NCLEX Review Concepts
Measuring fundal height
12 weeks = just above the symphysis pubis 20-22weeks = at the umbilicus 36 weeks = xiphoid process
How much fluid should someone drink per day? How much urine should be produced per hour? minimum and maximum
2,000--3,000mL per day 30mL to 50mL per hour or 0.5mL/kg/hr
What is the Parkland formula?
4mL X weight (kg) X TBSA burned=total infusion volume Patient weighing 85kg with 40% burns 4mL X 85 kg X 40% TBSA =13,600 mL
A perineal pad that is saturated in ____ hour(s) indicates heavy/excessive bleedings?
<1 hour
Clinical signs of fluid volume overload include the following:
•Peripheral edema •Increased urine output that is dilute •acute, rapid weight gain •jugular venous distension •S3 heart sound in adults •Tachypnea, dyspnea, crackles in lungs • Bounding peripheral pulses
What are the developmental milestones of a 2 year old?
Gross motor -walks up/down stairs alone;1 step at a time -runs without falling -kicks ball Fine motor -builds tower of 6 or 7 blocks -when looking at books, turns 1 page at a time -draws line Language -Has a vocabulary of 300+ words -can form phrases of 2 or 3 words -states own name Social/cognitive -begins parallel play -begins to gain independence from parents
Typically the therapeutic INR range for clients receiving warfarin should be:
1.5 to 2 times the normal "control value INR of 2 to 3 for medical reasons such as DVT, Atrial fibrillation, or stroke. 3 to 3.5 is desired for the client with a mechanical heart valve. If the INR is >3.5 warfarin should be held and the HCP should be contacted. An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote
What are the levels of "Maslow's Hierarchy of needs" from bottom (most important) to top (least important)?
(1) Physiological (survival) Oxygen, fluids, nutrition, body temperature, elimination, sleep, shelter, sex. (2) Safety & Security (physical, psychological) Protection, security (3) Love & belonging Family, affection, friendships (4) Self-esteem Achievement, confidence (5) Self-actualization Fulfillment
How are the different forms of the hepatitis virus (A,B,C,D) contracted?
(A) From contaminated food and water and is spread via the fecal-oral route (B) Contact with infected body fluids (blood, sexual fluids, saliva, and tears) (C) Blood-to-blood transmission via intravenously (IV) *(D) spread through contract with infected blood (can only be infected with hep D if you have hep B already) (E) From contaminated food and water and is spread via the fecal-oral route
What are the Absolute contraindication(s) to combined contraceptive pills
-Active breast cancer -Migraines with aura -Uncontrolled hypertension -Active hepatitis, severe cirrhosis, liver cancer -Age >35 & >15 -Ischemic heart disease, stroke -<3 weeks postpartum -Prolonged immobilization -Thrombophilia (e.g, factor V Leiden, antiphospholipid antiboidy syndrome) -Venous thromboembolism
Risk factors for DVT
1. Trauma (endothelial injury and venous stasis from immobility) 2. Major surgery (endothelial injury and venous stasis from immobility) 3. Prolonged immobilization (eg, stroke, long travel) causing venous stasis 4. Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) 5. Oral contraceptives (estrogen is thrombotic) 6. Underlying malignancy (cancer cells release procoagulants) 7. Smoking (produces endothelial damage by inflammation) 8. Old age 9. Obesity and varicose veins (venous stasis) 10. Myeloproliferative disorders (increase blood viscosity)
1. Autonomic dysreflexia (AD [hyperreflexia]) can occur in any individual with a spinal cord injury at? 2. What are the S&S of autonomic dysreflexia? 3. What are the common causes of AD?
1. at or above T6 2. S&S include: -acute onset of throbbing headache -Nausea -blurred vision -uncontrolled hypertension & bradycardia -diaphoresis and skin flushing above the level of the injury 3. common triggers include bladder or rectum distention, tight clothing, and pressure ulcers
Management of the client with PKU includes?
