NCLEX Review Questions Flashcards
(319 cards)
1
Q
Best practice for confirming NG tube?
A
aspirating gastric contents and testing pH (should be below 5)
2
Q
Procedure for neutropenic precautions
A
- PPE
- private room
- visitor restriction
- no raw vegetable or fruits
- bathe daily
3
Q
Team Nursing
A
- Most common delivery system
- team of nursing personnel provides total care to a group of clients
4
Q
What endocrine disorder leads to dry scaly skin, muscle cramps, tingling of the lips, fingers and toes
A
Hypoparathyroidism
5
Q
First Stage of Labor Transitional Phase lasts for
A
10-15 minutes
6
Q
What medication is the only FDA approved med to treat PTSD
A
SSRIs
7
Q
What is a priority for a patient after orchiectomy?
A
removll of testis for prostate cancer. PAIN MGMT
8
Q
Diet for crohn’s disease
A
increased protien increase calorie. Low fat, Low Residue (fiber)
9
Q
Hallmark Signs of tonsillitis
A
viral or bacterial. Difficulty swallowing, ear pain, fever/chills, headache, sore throat
10
Q
What is the septum
A
a wall between the ventricles, there should be no opening
11
Q
Which age range is at increased risk for poisoning?
A
Toddlers age 1-3 years b/c increasing mobility
12
Q
Activity Lifestyle changes after MI
A
decrease physical activites. Need Cardiac Rehab
13
Q
When is glucagon normally used?
A
If client is a ketoacidosis or coma. They are usually unconscious
14
Q
What is the primary purpose of a transitional care program
A
reduce readmissions to the hosptial
15
Q
What is always a concern with mysathenia gravis
A
airway
16
Q
If a mother is RH negative and rbeastfeeding exclusively, what is a concern
A
hyperbilirubemia
17
Q
What is the role of the MDS coordinator
A
interacts with health care staff to coordinate care processes of client assessment and care planning. Usually an RN
18
Q
What type of diet does a patient with preeclampsia need?
A
protein. Lie on the left side, adequite fluids. Protein restores osmotic pressure
19
Q
What patient is good to put next to a depressed patient
A
another depressed paitent or someone who’s condition is more stable. Matching roommates ages as closely as possible
20
Q
If a patient has and SCI injury at C-5, what is his sexual functioning
A
sexual functioning may be possible, depends on severity of the injury, age of the client.
21
Q
What is the algorithm for safe client handling and repositioning in bed
A
- 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
22
Q
What is the glabellar reflex
A
tap the bridge of ose and baby will close both eyes
23
Q
When a patient has a spinal cord injury what is the biggest risk
A
immobility. place client on pressure reducing support surface.
24
Q
Heberden’s nodes are characteristic of
A
osteoarthritis nodules. Strongly inherited.
25
What is a major side effect of INH
peripheral neuropathy
26
Where is the apical pulse heard? (apex/mitral area)
4-5th intercostal space midclavicular line
27
PPE for Contact Precautions
Gown, Gloves
28
This GI issue Pain localizes to the right upper quadrant, but may radiate to the right shoulder or scapula
Cholecystitis
29
What is the 3rd stage of labor
placental separation and expulsions. Lasts 5-30 minutes
30
31
Therapeutic range for lithium
0.8 - 1.2 mEq/L
32
Why type of solution is lactated ringers?
isotonic
33
Fetal Attitude
the relationship of the fetall body part to one another
34
What is placenta previa
placenta is abnormally implanted in the lower uterine segment. No vaginal exams, IVs to restore blood volume.
35
Bright flashes of light; blurred vision; "floaters" in the eye
Retinal detachment
36
Procedures for after a newborn is delivered
1. Asses infant's airway and breating
2. perform bulb suctioning if excessive mucus
3. assess infants heart rate
4. place id bands on mother and infant
5. administer vit k
37
Priority action for pt with preeclmapsia
have the client turn to the left side
38
Who establihed the Standards of Practice
the nursing profession (ANA)
39
How is Scope of Practice determines
Stat'es nurse practice act
40
TB treatment
medication is taken daily with monthly visits to the clinic
41
Infectious diseaseas that require contact precautions
meningitis, Varicella (Gown, Gloves)
42
arrett's esophagus is a complication of this condition
GERD
43
Things the nurse CANNOT delegate
* assessment
* evaluation of client date
* nursing judgment
* teaching and evaluation
* nursing dx, or care planning
44
Fetal station means
the relationship between the presenting part of the baby with the mother's pelvis
45
Why can't a CNA shave a client after surgery
they probably have taken anticoagulants only an electric shaver can be used.
