal cord is completed this is when voluntary control of sphincter muscles occurs. (between 18 and 24 months). Child has to be walking without holdingo n.
Where is the Rinne Test administered using tuning forks?
against the mastoid bone. Normal= air conduction is longer than bone conduction.
Abnormal= the reverse
Findings of pinworm
infection which includes intense perianal itching.
What can immunoglobulin therapy interfere with?
body’s ability to form appropriate amts of antibodies. Live attenuated immunizations should be delayed.
Droplet Precaution requirements
Mask, goggles
What intervention or advice does the nurse implement after instilling eye drop medication?
apply pressure for about minute to decrease systemic absorption of the medication
This condition may be caused by gallstones, chronic alcohol use, infections, medications, and trauma.
Pancreatitis
tx with IV fluids, antibiotics, pain relievers
What is the preferred site for ABG
radial. Apply firm pressure 5 min prior. Leave oxygen on. Sample should be cold on ice to minimize chemical reaction
what does stable eschar do for skin care?
serves as body’s natural cover
Hep A Precautions
wear gown and gloves during client contact
Probable changes in pregnancy
- Chadwicks Sign- vaginal vascularity- blue cervix
- Hepgar’s Sign- uterine vascularity
- Goodell’s sign- cervical softening from estrogen and progesterone
What is the maximum dose of IM injection for infants and toddlers
1mL
Functioning Nursing
- RN gives medications and UAP gives bed baths for one group of clients
- Needs are broken down into tasks
Indications of Intenstinal obstruction
abdominal distention, chills fever (toxic megacolon), fitula formation
In relation to the heart what direction do veins go?
towards the heart, they have valves.
CNS infection examples
meningiits, encephalitis
What does the mitral valve control?
flow between the left atrium and left ventricle (Atrioventricular Valve)
Postpartum assessment, BUBBLE
- Breasts
- Uterus
- Bowels
- Bladder
- Lochia
- Episiotomy/C-section incision
What lab values indicate protein/malnutrtion
cholesterol, hemoglobin, Total Lymphocyte Count
Post Op Tracheostomy position
Elevate HOB and turn to one side until consciousness returns
The bubbling in a water seal chest tube chamber indicates
lung has not yet re-expanded
Classic findings of pulmonary stenosis
heaviy brathing, dyspnea, tachycardia, peripheral edema
What should you think when a patient states ““I went to the bathroom and my urine looked very red but it didn’t hurt when I went.””
painless gross hematuria. Urgent associated with bladder cancer or kidney problems.
Procedural order for administeral total parenteral nutrition through Central Line
- Check solution ofr cloudiness or sediment
- select & flush the correct tubing and filter
- thread the IV tubing thru an infusion pump
- use aseptic tech when handling injection cap
- connect the tubing to the central line
- set infusion pump at prescribed rate
Procedure for patient who is lethargic and slow to respond
- Attempt to elicit a response by physically shaking
- quick neurological assessment
- call rapid response team
- remain with pt, send another staff member to get list of medications and chart
What is MDS
Minimum Data Set. Standardized assessment of all residents in Medicare or Medicaid certified facilities. Completed for any individual staying more than 14 days. Does not measure outcomes.
What pain medication can induce asthma attacks
aspirin
Fetal adaptions during labor
- engagement
- descent
- flexion
- internal rotation
- extension
- external rotation
- expulsion
Infectious diseases that are airborne?
TB, Rubeola, Varicella
What needs to happen to prep a client for iv pyelogram
- clean out gi tract
- NPO 8-12 hours
- administer laxative the evening before
- enema morning of the test
What is an example of behavioral therapy
using positive and negative reinforcement. Assertiveness trainsing and desensitiization.
good for phobias, sexual dysfunction, eating disorders, etc.
