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291 Cards in this Set
- Front
- Back
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Hypoxia: vitals?
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pulse rate up
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Dehydration: what is it? how to treat?
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not the same as hypovolemia - need free water replacement - use hyypotonic fluic - 0.45% saline or D5W
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Hypovolemia: how to treat?
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need volume expansion - LR or NS
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Potassium: what regulates? what can help reduce serum levels?
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regulated by kidneys, influenced by extracellular pH - INSULIN has big effect on K level
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Hypokalemia
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most common cause = loop orthiazide diuretic. effects: skeletal muscle, smooth muscle, BP, heart. Treatment: K salts, Oral KCL, IV KCL
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Hyperkalemia: what causes it? what are effects? how to treat?
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causes: severe tissue damage, untreated Addison's, acute acidosis, misuse of K sparing diuretics, OD on IV potassium. effects: disrupts electrical activity of heart. TX: diet, no K foods, withhold meds that cause K accumulation, infuse HCO3
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Hypomagnesium: what causes it? how to treat?
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causes: diarrhea, hemodialysis, kidney disease, prolonged IV feeding, chronic alcoholics. TX: Mg gluconate, Mg hydroxide, Mg sulfate
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Hypermagnesemia: what causes it?
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renal insufficiency
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Diabetic: what is polyuria caused by?
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polyuria results from osmotic diuresis: compensatory for hyperglycemia.
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Protein replacement: how to do it?
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increase Carbs, Protein and decrease fats
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Alcoholism: DT's happen when?
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watch for DT's 2-3 days after surgery
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Liver Disease: what would blood ammonia level be?
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blood ammonia 180 mg/dL
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Surgery: what is big risk post-op?
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biggest risk is diabetic: hypoglycemia
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Surgery: what is problem for elderly? what can help?
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elderly: avoid hypothermia, use shower cap during anesthesia
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Post OP: how to assess CV function?
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assess CV function by monitoring ABG. Infection surgical site 15%; Clean Contaminate wound infection = 5%
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Shock - hypovolemic: how much blood loss? how to assess?
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30% blood volume loss;
assess - decreased/concentrated urine, hypotension, small pulse pressure, tachycardia, thready pulse |
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Hypopharyngeal Obstruction: what are s/s?
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evidenced by choking, cyanosis, irregular respirations
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Wound Healing: how long does inflammatory stage last?
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after surgery, inflammatory phase lasts 3 days
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Drains: name two. What is the difference between them?
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Jackson Pratt (100ml) vs Hemovac.(100, 400, 800 mL) Difference is collection container.
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Vitamin C: what is it needed for? What is usual daily dose? What is given post op?
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essential for collagen formation. Single most important protein of connective tissue. daily dose 60 mg. Post Op 1000 mg
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Post OP: pneumonia risk for how many hours?
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pneumonia within 36 hours
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Surgery: post op positioning?
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positioning: provide for adequate thoracic expansion. breathing
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Drains: describe penrose drain. What is important when caring for penrose drain?
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Penrose - gravity. Not negative pressure. Change soiled dressing carefully so you don't pull it out. Drain is within several layers of gauze.
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Tonsillectomy: why icepop? What does frequent swallowing indicate?
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Ice pop, vasoconstricts. limits bleeding. Frequent swallowing = bleeding
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Obesity: what can it cause? why?
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can cause N/V: fat = pressure on abdomen, GI tract
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Drains: when do you change a portable wound drainage system? Why?
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empty portable wound drainage system when 1/2 full. Force of vaccum decreases as collection chamber fills.
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Hysterectomy: what is needed post op?
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do leg exercise. 10x per hour
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Central Line: where to place?
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in peripheral vein is better. will not cause pneumothorax. vs. subclavian vein (too close to apex of lung)
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Pulmonary Embolus PE: what are classic signs? what are two complications?
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classic signs: chest pain from local tissue hypoxia. Tachycardia: from systemic hypoxia
Hypotension: from decreased cardiac output |
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Heart Attack: what does BP do during heart attack?
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BP up up
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Post OP: what is important to do?
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two days. balanced fluid & electrolytes
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Post OP: mechanical ventilation complications
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expected outcome after general anesthesia: breathing. 97% pulse ox; bc in GA machine breathes for them. Must get breathing or alveoli can collapse
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Pain, acute: what do vitals do in acute pain?
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assess verbal vs nonverbal behavior: PULSE UP and BP UP together if in pain
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Hypovolemia: what do vitals do?
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loss of fluid: BP down, HR up
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Low blood sugar: what are s/s?
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wet and sweaty, faint and dizzy
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High blood sugar: what are s/s?
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dry, hot, flushed, thirsty
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Blood Donation: rules. rubella? oral surgery? allergies? childbirth?
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Rubella: wait 1 month, Oral Surgery: 72 hours; Allergies no recent ones, Childbirth 6 months
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Blood IV: gauge? before giving, check? what are you assessing for?