46
The most common healthcare associated infection
caused by staff
47
How much radiation in mammography is it equivalent to?
one hour of sun exposure
48
Foods to avoid if low WBCs
raw fruits and vegetables, undercooked meats, moldy cheeses, luch meat, salads things from the deli counter, brewed teas.
49
Common cause of aortic stenosis
aging heart, or rheumatic fever
50
What vegetarian foods are rich in
cereals and dried froot
51
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.*
52
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**
53
What is the rule for UAPs for documentation
they cannot document what they cannot assess
54
Responsibilities of UAP
* No scope of practice
* Non-invasive and non-sterile treatments
* bathing, transferring, ambulating, feeding, toileting, Vital signs
55
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)
56
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.
57
Total Client Care Case Method
* RN is responsible for ALL aspects of care
* May be seen in Critical care or PACU
58
Procedures with a patheint with bronchiolitis to RSV
1. Assess for respiratory distress
2. promote tissue ogyenation
3. institute droplet isolation precautions
4. administer medication
5. promote desired fluid intake
6. provide family teaching
59
What is the most common cause of diverticular disease
eating a low fiber diet
60
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
61
Clinical indicators for suctioning
* course breath sounds
* noisy breathing
* increased/decreased pulse
* increased/decreased respiration
* prolonged expeiratory breath sounds
62
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
63
What are the 5 Stages of grief?
1. Denial
2. Anger
3. Barganing
4. Depression
5. Acceptance
64
Procedure for child with ingestion of toxic substance
1. Stabilize the child (ABCs)
2. Start IV infusion (large bore needle)
3. Obtain history of ingestion
4. reverse or eliminate toxic substance
65
What is the most accuarete oxygen delivery method
venture mask mixes RA with 100% oxgyen max of 55%
66
Signs of Chronic Kidney Disease
Ecchymoses, hyperpigmentation, pruritus
67
What are you worried about with neuroleptic malignant syndrome
very high temperature
68
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
69
Renal Encephalopathy signs pt with hemodlialysis
confusion irritability, elevated BUN and Creatnine
70
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
71
What type of pain delivery system is well suited for pts with cancer
SubQ
72
What could be a cause at home for a child to have an astma attack
new pillow
73
What is the most important intervention when body iimage is a factor
touch
74
What is buck's traction used for
to immobilize, position and align the lower extremity.
5-7 lbs is recommended for skin traction
75
What is a milkwakee brace used for?
scoliosis 1-2 years, during periods of growth
76
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
77
A child with burn is at risk for dehydration, what finding would indicate decrease in status
increased hematocrit and decrease in urine volume
78
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
79
What is the most accurate way of determining proper NG tube placement?
measure hte pH of aspirated gastric contents
80
Pediculosis capitis, signs
whitish oval specks sticking to the hair shaft. (Head lice)
81
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.
82
Where is the Rinne Test administered using tuning forks?
against the mastoid bone. Normal= air conduction is longer than bone conduction.
Abnormal= the reverse
83
Findings of pinworm
infection which includes intense perianal itching.
84
What can immunoglobulin therapy interfere with?
body's ability to form appropriate amts of antibodies. Live attenuated immunizations should be delayed.
85
Droplet Precaution requirements
Mask, goggles
86
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
87
This condition may be caused by gallstones, chronic alcohol use, infections, medications, and trauma.
Pancreatitis
tx with IV fluids, antibiotics, pain relievers
88
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
89
what does stable eschar do for skin care?
serves as body's natural cover
90
Hep A Precautions
wear gown and gloves during client contact
91
Probable changes in pregnancy
* Chadwicks Sign- vaginal vascularity- blue cervix
* Hepgar's Sign- uterine vascularity
* Goodell's sign- cervical softening from estrogen and progesterone
92
What is the maximum dose of IM injection for infants and toddlers
1mL
93
Functioning Nursing
* RN gives medications and UAP gives bed baths for one group of clients
* Needs are broken down into tasks
94
Indications of Intenstinal obstruction
abdominal distention, chills fever (toxic megacolon), fitula formation
95
In relation to the heart what direction do veins go?
towards the heart, they have valves.