Responsibilities of LPN/VN
- implementation of a plan
- assessing abnormal/normal
- reinforce information given by RN
- care for stable clients with predictable condition
early sign of intenstinal obstruction
hyperactive bowel sounds
How can over training in exercise increase risk with osteoporosi
can decrease estrogen levels in women and may increase risk
Normal range for neonate blood sugar
40-90
depending on weight of newborn, may need blood sugar checks q 2 hours
When does engagement of the fetus occur in pregnancy
2 weeks before birth
Risk factors for CT scan with contrast
- history of asthma
- positive pregnancy
- Poor renal function
- Beta blockers
- heart, kidney, thyroid disease
What is always an intervention when puncturing the spine
need fluids
What other treatment options are there for an Afib clinet that does not respond to antiarrhythmics or cardioversion?
radiofrequency catheter ablation. After ablation pt will need to take anticoagulatns
What action is benefical to prevent hypercalcemia
walking as much as possible keeps the calcium in the bone
What types of food can prevent kidney stones
high calcium, dairy products
What is a keyword to consider with a public health nurse
groups rather than invidivuals
Hallmark signs of Myasthenia Gravis
drooping eye lid, mouth weakness, difficulty chewing, swallowing or taking. Arm or Leg Weakness
Examples of urniraty tract infections
cystitis, pyelonephritis
Diagonal communication
staff from different levels work together on a project
When does the second stage of labor occur?
Complete dilation through birth (30-50 minutes for primipara)
What lab values can indicate pre-eclampsia
Magnesium will be low, Creatnine will be high
Symptoms of a Panic episode
- Palpitations
- Aabdominal distress
- Nausea
- Increased persiration
- Chest pain
Causes of myocarditis
mononucleuosis, parvovirus (5th disease), HIV
What does downward communication mean?
used to relate organizationl policy such as position description and rules and regulations
What is the main finding of pericardities
sharp, stabbing pain in the center or left side of chest.
What is the treatment time with a halo vest?
12 weeks
First Stage of labor Latent Phase
lasts 8 hours for primipara, 4-5 hours for multipara
Hallmark signs of emphysema
carrel chest, chronic cough, SOB, wheezing, Weight loss
What is upward communications?
staff meetings
What is the most serious complication following gastric bypass surgery (bariatric surgery)
anastomotic leak. Monitor for back, shoulder, abdominal pain, restlessness, unexplained tachycardia, oliguria. Immediately report to surgeon. Do not manipulate NG tube. Elevate HOB.
What should you NOT include in the chart in general
incident reports, abbreviations
What is an early sign of diminished oxygenation
increasing pulse rate, compensatory mechanism.
A client is in the third month of her first pregnancy. During the interview, she tells a nurse that she has several sex partners and is unsure of the identity of the baby’s father. Which of these nursing interventions is best at this time?
counsel the woman to consent to HIV screening
Common findings in mitral valve regurgitation include
heart murmurs, SOB, fatigue, Paroxysmal noctural dyspnea
What does justice mean?
fairness
What is the antidote for metformin
acetylcestein (24-48 hrs after contrast)
Positioning for pregnant woman
left side lying, prolasped cord (reverse trendelenburg)
What is a common temporary side effect of Pepto Bismol (Bismuth Subsalicylate)
dark tint of the tongue
What can cause false positive result on fecal occult test
- eating red meat
- NSAIDS
- steroid use
- bleeding gums
Labs for a patient with hyperosmolar hyperglycemic nonketotic state?
ABGs, CBC with idfferential, urinalaysis, glucose, BUN, electrolytes, chem profile, and creatnine. Rapid infusion of IV fluids
What does RACE stand for
Rescue clients, Activate fire alarm, Contain fire, Extinguis flames
Does an RN have a legal duty to provide Good Samaritan care at a traffic accident?
No, not legally required
Expected findings with inflammatory bowel disease
persistent diarrhea, ab pain, blood mucus in the stools
in a psychiatric unit, which client should you see first typically
auditory hallucination, make sure they are not telling the lcient o harm self or others
When is handwashing a requirement?
