Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

KAPLAN > Saunders- NCLEX > Flashcards

Saunders- NCLEX Flashcards

1
Q

Triage Levels

A

Emergent (red):

Immediate threat to life, requires immediate tx and continuous evaluation

ex) trauma, chest pain, severe respiratory distress or cardiac arrest, pt w/ limb amputation, pt w/ acute neurological deficits, chemical splashes to eyes

Urgent (yellow):

not life-threatening if treated w/in 1-2 hours, require continous evaluation every 30-60 min thereafter

ex) simple fracture, asthma w/o respiratory distress, fever, HTN, abdominal pain or renal stone

Nonurgent (green):

local injuries w/o complications and can wait several hours for medical tx, require evaluation every 1-2 hrs after.

ex) minor laceration, sprain, or cold symptoms

Dead or dying (black):

injuries to severe to benefit from care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Type of Leader

A

Autocratic:

  • focused, maintains strong control, makes decisions, and addresses all problems.
  • dominates the group and commands, rather than seeks suggestions or input

Situational:

  • use a combo of styles based on needs of group and the tasks to be achieved
  • work w/ the group to validate that the info gained is accurate and problem exists
  • Take time to get to know the group

Democratic:

  • participative, and would likely meet w/ each staff person individually to determine the staff member’s perception of the problem
  • speak w/ staff about any issues and ask for input with developing a plan

Laissez-faire:

  • passive and nondirective
  • state what problem is and inform the staff that they needed to come up with a plan to “fix it”
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Guidelines that the nurse should use when delegating and planning assignments

A
  • ensure client safety
  • be aware of individual variations in work abilities
  • determine which tasks can be delegated and to whom
  • match the task to the delegatee on teh basis of nurse practice act and appropriate position descriptions
  • provide directions that are clear, concise, accurate, and complete
  • validate the delegatee’s understanding of the directions
  • communicate a feeling of confidence to the delegatee
  • provide feedback promptly after the task is performed
  • maintain continuity of care as much as possible when assigning pt care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Normal osmolality of plasma

A

270 - 300 mOsm/gk water

Osmolality refers to the number of osmotically active particles per kg of water; concentration of a solution

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Hypotonic solution

A

when a solution contains a lower concentration of salt or solute than another, more concentrated solution

1/2 NS, 1/3 NS, 1/4 NS

  • has less salt, and more water than isotonic sol’n
  • lower osmolality than blody fluids
  • WATER LEAVES SOL’N (vascular space) and ENTERS CELLS VIA OSMOSIS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Hypertonic solution

A

has higher concentration of solutes than another, less concentrated solution

3% NS, 5% NS, D10W, D5W with NS

  • fluid pulled out of the cells
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Electrolyte imbalance affect on ECG: wave changes

A

Hypocalcemia:

  • prolonged ST segment
  • prolonged QT interval

Hypercalcemia:

  • shortened ST segment
  • widened T wave

Hypokalemia:

  • ST depression
  • Shallow, flat, or inverted T wave
  • Prominent U wave

Hyperkalemia:

  • tall peaked T waves
  • Flat P waves
  • widened QRS complex
  • prolonged PR interval

Hypomagnesemia:

  • tall T waves
  • depressed ST segment

Hypermagnesemia:

  • prolonged PR interval
  • widened QRS complexes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Absent P waves

A

atrial fibrillation

junctional rhythms

ventricular rhythms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Foods high in sodium

A

bacon

butter

canned food

cheese

frankfurters

ketchup

lunch meat

milk

mustard

processed food

snack food

soy sauce

table salt

white and whole-wheat bread

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Foods high in Potassium

A

avocado

bananas

cantaloupe

carrots

fish

mushrooms

oranges

potatoes

pork, beef, veal

raisins

spinach

strawberries

tomatoes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Foods high in Calcium

A

cheese

collard greens

milk and soy milk

rhubarb

sardines

spinach

tofu

yogurt

(fruit doesn’t seem helpful)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Foods high in magnesium

A

avocado

canned white tuna

cauliflower

green leafy vegetables (spinach and broccoli)

milk

oatmeal, wheat bran

peanut butter, almonds

peas

port, beef, chicken, soy beans

potatoes

raisins

yogurt

(fruit doesn’t seem helpful)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Foods high in phosporus

A

fish

pumpkin, squash

nuts

pork, beef, chicken, organ meats

whole-grain breads and cereals

dairy products

(fruit doesn’t seem helpful)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Normal Electrolyte levels

A

Sodium 135- 145

Potassium 3.5- 5.0

Calcium 8.6- 10

Magnesium 1.6- 2.6

Phosphorus 2.7- 4.5

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

signs of fluid volume deficit

A

increased respirations and HR

decreased CVP

weight loss

poor skin turgor

dry mucous membranes

decreased urine volume

increased urine specific gravity

increased hematocrit

altered LOC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

causes of FVD

A

vomiting

diarrhea

conditions that cause increased respirations

conditions that cause increased urine output

insufficient IV replacement

draining fistula

presence of ileostomy or colostomy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

causes of fluid volume excess

A

decreased kidney function

heart failure

use of hypotonic fluids to replace isotonic fluid losses

excessive irrigation of wounds and body cavities

excessive ingestion of sodium

pt taking diuretics

pt with an ileostomy

pt who requires GI suuction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Causes of respiratory acidosis

