NCLEX RN Study Guide: Common Symptoms and Treatments, Exams of Nursing

Download NCLEX RN Study Guide: Common Symptoms and Treatments and more Exams Nursing in PDF only on Docsity! 1 1 Evaluate Assess Teach Don’t delegate Unstable patients Initial Assessment, Teaching, IV drips, Evaluations only RN AIRBORNE TRANSMISSION-BASED PRECAUTIONS: MTV Measles TB Varicella-Chicken Pox/Herpes Zoster-Shingles Private Room: Negative pressure with 6-12 air exchanges/hr Mask: N95 for TB DROPLET TRANSMISSION-BASED PRECAUTIONS: Think of SPIDERMAN! Sepsis Scarlet fever Streptococcal Pharyngitis (Streptococcus group A/ Strep Throat): Can Lead to Glomerulonephritis & Rheumatic Parvovirus B19 Fever. Pneumonia Pertussis Influenza/ Haemophilus influenza type B 2 NCLEX RN STUDY GUIDE DO NOT DELEGATE WHAT YOU CAN EAT! 2 2 Diphtheria (Pharyngeal): Serious bacterial infection. Epiglottitis: Medial Emergency! No Throat Inspection. Rubella/ German measles 5 5 2 NCLEX RN STUDY GUIDE /S: Fever, Cough, SOB, and Death. The Incubation Period is 5-6 days but can range from 2-14 days. CDC: Standard (Gloves), Contact (Gown), Eye Protection (Goggles), Airborne Precautions (N95) Negative room: Negative disease (TB, Disseminated Herpes Zoster) Positive room: Protect the Patient (HIV, Cancer) Addison’s= hyponatremia, hypotension, decreased blood vol, hypoglycemia, hyperKalemia, HyperCalcemia. Cushing’s= HyperNatremia, HyperTension, Incr. Blood Vol, HyperGlycemia, hypokalemia, hypocalcemia. Managing Stress in a patient with Adrenal Insufficiency (Addison’s) is paramount, because if the Adrenal glands are stressed further it could result in Addisonian Crisis. Addison’s: Remember BP is the most Important assessment parameter, as it causes Severe Hypotension. Addison’s: (need to "add" hormone): Hypoglycemia, Dark pigmentation, Decr. Resistance to Stress, fractures, Alopecia, Weight Loss, GI distress. Vitiligo. Mood swings (Normal) Need to Report S/S of Infection/ Fever (Addisonian Crisis) Tx: Mineral Corticoids. Addisonian Crisis: Hypoglycemia, Confusion, n/v, Abd Pain, Extreme Weakness, Dehydration, Decr. BP. Cushings: (have extra "Cushion" of Hormones): Hyperglycemia, prone to Infection, Muscle Wasting, Weakness, Edema, HTN, Hirsutism, Moonfaced/Buffalo Hump Cause: Excessive production of Corticotropin (Hyperplasia of the Adrenal Cortex) & Cortisol-secreting Adrenal Tumor. Prednisone Toxicity: Cushing’s syndrome- Buffalo Hump, Moon face, Hyperglycemia, Hypertension. 6 6 Acetaminophen: 10-20. Max 4000mg per day. Acetaminophen Poisoning: Possible Liver Failure for about 4 days. Close observation required. Tx: (Antidote) n-AcetylCysteine/Mucomyst 7 7 NCLEX RN STUDY GUIDE (ASA): Metabolic Acidosis. S/S: Tinnitus, Coffee Ground Emesis (Old Blood), Black tarry stools (Melena), Bruising, Tachycardia, Hypotension, GI Ulcers. Tx: Activated Charcoal, then IV Na+ Carbonate. Acromegaly: Coarse Facial feature. Assess Cardiac Problems (eg. S3, S4). Acute Respiratory Distress Syndrome (ARDS): The 1st Sign is Incr. Respirations. Later comes Dyspnea, Retractions, Air Hunger, Cyanosis. Cardinal sign is Hypoxemia (Low O2 level in tissues). Refractory Hypoxemia is the hallmark of ARDS, a progressive form of acute respiratory failure that has a high Mortality rate. It can develop following a Pulmonary Insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the Lung. The Inability to improve Oxygenation With Incr. in O2 concentration. The insult triggers a Massive Inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a Noncardiogenic Pulmonary Edema. The lungs become Stiff and Noncompliant, which makes Ventilation and Oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. ARDS (fluids in alveoli), DIC (Disseminated Intravascular Coagulation) are always Secondary to something else (another disease process). – Impaired Gas Exchange. PreOxygenated with 100% O2, and Suction should be applied for no more than 10 seconds to prevent hypoxia. The nurse must wait 1-2 minutes between passes to ventilate to prevent hypoxia. 2 AcetylSalicyclic Acid 10 10 Amyotrophic Lateral Sclerosis (ALS): a condition in which there is a Progressive, Degeneration of Motor Neurons in both the Upper & Lower Motor Neuron systems. Upper Motor Neuron issue: Hyper Reflexes Lower Motor Neuron issure: Absent Reflexes 11 11 2 NCLEX RN STUDY GUIDE /S: Limb weakness, Dysarthria (difficulty speaking), and Dysphagia. Iron: IM: should be given Z-track so they don't leak into SQ tissues IV: Iron Dextran (Imferon). Can cause hypersensitivity reaction (anaphylaxis), test dose needs to be given First. PO: give with Vitamin C or on an Empty stomach or Btw Meals. Place it on the back of the Month (Stain teeth). Expect Black/Green Tarry Stools. Take iron elixir with juice or water .... Never with milk (Vit D). Iron Poisoning: GI Bleed. Antidote: Deferoxamine Iron Deficiency Anemia: Microcytic anemia. S/S: Fatigue, Pallor, Fissures at the corner of the mouth, Spooning of the fingernail, Reduced exercise tolerance Thalassemia Major (Cooley’s Anemia): Microcytic anemia. S/S: Maxillary Hyperplasia, Frontal Bossing. Caused by: Defects in both Beta-chains of the Hgb molecule. Pernicious Anemia: Macrocytic anemia, Lack of required Intrinsic factor (B12 Deficiency) S/S: Pallor, Tachycardia, Sore Red Tongue (Beefy tongue), Enlarged Liver that can lead to R-sided HF. Take Vit. B12 for life. Shilling Test: Test for Pernicious Anemia. How well one absorbs Vit B12 12 12 Folate (Folic Acid) Deficiency: Macrocytic anemia. Risk: Alcoholism or