-Monitoring serum levels of phenylalanine -Including synthetic proteins and special formulas in the diet -Eliminating high-phenylalanine foods (meats, eggs, milk) from the diet -Encouraging the consumption of natural foods low in phenylalanine (most fruits and vegetables)
What are the signs and symptoms of cardiac tamponade?
-Narrowed pulse pressure -hypotension -jugular venous distention (JVD) -muffled or distant heart tones -pulsus paradoxus -dyspnea -tachypnea -tachycardia
Implied consent in emergency situations includes the following criteria:
-There is an emergency -Treatment is required to protect the client's health -It is impractical to obtain consent -It is believed that the client would want treatment if able to consent
After less-restrictive safety measures have been ineffective, what should the RN do to ensure patient safety while ensuring that the restraints are effective? 1. Where should the restraint straps be placed on the bed? 2. How should the patient be positioned? 3. How frequent should the patient be assessed with restraints? 4. What sort of knot is used when tying the restraint straps to the bed? 5. What can be placed onto bony prominences under the restraints to prevent skin breakdown?
1. Attach restraints to parts of the bed frame that move with the bed position changes 2. Supine position is avoided to decrease aspiration risk. Side-lying or semi-fowler position promotes drainage of emesis or oral secretions 3. Depends on hospital policy (e.g., q15min) 4. Quick-release knots are used to immediately release knots in case of perfusion compromise. 5. Use gauze to pad bony prominences under restraints
What are the steps in order for performing peak flow measurements
1. Before each use, slide the indicator on the numbered scale on the flow meter to 0 (or the lowest value), and stand or sit as upright as possible. 2. Inhale deeply, place the mouthpiece in the mouth, and close the lips tightly around the mouthpiece to form a seal. 3. Exhale as quickly and completely as possible and note the reading on the numbered scale. 4. Repeat the procedure 2 more times, with a 5- to 10-second rest period between exhalations. 5. Record the highest reading (ie, personal best) in the peak flow log.
metabolic syndrome is characterized by the presence of 3 or more of the following criteria?
1. Increased waist circumference: >40 in men or >35 in women 2. Blood pressure: >130mm Hg systolic or >85 mm Hg diastolic or drug treatment for HTN 3. Triglyceride levels: >150 4. High-density lipoprotein (HDL) levels: <40 in men and <50 in women 5. Fasting glucose levels: >100 or drug treatment for elevated blood glucose.
When mixing insulins what is the correct order that the insulin should be drawn up in?
1. Inject the NPH insulin vial with how ever many units of air you will be removing from the vial, without inverting the vial or passing the needle into the solution. e.g., if you need to take 20 you instill 20 units of air. 2. Inject how many units of air into the regular insulin that you will be taking out of the vial and withdraw the dose, leaving no air bubble. 3. Draw NPH, totaling 26 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the total quantity. Remember You always draw up Clear before cloudy or RN: Regular NPH
What is the criteria for activating the rapid response team (RRT)?
Any staff member is worried about the client's condition OR An acute change in any of the following: •HR <40 or >130/min •SBP <90 mm Hg •RR <8 or >28/min •Oxygen saturation <90% despite oxygen •Urine output <50mL in 4 hours •Level of consciousness
When assessing a patient for skin cancer what rule should you follow?
Asymmetry (e.g., one half unlike the other) Border irregularity Color changes and variation (e.g., different brown or back pigmentation) Diameter of 6 mm or larger (size of a pencil eraser) Evolving (e.g., appearance is changing in shape, size, color)
What is the difference in the ECG strip between Atrial flutter versus Atrial fibrillation?
Atrial fibrillation (AF) is characterized by a total disorganization of atrial electrical activity that results in the loss of effective atrial contraction. P waves are not visible and are replaced by fibrillatory waves. Atrial flutter is characterized by recurring, regular, sawtooth-shaped flutter waves.