A

PRIMARY DEFECTS IN THE FUNCTION OF THE LUNGS OR CHANGES IN NORMAL RESPIRATION PATTERNS

Any condition that causes an obstruction of the airway or depresses the respiratory system

asthma

atelectasis

brain trauma

bronchiectasis

bronchitis

central nervous system depressants

emphysema

hypoventilation

pneumonia

pulmonary edema

pulmonary emboli

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Causes of respiratory alkalosis

A

CONDITIONS THAT CAUSE OVERSTIMULATION OF RESPIRATORY SYSTEM:

fever

hyperventilation

hypoxia

hysteria

overventilation of mechanical ventilators

pain

20
Q

PT and INR

A

for warfarin therapy

PT: 9.6 to 11.8 seconds (male adult); 9.5 to 11.3 seconds (female adult)

**PT should be 1.5 to 2x the labortory control value

INR: 2 to 3 for standard warfarin therapy

INR: 3 to 4.5 for high-dose warfarin therapy

BLEEDING PRECAUTIONS IF PT > 30 sec

21
Q

aPTT

A

for heparin therapy

aPTT: 20 to 36 seconds, depending on the type of activator used

  • **should be between 1.5 and 2.5 times normal when the client is receiving heparin therapy (so not less than 30 or greater than 90sec)*
  • **BLEEDING PRECAUTIONS IF > 90sec*
22
Q

serum GI lab studies

A

Albumin: 3.4 - 5

Ammonia: 10-80

ALT: 10-40

AST: 10-30

Amylase: 25-151 (chronic pancreatisis, level not to exceed 3x normal/ acute can be 5x normal)

Lipase: 10-140

Cholesterol: 140-199

LDLs: lower than 130

HDLs: 30-70

Triglycerides: lower than 200

Protein: 6-8

Total bilirubin: lower than 1.5 (pt with liver dz have prolonged clotting times and need prolonged pressure on punctures site)

23
Q

Renal Function lab studies

A

serum Creat: 0.6-1.3 (increased levels indicate slowing glomerular filtration rate)

BUN: 8 -25 (increased level can indicate dehydration, below normal may be caused by FV overload)

24
Q

WBC

A

WBC: 4500 - 11000

Differential: info on specific white blood cell types

“shift to the left” means that an increased number of immature neutrophils is present in the blood

25
Q

normal Digoxin level

A

0.5 - 2.0

26
Q

Troponin level that indicates a MI occured

A

troponin T value that is higher than 0.1 to 0.2 ng/mL

27
Q

HgbA1c

A

Good control: 7% or less

Fair control: 7% - 8%

Poor control: 8% or higher

28
Q

Signs of hyperglycemia

A

excessive thirst

fatigue

restlessnes

confusion

weakness

Kussmaul’s respirations

diuresis

coma (when severe)

29
Q

6 rights of medication administration

A
30
Q

Intervention for air embolism

A
  1. clamp tubing
  2. turn pt on left side w/ HOB lower than feet to trap air in rt atrium (trendelenburg)
  3. notify HCP
31
Q

autonomic dysreflexia

A

overstimulation of nervous system

32
Q

signs of infection

A

Local:

redness, swelling, and drainage at site

Systemic:

chills, fever, malaise, h/a, N/V, backache, tachycardia

33
Q

signs of infiltration

A

edema, pain, coolness at site

may or may not have blood return

(from seepage of IV fluid out of vein)

34
Q

signs of phlebitis

A

heat, redness, tenderness at the site

not swollen or hard

intravenous infusion sluggish

(from mechanical or chemical/medication trauma or from a local infection that causes inflammation)

35
Q

sign of thromobplebitis

A

hard and cordlike vein

heat, redness, tenderness at site

IV infusion sluggish

36
Q

sign of circulatory overload

A

increased BP

distended jugular veins

rapid breathing

dyspnea

moist cough and crackles

37
Q

signs of catheter embolism

A

decrease in BP

pain along the vein

weak, rapid pulse

cyanosis of the nail beds

loss of consciousness

38
Q
A
39
Q

proper documentation

A

Document the occurence, actions taken, and pt’s response

40
Q

signs of hypoxemia

A
41
Q

signs of pulmonary embolism

A

sudden dypsnea

sudden sharp chest or upper abdominal pain

cyanosis

tachycardia

a drop in BP

LIFE THREATENING AND REQUIRES EMERGENCY ACTION

42
Q

signs of hemorrhage

A

restlessness

weak and rapid pulse

hypotension

tachypnea

cool, clammy skin

reduced urine output

CAN LEAD TO SHOCK!!!

43
Q

signs of wound infection

A

REEDA

redness

erythema

ecchymosis

drainage

approximation of wound edges

44
Q

autonomic dysreflexia

A

sudden onset of excessively high BP

45
Q
A

KAPLAN (13 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions