Kaplan nclex review

Question Answer
can LPNs admister chemo drugs or flush a central line? NO
Advance directeives and the right to refuse/accept medical directives is under which act? Patient self determination act
The right for a client to obtain there medical records is under what act? HIPPA
what must be included in informed conset? Details of procedure, risks/benifts, alternative procedures and consequences of refusing tx
Info on organ donation should be included where? medical record
position for insertion of CVC? trendelburg
Maslows in order? physiological, safety and secureit, love and belonging, esteem and self actualzation
potentiates risk for dig toxicity? hypokalmeia
where is liver located? right side
a ride sided CVA means? the left side is affeced
APT M go! Aorta, (Right side second intercostal space close to sternum), Pulmonic (2ncd intercostal space left side close to sternum), Tricuspid (fourth and fifth intercostal space left side close to sternum) Mitral (5th intercostal space midclavicular line)
Where is erbs point 3rd intercostal space left of sternum
when take alpurinol? with food, and make sure pt has lots of water throughout day
a child should be in a booster seat till? 4 feet 9 inches and at least 80 lbs
what age is important to start educating about fire/water safety school aged
age group at highest risk for falls and burns? infants
toddlers mobility and curiosit buts them at risk for? poisioning, choking and dorwning
what is primary survey in an emergency? airway, breathing, circulation, diability and exposure
What is part of secondary survery Full set of virals, give comfort measures, history and head to toe assement, and inspect posterior surface
In this part of the assment make you idenitfy ALL injuries Secondary
order to put on PPE? wash hands, then gown, the mask, then eye protection and gloves last TAKE OFF IN REVERSE
3 dz that require airborne precautions? measles, chickenpox and tuberculosis
Haemophilus influenzae is what kind of precatuion? droplet
HSV is what kind of prectaution? contact
those with rheumatic heart disease needs to inform dentist if they need any dental work as they are? Suceptible to infection and may need abx
what does a tuberculin skin test show? if the client has been infected with TB bacteria
steps to blood admin? 1. Verify doctors order 2. Assess that the client has a blood bank ID armband 3. Explain procedure to client 4. Obtain VS 5. prime line with NS 6. obtain blood from lab and 7. perform bedside confrimation with another nurse
steps of blood admin according to college? obtain conset, explain procedure. take VS, check IV for patency, obtain blood, check with another nurse, then prime with NS and then spike bag
STD that must be reported to the state? gonorhea
every 2 hours ask the client if he needs to use the bathroom and provide TOM exercises to a client in? restraints
a new physians order must be obtained how often for restraints? every 24 hours
After obtianing PRBCs from the lab how long do you have to begin administration 30 minutes
Blood must be admistered fully within? 4 hours
what to do if a client that requires a hoyer lift suddenly has to go to the bathroom? encourage the client to be patient and set up the lift
what is removed first from PPE? Gloves
who completes the incident report? the one who found the client
while the incident report should never be mentioned in clients medical record what should be included? the facts of the incident
when is full term? 37 weeks
are ulcer drugs like cytotec CI in pregnancy? yes
can a pregnant peron receive vaccine for measles, mumps or small pox? NO ci
when give RH immuno globulin? IF mother is RH negative and father is RH positive
When give rhogam immunoglobulin in prenatal period? 28th week
FHR is prenatal period? 120-160
when may a prego person experience quikening (first fetal movement felt by mom) 17 weeks
assess the umbilical cord for what? two arteries and one vein
What 5 factors does APGAR rate baby on? 1.color (apperance) 2. hear rate 3. grimace (reflex irritability), acrivity (muscle tone and respiration
How is a APGAR graded 10 is max 0 (not good) 1(ok) or 2 (good) for each of five categories then add them up
when does postpartum blues occur? second or third week postpartum
how old are infants? 1-12 months
what age should child be able to tranfer toy from hand to hand? 9 months
when should baby be able to roll from tummy to side? 10 months
what is preschool agr? 1-4
chilcren should walk by? 18 months
by this age group the child must speak at least 15 words? preschool
when may a child follow simple instructions between 1-4
school age is what age? 5-12
when should a child know there full name and adress? school age
erickson stage of 19-34? intamicy versus isolation
erickson age 35-64? generavity versus stagnation
what is erickon at 65-85? ego integrity versus despair
when do BSE for women in puberty? day 7 of period
When do BSE after menopause? same time each month
when start flu shot? 6 months
when start going to dentist? 2 years
blood sugar level more than _________- without fasting requires work up? 199
blood sugar more than _______ with fasting requires work up? 125
triglycerides should be less than? 150
LDL's should be less than? 100
part of stephescope that assesses high frequency sounds? diaphragm
4 parts pf physical exam? inspection, palpation, percussion, auscultation
does hormone replacement therapy increase the risk of osteoporosis? no
blocked sebacious glands are normal in newborns and are called? milia
swollen genitalia and breast are ______ in newborn? normal
after giving birth vaginal drainage with streaks of bright red blood is normal for how long? first 3-6 weeks
what tell parents to do if infant vomits more than once in 24 hours? call doc