96
CNS infection examples
meningiits, encephalitis
97
What does the mitral valve control?
flow between the left atrium and left ventricle (Atrioventricular Valve)
98
Postpartum assessment, BUBBLE
* Breasts
* Uterus
* Bowels
* Bladder
* Lochia
* Episiotomy/C-section incision
99
What lab values indicate protein/malnutrtion
cholesterol, hemoglobin, Total Lymphocyte Count
100
Post Op Tracheostomy position
Elevate HOB and turn to one side until consciousness returns
101
The bubbling in a water seal chest tube chamber indicates
lung has not yet re-expanded
102
Classic findings of pulmonary stenosis
heaviy brathing, dyspnea, tachycardia, peripheral edema
103
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.
104
Procedural order for administeral total parenteral nutrition through Central Line
1. Check solution ofr cloudiness or sediment
2. select & flush the correct tubing and filter
3. thread the IV tubing thru an infusion pump
4. use aseptic tech when handling injection cap
5. connect the tubing to the central line
6. set infusion pump at prescribed rate
105
Procedure for patient who is lethargic and slow to respond
1. Attempt to elicit a response by physically shaking
2. quick neurological assessment
3. call rapid response team
4. remain with pt, send another staff member to get list of medications and chart
106
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.
107
What pain medication can induce asthma attacks
aspirin
108
Fetal adaptions during labor
* engagement
* descent
* flexion
* internal rotation
* extension
* external rotation
* expulsion
109
Infectious diseases that are airborne?
TB, Rubeola, Varicella
110
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
111
What is an example of behavioral therapy
using positive and negative reinforcement. Assertiveness trainsing and desensitiization.
good for *phobias, sexual dysfunction, eating disorders, etc.*
112
Responsibilities of LPN/VN
* implementation of a plan
* assessing abnormal/normal
* reinforce information given by RN
* care for stable clients with predictable condition
113
early sign of intenstinal obstruction
hyperactive bowel sounds
114
How can over training in exercise increase risk with osteoporosi
can decrease estrogen levels in women and may increase risk
115
Normal range for neonate blood sugar
40-90
depending on weight of newborn, may need blood sugar checks q 2 hours
116
When does engagement of the fetus occur in pregnancy
2 weeks before birth
117
Risk factors for CT scan with contrast
* history of asthma
* positive pregnancy
* Poor renal function
* Beta blockers
* heart, kidney, thyroid disease
118
What is always an intervention when puncturing the spine
need fluids
119
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
120
What action is benefical to prevent hypercalcemia
walking as much as possible keeps the calcium in the bone
121
What types of food can prevent kidney stones
high calcium, dairy products
122
What is a keyword to consider with a public health nurse
groups rather than invidivuals
123
Hallmark signs of Myasthenia Gravis
drooping eye lid, mouth weakness, difficulty chewing, swallowing or taking. Arm or Leg Weakness
124
Examples of urniraty tract infections
cystitis, pyelonephritis
125
Diagonal communication
staff from different levels work together on a project
126
When does the second stage of labor occur?
Complete dilation through birth (30-50 minutes for primipara)
127
What lab values can indicate pre-eclampsia
Magnesium will be low, Creatnine will be high
128
Symptoms of a Panic episode
* Palpitations
* Aabdominal distress
* Nausea
* Increased persiration
* Chest pain
129
Causes of myocarditis
mononucleuosis, parvovirus (5th disease), HIV
130
What does downward communication mean?
used to relate organizationl policy such as position description and rules and regulations
131
What is the main finding of pericardities
sharp, stabbing pain in the center or left side of chest.
132
What is the treatment time with a halo vest?
12 weeks
133
First Stage of labor Latent Phase
lasts 8 hours for primipara, 4-5 hours for multipara
134
Hallmark signs of emphysema
carrel chest, chronic cough, SOB, wheezing, Weight loss
135
What is upward communications?
staff meetings
136
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.
137
What should you NOT include in the chart in general
incident reports, abbreviations
138
What is an early sign of diminished oxygenation
increasing pulse rate, compensatory mechanism.
139
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
140
Common findings in mitral valve regurgitation include
heart murmurs, SOB, fatigue, Paroxysmal noctural dyspnea
141
What does justice mean?
fairness
142
What is the antidote for metformin
acetylcestein (24-48 hrs after contrast)
143
Positioning for pregnant woman
left side lying, prolasped cord (reverse trendelenburg)
144
What is a common temporary side effect of Pepto Bismol (Bismuth Subsalicylate)
dark tint of the tongue
145
What can cause false positive result on fecal occult test
* eating red meat
* NSAIDS
* steroid use
* bleeding gums
146
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
147
What does RACE stand for
Rescue clients, Activate fire alarm, Contain fire, Extinguis flames
148
Does an RN have a legal duty to provide Good Samaritan care at a traffic accident?
