Hesi Exit Exam Prep Questions and Answers


Always prioritize by ABCs!

      Airway: physical airway       Breathing: pneumo/lung issues       Circulation: bleeding/heart

Nursing Process

1.      Assessment 2.      Diagnosis (Analysis) 3.      Planning 4.      Implementation (treatment) 5.      Evaluation

Maslow's Hierarchy of Needs

1.     Physiologic 2.     Safety 3.     Love and Belonging 4.     Esteem 5.     Self-actualization
Top 5 Nursing Interventions (What is the priority/next action Questions) HESI prioritizes interventions in this order. When you are figuring out what to do, find out where you are in this list and do the next intervention. (Answer interventions that are in the scope of the nurse. If one of the priority actions is "Prepare the patient for surgery," that is usually the WRONG answer because that is not up to us.)         1.   Check your patient 1.       Monitor, assess, ask Hx. 2.       Assess for signs of distress (low BP, etc) 3.       If you already have numbers, you do NOT need to assess anymore; take action! 4.       Seeing dyspnea is enough of a sign/symptom to know DISTRESS! Intervene! 2.        Change position 1.       Change patient to a better position if their current position is not adequate. 2.       Patient is prone then becomes dyspneic. Elevate the HOB before anything. 3.       She said "HESI will rarely ask you to position in unusual positions (trendelenburg) or above 45 degrees. 3.       Administer O2/Obtain O2 sats 1.       "HESI will never ask you to go above 6L. Anything above O2 at 6L is the wrong answer." 4.       Notify HCP 1.       If nursing intervention will not work, call the HCP. 2.       "If the patient is blue, there's nothing you can do! Call the HCP" 1.  Pt is cyanotic, it's beyond our hands. 5.       Document the findings.

Normal Lab Values

Hgb        Males 14-18        Females 12-16 Hct        Males 42-52        Females 37-47 RBCs        Males 4.7-6.1 million        Females 4.2-5.4 million WBCs        4.5-11k Platelets        150-400k PT (Coumadin/Warfarin)        11-12.5 sec (INR and PT TR = 1.5-2 times normal) APTT (Heparin)        0-70 sec (APTT and PTT TR = 1.5-2.5 times normal) BUN 10-20 Creatinine 0.5-1.2

Glucose 70-110 Cholesterol - 125-200mg/dl Bilirubin Newborn 1-12 mg/dl

Phenylalanine Newborn -screening- 1 in 10,000 - Normal: 0.5mg -1mg/dl Na+ 136-145 K+ 3.5-5

HypoK+ . . . Prominent U waves, Depressed ST segment, Flat T waves HyperK+ . . . Tall T-Waves, Prolonged PR interval, wide QRS

Ca++ 9-10.5 Hypocalcemia ... muscle spasms, convulsions, cramps/tetany, + Trousseau's, + Chvostek's, prolonged ST interval, prolonged QT segment Mg+ 1.5-2.5 Cl- 96-106 Phos 3-4.5 Albumin 3.5-5 Low albumin = edema

Spec Gravity 1.005-1.030

Glycosylated Hemoglobin (Hgb A1c): 4-6% ideal, Dilantin TR = 10-20 Lithium TR = 0.5-1.5

Arterial Blood Gases ... Used for Acidosis vs. Alkalosis

       PH 7.35-7.45        CO2 35-45 (Respiratory driver) ... High = Acidosis        HCO3 22-26 (Metabolic driver) ... High = Alkalosis        O2 80-100        O2 Sat 95-100% *remember: As pH goes, so does the patient. (Except for potassium and urine output)  pH and bicarb same direction, it’s metabolic! Opposite direction is respiratory Think of CO2 as acid and HCO3 as Base.


Digoxin - Digiband Coumadin - Vitamin K (Keep PT and INR @ 1-1.5 X normal) Benzodiazepines - Flumazenil (Romazicon) Magnesium Sulfate - Calcium Gluconate Heparin - Protamine Sulfate (Keep APTT and PTT @ 1.5-2.5 X normal) Tylenol - Acetylcysteine / mucomyst Opiates (narcotic analgesics, heroin, morphine) - Narcan (Naloxone) Cholinergic Meds (Myasthenic Bradycardia) - Atropine Methotrexate - Leucovorin

Triage Ordering: (START system)

       Immediate (red)        Delayed (yellow)        Walking wounded/minor (green)        Deceased/expectant (black)        Inevitably dead = last priority Signs of inevitable death: ○ Agonal respirations/Cheyenne-Stokes ○ Open head wound & comatose Patients who are breathing and have any of the following conditions are classified as immediate:        Respiratory rate greater than 30 per minute;        Radial pulse is absent, or capillary refill is over 2 seconds;        Unable to follow simple commands All other patients are classified as delayed. The only medical intervention used prior to declaring a patient deceased is an attempt to open the airway. Any patient who is not breathing after this attempt is classified as deceased and given a black tag. No further interventions or therapies are attempted on deceased patients until all other patients have been treated.


Which Patient To See First (subjective order) 1.       The sickest patient (most unstable/symptoms) 2.       Change in LOC/sudden change in condition 3.       Patient with "unrelieved" symptom/pain despite treatment 4.       Time frame- recent surgery 5.       Old (probably less of a priority) Sepsis workup prioritization: 1.      Measure lactate 2.      Obtain blood cultures 3.      Administer abx 4.      Start fluids (lactated ringers) 5.      Begin vasopressors ALWAYS get cultures before starting abx for any reasons, and stop abx if viral


RN Only:       Assess a patient       Handle complicated meds/IV meds       Start IV       Triage       Education       Blood Products (2 RNs must check)       Clotting Factors       Sterile dressing changes and procedures       Assessments that require clinical judgment       Ultimately responsible for all delegated duties What a UAP/CNA can do       Obtain finger stick (blood sugar)       Record/measure numbers (urine output)       Transport patient       Non-urgent Call What a PN/LP/LVN can do       Give medications       Injections: SubQ, IM       Routine sterile procedures                            Catheter                             NG tube       Reinforce teaching       Can NOT do anything invasive, e.g., can not insert IV

Precautions & Room Assignments

Universal (Standard) Precautions ... HIV initiated        Wash hands        Wear Gloves        Gowns for splashes        Masks and Eye Protection for splashes and droplets        Don't recap needles        Mouthpiece or Ambu-bag for resuscitation        Refrain from giving care if you have skin lesion Droplet (Respiratory) Precautions (Wear Mask)        Sepsis, Scarlet Fever, Strep, Fifth Disease (Parvo B19), Pertussis, Pneumonia, Influenza, Diphtheria, Epiglottitis, Rubella, Rubeola, Meningitis, Mycoplasma, Adenovirus, Rhinovirus        RSV (needs contact precautions too)        TB ... Respiratory Isolation Contact Precautions = Universal + Goggles, Mask and Gown No infection patients with immunosuppressed patients

Weird Miscellaneous Stuff

Rifampin (for TB) ... Rust/orange/red urine and body fluids Pyridium (for bladder infection) ... Orange/red/pink urine Glasgow Coma Scale  <8, you intubate If someone is electrocuted, the body muscles are damaged and it releases myoglobin, which may clog kidneys! So worry about kidneys. If someone suffers from crush injury, intracellular K+ is released so worry about hyperkalemia/dysrhythmias. .

Acid-Base Balance

       If it comes out of your A**, it's Acidosis.        Vomiting = Alkalosis Skin Tastes Salty = Cystic Fibrosis Lipitor (statins) in PMs only - No grapefruit juice Stroke ... Tongue points toward side of lesion (paralysis), Uvula deviates away from the side of lesion (paralysis) Hold Digoxin if HR < 60 Stay in bed for 3 hours after first ACE Inhibitor dose ACE Inhibitors SE: dry cough; angioedema Avoid Grapefruit juice with Ca++ Channel Blockers Anthrax = Multi-vector biohazard Pulmonary air embolism prevention = Trendelenburg (HOB down) + on left side (to trap air in right side of heart) Head Trauma and Seizures ... Maintain airway = primary concern Peptic Ulcers ... Feed a Duodenal Ulcer (pain relieved by food) ... Starve a gastric ulcer Acute Pancreatitis ... Fetal position, Bluish discoloration of flanks (Turner's Sign), Bluish discoloration of periumbilical region (Cullen's Sign), Board like abdomen with guarding ... Self digestion of pancreas by trypsin. Hold tube feeding if residual > 100mL In case of Fire ... RACE (rescue, alarm, confine, extinguish) and PASS (pull, aim, squeeze, sweep) Check Restraints every 30 minutes ... 2 fingers room underneath Guillain-Barre Syndrome: Weakness progresses from legs upward - Resp arrest Trough draw = ~30 min before scheduled administration                                                              Peak Draw = 30-60 min after drug administration.

Mental Health & Psychiatry

Psych Nursing Priority Interventions: 1.       Remove to Cool, Calm, Quiet environment 2.       Listen 3.       Medicate 4.       Supervise Most suicides occur after beginning of improvement with increase in energy leveled MAOIs ... Hypertensive Crisis with Tyramine foods        Nardil, Marplan, Parnate        Need 2 wk gap from SSRIs and TCAs to admin MAOIs Sexual dysfunction is common with psychiatric meds- watch for noncompliance. Welbutrin is one of the only antidepressants w/o sex dysfuntion. ALWAYS wean slowly on and off of psych meds- and ensure that there are family or trusted support to monitor and protect pt especially in times of weaning. Effexor has terrible withdrawal effects- educate on appropriate dosing and discontinuation. Lithium Therapeutic Range = 0.5-1.5- Avoid low sodium diets and dehydration because this can increase the risk of lithium toxicity Phenothiazines (typical antipsychotics) - EPSEs, Photosensitivity Atypical Antipsychotics - work on positive and negative symptoms, less EPSEs Benzos (Ativan, Lorazepam, etc) good for Alcohol withdrawal and Status Epilepticus Antabuse for Alcohol deterrence - Makes you sick with ETOH intake Alcohol Withdrawal = Delerium Tremens - Tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia ... (DTs start 12-36 hrs after last drink) Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose, pinpoint pupils, N/V/D, cramps Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep

Medical-Surgical Miscellaneous

Hypoventilation = Acidosis (too much CO2) Hyperventilation = Alkalosis (low CO2) No BP or IV on side of Mastectomy

