NCLEX wrong answers

Vitamin D rich foods

- oily fish, egg yolks, fortified milk,

sinusoidal fetal heart rate pattern

-classically occurs with severe fetal anemia Repetitive wave like, non fluctuating with no variability Requires immediate intervention May need intrauterine resuscitation or rapid delivery

Renal system exam steps

1. Empty bladder 2.inspect skin and contour of stomach and lower back 3.auscultation of renal arteries 4.percuss and palpate Document

What complication is most concerning during sickle cell crisis

1. Enlarged spleen ( could mean spleenomegaly, leading to rupture and major blood loss, 2. Arm weakness or facial drooping (stroke)

Introduction of solid foods age

4-6 months, introduce separately,

A symptomatic blood glucose in infants

>35, initially treat with feeding

Ovarian cancer symptoms

ABDOMINAL BLOATING PELVIC PAIN OR PRESSURE early satiety abdominal, back, or leg pain urinary urgency/frequency gi disturbances Usually in older adults

HTN medication to avoid during pregnancy

ACE inhibitors ex. Lisinopril

Oxytocin risks for patients

Abnormal or indeterminate fetal heart rate patterns, post partum hemorrhage, uterine tachysystole

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy which of the following instruction should the nurse include to prevent dumping syndrome select all that apply

Add high-protein foods to diet, eat small frequent meals, lie down after eating

lead poisoning

Affects the neurologic system, hyperactivity, impulsiveness, developmental delays, reading difficulties, visual motor issues, seizures, blindness, death

Precautions for chicken pox

Airborne and contact precautions

Appropriate nursing actions for postmortem care

Allow family to assist, gently close eyes, place pad under perineum

Myasthenia Gravis Treatment

Anti-cholinesterase drugs before meals to strengthen swallowing muscles, soft easily chewed food inappropriate vaccinations

Clopidogrel (Plavix) Assessments

Assess for; bruising tarry stools platelet levels signs of bleeding

Nursing actions during IV vancomycin administration

Assess skin for flushing or red rash on face and torso, infuse over at least 60 minutes, monitor blood pressure, observe IV site every 30 minutes

spontaneous abortion

Avoid sexual intercourse and tampons as prescribed for about two weeks, report foul smelling vaginal discharge heavy vaginal bleeding and severe pain, continue for your vitamins with iron anemia caused by the blood loss and use ibuprofen to alleviate cramping

What needs to be controlled for a arteriovenous malformation

BLOOD PRESSURE, high risk for intracranial bleeds, hemorrhage, severe headache, N/V are first signs of hemorrhage

V-tach

Can be pulse less or have a pulse, always check pulse first

Indications for an isotonic IV fluid

Capillary refill more than three seconds in modeling pre-dehydration before an epidural in adequate urine output and tachycardia from hyper emesis

Penicillin allergies can also cause allergies with

Cephalosporins (cefazolin, cephalexin, ceftriaxone), if pt has penicillin allergy and is ordered a cephalosporin inquire about the type of allergic reaction

Characteristics of Bell's palsy

Change in formation of tears on affected side, Flattening of the nasal labial fold, and inability to smile symmetrically

Calcium rich foods

Cheese,ice cream, green veggies, soy milk, almonds,tofu

A nurse in the emergency department cares for four clients with orthopedic injuries which clients are the nurse assess first

Client with pain and ivy shoulder to formally recording a pins and needles sensation In orthopedic emergency because articular tissues nerves are stretched and compressed neurovascular compromise may occur prolong disruption of the vasculature and nerves may cause permanent injury and even loss of the distal extremity

Signs of peritonitis during peritoneal dialysis

Cloudy outflow, tachycardia, low-grade fever

Nursing actions prior to surgery

Confirm informed consent is signed, encourage client to void, ensure NPO status is maintained, witness surgical site is marked properly

Vancomycin resistant enterococcal bacteremia precautions

Contact precautions

Findings that support pneumonia

Course crackles, pleuritic chest pain, shortness of breath

myelomeningocele Priority interventions

Cover with a sterile moist dressing to decrease Infection risk place baby on abdomen with face turn to the side

