NCLEX-RN U-WORLD REVIEW TEST BANK (2022/2023) UPDATED VERSION, Exams of Nursing

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NCLEX-RN U-WORLD REVIEW Allen's test - This diagnostic test is performed prior to initiating radial cannulation to ensure adequate circulation proximal and distal to the site Agoraphobia - Defined as the fear or anxiety about being in (or anticipating) certain situations or physical spaces; Ex- being on a train for an extended period of time Delirium - Defined as an acute onset cognitive dysfunction where consciousness is impaired, memory may be impaired and is reversible; Seen in ICU's Dementia - Defined as a chronic, gradual condition which causes irreversible and progressive cognitive decline; LOC intact, some memory loss is present and is irreversible Depression - Defined as a disease with gradual progression, may be episodic & is reversible - Providing a calming environment with minimal stimulation - Private room AWAY from nurses station is key - Use quiet/monotone voice - Use eye contact/gestures carefully - Limit visual clutter - Maintain minimal lighting - Provide child with single object to focus on - When caring for a child with autism spectrum disorder, what are nursing actions/interactions that should be implemented? Autism Spectrum Disorder (ASD) - Patients with this cognitive disorder often exhibit sensory processing problems to sounds, movement, touch, taste and smells Oligohydramnios - A condition characterized by low amniotic fluid volume Pulmonary hypoplasia & umbilical cord compression - What are two major complications of oligohydramnios at time of birth? Pulmonary hypoplasia - A complication of oligohydramnios defined as lack of normal alveolar dissension by aspirated amniotic fluid Umbilical cord compression - A complication of oligohydramnios which can present as late/variable decelerations; Requires continuous fetal monitoring at birth Polyhydramnios - Defined as a complication of excessive amniotic fluid volume, putting the mother at risk for post partum hemorrhage Pull the pinna upward & back to straighten the external ear canal - When administering an otic medication to an adult or child age 3 and older, how should the nurse manipulate the pinna? Instilling cold drops into the ear can cause vestibular reaction, resulting in dizziness/vomiting - Why should otic medication be warmed to room temperature before administration? ACE inhibitors - What class of blood pressure medications is category X in pregnancy and are extremely teratogenic? Placental abruption (Placento abrupto) - Defined as a complication of preeclampsia that occurs when the placenta tears away from the wall of the uterus due to stress, causing significant vaginal bleeding HELLP syndrome: H - Hemolysis EL - Elevated liver enzymes LP - Low platelets - A complication of pregnancy defined as severe eclampsia; What does this acronym stand for? At least 0.5 mL/kg/hr or approximately 30 mL/hr - What is normal urine output for an adult? DKA - Diabetic Ketoacidosis - An endocrine disorder characterized by breakdown of fat for fuel and the resulting byproducts are acidic ketones; Polyuria & kussmaul respirations are present to help blow off extra co2 Palpation - This disorder of pediatrics presents as an abdominal pass. What nursing intervention is PROHIBITED with this diagnosis? Sickle cell anemia - This disorder can present as a vasoocclusive crisis leading to ischemia and severe pain; Bilirubin released from the destroyed RBC's leads to jaundice and brownish hue to urine Codeine - This medication is an opioid drug prescribed to treat mild/moderate pain & is also an antitussive to suppress the cough reflex Allopurinol - This medication is prescribed to prevent gout attacks characterized by pain/inflammation in the joints due to uric acid deposits; Will need to be taken for the rest of life Allopurinol should be taken with a FULL glass of water & overall fluid intake should be increased when taking this medication - What is the MOST important teaching topic when educating a patient about administration of allopurinol? - Monitor vital signs - After recognizing that a patient is experiencing a transfusion/hemolytic reaction to a blood product, what is the nurses next actions? 2.0-3.0; Up to 3.5 for prosthetic heart valves/valve disease - For patients prescribed warfarin, what is the therapeutic value for their INR? Meningitis - Defined as inflammation of the meninges of the brain and spinal cord caused by infection - Fever - Restlessness - High pitched cry - Bulging/tense fontanels (Due to hydrocephalus and increased ICP - Increased head circumference - What are the clinical manifestations of meningitis in an infant? Pulse pressure - Defined as the difference between systolic and diastolic blood pressures Systolic HTN, widened pulse pressure, bradycardia, altered respirations (Hypo or hyper) - What does Cushing's triad consist of r/t increased ICP? The patients farthest away from the exposure site because they are most salvageable - For patients suspected of being exposed to radiation, when triaging, what victims should the RN assess first? Botulism - Caused by clostridium botulinum - Clinical manifestations of this biological weapon include: - Symmetrical descending flaccid paralysis - Cranial nerve palsies (Ptosis, diplopia, dysphagia, dysphonia) - Shakiness - Palpitations - Nervousness - Diaphoresis - Anxiety - Hunger - Pallor - Change in LOC - What are the classic s/s of hypoglycemia? 15-20 grams of a quick acting carbohydrate: - 4-6 ox regular soda - 8-10 lifesaver candies - 1 tbs honey or syrup - 4 tsp jelly - 4-6 oz orange juice - 8 oz low fat milk - Commercial dextrose products - What is the appropriate treatment for hypoglycemia for an alert & oriented patient? Subq or IM injection of 1 mg glucagon; Alternate treatment of 25-50 mL of 50% glucose IV - What is the appropriate treatment for hypoglycemia for an unconscious patient? Uterine rupture - For patients with a hx of c-section that attempt a vaginal birth (VBAC), what are they at highest risk for? First sign: Abnormal fetal heart rate patterns Other manifestations: Constant abdominal pain, loss of fetal station, sudden cessation of uterine contractions - What is the first sign of uterine rupture? What are other clinical manifestations? Magnetic resonance cholangiopancreatography (MRCP) - This diagnostic test is a non- invasive test used to visualize the biliary and hepatic ducts via MRI - Presence of certain metal implants (Pacemaker, aneurysm clip, cochlear implant) - PREGNANCY - Allergy to gadolinium (Contrast media used) - Most orthopedic implants are safe - For patients scheduled to undergo a magnetic resonance cholangiopancreatography (MRCP), what are some contraindications to this procedure? Botulism - This neurotoxin is found in soil and can grow in any food contaminated with the spores; Main source is improperly canned or stored foods -Raw (Wild) honey - Ingestion of what food can potentially cause infection with botulism in infants? - Prodromal phase - Aural phase - Ictal phase - Postictal phase - What are the 4 phases of seizures? Prodromal phase - This phase of seizures is the period with warning signs that precede the seizure Aural phase - This phase of seizure is the period before the seizure occurs when the client experiences visual or other sensory changes Ictal phase - This phase of seizures is the period of active seizure activity Postictal phase - This phase of seizures is where the client may experience confusion from recovering - AVOID HIP ADDUCTION AND FLEXION - Place abductor wedge pillow between the legs/knees when turning client from side to side - Educate the pt not to cross legs at ankles OR knees to avoid adduction - HOB should be maintained at < 45 degrees - Educate pt that they should not sleep or be position on AFFECTED side unless directed by HCP - When caring for a patient post total hip arthroplasty, what are proper nursing interventions? Malignant hyperthermia (MH) - Defined as a rare but life threatening inherited muscle abnormality that is triggered by specific inhaled anesthetic agents and the depolarizing muscle relaxant succinlcholine to induce general anesthesia Calcium - For patients experiencing malignant hyperthermia due to depolarizing muscular blocker, Succinylcholine, excessive release of which element from the muscles causes sustained muscle rigidity and contraction? - Jaw/upper body rigidity (early sign) - Increased oxygen demand and metabolism - Dangerously high temperature (later sign) - What are the clinical manifestations of malignant hyperthermia? Creatinine clearance (Cr) - Defined as a measure of glomerular function and is a sensitive indicator of renal disease progression - A 24 HOUR urine collection is necessary for this test - First urine specimen is discarded and time is noted - All other voided urine in next 24 hours is collected and kept cool (On ice or refrigerated) - Blood is drawn to measure serum Cr in addition to urine Cr - How is creatinine clearance measured? Calcium scoring CT exam; No preparation is required - This diagnostic test is a noninvasive procedure that is performed to visualize calcification of the coronary arteries and heart valves. What type of client preparation is required? 