A client reports to the nurse he has not had a BM in 2 days. Which intervention
should the nurse implement first?
A. instruct caregiver to offer a glass
... [Show More] of prune juice
B. notify HCP and request script for stool softener
C. Assess clients med rec and see normal BM pattern
D. Instruct caregiver to increase clients fluids to five 8 ounce glasses per day.
✅- C!! Always assess first. You dont know enough to ask for stool softener
A client who has COPD is resting in semi fowlers w/ O2 BNC 2L. The client
develops dyspnea. What action does the nurse take first?
A. Call HCP
B. Obtain bedside pulse ox
C. Raise HOB
D. Assess clients vital signs
✅- C!! B and D are the same-- that is a flag
A client who has hyperparathyroidism is scheduled to receive a prescribed dose of
oral phosphate. The RN notes that the clients serum calcium level is 12.5mg/dL.
What action should to nurse take?
A. hold the phosphate and notify the HCP
B. review clients serum PTH
C. Give PRN IV Ca
D. Admin oral dose of PO4
✅- D! Ca and PO4 have an inverse relationship
In completing a clients pre-op routine, the RN finds that the consent has not been
signed. The clients begins to ask more questions about the surgical procedure.
What action should the nurse take next?
A. Witness the client's signature on the consent
B. Answer the clients questions about the surgery
C. Inform the HCP that the client has questions about the surgery.
D. Reassure client that the surgeon will answer questions before anesthetic is
administered.
✅- C! The nurses role with surgical consent is to witness-- the HCP needs to
answer questions.
What foods do you avoid within 1 hour of taking iron?
✅- dairy and caffeine
Do you give injections to pt with edema?
✅- NO
living will ✅- a client documents his or her wishes regarding future care in the
event of terminal illness.
durable power of attorney
✅- a client appoints a representative (healthcare proxy) to make healthcare
decisions.
An awake and alert client with impending pulmonary edema is brought to the
emergency department. The client provides the nurse with a copy of a living will
that states that no invasive medical procedures should be used to keep her alive. the
healthcare team is questioning whether the client should be intubated. What
information should guide the teams decision?
A. the living will removes the obligation to involve the client in any medical decision
making.
B. The client is awake and alert, which makes the living will irrelevant and
nonbinding.
C. Lifesaving measures do not need to be explained to the client because of the signed
will.
D. The family should be contacted to determine who has durable POA for healthcare
for a client.
✅- B!! since the client is awake and alert, the living will is not indicated at the
time.
A family member of a client who is in a posey vest restraint asks why the restraint
was applied. How should the nurse respond? A. The restraint was prescribed.
B. There are not enough staff to keep client safe at all times.
C. The other clients are upset when the client wanders at night.
D. The client's actions place her at high risk for harming herself.
✅- D!!
What nursing action has the highest priority when admitting a client to a
psychiatric unit on an involuntary basis?
A. Reassure the client that the admission is only for a limited time.
B. Offer the client and family the opportunity to share their feelings about the
admission.
C. Determine the behaviors that resulted in the need for admission.
D. Advise the client about the legal rights of all hospitalized clients.
✅- C!! SAFETY FIRST!! You need to know why they are there. What if they are
there due to suicidal idealizations? you do not want to miss that.
The nurse enters the room of a preoperative client to obtain the client's signature on
the surgical consent form. Which question is most important for the nurse to ask
the client?
A. "When did the surgeon explain the procedure to you?"
B. "Is any member of your family going ot be here during surgery?"
C. "Have you been instructed in postoperative activities and restrictions?"
D. "Have you received any preoperative pain medications?"
✅- D!! It is MOST IMPORTANT because the client cannot sign if they have had
pain meds and she is there to obtain a signature.
The charge nurse confronts a staff nurse whose behavior has been resentful and
negative behavior has been resentful and negative since a change in unit policy was
announced. The staff nurse states, "Dont blame me; nobody likes this idea." What
is the charge nurse's priority action?
A. Confront the other staff members involved in the chane of unit policy
B. Call a unit meting to review the reasons the change was made
C. Develop a written unit policy for the expression of complaints
D. Encourage the nurse to be accountable for he own behavior
✅- D!! the democratic process of implementing a new policy has already taken
place and now it is time to address the nurses actions, not policy.
Which situation warrants an incident report by the nurse?
A. A client refuses to take prescribed medication
B. A client's status improves before completion of the course of medication
C. A client has an allergic reaction to a prescribed medication.
D. A client received medication prescribed for another client. ✅- D!! this could
cause harm to the client and it was by nurse error.
A charge nurse is making assignments for 5 clients. The nursing team has an RN, a
PN, and two UAPs. Which client would be assigned to the RN? A. A client from
the previous shift with unstable angina.