Osteoarthritis manifestations

Crepitus with joint movement, morning stiffness for 10 to 15 minutes, pain with weight bearing activities

Coming causes of metabolic acidosis

Diarrhea ketoacidosis diabetes alcoholism starvation sepsis hypo perfusion Renal failure salicylate toxicity

Tamoxifen gives women a risk for what

Endometrial cancer

social interaction with schizophrenia

Facilitate interaction with nurse first then encourage interaction with other patients

persecutory delusions nursing interventions

Focus on reality and verbally enforce it, focus on pts feelings 2nd to the delusions

What food can you not eat with CCBs

GRAPEFRUIT OR GRAPEFRUIT JUICE

What does should you avoid changing a cats liter box

HIV

risk for cervical cancer

HIV, HPV, Multiple sexual partners, sex before 18

Steps to blood draws from central line

Hand hygiene, gloves, biohazard bag, scrub hub

Appropriate nursing action when administering blood

Have another nurse verify identifiers and blood before administration, prepares oh negative blood for an a B positive client, uses filter tubing with normal Celine

Alcoholism Complications

Hypoglycemia, thiamine (B1) deficiency (can cause wernicke encephalopathy)

Common characteristics of child abuse perpetrators

I've often grown-up and domestic violence environments, have a history of substance abuse, often have a low self esteem, teenage parents are more valuable of child abuse

Trismus

Inability to open the jaw due to pain, usually associated with tonsillitis or peritonsillar abscess in children

What risk are clients taking carbamazepine at risk for

Infection risk

pursed lip breathing

Inhale through nose for 2 seconds Exhale through pursed lips for 4 seconds

Signs of neonatal abstinence syndrome

Irritability restlessness nasal congestion frequent sneezing poor feeding loose stools Jerry vomiting sweating pupillary dilation

Visualizing the air way in a trauma situation

Jaw thrust maneuver in supine on backboard

Bacteremia precautions

Keep dedicated equipment in the room, perform hand hygiene before exiting room, wear a gown when providing care, private room, wear gloves

Signs of congenital hypothyroidism in babies

Lethargy, poor feeding, enlarged fontanelles, protruding tongue, puffy face, umbilical hernia, constipation, jaundice, dry skin

Malignant hyperthermia

Life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia common signs and symptoms include hypercapnia muscle rigidity and hyperthermia

Varicella Zoster vaccine is a __________ virus

Live

Patent ductus arteriosus assessment finding

Loud machine like murmur

Characteristics of syndrome of inappropriate antidiuretic hormone

Low serum osmolality, Low serum sodium, high specific gravity

Diet for patients with chronic kidney disease

Low sodium low potassium low phosphorus low protein (no salt substitutes)

Hemophilia A teaching

Medical alert bracelet, no medicines containing aspirin, non contact sports

Common medications used to treat C diff

Metronidazole (flagyl) vancomycin

fetal alcohol syndrome characteristics

Microcephaly, short palpebral eyelids, epicanthal folds, flat mid face, smooth thin upper lip

Vitamin D and calcium rich foods

Milk, sardines, yogurt, salmon, cereal

Hydroxychloroquine education

Need eye exam every 6 month

Myastenia Gravis (MG)

Neuromuscular disease with muscle weakness in my head and neck specifically eye-movement speaking swallowing and breathing

Naproxen patient teaching

Notify healthcare provider of any black tarry stools, take with food

What is the essential nursing action when starting a client on atorvastatin therapy

Obtain base line liver function test

coup-contrecoup injury

Occurs when the head strikes an object and the Brain receives an injury under the area of impact after which it rebounds to the opposite side of the scar and sustained an injury on that side as well

New born airway resuscitation position

On back with neck slightly extended

Irrigation of a laceration steps

Pain relief 30-60 minutes before, Ppe, fill 30-60ml syringe, use 18 or 19 gauge needle, continuous pressure

What supplements do children with cystic fibrosis need with meals and snacks/ what type of diet do they need

Pancreatic enzymes/ high carb, protein, fat with increased salts during times of increased sweating

