NCLEX 3 Flashcards
(50 cards)
IV gauges?
24 G = infant/peds and temporary access
22 G = Peds, IV contrast, med/surg, and easily blown veins
20 G = most adults, CT angiography, and blood transfusions
18 G = massive trauma, codes, and RRTs (increased risk for mechanical phlebitis)
kids under 5 yo, inflammation of blood vessels throughout body.
Kawasaki Disease
S/S: strawberry tongue, fever, rash, conjunctivitis, oral mucosa changes, and swollen lymph nodes
Addison’s disease S/S?
hair loss, hyperpigmentation (tan), wt loss, GI upset, fatigue, hypoglycemia, postural hypotension, and weak
Adrenal crisis – extreme fatigue, dehydration, fever, hypotension, renal shut down, increased serum K+, and decreased serum Na+
Lumbar puncture?
spinal needle inserted into subarachnoid space to collect CSF sample
pt fetal side lying position (stay still)
post: keep pt flat for several H, monitor for comp. (increased ICP), and encourage increase fluid intake
Acute glomerulonephritis?
secondary to many conditions/ infection processes (strep, mono, hepatitis)
clinical feat. – oliguria, fatigue, fluid retention, proteinuria, hematuria, and increased BP.
Prevent FVO, no fluids, Na+, and K+, monitor I&O, wt, and BP
most common heart anomaly
CoA
monitor – VS, BP, HR, and O2, reg assess peripheral pulses, cap refill, skin color, and temp
Help w/ feeding – poor heart output and resp compromised = poor feeding, monitor I&O
potential causes of late decels?
uteroplacental insufficiency, maternal hypotension, uterine hyperstimulation, and maternal hypoxemia
anaphylactic shock treatment?
epi
corticosteroids
bronchodilators
neurogenic shock treatment?
spinal cord injury
cooling
supportive care
septic shock treatment?
systemic RTX cause release of inflammatory cytokines
IV ABX
IV fluids
preterm labor causes?
dehydration
infection
sex
exercise (strenuous)
activities
stress
environmental factors
neurogenic shock CM?
hypotension
bradycardia
hypothermia
tachypnea
decreased U/O
anxiety
significant peripheral vasodilation, inhibition of baroreceptor response, and impaired thermoregulation
hyperthyroidism S/S?
tremor
HR drop
fatigue
restless
oligomenorrhea and amenorrhea
intolerant to heat
diarrhea
irritable
sweat
muscle wasting and wt loss
DKA?
factors: infection, stress, inadeq. insulin dose
S/S: ketosis, kussmaul resp, rotting fruit breath, nausea, and abd pain
serum glucose: >300
serum ketones: yes, increased anion gap >12
ABGs: acidosis
more likely to occur in DMT1
HHS?
factors: infection, stress, poor fluid intake
S/S: dehydration and altered LOC
serum glucose: >600
serum ketones: no
ABGs: metabolic alkalosis
heart auscultation?
Aortic: 2nd ICS to R of sternal border
Pulmonic: 2nd ICS to L of sternal border
Erbs point: 3rd ICS to L of sternal border
Tricuspid: 4-5th ICS to lower L of sternal border
Mitral: 5th ICS at midclavicular line (Apex)
Liver Biopsy?
post-procedure position pt R side w/ pillow under site, observe for bleeding 2-4 H post procedure
calf pain at dorsiflexion of foot, DVT
Homans sign
pt lies on back and leg = extended, painful and leg cannot be fully extended, meningitis
Kernings sign
hip and knee flex when neck = flexed, meningitis
Brudzinskis sign
blue discolor of umbilicus, pancreatitis
cullens sign
blue discolor of flanks, pancreatitis
grey turners sign
CV tamponade treatment?
pericardiocentesis (needle inset to aspirate the pericardial fluid in U/S guided procedure)
+ pressure vent complications?
barotrauma
vent associated injury
neurodynamic effect
