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NCLEX-RN (Study guide) Questions Answered 100% correct
Autonomic Dysreflexia Complications: -severe pounding headache (from onset of HTN) -Profuse sweating -Nasal congestion Iron daily requirements f... [Show More] or women 15 mg/day Blood transfusion (hemolytic reaction) S/S: -chills -headache -backache -dyspnea -hypotension -fever Manic episode (behaviors) -Grandiose delusions -difficulty concentrating -agitation Meniere's disease/syndrome Is an inner ear disorder that causes episodes of vertigo/spinning Boggy uterus deviated to right -indicates full bladder -encourage client to void (offer bedpan) Cystic Fibrosis (diet requirements) -High protein -High calorie Cerebellum Maintains balance IVP (intravenous pyelogram) Is a radiological procedure used to visualize abnormalities of the urinary system, including the kidneys ureters and bladder Nursing management: -because of the need to visualize the abdominal area, cleansing enemas the evening before and IVP are usually ordered Rho (D) immune globulin (RhoGam) Is given to an Rh-negative mother who delivers an Rh positive baby when the baby has a negative Coombs test Cane use (going downstairs) -advance cane and weak leg -then strong leg Memory trick: the good goes up, the bad goes down Delegation to remember LPN/LVN and "pulled" or "re-assigned" RN from another unit - receive stable patients with expected outcomes Room assignments -clients with fracture are considered "clean" -do. Not place elderly pts with pneumonia pts IBS (irritable bowel syndrome) Hx of symptoms: -pattern of alternating diarrhea and constipation Immunizations DPT (diptheria, tetanus, pertussis) -1st dose: may be given at 2 mos -2nd dose: given around 4 mos -3rd dose: given around 6 mos MMR: given at 12-15 mos rotavirus: 2, 4, and 6 mos Varicella: 12 to 15 mos Cushing's syndrome (too many steroids) Assessment findings: -buffalo hump -weight gain -moon face -purple striae -osteoporosis -mood swings -high susceptibility to infections -hyperglycemia -hypernatremia Insulin administration Insulin should be administered at room temperature; temp extremes should be avoided Lumbar lesions (ruptured disc) Cause paresthesia, pain, muscle weakness and atrophy in the lower extremities Guillain-Barre syndrome (symptoms) -resp failure -flaccidity due to paralysis of the muscles -urinary retention due to loss of sensation Myelogram -Test involves a lumbar puncture with infection of contrast medium, allowing x-ray visualization of the vertebral canal -indentifies tumors, cysts, herniated vertebral disks Rubella (german measles) Requires airborne precautions; particulate respirator ECT (electroconvulsive therapy treatment) Expected effects: -headache -disrupted memory (short and long term) -general confused state -backache EDB (estimated date of birth) Naegele's rule: -add 7 days to 1st day of last mentrual period and subtract 3 mos Continuous tube feeding -rinse bag and change the formula every 4 hours -there is an increased growth of organisms after 4 hours Type 1 diabetes (insulin needs during pregnancy and after delivery) During pregnancy: Insulin needs increase After delivery: Insulin needs decrease Duodenal ulcers -clients experience pain after meals 2-4 hrs after meals Hypoglycemia symptoms -irritability -tachycardia -diaphoresis Autologous blood transfusion This is blood lost during surgery that is being re-infused into the patient "blood salvage" Central Venous catheters Anything having to do with CVAD (central venous access devices) ; it is ALWAYS A STERILE PROCEDURE -make sure to FLUSH with 10ml syringe to keep patency RESTLESS= HYPOXIA What happens to a pulse when you lower blood pressure? The HR goes up to compensate. Impetigo A highly contagious skin infection that causes red sores on the face. -Staph infection -causes fluid-filled vesicles, honey-colored crusts, reddened areas -can be treated with an antibiotic cream or oral antibiotic -wash hands before and after applying a topical antibiotic -child can be in contact with other children 24hrs after starting the antibiotic Dumping syndrome Rapid gastric emptying To avoid rapid emptying: -include foods that contain fats and protein at every meal -lie down or sit for 30 to 60 mins after eating -wait for 1 hour after meals before drinking fluids Levothyroxine (T4) Thyroid hormones -mgmt of hypothyroidism, myxedema coma, thyroid replacement Side effects: -weight loss -arrhythmias -insomnia, irritability -nervousness -heat intolerance -menstrual irregularities Nursing: -take at the same time daily -avoid OTC meds with Iodine -Treatment is lifelong -Take on an empty stomach Famotidine (Pepcid) Antiulcer medications Treatment of duodenal and gastric ulcers, GERD, heartburn Side effects: -headache -blood dyscrasias -hepatitis -dizziness -constipation Nursing: -can take at bedtime -avoid taking with antacids-milk of magnesia Restless= Hypoxia Order on how to instruct a client of the use of an incentive spirometer: 1. Assume a high Fowler's position 2. Seal the lips tightly around the mouthpiece 3. Inhale slowly 4. Hold his breath for at least 3 seconds 5. Exhale slowly through the mouth for 2 to 6 seconds 6. Cough and deep breathe 2 to 3 times Tetralogy of Fallot -combination of four heart defects present at birth -infants get tired really fast -use a high-flow soft nipple for feeding Important symptom of sickle cell crisis is... Severe pain Atropine Anticholinergic, antimuscarinics -Treatment of sinus bradycardia and heart block Lobes of the brain and function FRONTAL LOBE: -largest -voluntary movement -speech -intellectual thoughts -intelligence -concentration -temper -personality -emotional control PARIETAL LOBE: -sensation TEMPORAL LOBE: -language -hearing -olfaction (smell) OCCIPITAL LOBE: -Vision -process colors/shapes Considerations for radiation exposure -TIME -DISTANCE -SHIELDING Fixed specific gravity -Values do not change regardless of fluid intake -if pt has a diagnosis of acute glomerulonephritis and you see that their urine specific gravity is fixed and has not changed, the pt is now in severe renal failure, progressed to chronic -seen in chronic glomerulonephritis Foods high in Potassium Bananas Orange juice Beans Winter squash Potatoes Early signs of hypoxia Increased HR Late signs of hypoxia Cyanosis Airborne precautions Chicken pox Measles TB ACUTE respiratory distress No abnormal lung sounds are present on auscultation because the edema occurs first in the interstitial spaces not in the airways Hep A vaccine persons traveling to countries with high to medium rates of hepatitis should be vaccinated; countries in Africa, South America, and Asia have high to medium rates of hepatitis A; other candidates for vaccine include clients diagnosed with chronic liver disease and clients with hemophilia receiving clotting factor Low Albumin Assess pt for edema Low serum albumin means that they are not holding volume in their vascular space and its escaping to the interstitial tissues=edema Projection attributing to others one's feelings, impulses, thoughts, or wishes (blaming or scapegoating) Signs of infection in the Elderly in the elderly, change in mental status, particularly confusion, is very often the presenting symptom of infection; fever may be absent even when bacteremia or pneumonia are present Normal pulmonary artery wedge pressure (PAWP) 6-12 mm Hg Neonate normal head circumference 32-37 cm When should neonate void and pass meconium? During the first 24 hrs Desquamation is also known as peeling skin and is a normal finding in neonates. Moisturizers can be applied to the neonate's skin to resolve desquamation. Signs of respiratory distress in neonates Nasal flaring, chest wall retractions, and grunting with respirations are a sign of respiratory distress. What is the recommended infusion rate for KCL IV? 5-10 mEq/hr KCL IV (nursing priority action) if pt is complaining of burning and discomfort at the site? The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort. Myasthenia gravis Myasthenia gravis involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations. Management of sickle cell crisis 1. Pain control with narcotics - analgesics are provided around the clock or with patient-controlled analgesia, rather than as needed, to prevent breakthrough pain. Clients with SCD often need large doses of narcotics. 2. Hydration - aggressive intravenous and oral hydration is recommended (to reduce the viscosity of the blood) 3. Oxygenation - to prevent pulmonary complications and provide comfort 4. Infection prevention - age-appropriate vaccination plus pneumococcal, influenza, and meningococcal vaccination 5. Diet - the client is encouraged to have a high-protein, high-calorie diet with folic acid and a multivitamin without iron 6. Folic acid - given to help in the creation of the new red blood cells needed due to the hemolysis Note: cold promotes sickling and should be avoided Which medications interfere with absorption of Levothyroxine (Synthroid)? antacids, calcium, and iron preparations. Heart attack symptoms in women and elderly with a history of diabetes. nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue. Placenta previa Placenta previa is suspected in any client with painless vaginal bleeding after 20 weeks gestation. Clients with placenta previa are at high risk for hemorrhage. In the presence of profuse or constant bleeding, the client should be prepared for an emergency cesarean delivery. Nurse should be prepare for: -blood draw for hemoglobin -electronic fetal heart monitoring -pelvic ultrasound Abdominal aneurysms Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. s/s of hypoglycemia shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, pallor, and changes in mental functioning (eg, difficulty speaking, visual disturbances, confusion). Long acting nitrates for angina Long-acting nitrates are used to reduce the incidence of anginal attacks. Nitrates are effective if the client is able to do activities without the incidence of chest pain. The client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates. Clients at highest risk of MRSA Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for MRSA. Elevation of which cells indicates ALLERGY response? eosinophils [Show Less]
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NCLEX-RN Practice Questions Answered 100% correct
A client is referred to a surgeon by the general practitioner. After meeting the surgeon, the client decides to find a different surgeon to continue treatm... [Show More] ent. The nurse supports the client's action, utilizing which ethical principle? 1. Beneficence 2. Veracity 3. Autonomy 4. Privacy Answer: 3 Rationale: Autonomy is the right of individuals to take action for themselves. Beneficence is an ethical principle to do good and applies when the nurse has a city to help others by doing what is best for them. Veracity refers to truthfulness. Privacy is the nondisclosure of information by the health care team. Cognitive Level: Applying Client Need: Management of Care Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The core issue of the question is the ability to interpret which ethical principle is operating in a specific situation. Eliminate beneficence and veracity next because they focus on the obligation of the nurse rather than on a right of the client. A nurse forgets to administer a client's diuretic and the client experiences an episode of pulmonary edema. The charge nurse would consider the medication error to constitute negligence because the situation contains which element? 1. Purposeful failure to perform a health care procedure 2. Unintentional failure to perform a health care procedure 3. Act of substituting a different medication for the one ordered 4. Failure to follow a direct order by a physician Answer: 2 Rationale: Negligence is the unintentional failure of an individual to perform or not perform an act that a reasonable person would or would not do in the same or similar circumstances. A purposeful failure to perform a procedure would be the opposite of negligence, which is unintentional. Substituting a different medication does not fit the description of the situation in the question. Failure to follow a direct order does not fit the description in the situation in the question. Cognitive Level: Applying Client Need: Management of Care Integrated Process: Nursing Process: Assessment Content Area: Fundamentals Strategy: Two options are opposites, which is a clue that one of them may be correct. Choose unintentional failure to carry out a procedure over purposeful failure because it matches the definition of negligence. A client asks why a diagnostic test has been ordered and the nurse replies, "I'm unsure but will find out for you." When the nurse later returns and provides an explanation, the nurse is acting under which principle? 