1.

I prayed hard and even said a prayer before i started my test and with the good Lord's help I passed. Just remember this - God
did not bring you through Nursing school if he didnt want you to be one. Keep the faith and I in turn will pray for you and
anyone else who is attempting NCLEX. Thank you so much and remember - KEEP THE FAITH AND KNOW YOU CAN
DO IT ! ! ! !

A kid with Hepatitis A can return to school 1 week within the onset of jaundice.
2. After a patient has dialysis they may have a slight fever...this is normal due to the fact that the dialysis solution is warmed by the
machine.
3. Hyperkalemia presents on an EKG as tall peaked T-waves
4. The antidote for Mag Sulfate toxicity is ---Calcium Gluconate
5. Impetigo is a CONTAGEOUS skin disorder and the person needs to wash ALL linens and dishes seperate from the family. They
also need to wash their hands frequently and avoid contact.
positive sweat test. indicative of cystic fibrosis
1. Herbs: Black Cohosh is used to treat menopausal symptoms. When taken with an antihypertensive, it may cause hypotension.
Licorice can increase potassium loss and may cause dig toxicity.
2. With acute appendicitis, expect to see pain first then nausea and vomiting. With gastroenitis, you will see nausea and
vomiting first then pain.
3. If a patient is allergic to latex, they should avoid apricots, cherries, grapes, kiwi, passion fruit, bananas, avocados,
chestnuts, tomatoes and peaches.
4. Do not elevate the stump after an AKA after the first 24 hours, as this may cause flexion contracture.
5. Beta Blockers and ACEI are less effective in African Americans than Caucasians.
1.

for the myelogram postop positions. water based dye (lighter) bed elevated. oil based dye heavier bed flat.
2.autonomic dysreflexia- elevated bed first....then check foley or for impaction
3. any of the mycin's..check for tinnitus or hearing loss
4. cloudy dialysate...always futher assess and call doctor
5.osteoporosis prevention and mgt. choose weight bearing (walking) instead of calcium if both are choices

1.

Dilantin can cause gingival hypoplasia, advise good oral hygiene and freq. dental visits, IVP 25-50 mg/min
2. Placentia Previa is painless, bright red bleed
3. Abruption is painful, board-like abdomen
4. Need MAP of 70-90 to perfuse organs
5. Vitamin C can cause false + occult blood

1.

celiac disease cant have BROW! BARLEY RYE OAT WHEAT

2. any eye surgery place on pt on unaffected side
3. if pt has lung cancer, craniotomy, or some kinda pituitary surgery watch for diabetes insipidus
4. sickle cell- hydration hydration important and treat pain if in crisis
5.dont palpate a wilm's tumor on the peds pt. can cause cancer cells to be released!
oh one more:
6. terbutaline (Brethine) and mag sulfate- tx for preterm labor

Librium-antianxiety used to tx symptoms of acute alcohol withdrawal.

Cogentin-used to tx parkinsonian side effects of Thorazine (antipsychotic med)
Methadone hydrochloride-opiod analgesic; tx for narcotic withdrawal
Procardia-antianginal med (CCB) decreases myocardial O2 demand.
Digoxin-strengthens myocardial contractio0n & slows conduction thru AV node
Coumadin-inhiits prothrombin synthesis
Amicar-antifibrinolytic; prevents recurrence of subarachnoid hemorhage.
Lithium-tx manic phase of bipolar
Nimodipine-CCB; decreases spasm in cerebral blood vessels
diltiazem-CCB; inhibits Ca+ influx in vascular smooth muscle; reduces myocardial O2 demand & decreases force of ventricular
contraction
clotrimazole-antifungal; treats rashes.
NEVER NEVER NEVER administer KCl via IV push.
The level in the water seal chamber (chest tubes) fluctuates with respiration- no fluctuation indicates an obstruction and excessive
bubbling indicates an air leak.
Stay with the client for 15 minutes at the start of a blood transfusion.
Nephrotic Syndrome leads to proteinuria while Glomerulonephritis leads to hematuria.
Goodell's Sign is the softening of the cervix at the start of the 2nd month of pregnancy
Nagele's Rule is First date of last menstrual period + 7 days - 3 months + 1year.
Vinca Alkaloids (Vincristine) lead to neurotoxicity and can present with numbness and tingling in the legs or paralytic ileus.
Avoid herbal supps like ginsing, ginger, ginko, garlic (all the G's) if on any clotting drugs/products (coumadin, platelets, ASA, Plavix)
High triglycerides may cause a false HIGH Hemoglobin A1C (normal is 2.6-6)
Deer ticks transmit Lyme Disease and it is most common in the NE Atlantic states. (Go figure I thought it was down here in the South)
Think of pain last or as a psychosocial UNLESS: Burns, sickle cell crisis, or kidney stones.
Anemia of pregnancy is common in the 2nd trimester due to rapid expanding blood volume and is not a cause for concern. It can get
as low as 10.5 and still be OK. 1st and 3rd trimesters can go as low as 11 and still be ok
Preterm labor--after 20 weeks and before 37
true labor INCREASES with activity and usually moves from the back to the front (according to our instructors but from personal
experiance IT HURT ALL OVER THE DANG PLACE AND INCREASED WITH EVERYTHING ).
Recommended weight gain for pregnancy 1.5-16 kg or 25-35 lbs HAHAHAHAHAHAHAHAH yeah right. I myself classified as
Shamu's little sister by week 39 .
OK one more for 2nite....
normal newborn jaundice-- AFTER 24 hours of life
pathologic jaundice-- BEFORE 24 hours of life

If it come out your ass...its metabolic acidosis...

by vomitting...metabolic alkalosis...
1.

priority unstable pt- words to look for: cyanotic, sudden, increasing pain, hypoxic, restlessness
2. when left with two choices pick the one thing you can do to make pt. comfortable, safe, and more stable
3. no narcotics to any head injury..wont be able to accurately assess LOC. so pick the narcotic if you have an
order to question.

4. fluid resus. burn formula: kg X 4ml/kg X %(burn area)= total

give half of total in first 8 hours
5. after thyroid surgery-maintain airway-keep emergency trach set nearby, check for blood at sides and
back of dressing, teach pt to support neck
6. bucks traction-no pins tongs. skin traction
7. should not hear a bruit over anything except dialysis shunts. if so this is the unstable pt
8. DVT- elevate extremity

, bed rest, warm (not hot) compresses

Rubella- rash on face goes down to neck and arms then trunk and legs
pregnant women should avoid contact with any child who has Rubella or just recieved the vaccine. if she does she has to get vaccine
after she has delivered
mmr #1 @ 12- 15 months mmr #2 4-6 years old

before checking or measuring fundal height have the patient empty her bladder! A full bladder can throw off the measurement by 3cm.
Meniers disease= ringing in the ears and hearing damage cause from HIGH sodium levels. Need diuretics. Avoid caffeine, nicotine,
and ETOH
Meningitis= look for nuchal rigidity, Kernigs sign(can't extend knee when hip is flexed) and Brudinskis sign (flex neck and knee
flexes too) petichial rash. People who have been in close contact may need Rifampin as a prevention. Vaccine for meningitis after 65
years of age and every 5 years
MI=#1 pain relief, helps decrease 02 demand
Acute Asthma = diffuse expiratory wheezes
Cessation of wheeze omnimous
Infective endocarditis = murmur
Fluid overload = auscultate lungs 1st
24 hours after thyroidectomy, watch for s/s of thyroid storm not for decreased levels of thyroid hormones
1.hypoglycemia= T.I.R.E.D
T-tachycardia
I- irritability
R- restless
E- excessive hunger
D- diaphoresis
2.posturing- deceberate(brainstem problem)- hands like an "e", decorticate (cord problem)- hands pulled in toward
the cord
3.tetralogy of fallot- have child squat to increase return to heart. just remember fallot=squat
4. cant sign consent after preop meds are given...call doctor if not signed
5. rubella (german measles)-airbone contact precautions, 3 day rash

6. rubeola (red measles)- droplet contact precautions, koplik spots in mouth

Amphetamine= Depression, disturbed sleep, restlessness, disorientation
Barbituates= nausea & vomiting, seizures, course tremors, tachy
Cocaine= Sever cravings, depression, hypersomnia, fatigue
Heroin= Runny nose, Yawning
1.

, fever, muscle & joint pain, diarrhea (Remember Flu like symptoms)

When using a cane to aid ambulation: Step up on the good extremity then place the can and affected extremity on the step.
Reverse when coming down. (Up with the good, down with the bad)
2. In infants, pyloric stenosis = projectile vomiting
3. Croup: seal-bark cough, dyspnea, inspiratory stridor, irritable. In children considered a medical emergency due to
narrowed airway
4. Skull fracture: Battle's sign (bruising over mastoid bone) and raccoon eyes
5. Pheochromocytoma: catecholamine secreting tumor. Look for persistent hypertension, pounding headache

1.

peritoneal dialysis- if outflow slow check tube for patency, turn pt side to side
2. pts with the same infection can room together or two clean non contagious disorders can room together.
3. pulse parodoxus- pulse is weak on inspiration and strong on expiration...could be a sign of CARDIAC
TAMPONADE
4. fat embolism- high risk pt...fracture of long bone..greatest risk in first 48 hrs.
5. pancreatitis-elevated amylase (cardinal lab value)
6. JP DRAIN- SQUEEZE=SUCK... squeeze the bottle to let air out then repalce cap.
7.lymphocytic leukemia causes a decrease in all blood cells...hmmm i got this wrong on a test once...i didnt
know it causes rbcs to be low also!
8. mannitol for ICP

Oxytocin is always given via an infusion pump and and can never be administered through the primary IV.
One of the first signs of ICP (increased intracranial pressure) in infants is a high pitched cry.
Regarding blood transfusions, a hemolytic reaction is the most dangerous kind of reaction...S & S include
NAUSEA
VOMITING
PAIN IN LOWER BSCK
HEMATURIA Treatment is to STOP blood, get a urine specimen and maintain perfusion and blood volume.
Febrile reaction S&S
FEVER
CHILLS
NAUSEA
HEADACHE
Narcan is given for to reverse respiratory depression...a rate of 8 or less is too low and requires nursing action.

Miller abbott tube is used for decompressing intestine, which relieves the small intestine by removing fluid and gas from small
intestine.
If a client takes lithium the nurse should instruct the client to take in a good amount of sodium, without it causes retention of lithium
and in turn leads to toxicity.
Rinne test- a vibrating tuning fork is held against the mastoid bone till pt can't hear sound...then moved to ear.
1) A subarachnoid (spinal block) for labor may cause a headache, a lumbar epidrual will not since the dura mater is not
penetrated
2) Tracheoesophageal fistula: 3 C's: coughing, choking, & cyanosis
3) Hypothyroidism: Decreased T3 +T4, but increased TSH
Hypertyroidism: Increased T3 + T4, but decreased TSH
4) NO tyramine containing foods if taking and MAO inhibitor ( smoked meat, brewer's yeast, aged cheese, red wine)
5)Regular insulin is the only type that can be given IV
1.

Dilantin can cause gingival hyperplasia, advise good oral hygiene and freq. dental visits, IVP 25-50 mg/min
ESSR method of feeding (cleft palate)
ENLARGE nipple
STIMULATE sucking
SWALLOW
REST

1)Immunizations
Before 1 years old:
Hep B 3x):Only one that is given at birth and one month (3rd dose at 6 months)
IPV(4x), DTaP(5x), Hib(4x), PCV(4x): all given at 2, 4, & 6 months
Hib, PCV: again at 12-15month
DTaP: again at 12-18months
DTaP, IPV: last doses are given 4-6yrs
1yrs old and older:
MMR: (2x) 12-15months, then at 4-6 years* *if dose not given from 4-6 give from 11-12yrs old
Varicella Zoster: (1x) 12-18months
Td: (1x): 11-12yrs old

2)Fundal height: pt supine, measure from symphysis pubis to top of fundus, if patients is 18+ wks pregnant the height in cm will be
same as weeks pregnant give or take 2 cm

3)Isolation**:
STRICT Contact: use universal precautions, gown when contact with pt., single pt. room in most situations
Used with: Any colonizing infections, MSRV, Fifths disease, RSV, infected wounds, skin, or eyes
STRICTER Droplet: include all universal precautions, gown, goggles, masks on you, on pt. if leaving room, single pt. rooms
Used with: Majority of infectious diseases
STRICTEST Airborne: include all universal precautions and negative pressure single patient rooms, gown, goggles, mask on you,
mask on pt. if leaving room which should only be done if absolutely necessary

Used with:
Measles
Varicella
Disseminated Varicella Zoster
Tuberculosis
**Always check facilities policies when following isolation precautions/procedures

4) Self breast exams: do monthly, 7-10 days after menses

5) Pt's taking Monoamine Oxidase inhibitors (for depression usually) should avoid foods containing tyramine which include

Avocados, bananas
Beef/chicken liver
Caffeine
Red wine, Beer
Cheese (except cottage cheese)
Raisins
Sausages, pepperoni
Yogurt, sour cream

1.

dumping syndrome-tx no fluids with meals /no high carbs /lie down after eating. they need a high fat high
protien diet
2. multiple sclerosis- avoid hot showers and baths
3. parial thickness burns=blisters...... full thickness-charred, waxy
4 PKU- no nuts, meats, dry beans, eggs, dairy (basically no protein stuff) give specially prepared formula to
baby because they can digest this protein well
5. introduce rice cereal to infant at 6 mos and strained veggies one at a time
6. pt must keep taking prescribed insulin on sick days, drink plenty of fluids and notify doctor. also insulin is
also given when pt comes from surgery on NPO status because trauma and infection makes sugar go up!

In an infant of a diabetic mom, hypoglycemia 30-90 min after birth...then look for them to also have hypocalcemia after 24 hours
Non Stress Test on a preggo....should be REACTIVE (rise of 15 bpm above baseline for 15 sec) if it's NOT reactive they need a
contraction stress test and the result that you want from it is NEGATIVE
With Diabetic Ketoacidosis don't give K+ until the patient has been hydrated and urine output is adequate.
Post-op Total Hip replacement-- abduction (toes pointing in) or patient laying on non-operative hip. Avoid adduction (letting the foot
turn out)
mother/baby stuff
1. Rh negative mom gets Rhogam if baby Rh positive. Mom also gets Rhogam after aminocentesis, ectopic
preganancy, or miscarriages.
2. fetus L/S Ratio less than 2= immature lungs......2-3=borderline....greater than 3=good lung maturity dude!! may
give dexamethasone to speed up maturity if baby needs to be delivered soon.
3. prolasped cord position knee chest or trend..call for help!! GET THAT BOTTOM OFF THE CORD! SUPPORT

CORD WITH YA HAND

4. decelerations early vs late----always good to be early but dont ever show up late. early mirrors the contraction,
late comes after the contraction
5. LOCHIA SEQUENCE...lochia rubra- red, clotty....lochia serosa...pink, brown....lochia alba..white.........SHOULD
NEVER HAVE A FOUL ODOR!
1.

In prioritizing cardiac patients, check the pt with INDIGESTION first because that could be a sign of MI.
2. ABG's need to be placed on ice and sent to the lab ASAP.
3. If active TB is suspected, a sputum culture for acid-fast bacillus is the only metod to actually confirm active TB (NOT a
mantoux skin test!)
4. Celebrex is contraindicted in pts with a history of cirrhosis.
5. In psych pts, the client most at risk for self-harm is always the pt that has stopped taking their meds.
One more!
6. Change in resp rate in a pt receiving mag sulfate could indicate toxicity.

1.

dont give atropine for glaucoma. it increases intraocular pressure!

2. drug abusers at risk for heart valve disease.
3. after a liver biopsy place pt. on right side to put pressure on site.
4. end stage cirrhosis the ammonia level is elevated. doctor may order lactoluse to decrease levels.
5. dont do a vaginal exam on a pregnant cliet thats bleeding

Ulcerative colitis...3-30 stools per day WITH blood and mucus.

Pain in LLQ: relieved by defecation.
Crohns disease-NO obvious blood or mucus in stool.
Pain: Right lower quadrant pain that is steady or cramping...or pain could be in periumbilical area, tenderness and mass in the RLQ.
Rheumatoid arthritis: Pain and stiffness is on arising, lasting less than an hour...can also occur after long periods of inactivity. Joints
red, hot swollen, boggy, and decreased ROM.
Osteoarthritis: Pain and stiffness occurs during activity. Joints may appear swollen, cool, and bony hard.
Hemodialysis: disequilibrium syndrome- N&V, headache, decreased LOC, rapid changes in PH, bun...
Transfusion reaction: Chills, dyspnea, itching, uticaria, back or arm pain, fever.
Peritoneal dialysis: When more dialysate drains than has been given, more fluid has been lost(output). If less is returned than given, a
fluid gain has occured.
Slow dialysate instillation- increase height of container, reposition client.
Poor dialysate drainage-Lower the drainage, reposition.
If you give terbutaline and a corticosteroid together, a possible drug interaction is pulmonary edema (Smeltzer)

Rapid: (Lispro) Onset: <15min Peak: 1hr Duration : 3hr

Short: (Regular) Onset: 1/2hr-1hr Peak: 2-3 hr Duration: 4-6 hr
Intermediate: (NPH or Lente) Onset: 2hr Peak: 6-12 Duration: 16-24
Long Acting: (Ultralente) Onse:t 4-6 hr Peak: 12-16hr Duration: >24 hrs
Very Long: (Lantus) Onset: 1 hr Peak: NONE Duration: 24 hr continuous
Mydriatic: with a D= Dilate pupils
Miotic:with an O= cOnstrict pupils
aniticholinergic SE:
can't see
can't pee
can't spit
can't sh*t
Hyperkalemia "MACHINE"- causes of incr serup K+
M-medications (ace inhibitors, Nsaids)
A-acidosis (Metabolic and respiratory)
C-cellular destrx-burns, traumatic injury
H-hypoaldosteronism, hemolysis
N-nephrons, renal failure
E- excretion-impaired
Signs and symptoms of incr serum K+= MURDER
M-muscle weakness
U-urine, oliguria, anuria
R-respiratory distress
D-decr cardiac contractility
E-ECG changes
R- reflexes, hyperreflexia, or flaccid
HYPERNATREMIA-you are fried
F-fever (low grade), flushed skin
R-restless (irritable)
I-incr fluid retention and incr BP
E-edema ( peripheral and pitting)
D-decr urinary output, dry mouth
Hypocalcemia-"CATS"
C-convulsions
A-arrythmias
T-tetany
S-spasms and stridor
For those of you who have trouble with mcg/kg/min problems.
try this solution.
Exp: 7mg of dopamine in 500ml in NS ; pt is 110lbs
first convert 110lbsto kg =110lbs/2.2 kg=50kg
then change 7 mg to mcg =7000 mcg
Now plug in the numbers. 7000* 50kg*60mins
-----------------500ml

answer is 16.8 mcg/kg/min

A way we were taught to remember which Beta Blockers are contra-indicated in patients with Resp problems are easy....
Contra-Indicated- so think.... Coreg, Corgard, Inderal

Administering ear medication... pull the ear UP and back for OLD, and down for young (<3 yo)
Fill for a thrill, listen for a bruit.
Assess your patient. not the monitor.... So, If a question asks what you do FIRST.... always, always go with assess the patient.
Carbamazepine therapeutic serum level is 4 - 12 mcg/dL
Cycloserine is an antituburculan and needs weekly drug levels
foscarnet (Foscavir) can be toxic to kidneys so creatinine is monitored.
Android Pelvis is wedge shaped, narrow and unfavorable for birth
Therapeutic serum digoxin is 0.5 - 2 mg/dL
No meperidine (Demerol)to pancreatitis pt. b/c is causes spasms in the Sphincter of Oddi
Hyperkalemia = narrow, peaked T waves on cardiac monitor
Hypokalemia = Peaked P, Flat T, Depressed ST and Prominent U
p24 Antigen Assay confirms HIV in an infant
MORPHINE IS CONTRAINDICATED IN ACUTE PANCREATITIS BECAUSE IS CAUSES THE SPASMS BUT THE
DEMEROL IS THE DRUG OF CHOICE. AT LEAST THATS HOW I LEARNED IT.
if you see Mg/Ca, think MUSCLE first. Mg and Ca act like SEDATIVES.
HYPOCALCEMIA (not enough sedatives)
+ trouseau and + chovstek's sign
incr DTR
stridor, laryngospasm
swallowing problem=aspiration
BURN pt.
Carbon monoxide poisoning is the MOST COMMON airway injury.
Carboxyhemoglobin : blood test to determine carbon monoxide poisoning.
Treat burn pt with fluid replacement therapy;Check hourly to make sure you are not overloading them with CVP= measures the right
atrial pressure.
Rubella is spread by droplets....
The benefit of a venturi mask- oxygen can be regulated to deliver between 24 and 50%.
Shilling test is done to detect pernicious anemia.
Shift to the left in WBC differential reflects bacterial infection
Pneumocystis carinii pneumonia is caused by Protozoal infection.

Open-angle glaucoma is characterized by Halo and blurred vision

Detached retina- floater or sensation of a curtain or veil over the visual field
Good lung down- position a patient with right side pneumonia , with the left side dependent
Atrial fibrillation might require synchronized cardioversion
Ventricular tachycardia require defribillation
Second degree heart block- needs a pace maker
Respiratory syncytial virus- contact precautions
systemic lupus erythematosus- butterfly rash on nose and cheek. avoid sunlight
with DIC...get worried if you see blood oooze from the IV line. notify doctor
Tegratol- tx for seizures..watch for drowsiness, n/v, blurred vision, h/a.
kayexalate- may be ordered for a high potassium level
THERAPEUTIC LEVEL
10-20 mcg/ml
Theophylline
Acetaminophen
Phenytoin
Chloramphenicol
10-21 mmHg - normal intraocular pressure
1.

nebulizers used by HIV patients are cleansed with warm water after each treatment and allow it to air dry. soaked in wht
vinegar and water for 30f min at the end of the day
2.SHARE support group for parents who have experienced misscarriage
3. RESOLVE support grp for infertile clients
4. CANDLELIGHTERS families who have lost child to cancer
5 FETAL ALCOHOL SYNDROME child small head circumferance, low birth wt, underdeveloped cheeks.

DO not radiate children under 8 y.o.

Insulin can be kept on room temp 1 month.
PARATHYROID PROBLEMS
hyperparathyroidism= hypercalcemia=hypophosphatemia
hypoparathyroidism=hypocalcemia=hyperphosphatemia
**calcium and phosphorus are inversely related**
THYROID PROBLEMS
hypothyroid (myxedema):no energy, depress pt. everything is slow
hyperthyroid (grave's): very ENERGETIC, manic pt., everything is high
**watch out for heart problems, rhythm changes**

Dantrium (dantroline) common drug kept in the OR for us with Malignant Hyperthermia.
some oncology
dont give methotrexate in the first trimester of pregnancy.
radioactive iodine- excreted in urine
sealed source implant- body fluids not radioactive- nursing care-limit total time care provider with pt. limit
distance around pt. no pregnant women in room or children. keep forceps and lead container in room.
chemo drugs: in case of extravasation...stop infusion...remove any remaining drug from tubing and aspirate the
infiltrated area...do not remove needle...notify doctor.
Prenatal Visits
q 4 weeks -28-32 weeks
q 2 weeks -32-36 weeks
q1 week -36-40 weeks
care of the NEWBORN
term infant -38-42 weeks
L-45-55 cm =18-22inches
W-2500-4300 kg=5.5-9.5lb
in males prepuce retractable on about 3 y.o. dont do that before->Adhesions
Normal Hyper- Bi-emia after 24 hr, if before pathological. (in premature it appears after 48 hr, if before Report)
Hyperbilirubinemia- DO normal Breast feeding,q2-4hr.
RDS-basically bcoz infant cant expand lungs->cant breath normally, because of luck of surfactant in lungs.
s/s:cyanosis,increased RR, nasal flaring, grunting.
treatment-intratracheal surfactant, and supportive -O2-if on O2 worry about retinal damage.
if Mother-DRUGS: NEWBORN -Irritable->Swaddle&reduce stimulation aside from abcd.
FAS(fetal alcohol syndrome)-craniofascial abnormalities, growth retarded,, palmar creases. IRRITABILITY.RNs goal-nutritional
balance.
When BATHIN Newborn go from CLEAN to DIRTY -eyes, face...diaper area the last.
in Diabetic mother the newborn at risk for hypoglycemia, RDS, hypo Ca emia, congenital anomal.
Diabetic mother during pregnancy-1st trimester insulin DECREASE. 2 and 3rd Trimester INCREASE INSULIN (placental hormones
produce insulin resistance)
BUT after PLACENTAL DELIVERY INSULIN REQUIREMENTS DECREASE.
about Scoring
Apgar measures HR,RR,Muscle tone, Reflexes,Skin color
each 0-2 point. 8-10 OK. 0-3 RESUSCITATE.
GLASGOW COMA SCALE. EYES, VERBAL,MOTOR!
It is similar to measuring dating skills...max 15 points -one can do it
if below 8 you are in Coma.
So, to start dating you gotta open your EYES first, if you albe to do
that spontaneously and use them correctly to SEE whom you dating you earn 4. But if she has to scream on you to make you
open them it is only 3....and 1 you dont care to open even if she tries to hurt you.
if you get good EYE contact (4 points) then move to VERBAL.

talk to her/ him! if you can do that You are really ORIENTED in
situation she/he uncontiously gives you 4 points! if you like her try not to be CONFUSED (3), and of cause do not use
INAPPROPRIATE WORDS (3), she will not like it)), try not to RESPOND WITH INCOMPREHENSIBLE SOUNDS (2), if you do
not like herjust show no VERBAL RESPONSE(1)
Since you've got EYE and VERBAL contact you can MOVE now using your Motor Response Points.
THis is VERY important since Good moves give you 6!
filgrastim (Neupogen) - increase NEUtrophil count
epoietin alfa (Epogen) - increase RBC/erythrocytes
Cholecystectomy due to cholelithiasis and colesysthitis, WATCH for BLEEDING problems, because vit K FAT soulble, is poorly
absorbed in the absence of bile. by the way T-tube used for drainage-Reason for T tube to maintain patency of common bile duct.
Chronic RF the best way to asses fluid status-WEIGHT the PATIENT daily
When NGT present mouth care ICE CHIPS but be aware not give that too much-> it becames water->stomach->NGT suck it with K
and other electrolites present in stomach. LOST K
Heat cramps in hot weather-Sodium (Na) loses
Following Gastrectomy NGT drainage should NOT be BLOODY after 12 hr
Thyroid storm's main sign is FEVER
ALDOSTERONE insufficiency -Hypo-Na-emia, Hyper-K-emia, hypo-Volemia. WHEN Na decrease, K increase
easy way to remember addisons and cushings
addisons= down, down down up down
cushings= up up up down up
addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia
everything else wouldnt be hard to remmenber> moon face, hirsutism, buffalo hump, obesity
1.

prozac, zoloft, paxil- tx of depression.

2. sodium nitroprusside- sheild from light. wrap in foil
3. cephalosporins- CHECK FOR ALLERGIES TO PENICILLINS. pt could be hypersensitive.
4. pts recieving Lasix should be assessed for tinnitus and hearing loss
5. anticoagulants cant dissolve a formed thrombus but tPAs can.

1.

Shock: BP <90/60 Pulse > 100

2. Fluid of choice in pt in shock are isotonic: NS, LR
3. PVCs: Always treat: >6 UNIFOCAL and/or >3 MULTIFOCAL with LIDOCDAINE 75mg 4:1 drip
4. SIADH
Na <120
Hx of lung cancer
Specific gravity > 1.035

Diabetes Insipidus
Na> 160
head injury
Specific gravity <1.005
5. Pt with radium implants you can only stand at the head of their bed. When performing bath remember: 'pits and crotch'
ONLY
1.

Verapamil (calan) - treatment of supraventricular tachycardias, check heart rate

2. clomid - inducesovulation by changing hormonal effect on the ovary
3. phobias include projection and displacement
4. blood glucose monitoring of glucose preferred over urine because the level of glucose starts to appear in the urine
increases, leading to false negative readings
5. corneal abrasion - unable to close the eye voluntarily, cranial nerve VII affected, secretions unable to protect the eye,
complication of CVA, prevented with RN care
other randoms
- when the lungs re-expanded, the fluid in the water seal does not fluctuate with respirations
- pacemaker- increases cardiac output, acts to regulate cardiac rhythm

NEVER examine a bleeding gravida vaginally

contractions > 90 seconds, FHR < after contraction peak. . .turn off the pitocin [oxytocin] (if running) give O2 by tight face mask,
reposition on left side, increase IV fluid rate, notify caregiver, document
use reliable form of birth control for at least 4 weeks (8 is better) after rubella immunization [of course this applies to women only]
abdominal pain, tender uterus, dark red or no bleeding = abruption
painless, bright red bleeding usually first episode in 2nd trimester = placenta previa
DO NOT give a pregnant laboring patient on methadone STADOL (precipitates withdrawal)
KVO rate is 20ml/hr
MAOIs: Nardil, Marplan, Parnate
Of course, no tyramine because of hypertensive crisis, which is treated with Procardia.
Aminoglycosides (gentamycin, etc.) affect 8th cranial nerve function (hearing) and are nephrotoxic.
Hyperparathyroid states can cause renal stones which can present with hematuria.
Bell's Palsy- facial paralysis, prevent corneal abrasions.
I teach APGARs this way
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)
DO NOT delegate what you can EAT!
E - evaluate
A - assess
T - teach

only the RN should do this...hope that helps

macular degeneration: mac is in the middle (central vision loss)
digoxin toxicity: halos, nausea, vomiting
Fractured hip: shorter extremity and external rotation
hip replacement: teach pt not to cross legs; keep leg abducted to avoid dislocation of hip
Schillings test: measures % of B12 excreted in 24hr used to diagnose pernicious anemia
1.

cardiac meds: -pine=calcium channel blockers

-olol=beta blockers
-pril=ACE inhibitors
-artan=angiotensin II receptor blockers
2. No pee no K+
3. Before treating BPH, must restore urinary flow
4. Sign of toxic ammonia leve's is asterixis (hands flapping)
5. Diuretics: Lasix and Bumex are K+ wasting Aldacton is K+ sparing

1 - Dopamine and Lasix are incompatible

2 - Hypoglycemic jitters can be stopped by holding the limb, seizure clonus can't
3 - Normal urine output in an infant is at least 1cc/kg/hr
4 - Septic babies will often DROP their temp
5 - SE of PGE1, used to keep the ductus arteriosus open, are hypotension, fever, and apnea. The therapeutic effect is not necessarily
dose-dependent, but the severity of SE is.
The adverse effects of Anti psychotics can be remembered using this: SHANCE
S-SUNLIGHT SENSITIVITY( Use hats and sunscreen)
H-HEPATOTOXICITY( Monitor LFT)
A-AGRANULOCYTOSIS( Characterised by fever and sore throat)
N-NEUROLEPTIC MALIGNANT SYNDROME( Characterised by fever and muscular rigidity)
C-CIRCULATORY PROBLEMS( Leukopenia and orthostatic hypotension)
E-EXTRA PYRAMIDAL SYMPTOMS( Administer anticholinergics and anti parkinsonian agents)
Now for some skin assessment!
ABCDEs of malignant melanoma:
A = Asymmetry;
B = Border;
C = Color;
D = Diameter;
E = Elevation
Antidote for Coumadin- Aquamephyton
Side effect of Aminophylline-head and irregular pulse
Treatment for Angina-sublingual nitro (given q5min X3)and rest
Anterior fontanel closes at-12-18mon
Posterior fontanel closes at-birth to 3mon
Classic sign of Diabetes-3 "p"s (polyuria, polydysia, polyphasia)

CVA pt with hemianopsia-approach from unaffected side

Discharge teaching after cataract surgery-avoid sneezing, coughing,
straining or bending
Lyme disease-wear long sleeves clothing
Post laminectomy -flat position
Diet for cirrhosis-low protein, high calorie
Fundus displaced to right side-ask pt to void
fundus is boggy-message fundus
Self breast exam-done 5-7 days after menses
SandS of Pyloric Stenosis-projectile vomit, metabolic alkalosis,olive size bulge unger the ribcage
Position for Meneries-affected side
Raynards disease-wear gloves, keep hands warm

Trigeminal neuralgia (tic douloureax) - eat warm, soft foods

Preparing to breast feed - wash braest with water and rub with a towel everyday
Ventricular gallop is the earliest sign of heart failure
Levin tube - feedings at room temperature, do not clamp between feedings
position for liver biopsy - supine with arms raised above head
rheumatoid arthritis - heat, ROM, weight reduction
Bells Palsy: avoid cold temperatures: make sure pt. closes windows when they are sleeping. Some even take eyes shut.
Nurses' priority intervention after a patient receives a skin graft is to prevent movement of the graft.
Greatest risk for postpartum hemorrhage is from distended bladder.
Herpes zoster (shingles) is from reactivation of the varicella virus.
1 grain = 60mg (I always forget this one)
Risk factors for legionnaires disease: advanced age, immunosuppression, end stage renal disease, and diabetes
Hepatitis
5 types
A,B, C, D, and E
Hep A-spread by drinking unsanitary water and uncooked foods
Hep B-spread by contact with blood or bodily fluids and is an STD
Hep C-spread by contact the same way as Hep B, can lead to cirrhosis (mostly seen with alcoholism)
Hep D-only contracted if you already have Hep B
Hep E-usually spread by contact with contaminated water
In nursing school, my instructor taught us to remember the different types like this:
VOWEL = BOWEL
Hep A and E---if your infected you will have problems with bowels...
Some Therapeutic Drug Levels
Digoxin 05-2.0 ng/ml
Lithium 0.6-1.5 mEq/L
Dilantin 10-20 mcg/dl
Theophylline 10-20 mcg/dl

Lithium 0.5-1.5 mEq/L

Coumadin PT: 12-20 sec....therapeutic range 1.5-2 times the control
INR: 2-3
Heparin PTT: 30-60 sec...therapeutic range 1.5-2 times the control

CREATININE AND CREATININE CLEARANCE

With renal impairment, serum creatinine goes up,urinary clearance goes down.
Serum Creatinine-men 0.8-1.8mg/dl
women-0.5-1.5mg/dl
Urinary creatinine clearance-85-135ml/min--requires a 24 hour urine specimine. Decreases with renal malfunction.
With a unilateral kidney disease, if one of the kidneys is healthy, a decrease in the creatinine clearance is not to be expected.
ATROPINE OVERDOSE
Hot as a Hare(temperature)
Mad as a hatter(confusion, delirium)
Red as a Beet(flushed face)
Dry as a bone(decreased secretions, thirsty)
CYSTIC FIBROSIS
Diet: Low in fat and high in sodium
Meds: Antibiotics, liposoluable vitamins(A D E K) Aerosol Bronchodialators, mucolytics, pancreatic enzymes.
5 A's to alzheimers
Anomia-unable to remember things
Apraxia-failure to identify objects
Agonsia-can't recognize sounds, tastes and other sensations, familiar objects.
Amnesia-memory loss
Aphasia-can't express SELF through speech.
GLOMEULONEPHRITIS-it's an antigen antibody complex from a recent strep infection which causes inflammation/ decreased
glomerular filtration rate.
BETA BLOCKERS
B1-affects the heart
B2-affects lungs
EMERGENCY DRUGS TO LEAN ON
Lidocain
Epinephrine
Atropine
Narcan
AUTONOMIC DYSREFLEXIA-triggered by sustained stimuli at T6 or below. Vasodialation above injury,(flushed face, increased bp
etc) vasoconstriction below injury(pale, cool, no sweating.)
AIRBORNE
My - Measles
Chicken - Chicken Pox
Hez - Herpez Zoster
TB
Private Room - negative pressure with 6-12 air exchanges/hr
Mask, N95 for TB

DROPLET
think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diptheria (pharyngeal)
E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus
Private Room or cohort
Mask
CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile
E - eye infxn - conjunctivitis
SKIN INFECTIONS
VCHIPS
V - varicella zoster
C - cutaneous diphtheria
H - herpez simplex
I - impetigo
P - pediculosis
S - scabies
Private room or cohort
Gloves
Gown
Airborne
*keep door closed*
In addition to DROPLET PRECAUTION:
*Maintain spatial separation of 3 feet between infected patient and visitors. Door may remain open.

1. Widening pulse pressure is a sign of increased ICP

2.Pt taking Digoxin should eat a diet high in potassium (hypokalemia-> dig toxicity)
3.Key sign of PUD... hematemesis which can be bright red or dark red with the consistency of coffee grounds
4.Common symptom of Aluminium hydroxyde: constipation
5.In a child anemia is a the first sign of lead poisoning
6.Diuretic used for intracranial bleeding, hydrocephalus (Increased ICP,...) MANNITOL (osmotic diuretic)
7.Treatment of celiac disease: gluten free diet
8.cystis fibrosis==> excessive mucus production, respiratory infection complications,...
9.Cholelithiasis causes enlarged edematous gallbladder with multiple stones and an elevated bilirubin level.
10.Fat embolism is mostly seen in LONG BONES (femur,...)
1.
2.

Abruptio placentae may be a complication of severe preeclampsia

Syrup if ipecac is not administered when the ingested substance is corrosive in nature

3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.

Pt before liver biopsy is NPO 4-6 hours

Assess renal fct before giving an osmotic diuretic (mannitol)
Patient in addisonian crisis ecreased BP, Na, Blood glucose, Increased K
Amniocentesis is done as early as 14 weeks of gestation
Chorionic villi sampling is done as early as 10 weeks of gestation
Increased level of alpha fetoprotein in pregnant woman => neural tube defects
Insulin is safely given throughout pregnancy; oral hypoglycemic agents are contraindicated
Phenobarbital (Luminal) is commonly used to treat and prevent recurrent seizures in infants and young children
Aspirin is associated with Reye's syndrome in children with fever or viral infection
Glycerin suppositories are preferred agents to treat constipation in children
Corticosteroids may produce an altered effect of a vaccine
Thiazide diuretics (HCTZ,...) may induce hyperglycemia
Anticonvulsants INCREASE the seizures THRESHOLD!!!!
Hyperbilirubinemia in newborn: bilirubin levels are greater than 13-15 mg/dl

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Postpartum period: circulating hcG disappears within 8-24 hours

S/S opioid withdrawl: rhinorrhea, dilated pupils, abdominal cramps
S/S sedative withdrawl: Increased motor activity, tachycardia
S/S alcohol withdrawl: tremors, N/V, diaphoresis
S/S stimulant withdrawl: CNS depression, fatigue, depression, confusion,...
Hb values: neonates have Hb higher than those of older children to sustain them until active erythropoiesis begins
Toclytic therapy: to arrest preterm labor
Child with chickenpox can be treated with oatmeal preparation baths and calamine lotion at home to relieve the itching...
child with rheumatoid arthritis should sleep in bag to keep joints warm and promote flexibility!!!! Wow...
When an eye patch is used to correct strabismus, the normal eye is patched. That forces the child to use the "lazy" eye,
thereby increasing that eye's muscle strengths
11. If a chest tube accidently get disconnected, clamp it or place the open end of the tube in a container of sterile water or saline
solution
12. Women should avoid pregnancy for at least 3 months after a rubella vaccine
13. Most accurate method to detect TB: sputum culture!!!
A child with KAWASAKI disease might be given a high dose of aspirin to reduce the risk of heart problems.
some respiratory
1. RSV- child in private room...CONTACT PRECAUTIONS..not droplet or airbone. (sometimes i get this mixed
up because its called respiratory synctical virus..i used to pick droplet precautions but i have down now lol!
2. Elderly adults generally present with confusion rather than S/S of an illness.
3. pneumonia- droplet precautions
4. COPD pts should get low flow Oxygen b/c of the hypoxic drive. (1-3L/min) teach pursed lip breathing.
5. ARDS- this pt doesnt respond to even 100% FiO2
6. TB- hemotysis (advanced stage) v/s pulmonary edema- frothy blood tinged sputum
7. Allen's test- done b/f an ABG by applying pressure to the radial artery to determine if adequate blood
flow is present.
8. INH (Isoniazid)- tx of TB. give vit B6 to prevent peripheral neuritis
9. SIMV mode on vents commonly used for weaning pt off ventilator.
10. vent alarms: high alarm (increased secretions then suction......, biting tube-need an oral airway,...... or
coughing and anxiety- need a sedative)
low alarm- there is a leak or break in system...check all connectors and cuff.

11. if a trach becomes accidently dislodged try to replace it with an obturator..if no luck keep the hole open
with hemostats until physician arrives.
No Pee, no K (do not give potassium without adequate urine output)
Most common cause of SIADH is cancer, esp. lung cancer
IV KCL should infuse no faster than 20 mEq/hr
Valsalva maneuver is used for symptoms of SVT
Ototoxic drugs: loop diuretics (Lasix), NSAIDs, and cisplatin (Platinol-AQ)
And thank you whomever posted about Demerol being the DOC for pancreatitis! That has already come in handy on my practice tests!
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Profile of gallbladder disease: 5Fs: fair, fat, forty, five pregnancies, flatulent(disease can occur in all ages and both sexes)
Hip fractures commonly hemorrhage, whereas femur fractures are at risk for fat emboli
Religious beliefs: Hindu- No beef or items containing gelatin
Renal diet- High calorie, high carbohydrate, low protein, low K, low Na, and fluid restricted to intake = output +500 ml
Treatment for sickle cell crises- HHOP: Heat, hydration, oxygen, pain meds
RN and MD institute seclusion protection
MD or hospice RN can pronounce the client dead
For hospital triage, care for the client with a life-threatening illness or injury first
For disaster triage, choose to triage first those clients who can be saved with the least use of resources!
It is contraindicated to induce vomiting if the patient has ingested gasoline, acid and alkaline!!!

MAOIs
Non-Popular Meds
Nardil
Parnate
Marplan

1.

teach a pt with GERD after meals to remain upright for at least 20 min.
2.levodopa toxicity- notify physician if twitching develops.
3. Curling's ulcers or stress ulcers can cause sudden massive hemmorage.
4. 5 mm induration positive reaction (mantoux test) for HIV or immunosuppressd pts
5. Schilling test done to see how well a pt can absorb vit b12. checking to see if they have pernicious anemia.
6. Prednisone, Prograf, and Cellcept helps to prevent kidney rejection.

1.

Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) -->
turn pt to left side and lower the head of the bed.
2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) --> turn on left side
(and give O2, stop Pitocin, increase IV fluids)
3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the stomach) with the HOB
elevated (to prevent aspiration)
4. During Epidural Puncture --> side-lying
5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent headache and leaking of

CSF)
6. Pt w/ Heat Stroke --> lie flat w/ legs elevated
7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be kept straight. No other
positioning restrictions.
8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of secretions)
9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks.
10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders.
11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture
12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction
13. After Total Hip Replacement --> don't 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 with pillows.
14. Prolapsed Cord --> knee-chest position or Trendelenburg
15. Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright
position.
16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in reclining position, lie down after
meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals)
17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide for hip extension.
18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.
19. Detached Retina --> area of detachment should be in the dependent position
20. Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed
21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees
22. After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on either side.
23. During Internal Radiation --> on bedrest while implant in place
24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh,
bradycardia, hypertension) --> place client in sitting position (elevate HOB) first before any other implementation.
25. Shock --> bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg)
26. Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure

some GI/hepatic
hepatitis--all forms standard precautions
s/s of bowel perforation--sudden diffuse abdominal pain, no bowel sounds, resp. rapid and shallow, rigid abdomen.
nursing care for undiagnosed abdominal pain--npo, no heat on stomach, no enemas, no narcotics, no laxatives.
crohns-small intestine vs ulcerative colitis-large intestine..sulfasalzine used to treat both.
pyloric stenosis- olive shaped mass felt in R. epigastric area, projectile vomiting

if a pt requires TPN and it is temp. unavailable then give D10W OR 20% DW until available.
before a Dx test of after 3 enemas, returns are not clear, notify physician
if diarrhea occurs with a colostomy. check meds (some cause diarrhea)..dont irrigate
as a general rule antacids should be taken 1-2 hours after other oral meds.
Symptothermal method of birth control - combines cervical mucus evaluation and basal body temperature evaluation, nonprescription/drug
percipitus/rapid labor - risk factor for early postpartum hemmorhage and amniotic fluid embolism
In elderly, change in mental status and confusion are often the presenting symptoms of infection
antiseizure meds - notify anesthesia prior to surgery, may need to decrease the amount of anesthetic given
neuroleptic malignant syndrome - increased temp, severe rigidity, oculogyric crises, HTN, complication of antipsychotic meds, notify
MD
Dilantin - pregnancy risk category D, should investigate possibility of pregnancy (LMP) prior to administering
Transcutaneous electrical nerve stimulation (TENS) - used for localized pain (back pain, sciatica) - use gel, place electrodes over,
above or below painful area, adjust voltage until pain relief/prickly "pins and needles"
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

S/S delusional thought patterns => suspiciousness and resistance to therapy

Use of neologism (new word self invented by a person and not readily understood by another) =>associated with thought
disorders
Age and weight are VERY important to know after a child has ingested a toxic substance
Child with celiac disease can eat corn, rice, soybeans and patatoes (gluten free)
Anaphylactic rx => administer epinephrine first, then maintain an open airway. (Not the other way around )
Client with asthma => monitor peak of airflow volumes daily. Pulse ox after!!!!
DKA pt => a HCT of 60 (way high...) (extreme dehydration) would be more critical than a pH less than 3! (Fluids first...)
Assess for abdominal distention after placement of a VP shunt! (You know why right? )
GFR is decreased in the initial response to severe burns, with fluid shift occuring. Kidney fct must be monitored closely or
renal failure may follow in a few days
Vomiting => metabolic alkalosis (loss of stomach acid content)
Diarrhea => metabolic acidosis (loss of bicarbonate)
COPD => respiratory acidosis (CO2 retention)
Anxious client => hyperventilation can cause respiratory alkalosis. A paper bag will help. (Increase CO2) Right?
Client with low H&H after splenectomy => the initial priority is REST due to the inability of RBCs to carry O2
Mild to moderate diarrhea in a child => maintain a NORMAL diet with fluids to rehydrate the poor child

Don't forget Vancomycin can cause "Red man Syndrome" = decreased BP and flushing of face and neck --> give antihistamine.
Also watch for liver damage with this one.
Peripheral vascular disease - patient should sit with feet flat on floor to prevent hypereflexion of the knee
Myelominigocele - baby should like on abdomen with head to the side
Tegretol - interferes with actino of hormonal contraceptives, should use alternate type of birth control
Clozapine (Clozaril) - antipsychotic, treats schizophrenia, potential to suppress bone marrow and cause agranulocytosis (look for sore
throat and fever)
Bucks traction - remove foam boots 3x/day to inspect skin, turn client to unaffected side, dorsiflex foot on affected side, elevate foot
of bed

phlebitis - tenderness and redness at IV insertion site and redness proximally along the vein. Remove the IV adn apply warm soaks
Cred e maneuver - apply mannual pressuer to bladder, aids in emptying the bladder completely, results in reduced risk for infeciton; if
performed every day can result in bladder control for some SCI
Frequent use of nasal sprays to releive allergic symptoms can result in vasconstriction that causes atrophy of nasal membranes
(frequent nosebleeds)
Lung cancer is a common cause of SIADH (abnormal secretion of ADH, increase water absorption and dilutional hyponatremia)
ginko - antiplatelet, CNS stimulant, given for dementia, increase risk of bleeding with NSAIDS
Native Americans are present oriented and do not live by the clock (will be late for appointments)
Pulmonic area - 2ICS, left of sternum
Chronic alcohol use is the most common cause of hypoMg, which ma result in cardiac arrest (increase neuromuscular irritability,
tremors, tetant, seizures)
SCD - two fingers between sleeve and leg, opening at the knee and popliteal pulse point, antiembolism stockings (always wear them)
can be applied under sleeve to decrease itching, sweating and heat buildup
Peritoneal Dialysis when Outflow is Inadequate --> turn pt from side to side BEFORE checking for kinks in tubing (according to
Kaplan)
Timeouts for children - 1minute for each year of age
Temporal lobe - hearing
Frontal - personality changes
Occipital - visual
brain stem - bladder/bowel
Bulemia - susceptible to tracheosophageal fistula from esophageal tear, laryngitis is a danger sign (hoarse voice that is barely audible)
mycins - if fever, notify MD
screening for HTN - two raedings, 5minutes apart
encourage geriatric patients to talk about life adn important thigns in his/her past, especially with recent memory loss
NO morphine for pancreatitis and cholecystitis.... google for the reason
1 unit of packed RBCs = 220mL
if allergic to sulfonamides dont take acetazolamide (Diamox)
VENTRICULAR FIBRILLATION: TREATMENT
"Shock, Shock, Shock, Everybody Shock, Little Shock, Big Shock, Momma Shock, Poppa Shock":
Shock= Defibrillate
Everybody= Epinephine
Little= Lidocaine
Big= Bretylium

Momma= MgSO4
Poppa= Pocainamide
methotrexate- dont take supplemental folic acid and please dont take while pregnant..can cause premature labor
and bleeding.
oh dont take cytoxan while pregnant or dont handle the drug while pregnant.
infections that occur with AIDS clients are called opportunistic infections.
Pneumocystis carinii pneumonia is not contagious unless you are immunocomprimised. this infections occurs mostly
with AIDS pts.
infant with HIV should NOT recieve chickenpox or oral polio vaccine. can give inactivated polio vaccine though.
Priority...
if patient having allergic reaction or going into anaphilactic BUT still consious... what you do 1st action:
1. call immideately MD
2. Ensure Airway
3. Give O2 by mask
4. Epinephrine as prescribed
****
by the way who took NCSBN questions online. What score may say that you likely to pass NCLEXRN
______
answer 4
After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent headache and leaking of CSF)
not very correct. The head is usually ELEVATED if an OIL-based or water -soluble contrast agent is used.
lumbar puncture - flat
OIL based - flat
WATER soluble contrast - elevate 15-30 degrees

palpating the carotid pulses together can cause a vagal response and slow the clients heart rate
adrenal insufficiency - steroids increased prior to surgery
thyroidectomy - acess for numbness from decreased Ca
Bactrim - mild to moderate rash the most common SE
If when removing a PICC a portion of the catheter breaks - apply tournaquet to the upper arm, feel radial pulse
emptying a drainage evacuator - wash hands, don gloves, elevate bed, pour drainage itno measuring cup, compress the evacuator and
replace the plug
Percodan - oxycodone and aspirin
Percocet - oxycodone and acetaminophen

low back pain, h/a and restless...cardinal of hemolytic transfusion reaction..stop transfusion..change tubing...infuse
NS.
initate a blood transfusion w/i 30 min of recieving blood.
fresh frozen plasma administerd to DIC because of the clotting factors in it
cryoprecipitate given in hemophilia...also with hemophilia they tend to bleed into the joints so they may have joint
problems.
Myasthenia Gravis: worsens with exercise and improves with rest.
Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse
Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle
Prior to a liver biospy its important to be aware of the lab result for prothrombin time (PT)
Pregnancy Induced Hypertension: The nurse would be MOST concerned if the patient complained of epigastric pain and a HA.
COPD: Administer low flow Oxygen! We never administer: 5L NC
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Watery vaginal discharge and painless bleeding => endometrial cancer

Frothy vaginal discharge => trichomonas infection
Thick, white vaginal discharge => candida albicans
purulent vaginal discharge => PID
Approximately 99% of males with cystic fibrosis are sterile due to obstruction of the vas deferens
Lyme's disease is transmitted by ticks found on deer and mice in wooded areas
Children 18-24 months normally have sufficient sphincter control necessary for toilet training
Complications of TPN therapy are osmotic diuresis and hypovolemia!!!
L/S ratio => fetal lung maturity
Kava-kava can increase the effects of anesthesia and post-op analgesia
NEVER give chloride potassium by IV push
GINKGO interacts with many meds to increase the risk of bleeding; therefore, bruising or bleeding should be reported to MD
Vanco therapeutic range 10-20 mcg/mL
Client with disseminated herpes zoster (shingles) => AIRBORNE precautions
The client taking methotrexate should avoid multivitamins b/c multivitamins contain folic acid. Methotrexate is a folic acid
antagonist!!!

1.
2.

Pt with increased ICP => Lumbar puncture is contraindicated b/c risk of brain herniation
If pt states "I have a constant throbbing headache! This is the worst headache I ever had" => may be having ICB
(Intracranial bleeding); assess pt for increased ICP, and of course notify MD
Cardinal sign of increased ICP => change in LOC (level of consciousness)
Diabetes insipidous => dilute urine, concentrated plasma
SIADH => concentrated urine , dilute plasma

3.
4.
5.

Hypovolemia and osmotic diuresis that are complications of TPN result from hyperglycmia!
Let's recapitulate TPN => Hyperglycemia => osmotic diuresis & hypovolemia...
Drooling - 4 months
Responds to own name 6-8months
deliberate steps when standing 9-10months
picks up bite size peices of cereal 11months

24months: kick ball w/o falling, build tower of 6blocks, 2-3 word phrases, 300 word vocab
30months: jump with both feet, run, say first and last name
36months: tricycle
Left CVA - speech, math skills, analytical thinking
Right CVA - behavior, disorientation to person, place and time
Ectopic pregnancy - LLQ pain, vaginal spotting
tricuspid valve: 5ICS left sternal border
Here are some that help me and hope they help you guys too.
1. Always identify the topic and assess before anything else!!!
2. Dont ask open ended questions and never ask a patient why!
3. With removal of the thyroid, elevated vital signs signify thyroid storm, give Inderal, PTU, and oxygen!
4. With renal calculi, sickle cell, and pancreatitis: Pain is priority...or IV hydration in sickle cell laboring patients.
5. With otitis media, a complication can be meningitis.
6. To determine HR, count the small boxes between R waves and divide by 1500.
7. For dumping syndrome: lay patient flat for an hour after meals and dont give fluids after meals.
8. Never remove traction weights!
9. For hypothermia, monitor for VFIB
10. PICC LINE complications: air embolism s/s: pale, SOB, tachy. Place pt. in trendelenberg and to their Left!

compartment syndrome...significant increase in pain not responsive to pain meds.

Plaquenil-tx of Rhem Arthritis...recommend eye exam every 3 mo.
Statins- tx of high cholesterol...ASSESS FOR MUSCLE PAIN...moniter liver enzymes.
Nicotinic Acid (Niacin)-tx of high cholesterol- flushing occurs in most pt. will diminish over several weeks.
stages of shock (its more but i made it simple "KISS" keep it simple stupid lol!)
early- increase in pulse...normal urine output
intermediate-RAS (renin-angioten system), low urine output, cool skin, pallor
late-no urine output, low BP irreversible stage!
Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin and hair
Graves disease/hyperthyroidism: accelerated physical and mental function; sensitivity to heat, fine/soft hair
Thyroid storm: increased temp, pulse and HTN
Post-thyroidectomy: semi-Fowlers, prevent ncek flexion/hyperextension, trach at bedside
Hypo-parathyroid: CATS convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium), high Ca, low
phosphorus diet
Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium), low Ca, high
phosphorus diet
Hypovolemia incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity >1.030
Hypervolemia bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine specific gravity <1.010;

Semi-Fowlers
Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration, weakness, administer Pitressin
SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, HA; administer
Declomycin, diuretics
Hypokalemia: muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes,
carrots, celery)
Hyperkalemia: MURDER muscle weakness, urine (oliguria/anuria), respiratory depression, decreased cardiac
contractility, ECG changes, reflexes
Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids
Hypernatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution
Hypocalcemia: CATS convulsions, arrhythmias, tetany, spasms and stridor
Hypercalcemia: muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative
effect on CNS
HypoMg: tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity
HyperMg: depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deep tendon reflexes, shallow
respirations, emergency
Addisons: hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight
loss, GI distress
Cushings: hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism,
moonface/buffalo hump
Addisonian crisis: n/v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP
Pheochromocytoma: hypersecretion of epi/norepi, persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor,
pounding HA; avoid stress, frequent bating and rest breaks, avoid cold and stimulating foods, surgery to remove tumor
--In complete heart block, the AV node blocks all impulses from the SA node, so the atria and ventricles
beat independently, b/c Lidocaine suppresses ventricular irritability, it may diminish the existing
ventricular response, cardiac depressant are contraindicated in the presence of complete heart block.
--administrate Glucagon when pt is hypoglycemia and unresponsive
--Bromocriptine (Parlodel) or Dantrolene (Dantrium) is used for CNS toxicity
--Ibuprofen (Motrin) S/E includes epigastric distress, nausea, occult blood loss, peptic ulceration, use
cautiously with history of previous gastrointestinal disorders.
--Aminophylline (Truphylline) use with Propranolol (Inderal) may decrease metabolism and lead to toxicity
--Antianxiety medication is pharmacologically similar to alcohol, is used effectively as a substitute for
alcohol in decreasing doses to comfortably and safely withdraw a client from alcohol dependence
-- Tagamet decrease gastric secretion by inhibiting the actions of histamine at the H2-receptor site,
constipation is a common side effect of this med, should increase fiber in diet. Take with meals and at
bedtime.
--elderly clients and clients with renal problems are most susceptible to CNS side effects (confusion,
dizziness) of the medication
Ultrasound screening -can be vaginal or Abdominal (in latter make Her drink water to fill bladder)
-Confirms viability
-Indicates fetal presentation
-Confirms multiple gestation
-Identifies placental location
-Measurements can be taken to confirm/estimate gestational age
-Identify morphologic anomalies
Chorionic villis sampling
8-12 weeks
for early diagnosis of genetic, metabolic problems
Amniocentesis -13-14 weeks
Is done under US scan to obtain a sample of amniotic fluid for direct analysis of fetal chromosomes, development, viability

and lung maturity

AFP
15-18 weeks-Maternal Blood Drawn
AFP also called =Quad marker screening:
-maternal serum alpha fetoprotein (MSAFP),
-human chorionic gonadotropin (HcG),
-unconjugated estriol (UE),
-and inhibin A
low AFP-Down syndrome
high-Spina bifida
it is not an absolute test if it is abnormal -further investigation is recommended
Kick counts (tests Uretro placental capability)
Same time every day mother records how often she feels the fetus move
if mininum 3 movements are not noted within an hour's time, the mother is encouraged to call her physician immediately!
Nonstress Test
checks FHR and mother detects Fetal movements.
Contraction Stress Test -tests perfusion between Placenta and Uterus (basically O2 and CO2 exchange)
-IV accessed and performed in a labor and deliver unit under electronic fetal monitoring
contractions initiated by Pitocin or nipple stimulation
the desired result is a "negative" test which consists of three contractions of moderate intensity in a 10 minute period
without evidence of late decelerations
the test is done to detect problems so if it is Positive (persistent late decelerations
) then-CS
how is done:
The electronic fetal monitor is placed on the maternal abdomen for 20-30 minutes
Each time the fetus moves, FHR should accelerate 15 beats/min above the baseline for 15 seconds
A reactive (good) test =>2 accelerations in FHR occur with associated fetal movement
Biophysical Profile (BPP)
identification of a compromised fetus and consists of 5 components:
-fetal breathing movement
-fetal movement of the body or limbs
-fetal tone (extension or flexion of the limbs)
-amniotic fluid volume index (AFI) visualized as of fluid around the fetus
-reactive non-stress test
each component 0-2, 8-10-desirable.
Percutaneous Umbilical Blood sampling -like amniocentesis but cord punctured
-chromosomal anomalies, feta karyotyping, and blood disorders
Evrywhere where woman's abdomen is punctured informed consent is needed, and risks like amnionitis spontaneous
abortion, preterm labor/delivery, and premature rupture of membranes must be explained. If she Rh--she may be
RHoGAM given.

Determination of lung maturity through amniocentesis is done at the last trimester of pregnancy
"Amniocentesis may be done after 13-14 week of pregnancy. Performed to determine genetic disorders, metabolic defects, and FETAL
LUNG MATURITY"
echocardiogram-used to assess heart valves.
valve disorders require prophylactic antibiotics before invasive procedures.
avoid IM injections when suspecting MI can affect CK levels

hemodynamic measurements-transducer placed @ the midaxillary line at the fourth or fifth intercostal space
phlebostatic axis.
calcium channel blockers-assess for constipation
1.

Neuroleptic malignant syndrome (NMS):

-NMS is like S&M;
-you get hot (hyperpyrexia)
-stiff (increased muscle tone)
-sweaty (diaphoresis)
-BP, pulse, and respirations go up &
-you start to drool
2. I kept forgetting which was dangerous when you're pregnant; regular measles (rubeola), or German measles (rubella), so
remember:
-never get pregnant with a German (rubella)
3. When drawing up regular insulin & NPH together, remember:
-RN (regular comes before NPH)
4. Tetralogy of fallot; remember HOPS
H- hypertrophy of right ventricle
O- over-riding aorta
P- pulmonary stenosis
S- septal defect
5. MAOI's that are used as antidepressants:
weird way to remember, I know. pirates say arrrr, so think; pirates take MAOI's when they're depressed.
- explanation; MAOI's used for depression all have an arrr sound in the middle (Parnate, Marplan, Nardil)

Autonomic dysreflexia: potentially life threatening emergency

- elevate head of bed to 90 degree
- loosen constrictive clothing
- assess for bladder distention and bowel impaction (triger)
- Administer antihypertensive meds (may cause stroke, MI, seisure )
Normal ICP : 0 - 15mmHg
Pulmonary embolus: S/S
- pleuritic chest pain, dyspnea, low-grade fever, tachycardia, blood-tinged sputum.
COPD : S/S
- dyspnea on exertion, barrel chest, clubbed fingers and toes, tachypneic with prolonged expiratory phase.
Tension pneumothorax - tracheal shift to opposite side, decreased venous return, neck vein bulge, tachycardia and tachypnea.

allopurinol - for chronic gout

colchicine - for acute gout attack
easy way to remember MAOI'S!
think of PANAMA!
PA - parnate
NA - nardil
MA marplan
the laxative step-ladder....to manage constipation
1. bulk-forming laxatives are first

2. stool softners
3. osmotics
4. stimulants
5. suppositors
6. enemas are last

atropine is contraindicated in paralytic ileus, ulcerative colitits, obstructive GI disorders, benign prostatic hypertrophy, myasthenia
gravis and narrow angle glaucoma
withdrawal s/s of benzos: agitation, nervousness, insominia, anorexia, sweating, muscle cramps.....basically about the same as alcohol
withdrawal s/s.
thrombophlebitis s/s: redness, warmth, and induration along the vein, tenderness on palpation of the vein.
hypokalemia-prominent U WAVE (u is down hypo), hyperkalemia-tall T wave (T is tall hyper)
superior vena cava syndrome s/s: nosebleeds, edema in the eyes, edema of hands, dyspnea, mental status changes.
s/s of rheumatic fever: painful swollen joints, jerky movements, enlarged heart, heart murmur, nontender lumps on bony areas, white
painful lesions on the trunk
s/s of vit B12 deficiency: pallor, slight jaundice, smooth beefy red tongue, tingling hands and feet, and difficulty with gait
good pasture syndrome affects the lungs and kidneys so expect pulmonary symptoms and kidney symptoms (failure symptoms)

Metronidazole (Flagyl)- antiviral: no alcohol (unless you planning on vomiting for awhile)...this drug has a metallic bitter taste.
Digoxin-check pulse, less than 60 hold, check dig levels and potassium levels.
Amphojel: tx of GERD and kidney stones....watch out for contipation.
Vistaril: tx of anxiety and also itching...watch for dry mouth. given preop commonly
Versed: given for conscious sedation...watch for resp depression and hypotension
PTU and Tapazole- prevention of thyroid storm
Sinemet: tx of parkinson...sweat, saliva, urine may turn reddish brown occassionally...causes drowsiness
Artane: tx of parkinson..sedative effect also
Cogentin: tx of parkinson and extrapyramidal effects of other drugs
Tigan: tx of postop n/v and for nausea associated with gastroenteritis
Timolol (Timoptic)-tx of gluacoma
Bactrim: antibiotic..dont take if allergic to sulfa drugs...diarrhea common side effect...drink plenty of fluids
Gout Meds: Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim)
Apresoline(hydralazine)-tx of HTN or CHF, Report flu-like symptoms, rise slowly from sitting/lying position; take with meals.
Bentyl: tx of irritable bowel....assess for anticholinergic side effects.
Calan (verapamil): calcium channel blocker: tx of HTN, angina...assess for constipation
Carafate: tx of duodenal ulcers..coats the ulcer...so take before meals.

Theophylline: tx of asthma or COPD..therap drug level: 10-20

Mucomyst is the antedote to tylenol and is administered orally
Diamox: tx of glaucoma, high altitude sickness...dont take if allergic to sulfa drugs
Indocin: (nsaid) tx of arthritis (osteo, rhematoid, gouty), bursitis, and tendonitis.

Synthroid: tx of hypothyroidism..may take several weeks to take effect...notify doctor of chest pain..take in the AM on empty
stomach..could cause hyperthyroidism.
Librium: tx of alcohol w/d...dont take alchol with this...very bad nausea and vomiting can occur.
Oncovin (vincristine): tx of leukemia..given IV ONLY
kwell: tx of scabies and lice...(scabies)apply lotion once and leave on for 8-12 hours...(lice) use the shampoo and leave on for 4
minutes with hair uncovered then rinse with warm water and comb with a fine tooth comb
Premarin:tx after menopause estrogen replacement
Dilantin: tx of seizures. thera drug level: 10-20
Navane: tx of schizophrenia..assess for EPS
Ritalin: tx of ADHD..assess for heart related side effects report immediately...child may need a drug holiday b/c it stunts growth.
dopamine (Intropine): tx of hypotension, shock, low cardiac output, poor perfusion to vital organs...monitor EKG for arrhythmias,
monitor BP
1.
2.
3.
4.
5.
6.
7.
8.

9.
10.
11.
12.
13.
14.
15.

Terbutaline a beta-2 agonist is given for preterm delivery to relaxe smooth muscle and halt contractions
High circulating levels of progesterone released by the "corpus luteum" are thought to be responsible for
the immediate post-ovulation rise in body temperature
Geriatrics pts may increase consumption of salt and sweets b/c change in test perception... Watch for
health problems that may result from that!
8 month infant => Recognizes but is fearful of strangers
10-12 months infant => 3-words vocabulary1!!!
12 months infant => stands alone
8-12 weeks infant => can hold head up
Pregnant woman with "Charley horse" pain (pain in the "gastrocnemius muscle" =>the muscle in the back part of
the leg that forms the greater part of the calf; responsible for the plantar flexion of the foot) is relieved by
dorsiflexing the foot, which reduces the muscle spasm
The criteria used to distinguish TRUE from FALSE labor is "evidence of cervical change"... Wow!
Pediatrics... Lead poisoning primarly affects the CNS, causing increased ICP. This results in irritability and
change of LOC, as well as seizure disorders, hyperactivity and learning disabilities
4 months infant => palmar grasp
7-9 months infant => can bang 2 cubes together
9-12 months infant => can put a block in a cup
10-12 months infant => can demonstrate pincer grasp
Hydatidiform mole => increased HCG levels, marked nausea and vomiting

A possible complication of impetigo is posstreptococcal glomerulonephritis and periorbital edema is indicative of postreptocccal
glomerulonephritis.
client should weight themselves daily when taking lithium-- and after the first dose, client should have his/her levels checked within 8-

12 hours and two times a week for the first month. Lithium also causes polyuria and dehydration. S&S of toxicity are, ataxia,
vomiting, diarrhea, muscular weakness and drowsiness.
Gurie blood test helps determine PKU for neonate.
child can return to school with Hep A, a week after onset of jaundice
bulge test is a test for confirming fluid in the knee
it's important not to touch the bed when using defibrilator in order to prevent accidental countershock!!
Extrusion reflex means is the same meaning as tongue thrust which disappears between 3- 4mos of age.
Administer oral steroids in the morning with food to prevent ulcerogenic effects!
Increased abdominal distention, nausea and vomiting are signs of paralytic ileus that should be reported to the physician!
It's important for a client with an internal radium implant to be on a low residue diet in order to prevent many bowel movements
because stool can dislodge it.
Heparin is not transmitted to infant from breastfeeding.
Haldol is effective for reducing assaultive behavior, for example, a pt threatening to hurt another.
Narcotic analgesics are contraindicated for pt's with ICP because it can mask symptoms.
Pt's with SLE(lupus) should be in remission for 5 months before becoming pregnant.
Fixed and DIALATED pupil are signs of ICP and should be reported, it is an emergency.
For stabismus, the brain receives two images.
Vomiting is contraindicated for a pt/child who swallows lighter fluid(hydrocarbons) because there's a risk of aspiration.
Change IV tubing every 48-72hourse(every time I want to choose every 24 hours!)
Extreme tearing and redness are signs of viral conjunctivits and if there is a worker with these signs, make sure they are sent home
because it is contagous!
For amputations after wound has healed..., assess for skin breakdown, wash, rinse and dry stump daily, alcohol dries so don't apply
DARN IT! , no lotion. Elevate stump 24-48 hours after surgery, discourage semi fowler's position to prevent contractures of the hip.
Flush NG tube with 30ml of air before aspirating fluid.
Turp(transurethral resection of the prostate)--hemorrhage is a complication, bleeding should gradually decrease to light pink in 24 hrs.
DVT: tx with compression stockings (always wear the stockings), low dose heparin, discourage sitting for prolonged periods.
Hot and dry=sugar high(symp of hyperglycemia)
cold and clammy=need some candy(hypoglycemia)
Type one diabetes is diagnosed usually before age 15. NO insulin produced
Type 2 diabetes--INSUFFICIENT insulin production. Keto acidosis not common. Affects adults over 40 mostly.
Diabetes insipidus--history of head injury or pituitary tumor or craniotomy...HYPOsecretion of ADH. Polyruria,
decreased specific gravity, decreased osmolarity, HYPOvolemia, increased thirst, tachycardia, decreased bp.
SIADH--excess ADH is released. HYPERvolemia, weightgain, administer diuretics...Declomycin could be prescribed.
Adrenal crisis: Profound fatigue, dehydration, vascular collapse, renal shut down, decreased NA, increased K.

Good ol' Maslow:

1st Physiologic needs
2 Security and safety
3 Love and belonging
4 Self actualization
Sterile field and procedure facts...
For sterile field--never turn your back, avoid talking
over sterile field.

, moisture barriers carries bacteria, open pack away from field, do not reach

Sterile procedures--Surgical procedures, biopsies, caths, injections, infusions, dressing changes.

In regards to surgery, aspirin, antidepressants, steroids, nsaids are drugs that put clients at risk!
The consent for surgery--Dr. gives client explanation, consent signed by Dr., client and witness. Signed prior to pre op meds, remains
a permanent part of client chart.
For pain: PQRST
Provoking
Quality
Region
Severity
Timing
Ask if pain is stabbing, burning crushing.
Narcotics---MORPHINE, MEPERIDINE(DEMEROL), HYDROMORPHONE(DILAUDID), OXYCODONE(OXYCOTIN).
Non-narcotics--ACETOMINOPHEN(TYLENOL), SALICYLATES.
Non steroidal(NSAIDS) TYLENOL, IBPROFEN, NAPROSYN, INDOCIN.
Clozapine(Clozaril) is used for schizophrenic patient's who don't respond to other antipsychotic drugs.
(Benztropin)Congentin is used for the extrapyramidal effects associated with antipsychotic agents.
Chlorpromazine (Thorazine) is used to treat hallucinations, agitation, and thought disorders.
Adenosine(Adenocard) is an antiarrhythmic drug, this drug is good for paroxysmal atrial tachycardia...it slows conduction from av
node.
Atropine for symptomatic bradycardia.
Digoxin for atrial fibrillation.
Lidocaine for ventricular ectopy.
For assessing the abdomen, correct order is INSPECTION, AUSCUTATION, PERCUSSION, PALPATION "I Am Peed PAAAAA!"
)
Cheyne strokes respirations are periods of apnea for 10-60 seconds then slowly increasing rate and depth... occur typically with heart
failure and cerebral depression.
Bulls eye rash is classic in lymes disease.
To relieve breast engorgement, pt should pump each breast for 10 minutes every 3-4 hours and during the night if she's awake.
Anticholinergic effects(drugs that block acetylcholine) cause dry mouth, constipation, urine retention.
5 rights of delegation
Right task
Right circumstance
Right communication

Right person
Right feed back
Cystic fibrosis is a recesssive trait, there is a one in four chance that each offspring will have the trait or disorder.
Cushings triad is something to look out for in patient's with increased ICP which is decreased heart rate, decreased respiratory rate
BUT increased blood pressure.
Withdrawal from stimulants results in depression, fatigue and confusion.
Withdrawal from alcohol results in vomiting, nausea, tremors and diaphoresis.
Withdrawal from sedatives results in increased motor activity and tachycardia.
Withdrawal from opioids results in rhinorrhea, abdominal cramps and DIALATED pupils.
Inflammation: HIPER
Heat
Induration
Pain
Edema
Redness
Hallucinations--sensory perceptions without external stimuli.
Illusions--real stimuli is misinterpreted.
Delusions--falsed fixed belief('I am the queen of England!" for example)
Ok here is for TB drugs
Think SPRITE
S- Streptomycin (Monitor for ototoxic, nephrotoxic and neurotoxic rxn)
P-Pyrazinamide ( Photosensitivity-- so avoid sunlight or UV rays)
R- Rifampin ( Red orange urine is normal.. think about R for rifampin and R for red urine)
I- INH ( SE is Vit B6 deficiency so pt needs inj. and avoid tyramine containing foods)
T- Tubasal aka Aminosalicylate sodium ( avoid aspirin with this med)
E- Ethambutol ( E for eye problems- assess visual acuity and color discrimination esp to green)
Also for ventilator alarms
HOLD
High alarm- Obstruction due to incr. secretions, kink, pt. coughs, gag or bites
Low press alarm- Disconnection or leak in ventilatior or in pt. airway cuff, pt. stops spontaneous breathing
to remember blood sugar:
hot and dry-sugar high (hyperglycemia)
cold and clammy-need some candy (hypoglycemia)
2. ICP AND SHOCK HAVE OPPOSITE V/S
ICP-increased BP, decreased pulse, decreased resp.
shock- decreased BP, increased pulse, increased resp.
3. cor pulmonae: right sided heart failure caused by left ventricular failure (so pick edema, jvd, if it is a choice.)
4. herion withdrawal neonate: irratable poor sucking
5. Jews: no meat and milk together
6. Brachial pulse: pulse area cpr on an infant.

7. Test child for lead poisioning around 12 months of age

8. bananas, potatoes, citrus fruits source of potassium
11. Cultures are obtained before starting IV antibiotics
12. a pt with leukemia may have epitaxis b/c of low platelets
13. best way to warm a newborn: skin to skin contact covered with a blanket on mom.
14. when a pt comes in and she is in active labor...nurse first action is to listen to fetal heart tone/rate
15. phobic disorders...use systematic desensitiztion.

1.
2.
3.
4.

