page 1-10 Flashcards
ABO
What is the ABO antigen system?
It is the different classes of human blood.
ABO
What part of the blood is classified?
The RBCs are distinguished.
ABO
What other blood is compatible with Type A?
Type A or O
ABO
What other blood is compatible with Type B?
Type B or O
ABO
What other blood is compatible with Type O?
Type O only
ABO
What other blood is compatible with Type AB?
Type A, B or O
Acetylsalicylic Acid
What is another name for Acetylsalicylic Acid?
Aspirin
What is the indication to give Acetylsalicylic Acid?
Mild to moderate pain
Acetylsalicylic Acid
Does aspirin increase or decrease the effects of methotrexate?
INCREASE
Acetylsalicylic Acid
What is methotrexate used for?
Chemotherapy agents & rheumatoid arthritis
Acid Reflux (GERD)
What is the primary symptom?
Heart burn (pyrosis)
Acid Reflux (GERD)
What test confirms GERD?
Barium swallow fluoroscopy
Acid Reflux (GERD)
What malfunction allows reflux in gerd?
Lower esophageal sphincter
Acid Reflux (GERD)
What is the client teaching?
Low fat, high protein diet
take antacids
avoid lying flat after eating
Acquired Immunodeficiency Syndrome
What is the virus that causes AIDS?
HIV
Human Immunodeficiency Virus
Acquired Immunodeficiency Syndrome
How is HIV transmitted?
Sexual intercourse
Direct contact with infected blood/body fluids (semen, breast milk)
Acquired Immunodeficiency Syndrome
What are the symptoms of HIV?
Fever weight loss night sweats diarrhea fatigue
Acquired Immunodeficiency Syndrome
How is the presence of HIV confirmed?
Screening is done FIRST to see if HIV antibodies are present.
The test is performed to specifically identify the HIV antibodies.
Acquired Immunodeficiency Syndrome
What is the screening test?
ELISA
Acquired Immunodeficiency Syndrome
How does the HIV attack the body?
It attacks the immune system by destroying the T-lymphocytes.
The virus also rapidly self-replicates.
Acquired Immunodeficiency Syndrome
What is so important about T-lymphocytes?
T-cells help immune system to recognize & fight pathogens.
Acquired Immunodeficiency Syndrome
What is another name for T-lymphocytes?
CD4 cells
Acquired Immunodeficiency Syndrome
Why is the CD4 count important?
The lower the CD4 count, the more damage the virus has done to the body.
Acquired Immunodeficiency Syndrome
What is a normal CD4 count?
500-1500
Acquired Immunodeficiency Syndrome
What is the normal CD4 count in a client with HIV?
Anything at or above 500, client is considered in good health. If below 200, HIV has progressed to AIDS.
Acquired Immunodeficiency Syndrome
If a client’s CD4 count is below 200, client is at risk for what?
Opportunistic infections
Acquired Immunodeficiency Syndrome
List some opportunistic infections.
- Oral pharyngeal infections (mouth fungus)
- Kaposi’s sarcoma (skin cancer)
- Pneumocystis pneumonia
- Cytomegalovirus (blindness)
- Meningitis
Acquired Immunodeficiency Syndrome
What is the goal of HIV medications?
To interfere with the virus replicating
Acquired Immunodeficiency Syndrome
The most important medication to know is __________?
Z i d o v u d i n e
Acquired Immunodeficiency Syndrome
Which isolation precautions are used with HIV?
Universal/standard precaution
Patients do not have to tell anyone they have HIV, treat everyone as if they are infected.
Acquired Immunodeficiency Syndrome
How do precautions change with AIDS?
If a client has a low CD4 count & risk for opportunistic infection, implement:
- private room
- reverse isolation
RN wears gloves, gown, googles, mask when in direct contact with body/blood fluids.
Acquired Immunodeficiency Syndrome
What are teaching points for parents who have a child with HIV?
