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NCLEX study - Mark Klimek Blue book (the A's)

NCLEX-RN study questions from Mark Klimek's blue book - Abruptio Placenta, Accidental Poisoning, Acne, Aquired Immune deficiency syndrome,Acute Glomerular Nephritis, Adult Development, Amputation, Aneurysm, Agina Pectoris, Anorexia Nervosa, Apgar Scoring, Appendicitis
In Abruptio Placenta, the placenta _______________ from the uterine wall ____________.
Separates, prematurely
Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________.
Multi, 35 (HTN, trauma, cocaine)
How is the bleeding of Abruptio Placenta different from that in placenta previa?
pain and less voluminous in abruptio
If you are the nurse starting the IV on the client with Abruptia Placenta, what guage needle should you use?
18 (in preparation to give blood if necessary)
How often should you measure the vital signs, vaginal bleeding, fetal heart rate during Abruptio Placenta>?
Q5-15 minutes for bleeding and maternal VS, continuous fetal monitoring, deliver at earliest sign of fetal distress
How is an infant delivered when Abruptio Placenta is present?
Usually C-section
Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa?
In what trimester does Abruptio Placenta most commonly occur?
At what age are accidental poisonings most common?
2 years old
If a child swallows a potentially poisonous substance, what should be done first?
call medical help
When taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER?
the suspected poison
An elderly client is a (high/low) risk for accidental poisoning? What about a school age child?
high - due to poor eyesight, high
What types of chemicals cause burns to oral mucosa when ingested?
Lye, caustic cleaners
Children at highest risk for seizure activity after ingestion are those who have swallowed _____________ and ______________.
drugs, insecticides
Can impaired skin integrity ever be an appropriate nursing diagnosis when poisoning has occurred?
Yes, when lye or caustic agents have been ingested
What is the causative organism of acne?
P. acnes (propionibacterium acnes)
What structures are involved in acne vulgaris?
The sebaceous glands
Name 3 drugs given for acne?
Vitamin A, Antibiotics, Retinoids
Dietary indiscretions and uncleanliness are causes of acne?
What are the 3 causative factors in acne vulgaris?
Heredity, Bacterial, Hormonal
What is the most common retinoid given to people with acne?
Accutane is an analog of which vitamin?
Vitamin A
What is the most common side effect of accutane and Tetracycline?
birth defects
What is the antibiotic most commonly given to clients with acne?
How long will it take for the person to see results when acne is being treated?
4 to 6 weeks
Does stress make acne worse?
How often should the client with acne wash his face each day?
twice a day
What instructions do you give to a client taking tetracycline?
Take it on an empty stomach and avoid the sunlight (photosensitivity)
What are comedones?
Blackheads and white heads
What virus causes AIDS?
HIV - Human immunodeficiency virus
The AIDS virus invades helper ____________.
T-lymphocytes (or CD4 cells)
AIDS is trasmissible through what four routs?
blood, sexual contact, breast feeding, across placenta in utero
HIV is present in all body fluids?
Yes, but not transmitted by all, only blood, semen and breast milk
Name the 5 risk groups for AIDS
Homosexual/bisexual men, IV drug users, hemophiliacs, heterosexual partners of infected people, newborn children of infected women
What is the first test for HIV antibodies?
What test confirms the ELISA?
Western Blot
Which test is the best indicator of the progress of HIV disease?
CD4 count
A CD4 count of under __________ is associated with the onset of AIDS-related symptoms.
A CD4 count of under _______ is associated with the onset of opportunistic infections.
Give 6 symptoms of HIV disease.
Anorexia, fatigue, weakness, night sweats, fever, diarrhea
Which 2 classes of drugs are given in combination for HIV sero-positivity?
NRTI's (nucleoside reverse transcriptease inhibitors) and PI's (protease inhibitors)
NRTI (nucleoside reverse transcriptease inhibitors)
an antiviral drug used against HIV (is incorporated into the DNA of the virus and stops the building process; results in incomplete DNA that cannot create a new virus; often used in combination with other drugs)
PI's (Protease inhibitors)
most potent of antiviral meds, inhibit cell protein synthesis that interferes with viral replication, does not cure but slows progression of AIDS and prolongs life, used prophylactically, used in AIDS to decrease viral load and opportunistic infections
What do NRTI's and PI's do?
They prevent viral replication
What does the physician hope to achieve with NRTI's and PI's for HIV?
A delayed onset of AIDS for as long as possible (usually can delay onset for 10-15 years)
What is the most common NRTI used?
AZT (zidovudine)
What is the most challenging aspect of combination of drug therapy for HIV disease?
The number of pills that must be taken in 24 hours can be overwhelming. The frequency also makes it hard to remember-an alarm wristwatch is used.