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Consent. at least 20 gauge, 18 is better (if too small, will damage cell walls of RBC) Before giving - check allergies and listen to lungs - can cause fluid overload - assess for congestive heart failulre. Lside fail = crackles. Rside fail = JVD, peripheral edema, liver engorgement.
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Heart L side fail: s/s L side heart failure
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crackles, orthopnea
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Heart R side fail: s/s R side heart failure
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JVD, peripheral edema, liver engorgement
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Surgery: what color incision line?
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incision line should be pink, NOT red.
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Blood Types: What is universal DOOR
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universal red cell donor Type O negative blood type.
universal plasma donor has Type AB positive blood AB+ is the universal recipient Group A – has only the A antigen on red cells (and B antibody in the plasma) Group B – has only the B antigen on red cells (and A antibody in the plasma) Group AB – has both A and B antigens on red cells (but neither A nor B antibody in the plasma) Group O – has neither A nor B antigens on red cells (but both A and B antibody are in the plasma) |
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Blood - Autologous Transfusion Prep
what to give before? and why? how often and when can person donate? |
Give Epogen & Procrit - are forms of erythropoietin - stimulate bone marrow to produce RBC. May get iron to prevent depletion of iron stores. One unit of blood a week for 6 weeks prior to surgery. NONE within 72 hours of surgery
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Cell Saver: when is it used and what does it do?
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catches blood lost during orthopedic surgery to re-infuse back into client. Cells are washed with saline and re-infused thru a filter back into client. Can't be stored. Must be used within 4 hours.
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Acute Renal Failure: what is diet? why?
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Diet: HIGH carbs (for calories), LOW protein (minimize toxic waste from metabolism)
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Uremic Frost: what is? what causes it?
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crystals on skin, results from irritating toxins deposited in tissues. Bathe in cool water. decreases itching too
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Percutaneous Liver Biopsy. What is complication? What vitals tell you this is happening?
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complication: hemorrhage. What best tells you about hemorrhage? pulse up, BP down, resp up.
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Blood transfusion: giving... use pump? what is rate?
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do not use pump. causes damage to cells. infuse at slow rate for first 10 min
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Acute Renal Failure: what is complication and what can you do about it?
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Hyperkalemia: decrease K level by giving regular insulin with glucose. will drive K into cells, lowering serum K levels temporally
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Flank Pain: during blood transfusion, what is it a symptom of? what is going on?
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Hemolytic transfusion reaction. caused by agglutination of RBC in kidneys/renal vasoconstriction. blood is being viewed as foreign by the body
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Alcohol withdrawal: s/s?
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coarse motor tremors, increased pulse, increased anxiety
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Blood transfusion - what to do if reaction occurs?
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stop transfusion. replace tubing, infuse normal saline to keep line patent and maintain blood volume. TEST urine
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Play Therapy: rationale?
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promotes communication: play is the language of children
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Vitamin K: what is is needed for? what s/s if you don't have enough?
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Fat soluible. needed to make prothrombin by liver. Lack: inadequate coagulation, hemorrhage
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Bone Marrow Aspiration: what to do after?
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apply pressure to puncture site. complications rare, no need to monitor vitals
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Tetanus antitoxin: what does it give?
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immediate passive immunity
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PPD: when to read?
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read in 3 days
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Anaphylactic Reaction: what is patho?
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Histamine. bronchial constriction, increased capillary permeability, dllation of arterioles, hypotension, poor perfusion of major organs.
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Blood transfustion reaction: patho?
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Causes lysis of RBC - hemoglobin freed into circulation - if 100 mL or more of incompatible blood is transfused - get permanent renal damage - chills/low pack pain = kidney involvement
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Shock, vasogenic: patho?
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humoral or toxic substances acting directly on the blood vessels, causing vasodilation
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Hypokalemia: s/s?
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hypo-reflexes
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Angiogram: positioning after?
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position after: to promote circulation. supine with right leg extended.
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Bone aspiration: where done in kids?
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children: iliac crest
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D Dimer: what is it for? what is normal?
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monitors Lovenox therapy. tests fibrin degradation products. ordered to r/o DVT/PE - detects increase in DIC. normal 0 - 250 ng/mL
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Shock categories: there are 6
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Hypovolemic,
Cardiogenic, Circulatory - vasogenic - distributive. a. anaphylactic, b. septic. c. neurogenic. |
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Fluid bolus: how to give? timing?
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rapid, unless cardiac. 1 L of 0.9% saline or RL over 15 minutes.
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Slept in my recliner: what does this mean? what do you do next?
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...orthopnea... listen to lungs... left sided heart failure?
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azotemia: what causes? s/s? BUN?
