NCLEX 5 Flashcards

Terms Definitions
haloperidol (Haldol)
12 - 18
Anion gap
10-12 mEq/L
Normal Cardiac sounds
Oral contraceptives
Suppress milk production
Pain assessment
What makes pain better?
Normal Blood Sugar
70-110 mg/dL
Base excess
+2 to -2
albuterol: S/E
Nervousness, restlessness, palpatations
S/E may diminsh after taking for a week or longer
Exteme fatigue, menstrual disturbances, hair loss, brittle nails, dry skin, intolerance to cold, anorexia, constipation, apathy
atorvastation (Lipitor)
Lipid-lowering agent
Grapefruit juice decreases enzyme that breaks it down
Propranolol (Inderal) decreases effectiveness
avoid narcotic sedatives, barbituates and anesthetics
eat high fiber foods to preent constipation
can't tolerate cold temperatures
verapamil (Calan)
Antihypertensive, calcium channel blocker
Trousseau's sign
indictive of neuromuscular reflexia
Identity vs. role diffusion
12-20 years
propranolol (Inderal): S/E
Antihypertensive, Beta Blocker
Increased airway resistance
Pt. may have bronchospams
Asses respiratory rate and call doctor
Aspirin: Fetus
Can cuase fetal hemorraghe
Cold Stress: Infant
Mottling of skin
Irregular Respirations
Treatment For Emphysema
Bronchodilator therapy, Beta-Adrenergic agonists, corticosteroid therapy, oxygen and nebulization therapy, chest physiotherapy, intermittent positive-pressure breathing, possibly mechanical ventilation, and possible surgical procedures
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
Diabetes insipidus: S/S
Increased urinary output 4-30L/day
Dilute urinary with specific gravity less than 1.005
Glucose Panic Values
< 40 mg/dL
>700 mg/dL
Encourage fluids to facilitate removal of concentrated urine
morphine sulfate
Depresses CNS, especially respiratory center in medulla
Used for moderate to severe pain
Children in pain: S/S
Restless and overactive
Clenching of teeth
Aggressive behavior
Trust vs. mistrust
Birth to one year
Alcohol withdrawal: S/S
restlessnes, agitation, and irritability
Client on hallucinogenic drugs
Decrease environmental stimulation
Symptoms will subside with time and decreased environmental stimulation
Hepatic encephalopathy: early s/s
Impaired thought process
Frontal lobe
Personality, behavior, emotions and intellectual function
Has a high glucose content
Important to monitor glucose levels
Biologic needs for food, shelter, water, sleep, oxygen, sexual expression.
Avoiding harm, attaining security, order, & physical safety
Love & belonging:
giving & receiving affection, companionship & identification with a group
Esteem & recognition:
self esteem & respect of others, success in work, prestige
Self actualization:
fulfillment of unique potential
search for beauty & spiritual goals
Generalized seizures are produced by electrical impulses from throughout the entire brain
Female: 12-16 Male; 14-18; Newborn 14-20g/dl 1. components of the RBC responsible or oxygen transport, decreased in anemia, chronic and acute blood loss, and bone marrow depression
Strongly held belief that is not validated by reality
7 year old child
39- 65.5 lb
44-51 inches
Lofenalac formula
Low in phenylalanine but contains minerals and vitamins to provide a balanced nutritional formula
Sickle Cell Crisis
Avoid people with infections
Give Demerol to reduce pain
Drink lots of water
Avoid aspirin, can cause hemorraghe
Pain relief
Necessary to establish a trusting relationship with patient
Necessary to work with patient to identify interventions to relieve pain
Heat is a sign of pressure
Pressure limits circulation
Low Hgb
Is caused by chemotherapy or cancer
Allow patient to be weaned from respirator
Allow for spontaneous breaths and tidal volume between ventilator breaths
Cholecystitis S/S
Pain in upper right abdominal quadrant
Bread & cereal, dary, dried beans, eggs, meats, fish, & poultry
Neonates normal temperature ranges?
96° to 99.5° F
What are normal calcium values?
8.5 - 10.5
The Stethoscope
is indispensable for determining the sounds inside the body. The diaphragm is used to hear high pitch sounds such as S1 and S2 murmurs of the mitral valve regurgitate pericardia and abdominal friction rub sounds. The bell is used to here low pitch heart sounds such as S3 and S$ an a murmur of the aortic stenosys
The diaphragm listen to bowl heart sounds and blood pressure
the catheter is inserted into the tracheotomy until slight resistance is met; suction is applied as the catheter is withdrawn.