What are the nursing interventions for a client that is having a seizure? Before, During, and After
Before -Remove potential sources of injury, place padding -Keep O2 at bedside -Assess therapeutic level of antiepileptic drugs -ID seizure triggers, areas for further client education During -Protect client's head from injury if possible -place client in rescue position (left lateral) -INSERT NOTHING into the mouth -DO NOT RESTRAIN limbs or torso After -Document timing, symptoms -Remain with client -Perform neurological assessment -assess for physical injury
What is the difference between O2 and CO in the body? What is the significance in carbon monoxide (CO) poisoning?
CO has a much stronger bond to hemoglobin than oxygen (O2) does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading. Treatment consist of administering highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to reverse this displacement of oxygen.
What are the Hemodynamic parameters for the following: Cardiac output (CO) Cardiac index (CI) Central venous pressure (CVP) Mean arterial pressure (MAP) Pulmonary artery wedge pressure (PAWP) Systemic vascular resistance (SVR)
Cardiac output=4-8 L/min Cardiac index=2.2-4.0 L/min/m2 Central venous pressure=2-8 mm Hg Mean arterial pressure= 70-105 mm Hg Pulmonary artery wedge pressure=6-12 mm Hg Systemic vascular resistance=800-1200dynes/sec/cm-5
US FDA drug risk categories during pregnancy
Category A: Safe for use in pregnancy -Human & animal studies with no fetal risk Category B: Likely safe to use in pregnancy -Animal studies show fetal risk, human studies showed no risk Category C: Use only if potential benefit outweighs risk -Fetal risk in animal studies without human studies Category D: Potential benefit may justify risk in severe circumstances -Positive fetal risk in human studies Category X: Potential benefits do not justify use in any circumstances -Known and established fetal risk in animal or human studies
What are the developmental milestones of a 18 month old?
Gross motor -walks up/down stairs with help -throws ball overhand -jumps in place Fine motor -builds tower of 3 or 4 blocks -when looking at books, turns 2 or 3 pages at a time -scribbles -uses cup & spoon Language -has vocabulary of 10+ words -Identifies common objects Social/cognitive -has temper tantrums -understands ownership ("mine") -imitates others
What are the differences between the following urinary test's? •Creatinine clearance test •Urine culture sensitivty
Creatinine clearance test: is a measure of glomerular function and is a sensitive indicator of renal disease progression. A 24-hour urine collection is needed for the test. When the test begins, the first urine specimen is discarded and the time is noted. All other voided urine for the next 24-hours is collected in a container and kept cool. At the end of the 24 hours, the client should void one last time and add the specimen to the container. Blood is drawn to measure serum creatinine level in addition to urine creatinine. Urine culture and sensitivity test: is used to determine specific organisms that can be caused urinary dysfunction (e.g., urinary tract infection). Clean catch or midstream urine samples are collected. The first AM void is preferable as an overnight specimen is more concentrated.
What are contact precautions?
Indications: •MDR organisms (e.g., MRSA, VRE) •Enteric organisms (e.g., CDIFF) •Scabies Infection-controled measures: Hand hygiene (soap & water for CDIFF) private room preferred PPE required: nonsterile gloves gown
During a central line tubing change the client suddenly begins gasping for air and writhing...an air embolism is suspected what should the RN do?
Clamp the catheter tubing to prevent more air from embolizing into the venous circulation Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium Administer O2 if necessary to relieve dyspnea Notify the HCP or call an RRT to provide further resuscitation measures Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.
What are the signs and symptoms of delirium tremens?
Confusion, agitation, fever, tachycardia, hypertension, diaphoresis, hallucinations onset since last drink: 48-96 hours
What are the differences between true labor and false labor?
Contractions True labor: -Regular intervals; frequency, duration, & intensity increase over time. -Contractions increase despite comfort measures. False labor: -irregular intervals; no increase in frequency, duration, or intensity; may dissipate over time. -Contractions may lessen or dissipate with comfort measures Cervical change True labor: -Increase in cervical dilation & effacement False labor: -No cervical change
what are the signs and symptoms of diabetes insipidus?
