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NCLEX Key Pts

NCLEX Key Points to Remember

TermDefinition
Piaget's Formal operations stage: Child has the ability to think abstractly and logically.
Sensorimotor stage The child begins to understand the environment.
Preoperational stage The child learns to think in terms of past, present, and future.
Concrete operational stage The child is able to classify, order, and sort facts.
Graphesthesia is the ability to recognize the form of written symbols. Identify 3 numbers or letters traced in the client's palm.
Stereognosis is the ability to identify the form of common objects using the sense of touch. Identify 3 objects placed in the hand, 1 at a time.
Extinction phenomenon and 2-point stimulation Identify the smallest distance between 2 skin pricks after pricking the skin with 2 pins at varying distances. State whether 1 or 2 skin pricks are felt, after applying sharp stimuli bilaterally to symmetrical areas of the client's skin.
Which priority item would the nurse have available during IV administration of Cyclosporine? Epinephrine
Roseola prevention of the transmission to siblings teaching: Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva.
Pt w/ CKD on antihypertensive is experiencing frequent hypotensive episodes. Which Hx medication would have the greatest tendency to cause hypotension? Methyldopa --> metabolized by kidneys; requires careful dosage adjustment according to the client's renal function to prevent hypotension.
Effective education statement for pt w/ prostatitis following kidney infection on management of the condition at home and prevention of recurrence. "I should use warm tub baths and analgesics to increase comfort."
Pertussis is transmitted by: direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase.
Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? Pulmonary capillary wedge pressure (PCWP) of 20. --> corresponds to volume overload of the left ventricle Normal PCWP ranges from 8 to 15 mm Hg.
EKG findings for hypocalcemia: Prolonged QT interval Prolonged ST segment normal serum calcium level is 9 to 10.5
Ventricular fibrillation is characterized by: irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.
Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? SATA Coughing Respiratory rate of 45 Restlessness Diaphoresis
When explaining to parents how to reduce the risk of SIDS, the nurse should teach about which measures? SATA Maintain a smoke free environment. Breastfeed the baby. Place the baby on their back to sleep. NO Wedge for side-lying positions; Bumper pads over bed rails; Sleeping w/ parents – NOTHING in bed BUT baby
The child has Viral Pharyngitis. What should the nurse advise the parents to do? SATA Use a cool mist vaporizer. Offer soft-to-liquid diet. Administer Acetaminophen (Tylenol)
The nurse is caring for a client with an ischemic stroke confirmed by CT scan. Which criteria would indicate the client is a candidate to receive tissue plasminogen activator (tPA)? SATA a. client denies history of gastrointestinal bleeding b.client's blood pressure is 148/88 mmHg c. platelet count of 200,000/mm3 d.one hour since the onset of symptoms
Which s/s of Leukemia would lead the nurse to suspect the pt has Thrombocytopenia? SATA Petechiae Epistaxis NOT - Dyspnea, Bone pain
The nurse must rearrange the room assignments for clients. Which clients would be best to put in the same room? SATA A 35 y/o woman w/ copious intractable nausea & vomiting. *A 43 y/o woman who underwent cholecystectomy 2 days ago. *A 53 y/o woman w/ pain r/t alcohol associated pancreatitis. A 62 y/o woman w/ colon cancer receiving chemo & radiation
A patient with COPD tells the nurse that he is always tired. What advice would the nurse give this patient to cope with his fatigue? SATA Don’t rush through your morning ADLs. Avoid working with the arms raised. Organize work area so that what you use most is easy to reach. Don't hold your breath while performing any activities.
Which topics will the nurse plan to include in discharge teaching for a client who has been admitted with HF? SATA How to monitor & record daily weight. Importance of stopping exercise if HR increases. Symptoms of worsening HF. How to read food labels for sodium content. Date and time for follow up appointments.
A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a Halo fixation device. When caring for this client, the nurse may assign which actions to the LPN? SATA Checking the client’s skin for pressure from the device. Observing the Halo insertion sites for signs of infection. Cleaning the Halo insertion sites with hydrogen peroxide. Administering oral medications as ordered.
A 23-year-old client with a history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the client's care are best to assign to an LPN whom the nurse is supervising? SATA Observing and documenting the onset and duration of any seizure activity. Administering phenytoin 200 milligrams PO three times a day. Turning the client to his or her side to avoid aspiration.
The RN is teaching a patient how to perform intermittent self-catheterization for a long term problem with incomplete bladder emptying. Which are important points for TEACHING this TECHNIQUE? SATA NOT a STERILE technique! Or having hm health nurse do it. Proper hand washing & cleaning of cath reduce risk for infection. A small lumen & good lubrication cath prevents urethral trauma. A regular schedule for bladder emptying prevents distension and mucosal trauma.
A client asks why she feels so much variability and fetal activity each day. The nurse explains that fetal movement is affected by which factors? SATA Fetal sleep. Barometric pressure. Blood glucose. Time of day. Cigarette smoking. Fetal sleep. Blood glucose. Time of day. Cigarette smoking. NOT Barometric pressure!
The nurse is reviewing discharge teaching with a client who is postoperative insertion of a permanent pacemaker. Which of the following instructions should the nurse include? SATA Count your pulse for one minute each morning. Avoid wearing tight clothes over the insertion site. Request to be scanned with a handheld metal detector when at the airport.