Clients of the islam religious group might want to avoid jello, pork and alcohol
Most common side effect of daunorucibin (cerubidine) for a client with leukemia is cardiotoxicity
Patient having a surgery on the lower abdomen should be placed in the trendelenburg position
Flumazenil (Romazicon) is the antidote for versed (Needless to remind you that versed is used for conscious sedation... Say
thank you Jean LOL)
5. Patients taking isoniazid (INH) should avoid tuna, red wine, soy sauce, and yeast extracts b/c of the side effects that can
occur such as headaches and hypotension
6. A Patient with gout who is placed on a low-purine diet should avoid spinach, poultry, liver, lobster, oysters, peas, fish and
otmeal
7. A patient who needs a high-iron diet should eat: sliced veal, spinach salad, and whole-wheat roll
8. Pegfilgastrin (Neulasta) is a chemotherapeutic drug given to patients to increase the white blood cells count
9. Amphoteracin B (Fungizone) should be mixed with D5W ONLY!!!
10. Pt with leukemia taking doxorubicin (Adriamycin) should be monitored for toxic effects such as rales and distended neck
veins (carditoxicity manifested by change in ECG and CHF)
11. Cardidopa/levodopa (Sinemet) is given to clients with Parkinson's disease. Watch for toxic effects such as spasmodic eye
winking
12. Nimotop (Nimodipine) is calcium channel blocker that is given to patients with ruptured cerebral aneurysm. Do you know
why? Look it up! Vasospasm...

hope this discussion is moved to Sticky Threads soon, it is so awesome.

1. A conductive hearing loss involves interference in the transmission of sound waves to the inner ear.
2. A sensorineural hearing loss is the result of nerve impairment.
3. An acoustic neuroma is a benign Schwann cell that adversely impacts the 8th cranial nerve.
4. DKA is an acute insulin deficiency followed by a decrease in glucose in body cells and an increase production of glucose by the
liver.
5. Lymphedema results from an obstruction of lymph circulation and can be aquired or can be secondary to other disorders.
6. The Reed-Sternberg cell is the malignant cell type associated with Hodgkin's Disease.
7. The incidence if Hodgkins and non - Hodgkins lymphomas are increased in those taking drugs such as phenytoin ( Dilantin ).

Necrosis is "tissue death " whereas gangrene is necrosis on a larger scale. Gangrene usually results from
interruption of blood flow/supply to large areas of tissue or bone. Commonly affected areas are the extremeties
( fingers, toes, lower legs, etc ) or the bowel.
Dry Gangrene= occurs when the necrotic tissue has little blood supply and is relatively aseptic.
Wet Gangrene= is potentially life threatening due to release of toxins into the bloodstream.
Gas Gangrene= is gangrene infected with a gas bacillus, most commonly, Colstridium Perfringens.
Treatment is usually debridement of the wound, cleansing the area with an antibacterial or antiseptic, removal of
the affected tissue, and possibly a course of antibiotics.
1.

S/S croup (child) => hoarse voice, inspiratory stridor, barking cough

2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

Client with hepatic encephalopathy => Neomycin decreases serum ammonia concentration by decreasing the number of
ammonia producing bacteria in the GI tract
A 2 year old can remove one garment
A 2 and half year old can build a tower of eight cubes and point out a picture
A 3 year old can wash and dry his/her hands
S/S perforated colon => severe abdominal pain, fever, decreasing LOC
Hyperglycemia => b/c polyuria assess for signs of deficit fluid volume such as rapid, thready pulse, decreased BP, and rapid
respirations
A child with nephrotic syndrome is at risk of skin breakdown from generalized edema
Tetracycline should be taken on an empty stomach. Avoid dairy products, Ca, Mg, Al and Fe (Iron)
Upper GI series => NPO 6-8 hrs b/f procedure
Mumps is the childhood infectious disease that most significantly affects male fertility
Client allergic to penicillin may be also allergic to cephalosporins
Infants and children up to age 7 are abdominal breathers
Placental transport of substances to/from the fetus begins in the 5th week
Duration of contractions => period from the onset of uterine tightening to uterine relaxation
Frequency of contractions => period b/t one contraction and the beginning of the next contraction
Erbs point => 3rd L ICS; pulmonic and aortic murmurs are best heard there

1.
2.

One of the CHF symptoms is S3 ventricular gallop

Hypertensive crisis => Priority in the first hour is brain damage due to rupture of the cerebral blood vessels. Neurologic
status must be closely monitored
3. Client with A-fib => a cold, pale lower leg suggests the presence of an embolus. Peripheral pulses should be checked
immediately
4. S/S anemia in a 10 months old infant => pale mucosa of eyelids and lips
5. S/S dehydration in 2 years old => sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and
increased pulse
6. Pt with anaphylaxis => The entire body may turn bright red b/c massive vasodilation
7. Teaching pt with Zollinger-Ellison syndrome => Report promptly to his/her healthcare provider any finding of peptic ulcer
(night time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite)
8. Infant with epiglottitis : 4 D's => Drooling, Dysphagia, Dysphonia and Distress inspiratory efforts
9. Niacin (Vit B) is a lipid lowering agent. Foods high in Niacin are meats, eggs, milk, dairy products
10. Child with 3 C's (Cough-Choke-Cyanosis) should be assessed for tracheoesophagial fistula
11. Gastric lavage is a priority for an infant who has been identified as suffering from botulism
12. Viral meningitis usually does not require protective measures

Myasthenia gravis--muscle weakness that occurs mostly in the throat and face as results from the deficits of the nerve impulses
conducting at the myoneural junction. Pancuronium and succinylcholine are neromuscular agents that should be used with caution
because of the chance of prolonging recovery.
Clients with CRF are to be on a high carbohydrate diet to prevent protein metabolism. Pt's must limit protein, sodium and potassium
and fluids because the kidneys cannot excrete an adequate amount of urine.
ABG's is the best way to monitor pulmonary status by analyzing the level of hypoxia caused by pulmonary edema and for monitoring
effects of treatment.
Cardiogenic shock--there is low cardiac output from heart pump failure such as in heart failure, sever cardiomyopathy, acute MI.
Nursing dx - Altered tissue perfusion related to decreased heart-pumping action.
Pancreatitis-high carb, low fat diet.
IV cimetidine(Tagamant) given as treatment for a bleeding peptic ulcer may experience hyptotention if given too rapidly
Watch for cardiac arrythmias when suctioning pt from an ET because of the loss of oxygen.
Chest pain and dypnea are classic signs of pulmonary embolism, typically they may have a cough with blood tinged sputum.

1.

Larngotracheobronchitis: inspiratory stridor and restlessness

2. Thorazine: antidote cogentine SE: akathisia(motor restlessness) dystonia(tongue protrusion, abnormal posture) and
diskinesia(stiff neck, difficulty swallowing)
3. Toddlers- parrallel play; infants enjoy company but self play.
4. IV infiltraton D/C IV and apply warm compress.
5. Urticaria= hives.
6. Graves disease: enlarged thyroid, increased metoblism and of course weight loss.
7. The goal for COPD is to improve ventilation.
8. From birth to 18 months Trust vs Mistrust
9 HbA1C- indicates BS for past 6-8 weeks(time varies with source) 2.5-6% normal.
10. myasthemia gravis: autoimmune disease of neuro jnx. destroys Acetylecholine receptors.
11. Meniere's: Inner ear disease: vertigo, tinnitus, sensorineuro hearing loss, N/V
12. Use play therapy for children d/t inability to verbalize emotions.
13. Phenergan: Check vein patency (very important)
14. Visine: contraindicated in glaucoma d/t vasocontriction

1.

Autonomic Dysreflexia--asses Bladder, Bowel, Skin

2. GIVE Dantrolene to treat pt. in MH crisis
3. JOMACS (mini mental status exam)= Judgement, Orientation, Memory, Affect, Consciousness, Speech
4. -ostomy- make opening
5. -oscopy- look into or at
6. -otomy- cutting into
7. -ectomy- removal of
9. Colporrhaphy- surgical repair of the vagina (Very random )
10. Do not Palpate WILM's tumor
11. Albumin is the best indicator of nutritional status
12. In V-fib always look at pt first anything can mimic the pattern on EKG
13. V-tach is usually caused by an underlying cause treat cause
14. Percipitous delivery may cause amniotic emboli
15. Hct: Hgb approx 3:1
16. WBC= 5-10 (thousand)
17. Platlets= 150-400 (thousand)
18. PPI's stop gastric acid secretion (permanantly)
19. Vasoconsrtiction stops itching and inflamation (give cool bath)
20. Anticholinergic effects- Cant SEE, Cant PEE, Cant POOP, and dry mouth
21. Trauma to frontal may casuse Frontal Lobe disinhibition
22. Creatinine is the best indicator of renal funtion
23. Every drop of urine counts during 24hr creatinine clearence (if one sample is thrown out must start over) First void of the
morning is not included but the first pee of the next morning is (because it is considered Last nights urine)
24. Best position to improve resp. effort = Left Lateral, Folwer & modifications of it

1. When getting down to two answers, choose the assessment answer (assess,
collect, auscultate, monitor, palpate) over the intervention except in an
emergency or distress situation. If one answer has an absolute, discard it.
Give priority to answers that deal directly to the patients body, not the
machines/equipments.
2. Key words are very important. Avoid answers with absolutes for example:
always, never, must, etc.
3. with lower amputations patient is placed in prone position.
4. small frequent feedings are better than larger ones.
5. Assessment, teaching, meds, evaluation, unstable patient cannot be
delegated to an Unlicensed Assistive Personnel.
6. LVN/LPN cannot handle blood.
7. Amynoglycosides (like vancomycin) cause nephrotoxicity and ototoxicity.
8. IV push should go over at least 2 minutes.
9. If the patient is not a child an answer with family option can be ruled
out easily.
10. In an emergency, patients with greater chance to live are treated first
.
11. ARDS (fluids in alveoli), DIC (disseminated intravascular coagulaton)
are always secondary to something else (another disease process).

12. Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues).

13. in pH regulation the 2 organs of concern are lungs/kidneys.
14. edema is in the interstitial space not in the cardiovascular space.
15. weight is the best indicator of dehydration
16. wherever there is sugar (glucose) water follows.
17. aspirin can cause Reyes syndrome (encephalopathy) when given to
children
18. when aspirin is given once a day it acts as an antiplatelet.
19. use Cold for acute pain (eg. Sprain ankle) and Heat for chronic (
rheumatoid arthritis)
20. guided imagery is great for chronic pain.
21. when patient is in distress, medication administration is rarely a good
choice.
22. with pneumonia, fever and chills are usually present. For the elderly
confusion is often present.
23. Always check for allergies before administering antibiotics (especially
PCN). Make sure culture and sensitivity has been done before adm. First dose
of antibiotic.
24. Cor pulmonale (s/s fluid overload) is Right sided heart failure caused
by pulmonary disease, occurs with bronchitis or emphysema.
25. COPD is chronic, pneumonia is acute. Emphysema and bronchitis are
both COPD.
26. in COPD patients the baroreceptors that detect the CO2 level are
destroyed. Therefore, O2 level must be low because high O2 concentration
blows the patients stimulus for breathing.
27. exacerbation: acute, distress.
28. epi always given in TB syringe.
29. prednisone toxicity: cushings syndrome= buffalo hump, moon face, high
glucose, hypertension.
30. 4 options for cancer management: chemo, radiation, surgery, allow to
die with dignity.
31. no live vaccines, no fresh fruits, no flowers should be used for
neutropenic patients.
32. chest tubes are placed in the pleural space.
33. angina (low oxygen to heart tissues) = no dead heart tissues. MI=
dead heart tissue present.
34. mevacor (anticholesterol med) must be given with evening meal if it is
QD (per day).
35. Nitroglycerine is administered up to 3 times (every 5 minutes). If
chest pain does not stop go to hospital. Do not give when BP is < 90/60.
36. Preload affects amount of blood that goes to the R ventricle.
Afterload is the resistance the blood has to overcome when leaving the heart.
37. Calcium channel blocker affects the afterload.
38. for a CABG operation when the great saphenous vein is taken it is
turned inside out due to the valves that are inside.
39. unstable angina is not relieved by nitro.
40. dead tissues cannot have PVCs(premature ventricular contraction. If
left untreated pvcs can lead to VF (ventricular fibrillation).
41. 1 t (teaspoon)= 5 ml
1 T(tablespoon)= 3 t = 15 ml
1 oz= 30 ml
1 cup= 8 oz
1 quart= 2 pints
1 pint= 2 cups
1 gr (grain)= 60 mg
1 g (gram)= 1000 mg
1 kg= 2.2 lbs
1 lb= 16 oz
* To convert Centigrade to F. F= C+40, multiply 9/5 and substract 40
* To convert Fahrenheit to C. C= F+40, multiply 5/9 and substract 40.

42. angiotensin II in the lungs= potent vasodialator. Aldosterone attracts

sodium.
43. REVERSE AGENTS FOR TOXICITY
heparin= protamine sulfate
coumadin= vitamin k
ammonia= lactulose
acetaminophen= n-Acetylcysteine.
Iron= deferoxamine
Digitoxin, digoxin= digibind.
Alcohol withdraw= Librium.
- methadone is an opioid analgesic used to detoxify/treat pain in
narcotic addicts.
- Potassium potentiates dig toxicity.
44. heparin prevents platelet aggregation.
45. PT/PTT are elevated when patient is on coumadin
46. cardiac output decreases with dysrythmias. Dopamine increases BP.
47. Med of choice for Vtach is lidocaine
48. Med of choice for SVT is adenosine or adenocard
49. Med of choice for Asystole (no heart beat) is atropine
50. Med of choice for CHF is Ace inhibitor.
51. Med of choice for anaphylactic shock is Epinephrine
52. Med of choice for Status Epilepticus is Valium.
53. Med of choice for bipolar is lithium.
54. Amiodorone is effective in both ventricular and atrial complications.
55. S3 sound is normal in CHF, not normal in MI.
56. give carafate (GI med) before meals to coat stomach
57. Protonix is given prophylactically to prevent stress ulcers.
58. after endoscopy check gag reflex.
59. TPN(total parenteral nutrition) given in subclavian line.
60. low residue diet means low fiver
61. diverticulitis (inflammation of the diverticulum in the colon) pain is
around LL quadrant.
62. Appendicitis (inflammation of the appendix) pain is in RL quadrant with
rebound tenderness.
63. portal hypotension + albuminemia= Ascites.
64. beta cells of pancreas produce insulin
65. Morphine is contraindicated in Pancreatitis. It causes spasm of the
Sphincter of Oddi. Therefore Demerol should be given.
66. Trousseau and Tchovoski signs observed in hypocalcemia
67. with chronic pancreatitis, pancreatic enzymes are given with meals.
68. Never give K+ in IV push.
69. mineral corticoids are give in Addisons disease.
70. Diabetic ketoacidosis (DKA)= when body is breaking down fat instead of
sugar for energy. Fats leave ketones (acids) that cause pH to decrease.
71. DKA is rare in diabetes mellitus type II because there is enough
insulin to prevent breakdown of fats.
72. Sign of fat embolism is petechiae. Treated with heparin.
73. for knee replacement use continuous passive motion machine.
74. give prophylactic antibiotic therapy before any invasive procedure.
75. glaucoma patients lose peripheral vision. Treated with meds
76. cataract= cloudy, blurry vision. Treated by lens removal-surgery
77. Co2 causes vasoconstriction.
78. most spinal cord injuries are at the cervical or lumbar regions
79. autonomic dysreflexia ( life threatening inhibited sympathetic response
of nervous system to a noxious stimulus- patients with spinal cord injuries
at T-7 or above) is usually caused by a full bladder.
80. spinal shock occurs immediately after spinal injury
81. Multiple sclerosis= myelin sheat destruction, disruption in nerve
impulse conduction.
82. myasthenia gravis= decrease in receptor sites for acetylcholine. Since
smallest concentration of ACTH receptors are in cranial nerves, expect fatigue

and weakness in eye, mastication, pharyngeal muscles.

83. Tensilon test given if muscle is tense in myasthenia gravis.
84. Guillain-Barre syndrome= ascending paralysis. Keep eye on respiratory
system.
85. parkinsons = RAT: rigidity, akinesia (loss of muscle mvt), tremors.
Treat with levodopa.
86. TIA (transient ischemic attack) mini stroke with no dead brain tissue
87. CVA (cerebrovascular accident) is with dead brain tissue.
88. Hodgkins disease= cancer of lymph is very curable in early stage.
89. Rule of NINES for burns
Head and Neck= 9%
Each upper ext= 9%
Each lower ext= 18%
Front trunk= 18%
Back trunk= 18%
Genitalia= 1% ?
90. Birth weight doubles by 6 month and triple by 1 year of age.
91. if HR is <100 do not give dig to children.
92. first sign of cystic fibrosis may be meconium ileus at birth. Baby is
inconsolable, do not eat, not passing meconium.
93. heart defects. Remember for cyanotic -3Ts( Tof, Truncys arteriosus,
Transposition of the great vessels). Prevent blood from going to heart. If
problem does not fix or cannot be corrected surgically, CHF will occur
following by death.
94. with R side cardiac cath=look for valve problems
95. with L side in adults look for coronary complications.
96. rheumatic fever can lead to cardiac valves malfunctions.
97. cerebral palsy = poor muscle control due to birth injuries and/or
decrease oxygen to brain tissues.
98. ICP (intracranial pressure) should be <2. measure head circonference.
99. dilantin level (10-20). Can cause gingival hyperplasia
100. for Meningitis check for Kernigs/ Brudzinskis signs.
101. Wilms tumor is usually encapsulated above the kidneys causing flank
pain.
102. hemophilia is x-linked. Mother passes disease to son.
103. when phenylalanine increases, brain problems occur.
104. Bucks traction= knee immobility
105. Russell traction= femur or lower leg
106. Dunlap traction= skeletal or skin
107. Bryants traction= children <3y, <35 lbs with femur fx., child's weight provides
countertraction, Buttocks slightly elevated off the bed
108. place apparatus first then place the weight when putting traction
109. placenta should be in upper part of uterus
110. eclampsia is seizure.
111. a patient with a vertical c-section surgery will more likely have
another c-section.
112. perform amniocentesis before 20 weeks gestation to check for cardiac
and pulmonary abnormalities.
113. Rh- mothers receive rhogam to protect next baby.
114. anterior fontanelle closes by 18 months. Posterior 6 to 8 weeks.
115. caput succedaneum= diffuse edema of the fetal scalp that crosses the
suture lines. Swelling reabsorbs within 1 to 3 days.
116. pathological jaundice= occurs before 24hrs and last7 days.
Physiological jaundice occurs after 24 hours.
117. placenta previa = there is no pain, there is bleeding. Placenta
abruption = pain, but no bleeding.
118. bethamethasone (celestone)=surfactant. Med for lung expansion.
119. dystocia= baby cannot make it down to canal
120. pitocin med used for uterine stimulation
121. Magnesium sulfate(used to halt preterm labor) is contraindicated if

deep tendon reflexes are ineffective. If patient experiences seizure during

magnesium adm. Get the baby out stat (emergency).
122. Do not use why or I understand statement when dealing with patients
123. milieu therapy= taking care of patient/environment
124. cognitive therapy= counseling
125. crisis intervention=short term.
126. FIVE INTERVENTIONS FOR PSYCH PATIENTS
-safety
-setting limits
-establish trusting relationship
-meds
-leas restrictive methods/environment.
126. SSRIs (antidepressants) take about 3 weeks to work.
127. Obsession is to thought. Compulsion is to action
128. if patients have hallucinations redirect them. In delusions distract
them.
129. Thorazine, haldol (antipsychotic) can lead to EPS (extrapyramidal side
effects)
130. Alzheimers disease is a chronic, progressive, degenerative cognitive
disorder that accounts for more than 60% of all dementias

For a nurse to treat chest pain with standing orders for the nurse to implement before notifying the physican, heres how the order
goes....
Give O2 2L/min(nasal canula)
Check vital signs(particularly blood pressure)
Administer sublingual nitro
Evaluate the client's response
Codeine's onset of action is 30 minutes.
Couple quick laboratory values:
Potassium--normal 3.5-5.5mEq/L( side note: hypokalemia depresses the release of insulin and also results in glucose intolorance)
Chloride--normal--100-110mEq/L
Bun--normal--8-26 mg/dl
Creatinine--normal--0.8-1.4mg/dl
The client with a laryngectomy should keep his house humidified to prevent irritation of the stoma that can occur during low
humidity---of course avoid swimming.
Lymphedema is the result of removing or irradiating the axillary lymph nodes.
The primary signs of breast cancer are a painless mass in the breast, usually in the upper outer quadrant.
Tamoxifen may help to prevent breast cancer.
After a mastectomy, patients should be advised to sleep on the unaffected side.
Simmond's disease is a rare disorder that results from destruction of the pituitary gland.
Diabetes insipidus results from a lack of antidiuretic hormone.
Aldactone is used to treat ascites, as it specifically antagonizes aldosterone.

Delirium is a sudden transient state of confusion that may be brought on by high fever, head trauma or other disorders.
In dementia, there is a gradual and irreversible loss of intellectual abilities.

Arterial disorders
Buerger's disease- males
Raynaud's disease - females
S/S- cold, numbness, decrease peripheral pulses, skin/nail changes classic sign-Intermittent claudication (pain while walking
because O2 demand incr)
Causes of Buerger and Raynaud's disease
-smoking, cold, emotions--causes VASOCONSTRICTION!!
-affects lower extremities and fingers
Treatment- Avoid smoking, avoid cold- Wear gloves and shoes that fit well and avoid trauma to foot
Never elevate legs because aterial blood (oxygenated blood) is having difficulty getting to tissue. Instead we dangle leg at side
of bed to promote circulation!!!
Radioactive iodine precautions- stay distance of 1 arm length from babies/ preggo within 24 hour period, avoid sharing foods and
utensils.
Hemophilia A is caused by a deficiency in clotting factor VIII.
No conduction between the atria and ventricles would be a third degree block.
A patient who gets an organ transplant is a t risk for graft-vs-host disease.
Eczema, recurrent bloody diarrhea, and thrombocytopenia are characteristic of Wiscott-Aldrich syndrome.
ACE-I exert their effect by reducing preload.
Digitalis and related cardiac glycosides act by directly inhibiting the Na/K pump in the cell membranes.
In the unconscious patient, a doll's eye reflex indicates intact brain stem function.
Just a couple I just thought of, not sure if anyone posted it already
1. To remember how to draw up INSULIN think:

Nicole Richie RN (a teacher taught us this is school, thought it was

funny and never forgot it!!!)

Air into NPH, then air into regular, draw up regular then draw up NPH
2. HYPERthyroidism think of MICHAEL JACKSON in THRILLER!
SKINNY, NERVOUS, BULDGING EYES, Up all night, heart beating fast
There is just a couple I thought of...i'll try to think of some more!
Atropine used to decrease secretions
Phenergan an antiemetic used to reduce nausea
Diazepam is a commonly used tranquilizer given to reduce anxiety before OR
Demerol is for pain control
Do not give demerol to pts. with sickle cell crisis.

Iron injections should be given Z-track so they don't leak into SQ tissues.
tay sach's disease - cherry-red spots in the macula
down's syndrome - white flecks in the iris
osteogenesis imperfecta - blue tinged sclera
Types of partial seizures
Simple partial: symptoms confined to one hemisphere
Complex partial: begins in one focal area; spreads to both hemispheres.
Types of generalized seizures
Abscense (petit mal): loss of responsiveness, but continued ability to maintain posture control and not fall.
Myoclonic: movement disorder (not a seizure)
Clonic: opposing muscles contract and relax alternately in rhythmic pattern.
Tonic: muscles are maintained in continuous contracted state (rigid posture)
Tonic-clonic: (grand mal, major motor); violent total body seizure
Atonic: drop and fall attack
Akinetic: suddenr brief loss of muscle tone or posture.

Terbutaline: Medication given to stop pre-term labor

Methergine: Given for postpartum hemorrhage.
Cervidil: Cervical ripening agent
Mag Sulfate: Pregnancy Induced Hypertension - prevents seizure. Absence of deep tendon reflex is sign of toxicity
Pitocin: Used for induction of labor and postpartum to help the uterus contract.
Early Decelerations are okay, follow the contraction.
Late Decelerations are a sign of fetal distress and continue after contraction. Reposition client (left side)
3- 5 beat Variability in FHR is good sign, you want to see that.
Stop pitocin if contractions longer than 90 seconds and closer than 2 minutes.
Once the membranes rupture, important to monitor temperature hourly as risk for infection increases.
First thing to do after rupture is to auscultate fetal heart tones! Assessing for cord prolapse if decels occur.
Analgesics are typically not given during the transitional phase of labor as delivery is imminent and could lead to decreased
respiratory rate in neonate.
If patient has boggy uterus - place the infant to nipple, it causes release of natural pitocin
If uterus deviated to one side - encourage client to void.
Rhogam given to Rh negative mothers with Rh positive babies.

1.

S/s of a perforated peptic ulcer include: sudden, severe upper abd pain, vomiting, and a very tender rigid abdomen.
2. After a cardiac cath--the site is monitored for bleeding and hematoma formation, the pulses palpated distal to the site q 15
min for at least an hour, patient is on bedrest with lower extremities extended for 8 hrs.
3. Cullen's sign (the bluish discoloration around the umbilicus) is often seen with with a perforated pancreas.
4. The 6 F's are causes of abd distention: flatus, feces, fetus, fluid, fat, and fatal neoplasm.
5. An elevated serum amylase level is a cardinal sign of pancreatitis.

6. S/s of digitalis toxicity: blurred vision, nausea, vomiting, light flashes, and yellowish-green halos around dark objects.

Tidal volume is the volume of air inhaled and exhaled with a normal breath.
Insiratory reserve volume is the maximum volume of air inspired at the end of normal inspiration.
Expiratory reserve volume is the maximum volume of air exhaled after a normal respiration.
Vital capacity is the maximum amount of air expired after maximal inspiration.
Pleurisy is an inflammation of the visceral and parietal pleura.
A collection of fluid between the visceral and parietal pleura is a pleural effusion.
1.Versedgiven before cardioversion/ hypnotic/sedative hold digitalis 48 before cardioversion to prevent ventricular fibrillation.
2. Plasmapheresis similar to hymodialysis/ done to remove antibodies that may be causing symptoms
- warm blankets to prevent chills and hypothermia that may occur during plasmapheresis
3. Cholsetyramine (Questran)-- for hypercholesterolemia -- comes in gritty powder that must be mixed thoroughly in juice or water
before administration
Monitor for s/sx of peptic ulcer
Taken with sufficient liquids.
4. Lovastin (Mevaco) shld not be administered with anti coagulant
Caution immunosuppressive medications
Monitor liver enzymes
Instruct pt to have eye exam bec the med causes cataract formation
5. Gemfibrozil (Lopid should not be taken with anticoagulants, and if client is taking anticoagulant, the anticoagulant shld be reduced
and the INR shld be monitor closely
Do not administer Lopid with lovastin
1.

Levophed infuse with dextrose solution

Client should be attended at all times
2. Dopamine - headache is an early symptom of drug excess/ use infusion pump
3. Isuprel do not t give at hs interrupts sleep patterns
4. Sudafed S/E dry mouth, palpitations, difficulty urinating. Do not take at hs/ dont combine with MAOI
5. Dobutrex incompatible with alkaline sol (Sodium Bicarb) / administer thru Central Venous Cath or large peripheral vein
using an infusion pump
Monitor EKG, BP, I and O, K+

1.

Before administering lidocaine, always check the vial label to prevent administering a form that contains epi or preservatives
because these solutions are used for local anesthesia only
1:100 only for inhalation
1:1000 for parenteral admin (SC or IM)
2. Do not administer antidysrthmics with food or antacids to reduce gastro stress
Always administer IV antidysrthymics via an infusion pump
3. Amiodarone hydrochloride may cause pulmonary fibrosis, photosensitivity, bluish skin discoloration, corneal deposits,
peripheral neuropathy, tremor, poor coordination, abnormal gait, and hypothyroidism.
Instruct client taking amiodarone to use sunscreen and protective clothing to prevent photosensitivity rxn
4. Bretylium tosylate may cause vertigo, syncope, and dizziness
After administering bretylium, keep the client supine and monitor for hypotension.
.
5. Sodium Nitroprusside (Nitropress) Direct Acting Vasodilator
Monitor cyanide and thiocyanate levels
Protect from light because the medication decomposes
When administering, solution must be wrapped in aluminum foil and is stable for 24 hrs. Discard medication when it turns

red or blue.
Myocardial Infarction: Think MONA: Morphine, O2, Nitro, ASA
When palpating a fundus on a postpartum patient, always have them void first
When Brethine is given for preterm labor, tachycardia is always the problem
Epiglottiditis: priority is having a trach set at the bedside and NEVER inspect the throat! It causes spasms and can occlude the airway
Veinous occlusion (DVT) think warm and red...increase venous RETURN by RAISING the leg
Arterial occlusion think cold and pale..increase arterial outflow by keeping the leg in a flat or slightly dependent position
Newborn infant with tuft of hair: spina bifida occulta
White spots on a babys gums are normal..called epsteins pearls
Fundal height > # of weeks pregnant = always suspect hydatiform mole
1 oz= 30 mL 1 tsp= 5mL 1 tbsp= 15 mLs
Patients taking antipsychotics are at risk for Neuroleptic Maligant Syndrome which is a medical emergency characterized by
hyperthermia
uncuffed endotracheal tubes are used in children up to age 8
1.epidural anesthesia is placed outside the dura
2.give 1 cc of epi of it enters the vessels to combat vascular collaspe
3.spinal anesthesia is placed in the subaracnoid space
4.children 1yr and older are NPO 8-hours prior to surgery
5.children under 1yr are given formula 6-hours prior to surgery and clear liquids 4-hours before
1.
2.
3.
4.
5.

S/S lithium toxicity: lethargy, vomiting, diarrhea

When giving rectal suppository, advance approximatively 3 inches into the rectum
Diphenhydramine (Benadryl) inhibits methotrexate excretion, which increase the risk of methotrexate toxicity
Glucagon interacts adversely with oral anticoagulants, increasing the anticoagulant effects
Amitriptyline (Elavil) is an antidepressant that can have an additive effect when used with other CNS depressants
(antihistamines, antpsychotics,...)
6. Concomitant use of corticosteroids and terbutaline (Bricanyl) may cause pulmonary edema
7. Tetracycline should be taken on an empty stomach
8. Tricyclic antidepressants can have anticholinergic adverse effects whith dry mouth being the most common
9. Metronidazole (Flagyl) commonly causes a metallic taste
10. Meteprolol masks the common signs of hypoglycemia; therefore glucose level should be monitored closely in diabetics
11. A cholinergic blocking agent may delay the sublingual absorption of nitroglycerin because of dry mouth

spantaneous abortion most commonly present Pain followed by bleeding

Medications that are contrindicated in breast-feeding mothers

Tetracyline inhibition of bone growth

Warfin * safe to use? Hand out
Chloramphenicol bone marrow suppression

Magnesium Sulfate becomes toxic at:

Loss of reflexes

Levels > 8 meq/L

Respiratory arrest

Level > 12 meq/L

Two drugs are used to treat Eclampsia

Magnesium Sulfate 4-6q IV bolus

Followed by a: 2 g/h infusion:

Hydralazine 10-20 mg IV

Staphylococcus aureus common cause mastitis

1st week of postpartum not present (mastitis)

Seen:
3-4 weeks post partum
SX:

Fever
Chills
swollen red breast

normal fetal heart rates

120-160 Bpm

Abnormal
If bradycardia is detected, position the mother on her left side
give O2
IV fluid Bolus.

when giving Bronchodilator & Glucocorticoids at the same time, give the bronchodilator first. remember B before G!
Acute blood loss ( hemorrhage ) is likely to cause sinus tachycardia.
When the heart rate increases with inspiration and decreases with expiration it is called sinus arrythmia.
When someones heart "skips a beat" this is most times called premature atrial complex.
The person who hyperventilates is most likely to experience respiratory alkalosis.
When a pleural effusion recurs within days or weeks following a thoracentesis, this usually indicates the
underlying cause is a malignancy.
Estrogen influences fibrocystic breast changes.
In the TNM classification system, the "N" stands for node.
Edema, ascites, and hepatomegaly are characteristic of right-sided cardiac failure.
When assessing for heart failure the echocardiogram is the most important test.
Lower extremity rubor indicates arterial damage.

The patient who is neutropenic from chemotherapy should not eat fresh produce or have fresh flowers in
their room. Visitors should be cautioned to wash their hands extra well before entering the room.
The most frequent cause of increased platelet destruction is DIC ( disseminated intravascular coagulation ).
With Hirschprung's disease the infant presents with failure to thrive, abdominal distention, and ribbon like stools.
Dopamine is used to treat hypotension.
Nitroprusside is used for hypertensive emergencies.
Tumor lysis syndrome is a potential complication of leukemia.
A deficiency of vitamin A is linked to lung cancer.
Following an angiogram, the nurse should watch for bleeding at the femoral insertion site.

Greatest threat to a pedi pt recovering from a bone marrow transplant is infection b/c of non-functioning WBCs.
* Clinical manifestations of intracranial tumor: Ha, vomit, papilladema, sz activity.
* Toxic effects of vincristine are: N/V/A, urinary retention, neurotox, alopecia
* A chemo agent that crosses the blood-brain barrier is cytarabine (Cytosar)
* Kids w/ Cerebal Palsy are at risk for nutritional deficits b/c they have difficulty chewing and swallowing.
* DUH -- how did I NOT get this question right -- Prednisone suppresses immunity!
* Pts with nephrotic syndrome require good skin care and frequent position changes d/t edema.
* Myelomeningocele involves a protruding, sac-like structure that contains: meninges, spinal fluid and neural tissue.
* When a 2 year old has 3 dolls and won't share w/ another child, the best way to deal w/ situation is to go find another doll
for the other kid -- once the kid is 3 y.o., they can begin to share toys (interesting factoid for me -- a single girl w/out kids).
* Therapeutic management for a kid with ringworm is oral griseofulvin.
* Increased physical exercise will increase the use of glucose and decrease the body's need for insulin.
* After leukemia, brain tumors cause the most deaths in peds.
Ready for cardio?...

Note: decr = decrease; incr = increase

*CVP will be increased in CHF; decr CVP is shock (vasodilation) or hemorrhage.

* Decr Na+ levels could be a development of dig toxicity.
* Newborn w/ sickle cell anemia will not have s/s b/c of incr Hgb in fetal blood (could go back up to peds, I know).
* S/S of pulmonary embolism: sharp, stabbing chest pain that worsens on inspiration; incr pulse, dyspnea; productive
cough;tachycardia; hemoptysis
* Diltiazin (Cardizem) a calcium-channel blocker, inhibits Ca++ transport in heart and vasculary muscle cells therefore
inhibiting excitation and subsequent contraction.
* 1st sign of digoxcin tox is decreased pulse.
* An AE for hyperstat which is given for hypertensive crisis is incr blood glucose.

* PVCs could lead to v. fib.

* DOC (drug of choice) for controlling vedntricular arrhythmias is lidocaine.
* Early sign of lidocaine OD is: bradycardia, decr BP, confusion, severe dizziness or faint.
* In aortic stenosis, CO will decrease
* S/S of angina: pain; tachy/bradyarrhythmia
* Contractility of myocardium decr in late stage of MI due to acidosis.
* In ventricular tachycardia, atria and ventricles usually beat independently.
* A mitral murmur can best be heard at the apex (bottom) of the heart -- I'd always gone by the mneumonic tri-right; mitral
-left, but it didn't get me very far on this question...

Epiglottitis often = kiddo in tripod position

Acid-Base
Check first for pH: If increase =alkalosis
If decrease =acidosis
If: Resp acidosis- ph= below 7.35 / PaC02 =above 100 (resp. depression)
Resp alkalosis-ph= above 7.45 / PaC02 =below 80mmHG(hypervent)
If: Metab acidosis- ph=below 7.35 / HC03 = below 21mEqL
Metab alkalosis-ph=above 7.45/HC03 = above 27mEqL
Niacin can produce negative effects ( when taken to excess as vitamin supp ). Reactions include a reddened flush on the skin of the
face,arms,and chest, accompanied by burning, tingling and itching.
Vitamin A is for vision, tissue growth ( skin and mucous membranes ),reproduction, and immune function.
Meconium ileus is a sign of cystic fibrosis.
" Blue spells " or "tet spells" is characteristic of tetrology of fallot.
An important pharmacologic regimine for cystic fibrosis is pancreatic enzymes.
Naturally aquired active immunity: results from having the disease and recovering successfully.
Naturally aquired passive immunity: antibodies received from placenta or breast milk.
Artificially aquired active immunity: from immunizations.
Artificially aquired passive immunity: antibodies transfered from sensitized person as in immune serum globulin ( gamma globulin ).
Altered direction of the urinary stream is indicative of hypospadias.
A gluten-free diet is needed in celiac disease.
The development of the fetus is directly related to the diet of the mother.
Egg protein has a higher biological value than meat protein.

1.

Ace Inhibitors can cause hyperkalemia and chronic cough- pt's should
not use salt substitutes because they are mostly made from K+ which
will further increase the K+
2. Valium- suppresses non-rem sleep. Overdose Antidote is flumazenil.
3. There is no antidote for barbiturates which suppress REM sleep. S/S of
allergy to barbiturates is Barbs=prickly sensation ,edema of
membranes in mouth.
4. Tylenol = Liver toxic (no more than 4 g/day) Give Mucomyst for
overdose. Whereas, Ibuprofen = kidney toxic
5. Vancomycin- treats MRSA; Adverse Effects- Red man syndromeflushing from quick admin of this Rx can be prevented with benadryl before admin of RX.

Ileostomy is an opening of the ileum onto the abdominal surface; most frequently done for treatment of
ulcerative colitis, but may also be done for Crohn's disease.
Continent ileostomy ( Kock's Pouch ) is an intra-abdominal reservoir with a nipple valve formed from the distal ileum. The pouch acts
as a reservoir for feces and is cleaned at regular intervals by insertion of a catheter.
Morphine causes spasms of the Sphincter of Oddi, which will result in worsening an episode of acute pancreatitis.
Oliguria is a primary sign of hypovolemic shock related to hemorrhage.

When teaching pt. with UTI priority teaching for home care is to take all prescribed antibiotics because sign and symptoms of
UTI usually disappear within several days of antibiotic therapy so pt has tendency to stop meds. Also, sexual intercourse is
permitted during treatment for UTI.
Four point gait is best for stability for pt. with arthritis since the client can bear weight on both legs.
Pt with rheumatoid arthritis who take prednisone( corticosteroids) for long period of time has complication of brittle bones
and breaking their bones with even a minor injury.

Carbidopa/Levodopa ( Sinemet )- tx for Parkinson's, carbidopa prevents metabolism of levodopa and allows more levodopa for
transport to brain. Levodopa ( Larodopa ) should be d/c'd 8 hours before statring Sinemet.
Bromocriptine ( Parlodel ) - tx of Parkinson's, amenorrhea, galactorrhea, female infertility, suppression of postpartum lactation,
acromegaly.
Ropinirole ( Requip ) - tx of idiopathic Parkinson's disease.
Quinidine - give with food, monitor electrolytes, monitor liver and kidney function, encourage patient to report dizziness or faintness
immediately.
Used in a-fib and a-flutter.

Practice universal precautions when caring for all clients regardless of their diagnosis in order to minimize contact with blood and
body fluids and to prevent the transmission of specific infections such as HIV and Hep.B:
1.Hands MUST always be washed before and after client contact.
2.Hands must be washed before and after gloves have been worn.

3.If hands come in contact with blood or body fluids or human tissue they should be immediately washed with soap and water. ( 20-30
seconds )
4.Gloves should be worn before touching mucous membranes or non-intact skin.
5.Gloves should be changed between each client contact and if torn.
6.Wear masks and protective eyewear during procedures that are likely to get splashed with body fluids.
7.Wear gowns during procedures that are likely to generate splashes of blood or other body fluids and when cleaning spills from
incontinent clients or changing soiled linen.
8.Disposible masks should be worn when performing CPR.
9.Dispose of used needles properly in designated sharps containers. They should not be recapped, bent, broken,or removed from
syringes.

Hypovolemic shock- decreased circulating blood volume-caused by blood loss, plasma loss as in burns, or
fluid loss as in from excess vomiting or diarrhea.
The concentration of dextrose in TPN solutions is usually at least 30%.
The patient receiving regional anesthesia has nerve impulses blocked but does not lose consciousness.
Calcium functions in development of bones and teeth, transmission of nerve impulses, muscle contraction,permeability of cell
membranes, catalyze thrombin formation, and maintenance of normal heart rhythm.
Trental is used for intermittent claudication.
Atropine sulfate would be given to a client with a dangerously slow heart rate.
Digitalis is used to slow and strengthen the heart in clients with heart failure.
Lidocaine is given to clients who have episodes of premature ventricular contractions.

Seven Warning Signs of Cancer! Caution!

C=change in bowel habits
A=a sore that does not heal
U=unusual bleeding or discharge
T=thickening or lump in breast ( or elsewhere )
I=indigestion or dysphagia
O=obvious change in wart or mole
N=nagging cough or hoarseness
TNM classification:
T=primary growth.1-4 with increasing size; T1s indicates carcinoma in situ
N=lymph node involvment.0-4 indicates progressively advancing nodal disease
M=metastasis.1 indicates presence of metastasis
Stages 0-IV: all cancers divided into 5 stages incorporating size, nodal involvement, and spread

Low Sodium diet for pt. with menieres disease

--HYPOkalemia= TPN, Steroid tx, Diarrhea
--HYPERkalemia= DKA, ACE inhibitors
--Finger foods for preschoolers, NO cooked veggie (raw instead)
--Dont encourage (force) to eat all food on plate
--Lyme disease test not reliable for 4-6wk post exposer
DO NOT BURN TICK why you ask? because it will spread the disease (who knew ) instead
flush down the potty
--avoid salt substitutes when taken dig and k-supplements because many are potassium based

--use portable X-RAY for pt with MRSA

--Bacillus Calmette-Guerin (BCG) Vaccine used to promote active immunity to TB (may give false
positive on PPD)
--Pt. taking Dig and Lasix shoould increase Potassium intake (bc of Lasix)
--Airborne= Mask, gloves
--Contact= Gown, glove
--Flail Chest= FX of 2 or more adjacent ribs with paradoxical movement of chest during
respiration
Autonomic dysreflexia - caused by bladder and bowel distention, patients often complain of a pounding headache and profuse
sweating.
Addison's disease (need to "add" hormone)
Cushing's syndrome (have extra "cushion" of hormones)
The cuff of an ED tube is for preventing aspiration and sealing the airway to prevent leaks. When the cuff deflates, aspiration is the
greatest risk (due to secretions)
Dumping syndrome: increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis, wait 1 hr after meals to
drink.
Use DISTRACTION methods with toddlers and manic patients only.
For radiologic procedures: if dye will be used, always check for shellfish allergy.
For blood types: "O" is the universal donor (remember "o" in donor)
"AB" is the universal receipient

Disseminated Herpes Zoster is AIRBORNE PRECAUTIONS, as to Localized Herpes Zoster is CONTACT PRECAUTIONS. A nurse
with a localized herpes zoster CAN care for patients as long as the patients are NOT immunosuppressed and the lesions must be
covered!
ADHD, antipsychotics, and corticosteroids can stunt growth in children.
Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfanomides WITH food.
Fat soluble vitamins are Vitamins A, D, E, K
IPV is given PO
Most live vaccines (rebulla, MMR) are given SQ
Non-live vaccines (Hep B, DTaP) are given IM
Coartication of the aorta is characterized by upper extremity hypertension and diminished pulses in the extremities.
Do not mix dilantin with dextrose as crystallization can occur. ( IV ) Flush IV line with normal saline before & after giving. Do not
give with other drugs.
Verapamil reduces afterload and with concurrent use of nitroglycerine can cause ( increase ) hypotension.

Menieres disease: vertigo, tinnitus, impaired hearing (menieres...in the ear)

Tuberculosis- assessment findings: cough ( yellow mucoid sputum ) , dyspnea, hemoptysis, rales or crackles, anorexia, malaise,
wt.loss, afternoon low grade temp., pallor, fatigue, pain, night sweats.
Diagnostic Tests used in TB - Chest x-ray indicates presence and extent od disease but cannot show if active or inactive. Skin test
(PPD) positive;area of induration 10mm or more in diameter after 48 hrs. Sputum positive for bacillus ( 3 samples is diagnostic for TB
). Culture will be positive. WBC & ESR will be elevated.
Trach care should be prvided once every 8 hours and prn.
A major goal for the pt with COPD is that the pt. will use a breathing pattern that does not lead to tiring and to plan activities so that
he/she does not become overtired. Care should be spaced, allowing frequent rest periods, and preventing fatigue.
Ethambutol, isonazid, streptomycin, and rifampin are first-line drugs in the treatment of TB.
With antibiotics:
Peak and Trough levels--each drug has their own peak/trough therapeutic index to tell us whether the drugs are working
therapeutically.
Peak: draw 45min to 1 hr after drug is administered -- highest peak
Trough: draw before administering next dose -- lowest level
Lidocaine is the drug of choice for reducing pvc's.
Colchicine relieves inflammation and is used to treat gout.
IV Valium and Dilantin are used to treat status epilepticus.
Solu-medrol is a 1st line drug used to control edema after spinal cord trauma.
Alprazolam ( Xanax )- antianxiety agent, usual dose is 0.25-0.5 mg two to three times
daily. Side effects: drowsiness, dizziness, lethargy, confusion.
Amlodipine ( Norvasc )- CCB used for systemic vasodilation and decreased blood pressure.
Coronary vasodilation and decreased frequency and severity of angina. CONTRAINDICATION BP
<90mmHg.
Fosinopril ( Monopril )- tx of hypertension and CHF; dosage is 5-40 mg once daily max dose
in a day is 80mg
Rosiglitazone ( Avandia )-tx type 2 diabetes; dosage is 4-8 mg as a single daily dose or
in 2 divided doses ( use cautiously if edema or CHF )
Drugs with these endings........ usually are in this class
-caine ;local anesthetics
-cillin; antibiotic
-dine ;anti-ulcer ( H2 blocker )
-done; opioid analgesic
-ide; oral hypoglycemics
-lam; antianxiety
-mide ;diuretic
-mycin ;antibiotic
-nium; neuromuscular blocking
-olol; beta blocker
-oxacin ;antibiotic
-pam ;antianxiety

-pril ;ACE inhibitor

-sone ;steroids
-statin ;cholesterol
-vir; antiviral
-zide; diuretic

Ativan is the treatment of choice for status epilepticus

When using a bronchodilator inhaler inconjuction with a glucocorticoid inhaler, administer the bronchodilator first
Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and Dilantin
Intal, an inhaler used to treat allergy induced asthma may cause bronchospasm
Isoniazid causes peripheral neuritis
Axid, Zantac, Pepcid, are H2 receptor antagonist used to treat active ulcer disease.
Tagamet, Nexium, Prevacid, are proton pump inhibitors
Peptic ulcers caused by H. pylori are treated with Flagyl, Prilosec and Biaxin. This treatment kills bacteria and stops production of
stomach acid, but does not heal ulcer.
Patients in the acute care setting are often given protonx to prevent stress ulcers.

For delegating : LVN / Float RN = with stable pt with predictable outcome

enteral feeding= check ph
never leave the pt.
review compartment syndrome
choice betwee mother and fetus... focus on fetus first unless mom is dying
observing not usually the answer
hydrocephalus child-- do not elevate head, do provide frequent feedings
to prevent subdural hematoma-- lie flat
pku- no meat,fish,vegis and whole grains
cystic fibrosis= no fats, increase protein
renal failure look at creat clearance.. ability to clear meds
psychosocial.. "I" and "why" question not usually the answer
dead pt... remain with the family
"restlessly" a key word=hypoxia
"sometimes" not usually the answer
Head injury--look for DI
Burns =if to the fron of the body.. think AIRWAY
IV lasix.. think check the BP
wbc<500= reverse isolation
Rhinoplasty--place on side

Glycopyrrolate ( Robinul )-tx preanethestic agent, adjunct in peptic ulcer disease therapy, reverse
neuromuscular blockade. * has less CNS effects than atropine. Do not mix with barbituates or alkaline
drugs.
Atropine sulfate causes dry mouth & decreases secretions, which is why it is given as a preanethestic.
Atropine can cause constipation; high fiber foods and fluids should be encouraged.

Cancers that origionate from blood forming organs are leukemias.

A characteristic of a malignant tumor is that it will have a greater than normal blood supply.
One expected side effect of radiation therapy is stomatitis which is an inflammatory reaction in the mouth.
Interferons are used to treat hairy cell leukemis, chronic myelogenous leukemia, melanoma, and Kaposi's sarcoma.
You have to know these common disease in NCLEX:
hypertension
provide for physical and emotional rest
provide for special safety needs
health teaching (client and family)
dysrhythmias
provide for emotional and safety needs
prevent thromboemboli
prepare for cardioversion with atrial fibrillation if indiated
provide for physical and emotional needs with pacemaker insertion
cardiac arrest
prevent irreversible cerebral anoxic damage
establish effective circulation, respiration
angina pectoris
provide relief from pain
provide emotional support
health teaching
myocardial infarction
reduce pain, discomfort
maintain adequate circulation, stabilize heart rhythm
decrease oxygen demand/promote oxygenation, reduce cardiac workload
maintain fluid electrolyte, nutritional status
facilitate fecal elimination
provide emotional support
promote sexual functioning
health teaching
cardiac valvular defects
reduce cardiac workload
promote physical comfort and psychological support
prevent complications
prepare for surgery
cardiac catheterization & percutaneous transluminal coronary angioplasty
precatheterization:
provide for safety, comfort
health teaching
postcatheterization:
prevent complications
provide emotional support
health teaching
cardiac surgery
cardiopulmonary bypass
preoperative:
provide emotional and spiritual support
health teaching
postoperative:

provide constant monitoring to prevent complications

promote comfort, pain relief
maintain fluid, electrolyte, nutritional balance
promote emotional adjustment
promote early mobilization
health teaching
heart failure (HF)
provide physical rest / reduce emotional stimuli
provide for relief of respiratory distress; reduce cardiac workload
provide for special safety needs
maintain fluid and electrolyte balance, nutritional status
health teaching
pulmonary edema
promote physical, psychological relaxation measures to relieve anxiety
improve cardiac function, reduce venous return, relieve hypoxia
health teaching (include family or significant other)
shock
promote venous return, circulatory perfusion
disseminated intravascular coagulation (DIC)
prevent and detect further bleeding
pericarditis
promote physical and emotionl comfort
maintain fluid, electrolyte balance
chronic arterial occlusive disease
promote circulation; decrease discomfort
prevent infection, injury
aneurysms
provide emergency care before surgery for dissection or rupture
prevent complications postoperatively
promote comfort
health teaching
Raynauds phenomenon
Maintain warmth in extremities
Increase hydrostatic pressure, and therefore circulation
Health teaching
Varicose veins
Promote venous return from lower extremities
Provide for safety
Health teaching
Vein ligation and stripping
Prevent complications after discharge
Health teaching to prevent recurrence
Deep vein thrombosis (thrombophlebitis)
Provide rest, comfort, and relief from pain
Prevent complications
Health teaching
Iron deficiency anemia & Hemolytic anemia
Promote physical and mental equilibrium
Health teaching
Pernicious anemia
Promote physical and emotional comfort

Health teaching
Polycythemia vera
promote comfort and prevent complications
health teaching
leukemia (acute and chronic)
prevent, control, and treat infection
assess and control bleeding, anemia
provide rest, comfort, nutrition
reduce side effects from therapeutic regimen
provide emotional/spiritual support
health teaching
idiopathic thrombocytopenic purpura (ITP)
prevent complications from bleeding tendencies
health teaching
splenectomy
prepare for surgery
prevent postoperative complications
health teaching
fluid volume deficit
restore fluid and electrolyte balance-increase fluid intake to hydrate client
promote comfort
prevent physical injury
fluid volume excess
maintain oxygen to all cells
promote excretion of excess fluid
obtain/ maintain fluid balance
prevent tissue injury
health teaching
common electrolyte imbalances
hyponatremia
obtain normal sodium level
prevent further sodium loss
prevent injury
hypernatremia
obtain normal sodium level
hypokalemia
replace lost potassium: increase potassium in diet
prevent injury to tissues
prevent potassium loss
hyperkalemia
decrease amount of potassium in body
hypocalcemia
prevent tetany
prevent tissue injury
prevent injury related to mediction administration
in less acute condition
hypercalcemia
reduce calcium intake: decrease foods high in calcium
prevent injury

hypomagnesemia
provide safety
health teaching
hypermagnesemia
obtain normal magnesium level
respiratory adidosis
assist with normal breathing
protect from injury
health teaching
metabolic acidosis
restore normal metabolism
prevent complications
health teaching
respiratory alkalosis
increase carbon dioxide level
prevent injury
health teaching
metabolic alkalosis
obtain, maintin acid-base blance
prevent physical injury
health teaching
pneumonia
promote adequate ventilation
control infection
provide rest and comfort
prevent potential complications
health teaching
severe acute respiratory syndrome (SARS)
infection control
supportive care
atelectasis
relieve hypoxia
prevent complications
health teaching
pulmonary embolism
monitor for signs of respiratory distress
health teaching
histoplasmosis
relieve symptoms of the disease
health teaching
tuberculosis
reduce spread of disease
promote nutrition
promote increased self-esteem
health teaching
emphysema
promote optimal ventilation
employ comfort measures and support other body systems
improve nutritional intake

provide emotional support for client and fmily

health teaching
asthma
promote pulmonary ventilation
facilite expectoration
health teaching to prevent further attacks
bronchitis
assist in optimal respirations
minimize bronchial irritation
improve nutritional status
acute adult respiratory distress syndrome (ARDS)
assist in respirations
prevent complications
health teaching
pneumothorax & hemothorax
prevent damage until medical intervention available
protect against injury during thoracentesis
promote respirations
prepare client for closed chest drainage, physically and psychologically
prevent complications with chest tubes
health teaching
chest trauma
Flail chest
restore adequate ventilation and prevent further air from entering pleural cavity
thoracic surgery
preoperative care:
minimize pulmonary secretions
preoperative teaching
postoperative care:
maintain patent airway
promote gas exchange
reduce incisional stress and discomfort
prevent complications related to respiratory function
maintain fluid and electrolyte balance
postoperative teaching
tracheostomy
preoperative care
relieve anxitety and fear
postoperative care
maintain patent airway
alleviate apprehension
improve nutritional status
health teaching
burns
alleviate pain, relieve shock, and maintain fluid and electrolyte balance
prevent physicl complications
promote emotional adjustment and provide supportive therapy
promote wound healing wound care
health teaching
rheumatoid arthritis
prevent or correct deformities
health teaching

lupus erythematosus
minimize or limit immune response and complications
health teaching
infectious diseases
Lyme disease
minimize irreversible tissue damage and complications
alleviate pin, promote comfort
maintain physical and psychological well-being
health teaching
acquired immunodeficiency syndrome (AIDS)
reduce risk of infection; slow disease progression
prevent the spread of disease
provide physical and psychological support
health teaching
The perioperative experience
Preoperative preparation
reduce preoperative and intraoperative anxiety and prevent postoperative complications
instruct in exercises to reduce complications
reduce the number of bacteria on the skin to eliminate incision contamination
reduce the risk of vomiting and aspiration during anesthesia; prevent contamination of abdominal operative sites by fecal
material
promote rest and facilitate reduction of apprehension
protect from injury;ensure final preparation for surgery
intraoperative preparation
prevent complications
promote comfort
observe for indications of malignant hyperthermia
postoperative experience
promote a safe, quiet, nonstressful environment
promote lung expansion and gss exchange
prevent aspiration and atelectasis
promote and maintain cardiovascular function
promote psychological equilibrium
maintain proper function of tubes and appatatus
general postoperative nursing care
promote lung expansion
provide relief of pain
promote adequate nutrition and fluid and electrolyte balance
assist client with elimination
facilitate wound and prevent infection
promote comfort and rest
encourage early movement and ambulation to prevent complications of immobilization
general nutritional deficiencies
prevent complications of specific deficiency
health teaching
celiac disease
altered nutrition, less than body requirements
diarrhea
fluid volume deficit related to loss through excessive diarrhea
knowledge deficit
hepatitis
prevent spread of infection to others
promote comfort
pancreatitis

control pain
rest injured pancreas
prevent fluid and electrolyte imbalance
prevent respirtory and metabolic complications
provide adequate nutrition
prevent complications
health teaching
cirrhosis
provide for special safety needs
relieve discomfort caused by complications
improve fluid and electrolyte balance
promote optimum nutrition within dietary restrictions
provide emotional support
health teaching
esophageal varices: life-threatening hemorrhage
provide safety measures related to hemorrhage
promote fluid balance
prevent complications of hepatic coma
provide emotional support
health teaching
diaphragmatic (hiatal) hernia
presurgical: promote relief of symptoms
postsurgical:
provide for postoperative safety needs
promote comfort and maintain nutrition
health teaching
gastroesophgel reflux disease(GERD)
promote comfort and reduce reflux episodes
health teaching
peptic ulcer disease
promote comfort
prevent/ recognize signs of complications
provide emotional support
health teaching
gastric surgery
promote comfort in the postoperative period
promote wound healing
promote adequate nutrition and hydration
prevent complications
dumping syndrome
health teaching
total parenteral nutrition
prevent infection
preent fluid and eclectrolyte imbalance
prevent complications
diabetes
obtain and maintain normal sugar balance
health teaching
nonketotic hyperglycemic hyperosolar coma (NKHHC)
promote fluid and electrolyte balance
cholecystits/ cholelithiasis
nonsurgical interventions romote comfort

preoperative: prevent injury

postoperative romote comfort
prevent complications
health teaching
obesity
decrease weight, initially 10% from baseline
appendicitis
promote comfort
hernia
prevent postoperative complications
health teaching
diverticulosis
bowel rest during acute episodes
promote normal bowel elimination
health teaching
ulcerative colitis & Crohns disease
prevent disease progression and complications
reduce psychological stress
health teaching
intestinal obstruction
obtain and maintain fluid balance
relieve pain and nausea
prevent respiratory complications
postoperative nursing care
fecal diversion-stomas
preoperative period:
prepare bowel for surgery
relieve anxiety and assist in adjustment to surgery
postoperative period:
maintain fluid balance
prevent other postoperative complications
initiate ostomy care
promote psychological comfort
hemorrhoids
reduce anal discomfort
prevent complications related to surgery
health teaching-avoid constipation
pyelonephritis (PN)
combat infection, prevent recurrence, alleviate symptoms
promote physical and emotional rest
acute glomerulonephritis
monitor fluid balance, observing carefully for complications
provide adequate nutrition
provide reasonable measure of comfort
prevent further infection & health teaching
acute renal failure (ARF)
maintain fluid and electrolyte balance and nutrition
use assessment and comfort measures to reduce occurrence of complications
maintain continual emotional support
health teaching
chronic renal failure

maintain fluid/ electrolyte balance and nutrition

employ comfort measures that reduce distress and support physical function
health teaching
dialysis
reduce level of nitrogenous waste
correct acidosis, reverse electrolyte imbalances, remove excess fluid
kidney transplantation
preoperative:
promoe physical and emotional adjustment
encourage expression of feelings
health teching
postoperative:
promote uncomplicated recovery of recipient
observe for signs of rejection-most dangerous complication
maintain immunosuppressive therapy

nephrectomy
preoperative ptimize physical and psychological functioning
postoperative
promote comfort and prevent complications
renal calculi (urolithiasis)
reduce pain and prevent complications
health teaching
lithotripsy
enourage ambulation and promote diuresis through forcing fluids
benign prostatic hyperplasia
relieve urinary retention
health teaching
prostatectomy
promote optimal bladder function and comfort
assist in rehabilitation
urinary diversion
prevent complications and promote comfort
health teaching
laryngectomy
preoperative care: provide emotional support and optimal physical preparation
health teaching
postoperative care
maintain patent airway and prevent aspiration
promote optimal physical and psychological function
health teaching
aphasia
assist with communication
Menieres disease
provide safety and comfort during attacks
minimize occurrence of attacks
health teaching
otosclerosis & stapedectomy
preoperative health teaching, whend you notice hearing problem
postoperative

promote physical and psychological equilibrium

health teaching
deafnessmaximize hearing ability and provide emotional support.health teaching
glaucoma
reduce intraocular pressure
provide emotional support
health teaching
cataract & cataract removal
preoperative
prepare for surgery
postoperative
reduce stress on the sutures and prevent hemorrhage
promote psychological well-being
health teaching
retinal detachment
preoperative:
reduce anxiety and prevent further detachment
health teaching
postoperative
reduce intraocular stress and prevent hemorrhage
support coping mechanisms
health teaching
blindness
promote independence and provide emotional support
health teaching
traumatic injuries to the brain
sustain vital functions and minimize or prevent complications
provide emotional support and use comfort measures
increased inrcranial pressure
promote adequate oxygenation and limit further impairment
craniotomy
preoperative btain baseline measures
provide psychological support
prepare for surgery
postoperative
prevent complications and limit further impairment
epilepsy
prevent injury during seizure
postseizure care
prevent or reduce recurrences of seizure activity
health teaching
transient ischemic attacks
reduce cerebral anoxia
promote cerebrovascular function and maintain cerebral perfusion
provide for emotional relaxation
client safety
health teaching
pain
immobility

complications of fractures
types of traction
teaching crutch walking
compartment syndrome
recognizes early indications of ischemia
prevent complications
osteoarthritis
promote comfort: reduce pain, spasms, inflammation, swelling
health teaching to promote independence
total hip replacement
preoperative:
prevent deep vein thrombosis or pulmonary emboli
prevent infection: antibiotics
health teaching
postoperative
prevent respiratory complications
prevent complications of shock or infection
prevent contractures, muscle atrophy
promote early ambulation and movement
prevent constipation
prevent dislocation of prosthesis
promote comfort
health teaching
total knee replacement
achieve active flexion beyond 70 degrees
amputation
prepare for surgery,physically and emotionlly
promote healing postoperatively
gout
decrease discomfort
prevent kidney damage
health teaching
primary hip arthroplasty
herniated/ reptured disk
relieve pain and promote comfort
health teaching
laminectomy
relieve anxiety
prevent injury postoperatively
promote comfort
prepare for early discharge
health teaching
spinal cord injuries
maintain patent airway
prevent further damage
relieve edema:anti-inflammatory medications,corticosteroids
relieve discomfort,analgesics,sedatives,muscle relaxants
promote comfort

prevent complications
health teaching
posterior spinal fusion (PSF)
spinal shock
prevent injury related to shock
autonomic dysreflexia
decrease symptoms to prevent serious side effects
maintain patency of catheter
promote regular bowel elimination
prevent decubitus ulcers
hyperthyroidism
protect from stress
promote physical and emotional equilibrium
prevent complications
health teaching
thyroid storm
thyroidectomy
promote physical and emotional equilibrium
prevent complications of hypocalcemia and tetany
promote comfort measures
hypothyroidism
provide for comfort and safety
health teaching
cushings disease
promote comfort
prevent complications
health teaching
pheochromocytoma
prevent paroxysmal hypertension
prepare for surgical removal of tumor
adrenalectomy
preoperative:reduce risk of postoperative complications
postoperative promoe hormonal balance
prevent postoperative complications
health teaching
Addisons disease
decrease stress
promote adequate nutrition
Health teaching
Multiple sclerosis
maintain normal routine as long as possible
decrease symptoms-medications as ordered
Myasthenia gravis
promote comfort
decrease symptoms
prevent complications
promote increased self-concept
health teaching

Parkinsons disease
promote maintenance of daily activities
protect from injury
Amyotrophic lateral sclerosis (ALS)
maintain independence as long as possible
health teaching
Guillain-Barre syndrome
prevent complications during recovery from paralysis
monitor for signs of autoimmune dysfunction
prevent tachycardia
assess cranial nerve function
maintain adequate ventilation
in acute phase:check for progression of muscular weakness
maintain nutrition
prevent injury and complications
support communication
Chemotherapy
assist with treatment of specific side effect
health teaching
Radiationtherapy
External radiation:
prevent tissue breakdown
decrease side effects of therapy
health teaching
internal radiation : sealed
assist with cervical radium implantation
health teaching
internal radiation: unsealed
reduce radiation exposure of others
Immunotherapy
decrease discomfort associated with side effects of therapy
health teaching
Palliative care
make client as comfortable as possible
assist client to maintain self-esteem and identity
assist client with psychological adjustment
Types of cancer:
Lung cancer
Make client aware of diagnosis and treatment options
Prevent complications related to surgery
Assist client to cope with alternative therapies
colon and rectal cancer
assist through treatment protocol
surgery reoperative
preparefor surgery
promote comfort
postoperative :
facilitate healing
prevent complications
facilitate rehabilitation
health teaching
breast cancer
assist client through treatment protocol

prepare client for surgery

reduce anxiety and depression
prevent postoperative complications
support coping mechanisms
health teaching
uterine cancer
prostate cancer
assist client through treatment protocol
prepare client for surgery
assist with acceptance diagnosis and treatment
prevent complication during postoperative period
bladder cancer
laryngeal cancer
additional typers of cancer,etc.
when taking cyclosporine (Sandimmune) to prevent graft rejection, remember that these GEAK, increase cyclosporine level...
G - grapefruit
E - erythromycin
A - amphotericin B
K ketokonazole
Atopic dermatitis is an inflammatory condition involving a skin reaction to irritants or allergens.
*Clinical features of SLE involve multiple body systems.When the musculoskeletal system is involved, the client has joint tenderness,
edema, and morning stiffness.
*Eyes that are red,burning,or tearing are commonly associated with allergic rhinitis ( hay fever ).
*Psoriasis is marked by profuse,erythmatous scales or plaques, often covering large areas of the body. The client may complain of
itching, pain and possibly of arthritic symptoms such as joint stiffness.
*Restasis is for dry eyes. ( as seen on tv )
*Boniva is for osteoporosis ( taken once a month )
Does anyone remember the side effects of Boniva? If you do could you please list them? I have not seen the commercial in a while.
Thanks!
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

UAP (Unlincensed Assisitive Personnel) should be able to perform "routine" trach care
Only RN & PN can delegate to UAPs. One UAP can not delegate task to another UAP
Antihistamines can aggravate urinary incontinence. Teach pt accordingly
Atropine is contraindicated for a client with angle-closure glaucoma b/c it can cause pupillary dilation with an increase in
acqueous humor, leading to a resultant increase in optic pressure
Warn asthma pt about using aspirin. It can induce an asthma attack
Assess mood change in pt taking Aldomet for HTN
It is critical to assess weight of a 10 years old starting heparin therapy
Demerol is contraindicated in clients with sickle cell disease. It may cause seizures
Silvadene (used for severe burns) may cause a transient neutropenia as well as renal fct changes with sulfa crystals
production & kernicterus
A pt with C4 spinal cord injury may still have an erection (reflex rx)
Normal serum albumin in elderey (3.0-5.0 g.dl)
Pt taking ACE inhibitors (Lisinopril, Captopril,...) may avoid foods high in K and salt substitutes (risk of hyperkalemia)
Malignant hypertheremia is a rare potentially fatal adverse rx to inhalated anesthetics. There is a great genetic predisposition
to this disorder
Anticholinergics may exacerbate symptoms of GERD
The eldery are at risk for developing confusion when taking Cimetidine (Tagamet)

Thiazide diuretics increase blood sugar.

*Diabetics need food high in potassium like oranges, bananas, and broccoli.

*Vitamin K is a natural coagulant, so should be avoided if using blood thinners.

*ACE-Inhibitors are the primary drug of choice for vasodilation in heart failure.
*Vitamin B12 is essential for nervous system function. Neurological manifestations of B12 deficiency can include paresthesias.
*Immobility can cause stores of calcium in the bone to enter the bloodstream which can result in hypercalcemia.
*Aldosterone conserves sodium and promotes potassium excretion which helps to control sodium and water balance.
*Low blood volumes stimulates the pituitary to secrete antidiuretic hormone.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Normal total serum protein level is 6.0-8.0 g/dL

Xanax is a short term benzo useful in controlling panic symptoms quickly
Prozac (a SSRI) side effects are diarrhea, dry mouth, weight loss, reduced libido
Succinylcholine (Anectine) is given before ECT (Electroconvulsive therapy)
Cardioversion is contraindicated if the pt received digoxin during the preceding 24 hours
The most common problem associated with enteral feedings is atelectasis
Infant with intussusception => "Currant jelly" stools (blood and mucus stools)
Infant with pyloric stenosis => projectile vomiting
Child with Hirschsprungs disease => Ribbonlike stools
Child with Wilms tumor => Palpable mass over the flank ... FYI NEVER PALPATE THE ABDOMEN IF YOU SUSPECT
WILMS TUMOR...
11. Infant with biliary atresia => abdominal distention, poor weight gain , clay-colored stools
12. A severe complication of Kawasaki disease is the creation of a giant aneurysm
13. Desferal (deferoxamine) is used to treat iron toxicity

Immunization schedule
Hep B - birth,2, 4, 6 months
Hep A- after 1st bday and 6 months later
Rotavirus- 3 doses total at 2, 4, 6 months ( must be given before 32 weeks of age)
Dtap 2, 4, 6, 12, months, age 4 or before school
Pneumococcal - 2,4, 6, 12 months
Inactivated poliovirsu - 2, 4, 6, 12, months and 4th dose at age 4
Infleunza after 6 months and yearly thereafter
Haemophilus influenza- 2, 4, 6 months & another dose after 1st birthday
MMR- after age 1, age 4
varicella 12 months, age 4
HPV- 9-25 years, 3 doses total give first dose, 2 months later give second dose, 6 months later give 3rd dose

When giving Kayexalate we need to worry about dehydration ( K ha ineverse relationship with Na)
Impetigo- ok to care by pregnant nurse, need to wear gloves and gowns
Yogurt has live cultures- dont give to immunosuppressed pt
Itching under cast area- cool air via blow dryer, ice pack for 10- 15 minutes. NEVER use qtip or anything to scratch area

PS: What is the antidote for digoxin and opioid analgesics? I am sure you know...
Antidote for digoxin is digibind
antidote for opiod analgesic is narcan
antidote for lovenox is protamin sulfate and NO labs reqd for lovenox

My way of understanding the ABGs:

pH=7.35-7.45 (below 7.35 is acidosis)
PCO2= 35-45 (above 45 is acidosis)
O2= 80-100%
HCO3= 22-26 (Below 22 is acidosis)
The value parameters are the opposite for alkalosis
If the pH is increased (>7.40) and the pCO2 is decreased (<35)...Resp alkalosis
If the pH is decreased (<7.40) and the pCO2 is increased (>45)...Resp acidosis
If the pH is increased (>7.40) and the HCO3 is increased (>26)...Met Alkalosis
If the pH is decreased (<7.40) and the HCO3 is decreased (<22)...Met Acidosis

Re: Anyoone up for random FACT THROWING??

Some more Nursing Nuggets ....
- Suction for an NG shouldn't exceed 25 mm Hg
- Serum Protein 6 - 8
- Ammonia 35 - 65 (increases hepatic disease, enceph, NO PROTEIN if eleveated
- Amylase - 25 - 151 (increases with pancreatitis, levels are higher in acute pancreatitis than with chronic pancreatitis. ETOH most
common reason for chronic Panc.)
- Lipase 10 - 140
- Kosher meals : NO dairy and meat in same meal. No shrimp/shellfish b/c fish must have scales.
- Low residue diet for ileostomy. NO stool softners or laxatives (no docusate or Milk of Mag, cuz might lead to fluid / electrolyte
imbalances)
- Pork is good source of thiamine
- If pt coughs/resp distress while putting in NG, pull back and wait until coughing/resp. distress is resolved then attempt again.
Remember pt should be in High Fowlers, when tube reaches orophar., neck must be flexed to cover airway and swallow sips of h20 to
facilitate tube).
- Pancreatitis pain: epigastric pain radiate to back (remember that pancreas is retroperitoneal (behind). Afterall, Turner's sign, seen
with panc. is grayish/bluish around the flanks.
- Prolapsed stoma - protrusion of stoma
- Retracted stoma - sunken, hidden
- Ischemic stoma - dusky
- Normal stoma - beefy red, may bleed a lil when washed/irrigated, normal
- Red Meat / Turnips / Hoarseradish may give false + for guaiac.
- When given an adult dose and asked about the kids dose you take the ADULT DOSE X Kids weight in POUNDS / 150 = childs
dose.
- No sunscreen for infants < 6 mo old.
- Normal responses to dye : feeling warm, face flushin, salty taste . URTICARIA IS NOT NORMAL - indicative of serious rxn
- ASA often is a trigger for an asthma attack
- Koch/Kock Pouch- is continent, doesn't nec need a drainage bag, use absorbent dressing on it. Drain with catheter Q 3-4.

PE prevention= Turn pt. Left side for 20-30 min allows air enter R atrium and Pulmonary artery
Ethambutol ADR =Optic Neuritis color blind for green is initially.
Pyrazinamide (PZA) = DC if big toe pain; means Hyperuricemia ;Gout.
Rifampin body fluids orange;contact lenses permanently stained.
Immediately after a pt is put on mech ventilator check BP (Hypotension)
Most important after ileostomy surgerycheck ileostomy output
Epiglottisinflamation of epiglotis, life threatning, NO tongue blade. Determine need for O2 by
Pulse OX and start IV. Tx : Moist O2 & antibiotics
Humera tx Rheumatoid arthritis, Chrohns if other meds no help, psoriasis prevent further
damage to bones/joints. get a TB test done before starting humera.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Adriamycin= bone marrow suppression =notify doctor if s/s infection (fever,sore throat)hematuria
ok for 1-2 days of start stomatitis(ulceration of mouth) ok after 10-15 days start =rinse mouth
with water, sponge brush for teeth.
Dislocation of prosthesis for hip surgery leg outwardly rotated, shortening, pain, inability to
move.
NO tongue blade for tonic clonic seizures ,can chip teeth.
Paracentisis provide a BP cuff. Check BP s/s of shock.
NO Tetrahydrolazine (Visine ) for Open Angle Glaucoma Ophtalmic vasoconstrictor used as gtt in
the eye. Caution with HTN.

Fifth disease (erythema infectiosum) is caused by human parvovirus B19 (droplet precautions right?...). It is found in
respiratory secretions. It is NOT CONTAGIOUS after the rash develops
Morphine toxicity => Patient's pupils are pinpoint
Neostigmine (Prostgmin) is a cholinergic and can cause bronchoconstriction in asthmatic patients
Native Americans have the highest incidence of cleft lip and palate
Prolapsed cord => Put pt in trendelenburg position
Latex allergies => Assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts,
tomatoes, peaches
Pt with glaucoma => The priority is to prevent deterioration of the vision; vision can not be improved
Myelogram => Meds that lower the seizure threshold (phenothiazines, thorazine), MAO inhibitors (Marplan, Nardil,
Parnate), tricyclic antidepressants (Tofranil, Elavil), CNS stimulants, psychoacive drugs (Ritalin) should be held for
48 hrs before and 24 hrs after test
In panic level anxiety, the pt is unable to see, hear or function
Double-bind communication => emotions communicated verbally are opposite of emotions communicated physically
Depressed client => help client to identify unrealistic behaviors
Benztropine (Cogentin) => treat parkinsonian side-effects of anitpsychotics meds
Imipramine (Tofranil) => tricyclic antidepressant used to treat panic attacks
CPR adults => depress sternum 1.5 to 2 inches; rescue breaths 12 times per minute
Pt with a dislodged trach => Priority is to hyperextend the pt neck (patent airway...) Not 100% sure about that one but you
can look it up or give additional inputs...
Pt allergic to sulfa drugs should take Cipro
Vecuronium (Norcuron) (neuromuscular blocking agent) is given to a pt who is fighting the ventilator... => Pt is unable to
blink! Administer complete eye care
Pt on dilantin => Urine may turn pink, red or brown...

