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NCLEX Study! things to Remember
Terms in this set (233)
Oprelvekin action, side effects, and uses
-stimulate platelet production
-side effects: Cardiac Dysrhythmias
-BMW cancer, give after chemo.
Hemoglobin normal value
14-18 g/dL (M)
12-16 g/dL (F)
Grapefruit juice interacts with
Calcium channel blockers
Statins adverse effects
-Rhabdo, monitor for muscle aches
Ca channel blockers adverse effect
May increase heart failure
Ace inhibitors adverse effects
can cause angioedema
Beta blockers caution use
Alpha2 Agonists adverse effect
contraindicated with anticoagulants
Increases heart rate (treats bradycardia), decreases saliva and secretions for surgery
Atropine nursing considerations
-Monitor Urine output
Hold digoxin if
hr <60 in adults, <70 on children, and <90 on newborns
Digoxin signs of toxicity
2nd: Halos, CNS
Side effects of Nitroglycerin
(Side effects:) Headache, flushing, dizziness, hypotension, and tachycardia.
Adenosine usage case, side effects,
converts SVT to sinus. (slows conduction time of av node)
side effects: flushing, bronchospasms
Amiodarone use case, side effects
assists with V-fib and unstable VT.
side effects: bradycardia, pulmonary complications, ATAXIA
Amiodarone nursing considerations:
Do not give with heparin
HDL normal range
40-60, the higher the better.
Total cholesterol level
LDL normal range
Less than 100; The lower, the better
Glucorticoids abrupt cessation may cause
Glucorticoids chronic use may cause
Leukotriene modifiers example and interact with?
Montelukast, interacts with warfarin & theophylline.
desmopressin use case, nursing considerations
-diabetes insipidus, bed wetting
-store in refrigerator like most hormones
How long to hold metformin before using dye for imaging, and what to do instead?
48hrs before 48 hrs after, sliding scale insulin (coverage insulin)
rapid-acting insulin: lispro, onset, peak, duration
Short-acting: Regular. Onset, Peak, Duration
peak: .1-5 hrs
intermediate: nph, onset, peak, duration
Long-acting: insulin glargine
how to treat hyperkalemia
insulin drip pushes potassium into cells, give d50 with it.
which insulins can be mixed
regular and nph
which insulin is only given iv
hyperthyroidism treatment least invasive
methimazole nursing consideration
no breast feeding
Albumin normal level
FFP usually is given to treat
bleeding related to warfarin
albumin usually is given to treat
platelets are usually given to treat
packed rbcs usually given to treat
hemmorhaging post partum uses which blood components
filgrastim side effects
epoetin alfa adverse effect
what increases iron absorption
vitamin c increases absorption
what decreases iron absorption
calcium and tannin (coffee, tea, dairy products)
If gi upset with iron, what do you do?
give with food
liquid preparations of iron nursing considerations
use straw, rinse mouth (stains teeth)
IM injections of iron consideration
use z-track, large bore needle, change it after drawing up, do not massage site
is clopidogrel a anticoagulant or antiplatelet?
alteplase, tenecteplase, reteplase
when do clot busters need to be given (time window)
radioactive implant nursing considerations: soap, lotion, visitors
mild soap and water, no lotion, limit visitors to 1/2 hr eacah day, remain 6 feet from the source.
Meperidine nursing considerations
Not used in kids can cause seizures
normal Lithium levels
How do you diagnosis diverticulitis?
Nursing considerations: children with autism
avoid too much stimulation.
pediatric respiratory distress is signified by respiratory rate over
2nd stage of labor
complete cervix dilation to birth
3rd stage of labor
delivery of placenta
1st stage of labor
ends with full dilation of cervix.
classifies cancer according to tumor size, node involvement, metastasis
Lead normal value
children iron level
side effects such as restlessness, involuntary movements (fine hand tremors, shuffling gait) and muscular tension.
tardive diskinesia symptoms
-writhing movements of tongue
-jerking movements of shoulders.
self mutilation is found in which personality disorder?
Borderline personality disorder.
