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NCLEX: NGN > General > Flashcards

General Flashcards

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1
Q

What is the priority for a psy patient who is upset, paranoid, angry, potentially violent?

A

Allow them to vent

This may diffuse the situation

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2
Q

Which of the following potential nursing actions would be undertaken with an 11 month old with possible bacterial meningitis

Incentive spirometer q2h
Oxygen via nasal canual
Continous pulse Ox monitoring
Droplet precautions

Seizure precautions
Neurological checks daily

Type & cross match for 2 units of PRBCs
Vital signs every hr
Contact HCP if temp > 102.4
Blood cultures

A

Oxygen via nasal canual
Continous pulse Ox monitoring
Droplet precautions

Seizure precautions

Vital signs every hr
Contact HCP if temp > 102.4
Blood cultures

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3
Q

Select if the findings are consistent with

Acute pancreatitis or Dehydration or Both

Fever
Tachycardia
Ab pain
Hypotension
Vomiting

A

Fever Both
Tachycardia Both
Ab pain Acute pancreatitis
Hypotension Both
Vomiting Acute pancreatitis

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4
Q

Acute abdominal pain
N/V
Blue-Gray discoloration of umbilicus area

Classic signs of..

A

Acute pancreatitis

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5
Q

Risk factors for CKD are…

Chronic Kidney disease

A

Diabetes
HTN
Other risk factors include:
Heart disease
Family history of CKD
Obesity

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6
Q

Pregnancy-related disorder that involves persistent high blood pressure, proteinuria, and poor placental perfusion

A

Preeclampsia

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7
Q

When can preeclampsia occur?

What are some consequences

A

Pregnancy or after giving birth

Potentially serious.

Liver and kidney damage, and a decrease in platelets

Dangerous to Mother & Child

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8
Q

HELLP syndrome AKA

What is it?

A

Also called: hemolysis (RBC breakdown), elevated liver enzymes, low platelet

A serious complication of high blood pressure during pregnancy.

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9
Q

Which are immediate concerns for a newborn?

RR 40 - 60
Intermittent expiratory grunting
Fine crackles
Occasional apenic episodes

Arms & legs relaxed
Crying
Relaxed body posture
Diminished reflexes

Skin molted (Reddish-purple streaks, spots)
Axillary temp 96.7
HR 132
Presence of a murmur

A

Expiratory grunting & apenic episode

Relaxed muscles / Posture is abnormal. Possible sign of respiratory compromise

Axillary temp is too low.

Normals
New born RR = 30 - 60

Fine crackles are normal / COURSE CRACKELS ARE NOT

HR = 100 - 160

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10
Q

54 yr admitted to ED with severe, watery diarrhea, weakness, occasional muscle twitching. No N/V, A&O X3

Has stage 3 CKD which is well managed by diuretics, diet, fluid restriction. Not receiving Kidney Replacement Therapy.

HR 59 & irregular. ECG Tall peaked T waves, flat P, widened QRS.

Labs
NA 145
K 5.9
Hg 11
Hct 35%
BUN 34
Creatine 2.8

Which findings need immediate follow-up?

A

54 yr admitted to ED with severe, watery diarrhea, weakness, occasional muscle twitching.

HR 59 & irregular. ECG Tall peaked T waves, flat P, widened QRS.

Labs
K 5.9
BUN 34

Low Hg & Hct are expected in stage 3 CKD.

Elevated creatinine is associated Only with Kidney function Not Fluid levels. Elevated is to be expected in Stage 3 CKD

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11
Q

Airway Clearance Therapy is needed in CF patients due to Thick Mucus production that can block bronchi & bronchioles.

Treatments include: (5)

A

Chest physiotherapy
Percussion & postural drainage
PEP Positive Expiratory Therapy
High frequency chest compressions
Exercise

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12
Q

CF causes thick mucus to block the pancreas.

What kind of problem will this have on the health

Type of diet for CF

Medications / Supplements needes?

A

Pancreatitic enzymes unable to reach duodenum - fats & protiens will be be properly absorbed

Diet: High protein, high calorie, Unrestricted Fatsneeded?

Meds: Pancreatic Enzymes with food
Multivitamin, esp (A,D,E,K) - Fat soluble

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13
Q

Why should clients with CF seperate 6’ from other clients with CF?

