NCLEX - RN

High risk of obesity & diabetes mellitus

Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans.

Jehovah's Witnesses

Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products.

Orthodox Judaism

Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered.

Overhydration or fluid overload & occurs when fluid intake or fluid retention

Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck & hand vein distention, altered LOC, & decreased hematocrit.

Common food sources of potassium:

Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, & tomatoes

Hyponatremia

Muscle weakness, increased urinary output, & decreased specific gravity of the urine would be noted

Hypophosphatemia

Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism.

Hyperphosphatemia

Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors. Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole grains, & carbonated beverages.

Causes of a fluid volume deficit

Vomiting, diarrhea, conditions that increased respiration's or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy. Diuretics, & gastrointestinal suctioning.

Causes of overhydration or fluid overload:

Decreased kidney function, heart failure, hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds & body cavities, & excessive ingestion of sodium.

Hyperkalemia causes:

Trauma, burns, sepsis, or metabolic or respiratory acidosis.

Hypokalemia causes:

Cushing's syndrome or colitis & over use of laxatives.

Metabolic acidotic

Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or diarrhea.

Metabolic alkalosis

Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms experienced would include hypoventilation & tachycardia.

Respiratory acidotic

Decreased pH and an increased CO2. Hypoventalation & COPD

Respiratory alkalotic

Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea) occurs.

Warfarin

Sample for PT & INR level to determine anticoagulation status & risk for bleeding

Heparin

aPTT monitors the effects. Anticoagulant used most often during hemodialysis. Monitors extent of anticoagulation checking PTT, which is appropriate measure heparin effect. Protamine sulfate is antidote.

Iron deficiency anemia foods in diet:

Dark green leafy vegetables good source iron, oranges are a good source of vitamin C, which enhances iron absorption.

Vegans

May lack B12 in diet.

Low sodium foods:

Include fruits & vegetables

High Sodium foods:

Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish & shellfish. Smoked foods,

Clear liquid diet:

Water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea.

Full liquid diet:

Pulling, Vegetable juice, Pureed vegetables, plain ice cream, sherbet, breakfast drinks, milk, pudding & custard, soups that are strained, refined cooked cereals, & strained vegetable juices.

High Thiamine foods

Pork products rich in this vitamin. Other good food sources include nuts, whole grain cereals, & legumes.

Suspects air embolism. Should immediately place client in which position?

On the left side, with the head lower than the feet. This position used to minimize effect of air traveling as a bolus to lungs by trapping it in right side of heart.

Fat emulsion (lipids)

Assess for known allergies to eggs to prevent anaphylaxis.

Hyperglycemia:

Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, & coma when severe. If has these symptoms, blood glucose level should be checked immediately.

Parenteral nutrition; PN monitor

Temperature and weight: Temperature monitored to detect infection, potential complication of therapy. Infection also could result in sepsis because catheter in blood vessel. Weight monitored for effectiveness nutritional therapy & detect hypervolemia.

Parenteral nutrition; Patients needing

Burns, exacerbation Crohn's disease, persistent nausea & vomiting due to chemotherapy. Had extensive surgery, multiple fractures, are septic, have advanced cancer or AIDS. (Electronic infusion pump used to administer)

Parenteral nutrition; If PN bag empty hang

10% dextrose in water until new PN solution becomes available.

Infiltrated IV

IV dislodged from vein & is lying in subcutaneous tissue. Pallor, coolness, & swelling are results of IV fluid being deposited in tissue. Corrective action is remove catheter & start new IV line at another site.

Phlebitis at IV site:

Discomfort at site, redness, warmth, & swelling proximal to catheter. If phlebitis occurs, discontinue IV line & insert new IV line at different site. Apply warm moist compresses to area speed resolution of inflammation. Notify (HCP). Document occurrence, actions taken, & client response.

An allergic reaction at IV site:

Produces a rash, redness, & itching.

Hematoma

Characterized by ecchymosis, swelling, & leakage at IV insertion site, as well as hard & painful lumps at site.

Hypersensitivity reaction:

Dyspnea, a swollen tongue, & cyanosis.

PICC line

Taught minor activity restrictions apply with this type of catheter. Protect site during bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as needed because catheter is for long-term use.

Central venous catheter insertion:

Before beginning administration IV solution, assess whether chest radiograph reveals central catheter is in proper place. Portable chest X-ray.

Systemic infection

Characterized by chills, fever, malaise, headache, nausea, vomiting, backache, & tachycardia.

Air embolism

Characterized by tachycardia, dyspnea, hypotension, cyanosis, decreased LOC, anxiety, feelings of impending doom, chest pain, & hypotension. Place left side in Trendelenburg's position. Lying left side may prevent air from flowing into pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases amount of blood pulled into vena cava during inspiration.