Clients with AIDS (gain/lose) weight?
The typical pneumonia of AIDS is caused by ___________ ____________.
Pneumocystic carinii
What type of oral/esophageal infections do AIDS patients get?
What is the #1 cancer that AIDS patients get?
Kaposi's sarcoma
Kaposi's sarcoma is a cancer of the ___________.
T/F: AIDS patients get lymphomas?
What lab findings are present in AIDS?
Decreased RBC's, WBC's and platelets
If the AIDS patient has leukopenia they will be on _____________ ________________.
protective (reverse) isolation
Define Leukopenia
decrease in wbc, indicated viral infection
Without leukopenia the AIDS patient will be on ____________ precautions.
Standard precautions or blood and body fluid precautions
When the AIDS patient has a low platelet count, what is indicated?
bleeding precautions; No IM's, no rectal temperatures, other bleeding precautions
Does AIDS require a single room?
Yes - if WBC counts are low
When do you need a gown with AIDS?
If you are going to get contaminated with secretions
When do you need a mask with AIDS?
Not usually unless they have an infection caused by an airborne bug
When do you need goggles with AIDS?
Suctioning, central line start, arterial procedures
If an AIDS patient's blood contaminates a counter top, with what di you clean?
1:10 solution of bleach and water
Are all articles used by AIDS patients double-bagged?
no - only those contaminated with secretions
Can AIDS patients leave the floor?
Yes, unless WBC's are very low
Is dietary protein limited in AGN?
Not usually, however if there is severe azotemia then it may be restricted
Define azotemia?
nitrogenous wastes in the blood (increased creatinine, BUN)
What is the best indicator of renal function?
The serum creatinine
Do people recover from AGN?
Yes, the vast majority of all clients recover completely from it
How can AGN be prevented?
By having all sore throats cultured for strep and treating any strep infections
What is the most important intervention in treating AGN?
Bedrest - they can walk if hematuria, edema and hypertension are gone.
What is the most common dietary restriction for AGN?
Moderate sodium restriction. Fluid restriction is #2 if edema is severe.
What are the urinaysis findings on AGN?
2 to 3 weeks after initial infection
How do you assess fluid excess in the child with AGN?
Daily weight
What organism causes acute glomerular nephritis?
Group A beta hemolytic strep
What happens to the kidney in AGN?
It becomes clogged with antigen-antibody complexes which then cause inflammation and loss of function.
How often are vital sign measurements taken in AGN?
Q4 hours with blood pressure
Will the client have hypo or hyper tension with AGN? Why?
Hypertension, because of fluid retention
What are the first signs of AGN?
Puffiness of face, dark urine
What are the three adult stages of development called
early adulthood, middle adulthood and later adulthood
What is the age range for early adulthood?
19 to 35 years of age
What is the age range for middle adulthood?
35 to 64 years of age
What is the age range for late adulthood?
64 years of age to death
What is the developmental task for early adulthood?
Intimacy vs. Isolation
What is the developmental task for middle adulthood?
Generativity vs. stagnation.
Intimacy vs. Isolation
Erikson's stage in which individuals form deeply personal relationships, marry, begin families
Generativity vs. Stagnation
Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service
What is the developmental task for later adulthood?
Ego Integrity vs. Despair
Ego Integrity vs. Despair
(Erikson) People in late adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be relived
"Time is too short to start another life, though I wish I could," is an example of ___________.
"If I had to do it over again, I'd life my life just about the same," is an example of ____ ____________
Ego Integrity
What does AKA mean?
Above the knee amputation
What does BKA mean?
Below the knee amputation
If the patient had an AKA they should lie ____________ several times per day.
prone (to prevent flexion contracture
The #1 contracture problem in AKA is ____________ of the _____________
flexion, hip
What will prevent hip flexion contracture after AKA?
Lying prone several times a day
What is the #1 contracture problem after BKA?
Flexion of the knee
How do you prevent flexion contracture of the knee after BKA?
Remide the patient to straighten their knee constantly while standing
To prevent post-op swelling, the stump should be __________.
How long should the stump be elevated to prevent post op swelling?
12-24 hours
How often should a stump be washed?
When a stump is wrapped, the bandage should be tightest _____________ and loosest _____________.
distally (far from the center), proximally (neareast to the point)
If after a right BKA, the client c/o pain in his right tow, he is experiencing _____________.
phantom limb sensation (which is normal)
When will phantom limb sensation subside?
in a few months
Name ways to toughen a stump so it will not breakdown due to the wear of the prosthetic leg?
push the stump against the wall, hitting it with a pillow
An aneurysim is an abnormal _______________ of the wall of a(n) artery.
widening (it is also weakening)
What artery is widened in a thoracic aneurysm?
the aorta
An aneurysm can result from an _____________ and from ____________.
infection, syphilis
The most common symptom of abdominal aneurysm is:
a pulsating mass above the umbilicus
Which aneurysm is most likely to have no symptoms?
the abdominal is most often "silent"
Which vital signs are most important to measure in clients with aneurysm?
