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nclex review1

QuestionAnswer
Stay with client for 1st ____ min of blood transfusion 15
Infuse blood within ____ hours 4
What type blood transfusion reaction manifests in pruritus, respiratory distress,urticaria, and flushing allergic
What type of blood transfusion reaction manifests in flank pain, chest pain, fever, chills, tachycardia, and tachypnea hemolytic
Erythropoietin is produced in the _________ kidneys
Pernicious anemia results from a deficiency in _____ usually caused by lack of the intrinsic factor in gastric juice B12
Lead poisoning can cause _____________ anemia hemolytic
Pain med of choice for sickle cell anemia dilaudid
Dilute liquid ________ preparations in juice or water and administer with a plastic straw to avoid staining teeth iron
Avoid antacids, coffee, tea, dairy products or whole grain breads for ___ after oral iron administration 1 hr
For iron injections, use a _______ guage, ___ inch needle 20, 3
Massage after injecting iron. t/f False
Change needles between drawing up iron and injecting to prevent staining. t/f True
A 45 year old man's lipid profile results are sent to the nurse practitioner. They are as follows total cholesterol= 287; HDL= 30' LDL= 165; triglycerides =150. The nurse interprets these results as: Abnormal: the total cholesterol and LDL levels are elevated, and the HDL is too low.
Barium swallow series Upper GI tract exam under fluoroscopy after ingesting barium sulfate to detect anatomical or functional abnormalities of the esophagus, stomach and small intestines
Increased fluids and laxatives may be prescribed after a swallow series to increase elimination of ________ barium
Lower GI tract exam done by ex-ray and fluoroscopy of the large intestine after rectal insertion of a ___________ Barium enema
Give clear liquid diet and laxative day before procedure, NPO after midnight, and cleansing enema before a ________________ and _____________ barium enema study, colonoscopy
For a colonoscopy, patient lies on ______ side with knees drawn up to chest left
x-ray that requires the client to consume a high-fat meal at 1200, a low-fat meal at 1700, and contrast tablets 12 hours before the procedure cholecystogram
Have client lie on ______ side for 1-2 hours after a liver biopsy Right
Assess placement of NG tube before each feeding and every ___ hours with continuous feeding 4
Always refeed residual of NG tube unless it exceeds ____ mL 100
TPN must be administered through a ___________ for rapid dilution and blood flow central line
Maintain __________ technique during TPN dressing changes aseptic
Change all TPN tubing and filters every ____ hours 24
Check blood glucose every __ hours for TPN 4
Methods to avoid ____________ include eating small frequent meals, avoiding liquids with meals, lying down after meals, and eating high-protein, high-fat, LOW-CARB meals Dumping syndrome
Eat a _____ residue diet to prevent diverticulitis and a ____ residue diet to heal it - ALWAYS avoid ______ high, low, seeds
Ulcerative colitis Bowel disease effecting large bowel, causing bleeding, pain, weight loss, and severe diarrhea
Crohn's Disease Bowel disease effecting small bowel, causing perianal involvement, fistulas, colicky pain, weight loss, and diarrhea
Hepatitis A Virus transmitted by fecal-oral contact; often seen with contaminated water or shellfish
Hepatitis B Virus transmitted through infected blood or unprotected sex - most common
Hepatitis C Virus transmitted through blood transfusions, IV drug abuse, health care exposure
Appropriate immune serum globulin must be administered within ____ days of exposure to Hepatitis viruses 2-7
cirrhosis diet This condition requires a high-calorie; low/no protein; low-fat; low-sodium diet
medication used to lower blood ammonia levels lactulose
Which condition can be treated with a Sengstaken-Balemore tube? esophageal varices
Murphy's sign Palpation of right subcostal area while client takes a deep breath - extreme pain indicates acute cholecystitis
Elevated serum amylase and lipase are seen with __________ pancreatitis
NPO with NG tube in place and TPN for moderate to severe cases occurs with ____________ pancreatitis
ID sites inner forearm,back,chest
SQ sites abdomen,outer arm,anterior thigh
SQ Heparin sites abdomen,posterior upper arm,low back,thigh,upper back
IM sites deltoid,ventrogluteal,dorsogluteal,vastus lateralis
dont use more than 2ml injection where? deltoid
preferred site for IM adults ventrogluteal
watch for sciatic nerve whene using what site dorsogluteal
