NCLEX Review Patient Care

1. CERVICAL CA
Risk Factors:
• African- American/ Native
women
• Behavior (Sexual promiscuity)
• Chronic instrumentation of cervix
• Disease –STD
• Early age of Sex
• High Parity
• Poor Hygiene
• Low economic status
• Multiple sexual partners
• Partner with Prostate CA
Sx:
• Post-coital bleeding
• Painful sex
• Menstrual irregularities
2. OVARIAN CA
Risk factors:
• Ovarian dysfunction
• Vaginal use of talcum powder
• Alcohol
• Race - White women & family
history
• Infertility
• Age - Peak=5th decade of life
• Nulliparity
• Genetic predisposition
3. DM FOOT CARE
• Meticulous care to feet
• Wash feet with warm water not hot &
dry
• Can use lotion but No lotion in
between toes
• Wear socks to keep feet warm
• Avoid thermal baths, heating pads
• Do not soak feet
• Inspect feet daily
• Do not treat corns, blisters
• Wear loose socks and no barefoot
• Change into clean cotton socks daily
• Break in new shoes gradually
• Use emery board
• Do not smoke
• Do not wear same pair of shoes 2
days in a row
• Check shoes for cracks before using
4. BLOOD TRANSFUSION
REACTION
• Transfusion Reactions
Hemolytic Reaction
Allergic Reaction
• Circulatory Overload
• Septicemia
• Iron Overload
• Hypocalcemia
• Disease Transmission
• Hyperkalemia
• Citrate Intoxication
5. HYPERTHYROIDISM
• Soft smooth skin & hair
• Mood swings
• HPN
• Diaphoresis
• Intolerance to heat
• PTU drug to block thyroid synthesis
6. LUNG CA
• Bronchogenic Carcinoma
• 1st leading cause of death
• From asbestos, bacterial invasion,
cigarette
• Sx: Nagging cough, hoarseness of
voice, dyspnea, diminished breath
sounds
7. SX OF PARKINSONS
• Tremors, akinesia, rigidity
• Weakness, “motorized propulsive
gait
• Slurred speech, dysphagia, drooling
• Monotonous speech
• Mask like expression
• Teach ambulation modification:
goose stepping walk (marching),
ROM exercises
• Meds—Artane, Cogentin, L-Dopa,
Parlodel, Sinemet, Symmetrel
• Activities should be scheduled for
late morning when energy level is
highest
• Encourage finger exercises.
• Promote family understanding of
disease intellect/sight/ hearing not
impaired,
8. ACUTE PANCREATITIS
• Abdominal Pain severe –acute sx
• Complication : Shock,Hypovolemia
• Limited fat & protein intake
9. CAST CARE
Don’t rest on hard surface
Don’t cover until dry 48+ hours
Handle with palms of hands not with
fingers
Keep above level of heart
Check for CSM
10. HYDROCEPHALUS
• Anterior fontanel bulges & nonpulsating
• Bones of head separated (cracked
pot sound)
• Check for sun-setting eyes
• D’ Increase ICP
• Evidence of Frontal Bossing
• Failure to thrive
• Irritability
• High-pitched cry
11. ESRD DIET
• Restricted protein intake
• Increase CHO
• Low K, P
• Restrict Na
12. NORMAL IN 8 MONTH OLD
CHILD
- can sit with out support
- can roll from front to back
- can hold a bottle
- closure of ant. fontanel
- can say mama and dada
- 2 teeth present
13. SUPERIOR VENA CAVA OCCLUSION
• Sx occur in the morning
• Edema of face, eyes & tightness of
shirt/ (Stoke’s sign)
• Late sx: edema of arms, hands,
dyspnea, erythema, epistaxis
14. ULCERATIVE COLITIS
Sx:
• Severe diarrhea with blood & mucus
• Abdominal tenderness & cramping
• Anorexia
• Wt. Loss
• Vit. K deficiency
• Anemia
• Dehydration
• Electrolyte imbalance
• Low residue & high protein diet
15. DILANTIN
• do not floss throughout the day
• do not use hard bristled
toothbrush
• Gingivitis S/E
16. ANAPHYLACTIC REACTION
(steps)
• Stop medication
• Maintain airway
• Notify MD
• Maintain IV access of 0.9 NSS
• Place in supine position with legs
elevated
• Monitor VS
• Administer prescribed
emergency drugs
17. BLADDER CA
Risk Factors:
• Hx of smoking
• Exposure to radiation
• Working in industrial Factory
18. S/S OF DKA
• Fruity breath Odor
• Oliguria
• Kusmaull'’s (deep & nonlabored)
19. SITE FOR IM INJECTION ADULT
• Deltoid
• Ventrogluteal
• Vastus Lateralis
• Gluteus Maximus
20. S/S OF BACTERIAL MENINGITIS
• N & V
• Seizures
• Stiff Neck
• Photophobia
• Positive Brudzinski sign
21. TB
• Waking up sweating at night
• Low grade fever
• Dull aching chest pain
• Cough streaked with blood
• Weight loss
• Anorexia
• Fatigue
22. LIVER CIRRHOSIS
• N & V
• Edema
• Ascites
23. PULMONARY EMBOLISM
Sx:
• Blood-tinged sputum
• Distended neck vein
• Chest Pain / Hypotension /
Cyanosis
• Cough / Shallow respirations
• Rales on auscultation
• Tachypnea / Tachycardia
24. COLON CA
Risk Factors:
• Family HX
• Age above 50
• Jewish
• Male
25. DIGOXIN THERAPY
• Do not administer in infants if <
90 bpm
• Do not give to older children if
<70 bpm
• Sx of toxicity to a child – N &V
26. S/S OF CAD
• Chest Pain
• Palpitations
• Dyspnea / Syncope
• Hemoptysis
• Excessive Fatigue
27. COPD
• Rhythmic, diaphragmatic
breathing
• If restless, perform purse-lip
breathing not more than 1
minute
• Perform deep breathing with
mouth held together during
expiration
28. SEEN IN 15 MONTH OLD CHILD
• Speaks 6 words
• Sits w/o support
• Builds a tower of 5 blocks
• Strong palmar grasp
29. CUSHING’S SYNDROME
• Osteoporosis
• Muscle wasting
• Hypertension
• Purple skin striations
• Moon face
• Truncal obesity
• Decreased resistance to infection
• Low Carbohydrate, Low Calorie,
High Protein, High K, Low sodium
• Monitor glucose level
• Check for color of stool, cortisol
increase secretion of gastric acid
– Peptic ulcer & GI bleeding
• C/I to Aspirin, increased bleeding
30. ADDISONS DISEASE
Fatigue
Weakness
Dehydration
Eternal tan
Decreased resistance to stress
Low Sodium
Low Blood Sugar
High Potassium
High protein, carbohydrate, Sodium,
Low potassium diet
Teach life-long hormone replacement
• Glucocorticoids (sugar) - Solu-
Medrol (succinate) to prevent
addisonian crisis
• Mineralocorticoids (salt) –
Florinef
6 A's of Addison's disease
1.) Avoid Stress
2.) Avoid Strenuous
3.) Avoid Individuals with Infection
4.) Avoid OTC meds
5.) A lifelong Glucocorticoids Therapy
6.) Always wear medic alert bracelet
Addisonian Crisis
• Hypotension
• Extreme weakness
• Nausea vomiting