1.010-1.025 - What is normal urine specific gravity? Suction control chamber - When caring for a patient with a chest tube, where can the nurse expect continuous, gentle bubbling in the collection device? Water seal chamber - When caring for a patient with a chest tube, where can the nurse expect tidaling to be observed? - Burning with urination (Dysuria) - Urinary frequency - Urinary urgency - Hematuria - Suprapubic discomfort - What are the clinical manifestations of cystitis (Lower UTI)? - Development of N&V - Present fever and chills - Flank pain - Costovertebral angle tenderness - For a patient diagnosed with a UTI, what assessment findings would be indicative that this patient developed pyelonephritis? Cirrhosis - Defined as a progressive, degenerative disease caused by destruction and subsequent disordered regeneration of the liver parenchyma; Associated diseases include ascites, varices and encephalopathy Hypotension, bradycardia and pink/dry skin due to vasodilation - What are the classic signs of neurogenic shock? - Amenorrhea - N&V - Urinary frequency - Breast tenderness - Quickening - Excessive fatigue - What are examples of presumptive (Subjective) signs of pregnancy? - Uterine/cervical changes (Goodell's, chadwick's, hegar, uterine enlargement) - Braxton hicks contractions - Ballottement - Fetal outline palpation - Uterine & funic souffle - Skin pigmentation changes (Linea nigra, cholasma, areola darkening) - Striae gravidarum (stretch marks) - Positive pregnancy test - What are examples of probable (Objective) signs of pregnancy? - Fetal heartbeat with doppler device - Fetal movement palpated by HCP - Visualization of fetus by ultrasound - What are examples of positive (diagnostic) signs of pregnancy? Scabies - This skin infection is caused by Sarcoptes scabies mite Person-to-person contact - How is scabies infection spread? - Treat all persons who have had contact with the infested child - Apply permethrin cream to all areas of body below the head - Place clothes, linens and stuffed animals in a plastic bar or wash them in hot water with hottest drying cycle - What is proper treatment regimen when a child in a household is diagnosed with scabies? NSAIDs and BBs NSAIDs - such as Motrin can cause hypersensitivity in asthmatics which can cause bronchospasm BB - Non-cardioselective beta blockers block beta cells in heart and lungs, leading to pulmonary compromise in asthmatics - What two classes of commonly used drugs can cause problems for clients with asthma? Hypospadias - Defined as a cogenital defect in which the urethral opening os on the underside of the penis Presence of urine output, indicating urethral patency - For a male infant post op hypospadias repair, what is most important for the nurse to monitor for? - Hypovolemia - Hypoxia - Hydrogen ions (Acidosis) - Hypokalemia or hyperkalemia - Hypothermia - What are the 5 H's that are reversible causes of asystole/PEA? - Tension pneumothorax - Tamponade, cardiac - Toxins (Benzo, narcotics) - Thrombosis (Pulmonary/coronary) - Trauma - What are the 5 T's that are reversible causes of asystole/PEA? Pulseless electrical activity (PEA) - On the EKG, this rhythm occurs when the cardiac monitor shows organized electrical activity but there is not adequate mechanical activity of the heart muscle Ventricular septal defect - Defined as an acyanotic congenital heart defect causing blood to shunt from the left side of the heart to the right, resulting in pulmonary hypertension Aspiration and inadequate nutrition to to eating/feeding difficulties - What is a child diagnosed with a cleft palate at risk for related to feeding? - Hold infant upright - Tilt bottle so that nipple is always filled with formula - Keep nipple down and away from cleft - Use special bottles and nipples - Burp infants often to avoid stomach dissension and regurgitation - Feed slowly over 20-30 minutes to prevent risk of aspiration - Feed q3-4hr - What is proper feeding technique for an infant with a cleft palate? - Re-experiencing traumatic event (Dreams, flashbacks, pounding HR, diaphoresis) - Avoiding reminders of trauma (Inability to set goals, amnesia) - Increased anxiety and emotional arousal (Insomnia, rage, fear, difficulty concentration, exaggerated startle response) - What are examples of reports of patients with PTSD? Fidelity - Ethical principle defined as exhibiting loyalty and fulfilling commitments made to oneself and others Accountability - Ethical principle defined as taking responsibility for ones actions Nonmaleficence - Ethical principle defined as doing no harm and protecting clients from danger when they are unable to do so themselves due to mental/physical condition Autonomy - Ethical principle defined as the patients right to make decisions for oneself; Ex: Informed consent Beneficence - Ethical principle defined as "Doing good!" Justice - Ethical principle defined as treating all clients fairly and without bias Veracity - Ethical principle defined as telling the truth as a fundamental part of building a trusting relationship 10-20 mcg/mL - What is the therapeutic index for theophylline? > 20 mcg/mL - At what level does theophylline toxicity occur? Isoniazid (INH) - This medication is the firs tline anti tubercular drug prescribed to treat TB Hepatotoxicity and peripheral neuropathy - Educate pt to report yellowing of skin/sclera or numbness and tingling of extremities - What two serious adverse effects are possible with Isoniazid (INR) therapy? What should the RN instruct the patient to report? Alcohol - INH causes hepatotoxicity - For patients taking Isoniazid (INH) to treat TB, what beverage should the RN educate the patient to AVOID? Thiamine (Vitamin B1) - For clients with history of alcoholism, what vitamin should be administered to prevent Wernickle encephalopahy? Transition phase - Presentation of mucous, and pink/dark brown blood is present during this phase of labor; Aka bloody show Once complete dilation (10cm) is achieved - When does the second stage of labor begin? - Bathe patients with MRSA with pre-moistened cloths or warm water containing chlorhexidine solution - For clients in the ICU diagnosed MRSA on the skin, what is the recommended bathing procedure for the UAP? - Apnetic and cyanotic during feeding - Frothy saliva, coughing, choking & drooling - At greatest risk for aspiration! - For newborns suspected of having esophageal atresia with tracheoesophageal fistula, how would this newborn most likely present? What are they at greatest risk for? Priapism - Defined as a prolonged, painful erection (>2 hours) caused by trapping blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis These patients require "Permissive hypertension" during the first 24-49 hours to allow for adequate perfusion through the damaged cerebral tissues - For a patient with an acute stroke presentation, what type of blood pressure management is required and for how long? - Ecchymosis and tenderness over the thigh/hip - Groin/hip pain with weight baring - Muscle spasm in the injured area - Shortening of the affected extremity* - Abduction or adduction of the affected extremity - Affected extremity usually externally rotated* - What are the most common clinical manifestations of hip fractures? Age 21 - When is screening for cervical cancer in women begin? Antihistamines & corticosteroids - For patients undergoing allergy skin testing, what class of medications needs to be withheld prior? Testicular torsion - Emergency medical condition in which the blood flow to the testis (scrotum) has stopped; The testicle rotates and twists the spermatic cord, initially causing obstruction that leads to severe pain & will lead to testicular ischemia and necrosis Osteoarthritis (OA) - This disorder is also called degenerative joint disease, seen in knees, hips and fingers - Pain - Exacerbated by weight baring - Crepitus: Grating noise/sensation with movement that can be palpated - Morning stiffness - Decreased ROM/mobility - Atrophy of the muscles that support the joint (Quads, hamstrings) - What are the clinical manifestations of OA in the knee joint? Ventricular rate decreased from 158/min to 88/min - For patients with a diagnosis of atrial fibrillation prescribed Cardizem, what client outcome best indicates that the medication has taken its intended effect? - Withdrawn behavior - Monotone speech that is difficult to understand - Speaks with a loud voice - What clinical manifestations will be present in a toddler suspected