Common in pts with shock, or about to die.
Blood should be hung within what period of time after receiving it from the blood bank?
S/S of lithium toxicity
nausea, vomiting, diarrhea, polyuria, muscle weakness, fine hand tremors.
s/s of respiratory alkalosis
lightheaded, faint, peri-oral numbness, numbness and tingling in fingers and toes, tetany, chest pain, dsypnea.
Initial treatment for someone with paralytic ileus.
NG Tube, to intermittent or constant suction to decompress gi tract.
Initial first and easy action to take when someone presents with DKA.
Sodiums relationship with Lithium
patients with low sodium intake are more likely to have lithium toxicity
Nsaids relationship with lithium,
NSAIDS increase likelihood of lithium toxicity
Causes of lithium toxicity:
NSAIDS, and low sodium intake.
incompetent cardiac sphincter of esophagus causing acid reflux.
Cullen's sign, what is associated with.
ecchymosis in umbilical area, seen with pancreatitis/intraabdominal pain.
Oxybutinin is used for
prevention of urinary incontinence
Etanercept is used for
slowing progression of arthritis
pregabalin is used for
quetiapine is used for
treats bipolar disorder
INR normal range
aptt normal value what drug does it measure
Metabolic Alkalosis causes
severe vomiting, excessive GI suctioning, diuretics, excessive NaHCO3
Metabolic Acidosis main cause
Respiratory acidosis causes
- Depression of the respiratory center.
- Head injuries.
- Oversedation with sedatives and/or narcotics.
- Conditions affecting pulmonary function.
When do you take Antacids?
1 hour after meals
when do you take sucralfate
on an empty stomach
When do you take PPI's?
before meals 1 hr
Common electrolyte imbalances of non-potassium sparing diuretics
used for ICP
Nursing Considerations with Rifampin
Client will secrete orange bodily fluids, avoid plastic contact lens, no alcohol
Ibandronate, was does it do? and nursing considerations
-Drink with water
-Take on empty stomach
-Sit up for 30min to an hour (prevent esophagitis)
Hydroxychloroquine nursing considerations
biannual eye exams
phenelzine nursing considerations
MAOI: don't give with SSRI's. tricyclic antidepressants, hypertensive meds, or with Tyramine foods.
-Mostly foods that are processed/aged: pepperoni, cheddar cheese, red wine.
-Pts can have white wine.
Zolpidem acute or long term?
should be acute/short term.
Typical anti-psychotics: typical means:
Atypical anti-psychotics: atypical means:
Typical anti-psychotic side effects:
-anticholinergic effects (dry mouth, tachycardia)
(Side effects: we can deal with it.)
Typical anti-psychotic adverse effects
-neuroleptic malignant syndrome
(adverse effects: We need to do something about)
Neuroleptic malignant syndrome
Adverse reaction to antipsychotics with severe "lead pipe" rigidty, FEVER, and mental status changes
Atypical side effects:
-lower risks of EPS and TD
-Agranulocytosis, seizures, and orthostatic hypotension.
2 examples of typical antipsychotics
2 examples of atypical antipsychotics
What are goals of parkinson's medications?
when is levodopa carbidopa contraindicated?
MAOI's, narrow-angle glaucoma benztropine
Levodopa carbidopa nursing considerations:
-change position carefully
-take with food
-instruct to report irregular or fast heart beats
-discuss potential for hallucinations or paranoia
involution of uterus
the uterus returns to its normal nonpregnant size
Difference between autonomic neuropathy vs sensory neuropathy
Sensory: most common type of neuropathy refers to loss of sensation in lower extremities
Autonomic: damage to the autonomic nervous system. Which controls involuntary bodily functions. (orthostatics)
Hepatic Encephalopathy indications
-Change in orientation
-fetor hepaticus (poop breath)
SG and osmolarity of urine in DI patient
decreased osmolarity, decreased sg
Legg-Calve-Perthes Disease, what is it? how to dx?
avascular necrosis of the femoral head, dx with radiographs
which diagnostic test assesses growth hormone deficiency?
