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NCLEX basic care & comfort
Terms in this set (149)
why would you not give a client admitted with hypertension and exacerbation of COPD codeine?
codeine = cough suppressant
*may lead to the accumulation of secretions
why is treating a patient with suspected sepsis more important than lowering a BP of 196/98?
sepsis can rapidly progress to septic shock if not treated immediately
*high BP might be the choice if nausea, vomiting, and headache were also present (hypertensive emergency)
nurse is caring for a 4 year old hospitalized with influenza. which activity is most effective in maintaining psychosocial integrity?
crayons to draw on mask
suggesting friends visit
crayons to draw on mask
*flu is droplet precautions
*medical play during preschool period (3-6) facilitates psychosocial integrity
where should you always start an IV?
on an upper extremity, as distal as possible
*dorsal surface of hand
what is done last in an infant assessment?
elicit moro reflex
*do after assessing pupillary reflex because the baby is usually already awake and crying at this point
rise in pulse >20 / min =
increased risk syncope and falls (orthostatic vitals)
risk factors for PPH (postpartum hemorrhage)
history of PPH
uterine distention (twins, polyhydramnios, infant >8lb)
labor lasting > 24 hours
1. gather supplies and position client
2. don mask, goggles, and clean gloves
3. remove soiled dressing
4. don sterile gloves; remove old disposable cannula and replace with new one
5. clean around stoma with sterile water or saline, dry, replace sterile gauze pad
characteristics of fetal alcohol syndrome:
-indistinct philtrum (smooth area between nose and mouth)
-thin upper lip
-short palpebral fissures (eyelids)
what should be taught to a client with early Alzheimers to promote future safety?
changes to home
*if they are done down, will decrease risk of falls in future
*should not chose anything about meds, that should be handled by caregiver
what should you avoid when taking rivoroxaban?
(it is an anticoagutant & NSAIDs with increase risk of bleeding / hemorrhage)
what should you do for a patient who has hemophilia and is admitted with a facial laceration?
frequent neuro checks (risk for intracranial bleed)
*every 30 min for 6 hours
what can occur following an endoscopic retrograde cholangiopancreatography?
acute pancreatitis!! (life threatening)
*abdominal pain radiating to the back
*Risk in amylase & lipase
hepatitis A is transmitted through the:
*hand hygiene is #1 way to prevent
what should a client on LEvetiracetam for seizures avoid?
*until primary HCP says it is safe
*don't want them to have a seizure while driving
A/E of levetiracetam = suicidal ideation and SJS
what is the most concerning s/s in a patient with a decreased platelet coutn?
(any change in LOC = intracranial bleed!! disorientation, anxiety, restlessness.... ALWAYS CHOOSE LOC)
how quickly can nitroglycerin SL work?
1-3 minutes is onset; assess effectiveness after 3
how often can nitroglycerin be repeated?
every 5 mins
Plan of care for client admitted with head injury:
pad side rails (@risk for seizure)
elevate HOB at 35 degrees
maintain neck in neutral position
maintain a quiet environment
what is a testicular emergency
*client reporting scrotal pain / edema
client education for valproic acid:
assess for mood changes
check stomach pain and jaundice
monitor ALT and AST
teach client not to discontinue medication abruptly
what intervention should NOT be done on a client with a skull fracture?
turning, coughing, and deep breathing
SHORT term goal for client with depression facing long term rehab:
increased interest in family visits
most important factor in determining if a vaginal birth is possible after a VBAC?
type of incision for cesarean
(low, transverse incision are candidates for TOLAC)
s/s of a SLE flare up:
what should you avoid while on metrondiazole?
patient restless on ventilator =
ensure patency of ET tube
priority patient always =
*new change in LOC
if a client is awake post-op but there is a complication that will need another procedure by HCP, what needs to be done about consent?
must be approved by family or spouse (healthcare proxy)
*client is not able to provide consent even if awake because of residual effects of sedation
primary concern that needs to be reported to HCP in a client with pre-eclampsia?
decreased urinary output
*severe headache and blurred vision are common with pre-eclampsia
client with s/s of pactreatitis -->
NG tube low suction
side-lying position with head elevated
hydromorphone PCA pump for pain control
contributing factors for stress incontinence include:
lack of estrogen
rising abdominal pressure
multiparous vaginal births
spinal cord injury results in what type of incontinence?
client with dementia has what kind of incontinence?
*cannot make it to restroom
side effect of zolpidem for insomnia
may do things in sleep that they will not remember the next day
physical assessment of client with hx. rheumatoid arthritis
nodules over bony prominences
morning stiffness lasting over 1 hour
report of weight loss
warm, red, swollen joints
client has developed abdominal wound evisceration. what position should you put the client in?
supine, HOB at 15 degrees with knees and hips bent
*decrease pressure on suture line and abdomen!
