NCLEX

A client who was in an automobile collision is now in hypovolemic shock. Why is it important for the nurse to take the client's vital signs frequently during the compensatory stage of shock?

Arteriolar constriction occurs so that blood can be shunted to vital organs. Contractility increases, cardiac workload increases, cardiac output increases.

Normal serum lipase

0-160 U/L

Normal AST

0-35 U/L

Normal digoxin level

0.5-2 ng/mL

Normal creatinine

0.6-1.3 mg/dL

Normal INR for healthy person not on warfarin

0.8-1.2 (would be dangerous for a person on warfarin!)

Chlamydia treatment

1 gram single dose azithromycin oral

Acute tracheitis

1 mo to 6 yr. Viral or bacterial with allergic component. Moderately progressive URI Croupy cough Purulent secretions High fever No response to LTB treatment

Acute spasmotic laryngitis

1-3 year. Viral infection with allergic component. Occurs suddenly at night URI with stridor, croupy cough, hoarseness, dyspnea, restlessness. Symptoms awaken child at night, disappear during the day.

Late decelerations priority interventions

1. Change maternal position to side-lying 2. Correct maternal hypotension by elevating legs 3. Increase rate of maintenance IV solution 4. Palpate uterus to assess for tachysystole 5. d/c oxytocin if infusing 6. Administer O2 8-10 L/min by nonrebreather mask 7. Notify provider or midwife 8. Consider internal monitoring for more accurate assessment 9. Assist w/ birth if pattern cannot be corrected

The nurse is caring for a client with vascular dementia. What does the nurse identify as the cause of this problem?

Disruptions in cerebral blood flow (sudden closure of lumen of arterioles), resulting in thrombi or emboli.

RAT BED: symptoms of hypoxia

Early: Restlessness Anxiety Tachycardia/tachypnea Late: Bradycardia Extreme restlessness Dyspnea

Symptoms of idiopathic thrombocytopenia purpura

Eccymosis Petechiae Bleeding gums Slightly palpable liver and spleen

A nurse cares for a client receiving hemodialysis. Which manifestations does the nurse assess for related to the treatment?

Elevated temperature, headache, hypotension, muscle cramps

interventions to prevent contracture post below the knee amputation

Ensure residual limb is positioned flat on the bed Position client prone several times per day (will stretch any flexion that has occurred as defensive withdrawal to muscle spasms)

Which physiologic activity is associated with the "proliferative phase" of normal wound healing?

Epithelial cells grow over the granulation tissue bed.

Which drugs are used in the treatment of osteoporosis?

Etidronate, zoledronic acid, and salmon calcitonin

Type III hypersensitivity reaction

Immune-complex mediated reactions, caused by bacteria, viruses, or fungi. Antibodies involved: IgG and IgM. Examples: lupus, rheumatoid arthritis

Type I hypersensitivity reaction

IgE mediated histamine reaction caused by allergens such as pollen, food, drugs, dust. Ex: asthma, allergic rhinitis

Which immunizations are safe to administer to a child with AIDS

Inactivated polo vaccine (NOT oral polio) HiB (haemophilius influenza) DTaP (diptheria, tetanus, pertussis)<--dead vaccine Children with HIV can recieve MMR (live virus), but children with AIDS cannot. Children with AIDS should not receive varicella (live virus)

The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained?

Lateral, this keeps the airway open and allows secretions to drain. Supine will cause tongue to block airway. Fowlers will cause head to tip forward and block airway.

IgE

Located in plasma and interstitial fluids. Fixes to mast cells and basophils, causes symptoms of allergic reactions, assists in defense against parasites

IgD

Located in plasma, on lymphocyte surface. Responsible for differentiation of B lymphocytes

IgM

Located in plasma, responsible for primary immune response. Forms antibodies to ABO antigens.

Wernicke's area

Located in the temporal lobe. Primarily involved in speech comprehension. People who are damaged in this area can hear words and repeat them back, but do not understand language. (contrast w/ Broca's area, which is involved in speech production and located in frontal lobe).

A nurse is caring for a client with a diagnosis of renal calculi secondary to hyperparathyroidism. Which type of diet should the nurse explore with the client when providing discharge information?

Low calcium, low phosphorous (since these are the components of the calculi)

Nephrotic syndrome diet

Low sodium, high protein (remember this is the exception to the protein/kidney disease rule, since there will be profound proteinuria and protein will need to be replaced)

Live vaccines

MMR, varicella, rotavirus, flu mist

patent ductus arteriosus symptoms

Machinery-like murmur May be asymptomatic, may show signs of HF Widened pulse pressure, bounding pulses

Post gastroscopy nursing interventions

Maintain NPO status until gag reflex returns Observe for hematemesis Connect to O2 sat monitor Monitor respirations (want to ensure scope did not damage any structures such as esophagus or lungs)

Nephrotic syndrome results in

Massive proteinuria, hypoalbuminemia, hyperlipidemia, edema, anorexia, pallor

Schilling's test

Measures the urinary excretion of vitamin B12 for diagnosis of pernicious anemia

Interleukin 2 is used to treat

Metastatic renal cell carcinoma and metastatic melanoma

What over the counter drugs are used to treat candidiasis?