Opiate OD = Pinpoint Pupils

Lesions of Midbrain = Decerebrate Posturing (Extended elbows, head arched back) Lesions of Cortex = Decorticate Posturing (Flexion of elbows, wrists, fingers, straight legs, mummy position) Urine Output of 30 mL/hr = minimal competency of heart and kidney function Kidney Stone = Cholelithiasis        Flank pain = stone in kidney or upper ureter        Abdominal/scrotal pain = stone in mid/lower ureter or bladder

Renal Failure- Restrict protein intake

       Fluid and electrolyte problems: Watch for HyperK+ (dizzy, wk, nausea, cramps, arrhythmias)        Pre-renal Problem = Interference with renal perfusion        Intra-renal Problem= Damage to renal parenchyma        Post-renal Problem = Obstruction in UT anywhere from tubules to urethral meatus.        Usually 3 phases (Oliguric, Diuretic, Recovery)        Monitor Body Wt and I&Os Steroid Effects = Moon face, hyperglycemia, acne, hirsutism, buffalo hump, mood swings, weight gain - Spindle shape, osteoporosis, adrenal suppression (delayed growth in kids) . . . (Cushing's Syndrome symptoms) Addison's' Crisis = medical emergency (vascular collapse, hypoglycemia, tachycardia ... Admin IV glucose + corticosteroids) ... No PO corticosteroids on empty stomach Potassium sparing diuretic = Aldactone (Spironolactone) ... Watch for hyperK+ with this and ACE Inhibitors. Cardiac Enzymes ... Troponin (1 hr), CKMB (2-4 hr), Myoglobin (1-4 hr), LDH1 (12-24 hr) MI Tx ... NTG - Yes ... NO Digoxin, Beta Blockers, Atropine Fibrinolytics = Streptokinase, Tenecteplase (TNKase) CABG = Coronary Artery Bypass Graft PTCA = Percutaneous Transluminal Coronary Angioplasty Sex after MI okay when able to climb 2 flights of stairs without exertion (Take nitro prophylactically before sex) BPH Tx = TURP (Transurethral Resection of Prostate) ... some blood for 4 days, and burning for 7 days post-TURP. Only isotonic sterile saline for Bladder Irrigation Post Thyroidectomy - Keep tracheostomy set by the bed with O2, suction and Calcium gluconate Pericarditis ... Pericardial Friction Rub, Pain relieved by leaning forward Post Strep URI Diseases and Conditions:        Acute Glomerulonephritis        Rheumatic Fever ... Valve Disease        Scarlet Fever If a chest-tube becomes disconnected, do not clamp- put end in sterile water Chest Tube drainage system should show bubbling and water level fluctuations (tidaling with breathing) TB- Treatment with multidrug regimen for 9 months. Rifampin reduces the effectiveness of OCs and turns pee orange. Isoniazid (INH) increases Dilantin blood levels Use bronchodilators before steroids for asthma:  Exhale completely, Inhale deeply, Hold breath for 10 seconds Ventilators: Make sure alarms are on & check every 4 hours minimum Suctioning: Pre and Post oxygenate with 100% O2. No more than 3 passes, no longer than 15 seconds. Suction on withdrawal with rotation COPD:        Emphysema = Pink Puffer        Chronic Bronchitis = Blue Bloater (Cyanosis, Rt sided heart failure = bloating/edema) O2 Administration        Never more than 6L/min by cannula        Must humidify with more than 4L/hr        No more than 2L/min with COPD ... (CO2 Narcosis)        In ascending order of delivery potency: Nasal Cannula, Simple Face Mask, Nonrebreather Mask, Partial Rebreather Mask, Venturi Mask        Restlessness and Irritability = Early signs of cerebral hypoxia IVs and Blood Product Administration: 18-19 gauge needle for blood with filter in tubing Run blood with NS only and within 30 minutes of hanging monitor VS and watch for unusual back pain (or other s/sx of rxn) Vitals and Breath Sounds ... before, during and after infusion (15 min after start, then 30 min later, then hourly up to 1 hr after) Check Blood: Exp Date, clots, color, air bubbles, leaks 2 RNs must check order, pt, blood product ... Ask Pt about previous transfusion Hx Stay with Pt for the first 15 minutes- if rxn occurs, immediately stop and KVO with NS Premedicate with Benadryl prn for previous urticaria rxns Isotonic Solutions        D5W        NS (0.9% NaCl)        Lactated Ringers        NS only with blood products and Dilantin


Leukemia: Anemia (reduced RBC production), Immunosuppression (neutropenia and immature WBCs), Hemorrhage and bleeding tendencies (thrombocytopenia)
       Acute Lymphocytic = most common type, kids, best prognosis (ALL is ‘ALLways’ better than AML) Testicular Cancer ... Painless lump or swelling testicle ... STE in shower > 14 yrs ... 15-35 = Age Prostate Cancer ... > 40 = Age        PSA elevation        DRE
       Mets to spine, hips, legs
       Elevated PAP (prostate acid phosphatase)
       TRUS = Transurethral US
       Post Op ... Monitor of hemorrhage and cardiovascular complication Cervical and Uterine Cancer
       Laser, cryotherapy, radiation, conization, hysterectomy, exenteration ... Chemotherapy = No help
       PAP smears should start within 3 years of intercourse or by age 21 Ovarian Cancer = leading cause of death from gynecological cancer Breast Cancer = Leading cause of cancer in women
       Upper outer quadrant, left > right
       Monthly SBE
       Mammography ... Baseline @ 35, Annually after age 50
       Mets to lymph nodes, then lungs, liver, brain, spine
       Mastectomy ... Radical Mastectomy = Lymph nodes too (but no mm resected)
       Avoid BP measurements, injections and venipuncture on surgical side Antiemetics given with Chemotherapy Agents (Cytoxan, Methotrexate, Interferon, etc.)
       Phenergan (Promethazine HCl)
       Compazine (Prochlorperazine)
       Reglan (Metoclopramide)
       Benadryl (Diphenhydramine)
       Zofran (Ondansetron HCl)
       Kytril (Granisetron)

Warning Signs of Cancer in Children

C   continued or unexplained wt loss H        headaches with vomiting in the morning I           increased swelling, persistent pain in bones, jts     L    lump or mass in abdomen, neck, or elsewhere D   development of whitish appearance in pupil R    recurrent fevers not due to infection E    excessive bruising or bleeding N   noticeable paleness or prolonged tiredness Iron Deficiency Anemia: Give Iron on empty stomach with citrus juice (vitamin C enhances absorption), Use straw or dropper to avoid staining teeth, Tarry stools, limit milk intake *If parenteral iron is required, use Z-track method for administration to prevent staining the skin* Sickle Cell Disease: Hydration most important!! SC Crisis = fever, abd pain, painful edematous hands and feet (hand-foot syndrome), arthralgia. Crisis is precipitated by hypoxia!                    Tx: rest, hydration. Avoid high altitude and strenuous activities

Sexually Transmitted Diseases

Syphilis (Treponema pallidum) ... Chancre + red painless lesion (Primary Stage, 90 days) ... Secondary Stage (up to 6 mo) = Rash on palms and soles + Flu-like symptoms ... Tertiary Stage = Neurologic and Cardiac destruction (10-30 yrs) ... Treated with Penicillin G IM. Gonorrhea (Neisseria Gonorrhea) ... Yellow green urethral discharge (The Clap) Chlamydia (Chlamydia Trachomatis) ... Mild vaginal discharge or urethritis ... Doxycycline, Tetracycline Trichomoniasis (Trichomonas Vaginalis) ... Frothy foul-smelling vaginal discharge ... Flagyl Candidiasis (Candida Albicans) ... Yellow, cheesy discharge with itching ... Miconazole, Nystatin, Clomitrazole (Gyne-Lotrimin) Herpes Simplex 2 ... Acyclovir HPV (Human Papillomavirus) ... Acid, Laser, Cryotherapy HIV ... Cocktails

Perioperative Care

Breathing is taught in advance (before or early in pre-op) Remove nail polish (need to see cap refill) Pre Op ... Meds as ordered, NPO X 8 hrs, Incentive Spirometry & Breathing Es taught in advance, Void, No NSAIDS X 48 hrs Increased corticosteroids for surgery (stress) ... May need to increase insulin too Post Op restlessness may = hemorrhage, hypoxia Wound dehiscence or extravasation ... Wet sterile NS dressing + Call Dr. Post Op Monitoring VS and BS ... Every 15 minutes the first hour, Every 30 min next 2 hours, Every hour the next 4 hours, then Every 4 hours prn 1-4 hrs Post Op = Immediate Stage ... 2-24 hrs Post Op = Intermediate Stage ... 1-4 days Post Op = Extended Stage Post Op Positioning        THR ... No Adduction past midline, No hip flexion past 90 degrees        Supratentorial Sx ... HOB 30-45 degrees (Semi-Fowler)        Infratentorial Sx ... Flat        Phlebitis ... Supine, elevate involved leg        Harris Tube ... Rt/back/Lt - to advance tube in GI        Miller Abbott Tube ... Right side for GI advancement into small intestine        Thoracocentesis ... Unaffected side, HOB 30-45 degrees        Enema ... Left Sims (flow into sigmoid)        Liver Biopsy ... Right side with pillow/towel against puncture site        Cataract Sx ... Opp side - Semi-Fowler        Cardiac Catheterization ... Flat (HOB no more than 30 degrees), Leg straight 4-6 hrs, bed rest 6-12 hrs        Burn Autograph ... Elevated and Immob 3-7 days        Amputation ... Supine, elevate stump for 48 hrs        Large Brain Tumor Resection ... On non-operative side Incentive Spirometry ... Inhale slowly and completely to keep flow at 600-900, Hold breath 5 seconds, 10 times per hr Post Op Breathing Exercises- Q2H


Sit up straight        Breath in deeply thru nose and out slowly thru pursed lips        Hold last breath 3 seconds        Then cough 3 times (unless abd wound - reinforce/splint if cough) Watch for Stridor after any neck/throat Sx & keep trach kit at bed side Staples and sutures removed in 7-14 days - Keep dry until then No lifting over 10 lbs for 6 weeks (in general) If chest tube comes disconnected, put free end in container of sterile water Removing Chest Tube- Valsalvas, or Deep breath and hold If chest tube drain stops fluctuating, the lung has re-inflated (or there is a problem) Keep scissors by bed if pt has S. Blakemore Tube (for esoph varices) if sudden respiratory distress - Cut inflation tubes and remove Tracheostomy patients- keep Kelly clamp and Obturator (used to insert into trachea then removed leaving cannula) at bedside Turn off NG suction for 30 min after PO meds NG Tube Removal ... Take a deep breath and hold it Stomach contents pH = normally 1.5-3.5 NG Tube Insertion- If cough and gag, back off a little, let calm, advance again with pt sipping water from straw NG Tube Length: End of nose, to ear lobe, to xiphoid (~22-26 inches) Decubitus (pressure) Ulcer Staging        Stage 1 = Erythema only        Stage 2 = Partial thickness        Stage 3 = Full thickness to SQ        Stage 4 = Full thickness + involving mm /bone

