NCLEX NGN TEST BANK 2024, Exams of Nursing

Download NCLEX NGN TEST BANK 2024 and more Exams Nursing in PDF only on Docsity! 1 Page | 1 NCLEX NGN TEST BANK WITH ACTUAL CORRECT QUESTIONS AND DETAILED RATIONALES ANSWERS LATEST 2023-2024 NEWEST ALREADY GRADED A+ A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal AV fistula in the RA. Which intervention should the nurse implement in caring for the client? SATA a. Assessing the radial pulse in the right extremity b. Using the LA ti take BP readings c. Drawing pre-dialysis blood specimens from the LA d. Assessing the area over the AV fistula for a bruit and three each shift e. Placing a pressure dressing over the site after each dialysis treatment f. Administering IV fluids through the venous site of the AV fistula as needed A, B, C, D A nurse is evaluating outcomes for a client with Guillain-Barre syndrome. Which outcome does the nurse recognize as optimal respiratory outcomes for the client? a. Normal deep tendon reflexes b. Improved skeletal muscle tone c. Absences of paresthesias in the lower extremities d. Clear sound in the lower lung fields bilaterally e. pO2 of 85 mmHg and pCO2 of 40 mmHg D, E A nurse of the telemetry unit is caring for a client who has had a MI and is now attached to a cardiac monitor. The nurse is monitoring the client's cardiac rhythm and nots ventricular fibrillation. Which nursing intervention should the nurse take first? a. Calling the rapid response team b. Preparing the client for cardioversion c. Asking the client to bear down and cough d. Preparing to administer diltiazem A The pattern of ventricular fibrillation is identified and can be a result after a patient with an MI. VF makes the patient feel faint, then loses consciousness and becomes pulseless and apneic (BP and heart sounds absent). Treatment is to terminate VF and covert it into a rhythm via defibrillation-> call a rapid and initiate CPR. Cardioversion is used for ventricular or supraventricular tachydysrhythmias. A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate into the plan to 2 Page | 2 prevent this complication? a. Keeping the fan running in the client's room b. Keeping the linens wrinkle free under the client c. Limiting bladder catheterization to once every 12 hours d. Avoiding the administration of enemas and rectal suppositories B The most frequent cause of autonomic dysreflexias are a distended bladder and impacted feces. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize these risks. A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further teaching? a. I need to get more fluids and fiber into my diet b. I should cut my food into small pieces before I eat c. I need to put powder under the vest twice a day to prevent sweating d. I have to check the pin sites everyday and watch for signs of infection C Cleanse the skin under the wool liner each day to prevent rashes and soars. A nurse is caring for a client with increased intracranial pressure. In which position should the nurse maintain the client? a. Supine with the head extended b. Side lying with the neck flexed c. Supine with the head turned to the side d. Head midline and elevated 30-45 degrees D Proper positioning promotes venous drainage from the cranium to minimize ICP. A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action first? a. Asses the clear fluid for protein b. Check the clear fluid for glucose c. Place cotton calls or dry gauze loosely in the ears d. Use an otoscope to assess the tympanic membrane for rupture B CSF contains glucose not protein. A nurse is caring for a client who has just undergone cardioversion. Which intervention is the nurse's priority after this procedure. a. Administer oxygen b. Monitoring the BP c. Administering antidysrhythmic medications d. Monitoring the client's LOC 5 Page | 5 A man calls the clinic and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first take which action? a. Place a cool compress on the sting site b. Apply an antipruritic lotion to the sting site c. Apply a topical corticosteroid to the sting site d. Take an oral antihistamine such as diphenhydramine (Benadryl) A A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should take which action first? a. Ask the client to sign a no-harm contract b. Ask the client to report any suicidal thoughts immediately c. Place the client under suicide precautions with 15-minute checks d. Check the dressings that were placed over the client's wrists in the emergency department D First assess the physical state of the patient for safety then implement precautions. A nurse is preparing to administer digoxin to a client with heart failure. When assessing the client, the nurse notes an apical pulse rate of 58 beats/min. Also, the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings? a. Contact the primary health care provider b. Administer an as-needed antiemetic c. Check the most recent digoxin level d. Administer the digoxin with an antacid C A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears stridor when auscultating over the trachea. On the basis of this finding, which is the priority nursing action? a. Assess the client's pulse oximetry Incorrect b. Place the client in a supine position c. Contact the primary health care provider d. Administer a nebulizer treatment with the use of a bronchodilator C Stridor indication there is an obstruction and the HCP should be notified immediately. The patient should be placed in high Fowlers and pulse oximetry can be completed by is not the priority. A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who received NPH and regular humulin insulin at 7:30 a.m. At 11 a.m. the child suddenly complains of dizziness, headache, and a shaky feeling. The nurse immediately takes which action? a. Contacts the physician b. Gives the child milk to drink 6 Page | 6 c. Arranges to have the child's lunch tray delivered early d. Prepares to administer intravenous 5% dextrose solution B A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. Which is the first action on the part of the nurse? a. Calling the physician b. Inserting an oral airway c. Turning the client on her side d. Noting the time of the seizure C A nurse is preparing to administer an injection of vitamin K to a newborn. At which site would the nurse select to administer the medication? 3 The preferred injection site for the administration of vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle (the newborn's thigh). This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of (2.164 mmol/L)35 mg/dL. The nurse would take which action first? Ask the mother to breastfeed the newborn Bottle-feed the newborn with diluted glucose Start an intravenous line for the administration of glucose Ask the laboratory to perform a blood glucose test immediately D Normal newborn levels are 40 mg/dL or greater. Glucose levels of less than (2.22-2.298 mmol/L))40 to 45 mg/dL measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance and prevent damage to the brain. A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which actions should the nurse perform? Select all that apply. Placing the woman in knee-chest position Administering oxygen at 2 to 4 L/min by nasal cannula Administering terbutaline to stop contractions With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution 7 Page | 7 A, C, D Oxygen should be administered at 8-10 L/min via face mask A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the primary health care provider. Which statement by the mother indicates the need for further instruction? "I'll call the doctor if she gets dizzy and acts sick." "I'll call the doctor if she has severe stomach cramps." "I'll call the doctor if her temperature is 102°F (38.9°C) or higher." "I'll call the physician if she goes longer than 6 hours without urinating." C Call doctor at temperature above 100. A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of which other issue? Refusal to suck Frequent diarrhea Recurrent otitis media Inability to pass stools C Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER. A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which diagnostic test will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find? Throat culture Blood urea nitrogen (BUN) Antistreptolysin (ASO) titer White blood cell (WBC) count C In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs which complication? Anemia Renal failure Thrombus formation Gastrointestinal disturbances C Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute febrile exanthematous 10 Page | 10 A A nurse assesses the chest tube drainage system of a client who has undergone thoracic surgery and notes intermittent