Miconazole and Clotrimazole

Nursing interventions for a client with Guillain-Barre

Monitor for contractures Provide therapeutic massage for pain relief Teach ROM exercises Refer to a physical therapist Provide frequent, high calorie meals (may need enteral or parenteral feedings)

A client is started on chlorpromazine. To prevent life-threatening complications from the administration of this medication to an anxious, restless client, it is important that the nurse take which action?

Monitor the client's vital signs. This drug can cause neuroleptic malignant syndrome, which manifests in tachypnea, tachycardia, and hyperprexia (high fever)

Which organs are affected by Candida albicans?

Mouth (thrush), vagina (vaginitis), intestines (candidiasis)

Beta interferon is used to treat

Multiple sclerosis

Cause of ronchi (sonorous wheezes)

Muscle spasm, fluid, or mucous in larger airways; new growth or external pressure causing turbulence

Expected findings when cervix dilated 8-10cm

Nausea and vomiting, profuse bloody show, inability to control shaking legs

Myopia

Nearsightedness, a condition in which the eye over-refracts the light and the bent images fall in front of, not on, the retina (distant objects are blurry)

The nurse assesses a client for the development of pernicious anemia after reviewing the client's history. Which condition did the nurse most likely find in the history?

Partial gastrectomy. Removal of the fundus of the stomach (gastrectomy) destroys the parietal cells that secrete intrinsic factor (needed to combine with vitamin B12 preliminary to its absorption in the ileum).

Dorsal recumbent position

Patient lies on back with lower extremities moderately flexed and rotated outwards.

What skills should a 4 and a half year old child demonstrate?

Prepares own cereal without help Copies a circle Speaks clearly Draws a person with at least 3 body parts

Interleukin 11 is used to

Prevent thrombocytopenia after chemotherapy

Primary source of stress for 5 year olds

Procrastination (delay in completing chores or activities)

What instructions should the nurse provide to parents of a child with sickle cell anemia?

Provide high calorie, high protein diet Deferasirox helps prevent liver damage from iron deposits. (Iron chelation agent shown to reduce the liver iron concentration due to repeated RBC transfusions. It binds iron.) Avoid high altitudes

A client has pneumonia. What interventions should the nurse include for the client's night sweats and fever?

Put a plastic cover over the pillow Keep a glass of water by the bed Keep a linen change in the room

Cause of lung crackles

Random, sudden reinflation of groups of alveoli; disruptive passage of air through small airways

A nurse is teaching about the function of the loop of Henle. Which functions should the nurse include?

Reabsorption of sodium in the ascending limb, reabsorption of water in the descending limb

Motor skills birth to 1 month

Reflexive grasp Still cannot sit upright, head lag persists, newborn reflexes persist

Chronic pyelonephritis

Renal inflammation and fibrosis induced by recurrent or persistent renal infection, vesicoureteral reflux, or other causes of urinary tract obstruction. Chronic pyelonephritis is associated with progressive renal scarring, which can lead to end-stage renal disease (ESRD). Bacteria in the urine is an expected finding, elevated creatinine is a concerning finding.

Early signs of hypoxia

Restlessness, agitation and tachycardia

Clinical manifestations of appendicitis

Right lower quadrant pain Fever Rigid abdomen Vomiting (typically follows onset of pain) Constipation or diarrhea Anorexia Tachycardia Rapid, shallow breathing Pallor Lethargy Irritability Stooped posture

A post-appendectomy client should be placed in which position?

Semi-fowler's (HOB elevated 35-45 degrees), to decrease pressure on the suture line. this is true for all clients after abdominal surgery!

A nurse is caring for a client with a fracture of the femoral neck. Which clinical indicator should the nurse expect to identify when assessing this client?

Shortening of the affected extremity with external rotation

Infant weight

Should double weight by 6 months and triple it by 1 year old.

The primary healthcare provider prescribes a neuroleptic (1st gen antipsychotic) drug to a client diagnosed with schizophrenia. On what basis would the primary healthcare provider choose the drug?