1. Nonmaleficence 2. Veracity 3. Beneficence 4. Fidelity Answer: 4 Rationale: Fidelity means being faithful to agreements and promises. This nurse is acting on the client's behalf to obtain needed information and report it back to the client. Nonmaleficence is the duty to do no harm. Veracity refers to telling the truth for example, not lying to a client about a serious prognosis. Beneficence means doing good, such as by implementing actions (e.g. keeping a salt shaker out of sight) that benefit a client (heart condition requiring sodium-restricted diet). Cognitive Level: Understanding Client Need: Management of Care Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Use the process of elimination. The correct answer is the one that matches the description in the stem; that is, the nurse made a promise to a client and kept it, which constitutes fidelity. An individual has a seizure while walking down the street. During the seizure, a nurse from a physician's office is noticed driving past without stopping to assist. The individual sues the nurse for negligence but fails to win a judgement for which reason? 1. The nurse had no duty to the individual. 2. The nurse did what most nurses would do in the same circumstance. 3. The nurse did not cause the client's injuries. 4. The nurse was off-duty at the time. Answer: 1 Rationale: To be guilty of negligence, the nurse must have a relationship with the client that involves a duty to provide care. The relationship is usually a component of employment. The nurse did not necessarily do what others would do in this situation. Although the nurse did not cause the client's injuries, it does not prevent the nurse from assisting in this situation. Although the nurse was off-duty, the nurse could have assisted if motivated to do so. Cognitive Level: Understanding Client Need: Management of Care Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Use the process of elimination and nursing knowledge. The correct answer is the one that recognizes that the nurse was not in the role of employee at the time of the incident, removing the requirement of acting on the client's behalf. An adult female ambulatory care client receiving an oral anticoagulant is given aspirin for a headache while visiting a neighbor, who is a nurse. The client subsequently has a bleeding episode because of a drug interaction. The legal nurse consultant interprets that which necessary elements of malpractice are missing from this case? Select all that apply. 1. Breech of duty 2. Duty owed 3. Injury experienced 4. Causation between nurse's action and injury 5. Intent to cause harm or injury Answer: 2, 5 Rationale: There was no nurse-client relationship because the nurse was acting as a neighbor and not in an employment capacity. Thus, there can be no duty owed. Intent is not a necessary element of malpractice, because malpractice can occur because of unintended actions as well. There was no breach of duty because there was no official nurse-client relationship, which accompanies an employment situation. There was injury experiences because of this event. The bleeding was caused by the interaction of the aspirin with the anticoagulant. Cognitive Level: Analyzing Client Need: Management of Care Integrated Process: Nursing Process: Evaluation Content Area: Fundamentals Strategy: Use the process of elimination. The wording of the question indicates more than one option is correct, and the focus is on necessary elements that must be present. First eliminate the intent to cause harm or injury, since this is not necessary to a charge of malpractice. Next note that there is no duty owed, and because of this, there can be no breach of duty, to choose these two options as the necessary missing elements. A client with cancer has decided to discontinue further treatment. Although the nurse would like the client to continue treatment, the nurse recognizes the client is competent and supports the client's decision using which ethical principle? 1. Justice 2. Fidelity 3. Autonomy 4. Confidentiality Answer: 3 Rationale: Autonomy refers to the right make one's own decisions, which is the principle supported in this situation. Justice refers to fairness. Fidelity refers to trust and loyalty. Confidentiality refers to the right to privacy of personal health information. Cognitive Level: Understanding Client Need: Management of Care Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Use the process of elimination. The wording of the question indicates that only one option is correct and that you need to select the principle that is consistent with the circumstances in the question. The health care provider orders a medication in a dose that is considered toxic. The nurse administers the medication to the client, who later suffers a cardiac arrest and dies. What consequence can the nurse expect from this situation? Select all that apply. 1. The health care provider can be charged with negligence, being the person who ordered the dose. 2. As the employing agency, only the hospital can be charged with negligence. 3. The nurse and physician may be terminated from employment to prevent a charge of negligence to the hospital. 4. Negligence will not be charged, as this event could happen to any reasonable person. 5. The nurse can be charged with negligence for administering the toxic dose. Answer: 1, 5 Rationale: Health care providers who prescribe incorrect dosages of medications are liable for their errors. The nurse is open to a charge of negligence for failing to verify and question the incorrect dose. The hospital can be sued as the responsible employing agency, but the health care provider and the nurse can also be charged with negligence. Terminating the health care provider and nurse from employment would not stop a lawsuit charging negligence for employee actions that have already taken place. Prescribing and administering incorrect doses are not considered events that routinely happen to "reasonable person." Cognitive Level: Applying Client Need: Management of Care Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: The wording of the question indicates that more than one option is correct. Choose the response that holds both individuals accountable, since the nurse failed to question an incorrect dose and the health care provider ordered the incorrect dose. A nurse and teacher are discussing legal issues related to the practice of their professions. The teacher asks what the functions are of the Nurse Practice Act (NPA) in that state. The nurse would include which thoughts in a response? Select all that apply. 1. Accredit schools of nursing 2. Enforce ethical standards of behavior 3. Protect the public 4. Define the scope of nursing practice 5. Determine liability insurance rates Answer: 3, 4 Rationale: A state's NPA serves to protect the public by setting minimum qualifications for nursing in relation to skills and competencies. One way it fulfills responsibility to protect the public is by defining the scope of nursing practice in that state. The state board of nursing approves schools to operate but does not enforce ethical standards. A state NPA has no role in setting liability insurance rates for nurses. Cognitive Level: Applying Client Need: Management of Care Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Use the process of elimination and basic nursing knowledge to answer the question. The wording of the question indicates that more than one option is correct and that the correct responses are worded as true statements. A staff nurse concerned about maintaining client confidentiality would take which action while carrying out assigned duties? 1. Read the records of clients not assigned to the nurse to become familiar with disease processes. 2. Share information about a client with nurses from the unit to which the client may eventually be transferred. 3. Allow the client's family to review the medical record to obtain answers to their questions. 4. Share information about the client with those involved in planning nursing care. Answer: 4 Rationale: Client confidentiality is maintained when the nurse shares client information only with those currently involved in the plan of care. Staff should only access information about clients currently assigned to their care and should not access information about other clients on the unit not assigned to them. Client information should not be shared with nurses who are not currently working with the client. Family members would need approval from the client and the health care provider prior to reviewing a medical record. Cognitive Level: Applying Client Need: Management of Care Integrated Process: Communication and Documentation Content Area: Fundamentals Strategy: Select the response that protects the client's information, but allows communication necessary for the delivery of quality care. The nurse working in an acute care environment would utilize which strategies to reduce the risk of malpractice litigation? Select all that apply. 1. Discuss any errors with the client and family in detail. 2. Keep incident reports on file. 3. Maintain expertise in practice. 4. Offer opinions to clients when the situation warrants. 5. Report unsafe staffing levels to supervisor. Answer: 3, 5 Rationale: Maintaining expertise in practice by keeping up to date in knowledge and skills aids in reducing the risk of malpractice claims by fostering continued competence in practice. Unsafe staffing levels can result in a higher incidence rate of errors, which could later lead to charges of malpractice. Thus, reporting such situations so they can be prevented should be beneficial. Discussing errors in detail with the client and family does not reduce the risk of malpractice claim. Incident reports should be kept on file but do not decrease the risk of malpractice litigation. The nurse should not offer opinions at any time as this not part of therapeutic communication. Cognitive Level: Applying Client Need: Management of Care Integrated Process: Nursing Process: Implementation Content Area: Fundamentals Strategy: Focus on malpractice as the concept being tested. Recall that maintaining expertise is the best way to reduce personal risk and that reporting unsafe staffing situations may help reduce personal risk and that reporting unsafe staffing situations may help reduce general agency risk by preventing omissions or errors due to insufficient numbers of caregivers to do the work required during the shift. The registered nurse (RN) must delegate care of an assigned client to an unlicensed assistive person (UAP) for the shift. Which client would be best to delegate to the UAP? 1. A client who would benefit from talking about the recent death of her husband. 2. A client with a urinary drainage catheter and nasogastric feedings who is on bedrest. 3. A client with an osmotic who has persistent problems with leakage. 4. A client who was transferred from the critical care unit 3 days ago is ambulatory Answer: 4 Rationale: Factors to consider when delegating care include complexity of task, problem-solving innovation required, unpredictability, and level of client interaction. The ambulatory client is best to delegate because this client in likely to be stable with a low level of unpredictability. The client who recently lost her husband would benefit from professional communication with the RN and requires a high level of client interaction. The client receiving enteral feedings and is immobilized represents a more complex client, who is better assigned to a licensed nurse. The client with a leaking osmotic would benefit from problem-solving innovation and is best cared for by the RN. Cognitive Level: Analyzing Client Need: Management of Care Integrated Process: Nursing Process: Planning Content Area: Leadership and Management Strategy: The core issue of the question is basic concepts that are useful when considering delegation to a UAP. Use this knowledge and the process of elimination to make selection. Which task would not be appropriate for the registered nurse (RN) to delegate to a licensed practical nurse (LPN) or unlicensed assistive personnel (UAP)? 