• Abdominal pain /
• Severe hypoglycemia
• Dehydration
• Administer NaCl IV, vasopressors,
hydrocortisone
• Monitor VS /Absolute bedrest
31. PLACENTA PREVIA
• Check Hematocrit level
• External fetal monitor not internal
• No vaginal examination
• Assess for bleeding
• Improperly implanted placenta at
lower uterine
• Painless bright red, vaginal
bleeding
• Soft, relaxed, nontender uterus
• Fundal height greater than
expected
32. ABRUPTIO PLACENTA
• Premature separation of
placenta from uterine wall
• Painful dark red bleeding
• Uterine rigidity
• Severe abdominal pain
• Maternal shock
• Fetal distress
33. HEMODIALYSIS
• Palpate for a bruit or thrill
• Weigh client daily, before, during
& after
• Hold antihypertensive drugs b4
dialysis
• Check for thrill and bruit q 8 hours
• Don’t use extremity for BP, finger
stick
• Monitor vital signs, weight, breath
sounds
• Monitor for hemorrhage
34. PERITONEAL DIALYSIS
• Weight before and after treatment
• Monitor BP
• Monitor breath sounds
• Use sterile technique
• If problem w/ outflow, reposition
client
• Side effects: constipation
35. TYPE 1 IDDM
• Test blood glucose every 4 hrs if
no feeling well
• Eat fruit or cheese sandwich
before exercise
• Do not exercise if blood glucose
is >250mg/dl & urinary ketones
present
• Administer regular insulin 30
minutes before meals
36. COMPARTMENT SYNDROME
• Increased pain & swelling
• Pain with passive motion
• Loss of sensation
• Inability to move joints
• Pulselessness
37. CARDIAC CATHETERIZATION
• NPO 6-8 hrs. & no liquid for 4
hrs. prior to prevent vomiting &
aspiration
• Feel a flush, warm, fluttery
feeling, desire to cough,
palpitations in introduction of dye
• Shave & Clean insertion site with
antiseptic solution
38. PERNICIOUS ANEMIA
• Severe pallor
• Smooth, beefy red tongue
• Slight jaundice
• Paresthisias of hands & feet
• Disturbances with gait & balance
39. DUMPING SYNDROME
• Occurs 30 minutes after eating
• Abdominal fullness & cramping
• Diarrhea
• Tachycardia
• Perspiration
• Weakness / dizziness
• Borborygmi sound
40. TPN COMPLICATIONS
• Air Embolism
• Fluid Overload
• Hyperglycemia
• Hypoglycemia
• Infection
• Pneumothorax
41. DIC
• Bruising, purpura
• Presence of occult blood
• Low fibrinogen level, hct, platelet
• Increased PT, PTT
• Complication: RENAL FAILURE
42. PERIPHERAL ARTERIAL DISEASE
• Dry scaly skin on lower
extremities
• Rest Pain, at night
• Intermittent claudication/
• Thickened toenails
• Cold & gray-blue color of skin
• Decreased or absent peripheral
pulses
• Instruct pt. to walk to point of
claudication, stop & rest & walk
a little farther
43. THROMBOPHLEBITIS
• Avoid pressure behind legs
• Avoid prolonged sitting
• Avoid constrictive clothing
• Avoid crossing the legs
• Avoid massaging the legs
44. SYPHILIS
Painless chancre
fades after 6 weeks
Low grade fever
Copper-colored rash on palms and
soles of feet
Spread by contact of mucous
membranes
Treat with Penicillin G IM
If patient has penicillin allergy, will
use erythromycin for 10-15 days.
After treatment, patient must be
retested to make sure disease is gone
45. POLYCYTHEMIA VERA
• Increased RBC
• Leukocytosis / Thrombocytosis
• Angina
• Intermittent claudication
• Dyspnea /HPN
• Lethargy / Syncope / Paresthesia
46. PRIMARY HPN
Risk Factors:
• Aging
• Black race
• Chronic stress
• Family Hx
• Obesity
• Smoking
• Men
47. CHOLECYSTITIS
Sx:
• N & V
• Belching
• Indigestion
• Flatulence
• Epigastric pain that radiates to the
scapula 2 hrs. after eating fatty food
• Pain localized in RLQ
• Guarding, rigidity & rebound
tenderness
• Cannot take a deep breath when
fingers are pressed below hepatic
margin (Murphy’s Sign)
II. COMPUTATION
1. Dopamine
2. Dobutamine drip: Order is
2.5mcg/kg/min, patient weights 176 lbs.
Stock is 500mg in 500ml of NSS,
Compute for ml/hr?
Formula: Stock (mg) x 1000 mcg/mg
Quantity (ml)
Flow rate: Dose (mcg/kg/min) x wt (kg) x
60 min/hr
Concentration
(mcg/ml)
Answer: 12ml/hr
3. Md with IV order for patient 3,000ml in
24 hrs., get the rate at ml per hour.
Solution: 3000/24 = 125 ml/hr
4. Tablets : Dose of 20 mg per dose in
stock dose of 5 mg per tablet, how many
tablets?
Solution: 20/5 x 1 = 4 tablets
III. TOPICS
1. SAFETY INFECTION CONTROL
AIRBORNE : Hepa Filter Mask / N95
Particulate MASK
PTB
Measles / Rubella
Chicken Pox/
Varicella
SARS
Anthrax
CONTACT : GGG
(gown,gloves,goggles)
Conjunctivitis
Open wounds /drainage
Lesions
MRSA / VRSA /
CDAD
RSV/ VRE
DROPLET : Surgical Mask
Scarlett Fever
Diphtheria
Meningitis
Strep. Pharyngitis
Pneumonia
ENTERIC: Gown , Gloves
Diarrhea
Hep. A
Salmonella
Acute Gastroenteritis
Peptic H. Pylori
Shigella / Rotavirus Giardiasis /
Cryptosporidium Muris
FROTECTIVE:
Blood dyscrasias
Aplastic anemia
Leukemia
Major burns (50%)
Organ transplant
Aids
Multiple Myeloma
Prolong Steroid Therapy
Concepts:
1. Infection control:
a. clean with clean for
example patients with
CVA, DM, Cardio disease
2. Same precaution
techniques:
a. Universal precaution:
Hep B,D, AIDS
2. PRIORITIZATION
Remember the rule of stable vs.
unstable. Although you consider the
client unstable but if it expected in him,
this is stable. Example. Asthma with
wheezing- you consider this unstable.
ABC, unstable , first think EXPECTED
in asthma so this will be considered
stable.
3. DELEGATION
RN - Newly admitted, needs
assessment, pre op teaching and post
op, nsg. Judgment & discharge
planning ,IV meds, BT.
LPN-Can give meds except IV, sterile
techniques like wound dressing,
catheterization, insertion of NG tube,
remove sutures.Stable expected
outcome.
NA/ UAP/CN/ Senior nursing student
- All “-ing” ex bathing, reading v/s in
long term pt. Testing occult blood, BS,
monitoring, soap sud enema, testing
occult blood,
-Isolation precautions, basic hygiene
ADL, Input & Output, Finger stick with
gestational diabetes, urinalysis, TSB,
turning unconscious patient, change
perineal pad, assist in ambulation,
discharge tomorrow,
-Stable v/s, pulse oximetry, reading,
terminally ill because of comfort only
needed.