- prior to eating
- after cleaning a wound
- after contact with inanimate object
- before having direct contact with a client
- C.Diff/soiled hands
What is the biological response modifier for cancer therapy
stimulates bodys defense mecahnism. flu-like sx are common
Practice Partnerships
partners work together on same schedule with same group of clients
When is the safest time to offer analgesia during labor?
dilation is between 4-7 cm
Charge nurse has received a call from ambulance of a multiple car accident with multiple casualties. What action should nurse take first
- notify supervisor and request additional staff
- prep the trauma room
If a medication ends in these letter, what should you do?
CR, CD, LA, SR, XL, XR, XT
Do not crush
What happens when medication are administered sub lingually or rectally and metabolism
avoids the first pass effect.
Smallpox causative agent
variola virus
What might excessive protein do to a patient with osteoporosis
may increase calcium loss in the urine
Oral PAIN med admin consideratations
- contraindicated with N/V
- assess response 1 hour after administration
- may require additional analgesic
how often should trach be cleaned
every 4 hours
Bubbling in a suction control chamber vs bubbling in water seal chamber?
Suction control bubbling is expected
Water seal, indicates air leak
notify HCP if draining is more than 100mL/hr
What my an elderly patient with a hearing deficit exhibit
suspicious of others, because pt can’t communicate well with other people.
What is Kawasaki disease, and what is the demographic?
boys younger than 5 and asian descent. Red eyes (conjuctivitis), rash on the body and genital area, strawberry tongue. Red skin on palms of hands. Last 2-12 wks without treatment
Fetal Lie
the relationship between the head to tailbone axis for both the fetus and the mother
In relation to the heart, what direction do arteries go?
away from the heart
What 4 things does the nurse practice act define?
scope of practice, nursing titles, qualification for licensure, actions taken if nurse does not follow the law.
What do variable decellerations in a fetus represent
prolapsed cord, reposition client, apply oxygen and notify HCP
What does veracity mean
telling the truth
What will a patient experience with placenta previa
painless vaginal bleeding (painful bleeding indicated abruptio placenta)
what discomforts should be noted for a laparscopy exam
carbon dioxide is trapped in the abdomen and may cause shoulder pain
to assess for patency in a dialysis fistula or graft, the nurse should..
- auscultate for a bruit and
- palpate for a thrill (you feel this)
What can excessive diarrhea do to ABGs?
What about excessive vomiting?
d: lead to metabolic acidosis.
v: metabolic alkalosis
What are pre-surgery procedures to ensure safety
- surgical site is marked by the surgeon
- client is asked to state his/her name and birthdate
- the client is asked to confrim the correct surgical site
What are contraindications for a halo crown
skull fractures, chest trauma, obesity and avadanced age
What is a good handoff report technique
- Introduction (yourself)
- Patient name, identifiers,
- Assessment, chief complaint, Vital signs/sx, Dx
- Situation (code status, recent changes, response to tx)
- Safety concerns (lab values, socioeconomic factors, allergies, falls
- Background (comorbidities, currend meds, family hx
- Actions (what did you do)
- Timing (level of urgency and explicit timing, priotixation actions
- Ownerhip (who is responsible)
- Next (blocking discharge, plan)
What is the rooting reflex
touching or stroing cheek beside mouth causes baby to turn head to the side and suck (stops at 3-4 months
Where my patient report pain if they have pancreatitis?
sharp pain in the epigastric area, above the belly button. Pt might report upper back pain, nurse needs to assess correct location regardless of how the client identifies it verbally.
Left sided heart failure signs
orthopnea, cough
What type of communication technique is best for patient with Wernicke’s Aphasi
non verbals, actions, movements, props. Wernicke have no understanding of language. They can speak, but it makes no sense
What drug should not be given with Lithium
diuretics (furosemide)
additional side effects include polyuria, polydipsia
What are early findings of shock?
