UWorld NCLEX - RN

Depression

Express long term goals is a good thing

At first normal to feel more energy

peripheral arterial disease (PAD)

Described by decreased perfusion which indicates poor healing, need adequate nutrients for healing

Pressure injuries stages

Stage 1: Intact skin, non blanchable with localized redness

Stage 2: Shallow, open ulcer, pink- red wound

Stage 3: Full thick skin loss with visible SQ fat

Stage 4: Full thick, exposed bone, tendon, muscle

Unstageable: Full thick skin loss, slough, eschar

Ventricular Trigeminy (PVC)

Every 3rd beat is a PVC , check the labs potassium might need to be supplemented

Respiredone

Atypical antipsychotic, watch for EPS!! no shaking

hyperglycemia

3 Ps

Polyphagia

Polyuria

Polydipsia

ACE

angiotensin-converting enzyme

Angioedema, Cough, Elevated Potassium

Example: Lisinopril

A ostomy bag should be changed

Every 5-10 days

Before administering intermittent NG feeds

1. Elevate HOB 35-45

2. Check tube placement marking

3. Confirm tube placement (x ray and aspirate)

4. Bowel sounds

5. Flush with 30 mL

6. If cramping occurs , slow the feed (fast or cold)

preeclampsia

HTN, proteinuria, HA, blurred vision, facial edema, oliguria, hyperactive DTR

Naloxone (Narcan)

opiate antagonist, reverses opioid induced resiratory depression

In hospice , ethical issue because reversing the effects can cause severe pain. Asses patient to see AAO

tPA (tissue plasminogen activator) C/I

- Give 3-4.5 hours from onset of symptoms

- < 100,000 platelets

- coagulation disorder

- any major surgery within 14 days

Ezetimibe (Zetia)

Zaps away cholesterol

Celecoxib (Celebrex)

NSAID, increases risk of thrombus

Lithium toxicity

Therapeutic window 0.6-1.2

QUESTION doctors order for hydrochlorothiazide (diuretic) , lithium must have a balance of water and sodium, water depletion can cause lithium to bind to sodium excessively = toxic, watch for blurred vision

Hearing Impaired

- repeat back

- well lit room

- sit in front of client

- use printed materials

Placebo

NEVER GIVE, if patient is not getting pain relief then notify health provider

Adverse Event

Something that is wrong, like mislabeling a specimen, giving the wrong medication

4 year old (preschool)

- draw a circle

- use spoon and fork

- walk up and down stairs

Lispro (fast acting insulin)

Onset: 15 min

Peak: 30 min

Duration: 3 hours

Give WITH meals!

SEVERE hypoxemia

PaO2 < 60 mmHg, report to the HCP

Petechiae on dark skin

Buccal mucosa and conjunctiva

Emphysema

hyperinflation of air sacs with destruction of alveolar walls —> lung become hyper inflated = hyperressonance, prolonged expiration, barrel chest

** STRIDOR should not be expected it indicates respiratory distress and is a MED EMERGENCY

Potassium

3.5-5.0

NEVER IV PUSH

If given through a pump should not be > 10 mEq/hr

Second degree heart block ( Wenckebach)

Irregular rhythm, increasing PR intervals followed by a P wave without a QRS complex.

NEED transcutaneous pacemaker

Initial interventions for substernal chest pain

- vitals

- 12-lead

- cardiac markers, electrolytes

- preparation

Mechanical valves

Pt needs to be on lifetime anticoagulant therapy to avoid thromboembolism

Risk for infective endocarditis

Need antibiotics for dental procedures

Bumetadine

Bumex, loop diuretic

"Water pill" give for pulmonary edema

Guafenesin (Mucinex)

expectorant

TORCH

Pregnant women AVOID

Toxoplasmosis, other, rubella, cytomegalovirus, herpes

ICP

Do not over elevate the head, decreases venous return to the head

Maintain body in midline

Suction only when ABSOLUTELY necessary

NO pillows for ICP

Reduce dyspnea in terminally ill

-opioids

- low flow O2

- comfort

- relieve anxiety

Postprocedural angina

** Thrombosis or stent occlusion

Restraints

Every hour keep assessing for the need to keep restraints

DO NOT remove because family is in the room

Renew order every 24

Check CMS

WHY do I need to do this?

Contact provider to repeat explanation before having patient sign the consent

Dabigatran

Pradaxa

- Watch for signs of excess bleeding

Expected finding of G-tube

Moves 0.2 in when patient coughs

TB PPD induration

> 10mm if immigrant = ask about vaccine and x-ray

> 15mm if no issues

New S3 heart sound

Sign of volume overload, possible CHF

Newborn expected

Respiratory rate 30-60

Glucose <70-100 but over 40

VSD is not expected but it is not TRouBle

Hypoxia in toddler

Irritability

Vaginal Hematoma

A client that just delivered a term infant reports persistent, severe vaginal pain & a feeling of fullness. What does the nurse suspect?

What can help appetite?

Brushing teeth before meals

If patient is dizzy when walking to the bathroom

PRIORITY is assisting patient to a sitting position

Somatic symptom disorder

psychological disorder in which the symptoms take a somatic (bodily) form without apparent physical cause

** limit discussing signs and symptoms

Long acting nitrate

Good sign is able to perform ADLs without chest pain

Torsades de pointes

Multiple PVC's with rotating ventricular ectopic pacemakers (above) are called

Give Mag IV**

When to slow an NG feed?

