REMAR QUCK FAST PG 31-40

immunizations birth

hep B \#1

immunizations 2 months

hep B \#2, DTAP, Hib, IPV, PCV

immunizations 4months

all 2 month immunizations except hep B

immunizations 6months

all 2 month immunizations

immunizations 12 months

MMR \#1, hib, PCV, varicella

tetanus and diphtheria are optional vaccinations; what is the earliest they can be given

2 months

what is a booster shot

an additional dose of vaccination to increase effectiveness

what are the side effects of immunizations

low grade fever, tenderness, swelling at the site, child may become irritable

what medication should be given for these effects

acetaminophen

never give \_____ to children experiencing these effects

aspirin

when should the meningitis vaccine be given

before going to college

if an adult woman receives an MMR shot, what should you teach her

wait three months before pregnancy

how soon can a child get the influenza vaccination

not until 6 months

do not give MMR if the client is allergic to \_____ or \_______

eggs or neomycin

Do not give the influenza vaccination if the client is allergic to \________.

eggs

what is active immuity

stimulating the body to produce antibodies by giving a vaccine

what is passive immunity

antibodies that are formed in another body but passed down for short term use. ex:breast milk

crohns disease

location: anywhere in the digestive tract from mouth to anus
signs:3-4 semi-soft stools, no blood, anorexia, fistulas
lifestyle: associated with smoking
treatment: anti-inflammatory steroids, NPO status- bowel rest, surgery will not help disease will reoccur

ulcerative colitis

location: primarily colon
Signs: bloody diarrhea, weight loss
Lifestyle: non-smokers
Treatment: anti-inflammatory steroids, NPO status bowel rest, surgery to remove the affected area

incentive spirometry is a method of \_____ \_____ that helps maximize lung inflation

deep breathing

instruct the client to place \_____ tightly around the mouth piece

lips

incentive spirometry is used after surgery to prevent

atelectasis

what is the normal intracranial pressure range

5-15 mm Hg

what are the common causes of ICP?

trauma, hemorrhage, edema, tumors

what do you assess?

level of consciousness, it decreases as ICP increases

this is the earliest sign of ICP

decreased level of consciousness

the client will often appear

restless, agitated, complaining of headaches

what will babies physically present with

bulging fontanelles

late signs of ICP

unilateral pupil dilation, hypertension or hypotension, bradycardia

clients may complain of \_____ \_____ \_______ \______

projectile vomiting without nausea

how will vital signs appear with ICP

B/P (up), temp (up), resp (up then down), heart rate(up)

what is widening pulse pressure and how is it related

when systolic blood pressure goes up and diastolic blood pressure continues to go down so that they become further apart (ex:135/40 is a bad sign)

what is cushings triad

Three things:
Widening pulse pressure
Cheyne stokes respirations
Bradycardia

initiate \_____ precautions

seizure

elevate head of bed to

10 to 30 degrees, to promote jugular venous outflow

what medications will be prescribed

anticonvulsants, blood pressure medications, corticosteroids, diuretics

tell the client not to \_____ \______ or \_______

strain, cough, or sneeze

nursing interventions would be to?

decrease environmental stimuli, maintain body temperature. limit fluid intake, monitor intake and output

ear medications
medications should be \____ temperature

room

what position should client be in when receiving ear medication

supine, with affected ear up

when administering ear meds to adults, draw the pinna back and \______

up

when administering ear meds to children, draw the pinna back and \_____

down

how long should the head be tilted to allow medication to travel the ear canal? \_______ minutes

5minutes

when giving eye medications, do this to prevent meds from going into the nasal passage

apply pressure

pull the \_____ eye lid down against the \________

lower, cheek

squeeze the drop in the \_____ \____

conjunctiva sac

if more than one drop is prescribed, wait \_____ to \______ minutes before applying another drop

3 to 5 minutes

do not let the \_____ \______ touch the \_______

medication bottle, eyeball

why are IV fluids used

they are a quick way to replace nutrients, water, and electrolytes

what are three types of IV fluids

isotonic, hypotonic, hypertonic

describe isotonic fluid/give examples

isotonic fluid is the same as the inside of the cell. 0.9% normal saline, lactated ringer, D5W

why would you give isotonic fluids

D.K.A. burns, replace sodium & chloride *0.9% NS always hung with blood

describe hypotonic/give examples

hypotonic fluid is less concentrated than the cell. this would cause water to move into the cell.
0.45%NS is an example.
dehydration, hypernatremia, lowers blood pressure

why should this fluid be closely monitored

Because rapid increase in fluid shifting into the cells can cause cellular and cerebral edema

describe hypertonic fluid/give examples

Hypertonic fluid is more concentrated than cells. This would cause movement out of the cell.
5%NS, D5%NS, D5%LR

why would you give hypertonic fluid

hyponatremia, nutrition

why should this fluid be closely monitored

because it can cause electrolyte imbalance and dehydration

before you start IV fluids, assess clients \_______

IV; make sure its patent

If IV is infiltrated what would you see

Cool,
Swollen;
Tender;
Painful at site

laminectomy
surgery is the removal of \_____ so the spinal cord can be seen

bone

to move client after surgery, \____ \_____ this client!

log roll

what is the highest risk factor in ingesting lead

Age, younger kids put things in their mouths

what is most likely ingested item to cause lead poisoning

lead paint chips

the most dangerous side effect of ingesting lead is \_____ \________.

mental retardation

what are the signs of lead poisoning

signs more serious if larger amount ingested; headache, abdominal pain, fatigue, muscle weakness, and respiratory depression

how do you treat lead poisoning

chelating agents

how are these agents given

by receiving many IM injections

do not give \____ to induce vomiting

ipecac

negligence is when a nurse does

not provide appropriate care according to set standards

if a nurse does a treatment without consent, it is an example of

battery

if your clients falls out of bed because you forgot to put up side rails, this is \____

neglect

any nclex question that has the word threat think?

assault

are advanced directives are important because they

allow the client to direct how/what care they are to receive if they become unable to make decisions in the future

are advanced directives mandatory

no

the document that specifically names a person to make decisions on another persons behalf is

durable power of attorney

the client must be of \____ \_____ to write a will

sound mind

what is the cause of crackles

fluid or secretions in the airway

when do you hear crackles

On inspiration ( Sounds like rice crispies in milk)

what are some possible causes of crackles

pneumonia, edema, or bronchitis

what is another name for crackles

rales

what are the characteristics of wheezes

high pitch musical sounds

when do you hear wheezes

inspiration and expiration

what are possible causes of wheezing

asthma, smoking, allergic reactions

wheezes can often be heard without a

stethoscope

\____ air will help relieve symptoms of wheezing

humidified

what are the characteristics of stridor

high-pitched harsh sound heard in upper airway

what is the cause of stridor

laryngeal spasm or swelling, croup, epiglottitis

stridor is often confused with

wheezing

which age group is stridor often seen

children

lymes disease
this type of infection is caused by

bite from a tick

how long after a bite can you test for this disease

between 4 to 6 weeks

what is the treatment plan

take antibiotics
doxycycline (adults)
amoxicillin (children)

Maslow's Hierarchy of Needs

physiological needs
safety and security
love and belonging
self esteem
self actualization

mastectomy
this surgery is to remove \______ \_______ or \______

breast tissue or nipple

after surgery \______ the affected arm to prevent \________

elevate, lymphedema

no \____ or \____ in affected arm

BP, venipuncture

always asses site for signs of \____ after surgery

infection

list signs of infection

swelling, redness, fever, chills, elevated WBC count

encourage clients to do \____ \____ \_____ on the remaining breast

self breast exam

what are the six rights of medication administration

Right: client, medication, time, documentation, dose, and route