Serum Insulin like growth factor (IGF-1)
-Avoid meat, milk, dairy, eegs
-Eat fruits, juices, cereal, bread, starches
-Avoid protein for 3 months prior to getting pregnant.
absence seizures are treated by which medications:
If a patient starts gagging/choking during insertion of NG tube, what should the nurse do?
withdraw tube slightly and wait until gagging stops
s/s of polycythemia vera
reduced blood flow, plethora (ruddy complexion), fatigue, dizzy, headache, gout, visual disturbances
Legg-Calve-Perthes Disease manifestations
-onset often insidious
-hx of limp, hip pain, limited ROM
-may have a vague hx of trauma
Why is caffeine avoided in GERD?
Caffeine relaxes the lower esophageal sphincter
Manifestations of PE
-crackles and cough
Beta blockers affect on heart
slow down the HR
Albuterol is a beta-agonist, which
dilates the bronchioles, and speeds up the heart.
-potasium iodide-iodine solution, inhibits release of thyroid hormone in individuals with hyperthyroidism, used for thyroid storm, and preop thyroidectomy.
Risks for patients without spleens
-infection (the spleen clears out harmful bacteria, viruses, and parasites from the body)
-thrombosis (spleen stores excess platelets)
Side effects of adhd medications (methylphenidate)
anorexia, difficulty sleeping, headaches, hypertension, weight loss, nervousness, exacerbation of vocal or motor tics; nausea and vomiting.
What is acute respiratory failure characterized by? ABG values
PaO2 <60mmHg or PaCO2 >50mmHg.
Normal Magnesium levels
Preeclampsia acceptable magnesium level
Infant with heart failure nutritional needs
add corn oil to bottle
Positive tuberculin skin test is what in immunocompromised individuals
Positive tuberculin skin test in healthy individual
Nursing considerations for Iodine uptake test
-Radioactive iodine is given and then scans are taken at 2, 6 and 24hrs.
-Client should top thyroid medications for 5-7 days before test
-if recent contrast ct has been done this could alter results.
-female patients need a pregnancy test
-NPO 2-4 hrs before procedure
-Remove any jewelry, metal around neck, and dentures
-performed without sedation
-no breastfeeding until few days after procedure.
-drink lots of fluids after procedure
Thyroid Iodine uptake test: patho
-It helps differentiate between hyperthyroidism related to overproduction of hormone vs due to inflammation and destruction of thyroid tissues.
s/s of approaching death
-mottling of extremities
-inability to swallow
BMW transplant nursing considerations before transplant
-crossmatching client's serum against donor's lymphocytes
-administration of acyclovir and cytovene.
LPN's can do what?
-administration of regular and injection medication, suctioning and tube feeding, sterile procedures including dressing changes and placement of urinary catheters, and higher level assessments of STABLE clients.
how to convert celsius to farenheit?
multiply celsius reading by 9/5 and add 32
normal aptt, normal aptt for someone with anticoag therapy
normal: 30-40 seconds
relay station for sensory impulses, pain
water balance/bp/temp regulation/hunger/thirst/sex.
stiff joint condition
Stages of Parkinson's Disease
-minimal/absent; unilateral (may not have diagnosis yet or may not be really noticing signs)
-minimal (B) or midline movement; balance is not impaired (starting to notice more signs)
-impaired righting reflexes; unsteadiness when turning or rising from chair
-some activities are restricted but patient can live (I) and continue some form of employment
-all symptoms present and severe; standing and walking only with assistance
-confined to bed or wheelchair
scanty production of urine
involuntary loss of urine associated with overdistention and overflow of the bladder.
-Found in patients with strokes.
3 year olds can
-copy a circle
-build a bridge with 3 cubes
-learn from experience
-ride a tricycle
-walks backward and downstairs without assistance
-undress without help
-have at least 300 words
-may invent an imaginary friend
3 phases of ptsd
1. initial response phase
2. the second phase
3. and third phase
Pinkish/brown, serosanguineous. Lasts day 4-10 postpartum
Yellowish, white cream color. Lasts approx 11 days-6 weeks postpartum
Reddish or red-brown vaginal discharge that occurs immediately after childbirth; composed mostly of blood.