Diet Low in Vegetables. S/S: Stomatitis, Ulcerations on the tongue. Dysphagia, Flatulence, watery Diarrhea 15 15 2 NCLEX RN STUDY GUIDE Penicillin Allergy: No Cephalexin, Cephalosporin. Amphotericin B: (antifungal) causes Hypokalemia. Premeditate Before giving. Pts will most likely get a Fever. Mebendazole: (antiparasite) Take it with High Fat diet (increases absorption). Anticholinergic Effects: Assessment Blocks the action of Acetylcholine (Neurotransmitter), blocks involuntary muscle movement. Many antihistamine (diphenhydramine) have anticholinergic effect. Dry mouth (Xerostomia)- can't spit Urinary retention- can't pee Constipated- can't poop Blurred vision- can't see Decreased Acetylcholine is related to Senile Dementia. Glucagon increases the effects of Oral Anticoagulants (Rivaroxaban). Appendicitis: Pain is in RL quadrant with Rebound Tenderness. Continuous. Guarding. Anorexia. N/V. McBurney’s Point – pain in RLQ indicative of appendicitis. Position on Right side with legs flexed After Appendectomy. Risk for Peritonitis. 16 16 Peritonitis: Mucus in Ileal Conduit is expected. Blumberg’s Sign: Presence of rebound tenderness in the abdomen. Aortic Dissection: Risk Factor: HTN S/S: (Ascending)- Chest Pain, Radiate to the Back 17 17 2 NCLEX RN STUDY GUIDE (Descending)- Abrupt in Onset, “Worst Ever” “Tearing”, Ripping Pain, Moving Back Pain, Epigastric Pain Abdominal Aortic Aneurysm (AAA): Definitive Diagnosis- CT scan. Hypoactive BS for few days after the Surgery. Computed Tomography (CT) Scan: Assess Allergies Osteoarthritis: a Degenerative Disease, causing pain With Activity. Inflammation occurs, but the joint does Not usually become swollen or red. It commonly affects the Larger, weight-bearing joints and affects both genders equally. Rheumatoid Arthritis: causes Pain and Inflammation After periods of rest. It affects the Small joints (like fingers) and is more common in women. Pain is usually the Highest Priority. Heat for Chronic (Rheumatoid Arthritis): Warm Shower/Bath in the Morning. Swimming is the Best. Order of Assessment: Inspection, Palpation, Percussion and Auscultation. Except… Abdomen Assessment: Inspect, Auscultate, Percuss then Palpate (Last, bc it may induce pain) Assessment with Kids: Least invasive to Most invasive. An example of when you would Implement Before going through a bunch of Assessments is when someone is experiencing Anaphylaxis. Get the Ordered Epinephrine in them STAT, especially if they clearly States the S/S (Difficulty Breathing, Increasing Anxiety, etc.) 20 20 Atropine Overdose: Hot as a Hare (Temp), Mad as a Hatter (LOC), Red as a Beet (Flushed face) and Dry as a Bone (Thirsty) ADHD: Inattention, Hyperactivity, Impulsivity. 21 21 2 NCLEX RN STUDY GUIDE ethylphenidate/ Ritalin: Assess for Heart related side effects report immediately. May need a Drug Holiday- it Stunts Growth. Dextroamphetamine: may alter Insulin needs, Avoid taking with MAOI's, take in Morning (Insomnia possible side effect) Atomoxetine: Norepinephrine-Specific Reuptake Inhibitor, and can be used for Depression. Autonomic Dysreflexia/Hyperreflexia: Neuro T6 or above. Life-threatening emergency. Uncompensated SNS stimulation (Inhibited Sympathetic Response) Tigger by: Bladder distention and Bowel impaction S/S: pounding/severe HA, profuse Sweating (Diaphoresis), Nasal Congestion, Bradycardia (30~40), Flushing, Piloerection (goose bumps), Nausea, Seizure, Uncontrolled HTN. Can occur weeks to years after the injury. Tx: Place client in sitting position (Elevate Hob) first before any other implementation. High Fowler’s (90o): assist w/ventilation & prevention of HtN Stroke! Loosen constrictive clothing (Decr. skin stimulation) SBP> 300mmHg. Administer antihypertensive meds (may cause stroke, MI, seizure) Most spinal cord injuries are at the Cervical or Lumbar regions. Spinal Shock occurs Immediately after Spinal Injury Halo: remember Safety First; have a Screwdriver nearby. Myelogram: NPO 4-6hr, allergy hx, Phenothiazine, CNS depressants, and Stimulants withheld 48hr prior, table will be moved to various positions during test. Post: Neuro q2-4, Water Soluble HOB Up. Oil Soluble HOB Down (Lie Flat Supine, to prevent HA, and Leaking of CSF) oral analgesics for HA, encourage PO fluids, assess for Distended Bladder, Inspect Site. 22 22 Benign Prostatic Hyperplasia (BPH): Enlarged Prostate. Reduced size & force of urine. Tamsulosin, Terazosin, Prazosin (Antitensive med): Alpha1 Antagonist: Cause Orthostatic Hypotension & Dizziness. Take it at Bedtime to avoid Syncope and Dizziness or Lightheadedness. 25 25 NCLEX RN STUDY GUIDE Patch the Good eye, so the Weaker eye can get stronger). To relax Vocal Cords in Spasmodic Dysphonia. Bowel Sounds: Normal: High-Pitched, Gurgling sounds. Cardiovascular Bruits: (Swishing, Humming, Buzzing): usually indicate Arterial narrowing (Obstruction) or dilation (Aneurysm). After Surgery, BS are Absent first 24-48 hrs. Return to the Small intestine in 24hr; Large intestine may delayed 3~5 days. Borborygmi Sounds: are Loud, Gurgling sounds suggesting increased Peristalsis (Gastroenteritis, Diarrhea). Obstructed Ileostomy (Bowel Obstruction): S/S: N/V, Abd Distention, Decr. Stool. Ileostomy: Liquid Stool (Bypass the Colon). Low Fiber Diet: White rice, Pasta, Refined grains. Avoid High Fiber (Popcorn, Coconut, Brown Rice, Multigrain bread), Stringy Veg (Celery, Broccoli, Asparagus), Seeds or Pits (Strawberry, Raspberries, Olives), Edible Peels (Apple, Cucumber, Dried fruit). Colon: Fluid & Electrolyte Absorption, Vit K Production. 