NCLEX MEMORY SHAT

Fluids for Burns : Consensus Formula

4mL LR x Wt in kg x TBSA burn (Calculate Amt needed in 1st 24 hours, then give half of it in first 8 hours) -measure CVP hourly to ensure not overloading pt

Normal WBC Lab Value Range

5,000 - 10,000

Total Protein Lab

6.4 - 8.3

LDL Normal range

60- 180

Normal Glucose LAB value

70-110 mg/dL

Normal Calcium Lab value

9.0 - 10.5 mg/dL

Total Cholesterol Norm Lab

< 200

What does ADH do? Whats another name for ADH?

ADH makes you retain water! Another name is vasopressin or desmopressin acetate (DDAVP) may be used for ADH replacement in DI pts

Antidote for Acetaminophin (Tylenol)

Acetylcistine (MucoMyst)

Disease with too little Aldosterone

Addisons

Burns Urine Output

Adults: .5 mL/kg/hr Kids: 1mL/kg/hr

Bedrest induces....

Bedrest induces Dieuresis! -unless contraindicated, if on bedrest, PUSH FLUIDS!

Normal Central Venous Pressure Value

CVP 2-6 mmHg

Normal Central Venus Pressure Values? Where is CVP Measures?

CVP: 2-6 mmHg Measured in Right Atrium

Too Much Magnesium (Hypermagnesemia) - antidote?

Calcium gluconate (IVP slow)

Diseases with too much Aldosterone

Cushings Hyperaldosteronism (CONNs syndrome)

TX's for Excess Potassium

Dialysis Calcium Gluconate (arrythmias) Insulin ( puts glucose and K into cell) Sodium Polystyrene Sulfonate (Kayexlate)

TCA Meds... watch for..

Extrapyrimidal Effects --^Give Benedryl

Atrial Natriuretic Peptide (ANP) Wheres it found? How does it work?

Found in Atria of heart--released when atria stretches Opposite of Aldosterone --ANP excretes Na and Water

IF giving IV Calcium.....

GIVE SLOWLY & pt must be on heart monitor!!!

Glucose-6-phosphate dehydrogenase

Glucose-6-phosphate is an enzyme that assists in glucose metabolism. Deficiency in glucose-6-phosphate dehydrogenase is linked to a genetic defect.

Glycosylated hemoglobin test

Glycosylated hemoglobin: tests the average blood glucose over 90 days

post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority?

-BP! worry they are going into shock

A child is being admitted to the hospital with a diagnosis of acute glomerulonephritis. In performing the history and physical, what would be a priority assessment?

-Has child had a recent sore throat? Acute post-streptococcal glomerulonephritis (APSGN) results from a group A beta-hemolytic streptococci infection

Norm Ammonia Lab

10-80 mg/dL

PT Normal Lab range

11.0 - 12.5 seconds

Normal Hemoglobin LAB value- Female

12 - 16 g/dL

Normal Sodium Lab Value

135- 145 mEq/ L

Normal Hemoglobin LAB value- Male

14 - 18 g/dL

Normal Platelets Lab Range

150,000 - 400,000

Hemoglobin A1C Good Control Range

2.5 - 5.9% Fair= 6-8% Poor = > 8%

aPTT (same as PTT) Norm range

20-36 seconds AKA 1.5-2x the normal

The nurse is caring for a client admitted to rule out myocardial infarction. The nurse has administered sublingual nitroglycerin. What time frame should the nurse expect the earliest onset of effectiveness?

3 mins

Normal Phosphorus Lab (phosphate)

3.0 - 4.5

Normal Albumin Lab

3.5 - 5.0 g/dL

Normal Potassium LAB value

3.5 - 5.0 mEq/L

HDL

45-49 men 50-59 women

Sputum Specimen

best time = 1st thing in morning Treat like sterile specimen 1st have client rinse mouth out with water

what is Confabulation?

creating imaginary events to fill in memory gaps

Best time for Breast self exam?

days 7-12 of menstrual cycle Yearly mammograms start at age 40 Pap smears Q3 yrs start at age 21 Colonoscopy at age 50, every 10 years Men: DRE and PSA annually over 50

ABG NORMAL RANGES

pH: 7.35 -7.45 PaO2: 80-100 mmHg Pa CO2: 35-45 mmHg HCO3: 22-26 mEq/L SaO2: 94-100%

What to do with client who had a chest tube inserted for pleural effusion of the right lung...

semi fowlers put on O2 sat monitor assess respiratory status every 2 hours prevent dependent loops in closed drainage system tubing

Fasting blood glucose

tests immediate glucose levels

what is Apraxia?

the inability to carry out motor activities despite intact motor function

pt thoracentesis with lots of fluid removal...whats priority assessment?

vital signs! not O2

Glucose tolerance test

will show the immediate tolerance to a glucose load

Hepatic Encephalopathy. Which assessments by the nurse suggests that the client is developing this complication?