bubbling in the water seal chamber. One hour later, the nurse notes the presence of continuous bubbling in the chamber. On the basis of this finding, which would the nurse check first? The chest tube connection sites For bubbling in the suction-control chamber The amount of drainage in the collection chamber The amount of suction being applied to the chest tube system A A nurse on the day shift is assigned to care for four clients. In which order will the nurse assess the clients after receiving report from the night shift. A client scheduled for an electrocardiogram (ECG) at 11 a.m. A client on nothing-by-mouth (NPO) status who is for bronchoscopy at 9 a.m. A client who has undergone above-the-knee amputation who is scheduled for discharge home A client who had a seizure at 2 a.m. and was treated with intravenous (IV) diazepam and phenytoin D As a nurse is providing care, the client suddenly experiences a tonic-clonic seizure. The nurse would immediately take which action first? Call the physician Turn the client to the side Restrain the client's limbs Insert an airway in the client's mouth B A nurse is providing care to a client with a closed chest tube drainage system. When the nurse assists the client in turning onto his side, the chest tube is accidentally dislodged from the insertion site. The nurse must immediately take which action? Reinsert the chest tube Turn the client onto his back Contact the primary health care provider Apply pressure over the chest tube insertion site D A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes an audible wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. After immediately disconnecting the suction source from the catheter, which intervention does the nurse implement next? Calling a code Administering an inhaled bronchodilator Connecting oxygen to the suction catheter Encouraging the client to take deep breaths 11 Page | 11 C The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates bronchospasm and bronchoconstriction. The nurse must immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter, because the client is at risk for hypoxia. A client with skeletal traction applied to the right leg complains of severe pain in the leg. The nurse realigns the client's position, but this intervention does not relieve the pain. Which action would the nurse take next? Providing pin care Calling the primary health care provider Removing some of the traction weights Medicating the client with the prescribed analgesic B The nurse realigns the client and, if this is ineffective, calls the primary health care provider. The nurse never removes traction weights unless this is specifically prescribed by the primary health care provider. Severe leg pain, once traction has been established, indicates a problem. The client should be medicated after an attempt has been made to identify and treat the cause of the pain. A nurse is preparing client assignments for the day. Which assignments would be appropriate for a registered nurse who is pregnant? Select all that apply. A client with active herpes virus lesions in the perianal area A client who requires frequent abdominal wound irrigations A client with a solid sealed implanted radiation source who is restricted to bed rest A client with methicillin-resistant Staphylococcus aureus (MRSA) under contact precautions A client undergoing mechanical ventilation through a tracheostomy who requires frequent suctioning B, D, E A female client is examined in the clinic, and gonorrhea is diagnosed. The nurse provides information to the client about the disease and provides which information? Condoms will not help prevent transmission of the infection Healthcare providers are legally responsible for reporting all cases of gonorrhea to the health authorities It is not necessary for sexual partners to be examined, because the disease is not highly communicable Treatment includes the administration of an antibiotic, but it is not necessary for sexual partners to be treated B A nurse on the day shift receives the client assignment for the day. In which order will the nurse assess the assigned clients? A client who was admitted during the night because of congestive heart failure A client who has been fitted with a closed chest tube drainage system A client with a nasogastric tube who underwent bowel resection 2 days ago A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m. 12 Page | 12 A client who was admitted during the night because of congestive heart failure A client who has been fitted with a closed chest tube drainage system A client with a nasogastric tube who underwent bowel resection 2 days ago A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m. The nurse is observing a new nurse employee perform an otoscopic examination of an adult client. The nurse determines the new nurse employee understands the procedure if the new nurse employee takes which action? Uses a small speculum to decrease the discomfort Pulls the pinna up and back before inserting the speculum Tilts the client's head forward before inserting the speculum Pulls the earlobe down and back before inserting the speculum B Old= up Young= down A primigravida is admitted to the labor unit. During assessment, the client's membranes rupture spontaneously. What is the priority nursing action? Checking the amniotic fluid Checking the fetal heart rate Assessing the contraction pattern Preparing for immediate delivery B When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does the nurse, reviewing the plan of care, identify as the priority for this client? Fundal assessment Monitoring of urine output Frequent assessment of lochia Inclusion of iron in every meal C A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the titer indicate that the mother is not immune to rubella. The nurse realizes the patient understands patient teaching if the patient makes which statement? "I may need to get a therapeutic abortion." "I will need an immunization against rubella immediately." "Immunization against rubella is required after delivery." "Antibiotics will be prescribed to prevent the infection." C MMR vaccines are contraindicated in pregnancy 15 Page | 15 A nurse provides instructions to a pregnant woman about foods that contain calcium. The nurse realizes the client understands instructions if the client selects which products? Select all that apply. Cheese Yogurt Spinach Sardines Shellfish A, B, D A child who is HIV-positive is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The laboratory results show the CD4+ as 1000 cells/mm3. Which nursing action is appropriate? Administering the vaccine Contacting the primary health care provider Asking the laboratory to repeat the CD4+ test Informing the child's mother that the vaccine must not be administered at this time A The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3, the nurse would administer the vaccine. A client in a manic state emerges from her room wearing provocative clothing and quickly enters the dayroom. She announces to the group that she is the star of a burlesque show and will begin her performance shortly. Which is the priority nursing action? Ask the client to go to her room and to change her clothes Tell the client firmly that burlesque shows are not allowed in the nursing unit Tell the client that her bathroom privileges are being suspended because of her behavior Quietly and firmly assist the client to her room and help her dress in appropriate clothes D A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my coffin." Which response by the nurse is therapeutic? "Do you think that having asthma will kill you?" "You seem very distressed at learning that you have asthma." "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'" "Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant." B During a preoperative assessment, a nurse notices the client is crying. In light of this observation, which statement by the nurse is appropriate? "You seem upset. Would you rather be alone?" "You're crying. Tell me more about how you are feeling." "Your surgeon is the best and has done many of these operations." "Crying before a serious operation is common, but everything will be okay." 16 Page | 16 B A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this client? Ineffective coping skills Perceptual disturbances Chronic low self-esteem Risk for self-directed violence D A client who was sexually assaulted a year ago is self-contained and calm while discussing the assault. The client says to the nurse, "It still doesn't seem real." The nurse is considering requesting a referral to a mental health professional because which defense