- Clean up body/blood fluid with 10:1 water:bleach ration
- Get all immunizations except live ones such as (MMR, varicella, & oral poliovirus)
- Feed high calorie, high protein diet
- use gloves to change diapers
Acute Renal Failure
What is the definition of acute renal failure (ARF)?
Sudden loss of kidney function to excrete toxins & regulate fluids & electrolytes.
Acute Renal Failure
What are some possible causes of ARF?
Infection, obstruction, shock
Acute Renal Failure
What are three phases, what are they?
Oliguric
Diuretic
Recovery
Acute Renal Failure
During the oliguric phase, what will you see?
This phase lasts 1-2 weeks
low urine output
<400 elevated BUN/ creatinine fluid overload
Acute Renal Failure
What two electrolytes will be elevated?
Sodium
Phosphate
Acute Renal Failure
The diuretic phase is second, what will you see?
Urine output slowly returns, hypokalemia, hypotension
Acute Renal Failure
What does recovery phase mean?
The kidneys are recovering through a slow process.
Urine output increases & BUN is normal.
Acute Renal Failure
What are the nursing interventions?
Daily weights, strict I & O’s
treat the causes of renal failure & diuretics
Acute Renal Failure
What is the best diet for a client with ARF?
HIGH Carbohydrate
low protein
Adams-Stokes Syndrome
Where is the complication located?
This is a heart problem.
Adams-Stokes Syndrome
What will the client experience?
Sudden attacks of syncope & fainting
seizures may also be present
Adams-Stokes Syndrome
What will the nurse see on EKG?
Asystole or ventricular arrythmias
Adams-Stokes Syndrome
Is there adequate tissue perfusion during the attacks?
No there will be no tissue perfusion
Adams-Stokes Syndrome
What is the treatment?
The client will need an internal pacemaker via surgery.
Adams-Stokes Syndrome
What oral medications can be given after surgery?
Digoxin
Addison’s Disease
What is the cause?
A low production of hormones by Adrenal gland (glucocorticoids & mineralcorticoids)
Adams-Stokes Syndrome
What are some of the major symptoms?
Lethargy, weakness, weight loss
Addison‘s Disease
What color is the skin of a client with Addison’s disease?
Bronzed color (hyperpigmentation)
Adams-Stokes Syndrome
Will this client be overweight?
No weight loss is common
Adams-Stokes Syndrome
Will the serum blood glucose levels be high or low?
Low, so will the sodium levels
Adams-Stokes Syndrome
Will the serum potassium levels be high or low?
High
Addison‘s Disease
What is treatment?
Lifelong glucocorticoid therapy
Allergies
Clients allergic to latex may also be allergic to which foods?
Bananas
Kiwi
chestnuts
Allergies
What standard hospital equipment contains latex?
Blood pressure cuffs, gloves, stethoscopes, tourniquets, Band-aids, indwelling catheters
Allergies
What allergy is contraindicated for contrast IV dye?
Iodine/shellfish allergy
Amputation
What are the major complications of having an amputation performed?
Infections
Skin breakdown
phantom limb pain
joint contractures
Amputation
What is the positioning for post-op care?
AKA (above the knee) amputation
Elevate first 24 hours
then, prone position 2x daily to prevent hip flexion
Amputation
BKA (below the knee) amputation
Elevate foot of bed first 24 hours, the prone position 2x daily to prevent hip flexion
Amputation
What should you encourage?
Expressing feelings about lost limb
Amputation
What is phantom limb pain?
Pain felt in an area that has been amputated
Anemias
Aplastic Anemia
What are the signs?
Signs:
decreased erythrocytes
bleeding mucous membranes
thrombocytopenia
Anemias
Aplastic Anemia
Treatment
Blood transfusions
Bone marrow transplantations
Anemias
Iron Deficiency Anemia
What are the signs?
Signs: low hgb, hct pallor, fatigue tissue hypoxia tachycardia *most common during pregnancy
Anemias
Iron Deficiency Anemia
Treatment
Iron supplements
Dietary changes
Anemias
Vitamin B 12/ Pernicious Anemia
What are the signs?