Acute Care

VA ... Hemorrhagic or Embolic        A-fib and A-flutter = thrombus formation        Dysarthria (verbal enunciation/articulation), Apraxia (perform purposeful movements), Dysphasia (speech and verbal comprehension), Aphasia (speaking), Agraphia (writing), Alexia (reading), Dysphagia (swallowing)        Left Hemisphere Lesion ... aphasia, agraphia, slow, cautious, anxious, memory okay        Right Hemisphere Lesion ... can't recognize faces, loss of depth perception, impulsive behavior, confabulates, poor judgment, constantly smiles, denies illness, loss of tonal hearing Head Injuries ...        Even subtle changes in mood, behavior, restlessness, irritability, confusion may indicate increased ICP        Change in level of responsiveness = Most important indicator of increased ICP        Watch for CSF leaks from nose or ears - Leakage can lead to meningitis and mask intracranial injury since usual increased ICP symps may be absent. Spinal Cord Injuries        Respiratory status paramount ... C3-C5 innervates diaphragm        1 wk to know ultimate prognosis        Spinal Shock = Complete loss of all reflex, motor, sensory and autonomic activity below the lesion = Medical emergency        Permanent paralysis if spinal cord in compressed for 12-24 hrs        Hypotension and Bradycardia with any injury above T6        Bladder Infection = Common cause of death (try to keep urine acidic) Burns        Infection = Primary concern        HyperK+ due to cell damage and release of intracellular K+        Give meds before dressing changes - Painful        Massive volumes of IV fluid given, due to fluid shift to interstitial spaces and resultant shock        First Degree = Epidermis (superficial partial thickness)        Second Degree = Epidermis and Dermis (deep partial thickness)        Third Degree = Epidermis, Dermis, and SQ (full thickness)        Rule of 9s ... Head and neck = 9%, UE = 9% each, LE = 18% each, Front trunk = 18%, Back Trunk = 18% Singed nasal hair and circumoral soot/burns = Smoke inhalation burns Fractures        Report abnormal assessment findings promptly ... Compartment Syndrome may occur = Permanent damage to nerves and vessels        5 P's of neurovascular status (important with fractures)                            Pain, Pallor, Pulse, Paresthesia, Paralysis        Provide age-appropriate toys for kids in traction

Special Tests and Pathognomonic Signs

Tensilon Test ... Myasthenia Gravis (+ in Myasthenic crisis, - in Cholinergic crisis) ELISA and Western Blot ... HIV Sweat Test ... Cystic Fibrosis Cheilosis = Sores on sides of mouth ... Riboflavin deficiency (B2) Trousseau's Sign (Carpal spasm induced by BP cuff) ... Hypocalcemia (hypoparathyroidism) Chvostek's Sign (Facial spasm after facial nerve tap) ... Hypocalcemia (hypoparathyroidism) Bloody Diarrhea = Ulcerative Colitis Olive-Shaped Mass (epigastric) and Projectile Vomiting = Pyloric Stenosis me Currant Jelly Stool (blood and mucus) and Sausage-Shaped Mass in RUQ = Intussusception Mantoux Test for TB is + if 10 mm induration 48 hrs post admin (previous BCG vaccine recipients will test +) Butterfly Rash = SLE ... Avoid direct sunlight 5 Ps of NV functioning ... Pain, paresthesia, pulse, pallor, paralysis Cullen's Sign (periumbilical discoloration) and Turner's Sign (blue flank) = Acute Pancreatitis Murphy's Sign (Rt. costal margin pain on palp with inspiration) = GB or Liver disease HA more severe on wakening = Brain Tumor (remove benign and malignant) Vomiting not associated with nausea = Brain Tumor Elevated ICP = Increased BP, widened pulse pressure, increased Temp Pill-Rolling Tremor = Parkinson's (Tx with Levodopa, Cardidopa) - Fall precautions, rigid, stooped, shuffling IG Bands on Electrophoresis = MS ... Weakness starts in upper extremities - bowel/bladder affected in 90% ... Demyelination - Tx with ACTH, corticosteroids, Cytoxan and other immunosuppressants Reed-Sternberg Cells = Hodgkin's Koplik Spots = Rubeola (Measles) Erythema Marginatum = Rash of Rheumatic Fever Gower's Sign = Muscular Dystrophy ... Like Minor's sign (walks up legs with hands)


In newborns, temperature becomes part of your ABCs: TABC. Bench Marks        Birth weight doubles at 6 months and triples at 12 months        Birth length increases by 50% at 12 months        Post fontanel closes by 8 wks        Ant fontanel closes by 12-18 months        Moro reflex disappears at 4 months        Steady head control achieved at 4 months        Turns over at 5-6 months        Hand to hand transfers at 7 months        Sits unsupported at 8 months        Crawls at 10 months        Walks at 10-12 months        Cooing at 2 months        Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mo        Mama, Dada + a few words at 9-12 months        Throws a ball overhand at 18 months        Daytime toilet training at 18 mo - 2 years        2-3 word sentences at 2 years 50% of adult height at 2 years        Birth Length doubles at 4 years        Uses scissors at 4 years        Ties shoes at 5 years        Girls' growth spurt as early at 10 years ... Boys catch up ~ Age 14        Girls finish growing at ~15 ... Boys ~ 17 Autosomal Recessive Diseases        CF, PKU, Sickle Cell Anemia, Tay-Sachs, Albinism,        25% chance if: AS (trait only) X AS (trait only)        50% chance if: AS (trait only) X SS (disease) Autosomal Dominant Diseases        Huntington's, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney Disease        50% if one parent has the disease/trait (trait = disease in autosomal dominant) X-Linked Recessive Diseases        Muscular Dystrophy, Hemophilia A        Females are carriers (never have the disease)        Males have the disease (but can't pass it on)        50% chance daughters will be carriers (can't have disease)        50% chance sons will have the disease (not a carrier = can't pass it on)        This translates to an overall 25% chance that each pregnancy will result in a child that has the disease Scoliosis- Milwaukee Brace - 23 hrs/day, Log rolling after Sx Down Syndrome = Trisomy 21.  Simian creases on palms, hypotonia, protruding tongue, upward outward slant of eyes Cerebral Palsy- Scissoring = legs extended, crossed, feet plantar-flexed PKU: can cause mental deficits. Guthrie Test to dx. .Aspartame (NutraSweet) has phenylalanine in it and should not be given to PKU patient Hypothyroidism: lethargy, fatigue, wt gain, dry skin/hair, bradycardia, constipation, forgetfulness, sometimes goiter Prevent Neural tube disorders with Folic Acid throughout pregnancy Myelomeningocele- Cover with moist sterile water dressing and keep pressure off Hydrocephalus- Signs of increased ICP are opposite of shock Shock = Increased pulse and decreased BP        ^ ICP = Decreased pulse and increased BP ... (+ Altered LOC = Most sensitive sign)        Infants ^ICP = Bulging fontanels, high pitched cry, increased hd circum, sunset eyes, wide suture lines, lethargy. Treat with peritoneal shunt - don't pump shunt. Older kids IIPC = Widened pulse pressure        IICP caused by suctioning, coughing, straining, and turning - Try to avoid Muscular Dystrophy:  X-linked Recessive, waddling gait, hyper lordosis, Gower's Sign = difficulty rising walks up legs (like Minor's sign), fat pseudohypertrophy of calves. Seizures:  Nothing in mouth, turn hd to side, maintain airway, don't restrain, keep safe ... Treat with Phenobarbital (Luminol), Phenytoin (Dilantin: TR = 10-20 ... Gingival Hyperplasia), Fosphenytoin (Cerebyx), Valproic Acid (Depakene), Carbamazepine (Tegritol) Meningitis (Bacterial) Lumbar puncture shows Increased WBC, protein, ^ICP and decreased glucose        May lead to SIADH (Too much ADH) ... Water retention, fluid overload, dilutional hyponatremia CF Kids taste salty and need enzymes sprinkled on their food Children with Rubella = threat to unborn siblings (may require temporary isolation from Mom during PG) Pain in young children measured with Faces pain scale No MMR Immunization for kids with Hx of allergic rxn to eggs or neomycin Immunization Side Effects: Call Physician if seizures, high fever, or high-pitched cry after immunization All cases of poisoning: call Poison Control Center- No Ipecac! Epiglottitis = H. influenza B ... Child sits upright with chin out and tongue protruding (maybe Tripod position) ... Prepare for intubation or trach ... DO NOT put anything into kid's mouth Isolate RSV patient with Contact Precautions ... Private room is best ... Use Mist Tent to provide O2 and Ribavirin - Flood tent with O2 first and wipe down inside of tent periodically so you can see patient


Acute Glomerulonephritis ... After B strep - Antigen-Antibody complexes clog up glomeruli and reduce GFR = Dark urine, proteinuria



Wilms Tumor = Large kidney tumor ... Don't palpate



TEF = Tracheoesophageal Atresia ... 3 C's of TEF = Coughing, Choking, Cyanosis



Cleft Lip and Palate ... Post-Op - Place on side, maintain Logan Bow, elbow restraints



Congenital Megacolon = Hirschsprung's Disease ... Lack of peristalsis due to absence of ganglionic cells in colon ... Suspect if no meconium w/in 24 hrs or ribbon-like foul smelling stools



Iron Deficiency Anemia ... Give Iron on empty stomach with citrus juice (vitamin C enhances absorption), Use straw or dropper to avoid staining teeth, Tarry stools, limit milk intake



Sickle Cell Disease ...Hydration most important ...SC Crisis = fever, abd pain, painful edematous hands and feet (hand-foot syndrome), arthralgia ...Tx + rest, hydration ... Avoid high altitude and strenuous activities



Tonsillitis ... usually Strep ... Get PT and PTT Pre-Op (ask about Hx of bleeding) ... Suspect Bleeding Post-Op if frequent swallowing, vomiting blood, or clearing throat ... No red liquids, no straws, ice collar, soft foods ... Highest risk of hemorrhage = first 24 hrs and 5-10 days post-op (with sloughing of scabs)



Primary meds for ER for respiratory distress = Sus-phrine (Epinephrine HCl) and Theophylline (Theo-dur) ... Bronchodilators



Must know normal respiratory rates for kids ... Respiratory disorders = Primary reason for most medical/ER visits for kids ...