1. Instructing the LPN to reinforce teaching of the RN's assigned clients prior to discharge 2. Assigning UAPs to complete vital signs and document and report changes to the RN 3. Asking the UAP to assess and evaluate the client response to IV pain medication 4. Instructing the LPN to remove a dressing from a postoperative client's abdominal would Answer: Rationale: Cognitive Level: Client Need: Integrated Process: Content Area: Strategy: The charge nurse on the night shift reports that the narcotic count is incorrect. The nurse has spoken to the responsible staff nurse and believes that substance abuse by the nurse is the cause. If substance abuse proves to be the cause of the incorrect count, what is the most appropriate next step? 1. Recount the narcotics with the staff nurse and take disciplinary action 2. Ask the staff nurse to leave the unit and report the incident to the American Nurses Association 3. Complete an incident report and report findings to the pharmacy and nursing administration 4. Submit the findings to the Council on Nursing Practice Answer: Rationale: Cognitive Level: Client Need: Integrated Process: Content Area: Strategy: A quarterly audit is now due to evaluate implementation of an electronic medical record system on the nursing unit. As the unit representative who supervised the adaptation of this documentation system, how can the nurse best determine if nursing staff have accepted this change? 1. Nursing staff uses the electronic medical record daily in routine documentation 2. Nursing staff verbalizes the need for the electronic record but still hand-write nursing notes into the clients' charts 3. Nursing staff uses the electronic record sporadically to monitor clients' progress 4. Nursing staff likes the electronic record because they believe it saves them time Answer: Rationale: Cognitive Level: Client Need: Integrated Process: Content Area: Strategy: The nurse on the hospital quality improvement team has been asked to evaluate nursing care on the nurse's assigned unit. After deciding to ask the nursing staff for assistance in this effort, what would be most appropriate for the nurse to initially ask the staff to do? 1. Track the number of supplies used by clients on the unit 2. Document the time spent on direct client care 3. Administer a client and family satisfaction survey 4. Assess clients and report acuity daily Answer: Rationale: Cognitive Level: Client Need: Integrated Process: Content Area: Strategy: An RN is about to make first rounds after receiving an inter shift report at 3pm. In what order should the RN see the following clients? Place the options in order. All options must be used. 1. A 54-year-old client 4 hours post-cardiac catheterization who has mild discomfort at the access site 2. A client newly diagnosed with diabetes mellitus who needs reinforcement of sick day management guidelines 3. A client who arrived 30 minutes ago from the postanesthesia care unit 4. A client who is ready for discharge but will not have transportation home available until 5pm 5. A client with pneumonia who has received two doses of IV antibiotics and has an oxygen saturation of 93% Answer: Rationale: Cognitive Level: Client Need: Integrated Process: Content Area: Strategy: [Show Less]
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NCLEX-RN (Study guide) Questions Answered 100% correct
Autonomic Dysreflexia Complications: -severe pounding headache (from onset of HTN) -Profuse sweating -Nasal congestion Iron daily requirements f... [Show More] or women 15 mg/day Blood transfusion (hemolytic reaction) S/S: -chills -headache -backache -dyspnea -hypotension -fever Manic episode (behaviors) -Grandiose delusions -difficulty concentrating -agitation Meniere's disease/syndrome Is an inner ear disorder that causes episodes of vertigo/spinning Boggy uterus deviated to right -indicates full bladder -encourage client to void (offer bedpan) Cystic Fibrosis (diet requirements) -High protein -High calorie Cerebellum Maintains balance IVP (intravenous pyelogram) Is a radiological procedure used to visualize abnormalities of the urinary system, including the kidneys ureters and bladder Nursing management: -because of the need to visualize the abdominal area, cleansing enemas the evening before and IVP are usually ordered Rho (D) immune globulin (RhoGam) Is given to an Rh-negative mother who delivers an Rh positive baby when the baby has a negative Coombs test Cane use (going downstairs) -advance cane and weak leg -then strong leg Memory trick: the good goes up, the bad goes down Delegation to remember LPN/LVN and "pulled" or "re-assigned" RN from another unit - receive stable patients with expected outcomes Room assignments -clients with fracture are considered "clean" -do. Not place elderly pts with pneumonia pts IBS (irritable bowel syndrome) Hx of symptoms: -pattern of alternating diarrhea and constipation Immunizations DPT (diptheria, tetanus, pertussis) -1st dose: may be given at 2 mos -2nd dose: given around 4 mos -3rd dose: given around 6 mos MMR: given at 12-15 mos rotavirus: 2, 4, and 6 mos Varicella: 12 to 15 mos Cushing's syndrome (too many steroids) Assessment findings: -buffalo hump -weight gain -moon face -purple striae -osteoporosis -mood swings -high susceptibility to infections -hyperglycemia -hypernatremia Insulin administration Insulin should be administered at room temperature; temp extremes should be avoided Lumbar lesions (ruptured disc) Cause paresthesia, pain, muscle weakness and atrophy in the lower extremities Guillain-Barre syndrome (symptoms) -resp failure -flaccidity due to paralysis of the muscles -urinary retention due to loss of sensation Myelogram -Test involves a lumbar puncture with infection of contrast medium, allowing x-ray visualization of the vertebral canal -indentifies tumors, cysts, herniated vertebral disks Rubella (german measles) Requires airborne precautions; particulate respirator ECT (electroconvulsive therapy treatment) Expected effects: -headache -disrupted memory (short and long term) -general confused state -backache EDB (estimated date of birth) Naegele's rule: -add 7 days to 1st day of last mentrual period and subtract 3 mos Continuous tube feeding -rinse bag and change the formula every 4 hours -there is an increased growth of organisms after 4 hours Type 1 diabetes (insulin needs during pregnancy and after delivery) During pregnancy: Insulin needs increase After delivery: Insulin needs decrease Duodenal ulcers -clients experience pain after meals 2-4 hrs after meals Hypoglycemia symptoms -irritability -tachycardia -diaphoresis Autologous blood transfusion This is blood lost during surgery that is being re-infused into the patient "blood salvage" Central Venous catheters Anything having to do with CVAD (central venous access devices) ; it is ALWAYS A STERILE PROCEDURE -make sure to FLUSH with 10ml syringe to keep patency RESTLESS= HYPOXIA What happens to a pulse when you lower blood pressure? The HR goes up to compensate. Impetigo A highly contagious skin infection that causes red sores on the face. -Staph infection -causes fluid-filled vesicles, honey-colored crusts, reddened areas -can be treated with an antibiotic cream or oral antibiotic -wash hands before and after applying a topical antibiotic -child can be in contact with other children 24hrs after starting the antibiotic Dumping syndrome Rapid gastric emptying To avoid rapid emptying: -include foods that contain fats and protein at every meal -lie down or sit for 30 to 60 mins after eating -wait for 1 hour after meals before drinking fluids Levothyroxine (T4) Thyroid hormones -mgmt of hypothyroidism, myxedema coma, thyroid replacement Side effects: -weight loss -arrhythmias -insomnia, irritability -nervousness -heat intolerance -menstrual irregularities Nursing: -take at the same time daily -avoid OTC meds with Iodine -Treatment is lifelong -Take on an empty stomach Famotidine (Pepcid) Antiulcer medications Treatment of duodenal and gastric ulcers, GERD, heartburn Side effects: -headache -blood dyscrasias -hepatitis -dizziness -constipation Nursing: -can take at bedtime -avoid taking with antacids-milk of magnesia Restless= Hypoxia Order on how to instruct a client of the use of an incentive spirometer: 1. Assume a high Fowler's position 2. Seal the lips tightly around the mouthpiece 3. Inhale slowly 4. Hold his breath for at least 3 seconds 5. Exhale slowly through the mouth for 2 to 6 seconds 6. Cough and deep breathe 2 to 3 times Tetralogy of Fallot -combination of four heart defects present at birth -infants get tired really fast -use a high-flow soft nipple for feeding Important symptom of sickle cell crisis is... Severe pain Atropine Anticholinergic, antimuscarinics -Treatment of sinus bradycardia and heart block Lobes of the brain and function FRONTAL LOBE: -largest -voluntary movement -speech -intellectual thoughts -intelligence -concentration -temper -personality -emotional control PARIETAL LOBE: -sensation TEMPORAL LOBE: -language -hearing -olfaction (smell) OCCIPITAL LOBE: -Vision -process colors/shapes Considerations for radiation exposure -TIME -DISTANCE -SHIELDING Fixed specific gravity -Values do not change regardless of fluid intake -if pt has a diagnosis of acute glomerulonephritis and you see that their urine specific gravity is fixed and has not changed, the pt is now in severe renal failure, progressed to chronic -seen in chronic glomerulonephritis Foods high in Potassium Bananas Orange juice Beans Winter squash Potatoes Early signs of hypoxia Increased HR Late signs of hypoxia Cyanosis Airborne precautions Chicken pox Measles TB ACUTE respiratory distress No abnormal lung sounds are present on auscultation because the edema occurs first in the interstitial spaces not in the airways Hep A vaccine persons traveling to countries with high to medium rates of hepatitis should be vaccinated; countries in Africa, South America, and Asia have high to medium rates of hepatitis A; other candidates for vaccine include clients diagnosed with chronic liver disease and clients with hemophilia receiving clotting factor Low Albumin Assess pt for edema Low serum albumin means that they are not holding volume in their vascular space and its escaping to the interstitial tissues=edema Projection attributing to others one's feelings, impulses, thoughts, or wishes (blaming or scapegoating) Signs of infection in the Elderly in the elderly, change in mental status, particularly confusion, is very often the presenting symptom of infection; fever may be absent even when bacteremia or pneumonia are present Normal pulmonary artery wedge pressure (PAWP) 6-12 mm Hg Neonate normal head circumference 32-37 cm When should neonate void and pass meconium? During the first 24 hrs Desquamation is also known as peeling skin and is a normal finding in neonates. Moisturizers can be applied to the neonate's skin to resolve desquamation. Signs of respiratory distress in neonates Nasal flaring, chest wall retractions, and grunting with respirations are a sign of respiratory distress. What is the recommended infusion rate for KCL IV? 5-10 mEq/hr KCL IV (nursing priority action) if pt is complaining of burning and discomfort at the site? The nurse's priority action is to slow the infusion rate if the client feels a burning discomfort at the IV site shortly after initiation of the infusion. KCL irritates the vein, and irritation and discomfort at the site is expected. Slowing the infusion rate is effective in alleviating discomfort. Myasthenia gravis Myasthenia gravis involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations. Management of sickle cell crisis 1. Pain control with narcotics - analgesics are provided around the clock or with patient-controlled analgesia, rather than as needed, to prevent breakthrough pain. Clients with SCD often need large doses of narcotics. 