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buildup of nitrogen. N/V, lethargy, confusion. BUN 80-90
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Acute Renal Failure: describe specific gravity
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low specific gravity - cannot concentrate urine, tubular damage. 1.010 - 1.025
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hematocrit: what is? when is it increased/decreased? What is normal values in men, women, babies. What conditions does it identify?
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percent of RBC by volume in whole blood. INcreased in hypovolemia (hemoconcentration). DECreased in hemorrhage. women 35-47%, men 42-52%, baby 55-68%. ID's anemia or polycythemia
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CO2: what does low CO2 cause?
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low CO2 starts respirations
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Dialysis Peritoneal: describe catheter? how to enhance draining?
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catheter is sutured in place. To enhance draining, turn from side to side. DO NOT press on abdomen. May milk if there is occlusion.
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Shock Toxic Shock Syndrome: what is treatment? what type of shock is it?
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give fluids and antibiotics. Is a type of septic shock. circulatory answer: give fluids FIRST before antibiotics
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Heart Failure: Left side vs Right side? Which is priority?
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Left side: breathing - ask - where do you sleep at night. Right Side: peripheral edema (ankles) or feel yucky after dinner. PRIORITY is respiratory, left sided failure
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chest tube: what does it mean if water seal chamber bubbles? What can it cause? What s/s to report?
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if water seal chamber bubbles = air leak into system, could lead to pneumothorax. report bright red drainage.
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pneumothorax: before chest tube is removed, what must be done?
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CXR must confirm lung re-expansion before chest tube removed. when removed, do Valvalsa maneuver to increase pressure - so no air enters pleural cavity
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tracheotomy: how to clean?
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clean stoma with equal parts saline/hydrogen preroxide, suction on high, replace inner cannula every time trach care is given.
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tracheostomy cuff: inflated/deflated when?
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make sure inflated to decrease risk of aspiration
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sarcordosis: what is it?
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systemic disease, multiple masses (granulomas). causes lymphadenopathy, pulmonary infiltration, skeletal, liver, eye and skin lesions. cause unknow. hypersensitivity response. not contagious
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Kussmaul's respirations: what is? when seen?
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deep gasping - diabetic acidosis/coma
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bronchoscopy: after what is problem?
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gag/cough, reflexes suppressed by anesthetic. Risk of aspiration until reflexes return
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pneumonectomy: positioning? complications?
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affected side down; good lung up
complications: pulmonary edema, mediastinal shift, atrial arrhythmias |
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nasopharyngeal airway: how to insert?
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gently push airway along floor of the nostril, water based lubricant, supine, push tip of nose up, pre-determine length (nose to earlobe)
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oropharyngeal tube: how to insert?
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when inserting point tip up to roof of mouth
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suctioning: describe improper. what results?
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prolonged, vigorous can cause hypoxemia, cardiac arrhythmias, hypotension
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sputum collection: position? how? how much?
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high fowler's, rinse mouth with water (reduce contamination by oral bacteria or food), cough deeply, expectorate 15 ml if possible
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Acute Respiratory Distress Syndrome: what is it? cause? result?
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resistant hypoxia, caused by trauma, form of pulmonary edema.
injury reduces bloodflow to lungs, platelets aggregate, release histamine, serotonin, bradykinins. histamine especially inflames/damage alveoli capillary membrane. increases capillary permeability - proteins and fluids leak out, increased interstitial osmotic pressure. fluid shifts to interstitial space, leading to pulmonary edema. |
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Pulmonary Function Tests: preparation - don't do what before test?
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spirometer - do not take bronchodilator for 4 hours before test. NPO after meidnight
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COPD: what kind of mask? why?
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need accurate oxygen - use venturi. essential because too much O2 could stop the respiratory drive - driven by low PaO2. Partial REbreather Mask: increases concentration but in a range.
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Reaction Formation: what do you see?
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opposite behaviors
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Pleuritic Chest Pain: describe the pain
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intermittant, sharp, very painful. gets worse with deep inspiration & movement
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endocarditis: what relieves pain?
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pain relieved while leaning forward
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Pulmonary Embolism: what is?
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thrombus lodged in branch of pulmonary artery, partially or totally occluding it, lung ventilated but not perfused
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chest tube: what is nursing care?
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listen to respirations Q4H
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Flail Chest: what is? what is treatment?
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"contracts on inspiration, bulges on expiration" = 2 + adjacent ribs are fx at two or more sites. free floating segment, loss of chest wall stability; respiratory impairment, paradoxical movement. PARADOXICAL chest movement.
treatment: endotrachial intubation + mechanical ventilation |
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pneumothorax: what do you see?
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unequal chest expansion.
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pneumothorax, tension: what do you see?
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mediastinal shift/trachial deviation toward unaffected side.
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smoker: pack years?
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cigarette pack years: # years smoked x # packs per daay
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auscultation: what do you hear for asthma?
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asthma - breath distant, wheeze on expiration, expiration prolonged
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auscultation: what do moist crackles at bases mean?