Increase RR, Inc HR, Oxygen is the most critical intervention
When does a pregnant women need to increase insulin dosage
during first 3 months of pregnancy
If you notice a mass in the umbilica area, which assessment should you NOT perform?
palpate/percuss b/c risk of rupture. Auscultate, bruit would confirm an aneurysm
How do you protect against extravasation in vesicant drugs for cancer?
aspirate positive blood return prior to use
early sign of diabetic nephropathy
albumin in the urine
How can you tell a patient is taking lithium
shaky hands
Why might a patient be asked to bear down during a central venous catheter insertion?
IV pressure must exceed astmospheric pressure to prevent air from entering the catheter and traveling to the heart and lungs
What solution should be used to clean around the pins in skeletal traction?
saline or sterile water (not alcohol or iodine which can cause corrosion)
Why does a client lie in prone position prior to amputation
stretch hip flexor muscles.
Signs of True Labor
- contractions regular pace,
- continue despite change of position
- start in the lower back and move to the front of the abdomen
- effacement and dilation
When is an electronic blood pressure machine contraindicated?
irregular HR, peripheral vascular disease, seizure, tremors, and shivering
When is it NOT the time to have client Turn Cough and Deep Breathe
immediately after srugery
Signs of False Labor
- Irregular contractions
- Diminish with activity
- Contractions get weaker
- Felt in the front of the abdomen or pelvic region
- membranes in tact, no cervical changes
What is a contraindication for receiving influenza vaccine
allergy to egg proteins b/c grown on egg embryos
A harrington rod is used for scoliosis, what do you want to assess
neuro checks b/c of spine
If nurse makes a medication error, what are the appropriate actions to take?
- Monitor vital signs
- notify HCP
- Document the administration
- Notify nurse manager
What is the consequence if a nurse attempts to resuscitate a client with a DNR
committing battery
S1 Auscultation
- closing of the mitral valve.
- heard best at apex
- after long diastolic pause, before short systolic pause
What is the biggest concern with first time dosing effect
orthostatic hypotension
Steps to using a peak flow meter
- move the indicator to the bottom of the numbered scale
- stand up
- take deep breath
- place in mouth and close lis around it
- blow out hard and fast
- record number achieved on the indicator
- Repeat 2x more (3 attempts
What is important to know for all anti-infective drugs
decrease effectiveness of oral contraceptives
When are hemovac or jackson pratt’s removed after total kneww surgery
the morning after
If client wishes to die, who should be the one to report that to the family
the client, not the nurse. encourage pt to discuss with HCP and family.
If a toddler does not want to take medication, what is the correct method or intervention to take?
leave the room and return five minutes later and give the medicine. Nurse must comply with child’s choise to build trust. Toddlers to not have an accurate sense of time.
What does a cisternography assess
ciculation of cerbrospinal fluid within the skull or subarachnoid spaces
What does crepitus mean?
air in sub q space (usually due to pneumothorax)
How much water must pt drink prior to ultrasound of urinary bladder
32 ounces
Nursing considerattions with Vincristin (Oncovin)
- Used for ALL (Acute Lymphocytic Leukemia)
- IV use only
- Intrathetcal admin can be fatal
- Vesicant can cause local damage if extravasation occurs
- Tx includes warm compresses
- Peripheral neuropathy is a major side effect
- monitor for decreased hepatic functining b/c gets metabolized in the liver
What is the extrusion reflex
touch or depress the tongue and it is forced outward. Stops by 4 months of age
Acronym OLD Cart for Pain scale
- Onset
- Location
- Duration
- Characteristics
- Attributes
- Related findings
- therapy and timing
GI infections
staph food poisoning, botulism
What is the pathogen of peptic ulcer disease
heliobacter pylori
How do you relieve flatus from a patient with an ostomy pouch
open the bottom of the pouch in privacy will cause odor.
Client with Irritable Bowel Syndrome is having problems with fiber, what should you do
- increase fiber gradually 2 - 3 mg per day, help to reduce gas and bloating
- Dairy products can contribute to gas formation
- small frequent meals to reduce gas
goal is to reduce gas and bloating
How might restrains without consent or sufficient justification be interpreted?
false imprisonment
what does an elevated d-dimer test indicate following aprution of placenta
concern for DIC. Notify HCP right away.