2 Botox (Botulin Toxin): Used with Strabismus ( 26 26 Don’t Fall for ‘reestablishing a normal bowel pattern’ as a priority with Small Bowel Obstruction. Because the patient Can’t take in oral fluids ‘Maintaining Fluid Balance’ comes First. Small Bowel Follow-Through (SBFT): Sequential X-ray images to visualize the Structure and Function. Barium is Ingested, and X-ray images are taken every 15-60 minutes to visualize the barium as it passes through 27 27 2 NCLEX RN STUDY GUIDE he small intestine. Using this technique, Decreased Motility (eg, Ileus), increased motility (eg, Malabsorption Syndromes), Fistulas, or Obstructions are identified. Fast 8 hours Prior to the examination. The test usually takes 60-120 minutes, but if obstruction or decreased motility is present, it can take longer. Drink plenty of Fluids After the examination to facilitate barium Removal. Chalky stools may be present 24-72 hours after the examination. If brown stools do Not return after 72 hours or abdominal pain or fullness is present, contact the HCP. Burns: Rule of Nines Head and Neck= 9% Each upper ext= 9% Each lower ext= 18% Front trunk= 18% Back trunk= 18% Genitalia= 1% Assess for Smoke Inhalation/ Burns: 1st Degree - Red and Painful 2nd Degree - Blisters 3rd Degree - No Pain because of Blocked and Burned nerves. Tx: High-Flow O2 (100%) to displace CO & Cyanide from hgb. (1st 24 hour): Lactated Ringer’s: 4mL/kg 30 30 Celiac Disease: Barley, Rye, Oats, Wheat. Cephalhematoma (Caput Succinidanium): Resolves on its own in a few days. This is the type of Edema that Crosses the Suture lines. 31 31 NCLEX RN STUDY GUIDE muscle control due to birth injuries and/or Decrease Oxygen to brain tissues. Head Injury: Elevate HOB 30o to Decr. Intracranial Pressure. No Nasotracheal Suctioning with Head Injury or Skull Fracture. Basilar Skull Fracture: Otorrhea (discharge from the external ear) Orbital Fracture: Battles Sign and Raccoons Eyes Cushing Ulcer: Gastric ulcer associated with IICP. (r/t Brain Injury) Mannitol: Head injury Medication (Osmotic Diuretic): Decr. Cerebral Edema, Decr. ICP, Incr. Urine Output Crystallizes at Room Temp so Always use Filter needle. TIA (Transient Ischemic Attack): Mini Stroke with No Dead Brain Tissue. Short period of cerebral Ischemic. S/S: Brief period of Loss of Vision, Hemiparesis and Slurred Speech. CVA (CerebroVascular Accident): with Dead Brain Tissue. Permanent Deficits. Horner Syndrome. R-CVA: Left-sided hemiplegia, Impulsive, Lack Judgment L-CVA: R-sided hemiplegia, Impairment in Speech and Language. Broca’s area (Frontal): Expressive Aphasia. Wernicke’s area (Parietal/Temporal): Receptive Aphasia. TPA- Aminocaproic Acid Stroke is Not considered Stabilized until approximate 48hr pass without changes. 2 Cerebral Palsy: Poor 32 32 Cerebral Angiogram: Prep: well Hydrated, lie Flat, site Shaved, pulses Marked Post: keep Flat 12-14hr, check Site & Pulses, force Fluids. 35 35 2 NCLEX RN STUDY GUIDE Risk for Endometrial Cancer (Heavy Period) & Thromboembolic Event. Hemovac: used after Mastectomy. Empty when Full or q8hr, remove plug, empty contents, place on flat surface, cleanse opening and plug with Alcohol sponge, compress evacuator completely to remove air, release plug, check system for operation. Don’t place Immunosuppressed pt With Any pt with an Infectious disease or Open wound. Basal Cell Carcinomas: Translucent, Raised, and Smooth. Rarely Metastasize or cause death. Most Common. Squamous Cell Carcinomas: characterized by Local Invasion. Fast Growing and Infrequent Metastasis. They are Red Nodules with Crust or Ulceration. Malignant Melanomas: Appears Black or Brown with Irregular Borders. Often Metastasize. Most Deathly form of Skin Cancer. Least Common. Chest Tube Drainage System: Placed in the Pleural space. If chest tube is dislodged, immediate action should be to apply a Sterile Occlusive Dressing (eg, petroleum jelly dressing) taped on 3 sides. This permits air to escape on exhalation and inhibits air intake on inspiration. Notify the HCP and arrange for the reinsertion of another chest tube. Suction Control Chamber: Set at -20 cm H2O to maintain Negative pressure in the system. Bubbling will occur when suction is applied. Water Seal Chamber of the chest tube drainage system is filled with Sterile water and acts as a One-Way Valve preventing air from entering the client's chest cavity. Tidaling: The water level in the water seal chamber Rises and Falls with Inspiration and Expiration. (Maintaining appropriate Negative pressure/ indicating Proper function of the chest tube drainage system) 36 36 Air Leak Gauge: (part of the Water Seal Chamber) allows for assessment of air leaks. Continuous Bubbling: indicates an Air Leak in the system. Drainage Collection Chamber: which Fluid from the client's Pleural Cavity will collect; the nurse will assess the color and amount and record the output. Sucking Stab Wound: Immediately dress the wound and tape it on Three sides which allows air to Escape. Do not use an occlusive dressing, which could convert the wound from Open pneumo to Closed one. 37 37 2 NCLEX RN STUDY GUIDE ension Pneumothorax: develops when air enters the pleural space but Cannot escape. Increased intrapleural pressure and excessive accumulation of air can apply pressure to the heart and great vessels and drastically decrease cardiac output. An occlusive dressing taped on 4 sides would prevent the air in the pleural space from escaping on exhalation and would increase