A

Reduced Infections

The stagent mucus is a Breeding Ground for BACTERIA INFECTIONS

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14
Q

Why is diabetes (CFRD) common with CF?

How is it diagnoses?

A

Reduction in Islets of Langerhan - where beta cells produce Insulin

OGTT

2 hrs after glucose administration 240 BS = Diabetes

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15
Q

CF patient requires more of this electrolyte?

A

Sodium.

It is lost in the sweat , parents describe their child as tasting Salty

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16
Q

Laparotomy vs laparoscopy.

A

Laparotomy: Open exploratory procedure to examine the abdominal organs. Large incision, quicker & easier.

laparoscopy: lighted camera is inserted into the abdomen through a “Key-Hole” to examine the organs in the abdomen

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17
Q

Colectomy is….

Why is it preformed?

A

Surgical procedure that removes part or all of the colont

Cancer, inflammatory disease, or diverticulitis.

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18
Q

Minimum urine voided per hour?

A

30 mL

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19
Q

Atelectasis can occur after surgery due to: Anesthesia, analgesics, or Immobility.

Name (5) S&S

A

Elevated RR
Dyspnea
Fever
Crackles
Productive cough

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20
Q

Hemorrhage/ Bleeding after surgery due to slipping of suture or dislodged clot

S/S
Hypertension/ Hypotension
Bounding Pulse/ Weak Pulse
Skin: Cool & Clammy / Hot & Dry
RR: Decrease/ Increase

A

Hypotension
Weak Pulse
Skin: Cool & Clammy
RR: Increase

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21
Q

Tamoxifen is this type of medication

Used for…

How does it work

A

Estrogen modulator that blocks estrogen in breast tissue.

Use to treat breast cancer & prevents breast cancer

Works by blocking estrogen receptors Inhibit growth and proliferation of cancer cells

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22
Q

Tamoxifen blocks the effects of estrogen in breast tissue (Prevent / Treat) breast cancer.

Has the serious adverse side effect

List SE:

A

Cause endometrial cancer

S&S
Hypercalcemia (Bone Pain) / Fractures / Bone Metastasis
Menstrual bleeding post menopause
Pelvic pain
Vaginal discharge
Vasomotor (Hot Flashes)

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23
Q

Chorioamnionitis, also known as intra-amniotic infection …

A

Common pregnancy complication

Inflammation & infection of the fetal membranes and placenta

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24
Q

( Gravida / Para)
Number of times a female is or has been pregnant, regardless of the pregnancy outcome.A current pregnancy, if any, is included in this count. A multiple pregnancy (e.g., twins, triplets, etc.) is counted as 1.

(Gravida / Para “Parity”)
Number of births (including live births and stillbirths) where pregnancies reached viable gestational age. A multiple pregnancy (e.g., twins, triplets, etc.) carried to viable gestational age is still counted as 1.

A

Gravida
Number of times a female is or has been pregnant, regardless of the pregnancy outcome.A current pregnancy, if any, is included in this count. A multiple pregnancy (e.g., twins, triplets, etc.) is counted as 1.

Para “Parity”
Number of births (including live births and stillbirths) where pregnancies reached viable gestational age. A multiple pregnancy (e.g., twins, triplets, etc.) carried to viable gestational age is still counted as 1.