A parent asks the nurse how to care for a child with chickenpox. What should the nurse include in the plan of care? SATA Encourage oatmeal baths. Keep fingernails short. Avoid overheating. Don't return to school until all lesions have crusted over.
A client with bipolar disorder has been prescribed Olanzapine 5mg two times a day and Lamotrigine 25mg two times a day. Which adverse effects should the nurse report to the health care provider immediately? SATA Rash. Hyperthermia. Muscle rigidity. NOT Nausea or Sedation (side effects)
Which interventions should the nurse include in the plan of care to prepare a client for electroconvulsive therapy ECT? SATA Maintain NPO status. Verify if consent is signed. Remove dentures. Request the client to void.
A pt has been transferred to hospital psychiatric unit from a nursing home for increasing confusion. His behavior is found to be the result of cerebral arteriosclerosis. Which nursing staff actions should positively influence the clients behavior? SATA Limiting the client's choices. Accepting the client as he is. Explaining to the client what he needs to do step by step.
A pt has been in the ICU for 3 days post severe MI. He's medically stable, but having fluctuating episodes of consciousness, illogical thinking, anxiety. He’s picking at the air to “catch these baby angels flying around my head”. While waiting for medical and psychiatric consults, which needs have the highest priority? SATA Decreasing as much abnormal stimuli as possible. Avoiding challenging the client's perception about baby angels. Gently presenting reality as needed.
Child diagnosed with Hepatitis treatment? Supportive Care
Asphyxia in utero expected findings: The nurse strokes the sole of newborn's feet w/ no response. The Neonate is unresponsive when nurse claps hands above him. The Neonate has weak & ineffective sucking NOT - There is a present palmar-grasp reflex
A nurse is providing care to a neonate who has received prolonged mechanical ventilation following birth. For which condition should the nurse carefully monitor this neonate? Bronchopulmonary dysplasia
The nurse is assisting w/ the birth of a newborn and observes that the amniotic fluid is meconium stained. After delivery of the newborn, there are no spontaneous respirations. Which interventions should the nurse perform to provide a patient airway? SATA Administer 100% O2 under pressure. Suction with low pressure for less than 10 seconds. Have supplies ready for the health care provider to intubate.
You're caring for a pt w/ Raynaud's disease who has intractable pain. Pt is scheduled for sx interruption of pain conduction pathways to improve vascular blood supply & eliminate vasospasm & pain. What type of sx is the patient most likely to undergo? Sympathectomy. NOT - Cordotomy = Interrupts pain/temp sensations below tract. Rhizotomy = Interupts ant or post nerve root (Ant -Stop spastic mvnts (paraplegia) or Post. eliminates pain in area innervated.) Neurectomy - intractable localized pain.
Which of the following clients is at greatest risk for toxicity to Lithium? A 25 year old female client who is taking ibuprofen.
Which of the following are classic manifestations of nephrotic syndrome? SATA Proteinuria Hypoalbuminemia Edema NOT - Loss of appetite
An 8 y/o with sudden swelling & pain in the knees. Lyme disease suspected. What question should be included in the interview? "Do you have headaches, malaise, or a sore throat?"
The nurse is preparing to obtain a wound culture on an infected leg ulcer. Before swabbing the wound to obtain the culture, the nurse should: Clean the wound with normal saline. NOT don Sterile gloves
A nurse is caring for a pt w/ a T4 SCI. As the nurse enters the room, the PT exits after completing pt's daily session. Which of the following statements, if spoken by pt, would indicate a need for an additional review of basic transfer techniques? "I should lead with the same arm and go the same direction when transferring if possible."
The RN is preparing teaching handouts about developmental milestones with parents who have a 6 month old child. The child was born at 28 weeks gestation, which of the following handouts are most appropriate when discussing the child's development? Developmental milestones for 3 month old
Which of the following is a priority for the nurse to monitor for during the acute management of a patient who has taken an overdose of aspirin? Onset of pulmonary edema. NOT - Respiratory Alkalosis
A 3 y/o presents to ED w/ a sore throat, large red, edematous epiglottis, drooling, moderate subcostal retractions. On exam HR 188, RR 72, BP 88/56, Temp 39 C. Suspects epiglottitis. She should avoid which actions to maintain the child's airway? SATA Taking an oral temperature. Visualizing the posterior pharynx. Obtaining a throat culture.
The nurse is caring for a patient who is recovering from open heart surgery. For the first 24 hours following the surgery, there is a noticeable pinkish fluid oozing from the incision site. Which phase of the inflammatory response does this represent? Exudate formation.
For a non-stress test to be considered reactive, several factors have to be present period which of the following are components of a reactive non stress test? SATA The test occurs over a 20 minute period There are two or more accelerations. Accelerations are 15 beats/minute lasting 15 seconds.
Which of the following would cause an increase in cardiac output? SATA 2 liters normal saline fluid bolus. Furosemide. Propanolol. Dopamine. 2 liters normal saline fluid bolus. Dopamine.
Recent outbreak of meningococcal meningitis. Recommendation for students who have been in contact with sick students for prophylactic treatment? Ciprofloxacin. Rifampin Meningococcal conjugate vaccine. NOT - Amoxicillin
The nurse is caring for a client with hypernatremia. Which prescribed IV fluid would be appropriate? Dextrose 5% in water (D5W) 3% saline. Lactated ringers. 0.9% saline. Dextrose 5%
Which of the following does the nurse know are possible causes of Constipation in the pediatric patient? SATA Hirschsprung's disease. Spina bifida. Iron supplements. Psychosocial factors. Hirschsprung's disease. Spina bifida. Iron supplements. Psychosocial factors.