mechanism has been used for an extensive period of time? Denial Projection Rationalization Intellectualization A A nurse completes an initial assessment of a client admitted to the mental health unit. Which assessment finding is the priority concern? Bruises on the client's neck The client's report of not sleeping well The client's report of suicidal thoughts The spouse's statement "I don't approve of this treatment." C A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the nurse respond to the client? "No one is going to kill you." "Your medication is making you feel like this." "Are you worried that people are trying to hurt you?" "What makes you think that terrorists were sent to hurt you?" C A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say to the client? "Leave the room." "Go to the nurses' station until our group therapy session is finished." "I will recommend that group therapy be eliminated from your treatment plan." "Thank you for your comments. Now, try to stop talking and listen to the others." D 17 Page | 17 A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain. The nurse attempts to comfort the child by providing which explanation? The pain is a normal, temporary condition The pain occurs because nerves have been cut This pain will go away once a prosthesis is used Pain medication may be needed for life to alleviate the discomfort A Phantom limb pain is a temporary condition that some people who undergo amputation experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child should be reassured that the condition is normal. A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his belongings from where he always kept them. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? "I know just how you feel, because I lost my husband last summer." "It's OK to grieve and be angry with your daughter and anyone else for a time." "You need to focus on the many good years you enjoyed together and move on." "I know it's a troubling time for you, but try to focus on your children and grandchildren." B The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think that the twins should come to the funeral service for their grandfather. What do you advise?" Which response by the nurse would be therapeutic? "What do you and your husband believe is the right thing for your children?" "By all means have them attend. Keeping them home will only prolong their grief. " "I agree with your mother-in-law. Just tell your children that their grandfather is in heaven." "It's a difficult decision, but given their young age, maybe it would be best to keep them home from the wake and just let them attend the funeral." A pH 7.35-7.45 PCO2 35-45 20 Page | 20 3.5-5 -checks liver and kidney function - high=dehydration, diarrhea -low=kidney/liver disease, infection, inflammation amylase 25-151 Enzyme helps digest carbs lipase 10-140 Enzyme made in pancreas that break down fats High- problem w prancers ammonia 10-80 Toxic waste product made during protein digestion High- liver disease, kidney failure, genetic disorder, Reyes ALT/AST 10-40 Bilirubin total less then 1.5 glucose 70-100 A1C under 6% Average blood sugar over 3 months 21 Page | 21 hemoglobin woman 12-15, male 14-16 hematocrit female 35-45% male 40-50% platelets 150,000-400,000 aPTT 20-30 seconds PT 9-11 seconds INR 1 (with warfarin 2-3) 22 Page | 22 K 3.5-5.0: intracellular, neuromuscular/muscular contraction, regulated by kidney. o Foods: avocado, potatoes, spinach, strawberries, tomatoes, raisins o NEVER GIVEN IV PUSH, IM, SUBQ, max infusion 10 mEq/hr, K can cause phlebitis=assess IV site frequently, assess renal function before administering, monitor I&O o High/low=impacted heart rhythm, and muscle function w/ leg cramping o High d/t: K retaining diuretics, CRF, Addison's, tissue damage- if CRF=Kayexalate, IV glucose with insulin, Ca, dialysis, avoid salt substitutes o Low d/t diuretics/corticosteroids, vomiting, diarrhea, NG suction, CRF, -no supplements on empty stomach o Hypo=st depression Hyper=Tall T waves Na 135-145: extracellular, regulates cell size and osmosis, maintains water balance, nerve impulses, muscle contraction, BP, blood volume, regulates acid-base balance, regulated by salt intake, aldosterone, urinary output o Hyponatremia: d/t burns, diarrhea, HF, diuretics, vomiting, diaphoresis, CRF, SIADH, ^BS *Lithium Tox! • S/s: mental confusion, seizures, hallucinations, brain herniation, death o Hypernatremia: HTN, edema, Cushing's, CRF, hyperaldosteronism, hormones, NSAIDS • s/s: lethargic, excitability, hypovolemia, pulm edema, muscle twitches, coma, dry flushed skin Chloride 96-106: helps balance Na, extracellular fluid WBC 25 Page | 25 Beta-blockers- to prevent arrhythmias and reduce heart workload Low sodium diet- to prevent fluid retention Exercise as tolerated - to monitor response to therapy and return to baseline functional status CARDIAc LeVeLS mnemonic for cardiac assessment: Chest discomfort Activity tolerance Response to drug therapy Depression & anxiety Increased weight Arrhythmias c... Lightheadedness e... Vital sign changes e... Level of consciousness decreased Shortness of breath Self-care instructions for heart failure: R-E-A-L Report findings of heart failure to provider - weight gain, worsening dyspnea, orthopnea, fatigue Exercise is important - start low & go slow to increase functional capacity, attending to symptoms Adherence to cardiac medications is essential to staying healthy Low sodium diet - 2000 mg per day Pericarditis s/s: sharp pain relieved leaning forward, pulses paradoxes Rx: NSAIDS, steroids, abx, NO anticoags (^risk of bleeding) myocarditis s/s: S3 gallop, joint swelling Rx: DO-ABLE, dig at home (tox: anorexia, n/v, blurred vision, arrhythmias) endocarditis can vegetate=embolize, d/t grp B strept, staph aureus, fungus s/s: fever, petechiae, splinter nails Rx: IV abx 6 weeks, need long term venous access 26 Page | 26 rheumatic heart disease damage d/t grp A strept pharyngitis, fever 104, chorea (emotional instability) jerky movements, ring-like rash on trunk/extremities, murmur mitral stenosis/regurgitation damage d/t rheumatic fever s/s: L HF, paroxysmal nocturnal dyspnea (sudden waking d/t sob) rx: DO-ABLE nursing: CARDIAc LeVeLS teach: REAL myasthenia gravis autoimmune, progressive weakness of voluntary muscles, d/t blocked ACH s/s: fatigue, weakness (better w/rest), ptosis (drooping eyelid) reduced eye closure, weak smile, diplopia, blurred vision, speech/swallowing disorders, weakness of facial muscles, restrictive lung disease. Rx: Tensilon test (injection to improve muscle strength +MG), Pyridostigmine, sterioids, immunosuppressants, thymectomy, plasmapheresis MS demyelination of white matter, unknown cause, improves and worsens unpredictably, more in women. S/s: blurred vision, dysphagia, diplopia, weakness, numbness, paralysis, spasticity, gait disturbances, tremor, ataxia, decreased short-term memory, urinary retention/incontinence, loss of bowel control. Rx: Avonex. Nursing: maintain functional abilities, avoid stress/fatigue, take rests, exercise regularly, avoid triggers (stress, pregnancy, temp extremes) 27 Page | 27 SIADH to much ADH, water is excessively retained, UO drops, specific gravity increases, more common in chronic phase after head injury Diabetes insipidus decreased ADH and body excretes too much fluid, ^UO, low specific gravity, common in initial/acute phase of head injury TBI s/s: LOC, nasal discharge, stiff neck, restlessness, n/v, posturing (decerebrate/decorticate) CSF leakage, hyperthermia, Cushings triad hypertension, bradycardia, widening pulse pressure Rx: Mannitol, steroids (Decadron) IV push, barbiturate coma induced to treat refractory IICP, neuromuscular blocking agent (Norcuron) to decrease agitation, ICP monitor Nursing: HOB 30˚, midline, avoid flexion/extension of head, O2, avoid morphine, maintain body temp to prevent shivering (increases ICP), decrease stim, limit fluid intake to 1200ml day, avoid straining, seizure precautions, monitor for herniation: irreg breathing, irreg pulse, loss of brainstem reflexes (blinking, gagging, pupil reaction) resp/cardiac arrest Parkinson's disease 30 Page | 30 autoimmune symmetric ascending motor paralysis, fatal if respiratory muscles are affected. d/t viral infection 2wks later. s/s: weakness, bilateral, ascending, loss of DTR, dysphagia Rx: LP (+protein in CSF) supportive, vent, IVF, immunoglobulin therapy, morphine for pain. Nursing: maintain resp status, provide communication needs myasthenia gravis crisis acute exacerbation d/t triggers (stress, infection, inadequate meds) NO ACH s/s: ^HR, ^RR, ^BP, sudden inability to swallow, speak or maintain