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Remar Quick Facts for Nclex
Terms in this set (529)
What is the parkland formula?
4 ml of LR x wt(kg) x % of body burned
What is the primary symptom of GERD?
What tests confirms GERD?
Barium Swallow fluoroscopy
What malfunction allows reflux in GERD?
lower esophageal sphincter
what is the client teaching for GERD?
Low fat high protein diet, take antacids, avoid lying flat after meals
What is the virus that causes AIDS?
human immunodeficiency virus (HIV)
How is HIV transmitted?
sexual intercourse, direct contact with infected blood/ body fluids ( body fluids- semen, breast milk) HIV mother gives birth to baby
What are the symptoms of HIV
Fever, weight loss, night sweats, diarrhea, fatigue
How is the presence of HIV confirmed?
Screening is done FIRST to see if HIV antibodies are present. The test is performed to specifically identify the HIV antibodies
What is the screening for AIDS?
What confirms the screening test for HIV
Hos does HIV attack the body?
It attacks the immune system by destroying T-lymphocytes The virus also rapidly self=replicates
What is so important about T-lymphocytes?
T cells help immune system + recognize and fight pathogens
What is another name for T-Lymphocytes?
Why is the CD4 count important?
The lower the CD4 count the more damage the virus has done to the body.
What is a normal cd4 count?
What is the normal CD4 count in a client with HIV?
Anything at or above 500. Client is considered in good health. If below 500 HIV has progressed to AIDS.
If a client's CD4 count is below 200, client is at risk for what?
List some opportunistic Infections
-Oral pharyngeal canididal infection (mouth fungus)
-Kaposi's sarcoma (skin cancer)
What is the goal of HIV medications?
To interfere with the virus replicating
The most important medication for HIV/ AIDS is?
Zidovudine (AZT, Retrovir)
Which isolation precautions are used with HIV?
Universal precautions, patients do not have to tell you they have HIV, treat everyone as if they are INFECTED!
How do the precautions change with AIDS?
If the client has a low CD4 count and is at risk for opportunistic infection implement private room, reverse isolation, RN wears gown, goggles, and mask when in direct contact with blood or body fluids.
What are teaching points for parents who have a child with HIV
clean up body fluid/blood with a 10:1 water/bleach ratio
get all immunizations except MMR, Varicella and oral poliovirus(live vaccines)
High Calorie High protein diet
gloves when changing diapers.
What is the definition of ACUTE RENAL FAILURE?(ARF)
Sudden loss of kidney function to excrete toxins and regulate fluids/electrolytes
What are some possible causes of ARF?
Infection, obstruction, shock
What are the three phases of ARF
Oliguric, diuretic, recovery
During the Oliguric phase what will you see?
This phase lasts one to two weeks.
Low urine output <400
hyperkalemia, hypertension, elevated BUN/creatinine
What other two electrolytes will be elevated in the oliguric phase of ARF?
Sodium and potassium
The diuretic phase is second in ARF what will you see?
Urine output slowly returns, hypokalemia, hypotension, BUN/creatinine decreases but still elevated.
What does recovery phase mean?
Kidneys are recovering through a slow process, urine vl & BUN is normal
What are nursing interventions? ARF
Daily weights strict I and O treat the causes of renal failure and diuretics
What is the best diet for a client with ARF?
High carb & low protein
Clients allergic to latex may also be allergic to which foods?
bananas, kiwi, chestnuts
What standard hospital equipment contains latex?
Blood pressure cuffs, gloves, stethoscopes, tourniquets, band aids, and indwelling catheters
What allergy is contraindicated for IV contrast dye?
What are the major complications of having an amputation performed?
Infections, skin breakdown, phantom limb pain, joint contractures
what is the positioning for post op care? AKA (above the knee) amputation
Elevate first 24 hours, then prone position twice daily to prevent hip flexion
What is the positioning for post op care BKA(below the knee) amputation
elevate foot of bed first 24 hours, then prone position twice daily to prevent hip flexion
What should you encourage with an amputation?
Expressing feelings about lost limb
Pain felt in an area that has been amputated
Pain felt in an area that has been amputated
True or False? An aneurysm is a dilation formed at a weak point on the wall of an artery
What are the symptoms of aneurysms inside the body?
most aneurysms inside the body have NO symptoms
what sound would be heard on auscultation of an aneurysm
what are some of the risk factors of an aneurysm
arteriosclerosis, infection (syphilis), smoking, HTN
What is the treatment for an aneurysm?
Surgery-depends on size, strict blood pressure control with medications
What are the signs of a ruptured aneurysm?
Severe pain, nausea, vomiting, tachycardia, decreased level of conscious, hypotension
List important NCLEX teaching points for aneurysm?
Avoid straining, lifting, or exerting, take medications on schedule, report severe back/flank pain.
What is the primary symptom of anorexia nervosa
what is the perception of the body with anorexia nervosa
at what age does anorexia nervosa occur
What is the usual personality type of someone with anorexia nervosa
perfectionist, overachievers, low esteem
What is a major cardiac complication of anorexia?
What is a majore gynecological complication of anorexia?
What is the treatment involved in the recovery of anorexia
small, frequent meals with inpatient counseling and milieu therapy
Commonly seen in what age range? Appendicitis?
What is the classic sign of appendicitis?
Acute right lower abdominal pain
what are some other signs/ symptoms of appendicitis?
loss of appetite, nausea, vomiting, low grade fever
Localized tenderness is found where in appendicitis?
What are the tests used to determine appendicitis?
Complete history and physical exam with WBC it will be elevated
What is the treatment for appendicitis?
Immediate surgery to remove the appendix, IV antibiotics, Semi-Fowlers position, NPO- gut t rest
What is the general treatment for any acute abdominal pain?