Decreased urine specific gravity (<1.003) Elevated serum osmolality Hypernatremia (>145) Hypovolemia and potential hypotension Polydipsia Polyuria
When descending stairs with a cane the client should? When ascending stairs with a cane the client should?
Descending -Lead with the cane -Bring the weaker leg down next -Finally, step down with the stronger leg Ascending -Step up with the stronger leg first -Move the cane next, while bearing weight on the stronger leg -Finally, move the weaker leg To remember the order, use the mnemonic "up with the good and down with the bad." the cane always moves before the weaker leg.
Priority nursing actions included when performing care for a victim of sexual assault includes?
Determining whether the client has bathed, showered, or douched, as these actions may compromise evidence Educating the victim that a pelvic examination is recommended to identify injuries and collect evidence Obtaining the date of the client's last menstrual period and current method of birth control to ID risk for pregnancy. Performing a head-to-toe assessment to ID physical injuries requiring treatment and thoroughly documenting all injuries on a body map. Providing prophylactic therapies for sexually transmitted infections and pregnancy
When preparing medication from a glass ampule what do you need to know?
Do's Flicking the upper stem ensures removal of medication from the ampule neck To prevent the accidental administration of glass shards, a filter needle rather then an injection needle should be used when withdrawing medication. using sterile gauze to break the ampule neck away from the nurse's body to prevent injury from glass shards Setting the ampule on a flat surface or inverting it to withdrawal the medication Dispose of the glass ampule in a sharps container Don't Air Should NOT be injected into a glass ampule. Ensure that the filter needle does not touch the glass edges, which are not sterile, as this can introduce bacteria.
Which findings are consistent with clients with obstructive sleep apnea?
Excessive daytime sleepiness Morning headaches Snoring during sleep Witnessed episodes of apnea
Manifestations of septic shock include the following:
Fever or hypothermia Hypotension Prolonged capillary refill Tachycardia WBC count: >12,000
What are the differences between first-level priority problems and second level priority problems?
First-level priority problems (ABC's) -Airway -Breathing -Circulation & cardiac (become first priority in cardiac arrest) -vital signs Second level priority problems -Altered mental status -acute pain -untreated medical problems (e.g., hyperglycemia) -chronic pain -acute elimination issues -abnormal lab results -risk for infection -safety
Tracheostomy care
Gather supplies and position client in semi-fowler's position Don PPE: mask, googles, and clean gloves Remove solid dressing and remove clean gloves. Don sterile gloves; remove old disposable cannula and replace with new one Clean around stoma with sterile water or saline; dry and replace sterile gauze pad
What are the risk(s) associated with the following herbal supplements: Ginkgo biloba Ginseng Saw palmetto Black cohosh Kava St. John's wort Licorice Echinacea Ephedra
Ginkgo biloba -increased bleeding risk Ginseng -increased bleeding risk Saw palmetto -mild stomach discomfort Black cohosh -hepatic injury Kava -Severe liver damage St. John's wort -drug interactions: •antidepressant (serotonin syndrome) •oral contraceptives •anticoagulants •digoxin -HTN crisis Licorice -HTN -Hypokalemia Echinacea -Allergic reactions -Dyspepsia Ephedra -HTN -Arrhythmia/MI/sudden death -stroke -seizure
What is the green, yellow, and red zones for peak expiratory flow rate?
Green zone (>80% of personal best): no intervention needed. Yellow zone (50%-79% of personal best): intervention needed (e.g., short-acting bronchodilator [e.g., albuterol] and/or treatment plan modification by the health care provider. Red zone (<50% of personal best): emergency medical care and short-acting bronchodilators required and hospital admission possible.
What are the developmental milestones of a 12 month old?
Gross motor -walks 1st steps independently -crawls up stairs Fine motor -uses 2-finger pincer grasp -hits 2 objects together Language -Says 3-5 words -uses nonverbal gestures (e.g., waving goodbye) Social/cognitive -May have separation anxiety -searches for hidden objects
What are the developmental milestones of a 3 year old?
