Nclex Review
Fetal Heart Rate normal range
120-160 bpm
Benztropine mesylate
An anticholinergic that conteracts the extrapyramidal symptoms (EPS) seen with the use of haloperidol.
Intrapartum Care
Care that is given during labor and birth
What kind of room should a child with acute gastroenteritis?
A private room since it is contagious
Hepatitis B route of transmission
Contact precautions. Transmitted through blood or body fluids
What prescriptions are appropriate to initiate to a newborn?
Hepatitis B vaccine, erythromycin ointment, Vitamin K, PKU screening
What is the minimum age to receive a flu shot?
6 months old
Circurmoral cyanosis
A bluish discoloration of and around the lips. It is an indicator of cyanotic heart defect.
Justice
A fair, equitable, and appropriate treatment
Advance Directive
A legal document, such as a living will, a health care proxy, or a Durable power of attorney for health care. It provides guidance to caregivers about the client's wishes and are followed if a client's decision-making powers become impaired
Nonmaleficence
A nurse's duty to do no harm
Beneficence
A nurse's duty to do what is in the best interest of the client
Perseveration
A person persistently repeats the same word or idea in response to different questions.
Nursing Informatics
A specialty of nursing that integrates nursing and computer science
Dissociative Fugue
A sudden, unexpected travel away from home or customary places of daily activities, with inability to recall some or all of one's past. The person cannot recall personal identity and often assumes a new identity. This person is unaware that he/she has forgotten anything.
Primipara
A woman who has completed 1 pregnancy with a fetus or fetuses who have reached 20 weeks of gestation
Multipara
A woman who has completed 2 or more pregnancies to 20 or more weeks of gestation.
Multigravida
A woman who has had 2 or more pregnancies.
Primigravida
A women who is pregnant for the first time
Quality Improvement
Activities such as identifying opportunities and developing policies for improving the quality of nursing practice.
Calculating Expected Delivery Date
Add 7 days and 9 months to the first day of the last menstrual period
A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority?
Administer naloxone hydrochlride 0.4 mg IV every 2-3 minutes prn. Naloxone is an antidote for opioid overdose
What client statement is most indicative of gallbladder disease?
After eating a hamburger and fries, my belly really hurt. Client may experience discomfort after meals high in fat
Measles type of isolation
Airborne
Gamma globulin
An immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell.
Dissociative amnesia
An inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness and is not due to the direct effects of substance abuse.
Colostomy
An opening into the colon
Ilestomy
An opening into the distal end of the small intestine
Stress test
Assesses cardiovascular response to increased workload
Bladder distention and bowel impaction can result in ________, causing a critical increase in _________
Autonomic dysreflexia, blood pressure
Tranylcypromine food to avoid
Avoid foods rich in tyramine or tryptophan, such as: cured foods, those that have been aged, pickled, fermented, or smoked. These can precipate a hypertensive crisis.
With pernicious anemia the client will have to take what for the rest of their lives?
B12 injections given once a month, since they lack the intrinsic factor
Echopraxia
May purposelessly imitate movements made by others.
Category X medication contraindicated during pregnancy
Birth control pills, accutane, some hyperlipidemia medications, warfarin (coumadin), ulcer drug (cytotec), vaccines for measles, mumps, and smallpox
The nurse is preparing a client for a renal biopsy Which is most important for the nurse to assess prior to this procedure?
Bleeding time and coagulation studies
Russell's traction
May reduce fractures of the hip or femur
Depersonalization Disorder
Characterized by a temporary change in the quality of self-awareness, which often takes the form of feelings of unreality, changes in body image, and feelings of detachment from the environment.
Dissociative Identity Disorder
Characterized by the existence of two or more personalities in a single individual.
The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection?
Color changes, drainage, odor, fever & increased pain.
Rinne test
Compares bone conduction to air conduction in the ears
Virtues
Compassion, trustworthiness, integrity, and veracity (truthfulness)
Chest tube problem
Constant bubbling in the water seal chamber is indicative of an air leak
Aminocenntesis
Withdrawing amniotic fluid for analysis is done after the 14th week
After obtaining blood from the blood bank, how long does the nurse have to administer it?
Within 30 minutes
Client with a 3-way indwelling urinary catheter is exhibiting dark red output what should the nurses first action be?
Dark red urine is an expected outcome and the nurse should increase the irrigation rate until the urine becomes light pink
The drug nadolol is prescribed for a client with stable angina. Which finding would indicate to the nurse that the drug is effective?