NPO status, no heat on abdomen, assess abdominal distention, IV fluid therapy.
Where are most ABG samples drawn from?
Radial artery in wrist
How long should pressure be applied to the site after collecting an ABG sample?
What test should be performed before collecting an ABG on a client?
Asperger's syndrome is from what?
What is the treatment focuses on improving with Aspergers?
Communication/ patient social skills
An obstructive airway disease caused by ________ and ________ of the bronchioles?
spasms and inflammation
What are the signs of asthma
Shortness of breath, tachycardia, expiratory wheezes, and possibly a cough.
When will the client experience the cough with Asthma?
What is the primary treatment goal for asthma?
identify the allergens
What medications work best for the treatment of asthma?
Anti-inflammatory, Corticosteroids, Bronchodilators, leukotriene modifiers, metered dose inhalers
Which should you give first- the steroid or the bronchodilator- when treating asthma?
What are leukotriene modifiers?
they are drugs used to block the chemical leukotriene which reduces inflammation.
STEPS TO USE A METERED DOSE INHALER
1. Shake the inhaler well before use; 3 to 4 shakes.
2. Remove the cap
3. Breathe out, away from your inhaler
4. Bring the inhaler to your mouth. Place it in your mouth between your teeth and close your mouth around it.
5. Start to breathe in SLOWLY, press the top of your inhaler once and keep breathing in slowly until you have taken a full breath (3-5 seconds)
6. Remove the inhaler from your mouth and hold your breath for about 10 seconds then breath out.
What are NCLEX teaching points for Metered dose inhaler
if patients cannot tolerate the bitter taste use a spacer, rinse your mouth after each dose to prevent thrush, client should wait only one minute between each puff.
Autonomic dysreflexia occurs in clients with what kind of injury?
Spinal cord injury ( T-5 or above)
What can cause autonomic dysreflexia?
Noxious stimuli such as a full bladder or fecal impaction
Why is autonomic dysreflexia so serious?
Life threatening due to clients becoming extremely HYPERTENSIVE
What are the signs of autonomic dysreflexia
Increased BP 40 mm/Hg, headache, bradycardia, blurred vision, sweating
What should be done during an episode of Autonomic Dysreflexia
Place client in high fowlers, check bladder distention, loosen clothing
What is the treatment for Autonomic dysreflexia?
Removal of the stimuli, patient needs to void/ bowel movement
What cranial nerve is affected in bells' palsy
Cranial nerve #7
What does the client with Bell's palsy suffer from?
Temporary facial paralysis, that affects chewing, eating and closing the eye
What is the treatment for Bell's palsy?
Wear an eye patch at night, use artificial tears, wear glasses to protect the eye, STEROIDS to reduce edema and swelling
BPH is caused by?
The cause is unknown, but its an enlargement of the prostate gland.
Because the prostate blocks the urethra opening, clients will feel and see what when they urinate?
Straining to urinate, decreased urine stream, feeling like they have to go all the time, dribbling urine flow
Who usually gets BPH
Men usually > 50.
What is the best way to assess for BPH
Rectal exam, physician will feel a pea-sized nodule
What is the common surgical treatment for BPH?
Transurethral resection of the prostate (TURP)
How is a TURP performed?
Aa scope goes through the penis and removes part of the prostate.
After a TURP what is the client at risk for?
bleeding, monitor for hemorrhage
All clients will get what before a TURP>
three way lumen foley catheter
What are the three lumens for in a three way lumen foley catheter?
Inflating the balloon, inflow of solution and outflow of urine
What will the doctor order to be done after a TURP?
Continuous Bladder irrigation (CBI)
What is the goal of the bladder irrigation after a TURP?
Reduce/ prevent blood clot formation
Will an incision be made during the irrigation after a TURP?
No, irrigation will be done using the in-dwelling catheter.
What types of fluid is used to irrigate the bladder after a TURP?
Isotonic sterile saline
What color do you want the urine to be after a TURP?
During CBI what must the client be monitored for?
Bladder distention, fluid overload, hyponatremia, blood loss
If bladder spasms occur what can you give?
Belladonna/opium suppositories or Ditropan
What is the best position for a client post op TURP?
lying flat because sitting up puts pressure on the bladder
List some discharge instructions for someone who had a TURP?
Drink two to three liters of fluids daily. No lifting or straining, if bright red clots are present call MD, do kegal exercises to strengthen the pelvis muscles.
What must be received before a blood transfusion can be started?
Signed written consent
What blood type is considered universal and can be used for all other donors?
What blood type is considered the universal recipient and can receive all blood
Type AB positive
What is the most common infection spread through blood transfusion?
In order to determine donor compatibility, what must be done?
Type and cross match
What must be done to determine a clients baseline before starting a transfusion?
Take vital signs
What size IV must the client have?
18 G with a filter needle
How many nurses must confirm the unit of blood?
How long after blood is removed from the blood banks refrigerator do you have to start it?
How long must you stay with the client after transfusion is started?
How many mLs are in one unit of packed red blood cells
About 250 mL
What are the signs of an adverse reaction to blood?
Restlessness, nausea, hives, SOB, fever, chills, back pain
What do you do if an adverse reaction occurs when hanging blood?
Stop blood and run the normal saline that hangs with blood, do vitals, notify physician and blood bank,. Make sure urine and blood cultures are done.
Why must you run blood at a slow rate?
Because running blood fast can cause fluid overload
What drug is also used to treat anemia because it increases red blood cell production?