The pulse and blood pressure
An aneurysm will most affect which of the following, the blood pressure or the pusle?
the pulse (many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change.
What activity order is the client with an aneurysm supposed to have?
Bedrest. do not get these people up
If the client with aneurysm is physically unstable, should you encourage turning, coughing and deep breathing?
no, bedrest until the client is stable!
What class of drugs is the client with an aneurysm most likely to be on?
What is the BIG danger with aneurysms of any type?
Rupture, leads to shock and death
If an aneurysm is ruptured how would you know it?
decreased LOC (restlessness), tachycardia, hypotension - all signs of shock
If an aneurysm ruptures what is the #1 priority?
Get them to the operating room ASAP
Is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room?
Yes, if available you can get them into antishock trousers but not if this causes a delay in getting them to the operating room
The post op thoracic aneurysm is most likely to have which type of tube?
Chest tube, because the chest was opened
The post op abdominal aneurysm repair client is most likely to have which type of tube?
NG tube for decompression of bowel
If you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hours?
check the distal extremity (far from center) for color, temperature, pain and PULSE, also document
What causes angina pectoris?
Decreased blood supply to myocardium, resulting in ischemia and pain
Describe the pain of angina pectoris
crushing substernal chest pain that may radiate
What drug treates angina pectoris?
How do you tell if a client has angina or an MI?
the pain of the two is similar, the way to tell the difference is if nitro and rest relieve the pain. For angina, nitro and rest relieve the pain, for MI, nitro and rest do not relieve the pain
How many nitro tabs can you take before you call the doctor?
How many minutes should lapse between the nitro pills you take?
5 minutes - take one nitro tab every 5 minutes 3 times, if no relief, call MD
By what route do you take nitro?
What is the action of nitro?
dilates coronary arteries to increase blood supply (O2 supply) and reduces preload.
What are the top 2 side effects of nitro?
headache and hypotension
What precaution must the nurse take when administering topical nitro paste?
wear gloves, nurse may get a dose of the med
Everyone with angina needs bypass surgery? t/f
Anorexics are usually __________ under the age of _____.
females, 25
The diagnosis is made when there is a weight loss of _______% or more of body weight.
15 (weigh < 85% of normal body weight), hospitalize if 30% weight loss
A major mental/emotional nursing diagnosis seen in anorexia nervosa is ___________.
Altered body image
The pulse rate of anorexics is tachycardic or bradycardic?
List the most common gynecologic symptom of anorexia nervosa?
What is found over the body of the client with anorexia nervosa?
What is the top priority in the care of the client with anorexia nervosa?
intake of enough food to keep them alive, have them gain weight
The best goal to evaluate the progress of the client with anorexia nervosa?
an adequate weight gain
What is the apgar scale?
quick objective way to evaluate the vital functions of the newborn
When is apgar scoring performed on infants?
at one minute and again at 5 minutes after the birth
Name the 5 criteria that are recorded on an apgar scale
Cardiac status, respiratory effort, muscle tone, neuromuscular irritability, and color
The total apgar score can range from
0 to 10
The maximum score and infant can receive on any one of the criteria is
A 10 on the apgar means the baby is
in terrific health
A 0 on the apgar means the baby
is stillborn
On heart rate or cardiac status, a 2 means that the HR is above _______ BPM.
On the HR criteria an infant scores a "1" if their HR is _________ than 0 and ____________ 100
greater, less than
Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.
Apendicitis is an _________ of the appendix due to __________.
inflammation, obstruction
Apendicitis occurs most in what age group?
15 to 35
What is the most common complication of appendicitis?
inflammation of the peritoneum
What is the first sign of appendicitis?
right upper quadrant pain
What follows the RUQ abd pain of appendicitis?
Where does the pain of appendicitis finally end up?
What is the name of the RLQ abd pain where appendicitis pain finally localizes?
McBirney's point
What is present when rebound tenderness is present?
Peritoneal inflammation
What is the hightes that the temp will be in appendicitis?
102 F
What blood count is elevated in appendicitis?
What is the name for an elevated WBC?
What is the only treatment recommended for appendicitis?
surgery - appendectomy
Before the client with suspected appendicitis sees the physician what should be avoided?
pain meds, enemas, laxatives, food! NPO
To lessen pain place the client in ___________ position.
fowlers (a sitting position) (also use post op)
Never apply __________ to the area of the appendix.
heat (it causes rupture)
After appendectomy, document in the nurses notes the return of __________
bowel sounds (peristalsis)