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moist crackles at bases = L side heart failure
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auscultation: what does bronchial breath sounds at lung bases mean?
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bronchial breath lung bases - lowerlobe pneumonia
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ventilator: assist control mode?
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assist control mode = + pressure to patient effort, auto takes over
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ventilator: what is CPAP?
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CPAP - patient breathes spontaneously machine maintains pressure above atmospheric
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Infant - fontanel. normal and abnormal?
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soft, flat NOT BULGING or FULL - increased ICP
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circumcision: normal at 3 days?
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normal: 3 day old, yellowish exudate
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hemophilia: patho? how transmitted?
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can't create blood clots. internal bleeding most dangerous. carried on X chromosome. women have to have it on both chromosomes to be hemophiliac. women transmit it to 50% of their kids. men have only one x, so if gene is on it, they have it.
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infant: at 6 months, should be able to?
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6 month old: should sit with support
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infant: at 9 months, should be able to?
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9 month old: should have pincer grapsh
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infant: at 1 year, should have?
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1 year: triple weight
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infant: when does fontanel close?
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fontanelle is closed by 2 - 3 months
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suction: how long?
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10-15 seconds
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psych phobias: name two
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projection and displacement;
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psych projection: what is?
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attributing one's thoughts or impulses to another
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psych displacement: what is?
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shifting of emotion concerning person /object to another neutral or less dangerous person /object
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psych sublimation: what is?
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diversion of unacceptable drives into socially acceptable channels
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psych internalization: what is?
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incorporation of someone else's opinion as one's own
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psych rationalization: what is?
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attempt to make behavior appear to be the result of logical thinking
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psych reaction formation: what is?
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development of conscious attitues & behavior paterns into opposite of what one really wants to do
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VDRL: what is?
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The Venereal Disease Research Laboratory test or VDRL is a blood test for syphilis
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elderly - ROM - what does it do?
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"sufficient ROM assists the elderly to carry out ADL's" of course
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fetal alcohol syndrome: characteristics?
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small head, low birth weight, facial abnormalities (undeveloped cheekbones)
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elderly - glucose - changes?
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the renal threshold for glucose is elevated in the elderly.; get false negatives;
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pregnancy - ultrasound - what does it do?
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ultrasound detects the gestational age
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pregnancy - amnio - what does it detect?
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lungs, spinal cord problems, problems with baby's blood
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lice - how to treat?
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kwell - needs to be repeated in 5-7 days, after eggs hatch. NIX kills lice & nits after one application
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enema - positioning?
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left side-lying, Sims, knees flexed
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Croup - laryngotracheobronchitis LTB - s/s?
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18 month old - early symptom - inspiratory stridor and restlessness, increased respiratory rate; edema and inflammation of upper airways
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tracheostomy - describe secretions?
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loss of the upper airway increases the amount and viscosity of secretions. ineffective airway clearance
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hypoparathyroidism - diet? why?
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diet: high calcum and low phosphorus. parathyroid controls calcium balance
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hypoparathryoidism - s/s?
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tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia, laryngeal spasm
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pregnancy: pre-eclampsia: early and late s/s?
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early: facial swelling, proteinuria. Later: blurred vision, oliguria
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CVA: s/s? what to help prevent?
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facial paralysis; person cant' close eye - , cranial nerve VII, lacrimal gland no longer secrete, must act to prevent corneal abrasion
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play: 4 year old - what kind?
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associative play
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play: toddler - what kind?
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parallel play
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play: infant - what kind?
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solitary play
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Addison Crisis s/s?
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shock: restlessness and rapid, weak pulse
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Addision Disease: describe s/s
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weak, fatigue, dark skin, GI prob, anexorea
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pregnancy: 4th stage: where is uterus?
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uterus contracted/palpable at the umbilicus
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alcohol problem: s/s?
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complaints of pain unrelated to admissions problem, tremors, elevated temp, nocturnal leg cramps
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Pituitary dwarfism: s/s?
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small size, normal body proportions. appears younger than chronological age
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erikson: old 65+: what is stage?
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integrity vs. despair
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erikson: 45 - 64: what is stage?
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generativity vs stagnation
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erikson: young adult: what is stage?
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intimacy vs isolation
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erikson: adolescent: what is stage?
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indentity vs role diffusion
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hypothryoidism: what should you avoid?
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avoid narcotic sedatives.
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Rinne Tests: what does it test? how is it done?
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stem of tuning fork - against mastoid bone - until can't hear sound. then move in front of auditory canal.
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Weber test: what does it test? how is it done?
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stem of tuning fork - middle of forehead - assess hearing in both ears.
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diabetes type 1: effects on eye?
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gradual destruction/degeneration of of the retina, vessels deteoriate
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kidney transplant: visiting rules?
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visitors = handwashing. immunosuppressed. no masks needed
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diabetes type 2: after surgery or NPO?