-Asterixis -Lethargy -Amnesia -Behavioral changes

Which client should the nurse recognize as being at greatest risk for the development of cancer?

-NOT 30 yr smoker.. -answer: Older individual with acquired immunodeficiency syndrome Cancer has a high incidence in the immune deficiency client and in the older adult

POTASSIUM GENERAL FACTS

-Never PUSH -IV K burns -excreted by kidneys, check output before giving -if Oral K, give with food -Inverse with Na -Spironolactone = K sparing dieuretic

What should the nurse include when teaching a client scheduled to receive radioactive iodine?

-Radioactive iodine will leave the body in urine and saliva within a few days. -You cannot receive radioactive iodine if you are pregnant.

which interventions implemented to decrease the risk of DVT?

-apply compression hose -assist in performing active foot and leg exercises -use intermittent sequential compression devices -DO NOT assess Homan's sign...it may dislodge the clot

Antibiotic drugs ending in MYCIN

-can lead to ototoxicity and nephrotoxicity -check BUN & Creatinine

Signs/symptoms would lead a nurse to suspect Fifth disease in a child brought into a pediatric clinic?

-erythema on the cheeks -joint pain -swollen knees -pruitic rash on soles of feet

What adverse effects should the nurse monitor for post ECT procedure?

-malignant hyperthermia -apnea -arrhythmias -HYPERkalemia -profound muscle relaxation

A client requires external radiation therapy. The nurse knows external radiation may cause which problems?

-pancytopenia -erythema -fatigue (NOT FEVER OR EDEMA)

care for a laboring client who is about to be started on oxytocin. What interventions should the nurse include?

-piggyback oxytocin to main IV fluid -d/c if contractions last more then 60 sec -maintain one-on-one pt care; stay with pt -continous monitor for fetal distress/HR -monitor for LATE decels (early are ok)

Which prescriptions would the nurse recognize as being appropriate for the client with shingles?

-private room -negative pressure airflow -respirator mask

Symptoms would indicate to the nurse that the client is having an anaphylactic response after receiving penicillin?

-scratchy throat -wheezing or stridor--any breathing difficulty -pt states "i feel something is wrong" -thready pulse -*BP with systolic below 90 could indicate shock

Halo traction teaching:

-sleep in whatever position is most comfortable -never pull on any part of the halo traction -clean around pins at least twice daily with a new cotton tip for each pin site

risk factors for developing peripheral neuropathy

-uncontrolled diabetes -alcohol abuse -rheumatoid arthritis -varicella-zoster virus

Total Bilirubin Lab

0.3- 1.0 mg/dL

Digoxin Normal range

0.5 - 2 ng/ml

Therapeutic Lithium Level (Psych)

0.6 - 1.2

Normal Magnesium Lab value

1.3-2.1 mEq/L

Normal BUN Lab Range

10-20 mg/dL

Components of APGAR score

1. breathing effort 2. Heart Rate 3. Muscle tone 4. Reflexes 5. Skin color

AIRBORNE precautions = MTV

1. measles 2. TB 3. Varicella/chicken pox , Herpes zoster/shingles

INR Normal range

1.3 - 2.0 -most ppl therapeutic INR is 2.0-3.0

Dont use Isotonic Solutions in which clients?

Hypertensive Cardiac or Renal

The nurse is caring for a newly diagnosed diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate the immediate treatment plan for this client will include?

IV isotonic saline Clients who present with HHNK are severely dehydrated. This is because high glucose levels in the vascular space lead to particle induced diuresing (PID) or osmotic diuresing. The clients lose large amounts of volume out of vascular space. The client may even be "shocky". Isotonic saline is the treatment of choice for clients who are in HHNK.

Best IV solution for shock?

LR

Which electrolytes act like Sedatives?

Magnesium and Calcium! = Sedative effect

Antidieuretic Hormone (ADH) Whats it do? Where does it come from?

Makes you retain Water! Found in Pituitary (frontal brain/sinuses)

What drug may be ordered to flush out kidneys? In burn pt with brown or red urine

Mannitol

Hydromorphone (Dilaudid) : Antidote for Overdose?

Naloxone (Narcan)

Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider?

Nonmaleficence is best illustrated with the nurse's action, as the goal is to do no harm to the client. With timely reporting of an error, further complications may be prevented

Best IV solution when administering blood?

Normal Saline

Calcium has inverse relation with what?

Phosphorus

Aldosterone What does it make you do? Where does it come from?

Retain Sodium and Water Found in Adrenal Gland

How to decrease hypercalcemia

Sodium phosphate (Inverse) Steroids (decrease calcium) vitamin D Calcitonin (decreases serum calcium) Add phosphorus/ protein to diet

The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease?

The gallbladder assists in digestion of fat. When foods high in fat are ingested, bile is released from the gallbladder to assist in digestion. If gallstones are formed in the gallbladder or are blocking the outlet to the gallbladder, the client may experience epigastric discomfort after a meal high in fat.