2. Hydration - aggressive intravenous and oral hydration is recommended (to reduce the viscosity of the blood) 3. Oxygenation - to prevent pulmonary complications and provide comfort 4. Infection prevention - age-appropriate vaccination plus pneumococcal, influenza, and meningococcal vaccination 5. Diet - the client is encouraged to have a high-protein, high-calorie diet with folic acid and a multivitamin without iron 6. Folic acid - given to help in the creation of the new red blood cells needed due to the hemolysis Note: cold promotes sickling and should be avoided Which medications interfere with absorption of Levothyroxine (Synthroid)? antacids, calcium, and iron preparations. Heart attack symptoms in women and elderly with a history of diabetes. nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue. Placenta previa Placenta previa is suspected in any client with painless vaginal bleeding after 20 weeks gestation. Clients with placenta previa are at high risk for hemorrhage. In the presence of profuse or constant bleeding, the client should be prepared for an emergency cesarean delivery. Nurse should be prepare for: -blood draw for hemoglobin -electronic fetal heart monitoring -pelvic ultrasound Abdominal aneurysms Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. s/s of hypoglycemia shakiness, palpitations, nervousness, diaphoresis, anxiety, hunger, pallor, and changes in mental functioning (eg, difficulty speaking, visual disturbances, confusion). Long acting nitrates for angina Long-acting nitrates are used to reduce the incidence of anginal attacks. Nitrates are effective if the client is able to do activities without the incidence of chest pain. The client should be taught to report any increase in chest pain and how to manage headaches, a common side effect of nitrates. Clients at highest risk of MRSA Clients at highest risk for hospital-acquired MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines (hemodialysis clients). Clients in the intensive care unit (ICU) are especially at risk for MRSA. Elevation of which cells indicates ALLERGY response? eosinophils Placental abruption Placental abruption usually presents with abdominal pain and dark red vaginal bleeding. The main concerns are maternal blood loss resulting in hypotension and shock and fetal compromise. Maternal stabilization and expedited birth are indicated. Abruption may require rapid volume replacement with IV fluid and blood products, requiring large-bore IV access. Peripheral IV access with a 16- or 18-gauge catheter should be initiated. Signing out AMA (against medical advice) For a client to sign out AMA, the client must be competent and cannot be impaired by drugs or alcohol. Clients cannot be a danger to themselves (suicidal) or others (homicidal). An emancipated minor or a health care provider-determined "mature minor" can give consent. Good dietary source of both calcium and vitamin D Sardines Administering meds through feeding tube When a feeding tube is used, medications should be crushed, dissolved, and administered separately to prevent interactions. Sterile water should be used to dissolve medications and flush the feeding tube. Liquid medications should be used if possible. Stress-induced hyperglycemia Stress-induced hyperglycemia causes complications in the hospitalized client. To minimize complications, the recommended target glucose range for critically ill clients is 140-180 mg/dL [7.8-10.0 mmol/L]. For non-critically ill clients, <140 mg/dL (7.8 mmol/L) fasting and <180 mg/dL (10.0 mmol/L) random blood glucose are recommended. Malignant hyperthermia Malignant hyperthermia (MH) is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia. The most specific characteristic signs and symptoms of MH include hypercapnia, muscle rigidity, and hyperthermia. Liver failure lab findings Laboratory abnormalities common in liver failure include low serum albumin (causes ascites), elevated INR (increases risk for bruising and bleeding), elevated serum ammonia (causes lethargy and confusion), and increased bilirubin (causes jaundice and itching). Prevention of VAP Prevention of ventilator-associated pneumonia focuses on minimizing mechanical irritation and bacterial access to the lungs. Specific steps include sealing the endotracheal tube cuffing with ≥20 cm H2O (15 mm Hg), routine oral hygiene with chlorhexidine, elevating the head of the bed, minimizing sedation, and extubating as soon as possible. [Show Less]
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Exam Cram NCLEX RN Practice Questions Exam 1 Questions Answered 100% correct
A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client? A. 1 cup beef broth B. 1 baked potat... [Show More] o C. 1/2 cup raisins D. 1 cup rice D (1 cup of rice) ( Answer D is correct because one cup of rice is considered a low-potassium food. The foods in answer A, B, and C are incorrect because they contain higher amounts of potassium) An appropriate nursing intervention for the client with borderline personality disorder is: A. Observing the client for signs of depression or suicidal thinking B. Allowing the client to lead unit group sessions C. Restricting the client's activity to the assigned unit of care throughout hospitalization D. Allowing the client to select a primary caregiver A (observing the client for signs of depression or suicidal thinking) (Clients with borderline personality frequently suffer from depression and suicidal thinking and should be assessed for risk of self-injury. Answers B and D are incorrect choices because they allow the client too much control of the therapeutic environment. Answer C is incorrect because the client's activities do not have to be restricted to the unit after the level of depression has been determined ) Which of the following is an expected finding in the assessment of a client with bulimia nervosa A. Extreme weight loss B. Presence of lanugo over body C. Erosion of tooth enamel D. Muscle wasting C (Erosion of tooth enamel) (Erosion of tooth enamel caused by frequent self-induced vomiting is an expected finding in a client with bulimia nervosa. Answers A, B, and D are expected findings in the client with anorexia nervosa; therefore, they are incorrect.) Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning? A. One-year-old B. Four-year-old C. Eight-year-old D. Twelve-year-old B (Four-year-old) (Because of their increased mobility, manual dexterity and curiosity, the four year old is at greater risk for accidental poisoning. Other accidental injuries in this age group include being struck by a car, falls, burns, and drowning. Answer A is incorrect because the one-year-old lacks the developmental skill to be at risk for accidental poisoning. Answers C and D are incorrect because the eight-year-old and the twelve-year-old are at less risk because they are aware of the dangers of accidental poisoning) Which term describes the play activity of the preschool aged child? A. Cooperative B. Associative C. Parallel D. Solitary B (Associative) (Play of the preschool aged child is described as associative. At this stage, children are more interested in playing with other children than they are with playing with toys. The child may talk to other children and exchange toys or play games without any rules. Answer A describes the play of a school-aged child. Answer C describes the play of an infant.) The nurse is ready to begin an exam on a nine-month-old infant who is sitting quietly on his mother's lap. Which should the nurse do first? A. Check the Babinski reflex B. Listen to the heart and lung sounds C. Palpate the abdomen D. Check tympanic membranes B (Listen to the heart and lung sounds) (While the infant is quiet, the nurse should begin the exam by listening to the heart and lungs. If the nurse elicits the Babinski reflex , palpates the abdomen, or checks the tympanic membranes, the infant may cry and it will be difficult to adequately listen to the heart and lungs; therefore answers A,C, and D are incorrect.) In terms of cognitive development, a three-year-old would be expected to: A. Think abstractly B. Use magical thinking C. Understand conservation of matter D. See things from the perspective of others B (Use magical thinking) (A three-year-old is expected to use magical thinking, such as believing that a toy bear is a real bear. Answers A, C, and D are incorrect because of abstract thinking, conservation of matter, and the ability to look at things from the perspective of others are cognitive abilities of an older child) Which of the following describes the language development of a two-year-old? A. Doesn't understand yes and no B. Understands the meaning of all words C. Can combine three or four words D. Repeatedly asks "why?" C (can combine three or four words) (The two year old can combine three to four words. Answers A and B are incorrect because the two-year-old understands yes and no, but does not understand the meaning of all the words. Answer D is incorrect because seeking information and asking "why?" is typical of the three-year old) A client who has been receiving Urokinase (uPA) for deep vein thrombosis is noted to have dark brown urine in the urine collection bag. Which action should the nurse take immediately? A. Prepare an injection of vitamin K B. Irrigate the urinary catheter with 50 mL of normal saline C. Offer the client additional oral fluids D. Withhold the medication and notify the physician D (Withhold the medication and notify the physician) (Urokinase is a thrombolytic agent used in the treatment of deep vein thrombosis, pulmonary embolus, or myocardial infarction. The presence of dark brown or rust-colored urine suggests bleeding. The nurse should withhold the medication, call the doctor immediately, and prepare to administer Amicar. Answer A is correct because vitamin K is not the antidote for urokinase. Answers B and C are incorrect because they do not address the adverse problem of bleeding) Which of the following can occur with the frequent use of calcium based antacids? A. Constipation B. Hyperperistalsis C. Delayed gastric emptying D. Diarrhea A (Constipation) (The client taking calcium-based antacids will frequently develop constipation. Answers B, C, and D are not associated with the use of calcium-based antacids; therefore, they are incorrect.) Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin? A. "I will administer the medication 1-2 inches away from the umbilicus." B. "I will not massage the injection site after administering the heparin." C. "I will check the PTT before administering the heparin." D. "I will need to gently aspirate when I give the heparin." D ("I will need to gently aspirate when I give the heparin.") (The nurse should not aspirate when giving heparin; therefore, answer D indicates a need for further teaching regarding heparin administration. Answers A, B, and C indicate the student nurse understands the the correct administration of heparin and are, therefore, incorrect answers. ) To correctly assess the oxygen saturation level of an adult client, the pulse oximeter should not be placed on the: A. Finger B. Earlobe C. Extremity with noninvasive BP cuff D. Nose C (Extremity with noninvasive BP cuff) (To obtain a correct oxygen saturation reading using pulse oximetry, the probe should not be placed on the arm with a noninvasive BP cuff or intraarterial line. Suitable sites are the finger, earlobe, or nose; therefore, Answers A, B, and D are incorrect.) While caring for an elderly patient with hypertension, the nurse notes the following vital signs: BP of 140/40, pulse 129, respirations 36. The nurse's initial action should be to: A. Report the findings to the physician B. Recheck the vital signs in one hour C. Ask the patient if he is in pain D. Compare the current vital signs with those on admission A (Report the findings to the physician) (The client is exhibiting a widened pulse pressure, tachycardia, tachypnea. The first nursing action after obtaining these vital signs is to notify the physician for additional orders. Answers B, C, and D can be done after the physician is notified; therefore, they are incorrect choices as a first action.) The nurse is preparing s client with an axillopopliteal bypass graft for discharge. The client should be taught to avoid: A. Using a recliner to rest B. Resting in supine position C. Sitting in a straight chair D. Sleeping in right Sim's position C (Sitting in a straight chair) (The client with the axillo-popliteal graft should avoid activities that can occlude the femoral artery graft. Sitting in the straight chair and wearing tight clothes are prohibited for this reason. Answers A, B, and D are incorrect because resting in a supine position, resting in a recliner, and sleeping in the right Sim's position are allowed.) The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows the antithrombotic stockings should be applied: A. Before the client arises in the morning B. With the client in a standing position C. After the client has bathed and applied lotion to the legs D. Before the client retires in the evening A (Before the client arises in the morning) (The best time to apply antithrombotic stockings to the client is in the morning before the client arises. If the physician orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely ) The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first? A. A client recovering from a stroke with an oxygen saturation rate of 99% B. A client three days port-coronary artery bypass graft with an oral temperature of 100.2 degrees Fahrenheit C. A client admitted one hour ago with rales and shortness of breath D. A client being prepared for discharge following a right colectomy C (A client admitted one hour ago with rales and shortness of breath) A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with: A. Hypothyroidism B. Diabetic ulcers C. Gastroenteritis D. Bacterial pneumonia A (Hypothyroidism) The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching? A. "I will have blood drawn every month." B. "I will assess my skin for rash." C. "I take aspirin for a headache." D. "I will use an electric razor to shave." C ("I take aspirin for a headache.") The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation? A. Pedal pulses regular B. Urinary output 20mL in the past hour C. Blood pressure 108/50 D. Oxygen saturation 97% B (Urinary output 20mL in the past hour) The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider? A. Diet pattern B. Mobility C. Fluid intake D. Sexual function D (Sexual function) B C A A B A B A A B B A C B D [Show Less]
