NCLEX
Ca Channel Blocker
(-ipine/-amil) vasodilate and adverse effects (2) may cause increased heart failure slows movement of calcium into smooth muscle
What signs/symptoms would the nurse expect to assess in a client diagnosed with multiple sclerosis (MS)?
1. Fatigue 3. Blurry vision 4. Leg weakness 6. Electric shock sensation when bending neck forward
Patient with bacterial meningitis will present with what symptoms
1. Positive Kernig's sign 2. Positive Brudzinski's sign 4. Photophobia 5. Severe headache 6. Nuchal rigidity
nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding?
1. Regular rhythm 2. Rate of 101-200 3. P wave normal 5. QRS complex normal
Urine Specific Gravity
1.010-1.030 the higher it goes the more dehydration
Magnesium
1.3-2.1
Ammonia
10-80
The nurse is teaching a group of teenagers about decreasing the risk of developing skin cancer. What information should the nurse include?
2. A self-tanning product containing dihydroxyacetone (DHA) is safe to use. 3. Put on sunscreen every day, even on days when it is cloudy. SPF 15 or higher 4. Stay in the shade between 9 AM and 4 PM.
Total protein
6-8
Fasting glucose
70-110
Calcium
9-10.5
Chloride
98-106
Standard Precautions
A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious.
The nurse is discussing information on adolescent obesity with parents of high-school students. What statement by the nurse is most comprehensive regarding obesity among teens?
Adolescent obesity is usually an inability to recognize signals of hunger or satiety.
Partially compensated
All values are abnormal
Adenosine
Antiarrhythmic converts SVT to sinus Stops the heart and restarts
Amiodarone
Antiarrhythmic used for v fib and v tach
Atropine
Antidysrhythmic agent. Increases firing of the sinoatrial node (SA) and conduction through the atrioventricular node (AV) of the heart, opposes the action of the vagus nerve by blocking acetylcholine receptor sites. Used for bradycardia and known exposure to chemical nerve agent (AtroPEN).
AST, ALT, ALP, GTTF
Blood tests that help identify liver disorders AST 0-35 ALP 30-120 ALT 4-36 GTTF Male 0-65 Female 0-48
alpha2 agonists
Clonidine Methyldopa contrindicated with anticoags
Hypertonic
D10W D50W D5NS D5LR
Amylase
Enzyme in saliva that breaks the chemical bonds in starches 30-220
What should you watch in feeding tube patients>
Feeding tube clients tend to get dehydrated, especially clients on bed rest, because bed rest induces diuresis! If the client is already having neurological signs, a grand-mal seizure may be next! Better take seizure precautions while awaiting the serum sodium results.
Mycophenolate
Immunosuppressant/ organ transplantation ***notify doctor if any signs of infection occur***
What type of breathing does a patient display with respiratory alkalosis
Kussmauls
Airborne precautions
MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB
In any type of metabolic acidosis what is going to happen to the serum potassium level? Therefore, what is the major electrolyte imbalance that they will have, and what is the major side effect that they will have?
Metabolic acidosis increase the serum Potassium and that can cause ventricular tachycardia HEART ARRYTHMIA
What chemicals should come to mind when you think kidneys
PCo3 -bicarb
why do you have to worry about hypokalemia in the alkalotic patient? what life threatening complication can occur
Potassium goes down, low potassium leads to heart arrythmias
respiratory alkalosis causes
Primary cause: Hyperventilation (causes hypocapnia); Contributing Causes: Overventilation on a ventilator, Response to acidosis, Bacteremia, Thyrotoxicosis, Fever, Hepatic failure, Response to hypoxia, Hysteria
Early signs of hypoxia
RESTLESSNESS AGITATION TACHYCARDIA
If you have a client on a ventilator and the respiratory rate is set too high, will the client go into resp acidosis or alk?
