Nclex Study Guide Flashcards
Nursing delegations: You can't delegate what you can EAT!
E = EvaluateA = AssessT = Teach
Addison's vs Cushings: BP & electrolytes
Addison's: all downhill but K(hypotension, decreased blood volume, hypoglycemia, hyponatremia, hyperkalemia)Cushings: all uphill but K(hypertension, increased blood volume, hyperglycemia, hypernatremia, hypokalemia)
Potassium: nursing implications
No pee, no potassium (K)
Positioning for better perfusion
eleVate Veins, dAngle Arteries
APGAR
A= appearance (pink, pink/blue, blue)P= pulse (>100, <100, absent)G= grimance (cough, grimace, no response)A= activity (flexed, flaccid, limp)R= respirations (strong cry, weak cry, absent)
AIRBORNE precautions
Measles' Chicken Hez TBMeaslesChicken: chicken pox/varicellaHez: herpez zoster/shinglesTB*1. private room: negative pressure w/ 6-12hr air exchanges/hr2. mask (N95 for TB)
DROPLET precautions
SPIDERMAN!S: sepsis, scarlet fever, strep P: parvovirus B19, pneumonia, pertussisI: influenzaD: diptheria (pharyngeal)E: epiglottitisR: rubellaM: meningitis, mycoplasma/meningeal pneumoniaAn: adenovirus*Private room/cohort, mask
CONTACT precaution
MRS. WEEM: multidrug resistant organismR: respiratory infectionS: skin infectionW: wound infectionE: enteric infection (C. diff)E: eye infection (conjunctivitis) S: skin infections (VCHIPS)V: varicella zosterC: cutaneous diphtheriaH: herpez simplexI: impetigoP: pediculosisS: scabies
Air/pulmonary embolism: s/s & pt positioning
1. S/S: - chest pain - difficulty breathing - tachycardia - pale/cyanotic - sense of impending doom2. Pt positioning: - turn pt to LEFT side & LOWER the HOB
Woman in labor w/ Un-reassuring FHR: pt positioning
1. un-reassuring FHR: late decels, decreased variability, fetal bradycardia, etc2. Treatment: a. position on LEFT side b. O2 c. stop pitocin d. increase IV fluids
Tube feeding w/ decreased LOC: positioning
- position pt on RIGHT side (promotes emptying of the stomach)- w/ HOB elevated (to prevent aspiration)
Epidural puncture: during procedure position pt _____ -______
during epidural: position pt side-lying
Lumbar puncture: after procedure position pt ________
Post-lumbar puncture (& oil-based Myelogram): pt should be flat supine for 4-12hrs*this prevents headache & leaking of CSF
Continuous Bladder Irrigation (CBI): positioning
- catheter is taped to thigh so leg should be kept straight(no other positioning restrictions)
Myringotomy: post procedure positioning
Post-myringotomy: position pt on affected side (allows for drainage of secretions from ear)
Cataract Surgey: post-procedure positioning
Post-cataract surgery: pt should sleep on unaffected side w/ a night shield for 1-4wks(this will decrease ICP pressure)
Thyroidectomy: post procedure positioning
Post-thyroidectomy: pt should be in low or semi-Fowler's- support head, neck & shoulders
Spina Bifida positioning
Position infant prone (on abd) to prevent rupture of the sac
Buck's Traction (skin traction) positioning
elevate foot of bed for counter-traction
Total Hip Replacement: post procedure
- teach pt to not sleep on operated side- don't flex hip more than 45-60 degrees- don't elevate HOB more than 45 degrees- maintain hip abduction by separating thighs w/ pillows
prolapsed cord: position
place pt in knee-chest position or in Trendelenburg
infant w/ cleft lip: position
position on back or in infant seat to prevent trauma to suture line- while feeding, hold in upright position
Dumping syndrome: prevention
(postop ulcer/stomach surgeries)= 1. eat in reclining position2. lie down after meals for 20-30 minutes3. retrict fluids during meals4. low CHO & fiber diet5. small, freq meals
above knee amputation: position
- elevate for first 24hrs on pillow- position prone daily to provide for hip extension
below knee amputation: position
- foot of bed elevated for first 24hr- position prone daily to provide for hip extension
detached retina: position
area of detachment should be in the dependent position
enema: administration
- position pt on LEFT side-lying (Sim's) w/ knee flexed
Supratentorial surgery: postop position
(supratentorial= incision behind hairline)- elevate HOB 30-45 degrees
Infratentorial surgery: postop position
(infratentorial= incision at nape of neck)- position pt flat & lateral on either side
internal radiation: position
- remain on bedrest while implant is in place
autonomic dysreflexia/hyperflexia: s/s, position
S/S: a. pounding headache b. profuse sweating c. nasal congestion d. goose flesh e. bradycardia f. hypertensionposition: - place pt in sitting position (elevate HOB) b/f any other implementations
autonomic dysreflexia: treatment
*potentially life-threatening emergency- elevate HOB to 90 degree- loosen constrictive clothing- assess for bladder distension & bowel impaction (trigger)- admin antihypertensive meds (may cause stroke, MI, seizure)
Shock: position
- bedrest w/ extremities elevated 20 degrees, knees straight, head slightly elevated (mod. Trendelenburg)
peritoneal dialysis when outflow is inadequate
- turn pt from side to side B/F checking for kinks in tubing
pancreatitis pain med
give pt demorol, not morphine sulfate
Tensilon use in Myasthenia Gravis Crisis
Tensilon will improve MG crisis symptoms*MG worsens w/ exercise & improves w/ rest.
Tensilon use in cholinergic crisis
When cholinergic crisis is caused by excessive medication- stop med*giving tensilon will make it worse
head injury medication: mannitol precaution
Mannitol (osmotic diuretic) crystallizes at room tempALWAYS use a filter needle
Liver biopsy precaution
- prior to a liver biopsy, be aware of the lab report for prothrombin time
metabolic acidosis vs. alkalosis causes
- acidosis: "From the ASS" (diarrhea)= metabolic acidosis- alkalosis: ("From the mouth" (vomiTUS)= metabolic alkaloSIS
Myxedema/hypothyroidism: s/s
*overall slowed physical & perception function- sensitivity to cold- dry skin & hair- Decreased activity level- sensitivity to cold- potential alteration in skin integrity- decreased perception of stimuli- obesity, wt gain- potential for respiratory difficulty- constipation- alopecia- bradycardia- reproductive problems
Graves' disease/hyperthyroidism: s/s
*overall accelerated physical & perception function- sensitivity to heat- fine/soft hair- hyperactivity- sensitivity to heat- rest/sleep deprivation- increased perception to stimuli- wt loss- potential for respiratory difficulty- diarrhea- tachycardia- exophthalmus- freq mood swings- nervous, jittery- fine, soft hair
Grave's disease (thyroid storm): s/s
- increased temperature- increased pulse- HTN
Post-thyroidectomy: nursing care
- semi Fowler's position- prevent neck flexion/hyperextension- trach at bedside
hypoparathyroidism: s/s
CATS-CaPSConvulsionsArrhythmiasTetanySpasms(low) Calcium*(high) Phosphorus Stridor (decreased calcium)*Trousseau's & Chvostek's signs
hypoparathyroidism: treatment
- Emergency treatment: calcium chloride or gluconate over 10-15min- calcitriol 0.5-2mg daily for acute hypocalcemia- Ergocalciferol 50,000-400,000 units daily- observe for tetany- low phosphorus, high calcium diet- provide vit D (aids in Ca absorption)
hyperparathyroidism: s/s
- (high) Calcium- (low) Phosphorus- Fatigue- Muscle weakness- Renal Calculi- Cardiac Dysrhythmias- Joint & back pain- High phosphorus diet
hyperparathyroidism: treatment
