NCLEX study 2 Flashcards

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Terms Definitions
VIR
ANTIVIRALS
SONE
STEROIDS
PTT
Heparin
ALBUMIN
3.8-5.0 G/DL
Normal CO2
35-45
normal magnesium range
1.5-2.5mEq/L
Increasing confusion: Indicates
Hypoxia
PT
INR
APTT
9.5-12 secs
1-2
20-45 secs
Mg++
1.5 to 2.5
ACE inhibitor
ends in "pril"
Hypermagnesemia
Causes CNS depression
Assess respirations
Measure deep tendon reflexes
Influenza
Therapeutic Management- Amantidine (type A) Zanamivir and rimantadine Type B. Prevention IM Vaccines live nasal spray. Nursing considerations- most contagious 24 hrs before and after onset of symptoms.
Phobias involve:
Projection & displacement
Pheochromocytoma A chromaffin-cell tumor of the adrenal medulla that secretes an excessive amount of the catecholamines epinephrine and norepinephrine, which results in severe hypertension, increased metabolism, and hyperglycemia.
Not S/S of heat stroke
Nystagmus
Hypertension
Isotonic solution: Volume expander
Ringer's lactate
Hypopituitaryism
obesity, cardiac output dec, infertility, fatigue, low BP
Lung sounds r/t laryngotracheobronchitis:
Inspiratory stridor
restlessness
SERUM ELECTROLYTE

SODIUM
135 - 145 MEQ/L
Lipodystrophy
Any disturbance in fat metabolism.
Hyperthyroidism
Disorder involving overproduction of thyroid hormone, leading to a metabolic imbalance.
Hypernatremia s/s
elevated temp, weakness, disorientation, delusions/hallucinations, thirst, dry swollen tongue, sticky mucous membranes, hypotension, tachycardia
8-13 mmHgAcute resp.distress syndrome has normal PCWP
Emphysema
amitryptyline (Elavil)
TCA's (tricycline anti- depressant )
Cataract Surgery: Major complication
Intraocular pressure
Vomiting increases, should be reported
Do not place head in dependent position
Laminectomy: Postop
Maintain body alignment
Asses for sensation and circulatory status of lower extremities
TB: isoniazid S/E
Peripheral neuritis
Hepatic enzyme elevation
Hepatitis Hypersensitivity
Glaucoma: Treatment
Surgery can't correct problems resulting from increased pressure
Chronic health problem
Blindness prevented by lifelong treatment
Hypokalemia S/S
thready, weak, irregular pulse; anxiety, ST depression, T wave
INTERMITTENT bubbling in the water seal chamber of a closed chest drainage system indicates
pneumothorax
Parkison's disease is...
progressive degenerative disorder caused by dopamine depletion and results in a generalized decline in muscular functioning

tremor at rest
rigidity
slow movement
shuffling gait
mask like face
emotional lability
autonomic symptoms: drooling, sweating constipation
CHEMISTRY VALUES