of having hearing deficit? Spina bifida - This congenital defect is characterized in which the spinal cord contents can protrude through the vertebrae that did not close A tuft of hair or a hemangioma at site - Upon examining a newborn, the nurse suspects spina bifida a when she assess which finding? Folic acid - Deficit of which supplement can lead to neural tube defects in newborns? Mongolian spots - Congenital dermal melanocytosis - Defined as bluish discolored areas on the lower back and or buttock, most commonly seen in african american, asian, hispanic and native american infants - Older adults - Patients with suppressed immunity - Long history of antibiotic use - Invasive tubes/lines - Patients in ICU - Patients on ventilators - What are examples of clients that are at highest risk for MRSA? Hyperemesis gravidarum - During pregnancy, this disorder causes pregnancy clients severe nausea and vomiting leading to fluid and electrolyte imbalances, nutritional deficiencies, ketonuria and weight loss - Positive urine ketones - BP/HR changes for hypovolemia (Tachycardia, hypotension) - Poor skin turgor - Delayed capillary refill - Urine specific gravity > 1.025 due to concentrated urine - BUN > 20 - What are the clinical manifestations of hyperemesis gravidarum? Placenta previa - During pregnancy, defined as an abnormal implantation of the placenta resulting in partial or complete covering of the cervical os (opening) Placenta previa - A woman at 20 weeks of gestation reports mild contractions & painless vaginal bleeding. What should the nurse suspect? - Blood draw for type/screen (Possible hemorrhage) - Continuous electronic fetal monitoring - Initiation of 2 large bore IV catheters - Assessment of peripads to assess amount of bleeding/saturated pads per hour - When caring for an expectant mother suspected of having placenta pre via, what nursing interventions are appropriate? Digital vaginal examinatio - When placenta previa, abrupt placenta & vaginal bleeding of unknown origin are suspected, what nursing intervention is completely CONTRAINIDICATED? Osteoporosis - PPI's decrease absorption of calcium and a bone density test will need to - For patients on long term therapy with PPI's, what is an adverse effect that may develop over time? What test will need to be performed? - Alcohol/drug intoxication - Altered consciousness - Mental illness (Hearing voices) - Chemical influence (Narcotics, benzos) - If deemed a danger to self or others - What are contraindications to a patient being able to sign out AMA? - Documentation on discussion of risks with client's decision & understanding of these risks - Signature of client on AMA document (Client's cannot be held against will if not willing to sign) - Should be witnessed and documented - For a patient wishing to sign out of the hospital APA, what must be discussed with patient & what documentation must be present? Sulfonylureas - Glyburide (long acting agent); can cause severe and prolonged hypoglycemia - According to the beer's criteria, what anti diabetic agents are contraindicated in older adult clients? What is an example of this medication class? - Trauma - Major surgery - Prolonged immobilization (Stroke, long travel) - Pregnancy - Oral contraceptives Urine remains light pink without clots - When caring for a patient post TURP, while receiving continuous bladder irrigation, how does the RN know that the irrigation is running at an adequate rate? Urine is dark red with positive clots present - When caring for a patient post TURP, while receiving continuous bladder irrigation, how does the RN know that the irrigation is NOT running at an adequate rate? Gonorrhea and chlamydia - What two STD's are the leading causes of pelvic inflammatory disease (PID) and infertility? - Adherence to a high calorie diet (4000-5000/day) - Consumption of 6 full meals and snacks high in protein, carbs and vitamins/minerals - Avoidance of high fiber foods do to increased stimulation of GI tract - Avoidance of stimulating substances (Caffeinated drinks, coffee, tea, soda) - Avoidance of spicy foods (Will increase gastric stimulation) - For patients diagnosed with hyperthyroidism, what patient education points does the nurse need to touch on? Hyperthyroidism - This endocrine disorder refers to sustained hyper functioning of the thyroid gland due to excessive secretion of thyroid hormones (T3, T4) leading to increased metabolic rate - Use interpreter of same gender if topic sensitive - Make good eye contact when communicating with client (Communication with client, not interpreter) - Interpreter should translate words literally - RN should use simple terms not medical terms - RN should speak slowly and in short sentences - When caring for a patient who does not speak their native tongue, how should the nurse implement proper use of a professional interpreter? Suctioning - This nursing intervention involves removing secretions from a client's airway No more than 10 seconds - When suctioning a patient, how long should suction be applied for? 1-2 minutes - When suctioning a patient, how long should the nurse wait between suction passes? Hyperoxygenate the patient with 100% o2 - Prior to suctioning a patient, what does the nurse need to do? Between 100-120 mm Hg for adults & 50-75 mm Hg for children - When suctioning a patient, at what pressure should the suction be set at for adults? Children? 150,000-400,000 - What is the normal lab value for platelets? - Reduce stimuli in bedroom (Reading, TV) - Avoid naps later in day - Keep bedroom slightly cool, quiet & dark - Avoid caffeine, nicotine and alcohol within 6 hours of sleep - Avoid exercising or strenuous activity within 6 hours of going to bed - Avoid going to bed hungry - Practice relaxation techniques - For patients with trouble sleeping, what should the RN educate the patient about for better sleep patterns? - Counseling or psychosocial support - Gentle massage with water based lotion to alleviate itching and minimize scarring - Plan for reconstructive surgery - Pressure garments to prevent hypertrophic scars and promote circulation - ROM exercises to prevent contractors - Sunscreen to prevent sunburn - For patients in the rehabilitation phase of burn injury, what are proper interventions to include in plan of care? - Do not eat, drink or smoke on the day of test - Avoid caffeine 24 hours before test - Avoid decaffeinated products 25 hours before test - Ask HCP about diabetes medications prior to test; Hypoglycemia can result while patient is NPO for test - Avoid nitrates, dipyridamole and BBs prior to test*** will masks s/s of angina - For patients set t undergo a pharmacologic nuclear stress test, what are pre-procedure client instructions? - Discomfort, redness and a few vesicles at the injection site - What are some s/s of varicella immunization administration? - Cover the vesicles with clothing or a small bandage until they are dried or crusted over (No longer contagious) - What is proper nursing intervention when a patient develops several small vesicles at the injection site of varicella vaccine? Aspirin - What medication is completely contraindicated in children due to the development of Reye syndrome? Positive abdominal tenderness & rigid abdomen - For a patient that underwent a colonoscopy, what is a concerning finding that could indicate perforation of the colon? - Keep cord stump clean and dry - Keep cord open to air to allow for adequate drying - Do NOT apply antiseptics (Alcohol, chlorhexidine) to stump - Report any s/s of infection to HCP - When caring for a newborns umbilical cord, what is proper technique and what needs to be reported to HCP? 2-3 days - How long after cutting the umbilical cord will it begin to shrivel and turn black? Lactose intolerance - This GI disorder is due to a deficiency in the enzyme lactase, which is required for digestion of lactose Calcium and vitamin D - For patients with lactose intolerance, what vitamin supplementation will be required? Hemophilia - This disorder is caused by a deficiency in coagulation proteins, lacking factor VIII or factor IX Joint destruction - Most frequent sites of bleeding are the joints, especially the knee, causing chronic swelling and deformity - For patients diagnosed with hemophilia, what is a long term complication associated with this bleeding disorder and why? Frostbite - This disease involves tissue freezing, resulting in ice crystal formation in intracellular spaces that causes peripheral vasoconstriction, reduced blood flow , vascular stasis and cell damage - Remove clothing and jewelry to prevent constriction - DO NOT MASSAGE, rub, or squeeze area involved - Immerse affected area in heated water - Provide analgesia as appropriate - Elevate injured areas due to possible edema - Keep wounds open and allow them to dry before applying a loose, sterile dressing - What is proper treatment of frostbite? Serotonin syndrome - Defined as a potentially life threatening condition that develops when drugs affecting the body's serotonin levels are administered simultaneously in overdose St. John's Wort - What herbal supplement taken in conjunction with an antidepressant can potentially cause serotonin syndrome? - Mental status changes (Disorientation, anxiety) - Autonomic dysregulation (Hyperthermia, diaphoresis, tachycardia, HTN) - Neuromuscular hyperactivity (Tremor, muscle rigiditu, clonus, hyperreflexia) - Fever - Warm, moist skin - What are examples of clinical manifestations that may be present with serotonin syndrome? 