Resp Alk they are expelling to much C02
Hyponatremia signs and symptoms
SALT Stupor/coma Anorexia Lethargy Tendon reflexes decreased LOSS Limp muscles Orthostatic hypotension Seizures/headache Stomach cramps
What measures renal function
Serum creatinine (0.6-1.2 male, 0.5-1.1 female) BUN 10-20 Creatinine clearance (90-139 male, 80-125 female)
Brudzinski's sign
Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.
Temp conversion
Temp x 1.8 + 32 cel to fah Temp x 1.8-32 fah to cel
Reverse Trendelenburg's position
The head of the bed is raised and the foot of the bed is lowered
The nurse is caring for a client taking digoxin. Which electrolyte imbalance should be of most concern?
The serum potassium level is monitored because the effect of digoxin is enhanced in the presence of hypokalemia and digoxin toxicity could occur
pernicious anemia
Vitamin B12 deficiency symptoms include -smooth red tongue -burning in feet -lightheaded dyspnea upon exertion
airborne, droplet, contact
What are the three types of transmission-based precautions?
WBC
White blood cells 5,000-10,000
Kernig's sign
a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down
aPTT
activated partial thromboplastin time 30-40 seconds
Ketones
chemical substances that the body produces when it does not have enough insulin in the blood 0----very bad
A1C
glycosylated hemoglobin 4.5-7....higher is poor diabetes management
What is the most important vital to monitor post MI
heart rate
HcT
hematocrit-percentage of erythrocytes in a volume of blood Female 37%-47% Male 42%-52%
What kind of diet should a patient with hypothyroidism be on?
high fiber, these patients will have constipation
Metabolic Alkalosis
high pH, high HCO3
LDL
low-density lipoprotein-bad l/s 130
What organ compensates for a metabolic imbalance?
lung
In respiratory alkalosis or acidosis what is the problem
lungs
What chemicals should you think of with the lungs
pH and Co2
What are the major acid/base chemicals? What organs control each
pH and PCo2 controlled by the lungs-acids HCo3 controlled by the kidneys-bicarb-base
Uncompensated
pH and one other value are abnormal.
Compensated
pH is normal
Homan's sign
pain in *calf upon dorsiflexion* of foot and may indicated thrombophlebitis
What organ does not like when the pH is messed up>
the kidneys, means the lungs aren't working
DASH diet
whole grains, fruits, veggies, low fat no high sugars, no high fat or high salt items
Total bilirubin
0.1-1.0
Discharge teaching for a mild concussion
1. Concussion symptoms may last anywhere from hours and days to weeks and months. 2. Return to the emergency department for worsening headache. 4. Avoid physical activities until released from care. 5. Awaken the client every two hours.
BUN
10-20
ACE inhibitor drugs
Captopril (Capoten), Enalapril (Vasotec), Enalaprilat (Vasotec IV), Fosinopril (Monopril), Lisinopril (Prinivil) produces vasodilation to decrease BP can cause angioedema used to treat hypertension, HF, MI
HgB
Hemoglobin and tells % of RBC's Female 12-16 Male 14-18
when someone is in respiratory alkalosis, what organ is going to compensate? with what chemicals are they going to compensate?
Kidneys will compensate with bicarb (hco3)
Respiratory Alkalosis
high pH, low CO2
dorsal recumbent position
the back-lying or supine position
Burn Fluid needs
weight in kilograms X fluid per hour (2-4ml) x total percentage burned 1/2 in first 8 hours, 1/2 over next 16 hrs Day 2: Half of Day 1 example: Patient weights 70 kilograms and has 40% of their body burned, the doctor has ordered 4ml IV solution, what is the total to be given in 24 hrs 70kg X 4ml=280 280 X 40(percentage burned)=11200 total in first 24 hours
Kawasaki disease
(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. signs and symptoms strawberry tongue high persistent fever erythema on palms and souls enlarged cervical lymph nodes The nurse should recognize strawberry tongue, high and persistent fever, enlarged cervical lymph nodes, and redness of the palms of the hands and soles of the feet as signs of Kawasaki disease. Kawasaki disease is an autoimmune disease in which the medium-sized blood vessels throughout the body become inflamed. Many organ systems, mainly those including the blood vessels, skin, mucous membranes, and lymph nodes, are affected. The most prominent signs are a high and persistent fever that is not responsive to normal treatment with acetaminophen or ibuprofen, extreme irritability, and the presence of a "strawberry tongue" caused by necrotizing microvasculitis.