You are monitoring an 18-month-old patient who has just had surgical correction of an Epispadias completed. Which of the following assessment findings would the nurse need to report to the HCP? SATA Cloudy, foul smelling urine. Stent in the meatus appears clogged.
Which of the following statements is true regarding fetal circulation? SATA The ductus venosus allows freshly O2'd blood to go to fetal brain first. There are higher pressures in R atrium in the fetal circulation. There are high pressures in fetal lungs causing decreased pulmonary circulation. NOT - Blood shunts from L to R
The nurse is caring for a client who arrives to the Ed complaining of chest pain radiating to the arm. The nurse should do which of the following? SATA Obtain an electrocardiogram. Prepare the client for a prescribed cardioversion. Establish IV access Insert an indwelling urinary catheter. Administer prescribed nitroglycerin.
While providing education to your pediatric patient diagnosed with atopic dermatitis, which of the following points are important to make? SATA Avoid harsh soaps and detergents. Apply lotion immediately after bathing. Keep nails short. NOT - Wash the affected area four to five times a day.
The nurse is caring for an infant with the below tracing on the ECG. The nurse should plan to take which initial action? See image Instruct the infant to bear down. Prepare a bag filled with ice and water. Assess the infants auxiliary temperature. Obtain the infants carotid pulse.
Which of the following educational points are correct when teaching a patient about iron supplements? SATA Drink a glass of orange juice with your iron supplement. Drink the iron suspension with a straw. NOT - Take the iron supplement 30 minutes after a meal. Report any black stools to your doctor.
Which of the following signs does the nurse know to expect for her 1-year-old patient in heart failure? SATA Diaphoresis. Insomnia. Poor feeding. Weight loss. Diaphoresis. Poor feeding. NOT - Weight loss, insomnia.
The nurse is caring for a client with the following tracing on ECG. They have oral temp of 101 F (38.3 C). The nurse should be prepared to obtain which prescription from the HCP? SATA see image Image: Supraventricular Tachycardia --> Prepare a bag filled w/ ice & water Q # 62
The nurse is caring for a client newly admitted to the mental health unit with bulimia nervosa. Which client statement requires immediate follow up? I feel really dizzy right now. NOT - I hate my life and wish it was over.
Which of the following signs and symptoms are indicative of cystic fibrosis? SATA Steatorrhea. Hypernatremia. Meconium ileus. Salty sweat. Steatorrhea. Meconium ileus. Salty sweat. NOT - Hypernatremia.
Which of the following are features characteristic of fetal alcohol spectrum disorder? SATA Macrocephaly. Attention deficit disorder. Encephalopathy. Enlarge philtrum. Attention deficit disorder. Encephalopathy. NOT - Macrocephaly, Enlarge philtrum.
The nurse knows that benefits of delayed cord clamping in the newborn include? SATA Increase blood volume. Decreased brain hemorrhages. Decreased risk of polycythemia. Decreased jaundice. Decreased brain hemorrhages. Decreased jaundice.
Which of the following are bypasses in fetal circulation? SATA Ductus arteriosus. Foramen ovale. Ductus pulmonic. Foreman aortic. Ductus arteriosus. Foramen ovale.
The newly licensed RN is tasked by a nurse educator to perform a wet to dry dressing change on a client with a stage three pressure ulcer. Which action would indicate to the nurse educator that the RN is following proper technique? The RN packs wet gauze into the ulcer without overlapping it onto skin. NOT - Packs incision w/ sterile gauze then pours sterile NS over dressing.
Which of the psychological symptoms occurring at EOL, is accurately paired w/ an appropriate intervention? Spiritual distress: Diazepam. Delirium: Lorazepam. Hallucinations: Dopamine antagonist. Agitation without delirium: Haloperidol. Hallucinations: Dopamine antagonist.
Caring for a pt receiving Mirtazapine. Which statements if made by the client would indicate a therapeutic response? SATA I am not smoking cigarettes anymore. My BG has decreased. My depression has gotten better. I am sleeping 8 hours a night. My BP My depression has gotten better. I am sleeping 8 hours a night.
The nurse is caring for a client that underwent a total knee arthroplasty the previous day. The nurse will include which intervention in the patient's care plan? Placed the client on a continuous passive motion exerciser for 6-8 hours a day
A family who is experiencing the loss of a child that was given up for adoption. They aren't sharing this loss/ accompanying grief with people outside of their family who they usually do for support. What type of pain is this family experiencing? Disenfranchised grief.
Disenfranchised grief. Occurs after an injury that is not socially, culturally, religiously, or otherwise not acceptable, such as an abortion, suicide, and an adoption.
While orienting a new graduate nurse in the ICU, you take care of a patient scheduled for peritoneal dialysis. Which of the following principles do you explain to the new graduate about peritoneal dialysis functions? SATA Osmosis. Diffusion. NOT - Oncotic pressure, Osmotic pressure.
RhoGAM is given to Rh-negative mother to prevent what? Prevent the mother from producing antibodies against their Rh-positive fetus. NOT - Prevents baby from developing antibodies against mom's blood.