Side effects

Motor skills 6-8 months old

Sits alone without support Bears full weight on feet and can hold onto furniture Can move from sitting to kneeling position Bangs objects together Pulls a string to obtain an object Transfers objects from hand to hand

Diptheria symptoms

Sore throat, fever, HA, grey or dirty yellow membranous patches in back of throat (ex: on tonsils)

Motor skills 10-12 months

Stands alone Walks holding onto furniture Sits down from standing position Can place objects into containers Can hold crayon or pencil and make mark on paper

Late signs of hypoxia

Stridor, substernal retractions, cyanosis

A nurse who is assessing a full-term newborn elicits the Moro reflex. Which method would the nurse utilize to best elicit this reflex

Striking infant's crib suddenly (moro=startle reflex)

Variable decelerations

Sudden decrease in FHR below baseline, lasting about 15 seconds and returning to baseline within 2 minutes. Indicates cord compression, usually relieved with position change

Type IV hypersensitivity reaction

T-cell mediated delayed hypersensitivity reactions. Contact dermatitis to poison ivy.

Parents of a child with sickle cell anemia ask about their child taking iron supplements to help treat the anemia. What would be the best response?

Taking supplements will not help with this condition. Sickle cell anemia is not caused by too little iron in the blood; it's caused by not having enough red blood cells.

What EKG change is a sign of hyperkalemia?

Tall peaked T waves

While performing patterned, paced breathing during the transition phase of labor, a client experiences tingling and numbness of the fingertips. What should the nurse do?

Tell the client to breathe into a paper bag (this will correct respiratory alkalosis s/t hyperventilation)

Pheochromocytoma

a benign tumor of the adrenal medulla that causes the gland to produce excess catecholamines Symptoms: hypertension (may be life threatening!), tachycardia, hyperglycemia, hypermetabolism, headache, profound sweating, paleness in the face, SOB (less common signs are anxiety/sense of doom, constipation, abdominal pain, weight loss) Symptoms often occur in brief spells of 15-20 min

Astigmatism

a condition in which the eye does not focus properly because of uneven curvatures of the cornea

Evaluation research

a study that tests how well a program, practice, or policy is working

Which conditions result in T cell mediated immunity?

Tuberculosis, contact dermatitis

Trigeminal autonomic cephalalgia (cluster headaches)

Unilateral headaches of short duration, lasting 30 min to 2 hours. Caused by an overactive and enlarged hypothalamus. Most common in men ages 20-50.

Tensilon test

Used to diagnose MG and to differentiate between myasthenic crisis and cholinergic crisis. If tensilon produces brief increase in muscle strength, patient has MG. If tensilon intensifies muscle weakness, patient is in a cholinergic crisis. No change=negative for both

Rheumatic fever

Usually occurs after strep infection -Low grade fever that spikes in pm -Chorea: involuntary movements of extremities and face -Arthralgia Carditis Erythema marginatum: red skin lesions starting at trunk and spreading peripherally Subcutaneous nodules Elevated erythrocyte sedimentation rate or C-reactive protein Prolonged PR interval on electrocardiogram Confirm diagnosis with anti-streptolysin O titer

Tetralogy of fallot

Ventricular septal defect Pulmonary stenosis Overriding aorta Right ventricular hypertrophy Infant may be cyanotic at birth, or cyanosis may progress gradually as pulmonic stenosis worsens Characteristic murmur Tet spells: acute episodes of cyanosis and hypoxia, more likely during periods of increased O2 demand (feeding, crying, defecating) Tet spell treatment: Knee-chest position, administer 100% O2, administer morphine Squatting in children is a compensatory mechanism to facilitate return of blood to the heart

pernicious anemia

Vitamin B12 deficiency, likely caused by lack of intrinsic factor in the stomach

Tetracycline antibiotic patient education

Wear sunscreen and long sleeves when outside Take on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking (will affect absorption) Use backup non-hormonal birth control Do not take after expiration date: can cause kidney damage

Motor skills 2-4 month infants

When prone, lifts head and chest and bears weight on forearms Sits up with support, good head control Turns from side to back Holds rattle for short periods Looks at and plays with fingers Able to bring objects from hand to mouth

Creatine kinase

muscle enzyme found in skeletal and cardiac muscle; elevated blood levels associated with heart attack, muscular dystrophy, and other skeletal muscle pathologies. Male: 20-200 U/L Female: 20-180 U/L

Decerebrate posturing

teeth clench and the arms are stiffly extended, adducted, and hyperpronated. The legs are stiffly extended with plantar flexion of the feet. Abnormal extension occurs with lesions in the area of the brain stem.