TOTAL CHOLESTEROL
130 - 200 MG/DL
Audiometry
Evaluation of hearing using an audiometer. Various audiometric tests identify the lowest intensity of sound at which a client can perceive an auditory stimulus, hear different frequencies, and differentiate speech sounds. Pure tone audiometry evaluates th
Bulimia
An eating disorder characterized by episodes of binge eating that may end in self-induced vomiting, alternating with periods of normal eating or fasting. Depression and awareness of the abnormal behavior are part of this illness.
Broviac catheter
Single-lumen silicone central venous catheter used for long-term venous access.
anorexia, n/v, muscle weakness, paresthesias, dysrhythmias, inc sensitivity to dig
hypokalemia implementations
most reliable indicator for determining adequacy of fluid resuscitation
Urine output
A client with AIDS has histoplasmosis. A nurse checks the client for which sign/symptom?
Dyspnea
Buck's traction patient
Assess for fat embolism
Respiratory patient takes prioirty
Radiation Exposure
Contact Director of Nursing to initiate disaster plan
Priority is to notify hospital administration and then disaster plan will be implemented
Commercial mouthwashes
Avoided because of high alcohol level
Causes burning feeling in irritated oral mucosa
SADDLE
LIKE A CONDYLOID BUT WITH DEEPER ARTICULATING SURFACES
Tuberculosis
symptoms include a low grade fever, persistent cough for 2 weeks or less, night sweats, progressive fatigue, and lethargy.
Metabolic Acidosis- S/S
Fruity breath, kussmaul respirations, HA, nausea, vomiting,hyperkalemia
metabolic acidosis
A condition resulting from excessive accumulation of acid or depletion of bicarbonate
Cardiac Tamponade
Diagnostic tests used to detect cardiac tamponade is a chest x-ray which shows a slightly widened mediastinum and enlarged cardiac silhouette.
FIVE P'S OF FRACTURES AND COMPARTMENT SYNDROME?
PAIN
PALLOR
PULSELESSNESS
PARESTHESIA
POLAR (COLD)
Fifth disease
A contagious, relatively benign disease caused by the Parvovirus B19; most commonly occurs in children ages 2 to 12 and is characterized by a red rash on the cheeks. Also called erythema infectiosum.
Intertrigo
Dermatitis that occurs at moist, warm sites where skin surfaces rub together, such as the armpits, the inner surfaces of the thighs, and between the buttocks; caused by an overgrowth of normal flora.
Auscultatory gap
Absence of Korotkoff sounds between phases I (onset of faint, clear tapping sound that gradually intensifies) and II (onset of swishing-like sound) while obtaining a blood pressure reading.
Cauda equina
The aggregation of spinal roots, resembling the tail of a horse, that descend from the first lumbar vertebrae and occupy the vertebral canal below the cord.
Polyuria
The excessive excretion of urine from the kidneys.
BR with extremities elevated 20 degrees, knees straight, head slightly elevated(modified Trendelenburg)
Head Injury
dec in LOCbradycardiafixed/dilated pupils
Early sign of ICP
RISK FOR INFECTION
THE PRIORITY NURSING CONCERN FOR CLIENTS WITH DISORDERS SUCH AS BURNS, PSORIASIS, AND SHINGLES IS?
Cataract
complete or partial opacity of he lens is known as a ccataract. It may occur at birth (congenital cataract); however, it occurs most commonly in adults past middle age (senile cataracts)
DVT: S/S
Right calf pain with movement
3 days post R knee surgery
Notify doctor immediately
Endotracheal tube
No inner cannula in an endotracheal tube
Peptic Ulcer Disease: S/S
Dull, gnawing pain
Burning in midepigastrium
Cane
Should always hold cane in hand that is opposite of affected extremity
Blitz rape
Rape is violent between strangers, is unforeseen and abrupt, often involves a weapon.
What does apgar stand for
A=apperance, P=pulses, G=grimice, A=activity, R=reflexes
Ataxia: definition
Gross lack of muscle coordination and movements.
Cardiac Glycosides
Cardiac Glycosides may be used safely for a pregnant client with cardiovascular disease, also comon antiarrhytmics, such as procainamide and quinidine may be used. If anticoagulants are needed, heparin is the drug of choice, not warfarin.
Autoimmunity
A condition in which the immune system mounts an attack against the individual's own body tissues. One theory proposes that autoimmunity reflects an inability of the immune system to distinguish between autoantigens and foreign substances, caused by some
inc BP, purple striae, hirsutism, emaciation, inc infection, obesity (trunk), blood sugar imbalance
Cushing's Syndrome TX
transfusion reaction
1. stops transfusion2. infuses NS at TKO (NS is choice over dextrose b/c NS does not cause RBC to clump)
Fractures: Preventing complications while in skeletal Traction:
*provide pin care, keep crusting around pins to a minimum to prevent infection and unnecessary pulling of skin.( Osteomyelitis most serious complication associated)
*Keep hydrated, follow plan to prevent constipation
*ROM to unaffected extremities, breathing excercises
Open-angle glaucoma (POAG)
most common form. Flow of aqueous humor is slowed or stopped by obstruction, thus increasing g intraocular pressure; characterized by a slow onset; chronic and progressive.
Systemic lupus erythematous: Lab test
Proteinuria and hyperlipidemia are common
Order a lipid profile and urinalysis with yearly exam
Arteriosclerotic Heart Disease: Diet
Low fat, low sodium
Baked chicken, green vegetables, and fresh fruit
What type of solution is ringer's lactate?
An isotonic solution
Juvenile Rheumatoid arthritis:
When parents of a preschooler asks 4 info about the dz, the nurse should advise:
Long periods of spontaneous remission are typical. Often, JRA improves or goes into remission at puberty. Approx. 75% of JRA pts enter remission with minimal functional loss & deformity
Low Birth Weight Babies
Adolescent girls, especially those age younger than 15 years are at a higher risk for delivering low birth weight neonates unless they gain adequate weight during pregnancy.
Synchronized cardioversion
Delivery of an electrical shock to the client in conjunction with the R wave on his ECG, just as the heart muscle contracts. Delivery is timed to avoid the T wave because an electrical discharge at this time may cause ventricular fibrillation.
Autonomic dysreflexia results from
sudden strong discharge of sympathetic nervous system in response to a noxious stimulus.s/sx: pounding HA, nausea, nasal stuffiness, slushed skin, piloerection,diaphresis, HTN.
Diabetes Mellitus: Reinforce teaching to a school age child:
*most common type I insulin dependent
*a multidose basal-bolus insulin program works well for most= glougine at HS, paired with aspart insulin and using insulin algorithms as a guide for insulin food-activity decisions 4-5x a day.
*frequent BG monitors
Normal Values
PH = 7.35-7.45, PCo2 = 35-45, HCo3 = 22-26
lithium carbonate (Eskalith): Late s/s of toxicity
Coarse hand tremor
GI upset
Mental confusion
Coordination
Ataxia
13. Which of the following is not a sign of anxiety?
moist mouth
How long can an insulin vial be kept at room temperature withough significant loss of activity
1 month
Babinski's reflex
sole of foot is stroked from heel to ball. Toes should curl downward.

