RN 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 perscribed after TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder

what is the nurses care of monitoring CBI?

monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed

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 spime immobilization, close neurologic monitoring, and support of ABCs

vomiting with intake may mean

viral or bacterial infection

tympanosomty tubes are placed for

recurrent otis medias

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 musclec ontractions can occur during a seizure

what are some early symptoms of ICP?

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

client who has a TIA is often placed on

prophylactic antithrombotic treatment like aspirin or clopidogrel

glascow coma scale ranges from

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

what are the 3 components?

eye opening

motor response

verbal response

what is a primary component in TPN?

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

when a client is on TPN, the nurse must assess for hyperglycemia why?

bc a primary component is glucose. therefore the nurse must be assessing to see if the client is getting too much glucose (hoerglycemia). and with a large urinary output like 4800, this could indicate symptoms of hyperglycemia

signs of hyperglycemia

- polydipsia,

- polyuria,

- restless,

- confused,

- bg over 200,

- fatigue,

- headache

- blurred vision

- kussmaul resp

Interventions to resolve TPN-associated hyperglycemia

- reduce amount of carbohydrate in TPN solution

- slow down infusion rate

- administer subcutaneous insulin

what is the goal for mass casualty events?

do the greatest good for the greatest number of people

keep in mind that disaster triage ranks the likelihood of survival with treatment, not necessarily the severity of the injury

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

extrapyramidal side effects

ACUTE DYSTONIC REACTION: sudden onset sustained muscle contractions

AKATHISIA: restlessness with inability to sit still

drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces

AKINISIA: loss of involuntary movement

TARDIVE DYSKININIA

NEUROLEPTIC MALIGNANT SYNDROME

dont give morphine if RR under 12 bc it can cause

respiratory depression

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

UAP soft wrist restraints can:

do ROM exercises

reapply wrist restraints

report changes in skin to nurse

turn/reposition client in bed

a client with major depression and severe weight loss needs what type of diet?

high in calories and protein, also foods that are easy to chew and dont require a lot of energy bc they may have a low energy level

examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta

also small frequent meals

memorize MAOIs and remember

they cant eat foods high in tyramine like aged cheese, yogurt, fermented foods, beer, red wine, cocolate, avocados

do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart failure or edema

you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics, analgesics, and antinflammatories

examples are

Mucinex, Ibuprofin,

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 air

also will find weak and thready pulse

a client is not dead until warm and dead!!!

nc sometimes a pt is so cold that a pulse cannot be felt

intussusception

causes intestinal obstruction

ileum telescopes into cecum, pain obstruction, edema, compression of BVs, bowel ischemia, rectal bleeing (CURRANT JELLY stools)

signs of intussusceotion

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

how is it treated?

an air enema

guaifenesin (Mucinex)

expecorant med that inc resp fluids and thins secretions to facilitate expectoration

erythropoeitin Epogen

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

when is hemoccult done?

when hidden (occult) blood is suspected due to dark and tarry stool

treat intussusception with

AIR ENEMA

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 diarhea

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

speicen collection from a foley is considered sterile and should not be delegated to uap

a clients first and last name is not PHI privileged health info

it is not a violation to cal them by their first and last names or have info heard inadvertently

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

what happens if a client does not full undersnad infromed consent?q

the nurse must contact the doctor. the nurse is not responsible for verifiying that the client understands

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

Amlodipine

calcium channel blocker used to treat hypertension

Gabapentin (Neurontin)

used for neuropathic pain

Phenytoin (Dilantin)

antiseizure

Glipizide

oral sulfonylurea controls blood sugar

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

normal calcium level

8.6-10.2

review heart rhythms

lactated ringers is often used for burns

addisons disease= hyperpigmentation of the skin

what is one of the earliest signs of ICP?

change in respsonsiveness

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 symtpoms that can last up to 6 weeks

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

what are these 3 signs indicative of?

meningitis

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 an 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

long term management of hyptertension

important to take bp meds as perscribed

what do statin drugs like atorvastatin, rosuvastatin do?

cut LDL drastically and reduce total cholesterol and triglycerides, and inc HDL

good cholesterol

HDL

bad cholesterol

LDL

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 bing eating followed by self induced vomiting

using enemas/laxatives

intense frequent exercise

signs of bulemia 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

weight loss/gain in anorxic.bulemic pt

anorexic: lose weight

bulemic: maintain weight

children born before 38 weeks are

preterm and must "catch up" their developmental milestones

onset of type 1 diabetes

childhood

onset of tpe 2 diabetes

after age 40