Epogen (epoetin alfa)
Clients taking Epogen should be monitored for what?
hypertension and seizures
What is blood pressure
force of blood flowing through the arteries
what is the recommended blood pressure?
what are the top and bottom values of blood pressure
systolic and diastolic pressures
Define the terms systolic and diastolic pressure
Systolic- pressure while the heart beats
Diastolic- Pressure while the heart rests
Which value determines if you have HTN?
Diastolic- if the pressure of the heart is elevated at rest, then HTN is present.
What are the risk factors for hypertension?
African American, obesity, anxiety, diabetes, smoking
What are the physical signs of hypertension?
blurred vision, headache, chest pain, but remember it is called the silent KILLER, because most have NO symptoms
How can the size of the blood pressure cuff affect the blood pressure reading?
if its too small the BP will be higher that it really is, if its too big, the BP will be lower than it actually is.
What are some factors that alter blood pressure
position, caffeine, anxiety, activity
What is pulse pressure?
The difference between the systolic and diastolic numbers
What is mean arterial pressure (MAP)?
Diastolic pressure (+) 1/3 of pulse pressure; this value should be greater than 60.
2(diastolic) + (systolic) /3
Before you give a blood pressure medication always check?
Blood pressure and pulse rate
Hold the medication if the BP is less than ? heart rate is less than?
What classes of medication are used for HTN?
Diuretics, Beta Blockers, Calcium channel blockers, Vasodilators
Medications that end in "pril" are ?
Ace inhibitors correct heart failure by _____ afterload?
Decreasing they also promote vasodilation by inhibiting the production of angiotensin.
_________ is an adverse reaction seen with the use of ACE inhibitors?
Signs of angioedema are?
Swelling of the lips and mouth
Clients may also have a persistent nagging _____ with ACE inhibitors
Which is more dangerous in angioedema: a cough or swelling of the lips and mouth?
Swelling of the lips and swelling of the mouth, may indicate laryngeal angioedema. A compromised airway is the priority.
Medications that end in "lol" are ?
Clietns who take anti-hypertensive medications should be taught what method to avoid falling?
Sit in a chair or at the bedside for 30 minutes after taking medication to adjust to a lower circulating blood pressure
what herbal medications are used to lower BP?
Clients taking anti- hypertensive medications should avoid hot showers, baths and weather? True or False
True- these things can cause dizziness
What is the best diet for hypertensive client?
Low sodium, low fate, DASH diet
Breast feeding moms will often feel what while feeding the baby?
why does breast feeding cause abdominal cramps?
its the release of prolactin and oxytocin
What is the best way to burp a bay
While he/she is sitting up
What are the benefits of breastfeeding?
Quicker weight loss in mother
After birth, increase in bonding economically less expensive
Buerger's Disease (thromboangiitis obliterans) is the obstruction and inflammations of blood vessels mainly where?
hands and feet
Clients with Buerger's Disease present with what symptoms?
pale, blue, cold hands and feet, they may tingle or be painful
who is at most risk for buerger's disease?
males who smoke or chew tobacco
What are the treatment goals for buerger's disease?
there is no cure, only symptom control; teach client to stop smoking, dress appropriately for the weather and try to reduce life stressors
What is the eating cycle of someone with bulimia
eating binges followed by purging
Will you be able to see physical changes or weight loss with someone with bulimia?
Client usually remains at the same or normal weight.
Besides purging what other methods are used to lose weight in bulimia?
Vomiting, enemas, drugs (speed), diuretics, diets and pills
What are the medical complications associated with bulimia?
Tooth decay, electrolyte imbalances, ulcers, cardiac arrhythmias
Safety is a concern in clients with bulimia because of
what are the treatment goals for bulimia?
encouraging talking, safety and assessing suicidal potential, establishing a diet plan, supervision during meal times, and antidepressants may also be prescribed.
what are the two age groups most at risk for suffering a burn injury?
children and elderly
what are the four types of burns
Chemical, electrical, thermal, radiation
if the face or neck has been burned what is the nursing priority?
you use what rule to estimate the body surface area that has been burned?
Rule of nines.
1st degree (superficial partial thickness)
skin pink, red, painful (e.g. Sunburn)
2nd degree (deep partial thickness)
Skin red/ white, blisters, swelling
3rd degree burn (full thickness)
Skin black/ brown, edema, all layers of skin burned, grafting needed.
What is the formula used to determine fluid replacement for the first 24 hours
What is the parkland formula?
4 mL of LR x wt (kg) x % ;of body
How much fluid do you give in the first 8 hours with the parkland formula?
1/2 of the total volume
How much fluid do you give for the second eight 8 hrs?
1/4 of the total volume
How much fluid do you give the third 8 hr?
1/4 total volume
Should you burst a blister
what is the best route for pain meds with burns?
What diet is appropriate with burn clients
high calorie, high protein
what is a common electrolyte problem with burn clients
Hypokalemia or hyperkalemia both can be seen in clients with burns.
Due to prolonged stress, clients are at risk for what type of ulcers?
What medication should be given before doing a dressing change?
True or false? Cancer is an abnormal growth of cells
True Growth of cells is uncontrolled
When the cancer cell travels from the original location to a new place whit is that called
What is the acronym used for warning signs of cancer
C-change in bowel or bladder
A- any sore that does not heal
U-Unusual bleeding/ discharge
T- Thickening in breast
O- obvious change in wart
N-nagging cough or hoarseness
What are the two ways to describe a tumor?
By grading and staging
What is the difference between the two?
Grading describes a tumor by the cells, staging describes the progression of the tumor by the clinical symptoms
What are the three types of radiation treatment?
External unsealed; internal sealed; and internal
What precautions must be taken for a client receiving radiation treatment?