at 7 months is it normal for a prego client to have braxton hicks contractions? yes any time after 20 weeks
is marked swelling of hands a concern to the nurse if client is prego? yes
when should child be able to roll from tummy to side? by a year
when should child respond selectively to words? by a year
at three years of age the child should be speaking in _____________ word sentences? 3 or four word
examples of indtrumental activies of daily living? Houskeeping and grocery shopping
Examples of activities of daily living? basic functions of self care such as feeding dresssing and bathing
continued smoking is more prevelant in what income family? low
after giving birth if mom has a elevated temp without other symtpoms? call doc
Describe heart rate in apgar scoring? 0 points if absent 1 if less than 100 and 2 if above 100
describe resp effort in apgar scoring? 0 absent, 1 if irregulat, slow weak cry, 2 if good strong cry
describe muscle tone in apgar? 0 limp 2 some flexion of extemities and 2 well flexed
describe reflex irritability in apgar? 0 no response 1 grimace 2. cry,sneeze
explain color in apgar? 0 blue, pale, 1. body pink, extremities blue. 2 completely pink
alchol withdrawl with tremors is often treated with? benzos
loosing track of time and/or person and instead finding another representation of self in order to continue in the moment is what coping mech? discoaitation
nonverbal communication is the most acurate reflection of? attitude
this therapeuitc communication paraphrases what client says? reflecting
before reporting possible abuse do what? utilize other discplines to gather more facts before deciding for further steps
meperidine is for? pain
quetiapine is what kind of drug? anti pyschotic
mirtazapine is what kind of drug? antidepressant
if a teenage client is frequently alone and quiet what would be a good intervention? encourage the client to join a youth group so he gets the peer interaction his developmental growth needs
when a client dies do what two things? acknowledge the loss and offer time to view the body
does a parent who is alert and oriented have the ability to have the daughter make all the descions? yes but document in advance directives
cystitis means? inflamation of the bladder
an inconctince where the client is unable to get to bathroom do to a physical or mental reason? functional incontinence
An opening into the distal end of the small intestine? ileostomy
Fat soluble vitamins? A, D, E and K
hypnotics may aid in? Sleeping
if infant is having sleep distrubances related to night time feeding what is an apporiate intervention? feeding late and putting the infant to bed awake helps the infant learn to recognize bed time and self soothe
serves to immobilize the tibia and fibula by being placed above and below the knee and ankle joints? a long leg cast
position for thoracentesis? sitting over bedside table
do short walks at least two times per shift increase circulation for someone in HF? yes it also promotes overall well being by creating distraction and increased mobility
if someone is in immediate pain from constipation do you notify doctor or encourage fluids to ease constipation first? contact doc as fluids will take awhile to work to ease constipation and the client is in immediate pain
post op interventions after a child has a vescitomy? hydration, cleansing and drying the area, absorbent diapers and daily dilation of the opening
Why may a kid need a vesictomy? for frequent UTIs or chronic neurogentic bladder
can a client in traction do his own bed bath? no he may be able to reach most parts but he can not independently clean his back while maintainig traction
why avoid lots of milk products while on bed rest? because the client is already at risk for kidney stones
kids with diarhea should educate parents on s/s of? dehydration
diet for someone with pancreatic cancer? Use spices to stimulate taste buds, eat cool foods to decrease odor and eat small but frequent high protein and high carb meals
this traction is used in children younger than 2 years of age to reduce femur fractures or stabalize the hip? Bryants traction
May reduce fractures of the hip or femur? Russels traction
Is used on the femur if skin traction isnt suitable? 90 degree traction
Used to temoraily immobilize a fractured leg Bucks traction
Used to stabalize a spinal fracture of muscle spasms? Cervical traction
when can client be an autolongous donor? 4-5 weeks before surgery
anemia and blood loss may call for admin of what kind of blood? RBCs
Coagulation deficiecny may call for admin of what kind of blood Fresh frozen plama
thrombocytopenia may call for admin of what kind of blood Platelets
This may be administered in shock, blood loss, or low protein levels due to surgery or liver failure? albumin
This may be administered for blood loss or immediatly prior to an invasive procedure in clients with significant hypofibrinogenmia Cycropreciptate
order of blood admin? Verify client consent, Check VS, check physian orders, Ensure patent IV site, Obtain blood, verify ID with another nurse, Hang blood, begin transfusion at a slow rate, recheck VS after first 15 mins,
After 15 minurs of blood transfusion if all goes well? increase the transfusion
Montior clinets vitals signs and lung sounds how long in regards to blood admin? for one hour after transfusion is complete
what is a good rate to start blood transfusion? 2 ml per minute
hickman and broviac are examples of? Tunneled CVC
this type of CVC often remains for longer periods of time? PICCS
where is a PICC inserted? Basilac or cephalic vein in antecubital space
Where do CVC's terminate? Superior vena cava
A nasogastric tube goes? Through the nose and into the stomach
A nasointestinal tube goes? Through the nose, past the stomach and into the small intestine.