Pallor
‘‘beefy red tongue’’
fatigue
paresthesia
Anemias
Vitamin B 12/ Pernicious Anemia
Treatment
Cyanocobalamin (Vit B12)
Injections
Dietary Changes
Aneurysm
True or false?
An aneurysm is a dilation formed at a weak point on the wall of an artery.
TRUE
Aneurysm
What are the symptoms of aneurysms in the body?
Most aneurysms inside the body have no symptoms
Aneurysm
What are some of the risk factors?
Arteriosclerosis
Infection (syphilis)
Smoking
Hypertension
Aneurysm
What is the treatment for an aneurysm?
Surgery - depends on size
Strict blood pressure control with medications
Aneurysm
List important NCLEX teaching points.
- AVOID straining, lifting or exerting
- Take medications on schedule
- Report severe back/flank pain
Anorexia Nervosa
The primary symptom of illness is?
Starvation
Anorexia Nervosa
What is the perception of the body?
Distorted
Anorexia Nervosa
At what age does this disease occur?
Adolescent
Anorexia Nervosa
What is the usual personality type?
- Perfectionist
- overachievers
- low esteem
Anorexia Nervosa
What is a major cardiac complication of anorexia?
Arrythmias
Anorexia Nervosa
What treatment is involved in recovery?
Small frequent meals with counseling & milieu therapy
Anorexia Nervosa
What is a major gynecological complication of anorexia?
Amenorrhea
Appendicitis
Is commonly seen in what age range?
10-30 yo
Appendicitis
What is the classic sign of appendicitis?
Acute right lower abdominal pain
Appendicitis
What are some other signs/symptoms?
- loss of appetite
- N V
- low-grade temperature
Appendicitis
Localized tenderness is found where?
McBurney’s point
Appendicitis
What are the tests to determine Appendicitis?
Complete history & physical exam with WBC count (it will be elevated)
Appendicitis
What is the treatment for appendicitis?
- Immediate surgery to remove appendix
- IV antibiotics
- Semi-Fowler’s position
- NPO to rest stomach
Appendicitis
What is the general treatment for any acute abdominal pain?
- NPO status
- NO HEAT on abdomen
- assess abdominal distention
- IV Fluid therapy
Arterial Blood Gas
Where are most samples drawn from?
Radial artery in the wrist
Arterial Blood Gas
How long should pressure be applied to the site after collecting a sample?
5 minutes
Arterial Blood Gas
Which test should be performed before collecting ABG on a client?
Allen’s Test
Asperger’s Syndrome
This syndrome is a form of __________?
Autism
Asperger’s Syndrome
The treatment focuses on improving?
Communication/client social skills
Asthma
An obstructive airway disease caused by ____ & ____ of the bronchioles?
Spasms & inflammation
Asthma
What are the signs of asthma?
- SOB
- Tachycardia
- expiratory wheezes
- and possibly a cough
Asthma
When will the client experience the cough?
At night
Asthma
What is the primary treatment goal?
To identify allergen
Asthma
Which medications work best for the treatment?
- Anti-inflammatory
- Corticosteroids bronchodilators
- leukotriene modifiers
- Metered dose inhalers
- Bronchodilator
Asthma
Which should you give first– the steroid or bronchodilator– when treating asthma?
Bronchodilator
Asthma
What are leukotriene modifiers?
They are drugs used to block the chemical leukotriene, which reduces inflammation.
Steps to use a metered dose inhaler
NCLEX Teaching Question
6 steps
- If pxs cannot tolerate a bitter taste/ are experiencing side effects, they may need a spacer.
- Rinse mouth after each dose to prevent thrush.
- Pxs should wait only 1 minute between each puff
- Remove the cap
- Shake the inhaler well before use
- Breathe out, away from your inhaler.
- Bring the inhaler to your mouth. Place it in mouth between the teeth & close mouth around it.
- Start to breathe SLOWLY. Press the top of your inhaler once & keep breathing in slowly until you have taken a full breath (3-5 sec)
Autonomic Dysreflexia
Autonomic Dysreflexia occurs in clients with what kind of injury?