Here's my share:
BRAT (Banana, rice, apple, toast/tea) - NOT recommended for a child with acute diarrhea (has low nutritional value, low
protein/energy, high carbs)
SHOCK - elevate lower extremities to improve circulation to the brain and vital organs
Ct with dementia - reinforce ROUTINE, talk to ct face-to-face
Barium enema - take slow deep breaths, tell ct stool will be light-colored for 2-3 days after test
DIC - oozing blood; sepsis is most frequent cause
hospitalized school-age child = greatest fears are perceived loss of control and separation to friends/peers
Licorice - increases K+ loss, DONT take to prevent Digoxin toxicity
epiglottitis - NEVER insert a tongue blade - gag reflex can obstruct airway
Dilantin comes in a suspension, SHAKE it!!

So Many Wonderful Tips! Thanks to all who have contributed to this thread!!!!!
* Active aquired immunity consists of immunologic responses that develop as the body is being defended.
* Rheumatic endocarditis results from rheumatic fever caused by group A streptococcal infection.
* People with type O blood are more susecptible to peptic ulcers.
* Tagamet is used in tx of peptic ulcers because it inhibits acid secretion.
* Diverticulitis is most often tx with diet and meds.

*The ideal tx for UTI is an antibacterial agent such as trimethoprim-sulfamethoxazole.

* A positive antibody test for HIV means you have been infected with the HIV virus & your body has produced
antibodies.
* AZT ( Zidovudine ) works to fight against AIDS by inhibiting new virus production.
* Herpes Simplex Type I is the virus that causes cold sores on the lips.
* Signs of meningitis include a positive Kernig's sign, a positive Brudzinski's sign , headache , fever and nuchal
rigidity.
* Varicella Zoster is transmitted by airborne contact.
* Ceftriaxone and doxycycline are used to tx gonorrhea.
* Wear gloves when in contact with excretions, secretions, blood, or any other body fluids.
* Complications of chlamydial infections significantly contributes to the incidence of ectopic pregnancy.

The secondary stage of syphilis is when the rash appears.

The medication of choice for syphilis is penicillin G benzathine.
Staphylococcous is the organism responsible for most skin infections.
The drug of choice for MRSA is vancomycin.
When assessing a pt. with diarrhea, the nurse should first determine hydration status.
Legionaire's disease is treated most often with ethromycin.
Signs & symptoms of wound sepsis include elevated pulse and temperature, elevated WBCs , swelling, warmth, and tenderness.
Lesions at the midbrain result in decerebrate posturing.
The motor cortex governs voluntary motion.
Upper motor neurons refer to motor pathways from the brain to the spinal cord.
Destruction or dysfunction of the basal ganglia leads to muscle rigidity.
Most important indicator of increased ICP is a change in LOC.
In adults, most brain tumors origionate from glial cells.

More facts:
* Tensilon is used in myesthenia gravis to confirm the diagnosis.
* Myesthenia gravis is caused by a disorder in the transmission of impulses from nerve to muscle cell.
* Amyotrophic lateral sclerosis ( ALS ) is a condition in which there is a degeneration of motor neurons in both the upper & lower
motor neuron systems.
* The trend in tx of rheumatoid arthritis is with COX-2 that acts as an anti-inflammatory.
* Paget's disease is characterized by excessive bone destruction, skeletal deformities, and cortical thickening.
Chicken Pox-tx with Acylovir
Diptheria-tx with diptheria antitoxin, penicillin; erythromycin
Lyme Disease-tx with tetracycline;penicillin
Typhoid Fever-tx with chloramphenicol; ampicillin; sulphatrimethoprim
Expected patient outcomes for a patient with osteoporosis include: has positive self-esteem, experiences no new fractures, understands
factors that contribute to potential injury.

Nursing management of pt.with cerebral aneurysm or intracranial hemorrhage:

use gentleness in moving pt.
keep room darkened
keep pt. on bedrest, HOB at 30 degrees
give no ice water
initiate bowel program to prevent straining at stool
only a few visitors at a time
decrease stimuli, no tv no radio in severe cases
no rectal temperatures, no enemas, no suppositories
Tips on answering nclex-rn questions
Decide What the Question is Dealing With:
Which part of the Nursing Process: Assessment; Analysis; Planning; Implementation or Evaluation?
Next, Decide the Order of Priority First you must decide what part of the nursing process the question is connected with:
ANALYSIS--is the process of identifying potential and actual health problems. Most identify pertinent assessment information and
assimilate it into the nursing diagnosis. Prioritize the needs that have been identified during analysis. Some common words that are
associated with ANALYSIS questions: diagnose; contrast; compare; analyze; order; prioritize; define; classify; catagorize; synthesize;
sort; arrange;
ASSESSMENT--consists of a collection of data. Baseline information for pre and post procedures is included. Also included the
recognition of pertinent signs and symptoms of health problems both present and potential. Verification of data and confirmation of
findings are also included. Assess a situation before doing an intervention. Some common words that are associated with
ASSESSMENT questions: observe; gather; collect; differentiate; assess; recognize; detect; distinguish; identify; display; indicate;
describe; PLANNING--Involves formulating goals and outcomes. It also involves various members of the health care team and the
patient's family. All outcome criteria must be able to be evaluated with a specific time frame. Be sure to establish priorities and modify
according to question. Some common words that are associated with.
PLANNING questions: rearrange; reconstruct; determine; outcomes; formulate; include; expected; designate; plan; generate;
short/long term goal; develop;
IMPLEMENTATION--Addresses the actual/direct care of a patient. Direct care entails pre, intra and postoperative management,
preforming procedures, treatments, activities of daily living. Also includes the coordination of care and referral on discharge. It
involves documentation and therapeutic response to intervention and patient teaching for health promotion and helping the patient
maintain proper health. Some common words that are associated with IMPLEMENTATION questions: document; explain; give;
inform; administer; implement; encourage; advise; provide; perform;
EVALUATION--Determines if the interventions were effective. Were goals met? Was the care delivered properly? Are modification
plans needed. Addresses the effectiveness of patient teaching and understands and determines in proper care was offered. Evaluation
can involve documentation, reporting issues, evaluates care given and determine the appropriateness of delegating to others. Most
significantly, it finds out the response of the patient to care and the extent to which the goals we met. Some common words that are
associated with EVALUATION questions: monitor; expand; evaluate; synthesize; determine; consider; question; repeat; outcomes;
demonstrate; reestablish; After determining what part of the nursing process the question is concerned with, next focus your attention
on determining the category of priority: Safe and effective care environment is always first. Patient safety is related to the proper
preparation and delivery of nursing techniques and procedures as part of the nursing practice. It relates to every aspect of the delivery
of care. Physiologic integrity is the ability to provide competent care Information that may be described as traditionally medicalsurgical and pediatric nursing falls into this category. Specific questions in this area can be related to many direct-care aspects of
nursing practice. The importance of this area is highlighted because it is one in which planning, implementation and evaluation of care
needs can easily be identified and tested. Physiologic integrity is always a slight lower priority than safety unless it involves airway,
breathing and circulation. "ABC's" always comes first! Psychosocial integrity tests the knowledge about a patients response to a
disease or disorder. An understanding of stress, anxiety and ways to cope are essential. This is a lower priority the physiological
integrity. Health maintenance deals with health promotion, health teaching, disease prevention and assessment of risk factors for
health problems. Normal growth and development is a major theme in this category. This however, is a low priority.
In Summary, when choosing the right answer for you NCLEX exam question: 1) ask yourself, "what part of the nursing process is this
question dealing with: analysis, assessment, planning, implantation or evaluation? and 2) Remember to prioritize your choices: safety
always being first, second physiological integrity, third,psychosocial integrity and health maintenance always has the lowest priority
when choosing an answer.

Other tidbits: avoid choices with the answers "all" "always" "never" or "none". Nothing is ever a definite in Science. look for answers
that are different. If three answers say the same thing but in different words, choose the answer that is different. when given choices
that are pharmacologically based or non pharmacologically based, choose the non pharmacological intervention. It is more often then
not, the correct answer.
the decelerations during pregnancy get confused in my head. this is what I use to keep them straight. note the bold text.
early deceleration - fetal head compression (the ear is a part of the head)
late deceleration - uteroplacental insuffiency
variable deceleration - umbilical cord compression

with urolithiasis avoid wearing synthetic underwear and pantyhoses.

salt substitutes shouldnt be used by clients with chronic renal failure due to risk of hyperkalemia.
s/s of epididymitis- scrotal pain and edema, n/v, and chills

SPINAL NERVES cross tracts as opposed to CRANIAL NERVES if you are paralyzed on the left, your right brain is screwed up.
HOWEVER, if your left eye doesnt constrict its your LEFT BRAIN thats screwed up (Get it? Cuz the cranial nerves dont cross
tracts but the spinal nerves that innervate your skeletal muscles do..)
Most likely for things to go down the Right Bronchus cuz its shorter, fatter and more vertical. If after intubation, there are decreased
breath sounds/ decreased lung expansion on the left, its probably b/c the person who intubated put the ETTube down too far, past the
carina (where its supposed to be) and its in the right bronchus.
Kids with spina bifida are more prone to latex allergies
Pregnant women can not administer Ribavarin (for RSV)
Mumps can lead to male infertility
BNP (B type natriuretic peptide) should be <100, used to diagnose CHF
RAST radioallergosorbent test measures Ig E for latex allergy
6L Nasal Cannula is the most you can give, anything above that really doesnt improve oxygenation. 1L NC = 24% Fi02, 2 L = 28%, 3
L = 32% get it? Keep adding four until you get to 6L = 44% Fi02
Nonrebreather give you the most Fi02, Venturi allows you to give the most precise amount, Face tent is use with facial trauma/burns
Incentive spirometer tell patient to inspire, hold, get floater-thing to about 600-900 then exhale.. 10X per hour awake. Pt must be
able to breathe spontaneously and make a tight seal around the mouthpiece.
Yearly Occult blood tests are good to catch colon cancer (I would be hesitant to pick colonoscopy over occult blood tests).
With Hepatitis, early signs include bone pain (arthalgia) and flu like symptoms
T tube to drain bile. Normal output/day = 500 1000cc. Clamp before meals so pt can use bile to digest food.
With pneumonia, you will hear BRONCHIAL sounds in areas of consolidation.
BiPAP = CPAP and PEEP
ARDS is often unresponsive to increased 02 intubate. Placing prone may help.

Pancreatitis is a painful inflammatory condition where it's enzymes are prematurely activated and results in autodigestion. Some of the
most common causes are: gallstones, alcoholism, trauma, viral infection, genetics, etc.
Nursing Priorities:
1. control pain and promote comfort
2. treat/prevent fluid & electrolyte imbalance
3. reduce pancreatic stimulation while maintaining adequate nutrition
4. prevent complications
5. provide client teaching re: disease process, prognosis, treatment needs
Give meds as ordered which usually include: narcotic analgesics, sedatives ( valium, antispasmodics like atropine ), antacids
( maalox ), may also give Prevacid or Tagamet, etc.
Here are some more:
Levothyroxine (Synthroid)thyroid preparation. Give at breakfast to prevent insomnia.
Carbamazepine (Tegretol)interferes with contraceptives. SE: photosensitivity.
Isoniazid (INH)SE: peripheral neuropathy (administer pyridoxine Vit. B6), rash, urticaria, and swelling of
the face, lips, and eyelids.
Carbamazepine (Tegretol)prevention of seizures and relief of pain in trigeminal neuralgia. Trigeminal
neuralgia (Tic douloureux) is an agonizing pain that may result in severe depression and suicide.
Clonidine (Catapres-TTS)a centrally acting alpha-adrenergic for HTN; SE: drowsiness, sedation,
orthostatic hypotension, heart failure. If patch used be cautious around microwaves results in burns,
dispose of carefully, and heat will increase medication absorption leading to toxicity.
Autologous bloodmay 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 Parkinsons disease. Take immediately before
meals and high-protein meals may impair effectiveness of medication. Reduces rigidity and bradykinesis
and facilitates clients mobility.
Doxycycline (Vibramycin)a tetracycline 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. SE: 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 . SE: fungal infections, dry mouth, throat infections.
Topiramate (Topamax) 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 may mask symptoms of hypoglycemia
Phenazopyridine (Pyridium)acts on urinary tract mucosa to produce analgesic or local anesthetic effects.
SE: bright orange urine, yellowish discoloration of skin or sclera indicates drug accumulation due to renal
impairment.
Trimethoprim-sulfamethoxazole (Bactrim)most common SE : mild to moderate rash (urticaria)
Aminoglycosides are ototoxic.
Butorphanol Tartrate (Stadol)analgesic for moderate/ severe pain; SE: change in BP, bradycardia,
respiratory depression.

Onchyomycosis is a fungal infection of the nail plate.

* Hirsutism is a male pattern of hair growth in women that may be normal or the result of excessive secretion of androgenic

hormones.
* Psoriasis is a chronic skin disease with thickening of both the epidermis and dermis, with scaly, pruritic, erythmatous
plaques.
* A furnucle is an infection of the hair follicle that extends to the surrounding tissue.
* A carbuncle is a collection of infected hair follicles that forms a draining abcess.
* Cellulitis is a diffuse infection of the dermis and subcutaneous tissue.
Some more nuggets:
1) Oligomenorrhia/Amenorrhia - Thyroid Storm/Thyrotoxicosis
2) Menorrhagia - Hypothyroidism
3) PTU, used to tx hyperthy causes leukopenia, agranulocytosis - watch out for sore throat and other signs of dec. immune sys
4) Addison's pts may need more glucocorticoids (sugar) in times of stress: ie before dental surgery/oral procedure / surgery
5) Excessive Prolactin causes galactorrhea (excessive milk flow), decreased libido in men, impotence. Hypophysectomy can help.
6) Incision in a transphenoidal hypophysectomy is made between the gingival mucosa of the upper teeth and upper lip area. (So btw
upper gum and upper lip)
7) S/S Disulfram rxn - flushing, angina, palpitations, vertigo,
8) It is the OCULOMOTOR (CN III) not OPTIC that causes the pupillary changes in increased ICP.
9) Loss of central vision is a sign of macular degeneration

Macrocytic/megaloblastic anemias are most commonly caused by vitamin B12 deficiency. Pernicious anemia can be fatal
unless vitamin B12 replacement is given.
* Microcytic-hypochromic anemias are characterized by small red cells with insufficient hemoglobin content. The most
common cause is iron-deficiency.

Always taper steroids if taking chronically --> never stop abruptly!

Earliest sign of larynx cancer is hoarseness or change in vocal quality.
If in doubt whether a patient is hyper or hypoglycemic, treat pt for hypoglycemia.
CSF leakage through the nose (rhinorrhea) or through the ear (otorrhea) = increased ICP --> DO NOT SUCTION!
Positioning for Cleft lip and Cleft palate
Cleft lip - on side or upright in infant seat (not prone)
Cleft palate - on side or abdomen
Transesophageal Fistula (TEF) - esophagus doesn't fully develop (this is a surgical emergency)
The 3 C's of TEF in the newborn:
1) Choking
2) Coughing
3) Cyanosis
Pyloric stenosis - projectile vomiting
Intussusception - "currant jelly" stools (blood and mucus mixed)
Here's One....
A person with eczema is at greatest risk for latex allergy!
Two...
Always see difficulty breathing, swallowing, or person with pain after giving pain med an hour ago FIRST
Three...
When getting pt out of bed have open end of chair facing the foot of the bed.
Four...

Ausculate S3 and S4 extra heart sounds by turning pt on the left side and using the bell of stethoscope to listen at apex.
Five...
The more babies out.. its get loose... more prone to hemorrhage
Some pharm stuff I typed from before using the ATI review:
(hope it helps)....
Hallmark signs of digoxin toxicity blurred and double vision
Guaifenesin can cause drowsiness, so ct should avoid drivingthat requires alertness
Anticholinergic effect urinary retention
Safe to take with albuterol (Proventil) for a ct with cardio disease spironolactone (aldactone) =>K+
sparing diuretic that decreases risk of hypokalemia & ECG changes)
Supplemental thyroid hormone (Levothyroxine) for hypothyroidism will be required throughout the childs
LIFETIME.
Severe allergic rxn to Cephalosporins ct have high incidence of allergic rxns to PENICILLINS (avoid
penicillins)
Ct receiving Phenobarbital IV for anticonvulsant therapy, interventions include:
Observing the ct for RR depression
Monitoring the ct for excessive sedation
Avoiding extravasation of the parental soltn
Sumatriptan (Imitrex) SQ therapy take medication AS SOON AS MIGRAINE SXS APPEAR/ATTACK
Intravenous fastest, most effective route; deliver the medication directly into the bloodstream, allowing
rapid distribution throughout the body
Opioid antagonist (Naloxone, narcan) increase RR, improvement of RR
Baclofen improved ability to perform ADLs in spinal cord injury pts (decreases frequency & severity of
MUSCLE SPASMS)
Erythromycin (Erythrocin) contraindicated with chronic alcoholism & cirrhosis who has resp infection
(liver toxicity)
Review insulin drawing in syrine (units)
Cts taking K+-sparing diuretics should avoid consuming foods that contain high levels of K+. Salt
substitutes are high in K+ chloride content.
A ct dx with acute MI is tx in an emergency dept with alteplase (Activase) which has a short half-life
must administer drug concurrently with alteplase => heparin (short half-life opens an occluded artery
quicky, reduce risk of reocclusion with heparin)
17 yr old ct receiving testosterone (Depo-Testosterone) injections monthly to correct delayed puberty,
monitor use x-rays of the hand & wrist q 6 mos. (determine rate of bone maturation, drug can help
bone mature w/o producing a compensating gain in liner growth)
With renal impairment, there is decreased elimination of atropine => [FONT='Times New Roman','serif'][/font]
anticholinergic effects of atropine = confusion
A diuretic Acetazolamide (Diamox) contraindicated with SULFONAMIDES
Hold Metoprolol (Lopressor) dose if client develops DYSPNEA (sign of exacerbation of congestive heart
failure, might precipitate it)
Progestins (oral contraceptive) can cause WT GAIN can increase appetite
How to use a metered-dose inhaler to administer albuterol (Proventil)
Hold the inhaler so that drugs metal canister is inverted
Release 1 or more test sprays into the air if its a new inhaler
Shake the inhaler before administering a dose
Rinse mouth with water p the last inhalation
A pplying a cool, damp cloth to persons forehead, neck, wrists helps promote comfort for pts who are
N&V
Ct taking Allopurinal (Zyloprim) to reduce uric acid level for secretion, must avoid CORN tends to
acidify urine and might increase the risk of URIC ACID STONE formation.
Dry persistent cough common during 1st wk of ACE inhibitor therapy d/t accumulation of bradykinin
from inhibition of angiotension-converting enzymes
Giving 2 antiHTNs together interact synergistically (potentiation) => the effect of giving both drugs
should be greater than that of either administered alone

Lasix/furosemide check BP (can cause a substantial drop in BP by decreasing circulatory volume and
by relaxing venous smooth muscle => reduce venous bld return to the heart)
Collagenase (Santyl) to tx leg ulcers within about a week, this ointment will remove dead tissue so that
ulcers can heal
Immunizations with live vaccines long-lasting active immunity
Ct receiving Epoetin (Procrit) to tx anemia, rxn r/t this drug HA (if hct rises too quickly, HTN & seizure
can result HA is early sign)
2nd cycle of Fertinex for fertility txment verifies that todays dose is based on the cts response in the
preceding cycle
Bronchospasm SOB and hypoxia
Interaction between Reglan & Morphine increased SEDATION
MANNITOL MUST BE USED WITH EXTREME CAUTION IN CTS WHO HAVE HEART DISEASE => CHF AND
PULMONARY EDEMA
Benadryl DONT USE SLEEPING PILL (avoid CNS depressants to could increase sedation)
Life-threatening rxn to GAMMA GLOBULIN = chest tightness, bronchoconstriction,
angioedema, hypoTN anaphylaxis
Nurse to apply sulfamylon to burn injury:
o Administer the PRN analgesic 30mins before applying (for pain, b/c it is painful)
o Apply p daily tubbing (to remove old previously applied cream)
o Monitor f&e & acid base balance
o Sched wound care at least 1hr before meals (time to recover)
Thrombocytopenia = platelet count <150,000/microleter
Cyclosporine (Neoral) mix the drug with milk/juice to increase taste/palatability
Hexachlorophene (phisohex) harmful for breastfeeding
Review PEDS calculations (with kg)
Gold salt therapy on rheumatoid arthritis slows progression of disease
Uric acid should be monitored prior to and periodically throughout therapy with thiazides and related
diuretics (hyperuricemia is one or more common SE of thiazides)
Simvastatin (Zocor) required lab test during therapy Creatine kinase
Ct who has most risk factors for depression 35 yr old single FEMALE (living alone, ages: 25-44)
The public health nurse provides health care to a single population of ppl. The primary difference
between PHN & Occupational & School health nsg is that O&S are limited to one geographic setting and
one subpopulation (type) of ct
Adult day care centers provide temporary care for elders who live at home with family/friends, but
need supervision & help during workday
LBW Baby consumed cows milk before 6 months of age iron deficiency anemia => get hgb level
To achieve complete eradication of Hepatitis B required immunization of all infants & children
Family 1 or more individuals possess some common emotional bond
Ethnicity group of ppl who share common, distinctive characteristics such as race, ancestry,
nationality, language, religion, food preferences, hx
Medicaid administration falls to STATE govts
Healthy ppl 2010 set of health goals for aggregates; rationale is that our society can little afford the
cost of tx preventable diseases and injuries
Early crisis w/c can last from moments to days, rxn is primarily emotional;cts express shock, disbelief,
numb, panicky, cant cope
Public Health Dept PHN focus is the health of the community. During a home visit, will provide
education & referrals for specified problems that impact the health of the community
Occupational health nurse work for businesses & industries to support employee health (eg; job related
injury)
Breast self-exam 14-19yrs (must begin in high school)
The most basic and important action for nurses in providing culturally competent care confront own
racism & ethnocentrism (if the nurse isnt aware of his/her own culture, biases and prejudices, its not
possible to competently assess and communicate with indiv of other cultures)
When designing maternal-infant programs and services in a community, most important consideration
developmental level of the groups being served (to identify needs of specific aggregates for whom services

are intended (adolescents, career women, migrants).

Understanding of the developmental tasks & psychosocial issues of each population should be
the cornerstone of a well-developed program.
Compared to younger ppl, it is even more important for interventions targeted to the elderly to promote
physical exercise (People aged 65yrs and older are less likely than younger ppl to exercise)
A female student comes to the school nurses office to express concern about a friend who induces
vomiting in the BR p lunch q day. nurse must continue to assess for other signs that might indicate a
mental disorder.
The best way to evaluate the success of a campaign to increase the # of immunizations in a school
district is to compare the # of children in the district who were immunized during the past year to the #
immunized in the preceding year.
Common aspect of both elder abuse & child abuse victims are usually dependent on the abuser
Rural American group have an uninsured or underinsured status
Single most prevalent health problem among the homeless ALCOHOLISM
Denver II test overall devt status can be appropriately screened during bith to 6 yrs (revision of the
classic Denver Devtal Screening Test)
Highest risk of dying from severe burn injury toddlers (1-9yrs)
An intervention to address alcohol/drug abuse at the level of subgroups within a community would be to
provide a support group for employees who are recovering from alcohol or drug abuse (the support
group constitutes a sub-group within the community; the intervention is targeted for just those ppl)
EMPOWERMENT CITIZEN PARTICIPATION
Women expected to live 6yrs longer than men b/c Men are less likely than women to obtain preventive
physical exam (women more likely to engage in health maintenance)
OSHA regulation of potential hazards in the workplace
Salmonella properly store & thoroughly cook eggs and poultry
E coli raw beef; wash hands
C.jejuni drink only chlorinated drinking water

ere's some more Community Facts: (sorry if they're too long.....)

Eriksons Generativity vs. Stagnation middle adults (>40y) guide and care for the younger
generation and assist the older one
Neonate should gain 0.5-1 oz (15-30g/day)
Serum lead [c] = 16mg/dL and been above 10mg/dL for several months investigate the childs
environment
(+) reaction to tuberculin skin test induration (hardening) larger or equal to 15mm in a person >4yrs
who has not risk factors for TB
Pertussis vaccine composed of INACTIVATED bacteria
Disaster cannot be relieved without assistance (thats why disaster preparedness is important)
o OUTSIDE AREA area not directly affected by the disaster but can offer assistance
Community competence parts of community (org, groups, aggregates) collaborate effectively in
identifying the problems & needs of a community, achieving similar goals and priorities
Behavior or lifestyle greatest effect on the health of a community as a whole. This underscores the
importance of primary prevention.
Nursing strategy for HOMELESS:
o Using reflective statements that convey an understanding of situation
o Accepting the political commitments essential for advocacy for homeless cts
o Focus on primary prevention (identify other educational, placement, and legal services that they cant
access)
Hospice focus of care is COMFORT for individual facing death
Evaluation in community assessment barrier setting goals that are unrealistic or inappropriate tend to
break down progress rapidly
Morbidity stats reflect the extent and distribution of illness and disability in the community
Prevalence rate # of old & new cases of specified disease
Incidence rate # of NEW cases of a specified disease within a pop
Older smokers who try to quit smoking are MORE LIKELY to stay off cigarettes.

Older adults might be at risk for POOR NUTRITION loss of dentition (or poor fitting dentures interfere
with biting/chewing)
Nurse refers client to inappropriate health care provider making negligent referral
Secondary prevention working with person in affected pop (ppl experiencing effects of violence and
ensuring safety)
Providing doc of physical evidence in a case of suspected physical/sexual abuse use body mapping &
photographs in addition to written doc
Boy fell forward in the ground Fracture of the forearm
Physical exercise greater energy reserve
o Does NOT change persons perception of stress
Immunization in order:
o Hepatitis B
o DTaP, Hib, IPV, PCV
o Influenza
o MMR and varicella
HIPAA to protect workers from losing health care coverage with a job change or loss
Nicotine GATEWAY for substance abuse
SIDS "back to sleep"
Tertiary prevention helping a ct with asthma use an inhaler (long-term & chronic)
Secondary prevention giving first aid for injuries sustained during activities
Enviro-mechanical hazards in the workplace:
o Inadequate lifting device (risk for injury)
o Excessively cluttered work areas
o Slippery floors
o Poor workstation-worker fit
Ethnocentrism belief that ones own ways are the best, most superior
Ok for those of you who did not take Kaplan, this is their infamous Decision Tree
(Can't say I use it a lot, but some swear by it)
1. Can you identify the Topic?
Yes= proceed to step 2
No= read answers for clues, read stem, re word question
identify and proceed to step 2
2. Are all answers Assessments or Implementations?
Yes= proceed to step 3
No= determine from stem if assessment needed, validation needed; if so assess
*if no assess in stem then you need to assess
*if assess in stem, do you need validation?
*if assess or validation required and there are no right assess answers, then implement
3. Does Maslows fit?
Yes= Do they make sense? Apply ABC's.
*eliminate psychosocial/pain (consider pain psychosocial for nclex)
*don't always pick airway
No= are all physical? yes..then proceed to step 4
are all psychosocial? yes..then proceed to step 5
4. Are all answers physical?
Yes= apply ABC's
No= proceed to step 5
5. What is outcome of each?

do they make sense?

why?
and yes folks then you should have your answer!!!!

INFECTION CONTROL
Airborne Precautions:
Varicella
TB
Rubeola
pt must wear mask when transporting
what else?!?
Droplet Precautions:
Mennigittis
Pneumonia
Pertussis
Rubella
Mumps
private room unless other pt has same organism
maintain 3 feet distance unless giving care
anything else??
Contact Precautions:
RSV
Synctial virus
C Diff
MRSA
Ecoli
Scabies
Impetigo
Room needs to be private unless same organism
gloves/gown when in contact with secretions
anything else??
Standard Precautions:
CF
Bronchitis
Hantavirus
Tonsillitis
Cutaneous Anthrax
For airborne, make sure the patient is in a room that has negative air pressure with at least 6-12 exchanges an hour,
and N95 mask for TB.
Also remember MTV Cd for airborne: Measles (Rubeola), TB, Varicella (Shingles), Chickenpox, Disseminated varicella zoster.
Piaget is known for cognitive development.
Freud veiws anxiety as a warning to the person of impending danger.
Vitamin B1 deficiency is linked to Korsakoff's syndrome.
Korsakoff's syndrome is associated with ataxia, confabulation, and myopathy.

A liver that is tender on palpation is suggestive of viral hepatitis.

The inability of diseased liver cells to clear normal amounts of bilirubin from the blood is found in hepatocellular jaundice.
Hepatitis B has an incubation period of 2-5 months.
Patients with renal disease need to be monitored for potassium imbalances especially hyperkalemia. The primary method of treating
hyperkalemia is with hemodialysis.
Here are some I've found while studying:
Approximately 2 weeks after starting pt on antidepressants, assess for increased energy, could be sign of suicidal ideation
If you believe pt to be in respiratory detress, assess lung sounds first, LOC, retractions, skin color, etc would all be late signs
if dealing with a pt that is hallucinating, ask pt what voices in head are saying to assess for presence of command hallucinations
Bi-polar pt in mania phase will be full of energy, difficulty sitting still, provide finger foods as well as private room
Chest tube water seal chamber should fluctuate with breaths, this is normal
Chest tube should not bubble, this could be sign of air leak
Trach balloon should be inflated any time there is any risk of pt aspirating (ie eating, increased secreations, when getting tube feeds,
on vent, and 30 min after eating)
When changing trach ties, remove old ties with non-sterile gloves, then put on sterile gloves to apply clean ties
With a pt receiving tube feeds, only fill bag with enough feeds for 4 hrs, and assess for residuals every 4 hours
Cystic Fybrosis pt---Contact and Droplet precautions, pt must wear mask if leaving room
Avoid asking "why"
After administering Fosamax, instruct pt to remain sitting up for 30 min
Never palpate a Wihlm's Tumor, could cause cancer cells to break off
When doing adominal assessment, auscultate, then palpate, Palpating first will alter bowel sounds
When instilling eye drops into the lower conjunctival sac hold the dropper 1 to 2 cm ( 0.4 to 0.8 inches ) above the sac.
Discolored amniotic fluid such as green is a sign of fetal distress.
Placenta previa = painless bleeding. No vaginal exams.
After the rupture of membranes, the babies heart is checked then rechecked a few minutes later or after next contraction.
In the apgar score, the first time done reflects the transitional score, the second apgar score reflects the planning of care for the
newborn.
Score over 7, baby is ok but score under 5 needs recussitation or intensive care.
Hep.B vaccine given within 12 hours of birth.
Anterior fontanelle closes at 12 to 15 months.
At 7-12 months they are aware of themselves and can imitate. Be sure toys have no small pieces. Should be weaning from bottle to
sippy cup by 12 months ( 1 year ).
At 10 to 13 months walks while holding on to furniture and can stand ok. According to my kids pediatrician, " They are supposed to
entertain themselves for periods of time ". YEAH RIGHT! Mine were calling mommy all the time.

At 2-3 months they should be able to smile and follow objects.

Anaphylactic reaction to baker's yeast is contraindication for Hep B vaccine.
** Ask for allergy to eggs before Flu shot
** Ask for anaphylactic rxn to eggs or neomycin before MMR
** When on nitroprusside, monitor thiocynate (cyanide). Normal value should be 1, >1 is heading toward toxicity
**If kid has cold, can still give immunizations
**SARS (severe acute resp syndrome) airborne + contact (just like varicella)
** Hepatitis A is contact precautions
** Tetanus, Hepatitis B, HIV are STANDARD precautions
** William's position - Semi Fowlers with knees flexed (inc. knee gatch) to relieve lower back pain.
** SIGNS of a Fractured hip: EXTERNAL ROTATION, SHORTENING, ADDUCTION
** Fat Embolism: Blood tinged sputum (r/t inflammation), inc ESR, respiratory alkalosis (not acidosis r/t tachypnea),
hypocalcemia,increased serum lipids, "snow storm" effect on CXR.
**Complications of Mechanical Ventilation: Pneumothorax, Ulcers
** Paget's Disease - tinnitus, bone pain, enlargement of bone, thick bones.
** NO VITAMIN C with Allopurinol
** IVP requires bowel prep so they can visualize the bladder better
**Acid Ash diet - cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread
** Alk Ash diet- milk, veggies, rhubarb, salmon
** Orange tag in triage is non emergent Psych
** Greenstick fractures, usually seen in kids bone breaks on one side and bends on the other
Gout- a build up of crystals of uric acid (Kidney stones) depositing in tissues of the body. Tx: adequate fluid intake, reduce alcohol,
medications that reduce hyperuricemia, and diet changes like decrease in foods that contain purines( organ meats, seafood etc.)
Moxifloxacin, can cause inflamed and ruptured tendons, so assess for tendon swelling and pain
Steroids can increase gastric secretions, increasing your risk of gastric ulcers and GI bleeds, so try to avoid asprin
Letrozole is used to treat advanced breast cancer, skeltal and bone pain is a common side effect
Lopressor and other Beta Adernergic blockers can commonly cause impotence
When administering chemotherapy, remember to wear gloves, eye protection, and a mask that covers both your mouth and nose
Mg toxicity, assess for loss of deep tendon reflexes, respiratory depression, drop in heart rate and blood pressure, and a sudden drop in
fetal heart rate
Klonopin, pt will experience clumsiness and unsteadiness early in therapy, should disappear with long term use
Rifampin and INH, take together on empty stomach for maximum absorption
Administer Haldol and anti-Parkinson medications at same time to decrease risk of extrapyramidal effects of the Haldol
When instructing a pt on how to hold a cane, it should be at the level of the greater trochanter and femur, on the good side
When administering an enema, position the pt in a left Sims position. Do not elevate the head of bed
Tinnitus, most common symptom pts experience with inner ear disorders
Administering ear drops in a child, pull down and back on ear lobe
In adult, pull up and back on auricle. Instruct pt to keep head up for 10-15 min after administering drops
An isolated warmer area in the middle of a cast could be indicative of infection
PVC's are concerning of there are greater than 6 per min, if they occur in pairs, are multifocal, or if the fall on the T wave

Niacin, used to treat hyperlipidemia

Antiparkinson drugs, monitor for urinary retention, hypotension
Synthroid (for hypothyroidism), should only be given in the morning because of it's risk of causing insomnia if given at bedtime
Hyperthyroidism (Grave's Disease)---things speed up, monitor for tachycardia, nervousness, insomnia, weight loss, bulging eyes,
diarrea, sensitive to heat
Hypothyroidism (Myexedma)--things slow down, weight gain, constipation, decreased activity level, bradycardia

Incontinence is normal with aging--not a prob

Lymes is found mostly in Conneticut
Cervical cancer--hx of many sexual partners--risk factor
Breast cancer--hx of young menstural age and oral contraceptives for 8yrs
Asthma and Arthritis--swimming best
Asthma has intercostal retractions--be concerned
Braxton hick contractions in pregnancy are normal--it's when the stomach is tensed and relaxes
Post pituitary hormones--oxytocin, vasopressin, and ADH
Ant pituitary hormones--growth, TSH, ACTH, LH, and FSH
Water heater temp should be set no higher then--120 degrees--children precautions
DKA--300-600
HHNKS--600-1200 Blood sugars
CVP normal range 3-12
Transition phase of labor--shallow resperation (pant)
PCA--patient controlled analgesics--itching is common side effect
S3 vetricular gallop is early sign of HF
Inflow and Intake recorded seperately
Cystic fibrosis--both parents carry recessive trait, an autosomal recessive trait
Nephrotic syndrome--complication--venous thrombosis
placenta previa--c-section
FVO-fluid vol overload--rales and inc Pulse
Cystic fibrosis--pos sweat test=replace enzymes and inc salt intake
a resp and GI disease
Hartavirus Pulm syndrome--assess for s/s of thrombocytopenia
--caused by rodents
IOP--intra ocul pressure--10-21mm/hg

Vitamin
B-12 ==anemia
B-1 ==alcohol
B-9 == folic acid
B-6 ==TB
Synthroid in morning to prevent insomnia
Tardive Dyskinesia - irreversible - involuntary movements of the tongue, face and extremities, may happen
after prolonged use of antipsychotics
Akathisia - motor restlessness, need to keep going, tx with antiparkinsons meds, can be mistaken for
agitation.
Schizophrenia - disturbances in affect, mood, behavior, & thought processes. " do not go along with the
delusions or hallucinations", set limits on the persons behavior when it interferes with others & becomes
disruptive.
Protein and vitamin C are necessary for wound healing.
Poultry and milk are good sources of protein. ( to name a few )
Broccoli and strawberries are good sources of vitamin C. ( to name a few )
Normal serum creatinine level is 0.6 to 1.3 mg/dl. The person with mild renal insufficiency would have a
slightly increased level. Levels of 3.5mg/dl means possible acute or chronic renal failure.

Theophylline increases risk of digoxin toxicity and it decreases effects of both lithium and dilantin. Barbituates
decrease the effects of theophylline.
If the question asks for an immediate action/response, all options might be correct so select the answer based on
priorities.
Capsules & sustained release meds are not to be crushed.
After cataract surgery the person should not sleep on the operative side.
After liver biopsy the person is instructed to lay on their right side.
When giving an enema place the patient in left laying Sim's position so the enema can flow by gravity in the natural
direction of the colon.
After a craniotomy keep head of bed ( HOB ) elevated 30 degrees to 45 degrees.
When drawing an ABG, you need to put the blood in a heparinized tube, make sure there are no bubbles, put on ice immediately after
drawing, with a lable indicating if the pt was on room air or how many liters of O2.
Remember to preform the Allen's Test prior to doing an ABG to check for sufficient blood flow
Before going for Pulmonary Fuction Tests (PFT's), a pt's bronchodilators will be with-held and they are not allowed to smoke for 4 hrs
prior
For a lung biopsy, position pt lying on side of bed or with arms raised up on pillows over bedside table, have pt hold breath in
midexpiration, chest x-ray done immediately afterwards to check for complication of pneumothorax, sterile dressing applied
For a lumbar puncture, pt is positioned in lateral recumbent fetal position, keep pt flat for 2-3 hrs afterwards, sterile dressing, frequent
neuro assessments
EEG, hold meds for 24-48 hrs prior, no caffine or cigarettes for 24 hrs prior, pt can eat, pt must stay awake night before exam, pt may

be asked to hyperventilate and watch a bright flashing light, after EEG, assess pt for seizures, pt's will be at increased risk
Diamox, used for glaucoma, can cause hypokalemia
Dexedrine, used for ADHD, may alter insulin needs, avoid taking with MAOI's, take in morning (insomnia possible side effect)
Cytovene, used for retinitis caused by cytomegalovirus, pt will need regular eye exams, report dizziness, confusion, or seizures
immediately
INH, used to treat and prevent TB, do not give with dilantin, can cause phenytonin toxicity, monitor LFT's, give B6 along with,
hypotension will occur initially, then resolve
Rifampin, for TB, dyes bodily fluids orange
If mixing antipsychotics (ie Haldol, Throazine, Prolixin) with fluids, med is incompatible with caffine and apple juice
Haldol preferred anti-psychotic in elderly, but high risk extrapyramidal side effects (dystonia, tarditive dyskinesia, tightening of jaw,
stiff neck, swollen tongue, later on swollen airway), monitor for early signs of reaction and give IM Benadryl
Risperdal, antipsychotic, doses over 6mg can cause tarditive dyskinesia, first line antipsychotic in children
Levodopa, for parkinsons, contraindicated in pts with glaucoma, avoid B6
Sinemet, for parkinsons, contraindicated with MAOI's
Hydroxyurea, for sickle cell, report GI symptoms immediately, could be sign of toxicity
Zocor, for hyperlipidemia, take on empty stomach to enhance absorption, report any unexplained musle pain, especially if fever
Cushing Syndrome:
salt, sugar, stress is UP
Addison's:
salt, sugar, stress is down
Hypocalemia, Hypomagnesia, and Hypokaleia, all increase risk of digoxin toxicity
Ulcerative colitis, frequent liquid stools, contain blood, affects rectum and left colon
Chrohn's---diarrhea, contains fat, affects ileum and right colon
Remember McBurney's Point (pain between umbilicus and right iliac crest) when assessing pts with appendicitis
Appendicitis, no hot packs, may have ice to alleviate pain, no pain meds (may mask rupture)
Hirschsprung's disease, infant fails to pass meconium, abd distention, caused by obstruction in intestine, will get colostomy, that is
usually reversed when child is 17-22 lbs.
Aside from monitoring the vital signs of a pt. post-tonsillectomy check for frequent swallowing which could be a sign of
post-op bleeding.
Trach cuffs should be deflated & reinflated periodically to prevent necrosis of trachial tissues.
Post tonsillectomy/adenoidectomy no straws!
Monitor the daily weight if pt. taking Lasix.
Post-thyroidectomy, monitor for s/s of airway obstruction; hemmorhage (be sure to check behind client's neck, as bandage may
appear clean when severe bleeding may be draining underneath); thyroid storm; tetany; and recurrent laryngeal nerve damage

Chvostek's Sign - Test which reveals spasm of the facial muscle when the face is tapped over the facial nerve, in the area of the
parotid gland - positive results may indicate hypocalcemia, acid-base imbalance, or reaction to a blood transfusion
Trousseau's Sign - A carpopedal spasm that occurs when a blood pressure cuff is inflated above the client's SBP and left in place 2-3
minutes - an indication of latent tetany, which may indicate hypocalcemia (although it is a less sensitive test than Chvostek's)
Mannitol (Osmitrol): A hyperosmotic agent that increases intravascular pressure by drawing fluid frin the interstitial spaces and from
the brain cells (monitor renal function)
Corticosteroids: Stabilize the cell membrane, reduce the leakiness in the blood-brain barrier, and decrease cerebral edema (clients
must be withdrawn slowly from corticosteroids to prevent adrenal crisis)
Antihypertensives: May be required to maintain cerebral perfusion at a normal level (notify physician if BP range below 100 or
above 150)
Antipyretics and Muscle Relaxants: Temperature reduction decreases metabolism, cerebral blood flow, thus ICP; muscle relaxants
prevent shivering
Anticonvulsants: May be given prophylactically to prevent seizures, which increase metabolic requirements, thus increasing ICP
IV Fluids: Administered via IV infusion pump to control the amount of fluid administered (NO HYPERTONIC SOLUTIONS are
given, due to the risk of promoting additional cerebral edema)
Erikson's Stages
birth to 18 months = trust vs. mistrust
18 months to 3 yrs = autonomy vs. shame & doubt
3 yrs to 6 yrs = initiative vs. guilt
6yrs to 12 yrs = industry vs. inferiority
12 yrs to 20 yrs = identity vs. role confusion
20 yrs to 35 yrs = intimacy vs. isolation
35 yrs to 65 yrs = generativity vs. stagnation
65 yrs to death = integritiy vs. despair

Dumping syndrome happens most often after gastric resection. s/s occur approx. 30 minutes after eating, nausea &
cramping, feeling of fullness, diarrhea, palpitations, tachycardic, sweaty, weak & dizzy, gas!
Diet 4 this is: high protein, high fat, & low carbs, tell pt to eat small frequent meals and lay down after eating & avoid
sugar and salt.
Poisoning
Prevention is the key! Treat the patient, then the posion!
Contraindications to vomiting: danger of aspiration or aspiration pneumonia (diminished gag reflex), decreased LOC,
ingested lighter fluid or kerosene, ingested drain cleaner
Aspirin poisoning: symptoms include tinnitus, change in mental status, increased temp, hyperventilation (resp. alkalosis),
bleeding issues (decreased platelet aggregation)
Tylenol poisoning: symptoms include n/v, hypothermia (if NO treatment --> major danger-liver damage). Mucomyst is
the antidote for tylenol poisoning.
Lead toxicity (AKA plumbism): symptoms include lethargy, decreased activity, increased ICP (seizures), diagnostic tests
include blood lead level (>9 mcg = toxic), xray of long bones (will show lead deposits)
Lead can be ingested --> pica-eating of non-food items such as chalk, dirt, lead, paint
Hazardous wastes: if chemical poses a threat to the patient, decontaminate first! If chemical poses no threat or patient is
contaminated, then begin care. If immediate threat to life, put on PPE and stabalize patient!

Disaster Planning: do greatest good for greatest number of people

Resources used for patients w/ greatest probability of survival
Triage-order treated:
Red-unstable (SOB, bleeding)
Yellow-stable, can wait (brooken bone, burn)
Green-stable can wait longer ("walking wounded"-sore back, hang nail)
Black-unstable, probably fatal (fatal injury, less likely to survive)
DOA -dead on arrival
External radiation:
Leave markings on skin, avoid use of creams, lotions, check skin for redness, cracking
Internal radiation:
Sealed source --> lead container and long-handled forceps in room, save all dressings, bed linen until radiation removed;
urine and feces not radioactive, don't stand close or in line with source, patient is on bedrest while implant is in place
Unsealed source of radiation --> all bodily fluids are contaminated --> greatest danger 1st 24-96 hours. Time and distance
is important, private room, sign on door, nurse wears dosimeter film badge at all times, limit visitors and time spent in
patient's room, rotate staff
For an ear exam:
adult --> pull up and back
child --> pull back and down
(remember it like the alphabet --> b, child, d)
Cranial Nerve Disorders
Trigeminal Neuralgia--stabbing, burning facial pain, facial muscle twitching
Bell's Palsy--(7th cranial nerve)-inability to close eye, increased lacrimation, distorted side of face
Acoustic Neuroma--deafness, dizziness

Tetrology of Fallot
Tetra means four so it consists of four defects:
pulmonary artery stenosis
hypertrophy of right ventricle
venticular septal defect
overriding of aorta
Dx of Tetrology of Fallot is done by chest x-ray that shows a typical boot shaped heart. An echocardiogram, 3
dimentional echocardiography, & cardiac cath help to confirm diagnosis.
s/s of TOF include: " blue spells or tet spells " relieved by having child squat. Murmur may be present. Poor growth,
clubbing of fingers.

1) Detached Regina - curtain being drawn over field, floaters, must patch BOTH EYES !
2) Cataracts - decreased Color vision, Cloudy, better vision with dim light (pupil dilation)
3) Glaucoma - halo around lights, decrease peripheral vision, intraocular pressure > 22mmHg. They see better with
light. COAG (chronic open angle glaucoma has little to no symptoms, pressure in the eye gradually increases 3050mmHg), while acute closed angle glaucoma has sudden pain and the pressure in the eye is usually higher ( 50 70).
4) Ishihara chart - to assess color vision (specifically red -green blindness)

5) Post op stapedectomy - vertigo, nausea, vomitting is expected

Contraindications to immunizations:
Flu-= allergy to eggs
MMR=allergy to neomycin, pregnancy
HepB= allergy to yeast
IPV= allergy to strptomycin,polymycin,neomycin
Varicella=allergy to gelatin, untreated TB, HIV, pregnancy
Hep A= allergy to alum
SOme more.......
PT to be put on streptokinase ask if they had a recent strep infections, med won't be as effective
Caution with the "Mycins" for pt with Multiple Sclerosis, Myasthenia Gravis, THESE EXACERBATE MUSCLE WEAKNESS
Management for sprain:
R- Rest
I - Ice
C -Compression
E - Elevate
Management for Sickle Cell Crisis: (In order of PRIORITY)
H - Hydration
H - Heat
O - Oxygen (why? coz if you give oxygen before hydration it doesn't make sense at all since hydrating the client would prevent
further clumping of RBC's thus increasing oxygenation)
P Pain
Renal Function:Norms
BUN = 8 to 25 mg/dl
Serum Creatinine = 0.6 to 1.3 mg/dl
Creatinine Clearance = 100 to 120 mL per minute
Serum Uric Acid = 2.5 to 8.0 mg/dl
Urine Uric Acid = 250 to 750 mg/ 24 hours
Normal activated partial thromboplastin time ( APTT ) is 20-36 seconds
At theraputic levels, heparin will increase this by 1.5 to 2.5 times the normal
If the APTT is over 80, dosage needs to be reduced
Heparin is for prevention of DVT/thromboembolism
Coumadin monitored with PT & INR
Average PT is 9.6 to 11.8 seconds coumadin makes these numbers longer
The higher the number the greater the chances of bleeding
Normal INR is 1.3 to 2.0 a theraputic INR for most patients will be 2 to 3. Some pts. it may be ok to go higher
When performing a heel stick, put thumb over walking surface of the heal, strike later aspect of heal, wipe of 1st drop, don't smear,
streak or sqeeze area (due to high ECF in infants)
~ Before infant feeds, insert gloved hand into mouth to assess palate.
~ Head circumference should be 2cm > than chest when born, but equal by 1 year.
~ Skin tags and low set ears in infants - suspect chromosomal abnormalities
~ Circumoral cyanosis in infants - see if it improves with crying. If it doesn't , report it cuz it might indicate cardiac pathology.

~ Toilet Training - when kid can communicate need to go (non verbal or verbal), holds on to please mom and doesn't let go to please
self, sphincter control 18 months - 24 months (myelination of the cord is complete now), motor skill. Ability to stay dry for 2hours,
can sit still on toilet for 5 - 10 mins without fussing, curiousity about older people's habits. No right or wrong time !
~ 1 TABLESPOON per year of age = a serving (so 2 year old's serving is 2 tablespoons or an ounce)
~ Toddlers should be drinking 3-4 cups of milk max, need to make sure they get nutrients from other foods.
~ Infants need 110kcal/kg/day
~ Breast milk has 20 kcals per ounce (so 20 kcal per 30 cc)
~ Breast milk has everything BUT slightly deficient in Vitamin D

Pleural Drainage System:

Bottle 1 = Drainage= No bubbles
Bottle 2 = Water Seal = Intermittent bubbles
Bottle 3 = Suction= Continuous bubbles
Mental Health:
Language & Communication
NEOLOGISM = a new word made up that has meaning only to the patient
ECHOLALIA = repeating of words or phrases they heard someone else say
WORD SALAD = form of speech in which words & phrases are connected without any meaning
MUTISM = absense of verbal speech
CLANG ASSOCIATION = repeating of words & phrases that are similar in sound but not in any other way ( Dr. Seuss type
of speech )
Defense Mechanisms:
Compensation = putting extra effort to achive in areas of real or not-real weaknesses
Sublimation = replacing of an unacceptable need, attitude or emotion with one that is more accepted
1. Widening pulse pressure is a sign of increased ICP
2.Pt taking Digoxin should eat a diet high in potassium (hypokalemia-> dig toxicity)
3.Key sign of PUD... hematemesis which can be bright red or dark red with the consistency of coffee
grounds
4.Common symptom of Aluminium hydroxyde: constipation
5.In a child anemia is a the first sign of lead poisoning
6.Diuretic used for intracranial bleeding, hydrocephalus (Increased ICP,...) MANNITOL (osmotic
diuretic)
7.Treatment of celiac disease: gluten free diet
8.cystis fibrosis==> excessive mucus production, respiratory infection complications,...
9.Cholelithiasis causes enlarged edematous gallbladder with multiple stones and an elevated
bilirubin level.
10.Fat embolism is mostly seen in LONG BONES (femur,...) HIV QUICK NOTES:
Transmission thru contact with body and oral fluids
Primary symptoms: Flu like, progressive weight loss, decreased CD4 count
High risk: IV drug users,multiple sexual partners,contaminated blood prdcts, perinatal transmission
Diagnostics:
1. ELISA detects dvpt of antibodies. test is positive or negative
2. Western blot detects HIV infection and viral load. It confirms positive or negative
CD4 and viral load levels indicate response to treatment.
Management:
Antiretroviral- taken daily and on time to avoid replication and mutation
megace for apetite stimulation
immunization against disease is encouraged
small frequent high calori meals. PLASTIC UTENSILS USED instaed of metal ones to avoid altered food perception not to

prevent spread of disease.

Confidentiality a must, periodic evaluations, lab works always
Paracentisis is most commonly used to drain peritoneal fluid caused by ascites, they check the fluid for
microorganisms, cell count, specific gravity, and protein. Ascites can cause abdominal discomfort/pain and
may also cause some respiratory distress so the paracentisis can help alleviate that as well.
Care of T-tubes:
make sure it is closed to gravity drainage system. avoid any kinks, clamping, or pulling of tube. expect
300-500 ml of bile during first 24 hours. monitor color of urine & stools which will be light colored changing
gradually to normal coloring ). assess for s/s of peritonitis, assess skin around t-tube; clean often & keep
dry.
Nursing mgt/teaching for home care;
1. wash hands before and after
2.use humidifier/nebulizer for extra moisture.Drink lotsa fluid
3. Avoid OTC cough meds as they dry out airway
4.For suctioning: 4-5 deep breaths before inserting sucionng catheter. do not suction more than 10 sec. Do not suction more than 3
times per session. Wait 5-10 minutes between sessions
5. CAtheter care: clean catheter in hot soapy water,rinse with tap water. soak in 50:50 water and vinegar for 1 hr and rinse with saline
solution. Dry in clean covered container. Wash suction tube daily with hot,soapy water.
6. May use thin vaseline coat outside stoma t prevent crusting.
7. Stoma can be covered with ccarf, gauze when bathin, no swimming.
8. pt loses sense of smell and taste, so dental care and smoke detector are a must.
And....
Esophageal speech 101: Pt swallows air into her esophagus and she burps up the air at the moment of articulation.
Cast Care:
Nursing Assessment:
Neuro check to areas below/distal to cast and above, compare
report absent or diminished pulses, cyanosis, blanching, coldness, lack of sensation, unable to move toes or fingers,
any swelling
check for odor that may indicate infection
report all complaints of numbness/tingling or burning sensations
check for bleeding and " hot spots " that can signal inflammation under the cast
teach pt. to wriggle fingers/toes
elevate affected extremity to reduce swelling and for pain control
apply ice if ordered
The first step in decontamination is the removal of the pts clothing & jewelry & rinsing
the pt with water very well.
Those with symptoms of anthrax who have been in a hot zone should be given 60 days of
prophylactic antibiotic therapy.
The pt who is returning to the unit post-lumbar spinal fusion should be kept flat in bed.
Pituitary Gland = Master Gland ; the anterior lobe secretes, TSH, ACTH, FSH, LH, GH or
somatotropin and LTH or prolactin.
Amputation Care:
* provide routine post op care
* prevent contractures,i.e in above the knee amps, do not keep leg up after 24 hrs
* avoid letting pt sit too long with hips flexed
* have pt lay prone several time a day & position hip in extension, unless otherwise
ordered
* do not elevate stump longer than 24 hrs unless otherwise ordered
* give pain meds
* stump bandages should be tight to promote prothesis fitting
* initiate active ROM when ordered

* provide stump care: look daily for signs of skin irritation, wash daily with warm water
and bacteriocide soap then rinse and dry well, do not use irritating stuff like lotions,
powders or alcohol.
PACEMAKER TEACHING:
*fundamental cardiac physiology
*daily pulse check for 1 full minute
*report any sudden slowing/speeding up of the heart rate
*importance of following up with weekly monitoring during first 1-2 months after placement & at anticipated
battery depletion time
*wear loose fitting clothing around area with pacemaker
*call doctor if develop pain/redness over site
*no heavy contact sports
*carry ID card/medic alert braclette with info on model of pacemaker, rate set at, and manufacturer
*remind of need for periodic hospitalization for battery changes or possible unit replacement
Blood Transfusion Reactions:
* chills * sweating * thready, rapid pulse * pallor * cyanosis * muscle aches, back pain *
chest pain * headache * rash/hives * aprehension * n/v and diarrhea
Reactions that are not immediate include:
* fever, jaundice, low Hct level
If a reaction happens the pt. should be closely monitored for life-threatening symptoms.
The infusion is stopped immediately & the doctor is called!!!! The blood bag and the
tubing must be returned to blood bank with an explaination of the reaction. Nurse must
stay with pt. during first 15 minutes of transfusion. Also, if the temperature goes up by
2 degrees from the baseline during an infusion this could be a reaction.

1) Gout : low purine diet, avoid organ meat e.g. liver.

2) Hypertension : low sodium diet.
3) Renal calculi, calcium kidney stones : follow alkaline ash diet e.g. spinach, milk, banana. Aim is to increase pH.
Before start INH for TB, usually a baseline live function test is recommended.
TB skin positive, normal 10mm, if HIV, 5mm is positive
Corticosteroids can cause stomach ulcers.
Isoniazid can cause drug induced hepatitis-look for yellow color of the skin,nausea,vomitting.
Re: Anyoone up for random FACT THROWING??
14. 1. for the myelogram postop positions. water based dye (lighter) bed elevated. oil based dye heavier bed flat.
2. autonomic dysreflexia- elevated bed first....then check foley or for impaction
3. any of the mycin's..check for tinnitus or hearing loss
4. cloudy dialysate...always further assess and call doctor
5. osteoporosis prevention and mgt. choose weight bearing (walking) instead of calcium if both are choices.
1. Dilantin can cause gingival hyperplasia, advise good oral hygiene and freq. dental visits, IVP 25-50 mg/min
2. Placentia Previa is painless, bright red bleed
3. Abruption is painful, board-like abdomen
4. Need MAP of 70-90 to perfuse organs
5. Vitamin C can cause false + occult blood

MAP= diastolic x 2 + systolic

___________________
divided by 3
1. celiac disease cant have BROW! BARLEY RYE OAT WHEAT
2. any eye surgery place on pt on unaffected side
3. if pt has lung cancer, craniotomy, or some kinda pituitary surgery watch for diabetes insipidus
4. sickle cell- hydration hydration important and treat pain if in crisis
5.dont palpate a wilm's tumor on the peds pt. can cause cancer cells to be released!
oh one more:
6. terbutaline (Brethine) and mag sulfate- tx for preterm labor
Librium-antianxiety used to tx symptoms of acute alcohol withdrawal.
Cogentin-used to tx parkinsonian side effects of Thorazine (antipsychotic med)
Methadone hydrochloride-opiod analgesic; tx for narcotic withdrawal
Procardia-antianginal med (CCB) decreases myocardial O2 demand.
Digoxin-strengthens myocardial contractio0n & slows conduction thru AV node
Coumadin-inhibits prothrombin synthesis
Amicar-antifibrinolytic; prevents recurrence of subarachnoid hemorrhage.
Lithium-tx manic phase of bipolar
Nimodipine-CCB; decreases spasm in cerebral blood vessels
diltiazem-CCB; inhibits Ca+ influx in vascular smooth muscle; reduces myocardial O2 demand & decreases force of
ventricular contraction
clotrimazole-antifungal; treats rashes.
The level in the water seal chamber (chest tubes) fluctuates with respiration- no fluctuation indicates an obstruction and
excessive bubbling indicates an air leak.
Stay with the client for 15 minutes at the start of a blood transfusion.
Nephrotic Syndrome leads to proteinuria while Glomerulonephritis leads to hematuria.
Goodell's Sign is the softening of the cervix at the start of the 2nd month of pregnancy
Nagele's Rule is First date of last menstrual period + 7 days - 3 months + 1year.
Vinca Alkaloids (Vincristine) lead to neurotoxicity and can present with numbness and tingling in the legs or paralytic ileus.
A few more.... and forgive the spelling it is way late and my brain is turning to MUSH.
Avoid herbal supps like ginseng, ginger, ginkgo, garlic (all the G's) if on any clotting drugs/products (coumadin, platelets,
ASA, Plavix)
High triglycerides may cause a false HIGH Hemoglobin A1C (normal is 2.6-6)
Deer ticks transmit Lyme Disease and it is most common in the NE Atlantic states. (Go figure I thought it was down here in
the South)
Think of pain last or as a psychosocial UNLESS: Burns, sickle cell crisis, or kidney stones.
Anemia of pregnancy is common in the 2nd trimester due to rapid expanding blood volume and is not a cause for concern. It
can get as low as 10.5 and still be OK. 1st and 3rd trimesters can go as low as 11 and still be ok
Preterm labor--after 20 weeks and before 37
true labor INCREASES with activity and usually moves from the back to the front (according to our instructors but from
personal experience IT HURT ALL OVER THE DANG PLACE AND INCREASED WITH EVERYTHING ).

Recommended weight gain for pregnancy 1.5-16 kg or 25-35 lbs

normal newborn jaundice-- AFTER 24 hours of life
pathologic jaundice-- BEFORE 24 hours of life
*feed orally ASAP because if it gets too high Kernicterus
5. after thyroid surgery-maintain airway-keep emergency trach set nearby, check for blood at sides and back of dressing,
teach pt to support neck
6. bucks traction-no pins tongs. skin traction
7. should not hear a bruit over anything except dialysis shunts. if so this is the unstable pt
8. DVT- elevate extremity , bed rest, warm (not hot) compresses
Menieres disease= ringing in the ears and hearing damage cause from HIGH sodium levels. Need diuretics. Avoid caffeine,
nicotine, and ETOH
Meningitis= look for nuchal rigidity, Kernings sign(can't extend knee when hip is flexed) and Brudinskis sign (flex neck and
knee flexes too) petichial rash. People who have been in close contact may need Rifampin as prevention. Vaccine for
meningitis after 65 years of age and every 5 years
MI=#1 pain relief, helps decrease 02 demand
Acute Asthma = diffuse expiratory wheezes
Cessation of wheeze ominous
Infective endocarditis = murmur
Fluid overload = auscultate lungs 1st
1.hypoglycemia= T.I.R.E.D
T-tachycardia
I- irritability
R- restless
E- excessive hunger
D- diaphoresis
2.posturing- deceberate(brainstem problem)- hands like an "e", decorticate (cord problem)- hands pulled in toward the cord
3.tetralogy of fallot- have child squat to increase return to heart. just remember fallot=squat
4. cant sign consent after preop meds are given...call doctor if not signed
5. rubella (German measles)-airborne contact precautions, 3 day rash
6. rubeola (red measles)- droplet contact precautions, koplik spots in mouth
Withdrawl Symptoms:
Amphetamine= Depression , disturbed sleep, restlessness , disorientation
Barbiturates= nausea & vomiting, seizures, course tremors,
tachy
Cocaine= Sever cravings, depression , hypersomnia, fatigue
Heroin= Runny nose, Yawning , fever, muscle & joint pain, diarrhea (Remember Flu like symptoms)
1. When using a cane to aid ambulation: Step up on the good extremity then place the can and affected extremity on the step.
Reverse when coming down. (Up with the good, down with the bad)
2. In infants, pyloric stenosis = projectile vomiting
3. Croup: seal-bark cough, dyspnea, inspiratory stridor, irritable. In children considered a medical emergency due to

narrowed airway
4. Skull fracture: Battle's sign (bruising over mastoid bone) and raccoon eyes
5. Pheochromocytoma: catecholamine secreting tumor. Look for persistent hypertension, pounding headache
Oxytocin is always given via an infusion pump and can never be administered through the primary IV.
One of the first signs of ICP (increased intracranial pressure) in infants is a high pitched cry.
Regarding blood transfusions, a hemolytic reaction is the most dangerous kind of reaction...S & S include
NAUSEA
VOMITING
PAIN IN LOWER BSCK
HEMATURIA Treatment is to STOP blood, get a urine specimen and maintain perfusion and blood volume.
Febrile reaction S&S
FEVER
CHILLS
NAUSEA
HEADACHE
Narcan is given for to reverse respiratory depression...a rate of 8 or less is too low and requires nursing action.
Miller abbott tube is used for decompressing intestine, which relieves the small intestine by removing fluid and gas from
small intestine.
If a client takes lithium the nurse should instruct the client to take in a good amount of sodium, without it causes retention of
lithium and in turn leads to toxicity.
Rinne test- a vibrating tuning fork is held against the mastoid bone till pt can't hear sound...then moved to ear.
1) A subarachnoid (spinal block) for labor may cause a headache, a lumbar epidural will not since the dura mater is not
penetrated
2) Tracheoesophageal fistula: 3 C's: coughing, choking, & cyanosis
3) Hypothyroidism: Decreased T3 +T4, but increased TSH
Hyperthyroidism: Increased T3 + T4, but decreased TSH
4) NO tyramine containing foods if taking and MAO inhibitor ( smoked meat, brewer's yeast, aged cheese, red wine)
5)Regular insulin is the only type that can be given IV
1)Immunizations
Before 1 years old:
Hep B 3x):Only one that is given at birth and one month (3rd dose at 6 months)
IPV(4x), DTaP(5x), Hib(4x), PCV(4x): all given at 2, 4, & 6 months
Hib, PCV: again at 12-15month
DTaP: again at 12-18months
DTaP, IPV: last doses are given 4-6yrs
1yrs old and older:
MMR: (2x) 12-15months, then at 4-6 years* *if dose not given from 4-6 give from 11-12yrs old
Varicella Zoster: (1x) 12-18months
Td: (1x): 11-12yrs old
2)Fundal height: pt supine, measure from symphysis pubis to top of fundus, if patients is 18+ wks pregnant the height in cm
will be same as weeks pregnant give or take 2 cm

3)Isolation**:
STRICT Contact: use universal precautions, gown when contact with pt., single pt. room in most situations
Used with: Any colonizing infections, MSRV, Fifths disease, RSV, infected wounds, skin, or eyes
STRICTER Droplet: include all universal precautions, gown, goggles, masks on you, on pt. if leaving room, single pt. rooms
Used with: Majority of infectious diseases
STRICTEST Airborne: include all universal precautions and negative pressure single patient rooms, gown, goggles, mask on
you, mask on pt. if leaving room which should only be done if absolutely necessary
Used with:
Measles
Varicella
Disseminated Varicella Zoster
Tuberculosis
**Always check facilities policies when following isolation precautions/procedures
4) Self breast exams: do monthly, 7-10 days after menses
5) Pt's taking Monoamine Oxidase inhibitors (for depression usually) should avoid foods containing tyramine which include
Avocados, bananas
Beef/chicken liver
Caffeine
Red wine, Beer
Cheese (except cottage cheese)
Raisins
Sausages, pepperoni
Yogurt, sour cream
1. dumping syndrome-tx no fluids with meals /no high carbs /lie down after eating. they need a high fat high protein diet
2. multiple sclerosis- avoid hot showers and baths
3. partial thickness burns=blisters...... full thickness-charred, waxy
4 PKU- no nuts, meats, dry beans, eggs, dairy (basically no protein stuff) give specially prepared formula to baby because
they can digest this protein well
5. introduce rice cereal to infant at 6 mos and strained veggies one at a time
6. pt must keep taking prescribed insulin on sick days, drink plenty of fluids and notify doctor. also insulin is also given when
pt comes from surgery on NPO status because trauma and infection makes sugar go up!
1. In prioritizing cardiac patients, check the pt with INDIGESTION first because that could be a sign of MI.
2. ABG's need to be placed on ice and sent to the lab ASAP.
3. If active TB is suspected, a sputum culture for acid-fast bacillus is the only method to actually confirm active TB (NOT a
mantoux skin test!)
4. Celebrex is contraindicated in pts with a history of cirrhosis.
5. In psych pts, the client most at risk for self-harm is always the pt that has stopped taking their meds.
One more!
6. Change in resp rate in a pt receiving mag sulfate could indicate toxicity.
1. Cushing's Triad = HTN (widening pulse pressure, systolic rises), Bradycardia, irregular resp.

2. Tx of DIC = Heparin
3. Assessment for Cancer =
C: Change in bowel or bladder habits
A: A sore that doesnt heal
U: Unusual bleeding or discharge
T: Thickening or lump
I: Indigestion or difficulty swallowing
O: Obvious changes in a wart or mole
N: Nagging cough or hoarseness.
4. Acid Base =
Respiratory
Opposite
Metabolic
Equal
5. For Injuries such as twisted ankles use RICE acronym
Rest
Ice
Compress
Elevate
Ulcerative colitis...3-30 stools per day WITH blood and mucus.
Pain in LLQ: relieved by defecation.
Crohns disease-NO obvious blood or mucus in stool.
Pain: Right lower quadrant pain that is steady or cramping...or pain could be in periumbilical area, tenderness and mass in the RLQ.
Rheumatoid arthritis: Pain and stiffness is on arising, lasting less than an hour...can also occur after long periods of inactivity. Joints
red, hot swollen, boggy, and decreased ROM.
Osteoarthritis: Pain and stiffness occurs during activity. Joints may appear swollen, cool, and bony hard.
Hemodialysis: disequilibrium syndrome- N&V, headache, decreased LOC, rapid changes in PH, bun...
Transfusion reaction: Chills, dyspnea, itching, uticaria, back or arm pain, fever.
Peritoneal dialysis: When more dialysate drains than has been given, more fluid has been lost(output). If less is returned than given, a
fluid gain has occurred.
Slow dialysate instillation- increase height of container, reposition client.
Poor dialysate drainage-Lower the drainage, reposition.
INSULIN:
Rapid: (Lispro) Onset: <15min Peak: 1hr Duration : 3hr
Short: (Regular) Onset: 1/2hr-1hr Peak: 2-3 hr Duration: 4-6 hr
Intermediate: (NPH or Lente) Onset: 2hr Peak: 6-12hr Duration: 16-24
Long Acting: (Ultralente) Onset: 4-6 hr Peak: 12-16hr Duration: >24 hrs
Very Long: (Lantus) Onset: 1 hr Peak: NONE Duration: 24 hr continuous
Mydriatic: with a D= Dilate pupils
Miotic:with an O= cOnstrict pupils

aniticholinergic SE:
can't see
can't pee
can't spit
can't sh*t
Hyperkalemia "MACHINE"- causes of incr serum K+
M-medications (ace inhibitors, Nsaids)
A-acidosis (Metabolic and respiratory)
C-cellular destrx-burns, traumatic injury
H-hypoaldosteronism, hemolysis
N-nephrons, renal failure
E- excretion-impaired
Signs and symptoms of incr serum K+= MURDER
M-muscle weakness
U-urine, oliguria, anuria
R-respiratory distress
D-decr cardiac contractility
E-ECG changes
R- reflexes, hyperreflexia, or flaccid
HYPERNATREMIA-you are fried
F-fever (low grade), flushed skin
R-restless (irritable)
I-incr fluid retention and incr BP
E-edema ( peripheral and pitting)
D-decr urinary output, dry mouth
Hypocalcemia-"CATS"
C-convulsions
A-arrhythmias
T-tetany
S-spasms and stridor
V-FIB=DEFIB
DONT SHOCK ASYSTOLE!
EEG- MUST BE SLEEP DEPRIVED FOR THE PROCEDURE
Albumin best indicator of nutrition normal range 3.5 - 5.5
altered LOC- earliest sign of ICP
to check dehydration in an infant (inner thigh)...elderly (on top of forehead or sternum)
shift to the left when number of immature cells are increasing in the bloodstream to fight an infection
Respiratory syncytial virus- contact precautions
systemic lupus erythematosus- butterfly rash on nose and cheek. avoid sunlight
with DIC...get worried if you see blood oooze from the IV line. notify doctor
Tegratol- tx for seizures..watch for drowsiness, n/v, blurred vision, h/a.
kayexalate- may be ordered for a high potassium level
THERAPEUTIC LEVEL
10-20 mcg/ml

Theophylline
Acetaminophen
Phenytoin
Chloramphenicol
10-21 mmHg - normal intraocular pressure
1. nebulizers used by HIV patients are cleansed with warm water after each treatment and allow it to air dry. soaked in white vinegar
and water for 30f min at the end of the day
2. SHARE support group for parents who have experienced miscarriage
3. RESOLVE support group for infertile clients
4. CANDLELIGHTERS families who have lost child to cancer
5 FETAL ALCOHOL SYNDROME child small head circumference, low birth wt, underdeveloped cheeks.
here is a quick one.... Dantrium (dantroline) common drug kept in the OR for us with Malignant Hyperthermia.
No birth control pills with antiseizure meds....lowers the BCP's effects
filgrastim (Neupogen) - increase NEUtrophil count
epoietin alfa (Epogen) - increase RBC/erythrocytes
Apgar measures HR, RR, Muscle tone, Reflexes, Skin color
each 0-2 point. 8-10 OK. 0-3 RESUSCITATE.
GLASGOW COMA SCALE. EYES, VERBAL,MOTOR!
It is similar to measuring dating skills...max 15 points -one can do it
if below 8 you are in Coma.
Cholecystectomy due to cholelithiasis and cholesysthitis, WATCH for BLEEDING problems, because vit K FAT soluble, is poorly
absorbed in the absence of bile. by the way T-tube used for drainage-Reason for T tube to maintain patency of common bile duct.
Chronic RF the best way to asses fluid status-WEIGHT the PATIENT daily
When NGT present mouth care ICE CHIPS but be aware not give that too much-> it becomes water->stomach->NGT suck it with K
and other electrolytes present in stomach. LOST K
Heat cramps in hot weather-Sodium (Na) loses
Following Gastrectomy NGT drainage should NOT be BLOODY after 12 hr
Thyroid storm's main sign is FEVER
ALDOSTERONE insufficiency -Hypo-Na-emia, Hyper-K-emia, hypo-Volemia. WHEN Na decrease, K increase
Addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
Cushings= hypernatremia, hypertension, increased blood vol, hypokalemia, hyperglycemia
1. Prozac, Zoloft, Paxil- tx of depression.
2. sodium nitroprusside- shield from light. wrap in foil
3. cephalosporins- CHECK FOR ALLERGIES TO PENICILLINS. pt could be hypersensitive.
4. pts receiving Lasix should be assessed for tinnitus and hearing loss
5. anticoagulants cant dissolve a formed thrombus but tPAs can.
A= appearance (color all pink, pink and blue, blue [pale])

P= pulse (>100, < 100, absent)

G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)
1. cardiac meds: -pine=calcium channel blockers
-olol=beta blockers
-pril=ACE inhibitors
-artan=angiotensin II receptor blockers
2. No pee no K+
3. Before treating BPH, must restore urinary flow
4. Sign of toxic ammonia levels is asterixis (hands flapping)
5. Diuretics: Lasix and Bumex are K+ wasting Aldacton is K+ sparing
The adverse effects of Anti psychotics can be remembered using this: SHANCE
S-SUNLIGHT SENSITIVITY( Use hats and sunscreen)
H-HEPATOTOXICITY( Monitor LFT)
A-AGRANULOCYTOSIS( Characterized by fever and sore throat)
N-NEUROLEPTIC MALIGNANT SYNDROME( Characterized by fever and muscular rigidity)
C-CIRCULATORY PROBLEMS( Leukopenia and orthostatic hypotension)
E-EXTRA PYRAMIDAL SYMPTOMS( Administer anticholinergics and anti parkinsonian agents)
acute renal failure-abrupt loss of kidney function, usually reversible, with minor functioning loss
prerenal (renal ischemia)
intrarenal (any kidney tissue disease)
postrenal (obstruction...i.e calculi, prostatic hypertrophy)
chronic renal failure- progressive, irreversible loss of renal function.
-statin = lipid lowering agents
-mycin= antibiotics; watch for oto and nephrotoxicity
-vir=antivirals
-zine=can be antipsychotics or antiemtics; watch for agranulocytosis and eps effects
-tidine=H2 blockers
-prazole=proton pump inhibitors
Bells Palsy: avoid cold temperatures: make sure pt. closes windows when they are sleeping. Some even take eyes shut.
Nurses' priority intervention after a patient receives a skin graft is to prevent movement of the graft.
Greatest risk for postpartum hemorrhage is from distended bladder.
Herpes zoster (shingles) is from reactivation of the varicella virus.
1 grain = 60mg (I always forget this one)
Risk factors for legionnaires disease: advanced age, immunosuppression, end stage renal disease, and diabetes
Heart Arrhythmias:
SVT - Adenosine
Atrial Flutter - Anticoagulants
Atrial Fibrillation - Beta Blockers, Digoxin
PVC - Amiodarone
Ventricular Tachycardia - Amiodarone
Ventricular Fibrillation - Defibrillation
Torsades de Pointes - Magnesium Sulfate

1st Degree AV Block - No treatment usually

2nd Degree AV Block Type I - Atropine
2nd Degree AV Block Type II - Pacemaker
3rd Degree AV Block Complete - Emergent Pacemaker, Atropine, Epinephrine, Dopamine
Sinus Bradycardia - Atropine or Epinephrine
Sinus Tachycardia - Beta Adrenergic or Calcium Channel Blocker
Hepatitis
5 types
A,B, C, D, and E
Hep A-spread by drinking unsanitary water and uncooked foods
Hep B-spread by contact with blood or bodily fluids and is an STD
Hep C-spread by contact the same way as Hep B, can lead to cirrhosis (mostly seen with alcoholism)
Hep D-only contracted if you already have Hep B
Hep E-usually spread by contact with contaminated water
In nursing school, my instructor taught us to remember the different types like this:
VOWEL = BOWEL
Hep A and E---if your infected you will have problems with bowels...
Some Therapeutic Drug Levels
Digoxin 0.5-2.0 ng/ml
Lithium 0.6-1.5 mEq/L
Dilantin 10-20 mcg/dl
Theophylline 10-20 mcg/dl
Lithium 0.5-1.5 mEq/L
Coumadin PT: 12-20 sec....therapeutic range 1.5-2 times the control
INR: 2-3
Heparin PTT: 30-60 sec...therapeutic range 1.5-2 times the control
CYSTIC FIBROSIS
Diet: Low in fat and high in sodium
Meds: Antibiotics, liposoluble vitamins(A D E K) Aerosol Bronchodilators, mucolytics, pancreatic enzymes.
5 A's to Alzheimers
Anomia-unable to remember things
Apraxia-failure to identify objects
Agonsia-can't recognize sounds, tastes and other sensations, familiar objects.
Amnesia-memory loss
Aphasia-can't express SELF through speech.
GLOMEULONEPHRITIS-it's an antigen antibody complex from a recent strep infection which causes inflammation/ decreased
glomerular filtration rate.
BETA BLOCKERS
B1-affects the heart
B2-affects lungs
EMERGENCY DRUGS TO LEAN ON
Lidocaine
Epinephrine
Atropine
Narcan
AUTONOMIC DYSREFLEXIA-triggered by sustained stimuli at T6 or below. Vasodilation above injury,(flushed face, increased bp
etc) vasoconstriction below injury(pale, cool, no sweating.)
4.Common symptom of Aluminum hydroxide: constipation
5.In a child anemia is a the first sign of lead poisoning

6.Diuretic used for intracranial bleeding, hydrocephalus (Increased ICP,...) MANNITOL (osmotic diuretic)
7.Treatment of celiac disease: gluten free diet
8.cystis fibrosis==> excessive mucus production, respiratory infection complications,...
9.Cholelithiasis causes enlarged edematous gallbladder with multiple stones and an elevated bilirubin level.
10.Fat embolism is mostly seen in LONG BONES (femur,...)
TRANSMISSION-BASED PRECAUTIONS:
Remember ADC - airborne, droplet, contact
AIRBORNE
My - Measles
Chicken - Chicken Pox
Hez - Herpes Zoster
TB
Private Room - negative pressure with 6-12 air exchanges/hr
Mask, N95 for TB
DROPLET
think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diphtheria (pharyngeal)
E - epiglottis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus
Private Room or cohort
Mask
CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile
E - eye infxn - conjunctivitis
SKIN INFECTIONS
VCHIPS
V - varicella zoster
C - cutaneous diphtheria
H - herpes simplex
I - impetigo
P - pediculosis
S - scabies
Private room or cohort
Gloves
Gown
1. Abruptio placentae may be a complication of severe preeclampsia
2. Syrup if ipecac is not administered when the ingested substance is corrosive in nature

3. Pt before liver biopsy is NPO 4-6 hours

4. Assess renal fct before giving an osmotic diuretic (mannitol)
5. Patient in addisonian crisis decreased BP, Na, Blood glucose, Increased K
6. Amniocentesis is done as early as 14 weeks of gestation
7. Chorionic villi sampling is done as early as 10 weeks of gestation
8. Increased level of alpha fetoprotein in pregnant woman => neural tube defects
9. Insulin is safely given throughout pregnancy; oral hypoglycemic agents are contraindicated
10. Phenobarbital (Luminal) is commonly used to treat and prevent recurrent seizures in infants and young children
11. Aspirin is associated with Reye's syndrome in children with fever or viral infection
12. Glycerin suppositories are preferred agents to treat constipation in children
13. Corticosteroids may produce an altered effect of a vaccine
14. Thiazide diuretics (HCTZ,...) may induce hyperglycemia
15. Anticonvulsants INCREASE the seizures THRESHOLD!!!!
16. Hyperbilirubinemia in newborn: bilirubin levels are greater than 13-15 mg/dl
PVD if it's arterial they are hairless dry scaly and dependent ruber; venous is edematous, weepy, and dependent cyanosis

1. Postpartum period: circulating hcG disappears within 8-24 hours

2. S/S opioid withdrawl: rhinorrhea, dilated pupils, abdominal cramps
3. S/S sedative withdrawl: Increased motor activity, tachycardia
4. S/S alcohol withdrawl: tremors, N/V, diaphoresis
5. S/S stimulant withdrawl: CNS depression, fatigue, depression, confusion,...
6. Hb values: neonates have Hb higher than those of older children to sustain them until active erythropoiesis begins
7. Toclytic therapy: to arrest preterm labor
8. Child with chickenpox can be treated with oatmeal preparation baths and calamine lotion at home to relieve the itching...
9. child with rheumatoid arthritis should sleep in bag to keep joints warm and promote flexibility!!!! Wow...
10. When an eye patch is used to correct strabismus, the normal eye is patched. That forces the child to use the "lazy" eye, thereby
increasing that eye's muscle strengths
11. If a chest tube accidently get disconnected, clamp it or place the open end of the tube in a container of sterile water or saline
solution
12. Women should avoid pregnancy for at least 3 months after a rubella vaccine
13. Most accurate method to detect TB: sputum culture!!!
1. RSV- child in private room...CONTACT PRECAUTIONS..not droplet or airborne. (sometimes i get this mixed up because its called
respiratory synctical virus..i used to pick droplet precautions but i have down now lol!
2. Elderly adults generally present with confusion rather than S/S of an illness.
3. pneumonia- droplet precautions
4. COPD pts should get low flow Oxygen b/c of the hypoxic drive. (1-3L/min) teach pursed lip breathing.
5. ARDS- this pt doesnt respond to even 100% FiO2
6. TB- hemolysis (advanced stage) v/s pulmonary edema- frothy blood tinged sputum
7. Allen's test- done b/f an ABG by applying pressure to the radial artery to determine if adequate blood flow is present.
8. INH (Isoniazid)- tx of TB. give vit B6 to prevent peripheral neuritis
9. SIMV mode on vents commonly used for weaning pt off ventilator.
10. vent alarms: high alarm (increased secretions then suction......, biting tube-need an oral airway,...... or coughing and anxiety- need a
sedative)
low alarm- there is a leak or break in system...check all connectors and cuff.
11. if a trach becomes accidently dislodged try to replace it with an obturator..if no luck keep the hole open with hemostats until
physician arrives.