A percutaneous tube goes? Through the skin directly into the stomach
Before administering meds flush all enteral tubes with? 30 ML of water
a spacer is attached to a MDI and esures that more medication is delivered to the? lungs
6 rights of med admin? Right client, right drug, right dose, right route, right time, right documentation
what things must an order have? date, time, clients last name and signed by doctor
how the body absorbs, distrubutes and metabolizes meds? pharmacokinetics
How a drug moves through the body from absoprition site to action sire Distrubution
Conversion of a drug by enzymes into a less active, excretable substance Metabolism
When giving TPN make sure the IV line is? only used for TPN
When taking nitro if the pt gets blurred vision? immediately report to doc
first step in doxorubicin (a chemo drug) associated extravasation of drug given via peripheral IV? Attempt to remove any residual drug
Xerostomia is? Dry mouth
interventions to decrease dry mouth? chew gum
When is the rectal route CI for med admin? anal or rectal lesions, mucositis, thrombocytopenia or neutropenia
is fever a CI for rectal admin of meds? NOOO but neutropenia is
Since FFP, Platlets and Cryroprecipitate lack RBC;s they do NOT require? Cross matching
Filter needed for admin of platlets? A specialized platlet filter
What checks for platelet admin need to be done on the product? ABO compatability, and RH compatibility
antidote for heparin? Protamine sulfate
This is a valved catheter that does NOT require heparin flushing so good for those with Thrombocytopenia? A groshong catheter
The hickman, broviac and port all require? routine flushes with heparin
max does of acetaminophen? 4 grams
aderall is asscoiated with what mental disroder? depression
does aderal cause restlesness or somnolence? restlessness
steps for Z track 1. displace skin lateral to injection site, then admister drug IM, then withdraw needle and finally release the skin
does lisinopril cause orthrostatic hypotension? yes
common side effect of doxobrucin (a chemotherapy agent) red colored urine
Is the risk of thrombophlebitis increased with age? YES
how label your clients specimens? Clients name, date, exact time of colelction and type of specimen
how do you set up Fetal heart monitoring inserting a fetal electrode through the clients cervix and attaching it it the epidermis of the fetus
when are trough levels drawn? when dose is at its lowest, right before next scheduled drug admin.
When are peak levels drawn? when the dose is at its highest, 30 minutes after infusion
Normal BNP less than 100
you want bilirubin less than? 1
normal Calcium? 8.6-10.2
normal magnesium? 1.5-2.5
normal phosphorous? 2.4-4.4
normal potasssium? 3.5-5
normal albumin? 3.5-5
normal total protein? 6.4-8.3
normal sodium? 135-145
normal AST? 10-30
notmal ALT? 10-40
normal trops? less than 0.5
normal aPTT 25-35 SECS
NORMAL PT? 11-16
Normal fibringoen? 200-400
normal FSP? less than 10
normal D dimer? less than 250
normal hct? 35-50% ish
normal hgb? 11.7-17.3
normal platlets? 150- 400
normal WBC? 4-11
normal ammonia? 15-45
normal creatine? 0.6-1.3
normal specific gravity? 1.003-1.030
normal lipas? 31-186
therapeutic INR? 2-3
normal PH of urine ? 4-8
CPP is equal to the? MAP minus ICP
normal Cerebral perfusion pressure? 60-100
How calculate MAP? SBP + 2(DBP) all dived by 3
normal ICP? you want it below 20 anything above =bad
normal MAP? 70-150
normal dig levels? 0.5-2
TX for gonnorhea in pregnancy is best with what abx? Cefriaxone
tx for chlamydia? azithromycin
Tetracylcines and fluroquinolones are ________ in pregnancy CI
CIPROFLOXIN BELONGS TO WHAT DRUG CLASS? fluroquinones
most effeftive tx for preeclampsia? delivery of baby
if clients wound dehisces what is the first step? nurse stay with the client and have a colegue notify the physian
Position to put a client in if his abdominal wound dehisses? hise head slighlt elevated and knees bent to decrease abdominal pressure
If the wound eviscerates what do you put on it? sterile normal saline soaks
How does the nurse evaluate cerebellar function? testing the clients balance and coordination
the tensilon test is used for what disease? Myathenina gravis
Why is a electromyography used for myasthenia gravis? help differentiate nerve disorders fro muscle disorders
This is used to dx Multiple scleoris, as a result of pregressive demylenization of the white matter of the brain and spinal cord EEG
3 common tests used in a pt with myasthenia gravis? Tensilon, nerve conduction studies and electromyography
a weakness and rapid fatigue of muscles under voluntary control? myasthenia gravis
if a client has a DVT do NOT allow them to? ambulate till doctor orders
serum globulin levels in hepatitis are? high
PT time in hepatitis is? prolonged
Bili in urine in hepatitis is? increased
serum albumin levels in hepatis are? low
is anorexia assoiated with addisons disease? yes
nurses first priority during a seizure? protect client from injury so remove objects from the surrondings
When does the nurse check for breathing if client is have a seizure? when seizure stops
bronze skin discolaration is s/s of? addisons
craving of ______ foods is s/s of adisons? salty food
numbness and tingling of fingers and blanching of skin at fingertips points to what disease? Raynauds disease
those with sickle cell anemia should avoid what type of exercise? strenous exercise as it induces hypoxia
pain in cirhosis? dull abdominal ache
explain the tissue turgor in cirhosis? poor
explain breath in cirrhosis? musty
since the PT time is prolonged in cirrhosis what is a common s/s? bruising
a blood transfusion needs to be completed in how much time? 4 hours
what kind of foods should a patient with gout avoid? foods high in purines!!