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25
Prelabor rupture of membranes (PROM) - Spontaneous rupture of amniotic sac with subsequent leakage of amniotic fluid Preterm prelabor rupture of membranes (Same as above) but happens < ___ week of pregnancy Risk Factors include
37th Cigarettes urinal / gential tract infection, previous Preterm birth history of cervical cerclage (surgical procedure: Stitches around the cervix to help prevent preterm birth) Short cervix length Contractions during pregnancy Uterine overdistension Bleeding 2nd / 3rd trimester Pulmonary disease Connective tissue disorder Low BMI Nutrition deficiency
26
Placental abruption ... S/S
When the placenta becomes dislodged from the uterus (womb) Serious Problem Bleeding from vagina Stomach / Back pain Contractions
27
Retained placenta ..
All or part of the placenta or membranes remain in the uterus during the third stage of labor. It's not common, but it can be serious and lead to severe infection or life-threatening blood loss for the mother
28
Intrauterine infection, also known as chorioamnionitis...
Infection that occurs in the uterus during pregnancy, when the placenta, amniotic fluid, or membranes become infected. It can also develop after birth, when the lining of the uterus becomes infected
29
Umbilical Cord Prolapse Umbilical cord comes out of the uterus before the baby Effects on baby: Factors that cause Umbilical Cord Prolapse
Bradycardia <120 Hypoxia Factors: Umbilical Cord seen as water breaks Drop in babies HR Change in blood pressure
30
Pulmonary hypoplasia (PH) Rare congenital malformation that causes incomplete lung development Small or abnormally low numbers of alveoli or bronchopulmonary segments. When does this happen on fetal development
<20 weeks
31
32 yr old G²P¹ First delivery unremarkable History of mitral valve stenosis, monitored No medication Post delivery Peripad soaked with blood Abdominal cramps Fundus is soft & 4 fingerbreaths above the umbilicus, devianted right. HR: 120 BP 98/ 62 RR: 24 SpO²: 92% RA The nurse would immediately plan for (1.) _______ and (2.) _____ 1. Uterine massage Rapid administration of blood Administration of methylergonovine Manual exploration if Uterine cavity 2. Hysterectomy Uterine tamponade Oxygen administration IV infusion of oxytocin
The nurse would immediately plan for Uterine massage and IV infusion of Oxytocin Initial interventions for excessive postpartum bleeding = Contract the uterus & stop bleeding Immediate interventions (Uterine Atony) Firm massage of fundus, expression of clots in uterus, Elimination of bladder distention, Continous IV Oxytocin. Methylergonovine admin IM produces sustained Uterine Contractions, However, it is contradicted with HTN or Cardiovascular disease due to vasoconstriction.
32
Methylergonovine is used for what?
admin IM Sustained Uterine Contractions Contradicted with HTN or Cardiovascular disease due to vasoconstriction.
33
uterine balloon tamponade Stops post-partum hemorrhage due to a ________. It's inserted inside the uterus, filled with fluid and works by compressing the bleeding vessels
Relaxed uterus
34
Postpartum hemorrhage First: Massage Fundus (if it is soft) Admin Oxytocin IM Admin methylergonovine If bleeding continues PHCP will perform.... If this is ineffective, then....
Manual explanation of uterine cavity for retained clots or placental fragments Uterine tamponade/ Surgical Management Hysterectomy maybe needed
35
Which of the following are indicated directly following an ischemic stroke Complete swallow screen Allow thickened liquids only Administer fibrinolytic therapy Obtain electronic infusion pump Perform cardiovascular assessment Insert indwelling urinary catheter Admin IV Antihypertensive meds (BP = 152 / 84) Perform frequent neurological assessment
Complete swallow screen Administer fibrinolytic therapy (break up blood clots) Obtain electronic infusion pump (Used to deliver fibrinolytic therapy / must be 2 RN check) Perform cardiovascular assessment Perform frequent neurological assessment Ischemic Stoke BP of 150/100 is needed to maintain Cerebral perfusion Ischemic stroke is caused by a blockage of a cerebral or carotid artery. Fibrinolytic therapy No Invasive tubes placed 24 hrs or until stable (bleed risk)
36
Exclusion for this therapy include >4.5 hrs from onset of symptoms >80 yrs Anticoagulant use Ischemic injury to > 1/3 of brain Significant neurological impairment History both Stroke & DM
Fibrinolytic therapy
37
Evisceration is most common 5 - 10 days after surgery in obese, diabetic, malnourished, immune deficit, steroid using clients. What nursing actions will be taken: (5)
Cover with sterile,warm saline soaked dressing Stay with patient & notify rapid response team Place supine HOB 15 - 20 ° Assess VS q10min Prepare for surgery