Gross motor -walks up stairs with alternating feet -pedals tricycle -jumps forward Fine motor -draws circle -feeds self without help -grips crayon with fingers instead of fist Language -can form sentences of 3 or 4 words -asks why questions -states own age Social/cognitive -begins associative play -is toilet trained, except wiping
Know your signs: 1. Trousseau sign 2. Chvostek sign 3. Kernig's sign 4. Brudzinski's sign
Hypocalcemia 1. Trousseau's: blood pressure cuff causes hand to curl inward. 2. Chvostek's: Tap of the cheek causes cheek muscle to twitch. Meningitis 3. Kernig's: Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. 4. Brudzinski's: Severe neck stiffness causes a patient's hips and knees to flex when the neck to flexed.
What are the solutions (isotonic, hypotonic, and hypertonic)?
Hypotonic solutions: 1/2 NS (.45%) 1/3 NS (0.33%) 1/4 NS (.225%) D5W (once in the body) Isotonic solutions: Normal saline Lactated Ringers *D5W (Before administration) 5% dextrose in 1/4 NS Hypertonic solutions: 3% saline 5% saline D10W D50W 5% dextrose in NS 5% dextrose in 1/2 NS 5% dextrose in LR
What are the 12 cranial nerves?
I. Olfactory: smell II. Optic: vision III. Oculomotor: eye movement & pupil constriction IV. Trochlear: eye movement (in, down, laterally) V. Trigeminal: chewing & face sensation VI. Abducens: eye movement laterally VII. Facial: face muscles, taste (2/3 anterior), spit and tears VIII. Vestibulocochlear: hearing and balance IX. Glossopharyngeal: gag reflex, 1/3 posterior taste X. Vagus: swallowing, speech, gag reflex XI. Accessory: neck muscles (shrugging) XII. Hypoglossal: tongue movement CN's 3,4, and 6 are tested together for eye movement deficits
Orthostatic vital signs are positive if a change in the patient blood pressure is?
If any position change produces decreased systolic BP >20 mm Hg, decreased diastolic BP >10 mm Hg and or increased pulse >20/min from supine values the client should be placed in the recumbent position and the HCP should be notified. Each measurement should be obtained after maintain each position (supine, sitting, and standing) for 2 minutes.
What are airborne precautions?
Indications: •Tuberculosis •Varicella (chicken pox) •Herpes Zoster (shingles) •Rubeola (Measles) PPE required: -N95 respirator or powered air-purifying respirator -As needed if contact with body fluid is anticipated: clean gloves, disposable gown, goggles/face shield. Infection-controled measures: -Negative-pressure isolation room with high-efficiency particulate air filter
How do you calculate Mean Arterial Pressure (MAP)?
MAP=systolic blood pressure + (Diastolic blood pressure X 2)/3 A normal MAP is 60-105mm Hg. A map <60 mm Hg will not allow for adequate perfusion of vital organs
Precipitating factors of delirium are numerous and include?
Medications (e.g., opioids) Electrolyte imbalances Hypoxia acute infection (e.g., fever, positive culture) Sleep deprivation Dehydration or malnutrition metabolic disorders (e.g., hypoglycemia)
What is the difference between Myopia and Hyperopia?
Myopia (nearsightedness), is reduced visual acuity when viewing objects at a distance. Near vision is usually intact, and many people with myopia report needing to hold objects near their face or sit near objects to see clearly. Hyperopia (farsightedness), is reduced visual acuity when viewing near objects; but able to see clearly far.
What is the management for a patient who has acute pancreatitis?
NPO status: Prevents the stimulation and release of pancreatic enzymes. Nasogastric tube: used to suction out gastric secretions Pain management: IV fluids: prevents hypovolemic shock
What is the recommended rate for an intermittent I V infusion of potassium chloride (KCl)?
No greater than 10 mEq over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr when infused though a central line.