- Routinary Procedure
4. Patient Hx C/I for MRI :
• Mitral Valve Replacement
5. Glaucoma :
• Halos around light
6. U waves :
• Hypokalemia
7. Patient with arterial insufficiency
• Elevate the affected leg
8. Patient with Dumping Syndrome:
• Avoid cheese
9. Adverse Effect of Anti-metabolite 5FU
• Stomatitis
10. Obtaining sputum specimen from pt.
with tracheostomy:
• Instruct pt. to cough prior to
obtaining sputum
11. Post-hypophysectomy pt. Report if:
• Specific Gravity of 1.005
12. Diet for Hypothyroidism
• Low sodium, High K
13. Patient with CHF cor pulmonale S & S
• Jugular vein distention &
peripheral edema
14. Circumcision of a new infant:
• Diaper fasted loosely
15. Acute Pancreatitis
• Increase lipase/amylase
16. Short-term goal for anti-social patient
• Follow unit rules
17. Use of walker
• Partial weight bearing
• Stand in front, walk unto walker
18. Borderline patient
• Splitting
19. Neonates in nursery developed diarrhea
• Meconium stool study w/in 24
hrs.
20. Nsg. Action in pt. post cardiac
catherization
• Check pulse in lower
extremities
21. Diet for Diverticulitis
• Avoid high-fiber foods when
inflammation occurs, only low
residue
• Introduce soft high-fiber foods
when inflammation has
resolved
22. Low iron.WBC & albumin, what type?
• Nutritional deficit
(malnutrition)
23. What will you ask on pt for cardiac
stress test (Thallium stress test)?
• Is he on beta-blocker?
(if with radionuclide already,
Persantine, then invasive & shld.
avoid caffeine, calcium channel
blockers, b-blockers, theophylline)
24. Highest risk of accident
• 9 month infant eating grapes
& apricot
25. Pancrease in Cystic Fibrosis
• Give with meals, dilute in
applesauce
26. Client post-CVA, diet teaching
• Low salt, low fat
27. Client passing stones with calcium, diet
teaching:
• Should be acid-ash diet &
avoid oxalate rich & Ca rich
food such as tea, almonds,
rhubarbs beans, spinach,
cocoa, vegetables, fruits
• Give cranberries, prunes,
plums, tomatoes, cereals,
corn, legumes
I
28. Paget’s Disease
• Bowing of bones
29. Side Effect of Ansef (Cefazolin)
• Antibiotic (RTI,URTI)
• Diarrhea, Nausea
• Oral candidiasis
• Pancythopenia
30. Peptic ulcer disease
• Avoid stressful situation to
prevent exacerbation
31. Schilling’s Test
• For pernicious anemia
32. Prior To MUGA SCAN:
• Informed consent
• Allergy not a concern
33. Action of Aquamephyton
• Prevention of
hypoprothrobinemia
34. Action of Lipitor
• Anti-lipimec
35. Positioning of Hip Spica Cast in children
• Maintain flexion, abduction &
external rotation
36. Fear of 3 y/o child
• Injury (abandonment,
castration)
37. To prevent ureteral stones
• Increase
38. MDI
• Hold breath
39. Frostbite
• Soak in warm water
40. Normal respiratory changes in elderly
• Decreased cough reflex
41. Patient w/ DM & HPN, question if
• Given beta-blocker (causes
bronchospasm )
42. Maximum injection on 10 month old
infant
• 1 ml
43. Pt. with endometriosis takes Danocrine,
action of the drug?
• Suppress menstruation/
ovulation
44. Post NSD with epidural anesthesia with
bladder distension
• Offer bedpan
45. Apmhotericin B, side effect?
• Headache
• Hypokalemia
• Hypotension
46. PT. with angina unrelieved by 3
nitroglycerin
• Administer O2
47. Patient on Halo Vest
• Tape the wrench to the vest
(Torque screw)
48. Pre-menopausal syndrome
experiencing hot flashes
• Black Cohosh for menoposh
49. Abdominal Assessment
• Inspection
• Auscultation
• Percussion
• Palpation
50. Sclerotherapy
• Application of pressure dressing
for 12-48 hrs.
51. RSV
• Droplet precaution
52. SIADH
• Sodium 128 only (Normal:
135-145)
53. Dementia of Alzheimer Type
• Check what the pt. is taking
54. PEG
55. What medicine if given shld be
monitored for bleeding
• Indomethacin (NSAID)
56. GBS, priority nursing diagnosis
• Aspiration
57. Discharge teaching for Bell’s Palsy
• Provide eye care at bedtime
58. Sign of Scoliosis
• Asymmetry of the iliac crest
59. Normal for a 3 day old infant
• Describe normal tonic neck
reflex
60. Manifestation of Paranoid Schizophrenia
• Inappropriate anxiety with
delusion
61. Sign of Alcohol withdrawal
• Feeling of euphoria in 1st 24 hrs.
62. Activity for Alzheimer disease
• Reading magazine
63. Type 1 IDDM post renal test 48 hrs ago,
watch out for:
• Hematuria
64. Correct understanding of antidepressant
• Anti-depressant takes effect
after 1 week
65. DUROGESIC PATCH / FENTANYL
• For chronic pain lasts 3 days
• Maybe worn while bathing,
showering, swimming
• Apply to flat, nonirritated,
nonirradiated area like chest,
flank, upper arm, back
• Overdose : difficulty in breathing
66. Signs of increase ICP in pt. with close
head injury
• Increase systolic pressure &
weak bounding pulse
67. Positive outcome for Calcium Channel
blockers
• Decrease chest pain
68. Obsessive Compulsive Behavior
• To alleviate anxiety
69. Patient with back pain, proper body
mechanics
• Sit with knees higher than hips
70. What to check prior administration of
EPOETEN
• BP
• S/E : HPN, Seizures
71.
72. Patient with pancreatitis if developing
ascites would manifest:
• Cullen’s Sign (bluish
discoloration of abdomen or
peri-umbilical hematoma)
• Turner’s Sign (gray-blue
discoloration of flank)
• Shallow, rapid breathing
• Abdominal pain
• Dyspnea & difficulty eating
• Orthopnea
73. Digitalis + Lasix = Weight Loss
74. Side effect of Garamycin
• Ototoxicity
• Nephrotoxic
• Hypomagnesimea
• Muscular paralysis
• Hypersensitivity
75. Side Effect of Theophylline
• Tremors & tachycardia
• Insomnia
76. Nsg. Management for cleft palate infant
• Enlarged nipple for feeding
• Stimulate sucking
• Swallow
• Rest
• Burp frequently
77. Patient with expressive aphasia, best
communication:
• Use picture language
78. Diet for patient with colostomy
• DAT
• Low residue food 1-2 days postopt
• Avoid gas-forming foods
79. Patient allergic to Pseudoephedrine,
What is contraindicated?
• Patient taking Ma Huang
80. Patient with testicular cancer, correct
understanding?
• Testicular CA is painless
81. 1st intervention in prolapsed cord
• Positioning – knee
chest/trendelenberg
82. 2nd Stage of labor
• Cervical dilatation to delivery of
baby
83. Thiazide diuretic, what to watch out for?
• Potassium
84. Manic pt. taking lithium
• Watch out for sodium serum
85. Diet for patient with ileostomy
• Post opt 4 wks -- LOW FIBER
non-irritant diet to decrease fast
movement of liquid stool, after
can tolerate high fiber diet
already
• Foods that thicken stool like
boiled rice, low fat cheese
should be given
• Low fat diet
• Normal stool is liquid
86. G & D of a 2 y/o
• Combines 2 words
• Kicks a ball
• 50 word vocabulary
87. ALS
• Decreased sensation of touch
• Muscle weakness
• Excess glutamate
88. S/S of Kawasaki
• Desquamation of skin
• Joint pain
• Mucocutaneous lymph node
syndrome
89. Watch out for in lumbar puncture
• Increased ICP
• Brain Herniation
90. S/S of DVT
• Edema
• Calf or groin tenderness
• Pain with or w/o swelling
• + Homan’s Sign
• Warm skin
91. Developmental Milestone of 10 month
old
• Pincer grasp
92. Risk for breast CA
• 38 y/o female on oral
contraceptive
93. Need to consider anti-coagulant therapy
• If taking Gingko Biloba
94. Check 1st before tonsillectomy
• Bleeding time
95. Complication of CAST
• Compartment syndrome
• Fat embolism
• Shock
• Avascular necrosis
96. What should the nurse question?
• St. John’s Wort to a kidney
transplant
(C/I to anti-neoplastic drugs, lessen
effect)
97. Physician orders beta-blockers, for w/c
pt. should the nurse question the order:
• Patient on insulin
(B-blockers may mask signs of
hypoglycemia)
98. Patient hypersensitivity
• Give macrolides like
erythromycin,azithromycin
(Penicillin & Cephalosporins the same)
99. Patient with autonomic dysreflexia
• Pounding headache ,
piloerection
100. Pt. with carafate & antacids order,
select the schedule.