B. A client with a stage 3 pressure ulcer who needs a bed bath.
C. A client with an enteral feeding absorbing at 30mL/hr.
D. A cardiotomy client who is day 2 postop and who has chest tubes.
E. A client with quadriplegia for whom urinary catheterization has been
prescribed.
✅- A & D!!
72 yr old client returned from surgery 6 hours ago. Client received hydromorphone
2mg IV 30mins ago for a pain rating of 8/10. The family member requests the
nurse check on the client immediately. On arrival, the nurse finds that the client is
difficult to arouse, which a respiratory rate of 6. What is the priority nursing
action?
A. Elevate HOB
B. Admin naloxone 0.4mg IV
C. Assess breath sounds
D. Check vital signs and pulse oximetry.
✅- B!! the nurse has already done assessments and narcan is indicated.
The changes in ____________causes fluid shifts. ✅- osmolarity
The ECF osmolarity is almost entirely due to ✅- sodium
The ICF osmolarity is related to many particles, but the main one is
✅- potassium
The client who is HIV positive, asks why it is necessary to have viral load study
performed every 3 to 4 months. What would be the nurses best response?
A. To determine the progression of the disease
B. To evaluate the enzyme-liked immunobsorbent assay ELISA
C. To monitor the effectiveness of the treatment
D. To track the effectiveness of the vaccine
✅- C!! this is asking about VIRAL LOAD, which you check with HAART every
3 to 4 months.
alkaline phosphatase blood levels will be elevated with
✅- liver disease or metastsis to the bone or liver
calcitonin may be elevated when
✅- cancer of thyroid, breast cancer, and oat cell cancer of the lung
The charge nurse is assigning rooms for four new clients. Only one private room
available on the oncology unit. Which client should be placed in the private room.
A. the client with ovarian cancer who is receiving chemotherapy
B. The client with breast cancer who is receiving external beam radiation
C. The client with prostate cancer who has just had a TURP
D. The client with cervical cancer who is receiving intra-cavitary radiation.
✅- D!! someone with this is always exposing radiation to the external
environment
The CBC results for a client receiving chemo are hgb 5 and hematocrit 32%; WBC
count, 6.5X 109. which meal choice is best for this client?
A. Grilled chicken, rice, fresh fruit, milk
B. Broiled steak, whole wheat rolls, spinach salad, coffee
C. Smoked ham, mashed potatoes, applesauce, iced tea
D. Tuna noodle cassarole, garden salad, lemonade
✅- B!! they are anemic. This option gives iron in the meat and with the spinach to
help bind.
After the change of shift report, the nurse reviews her assignments. Which client
should the RN asses first?
A. the client receiving palliative care for heart failure who complains of constipation
and nervousness
B. The adult client who is 48 hours postop for a colectomy and is reported to be
having nausea and vomiting.
C. Middle age client with CRF whose urinary cath has been draining 95mL for 8
hours.
D. The client who is 2 days postop for a thoracotemy and has chest tubes, is on O2 at
3L, and has a respiratory rate of 12 breaths/min.
✅- B!! both acute and concerning and unexpected
The nurse is monitoring the status of a client recovering from an MI. Which
symptom indicates an evolving problem?
A. a steady pulse of 88 beats/min
B. Rising systolic pressure from 110 to 120mmHg
C. thee premature ventricular contractions/min
D. Central venous pressure of 8 mmHg
✅- C!! they may be going into v-tach and this indicates an EVOLVING
PROBLEM
Increases preload ✅- crystalloids and colloids
Decreases preload ✅- nitrates, diuretics, morphine
Increases afterload ✅- vasopressors
Decrease afterload ✅- ACE inhibitors and ARBS
Increase contractility ✅- dobutamine, dopamine, and digoxin
Decrease contractility ✅- beta-blockers, calcium channel blockers
Known side effect of ACE inhibitors (prils) ✅- coughing and anaphylaxis in
African Americans that is out of nowhere
Safety with ARBS (sartans) ✅- orthostatic hypotension
A client in shock develops a MAP of 60mmHg and a heart rate of 110 beats/min.
Which prescribed intervention should the nurse implement first?
A. Increase the rate of O2 flow
B. Obtain ABG
C. Insert an indwelling urinary catheter
D. Increase rate of IV fluids
✅- D!! MAP is low and HR is high! Not O2 bc can have a fluid imbalance
without resp depression
A client is admitted to the acute care unit with stable angina. At 7:00am the client
has had stable vital signs and is on 2L nasal canula. At 10:00am the client reports
chest pain as 6 on a scale of 1 to 10, is slightly diaphoretic and pale, blood pressure
is 100/52, and respiratory rate is 24. Which action will the nurse implement first?
A. Apply 4L O2 as ordered
B. Administer a fluid bolus of 0.9% NS
C. Administer the prescribed opioid for pain control
D. Obtain a full set of vital signs including temperature
✅- A!! Chest pain--- give O2 or increase O2 if already present!
