NCLEX RN Review 2 Flashcards

Diagnostic Tests
Terms Definitions
1.6-2.6 mg/dL
Medical/Nursing Management
Medical/Nursing Management

• Medical Tx:
– Chronic transfusions
– Sometimes splenectomy
– Bone marrow transplant
• Nursing Issues:
– Blood Transfusions
– Chelation therapy
– Risk of infection, post-
– Patient/Family Education
Digoxin therapeutic level

· Respiratory status

· Cardiovascular status

· Vital signs

· Pulse ox

· I&O

§ Breathing exercises

§ Encourage physical activity
Diagnostic tests:

§ Autopsy

o Treatments:

§ Allow parents to interact with child allows parents to say good-bye

§ Allow parents to express grief

§ Provide emotional support

§ Reassure parents there was nothing they could have done
Low-pitched, rumbling and hyperresonant sounds on inspiration
Amount of amniotic fluid

· Respiratory status

· Cardiovascular status

· Neurological status

· Vital signs

· Pulse ox

· I&O

· Assess fontanels for bulging

§ Provide calm environment

§ Provide emotional support

§ Gentle activities
Where is erythropoietin produced?
Quinine Sulfate
s.e.: eye disturbances, NV, Anorexia
N.C.: mgmt of malaria,nocturnal leg cramps
-peak 1-3 hrs
-take same time ea day to maintain bl. levels
-avoid OTC cold meds, tonic water
-preg X
Contributing factors:

o Clinical findings:

§ Failure to thrive

§ Weight loss

§ Recurrent diarrhea

§ Fever

§ Malnutrition

§ Fatigue and weakness

§ Night sweats

§ Opportunistic infections

§ Pallor
Asthma monitor
Respiratory status

· Cardiovascular status

· Vital signs

· Cough:

o Description

o S/S of infection

· Exposure to smoke

§ Raise mouth after inhaling medication

§ Modify inhalant to avoid allergens

§ During attacks:

· High fowler’s position

· Monitor for distress

· Calm environment

· Assess affective of drug therapy
Phenobarbital (Luminal)
s.e: CNS effects, depressive effects on body systems, rash, initially constricts pupils, Respiratory depression
-mgmt of epilepsy, febrile seizures in child.,sedation, insomnia
-IV: slow rate-crash cart availible
-IM: inject deep into large muscle, onset 10-30 min
-PO: onset 20-60 min pk 8-12 hrs, dur. 6-10 hrs
-caution w/activitie
-Nystagmus may indicate early toxicity
-Physical dependence, withdrawal problems
-give Vit D if long-term use
Clinical findings:

§ Poor attention span

§ Poor organization

§ Easily distracted

§ Difficulty waiting turn

§ Excessive climbing, running or talking

§ Frequent forgetfulness

§ Impulsive behavior

§ Failure to:

· To listen

· Follow directions

o Diagnostic tests:

§ Complete psychological, medical and neurologic evaluation

o Treatments:
2 separate ovum are fertilized
an assumtion of cultural superiority and an inability to accept the ways of another culture
Respiratory System:
The child’s respiratory status differs from the adult in the following ways:

· Lungs are not fully developed at birth

· There is an increase in size and number of alveoli until the age of 8

· Until age of 5; there is a narrower lumen when compared to the adult

· Increase in elastic connective tissue as child grows

· Child’s higher respiratory rate
Chadwick's Sign
ncreased vascularization causes a softening and blue-purple discoloration which occurs at about 6 weeks gestational age.
bloody show
dislodging of the mucus plug
High-pitched cry

§ Rapid increase in head circumference

§ When percussing head the is a “cracked pot” sound

§ Distended scalp veins

§ Irritability

§ Lethargy

§ Decrease attention span

o Diagnostic tests:

§ Skull X-ray

§ Light reflects off opposite side of skull with transillumination

§ Angiography

§ CT scan

Cyanotic heart defects:

§ Crouching position

§ Clubbing

§ Irritability

§ Tachycardia

§ Tachypnea

§ History of poor feeding
Acute Myelogenous Leukemia
Malignant proliferation of
myeloid cells n bone marrow