Where can you find standard of care?
institutional policy and procedure documents
Can CNAs collect urin specimens
yes
What is the most common and life threatening metabolic complication of renal failure?
hyperkalemia
Hallmark Signs of Tensions Pneumothoraz
chest pain, muffled heart/lung sounds. medistinal shift, respiratory distress.
Findings of Endocarditis
- Red spots on palms/soles (Janeway lesions)
- Red painful sores on fingetips and tes (Osler’s Nodes)
- fever, night sweats muscle aches.
Causes of Pericardities
infection, heart attack, injury to the chest esophagus or heart (MI)
Guthrie Bacterial Inhibition test (PKU)
- Can be done after 6 weeks of age
- Mandatory in the U.S.
- identifies an inherited disease
- Best results occur after baby has been breast feeding or drinking formula for 2 full days
- Test is delays if baby is less than 5 lbs
- positive test require dietary control for prevention of brain damage
Russells sign is observed with this disorder
bulimia nervosa
will have scraped or raw areas on the knuckles.
When you see the word thrombophlebitis, what should you think
embolism DVT/VTE
Actions for nurse to take after administration of restraints
- explain rationale for restraints
- tie using quick release
- thorough assessment
- document which alternative interventions were attempted
Why is pain med a priority for MI
pain wil increase oxygen demand
How do you reduce risk of lead contamination in tap water
let water run for 2 minutes
What is the first sign of worsening asthma
a fall in peak flow rates. Feeling tired, sneezing, stomach ache, poor appeptite, night time cough.
What indicates child has swallowed something corrosive
irritation of tissues. Mout would be burning and throat pain.
Which organ is most susceptible to damage during a hypertensive crisis
the brain due to rupture of cerebral blood vessels. Monitor neuro.
5Ps Factors affecting Pregnancy
- Passageway bony pelvis, soft tissues
- Passenger (fetus)
- Power (uterine contractions, bearing down)
- Position of laboring woman
- Psyche of birth
How do you know if IV pump is not functioning
calculate how much is left, more than expected amount would be left in the container
Fire Rescue plan, what does PRC stand for
Protect clients, Report the Fire, Contain the Fire
Normal therapeutic range for PTT
1.5-2 times normal
Normal: 20-25
Upper: 32-39
What is the safe action for removing an NG tube
ask the client to hold breath until tube is completely out. Closes the epiglottis and helps prevent aspiration. When inserting it is easier of the pt swallows.
What is a sign and risk when infant is receiving ventriculoperiotneal shunt?
ICP, sign is irritability, bulging fontanel, high pitched cry, continual crying when held.. Variable pulse. Slow respirations
What is the normal range for prothrombin time?
What is the normal range for Warfarin
10-14 seconds
20-28 seconds
Name an example of a hypotonic solution
0.45% sodium chloride
pregnancy and type 1 insulin requirements
increase during pregnancy and decrease after delivery
What intervention is crucial for pt with NG tube
frewuent oral care (ice chips/mints could be contradindicated)
Priorities if a patient has fallen out of bed
- Obtain Vital Signs
- Assist client back to bed (if does not appear injured)
- Call HCP to report Incident
- Incident Report
What is the first principle of safe assignments?
match skills with the task. New nurses should not be assigned task for which they are not competent
What is Most important to note while a patient is having a seizure
observe the sequence and types of movements
What does the nurse challenge rule refer to?
assertively voice concerns at least 2 times to ensure that it has been heard. If not heard contact supervisor or the attending physician.
