NCLEX UWorld

When do advanced directives go into effect?

when person is unable to speak for him/herself due to either:
1. Mental Incapacity - coma (GCS score ≤ 7)
2. Aphasia

(≠as soon as signed; directives can always be changed later by person)

SBAR Communication Framekwork Components

1. S = Situation - what prompted the communication (eg what changes occurred)
2. B = Background - pertinent information, relevant history, vital signs
3. A = Assessment - nurse's assessment of the situation (when & what changes occurred)
4. R = Recommendation - request for prescription or action from HCP

Appropriate order of actions when client found on floor

1. Assessment of physiological stability ABCs
2. Assessment of injuries
3. Moving client
4. Notifications
5. Documentation

Conditions of being ineligible to leave AMA

1 danger to self or others
2. lack of consciousness
3. Altered consciousness
4. Mental illness
5. Being under chemical influence
6. Court decision

Effective handoff communication components

Nurse should:
1. Provide identifying information (eg client's name and room number)
2. Note care priorities and upcoming or outstanding tasks (eg time to replace medication infusion bag, need to perform delayed wound care and cause of delay)
3. Provide exact, pertinent information (eg medication dose, time, measurable outcomes)
4. Include multidisciplinary plans (eg radiology examinations, family meetings, physical therapy)
5. Relay significant client changes in a clear manner

Risk factors for cervical cancer

1. Infection with high-risk HPV strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use

what medications interact with grapefruit?

1. calcium channel blockers (diltiazem, nifedipine, verapamil, etc)
2. statins
3. SSRIs

Risk associated with stent placement using the femoral approach

retroperitoneal hemorrhage

what are early signs of bleeding into the retroperitoneal space?

hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses

what is the grey-turner sign and what is it a sign of?

bruising of the flanks and retroperitoneal hemorrhage and is a bluish color

what are some physical signs of peripheral arterial disease?

intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the extremities)

transplanted hearts are expected to be

tachycardic like 90-110

what is the priority intervention for pain with sickle cell crisis and why?

administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion

what is the purpose of continuous bladder irrigation?

it is prescribed after TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder

characteristics of a basilar skull fracture

periorbital hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising)

immediate client care for basilar skull fracture

cervical spine immobilization, close neurologic monitoring, and support of ABCs

nurse actions during a seizure

assist them to lie down is standing/sitting, put them on side for patent airway, loosen tight clothing, give oxygen as needed, remove objects from immediate area, document time and duration of seizure (for tests are done later to see which type of seizure and maybe what exacerates it)
never put anything in mouth or restrain them since muscle contractions can occur during a seizure

what are some early symptoms of Increased Cranial Pressure?

altered LOC, headache, abnormal breathing, rise in bp, slow pulse, vomiting

glasgow coma scale ranges from

3-15; 3 being worst 15 being best condition (8 or below in a coma)

what is a primary component in TPN?

glucose, so the nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia

what are the 4 categories for triaging?

immediate (red tag)- life threatening injuries with good prognosis once treated
delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment

rule of nines

head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1

parkland formula for burns

% BSA x weight (kg) x 4

give 1/2 fluids in first 8 hours.
remaining 1/2 in last 16 hours.

airborne precautions

tuberculosis, varicella, and rubeola (measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage

droplet precautions

spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)

contact precautions

Methods of infection control that must be used for patients known or suspected to be infected with epidemiological microorganisms that can be transmitted by either direct or indirect contact.

UAP soft wrist restraints can:

do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed

no lasix to what kind of patient

a pneumonia patient with fine crackles bc they dont result from heart failure or edema

decerebrate posturing (toes point down and amrs/legs straight out) is a sign of

severe brain damage

near drowning hypothermia

warm iv fluids, blankets, and oxygen
also will find weak and thready pulse

intussusception
causes intestinal obstruction

ileum telescopes into cecum, pain obstruction, edema, bowel ischemia, rectal bleeding (CURRANT JELLY stools)

signs of intussusception

initial periodic pain with legs drawn up to abdomen, pain is severe and progressive though, inconsolable crying, blood/mucousy stools "currant jelly"

guaifenesin (Mucinex)

expectorant med that thins secretions to facilitate expectoration

erythropoeitin Epogen

stimulates bone marrow to make RBCs and combats the effects of chemo and used for kidney disease

tetraology of fallot

exacerbation can happen when infant or child cries, becomes upset, or is feeding
you immediately place them in KNEE CHEST position

hemolytic uremic syndrome

life threatening complication of e. coli diarrhea

what are the signs?

anemia (pallor), low platelets (petechiae and purpura, and acute kidney injury (low UO)

cognitive behavioral therapy (CBT) 5 basic components

education about pts disorder
self observing and monitoring
relaxation techniques
cognitive restructuring
behavioral strategies

Written consents - Nurse's Role

1. Witness that consent was signed voluntarily
2. That patient was competent at time of signing
3. Documenting in medical records after signature obtained with date/time of signature

how to stop epistaxis

tilt the head forward and apply direct continuous pressure on the alaes (sides) for about 5-20 mins
can also hold a cold washcloth to the bridge of nose for vasoconstriction
keep child calm and quiet

IV iodinated contrast used for ct scan can cause

kidney injury; metformin is discontinued on the day of IV iodine contrast exposure

Gabapentin (Neurontin)

used for neuropathic pain

Phenytoin (Dilantin)

antiseizure

Levofloxacin (Levaquin)

antibiotic

testicular self examination

perform monthly and on same day
perform while taking hot shower bc temps will relax scrotal tissue and make testis hang lower in scrotum
use both hands to feel each testis separately
palpate gently using thumb and first 2 fingers

lactated ringers is often used for

burns

Addison's disease

occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone;
hyperpigmentation of the skin

what are some expected symptoms in a TBI?

low grade constant HA, slowness in thinking, memory problems, loss of balance, poor coordination, constant exhaustion, inc sensitivity to light, and heightened irritability
all symptoms that can last up to 6 weeks

Meningitis causes

Infections (viral, bacteria, fungal)
Neurosurgical procedure, basilar-skull fracture
Otitis media, mastoiditis

bacterial meningitis

high fever
change in loc
nuchal rigidity
meningeal signs (positive kernig and brudzinski signs)-- treat with antibiotics

what is the kernig sign?

patient lies supine, thigh is flexed at right angle, and it hurts to extend leg

what is the brudzinski sign?

bending of neck causes flexion of knee and hip

client identifiers

first and last name
medical record number
DOB

expected term newborn findings

plantar creases up entire sole
presence of babinski
Epstein's pearls

is the babinski sign present at birth?

yes but it disappears at 1 year

what does an absent babinski or weak reflex indicate?

a neurological deficit

babinski sign for a child less than 1 year

great toe bends upward and smaller toes fan out. this is NORMAL

babinski sign for child more than 1 year and an adult

plantar flexion
normal toe flexion (no babinski)

what are epsteins pearls?

white pearl like cysts on gum and palate that are benign and usually go away within a few weeks

when does the umbilical cord detach from body?

within 2 weeks

jaundice in a newborn

during first 24 hours: jaundice is pathological (r/t liver problems)
after 24 hours: physiological jaundice r/t inc amount of unconjugated bilirubin in system

infant formula key points

never dilute or concentrate formula
wash tops of forumla cans before opening
unused prepare formula can be used for up tp 48 hours and then discarded after
to warm prepared bottle, place in pan of hot water
never microwave formula
any forumula left over should be thrown out immediately when done

what must be checked before starting statin drugs

liver function tests bc they can cause hepatotoxicity
can cause muscle aches and weakness
take with evening meal or at bedtime

what is a serious complication of statin meds?

rhabdomyolysis

what is rhabdomyolysis?

the breakdown of muscle tissue releases muscle fiber contents into the blood. these substances can cause kidney damage

what are some early signs of rhabdomyolysis?

muscle aches or weakness- immediately report to hcp!

behaviors of bulimic person

episodes of binge eating followed by self induced vomiting
using enemas/laxatives
intense frequent exercise

signs of bulimia someone may notice

going to bathroom after meals
large amonts of food disappearing
hidden wrappers/empty food containers like sweets
intense physical exercise
parotid gland enlargement
calluses on hands
preoccupation with weight food and dieting

first thing to do if a pt is in ventricular tachycardia?

assess them for a pulse (bc they can either have a pulse or not)

what is in the lpn scope of practice?

monitor RN findings
reinforce education
routine procedures like catheterization
most medication administrations
ostomy care
tube patency and enteral feeding
specific assessments

notify hcp if child temp is over 100.4 after

immunizations

what are common SE of immunizations?

mild fever and soreness and redness at injection site
anorexia/fussiness in the first 24 hours

thrombocytopenia

low platelet count; so this increases risk for bleeding;<100,000 platelet count

what is SIADH?

high antidiuretic hormone production leads to
water retention
increased total body water
DILUTIONAL HYPONATREMIA

-will see signs of fluid volume overload, changes in loc, weight gain w/o edema, hypertension, tachycardia
-seizure precautions

what can hyponatremia cause?

SEIZURES, confusion, neurologic complications
institute seizure precautions

treatment of SIADH

fluid restriction less than 1000 ml per day
oral salt tablets to increase serum sodium
hypertonic saline (3%) or NS IV and/or vasopressin receptor antagonists to decrease renal response to ADH

so a pt with SIADH

does not need extra fluid
needs salt
seizure precautions
strict I/Os

RACE for FIRES in a hospital

R: rescue any pts in immediate danger and move them to safety
A: alarm- sound alarm
C: confine fire by closing all doors to all rooms
E: extinguish fire with extinguisher

what is asystole?

complete absence of ventricular electrical activity in the heart. no ventricular contraction occurs
client is pulseless, apneic, and unresponsive

how to treat asystole?

CPR
initiate advanced cardiac life support
give epinephrine and/or vasopressin
place an airway

hepatic encephalopathy

impaired ammonia metabolism causes cerebral edema. s/s: change in LOC, memory loss, asterixis (flapping tremor) impaired handwriting, hyperventilation w/ resp alkalosis. treatment: lactulose-traps ammnia and lwoers pH, low protein, safety, rest

asterixis

flapping tremors of the hands
to assess, have pt extend the arms and dorsiflex the wrist

full weight bearing

independent; no assistance needed unless they are uncooperative or they are a fall risk, which is 1 person standby

partial weight bearing

1 person assist stand & pivot transfer with gait belt or motorized assist device if cooperative
2 person assist with full body sling if uncooperative

no weight bearing

motorized assist device if cooperative and they have upper body strength
2 person assist with full body sling if uncooperative and/or has no upper body strength

how to measure how to safely transfer a pt the first time

assess if they can bear weight
assess whether they are cooperative

how to measure UO in diapers?

subtract the weight of the diaper when dry from its weight when wet

how often and where is growth hormone replacement given to a child?

daily sub q injections
tretment is most successful when it begins early in a child's life, as soon as growth delays are noted; it stops when bone growth finishes or when parents decide

what is the classic sign of a tension pneumothorax?

mediastinal shift and tracheal deviation

why does tension pneumothorax cause hypotension?

bc the heart and great vessels are compressed/shifted and cardiac output is reduced
it is LIFE THREATENING

what is the treatment for tension pneumothorax?

emergency large bore needle decompression
chest tube

if injury to the spinal cord, what important precaution to take?

hard cervical collar and backboard

major depressive disorder demonstrates

loss of appetite, weight loss, and insomnia or hypersomnia
sleep disturbances

how to help improve sleep

dont nap during day
physical activity at least 5 hours before bed 20 mins of natural sunlight
avoid caffeine after noon
avoid alcohol or smoking at bedtime
relaxing activity before bed
decrease environmental stimuli
avoid heavy meals or large amounts of fluid at bedtime
warm milk or small carbs before bed

what can a baby born to an opioid dependent mom have?

neonatal abstinence syndrome. the baby experiences opiod withdrawal 24-48 hrs after birth

wht are symptoms of withdrawal from opioid in infants?

the baby is HYPERSENSITIVE
irritability
high pitched cry
jitteriness
sneezing
diarrhea
vomiting
poor feeding

tx: opioid therapy like methadone or morphine

what is the nursing care focus opioid dependent newborns?

reduce stimulation
promote nutrition and comfort

after feeding an infant, what does placing it in the side lying position do

promotes gastric emptying and reduces the risk of vomiting

Acceptable methods of blood collection in neonate

- heel stick
- venipuncture (drawing blood from vein) - considered less painful and often requires fewer punctures to obtain sample, especially if larger volume is needed

Neonatal heel stick

- used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg congenital hypothyroidism, phenylketonuria)