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after surgery, insulin injections: NPO inhibits normal blood sugar control: temporary control by insulin
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rehab: assess what?
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assess client's personal goals for rehabilitation
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delusions of reference: what is?
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public events or people are directly related to the individual
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breastfeeding: how many extra calories per day?
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+500 cal per day
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chest tube: pleu-evac: how to tell if lungs re-expanded?
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lung re-expanded if: the fluid in water seal chamber does not fluctuate with respirations
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chest tube: pleur-evac
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air leak: continuous bubbling in waterr seal chamber. check for location of leak
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infant: barium swallow: preparation?
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NPO 3 hours
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blood transfusion: s/s allergic reaction?
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allergic rx: resipiratory wheezing: urticaria (hives) facial flushing, epiglottal edema
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blood transfusion: s/s of hemolytic transfusion reaction?
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hemolytic transfusion rx: lower back discomfort, chills, hypotension
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pacemaker: what does it do?
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increases cardiac output; acts to regulate cardiac rhythm
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lead poisoning: what's best to give a toddler?
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toddler. fluid = milk. Vitamin D. optimizes deposition of lead in long bonds. removes it from blood and soft tissues
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adjustment to terminal illness: stages?
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1=denial/isolation. 2=anger, 3=bargaining. 4=depression. 5=acceptance
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immunity: natural passive: describe
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child receives antibodies from outside the body. placenta, colostrum, breast milk
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immunity: artifical active: describe
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gets antigens agains virus. vaccination. body makes antibodies
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immunity: natural active: describe
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body makes antibodies itself bc it is infected
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immunity: artificial passive: describe
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injection with antibodies produced in another person/animal
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what is this group for? SHARE
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miscarriage, dead newborn
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what is this group for? RESOLVE
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infertility
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what is this group for?: CANDLELIGHTERS
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child die from caner
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elderly - fluid status - how to monitor?
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maintain accurate I & O. do NOT assess tissue turgor (skin elasticity changes in elderly)
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child: nephrotic syndrome - diet?
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diet: adequate protein, low sodium. if they can tolerate protein.
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colostomy irrigation how and when to do?
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same time each day - assist in establishing a normal pattern of elimination, once a day, fluid at body temperature, 4 inches into stoma
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apraxia: what is it?
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loss of purposeful movement
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cardiac catheterization: assess prior for?
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SHELLFISH ALLERGy. IODINE. anaphylactic shock
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ataxia: what is it?
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poor coordination
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gout: what color will foot be?
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foot should be pale
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respiratory syncytial virus: what is it? what kind of precautions? what room?
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acute viral infection; requres contact precautions, assign to private rm or with same
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Kawasaki Disease: what is it? what precautions?
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acute systemic vasculitis in children under 5, standard precautions
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mononucleosis: what precautions?
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standard precautions
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autonomic dysreflexia: s/s?
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headache, sweating, nasal congestion, BP up. pulse will SLOW
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tetralogy of fallot: what is it?
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cardiac abnormality detected at birth: pulmonary stenosis, ventricular septal defect, overriding aorta, hypertrophy of right ventricle
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talipes equinovarus: what is it?
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clubfoot. detected at birth
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hemolytic disease of the newborn: what is it? how do you find it?
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maternal antibodies destry fetal RBC, bilirubin secreted bc of hemolysis, detected with ultrasound
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cleft lip/palate: when is it detected?
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congenital detected at birth.
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iron requirements: amounts?
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women 15 mg. Men 10 mg. Preggers 30 mg
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circulatory overload: s/s?
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wet breath sounds, severe shortness of breath
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Quality of Ventilation: what does this mean?
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refers to the levels of carbon dioxide and oxygen
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HbA1c glycoslyated hemoglobin: what is normal?
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normal 2.5-6% when RBC are formed, sugar is attached (glycoslyated) and remains attached thru the life of the RBC. 6-8 weeks
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Graves Disease: what is it? s/s?
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increased metabolic rate. causes weight loss even with increased appetite. 10 lbs - 3 weeks, restless, hyperactive reflexes. can't stand heat - due to increased metabolic rate
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erikson- birth to 18 mo - stage?
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develop trust from interaction with dependable primary caregiver
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erikson - toddler - stage?
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autonomy verses shame and doubt
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erikson - preschool - stage?
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initiative versus guild
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erikson - school age 6-12 yrs - stage?
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industry versus inferiority
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hypercalcemia: s/s?
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constipation, depressed reflexes, decreased muscle strength
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hypocalcemia: s/s?
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positive Trousseau's sign - neuromuscular hyper-reflexia
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Miller-Abbott tube: what is it used for?
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intestinal decompression, used for treatment of paralytic ileus, removes fluid and gas from small intestine.
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Levin tube, salem sump: what is it used for?