       Newborn ... 30-60 ● 1-11 mo ... 25-35



       1-3 years ... 20-30



       3-5 years ... 20-25



       6-10 years ... 18-22



       11-16 years ...16-20



Warning Signs of Cancer in Children


C   continued or unexplained wt loss



H        headaches with vomiting in the morning



I           increased swelling, persistent pain in bones, jts    



L   lump or mass in abdomen, neck, or elsewhere



D   development of whitish appearance in pupil



R   recurrent fevers not due to infection



E   excessive bruising or bleeding



N   noticeable paleness or prolonged tiredness





Hypertension medication regimen noncompliance is the #1 cause of stroke



2 types of stroke:



1.       Hemorrhagic: caused by a slow or fast hemorrhage into the brain tissue; often related to






2.       Embolic: caused by a clot that has broken away from a vessel and has lodged in one of the arteries of the brain, blocking the blood supply. It is often related to atherosclerosis (so it may occur again).



R sided stroke will cause L sided motor losses and vice versa. R sided stroke will be very reckless and have trouble with rash decision making. L sided stroke will be very anxious and aware of their deficits.



Words that describe losses in strokes include the following:



1.  Apraxia: inability to perform purposeful movements in the absence of motor problems



2.  Dysarthria: difficulty articulating



3.  Dysphasia: impairment of speech and verbal comprehension



4.  Aphasia: loss of the ability to speak



5.  Agraphia: loss of the ability to write



6.  Alexia: loss of the ability to read



7.  Dysphagia: dysfunctional swallowing



Steroids are administered after a stroke to decrease cerebral edema and retard permanent disability. H2 inhibitors are administered to prevent peptic ulcers.



Myocardial Infarction (MI)


Women typically present with more subtle s/sx of MI: dyspnea, fatigue, trouble sleeping -      Like strokes, MIs are caused by thrombus/clotting or shock/hemorrhage - Unlike angina, this pain will not be relieved by nitroglycerin and rest.



Troponin is released into the blood following an MI- the presence of troponin always should alert us to a cardiac issue



Tx: Administer medications as prescribed.



1.  For pain and to increase O2 perfusion, IV morphine sulfate (acts as a peripheral vasodilator and decreases venous return)



2.  Other medications often prescribed include:



a.  Nitrates (e.g., nitroglycerin)



b.  ACE inhibitors



c.  Beta blockers



d.  Calcium channel blockers (when beta blockers are contraindicated:bradycardia, AV block, decompensated heart failure, and asthma.) e. Aspirin



f. Antiplatelet aggregates Consider medical interventions:



1.      Thrombolytic agents, within 1 to 4 hours of MI, but not more than 12 hours after MI



2.      Intraaortic balloon pump (IABP) to improve myocardial perfusion 3.            Surgical reperfusion with CABG



                        4.    PCI with stenting.



Remember MONA when administering medications and treatments in the client with MI. MONA: Morphine, Oxygen, Nitroglycerin, Aspirin


**Nitroglycerin can be given 3 times, 5 minutes apart for tx of angina pain. Will cause headache, so pair with an analgesic.**



Acyanotic = VSD, ASD, PDA, Coarc of Aorta, Aortic Stenosis



       Antiprostaglandins cause closure of PDA (aorta - pulmonary artery)



Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG



(Transposition of Great Vessels) ... Polycythemia common in Cyanotic disorders



       3 T's of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition)



Tetralogy of Fallot-  Unoxygenated blood pumped into aorta



       Pulmonary Stenosis






       Overriding Aorta



       Right Ventricular Hypertrophy



       TET Spells ...Hypoxic episodes that are relieved by squatting or knee chest position



CHF can result- tx with digoxin TR = 0.8-2.0 for kids



Ductus Venosus = Umbilical Vein to Inferior Vena Cava



Ductus Arteriosus = Aorta to Pulmonary Artery



Rheumatic Fever: Acquired Heart Disease that affects aortic and mitral valves



       Preceded by beta hemolytic strep infection



       Erythema Marginatum = Rash



       Elevated ASO titer and ESR



       Chest pain, shortness of breath (Carditis), migratory large joint pain, tachycardia (even during sleep)



       Treat with Penicillin G = Prophylaxis for recurrence of RF



Abdominal Aortic Aneurysm (AAA)



       The most common cause of abdominal aortic aneurysm is atherosclerosis. It is a late manifestation of syphilis.



       Without treatment, rupture and death will occur.



       AAA is often asymptomatic.



       The most common symptom is abdominal pain or low back pain, with the complaint that the client can feel their heart beating.



       Those taking antihypertensive drugs are at risk for developing AAA.





Pituitary is the “master gland”



Thyroid connects nervous and endocrine systems






Thyroid storm: a life-threatening event that occurs with uncontrolled hyperthyroidism due to Graves disease. Other causes include childbirth, congestive heart failure (CHF), diabetic ketoacidosis (DKA), infection, pulmonary embolism, emotional distress, trauma, and surgery. Symptoms include: fever, tachycardia, agitation, anxiety, and HTN.



-          Primary nursing interventions include maintaining an airway and adequate aeration.



-          Propylthiouracil (PTU) and methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm. Propranolol (Inderal) may be given to decrease excessive sympathetic stimulation.



Graves disease: is thought to be an autoimmune process and accounts for most cases of hyperthyroidism.






A.    Enlarged thyroid gland



B.    Acceleration of body processes



1.  Weight loss



2.  Increased appetite



3.  Diarrhea



4.  Heat intolerance



5.  Tachycardia, palpitations, increased systolic BP



6.  Diaphoresis, wet or moist skin



7.  Nervousness, insomnia



C.    Exophthalmos (bulging eyes)



D.   T3 elevated above 220 ng/dL



E.    T4 elevated above 12 mcg/dL



Common treatment for hyperthyroidism—goal is to create a euthyroid state



1.  Thyroid ablation by medication



2.  Radioactive iodine therapy



3.  Thyroidectomy



4.  Adenectomy of portion of anterior pituitary where TSH-producing tumor is located



All treatments make the client hypothyroid, requiring hormone replacement.



**After a thyroidectomy, be prepared for the possibility of laryngeal edema. Put a tracheostomy set at the bedside along with O2 and a suction machine; calcium gluconate should be easily accessible if parathyroid glands have been accidently removed.**



If two or more parathyroid glands have been removed, the chance of tetany increases dramatically.



       Monitor serum calcium levels (9.0 to 10.5 mg/dL is normal range).



       Check for tingling of toes and fingers and around the mouth.



       Check Chvostek sign (twitching of lip after a tap over the facial nerve at the angle of the jaw means it is positive.)



       Check Trousseau sign (carpopedal spasm after BP cuff is inflated above systolic pressure and held for 3 minutes means it is positive.)



Hypothyroidism (Hashimoto’s/Myxedema): Hashimoto's is an immune response that causes hypothyroidism and myxedema is a gland problem.



Myxedema coma can be precipitated by acute illness, withdrawal of thyroid medication, anesthesia, use of sedatives, or hypoventilation (with the potential for respiratory acidosis and CO2 narcosis). The airway must be kept patent and ventilator support used as indicated.









       Thin, dry hair; dry skin- thick, brittle nails






       Bradycardia, hypotension






       Periorbital edema, facial puffiness



       Cold intolerance



       Weight gain



       Dull emotions and mental processes ●          Husky voice, slow speech ●    Diagnosis:



                            Low T3 (below 70)



                            Low T4 (below 5)



                            Presence of T4 antibody (indicating that T4 is being destroyed by the body)



Addison’s Disease: Autoimmune process commonly found in conjunction with other endocrine diseases of an autoimmune nature; a primary disorder; hypofunction of the adrenal cortex A. Sudden withdrawal from corticosteroids may precipitate symptoms of Addison disease



B.   Addison disease is characterized by lack of cortisol, aldosterone, and androgens.



C.   Definitive diagnosis is made using an ACTH stimulation test.



D.   If ACTH production by the anterior pituitary has failed, it is considered secondary Addison disease.






       Fatigue, weakness, weight loss, anorexia, N/V



       Postural hypotension



       Hypoglycemia, Hyponatremia, Hyperkalemia



       Hyperpigmentation of mucous membranes and skin (only if primary Addison disease; not seen in secondary Addison disease)



       Signs of shock when in Addison crisis



       Loss of body hair






                            1. Hypotension



                            2. Tachycardia



                            3. Fever



Addison crisis is a medical emergency. It is brought on by sudden withdrawal of steroids, a stressful event (trauma, severe infection), exposure to cold, overexertion, or decrease in salt intake.



A.   Vascular collapse: Hypotension and tachycardia occur; administer IV fluids at a rapid rate until stabilized.



B.   Hypoglycemia: Administer IV glucose.



C.   Essential to reversing the crisis: Administer parenteral hydrocortisone.



D.   Aldosterone replacement: Administer fludrocortisone acetate (Florinef) PO (available only as oral preparation) with simultaneous administration of salt (sodium chloride) if client has a sodium deficit.



**HESI/NCLEX questions about addison’s often focus on educating pt about sticking to steroid regimen and only weaning carefully with physician’s instruction and observation.**



Diabetes Mellitus (DM)- A metabolic disorder characterized by high levels of glucose resulting from defects in insulin secretion, insulin action, or both



-          Remember that the body’s response to illness and stress is to produce glucose. Therefore, any illness results in hyperglycemia. Pt teaching about insulin management will be essential!!



-          HyPOglycemia is always more dangerous than hyPERglycemia. If you are unsure, treat hypoglycemia first.



-          Teach pt about foot care! When assessing a diabetic pt who is feeling unwell, make sure to check their feet for lesions and infection.



Hypoglycemia - confusion, HA, irritable, nausea, sweating, tremors, hunger, slurring



Hyperglycemia - weakness, syncope, polydipsia, polyuria, blurred vision, fruity breath



Diabetic Coma vs. Insulin Shock ... Give glucose first - If no help, give insulin



Glucagon causes smooth muscle relaxation- immediate vomiting. Sometimes given intentionally to make pt vomit and empty stomach contents.