Geriatric Patients
Should be encouraged to talk about life and important things in the past because of recent memory loss
Direct conversation towards reminisce and talk about important past life events
Diabetes insipidus
Disorder of water metabolism caused by deficiency of ADH by pituitary gland
Pillow behind patient's knees
Puts pressure on popliteal space
Restricts circulation and increases risk for thrombophlebitis
diazepam (Valium): overdose
Focus on physical first
Because of potenially threatening life complications such as respiratory failure, pulmonary edema, and seizures, prioity is observation and documentation of vital signs
procainamide (Pronestyl): A/E
Severe hypotension or bradycardia are signs of adverse reatction to medication
Third trimester: expected observation
Shortness of breath
Increased rectal pressure
Inappropriate sexual behavior
Nurse should confront client
"I feel uncomfortable when you make those suggestive remarks. It makes me dificult to do my job"
Weight gain of 5 lbs
Pulse 116
Serum sodium 110 mEa/L
Erikson Stage: 12-20 yrs
Identity vs role confusion
developing sense of identity
Major concern is body image. Discuss things when parents are not in the room & always direct questions to the adolescent.
Cancer of the Larynx
Characterized by hoarseness and/or voice characteristics, palpable jugular nodes, pain when swallowing, and unexplained earache.
Which sign is the softening of the cervix?
Absence Seizure
short loss of consciousness (just a few seconds) with few or no symptoms. The patient, most often a child, typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are usually not aware that they are having a seizure, except that they may be aware of "losing time."
Infant with reflux
Maintain head of bed at 30 degrees
Feedings should be smaller and more frequent
6-12 year old: growth rate
2 inches/year growth
4.5-6.5 lbs/ year
Antianxiety medication
May be used for social phobia or social anxiety disorder
Infant: emesis
Would expect emesis to contain milk or formula
Should not be bile-colored
Most effective way to reduce infection
Good handwashing
Important with immunosuppressed patients
Crutches and Canes: Stairs
Up with good, down with bad
Internal fetal monitor
goal is to detect mild fetal hypoxia
Diabetic: Dawn phenomena
Treatment is to adjust evening diet, bedtime snack (not eliminate it), insulin dose(NPH) and to prevent early morning hyperglycemia
Insulin needs in pregnancy
Increase during pregnancy due to hormonal interference in glucose metabolism
Needs decrease after delivery
1 kg = how many liters of water?
1 L
What are the dietary considerations for pancreatitis?
Avoid aldohol
bland foods
small, frequent meals
decrease fat
A client with thrombophlebitis is being treated with heparin sodium (Liquaemin) therapy. The registered nurse (RN) asks the licensed practical nurse (LPN) to check the medication supply to ensure that the antidote for this therapy is available. The nurse
1. Protamine sulfate
Rationale: Protamine sulfate is the antidote for heparin sodium. Streptokinase is a thrombolytic agent used to dissolve blood clots. Vitamin K is the antidote for warfarin (Coumadin). Amicar is an antifibrinolytic used to prevent the breakdown of clots already formed.
Turn, cough, deep breath
Should be taught the night before surgery
Done every 2 hours to prevent respiratory complications
Splinting prevents abdominal jarring
Teaching patient to use cane
Stand slightly behind on strong side
Patient in seclusion room
Should eat meal at regular time
Should remain in seclusion room
Confusion in older adults
Stress of an unfamilar situation or environment may lead to confusion in elderly clients
Grasp Reflex
Touching of palms of hands or soles of feet causes flexion of hands or toes
Palmar grasp disappears around 3 months of age
Plantar grasp lessens around 8 months of age
"When taking a BP, if the arm is below the heart level, will the BP reading be elevated or decreased?
The LPN/LVN assigned to a homosexual male is responsible for relaying positive HIV test results to the client. Which of the following responses would the nurse expect initially?
(A) Disbelief
(B) Acceptance
(C) Anger
(D) Depression
(A) Disbelief
Rationale: Initial response to receiving sad or bad news is disbelief or denial. Grief is a normal response to loss or feelings of powerlessness. When people experiencing grief, they must work through the stages of changing emotions, which usually progress as follows: disbelief, anger, bargaining, depression, and eventually acceptance.
