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NCLEX CRAM 2019
Terms in this set (288)
VALUES: (Vital signs)
37 C or 98.6 F
4.5-5 million per mm3
4,500-11,000 per mm3
VALUES: (Acid-base balance)
3.5-5 (same as K+)
Normal Urine test values
Ketones, Protein, Bilirubin, Casts, Crystals, bacteria
Troponin I and T
0-5% of total
CK-MM = 95-100%
lesss than 0.6
more tahn 1.5 is indicative of MI
more than 0.2 indicates MI
less than 90mcg/L
(more is indicative of possible MI)
less than 100 pg/mL
Sodium warfarin (Coumadin)
PT: 10—12 seconds (control). The antidote is Vitamin K
used with coumadin. normal is 0.9-1.2
PTT: control is 30-45 seconds
what is Heparins antidote
Protamine sulfate w/in 30 minutes
VALUES: unit conversions
1 oz = ? mL
1g = ? mg
1 kg = ? lbs
1 cup = ___ oz
Maternity Normal Values
normal amount of amniotic fluid
- time apart
2—5 minutes apart with a duration of < 90 seconds and an intensity of <100 mmHg.
umbilical cord has two arteries and one vein (arteries carry deoxygenated blood and veins carry oxygenated blood)
what is APGAR
appearance, pulse, grimace, activity, respiration
When is the APGAR score done?
Done at 1 minute & 5 minutes
0 for absent
1 for decreased
2 for strongly positive
what is a normal APGAR
7 and above
what is a low APGAR
what is a critical APGAR
EPIDURAL ANESTHESIA IN MATERNITY
What is STOP
treatment for maternal hypotension after an epidural anesthesia
what does the mnemonic STOP stand for?
top infusion of Pitocin (causes contractions)
urn client to left side
ush IV fluids, if hypovolemia is present
Pregnancy Category of Drugs
no risk to fetus
Studies indicate no risk to the animal fetus; information for humans is not available
Risk not ruled out. Examples:
There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.*
Contraindicated in Pregnancy. Examples: Isotretinoin (Accutane), Thalidomide (Immunoprin), etc.
not yet classified
NOT accepted for medical use the USA.
Have the HIGHEST POTENTIAL for ADDICTION
Exposure can cause harm
drugs with high potential for abuse and requires written prescription (e.g., Ritalin, hydromorphone (Dilaudid), meperidine (Demerol), and fentanyl
requires new prescription after six months or five refills (e.g., codeine, testosterone, ketamine)
requires new prescription after six months (e.g., Darvon, Xanax, Soma, and Valium)
(NOT 5 refills)
no need for prescription
reduce hydrochloric acid in the stomach
increase blood cell production
decreases oral secretions
Prevent clot formation
used for management of seizures and/or bipolar disorders
Decrease gastric motility and reduce water in bowel
block the release of histamine
Lower blood pressure and increase blood flow
used for the treatment of infections
dilates large air passages in asthma or lung diseases (like COPD)
decrease blood pressure by decreasing blood volume
decreases water/sodium from the Loop of Henle
promotes the passage of stool
constricts the pupils
dilates the pupils
relieves moderate to severe pain
Rule of Nines
used to calculate TBSA (total body surface area) for burns
Rule of 9's
Head and neck = 9%
Upper Ex = 9% each
Lower Ex = 18% each
Front trunk = 18%
Back trunk = 18%
Genitalia = 1%
Important facts about medications to remember
1) what to check for before administration
2) levels to check?
1) assess pulses for a full minute (if less than 60 hold dose)
2) check digitalis and K+ levels
Aluminum Hydroxide (amphojel)
1) what does it treat?
2) what to watch out for?
1) Treatment of GERD and kidney stones.
2) WOF (watch out for) constipation.
1) what does it treat
2) what to WOF
1) Treatment of anxiety and itching
2) WOF dry mouth
1) why is it given
2) WOF what?
1) given for conscious sedation
2) WOF respiratory depression and hypotension
1) WOF what?
2) when to take missed doses
3) taking a double dose?
1) WOF diaphoresis, dyspnea, lethargy
2) take missed dose any time in the day or to skip it entirely
3) DO NOT take double dose
2) stress importance of...
1) WOF bleeding, diarrhea, fever, rash
2) stress importance of complying with prescribed dosage and follow up-appointments
1) treats what?
2) assess for what?
3) why is a drug holiday needed?
2) assess for Heart related side effects and report immediately
3) drug stunts growth... so client may need drug holiday
1) treats what?
2) monitor for...