What to do for an 3rd degree AV block?
how to calculate body surface area
multiply weight (kg) by height (cm)
divide by 3600
then apply square root to answer.
Nursing considerations for neonatal abstinence syndrome
-swaddle the newborn and place in a side-lying position for feeding.
-avoid too much stimulation
MAOI foods to avoid
What is an ileal conduit?
is a cutaneous urinary diversion. An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel
Which spot on a patients chest can you hear s1 and s2 equally?
Erbs point, third intercostal space on left side of chest.
Hip fractures manifestations
-usually appears externally rotated
-shortened on affected side (muscle spasm)
-tenderness and ecchymosis over site
-groin pain with weight bearing.
pt is 39 weeks gestation, in active labor with an oxytocin infusion, you notice persistent late decels, what does this mean and what actions do you take?
placental insufficiency which includes impaired fetal oxygenation.
-discontinue uterotonics (Reduce uterine activity)
-change maternal positions to left side to relieve compression on inferior vena cava.
-give iv bolus of lactated ringers
-notify healthcare provider
1. A Nitrazine test strip is used to detect presence of amniotic fluid in vaginal secretions, if rupture of membranes is suspected in premature labor.
manifestations of bells palsy
-alteration in tear production
-can't close eye on affected side
-flattening of nasolabial fold
-inability to smile or frown symmetrically
Which prescription should a nurse implement for a client with suspected acute appendicits first?
-draw blood for cbc and electrolyte levels
-initiate iv access and infuse normal saline
-obtaine urine sample
-initiate iv access and infuse normal saline
-ABC's (circulation) is more important than labwork.
-Think about the disease process and what it leads too or causes: in this case: vomiting, diarrhea, npo status.
manifestations of spina bifida
-tuft of hair
-dimple along the base of the spine.
Acute pericarditis manifestations and considerations:
-st segment elevation in ALL leads. (contracts with acute MI which would be st elevation is only seen in localized leads)
-monitor for signs of cardiac tamponade: muffled heart tones, hypotension, JVD.
-if pt reports chest pain that is worse with deep inspiration, place client in fowlers position with support to lean on for comfort.
manifestations of macular degeneration
-Gradual, mild to moderate reduction of central vision
-peripheral vision remains intact
What condition is associated with long-term total parenteral nutrition (TPN).
-Central vein infections/thrombosis
-liver failure (occurs more frequently in children)
How to verify a ng tube suction is working properly?
temporarily disconnect the tubing between ng and the drainage tube and listen for suction noises.
Manifestations of Cirrhosis
anorexia, nausea, jaundice, edema, pain, ascites, anemia, gynecomastia, bruising, asterixis
Feeding clients with bipolar mania and nursing diagnosis of: imbalanced nutrition: less than body requirements.
Pt will be too agitated to sit and eat. So pt should be provided High calorie foods that are easy to eat, hamburger, fries, milkshake, banana.
appropriate use of corticosteroid cream
-thin layer of medication to damp skin
-use gloves when applying
-avoid applying to skin folds
-1-4 times daily
How often do you remove a wrist restraint?
every 2 hrs, check for skin integrity, color, and circulation.
Supine with legs elevated.
supine with knees flexed.
Instructing clients how to walk with a cane
-cane goes first or with weakened extremity.
-move cane forward 6-10in, then move the weaker leg forward.
-Finally, advance the stronger leg past the cane.
normal chloride levels
infant normal hr
fontanel bulging means.
-Can be from crying which increases icp
-or fluid overload, but if pt is crying and bulging assume normal.
NG tube insertion clean or sterile?
clean, normal gloves.
direct coombs test
The direct Coombs' test is used to detect idiopathic hemolytic anemia in infants by detecting the presence of autoantibodies against the client's RBCs.
