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NCLEX: Mix > Passpoint 2 > Flashcards

Passpoint 2 Flashcards

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1
Q

Why is 20mL of urine output a concern for a nurse with a client who just suffered from MI

A

Oliguria is a sign of cardiogenic shock, due to reduced blood flow to the kidneys.

Low BP
Rapid weak pulse
Confusion due to reduced blood flow to brain

Cardiogenic shock is serious with 90% death rate

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2
Q

Which is most important for a client with pertussis

A. Gloves & Gown
B. Negative Pressure Room
C. Masks for everyone
D. Use goggles for direct contact with child

A

C.

Pertussis (whooping cough) is spread via droplets

Masks requiered for first 5 days after start of medical treatment

TB, Measles, Varicella need negative pressure

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3
Q

Respiratory Alkalosis S/S

Vs

Respiratory Acidosis

A

Alkalosis = lightheaded / paresthesia

Acidosis = Nausea, Vomit, Diarrhea

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4
Q

Left-sided heart failure S / S

Vs

Right-sided heart failure

A

Left = pulmonary edema, bibasilar crackles (Bubbling orcracklingsound originating from the base of the lungs. Occur inflation or deflation)

Right = jugglar vein distention, right quadrant pain (hepatomegaly), and dependent edema (Gravity Caused feet & hands) - Usually Chronic

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5
Q

Cystitis is …

A

an infection of the bladder that almost always follows (is secondary to) bacterial infection in the urine. It is the most common type of urinary tract infection (UTI), particularly in women.

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6
Q

After surgery

  1. Establish air patency
    Check: Bleeding, VS, and promote urine output

VS: HR 130, BP 98 / 56, Respiration 24

These are signs of

A

Shock

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7
Q

rare condition caused by a combination of four heart defects that are present at birth.

defects cause oxygen-poor blood to flow out of the heart and into the rest of the body.

Risk factors include a viral illness such as rubella during pregnancy, maternal alcoholism, or a family history of the condition.

A

Tetralogy of Fallot

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8
Q

Polyneuritis

A

disorder affecting several or many peripheral nerves, especially when thought to be of inflammatory origin.

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9
Q

Guillian-Barre syndrome
(Immune system attacks the nerves)
which assessment is most important

Lungs
ICP
pain
Metabolic State

A

Lungs

Polyneuritis causes weakness and paralysis, which may ascend to the trunk amd lungs

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10
Q

Which will help a client with thick secretions

A. Elevation of bed 30 degrees
B. Turning q2hrs
C. Increase of fluids
D. Cool room temperature

A

Increase fluids

Helps to thin the thickened mucous

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11
Q

Match

Wheezing in Single lung field

Decreased / absent lung sounds in base of lungs & decreased Ox Sat

Wheezing Bilateral lung fields, coughing, shortness of breath

Acute bronchitis

Atelectasis

Aspiration pneumonia

A

Aspiration pneumonia

Wheezing in Single lung field

Atelectasis

Decreased / absent lung sounds in base of lungs & decreased Ox Sat

Acute bronchitis

Wheezing Bilateral lung fields, coughing, shortness of breath

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12
Q

IV corticosteroids are prescribed for asthma, bronchitis, ______

A

Anaphylaxis

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13
Q

Client has an obstruction due to foreign body aspiration

What is required to remove it

A

Bronchoscopy

Bronchoscope, a thin, flexible tube with a light and camera on the end, to look for signs of blockages or disease in the throat, airways, and lungs

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14
Q

_____ aka ataxic or Biot’s breathing, is a dangerous, irregular, unpredictable deep breaths followed by periods of apnea.

Alert HCP

A

Cluster breathing

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15
Q

Which is most important for nurse to include in discharge for asthma patient with a Rescue Inhaler

Monitor HR
Report Nausea/ Vomiting
Watch for hyperactivity
Record change in taste

A

Monitor Hr

Tachycardia is the most serious SE of rescue inhalers

All other SE are valid

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16
Q

A lesion in the upper medulla or lower pons is usually the cause of (this type) of dangerous breathing

A

cluster

pattern characterized by rapid, shallow, rhythmic breathing cycles in clusters, followed by periods of apnea

Biot’s respiration

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17
Q

Sucking stab wound in chest gets covered with gauze and tape on 3 side.

Why is this done?

A

Prevent pneumothorax (Collapsed Lung)

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18
Q

Cardiac tamponade (Fluid in pericardial sac) is a medical emergency

It prevents ____ from filling with blood

Manifestaciones

Pulsus Paradoxus ( condition where a patient’s blood pressure drops by more than 10 millimeters of mercury (mmHg) during inspiration.)
hypotension, chest pain, jugular distention, diminished heart sounds

A

Left ventricle

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19
Q

Tension pneumothorax occurs when an injury to the chest allows air to enter but not leave the pleural space.

What can be the result of this

A

Shifting of heart to uncompromised side

Result

MI

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20
Q

Why would a patient with Emphysema have respiratory Acidosis

A. Narrowed bronchioles and decreased oxygen

B. Increased work of breathing

C. Increased production of mucus, lack of oxygen

D. Alveoli lost elasticity, retains carbon dioxide

A

Alveoli lost elasticity, retains carbon dioxide

Narrowed bronchioles and increased mucus production is characteristics of chronic bronchitis which causes Hypoxemia

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21
Q

Crackles are typically heard (inspiration/ expiration) can be high or low pitched and classified as fine or course.

