NCLEX Review

What is the ABO antigen system?

It is the different classes of human blood.

What part of the blood is classified?

The red blood cells are distinguished

What other blood is compatible with Type A?

Type A or O

What other blood is compatible with Type B?

Type B or O

What other blood is compatible with Type O?

Type O+ or O-

What other blood is compatible with Type AB?

Type A, B, or O

What is the priority for a patient with hypovolemia caused by a hemorrhage, anemia, or clotting deficiencies?

Blood transfusion

A doctor places an order for a blood transfusion. How many nurses must verify before the transfusion starts?

2 Nurses

What is the primary symptom of Acid Reflux?

Heartburn (Pyrosis)

What test confirms GERD?

Barium swallow fluoroscopy

What body part malfunction occurs in GERD?

The lower esophageal sphincter

What types of meals should a patient experiencing GERD have?

Small and frequent

When should a patient with GERD take an antacid?

1 hour before or 1 hour after medications

What is the virus that causes AIDS?

Human Immunodeficiency Virus (HIV)

How is HIV transmitted?

Sexual intercourse, direct contact with infected blood or body fluids such as semen and breast milk

What are the symptoms of HIV?

Fever, weight loss, night sweats, diarrhea, fatigue

How is the presence of HIV confirmed?

Screening is done first and then test after antibodies are confirmed

What is the screening test for HIV?

ELISA

What is ELISA?

It is the enzyme linked immunosorbent assay. A blood test that uses special enzymes that attach to blood

How does HIV attack the body?

Destroying the immune system by breaking down T-lymphocytes and self replicating

What is so important about T-lymphocytes?

T cells help the immune system to recognize and fight pathogens

What is another name for T-lymphocytes?

CD4 cells

Why is the CD4 count important?

The lower the CD4 count, the more damage the virus has done to the body

What is the normal CD4 count in a patient WITHOUT HIV?

500-1500 in healthy adult

What is the normal CD4 count in a patient with HIV?

CD4 below 200 means the HIV has progressed to AIDS

What is the goal of HIV medications?

To interfere with the virus replicating inside of the patient

What antiretroviral medication is used to treat HIV and prevent mother to child transmission?

Zidovudine (AZT)

What isolation precautions are used with HIV?

Universal precautions. All blood should be suspected of HIV as patients do not have to tell anyone they have HIV. The nurse should treat blood or body fluids as if it is infected.

What are the teaching points for parents who have a child with HIV?

10:1 water/ bleach ratio, high calorie & protein diet, use gloves to change diapers

What is the definition of acute renal failure? (ARF)

The sudden loss of kidney functions to excrete toxins and regulate fluids and electrolytes

What are some possible causes of ARF?

Infection, obstruction, shock

What are the three phrases of acute renal failure?

Oliguric, diuretic, recovery

During the oliguric phase, what should the nurse expect to see clinically?

Low urine output of less than 400 ml per day, hyperkalemia, hypertension, elevated BUN/creatinine levels and fluid overload

What two electrolytes will be elevated with ARF?

Sodium and phosphate

The diuretic phase is second in ARF; what is expected?

Urine output slowly returns, hypokalemia, and hypotension returns, BUN/ creatinine decreases but still elevated

What does the recovery phase in ARF mean?

Kidneys are recovering. GFR increases which allows urine output to increase. BUN and creatinine return to normal

What is the best diet for a client with ARF?

Healthy carbs, low protein, and low sodium

Where in the body is Adams Stokes syndrome complication located?

Heart condition

What will a client with Adams-Stokes Syndrome experience?

Sudden attacks of syncope & fainting. Seizures may also be present.

What will a nurse expect to see on the EKG/ECG of a patient with Adam stokes syndrome?

Asystole or ventricular arrhythmias

Is there adequate tissue perfusion during Adam stokes syndrome?

No tissue perfusion during the attacks

What is the treatment for Adam stokes syndrome?

An internal pacemaker is inserted

What oral medication can be given after surgery for adam stokes syndrome?

Digoxin

With Adam stokes syndorme, what medication is used to treat the ventricular standstill?

Epinephrine

The cause of fainting with Adams-stokes syndrome is due to what?

Lack of oxygen to the brain

What is the cause of Addison’s disease?

Low production of hormones by the adrenal gland due to damage or dysfunction of the adrenal cortex

What are some of the major symptoms of Addisons disease?

Lethargy, weakness, and weight lossW

What color is the skin of a client with Addisons disease?

Bronzed color (hyperpigmentation)

Will a client with Addisons disease be overweight?

No, weight loss is common

Will the serum BG levels be high or low in a patient with Addisons Disease?