2 days after chest tube insertion, nurse notes constant bubbling. what is the priority action
notify primary HCP
*constant bubbling = air leak
suspected C. Diff =
wash hands (alcohol foam is not good enough)
implement contact precautions for everyone (even if it is not confirmed)
what food product is high in phosphate?
how to decrease risk of DVT on long trips?
wear compression stockings while traveling
move every 2 hours (at least)
avoid caffeine & alcohol (dehydration)
frequently move legs while sitting
do not cross legs at all
what helps diverticulitis?
decreasing fiber in the diet
what foods are good sources of potassium?
home-care: intermittent catheterization
wash catheter after every use with soap and water
nursing considerations for child in Bryant's tractioN/
perform neruovascualr checks every 2 hours
maintain hip flexion at 90 degrees with buttocks raised 1inc off bed
reposition slightly every 1-2 hours
traction should NEVER be relieved, so do not remove straps for skin care
what to do if you are assessing a client at home and notice s/s of imminent death?
communicate the client's impending death to the family while they are together
client has to void after receiving IV lorazepam pre-op. what is the best option?
*ambulating to bathroom (even with help) is a fall risk
what is not helpful in an anxious client/
written information or false reassurance
*instead, offer to stay with them and suggest presence of a family member
how to move a client who weighs 280 lbs
use 2 UAP's & a mechanical lift
*in the real world, there will always be enough UAP's (safety risk for UAP to do alone)
acupuncture, yoga, tai chi, and reiki are all considered:
complementary and/or alternative therapies
after a knee amputation, what should you do for positioning?
elevate the foot of the bed
What to do for a DVT?
do NOT massage
what type of mental health client is emotionally unstable in relationships and often engages in harmful behaviors like cutting, substance abuse, and suicidal thoughts?
what to do if a client with CF is found to be positive for B. cepacia?
administer high dose antibiotic therapy
when should a nurse refer to social services for a blood lead level?
* > 20 = call poison control
* > 45 = chelation therapy
rescucitation phase of burn injury =
avoid tyramine foods like: avocado, smoked meats, cheeses
is stoma care sterile or clean?
channeling energy into a new hobby
avoiding feelings of a loss
justify not doing something with an excuse
(ex. not going to appointments bc they're too busy)
client is receiving continuous bladder irrigation and the UO decreases. client reports bladder spasm. what is the priority action of the nurse?
irrigate the catheter with 0.9% sodium chloride
oral glucose test
-maintain usual level of activity for 3 days prior
-instruct client to fast overnight
-avoid caffeine for 12 hours before
-unrestricted diet for 3 days before (don't limit carbs)
what position should a client be in for a gastric lavage?
Chvostek's and Trousseau's signs.
(chvosteks = cheek)
acid base imbalance with COPD:
adverse reaction to epi:
common adverse effect of clonidine
what should the nurse do if a client is started on risperidone (for schizophrenia)
fall risk precautions
*can cause dizziness and orthostatic hypotension
pulses paradoxus =
coughing up blood
(> 250 mL/24 = risk for hemorrhage)
weight loss will put a client at risk for
pressure ulcer development
facial flushing, nasal congestion, headache
what not to use for a client who has diabetes and sprains an ankle?
temp therapy (don't use ice packs or heating packs)
fever unresponsive to anti-pyretics =
lack of remorse =
antisocial personality disorder
client positioning post-tonsillectomy:
supine, head below level of chest
stage 2 pressure ulcer
partial thickness skin loss (blister)
stage 3 pressure ulcer
visible subcutaneous tissue
antidote for lorasepam
what indicates a vaso-occlusive crisis in sickle cell anemia
confusion + lithium =
#1 thing to look for in a newborn:
food high in vitamin A
yellow & orange veggies
(ex. 1 medium raw carrot)
patient with agonal respirations =
s/s of oxygen toxicity
amount of fluid for an immobile patient
stroke infant's cheek
*should turn towards that side and suck
amytriptyline side effects
dry mouth & constipation
can you administer TPN without a pump?
*dextrose 10% at drip rate instead
what position should a pregnant client admitted with severe pre-eclampsia be placed in?
Artificial rupture of membranes causes sharp decelerations between contractions. what is the nurses priority action?
place the client in a knee-chest position
(relieve compression on the cord being trapped between presenting part and pelvis)
if a client gains too much weight during the first month, what is the first thing you thinK?
too many calories
*ask about snacking, 24 hour diet recall, eating healthy
what s/s during the third trimester should be reported to HCP immediately?
what type of birth is the HIGHEST risk of hemorrhage?
*twins are a risk, but not at much as a cesarean
*cutting of the abdomen and uterus
what is a nursing priority for choosing a private room?
*even if post-delivery, still at high risk for a seizure
what is normally elevated in women's blood work postpartum?
what to do if a clients BP drops post epidural?
turn them on their side!
*relieves pressure on vena cava and increase BP
s/s of congenital hip disorder?
limited abduction of one leg
asymmetrical gluteal folds
presence of an Ortolani click
what procedure should be performed if a client (34 weeks gestation) has profuse, painless, bright red bleeding?