airway, incontinence, absent cough Rx: vent support, ^ meds Cholinergic crisis overdose of Pyridostigmine TOO MUCH ACH (skeletal muscle neurotransmitter) s/s: hypotension Cholinergic Toxicity: S-salvation L-lacrimation U-urinary stasis D-dizzy/diaphoresis/defication G-gi upset E-emesis Rx: atropine (increases HR) may need vent. Nursing: rest periods, avoid extreme temps, people with resp infections 31 Page | 31 seizure abnormal electrical discharge in brain. Epilepsy: chronic, recurring. Absence: petit mal, less than 10 seconds, blank starring, between 4-14 yrs old Myoclonic: jerking of 1 or more extremities, occurs in the morning Clonic: SHAKING violent bilateral muscle movements, hyperventilation, diaphoresis, tachycardia, excess salivation Tonic: RIGID loss of consciousness, contraction bilaterally, jaws clenched, loss of bladder control, apnea, cyanosis, lasts less than 1 min Tonic-clonic: grand mal: most common, prodromal, lasts 2-3 mins, incontinent, post ictal 5 mins after, confusion after, ha Status epilepticus: w/o pauses, EMERGENCY risk for hypoxia Rx: benzos (valium, Ativan) for active seizures, anticonvulsants (Dilantin) barbiturates (phenobarbital) Nursing: suction/O2 ready, help to floor, place a pillow under head, loosen clothing, observe and record seizure activity, call RRT if lasts longer than 5 mins. after: turn on side, allow to rest, document. Acute closed-angle glaucoma EMERGENCY: iris bulges forward against cornea, women after 45. s/s: SUDDEN blurred vision, halos, colored rings, SUDDEN frontal ha, SUDDEN severe eye pain, reddening n/v, profuse lacrimation, dilated nonreactive pupil, BLINDNESS IN 2-5 DAYS IF UNTREATED Menieres disease 32 Page | 32 volume of endolymph expands, 40-60 yr olds/ s/s: attacks intermittent: vertigo, tinnitus, hearing loss. Rx: cholinergic blockers (atropine), diuretics, valium, epinephrine, low salt/triglyceride diet. Nursing: keep pt in quiet dark room, avoid unnecessary movement, restrict salt and water intake, avoid tobacco, caffeine Antianginals nitrates: used to treat and prevent attacks of angina; acute treatment calcium channel blockers and beta blockers are used prophylactically for longer-term management Antianxiety agents benzodiazepines: better for intermittent or short-term use in the management of anxiety buspirone, paroxetine, venlafaxine: better for long-term use Antiarrhythmics suppression of cardiac arrhythmias generally classified by their effects on cardiac conduction tissue (Class IA, IB, IC, II, III & IV) atropine and digoxin: also used as antiarrhymics Anticholinergics atropine: bradyarrhythmias ipratropium: bronchospasm atropine: also used as ophthalmic mydriatic benztropine: management of Parkinson's disease Antiemetics used to manage nausea and vomiting due to many causes, including surgery, anesthesia, and antineoplastic and radiation therapies 35 Page | 35 used as a part of a total plan, including diet and exercise, to reduce blood lipids in an effort to reduce the morbidity and mortality of atherosclerotic cardiovascular disease and its sequelae memory trick - many end with "STATIN", e.g., atorvastatin (Lipitor), simvastatin (Zocor), rosuvastatin (Crestor) Nonsteroidal anti-inflammatory agents used to control mild to moderate pain, fever, and various inflammatory conditions, e.g., rheumatoid arthritis and osteoarthritis IICP restlessness, irritability, confusion, lethargy, pupils ipsilaterally, blurred vision fixed, hemiparesis, decorticate then decerebrate, flaccid, abnormal reflexes: hyper- or hyporeflexia, +Babinski , Cushing's triad hypertension; progressively increasing systolic pressure with widening pulse pressure; bradycardia, Cheyne-Stokes, vomiting, headache, seizures, infant "high shrill cry" Nursing: HOB 30°, head midline-no flexion of neck/hips (to encourage jugular venous drainage), O2, no morphine, vent PaCO2 at 30-35 (will vasoconstrict= decreased ICP), prevent shivering (which can ^ ICP), , limit fluids 1200 mL/day, avoid straining, Meds: Anticonvulsants, Antipyretics and muscle relaxants, Blood pressure medication, Corticosteroids, IVF, Hyperosmotic agent) Herniation syndrome: Irr RR, HR Loss of brainstem reflexes (blinking, gagging, pupils) decorticate flexion into body, decerebrate extension away from body, pronation of arms/legs 36 Page | 36 Reyes syndrome acute encephalopathy following viral illness w/cerebral edema d/t ASA w/fever s/s: fever, n/v, lethergy, neuro deterioration, increased ammonia levels autonomic dysreflexia paroxysmal hypertension bradycardia diaphoresis, facial flushing , pilomotor responses, ha, dilated pupils, blurred vision, restlessness d/t injury above T6 after spinal shock Triggers visceral stimulation from a distended bladder or impacted rectum. a neurological emergency and must be treated immediately to prevent a hypertensive stroke. It is also known as autonomic hyperreflexia. nursing: raise HOB, loosen tight clothing, check bladder distention and other noxious stimulants, administer antihypertensive meds neurogenic shock injury above T6, massive vasodilation causes pooling of blood and low SVR=hypotension s/s: hypotension, bradycardia spinal shock complete but temporary loss of motor, sensory, reflex, and autonomic function immediately after injury- lasts less than 48hrs- weeks s/s: flaccid, bradycardia, hypotension, paralytic ileus 37 Page | 37 CSF cushion, aids in exchage of nutrients and wastes normal pressure 50-175 normal volume 125-150 yellow "halo" ring CT dye assess allergies to iodine, shellfish, contrast dyes, claustrophobia after: replacement fluids to diuresis the dye MRI no metal objects, pacemaker, implanted defibrillator, hip prosthesis, vascular clips, no IVF, no pregnant women LP 40 Page | 40 -Chest pain: Ischemia to myocardium -Coughing at night: pulm congestion L HF -Coughing up blood: severe L HF -Dependent edema: R HF -Fatigue/weakness: poor perfusion -Intermittent claudication: obstruction of arterial vessels in legs (s/s w/ exercise, place feet down) -Nocturia: HF (L or R) -Orthopnea: L HF -Palpitations: cardiac dysrhythmias -Paroxysmal nocturnal dyspnea: L HF -SOB: L HF -Syncope: reduction of blood flow to brain -Weight loss/gain: R HR myocardial infarction insufficient oxygen supply kills myocardial tissue, total event can take 3-6 hrs. d/t: CAD/atherosclerosis. Mortality 25% s/s: crushing pain, radiates does not resolve w/ rest, fatigue, n/v, sob. ECG: ST changes, CK-MB rises 3-4 days. Troponin rises 2 weeks. "time is muscle" Nursing: temp, daily weight, I&O, S3, sex after 2 flights of stairs w/o s/s. no Viagra Meds: OH BATMAN: • Oxygen• Heparin• Beta blocker• ASA•Thrombolytics• Morphine• ACEI• Nitro Nursing care: Cardio care 6: ABCEDF: • ADL's• Best rest• Commode• Diversions• Elevate• Feelings cardiac tamponade fluid fills pericardial sac s/s: Becks TRIAD: HYPOTENSION, MUFFLED HEART SOUNDS, JVD, pulsus paradoxus (SBP drops 41 Page | 41 w/inspiration) narrowed pulse pressure (difference between SBP and DBP). RX: emergency pericardiocentesis! Nursing: HOB 45˚ cardiac arrhythmias Atrial: Tachy/brady/arrhythmia/pvc/a-flutter/afib (needs anticoag), junctional tachy Ventricular: v-tach/v-fib (defib), asystole (no defib) Blocks: if R is from from P=1st˚ (long PRI), longer longer longer drop=Wenkeback 2nd˚, if some P's don't get through then you have Mobitz II, if P's and Q's don't agree then you have 3rd˚ Afib: ABCD: anticoag, bb, cardioversion, digoxin Nursing: treat the pt not just the monitor. SVT (too fast): vagal stim, adenosine, CCB, BB, cardioversion Ventricular arrhythmias: ABCD (airway breathing circulation disability), cardioversion AV conduction (too slow): atropine (anticholinergic that blocks vagal nerve stim), pacemaker intermittent claudication (PAD) . 