HESI EXIT EXAM PREP
Always prioritize by ABCs!● Airway: physical airway ● Breathing: pneumo/lung issues ● Circulation: bleeding/heart
Nursing Process1. Assessment 2. Diagnosis (Analysis) 3. Planning 4. Implementation (treatment) 5. Evaluation
Maslow's Hierarchy of Needs1. Physiologic 2. Safety 3. Love and Belonging 4. Esteem 5. Self-actualization
Normal Lab ValuesHgb ● 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/dlPhenylalanine 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 QRSCa++ 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 1.005-1.030Glycosylated 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.
AntidotesDigoxin - 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.
PrioritizationWhich 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
DelegationRN 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 AssignmentsUniversal (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 StuffRifampin (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 & PsychiatryPsych 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 MiscellaneousHypoventilation = Acidosis (too much CO2) Hyperventilation = Alkalosis (low CO2) No BP or IV on side of Mastectomy
Opiate OD = Pinpoint PupilsLesions 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
Hematology/OncologyLeukemia: Anemia (reduced RBC production), Immunosuppression (neutropenia and immature WBCs), Hemorrhage and bleeding tendencies (thrombocytopenia)
Warning Signs of Cancer in ChildrenC 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 DiseasesSyphilis (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 CareBreathing 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
Acute CareVA ... 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 SignsTensilon 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)
PediatricsIn 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
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
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
● 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
● 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
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.
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
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?
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?
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:
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?
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:
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:
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:
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