what kind of foods are high in purine? anchoives, liver, sardines and lentils
can a client with gout ear oranges? yes
can a pt with gout eat cauliflower, asparagus and mushrooms? yes
thrombolytic therapy is CI in those that had a stroke within the past? 2 months
the key to preventing diabetic foot complications is to? follow the reccomended diet
what is better way to prevent diabetic foot complicaitons, taking the meds as ordered or following the recomended diet? following the recomened diet
where is the V1 lead placed in a ECG? fourth intercostal space to the right of sternum
this lobe deals with higher level sof cognitive functions such as reasoning and judgment. It also contains areas involved in control of voluntary muscle movements, including those necesary for the production of speech and swallowing? frontal lobe
this lobe is asscoiated with sensation and is involved in writing and some parts of reading parietal lob
This lobe is asscoaited with auditory processing, olfaction and word meaning temporal lobe
This lobe is involved in vision occipital lobe
Steps for the hemilich maneuver? 1.Ask client if choking 2. Stand behind client 3. make fist with one hanf 4. place thumb toward the client, below rib cage/ above the waist, wrap one arm around client, 5. wrap other arm around client/ place that hand on top of fist. 6. thrust upward
V 2 ecg placement 12 lead? fourth intercostal space at left sternal border
V3? hlafway between v2 and V4
V4? fifth intercostal space at left midclavicular line
v5? fifth intercostal space at anterior axillary line
v6? fifth intercostal space at the left midaxillairy line
Six elements of infection? Suceptible host, portal of entry, cause, reservoir, portal of exit and modes or transmission
for hemodynamic monitoring according to Kaplan position the tranducecer at the level of the? right atrium
A ventriculostomy measures ICP and can drain where does it have to be positioned? tragus of ear
for those in hypothermia do not increase the core more than? 0.9 degrees farenheight or 0.5 degress celcius
wounds are cleaned with what gloves? sterile
Is the Diaslylate for continous ambulatory peritoneal dialysis refrigerated? NO just rewarmed prior to giving
acording to kaplan should the nurse use sterile technique when working with a pernament Peritoneal catheter for dialyses? yes and when hub is exposed have client and nurse wear mask
The cleansing and dressing of the trache stoma should be done every? 8 hours
The inner canula of a trache should be changed/cleaned every? 8 houra
what is used to cleanse the stoma area of the tracheostomy? Hyrdogen peroxide then sterile soaked gauze to remove hydrogen peroxide, then dry the stoma area
Suctioning the trachea before trache care keeps the area? clean longer
technique to remove sutures is? sterile technique
Positive chevostek and trouseas indicates? hypocalcemia
after administering lasix be careful not to? have a sudden drop in BP
What would show effictiveness of lasix? Urine output increase/ diuresis to remove the fluid
What is considered hypotensive BP? 90/60
perferred site for left sided cardiac catherization? left femoral artery
should meds ever be infused into a A line? NO
First thing to do if moniitor says pt is in V tach? Assees monitor and check lead placement
can the nurse use a cvc that the client has for dialysis for anything? NOOOO
If a person falls and hits there head and is unresponsive do you still call 911? YES, unless the cient has indicated no emergency treatment or no hosptilization, untill then the nurse should do necessary treatment up to the point of resucitation
untill a persons heart stops with DNR? do everything unless specifically written
what do you do if a wound eviscerates? Place sterile dressing with NS over the wound and hold in place with sterile glove
Components of a ventilator bundle? elevate head 45 degrees, daily sedation holidays and assess readiness to wean, Peptic ulcer dz prophlyaxis, VTE prophlaxis, daily oral care with chlorahexidine
will suctioning oral and pharnx secretions and provide thorough otal care at least every 2 hours a way to prevent VAP? YES
Cefazolin is what class of abx? cephalosporin
Those with a reaction to ____________ may also have a reaction to cephalasporin? penniclin
if someone has s/s of an acute hemolytic reaction do what? Stop the infusion and run NS to keep the vein open
when draw a peal and trough? trough 30 mins prior to dose and peak 60 mins after infusion
if a mom delivers one day ago and has cramping is this normal? yes
if a mom has a kid and has burning on uriantion? They probably have a UTI and require follow up
When planning which pt to see first, see which first? the most unstable
to determine the structural relationship of one hospital department to another , the nurse would consult what? Organizational chart
greater than what induration in normal people needed for positive tuberculosis test? 10 mm induration
greater than what induration in pts with aids needed for positive tuberculosis test? GREATER than 5.