1) treatment of hypotension, shock, and low cardiac output
2) monitor ECG for arrhythmias and blood pressure
1) causes what?
Causes red-orange tears and urine
causes what problems (2)
causes problems with vision and liver
Can cause peripheral neuritis, take V B6 to counter
able to turn head up
can turn to side
makes cooing or gurgling noises
can turn head to sound
grasps, switch and roll over tummy to back. Can babble and mimic sounds
sits at 6 and waves bye-bye. Can recognize familiar faces and knows if someone is a stranger. Passes things back and forth between hands.
stands straight at eight, has favorite toy, plays peek-a-boo.
belly to butt
twelve and up, drinks from a cup. Cries when parents leave, uses furniture to cruise.
1) illness is caused by
2) how are they oriented
3) higher incidences of (4)
May believe that illness is caused by supernatural causes and seek advice and remedies form faith healers; they are family oriented; have higher incidence of high blood pressure and obesity; high incidence of lactose intolerance with difficulty digesting milk and milk products.
May remain silent about health problems such as STIs, substance abuse, and mental illness; a devout Muslim may interpret illness as the will of Allah, a test of faith; may rely on ritual cures or alternative therapies before seeking help from health care provider; after death, the family may want to prepare the body by washing and wrapping the body in unsewn white cloth; postmortem examinations are discouraged unless required by law. May avoid pork and alcohol if Muslim. Islamic patients observe month long fast of Ramadan (begins approximately mid-October); people suffering from chronic illnesses, pregnant women, breast-feeding, or menstruating don't fast. Females avoid eye contact with males; use same-sex family members as interpreters.
May value ability to endure pain and grief with silent stoicism; typically family oriented; extended family should be involved in care of dying patient; believes in "hot-cold" yin/yang often involved; sodium intake is generally high because of salted and dried foods; may believe prolonged eye contact is rude and an invasion of privacy; may nod without necessarily understanding; may prefer to maintain a comfortable physical distance between the patient and the health care provider.
May view illness as a sign of weakness, punishment for evil doing; may consult with a curandero or voodoo priest; family members are typically involved in all aspects of decision making such as terminal illness; may see no reason to submit to mammograms or vaccinations.
May turn to a medicine man to determine the true cause of an illness; may value the ability to endure pain or grief with silent stoicism; diet may be deficient in vitamin D and calcium because many suffer from lactose intolerance or don't drink milk; obesity and diabetes are major health concerns; may divert eyes to the floor when they are praying or paying attention.
May value technology almost exclusively in the struggle to conquer diseases; health is understood to be the absence, minimization, or control of disease process; eating utensils usually consists of knife, fork, and spoon; three daily meals is typical.
Acute renal disease
protein-restricted, high-calorie, fluid-controlled, sodium and potassium controlled.
increased sodium, low potassium
ADHD and Bipolar
high-calorie and provide finger foods.
high protein, high caloric, increase in Vitamin C.
high-calorie, high protein
Chronic Renal Disease
protein-restricted, low-sodium, fluid-restricted, potassium-restricted, phosphorus-restricted.
Cirrhosis w/ hepatic insufficiency
restrict protein, fluids and sodium
high fiber, increased fluids
soft, high-calorie, low-carbohydrate, high-fat, small frequent feedings
liquid, low fiber, regular, fluid and electrolyte replacement
Low fiber, bland diet
regular, high calorie, high protein
heart failure, CAD low sodium, calorie restricted, fat controlled
Increase fluid intake, calcium controlled, low oxalate
sodium-restricted, high-calorie, high-protein, potassium-restricted.
calorie restricted, high fiber
low-fat, regular, small frequent feedings; tube feeding or total parenteral nutrition.
Peptic Ulcer Disease (PUD)
increase V B12 (Cobalamin)... found in high amounts in shellfish, beef liver, and fish
sickle cell anemia
- Increase fluid intake, Sickle cell causes RBCs to become crescent shaped and function abnormally and cause increased viscosity = painful episodes and increase of fluids to prevent dehydration during a crisis.
mechanical soft, regular, or tube feeding
high calorie, high protein
fluid and electrolyte replacement
Orthopneic position where pt is sitting up and bent forward with arms supported on table or chair arms
flat on bed with head hyperextended
HOV elevated 30 degrees to reduce ICP and facilitate venous drainage
keep site extended
(nose bleed) lean forward
above knee amputation
elevate for first 24 hours on pillow, position prone daily to provide for hip extension.
Below the knee amputation
foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.