6 P's: Pain-pallor-paralysis-poiklithermia (inability to regulate temp)-paresthesia-pulselessness pain w/ activity, limb=waxy, hairless, cool, pale, weak, absent pulses, non-healing wounds, impotence in men, reduced arterial-brachial index. RX: anticoag, vasodilators, antiplatelets, Trental "slippery blood" no compression, keep low. Sx: endartecetomy, bypass, amputation, angioplasty 42 Page | 42 Raynauds episodic vasospasm, cyanosis bilaterally, autoimmune, triggered: stress, cold, smoking, caffeine, chocolate DVT clot in deep vein, Virchow's triad: hypercoagulabilty, hemodynamic changes (stasis, turbulence) endothelial injury/dysfunction. s/s: unilateral edema, warmth, tenderness, redness. sickle cell disease vaso-occlusive crisis, hypoxia, organ dysfunction, ischemia, infarction. Rx: hydration, oxygen, analgesics, abx, folic acid, IV steroids, transfusion, vaccines. Nursing: fluids, I&O, avoid triggers, keep hydrate Von Willebrands deficient clotting protein, congenital, factor 8, easy brusing, nosebleeds, heavy periods, prolonged PT. no RX- avoid blood thinners 45 Page | 45 hyperkalemia causes asystole, ventricular dysrhythmias, TALL TENTED T waves, wide QRS, prolonged PRI, flat P waves hypocalcemia ventricular dysrhythmias, prolonged ST and QT, cardiac arrest hypercalcemia short ST, wide T, AV block, tacky/brady, cardiac arrest hypomagnesium v-tach/v-fib, TALL T waves, depressed ST hypermagnesium weakness, hypotension, bradycardia, wide QRS PRI 0.12-0.20 beginning of P to end of PR QRS 46 Page | 46 ventricular depolarization 0.04-0.1 (less then PRI) QT ventricular refractory time 0.32-0.5 cardiac catheterization assess for allergies, NPO 8 hrs before, height/weight for dye, lie still and quiet for 2hrs, feel "flutter" feelings w/ cath, warm flush w/ dye and desire to cough d/t heart irritability after: keep extremity extended 4-6 hrs, strict bed rest 6-12 hrs sinus brady less then 60 O2, atropine, pacemaker, IVF sinus tachy 100-180 treat cause 47 Page | 47 a-fib no p wave give O2, anticoags, cardioversion, antidysrhythmics PVC irritability of ventricles give O2, check electrolytes (hypokalemia), amiodarone v tach SHOCK synchronized on R wave 140-250 can lead to cardiac arrest bigeminy-every other beat trigeminy-every 3rd beat give O2 if stable unstable: shocks, CPR, O2, antidysrhytmics, cardioversion v fib 50 Page | 50 Duodenal ulcer pain, heartburn at night or when stomach is empty, pain relieved w/food, melena (black tarry stool) Dumping syndrome rapid emptying of the stomach. s/s: tachycardia, palpitation,syncope,diaporesis, diarrhea, nausea, abd distention, post-op complication, subsides after a few months, slow eating, low carbs, high protein, avoid liquids w/meals GERD gastric contents leak backwards into the esophagus risk factors: hiatal hernia, obesity, pregnancy, smoking, scleroderma. s/s: Pain w/ bending, laying down, relieved w/antacids, infant: voming/spitting up with meals, failure to thrive, irritable, cyanosis. Rx: smaller more frequent meals, no caffeine/acidic foods, do not lie down 2 hrs after eating, sleep with HOB elevated, no smoking, Tagamet, ppi Ulcerative colitis inflammatory bowel disease, begins in rectum→up through the colon, abscesses. s/s: bloody diarrhea up to 20 a day, stools w/ pus and mucus, L sided pain, fever, weight loss, anemia, tachycardia, dehydration. Rx: steroids, anticholinergics, antidiarrheals, high calorie, high protein, LOW roughage, NO milk products. Complications: increased risk of colon cancer, toxic megacolon, and perforation. 51 Page | 51 Crohn's inflammatory bowel disease, small intestine. s/s: diarrhea w/ steatorrhea (unprocessed fats), abd pain RLQ, fatigue weight loss, dehydration, fever. Complications: fistula, peritonitis. Rx: NPO, TPN, steroids, colectomy Diverticulitis outpouching of intestinal mucosa, most in sigmoid, stool and bacteria retained, s/s: crampy, lower L abd pain, alternating constipation/diarrhea. Rx: high fiber, high residue, bulk laxatives, stool softners, anticholinergics, NPO rest bowel during acute phase, abx. Complications: abscess, perforation, peritonitis, fistula, obstruction, hemorrhage. Nursing: avoid straining cirrhosis irreversible, chronic, progressive degeneration of liver w/fibrosis. s/s: fatigue, hepatomegaly, RUQ pain, jaundice, steatorrhea, clay-colored stools, ascities, hepatic encephalopathy. Rx: steroids, vit B. Nursing: increased carbs, restrict protein, monitor for bleeding, rest periods, assess LOC, daily weight, I&O Portal hypertension 52 Page | 52 s/s prominent abd wall veins (caput medusa) hemorrhoids, enlarged spleen, anemia, GI bleeding, esophageal varices. Rx: balloon, vasopressin, nitro, TIPS. Nursing: assess bleeding, no alcohol, monitor for infection ascites accumulation of fluid in peritoneum d/t portal htn, hypoalbuminemia, hyperaldosteronism, fluid leaks. s/s: fluid wave, distention, dull sound on percussion, dyspnea. Rx: diuretics, IV albumin, paracentesis, low sodium. Nursing: daily weight, I&O, restrict fluids, semi-fowlers Hepatic encephalopathy impaired ammonia metabolism causes cerebral edema. s/s: change in LOC, memory loss, asterixis (flapping tremor) impaired handwriting, hyperventilation w/ resp alkalosis. Rx: lactulose, low protein, safety, rest Pancreatitis d/t alcohol, gall stones, drugs, viral, trauma. Autodigestion from enzymes. s/s: LUQ pain worse w/ food and when flat, n/v, hypovolemia, hemorrhage, ecchymosis around umbilicus, tachypnea, atelectasis, elevated amylase/lipase, hypocalcemia, prepare for ERCP. Rx: Demerol, NPO, NG tube anticholinergics, H2 Cholecystitis 55 Page | 55 Chronic kidney disease progressive, irreversible deterioration in renal function d/t HTN, DM, glomerulopathy, mephritis, polycystic disease, congenital. s/s: pulm edema, HTN, hyperkalemia, lethargy, hyperlipidemia, glucose intolerance, water retention, metabolic acidosis, hyperkalemia, hypocalcemia, hypermagnesemia, hypophosphatemia, anorexia, n/v, gastric ulcerations, hemorrhage, anemia,hyperpigmentation, ecchymosis) Labs: elevated BUN, Cr Phosphorus. Rx: meds for hypertension, statins, epoetin, diuretics, calcium, LOW protein, low salt, restrict K, phosphorus (no chicken, milk, legumes, carbonated drinks), dialysis. Nursing: assess fistula for thrill and bruit, edema STD Chlamydia: most common, "silent epidemic" d/t most don't know they are infected, s/s: abd pain, burning w/ urination, discharge. Rx: azithromycin, doxycycline, newborns=prophylactic erythromycin eye ointment. Prognosis 95% cured after abx, may lead to PID, ectopic preg, infertility. Nursing: screen yearly, safe sex Gonorrhea: oldest known STD, s/s: itching, burning vagina, thick yellow-green discharge, bleeding between periods, urinary frequency, sore throat, rectal pain/discharge. Rx: cephalosporins (Rocephin) 99% cure w/ abx, -newborns can cause blindness if untreated. Nurisng: regular pap Syphilis: chronic STD "great imposter" 4 stages: primary phase: sore (chancre), secondary phase 4-10 wks (flu-like symptoms), dormant phase 1 yr+ after first chancre w/ relapses, tertiary phase 4-20 years after, may have lesions, cv findings, neuro findings. Rx: tetracyclines/doxycycline, prognosis in the first 2 stages cured w/abx, poor outcomes in the tertiary phase. Nursing: follow up testing HSV: clustered painful vesicles, can be reactivated w/stress, infection pregnancy, sunburn. Rx: acyclovir. Prognosis: lifelong viral infection. Preg=c-section, fatal to newborn. Nursing: avoid tight clothing, apply ice packs to reduce pain and swelling Genital warts: highly contagious, HPV, flesh colored/ grey growths around genitals/rectum, painless, itching, discharge. Rx: vaccine Gardasil, cryotherapy, topical. No cure/treatment. HPV: d/t hepatitis B virus, more infectious than HIV, incubation period 6wks-6months. ½ have no s/s. s/s: fatigue, n/v, itching, pain, jaundice, dark urine, pale-colored stools. Rx: vaccination. Nursing: do not share toothbrush, razor, cover open cuts, clean blood spills with bleach 56 Page | 56 HIV multi-year chronic illness, depletes CD4 lymphocytes, when below 200=AIDS (opportunistic infections pneumonia, toxoplasma, TB) transferred in bodily fluids (blood, semen, vaginal secretions, breast milk) into mucous membrane/injection. s/s: varies, can be w/o for 10 years, fatigue, weight loss, fevers, skin rashes, short-term memory loss, herpes sores, sob, seizures, Kaposi sarcoma (malignant tumor on endothelium of heart, skin), screen with ELISA, PCR. No known cure, antivirals, HAART, HIV is a reportable disease to CDC. Nursing: standard precautions, dies high cal and protein, low residue Hypothyroidism autoimmune, s/s: constipation, sensitivity to cold, fatigue, heavy periods, pain, dry skin, depression, thin hair/nails, weight gain, puffy face/hands/feet, slow speech, thick skin. TSH ^, T3/T4 decreased. Nursing: take synthroid in the morning on empty stomach, drink 8 oz of water, watch for cardiac dysrhythmias, do not change brands of thyroid meds, lifelong therapy myxedema crisis - EMERGENCY (coma, below body temp, decreased breathing, low BP, low BS, unresponsive) hypothyroidism Hyperthyroid s/s: fatigue, hyperphagia, weight loss, diarrhea, goiter, exophthalmos, tachycardia, palpitation, thin hair, insomnia, T3/T4 elevated, TSH decreased. Rx: tapazole, BB, radioactive iodine 57 Page | 57 thyroid storm - EMERGENCY (agitation, confusion, diarrhea, increased body temp, tachycardia, restlessness, shaking, sweating) hyperthyroid Hypoparathyroid injury s/s: irritability, weakness, numbness, tetany, seizures, hair loss, +Chvostek/Trousseau. Rx: calcium. Nursing: monitor tetany, airway, seizure precautions, keep calcium gluconate at bedside if ^present, teach: consume more calcium and get vit D from sun, reduce phosphorus intake (fish, eggs, cheese) Hyperparathyroidism GI upset, constipation, pathological fractures, kidney stones d/t ^calcium levels, blurred vision (d/t cataracts) weakness, depression→ moans, groans, stones, bones, and psychic overtones Rx: drink more fluids, mobility, diet rich in calcium Addisons HYPO aldosterone/cortisol, autoimmune, s/s: ha, weakness, confusion, lethargy, HYPOtension, HYPOglycemia hyperkalemia,/hypercalcemia, dark skin, Rx: give steroids, diet high in protein, carbs, sodium. Addisonian crisis-EMERGENCY-circulatory collapse, IV steroids. Nursing: 60 Page | 60 contusions bleeding under skin/ecchymosis. Rx: 24-48hrs ice 15mins 3x a day, wrap, heat if needed, should heal in 7-10 days, color changes from blue-yellow in 3-5 days strain stretched muscle 1st degree: tenderness, RICE, NSAID 2nd degree: muscle spasm, ROM causes pain, edema. RICE, NSAID, PT 3rd degree: snapping/burning, edema, cannot move. RICE, NSAID, muscle relaxant, PT (rest-ice-comression-elevation) sprain greater than strain on ligament. 