The nurse is caring for an older adult client undergoing bowel prep for a scheduled colonoscopy. Which nursing diagnosis is the priority to integrate into the care plan? Risk for falls. NOT - Altered elimination pattern, impaired skin integrity.
You’re providing education to an HIV+ mother about what she will need to do for her baby after he is born. Which of the following teaching points are appropriate? SATA Monitor infant closely for signs of HIV for at least 18 months. Keep track of weight gain & notify the pediatrician if he doesn't gain weight as expected. NOT - Ensure infant receives all Vx on time, Follow exclusive breastfeeding for proper nutrition
Delivery of an infant that’s 41 wks. They suspect meconium in the amniotic fluid. After birth, which of the following signs would help you confirm a meconium delivery? SATA Brown tinged amniotic fluid. Brown discoloration of the infants nails. NOT - Thick, white substance coating the newborn, Vigorous cry.
Vernix Caseosa A thick, white substance coating the newborn. It's a potent substance and serves to moisturize the newborn skin.
Appropriate Lab Tests for Rx'd Medications: Liver function for Atorvastatin Serum Crea for Lisinopril HgbA1C for Olanzapine NOT - INR for Rivaroxaban --> Selective factor Xa inhibitor - Advantage since doesn't require frequent labs. ACE-I can be Nephrotoxic
When assessing eyes for accommodation which of the following actions would the nurse perform? Ask the client to gaze at a distant object and then at a test object. Penlight from side of face to eye = Pupil response Weber test - tuning fork at center of forehead = Conductive hearing loss. Snellen Chart - stand 20 ft away = Visual Acuity.
Client arrives at ED w/ chest pain radiating to arm. Do which of the following interventions? SATA Obtain ECG Establish IV access Give prescribed Nitroglycerin NOT - Prepare for Cardioversion / Insert urinary catheter.
Best example of Natural adaptive immunity? Cell-mediated response.
Food for toddler w/ constipation? SATA Whole grains Black beans NOT - whole milk
Sinus Tachycardia treatment? Q 64 0.9% Saline bolus Acetaminophen NOT - Enalapril, Levothyroxine, Metoclopramide (causes gastric emptying)
Nursing action that reflects affective time management? Nurse asks the patient what is their priority to accomplish each day. Q 69
When assessing eyes for accommodation which of the following actions would the nurse perform? Ask the client to gaze at a distant object and then at a test object.
Clients with ______ Are classified as Emergent / Highest priority. Trauma Chest pain Severe respiratory distress or Cardiac arrest Limb amputation Acute neurological deficits Chemical splashes to the eyes
Clients with ______ Classified as Urgent needs / 2nd priority. Simple fracture Asthma w/out respiratory distress Fever Hypertension Abdominal pain Renal stone
Clients with ______ Classified as Non-urgent / 3rd priority. Minor laceration Sprain Cold symptoms
PRIORITY - Maternity A client who has just received an IV loading dose of Magnesium sulfate to stop preterm labor. Magnesium sulfate is a central nervous system depressant, and the client could experience adverse effects that include depressed respiratory rate (fewer than 12 breaths/min), severe hypotension, and absent deep tendon reflexes.
The client who has a mastectomy is expected to have sensations of tightness and pulling.
If uterine hypertonic contractions occur, immediately intervene to reduce uterine activity & increase fetal O2. Stop Oxytocin infusion & increase rate of NS solution. Position client in side-lying position. Administer O2 by face mask at 8-10 L/min. Attempt to determine the cause & perform vaginal exam to check for Prolapsed cord. Then BP.
Air embolism is a complication of Hemodialysis. S/S include: Dyspnea, Tachypnea, Chest pain, Hypotension, Reduced SpO2, Cyanosis, Anxiety, & changes in sensorium. If suspected, hemodialysis stopped, pt placed in left side-lying position w/ head lower than feet (TRENDELENBURG). HCP notified, O2 given. VS assessed
Cardiac tamponade 3 classic triad of signs: Hypotension Muffled ❤️ sounds Marked jugular vein distention
DIC s/s Bleeding Blood clots Bruising Drop in blood pressure
Raynaud's phenomenon Sequence of color changes in skin in response to cold or stress
Occlusive arterial disease S/S 6 P's: Pain Pallor Paresthesia Pulselessness Paralysis Poikilothermia
Cor pulmonale S/S Cough Exertional Dyspnea Fatigue Fainting Swelling of feet or ankles
Emphysema S/S Barrel chest Chronic cough SOB Wheezing Weight loss
Tension pneumothorax S/S Chest pain Muffled ❤️ & Lung sounds Mediastinal shift Respiratory distress
Tonsillitis S/S Difficulty swallowing Ear pain Fever & chills Headache Sore throat
Myasthenia Gravis S/S Drooping eyelids Mouth weakness Arm or leg weakness
Severe acute respiratory syndrome (SARS) S/S Cough Difficulty breathing Fatigue Fever > 100.4F (38C) Headache Myalgia
Cyclothymia (cyclothymic disorder) is a rare mood disorder. It causes: Emotional ups & downs, but they're not as extreme as bipolar I or II disorder. They experience periods when your mood noticeably shifts up and down from your baseline.