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NCLEX RN 2023 Review Questions Answered 100% correct
A client who has amyotrophic lateral sclerosis is having frequent episodes of dysphagia. Which of the following referrals is appropriate for the nurse to m... [Show More] ake currently? 1. Physical Therapist 2. Speech Pathologist 3. Registered Dietitian 4. Occupational Therapist 2. Speech Pathologist A client who has chronic progressive dementia exhibits symptoms of malnutrition. Which action is needed at this time? 1. Notify social services about concern for abuse. 2. Initiate a consult for physical therapy to visit daily. 3. Ask home care services to provide written instructions. 4. Arrange a meeting with the interprofessional team to coordinate care 4. Arrange a meeting with the interprofessional team to coordinate care A nurse should recognize which of the following clients are likely to need rehabilitation services after hepatization? (SATA) 1. School-age child who is recovering from an appendectomy. 2. Client who had a cesarean delivery for a breech presentation. 3. An adult client who has left hemiplegia after a stroke. 4. An adult client who is recovering from Guillain-Barre syndrome. 5. An older adult client who had a left hip replacement. 6. An adolescent client who required hospitalization due to asthma. 3. An adult client who has left hemiplegia after a stroke. 4. An adult client who is recovering from Guillain-Barre syndrome. 5. An older adult client who had a left hip replacement. A nurse is assigned to a group of clients. Which of the following has an increased risk of aspiration while eating? (SATA) 1. A client who has a new diagnosis of gastroesophageal reflux disease. 2. A client who has admitted with a diagnosis of cerebrovascular accident. 3. A client who is 4 hr. post-op and received general anesthesia. 4. A client who is 8 hr. following traumatic laryngeal nerve damage. 5. A client who continually experiences prolonged coughing episodes. 2. A client who has admitted with a diagnosis of cerebrovascular accident. 3. A client who is 4 hr. post op and received general anesthesia. 4. A client who is 8 hr. following traumatic laryngeal nerve damage. 5. A client who continually experiences prolonged coughing episodes. A client is receiving packed RBCs and becomes tachypneic. The client's temperature changes from 36.8C (98.4F) to 38.4C (101.2F). Which of the nursing interventions should the nurse perform first. 1. Give 750 mg acetaminophen orally. 2. Collect blood and urine specimens for analysis. 3. Administer and IV infusion of 0.9% sodium chloride. 4. Stop the infusion and return the blood to the lab. 4. Stop the infusion and return the blood to the lab. A nurse receives a request from four clients at the same time. Which of the following clients should the nurse address first? A client who 1. Needs to void 1 hr. after removal of an indwelling urinary catheter. 2. Reports restlessness and shortness of breath following surgery for a fractured femur. 3. Asks for a stool softener 2 days following surgery. 4. Demands to take prescribed insulin early the spouse is bringing dinner. 2. Reports restlessness and shortness of breath following surgery for a fractured femur. After receiving the report, a nurse should plan to access the clients in which priority order? 1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally. 2. A 6-year-old who is receiving continuous chemotherapy via a central venous catheter. 3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy. 4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter. 1st) 2. A 6-year-old who is receiving continuous chemotherapy via a central venous catheter. 2nd) 1. A 9-month-old who is receiving hydration therapy with IV fluids infusion peripherally. 3rd) 4. An 8-year-old who is 2 days postoperative with an indwelling urinary catheter. 4th) 3. A 14-year-old who is awaiting discharge instructions receiving prednisone therapy. A nurse received the report and should plan to see which of the following client first? 1. A client at 39 weeks of gestation who is having contractions over 5 min lasting45 to 60 seconds. 2. A client who is pregnant and has a blood glucose level of 150mg/dl. 3. A client at 33 weeks of gestation who is receiving magnesium sulfate IV. 4. A client 1 day postpartum who has changed perineal pads twice in the last 7 hr. 3. A client at 33 weeks of gestation who is receiving magnesium sulfate IV. After receiving the report, which of the following clients should the nurse see first? 1. A client who was admitted with kidney stones and is crying with back pain. 2. A client who had chest discomfort prior to admission and is now requesting coffee. 3. A client who is scheduled for surgery and needs the linen changed. 4. A client who is to receive one unit of packed RBCs today and needs an IV restarted. 1. A client who was admitted with kidney stones and is crying with back pain. The nurse should triage which of the following clients first? 1. Vomiting, photosensitivity, and stiff neck. 2. Elevated temperature, sore throat, and fatigue. 3. A guarded gait and a bruised, edematous ankle. 4. Cloudy urine with painful urination. 1. Vomiting, photosensitivity, and stiff neck. 5 Rights of Delegation Right Person Right Task Right Circumstance Right Direction/Communication Right Supervision/Evaluation Scope of Practice RN - LPN - UAP - RN - Unstable clients, Assessments, Initiate Care Plans, Initial Teaching, Blood Productions, IV Fluids and IV Push Medications. LPN - Stable clients, Gather data, Contribute to Care Plan, Reinforce Teaching, Monitor IVFs and Blood Transfusions, Administer Piggybacks. UAP - Stable clients, Obtain Vital Signs, Gather specific date, Hygiene care, Bed making, Feeding, Positioning, Ambulation. A nurse is organizing care for four clients, which of the following tasks should the nurse instruct the UAP to perform? 1. Measure the urine output from a client who was recently admitted with dehydration. 2. Bathe and shampoo hair for a client who was just admitted after a motor vehicle crash. 3. Help a client who is requesting a bedpan after a lumbar puncture. 4. Decrease the oxygen on a nasal cannula for a client who is being discharged with COPD. 1. Measure the urine output from a client who was recently admitted with dehydration. Which of the following tasks should a nurse assign to the experienced unlicensed assistive personnel (UAP)? (SATA) 1. Completing intake and output measurements. 2. Feeding a client who has early dementia. 3. Explaining oral hygiene to a client receiving chemotherapy. 4. Bathing a client two days after a cerebrovascular accident. 5. Ambulating a client who is one-day post-hysterectomy. 6. Assisting a client who has hypertension select low-sodium snacks. 1. Completing intake and output measurements. 2. Feeding a client who has early dementia 4. Bathing a client two days after a cerebrovascular accident. 5. Ambulating a client who is one-day post-hysterectomy. A nurse is supervising care delegated to a UAP. The nurse should take corrective action if which of the following is observed? 1. Allowing a client to sit in a bedside chair while discarding bathwater. 2. Pulling the curtain partially around the bed while performing perineal care. 3. Raising the bed and lowing the side rail while repositioning a client. 4. Answering a call that rings the hospital telephone while the client is away. 2. Pulling the curtain partially around the bed while performing perineal care. A nurse delegates hygiene care for a client hospitalized with COPD to unlicensed assistive personnel. Which of the following is the most appropriate instruction for the nurse to give? 1. Delay hygiene care until one hour after breakfast. 2. Allow the client to nap with the lead of the bed elevated. 3. Encourage the client to participate in hygiene care. 4. Teach the client to breathe slowly and deeply. 1. Delay hygiene care until one hour after breakfast. An LPN reports the following data to the supervising RN regarding data collection for a client who has congestive heart failure: Pulse oximetry 85%, respirations 48/min and labored. What is the priority action at this time? 1. The LPN will administer IV Furosemide. 2. The respiratory therapist will be notified. 3. The client will be prepared for a chest x-ray. 4. The care of the client will be reassigned to an RN. 4. The care of the client will be reassigned to an RN. [Show Less]
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NCLEX REVIEW - 2023! Questions Answered 100% correct
Pitocin: Indication? Adverse Effects/Monitoring? Given to strengthen contractions and labor. Can cause uterine hyperstimulation. Contractions should be N... [Show More] O LONGER than 90 seconds and no closer than 2 minutes apart. If they are any more than that; slow pitocin How to Mix insulins (step 1-5) 1. Draw up the total amount of (AIR) 2. Air into N 3. Air into R 4. Draw up R 5. Draw up N IM injection - Needle size + length? Sub-Q Size + length? IM: 21g 1 inch needle Memory clue: I looks like 1 Sub-Q: 25g 0.5 inch Memory clue: S looks like 5 Cephalohematoma vs Caput Succedaneum Cephalohematoma: bleeding in brain of newborn. Does not cross suture line and is asymmetrical Caput Succedaneum: Crosses suture line and is symmetrical. Memory clue: think CS = crosses suture, CS = Caput symmetrical Terbutaline: Indications? Nursing considerations? Contraindication? Used to slow down birth and contractions Contraindicated: in mothers with heart disease due to its common side effect of tachycardia Fundal Height - Postpartum: Height right after birth? Everyday after that? Fundal height right after birth is at the umbilicus - Every day after birth it will go down by 1, height correlates with the day postpartum Put the following tracheostomy care steps in order: - Remove old dressing - clean around stoma w/ sterile water or saline then replace gauze - Don sterile gloves, remove old disposable inner cannula and replace with new one - Collect supplies and position patient - Don PPE 1. Collect supplies and position patient 2. Don PPE 3. Remove old dressing 4. DON sterile gloves and remove old disposable inner cannula then replace with new one 5. Clean around stoma with sterile water or saline then replace gauz Second stage of labor (delivery): Place steps in order for delivering BB. - Make sure baby has an ID before leaving delivery area - Suction babies mouth then nose - Deliver shoulder then body - Check for nuchal cord - Deliver babies head then tell mom to stop pushing 1. Deliver babies head and tell mom to stop pushing 2. Suctions babies mouth then nose 3. Check for nuchal (cord around neck) around neck 4. Deliver shoulders then body 5. Make sure BB has ID before leaving delivery area After the delivery of the placental: What are the nursing interventions and assessments? Ensure placenta is intact and check for vessels in the cord should be AVA Fourth stage of labor: what is it? what are we assessing? What are nursing Interventions? Fourth stage is recovery. NOTE: assess 4 things during the 4th stage of labor four times an hour (every 15 minutes) 1. Assess V/S q15 to monitor for shock plus S/S cool, pale, clammy skin, tachycardia, hypotension 2. Monitor fundus: If boggy massage it, if displaced catheterize 3. Monitor Lochia: Pt is bleeding too much if she is saturating a pad every 15 minutes. report ASAP. 4. Monitor for Thrombophlebitis: measure bilat calf circumference!! Medical Battery - What is it? The intentional touching of a patient without consent ex: doing a procedure that the patient denied, lying about the medication you're giving Hirschsprung's Dz S/S? Critical findings that must be reported ASAP? S/S: failure to pass meconium, abdominal distention, bilious vomit Critical finding that should be reported: fever and diarrhea Normal weight gain for pregnancy? 28 + or - 3lb How to calculate what weight gain should be in pregnancy? What to do if Shes overweight or underweight? # of week pregnant - 9 can range -/+ 1-2 lbs = normal If +/- 3 = assess the patient If +/- 4 = trouble perform biophysical profile on the baby When is the fundus palpable? - Not until 12 weeks NOT palpable in first trimester! When is the fundus at umbilicus? 20-22 weeks gestation When can you first detect FHR and quickening? FHR: 8wks Quickening: 16 weeks When would you most likely detect FHR and quickening? FHR: 10 weeks Quickening: 18 weeks When should you be able to detect FHR and quickening? FHR: 12 wks Quickening: 20wks [Show Less]