1st degree: Compress, RICE 2nd degree: ½ torn, splint, immobilize, RICE (alternate ice/heat) analgesics, PT 3rd degree: torn completely, severe edema, pain, loss of function, casting, sx (rest-ice-comression-elevation) fracture 61 Page | 61 complete: bone broken in 2+ pieces incomplete: bone still in one piece open: compound, bone through skin close: does not break skin linear: parallel to bone oblique: d/t twisting, diagonal spiral: diagonal all they way up transverse: common pathological, across bone avulsion: bone fragments comminuted: splintered fragments w/tissue injury compression: lumbar squish greenstick: children d/t more pliable bones, bone bends impacted: telescoped, bone into bone stress: incomplete d/t repetitive trauma traction skin: 5-7 pounds- to immobilize and alleviate muscle spasms (Bucks/Donlops/Bryants) weights attached w/tape, cuffs skeletal: pins inserted, 25-40 pounds TRACTION: temp ropes hang freely alignment circulation type/location of fx increase fluids overbed trapeze no weights on bed/floor nursing circulation/fracture assessment 62 Page | 62 6 P's pain-pulse-pallor-paresthia-paralysis-pressure/poikilothermia (temp of limb same as the body) Osteoarthritis more white people, degeneration of cartilage, weight-bearing joints, stiffness w/ rest, pain relieved w/ rest Chondromalacia patellae: progressive, degenerative softening of the bone- progressive exercise routine to strengthen muscles will help normalize the patella Rheumatoid arthritis chronic inflammatory disease of the connective tissue, starts in feet/hands w/gradual irreversible destruction, bilateral, autoimmune disorder, ulnar deviation, swan-neck deformity of fingers, foot drop, spinal cord compression. Rx: NSAIDS, Paquenil, immunosuppressive, steroids, rest, weight reduction, calcium supplements SLE chronic, systemic, inflammatory disease of collagen tissues, more in women, AA, Hispanics, Asians. Dx w/ 4 or more s/s: arthritis, butterfly rash over cheeks and nose, skin lesions, photosensitivity, oral ulcers, pleurisy, proteinuria, seizures, anemia. Rx: control symptoms, NSAIDS, steroids, antimalarial drugs. Nursing: pain management, rest periods, skin protection in the sun 65 Page | 65 Amputation phantom limb pain may occur up to 3 months post-op, most common AKA, pain relief: stump desensitization, TENS, Preventing contractures BKA: lie supine with leg extended 20-30 mins 3-4 times a day, AKA: prone, extended 20-30 mins 3-4x day External fixation monitor neurovascular q2hrs, elevated to reduce edema, assess pin sites for infection, daily pin care, isometric exercise. No alcohol/iodine- these cause corrosion of the pins. Clean with hydrogen peroxide or betadine compartment syndrome Condition in which pressure increases in a confined anatomical space, leading to decreased blood flow, ischemia, and dysfunction of these tissues. Initial ischemia with pain, pallor, paresthesia, muscle weakness, and loss of pulses may progress to necrosis and permanent muscle cell dysfunction. Neuromuscular blocking agents succinylcholine-rapid intubation, resp depression, malignancy hyperthermia. Nursing: remain at bedside, keep emergency equip near, teaching about muscle pain, temp paralysis 66 Page | 66 Skeletal muscle relaxers cyclobenzaprine/Flexeril: muscle spasm, high risk Beers (elderly) d/t anticholinergic/sedation effects. Contra: heart block, HF. Nursing: collaborate with PT, avoid abrupt withdrawal, fluids/fiber Ibuprofen (Advil) max dose 3200mg/day, give w/ food NSAID inhibits prostaglandins, anti-inflammatory. AF: bleeding, HTN, GI bleeding. Contra: HTN, bleeding disorders, recent sx. Nursing: CBC, liver enzymes, avoid OTC, do not crush/chew. Celebrex black box CV and GI bleeding. Nursing: take with 8oz of water/milk w/food, Avoid ASA or other NSAIDS ASA used for analgesia, inflammation, fever, decrease TIA/MI. AF: tinnitus, GI bleeding, anemia. Contra in bleeding disorders, ETOH use, Reye's syndrome in children w/viral infections. Nursing: increase anticoags. Chelating agent 67 Page | 67 (Cuprimine) prevents stone formation, related to pcn. Used in RA, biliary cirrhosis. AE: anemia, thrombocytopenia. Nursing: CBC, UA, monitor lymph nodes, give on empty stomach, take temp at bedtime Anti-gout inhibits reabsorption of uric acid. AE: anemia. Nursing: purine-restricted diet (high carbs, low protein, avoid: sardines, beer, yeast, organ meats, beans, meats, mushrooms, spinach), avoid NSAIDS, drink 3L day, avoid caffeine Calcitonin decrease serum calcium and increase bone density. Used in Paget's disease, osteoporosis. AF: bronchospasm, angioedema. Nursing: keep calcium gluconate avail if hypocalcemia=tetany. Teach: weight bearing exercise daily and ca/vit d rich foods Bisphosphonates Fosamax: inhibit bone resorption used in osteoporosis. AE: dysphagia, esophageal ulcer. Nursing: take 1st thing in the morning w/o food, 8oz of water, remain upright for 30mins after taking, if dose missed- skip nursing process ADPIE Assessment: 1st step, subjective and objective data Diagnosis: analysis, formulation of nursing diagnosis Planning: prioritizing problems, determining goals, plan of care Implementation: nursing action (rather than medical action) Evaluating: comparing outcomes, communicate and document findings 70 Page | 70 3rd trimester 27-40wks kick counts (10 in 2 hrs, 3x per hr) NST 32-34wks, (reactive good= accelerate 15 beats for 15 seconds) BPP: breathing movement, limb movement, tone/flex limbs, AFI (fluid pockets), reactive NST= 8-10 desired 32wks: increased chance of survival 36wks: lanugo disappears, grp B strep 40wks: full term PKU Guthrie Bacterial Inhibition test mandated, best after baby eats 2 full days/48hrs, delayed if less than 5 pounds, + req dietary control to prevent brain damage, test identifies an inherited disease, urine test 6wks signs of labor S/s labor: lightening, bloody show, Braxton-hicks, burst of energy, backache True labor: contractions regular and continue, increase in strength, start lower back and move to front, effacement False labor: contractions irregular and sporadic, get weak, only in the front, no cervical changes stages of labor 1st: dilating stage 3 phases: Latent (0-3cm) Active (4-7cm) Traditional (8-10cm w/ urge to push) 2nd stage: delivery 3rd: placental delivery 4th: recovery- primary goal to prevent hemorrhage from uterine atony, 1st void within 1 hour and then q2-3 hrs, Rhogam 71 Page | 71 postpartum assessment BUBBLE-LEB—fever +100.4 B= breast U= uterus(firm or boggy) location (deviated=go to bathroom) descends 1cm a day until day 10, At umbilicus after birth, 1 finger above day 1, nonpalpable day 10 B= bladder (palpable?) B= bowels (last BM) L= lochia: rubra (1-3 days) serosa (3-7 days) alba (day 10) E= episiotomy or incision: REEDA (redness-edema-ecchymosis-discharge-approximation) L= legs (Homans) pain/pulses/sensation/movement E= emotions B= bonding "taking in" gazing, holding, calling baby by name FHR 120-160 for full term. FHR decreases during contractions but should return after VEAL-CHOP V: variable decels C: cord compression Reposition, O2, notify dr E: early decels H: head compression Normal A: accels O: okay L: late decels P: placental deficiency Turn, O2, d/c Pitocin, notify dr 72 Page | 72 newborn assessment Temp 97.9-99.7, HR 110-160 BP 50-75 RR 30-60 glucose 40-60 bilirubin elevated:10 (preterm) 15 (full term) 1st void and stool within 24 hrs Caput succedaneum scalp swelling d/t delivery-no Rx needed, resolves in a few days