• Carafate 1 hr. before meals &
antacids after meals
101. Increasing pulse pressure
• Widening pulse pressure (late
sign)
• Decreased LOC, restlessness
(Early)
102. Pt. with Hemophilia & Leukemia
• Can lead to DIC
103. Effective teaching to DM patient
• Peak of NPH insulin 8 hrs.
104. Mg SO4 given to PIH pt. Nurse
should watch out for?
• Epigastric pain & headache
105. Pt. with calcium oxalate stones
• Diet with fig & wheat germs
106. Cancer & Sepsis can lead to DIC
• low platelet count
107. Pt. in labor with crusted popular
eruption, priority?
• Eye prophylaxis of the newborn
108. Heroin addicted mother in labor,
nursing action?
• Avoid withdrawal in active stage
109. Signs of Heroin intoxication?
• Euphoria
• Decrease response to pain
• Respiratory depression
• Apathy
110. Venorofaxen
111. Scarlett Fever isolation precaution
• Respiratory precaution
• droplet until 24 hrs. start of
treatment
112. Laryngectomy
• Avoid swimming, showering,
using aerosol sprays
• Teach client clean suction
technique
113. External irradiation therapy
• Time & distance shielding
114. Pt. with anorexia nervosa, signs
• Tachycardia
115. Brain injury
• Decorticate rigidity
116. Signs of renal failure
• Urine output less than 100ml/hr
117. Post-thyroidectomy patient, WOF
• Tingling sensation in the cheek
(complication)
118. Ventricular Fibrillation
• Do chest compression
119. Pt. in crutches, nurse should check
• Check armpits to see if there is
pressure secondary to crutch
(Pressure shld be on the hands not on
the axilla)
120. Influenza Vaccine indicated for:
• Anyone 50 y/o & above
annually
• Age 6 months & up with risk like
asthma
• Immunocompromised patients
• Pts with cardiac & pulmonary
disease
121. Herpes Simplex I & II
• 2 strains of herpes virus family
• HSV I – cold blisters / fever
blisters
• HSV II – in STD /Genital
Herpes/Shingles & varicella
zoster infection same with
chicken pox
122. Above the knee amputation, patient
shld
• Prevent internal or external
rotation of the limb
• Place sandbag or rolled towel
along side of thigh to prevent
rotation
123. HIV suspect patient
• Hairy tongue and leukoplakia
(Leukoplakia, pre-malignant lesion)
124. DVT on Heparin therapeutic goal
• Ambulate ASAP
( Prevent thrombus formation)
125. Esophageal varices, refer pt if
• Cold clammy skin ( sx of shock)
126. Pregnant 39 weeks, knows true
labor if
• Contractions from back going to
abdomen
127. Bipolar manic patients, what to do?
• Limit group activities
128. Multiple Myeloma, care
• Force fluid from 3 - 4 L/day to
offset hypercalcemia,
hyperurecemia
• Encourage ambulation to
prevent renal stones
129. Post pace maker transplant, correct
understanding
• Patient CAN USE electric
blankets, cell phones <3 watts,
microwave ovens, metal
detectors
130. Patient taking garlic supplements
should take precaution when on aspirin
therapy
131. DKA patient, what to administer 1st?
• Start IV line 0.9 NaCl
132. Hearing aid, correct teaching:
• Turn off & remove battery when
not in use
• Avoid excessive wetting of
hearing aid, keep dry
• Ear mold is the only part that
may be washed w/ soap &
water
• Cannula is cleaned with small
pipe cleaner device or toothpick
133. PEEP
134. 18 day old infant, how to assess
trunk curvature
• Place in prone position & stroke
spinal colum, see if infant’s body
move towards the stimulated
area
135. Postural drainage, correct
understanding:
• Position—lung segment to be
drained is uppermost
• Drink a glass of water before PD
to loosen secretions
136. Sign of Abdominal Aortic Aneurysm
• Pulsation between umbilicus &
pubis
137. Echinacea
• To boost immune system
• Use only up to 8 weeks
138. Action of PILOCARPINE
• Increase outflow of aqueous
humor
• For OPEN ANGLE GLAUCOMA
139. Signs of acute angle glaucoma
• Eye pain / headache
140. Phenytoin for seizure. Watch out for:
• Gum Bleeding
141. Coumadin Therapy. Correct
understanding?
• Ask MD before taking OTC
drugs
142. Diet for hepatic encephalopathy
• Adequate caloric intake in form
of glucose
143. Side effect of TCA
• Urinary retention
144. HELLP
• Nausea
• Epigastric Pain
• Tx: FFP / Platelets
145. Drugs that can produced
Hyperglycemia
• Prednisone
146. Side effect of Haldol
• EPS, NMS
147. CA (Internal & External Radiation)
External Radiotherapy
• Leave markings on skin
• Avoid use of creams, lotions
• Only vitamin A&D =ointment)
• Check for redness, cracking
• Wear cotton clothing
• Administer antiemetics
• Do not pose any hazard to
anyone
Internal radiation
sealed source
• Lead container and longhandled
forceps in room
• Save all dressings, bed linen
until source removed
• Urine and feces not
radioactive
• Don’t stand close or in line
with source
• Patient on bed rest Cancer
Implementation:
Internal Radiation
• Time and distance important
• Private room sign on door
• Nurse wears dosimeter at all
times
• Limit visitors and time spent in
room
• Rotate staff
• Self-care when can do
Internal radiation
unsealed source
• All body fluids contaminated
• Greatest danger first 24-96
hours
148. LTB (Croup). Correct
understanding.
• Mother can be in the tent with
the child
149. Liver cirrhosis. What to assess
before nasotracheal suctioning?
• Platelet (risk for bleeding)
150. Adverse effect of 5FU (Fluoronacil)
• Antagonistic to iron – Anemia
151. Transition phase of labor
• Do short, shallow (PANT)
breathing
152. Mother (-), baby (+), Direct Coomb’s
test (-)
• Give Rhogram
153. Legionnaire’s disease
• Type of pneumonia
• Droplet precaution
• Sx: Fever, chills, cough, ataxia,
muscle aches, Diarrhea
• Middle age & older persons
• Treated with antibiotics ,
macrolides
154. Hepatitis C, Signs & sx
• Same with Hep B.