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decompresses the stomach, prevents fluid and gas accumulation in the stomach
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infant PKU test: when is test done?
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initial specim collected as close to discharge as possible but not after 7 days. If intial specimen is collected before 24 hours old, repeat test by 2 weeks of age.
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Buerger's Disease: what is it? s/s?
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vasculities of blood vessels in upper & lower extremities. digital sensitivity to cold. pain with exercise (intermittent claudication)
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Suctioning: how determine effectiveness?
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to determine effectiveness, auscultate chest to determine if adventitious sounds are cleared and that the airway is clear of secretions
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newborn Fetal Alcohol Syndrome: what is treatment?
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replace vitamins depleated as a result of poor maternal diet. B vitamins. needs to be held and cuddled due to a poorly developed CNS
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Laparotomy, exploratory: what is complication?
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complication of internal obstruction = distended abdomen with c/o pain. Bowel sounds will be absent or decreased immediately after surgery anyway, so not a sign. don't get ascites
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toilet training: when?
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20 months. not able to control sphincters until 18 months
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hypoparathryoidism: s/s?
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cardiac dysrhythmias due to low serum calcium
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elderly - nocturia, stress, urge incontinence - why?
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nocturia: can't concentrate urine as well leads to increased urine formation, have to get up at night to pee. Stress and Urge Incontinence due to loss of muscle tone in ureters, bladder & urethra. frequency increases bc bladder capacity decreases.
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hematuria: what is it a sign of?
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sign of cancer, infection, trauma of urinary tract, glomerular diisease, renal calculi, bleeding disorders
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CBI continuous bladder irrigation: what is the purpose?
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"enables urine to keep flowing", prevents formation of clots that can lead to obstruction / spasm in postop TURP.
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erikson +65 stage?
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integrity vs despair and disgust
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erikson 19-35 stage?
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intimacy vs isolation
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TPN - s/s if abruptly discontinued?
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if abruptly d/c, see diaphoresis, confusion, tachycardia:
- insulin levels remain high while glucose levels decline; results in hypoglycemia, will also see restlessness, HA, weakness, irritability, apprehension, lack of muscle coordination |
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duodenal ulcer: when do you get the pain?
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pain 2-3 hours after meal,
or during the night, prior to injestion of food |
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gastric ulcer: when do you get the pain? does food help it?
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pain 30 min to 1 hour after food. rarely at night. not helped by food.
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hypoxia - child - s/s?
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tachycardia, tachypnea, anxious, restless. "generally not described as irritable"
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auscultation: where to hear right middle lobe?
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Right Middle Lobe. stethoscope - right anterior chest between 4th and 6th intercostals. CANNOT hear it from posterior.
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Hypoglycemia - TIRED s/s?
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Hypoglycemia s/s: "TIRED"
Tachycardia Irritable Restless Excessive hunger Diaphoretic / Depression |
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apical pulse: where to find?
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left of sternum, midclavicular, right 5th intercostal
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Myasthenia gravis - better early or late in day?
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- autoimmune
increased muscle fatigue, needs more assistance toward end of day, assess muscle groups toward the end of the day. - weakness worsens with activity, improves with rest |
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Meniere's Syndrome: s/s?
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hearing, vertigo. stand in front of client to talk - so does not have to turn head.
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Hepatitis A: what precautions? What is mode of transmission?
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standard precautions.
transmission: Saliva, Feces, Blood. Use contact isolation if fecal incontinent |
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Sickle Cell - HHOP?
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For sickle cell anemia think HHOP
Hydration Heat Oxygen Pain relieve |
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Diuretic Therapy. How to judge effectiveness?
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effectiveness = daily weights
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Cushing's Syndrome: s/s?
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thin extremities, easy brusing. Fat torso. petechiae. BP increases
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Insulin - human: why better than synthetic?
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protein molecules identical to human insulin. does not cause the formation of antibodies.
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AIDS dementia complex: s/s in early & late stage?
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late stage: disoriented x 3. cognitive confusion. early stage: impaired concentration and memory loss
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blood loss 50%: what s/s would you see?
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pain, dizzi, swelling
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blood loss 30%: what s/s would you see?
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postural hypotension, tachycardia w/activity
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posey vest: nursing actions?
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to toilet q2h, quick release tie, reorient q2h. extremity restraint worse than posey restraint
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Hepatitis B versus AIDS: which is more infectious?
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more infectious than AIDS
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myelogram: what is it? Follow up care?
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xray + dye: looks at spine. lumbar puncture. lie in bed for 4-24 hours
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Myocardal infarction: MONA - what does this mean?
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MONA: morphine, oxygen, nitrate, aspirin
morphine decreases oxygen demand and pain. decreases preload and afterlaod |
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LPN: can't do what?
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CANNOT make judgement
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Suction: who can suction?
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nursing assistant can't. LPN can
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Restraints: how often to assess circulation?