A client with burn injuries has lost a significant amount of body fluid. An IV of LR
is infusing at 200mL/hr, with urine output for the past 8 hours is 400mL. Which
sign or symptom relates to early distributive shock?
A. Change in BP from 118/60 to 102/68
B. A change in LOC from awake to restless
C. A decrease in O2 saturation from 98% to 93%.
D. A decrease in urine output over 8 hours from 400 to 240 mL ✅- B!! EARLY
A client recovering from ARDS is awake and alert, has residual fatigue and
generalized weakness. His current VS are HR 83, blood pressure 104/64,
respiratory rate 25, SpO2 on 2L/min nasal oxygen air is 92%. Which value should
the UAP report immediately to the nurse?
A. HR of 88
B. BP of 104/64
C. Respiratory rate of 25 resps
D. SpO2 92%
✅- C!! they are recovering from ARDS, most related and this will tire them out
quicker
An elderly clients VS are 103F, HR 109, RR 37, BP 86/42. After an infusion of 1L
of 0.9 NS IV there are few changes in vital signs. The nurse assesses the client and
determines that more fluids would be appropriate based on which parameters?
select all that apply
A. Urinary output of 40mL in last hour
B. Central venous pressure of 5mmHg
C. HR increase from 109 to 129 when sitting
D. Peripheral pulse change from +2 to +1
E. MAP of 70
✅- A, B, C-- all pertain to fluid problems
A 22 year-old client is admitted through the ED with a 2 day hx of cough, fever,
and fatigue. The medical hx is positive for T1DM and recent URTI. Vital signs are
HR 109, BP 102/58, RR 24, temp 104, and SpO2 92% on 2L NC. Which is the
priority?
A. Initiate large bore IV
B. Draw 2 sets of blood cultures
C. Administer the ordered IV products
D. Draw serum lactate and glucose level
✅- B!! We are MOST concerned about what kind of infection this is. on NCLEX,
you pick what is most important, not what you do in practice in order, that is why A
is not right.
A client with a hx of uterine fibroids had a c section delivery 12 hours earlier and
delivered healthy twin girls. At shift change, the nurse assesses the client and notes
SOB, cool extremities, and oozing bood from the incision site. Based on the clients
presentation, what action is the highest priority?
A. assess temp
B. notify HCP
C. clean blood from incision site
D. draw labs for PT, PTT, CBC, fibrinogen ✅- B!! this is deadly, doc needs to
know ASAP
The cardiac monitor alarm goe off, and the nurse arrives to find the 59 year old
client slumped in the chair. Place the actions in order of priority
A. activate the code team and get defib
B. determine unresponsiveness
C. Assess rhythm using quick look paddles
D. Asses for a pulse ( carotid)
E. Open airways and give two rescue breaths by bag valve mask
F. Move the client to a flat position in bed or on the floor
G. Begin compressions ✅- B, A, D, F, G, E, C
Goal of triage ✅- START
simple triage and rapid treatment method
Four clients arrive in the ED after an explosion at an apartment complex. IN which
order should they be assessed?
A. 70 year old who is complaining of a pain level of 8/10 from a hand burn B.
35 year old with partial and full thickness burns to the anterior and posterior
chest
C. 25 year old with a superficial burn to the right anterior arm and lateral chest
D. 42 year old with a partial thickness burn to the anterior lower extremity and
confusion ✅- B, D, A, C
look at area that was burned. Further, shock is reversible in the first stage, and it is
indicated that D is in a later stage of shock, so B would be best to go to first
when you see burns think ✅- fluid status, hypovolemic shock
what do you treat anthrax poisoning with? ✅- cipro
Which precautions are used for anthrax? ✅- airborne, contact, droplet, and
standard
when you see v-fib, if you dont see an answer that says shake and shout, what do
you do? ✅- SHOCK EM
The nurse is caring for a client in shock of unknown etiology and observes the
above rhythm on the monitor. What is the nurses first priority?
A. check carotid pulse
B. Defibrillator the patient with 360 joules of energy
C. Administer an IV saline bolus
D. Give 2 breaths via Ambu bag ✅- B!! if its v-fib, Defib!! even if a lead was off,
you would not see v fib on a monitor. the monitor is a sure sign for v fib.
how much drainage from a chest tube in one hour should be concerning enough to
contact the hcp? ✅- more than 70mL/hr
chest tube dislodgement interventions ✅- 1. cover with dry, sterile dressing 2.
if air leak is noted, tape the dressing on three sides only to allow air to escape
and prevent tension pneumothorax
3. urgently notify hcp
A client who is 1 day postop from a left pneumonectomy is lying on their right side
with the HOB elevated 10 degrees. The nurse assesses his resp rate at 32
breaths/min. What action should the nurse take first?