Tube feeding for patients with decreased LOC
position patient on right side to promote emptying of the stomach with HOB elevated to prevent aspiration
turn patient to left side and lower HOB
Lung segment to be drained should be in the uppermost position to allow gravity to work.
Post Lumbar puncture
patient should lie flat in supine to prevent headache and leaking of CSF.
Continuous Bladder Irrigation (CBI)
catheter should be taped to thigh so legs should be kept straight
position on the side of AFFECTED ear, allows drainage.
Post Cataract Surgery
patient will sleep on unaffected side with a night shield for 1-4 weeks
area of detachment should be in the dependent position-- dependent meaning supported by something
low or semi-Fowler's, support head, neck and shoulders.
sitting on the side of the bed and leaning over the table (during procedure); affected side up (after procedure)
position infant on prone so that sac does not rupture
elevate foot of bed for counter traction
Post total hip replacement
don't sleep on operated side, don't flex hip more than 45- 60 degrees, don't elevate HOB more than 45 degrees.
Maintain hip abduction by separating thighs with pillows.
Knee to chest or Trendelenburg
oxygen 8 to 10 L
position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position.
assist to lateral position
Preventing Dumping syndrome
eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low fiber diet, and small frequent meals).
position patient in left-side lying (Sim's position) with knees flexed.
Post supratentorial surgery (incision behind hairline)
elevate HOB 30-45
Post infratentorial surgery (incision at nape of neck)
position patient flat and lateral on either side
back as straight as possible; log roll to move and sand bag on sides
Spinal Cord injury
immobilize on spine board, with head in neutral position. Immobilize head with padded C-collar, maintain traction and alignment of head manually. Log roll client and do not allow client to twist or bend.
right side lying with pillow or small towel under puncture site for at least 3 hours
flat on bed or sitting
place patient on right side to facilitate passage into duodenum
elevate HOB 30 degrees to prevent aspiration. Maintain elevation for continuous feeding or 1hour after intermittent feedings.
knee-chest position, Sim's, or dorsal recumbent
During internal radiation
patient should be on bed rest while implant is in place
(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)
first thing to do is place pt in sitting position (elevate HOB before any other intervention)
bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg)
elevate HOB 30 degrees to decrease ICP
Peritoneal Dialysis (when outflow is inadequate)
Turn client from SIDE to SIDE--BEFORE checking for kinks in the tubing
myelogram (water-based dye)
semi fowler's for at least 8 hours
myelogram (oil-based dye)
flat on bed for at least 6-8 hours to prevent leakage of CSF
myelogram (air contrast)
Common signs and symptoms
pulmonary tuberculosis (PTB)
WII (what is it?): A contagious infection caused by bacteria that mainly affects the lungs but also can affect any other organ.
low grade afternoon fever
WII:Infection that inflames air sacs in one or both lungs, which may fill with fluid.
rusty colored sputum
WII: A condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe.
wheezing on expiration
WII: Emphysema is one of the diseases that comprises COPD (chronic obstructive pulmonary disease). Emphysema involves gradual damage of lung tissue, specifically thinning and destruction of the alveoli or air sacs.
WII: A condition that causes inflammation in the walls of some blood vessels in the body.It's most common in infants and young children
strawberry tongue, fever for 5 days (then seems to go away b4 red tongue)
only disease in which you give aspirin to a child
Pernicious anemia (PA)
WII: A decrease in red blood cells when the body can't absorb enough vitamin B-12.Common causes include a weakened stomach lining or an autoimmune condition.
red beefy tongue
WII: A genetic chromosome 21 disorder causing developmental and intellectual delays.Down syndrome is a genetic disorder caused when abnormal cell division results in extra genetic material from chromosome 21.
WII: A bacterial disease of the small intestine causing severe diarrhea and dehydration, usually spread in water.Cholera is rare in industrialized countries. It's fatal if not treated right away.
rice-watery stool and washer woman's hands (wrinkled hands from dehydration).
WII: an intermittent and remittent fever caused by a protozoan parasite that invades the red blood cells. The parasite is transmitted by mosquitoes in many tropical and subtropical regions
stepladder like fever--with chills
WII:A bacterial disease spread through contaminated food and water or close contact. Vaccines are recommended for travelers to developing nations where typhoid fever is common
- high fever is common
rose spots in the abdomen
WII: A mosquito-borne viral disease occurring in tropical and subtropical areas.
fever, rash, and headache. Positive Herman's sign
WII: A serious infection of the nose and throat that's easily preventable by a vaccine. A sheet of thick, gray matter covers the back of the throat, making breathing hard.
WII: A viral infection that's serious for small children but is easily preventable by a vaccine.
