Mega NCLEX study

restlessness, stupor, twitching, fever

What are 4 s/s of hypernatremia/chloremia?

seizure, increased ICP, abd cramps, decreased DTRs, spasms

what are 5 s/s of hyponatremia/chloremia?

muscle weakness, shallow resp, peaked T waves, hypotension

what are 4 s/s of hyperkalemia?

flat T waves, u waves, decreased DTRs, flaccidity

what are 4 s/s of hypokalemia?

DVTs, sedation, decreased DTRs, bradycardia

what are 4 s/s of hypercalemia?

chvostek’s sign, trousseau’s sign, paresthesia, irritable

what are 4 s/s of hypocalcemia?

monitor circulation q4h first 24 hrs, use saline/Vaseline dressing q8-12h

what are 2 nursing considerations for traction?

kg/m²

what is the formula for calculating BMI?

>500 mL

how much residual would cause and NGT feed to be held?

Sims position, warm solution

what are 2 nursing considerations for delivering an enema?

empty when 1/3-1/2 full, change every 3-5 days

what are 2 nursing considerations for ostomies?

opens airways, reduce reflux

What are 2 reasons we use semi-fowler’s, fowler’s, or high fowlers (improves this with each level)?

helps drain secretions, reduce vomiting, aspiration, expand hips

what are 4 reasons to use the prone position?

promote venous return, hypotension, prolapsed umbilical cord

what are 3 reasons we use Trendelenburg (Pt is tilted head down)?

promotes blood flow, settles GI content

what are 2 reasons we use reverse Trendelenburg (Pt is tilted feet down)?

easier than prone, enema

what are 2 reasons for the sims position (L laying with R hip/ knee flexed, L leg extended)

RSV, diphtheria, polio

What 3 diseases are considered contact precautions?

C. diff, norovirus, rotavirus

what 3 disease are contact enteric precautions (can’t use hand sanitizer only soap and water)?

pertussis, mumps, rubella, bacterial meningitis, RSV

what 5 diseases require droplet precautions?

Rubeola virus (measles), varicella, SARS, smallpox

What 4 diseases require airborne precautions?

HCP in 24 hrs, RN assess q1-2h, order expires 24 hrs

what are the 3 rules for restraints on a nonviolent patient?

HCP in q1h, RN assess q15mins, 4 hrs, 2 hrs, 1 hr

what are 2 rules for restraints on a violent patient? When does the order expire for adults, 9-17 y.o, or <9 y.o?

rear facing until 2 y.o, retainer clip at armpit level, straps below shoulders, 5 point harness

what are 3 rules for car seats and kids?

rescue, alarm, contain, extinguish

what does RACE stand for in relation to fires?

keep scissors at bedside

what is the 1 nursing consideration for a Blakemore tube (device used for esophageal varices)?

>100 ml/hr

at what level would you call the provider over chest tube drainage?

cover w/ sterile dressing, tape on 3 sides, stay with pt

what are 3 things you should do if the chest tube comes out of the pt?

5-15

what is normal ICP?

headache, vomiting, cushing’s triad, posture changes

what are 4 s/s of increased ICP?

eyes, verbal, motor, <8

what are the 3 things the GCS looks for? at what level would you intubate your patient?

decorticate

an abnormal flexion of the body that indicates damage to the midbrain

decerebate

an abnormal extension that indicates damage to the deep brain structures (worse kind)

level with tragus

where do you keep the drain for an external ventricular drain (used for increased ICP emergencies).

gingival hyperplasia, avoid antacids

what are 2 nursing considerations for a patient taking phenytoin (long term seizure control)?

Battle sign, raccoon eyes, CSF drainage, never insert NGT

what are 3 s/s of a basilar skull fracture? what is 1 important nursing consideration?

permissive HTN, tPA in 60 mins, surgery

what are 3 things we do to manage an ischemic stroke?