38
3 month old with heart failure due to Ventricular Septal Defect Prescribed: digoxin, enalapril, carvedilol, furosemide RR: 64 HR: 164 T: 97.8 BP: 78/ 48 SPO² 91% RA Which intervention would the nurse plan for this baby Maintain fluid restrictions Admin Sodium Bicarbonate Admin K supplements Plan feeding around infants sleep schedule Allow baby to cry for 5 minutes before feeding Monitor for Bradycardia, Bradypenea, HTN
Plan feeding around sleep schedule Metabolic needs are higher in infants with Heart Failure and require more calories K level will probably be fine Even though furosemide (K wasting diuretic) is given ACE inhibitors blocks Aldosterone, blocking of Aldosterone leads to Hyperkalemia
39
The Modified Early Warning Score (MEWS) is a bedside scoring system that evaluates a patient's physiological state using six vital parameters: (Name Them) Critical MEWS score
systolic blood pressure, heart rate, respiratory rate, axillary temperature, mental status, and urine output For a critical total MEWS score of ≥5 or a single physiological parameter score of 3
40
In the following patient 80 F, UTI. MEWS preformed to monitor warning signs of Sepsis VS: RR: 12, HR: 110, Systolic BP: 92, Temp 100.5, A&Ox3 Indicated or Contradicted Hourly VS, I&O, neurological, and cardiopulmonary Admin prescribed BP meds Administration of Ibuprofen for fever Administration prescribed antibiotics Notify physician of increases MEWS score
Hourly VS, I&O, neurological, and cardiopulmonary Administration prescribed antibiotics Notify physician of increases MEWS score Contradicted: Admin prescribed BP meds Systolic BP = 90, THIS WILL GIVE HYPOTENSION Administration of Ibuprofen for fever. Increase likelihood of Shock (NSAID)
41
Right sided cerebral stroke will cause weakness on which side of the body? What field of vision will be diminished?
Right side stroke = left side weakness / paralysis Left field of vision in both eyes
42
Right cerebral stroke Which of the statements demonstrates UNDERSTANDING or FURTHER TEACHING 1. Client places right arm into shirt first when dressing 2. Spouse states " it will help if vision if I approach him from the right side" 3. Spouse " I will talk to the home aids and be sure they get all the care done in the first hour after arrival " 4. Client turns head to the left & right before taking on an activy. 5. I know that I will need help to use the bathroom 6. I can skip the stool softener if I have a BM 7. Picks up washcloths with left hand to wash face.
1. Client places right arm into shirt first when dressing FURTHER TEACH (Affected side should be used first) 2. Spouse states " it will help if vision if I approach him from the right side" UNDERSTOOD: Approach from UNAFFECTED SIDE 3. Spouse " I will talk to the home aids and be sure they get all the care done in the first hour after arrival." FURTHER TEACHING (Task should be broken into steps- Inability to concentrate after stroke) 4. Client turns head to the left & right before taking on an activity. UNDERSTOOD (Scanning will help to see the environment) 5. I know that I will need help to use the bathroom UNDERSTOOD 6. I can skip the stool softener if I have a BM FURTHER TEACHING 7. Picks up washcloths with left hand to wash face. UNDERSTOOD (Always use weak side for ADL and assist with strong side)
43
It is normal and expected that a new born have elevated bilirubin levels. Levels must exceed ___ before jaundice is observed. "Normal" levels are 0.2 - 1.4
5
44
New born will urinate up to ___ times daily due to bladder involuntarily empties at 15 mL
20
45
Transitional stools appear by the 3rd day in new borns initial feeding and are Greenish brown to Yellowish Brown, thin, and less sticky then ______ (1st Poop) - describe
Meconium Composed of materials ingested during the time the infant spends in the uterus: intestinal epithelial cells, lanugo (Soft hair that can cover a new born), mucus, amniotic fluid, bile, and water. Meconium, unlike later feces, is viscous and sticky like tar – its color usually being a very dark olive green and it is almost odorless
46
Normal temperature for a new born
97.7 - 98 Axillary
47
Apical HR newborn
120 - 140
48
RR for a new born
30 - 60
49
A change in drainage from darker red to brighter red is a positive sign that healing is improving. T or F
F It could mean a fresh bleed Contact Surgeon
50
Purpose of the water seal chamber in a drainage collection system?
Prevent air from reentering
51
What does intermittent bubbles in the water seal chamber signify
Air is leaving the pleural space Good thing
52
Water level stops "tidling" going up and down in waterseal chamber What 2 things can this mean