A. further elevate HOB
B. assist the client to a supine position
C. measure the clients O2 sat
D. administer IV PRN morphine ✅- B!! when the pt is in distress, do not assessACT! also they should NOT BE ON THEIR SIDE
penicillins pt teaching ✅- allergies??, may get rash, GI problems common
tetracycline pt teaching ✅- avoid dairy, photosensitivity, and they stain teeth
aminoglycosides (gentamycin and vanc) pt teaching ✅- ototoxic, nephrotoxic, and
hepatoxic
cephalosporins (ceftriaxone) pt teaching ✅- are you allergic to PCN?? (can have
anaphylaxis)
macrolides (clarithromycin)pt teaching ✅- GI issues
fluoriquinolones (cirpoflaxin) pt teaching ✅- tendon rupture
inhaled anticholinergics ✅- ipratropium and aclidinium bromide
beta 2 agonists work on ✅- the lungs, but can also have cardiac effects
LABA ✅- salmeterol
The nurse palpates a crackling sensation of the skin around the insertion site of a
chest tube in a client who has had thoracic surgery. What action should the nurse
take?
A. Return the client to surgery
B. Prepare for insertion of a larger chest tube
C. Increase water-seal suction pressure
D. Continue to monitor the insertion ✅- D!! watch it to make sure it doesnt get
bigger! crackles at the site are okay unless it enlarges
The nurse is preparing to administer a Mantoux test to a client who is entering
nursing school. Which action by the nurse is of highest priority? A. Prepare
0.1mL soln per tB syringe.
B. Assess the skin condition on the forearm.
C. Teach the client about positive findings.
D. Inquire about bacillus Calmette-Geurin vaccine history ✅- D!! this vaccine has
a bad interaction with the tb injection.
Tb interventions ✅- airborne preacution isolation, single occupancy room with
neg pressure and air flow 6-12 exchanges per hour, wear high efficiency particulate
air (HEPA) masks, and notify public health department
Tb medications ✅- INH, rifampin, pyrazinimide, ethambutol.
-will take for a long time
- take all doses
- your secretions (urine, tears, etc) may turn orange or blue
- may cause GI irritation
- may cause joint pain
- do not use alcohol
-hepatotoxicity- do LFTs
-decreased red-green discrimination
A client who is receiving a transfusion of PRBCs has an inflamed IV site. Which
action should the nurse take?
A. Double check the blood type of the transfusing unit of blood with another nurse.
B. Discontinue the transfusion and send the remainng blood and tubing to the lab.
C. Immediately start another IV at another site and resume the transfusion at the
new site.
D. Continue to monitor the site for signs of infection and notify the HCP ✅- C!!
don't keep an inflamed site, always change that! it doesn't take much time and
ensures safety. Further, this is not a systemic reaction, it is just irritation, so not an
emergency reaction.
CABG pt teaching ✅- get up and walk ASAP. may have a chest tube. pain
management. splint coughing
left sided heart failure manifestations ✅- dyspnea, cough, orthopnea, pulmonary
edema, paroxysmal nocturnal dyspnea, tachycardia, S3 gallop
right sided heart failure manifestations ✅- dyspnea on exertion, fatigue, weight
gain, fluid retention, JVD, peripheral or sacral edema
The nurse is administering 0900 medications to three clients on a telemtry unit
when the UAP reports that another client is complaining of a sudden onset of
substernal discomfort. What action does the nurse take?
A. ask the UAP to obtain the clients vital signs
B. asses the clients discomfort
C. advise the client to rest in bed
D. observe the clients ECG pattern ✅- B!! always assess first! you go back, not
the UAP, you need to see for yourself
the only shockable rhythms ✅- v-fib and pulse less v-fib
valvular heart disease always ends in ✅- HF- so look for symptoms of HF
The nurse has just received report on four clients. Which client should the nurse
assess first?
A. a client with pericarditis with pain relieved by leaning forward
B. A client with fractured ribs with pain reported at 8/10 on a scale of 1 to 10
C. A client with stable angina who is awaiting discharge instructions
D. A client with HF who needs transporting or an echocardiogram ✅- A!! yes,
sometimes these patients get relief from leaning forward, but you need to
further evaluate this finding because it can indicate cardiac tamponade.