• Transmitted parenterally
• Common to drug users
• Major cause of post-transfusion
hepatitis
• Universal Precaution same with
Hep. B
155. Sx of Furosemide
• Decreased edema, abdominal
girth, BP & calcium
• Increased urinary output
156. Colchicines Toxicity
• Anti-gout drug
• Nausea & Diarrhea
• Vomiting
• Sore gums
• Metallic taste
157. TENS, how to explain procedure
• Use for chronic nerve pain
• Uses only electrodes
• Painless
• Non-invasive, passive modality
158. PROBENECID
• Treat gout /hyperurecemia
• Increase uric acid removal in
the urine
159. Meaning of death to a 5 y/o
• Magical thinking
• Death as temporary
160. Meaning of death to a 7 y/o
• Death as punishment
161. Meaning of death to 9 y/o
• Death as irreversible
162. Death to an adolescent
• Universal
163. Infant sounds
• 1 – 3 months = Cooing
• 4 -6 months = Babbling
• 6 -8 months – interest in sounds
• 9 -12 months = use of gestures
164. CEFTRIAXONE/ROCIPHEN
• Monitor tongue & oral cavity
165. EMG
• Stop all CNS meds 240 prior
procedure
• Skin prep on site
• To be stimulated with needles
166. Pt with uncomplicated cholelithiasis,
expect elevated?
• Alkaline Phosphotase
167. CANE
• COAL (cane opposite affected
leg)
168. Hep A, predisposing factor?
• From day care centers
169. Patient with Testicular CA
• Undescended testes
170. Diet teaching for Celiac Disease
(SPrue)
• Gluten free diet
• C/I wheat/rye/oats/barley)
• Give corn, rice, soybeans &
potatoes
171. Aspirin
172. Isoniazid (INH)
• S/E: peripheral neuropathy
(administer pyridoxine)
• Rash, urticaria
• Swelling of the face, lips, and
eyelids.
173. Rifampicin
• Hepatotoxic
174. Triage (External)-
• Treat first the stable before the
unstable.
• Emergent first before urgent. But
kung E.R. unstable muna
before stable. ABC
175. Spinal Cord Injury
176. Reflexes
177. LABORATORY VALUES
178. DIET
Clear liquid
No milk
No juice with pulp Full liquid
No jam
No fruit
No nuts
Low Fat /Cholesterol
Can eat lean meat
No avocado, milk, bacon, egg
yolks butter Sodium restricted
No cheese High roughage, high
fiber
No white bread without fiber
Low Residue Diet
Minimize intestinal activity
Buttered rice white processed food
No whole wheat corn bran
High Protein diet
Reestablish anabolism to raise
albumin levels
Egg, roast beef sandwich,
No junk food Renal
Keeps protein, potassium and
sodium low
No beans, no cereals, no citrus
fruits
Low Phenylalanine diet
Prevents brain damage from
imbalance of amino acids
Fats, fruits, jams allowed
No meats eggs bread
179. Lumbar puncture
180. Laminectomy
181. Myasthenia gravis
• Ptosis
182. Multiple sclerosis
• Fatigue / Ataxia /Vertigo
183. PCA
184. Influenza Vaccine, C/I?
• Allergy to eggs
185. Nephrotic syndrome
• PROTEINURIA – frothy urine
186. HERBAL MEDS
187. AUTONOMIC DYSREFLEXIA
• C6 injury
188. Primary, team, functional Nsg.
189. Consent and Advance Directives
190. Glasgow coma scale
191. Glomerulonephritis
• HEMATURIA
• cola/tea urine
Glomerulonephritis Assessment
• Fever, Chills
• Hematuria
• Proteinuria
• Edema
• Hypertension
• Abdominal or flank pain
• Occurs 10 days after beta
hemolytic streptococcal throat
infection
Implementation
• Antibiotics, corticosteroids
• Antihypertensives,
immunosuppressive agents
• Restrict sodium and water intake
• Bedrest
• I&O
• Daily weight
• High Calorie, Low protein
192. PEAK FLOW METER vs. METERED
DOE INHALER vs. INCENTIVE
SPIROMETER
193. Rheumatoid vs. Osteoporosis vs Gouty
194. Burn
Assessments
• Superficial partial thickness—pink to red,
painful
• Deep partial thickness—red to white,
blisters, painful
• Full thickness—charred, waxy, white,
painless
Wound Care for Burns
Never break blisters
Isotonic fluids (Lactated Ringer’s)
Closed method (Silvadene) covered
with dressings
Open method (Sulfamylon) that are not
covered with dressings
IV pain medication initially: not PO
takes too long, not IM circulation impaired
Medicate patient before wound care
Silver nitrate (warn patient skin will
turn black)
High calorie, High carbohydrate, High
protein diet
Vitamin B,C, and Iron
TPN maybe
Prevent contractures
195. Chest Tubes
1. Air-leak if bubbling in water-seal
chamber
(middle chamber)
2. Obstruction: “milk” tube in direction
of drainage
3. Removal of chest tube:
• Pt. does valsalva maneuver
• Clamp chest tube,
• Remove quickly
• Apply occlusive dressing
4. Dislodged
• Apply tented dressing
• Tube becomes disconnected
from drainage system, cut off
contaminated tip, insert
sterile connector
and reinsert
• Tube becomes disconnected
from drainage
system, immerse in 2cm of
water
Jackson-Pratt:
• Notify physician if drainage
increases or becomes bright
red
• Penrose: Expect drainage on
dressing
196. Cataract
Assessments
Distorted, blurred vision
Milky white pupil Cataracts
Postop: check for
hemorrhage
Check pupil—constricted
with lens implanted,
dilated without lens
Eye drops / Night shield
Sleep on unaffected side
197. Glaucoma
Abnormal increase in intraocular
pressure that leads to blindness
Blurred vision
Lights with halos
Decreased peripheral vision
Pain
Headache Glaucoma
Administer miotics (constrict
pupil) Carbonic
anhydrase inhibitors
Surgery
Avoid heavy lifting, straining of
stool
Mydriatics C/I with glaucoma.
198. Detached Retina
Flashes of light
Loss of vision
Particles moving in line of
vision confusion a Implementations
Bedrest, affected eye in dependent
position
Eye patched (one or both)
Surgery
Sedatives and tranquilizers
Avoid stooping, straining at stool,
strenuous activity
199. FLORINEF (fludrocortisones
acetate)
• For Addison’s Disease
• Given AM with meals, causes
PUD
• Causes Cushing-like syndrome
200. Traction
Buck’s Traction
Use to relieve muscle spasm of
leg and back
If used for muscles spasms only,
they can turn to either side.
If used for fracture treatment,
only can turn to unaffected side.
Use 8-20 lbs of weight, if used for
scoliosis will use 40 lbs of weight.
Elevate head of bed for counter
traction or foot bed
Place pillow below leg not under
heel or behind knee.
Russell’s Traction
Sling is used
Check for popliteal pulse
Place pillow below lower leg and
heel off the bed
Don’t turn from waist down
Lift patient, not the leg
Cervical Tongs
Never lift the weights
No pillow under head during
feedings
Balanced Suspension Traction
For femur realignment
Maintain weights hanging
free and not on floor
Maintain continuous pull
Halo Jacket
Maintain pin cleansing
201. Fractured Hip
Assessments
Leg shortened
Adducted
Externally rotated
Care after a total hip replacement
• Abduction pillows
• Crutch walking with 3-point gait
• Don’t sleep on operated side
• Don’t flex hip more than 45-60
degrees
• Don’t elevate head of the bed more
than 45 degrees
202. IV SIDE EFFECTS
Change tubing Q72 hours
Change bottle Q24 hours
Infiltration
• Assessment: cool skin, swelling,
pain, decrease in flow rate
• Implementation: discontinue IV,
warm compresses, elevate arm,
start new site proximal to
infiltrated site
IV Phlebitis, Thrombophlebitis
• Assessment—redness, warm,
tender, swelling, leukocytosis
• Implementation—discontinue IV,
warm moist compresses, start IV in
opposite extremity
Hematoma
• Assessment—ecchymosis,
swelling, leakage of blood
• Implementation—discontinue IV,
apply pressure, ice bag 24 hours,
restart IV in opposite extremity
IV Clotting
• Assessment—decreased flow rate,
back flow of blood into tubing
• Implementation—discontinue, do
not irrigate, do not milk, do not
increase rate of flow or hang
solution higher, do not aspirate
cannula, inject Urokinase, D/C and
start on other site.