Acute laryngotracheobronchitis (croup)

Infant or child <5. Slowly progressive URI Stridor, brassy, seal-like cough (sounds worse than looks) Hoarseness Dyspnea Restless, irritable Non-toxic appearance

Cleansing enema volume indicated by age

Infant: 150-250 mL Toddler: 250-350 mL Child: 300-500 mL Adolescent: 500-750 mL

Urinary catheter sizes by age

Infant: 5-6 fr Child: 8-10 fr Adult: 14-16 fr Some adult males: 6-18 fr

Symptoms of chronic arterial insufficiency

Intermittent claudication (pain with walking relieved by rest) Decreased or absent pulses in extremities Extremities cool to touch Paleness of extremity when elevated, possible redness when lowered Loss of hair on affected extremity Thick nails

Cheyne-Stokes respirations

Irregular respirations that progress to deep, rapid breathing alternating with periods of apnea. Symptom of increased ICP Can lead to respiratory acidosis

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis?

Irritability, restlessness, headache (signs of cerebral hypoxia)

hich medication should be immediately started when a client has an anaphylactic attack?

Isoproterenol, a beta-adrenergic, sympathomimetic drug

Which drug is used to treat acne vulgaris in adolescents but is contraindicated in pregnancy due to its teratogenic effects?

Isotretinoin

Why is it important to administer vitamin K to every newborn?

It is required to initiate clotting factor production

Sources of stress for 3-4 year olds

Jealousy, stubbornness, and companionship

What drug is given to patients with cirrhosis to decrease ammonia levels?

Lactulose

Primary source of stress for 6 year olds

Competition (wanting to be first or best, winning)

Instructions for parents of an adolescent with a mild concussion

Concussion symptoms may last anywhere from hours to days to weeks to months Return to the ED for worsening headache, severe vomiting, worsening dizziness Avoid physical activities until released from care Awaken the client every 2 hours to assess for neuro changes

What are symptoms of hypercalcemia?

Confusion, polyuria, severe abdominal pain

Acute spasmotic laryngitis treatment

Cool mist and reassurance

Acute LTB treatment

Corticosteroids Fluids Nebulized epinephrine Heliox: moderate to severe croup

Motor skills 8-10 months old

Crawls or pulls body on floor using arms Pulls self to standing or sitting Picks up small objects Pincer grasp Shows hand preference

Signs someone is experiencing pulmonary embolism

Cyanotic, gasping for breath, reports right sided chest pain

Type II hypersensitivity reaction

Cytotoxic, mediated by IgM and IgG. Examples: transfusion reaction, autoimmune such as Graves' disease, thrombocytopenia purpura, and Goodpasture syndrome

Inactivated vaccines

DTAP, PEDIATRIX, Hib, polio, hepatitis A, hepatitis B, flu injection

What are symptoms of acute hyperkalemia?

Decreased HR, paresthesias, muscle weakness of extremities

Primary source of stress for 7 year olds

Demanding privacy, the desire to be like an idol, and becoming more selective with playmates

Kernig's sign

Diagnostic sign for meningitis Place client supine with one leg flexed up toward the abdomen. The lower leg is then gently extended upward, producing severe pain in the presence of meningitis.

Alcohol withdrawal symptoms

Diaphoresis, tremors, agitation, hypertension, insomnia

Findings of concern after gall bladder removal

Clay colored stool Pruritis: indicates bile deposits in skin Icteric sclera Remember, RUQ discomfort is normal in this case because that is the surgical site!

A client with arterial insufficiency of both lower extremities is visited by the home healthcare nurse. What client teaching is an essential nursing intervention?

"Check pulses in the legs regularly."

During a physical exam, the client reports having fatigue and trouble concentrating. What other client statement during the assessment would lead the nurse to suspect marijuana use?

"My eyes have looked bloodshot lately" "I sometimes feel that I am off balance" "I don't have the desire to do the things I used to do" "My heart seems to beat fast most of the time" "My appetite has been increasing lately"

The nurse is giving discharge teaching to a client seven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?

"There is a risk of cardiac rupture for about 6 weeks after a heart attack, then scar tissue forms. When you can climb 2 flights of stairs without problems, it is generally safe."

Variable decelerations priority interventions

1. Change position to side to side or knee-chest. If that doesn't work, 2. Stop oxytocin if infusing. If that doesn't work, 3. Give O2 @ 8-10 L/min via nonrebreather 4. Notify provider or midwife 5. Assist w/ vaginal or speculum exam to assess for cord prolapse 6. Assist w/ amnioinfusion if ordered (isotonic fluid instilled into amniotic sac) 7. Assist w/ birth (vaginal or c-section) if pattern cannot be corrected.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Select all that apply.

1. The RR intervals are relatively consistent 2. One P wave precedes each QRS complex 3. 6-10 complexes occur in a 6-second strip 4. PR interval is 0.12-1.2 seconds 5. QRS duration is less than .12 seconds

Normal urine specific gravity

1.010-1.030

Normal serum magnesium

1.3-2.1 mmol/L

What is the maximum recommended length for enema tube insertion in an adolescent?

10 cm

How should the client with HIV clean a spill of blood or body fluid?