Fruity Breath = Diabetic Ketoacidosis





First IV for DKA = NS, then infuse regular insulin IV as Rx'd



Insulin may be kept at room temp for 28 days



Draw Regular (Clear) insulin into syringe first when mixing insulins Rotate Injection Sites (Rotate in 1 region, then move to new region)



       Rapid Acting Insulins: Lispro (Humalog) and Aspart (Novolog) O: 5-15 min, P: .75-1.5 hrs



       Short Acting Insulin: Regular (human) O: 30-60 min, P: 2-3 hrs (IV Okay)



       Intermediate Acting Insulin: Isophane Insulin (NPH) O: 1-2 hrs, P: 6-12 hrs



       Long Acting Insulin: Insulin Glargine (Lantus) O: 1.1 hr, P: 14-20 hrs (Don't Mix) Oral Hypoglycemics decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production



       Glyburide, Metformin (Glucophage), Avandia, Actos



       Acarbose blunts sugar levels after meals





GCS <8 = intubate



-          Paralytic ileus is common in comatose clients. A gastric tube aids in gastric decompression.



-          Any client on bed rest or immobilized must have ROM exercises often and very frequent position changes. Do not leave the client in any one position for longer than 2 hours. Any position that decreases venous return, such as sitting with dependent extremities for long periods, is dangerous.



-          Restlessness may indicate a return to consciousness but can also indicate anoxia, distended bladder, covert bleeding, or increasing cerebral anoxia. Do not oversedate and report any symptoms of restlessness.



-          Try not to use restraints; they only increase restlessness. Avoid narcotics because they mask the level of responsiveness.



Spinal cord injury:



Anything above C4 will knock out respiratory drive- concentrate on protecting airway



C6 injury results in partial paralysis of hands and arms, and full paralysis of lower body



T6 injury results in paralysis below the chest



L1 injury results in paralysis below the waist



Spinal shock is characterized by loss of reflexes, loss of sensation, absent thermoregulation, and flaccid paralysis below the injury and lasts for days to weeks. It can mask the more permanent deficits caused by the injury.



Neurogenic shock is characterized by hypotension, bradycardia, loss of SNS innervation, peripheral vasodilation (resulting in venous pooling) and decreased CO. This only occurs in injuries T6 or above.



**educate pt and monitor for possible Autonomic Dysreflexia, which is a massive uncompensated cardiovascular response to sensory input (usually distended bladder or bowel impaction) that causes HTN, bradycardia, intense headache, piloerection, and noticeable diaphoresis and flushing above the level of the injury. Can also cause spotty vision, anxiety, nausea, and nasal congestion. Remove tight clothing and try to relieve the stimulus (i.e. bladder catheterization and removal of impaction) HTN can be deadly if not treated promptly.**



Multiple Sclerosis (MS): Demyelinating disease resulting in the destruction of CNS myelin and consequent disruption in the transmission of nerve impulses



Symptoms involving motor function usually begin in the upper extremities with weakness progressing to spastic paralysis. Bowel and bladder dysfunction occurs in 90% of cases. MS is more common in women. Progression is not “orderly.”





       Optic neuritis (loss of vision or blind spots)



       Visual or swallowing difficulties



       Gait disturbances; intention tremors



       Unusual fatigue, weakness, and clumsiness



       Numbness, particularly on one side of face



       Impaired bladder and bowel control



       Speech disturbances



       Scotomas (white spots in visual field, diplopia) Tx:



       Encourage self-care and frequent rest periods.



       With exercise programs, encourage client to work up to the point just short of fatigue.



       Initially, work with client on a voiding schedule.



       Teach client that, as incontinence worsens, the female may need to learn clean selfcatheterization; the male may need a condom catheter.



       Administer steroid therapy and chemotherapeutic drugs in acute exacerbations to shorten length of attack.



       ACTH, cortisone, cyclophosphamide (Cytoxan), and other immunosuppressive drugs



Myasthenia Gravis: a neuromuscular disorder that causes weakness in the skeletal muscles, which are the muscles your body uses for movement. It occurs when communication between nerve cells and muscles becomes impaired.



       Diplopia (double vision), ptosis (eyelid drooping)



       Mask-Like affect: sleepy appearance due to facial muscle involvement



       Weakness of laryngeal and pharyngeal muscles: dysphagia, choking, food aspiration, difficulty speaking



       Muscle weakness improved by rest, worsened by activity



       Advanced cases: respiratory failure, bladder and bowel incontinence



       Myasthenic crisis symptoms (attributed to disease worsening) associated with undermedication. Weakness with change in vitals (give more meds) Increase in myasthenic gravis symptoms; more difficulty swallowing, diplopia, ptosis, dyspnea. Cholinergic crisis (attributed to anticholinesterase overdosage): Weakness with no change in vitals (reduce meds) diaphoresis, diarrhea, fasciculations, cramps, marked worsening of symptoms resulting from overmedication





Day 1 of cycle = First day of menses (bleeding), Ovulation on Day 14. 28 days total



Sperm lives 3-5 days, Eggs 24 hrs. Fertilization occurs in Fallopian Tube



Chadwick's Sign = Bluing of Vagina (early as 4 weeks)



Hegar's Sign = Softening of isthmus of cervix (8 weeks)



Goodell's Sign = Softening of Cervix (8 weeks)



Pregnancy Total wt gain = 25-30 lbs (11-14 kg)



Increase calorie intake by 300 calories/day during PG, Increase protein 30 g/day,  Increase iron, Ca++, Folic Acid, A & C



Dangerous Infections with PG- TORCH = Toxoplasmosis, other, Rubella, Cytomegalovirus, 






Braxton Hicks common throughout PG



Amniotic fluid = 800-1200 mL



Polyhydramnios and Macrosomia (large fetus) with Diabetes



Umbilical cord: 2 arteries, 1 vein ... Vein carries oxygenated blood to fetus (opposite of normal)



FHR = 120-160



Folic Acid Deficiency = Neural tube defects



Pre-term = 20-37 weeks



Term = 38-42 weeks



Post-term = 42 weeks+



TPAL = Term births, Pre-term births, Abortions, Living children



Gravida = # of Pregnancies regardless of outcome



Para = # of Deliveries (not kids) after 20 wks gestation



Nagale's Rule:  Add 7 days to first day of last period, subtract 3 months, add 12 months = EDC Hgb and Hct a bit lower during PG due to hyperhydration



Side-lying is best position for uteroplacental perfusion (either side tho left is traditional )



2:1 Lecithin:Sphingomyelin Ratio = Fetal lungs mature



AFP in amniotic fluid = possible neural tube defect



Need a full bladder for Amniocentesis early in PG (but not in later PG)



Lightening = Fetus drops into true pelvis



Nesting Instinct = Burst of Energy just before labor



True Labor = Regular contractions that intensify with ambulation, LBP that radiates to abdomen, progressive dilation and effacement



Station = Negative above ischial spines, Positive below



Leopold Maneuver tries to reposition fetus for delivery



Laboring Maternal Vitals ... Pulse



NON-Stress Test:  Reactive = Healthy (FHR goes up with movements)



Contraction Stress Test (Oxytocin Challenge Test)- Unhealthy = Late decels noted (positive result) indicative of UPI "Negative" result = No late decels noted (good result)



Watch for hyporeflexia with Mag Sulfate admin- Diaphragmatic Inhibition (mag sulf is given in preeclampsia patients to prevent seizing)



                   Keep Calcium gluconate by the bed (antidote)






                   fetal HB-. 8-12 weeks by Doppler, 15-20 weeks by fetoscope



                   Fetal movement = Quickening, 14-20 weeks



                   Showing = 14 weeks



                   Braxton Hicks - 4 months and onward Early Decels = Head compression = OK



Variable Decels = Cord compression = Not Good



Late Decels = Utero-placental insufficiency = BAD!



If Variable or Late Decels- Change maternal position, Stop Pitocin, Administer O2, Notify Physician



DIC- Tx is with Heparin (safe in PG)  Fetal Demise, Abruptio Placenta, Infection



Fundal Heights



                   12-14 wks ... At level of symphysis



                   20 weeks ... 20 cm = Level of umbilicus



                   Rises ~ 1 cm per week



Stages of Labor



                   Stage 1 = Beginning of Regular contraction to full dilation and effacement



                   Stage 2 = 10 cm dilation to delivery



                   Stage 3 = Delivery of Placenta



                   Stage 4 = 1-4 Hrs following delivery



Placenta Separation ... Lengthening of cord outside vagina, gush of blood, full feeling in vagina ... Give oxytocin after placenta is out - Not before.



Schultz Presentation = Shiny side out (fetal side of placenta)



Postpartum VS Schedule



                   Every 15 min X 1 hr



                   Every 30 min X next 2 hours



                   Every Hour X next 2-6 hours



                   Then every 4 hours



Normal BM for mom within 3 days = Normal



Lochia: no more than 4-8 pads/day and no clots > 1 cm Fleshy smell is normal, Foul smell = infection



Massage boggy uterus to encourage involution. empty bladder ASAP - may need to catheterize Full bladder can lead to uterine atony and hemorrhage



Tears: 1st Degree = Dermis, 2nd Degree = mm/fascia, 3rd Degree = anal sphincter, 4th Degree = rectum



APGAR = HR, R, mm tone, Reflex irritability, Color @ 1 and 5 minutes. 7-10 = Good, 4-6 = moderate resuscitative efforts, 1-3 = mostly dead



NB eye care = E-mycin + Silver Nitrate for gonorrhea



Pudendal Block = decreases pain in perineum and vagina - No help with contraction pain



Epidural Block = T10-S5 Blocks all pain. First sign = warmth or tingling in ball of foot or big toe



Regional Blocks often result in forceps or vacuum assisted births because they affect the mother's ability to push effectively



WBC counts are elevated up to 25,000 for ~10 days postpartum



Rho(D) immune globulin (RhoGAM) is given to Rh- mothers who deliver Rh+ kids... Not given if mom has a +Coombs Test ... She already has developed antibodies (too late)



Caput Succedaneum = edema under scalp, crosses suture lines



Cephalhematoma = blood under periosteum, does not cross suture lines



Suction Mouth first - then nostrils



Moro Reflex = Startle reflex (abduction of all extremities) - up to 4 months



Rooting Reflex- up to 4 months



Babinski Reflex- up to 18 months



Palmar Grasp Reflex- Lessens by 4 months



Ballard Scale used to estimate gestational age



Heel Stick = lateral surface of heel



Physiologic Jaundice is normal at 2-3 days. Abnormal if before 24 hours or lasting longer than 7 days. Unconjugated bilirubin is the culprit.