The disease spreads through the air by respiratory droplets produced from coughing or sneezing
Koplik's spots (clustered white lesions on buccal mucosa)
Systemic lupus erythematosus
WII: An inflammatory disease caused when the immune system attacks its own tissues
"Butterfly" facial rash and Raynaud phenomenon in a young female
WII: A chronic, curable infectious disease mainly causing skin lesions and nerve damage.
Leprosy is caused by infection with the bacterium Mycobacterium leprae.
leonine facies (thickened folded facial skin)
WII:an emotional eating disorder involving distortion of body image and an obsessive desire to lose weight, in which bouts of extreme overeating are followed by depression and self-induced vomiting, purging, or fasting
Chipmunk face (parotid gland swelling)
WII: A condition in which the appendix becomes inflamed and filled with pus, causing extreme pain.
rebound tenderness at McBurney's point. Rovsing's sign (palpation of LLQ elicits pain in RLQ). Psoas sign (pain from flexing the thigh to the hip).
WII: Inflammation of brain and spinal cord membranes, typically caused by an infection. Meningitis is usually caused by a viral infection but can also be bacterial or fungal. Vaccines can prevent some forms of meningitis.
- Kernig's sign (leg flex then leg pain on extension- caused by stiffness of hamstring causing inability to straighten the leg when hip is flexed 90 degrees)
- Brudzinski sign (forced flexion of neck elicits a reflex flexion of lower leg/ hips).
WII: a condition marked by intermittent muscular spasms, caused by malfunction of the parathyroid glands and a consequent deficiency of calcium
- hypocalcemia (+) Trousseau's sign/carpopedal spasm; Chvostek sign (facial spasm).
WII: A serious bacterial infection that causes painful muscle spasms and can lead to death.
Tetanus is a potentially fatal bacterial infection that affects the nerves. A vaccine can easily prevent the infection, which has no cure.
Risus sardonicus or rictus grin
WII: An inflammation of the organ lying behind the lower part of the stomach
Cullen's sign (ecchymosis of the umbilicus), Grey Turner's sign (bruising of the flank).
WII: A condition in which the opening between the stomach and small intestine thickens.Pyloric stenosis occurs most often in babies under six months. In this condition, the pylorus muscles block food from entering the small intestine. It occurs more often in males
olive like mass
patent ductus arteriosus
WII: Patent ductus arteriosus (PDA) is a condition wherein the ductus arteriosus fails to close after birth. Early symptoms are uncommon, but in the first year of life include increased work of breathing and poor weight gain.
washing machine-like murmur
WII:Addison's disease is caused by damage to your adrenal glands, resulting in not enough of the hormone cortisol and, often, not enough aldosterone as well.
bronze-like skin pigmentation
WII: An adrenal gland disease in which for some reason high levels of cortisol occur
Moon face appearance and buffalo hump
Grave's Disease/ hyperthyroidism
WII: Graves' disease is an autoimmune disorder that causes hyperthyroidism, or overactive thyroid. With this disease, your immune system attacks the thyroid and causes it to make more thyroid hormone than your body needs.
Exophthalmos (bulging of the eye out of the orbit).
WII: Intestine telescopes into self
sausage shaped mass
Multiple Sclerosis (MS)
destruction of the myelin sheath on neurons in the CNS and its replacement by plaques of sclerotic (hard) tissue
--> charcot's triad (nystagmus, intention tremor, and dysarthria)
WII: Myasthenia gravis is a chronic autoimmune neuromuscular disease that causes weakness in the skeletal muscles, which are responsible for breathing and moving parts of the body, including the arms and legs. The name myasthenia gravis, which is Latin and Greek in origin, means "grave, or serious, muscle weakness."
muscle weakness, ptosis (drooping of eyelids)
Guillain Barre syndrome
WII:Guillain-Barré syndrome (GBS) is a rare neurological disorder in which the body's immune system mistakenly attacks part of its peripheral nervous system—the network of nerves located outside of the brain and spinal cord. ... Fortunately, most people eventually recover from even the most severe cases of GBS.
ascending muscle weakness
deep vein thrombosis (DVT)
(calf pain at dorsiflexion of the foot)
WII: Chest pain caused by reduced blood flow to the heart
Crushing, stabbing pain
Parkinson's disease (PD)
WII:A disorder of the central nervous system that affects movement, often including tremors.