A

Inspiration

Pneumonia, acute respitory syndrome, pulmonary edema

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22
Q

____ embolism is a relatively rare but serious consideration 24 - 48 hrs after an injury to a Long Bone.

A

Fat

The fat breaks down into fatty acids which are toxic to the lungs, result maybe pulmonary hypertension

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23
Q

Volkmann contracture….

A

a deformity of the hand, fingers, and wrist caused by injury to the muscles of the forearm. Th

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24
Q

Lower abdominal surgeries:

This position helps gravity pull intra-abdominal organs away from the pelvis, allowing for better access to pelvic organs. It’s used for colorectal, gynecological, and genitourinary procedures.

Central venous catheter placement: This position is used to place a central venous catheter in the internal jugular or subclavian vein.

Hypotension: This position is often the first measure used to treat hypotension.

Vagal discomfort: This position is used to treat vagal discomfort.

Robotic procedures: This position is often used for patients undergoing robotic procedures

Name this posistion

A

Trendelenburg

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25
Q

First priority for a child with vomiting and diarrhea is to replace fluid and electrolytes.

Dehydration puts them at risk for which serious complication

A

Heart Arrhythmia caused by hypokalemia <3

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26
Q

Promethazine is a medication used to manage and treat allergic conditions, nausea and vomiting, motion sickness, and ____

A

Sedation

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27
Q

What is considered a normal urine output per hour.

A

30 - 50 mL

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28
Q

Which of the following are suggested with loop diuretics

A. Reduce sodium
B. Use salt substitutes to enhance food flavor
C. Adivse HCP if edema occurs
D. Take meds on regular schedule
E. Take meds with evening meal

A

A, C, D

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29
Q

How many wet diapers daily should a 1 week old have

A

6 - 8

30
Q

Destruction of malignant cells during chemotherapy causes large amounts of _____ and tubular obstruction from the crystals.

Allopurinol reduces this build-up

Intervention: Increase fluid intake

A

Uric acid

31
Q

Which IV solution is compatible with blood infusions

A

0.9% NS

32
Q

Client returns from cardiac step-down unit following cardiac catheterization

Which information should be obtained first

Lab values
Neurological status
Puncture site appearance
Skin warmth and tugor

A

Puncture site appearance

33
Q

During discharge of a client with an ileostomay to treat IBD, the nurse should stress the importance of

A. Increase fluid prevent dehydration
B. Wear appliance only at bedtime
C. Consuming low protein, high fiber
D. Take only enteric coated pills

A

A.

Stool usually forms in large intestines

Ileostomy drains mostly liquid poop
Extra water is needed to prevent dehydration

Avoid high fiber foods - may bother intestines

Avoid enteric coated bc body cant absorb them

34
Q

Accessing 4 year-old prepheral IV line and notice its not infusing.

What would be the first action

A

Resposistion the child’s extremity.

Most likely reason of IV not infusing is postitional issues of the child or extremity

35
Q

Which Score is used 1& 5 minutes after birth to access the health of a newborn

Describe 5 characteristics & scoring

What is a dangerous score

A

APGAR score

Breathing effort
Heart rate
Muscle tone
Reflexes
Skin color
0 - 2 Zero = Worst

<6

36
Q

What is a normal urine output ratio

A

0.5 mL / kg / hr

37
Q

SIADH which is the most likely outcome

A. Cerebral edema
B. Hypovolemic Shock
C. Hyperkalemia
D. Tetany

A

Cerebral edema is seen in SIADH

Due to the hypotonic/ hypovolemic the hypotonic fluid will go into the hypertonic brain fluid

38
Q

First time dialysis patient what should you monitor

A

Neurological Status

First time may have confusion/ seizures

39
Q

First time dialysis, monitor for

A

Neurological Status

Common confusion/ seizures first time

40
Q

Hh

A

Jj

41
Q

Kegel exercises can be performed in any position

2x daily and 10 minutes

Strengthen pelvic muscles

When will changes be noticed

A

6 weeks

42
Q

To prevent nausea how long should a client wait after eating dry foods to drink water.

A

30 minutes

43
Q

Episiotomy, also known as perineotomy, is…

A

surgical incision of the perineum and the posterior vaginal wall generally done by an obstetrician. This is usually performed during second stage of labor to quickly enlarge the aperture allowing the baby to pass through

44
Q

Bandage: joints, ankles, elbow, wrist, knee

This technique

A

Figure 8

45
Q

Bandage: use this technique to anchor a Bandage

A

Circular

46
Q

Bamdage: Stump, hand, scalp

A

Recurrent

47
Q

Bandage: increasing circumference. Ie. A cast

A

Spiral reverse

48
Q

Reiki is based on which principal of healing.