When exiting the room of a client on airborne precautions what is the following order your PPE is removed in?
Place the call light within the client's reach. Remove the gown and gloves without contaminating hands. Discard the gown and gloves and perform hand hygiene. Exit the negative-pressure room and close the door. Remove the N95 respirator mask and perform hand hygiene
What are the different phases of a seizure?
Prodromal phase: is the period with warning signs that precede the seizure Aural phase: is the period before the seizure when the client may experience visual or other sensory changes. Ictal phase: is the period of active seizure activity Postictal phase: period after the seizure. during this period the client may experience confusion and headache as they recover.
Signs and symptoms of tardive dyskinesia (TD) include:
Protruding and twisting of the tongue Lip smacking Puffing of cheeks Chewing movements Frowning or blinking of eyes Twisting fingers Twisted or rotated neck (torticollis)
What are the Onset, Peak, and duration of the different types of insulins?
Rapid acting: Onset: 15-20" Peak: 1-2 hr Duration: 3-4 hr Short acting: Onset: 30" Peak: 2-4 hr Duration: 5-8 h Intermediate acting: Onset: 1-1.5 hr Peak: 4-12 hr Duration: 16-24' Long acting: Onset: 2-4 h Peak: none Duration: 24 h **ultra-long acting w 42 h duration Inhaled insulin: Onset: 15" Peak: 30" Duration: 2-3 h
What is the only insulin that can be administered via IV push?
Regular insulin; All other forms of insulin should NOT be pushed via IV route.
Describe the Heart sound & locations using the proper anatomy and terminology.
Remember "APE-To-Man" Aortic -2nd ICS to the right sternal border Pulmonic -2nd ICS to the left sternal border Erb's point -3rd ICS to the left sternal border Tricuspid -5th ICS to the lower left sternal border Mitral -Apex (top), PMI & 5th ICS at MCL (mid-clavicular line)
What are the symptoms of hypoglycemia? Hypoglycemia treatment in a CONSCIOUS client consist of?
S&S Sweating & pallor Irritability Tremors & weakness Tachycardia Drowsiness Hunger Treatment in a conscious client is administration of 15 g of a quick-acting carbohydrate. After treatment recheck BG q15min 15 g of quick-acting carbs -4 oz of a regular soft drink or fruit juice -8 oz of low-fat milk -1Tbsp of honey or syrup -6 hard candies -Commercial dextrose products
How to use a metered-dose inhaler (MDI)
Shake MDI and attach it to spacer Exhale completely Place lips tightly around the mouth piece Deliver one puff of medication into spacer take a slow deep breath and hold for 10 seconds Rinse mouth with water Any child under age 12 should use a spacer with the MDI to ensure the entire dose is inhaled appropriately.
BMI (body mass index) ranges
Underweight - Less than 18.5 Normal - 18.5 - 24.9 Overweight - 25 - 29.9 Obese I - 30 - 34.9 Obese II - 35 - 39.9 Obese III - 40+
What are the signs and symptoms of major depression? Remember "SIGECAPS"
Sleep (increased or decreased) Interest deficit (anhedonia) Guilt (worthless, hopeless) Energy deficit Concentration deficit Appetite (increased or decreased) Psychomotor retardation or agitation Suicidality
What are the different stages of birth?
Stage 1: Latent: 0-5 cm cervical dilation Active: 6-10 cm cervical dilation Stage 2: 10 cm (complete) cervical dilation to birth Stage 3: Birth of baby to expulsion of placenta Stage 4: 1 to 4 hours after birth, maternal physiologic readjustment
What are the different levels of infection precautions and what are the required PPE and rooms required?
Standard precaution (lowest precaution) -gloves -Required for every patient when coming into contact with potential infectious material. Contact precaution -gloves & gown e.g., MRSA, CDIFF, and VRE Droplet precaution -gloves, gown, surgical mask, goggles, and face mask Airborne precaution (highest precaution) -gloves, gown, N95 mask, goggles, and face mask -Negative pressure room Immunocompromised rooms consist of a positive pressure room and typically involved droplet precaution according to hospital policies.