Pt with type 1 diabetes and breastfeeding
breastfeeding has antidiabetogenic effect, which decreases the need for insulin.
insulin needs for type 1 diabetes pt in 3rd trimester
needs for insulin will increase due to increased insulin resistance
when does ovulation occur?
day 14 of the menstrual cycle
appearance and consistency of fertile cervical mucus.
Is cervix hard or soft during ovulation?
fertile mucus appears clear, thin, watery, and stretchy.
How to prevent skin breakdown of limb in cast
-Increase blood flow through isometric exercises. is the BEST way.
complications post thyroidectomy
laryngeal nerve injury, thyroid storm, hemorrhage, respiratory obstruction, tetany (decreased calcium from parathyroid involvement), check Chvostek's and Trousseau's signs.
Peritoneal Dialysis positioning
supine, low fowlers, wearing a mask.
Nursing considerations for dialysate during peritoneal dialysis
-warm dialysate, not in microwave with heating pad or in warmer.
Which action is priority if the nurse suspects a break in the CVAD?
a trickle of fluid indicates catheter breakage or disconnection, which places the client at risk for air embolism; turn the client on the left side and position the head lower than feet; notify the health care provider
The nurse is caring for a client one day after an abdominal-perineal resection for rectal cancer. The nurse should question which of the following prescriptions? (explain each answer!)
Remove nasogastric tube if audible bowel sounds.
Irrigate the colostomy every 8 hours for 2 days.
Cover the stoma site with petrolatum gauze.
Administer meperidine 50 mg IM for postoperative pain.
Remove nasogastric tube if audible bowel sounds—audible bowel sounds usually indicate the return of peristalsis. The health care provider will also prescribe a clear liquid diet, and then advance the diet as tolerated Irrigate the colostomy—CORRECT: colostomy irrigation should not be performed immediately after surgery when the colostomy is not yet functioning; the colostomy commonly begins to function 3-6 days after surgery Cover the stoma site with petrolatum gauze—petrolatum gauze may be used to cover the stoma and keep the stoma moist if there is not a pouch in place Administer meperidine 50 mg IM for postoperative pain—opioid analgesic that can effectively relieve postoperative pain
CK-MB normal lab value
client positioning for paracentesis
positioned in an upright position with feet supported for the procedure; if the client can tolerate the abdomen pushing up against the diaphragm, the client can also be positioned supine for the procedure
The nurse is teaching a client who is scheduled for a paracentesis. Which of the following statements by the client to the nurse indicates that teaching has been successful?
"I will be in surgery for less than an hour."
"I must not void prior to the procedure."
"Two to 3 liters of fluid will be removed."
"I will lie on my side and breathe slowly."
"I will be in surgery for less than an hour."—not a surgical procedure "I must not void prior to the procedure."—bladder emptied prior to the procedure to prevent inadvertent puncture "Two to 3 liters of fluid will be removed."—CORRECT: health care provider slowly removes 2 to 3 liters of fluid to decrease ascites; in severe cases, can remove up to 6 liters "I will lie on my side and breathe slowly."—positioned in an upright position with feet supported for the procedure; if the client can tolerate the abdomen pushing up against the diaphragm, the client can also be positioned supine for the procedure
Chest physiotherapy before or after meals?
before meals, prevents nausea and vomiting
The home care nurse is performing chest physiotherapy on a client with chronic airflow limitations (CAL). Which of the following actions should the nurse take first?
Perform chest physiotherapy prior to meals. A
uscultate breath sounds before the procedure.
Administer bronchodilators after the procedure.
Percuss each lobe prior to asking the client to cough.
Perform chest physiotherapy prior to meals—prevents nausea, vomiting, and aspiration; nurse should auscultate breath sounds prior to performing chest physiotherapy Auscultate breath sounds before the procedure—CORRECT: helps identify areas of the lung that require drainage; auscultate breath sounds after the procedure to determine effectiveness Administer bronchodilators after the procedure—given before chest physiotherapy to dilate the bronchioles and to liquefy secretions; nurse should auscultate breath sounds prior to and after administering bronchodilator to help measure effectiveness Percuss each lobe prior to asking the client to cough—may cause fractures of the ribs, especially in older adult clients with a preexisting diagnosis of osteoporosis; percussion helps loosen thick secretions; nurse should auscultate breath sounds before percussion.
diet considerations for liver disease
-Early stages: high-protein, high-carb diet;
-Advanced stages: fiber, protein, fat, and sodium restrictions. Protein breakdown increases ammonia levels.