Cephalohematoma hemorrhage between skull-periosteum, may develop jaundice, hypotension- takes weeks to resolve newborn cold stress Hypothermia and cold stress cause a variety of physiologic stresses including: increased oxygen consumption, metabolic acidosis, hypoglycemia, tachypnea and decreased cardiac output 75 Page | 75 ear exam 3+ adult auricle UP/back peds auricle DOWN/back Tympanic membrane: translucent, shiny, light gray, taut, say "ah"=intact/vibrates Hearing: whisper, Weber (bone conduction=top of head), Rinne (sound conduction=mastoid bone) Geriatrics: ear lobes pendulous, presbycusis at 50, slowly progressive hair pediculosis capitis (lice): whitish oval specks sticking to hair shaft • Tinea capitis (ringworm): oval pattern of hair loss Heart APE to MAN aortic-pulmonic-erb's-tricuspid-mitral), apical 4/5th ICS, pulse deficit=apical ^radial • S1: closing mitral valve, heard at apex/ S2: closing aortic valve, heard over aorta • Murmur: d/t turbulent blood flow, graded 1-6 (loudest/thrill) • Pulse: strength: 0 (absent), 1+weak/thready, 2+ normal, 3+ bounding lung sounds 76 Page | 76 AP ratio 1:2/barrel chest 1:1, peds: smaller airway • Cheyne-stokes: alter apnea/tachypnea, Kussmauls= deep labored met acidosis, Biot: quick/shallow • Crackles/rales: inflammation/infection/fluid/ARDS-CHF-atelectasis-pneumoia-fibrosis • Pleural friction rub: grating, inflammation/pleurisy (DDX: pericardial friction rub=hold breath) • Rhonchi: lower wheeze/pneumonia • Stridor: high-pitched/upper airway obstruction/tonsillar abscess/injury/croup/foreign object • Wheeze: whistle/asthma/bronchitis/COPD/narrow airway • Whispered pectoriloquy: "99" resonance/lung consolidation/pneumothorax/pleural effusion breast assessment common benign causes of lumps: fibroadenoma, cystic breast changes Abdomen assessment Auscultate first: bowel sounds 5-30 times per min, start RLQ (sounds=no obstruction above) • Renal artery=bruit, percussion: tympany= stomach/intestines, dullness=liver, spleen, pancreas • Distention, ascites, paralytic ileus, borborygmus (grumbling), guarding neuro assessment MSE, cranial nerves, LOC, Glasgow, sensory, motor Therapeutic communication 77 Page | 77 acceptance, listening, empathy, silence, eye contact, clarification, restating, open-ended, focusing Aphasia global: most severe (cannot read, write, understand speech), Broca's (broken language/understands) Wernicke's (jargon) Anxiety disorders excessive fear may be w/ depression and substance abuse. s/s: worry +6 months, fears stronger than appropriate, prob concentrating, fatigue, irritability, sleep, GI, SOB Rx: talk therapy, Antidepressants: Prozac, Wellbutrin, tricyclic (Tofranil) MAOI: PaNaMa (Parnate-Nardil- Marplan) anti-anxiety: Buspar, Betablockers(propranolol), benzos (-zepam), stress/relaxation techniques nursing: non-demanding environment, do not force, distract, identify triggers, encourage responsabiltiy Bipolar disorder depression/mania, changes Types: I (severe), II, cyclothymic (more depression) Rx: mood stablizers (Lithium 0.8-1.2, tox s/s: n/v, diarrhea, drowsy, weakness, tremor, blurred vision, tinnitus), anticonvulsants (Depakote) antidepressants (Prozac), atypical antipsychotics (Abilify), ECT safe and effective for depression, triggers seizure, confusion/temp memory loss expected side effect Nursing: mania: high protein/cal finger food, supplements, set limits, reduce stim. Depression SIGECAPS (sleep-interest-guilt-energy-concentraion-appetit-psychomotor-suicide) Rx: antidepressants: therapeutic effects may take up to 8 wks, ECT 80 Page | 80 Feeding tubes complications= aspiration, diarrhea, electrolyte imbalances nursing: HOB 30˚ to prevent aspiration 1.5-2 hrs after feeding placement: x-ray, aspirate gastric contents (pH acidic), no longer accepted to inject air and listen bag and tubing change q 24 hrs no more than 300ml per hr to prevent F&E changes check residual q 4 hrs if continuous or prior to intermittent, if residual greater then 100-150ml hold feedings reinsert residual to prevent metabolic alkalosis, flush tube with 30-60 ml water after feeding Measures to improve intake: small frequent meals, adequate dentition, feeding assistance, offering preferred foods, ethnic foods injections Interdermal: TB test, 25-27 g 15˚ angle Sub Q: 21g, 45˚ angle, no aspiration required, back of arm, belly, lower back fat IM: 90˚ ventrogluteal ("V" at hip), vastus lateralis, (outer thigh, children) deltoid (1-2" below acromion) central lines Nontunneled central lines: ^risk for infections, directly into a superior vena cava, can be done at the bedside, lasts <1 month Pt in trendelenburg w/ towel between shoulder blades, "bear down" to increase venous pressure (prevents air) Dressing changes w/aseptic technique Tunneled: inserted into central vein w/ remainder tunneled sub Q to distant site, done in OR/IR, lasts months-yrs 81 Page | 81 PICC PICC: longer then PIV, arm→ends in superior vena cava, at bedside, need CXR to confirm placement, lasts 1yr+, flush unused ports w/ heparin. The rapid push-pause flush technique involves rapid instillation of 1-2 mL of flush with each push of the plunger. This technique creates turbulence, which decreases the adherence of fibrin and platelets to the lumen wall and prevents occlusion. To avoid excess pressure on the catheter, a syringe barrel of at least 10 mL should be used to flush a PICC. The plunger should not be fully depressed when it's removed from the PICC because this creates negative pressure, resulting in a reflux of blood into the catheter lumen and possible thrombus formation. IV solutions Isotonic: solution remains in extracellular space and increases volume (0.9 NS, LR, D5W Hypotonic: into cell- shift from intravascular→intracellular, DKA/HHMS (0.45NaCl, D2.5W) Hypertonic: out of cell water from intracellular→extracellular increases volume, cerebral edema (3%NaCl, D10W) 5 rights of med administration right pt, right dose, right time, right route, right drug Antihypertensive assess: vasodilators, CNS depressants, take bp and pulse daily, no caffeine, alcohol 82 Page | 82 Anticholinergic assess: sips of water, frequent oral care, stand assist Anticoagulants assess: min invasive proceudres, no shaving, gentle tooth brush, avoid NSAIDS, alcohol, vit K Antidystrhythmics assess: PFT, ECG, bp, electrolytes, LOC Antiinfectives: assess: obtain cultures before administration, nephroptoxic/hepatotoxic, renal function test, jaundice, n/v Loop diuretics assess: circulatory collapse, ototoxicity, verify UO before giving, monitor F&E, edema, bp Female hormones assess: thromboembolic disorders, ^ breast ca, edema, perfusion TPN hyperalimentation (artificial supply of nutrients) for pts that cannot use GI tract for absorption Infuses via central venous catheter Get labs: BUN, Cr, liver enzymes, pH, BS once per shift: 85 Page | 85 blocks factor X. Assess PTT, have double RN check, Antidote: protamine sulfate. AE: hemorrhage, thrombocytopenia (low platelet), HIT ACE inhibitors -pril: HTN, HF. AD: angioedema, cough, hypotension, hyperkalemia, hepatotoxicity, neutropenia, agranulocytosis, pancreatitis, SJS. Contra: pregnancy. Nursing: empty stomach, monitor for infection, dry cough, use contraception (teratogenic), avoid sports drinks/salt substitutes (extra K) ARB -sartan: HTN, HF. AE: angioedema, hypotension, hyperkalemia, renal impairment. Contra: pregnancy. Nursing: may take with food, take with full glass of water calcium channel blockers -dipine: HTN, angina, arrhythmias. AE: hepatotoxicity, paralytic ileus, HF, AV block. CONTRA: A-FIB/FLUTTER, SSS, cardiogenic shock. Nursing: BUN/Cr, liver enzymes. Avoid: grapefruit juice, in older=constipation beta blockers -olol: slow HR, decrease vasoconstriction, decrease O2 consumption. Used in: HF, HTN, HR control, angina, migraine. AE: HF, bronchospasm, dizzy, constipation, suppresses hypoglycemia indicators. 