Dupuyten contracture - slow, progressive contracture of the palmar fascia causing flexion on the 4th and 5th fingers. Risk factors
include men over 50, diabetes, gout, arthritis, alcoholism
Condom cath- remove hair on penis, apply tape in a spiral manner, 1-2in space between end of the condom and tip of the glans penis
Bulge test - confirms presence of fluid in the knee, legs should be extended and supported on the bed
Lofenalac formula - for PKU
1. Profile of gallbladder disease: 5Fs: fair, fat, forty, five pregnancies, flatulent(disease can occur in all ages and both sexes)
2. Hip fractures commonly hemorrhage, whereas femur fractures are at risk for fat emboli
3. Religious beliefs: Hindu- No beef or items containing gelatin
4. Renal diet- High calorie, high carbohydrate, low protein, low K, low Na, and fluid restricted to intake = output +500 ml
5. Treatment for sickle cell crises- HHOP: Heat, hydration, oxygen, pain meds
6. RN and MD institute seclusion protection
7. MD or hospice RN can pronounce the client dead
8. For hospital triage, care for the client with a life-threatening illness or injury first
9. For disaster triage, choose to triage first those clients who can be saved with the least use of resources!
10. It is contraindicated to induce vomiting if the patient has ingested gasoline, acid and alkaline!!!
MAOIs
Non-Popular Meds
Nardil
Parnate
Marplan
avoid Tyramine
teach a pt with GERD after meals to remain upright for at least 20 min.
2.levodopa toxicity- notify physician if twitching develops.
3. Curling's ulcers or stress ulcers can cause sudden massive hemorrhage.
4. 5 mm induration positive reaction (mantoux test) for HIV or immunosuppressd pts
5. Schilling test done to see how well a pt can absorb vit b12. checking to see if they have pernicious anemia.
6. Prednisone, Prograf, and Cellcept helps to prevent kidney rejection.
Positioning Facts:
1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) --> turn pt
to left side and lower the head of the bed.
2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) --> turn on left side (and give O2,
stop Pitocin, increase IV fluids)
3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the stomach) with the HOB elevated (to
prevent aspiration)
4. During Epidural Puncture --> side-lying
5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent headache and leaking of CSF)
6. Pt w/ Heat Stroke --> lie flat w/ legs elevated
7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be kept straight. No other positioning
restrictions.
8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of secretions)

9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks.
10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders.
11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture
12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction
13. After Total Hip Replacement --> don't 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 with pillows.
14. Prolapsed Cord --> knee-chest position or Trendelenburg
15. Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position.
16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in reclining position, lie down after meals for 2030 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals)
17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide for hip extension.
18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.
19. Detached Retina --> area of detachment should be in the dependent position
20. Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed
21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees
22. After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on either side.
23. During Internal Radiation --> on bedrest while implant in place
24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia,
hypertension) --> place client in sitting position (elevate HOB) first before any other implementation.
25. Shock --> bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg)
26. Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure some GI/hepatic
hepatitis--all forms standard precautions
s/s of bowel perforation--sudden diffuse abdominal pain, no bowel sounds, resp. rapid and shallow, rigid abdomen.
nursing care for undiagnosed abdominal pain--npo, no heat on stomach, no enemas, no narcotics, no laxatives.
crohns-small intestine vs ulcerative colitis-large intestine..sulfasalzine used to treat both.
pyloric stenosis- olive shaped mass felt in R. epigastric area, projectile vomiting
if a pt requires TPN and it is temp. unavailable then give D10W OR 20% DW until available.
before a Dx test of after 3 enemas, returns are not clear, notify physician
if diarrhea occurs with a colostomy. check meds (some cause diarrhea)..dont irrigate
as a general rule antacids should be taken 1-2 hours after other oral meds.
Symptothermal method of birth control - combines cervical mucus evaluation and basal body temperature evaluation, nonprescription/drug
percipitus/rapid labor - risk factor for early postpartum hemmorhage and amniotic fluid embolism

In elderly, change in mental status and confusion are often the presenting symptoms of infection
antiseizure meds - notify anesthesia prior to surgery, may need to decrease the amount of anesthetic given
neuroleptic malignant syndrome - increased temp, severe rigidity, oculogyric crises, HTN, complication of antipsychotic meds, notify
MD
Dilantin - pregnancy risk category D, should investigate possibility of pregnancy (LMP) prior to administering
Transcutaneous electrical nerve stimulation (TENS) - used for localized pain (back pain, sciatica) - use gel, place electrodes over,
above or below painful area, adjust voltage until pain relief/prickly "pins and needles"
1. S/S delusional thought patterns => suspiciousness and resistance to therapy
2. Use of neologism (new word self invented by a person and not readily understood by another) =>associated with thought disorders
3. Age and weight are VERY important to know after a child has ingested a toxic substance
4. Child with celiac disease can eat corn, rice, soybeans and potatoes (gluten free)
5. Anaphylactic rx => administer epinephrine first, then maintain an open airway. (Not the other way around )
6. Client with asthma => monitor peak of airflow volumes daily. Pulse ox after!!!!
7. DKA pt => a HCT of 60 (way high...) (extreme dehydration) would be more critical than a pH less than 3! (Fluids first...)
8. Assess for abdominal distention after placement of a VP shunt! (You know why right?)
9. GFR is decreased in the initial response to severe burns, with fluid shift occurring. Kidney fct must be monitored closely or renal
failure may follow in a few days
10. Vomiting => metabolic alkalosis (loss of stomach acid content)
11. Diarrhea => metabolic acidosis (loss of bicarbonate)
12. COPD => respiratory acidosis (CO2 retention)
13. Anxious client => hyperventilation can cause respiratory alkalosis. A paper bag will help. (Increase CO2) Right?
14. Client with low H&H after splenectomy => the initial priority is REST due to the inability of RBCs to carry O2
15. Mild to moderate diarrhea in a child => maintain a NORMAL diet with fluids to rehydrate the poor child
Clozapine (Clozaril) - antipsychotic, treats schizophrenia, potential to suppress bone marrow and cause agranulocytosis (look for sore
throat and fever)
Bucks traction - remove foam boots 3x/day to inspect skin, turn client to unaffected side, dorsiflex foot on affected side, elevate foot
of bed
phlebitis - tenderness and redness at IV insertion site and redness proximally along the vein. Remove the IV adn apply warm soaks
Cred e maneuver - apply manual pressure to bladder, aids in emptying the bladder completely, results in reduced risk for infection; if
performed every day can result in bladder control for some SCI
Frequent use of nasal sprays to relieve allergic symptoms can result in vasoconstriction that causes atrophy of nasal membranes
(frequent nosebleeds)
Lung cancer is a common cause of SIADH (abnormal secretion of ADH, increase water absorption and dilutional hyponatremia)
ginkgo - antiplatelet, CNS stimulant, given for dementia, increase risk of bleeding with NSAIDS
Native Americans are present oriented and do not live by the clock (will be late for appointments)
Pulmonic area - 2ICS, left of sternum
Chronic alcohol use is the most common cause of hypoMg, which may result in cardiac arrest (increase neuromuscular irritability,
tremors, tetany, seizures)
SCD - two fingers between sleeve and leg, opening at the knee and popliteal pulse point, antiembolism stockings can be applied under
sleeve to decrease itching, sweating and heat buildup
if allergic to sulfonamides dont take acetazolamide (Diamox)
methotrexate- dont take supplemental folic acid and please dont take while pregnant..can cause premature labor and bleeding.
oh dont take cytoxan while pregnant or dont handle the drug while pregnant.

infections that occur with AIDS clients are called opportunistic infections.
Pneumocystis carinii pneumonia is not contagious unless you are immunocompromised. this infection occurs mostly with AIDS pts.
infant with HIV should NOT receive chickenpox or oral polio vaccine. can give inactivated polio vaccine though.
Erb's point - 3ICS left of the sternum
Ambulatory electrocardiography - continuously records cardiac activity during a 24hour period, should not use electric devices, bathe
or shower, no diet changes, record everything in daily log
Demerol -crosses the placenta which decreases FHR variability
Ascites management - albumin given to pull fluid back into blood vessels then diuretic given to excrete excess fluid
TB - need vitamin B6
bloody dyalasate (spelling?) - assess if patient is menstruating
placing an abductor pillow between patients legs after hip replacement prevents dislocation of the hip while turning, important
especially when the client is confused
palpating the carotid pulses together can cause a vagal response and slow the clients heart rate
adrenal insufficiency - steroids increased prior to surgery
thyroidectomy - access for numbness from decreased Ca
Bactrim - mild to moderate rash the most common SE
If when removing a PICC a portion of the catheter breaks - apply tourniquet to the upper arm, feel radial pulse
emptying a drainage evacuator - wash hands, don gloves, elevate bed, pour drainage into measuring cup, compress the evacuator and
replace the plug
Percodan - oxycodone and aspirin
Percocet - oxycodone and acetaminophen
Myasthenia Gravis: worsens with exercise and improves with rest.
Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse
Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle
Prior to a liver biopsy its important to be aware of the lab result for prothrombin time (PT)
1. Watery vaginal discharge and painless bleeding => endometrial cancer
2. Frothy vaginal discharge => trichomonas infection
3. Thick, white vaginal discharge => candida albicans
4. purulent vaginal discharge => PID
5. Approximately 99% of males with cystic fibrosis are sterile due to obstruction of the vas deferens
6. Lyme's disease is transmitted by ticks found on deer and mice in wooded areas
7. Children 18-24 months normally have sufficient sphincter control necessary for toilet training
8. Complications of TPN therapy are osmotic diuresis and hypovolemia!!!
9. L/S ratio => fetal lung maturity
10. Kava-kava can increase the effects of anesthesia and post-op analgesia
11. NEVER give chloride potassium by IV push
12. GINKGO interacts with many meds to increase the risk of bleeding; therefore, bruising or bleeding should be reported to MD
13. Vanco therapeutic range 10-20 mcg/mL
14. Client with disseminated herpes zoster (shingles) => AIRBORNE precautions
15. The client taking methotrexate should avoid multivitamins b/c multivitamins contain folic acid. Methotrexate is a folic acid
antagonist!!!
Hypovolemia and osmotic diuresis that are complications of TPN result from hyperglycemia!

Let's recapitulate TPN => Hyperglycemia => osmotic diuresis & hypovolemia...
Drooling - 4 months
Responds to own name 6-8months
deliberate steps when standing 9-10months
picks up bite size pieces of cereal 11months
24months: kick ball w/o falling, build tower of 6blocks, 2-3 word phrases, 300 word vocab
30months: jump with both feet, run, say first and last name
36months: tricycle
Left CVA - speech, math skills, analytical thinking
Right CVA - behavior, disorientation to person, place and time
Ectopic pregnancy - LLQ pain, vaginal spotting
tricuspid valve: 5ICS left sternal border
Meconium should be passed within 12-24 hrs
transitional stools - 3rd day - thin greenish brown
breastfed baby - golden yellow stools with sour milk odor
compartment syndrome...significant increase in pain not responsive to pain meds.
Plaquenil-tx of Rhem Arthritis...recommend eye exam every 3 mo.
Statins- tx of high cholesterol...ASSESS FOR MUSCLE PAIN...monitor liver enzymes.
Nicotinic Acid (Niacin)-tx of high cholesterol- flushing occurs in most pt. will diminish over several weeks.
stages of shock (its more but i made it simple "KISS" keep it simple stupid lol!)
early- increase in pulse...normal urine output
intermediate-RAS (renin-angioten system), low urine output, cool skin, pallor
late-no urine output, low BP irreversible stage!
Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin and hair
Graves disease/hyperthyroidism: accelerated physical and mental function; sensitivity to heat, fine/soft hair
Thyroid storm: increased temp, pulse and HTN
Post-thyroidectomy: semi-Fowlers, prevent neck flexion/hyperextension, trach at bedside
Hypo-parathyroid: CATS convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium), high Ca, low phosphorus diet
Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium), low Ca, high phosphorus diet
Hypovolemia increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity >1.030
Hypervolemia bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010; Semi-Fowlers
Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration, weakness, administer Pitressin
SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, HA; administer Declomycin, diuretics
Hypokalemia: muscle weakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery)
Hyperkalemia: MURDER muscle weakness, urine (oliguria/anuria), respiratory depression, decreased cardiac contractility, ECG
changes, reflexes
Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids
Hypernatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution
Hypocalcemia: CATS convulsions, arrhythmias, tetany, spasms and stridor
Hypercalcemia: muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect on CNS
HypoMg: tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity
HyperMg: depresses the CNS, hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations,
emergency
Addisons: hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI
distress

Cushings: hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo
hump
Addisonian crisis: n/v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP
Pheochromocytoma: hypersecretion of epi/norepi, persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA;
avoid stress, frequent bating and rest breaks, avoid cold and stimulating foods, surgery to remove tumor
Screenings for Fetal Problems
1st TRIMESTER (Chorionic villis sampling, US scan)
2nd TRIMESTER (AFP screening or Quad Screening,Amniocentesis)
3rd TRIMESTER (kick counts,Nonstress Test, Biophysical Profile, Percutaneous Umbilical Blood sampling, Contraction Stress Test )
Ultrasound screening -can be vaginal or Abdominal (in latter make Her drink water to fill bladder)
-Confirms viability
-Indicates fetal presentation
-Confirms multiple gestation
-Identifies placental location
-Measurements can be taken to confirm/estimate gestational age
-Identify morphologic anomalies
Chorionic villis sampling
8-12 weeks
for early diagnosis of genetic, metabolic problems
Amniocentesis -13-14 weeks
Is done under US scan to obtain a sample of amniotic fluid for direct analysis of fetal chromosomes, development, viability and lung
maturity
AFP
15-18 weeks-Maternal Blood Drawn
AFP also called =Quad marker screening:
-maternal serum alpha fetoprotein (MSAFP),
-human chorionic gonadotropin (HcG),
-unconjugated estriol (UE),
-and inhibin A
low AFP-Down syndrome
high-Spina bifida
it is not an absolute test if it is abnormal -further investigation is recommended
Kick counts (tests Uretro placental capability)
Same time every day mother records how often she feels the fetus move
if minimum 3 movements are not noted within an hour's time, the mother is encouraged to call her physician immediately!
Nonstress Test
checks FHR and mother detects Fetal movements.
Contraction Stress Test -tests perfusion between Placenta and Uterus (basically O2 and CO2 exchange)
-IV accessed and performed in a labor and deliver unit under electronic fetal monitoring
contractions initiated by Pitocin or nipple stimulation
the desired result is a "negative" test which consists of three contractions of moderate intensity in a 10 minute period without evidence
of late decelerations
the test is done to detect problems so if it is Positive (persistent late decelerations
) then-CS
how is done:
The electronic fetal monitor is placed on the maternal abdomen for 20-30 minutes
Each time the fetus moves, FHR should accelerate 15 beats/min above the baseline for 15 seconds
A reactive (good) test =>2 accelerations in FHR occur with associated fetal movement
Biophysical Profile (BPP)
identification of a compromised fetus and consists of 5 components:
-fetal breathing movement
-fetal movement of the body or limbs
-fetal tone (extension or flexion of the limbs)

-amniotic fluid volume index (AFI) visualized as of fluid around the fetus
-reactive non-stress test
each component 0-2, 8-10-desirable.
Percutaneous Umbilical Blood sampling -like amniocentesis but cord punctured
-chromosomal anomalies, feta karyotyping, and blood disorders
Everywhere where woman's abdomen is punctured informed consent is needed, and risks like amnionitis spontaneous abortion,
preterm labor/delivery, and premature rupture of membranes must be explained. If she Rh--she may be RHoGAM given.
--In complete heart block, the AV node blocks all impulses from the SA node, so the atria and ventricles beat independently, b/c
Lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response, cardiac depressant are contraindicated
in the presence of complete heart block.
--administrate Glucagon when pt is hypoglycemia and unresponsive
Bromocriptine (Parlodel) or Dantrolene (Dantrium) is used for CNS toxicity
Ibuprofen (Motrin) S/E includes epigastric distress, nausea, occult blood loss, peptic ulceration, use cautiously with history of
previous gastrointestinal disorders.
Aminophylline (Truphylline) use with Propranolol (Inderal) may decrease metabolism and lead to toxicity
Antianxiety medication is pharmacologically similar to alcohol, is used effectively as a substitute for alcohol in decreasing doses to
comfortably and safely withdraw a client from alcohol dependence
Tagamet decrease gastric secretion by inhibiting the actions of histamine at the H2-receptor site, constipation is a common side effect
of this med, should increase fiber in diet. Take with meals and at bedtime.
elderly clients and clients with renal problems are most susceptible to CNS side effects (confusion, dizziness) of the medication
atropine is contraindicated in paralytic ileus, ulcerative colitis, obstructive GI disorders, benign prostatic hypertrophy, myasthenia
gravis and narrow angle glaucoma
withdrawal s/s of benzos: agitation, nervousness, insomnia, anorexia, sweating, muscle cramps.....basically about the same as alcohol
withdrawal s/s.
thrombophlebitis s/s: redness, warmth, and induration along the vein, tenderness on palpation of the vein.
hypokalemia-prominent U WAVE (u is down hypo), hyperkalemia-tall T wave (T is tall hyper)
superior vena cava syndrome s/s: nosebleeds, edema in the eyes, edema of hands, dyspnea, mental status changes.
s/s of rheumatic fever: painful swollen joints, jerky movements, enlarged heart, heart murmur, nontender lumps on bony areas, white
painful lesions on the trunk
s/s of vit B12 deficiency: pallor, slight jaundice, smooth beefy red tongue, tingling hands and feet, and difficulty with gait
good pasture syndrome affects the lungs and kidneys so expect pulmonary symptoms and kidney symptoms (failure symptoms)
For donning: Got my free gold: gown, mask, face shield (goggles), gloves
For removing: Google for glad Molly: gloves, face shield (goggles), gown, mask
Also gloves are the last thing you put on and the first thing that you take off.
Metronidazole (Flagyl)- antiviral: no alcohol (unless you planning on vomiting for awhile)...this drug has a metallic bitter taste.
Digoxin-check pulse, less than 60 hold, check dig levels and potassium levels.
Amphojel: tx of GERD and kidney stones....watch out for constipation.
Vistaril: tx of anxiety and also itching...watch for dry mouth. given preop commonly
Versed: given for conscious sedation...watch for resp depression and hypotension
PTU and Tapazole- prevention of thyroid storm
Sinemet: tx of Parkinson...sweat, saliva, urine may turn reddish brown occasionally...causes drowsiness
Artane: tx of Parkinson..sedative effect also
Cogentin: tx of Parkinson and extrapyramidal effects of other drugs

Tigan: tx of postop n/v and for nausea associated with gastroenteritis

Timolol (Timoptic)-tx of glaucoma
Bactrim: antibiotic..dont take if allergic to sulfa drugs...diarrhea common side effect...drink plenty of fluids
Gout Meds: Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim)
Apresoline(hydralazine)-tx of HTN or CHF, Report flu-like symptoms, rise slowly from sitting/lying position; take with meals.
Bentyl: tx of irritable bowel....assess for anticholinergic side effects.
Calan (verapamil): calcium channel blocker: tx of HTN, angina...assess for constipation
Carafate: tx of duodenal ulcers..coats the ulcer...so take before meals.
Theophylline: tx of asthma or COPD..therap drug level: 10-20
Mucomyst is the antidote to Tylenol and is administered orally
Diamox: tx of glaucoma, high altitude sickness...dont take if allergic to sulfa drugs
Indocin: (nsaid) tx of arthritis (osteo, rheumatoid, gouty), bursitis, and tendonitis. Synthroid: tx of hypothyroidism..may take several
weeks to take effect...notify doctor of chest pain..take in the AM on empty stomach..could cause hyperthyroidism.
Librium: tx of alcohol w/d...dont take alcohol with this...very bad nausea and vomiting can occur.
Oncovin (vincristine): tx of leukemia..given IV ONLY
kwell: tx of scabies and lice...(scabies)apply lotion once and leave on for 8-12 hours...(lice) use the shampoo and leave on for 4
minutes with hair uncovered then rinse with warm water and comb with a fine tooth comb
Premarin:tx after menopause estrogen replacement
Dilantin: tx of seizures. thera drug level: 10-20
Navane: tx of schizophrenia..assess for EPS
Ritalin: tx of ADHD..assess for heart related side effects report immediately...child may need a drug holiday b/c it stunts growth.
dopamine (Intropine): tx of hypotension, shock, low cardiac output, poor perfusion to vital organs...monitor EKG for arrhythmias,
monitor BP
IF it is a depression med,
AND it look likes it's been in a commercial / you know someone on it (e.g. Prozac, Paxil, Celexa, zoloft)
then it is an SSRI.
IF not,
then it is either a tricylic OR a MAOI...
... common tricylics USUALLY have 3 syllables (pamelor, elavil). (remember: tri = 3)
... common MAOI's USUALLY have two (nardil marplan)
If ya can't remember, go with the syllables.
Serotonin syndrome is a risk for all depression meds, it is marked by vasoconstrictive crisis (hypertension, temp increase, mentation).
Remember: serum toner (serotonin)... the first discovered role of serotonin was in vasoconstriction!
This is a medical emergency, similar to NMS.
MAOI drugs have a specific risk for tyramine ingestion. Aged cheeses and wine are high in it, fermented / moldy foods. M for
munchies, A for aged
Respiratory Rate:
Newborn35-40

Infant 30-50
Toddler 25-35
School Age 20-30
Adolescent/Adult 14020
Adult 12 -20
Heart Rate
Infant 120-160 (110 at rest)
Toddlers 90-140
Preschool/School Age 75-110
Adolescent/Adult 60-100 (max 120 before concern)
Pulse
Bounding 4+
Normal 3+
Difficult to palpate 2+
Weak 1+
None 0
Have trouble remembering fhr patterns in OB? Think VEAL CHOP
VC
EH
AO
LP
V = variable decels; C = cord compression caused
E = early decels; H = head compression caused
A = accels; O = okay, not a problem!
L = late decels P = placental insufficiency, can't fill
For cord compression, place the mother in the TRENDELENBERG position because this removes pressure of the presenting part off
the cord. (If her head is down, the baby is no longer being pulled out of the body by gravity)
If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection.
For late decels, turn the mother to her left side, to allow more blood flow to the placenta.
For any kind of bad fetal heart rate pattern, you give O2, often by mask...
When doing an epidural anesthesia hydration before hand is a priority.
Hypotension and bradypnea / bradycardia are major risks and emergencies.
NEVER check the monitor or a machine as a first action. Always assess the patient first; for example listen to the fetal heart tones with
a stethoscope in NCLEX land. Sometimes it's hard to tell who to check on first, the mother or the baby; it's usually easy to tell the
right answer if the mother or baby involves a machine. If you're not sure who to check first, and one of the choices involves the
machine, that's the wrong answer.
If the baby is a posterior presentation, the sounds are heard at the sides.
If the baby is anterior, the sounds are heard closer to midline, between the umbilicus and where you would listen to a posterior
presentation.
If the baby is breech, the sounds are high up in the fundus near the umbilicus. If the baby is vertex, they are a little bit above the
symphysis pubis
A possible complication of impetigo is poststreptococcal glomerulonephritis and periorbital edema is indicative of postreptocccal
glomerulonephritis.
client should weight themselves daily when taking lithium-- and after the first dose, client should have his/her levels checked within 812 hours and two times a week for the first month. Lithium also causes polyuria and dehydration. S&S of toxicity are, ataxia,
vomiting, diarrhea, muscular weakness and drowsiness.

Gurie blood test helps determine PKU for neonate.

child can return to school with Hep A, a week after onset of jaundice
bulge test is a test for confirming fluid in the knee
it's important not to touch the bed when using defibrillator in order to prevent accidental countershock!!
Extrusion reflex means is the same meaning as tongue thrust which disappears between 3- 4mos of age.
Administer oral steroids in the morning with food to prevent ulcerogenic effects!
Increased abdominal distention, nausea and vomiting are signs of paralytic ileus that should be reported to the physician!
It's important for a client with an internal radium implant to be on a low residue diet in order to prevent many bowel movements
because stool can dislodge it.
Heparin is not transmitted to infant from breastfeeding.
Haldol is effective for reducing assaultive behavior, for example, a pt threatening to hurt another.
Narcotic analgesics are contraindicated for pt's with ICP because it can mask symptoms.
Pt's with SLE(lupus) should be in remission for 5 months before becoming pregnant.
Fixed and DIALATED pupil are signs of ICP and should be reported, it is an emergency.
For strabismus, the brain receives two images.
Vomiting is contraindicated for a pt/child who swallows lighter fluid(hydrocarbons) because there's a risk of aspiration.
Change IV tubing every 48-72hourse(every time I want to choose every 24 hours!)
Extreme tearing and redness are signs of viral conjunctivitis and if there is a worker with these signs, make sure they are sent home
because it is contagious!
For amputations after wound has healed..., assess for skin breakdown, wash, rinse and dry stump daily, alcohol dries so don't apply
DARN IT! , no lotion. Elevate stump 24-48 hours after surgery, discourage semi fowler's position to prevent contractures of the hip.
Flush NG tube with 30ml of air before aspirating fluid.
Turp(transurethral resection of the prostate)--hemorrhage is a complication, bleeding should gradually decrease to light pink in 24 hrs.
DVT: tx with compression stockings, low dose heparin, discourage sitting for prolonged periods.
Hot and dry=sugar high(symp of hyperglycemia)
cold and clammy=need some candy(hypoglycemia)
Type 1 diabetes is diagnosed usually before age 15. NO insulin produced
Type 2 diabetes--INSUFFICIENT insulin production. Keto acidosis not common. Affects adults over 40 mostly.
Diabetes insipidus--history of head injury or pituitary tumor or craniotomy...HYPOsecretion of ADH. Polyruria,
decreased specific gravity, decreased osmolarity, HYPOvolemia, increased thirst, tachycardia, decreased bp.
SIADH--excess ADH is released. HYPERvolemia, weight gain, administer diuretics...Declomycin could be prescribed.
Adrenal crisis: Profound fatigue, dehydration, vascular collapse, renal shut down, decreased NA, increased K.
Good ol' Maslow:

1st Physiologic needs

2 Security and safety
3 Love and belonging
4 Self actualization
Sterile field and procedure facts...
For sterile field--never turn your back, avoid talking , moisture barriers carries bacteria, open pack away from field, do not reach over
sterile field.
Sterile procedures--Surgical procedures, biopsies, caths, injections, infusions, dressing changes.
In regards to surgery, aspirin, antidepressants, steroids, nsaids are drugs that put clients at risk!
The consent for surgery--Dr. gives client explanation, consent signed by Dr., client and witness. Signed prior to pre op meds, remains
a permanent part of client chart.
For pain: PQRST
Provoking
Quality
Region
Severity
Timing
Ask if pain is stabbing, burning crushing.
Narcotics---MORPHINE, MEPERIDINE(DEMEROL), HYDROMORPHONE(DILAUDID), OXYCODONE(OXYCOTIN).
Non-narcotics--ACETOMINOPHEN(TYLENOL), SALICYLATES.
Non steroidal (NSAIDS) TYLENOL, IBPROFEN, NAPROSYN, INDOCIN.
Clozapine (Clozaril) is used for schizophrenic patient's who don't respond to other antipsychotic drugs.
Cogentin (Benztropin) is used for the extrapyramidal effects associated with antipsychotic agents.
Chlorpromazine (Thorazine) is used to treat hallucinations, agitation, and thought disorders.
Adenosine(Adenocard) is an antiarrhythmic drug, this drug is good for paroxysmal atrial tachycardia...it slows conduction from av
node.
Atropine for symptomatic bradycardia.
Digoxin for atrial fibrillation.
Lidocaine for ventricular ectopy.
For assessing the abdomen, correct order is INSPECTION, AUSCUTATION, PERCUSSION, PALPATION "I Am Peed PAAAAA!" )
Cheyne strokes respirations are periods of apnea for 10-60 seconds then slowly increasing rate and depth... occur typically with heart
failure and cerebral depression.
Bulls eye rash is classic in lymes disease.
To relieve breast engorgement, pt should pump each breast for 10 minutes every 3-4 hours and during the night if she's awake.
Anticholinergic effects(drugs that block acetylcholine) cause dry mouth, constipation, urine retention.
5 rights of delegation
Right task
Right circumstance
Right communication
Right person
Right feedback

Cystic fibrosis is a recessive trait, there is a one in four chance that each offspring will have the trait or disorder.
Cushings triad is something to look out for in patient's with increased ICP which is decreased heart rate, decreased respiratory rate
BUT increased blood pressure.
Withdrawal from stimulants results in depression, fatigue and confusion.
Withdrawal from alcohol results in vomiting, nausea, tremors and diaphoresis.
Withdrawal from sedatives results in increased motor activity and tachycardia.
Withdrawal from opioids results in rhinorrhea, abdominal cramps and DIALATED pupils.
to remember blood sugar:
hot and dry-sugar high (hyperglycemia)
cold and clammy-need some candy (hypoglycemia)
2. ICP AND SHOCK HAVE OPPOSITE V/S
ICP-increased BP, decreased pulse, decreased resp.
shock- decreased BP, increased pulse, increased resp.
3. cor pulmonae: right sided heart failure caused by left ventricular failure (so pick edema, jvd, if it is a choice.)
4. heroin withdrawal neonate: irritable poor sucking
5. Jews: no meat and milk together
6. Brachial pulse: pulse area cpr on an infant.
7. Test child for lead poisoning around 12 months of age
8. bananas, potatoes, citrus fruits source of potassium
11. Cultures are obtained before starting IV antibiotics
12. a pt with leukemia may have epitaxis b/c of low platelets
13. best way to warm a newborn: skin to skin contact covered with a blanket on mom.
14. when a pt comes in and she is in active labor...nurse first action is to listen to fetal heart tone/rate
15. phobic disorders...use systematic desensitization.
1. Clients of the Islam religious group might want to avoid jello, pork and alcohol
2. Most common side effect of daunorucibin (cerubidine) for a client with leukemia is cardiotoxicity
3. Patient having a surgery on the lower abdomen should be placed in the trendelenburg position
4. Flumazenil (Romazicon) is the antidote for versed (Needless to remind you that versed is used for conscious sedation... Say thank
you Jean LOL)
5. Patients taking isoniazid (INH) should avoid tuna, red wine, soy sauce, and yeast extracts b/c of the side effects that can occur such
as headaches and hypotension
6. A Patient with gout who is placed on a low-purine diet should avoid spinach, poultry, liver, lobster, oysters, peas, fish and oatmeal
7. A patient who needs a high-iron diet should eat: sliced veal, spinach salad, and whole-wheat roll
8. Pegfilgastrin (Neulasta) is a chemotherapeutic drug given to patients to increase the white blood cells count
9. Amphoteracin B (Fungizone) should be mixed with D5W ONLY!!!
10. Pt with leukemia taking doxorubicin (Adriamycin) should be monitored for toxic effects such as rales and distended neck veins
(carditoxicity manifested by change in ECG and CHF)
11. Cardidopa/levodopa (Sinemet) is given to clients with Parkinson's disease. Watch for toxic effects such as spasmodic eye winking
12. Nimotop (Nimodipine) is calcium channel blocker that is given to patients with ruptured cerebral aneurysm.
A conductive hearing loss involves interference in the transmission of sound waves to the inner ear.
2. A sensorineural hearing loss is the result of nerve impairment.
3. An acoustic neuroma is a benign Schwann cell that adversely impacts the 8th cranial nerve.
4. DKA is an acute insulin deficiency followed by a decrease in glucose in body cells and an increase production of glucose by the

liver.
5. Lymphedema results from an obstruction of lymph circulation and can be acquired or can be secondary to other disorders.
6. The Reed-Sternberg cell is the malignant cell type associated with Hodgkin's Disease.
7. The incidence if Hodgkins and non - Hodgkins lymphomas are increased in those taking drugs such as phenytoin ( Dilantin ).
On the ECG or EKG:
P wave = atrial depolarization
P-R interval = represents atrial,AV node, & Purkinje depolarization
Q wave = septal depolarization
R wave = apical depolarization
S wave = depolarization of lateral walls
QRS complex = spread of excitation through the muscle of the ventricles
T wave = ventricular repolarization
Starling's Law = the greater the strength of the myocardium as the ventricles fill with blood, the stronger the contraction.
Cardiac output = the amount of blood that is pumped out of the LV each minute.
The mitral valve is the most common site for vegetations.
1. S/S croup (child) => hoarse voice, inspiratory stridor, barking cough
2. Client with hepatic encephalopathy => Neomycin decreases serum ammonia concentration by decreasing the number of ammonia
producing bacteria in the GI tract
3. A 2 year old can remove one garment
4. A 2 and half year old can build a tower of eight cubes and point out a picture
5. A 3 year old can wash and dry his/her hands
6. S/S perforated colon => severe abdominal pain, fever, decreasing LOC
7. Hyperglycemia => b/c polyuria assess for signs of deficit fluid volume such as rapid, thready pulse, decreased BP, and rapid
respirations
8. A child with nephrotic syndrome is at risk of skin breakdown from generalized edema
9. Tetracycline should be taken on an empty stomach. Avoid dairy products, Ca, Mg, Al and Fe (Iron)
10. Upper GI series => NPO 6-8 hrs b/f procedure
11. Mumps is the childhood infectious disease that most significantly affects male fertility
12. Client allergic to penicillin may be also allergic to cephalosporins
13. Infants and children up to age 7 are abdominal breathers
14. Placental transport of substances to/from the fetus begins in the 5th week
15. Duration of contractions => period from the onset of uterine tightening to uterine relaxation
16. Frequency of contractions => period b/t one contraction and the beginning of the next contraction
17. Erbs point => 3rd L ICS; pulmonic and aortic murmurs are best

PE ( Pulmonary Embolism )
Risk factors:
* venous thrombosis * immobility * post-op pts. * trauma * pregnancy * CHF * obesity * oral contraceptives
Signs/Symptoms:
* pleuritic chest pain
* severe dyspnea
* feeling of doom
* tachypnea & tachycardic
* hemoptysis
* shock ( if huge )
* low pCO2, increased pH ( from hyperventilating )
* fever
* rales/crackles
RISK for DIABETES:
* genetics/family hx
* obesity
* race ( African-American, Native American, Hispanic, Asian, Pacific Islanders )
* over 40 yrs
* had an impaired fasting glucose or impaired glucose tolerance before
* HTN
* High cholesterol and triglycerides

* hx of gestational diabetes
Lithium
therapeutic range is small watch closely, 0.6 to 1.2 mEq/L.
Check Lithium level every 1-2 months or with behavior change.
Some side effects:
* polyuria
* polydipsia
* mild thirst
* hand tremors
* bloating of abdomen
* weight gain
* lethargy
* headache
Watch salt intake & ensure pt getting enough.
monitor renal function
don't give diuretics with lithium
no alcohol
maintain good oral fluid intake
CRUTCHES:
The three point gait is the most commonly used. It is used when the pt can only have weight on 1 extremity.
* advance the crutches together first along with the affected leg all at same time.
* bring the unaffected leg up to the crutches, supporting the weight of the body on the hands.
* ensure proper length of the crutches, when pt is standing as upright as possible position the top of crutch 2 inches below armpit, and
tip of each crutch is 6 in. to the front and side of the feet. Pts. elbows should be slightly flexed when the hand is on the grip.
EGD is an invasive diagnostic test to see into the esophagus & stomach to accurately diagnose an ulcer & evaluate the effectiveness of
the patient's tx.
An occult blood test shows the presence of blood but does not show where it is coming from.
Gastric ulcer pain usually happens 30-60 minutes after a meal & not at night. A duodenal ulcer has pain during the night that is often
relieved by eating food. So, gastric ulcer food=pain. Duodenal ulcer food eases pain.
Sharp pain in the upper stomach ( abdomen ) after eating a heavy meal is a symptom of gallbladder disease.
Hirschsprung's disease, infant fails to pass meconium, abd distention, caused by obstruction in intestine, will get colostomy, that is
usually reversed when child is 17-22 lbs.
Naturally acquired active immunity: results from having the disease and recovering successfully.
Naturally acquired passive immunity: antibodies received from placenta or breast milk.
Artificially acquired active immunity: from immunizations.
Artificially acquired passive immunity: antibodies transferred from sensitized person as in immune serum globulin ( gamma
globulin ).
1. Ace Inhibitors can cause hyperkalemia and chronic cough- pt's should
not use salt substitutes because they are mostly made from K+ which
will further increase the K+
2. Valium- suppresses non-rem sleep. Overdose Antidote is flumazenil.
3. There is no antidote for barbiturates which suppress REM sleep. S/S of
allergy to barbiturates is Barbs=prickly sensation ,edema of
membranes in mouth.

4. Tylenol = Liver toxic (no more than 4 g/day) Give Mucomyst for
overdose. Whereas, Ibuprofen = kidney toxic
5. Vancomycin- treats MRSA; Adverse Effects- Red man syndromeflushing from quick admin of this Rx can be prevented with Benadryl before admin of RX.
Terbutaline: Medication given to stop pre-term labor, contraindicated if tachycardia
Methergine: Given for postpartum hemorrhage.
Cervidil: Cervical ripening agent
Mag Sulfate: Pregnancy Induced Hypertension - prevents seizure. Absence of deep tendon reflex is sign of toxicity
Pitocin: Used for induction of labor and postpartum to help the uterus contract.
Early Decelerations are okay, follow the contraction.
Late Decelerations are a sign of fetal distress and continue after contraction. Reposition client (left side)
3- 5 beat Variability in FHR is good sign, you want to see that.
Stop pitocin if contractions longer than 90 seconds and closer than 2 minutes.
Once the membranes rupture, important to monitor temperature hourly as risk for infection increases.
First thing to do after rupture is to auscultate fetal heart tones! Assessing for cord prolapsed if decels occur.
Analgesics are typically not given during the transitional phase of labor as delivery is imminent and could lead to decreased
respiratory rate in neonate.
If patient has boggy uterus - place the infant to nipple, it causes release of natural pitocin
If uterus deviated to one side - encourage client to void.
Rhogam given to Rh negative mothers with Rh positive babies.
Therapeutic Ranges
PACT of 10-20
-Phenytoin
-Acetaminophen
-Chloramphenicol
-Theophylline
...amine=150-300 ng/ml
-Imipramine
-Desipramine
...LOL Valproic 50-100!
-propranoLOL ng/ml
-Valproic Acid mcg/ml
MgSO4 = 4-7
**************
Phenobarbital =10-30
Therapeutic range of these drugs are CODED in their names; Di=2(means two) Amide-5 letters,
the rest in CAPITAL Letters (lower range) and total number of letters (higher range).
DIsopyrAMIDE 2-5
GENTAmicin 5-10
TOBRAmycin 5-10
CARBAmazepin (e) 5-12
*************
EthoSUXemide 40-100, it is just suxs))
I dont gave LITHIUM, Digoxin, lidocain since we already must know them!
Li =0.5-1.3 mEq/L
Di=0.5-2 ng/ml
Lido 1.5-5 mcg/ml

1. Autonomic Dysreflexia--asses Bladder, Bowel, Skin

2. GIVE Dantrolene to treat pt. in MH crisis
3. JOMACS (mini mental status exam)= Judgement, Orientation, Memory, Affect, Consciousness, Speech
4. -ostomy- make opening
5. -oscopy- look into or at
6. -otomy- cutting into
7. -ectomy- removal of
9. Colporrhaphy- surgical repair of the vagina (Very random )
10. Do not Palpate WILM's tumor
11. Albumin is the best indicator of nutritional status
12. In V-fib always look at pt first anything can mimic the pattern on EKG
13. V-tach is usually caused by an underlying cause treat cause
14. Precipitous delivery may cause amniotic emboli
15. Hct: Hgb approx 3:1
16. WBC= 5-10 (thousand)
17. Platelets= 150-400 (thousand)
18. PPI's stop gastric acid secretion (permanently)
19. Vasoconstriction stops itching and inflammation (give cool bath)
20. Anticholinergic effects- Cant SEE, Cant PEE, Cant POOP, and dry mouth
21. Trauma to frontal may cause Frontal Lobe disinhibition
22. Creatinine is the best indicator of renal function
23. Every drop of urine counts during 24hr creatinine clearance (if one sample is thrown out must start over) First void of the morning
is not included but the first pee of the next morning is (because it is considered Last nights urine)
24. Best position to improve resp. effort = Left Lateral, Folwer & modifications of it
1. When getting down to two answers, choose the assessment answer (assess,
collect, auscultate, monitor, palpate) over the intervention except in an
emergency or distress situation. If one answer has an absolute, discard it.
Give priority to answers that deal directly to the patients body, not the
machines/equipments.
2. Key words are very important. Avoid answers with absolutes for example:
always, never, must, etc.
3. with lower amputations patient is placed in prone position.
4. small frequent feedings are better than larger ones.
5. Assessment, teaching, meds, evaluation, unstable patient cannot be
delegated to an Unlicensed Assistive Personnel.
6. LVN/LPN cannot handle blood.
7. Amynoglycosides (like vancomycin) cause nephrotoxicity and ototoxicity.
8. IV push should go over at least 2 minutes.
9. If the patient is not a child an answer with family option can be ruled
out easily.
10. In an emergency, patients with greater chance to live are treated first
.
11. ARDS (fluids in alveoli), DIC (disseminated intravascular coagulation)
are always secondary to something else (another disease process).
12. Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues).
13. in pH regulation the 2 organs of concern are lungs/kidneys.
14. edema is in the interstitial space not in the cardiovascular space.
15. weight is the best indicator of dehydration
16. wherever there is sugar (glucose) water follows.
17. aspirin can cause Reyes syndrome (encephalopathy) when given to
children
18. when aspirin is given once a day it acts as an antiplatelet.
19. use Cold for acute pain (eg. Sprain ankle) and Heat for chronic (
rheumatoid arthritis)
20. guided imagery is great for chronic pain.
21. when patient is in distress, medication administration is rarely a good
choice.
22. with pneumonia, fever and chills are usually present. For the elderly
confusion is often present.
23. Always check for allergies before administering antibiotics (especially
PCN). Make sure culture and sensitivity has been done before adm. First dose

of antibiotic.
24. Cor pulmonale (s/s fluid overload) is Right sided heart failure caused
by pulmonary disease, occurs with bronchitis or emphysema.
25. COPD is chronic, pneumonia is acute. Emphysema and bronchitis are
both COPD.
26. in COPD patients the baroreceptors that detect the CO2 level are
destroyed. Therefore, O2 level must be low because high O2 concentration
blows the patients stimulus for breathing.
27. exacerbation: acute, distress.
28. epi always given in TB syringe.
29. prednisone toxicity: Cushings syndrome= buffalo hump, moon face, high
glucose, hypertension.
30. 4 options for cancer management: chemo, radiation, surgery, allow to
die with dignity.
31. no live vaccines, no fresh fruits, no flowers should be used for
neutropenic patients.
32. chest tubes are placed in the pleural space.
33. angina (low oxygen to heart tissues) = no dead heart tissues. MI=
dead heart tissue present.
34. mevacor (anticholesterol med) must be given with evening meal if it is
QD (per day).
35. Nitroglycerine is administered up to 3 times (every 5 minutes). If
chest pain does not stop go to hospital. Do not give when BP is < 90/60.
36. Preload affects amount of blood that goes to the R ventricle.
Afterload is the resistance the blood has to overcome when leaving the heart.
37. Calcium channel blocker affects the afterload.
38. for a CABG operation when the great saphenous vein is taken it is
turned inside out due to the valves that are inside.
39. unstable angina is not relieved by nitro.
40. dead tissues cannot have PVCs(premature ventricular contraction. If
left untreated pvcs can lead to VF (ventricular fibrillation).
41. 1 t (teaspoon)= 5 ml
1 T(tablespoon)= 3 t = 15 ml
1 oz= 30 ml
1 cup= 8 oz
1 quart= 2 pints
1 pint= 2 cups
1 gr (grain)= 60 mg
1 g (gram)= 1000 mg
1 kg= 2.2 lbs
1 lb= 16 oz
* To convert Centigrade to F. F= C+40, multiply 9/5 and substract 40
* To convert Fahrenheit to C. C= F+40, multiply 5/9 and substract 40.
42. angiotensin II in the lungs= potent vasodilator. Aldosterone attracts
sodium.
3. REVERSE AGENTS FOR TOXICITY
heparin= protamine sulfate
coumadin= vitamin k
ammonia= lactulose
acetaminophen= n-Acetylcysteine.
Iron= deferoxamine
Digitoxin, digoxin= digibind.
Alcohol withdraw= Librium.
- methadone is an opioid analgesic used to detoxify/treat pain in
narcotic addicts.
- Potassium potentiates dig toxicity.
44. heparin prevents platelet aggregation.
45. PT/PTT are elevated when patient is on coumadin
46. cardiac output decreases with dysrythmias. Dopamine increases BP.
47. Med of choice for Vtach is lidocaine

48. Med of choice for SVT is adenosine or adenocard

49. Med of choice for Asystole (no heart beat) is atropine
50. Med of choice for CHF is Ace inhibitor.
51. Med of choice for anaphylactic shock is Epinephrine
52. Med of choice for Status Epilepticus is Valium.
53. Med of choice for bipolar is lithium.
54. Amiodorone is effective in both ventricular and atrial complications.
55. S3 sound is normal in CHF, not normal in MI.
56. give carafate (GI med) before meals to coat stomach
57. Protonix is given prophylactically to prevent stress ulcers.
58. after endoscopy check gag reflex.
59. TPN(total parenteral nutrition) given in subclavian line.
60. low residue diet means low fiver
61. diverticulitis (inflammation of the diverticulum in the colon) pain is
around LL quadrant.
62. Appendicitis (inflammation of the appendix) pain is in RL quadrant with
rebound tenderness.
63. portal hypotension + albuminemia= Ascites.
64. beta cells of pancreas produce insulin
65. Morphine is contraindicated in Pancreatitis. It causes spasm of the
Sphincter of Oddi. Therefore Demerol should be given.
66. Trousseau and Tchovoski signs observed in hypocalcemia
67. with chronic pancreatitis, pancreatic enzymes are given with meals.
68. Never give K+ in IV push.
69. mineral corticoids are give in Addisons disease.
70. Diabetic ketoacidosis (DKA)= when body is breaking down fat instead of
sugar for energy. Fats leave ketones (acids) that cause pH to decrease.
71. DKA is rare in diabetes mellitus type II because there is enough
insulin to prevent breakdown of fats.
72. Sign of fat embolism is petechiae. Treated with heparin.
73. for knee replacement use continuous passive motion machine.
74. give prophylactic antibiotic therapy before any invasive procedure.
75. glaucoma patients lose peripheral vision. Treated with meds
76. cataract= cloudy, blurry vision. Treated by lens removal-surgery
77. Co2 causes vasoconstriction.
78. most spinal cord injuries are at the cervical or lumbar regions
79. autonomic dysreflexia ( life threatening inhibited sympathetic response
of nervous system to a noxious stimulus- patients with spinal cord injuries
at T-7 or above) is usually caused by a full bladder.
80. spinal shock occurs immediately after spinal injury
81. Multiple sclerosis= myelin sheat destruction, disruption in nerve
impulse conduction.
82. myasthenia gravis= decrease in receptor sites for acetylcholine. Since
smallest concentration of ACTH receptors are in cranial nerves, expect fatigue
and weakness in eye, mastication, pharyngeal muscles.
83. Tensilon test given if muscle is tense in myasthenia gravis.
84. Guillain-Barre syndrome= ascending paralysis. Keep eye on respiratory
system.
85. parkinsons = RAT: rigidity, akinesia (loss of muscle mvt), tremors.
Treat with levodopa.
86. TIA (transient ischemic attack) mini stroke with no dead brain tissue
87. CVA (cerebrovascular accident) is with dead brain tissue.
88. Hodgkins disease= cancer of lymph is very curable in early stage.
89. Rule of NINES for burns
Head and Neck= 9%
Each upper ext= 9%
Each lower ext= 18%
Front trunk= 18%
Back trunk= 18%
Genitalia= 1% ?
90. Birth weight doubles by 6 month and triple by 1 year of age.

91. if HR is <100 do not give dig to children.

92. first sign of cystic fibrosis may be meconium ileus at birth. Baby is
inconsolable, do not eat, not passing meconium.
93. heart defects. Remember for cyanotic -3Ts( Tof, Truncys arteriosus,
Transposition of the great vessels). Prevent blood from going to heart. If
problem does not fix or cannot be corrected surgically, CHF will occur
following by death.
94. with R side cardiac cath=look for valve problems
95. with L side in adults look for coronary complications.
96. rheumatic fever can lead to cardiac valves malfunctions.
97. cerebral palsy = poor muscle control due to birth injuries and/or
decrease oxygen to brain tissues.
98. ICP (intracranial pressure) should be <2. measure head circumference.
99. dilantin level (10-20). Can cause gingival hyperplasia
100. for Meningitis check for Kernings/ Brudzinskis signs.
101. Wilms tumor is usually encapsulated above the kidneys causing flank
pain.
102. hemophilia is x-linked. Mother passes disease to son.
103. when phenylalanine increases, brain problems occur.
104. Bucks traction= knee immobility
105. Russell traction= femur or lower leg
106. Dunlap traction= skeletal or skin
107. Bryants traction= children <3y, <35 lbs with femur fx.
108. place apparatus first then place the weight when putting traction
109. placenta should be in upper part of uterus
110. eclampsia is seizure.
111. a patient with a vertical c-section surgery will more likely have
another c-section.
112. perform amniocentesis before 20 weeks gestation to check for cardiac
and pulmonary abnormalities.
113. Rh- mothers receive rhogam to protect next baby.
114. anterior fontanelle closes by 18 months. Posterior 6 to 8 weeks.
115. caput succedaneum= diffuse edema of the fetal scalp that crosses the
suture lines. Swelling reabsorbs within 1 to 3 days.
116. pathological jaundice= occurs before 24hrs and last7 days.
Physiological jaundice occurs after 24 hours.
117. placenta previa = there is no pain, there is bleeding. Placenta
abruption = pain, but no bleeding.
118. bethamethasone (celestone)=surfactant. Med for lung expansion.
119. dystocia= baby cannot make it down to canal
120. pitocin med used for uterine stimulation
121. Magnesium sulfate(used to halt preterm labor) is contraindicated if
deep tendon reflexes are ineffective. If patient experiences seizure during
magnesium adm. Get the baby out stat (emergency).
122. Do not use why or I understand statement when dealing with patients
123. milieu therapy= taking care of patient/environment
124. cognitive therapy= counseling
125. crisis intervention=short term.
126. FIVE INTERVENTIONS FOR PSYCH PATIENTS
-safety
-setting limits
-establish trusting relationship
-meds
-leas restrictive methods/environment.
126. SSRIs (antidepressants) take about 3 weeks to work.
127. Obsession is to thought. Compulsion is to action
128. if patients have hallucinations redirect them. In delusions distract
them.
129. Thorazine, haldol (antipsychotic) can lead to EPS (extrapyramidal side
effects)
130. Alzheimers disease is a chronic, progressive, degenerative cognitive
disorder that accounts for more than 60% of all dementias

Fluids:
0.45% NaCl - best for dehydration - hypotonic
D5NS - contraindicated in dehydratoin - hypertonic
Lactated ringers - isotonic, used to replace electrolytes
0.9% NaCl - Isotonic
Pregnancy r/t:
Add 300 Calories to diet when pregnant, 500 when breastfeeding.
Calcium Gluconate can cause severe chemical burns - most important to check patency of veins when giving (given to a patient
experience magnesium sulfate toxicity)
Take prenatal vitamins in the morning with orange juice - acid aids in absorption.
Misc:
If a tracheostomy tube falls out, replace it immediately (maintain airway) then check for breath sounds.
If patient in Buck's traction is sliding down in bed, elevate the foot of bed with blocks. Keeps leg straight, doesn't alter pull of
traction.
When Charting Chief Complaint it should be written in pt's own words.
Pharmacology:
Artane and Cogentin - Tx for acute extrapyramidal symptoms from antipsychotics
INH - Tx for TB may cause peripheral neuropathy - tingling
Flagyl and Alcohol causes an Antabuse like reaction - n/v, flushed skin

Larngotracheobronchitis: inspiratory stridor and restlessness

2. Thorazine: antidote cogentine SE: akathisia(motor restlessness) dystonia(tongue protrusion, abnormal posture) and diskinesia(stiff
neck, difficulty swallowing)
3. Toddlers- parallel play; infants enjoy company but self play.
4. IV infiltration D/C IV and apply warm compress.
5. Urticaria= hives.
6. Graves disease: enlarged thyroid, increased metabolism and of course weight loss.
7. The goal for COPD is to improve ventilation.
8. From birth to 18 months Trust vs Mistrust
9 HbA1C- indicates BS for past 6-8 weeks(time varies with source) 2.5-6% normal.
10. myasthenia gravis: autoimmune disease of neuro jnx. destroys Acetylcholine receptors.
11. Menieres: Inner ear disease: vertigo, tinnitus, sensorineuro hearing loss, N/V
12. Use play therapy for children d/t inability to verbalize emotions.
13. Phenergan: Check vein patency (very important)
14. Visine: contraindicated in glaucoma d/t vasoconstriction
1. One of the CHF symptoms is S3 ventricular gallop
2. Hypertensive crisis => Priority in the first hour is brain damage due to rupture of the cerebral blood vessels. Neurologic status must
be closely monitored
3. Client with A-fib => a cold, pale lower leg suggests the presence of an embolus. Peripheral pulses should be checked immediately
4. S/S anemia in a 10 months old infant => pale mucosa of eyelids and lips
5. S/S dehydration in 2 years old => sunken eyes, dry tongue, lethargy, irritability, dry skin, decreased play activity, and increased
pulse
6. Pt with anaphylaxis => The entire body may turn bright red b/c massive vasodilation
7. Teaching pt with Zollinger-Ellison syndrome => Report promptly to his/her healthcare provider any finding of peptic ulcer (night
time awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite)
8. Infant with epiglottitis : 4 D's => Drooling, Dysphagia, Dysphonia and Distress inspiratory efforts
9. Niacin (Vit B) is a lipid lowering agent. Foods high in Niacin are meats, eggs, milk, dairy products
10. Child with 3 C's (Cough-Choke-Cyanosis) should be assessed for tracheoesophagial fistula
11. Gastric lavage is a priority for an infant who has been identified as suffering from botulism
12. Viral meningitis usually does not require protective measures
When using an inhaler, instruct the patient to exhale forcefully, use lips to form a tight seal around the inhaler, press top of inhaler and
inhale deeply, hold breath as long as possible, wait 3-5 mins before taking another inhalation of the drug.
-Munchausen Syndrome is a psychiatric disorder that causes an individual to self-inflict injury or illness or to fabricate symptoms of
physical or mental illness, in order to receive medical care or hospitalization. In a variation of the disorder, Munchausen by proxy
(MSBP), an individual, typically a mother, intentionally causes or fabricates illness in a child or other person under her care.
-Multiple Sclerosis is a chronic, progressive disease with demyelinating lesions in the CNS which affect the white matter of the brain

and spinal cord.

Motor S/S: limb weakness, paralysis, slow speech
Sensory S/S: numbness, tingling, tinnitus
Cerebral S/S: nystagmus, ataxia, dysphagia, dysarthria
Huntington's Chorea: 50% genetic, autosomal dominant disorder
S/S: chorea --> writhing, twisting, movements of face, limbs and body
-gait deteriorates to no ambulation
-no cure, just palliative care
-WBC shift to the left in a patient with pyelonephritis (neutrophils kick in to fight infection)
-Definitive diagnosis for abd. aortic aneurysm (AAA) --> CT scan
-Don't use Kayexalate if patient has hypoactive bowel sounds.
-Uremic fetor --> smell urine on the breath
-Hirschsprungs --> bile is lower obstruction, no bile is upper obstruction; ribbon like stools.
-Pancreatic enzymes are taken with each meal! Not before, not after, but WITH each meal.
Leukemia - the main affected are: Blood, Bone mArrow, Spleen, & Lymph. The biggest problem of leukemia is the big "ANT"
Anemia, Neutrepenia, and Thrombocytopenia.
ALL- problem of B & T-lymphocyte (more in children)
AML- problem of macrophage, granulocytes, RBC, & platelets (more in children)
CML & CLL - more in elderly
Note: there's 2 types- Acute and Chronic
and 2 category- myeloid (myelocitic) & lymphoid (lymphocytic)
Bioterrorism
Level I- local emergency
Level II- regional aid from surrounding counties
Level III- local and regional assets are overwhelmed state or federal assistance is needed
Disaster tagging tags are numbered and identify the triage priority; includes the name, address, age, location and description of
injuries and treatment and meds given
Ethical conflicts- they arise because of the perspective of disaster nursing.
There are 4 levels of protective equipment
Level A highest priority covered from head to toe
Level B RESP covered but less skin and eye precautions
Level C- requires air purified respirator chemical- resistant coverall with splash hood, gloves and boots
Level D work uniform
Decontamination is a 2 step process
1.removal of clothing and jewelry and rinsing with water
2.thorough soap and water wash and rinse

ALL OF THESE BIOLOGICAL WARFARE AGENTS CAN BE MADE!

Anthrax can be topical, inhaled or ingested
topical contact precautions
inhaled standard precautions
ingested standard precautions
Smallpox on contact precautions
Botulism - standard precautions
Tularemia- standard precautions
Types of radiation
Alpha particles - cannot penetrate the skin but can enter through inhalation, ingestion. Localized damage
Beta particles- can moderately penetrate the skin and cause cell damage or internal injury if penetrates the skin * exposure time is a
key factor
Gamma radiation - is penetrating and is difficult to shield against
Exposure to radiation time, distance and shielding
Three types of radiation induced injury can occur
1.external -pt is not radioactive does not require isolation
2.contamination from gases, liquids or solids *requires immediate intervention to prevent incorporation
3.incorporation - uptake of radioactive material into every cell, tissue, organ
Acute radiation syndromeN/V
Bloody diarrhea
Fever
Cerebral edema
Increased ICP- poor outcome and imminent death
HA
Skin may be red and become necrotic within day to months
Airborne Precautions
Airborne Precautions
Patients who have or may have an infectious disease that is spread by the airborne route must be placed on Airborne Precautions in
addition to Standard Precautions. Airborne Precautions (formerly respiratory isolation) applies to most infections which were
previously classified as requiring "Strict," "AFB," and "Respiratory" isolation under the old category-specific system of isolation
precautions.
Diseases Requiring Airborne Precautions

Tuberculosis, Pulmonary (or laryngeal)

-suspected or confirmed
Criteria for Using Airborne Precautions for a Patient Suspected or Confirmed to Have Pulmonary Mycobacterium Tuberculosis

Varicella (chickenpox)
[requires use of Contact Precautions as well]
Herpes Zoster (shingles) - in an immunocompromised patient
[requires use of Contact Precautions as well]
Herpes Zoster (shingles) - disseminated
[requires the use of Contact Precautions as well]
Rubeola (Measles)
Note: Airborne Precautions require a negative pressure room in addition to a private room. Negative pressure rooms are specially
designed to prevent the flow of air from the room into the corridors and common areas where susceptible persons may be exposed.
This is accomplished through fans and vents that direct the airflow outside of the building and/or through HEPA filters.
Droplet Precautions

Droplet Precautions are designed to reduce the risk of droplet transmission of infectious agents. Droplet transmission involves contact
of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large particle droplets containing
microorganisms generated from a person who exhibits a clinical disease or who is a carrier of the microorganism. The patient can
generate these droplets from coughing, sneezing, and talking, as well as during certain procedures such as suctioning and
bronchoscopy. Transmission via large droplets requires close contact (within 3 feet or less) between the source patient and the
susceptible individual. Droplets (due to their large size) do not remain suspended in air and travel short distances - three feet or less.
Thus, Droplet Precautions require the use of a standard surgical mask within three feet of the patient. However, it is prudent to wear a
mask upon entering the room of a patient on Droplet Precautions to avoid any inadvertent exposure.
Bacterial:
Invasive Hemophilus influenzae disease:
meningitis, pneumonia (in infants and small children), epiglottitis.
Invasive Neisseria meningitidis disease:
meningitis, pneumonia, and bacteremia.
Mycoplasma pneumonia
Group A Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children
Viral
Influenza

Adenovirus
(requires Contact Precautions in addition)
Mumps

Parvovirus B19
Rubella
Contact Precautions

Contact Precautions are designed to reduce the risk of transmission of organisms and specific diseases by direct or indirect contact.
Direct contact transmission involves skin to skin contact and physical transfer of microorganisms to a susceptible host from an
infected or colonized person, such as occurs when personnel turn patients, bathe patients or perform other patient care activities that
require physical contact. Direct contact can also occur between patients that may have physical contact with each other.
Indirect contact transmission involves a susceptible host with a contaminated intermediate object, usually inanimate, in the patient's
environment.
Contact Precautions are to added to Standard Precautions for patients known or suspected to have organisms and/or diseases easily
transmitted via direct or indirect contact.
Contact Precautions are required if:

A patient is colonized and/or infected with multidrug-resistant organism. A multidrug-resistant organism is an organism that is
resistant to treatment with standard first-line antibiotics.

A particular organism is identified as being potentially hazardous to others and/or to the ecology of the hospital environment because
of its antibiogram, pathogenicity, virulence, or epidemiologic characteristics (i.e., VRE, MRSA).

Contact Precautions Disease List

In addition to Standard Precautions, Contact Precautions must be used for patients known or suspected to have specific
diseases/multidrug- resistant organisms easily transmitted by direct patient contact or contact with items in the patient's environment.
Examples of such illnesses/organisms include:

Vancomycin Resistant Enterococcus (VRE)

Methicillin Resistant Staphylococcus aureus (MRSA)

Any organism deemed to be of special clinical and epidemiologic significance judged by YNHH Hospital Epidemiology and Infection
Control

Clostridium difficile colitis

Respiratory Syncytial Virus (RSV)

Parainfluenza virus

Enteroviral infections in infants and young children

Pediculosis

Scabies

Escherichia coli 0157:H7, Salmonella, Shigella, Hepatitis A, Rotavirus-in diapered or incontinent patients

Diptheria (cutaneous)

Herpes Simplex virus

(neonatal, disseminated, or severe mucocutaneous)

Impetigo

Major (uncontained) abcesses or decubiti

Varicella (chickenpox), Herpes, Zoster (disseminated or in the immunocompromised host) also requires Airborne Precautions

Viral/ Hemorrhagic Conjunctivitis

Viral Hemmorrhagic Fevers

(e.g., Ebola, Lassa, or Marburg)
Nclex tips
Assess first( check the question to see if the assessment has been done)
Take care of the patient first, the machines and documentation later
Always choose the most complete answer with the least opportunity for error
In Priority question, look for acute and unstable pt to see first
Always remember your ABCs
Maslow's will usually work and pain is seen as a psychosocial need---Not a physical need
Incident or Occurrence reports--Never refer to them in the pt's chart
should complete for any time there is a variance from what should have happened with Pt care
should not include blame or anything but just the facts
when charting, do not use the words, " Error, mistake, accident or incorrect."
Errors in charting are corrected by making one simple line through the words
If a RN comes from another unit, give that RN a pt who does not need to have a RN from specific unite care for him/her. EX. --Post
op mastectomy needs an ONco nurse to take with.
Delegation--If you are assigning pt care to LPN/NA, rank order the pt as to the ones who have the least acute problems/changes to the
most
Anytime a question comes up about a procedure or diagnostic test, consider the possible complications
Vital signs are a LATE signa of pt status change
Rales=CHF
Rhonchi=pneumonia
Wheezes=asthma
Hemoptysis=Lung cancer or TB
Pleural Pain=Pssible PE
Intercostal retractions=respiratory distress
Role play the situation
Read the question and answers out loud
Safety for the pt is always first, then the family, then the nurse
Never isolate a pt with Alzheimer's disease
Any time a pt has traction applied or a broken bone, consider:
circulation

Movement
Sensation
compartment syndrome
skin integrity
restlessness is often the first sign of hypoxia
if you chose an answer withthe word, why or check in it, make sure it is truly the best answer.
Rarely is the right answer to call the physician--Don't pass the responsibility
Psychiatric pt:
--For someone with psychosis--acknoledge the hallucination or delusion and then realityorientation
--for someone with dementia--change the subject, divert the attention
Medications to know: antipsychotics--Haldol, Thorazine, Zyprexa, Geodon\
antidepressants--Tricyclics--typically sedating so take at bedtime, cause otthostasis, dry mouth, very dangerous with OD. NEED to
wean off.
MAO-I---low tyramine diet, if they eat something high tyramine--hypertensive crisis
Interact with a lot of other meds, can have hypertensive crisis with other meds
Need to be off other antidepressants for at least 2 wks before starting.
SSRI--can treat anxiety to. Typically take in the morning because they are more likely to be stimulating. Can cause diarrhea. Need to
wean off.Serotonin serge.
Anti-mania--lithium--need to have levels drawn, Tend to get increased level if sweating, vomiting. Know the S/S of toxicity. Know
normal Li levels( 0.6-1.2)
Anti-seizure family( Depakote, Tegretol, Lamictal, Trileptal, etc) most can lead to liver failure. Should have levels of
Depakote/Tegretol done at intervals.
Anti-anxiety-Benzodiazepines----addictive and lead to seizures during withdrawl. Very dangerous if combined with alcohol. Sedating
except may have paradoxical
Reaction in the elderly
Safety is always first priority if someone is losing control of her/his behavior.
--must try all other interventions before using restraints/seclusion
someone must stay within arms's reach of the pt if they are restraints
Need to release one restraint or do Prom every 15 min.
Restraint to orders need to be specific and cannot be PRN and only good for 24hrs.
Chemical restraints count as restraints
The pt with Depression needs to increase interaction.
the pt with psychosis typically is very concrete in thinkgs and it not going to be able to process groups, etc
Well pt with addictive disorders use the denail as their primary coping mechanism
Manic phase pts need finger foods or calories as they burn a lot being busy
Suicidal pts --look for any phrase that implies helplessness, hopelessness, worthlessness

Post op eye surgery--don't bend at the waist, avoid straining

If someone has an object that has penetrated his/her body, leave it there until it is assessed as safe to remove.
INTERVENTIONS FOR COPD (using ABCDEF)
A-Aminophylline
B-Brochodilators
C- Chest Physiotherapy
CORTICOSTEROIDS
D- Deliver oxygen at 2 liters
E- Expectorants
F- Force Fluids
Tuberculosis ( Meds) Use RISE
R-Rifampin
I-Isoniazid (INH)
S-Streptomycin
E-Ethambutol
Care of Client After Masectomy
(BREAST)
B-Bp not on affected side
R- Reach recovery
E-Elevate affected side
Exension and flexion exercise- initialy (Squeeze a ball)
A-Abduction and external rotation should not be initial exercise
S-SBE- Once a month- about one week after period
T-To promote a positive self image
TURPS
T-Tubes
U-Urinary output
R- Red drainage
P-Pieces of clots
S-Spasms

Meniere's Disease
Administer diuretics to decrease endolymph in the cochlea, restrict sodium, lay on affected ear when in bed.
TRIAD
-vertigo
-Tinnitus
-Nausea and vomiting.
Use FIRST to help you remember
F- find hypoxia
I- Immunocompromised
R- Real bleeding ( Trauma, hemorrhage)
S-Safety
T- Try infection
Breast Cancer Risk Factors:

>50 years of age

FIRST child born after 30 years of age
Grandmother, Mother, Sister has it
Personal history of breast cancer

Garlic has a hypoglycemic effect do not give with insulin

Eye problems do not want head in dependent position. Lie on good side and have bad eye up or elevate the head of the bed to 35
degrees.
Lay on right side after liver biopsy.
Clear fluid from head CSF medical emergency call the doctor
1 yr old with nausea, vomiting, and diarrhea is emergency because young children become dehydrated very easily
Assess pt for claustrophobia with CAT scans and MRIs, also, NO METAL.