What form of medication is best for a client on suicide precautions
liquid
Positive Signs of pregnancy
- presence of fetus
- fetal heart tones, visualization of fetus, plpating fetal movements
What is Total Lymphocyte count used for?
to assess immune function and is below 1500 when pt is malnourished (protein)
What is raynaud’s phenonemon
cold temperatures or strong emotions cause blood vessel spasms. Block blood flow to fingers, toes, ears and nose
What fluid and electrolyte imbalance happens with vomiting?
loss of acid in the stomach. Metabolic Alkalosis
Who should nurse manager consult with regarding bad behavior by a nurse?
human resources to determine procedures for documenting and reporting behavior
Symptoms of Cardiogenic shock
oliguria, jugular vein distention, crackles in bilateral bases, pitting sacral edema, weight gain
When doing an abdominal assessment, what quardant do you start in?
Right Lower Quadrant
What can cause mitral valve regurgitation
any disease or porblem that weakens the valve or heart tissue.
What should be done if a physician yells at a nurse in front of a client
nurse manager should request an immediate private meeting with HCP and staff nurse
Broca’s Area affects expressive aphasia or receptive aphasia?
Expressive Aphasia
What is lateral communication
between staff members i.e. coordinate activities
precautions with a fistula
never take blood pressure or draw blood from arm with fistula
Primary clients for C. Difficile
hospitalized, receiving antibiotic therapy- Ampicillin, amoxicillin and cephalosporins (Cephalexin)
Acute bacterial, viral gastroenteritis infections
salmonella, gastroentereitis, viral hepatitis, C. difficile
Normal Newborn Blood Pressure
50-75
What do you do if outer cannula of trach gets expelled?
ventilate the chest using a manual resuscitation bag
First Stage of Labor Active Phase
lasta 4 hours for primipara, discuss regional anasthesia
Malabsorption syndrome and Wernicke-Korsakoff syndrome are associated with which disorder
Chronic Alcoholism
malabsorb fat, nitrogen, sodium, water, thiamine, folic acid and vitamin b12. Wernicke’s is caused by a lack of thiamine.
Complications with cold stress
metabolic acidosis, hypoglycemia, reduced partial pressure of oxygen in arterial blood
If pt is experiencing chest pain and nausea and dizziness what lab values should you request
CBC, Cardiac Enzymes. R/t MI or Angina
How long before anginal client can resume sexual activity
1 week
If the dose of med exceeds 1 ml For infants receiving an IM injection. How should it be administered?
2 separate doses
Naegeles Rule for confirmng pregnancy date
first day of last period + 7 days - 3 months + 1 year
Example: June 10th is first day of last period = March 17 due date
Priority action for client with hypovolemia
- increase IV rate
- elevate lower extremities
- assess surgical dressing for bleeding
- reassess vital signs
What is the casative agent for the plague
yersinia pestis. Deteriorating pneumonia, fever, chest pain, bloody or watery sputum.
What should clients expect after transurethral resection of the prostate
3 way indwelling has a large diamtere, will continuously feel the urge to void for 24-48 hours
Fetal Presentation
portion of the fetus that enters the pelvic inlet first (cephalic, breech, shoulder)
What is the common cause of old age related drug absorption
decrease in lean body mass and increase in body fat.
Chancres, flu-like symptoms, hair loss, palmar rash signs of
syphyillis
Gout Diet
low purine. Organ meats, anchovies, mushrooms, spinach, dried beans, peas.
IM pain med administration consideration
- assess for response to therapy 30 minutes after admin
- avoid with hypothermia and vasoconstriction
Normal Newborn Respiration
30-60
What is a risk when the membranes rupture
increased risk fo cord prolaspe if head is at a minus level
Sucking Reflex
slowly relaced by voluntary sucking by 2 months of age.
Hallmark Signs of Severe Acute Respiratory Distress Syndrome
cough, difficulty breathing, fatigue, fever > 100.4, headache, myalgia.