N/V, diarrhea, cramping

Phantom limb pain

pain in a limb (or extremity) that has been amputated

** Real pain and should be treated

Greatest risk for pressure injuries

Weight

Albumin level

MAP (over 70)

When is rapid response team activated?

- HR <40 or >130

- SBP <90

- RR <8 or >18

- O2 <90%

- U/O <50mL/4hrs

- Decreased LOC

RN Scope of Practice

- Clinical assessment

- Initial client education

- Discharge education

- Clinical Judgement

- Initiating blood transfusion

LPN/LVN Scope of Practice

- Monitor RN findings

- Reinforcing education

- Routine procedures (foley)

- Medication (NO IV)

- Ostomy care

- Tube potency and enteral feedings

- Specific assessment (lungs, bowels, neurovascular)

UAP Scope of Practice

- ADLs

- Hygiene

- Linen

- Routine, stable vitals

- Document I/O

- Positioning

Benztropine

Anticholinergic medication and is C/I in Glaucoma

Separation Anxiety

Starts when infant is 6 mo old

Caregiver role strain

Caregiver's felt difficulty in performing the family caregiver role.

Allow the person to talk about the role

**NOT psychotic

Adolescent depression

- losing weight without trying

- Skipping school

- Excessive sleeping in class

- Agitated

Sun downing dementia

Reorient the patient if found wandering

Jaw thrust maneuver

A means of correcting blockage of the airway by moving the jaw forward without tilting the head or neck. Used when trauma, or injury, is suspected to open the airway without causing further injury to the spinal cord in the neck.

** If there is injury to head and upper back

12 months old

- Sits from standing position

- Birth weight tripled

- Fully developed pincer grasp

Infective Endocarditis

Expected: Arthralgias (joint pain)

NOT expected: Pain and pallor in one foot

Local organ procurement

All client deaths should be reported here, per hospital protocol

Developmental Dysplasia of Hip

Pavlik harness is used

- Dress child in shirt and knee socks under straps

- Lightly massage the skin under the straps

- Place diaper under the straps

Common symptom for women with MI

Jaw pain

Rivaroxaban

Xarelto Anticoagulant; Factor Xa Inhibitor; Direct Oral Anticoagulant (DOAC)

Large infant risk

Postpartum hemorrhage

Corticosteroid

- can elevate glucose (check blood sugar)

- Immunosuppressive

- Long term use can cause osteoporosis

Guillain Barre expected

Absence of knee reflexes

Interventions for preterm labor before 34 weeks

1. IM steroid

2. Antibiotics

3. Mag Sulfate

4. Give tocolytics (Mag Sulfate is an example and suppresses uterine contractions)

MED EMERGENCY

STRIDOR

Epiglottis

Accutane with vit A

TOXIC

Myelomeningocele

most severe form of spina bifida in which the spinal cord and meninges protrude through the spine

Creatinine clearance

24 hour urine collection

Overnight specimen is

More concentrated (think marinating)

Adenosine

Used for SVT

Administer RAPID IV push in under 6 seconds

Patient might be a systole for under 30 seconds

Flush with 20 mL after IV push

Infant can not have !

ASA or Honey

Phobostatic axis ?

4th ICS, mid AP diameter

Thoracic Aortic Aneurysm

Trouble swallowing because of pressure on the esophagus

SUDDEN ONSET

Big key word**

Tetralogy of Fallot

RAPS

Watch for polycythemia as a result of hypoxemia

Theophylline

Bronchodilator, Range is 10-20

Morphine is C/I in

COPD —> can cause respiratory depression

Splenectomy

Spleen filter infection so removal will make the patient highly IMMUNOCOMPROMISED

Pericarditis, Endocarditis, Rheumatic fever can lead to

Cardiac Tamponade —> Medical emergency ** Priority

Especially if it is Acute

Anorexia or Bulemia

Priority is to monitor for electrolyte imbalance —> especially K+

Histoplasmosis

fungal infection of the lungs, an opportunistic infection

Peripheral Arterial Disease C/I

Heating pad because it can alter tissue perfusion

Peritoneal dialysis bag spike

Sterile technique **

Acute pancreatitis

LUQ pain radiating to the back

Transfusion reaction interventions

1. Stop transfusion and disconnect cath hub

2. Maintain IV access with normal saline

3. Notify HCP and blood bank

4. Vitals

5. Recheck labels

6. Treat S/S

7. Collect specimen to check for hemolysis

8. Return blood and tubing to test bank

9. Document

When can you do the 1 hour gestational diabetes test

Anytime of the day without fasting

Shunt malfunction S/S

Vomiting, headache, vision changes, and LOC changes

If patient is not breathing, what do you do first?

1. Check the pulse

2. Call HCP

VTE prevention

Heparin NOT ASA

"It is normal to experience x,y,z after a trauma"

Appropriate nurse response

Zika in Pregnancy

If traveling to a place with an outbreak suggest postponing the trip because Zika can cause birth defects and dev dysfunction

Serotonin Syndrome S/S

Muscle rigidity, restless, agitation, tachycardia

Gastric lavage

1) done through orogastric tube

2) high risk of complications (aspiration, perforation, Dysrhythmias)

3) Done one hour within lethal overdose

4) Need intubation and suction at bedside

Activated Charcoal Indications

Overdose but NOT lithium, iron, alcohol