2nd ICS right sternal border - When auscultating heart sounds, where is the aortic valve located? - Rebound tenderness - Board like abdomen* - What are late clinical manifestations of peritonitis? - Identify patient using 2 identifiers - Perform hand hygiene and apply clean gloves - Elevated HOB > 30 degrees and keep elevated for at least 30 minutes to prevent aspiration - Validate tube placement by checking gastric pH and comparing it with measurement of tube length at time of insertion - Check residual volume - Flush tube with 30 mL of water - Administer prescribed enteral feeding solution by setting the rate on infusion pump - What are the steps for administering a continuous enteral feeding to a patient? Asians - What ethnic group is at highest risk for developing a dry cough with ACE inhibitors? - Elevating the affected harm to heart level (Reduces fluid retention and lymphedema) - Hand and arm exercises (to maintain muscle tone, prevent contractors and improve circulation) - Keeping patient in semi fowler position - Place sign over bed that says "restricted left/right extremity" - No BP, venipuncture or injections on affected extremity - What are vital nursing interventions when caring for a patient post mastectomy? - Pneumococcal vaccine & annual influenza vaccine - What is the current vaccination recommendations for patients with COPD, regardless of age? Flail chest - multiple ribs sustained multiple fractures and become independent of chest wall, floating on top of the lung and pleura - When triaging victims after a major disaster, what does see saw movement with respirations indicate? Umbilical cord prolapse - Complication of pregnancy that occurs when the umbilical cord slips below the presenting fetal part and may cause cord compression and impaired fetal oxygenation Emergency c-section unless vaginal birth is imminent and considered safe by HCP - What is the treatment for umbilical cord prolapse? Position the client on hands and knees to relieve cord compression - Upon vaginal assessment of a patient in labor, the nurse visualizes a loop of umbilical cord protruding from the vagina. What is the nurse's first action? - Self-induced vomiting - Fasting - Laxative abuse - Excessive exercise - What are examples of weight maintenance behaviors of a patient diagnosed with bulimia nervosa? 1-2 hours after meals - For clients diagnosed with bulimia nervosa, when is it vital the nurse monitor the patient? Infiltration - Complication of IV therapy defined as leaking of solution into surrounding tissues of the infusion site - D/C IV line ASAP - Start IV on opposite extremity - Elevate the affected extremity to decrease swelling - Apply a cold/warm moist compress to site - Notify HCP if other complications develop - What are proper nursing interventions when observing that an IV line is infiltrating? q82-96hr - How often should peripheral IV sites be changed? Abdominal aneurysm - Upon abdominal assessment of a patient, the nurse notes a pulsatile mass in the periumbilical area. What does she suspect? - Back/abdominal pain (Due to compression of nearby anatomical sites) & a pulsatile abdominal mass - What are the clinical manifestations of a AAA? - Emergency surgery to repair the aneurysm to prevent rupture - What is the treatment for a AAA? Nystatin - What is the preferred treatment for oral candidiasis due to corticosteroid/antibiotic use? Swish liquid in mouth for several minutes and then swallow it - For the treatment of oral candidiasis, how should the nurse instruct the patient to administer oral nystatin? Gloves - the most dirty - When removing PPE after a wound dressing change for a patient with MRSA, what article of PPE should be removed first? Pericardial effusion - Defined as a buildup of fluid in the pericardium Cardiac tamponade - Defined as a serious complication of a pericardial effusion Emergency pericardiocentesis - Needle inserted into pericardial sac to remove excess fluid constricting the heart from beating - What is the immediate treatment of cardiac tamponade? - Hypotension - Narrowed pulse pressure - Muffled/distant heart tones - JVD - Pulsus paradoxus - Dyspnea, tachypnea - Tachycardia - Weak, thready pulses - What are the s/s and clinical manifestations of cardiac tamponade? 14 days - to prevent risk of developing serotonin syndrome - How long after cessation of an MAOI can an SSRI be started and why? General anesthesia & a skeletal muscle relaxant - What medications are administered prior to ECT therapy? Confusion and memory loss - What are common side effects after ECT therapy? Anticonvulsants - ECT is used to provoke convulsion - What medication class is contraindicated prior to ECT therapy and why? Hypertensive crisis - Defined as a life threatening emergency & if left untreated will cause intracranial hemorrhage, HF, MI, renal failure, aortic dissection or retinopathy - IV vasodilators (Nitroprusside sodium) - What is the emergency treatment for hypertensive crisis? - To decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg - When caring for a patient diagnosed with a hypertensive crisis, what is the initial goal of treatment? Too rapid of a drop may cause decreased perfusion to the brain, heart and kidneys, resulting in stroke, renal failure or MI - When caring for a patient diagnosed with a hypertensive crisis, what is the risk in lowering the BP too quickly? Live vaccinations - IVIG administration will interfere with desired immune response to live vaccines (Varicella, MMR, influenza) - After IVIG administration for Kawasaki disease, what immunizations should be delayed in this client? Hypocalcemia - due to chronic ingestion of alcohol - What is a probable electrolyte imbalance seen in chronic pancreatitis and why? - Numbness/tingling in finers and lips - Trousseau's sign (BP cuff) - Chvostek's sign (Facial twitching) - What are s/s of hypocalcemia? CVP - Central venous pressure - In critical care, this is a measurement of right ventricular preload and reflects fluid volume status congenital pulmonic stenosis, what assessment finding would potentially delay this procedure? - Encourage the patient to cut nails short - Wear cotton gloves - Wear long sleeved shirts to avoid injury by itching - Taking baking soda baths - Applying calamine lotion - Applying cool, wet cloths to irritated skin - For patients diagnosed with cirrhosis, what are nursing interventions to reduce pruritus? Due to buildup of bile salts beneath the skin - For patients diagnosed with cirrhosis, why do they experience pruritus? Cholestyramine (Questran) - What medication will be prescribed for patients with cirrhosis to decrease the pruritus experienced due to accumulation of bile salts underneath the skin? - Powder; Must be mixed with food (Applesauce) or juice and should be given one hour AFTER other medications are administered - What is proper medication administration for Cholestyramine (Questran) when treating pruritus in cirrhosis? Kawasaki Disease (KD) - This childhood disorder is also known as mucocutaneous lymph node syndrome Kawasaki Disease (KD) - This pediatric disease is characterized by > 5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash and extremity swelling To prevent coronary aneurysms and subsequent occlusion - Why is IV immunoglobulin and aspirin given to treat Kawasaki Disease (KD)? To prevent heart disease - What is the therapeutic effect of IVIG and aspirin for Kawasaki Disease (KD)? - Patient should take potassium tablets with plenty of water - Patient should remain sitting up right for > 30 minutes after ingestion - For patients prescribed loop diuretics, how should potassium supplementation be taken? Pill induced esophagitis and erosion of esophagus - If potassium supplementation tablets are not taken with enough water or if the patient does not sit upright for > 30 minutes after ingestion, what can potentially happen? Vitamin D - What vitamin helps with calcium absorption? - Apply clean gloves and position the client supine with knees and feet raised - Lubricate the tip of suppository with water soluble jelly - Insert suppository past internal sphincter using the fifth finger - Angle suppository and guide it along the rectal wall - Hold buttocks together for several