pericarditis is the most serious diagnosis here
PAD S/S ✅- smooth, shiny skin;loss of hair
pallor on elevation weak or
absent peripheral pulses
sharp or tingling pain cool to touch cap refill
>3sec intermittent claudication (classic
symptom) painful nonedematous ulcers that
are rounded bruits
venous arterial problems S/S ✅- bronze-brown pigmentation
normal peripheral pulses warm to touch
slightly painful ulcers with marked edema
cap refill <3sec pruritis
PAD interventions ✅- bed rest, extremity kept below level of heart, topical
antibiotics, antiplatelet drug (Cilostazol), surgical grafting
venous arterial disease interventions ✅- wound care, diet that promotes healing
(zinc, vitamins A/C), compression stockings day and evening, teach client to
elevate legs at least 20 minutes 4-5times per day
who gets dumping syndrome? ✅- one third to one half of clients following
surgery for peptic ulcers or gastric bypass
chrons disease ✅- -can occur anywhere along the GI tract, areas impacted have a
cobblestone appearance, symptoms include RLQ pain, nausea and vomiting,
weight loss, fever, dehydration steatorrhea, 3-4 stools per day, no blood present in
stool, unexplained anemia
ulcerative colitis ✅- confined to mucosa and submucosa of the colon. S/S include
blood diarrheal liquid stools, electrolyte imbalance, fever, tachycardia, abdonminal
cramping, anemia
pt teaching with UC ✅- elemental diet high in calories without lactose!!
pt teaching with chrons ✅- low residue diet, high proteins, high calorie, lots
fluids, and get vitamin B12 shots
The graduate nurse is teaching a pt about Chron's disease. The new nurse is correct
in identifying what complications as being the result of cobblestone lesions of the
small intestine?
A. malabsorption of nutrients
B. Severe diarrhea 15-20 per day
C. high probability of developing intestinal cancer
D. an inability of the body to absorb water ✅- A!! dont have severe diarrhea with
chrons, water is absorbed in the colon
a common complication of cirrhosis that can cause esophageal varices ✅- portal
hypertension
to avoid rupture with an esophageal varice- give this drug ✅- propanolol
manifestations of acute pancreatitis ✅- PAIN in LUQ, can radiate to back, sudden
onset, flushing, cyanosis, dyspnea, N/V, low grade fever, jaundice, Grey Turners
spots (bluish flank discoloration), cullens sign (a bluish periumbilical
discoloration), hypotension, tachycardia
A client who has an obstruction of the common bile duct caused by cholelithiasis
passes clay-colored stools containing streaks of fat. What action should the nurse
take?
A. auscultate for diminished bowel sounds
B. send a stool specimen to the lab
C. document the assessment in the chart
D. notify the HCP ✅- C!! this is expected
The nurse is caring for a client with peritonitis. Which information should the nurse
report immediately to the HCP?
A. BP reading of 92/64, 110/70, 100/68 over past hour
B. Urine output of 300mL over past 8 hours
C. Rebound tenderness and pain client rates as a 7/10
D. Dry mucous membranes and nausea ✅- C!! this indicates a possible
perforation. pain is expected, but this is high. BP is normal for this pt indicated by
the serial BPs
drugs used for bladder spasms (antispasmodics) ✅- bentyl (dicyclomine
hydrochloride) and ditropan (oxybutynin chloride)
AKI oliguric phase labs ✅- decrease urine output(less than 400mL), sodium, pH
increase BUN/Cr, K, urine sodium
AKI diuretic phase labs ✅- increase urine output
decrease fluid volume, K, Na, Urine specific gravity, urine sodium
early stage CKD ✅- polyuria and renal insufficiency
end stage CKD ✅- anuria (less than 100 mL in 24 hours)
renal diet ✅- low protein, sodium, potassium, and phosphate
orlistat ✅- blocks fat breakdown in GI tract and is used with a reduced calorie diet
to treat obesity
hyperthyroidism Graves Disease CMs ✅- enlarged thyroid, exopthalmos, weight
loss, T3 elevated, T4 elevated, diarrhea, tachycardia bruit over thyroid
diet for hyperthyroidism ✅- high protein and calorie, low caffeine and fiber
what electrolyte is low after thyroidectomy? ✅- calcium!! have calcium gluconate
at the bed side
hypothyroidism (Hashimotos) CMs ✅- fatigue, bradycardia, weight gain,
constipation, periorbital edema, cold intolerance, low T3 (less than 70), low T4
(less than 5)
Addisons disease (lack of adrenal hormones) CMs ✅- progressive weakness,
weight loss, N/V, hypovolemia, hypoglycemia, hyponatremia, hyperkalemia, loss
of body hair, postural hypotension, hyperpigmentation
Cushings Syndrome (excess adrenal hormones) CMs ✅- moon face/edema of
lower extremities, flat affect, irritability, anxiety, depression, psychosis, truncal
obesity, abdominal striae, buffalo hump, muscle atrophy, weakness, thin dry pale
skin, hypertension, osteroporosis, immunosuppresion, hiritsuism, hyperglycemia,
hypernatremia, hyocalcemia and hypokalemia
cushings triad ✅- 1. widening pulse pressure
2. slowing heart rate with full bounding pulse
3. slowing and irregular respirations
The nurse is planning a class on stroke prevention for clients with htn. What is
most important information to provide to the class?