What factors contribute to hospital readmissions among older adults? (SATA) Client health status Family preferences Poor communication among providers
The pt, who is diagnosed with dementia, wanders throughout the long-term care facility. How can the nurse best ensure the safety of a pt who wanders? Attach a monitoring band to the pt's wrist. A wander management system is used to give people with dementia and other "at risk" pts the ability to move freely where they live.
Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Generally well tolerated /has a low toxicity, it may cause Neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ. --> Check complete blood count (CBC) with differential if pt on it
Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction. TEACHING: Handwashing, Soft toothbrush Avoid hot, spicy, or high in Vitamin C foods; Oral hygiene 30 mins prior or after meals; instruct to refrain from eating or drinking for 30 mins after oral hygiene; and offer moist, soft, bland foods
Cystic fibrosis (CF) - Medication & Diet? Oral pancreatic enzymes High fat, high-calorie diet
Orthostatic VS on pt w/ cardiomyopathy, the SBP decreases from 145 to 110 between positions while the HR rose from 72 to 96. In addition, pt reports feeling lightheaded when standing up. The nurse should implement which of the following actions? Instruct client to increase fluid intake for several hours
Postural hypotension, decrease in SBP 15 & an increase in HR 15 to 20 beats above baseline with a change in position from supine to upright. This is often accompanied by lightheadedness. IV fluids appropriate, done very cautiously. Pt has cardiomyopathy - very sensitive to changes in fluid status - fluid overload risk! After pt increases fluid intake for 1-2 hrs, the client should be reassessed for resolution of the postural hypotension.
Pt with Chronic renal failure --> Aluminum hydroxide decreases serum Phosphate Aluminum binds phosphates that accumulates in chronic renal failure from decreased filtration capacity of kidney. Antacids such as Amphojel are also commonly used to decrease serum Phosphate.
Late stages of ALS finding to expect? --> Shallow respirations Chronic progressive neurodegenerative disease; affects nerve cells in brain & spinal cord. Upper & lower motor neurons die /stop sending messages to muscles; all muscles under voluntary control weaken/atrophy. Lose ability to speak, eat, move, breathe. DON'T impair their mind, intelligence, ability to see, smell, taste, hear or recognize touch.
Multiple myeloma: Abnormal plasma cells (myeloma cells) collect in several bones. May also harm other tissues/ organs (esp kidneys). Causes: Hypercalcemia Renal failure Anemia Bone damage. --> Can cause bone mass erosion & fractures --> Careful repositioning!
The New Ballard Scale to assess gestational age of a newborn. Score total very high = The baby is post-term Scale adds up individual scores for 6 physical asmts & 6 neuromuscular; the total score ranges from -10 to 50. Premature = lower scores Fetal distress during labor = can result in lower scores.
95 F (35 C) Hypothermia & Cold stress cause physiologic stresses including: Reduced PaO2. Increased O2 consumption. Decreased CO. Metabolic acidosis Hypoglycemia Tachypnea Newborn must be warmed immediately to increase temp to at least 97 F (36 C).
A Hip Spica cast keeps child's hips (pelvis) & 1 or both legs in the right position to heal. They will not be able to move their thighs or bend at the hips. It can only be put on in an operating room. Apply waterproof plastic tape to cast around genitals The most important aspects of caring for the cast is to keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape will be applied around the genital area to prevent soiling.
Most important aspects of home care for a child w/ Acute Spasmodic Croup are: Humidified air & increased oral fluids. Humidified air helps reduce vocal cord swelling. Taking the child out into the cool night air for 10 to 15 minutes can also reduce night time symptoms.
Kawasaki disease affects the mucus membranes, lymph nodes, walls of blood vessels & the heart. At Risk for: Coronary Artery Aneurysm & Heart Attack in a Child
Do Not Use List: "OD" can mean "right eye" or "once daily". The abbr "Q" should be written out as "every." Although "gtt" is not on the official list, it's best to use "drop" instead.
Tracheal deviation means pt has: Tension pneumothorax
Pt w/ Acute angina on IV infusion of Nitroglycerin priority assessment: Blood pressure. BP evaluated Q 15 mins until stable, then Q 30-60 mins; also require continuous ECG monitoring.
Fetus w/ HR between 120-160 BPM. Fetal tachycardia may be an early sign of hypoxia. Interventions: Contact HCP Assist Pt to change positions Administer Oxygen Intravenous fluids.
ACE inhibitors in Pregnancy: Are pregnancy category X, as they can cause Teratogenic effects
3 y/o Expected Motor Skills: GROSS/ Large Muscle Group - Pedaling a tricycle Standing on one foot for a few seconds Walking backwards Jumping with both feet.
Dexamethasone for transplant rejection prophylaxis Teaching: "Take the medication with food" "Take acetaminophen for minor pain or aches." "You might experience an increase in weight." "Do not stop taking the drug abruptly."
Suddenly stopping a Beta Blocker can cause: Angina HTN Arrhythmias Heart attack.
Chickenpox: Papules, vesicles and crusts will be present at one time. All 3 stages of chickenpox lesions will be present at same time. They’re contagious 1-2 days before blisters appear & remain until blisters have crusted over. OTC Hydrocortisone creams can help relieve itchy skin.
Isoniazid & other anti-TB meds - REPORT: Extremity tingling and numbness – REPORT to HCP!! Peripheral neuropathy is a common side effect of Isoniazid & other anti-TB meds.
Food choice highest in Potassium: Apricots Oranges Bananas Potatoes A baked potato contains 610mg of potassium. Apricots, oranges, bananas do have high potassium, but because of size not highest in potassium.