Spinal injury (T6 or above)
Autonomic Dysreflexia
What can cause Autonomic Dysreflexia?
Stimuli such as a full bladder / fecal impaction
Autonomic Dysreflexia
Why is it serious?
Life threatening due to clients becoming extremely HYPERTENSIVE
Autonomic Dysreflexia
What is the common cause?
Urinary obstruction
Autonomic Dysreflexia
What are the signs of Autonomic Dysreflexia?
- Increase in BP 40 mm Hg
- Headache
- Bradycardia
- Blurred vision
- Sweating
Autonomic Dysreflexia
What should be done during an episode?
1st Place px in High Fowler’s
- Check for bladder distention
- Loosen restrictive clothing
Autonomic Dysreflexia
What is the treatment?
- Removal of the stimuli
- Px needs to void or have bowel movement
Bell’s Palsy
Bell’s Palsy affects which cranial nerve?
Cranial Nerve #7
Bell’s Palsy
What does the client with Bell’s Palsy suffer from?
Temporary facial paralysis that affects chewing, eating, & closing the eyes
Bell’s Palsy
What is the treatment for Bell’s Palsy?
- Wear an eye patch night
- Use artificial tears
- Wear glasses to protect the eyes
- Steroids to reduce edema/swelling
Benign Prostatic Hyperplasia (BPH)
BPH is caused by _____?
The cause is unknown, but it’s an enlargement of the prostate gland.
Benign Prostatic Hyperplasia (BPH)
Because the prostate blocks the urethra opening, what will clients feel & see when they urinate?
Straining to urinate, decreased urine stream, feeling like they have to go all the time, dribbling urine flow
Benign Prostatic Hyperplasia (BPH)
Who usually gets BPH?
Men usually >50
Benign Prostatic Hyperplasia (BPH)
What is the best way to assess for BPH?
Rectal exam, physician will feel a pea-sized nodule
Benign Prostatic Hyperplasia (BPH)
What is the common surgical treatment for BPH?
Transurethral resection of the prostate (TURP)
Benign Prostatic Hyperplasia (BPH)
How is a TURP performed?
A scope goes through the penis & removes parts of the prostate.
Benign Prostatic Hyperplasia (BPH)
After the procedure, what is the client at risk for?
Bleeding; monitor for hemorrhage
Benign Prostatic Hyperplasia (BPH)
All clients will get a ______ before a TURP.
Three-way (lumen) Foley catheter
Benign Prostatic Hyperplasia (BPH)
What are the three lumens for?
Inflating the balloon, inflow of solution, & outflow of urine
Benign Prostatic Hyperplasia (BPH)
What will the doctor order to be done after a TURP?
Continuous Bladder Irrigation (CBI)
Benign Prostatic Hyperplasia (BPH)
What is the goal of the bladder irrigation?
Reduce / prevent blood clot
Benign Prostatic Hyperplasia (BPH)
Will an incision be made during the irrigation?
No, irrigation will be done using the indwelling catheter.
Benign Prostatic Hyperplasia (BPH)
What type of fluids is used to irrigate the bladder?
Isotonic sterile saline
Benign Prostatic Hyperplasia (BPH)
What color should the urine be?
Light pink
Benign Prostatic Hyperplasia (BPH)
During CBI what must the client be monitored for?
- Bladder distention
- fluid overload
- *hyponatremia & blood loss
Benign Prostatic Hyperplasia (BPH)
If bladder spasms occur, give ____ or ____.
Belladonna/opium suppositories or oxybutynin
Benign Prostatic Hyperplasia (BPH)
The best position for this client post-op is?
Lying flat because sitting up puts pressure on the bladder
Benign Prostatic Hyperplasia (BPH)
List some discharge instructions.
- Drink 2 to 3 liters fluids daily.
- No lifting or straining.
- If bright red clots are present, call MD.
- Do Kegel exercises to strengthen pelvis muscles.