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World NCLEX-RN TEST 2 Questions Answered 100% correct
A nurse coworker is called into work from home to help care for an influx of clients being admitted after a bus accident. While assisting the coworker prep... [Show More] are for incoming clients, the nurse becomes concerned that the coworker may be under the influence of an impairing substance. Which action by the nurse is best? 1. Ask another coworker to observe the individual to confirm the suspicion 2. Confront the coworker about the concern and offer emotional support 3. Speak with the nursing supervisor about the concern 4. Telephone the appropriate regulatory agency and make a report 3. A nurse is administering a rituximab infusion to a client with lymphoma in an oncology clinic. Which client symptom would be a priority to report to the health care provider? 1. Dizziness and sudden diarrhea 2. Nausea and onset of vomiting 3. New-onset tachypnea and dyspnea 4. Temperature of 101 F (38.3 C) 3. The student nurse plans postmortem care for an Orthodox Jewish client hospitalized for the last week with heart failure who did not sign consents for any postmortem actions. Which statement by the student would require further education by the supervising nurse? 1. "I will allow the family to remain with the client at all times." 2. "I will call the next of kin before providing any postmortem care." 3. "I will prepare the client for transfer to the morgue for autopsy." 4. "I will provide a sheet to be placed over the client's face." 3. The nurse is caring for a client with chronic pancreatitis. Which meal should the nurse recommend when assisting the client in selecting food items from a menu? 1. Baked tilapia with lemon wedge, sweet potatoes, and green peas 2. Cream of potato soup and roast beef sandwich on a croissant 3. Sautéed salmon, macaroni and cheese, string beans, and a biscuit 4. Shrimp enchiladas with tomato salsa, rice, cornbread, and refried beans 1. The nurse is preparing to change the dressing of a client's subclavian central venous catheter using a chlorhexidine gluconate (CHG)-impregnated patch and transparent adhesive dressing. Place the procedural steps in the correct order. All options must be used. Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry completely Discard the clean gloves, perform hand hygiene, and apply sterile gloves Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves Remove old dressing and CHG-impregnated patch; assess insertion site Perform hand hygiene, don face mask, place a mask on the client, and apply clean gloves Remove old dressing and CHG-impregnated patch; assess insertion site Discard the clean gloves, perform hand hygiene, and apply sterile gloves Cleanse the site with CHG for at least 30 seconds using friction; allow to air dry completely Apply CHG patch over catheter insertion site and cover with a sterile transparent dressing Four clients enter the pediatric emergency department at the same time. Which client should the nurse see first? 1. 2-week-old with tricuspid atresia who has dusky lips and nailbeds 2. 5-week-old with forceful vomiting after every feeding who is crying 3. 12-month-old who was wheezing at home and is now lethargic with no wheezing 4. 3-year-old with fever who had a brief seizure at home and is asleep 3. The unlicensed assistive personnel (UAP) reports being splashed in the eye while emptying urine from the catheter bag of a client with AIDS. The UAP is afraid of becoming infected with HIV and requests immediate testing. What is the nurse's priority action? 1. Direct the UAP to immediately flush the eye with water at the unit's eyewash station 2. Reassure the UAP that the risk for HIV is low as urine does not transmit the virus 3. Refer the UAP to the occupational health department for postexposure prophylaxis 4. Send the UAP to the facility's emergency department for medical evaluation 1. The nurse prepares to administer a client's scheduled prandial regular insulin plus a correctional dose based on a sliding scale as the client's breakfast tray arrives. The client's fasting blood glucose level is 210 mg/dL (11.7 mmol/L). How many total units of regular insulin should the nurse administer? Click the exhibit button for additional information. Record your answer using a whole number. EXHIBIT: Medication administration record: Allergies: NKA Medications: -Regular insulin: 4 units subcutaneously with each meal (0800, 1200, 1700) -Regular insulin: per sliding scale, subcutaneously with each meal and before bed (0800, 1200, 1700, 2100) Sliding-Scale Blood Glucose Levels: <150 mg/dL - 0 units 150-199 mg/dL - 3 units 200-249 mg/dL - 6 units 250-299 mg/dL - 9 units 300-349 mg/dL - 12 units ≥350 mg/dL - 15 units; notify HCP Answer: 10 (units) The nurse is caring for a client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? 1. "Have you had any recent changes or added stresses in your life?" 2. "It is too early to notice any difference. Please continue to take the medicine as prescribed." 3. "Let's talk more about how you have been taking this medication." 4. "We will talk with your health care provider about changing the prescription." 3. The nurse reinforces teaching to the parents of a 12-month-old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? 1. "I can allow my child to sleep with a bottle for comfort while weaning." 2. "I can start substituting breastfeeding sessions with whole cow's milk." 3. "I should discourage my child from drinking milk to increase solid food intake." 4. "I will stop breastfeeding completely to expedite the weaning process." 2. The home health nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse recommends a hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? 1. "A hospital bed will make your spouse's care easier." 2. "Are you not ready for this particular change?" 3. "What upsets you about having a hospital bed?" 4. "You seem upset. We don't have to talk about this right now." 3. [Show Less]
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NCLEX RN Mnemonics Questions Answered 100% correct
Cranial Nerves, Sensory vs Motor Think: "Some Say Money Matters But My Brother Says Big Brains Matter Most." S-Sensory, M-Motor, B-Both S-Olfactory I ... [Show More] S-Optic II M-Oculomotor III M-Trochlear IV B-Trigeminal V M-Abducens VI B-Facial VII S-Auditory VIII) B-Glossopharyngeal IX B-Vagus X M-Accessory XI M-Hypoglossal XII Autonomic Nervous System Function Rhyme Sympathetic: fight or flight Parasympathetic: rest and digest Causes of HTN Think: ABCDE Aldosterone/Apnea Bad kidney/Bruits Catecholamine/Cushings syndrome Drug/Diet Endocrine All the above are secondary causes, primary causes occur when there is no identifiable cause. Disease caused by Streptococcus Pyogenes Think: GET NIPPLES Glomerulonephritis Endocarditis (Heart Valve) Toxic shock syndrome Necrotizing fascitis and myositis Impetigo Pharyngitis Pneumonia Lymphangitis Erysipelas and cellulitis Scarlet fever/Rheumatic fever Causes of Hyperkalemia Think: MACHINE Meds (ACE1, Steroids, Beta Blockers) Acidosis Cellular destruction (Rhabdo, burns, trauma) Hypoaldossteronism, hemolysis Intake, excessive Nephrons, renal failure Excretion, impaired Causes of Hypokalemia Think: GRAPHIC IDEA GI loss Renal Aldosterone Periodic paralysis Hypothermia Cushing's syndrome Insufficient intake Diuretics Elevated beta adrenergic activity Alkalosis Signs of Hypokalemia Think: 6L's Lethargy Lethal cardiac arrhythmia Leg cramps Limp muscles Low, shallow respiration's Less stool (constipation) Insulin Functions on Cells Think: INsulIN INsulIN stimulates 2 things to go IN 2 cells: Potassium and Glucose Activities of Daily Living Think: BATTED Bathing Ambulation Toileting Transfers Eating Dressing Therapeutic Dosage and Toxicity values Think: The magic 2's Digitalis 0.5-1.5 Toxicity 2.0 Lithium 0.6-1.2 Toxicity 2.0 Theophylline 10-20 Toxicity >20.0 Dilantin 10-20 Toxicity >30.0 APAP 1-20 Toxicity 120 Staph Aureus Think: causes SOFT PAINS Skin infections Osteomyelitis Food poisoning Toxic shock syndrome Pneumonia Acute endocarditis Infective arthritis Necrotizing fascitis Sepsis Hypertension Treatment Think: ABCD ACE inhibitors/ARBS Beta Blockers Calcium Channel Blockers Diuretics Hypertension Nursing Interventions: Think: DIURETIC Daily weight Intake & Output (I&O) Urine output Response of BP Electrolytes Take Pulses Ischemic Episode (TIA) Complications: 4C's Signs of Hypernatremia Think: you are FRIED Fever Restless Increased Edema Decreased urinary output Maniac Symptoms Think: DIG FAST Distractibility Indiscretion Grandiosity Flight of ideas Activity increases Sleep deficit Talkative Hypersensitivity Reactions Think: ACID Anaphylactic-type 1 Cytotoxic-type 2 Immune complex-type 3 Delayed hypersensitivity-type 4 Intestinal Components Think: Dow Jones Industrial Can't Choose Duodenum Jejunum Ileum Cecum Colon Sigmoid ARB side effects (Angiotension II Receptor Blocker) Think: Halt Dangerous Hypertension Headache Dizziness Hyperkalemia Aspirin side effects Think: ASPIRIN Asthma Salicyalism Peptic ulcer disease Intestinal blood loss Reye's syndrome Idiosyncrasy Noise (tinnitus) Hyperglycemia Think: 3 P's Polyphagia Polydipsia Polyurea Hot & Dry, Sugar is High Serotonin Syndrome Characteristics Think: they cause HARM Hyperthermia Autonomic instability (delirium) Rigidity Myoclonus Signs of Esophageal Atresia and Tracheoesophageal Fistula Think: 3 C's Coughing Choking Cyanosis Cancer's Early Warning Signs Think: CAUTION UP Change in bowel or bladder A lesion that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious changes in wart or mole Nagging cough or persistent hoarseness Unexplained weight loss Pernicious anemia Acute Lithium Toxicity Symptoms Think" CAN HAM SUCS Confusion An increase in urine & thirst Nausea Hand tremors Ataxia (in-coordination of arms and legs) Muscle twitches Seizures Uncontrollable eye movement Coma Slurred speech Bleeding Precautions Think: RANDI Razor electric no blades Aspirin No needles (esp. in small gauge) Decrease needle sticks Injury (protect from) Morphine side effects Think: MORPHINES Myosis Orthostatic HTN Respiratory depression Pneumonia (aspiration) Hypotension Infrequent waste release (constipation & urine retention) Nausea Emesis Sedation SNRI side effects Think: BAD SNRI Body weight increases Anorexia Dizziness Suicidal thoughts Nausea/Vomiting Reproductive/sexual dysfunction Insomnia Melanoma Characteristics Think: ABCDE Asymmetrical Borderline irregular Color dark and variation Diameter is large (>6mm) Evolving Acidosis/Alkalosis Think: ROME Respiratory Opposite *pH up & PCO2 down = Alkalosis *pH down & PCO2 up = Acidosis Metabolic Equal *pH up & HCO2 up = Alkalosis *pH down & HCO2 down = Acidosis Hormones that Increase Blood Glucose Think: STENGG Somatotropin (growth hormone) Thyroid hormones (thyroxine & triiodthyorine) Epinephrine Norepeinephrine Glucagon Glucocorticosteroids Tricyclic antidepressants (TCA) side effects Think: TCA'S Thrombocytopenia Cardiac (arrhythmia, MI, stroke) Anticholinergic effects (tachycardia, urinary retention, ect) Seizures Indications for Thiazide Diuretic use Think: CHIC CHF Hypertension Insipidous (Lithium induced) Calcium calculi 6 P's of Dyspnea Pneumonia Pulmonary Bronchial Constriction Possible foreign body Pulmonary embolus Pneumothorax Pump failure Heart Valves by Order of Blood Flow Think: Toilet Paper My Ass Tricuspid Pulmonic Mitral Aortic White Blood Cells (in order of decreasing numbers) Think: Never Let Monkeys Eat Bananas Neutrophils Lymphocytes Monocytes Eosinophils Basophils SSRI side effects Think: BAD SSRI Body weight increases Anxiety Dizziness Serotonin syndrome Stimulated CNS Reproductive/sexual dysfunction Insomnia ACE Inhibitor side effects Think: CAPTOPRIL Cough Angioedema/Agranulocystosis Potassium excess Taste changes Orthohypotension Pregnancy contraindications Renal artery stenosis contraindication Inflammation-related pain Lower GFR (glomerular filtration rate) Hypoxia symptoms Think: RAT BED Early hypoxia: Restlessness Anxiety Tachycardia/Tachypnea