203. Lung Sounds
204. Shock
205. NORMAL AGING PROCESS
206. Levin vs. Salem vs.
Sengstaken tube
Nasogastric Tubes:
• Levin-single—single-lumen, used for
decompression or tube feeding
• Salem sump—double-lumen, used for
decompression or tube feeding
• Sengstaken-Blakemore—triple-lumen,
used for bleeding esophageal varices
• Linton-Nachlas—4-lumen, used for
bleeding esophageal varices
• Keofeed/Dobhoff—soft silicone, used
for long-term feedings
• Cantor—single lumen with mercuryfilled
balloon and suction port
• Miller-Abbott—double-lumen with
mercury-filled balloon and suction port
• Harris—single lumen with mercuryfilled
balloon and suction port
NG tube placement:
“BEST WAY” to check is to aspirate for
gastric
contents and check for pH of aspirate
<4
Implementation of feeding:
• Check residual before intermittent
feeding, reinstall residual
• Check residual Q4 hours with
continuous feeding, reinstall residual
• Hold feeding if >50% residual from
previous hour (adults) or >25%
(children)
• Flush tube with water before and after
feeding
• Use pump to control rate of tube
feeding
• Administer fluid at room temperature
• Change bag Q8 hours for continuous
feeding
• Elevate head of bed while feeding is
running
• Check patency Q4 hours
• Good mouth care
NG Irrigation Tubing:
• Verify placement of tube
• Insert 30-50 cc of normal saline into
tube
• If feel resistance, change patient
position, check for kinks
• Withdraw solution or record amount as
input
NG removal:
• Clamp tube
• Remove tape
• Instruct patient to exhale
• Remove tube with smooth, continuous
pull
Intestinal Tubes (Cantor, Mill-Abbott,
Harris)
o After tube is in stomach, have patient
lie on right side, then back in Fowler’s
position, then left side
o Gravity helps to position tube
o Coil excess tube loosely on bed, do
not tape
o Position of tube verified by x-ray
o Measure drainage QShift
• Removal
o Clamp tube
o Remove tape
o Deflate balloon or aspirate contents of
intestinal tube balloon
o Instruct patient to exhale
o Remove 6” every 10 min. until reaches
the stomach, then remove completely
with smooth, continuous pull
T-Tube: 500-1000 cc/day, bloody first 2
hours
Penrose: expect drainage on dressing
207. Immunizations
208. PHEOCHROMOCYTOMA
• Persistent hypertension
• Hyperglycemia
• Pounding headache
• Palpitations
• Visual disturbances
• Histamine Test, Regitine Test, 24-
hour urine VMA test
• Avoid emotional and physical stress
• Encourage rest
• Avoid coffee and stimulating foods
• Postop care after adrenalectomy
209. Chron’s Disease
• Fever, cramp-like colicky pain
after meals
• Abdominal distention
• Diarrhea (semi-solid)
• Anorexia, N & V
210. PIH, APGAR
211. EVISTA
212. SAW PALMETTO
213. CIALIS
214. SANDIMMUNE,
215. CELESTONE
216. PNST, CST, COLONOSCOPY,
ARTERIOGRAPHY,
217. CPR, CARDIOVERSION
Defibrillation
• Start CPR first
• 1st attempt – 200 joules
• 2nd attempt – 200 to 300 joules
• 3rd attempt – 360 joules
• Check monitor between shocks for
rhythm
Cardioversion
• Elective procedure, Informed Consent
• Valium IV
• Synchronizer on
• 25-360 joules
• Check monitor between rhythm
CPR
Shake, shout, summon help, open airway,
look, listen, feel for signs of breathing, pinch
nose, give 2 full breaths (if no rise,
reposition)
Adults 12/min check carotid, chest
compressions
80-100/min 1.5 inches
Infants 20/min check brachial pulse, chest
compression
100/min ½ - 1 inch
15:2 Adult 4 cycles
Infant 20 cycles
Reassess pulse and breathing
Continue CPR until:
• Victim responds
• Someone else takes over
• Victim is transferred
• Rescuer is unable to continue
218. POSITIONING
Therapeutic Positions
Supine—avoids hip flexion
Dorsal recumbent—supine with knees
flexed
Prone—extension of hip
joint(after amputation)
Side lateral—drainage of oral secretions
Knee-chest—visualization of rectal area
Sim’s—decreases abdominal tension (side
lying with legs bent)
Fowler’s—increases venous return,
lung expansion
High Fowler’s—60-90
Fowler’s—45-60
Semi-Fowler’s—30-45
Low Fowler’s—15-30
Modified Trendelenburg—used for shock;
Feet elevated 20 degrees, knees straight,
trunk flat, head slightly elevated
Elevation of extremity—increases blood
to extremity and venous return
Lithotomy—used for vaginal exam
219. Cushing what will you expect?
a. Na of 142 b. ph 7.41 c. K of 3.1
220. ff statements is correct for
malpractice?
a. a nurse giving Celebrex to an RA pt
who has an allergy to aspirin
b. a nurse telling the pt not to take
zafirlukast during an asthma attack ( C/I
DURING ASTHMA ATTACK USE AS
PROPHYLAXIS FOR & TX FOR CHRONIC
BRONCHIAL ASTHMA)
221. Diet for Addison’s?
a. high calcium
222. A pt with pneumonia will go to
radiology for x-ray?
• pt will wear a surgical mask while
traveling in the hallway.
223. a pt with pneumonia safety
precaution?
• wear mask while bathing the pt.
224. sealed radiation what will be the
safety to the nurse?
a. limit exposure for 30mins close
contact to pt during shift
b. giving the radiation bandage/band to
the nurse for the next shift
225. Lipitor what will be the concern?
a. muscle
weakness/pain –
b. adverse effect:
myalgia &
rhabdomyositis
226. Break confidentiality?
• nurses talking in the hallway
227. Gastrochisis?
• put soaked gauze with nss to
abdomen
228. Clostridium deficille? private rm
229. suctioning pt needs further
teaching?
• my wife have shortness of breath
during my suctioning.
230. sickle cell crisis what is your
concern?
• i still have joint pain even though
im taking analgesic daily
231. dysphagia pt how to feed?
• put head of bed to 60degrees
before feeding
232. total knee replacement immdtly post
op what is the correct statement?
• ill put an abduction pillow
233. Tapazole?
• with meals
234. a 28yrs old pt 35wks pregnant is
having internal bleeding was rushed to
ED, what does the nurse do first?
• fhr external monitoring
235. a pt taking captopril what will check
or concern?
im having cough at night
236. Jewish orthodox dead?
• dont leave body alone, should be
with relatives
237. Reglan?
• take 30mins before meals
238. Maoi- C/I?
• chicken bullion and cheese
239. what food to give to a child?
• Crackers
240. food rich in Ca?
• broccoli
241. fracture of arm what position?
• place pillow under arm
242. pt is constipated what health
teaching?
