NCLEX 1 Flashcards

(50 cards)

1
Q

UAP scope of practice?

A

assist with ROM, ambulate, hygiene, and ADLS
feed and PO care on stable pts
routine VS and I&O
position and linen changes
transport
report concerns to RN/LPN

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2
Q

LPN scope of practice?

A

monitor RN findings
gather data on stable pts
maintain and remove PIVS
basic care
report pts status to RN/HCP
care for stable pts with predictable outcomes
reinforce RN edu

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3
Q

What is the lab value to evaluate the IVF’s efficacy with septic shock?

A

serum lactic acid

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4
Q

treatment goals with sepsis shock?

A

optimal perfusion demonstrated by a MAP > 65
norm – RR, HR, temp, o2 sat, U/O
clearance of lactic acid, decrease lactic

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5
Q

Contact precautions?

A

MRSA
VRE
RSV
Herpes
Conjunctivitis
Diphtheria
Lice
Scabies
Human metapneumovirus
Staph
Polio
C. Diff
Norovirus
Rotavirus

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6
Q

Droplet Precautions?

A

Flu
Pertussis
Mumps
Rhino
Adenovirus
Rubella
Epiglottitis
Diphtheria (pharyngeal)
Bacterial meningitis (not viral)
HIB
RSV (+contact)

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7
Q

Airborne Precautions?

A

TB
Rubeola virus (Measles)
Chicken pox
SARS
Smallpox
Disseminated varicella zoster virus (VZV)

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8
Q

Positioning for cord prolapse?

A

knee to chest and exaggerated sims position

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9
Q

low predictive value for the presence or absence of DVT

A

Homans sign

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10
Q

reliable DVT signs?

A

pain, swell, and warmth

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11
Q

Hyponatremia S/S?

A

LOC (altered)
weak muscles
osmolarity low
ortho hypotension
seizures
diarrhea
increased ICP
urine osmolarity high
hyperactive bowel sounds

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12
Q

Presumptive signs of preg?

A

amenorrhea
N/V
fatigue
urine freq.
quickening (slight flutter movement between 16-20 weeks gestation)

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13
Q

Probable signs of preg?

A

goodells sign (soften of cervix)
braxton hicks ctx
chadwicks sign (blue appearance of cervix)
hegars sign (soften of isthamus of cervix)
pos. preg test
palp of fetal outline
ballottement (sudden tap on cervix during the vag exam may cause fetus to rise in the amniotic fluid and then rebound to OG position)

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14
Q

Positive signs of preg?

A

fetal movement detected by examiner
auscultation of fetal heart sounds
visual of embryo or fetus

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15
Q

what heart sound is expected during preg?

A

S3 heart sound bc of increased bld volume

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16
Q

Hypernatremia S/S?

A

fever
restless and agitation
increased fluid retention
edema
dry mouth
skin flush
altered LOC and confused
low U/O
thirst
BP increased
decreased energy

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17
Q

What is expected for a K+ level over 5.0?

A

altered heart rhythm, tall peaked T waves with shortened QTI are the 1st finding

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18
Q

Chest tube findings?

A

Suction control: no tidal, replace with sterile H2O PRN, gentle bubble, connect to suction
H2O seal: fluid level moves up and down (tidal), intermittent bubble
Drainage: no tidal, connected to pt, pink drainage, no bubble

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19
Q

Injection angles?

A

IM: 90
SUBQ: 45
IV: 25
Intradermal: 5-15, epidermis

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20
Q

What is increased with GOUT?

A

uric acid

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21
Q

RhoGam?

A

given at 26-28 weeks and 72 H after delivery

22
Q

what happens with cold stress?

A

poor muscle tone
weak/jittery
metabolic acidosis

23
Q

HTN care?

A

daily wt
I&O
U/O
response of BP
electrolytes
take pulses
ischemic episodes
complications

24
Q

Correct order for a stroke?

A

assess and stabilize w/in 10 M
neuro eval. w/in 25 M
obtain CT of head with no contrast w/in 45 M
ischemic = tPA
admin tPA w/in 60 M (w/in 4-5 H of onset)
admin to stroke unit w/in 3 H of entry to ED

25
Ischemic stroke?
permissive HTN tPA (60 M) surgical removal of clot (percutaneous thrombectomy)
26
hemorrhagic stroke?
get bleeding under control aneurysm? coling and clipping craniotomy EVD
27
What is Digoxin?
mainstay for heart failure treat systolic heart failure and A Fib low K+ and mg levels may increase risk of toxicity
28
What interacts with grapefruit juice?
CCB and anticoagulants
29
what interacts with tyramine foods?
MAOIs
30
What are the 5 p's of compartment syndrome?
pain pallor pulseless paresthesia pressure
31
what is ARDS cm?
hypoxemia (PaO2 less than 80) norm PaO2 = 80-100
32
unconscious suppression of unwanted thoughts or info from consciousness
repression
33
attributing ones own feelings, thoughts, behavior, or motives
projection
34
revert to behavior from early stage of development in response to stress
regression
35
channel neg. emotions or socially unacceptable impulses into socially acceptable behavior
sublimation
36
Pre-op ABX?
give 1 H b4 surgical incision
37
Elicited by tapping on face just below and in front of ear to trigger facial twitch of 1 side of the mouth, nose, and cheek
Chvostek sign
38
elicited by place BP cuff around arm, inflate cuff to greater than pts SBP, and keep inflated for 1-4 M
Trousseaus sign
39
ABGs?
resp alk = pH increased, PaCO2 decreased, HCO3 norm resp acid = pH decreased, PaCO2 increased, HCO3 norm meta alk = pH increased, PaCO2 norm, HCO3 increased meta acid = pH decreased, PaCO2 norm, HCO3 decreased
40
Inflammation of peritoneum, abd distension, pain increased w/ cough and movement, pain decreased when bend R hip, rigid, board like abd
peritonitis
41
PP hemorrhage risk?
polyhydramnios (increase amniotic fluid), prolonged labor antepartum HTN recent bleeding HX twins uterine fibroids multi-parity
42
HTN management?
diet modify exercise anti HTN meds smoking cessation lifestyle modify
43
Hypercalcemia S/S?
weak, flaccid, decreased DTR bradycardia, cyanosis, DVT fatigue and decreased LOC decreased peristalsis, hypoactive BS, abd pain, N/V, constipation, and kidney stones
44
ABX admin, nursing care?
monitor for super-infections eval. liver and renal function diarrhea manage inform HCP if taking other meds cultures B4 admin no alc. take entire course eval. cultures, WBC, CRP, and temp
45
walking with a cane?
cane opposite affected leg
46
what are the 5 rights of delegation?
task, circumstance, person, direction and comm, and supervision and eval.
47
Lithium?
therapeutic level: 0.6-1.2 bipolar disorder efficacy in 1-2 weeks fine hand tremors, wt gain, acne, and hair loss = common avoid: ACE, NSAIDS, and diuretics vomit, ataxia, confused, vision blurred = toxic labs to monitor: thyroid panel, creatinine, NA+, lithium levels, daily fluids intake (1-2L)
48
Bells Palsy S/S?
blink reflex abdnormal earache/ eyes roll up lower corner of mouth and eyelids loss of taste and brow movement sudden onset (H-days) paralysis unilateral (facial nerve: VII)
49
Management styles?
autocratic: manager makes all decisions democratic: decisions made by group w/ manager support laissez-faire: little structure or support by manager transactional: reward well work, consequence for poor work
50
Non-Stress Test?
fetal NST eval. if changes in the FHR occur w/ movement non-reactive = NOT GOOD!