A order that says Grains X means? 10 grains
How many mg is in one grain? 60
normal HR of newborn? 120-160
crying with a buldging anterior fontanell in newborn is? normal
normal resp rate of newbron? 30-60 breaths per minute with apneic epsiodes
Acrocyanosis is normal for how long after delivery? 2-6 hours
A client refusing meds to tx cancer of colon requires what personell? RN as they need assement
A client with a right sided CVA who requires assitance with bathing may be assinged to a? UAP
A client with a colostomy who requires assitance with a colostomy irrigation may be assigned to a? LPN
a CLIENT with a chest tube who is ambulating in the hall may be asigned to a? LPN
Oral contraceptives predispose females to? Yeast infection
besides oral contraceptives what are other R/F for yeast infection? Glycosuria and pregnancy
when is direct coombs test done? on cord after delivery.
If both indirect and direct coombs are negative and the MOTHER is rh negative and baby is rh positive this is given? rhogam
When is rhogam given? reccomened at 28 weeks and within 72 hours after birth
a coombs test is used to evaluate if? the mom is sensitized
umbilical prolapse usaully occurs when? the presenting part is not engaged
notify doc if after amniotomy (artificial rupture of fluid) temp is more than? 100.4
If fetal vertex is +1 this means? the baby is engaged
if abuse is sucepted is it ok to ask are you being battered by your partner? yes preventing injury is important
How to determine fertile period based on ovulation? drop in basal body temp before and a slight rise after ovulation
during non fertile period what is the cervical mucus like? thick, cloudy and sticky
During ovulation what is the cervix mucus like? Abundant, clear, thin and stretchy
During ovulation is when you are most? fertile
when does ovulation occur? ovulation occurs about 14 days after start of menstrual period
Quadricep setting is? push back knees into bed
gluteal setting is? push heels into bed
when in a cast perform what type of exercise to the affected limb? isometric (contraction of musle without moving joint)
this promotes venous retun and circulation, prevents thrombi in those in a cast? isometric exercises
will preforming isometric exercises of the leg in a cast promote skin integrity? yes as it increases circulation
How to use a cane? hold can on opposite side of bad leg, advance cane and bad leg, lean on cane when moving good leg
How to go up stairs with a cane? Same with crutches, going up stairs use good leg first when going down bad leg first (UP WITH THE GOOD DOWN WITH THE BAD)
A pt is having TPN from a central line and you see a trickly of fluid what does this mean? There is a break in connection, thus at risk for embolim so position the client on left side with head lower than feet and call doc
If you see the client with a left leg that is shorter than the right leg and adducted this means? Fracture of the left hip
In a fracture will the affected extremity be longer or shorter? shorter
if a client has a fracture before the client is moved do what? immobilize joint above and below fracture
if there is bleeding in an open fracture do what? apply pressure
how do you use a walker? LIFT and move walker forward 8-10 inches, step forward with affected leg, supporting self on arms and follow with good leg
A colostomy does not begin to function for? 3-6 days so hold off on irrigations till then!!
use this to protect skin around stoma? skin barrier
in colostomy care use skin sealant under all? tapes
B12 shots are usually given? IM
When should stockings to promote venous return be used? When you get up in the morning
position for paracentesis? upright with feet elevated
normal chloride? 95-105
reasons bicarb may be low? starvation, renal failure and dehydratiom
elevated BUN may mean? protein catabolism, kidney dysfunction and dehydration
hypernatremia is seen in? dehydration and insufficent water intake
elvated sodium, and elevated BUN is seen in? Dehydration
If there was alterations in patterns of urinary elimination what electrolyte would be off? potssium
inital rate of tpn infusion? 50 ml/hr
too much tpn too quick causes? hyperosmolar state s/s are headache, nausea. fever chills and malaise
how often are central catheter dressings changed? once a week or PRN
Do not use an IV line receiving TPN for? anything else
client developed weakness and numbness in the legs the previous day and now his body feels the same way, denies any pain but appears anxious to the nurse, vitals are stable what are you thinking it is? Gullian bare syndrome
Ask the client this to assess for new gullian bare syndrome? Have you recently had a viral infection as Gulian bare syndrome is often preceeded by a viral infection
diet for pancreatic cancer? high cal, bland low fat diet small frquent feedings
Weight in those with pancreatic cancer? Anorexia and weight loss so nutrition is a BIG concern more so then skin integrity according to maslows
main chaercteristic of narcistic disorder? Lack of empathy
Im sick of hearing about all your tragedies is something a narcisitic personality disorder may say
someone who says I know i am interupting others so what? is? Antisocial personality disorder
these blame others, indifferent to criticism, dont understand others feelings, and expect special treatment Narcistic personality disorder
pts with this disease are prohibited from donating organs? HIV
Are anticholinergics used in chronic pancreatis? YEs
are there specific activity restrictions in those with chronic pancreatitis? no
when take pancreatic enzymes? before eating
diet for chronic pancreatitis? small frequent meals are most benificial
affter removal of gall bladder assess for what electorlyte imbalances? sodium and potassium losses
keep the drainage bag after gallbladder surgery level with? gallblafer
If a client reports abdominal pain and bloating after cholestectomy (removal of gall bladder) do what? encourage the client to ambulate to release the air caused by carbon dioxide during surgery
when should a breast feeding infant surpass there birth weight? in 10-14 days
How many wet diapers should a breast feeding infant have? 6-8 and at least 2 bowels
how long will an infant feed per breast approximately? 20 mins
how does a defibrilator work? it produces asystole of the heart to allow the SA node to resume as pacer of heart
treatment for DVT/thrombophlebitis? bed rest, elevate extremity and anticoagulant
if a person has variscoties they are at risk for DVT so best way tp prevent dvt? Encourage frequent and early ambulation
if a cast is applied to the femur what exercise is best for the client? Quadriceps setting of affected limb (isometric exercise, contraction of muscle without movement maintains strength.