Private room/ bathroom, limit visitors, rotate nursing staff who provide care, place a sign at door and bedside
what is the most dangerous type of radiation?
Sealed internal radiation because a solid radioactive implant is placed inside the tumor.
What additional precautions must be taken for clients receiving sealed internal radiation?
All body fluids are radioactive and you must use a hazardous clean up gown and gloves
if a client's sealed internal implant falls out (ex. Cervical implant) what should you do
Pick up with long handle
put in lead container
Chemotherapy works by destroying cell __________.
What are the side effects of chemotherapy
Nausea, anorexia, alopecia, sterility,
decreased bone marrow and platelets
Why is Reglan (metoclopramide) given?
Is the alopecia of chemotherapy permanent?
NO, it will grow back (remember, the alopecia of radiation therapy is permanent because the follicle is destroyed too)
Is the sterility from chemotherapy permanent?
Clients with cancer will also need ___________.
What are neutropenic precautions?
Strict hand washing
No visitors who are sick
No raw food, no live plants
No free standing water
What is Neupogen (filgrastim)?
Drug used to treat neutropenia; monitor WBCs
When is the best time to do a breastfeeding self exam
One week after menstruation
When is the best time to do self testicular exam?
The same day each month
If a client has had a mastectomy, can you do a blood pressure on the affected side?
No IV or BP on affected side
List some other post-mastectomy patient education tips
Elevate affected extremity, no initial exercise after surgery, encourage discussion for positive self-image
What are the criteria for a child to be in a car seat?
If they are under 4 or under 40# if no backseat no child in car!!!
What are the signs of cataracts
Milky/ white lens painless, blurred vision
How are cataracts treated?
No treatment until vision is severely impaired
During surgery for cataracts what is done?
The cataracts are removed and new lens may be implanted
After surgery for cataracrsbwill vision be corrected
Only if a new lens is placed. If no lens is placed clients will have to wear glasses
After cataract surgery what is main concern?
Check for hemorrhage of the eye. Semi-Fowlers position
What do you tell clients to avoid when having cataract surgery
Coughing, sneezing bending over at the waist straining rubbing eyes or crying
No lifting over five pounds
How should a cataract patient sleep post op?
Sleep on unaffected side or if surgery was on both eyes sleep on back use eye shield at night to protect eye.
In celiac disease malabsorption of ...... occurs
Foods containing ....... must not be eaten?
What foods contain gluten?
( barley, rye, oats, wheat)
Celiac patients abdomen ofteb look
What does a client with celiacs stool look like
Smelly pale bulky expect lots of gas with some diarrhea
The best food substitute for gluten is
Corn and rice
define the term CVA (cerebrovascular Accident)
Reduction of cerebral blood flow and oxygen causing brain cell damage
The three most common causes of a cva are
Embolism, Hemorrhage, Thrombus
What are the signs of a CVA
Client complains of headache, nausea,nuchal (neck stiffness) rigidity, HTN, slow bounding pulse, Cheyne-Stokes respirations, speech changes, facial droop
What is the difference between a CVA and a TIA
-CVA is the same process as a TIA, BUT lost function is permanent
-clots or hemorrhagic cause TIA & CVA's
-treat all strokes as hemorrhagic at very beginning unitl you know what it is for sure
What is agnosia?
Inability to use an object correctly
Expressive aphasia occurs when
Client can not communicate properly. Aphasia can be expressive or receptive
If the left hemisphere of the brain were damaged, which part of the body would be MOST directly affected?
the right half
If the right hemisphere is affected you will see weakness on the which side (CVA)
Remember to place the clients belongings on the ....... side
The tests used to determine a CVA are
CT, EEG, and Cerebral Arteriography
What are the nursing assessments of a CVA
Monitor vital signs, neuro checks, watch for seizures, monitor for increase in cranial pressure, check ability to swallow
What complication of the eye can happen in CVA patients
Corneal abrasion because lacrimal glands will not produce secretions
How should the room environment be (CVA)
Quiet, peaceful with objects in reach on unaffected side
How do you position the CVA client
Turn q 2hrs on unaffected side, 20 mins on affected side, make sure to elevate affected extremities
Why would a thrombolytic be given to the CVA client?
Do not give thrombolytics if the cause is what( CVA)
What other medications may be prescribed to treat a CVA?
Anti-hypertensive, Anti-coagulants(not for hemorrhage), Anti-convulsants
Do anti-coagulants like Coumadin and aspirin dissolve clots?
NO. They only thin the blood not dissolve clots.
What are the three disorders that make up COPD
asthma, bronchitis, emphysema
What are the signs and symptoms of copd?
SOB with activity, wheezing, productive cough, cyanosis
What would the ABG of a client w/ COPD show?
what does the chest of a client with COPD look like?
What would the fingers of a client with COPD look like?
Due to SOB w/activity clients may experience _____ _________ because of difficulty eating?
Why must you assess the amount of O2 to your COPD client receives?
COPDers keep a high level of CO2 in their blood; breathing is controlled by this fact
a client with copd should not received 02 by NC greater than _____
to control sob, the _ _ _ technique should be taught
pursed lip breathing
chronic renal failure is progressive and irreversible? true or false
what are the possible causes of CRF?
DM II ( diabetes Mellitus 2)
Renal or Urinary obstruction
what signs/symptoms would client's show?
Decreased urine output, hypertension, decreased urine specific gravity, fluid overload
what is uremic frost?
Urea crystals that come through the skin with perspiration
where would you see this frost?
Face, underarms, groin; teach client to wash skin with plain water
what are the nursing interventions for chronic renal failure?
modification of diet, diuretics, anti-hypertensives, monitor BUN and CRT, daily weight
Clients may need what to assist with waste removal
What is the best diet for chronic renal failure?