No, not legally required
149
Expected findings with inflammatory bowel disease
persistent diarrhea, ab pain, blood mucus in the stools
150
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
151
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
152
What is the biological response modifier for cancer therapy
stimulates bodys defense mecahnism. flu-like sx are common
153
Practice Partnerships
partners work together on same schedule with same group of clients
154
When is the safest time to offer analgesia during labor?
dilation is between 4-7 cm
155
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
156
If a medication ends in these letter, what should you do?
CR, CD, LA, SR, XL, XR, XT
Do not crush
157
What happens when medication are administered sub lingually or rectally and metabolism
avoids the first pass effect.
158
Smallpox causative agent
variola virus
159
What might excessive protein do to a patient with osteoporosis
may increase calcium loss in the urine
160
Oral PAIN med admin consideratations
* contraindicated with N/V
* assess response 1 hour after administration
* may require additional analgesic
161
how often should trach be cleaned
every 4 hours
162
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
163
What my an elderly patient with a hearing deficit exhibit
suspicious of others, because pt can't communicate well with other people.
164
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
165
Fetal Lie
the relationship between the head to tailbone axis for both the fetus and the mother
166
In relation to the heart, what direction do arteries go?
away from the heart
167
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.
168
What do variable decellerations in a fetus represent
prolapsed cord, reposition client, apply oxygen and notify HCP
169
What does veracity mean
telling the truth
170
What will a patient experience with placenta previa
painless vaginal bleeding (painful bleeding indicated abruptio placenta)
171
what discomforts should be noted for a laparscopy exam
carbon dioxide is trapped in the abdomen and may cause shoulder pain
172
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)
173
What can excessive diarrhea do to ABGs?
What about excessive vomiting?
d: lead to metabolic **acidosis.**
v: metabolic alkalosis
174
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
175
What are contraindications for a halo crown
skull fractures, chest trauma, obesity and avadanced age
176
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)
177
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
178
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.
179
Left sided heart failure signs
orthopnea, cough
180
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
181
What drug should not be given with Lithium
diuretics (furosemide)
additional side effects include polyuria, polydipsia
182
What are early findings of shock?
Increase RR, Inc HR, Oxygen is the most critical intervention
183
When does a pregnant women need to increase insulin dosage
during first 3 months of pregnancy
184
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
185
How do you protect against extravasation in vesicant drugs for cancer?
aspirate positive blood return prior to use
186
187
early sign of diabetic nephropathy
albumin in the urine
188
How can you tell a patient is taking lithium
shaky hands
189
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
190
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)
191
Why does a client lie in prone position prior to amputation
stretch hip flexor muscles.
192
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
193
When is an electronic blood pressure machine contraindicated?
irregular HR, peripheral vascular disease, seizure, tremors, and shivering
194
When is it NOT the time to have client Turn Cough and Deep Breathe
immediately after srugery
195
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
196
What is a contraindication for receiving influenza vaccine
allergy to egg proteins b/c grown on egg embryos
197
A harrington rod is used for scoliosis, what do you want to assess
neuro checks b/c of spine
198
If nurse makes a medication error, what are the appropriate actions to take?
* Monitor vital signs
* notify HCP
* Document the administration
* Notify nurse manager
199
What is the consequence if a nurse attempts to resuscitate a client with a DNR
committing battery
200
S1 Auscultation
* closing of the mitral valve.
* heard best at apex
* after long diastolic pause, before short systolic pause
201
What is the biggest concern with first time dosing effect
orthostatic hypotension
202
Steps to using a peak flow meter
1. move the indicator to the bottom of the numbered scale
2. stand up
3. take deep breath
4. place in mouth and close lis around it
5. blow out hard and fast
6. record number achieved on the indicator
7. Repeat 2x more (3 attempts
203
What is important to know for all anti-infective drugs
decrease effectiveness of oral contraceptives
204
When are hemovac or jackson pratt's removed after total kneww surgery
the morning after
205
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.
206
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.