Potassium High sources include bananas, peaches, melons, raisins, dried fruits, black licorice, nuts, salt substitutes, vegetables, and tomato, orange, and grape juices,
Which side effect of hydrochlorothiazide, a thizide diuretic should a diabetic patient be monitored for? Increased hyperglycemia
An elderly white man with a long history of asthma has recently ben given a diagnosis of hypertension. Which class of antihypertensive agents should the nurse avoid for this client? Beta Blockers
Your patient is receiving unfractionatedheparin. In addition to the PTT, which laboratory value must be monitored? Platelets
Which drug counteracts heparin? Protamine sulfate
CD4 count less than _______ indicates AIDs 200
chronic inflammatory disease involving vascular and connective tissue of multiple organs causing butterfly rash on cheeks and across nose, polyarthralgia, anemia, fever, malaise, weight loss, Raynaud's Lupus
Which birth control method is contraindicated for patients with Lupus? IUD
Burn percentage of head and neck 9
Burn percentage of anterior trunk 18
Burn percentage of posterior trunk 18
Burn percentage of arms 18
Burn percentage of legs 36
Burn percentage of perineum 1
The shock phase of a burn victim occurs for ___ -____ hours - this is when massive edema, protein and fluid loss, and increase in potassium occurs 24-48
For burn victims, give half of total fluids in first ___ hours 8
Sodium High sources include table salt, processed foods, baking soda, MSG
Calcium High sources include dairy products, sardines, salmon, tofu, soy,and nuts
Magnesium High sources include fruits, peas, nuts, pumpkin seeds, sunflower seeds, spinach, salmon, halibut, black and navy beans
Administration of glucose and insulin facilitate entry into cells Potassium
Kayexalate can be given for excess of this electrolyte Potassium
Never give this electrolyte by bolus IV or PO - Must be diluted and infused at no greater than 40 mEq/L Potassium
Use ___ instead of tap water for irrigation or enemas in the presence of hyponatremia NS
In the presence of surplus _________, signs include edema, hypertonicity, dry sticky mucous membranes, elevated temperature, flushed skin, and thirst Sodium
Proportions in body are always inversely related to phosphorus proportions Calcium
May be deficient in hypoparathyroidism or removal of thyroid Calcium
Calcium Deficiency causes tetany, cramps, tingling, numbness, hyperactive reflexes, cardiac arrhythmias, and Chvostek and Trousseau's signs
This vitamin facilitates absorption of calcium D
Deficiency of this can be related to alcoholism magnesium
Do not administer antacids containing ______________ to renal failure patients magnesium
Post-renal biopsy, patient must remain in a _______ position and be on bed rest for ___ hours supine, 24
Antibiotics of choice for UTIs sulfonamides
Type of acute renal failure resulting in inflammation of the kidney's that is thought to be related to strep infection glomerulonephritis
This type of acute renal failure usually occurs in children and has a good prognosis glomerulonephritis
Reduce dietary protein and sodium and increase calories for ____________________ glomerulonephritis
acute renal failure Symptoms include sudden onset of oliguria, edema, elevated BUN, creatinine, potassium, decreased protein and calcium, phosphate, decreased specific gravity, acidosis, heart failure
Diet for _________ renal failure is low-protein, low-potassium, low sodium, low phosphate, high-carb,, with vitamin and calcium supplements with fluid restriction Chronic
Never clamp a nephrostomy tube. t/f True
Medications which promote urinary flow alpha-blockers
If fluid intake is encouraged, this usually means at least ___________mL per day 3,000
TURP syndrome Hyponatremia, confusion, brady./tachycardia, hypo/hypertension, N/V, or visual changes resulting from absorption of irrigating fluids through prostate tissue during surgery
Urge incotinence Type of incontinence in which patient cannot hold urine when stimulus to void occurs
Functional incotinence Type of incontinence when the patient cannot physically get to the bathroom or doesn't know to
Stress Incotinence Type of incontinence when pressure such as coughing, straining, or laughing causes urine to escape
Decorticate Abnormal posturing indicated by rigidity, flexion of arms, clenched fists, extended legs
Decerebrate Abnormal body posturing indicated by rigid extension of arms and legs, downward pointing of toes, and backward arching of head