Decreased anxiety, relief of chest pain, lowered blood pressure
A client being treated for osteoporosis with alendronate complains of slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect?
Drink plenty of water with the medication, sitting upright following the administration of the medication, and avoiding sucking on the tablet
The focus of secondary prevention is
Early detection,use of referral services and rapid initiation of treatment to stop the progress of the disease.
Hepatitis A route of transmission
Fecal-oral route, primarily through ingestion of contaminated food
Antepartum Care
Given to the mother and baby before birth, also known as prenatal care. It involves keeping track of the client's history and includes a number of important examinations
Elderly client receiving a blood transfusion is at greatest risk for what ?
Fluid volume overload. Assess for breath sounds
Signs and symptoms of recurrent nephrotic syndrome?
Foamy urine, which may be caused by excess protein in the urine, swelling (edema), particularly around the eyes (periorbital) and in the ankles and feet, weight gain
What type of STD needs to be reported to the department of public health?
Gonorrhea
In what position should the nurse place a client post intracranial surgery?
HOB elevated 30-40 degrees will prevent ICP from increasing
A child is admitted to the hospital with a temp of 102.2°F/ 39.0°C, lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child?
Immediate blood cultures should be obtained on this child, as sepsis is suspected with any temperature this high.
Treatment for constipation
Increase fluid intake, including hot liquids and fruit juices, advise a high fiber diet
Hormone replacement therapy risks and benefits
Increase risk of coronary artery disease, increased risk of DVT, decreases risk for osteoporosis-related bone fractures, increase risk for breast cancer
After a fracture, what is the factor that would most likely lead to shock?
Loss of blood into the soft tissue surrounding the fracture.
Cystitis
Inflammation of the bladder
Prostatitis
Inflammation of the prostate
Urethritis
Inflammation of the urethra
A depressed client is prescribed fluoxetine. What is the best response by the nurse when the client says, "What will this medicine do to me?"
It will regulate a neurotransmitter called serotonin
Fidelity
Keeping faithful to ethical principles and the ANA code of Ethics for Nurses
What preparation is needed for a colonoscopy?
Laxatives are taken the night before a to ensure stool is cleared from the colon.
Which assessments will provide the nurse with the most information regarding neurologic function?
Level of consciousness, verbal ability, orientation, and ability to move on command
Treatment for flatulence
Limit gum, carbonated beverages, cabbage, cauliflower, beans, and onions
Confidentiality
Maintaining the client's privacy by not disclosing personal information about the client
Pulse oximeter
Measures the oxygen saturation of blood by determining the percentage of hemoglobin-carrying oxygen
Client presents with abdominal pain, hypotension, increased respirations, and flushed, warm, dry skin
Metabolic acidosis
Client admitted with persistent vomiting, complaining of weakness and leg cramps, and irritability
Metabolic alkalosis
Client presents with anxiety, muscle cramps, excessive energy, arrhythmias, and decreased respiratory effort
Metabolic alkalosis
Symptoms of serotonin syndrome
Myoclonus, shaking chills, muscle jerking, and mental confusion
Smallpox precautions
Negative-pressure room, healthcare workers wear N95 respirator mask, Airborne precaution
Is captopril during pregnancy safe?
No, it can cause serious harm to an unborn baby, it should not be taken during pregnancy
Tranylcypromine teaching
OTC cold medications could result in hypertensive crisis when combined with the monoamine oxidase inhibitor. Warnings are placed on cold preparations and other medicines that are not to be taken with the MAOIs.
Which intervention is most important for the nurse to implement when administering a medication through a nasogastric (NG) tube?
Place client in semi-fowlers position, stop the feeding for 30 minutes prior to medication administration, give the medication, flush the tubing, and resume feeding after 1 hour
Post electroconvulsive therapy interventions
Position the client on their left side and stay with the client until they are fully awake
Early sign of testicular cancer
Painless testicular enlargement
A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect?
Pesticide exposure
Tuberculin (Mantoux) skin test
Preformed to determine of a person has ever had tuberculosis (TB)
Precautions for a client with shingles
Private room, negative-pressure room, respirator mask
Cause of ammenorrhea?
Progesterone
Client with TB is receiving isoniazid therapy what medication will prevent peripheral neuropathy?
Pyridoxine
The nurse is caring for a client who has developed hypovolemic shock. The client is receiving albumin. What assessment findings indicate that the albumin has been effective?