86 Page | 86 Contra: asthma, bradycardia, SSS. Nursing: check HR before giving. Teach: take med at bedtime, do not stop abruptly. Propranolol=essential tremors, Parkinsons Vasopressor Å and ß: Dopamine/Levophed/Epinephrine: ^HR/BP, ACLS, CO, shock, refractory HF. AE: pulm edema, arrhythmias, HTN, cerebral hemorrhage. Antidote for extravasation: Regitine ß: Dobutamine: ^CO/BP. Used in HF. AE: seizures, cardiac arrest, bronchospasm, restlessness, tremor. Nursing: monitor BP and HR q15 mins Vasodilators Persantine adjunct thromboembolism prevention. AE: bronchospasm, MI. Teach: avoid ETOH, report bruising cardiac conduction SA node: "pacemaker" intrinsic rate 100 bpm AV node: 40-60 bpm Bundle branch/purkinje: 20-40 bpm Hemophilia bleeding disorder, sex linked, s/s: prolonged bleeding. Nursing: prevent bleeding/falls, brush teeth with soft toothbrush. Genetic counseling for parents 87 Page | 87 Anemia aplastic=not producing RBC, congenital/pregnancy, hepatits. s/s: petechiae, bruising, fatigue, ha. Rx: steroids, abx, Nursing: hemorrhage precautions Antitubercular AE: hepatotoxicity, agranulocytosis, aplastic anemia, optic neuritis, neuropathy, psychosis. Nursing: Cr, liver enzymes, eradicated after 3 - sputum cultures, Avoid ETOH, tyramine, take vit B6 for neuropathy, duration of therapy months to years 1st line: isoniazid: daily for 6-18 months. Hepatotoxic. Nursing: take on empty stomach 1st line: rifampin: daily 4-6 months. Red-orange body fluids, ^ALT/AST. Nursing: no contacts 1st line ethambutol: contra optic neuritis. Nursing: eye exam regularly 1st line: streptomycin: IM q24hrs 5-7 times weekly 2nd line: ethionamide: metallic taste, take w/food Bronchodilators AE: adrenal suppression, hyperglycemia, ha, infection. Nursing: small freq meals, take before other inhaled meds, 30-60mins before exercise. LABA has to be paired with steroid d/t black box warning Theophylline: stims CNS. Nursing: narrow therapeutic range 5-15, toxic >20, avoid caffeine Anticholinergic: Atrovent: AE: angioedema, glaucoma, bronchospasm. Nursing: not for rescue, rinse mouth Mucolytics Acetylcysteine: thins resp secretions/mobilizes secretions. Used in trach care, CF, acetaminophen overdose. Contra: asthma, inadequate cough. Nursing: combine w/ ambulation, cough, and deep breathing 90 Page | 90 Sarcoidosis granulomas in lungs, more in AA, s/s: dyspnea, cough, chest pain Rx: steroids. Nursing: prevent infections, take rest periods, O2, small frequent meals, activity w/ tolerance Nursing: chest tube ensure chest tube drainage system is closed, no leaks, connections are taped, no kinks, monitor volume (notify Dr if +100ml/hr and/or sudden bright read, free flowing drainage, keep collection device below chest level/insertion, fluctuation of water level is expected, do not strip tubing, occlusive dressing prevents air from entering pleural space, BUBBLING=AIR LEAK Pneumothorax lung collapse, high pressure causes mediastinal/tracheal shift AWAY from affected side compressing the heart and preventing adequate CO, results in cardiac tamponade. Rx: chest tube Pneumonia d/t infection, inflammation, pseudomonas, aspiration, leading cause of death from infectious causes. s/s: fever, chills, malaise, sob, decreased sat, productive cough, pleurisy chest pain, crackles, egophony/whispered pectoriloquy (indicating consolidation), older adult=confusion, infants=lethargy, irritability, poor appetite. 91 Page | 91 Rx: abx, analgesic, expectorants, antitussives, resp support as needed. Nursing: promote hydration to liquefy secretions, teach improvement after 48-72 hrs of abx, get vaccine TB chronic infection d/t acid-fast bacillus d/t inhalation/ingestion of infected droplets, dormant-later reactivating, increased prevalence in AIDS. s/s: weakness, fatigue, anorexia, weight loss, night sweats, chest pain, productive cough (blood). Cxr: "coin" calcified lesions. TB test: Mantoux skin test positive if >10mm Rx: long term 6-24 months isoniazid, rifampin, ethambutol, high carb-high protein diet w/ small frequent meals, reportable disease. Nursing: airborne precautions, negative flow room, N95 mask, visitior wear surgical masks, obtain sputum specimen early in morning for dx, no OTC, no contacts w/rifampin (red- orange), adherence, increase B6 SARS d/t coronavirus, infection via direct contact. s/s: fever, aches, dry cough, dyspnea. Rx: droplet precautions, report to CDC, supportive care. Nursing: monitor for pneumonia, frequent hand washing, pt should wear a mask PE embolism-blood clot/air/fat/amniotic that blocks arteries that feed the lung=pulm infarction and decreased CO, pt breathing but no gas exchange, hypoxemia, can be fatal, d/t prolonged immobility, poor hydration, a-fib, fat embolism w/in 24 hrs after fracture. s/s: sudden onset of dyspnea, cough, low sat, pleurisy chest pain, anxiety "impending doom" cough, tachycardia, tachypnea. Rx: O2, anticoags, thrombolytic. Nursing: early ambulation, compression stockings to prevent ARDS 92 Page | 92 acute lung injury, inflammation, damage to alveoli, non-cardiac pulm edema. s/s: restless, anxiety, low sat, dyspnea, tachypnea, resp failure, tachycardia, cyanosis, retractions, frothy sputum, clear-then crackles, white out CXR. Hypoxemia/hypercapnia. Nursing: abx, vent, ECMO, sedation, steroids, fluid restriction, frequent position changes, ROM, monitor O2 trends, behavioral changes Cor pulmonale R HF d/t sustained lung resistance in COPD, dilation/hypertrophy d/t increased PVR. s/s: fatigue, tachypnea, cough, chest pain, hemoptysis, syncope. Nursing: O2, frequent rest periods, meds: dig, diuretics, restrict fluids, pace activities respiratory failure lungs cannot maintain arterial oxygen levels, or eliminate CO2, d/t disease. s/s: PaCO2/PaO2 50/50, hypoxemic, hypercarbic, hypoventilation, EMERGENCY, O2, cpap, intubation, vent Huntingtons progressive atrophy of basal ganglia, genetic, progressive decline in cognitive function. Rx: psychotropics Nursing: foster independence in ADLs, teach nutrition, increase cal intake, support group ADPIE • Assessment: 1st step, subjective and objective data • Diagnosis: analysis, formulation of nursing diagnosis 95 Page | 95 Chain of infection agent →reservoir (people, equip) → portal of exit (droplets, excretions) → transmission route (airborne, direct, ingestion→ portal of entry (broken skin, GI tract, resp tract, mucous membranes) → susceptible host (burns, CVD, DM, sx, immunosuppression) Medical asepsis/surgical asepsis Medical asepsis: "clean technique" to reduce to # and spread of microorgs (handwashing, no nail polish, disinfectants, PPE) Surgical asepsis: "sterile technique" destroys all microorgs and spores, skin cannot be sterile, hands above elbows, no reaching over sterile field, 1-2 inch edges are contaminated (if questionable, out of range of vision, below waist, wet, prolonged exposure to air): Used in: care of sx wounds, some dressing changes, Catheterizations, Trach care, Suctioning, sx Standard precautions all pts (except sweat) to prevent spread of orgs, PPE: gloves, masks, gowns, goggles, head covering Contact precautions VRE, C-Diff (wash with water and soap), MRSA, gown and gloves, close door Droplet precautions respiratory, 3 ft or less, first 24˚ strep, viruses, Neisseria, meningitis, pertussis 96 Page | 96 Airborne precautions in air over long distances, N95 respirator, MTV (measles, tb, varicella) Neutropenic precautions immunocompromised, strict hand washing, private room, no raw veggies/fruits, daily baths, visitors are restricted Emergency preparedness o Mitigation: actions to prevent the occurrence, awareness o Preparedness: plans for rescue, evacuation, training, gathering resources, inventory of supplies o Response: putting disaster plan services into action, safety, physical/mental health of pts o Recovery: actions taken to return to normal situation • Have: flashlight, supply of batteries, battery operated radio, extra pair of eyeglasses Emergency triage o Emergent-Red-highest: trauma, chest pain, resp distress, cardiac arrest, amputations, acute neuro deficits, chem to eye o Urgent-Yellow-complications that are not life-threatening, treatment w/in 1-2 hrs-fx, fever, abd pain o Nonurgent-Green-can wait several hrs: lacerations, sprains, cold symptoms o Black- dead or soon will be, cannot benefit from care d/t severity of injuries Findings of pregnancy o Presumptive/possible: subjective, amenorrhea, n/v o Probable: objective, chadwicks, hegar's, goodell's, ballottement, Braxton hicks o Positive: presence of fetus, heart tones, visualization of fetus, palpating fetal movements 97 Page | 97 Naegeles rule add 7 days to LMP, subtract 3 months, add 1 year levels of prevention Primary: prevent/promotion Secondary: screen-early detection Tertiary: treat- to prevent further deterioration, rehab history of present illness (HPI) OLDCARTS (onset-location-duration-character-allieving/aggravating-time-severity) General health status PMH, FMH, social history, occupation, sleep pattern, nutrition, meds, OTC, CAM, psych Percussion Percussion: dull=solid, flat=muscle, hyperresonance=trapped air, resonance=lungs, tympany=air/stomach ear earache, discharge, tinnitus, vertigo, adult auricle UP/back, peds auricle DOWN/back Tympanic membrane: translucent, shiny, light gray, taut, say "ah"=intact/vibrates Hearing: whisper, Weber (bone conduction=top of head), Rinne (sound conduction=mastoid bone) Geriatrics: ear lobes pendulous, presbycusis at 50, slowly progressive