the risk for a tension pneumothorax. Tension pneumothorax trachea shifts to Opposite side. Tracheal Deviation: Reduce Cardiac Output & Hypotension. After that get your Chest Tube Tray, Labs, IV. Removal: Take a breath and hold it or Bare down by attempting to Exhale through the mouth and nose with your lips held Closed. Cholecystitis: Limit Fatty foods. Fat stimulates the release of Bile form the Gallbladder. N/V, Restlessness, Diaphoresis. Referred to the R Scapula & Epigastric tenderness. Murphy’s Sign: Pain w/ palpation of Gallbladder (RUQ) area. Cholera: Infection of the small intestine by some strains of bacterium Vibrio Cholerae. Acute Diarrheal Disease; Rice Watery Stool. Chronic Obstructive Pulmonary Disease (COPD): the Baroreceptors that detect the CO2 level are destroyed. Therefore, O2 level must be Low bc High O2 Conc. blows the patient’s Stimulus for Breathing. 2L Nasal Cannula or less (Hypoxic Not Hypercapnic drive), PaO2 of ~60 Chronic CO2 retainer: SaO2 90% (Normal) CO2 causes Vasoconstriction. Venti Mask for Distress COPD pt. Tiotropium, Ipratropium, Benztropine. 40 40 Feel (Facial VII) Brother -Bell’s Palsy A (Auditory VIII) Says Girls (Glossopharyngeal IX) Big -Swallowing & Gag reflex Vagina (Vagus X) Bras - Swallowing & Gag reflex 41 41 2 nd (Accessory XI) Matter Hymen (Hypoglassal XII) More NCLEX RN STUDY GUIDE Assessing Extraocular Eye Movements: Check Cranial Nerves 3, 4, and 6. Cystic Fibrosis: Salty Skin. Fatty Stools. Diet: Low Fat, High Sodium, Fat Soluble Vitamins ADEK. Pancreatic Enzymes are taken with each meal. Respiratory Problems are the Chief concern: Treat with Aerosol Bronchodilators, Mucolytic. Cystitis: Burning on Urination. Frequency, Urgency, Suprapubic Discomfort, Hematuria. CytoMegaloVirus: Ganciclovir: For CMV Retinitis. Pt will need regular Eye exams, report Dizziness, Confusion, or Seizures Immediately. DecortiCate: (Flexor) Toward the 'Cord'. Cortex involvement. Problem with Cervical Spinal Tract or Cerebral Hemisphere. DecerEbrate: (Extensor) The Other way (Out). Cerebellar, Brain Stem involvement. Problem w/in Midbrain or Pons. Weight is the Best indicator of Dehydration. 1kg = 1L 42 42 Diagnose of Delirium: Acute Mental Changes, Inattention with disorganized thinking, Altered Level of Consciousness, Hallucination. Dengue Fever: Hemorrhagic. Petechiae or (+) Herman’s sign. 45 45 2 ake about 3 weeks to Work. NCLEX RN STUDY GUIDE Sertraline: Agitation, Sleep disturb, and Dry mouth St John's Wort: used to treat Depression and Anxiety. Mimics the action of SSRI by Increasing available Serotonin in the brain. Taken in combination with an SSRI, may cause an Excess of Serotonin, resulting in Serotonin Syndrome. Serotonin Syndrome: characterized by Mental Status Changes (anxiety, agitation, disorientation) Autonomic Dysregulation (hyperthermia, diaphoresis, tachycardia/hypertension) Neuromuscular Hyperactivity (tremor, muscle rigidity, clonus, hyperreflexia) Mydriasis (dilation of pupil) Caused by: taking More Than One or an Overdose of Antidepressant med that incr. Serotonin levels. Diabetes Mellitus (DM): Polyuria, Polydipsia, Polyphagia. Metformin: Can’t be Given w/Contrast for CT Scan (Kidney Injury). Hold for 48hr. HbA1c - test to assess how well blood sugars have been controlled over the past 90-120 days. 4- 6 corresponds to a blood sugar of 70-110; 7 is ideal for a diabetic and corresponds to a blood sugar of 130. Diabetic ketoacidosis (DKA): when body is breaking down fat instead of sugar for energy. Fats leave Ketones (acids) that cause pH to decrease. DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats. 46 46 Serum acetone and serum ketones Rise in DKA. As you treat the Acidosis and Dehydration expect the potassium to Drop rapidly, so be ready, with K+ Replacement. While treating DKA, bringing the Glucose Down too far and too fast can result in Increased ICP due to water being pulled into the CSF. Wherever there is Sugar (Glucose) Water Follows. 47 47 2 NCLEX RN STUDY GUIDE /S: Kussmauls breathing (Deep Rapid RR), N/V, Abd Pain (Acidic Ketones). Can lead to Death. Fluids are the most important intervention with HHNS as well as DKA, so get Fluids going first. With HHNS there is No Ketosis, and No Acidosis. Potassium is Low in HHNS (due to Diuresis). Second Voided Urine most accurate when testing for Ketones and Glucose. Oral Hypoglycemic: Typical Adverse reaction: Rash, Photosensitivity Extra Insulin may be needed for a patient taking Prednisone (Steroids cause Increased Glucose). Diabetes Insipidus (decreased ADH): Thirst, Dehydration, Weakness, Excessive Urine Output (Diluted Urine) Administer Pitressin SIADH (increased ADH): Change in LOC, Decr. deep tendon reflexes, Tachycardia, n/v, HA, No Urine Output (Conc. Urine). HypoNa+, HypoCa2+. Administer Declomycin, Diuretics 50 50 Serious bacterial infection that can cause Organ Damage and Breathing problems. Disseminated Herpes Zoster: Airborne Precaution Localized Herpes Zoster: Contact Precaution 51 51 2 NCLEX RN STUDY GUIDE nurse with a Localized herpes zoster can care for patients as long as the Patients are Not Immunosuppressed and the lesions must be Covered. Diverticulitis: Inflammation of the Diverticulum in the Colon. Often in the Sigmoid Colon. Pain is around LL quadrant. Low Residue (Low Fiber), No Seeds, Nuts, Peas. Complication: Peritonitis (LUQ Pain). Down Syndrome: Protruding Tongue. Floppy muscle tone. To Prevent Dumping Syndrome (Post-Operative ulcer/stomach surgeries): eat in Low-Fowler’s during meals, lie Down after meals for 20-30 minutes (Decrease Peristalsis), Restrict Fluids during meals (wait 1hr), Low CHO and Fiber diet, Incr. Fat and Protein, Small frequent meals, Eat slowly. S/S: Dizziness, Hypotension, Syncope, Generalized Sweating, Tachycardia, Palpitation, n/v, Diarrhea, Abd pain. Gastrojejunostomy (Roux-En-Y Surgery): Risk for Dumping Syndrome. Iron Deficiency Anemia. Cobalamin Deficiency. DVT (Homan’s Sign): who need Enoxaparin, should not be Delegate. Does Not Need to be on bed rest, unless they have Severe Edema or Leg Pain. Edema: is in the Interstitial Space Not in the Cardiovascular Space. 