Hypernatremia signs and symptoms
-thirst -elevated temp. -swollen dry tongue; sticky mucous membranes -hallucinations -lethargy -restlessness -irritability -seizures -pulmonary edema -twitching -nausea -vomiting -anorexia -increased pulse -increased BP
Which interventions should the nurse include for a client with sickle cell crisis who is experiencing pain?
. Massage affected areas gently. Support and elevate swollen joints. Monitor pain level by looking for BP, respiratory, and heart rate elevation. 6. Administer Normal Saline (NS) at 125 mL/hour. Apply warm, moist compresses to affected joints or other painful areas. Avoid use of ice or cold compresses. Warmth causes vasodilation and increases circulation to hypoxic areas. Cold causes vasoconstriction and compounds the crisis. The sickle cell client should not be kept from eating or drinking. Hydration is an important component of therapy. Dehydration promotes sickling process.
what are miotics
. Miotics are medications that cause pupillary constriction such as pilocarpine. The action of miotics are to increase aqueous fluid outflow by contracting ciliary muscle and causing miosis (constriction of the pupil) and opening of the trabecular network.
hypotonic solution
0.45% NS, 2.5% dextrose in 0.45% saline (d2.545%NS)
Creatinine
0.6-1.2
Isotonic
0.9% NS LR D5W
An alcoholic client has agreed to take disulfiram 250 mg PO daily. The nurse recognizes that education has been successful when the client makes which statements?
1. "If I decide to stop taking disulfiram, I should not ingest any alcohol for at least 2 weeks or I will have a reaction." 2. "I must read labels carefully so that I know that alcohol is not an ingredient." 4. "This medication is not a cure. I still need to attend therapy sessions." 5. "I should avoid eating a lot of chocolate while on this medication."
PT
11-12.5 seconds
Sodium
135-145
Platelets
150,000-400,000
Infant Milestones
2 months - holds up head 4 months - rolls from abdomen to back 7 months - sits alone 9 months - crawls 8 - 15 months - standing with support & walking neonate - palmer grasp reflex teething at 6 months
What is the minimal length of therapy time for TB
3 months of medication
Phosphorus
3-4.5
What should the nurse include when teaching a client diagnosed with Grave's disease who is scheduled to receive radioactive iodine?
3. Radioactive iodine will leave the body in urine and saliva within a few days. 4. You cannot receive radioactive iodine if you are pregnant.
Albumin
3.5-5
Potassium
3.5-5
What is a good technique to assess lung sounds in a 3 yr old with asthma
Assessing lung sounds requires a client to inhale and exhale while the nurse auscultates. The most efficient method is to have the child participate in a game that requires breathing in and out. Blowing a cotton ball across a table is an appropriate activity which can be easily understood by a 3 year old child and mimics a game that will encourage participation.
A client wishing to stop smoking receives a prescription for bupropion from the healthcare provider. What educational points should the nurse include regarding this medication?
Bupropion is an antidepressant medication prescribed for major depressive disorders and seasonal affective disorder. Bupropion is used to help people stop smoking by reducing cravings and other withdrawal effects. This medication can cause a false positive drug screening test so the client should inform the laboratory personnel that the client is taking bupropion. Nicotine patches or gum may be prescribed to further support smoking cessation treatment as bupropion is a nicotine free prescription. The client can continue to smoke for about 1 week after starting the medicine. A date to quit smoking during the second week of treatment is determined. The recommended length of bupropion therapy is seven to twelve weeks. Dont drink can cause seizures Common side effect is decreased sex drive
What developmental milestone does the nurse expect to see in an 18 month old toddler?
By the age of 18 months, the nurse would expect the baby to say and shake the head "no", point to a body part, drink from a cup, and point to what they want.