Early findings of Shock are from ____ & are: From Hypoxia Tachycardia Tachypnea. (Before Hypotension) --> Oxygen most critical initial intervention, then --> Fluids Cardiac Monitoring BP Monitoring
Patients w/ PE, whether pregnant or not, are initially treated with: Heparin infusion to keep aPTT 1.5- 2 X
Which Stomal diversion poses highest risk for skin breakdown? Ileostomy NOT ileal Conduit
Triage Color Code Categories: RED (Immediate) severe injuries but high potential for survival with treatment; taken to collection point first.
Triage Color Code Categories: YELLOW (Delayed) serious injuries but not immediately life-threatening
Triage Color Code Categories: GREEN (Walking wounded) minor injuries
Triage Color Code Categories: BLACK (Deceased/expectant) injuries incompatible with life or without spontaneous respiration; should not be moved forward to the collection point.
A greenstick fracture occurs when: Bones of children are more ____ than adults, and often have ____ breaks. --> A bone is angulated beyond the limits of bending. --> "Bones of child more porous than adults; often have incomplete breaks." This allows the pliable bones of growing child to bend, buckle, break in a "greenstick" manner.
Acute Renal Failure - Lab findings: Low Magnesium & High Creatinine
TB Precautions: Place pt in Negative pressure private room & have disposable particulate respirators (N95) available for hospital employees
What 3 drugs are the most common treatment of Alzheimer’s? Complementary/ integrative therapies: Donepezil Rivastigmine Galantamine Complementary/ integrative therapies: Ginkgo biloba Omega-3. NOT COCONUT OIL!
Coarctation of the aorta (narrowing or constriction of descending aorta) causes what? Cardinal signs: “Bounding pulses in the arms”. Cardinal signs: Resting systolic HTN Absent/diminished Femoral & Pedal pulses Widened pulse pressure.
When the membranes rupture, fetal monitoring must now assess for what complication? Variable decelerations. --> Increased risk initially of cord prolapse if the head is at a minus level. --> Require immediate nursing action to: Reposition the client Apply oxygen Notify the health care provider.
Duodenal Ulcer treated with what meds? Patient Teaching: Lansoprazole & Sucralfate Teaching: Take Lansoprazole first, wait at least 30 minutes, then take Sucralfate.
Patient asks “What could’ve caused my Right Sided HF?” Response: --> High Blood Pressure in the LUNGS NOT Long-Term Hypertension – That’s Left Sided HF --> HTN increases AFTERLOAD --> Causing Backflow to L side of Heart
Serotonin Syndrome S/S: Myoclonus High Temp Agitation Tremors/ Shaking Chills, Diaphoresis Confusion Hyper reflexes Dilated pupils Diarrhea --> Can be FATAL if severe
Regular insulin peaks in: Rapid acting insulin peaks in: Intermediate acting insulin peaks in: Regular insulin peaks 2-3 hrs. after given. Greatest risk for hypoglycemia. Ex: 8am - 11am Rapid acting insulin peaks in 30 mins. Intermediate acting insulin peaks at 4 hours.
Insulin Lispro (Humalog) is a: PEAKS at: Rapid-acting insulin, starts 10-15 mins; Will peak in 1.5 to 2.5 hours.
What Equipment needed for Discharge Home in Terminal Hepatic Encephalopathy? (pt unresponsive from Toxins) Alternating pressure mattress Hospital bed Suction equipment Oxygen
High CVP results in: Assessment findings: Normal CVP: Fluid Volume Excess. RALES in Posterior Chest JVD Tachypnea Weight Gain Normal CVP = 2-8
Patient w/ Lesion suspected to be caused by ANTHRAX – Question to ask Pt: “Have you recently worked with any farm animals or any animal skin products?”
GUTHRIE TEST - 1. Purpose - determine presence of Phenylalanine in the blood 2. Indication if positive - Metabolic Disorder 3. Conducted - Blood sample taken from baby's heel. 4. What can interfere w/ test 5. Screening protocol 4. Low protein intake can interfere with test. 5. Test infant as close to discharge as possible, but no later than 7 days after birth. If the infant is < 24 hours old when collected, a repeat test should be done before the infant is 2 weeks of age.
Abdominal Assessment to report IMMEDIATELY: High-Pitched Bowel Sounds = Early indication of Bowel Obstruction! (Hypoactive BS develop as obstruction worsens).
Normal Abdominal Assessment finding: Borborygmi BORBORYGMI is NORMAL – rumbling gas movement.
The HCP has prescribed phenytoin 100mg IV push stat through a non-tunneled central venous catheter with no other medications or fluids infusing. In what order should the nurse administer this prescription? Clean access port. Connect 10ml NS to access port. Gently aspirate for blood. Flush saline using push-pause method. Administer phenytoin. Flushed with normal saline, then with heparin.