Nuchal rigidity, photophobia, Kernig’s sign, Brudzinski’s sign

what are 4 s/s of meningitis?

ataxia, nystagmus, hypotonia, spasticity, inability to preform rapid alternating movements

what are 5 s/s of MS?

blurry vision, difficulty breathing, descending paralysis

what are 3 s/s of botulism?

ptosis, weak muscles, +tensilion test (edrophonium)

what are 3 s/s of myasthenia gravis?

terbutaline

a rescue/relief and mantinence drug for wheezing, SOB, and coughing assess for HR, BP, EKG, and BG

budesonide/ fluticasone

this is an inhaled corticosteroid used for long term control of asthma take daily

montelukast

this is a leukotriene modifier used in the long term control of asthma by reducing reactions to triggers

theophylline

this is a bronchodilator used for long term treatment of asthma to prevent wheezing, must be used regularly

L lateral Trendelenburg

what position should we place the pt in if they have an air embolism?

high folwers

what position should we place the pt in if they have a pulmonary embolism?

blocks conversion of angiotensin I to angiotensin II, assess dry cough, BP, pregnancy, HTN, CHF

what is the action of ACE inhibitors (ALWAYS ENDS IN PRIL), what are 3 nursing considerations? 2 uses?

inhibits vasoconstriction from angiotensin II, monitor BP, fluids, pregnancy, HTN, CHF, DM neuropathy

what is the action of ARBs (LOSARTAN), 3 nursing considerations? 3 uses?

HTN, angina, avoid grapefruit, monitor orthostatic hypotension, gingival hyperplasia

what are 2 uses of calcium channel blockers (ENDS IN PINE OR MIL), 3 nursing considerations?

antiarrhythmic slows HR, do not discontinue suddenly, can mask hypoglycemia, cause bronchospasms

what does a beta-blocker do (ENDS IN LOL), what are 3 nursing considerations?

SVT, stops heart, rapid push, caution with asthmatics

when is adenosine given? how does it work? 2 nursing consdierations?

arrythmias, stops K from leaving cells, can disturb thyroid, no pregnancy, may cause heart block

when is amiodarone given? how does it work? 3 nursing considerations?

sinus bradycardia, heart block, monitor urinary retention, constipation, no glaucoma

what are 2 uses for atropine? 3 nursing considerations?

N/V, vision changes, bradycardia, arrythmia

what are 2 early s/s of digoxin toxicity? what are 2 late s/s?

hypokalemia, hypomagnesemia, hypercalcemia, elderly

what are 4 risk factors for digoxin toxicity?

dopamine, dobutamine, milrinone

name 3 inotropes (increases heart contractility)

vasopressin, epinephrine, phenylephrine

name 3 vasopressors

brown skin, swelling, uneven wound edges, pulse present, elevate legs

what are 4 s/s of PVD? 1 tx?

pallor w/ dependent rubor, hairless, poor pulses, pain stops with rest, dangle legs, antiplatelet

what are 4 s/s of PAD? 2 tx?

abd/back pain, gnawing/sharp pain

what are 2 s/s of a abd aortic aneurysm (AAA)?

SOB, back pain, hoarseness, struggling to swallow

what are 4 s/s of a thoracic aortic aneurysm?

SOB, decreased CO, JVD, narrowed pulse pressure, pericardiocentesis

what are 4 s/s of cardiac tamponade (fluid in pericardial sac)? 1 tx?

0.12-0.20, 0.04-0.10

what is the normal timing of a PR interval? QRS complex?

PR interval >0.20

what is the defining characteristic of a first-degree heart block?

PR interval gets longer until it drops off QRS

what is the defining characteristic of second degree type 1 heart block?

random QRS drop offs, normal QRS

what are 2 defining characteristics of second degree type 2 heart blocks?

p waves and QRS don’t work together

What is the defining characteristic of a third degree heart block?

sawtooth p waves, regular rhythm

what are the 2 defining characteristics of atrial flutter?

weird p wave, irregular rhythm

what are 2 defining characteristics of atrial fibrilation?

-sone/-lone, monitor for Cushing’s, hyperglycemia, osteoporosis

what do all steroids end in? what are 3 nursing considerations?

Lugol’s, radioactive iodine, methimazole

what are 3 antithyroid medications?

calcium chloride, gluconate, lactate, calcitrol

what 4 medications help increase serum calcium (last one is vitamin D)?

alendronate, risedronate, calcitonin

what 3 medications decrease serum calcium?

away from heat, store in fridge, room temperature for use, good for 28 days

what are 4 nursing considerations for insulin storage?

no renal/hepatic impairment, take with food, hold 24-48 hrs before contrast

what are 3 nursing considerations for metformin?

fatigue, weight loss, hypoglycemia, hyperkalemia, hyponatremia, hypovolemia

what are 6 s/s of Addison’s disease (insufficient adrenosteroids)?

fluid retention, moon face, buffalo hump, trunk obesity, immunosupression

what are 5 s/s of cushing’s disease (excess steroids)?