A

Energy from hands being placed lightly or at a distance can be used to heal

49
Q

Can muslims have caffeine

A

Yes

50
Q

Chloroxazone is a centrally acting skeletal muscle relaxant used to treat (acute / chronic) symptoms

A

Acute

51
Q

What is the first intervention in the home environment fir minor and major burns

A

Place affected area in cool water to stop the burn

52
Q

Discomfort at IV site.

Blanching around site
Swelling, coolness to touch
WBC within normal range

What is occurring

A. Infiltration
B. Phlebitis
C. Infection
D. Infection & Infiltration

A

A. Infiltration (IV fluid goes into tissues rather than vein)

Discontinue and restart at different site

Phlebitis is evident by redness at cannula tip and long length of vein

53
Q

Significant hypotension doesnt occur until ___ % of volume loss occurs

A

30

54
Q

Right sided heart failure

Assess for

Intermittent Claudication
Dyspnea
Dependent edema
Crackles

A

Dependent edema: aka pitting edema, buildup in the veins, which leads to swelling in the feet, ankles, and legs.

Rigjt sided heart failure: venous congestion result: peripheral edema, splenomegaly, hepatomegaly, neck vein distention.

Left heart failure: Dyspnea & Crackles associated with pulmonary edema

Intermittent Claudication = arterial occulsion

55
Q

_______ is pain in the arms or legs that occurs while walking or using the arms.

It can also feel like a cramp or fatigue in a muscle group of the lower extremity. Claudication is caused by too little blood flow to the legs or arms.

It can be a symptom of _______ In most cases, lifestyle changes, exercise, and medications can slow or reverse the symptoms.

Two drugs, cilostazol and pentoxifylline, are approved for treatment of intermittent claudication

A

Claudication

peripheral artery disease
(PAD).

56
Q

Match

Serous
Purulent

Clear, watery plasma

Thick yellow tinged

A

Serous Clear, watery plasma

Purulent Thick Yellow Tinged

57
Q

Partial thickness burns

Which IV is given first

Albumin
D⁵W
Lactated Ringers solution
0.9 NS woth 20 mEq of potassium per 1,000 mL

A

Lactated Ringer’s

Replaces sodium & corrects metabolic acidosis, Both occur after burn

Albumin is ised as adjunct therapy

D⁵W isn’t given during first 24 hrs , due to pseudo-diabetes effect

Client after burn is Hyperkalemic, potassium would be contradicted

58
Q

(Negative/ Positive) pressure wound therapy

Applies subatmospheric pressure
Increase local blood flow
Reduce drainage
Stimulate Granulation Tissue

A

Negative

59
Q

Tropin levels (increase/ decrease) with ischemia and necrosis of cardiac muscle

A

Increase

60
Q

Fasciotomy is a procedure to relieve ____ syndrome

A

Compartment

61
Q

S/S this skin disease include:

Painless, dry, flaky, rough patches of skin with bumps, maybe itchy

Usually on Hands, Feet, Face, Chest, Neck

Caused by: Stress, exacerbated by hot showers and lack of moisturizer

A

Atopic dermatitis aka eczema

62
Q

Skin disease

Proliferative inflammatory disease, well-demarcated erythematous, papules and plaques covered in Silvery Scales. (Usually appear on knees, elbows, extremities, scalp)

A

Psoriasis

63
Q

High levels of ____ in blood can suggest a autoimmune disease such as Rheumatoid Arthritis, Scleroderma, Systemic lupus erythematous

A

Rheumatoid Factor

(RF) is a protein produced by the immune system that can attack healthy tissue in the body

64
Q

Sever itching in both hands worse at night.

Gray-brown burrows with epidemal curved ridges and follicular papules.

Is indicative of….

A

Scabies

65
Q

Normal albumin levels

What does albumin do?

Causes hypo/hyper

S/S hypo/hyper

A

3.5 - 5

Basically, same as K

Albumin keeps blood in veins

Causes

Hypo:

Liver / Kidney disease, malnutrition

Hyper:

Dehydration/ diarrea

S/S

Hypoalbuminemia
Swelling, dry/itchy skin, thin hair,

Hyper: No specific s/s

66
Q

During IV infusion of a chemotherapeutic vesicant drug, the nurse observes that there is a lack of blood return from the IV catheter.

What would the nurse do first

A

Stop Administration of Drug

IV catheter with no blood return is most likely occluded or not patent.

Infiltration or extravasation of vesicant drug into tissues can cause severe damage

67
Q

vesicant drug….

A

Causes blisters or necrosis

68
Q

_____ causes blanching, cyanosis, coldness, numbness, and throbbing pain in the hands when client is exposed to COLD or STRESS

A

Raynaud’s Phenomenon

69
Q

______, also known as ringworm of the body, is a fungal skin infection
. It’s a common, contagious, but not serious infection that can often be treated with an over-the-counter topical fungicidal medication.

A

Tinea corporis

70
Q

82 yrs resident LTC reports

Burning, Stabbing Pain left flank wraps around to abdomen

Next day, small red vesicular lesions around left flank.

Which disease may it be

A

Herpies zooster

Shingles

71
Q

Post-herpetic neuralgia is..

A

a lasting pain in the areas of your skin where you had shingles

NCLEX: Mix (18 decks)

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