High carbohydrates, low protein; goal of this diet is to provide energy while decreasing protein metabolism
Compazine belongs to which class of antipsychotics
This drug in smaller doses can be used an antimetic, which mean it suppresses what and what
nausea and vomiting
it will make you ____, so avoid driving and operating heavy machinery.
the routes of administration are IV, IM, PO. Which route lasts longest?
IM (deconate form)
As with all anti-psychotic drugs clients must be monitored for what reactions
What are extrapyramidal symptoms?
dystonia, tardive dyskinesia, akathisia
what class of medications can be given to decrease extra-pyramidal reactions?
anti-parkinsons (ie cogentin [benztropine])
What herbal medication is contraindicated with compazine
Most corticosteroids end in _____.
what are some examples of corticosteroids?
Dexamethasone, Cortisone, Prednisone
what are the primary functions of corticosteroids?
To decrease inflammation and hormone replacement
what should you teach clients about stopping corticosteroid therapy?
gradually decrease use, do not abruptly stop
what must be monitored while a client is taking a steroid?
potassium, glucose, and I&O
corticosteroids may cause symptoms of
corticosteroids will also delay __ Healing
If the client is NPO for surgery should you still give the steroids?
yes, during surgery, stress and illness in the body increase the need for corticosteroids. in all other situations, do not take steroids on an empty stomach
cranial nerves I
cranial nerve II
Optic - vision
Cranial nerve III
Oculomotor (motor) eye movement
cranial nerve IV
Trochlear; eye movement
cranial nerve VI
Abducens; eye movement
cranial nerve VII
Facial - controls most facial expressions & secretion of tears & saliva & taste
cranial nerve VIII
cranial nerve IX
Glossopharyngeal - gag and swallow
cranial nerve x
vagus- gag and parasympathetic
cranial nerve XI
spinal accessory; back and neck muscles
cranial nerve XII
the client is unable to shrug his shoulders; which nerve is dysfunctional?
CN XI Accessory
A client is unable to smell his morning coffee; which nerve is dysfunctional?
CN I Olfactory
a client is unable to distinguish between salty and sweet tastes; which nerve is dysfunctional?
CN VII Facial
chron's disease is an ____ of the bowels
Can Crohn's disease be cured w/ surgery ?
No, symptoms frequently reoccur
chron's disease affects the digestive tract from the mouth to anus? true or false?
what are symtpoms of Chron's disease?
abdominal pain, diarrhea, weight loss
Excessive diarrhea will cause what electrolyte imbalance?
What foods should be avoided?
dairy products and high-fiber meals, which may worsen diarrhea
chron's disease can lead to what kind of cancer
what are the treatment goals?
Drugs and Nutrition to reduce inflammation
in cystic fibrosis, the _ _ or exocrine glands are affected
how does cystic fibrosis abnormally change mucous gland secretions?
the mucous will become sticky and thick causing obstructions
what are the two symptoms most affected by cystic fibrosis?
respiratory: mucous gets trapped in the lungs
digestive: mucous blacks the pancreas and digestive enzymes, making the absorption of nutrients very difficult
what is the most accurate test for cystic fibrosis?
sweat test- the chloride level will be >60 mEq/L
what are other ways to diagnose cystic fibrosis?
Chest x-Ray, stool analysis, pulmonary function tests
How does poor absorption of fat in the digestive change the appearance of stool?
it causes steatorrhea (greasy, foul-smelling, pale stool)
__ are given with each meal to help with the absorption of nutrients?
what is the most appropriate diet for cystic fibrosis?
high calorie, high protein
__ is a common technique used to clear thick mucous from the lungs. this is important for preventing respiratory infections.
what should parents who already have a child with cystic fibrosis do before having another child?
genetic counseling because CF is hereditary
what type of diabetes is controlled by diet and exercise?
Type II diabetes mellitus
which type of diabetes is controlled mostly by insulin?
Type I Diabetes mellitus
what should you teach diabetics about foot care?
Have MD cut toe nails
cut toe nails straight across
inspect feet daily for sores
keep skin clean and dry
If a diabetic vomits after taking PO insulin what should they do?
monitor blood sugar and do not repeat dose. the medication may have been absorbed
how often should a diabetic get an eye exam?
Yearly; diabetes can cause retinopathy
what is insulin lipodystrophy?
It is the result of not rotating SQ insulin injection sites. so if the client injects in the same place continuously fatty mass masses will appear decreasing insulin absorption in that area, Teach injection site rotation
Do you need to aspirate if injecting insulin SQ?
Exubera is an ________ insulin.
exercising _____ blood glucose
alcohol, oral contraceptives, aspirin, and MAOI ______ blood glucose
Infection, dehydration, stress, surgery, does what to the blood glucose
what do you give when your client is hypoglycemic and unconscious?
glucagon (IV or IM)
Why is digoxin prescribed?
To treat heart failure and arrhythmias
Digoxin is a:
• Cardiac glycoside
• If you can only pick one and not both - pick cardiac glycoside
Always hold digoxin if heart rate is less than
what is the therapeutic blood range?
1-2 great than 2= toxic
what are the signs of digoxin toxicity?
Seeing yellow spots, nausea, vomiting, abdominal pain
How is digoxin toxicity treated?
Dose will be lowered; in severe cases give activated charcoal or Digiband.
what are three ways a diuretic can be given?
PO, IV, IM
why are diuretics prescribed?
Chronic heart failure, fluid overload, renal failure
when should clients take this medication?
in the morning to prevent nocturia
Why should clients take diuretics in the AM?