minutes or until urge to defecate has passed - When administering a rectal suppository to an infant, what is proper procedure? Retinoblastoma - Defined as a unilateral or bilateral retinal tumor and is the most common childhood intraocular malignancy Parents report a white "glow" of the pupil - How is retinoblastoma usually first recognized in children? Leukocoria (white glow of pupil) & strabismus (Misalignment of eyes) - What are the most common clinical manifestations of retinoblastoma? Radiation therapy or enucleation (Removal of eye) - What is the treatment for retinoblastoma in children? - Frequent use of pacifier - Infant's immunization status - Infant's position while drinking from bottle - What are risk factors for infants developing recurrent otitis media? Otitis media (OM) - Defined as inflammation or infection of the middle ear - Recurring exposure to tobacco spoke - Regular pacifier use - Drinking from a bottle when lying down - Lack of immunizations - What are modifiable risk factors to alter to prevent recurrent otitis media in infants? Bathing or swimming and getting water in the ears - What is a risk factor for infants and children contracting otitis externa? - Cardiac pacemaker - Implantable cardioverter defibrillator (ICD) - Cochlear implant - Retained metallic foreign body, such as in the eye - What are absolute contraindications for an MRI? Sucralfate - This medication is an oral medication that forms a protective layer in the GI mucosa which provides a physical barrier against stomach acids and enzymes - 1 hour prior to meals on an empty stomach with a full glass of water - Provides protective layer and physical barrier against stomach acids and enzymes - When is sucralfate typically prescribed and why? Morphine - What medication is typically used to manage dyspnea, tachycardia and restless associated with withdrawing mechanical ventilator support at end of life? Bladder exstrophy - Defined as a congenital disorder in which the bladder was not developed in the abdominal cavity during fusion in the embryo and is exposed externally at birth Placing a protective film of plastic over the exposed bladder to keep the tissue moist and help prevent infection - What is the most important nursing intervention when caring for an infant with bladder exstrophy? Autonomic dysreflexia - Defined as a life threatening condition caused by sensory stimulation that occurs in clients who have a spinal cord injury at T6 or higher - Asparagus - Turnip/mustard greens - Fortified breakfast cereal - Cooked dried beans - Liver - Leafy greens (Broccoli, spinach) - Beats - Rice - Peanut butter - What are examples of foods high in folic acid? - Mild: Anxiety, insomnia, diaphoresis, palpitations, GI upset Seizures: Single or generalized Hallucinosis: Visual, auditory or tactile hallucinations - What are some s/s of alcohol withdrawal syndrome (DTs)? - Confusion - Agitation - Fever - Tachycardia - Hypertension - Diaphoresis - Hallucinations - What are s/s of delirium tremens (DTs)? Administration of benzos - How can the DT's be prevented during hospitalization? The nurse should place her fingers halfway between the shoulder and elbow, palpating the brachial artery - When palpating a pulse on an infant, where should the nurse place her fingers? What artery is this? Ringworm aka tinea corporis - Defined as a fungal infection on the superficial keratin layers of the skin, hair and/or nails - Educating about splinting the abdomen by holding a pillow or folded blanket against abdomen when coughing and moving - What nursing interventions are vital to prevent the occurrence of dehiscence after abdominal surgery? - Keep bottles/nipples/caps as clean as possible - Wash the tops of formula cans prior to opening to prevent contamination - Prepared formula must be kept in fridge and discarded after 48 hours - Prepared bottles can be warmed in a pain of hot water NOT MICROWAVE - Test temperature of bottle on inner wrist before giving to infant - What is proper storage/handling of formula/milk related to infant feeding? Microwaving formula can cause irregular heating and mouth burns in infants - Why is infant formula NEVER microwaved? - Water intoxication r/t hyponatremia - Why should formula never be diluted or concentrated? Addison's disease - Defined as primary adrenocortical insufficiency or hypo function of the adrenal cortex - Glucocirticoids - Androgens - Mineralocorticoids - What are the adrenal glands responsible for secreting? - Bronze pigmentation of skin in sun exposed areas - Vitiligo (Patchy/blotchy skin) - Slow, progressive onset of weakness and fatigue - Anorexia/weight loss - Orthostatic hypotension - Hyponatremia & Hyperkalemia - Salt cravings - N&V - Depression and irriaibility - What are clinical manifestations of Addison's disease? Epstein-Barr virus - Infectious mononucleosis (Mono) is caused by what virus? Spleen rupture - What is a serious complication of infectious mononucleosis? Lithium - This medication is a mood stabilizer that is most often used to treat bipolar affective disorders 0.6-1.2 - What is the therapeutic range of Lithium? (Think Cr) 0.6-1.2 - What is the therapeutic range of Lithium? - Dehydration - Decreased renal function - Diet low in sodium - Drug-drug interactions (NSAIDs, thiazide diuretics) - What are some risk factors for developing lithium toxicity? Sodium - Reduction in which electrolyte potentiates lithium toxicity? - Verify unresponsiveness by tapping/shaking & saying "Hello are you all right?" - Activate emergency response system by calling for help or calling 911 - Simultaneously check for the carotid pulse and assess for spontaneous breathing for no more than 10 seconds - Attempt CPR if no pulse is felt - What is the sequence of basic life support (BLS) for an unconscious, pulseless patient? 100-120/min - At what rate should chest compressions be in BLS? Elevated bilirubin & elevated reticulocytes - During a vaso-occlusive crisis, a complication of sickle cell anemia, what is there an increased presence of in the laboratory values? Addisonian crisis - life threatening complication - For a patient diagnosed with Addison's disease, what can abrupt discontinuation of corticosteroids lead to? Cataracts - What is an ocular problem that results from long term corticosteroid use, specifically glucocorticoids? True contractions - These types of contractions come in regular intervals; frequency, duration and intensity increase over time Braxton Hicks Contractions - These types of contractions come in irregular intervals; No increase in frequency, duration or intensity & may dissipate over time True contractions - These types of contractions increase despite implementation of comfort measures (Change of position, hydration, walking) Braxton Hicks Contractions - These types of contractions may lessen or dissipate with comfort measures (Walking, change of position, hydration) True contractions - These types of contractions cause an increase in cervical dilation and effacement Braxton Hicks Contractions - These types of contractions cause no cervical change in the mother Sudden infant death syndrome (SIDS) - Defined as the leading cause of death among infants aged 1 month to 1 year - Place infants less than 1 year old on their BACK (Supine) to sleep - Firm mattress should be chosen - Avoid soft objects such as stuffed animals, heavy blankets etc - Avoid bumper crib pads* - Maintain SMOKE FREE house hold - Avoid overheating of infant* - Encourage use of pacifier - Breast feeding is encouraged - Keept infant up to date with immunizations - What measures does the RN need to educate new parents about r/t prevention of SIDS? Breastfeeding & up to date immunizations - What two factors contribute greatly in the prevention of SIDS? PEEP - Positive end-expiratory pressure - This ventilator setting applies a given pressure at the end of expiration during mechanical ventilation It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange - What is the therapeutic effect of PEEP? 5 cm of h2o - At what level is PEEP typically kept on? 10-20 cm of h2o - What is the range for high levels of PEEP? Overdistension and rupture of alveoli resulting in barotrauma to the lung - What can continuously high levels of PEEP cause? - Verify informed consent - Gather the lumbar puncture tray and needed supplies - Explain the procedure to older child and adult - Have client empty their bladder - Place client in appropriate position (Side lying with knees drawn up to chest) - Assist client in maintaining proper position - Provide a distraction measure throughout procedure 0 Label specimen containers as they are collected - Apply bandage to the insertion site - Deliver specimens to lab - What is the nurses role when assisting with an LP? Toxoplasmosis - Defined as a parasitic infection which may be acquired from exposure to infected cat feces or ingestion