-small, frequent feedings; fluid restriction; avoid alcohol.
When is a CVAD dressing changed.
transparent semipermeable dressing changed every 5-7 days, gauze dressing is changed every 2 days, and both are immediately changed if soiled, dislodged, or integrity compromised
manifestations of Guillain barre syndrome
weakness, paralysis, parestheis, pain, diminished reflexes, bulbar weakness.
- All symptoms start in lower extremities and progress upward
-Usually manifests after a viral infection or an immunization.
high levels of calcium result in which medical condition?
-edema, hyperglycemia, hypokalemia, and peptic ulcer.
-euphoria, agitation, aggression, and behavioral changes
Client with heart failure teaching: diet, exercise.
-client should exercise 3x a week, starting gradually, and should stop if pt experiences sob, chest pain, or cannot carry on a conversation
-restrict fluid to less than 2000ml
a state of unresponsiveness to one's outside environment, usually including muscle rigidity, staring, and inability to communicate
clinical manifestations of retinoblastoma
-most common: white eye reflex (leukocoria)
-second most common: strabismus
Neuroleptic Malignant Syndrome manifestations
fever, muscular rigidity, altered mental status, and autonomic dysfunction (sweating, hypertension, tachycardia)
Which drugs cause neuroleptic malignant syndrome
NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome.
How many mls on a bladder scan should be reported to a provider?
>100, as this could indicated urinary retention.
protective factors for sids
-up-to-date on vaccinations
-firm sleep surface
-removal of loose items in bed
contraindications of sumatriptan
inadequately controlled HTN
-because of sumatriptans vasoconstrictive properties.
What is the initial treatment for aspirin poisoning/overdose
-turns secretions reddish brown, this is normal
-stand slowly, sit on edge of bed first
-takes a few weeks to work
-avoid high protein meals
Inability to open the jaw due to pain
Appropriate weight gain during pregnancy
impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).
inability to organize movement (whistling, clapping, dressing)
slurred speech, due to weakness of muscles used for speech.
Report foul odors or hot areas (hot spots) in the cast, which may indicate infection (Option 1). Avoid getting the cast wet, which may damage the cast and cause skin irritation/infection (Option 2). Elevate the affected extremity above heart level for the first 48 hours to reduce edema (Option 3). Regularly perform isometric and range of motion exercises to prevent muscle atrophy.
Adverse effect of erythropoeitin
Hypertension is a major adverse effect of erythropoietin administration. Therefore, uncontrolled hypertension is a contraindication to recombinant erythropoietin therapy. Blood pressure should be well controlled prior to administering erythropoietin
macular degeneration main manifestations
loss of central vision
Do not use if ob patient is hypertensive (vasoconstrictive properties)
malignant hyperthermia occurs with which drugs? What is the antidote?
mostly anesthesia medications: desflurane, isoflurane, halothane and succinylcholine.
Antidote: IV Dantrolene
Normal central venous pressure
Fundal height during pregnancy?
After 20 weeks gestation, the fundal height measurement in centimeters should correlate closely with the number of weeks pregnant (eg, 24 cm = 24 weeks). The client should empty the bladder before having fundal height measured, as a full bladder can displace the uterus and affect measurement accuracy.
malignant hyperthermia s/s
The most specific characteristic signs and symptoms of MH include hypercapnia (earliest sign), generalized muscle rigidity (eg, jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm a suspicion of MH. The nurse monitors the temperature as it can rise 1 degree Celsius every 5 minutes and can exceed 105 F (40.6 C).
Partial Thromboplastin Time (PTT)
when is PTT monitored? and what drug correlates with this value?
when infusing heparin.
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