52 52 Electrocardiogram (EKG): Atrial Fibrillation: Cardioversion: Anterior-Posterior Paddle Placement- One paddle is places just to the Right of the sternum at the Fourth Intracostal space and the Other paddle is placed between the scapulae on the Back. The Shock runs Diagonally through the chest. Cardiac Output Decreases with Dysrhythmias. Dopamine increases BP. 55 55 2 NCLEX RN STUDY GUIDE evere Inflammatory Obstruction. Drooling, Dysphonia (hoarse voice), Dysphagia (difficulty swallowing). Tripod Position. Inspiratory Stridor (Airway Distress). Caused by: Hib w/O Vaccine. Tx: Endotracheal Intubation w/ Tracheostomy Kit Standby. Dealing with Fire in Inpatient Setting (RACE): Rescue Activate the fire Alarm, Code Red Confine/ Close the Doors/Windows Extinguish the Fire. No Water. Using the Extingusher (PASS) Pull the Pin Aim the Nozzle Squeeze the Handle Sweep back and forth over the fire. Fractured Hip: S/S: External Rotation, Shortening, Adduction. Fat Embolism: Blood tinged sputum (r/t Inflammation), Incr. ESR, Respiratory Alkalosis (Not Acidosis r/t Tachypnea), Resp. Distress, Altered Mental Status, Hypocalcemia, Incr. serum Lipids, "Snow Storm" Effect on CXR. Petechiae (Treated w/ Heparin) in the chest, axillae, soft palate. Heparin Prevents Platelet Aggregation. No ASA & NSAID. Monitor PTT. Antidote: Protamine sulfate Reduce the Risk: Minimizing the move of a fractured long bone &early stabilization of the injury w/ surgery. Tx? 56 56 Greenstick Fractures: usually seen in Kids bone breaks on one side and bends on the other 57 57 2 NCLEX RN STUDY GUIDE ompartment Syndrome: an Emergency situation. Paresthesia and Incr. Pain are classic symptoms. Neuromuscular Damage is Irreversible 4-6 hours After onset. Cast: Petal the rough edges of a plaster cast with tape to avoid skin irritation. Itching under cast area- cool air via blow dryer, ice pack for 10- 15 minutes. Never use anything to scratch area Place Wheelchair Parallel to the bed on the side of Weakness. “Step Up” when picturing a person going Up Stairs with crutches. The Good leg goes Up first, followed by the crutches and the bad leg. The opposite happens going Down. The Crutches go first, followed by the good leg. COAL (Cane Walking) Cane Opposite Affected Leg 4 Point Gait: Move the Right crutch forward. Move the Left foot forward. Move the Left crutch forward. Move the Right foot forward. GastroEnteritis (Stomach Flu): Trimethobenzaminde: Tx for Nausea associated with Gastroenteritis (Stomach Flu) and PostOp n/v GastroEsophageal Reflux Disease (GERD): Barrett’s Esophagus (Erosion of the Lower portion of the Esophageal Mucosa) Patients should lay on their Left side with the HOB elevated 30 degrees. Weight Loss. Small Frequent Meals 60 60 Long term use leads to Weaker Bones (Decr. Phosphates, Incr. Ca2+ (from the Bones). Sevelamer HCl (Phosphate Binder): Take with food. Sucralfate (Antacid): Risk for Constipation. 61 61 2 NCLEX RN STUDY GUIDE x of Duodenal Ulcers. Coats the ulcer/Mucosal Barrier (take one hour Before meals to Coat the stomach). Create Viscous Substance Forms a Protective Barrier. Misoprostol: Prevent Stomach Ulcers caused by NSAIDs. Give Antacid to a Mechanically Ventilated patient w/ NG tube if the pH of the Aspirate is < 5.0, Checked at least every 12 hrs. Glasgow Coma Scale Eye opening (Maximum = 4) 4 - Spontaneous (open with blinking at baseline) 3 - To speech 2 - To pain only 1 - None (C - Not assessable [eg, trauma, edema]) Verbal response (Maximum = 5) 5 - Oriented 4 - Confused (converses but confused, disoriented) 3 - Inappropriate (inappropriate words) 2 - Incomprehensible (sounds, no words) 1 - None (T - Not assessable [intubated]) Motor response (Maximum = 6) 6 - Obeys commands for movement 5 - Localizes to pain 4 - Withdraws from pain 3 - Flexion in response to pain (decorticate posturing) 2 - Extension in response to pain (decerebrate posturing) 1 - None Use best response for each category (range, 3-15). Coma: Does not open eyes, does not follow commands, and does not utter understandable words; GCS 3-8. Head injury classification: Mild, GCS 13-15; moderate, GCS 9-12; severe, GSC ≤8. Below 8 you are in Coma. Intubated for Airway Protection. 