Reduction in tachycardia
Client presents with muscle weakness, anxiety, tachycardia, change in consciousness
Respiratory acidosis
Respiratory failure, COPD, and muscle weakness can lead to what?
Respiratory acidosis
Signs and Symptoms: hypoventilation, sensorium changes, somnolence, semicomatose to comatose state. pH < 7.35, pCO2 > 45, HCO3 normal.
Respiratory acidosis
Client presents with hyperventilation, lightheadedness, tingling of lips and fingers, and a head injury
Respiratory alkalosis
Accountability
Responsibility for one's actions
Extrapyramidal symptoms (EPS) seen with the use of haloperidol
Restlessness, muscle weakness, drooling, and a shuffling gait
In what position should the nurse place a client post liver biopsy?
Right Lateral Decubitus
St. John's Wort in combination with a selective serotonin reuptake inhibitor could cause what?
Serotonin syndrome which can be fatal
Associative looseness
Thinking is characterized by speech in which ideas shift from one unrelated subject to another. The person is not aware that the topics are unconnected.
A client has recently been diagnosed with rheumatoid arthritis. The nurse anticipates which class of pharmacologic agents will likely be a part of their treatment regimen?
Systemic glucocorticoids
Signs and symptoms of transplant rejection
Tenderness over the transplant site, fever, increased BUN/CR, weight gain, decreased urine output, and increased BP
Prevention and avoidance measures for otitis externa
Thorough ear canal drying and use of acidifying or astringent drops after swimming or bathing.
What occurs during an upper GI series?
The client swallows barium contrast while x-rays are taken
Autonomy
The right of individuals to make decisions for themselves
Encryption
The conversion of information to code during transmission to keep the information secure
Case management
The coordination of care to reduce fragmentation and costs, a well as to improve quality and outcomes
Depersonalization
The unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one's parts have changed or a sense of seeing oneself from a distance).
Telecommunications
The electronic transmission of data over phone-based lines
Collaboration
The interdisciplinary interaction between different health care professionals, such as nursing, medicine, and social work
Neologism
The invention of new words by a psychotic client
Concrete thinking
The literal interpretations of the environment, represents a regression to an earlier level of cognitive development.
The nurse is caring for a client in end-stage renal disease with an arterio-venous dialysis access. What assessment by the nurse indicates patency of the access?
The nurse palpates the thrill and listens for the bruit to ensure patency of the access device.
Advocacy
The nurse's duty to act on behalf of the client
Magical thinking
The person believes that his or her thoughts or behaviors have control over specific situations or people.
Tangentialit
The person never really gets to the point of the communication. Unrelated topics are introduced, and the original discussion is lost.
Patient Self-Determination Act
To ensure that upon admission to hospitals, long-term care facilities, and home health agencies, patients are informed that they have the right to accept or refuse medical care, as well as to specify in advance, through advance directive, what their wishes are
Hepatitis C route of transmission
Transmitted through blood and parenteral routes
Treatment for diarrhea
Understand and treat the underlying cause, advise bland foods and a low-fiber diet. Avoid spicy foods, alcohol, and caffeine while symptoms are present
Which evaluation criteria for a client with a major burn, indicates fluid resuscitation has been effective during the first 24 hours of care?
Urinary output is the best indicator of successful fluid resuscitation
Byrants traction
Used in children younger than age 2 to reduce femur fractures or stabilize hips
When is a nasopharyngeal airway initiated?
Used on alert clients to keep the airway open
90-degree traction
Used on the femur if skin traction isn't suitable
Tznack test
Used to detect the herpes virus
Patch test
Used to identify the causes of allergic contact sensitization and is indicated in clients with suspected allergies or allergies from an unknown cause
Cervical traction
Used to stabilize a spinal fracture or muscle spasm
Buck's traction
Used to temporarily immobilize a fractured leg
Telehealth
Uses transmissions via telecommunications technology to transmit health information remotely
Nursing care unit following a gastroscopy
VS check Q15 mins x4, NPO until gag reflex returns, and elevate HOB
The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider?
Weight gain of 5lbs in one week, angioedema, serum potassium of 5.8 mEq, BP 150/108 decreases to 138/86
What is the priority lab value to check before initiating the heparin infusion?
aPTT
The Uniform Anatomical Gift Act
governs organ donations for transplantation and how to donate one's cadaver as an anatomical gift
RhoGAM
if the mother is Rh-negative and the father is Rh-positive, the mother needs to have RhoGAM in the 28th week of pregnancy