of undercooked meat or soil contaminated fruits/veggies Lateral recumbent or sitting up right - What position is a patient typically placed in for an LP? - Step behind client and place arms under axilla/around waist - Place feet wide apart with knees bent - Place one foot behind the other and extend front leg - Let patient slide down the extended leg to the floor - To prevent injury in a client who is actively falling, what are proper actions by the nurse? Anencephaly - This condition is considered a severe neural tube defect resulting in little to no brain tissue or skull formation in utero Many are born stillborn and those that are born alive are not compatible with life - What is the prognosis for infants born with anencephaly? Dialysis disequilibrium syndrome (DDS) - Defined as a rare but potentially life threatening complication that can occur in clients during the initial stage of hemodialysis - N&V - Headache - Restlessness - Change in mentation - Seizure activity - What are the clinical manifestations of dialysis disequilibrium syndrome? Contact the HCP ASAP! EMERGENCY* - If dialysis disequilibrium syndrome (DDS) is suspected, what is the nurses first action? Antihypertensives - What medication class is held prior to dialysis to minimize the risk for hypotension? Enoxaparin (Lovenox) - Defined as low molecular weight heparin Subq injection at a 90 degree angle, to the right or left side of abdomen (Love handles), at least 2 inches away from the umbilicus - How should the nurse administer LMWH, Enoxaparin (Lovenox)? Hyperkalemia & fluid volume overload (FVE) - For patients diagnosed with chronic kidney disease, what are they at greatest risk for? > 100 mL/hr - Greater than what amount of chest drainage needs to be reported to the HCP? - Report any s/s of infection (Redness, swelling, drainage, fever) - Keep a pacemaker ID card with you - Wear a medic alert bracelet - Microwave ovens are safe to use* - Report if pulse is under HCP recommendation - Do not place cell phone directly over pacemaker - AVOID MRI SCANS - Avoid lifting arm above the shoulder until approved by HCP - Air travel is not restricted - Notify airport security that you have a pacemaker (Will set off metal detector) - For patients that underwent placement of a permanent pacemaker, what education should the nurse give the patients? Coup- countercoup - This type of head injury occurs when a body in motion stops suddenly, causing contusions of brain tissue as the brain moves back and fourth within the skull Frontal lobe - Deficit in memory, speech & executive function (Decision making) Occipital lobe - Deficit in vision and interpretation - With a coup-cointrecoup head injury due to a car accident, what types of deficit can the nurse expect? Dabigatran (Pradaxa) - This medication is an example of a thrombin inhibitor that reduces the risk of clot formation and stroke in clients with chronic atrial fibrillation Capsules should be kept in their original container blister pack until time of use to prevent moisture contamination - For patients prescribed Dabigatran (Pradaxa), how should this medication be stored? Rifampin and rifampin derivatives reduce efficacy of oral contraceptives by increasing their metabolism; Alternative BC method will need to be implemented during treatment - For patients prescribed Rifapetine, a derivative of rifampin, how should the nurse instruct these patients on use of birth control? < 3-4.5 hours - What is the appropriate time range from TPA to treat an ischemic stroke? Myasthenia gravis - Defined as an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction - Weakness of skeletal muscles - Ptosis/diplopia - Bulbar signs (Difficulty speaking/swallowing) - Difficulty breathing - What are examples of clinical manifestations of myasthenia gravis? Anticholinesterase drugs - Pyridostigmine (Mestinon) - What is the treatment for myasthenia gravis? Before meals - In treating myasthenia gravis, when are anti cholinesterase medications administered? Aspiration - What is the greatest risk for patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF)? - Maintaining NPO status - Positioning pt supine with HOB at > 30 degrees - Keep suction equipment at bedside - Prevent aspiration - What are priority nursing interventions for patients diagnosed with EA/TEF? Cognitive behavioral therapy (CBT) - This form of therapy can be effective in treating anxiety disorders, eating disorders, depressive disorders and medical conditions such as insomnia and smoking - Education about client's specific disorder - Self observation and monitoring - Physical control strategies - Cognitive restructuring - Behavioral strategies - What are the 5 basic components of cognitive behavioral therapy (CBT)? - Avoid oil based lubricants on nostrils (Flammable) - Water-soluble lubricants are acceptable - Keep oxygen canisters at least 5-10 feet away from fire sources - Do NOT increase o2 flow rate without HCP prescription; Drive to breath can be potentially decreased - Avoid nail polish remover with oxygen (Flammable) - Avoid synthetic and wool fabrics (Flammable) - Cotton blankets/fabrics are recommended - When discharging a patient with COPD with home oxygen, what are nursing education points that should be voiced at this time? Peak flow meter - Defined as a hand held device that is used to measure peak expiratory flow rate (PEFR) and is most helpful for patients with moderate-severe asthma - Move the indicator on the numbered scale to 0 before using device - Exhale as quickly and forcibly as possible through the mouthpiece - Mouthpiece evaluates the degree of airway narrowing by measuring the volume of air that can be exhaled in one breath - How should a nurse instruct a patient on how to use a peak flow meter? What does it measure? - Clamp catheter to prevent more air from embolizing into circulation - Place pt in trendelenburg position on the left side, causing air to rise and become trapped in right atrium - Administer o2 prn - VI - A nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. What CN's are being tested? (Think saying learned in ATI) Psychomotor retardation - This clinical symptom of major depressive disorder include slowed speech, decreased movement and impaired cognitive function - Meats (Beef, lamb, liver, chicken, pork) - Shellfish (Oysters, clams, shrimp) - Eggs - Green leafy veggies - Dried fruits - Beans - Brown rice - Oatmeal - What are examples of foods that are high in iron? Pinworm infection - A child is experiencing anal itching and trouble sleeping. What infection does the nurse suspect? The patient should be positioned with the good lung down which promotes better ventilation and drainage of bad lung - For a patient with lobular pneumonia, how should they be positioned in bed to prevent drops in pulse oximetry and increased respiratory distress? Epiglottitis - Pediatric ailment that ewers to inflammation of the epiglottis that may result in a life threatening airway obstruction Haemophilus influenzae type b (Hib) - What is the most common causative agent for epiglottitis? - Drooling - Dysphonia (Trouble speaking) - Dysphagia (Trouble swallowing) - Distressed airway (Stridor) - What are the 4 D's r/t epiglottitis? Epiglottitis - This pediatric ailment presents as tripoding (Sitting up and leaning forward) with inspiratory stridor Blurred vision - Optic neuritis is possible to develop - For a patient diagnosed with TB being treated with ethambutol (Myambutol), what AE does the nurse need to instruct the patient to report to HCP? Parietal lobe - This area of the brain integrates somatic and sensory input & injury to this area can result in a deficit with sensation Frontal lobe - This area of the brain controls higher-order processing, such as executive function and personality. Injury to this area results in behavioral changes Temporal lobe - This area of the brain integrates visual and auditory input and past experiences. Injury to this area may result in inability for the client to understand verbal/written language Occipital lobe - This area of the brain registers visual images. Injury to this area can result in a deficit with vision CN VII - Facial nerve - Bell's palsy is characterized by facial paralysis resulting from inflammation of which CN? - Inability to completely close eye on affected side - Flattening of the nasolabial fold on the side of paralysis - Inability to smile/frown symmetrically - Alteration in tear production due to eyelid muscle weakness - Loss of taste on the anterior 2/3 of tongue - What are clinical manifestations of Bell's palsy? - Oxygen - Fluids - Maintenance of body temperature (Homeostasis) - Sleep - Proper elimination - Adequate shelter - According to Maslow, what are considered physiological needs that are vital for survival? - Take BP sitting then standing - What is the best way the nurse can assess for autonomic neuropathy? Involuntary body functions: - BP - HR - Perspiration - Sexual function - Digestion - What is the autonomic nervous system in control of? - PaCO2 > 45 mm Hg - PaO2 < 60 mm Hg - Respiratory acidosis - Paradoxical breathing (Abnormal inward movement of chest on inspiration and outward movement on expiration) - Mental status changes (Restlessness, confusion) - Absence of wheezing and silent chest - Single word dyspnea - What are clinical manifestations of impending respiratory failure? 