ALPHABET NURSING FACT:

Activated charcoal - To absorb poison
AAA- Complication is hemorrhage and shock
A positive mantoux test indicate the pt has produced an immune response
Complication of warfarin- (3H) hemorrhage, hematuria and hepatitis
Colchine for treatment of gout attack
Codeine- onset- 30mins, peak- 1hr, duration 4-6hrs
COPD -use of acessory muscle for respiration indicate the pt is having difficulty breathing
Chlamydia, Genital herpes and HPV - Do not report

Crackles are heard on inspiration and dont clear with cough

Diaphramatic and purse lip breathing are the best for pt with COPD
DMD- X-linked recessive and female are carrier and male are affected.
DI- Treatment is DDAVP
Gastric lavage - To remove poison
Indomethacin - helps in closing PDA
Left sided HF- pulmonary
Myelomingocele complication - clubbfoot and hydrocephalus
Meningitis- Droplet
Osteoarthritis- Joint pain, crepitus, heberden's node, bouchard's node and enlarge joints
Pentoxifyline- hemorheologic Agent that improve blood flow and is used to treat intermittent claudication
Prostaglandin E is administerd to provide blood ming and also help to keep open the ductus arteriosus
Right side HF- systemic
Rhonchi are heard on expiration and clear with cough
Rabies- contact precaution
tPA- used to treat Acute MI
Thrombolytic- dissolve clots
To avoid falsely elevated serum digoxin, the nurse should wait @ least 8hrs after administering oral digoxin and @ least
6hrs after administering I.V digoxin to draw a blood sample.
TB- airborne
Disaster planning
A disaster plan needs to be activated when there is a life threatening situation with a large number of patients involve. A way to
remember who to remove first is by using ABC
A- Ambulatory
B- Bed Ridden
C- Critical Care
You may ask why but the goal is to move the greatest number of clients.

Appendicitis- position of comfort is on the side with the legs flexed agains the abdomen. HOB should remain slightly elevated to
decrease the upward spread of infection in case the rupturing of appendix occurs.

Here are a few facts I came across while doing questions.

Brown pigmentation around the ankles of patient indicates venous insufficeny
Cloudy outflow during peritoneal dialysis indication of infection and needs to be reporeted to MD
Afte colonoscopy a patient should report rebound tenderness. Abdominal cramping, fatigue and passage of liquid stool are all normal
findings after colonoscopy.
A patient with pertussis should be in a private room, mask and under droplet precautions.
Hydromorhone ( Dilaudin) can Cause urinary retention.
Respite care important for caretaker of Alzheimer's patient to allow for physical and emotional rest.
Antihistamines can cause urinary retention and exacerbate symptoms of BPH.
Applying pressure to the inner cantus of the eye prevents overflow of medication into the nasolacrimal duct and possibly systemic
absorption.
Ethical dilema- Determination of facts. identify possible solutions, consider patients wishes.
An Increase in peak expiratory flow rate indicates that airway restriction is resolving ( asthma patient)
Salem sum tube- turn patient every 2 hours to promote emptying of stomach contents.
Fatigue, abdominal bloating and persistent dyspnea of patient with COPD contributes to patients inability to maintain adequate
nutrition.
Serosanguienous drainage beyond post-op day 5 may indicate dehiscence; therefore surgeon should be notified.
There is no need for a parent of a child who is HIV positive to notify the childs daycare provider.
INDERAL- serious side effect decrease heartrate due to blockade of betta1 receptors in the heart.
Bulima patient with bloody emesis due to esophageal tears due to purging.
Pacemaker spikes on T wave indicate that the pacemaker is not capturing appropriately and should be adjusted for this patient.
A patient who is having muscle spasm while in traction should be repositioned to see if the spasms decrease.
REASONS FOR UNCONSCIOUSNESS ( skin Color)
RED- Stroke or increase in blood pressure
BLUE- Respiratory or cardiac arrest
WHITE- Shock or Hemorrhage.
BETA BLOCKERS
B-bronchospasm( do not give to asthma, bronchial constriction patients)
E- elicits a decrease in cardiac out put and contractility.
T- treats hypertension
A- Av conduction decreases

T- tenormin ( atenolol) hypertension & angina

L- Lopressor ( metopolol) hypertension & angina
C- Corgard ( naldolol) hypertension & angina ( renally excreted)
Glomerulonephritis- fever, periorbital edema, weakness, and chills caused by grop B strep.
It is normal for a patient that has had dialysis to have a slight fever afterwards due to the dialysis solution being warmed by the
machine.
Positive sweat test indicative of cystic fibrosis.
After thyroid surgery- maintain airway keep a trach kit at patients bedside, check for bleeding, be sure to check at sides and back of
neck due to gravity and teach patient to support their neck.

A bit about B-Vitamins

B-1 (thiamine) and all B vitamins Alcoholic (to prevent Wernickes encephalopathy and Korsakoffs syndrome.
B-6 (pyridoxide hydrochloride) TB patient (Pt is likely on INH which can cause peripheral neuropathy, dizziness, and
ataxias, B-6 can prevent these unwanted affects).
B-9 (folic acid) Pregnant pt to prevent neural tube defects in fetus
B-12 (cobalamine) Pernicious anemia (autoimmune disease that attacks the parietal cells preventing intrinsic factor from
being released, which is needed to absorb B-12.

1.

Hep B immune globulin and Hep B vaccine are given to infants with perinatal exposure to prevent hepatitis and achieve
lifelong prophylaxis; administered within 12 hours of birth.
2. Immune globulin is given to prevent Hep A.
3. Cyanocobalamin (Vit B12) is used to treat states of vit B12 deficiency; the most common manifestation of untreated
cyanocobalamin deficiency is pernicious anemia.
4. Pernicious anemia is one of the risk factor for gastric cancer.

1.

5. child with Celiac disease: dietary management is the mainstay; eliminate all wheat, rye, barley, and oats; replaced with
corn and rice; vitamins supplements, especially fat-soluble vit and folate, may be needed in the early period of treatment to
correct deficiencies.
Acid is lost from the stomach (emesis) leading to metabolic alkalosis
2. Bicarbonate is lost from diarrhea leading to metabolic acidosis
3. Irritability (rather than lethargy) is an initial finding for cerebral hypoxia which would occur from the retained fluid in the
brain that results in increased ICP
4. Signs of increased ICP in infants include: bulging fontanel, irritability, high pitched cry, and continually cries when held; R
more often slow, deep and irregular
5. The peak airflow volume decreases about 24 hours before clinical manifestations of exacerbation of asthma; it is the most
important to monitor for asthma pts
6. the peak flow meter is used to measure peak expiratory flow volumes; provides useful info about the presence and/or
severity of airway obstruction: green (good); yellow/red (caution and get help)
7. When a pregnant women is admitted with C/O painless vaginal bleeding: do abdominal ultrasound because it's the least
invasive diagnostic test
8. dexamethasone (Decadron) increases the production of HCl, which often leads to GI ulcers; take it with food or milk
9. Pancreatic enzymes are to be given to pt with cyctic fibrosis; with each meal and every snack to allow for digestion of all
foods that are eated

10. If the peak flow reading is 50% less of the pt's baseline reading, give a short-acting beta-agonist immediately (rather than
giving oxygen because the pt's airways need to be opened up first)
NCLEX TRAPS
When you read the question ask yourself can I IDENTIFY the TOPIC of this question?
Note: NCLEX HIDES the TOPIC of a question
Example:
A nurse is evaluating the effects of medical therapy for a client with pulmonary edema. The nurse
determines that the interventions that were most effective if the client exhibited which of the following?
U=urine output RR= respiratory rate BP=blood pressure P=pulse
a) BP= 96/56 mmHg; P=110 beats/min; RR=28 breaths/min; U=20 ml/hr
b) BP=88/50 mmHg; P= 116 beats/min; RR=26 breaths/min; U=25 ml/hr
c) BP=108/62 mmHg; P=98 beats/min; RR=24 breaths/min; U= 40 ml/hr
d) BP= 116/70 mmHg; P= 88 beats/min; RR= 20 breaths/min; U= 50 ml/hr
This question has been copied from another thread in which the person was inquiring why the answer she chose was not correct, and
from eight responses no one could tell the person who posted this example the rationale for the correct answer. First thing: identify the
topic which is client's needs- physiological integrity. The NCLEX makers want to know if you know how to apply the fifth nursing
process which is evaluation within the context of physiological integrity. You need to evaluate if the set of vitals you took after giving
medication therapy are withing normal limits. Eliminate first the wrong answers. Answers #a and # b are wrong (below normal
limits)...just by looking at the blood pressures, you know those answers are wrong. You are just left with two choices which is better
than having to choose between fours answers. Do you see the advantages of elliminating wrong answers, first?
The next step is to eliminate the last wrong answer, let's look at answer # c...everything is within normal limits except the
respiratory rate (normal for an adult RR=12-20 bpm). Since you have to eliminate # c, then the right answer must be # d, which is
indeed, all those numbers are within normal limits, by the way, normal urinary output is at least 30 ml/hr. That is a good example of
how cleverly the NCLEX makers could hide the topic. They wanted to know if the test taker knows how to apply the nursing process
of evaluation by throwing a question about evaluating a set of vitals.
IDENTIFY THE TOPIC OF THE QUESTION:

if you have no idea what is the question asking: read the answer choices for clues to identify the topic

In some questions validation is required in order to answer the question corectly...meaning the question may ask you to assess or
evaluate as opposed to implement (do some action, for example, call the doctor, start CPR, reposition the patient or give oxygen to
the patient, etc.) Remember the intent of the question will be hidden to you.

read the stem question for determining whether you should assess or implement and within that context eliminate the answers
which do not fit to with what you must do, that will lead you to the right response.

If all the anwers fit in to implementation, then move on to use Maslow Hierarchy of Human Needs
--Physical needs take priority over other needs-Pain is not a physical need--it is considered psychosocial, so it goes higher up on Maslow scheme
If all answers fit in to the physical needs apply ABC (air/blood/circulation) scheme
do not automatically select respiratory answers--remember to thow out wrong answers first
If all answers are psychosocial do not choose the answer that "sounds right": determine the outcome of each answer, throw out
first the answers with negative outcome. Ask yourself "is this answer choice has a desired outcome?"
Examples of Undesirable Answers you are Looking for to Throw Out First:

a) pass the buck

b) judgmental
c) bad nursing
d) off topic
e) take the buck
f) encourage dependency
g) asking why
h) do not persuade
i) leave patient alone
J) non therapeutic
k) gives false reasurance
l) blame
m) do nothing answers
n) answers which by pass the nursing process such as implementing a particular tx before assessing the situation
o) by pass proper delegation qualifications
p) by pass priority of care
q) do not involve the patient in their own healing process
r) do not listen to the patient in a respectful manner
s) violate patient's rights
t) do not show cooperation with the health team
u) answers that contain absolute worlds such as only, always--watch for those
If Manslow and ABC does not apply: Evaluate ask yourself why, as I did in the example above, the answers presented are wrong by
comparing them against the normal values, throw out first wrong ones for that will lead you to the one you are looking for: the right
answer. Best wishes to all of you who are taking the NCLEX in February. feliz3
Fosamax (alendronate sodium)
-treatment for OSTEOPOROSIS
Teach the patient --FOSAMAX causesESOPAGITIS.
1)Remain upright for 30 minutes and do not eat or drink anything else for 30 minutes,to prevent delay of the drug through the
esophagus
2)Take these drugs on an empty stomach, first thing in the morning, with water.Must be taken with a sufficient amount of water so it
does not pass through the esophagus completely...

What I've learned today in my review

1.Tagamet- to be taken at bed time
2.Dilatin- Aside from the regular visit to the dentist, when given IV can only be given w/ normal saline,to be kept in room
temperature, AE agranulocytocis and aplastic anemia, client will need freq. CBC
3.Side effect of ZYPREXA development of parkinson
4. Client taking Methotrexate should avoid multi Vitamins because they contain Folic Acid( antidote of Methotrexate)
5.Client taking Isoniazid should have negative sputum within 3 months.
3.
Nurses must assume what the physician will order first:
DKA-----Initiate fluid replacement first ( IV .9% normal saline)
Hemophilia A-------- transfuse Factor VII
Ventricular Fibrillation (UNRESPONSIVE)-----Defibrillate 200j (300j:360j)
if unsuccessful ------CPR
Sickle cell anemia---------- 0xygen 100% Fi02 (HHOP)
ARDS (acute respiratory distress syndrome)-----(O2 nonrebreathing mask)
if no improvement w/ nonrebreather mask----intubate /mechanical ventilator
Pulmonary edema (sx. asses breath sound--crackles)----------tx: Furosemide

MI (chest pain)----------tx.morphine
Skin test reaction(SOB,anxious,reddened blotches,dizzy)-administer epinephrine
tenision pneumothorax-----------------chest tube
Fractures:
Immobilize joint above and below fracture
Cover open fracture with cleanest material available Check temperature, color, sensation, capillary refill distal to fracture
Close reductionmanually manipulate bone or use traction
Bucks 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 countertraction or foot bed
Place pillow below leg not under heel or behind knee.
Russells Traction
Sling is used
Check for popliteal pulse
Place pillow below lower leg and heel off the bed
Dont 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
Casts
Dont rest on hard surface
Dont cover until dry 48+ hours
Handle with palms of hands not with fingers Keep above level of heart
Check for CSM
Fractured Hip
Assessments
Leg shortened
Adducted
Externally rotated
Implementation
Care after a total hip replacement
Abduction pillows
Crutch walking with 3-point gait
Dont sleep on operated side
Dont flex hip more than 45-60 degrees
Dont elevate head of the bed more than 45 degrees

Amputations
Guillotine (open)

 Flap (closed)
Delayed prosthesis fitting
Residual limb covered with dressing and elastic bandage (figure eight)
Figure-8 doesnt restrict blood flow, shaped to reduce edema
Check for bleeding
Elevated 24 hours (AKA-pillow, BKA-foot of bed elevated)
Position prone daily
Exercises, crutch walking
Phantom Pain: acknowledge feelings, that pain is real for them
Isoniazid (INH)-Anti-tuberculosis
s.e.: peripheral neuropathy-watch out for signs:numbness, tingling or weakness
liver damage-watch out for signs of hepatitis:yellow eyes or skin, NV, anorexia, dark urine, unusual tiredness, or weakness
Aminoglycosides: Anti-infective
Amikacin(Amikin) Gentamicin,(Garamycin) Tobramycin (Tobrax)
s.e.Ototoxicity(CN VIII)-immediately report hearing or balance problems
Nephrotoxicity -Teaching:encourage fluids 8-10 glasses daily
Antihistamine
Loratadine (Claritin),Fexofenadine (Allegra),Cetirizine HCI (Zyrtec)
s.e. Drowsiness/Dizziness -teach pt:caution in potentially hazardous activities..
-avoid use of alchohol,& other CNS depressants
Dry mouth
-*generic name ends with "zine"*
cyclizine, trimeprazine, methdilazine, meclizine, and promethazine
an antihistamine preventing or countering motion sickness as well as
nasea and vomiting.
Heparin /-anticoagulant
s.e.: hemorrhage- watch out for:bleeding gums, nose, unusual, black tarry stools, hematuria, fall in hemacrit or bl. pressure, guaiacpositive stools
teach pt:avoid ASA & NSAIDs
-antidote: protamine sulfate w/in 30 min
-injec.=deep SQ-onset 2-6- min, dur. 8-12 hrs
-IV: pk 5 min, dur. 2-6 hrs/NEVER GIVE IM
-check -therapeutic PPT (20-36) @1.5-2.5 X the control
Warfarin (Coumadin)/anticoagulant
s.e.:hemorrhageCaution:if pt said "I LOVE TO EAT VEGETABLE IN THE GARDEN)
teach:-avoid foods high in Vit K, green leafy vegs
-antidote: vit. K
-therapeutic PT (9.6-11.8)@1.5-2.5 X control, INR @ 2.0=3.0
-onset: 12-24 hrs, pk 1-1/2 to 3 days, dur: 3-5 days
Anti-malarials
Hydrozychloroquine (Plaquenil),Quinine Sulfate
s.e.: eye disturbances, NV, Anorexia
Teach:take at same time each day to maintain blood levels
Anti-protozoals:
Metronidazole (Flagyl, Flagyl ER)
s.e.-CNS symptoms, abd cramps, metallic taste,
teach pt o not drink alcohol in any form, during and 48 hrs after use,
disulfiram-like reaction can occur.
-avoid hazardous activities
-dark-reddish brown urine
Opioid AnalgesicMethadone, Hydromorphone (Dilaudid) , Propoxyphene (Darvon, Darvocet-N (propoxyphene with acetominophen),

Oxycodone (Oxy Contin; with aspirin Percodan, with acetaminophen Percoset)

Codeine,Meperidine(Demerol),Hydrocodone Bitartrate & Acetaminophen
(Lortabs)
s.e.-Drowsiness, sedation,nausea, vomiting, anorexia,Respiratory depression
constipation, cramps,orthostatic hypotension,confusion, headache,rash
-do not give if RR less than 12 per min
Cephalosporins(generic name begins with "cef/cep")
Cefadroxil (Duricef) ,Cephalexin (Keflex, Keflet) ,Cephapirin (Cefadyl)
Cephradine (Velosef) ,Cefaclor (Ceclor, Ceclor CD) ,Cefamandole (Mandol)
Cefonicid (monocid) ,Cefotetan (Cefotan)
s.e. Diarrhea
*generic name ends with "phylline"*
Xanthine bronchodilator aminophylline, dyphylline, oxtriphylline, theophylline
s.e.- nausea,vomiting,anorexia,gasstrointestinal reflux,TACHYCARDIA
indication:acute asthma, chronic bronchitis, emphysema, COPD
contraindicated:peptic ulcer,hyperthyroidism,cardiac dysrhythmias
Child undergoing cardiac catheterization - priority nursing Dg. is - Deficit knowledge ( parental ) related to cardiac. cath., not
decreased cardiac output related to structural defect !
Planning care for child before corrective surg. for Tetralogy of Fallot - priority nursing Dg. - Deficit knowledge related to upcoming
surg. and postoperative events, not impaired gas exchange related to structural cardiac def.
Kawasaki Disease - aspirin + IV gamma globulin - to reduce immune response
- steroids contraindicated - increase aneurysm formation
- dipiridamole to increase coronary vasodilatation and decrease platelet accumulation
A positive Kernig's Sign is a manifestation of meningeal irritation
2. A serum creatinine above1.4 mg/dl indicates renal failure
3. Epioglottis develops acutely and emergently
4. Bells Palsy is Cranial Nerve VII
5. Bridiging Technique ,which I had never heard of is a type os positioning of pillows used to relieve pressure on bony prominences
CARE OF A PATIENT IN TRACTION
T = Temperature
R = Ropes hang freely
A = Alignment
C = Circulation - the 5 P's - Pain, pulse, pallor, paresthesia, paralysis
T = Type and location of fracture
I = Increase fluid intake
O = Overhead trapeze
N = No weights on bed or floor

Here are my five: Knowledge Based

I am back to the drawing board with Fluids & Electrolytes
Hypovolemia: decreased urinary o/p; increased urine specific gravity
Hypervolemia: increased urinary o/p; decreased urine specific gravity
Hyponatremia: increased urinary o/p; decreased urine specific gravity (just think of dehydration-losing fluids).
Hypernatremia: decreased urinary o/p; increased specific gravity(just think of the body holding the Na+ in, and output will be
decreased).
Hyponatremia: Monitor for lithium toxicity if pt is on this med. It can decrease lithium excretion, causing lithium toxicity.
Hypokalemia: Increased urinary o/p; decreased specific gravity (just think of the body losing fluids, just like with hyponatremia).
This condition is life-threatening, b/c it affects every body system.

TX: give K+ Chloride- Never give K+ IV push, IM, or SQ.

Never exceed 20 mEq/hr
If pt receives >10 mEq/hr place on cardiac monitor.
Assess renal function before administering med and monitor I/O's during tx.
Hyperkalemia:
Early sx muscle twitches, cramps, parasthesias.
Place on cardiac monitor.
Hypocalcemia: Positive Trousseau's & Chvostek's sign
Monitor cardiovascular, respiratory, neuromuscular, GI; place on cardiac monitor.
Give Ca+ supplements PO or Ca+ IV.
Ca+ IV-Warm solution to body temp. before admin. & give slowly; monitor for ECG changes.
Hypercalcemia:
early sx is increased HR.
late sx: Bradycardia that can turn into cardiac arrest.
Increased urinary o/p that can lead to dehydration.
Check for urinary stones, by straining the urine. Place on cardiac monitor.
Hypoactive bowel sounds.
Don't combine aspirin with glipizide (Glucotrol) therapy or
alcohol with insulin; both can cause hypoglycemia.
1.

Barium swallow for 3 month old infant - NPO for three hours
2. Temporary pacemaker for MI client - increase cardiac output is the primary purpose
3. Plasma cholesterol screening - only sips of water for 12 hours
4. Reminiscing group - primary goal is to review and share their life experience with the group member
5. Miller-abbott tube - removes fluid and gas in the small intestine; provides intestinal decompression
6. Levin or salem stump - decompresses the stomach; prevent fluid and gas accumulation in the stomach
7. Promethazine Hcl (Phenergan) - check patency of the patient's vein before admin of drug, extravasation will cause
necrosis
8. Insulin dependent diabetic, unable to urinate -- autonomic neuropathy
9. Overdose of aspirin will produce parkinsons dse type sx
10. Do not admin erythromycin to Multiple Sclerosis pt

Here are my five for today: NCLEX answers 1) If you have never heard of it, nobody else probably had, so don't choose that answer.
2) If your pt. is unstable don't choose reassess in 15 min. He might be dead in 15 min - don't delay treatment. find first question that
will kill or harm pt., secondly that will delay treatment and eliminate those. if there is something you can do before calling doctor, do
it ( pick that question ). sometimes to call the doctor may be the only right option.
3)Maslow's hierarchy : Physiologic needs A) Maintaining airways and respiration
B) Maintaining circulation
C) Nutrition and elimination
D) Sleep
Safety needs - when no physiological needs exist, safety takes priority - mainatining safe and secure enviroment for pt. and nurse
4) Communication - focus on pt. feelings first
5) Teaching and learning - motivation and readiness - assess if pt. had previous experiences or any information first
How to Determine Whether to Delegate or Not
UAP= unlicensed assistive personnel
Ask yourself:
1) Are the and rules in place which support the delegation?
a) yes---go to step 2
b) no--- do not delegate
2) Is the task to be delegated within the scope of practice of the RN/LPN?
a) yes---got to step 3

b) no---do not delegate

3) Is the RN/LPN has the knowledge and experience to make delegation decisions?
a) yes---go to step 4
b) no---do not delegate. Action to take: provide education and document education provided
4) Has there been assessment of the client's needs?
a) yes---move to step 5
b) no---assess client's needs first, then proceed with considerations to delegations
5) Is the UAP competent, has the experience to accept the delegation?
a) yes---move to step 6
b) no---do not delegate. Action to take: Provide education and document the education given to the UAP
6) Does the ability of the care giver match the care needs of the client?
a) yes---go to step 7
b) no---do not delegate
7) Can the task to be delegated be performed without requiring nursing judgment?
a) yes---move to step 8
b) no---do not delegate
8) Are the results of the task reasonably predictable?
a) yes---move to step 9
b) no---do not delegate
9) Can the task be safely performed according to exact, unchanging directions?
a) yes---move to step 10
b) no---do not delegate
10) Can the task be safely performed without complex observations or decisions based on critical thinking?
a) yes---move to step 11
b) no---do not delegate
11) Can the task be performed without repeated nursing assessments?
a) yes---move to step 12
b) no---do not delegate
12) Is appropriate supervision available?
a) yes--- all other steps met, it is safe to delegate
b) no---do not delegate
Delegation= Transferring a selected nursing task in a situation to an individual who posses the knowledge, experience that makes the
person competent to perform that specific task.
The Nurse Practice Act and any practice limitation, such as been unfamiliar with the particular task which needs to be delegated,
define which aspects of care can be delegated and which must be performed by the registered nurse.
Only the task not the ultimate accountability may be delegated to another. The nurse who delegates maintains accountability for the
overall nursing care of the client. The nurse must know what are her clients preferred outcomes in terms of health care delivery goals,
so that the process of delegation is geared toward achieving desirable outcomes.

The RN must match the task to be delegated based on the Nurse Practice Act and appropriate position descriptions.
Task that which are the responsibility of the RN only:
a) unstable patients with the least predictable medical outcomes
b) central line care
c) any tasks involving teaching, observation, discharge of a patient, assessment and critical thinking based decisions
d) blood transfusions
e) parenteral nutrition
f) patient controlled analgesia
g) development of a plan of care
h) taking a medical history
i) taking phone doctor's orders for prescription and treatment
j) doing an admission assessment
K) initiate a Care Plan
Task that can be delegated to LPN/LVN only
a) patients who are stable and with predictable outcomes and common, well-defined health problems
b) give meds, oral, topical and inhalants, can administer treatments such as sterile wound care, blood sugar testing, nasogastric tube
insertion, tube feedings and charting
c) LPN/LVN can start an IV of saline and superimpose IV fluids with vitamins, nutrients and electrolytes by primary or secondary
infusion lines, infuse blood and blood products with IV Certification
d) give injections
e) monitor running IV
f) give enemas
g) monitor a urinary catheter
h) do simple wound dressing change
i) any task which does not require nursing judgment or complex observation, nurse can delegate to the LPN. RN must inform the
parameters of what to report as abnormal
j) use sterile technique procedures such as putting a urinary catheter
K) can give intra muscular injections, subcutaneous, intradermal
l) cannot give IV Push, infuse antibiotics or other medications via secondary IV line
m) can initiate teaching and a care plan
n) cannot infuse IV fluids such as TPN or other fluids via a central line and cannot do blood withdrawal via central line
o) can do blood withdrawal via venipuncture or peripheral line with blood withdrawal certification
sources: http://www.vocationalnursingdirectorsofca.org
http://www.rn.ca.gov/noa.htm
http://www.bvnpt.ca.gov/pdf/vnregs.pdf
UAP
a) bathing patient
b) ambulation
c) making beds
d) routine vital signs feeding patients
e) transferring patients

SLAP---Quick Suicide Assessment

S---assess how specific is the plan: goes beyond thinking about it = suicide ideation
L---assess how lethal is the method of doing it
A---assess the availability of whatever object the person chooses to commit suicide with
P---proximity how far or close this person is from getting help or from someone to notice his/her intentions and try to stop him/her
If at least one these four items is affirmative on a patient, the patient is at risk and rising if there is no intervention in place such as
placing the patient on suicide precautions.

AIRBORNE PRECAUTIONS:
a) private room with monitored negative air pressure flow with 6-12 air changes per hour
b) keep the door closed and patient in the room
c) can cohort or place the patient with another patient with the same organism but no other organism
d) care giver ware mask N-95 and respirator around mouth and nose
e) place a mask on the client if being transported
DROPLET PRECAUTIONS:
a) involves contact of conjuntive or mucous membranes of nose, mouth that happens during coughing, sneezing, talking or during
procedure such as suctioning or bronchoscopy
b) private room or with patient with same infection but no other infection
c) maintain a spacial separation of three feet between infected patient and visitors or other patients
d) door may remain open
e) place mask on patient if being transported
CONTACT PRECAUTIONS:
a) needed for patient care activities that require skin-to-skin contact such as turning a patient, bathe a patient or hand contact between
two patients or contact with a contaminated objects in the patient's environment
b) private room or with another patient with the same infection but no other infection
c) clean nonsterile gloves when entering the room
d) change globes after patient contact with fecal material or wound drainage
e) remove globes before leaving patient's environment and wash hands with antimicrobial agent
f) wear a gown before entering the room if clothing will have contact with patient, environment surfaces, or if patient is incontinent,
has diarrhea, an ileostomy, colostomy or wound drainage
g) remove the gown before leaving the room
h) use dedicated equipment or clean and disinfect between patients
Entrance into the Isolation Room:
a) put the surgical mask or respirator around mouth and nose (type of mask depend on the type of isolation)
b) apply eyeware or goggles snugly around the face and eyes (when needed)
c) apply gown and make sure it covers all outer garments, pull sleeves down to wrist and tie the gown securely on the neck and waist
d) apply disposable globes to cover over the edge of the gown sleeves
e) enter the patient's room
f) equipment such as stethoscope, pressure cuff, thermometer--disposable--.
g) nondisposable equipment remains in the room... clean nondisposable equipment with alcohol before and after using it, place
dedicated equipment on a clean surface
Leaving Isolation Room:
a) remove gloves, discard
b) untie top mask string and then bottom string pull mask away from face and do not touch the outer surface of the mask
c) untie waist and neck string of the the gown, allow the gown to fall from the shoulders
d) remove hands from sleeves without touching the outside of the gown
e) hold the gown inside at the shoulders seams and fold inside out and discard
f) remove eyeware or goggles
g) wash hands
h) leave the room and close the door if the patient is on airborne precautions
. The 3 classic signs of pre-eclampsia are: Hypertension, generalized edema and proteinuria.
2. REFLEXES
Moro reflex- Elicited by striking a flat surface the infant is lying on. The reflex of abducting extremities and
fanning fingers when a sound is heard should be gone by 3-4 months. Strongest at 2 months.

Rooting - When the cheek of the newborn is stroked, the newborn will turn his head in the direction of the
stroke.
Tonic neck - While the n/b lies supine, his head is turned causing the extremities on the same side to straighten
and those on the opposite side to flex.
Babinski - When the sole of the foot on the side of the n/b small toe is stroked upward, the toes will fan upward
and out.
Plantar grasp - Infants toes will curl downward when sole of foot is touched.
Startle - A loud noise such as a hand clap will elicit the n/b to abduct his arms and flex his elbows.
3. Terbutaline (Brethine) and Mag sulfate - treatment for preterm labor.
4. Nageles Rule: First day of last menstrual period + 1 year & seven days minus 3 months.
5. True labor INCREASESwith activity.
6. Normal newborn jaundice - AFTER 24 hours of life.
Pathologic jaundice - BEFORE 24 hours of life.
7. Fetal Fibronectin (FFN) test helps determine if there is pre-term labor.
8. A subarachnoid (spinal block) for labor may cause a headache, a lumbar epidural will not since the dura mater is
not penetrated.
9. Tracheoesophageal fistula: 3 C's: coughing, choking, & cyanosis.
10. Pregnancy r/t: Add 300 Calories to diet when pregnant, 500 when breastfeeding.
11. Non Stress Test on a pregnant female....should be REACTIVE (rise of 15 bpm above baseline for 15 sec) if it's
NOT reactive they need a contraction stress test and the result that you want from it is NEGATIVE.
12. Pregnancy Induced Hypertension: The nurse would be MOST concerned if the patient complained of epigastric
pain and a headache.
13. LOCHIA SEQUENCE.: lochia rubra- red, clotty....lochia serosa...pink, brown....lochia alba..white.........SHOULD
NEVER HAVE A FOUL ODOR!

14. When a pregnant women is admitted with C/O painless vaginal bleeding: do abdominal ultrasound because it's
the least invasive diagnostic test

15. Calcium Gluconate can cause severe chemical burns - most important to check patency of veins when giving
(given to a patient experience magnesium sulfate toxicity)
16. Take prenatal vitamins in the morning with orange juice - acid aids in absorption.
17. Fetal heart rate: 120-160 BPM
Variability: 6-10 BPM
Contractions:
Frequency - every 2-5 minutes
Duration - less than 90 secs.
Intensity - less than 100 mmHg
Amniotic fluid - 500 to 1200 ml - Nitrozene paper (litmus paper) - if urine it turns green. If amniotic fluid litmus
paper turns blue.
18.FAB 9 - Folic Acid (AKA B9) B = Brain. Decreases the incidence of neural tube defects. The client should begin

taking B9 three months prior to becoming pregnant.

19. AVA - The umbilical artery has 2 arteries (carries deoxygenated blood) and 1 vein (carries oxygenated blood).
20. TORCH syndrome in the neonate - A combination of diseases: Toxoplasmosis, Rubella (German measles),
cytomegalovirus, herpes, and syphilis. Pregnant nurses should not be assigned to care for a client with
toxoplasmosis or cytomegalovirus.
21. Android Pelvis is wedge shaped, narrow and unfavorable for birth.
22. Prenatal Visits
q 4 weeks -28-32 weeks
q 2 weeks -32-36 weeks
q 1 week -36-40 weeks
23. Posterior fontanel close - 2-3months
Anterior close After - 12-18 months
24. Most dangerous when you're pregnant; regular measles (rubeola), or German measles (rubella), so remember:
Never get pregnant with a German (rubella).
25. Apgar measures heart rate, respiratory rate, muscle tone, reflexes, and skin color.
Measured by 0 for absent, 1 for decreased, 2 for strong positive. 8-10 OK. 0-3 RESUSCITATE. Performed at 1 and
5 minutes.
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)
26. In the Apgar score, the first time done reflects the transitional score, the second Apgar score reflects the
planning of care for the newborn. Score over 7, baby is ok but score under 5 needs resuscitation or intensive care.
27. NEVER examine a bleeding gravida vaginally.
28. Maternal hypotension = STOP
Stop Pitocin (oxytocin) infusion
Turn patient on left side
Oxygen
Push IV fluids.
29. The criteria used to distinguish TRUE from FALSE labor is EVIDENCE OF CERVICAL CHANGE.
30. Fetal heart patterns in OB? Think VEAL CHOP
V C V = variable decels; C = cord compression caused
E H E = early decels; H = head compression caused
A O A = accels; O = okay, not a problem!
L P L = late decels P = placental insufficiency, can't fill
For any kind of bad fetal heart rate pattern, you give O2, often by mask...
Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) --> turn on left
side (and give O2, stop Pitocin, increase IV fluids)

31. For cord compression, place the mother in the TRENDELENBERG position because this removes pressure of the
presenting part off the cord. (If her head is down, the baby is no longer being pulled out of the body by gravity).
If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection.
Place client in knee-chest position or Trendenlenberg
32. Once the membranes rupture, important to monitor temperature hourly as risk for infection increases. First
thing to do after rupture is to auscultate fetal heart tones!
Assessing for cord prolapse if decels occur.
33. For late decels, turn the mother to her left side, to allow more blood flow to the placenta.
34. Greatest risk for postpartum hemorrhage is from distended bladder.
35. Hypotension and bradypnea/bradycardia are major risks and emergencies.
36. NEVER check the monitor or a machine as a first action. Always assess the patient first; for example listen to
the fetal heart tones with a stethoscope in NCLEX land. Sometimes it's hard to tell who to check on first, the
mother or the baby; it's usually easy to tell the right answer if the mother or baby involves a machine. If you're
not sure who to check first and one of the choices involves the machine, that's the wrong answer.
37. If the baby is a posterior presentation, the sounds are heard at the sides.
the baby is anterior, the sounds are heard closer to midline, between the umbilicus and where you would listen to a
posterior presentation.
If the baby is breech, the sounds are high up in the fundus near the umbilicus. If the baby is vertex, they are a
little bit above the symphysis pubis.

38. Use reliable form of birth control for at least 4 weeks (8 is better) after rubella immunization [of course this
applies to women only].
39. Increase calorie intake by 300 for pregnancy; 200-500 for lactation.
40. Fluid intake for pregnancy minimum 2000 mL; minimum 3000 mL for lactation.
41. Interventions for late decels: Stop Pitocin if on, turn mom to left side, increase IV fluids, O2 8-10 L/min.
42. Ways to speed delivery: Prostaglandins (Prepidil or Cervidil), Misoprostol, (Cytotec), artificial rupture of
membranes, oxytocin (Pitocin).
43. Spontaneous abortion: Most commonly present Painfollowed by bleeding
44. RHoGAM : given at 28 weeks, 72 hours post partum, IM. Only given to Rh NEGATIVE mother. Also if indirect
Coombs test is positive, dont need to give RHoGAM cause she has antibody only give if negative Coombs
45. Discolored amniotic fluid such as green is a sign of fetal distress.
46. Placenta previa = painless bleeding. No vaginal exams.
47. After the rupture of membranes, the babies heart is checked then rechecked a few minutes later or after
next contraction.

48. Hep. B vaccine given within 12 hours of birth.

49. GP-TPAL: G=#pregnancies, P=#births, T=#term pregnancies (38+ weeks), P=#preterm pregnancies (20 weeks37 6/7 weeks), A=#abortions (spontaneous and therapeutic <20 weeks), L=#living children.
50. Fetal Development in utero:
Week 1 : free floating blastocyst
Week 2-3 : 2mm long
Week 8 : 3 cm long and may weigh in at 2 grams
Week 12 : 8 cm long
Week 20 : approx. 19 cm long & weighing in at 465 grams
Week 32 : 30 cm long
51. Estrogen stimulates uterine development to provide a environment for the fetus, and stimulates the breasts to
prepare for lactation.
52. Measure fundal Height: Start measuring at 18 weeks. Should equal the week of gestation. Have client empty
bladder.
Step 1 - place client in supine position
2 - place end of tape measure at level of symphysis pubis
3 - stretch tape to top of uterine fundus
4 - note and record the measurement

53. Staphylococcus aureus common cause mastitis

1st week of postpartum not present (mastitis)
Seen: 3-4 weeks post partum
SYMPTOMS: Fever, Chills, swollen red breast. Normal fetal heart rates,
54. Normal heart rate: 120-160 Bpm
Abnormal: If bradycardia is detected, position the mother on her left side
55. Abdominal pain, tender uterus, dark red or no bleeding = abruption
Painless, bright red bleeding usually first episode in 2nd trimester = placenta previa
56. DO NOT give a pregnant laboring patient on methadone STADOL (precipitates withdrawal)
57. Analgesics are typically not given during the transitional phase of labor as delivery is imminent and could lead to
decreased respiratory rate in neonate.
58. If patient has boggy uterus - place the infant to nipple, it causes release of natural Pitocin If uterus deviated
to one side - encourage client to void.
59. RHoGAM given to Rh negative mothers with Rh positive babies within 72 following birth. RHoGAM : given at 28
weeks, 72 hours post partum, IM. Only given to Rh NEGATIVE mother. Also if indirect Coombs test is positive,
dont need to give RHoGAM because she has antibody, only give if negative Coombs. Rh- mothers receive RHoGAM
to protect next baby.
60. SIGNS OF PREGNANCY
Presumptive Probable Positive
Amenorrhea Hegars sign Fetal heart sounds
Nausea/vomiting Chadwick sign Fetal movement
Quickening Goodells sign visualization of fetus

Striae gravidarum Braxton Hicks

Linea nigra + pregnancy test
Breast changes Abdominal enlargement
Presumptive - Changes experienced by the woman that make her think she is pregnant.
Probable - Changes observed by the examiner that make the examiner believe she is pregnant
Positive - Signs that can be only be explained by pregnancy.
Goodells sign: Softening of the cervical tip.
Chadwicks sign: Bluish discoloration of the vaqinal mucosa
Hegars sign: Softening of the lower uterus.
61. The postpartum check should include: status of fundus, lochia, breasts, perineum, Homan's sign, pain, evidence
of parent-baby bonding.
62. The woman with hydatidiform mole ( gestational trophoblastic disease ) should get follow up medical care for at
least a year for possibility of choriocarcinoma. Advise pt. not to get pregnant during this time.
63. At 0 station, the presenting part is at the level of the ischial spines. Above zero is - and below is +(+ is closer
to delivery).
64. IgA breAst milk
65.Contraindications to Breast feeding include
1.) Baby has galactosemia
2) Mom HIV and on antiretrovirals
3) Mom on Chemo or Radiation

66. The greatest period of danger to the developing fetus for structural anomalies is day 15 to 18 weeks from
conception.
67. Begin assessing fetal movement between 16 and 20 weeks.
68. Estrogen stimulates uterine development to provide a environment for the fetus, and stimulates the breasts to
prepare for lactation.
69. Physiologic jaundice of the new born is due to mild hyperbilirubinemia that subsides in a week or two. Pathologic
jaundice is due to severe hyperbilirubinemia and can cause brain damage. pathological jaundice= occurs before
24hrs and last7 days. Physiological jaundice occurs after 24 hours.

70. Pregnant women cannot administer Ribavarin (for RSV).

80. Abruptio placentae may be a complication of severe preeclampsia.
90. Fundus displaced to right side-ask pt to void. Fundus is boggy-message fundus.
91. Postpartum period: circulating HcG disappears within 8-24 hours.
92. Symptothermal method of birth control - combines cervical mucus evaluation and basal body temperature
evaluation, non-prescription/drug
93. Precipitous/rapid labor - risk factor for early postpartum hemorrhage and amniotic fluid embolism.

94. A patient with a vertical c-section surgery will more likely have another c-section.
95. Caput succedaneum= diffuse edema of the fetal scalp that crosses the suture lines. Swelling reabsorbs within 1
to 3 days.

96. Dystocia= baby cannot make it down to canal.

97. Meconium ileus is a sign of cystic fibrosis.
98. Blue spells " or "TET spells" is characteristic of tetrology of fallot.

99. Transesophageal Fistula (TEF) - esophagus doesn't fully develop (this is a surgical emergency)
The 3 C's of TEF in the newborn:
1) Choking
2) Coughing
3) Cyanosis
100. CARDIOVASCULAR DISORDERS OF THE NEWBORN
Tetrology of Fallot - Tetra means four so it consists of four defects:
pulmonary artery stenosis
hypertrophy of right ventricle
venticular septal defect
overriding of aorta
Dx of Tetrology of Fallot is done by chest x-ray that shows a typical boot shaped heart. An echocardiogram, 3
dimensional echocardiography, & cardiac cath help to confirm diagnosis. S/S of TOF include: " blue spells or tet
spells " relieved by having child squat. Murmur may be present. Poor growth, clubbing of fingers.
Atrial Septal Defect : abnormal opening between atria which causes increased flow of oxygenated blood to go into
right side of heart. Right atrial & right ventricle enlarge. May be closed using cardiac catheterization or surgically
with cardiopulmonary bypass which is done before school age.

Ventricular Septal Defect: characteristic murmur, CHF is common, many times will close by itself if smallmoderate defect.

Patent Ductus Arteriosus ( PDA ): characteristic machine like murmur , can be asymptomatic or s/s of CHF, wide
pulse pressure & bounding pulses.
Coarctation of the aorta: narrowing near insertion of ductus arteriosus. S/S of CHF in infants, HTN & bounding
pulses in arms but weak or absent femoral pulses, low extremities may be cool.

101. Omphalitis - infection of umbilical stump. Don't rely on smell to detect infection b/c umbilical stump heals thru
gangrene.
102. Make sure to assess vernix and heel creases soon after baby is born because vernix will be wiped off and heel
creases develop as soon as foot dries.

103. SQUARE WINDOW - term infants can flex wrist onto arm, preterms can only do a 90degree flexion which
creates a "square window"
104. SCARF SIGN - term infants can't extend elbow past midline but preemies can, they extend hand across
created a "scarf" effect since they have no resistance
105. On the Ballard Scale, score of 35 is 38 weeks, 40 is 40 weeks and 45 is 42 weeks.

106. Post-term babies are at risk for..

- Polycythemia r/t hypoxia, less 02 from placental (placental insufficiency)
- Meconium Aspiration - hypoxia relaxes anal sphincter and they poop
- Hypoglycemia - Interference with nutrient supply as placenta deteriorate

107. When performing a heel stick, put thumb over walking surface of the heal, strike latter aspect of heal, wipe of
1st drop, don't smear, streak or squeeze area (due to high ECF in infants)
108. Before infant feeds, insert gloved hand into mouth to assess palate.
109. Head circumference should be 2cm > than chest when born, but equal by 1 year.

110. Skin tags and low set ears in infants - suspect chromosomal abnormalities
111. Circumoral cyanosis in infants - see if it improves with crying. If it doesn't , report it because it might indicate
cardiac pathology.
112. Infants need 110kcal/kg/day
Breast milk has 20 kcals per ounce (so 20 kcal per 30 cc)
Breast milk has everything BUT slightly deficient in Vitamin D

113. Shoulder and Upper back lanugo is normal for term baby and vernix in deep creases and skin folds is also ok
for term babies.
114. Fetal Alcohol Syndrome babies will appear with a small head circumference, low birth weight, and
underdeveloped cheekbones. They may need vitamins (especially B's).
115. Pregnancy diabetes, during the first trimester, maternal insulin need decrease. During second and third
trimesters, requiring an increase in the clients insulin dose. After placental delivery, insulin requirements
decrease.

116. Autosomal DOMINANT disorders :

**Marfans (prone to aneursyms, long long long people "Abe Lincoln" type folks ).
**Polydactly (too many digits)
**Achondroplastic dwarfism
** PKD polycystic kidney disease
**Huntington (doesn't show up until 40s 50s, which is why the gene is perpetuated in the gene pool because when
the symptoms show up in the 40s/50s, you've probably already had kids and passed the gene along)

Autosomal Recessive
** Sickle Cell
** Cystic Fibrosis
** PKU
** Galactosemia (can't digest galactose in breast milk)
117. Spinnbarkheit: Describes the elasticity of the cervical mucus that is present at ovulation.
118. Ferning: Formation of a palm-leaf pattern by crystallization of cervical mucus as it dries at mid-cycle. Helpful
in determining time of ovulation.
119. Aerocyanosis: is a bluish discoloration of the hands and feet and may be present in te first few hours
after birth, but resolves as circulation improves.
120. Erythema appears: as a rash on newborns usually after 24-48 hrs of live.

121. Harlequin color results as: a vasomotor disturbance, lasting 1-20 seconds, which is transient in nature
and not of clinical consequence.

122. Vernix caseosa: is a cheese like substance that protected the newborn skin while in utero.
123. Ovulation typically occurs 1to2 years after menarche.
124. To prevent anemia, females ages 10 to 55 should consume 18mg of iron daily.
125. Climacteric is the cessation of the reproductive functioning in women (menopause) and decreasing
testicular action in men.
126. In Diabetic mother the newborn at risk for hypoglycemia, RDS, hypocalcemia congenital anomalies. Diabetic
mother during pregnancy-1st trimester insulin DECREASE. 2 and 3rd Trimester INCREASE INSULIN (placental
hormones produce insulin resistance). BUT after PLACENTAL DELIVERY INSULIN REQUIREMENTS DECREASE.
Insulin is safely given throughout pregnancy; oral hypoglycemic agents are contraindicated.

MATERNITY MEDS
Bethamethasone (celestone)=surfactant. Med for lung expansion.
Metylergonovine- To contract uterus. before giving check BP. dont give if vascular diseases are present.
Terbutaline: Medication given to stop pre-term labor Methergine: Given for postpartum hemorrhage.
Cervidil: Cervical ripening agent.
Magnesium Sulfate: CNS depressant and Anticonvulsant = normal range 4-7.5, effective if no seizures. 4-6q IV
bolus, Followed by a: 2 g/h infusion:
Magnesium Sulfate becomes toxic at levels > 8 meq/L. Respiratory arrest occurs at levels > 12 meq/L.
Magnesium sulfate(used to halt preterm labor) is contraindicated if deep tendon reflexes are ineffective. If
patient experiences seizure during magnesium administration. Get the baby out stat (emergency).
Adverse reactions: Inform client of these: Flushing, decrease in respiratory rate, muscle weakness. TOXICITY
S/S: Absence of deep tendon reflex, Urine output < 30 ml/hour, ed LOC, respirations <12/minute.
Pregnancy Induced Hypertension - prevents seizure.
ANTIDOTE: Calcium Gluconate

Pitocin: Used for induction of labor and postpartum to help the uterus contract. Causes uterine stimulation.
Medications that are contraindicated in breast-feeding mothers
Tetracycline - inhibition of bone growth
Warfin * safe to use? Hand out
Chloramphenicol bone marrow suppression
Two drugs are used to treat Eclampsia
Magnesium Sulfate 4-6q IV bolus
Followed by a: 2 g/h infusion:
Hydrolazine 10-20 mg IV
MATERNAL TESTING
1st TRIMESTER (Chorionic villas sampling, US scan)
2nd TRIMESTER (AFP screening or Quad Screening, Amniocentesis)
3rd TRIMESTER (kick counts, Nonstress Test, Biophysical Profile, Percutaneous Umbilical Blood sampling,
Contraction Stress Test )
Ultrasound screening -can be vaginal or Abdominal (in latter make Her drink water to fill bladder)
-Confirms viability
-Indicates fetal presentation
-Confirms multiple gestation
-Identifies placental location
-Measurements can be taken to confirm/estimate gestational age
-Identify morphologic anomalies
Chorionic villus sampling
8-12 weeks - for early diagnosis of genetic, metabolic problems
Amniocentesis -13-14 weeks
Is done under US scan to obtain a sample of amniotic fluid for direct analysis of fetal chromosomes, neural tube
defects, sex of the baby, development, viability and lung maturity. Can be used to measure fetal lung maturity
ONLY in the 3rd trimester.
AFP - also called =Quad marker screening:
15-18 weeks-Maternal Blood Drawn
-maternal serum alpha fetoprotein (MSAFP),
-human Chorionic gonadotropin (HcG),
-unconjugated estriol (UE),
-and inhibin A
low AFP-Down syndrome
high-Spina bifida - Increased level of alpha fetoprotein in pregnant woman => neural tube defects. It is not an
absolute test if it is abnormal -further investigation is recommended.
Kick counts (tests Ureteroplacental capability)
Same time every day mother records how often she feels the fetus move if minimum 3 movements are not noted
within an hour's time, the mother is encouraged to call her physician immediately!
Nonstress Test
Checks FHR and mother detects Fetal movements.
Contraction Stress Test -tests perfusion between Placenta and Uterus (basically O2 and CO2 exchange)
-IV accessed and performed in a labor and deliver unit under electronic fetal monitoring
contractions initiated by Pitocin or nipple stimulation. The desired result is a "negative" test which consists of
three contractions of moderate intensity in a 10 minute period without evidence of late decelerations. The test is
done to detect problems so if it is Positive (persistent late decelerations) then-CS
how is done:

The electronic fetal monitor is placed on the maternal abdomen for 20-30 minutes
Each time the fetus moves, FHR should accelerate 15 beats/min above the baseline for 15 seconds. A reactive
(good) test =>2 accelerations in FHR occur with associated fetal movement
Biophysical Profile (BPP)
identification of a compromised fetus and consists of 5 components:
-fetal breathing movement
-fetal movement of the body or limbs
-fetal tone (extension or flexion of the limbs)
-amniotic fluid volume index (AFI) visualized as of fluid around the fetus
-reactive non-stress test
each component 0-2, 8-10-desirable.
Percutaneous Umbilical Blood sampling -like amniocentesis but cord punctured
-chromosomal anomalies, feta karyotyping, and blood disorders
Everywhere a woman's abdomen is punctured, informed consent is needed, and risks like amnionitis, spontaneous
abortion, preterm labor/delivery, and premature rupture of membranes must be explained. If she Rh--she may be
given RHoGAM.

Here is a little bit on Psych for NCLEX. Hope you all like. Remember to keep those of us who havent taken it yet in your prayers.
PSYCHIATRIC
1. In psych patients, the client most at risk for self-harm is always the patient that has stopped taking their meds.
2. Hallucinations: Sensory impressions without external stimuli - Redirect patient.
Illusions: Real stimuli misinterpreted.
Delusions: False fixed beliefs. Distract the patient.
3. Bipolar Disorder
Manic Depressive
Mood elevated Anxious, hopeless
Speech loud, fast, vulgar ed interest in pleasure
Grandiose delusions negative views
Distracted Fatigue
Hyperactive ed appetite
Flight of ideas Insomnia
Inappropriate dress Suicidal
4. FIVE INTERVENTIONS FOR PSYCH PATIENTS
-safety
-setting limits
-establish trusting relationship
-meds
-least restrictive methods/environment.
5. If patients have hallucinations redirect them. In delusions distract them.
6. Language & Communication
NEOLOGISM = a new word made up that has meaning only to the patient
ECHOLALIA = repeating of words or phrases they heard someone else say
WORD SALAD = form of speech in which words & phrases are connected without any meaning
MUTISM = absence of verbal speech

CLANG ASSOCIATION = repeating of words & phrases that are similar in sound but not in any other way ( Dr.
Seuss type of speech )
7. Defense Mechanisms:
Compensation = putting extra effort to achieve in areas of real or not-real weaknesses
Sublimation = replacing of an unacceptable need, attitude or emotion with one that is more accepted.
8. The adverse effects of Anti psychotics can be remembered using this: SHANCE
S-SUNLIGHT SENSITIVITY( Use hats and sunscreen)
H-HEPATOTOXICITY( Monitor LFT)
A-AGRANULOCYTOSIS( Characterized by fever and sore throat)
N-NEUROLEPTIC MALIGNANT SYNDROME( Characterized by fever and muscular rigidity)
C-CIRCULATORY PROBLEMS( Leukopenia and orthostatic hypotension)
E-EXTRA PYRAMIDAL SYMPTOMS( Administer anticholinergics and anti-parkinsonian agents)
Psychiatric emergencies
Acute alcohol intoxication
Assessment:
Drowsiness, slurred speech, tremor, impaired thinking ,nystagmus, nausea, vomiting, hypoglycemia, increased
respiration, grandiosity, loss of inhibitions, depression
Nursing diagnosis:
Injury , risk for
Nursing :
Quiet environment ,allow to sleep it off
Monitor vital signs
Protect airway from aspiration
Assess for injuries
Psychiatric emergencies
Hallucinogenic drug intoxication
Assessment :
Eye:
red-marijuana;
dilated-LSD, mescaline, belladonna;
constricted-heroin and derivatives
Care plan:
1, talk down :
* keep talking ,keep eyes open
* focus on here and now, inanimate objects
* use simple, concrete , repetitive statement,
* repetitively orient to time, place
* confidentiality; dont moralize, challenge beliefs
2. medication
* valium
* lithium
3. hospitalization: (if more than 12-18hrs)

Psychiatric emergencies
Homicidal or assaultive reaction
Cause:
* antisocial behavior, paranoid psychosis, previous violence, substance abuse, depression.
Intervention:
* physically restrain if client has a weapon
* separate from intended victims
* approach: calm and unhurried
* prevent suicidal behavior
Psychiatric emergencies
Suicidal
suicidal ideation
concepts and principles related to suicide
assessment of suicide
composite picture: male, older than 45 yrs, unemployed, divorced, living alone, depressed, history of substance
abuse and suicide within family
Psychiatric emergencies----suicidal
10 factors to predict potential suicide and assess risk:
*age, sex and race: teenage, older age, more women make attempts, more men complete ; occurs in all races and
socioeconomic groups.
*recent stress related to loss.
clues to suicide:
* verbal clues: direct I am going to shoot myself ; indirect: this is the last time youll ever see me
* behavior clues: direct: pills, razor; indirect: sudden lifting of depression, buying a casket, giving away cherished
belonging, writing a will.
Psychiatric emergencies----suicidal
suicide plan: the more details, the higher risk
previous suicidal behavior
medical and psychiatric status
communication: the risk reduced if the patient has talked about
Psychiatric emergencies----suicidal
style of life: such as substance abuse
alcohol: alcohol reinforce helpless and hopeless feeling
resources: the fewer resources, the higher risk
Psychiatric emergencies----suicidal
nursing care plan
short-term goals
* medical : gastric lavage, respiratory and vascular support, wound care
suicide precautions
*one to one supervision at all time
*check whereabout every 15 min
*explain to client what you will be doing, and why accompany the client for tests, procedures
*look through clients belongs, remove any potentially harmful objects : pills, matches, belts, razors, glass,

tweezers
*allow visit, but maintain one-to-one supervision
*check that visitors dont leave potentially harmful objects
*Meal tray : contains no glass or metal silverware
dont discontinue without order
Psychiatric emergencies----suicidal
General approaches
Observe closely at all times
Be available ; empathy
Avoid : extremes in your own mood
Focus : directly on clients self-destructive idea
Make a contract: no suicide within 24 hrs; or call someone
Point out clients self-responsibility for suicidal act
Support the part of the client that wants to live
Remove sources of stress : make all decision when client is severe depression
Prove hope: problem can be solved with help
Provide with opportunity to be useful

Psychiatric emergencies
Pseudo suicide attempts:
Cry for help
Desire to manipulate others
Need attention
Self-punishment
Wish to punish others
What will you do when you facing ~ ?
Crisis intervention
definition of crisis
Sudden event in ones life disturbs homeostasis, during which usual coping mechanisms cannot resolve the problem
a. maturational (internal, relate to developmental
stages and associated role changes)
b. situational (external, associate with a life event )
c. adventitious (relate to a disaster)
Crisis intervention
characteristic of crisis intervention:
a. acute, sudden onset
b. responsive to brief therapy with focus on immediate problem
c. focus shifted from the psyche in the individual to the individual in the environment; deemphasis on intrapsychic
aspects
d. crisis is time limited (usually up to 6wk)
Crisis intervention
nursing care plan:
Goal:
return to pre-crisis level
Focus here and how

Care plan:
Encourage expressing
Explore past coping skill and reinforce adaptive ones
Set limit
Use all resource
Domestic violence
Characteristics
1.victims: feel helpless, powerless; blame themselves, ambivalent about leaving the relationship
2. abusers: often blame the victims, use power to threaten and subject victims to their assault
3.cycle of stages
a. buildup of tension
b. battering
c. calm
risk factors
Learned responses
Pregnant women and whose with one or more preschool children
Women who Fear punishments form abuser
care plan
a. provide safe environment; refer to community resources for shelter.
b. treat physical injuries
c. document injuries
d. supportive, nonjudgmental approach
e. encourage individual and family therapy for victim and abuser.
Rape-trauma syndrome
Assessment :
Physical trauma
Emotional trauma: tears, hyperventilation, anxiety, self-blame, anger, fears, phobia, sleeping and eating problem.
Nursing care:
Acknowledge feeling,
Handle legal matters and police contact
Medical attention
Notify family and friends
Remain available and supportive
Contraception discussing
Explore guilt and shame feeling
Maintain confidentiality and neutrality
Health teaching :
*avoid isolated areas and being helpful to strangers
*how to resist attack : scream , run
*Teach what to do if pregnancy or STD is outcome
Battered child
Clues in history:
Delay in seeking medical care

 Discrepancies
Multiple ER visits
Vague and contradictory story
Clue in physical examination:
Child : withdrawn, apathetic, does not cry
Child : doesnt turn to parents for comfort; unusual desire to please parent; fear parents
Child: poorly nourished
Multiple bruises, old bruises in addition to fresh one
Burns: cigarette burs, rope marks
Clues in parent : exaggerate care and concern

Nursing :
Report suspected child abuse
Conduct assessment interview in private with child and parent separated
Be supportive and nonjudgmental
Evaluation:
Parents have agreed to seek help

Sexual abuse children

Assessment: (characteristic)
Relationship: filling paternal role (uncle, grandfather, cousin) with unquestioned access to the child
Methods of pressuring victim into sexual activity: offering material good, misrepresenting moral standards (it is
ok)
Methods of pressuring victim to secrecy : fearing of punishment ,no being believed, rejection, being blamed for
the activity, abandonment
Disclosure:
Direct visual or verbal confrontation and observation by others
Verbalization of act by victim
Visible clues : excess money and candy,, new clothes, pictures
Sings and symptoms: bed-wetting; excessive bathing ,tears, avoiding school, somatic distress
Overly solicitous parental attitude toward child
Sexual abuse children Child feeling:
guilty.
responsible for being a victim.
powerlessness
Nursing :
Safe environment
Encourage child to verbalize feeling
Observe for symptoms: phobic reaction when hearing or seeing offender; sleep pattern changes, nightmares
Look for silent reaction
Health teaching :
* teach child that his (her) body is private
* teach family

Elder abuse
Concepts:
Elders who are currently being abused often abused their abusers
Victim: diminished self-esteem, feeling responsibility for the abuse, isolated
Abuser: physical or psychosocial stressors
Legal : most states have mandatory laws to report elder abuse
Nursing :
Early case finding , early treatment
Report case to law enforcement agencies
Provide elder with phone number
Shelter
Self help group
Sleep disturbance
Types of sleep :
Rapid eye movement sleep
Non-REM sleep
Sleep cycle (90 min)
Adolescents spend 30% REM of total sleep time; adults : 15% ;
Nursing care:
Obtain sleep history
Duplicate normal bedtime rituals
Environment : quiet , dim lights,
Encourage daytime exercise
Allow uninterrupted sleep cycle: 90 min
Back rub, warm milk, relaxation
Taper off hypnotics
Avoid caffeine and hyperstimulation at bedtime
What about taking a nap during daytime?
Eating Disorders
Anorexia nervosa
Anorexia nervosa is an illness of starvation related to a severe disturbance of body image and a morbid fear of
obesity; it is an eating disorder, usually seen in adolescences.
Assessment:
Body-image disturbance
Ambivalence: hoards food; avoids food
Low sex drive
Pregnancy fears
Self-punitive behavior leading to starvation
Physical signs:
*Weight loss
*Amenorrhea and secondary sex organ atrophy
*Hyperactivity: compulsiveness, excessive gum chewing
*Constipation

*Hypotension, bradycardia, hypothermia

*Skin: dry, poor turgor
Bulimia
Bulimia nervosa is another type of eating disorder (binge-purge syndrome) also encountered primarily in late
adolescence or early adulthood. It is characterized by at least two binge-eating episodes of large quantities of high
calories food over a couple of hours followed by disparaging self-criticism and depression, self-induced vomiting,
abuse of laxatives, and abuse of diuretics are commonly associated
Eating Disorders
Analysis
a. altered nutrition, less than body requirements, and fluid volume deficit
b. risk for actual fluid deficit
c. risk for self-inflicted injury
d. altered eating
e. body image disturbance/chronic low self esteem
f. compulsive behavior
Nursing care plan
help reestablish connections between body sensations (hunger) and responses (eating).
*weigh regularly , at same time, with same amount of clothing , with back to scale
*Water drinking is avoided before weighing
*One-to-one supervision during and after mealtime to prevent attempts to vomit food
*Monitor exercise program, set limits in physical activity
monitor physiological signs and symptoms
health teaching
Explain normal sexual growth and development to improve knowledge and confront sexual fear
Behavior modification to reestablish awareness of hunger
Teach parents skills in communication
Evaluation:
Attains and maintains minimal normal weight for age and height
Regular meal
Awareness hunger, talking about being hungry
Increase self-esteem
Most drugs especially psychotropic medications acts as CNS STIMULANTS OR CNS DEPRESSANTS. THIS
strategy involves in determining which are the CNS excitations and CNS INHIBITIORS. if 3 of the options are all
CNS up and 1 CNS DOWN- pick the CNS DOWN. if 3 of the options are all CNS down and 1 is CNS UP - PICK THE
CNS UP.
FOR EXAMPLE.
The nurse administer WYAMINE to a client. The nurse should monitor which of the following adverse effect
associated with WYAMINE.
HYPOTENSION
BRADYCARDIA
SHOCK
HYPERTENSION

THE ANSWER IS (d) HYPERTENSION BECAUSE IT IS THE ONLY ONE WITH HIGN CNS.

HERE'S A LITTLE RESPIRATORY NURSING FOR NCLEX - GOOD LUCK ALL

RESPIRATORY
1.RSV- child in private room...CONTACT PRECAUTIONS. Not droplet or airborne.
2. Elderly adults generally present with confusion rather than S/S of an illness.
3. Pneumonia- droplet precautions.
4. COPD pts should get low flow Oxygen because of the hypoxic drive. (1-3L/min) teach pursed lip breathing.
5. ARDS- this pt doesnt respond to even 100% FiO2.
6. TB - hemoptysis (advanced stage) vital signs pulmonary edema- frothy blood tinged sputum.
7. Allen's test- done before an ABG by applying pressure to the radial artery to determine if adequate blood flow
is present.
.
8. INH (Isoniazid)- treatment of TB. Give vitamin B6 to prevent peripheral neuritis.
9. SIMV mode on vents commonly used for weaning pt off ventilator.
10. Vent alarms:
A. High alarm (increased secretions then suction......, biting tube-need an oral airway,...... or coughing and anxietyneed a sedative)
B. Low alarm- there is a leak or break in system...check all connectors and cuff.
11. If a tracheostomy becomes accidentally dislodged try to replace it with an obturator..if no luck keep the hole
open with hemostats until physician arrives.
12. When giving Bronchodilator & Glucocorticoids at the same time, give the bronchodilator first. Remember B
before G!
13. A collection of fluid between the visceral and parietal pleura is a pleural effusion.
14. RESPIRATORS
Tidal volume is the volume of air inhaled and exhaled with a normal breath.
Inspiratory reserve volume is the maximum volume of air inspired at the end of normal inspiration.
Expiratory reserve volume is the maximum volume of air exhaled after a normal respiration.
Vital capacity is the maximum amount of air expired after maximal inspiration.
Pleurisy is an inflammation of the visceral and parietal pleura.
Mechanical Ventilators:
Can be short term, long term or in between!!! As the nurse:
1) Assess pt. first then the vent 2) assess vitals, respiratory. rate and breathing pattern 3) monitor color of lips &

nail beds 4) monitor chest for symmetry 5) Assess need for suctioning & observe type, color, and amount of
secretions 6) check pulse ox 7) check alarms on vent 8) empty vent tubings when moisture collects 9) turn pt.
every 2 hours and PRN 10) have resuscitation equipment by bedside.
Causes of Alarms:
High Pressure Alarm
a) increased secretions in the airway
b) wheezing or bronchospasm
c) displaced ET tube
d) obstructed ET tube( check 4 kinks )
e) pt coughing, gagging, bites tube
f) pt. fighting vent (bucking)
Low Pressure Alarm
a) Disconnection or leak
b) Patient stops spontaneous breathing

15. TYPES OF RESPIRATIONS

Cheyne-stokes respirations: (rhythmic, with periods of apnea). May indicate a metabolic dysfunction or
dysfunction in the cerebral hemisphere or basal ganglia.
Neurogenic hyperventilation(regular, rapid and deep sustained respirations). Indicates a dysfunction in the low
midbrain and middle pons.
Apneustic respirations:(irregular, with pauses at the end of inspiration and expiration)
---Indicates a dysfunction in the middle or caudal pons
Ataxic Respirations: (totally irregular in rhythm and depth). Indicates a dysfunction in the medulla
Cluster respirations: (clusters of breaths with irregularly spaced pauses).. Indicates a dysfunction in the medulla
and pons
16. Signs of hypoxia: restless, anxious, cyanotic tachycardia, increased respirations. (also monitor ABG's).
17. The cuff of an ET tube is for preventing aspiration and sealing the airway to prevent leaks. When the cuff
deflates, aspiration is the greatest risk (due to secretions)
18. Weighted NI (Naso intestinal tubes) must float from stomach to intestine. Don't tape the tube right away
after placement, may leave coiled next to patient on HOB. Position patient on RIGHT to facilitate movement
through pylorus.

19. If you suspect an air embolus you must put patient in Trendenlenberg and position patient on the LEFT side
because you want the air embolus to trap/dissolve/disintegrate/burst/cease to exist in the RIGHT ATRIUM.
21. OXYGENATION
A. 6L Nasal Cannula is the most you can give, anything above that really doesnt improve oxygenation. 1L NC = 24%
Fi02, 2 L = 28%, 3 L = 32% get it? Keep adding four until you get to 6L = 44% Fi02.
B. Non-rebreather give you the most Fi02, Venturi allows you to give the most precise amount, Face tent is use
with facial trauma/burns
C. Incentive spirometer tell patient to inspire, hold, get floater-thing to about 600-900 then exhale.. 10X per
hour awake. Pt must be able to breathe spontaneously and make a tight seal around the mouthpiece.

22. BiPAP = CPAP and PEEP

23. ABG's is the best way to monitor pulmonary status by analyzing the level of hypoxia caused by pulmonary edema
and for monitoring effects of treatment.
24. The person who hyperventilates is most likely to experience respiratory alkalosis.
25. When a pleural effusion recurs within days or weeks following a thoracentesis, this usually indicates the
underlying cause is a malignancy.
26. Three lobes on the right. Two lobes on the left.
27. If you believe pt to be in respiratory distress, assess lung sounds first, LOC, retractions, skin color, etc would
all be late signs.
28. KEY SIGNS/SYMPTOMS OF RESPIRATORY DISORDER
Dyspnea
Fatigue
Cough
Accessory muscle use
Retractions
Adventitious breath sounds: Crackles, rhonchi, wheezing, & pleural friction rub.
Changes in mentation
Cyanosis
29. To remember which Beta Blockers are contra-indicated in patients with Respiratory problems are easy..
Contra-Indicated- think.... Coreg, Corgard, Inderal.
30. SUCTIONING
Encourage client to cough prior to suctioning.
Use surgical aseptic technique when opening suction catheter kits.
Medical aseptic technique is used for oral suctioning only. Surgical aseptic technique is used for all other types of
suctioning.
Set suction pressure to 80 to 120 mm Hg.
Limit each suction attempt to NO LONGER THAN 10-15 SECONDS. Limit suction attempts to 2-3 times.
Once suctioning is complete, clean tubing with water/normal saline solution.
NASOPHARYNGEAL/NASOTRACHEAL SUCTIONING
A. Suction is performed with flexible catheter.
B. Hyperoxygenate client during equipment preparation with 100% FiO2.
C. DO NOT APPLY SUCTION WHILE INSERTING THE CATHETER.
D. Intermittent suction is only applied during catheter withdrawal, lasting no longer than 10-15 seconds.
E. Allow client time to recover between sessions, 20-30 seconds. Hyperoxygenate the client before each suctioning
pass.
F. DO NOT reuse tubing.
ENDOTRACHEAL SUCTIONING (ETS)
A. ETS performed through tracheostomy or endotracheal tube.
B. Sterility must be maintained.
C. Advance the approximate distance from nose to base of earlobe.
D. Intermittent suction is applied during catheter withdrawal lasting no longer 10-15 seconds.
E. Allow client time to recover between sessions 20-30 seconds. Hyperoxygenate client before each suctioning
pass.
F. Hyperoxygenate client with 100% FiO2.
31. MECHANICAL VENTILATION
A. Assist mode: The patient initiates inspiration and receives a preset tidal volume from the machine which
augments patients ventilator effort & lets him determine his own rate.
B. Control mode: Ventilator delivers a set tidal volume at a prescribed rate using predetermined inspiratory and

expiratory times. This mode can fully regulate ventilation in a patient with paralysis or respiratory arrest.
C. Assist control mode: The patient initiates breathing and a backup control delivers a preset number of breaths at
a set volume.
D. Negative pressure systems provide ventilation for patients who cant generate adequate inspiratory pressures.
E. High-frequency ventilation (HFV) systems provide high ventilation rates with low peak airway pressures
synchronized to the patients own inspiratory efforts.
F. NURSING INTERVENTIONS
1. Check all connections between ventilator and patient q1-2 hours. Make sure all alarms are turned on. Make sure
patient can reach call bell.
2. Verify ventilator settings are correct and that ventilator is operating at those settings.
3. Check humidifier and refill as necessary.
4. Monitor fluid I&O and electrolyte balance. Monitor for stress ulcers.
5. Using sterile technique, change the humidifier, nebulizer, and ventilator tubing according to protocol.
6. Reposition patient frequently.
7. Provide emotional support to reduce stress and give antacids & medications as ordered to reduce gastric acid
production and to help GI complications.
8. Check stools and NG aspirates for blood.
32. Drugs that can be given via Endotracheal tube. LANE
Lidocane
Atropine
Narcan
Epinephrine
33. When drawing an ABG, you need to put the blood in a heparinized tube, make sure there are no bubbles, put on
ice immediately after drawing, with a lable indicating if the pt was on room air or how many liters of O2.
34. Remember to perform the Allen's Test prior to doing an ABG to check for sufficient blood flow
35. Before going for Pulmonary Function Tests (PFT's), a pt's bronchodilators will be with-held and they are not
allowed to smoke for 4 hrs prior
36. For a lung biopsy, position pt lying on side of bed or with arms raised up on pillows over bedside table, have pt
hold breath in mid-expiration, chest x-ray done immediately afterwards to check for complication of
pneumothorax, sterile dressing applied

DIAGNOSTIC TEST AND PROCEDURES

BRONCHOSCOPY
Direct visualization of the trachea and bronchial tree
Used to obtain biopsies and deep tracheal suctioning
Explain procedure to patient, obtain informed consent & place on chart. Without fluid and liquids.
Check for return of gag reflex before giving anything by mouth after procedure.
Monitor pulse oximetry.
PULMONARY ANGIOGRAPHY
Procedure using an injection of radiopaque dye through a catheter.
Radiographic examination of the pulmonary circulation.
Assess patients allergies to iodine, seafood and radiopaque dye.
Place written informed consent on patients chart
Assess neurovascular status.
Check insertion site for bleeding.
Monitor for delayed allergic response
SPUTUM STUDIES
Microscopic evaluation that includes culture & sensitivity, gram stain, and acid-fast bacillus
Obtain early morning sterile specimen from suctioning or expectoration.
Send to laboratory immediately after obtaining.

THORACENTESIS
Surgical perforation of the chest wall and pleural space to obtain specimens, instill medication into the pleural
space, remove fluid or air.
The amount of fluid removed is limited to 1 L at a time to prevent cardiovascular collapse
Ensure that informed consent is obtained and placed on chart.
Apply dressing over puncture site and position client on the unaffected side for one hour.
Encourage deep breathing to help in lung expansion.
Obtain post procedure chest x-ray to rule out pneumothorax.
Monitor V/S for hypotension, diaphoresis, faintness, reflex bradycardia
TUBERCULOSIS - TB
A. Lung infection caused by Mycobacterium tuberculosis
B. Any tissue can be infected.
C. Is an airborne disease caused by droplet nuclei.
D. CLINICAL MANIFESTATION:
Night sweats
Weight loss
Low-grade fever, chills, flu-like symptoms
Indigestion
Frequent cough with copious frothy pink sputum, mucoid or mucopurulent sputum - lasts longer than 3 weeks.
E. LABORATORY
1. Positive tuberculin skin test (indicates exposure) Mantoux skin test
Read test 48 - 72 hours after giving
Induration of 5 mm or less, negative
Induration of 10 mm or more indicates exposure only. Test further
2. Sputum culture
Obtain first morning sputum for 3 consecutive days.
3. Chest X-ray
A. Appearance of characteristic Ghon tubercle on x-ray.
B. Shows nodular lesions and patchy infiltrates.
F. TREATMENT /NURSING INTERVENTIONS
Antituberculotics
IV therapy - Saline lock
Precautions - Standard and airborne
Activity: Bed rest.
Place patient in a negative air pressure that has 6-12 full air exchanges per hour and is vented to the
outside or has its own filtration system.
Post precaution sign on patients door.
Staff fitted for N-95 respirator masks
Provide small frequent meals.
Provide emotional support
Instruct patient to cover nose and mouth when sneezing or coughing.
Reinforce need to finish entire course of medication 6 to 12 months.
G. NURSING INTERVENTIONS
Diet: High in calorie, protein, carbohydrates, vitamins
Vitamin B6 - Potatoes, bananas, beans, seeds, nuts, red meat, poultry, fish, eggs, spinach, & fortified cereal.
B. Vitamin C - Red berries, tomatoes, broccoli, spinach, orange and grapefruit juice, Kiwi, red & green bell pepper.
Provide negative pressure room
Monitor liver function test, urinary function test.
Instruct patient to cover nose & mouth with 2-ply tissue when coughing and sneezing. Do not use bare hands.
If patient leaves room, they must wear HEPA mask.
Monitor I & O

7. After 2-4 weeks patient is usually no longer infectious.

Tuberculosis- assessment findings: cough ( yellow mucoid sputum ) , dyspnea, hemoptysis, rales or crackles,
anorexia, malaise, weight loss, afternoon low grade temperature, pallor, fatigue, pain, night sweats.
Diagnostic Tests used in TB - Chest x-ray indicates presence and extent of disease but cannot show if active or
inactive. Skin test (PPD) positive; area of induration 10mm or more in diameter after 48 hrs. Sputum positive for
bacillus ( 3 samples is diagnostic for TB ). Culture will be positive. WBC & ESR will be elevated. Ethambutol,
Isoniazid, streptomycin, and Rifampin are first-line drugs in the treatment of TB.
for treatment of TB and major side effects:
Rifampicin(Red-urine, tears, sweat)
INH (the N is for Neurological, H is for Hepatic)
Pyrazinamide (hyperurecimia)
Ethambutol(optic neuritis)
The use of a multiple medication regimen destroys organisms as quickly as is possible and minimizes the
emergence of medication resistant organisms.
First-line medications: Isonazid, Rifampin, Ethambutol, Streptomycin, Pyrazinamide
These provide the most effective therapy for TB.
Second-Line medications: Capreomycin, Ethionamide, Aminosalicylate sodium, Cycloserine, Kanamycin
These are used in combination with first line medications but are more toxic.
Multi-drug therapy is used because of resistant strains.
With first-line meds for TB - watch for liver function, peripheral neuritis, hepatitis, dry mouth, dizziness,
hepatotoxicity, monitor CBC and blood glucose levels. Some side effect with 2nd line TB meds - nephrotoxicity,
ototoxicity, neuromuscular blockade.

