NCLEX Review - Advanced Clinical Concepts
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| What PO2 value indicates respiratory failure in adults? | PO2 below 60 mm Hg
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| What blood value indicates hypercapnia? | PCO2 above 45 mm Hg
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| Identify the condition that exists when the PO2 is less than 50 mm Hg and FIO2 is greater than 60%. | Hypoxemia
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| List three symptoms of respiratory failure in adults. | Dyspnea/tachypnea; intercostal and sternal retractions; cyanosis
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| List four common causes of respiratory failure in children. | Congenital heart disease; infection or sepsis; respiratory distress syndrome; aspiration; fluid overload or dehydration
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| What percentage of O2 should a child in severe respiratory distress receive? | 100%
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| Define shock. | Widespread, serious reduction of tissue perfusion, which leads to generalized impairment of cellular function
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| What is the most common cause of shock? | Hypovolemia
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| What causes septic shock? | Release of endotoxins by bacteria, which act on nerves in vascular spaces in the periphery, causing vascular pooling, reduced venous return, and decreased cardiac output and result in poor systemic perfusion
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| What is the goal of treatment for hypovolemic shock? | Quick restoration of cardiac output and tissue perfusion
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| What intervention is used to restore cardiac output when hypovolemic shock exists? | Rapid infusion of volume-expanding fluids
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| It is important to differentiate between hypovolemic and cardiogenic shock. How might the nurse determine the existence of cardiogenic shock? | History of MI with left ventricular failure or possible cardiomyopathy, with symptoms of pulmonary edema
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| If a client is in cardiogenic shock, what might result from administration of volume-expanding fluids, and what intervention can the nurse expect to perform in the event of such an occurrence? | Pulmonary edema; administer medications to manage preload, contractility and/or afterload. For example, to decrease afterload, nitroprusside (Nipride) may be administered.
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| List five assessment findings that occur in most shock victims. | Tachycardia; tachypnea; hypotension; cool, clammy skin; decrease in urinary output
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| Once circulating volume is restored, vasopressors may be prescribed to increase venous return. List the main drugs that are used. | Epinephrine (Bronkaid), dopamine (Intropin), dobutamine (Dobutrex), norepinephrine (Levophed), or isoproterenol (Isuprel)
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| What is the established minimum renal output per hour? | 30 mL/hr
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| List four measurable criteria that are the major expected outcomes of a shock crisis. | BP mean of 80 to 90 mm Hg; PO2 >50 mm Hg; CVP 2 to 6 mm HG H2O; urine output at least 30 mL/hr
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| Define ARDS | ARDS is an unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. Clients are critically ill and are managed in an intensive care setting. The mortality rate is high (50%).
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| List Interventions to prevent complications of clients on mechanical ventilation with ARDS | Elevate head of bed (HOB) to at least 30 degrees. Assist with daily awakening (“sedation vacation”). Implement a comprehensive oral hygiene program. Implement a comprehensive mobilization program.
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| Define DIC. | A coagulation disorder in which there is paradoxical thrombosis and hemorrhage
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| What is the effect of DIC on PT, PTT, platelets, and FSPs (FDPs)? | PT, prolonged; PTT, prolonged; platelets, decreased; FSPs, increased
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| What drug is used in the treatment of DIC? | Heparin
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| Name four nursing interventions to prevent injury in clients with DIC. | Gently provide oral care with mouth swabs. Minimize needle sticks and use smallest gauge needle possible when necessary. Turn frequently. Minimize the number of BP measurements. Use gentle suction. Apply pressure to any oozing site.
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| What is the first priority when a client with an unwitnessed cardiac arrest is found? | Begin CPR.
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| Define myocardial infarction. | Necrosis of the heart muscle due to poor perfusion of the heart
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| What criteria should alert a client with known angina who takes nitroglycerin tablets sublingually to call EMS? | chest pain does NOT go away immediately with rest or is NOT relieved in 5 minutes after taking nitroglycerin or if additional symptoms such as nausea and sweating are also present with the chest pain.
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| After calling out for help and asking someone to dial for emergency services, what is the next action in CPR? | For adults check carotid pulse and if no pulse deliver C-A-B.
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| In feeling for presence of a carotid pulse during CPR, how long should you palpate? | Palpate for no more than 10 seconds, recognizing that arrhythmias or bradycardia could be occurring.
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| During CPR, what is the ratio of compressions to ventilations for an adult? | 30:2
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| During CPR, what is the ratio of compressions to ventilations for a child? | 15:2 for a child or neonate with two rescuers and 30:2 for 1 rescuer.