If take in the evening clients will be going to the bathroom all night
what should clients be monitored for?
dehydration, low K+, hyponatremia, and weight loss
loop and thiazide diuretics inhibit which electrolytes?
potassium, sodium, chloride
lasix (furosemide) is a ______ diuretic?
thiazide diuretics are contraindicated in clients allergic to?
______ is an osmotic diuretic used to reduce ICP
Because Mannitol decreases ICP it can also be used to treat _________.
Mannitol crystallizes at room temperature, you will need a __________ needle to draw it up.
Spironolactone (Aldactone) is a
potassium sparing diuretic
Because Spironolactone helps the body retain potassium the client is at risk for?
if your client's K+=3.0 and lasix and spironolactone are both ordered, how would you proceed?
only give the spironolactone. the potassium is low and lasix will only create more K+ loss
to accurately measure urine output, a patient ________ _________ may be given
Donning Sterile Gloves
-gather all supplies
-wash and dry hands
-place package on dry waist-high surface
-open package using outer one-inch margin, facing gloves toward you
-with two fingers on non-dominant hand, pick up cuff of first glove
-place glove on dominant hand
-slide gloved fingers into the cuff of the other sterile glove
-place non-dominant hand into the glove, making sure not to touch the outside of the glove
-with both hands gloved, touch only sterile area to adjust for comfort
What is the epiglottis?
it is a lap of skin at the base of the tongue. it opens and closes during breathing
what is the cause of epiglottitis?
is this a virus or bacteria?
what is the usual age of children who get epiglottitis?
2-5 years old
what are the signs of epiglottitis?
Dysphagia-difficulty or discomfort in swallowing, as a symptom of disease.
Dysphonia- difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords.;(No voice).
What will the child look like during an episode of of epiglottis ?
sitting upright; tongue protruding; drooling; shallow; rapid breathing
Can epiglottis be treated at home?
No child must go to hospital immediately
if the child cannot breathe, what might be done?
what medication will be given to treat epiglottitis
how can epiglottitis be avoided ?
By getting the H. Influenza vaccine
How is genital herpes spread?
Through sexual contact or during birth
what are the symptoms for males?
painful, vesicular lesions
what are the symptoms for females?
painful, vesicular lesions
are these lesions always present on the body?
no, they come and go
if lesions are present in a pregnant woman, how should she deliver?
what triggers outbreaks of genital herpes?
Stress, anxiety, high emotion
how often should women with herpes get a pap smear?
every six months
Can genital Herpes be cured? what is the treatment?
no cure. acyclovir
How does glaucoma affect vision?
blurry and tunnel vision noted. there will be halos around light
this condition can be acute or chronic due to ____ _____ _______.
increased intraocular pressure
______ is the simple, painless procedure used to measure intraocular pressure.
what are the two types of glaucoma?
Open-angle, closed angle
which one is painful?
closed angle is painful but it is not the most common of the two
state the class of drugs used to constrict the pupil and let aqueous humor flow?
give an example of a miotic
timopotic or pilocarpine
Why might diuretics be given to clients with glaucoma?
to decrease aqueous humor production
what diuretic is usually prescribed?
mannitol because it is an osmotic diuretic
Never give ________ because they dilate the pupil. (Glaucoma)
If surgery is required, what should you monitor for? ( glaucoma)
What post-op teaching should be done ?( glaucoma)
No heavy lifting
No crying or rubbing eyes
immunizations given at birth
hep b #1
immunizations given at 2 months
hep b#2, DTap, Hib, IPV, PCV
Immunizations given at 4 months
All 2-month immunizations except Hep C
Immunizations given at 6 months
All 2 month immunizations
immunizations given at 1 year
MMR #1, Hib, PCV, varicella
tetanus and diphtheria are optional vaccinations; what is the earliest age they can be given?
What is a booster shot?
An additional dose of vaccination , increases effectiveness
what are the side effects of immunizaitons
low-grade fever, tenderness, swelling at the site, child may become irritable
what medication should be given for these affects?
Never give _________ for children experiencing side effects of immunizations.
when should the meningitis vaccination be given?
before going to college
If an adult woman receives an MMR shot what should you teach her
wait three months before pregnancy
How soon can a child get the influenza vaccination?
not until 6 months
Do not give MMR if client is allergic to _________ or ____________.
eggs or neomycin
Do not give the influenza vaccination if the client is allergic to ________.
what is active immunity?
Stimulating the body to produce antibodies by giving a vaccine
what is passive immunity?
Antibodies that are formed in another body but passed down for short term use (ex. breast milk)
inflammatory bowel disease: CHRON'S
location: anywhere in the digestive tract from mouth to anus
signs: 3-4 semi-soft stools, no blood, anorexia, fistulas
lifestyle: associated with smoking
treatment: anti-inflammatory steroids, NPO for bowel rest, surgery will not help; disease will reoccur
Inflammatory Bowel Disease: Ulcerative Colitis
location: primary colon
signs: blood diarrhea, weight loss
treatment: anti-inflammatory steroids, NPO status bowel rest, surgery to remove affected area
incentive spirometry is a method ____ ________ that helps maximize lung inflation
instruct the client to place ____ tightly around the mouth piece
incentive spirometry is used after surgery to prevent __________
what is the normal intracranial pressure range?
5-15 mm Hg
what are the common causes of ICP?
Trauma, hemorrhage, edema, tumors
what do you assess for ICP?
Level of conscious
this is the earliest sign of ICP
decreased level of conscious
the client will often appear?
restless, agitated, complaining of headaches
what will babies physically present with?
late signs of ICP are?
Unilateral pupil dilation
client may complain of _________ _______ _______ ______
projectile vomiting without nausea
how will the vital signs appear with ICP?