Septicemia

Occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, & development of shock

Platelets

Necessary for proper blood clotting. Insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, & mucous membranes.

Fire event

Order of priority is to rescue patient in immediate danger. Next activate fire alarm. Close all doors & fire extinguished.

Meningococcal pneumonia

Transmitted by droplet infection. Precautions include private room or cohort client & use of standard precaution mask.

Incentive spirometer

Best results sitting head of bed elevated 45 to 90 degrees. Semi-Fowler's or high Fowler's position. Mouthpiece should be covered completely & tightly while inhales slowly, with constant flow through unit. Breath should be held for 5 seconds before exhaling slowly.

Cleansing enema

Placed in left Sims position so enema solution can flow by gravity in natural direction of colon.

Anterior fontanel

Diamond-shaped & located on top of head. Soft & flat in normal infant, & it normally closes by 12- 18 months of age

older client is at risk for medication toxicity because

Decreased lean body mass & age-associated decreased glomerular filtration rate.

Romberg's test

Stand feet together & arms at sides, close eyes & hold position; normally client can maintain posture & balance. Positive Romberg's sign is a vestibular neurological sign found when client exhibits loss balance when closing eyes.

Cheyne-Stokes respirations

Rhythmic respirations with periods of apnea. Periods apnea followed by deep rapid breathing

Conductive hearing loss

Physical obstruction to transmission of sound waves

Sensorineural hearing loss

occurs as result pathological process in inner ear, defect in 8th cranial nerve, or defect of sensory fibers that lead to cerebral cortex.

Heart murmur

Abnormal heart sound & described as gentle, blowing, swooshing sound.

Pericardial friction rub

Described as a scratchy, leathery heart sound.

Assess for muscle weakness in eyes

Tests the six cardinal positions of gaze

Snellen eye chart

Visual acuity & cranial nerve II (optic).

Testing sensory function

Close eyes & then lightly touching areas of face & testing corneal reflexes assess cranial nerve V (trigeminal).

Positive Brudzinski's sign

tested insupine position. Flexes head (gently moves head to chest) & there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if passively flexes hip & knee in response to neck flexion & reports pain in vertebral column.

Fetal circulation

Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned by one umbilical vein. Arteries carry deoxygenated blood & waste products from fetus, umbilical vein carries oxygenated blood & provides oxygen & nutrients to fetus.

Ductus venosus

Connects umbilical vein to inferior vena cava

Foramen ovale

Is temporary opening between right & left atria.

Ductus arteriosus

Joins the aorta & pulmonary artery

Probable signs of pregnancy

Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement, Braxton Hicks contractions, & positive pregnancy test for presence of HCG.

Positive signs of pregnancy

Fetal heart rate detected by electronic device (Doppler transducer), active fetal movements palpable by examiner, & outline fetus by radiography or ultrasonography.

Rubella virus vaccine Postpartum

Pregnancy avoided for 1-3 months. Vaccine administered subcutaneous route.Exposure immunosuppressed individuals avoided. Hypersensitivity reaction can occur if client has allergy to eggs.

Classic signs of preeclampsia

Three classic signs are hypertension, generalized edema, & proteinuria.

Severe preeclampsia

Can trigger disseminated intravascular coagulation (DIC). Evidence of bleeding, such as in gums, petechiae, & purpura should be reported to HCP if noted on assessment.

Pregnant client tuberculosis is suspected; sputum culture obtained & identifies Mycobacterium tuberculosis

Isoniazid plus rifampin (Rifadin) will be required for 9 months.

Second Stage of Labor begins

When the cervix is dilated completely & ends with birth of the neonate.

Variable decelerations

Occur if umbilical cord becomes compressed, reducing blood flow between placenta & the fetus.

Early decelerations

Result from pressure on fetal head during a contraction.

Assessment finding following an amniotomy should be conducted first

Fetal heart rate assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Minimal vaginal examinations would be done because of risk of infection.

Abruptio placentae

Acute abdominal pain present. Uterine tenderness with abruption, especially central abruption & trapped blood behind placenta. Abdomen feels hard/boardlike on palpation as blood penetrates myometrium & causes uterine irritability. Premature separation placenta from uterine wall after 20th week gestation, before fetus delivered. Associated conditions; hypertension, smoking, alcohol/ cocaine abuse. Overdistention uterus; multiple gestation, polyhydramnios. In addition, short umbilical cord, physical trauma, increased maternal age & parity are risk factors. Painful vaginal bleeding, abdominal pain, & back pain identify signs/symptoms of abruptio placentae.

Concealed bleeding Prenatal

Symptoms increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability.