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| What is the first drug most likely to be used for an in-hospital cardiac arrest? | Epinephrine
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| A client in cardiac arrest is noted on bedside monitor to be in pulseless ventricular tachycardia. What is the first action that should be taken? | Defibrillation
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| How would the nurse assess the adequacy of compressions during CPR? | Check for a carotid or femoral pulse.
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| How would the nurse assess the adequacy of ventilations during CPR? | Watch for chest excursion and auscultate bilaterally for breath sounds.
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| If a person is choking, when should the rescuer intervene? | When the person points to his or her throat and can no longer cough, talk, or make sounds
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| One should never make blind sweeps into the mouth of a choking child or infant. Why? | Because the object might be pushed farther down into the throat
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| List four common causes of fluid volume deficit. | Gastrointestinal (GI) causes: vomiting, diarrhea, GI suctioning; decrease in fluid intake; increase in fluid output such as sweating, massive edema, ascites
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| List four common causes of fluid volume overload. | Heart failure, renal failure; cirrhosis; excess ingestion of table salt or overhydration with sodium-containing fluids
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| Identify two examples of isotonic IV fluids. | Ringer’s lactate; normal saline
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| List three systems that maintain acid-base balance. | Lungs; kidneys; chemical buffers
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| Why is the Allen test used before drawnig a sample for ABGs from the radial artery? | The Allen test ensures collateral circulation to the hand if thrombosis of the radial artery should follow the puncture.
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| Describe the Allen test | Make hand blanch by obliterating both radial and ulnar pulses. release the ulnar artery only. If flow through the ulnar artery is good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can be used for puncture.
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| Normal pH | 7.35 to 7.45 pH
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| Normal PCO2 | 35 to 45 mm Hg PCO2
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| Normal HCO3 | 21 to 28 mEq/L HCO3
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| Determine the following acid-base disorder: pH 7.50, PCO2 30, HCO3 28 | Respiratory alkalosis
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| Determine the following acid-base disorder: pH 7.30, PCO2 42, HCO3 20 | Metabolic acidosis
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| Determine the following acid-base disorder: pH 7.48, PCO2 42, HCO3 32 | Metabolic alkalosis
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| Determine the following acid-base disorder: pH 7.29, PCO2 55, HCO3 28 | Respiratory acidosis
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| Identify the waveforms found in a normal ECG. | P wave, QRS complex, T wave, ST segment, PR interval
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| In an ECG reading, which wave represents depolarization of the atrium? | Represented by the P wave
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| In an ECG reading, what complex represents depolarization of the ventricle? | QRS complex
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| What does the PR interval represent? | The time required for the impulse to travel from the atria through the AV node
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| If the U wave is most prominent, what condition might the nurse suspect? | Hypokalemia
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| Describe the calculation of the heart rate using an ECG rhythm strip. | Count the number of RR intervals in the 30 large squares and multiply by 10 to determine the heart rate for 1 minute.
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| What is the most important assessment data for the nurse to obtain in a client with an arrhythmia? | Ability of the client to tolerate the arrhythmia
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| List five variables that increase surgical risk. | Age: very young and very old, obesity and malnutrition, preoperative dehydration/hypovolemia, preoperative infection, use of anticoagulants (aspirin) preoperatively
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| Why is a client with liver disease at increased risk for operative complications? | Impairs ability to detoxify medications used during surgery; impairs ability to produce prothrombin to reduce hemorrhage
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| Preoperative teaching should include demonstration and explanation of expected postoperative client activities. What activities should be included? | Respiratory activities: coughing, breathing, spirometer; exercises: ROM, leg exercises, turning; pain mgmt: medications, splinting; dietary restrictions: NPO evolving to progressive diet; dressings and drains; orientation to recovery room environment
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| What items should the nurse assist the client in removing before surgery? | Contact lenses, glasses, dentures, partial plates, wigs, jewelry, prostheses, makeup, and nail polish
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| How is the client positioned in the immediate postoperative period, and why? | Usually on the side or with head to side to prevent aspiration of any emesis
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| List three nursing actions that prevent postoperative wound dehiscence and evisceration. | Teaching client to splint incision when coughing; encouraging coughing and deep breathing in early postoperative period when sutures are strong; monitoring for signs of infection, malnutrition, and dehydration; encouraging high-protein diet
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| Identify three nursing interventions that prevent postoperative urinary tract infections. | Avoiding postoperative catheterization; increasing oral fluid intake; emptying bladder every 4 to 6 hours; early ambulation
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| Identify nursing/medical interventions that prevent postoperative paralytic ileus. | Early ambulation; limiting use of narcotic analgesics; NG tube decompression
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| List four nursing interventions that prevent postoperative thrombophlebitis. | Teaching performance of in-bed leg exercises; encouraging early ambulation; applying antiembolus stockings; teaching avoidance of positions and pressures that obstruct venous flow
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| During the intraoperative period, what activities should the OR nurse perform to ensure safety during surgery? | Ascertain correct sponge, needle, and instrument count; position client to avoid injury; apply ground during electrocautery use; apply strict use of surgical asepsis
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| Identify the ways HIV is transmitted. | HIV is transmitted through blood and body fluids—e.g., unprotected sex, sharing needles, infected blood products (rare), breast milk (mother-to-fetus transmission), and breaks in universal precautions (needle sticks or similar occurrences).