10% mixture of bleach and water. Leave bleach solution on the area for 10-20 minutes, then rinse with hot water. Any cloths used to clean the area should be double bagged and discarded.

In the immediate postoperative period after a gastrectomy, the client's nasogastric tube is draining a light-red liquid. How long should the nurse expect this type of drainage?

10-12 hours

Normal mean pulmonary artery pressure

10-20 mmHg

Insulin aspart onset

10-30 min (rapid acting)

Normal ALT

10-36 U/L

Normal urine calcium

100 to 400 mg/24 hr

Normal PT

11-13.5 sec

Normal fetal heart rate 1st trimester (1-12 weeks)

120-180 bpm

What size of induration after a tuberculin test signifies a positive result in a 16-year-old client?

15 mm (1.5 cm)

Normal INR on warfarin

2-3

How many pounds in a kilogram

2.2

Normal bicarbonate (HCO3)

22-26 mEq/L

Gonorrhea treatment

250 mg ceftriaxone IM single dose

Normal serum phosphorous

3-4.5 mg/dL

Normal serum amylase

30-220 U/L

Normal PTT

30-40 sec if not on anticoagulant therapy Remember, PTT is the test for heparin. Desired outcome of heparin therapy is PTT of 1.5-2.5 times the control without signs of hemorrhage. For clients on heparin, goal=60-80

Normal PTT (measured on heparin)

30-50

Normal IONIZED calcium

4.5-5.5 mg/dL

Hypokalemia symptoms

Abdominal cramps, muscle weakness, irregular HR/dysrhythmias, depressed or flat T waves, decreased bowel sounds/paralytic ileus, HYPOactive DTRs

Genital herpes treatment

7 day course of acyclovir (treats outbreak, but herpes can't be cured)

Normal BUN

8-20 mg/dL

Intubate if vital capacity is below...

800 mL

Normal serum calcium

9.0-10.5 mg/dL

An infant has been prescribed Bryant's traction for a diagnosis of developmental dislocated hips (DDH). At what degree of hip flexion should the nurse maintain the infant's hip for proper traction alignment?

90

Normal GFR

90 to 120 mL/min/1.73 m2

Correlational research

A study that explores the interrelationships among variables of interest without any active intervention by the researcher

Descriptive research

A study that measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur.

Before surgery, what should be given to a client with hemophilia?

A unit of cryoprecipitate

Symptoms of ulcerative colitis

Abdominal cramping, diarrhea, fever, rebound tenderness, rectal bleeding

Kawasaki disease (mucotaneous lymph node syndrome)

Acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, enlargement of cervical lymph nodes Subacute stage: cracking lips and fissures, desquamation of skin on tips of fingers and toes, joint pain, thrombocytosis, cardiac manifestation (risk of permanent complications, aneurysms if not treated) Avoid contact sports if taking aspirin or anticoagulants

Which clients are at risk for developing hypovolemic shock?

Addisonian crisis (loses sodium and water due to aldosterone deficiency) Severe burn victims Type 2 diabetic with hyperglycemic hyperosmolar nonketotic coma (HHNK) (this will cause polyuria, and with polyuria we always worry about shock!!)

Epiglottitis

Affects children 2-5. Rapidly progressive symptoms: dysphagia, stridor activated when supine, drooling, high fever, toxic appearance, tachycardia and tachypnea

Epiglottitis treatment

Airway protection! Possible intubation or tracheostomy. Humidified O2 Fluids Antibiotics

Presbyopia

An age-related problem in which the lens loses its elasticity and is less able to change its shape to focus the eye for close work. As a result, images fall behind the retina

Exploratory research

An initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena

Inhalation anthrax

Bacterial infection caused by Bacillus anthracis from contaminated soil Symptoms: Fever, fatigue, dry cough Fatality rate 100% if untreated Drug therapy: ciprofloxacin, doxycycline, amoxicillin

A client has iron deficiency anemia. Which foods does the nurse instruct the client to eat?

Baked beans, pistachios, chicken liver

Which WBCs mediate histamine repelase?

Basophils

Acute tracheitis treatment

Antibiotics and fluids

Suctioning safety

Apply suction only after catheter inserted and is being withdrawn Limit suctioning to 10 seconds

Which antipyretic medication may cause Reye syndrome in children?

Aspirin, because it increases the risk of swelling in the brain and liver

Motor skills 4-6 months old

At 5 months: abdomen to back At 6 months: back to abdomen Can support much of own weight when pulled to stand No head lag when pulled to sit Grasps objects at will and can drop them to pick up another object Pulls feet to mouth Can hold a baby bottle

signs of anaphylaxis

Audible stridor, feeling of impending doom, tachycardia, nausea/vomiting.

In children suspected to have a diagnosis of diabetes, which complaints would be most likely to prompt parents to take their school age child for evaluation?