*do NOT do a vaginal exam
*contraction stress test could cause further detachment of placenta
what procedure is done to determine fetal lung maturity when a pre-term labor is expected?
s/s of a premature infant
folded ear pinna springs back slowly
shoulders and chest have moderate lanugo
vernix covering axilla, back, and buttocks
no creases on the feet soles
can a LPN check fundal height and FHR?
what happens to a newborn who is going through phototherapy?
their urine will be dark & have green stools
*from breakdown of bilirubin for excretion
when is a contraction stress test contraindicated?
before 27 weeks gestation
in clients with previous cesarean section deliveries
clients with history of placenta previa
what drug is used in a pregnant woman having a seziure?
what should you do if a 37 week pregnant woman begins to seize?
place clients head in nurse's lap (lowered to floor gently)
monitor tonic-clonic activity
client with PIH complains of "heartburn", what should you do?
call HCP immediately
(associated with ruptured liver and seizures)
milestones for a 2 month old:
holds head up
turns head toward sound
what can cause iron deficiency anemia in children?
too much milk
s/s of fifth disease
*slapped cheek syndrome
-erythema on cheeks
-pruritic rash on feet
when can a baby respond to it's own name?
when should a child watch something fall?
what can happen to a child's temperature with juvenile arthritis?
elevate at same time every day
*room them with a child around the same age & same sex with another chronic disease
when can children begin to follow simple directions like "pick up the toy"?
around 1 year
-looks for fallen object
-plays peek a boo
-picks up cereal between thumb and index finger
-stands while holding on to something
for an 8 month old admitted to the pediatric unit, what major developmental stressor should the nurse plan for?
*can be worse if they are hungry, tired, or sick
*keep good-bye's short and sweet
if a child's bed wetting problem has returned, what is the FIRST thing you assess?
-physiologic problem (perform urinalysis to check for UTI)
*even if regression is likely the cause, assess physical problems first to rule it out
teaching for parents of a child with a concussion
symptoms very in length
return to ED for worsening headach
avoid physical activities until released from care & reduce cognitive demands (watching TV or reading)
awaken client every 2 hours
T or F: if a kid doesn't like a food after the 3rd attempt, they never will
*keep trying new foods
how long must an infant stay in the back seat facing backwards?
at LEAST a year old
a client with gestational diabetes delivers and infant with macrosomia. what is the most important thing to do?
frequent blood glucose monitoring
*infants of diabetic mothers are at risk for hypoglycemia following birth
what is one of the most dangerous complications of Bell's Palsey?
keratitis (inflammation of cornea)
*teach client proper methods of closing eyelids and eye-patching
what is important to assess before an amniotomy?
risk factors for type 2 diabetes:
fat distribution greater in abdomen than in hips
polycystic ovary syndrome
Blacks, hispanics, and american indians are at a greater risk than caucasian's
when is the hepatitis B vaccine given to a baby?
right after they are born, before discharge (as a newborn)
if you drop a bottle of IV fluid in the hallway and it shatters, what should you do>
pick up glass with broom and dustpan & dispose into a puncture resistant sharps container
*don't call housekeeping (delaying action! could get hurt waiting!)
is intermittent self-catheterization a clean or sterile procedure?
what should you do if a child's clothing catches on fire
lay them flat and roll in a blanket
who is the most appropriate audience for a nurse preparing a lecture on suicide?
high school teachers
*teach about the warning signs of suicide to high school teachers, students, and parents of teens and young adults, particularly male.
pain scale for kids between 2 months and 7 years:
FLACC (based on nursing observation)
*CRIES is for neonates and infants
*FACES is not a good scale if the client has a developmental delay
if family members are asking triage nurses if their loved ones were admitted due to a mass casualty, what should you do?
inform them if they have been admitted or not
*emergency state waives HOPAA
can a UAP check for skin breakdown?
NO --> this is assessment!!
if you suspect that a patient has increased IOP; what is the FIRST thing to do?
notify primary HCP
*repositioning or giving pain meds will not fix the problem
oxytocin IV may put a client at risk for:
uterine tachysystole (too many contractions too close together)
phobia of being in certain small spaces (ie. a train)
how to prevent recurrence of otitis media?
smoking cessation in the home
*also discontinuing a pacifier after 6 months
30 or greater
how often should normal saline be changed out if unused?
every 24 hours
common complication of hemophilia
what prescription should be questioned post-abdominal surgery?
inserting NG tube (can disrupt suture site)
PRIMARY thing to check for client with new trach
secured correctly!!! displacement is the worst complication
-check tightness of ties and adjust to fit 1 finger under
what is the PURPOSE of diltiazem?
ventricular rate control!!!
*intended effect: HR decreases from 118 to 88
*auditory hallucinations are not concerning
*s/s toxicity are most important (N/V/D & tremors)
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