4 things that protect the brain
meningies, csf, blood-brain barrier, skull
Mental Health: Phone Use
All patients are allowed to use the phone unless otherwise indicated by court or physican's order
Nursing Hx of 2 year old
Document child's routines and rituals at home
Child will have sense of security
Following seizure most important question?
"What were you doing before the seizure?"
Triggering mechanism: loud nosie, music, flickering light, prolonged reading, drugs
What is the normal heart rate of an adult?
60-100 per minute
Toddlers 1-3 years PRAISE
P- Push pull toys / parallel play autononimiss like playing side by side but not sharing
R- Rituals and routines / regression must have constituency regression may occur during hospitalization praise appropriate behavior
A- Autonomy v shame and doubt / accidents they like to help dress and undress themselves accidents are leading cause of deaths ex poisoning or drowning
I- Involved Parents parents can comfort them
S- Separation Anxiety allow parents to stay with child
E- Elimination / Explore toilet training is a major milestone browses on extremities from climbing
Make sure to keep poisons out of reach and childproof your home
Mrs. foster thinks she might be pregnant and visit's the physician's office. a urine sample pregnancy test is performed. The evaluation of which of the following hormones in the urine would indicate that Mrs. Foster is indeed pregnant?
(A) Human growth ho
(B) Human chorionic gonadotropin (hCG)
Rationale: Human chorionic gonadotropin (hCG) is released by the trophoblast, outer cell layer of the developing fetus in the zygote stage. hCG can be detected in the blood and urine as early as 10 to 14 days after conception, indicating early pregnancy. Human growth hormone (hGH) is responsible for the growth of bones, muscles and other organs. Estrogen is important for maintaining pregnancy, but it is not used to diagnose pregnancy. Estrogen elevation does not occur until the seventh week of gestation. Oxytocin promotes uterine contractility and the stimulation of milk ejection from the breasts. During pregnancy oxytocin assists the labor process that results in birth.
Dry. parched mouth and tongue
Rinse mouth with warm tap water before and after meals
Will hydrate mucous membranes and keep mouth clean
Meniere's Disease: nurse stands in front
By decreasing movement of head vertigo attacks will be decreased
Client does not have to turn head to see nurse
Do Mydriatic drops constrict or dilate the pupils?
Dilate -- myDriatic (d for dilate)
"The lens is normally transparent
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
During hospitalization, Mrs. Granger is diagnosed with peptic ulcer disease (PUD). The physician has ordered her discharge home. After reviewing the discharge instructions with Mrs. Granger, which of the following statements indicates to the LPN/LVN that
(C) "I will make aspirin my pain reliever of choice."
Rationale: Aspirin irritates the mucosal lining of the gastrointestinal tract and is not recommended for use by clients with peptic ulcer disease, making answer (C) correct. It is suggested to client's with peptic ulcer disease to avoid a diet rich in milk and cream, which stimulate acid secretion. Coffee, even decaffeinated forms, stimulates acid secretion also. Smoking causes decreased secretion of bicarbonate into the duodenum from the pancreas. Bicarbonate decreases the acidity in the GI tract. Therefore, clients with PUD should be encouraged to stop smoking.
During her visit to the clinic, testing is performed that confirms Mrs. Foster's suspected pregnancy. Mrs. Foster states that her last menstrual period (LMP) began on March 12. Using Nagele's rule, what would the LPN/LVN calculate Mrs. Foster's estimated
(D) December 19th of that year
Rationale: Nagele's rule calculates the estimated date of confinement (EDC) using the following formula: the first day of the last normal menstrual period (LMP) minus 3 months, plus seven days, plus one year. Three months before the date of Mrs. Foster's LMP is December 12th of the previous year. December 12th plus 7 days is December 19th of the previous year. Therefore, the EDC is December of that year, answer (D).
Back arched; rigid extension of all four extremities.
Which of the following describes decerebrate posturing?
The LPN/LVN is preparing to administer Vancomycin 1 gram mixed in 500 mL of IV solution. The medication is to be administered over 90 minutes. At what rate should the medication be set at in drops per minute with a drop factor of 15 gtt/mL?