Bed wetting, fatigue

Early decelerations

Benign, caused by head compression

Syphilis treatment

Benzathing penicillin G IM single 2.4 million unit dose

A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer?

Benztropine, an anticholinergic used to treat pseudoparkinsonism, an EPSE associated with haloperidol

BRATT diet

Bland diet given to children in the first 24 hours following gastroenteritis Bananas Rice Applesauce (but not apples, too much fiber!) Toast Tea

Hypoglycemia

Blood glucose less than 70

A nurse cares for a client diagnosed with preeclampsia. The nurse prepares to administer magnesium sulfate as prescribed. Which data is important prior to initiation of the magnesium sulfate?

Blood pressure Respiratory rate Deep tendon reflexes Urine output

Coarctation of the aorta symptoms

Blood pressure higher in the upper extremities than lower extremities Bounding pulses in arms, weak or absent femoral pulses, cool lower extremities

Digoxin toxicity symptoms

Bradycardia, vomiting

Late decelerations

Caused by uteroplacental insufficiency. Possible contributing factors: Uterine tachysystole Maternal supine hypotension Epidural or spinal anesthesia Placenta previa or placental abruption Hypertensive disorders Postmature fetus intrauterine growth restriction Intraamniotic infection Diabetes mellitus

Which medications are useful to relieve pain associated with muscle spasms?

Central and peripheral muscle relaxants such as carisoprodol, methocarbamol, and cyclobenzaprine

A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?

Chalmydia

CAUTION cancer symptoms

Change in bowel/bladder habits A sore that does not heal Unusual bleeding/discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough or hoarseness

A nurse teaches a new mother about neonatal weight loss in the first 3 days of life. How does the nurse explain the cause of this weight loss?

Excretion of accumulated excess fluids.

Tuberculosis symptoms

Fatigue, nausea, anorexia, weight loss, low grade fever, SOB, night sweats, hemoptysis

Which fetal complications are associated with oligohydramnios?

Fetal cord compression Fetal renal agenesis Fetal growth restriction

Priority assessment before artificial rupture of membranes by physician in labor that has not progressed:

Fetal engagement (if fetus is not far down enough, could cause prolapsed cord)

Symptoms of recurrent nephrotic syndrome

Foamy urine (sign of proteinuria) Edema of hands and feet as well as periorbital edema

Murphy's sign

Gall bladder inflammation: nurse places fingers beneath right rib cage and asks client to take a deep breath

Imquimod indication

Genital warts in clients with HPV

HPV vaccine is given to

Girls and boys between 11 and 12 Can be given to female clients up to age 26, and male clients up to age 21, unless it is a man who has sex with men, then up to 26 Recommended for immunocompromised men and women up to 26

What is the purpose of giving glycopyronate before ECT?

Glycopyronate is an anticholinergic. The purpose is to decrease stomach and oral secretions, which will decrease risk of aspiration while the client is sedated.

A client is instructed to avoid straining on defecation postoperatively. Which food item chosen by the client indicates successful learning?

Green vegetables (has fiber, which promotes elimination)

A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?"

Green vegetables and liver

Newborn vitals

HR: 100-160 RR: 30-60

Alpha interferon is used to treat

Hairy cell leukemia, chronic myelogenous leukemia, malignant melanoma

Which antipsychotic drugs have the higher risk of causing tardive dyskinesia?

Haloperidol, loxapine (first generation antipsychotics)

Labs that will be elevated after a burn

Hematocrit (due to fluid shift out of vasculature) Creatinine (kidney damage from decreased CO and myoglobin buildup) Potassium (due to cell lysis)

Which type of hepatitis virus spreads through contaminated food and water?

Hepatitis A

Liver disease diet

High carb, low protein, low sodium (We want to reduce protein breakdown in liver)

Hypoparathyroid lab values

High phosphorous, low magnesium, low calcium

Cause of wheezes (silbant wheeze)

High-velocity airflow through severely narrowed or obstructed airway

What treatment does the nurse anticipate for AKI (acute kidney injury)?

IV insulin and dextrose

The nurse is caring for a client diagnosed with type 2 diabetes who was brought to the emergency department in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse prepares for the administration of which initial therapy?

IV normal saline. We are worried about shock due to polyuria. We will also give short-acting insulin.

Emergency treatment for tension pneumothorax

Needle decompression: Insert a large bore needle into the 2nd intercostal space, midclavicular line on the affected side. This will get rid of the air that is compressing the heart and lungs and decreasing oxygenation. Also, if an occlusive dressing is covering the wound, REMOVE IT! Dressings should only be taped on 3 sides to allow air to escape

Which white blood cells are most numerous in the healthy client?