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circulation q 30 minutes
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G tube feeding: who can do this?
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nursing assistant can do
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Myastenia gravis: cause? nursing actions?
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- autoimmune
- airway issues, muscle fatigue issues, nursing assistant CANNOT feed them, at risk for aspiration - muscle weakness worsens with activity and improves with rest. |
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glomerulonephritis: what is it? what causes it?
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Glomerulonephritis is a postinfectious inflammation of the glomeruli within the kidney caused by a streptococcal, pneumococcal, or viral infection.
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gastroparesis: what is it?
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Gastroparesis, also called delayed gastric emptying, is a disorder that slows or stops the movement of food from the stomach to the small intestine
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tonic clonic seizures: what should you have available? What is not needed?
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have oxygen equpment and suction equipment at bedside. padded side rails are considered restraints.
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infant: s/s of neurological problem?
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High-pitched crying and arching of the back are cardinal signs of a neurological problem.
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chemotherapy: most frequent side effect?
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Nausea is most frequent side effect: include in plan of care
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droplet precautions. When used? describe
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gown, gloves, mask, goggles: meningococcal meningitis. bacteria are airborne, but don't stay in air very long
- wear mask within 3 feet of patient. - pneumonia + Many, many. memorize airborne instead (TB, measles,varicella) |
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airborne precautions When used? describe
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bacterial suspended for a long time.
droplet precautions + N95 respirator, gown, gloves, goggles TB, measles, and varicella. |
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PPD of 5: positive or negative?
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is positive for immunocompromised. if not, 10 is positive.
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salmonella: when are you cured?
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after treatment, you can be a carrier, potentially contagous for 1 year!
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noncompliance with meds: what should you assess?
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assess what is going on with patient - how does med make you feel?
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pregnancy - what condition gives a high risk for infection?
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Premature rupture of membranes: PROM. (midline epis. is not a huge risk. a tear would be bad)
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restraint removal (psych): when?
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when the person exhibits appropriate behaviors
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electrophysiology study: what is it and why is it done?
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assesses the electrical conduction system of the heart; done to find dysrhythmias
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lead poisoning: symptoms? lab values?
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over 10 mcg/dl. symptoms - constipation. concern in growth and development, poor appetite, will lose weight
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hepatitis: toxic - what is it? communicative?
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not communicative: overdose on carbon tetracloride, gold, or acetaminophen: treat with plasmapheresis
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tuberculosis - latent - nurse - can she provide care?
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spouse has TB, person has positive PPD but no active disease & refuses preventative treatment. you CAN take care of patients- you do not have active disease. should tell her "contact your MD if you have weight loss or a decreased appetite"
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tuberculosis: what indicates cure?
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need 3 negatvie sputums
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Toddlers: "no good" foods?
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toddlers - NO grapes, hot dogs, popgorn, carrrots, gum, peanuts
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Toddlers: how long in car seat?
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car seat until 1 year or 30 pounds
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babies - breast fed - # diapers, # poops?
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8-10 wet diapers and 2-3 poops
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psych mania: guidelines?
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mania: at risk dehydration, will be diruptive, trouble following rules, want to decrease stimulations, provide protection
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psych depression: guidelines?
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stay with pt, show they are important, NUTRITION
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psych schizo: guidelines?
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reality testing
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psych OCD: guidelines?
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obsessive, distract, redirect, limit behavoir
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psych substance abuser: guidelines?
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manipulative, give clear rules, boundaries
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pregnancy - early decelerations
V C E H A O L P |
E: Early decelerations H: Head compression/movement
- the cervix is dilated, and the labor may have progressed to the second stage. |
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pregnancy heart tones: where do you find them?
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Left Occupital Anterior if head down: heart tones below umbilicus. if butt down, above the umbilicus. then L/R
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pregnancy - late deceleration: what does it mean and what to do?
V C E H A O L P |
Late deceleration = Placental insufficiency
fetal hypoxia: give oxygen VEAL CHOP |
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atopic dermatitis - what to avoid?
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Fabric softeners often contain chemicals or components that are irritants for those with atopic dermatitis. Dermatitis is not a contagious condition, so using separate towels is not necessary. Avoidance of certain foods in treating atopic dermatitis is controversial. It is recommended that only known allergens be avoided. The sun is not a trigger.
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one strategy for answering NCLEX questions - what to avoid?
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avoid yes/no questions. they love "describe". gives more information, can encompass the other choices
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infant vitals. Name em.
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moro reflex,
acrocyanosis (blue extremities) HR 130-160. BP 80/40, fine crackles ok, respiratory rate 30-60 |
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infant breathing: what does normal/abnormal look like?
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if thorax expands/contracts = a problem. abdomen can go in and out.
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infant bili lights: how often monitor? what to monitor?
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monitor infant activity level every 2 hours
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blood: DELAYED hemolytic transfusion reaction: s/s?