1. Displaced chest tube - Xray confirm 2. Lung has reexpanded
53
Continous bubbling in water seal chamber 2 reasons
1. Leak in system 2. Pneumothorax
54
Constant bubbling in air chamber How does nurse determine cause of the bubbling? Which nursing interventions do you perform with these findings Leak from placement Leak from tubing / device
1. Clamp tube closest to patient insertion site. If bubbling stops then bubbling is due to improper insertion of chest tube. Bubbling continues faulty tube,connection, device. Intervention: Improper Placement: Check for subcutaneous crepitus (Snap, Crackles, Pop undernskin) Put 3 sided petroleum gauze over insert point. System problem; Replace system When disconnecting system put tube underwater
55
Air leaks in chest tubes need to be resolved due to possible pneumothorax which can lead to this heart condition
Cardiac Tamponade Fluid filled sac surrounding the heart compresses it. Prevents proper filling Low BP, SOB, lightheadedness
56
Non alcoholic steatohepatitis (NASH) an aggressive form of: Non alcoholic Fatty Liver Disease (Too much fat is stored in the liver) S/S liver inflammation leads to Cirrhosis & liver failure. Tired,weak,weight loss & yellowing of skin & eyes, Web-like clusters of enlarged blood vessels under skin & Itching. If NASH results in Cirrhosis what will be the S/S (4)
Fluid retention Internal bleeding Muscle wasting Confusion
57
Risk factors for fatty liver disease (5)
Obesity, (pre)DM, >cholesterol & triglyceride levels, HTN
58
Liver biopsy shows: Fat present, No inflammation/tissue damage
NAFLD nonalcoholic fatty liver disease Fat present, No inflammation/tissue damage NASH nonalcoholic steatohepatitis Fat, Inflammation, Liver damage Scar tissue (fibrosis) present Cirrhosis
59
Can liver damage reverse itself
Yes
60
After birth Fundus should be : Firm,midline, & involute 1 cm daily. If it is soft, boggy, or higher than expected this could mean... (this problem)
Uterine Atony Uterus doesn't contract enough after giving birth. Most common cause of postpartum hemorrhage
61
Lochia is...
lochia is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue.[1] Lochia discharge typically continues for four to eight weeks after
62
Describe time frame and changes of lochia 1 - 3 4 - 10 >10
1 - 3 Lochia rubra: Dark Red 4 - 10 Lochia Serosa: brownish red to pink >10 Lochia alba Yellowish white
63
Over distended bladder post partum can lead to (3)
Fundal displacement Uterine Atony Excessive Locha
64
Is peripheral edema an expected finding post partum
Yes, lower extremities
65
Acute Post Streptococal glomerulonephritis happens 1 or 2 weeks post Strep Throat or 3 - 6 weeks post skin infection. Give S&S of this disease
Facial puffiness - Morning, spreads to other areas of body. Periorbital edema Anorexia Decreased urine output BP elevated Cola colored urine Hematuria & Proteuria NO BACTERIA PRESENT in Urine
66
Autonomic reflexia is..... caused by... Found in these patients... Intervention....
Potentially life-threatening condition in which noxious visceral cause Sudden, Massive sympathetic reflex arch Causes: Bladder distention, UTI, epididymitis, bowel distention/ obstruction Found in: High level spinal cord injury patients Interventions: ID noxious source & remove it. Sit patient up right Remove tight clothes Monitor BP
67
Type of shock attributed to severe CNS damage Hypotension Bradycardia Peripheral vasodilation
Neurogenic shock
68
Post partum Scant amount of lochia is <2" Excessive amount is soak pad in <____min
15
69
How long after post partum is the uterus not palpable
2 weeks
70
Day ___ the fundus is halfway way between the umbilicus & symposis process
6
71
Post partum The fundus decends ___ cm daily
1 cm
72
12 hours after delivery, describe the fundus posistion
Firm, midline, and @ level of umbilicus
73
Fundus is laterally shifted Which intervention would nurse take to correct this
Have client empty bladder Less to most invasive means
74
Why does breastfeeding stop post partum hemorrhage
Baby suckling on nipples release oxytocin Oxytocin contracts uterus
75
(Pre) eclampsia can happen during this window of time
Pregnancy >20wks - 6 weeks post partum
76
Eclampsia differs from pre-eclampsia how?
Eclampsia involves seizures
77
(Pre) eclampsia defining characteristics
New onset HBP & Protein urea
78
Severe pre-eclampsia >160/>110 can have these 2 serious side effects
1. Hemorrhagic Stroke 2. Detached placental abruption
79
During (Pre) eclampsia thrombin formations in blood vessels will cause hemolysis of RBCs. Which condition has destruction of RBC, elevated liver enzymes, low platelet count
HELLP
80
How can (Pre) eclampsia be treated?
Delivery of baby & placenta

NCLEX: NGN (3 decks)

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