why is it SO important that a client dx with myathenia gravis receives there pyridostigmine bromide on time? the drug is a cholinertase inhibitor which increases acetcholine, early admin can preceiptate a cholinergic crises late admin can preciptate myasthenic crises
Defficinecy of acethycholine at myoneural junction? Myasthenia gravis
musclular weaknes, produced by repeated movements that soon disaper following rest, diplopia, ptosis, impaired speech and dysphagia Myasthenia gravis
when hyperactivity esclates do what? accompany client to room
Distract a hyperactive client and escort her back to her room is a? nonthreatning aproach
curtain falling across visual field? Detached retina
Post op interventions for corection of detached retina? check eye patch for drainage, no rapid eye movement (reading, sewing) no coughing, vommiting or sneezing
After detached retina surgical corection of right eye make sure client? Limits movement of both eyes
nageles rule starts on? The first day of the last menstrual period remeber subtract 3 months add 7 days
if there are s/s of hypoglycemia and checking glucose is not an option do what? give fast acting sugar and recheck glucose in 15 minutes
example of fast acting sugar for hypoglycemic client? 6 ounce of skim milk
when does NPH peak? 2-15 hours
confusion, tremors, hypotension, cool clammy skin, diaphroesis are s/s of? hypoglycemia
in a Glucose tolerance test how is it done? high glucose load given then glucose measured at 1 hr intervals for 3 hours.
physical needs trumps? psycholical needs
Those with pernicious anemia have a lack of intrinisic factor from the stomach and will need? lifelong B12 injections
Best muscle to administer an IM injection? Vastus lateralis
IS gluteus maximus and dorsogluetal used often for iM injection? Somethimes but there is risk of damage to the sciatic nerve so not as common as vastus lateralis
if a person has preclasia positioning tx? bed rest lying on left side
diet for women with preclamsia? increased protein (as there is a lot of protein being lost in the urine) and decreased sodium
The edema in preclamsia causes wieght gain with bed rest it should? decrease
if a person with preclamsia gains a lot of wait in a short time? call doc as the edema is getting worse
3 things that charecterize preclampsi? hypertension, proteinuria and edema
after taking antipyshotic and have sytonic reactions, muscle tigness, difficulty swallowing what do you do? get order for benadryl or congentin
PT is used to monitor what therapy? Warfarin
What is used to monitor heparin therapy? Clotting time or PTT
therapuitic for heparin clotting time is? 2 times the control
eggs, milk product, meat, beans, nuts and cereals are high in? protein
What has a lowr protein content tomatoes and flounder or cranberries and broiled chicken? cranberries and broiled chicken
do cranberries have any protein in them? no
diarhea 15 minutes after eating points to? dumping syndrome
Interventions for dumping syndrome? Avoid fluids with meals!!, decrease intake of carbs ie bread. eat small meals frequently, lay down after eating
If you have dumping syndrome drink fluids with meals? NOOO
eat in what position with dumping sydrome? Semirecumbnant
Diet for dumping syndrome? High protein, high fat, low carb, dry
if a client with aids has pneumocystitis jirvoceci penumonia do visitors need to wear a mask? NO if they are immunocompromised then they should not visit
do you need to wear a mask with Pneumocystitis pneumonia when taking care of an aids pt? no only if there is contact with blood
if the baby is in right ocipital anterior (ROA) where should nurse look for fetal heart rate? below umbilicus on right side (best heard on babys back)
when may fetal heart tone be heard above the umbilicus? in a breach position
LOA means what is the presenting part? head
What is homnomous hemianopia? Blindness in half of each visual field
In this clients cannot see past midline toward the side opposite the lesion with out turning the head toward that side Homonoyus hemianopia
intervention for stroke pt with left sided pralysis? provide care from the clients right side
Since the client with homonoyous hemianopia cannot see past midline toward the side opposite the lesion with out turning the head toward that side if someone had paralyis on the left side approach what side as vision is not impaired as much? Right side
whaat is the primary inital symptom of a perforated duodenal ulcer? PAIN, sudden sharp, and boardlike abdomen
Pain, nausea, vommiting, rigid abdomen, fever, absent bowel sounds and shallow resps are s/s of? periotonitis
if a bipolar client paces endlessly in the halls and makes hostile comments to other clients and resists nurses attempts to move him to a room what do you do? Give haldol as he is at risk of dehydrating and not eating food
encourage early ambulation after a cholestyectomy to promote? removal of CO2
How long is fat restriction required after a cholestecomy? untill the client tolerates fats usually not forver
how much fluid is usally removed during a paracentesis? 2-3 L
After having client void before a paracentesis put in what position? Sitting with lower extremities well supported
what organ syntesizes albumin? liver