Low, along with sodium levels. Salt should be increased

Will the serum potassium levels be high or low with Addisons disease?

High

What is the treatment for Addisons disease?

Lifelong glucocorticoid therapy

Clients allergic to latex may also be allergic to which foods?

Bananas, kiwi, chestnuts

What standard hospital equipment contains latex?

BP cuffs, gloves, stethoscopes, tourniquets, Band-aids, and indwelling catheters

Patients in which careers are most likely to develop a latex allergy?

Healthcare workers, hairdressers, and mechanics

What allergy is contradicted for IV contrast dye?

Iodine/shellfish allergy

What is the best medication to treat anaphylactic shock on NCLEX?

Epinephrine

What are the major complications of having an amputation performed?

Infections, skin breakdown, phantom limb pain, and joint contractures

What is the positioning for post op care of an amputation?

Elevate first 24 hours, then prone place client in the position twice daily to prevent hip flexion

For a below the knee amputation how should you position?

Elevate foot of bed first 24 hours, then prone position twice daily to prevent contractures.

What should you encourage from a patient who has underwent an amputation?

Expression of feelings about the lost limb

What is phantom limb pain?

Pain felt in an area that has been amputated

This type of Anemia has decreased erythrocytes, bleeding mucous membranes, and thrombocytopenia. Blood transfusions are used to treat it, ALG, and bone marrow transplantations… What anemia is this?

Aplastic anemia

This type of anemia has low hemoglobin & hematocrit. Palor, fatigue, tissue hypoxia, tachycardia and this is most common and expected during pregnancy. What anemia is this?

iron deficiency anemia

This type of anemia involves pallor, “beefy red tongue” fatigue, and paresthesia. Cyancobalmin injections are used to treat this (Manufactured version of B12) . What anemia is this?

Pernicious Anemia

True or false? An aneurysm is a dilation formed at a weak point on the wall of an artery.

True

What are the symptoms of aneurysms inside the body?

Most do not have symptoms

What sound would be heard on auscultation of an aneurysm?

A blowing bruit is heard

What are some of the risk factors of an aneurysm?

Arteriosclerosis, infection, hypertension, smoking

What is the treatment for an aneurysm>

Surgery is an option, strict BP control with medications

What are the signs of a ruptured aneurysm?

Severe pain, N/V, tachycardia, decreased LOC, hypotension

What education should you give a patient with an aneurysm?

Avoid straining, lifting, or exerting, take medications on schedule, report severe back and flank pain

With Anorexia what is the primary symptom of illness?

Starvation W

What is the mental perception of the body with anorexia?

Distorted

At what age does anorexia nervosa occur?

Adolescent or teenage years

What is the usual personality type of anorexia?

Perfectionist or overachiever with low esteem

What is a major cardiac complication of anorexia?

Cardiac arrythmias

What is a major gynecological complication of anorexia?

Amenorrhea

What is the treatment of anorexia nervosa?

Small, frequent meals with counseling and milieu therapy

Clients with anorexia are at risk for what?

Refeeding syndrome

What age range is most affected with appendicitis?

10-30 years old

What is the most common sign of appendicitis?

Acute right lower abdominal pain

What are other signs and symptoms of appendicitis?

Loss of appetite, N/V, low grade temperature

The localized tenderness of appendicitis is found where?

Mcburney’s point

What are the tests to determine appendicitis?

Complete history and physical exam with WBC count- the results will be elevated W

What is the treatment for appendicitis?

Immediate surgery to remove appendix, IV antibiotics, semi fowlers position. NPO diet

Where are most ABG samples drawn from?

Radial artery in the wrist

How long should pressure be applied to the site after collecting a sample?

5 minutes

Which test should be performed before collecting an ABG on a client?

Allen’s test

What is a quick non-invasive substitute?

Pulse oximetry reading will tell a quick measurement of oxygenation status

Aspergers is a form of…

Autism

What is autism?

A developmental disorder that impairs the ability to communicate and interact

What is the treatment for autism?

Speech therapy, physical and occupational therapy. Currently there is no medication.

What does treatment of autism improve?

Communication and the clients social skills.

An obstructive airway disease is caused by _______ and _________ of the bronchioles?

Spasms and inflammation

What are the signs of asthma?

Shortness of breath, expiratory wheezes, and possibly a cough.

When will the client experience a cough during asthma?

At night

What is the primary treatment goal of asthma?

Anti-inflammatory

What medications work best for treatment of asthma?

corticosteroids, bronchodilators leukotriene modifiers and metered dose inhalers

Which should a nurse give first - the steroid or bronchodilators when treating asthma?

Bronchodilator- opens up the airway