62 62 Dysphagia: Difficulty Swallowing (Risk for Aspiration) 65 65 2 NCLEX RN STUDY GUIDE Indomethacine: to reduce pain and inflammation during acute attacks. Elevate the Inflamed Joints, Keep the area Bare, and apply Ice. Encourage Gradual weight loss. Guillain-Barre Syndrome (GBS): Ascending Paralysis. Ascending bilateral paralysis from segmental demyelination (remyelination eventually occurs). If the current level of paralysis is at the Knees and is therefore not the priority as it has not yet reached the Diaphragm. Keep eye on Respiratory System (absence of reflexes). Muscle weakness can lead to Resp. muscle paralysis, patient Unable to Cough effectively (Risk for Aspiration). Risk for Neuromuscular Respiratory Failure. Heart Failure: Anytime you see Fluid Retention. Think Heart problems first. Adding K+ to a diet, especially when substituting it for sodium, can Decrease BP and fluid retention. Avoid Sodium. S3 sound is Normal in CHF, not in MI. Fluid Volume Overload caused by IVC fluids infusing too quickly (or whatever reason) Nitroprusside (vasodilator): monitor Thiocyanate (Cyanide). Normal value should be 1. Greater than 1 is heading toward Toxicity ACE Inhibitor: Med of choice for CHF. Furosemide: May Cause Low K+, can Cause Anorexia due to Reduced K+. Give it slowly to prevent Ototoxicity, when giving more than 120mg. Digoxin (Cardiac Glycoside): check Pulse, Hold if hr < 60, (Children: Hold if hr <100). Check Dig levels (0.5-2.0) and K+ levels. Patient on Dig and Furosemide: Low K+ Potentiates Dig and can Cause Dysrhythmias. 66 66 Digitalis Increases Ventricular Irritability, and could Convert a rhythm to V-Fib following Cardioversion. You better pick ‘Do Vitals’ Before administering that Dig. (Apical pulse for One full minute). Avoid salt substitutes when taken Dig and K-Supplements because many are Potassium based Antidote: Digoxin immune fab. 67 67 2 NCLEX RN STUDY GUIDE Right-Sided HF: Systemic Venous Congestion. Cor Pulmonale (Fluid Overload): caused by Pulmonary disease (Bronchitis/ Emphysema) Juglar Venous Distension: Elevated Central Venous Pressure (CVP) Hepatomegaly Splenomegaly Ascites Edema: related to Sodium and Fluid Retention Left-Sided HF: Pulmonary Congestion. Cardiomegaly: Displaced PMI, S3 sound Pulmonary Edema: Dyspnea, Orthopnea, Crackles B-type Natriuretic Peptides (BNP): peptide that causes Natriuresis. Made, stored, and released primarily by the Ventricles. They are produced in response to Stretching of the Ventricles (blood volume and higher levels of extracellular fluid (Fluid Overload)). Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea. Acute Decompensated Heart Failure (ADHF): marginally Low BP, Crackles in the Lungs, Low O2 saturation, Jugular Venous Distension (JVD), and Peripheral Edema. Beta blockers (LOL) can Cause the client to further Deteriorate. It can Worsen heart failure symptoms by Decr. normal compensatory Sympathetic Nervous System responses and Myocardial Contractility. It is a Potentially Fatal Cause of Acute Respiratory Distress. Tx: Sit Upright (to clear the lungs, facilitate O2), Administer Dobutamine, Furosemide, Reduce Stress. 70 70 Increased ICP: BP (Hypertension), Pulse (Bradycardia), Resp.(Bradypnea) LOC is Priority (think ICP or Hemorrhage). Slowed Cheyne-Stokes (Irregular) Resp. 71 71 2 NCLEX RN STUDY GUIDE ushing's Triad: Systolic Hypertension with Widened Pulse Pressure, Bradycardia, Resp. Depression Should be Less than 2, Measure Head Circumference. Infectious Mononucleosis: Hallmark- Sore Throat (Pharyngitis), Cervical Lymph Adenopathy (Node Swelling), Fever, Fatigue, Splenomegaly, Hepatomegaly. Caused by: Epstein-Barr Virus (EBV). Tx: Pain Control. Rest is Important. Serious Complication: Spleen Rupture (LUQ Sudden Onset of Abd Pain). Infective Endocarditis (IE): the Vegetation over the Valves can break off; Emboli to various Organs, resulting in Life-Threatening Complications. Stroke - paralysis on one side Spinal Cord Ischemia - paralysis of both legs Ischemia to the Extremities - pain, pallor, and cold foot or arm Intestinal Infarction - abdominal pain Splenic Infarction - left upper-quadrant pain Common S/S: Fever, Arthralgia (Joints Pains), Weakness, Murmur, Fatigue, Splinter hemorrhage, Osler’s Node (painful, red raised lesions), Janeway Lesion. Tx: IV Abx for 4-6 weeks. Fever may persist for several days after treatment is started. Risk Factor: Hx of Mechanical Heart Valve Replacement, Rheumatic Fever, Dental Procedures, IV Drug Use, and Immunosuppression. Irritable Bowel Syndrome: Dicyclomine (Antispasmodic): Assess for Anticholinergic side effects. 72 72 Above Knee Amputation: Elevate for first 24 hours on pillow, position Prone daily to provide for hip extension. Do Not apply Lotions, Creams, or Oils. 75 75 2 NCLEX RN STUDY GUIDE lbumin: (3.5 ~ 5g/dL) Low Level. Pitting Edema. Periorbital Edema. Ascites. Sengstaken-Blakemore Tube used for Tx of Esophageal Varices (to Stop Bleeding), Keep Scissors at bedside. A patient w/ liver cirrhosis and edema May Ambulate, then sit with Legs Elevated to try to mobilize the edema. Ascites: Portal Hypertension & Hypoalbuminemia. Paracentesis: Semi-Fowlers or Upright on Edge of bed, Empty Bladder. Post: VS, report Elevated Temp, Observe for signs of Hypovolemia. Hepatic Encephalopathy (HE): frequent Complication of Liver Cirrhosis. It results from accumulation of ammonia (Elevated Ammonia levels) and other toxic substances in blood. 