Neutrophils

Client education after eye surgery

No coughing, no lying down (keep HOB in fowlers), no warm compresses. These all increase intraocular pressure.

Symptoms of laryngeal cancer

No early signs! Hoarseness, lump in neck, sore throat, cough, problems breathing, earache, weight loss

Potassium chloride (KCl) infusion rate

No faster than 40 mEq/hour. Otherwise you could have life-threatening arrhythmias

Why are gastrectomy clients at risk for pernicious anemia?

No stomach-->No intrinsic factor-->can't absorb oral B12-->can't make good RBCs-->anemia

Can a UAP insert or remove a catheter?

No, this is an invasive procedure. UAPs cannot perform sterile or invasive procedures.

What are the first respiratory signs to appear in a client newly diagnosed with cystic fibrosis?

Noisy respirations and dry non-productive cough

Normal INR

Not on warfarin: 0.8-1.1 On warfarin: 2.0-3.0

What action is most important for the nurse to take when a client receiving a cephalosporin develops abdominal cramping and diarrhea?

Notify the provider because cephalosporin-associated diarrhea can result in C-diff. The provider will likely change the prescription.

What will the nurse do to assess a client's response to ongoing serum albumin therapy for cirrhosis of the liver?

Obtain the client's weight at least once per day. (Because albumin should be increasing intravascular volume and UOP, solving fluid retention problems which should lead to weight loss)

Substance abuse skin findings

Opioid abuse: needle marks Alcohol abuse: spider angiomas Sedative hypnotic abuse: diaphoresis Phencyclidine abuse: red, dry skin Cocaine abuse: vasculitis

Which clinical indicator does the nurse expect to identify when assessing a client admitted with a herniated lumbar disk?

Pain radiating to the hip and leg due to compression of the sciatic nerve

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated?

Pallor, coolness @ infiltration site (because solution is lower temperature than body temp), edema, decreased flow rate

How to assess for subcutaneous emphysema

Palpate the neck or face

A client post-cholecystectomy reports sweating, dizziness, and palpitations with meals. Which interventions will help decrease these symptoms?

The client is experiencing dumping syndrome. They should drink fluids between meals, not during meals, to slow progress of food through the digestive tract. They should reduce carbohydrates. They should eat small, frequent meals in a semi-recumbent position to slow passage of food through the GI tract. After eating, the client should lie down on the left side to keep food in the stomach longer.

Lyme disease

Tick-borne disease caused by the spirochete Borrelia burgdorferi. Manifests as warm, itchy, painful rash in groin, axillae, trunk, legs, and upper arms. May also have cardiac, neuro and arthritic complications

To determine the presence of respiratory alkalosis in a client, what should the nurse evaluate her for?

Tingling in the hands

What drugs are used to treat trichomoniasis?

Tinidazole and metronidazole

The provider prescribes octreotide for a client with bleeding esophageal varices. What is the purpose of this medication?

To decrease bloodflow to the liver, which will lower the pressure in the liver, which will stop the varices from bleeding.

Why do we give erythromycin and tetracycline ophthalmic ointment to newborns?

To prevent opthalmia neonatorum from gonorrhea or chlamydia in the vaginal tract (administer within 1-2 hours of birth)

Decorticate posturing

Towards the CORE upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion

Lithium toxicity/symptoms

Toxic above 1.5 1.5-2.0: blurred vision, ataxia, tinnitus, persistent nausea and vomiting, severe diarrhea 2.0-3.5: excessive output of dilute urine, increasing tremors, muscular irritability, psychomotor retardation, mental confusion, giddiness. above 3.5: impaired consciousness, nystagmus, seizures, coma, oliguria/anuria, arrhythmias, myocardial infarction, cardiovascular collapse.

What are symptoms of hypokalemia?

anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias

The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about:

left ventricular functioning

Which conditions result in humoral immunity? (B cell mediated)

atopic diseases, bacterial infections, anaphylactic shock

Gout diet

low purine (no beef, pork, goat), low fat, high carb

Sims position (lateral recumbent)

lying on left side with left leg straight and right hip and knee bent. Used for vaginal and rectal exams, enemas. Not for clients with respiratory problems!

Hyperopia (hypermetropia)

farsightedness, a condition in which refraction is too weak, causing images to be focused behind the retina (close objects are blurry)

Iron should be taken with which foods to improve outcomes?

Orange juice and strawberries (vitamin C increases absorption)

Blood Gas Ranges

PaO2: 80-100 mmHg PaCo2: 35-45 mmHg pH: 7.35-7.45 HCO3 (bicarbonate): 22-28 mEq/L

A nurse cares for a client diagnosed with Von Willebrand disease. Which clinical finding does the nurse document that supports this diagnosis?