A. salt restriction diet
B. Weight reduction
C. Medication compliance
D. Risk for stroke ✅- C!! the largest risk for stroke in pt with htn is
noncompliance with medication. D is incorrect because this is not a prevention
strategy.
During evaluation, which assessments indicate an early sign of increased ICP for a
client newly diagnosed with a CVA? select all that apply
A. alteration in ability to respond to questions
B. alteration in ability to respond to verbal stimuli
C. consensual response of pupils
D. HR 50, BP 192/60
E. Drooping of the mouth on one side ✅- A&B!! not D because cushings triad is
a late sign
carbidopa-levodopa pt teaching ✅- -take at bedtime
- apply sunscreen if outdoors
-keep hydrated & monitor I/Os-- can cause renal insufficiency
- take with meals
- do not take with food high in protein or vitamin B6
anticholinergic pt teaching ✅- urine retention
antihistamine pt teaching ✅- sedation
MAOI pt teaching ✅- do not ingest thiamine will case htn crisis
what do interferons do? ✅- immunodmodulators--increase immunity
CNS stimulant pt teaching (metylphenidate and modafinil) pt teaching ✅-
palpitations/anxiety
myasthenia gravis assessment for myasthenia crisis ✅- facial muscle weakness,
loss of expression, choking, regurgitation of fluid, slurred speech, jaw drop, fine
motor movement issues (handwriting, walking, stairs), diploplia, positive tensilon
test
what to give for myasthenic crisis ✅- neostigmine
injury above C8 ✅- quadriplegia/tetraplegia
injury above T6 ✅- Possible hypotension and bradycardia & possibility of
autonomic dysreflexia
DMARDS ✅- anti-rheumatic drugs. make sure they are not allergic to sulfa drugs.
They need folic acid with methotrexate. Cannot take methotrexate when pregnant
Bouchard's nodes ✅- Osteoarthritis (PIP swelling 2° to osteophytes)
Heberden's nodes ✅- Osteoarthritis (DIP swelling 2° to osteophytes)
glaucoma ✅- clogged drainage channels, increased intraocular pressure, decrease
aqueous humor flow, loss of peripheral vision, may see halos around lights
cataracts ✅- clouding or opacity of the lens due to trauma, aging, or genetic
defect. Early signs include blurred vision and decreased color vision. Late signs
include double vision and clouded pupil.
The nurse is teaching an 86 year old client who has glaucoma and bilateral hearing
loss. Which intervention should the nurse implement?
A. Maintain constant eye contact
B. Stand on the side unaffected by gluacoma
C. Speak in a lower tone of voice
D. keep the environment dimly lit ✅- C!! they have sensioroneural hearing loss,
therefore they cannot hear high toned voices.B not right because glaucoma has
decreased peripheral vision
ototoxic drugs ✅- gentamicin, vancomycin, and lasix
What is a contraindication to getting a throat culture on a client? ✅- epiglottitis bc
it can block airway
first sign of CF at birth ✅- meconium ileus
when do you withhold digoxin in a child? ✅- when apical pulse rate is less than
90-110 at rest
A school age child with nephrotic syndrome has just received hemodialysis. Which
assessment is most important to obtain after hemodialysis?
A. pain assessment
B. Capillary refill
C. Urine ketones
D. Daily weight ✅- D!! most important!!
Normal weight gain in pregnancy ✅- 23-35lbs
1-2kg in first trimester
0.5kg in 2nd and 3rd trimester
where is the fundus immediately after delivery? Where is the fundus within 12
hours of delivery? 10days? ✅- after: several centimeters below umbilicus
12 hours: fundus rises to umbilicus
10 days: fundus below symphysis pubis ans should be midline and firm
magnesium sulfate ✅- Tocolytic. Side effects: warmth, flushing, respiratory
depression, diminished DTRs, decreased urine output, pulmonary edema. Monitor
VS and DTRs, monitor magnesium levels (therapeutic range 4-8 mg/dL),
administer via infusion pump in diluted form, use indwelling catheter to monitor
urinary elimination. ANTIDOTE= calcium gluconate
abruptio placentae ✅- premature separation of the placenta from the uterine wall.
concealed bleed, painful, board like abdomen, abnormal FHR
placenta previa ✅- the abnormal implantation of the placenta in the lower portion
of the uterus. Bright red vaginal bleeding, painless, ok FHR, do not do any
manipulating exams
when do you take TCAs?(venlafaxine, impiramine) ✅- at night because they
cause sedation... may also be used for insomnia
A client diagnosed with bulemia is admitted to the mental health unit. What
intervention is most important for the nurse to include in the initial treatment plan?