Administering IV narcotics during labor is done best during

Peak of contraction, given slowly

Poorly controlled diabetes during pregnancy causes

Poor oxygenation to baby causing over production of RBCs, baby will have elevated hematocrit level

Magnetic resonance cholangiopancreatography Contra indications

Pregnancy, metal implants, allergy to die or shellfish, hearing aids must be removed, NPO for at least four hours

Priority action for infant with a topic dermatitis

Prevent scratching

Absolute Contraindications to thrombolytics

Prior intercranial hemorrhage, structural Cerebral vascular lesion, ischemic stroke within three months, suspected aortic dissection, active bleeding, significant head trauma within three months

Side effects of metoclopramide

Protruding and twisting tongue, lips smacking, puffy cheeks, chewing movements, frowning or blinking eyes, twisting fingers, twisted or rotated neck

Nursing action for shoulder dystocia during labor

Push down on symphius pubis

Priority intervention for rhabdomyolosis

Rapid IV fluid resuscitation

Dumping syndrome

Rapid emptying of gastric contents into small intestines. Client experience ab pain, nausea, vomiting, explosive diarrhea, weakness, dizziness, palpitations & tachycardia. To delay gastric emptying and reduce the risk of dumping syndrome client should consume meals low in carbs and high in fiber proteins and fats avoid fluids during meals eat small frequent meals and lay down after eating

Metoclopramide

Reglan

ventricular septal defect

Septal opening between ventricles causing left to right blood flow leading to excess blood flow to the lungs, monitor for respiratory exertion and signs of CHF

hyperosmolar hyperglycemic state

Serious condition characterized by hyperglycemia, hyperosmolarity and dehydration and the absence of ketoacidosis that may occur in type 2 diabetes, glucose >600, bicarbonate >18, neg ketones, serum osmolality >320, neuro symptoms

Pain relief position for pericarditis

Sitting up leaning forward

Hepatic encephalopathy manifestations

Sleep disturbances, altered mental status, lethargy, elevated ammonia, asterixis

Parental prevention of otitis media

Smoking cessation

Epiglottitis in infants is preventable by

Standard vaccinations

Juvinile idiopathic arthritis appropriate activities

Stationary bicycling, swimming, yoga, low impact activities

cervical cerclage

Stitching of cervix shut during pregnancy to prevent preterm delivery, report any low back pain could be pre term labor

Signs of infective Cardenas

Stroke, spinal cord ischemia, paralysis of both legs, ischemia to the extremities, splinter hemorrhages, abdominal pain, blood clots

Signs of spina bifida and a newborn

Tuft of hair on buttocks, Hemangioma, dimple at top of butt crack

Best indicator for fluid replacement success and burn victims

Urine output

psychomotor retardation

Visible generalized slowing of movements and speech.

Damage to the occipital lobe of the brain is indicated by

Visual disturbances (occipital=optic)

Paracentesis nursing actions

Witness informed consent, obtain baseline vitals abdominal circumference and weight, place client and high Fowlers position or as operate as possible, have client empty bladder

histrionic personality disorder

a personality disorder characterized by excessive emotionality and preoccupation with being the center of attention; emotional shallowness; overly dramatic behavior

arteriovenous malformation

a tangle of abnormal blood vessels connecting arteries and veins in the brain, can cause seizures, headaches, neurological deficits

symptoms of intussusception

colicky abdominal pain, sausage-shaped mass in abdomen, passage of currant jelly stools, insoluble crying, knee to chest position, vomiting

agoraphobia

fear or avoidance of situations, such as crowds or wide open places, where one has felt loss of control and panic

Autonomic Dysreflexia

involves uncontrolled activation of autonomic nervous system, can lead to hypertensive emergency, triggers include bladder or rectum distinction and pressure ulcers

SIADH

low sodium level, low serum osmolality

Magnetic resonance cholangiopancreatography (MRCP)

magnetic resonance imaging (MRI) is used to visualize the biliary and pancreatic ducts and gallbladder in a noninvasive manner,

Five P's of compartment syndrome

pain, pallor, pulselessness, paresthesia, paralysis

Tines corporis

ringworm

intussusception

telescoping of a segment of the intestine

What do you give first for alcoholic patients

thiamine IV then glucose IV