Maintaining Closed Drainage Unit – Chest Tube 1. Semi-Fowler’s Position 2. SpO2 Monitor 3. Assess RR every 2 hours - Watch for fluctuations w/ Resp 4. Prevent Dependent loops 5. Keep below level of chest 6. Monitor water level / Watch for bubbling
Drug to stimulate Maturation of Baby Lungs for client in Preterm Labor: 1. Stops Preterm Labor: 2. CONTRINDICATED in Preterm Labor: 3. Stops Growth of Embryo in Ectopic Pregnancy: Betamethasone 1. Magnesium Sulfate 2. Terbutaline 3. Methotrexate
Erikson's Stages of Psychosocial Development: 1. Infant - 18 months 2. 18 months - 3 years 3. Three - 5 years 4. 5-13 years 5. 13 - 21 years 6. 21 - 39 years 7. 40 - 65 years 8. Age 65+ 1. Trust vs Mistrust 2. Autonomy vs Shame/Doubt 3. Initiative vs Guilt 4. Industry vs Inferiority - Competency 5. Identity vs Confusion - Fidelity 6. Intimacy vs Isolation - Love 7. Generativity vs Stagnation - Care 8. Integrity vs Despair
VACCINE SCHEDULE: Page 8 on study guide
SHINGLES Isolation: AIRBORNE Private Room NEGATIVE Pressure Airflow N95 Respirator Mask
POSITIVE Pressure rooms: ONLY for IMMUNOCOMPROMISED patients!
Post Gastroscopy Interventions: *Vital sign checks every 15 min X 4 *NPO until return of gag reflex *HOB elevated **Supine for 6 hours is used after Heart Catheterization**
Family member teaching prior to visiting Pt w/ Agranulocytosis: *Meticulous handwashing is needed *Do not visit if you have any infection *Children under 12 may not visit *Flowers are not allowed in the room *Mask must be worn by visitor, not patient
If on MAOI avoid foods with: GOOD meal for them: fried catfish, french fries, coleslaw, and apple juice. Tyramine Found in protein containing foods. Strong/ aged cheese, cured meats, smoked/processed meats, liver, pickled/fermented foods, sauces, soy beans, dry or over ripe fruits, meat, tenderizers, brewers, yeast, alcohol, caffeine (tea also).
Client with Pancreatitis rationale for being NPO with NG tube hooked to low suction: Reduce pancreatic secretions. --> NOT relieve nausea
Pt. receiving Pentamidine. The client develops a temperature of 101º F (38.3º C). The nurse continues to assess the client, knowing that this sign most likely indicates which condition? Frequent adverse effects of this med include? That the client has developed another infection caused by leukopenic effects of the medication. --> Frequent adverse effects of this med include: Leukopenia. Thrombocytopenia. Anemia.
Sepsis diagnostic criteria: Temp? HR? Respiratory Rate? Blood Pressure? OTHER: Fever > 100.9° F [38.3° C]) or hypothermia < 97° F [36° C]) Tachycardia HR > 90 Tachypnea RR > 22 SBP </= 100 Change LOC Edema or positive fluid balance Oliguria ileus (absent bowel sounds) Decreased capillary refill Mottling of skin.
Pt receiving Dopamine hydrochloride IV infusion. If INFILTRATION occurs, give: Give Phentolamine --> prevents dermal necrosis and sloughing after infiltration of norepinephrine or dopamine.
1. Antidote for Cholinergic crisis: 2. Antidote for heparin: 1. Atropine sulfate 2. Protamine sulfate
Medication for Severe Acne? Side Effects? Nursing Precautions? Isotretinoin. --> can elevate Triglyceride levels. --> Measure before & periodically after administration.
Discharge teaching for New Pacemaker: A) Use cell phone on opposite side of pacemaker C) For 1 wk, limit activity on pacemaker side. D) You will need to inform airport security about your pacemaker before you fly anywhere E) It would be a good idea to check your pulse daily
Sinus bradycardia – 40 beats per minute Treatment: No interventions unless showing symptoms --> Give Atropine or client gets a pacemaker --> It will speed the heart rate up
Sinus tachycardia – 130 beats per minute Give meds to slow the heart rate down. Beta blockers Calcium channel blockers ACE inhibitors Digoxin
Asystole – 0 beats per minute Start CPR Epinephrine NO DEFIBRILLATION
Ventricular fibrillation – no obvious heart rate Defibrillation CPR Epinephrine Amiodarone (give Lidocaine as an alternative)
Ventricular tachycardia – may or may not have a pulse Pulseless: Pulse: Pulseless: • CPR • Defibrillation • Epinephrine • Amiodarone (Lidocaine as an alternative) With a pulse: • Amiodarone (Lidocaine as an alternative)
Myocardial infarction – ST segment elevation O.A.N.M. • Oxygen • Aspirin • Nitroglycerin • Morphine Thrombolytics within the first 6 hours if from a clot • T-PA, retepase
Atrial fibrillation – 90 beats per minute and irregular High risk for blood clots • Anticoagulants • Antiplatelets Meds to decrease heart rate: Beta blockers Calcium channel blockers ACE inhibitors Digoxin
A-Fib Tx from NCLEX Question: Oxygen therapy An Echocardiogram An intravenous dose of Metoprolol A bolus of IV Heparin followed by a continuous infusion
Atrial flutter – 70 beats per minute Same care as atrial fibrillation – see above!
1st degree AV block – 70 beats per minute 3rd degree AV block – 30 beats per minute General treatment for all heart blocks. --> Give Atropine or client gets a Pacemaker It will speed the heart rate up.