Respiration (Up then down)
Heart rate ( Up)
whati s widening pulse pressure and how is it related?
when systolic blood pressure goes up and diastolic continues to go down so that they become further apart (BAD SIGN)
what is cushing's triad?
Widening pulse pressure
Cheyne stokes respirations
initiate _______ precautions
elevate head of bed to?
10 to 30 degrees, to promote jugular venous outflow
what medications will be prescribed?
anticonvulsants, blood pressure medications, corticosteroids, diuretics
tell the client not to ______, _____, or ______
strain, cough or sneeze
nursing interventions would be to?
decrease environmental stimuli, maintain body temp, limit fluid intake, monitor I&O
medication should be ____ temperature? (ear meds)
room temp- too hot or too cold could have side affects
what position should the client be in when receiving ear medication?
supine, with affected ear up
when administering ear meds to an adult, draw the pinna back and __?
when administering ear meds to a child, draw the pinna back and ____?
how long should the head be tilted to allow medication to travel to the ear canal? _ minutes
when giving eye meds, do this to prevent meds from going into the nasal passage
pull the _____ eye lid down against the _____. Squeeze the drop in the ___________ ___.
if more than one drop is prescribed, wait _ to _ minutes before applying another drop.
3 to 5 minutes
do not let the __________ ______ touch the _______
medication bottle, eyeball
why are IV fluids used?
They are quick way to replace nutrients, water and electrolytes
what are the three types of fluids?
isotonic, hypotonic, hypertonic
describe isotonic fluid/give examples.
istonic fluid is the same as the inside of the cell. 0.9% NS, lactated ringers, D5W
why would you give isotonic fluids?
D.K.A. burns, replace sodium & chloride *0.9% NS always hung with blood
describe hypotonic fluid/ give examples
Hypotonic fluid is less concentrated then the cell. this would cause water to move into the cell.
0.45% NS,is an example
why would you give hypotonic fluids?
Dehydration, hypernatremia lowers blood pressure
why should this fluid be closely monitored?
Because rapid increase in fluid shifting into the cells can cause cellular and cerebral edema
describe hypertonic fluid/give examples
Hypertonic fluid is more concentrated than cells. This would cause movement out of the cell.
5%NS, D5%NS, D5%LR
why would you give hypertonic fluids?
why should this fluid be closely monitored?
Because it can cause electrolyte imbalance and dehydration
before you start an IV fluid, assess the client's
IV; make sure it's patent
If IV is infiltrated what would you see
Painful at site
surgery is the removal of ____ so the spinal cord can be seen (laminectomy)
to move the client after surgery, ___ ____ this client!
what is the highest risk factor for ingesting lead?
age; younger kids put things in their mouths
what is the most likely ingested item to cause lead poisoning?
lead paint chips
the most dangerous side affect of ingesting lead is _____ ___________
what are the signs of lead poisoning?
More serious if greater amount is ingested:
how do you treat lead poisoning?
how are these agents given?
by receiving many im injections
do not give ______ to induce vomiting.
Negligence is when a nurse does what
Not provide appropriate care according to set standards
If a nurse does a treatment without consent it is example of what
if your client falls out of bed because you forgot to put up the side rails, this is a _______.
Any NCLEX question that has the word "threat" think?
advanced directives are important because they...
allow the client to direct how/what care they are to receive if they become unable to make decisions in the future
Are advanced directives mandatory for a client
the document that specifically names a person to make decisions on another person's behalf is
durable power of attorney
the client must be of _____ ____ to write a will
what is the cause of crackles?
Fluid or secretions in the airway
when do you hear crackles?
On inspiration ( Sounds like rice crispies in milk)
what are some possible causes of crackles?
Pneumonia, edema, or bronchitis
what is another name for crackles?
what are the characteristics of wheezes?
high pitched musical sounds
when do you hear wheezes?
inspiration and expiration
what are the possible causes of wheezing?
asthma, smoking, allergic reactions
Wheezes can often be heard without a
__________ air will help relieve symptoms of wheezing
what are the characteristics of stridor?
High pitched harsh sound heard in UPPER airway
what is the cause of stridor?
Laryngeal spasm or swelling, Croup, Epiglottitis
stridor is often confused with ________
which age group is stridor often seen in?
lyme disease is a type of infection caused by
bite from a tick
how long after a bite can you test for this disease?
between 4 to 6 weeks
what is the treatment plan?
take antibiotics- doxycycline (adults) amoxicillin (kids)
what are the most important factors of maslow's heirarchy of needs?
safety and security
love and belonging
mastectomy is a surgery to remove _____ ______ or ______
breast tissue or nipple
after surgery, ______ the affected arm to prevent __________
no __ or __ in the affected arm
BP or IV
always assess site for signs of ________ after surgery
list signs of infection
swelling, redness, fever, chills, elevated WBC count
encourage clients to do ____ _____ ____ on the remaining breast
self breast exam
what are the six rights of medication administration?
right: client, medication, documentation, time, dose, route
What two verifiers do you ask a client before giving a medication
name and birthdate
do not give a medication if
you don't know what it does. trust me, clients ask! if you can't give them an answer, they won't trust you
do not store medications __ ___ ______
at the bedside
can you give medication prepared by another RN?
no, never do this. it's illegal
what does it mean if a medication is PRN?
it means to give only when needed
do not _____ sustained-release capsules or enteric-coated tablets
what should a nurse do if she/he administers the wrong medication
notify physician; do not document in client's chart and complete an incident form. these are not part of the client records
what are the symptoms of meniere's syndrome?