What are the steps for a client who is experiencing an anaphylactic reaction to an IV medication?
Stop the infusion and call for help Assess airway and place client on oxygen Give IM epinephrine and start IV normal saline Administer adjunctive therapies: bronchodilators, antihistamines, and corticosteroids to decrease airway inflammation and swelling associated with the allergic reaction. Monitor vital signs for changes
FLACC scale is used for
The FLACC scale (face, legs, activity, cry, consolability) can be used to assess pain in nonverbal clients who are receiving end of life care.
Which vaccines contain live viruses and are contraindicated in pregnancy and immunocompromised patients?
The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine contain live viruses Influenza injection, Tetanus, diphtheria, and pertussis (whooping cough)
What is the therapeutic aPTT range for clients receiving unfractionated heparin (anticoagulant)?
The normal aPTT is 25 to 35 seconds. Typically 1.5 to 2 times the normal value. Therapeutic value for aPTT is 46 to 70 seconds.
what is the PTT
The normal reference range is typically 25-35 seconds
signs and symptoms of fat embolism syndrome (FES)
Triad of symptoms: Respiratory distress (SpO2 showing hypoxia) mental status changes (confusion & restlessness) petechial skin rash (over the neck and chest [picture])
Myocardial infarction symptoms are different in females compared to their male counterparts, what are the things to look out for?
They can be vague in female clients and can include nausea, Pain or discomfort in one or both arms, the upper back, neck, jaw or stomach.
When administering a tuberculin (TB) skin test what does the RN need to know?
Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe Administer injection on inner forearm and insert the needle almost parallel to skin at a 10-degree angle with bevel up. Advance the tip of the needle through epidermis into dermis; Outline of bevel SHOULD be VISIBLE under the SKIN. Make a wheal (bleb), and instruct client to avoid rubbing site after injection. Circle the area with a pen The site must be assessed 48-72 hours later for a reaction afterward. Reactions are positive when 15mm or larger.
What is the Glasgow Coma Scale used for?
Used to asses the level of consciousness and neurological functioning after a TBI by measuring eye opening, best motor response, and best verbal response
The procedure for safe blood administration includes the following:
Verify the blood product with another nurse at the client's bedside obtain vital signs for baseline before administration begins Use a Y tubing, prime with ONLY normal saline; The saline is only used to prime the tubing and flush after the infusion. It does not infuse simultaneously. set the infusion pump to deliver blood over 2 to 4 hours Remain with the client for at least the first 15 minutes and watch for sings of blood transfusion reaction. If adverse reaction occurs STOP the transfusion immediately. Take another set of vital sings 15 minutes after infusion starts and continue in accordance with policy. Always take a final set once infusion completed. On completion of the transfusion open the saline side clamp of the Y tubing to flush all blood in the tubing though with NS. Return the blood bag with the attached set-up to the lab after completion or dispose of in accordance with hospital policy. Always use new IV Y tubing if second unit of blood is ordered.
What is the proper way to Don and Doft PPE in relationship to airborne precautions?
When donning airborne PPE you should? When dofting airborne PPE you should?
Which administering an otic medication which way does the pinna go up?
adults or child age 3 and older, the pinna is pulled upward and back. for children under 3 the pinna is pulled downwards
What are the signs and symptoms of Neuroleptic malignant syndrome?
characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (e.g., diaphoresis, hypertension, tachycardia). NMS is most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome.