Supraventricular tachycardia – 170 beats per minute Give Adenosine: will convert to normal sinus rhythm
Pre-ventricular contractions – 110 beats per minute and irregular Give meds to slow the heart down and prevent the PVCs Beta blockers Amiodarone Flecainide
Torsades de Pointes – no obvious pulse Give IV Magnesium first
A pt’s IV site is wet after last tubing change and determines that the dressing needs to be changed. The nurse has performed hand hygiene, stopped the current infusion, and has removed the old dressing. Which best describes the next step in this process? 1. Cleanse the site with chlorhexidine or approved solution 2. Put on a new pair of gloves 3. Ask the client if he or she is in pain 4. Place a transparent dressing over the IV site
Which of the following is info protected under the client Privacy Rule according to HIPAA? SATA - FIXX 1. Case manager's notes covering situation that don't ID client. 2. The client’s demographic info r/t health condition. 3. Nurses' notes regarding care provided to the pt 4. Provision of payment of services for pt. 5. Provider's progress notes in chart
How does passive absorption of medications occur? 1. Active transport 2. Enzyme enabled 3. Protein enabled 4. Diffusion
A nurse is caring for a client who has just had ear surgery. Which of the following are nursing interventions that would prevent complications? Select all that apply. 1. Change the dressing frequently 2. Teach the client to avoid nose blowing, sneezing, and coughing 3. Observe for vertigo 4. Apply pressure if bleeding is noted 5. Observe for facial nerve damage
A nurse must move the med cart on the unit from 1 end of hallway to the other. Which principles would nurse utilize in order to best stay protected from being injured while pushing cart? Sata 1. Assess the weight of the cart before pushing it 2.Push w/ shoulders & upper back instead of arms/ legs 3. Keep an eye out for obstacles in the way of the cart 4. If possible, pull the cart instead of pushing it 5. Keep the elbows close to the body
A nurse believes that her elderly neighbor is being abused by someone in her home. Before further assessing the situation, the nurse first recognizes that the conditions which predispose an older adult to being abused include which of the following? SATA 1. Dementia 2. Financial security 3. Caregiver stress 4. A history of family violence 5. Social isolation
The parents of a 4-year-old are concerned that their child is not on target with developmental activities. Which activity should the nurse recommend that the parents observe for to determine if this child is developing appropriately? 1. The child is losing her baby teeth 2. The child can go up the stairs holding a hand 3. The child learns to tie shoes 4. The child is dressing without much help
A client with chronic diarrhea tells the nurse that she wants to start taking probiotics to regulate her digestive system. In which products are probiotics most commonly found? SATA 1. Sauerkraut 2. Spinach 3. Yogurt 4. Milk chocolate 5. Wheat bread
Which of the following are examples of intergroup conflict that could occur within the healthcare facility? SATA - FIXX 1Members of hospital safety committee disagree about where to put fire extinguishers. 2Radiology feel lab ppl aren't timely w/ results Clinical nurse specialists in hospital want to implement EBP but administration won't allow it. Dietary dpt no longer stocking food in unit kitchens cause they feel that the nursing staff eat too much of it
A nurse must give a diuretic as an IV bolus to a client with a peripheral IV. Which of the following elements must the nurse consider when administering an IV drug bolus? SATA - FIX 1. Volume of bolus infusion is typically smaller than standard infusion. 2. Best method of accessing tubing is w/a needle/syringe at closest port. 3. Nurse should scrub access port of IV w/alcohol b4 connecting med to tubing. 4. Nurse should clamp/pinch tubing below inj site while pushing IV bolus, release when complete 5.
Contraindicated in Diabetes: What type of socks do we rec they wear: BED REST Because it slows Glucose uptake into cell, leading to even higher blood Glucose levels. --> COTTON Socks - NOT NYLON to prevent friction from shoes
Hyperosmolar = Hyperglycemic --> Underling cause is DEHYDRATION --> "Hyper-Concentrated serum Glucose"
Normal Urine output Average = ~80 SoOo 50-75mls/hr does not increase risk for dehydration (from diabetes lecture)
Heart Failure Physiological Changes: Decreased CO: Ejection Fraction Stroke Volume decrease --> Increases HR Afterload Tissue Perfusion FLUID OVERLOAD: Peripheral Edema / Pulmonary Edema
ONLY Beta Blocker Allowed for Heart Failure: Diagnostic Test for HF & what it looks at: Carvedilol ECHOCARDIOGRAM: Heart Wall Heart Size Ejection Fraction BNP: < 100 Released by Heart in response to overstretching Natural Diuretic
Right HF vs Left HF s/s RISK FACTORS HF: MI; HTN Right HF s/s: JVD Right upper Quadrant pain Peripheral Edema Risk Factor/Caused by: Pulmonary HTN & COPD LEFT HF S/S: Oliguria Pulmonary Edema Bibasilar Crackles Dyspnea Decreased SpO2
Pregnancy Category of Drugs: Category B — NO RISK. Examples: Amoxicillin Cefotaxime.
Category C — Risk not ruled out. Examples: Rifampicin (Rifampin) Theophylline (Theolair)
Category D — Positive evidence of risk. Examples: Phenytoin Tetracycline.
Category X — Contraindicated in Pregnancy. Examples: Isotretinoin (Accutane) Thalidomide (Immunoprin)
S.T.O.P.—Treatment for maternal hypotension after an epidural anesthesia: Stop infusion of Pitocin. Turn the client on her left side. Administer oxygen. If hypovolemia is present, push IV fluids.
Created by: cnhaygood
 

 



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