If toes fan upward (after age two)= abnormal= brain stem or spinal cord involvement
Electrocardiogram interpretation
Analysis of the waveforms seen on an electrocardiogram
oral K+ supplements (dilute w/OJ)increase in raisins, bananas, apricots, oranges, beans, potatoes,
IV supplements (NEVER IV PUSH K+)
Sources of nutrition:managing potassium level
Most of the extra potassium eaten in the diet is removed by the kidneys
-healthy kidneys take in at least 4.7 grams of potassium each day.
-kidney disease (not on dialysis) take in 2 to 4 grams of potassium per day
-SAFE range of blood potassium levels is 3.5-5.0 mEq/L.
Laminectomy: Getting out of bed
Focus on using arms
Left elbow as pivot with left hand grasping the mattress edge
R hand pushing on mattress above the elbow
Slide legs over
A client is on chemotherapy for acute myelogenous leukemia. The nurse assesses the following laboratory test daily:
A. Complete blood count
A client is on chemotherapy for acute myelogenous leukemia. The nurse assesses the following laboratory test daily:
A. Complete blood count.
B. Electrolyte panel
C. Prothrombin Time
D. Blood urea nitrogen and creatinine
Home Care for Tracheostomy Care
At home, the procedure of tracheostomy care is clean or medically aspetic because of the cost and difficulty of performing a completely sterile procedure.
Fluid volume deficit is resolving, look for
capillary refill < 3 secspecific gravity of 1.002 to 1.025UO of at least 1 mL/kg/hradequate tear production
A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in evaluating this client?
A hyperinflated chest on x-ray.
A client with IDDM is recovering from diabetic ketoacidosis. Information on the serum level of the following substance will be very important to the nurse:
C. Potassium
A client with IDDM is recovering from diabetic ketoacidosis. Information on the serum level of the following substance will be very important to the nurse:
A. Sodium
B. Calcium
C. Potassium
D. Magnesium
Managing Diarrhea in a Young Child
Clear fluids by mouth are not recommended, these fluids usually are high in cimple sugars or simple carbohydrates, are very low in electrolyes and have a high osmolality, which can exacerbate vomiting and diarrhea.
reason for vitamin K IM to be given to newborn at birth
to prevent hemorrhagic disorders
A sexually active couple present to the women's health clinic. The male partner has been dx'd with candidiasis. The female partner has no symptoms and claims that he has been unfaithful to her. Which of the following nursing statements would be appropriat
d. Often males are symptomatic while females remain asymptomatic. We will need to test you
A sexually active couple present to the women's health clinic. The male partner has been dx'd with candidiasis. The female partner has no symptoms and claims that he has been unfaithful to her. Which of the following nursing statements would be appropriat
a candidiasis always causes a noticeable discharge and pain on intercourse.
b. your partner may have been unfaithful. There's no way to know.
c. candidiasis is not trasmitted sexually. Don't worry about this
Often males are symptomatic while females remain asymptomatic. We will need to test you.
LIGHT SKINNED PPL WHO WORK INDOORS
WHAT GROUP OF PEOPLE ARE MOST AT RISK FOR DEV MALIGNANT MELANOMA?
The nurse's teaching plan for a rape prevention class should include which of the following regarding Flunitrazepam (Rohypnol)?
a. ingestion of the drug accelerates intoxication
The nurse's teaching plan for a rape prevention class should include which of the following regarding Flunitrazepam (Rohypnol)?
a. ingestion of the drug accelerates intoxication
b. a white sediment develops in the drink laced with Rohypnol
c. always smell your drinks because adding the drug to a drink creates a citrus aroma.
d. after ingestion, the client may become hyperactive
Which of the following statements made by a preteen girl indicates successful adaptation to menarche?
a - my cycle should occur every 28 days and last about five days
Which of the following statements made by a preteen girl indicates successful adaptation to menarche?
a. my cycle should occur every 28 days and last about 5 days.
b. I won't need to wear protection on the last few days of my period.
c. My cycle should occur every 20 days and last about 3 days.
d. super absorbent tampons are the best for teenagers
7. A 24 year old female is admitted to the ER for confusion. This patient has a history of a myeloma diagnosis, constipation, intense abdominal pain, and polyuria. Which of the following would you most likely suspect?
A. Diverticulosis B. Hypercalcaemia C. Hypocalcaemia D. Irritable bowel syndrome
A nurse is taking a sexual hx from a client in the womens' health clinic. Which of the following statements or questions by the nurse would be most useful in eliciting information concerning the client's risk for sexually transmitted diseases?
a. what types of sexual behaviors are you involved in?
A nurse is taking a sexual hx from a client in the womens' health clinic. Which of the following statements or questions by the nurse would be most useful in eliciting information concerning the client's risk for sexually transmitted diseases?
a. what types of sexual behaviors are you involved in?
b. are you happy with your current sex life?
c. women often have concerns or questions about sti's. Do you?
d. I need to write down everything you have to say about your sexual past because this info is very important.
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