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Clinical manifestations of a delayed hemolytic reaction include jaundice, anemia, fever, oliguria, flank pain, and bleeding.
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elderly patient: if think they have c-diff? what to do?
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think they have c-diff. first action is to review meds & IV fluids. Cdiff often caused by antibiotic use - need to figure out what is causing it. THEN send stool sample. (some hospitals dont' think Cdiff until 8-10 bad stools) Also, question refers to chart - reviewing chart is the only answer that pertains to records.
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breast self exam: when?
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last day of menstrual period
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infant: addiction/withdrawal: s/s?
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excessive mucus (runny nose) and a high -pitched cry 16 hours after birth. withdrawal symptoms seen in 12 to 24 hours. will see HYPERreflexia. increased respiratory rate.
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UTI - child - s/s?
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UTI -child 2 years of age or older include enuresis, dysuria, frequency, urgency, fever, dribbling, foul-smelling urine, flank pain, and straining at urine.
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IUD: what matters to prevent complications?
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HTN, and smoking DO NOT matter (does with pill & ring). "monogamous relationship"
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Dialysis Steal Syndrome: what is it? what is complication? s/s?
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A symptom complex that occurs whenever there are extensive anastomoses between 2 vascular beds, and the arterial supply to one of the beds A client with a vascular access site who is receiving hemodialysis is experiencing arterial steal syndrome if the client is pale with cold and numb fingers. If prompt treatment is not initiated, the fingers may become gangrenous. Nausea, vomiting, and headache occur from a rapid decrease in the blood urea nitrogen level during hemodialysis and indicate dialysis disequilibrium syndrome. Redness, warmth, and edema at the site of the fistula indicate the presence of an infection at the vascular access route. A distended abdomen and an abdomen tender upon palpation indicate the presence of abdominal pain that may occur as a result of a complication of peritoneal dialysis. is stenosed or occluded, resulting in diversion of blood to the other vascular bed.
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Osteoarthritis: how to prevent?
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maintain your weight. no smoking (leads to cartilage loss)
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rhumatoid arthritis: what meds?
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take fish oil and anti-oxidents
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immunocompromised kid exposed to chicken pox: what is treatment?
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needs to go to office to get treated with gamma globulin. will have immediate effect. even if had vaccine - antibodies in immunocompromised diminish over time. Focus on the patient, not the status of the other kid.
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alcohol withdrawal: what is concern? what can you do?
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concern for seizures - put mattress on the floor beside the client's bed. thiamine deficiency not a top priority
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rhabdomyosarcoma: what is it?
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soft tissue cancer
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hydrocele: what is it?
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fluid around the testes
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pregnany- pre-eclampsia: what is one s/s?
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weight gain of 3 pounds is bad in one day.
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neuroleptic malignant syndrome: what is it and what is treatment?
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severe parkinsonian muscle rigidity, really high fever up to 107, sweating, autonomic dysfn., seizures, coma. parladil or dantrium for treatment
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akasthisia: what causes it and what is treatment?
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restless leg syndrome: treated with beta blockers, benzo, anticholinergics. often seen in first few weeks of antipsychotic treatment
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oculogyric crisis - what causes and what is treatment?
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rotating eyeballs a few days after anti-psychotic therapy. treat with cogentin or benedryl
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psych factitous disorder - what is it?
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- an intentional effort on the part of the client to produce physical or psychological manifestations to gain attention. As with all other somatoform disorders, at least four pain clinical manifestations must be present, and the clinical manifestations are not explained by a medical condition.
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pregnancy - late decelerations
V C E H A O L P |
Late decelerations = Placental deficiency
Vena cava syndrome caused by pressure of the uterus on the inferior vena cava, which impedes venous return to the heart, decreasing cardiac output and lowering blood pressure; it also causes uteroplacental insufficiency evidenced by late decelerations. Turning the woman on her side and giving oxygen will correct this situation. |
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food supplements: what is the problem?
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be careful - may interact with other meds - NCLEX does not like
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endometriosis: what will help?
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pregnancy will alleviate symptoms
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cocaine toxicity: s/s and complication?
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vasoconstriction - concern for MI
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Neonatal Rhythm - Cause
V C E H A O L P |
VEAL CHOP
RHYTHM CAUSE V: Variable decelerations C: Cord Compression E: Early decelerations H: Head compression/movement A: Accelerations O: Okay-it's a good thing! L: Late decelerations P: Placental insufficiency |
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Variable decelerations - what to do?
V C E H A O L P |
V: Variable decelerations C: Cord Compression
- Change the position of the mother from side to side - An amnioinfusion is the instillation of an isotonic glucose-free solution into the uterus to form a cushion for the umbilical cord or to thin out the meconium. - Give O2 - oxygen will saturate the mother's blood, with the goal of supplying an adequate oxygen source to the fetus when the cord compression is relieved. |