• Presenting symptoms:
Flu-like, bleeding, or as
in ALL

• TX:
– Induction phase
– Intensive chemotherapy

• Increased incidence of DIC
Neuroleptic Malignant syndrome
Rigidity, fever, hypertension, diaphoresis
-NMS is caused almost exclusively by antipsychotics, including all types of neuroleptic medicines along with newer antipsychotic drugs
-Dantrolene, a hydantoin reduces the catabolic processes and is admin to alleviate the symptoms of NMS
Lamotrigine (Lamictal)
s.e.: CNS symptoms, NV, anorexia, abd. pain, dysmenorrhea
N.C.: for mgmt of seizures
in peds, stop at 1st sign of rash, inform M.D.
-take divided doses w/meals or pc to decrease adverse eff.
=use caution w/activitie
=physical dependence, withdrawal problems
- wear med tags
Rx preg C
NO otcs check with md first
Adverse effects of sertraline (Zoloft) a SSRI, are agitation, sleep disturbance and dry mouth
a group of people with characteristic patterns of behavior that distinguish the group from the larger culture or society
Duchenne’s muscular dystrophy:

This genetic disorder occurs only in males. It is associated with progressive muscular degeneration throughout childhood. Death is generally a result of cardiac or respiratory arrest in the late teens or early 20’s.
contributing factors:

§ Sex-linked recessive trait

o Clinical findings:

§ Weakness of pelvic girdle, seen by waddling gait or frequent falls early sign

§ Gowers’ sign use of hand to push owns self up from the floor

§ Eventual muscle weakness and wasting

§ Delayed motor development

§ Cardiac or respiratory failure

§ Inability to perform activities of daily living(ADLs)

o Diagnostic tests:

§ Muscle biopsy

§ Electromyography

o Treatments:

§ Physical therapy

§ Supportive devices: splints, braces and wheel chair

§ High protein and fiber; low calorie diet

§ Gene therapy investigational stage


§ Encourage coughing, deep breathing and diaphragmatic breathing

§ Use of high-top sneakers and foot cradle prevent foot drop

§ Provide emotional support to both parent and child

§ Genetic counseling
American Indians
no meat in pre natal period
Amikacin, Gentamicin, Tobramycin (Amikin, Garamycin, Tobrax)
s.e.:do not use during preg. may cause bilateral congenital deafness,
Ototoxicity cranial nerve VIII
Allegric reactions: fever, diff. breathing, rash
N.C.: trtmt of severs systemic inf. of CNS, resp.,GI, urinary tract, Bone, skin, soft tissures, acute PID
-IV over 1/2 -1 hr: IM deep,slow, never SQ
-monitor bl.levels
-ch peak-2 hrs after admin
-ck trough-at time of dose/prior to med
-monitor for superinfection(diarrhea, URI, coated tongue)
-immediately report hearing or balance problems
-encourage fluids 8-10 glasses daily
preg C
this drug prescribed to prevent a thromboembolic stroke it inhibits platlet aggregation by interferring with adenosine diphosophate releases in the coagulation cascade and is used to prevent thrombomblic stroke
svt tx
Performing the valsalva maneuver can reverse SVT, blowing should occur for 30 to 60 seconds; other possible vagal maneuvers include ice to the face, holding the breath and bearing down, also massaging the carotid artery on only one side of the neck.
Autonomic Dysreflexia
this condition displays an anxiety, flushing above the level of lesion, piloerection, hypertension, and bradycardia.
A child with Wilm’s tumor labs should be checked for
foramen ovale
heart problem that diverts blood between the atriums
when presenting part dips into inlet but can be displaced with upward pressure from examiners fingers
Theophylline (Theo-Dur) is a
xanthine bronchodilator

it dilates respiratory airways and relaxes the bronchial smooth muscles
Where are Kupffer's cells located?
Liver and spleen
Postpartum Assessments:
onitor: Vital signs every 15minutes first 1-2hrs; then every 4 for first 24hrs

o Respiratory rate: should return to normal after delivery

o Temperature:

§ May be slightly elevated 100.40F related to dehydration or exertion

o Heart rate:

§ May 50-70 beats per minute due to decrease cardiac strain post delivery

o Blood pressure:

§ Return to normal within 24 hours

· Fundus: assess every 15mins first 1-2hrs; then every shift

o Monitor fundus tone and location

o Location should be:

§ 1-2 hours post delivery: midway between umbilicus and symphysis

§ 12 hours post delivery: at or 1cm above the level of the umbilicus

§ 3rd day post delivery: 3cm below umbilicus

o Tone: should be firm

o Nursing actions required:

§ Massage boggy(soft) fundus
once the fertilized egg is implanted in the uterus, the body’s natural response is to dilate blood vessels to allow more blood to the fetus. However, in PIH, the opposite occurs. The reason is not really known. What happens?: Vasocontriction, Leads to microbreakdown of the vessels (small tears and cracks, Leads to leaking of fluids into the tissues, Causes edema (this is why weight is checked at prenatal visits), Causes protein to be found in the urine. (this is why urine is checked at prenatal visits)

Pregnant women have dependent edema anyway due to the pressure of the growing uterus on vessels. This is why when laying down, particularly while you sleep, it causes more blood to flow, which causes more urine production. Pt’s with chronic HTN may have poor placental implantation.
Acyanotic heart defects monitor

· Cardiovascular status

· Respiratory status

· Vital signs

· Pulse ox

· I&O

· Weight

· Fluid and electrolyte status

§ Fluid restriction

§ Weight child daily

§ High calorie; easy to chew diet

§ Maintain normal body temperature

§ Activity with frequent rest periods

§ Head of bed elevated
Signs/Symptoms of Sepsis
1. Increased cardiac output
2. Hypotension, tachypnea
3. Poor regulation of body temp - either up or down
PG Psychological Maladaptation:

This is a condition of depression of serve duration and depth, lasting longer than 2 weeks.

Contributing factors:

· Neonatal complications

· Hormonal shifts

· Poor family support or self-esteem

· Stress

· Troub
Clinical findings:

· Increase anxiety about the health of baby and self

· Inability to stop crying

· Anxiety about being left alone

· Overwhelming feeling of sadness


· Psychotherapy

· Counseling for patient and family at risk

· Group therapy

· Drug therapy:

o Antidepressants:

§ Imipramine (Tofranil)

§ Nortriptyline (Pamelor)

· Monitor:

o Health history

o Maternal support system

o Maternal-infant bond

· Provide emotional support
Droplet Precautions
1. Private room
2. Wear mask (surgical) when working within 3 feet of client
3. Keep client door closed
4. Clients w/ meningitis, flu
Most common
causative organisms
Haemophilus influenza b

• Strep pneumoniae

• Neisseria menigitidis
Cyanotic heart defects monitor

· Cardiovascular status

· Respiratory status

· Vital signs

· Pulse ox

· I&O

§ Oxygen

§ Decrease oxygen consumption

§ Adequate hydration

§ Prevent patient distress
cultural assimilation
process in which individuals from a minority group are absorbed by the dominant culture and take on the characteristics of the dominant culture
Administration of which of the following drugs
would be the most important in treating
transposition of the great arteries?
4. Prostaglandin E1

This is inflammation of the brain and/or spinal cord meninges.

o Contributing factors:

§ Viral or bacterial agents
Clinical findings:

§ Nuchal rigidity

§ Positive Brudzinski’s sign

§ Positive Kernig’s sign

§ Coma

§ Delirium

§ Fever

§ Headache

§ Irritability

§ High-pitched cry

§ Petechial or purpuric lesions associated with bacterial meningitis
spinal bifida
Spina bifida occulta :

· Dimpling of skin over affected area

· Not associated with neurological dysfunction

· Port wine nevi

· Soft fatty deposits

· Trophic skin disturbances

· Tuft of hair

§ Meningocele:

· Not associated with neurological dysfunction

· Saclike protrusion over spine

§ Myelomeningocele:

· Hydrocephalus

· Permanent neurological dysfunction

· Arnold-Chiari syndrome

· Possible mental retardation

· Curvature of spine

· Knee contractures

· Clubfoot

· Saclike protrusion over spine
Cyanotic heart defects tx
Transposition of great vessels corrective surgery by age of one