2~3 BM ok. Precipitating factors: Hypokalemia, Constipation, Gastrointestinal Hemorrhage, and Infection. S/S: Sleep disturbances (Early) to lethargy and coma. Mental status is altered. Asterixis (Flapping Tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists. Fetor Hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. Monitor for Dehydration, Incr. Na+, Decr. K+. Antidote Ammonia: Lactulose. Prior to Liver Biopsy: Important to be aware of the lab result for Prothrombin Time (9~12sec) Administer Vit K+, NPO Morning of exam 6hr, give Sedative. During: Hold breath for 5-10 sec, Supine position, Lateral with Upper arms Elevated. Post- Position: Lay on Right side, Frequent VS, Report Severe abd Pain STAT, No Heavy lifting 1 week. 76 76 Lyme Disease: found mostly in Connecticut. S/S: Bull’s Eye Rash (Circular outwardly expanding Rash). Tx: Doxycycline (abx) 77 77 2 NCLEX RN STUDY GUIDE Macular Degeneration: (Age Related) Progressive, Incurable disease of the eye in which the Central Portion of the Retina, the macula, begins to deteriorate with Age. S/S: Distortion (Blurred or Wavy disturbances) or Loss of the Central field of Vision; the Peripheral vision remains Intact. "Dry" Macular Degeneration: occurs when the microvasculature supplying the macula is Blocked, causing Ischemia. "Wet" Macular Degeneration: Abnormal blood vessels form and eventually Destroy the macula. Magnetic Resonance Imaging (MRI): Claustrophobia, No Metal, assess Pacemaker. Malaria: Step Ladder like Fever with Chills. Koplick's Spots are red spots with blue center characteristic of Prodromal stage of Measles. Usually in mouth. Complications of Mechanical Ventilation: Pneumothorax, Ulcers. Meniere's Disease: Administer Diuretics to Decr. Endolymph in the Cochlea, Restrict Na+, lay on Affected ear Triad: N/V, Tinnitus (Excess fluid inside the inner ear), Vertigo. Drop attacks. Aural Fullness. Fall Precaution. Salt Restriction. Meningitis: CSF- High Protein, Low Glucose. Nuchal Rigidity, Photophobia. Kernig’s Sign: Leg flex then leg Pain on extension. Brudzinski Sign: Neck flex; Lower Leg flex. Lumbar Puncture: pt is Positioned in Lateral Recumbent Fetal position. 80 80 Cerebral S/S: nystagmus, ataxia, dysphagia, dysarthria. Munchausen Syndrome: Psychiatric Disorder that causes an individual to Self-Inflict Injury or Illness or to Fabricate symptoms of physical or mental illness, in order to receive medical care or hospitalization. 81 81 2 NCLEX RN STUDY GUIDE Munchausen by proxy (MSBP): an Individual, typically a mother, Intentionally Causes or Fabricates illness in a child or other person under her care. Myasthenia Gravis: Disorder in the transmission of impulses from Nerve to Muscle Cell. Worsens w/ Exercise (Fatigue of voluntary muscles), Improves with Rest. Muscle stronger in the morning AM. Decrease in Receptor Sites for Acetylcholine. Since smallest concentration of ACTH receptors are in cranial nerves, expect fatigue and weakness in Eye, Mastication, Pharyngeal muscles. Descending muscle weakness (Not enough Acetylcholine), Bulbar Signs (Difficulty speaking or swallowing) Pyridostigmine: Incr. Muscle strength, give before meal AC. Neostigmine: Give to pt about 45 min. Before eating, so it will help with Chewing and Swallowing. Neostigmine/Atropine (anticholinergic)- Pancuronium Bromide (Antidote) Edrophonium/ Tensilon: Prevents the breakdown of the chemical acetylcholine, a neurotransmitter that nerve cells release to stimulate your muscles. (Acetylcholinesterase Inhibitor) Tensilon Test: To Confirm the Diagnosis; Positive if muscle is Improved. Myasthenia Crisis: a Positive reaction to Tensilon--will improve symptoms (Edrophonium) Cholinergic Crisis: Caused by Excessive medication (anticholinesterase). Stop Med. Giving Tensilon will make it Worse. Myocardial Infarction: Dead Heart Tissue Present. Crushing stubbing pain which Radiates to left shoulder, neck, arms, Unrelieved by NTG. Atypical symptoms (eg, Shoulder Pain, Nausea). ST Elevation. Unstable Angina: is Not relieved by NTG. Myocardial Ischemia: ST Depression. 82 82 Angina: Low Oxygen to Heart Tissues (No dead heart tissues). Crushing stubbing pain Relieved by NTG. Preload: affects amount of blood that goes to the R ventricle. 85 85 2 NCLEX RN STUDY GUIDE idney injury - long-term use is associated with kidney injury Hypertension and heart failure - can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension Indomethacine: Tx of Arthritis (Osteo, Rhematoid, Gout), Bursitis, and Tendonitis. Use Cold for Acute pain (eg. Sprain ankle) and Heat for Chronic (Rheumatoid Arthritis) Guided imagery is great for Chronic Pain. When patient is in Distress, medication administration is Rarely a good choice. Statin (Anticholesterol med): must be given with Evening meal (most cholesterol is Synthesized by the Liver during the fasting state, at night). Contraindicated severe Liver or Muscle injury. Simvastatin, for hyperlipidemia, take on Empty stomach to enhance absorption, report any unexplained muscle pain, especially if fever. Ezetimibe: Inhibits the intestinal absorption of Cholesterol and is often Combined with a Statin to treat hyperlipidemia. After Myringotomy (Ear Tube): position on side of Affected Ear after surgery (allows drainage of secretions). Nasogastric (NG) Tube: connect the main lumen of the NG tube (using an adaptor) to the suction apparatus and leave the blue pigtail lumen Open to air to facilitate gastrointestinal decompression. Regular flushing of the NG tube with water prevents clogging and allows the suction apparatus a clear pathway to decompress the suction. 86 86 An NG tube can be Irrigated with Cola, and should be taught to family when a client is going Home with an NG tube. Flush and Aspirate the tube w/ Warm water. Then try it w/ Digestive Enzyme Solution. Weighted Nasointestinal Tube: must float From Stomach to Intestine. Don't tape the tube right away after placement, may leave coiled next to pt on HOB. Position patient on Right to facilitate movement through Pylorus. 