What are the weight milestones for a child in relationship to the child's birth weight?
doubles by 6 months triples by 12 months (1y) quadruples by 30 months (2.5y)
What are the oxygen concentrations for the various oxygen delivery devices?
find out accurate information****
Dumping syndrome is characterized by the following signs and symptoms? What are the recommendations to prevent this from happening?
hypotension abdominal pain N/V Dizziness generalized sweating Tachycardia Recommendation to delay gastric emptying and avoid dumping syndrome include: -Consume meals high in fat, protein, and fiber -Avoid consuming fluids with meals -slowly consume small, frequent meals -avoid meals high in simple carbohydrates -avoid sitting up after a meal, instead lying down after meals is encouraged
The clinical findings of shaken baby syndrome are?
lethargy, vomiting, retina bleeding, seizures, irritability, inability to eat, and inconsolable crying. severe shaking episodes can result in breathing difficulty and lifelessness
The Apgar scale measures the:
newborn's condition following birth.
Normal adult ABG values at sea level are?
pH: 7.35 to 7.45 PaO2: 80 to 100 mm Hg PaCO2: 35 to 45 mm Hg HCO3: 22 to 26 mEq/L Saturation (SaO2): 95% to 100% ABG's best evaluate the client's oxygenation and ventilation status
What is an indirect Coombs test used for?
screens for Rh sensitization in Rh-negative mothers. If the test results are positive, the fetus and subsequent pregnancies are at risk for serious complications. Rh immune globulin (e.g., RhoGAM) is given at 28 weeks gestation and within 72 hours postpartum as well as any time there is maternal trauma.
What is the "Scope of Practice" for a LPN detail?
•Monitoring RN findings •Reinforcing already taught education •Routine procedures (e.g., catherization) •Most medication administrations •Ostomy care •Tube patency & enteral feeding •Specific assessments* (e.g., lung/bowel sounds & neurovascular checks) *Don't get tricked LPN's cannot perform any blood or chemotherapy transfusions that is only done by an RN
Pressure injury staging
stage 1: non blanchable erythema of intact skin stage 2: partial-thickness skin loss with exposed dermis stage 3: full-thickness skin loss stage 4: full-thickness skin and tissue loss unstageable: obscured full-thickness skin and tissue loss. The extent of the damage cannot be confirmed because it is obscured by slough or eschar deep tissue pressure injury: persistent non-blanchable deep red, maroon, or purple discoloration
What is Naegel's formula?
the last menstrual period minus 3 months plus 7 days e.g., the clients last menstrual period was September 7th....According to Naegele's rule, the expected date of delivery is June 14th.
The Bishop scoring system:
used to determine if mom is a good candidate for induction. ≥6 to 8 is okay to induce
Types of impaired thought processes seen in individuals with schizophrenia include the following: -Neologisms -Concrete thinking -Loose associations -Echolalia -Tangentiality -Word salad -Clang associations -Perseveration
• Neologisms - made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox." • Concrete thinking - literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener • Loose associations - rapid shifting from one idea to another, with little or no connection to logic or rationality. • Echolalia - repetition of words, usually uttered by someone else • Tangentiality - going from one topic to the next without getting to the point of the original idea or topic • Word salad - a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table, sky, apple." Clang associations - rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the bike near the tyke. • Perseveration - repeating the same words or phrases in response to different questions
What is the "Scope of Practice" for a UAP detail?
•Activities of daily living •Performing personal hygiene and skin care (oral care, bathing) •Linen change •Routine, stable vital signs (measuring and obtaining blood glucose levels) •Documenting I&O's (urinary, drainage) • Performing passive and /or active range-of-motion exercises •Positioning
What is the "Scope of Practice" for a RN detail?
•Clinical assessment •Initial and discharge client education •Clinical judgment •Imitating blood transfusion *use the acronym PACET when trying to determine RN delegation Planning Assessing Collaboration Evaluation Teaching
To avoid pyrosis, or heartburn related to conditions like GERD what lifestyle changes should the person make for reducing discomfort related to these conditions?
•Keep the head of the bed •Elevated using pillows •Sit upright after meals •Eat small, frequent meals •Avoid tight-fitting clothing •Eliminate common dietary trigger (e.g., fried/fatty foods, caffeine, citrus, chocolate, spicy foods, tomatoes, carbonated drinks, peppermint)