Placenta previa

Improperly implanted placenta lower uterine segment. Manual pelvic exam contraindicated vaginal bleeding apparent until diagnosis made & placenta previa ruled out. Digital exam cervix can lead to hemorrhage. Diagnosis by ultrasound. Hemoglobin/Hematocrit level monitored, external electronic fetal heart rate monitoring initiated; crucial evaluating status fetus, risk for severe hypoxia. Soft abdomen & painless, bright red vaginal bleeding in second/third trimester pregnancy symptom. (Sudden onset painless vaginal bleeding)

Pulmonary embolism is suspected

Oxygen administered, 8 to 10 L/min, by face mask. Oxygen used decrease hypoxia. Kept on bed rest with head of bed slightly elevated reduce dyspnea. Morphine sulfate may be prescribed, not initial nursing action. IV also required, & vital signs need to be monitored, but these actions would follow administration of oxygen.

Cystitis

Infection of bladder. Should consume 3000 mL of fluids per day if not contraindicated.

Newborn infant with respiratory distress syndrome

May present clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

Acrocyanosis

Bluish discoloration of hands & feet, is associated with immature peripheral circulation, & common in first few hours of life.

Fetal alcohol syndrome

Craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, & respiratory distress. Hypotonia, irritability, & poor sucking reflex.

Fetal alcohol syndrome

May exhibit hyperirritability, vomiting, diarrhea, or uncoordinated sucking & swallowing ability. Quiet environment with minimal stimuli & handling would help establish appropriate sleep-rest cycles in newborn as well.

Erythromycin ophthalmic ointment

Used as prophylactic treatment for ophthalmia neonatorum, which is caused by bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law

Magnesium Sulfate

Central nervous system depressant & relaxes smooth muscle, including uterus. Used to halt preterm labor contractions & used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, & elevated serum magnesium levels.

Betamethasone

Glucocorticoid, given increase production of surfactant to stimulate fetal lung maturation. Administered clients preterm labor at 28 to 32 weeks of gestation if labor can be inhibited for 48 hours.

Nalbuphine

Opioid analgesic.

Rho(D) immune globulin (RhoGAM)

Given to Rh-negative clients to prevent sensitization.

Dinoprostone

Prostaglandin given ripen & soften cervix & stimulate uterine contraction

Beractant

Respiratory Distress Syndrome serious lung disorder caused by immaturity & inability to produce surfactant, resulting in hypoxia & acidosis. Common premature infants & may be due to lung immaturity: result of surfactant deficiency. Mainstay treatment administration exogenous surfactant, administered by intratracheal route

Naloxone

Opioid antagonist, which reverses effects of opioids & given for respiratory depression.

Scabies

Appears burrows or fine, grayish red, threadlike lines. May be difficult to see if they are obscured by excoriation & inflammation. Multiple straight or wavy, threadlike lines beneath skin. Wear a gown & gloves for close contact.

Herpes Virus

Clusters of fluid-filled vesicles

Impetigo

Contagious bacterial infection skin. Common during hot, humid summer months. May begin area broken skin, such as an insect bite or atopic dermatitis. Impetigo very contagious. Lesions usually located around mouth & nose, but may be on hands & extremities. Mupirocin(Bactroban) topical antibacterial agent active against impetigo.

Hemophilia

Group bleeding disorders resulting from deficiency specific coagulation proteins Abnormal laboratory results indicate prolonged partial thromboplastin time. Female offspring of affected male & carrier female are at risk for hemorrhage once puberty is attained & menstrual cycles begin, depending on severity of hemophilia, hysterectomy or ablation may be performed

Deferoxamine

Classified as antidote for acute iron toxicity.

Symptom of increased ICP

Early sign slight change LOC, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late sign ICP include significant decrease LOC, bradycardia, decreased motor & sensory responses, alterations pupil size & reactivity, posturing, Cheyne-Stokes respirations, & coma.

Leukemia

Confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate & biopsy.

Hodgkin's disease

Malignancy lymph nodes. Presence of giant, multinucleated cells (Reed-Sternberg cells) is classic characteristic of this disease.

potassium chloride

Never be administered in the presence of oliguria or anuria. Checks amount urine output before administration.

Hirschsprung's disease

Also known as congenital aganglionosis or megacolon. Pellet or ribbon-like stools: foul-smelling is clinical manifestation of disorder. Delayed passage or absence of meconium stool in neonatal period also a sign. Bowel obstruction in neonatal period, abdominal pain & distention, & failure to thrive also clinical manifestations.

Pyloric stenosis

Projectile vomiting, irritability, hunger & crying, constipation, & signs dehydration including decrease urine output.