A. Observe the client after meals for purging
B. Assess daily weight and vital signs
C. Monitor serum potassium and calcium
D. Provide a structured environment at mealtime ✅- C!! MOST IMPORTANT
serotonin syndrome ✅- Similar to NMS but caused by serotonin medications, and
has HYPERreflexive muscle activity, hyperthermia, cognitive impairments
Lithium toxicity ✅- 2 or greater, tremors, metallic taste, severe diarrhea, number
one intervention, give fluids, if sweating give electrolytes too
antipsychotic drug side effects/adverse effects (Haldol) ✅- EPS, Anticholinergic,
Neuromalignant syndrome
acetaminphen (tylenol) ✅- non-NSAID pain relief. monitor liver and kidneys.
antidote=acetylcysteine
NSAIDS ✅- ibuprofen (Motrin), salicylates (Aspirin), ketorolac-- do not give to
pt who has recently had heart surgery. hepatotoxic
PCA pump considerations ✅- it is important to determine if clients are using
herbal remedies and you need to notify HCP if they are
ECF excess causes ✅- HF, aldosterone or glucocorticoid excess, acute or chronic
oliguric renal disease, cirrhosis
Lab findings in ECF excess ✅- hemodilution-- decreased hematocrit, decreased
BUN below 10
ECF volume deficit causes ✅- inadequate intake, blood or plasma loss, burns,
vomiting, diarrhea, adrenal insufficiency (deficit of cortisol and aldosterone)
ECF volume deficit symptoms ✅- sudden weight loss (overnight), postural
hypotension, tachycardia, thready pulse, dry mucuous membranes, poor skin
turgor, slow vein filling, flat neck veins when supine, dark yellow urine
ECF volume deficit lab findings ✅- hemoconcentration-- increased hematocrit,
BUN above 25, increased urine specific gravity unless renal cause
sodium function ✅- skeletal muscle contraction, cardiac contraction, nerve
impulse transmission, normal osmolarity and volume of the ECF.
S/S of hyponatremia ✅- weakness, anorexia, muscle cramps, confusion, fatigue,
headache, and seizures
S/S of hypernatremia ✅- dry mucous membranes with thick mucus, low urinary
output, firm rubbery tissue turgor, restlessness, agitation, confusion, flushed skin
Tx of hypernatremia ✅- no IVs that contain sodium, restrict sodium in diet, weigh
daily
potassium function ✅- maintains resting membrane potential of skeletal, smooth,
and cardiac muscle, allowing normal muscle funciton; regulates cell metabolism of
carbohydrates and proteins and controls hydrogen ion concentration
hypokalemia (less than 3.5) causes ✅- excessive use of potassium free IV
solutions, alkalosis, acute or chronic diarrhea, vomiting, or other GI loss, use of K
wasting diuretics, aldosterone excess, polyuria, glucocorticoid therapy
S/S of hypokalemia ✅- bilateral muscle weakness that begins in quadriceps and
may ascend to respiratory muscles, abdominal distension, decreased bowel sounds,
constipation, dysrhythmias
foods high in potassium ✅- oranges, bananas, apricots, cantaloupe, legumes, leafy
greens, potatoes, mushrooms, tomatoes, carrots, meat.
hyperkalemia S/S ✅- MURDER Muscle weakness, Urine (olig, anuria) Resp
depression, decreased cardiac contractility, ECG changes, reflexes
hyperkalemia causes ✅- M.A.C.H.I.N.E. M
- Medications - ACE inhibitors, NSAIDS
A - Acidosis - Metabolic and respiratory
C - Cellular destruction - Burns, traumatic injury
H - Hypoaldosteronism, hemolysis
I - Intake - Excesssive
N - Nephrons, renal failure
E - Excretion - Impaired
treatment of hyperkalemia ✅- C BIG K: calcium gluconate, bicarbonate insulin
glucose, Kayexalate, beta-agonists
calcium function ✅- maintains bone strength, activates enzymes, allows
skeletal/cardiac muscle contraction, controls nerve impulse transmission, allows
blood clotting
hypocalcemia ✅- decreased intake and absorption(vitamin D deficient) ESRD,
diarrhea, laxative use, steatorrhea. Shift of calcium to bone (hypoparathyroidism,
hyperphospatemia, hypoalbuminemia, alkalosis.