Vitamin K given to help with formation of clotting factors due to the fact that the newborn gut lacks the bacteria necessary for vitamin K synthesis initially. Vastus lateralis mm IM



Abruptio Placenta = Dark red bleeding with rigid board like abdomen



Placenta Previa = Painless bright red bleeding



DIC = Disseminated Intravascular Coagulation ... clotting factors used up by intravascular clotting - Hemorrhage and increased bleeding times result ... Associated with fetal demise, infection and abruptio placenta.



Magnesium Sulfate used to reduce preterm labor contractions and prevent seizures in Preeclampsia ... Mg replaces Ca++ in the smooth mm cells resulting relaxation ... Can lead to hyporeflexia and respiratory depression - Must keep Calcium Gluconate by bed when administering during labor = Antidote. Monitor for:



       Absent DTR's






       Urinary Output



       Fetal Bradycardia



Pitocin (Oxytocin) used for Dystocia... If uterine tetany develops, turn off Pitocin, admin O2 by face mask, turn pt on side. Pitocin can cause water intoxication owing to ADH effects.



Suspect uterine rupture if woman complains of a sharp pain followed by cessation of contractions



Pre-Eclampsia = Htn + Edema + Proteinuria



Eclampsia = Htn + Edema + Proteinuria + Seizures and Coma ... Suspect if Severe HA + visual disturbances



No Coumadin during PG (Heparin is OK)



Hyperemesis Gravidarum = uncontrollable nausea and vomiting. May be related to H. pylori- if so, tx with Reglan (metoclopramide). Otherwise tx with antiemetics and give IV fluids



Insulin demands drop precipitously after delivery



No oral hypoglycemics during PG - Teratogenic. Insulin only for control of DM



Babies born without vaginal squeeze more likely to have respiratory difficulty initially



C-Section can lead to Paralytic Ileus ... Early ambulation helps



Postpartum Infection common in problem pregnancies (anemia, diabetes, traumatic birth)



Postpartum Hemorrhage = Leading cause of maternal death ... Risk factors include:



● Dystocia, prolonged labor, overdistended uterus, abruptio placenta, infection



Tx includes ... Fundal massage, count pads, VS, IV fluids, Oxytocin, notify physician



Jitteriness is a symptom of hypoglycemia and hypocalcemia in the newborn



Hypoglycemia ... tremors, high pitched cry, seizures



High pitched cry + bulging fontanels = IICP



Hypothermia can lead to Hypoxia and acidosis ... Keep warm and use bicarbonate prn to treat acidosis in newborn.



Lay on right side after feeding ... Move stomach contents into small intestine



Jaundice and High bilirubin can cause encephalopathy ...





K+ in Bananas, dried fruits, citrus, potatoes, legumes, tea, peanut butter



Vitamin C: Citrus, potatoes, cantaloupe



Ca++ in Milk, cheese, green leafy veggies, legumes



Na+ in Salt, processed foods, seafood



Folic Acid in Green leafy veggies, liver, citrus



Fe++ in Green leafy veggies, red meat, organ meat, eggs, whole wheat, carrots



       Use Z-track for injections to avoid skin staining



Mg+ in Whole grains, green leafy veggies, nuts



Thiamine (B1) in Pork, beef, liver, whole grains



B12 in Organ meats, green leafy veggies, yeast, milk, cheese, shellfish



       Deficiency = Big red beefy tongue, Anemia



Vitamin K in Green leafy veggies, milk, meat, soy



Vitamin A in Liver, orange and dark green fruits and veggies



Vitamin D in Dairy, fish oil, sunlight



Vitamin E in Veggie oils, avocados, nuts, seeds



BMI: 18.5-24.9 = Normal (Higher = Obese)





“Essentially everyone goes to hell in a progressively degenerative hand-basket”



       Thin skin, bad sleep, mm wasting, memory loss, bladder shrinks, incontinence, delayed gastric emptying, COPD, Hypothyroidism, Diabetes



Common Ailments:



       Delerium and Dementia



       Cardiac Dysrhythmias



       Cataracts and Glaucoma



       CVA (usually thrombotic, TIAs common)



       Decubitus Ulcers






       Thyrotoxicosis (Grave's Disease)



       COPD (usually combination of emphysema and CB)



       UTIs and Pneumonia ... Can cause confusion and delirium



Memory loss starts with recent - progresses to full



Dementia = Irreversible (Alzheimer's) Depression, Sundowning, Loss of family recognition Delerium = Secondary to another problem = Reversible (infections common cause)



Parkinson’s: Chronic, progressive, debilitating neurologic disease of the basal ganglia and substantia nigra, affecting motor ability and characterized by tremor at rest, increased muscle tone (rigidity), slowness in the initiation and execution of movement (bradykinesia), and postural instability (difficulties with gait and balance)



A.    Rigidity of extremities



B.    Masklike facial expressions with associated difficulty in chewing, swallowing, and speaking



C.    Drooling



D.   Stooped posture and slow, shuffling gaitE. Tremors at rest, “pill-rolling” movement



F.     Emotional lability



G.   Increased tremors with stress or anxiety



Bc the issue is with dopamine, the tx is usually a dopamine precursor: levodopa carbidopa (sinemet)



The focus with most gerontologic diseases and especially parkinsons is SAFETY



Medication Alert! Due to decreased renal function, drugs metabolized by the kidneys may persist to toxic levels



When in doubt on NCLEX ... Answers should contain something about exercise and nutrition.



Developmental Stages


Erikson - Psycho-Social Development



       0-1 yr (Newborn) ... Trust vs. Mistrust



       1-3 yrs (Toddler)... Autonomy vs. Doubt and Shame ... Fear intrusive procedures -



Security objects good (Blankies, stuffed animals)



       3-6 yrs (Pre-school) ... Initiative vs. Guilt ... Fear mutilation - Band-Aids good



       6-12 yrs (School Age) ... Industry vs. Inferiority... Games good, Peers important ... Fear loss of control of their bodies



       12-19 yrs (Adolescent) ... Identity vs. Role Confusion ... Fear Body Image Distortion



       20-35 yrs (Early Adulthood) ... Intimacy vs. Isolation



       35-65 yrs (Middle Adulthood) ... Generativity vs. Stagnation



       Over 65 (Older Adulthood) ... Integrity vs. Despair



Piaget - Cognitive Development



       Sensorimotor Stage (0-2) ... Learns about reality and object permanence



       Preoperational Stage (2-7) ... Concrete thinking



       Concrete Operational Stage (7-11) ... Abstract thinking



       Formal Operational Stage (11-adult) ... Abstract and logical thinking



Freud - Psycho-Sexual Development



       Oral Stage (Birth -1 year) ... Self gratification, Id is in control and running wild



       Anal Stage (1-3) ... Control and pleasure wrt retention and pooping - Toilet training in this stage



       Phallic Stage (3-6) ... Pleasure with genitals, Oedipus complex, SuperEgo develops



       Latency Stage (6-12) ... Sex urges channeled to culturally acceptable level, Growth of Ego



       Genital Stage (12 up) ... Gratification and satisfying sexual relations, Ego rules



Kohlberg - Moral Development



       Moral development is sequential but people do not automatically go from one stage to the next as they mature



       Level 1 = Pre-conventional ... Reward vs. Punishment Orientation



       Level 2 = Conventional Morality ... Conforms to rules to please others



       Level 3 = Post- Conventional ... Rights, Principles and Conscience (Best for All is a concern)



Calculations Rules & Formulas


Round final answer to tenths place



Round drops to nearest drop



When calculating mL/hr, round to nearest full mL



Must include 0 in front of values



Pediatric doses rounded to nearest 100th. Round down for peds



Calculating IV Flow Rates



      Total mL X Drop Factor / 60 X #Hrs = Flow Rate in gtts/min



Calculating Infusion Times



      Total mL X Drop Factor / Flow Rate in gtts/min X 60 = Hrs to Infuse





1 t = 5mL



1 T = 3 t = 15 mL



1 oz = 30 cc = 30 mL = 2 T



1 gr = 60 mg



1 mg = 1000 ug (or mcg)



1 kg = 2.2 lbs



1 cup = 8 oz = 240 mL



1 pint = 16 oz



1 quart = 32 oz



Degrees F = (1.8 X C) + 32 Degrees C = (F - 32) / 1.8



       37 C = 98.6 F



       38 C = 100.4 F



       39 C = 102.2 F



       40 C = 104 F



Fall Precautions


Room close to nurses station



Assessment and orientation to room



Get help to stand (dangle feet if light headed)



Bed low with side rails up



Good lighting and reduce clutter in room



Keep consistent toileting schedule Wear proper non-slip footwear At home:



      Paint edges of stairs bright color



      Bell on cats and dogs



Neutropenic (Immunosuppressed) Precautions


No plants or flowers in room



No fresh veggies- Cooked foods only



Avoid crowds and infectious persons



Meticulous hand washing and hygiene to prevent infection



Report fever > 100.5 (immunosuppressed pts may not manifest fever with infection)



Immunosuppressed pt on chemo should not receive live vaccines



            NO live vaccines









If child who has not had chickenpox is exposed needs to receive VZIG (varicella zoster immunoglobulin) within 72 hours of exposure



Bleeding Precautions (Anticoagulants, etc.)


Soft bristled toothbrush



Electric razor only (no safety razors)



Handle gently, Limit contact sports



Rotate injection sites with small bore needles for blood thinners



Limit needle sticks, Use small bore needles, Maintain pressure for 5 minutes on venipuncture sites



No straining at stool - Check stools for occult blood (Stool softeners prn)





1.  Which information is a priority for the RN to reinforce to an older client afterintravenous pyelography?



D: Measure the urine output for the next day and immediately notify the health care provider if it should decrease.



2.  A client has altered renal function and is being treated at home. The nurse recognizes



that the most accurate indicator of fluid balance during the weekly visits is D: weekly weight



3.  A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client?



B: It is critical to report promptly to your health care provider any findings of peptic ulcers.



4.  A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first? B: Have the client turn to the left side



5.  The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern?



C: A cold, pale lower leg



6.  The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? B: Fever of 103 degrees F (39.5 degrees C)



7.  A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?



A: Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.



8.  A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture?



C: The flow of life is believed to flow through major pathways or nerve clusters in your body.