ANTITUBERCULOTICS
1. CYCLOSERINE
Maximum dose is 1 gm daily.
ADVERSE REACTIONS
Suicidal behavior, psychosis, loss of memory
Coma, seizures.
Hyperirritability, paresthesia.
If taken with Isoniazid may increase risk of CNS toxicity causing dizziness or drowsiness.
D. NURSING CONSIDERATIONS
Advise patient to avoid alcohol - increases risk for CNS toxicity.
Give with other antituberculine drugs to prevent the development of resistant organisms.
Monitor levels periodically for symptoms of CNS toxicity.
Observe for psychotic symptoms.
Monitor CBC levels and liver function tests.
2. ETHAMBUTOL - (Etibi, Myambutol)
0.5 to 1 gm daily
Not given in children under the age of 13.
ADVERSE REACTIONS
Headache, dizziness, confusion
Optic neuritis - Causes red/green color discrimination. If this develops discontinue drug
Joint pain.
D. NURSING CONSIDERATIONS
Perform baseline visual acuity test and color discrimination test during therapy

Monitor uric acid levels and for symptoms of gout.

Give one hour before or two hours after antacids containing aluminum because they reduce absorption.
Obtain AST and ALT levels before therapy and monitor every 3-4 weeks.
Give drug with other antitubuculotics.
Monitor uric acid levels; observe patient for signs and symptoms of gout.
3. ISONIAZID -( Isotamine, Nydrazid)
Up to 300 mg daily.
Drug of choice.
Continued for 6 months to 18 months.
Not for use with children under age of 15.
Continued for 6 months up to 18 months.
F.. ADVERSE REACTIONS
Toxic encephalopathy. Seizures.
Optic neuritis
Nausea, vomiting, epigastric distress.
Hepatitis. Jaundice.
Rheumatic and lupus-like symptoms
G. NURSING CONSIDERATIONS
1. Advise patient that antacids and laxatives containing aluminum may decrease absorption. Give at least one hour
before antacids or laxatives.
Demerol may increase CNS adverse reactions and hypotension. Monitor for toxicity
If given with Rifampin monitor liver function tests. May increase risks for hepatotoxicity.
Advise that foods containing tyramine - Beer, aged cheese, chocolate, sauerkraut, soy sauce, tofu, teriyaki sauce,
avocados, eggplant, fruit - figs, oranges, raisins, plums, pineapple, prunes may cause hypertensive crisis. Advise
patient to avoid such foods. Clients who are taking INH should avoid tuna, red wine, soy sauce, and yeast extracts
because of the side effects that can occur, such as headaches and hypotension
Monitor for hepatitis and liver function tests. Severe hepatitis may develop. S/S: fever, jaundice, right
upper quadrant abdominal pain.
Advise to take drug one hour before or 2 hours after meal.
Give pyridoxine to prevent peripheral neuropathy.
Increase intake of vitamin B-6 - potatoes, bananas, beans, seeds, nuts, red meat, poultry, eggs, spinach and
fortified cereals.
Always give with another antituberculotic.
Patients receiving Isoniazid should be questioned about numbness, tingling, paraesthesias, and feeling of
heaviness in the arms and legs as this may indicate the development of peripheral neuropathy.
Should be taken on an empty stomach.
Vitamin B6 (pyridoxine) is used to prevent toxicity from isonizid.
Monitor for neurotoxicity.
4. RIFAMPIN- (Rifadin, Rimactane,Rimycin, Rofac)
Up to 600 mg daily.
Give one hour before or 2 hours after meal with full glass of water
Give with at least one other antituberculotic.
Liver abnormalities are most common side effect. Symptoms that may indicate liver dysfunction are: anorexia,
malaise, jaundice, change in stools.
If given with Isoniazid, may increase risks for hepatotoxicity.
If patient drinks alcohol this increases risks for hepatotoxicity.
NURSING CONSIDERATIONS
Monitor liver function tests and CBC
Alert patient that body fluids (sweat, tears, urine, feces) may turn orange-Red

Advise patients taking oral contraceptives, anticoagulants, oral hypoglycemic agents, or steroids that absorption
is decreased. Advise with patient taking oral contraceptives the need for alternative methods for birth control.
Give one hour before or 2 hours after a meal.
Advise against use of alcohol.
5. STREPTOMYCIN
Maximum dose 3 g/daily.
Streptomycin is also an aminoglycoside.
Second line of treatment for tuberculosis.
Causes ototoxicity and nephrotoxicity. Monitor hearing ability and renal function.
Monitor patients hearing and kidney function before starting therapy.
Causes 8th cranial nerve damage (acoustic nerve - hearing)
Use gloves when preparing drug to prevent skin irritation.
Do not use a heparinized tube; heparin is incompatible with streptomycin and other aminoglycosides.
NURSING CONSIDERATIONS
Monitor fluid intake. Fluids should be increased 2.5 to 3 liters/day.
Monitor for tinnitus, vertigo, deafness, renal function test - BUN, creatinine
If patient on Lasix or other antidiuretics monitor for ototoxicity - increases risks for ototoxicity.
Protect hands when preparing drug.
Alternate injection sites.
Monitor for signs of super-infection: Continued fever, chills, increased pulse rate.
7. Offer small frequent meals and maintain bed rest.
6. To decrease the development of drug resistance, newer drugs contain a combination of Rifampin and
Isoniazid (rifamate) or Rifampin, Isoniazid and pyrazinamid (rifater). Drug non-compliance is a major
contributing factor in the development of resistant strains of TB.
PNEUMONIA
A. Inflammatory process that produces excess fluid .
B. With pneumonia, you will hear BRONCHIAL sounds in areas of consolidation.
C. Two types of pneumonia.
Community acquired pneumonia - Often a complication of influenza.
Hospital acquired pneumonia - AKA nonsocomial pneumonia. High mortality rate, more likely to be resistant to
antibiotics.
D. SIGNS AND SYMPTOMS
Viral
Low grade fever
Nonproductive cough
WBC normal to slightly high
Less severe than bacterial pneumonia.
Bacterial
High fever
Productive cough
WBC high
More severe than viral pneumonia.
Crackles/wheezes
E. NURSING INTERVENTIONS
Administer medications as ordered: Penicillins and cephalosporins, bronchodilators, steroids. Prednisone
suppresses immunity!
Obtain sputum culture before starting antibiotics
1. Rusty, green or bloody - Pneumococcal pneumonia.
2. Yellow-Green - Bronchopneumonia.

For steroids monitor for side effects of immunosuppression, fluid retention, hyperglycemia, poor wound healing.
Steroids increase blood sugar and weaken immune system. Always taper steroids if taking chronically --> never stop
abruptly!
Administer heated and humidified oxygen.
Position high fowlers
Encourage coughing and deep breathing and suction
Teach importance of flu vaccinations
Monitor for complications
o ATELECTASIS: Collapse of lung. Diminished or absent breath sounds over affected area.
o ACUTE RESPIRATORY FAILURE (ARDS): Persistent hypoxemia. Monitor O2 levels and acid/base balance.
Prepare for intubation and mechanical ventilation (PEEP). Cardinal sign of ARDS is hypoxemia (low oxygen level in
tissues).
o SEPSIS (Bacteremia)
o ARDS (fluids in alveoli), DIC (disseminated intravascular coagulaton)
are always secondary to something else (another disease process).
Provide rest periods.
Increase fluids, 3-4 L/day.
Diet: High calorie, high protein.
With pneumonia, fever and chills are usually present. For the elderly
confusion is often present.
COPD
COPD is a group of diseases that results in persistent obstruction of the bronchial airflow.
Disease include:
Emphysema
Stimulus to breathe is low partial pressure of arterial oxygen (PaO2). PaO2 measures oxygen in the blood.
Characterized by loss of lung elasticity and hyperinflation of lung tissue.
Asthma
A chronic inflammatory disorder of the airways.
Characterized by airflow obstruction and airway hyper-responsiveness to various stimuli.
Bronchiectasis
Chronic dilation of the bronchi and bronchioles.
Infection destroys the bronchial mucosa which is replaced by fibrous scar tissue.
Chronic bronchitis
Chronic inflammation of the lower respiratory tract characterized by excessive mucous section, cough, and
dyspnea associated with recurrent infections of the lower respiratory tract.
Excessive bronchial mucous production causes chronic or recurrent productive cough.
SIGNS AND SYMPTOMS
Productive cough and sputum production lasting at least 3 months a year for 2 successive years.
Barrel chest - due to air trapping with diaphragmatic flattening.
Exertional dyspnea.
D. Wheezes, crackles
E. Use of accessory muscles.
COPD is chronic, pneumonia is acute. Emphysema and bronchitis are
both COPD.
In COPD patients, the baroreceptors that detect the CO2 level are
destroyed. Therefore, O2 level must be low because high O2 concentration
blows the patients stimulus for breathing.

NURSING INTERVENTIONS

Position client for maximum ventilation - high fowlers.

Administer medications:
Short acting Beta2 agonists: Albuterol (proventil, ventolin) provide rapid relief.
If patient is also using a corticosteroid inhaler, instruct them to use the
Bronchodilator first and then wait 5 minutes before using the corticosteroid. This lets the bronchodilator
open the air passages for maximum effectiveness.
Anti-inflammatories: Decreases airway inflammation (Corticosteroids - Fluticasone (flovent) and prednisone).
Monitor for serious side effects - immunosuppression, fluid retention, hyperglycemia, poor wound healing.
Administer heated and humidified oxygen. Monitor for skin breakdown.
Instruct patient on pursed lip breathing and diaphragmatic breathing.
Diet: High in protein, carbohydrates, vitamin C, calories - small frequent meals.
Encourage/Force fluids - 3000 ml/day.
Oxygen therapy - 2-3 liters/minute.
o DO NOT GIVE OXYGEN AT 100% TO PATIENTS WITH COPD because you can depress the respiratory
center drive. In COPD patients the drive to breathe is hypoxemia.
Nebulizer treatments should be given before meals to improve lung ventilation and reduce fatigue that
accompanies eating.
Reinforce pursed lip breathing to prolong expiration and to increase airway pressure.
PNEUMOTHORAX
A. Collapse of the lung due to loss of negative intrapleural pressure.
B. Air accumulation in the pleural space.
C. SIGNS AND SYMPTOMS
Dyspnea. Tachycardia, tachypnea
Subcutaneous emphysema
Tracheal deviation to the unaffected side.
Diminished breath sounds on the affected side and tension pneumothorax.
Unequal chest expansion (is reduced on the affected side).
Crepitus over the chest.
Restlessness, anxiety
Unequal chest expansion
Signs of mediastinal shift.
D. MANAGEMENT
O2 Therapy
Needle decompression (tension pneumothorax).
Insertion of chest tube to water seal drainage.
Laboratory ABG values
Position high Fowlers
Analgesic: Tylox
Insertion of large bore needle into the 2nd intercostal space may be done to alleviate pressure before chest tube
insertion with a tension pneumothorax.
E. NURSING INTERVENTIONS
Assess respiratory status
Administer oxygen
Keep patient in high Fowlers
Monitor and record chest tube drainage, air leak, or subcutaneous emphysema, and labs.
Document ventilator settings every hour.
Monitor ABGs, V/S, SaO2
F. MEDICATIONS
1. Lorazepam (Ativan) & Midazolam (Versed)
Keep emergency oxygen & resuscitation equipment available.

Monitor respirations every 5 to 15 minutes and before each IV dose.

Refrigerate intact vials and keep from sunlight.
Monitor for hypoventilation and hypotension
LARYNGECTOMY
A. Temporary or permanent artificial airway.
B. Partial laryngectomy: Surgical excision of a lesion on one vocal cord.
C. Total laryngectomy: Surgical removal of the larynx, hyoid bone, and tracheal rings with closure of the pharynx
and formation of a permanent tracheostomy.
D. NURSING INTERVENTIONS
Establish methods of communication: Writing, call bell, magic slate, and picture board.
Maintain aseptic conditions when suctioning or cleaning tracheostomy.
Advise clients with total laryngectomies they will lose their natural voice.
Keep tracheostomy tube obturator at head of bed for reinsertion in case of accidental dislodgement.
Encourage the patient to express their feelings about changes in their body and loss of their voice.
Assess pain level, administer medications.
Observe for hemorrhage.
Keep a spare unused tracheostomy tube at bedside for emergency use.
Encourage turning, coughing, deep breathing and use of incentive spirometer.
Keep patient in semi-Fowlers
Assess color, amount, and consistency of sputum.
Demonstrate ways to prevent debris from entering the stoma.
Use thickened liquids, cut food into small pieces, and provide food that can be formed into a bolus.
Trach balloon should be inflated any time there is any risk of pt aspirating (ie eating, increased secretions, when
getting tube feeds, on vent, and 30 min after eating).
When changing trach ties, remove old ties with non-sterile gloves, then put on sterile gloves to apply clean ties.
If pt coughs/respiratory distress while putting in NG, pull back and wait until coughing/respiratory. Distress is
resolved then attempt again. Remember pt should be in High Fowlers, when tube reaches oropharynx., neck must be
flexed to cover airway and swallow sips of h20 to facilitate tube).
If a tracheostomy tube falls out, replace it immediately (maintain airway) then check for breath sounds.
RADICAL NECK DISSECTION
1. Removal of all tissue under the skin from the ramus of the jaw down to the clavicle, from midline back to the
angle of the jaw.
2. Surgical excision of the sternocleidomastoid and omohyoid muscles, muscles of the floor of the mouth,
submaxillary gland, internal jugular vein, external carotid artery, and cervical chain of lymph nodes, in addition to
laryngectomy.
NURSING INTERVENTIONS
Assess for respiratory compromise dyspnea, cyanosis, edema, dysphagia, hoarseness.
Auscultate for decreased breath sounds, crackles, and wheezes.
In the immediate post-op state, Auscultate over the trachea to assess for stridor indicative of edema.
Assess vital signs, s/s of infection. Observe patient for hemorrhage.
Keep emergency suctioning and airway equipment at bedside during meals.
Ask if patient would prefer privacy during meals.
Place call bell and other articles that patient may need within easy access.
Observe for lower facial paralysis which may indicate facial nerve injury.
Watch for shoulder dysfunction which may occur after surgery.
Keep patient high Fowlers.
Advise patient against swimming, showers and using aerosol sprays.
LUNG RESECTION
A. Lobectomy Surgical removal of one lobe of the lung

B. Wedge resection surgical removal of a wedge-shaped section of a lobe.

C. Pneumonectomy Surgical removal of a lung.
D. NURSING INTERVENTIONS
Maintain patients positioning.
1. Pneumonectomy: On back or side of surgery until stabilized.
2. Lobectomy or wedge resection: On back or side opposite surgery.
Assess chest tube insertion for subcutaneous air & drainage.
Reinforce turn, cough, and deep breathing, use of incentive spirometer.
Provide suction, chest physiotherapy and postural drainage.
Pneumonectomy usually does have a chest tube in order to let fluid collect in the lung space.
Assess pain level, administer medication, and check effectiveness.
Administer O2 and maintain ET tube to ventilator.
Monitor V/S, I & O, labs, ECG.
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, shock lung)
A. Respiratory failure that occurs in critically ill patients.
B. Persistent hypoxemia. Monitor O2 levels and acid/base balance. Prepare for intubation and mechanical ventilation
(PEEP). Cardinal sign of ARDS is hypoxemia (low oxygen level in tissues).
C. Lung injury causes platelets to aggregate. Alveoli collapse impairing gas exchange.
D. Oxygen and carbon dioxide levels in the blood decrease
E. Metabolic acidosis results.
F. SIGNS AND SYMPTOMS
Dyspnea, tachypnea, tachycardia, cyanosis, and hypotension.
Intercostal and substernal retractions
Cough
Crackles/rhonchi
Anxiety
Restlessness, altered LOC
Decreased breath sounds
G. NURSING INTERVENTIONS
Oxygen therapy. Intubation and mechanical ventilation using PEEP (positive end expiratory pressure). Monitor
mechanical ventilation.
Monitor V/S, I&O, CVP, ECG, etc.
DIET: RESTRICT FLUID INTAKE
Position: High Fowlers
Activity: Bed rest
DVT prophylaxis
Administer TPN
Weigh patient daily
Allow patient to express feelings.
H. MEDICATIONS
Antibiotics: Amoxicillin (Amoxil), ampicillin (Omnipen)
Analgesics: Morphine
Diuretics: Lasix (furosemide), Edecrin (Ethacrynic acid)
Anticoagulant: Heparin
Steroids: Hydrocortisone (Solu-Cortef), solu-medrol
Antacid: Aluminum hydroxide gel (AmternaGel)
Sedative: Lorazepam (Ativan)
Neuromuscular blocking agents: Pancuronium (Pavulon) Vecuronium (Norcuron)
Mucosal barrier fortifier: Sucralfate (Carafate).
BRONCHIECTASIS
A. Chronic cough that produces copious, foul-smelling, mucopurulent sections, possibly totaling several cupfuls a

day.
B. Is marked by chronic abnormal dilation of bronchi (large air passages of the lungs) and destruction of the
bronchial walls.
C. It is an irreversible condition.
D. SIGNS/SYMPTOMS
Chronic persistent cough that produces copious amounts of purulent foul smelling sputum.
Course crackles during inspiration.
Dyspnea, wheezes.
Weight loss.
Recurrent fever and bouts of pulmonary infection.
Intermittent hemoptysis and breathlessness.
Finger clubbing.
E. NURSING INTERVENTIONS
Perform chest physiotherapy including postural drainage and chest percussion several times a day. BEST TO
PERFORM IN EARLY AM or just before bedtime.
Encourage increased fluids.
Instruct patient to avoid noxious fumes, dust, smoke and other pulmonary irritants
Teach patient to monitor sputum. Report if change in quantity or character occurs.
Encourage regular dental care because copious sputum may affect dentition.
Administer medications: Antibiotics and bronchodilators.
ASTHMA
A. A chronic reactive airway disorder that causes episodic, reversible airway obstruction with bronchospasm,
increased mucous secretion and mucosal edema.
B. An airway disorder characterized by airflow obstruction and airway hyperresponsiveness to various stimuli.
C. Two forms of asthma
1. Extrinsic (atopic): caused by sensitivity to a specific external allergen (pollen, dust, dander, food additives).
2. Intrinsic (nonatopic): Caused by reaction to internal non-allergic factors. (Endocrine changes, noxious fumes,
respiratory infections, stress, humidity/temp)
D. SIGNS AND SYMPTOMS
Absent or diminished breath sounds during severe obstruction.
Chest tightness
Dyspnea, tachypnea, tachycardia, prolonged expiration.
Productive cough with thick mucus.
Lack of symptoms between attacks.
Wheezes primarily on expiration but also sometimes on inspiration.
E. NURSING INTERVENTIONS
Take appropriate measures to maintain airway, relieve bronchoconstriction.
Administer low flow humidified O2 to reduce inflammation, ease breathing and increase SaO2.
Administer medications
1. Bronchodilators: Terbutaline (Brethine), Aminophylline, Theophylline (Theo-Dur) Theophylline: therapeutic drug
level: 10-20. via a metered dose inhaler
2. Steroids: hydrocortisone (Solu-Cortef), methylprednisolone (Solu-Medrol)
3. Beta-adrenergic drugs: Epinephrine (Adrenalin), salmeterol (Serevent)
4. Antacids
5. Antibiotics
Auscultate lungs for improved breath sounds and effectiveness of therapy.
Activity as tolerated.
Keep patient in high Fowlers.
Encourage fluids.
Monitor and record color, amount, and consistency of sputum.
Monitor V/S. Tachycardia may indicate worsening asthma or drug toxicity.

Teach proper use of inhaler and taking medications correctly.

Teach pursed lip & diaphragmatic breathing.
Increase fluid intake to 3 qts (3L) a day.
FLAIL CHEST
A. Flail Chest= Fracture of 2 or more adjacent ribs with paradoxical movement of chest during respiration.
B. Loss of stability of the chest wall as a result of multiple rib fractures, or combined rib and sternum fractures.
C. During respiration, the detached part of the chest will be pulled in on respiration and blown out on expiration
(paradoxical movement).
D. It is accompanied by severe respiratory distress.
E. Associated with lung contusion, lung laceration, and diffuse alveolar damage.
F. SIGNS AND SYMPTOMS
Paradoxical movement of the chest
Increased respiratory effort, pain on inspiration
Cyanosis
Dyspnea
G. NURSING INTERVENTIONS
Stabilize the flail portion of the chest with hands, apply pressure dressing and turn on injured side or place a 10
lb sandbag on flail portion.
Prepare for ET insertion and mechanical ventilation.
Position semi-Fowlers unless patient requires shock position.
Analgesic: Morphine.
Mechanical ventilation using positive pressure.
TENSION PNEUMOTHORAX
A. Occurs when air enters the pleural space during inspiration and is trapped there.
B. The increase in pressure compresses the blood vessels and limits venous return, leading to a decrease in cardiac
output.
C. Relief of tension pneumothorax is considered as a medical emergency.
D. Can be converted to a simple pneumothorax by insertion of a large bore needle into the pleural space which
relieves the pressure and vents the air trapped to the outside.
E. SIGNS AND SYMPTOMS
Air hunger
Agitation, hypotension, and cyanosis
Asymmetrical lung expansion and tracheal deviation to the affected side.
Cyanosis.
Subcutaneous emphysema.
Jugular vein distention.
F. Immediate thoracentesis is done to relieve positive pressure or tension in the lung.
CARDIAC TAMPONADE
A. Compression of the heart as a result of fluid within the pericardial sac that is usually caused by blunt or
penetrating trauma to the chest.
B. SIGNS AND SYMPTOMS
Falling blood pressure
Distended jugular veins elevated CVP.
Muffled heart sounds from impaired diastolic filling of the heart.
Pulsus paradoxus (audible blood pressure fluctuation with respiration). Systolic blood pressure drops and
fluctuates with respiration.
Dyspnea, cyanosis, and shock.
Patient may be anxious, confused and restless.
Dyspnea, tachypnea, and precordial pain.
C. BECKS TRIAD - 3 Ds of cardiac tamponade
D = DISTANT HEART SOUND

D = DECREASED BLOOD PRESSURE

D = DISTENDED JUGULAR VEIN
D. TREATMENT
Thoracotomy
Pericardiocentesis needle aspiration of fluid from the pericardium.
COR PULMONALE
A. Is the enlargement of the right ventricle that results from diseases affecting the function or the structure of
the lungs. It is heart disease caused by lung disease.
B. A condition that deprives the lungs of oxygen.
C. SIGNS AND SYMPTOMS
Increasing dyspnea and fatigue, orthopnea, paroxysmal nocturnal dyspnea.
Distended jugular veins, peripheral edema, hepatomegaly.
Bibasilar crackles, split second heart sound on auscultation.
Edema of the feet and legs.
Ascites.
Chronic productive cough.
D. NURSING INTERVENTIONS
Diet: Low salt with restricted fluid intake to prevent fluid retention. Provide small, frequent feedings rather than
three heavy meals.
Limit patients fluid intake to 1-2 qt (1-2 l/day).
Monitor serum potassium levels. Low levels can increase risk of toxicity.
Teach the patient to take radial pulse before taking a cardiac glycoside & to report any changes.
Monitor Digoxin levels to prevent symptoms of cardiac glycoside toxicity (anorexia, nausea, vomiting, and yellow
halos around visual images).
Provide meticulous respiratory care, and teach pursed lip breathing.
Monitor ABG levels.
Avoid CNS depressants (opiods, hypnotics).
E. MEDICATIONS
Diuretics to lower PAP by reducing total blood volume and excess fluid in lungs. Lasix (furosemide)
Angiotension converting enzyme inhibitor captopril (Capoten)
Calcium channel blockers: diltiazem (Cardizem)
Vasodilators: Diazoxide (Hyperstat), hydralazine (Apresoline), Nitroprusside (Nitropress),
PLEURAL EFFUSION & EMPYEMA
A. Pleural effusion is an excess of fluid in the pleural space.
B. Empyema is the accumulation of pus and necrotic tissue in the pleural space.
C. Pleural effusion is almost always secondary to other diseases.
D. Empyema is usually associated with infection in the pleural space.
E. SIGNS AND SYMPTOMS
Dyspnea, pleuritic chest pain, dry cough.
Dullness or flatness to percussion (over areas of fluid) with decreased or absent breath sounds. Decreased chest
motion.
Pleural friction rub.
Tachycardia and tachypnea.
F. NURSING INTERVENTIONS
Administer oxygen as ordered.
Provide meticulous chest tube care using sterile technique for empyema. Record amount, color, and consistency of
tube drainage.
Observe patients breathing pattern, O2 sats, and other vital signs.
Ensure chest tube patency by watching for bubbles in the underwater seal chamber to prevent respiratory
distress resulting from chest tube obstruction.
PNEUMOCYSTIS CARINII PNEUMONIA

A. Part of the normal flora in most healthy people.

B. Pneumocystis carinii pneumonia (PCP) is an opportunistic infection strongly associated with HIV infection. Also
seen in other immunocompromised patients leukemic patients, cancer, organ transplants, and lymphoma.
C. SIGNS AND SYMPTOMS
Generalized fatigue
Low-grade, intermittent fever
Nonproductive cough
Shortness of breath, tachypnea. Progresses to intercostal retractions, nasal flaring and cyanosis
Weight loss
Insidious onset
D. NURSING INTERVENTIONS
Assess respiratory status frequently and monitor ABG levels q4h.
O2 therapy prn and ambulate. Deep breathing and incentive spirometry to facilitate effective gas exchange.
Administer medications
A. Antipyretics as required.
B. Antibiotics: Co-trimoxamole (Bactrim), Clindomycin (Cleocin) with primoquine. Pentamidine.
1. If patient is receiving Bactrim watch for nausea, vomiting, rash, bone marrow suppression, thrush, fever,
hepatotoxicity and anaphylaxis.
2. Never give pentamidine IM because it can cause pain and sterile abscesses. Administer the IV drug form slowly
over 60 minutes to reduce the risk of hypotension.
3. If patient is receiving pentamidine monitor for hypotension, cardiac arrhythmias, dizziness, azotemia (abnormal
increase in urea in blood), hypocalcemia and hepatic disturbances. These measures detect problems early to avoid
crisis.
Diet: High calorie, protein rich diet. Offer small frequent meals. Allow ample time for meals to reduce anxiety.
Provide a relaxing environment, eliminate excessive environmental stimuli.

NEUROSENSORY SYSTEM
PARKINSONS DISEASE
1. A progressive degenerative disease of the CNS system associated with Dopamine deficiency.
2. The lack of Dopamine impairs the area of the brain responsible for control of voluntary movement.
3. SIGNS AND SYMPTOMS
Pill rolling tremors at rest
Mask-like facial expression.
Shuffling gait, dyskinesia, cogwheel rigidity, stopped posture.
Small handwriting.
Bradykinesia (slowness of movement)
Nonexistent arm swing.
4.MANAGEMENT
A. Anticholinergics: To reduce transmission of cholinergic pathways. Effective in controlling tremor but causes confusion and
hallucinations.
Are more likely to cause mental problems in older patients.
Are contraindicated in patients with glaucoma.
B.DRUGS: Artane,
A. Congentin (benztropine) Toxic psychosis. Advise patient to avoid hot weather because of drug induced
lack of sweating may cause overheating.
Never stop drug abruptly. Reduce dosage gradually.
B. Amantadine (symmetrel)
Increases the release of dopamine in the brain.
Monitor for mental status changes and suicidal tendencies. Drug can worsen mental problems in patients
with mental disorders.

C. Levodopa (larodopa)
Used when other drugs cannot adequately relieve symptoms.
Use cautiously in patients with heart disease, asthma, emphysema, glaucoma.
Monitor for psychiatric disturbances: Dementia, hallucinations, suicide ideation, mood changes, delirium, depression.
May cause blepharospasm eye twitching. Early sign of toxicity.
Antacids may decrease absorption. Give antacids 1 hour before or 2 hours after levodopa.
D. Pyridoxine (vitamin B6) may decrease the effectiveness of levodopa. Teach patient to avoid vitamins and foods high in B6.
Advise patient to take with food to lessen GI symptoms. Avoid high protein foods.
Advise patient and caregivers that multivitamins, fortified cereals and certain over the counter drugs may contain vitamin
B6.
Levodopa-carbidopa (sinemet) (Parcopa)
Drug combination
May cause suicidal tendencies.
Do not give with iron salts. Give iron one hour before or 2 hours after sinemet.
Do not give with MAO inhibitors may cause severe hypertension.
Teach patient to avoid foods high in protein. Dont give levodopa with high protein foods.
If patient takes levodopa, stop drug at least 8 hours before starting levodopa-carbidopa.
E. NURSING INTERVENTIONS
Encourage patient to participate in daily exercise, stretching exercises.
Instruct patient to use a broad-based gait. Reinforce gait training to improve mobility.
Have patient make a conscious effort to swing arms while walking.
Instruct patient to chew slowly.
Monitor V/S, monitor for hypotension.
Instruct patient to rise slowly out of bed and chair.
TEACH PATIENT TO AVOID VITAMIN B6 PREPARATIONS AND FOODS HIGH IN B6. Eat high fiber foods.
Teach patient to adhere to medication regimen and to not stop taking medications abruptly.
Teach client and family for malnutrition, fall precautions and environmental hazards.
MULTIPLE SCLEROSIS
1. A progressive disease that destroys myelin in the neurons of the brain and spinal cord.
2. Degeneration of the myelin sheath results in patches of sclerotic tissue and impairs the ability of the
nervous system to conduct motor nerve impulses.
3. There is no known cure for the disease.
4. Is characterized by exacerbations and remissions
5. SIGNS AND SYMPTOMS
Fatigue and weakness.
Abnormal reflexes absent or exaggerated.
Vision disturbances: Double vision, blurred, optic neuritis and nystagmus.
Scanning speech
Urinary and bowel disturbances. Frequency, urgency, incontinence. Frequent urinary infections.
Intolerance to heat.
Mood swings, irritability.
Intention tremor
Inability to sense of gauge body position.
6. MANAGEMENT
Overall goal of care is to maintain as much independent function as possible.
Include rest periods to prevent fatigue which exacerbates the symptoms.
Maintain a fluid intake of 2,000 ml/day to maintain bladder and bowel function and to prevent impaction
and urinary tract infection.
Avoid sources of infection: Illness can act as a stressor and trigger an exacerbation.
Advise patient on avoiding extreme temperatures which exacerbates acteric.
7. MEDICATIONS:
Corticosteroids are used to decrease inflammation, shorten duration of relapse or exacerbation

 Prednisone (Deltasone)
A. Cause the kidney to retain sodium and water while promoting potassium loss.
B. Can cause edema and hypokalemia.
C. Monitor for hyperglycemia, hypokalemia, carbohydrate intolerance, growth suppression in children, delayed
wound healing, acute adrenal insufficiency.
D. Advise against abrupt withdrawal of drug may cause rebound inflammation, fatigue, weakness, dizziness,
lethargy, depression. After prolonged use, abrupt stoppage can be fatal.
E. If taking with anticoagulants monitor PT and INR.
F. Use cautiously in patient with GI ulcer, renal disease, diabetes, hypertension, ulcerative colitis, recent
MI, myasthenia gravis.
G. Give with food.
H. Diabetic may need insulin dose increased.
I. Monitor for infections. Decreases immunity.
Interferon Beta-1a (Avonex, Rebif) & Beta-1b (betaseron)
A. Beta interferons are derived from fibroblasts (connective tissue cells)
B. Monitor for blood toxicity- WBC, platelet count, liver function test,
C. Monitor patient closely for depression and suicidal ideation.
D. Use drug as soon as possible but must be used within 6 hours of reconstituting. Store at 36-46 degrees.
Do not freeze.
E. Rotate sites of injection.
F. Inform patient that drug causes flu-like symptoms fever, fatigue, muscle fatigue, aches, headaches, chills and joint pain
occur as a side effect.
G. Advise patient to use sunscreen and avoid sun exposure.
H. Beta-1b can cause serious liver damage including liver failure requiring transplant. Monitor liver function
test.
I. Inject immediately after preparing.
J. Advise patient to report signs of tissue death.
CYCLOPHOSPHAMIDE (Cycloblastin, Cytoxan, Endoxan, Neosar, Procytox) SEE ONCOLOGY FOR DRUG
MYASTHENIA GRAVIS
1. Myasthenia gravis means grave muscle weakness.
2. A chronic progressive disorder of the peripheral nervous system affecting transmission of nerve impulses
to voluntary muscles. Causes muscle weakness and fatigue that increases with exertion and improves with
rest. Eventually leads to fatigue without relief from rest.
3. Onset is usually slow but can be precipitated by emotional stress, hormonal disturbances, infection,
vaccinations, trauma, surgery, temperature extremes, excessive exercise, etc.
4. Myasthenia Gravis: worsens with exercise and improves with rest.
5. Myesthenia gravis is caused by a disorder in the transmission of impulses from nerve to muscle cell.
6. SIGNS AND SYMPTOMS
Extreme muscular weakness and fatigue that decreases with rest.
Vision disturbances: Diplopia and ptosis from ocular weakness.
Facial muscle weakness that causes a masklike appearance.
Dysarthria and dysphagia.
Hanging jaw.
Bobbing motion of the head.
Respiratory failure.
7.DIAGNOSIS: Tensilon test. IV administration of Tensilon which allows acetylcholine to bind with its receptors which
improves the symptoms of myasthenia gravis.
Tensilon (edrophonium) also differentiates myasthenic gravis crisis from cholinergic crisis.
In cholinergic crisis, symptoms worsen with tensilon.
Tensilon (edrophonium) is used only for diagnostic purposes to determine whether muscular weakness is due

to worsening of the disease (myasthenic crisis) or to overmedication (cholinergic crisis)

When edrophonium is used, keep suction equipment, oxygen, mechanical ventilation and emergency drugs
atropine at bedside
8. TREATMENT:
A. ANTI-CHOLINESTERASES:
Neostigmin (prostigmin), Pyridostigmin (Mestinon): Counteracts fatigue and muscle weakness. Promotes
muscular contractions
Anticholinesterase drugs are not effective during a myasthenic crisis so they are discontinued until
respiratory function improves.
Take with food to decrease GI symptoms.
Advise patient to eat within 30 minutes of taking drug to strengthen chewing and reduce aspiration risk.
Advise patient to take drug at same time every day, not to miss a dose.
Schedule patients diagnostic studies around medication schedule. If patient must be off unit when drugs are to be
administered, take the medication to the patient
Observe for nausea, vomiting, cramps, facial muscle twitching and dyspnea may indicate toxicity.
Avoid morphine and its derivatives, curare, quinine, mycin antibiotics and drugs containing magnesium. These reduce
cholinergic effects.
Corticosteroids reduce the effects of drug, monitor patient closely.
1. IMMUNOSUPPRESSANTS (Corticosteroids)
A. Azathioprine (Imuran)
Decrease dosage of Imuran if patient is also taking Allopurinol because it inactivates Imuran.
Watch for clay-colored stools, dark urine, jaundice HEPATOTOXICITY
Monitor liver function test, WBC and CBC.
Give after meals to minimize GI effects.
Avoid giving IM injections if platelet count below 100,000.
Warn patients to report even mild infections cold, fever, sore throat, malaise because drug is a potent
immunosuppressant.
Warn patient hair may lose hair and thin.
Cyclosphoshamide (Cytoxan) SEE ONCOLOGY FOR MORE
Dont give drug at bedtime; infrequent urination during the night may increase possibility of cystitis. Test
urine for blood.. Hydrate patients before and after dose. May cause hemorrhagic cystitis.
Encourage patient to urinate every 1-2 hours while awake and drink at least 3 liters of fluid/daily
Advise patient not to take tablet form before bedtime
2. NURSING MANAGEMENT
Maintain patients diet: High calorie, soft foods. Encourage small frequent meals. Assess clients gag and
swallow reflexes before each meal.
Administer medications before meals to maximize muscles for swallowing.
Determines patients activity tolerance.
Teach patient to avoid exposure to infections, especially respiratory.
Provide eye care: Instill artificial tears, use patch over eye for double vision. Sunglasses to protect eyes
from too much sun.
Instruct patient to avoid extremes of hot or cold, exposure to infections, emotional stress and OTC drugs
which exacerbate symptoms. Instruct patient to avoid taking medication with fruit, coffee, tomato juice or
other medications.
Teach patient to recognize symptoms of crisis

MYASTHENIA CRISIS Under-medication

A. Symptoms of myasthenia gravis are worsened.
B. Extreme fatigue.
C. Respiratory distress.
D. Symptoms improve with tensilon

CHOLINERGIC CRISIS Overmedication

A. Respiratory distress, needs mechanical ventilation
B. Symptoms worsen with tensilon.
C. Symptoms improve with administration of anticholinergic medication Atropine.
D. NEVER LEAVE PATIENT ALONE DURING A CRISIS

Anyone up for some pediatric info for NCLEX?

PEDIATRICS
Growth and development
1. Motor skills progress in a proximal to distal manner.
2. NEONATE (Birth to 28 days):
A. Vital signs:
1. Pulse: 110 - 160 BPM count apical for one minute
2. Respiratory rate: 32 - 60 BPM. Neonate is an obligate nose breather.
3. Blood pressure: 82/46.
4. Temperature regulation is altered because of poorly developed sweating and shivering mechanisms.
A. Limit exposure time during baths.
B. When the neonate is wet or cold cover his head.
5. Mortality rate is higher in the neonatal period than in any other growth stage.
B. Head and chest circumference are relatively equal. Head circumference may be up to greater than the chest circumference.
C. Head length is one-fourth total body length.
D. Brain growth depends on myelinization.
E. All behavior is under reflex control. Extremities are flexed.
1. Moro reflex- Elicited by striking a flat surface the infant is lying on. The reflex of abducting extremities and fanning fingers when a
sound is heard should be gone by 3-4 months. Strongest at 2 months
2. Rooting - When the cheek of the newborn is stroked, the newborn will turn his head in the direction of the stroke.
3. Tonic neck - While the newborn lies supine, his head is turned causing the extremities on the same side to straighten and those on
the opposite side to flex.
4. Babinski - When the sole of the foot on the side of the newborn small toe is stroked upward, the toes will fan upward and out
5. Plantar grasp - Infants toes will curl downward when sole of foot is touched.
6. Startle - A loud noise such as a hand clap will elicit the newborn to abduct his arms and flex his elbows.
F. Hearing and touch are well developed; a hearing screening is recommended.
G. The neonate is stimulated by being held or rocked; listening to music and watching a black-white mobile.
H. While laying prone, the neonate can lift his head.
3. INFANCY: Age 1 month to 1 year.
A. Period of rapid growth in which the head, especially the brain, grows faster than other tissues.
B. According to Erickson, the infant is in the critical stage of Trust vs. mistrust. It is important for the child to develop a trusting
relationship with a consistent primary caregiver. Interference may cause failure the thrive.
C. Birth weight doubles in 6 months.
D. Birth weight triples in one year.
E. Posterior fontanel closes by 2-3 months.
F. Anterior fontanel remains open until 18 months.
G. Height increases by 50% in 1 year.
H. Head circumference > than chest circumference until 1 year.
I. Tooth eruption starts at 4 months -> 1 tooth per month.
J. AGES 1 TO 4 MONTHS
1. Instinctual smile appears at age 3 months. The social smile is the infants first social response. The social smile initiates social
relationships, indicates memory traces, and signals the beginning of thought processes.
2. The infant develops binocular vision; the eyes can follow an object 180 degrees and any intermittent strabismus should be resolved
by age 4 months.
3. The infant reaches out voluntarily but uncoordinatedly.
4. At age 4 months the infant laughs in response to environment.
5. Recognizes parents voices.
6. Explores his feet.
7. Appropriate toys: Music box, mobile, mirror.
K. AGES 5-6 MONTHS
1. Birth weight doubles.
2. Can sleep through the night with 1-2 naps a day.

3. Lower central incisors appear first. Results in ed drooling and irritability.

4. Rolls over from stomach to back.
5. Infant cries when parents leave - a normal sign of attachment. Exhibits stranger anxiety.
6. Can transfer toys from one hand to another
7. Exhibits comforting habits - sucks thumb, rubs his ears, holds a blanket or stuffed toy.
A. All these symbolize parents and security.
B. Thumb sucking in infancy doesnt result in malocclusion of permanent teeth.
8. Appropriate toys: Bright toys, soft toys, rattle - THINK SAFETY.
L. AGES 7 - 9 MONTHS
1. Sits alone without assistance
2. Creeps on his hands and knees with his belly off of the floor.
3. Infant stands and stays up by grasping for support.
4. Develops a pincer grasp; places everything in his mouth - ed risk of aspiration.
5. Self-feeds crackers; the infant whos physically and emotionally ready can begin to be weaned to a cup.
6. Likes to look at self in mirror.
7. Develops object permanence and searches for objects outside his perceptual field.
8. Understands the word NO; discipline can begin. Cries when reprimanded.
9. Can verbalize consonants but speaks no intelligible words. 10. Appropriate toys: Peek-a-boo, cloth toys.
M. AGES 10 - 12 MONTHS
1. Birth weight triples and birth length increases about 50%.
2. Imitative behaviors.
3. Infant cruises (takes steps while holding on) at age 10 months, walks with support at 11 months, and stands alone and takes his first
steps at 12 months.
4. Infant claps his hands, waves bye-bye and enjoys rhythm games.
5. Enjoys books and toys to build with and knock over.
6. Cooperates when dressed.
7. Can say Mama/dada and two syllable words.
8. Shows jealousy.
9. Infant explores everything by feeling, pushing, turning, pulling, biting, smelling, and testing for sound.
10. Appropriate toys: Push toys, large ball, large blocks.
N. NUTRITION
1. Introduce foods in this sequence
A. Breast milk or iron-fortified formula: According to AAP (American Academy of Pediatrics) they recommend breast feeding
exclusively for the first 4-6 months of life and then in combination with infant foods until age 1.
1. Give breast fed infants iron supplements after age 4 months because iron received before birth is depleted.
2. Breast milk is a rich source of linoleum acid (essential fatty acid) and cholesterol which are needed for brain development.
3. Contains immune factors that protect infants from infection.
B. Dont give solid foods for the first 6 months
1. Before age 6 months, the GI tract tolerates solid food poorly.
2. Because of strong extrusion reflex, the infant pushes food out of his mouth.
3. The risk of food allergy development may increase.
C. Provide rice cereal as the first solid food followed by any other cereal except wheat.
D. Give yellow or green vegetables next.
E. Provide no citrus fruits followed by citrus fruits after age 6 months.
F. Give infants teething biscuits during teething period.
G. Provide food with sufficient protein such as meat, after age 6 months.
H. After 12 months, switch from formula to regular WHOLE milk.
1. Dont give skim milk because fatty acids are needed for myelinization.
2. Whole milk should be continued until age 2 as recommended by the AAP.
I. RULES FOR FEEDING
1. Dont prop up baby bottle - s risk of aspiration & ear infections.
2. Dont put food or cereal in a baby bottle.
3. Introduce one new food at a time; wait 4-7 days before introducing new food to determine infants tolerance to it and the potential
for allergy.
O. SAFETY GUIDELINES
1. Place infants supine for sleep to decrease the risk of sudden infant death syndrome.
2. Keep crib rails up at all times, keep away from windows and curtain cords. Crib slats should not be more than 2 apart with mattress
firmly against its rails to prevent infant falling in-between mattress and slats.
3. Use car seats properly - keep infant placed facing back of back seat.
4. Never leave infant unattended on dressing table or any other high place.
5. Dont warm formula or breast milk in microwave. Defrosting in microwave may destroy its immune factors. Formula/food should
be lukewarm.

6. Insert safety plugs in wall outlets

7. Use gates along stairways.
8. Keep soft objects and loose bedding out of the crib. Pillows, quilts, sheepskins and comforters should be kept out of infants
sleeping environment.
9. Avoid overheating; infant should be lightly clothed for sleep.
10. ALWAYS support infants head.
11. Check temperature of bath water - should be 90-100 degrees.
P. TODDLER (Ages 1 to 3)
1. Vital signs: Pulse 100 BPM
Respiratory rate: 26 BPM
Blood pressure: 99/64
2. Period of slow growth with a weight gain of 4-6 lbs per year. Normally weighs four times birth weight.
3. Anterior fontanel closes between ages 12 and 18 months.
4. The toddler is egocentric.
5. Follows parents wherever they go.
A. Start playing peek-a-boo to develop trust.
B. Progress to playing hide and seek to reinforce the idea that his parents will return.
6. Separation anxiety arises.
A. The toddler sees bedtime as desertion.
B. Develops a fear of the dark. Nightmares begin around 2-3.
C. Separation anxiety demonstrates closeness between the toddler & his parents.
D. The parent who is leaving should say so and should promise to return.
1. Parent should leave a personal item with the toddler.
2. Prepare the parents for the toddlers reaction, and explain that this process promotes trust.
E. According to Erickson, this is the critical stage of AUTONOMY (self control & will power) VS SHAME. The child develops a
sense of independence and should be allowed to explore the environment with the encouragement of the primary caregiver. Temper
tantrums, negativism, and disciplinary problems are the hallmarks of this age group as the child learns to control his environment and
express his will. The child should be taught to tolerate frustration through socialization and proper toilet training.
1. According to Freud, toddlers are egocentric and possessive and struggle with holding on and letting go behaviors (ANAL STAGE).
2. Toddlers usually begin to imitate sex role behavior.
3. Piaget: Sensorimotor stage the child enters the pre-operational stage in which he begins using a trial and error method of thinking
and reasoning.
F. The toddler may engage in solitary play and have little interaction with others, this progresses to parallel play (toddler plays alongside but not with other children.
G. To promote development of autonomy, allow the toddler to perform tasks independently.
H. Toddler understands object permanence.
I. Discipline during this stage should be a demonstration of love, not anger. The toddler needs limits set on unacceptable demands,
such limits offer security. He should be praised liberally, but only when deserved.
J. Things to expect:
1. Sphincter control begins at age 2.
2. All deciduous teeth erupt by 21 months - 2 years.
3. Pot-bellied appearance.
K. 18 months
1. Is in the MY stage. 2. Vocabulary of 25 words.
3. Walks independently 4. Can use a spoon.
5. Climbs.
Appropriate toys: Push/pull toys, blocks.
L. 24 months
1. Negativistic 2. Temper tantrums
3. Transitional object 4. 2-4 word sentences, 400 words
5. Walks up/down stairs 6. Turns door knobs
7. Builds tower of 6 blocks 8. Removes clothes
9. Appropriate play: Parallel play, sand, riding toys, water play, finger paints.
10. Manage temper tantrums: Ignore behavior, monitor for safety.
11. Toddler uses NO excessively and shows assertiveness. Is curious how parents will react to use of NO.
12. Overcriticizing and restricting the toddler may dampen his enthusiasm and increase shame and doubt.
13. Total sleep required is 12-14 hours. Sleep problems are common.
14. Toilet training
A. Consider emotional readiness
B. The toddler acts to please others, trusts enough to give up his body products, and begins autonomous behavior
C. Parents must be committed to establishing a toileting pattern and must communicate well with the toddler.

D. Offer PRAISE for success - NEVER punishment for any failure.

E. Dont refer to bowel movements as being dirty or yucky. Excrement is the toddlers first creation.
F. Introduce underpants as a badge of success and maturity.
G. Most toddlers achieve day dryness by age 18 months to 3 years and night dryness by ages 2-5. NEVER punish for ACCIDENTS.
If toddler is not trained by age 5, seek further evaluation.
H. Toddler may fear being sucked into the toilet.
I. Teach proper wiping technique (front to back) and hand washing.
15. When the toddler starts climbing over the crib rails, switch to a bed.
16. Use locks on cabinets, keep handles away from edges of tables or stoves.
17. AVOID bean bag toys.
18. Appropriate toys: Nested toys, toys with parts that open and close. Toys designed for pounding such as play hammers and drums.
Toy telephones, dolls. Provide the child with opportunities for positive imitative play. They enjoy simple songs with repetitive rhymes
as well as moving in time to music. A musical activity should be scheduled into each day.
19. NUTRITION:
A. Toddler feeds himself, provide finger foods in small portions
B. Because of increased risk of aspiration avoid foods such as hot dogs, grapes, nuts and candy (or cut into small pieces).
C. Nutritional needs decrease because of slow growth period.
D. Child may become a picky eater. Nutritional content of food is important.
E. The toddler shouldnt drink more than 24 ounces of milk a day in order to have room for
BURNS
1. Smoke and inhalation injuries result from inhalation of hot air or noxious chemicals.
2. The resulting effect of burns is influenced by the temperature of the burning agent, the duration of contact time, ad the tissue type
burned.
3. Burn treatment is related to injury severity determined by depth. The extent is calculated by the percent of the total body surface
area (TBSA), location, and patient risk factors.
4. Causes
A. Radiation: X-ray, sun, nuclear reactors
B. Mechanical: Friction
C. Chemical: Acids, alkalies, vesicants. Chemical burns alter tissue perfusion and lead to necrosis.
D. Electrical: Lightening, electrical wires. Severity depends on type and duration of current and amount of voltage - they follow the
path of least resistance (muscles, bone, blood vessels and nerves)
E. Thermal: Flame, steam, frostbite, scald. These cause cellular destruction that results in vascular, bony, muscle, or nerve
complications; thermal burns can also lead to inhalation injury if the head, neck or chest area is affected.
5. Burns are defined by degrees: First degree (superficial partial thickness burn), second degree (deep dermal partial thickness burn),
and third degree (full-thickness burn)
A. Superficial partial-thickness burn (first degree): Sunburn type. Involves only the dermal layer. S/S: Erythema, edema, pain,
blanching.
B. Deep dermal partial-thickness (2nd degree): Involves the epidermal and dermal layers. S/S; Pain, oozing, fluid filled vesicles,
Erythema, Shiny wet subcutaneous layer after vesicles rupture.. No ointments or soap
C. Full-thickness burn (3rd & 4th degree): Involves epidermal, dermal, and subcutaneous layers, and nerve endings, muscle, tendons
and bone. S/S: Eschar, edema, little or no pain.
6. Second and third degree burn extent can be determined using a total body surface area based on two guides: Lund-Browder chart
and Rule of Nines. Burn extent is often revised after edema subsides and demarcation of injury zones occurs.
A. RULE OF NINES
Head= 9% Arms = 18%( 9% each) Back= 18% Legs= 36%( 18% each)
Genitalia= 1%
B. LUND-BROWDER CHART: This method accounts for changes in body proportion that occur with age. Its greater accuracy can be
used to help determine a patients exact fluid replacement requirements after a burn injury.
7. Hands, feet, and eye burns may make jeopardize future function. Buttocks or genitalia burns are more susceptible to infection.
Circumferential burns to the extremities can cause circulatory compromise distal to the burn.
8. Patient usually tetanus and immune globulin.
9. Burn management is organized chronologically into 3 phases: Emergent (resuscitative), Acute (wound healing), and rehabilitation
(restorative)
A. EMERGENT: Period of time required to resolve immediate, life-threatening problems. Phase may last from time of burn to 3 or
more days, but usually lasts 24- 48 hours.
1. Priority care is on ABCs. Assess for smoke inhalation (singed nares, eyebrows, or lashes; burns on the face or neck: stridor,
increasing dyspnea) and give oxygen at 100% as prescribed. Be prepared for emergency intubation and mechanical ventilation if
severe inhalation injury or carbon monoxide inhalation has occurred.
2. Assess for signs of shock caused by fluid shifts (increased pulse, falling B/P and urine output, pallor, cool clammy skin,

deteriorating level of consciousness.

3. Initial fluid shift/Fluid resuscitation: Occurs in first 24 hours after burn.
A. Fluid seeps out of the tissue because of increased capillary permeability. The majority of this leaking occurs within the first 24
hours. Fluid deficit = shock.
B. H & H is elevated due to loss of fluid volume and fluid shift into interstitial space (third spacing)
C. Sodium is decreased due to third spacing.
D. Potassium is increased due to cell destruction.
E. Common rule: Calculate what is needed for the first 24 hours and give of the volume calculated during the first 8 hours (Parkland
formula)
1. BROOKE FORMULA: Uses 2 mL/kg/% TBSA burned ( crystalloid plus colloid) plus maintenance fluid of 2,000 mL D5W per
24 hours.
2. PARKLAND FORMULA: Uses 4 mL formula uses 4 mL/kg/TBSA burned per 24 hours = total fluid requirements for the first 24
hours.
A. 1st 8 hours = of total volume
B. 2nd 8 hours = of total volume
C. 3rd 8 hours = of total volume
3. No matter what formula the doctor uses, the formula will tell the amount of fluid the patient will get per hour.
4. Medication therapy: Pain therapy, tetanus prophylaxis, topical antimicrobial as well as systemic antibiotics.
5. Primary concern is the onset of hypovolemic shock and edema formation. Toward the end of the phase, if fluid replacement is
adequate, the capillary membrane permeability is restored.
6. Fluid loss and edema formation cease. The interstitial fluid gradually returns to the vascular space.
7. Diuresis occurs with low urine specific gravities.
8. Manifestations include shock from the pain and hypovolemic. Areas of full thickness and deep partial-thickness burns are initially
anesthetic because the nerve endings are destroyed. Superficial to moderate partial-thickness burns are painful.
9. Shivering occurs as a result of chilling and most patients are alert.
10. COMPLICATIONS
A. Cardiovascular system: Dysrhythmias and hypovolemic shock.
B. Respiratory system: Vulnerable to upper airway injury causing edema formation and/or obstruction of airway and inhalation injury.
C. Renal system: If patient is hypovolemic, kidney blood flow may decrease, causing renal ischemia. If it continues, acute renal failure
may develop.
D. With full-thickness burns, myoglobin and hemoglobin are released into the bloodstream and occlude the renal tubules.
11. DIET: High protein, high calorie with increased fluids, high calorie high protein drinks.
12. If fingers/toes are burned, wrap each finger/toe separately.
13. Monitor urine output - if less than 30 mL/hour, assess for renal failure.
B. ACUTE PHASE
1. Begins with the start of diuresis (usually 48 to 72 hours post-burn) and ends with closure of the burn wound. Phase concludes with
burned area is completely covered with skin grafts or when wounds are healed.
2. Margins of full-thickness Eschar take longer to separate. As a result, they require surgical debridement and skin grafting for healing.
3. Because the body is trying to reestablish fluid and electrolyte homeostasis, it is important for the nurse to follow the patients serum
electrolyte levels closely (hypo - or hypernatremia, or hypo- or hyperkalemia).
4. Complications include wound infection progressing to transient bacteremia as a result of manipulation (after hydrotherapy and
debridement). Same cardiovascular and respiratory system complications as in emergent phase may continue.
5. Patient can become extremely disoriented, withdraw, or be combative. This is a transient state lasting from a day to several weeks.
ROM may be limited and contractures can occur. Paralytic ileus results from sepsis.
6. Management involves wound care with daily observation, assessment, cleansing, debridement, and dressing reapplication.
1. Use sterile technique when handling burn.
2. Give pain killer before dressing changes and hydrotherapy. Pain control is usually opioid analgesics required.
C. REHABILITATIVE PHASE
1. Begins with wound closure and ends when the client returns to the highest level of health restoration.
2. Goals are to assist the patient in resuming a functional role in society and accomplish functional and cosmetic reconstructive
surgery.
3. Provide support and management. Use preventive measures to prevent contractures
10. NURSING INTERVENTIONS
A. Ensure airway patency and provide oxygen
B. Monitor V/S, laboratory findings, capillary refill, adequate tissue perfusion.
C. Keep patient NPO and administer H2 antagonist to prevent Curling (stress) ulcer.
D. Elevate clients extremities (increase venous return).
E. Use pressure dressings to prevent scarring and edema.
F. Give pain medication prior to any treatment and especially before dressing changes.
G. Nutritional requirements are increased with burns.
H. Encourage ROM. Neutral positions are best to prevent contractures, unless neck is burned, then hyperextend.

I. Maintain warm environment during acute phase.

J. Monitor for shock symptoms. Maintain protective precautions. Reverse isolation.
K. If client underwent grafting, keep pressure off donor side to maintain blo
Re: Anyoone up for random FACT THROWING??
Here is a little info on the thyroid gland - hope this helps
DISORDERS OF THE THYROID GLAND
1. GRAVES DISEASE - Hyperthyroidism - TOO MUCH ENERGY
A. Increased synthesis of thyroid hormone from overactivity.
B. Excessive secretion of thyroid hormone
1. Leads to increased basal metabolic rate (BMR).
2. Increased cardiovascular function, ^ed GI function, ^ed neuromuscular function, weight loss, and heat intolerance.
3. Thyroid hormone affects metabolism of fats, carbohydrates, and proteins.
4. Calcitonin inhibits mobilization of calcium from bone and s blood calcium levels
C. An autoimmune disorder.
D. Etiology: Excess secretion of TSH from pituitary gland. Thyroiditis, tumor, goiter. Physiological or psychological stress, infections,
F. S/S: Nervousness, weight loss despite increased appetite, sweaty/hot (heat intolerance), exophthalmus (no cure for this),
hyperactivity (cant sit still), ^ed appetite, B/P ed, flushed smooth skin, oliogomenorrhea or amenorrhea, palpitations, insomnia. ALL
V/S ARE ^ed - think of patient as being hyperactive.
G. DIAGNOSIS: Serum T3 and T4 are increased. Radio-iodine uptake is increased. Thyroid scan shows enlarged thyroid gland or
nodules.
H. TREATMENT/NURSING INTERVENTIONS
1. Monitor V/S & I & O - determine presence of thyroid storm.
2. Lifelong antithyroid medication.
3. Surgical removal of thyroid.
A. Radioactive iodine 131
1. The thyroid gland absorbs the I-131 which destroys some of the thyroid cells over a period of 6 to 8 weeks. RULE OUT
PREGNANCY FIRST.
2. Advise patient against close contact with other people, avoid kissing for 24-hours.
3. Test females for pregnancy. Pregnancy should be delayed 12 months.
4. Advise patient to drink with straw
B. Thyroidectomy or partial thyroidectomy
1. Instruct patient to hold hands behind neck when coughing, sitting, turning, or getting up/back into bed to reduce post-op pain and
decrease tension on suture line.
2. Position semi-fowlers with head and neck supported. Ice collar to wound to prevent edema.
3. Monitor for hemorrhage, edema, exudates over upper chest, upper back, shoulders, back of neck.
4. Promote patent airway - keep HOB elevated 30 degrees. Keep sterile oral suction and emergency tracheotomy tray within reach.
Avoid hyperextension of the neck
5. Keep phone, personal items, call bell, remote control within reach.
6. Diet: Increase calories
7. Assess for laryngeal nerve damage: assess for hoarseness. Could lead to vocal cord paralysis. If there is paralysis of both cords,
airway obstruction will occur requiring immediate trach. Bilateral nerve damage = breathing difficulties and aphonia (inability to
speak)
8. Instruct patient to report any signs of pressure on neck.
9. Give eye care for exophthalmus: Moisten eyes frequently with artificial tears to prevent irritation corneal infection. Protect eyes
from photophobia with glasses. Sleep with HOB elevated to minimize pressure on optic nerve and eye patches to protect eyes during
sleep if lids do not close. Soothe eyes with cool compresses.
10. Prevent tetany by identifying hypocalcemia - numbness or tingling of toes, extremities, and lips, muscle twitches, positive
Chvosteks & Trousseau.
I. THYROID STORM/THYROID CRISIS
1. Life threatening emergency that occurs in EXTREME hyperthyroidism.
A. Thyrotoxicosis, and thyrotoxic crisis and thyroid storm are the same.
B. It is hyperthyroidism multiplied by 100.
C. Results from a sudden surge of large amounts of thyroid hormones into the bloodstream causing a greater in body metabolism
2. S/S: Temperature > 102 up to 106 (hyperthermia). Tachycardia, systolic hypertension, abdominal pain, N/V, diarrhea, agitation,
tremors, confusion, seizures, delirium to psychosis. Triad S/S of thyroid storm: Tachycardia, hyperthermia, agitation. ALL
HYPERTHYROID MANIFESTATIONS ARE ^'ed.

3. May be precipitated by stress - surgery or infection, etc.

4. TREATMENT
A. Focuses on reducing circulating thyroid hormone levels by drug therapy.
B. Inhibition of thyroid hormones with propranolol (Inderal), corticosteroids, and thioamides (PTU)
C. Treat hyperthermia with cooling blankets, Tylenol (acetaminophen). Aspirin is contraindicated -it releases thyroxin, provide cool
sponge baths or ice packs to axilla and groin to decrease fever.
D. Treat dehydration with IV fluids and electrolytes.
E. Treatment of precipitating event.
F. Administer insulin for hyperglycemia. B-blockers (-LOL) for tachycardia
2. MYXEDEMA - Hypothyroidism - NOT ENOUGH ENERGY/ CRETINISM
A. Occurs when there is an insufficient amount of thyroid hormone (TH) being secreted by the thyroid gland causing a ed metabolic
rate, decreased heat production. CRETINISM: Hypothyroidism present at birth
B. Hyposecretion of thyroid hormone results in overall decrease in metabolism.
C. ETIOLOGY: An autoimmune disorder (Hashimotos thyroidism)causing destruction of the thyroid gland. External irradiation of the
thyroid gland, infections, iodine deficiency. Lithium therapy.
1. Hashimotos thyroidism: The immune system attacks the thyroid gland.
D. S/S: Fatigue, weight gain, dry flaky skin, cold intolerance, course brittle hair, hypothermia, lethargy, diminished reflexes,
periorbital edema, bradycardia, dysrhythmias, infertility, C/O cold hands and feet, hair loss, prolonged DTR-ed, enlarged heart,
muscle aches or weakness, constipation & ed libido.
E. CRETINISM: Hypothyroidism that is present at birth. Is very dangerous and can lead to slowed mental and physical development if
undetected.
1. State of severe hypothyroidism in infants. Infants do not produce normal amounts of thyroid hormone.
2. Their skeletal maturation and CNS development are altered resulting in retardation of physical growth, mental growth, or both.
F. TREATMENT/NURSING INTERVENTIONS
1. Diet: High fiber, high protein, low calorie, ^ed fluid intake (2000 mL/day)
2. Because of altered metabolism, patients do not tolerate barbiturates or sedatives. Therefore CNS depressants are contraindicated.
3. Give medication in the AM one hour before food or 2 hours after.
4. Do not give beta blockers to asthmatics or diabetics - hides symptoms of hypoglycemia.
5. Start thyroid medications at lowest dose and graduate to larger doses.
A. Dosage is increased every 2-3 weeks until the desired response is achieved. Advise patient that treatment is lifelong requiring
constant monitoring by MD. If thyroid drug is discontinued, it must be tapered.
B. Teach patient S/S of hyperthyroidism which can occur with overmedication.
6. Caution patient against electric blankets, extra clothing because of vasodilation.
G. MYXEDEMA COMA: Life threatening crisis state of hypothyroidism.
1. Myxedema coma/crisis occurs as a result of long-standing or untreated hypothyroidism who experience significant stress as
infection, medication, exposure to a cold environment or systemic disease.
A. Can be precipitated by infection, drugs - especially opioids, tranquilizers, and barbiturates.
2. Myxedema is an accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues. This causes characteristic signs
of hypothyroidism: puffiness, periorbital edema, and mask-like affect. Thinning eyebrows.
3. Virtually every organ system is affected.
4. S/S: Lethargy, stupor, ed oxygen & blood flow to the brain occurs. Bradycardia & ed contractility = low cardiac output. ed
renal function. Unresponsiveness, edema, hypoventilation, hyponatremia, hypotension, hypothermia, Progressive stupor. Periorbital
edema, non-pitting edema, puffy face and tongue. Significantly depressed respirations.
5. TREATMENT
A. The overall treatment is restoration of euthyroid state (having a normal thyroid gland as rapidly and safely as possible with
hormone replacement. Levothyroxine (Synthroid) is the drug of choice - give slowly
B. Maintain airway patency.
C. Maintain circulation with IV therapy and ECG monitoring.
D. Monitor V/S, ABG, I & O, patient temperature.
E. Keep patient warm
F. Administer corticosteroids as ordered. Assess for infections.
G. Patient at risk for CAD - monitor
H. Assess for skin alterations - apply lotion, etc.
I. With rapid administration of thyroid hormone, plasma T4 levels may initiate adrenal insufficiency, hence steroid therapy may be
ordered.
6. MEDICATIONS
A. SYNTHROID (thyroxin- T4) - Contraindicated in patients with MI, use cautiously in elderly and patients with diabetes, diabetes
insipidus.

1. When starting thyroid replacement therapy, care must be taken with older patients and those with CAD to avoid coronary ischemia
because of increased O2 demands of the heart. Start with lower doses first then .
2. Teach to take at same time each day 1 hour before meals/2 hours after. 3. Advise to take with plenty water or milk. Optimal time is
before breakfast.
4. Withhold medication if heart rate above 100 or notify MD.
5. Report weight gain of 5 pounds.
B. CYTOMEL (liothyronine sodium {T3}) - Use cautiously in elderly patients and those with angina, renal insufficiency or ischemia.
1. Long term use causes bone loss.
2. Monitor B/P and pulse.
3. Do not give IM or subcutaneously.
C. PTU - Propylthiouracil (Propyl-Thyracil)
1. Inhibits oxidation of iodine in thyroid gland, blocking ability of iodine to combine with tyrosine to form T3. May prevent formation
of T4
2. S/E: Headache, N/V, vertigo, paresthesia, CNS stimulation, fever, hepatotoxicity, visual disturbances, diarrhea, leukopenia, myalgia.
3. INTERVENTIONS.
1. Advise patient that iodized salt and shellfish should not be eaten because they alter drugs effectiveness.
2. Instruct patient to take with meals to reduce GI reaction.
3. Monitor lab values, especially CBC and hepatic function.
D. RADIOACTIVE IODINE (sodium iodide 131)
1. Limits thyroid hormone secretion by destroying thyroid tissue
2. S/E: N/V, skin rash, urticaria, pruritus, pain on swallowing.
3. INTERVENTIONS
A. ALL antithyroid drugs must be stopped 1 week before 1st dose.
B. Not used on patients younger than 30.
C. Institute full radiation precautions. Isolate patient, advise to avoid close contact with other people for at least 24 -48 hours
D. Advise patient to fast overnight before therapy and to force fluids
E. Monitor thyroid hormone levels
E. POTASSIUM IODIDE (SSKI, Lugol solution, ThyroSafe, Thyroshield)
1. Inhibits thyroid hormone formation, limits iodide transport into the thyroid gland and blocks thyroid hormone release.
2. Used to prepare patient for thyroidectomy: given TID after meals for ten days before surgery.
3. S/E: periorbital edema, N/V, diarrhea, inflammation of salivary glands, burning mouth and throat, sore teeth and gums, potassium
toxicity, acne- type rash. DO NOT GIVE ace inhibitors or potassium sparing diuretics with drug; may cause hyperkalemia.
F. PROPRANOLOL (Inderal) "OLOL"- A adrenergic blocker. Relieves the adrenergic effects of excess thyroid hormone (sweating,
palpitations, tremors)
G. INTERVENTIONS
1. Dilute oral solution in water, milk, or juice and give AFTER meals.
2. Give through straw to avoid teeth discoloration.
3. Earliest signs of delayed hypersensitivity reactions caused by iodides are irritation and swollen eyelids.
4. Signs of iodide hypersensitivity are: Angioedema, cutaneous and mucosal hemorrhage, fever, arthralgia, lymph node enlargement,
and eosinophilia.
5. Monitor patient for iodism which can cause a metallic taste, burning in mouth and throat, sore teeth and gums, increased salivation,
sneezing, eye irritation with swelling of eyelids, severe headache, rash or soreness of the pharynx, larynx, and tonsils, GI irritation.
6. Advise patient that sudden withdrawal may cause thyroid crisis.
7. Teach patient S/S of K+ toxicity: confusion, irregular heartbeat, numbness, tingling, pain or weakness of hands and feet & tiredness.
8. Advise patient NOT to increase potassium in diet.
9. Advise patient not to eat iodized salt or shellfish.
I. THYROIDECTOMY CARE
1. O2 therapy, suction secretions.
2. Monitor for signs of bleeding and excessive edema
3. Elevate HOB 30. Support head and neck to avoid tension on sutures
4. Check dressing frequently, check behind the neck, shoulders for bleeding.
5. Assess for signs of respiratory distress, hoarseness (laryngeal edema or damage.
6. Keep tracheostomy set in patients room for emergency use.
7. Administer food and fluid with care (dysphagia is common).
8. Encourage client to gradually ROM of neck.
9. Teach about medications, frequent follow-up. If thyroidectomy - life long replacement of medication (T5, T4). Subtotal
thyroidectomy - careful monitoring of return of thyroid function.

10. THINK BOW TIE:

B = Bleeding
O = open airway
W = whisper
T = trach set
I = incision
E = emergency
11. Be alert for post op complications
A. Tetany: Due to hypocalcemia caused by accidental removal of parathyroid gland. Assess for numbness, tingling, or muscle
twitching. Monitor for Chvosteks sign and Trousseaus sign. Give calcium gluconate IV slowly.
B. Hemorrhage: Monitor for hypotension, tachycardia, other signs of hypovolemia. Irregular breathing, swelling, choking - possible
hemorrhage and tracheal compression. Early signs of hemorrhage: Repeated clearing of throat, difficulty swallowing.
C. Thyroid storm: Life threatening. Sudden increased release of thyroid hormone. Assess for fever, tachycardia, ing restlessness,
agitation, and delirium.
GROWTH AND DEVELOPMENT FOR PEDIATRICS
PEDIATRICS
1. Motor skills progress in a proximal to distal manner.
2. NEONATE (Birth to 28 days):
A. Vital signs:
1. Pulse: 110 - 160 BPM count apical for one minute
2. Respiratory rate: 32 - 60 BPM. Neonate is an obligate nose breather.
3. Blood pressure: 82/46.
4. Temperature regulation is altered because of poorly developed sweating and shivering mechanisms.
A. Limit exposure time during baths.
B. When the neonate is wet or cold cover his head.
5. Mortality rate is higher in the neonatal period than in any other growth stage.
B. Head and chest circumference are relatively equal. Head circumference may be up to greater than the chest
circumference.
C. Head length is one-fourth total body length.
D. Brain growth depends on myelinization.
E. All behavior is under reflex control. Extremities are flexed.
1. Moro reflex- Elicited by striking a flat surface the infant is lying on. The reflex of abducting extremities and
fanning fingers when a sound is heard should be gone by 3-4 months. Strongest at 2 months
2. Rooting - When the cheek of the newborn is stroked, the newborn will turn his head in the direction of the
stroke. Usually disappears 3-4 months
3. Tonic neck - While the newborn lies supine, his head is turned causing the extremities on the same side to
straighten and those on the opposite side to flex (fencing posture). Disappears at 3-4 months.
4. Babinski - When the sole of the foot on the side of the newborn small toe is stroked upward, the toes will fan
upward and out
5. Plantar grasp - Infants toes will curl downward when sole of foot is touched.
6. Startle - A loud noise such as a hand clap will elicit the newborn to abduct his arms and flex his elbows. Best
elicited after infant is at least 24 hours old and disappears within 4 months.
7. Palmar/plantar grasp - Place a finger in the palm of the newborns hand and then place a finger at the base of
the toes, the newborns fingers and toes curl downward.
F. Hearing and touch are well developed; a hearing screening is recommended.
G. The neonate is stimulated by being held or rocked; listening to music and watching a black-white mobile.
H. While laying prone, the neonate can lift his head.
3. INFANCY: Age 1 month to 1 year.
A. Period of rapid growth in which the head, especially the brain, grows faster than other tissues.
B. According to Erickson, the infant is in the critical stage of Trust vs. mistrust. It is important for the child to
develop a trusting relationship with a consistent primary caregiver. Interference may cause failure the thrive.