Prolonged activated partial thromboplastin time (due to clotting factor deficiency)

An older client with vascular dementia has difficulty following simple directions for selecting clothes to be worn for the day. What does the nurse identify as the cause of these problems?

Receptive aphasia: difficulty interpreting and defining words, following directions

Lochia expected color

Rubra: days 1-3 Serosa: days 3-10 Alba: Day 10, persists 1-2 weeks

A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:

Should be taken in the morning to minimize the side effect of insomnia

A nurse instructs a client with viral hepatitis about the type of diet that should be ingested. Which lunch selected by the client indicates understanding about dietary principles associated with this diagnosis?

Salad, sliced chicken sandwich, gelatin dessert The diet should be high in carbohydrates with moderate protein and fat content.

Calcitonin

Secreted by parafollicular cells of the thyroid gland. Decreases calcium in the blood by putting it back in the bone, which is why it is given to treat osteoporosis. Opposite effect of PTH.

Which medication is prescribed to an infant with congenital syphilis?

IV penicillin

A nurse is caring for several clients with major thought disorders such as schizophrenia. They are all being treated with neuroleptic drugs. How do these drugs act in the body to promote mental health?

By blocking access to dopamine receptors and increasing serotonin at the postsynaptic receptor site

BMI calculation

weight (kg) / height (m^2) OR Weight in pounds / height in inches^2, multiplied by a conversion factor of 703 (lbs x in^2)x703=BMI

Diet for Hirschsprung's Disease

Low fiber (could cause obstruction), low-residue, high protein and calories, possibly TPN if obstruction

A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:

Manage pain

A pregnant woman with a history of heart disease visits the prenatal clinic toward the end of her second trimester. Which intervention does the nurse anticipate will be part of this client's care plan?

Prophylactic antibiotics at time of birth (to prevent bacterial endocarditits)

A client has recently started taking a new neuroleptic drug, and the nurse notes extrapyramidal effects. Which class of drug does the nurse anticipate will be prescribed to limit these side effects?

Anticholinergic

A nurse is teaching a client and family about the characteristics of dementia of the Alzheimer type. What physiologic characteristic should the nurse include?

Areas of brain destruction called senile plaques, caused by unusual deposits of iron on nerve cells.

A client with anorexia nervosa is admitted to the critical care unit following a period of prolonged starvation. What signs or symptoms indicate to the nurse that the client may have hypokalemia? Select all that apply.

Muscle weakness, cardiac dysrhythmias, low respiratory rate, respiratory acidosis (everything comes down to weaker muscles: weaker heart muscle, weaker respiratory muscles)

A nurse is caring for a client who was admitted to the hospital with the diagnosis of tertiary syphilis. Which system of the body should the nurse assess most closely in this stage of the disease?

Cardiovascular, because aortic valvular disease and aortic aneurysms can occur.

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client 2 days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of what?

Tissue necrosis

Types of hypersensitivity reactions

Type 1: Immediate (ex: anaphylaxis) Type 2: Cytotoxic (result in conditions such as myasthenia gravis and goodpasture syndrome, also blood transfusion reactions) Type 3: Immune complex mediated (lupus) Type 4: Delayed (graft rejection, sarcoidosis)

A nurse is caring for an infant that has recently been diagnosed with a congenital heart defect. Which of the following clinical signs would most likely be present?

Weight gain (caused by fluid accumulation)

Match the cytokine to the disease it is used to treat

Erythropoietin: Anemia Alpha interferon: hairy cell leukemia, malignant melanoma Interleukin-2: Metastatic and renal cell carcinoma Interleukin 11: To prevent thrombocytopenia after chemo

Which term refers to the exaggeration of the posterior curvature of the thoracic spine?

Kyphosis (hunching of the back)

Foods high in vitamin B1 (thiamine)

Lean beef or pork, organ meats, nuts, legumes, whole and enriched grains

Which drug may cause Ebstein anomaly (tricuspid valve malformation) as a teratogenic effect and is also contraindicated in breast-feeding clients?

Lithium

IgA

Located in body secretions (tears, breastmilk, colostrum, saliva). Lines mucous membranes and protects body surfaces.

IgG

Located in the plasma and interstitial fluid, responsible for secondary immune response, only immunoglobulin that crosses placenta.

Which term refers to an excessive inward curvature of the lumbar part of the spine?

Lordosis

Symptoms of cardiogenic shock

Pallor, tachycardia, agitation, cold and clammy skin, low BP with narrow pulse pressure, decreased UOP

What are the integumentary manifestations of chronic kidney disease?

Pruritis, uremic frost, ecchymosis (bruising), purpura, decreased skin turgor, dry skin, yellow-grey pallor, soft tissue calcifications

Which pulse site is used for Allen's test?

Ulnar (clench fist, occlude ulnar and radial arteries, release and see how long it takes for color to return)