§ Tetralogy of Fallot surgical repair before age of one

§ Hypoplastic left heart syndrome heart transplant

§ Truncus arteriosus medial management until surgical repair

§ Drug therapy:

· Prostaglandin E prevent closure of ductus arteriosus

· Beta-adrenergic blocker:

o Propranolol (Inderal)

· Narcotic analgesic:

o Morphine

This disorder is also known as Wilms’ tumor. This is an embryonal cancer that diagnosed at age of 2-4 years old
Contributing factors:

§ Genetic predisposition

o Clinical findings:

§ Nontender mass

§ Associated congenital abnormalities:

· Microcephaly

· Mental retardation

· Genitourinary problems

§ Hypertension

§ Constipation

§ Abdominal pain

§ Hematuria

o Diagnostic tests:

§ Urography

§ CT scan

o Treatments:

§ Nephrectomy within 24-48 hours

§ Radiation post-operatively

§ Drug therapy:

· Chemotherapy:

o Vincristine (Oncovin)

o Dactinomycin (Cosmegen)

· Analgesics as necessary

§ Monitor:

· Vital signs

· I&O

· After surgery:

o Urine output report less than 30ml/hr

o Respiratory status

o Pain level

o Dressing S/S of bleeding

o Postoperative complications

§ Do not palpate abdomen

§ Careful handling of child

§ Provide emotional support to child and family

§ Prepare patient and family for surgery
Valproic Acid (Depakene, Myproic acid)
CNS symptoms, mental status, behavioral changes, NVCD,heartburn, prolonged bleeding time
N.C.:mgnt of seizures
-take w/meals or pc
-swallow whole,no crushing
-withdrawal problems
-monitor bl. levels, platelets, bleeding time, liver function tests
-onset 2-4 days, pk level of syrup 15-120 min, caps-1-4 hrs,, dur: 6-24 hrs
-wear med tag
-preg D```
Xanthine bronchodilators stimulate the
CNS and respirations,

dilate coronary and pulmonary vessels, causing diuresis,

and relax smooth muscles
Trousseau's Sign
Contraction of the finger and hand, when a BP cuff is kept inflated on the upper arm for 5 minutes at diastolic pressure. Sign of hypocalcemia.
A patient with a rapid, irregular heart rhythm is being treated in the emergency department with adenosine. During administration of this drug, the nurse should be prepared to monitor the patient for what effect?
Transitory asystole
Reactive stress test shows
reacive is:
1. two FHR accelerations
2. lasting 15 seconds or more
3. over 20 minutes
Burns percentage
ead and neck 9%

trunk: front 18%, back 18%

arms: 9% each

legs: 18% each
Systemic Lupus Erythematosus
multi-system inflam d/o involving the connective tissues such as the muscles,kidneys,heart,serous membranes
-may affect the skin,lungs, and nervous system
Chvostek's Sign
Spasm of the muscles inervated by the facial nerve when the client's face is tapped lightly below the temple. Sign of hypocalcemia.

This is an infection of the lactating breast
Contributing factors:

· Staphylococcus aureus most common cause

· Engorgement and milk stasis

· Bra that is too tight

· Injury to nipple

Clinical findings:

· Localized area of reddens and inflammation

· Temperature of 101.10F or greater

· Chills

· Purulent drainage

· Edema or heaviness of breast

· Flue like symptoms:

o Aching muscles

o Fatigue

o Headache
Cleft lip and palate

In this condition there is a failure of the bone and tissue to fuse completely at the midline
Contributing factors:

§ Prenatal exposure to teratogens

§ Congenital defects

§ Part of another chromosomal abnormality

o Clinical findings:

§ Ranges from a simple notch on upper lip to a complete cleft from lip edge to floor of nostril

o Diagnostic tests:

§ Prenatal ultrasound
When is a PKU test performed?
breastfed=one week old
bottlefed=3 days old
The nurse would plan to administer which channel blocking drug to a patient with cerebral arterial spasms following a subarachnoid hemorrhage?
Nimodipine (Nimotop)
Nimodipine crosses the blood-brain barrier and has a greater effect on the cerebral srteries than on other arteries in the body, thus it is indicated for the treatment of cerebral arterial spasm following subarachnoid hemorrhage.
hodgkin's lymphoma
Lymphoma is a type of cancer involving cells of the immune system, called lymphocytes.
Obstetric conjugate
Distance from the middle of the sacral promontory to an area approximately 1 cm below the pubic crest.
What does albumin prevent?
Plasma from leaking into the tissues
Potassium Supplements Nursing Implications
1. Give oral preparation with full glass of water/juice - Decreases GI upset
2. Ensure urinating adequately before starting admin
3. Parenteral K+ must be diluted and administered by IV drip
4. Do not give K+ IM or by IV push
5. IV K+ is irritating to the vein. If pain occurs, slow infusion rate or dilute solution in larger fluid volume
6. Admin with caution to clients with heart disease or taking digitalis preparations

This is a highly contagious superficial infection of the skin.
Contributing factors:

§ Group A beta-hemolytic streptococcal

§ Staphylococci

o Clinical findings:

§ Macular rash

§ Progresses to a papular and vesicular rash

§ As rash advances; oozes and forms a moist honey-colored crust

§ Commonly seen on:

· Face

· Extremities

· May spread to other parts of the body with scratching

o Diagnostic tests:

§ Based on physical inspection

o Treatments:

§ Wash area carefully with disinfectant soap three time a day

§ Drug therapy:

· Topical antibiotics

· Systemic antibiotics in severe cases

§ Cut child nails

§ Cover hands if necessary to prevent spreading

§ Cover lesions
· Episiotomy: surgical incision into perineum and vagina
Monitor every shift for:

§ Erythemia

§ Intactness of stitches

§ Edema

§ Odor

§ Drainage

o Within 24 hours incision edges should be sealed
lack of oxygen supply that leads to thrombosis and tissue necrosis and localized edema.
Dont push until fully dilated R/T
fetal hypoxia and maternal exhaustion
What are the 3 phases of wound healing?
inflammatory, proliferative, and remodeling
When cells hemolyze in excess, what condition may appear related to the liver?
Jaundice--bilirubin broken out of hemoglobin goes into circulation
Early Signs of Myasthenia Gravis
These include Ptosis and Dipolpa. Late signs include dysphagia, and respiratory distress occur later.
Describe the characterstics of entering the second stage of labor
Extends form the complete dilation of the cervix to delivery of the fetus; duration is 3 hours for nulliparas to 30 minutess for multiparas
When assessing a child with suspected
Kawasaki disease, which of the following
symptoms is common
. “Strawberry” tongue

1st sign - HIGH (not low) fever
· Lochia: discharge form uterine deciduas
Lochia rubra:

§ Bloody with small clots

§ Fleshy odor

§ Lasts 2-3 post delivery

o Lochia serosa:

§ Pinkish or brown

§ Serosanguineous consistency

§ Fleshy odor

§ Lasts 3-9 days post delivery

o Lochia alba:

§ Yellow to white discharge

§ 10 days-6 weeks

o Lochia appearance that requires further assessment:

§ Lochia may be scant; must always be present absence indicates infection

§ Foul-smelling

§ Large clots

§ Saturation of sanitary pad within 45 minutes

§ Seepage of bright red blood
what does a swan-ganz catheter measure
neasures the pulmonary artery wedge pressure which indirently measures the pressure in the ventricles
What is a second degree laceration during delivery
Tear of: Perineal skin, vaginal mucosa, fascia, muscle of the perineal body.
Which of the following home care instructions in included for a child postcatheterization?
1. Encourage fluids and regular diet.
A nurse is giving discharge instructions to the parents of a child with Kawasaki disease. Which of the following statements shows an
understanding of the treatment plan?
3. “My child should use a soft-bristled toothbrush.”
2. Clients receiving chemotherapy are at great risk for bone marrow suppression. When WBC counts drop severely, clients are in danger of life-threatening infections. Which would be most important to teach these clients to protect them from infection?
c. Bathing daily and washing their hands frequently, especially after using the restroom or handling contaminated objects.
A client who is taking antipsychotic medication develops a very high T, severe muscle rigidity, tachycardia, and rapid deterioration in mental status. the snurse suspects what complication of antipsychotic therapy?
Neuroleptic malignant syndrome. a rare but potentially fatal condition of antipsychotic medication.
Name all 5 components of Biophysical profile:
biophys profile is:
1. fetal breathing movement
2. fetal movement of body and limbs
3. fetal tone
4. amniotic fluid in pockets visualized
5. reactive FHR with activy (reactive NST)
The nurse receives the preoperative blood work report for a client who's scheduled to undergo surgery. Which of the following laboratory findings should she report to the surgeon?
Rationale: The nurse should call the surgeon for a serum creatinine level of 2.6 mg/dL, which is higher than the normal range of 0.5 to 1.0 mg/dL. An elevated serum creatinine value indicates that the kidneys aren't filtering effectively and has important implications for the surgical client because many of the anesthesia and analgesia medications need to be filtered out through the renal system. The red blood cell count, hemoglobin level, and blood urea nitrogen level are within normal limits and don't need to be reported to the surgeon.
What is a Biophysical Profile (BPP)?
ltrasound with Non Stress Test. Check for body movement, muscle tone, breathing movement, amniotic fluid and fetal heart beat. Checking that fetus has enough O2 in the womb.
laboring client complains to the nurse about intense pain located primarily in her back. Which fetal presentation should the nurse expect to see written on the client's chart?
Either occiput-posterior (LOP or ROP) position of the fetus is one that would cause a woman to complain of intense backache as the fetal head presents a larger diameter in the posterior position. The anterior positions or transverse positions do not place additional pressure on the sacrum and are not associated with intense backache.
Diet for a child with Cystic Fibrosis=
High protein, High calories and LOW fat
What are the three points to Virchow's triad?
- Stasis of blood
- Vessel damage
- Increased blood coagulability
The patient's PR interval comprises six small boxes on the ECG graph. The nurse determines that this indicates
The normal PR interval is 0.12 to 0.20 seconds and reflects the time taken for the impulse to spread through the atria, AV node and bundle of His, the bundle branches, and Purkinje fibers. A PR interval of six small boxes is 0.24 seconds and indicates that the conduction of the impulse from the atria to the Purkinje fibers is delayed.
What is DDH (developmental dysplasia of hip)
DDH is a malformation of the hip joint found in babies or young children

Risk factors include being the first child, being female, a breech delivery, and a family history of the disorder.
A client is hypovolemic, and plasma expanders are not availible. A nurse anticipates that which of the following solutions available on the nursing unit will be prescribed by the physician?
a solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available
A nurse is planning to provide a list of instructions to a client being discharged to home with a PICC. The nurse would avoid writing which of the following incorrect items on the instruction sheet?
only minor restrictions apply with this type of catheter. he should protect the site during bathing and shoudl carry or wear a Medic-Alert id. he should also have a repair kit because this is for long-term care
A nurse is caring for a client admitted to the birthing unit with rupture of membranes for two hours. A pelvic exam reveals a dilatation of 4 cm and the presenting part is not engaged. Which possible complication should the nurse anticipate?
When a pelvic exam reveals a dilatation of 4 cm and the presenting part is not engaged, the nurse should anticipate a prolapsed cord
The nurse is caring for a client in the transitional stage of labor. What objective data would indicate that the client is having pain?
Dilated pupils, along with increased blood pressure, pulse and respiration rate, indicate pain. Muscles would be tense.
When teaching a client to use the calendar method of contraception, which of the following should the nurse include in her teaching plan?
.Ovulation occurs around day 14 of the menstrual cycle, sperm are viable up to five days, and ovum live for 24 hours.
What are the things to remember about Brethine / Terbutaline?
Look out for: Tachycardia, if HR > 120, hold drug., Antedote: Propranolol (Inderol) – Beta Blocker.
How far can a baby see
8 - 15 inches in front - in 1 month can view 3 feet
During the evening following a partial gastrectormy, a client's oral temperature is 100F. Other data include a blood pressure of 134/68, a pulse of 88, and a respiratory rate of 18. The nurse should:
. Take the temp every hour until it is normal.
What are the things to remember with vaginal bleeding durng pregnancy?
it occurs < 12 weeks: It may be a spontaneous abortion which ma herold the need for a D&C

If it occurs > 12 weeks: It is more than likely a placental problem.

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