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| Vertical transmission (from mother to fetus) occurs how often if the mother is not treated during pregnancy? | Vertical transmission occurs 30% to 50% of the time.
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| Describe universal precautions. | Protection from blood and body fluids is the goal of standard precautions. Include handwashing; using gloves; using gowns and masks; using eye protection as indicated; preventing needle sticks by not recapping needles.
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| What are the side effects of amphotericin B? | Side effects of amphotericin B can be quite severe; they include anorexia, chills, cramping, muscle and joint pain, and circulatory problems.
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| What does the CD4 T-cell count describe? | CD4 T-cell count describes the number of infection-fighting lymphocytes the person has.
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| Why does the CD4 T-cell count drop in HIV infections? | CD4 T-cell count drops because the virus destroys CD4 T cells as it invades them and replicates.
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| Describe the ways a pediatric client might acquire HIV infection. | Pediatric acquisition may occur through infected blood products, through sexual abuse, and through breast milk.
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| What modalities are associated with the gate control pain theory? | Massage, heat and cold, acupuncture, TENS
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| How does past experience with pain influence current pain experience? | The more pain experienced in childhood, the greater is the perception of pain in adulthood or with current pain experience.
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| What modalities are thought to increase the production of endogenous opiates? | Acupuncture, administration of placebos, TENS
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| What six factors should the nurse include when assessing the pain experience? | Location, intensity, comfort measures, quality, chronology, and subjective view of pain
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| What mechanism is involved in the reduction of pain through the administration of NSAIDs? | NSAIDs act via a peripheral mechanism at the level of damaged tissue by inhibiting prostaglandin synthesis and other chemical mediators involved in pain transmission.
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| If narcotic agonist/antagonist drugs are administered to a client already taking narcotic drugs, what may be the result? | Initiation of withdrawal symptoms
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| List four side effects of narcotic medications. | Nausea/vomiting; constipation; CNS depression; respiratory depression
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| What is the antidote for narcotic-induced respiratory depression? | Narcan (naloxone)
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| What is the first sign of tolerance to pain analgesics? | Decreased duration of drug effectiveness
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| Which route of administration for pain medications has the quickest onset and the shortest duration? | Intravenous push, or bolus
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| List the six modalities that are considered noninvasive, nonpharmacologic pain relief measures. | Heat and cold applications; TENS; massage; distraction; relaxation techniques; biofeedback techniques
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| Identify the five stages of death and dying. | Denial, anger, bargaining, depression, acceptance
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| A client has been told of a positive breast biopsy report. She asks no questions and leaves the health care provider’s office. She is overheard telling her husband, “The doctor didn’t find a thing.” What coping style is operating at this stage of grief? | Denial
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| Your client, an incest survivor, is speaking of her deceased father, the perpetrator. “He was a wonderful man, so good and kind. Everyone thought so.” What would be the most useful intervention at this time? | Gently point out both the positive and negative aspects of her relationship with her father. Try to minimize the idealization of the deceased.
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| Your client feels responsible for his sister’s death because he took her to the hospital where she died. It has been 1 month since her death. Is this response indicative of a normal or a complicated grief reaction? | This is a normal expression of the anger and guilt that occur. Try to minimize rumination on these thoughts.
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| Mrs. Green lost her husband 3 years ago. She has not disturbed any of his belongings and continues to set a place at the table for him nightly. Is this response indicative of a normal or a complicated grief reaction? | This is a dysfunctional grief reaction. Mrs. Green has never moved out of the denial stage of her grief work.
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| Order of blood flow through the heart | Unoxygenated blood flows from superior and inferior vena cava into right atrium, to right ventricle. Then out of heart through pulmonary artery, to lungs. pulmonary vein delivers oxygenated blood back to left atrium, then to left ventricle and out aorta.
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