pill-rolling tremors (looks like they are rolling a pill in their hands, but they are not)
owls eye appearance of cells (huge nucleus of cells)
WII: Buildup of pressure inside the eye that can lead to the damage of the optic nerve
WII: an emergency when part of the eye (the retina) pulls away from supportive tissue
Flashes of light, shadow with curtain across the vision
WII: a rare disease of the arteries and veins in the arms and legs. Your blood vessels become inflamed, swell and can become blocked with blood clots (thrombi).
intermittent claudication (pain at buttocks or legs from poor circulation resulting in impaired walking)
Diabetic Ketoacidosis (DKA)
pregnancy induced hypertension (PIH)
proteinuria, hypertension, edema
polydipsia, polyphagia, polyurea
Hirschsprung disease (toxic Megacolon)
WII: a condition that affects the large intestine (colon) and causes problems with passing stool. The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby's colon
ribbon like stool
Herpes simplex type II
painful vesicles on genitalia
warts 1-2 mm in diameter
WII: Infection of the genital skin (Type of STD)
WII: A sexually transmitted bacterial infection that, if untreated, may cause infertility.Regular screening can help detect instances when an infection is present despite having no symptoms
green, creamy discharges and painful urination
WII: A common sexually transmitted infection that may not cause symptoms.Chlamydia affects people of all ages but is most common in young women
milky discharge and painful urination
WII: A yeast infection of the vagina and tissues at the opening of the vagina (vulva).This type of yeast infection is caused by the fungus candida
white cheesy oderless vaginal discharge
WII: A sexually transmitted infection caused by a parasite.Trichomoniasis is among the most common sexually transmitted infections
yellow, itchy, frothy, and foul-smelling vaginal discharges
Delegate _________ skills to an RN or LPN
Sterile (like dressing change)
Non skill care and a stable client can be delegated to a...
Assign the most critical patient to the...
CLients who are being discharged should have final assessments done by the __________
monitor clients with IV therapy
insert urinary catheters + feeding tubes
what can not be delegated to an unlicensed assistive personnel
assessment, teaching, medication admin, evaluation, unstable patients
What is the best indicator of dehydration
when a pt is in distress administration of medication is....
rarely the best choice
always check for ____________ before admin of antibiotics
neutropenic patients should not receive...
vaccines, fresh fruits or flowers
nitroglycerine sublingual is admin...
3 times with intervals of five min
morphine is contraindicated in pancreatitis bc...
- what should be given in its place
it causes spasms of the sphincter of Oddi.
Infants born to an HIV positive mother and immunizations
receive all immunizations of schedule
the number of pregnancies the woman has had (regardless of the outcome)
the number of pregnancies that reached viability, regardless fo whether the fetus was delivered alive or stillborn. (a fetus is considered viable at 20 weeks gestation)
Lochia rubra is...
the vaginal discharge of almost pure blood that occurs during the first few days after childbirth.
Lochia serosa is...
the serous vaginal discharge that occurs 4 to 7 days after childbirth.
Lochia Alba is...
the vaginal discharge of decreased blood and increased leukocytes that's the final stage of lochia. It occurs 7 to 10 days after childbirth.
in the event of a fire...
Rescue and remove patients in immediate danger
Activate the smoke/fire alarm
Contain the fire by closing doors and windows
Extinguish and/or evacuate
before signing an informed consent form the patient should (6)
1) know whether other treatment option are available
2) understand what will occur pre, intra, post
3) risk involved
4) possible complications
5) general idea of time and recovery of surgery
6) have an opportunity to ask questions
The first nursing intervention in a quadriplegic client who is experiencing autonomic dysreflexia is to...
elevate his head as high as possible
pt who have the same infection and are in strict isolation can share a room if necessary (T/F)
Truth and is an essential component of a therapeutic relationship between a health care provider and his patient
the duty to do no harm and the duty to do good. Theres an obligation in patient care to do no harm and an equal oblication to assist the pt
duty to do no harm
aged cheese, pepperoni, salami, avocados, figs, bananas, smoked fish, protein dietary supplements, soups, soy sauce, some beers, and red wine.
(may cause severe hypertension in a pt who takes monoamine oxidase inhibitors)
the unconcious assigning of a thought, feeling, or action to someone or something else
channeling socially unacceptable impulses and urges into socially acceptable behavior
An unconscious process that excludes unacceptable thoughts and feelings from awareness and memory.
People with obsessive-compulsive disorder realize that their behavior is unreasonable, but...
are powerless to control it
A significant toxic risk associated with clozapine (Clozaril) administration
Adverse effects of haloperidol (Haldol) admin include
drowsiness; insomnia; weakness; headache; and extrapyramidal symptoms
Hypervigilance and deja vu are signs of
posttraumatic stress disorder (PTSD)