207
What does a cisternography assess
ciculation of cerbrospinal fluid within the skull or subarachnoid spaces
208
What does crepitus mean?
air in sub q space (usually due to pneumothorax)
209
How much water must pt drink prior to ultrasound of urinary bladder
32 ounces
210
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
211
What is the extrusion reflex
touch or depress the tongue and it is forced outward. Stops by 4 months of age
212
213
Acronym OLD Cart for Pain scale
* Onset
* Location
* Duration
* Characteristics
* Attributes
* Related findings
* therapy and timing
214
GI infections
staph food poisoning, botulism
215
What is the pathogen of peptic ulcer disease
heliobacter pylori
216
How do you relieve flatus from a patient with an ostomy pouch
open the bottom of the pouch in privacy will cause odor.
217
218
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
## Footnote
*goal is to reduce gas and bloating*
219
How might restrains without consent or sufficient justification be interpreted?
false imprisonment
220
what does an elevated d-dimer test indicate following aprution of placenta
concern for DIC. Notify HCP right away.
221
Where can you find standard of care?
institutional policy and procedure documents
222
Can CNAs collect urin specimens
yes
223
What is the most common and life threatening metabolic complication of renal failure?
hyperkalemia
224
Hallmark Signs of Tensions Pneumothoraz
chest pain, muffled heart/lung sounds. medistinal shift, respiratory distress.
225
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.
226
Causes of Pericardities
infection, heart attack, injury to the chest esophagus or heart (MI)
227
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
228
Russells sign is observed with this disorder
bulimia nervosa
## Footnote
*will have scraped or raw areas on the knuckles.*
229
When you see the word thrombophlebitis, what should you think
embolism DVT/VTE
230
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
231
Why is pain med a priority for MI
pain wil *increase* oxygen demand
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How do you reduce risk of lead contamination in tap water
let water run for 2 minutes
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What is the first sign of worsening asthma
a fall in peak flow rates. Feeling tired, sneezing, stomach ache, poor appeptite, night time cough.
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What indicates child has swallowed something corrosive
irritation of tissues. Mout would be burning and throat pain.
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Which organ is most susceptible to damage during a hypertensive crisis
the brain due to rupture of cerebral blood vessels. Monitor neuro.
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5Ps Factors affecting Pregnancy
* Passageway bony pelvis, soft tissues
* Passenger (fetus)
* Power (uterine contractions, bearing down)
* Position of laboring woman
* Psyche of birth
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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
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Fire Rescue plan, what does PRC stand for
Protect clients, Report the Fire, Contain the Fire
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Normal therapeutic range for PTT
1.5-2 times normal
Normal: 20-25
Upper: 32-39
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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.
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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
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What is the normal range for prothrombin time?
What is the normal range for Warfarin
10-14 seconds
20-28 seconds
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Name an example of a hypotonic solution
0.45% sodium chloride
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pregnancy and type 1 insulin requirements
increase during pregnancy and decrease after delivery
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What intervention is crucial for pt with NG tube
frewuent oral care (ice chips/mints could be contradindicated)
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Priorities if a patient has fallen out of bed
1. Obtain Vital Signs
2. Assist client back to bed (if does not appear injured)
3. Call HCP to report Incident
4. Incident Report
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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
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What is Most important to note while a patient is having a seizure
observe the sequence and types of movements
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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.
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What form of medication is best for a client on suicide precautions
liquid
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Positive Signs of pregnancy
* presence of fetus
* fetal heart tones, visualization of fetus, plpating fetal movements
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What is Total Lymphocyte count used for?
to assess immune function and is below 1500 when pt is malnourished (protein)
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What is raynaud's phenonemon
cold temperatures or strong emotions cause blood vessel spasms. Block blood flow to fingers, toes, ears and nose
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What fluid and electrolyte imbalance happens with vomiting?
loss of acid in the stomach. Metabolic **Alkalosis**
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Who should nurse manager consult with regarding bad behavior by a nurse?
human resources to determine procedures for documenting and reporting behavior
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Symptoms of Cardiogenic shock
oliguria, jugular vein distention, crackles in bilateral bases, pitting sacral edema, weight gain
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When doing an abdominal assessment, what quardant do you start in?
Right Lower Quadrant
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What can cause mitral valve regurgitation
any disease or porblem that weakens the valve or heart tissue.
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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
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Broca's Area affects expressive aphasia or receptive aphasia?