(hypercalcemia)- relieve pain- prevent formation of renal calculi: increase fluid intake- admin high phosphorus, low calcium diet- prevent fractures- safety precautions- monitor K levels- provide postparathyroidectomy care- IV furosemide & saline promotion- IV phosphorus (only for rapid lowering of calcium level- offer acid-ash juicessurgery: parathyroidectomy
Hypovolemia: s/s
- increased temperature- rapid/weak pulse- increase respiration- hypotension- anxiety- urine SG > 1.030
hypervolemia: s/s
- bounding pulse- SOB- dyspnea- rales/crackles- peripheral edema- HTN- urine SG < 1.010*place pt in semi-fowlers
Diabetes Insipidus (decreased ADH): s/s
- excessive urine output - thirst- severe dehydration- weakness- constipation- high serum Na- administer vasopressin
SIADH (increased ADH): s/s
- decreased urinary output- change in LOC- decreased DTR- tachycardia- N/V/A- increased circulating blood volume- lethargy- restrict water intake (500-600ml/day)- diuretics- hypertonic saline (3% NaCl) IV- administer Declomycin & diuretics
hyponatremia: s/s
- N- muscle cramps- increased ICP- muscular twitching- convulsion*give diuretics, fluids
hypernatremia: s/s
- increased temperature- weakness- disorientation/delusions- hypotension- tachycardia- hypotonic solution
hypocalcemia: s/s
CATSSConvulsionsArrhythmiasTetanySpasmsStridor
hypercalcemia: s/s
- muscle weakness- lack of coordination- abd pain- confusion- absent DTR- sedative effect on CNS
HypoMg: s/s
- tremors- tetany- seizures- dysrhythmias- depression- confusion- dysphagia*dig toxicity
hyperMg: s/s
- depresses the CNS- hypotension- facial flushing- muscle weakness- absent DTR- shallow respirations*emergency
Addison's: s/s
- hypoNa- hyperK- hypoglycemia- dark pigmentation- decreased resistance to stress- fractures- alopecia- wt loss- GI distress
Addison's Crisis: s/s
- N/V- confusion- abd pain- extreme weakness- hypoglycemia- dehydration- decreased BP
Cushing's: s/s
- hyperNa- hypoK- hyperglycemia- prone to infection- muscle wasting- weakness- edema- HTN- hirsutism- moonface/buffalo hump
Pheochromocytoma:
- hypersecretion of epi/norepi- persistant HTN- increased HR- hyperglycemia- diaphoresis- tremor- pounding HATreat: - avoid stress- freq bathing & rest breaks- avoid cold & stimulating foods- surgery to remove tremor
Neuroleptic Malignant Syndrome (NMS): s/s
* NMS is like S&M: - you get hot (hyperpyrexia)- stiff (increased muscle tone)- sweaty (diaphroesis)- BP, pulse, & respirations go up &- you start to drool
Which is worse when pregnant: regular or German measles?
- Never get pregnant w/ a German (rubella)
When drawing up insulin in the same syringe, remember RN.
- RNRegular comes b/f NPH
Tetralogy of Fallot: "DROP"
"DROP"Defect, septalRight vent. hypertrophyOveridding aortsPulmonary stenosis
MAOI's used as antidepressants: "PANAMA"
*PANAMAPA- parnateNA- nardilMA- marplan
Digoxin: nursing implications
- check pulse- hold if pulse < 60- check dig & K levels
aluminum hydroxide (Amphojel): nursing implications
- treatment of GERD & kidney stones- watch out for constipation
hydroxyzine (Vistaril): nursing implications
- treatment of anxiety & itching- watch out for dry mouth*given preop commonly
midazolam (Versed): nursing implications
- given for conscious sedation- watch out for respiration depression & hypotension
propylthiouracil (PTU) & methimazole: nursing implications
- prevention of thyroid storm
carbidopa-levodopa: nursing implications
- treatment of Parkinson's- sweat, saliva, urine may turn reddish brown occassionally- causes drowsiness
trihexyphenidyl: nursing implications
- treatment of Parkinson's- sedative effect also
benztropine: nursing implications