Antihypertensives Drugs
Calcium Channel Blocker ACE inhibitor Beta Blockers Vasodilators Alpha2 Agonists
A client is admitted for management of ulcerative colitis. What sign/symptom would be of immediate concern to the nurse?
Guarding is a completely involuntary response of the muscles. In other words, you have no control over it. It's a sign that your body is trying to protect itself from pain. It can be a symptom of a very serious and even life-threatening medical condition.
In respiratory acidosis, what happens to the Co2 level in you blood? What is causing the increase?
Increases due to slow shallow breathing
A client with a suprapubic catheter is admitted for surgery and requires a catheter change before that procedure. What is the most important action for the nurse to take prior to changing this catheter?
It is important to maintain the same catheter size as the one currently in use since the surgical opening does not increase in size like a urethral opening. If the balloon is too small, urine can leak through the opening. If the balloon is too big, urine will not drain properly, leaving residual and the potential for infection.
A client with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria and hematuria. The primary healthcare provider prescribes corticosteroids. During the acute phase of the client's illness, what is most important for the nurse to do?
Look at the clues in the stem. Proteinuria and hematuria. When you see proteinuria what do you need to worry about? The kidneys! Protein is a great big molecule. The only way for protein to be seen in the urine is if there are holes in the glomerulus. So the kidneys are being damaged. Thus, the nurse knows that the biggest problem to "worry" about here is renal failure. The best methods for monitoring fluid status and renal status for a client are to monitor I and O and daily weights. (Also, remember that one weight doesn't mean anything. The hematuria indicates that there has already been glomerular damage.)
In respiratory acidosis, what organ is not working correctly and what organ is going to compensate?
Lungs are not working and the kidneys will compensate
timolol maleate eyedrops for glaucoma
This medication decreases the production of aqueous humor
A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations?
Vaccines are suspensions of antigen preparations intended to produce a human immune response to protect the person from future encounters with the organism. Vaccinations will help your baby produce antibodies against disease causing organisms."
Anaphylaxis reactions
angioedema dyspnea
What vital do you monitor with hypovolemic shock
apical pulse
side effect of amiodarone
ataxia
Urine pH
average 6.0; range 4.6-8.0
what is the immediate treatment for respiratory alkalosis
breathing into a brown paper bag, get the Co2 back into the lungs
Beta Blockers
decrease heart rate and dilate arteries by blocking beta receptors, decrease the release of renin from the kidneys caution in asthma patients lol endings
When someone gets very acidotic, what happens to the LOC
decreases, they become sleepy and lethargic
What is the only way to lower Co2 in the body
exhaling
What should the nurse who is educating about the most common initial visual changes associated with glaucoma inform the client?
f glaucoma is not diagnosed and treated early, an individual starts to lose peripheral vision, or the area of vision outside the central field of sight. People who have glaucoma experience tunnel vision and cannot see objects to the side, near the head, or by their feet. Central vision can be lost later if the disease progresses.
FVD
fluid volume deficit -weight loss -dry mucous membranes -increased HR, RR -thready pulse -cap refill is less then 3 seconds -orthostatic hypotension -poor skin turgor -oliguria -decreased CVP -FLAT NECK VEINS
FVE
fluid volume excess -cough/dyspnea -increased BP -tachypnea -tachycardia -weight increased -bounding pulses -pitting edema -JVD -increased CVP
HDL
high-density lipoprotein-good male 40-160 female 35-135
What is the only way that you can have a build up of Co2 in your body?
improper exhalation
Ataxia
inability to perform coordinated movements
Diverticulitis
inflammation of the diverticula
Peramivir
influenza treatment It is an inhibitor of the influenza virus and is indicated for the treatment of acute influenza in clients over the age of 2 years who have been symptomatic for no more than 2 days. The dose of this medication needs to be decreased if the creatinine clearance of a client is less than 50 mL/min, so the nurse must know the prescribe creatine clearance level of this client prior to administering peramivir.