S/S hypocalcemia ✅- Chvostek/Trousseau sign
Petechiae
Paresthesias
Cardiac arrhythmias
Increased HR
treatment of hypocalcemia ✅- ca supplements, ca gluconate, encourage dairy,
keep tracheotomy tray and resuscitation bag at bedside in case of laryngeal spasms
calctonin, renal dialysis ✅- reduces serum calcium
magnesium function ✅- skeletal muscle contraction, carbohydrate metabolism,
ATP formation, vitmain activation, cell growth
hypomagnesemia causes ✅- alcoholism, malabsorption, DKA, diuretics
hypomagnesemia S/S ✅- muscle weakness, hyperactive DTR, numbness and
tingling, painful muscle contractions, decreased GI motility
why do we give mag with IV pump ✅- bc rapid administration an cause cardiac or
respiratory arrest
foods high in magnesium ✅- Avocado
Canned white tuna
Cauliflower
Green leafy veggies, spinach and broccoli
Milk
Oatmeal
Peanut butter
Peas
Pork/Beef/Chicken
Potatoes
Raisins
Yogurt
hypermagnesemia causes ✅- renal failure, adrenal insufficiency, excess
replacement
hypermagnesemia S/S ✅- bradycardia, peripheral vasodilation, hypotension,
prolonged PR with widened QRS, decreased to absent DTR
pt teaching with mag ✅- if you have CKD limit intake!! if emergent ca gluconate
or ca chloride given IV
normal PCO2 ✅- 35-45
normal bicarb ✅- 22-26
HAART goals ✅- reduce viral load, maintain or raise CD4 count, delay
development of symptoms and opportunistic infections.
HAART mangament ✅- get regular blood counts to check viral load and CD4, do
LFTs and check GI symptoms
Amphotericin B ✅- anti-fungal. HIGHLY TOXIC
- infusin rxns (fever and chills)
-swish before swallowing oral form
- nephrotoxicity
- hypokalemia
- hepatoxicity
- gynecomasita
- C/I with aminoglycosides (just like PCN)
mammogram age ✅- at age 40
pap smear ✅- 21-29 ever 3 yrs, 30-65 every 5 years
colonoscopy ✅- every 10 years after 50
DRE ✅- at 50
stage 1 of shock ✅- MAP drops 10mmHg, increased HR & RR, agitation, restless,
cool pale skin
stage 2 of shock ✅- narrowing pulse pressure, increased HR, oliguria, pulse ox
90-95
sage 3 of shock ✅- confused, edema, anuria, dysrthmia, weak and thready pulse,
clammy skin, pulse ox 75-80
stage 4 of shock ✅- rapid LOC change, slow, shallow respiration, profound
hypotension, unresponsive to vasopressors, decreased HR, MODS< severe
hypoxemia/acidosis
cardiogenic shock ✅- pump problem- MI
distributive/vasogenic shock ✅- infection/anaphylaxis- excessive vasodilation and
fluid redistribution
obstructive shock ✅- pericarditis or cardiac tamponade
continuum of shock ✅- infection- bacteremia- sepsis- severe sepsis- septic shockMODS
SIRS reccognition ✅- temp above 100.4 or less than 96.8, HR over 100, RR more
than 20 or PaCO2 less than 32, WBC less than 4000 or more than 12000
septic shock characterization ✅- sepsis not responsive to fluid resuscitation
ARDS assessment ✅- hypoxemia, dyspnea, tachypnea, crackles, increased WOB,
early respiratory alkalosis, late respiratory acidosis, pleural effusion, decreased CO,
cyanosis
positioning for ARDS ✅- prone to shift perfusion from posterior bases of lungs to
anterior
ACLS ✅- determine unresponsiveness, call for help, check pulse (no pulse), 30
compression,, 2 airway, AED paddles, resume 30:2, admin epi
secondary level of preparedness ✅- conducting triage, treatment, shelter
supervision
primary level of preparedness ✅- conducting drills, planning, educating
what does a chest tube do? ✅- -drains the intrapleural space and mediastinum
-fluid or air
-creates negative pressure
-atelectasis
-pneumothorax
-pleural effusion
-empyema
-open-heart surgery
chest tube management ✅- -Tidalling SHOULD occur: Ball in water seal chamber
moves up and down with pt.'s inspiration and expiration, increase in water level
with inspiration, a return to baseline level during exhalation
-Bubbling in water seal chamber indicates AIR LEAK
-Bubbling in suction chamber is NORMAL
-NEVER CLAMP CHEST TUBE: Can increase positive pressure within the lungs
and collapse the lungs even more
-ONLY clamp chest tube if tube was severed, or if changing collection system or
when removing chest tube to see if pt. can handle no chest tube in place
-Ensure drainage system is BELOW the level of the chest
-Reposition the patient every 1.5-2 hours (promotes drainage
-Make sure the tubing is patent at all times
COPD ✅- emphysema and chronic bronchitis
breath sounds for bronchitis ✅- crackles, rhonchi, expiratory wheezes
breath sounds for emphysema ✅- distant, quiet, wheeze
which do you give first, heparin or warfarin? ✅- heparin because it works so
much faster, but use warfarin for longer
herparin reversal agent ✅- protamine sulfate
warfarin reversal agent ✅- Vitamin K
statins ✅- cholesterol lowering drugs- look out for rhabdo, liver probs, DM, [Show Less]