diet for cirrhosis pts? High cals, high carbs, low fat. possible protein restriction if they have a flare of enphalopathy
if a client is irate and throwing chairs first action? Get a team and put in seclusion, dont have other clients leave the room it gives too much power
inital aproach to a delusion? Claify, after do not discuss as it will reinforce them
generalized body edema, hypertension, oliguria, hematuria with smoky urine and proteinuria Acute post streptocoal glomerulonephritis
Peripheral edema MASSIVE protinuria hypertension, hyperlipidemia and hypoalbuminemia(if severe will have massive edema) Nephrotic syndrome
While a client at risk for dumping syndrome should limit carbs they should increase? fat and protein
after spinal infusion for a herniated disc how should the patient lay in bed? lay on side
The client should NOT do what after a spinal infusion for a herniated disc? Sit for longer than 20 minutes at a time, better to walk around or rest
refers to keeping faithgul to eithical princeples in the code of ethics? Fidelity
What ethical principle best supports keeping client and family care consitent with the nurse professional code of ethics? Fidelity
instructing the client on risk and benifts of a procedure promotes the clients? autonomy
should gait belts ever be used to lift a client? NEVER
a number 16 french catheter is usally used for? Adult women
A number 8 french cather would be used for? A pediatric client (its smaller)
a bmi over 30 is? obese
formula for calculating BMI? Weight X 703 / (ht)^2
BMI of 25-29.9 is? OVerweight
Bmi of less than 18.5 is? underweight
Do school aged kids want complete explanations of the procedure? YES
Doxorbubicin is a chemo agent that has a high risk of extravasation where is the best site? Distal forearm, less potenstial of harm to nerves and tendons
Why is the wrist and antecubital fossa not the best choice for meds likely to extravasate? movement may dislogdge IV increasing risk for exteavasation
If you follow up with a mom after she gives birth to a newborn and the babies eyes are yellow ask what? Do you breast feed as, breastfed babies may be jaundiced for a few days
Why may a NAP be assigned for a unstable client with diabetes who needs a blood sugar check? The NAP can get the glucose check the report to the nurse
a person who reports pain should not be assigned to a NAP as it requires? assement
A client asks a nurse why she is inquiring about past meds and past illnesses this is covered in what act? Patients bill or rights
Paroxetine or (Paxil) may decrease the effectiveness of? Warfarin
weight when taking paxil? may decrease
do clCIUM CHANNEL blockers increase or decrease contractility? decrease
Best place to give an IM injection to an infant? Vastus Lateralsis
when is fifths disease no longer contagious? When the rash develops
pupils in opiod overdose? pinpoint
pneumonia requires what precaution? droplets
does a positive elisa test confirm HIV? no
if a pt with asthma is prescribed neogostomine? Call doc it may cause bronchospasm
do you change the needle after drawing up iron? yes
right quad pain in a prego women may indicate? impaired liver function an impending sign of preclamsia
what race is most at risk for CL/CP? Native
how often instruct to do a testicular self exam? monthy
why are eye drops given at birht to newborns To prevent opthlamia neonatrum caused by gonnorhea or chlamydia as it can result in blindness
If amniotic fluid breaks and is meconium stain first intervention? Assess FHR if poor put mom on left side and give o2
kaplan says positioning of prolapsed cord is? Trendelburg
position after a myelogram? supine with HOB slightly elevated for several hours
if you are allergic to bannas you are often allergic to? latex
in bryants traction the hip should be? flexed
Position in bryants traction that provides countertraction? Buttocks slighlty elevated off the bed
damage caused by glaucoma can not be? Corrected, thus preventing further detoriation is the main goals
If someones foot is gangrene, why do a below the knee amputation, why not just take off the foot? need to promote circulation in the remainder of the extremities
where is the pulling force of traction applied? to the bone distal to the fracture site
the figure eight banage after a amputation is used to? decrease swelling
a pin in the femur is used to? Maintain alignment
If conducting a Myelogram hold any meds that? Lower the seizure threshold like antidepressants, CNS stimulants, antipyshcotics
Any inkling of abuse must be? Reported if elder or child especially
If a client says when I look in the mirror i can not see myself think? depersonalization
multiple personalities is an example of? Dissociation
sensory input in a panic attack is? Decreased
emotions communicated verbally are opposite of emotions communicated physically Double blind communication
iF A client has a negative self image have the client? idnetify unrealsitic expectations
Benztropine is used for? eps
Imiaprinine is a? Tricylic antidepressant used to tx panic attacks
Way to teach a clinet to do a BSE in a mirror? "Stand with your arms at your sides. Clasp your hands behind your head and press your hands forward. Place your hands on your hips and bow slightly toward the mirror.