INR
international normalized ratio 0.8-1.1
What happens to the bicarb level in in resp alkalosis
it increases
If you have a patient in met acidosis what is going to happen to their respiratory rate and why
it is going to decrease and become shallow bc the kidneys are trying to help the lungs
What is going to happen to the bicarb level (HCO3) in respiratory acidosis
it will increase because it is trying to fight off to Co2
HIV patients can suffer from
kaposi sarcoma, encephalopathy, pulmonary candidiasis prevent spreading by disinfecting with bleach
what are ketones and how do they affect the blood
ketones are fat cells that break down into acid in the blood
In metabolic acidosis or alkalosis what is the problem
kidneys
in metabolic acidosis what organ is the problem and what chemicals are altered
kidneys-hco3
Total serum cholesterol
less than 200 mg/dL
If you have a client who is in acidosis do you want to retain Co2 or lose it
lose it
How does vomiting or NG tube suction cause met alkalosis
losing too many electrolytes
Respiratory Acidosis
low pH, high CO2
Metabolic Acidosis
low pH, low HCO3
Gout diet
low purine diet no alcohol no sodas eat fish monitor BMI smoking doesnt impact
Vasodilators
medications that cause dilation of blood vessels Rapidly drop BP
ABG numbers pH PaCO2 HCO3
pH 7.35-7.45 PaCO2 45-35 HCO3 22-26
In a metabolic problem what chemicals will be altered
pH and C02 bc the lungs are helping the kidneys
Lipase
pancreatic enzyme necessary to digest fats 0-160
Orthopnic position
patient is bent over a bedside table or in high fowlers
Torsades des Pointes
prolonged QT interval profound hypomagnesemia- treat with IV magnesium
What patient care should be included with a cirrhosis patient?
q2 turns keep in semi fowler position monitor the color of urine and stool monitor creatinine levels keep on a low salt diet, not low calorie
RBC
red blood cell Female 4.2-5.4 Male 4.7-6.1
what happens to the pH in met acid
retains to much hydrogen and excretes to much base
Droplet precautions
spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask)
When a patient has a high level of Co2 in their blood, what is going to happen to the oxygen level of their blood
the 02 is going to down
pulse pressure
the difference between systolic and diastolic blood pressure
Who compensates when you are in metabolic acidosis or alkalosis
the lungs
If a patient is in respiratory acidosis what is the primary thing that has to be done
the lungs need to be fixed, fix the Co2 level
In metabolic alkalosis, which organ is going to compensate
the lungs will compensate because the kidneys are not functioning properly
Sims position
the patient is lying on the left side with the right knee and thigh drawn up with the left arm placed along the back
Why do antacids cause metabolic alkalosis
they are bicarbonates
How can a anorexic or bulimic patient go into met acidosis
they are breaking down fat and protein and it is turning into ketones
In respiratory acidosis, howw is the patient breathing? And how does this affect the Co2 level in the blood?
they are breathing slowly and shallow and increases the Co2 in the blood
How can diarrhea cause metabolic acidosis?
too much acid, the GI tract is base
Uricemia
uric acid in blood excessive uric acid is GOUT
Can Co2 be a chemical that makes you sick and be a chemical that makes you compensate?
yes
can bicarb and hydrogen be chemicals that make you sick and be chemicals that make you compensate
yes
respiratory acidosis causes
• Depression of the respiratory center. (1) Head injuries. (2) Oversedation with sedatives and/or narcotics. • Conditions affecting pulmonary function. (1) COPD (2) Pneumonia. (3) Atelectasis. • Conditions that interfere with chest wall excursion. (1) Thoracic trauma: flail chest. (2) Diseases affecting innervation of thoracic muscle (Guillain-Barré syndrome, myasthenia gravis, polio). (3) Mechanical hypoventilation.
Acute MI symptoms
• chest pain (smothering) • neck, jaw, arm, back • nausea, vomiting, sweating, shortness of breath • syncope or aborted SCD • heart failure symptoms (LV dysfunction) • silent MI Women and Older adults with diabetes often report no pain