9.  The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect?



C: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent



10.              A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission? A: Side-lying on the left with the head elevated 10 degrees



11.              A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? C: minimal drainage into the urinary collection bag



12.              A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? C: Participate with the compressions or breathing 13. The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? B: Jugular vein distention 14. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A: Can predispose to dysrhythmias



15.  A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? B: Pupils fixed and dilated



16.  A 14 year-old with a history of sickle cell disease is admitted to the hospital with adiagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis?



D: "I went to the doctor last week for a cold and I have gottenworse."



17.  Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?



B: Pale mucosa of the eyelids and lips



18.  The nurse is caring for a client in hypertensive crisis in an intensive care unit. Thepriority assessment in the first hour of care is D: Pupil responses



19.  Which of these clients who are all in the terminal stage of cancer is least appropriate



to suggest the use of patient controlled analgesia (PCA) with a pump? D: A preschooler with intermittent episodes of alertness



20.  The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive



(NOFTT). Upon entering the room, the nurse would expect the baby to be



D: Pale, thin arms and legs, uninterested in surroundings



21.  As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion?



D: Hair loss



22.  While caring for a client who was admitted with myocardial infarction (MI) 2 daysago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees celsius). The appropriate nursing intervention is to



B: Administer acetaminophen as ordered as this is normal at this time



23.  A client is admitted for first and second degree burns on the face, neck, anterior chestand hands. The nurse's priority should be B: Assess for dyspnea or stridor



24.  Which of these clients who call the community health clinic would the nurse ask tocome in that day to be seen by the health care provider?



D: I went to the bathroom and my urine looked very red and it didn’t hurt when I went.



25.  A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed?



D: Fibroids that cause no problems still need to be taken out.



26.  An elderly client admitted after a fall begins to seize and loses consciousness. What action bythe nurse is appropriate to do next?



A: Stay with client and observe for airway obstruction



27.  A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?



A: FHT 168 beats/min



28.  A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?



B: "I have been coughing up foul tasting, brown, thick sputum."



29.  The nurse is performing an assessment on a client in congestive heart failure.



Auscultation of the heart is most likely to reveal



A: S3 ventricular gallop



30.  Which of these observations made by the nurse during an excretory urogram indicatea complication?



B: The client’s entire body turns a bright red color



31.  A client is diagnosed with a spontaneous pneumothorax necessitating the insertion ofa chest tube. What is the best explanation for the nurse to provide this client?  B: "The tube will remove excess air from your chest."



32.  The nurse is reviewing laboratory results on a client with acute renal failure. Whichone of the following should be reported immediately? D: Serum potassium 6 mEq/L



33.  The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse’s immediate attention? C: Dyspnea



34.  The nurse is performing a physical assessment on a client who just had anendotracheal tube inserted. Which finding would call for immediate action by the nurse? C: Pulse oximetry of 88



35.  A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? D: restlessness



36.  The most effective nursing intervention to prevent atelectasis from developing in a postoperative client is to



B: Assist client to turn, deep breathe, and cough



37.  When caring for a client with a post right thoracotomy who has undergone an upper



lobectomy, the nurse focuses on pain management to promote B: Deep breathing and coughing



38.  A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? D: Assist with oral hygiene



39.  The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? B: Assess for postoperative arrhythmias



40.  A client has a history of chronic obstructive pulmonary disease (COPD). As the nurseenters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? C: Lower the oxygen rate



41.  A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A: Notify the health care provider



42.  The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The



upper leg dressing becomes saturated with blood. The nurse's first action should be to C: Reinforce the dressing and elevate the leg



43.  A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? B: Leukopenia



44.  A client has a chest tube in place following a left lower lobectomy inserted after a stabwound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? D: Continue to monitor the rate of drainage



45.  A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? C: Loss of pulse in the extremity



46.  A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void? C: Assist him to stand by the side of the bed to void



47.  The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform? B: Perform a quick assessment of the client''s condition



48.  The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? B: "I am allergic to shrimp."



49.  The health care provider order reads "aspirate nasogastric feeding (NG) tube every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A: Hold the tube feeding and notify the provider



50.  To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse mustA: Apply suction for no more than 10 seconds



51.  An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to



A: administer the medication in 2 separate injections



52.  The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to



D: prevent the drug from tissue irritation



53.  A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? C: improved respiratory status and increased urinary output



54.  While providing home care to a client with congestive heart failure, the nurse is askedhow long diuretics must be taken. What is the nurse’s best response? C: "The medication must be continued so the fluid problem is controlled."



55.  A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? B: Sore throat, fever



56.  A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain.In checking the client, which finding suggests a side effect of the analgesic? D: No bowel movement for 3 days



57.  A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? C: Activated PTT



58.  A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? D: Flush adequately with water before and after using the tube



59.  The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin).



Which of the following statements suggests that the teaching was effective?



B: "Our child should brush and floss carefully after every meal."



60.  Although non steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? D: Occult bleeding



61.  The nurse is caring for a client with clinical depression who is receiving a MAOI. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A: Avoid chocolate and cheese



62.  A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? D: Application of pediculicides



63.  The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A: Non-steroidal anti-inflammatory drugs



64.  A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element?



B: Potassium



65.  The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A: Stop the infusion



66.  Discharge instructions for a client taking alprazolam (Xanax) should include which ofthe following?



B: Sudden cessation of alprazolam



67.  A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? B: Hemoglobin and hematocrit



68.  A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin?



A: Protamine . Protamine binds heparin making it ineffective.



69.  The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? D: "I always make sure to shake the NPH bottle hard to mix it well."



70.  Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs?



A: Orthostatic hypotension is a common side effect



71.  The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? D: Baked potato.



72.  An 86 year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? B: Check the client’s gag reflex



73.  The nurse is planning care for a client with a CVA. Which of the following measures plannedby the nurse would be most effective in preventing skin breakdown? C: Reposition every two hours



74.  A nurse is assessing several clients in a long term health care facility. Which client is at highest risk for development of decubitus ulcers? A: A 79 year-old malnourished client on bed rest



75.  Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? B: Obtain a health and dietary history



76.  After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A: Abdominal x-ray



77.  A client was just taken off the ventilator after surgery and has a nasogastric tube draining bilecolored liquids. Which nursing measure will provide the most comfort to the client? C: Perform frequent oral care with a tooth sponge



78.  The nurse is instructing a 65 year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to



A: Exercise doing weight bearing activities



79.  The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? B: Sliced turkey sandwich and canned pineapple



80.  Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol?



D: Bed in lowest position, wheels locked, place bed against wall



81.  When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula B: Continuously



82.  The nurse is teaching an 87 year-old client methods for maintaining regular bowel



movements. The nurse would caution the client to AVOID C: Laxatives



83.  A client with diarrhea should avoid which of the following?A: Orange juice



84.  Which statement best describes the effects of immobility in children?



B: Immobility in children has similar physical effects to those found in adults



85.  A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the client’s comfort? C: Keep conversations short



86.  After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is



teaching the client about the diet, which meal plan would be the most appropriate D: 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange



87.  The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? B: Decreased sodium and potassium



88.  What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? B: Oozing liquid stool



89.  A client in a long term care facility complains of pain. The nurse collects data about the



client’s pain. The first step in pain assessment is for the nurse to C: Accept the client''s report of pain



90.  An 85 year-old client complains of generalized muscle aches and pains. The first action by the nurse should be



A: Assess the severity and location of the pain



91.  A 20 year-old client has an infected leg wound from a motorcycle accident, and the client hasreturned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that:



C: Visitors should wash their hands before and after touching the client



92.  A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? C: Place in respiratory/secretion precautions



93.  Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?



D: Altered patterns of urinary elimination related to nocturia



94.  A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation?



A: An infant who has been identified to have botulism



95.  A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse shouldreinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? D: Have gloves on while handling bedpans with feces



96.  Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours?



B: An elderly factory worker with a lab report that is positive for acid-fast bacillus smear



97.  A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? D: Contact



98.  The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements?



C: “Children are not to share hats, scarves and combs.”



99.  During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A: Wash hands thoroughly before and after client contact



100.          A nurse is reinforcing teaching with a client about compromised host precautions. The clientis receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? B: roast beef, mashed potatoes, and green beans



101.          After an explosion at a factory one of the workers approaches the nurse and says “I am an unlicensed assistive personnel (UAP) at the local hospital.” Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? C: Palpate pulses



102.          Which of these clients would the nurse recommend to keep in the hospital during aninternal disaster at the agency?



D: A young adult in the second day of treatment for an overdose of acetaminophen



103.          The mother of a toddler who is being treated for pesticide poisoning asks: “Why is activatedcharcoal used? What does it do?” What is the nurse's best response? B: "The charcoal absorbs the poison and forms a compound that doesn't hurt your child."



104.          The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say



B: Upon entering the room the nurse should ask: "What is your



name? What allergies do you have?" then check the client''s name band and allergy band



105.          Several clients are admitted to an adult medical unit. The nurse would ensureairborne precautions for a client with which medical condition? B: A positive purified protein derivative with an abnormal chest xray



106.          A client is scheduled to receive an oral solution of radioactive iodine (131I). In orderto reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements?



A: “In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice.”



107.          Which approach is the best way to prevent infections when providing care to clientsin the home setting?



A) Hand washing before and after examination of clients


108.  A 10 year-old child has a history of epilepsy with tonic-clonic seizures. The schoolnurse should instruct the classroom teacher that if the child experiences a seizure in the



classroom, the most important action during the seizure would be to D: Place the hands or a folded blanket under the head of the child



109.  A mother calls the hospital hot line and is connected to the triage nurse. The mother proclaims: “I found my child with odd stuff coming from the mouth and an unmarked bottle nearby.” Which of these comments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosive substance? A: “Ask the child if the mouth is burning or throat pain is present”



110.  The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? D: Place client in a negative pressure private room and have all who enter the room use masks with shields



111.  The charge nurse is planning assignments on a medical unit. Which client should beassigned to the PN? C: Irrigate and redress a leg wound



112.  When assessing a client, it is important for the nurse to be informed about culturalissues related to the client's background because A: Normal patterns of behavior may be labeled as deviant, immoral, or insane



113.  The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? D: Supervise a nursing assistant for skin care.



114.  The nursing student is discussing with a preceptor the delegation of tasks to anunlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? C: Care for a client with discharge orders



115.  After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can’t do anything that pleases him. I’m not going in there again." The nurse should respond by saying: C: "He is scared and taking it out on you. Let's talk to figure out what to do."



116.  A client with a diagnosis of bipolar disorder has been referred to a local boardinghome for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements?