Late hypoxia: Bradycardia Extreme restlessness Dyspnea Stages of Shock Think: CPR Compensatory stage Progressive stage Refractory stage Corticosteroids side effects Think: CUSHGOID Cataracts Ulcers Skin thinning, bruising, & striae Hyperglycemia/HTN/Hirsutism Infections Necrosis: Avascular necrosis of the femoral head Glycosuria Osteoporosis, Obesity Diabetes Hypoglycemia signs & symptoms Think: TIRED Tachycardia Irritability Restlessness Excessive hunger Diaphoresis Cold & clammy, need some candy Calcium Channel Blocker side effects Think: SHRED the GAPS Stevens Johnson Syndrome Headache Edema Dizziness the Gingival hyperplasia Angina Palpitations Sleepiness Liver Functions Think: PUSH DoG Protein synthesis Ureas synthesis Storage Hormone synthesis Detoxification Glucose and fat metabolism Potassium Increasing Agents Think: K-BANK K-sparing diuretics Beta Blockers ACE inhibitors NSAIDS K+ supplement Cholinergic Agonist effects Think: SLUDGE BAM Salivation/Sweating/Secretions Lacrimation Urination Defecation GI upset Emesis Bradycardia Abdominal Cramps Miosis Circulatory Checks Think: 5 P's Pain Paresthesia Paralysis Pulse Pallor Antipsychotic Drug side effects Think: ISHADE Impotence Sedation, Seizures Hypotension Akathsia (inability to sit still) Dermatological side effects Extrapyramidal reactions (acute, dystonias, rigidity, tremor, tachycardia) Signs of Inflammation Think: PRISH Pain Redness Immobility Swelling Heat Antimuscarinic/Anticholinergic side effects Think: ABCD'S Anorexia Blurry vision Constipation/Confusion Dry mouth Stasis of urine MAOI side effects Think: HAHA Hypertension/Hypertensive crisis Anticholinergic side effects Hepatocellular jaundice Arrhythmia/Anoxeria For better perfusion Veins & Arteries eleVate Veins dAngle Arteries APGAR means: APGAR measures: HR, RR, muscle tone, reflexes, and skin color each 0-2 point. A score: 8-10 is OK. A score: 0-3 RESUSCITATE. A= appearance (color all pink, pink and blue, blue [pale]) P= pulse (>100, < 100, absent) G= grimace (cough, grimace, no response) A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent) Airborne Precautions Think: My Chicken has TB! My - Measles Chicken - Chicken Pox/Varicella Hez - Herpes Zoster/Shingles TB - Tuberculosis) *Private Room - negative pressure with 6-12 air exchanges/hr Wear Mask, N95 for TB Droplet Precautions Think: SPIDERMAN! S - Sepsis, scarlet fever, streptococcal pharyngitis P - Parvovirus B19, Pneumonia, pertussis I - influenza D - Diphtheria (pharyngeal) E - Epiglottis R - Rubella M - Mumps, Meningitis, Mycoplasma, or Meningeal pneumonia An - Adenovirus Private Room or cohort Mask Contact Precautions Think: MRS. WEE M - Multidrug resistant organism R - Respiratory infection S - Skin infections W - Wound infection E - Enteric infection - clostridium difficile E - Eye infection- conjunctivitis [Show Less]
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MUST know for NCLEX Questions Answered 100% correct
airborne precaution MTV measles TB varicella droplet precauion SPIDERMAN Scarlet fever Sepsis Strepcoccal pharyngitis Parovirus B19 Pneumo... [Show More] nia Pertussis Dipheteria Epiglottis Rubella Meningitis Mumps Meningital pneumonia Adenovirus after lumbar puncture position supine After total hip replacement position No adduction No flexion Knee amputation post position supin 24 hr prone position for shock modified trendenberg head elevated, leg elevated 20 degree pancreatitis pain relief NO MORPHINE give merperidine NMS you get hot-hyperpyrexia sweaty-diphoresis stiff-increased muscle tone BP, pulse, RR go up drool fetal heart tone ventilator alarm HOLD High-obstruction Low-disconnection, leak tetralog of fallot DROP defect of septal Rright ventricular hypertrophy Overriding aorta Pulmonary stasis-cyanosis 1teaspoon= ?ml 1 tablespoon= ? ml 1 oz = ? ml 1 cup- ? oz F= 1 teaspoon= 5 ml 1 tablespoon=15ml 1 oz=30 ml 1 cup= 8 oz F=9/5C+32 med of choice for vtach lidocaine med of choice for CHF ace inhibitor first sign of cystic fibrosis meconium ileus at birh fontannels closes anteior-18month posterio-6-8 weeks Cranial nerves Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Auditory Glossopharyngeal-gag Vagus-ah Accesory-shoulder Hypoglossal-tongue 2-3 month 4-5month 6-7month 8-9 month 10-11 month 12-13 month 2-3 month=head side to side 4-5month-grasp, switch, roll 6-7month0sit and wave byebye 8-9 monthstand straight 10-11 monthbelly to butt 12-13 monthdrink from cup diaphragm stay in place 6 hr after intercourse fit if lose signaficant weight or annually Cushing triad IICP HTN, Bradycardia, irregular resp vit B6 with INH CSF in meningitis high protein low glucose test for protein-halo test alkalosis, acidosis with K alKaLOsis-K is LOW acidosis-K is high bc H is exchanged for K in cell vitamin B9 folic acid Vitamin B12 pernicious anemia backpain seen in labor ROP fetal face forward drainage post labor rubra 0-3 days serosa-4-7 alba 7019 coarctation of aorta bounfing pulse in upper extremity mantoux test 5mm-immunocompromised 10-normal 15-TB rare amniotic fluid color and pH alkaline-Blue-Rupture of membrane pink-acidic-normal vaginal discharge Crutch on stairs Good leg up Bad leg down Crutch goes before bad Maslow hierchy Physiological Safety Belong/love esteem needs Self-Actualization Coombs - mom Rh+ baby -Coombs give Rhogam 1 oz=?ml 30ml hypercalcemia Bones Moans-joint pain Groans-constipation Stones Overtones-confusion, depression osteoporosis polyuria, polydipsia hypocalcemia CATS convulsion arrythmia Tetany Stridor/spasm hyperkalemia MURDER Muscle cramps Urine abnormal Resp distress Decreasded cardiac EKG change Reflex change Hypokalemia ASICWALT alkalosis shallow resp irritability confusion weakness anorexia lethargy/fatigue thready pulse/hypotension Also v dysrhythmia hyperK and hypoK ecg hyper- T peak, Wide QRS hypo-ST depressed, U wave decorticate, decerebrate decorticate-Cortex Decerebrate-cerebellar, brain stem Multiple sclerosis hyperreflexia vision change spasticity post pituitary gland removal post thyroid gland removal pit: watch hypocorisol; Diabetes Insipitus thyroid: hypocalcemia-tingling Intussuception Hirschsprung pyloric stenosis Intuss-suasage like, jellylike stool Hirs-ribbon-like stool pylo-olive mass, projectile vomit pul capillary wedge pressure 8-13 acetaminophen 4000/day diet fo cystic fibrosis high Na Low fat ADEK pancreatic enzymes babinski sign toes curl-good toes fan-bad extraocular eye movement CN CN3,4,6 injection sites 6 month- vastus lateralis toddler more than 18 mont-ventrogluteal children-gluteus maximus, deltoid post lumbar puncture flat 2-3 hr post cerebral angiogram flat pre EEG no sleep-tired, more unusual activity post liver biopsy right side post laparoscopy walk to decrease CO2 buildup pyelogram assess allergy to shellfish, iodine rusty sputum pneumonia ashma SS wheezing on EXPIRATION preschool school-age kids pre school-ascribe to phenomenon. st is due to earlier misbehavior, imaginary friend, "why? school=5 and up; need explanation toddler dont give choice kawasaki cardiac aneurysm first intervention for authonomic reflexia elevate HOB anticholinergic effects Cant spit-dry mouth Cant shit-urine retention Cant poop-constipation Cant see-blurry vision Halo have screwdriver near keep neck, head in brace strabismus botox patch GOOD eye to get weak eye stronger humulin R, N R before N R-clear N-cloudy cloudy outflow in peritoneal dialysis need intervention indicate peritonitis MMR shot subq transesophagel fistula 3C's coughing cyanosis choking Continuous drooling SS fractured hip adduction flexion external rotation shortening tetanus risus sardonicus machine like murmur patent ductus arteriosus epiglotitis SS 3 D's drooling dysphonia dysphagia nagel's rule -3 month +7 days thrombophlebitis Virchow Triad venous stasis endothelial damage hypercoagulability fetus labor steps descent flexion internal rotation extension external rotation expulseion CO2 in IICP CO2 causes vasodilation-so Low Co2, low ICP WBC count Never Let Monkeys Eat Banana neutrophil Lymphocyte Monocyte Eosinophil Basophi Greater to Lower sickle cell crisis intervention IV fluid then O2 alcohol withdrawl syndorome treat give benzo -pam chlordiazepoxide Pulmonary wedge pressure CVP ICP MAP IIOP pupil length CPP Pulmonary wedge pressure= 6-12 (increase left Ventricular preload) CVP=2-4- (Increase=systemic V overload) ICP=5-15 MAP=70-105 IOP-10-21 pupil-3-5mm CPP- n>60-cerebral perfusion P (MAP-ICP=CPP) HELLP Hemolysis-jaundice, anemia Elevated Liver-high ALT, AST, NV Low Platelet-thrombycytopenia, aabnormal bleeding, prob DIC variation of gestational HPN malignant hyperthermia muscle ridigity hyperthermia hypercapnia treat with dantrolene=muscle relaxant due to general anethesia treatment for severe hyperkalamia 1. Ca gluconate stabilize myocardium 2. Insulin 3. polystyrene sulfonate 4. hemodyalisis TORCH dont give to pregnant- pregnant avoid Toxoplasmosis Other (parovirus V19, fifth disease, varicella zoster) Rubella cytomegalovirus Herpes simplex hallucination paranoid depressed orient to reliaty-I know voices ar real to you but I dont hear them. No argue paranois-present reality, acknowledge feeling depressed-give brief explanation-Dont overwhem client; avoid giving choices burn injuries hyperkalemia hyponatremia hypovolemia nonselective beta blocker propranolol nadolol Carvedilol dont give to asthma bc causes bronchospasm what causes increase in potassium ACE inhibitor ARBS spirolactone digoxin low K causes dig tox 0.5 to 2 only insulin given iV regular lithium tox GI-NV, diarrhea neuro-tremor, confusion, ataxia impetigo, strep, meningitis no contagious after 24 hr of abx cardiac tamponade muffled heart sound JVD pulsus paradoxus refeeding syndrome low PPM fluid overload, HF taking off PPE 1. take off gloves ( do not want anything to contaminate hair, face..) 2. goggles 3. gown 4. N95 respirator 5. hand hygiene [Show Less]
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NCLEX Review - Management of Care Questions Answered 100% correct
A client is being prepped for a surgical procedure and the nurse is reviewing the informed consent with the client. The client asks, "Is there any other wa... [Show More] y to take care of this without having surgery?" The nurse has a duty to first: 1) Reassure the client that the surgery is the best treatment option 2) Tell the client if they don't want the surgery, they don't have to have it 3) Notify the surgeon that the client has additional questions about alternatives to surgery 4) Call the surgeon and cancel the surgery until the consent form is signed 3 Rationale: The client has a right to an explanation of the treatment and its expected results, anticipated risks and benefits, possible alternative treatment options and all questions answered before a consent form is signed. Remember, the client is not asking you for your opinion. The client is asking about alternative treatments for the condition. Notify the appropriate health care provider if the client needs additional information that you cannot answer. Once the client has all the necessary information then they can decide not to sign the informed content and cancel the surgery. A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law? 1) Clinical specialty certification by an accredited organization 2) Complete and accurate documentation of assessments and interventions 3) Above-average performance reviews prepared by nurse manager 4) Sworn statement that health care provider orders were followed 2 Rationale: The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony). Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting. The new graduate nurse interviews for a position in a nursing department of a large health care agency that uses the approach of shared governance. Which of these statements best illustrate the shared governance model? 1) Staff groups are appointed to discuss nursing practice and client education issues 2) Non-nurse managers supervise nursing staff in groups of units 3) Nursing departments share responsibility for client outcomes 4) An appointed board oversees any administrative decisions 3 Rationale: Shared governance or self-governance is a method of organizational design. It promotes empowerment of nurses to give them responsibility for client care issues and outcomes with other divisions in the agency. The registered nurse (RN) and the unlicensed assistive person (UAP) are caring for clients on a surgical unit. Which action(s) by the UAP warrant immediate intervention? (Select all that apply.) 