• increase intake of fruits and
veggies
243. Arcabose is given to px health tx?
• helps pancreas to release insulin
244. px with myasthenia gravis what will
you monitor?
• k
245. 3 month old baby. parents plan to
buy/purchase an electronic door that
sings open when there is weight. what is
the health tx?
• delay purchase of electronic
device
246. pt taking nardil has stopped taking
the drug for 5 days and began taking
chocolate and cheeseburger. he
suddenly feels severe headache and
goes to er.
• pt is reacting to the food recently
taking
247. sickle cell crisis advice to give to
teenager?
• lessen physical activity
Sickle Cell Anemia
• Pain /Swelling/Fever
• Sclera jaundiced
• Cardiac murmurs / Tachycardia
• Check for signs of infection (prevent
crisis)
• Check joint areas for pain and
swelling
• Encourage fluids
• Provide analgesics with PCA pump c
crisis
248. how are you going to irrigate
ileostomy?
• with nss
249. px taking iron supplement, what
statement by px shld you be cautioned?
• will crush the tablet before i drink
it
250. Position after liver biopsy?
• sidelying on rt side with pillow
under right side of ribs
251. LYME’S DISEASE
Multi-system infection caused by
a tick bite. There are three stages.
Stage 1
Erythematous papule develops
into lesion with clear center
(Bull’s-eye)
Regional lymphadenopathy
Flu-like symptoms (fever,
headache, conjunctivitis)
Can develop over 1 to several
months
Stage 2
Develop after 1 to 6 months if
disease untreated.
Cardiac conduction defects
Neurologic disorders (Bell’s
palsy, temporary paralysis)
Stage 3
Develops after 1 to several months,
if reached at this stage may
persist for several years.
Arthralgias
Enlarged, inflamed joints
Teaching
Cover exposed areas when
in wooded areas
Check exposed areas for
presence of ticks
Antibiotics 3-4 weeks
Stage 1 use Doxicillin
IV penicillin with later
stages
252. Huntington's dse
253. Osteoporosis
254. NST
255. Early deceleration
256. Vanillylmandelic acid
1. used to diagnose
pheochromocytoma which is a
tumor in the adrenal gland.
24-hour urine collection. Save all the
urine in 24 hours..
257. Which is the wrong statement in
Addison’s disease?
• Administer potassium.
258. Stress management-- Instruct the
patient to imagine that he is in the
beach-- this is correct. this is guided
imagery wherein the patient imagines or
fantasizes to reduce stress. pls.
259. Multiple sclerosis-- low bed position-
-- think safety
260. Herpes zoster/shingles
• will the pt experience acute pain?
YES
261. What is the purpose of swimming in
arthritis?
262. Mycoplasma pneumonia-- what
precaution? DROPLET
263. How many ml is 1/2 banana?
264. Tamoxifen- inhibit estrogen
production
265. Total thyroidectomy d/c teaching?
• Monitor pulse rate and temp
266. 3rd degree burn
267. Digoxin +Quinidine?
268. IDDM advice lifestyle change?
a. Avoid strenuous ex
b. Increase insulin dose if involved to
sports
269. which among the ff psych meds is
incorrect statement?
• White wine is not ok with maoi, red
wine is ok
270. Earliest sign of magnesium sulfate
toxicity
271. Receptive aphasia? Picture board
272. SEROQUEL?
273. Internal disaster drill?
274. external disaster drill
275. what is normal for a 2 days old
baby?
276. enhance effect of Coumadin
277. Schizo pt- lalabas? Wear long
sleeves
278. Do not take garlic if you are
receiving aspirin. It increases the
antiplatelet effect!
279. Rattle snake bite
280. Car safety in children less than 20
lbs.
281. LASIX SIGNS THAT IT IS
WORKING = DECREASE
PERIPHERAL EDEMA,
282. PT WITH GLOMENOLEPHRITIS
URINE RESULT
• BLOOD
283. Dilantin detoxified by liver.
284. The nurse cares for a client
receiving IV antibiotics every 8 hours for
the past 4 days. The antibiotic is
mixed in D5W. The nurse determines
that a post-infusion phlebitis has
occurred if which of the
following is observed? .
• reddened, warm area noted around
insertion site or on path of vein;
discontinue IV, apply warm, moist
compresses, restart IV at new
site
285. How long should a client with
tuberculosis be on medication?
• 6-9 Months
286. What are symptoms of hepatitis?
Inflammation of Liver
Jaundice
Anorexia
RUQ pain
Clay-colored stools, tea-colored urine
Pruritis (bile salts eliminated through
skin)
Elevated ALT, AST
Prolonged PT (liver involvement with
clotting factor)
287. What is the transmission of
Hepatitis A?
Fecal/Oral
Consume contaminated food or water
Travelers to developing countries at
risk
Clients with hepatitis A should not
prepare food for
others
288. What is the transmission of
Hepatitis B?
Parenteral/Sexual contact
Blood or body fluids
At risk individuals are the one’s that
abuse IV drugs,
dialysis, healthcare workers
Vaccine developed
289. What is the transmission of
Hepatitis C?
Blood or body fluids
Can become chronic disease
290. Seen in patients with hemophilia
• (unable to clot)
291. What is the transmission of Delta
Hepatitis?
• Co-infects with hepatitis B
292. Where to put 4 y/o child in a car
• Booster seat
293. Toddler
• Playing side by side w/o sharing pf
toys
294. Lantus understanding
• I will avoid OTC with chromium
295. What nursing care are
recommended for Hepatitis?
Rest (mainly for liver)
Contact and standard precautions
Low-fat, High-Calorie, and High
Protein diet (needed for organ
healing)
No alcoholic beverages
Medications (Vitamin K, Aqua-
Mephyton for bleeding problems, Antiemetic
– no compazine, use Tigan or
(Dramamine).
Corticosteroids to decrease
inflammatory response, and antihistamines,
will use lotions or
baths than systemic ones.
296. Intermiettent claudication
intervention
• Lower the legs
297. Femoral fracture, indicate
complication
• Petechiae
298. Sickle cell crisis
• Increased reticulocyte count
299. Multiple Sclerosis
• Baclofen
300. Post-arthroscopy, notify md
• Painful knee
301. Osteoporosis history taking at risk
• Taking wine or beer
302. Wilm’s Tumor
• Flank pain
303. Fosamax
• 30 minutes before meals
304. Cotrimoxazole
• Yellow sclera
305. Tegretol
• With meals
306. Colchicine
• With meals
307. Valium
• Monitor liver function
308. Antivert
• 1 hour before travel
309. Mannitol, effective?
• Increase awareness
310. Orinase
• 30 minutes before meals
311. Diabeta (Glipizide)
• 30 minutes before meals
312. Metformin HCL
• Take with food to decrease GI upset
313. Gantrisin
• Drink 2-3 L for the whole day
314. Amaryl (Glimiperide)
• With or w/o breakfast
315. Start to assess radial pulse
• 2 y/o
316. Discharge teaching for postcholecystectomy
client.
• Reporting of complication (pale
stool & dark urine)
317. Diagnostic test for Renal Failure
• Monitor BUN, Creatinine, electrolyte
• Monitor for acidosis
318. Complications of TURP
• Sterility may or may not occur
• Bleeding is normal, moniot for
hemorrhage
• Bladder spasms common postopt,
ant-spasmodics are
prescribed
319. Drug therapy for Rheumatoid
Arthritis
• Salicylates
• Gold salts
IV. DRUGS
Ethacrynic Acid (Edecrin)—are considered
loop diuretics and are potassium wasting;
encourage client to increase intake of
potassium-rich foods. Orange
Juice/Bananas, etc.