(A) 15gtt/min
(D) 83 gtt/min
Rationale: The formula to calculate this problem is: x gtt/min = volume/time (in minutes) X drop factor.
x gtt/min = volume/time
15gtt/90min = 500/1
x gtt/min = 83
Or use
15gtt/90min X 500mL/1min
15 X 500 = 7500
90 X 1 = 90
7500/90 = 83gtt/min
Chest tube: Water sealed chamber
Water should be kept at level of 2ml to maintain negative pressure
When examining a pregnant woman for signs and symptoms of pregnancy, remember the alphabet ABCDEFGH. Chadwick's sign reflects vaginal changes, Goodell's sign reflects cervical changes, and Hagar's sign reflects lower uterine segment changes. Anatomically,
When instilling eardrops in the child and the adult, remember to pull the lobe up and back for the adult and down and back for the child. Note the "U" in Up and adUlt and the "D" in Down and chilD. Also, you can remember that up is to tall as down is to small. In other words, a tall adult and a small child.
A client with Bell's palsy is scheduled for a magnetic resonance imaging (MRI). The nurse should implement which of the following standard orders to ensure a safe environment in preparation for this test?
1. Shave the groin area for insertion of a femoral
3. Remove all objects containing metal from the client
Rationale: An MRI uses magnetic fields to produce a diagnostic image. All metal objects such as rings, bracelets, hairpins and watches should be removed. The client's history should also be reviewed to determine if the client has any internal metallic devices such as orthopedic hardware, pacemakers and shrapnel. A femoral catheter is not inserted. For an abdominal MRI, the client is usually NPO, but this is not necessary for an MRI of the head. In addition, an NPO status for 24 hours is unnecessary and may be harmful to the client. Metal-tipped electrodes are not used for this test.
A prenatal client who has acquired the sexually transmitted virus Condyloma acuminatum (human papilloma virus) asks the nurse to explain again the treatment for the infection. The nurse should reinforce additional information about which of the following
1. Laser therapy
Rationale: For the pregnant client, laser therapy is the most effective method of destroying the virus. This therapy is localized, whereas medications (which are considered toxic to the fetus) would have a systemic effect. The primary neonatal effect of the virus is respiratory or laryngeal papillomatosis, although the exact route of perinatal transmission is unknown. Options 2, 3 and 4 are incorrect.
A client with severe peptic ulcer disease undergoes a Billroth II surgical procedure. Which of the following best describes the alterations made to the gastrointestinal tract with this procedure?
(A) Antrectomy with anastomosis to the duodenum
(B) Antrect
(B) Billroth II, also known as gastrojejunostomy, begins with the removal of the lower section of the antral portion of the stomach. This is the part of the stomach that secretes gastrin, which stimulates the secretion of gastric acid. A small portion of the duodenum and pylorus are also removed. The remaining stomach is then attached with an opening (anastomosed to the jejunum of the small intestines. Answer (A) represents a Billroth I procedure. The severing of vagus nerves, answer (C), describes a vagotomy. Answer (D) describes a colon resection.
A client complaining of constipation is prescribed lactulose (Cephulac) 20 g p.o. BID. The nurse preparing the morning dose reads the constitution of medication to syrup solution as 10 g/15 mL. how many mL will the nurse prepare for the client?
(A) 10
(D) 30
Rationale: Solve for x mL using the following ration method:
10 g/15 mL = 20 g/x mL
10x = 300
x = 300/10
x = 30 mL
or desired over available:
20 g/10 g X 15 mL = x
20/10 = 2
2 X 15 = 30 mL
A rehabilitation center nurse is planning the client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant?
1. A client who had a below-the-knee amputation
2. A client on a 24-hour urine collection who is
2. A client on a 24-hour urine collection who is on strict bed rest.
Rationale: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. A client who had a below-the-knee amputation, is scheduled for an invasive procedure, or is scheduled to be transferred to the hospital for coronary artery bypass surgery has both physiological and psychological needs. The nursing assistant has been trained to care for a client on bed rest and urine collections. The nurse provides instructions, but the tasks required are within the role of a nursing assistant.
A nurse overhears a client ask the physician if the client the results of a biopsy indicated cancer. The physician tells the client that the results have not returned, when in fact the physician is aware that the results of the biopsy indicated the presen
3. Slander
Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. Although the physician may be aware of the biopsy results, the physician decides when it is best to share such a diagnosis with the client.