S2 Auscultation
- closing of the aortic valve
- after short systolic pause, before long diastolic pause
- heard best over aorta, secon right interspace
- high pitched dull in quality
Newborn Apical Heart Rate Normal
110-160
What is the best technique for improving patient outcomes
involve the client in making healthcare decisions. More motivated to adhere to recommendations when involved in the process
Most common areas affected by scabies
hands and feet
Typical symptoms of a client with Hyperosmolar Nonketotic State
- blood glucose above 600 mg/dL
- profound dehydration
- No ketones
- alkalosis
What happens to nitrogen balance in burns, infections, injuries, fever or starvation
negative nitrogen balance. Protein is the body’s only source of nitrogen. Must be balanced by excretion of urea wastes.
How is Hep A transmitted
fecal oral route, or someone w/ virus hands food without washing hands. Or drinking contaminated water, eating raw shellfish from polluted water
What is the only fuel source that neurons cannot store
glucose. Only fuel used by brain cells
Other than hypertension and mental health. What can beta blockers be used for?
essential tremors
Infectious Diseaseas that are droplet
rubella, meningitis
Prioriy procedures for patient with pneumonia and sepsis
- Oxygen administration
- Blood & Sputum (prior to admin of antibx)
- IV initiation of normal saline
- Administer antibiotics
- Fingerstick before each meal
What are signs of Wilms tumor in an 2 year old?
urinary output less. Malignant tumor of the kidney. Increase girth
Airborne precaution PPE
Mask, N95 Mask
Common reasons older adults get readmitted to the hospital
- inadequate primary care
- poor care coordination
- poo skilled nursing facility
- poor communication among providers
- family preferences
What is the term when a nurse causes unintended harm to a patient?
Negligence
he client is informed that the ultrasound suggests the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. What causes this change?
maternal hypertension. Common cause of late pregnancy fetal growth restriction. Vasoconstriction reduces placental exchange of oxygen and nutrients.
General Guide for serving size for children
one tables spoon per year of age.
a disease that causes inflammation and sores (ulcers) in the lining of the rectum and colon (large intestine)
Ulcerative colitis
What is the appropriate dressing for a stage II pressure ulcer
Hydrocolloid or foam dressing (duoderm). Eliminate answer choices that have the word “dry” in them
What is wander band used for
a sensor bracelet allows patients to roam around (dementia pt) trips an alarm system if they decide to leave.
How many wet diapers per day for infants and newborns?
6-8 wet diapers
Primary Nursing
- Primary nurse designs, implements and is accountable for nursing care of clients during entire stay on the unit
- continuity of care, not feasible with varying schedules
- greater nurse satisfaction, more personalized care, less turn over
- fewer negative outcomes for patients
What does coconut oil contain
caprylic acid, no scientfici evidence says it is safe and effective for cognitivie decline
right sided hf signs
anorexia, nausea, ab discomfort, peripheral edema
Abnormal vital sigs and taking fish oil garlic and naproxen
all thos medication increase risk for bleeding. check color of bowel, bruising, frequency of medication use
What is the priority action prior to getting a sputum sample
oral hygiene without the use of mouthwash (alchol can alter the spututm . Then pt should take deep breaths and cough
Requirements for 24 hr urine sampling
- container must be kept cool
- can help doctor confirm a diagnosis r/t kidneys
- how much creatnine clears thru kidneys
What is charcot’s join
degenerative condition. Joint instability, and hpermobility. Along with numbness and tingling. Tx includes casting for 12 weeks. No weight bearing acivity
10 year old cognitive capabilities
able to think logically in the organization of facts
How is metformin used for Type 2 Diabetes
it lowers the amount of glucose absorbed from food, lowers the amount of glucose produced by the liver and increases body’s response to insulin
Actions to take with sudden drop in BP and pulse
- Simultanously check apical and radial pulse manually
- Assess for chest pain, dyspnea, low oxygen sat, restlessness
- nofity HCP
- anticipate EKG, oxygen admin, and mergency pacing
Presumptive Signs of Pregnancy
subjective/objective reported by women
amenorrhea, fatigue, N/V, breast changes, elevation of basal body temperature, skin changes.
findings can be caused by conditions other than pregancy
What is most valuable tool for school aged children and physical assessment
weight and heigh compared to standard tables