C. Birth weight doubles in 6 months.

D. Birth weight triples in one year.
E. Posterior fontanel closes by 2-3 months.
F. Anterior fontanel remains open until 18 months.
G. Height increases by 50% in 1 year.
H. Head circumference > than chest circumference until 1 year.
I. Tooth eruption starts at 4 months -> 1 tooth per month.
J. AGES 1 TO 4 MONTHS
1. Instinctual smile appears at age 3 months. The social smile is the infants first social response. The social smile
initiates social relationships, indicates memory traces, and signals the beginning of thought processes.
2. The infant develops binocular vision; the eyes can follow an object 180 degrees and any intermittent strabismus
should be resolved by age 4 months.
3. The infant reaches out voluntarily but uncoordinatedly.
4. At age 4 months the infant laughs in response to environment.
5. Recognizes parents voices.
6. Explores his feet.
7. Appropriate toys: Music box, mobile, mirror.
K. AGES 5-6 MONTHS
1. Birth weight doubles.
2. Can sleep through the night with 1-2 naps a day.
3. Lower central incisors appear first. Results in ed drooling and irritability.
4. Rolls over from stomach to back.
5. Infant cries when parents leave - a normal sign of attachment. Exhibits stranger anxiety.
6. Can transfer toys from one hand to another
7. Exhibits comforting habits - sucks thumb, rubs his ears, holds a blanket or stuffed toy.
A. All these symbolize parents and security.
B. Thumb sucking in infancy doesnt result in malocclusion of permanent teeth.
8. Appropriate toys: Bright toys, soft toys, rattle - THINK SAFETY.
L. AGES 7 - 9 MONTHS
1. Sits alone without assistance
2. Creeps on his hands and knees with his belly off of the floor.
3. Infant stands and stays up by grasping for support.
4. Develops a pincer grasp; places everything in his mouth - ed risk of aspiration.
5. Self-feeds crackers; the infant whos physically and emotionally ready can begin to be weaned to a cup.
6. Likes to look at self in mirror.
7. Develops object permanence and searches for objects outside his perceptual field.
8. Understands the word NO; discipline can begin. Cries when reprimanded.
9. Can verbalize consonants but speaks no intelligible words. 10. Appropriate toys: Peek-a-boo, cloth toys.
M. AGES 10 - 12 MONTHS
1. Birth weight triples and birth length increases about 50%.
2. Imitative behaviors.
3. Infant cruises (takes steps while holding on) at age 10 months, walks with support at 11 months, and stands alone
and takes his first steps at 12 months.
4. Infant claps his hands, waves bye-bye and enjoys rhythm games.
5. Enjoys books and toys to build with and knock over.
6. Cooperates when dressed.
7. Can say Mama/dada and two syllable words.
8. Shows jealousy.
9. Infant explores everything by feeling, pushing, turning, pulling, biting, smelling, and testing for sound.
10. Appropriate toys: Push toys, large ball, large blocks.
N. NUTRITION

1. Introduce foods in this sequence

A. Breast milk or iron-fortified formula: According to AAP (American Academy of Pediatrics) they recommend
breast feeding exclusively for the first 4-6 months of life and then in combination with infant foods until age 1.
1. Give breast fed infants iron supplements after age 4 months because iron received before birth is depleted.
2. Breast milk is a rich source of linoleum acid (essential fatty acid) and cholesterol which are needed for brain
development.
3. Contains immune factors that protect infants from infection.
B. Dont give solid foods for the first 6 months
1. Before age 6 months, the GI tract tolerates solid food poorly.
2. Because of strong extrusion reflex, the infant pushes food out of his mouth.
3. The risk of food allergy development may increase.
C. Provide rice cereal as the first solid food followed by any other cereal except wheat.
D. Give yellow or green vegetables next.
E. Provide no citrus fruits followed by citrus fruits after age 6 months.
F. Give infants teething biscuits during teething period.
G. Provide food with sufficient protein such as meat, after age 6 months.
H. After 12 months, switch from formula to regular WHOLE milk.
1. Dont give skim milk because fatty acids are needed for myelinization.
2. Whole milk should be continued until age 2 as recommended by the AAP.
I. RULES FOR FEEDING
1. Dont prop up baby bottle - s risk of aspiration & ear infections.
2. Dont put food or cereal in a baby bottle.
3. Introduce one new food at a time; wait 4-7 days before introducing new food to determine infants tolerance to
it and the potential for allergy.
O. SAFETY GUIDELINES
1. Place infants supine for sleep to decrease the risk of sudden infant death syndrome.
2. Keep crib rails up at all times, keep away from windows and curtain cords. Crib slats should not be more than 2
apart with mattress firmly against its rails to prevent infant falling in-between mattress and slats.
3. Use car seats properly - keep infant placed facing back of back seat.
4. Never leave infant unattended on dressing table or any other high place.
5. Dont warm formula or breast milk in microwave. Defrosting in microwave may destroy its immune factors.
Formula/food should be lukewarm.
6. Insert safety plugs in wall outlets
7. Use gates along stairways.
8. Keep soft objects and loose bedding out of the crib. Pillows, quilts, sheepskins and comforters should be kept
out of infants sleeping environment.
9. Avoid overheating; infant should be lightly clothed for sleep.
10. ALWAYS support infants head.
11. Check temperature of bath water - should be 90-100 degrees.
P. TODDLER (Ages 1 to 3)
1. Vital signs: Pulse 100 BPM
Respiratory rate: 26 BPM
Blood pressure: 99/64
2. Period of slow growth with a weight gain of 4-6 lbs per year. Normally weighs four times birth weight.
3. Anterior fontanel closes between ages 12 and 18 months.
4. The toddler is egocentric.
5. Follows parents wherever they go.
A. Start playing peek-a-boo to develop trust.
B. Progress to playing hide and seek to reinforce the idea that his parents will return.
6. Separation anxiety arises.
A. The toddler sees bedtime as desertion.

B. Develops a fear of the dark. Nightmares begin around 2-3.

C. Separation anxiety demonstrates closeness between the toddler & his parents.
D. The parent who is leaving should say so and should promise to return.
1. Parent should leave a personal item with the toddler.
2. Prepare the parents for the toddlers reaction, and explain that this process promotes trust.
E. According to Erickson, this is the critical stage of AUTONOMY (self control & will power) VS SHAME. The child
develops a sense of independence and should be allowed to explore the environment with the encouragement of the
primary caregiver. Temper tantrums, negativism, and disciplinary problems are the hallmarks of this age group as
the child learns to control his environment and express his will. The child should be taught to tolerate frustration
through socialization and proper toilet training.
1. According to Freud, toddlers are egocentric and possessive and struggle with holding on and letting go behaviors
(ANAL STAGE).
2. Toddlers usually begin to imitate sex role behavior.
3. Piaget: Sensorimotor stage the child enters the pre-operational stage in which he begins using a trial and error
method of thinking and reasoning.
F. The toddler may engage in solitary play and have little interaction with others, this progresses to parallel play
(toddler plays along-side but not with other children.
G. To promote development of autonomy, allow the toddler to perform tasks independently and provide choices.
H. Toddler understands object permanence.
I. Discipline during this stage should be a demonstration of love, not anger. The toddler needs limits set on
unacceptable demands, such limits offer security. He should be praised liberally, but only when deserved.
J. Things to expect:
1. Sphincter control begins at age 2.
2. All deciduous teeth erupt by 21 months - 2 years.
3. Pot-bellied appearance.
K. 18 months
1. Is in the MY stage. 2. Vocabulary of 25 words.
3. Walks independently 4. Can use a spoon.
5. Climbs.
Appropriate toys: Push/pull toys, blocks.
L. 24 months
1. Negativistic 2. Temper tantrums
3. Transitional object 4. 2-4 word sentences, 400 words
5. Walks up/down stairs 6. Turns door knobs
7. Builds tower of 6 blocks 8. Removes clothes
9. Appropriate play: Parallel play, sand, riding toys, water play, finger paints.
10. Manage temper tantrums: Ignore behavior, monitor for safety.
11. Toddler uses NO excessively and shows assertiveness. Is curious how parents will react to use of NO.
12. Overcriticizing and restricting the toddler may dampen his enthusiasm and increase shame and doubt.
13. Total sleep required is 12-14 hours. Sleep problems are common.
14. Toilet training
A. Consider emotional readiness
B. The toddler acts to please others, trusts enough to give up his body products, and begins autonomous behavior
C. Parents must be committed to establishing a toileting pattern and must communicate well with the toddler.
D. Offer PRAISE for success - NEVER punishment for any failure.
E. Dont refer to bowel movements as being dirty or yucky. Excrement is the toddlers first creation.
F. Introduce underpants as a badge of success and maturity.
G. Most toddlers achieve day dryness by age 18 months to 3 years and night dryness by ages 2-5. NEVER punish
for ACCIDENTS. If toddler is not trained by age 5, seek further evaluation.
H. Toddler may fear being sucked into the toilet.
I. Teach proper wiping technique (front to back) and hand washing.

J. Toilet Training - when kid can communicate need to go (non verbal or verbal), holds on to please mom and doesn't
let go to please self, sphincter control 18 months - 24 months (myelination of the cord is complete now), motor
skill. Ability to stay dry for 2 hours, can sit still on toilet for 5 - 10 minutes without fussing, curiosity about older
people's habits. No right or wrong time !
15. When the toddler starts climbing over the crib rails, switch to a bed.
16. Use locks on cabinets, keep handles away from edges of tables or stoves.
17. AVOID bean bag toys.
18. Appropriate toys: Nested toys, toys with parts that open and close. Toys designed for pounding such as play
hammers and drums. Toy telephones, dolls. Provide the child with opportunities for positive imitative play. They
enjoy simple songs with repetitive rhymes as well as moving in time to music. A musical activity should be scheduled
into each day.
19. NUTRITION:
A. Toddler feeds himself, provide finger foods in small portions
B. Because of increased risk of aspiration avoid foods such as hot dogs, grapes, nuts and candy (or cut into small
pieces).
C. Nutritional needs decrease because of slow growth period.
D. Child may become a picky eater. Nutritional content of food is important.
E. The toddler shouldnt drink more than 24 ounces of milk a day in order to have room for other nutritious food.

MILESTONES
By Age 3:
Able to jump in place Able to kick a ball
Able to ride a tricycle Able to state name, age, and gender
Able to copy a cross and circle Most speech is understandable by others
By Age 4:
Able to sing simple songs Able to draw a person with 3 or more body parts
Able to distinguish between reality and fantasy
Able to state first and last name
Able to build tower with at least 10 blocks
Able to hop on one foot at least 3 times
Able to throw ball over handed All speech is understandable
By Age 5: (Enters Kindergarten)
Able to dress self without assistance
Able to state entire name (first, middle, and last)
Able to state home address and home phone number
Able to follow 2-3 step directions
Able to count to 10 on fingers
Able to copy a triangle or square
Able to draw a person with head, body, and all extremities
Able to recognize most letters of the ABCs and able to print a few
Plays make believe
By Age 6:
Able to walk heel/tow forward and backwards
Able to hop on either foot
Able to catch baseball size ball with 2 hands
Able to feed self correctly using knife, fork, and spoon
Able to cut out simple shapes with scissors
Able to distinguish between right and left hand
Able to play games involving matching skills
Able to repeat simples nursery rhymes

Able to choose peers for play

Is protective of younger siblings
NCLEX QUESTIONS
1. When does birth length double - By 4 years
2. When does child sit unsupported - By 8 months
3. When does a child achieve 50% of adult height - 2 years
4. When does a child throw a ball overhand - 2 years
5. When does a child speak 2-3 word sentences - 2 years
6. When does a child use scissors - 4 years
7. When can a child tie his/her shoes - 5 years
8. Girls growth spurt during adolescence begins earlier than boys. May begin as early as 10 years old.
9. Temper tantrums are common in the toddler; they are considered normal or average behavior.
10. Adolescence is a time when the child forms his/her identity and that rebellion against family values is common
for this age group.

Dont foget to d/c aspirin 48 hours before the pt's scheduled OR.
Page 299 on the forum
The only insulin that can be given IV is Regular which happens to be the only one of the insulins which is clear.
- bethanechol chloride (Urecholine) is used in neurogenic bladder & urinary retention, s/sx of overdose include increased salivation,
sweating and flushing, when administering keep atrophine sulfate nearby as an antidote
-don't forget to give bedpan since Urecholine promotes diuresis
- avoid grapefruit juice with cyclosporine (Neoral), it raises blood levels and increases risk of toxicity

Always administer Morphine IV push slowly,over 5 minutes to avoid cardiac arrest,cirulatory arrest.
Administer diuretics in the morning
Always administer Lipitor at 17:00 since the enzymes works best during the evening time.
Admisiter ACE inhibitors (prils) with food to avoid gastric upset.
Give aspirin with food to avoid gastric irritation.
Aspirin causes ear toxicity,teach patient to report the tinnitus to their HCP.
Dont even admister calcium channel blockers to a patient who just drank a grapefruit juice,doing so can cause the calcium
channels blockers to rise to dangerous levels.
Calcium channels blockers are contraindicated for patients with Congestive heart failure,the only calcium channel blocker
that can be safely administered to a pt with CHF is Norvasc.
Do not administer NSAIDS to a pt with CHF since NSAIDS promote sodium retention and peripheral vasoconstriction-actions
that can make CHF worse.Additionally they reduce the efficiency and intensify the toxicity of diuretics and ACE inhibotors.
Gingo Biloba helps to delay the progression of Alzheimer's Disease.
Dimenhydrinate (dramamine) is the most common OTC drug for motion sickeness.
Sumatriptan (Imitrex) an serotonin receptor agonist is given for migraine headache.
Antihistamines are prescribed for a variety of reasons like nausea,vomitting,dyskinesia,cough,allergy,itching, sedation.
Atropine is an antidote for wild mushroom toxicity,s/s of mushroom toxicity include increased salivation,excessive
tearing,diarrhea.
Give iron preparation with orange juice,since citrus juice enhance the absorption of iron.

For cardiac meds, remember if it ends in -ine, such as Atropine...think "it can't be seen"...vasoconstrictor...if it
ends in -ide, such as Nipride..think "makes them wide"..as in vasodilator..
With insulins, remember when mixing, Regular (clear) always comes before NPH (cloudy)...R before N = RN!
Morphine is contraindicated for patients with pancreatitis and gallbladder disease because it cost spasm of the
Sphincter of Odi
Sx of right sided heart failure:
Shortness of breath
Swelling of feet and ankles
Urinating more frequently at night
Pronounced neck veins
Palpitations
Irregular fast heartbeat
Fatigue
Weakness
Fainting

Sx of left sided heart failure:

(I think Left with Lung-they both start with L)
Cough (produces frothy or blood-tinged mucus)
Decreased urine production
Difficulty lying down; need to sleep with the head elevated to avoid shortness of breath
Fatigue, weakness, faintness
Irregular or rapid pulse
Palpitations
Shortness of breath
Waking up due to shortness of breath (paroxysmal nocturnal dyspnea)
Weight gain from fluid retention
1) Gout : low purine diet, avoid organ meat e.g. liver.
2) Hypertension : low sodium diet.
3) Renal calculi, calcium kidney stones : follow alkaline ash diet e.g. spinach, milk, banana. Aim is to increase
pH.
4) Post MI : incr troponin T, n/r : 0.1 to 0.2 ng/ml.
5) Post MI: incr isoenzyme for lactic dehydrogenase LDH1.
Always associate FRACTURES with fat embolism Always associate MAJOR SURGERIES with pulmonary
embolism.
Mumps: i remember (mumps- enlarged humps on neck & enlarged testicles(orchitis)
Rubella: bad for pregnant women
As far as immunization schedule for the infants and children it goes like that the newborns get their first
Hepatitis B shot at birth followed by 2 more doses.
Then the babies at 2 months recieve a couple of vaccinations which include (keep in mind that they have to be
at least 6 week old) Rotavirus dose (followed by two other doses at different time),DTaP
(Diphteria,Tetanus,Pertussis,followed by 4 more doses at different time period),Haemophilus Influenza type b
(followed by 3 other doses),Pneumoccocal vaccine (followed by 3 other doses) and finally Inactivated (dont
confuse with ACTIVATED,the word can be used as great mislead in one of the NCLEX question,activated polio
is no longer given to babies).
Next it is recommended for the babies to get influenza shot,however the baby must be at least 6 month of age
to get this vaccine.When the baby turn one year old it is time for MMR (Measles mumps,Rubella all- in
-one,remeber that the baby must be at least ONE year old or older),also at the same time the infant can get
its first varicella shot and Hepatitis A shot (for both the baby must be at least one year old)
Clozaril - the "Z" in Clozaril - med for SchiZophrenia. Most worrisome complication is agranulocytosis,
therefore weekly blood tests must be done
Corticosteroids can cause stomach ulcers.
Isoniazid can cause drug induced hepatitis-look for yellow color of the skin,nausea,vomitting.
Before start INH for TB, usually a baseline live function test is recommended.
TB skin positive, normal 10mm, if HIV, 5mm is positive
Nclex tips
Assess first( check the question to see if the assessment has been done)
Take care of the patient first, the machines and documentation later
Always choose the most complete answer with the least opportunity for error
In Priority question, look for acute and unstable pt to see first
Always remember your ABCs
Maslow's will usually work and pain is seen as a psychosocial need---Not a physical need
Incident or Occurrence reports--Never refer to them in the pt's chart
should complete for any time there is a variance from what should have happened with Pt care
should not include blame or anything but just the facts
when charting, do not use the words, " Error, mistake, accident or incorrect."
Errors in charting are corrected by making one simple line through the words
If a RN comes from another unit, give that RN a pt who does not need to have a RN from specific unite care
for him/her. EX. --Post op mastectomy needs an ONco nurse to take with.
Delegation--If you are assigning pt care to LPN/NA, rank order the pt as to the ones who have the least acute
problems/changes to the most

Anytime a question comes up about a procedure or diagnostic test, consider the possible complications
Vital signs are a LATE signa of pt status change
Rales=CHF
Rhonchi=pneumonia
Wheezes=asthma
Hemoptysis=Lung cancer or TB
Pleural Pain=Pssible PE
Intercostal retractions=respiratory distress
Role play the situation
Read the question and answers out loud
Safety for the pt is always first, then the family, then the nurse
Never isolate a pt with Alzheimer's disease
Any time a pt has traction applied or a broken bone, consider:
Circulation
Movement
Sensation
compartment syndrome
skin integrity
restlessness is often the first sign of hypoxia
if you chose an answer withthe word, why or check in it, make sure it is truly the best answer.
Rarely is the right answer to call the physician--Don't pass the responsibility
Psychiatric pt:
--For someone with psychosis--acknoledge the hallucination or delusion and then realityorientation
--for someone with dementia--change the subject, divert the attention
Medications to know: antipsychotics--Haldol, Thorazine, Zyprexa, Geodon\
antidepressants--Tricyclics--typically sedating so take at bedtime, cause otthostasis, dry mouth, very
dangerous with OD. NEED to wean off.
MAO-I---low tyramine diet, if they eat something high tyramine--hypertensive crisis
Interact with a lot of other meds, can have hypertensive crisis with other meds
Need to be off other antidepressants for at least 2 wks before starting.
SSRI--can treat anxiety to. Typically take in the morning because they are more likely to be stimulating. Can
cause diarrhea. Need to wean off.Serotonin serge.
Anti-mania--lithium--need to have levels drawn, Tend to get increased level if sweating, vomiting. Know the
S/S of toxicity. Know normal Li levels( 0.6-1.2)
Anti-seizure family( Depakote, Tegretol, Lamictal, Trileptal, etc) most can lead to liver failure. Should have

levels of Depakote/Tegretol done at intervals.

Anti-anxiety-Benzodiazepines----addictive and lead to seizures during withdrawl. Very dangerous if combined
with alcohol. Sedating except may have paradoxical
Reaction in the elderly
Safety is always first priority if someone is losing control of her/his behavior.
--must try all other interventions before using restraints/seclusion
someone must stay within arms's reach of the pt if they are restraints
Need to release one restraint or do Prom every 15 min.
Restraint to orders need to be specific and cannot be PRN and only good for 24hrs.
Chemical restraints count as restraints
The pt with Depression needs to increase interaction.
the pt with psychosis typically is very concrete in thinkgs and it not going to be able to process groups, etc
Well pt with addictive disorders use the denail as their primary coping mechanism
Manic phase pts need finger foods or calories as they burn a lot being busy
Suicidal pts --look for any phrase that implies helplessness, hopelessness, worthlessness
Post op eye surgery--don't bend at the waist, avoid straining

If someone has an object that has penetrated his/her body, leave it there until it is assessed as safe to
remove.
Drugs which are incompatible with INTRAVENOUS Potassium Chloride ( IV KCL)
adrenaline HCL ( this drug also interacts/incompatible with diazepam)
amphotericin B ( " " " " " diazepam )
cholesteryl (interacts with ergotamine tartrate)
sulfate complex (intereacts with methicillin sodium)
atropine sulfate ( interacts with phenytoin sodium)
cephalophin sodium ( " " phenytoin )
choramphenicol ( interacts with sulphadiazine sodium )
sodium succinate ( interacts with suxamethoniun chloride )
chlorpromazine HCL ( interacts with thiopentone sodium )
diazepam
ergatamine tartarate
methicilline sodium
phenytoin sodium
phenytoin
sulphadiazine sodium
suxamethonium chloride
thiopentone sodium
Drugs which CANNOT be given by IVPush Route
Potassium Chloride (KCL)---never to IVPush
Heparin SQ---can be given as a Drip, but no to IVP Route
Ibuprofen - PO
Insulin---only Regular (clear) can be given intravenous but never IVPush
Keppra--PO
Lovenox SQ
Mestinon PO, IV
Florinef PO
Dobutamine IV and drip ---NO to IVPush Route
Docusate PO
Coumadine PO
Cefazolin PO/IV/IM -------" " " "
Calcium Gluconate PO/IV/IM---never to IVPush Route

Atropine IV/PO/IM/SC
aspirin PO/PR
Albumin IV
acetaminophen PO/PR
Differentiating types of Crises for NCLEX mental health related questions

Types of Crises:
Situational Crisis= from an external source
Examples:
a) divorce
b) death of a love one
c) mental illness
d) abortion
e) loss of a job
f) a change in financial status
g) severe physical illness
Advantageous Crisis= from an external source
Examples:
a) earthquake
b) flood
c) any natural disaster
Maturational Crisis= related to rites of passage
Examples:
a) retirement
b) birth of a child
c) kids going to college, moving out---empty nest
d) marriage
Infection Control

The three bloodborne patogens of most concern to healthcare workers are:

HIV
Hepatitis B Virus
Hepatitis C Virus

Difference between Universal Precautions and Standard Precautions:

In 1980's the CDC created specific recommendations known as Universal Precautionsto prevent the spread of bloodborne patogens such as HIV, HBV HCV and
other bloodborne diseases in the healthcare environment.

Later Universal Precautions changed from being a CDC recommendation to a workplace regulation enforced by OSHA as a Prevention of Bloodborne Patogens
Standard.
Standard Precautions = A set of procedures designated by the CDC to prevent the spread of known and unknown sources of infection via body fluids, excretions
and secretions of the skin and oral mucosa. Please note, that the difference for Standard Precautions include all body fluids while Universal Precautions is about
bloodborne patogens only.

Memory aid for signs of potential problems for Oral Contraceptives = ACHES
A - Abdominal pain (possible liver/ gallbladder issue)
C- Chest pain or SOB (possibility of pulmonary embolus)
H - Headache (possibility of hypertension / brain attack)
E - Eye problem (possibile hypertension / vascular attack)
S - Severe leg pain (possible thromboembolic process)
Cleft Lip: nursing care plan (post OP) = CLEFT2 LIP

Crying = minimize
Logan bow
Elbow restraints
Feed w/ Brecht feeder
Teach feeding techniques; average age for repair is TWO months.
Liquid (sterile water)/ rinse after feeding
Impaired feeding (no sucking)
Position - never on abdomen
KAWASAKI DISEASE:
Unknown cause
Early tx with Gamma globulin to reduce cardio damage.
Abrupt onset of fever (102-106 F) lasting more than 5 days that get no better with antibiotics/antipyretics.
Conjunctivitis, bilateral and nonpurulent.
Peeling of the palms of the hands and feet.
Generalized rash on trunk and extremeties, w/o crusts or vesicles.

Lab tests results for KAWASAKI DISEASE = elevated ESR, WBC & Platelet count.
Screening tests.
-women should pay attention to their breast at the age of 20,this is the time when females should start
perform self breast examination,once a month 7 days after their menstrual period beggins,they dont have to
have a mammograph yet however it is recommended that women between ages 20-29 should have a
professional physical examination of breast every three years.
-women who are 40 and over should have a mammograph plus physical breast examination done every year.
-the first pap smear should be performed at the onset of sexual relations and done annually after a woman
reaches the age of 18.
-men who turn 50 (or man who are 40 with a risk factors) should have a prostate specific antigen test done
annually for prostate cancer.
-men who turn 40 should have a rectal digital exam done yearly to screen for colon cancer.
-men who turn 50 should have a a guiac test for occult blood done annually (to screen for colon cancer)
-men who turn 50 should have a proctoscopy done every 3 to 5 years to screen for a colon cancer.
-people especially men when they turn 45 and have a normal cholesterol level should have this test done
every five years.
-men (especially adolescent men) should perform self-testicular exam every month after a warm shower.
-all the people above the age of 21 should have their blood pressure checked.
When drawing two different insulins Cloudy CLEAR CLEAR Cloudy
Air in cloudy air in clear, draw clear draw cloudy
GI assessment Inspect Auscultate Percuss Palpate

Antidote for Coumadin- Vitamin K

Antidote for Heparin- Protamine Sulfate
Some antipsychotic drugs end in -done (like risperdone) and -zine (thorazine)
Common side effect of the antipsychotic drugs
-insomia
-weight gain
-agitation
-extrapyramidal movements
-orthostatic hypotension
-sedation
-diziness
-headache
-dry mouth
-trouble urinating
-constipation
-decrease in WBC

Some popular antipsychotic meds; zyprexa,seroquel,haldol,molindone.geodon,risperido ne,thorazine,clozaril

Spina Bifida- allergy likely to Latex
Streptoccocal glomeruler nephritis----ask if sore throats, pr impetigo (skin condition)- normal BP

nephrotic syndrome- BP high

After pregnancy BP should b normal
What does it matter if a patient has supplement O2 if they are hemmorhaging, okay she they will be
hemmorhaging oxygenated blood--ex circulation before airway
spirocyclone- is a potassium sparing diuretic--not exact spelling
Lithium--need to maintain normal sodium intake to not predispose to toxicity
Judisim- really care about pain relief at end of life care, once dead some will stay with body
Celiac Disease-- can have corn subsitutes--includes popcorn as a snack
infant with Hep A----is put on contact precautions becuase incontinent of feces

remember words::: Nance Reagan RN--for insulin adm-----put air into regular, put air into NPH, withdrawal
NPH then withdrawal Regular
Blood Transfusion Reactions
Allergic- You will see rash, fever, anaphalyxis reaction as well. Treatment: Oxygen, benadryl, monitor patent
airway (ABCs)
Hemolytic- It means blood incompatibility. You will see pain in lower back, hypotension, decrease urinary
output. Treatment: O2, benadryl, vasopressors, maintain patent airway
Febrile- Most common type of reaction, especially for patients who receive a lot of blood. The blood given has
antibodies that reacts with the patient's own. You will see fever, chill, nausea , tachy. Treatment: antibiotics
Bacteria- gave contaminated blood. You will see hypotension, shock, fever. Treatment: IV fluids, vasopressors,
steroids, antibodies.
Some meds..
Adrenergics ( Levophed, Dopamine, Adrenalin, Dobutrex) for CARDIAC ARREST, COPD
Anti- Anxiety ( Librium, Xanax, Ativan, Vistaril, Equanil) for MANIC, ANXIETY, PANIC ATTACKS
Antacids ( Amphojel, milk of mangnesia, maalox ) for PEPTIC ULCER, INDIGESTION, REFLEX ESOPHAGITIS.
CAUTION DONT GIVE ANTACIDS WITH FOOD BECAUSE IT DELAYS GASTRIC EMPTYING. ANTIACIDS
INTERFERE WITH ANTIBODIES, INH (TB MED), ORAL CONTRACEPTIVES, IRON PREPARATIONS.
Glucocorticoids ( Solu-Cortex, decadron, deltasone) for ADDISON DISEASE, CROHN'S DISEASE, COPD,
LEUKEMIAS
Mineralcorticoids ( Florinex) for ADRENAL INSUFFICIENCY
Cholinergics ( Tensilon, Prostigmin) for MYASTHENIA GRAVIS, POSTPARTUM URINARY RETENTION.
Anticonvulsants ( Dilantion, Luminal, Depakote, Tegretol, Klonopin) for SEIZURES
iNFECTION CONTROL
airborne- Rubeolla, Herpes zoster, Tb, chicken pox
droplet- pneumonia, meningitis
contact- MRSA, scabies, RSV
during seizures position patient on his or her side in a lateral position. Jaundice is best observe in sclera, nail
beds and mucous membranes. If patient is getting enema and has pain= clamp tubing for 30 seconds and
restart the flow at slower rate. After completing a tube feeding- patient is placed on right sie to promote
emptying of stomach while preventing aspiration. First step in problem solution is to indentify the problem
and generate possible solutions ( MANAGEMENT OF CARE). IOP tends to be higher in the morining, early
assessment of glaucoma is good AM for that reason. Bulge test- confirms presence of fluid in the knee. TPN
has a higher glucose content, monitor glucose level. Oral anticougulant therapy (coumadin) should be
instituted 4 to 5 days before discontinuing heparin therapy.......

1. Causes of Cor Pulmonale

Cor Pulmonale doesnt need to be a jolt to think of Colt: use COLT to remember the causes of Cor pulmonale.
C- COPD / and Cystic Fibrosis
O- Obesity
L- Living at high altitude
T- Tuberculosis
These all increase the hearts workload and lead to right side hypertrophy.
----------------------------------------------------------------------------------------------------------------------------2. Treatment of Cor pulmonale
Treatment of Cor pulmonale (right-sided heart failure) can be remembered by using the acronym SODA:
S- Sputum Culture
O- O2 administration

D- Digoxin
A- Antibiotics: to treat any underlying respiratory infection.

Signs and Symptoms of Conjunctivitis

Conjunctivitis is redness and swelling of the conjunctiva leading to redness and edema. Since the main cause for the spread of conjunctivitis is
poor hand washing use the word SOAP to remember the signs and symptoms of conjunctivitis.
S- Swollen, red eyelids
O- Occasional drainage from eye
A- An itching or burning
P- Photophobia
==================================================
================================================== ===================
Rheumatic Fever Signs and Symptoms
Rheumatic fever is a complication of untreated strep throat, caused by bacteria called Group A Streptococcus. It is potentially life threatening.
Since one of the main symptoms of rheumatic fever is pain in the joints, use the word, JOINTS to remember the signs and symptoms.
J- Joints are painful
O- Over a long period it can damage the heart
I- Infection may be too mild to be recognized
N- Nervous system can be affected leading to chorea
T- Throat that is sore
S- Swollen joints

POINTS TO REMEMBER (PHYSIOLOGY)

CARDIOVASCULAR SYSTEM
Cardiovascular disease is the leading cause of death among Americans.
Take blood pressures correctly
1. Give client 5 minutes rest.
2. Take blood pressure while client is lying, sitting, and standing.
3. Ask client if he/she has recently smoked, drank a beverage containing caffeine or was emotionally
upset. If so, repeat blood pressure in 30 minutes.
Rarely, the heart may lie on the right side instead of the left, this is calledDextrocardia.
Valves control the direction of the blood flow through the heart. Flow is unidirectional.
When the atria contract, the atrioventricular valves swing open, allowing the blood to flow down into the ventricles.
When the ventricles contract the valves snap shut preventing blood from flowing back up into the atria. Semilunar
valves open allowing blood to eject during ventricular contraction.
If the SA node fails to generate an impulse, the AV node takes over, generating a slower rate. If the AV node fails
to generate an impulse, the Bundle of His takes over, generating an even slower rate. If the Bundle of His fails to
generate an impulse, the Purkinje fibers take over and generate an even slower rate.
Damaged areas of the heart may also stimulate contractions and produce arrhythmias.
Rapid, short-term control of blood pressure is achieved by cardiac and vascular reflexes that are initiated by
stretch receptors (baroreceptors) in the walls of the carotid sinus and the aortic arch.
Many clients with angina or MIs benefit from involvement in a structured cardiac rehabilitation program to assist
clients to increase their activity level in a monitored environment.
Current research suggests that life style and personal habits are closely related to cardiac changes once
attributed to aging.
The elderly are less able to physically adapt to stressful physical and emotional conditions, because their hearts
do three things less quickly: the myocardium contracts less easily, the left ventricle ejects blood less quickly, and
the heart is slower to conduct the impulse for a heartbeat.
Because different enzymes are released into the blood at varying periods after a myocardial infarction, it is
important to evaluate enzyme levels in relation to the onset of the physical symptoms such as chest pain.
Clients who are in postoperative recovery, on bed rest, obese, taking oral contraceptives or had knee or hip
surgery should be monitored closely for thrombophlebitis.

RESPIRATORY

Oxygen is essential for life. So, before all else, keep airways open and ease breathing.
Clients with chronic lung disease use more oxygen and energy to breathe; this can create a vicious cycle in which
the client works harder, and continually requires more oxygen and more energy.
Nursing interventions for clients with lung disease should include pacing of activities, because clients have little
reserve for exertion.
Quality of life for clients can be significantly improved if you teach clientsdiaphragmatic breathing and pursed-lip
breathing.

Clients with asthma must understand the different types of inhalers and when to use each type. Some are rescue
inhalers for acute dyspnea; others are maintenance drugs.

A finger oximeter reading is simply one element of an assessment; it's not the whole picture.
Cyanosis is determined by oxygenation and hemoglobin content; anemic clients may be severely hypoxemic and
never turn blue; polycythemic clients may be cyanotic with adequate tissue oxygenation.
Control of pulmonary TB is a serious public health issue.
If a client is in respiratory distress, start out by administering oxygen by non-rebreather mask at 10-15 LPM until
the client's condition is clarified or stabilizes.
When caring for a client with a chest tube, you must know whether the client has a leak from the lung. Only when
you know there is no leak, should you apply an occlusive dressing.

When caring for a client on a ventilator, if an alarm sounds, first, assess the client. See if the alarm resets or if the
cause is obvious. If the alarm continues to sound and the client develops distress, disconnect the client from the
ventilator, use a manual resuscitation bag and page or call the respiratory therapist immediately.
To maximize therapeutic effect of inhalers, the key is technique. It is critical to teach clients the right technique and
test how well they use the inhaler.
Smoking cessation is critical to reduce the risk and severity of lung disease. Second-hand smoke hurts children
most.
Best treatment of pulmonary embolus is prevention by using intermittent compression stockings (with
anticoagulants in extra-high risk clients) to prevent clots in deep veins.
TB clients need intensive community follow up to ensure that they continue with pharmacological treatment once
discharged from the hospital. Clients who stop therapy too soon are the source for the more deadly multi-drug
resistant forms of TB.

NEUROLOGICAL SYSTEM
In Multiple Sclerosis, early changes tend to be in vision and motor sensation; late changes tend to be in cognition
and bowel control.
Peripheral nerves can regenerate, but nerves in the spinal cord cannot regenerate.
During a seizure, do not force anything into the client's mouth.
A major problem often associated with a left CVA is an alteration in communication.
Clients with CVAs are at high risk for aspiration. These clients must be evaluated to determine if dysphagia is
present.
The rate, rhythm and depth of a client's respirations are more sensitive indicators of intracranial pressure than
blood pressure and pulse.
When caring for a comatose client, remember that the hearing is the last sense to be lost.
A CVA can result in a loss of memory, emotional lability and a decreased attention span.
Communication difficulties in a CVA client usually indicate involvement of the dominant hemisphere, usually left,
and is associated with right sided hemiplegia or hemiparesis.
The client with myasthenia gravis will have more severe muscle weakness in the morning due to the fact that
muscles weaken with activity and regain strength with rest.
EYE

Anything that dilates the pupil obstructs the canal of Schlemm, increases intraocular pressure.
Color blindness is caused by a deficiency in one or more types of cones and is caused by a sex-linked recessive
gene.
Destruction of either the right or left optic nerve tract results in blindness in the respective side of both eyes
When mydriatics are instilled, caution clients that vision will be blurred for up to two hours
Following eye surgery teach client to avoid, for six weeks, activities that can increase IOP
o Stooping
o Bending from the waist
o Heavy lifting
o Excessive fluid intake
o Emotional upsets
o Constrictive clothing around neck
o Straining with bowel movement (or straining at stool)
Teach client proper administration of eyedrops

Ear

Provide sunglasses for photophobia

Assist with activities of daily living as required
When clients wear eye patches, they lose depth perception. Remember that this loss presents a safety risk.
Systemic disorders that can change ocular status include diabetes mellitus,atherosclerosis, Graves' disease
(hyperthyroidism), AIDS, leukemia, lupus erythematosus, rheumatoid arthritis sickle cell disease.

Changes in barometric pressure will affect persons with ear disorders

Hearing loss
o can be partial or total
o can affect one or both ears
o can occur in low, medium or high frequencies
AMA formula for hearing loss: hearing is impaired 1.5% for every decibel that the pure tone average exceeds 25
decibels (dB)
A hearing loss of 22.5% usually affects social functionality and requires a hearing aid
Noise exposure is the major cause of hearing loss in the United States
Ask client how he/she communicates: lip-reading, sign language, body gestures, or writing
To gain the client's attention, raise your hand or touch the client's arm
When talking with client, speak slowly and face him/her
Speak toward the client's good ear
If the client wears a hearing aid, allow him/her to show you how it's inserted
Speaking louder to a hearing impaired client does not increase his/her chances of hearing
Communicate the client's hearing loss to other staff members
Ototoxic drugs include:
o Aminoglycosides
o Antimyobacterials
o Thiazides
o Loop diuretics
o Antineoplastics
Tell clients taking ototoxic drugs to report any signs of dizziness, loss of balance, tinnitus, or hearing loss

GASTRO-INTESTINAL
Most obstructions occur in the small bowel.
Most large bowel obstructions are caused by cancer.
Onset of cirrhosis is insidious with symptoms such as anorexia, weight loss, malaise, altered bowel habits,
nausea and vomiting.
Management of cirrhosis is directed towards avoiding complications. This is achieved by maintaining fluid,
electrolyte and nutritional balance.
A client with esophageal varices must be monitored for bleeding (e.g., melena stools, hematemesis, and
tachycardia.
The rupture of esophageal varices is life threatening and associated with a high mortality rate.
Pancreatitis is often associated with excessive alcohol ingestion.
Pancreatic cancer is an insidious disease that often goes undetected until its later stages.
Diverticula are most common in the sigmoid colon.
Clients with diverticulosis are often asymptomatic.
A deficiency in dietary fiber is associated with diverticulitis.
Colostomies: an ascending colostomy drains liquid feces, is difficult to train and requires daily irrigation; a
descending colostomy drains solid feces and can be controlled.
Frequent liquid stools can be indicative of a fecal impaction or intestinal obstruction.
Bowel sounds tend to be hyperactive in the early phases of an intestinal obstruction.
GENITO-URINARY
After a urinary catheter is removed, the client may have some burning on urination, frequency and dribbling.
These symptoms should subside.
After a TUR (transurethral resection), tell the client that, because the three-way foley catheter has a large
diameter, he will continuously feel the urge to void.

After prostatic surgery, it is normal for the client's urine to be blood tinged and for him to pass blood clots and
tissue debris.
Because the prostate gland receives a rich blood supply, it is important to observe the client undergoing a
prostatectomy for bleeding and shock.
Breast cancer starts with the alteration of a single cell and takes a minimum of two years to become palpable.
At the time of diagnosis, about 1/2 of clients with breast cancer have regional or distant metastasis.
antidisrtythmic drugs:
sodium channel blockers: Lidocaine,quinidine,procainamide-have many adverse reactions given only after
other therapies have failed;
Adverse affects;prolonged Qtc or QRS,nausea,vomitting,heart block,confusion,seizures (especially with a
lidocaine),rash,sedation,respiratory depression,torsades de pointes,can cause increased bleeding when
combine with anticoagulants,should never be taken with potassium channel blockers,increased risk of digoxin
toxicity
Potassium channel blockers: Amiodarone,sotalol,can cause hear failure,pulmonary fibrosis,heart block,sinus
arrest,liver damage,use suncreen and protect your eyes
anticholinergics : Atropine-for bradycardia associated with increased vagal tone,high-alert drug,can cause
flushing of the skin for 20-30 minutes when given by injection,produces anticholigergic effect such as
sedation,constipation,dry mouth,urinary retention.
aceytlcholine-sensitive K-current activator:adenosine
uses:chemical conversion of supraventricular tachycardia after failure of vagal maneuver

Adverse affects;transient asystole,dysrythmias,dyspnea,chest tightness,hypotension,flushing,nausea

take tetracycline on emty stomach,do not take it with MILK products-delays absorption.
Take statins with at night with meals.
Do not administer calcium channel blockers with Grapefruit juice.
Do not administer aspirin to people with asthma.
Antilipids can cause bleeding and breakdown of skeletal muscles.
Niacin is an antilipid and can cause intense flushing,increased serum uric acid (stones),abdominal pain,joint
pain.
Do not administer beta blockers to pt with COPD or diabetes mellitus.
Beta blocker can cause depression in people.
Give ampicillin on empt stomach (penicillin can be given without regards to meals)
Give captopril one hour before meals.
Some more drug endings
-zosins-alpha1 blockers,they are used for hypertension and benign prostatic hyperthrophy.
-none-phosphodiesterase inhibitors for heart failure when other drugs fail or a pt is awaiting heart
transplants,side effects;letal dysrtythmias dangerous drug!
-kinase-thrombolytics-for MI,PE,deep vein thrombosis,for the MI must be given within 4 to 6
hr,contraindicated in brain neoplasm,cerebral hemmorage,recent major trauma or spinal surgery,high potential
for bleeding.
One more facts always check K+ when administering digoxin (contraindicated in hypokalemia) and -prils
(contraindicated in hyperkalemia)

Calcium Channel Blockers are

Very- Verapamil
Nice- Nifedipine
Drugs- Ditalizem aka Cardizem

1st degree heart block looks like NSR but the PR interval is 0.20 or greater
2nd Degree Heart block aka Mobitz 1 alsp aka Wenkeback the PR interval keeps getting longer and longer
then suddenly drops a PR interval- remember Wenkebach=Warning (the warning, the PR interval is getting
longer and longer)
2nd degree Heart block Type 2- no PR interval getting longer and longer it just suddenly drops
(suddenly=serious)

For Acute MI's remember MONA, not administered in that order : MONA Morphine, O2, Nitroglycerine, Aspirin
administration is least invasive to most so that would be : O2, Aspirin, Nitro x3 q5 min, Morphine

Meds:
---mab for Cancer:
bevacizumab (Avastin) blocks the growth of blood vessels to the tumor and cetuximab (Erbitux) and
panitumumab (Vectibix) both block the effects of hormone-like factors that promote cancer cell growth.
Lung---No.1 Killer among cancer
small cell or non-small cell and stage of cancer
; surgery, radiation therapy, chemotherapy,
and targeted biological therapies such as bevacizumab
(Avastin) and erlotinib (Tarceva).
--mab again: for lymphoma; monoclonal antibodies, such as rituximab (Rituxan) and alemtuzumab(Campath),
directed at lymphoma cells are used for initial treatment
and recurrence of some types of non-Hodgkin lymphoma,
as are antibodies linked to a radioactive atom,
such as ibritumomab tiuxetan (Zevalin) and iodine I 131
tositumomab (Bexxar).
----"have baby" and "use oral contraceptives " both decrease risk for ovarian cancer. ( I do not know that before, then
I should try first). Age is the big risk for ovarian cancer. Then I want to be young forever!!!!!!!!
-----Prostate cancer
most frequently diagnosed cancer in men. reasons unclear
second-leading cause of cancer death in men.
chemoprevention: finasteride and dutasteride

Substance Poisoning and Antidotes

Methanol =>ethanol
carbon monooxide=>Oxygen
Dopamine=>Phentolamine
Benzo=>flumazenil
Lead=>Succimer
Iron=>Deferoxamine

INTERVENTIONS FOR COPD (using ABCDEF)

A-Aminophylline
B-Brochodilators
C- Chest Physiotherapy
CORTICOSTEROIDS
D- Deliver oxygen at 2 liters
E- Expectorants
F- Force Fluids
Tuberculosis ( Meds) Use RISE
R-Rifampin
I-Isoniazid (INH)
S-Streptomycin
E-Ethambutol
Care of Client After Masectomy
(BREAST)
B-Bp not on affected side
R- Reach recovery
E-Elevate affected side
Exension and flexion exercise- initialy (Squeeze a ball)
A-Abduction and external rotation should not be initial exercise
S-SBE- Once a month- about one week after period
T-To promote a positive self image
TURPS

T-Tubes
U-Urinary output
R- Red drainage
P-Pieces of clots
S-Spasms
Meniere's Disease
Administer diuretics to decrease endolymph in the cochlea, restrict sodium, lay on affected ear when in bed.
TRIAD
-vertigo
-Tinnitus
-Nausea and vomiting.

pheochromocytoma: neuroendocrine tumor of the medulla of the adrenal glands. This causes
and increased secretion of catecholamines (epinephrine, and norepinephrine) Signs and Symptoms same
as body's Sympathetic Nervous System Response:
>Elevated HR
>Elevated BP
>Palpitations
>Anxiety
>Diaphoresis
>Headaches
>Pallor
>Wt. Loss
>Elevated Blood Glucose Level (due to catecholamine stimulation of lipolysis)
Tetany tests:
Chovstek's sign- Tap facial nerve 2 cm anterior to earlobe just below zygomatic arch. Twitching of facial
muscles indicates tetany.
Trousseau's sign- Inflate BP cuff to 20mmHg above Systolic. Carpal spasms w/in 2-5 mins indicates tetany.
Abnormal Breathing Patterns:
Cheyenne stokes- "Dead man breathing" Tachypnea with periods of apnea.
Kussmauls breathing- Deep and Fast, seen in pts experiencing Hyperglycemia also look for Fruity Breath.
The diabetes that isn't really a diabetes:
Diabetes Insipidus- Named diabetes b/c of the diuresis it causes similar to that which a person with
diabetes would experience. The polyuria is caused by a deficiency of the ADH(Anti-diuretic hormone)
causing the patient to excrete alot of urine. Check for Low Specific gravity, hypernatremia, Serum Osmolality
may be low for . Pt will have to urinate frequency, have extreme thirst and may easily become dehydrated.
Unlike SIADH (syndrome of inappropriate ADH) you want to increase fluid intake to hydrate the patient.

SIADH- Syndrome of Inappropriate ADH or as I like to think of it "Syndrome of IncreasedADH". Common in

patients with a damaged CNS (Central Nervous System). Excessive ADH is released from the Pituitary gland
resulting in hyponatremia, concentrated urine and fluid overload.
NSAIDS like Ibuprophen (Motrin) can cause GI bleeds, never take on an Empty stomach. Think"NSAIDS take
with BREAD"
No milk served with meat- Jews
Clients with physical disabilities frequently respond good to support groups
Dos and Donts
Dont
Dont
Dont
Dont

pass buck
provide false Reassurance
ask why
treat psychosocial first

Do ask patient to express themselves, their concerns

INH can cause liver problems so stay away from alcohol
Risk Factors for Pneumonia Old age, bed ridden, post op, pre existing lung problems
Cane walking- Hold the cane in hand opposite of weak leg and move with weak leg. I.E. with weak right leg,
advance left hand (cane) followed by right leg then left leg.
Lying prone prevents flexion contracture of hip

Poor Potassium values Call Physician. Cardiac Emergency!

Pavlik harness- is a harness applied to young children with hip dysplasia. it goes around their mid section
and over their shoulders in the front looking like a pair of suspenders. It then makes and x in the back and
connects to the child's feet and ankles in the front and back. The child should wear knee high socks and a
under shirt to prevent skin break down. Massage the skin under the straps daily (w/out lotions,
ointments) SEE HERE
JVD (jugular vein distention) is a symptom of a cardiac tamponade, a complication of CABGs caused
by blood accumulating around the heart in the pericardial sac and compressing the myocardium,
atrium, and ventricles.

IF you have a female patient undergoing Peritoneal Dialysis and the output is bloody you need to determine if
she is menstruating. The reason being, the dialysate is so concentrated to pull fluid from the abdominal cavity
that the hypertonicity may cause blood to be pulled from the uterus through the fallopian tubes and into the
effluent.
Here are a few facts:
Use FIRST to help you remember
F- find hypoxia
I- Immunocompromised
R- Real bleeding ( Trauma, hemorrhage)
S-Safety
T- Try infection
For Cardiac
It use to be MOAN but the American heart Association has changed it
Now it is ONAM
O- Oxygen
N-Nitoglycerine
A- Asprin

M- Morphine
Breast Cancer Risk Factors:
>50 years of age
FIRST child born after 30 years of age
Grandmother, Mother, Sister has it
Personal history of breast cancer
Garlic has a hypoglycemic effect do not give with insulin
Eye problems do not want head in dependent position. Lie on good side and have bad eye upor elevate the
head of the bed to 35 degrees.
Lay on right side after liver biopsy.

Clear fluid from head CSF medical emergency call the doctor
1 yr old with nausea, vomiting, and diarrhea is emergency because young children become dehydrated very
easily

Assess pt for claustrophobia with CAT scans and MRIs, also, NO METAL.
ALPHABET NURSING FACT:
Activated charcoal - To absorb poison
AAA- Complication is hemorrhage and shock
A positive mantoux test indicate the pt has produced an immune response
Complication of warfarin- (3H) hemorrhage, hematuria and hepatitis
Colchine for treatment of gout attack
Codeine- onset- 30mins, peak- 1hr, duration 4-6hrs
COPD -use of acessory muscle for respiration indicate the pt is having difficulty breathing
Chlamydia, Genital herpes and HPV - Do not report
Crackles are heard on inspiration and dont clear with cough
Diaphramatic and purse lip breathing are the best for pt with COPD
DMD- X-linked recessive and female are carrier and male are affected.
DI- Treatment is DDAVP
Gastric lavage - To remove poison
Indomethacin - helps in closing PDA
Left sided HF- pulmonary
Myelomingocele complication - clubbfoot and hydrocephalus
Meningitis- Droplet
Osteoarthritis- Joint pain, crepitus, heberden's node, bouchard's node and enlarge joints
Pentoxifyline- hemorheologic Agent that improve blood flow and is used to treat intermittent claudication
Prostaglandin E is administerd to provide blood ming and also help to keep open the ductus arteriosus
Right side HF- systemic
Rhonchi are heard on expiration and clear with cough
Rabies- contact precaution
tPA- used to treat Acute MI
Thrombolytic- dissolve clots
To avoid falsely elevated serum digoxin, the nurse should wait @ least 8hrs after administering oral digoxin
and @ least 6hrs after administering I.V digoxin to draw a blood sample.
TB- airborne

Disaster planning

A disaster plan needs to be activated when there is a life threatening situation with a large number of patients
involve. A way to remember who to remove first is by using ABC
A- Ambulatory
B- Bed Ridden
C- Critical Care
You may ask why but the goal is to move the greatest number of clients.
Appendicitis- position of comfort is on the side with the legs flexed agains the abdomen. HOB should remain
slightly elevated to decrease the upward spread of infection in case the rupturing of appendix occurs.
MEDS that can cause ototoxicity
Aminoglycosides
bumetanide, parenteral (Bumex)
cisplatin
erythromycin ( renal impairment and high doses)
ethacrynic acid ( Edecrin)
furosemide ( Lasix)
hydroxychloroquine ( Plaquenil)
nonsteroidal anti-inflammatory drugs (NSAIDs)
salicylates ( chronic high doses, overdose)
Vancomycin, parenteral ( high doses and renal impairment)
Drugs that can cause Nephrotoxicity
Acetaminophen ( high doses, acute)
Acyclovir, parenteral ( Zovirax)
aminoglycocides
amphotericin B, parenteral ( Fungizone)
analgesic combinations containing acetaminophen, asprin, or other salicylates in high doses, chronically
ciprofloxacin
cisplatin ( Platinol)
methotrexate ( high doses)
nonsteriodal anti-inflammatory drugs ( NSAIDs)
rifampin
sulfonamides
tetracyclines ( exceptions are doxycline and minocycline)
vancomycin, parenteral (Vancocin)
Drugs that can cause Hepatotoxicity
ACE inhibitors
acetaminophen
alcohol
iron overdose
erythromycins
estrogens
fluconazole ( Diflucan)
isoniazid ( INH)
itraconazole ( Sporanox)
Ketoconazole ( Nizoral)
nonsterodial anti-inflammatory drugs ( NSAIDs)
phenothiazines
Phenytoin ( Dilantin)
rifampin ( Rifadin)
sulfamethooxazole and trimethoprin ( Bactrin, Septra)
Sulfonamides

Differentiating Parathyroid Hormone and Calcitonin's effect on calcium placement.

Calci-Tonin increases Calcium in the BONE

PTHPuts
The calcium in the
Heme (blood)
Protease Inhibitors
indinavir ( Crixivan)
nelfinavir ( Viracept)
ritonavir ( Norvir)
saquinvir ( Invirase)
If you notice all end in vir
Nucleoside or Reverse transcriptase inhibitors
didanosine ( Videx)
lamivudine ( Epivir))
stavudine ( Zerit)
zalcitabine (HIVID)
zidovudine ( Retrovir)
Notice all of these end in (ine)

What helps me most with math problems is to break everything down

into its lowest components. For example, if you have 3gr or 180mg in
500ml, how many ml per single mg? Divide 500 by 180. Once you
know how many ml are in a single mg, you can multiply to get your
answer
Pericarditis
*chest pain, dry cough, fever, fatigue, anxiety.
Tx w/ steriods, pericardiocentesis, antibiotics, colchicine.
Myocarditis
*Chest pain, CHF sx, palpitations.
BPH
*weak urine stream, heard to start urination, dysuria, nocturia, frequency.
Labs to look for w/ dehydration
*increased specific gravity, increased urine and serum osmolarity, HYPERnatremia (think less water...so the
sodium becomes very concentrated) increased HCT, BUN....Anyone think of any I have forgotten??
ACE inhib
*dizziness, HA, hypotension.
Pulm embolism
*low grade fever, tachycardia, blood tinged sputum.
COPD
prolonged expiratory phase.
Tension Pneumo
*trachea deviate to opposite side ( I remember it like OP-opposite=pneumo, same=atelectasis.) hypotension
and bradycardia.
Albuterol
*tachycardia, nervousness, insomnia, anxiety.
Hip fracture
*Fractured leg shorter, externally rotated, adducted.
Radiation
*Stomatsis(irriation of mucous membrane), Xerostomia(dry mouth) and dysgeuia(decreased taste)

*protrusion of ileal conduit=stoma prolapse.

*Take nystatin after meals.
*lower lung sounds-vesicular close to trachea(but not directly over)=bronchial
*Multiple mylomas=increased immunloglobins expected.
COMMON DRUGS THAT SHOULD NOT BE CRUSHED

Trade name Generic Name

Cardizem.......................................... diltiazem hydrochlride

Depakote.........................................divalproex sodium valproic acid
EES............................................... .erythromycin ethylsuccinate
E-mycin...........................................er ythromycin base
Erythromycin ...................................erythromycin estolate
Feosol............................................ .ferrous sulfate
Glucotrol XL......................................glipzide
Klor-con...........................................pota ssium chloride
K-tab............................................... potassium chloride
MS Contin.........................................mor phine sulfate
Phazyme........................................... simethicone
Prilosec.......................................... ...omeprazole
Prozac............................................ ..fluoxetine hydrochloride
Slow-K..............................................pot assium chloride
Theobid........................................... ..theophylline
Theo-Dur...........................................theo philline

to enhance ingestion and prevent aspiration have your patient sit up. If sitting up position is not
possible, a side-lying position will also work.

when obtaining a bottle of medication you must watch for: expiration date, patient name, dose and
route.

the usual gauge (size of the needle) for an IM injection is 19-23.

The greater the viscosity (thickness) of the medication the larger the gauge (circumference of the
needle) needs to be.

for administering blood the usual gauge is 19

larger gauge = smaller gauge number

for IM injections given to adults the usual needle length is 1, 1 and a half (1/2) or 2 inches

the dorsogluteal (upper, outer quadrant of the buttock) is the traditional site for IM injections

for infants under 7 months, the vastus lateralis site if preferred because that muscle is more developed
than other sites.
Brown pigmentation around the ankles of patient indicates venous insufficeny
Cloudy outflow during peritoneal dialysis indication of infection and needs to be reporeted to MD
Afte colonoscopy a patient should report rebound tenderness. Abdominal cramping, fatigue and passage of
liquid stool are all normal findings after colonoscopy.
A patient with pertussis should be in a private room, mask and under droplet precautions.
Hydromorhone ( Dilaudin) can Cause urinary retention.
Respite care important for caretaker of Alzheimer's patient to allow for physical and emotional rest.
Antihistamines can cause urinary retention and exacerbate symptoms of BPH.
Applying pressure to the inner cantus of the eye prevents overflow of medication into the nasolacrimal duct
and possibly systemic absorption.
Ethical dilema- Determination of facts. identify possible solutions, consider patients wishes.
An Increase in peak expiratory flow rate indicates that airway restriction is resolving ( asthma patient)
Salem sum tube- turn patient every 2 hours to promote emptying of stomach contents.
Fatigue, abdominal bloating and persistent dyspnea of patient with COPD contributes to patients inability to
maintain adequate nutrition.
Serosanguienous drainage beyond post-op day 5 may indicate dehiscence; therefore surgeon should be
notified.
There is no need for a parent of a child who is HIV positive to notify the childs daycare provider.

INDERAL- serious side effect decrease heartrate due to blockade of betta1 receptors in the heart.
Bulima patient with bloody emesis due to esophageal tears due to purging.
Pacemaker spikes on T wave indicate that the pacemaker is not capturing appropriately and should be
adjusted for this patient.
A patient who is having muscle spasm while in traction should be repositioned to see if the spasms decrease.
REASONS FOR UNCONSCIOUSNESS (skin Color)
RED- Stroke or increase in blood pressure
BLUE- Respiratory or cardiac arrest
WHITE- Shock or Hemorrhage.
BETA BLOCKERS
B-bronchospasm(do not give to asthma, bronchial constriction patients)
E- elicits a decrease in cardiac out put and contractility.
T- treats hypertension
A- Av conduction decreases
T- tenormin ( atenolol) hypertension & angina
L- Lopressor ( metopolol) hypertension & angina
C- Corgard ( naldolol) hypertension & angina ( renally excreted)
Glomerulonephritis- fever, periorbital edema, weakness, and chills caused by grop B strep.
It is normal for a patient that has had dialysis to have a slight fever afterwards due to the dialysis solution
being warmed by the machine.
Positive sweat test indicative of cystic fibrosis.
After thyroid surgery- maintain airway keep a trach kit at patients bedside, check for bleeding, be sure to
check at sides and back of neck due to gravity and teach patient to support their neck.

B-1 (thiamine) and all B vitamins Alcoholic (to prevent Wernickes encephalopathy and Korsakoffs syndrome.
B-6 (pyridoxide hydrochloride) TB patient (Pt is likely on INH which can cause peripheral neuropathy, dizziness,
and ataxias, B-6 can prevent these unwanted affects).
B-9 (folic acid) Pregnant pt to prevent neural tube defects in fetus
B-12 (cobalamine) Pernicious anemia (autoimmune disease that attacks the parietal cells preventing intrinsic
factor from being released, which is needed to absorb B-12.

clozapine (Clozaril) can cause agranulocytosis so teach pt to watch for sore throat and fever!
phentoin (Dilantin) is EXTREMELY hepatotoxic; if liver is impaired, may cause toxicity of Dilantin b/c it can't be
metabolized & builds up

Cardiovascular toxicity is an issue that arises with the use of tricyclic antidepressants, so question such an
order if the client has cardiac disease.

Knowing Potentials Creates Meaning

K Po4=============
Ca Mg ============ Action Potentials seen in S/S
K Po4 =============
Ca Mg ============= Action Potentials seen in S/S

Lung CA is a common cause of SIADH which results in an increased water absorption and dilutional
hyponatremia...

Droplet Precautions

Nurses

and guests Use regular mask; clients wear surgical mask on transport

Droplets larger than 5 microns

Use standard prec within 3 feet
Private room
May be cohorted with clients with same infection without any additional infection
Diphtheria, Mycoplasma pneumonia, rubella, Pertussis, mumps, strep pharyngitis, pneumonia, scarlet fever
Door to room may remain open

Airborne
Negative air pressure room
N-95 respirator mask
Avoid coughing and sneezing into another
person; use napkins/wipes
Tuberculosis

Contact Isolation
Private

room

Use gown, gloves and mask

Example:
Clostridium difficile B infection

Putting Gown, Mask, Gloves

1. Wash

hands

2. Place mask on face

3. Put on gown
4. Put on clean or sterile gloves

Removing Gown, Glove, Mask

1. Remove gloves
2. Remove mask

3. Untie gown
4. Wash hands
5. Remove gown
6. Fold it inside out and discard
7. Wash hands again

CHVOSTEKS SIGN
Sign

of hypocalcemia

Characterized by twitching when tapped on the facial muscle

hypoparathyroidism

TB Test
Positive skin test (Mantoux test)- 10 mm
induration; not redness/erythema
Indicates exposure to bacilli
Confirmatory:
Chest X-ray, 3 (+) sputum AFB

Universal Precautions
Everybody is infected
Body, body fluids, secretions, excretions,
Mask, eye shields, gloves, gown
Hand hygiene

Myocardial Infarction (MI)

Immediate treatment: MONA

Morphine,
Oxygen,
Nitroglycerine,
ASA

Hypoxia
Early signs: REMEMBER (RAT)

Restlessness, Anxiety,Tachycardia / Tachypnea

Late signs: REMEMBER (BED)

Bradycardia, Extreme restlessness, Dyspnea (severe)

Iron Administration

REMEMBER:
Iron supplements IM or IV----iron dextran (IV route is preferred) draw up .2mL to make air lock, change needle after
drawing up med (so no med outside of needle)
IM causes pain, skin staining, higher incidence of anaphylaxis
Take oral supplements with meals if experience GI upset
Then resume between meals for max absorption
Use straw if liquids are used

Depression & Suicidal

Depression and signs and symptoms
of suicide: watch for suicidal ideation.
Suicide alert: when depressed mood
begins to lift and/or energy level increase.

INH
Prevent and treat TB
Remember when taking INH
Do not drink alcohol
Take vitamin B6 to prevent peripheral
neuropathy
Take with food if not tolerated on an empty
stomach
Do not get pregnant

Growth & Development

Birth weight doubles in 6 months
Pre-schooler - has imaginary friends
Infant gains head control by 4 months
Posterior fontanel closes at 2-3 months
Anterior fontanel closes by 12-18 months

Patient on MAOI
Monoamine Oxidase Inhibitors
No tyramine containing foods.
No aged cheese, wine or pickles

Insulin
Clear first before cloudy
Regular first before NPH

Pneumonia
Productive cough, yellow blood streaked
Rusty sputum - infection

Contact Precautions
While

giving bath and changing linens for a client with MRSA infection the nurse should:

Wear gown and gloves when giving direct care or touching contaminated surfaces
Wear gloves before entering room and remove before leaving room
Wash hands after removing gloves

Are you planning to kill yourself?

A client who is terminally ill says to the nurse, This is too much for me. You have been very good to me so I will give you my watch.
The nurses response should be:
a. Give it to your family.
b. Keep it.
c. Are you planning to kill yourself?
d. Dont worry.

Closed Liver Biopsy

PRE:

NPO 4-6 hours

Consent
Reinforce teaching about procedure
Baseline VS, bleeding parameter
Empty bladder
Supine position on far right side

Liver Biopsy
DURING:

Hold breath after exhalation to keep diaphragm and liver high in abdominal cavity during insertion
Needle insertion between the 6th-7th ICS
10 -15 seconds to obtain tissue

Liver Biopsy
AFTER:

Apply direct pressure right after needle removal

Right side lying position
Vitals to check for bleeding
NPO for 2 more hours
No coughing, lifting, or straining for 1-2 weeks. Most concerened if patient coughing after deep breathing, can hemorrhage (pain
radiate to shoulder = current liver problem)

Myxedema
Adult

form of hypothyroid crisis

Characterized by mental sluggishness, drowsiness, lethargy progressing to coma;

Hypotension

Which among these patients

need a private room?
HIV

patient

Client awaiting renal transplant

Hepatitis
Scabies
Answer: Scabies is caused by sarcoptes scabei leading to skin infestation. Female mite burrows in areas between fingers and toes
and warm folds of the body such as axilla, groin, to lay eggs.

Scabies
S/S:
Burrows - visible dark lines
Mite - seen as black dot at end of burrow
Severe itching
Scratching with resulting secondary infection

Scabies Treatment
Permethrin

Cream (Elimite)

Lindane lotion
Scrub body with soap and water then apply lotion on all areas except the face

 Leave permethrin on the skin for 8-12 hours and then wash off completely with warm water
All who had close contact with person within 30-60 day period should be treated

Hearing Impaired

DO not touch patient until they are aware youre in the room

Speak to the face

Articulate clearly but not too slowly
Move close to patient; do not cover mouth with hands
Provide alternate methods of communicating: Magic Slate, Sign

A mother is concerned of a breastfed baby about gaining too much weight!

With

adequate output (DIAPER COUNT) in infants this ensures adequacy of nutritional intake

Which should a nurse see first among these clients in active labor?
Gravida

1 para 0 with bulging of membranes

Gravida 2 1 cm dilated
Para 4, 1 cm dilated with history of C-section
Para 5, 2cm dilated

Answer
Para 4 with hx of c section takes priority in order monitor and prevent the occurrence of uterine rupture.

Which one of these patient assignment for a travel nurse should be reassigned?
HIV client
Client with contagious disease
Client who just developed a rash
Patient with green purulent sputum
Answer: Client with RASH as this requires

Verbal Orders
Which

of these medications need a specific written order from aprescribing physician?

Insulin
Digoxin
Coumadin
Chemotherapeutic agents
Answer: Chemotherapeutic agents as this requires also double checking with a chemo certified RN. A chemo certification is required
for administration of chemo agents

Conversion Guide

1tsp=5ml
3tsp= 1 Tbsp
0.06ml= 1 minim= 1 drop
10z= 30ml
1 kg=1000mg
1mg=1000mcg

1kg= 2.2 pounds

Safest site for Intramuscular

injections???

Vastus

lateralis

Deltoid
Gluteus maximus
Rectus abdominis
Answer: VASTUS LATERALIS is the safest spot
because it doesnt contain important nervous
tissues that may be damaged and it is less

vascular than the other areas mentioned

Medication Administration

7 Rs:
Right Drug
Right Amount
Right Route
Right time
Right patient
Right approach

Right documentation

Medication Administration
2 ml= maximum volume of injection per
site
Ear drops:
1-3 years: pull pinna down and back
Above 3 years: pull pinna up and back
Rationale: shorter ear canal in children
Microdrop factor for IV fluids- 60
Macrodrop factor for IV fluids- 15

Blood transfusions run for 4-6 hours

INSULINS
Draw

clear followed by cloudy insulins to avoid contamination of clear insulins by the cloudy

insulins
Roll vials in between palms
Rotate injection sites to prevent lipodystrophy
Be reminded of the peak hours of insulin administered- this is the best time to provide snacks as this time hypoglycemic effect of
insulin is peaks

Facilitate difusion of glucose from plasma to cells

Uses: treatment of diabetes mellitus and its acute complications
Given as subcutaneous shots or IV drip
S/E- HYPOGLYCEMIA
Lipodystrophy

DIGOXIN
LANOXIN

Given for mild to severe heart failure

(+) inotropic effect- increases force of ventricular contraction
(-) chronotropic effect- decreases heart rate
Check pulse rate prior- do not give if below 60/min
Side effects: Halo vision, yellow vision, bradycardia
Earliest s/e: anorexia, nausea, vomiting

Digoxin and Dudes and Babies

DO

NOT GIVE IF HEART RATE

Newborn- below 100/min

1-3 years old- below 90/min
3-8 years old- below 70/min
8 years old and above- below 60/min

Bronchodilators
Review

relevant history , VS, character of secretions, other conditions

Monitor VS and breath sounds

Increase fluid intake 2 to 3 Liters/day
Therapeutic levels of theophylline should be maintained

 Evaluate responses to medication

S/E: CNS stimulation,Tachycradia, tremors, headache, nausea, epigastric pain, bronchospasm

Diapers weight for volume

approximation
1 liter of fluid= I kilogram of weight
assuming dry weight of the source (diaper)
has been subtracted

Head lice

S/S: severe itching in affected areas; appearance of lice on hair or clothing

Tx: Kwell/lindane shampoo

Extra-fine-tooth comb
Wash all linens and clothing in hot water to destroy nits and eggs

Potassium Rich Diet

Fruits and fruit juices
Dried fruits/plums
Apricots
Bananas
Cantaloupe
Water melon

Sickle cell Anemia

Mgt:

Oxygenation
Hydration
Rest
Diet: High calorie High protein, increased fluids
Folic acid supplementation for anemia

Open-angle VS Close-angle
Glaucoma
Open-angle- loss of peripheral vision, tunnel vison, difficulty adapting to the dark, halos around
lights, difficulty focusing on near objects
Vague symptoms with client unaware of them for a time; visual acuity deteriorates over time with increasing IOP
Close-angle glaucoma- triggered by pupil dilationhigh emotions and darkness;

S/s: severe eye and face pain, N&V, cplored halos around lights

Crutches
Use palms of the hands when crutch walking
Going upstairs: Good boys go to heaven
good leg goes first bad leg goes last

Suppository Administration
2 inches vaginally or rectally
Lube it!!!!
Nothing more nothing less

Cardiac diet
Low sodium
Low cholesterol
For heart failure: low sodium
For hypertension: low na, low fat
For MI: low Na, low fat

Opening a Sterile Package

Check label for contents, expiry date, instructions
Break seal, touching only edge of package. Open one flap away from you. Do not bend over package
Open side flap, let fall on flat surface. Repeat same with other flap.
Lift flap nearest you

Inhalers
Hold inhaler 2 inches away from mouth
Shake canister before each puff
Exhalethrough pursed lips
Depress inhalation device slowly and
deeply through the mouth
Hold breath for 10 sec and exhale slowly
with pursed lips
Wait 2-5 min between puffs

Spacers

 Place lips tightly around mouthpiece so no

medication will escape
Same process as any inhalers
Good care of spacer: warm water rinses

MEDS for Hyperthyroidism

Antithyroids:Methimazole (Tapazole)
Beta-blockers: Propranolol (Inderal)
Iodine: Lugols solution
Radiation: Radioactive Iodine 131

Iron Rich Foods

Red

meats

Egg yolks
Leafy vegetables
Whole wheat breads
Legumes
Dried fruits

Potassium Rich Foods

Apricots

Avocado
Banana
Cantaloupe
Raw carrots
Dried peas, beans, fruits
Melon, orange, orange juice
Peanuts, white/sweet potatoes
Prune juice, spinach
Tomatoes and tomato products, winter squash

Insulins
Peak hours:

 Regular insulin- 2-4 hours

Insulin Aspart (Novolog)- 1-3 hours
Inslulin lispro (Humalog)- 1 hour
NPH/Humulin N- 6-12 hours
Insulin Zinc (Lente)- 8-12 hours
Ultralente- 18-24 hours
Insulin glargine- 5 hours
Humulin 70/30 4-8 hours

Appendicitis

Pain: located at McBurneys angle; right lower quadrant pain with rebound tenderness

Elevated WBCs
Surgery stat
Preop: NPO, no enemas, no pain medications,no heat applications just cold packs, IVFs, check lytes; Semi Fowlers right side-lying
to localize infection
Postop: immediate ambulation in 6-8 hours

Hypoglycemia

Always

a priority!!!!

Can cause brain damage

Manage according to facility protocol
Glucose tabs, Orange/apple juice if awake
Dextrose 50% 1/2 amp to 1 ampule IV
Glucagon shot
Dextrose 10% IV infusion

SLE
Systemic Lupus Erythematosus
Nursing

Interventions:

Emotional support in coping with prognosis

Alternative activity and planned rest periods
Avoid persons with infections, undue exposure to sunlight, and emotional stress to prevent exacerbations
Diet: high in Iron : liver, shellfish, leafy vegies, enriched bread and cereals

Restraints

Release every 2 hours for med-surg restraints

and check every 1 hour for color movement and

sensation in the extremity involved
Requires order renewal every 24 hours
Siderails, medications are considered restraints

Bone Scan
Isotope

imaging of skeleton

Prep: IV injection of radioactive tracer

Empty bladder prior; hold fluids 4-6 hours prior
to scan
Takes about an hour
May be asked for various positions during test
C/I: pregnancy; barium enema

Crohns Disease
Inflammatory

disease affecting small bowels and

possibly large bowels characterized by

ulcerations in intestinal linings, scar tissue
formation causing narrowing and thickness in
bowels
Unknown cause
May lead to perforation, stricture and obstruction

Crohns Disease
S/S:
Abdominal pain and cramping
Diarrhea
Weight loss
Fever
Anemia
Weakness and fatigue
Anorexia
Abdominal tenderness

Crohns Disease

 Meds: Sedatives, antidiarrheals, antibiotics, steroids, antispasmodics and analgesics

Hydration with IVF
High calorie, high-protein, low-residue diet

Occult Blood Testing

Avoid

red meats 3 days prior to test

May use stool specimen

anytime your pt is taking Antabuse , you should instruct them on AVOIDING any meds that contain alcohol,
such as OTC drugs

1.Conjuctivitis-until discharge ceases.

2.Diarrhea (with other acute symptoms)-until symptoms resolve and Salmonella infection is ruled out.
3.Hepatis A-until 7 days after the onset of jaundice.
4.Hepatits B (acute)-partial client restriction with gloves worn for procedures involving tissue trauma and
mucous membrane or non-intact skin.
5.Hepatitis B (chronic) -unit antigenemia resolves.
6.Group A streptoccocal Infection-until 24 hours after the start of the treatment.
7.Herpes simplex (hands)-until lesion resolve.
8.Herpes Zoster (acute)-Exclusion from care of clients at high risk for infection with use of appropiate barriers.
9.Herpes Zoster (postexposure)-From days 10 to 21 after exposure or until all lesion dry and crust.
10.measles (active)-until 7 days after rash appear.
11.Measles (post-exposure)-from day 5 to 21 after exposure
12.Mumps(active)-Until 9 day after after onset of parotitis
13.Mumps(post exposure)-from days 12 to 26 after exposure.
14.Scabies-until treated
15.S.Aureus skin lesions-until lesion resolve.
16.Upper respiratory infections-Until acute symptoms resolve with exclusion from care of clients at high risk
for infection.
17.Varicella (acute)-until all lesions dry and crust.
18.Varicella (post-exposure)-from day 10 to 21 after exposure.
Transmision based precautions
Precautions-Indications.
Airborne-private,negative airflow room with adequate filtration;mask;mask required by client during transport
out of the room,transmission via airborne route;measles,TB,varicella.
Droplet-private room or cohabitation with client infected with the same organism;mask required when working
within 3 feet of of client;mask worn by client during transport,transmission of large droplets through
sneezing,coughing,talking,haemophilus influenza,multidrug resistant strains,neisseria
meningitidis,diphtheria,rubella,mycoplasma pneumonia,mumps,scarlet fever,strep throat,epiglottis
Steps of the procedure of preparing and maintaining sterile field
Equipment:
*Flat work surface
*sterile drape.
*sterile supplies as needed (sterile gauze,sterile basin,solutions,scissors,foreceps),packed sterile gloves.
1.Wash your hands
2.Check for the integrity of the sterile package,expiration date etc.
3.During the entire procedure,NEVER turn your back on the sterile field or lower your hands below the level of
the field.
4.Open the sterile drape
*start from the outer wrapper and place the inner drape in the center of the of the work surface with the outer

flap facing away from you

*touching the outside of the flap only,reach around rather than over the sterile field to open the flap away
from you first
*open the side flaps,in the same manner,using the right hand for the right flap and the left hand for the left
flap.
5.Lastly ,open the inner most flap that faces you,being careful that it does not touch your clothing or any
object.
Adding sterile supplies to the the field.
general rule
*generally before opening the sterile package you want to assess the order in which supplies will be used
during the procedure so that supplies used first can be added to the field last
1.Prepackaged sterile supplies are open by peeling back the partially sealed edges with both hands or lifting
up the unsealed edge,taking care not to touch the supplies with your hands.
2.Hold supplies 10 to 12 inches above the field and allow them to fall to the middle of the sterile field.Wrapped
sterile supplies are added by grasping the sterile object with one hand and unwrapping the flaps with the
other hand.
3.Grasp the corners of the wrapper with the free hand and hold them against the wrists of the other hand
while you carefully drop the subject onto the sterile field.
Adding sterile solutions to a sterile field
1.Read the solution label and expiration date
2.Remove cap and place it within facing up on the flat surface.Do not touch the inside of the cap or rim of the
bottle.
3.Hold bottle 6 inches above the container on the sterile field and pour slowly to avoid spills.
4.Recap the solution bottle and label it with date and time of opening if the solution is to be reused.
5.Add any additonal supplies and don sterile gloves before starting the procedure.