Can you breast feed while taking Trifluoperazine? no its an antiphyscotic
phenalizine sulfate is ? A MAOI inhibitor no tryamine! aka nardil
is cheese and yogurt high in tryamine? yes
schizophrenic patients often lashed out because? they feel threatned
do calcium channel blockers decreased myocardial oxygen demand? yes
lightheadness and dizziness after colonoscopy may indicate? hypovolemic shock do to bowel perforation
what IV solution can be given with phenytoin? NS
After a liver bipsy instruct the client to not? Cough frequently
when should levothyroxine be taken? in the mornign
AFTER an acute blleding episode in patient with hemophilla do what? Encourage active ROM, to prevent crippling effects of bleeding
What is PRIMARY purpose of lasix? to increase excretion of sodium and water (augment kidney funciton)
Autonomic system problems cause? Postural hypotension, and constipation
You walk into a pts room and there trache is out and client is having a hard time breathing first thing to do provide patent airway by hyperextending the neck, place in semi fowlers, check breath sounds, use hemostat to open airway
Purpose of cuff on tracheostomy tube? Seperate the upper and lower airways, that way you dont aspirate secretions
Cephalexin is what kind of drug? Cephalosporin
Ciprofloxin is what kind of drug? fluroquinole
If you are allergic to penniclin stay away from? Cephalasporins
Rocephin is what drug? Cephalospitin
If you are allergic to penicilin and sulfa drugs may you have cirpofloxin? YES
going down stairs in cruthces? put crutch first, bad leg and then strong leg
those who are taller using crutches require? wider base of support
vecuronium bromide is used for? neuromusclular blockade for those fighting the vent
interventions when giving vecuronium bromide? Do eye care as the client has no blink reflex!
position in bed after stapedectomy? Flat in bed
anesthetic used in stapedectomy? local
post op stapedectomy you would expect? vertigo N/V as it is close to inner ear
this drug inhibits prothrombin synthesis warfarin
When you are dehydrated the hematocrit is? increased
common s/e of phentyoin? change in color of urine
interventions for prinzmetals angina? relaxation activities, no physical activity for 2 hours after meals
when caring for A CVC does the iodine or alchol go first? iodine
how does levodopa work in clients with parkinsons disease? it resotres dopamine levels in extrapyrimdal centers
diet for pyloric stenosis? Small frequent meals, position on right side upright after eating
classic symptom of hypertrophic pyloric stenosis? projectile vommiting
position after total hip? Supine with the head of the bed slightly elevated and a pillow between the legs.
are eggs and green leafy veg high in calcium if you are lactose intolerant? yes
urethrolithotomy is a procedure to break up a calculus do not? Irrigate
At first after a urethrolithotomy a small amount of blood tinged urine is ok but it should become? clear
Skin temp in an acute pain episode? decreased as there is diaphoresis
After cholestecomy a T tube is inserted to make sure the T tube is not dislodge make sure the drainage is? 400 ml/day
high fiber in chrons? NO WAY
infection is comon after amputation assess for? increase pain
This often indicates hypoxia? Restlesness
do not let psylium (metamucil) stand
Proton pump inhibitors do what? Decrease gastric acid secretion
Do you irrigate an ileostomy? No as stools remain loose
After a TURP avoid vigoruous exercise for? 3 weeks
if a person has gout excesive weight loss may? precipitate an attack
After obtaining ABGs first priority is to? Apply direct pressure
what hemisphere controls speech? left
early symptom of glomerulonephritis? oliguria
A thyroid scan measures ? uptake of iodine, so if any scans are needed that require contrast this must be done first else the results will be skewed
if mom is given an epidural and her blood pressure drops put her in what position? Side lying
When breast feeding do you need more or less insulin? les
during the third trimester insulin needs? Increase, then when baby bron decrease again
how to go up stairs with cane? step up on good leg, then place cane and affected extremity on step
If no pouch is in place for colostomy? put petroleum jelly over stoma
Before begining chest physiotherapy? Auscultate chest so you can idneitfy area needing drainage
are bronhodilators given before or after chest pyhiotherpy? before
avance liver disease requires what amount of protein? low
are vacines deterred in prescence of acute resp infection? yes
if outer cannula of trach comes out? maintain airway and call doc
for a clinet with a new colostomy do you want high fiber? no
if a child is scheduled for immunization and has a fever direct parents to? Keep him home till temp/infection resolves
where do you drop ear drops side of ear canal
truncal obesity, purple striations on skin and moon face are s/s of too much? steroids
ant ulcer diet? whatver does not bother the stomach
common complication of tube feeding? diarhea
is depression a normal response to lithium therapy? yes but monitor for sucidal ideas
estrogen therapy predisposes to? reproductive related cancers
according to Kaplan CVP measures pressure in the? right atrium
Bp in adrenal insufficency? hypotension
a client with osteoarthitis asks what she cn do to decrease pain and stifness in her joints at begining of each day how do this? Take a warm bath and rest for a few minutes
normal cvp acording to kaplan? 4-10
cvp according to book? 2-8 or 8-12 if in shock
adverse effect of sumatriptan? sudden numbness or weakness
example of advocacy ? teaching how to change an ostomy
when giving meds via NG? give each med seperately
those with MS are prone to what GI complication? constipation