Unilateral hearing loss;
what are the causes of meniere's syndrome
describe meniere's attacks
severe, sudden attacks that may cause permanent hearing loss. nausea and vomiting can also be present
what is the best environment for a client with this syndrome?
bed rest in a quiet room, moving head slowly, sedatives can be given to keep the client calm, low-playing music helps with tinnitus
what should the diet be?
is surgery needed?
in severe cases a removal of the labyrinth or labyrinthectomy is performed
what is meningitis?
inflammation of the arachnoid and pia mater of the brain/spinal cord
how is it transmitted?
direct contact and droplet
what are the signs and symptoms?
nuchal rigidity, tachycardia, headache, nausea, vomiting
meningitis can also cause _________ ____________ ________
increased intracranial pressure
what two physical signs are positive?
positive kernig's and brudzinski
what are the nursing interventions
monitor LOC, vitals, initiate seizure precautions, maintain isolation, elevate HOB
what medications are prescribed?
antibiotics and analgesics
what do mongolian spots look like?
bluish-black spots on body
where can you find these spots?
on the back and buttocks of newborns
What race are these Mongolian spots mostly seen in
Asian and African American
are they harmful and ow long do they appear?
no. they are normal in newborns and they gradually fade over time
true or false? MS is a chronic, progressive degenerative disease of the nervous system
what part of the nervous system is affected?
the problem is with demyelinization of the white matter of the brain and spinal cord
is there a cure for MS?
what are the signs of MS?
Numbness in the extremities;
what medication can be given for the spasms?
what medication will be given to reduce the amount of time a client experiences exacerbated symptoms?
if you were at a MS conference, what would you teach?
start regular bladder bowel program
avoid stressful situations
eat a well balanced diet
initiate a speech/physical therapy
remove safety hazards in home
what is the definition of munchausen syndrome
a psychiatric disorder that causes a person to self-inflict injury/harm to his/her own body. The person may also stay that he/she has a mental disorder
what is munchausen by proxy?
It is associated with a caregiver or guardian that cares for the child and inflicts harm to achieve attention
notes for nclex on munchausen syndrome
the child will have issues with no explained etiology. treatment of the issue does not help. assessments indicate child is healthy, symptoms get better when child is away from the caregiver. nursing priority: protect the child
true or false? myasthenia gravis is an autoimmune disease that results in extreme fatigue and muscle weakness
what is the malfunction in the body?
body produces antibodies that block acetylcholine receptors
is there a cure for myasthenia gravis?
what are the signs and symptoms?
difficulty talking, chewing, weak eye muscles, visual disturbances, unsteady gait
Do the symptoms of Myasthenia Gravis worsen with activity
yes they do
the ________ test is performed to diagnosis myasthenia gravis
if the client's muscle strength is increased, the test is ________ for myasthenia gravis
what medication will be given?
what would you teach at a myasthenia gravis conference?
take meds 30 minutes before eating, cough/deep breath, exercise, conserve energy by doing multiple short tasks. try to decrease stress, infections, and unhealthy habits
what is the cause of an MI?
Decreased oxygen supply to the heart
where is the pain felt?
substernal (sudden, crushing, radiating to jaw, shoulders, and back) and lasting longer than 30 minutes
MI pain is not relieved by _____ and ____
nitro and rest
what changes would you see on an ekg?
st elevation, inverted T waves
what lab values are given for an MRI?
what activity is prescribed for this client?
what is angina pectoris?
Chest pain due to the heart not receiving enough oxygen
where is the pain located?
the same areas of the chest as seen in Myocardial Infarction
what are some common causes of angina?
Early morning activity (Shoveling snow)
how is stable angina different from an MI?
Chest pain that has a typical onset, location, last for 3-5mins and is relieved by nitroglycerin/ rest
what is unstable angina?
Chest pain that occurs at rest
how is angina diagnosed?
Coronary artery bypass
Exercise/ Thallium stress test EKG with no ST elevation
what should you teach a client who has angina?
How to take nitro for pain (Can take up to 3 tabs SL q 5mins)
Diet modification (Low cholesterol)
what is neomycin sulfate?
It's an Aminoglycoside. It reduces amount of bacteria in the colon. It's given for the GI tract before surgery
why does this matter?
its given for the GI tract before surgery
how is it used in clients with hepatic encephalopathy?
it is used to treat this disease when ammonia levels are elevated in the liver?
when does neuroplectic malignant syndrome occur?
it could occur any time a client is on an anti-psychoitc med, most commonly when treatment begins or doses are increased
what are the signs of N.M.S
tachycardia-extreme fever, altered LOC, seizures, muscle rigidity, elevated WBC/LFT
what is the treatment?
discontinue the med, initiate safety and seizure precautions. give antipyretics to reduce fever
what position should the client be in during NG tube placement?
high fowlers with head tilted forward
the NG tube goes from ____ to _______
nose to stomach
what is a salem pump?
Double lumen of NG tube used to decompress the stomach
One lumen for gastric secretions
one lumen allow air, gas out of the stomach
what are the measuring points for determining the length of insertion?
nose to earlobe to xiphoid process
if the client starts to gag during placement, should you continue the procedure?
yes, wait until patient stops coughing/gagging, then continue to advance; offer water to help the tube go down
what should be done before using the NG tube for the first time?
x-ray; aspirate for gastric contents (PH should be >4)
if the ng is to suction, should you turn off the suction when medications are given PO
yes, for at least 30 minutes
if a patient vomits during the procedure should you keep going with the NG tube?
yes, wait for a few minutes then proceed. let the patient know they will feel better once the tube is in place
What medications can cause intrarenal failure?
What are predisposing factors for aspiration pneumonia?
What is the antidote for Narcotics? (OD)
how many hrs, after ineffective med therapy, should you wait to revascularize/catheterize an unstable angina patient?
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