Aminophylline (Truphylline)—is a
xanthine bronchodilator; major side effects:
palpitations, nervousness, rapid pulse,
dysrhythmias, nausea, and vomiting.
Toxic effects: confusion, headache,
flushing, tachycardia, and seizure.
Morphine Sulfate—decreases blood return
to the right side of the heart, and decrease
peripheral resistance. In other words,
decreases preload and afterload
pressures and cardiac workload; causes
vasodilation and pooling of fluid in
extremities; provides relief from anxiety.
Inotropin (Dopamine)—vasoactive
medication are given IV to restore BP in
hypotensive states; Increases blood return
to the right side of the heart, and increase
peripheral resistance;
S/E: headache, severe hypertension,
dysrhythmias; check BP q2 minutes until
stabilized, then q5 minutes
TPN—hang no longer than 24 hours; IV
tubing and
filters every 24 hours; site of catheter
changed every 4 weeks.
Fluoxetine (Prozac)—a selective serotonin
reuptake inhibitor (SSRI) used to treat
depression and obsessive compulsive
disorder.
S/E: postural hypotension, dry mouth, rapid
heartbeat, anorexia, weight loss, severe
headache. If dose is missed, omit dose &
instruct client to return to regular dosing
schedule.
Propanolol (inderal)—a beta-adrenergic
blocker used as antihypertensive;
S/E: bronchospasm, bradycardia,
depression. Take pulse before
administration & gradually decrease when
discontinuing. Do not give to asthmatic pts
Glipizide (Glucotrol)—an oral
hypoglycemic that decreases blood sugar by
stimulating insulin release from the beta
cells of the pancreas; may cause aplastic
anemia and photosensitivity.
Prednisone (Deltasone)—a corticosteroid.
Side effects: hyperglycemia
Bethanechol (Urecholine)—a cholinergic
or parasympathomimetic used to treat
functional urinary retention; mimics action of
acetylcholine.
Ventricular Tachycardia—causes chest
pain, dizziness, and fainting.
1 grain = 60mg
Levothyroxine (Synthroid)
—thyroid preparation should be
administered at breakfast to prevent
insomnia.
Carbamazepine (Tegretol)
—interferes with action of hormonal
contraceptives. Side effects:
photosensitivity.
Aluminum Hydroxide (Amphojel)
—an antacid; neutralizes hydrochloric acid
and reduces pepsin activity; take one hour
before and hour of sleep. Antacids most
effective after digestion has started, but prior
to the emptying of the stomach.
Isoniazid (INH)—S/E: peripheral
neuropathy (administer pyridoxine), rash,
urticaria & swelling of the face, lips, and
eyelids.
Pyridoxine (Vitamin B6, Beesix,
Doxine)—required for amino acid,
carbohydrate & lipid metabolism. Used in
the transport of amino acids, formation of
neurotransmitters & sythesis of heme.
Prevention of neuropathy.
Carbamazepine (Tegretol)—prevention of
seizures & relief of pain in trigeminal
neuralgia. Trigeminal neuralgia is an
agonizing pain result in severe depression &
suicide.
Clonidine (Catapres-TTS)—is a centrally
acting alpha-adrenergic used to treat HPN
S/E: drowsiness, sedation, orthostatic
hypotension, heart failure. If patch used be
cautious around microwaves results in
burns, heat will increase medication
absorption leading to toxicity.
Phlebitis—tenderness, redness; remove iv,
apply warm soaks to decrease inflammation,
swelling, and discomfort.
Autologous blood—may give blood 5
weeks before surgery; can give 2 to 4 units
of blood; may have to take iron pills
Carbidopa/Levodopa (Sinemet)—used to
treat symptoms of Parkinson’s disease.
Take immediately before meals and highprotein
meals may impair effectiveness of
medication. Reduces rigidity and
bradykinesis & facilitates client’s mobility.
Doxycycline (Vibramycin)—a tetracycline
that is taken at regular intervals but not
within 1 hour of bedtime because it may
cause esophageal irritation. Use another
method of birth control, do not take antacids
within 1-3 hours of taking medication, and
may cause photosensitivity.
Albuterol (Proventil)—a bronchodilator.
Side effects: tremors, headache,
hyperactivity, tachycardia. Use first before
steroid medication so opens up bronchioles
for steroid to get in. Wait one minute
between puffs of the inhalers for best effect.
Beclomethasone (Vanceril)—a steroid
medication. S/E: fungal infections, dry
mouth, throat,infections.
Insulin
—NPH Onset: 1.5 hours Peak: 4-12 hours
Regular Onset: 0.5 hours Peak: 2.5-5 hours
Topiramate (Topamax)—is an
anticonvulsant. Should drink 2000-3000ml of
fluid daily to prevent kidney stones.
Side effects: orthostatic hypotension, ocular
symptoms, blindness, and decrease effects
of hormonal contraceptives.
Propranolol (Inderal)—a beta-blocker that
takes up beta-adrenergic receptor sites,
which prevents adrenaline from causing
symptoms and glycogenolysis.
Inderal may mask symptoms of
Hypoglycemia, removing the body’s early
warning system.
Phenazopyridine (Pyridium)—acts on
urinary tract mucosa to produce analgesic or
local anesthetic effects.
Side effects: bright orange urine,
yellowish discoloration of skin or sclera
indicates drug accumulation due to renal
impairment.
Trimethoprim-sulfamethoxazole
(Bactrim)—most common
side effect mild to moderate rash (urticaria)
Aminoglycosides are ototoxic.
Butorphanol Tartrate (Stadol)—analgesic
used for moderate to severe pain; Side
effects include change in BP, bradycardia,
respiratory depression.
Infant normal resting heart rate:
120-140
Salt substitutes contain potassium
When directing a UAP, the nurse must
communicate clearly about each delegated
task with specific instructions on what must
be reported. Because the RN is responsible
for all care-related decisions, only
implementation tasks should be assigned
because they do not require independent
judgment.
When applying the nursing process,
assessment is the first step in providing
care. The 5 "Ps" of vascular impairment can
be used as a guide (pain, pulse, pallor,
paresthesia, paralysis)
Rash and blood dyscrasias are side effects
of anti-psychotic drugs. A history of severe
depression is a contraindication to the use of
neuroleptics.
The nurse instructs the client taking
dexamethasone (Decadron) to take it with
food or milk because Decadron increases
the production of hydrochloric acid, which
may cause gastrointestinal ulcers.
The protest phase of separation anxiety is a
normal response for a child this age (2 yearold
hospitalized child). In toddlers, ages 1 to
3, separation anxiety is at its peak
Signs of tardive dyskinesia include
smacking lips, grinding of teeth and "fly
catching" tongue movements.
Verapamil, Bretylium, and Amiodarone
increases serum dig levels, possibly causing
Digitalis Toxicity
Signs/Symptoms of Digital Toxicity: f1st
sx include abdominal pain, anorexia,
nausea, vomiting, visual disturbances,
bradycardia, and other arrhythmias. In
infants and small children, the 1st sx of
overdose are usually cardiac arrhythmias.
Left-Side CHF
• Dyspnea, orthopnea
• Cough
• Pulmonary edema
• Weakness/Changes in mental status
Right-Side CHF
• Dependent edema
• Liver enlargement
• Abdominal pain/Nausea/Bloating
• Coolness of extremities
CHF Implementations
• Administer digoxin, diuretics
• Low-sodium, low-calorie, low-residue diet
• Oxygen therapy
• Daily weight
• Teach about medications and diet