1) The UAP empties the indwelling catheter bag for the client who had a transurethral resection of the prostate (TURP) yesterday 2) The UAP applies moisture barrier cream to the client's excoriated perianal area 3) The UAP assists a client, who received an IV narcotic analgesic 30 minutes ago, to ambulate in the hall 4) The UAP applies a fingertip pulse oximeter on a client whose fingernail is painted dark blue 5) The UAP assists a client, who had a total knee replacement two days ago, to shave using a straight-edge razor 3, 4, 5 Rationale: The UAP can perform a number of nursing tasks, such as emptying an indwelling urinary catheter bag and applying moisture barrier cream after peri care. However, it is unsafe for the UAP to ambulate a client who recently received an IV push narcotic. Although UAP can shave clients, it is unsafe to shave someone using a straight-edge razor because a client who had knee replacement surgery is probably taking an anticoagulant; only an electric razor should be used. Pulse oximeter readings must be done on a finger that is warm and free from dark fingernail polish. An elderly client is admitted to a home care agency following hospitalization for exacerbation of heart failure. The client lives alone, has difficulty completing activities of daily living (ADLs) and is unable to drive. Reorder the steps in the case management process by dragging and dropping the options below. 1) Evaluation of progress towards client's goals 2) Referral to personal care attendant and transportation services 3) Assessment of biophysical and sociocultural considerations 4) Identification of nursing diagnoses 5) Reassessment of health status and ADL ability 3, 4, 2, 5, 1 Rationale: Case management is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs. A nurse has unintentionally given an incorrect dose of medication to their client. No harm was done to the client. What is the next action, if any, required by the nurse? 1) The nurse is not required to report the mistake because the client was not harmed 2) The nurse is not responsible for the mistake because they have not been provided current education by their employer 3) The nurse will immediately be suspended and their license will be revoked 4) The nurse will report the incident to their nurse manager and follow their organizational procedures for reporting 4 Rationale: Although the client was not harmed as a result of the mistake, the incident still needs to be reported. Nurses are responsible for their practice and for staying current and competent by becoming lifelong learners. In this case, neither an immediate suspension nor revoking a license are warranted. A nurse receives an illegible hand-written medication order. Which statement to the health care provider reflects appropriate assertive communication? 1) "Would you please clarify what you have written so I am sure I am reading it correctly?" 2) "Please print in the future so I do not have to spend extra time attempting to read your writing." 3) "I am having difficulty reading your handwriting. It would save me time if you would be more careful." 4) "I cannot give this medication as it is written. I have no idea of what you mean." 1 Rationale: Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information. All of the following clients are using morphine patient controlled analgesia (PCA) pumps and are two days post-op. Which client should the nurse check first? 1) 62 year-old following knee replacement surgery, BP 120/68, pulse 68, respirations 8 2) 79 year-old following tumor resection of shoulder head, whose reported pain level is 8 out of 10 3) 70 year-old following surgical repair of a femur fracture, no bowel movement since before surgery 4) 67 year-old following hip surgery, who just had a wound drain removed, with some bloody drainage on the dressing 1 Rationale: A surgical client using a narcotic PCA is at risk for respiratory depression, which is potentially life-threatening, and therefore the top priority. The other clients need assessment and attention, but the priority is given to the client with a respiratory rate of 8. Some bloody drainage on a dressing is expected after a drain is removed and of course the nurse would monitor this. Constipation is a side effect of narcotics but is not life-threatening. Pain control is also important but does not take priority over respiratory depression. The charge nurse is making assignment for the health care team. Which of these tasks can be safely delegated to the licensed practical nurse (LPN)? 1) Teach the initial ostomy care to a client and family members 2) Provide stoma care for a client with a well-functioning ostomy 3) Assess the function of a newly created ileostomy 4) Care for a recent complicated double barrel colostomy 2 Rationale: The care of a mature stoma and the application of an ostomy appliance may be delegated to a LPN. The condition of this client is stable, there's a low likelihood of any emergency and care of this client is not too complex. The other options require higher level care by the RN. The RN is the manager of care and is responsible for any initial teaching; the LPN can reinforce information once it has been introduced by the RN. The nurse manager is discussing the goals of total quality management (TQM) with the health care team. Which statement correctly identifies a key element of TQM? 1) All employees participate in systematically working toward common goals 2) It is a reactionary approach used to investigate the root cause of a problem 3) It is an incident management technique that focuses on employee retention 4) Top administrators are responsible for establishing plans for problem management 1 Rationale: TQM uses a strategic and systematic approach for continual improvement of processes, products, services and the workplace culture. The focus is on improving customer satisfaction. TQM involves all employees, not just top administrators. It is a proactive, not reactive, approach to solving problems. The client is two days post-op following a hip replacement and is not transferring well from bed to chair. The nurse checks and then confirms that the client is not progressing on any part of the mobility training program. What action is the nurse's priority? 1) Contact the family to discuss preoperative mobility problems 2) Discuss the problem with the client's surgeon 3) Instruct physical therapy to increase treatments to four times a day 4) Inform the case manager of the variance in the critical pathway 4 Rationale: Variances in the critical pathway need to be reported to the case manager. Certain goals need to be met to move the client forward in recovery and transfer to an appropriate venue for continued rehabilitation. The RN cannot order physical therapy treatment. Previous mobility problems are not priority post-operatively. The surgeon needs to be informed about the client's lack of progress, but this is not the priority. The nurse manager overhears a health care provider loudly criticize one of the staff nurses within hearing range of other staff and visitors. Which approach by the nurse manager is indicated in this situation? 1) Request an immediate private meeting with the health care provider and staff nurse 2) Notify the chief nursing officer about the breach of professional conduct 3) Walk up to the health care provider and quietly state: "Stop this unacceptable behavior." 4) Stay neutral and allow the staff nurse to handle this situation independently 1 Rationale: Assertive communication respects the needs of all parties to express themselves, but not at the expense of being in front of non-involved staff, visitors or clients. The nurse manager first needs to protect clients and other staff from this display of negative behavior and come to the assistance of the nurse employee. Privacy is a priority, as well as limiting the communication to only those involved. A client is admitted with a diagnosis of schizophrenia. The client refuses to take any medication and states, "I don't think I need those medications. They make me too sleepy and drowsy. I want you to explain their use and side effects of these medications." The nurse should respond with an understanding of which statement? 1) A referral is needed to the psychiatrist who should provide the client with answers to the request 2) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications 3) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication's uses and side effects 4) The client has a right to know about the use and side effects of the prescribed medications 4 Rationale: Clients have a right to informed consent, which includes detailed information about medications, treatments and diagnostic studies. The other options are incorrect approaches. A newly graduated nurse, who has recently completed orientation, voices concern about her assignment: "I have never taken care of anyone with a lumbar drain before." Which action would be most appropriate for the charge nurse? 1) Check with the nurse and the client often during the shift 2) Provide an immediate one-on-one, personal in-service about the drain 3) Assign the graduated staff nurse to be transferred to another floor for the shift 4) Change the assignment; reassign the client with the lumbar drain to a different nurse 4 Rationale: One of the first principles of safe assignments is to match skills with the task. New nurses should not be assigned tasks for which they are not competent. The assignment needs to be changed. The other options simply help support the nurse but may be dangerous for the client. And, of course, the new nurse will need training about caring for a client with a lumbar drain. The health care provider has finished writing admission orders for a client diagnosed with pneumonia and sepsis who has a history of type 1 diabetes. Prioritize how the nurse should complete the orders listed below (with 1 being the top priority). 1) Blood and sputum cultures 2) Oxygen 2 liters nasal cannula 3) Fingerstick before each meal and at bedtime 4) Ceftriaxone (Rocephin) 1 gram every 12 hours IVPB 5) IV normal saline at 100 mL/hr 2, 1, 5, 4, 3 Rationale: For establishing priorities, first look at the ABCs. Oxygen administration is the first priority (and the client's oxygen saturation is probably low given the patient has pneumonia). The next priority would be to have the lab come and draw blood for the cultures; this must be done prior to starting the antibiotics. Then an IV must be started (the antibiotic is ordered IV). Even though the patient is diabetic and it is dinner time, a finger stick is the last thing on the list to complete. A woman dressed in a business suit with no visible identification is at the nurses station looking at client charts. What nursing action is most appropriate? 1) Ignore the person; many outside vendors check charts to set up a transfer or to coordinate care 2) Report to the nurse manager about the witnessed suspicious activity 3) Request to see identification and an explanation as to why the woman is viewing client charts 4) Immediately call security for this breach in client confidentiality 3 Rationale: Nurses have a duty to protect the confidentiality of client records. In fact, HIPAA and other confidentiality laws require that nurses verify the identity and authority of individuals requesting information. Acceptable verification may include a photo ID and a copy of the documentation supporting legal authority to access information. The nurse needs to determine who the person is, ask to see a valid ID, and ask for the reason for reading the chart. Security may need to be called, but the nurse first needs more information. It is each nurse's duty to do this and no one should pass it off to a manager or ignore the situation. A registered nurse from the float pool is assigned to the critical care unit on the evening shift. Which of these clients should be assigned to the float pool nurse? 1) Report of unstable angina with continuous telemetry monitoring 2) Tracheostomy of 24 hours with the client showing some respiratory distress 3) Pacemaker insertion on the day shift 4) Dopamine IV drip with vital signs monitored every five minutes 3 Rationale: The nurse from the float pool should be assigned to care for the most stable client, which is the client who had the pacemaker inserted on the day shift. The other clients are unstable and have potentially life-threatening conditions. In most critical care units, the nurse can titrate dopamine upward or downward; this requires the expertise of the nurse who normally works on this unit. Although tracheostomies are not limited to critical care units, a nurse unexperienced in critical care should not be assigned to the client with a newly created tracheostomy. [Show Less]
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