Mrs. Palmer, a client with Parkinson's disease, is admitted to an extended-stay nursing facility. Up until this point she has been living on her own. Which of the following assessments is the most significant in developing the plan of care?
(A) Mrs. Palme
(C) Mrs. Palmer has a difficult time eating at dinner due to tremors
Rationale: Although it is important to consider all client needs holistically, the highest concern in establishing a plan of care is the physiological needs of the client. Physiological needs include ADLs (activities of daily living). ADLs are basic needs, such as eating, moving, dressing, toileting and other personal hygiene. Answer (C) is the correct answer because it is the only assessment that indicates a physical hindrance to a physiological need.
What is the most appropriate position for a client to assume when receiving a rectal suppository?
Answer: Lying on the left side with the right knee flexed
Rationale: The left side-lying or Sims' position with the right knee flexed allows medication to be inserted into the natural curve of the sigmoid colon. Assuming this position will decrease discomfort during the procedure and also reduce the risk of injury to tissue surrounding the rectum and colon.
A nurse is collecting information from a client about the client's suicide risk. The nurse should ask the client which most significant question?
1. "Why do you want to hurt yourself?"
2. "Do you have a plan to commit suicide?"
3. " Has anyone in your fam
2. "Do you have a plan to commit suicide?"
Rationale: When collecting information about suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Options 1, 3 and 4 do not directly provide this information.
A nurse is assigned to care for a client with cervical cancer who has an internal radiation implant. Which of the following required items should the nurse ensure is kept in the client's room during this treatment?
1. A lead shield
2. A bedside commode
4. Long-handled forceps and a lead container
Rationale: In the case of dislodgement of an internal radiation implant, the radioactive source is never touched with the bare hands. It is retrieved with long-handled forceps and placed in the lead container kept in the client's room. In many situations the client has a Foley catheter inserted and is on bed rest during treatment to prevent dislodgement. Although a lead shield may be in the room, it is not the required item. Nurses wear a dosimeter badge while in the client's room to measure the exposure to radiation.
This is the second post-op day for a 54-year-old client who had a CABG. At 8am her BP is normal; the pulse rate is 123 bpm (normally 82 bpm) and weak. The client is cold, clammy, and confused. Her respiratory rate is 44/min; bowel sounds are absent, and u
3. The signs are classic for shockl the BP can be normal.
The LPN/LVN at a clinic answers a phone call from an 18 year old rape victim. The nurse tells the victim to go to the emergency room for a medical examination. Which of the following additional instructions for the victim is of highest priority?
(A) Gathe
(D) Do not take a shower before going to the hospital
Rationale: Rape is any form of sexual violence or assault on an unwilling victim. A thorough physical exam will be performed at the hospital. Evidence may only be available on the victim or the victim's clothes. The victim should be advised not to shower, brush teeth, drink or eat, douche, change clothes, or manipulate any surface or body orifice that could contain evidence against the perpetrator. The victim can wait to tell the details of the incident to medical professionals at the hospital as opposed to writing them down. Gathering belongings and/or calling a support person may be helpful, but these actions are not high priorities in this situation.
A friend calls and states that he has taken three nitroglycerin tablets for his chest pain, but the pain is still there. The nurse advises him to:
1. Call his doctor
2. Drive to the nearest emergency room
3. lie down and rest to see if the pain goes aw
4. A rescue squad is best equipped to give emergency treatment.
A nurse is caring for a child with a fever. The nurse implements which safe action when giving this child a tepid tub bath?
1. Add some alcohol to the bath water
2. Let the child soak in the tub for 10 minutes
3. Add cool water slowly to the warmer bath w
3. Add cool water slowly to the warmer bath water
Rationale: Cool water should be added to an already warm bath because this will cause the water temperature to slowly drop. The child will be able to gradually adjust to the changing water temperature and will not experience chilling. The child should be in a tepid tub bath for 20 - 30 minutes to achieve maximum results. To achieve the best cooling results for the child with a fever, the water temperature should be at least 2 degrees lower than the child's body temperature.
/ 112

Leave a Comment ({[ getComments().length ]})

Comments ({[ getComments().length ]})


{[ comment.comment ]}

View All {[ getComments().length ]} Comments
Ask a homework question - tutors are online