1.5-2.5 mEq/L - What is the therapeutic level of magnesium? 4-7 mEq/L - What is the therapeutic level of magnesium sulfate for a pre-eclamptic patient? 4,000-11,000/mm3 - What is the normal range for WBCs? Neutropenia - Considered an absolute neutrophil count below 1,000/ mm3 Severe neutropenia - Considered an absolute neutrophil count below 500/mm3 Take a warm shower/bath upon awakening; Heat decreases stiffness and promotes muscular relaxation/mobility - What is an intervention to prevent morning stiffness of affected joints in patients with RA? Epidural hematoma - Defined as the accumulation of blood between the skull bone and dura mater Epidural hematoma - This kind of hematoma results from an arterial bleed, therefore it develops quickly and is an emergency Subdural hematoma - This kind of hematoma results from a venous bleed, therefore it develops slowly and is an extreme emergency Offer an elbow for guidance and walk slightly ahead of the patient - When walking with a client who is blind, what is proper protocol? Ensure cuff is inflated - For clients with a tracheostomy on mechanical ventilation, what nursing intervention is vital to prevent aspiration? Hemorrhagic stroke - This type of stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space - Too much stimulation (Bright room, frequent visitors) - Straining bowel/bladder - Coughing/sneezing - Exertion - HOB supine - Head off from midline position - What types of activities/interventions increase ICP? - Vasodilation: Hypotension and edema - Tachycardia - Stridor/hoarseness - B: Hepatitis B - D: DTaP - R: RV - H: Hib -I: IPV - P: PCV - Related to immunizations for a 6 month old patient, what does the acronym Be DR HIP stand for? - Suicide - Homicide - Accident - Within 24 hours of admission of facility - Under what circumstances is consent from family for an autopsy not required? We - waist circumference Better - blood pressure Think - Triglycerides High - HDL Glucose - Glucose - Related to metabolic syndrome, what does the nematic "We Better Think High Glucose" stand for? Raynaud's phenomenon - During a typical episode of this disease, digital arteries constrict and blood flow is impaired, causing the skin to turn pale and then blue, and feel numb and cold Potassium - This electrolyte is released when cellular damage occurs with burns - Muscle weakness - ECG changes (Tall, peaked t-waves, shortened QT interval) - Cardiac arrhythmias - What are the clinical manifestations of hyperkalemia? Myopia - Defined as nearsightedness - Headaches - Dizziness - Difficulty seeing objects clearly - Poor performance in school - Rubbing of eyes - Frequent blinking or squinting - What are the clinical manifestations and parent reports of children suspected of having myopia (Nearsigntedness)? Hirschsprung disease (HD) - This congenital disease occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering anal sphincter unable to relax; No peristalsis occurs & no stool is passed Ototoxicity - What is a major AE of high dose IV furosemide (Lasix) administration? 4 mg/min (Over 40 min) - For furosemide doses > 120 mg, what should the dosage/min not exceed? Opioids & benzos - Neonate abstinence syndrome is typically caused by abuse of what drug classes during pregnancy? - ANS: Stuffy nose, sweating, frequent yawning and sneezing - CNS: Irritability, restlessness, high pitched crying, abnormal sleep pattern, hyperactive reflexes - GI: Poor feeding, vomiting & diarrhea - What are clinical manifestations of neonate abstinence syndrome? - Supine positioning - Instruct pt to bear down & exhale - Apply air occlusive dressing - Pull line out cautiously (Do NOT pull harder if there is resistance) - What are proper nursing interventions when discontinuing a central venous catheter to prevent an air embolism from forming? IV 50% dextrose and regular insulin - For a patient with advanced kidney disease with a serum potassium of 7.1 and a serum creatinine of 4.5 with NO CURRENT ECG changes, what is the priority for the nurse to administer? Calcium gluconate IV followed by insulin/dextrose IV - For a patient with advanced kidney disease with a serum potassium of 7.1 and a serum creatinine of 4.5 with ECG CHANGES, what is the priority for the nurse to administer? - EPS - Tardive dyskinesia (TD) - Protruding and twisting of tongue - Lip smacking - Puffing of cheeks - Frowning/blinking of eyes - Twisting fingers - Twisted/rotated neck (torticollis) - What are the adverse effects of Metoclopramide (Reglan)? (Think antipsychotics) CCB - Non-dihydropiridine (Verapamil, Diltiazem) - This class of blood pressure medications has a direct effect on the HR and should be held for HR < 60 bpm Greater than or equal to 20 bpm increase - Positive orthostatic vital signs is a rise in pulse of how many bpm? Before - For patients diagnosed with CF, should bronchodilator treatments be administered before or after chest physiotherapy? Exophthalmos - A complication of hyperthyroidism defined as a protrusion of the eyeballs caused by increased orbital tissue expansion and can be irreversible - Maintaining HOB in raised position to facilitate drainage from periorbital area - Use of artificial tears to moisten eyes - Taping eyelids shut during sleep if they do not close on their own - Educate on importance of regular visits to ophthalmologist - Educate on importance of anti-thyroid medications - Restrict salt intake - Encourage smoking cessation - Use dark glasses to prevent irritation to eyes - Do eye ROM exercises - What is proper nursing management for patients experiencing the complication of Graves disease, exophthalmos? 30 mL - How many mL in one ounce? 2/3 inflated - When administering a non-rebreather mask, the oxygen flow rate must be high enough to keep the reservoir bag how inflated? - Finger tapping (tapping each finger to that hand's thumb) - Rapid alternating movements (Rapid supine and pronation) - Finger to nose testing - Heel to shin testing (Run heel down opposite shin) - What are proper nursing interventions to assess proper cerebellum functioning? Beta Blockers (BBs) - What blood pressure medication class can actually worsen heart failure symptoms by decreasing normal compensatory sympathetic nervous system responses and myocardial contractility Systemic lupus erythematosus (SLE) - Defined as an autoimmune disorder in which an abnormal immune response leads to chronic inflammation in different parts of the body Kayexalate - What is the trade name for sodium polystyrene sulfonate Sodium polystyrene sulfonate - What is the generic name for Kayexalate? Request a meeting with the palliative care team and the parents to discuss end of life choices - For an infant diagnosed with Edward's syndrome, what is an appropriate nursing action at birth? - Wear gloves when handling cold objects - Dress in warm layers in cold weather - Avoid extreme abrupt weather changes (Cold to hot) - Avoid vasoconstriction drugs (Cocaine, amphetamines, ergotamine, pseudoephedrine) - Refrain from tobacco products - Constipation - Cool/pale skin - Brittle nails/hair - Hair loss - Bradycardia - Joint pains/muscle aches - Dementia/depression due to mental slowing - Cold intolerance - Weight gain - Forgetfulness - What are the clinical manifestations of hypothyroidism? (Think slow) - Diarrhea - Warm, moist skin - Smooth, silky hair - Tachycardia/palpitations - Heat intolerance - Weight loss - What are the clinical manifestations of hyperthyroidism? (Think fast) 1) Place client in semi recumbent position 2) Have client breathe normally 3) Determine SBP using manual cuff 4) Inflate BP cuff to at least 20 mm Hg above previously measured SBP 5) Deflate cuff slowly, noting first korotkoff sound during expiration along with the pressure 6) Continue to slowly deflate cuff until you hear sounds throughout inspiration/expiration 7) Determine difference between two measurements, equaling amount of paradox - What is proper procedure for measurement of pulses paradoxus? Hyponatremia - This electrolyte imbalance can lead to seizures, confusion or other neurologic complications - Fluid restriction to < 1000 mL/day - Oral salt tablets - Hypertonic saline (3%) - Vasopressin - What is the treatment for SIADH? VAP - Ventilator associated pneumonia - Defined as the second most common health- care associated infection in the US, associated with increased mortality, hospitalization and