87 87 2 NCLEX RN STUDY GUIDE After G-Tube placement: the Stomach contents are Drained by Gravity for 24 hours Before it can be used for feedings. HyperNatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia, hypotonic solution Skin flushed Agitation Low grade fever Thirst Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids NephrOtic Syndrome: is caused by glomerular damage, which allows the Leakage of Proteins into urine. S/S: Generalized edema, Weight gain (fluid overload), Hypotension, massive Proteinuria (urine looks dark and frothy), Hyperlipidemia, Albuminuria, Hypoalbuminemia. WBC shift to the left in a patient with Pyelonephritis (Neutrophils kick in to fight infection) Turn and Reposition (risk for impaired skin integrity) Tx: Corticosteroids (In general are started at High Dose & Slowly Tapered to Reduce the Risk of Sudden Adrenal Crisis. Glomerulonephritis: take VS q 4hr and daily weights. Consider BP to be your most important assessment parameter. Dietary Restrictions: Fluids, Protein, Na+, K+. Gross Hematuria (Expected) 90 90 Opioid (Oxycodone, Hydrocodone, Heroin) Withdrawal: Related to increased SNS activity S/S: Anxiety/Restlessness, N/V, Pupil Dilation, Tachycardia, Fever, Abd Cramps, Rhinorrhea, Watery Eyes Antidote: Naloxone/Narcan Methadone: an Opioid Analgesic used to detoxify/treat pain in Narcotic Addicts. 91 91 2 ramadol: an Opioid Analgesic. Constipation: Side effect of opioid. NCLEX RN STUDY GUIDE Pruritus: Side effect of opioid. Treat it with Diphenhydramine. Positive Orthostatic Vital Signs: Rise in Pulse > 20min, indicate incr. risk of Syncope and Falls. Orthostasis is verified by a Drop in pressure with Increasing Heart rate (Rise in Pulse > 20/min) Osteomyelitis: Infectious Bone. Get blood cultures and Antibiotics. If necessary Surgery to Drain Abscess. Paget's Disease of the Bone: Tinnitus, Bone pain, Enlargement of bone, Thick bones. Risedronate: Bisphosphonate derivative that Inhibits osteoclast-mediated bone resorption and modulates bone metabolism. Can also Treat or Prevent Osteoporosis. Pancreatitis: Fetal position. Epigastric (upper) abd pain. Painful Condition. Tachycardia. Steatorrhea (Fatty Stools). Tx: NPO (gut rest), NGT (Suction out Gastric Secretion). Prepare antecubital site PICC- TPN/Lipids (Linoleic Acid). Demerol is given. NOT Morphine sulfate Morphine causes Spasm of the Sphincter of Oddi. Severe Epigastric pain radiating to the Back after an Alcohol Binge is most likely due to Acute Pancreatitis. It is a Serious condition but usually not immediately life-threatening. 92 92 Life-threatening Complication can occur after ERCP (Acute). S/S: Acute Epigastric/LQ pain, often radiating to the back, rapid rise in pancreatic enzyme (Amylase, Lipase). Can develop Respiratory Complications including Pleural Effusions, Atelectasis, and ARDS: often Due To activated Pancreatic Enzymes and Cytokines that are released from the pancreas into the circulation and Cause focal or systemic inflammation. Chronic Pancreatitis, Pancreatic Enzymes are given with meals. 95 95 2 NCLEX RN STUDY GUIDE Cardiac Tamponade: (Beck’s Triad) Hypotension, Muffled Heart Sounds, Distended Neck Veins. Paradoxical Pulse: Stroke Volume or Sbp > 10mmHg during Inspiration. PVD remember DAVE (Legs are Dependent for Arterial & for Venous Elevated) EleVate Veins; dAngle Arteries for better perfusion. Pheochromocytoma (PCC) (Benign Tumor on the Adrenal Gland/Medulla): Hypersecretion of Epi/Norepi, persistent HTN, Tachycardia, Palpitations, Hyperglycemia, Diaphoresis, Tremor, Pounding HA; Stress, Frequent rest breaks, Avoid Cold and Stimulating foods. Weight loss Tx: Surgery to remove Tumor Adrenal Medulla: Secrete Catecholamine (Epinephrine and Norepinephrine) and Dopamine. Adrenal Cortex: Secrete Glucocorticoids (Cortisol), Mineralocorticoids (Aldosterone), Androgens (Testosterone) Anterior Pituitary Gland: Prolactin, Growth Hormone, ACTH, Follicle-Stimulating Hormone (TSH), Thyroid-Stimulating Hormone (TSH), Luteinising Hormone (LH), Melanocyte-Stimulating Hormone (MSH). Posterior Pituitary Gland: ADH and Oxytocin. Removal of Pituitary Gland, watch for Hypocortisolim and Temporary Diabetes Inspidus. 96 96 Polycythemia: Elevated Hgb levels and Hct levels. Compensatory mechanism due to prolonged tissue hypoxia. Increase Blood Viscosity (risk for stroke or thromboembolism). Tx: Hydration. Polycythemia Vera (PV): Slow growing Blood Cancer. Chronic Myeloproliferative Disorder. Incr. RBC. Risk of Blood Clots (Heart Attack or Stroke). 97 97 300~500mL. NCLEX RN STUDY GUIDE Postoperative Cognitive Dysfunction (POCD): Memory Impairment & Problems with Conc., Language Comprehensive social integration and emotional ability after Major Surgery. Symptoms typically resolve after 4-6 weeks or when healing is complete. No Pee, No K+ (do not give Potassium without adequate Urine Output). Take it with Food. Never give K+ in IV Push. Low Potassium Potentiates Dig Toxicity. If every answer in front of you is an Abnormal value. If Potassium is there you can bet it is a problem they want you to identify, because values outside of normal can be Life-Threatening. Even a bun of 50 doesn’t override a Potassium of 3.0 in a renal patient in priority. Hyperkalemia: (MURDER) – Muscle weakness, Urine (oliguria/anuria), Respiratory depression, Decr. cardiac contractility, ECG changes, Reflexes. Bradycardia, Diarrhea, Nausea. Check Pulse first: Due to Dysrhythmias May be Due to Inability of the Adrenal Gland to Secrete Aldosterone (K+-Wasting Hormone) Kayexalate (Na+ Polystyrene Sulfonate): Need to worry about Dehydration (K+ has Inverse Relationship with Na+) Don't use Kayexalate if patient has Hypoactive Bowel Sounds. Hypokalemia: Muscle weakness, Dysrhythmias. 2 eriodic Phlebotomy: