NCLEX 3

The nurse is caring for a group of clients. It is a priority to follow up on which client situation? A client

A. admitted with an asthma exacerbation that is wheezing while receiving albuterol via nebulizer.

B. admitted with pulmonary emphysema who puts on their nasal cannula oxygen before eating.

C. with pneumonia is ambulating around the nursing unit while wearing a surgical mask.

D. receiving oxygen via nonrebreather and has an oxygen saturation of 92%.

D- a nonrebreather administers approximately 80-95% FiO2 so if the highest they can go is 92% then they might need more aggressive measures to improve oxygenation

Electrolyte abnormality associated with subarachnoid hemorrhage

hyponatremia (after experiencing a subarachnoid hemorrhage the client is at risk for SIADH and in turn hyponatremia)

Action necessary for nurse to take when caring for Native American

avoid excessive direct eye contact

What does administration of fresh frozen plasma do?

provide clotting factors

What complications should you assess for during TPN therapy?

-hyperglycemia

-infection

-air embolism

-dehydration

Renal diet

low potassium, phosphorus, protein, and sodium

What do you monitor during continuous infusion of norepinephrine?

-blood pressure

-IV site

-UO

-blood glucose

AE of motelukast

hallucinations

Cystitis vs Nephrolithiasis

Client Finding	Cystitis	Nephrolithiasis
Dysuria	x	x
Flank pain		x
Increased urinary frequency	x	x
Nausea and vomiting		x

Hemothorax vs asthma exacerbation

client findings	hemothorax	asthma exacerbation
tachypnea	x	x
reduced (or absent) breath sounds of the affected side	x
labored breathing	x	x
percussion on the involved side produces a dull sound	x
chest wall tenderness	x
use of accessory muscles to breathe	x	x

Isolation for infectious mononucleosis

standard precautions

Isolation for HIV

standard precautions

Foods high in magnesium

-spinach (green leafy veggies)

-salmon

-bananas

-dairy products

What fetal risk factor is commonly associated with shoulder dystocia?

macrosomia

What is essential for a client with a suspected ruptured AAA?

tight blood pressure control

What does aortic regurgitation do?

-increases preload in the left ventricle

-causes decreased cardiac output

-increases left ventricle end diastolic pressure

What kind of foods should be limited when taking an ACE-I?

potassium rich foods

What elements should be met in a negligence lawsuit?

-duty owed

-breach of duty owed

-causation

-harm or damages

What is acamprosate?

used to support alcohol abstinence

What kind of disturbances are expected for a client with a stroke affecting the occipital lobe?

visual disturbances

What kind of disturbances are expected for a client with a stroke affecting the parietal lobe?

disturbances in sensory input, proprioception, and taste

AE of aspirin

black tarry stools

What is hydralazine?

a vasodilator used to treat hypertension

Reversal agent for apixaban

andexanet

S/s of phenylketonuria (PKU)

-Children with phenylketonuria commonly have a musty odor to their urine.

-Hypopigmentation of the hair, skin, and irises is a prominent sign of the disorder.

-Common manifestations of PKU include lethargy, poor feeding, vomiting, diarrhea, hypoglycemia, and metabolic acidosis.

What meds can be used to treat opioid use disorder?

-naltrexone

-methadone

-buprenorphine

Hypothyroidism has intolerance to heat or cold?

cold

Cystitis vs Nephrlithiasis

AE of montelukast

hallucinations

LSHF vs RSHF

Clinical Finding	Left-sided Heart Failure	Right-sided Heart Failure	Both
Crackles auscultated bilaterally	x
Bilateral lower extremity edema		x
Paroxysmal nocturnal dyspnea	x
Fatigue			x
Weight gain of 4 pounds			x
Accessory muscle use	x
Juglar vein distension		x

What is spironolactone?

-mineralcorticoid receptor antagonist (MRA)

-blocks aldosterone effects

What is sacubitril/valsartan?

-angiotensin receptor-neprilysin inhibitors (ARNI)

-blocks RAAS and neprilysin

What is dapaglifozin?

-Sodium-glucose cotransporter 2 inhibitors (SGLT2)

-causes osmotic diuresis

If the client has primary hypothyroidism, the client’s thyroid panel will have high _____ and low _____.

high TSH; low T4

The nurse is assessing a group of clients prescribed lithium. The client at most significant risk for lithium toxicity is a client with

A. asthma taking both long- and short-acting bronchodilators.

B. chronic migraine headaches and was newly prescribed naproxen.

C. hypertension newly prescribed clonidine transdermal patch.

D. hypothyroidism and was recently prescribed levothyroxine.

B. chronic migraine headaches and was newly prescribed naproxen.

-NSAIDS, ACE-I, and diuretics should be avoided while a patient is taking lithium

Lithium requires a consistent intale of _____ rich foods.

sodium rich

What kind of laboratory monitoring should a client on lithium include?

thyroid panel

What kind of vital sign will be seen in a client with Wilms tumor?

hypertension

What reflexes will not be present in a 7 month old infant?

-rooting (disappears by 3-4 months)

-moro (disappears by 3-4 months)

-palmar (disappears by 5-6 months)

-tonic neck (disappears by 4 months)

When would you give a client albumin?

treatment of thermal burns or third spacing

When would you give a client platelets?

severe thrombocytopenia

What should you monitor for when you administer cefriaxone?

skin reactions

What meds increase the risk for falls?

-alprazolam (benzos)

-bumetanide (diuretics)

-verapamil (CCB)

What is mutual pretense at the end of life?

allows the client to preserve a degree of dignity and privacy at the end of life

Preeclampsia vs Severe preeclampsia vs Eclampsia

Assessment findings	Preeclampsia	Severe preeclampsia	Eclampsia
blood pressure 143/91 mm Hg	x
proteinuria	x	x	x
no abdominal pain	x
facial edema	x	x	x
frontal headache	x	x	x
photophobia		x	x

AE of sitagliptin

abdominal pain

Foods high in phosphorus

-garlic

-nuts

-turkey

Normal age related skin changes

-decreased dermal blood flow

-development of actinic lentigo

-degeneration of elastic fibers

-loss of subcutaneous fat

What are kosher meals?

Animals that have split hooves and chew the cud, such as cows, bulls, sheep, lambs, and goats, are allowed. Pig (pork) is forbidden. Certain poultry is allowed, such as chicken, goose, duck, and turkey, but all others are forbidden.

Acute pancreatitis vs Cholecystitis

Assessment Findings	Acute Pancreatitis	Cholecystitis
Severe epigastric pain	x
Gray-blue discoloration of the flanks	x
Nausea and vomiting	x	x
Leukocytosis	x	x
Elevated lipase and amylase	x
Hypocalcemia	x

The nurse is planning care for a client following bilateral adrenalectomy. The nurse should anticipate a prescription for which postoperative medication?

A. Pantoprazole

B. Propylthiouracil (PTU)

C. Propranolol

D. Hydrocortisone

D. hydrocortisone

-they are at risk for adrenal crisis post op

What is scleroderma?

medical condition that causes fibrosis to the connective tissue

-mans: skin thickening and hardening, vasospasms of the fingers, arthritis, muscle stiffness, fatigue, dysphagia, esophageal reflux, insult to kidneys that can lead to renal failure

Positioning for hypertensive crisis

semi fowlers

Conditions that may cause a client to manifest hyperglycemia

-pheochromocytoma (a tumor sitting on the adrenal medulla, leading to an excessive discharge of catecholamines, causing an individual to develop hyperglycemia, headaches, and high blood pressure)

-hyperpituitarism (excessive release of growth hormones, causing hyperglycemia)

-pancreatitis (inflammation of the pancreas, leading to the impairment of the beta-cells from secreting insulin)

The nurse is assessing a client with leukemia. Which of the following assessment findings would be expected?

A. Dyspnea, malaise, and hypotension

B. Bruising, fatigue, and bone pain

C. Bradycardia, hypotension, and palpitations

D. Paresthesia, facial rash, and abdominal pain

Bruising, fatigue, and bone pain

-Because the bone marrow is not making enough red blood cells and platelets, the patient will experience fatigue due to anemia and bruising due to decreased platelets. The stretching of the periosteum causes bone pain because of the excessive white blood cells. The CBC may show increased blasts or immature white blood cells, crowding out the healthy RBCs and platelets.

The nurse is conducting a community health fair. Which of the following clients is at the greatest risk of developing osteoporosis?

A. 27-year-old woman who jogs three times a week and drinks red wine daily

B. 60-year-old woman who smokes cigarettes and just recently stopped drinking alcohol

C. 51-year-old man who suffers from alcoholism and recently stopped smoking

D. 25-year-old man with asthma who takes inhaled corticosteroids

B. 60-year-old woman who smokes cigarettes and just recently stopped drinking alcohol

-post menopausal status and smoking cigarettes

Med for viral croup syndrome (laryngotracheobronchitis)

dexamethasone

-in viral croup, the upper airway becomes inflammed leading to airway narrowing and dexamethasone will reduce the edema

Unstable vs Stable angina

Assessment findings	Unstable angina	Stable angina
Location of pain	chest	chest
Onset of pain	abrupt, unpredictable, rest	predictable, triggered by activity
ECG findings	ST changes	no changes
Pain intensity	severe, crushing, prolonged	moderate chest pain
Duration of pain	persists for more than 5 minutes, unrelieved w/ nitro	subsides within 5 minutes, relieved w/ nitro

Early sign of retinal detachment

seeing bright flashes of light

SE of dexamthylphenidate

appetite suppression

Most common complications with a regular insulin infusion

-hypoglycemia

-hypokalemia

-blurred vision

Fetal heart rate pattern for a prolapsed umbilical cord

variable deceleration

Embolic stroke vs Hemorrhagic stroke

Findings	Embolic Stroke	Hemorrhagic Stroke
Abrupt unilateral weakness	x	x
Intense headache that begins suddenly		x
Remains alert during initial symptoms	x
Vomiting or convulsions early in symptom presentation		x
Trouble forming words or speaking clearly	x	x

Prevention for tumor lysis sundrome (TLS)

IV hydration

AE of risperidone

gynecomastia (d/t increasing prolactin levels)

What do you do if an over-the-counter nasal decongestant drop results in unrelieved and worsening nasal congestion?

discontinue the medication for several days

-a side effect associated is rebound congestion

Precaution for urticaria

standard (hives)

What does tranexamic acid do?

causes inhibition of fibrinolysis (reduces blood loss)

Position post surgical repair of cleft lip

on the opposite side of the repair

Why is dizziness after hemodialysis bad?

indicated hypotension or fluid volume depletion

Rheumatoid Arthritis vs Osteoarthritis vs Carpal Tunnel Syndrome

Client Finding	Rheumatoid Arthritis (RA)	Osteoarthritis	Carpal Tunnel Syndrome (CTS)
Fatigue	x
No Heberden's nodes	x		x
Low-grade fever	x
Pain relieved with nonsteroidal anti-inflammatory drugs	x	x	x
Pain relieved with splinting	x	x	x
Morning stiffness	x	x

Med used for urinary bladder urgency and incontinence

oxybutynin

How do you administer ceftriaxone?

in the ventrogluteal to avoid nerve damage

Pink frothy sputum indicates

pulmonary edema