length of stay - Purulent sputum - Positive sputum culture - Leukocytosis - Elevated temperature (> 100.4 F) - New progressive pulmonary infiltrates on chest x-ray - What are the clinical manifestations of VAP (Ventilator associated pneumonia)? Psoriasis - Defined as a chronic autoimmune disease that causes a rapid turnover of epidermal cells - Avoid triggers (Stress, trauma, infection) - Topical therapy (Corticosteroids, moisturizers) - Phototherapy (Ultraviolet light) - Systemic medications (Methotrexate, infliximab) - Avoidance of alcohol - Though there is no cure for psoriasis, what is proper nursing management? Cytotoxic and biologic agents such as: - Methotrexate - Infliximab - What pharmacologic agents are shown to assist in treatment of psoriasis? Scleroderma - Defined as an overproduction of collagen that causes tightening and hardening of the skin and connective tissue; Progressive and no current cure Renal crisis - Defined as a life threatening complication of scleroderma that causes malignant hypertension; Potentially fatal Sims' position - to facilitate movement of co2 utilized during surgery to fill the abdominal cavity - For patients post laparoscopic cholecystectomy, what is proper positioning post op and why? Ileostomy - Defined as a surgically created opening (stoma) in the abdomen that connects the small intestine to the external abdomen (Think placement) Ileostomy - In this type of ostomy, stool from the small intestine bypasses the colon and exits through external opening of abdomen via ostomy bag Liquid stool - when stool bypasses the colon, fluid and electrolyte absorption and vitamin k production do not occur, resulting in liquid stool - For patients with an ileostomy, what kind of stool will form and why? - High fiber (popcorn, coconut, multigrain bread) - Stringy veggies (Celery, broccoli, asparagus) - Seeds or pits (Strawberries, rasberries, olives) - Edible peels (Apple slices, cucumber, dried fruit) - What diet items should be absolutely avoided for a patient with an ileostomy? Calcium - The parathyroid gland regulates what serum electrolyte levels? Tamiflu - What is the trade name for Oseltamivir? Oseltamivir - What is the generic name for Tamiflu? Claratin - What is the trade name for Loratadine? Loratadine - What is the generic name for Claratin? Promethazine - What is the generic name for Phenergan? Phenergan - What is the trade name for Promethazine? Cerebrospinal fluid (CSF) - Leakage of this fluid can confirm skull fracture has occurred and transversed the dura - Raccoon eyes & Battle's sign; Indicates leakage of CSF - What are two clinical indications that confirm a skull fracture? What does this indicate? - Remove clothing & jewelry to prevent constriction - DO NOT MASSAGE, rub or squeeze area involved (Will lead to further tissue damage) - Immerse affected area in heated water (98.6-102.2F) - Provide analgesia during rewarming (Painful) - Monitor for compartment syndrome - What does the treatment of frostbite consist of? Thoracentesis - This procedure is commonly used to treat pleural effusions - Pneumothorax - Bleeding - Tension pneumothorax - Infection - What are some complications of thoracentesis? - Increased RR - Increased respiratory effort - Respiratory distress - Low pulse ox - Absent breath sounds on affected side - What are the clinical manifestations of a patient developing a pneumothorax? - Take medication at the same time daily - Report for periodic blood tests to assess for therapeutic effect - Avoid contact sports, vigorous teeth brushing and use of razor blades - Avoid aspirin and other NSAIDs - Avoid changing eating habits (Increase of leafy greens) - Do NOT take vitamin K supplements if on warfarin - Consult HCP before starting/stopping any herbal supplements (Ginko, garlic etc) - Wear a medical alert bracelet indicating what anticoagulant is being taken - What are some important patient teaching points related to anticoagulation therapy? similar to differentiate between - The nurse has orders to administer both blood products and Amphoteracin B. How should the nurse go about administering both of these medications? Why? - Remain with client - Protect airway using head tilt chin lift OR jaw thrust if spinal injury suspected - Deliver rescue breaths using bag-valve-mask with 100% o2 until re-intubation is achieved - If accidental extubation occurs when repositioning/turning a sedated patient in the ICU, what are vital nursing actions? Headache due to vasodilation of cranial vessels - After administering IV nitroglycerin to a patient with angina, what is an expected side effect from medication therapy and why? Tubing became disconnected OR there is an air leak - What could a low pressure alarm on a ventilator indicate? - Tubing is kinked - Obstruction (secretions) in tube - Pt is biting endotracheal tube (Fighting ventilator) - What could a high pressure alarm in an endotracheal or tracheostomy tube indicate? - Falls - Mislabeled laboratory specimens - Medication administration errors - Failure to communicate pertinent patient information to HCP - What are examples of client incidents that would require completion of an incident report? Buccal mucosa & conjunctivae - Where is the best area to assess for petechiae in dark skinned clients? Palms of hands and soles of feet - Where is the best area to assess for jaundice in dark skinned clients? - Activity intolerance - Barrel chest - Hyperresonance on percussion - Use of accessory muscles - Pursed lip breathing - Placement in tripod position - What are assessment findings found in patients with emphysema? T- Toxoplasmosis O - Other: Parovirus, varicella R - Rubella C - Cytomegalovirus H - Herpes simplex virus - What does TORCH stand for related to gestational infections that can cause fetal abnormalities - Move patient out of large bodies of water - Dry chest area before applying pads - Remove transdermal medication patches before application of AED - Before applying AED pads to a patient in the community setting, what are nursing considerations to have? - Hyperphosphatemia - Hyperkalemia - Hyperuricemia - Hypocalcemia - What are the severe electrolyte abnormalities seen in chemotherapy induced tumor lysis syndrome? Tumor lysis syndrome - Defined as an oncologic emergency occurring when cancer treatment successfully kills cancer cells, resulting in release of intracellular components, such as electrolytes - Fever or hypothermia - Poor feeding - Vomiting - Altered LOC (Irritable, restless) - Increased ICP (Bulging fontanelle) - What are s/s of meningitis in an infant? Laryngotracheobronchitis aka Croup - In pediatric clients, an occasional barking cough without stridor is most likely what? - Green, black, white or dusky coloration - Accumulations of air - Evidence of clotting or presence of inclusions - Malodor - Upon examination of an IV bag containing blood products, what are examples of indications of contaminated blood? Contamination - Return blood to blood bank & obtain a new bag - Upon examination of an IV bag containing blood products, what does a large air bubble at the top of the bag indicate? What is the proper nursing action? - Female gender - Older adults - Patiens with DM experiencing neuropathy - Patients with what two characteristics/history will have atypical presentation of MI symptoms? - Described as chest pressure, heaviness, tightness - Pain may radiate to jaw, arm, back or upper abdomen - CP lasting more than 30 minutes - CP not improved with rest or position changes - CP worsens with exertion - What are the TYPICAL clinical manifestations of impending MI? DMARD: Immunosuppressant Educate about: - Increased risk for infection - Bone marrow suppression - Avoid large crowds - Avoid known sick contacts - What drug class is Cyclosporine in? What does the nurse need to educate patients prescribed this about? Constipation - What is an AE of the gastrointestinal tract upon taking calcium channel blockers, specifically Verapamil? - Bradycardia - Irregular respirations - HTN with a widening pulse pressure - In relation to increased ICP, what defines the Cushing triad? Singed facial hair - Upon assessment of a patient, what assessment finding can indicate possible smoke inhalation injury? - Hypotension - Bradycardia - Dizziness - What are s/s of pacemaker malfunction? - Antiarrhythmics (Sotolol, amiodarone, ibutilide, dofetilide) - Macrolide antibiotics (Erhtyromycin, azithromycin) - Electrolyte abnormalities (Hypokalemia, hypomagnesemia) - What are examples of medications/medical conditions that can prolong QT interval and precipitate an episode of torasdes de points? Supine - For patients in restraints, what position is contraindicated due to increased risk for aspiration? - Side lying - Semi Fowler - High Fowler - What 3 positioning techniques are recommended for patients in restraints? - Hemoglobin > 11 g/dL - Uncontrolled HTN