D: I need to get the client’s written consent before I release any information to you.



117.  A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. I insist



that you explain their use and side effects.” The nurse should understand that B: The client has a right to know about the prescribed medications



118.  Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?



A: "Have the client sit on the side of the bed for at least 2 minutes before helping him stand."



119.  The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client



C: Was minimally responsive to voice and touch



120.  A client tells the nurse, "I have something very important to tell you if you promisenot to tell." The best response by the nurse is B: "I can’t make such a promise."



121.  Which task could be safely delegated by the nurse to an unlicensed assistivepersonnel (UAP)?



D: Apply and care for a client''s rectal pouch



122.  A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first



C: Obtain more details of the client’s claim of abuse



123.  A nurse from the maternity unit is floated to the critical care unit because of staffshortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with



B: A myocardial infarction that is free from pain and dysrhythmias



124.  An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?



D: "Have you reviewed the list of expected skills you might need on this unit?"



125.  A client frequently admitted to the locked psychiatric unit repeatedly compliments and



invites one of the nurses to go out on a date. The nurse’s response should be to D: Discuss the boundaries of the relationship with the client



126.  A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? D: Perform nostril and mouth care



127.  The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia.



Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? A: Test blood sugar every 2 hours by Accucheck



128.  A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensedassistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?



B: A middle-aged client with an obsessive compulsive disorder



129.  The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? B: Check temperature 15 minutes after hot liquids are taken



130.  A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to B: Assign 1 of the nursing staff to visit the client regularly



131.  A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? B: Observation of affect and behavior



132.  A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do?



D: Pour fluid over the forehead backwards towards the back of the



head and say "I baptize you in the name of the father, the son and the holy spirit. Amen."



133.  An American Indian chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague "I wonder if he has any idea



how ridiculous he looks -- he's a grown man!" The nurse's response is an example of D: Prejudice



134.  A client expresses anger when the call light is not answered within 5 minutes. The client



demanded a blanket. The best response for the nurse to make is D: "I see this is frustrating for you. I have a few minutes so let's talk."



135.  An elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in calling the daughter from daily to once a week, and the client's tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients?



B: A middle aged person who has been on the unit for 72 hours with a dysthymia



136.  A client diagnosed with anorexia nervosa states after lunch, "I shouldn’t have eaten all of that sandwich, I don’t know why I ate it, I wasn’t hungry." The client’s comments indicate that the client is likely experiencing A: Guilt



137.  A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states “everyone’s C: Ask the client if talking with a priest would be desired



138.  A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client’s drawer. The client tells the nurse that they are



antacids for stomach pains. The best response by the nurse would be C: "Tell me about your week prior to being admitted."



139.  A client who has a belief based in Hinduism is nearing death. The nurse should planfor which action?



A: After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client''s wrist



140.  An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied by a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next?



B: Ask the parent to identify the major problem



141.  Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode?



C: "I have powers to get you whatever you wish, no matter the cost."






142.  A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as D: Flight of ideas



143.  During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice?



D: "Doesn't she know there's such a thing as birth control?"



144.  Which of these statements by the nurse reflects the best use of therapeutic interaction techniques?



A: "You look upset. Would you like to talk about it?"



145.  A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first?



B: Interview the client without the persons who came with the client



146.  Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? The client



D: Recognizes feelings with appropriate expression of feelings



147.  A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time? D: Locate a room that has minimal stimulation outside of it for admission process



148.  A 2 day-old child with spina bifida and meningomyelocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents?



D: Disbelief



149.  Which statement by the client during the initial assessment in the the emergency departmentis most indicative for suspected domestic violence? D: "I have tried leaving, but have always gone back."



150.  A nurse states: "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of C: Stereotyping



151.  Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a healthcare setting is correct?



B: Improvement of the processes in a proactive, preventive mode is paramount.



152.  The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are



invited to participate in the study if they wish. This affirms the ethical principle of D: Autonomy



153.  When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included?



C: Diarrhea, dry mouth, weight loss, reduced libido



154.  The nurse is performing an assessment of the motor function in a client with a head injury.



The best technique is



D: Gentle pressure on eye orbit



155.  The nurse is teaching about non steroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions? B: Taking the medication 1 hour before or 2 hours after meals



156.  A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects ofthe medication. The client should be instructed to immediately report which of these? Extremity tingling and numbness



157.  The nurse admits a 2 year-old child who has had a seizure. Which of the followingstatement by the child's parent would be important in determining the etiology of the seizure? B: "He has had an ear infection for the past 2 days."



158.  A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? B: Apply a pressure dressing to the site



159.  An 18 month-old child is on peritoneal dialysis in preparation for a renal transplantin the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving immunizations to this child? B: The MMR vaccine should be given now, prior to the transplant



160.  The nurse is preparing to administer a tube feeding to a postoperative client. To accurately assess for a gastrostomy tube placement, the priority is to



A: Auscultate the abdomen while instilling 10 cc of air into the tube



161.  The 84-year-old male has returned from the recovery room following a total hip repair. He complains of pain and is medicated by morphine sulfate and promethazine. Which medication should be kept available for the client being treated with opioid analgesics? A. Naloxone (Narcan) Narcan is the antidote for the opioid analgesics.



162.  The nurse is taking the vital signs of the client admitted with cancer of the pancreas. The nurse is aware that the fifth vital sign is:



B. Pain



163. The client with AIDS tells the nurse that he has been using acupuncture to help with his pain. The nurse should question the client regarding this treatment because acupuncture:



C. Uses needles to stimulate certain points on the body to treat pain Acupuncture uses needles, and because HIV is transmitted by blood and body fluids, the nurse should question this treatment.



164. The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:



D. Check the site for bleeding


165. Which of the following lab studies should be done periodically if the client is taking sodium warfarin (Coumadin)?



A. Stool specimen for occult blood


166. The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient’s potassium level to be 2.5meq/L. The nurse should:



D. Withhold the drug and call the doctor Answer D is correct. The potassium level of 2.5meq/L is extremely low. The normal is 3.5– 5.5meq/L. Lasix (furosemide) is a nonpotassium sparing diuretic


167. The doctor is preparing to remove chest tubes from the client’s left chest. In preparation for the removal, the nurse should instruct the client to:



B. Hold his breath and bear down. The client should be asked to perform a Valsalva maneuver while the chest tube is being removed. This prevents changes in pressure until an occlusive dressing can be applied.



168. The nurse identifies ventricular tachycardia on the heart monitor. Which action should the nurse prepare to take?



C. Administer an antiarrhythmic medication such as Lidocaine. The treatment for ventricular tachycardia is lidocaine


169. A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should:



A. Call the doctor immediately. The normal central venous pressure is 5–10cm of water. A reading of 2cm is low and should be reported.



170. The nurse is evaluating the client’s pulmonary artery pressure. The nurse is aware that this test will evaluate:



B. The systolic, diastolic, and mean pressure of the pulmonary artery


Answer B is correct. The pulmonary artery pressure will measure the pressure during systole, diastole, and the mean pressure in the pulmonary artery. It will not measure the pressure in the left ventricle, the pressure in the pulmonary veins, or the pressure in the right ventricle.



171.          The physician has ordered atropine sulfate 0.4mg IM before surgery. The medication is supplied at 0.8mg per milliliter. The nurse should administer how many milliliters of the medication?



❍ B. 0.5mL



Answer B is correct. If the doctor orders 0.4mgm IM and the drug is available in 0.8/1mL, the nurse should make the calculation: ?mL = 1mL / 0.8mgm; × 0.4mg / 1 =






172.          If the nurse is unable to illicit the deep tendon reflexes of thepatella, the nurse should ask the client to:



A. Pull against the palms. If the nurse cannot elicit the patellar reflex (knee jerk), the client should be asked to pull against the palms. This helps the client to relax the legs and makes it easier to get an objective reading.



173. A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor?



A. An elevated white blood cell count. The elevated white blood cell count should be reported because this indicates infection.



174. A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:



B. Elevate the scrotum on a small pillow. The child with nephrotic syndrome will exhibit extreme edema. Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema.



175. The nurse is taking the blood pressure of an obese client. If the blood pressure cuff is too small, the results will be:



A. A false elevation


176. The client is admitted with thrombophlebitis and an order for heparin. The medication should be administered using:



B. A tuberculin syringe


177. The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for a low-protein diet is:



A. Protein breaks down into blood urea nitrogen and metabolic waste.



178.          The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The nurse is aware that the most likely explanation for the elevated temperature is: A. There was damage to the hypothalamus.



179.          The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing?



C. Temporal


180. A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches?



B. Measuring 3 inches under the axilla


181. The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?



D. Sexual function


182. The client returns to the recovery room following repair of an intrathoracic aneurysm.



Which finding would require further investigation?



B. Urinary output 20mL in the past hour


183. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?



C. “I take aspirin for a headache.”


184. A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with:



A. Hypothyroidism


185. The nurse has just received shift report and is preparing to make rounds. Which client should be seen first?



C. The client who was admitted 1 hour ago with shortness of breath


186. The doctor has ordered antithrombotic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is:



A. Before rising in the morning


187.          The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The clientshould be taught to avoid: C. Sitting in a straight chair



188.          While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to:



A. Call the doctor


189. The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the:



C. Earlobe


190. Dalteparin (Fragmin) has been ordered for a client with pulmonary embolism. Which statement made by the graduate nurse indicates inadequate understanding of the medication?



C. “I will check the PTT before administering the medication.”


191. The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:



A. Constipation


192. A client who has been receiving urokinase has a large bloody bowel movement. What nursing action would be best for the nurse to take immediately?



D. Stop the urokinase, notify the physician, and prepare to administer amicar 193. Which of the following best describes the language of a 24-month-old?



C. Able to verbalize needs



194. In terms of cognitive development, a 2-year-old would be expected to:



B. Use magical thinking


195. The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother’s lap. What should the nurse do first?



B. Listen to the heart and lung sounds


196. Which of the following examples represents parallel play?



B. Jimmy plays with his car beside Mary, who is playing with her doll.



197. Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?



B. A 4-year-old


198.          An important intervention in monitoring the dietary compliance of a client with bulimia is: C. Observing her for 1–2 hours after meals



199.          The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such a client is:



A. Setting realistic limits


200. A client with a diagnosis of passive-aggressive personality disorder is seen at the local mental health clinic. A common characteristic of persons with passive-aggressive personality disorder is:



B. Underlying hostility



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