- treatment of Parkinson's & extrapyramidal effects of other drugs
trimethobenzamide: nursing implications
- treatment of postop N/V - treatment of N ass/w gastroenteritis
Timolol (Timoptic) treat
- treatment of glaucoma
sulfamethoxazole (Bactrim): nursing implications
- antibiotic- don't take if allergic to sulfa drugs- diarrhea common side-effect- drink plenty of fluids
gout meds
- probenecid- colchicine- allopurinol
hydralazine: nursing implications
- treatment of HTN & CHF- report flu like symptoms- rise slowly from sitting/lying position- take w/ meals
dicyclomine: nursing implications
- treatment of irritable bowel- assess for anticholinergic side effects
verapamil: nursing implications
CCB- treatment of HTN, angina- assess for constipation
sucralfate: nursing implications
- treatment of duodenal ulcers*coats the ulcer, so take b/f meals
theophylline: nursing implications
- treatment of asthma or COPD- therapeutic range: 10-20
acetylcysteine: nursing implications
- antedote to tylenolPO
acetazolamide: nursing implications
- treatment of glaucoma, high altitude sickness- don't take if allergic to sulfa drugs
Indocin (NSAID): nursing implications
- treatment of arthritis (osteo, rhematoid, gouty), bursitis, tendonitis
synthroid: nursing implications
- treatment of hypothyroidism- make take several wks to take effect - notify HCP of chest pain- take in AM on empty stomach*could cause hyperthyroidism
librium: nursing implications
- treatment of alcohol w/d- DO NOT TAKE ALCOHOL W/ THIS! (severe N/V can occur)
Kwell: nursing implications
- treatment of scabies & lice- apply lotion once & leave on for 8-12hrs- (for lice): use shampoo & leave on for 4min w/ hair uncovered, then rinse w/ warm water & comb w/ fine toothed comb
Premarin
treatment after menopause (estrogen replacement)
dilantin
treatment of seizures- therapeutic drug level: 10-20
navane
treatment of schizophrenia- assess for EPS
ritalin
treatment of ADHD- assess for heart r/ side-effects, report immed- child may need a drug holiday b/c it stunts growth
dopamine (intropine)
- treatment of hypotension, shock, low CO, poor perfusion to vital organs- monitor EKG for arrhythmias- monitor BP
FHR patterns (VEAL CHOP)
VEAL CHOP- Variable decels; Cord compression caused- Early decels, Head compression caused- Accels, Okay, not a problem!- Late decels; Placental Insufficiency (can't fill) p.7
ABGs:
pH: 7.35-7.45PaCO2: 35-45HCO3: 22-26PaO2:
BUN (blood urea nitrogen)
6-20 mg/dL- urea nitrogen is byproduct of protein breakdown---goes to kidneys to get excreted out- increased BUN: acute renal function; CHF, dehydration, shock, hemorrhage, MI, stress; increased protein intake- decreased BUN: liver failure; malnutrition; overhydration; SIADH; malabsorption *BUN (can be reabsorbed)/creatinine is not; want BUN:creatinine ratio to be 10:1 - elevated BUN:creatinine ratio implies (volume depletion) decreased blood flow to the kidneys (CHF, dehydration, increased protein intake, GI bleed) - decreased BUN:creatinine ratio implies liver issues (liver disease, malnutrition, decreased protein intake)
creatinine
0.6-1.2- creatine contributes to ATP production for muscle use= becomes creatinine & should be nearly completely excreated out by kidneys(GFR: want close to 100> 60 = stage I, II CKD30-49 = stage III CKD< 30 = stage IV CKD)
cholesterol (total)
<200
Glucose
70-100
Hct
m= 42-52f= 36-46
Hgb
m= 14-17 f= 12-15
HgbA1c
4-6%; <7%
PLT
200,000-450,000
potassium (k)
3.5-5.0 (< or >= cardiac dysrhythmias
Na
135-145
WBC
5,000-10,000> 10,000 = infection
PT; PTT; INR (w/ & w/o therapy)
PT= 11-13.5sec (therapy= PTT= 25-35 sec (therapy= 2x)INR= 0.8-1.2 (therapy= 2-3)