Expressive Aphasia
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What is lateral communication
between staff members i.e. coordinate activities
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precautions with a fistula
never take blood pressure or draw blood from arm with fistula
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Primary clients for C. Difficile
hospitalized, **receiving antibiotic therapy**- Ampicillin, amoxicillin and cephalosporins (Cephalexin)
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Acute bacterial, viral gastroenteritis infections
salmonella, gastroentereitis, viral hepatitis, C. difficile
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Normal Newborn Blood Pressure
50-75
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What do you do if outer cannula of trach gets expelled?
ventilate the chest using a manual resuscitation bag
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First Stage of Labor Active Phase
lasta 4 hours for primipara, discuss regional anasthesia
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Malabsorption syndrome and Wernicke-Korsakoff syndrome are associated with which disorder
Chronic Alcoholism
## Footnote
*malabsorb fat, nitrogen, sodium, water, thiamine, folic acid and vitamin b12. Wernicke's is caused by a lack of thiamine.*
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Complications with cold stress
metabolic acidosis, hypoglycemia, reduced partial pressure of oxygen in arterial blood
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If pt is experiencing chest pain and nausea and dizziness what lab values should you request
CBC, Cardiac Enzymes. R/t MI or Angina
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How long before anginal client can resume sexual activity
1 week
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If the dose of med exceeds 1 ml For infants receiving an IM injection. How should it be administered?
2 separate doses
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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
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Priority action for client with hypovolemia
1. increase IV rate
2. elevate lower extremities
3. assess surgical dressing for bleeding
4. reassess vital signs
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What is the casative agent for the plague
*yersinia pestis*. Deteriorating pneumonia, fever, chest pain, bloody or watery sputum.
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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
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Fetal Presentation
portion of the fetus that enters the pelvic inlet first (cephalic, breech, shoulder)
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What is the common cause of old age related drug absorption
decrease in lean body mass and increase in body fat.
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Chancres, flu-like symptoms, hair loss, palmar rash signs of
syphyillis
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Gout Diet
low purine. Organ meats, anchovies, mushrooms, spinach, dried beans, peas.
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IM pain med administration consideration
* assess for response to therapy 30 minutes after admin
* avoid with hypothermia and vasoconstriction
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Normal Newborn Respiration
30-60
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What is a risk when the membranes rupture
increased risk fo cord prolaspe if head is at a minus level
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Sucking Reflex
slowly relaced by voluntary sucking by 2 months of age.
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Hallmark Signs of Severe Acute Respiratory Distress Syndrome
cough, difficulty breathing, fatigue, fever \> 100.4, headache, myalgia.
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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
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Newborn Apical Heart Rate Normal
110-160
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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
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Most common areas affected by scabies
hands and feet
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Typical symptoms of a client with Hyperosmolar Nonketotic State
* blood glucose above 600 mg/dL
* profound dehydration
* No ketones
* alkalosis
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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.
293
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
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What is the only fuel source that neurons cannot store
glucose. Only fuel used by brain cells
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Other than hypertension and mental health. What can beta blockers be used for?
essential tremors
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Infectious Diseaseas that are droplet
rubella, meningitis
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Prioriy procedures for patient with pneumonia and sepsis
1. Oxygen administration
2. Blood & Sputum (prior to admin of antibx)
3. IV initiation of normal saline
4. Administer antibiotics
5. Fingerstick before each meal
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What are signs of Wilms tumor in an 2 year old?
urinary output less. Malignant tumor of the kidney. Increase girth
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Airborne precaution PPE
Mask, N95 Mask
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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
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What is the term when a nurse causes *unintended* harm to a patient?
Negligence
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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.
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General Guide for serving size for children
one tables spoon per year of age.
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a disease that causes inflammation and sores (ulcers) in the lining of the rectum and colon (large intestine)
Ulcerative colitis
305
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
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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.
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How many wet diapers per day for infants and newborns?
6-8 wet diapers
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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
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What does coconut oil contain
caprylic acid, no scientfici evidence says it is safe and effective for cognitivie decline
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right sided hf signs
anorexia, nausea, ab discomfort, peripheral edema
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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
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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
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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
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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
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10 year old cognitive capabilities
able to think logically in the organization of facts
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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
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Actions to take with sudden drop in BP and pulse
1. Simultanously check apical and radial pulse manually
2. Assess for chest pain, dyspnea, low oxygen sat, restlessness
3. nofity HCP
4. anticipate EKG, oxygen admin, and mergency pacing
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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*
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What is most valuable tool for school aged children and physical assessment
weight and heigh compared to standard tables