__ or less on the Glasgow coma Scale indicates that the patient is in a coma 7
After a lumbar puncture, it is correct to position the patient flat for 20-60 minutes. T/F True
The first sign of increased ICP is altered _____ LOC
Change in LOC, N/V, pupil changes, diplopia, widening pulse pressure, bradycardia, Cheyne-Stokes respirations, and elevated temperature are signs of _______________ elevated ICP
With elevated ICP, keep HOB at ___-___ degrees and head in ________ position 30-45, neutral
Opiates and sedatives are contraindicated for ___________, but ___________ may be used if uncontrolled elevated ICP, barbituates
This med can only be administered with NS and has side effects of ataxia, diplopia, hirsuitism, and gum hypertrophy Phenytoin
medication of choice for status epilepticus Ativan
autonomic dysreflexia Life threatening syndrome of sudden, severe hypertension in response to noxious stimuli below cord damage such as bowel/bladder distension, pressure ulcers or points, and pain or spasms
multiple sclerosis Chronic, progressive disease of the CNS, characterized by small patches of demyelination in the brain and spinal cord
Parkinson's Manifestations include bradykinesia, rigidity, resting tremor, expressionless fixed gaze, drooling, slurred speech, constipation
amyotrophic lateral sclerosis Rapidly progressive, invariably fatal neurological disease that attacks the nerve cells that control the voluntary muscles
myasthenia gravis Disorder affecting neuromuscular transmission of voluntary muscle causing extreme muscular weakness, increased by fatigue
Guillain-Barre Syndrome Ascending, reversible paralysis cause by acute inflammatory disease of peripheral nerves
presbycusis progressive disorder associated with aging in which the patient loses the ability to hear sounds at high frequencies
presbyopia farsightedness associated with aging
Meniere's Disease Disorder of the inner ear that causes vertigo, tinnitus, hearing loss, and pressure in the ear due to increased fluid
Risk for _________ is an area for concern with patients with Meniere's disease Falls
It is important to take precautions against increasing _______ after a cataract surgery - severe pain should be reported immediately ICP
Patients with glaucoma should avoid all ______________ medications anticholinergic
Infant birth weight doubles by ____ months and triples by ____ months 6, 12
The posterior fontanel closes by ___ months 2
The anterior fontanel closes by __-___ months 12-18
Age of child in months minus 6 equals number of ______ teeth
Solids can be introduced into an infants diet around __-___ months 4-6
Infant can sit alone by __ months 7,8
Infant can pull self to feet by ___ months 9
Use a semi-reclining infant car seat that faces rear until ___ lbs 20
Forward facing seats for children weighing __-___ lbs 40-80
Sensorimotor Cognitive stage 12-14 months - objects are cause of action; separation anxiety
Preoperational Cognitive stage 2-7 years - egocentric in though and behavior; concrete, tangible thinking; vivid imagination (magical thinking, peak age for fears)
Play of the toddler parallel
Play of the Preschooler cooperative
Concrete Cognitive stage 7-11 years - classifies and sorts; enjoys collecting; concrete logic and problem solving; less egocentric; inductive thinking
formal operations Cognitive stage 11+ years - abstract thinking; ability to hypothesize
Ortalani's sign Audible click that can be heard with congenital hip dysplasia as the examiner slips the femoral head forward
_________ is used during an acute asthma attack, ________ is used daily for chronic asthma albuterol, salmeterol
Overdose of ________ can cause tinnitus, hyperpyrexia, seizures, bleeding, and hyperventilation aspirin
Overdose of _______ can cause liver necrosis in 2-5 days, N/V, Right upper gastric pain; coagulation abnormalities tylenol
Consumption of _________- can cause developmental regression, impaired growth lead
chelation therapy Treatment for lead poisoning (or other heavy metals)
Activated charcoal and gastric lavage are treatment for ______________ and _______________ - do NOT induce emesis hydrocarbons, corrosives
rheumatic fever Inflammatory disease affecting the heart, joints, and CNS 2-6 weeks after a upper respiratory strep infection
Wilm's tumor renal cancer usually in children around age 3 - Do NOT palpate abdomen
nephrotic syndrome renal disorder in very young children with increased permeability of the glomerular membrane to protein
Created by: Danielle Scher Danielle Scher on 2010-05-11



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