7. Diltiazem ( Cardizem ) adverse reaction is Heart Failure, hypotention Calcium channel blocking agents, such as diltiazem,
are used cautiously in clients with conditions that could be worsened by the medication, such as aortic stenosis, bradycardia,
heart failure, acute myocardial infarction, and hypotension.
8. Furosemide adverse effect Nocturia and sleep disturbances.
9. Anticholinergic agents cause Dry mouth and urine retention.
10. Atenolol ( Tenormin ) Decrease cardiac output and systolic and diastolic blood pressure. Atenolol may cause bradycardia.
11. Dexamethasone used to decrease cerebral edema and pressure.
12. Methyldopa to reduce blood pressure.
13. Phenytoin to prevent seizure.
14. propranolol adverse effects nausea vomiting depression fatigue impotence.
15. Morphine adverse effects Sedation nausea vomiting constipation and respiratory depression.
16. Nifedipine adverse effects flushing dizziness headache and pedal edema. The client receiving a calcium channel blocking
agent such as nifedipine may develop weakness and lethargy as expected effects of the medication.
17. Atrophine used to treat bradycardia.
18. Dobutamine used ti treat heart failure and low cardiac output.cardia.
19. Amiodarone used to treat ventricular fibrillation and unstable ventricular tachycardia.
20. Lidocaine used to treat ventricular ectopy ventricular tachycardia and ventricular fibrillation.
21 PTSA give antocoagulant aspirin
22. Hydrochlorothiazide is a potassium-losing diuretic, and clients are at risk for hypokalemia. Potassium is found in many
foods, especially unprocessed foods, many vegetables, fruits, and fresh meats. Because potassium is very water-soluble,
foods that are prepared in water are often lower in potassium than the same foods cooked another way (e.g., boiled versus
baked potato). Clients who need potassium added to the diet are encouraged to take in these foods. Many salt substitutes are
also high in potassium.
23. Phenazopyridine ( Pyridium)--Urine will appear orange.
24.Co trimoxazole ( trimethoprim-sulfamethoxazole) given for uti tell pt to drink at least eight 8 oz glasses of fluid daily.
25.Sulfamethoxazole (Gentanlol) adverse effect diarrhea.
26. Co trimoxazole ( Septra) Used to treat UTI and therefore absence of bacteria on urine culture indicates drug effective.
27. phenazopyridine ( pyridium) Used to treat UTI
28. Aldosterone is responsible for sodium reabsorption and potassium excreation by the kidney.
29. During oliguria phase fluids should be limit.
30. Dipyridamole ( Persantine ) to reverse effect if Dipyridamole nurse should have available Aminophyllin ( Theophylline )

Grave disease-hyperthyroidism

Anxiety

Irritability

Difficulty sleeping

Fatigue
A rapid or irregular heartbeat
A fine tremor of your hands or fingers
An increase in perspiration
Sensitivity to heat
Weight loss, despite normal food intake
Brittle hair
Enlargement of your thyroid gland (goiter)
Change in menstrual cycles
Frequent bowel movements

Pharm Prefix/Suffix:
-ase = thrombolytic
-azepam = benzodiazepine
-azine = antiemetic; phenothiazide
-azole = proton pump inhibitor, antifungal
-barbital = barbiturate
-coxib (cox 2 enzyme blockers
-cep/-cef = anti-infectives
-caine = anesthetics
-cillin = penicillin
-cycline = antibiotic
-dipine = calcium channel blocker
-floxacin = antibiotic
-ipramine = Tricyclic antidepressant
-ine = reverse transcriptase inhibitors, antihistamines
-kinase = thrombolytics
-lone, pred- = corticosteroid
-mab = monoclonal antibiotics
-micin = antibiotic, aminoglycoside
-navir = protease inhibitor
nitr-, -nitr- = nitrate/vasodilator
-olol = beta antagonist
-oxin = cardiac glycoside
-parin = anticoagulant
-prazole = PPIs
-phylline = bronchodilator
-pril = ACE inhibitor
-statin = cholesterol lowering agent
-sartan = angiotensin receptor blocker
-sone = glucocorticoid
-stigmine = cholinergics
-terol = Beta 2 Agonist
-thiazide = diuretic
-tidine = antiulcer
-trophin = Pituitary Hormone
-vir = anti-viral, protease inhibitors
-zosin = Alpha 1 Antagonist
-zolam = benzo/sedative
-zine = antihistamine

Alpha vs. Beta: ABCDE

Alpha = Constricts
Beta = Dilates
Beta 1 = Enhances
Rennin stops the runnin' (HOH retention)
Agonist vs. Antagonist
AGOnst - "A GO' - stimulates action

ANTAGOnist - "ANTI "NO GO" - blocks action

Drug Overdoses - ABCD
Anti Depressants (Tricyclics)
Beta Blockers
Calcium Channel Blockers
Digoxin
Diuretics:
Lasix = Loop
Mannitol = osmotic
LASIX = LAsts SIX hours
Aluminum vs. Magnesium Antacid SE's
Think aluminum can - b/c it can constipate
Mag - may move bowels (diarrhea)
Give Narcan for Narcotic OD
Opioid Examples: Her Cousin Meets More Deviates
- Heroin
- Codeine
- Methadone
- Morphine
- Demerol

Pepper has bacteria in it and clients who have aids have to avoid pepper d/t being immunocompromised.
Never would have though of that till it came up as a review question.

ANTICOAGULANTS - ends in parin, rin

THROMBOLYTICS - ends in ase, kinase
ACE INHIBITORS - ends in pril
ANGIOTENSIN II RECEPTOR BLOCKER- ends in sartan
ALPHA ADRENERGIC - ends in zocin
BETA-BLOCKERS - ends in olol
CALCIUM CHANNEL BLOCKER - ends in dipine
DIRECT ACTING VASODILATORS - starts with nitro
CARDIAC GLYCOSIDES - starts with dig
BRONCHODILATORS - ends in terol, terenol, phrine, phylline
ANTIHISTAMINES - ends in tadine, amine, ramine
H2 BLOCKER - ends in tidine
ANTI-EMETICS - ends in setron
PANCREATIC ENZYME REPLACEMENT - starts with pancrea
ADH MEDS - ends in pressin
THYROID MEDS - starts with thyro, thy, thro
CALCIUM REGULATORS - ends in dronate (hypocalcemia), tonin (hypercalcemia)
SULFONYLUREAS - ends in ide, amide, zide, ride
NON-SULFONYLUREAS - ends in glinide, glitazone
ANTIBIOTICS - ends in cillin
CEPHALOSPORINS - starts with ceph, cef
AMINOGLYCOSIDE - ends with mycin, micin
QUINOLONES - ends in floxacin, oxacin

*An antiacid shouldn't be taken w/ medication bcs antacid will affect the absorption of the medication.
*Lopressor---lowers blood pressure
Lo---Low

pressor---pressure
*Angiotensin-converting enzyme meds (ACE)---they end with "pril" such as Ecopril which are for treating
hypertension.

Colloidal Silver is usually excreted from the body when administered in low amounts (under 50 mg per day),
but when it accumulates, it can cause "argyria" which turns the skin grey or BLUE!

lol's -betablockers
prils- ace inhibitors
PTT- Heparin (because the two "tt's" make an H)
INR- Warfarin

BIOLOGICAL WARFARE: BP-AS-TOLERATED-FEVER

B - botulism > (AFW) - Air,Food,Wound contaminated
P - Plague > (FleaR) - Fleas, Rodents
A - anthrax > (GIS) - Gastrointestinal,Inhalation,skin
S - Smallpox > Air Droplet, Materials contaminated
Tolerated - tularemia > (Till death Apart) Tick,Deer flies, Animal infected
Fever - hemorrhagic Fever > (MR) Mosquitoes, Roddents

sources of potassium
P - potatoes,pork,beef,veel
O-oranges
T-tomatoes
A-avacado,banana,carrots,cantaloupe
S- spinach
S-strawberries,raisins
I- fIsh
U
M-mushrooms

Five quick facts for today.

Maternity: 1) Mother's temp > 100.4 F @ 2 consecutive readings, despite
increased hydration is considered febrile, report to physician.
2) Boggy uterine fungus, massage gently until firm, observe for increased
bleeding or clots.
3) Normal FHR : 110-160 bpm.
Pharmacology: 4) Glycerine emmolient used for dry, cracked and irritated
skin.
Cardiovascular: 5) Triametrene, a potassium sparing diuretic, avoid foods
high in potassium, e.g. bananas, avocados, oranges, mangoes, nectarines,
papayas and dried pprunes
Maternity: clinical manifestations of cord compression is variable
deceleration with brief accelaration after a gush of amniotic fluid.
Perform manual sterile vaginal exam to detect the prolapsed cord.
Pharmacology: Client with tachydysrythmias, dont give
bronchodilators containing catacholamines, e.g.
Epinephrine(Primatene Mist) and Isoproterenol HCL(Isuprel)
Child Health: After pyloromyotomy, surgical treatment for

hypertrophic pyloric stenosis, head of bed is elevated and the infant is

placed prone to prevent aspiration.

Infant with laryngomalacia(congenital laryngeal stridor), place in prone position with neck
hyperextended to decrease stridor.

Decorticate posturing: flexion of the upper extremities and the extension of the lower
extremities. Also plantar flexion of the feet. Decerebrate posturing: extension of the
upper extremities with internal rotation of upper arms and wrists. The lower
extremities extend with some internal rotation noted at knees and feet. Progression
from decorticate to decrebrate posturing indicates deteriorating neurological function.

Hep B related jaundice: may get worse before resolving.

Client teaching: discard unused nitroglycerine tablets 3-6 months after bottle opened
& obtain new prescription.

Oral intake after laryngectomy starts with semi-solid diet.

In a neonate, hypoglycemia causes central nervous system symptoms e.g. high

pitched cry, also exhibited by lack of strength during feeding.

Misoprostol(cytotec) is administered to prevent gastric mucosal injury caused by

regular use of NSAID's

MAOI diet ( Tyramine restrictions)

FOODS: MUST AVOID COMPLETELY
Aged red wines (cabernet sauvignon/merlot/Chianti)

Aged (smoked, aged, pickled, fermented, marinated, and

processed) meats (pepperoni/bologna/salami, pickled
herring, liver, frankfurters, bacon, ham)

Aged/mature cheeses (blue/cheddar/provolone/Brie/

Romano/Parmesan/Swiss)

Overripe fruits and vegetables (overripe bananas/

sauerkraut/all overripe fruit)

Beans (fava/Italian/Chinese pea pod/fermented bean curd/

soya sauce/tofu/miso soup)

Condiments (bouillon cubes/meat tenderizers/canned

soups/gravy/sauces/soy sauce)

Soups (prepared/canned/ frozen)

Beverages (beer/ales/vermouth/whiskey/liqueurs/nonalcoholic
wines and beers)

FOODS: USE WITH CAUTION (MODERATION)

Avocados (not overripe)

Raspberries (small amounts)

Chocolate (small amount)

Caffeine (2 8 oz. servings per day or less)

Dairy products (limit to buttermilk, yogurt, and sour cream

[small amounts]; cream cheese, cottage cheese, milk OK if
fresh)
MEDICATIONS: MUST AVOID

Stimulants and decongestants

OTC medications (check with PCP/pharmacist)

Opioids (e.g., meperidine

1. Insertion of CVC, pt. should NOT deep breath. instead pt SHOULD do Valsalva Maneuver.
2. Sulfonamides are to treat inflammatory bowel disease, increase fluids

3. Multiple Myeloma is unique as a neoplastic condition that is better dected with a plain radiograph than with a
nuclear scan. If bone scan is done then false negative result will occur. Therefore avoid bone imaginig for pt
with multiple myeloma.
4.mumps s/s= HA,malaise, anorexia, earache
A nurse is preparing to administer digoxin (Lanoxin) to an infant with congestive heart failure (CHF). Before
administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full min. and
obtains a heart rate of 88beats/min. Based on this finding, what is the appropirate nursing action?
Digoxin is effective within a narrow therapeutic range (1.0 to 2.0 ng/mL). Safety in dosing is achieved by
double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100
beats/min in an infant, the nurse would withhold the dose and contact the physician.
Differentiating Gastric ulcer pain & duedonal ulcer pain:
Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be
exacerbated by food. The pain occurs a half-hour to an hour after a meal and rarely occurs at night. Duodenal
ulcer pain is usually located to the right of the epigastrium. The pain associated with a duodenal ulcer occurs
90 minutes to 3 hours after eating and often awakens the client at night.
After amputations the nurse should ensure that a surgical tourniquet is in the client's room as one of the priority
items. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the
primary immediate complication of amputation. Therefore, a surgical tourniquet is kept at the bedside in case of
acute bleeding.
Educating of a patient who has arteriovenous (AV) fistula should include following info :
An AV fistula provides access to the client's bloodstream for the dialysis procedure. The client is instructed to
monitor fistula patency daily by palpating for a thrill. The client is instructed to avoid compressing the fistula
with tight clothing or when sleeping and that blood pressure measurements and blood draws should not be
performed on the arm with the fistula. The client also is instructed to assess the fistula for signs and symptoms
of infection, including pain, redness, swelling, and excessive warmth.
I like this Trend ,it has helped me alot in preparation for my test,Guys keep the ball rolling. Let me chip in this
fact hopefully it will help.
FLUROQUINOLONES: EXAMPLES,CIPROFLOXACIN,NORFLOXACIN,OFLOXACIN.
They may increase the serum level of methylxanthines eg theophyllines causing methylxanthines toxicity.
For CIPROFLOXACIN,use with caution on patients with renal disease,CNS,and seizure disoders,even those
taking theophylline.It can cause nausea, vomiting, diarrhrea, constipation, dizziness, flatulence, headache and
confusion.Watch out for toxic effect which can cause superinfecton
Cardio
VT
Ventricular tachycardia is characterized by the absence of P waves on ECG and there are wide QRS
complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/min. The
rhythm is regular.

Cardio
Pericardiocentesis (a procedure which can be performed to fix cardiac tamponade problem)
-- Following pericardiocentesis, a rise in blood pressure and a fall in central venous pressure are
expected.
--The client usually expresses immediate relief.
-- Heart sounds are no longer muffled or distant.

What to do when a patient comes to an ER with an insect in the ear?

-- Insects are killed before removal unless they can be coaxed out by a flashlight or by a humming
noise.
-- Mineral oil or diluted alcohol may be instilled into the ear to suffocate the insect, which is then
removed by using ear forceps.

-- When the foreign object is vegetable matter, irrigation is not used because such material may
expand with hydration, thereby worsening the impaction.

How to communicate with a patient who has a hearing impairment?

-- speaking in a normal tone; avoiding shouting
-- talking directly to the client while facing the client; and speaking clearly.

-- If the client does not seem to understand what is said, the statement
should be expressed differently. Moving closer to the client and toward the
better ear may facilitate communication, but talking directly into the
impaired ear should be avoided.
Weber's hearing test
-- In the Weber tuning fork test, the nurse places the vibrating tuning fork in
the middle of the client's head, at the midline of the forehead, or above the
upper lip over the teeth. Normally, the sound is heard equally in both ears by
bone conduction.
-- If the client has a sensorineural hearing loss in one ear, the sound is heard
in the other ear.

-- If the client has a conductive hearing loss in one ear, the sound is heard in
that ear.
How to conduct an otoscopic examination on an adult patient?
In the otoscopic examination;
--the nurse tilts the client's head slightly away and holds the otoscope upside
down as if it were a large pen.
--The pinna is pulled up and back and the nurse visualizes the external canal
while slowly inserting the speculum.

--A small speculum is used in pediatric clients. The nurse may not be able to
adequately visualize the ear canal if a small speculum is used in the adult
client.
Mastoidectomy:
What is the mastoid bone?
The mastoid bone is a bone located behind the ear (felt as a hard bump behind the
ear). Inside it looks like a honeycomb, with the spaces filled with air. These air cells
are connected to the middle ear through an air filled cavity called the mastoid
antrum. Although the mastoid bone serves as a reserve air supply to allow normal
movement of the eardrum, its connection to the middle ear may also result in the
spread of middle ear infections to the mastoid bone (mastoiditis).
What is a mastoidectomy?
A mastoidectomy is a surgical procedure designed to remove infection or growths

in the bone behind the ear (mastoid bone). Its purpose is to create a "safe" ear and
prevent further damage to the hearing apparatus.

After mastoidectomy,
-- the nurse should monitor vital signs and inspect the dressing for drainage
or bleeding.
-- The nurse also should assess for signs of facial nerve injury (cranial nerve
VII).
-- The nurse also should monitor for signs of pain, dizziness, or nausea.
-- The head of the bed should be elevated at least 30 degrees, and the client
should be instructed to lie on the unaffected side.

-- The client probably will have sutures, an outer ear packing, and a bulky
dressing, which is removed on approximately the sixth day postoperatively.
Presbycusis

Presbycusis is a type of hearing loss that occurs with aging. It is a gradual

sensorineural loss caused by nerve degeneration in the inner ear or auditory
nerve.
Motion sickness medications
-- To be maximally effective, medications to prevent motion sickness should
be taken at least 1 hour before the triggering event.
-- Medications that are commonly used for this purpose include
** imenhydrinate (Dramamine)
**scopolamine (Transderm-Scop)
**promethazine (Phenergan)
**prochlorperazine (Compazine).

Labs

Creatine Kinase MB and Troponin - indicative of a MI if elevated

Troponin is more popular... its more specific and will remain elevated for a longer
period of time after pt has a MI.
C-Reactive Protein - if elevated, pt has inflammation in body... it is not specific to
where the inflammation is
INR - Warfarin

aPTT - Heprin
MEDS
Digoxin - works by strengthening heart contraction, give to pt who has CHF
ACE Inhibitors - be cautious of a persistent cough (contact MD if present)
COPD pts
- teach pursed liped breathing
- never give more than 2L of O2

- Rubella immunization is contraindicated during pregnancy because the vaccine contains live virus
which ca have teratogenic effects on the fetus.
- (+) Homan's sign indicates thrombosis which is abnormal for a postpartum client
- Metropolol masks the signs of hypoglycemia
- Ambivalence is the most common characteristic among suicidal clients
- Salicylates may interact with insulin causing hypoglycemia.
- Kaposi's sarcoma is the most common cancer associated with AIDS

Valproic Acid (Depakene)- antiepileptic

Lithium- dose should be adjusted when sweating, adding meds, illness with high
fever
Thyroid replacement- lifelong therapy
Gentamycin- do not apply to large areas may cause toxicity
tPa- lab values that should be examined, Hemoglobin, hematocrit, and platelet
Interferon- tx of hepa B
Ulna- heals in about 12 weeks
Femur- heals in 24 weeks
Epstein Pearls- tiny hard white nodules found in the mouth of the neonate, normal
and usually disappears without tx
Stationary bike- best for non-wt bearing exercise

Endocrine tips
In the test result for glycosylated hemoglobin A1c,
----7% or less indicates good control,
---- 7% to 8% indicates fair control,
----8% or higher indicates poor control.
**This test measures the amount of glucose that has become permanently bound to the
red blood cells from circulating glucose. Elevations in the blood glucose level will cause
elevations in the amount of glycosylation.
**Thus, the test is useful in identifying clients who have periods of hyperglycemia that are

undetected in other ways. Elevations indicate continued need for teaching related to the
prevention of hyperglycemic episodes.

Endocrine
The primary goal of treatment in hyperglycemic hyperosmolar nonketotic syndrome
(HHNS) is
---to rehydrate the client to restore fluid volume and to correct electrolyte
deficiency.
---Intravenous fluid replacement is similar to that administered in diabetic
ketoacidosis (DKA) and begins with IV infusion of normal saline.
---Regular insulin, not NPH insulin, would be administered.

---An insulin pump provides a small continuous dose of regular insulin subcutaneously
throughout the day and night
--- the client can self-administer a bolus with an additional dose from the pump before
each meal as needed.
---Regular insulin is used in an insulin pump.

---Insulin doses should not be adjusted nor increased before unusual exercise.
---If ketones are found in the urine, it possibly may indicate the need for additional insulin.
---To minimize the discomfort associated with insulin injections, insulin should be administered at
room temperature.
---Injection sites should be rotated systematically within one anatomic site.

In DKA (Diabetic Ketoacidosis),

---the arterial pH is lower than 7.35,

---plasma bicarbonate is lower than 15 mEq/L,
--- the blood glucose level is higher than 250 mg/dL,
---ketones (Acids created by the process of burning body fat; if the body produces
too many ketones, they are excreted in the urine) are present in the blood and
urine.
---The client would be experiencing polyuria, and Kussmaul's respirations would be
present.
---A comatose state may occur if DKA is not treated, but coma would not confirm
the diagnosis.

---Shakiness is a sign of hypoglycemia and would indicate the need for food or glucose.
---A fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

During illness,

---the client should monitor blood glucose levels and should notify the physician if
the level is higher than 250 mg/dL.
--- Insulin should never be stopped. In fact, insulin may need to be increased
during times of illness.

---Doses should not be adjusted without the physician's advice and are usually
adjusted based on blood glucose levels.
Potassium chloride
--administered intravenously must always be diluted in IV fluid and infused via a
pump or controller.
--The usual concentration of IV potassium chloride is 20 to 40 mEq/L.
--Potassium chloride is never given by bolus (IV push). Giving potassium chloride
by IV push can result in cardiac arrest.
--Dilution in normal saline is recommended, but dextrose solution is avoided
because this type of solution increases intracellular potassium shifting.
--The IV bag containing the potassium chloride is always gently agitated before
hanging.
--The IV site is monitored closely because potassium chloride is irritating to the
veins and the risk of phlebitis exists.

--The nurse monitors urinary output during administration and contacts the
physician if the urinary output is less than 30 mL/hr.
After adding a medication to a bag of intravenous (IV) solution,
--the nurse should agitate or rotate the bag gently to mix the medication evenly in
the solution.
--The nurse should then attach a completed medication label.

--The nurse can then prime the tubing.

--Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal
atrophy, which reduces the ability of the body to withstand stress. When stress is
severe, corticosteroids are essential to life. Before and during surgery, dosages
may be increased temporarily.
--Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia.
--Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant.
--Conjugated estrogen (Premarin) is an estrogen used for hormone replacement
therapy in postmenopausal women.

***These other three medications may be withheld before surgery without undue
effects on the client.
Anticoagulants alter normal clotting factors and increase the risk of bleeding after
surgery.
--Aspirin has properties that can alter the clotting mechanism and should be
discontinued at least 48 hours before surgery.
Lisinopril
-- is an antihypertensive angiotensin-converting enzyme inhibitor.
--The usual dosage range is 20 to 40 mg daily.
--Adverse effects include headache, dizziness, fatigue, orthostatic hypotension,
tachycardia, and angioedema.
--Specific client teaching points include taking one pill a day, not stopping the
medication without consulting the physician, and monitoring for side effects and
adverse reactions.

--The client should notify the physician if side effects occur.

--Polypharmacy is a concern in the geriatric population.
--Duplication of medications needs to be identified before drug-drug interactions or
adverse side effects can be determined.

--The phone call to the health care provider is the intervention after all other
information has been collected.
Asthma is a chronic inflammatory disease of the airways.
--Inhaled aerosolized short-acting 2 agonists are quick relief medications and
recommended for clients with status asthmaticus after epinephrine has been
administered.

--Leukotriene modifiers, antiallergic medications, and nonsteroidal antiinflammatory medications are long-term control medications.
Hemophilia refers to a group of bleeding disorders resulting from a deficiency of
specific coagulation proteins.
--The primary treatment is replacement of the missing clotting factor; additional
medications, such as those to relieve pain, may be prescribed depending on the
source of bleeding from the disorder.

--A child with hemophilia A will be at risk for joint bleeding after a fall. Factor
VIII will be prescribed intravenously (IV) to replace the missing clotting factor
and minimize the bleeding.
In severe cystic acne, isotretinoin (Accutane) is used to inhibit inflammation.
--Adverse effects include elevated triglyceride levels, skin dryness, eye discomfort

such as dryness and burning, and cheilitis (lip inflammation).

--Close medical follow-up is required, and dry skin and cheilitis can be decreased
by the use of emollients and lip balms.

--Vitamin A supplements are stopped during this treatment.

Propylthiouracil is used to treat hyperthyroidism
---propylthiouracil (PTU) may convert the client from a hyperthyroid state to a
hypothyroid state. If this occurs, the dosage should be reduced.

--Temporary administration of thyroid hormone may be required.

--Levothyroxine (Synthroid) is a synthetic thyroid hormone that increases cellular
metabolism.
--Levothyroxine should be given in the morning in a single dose to prevent
insomnia and should be given at the same time each day to maintain an adequate
drug level.
Desmopressin acetate (DDAVP)
--is a synthetic form of antidiuretic hormone that causes increased reabsorption of
water, with a resultant decrease in urine output.
--The therapeutic response to DDAVP would be a decrease in serum osmolality,
because more fluid is retained, and an increase in urine osmolality, because less
fluid is excreted.

--Hypotension may be apparent with diabetes insipidus and blood pressure may
increase as extracellular fluid volume is restored.
Classic symptoms of hyperglycemia include
--polydipsia (Excessive thirst or drinking),
--polyuria

-- polyphagia (excessive appetite for food)

Polydipsia and polyuria are classic symptoms of diabetes insipidus. The urine is
pale, and the specific gravity is low. Anorexia and weight loss occur.
Because of the hypermetabolic state, the client with hyperthyroidism needs to be
provided with
--an environment that is restful physically and mentally.
--Six full meals a day that are well balanced and high in calories are required
because of the accelerated metabolic rate.
--Foods that increase peristalsis, such as high-fiber foods, need to be avoided.
--These clients suffer from heat intolerance and require a cool environment.

Following thyroidectomy,
--weakness and hoarseness of the voice can occur as a result of trauma from the
surgery.
--If this develops, the client should be reassured that the problem will subside in a
few days.

--Unnecessary talking should be discouraged.

DKA (Diabetic ketoacidosis) tretment
--Lack (absolute or relative) of insulin is the primary cause of DKA.

--Treatment consists of insulin administration (regular insulin), IV fluid

administration (normal saline initially), and potassium replacement, followed by
correcting acidosis.
Hyperglycemic hyperosmolar nonketotic syndrome
-- occurs in clients with type 2 diabetes mellitus.
--The onset of symptoms may be gradual.
--The symptoms may include polyuria, polydipsia, dehydration, mental status
alterations, weight loss, and weakness

To know the normal systolic for a child 1-7 years old

Age +90. Example 3yo child = 93 systolic.

Here is another. Do not mix zosyn and gentamycin IV wait at least an hour to
decrease the risk of gentamycin inactivation.
Coal tar
--is used to treat psoriasis and other chronic disorders of the skin.
--Coal tar suppresses DNA synthesis, mitotic activity, and cell proliferation.
--Coal tar has an unpleasant odor, frequently stains the skin and hair, and can
cause phototoxicity.

--Systemic toxicity does not occur.

Mafenide acetate
--is bacteriostatic for gram-negative and gram-positive organisms and is used to
treat burns to reduce bacteria present in avascular tissues.
--The client should be informed that the medication will cause local discomfort and
burning.

-- is a carbonic anhydrase inhibitor and can suppress renal excretion of acid,

thereby causing acidosis.
-- Clients receiving this treatment should be monitored for signs of an acid-base
imbalance (hyperventilation).

--If this occurs, the medication should be discontinued for 1 to 2 days.

Sodium hypochlorite
--is a solution used for irrigating and cleaning necrotic or purulent wounds.
--It cannot be used to pack purulent wounds because the solution is inactivated by
copious pus.
--The solution should not come into contact with healing or normal tissue and
should be rinsed off immediately following irrigation.
--The solution loses its potency during storage, so fresh solution should be
prepared frequently.
Isotretinoin (Accutane)
-- can elevate triglyceride levels.
--Blood triglyceride levels should be measured before treatment and periodically
thereafter until the effect on the triglycerides has been evaluated.
Lindane (treatment for scabies)
--is applied in a thin layer to the body below the head. No more than 30 g (1 oz)
should be used.

--The medication is removed by washing 8 to 12 hours later.

--In most cases, only one application is required.
Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from
regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum,
genitalia), and lower from regions where permeability is poor (back, palms, soles).
The normal platelet count is 150,000 to 450,000/mm3. When the platelets are lower than
50,000 /mm3, any small trauma can lead to episodes of prolonged bleeding. The normal white
blood cell count is 5,000 to 10,000/mm3. When the white blood cell count drops, neutropenic
precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal
ammonia value is 15 to 45 mcg/dL.
Crestor=Rhabdomyolysis (muscle Weakness)
PH of stomach acid lessthan 4 is good
Drug catagory X=risk for fetus
Colchicine=antigoout medication
Lasix=K wasting=increasebananas and oranges
heart failure infant=increased resp rate
PIH=periorbital and facial edema
Thallium stress test=allergic to Iodine should be asked
Warm insulin bottle is good for 1 month only
Causes of abdominal distention
The 6 F's
Flatus----Feces----fetus----Fluid---Fat----Fatal(Malignant) neoplasm
1. If mishap occured like patient fell, write up an incident report and NEVER chart in the medical
records that an incident report was filed.
2. If px died and was found on drivers license to be an organ donor, still have to get permission
from next of kin before taking organs. order of priority is
1st ask the spouse, if none...2nd ask son or daughter, 3rd mother, 4th adult brother or sister, 5th
Legal Guardian.
3. For airborne diseases measles, varicella, TB....use a particulate filter mask not a surgical mask

4. For droplet isolation patients, everyone must wear a mask if they are going wtihin 3 feet of the

patient.
5. PKU, baby born without ability to utilize essential amino acid called phenylalanine so don't give diet soda bec
it contains nutrisweet, nutrisweet contains phenylalanine.
The rules of Management:
Do not delegate assessment teaching or evaluation
Delegate care for stable pt's with expected outcomes
Delegate tasks that involve standard unchanging proceedures
Treatment for Monnucleosis= Bedrest

Amphojel=S/E Constipation
Diagnostic test for cirrhosis=Liver biopsy
Contaminated shellfish=Hep A
Murphy's sign=On deep inspiration pain is elicited and breathing stops
Abd Ultrasound=Dx for cholecystitis
Pancreatitis=avoid Caffine and alcohol
Pancreatitis= increased Amylase and lipase and glucose and decreased serum CA levels
After liver biopsy=place client on the right side laying position with the bed flat
Tensilon test=Mysthesia gravis
Xerostomia=dry mouth
dysgeusia=siminish sense of taste
Dilantin can cause decreased HR hypotension
Pyridium=Causes the urine to be red or orange
Club soda=sodium chloride
Gallbladder is on the right
Guthrie blood test is a test for PKU
Tetracycline can cause staining of the teeth
Test for seizures=EEG
Vit C may decrease warfarin effects
Vit E may increase warfarin effects
Dumping syndrome=moderate fat low carbs diet
Colostomy begins to function 3-6 days after surgery
Viagra=NO Nitroglycerin
250ml=I unit of PRBC (packed red blood cells)
Calcium and aluminum based antacids cause constipation
Magnesium based cause diarrhea
Mydriatics (big word big pupil) treats cataracts...I always picture a cat acting ( CAT ar ACTS) in a big whole ...it
sound stupid I know!
Miotics (small word small pupil) treats glaucoma
Maternal hypotension after an epidural anethesia: STOP
S= stop pitocin if infusing
T= Turn on left side
O=Oxygen
P= Push fluids (if hypovolemia)
HELLP= hemolysis, elevated liver enzymes, and low platelet count=elevated hepatic enzymes
Chronic renal failure patients should avoid astringent cleansing pads
Clients with a central venous catheter receiving TPN has an air embolus the nurse should clamp the catheter
immediately and notify the physician.
Crackles in the lung fileds of the peritoneal dialysis client result from overhydration or from insufficient fluid
removal during dialysis. Intake grater than the output of the peritoneal dialysis fluid would overhydrate the
client, resulting in lung crackles.
Colonoscopy=Left sims position
Normal platelets=150-400 cells mcg/l
No morphine=pancreatitis it causes spasms of oddis spincter.
Antineoplastic drugs=leukopenia=private room
Terminal patient=Palliative care
Tamoxifen increases the effects of Warfarin sodium
Tachycardia commonly occurs after giving Atropine
MMR Vaccine=Ask if Allergic to Gelatin, Eggs, or neomycin
Pneumocystis Carinii=Fungal
Vasopressin is a synthetic ADH Its used for treatment for Diabetes Insipidus which results from deficient ADH
Glyburide=30 mins before breakfast

Pt with Thrombus in the leg on heparin=Strict bed rest

Ticlopidine (Ticlid) is used as a antiplatelet drug for Salicylate (Aspirin) sensitivity.
Protamine sulfate=comes from the sperm of salmon and other fish so don't use if allergic to fish
Blood drawn for APTT on heparin is in 4 hours. Early would show high
Potassium is the most abundant cation in the ICP followed by Magnesium.Because Potassium isn't stored it
must be replaced every day.
Rh immunization for pregnant is:
Rh immunization of Rhogam is given when an Rh incompatibility occurs, which only oocurs if the mother is
Rh negative and the baby being born is Rh positive. It does NOT occur when an Rh positive mom gives birth to
an RH negative baby.
If some of the baby's red blood cells leak into RH-mom's system, then her body may produce antibodies to the
Rh D factor (a condition called sensitization). These antibodies can cross the placenta and destroy the red blood
cells in your unborn baby or in the next Rh-positive baby you have.
***In most cases, the mom will not be exposed to the baby's blood until she gives birth.......
This usually means that first baby will NOT be affected.
****HOWEVER, large amounts of the baby's blood can leak into the mother during delivery. If the mom is Rh
negative, the next Rh-positive baby that she could have may have problems if the Rh-negative mom has
developed antibodies
***** Occasionally, in the following situations, some of the baby's blood may leak into the mom's blood system
during pregnancy:
1.
2.
3.
4.

After amniocentesis or other invasive procedure

During a miscarriage or abortion
During an ectopic pregnancy
If the mom bleeds heavily during pregnancy.

Disseminated intravascular coagulation (DIC) and s/s

Disseminated intravascular coagulation (DIC) occurs when the body's clotting mechanisms are activated
throughout the body in response to an injury or a disorder, instead of being isolated to the area of initial onset.
Platelets circulating throughout the body form small blood clots (thrombi) primarily in the area of the
capillaries. This eventually causes the clotting factors to be used up, and none are left to form clots at the site
of the injury. The presence of numerous small clots precipitates the release of clot-dissolving mechanisms, and
the end result is generalized bleeding throughout the body.
This disorder can result in clots or, more often, in bleeding. The bleeding can be severe.
Risk factors for DIC include:
Blood transfusion reaction
Cancer, including leukemia
Infection in the blood by bacteria or fungus
Pregnancy complications (such as retained placenta after delivery)
Recent surgery or anesthesia
Sepsis (an overwhelming infection)
Severe liver disease
Severe tissue injury (as in burns and head injury)
Signs & Symptoms Include:

Bleeding (possibly from multiple sites in the body),

Blood clots,
Drop in blood pressure, AND
Sudden bruising
therapeutic level of Lithium..
I have answers from 2 different resources;
0.8 to 1.2 mEq/L ................AND ...................

0.6 to 1.2 mEq/L with therapeutic dose = 300-2700 mg/d

Risk factors for specific cancers:
Bladder = Smoking, exposure to industrial, chemicals, radiation.
Prostate= African American and age 55 and older
Laryngeal = Smoking, uses of tobacco and alcohol, exposure to environmental pollutants, exposure to radiation
and carcinogens, nutritional deficiency (riboflavin)
Lung = Smoking, exposure to environmental pollutant, vitamin A deficiency, heredity.
Pancreatic= High fiber and high carb, smoking, exposure to industrial chemicals, diabetes, chronic
pancreatitis.
Breast = family history, early menarche and late menopause, previous cancer of the breast, uterus, or ovaries,
nulliparity, obesity, high-dose radiation exposure to chest, diet high in fat, alcohol intake, the use of birth
control pills and hormonal replacement.
Endometrial= history of uterine polyps, nulliparity, polycystic ovary disease, estrogen stimulation, late
menopause, family history.
Ovarian= diet high in fat, family history of ovarian or breast cancer, alcohol use, history of breast cancer,
endometrium cancer, colon cancer, nulliparity, infertility,
Cervical= low socioeconomic, early first marriage, early and frequent intercourse, multiple sex partners, poor
hygiene, Human papillomavirus, HIV infection, smoking during pregnancy and cervical infection.
Testes= over the age of 15 and 40, infection, genetic and endocrine factors, cryptorchidism
PIH=Periorbital and facial edema
Pt. intubeted and a high alarm will sound when the patient is bitting the tube.
Halo traction=Sterile pin site care
T-12 spinal injury=No message to the bladder.
Thallium stress test=Allergic to Iodine should be asked
5 Post ops causes of fever
Wind-check lungs
Wound-Cl sirgoca; sote
Water-I V site
Walk-DVT check
Whiz-Catheter
Wonder drungs-drug fever
Measles warrents=resp isolation
Bacterial meningitis=Resp isolation
Methotrexate therapy=in 2 weeks expect to see signs of bone marrow depression
When pregnant increase your calories by 500 Kcals
Dystonia occurs after a few days of treatment of haldol
Heart failure infant=Increased resp rate
Trough level=lowest level of the drug should be done immediately before administering the next dose
Glycosylated hemoglobin values less than or equal to 7.5% indicates good diabetic control
Preterm infant before 37 weeks
Term infant older than 37 weeks
post erm 42 weeks
38-41 weeks is term
you should not insert a NG tube if there is a suspected skull fracture.
Deferoxamine is the antidote for iron poisoning
Cipro treats anthrax
Cretinism=Hypothyroidism found in the neonate
Nrdil (Pnenelazine) is a MAOI avoid figs, chocolate, and eggplant. It cause hypertensive crisis.
Multiple sclerosis=test EEG/LP
A pregnant nurse should not be assigned to any client with radioactivity present.
OK for a Preg nurse to care for a client receiving liner ascelerator radiation therapy for lung cancer.
Client with Cushing syndrome, with incresed level of cortisone cause the client to be immune suppressed, Pt
should be put in a private room.
complications of bucks traction=Weak peda pulses
1. To check for petechiae in a dark-skinned client, assess the oral mucosa
2. Seventh-Day Adventists are usually vegetarians
3. The three types of embolism are air, fat, and thrombus
4. Before discharge, a client who has had a total laryngectomy must be able to perform tracheostomy care and suctioning
and use alternative means of communication.
5. The universal blood donor is o negative
6. The universal blood donor is ab positive
7. Mucus in a colostomy bag indicates that the colon is beginning to function
8. Fatique is an adverse effect of radiation therapy.

9. celiac disease may eat rice

10. Dumping syndrome-limit liquids and high carbohydrate foods.
Addisons Disease: Hypo NA+, Hyoglycemia, Hypercalcemia and Hyperkalemia.... and the exact oppisite for Cushings
syndrome!
Diabetes Insip... can concentrat urine!
Addisoinan Crisis is treated with High dose steriods and Fluid replacment
for treatment of

hypertension try 4,3,2,1

ANGIOTENSIVE CONVERTING ENZYME INHIBITOR .
BETA ENVAS.
CALCIUM CANNEL BLOCKER.
DIURATICS

A 44-lb preschooler is being treated for inflammation. The physician orders 0.2 mg/kg/day of dexamethasone
(Decadron) by mouth to be administered every 6 hours. The elixir comes in a strength of 0.5 mg/5 ml. How
many teaspoons of dexamethasone should the nurse give this client per dose?
Answer:

Correct Answer: 2
Your Answer: 2
RATIONALES: To perform this dosage calculation, the nurse should first convert the child's weight
from pounds to kilograms:
44 lb 2.2 lb/kg = 20 kg
Then she should calculate the total daily dose for the child:
20 kg 0.2 mg/kg/day = 4 mg
Next, the nurse should calculate the amount to be given at each dose:
4 mg 4 doses = 1 mg/dose
The available elixir contains 0.5 mg of drug per 5 ml (which is equal to 1 teaspoon). Therefore, to
give 1 mg of the drug, the nurse should administer 2 teaspoons (10 ml) to the child for each dose.

page 355

Testing three weeks after the end of class?

If you are testing three weeks after the instructor-led portion of your preparation
ends, plan to answer 110 questions/day.
Week 1 after end of class
Answer and review:
Question Trainer Tests 4, 5, 6, and 7
Week 2 after end of class
Answer and review:
Qbank700 questions in 50-question blocks
Qbank10 questions
Week 3 after end of class
Answer and review:
Qbank700 questions in 50-question blocks

Qbank10 questions
Sample Test 1, 2, 3, and 4

Content
Dialysis (peritoneal all fluid, hemodialysis clots
MRA magnetic resonance angiography most important to report, vagal nerve stimulator device
implant 2 years ago (no iodine, dont care about shellfish)
Type 1 diabetes + Raynauds disease which requires intervention pulse ox and bp on same arm, pulse
ox on ring finger,
2 hours after percutaneous liver biopsy, which finding requires an intervention by nurse my stomach
feels tight and experiences ab pain when changing position in bed
Cystoscopy post op 24 hours, constant aching pain in lower abdominal area complication
8oz = 1 cup, 30mL = 1oz
Suction regulation pressure 80-120mmHg
Croup barking cough, high temp, sounds horase, noisy breath
cullen's sign bleeding around stomach, start IV, know theyre bleeding
Sick day rule diabetes - Check your blood sugar at least every 3 to 4 hours, or more often if it is rising
quickly while sick
Sickle cell drink more than 8 ounces fluid
Started chemo 4 days after check inside of clients mouth (stomatitis)
2 weeks after total laryngectomy, which state most concerns I clean the area around stoma with
alcohol (clean with water and soap once a week)
Ileostomy sit on edge of bed before getting up
Psoriasis (skin redness autoimmune) humira suppress immune stay away from people with cold
Impetigo (honey color crusts) treat with abx, wash hands before/after. loosened with Burrow's solution
compress, remove, then ointment), complication - periorbital edema, indicative of poststreptococcal
glomerulonephritis
Impetigo/influenza - child go be in contact with other at least 24 hours after abx
Aspirin one tablet daily, most important for the nurse to follow up on which statement I take 400mg
garlic tablet
Nurse gets call from parent of child with asthma, parent reports child irritable and neck/chest itching,
what question most important for nurse to ask what is your childs peak expiratory flow rate (best
asthma assessment question)
Detached retina has repair (sclera buckling) avoid jarring movement of head, no
reading/writing/straining/sewing, sleep on ab affected side down, assess for nausea (increases IOP)
Otitis media (ear infection) what instructions to include observe for headache, stiff neck, increasing
temp (meningitis), getting ready for surgery ask if problems with vertigo (prevent injury)
4 week old has plyroic stenosis, most important after feeding position R right 45 degree HOB
Pt alcohol and cirrhosis, which statement teaching effective cough and deep breath frequently
Lasix IV ordered, client reports SOB at rest and nurse notes BL 2+ pretibial pitting edema, most
important for nurse to take which action administration of the medication obtain clients BP..
Client with RA, ROM exercises ordered , what action should nurse take first observe client during
abduction, adduction, extension, and flexion of joint
Nurse cares for elderly client from extended care facility, client confused and fam reports 3 pound
weight loss over last week, most important action for nurse to take obtain a serum albumin level
(nutritional marker)
Nurse cares for a client with aplastic anemia (bone marrow not making enough RBC/WBC), most
important for nurse to take which action? observe oral mucosa and lips (assess severity of anemia)
Iron deficiency anemia look for eye (blue color in eye)
Home care nurse instructs client with right sided weakness about cane use which requires immediate
intervention client advanced the right leg first when going up (cane in strong hand, good up down
bad, cane should be at greater trochanter) elbow should be 30 degrees, tip of cane 15cm lateral to
fifth toe, for walking cane first, then bad leg then good leg

Clinic nurse reviews client records, nurse determines that which clients at risk of developing
pathological fracture cortisone, bone cancer, osteoporosis
Client with degenerative joint disease which indicate further teaching needed I need to decrease
smoking, I should bend at waist
Nurse performs assessment of client with terminal cancer. Client says SOB, no appetite, hurts
everywhere, which statement by nurse is best what have you found to be effective for pain control in
past
The nurse cares for an elderly client with fractured right femur, nurse is most concerned if which
observation made client plucks at bed covers and confused about date/location
Elderly client reports difficulty sleeping, which statement by nurse most appropriate how many times
do you awaken during night
Several hours after thyroidectomy, client diaphoretic/confused, temp 102, bp 160/90, pulse 118,
respirations 22, IV .9 NaCl running, which order will nurse do first propranolol (Inderal) 1mg IV
(thyroid storm)
Skeletal traction for a compound fracture of right femur, which finding will nurse investigate first leg
is raised to adjust traction, clients right foot toes are pale and cool
Adult from ER reporting left flank pain, n/v. an xray shows renal calculi, which action nurse take
initially? administer morphine sulfate
Elderly client brought by spouse to clinic. Nurse notes 10 year history of chronic renal failure, taking otc
cimetidine for 2 weeks. It is most important for nurse to investigate which statement made by clients
spouse my spouse seems to be having more trouble remembering things lately
Female client contacts nurse reports she becomes fatigued easily, has fewer menstrual periods, always
cold and her hair seems more brittle, which response by nurse is most appropriate (hypothyroidism)
can you describe how your muscles feel
72 yo client brought to clinic reports not eating well but healthy. Nurse determines which meal best for
client? Broiled chicken, broccoli, milk
Nutritional counseling for lactovegetarian diet oatmeal banana milk / yofu/veggie/tea, pb
toast/lemonade
Lacto-ovo diet can have eggs
Assess elderly w tpn, nurse most concerned w UO 150ml/hralbumin low (expected, 3.5.-5)
Nurse assess progress of client with acute glomerulonephritis most concerned with fixed urine
specific gravity
Nurse cares for a client with peritoneal dialysis, during 1 hour exchange, nurse infuses 2000mL
dialysate, 1900 outflow returned, client drinks 8oz, 2 cups water, voids 150mL. calculate intake in mL =
100mL, 8 ounces x 30 = 240, 2cups x 8 ounces x 30 = 480 + 240 + 100 = 820 mL
Nurse on med surg received report on 4 postop pt, which see first client 10 hours post realignment of
fractured left tibia, reporting severe pain, weak pulse (compartment syndrome)
RN, 2 LVN, NAP, RN Should care for which pt 6yo for observation following acute asthmatic attack
Nurse counsels client with CAPD, further teaching necessary if client makes which statement I need to
restrict driving while fluid in abdomen
Which will nurse see first myasthenia gravis difficulty talking (MS changes in peripheral vision
expected, type 1 DM burning and stinging sensation in toes and feet, casted fracture reports tingling
next)
Parent of a school aged child in halo traction calls nurse child has headache and sensitivity to light,
child has rash on back and napping frequently (meningitis) bring your child into clinical to be seen
HCP right away
3 RN, 1 LVN, who LVN get? 3 yo child 1 day post umbilical hernia (post Harrington rod rod in spine)
Nurse manager addresses concerns about visiting hours, most important for nurse manager to take
which action complete survey of visitors
RN instructs NAP to administer enteral feeding through NG tube, which action will the RN take next?
assess the pH of gastric aspirate
Who does nurse see first? Client schedule for cholecystectomy in 2 hours reports chills
See first laryngectomy complain green/yellow discharge (not tonometer 21, normal value 10-21)
which client complain sore throat, see first - 55yo taking 5-fluoruracil 5tu

see first pediatric - 9yo who has used weapon toward fam and caused physical harm to others
Several staff members call in sick, nurse manager concerned inadequate staffing, what action will
manager take first? contact nursing supervisor to close floor to admission
Elderly client from hip replacement transferred to SNF, RN will assign client to which staff member RN
with 2 months skilled care experience and 1 year OB
Nurse observes staff member from hospital lab take money from clients table, which action by nurse is
best report to nurses supervisor
Nurse plans care for client with hemiparesis after stroke 7 days ago, most important to assist with
bath in morning and change bed linen while client is IN PT (passive ROM doing too much, gag reflex
every meal too often, to bathroom every 4 hours need to do every 2 hours)
Which see first on oncology unit a client with lung cancer reports urinary incontinence and difficult
ambulating (lung cancer goes to spine)
RN determines assignments are appropriate if UAP encourages a client to practice the postop
exercises taught by RN
Who to see first? 50yo with HTN reports pain between shoulder and blades
See first lower leg fracture reporting severe leg pain receiving pain med (compartment syndrome)
and pt with new cast says tight
coffee emesis receiving rbc (expected)
Child fractured femur brought to er w parents saying he fell off sofa, on exam he has blistered, how to
document six areas of 1 cm diameter, reddened, moist blistered areas noted on buttocks (specific,
objective)
Client has hemodialysis from chronic renal failure, client declines hemodialysis, most important for
nurse to take inform client about eventual results of refusal of care
Delegate to UAP capillary blood glucose
Nurse supervises RN/LVN/NAP, nurse should intervene if which observed LVN inspects ulcer
Client with altered mental status and uti, posey vest ordered, care appropriate if which observed, SATA
- assist client to toilet q2h, secures restraints with quick release to frame of bed, reorient client every 2
hours
Absolute/all care worry about it, promote independence
Altered can give consent, dont need order to more restraints
Newborn nursery floated to orthopedic unit, most important nurse to take which action requestion
orientation to unit and inform supervisor that nurse hasnt cared for type of unit in couple years
Nursing team one rn, lvn, uap, Most important for RN to take which action discontinue for client
reporting swlling and pain at insertion site
NAP says would like to take care of 220, response of nurse you are assigned in rooms 200 and 220.
Not I assigned you to other clients because I feel it is better assignment
If it begins with I, its wrong
Tracheostomy humidified air to thin secretions, tube feeding semi fowlers to prevent aspiration, check
bowels 5min each quadrant, no powders (can occlude trach), never instill saline, trach first then mouth
New grad nurses get one try to do procedure, if fail demonstrate procedure
Leukopenia cook food thoroughly, no plants, no fresh plants
Measles, tb, varicella, herpes zoster airborne
Pain in joints reactive arthritis
Salmonellosis infectious for over a year after acute phase
Lead poisoning leads to slower growth + development, constipation, pregnant + children stay away
from old remodeled homes
Plasmapheresis get rid of antibodies, for acetaminophen toxicity also, can place in
immunosuppressed patient, chills
solitary play (0-1), parallel (2-3), associative (4 ie. tag), cooperative (5+, dodgeball)
Fetal HR 110-160, fetal bp (100/70), shrill cry = infxn or neuro, infants are belly breathers (not thorax,
chest shouldnt move), ok to have fine crackles and rate of 45
Risk factors cancer: More fat, more estrogen increase in cancer, 2 drinks a day, first degree relative
(mom, dad, sister, brother)
Infant jerking movements assess blood glucose

Withdrawal assess cry and respiratory 14 hours after birth, (withdrawal starts 12-24 hours after birth)
One saturated pad per hour is too much, inflammation response after delivery 36 hours, elevated temp
+ wbc
Pill worry about HTN, IUD monogamous relationship
Arthritis risk for is smoking
Tdap booster every 10 years, meningitis for military and crowded areas, heb p lifelong immunity,
pneumococcal vaccine for older than 65
Testicular cancer risk undescended left testicle, check in shower for self exam
First in ER: Tardive dyskinease SE of antipsychotic ok, akathisia motor restlessness, oculogyric crisis
eyes stuck up,
neuroleptic malignant syndrome muscle rigidity, fever, cognitive problems with anti psychotic med
(olanzapine, risperidone, chlorpromazine, haloperidol, clozapine, risperidone, ziprasidone,
metaclopramide,)
neuroleptic malignant syndrome - hot (hyperpyrexia, 105), stiff/muscle rigidity, diaphoretic,
bp/pulse/resp up, drool, toxic effect of antipsychotic or from stop taking med. hold med, call HCP, cool
body
Cocaine = heart attack, s/s of abuse: tachy, insomnia, rhinorrhea
highest risk of suicide 2-3 weeks after starting antidepressant
a.
LOA the most common position; left occiput anterior
b.
LOP - left occiput posterior
c.
ROA right occiput anterior
d.
ROP right occiput posterior
e.
LSA left sacrum anterior
f.
RSA right sacrum anterior

Involution at umbilicus at delivery than one fingerbreadth per day

elderly + long term abx infectious, risk of c diff
lupus autoimmune, not infectious. butterfly rash, arthritis, hematuria, proteinuria, pericarditis,
hyperlipidemia Tx- NSAID, immunosuppressive (cyclophosphamide, azathioprine), plasmaphersis,
decrease sunlight, high infection risk, avoid gardening, avoid UV light/tanning, avoid cuts and scrapes
confused and incontinent with alzheimer keep active and independent, beside commode q2h
hyperglycemia after surgery - give insulin, surgery + infection increase insulin needs
polyethylene glycol - with 4 to 8
high pitched music sounds (wheeze) asthma (acute respiratory distress if wheeze absent), high
pitched inspiration (crackles, fluid in lungs) - pneumonia, deep low pitched rumbling expiration
(rhonchi) - mucous in longs, bronchitis, grating sounds during inspiration (perciardial friction rub)
alzheimers disease - provide safety, re-orient. s/s early: restlessness, pacing, memory loss, head
flexion, wondering, agitation
quickening - feel baby after 18 weeks, 20 weeks for multigravida
32 weeks gestation + facial edema - preeclampsia
salt substitiutes contain potassium and spironolactone is potassium sparing, avoid salt substitute if
taking potassium supplement
informed consent - tell me about risks + benefits
new NAP - demonstrate skill (glucose check)
confused patient - look at chart for ID
newborn respiration 30-60, pulse 120-160, temp 97-100.3

mental health pt - be factual, dont ask why

head injury within 3 months is an absolute contraindication for thrombolytic therapy (other indications stroke, internal bleeding 6 months, major surgery 3 weeks, aneurysm, uncontrolled severe htn,
intracranial surgery)
AKA care residual limb - rewrap, expose to air 20 min/day, inspect limb, if cast comes off wrap with
elastic compression bandage first
epi - vasocontricts, decrease blood flow to organs used for anaphylactic shock
gastrectomy (remove stomach) limit fluids (drinking fluids causes stomach content to empty too
quickly)
partial gastrectomy - recline 30min after eating, fluid between meals, carbs reduced, avoid large meals
with simple sugars/liquids
kidney rejection - pain over right ab, oliguria (can't pee), edema, weight gain, tenderness over kidney
elevated Na and BUN with dehydration
rubella - 14-21 days incubation period, contagious 7 days before and 5 days after onset , droplet
precautions, rash day 28, greatest risk is first trimester pregnancy, no rubella for pregnant
PTT lower limit of normal 20 - 25 seconds, upper limit of normal 32 to 39 seconds, therapeutic range
1.5 to 2 times normal, 5 seconds is within therapeutic rane (INR 2-3, 2.5-3.5x for therapeutic)
adverse side effects glucocorticoids - decreased bone density, low K high Na, fluid retention, risk of
cataracts/glaucoma, hyperglycemia, decrease immune response not wbc
compression fracture 5th cervical verterbrae - autnomic dysreflexia high BP, place high fowlers
80 year old htn, heart failure - sit on edge of bed before arising, bp/hr assessed before ambulation,
antihypertensives cause vasodilation
eye surgery - assess for n/v which would increase ICP
high pitched cry - first signs of ICP, posterior fontanelle closes by 3 months
AST/ALT normal 8-20, eleveated with long term acetaminophen use
school age children - giving children responsibilities allows them to develop feelings of competence and
self-esteem through their industry
narcotic withdrawal - runny nose, yawning, fever, diarrhea (like flu)
barbituate withdrawal - Nausea and vomiting, tachycardia, coarse tremors, seizures.. alcohol +
barbiturate need to be hospitalized for withdrawal
amphetamine withdrawal - Depression, disturbed sleep, restlessness, disorientation.
cocaine withdrawal- Severe cravings, depression, fatigue, hypersomnia.
pregnancy and diabetes - blood sugar falls after delivery, decrease in insulin requirements
blood transfusion - hemolytic reaction: symptoms include nausea, vomiting, pain in lower back,
hematuria, no meds 1 hour before/during/after masks if allergic to med or blood, watch 30 min after for
reaction, obtain urine specimen
stop transfusion, NS, call md, urine sample, return blood
nonhemolytic: sudden chills and a temperature increase occur, along with headache, anxiety,
muscle pain, and flushing; usually treated with antipyretics
guillain barre immune system destroys myelin sheath, pins needles sensation in fingers, start from
bottom and work up, progress rapidly, weakness, respiratory failure, paralysis, urinary retention, give
warm blankets prevent chills from plasmapheresis to remove antibodies, high dose immunoglobulin
therapy, diagnostic EMG
multiple sclerosis dymyelenation of neuron (decreased perception to touch, temp, pain), numbness,
urinary retention, decreased short term memory, ataxia, hyperreflexia of extremities, most important
to avoid exposure to hold/cold pack, ambulate as tolerated, stretch/strengthen, social activites. Sleep
on stomach to help with spasms, when speaking say important first to avoid confusion, energy
conservation, safety, impaired judgment, decreased concentration
thyroidectomy for hyperthyroid - expect potassium
pinworms - collect specimen with scotch tape on anus, pinworms crawl outside early in morning to lay
eggs
penrose drain - remove layers one at a time to avoid dislodging
transplant patients - immune suppressed, protective isolation after surgery 72 hours

head injury/decrease ICP - place midline, hob 30, steroid (dexmathesaone, decreases edema), diuretic
(mannitol, glycerol), hyperventilate, keep temp low, avoid restraints/hip flexion, decreases suction,
space interventions, restrict fluid to 1200-1500cc
Kaposi's sarcoma - small painless purplish,brown spot with AIDS patients, shower daily with mild soap
pat skin dry, cleaned daily and covered if open
capd, continuous ambulatory peritoneal dialysis - check weights daily, if cloudy earliest sign of
peritonitis. Cap catheter during dwell (solution in ab) to prevent infection, make sure all fluid drained
move, walk around, ask if BM, high protein diet, dont milk catheter, main aseptic
RA - heat + ROM, gets rid of stiffness
nonstress test is a noninvasive test to evaluate the response of the fetal heart rate to the stress of fetal
movement, looks at babys heart to increase w activity, favorable result is 2 or more FHR accelerations
of 15 bpm lasting 15 seconds over a 20-minute interval
contraction stress test uses Pitocin, evaluates respiratory function of the placenta
apgar score - 8-10 good, suction if less than 8 and infant in respiratory distress, o2 if respirations
absent
activity: active, arms/legs flexed, absent
pules: 100, less than 100, absent
grimace: pulls away/sneezes/coughs, some flexion of extremities, flaccid
appearnce: pink, pink/blue, blue/pale
respiration: cry, slow irregular, absent
bka - prone 25 min every 3-4hours to prevent contracture, legs should be adducted, during first 24
hours lie prone for short period, after first day 3x for 30min a day, most important elevate limb on
pillow (after surgery for 1 day)
av fistula care - listen for whooshing/bruit, palpate for warmth/redness, avoid carrying heavy objects
seizure - turn to side after, pillow under head first
clean catch - clean meatus, void in sterile container. All urine collection is sterile
dysphagia - before eating, assess gag reflex
chemo patient not eating lost 10lbs, no appetite - ask fav foods
infiltration - cool/pale/swollen fluid leeks into tissue, remove iv and place on pillow, warm compress,
elevate arm
phlebitis - reddened warm area at insertion, red streaks. d/c, warm compress, restart new iv
cervical cancer - hpv, multiple sexual partners
thyroidectomy has tremors - parathyroid may be injured causing decrease in calcium, at risk for
hypocalcemia, which may be manifested by tetany, muscle twitching, paresthesia (tingling), airway
obstruction, respiratory arrest, cardiac dysrhythmias
tick bites - rash, intermittent fever, headache, fatigue, muscle pain, and stiff neck
elderly - assess for confusion by asking for meds, drug toxicity and polypharmacy may cause confusion
and decreased renal function
risk for metabolic acidosis - type 1 dm (DKA), salicylate toxicity (acidic med), acute renal failure (kidney
cant excrete acid/absorb base), diarrhea (lose base)
admitted with bulimia, which action most important - sit with client in silence as she discusses her life,
build trust is first priority, plan of care to identify s/s of electrolyte imbalance (ie. hypokalemia), often
hide eating disorder therapeutic to talk about it , immediate action if hoarse voice = esophageal tear,
parotid gland enlargement and black teeth = common from vomiting
lumbar laminectomy - log roll, pillow between leg and turn client
water just broke - check for crowning
kosher - no meat or poultry at the same meal as dairy, no scavenger fish, no pork
Small cell lung cancer = causes siadh (confusion, weight gain, low UO, low sodium/specific gravity)
bucks traction - elevate foot of bed, skin assessment, elastic bandages aren't too tight/loose, dorsiflex
affected leg, turn on unaffected side
gout - no redmeat, shellfish, organ meat, asparagus, peas, spinach, legumes, sardines, drink 2-3L daily,
low carb. Most concerned if losing too much weight a week (.5-1lb ok). NSAID, ice, gradual loss of
weight, limit alcohol/red meat, partial weight bearing while ambulating
experience severe anxiety - unable to process thoughts/feelings

lumbar puncture on child - restrain

menoapuse - 45-50, irregular menses
CVA - duration of Coumadin/warfarin 2-5 days, risk for cva if no warfarin. Oral anticoag (warfarin)
started 4-5 days prior to d/c heparin
scoliosis - 10 year old girl, skirt longer on one side, arms different lengths, limp during ambulation
trach dislodged - extend neck, call for help, place supine, check breath sounds
tpn, client improving if - edema decreases, protein levels cause fluid to move into interstitial space. If
receiving TPN and becomes dyspneic, diaphoretic + anxious = air embolism, Trendelenburg + left side
(lateral)
elderly - pneumonia vaccine every 5 years
alcohol withdrawal 48-72 hours after last drink; grand mal seizures 48 hours after; delirium tremens
72-96 hours after; client at high risk for seizures. Most important to ask when last drink was. earyl
symptoms: Hyper-alert, startles easily, anorexia, pulse, anxiety, tremors, insomnia, hallucinations
cholecystectomy - moer important to observe color client's urine + stool
lupus and pregnancy - remission for at least 5 months before conceiving, wait 2 years after diagnosis to
conceive
regular insulin peaks 2-4 hours, diaphoresis/trembling for hypoglycemia if given 3 hours ago
strabismus - crosseyed, closes one eye to see poster on wall
32 weeks gestation - increased vaginal discharge, abnormal if blood, foul smelling, complication of
positive for glucose and acetone
sickle cell crisis - provided adequate hydration
hemophilia - bleeding disorder, if injured give codeine instead, question orders with aspirin, risk for
crippling knee and joint deformities (due to bleeding into joints), see first if joint pain = bleeding,
priority is to infuse factor VIII (clotting factor) concentrate if risk for bleeding, active range-of-motion
encouraged after bleeding episode to prevent crippling effects of bleeding;

hip dysplasia - uneven gluteal fold and thigh creases, knee higher than other
AIDS - get candidiasis, give ketoconazole
hyponatremia - muscle twitching, convulsions, diarrhea, headache (pt has Na 124, first action place on
seizure precautions)
appendectomy - take 3 deep breaths, hold incision, then cough
cane - strong side, advance cane weaker leg then stronger leg, advance cane 6-10 inches
trigeminal neuralgia - nerve disorder, stabbing pain to face, eat warm soft food on unaffected side,
agonizing pain
lecithin/sphingomyelin (L/S) ratio - assess fetal lung maturity, 2:1 mature
DIC - bleed from everywhere
Ect Electroconvulsive therapy - keep NPO, ask if they had something to eat before, given anesthesia,
for depression (works if no longer mute or withdrawn)
pt flaccid ballder following spine injury - prune juice, cranberry, tomato (minimize risk of UTI, promotes
acidic), avoid citrus juice, milk, carbonated drinks
alcohol + drug dependence - most important action of discharge plan, encourage AA meetings with
sponsor/self help group greatest success
hep b- give a 1 and 6 motnhs
viral conjunctivitis - watery discharge from eye and red
effective behavior modification program, accurate baseline data must first be collected about the
target behavior
blanching or hyperemia that is a warning sign of pressure ulcers
BP should always be taken on the opposite arm from the graft
late decel receiving oxytocin FIRST: d/c oxy, turn left, oxygen, increase iv fluid. If continues, c section
pt ambulates after surgery and has ache in left leg - bedrest + extremity elevated
detached retina - photophobia (discomfort to bright lights), loss portion of visual field
glaucoma increase in intraocular pressure, cloudy/blurry/loss vision, lights have halos, decreased
peripheral, n/v, pain, headache. Plan of care return for tonometer readings normal 10-21. Higher IOP
in morning so plan appts then, damage to vision cannot be corrected; further damage can be prevented with
medication

bowel protrdues through incision - HOB 15, low Fowler's; reduces stress on suture line, may be placed
supine with hips and knees bent
IVP - bowel prep/laxative so they can visualize baldder better (pic of urinary tract), ask allegries
(iodine), NPO after midnight, burning/hot feeling when dye injected,
infant vitals - 30-60respirations, 60/40-80/50, pulse 120-140
right total hip replacement - no weightbearing on effected hip, prevents dislocation, notify md if
externally rotated (dislocation), abduction for 2-3months, flexion 60 for 6-7 days, then 90 for 23months, dont stand for long periods, dont cross legs beyond midline, most important to place
abductor pillows between legs (prevents dislocation important to use when client confused), spirometer
q1-2h. maintain abduction, dont cross legs, have other tie shoes/socks
cardiac cath - may feel burning/desire to cough with dye, bedrest 8-12 hrs, vitals started immediately
checked q15min for 2hr, then q30m, npo midnight before procedure, empty bladder,
palpitations/fluttering can be felt, pulses/bleeding q30 for 3 hours. Assess pulse distal to site (ie.
brachial, compare radial)
low rbc - fatigue, dyspnea, pallor, dizziness, malaise (tired), tachycardia
rheumatic fever - group a beto hemolytic strep, messed up heart + kidney, causes carditis leading to
mitral valve problems like mitral stenosis + HF
meniere disease - inner ear disorder that affects balance and hearing, s/s: vertigo (dizziness), tinnitus
(ringing), n/v, tx: diuretic, changes positions slowly, symptoms controlled by restricting Na (2g), lay on
affected ear
third trimester - epigastric pain = convulsion
renal calculi - force fluids 3L/day, measure/strain urine, pain med
pyloric stenosis - spits up formula, fussy/always hungry = lethargic, dehydrated, malnourished
mononucleosis - sore throat, enlarged lymph nodes (lymph adenopathy), can cause spleen rupture,
caused by Epstein-Barr virus, avoid contact sports (no energy, malaise, sore throat, fever, headache,
epistaxis (nosebleed)
panic disorder, generalized anxiety, bulimic - teach journaling
before surgery - surgical consent rechecked 1 hour before, client premedicated but no consent form inform nursing supervisor (don't see physician or get signed, stay within chain of command)
childs foot touching bed + weights on floor - steady the traction and push up on bed
postpartum mom uterus relaxed - due to bladder fullness, massage fundus to contract uterus, put
infant to clients breast, assess for bladder fullness
see first - ventricular gallop, earlier sign of HF, s3 venticular gallop
digoxin - helps slow HR, normal 0.8-2.0, dysrhthmias can be caused. Dose 1.25mg over 24 hours.
if water seal drain system (Pleur-evac)/chest tube not fluctuate - chest xray, fluctuations stop with reexpansion of lung or obstruction/kink/fluid in tube/laying on tube. only clamp with checking for leaks,
call md if output 100ml/hr, gentle continuous bubble ok, vigorous/excessive = air leak, if tube pulled
out of pleural space apply pressure w dressing
patient ambulating for first time after surgery - give pain med to prep for activity
post op surgery diet for healing - high protein, vit c, and calories
patient with RA - heat, ROM, weight reduction, firm mattress
colostomy - can resume all previous activities, stoma has bag over it with tight seal. Irrigate once every
2-3 days if at all
around-the-clock (ATC) administration of analgesics is more effective in maintaining blood levels to
alleviate the pain associated with cancer
rh-incompatibilty - rh neg move with rh pos man, mom has rh antibodies, rhogam given to negative
moms to protect next baby. negative coombs only
c-section - nursing goal to prevent fluid + electrolyte imbalance, due to hemorrhage and shock
client with fractured hip important to - turn every 2 hours to unaffected side, hob elevated 15, and
bedrest
talipes equinovarus - clubfoot, serial casting done to fix it
appendectomy - hob 30-45 to reduce stress on suture line
parathyroidectomy - low calcium/high phosphorus diet
toy for infant with dysplasia of hips - rottle

tb drugs are liver toxic, most concerned with - fatigue and dark urine (hepatic dysfunction), causes
orange urine glucosuria (pancrease)/proteinuria (renal), finish taking meds, no work/school until 3
negative specimens
aspirin overdose - epistaxis (nosebleed), tinnitus, gastric distress, hyperventilation, dizziness
glycerin swab - causes dryness of mucous membranes, water before/after meals will keep mouth clean,
dont use glycerin mouthwash
pt withdrawn schizophrenic - sit with client, dont make commands to participate, reorient, bring back to
reality
wet to dry dressing - remove old dressing dry (no saline) so debris are removed, straps can be used to
secure dressing,
assess comfort, remove dressing, observe,clean, apply gauze, record date
contractions should be longer than 2 minutes and shorter than 90 seconds to provide rest, if longer
than 2 d/c oxytocin
patient with right sided paralysis and aphasia - speak using phrases and short sentences, keep HOB
elevated to promote drainage from brain
sprained ankle on right side - stand on left side slighly behind client
trach suction - oxygenate 90-120, insert catheter til resistance and intermittent suction while
withdrawal, hyperoxygenate first, sterile gloves
oral medication for 4 month - empty nipple and allow infant to suck, infant never in reclining, meds
never added to formula
hands should be washed before removing mask to prevent transfer of microbes to face
thromblytic therapy dr order IM pain med - question order, patient can bleed
patient going through surgery has diabetes - Hold the morning dose of NPH and regular insulin and
monitor the blood glucose since patient NPO
entering transition phase of first stage of labor, rapid shallow breaths needed (pant breathing), sign pt
in transition = urge to pee
see first - man with heartburn that radiates (not pregnant with heartbean = gerd)
manic pt in seclusion room lunch - serve meal in seclusion room
if hyperglycemic in morning - adjust insulin, don't eliminate night time snack
bf has hep b, best response - have you had unprotected sex? (assess), not recommend testing
pt seeks attention - give patient unsolicited attention when accepting behavior (not develop
relationship with one person)
which indicates complication for pregnant - urienn test for glucose/acetone (gestational diabetes)
best indication of nutrition of tpn - albumin 4.0 (norm 3.5-5)
initial priority when managing an assaultive client - restore self control and prevent further loss of
control (not clear area)
MS 39 weeks gestations, nurse anticpate need for - reduction in pain med (MS has less pain perception)
cva left sided hemiparesis, decreased muscle tone, nursing dx - alteration in skin integrity r/t decrease
in tissue oxygenation (leading cause of skin breakdown)
pt return frmo surgery, nurse asks - client to lift head off pillow (assess if neuromuscular blocking
agents left)
client has drug induced cushing syndrome, first instruction - gradual withdrawal of drug
acetaminophin most concerned with - ast 30/ alt 27 norm 8-20 (not bun 9 normal 7-18)
diabetic client on o2 pulling on ng tube and picking at covers - check o2 (not glucose s/s suggest
decreased o2)
ewald tube - have suction equipment, large tube for lavage, risk for aspiration
school age - give responsbility around house (not teach read/write, stormy behavior at 11)
oxytocin safe administration if - palpate uterus frequently (assess uterus since oxytocin stimulates
uterus to contract)
68mg/DL BG and nausea = administer insulin, not give oj (may cause vomit)
most important initial goal of rape trauama - express feelings
Hepatitis A oral fecal, shellfish, food
hep b sex, blood products, bodily fluids
hep c blood transfusion

inflammation of liver lab tests show elevated liver enzymes AST/ALT (8-20)
Multiple trauma victim from mva next action arrange clergy to visit as requested
Epligottis client early sign of hypoxemia hr 148, throwing toys, nasal flare (not drooling, that is s/s of
epligottis)
walker - rubber caps on all four legs, practice tying shoes before ambualting, elbows bent 30, nonskid
socks
MRI - remove nitropatch which has aluminized layer, concern when pt claustrophobic
Dehydration pt IV - .45 NaCl (not 0.9% NS)
chief complaint proplery recorded - "stomach huts after dinner every night" (not rebound tenderness)
child has gastroenteritis, most important question - does child attend day care (promote infection)
burn pt - provide adequate time for dressing change + emotional support
dehydration, furhter teaching if - weigh myself daliy
dressing change at home - wash hands, use only what hcp orders, have someone look at it, throw away
in glove
nitro, most important to tell next shift about - bp 140/80 to 90/60, make sure it doenst cerease more
Which nursing action is MOST important to provide the client with effective pain relief? - trusting
relationship with client
necrotizing spider bite is to perform dressing changes at home - wash hands before redressing, only
use hcp ordered, make sure someone looks at it, throw away dressing in garbage
pt with ptds agreed increase participation in out of apt activities, most therapeutic to achieve this goal
if - joint support group
after ab cholecystectomy most important to say before surgery - place pillow against abo, take 3 deep
breaths, hold breath, cough 2-3 times
see first - unilateral dull abdominal pain for 4-6 weeks gestation, left lower quadrant pain, vaginal
spotting = ectopic pregnancy, emergency
burn pt most important to report - gastric ph less than 5, can develop Curling ulcer
pt with dysuria, urinary frequency, repeat analysis if - no wbc/rbc (s/s suggest there should be)
hyperparathyroidism report if - hematuria, signs of renal calculi, 55% of hyperparathyroid patients have
renal stones
pneumonectomy - remove lung, breath sound absent one side, position of trachea should be elevated
above sternal notch, no chest tube required
wet to dry - free dressing, dry skin, mositen gauze, apply single layer, apply dry dressing
mastectomy positioning - semi fowlers with arm elevated to ehance circulation/prevent edema
2-gm sodium diet. - egg, orange, milk (milk ok on salt restricted), not oatmeal/toast/oj (sodium added
to oatmeal)
expectant mothers - 300 calories, nursing moms 500 calories
sweat test - diagnostic for Cystic fibrosis, plan of care = replacement enzymes, positiong: head in
dependent (side lying with elevated chest, prone with ab elevated, knee chest with pillows under chest)
Sengstaken-Blakemore tube - used for bleeding esophageal varices (due to cirrhosis from portal htn ),
keep scissors at bed if in respiratory distress Cut the balloon ports and remove the tube, pressure of
25mmhg in esophageal balloon
prenatal vitamins take with OJ, vitamin c helps w absorption of iron
internal radiation - limit 3 hours/day, lead apron for close distance not routine, frequent rest, talk from
door. Strict bedrest, hob 20, foley. Limit exposure, no complete bed bath, 30min q4h, no pregnant or
kids under 16, wear dosimeter film badge, dont stand at foot of bed
depression of T cells - remove standing water
HPV illstrates sequelae of illness - return for pap smear in six months (HPV --> cervical cancer, not take
abx no abx for viral infection)
sequence for irrigating wound - wash ahnds, prep sterile field, remove soiled dressing
myelogram - ask about allergies since dye is infused, extra fluids before and after test, Pretest:
encourage fluids, check allergies. Antipsychotics, antidepressants, and anticoagulants may be withheld
for several days. Diazepam (Valium) can be given during pre-op. Post-test: position the patient in a
supine position with the head slightly elevated for several hours., diazepam given to lessen discomfort

dementia - talk about life and important thigns in past because pt has recent memory loss, speak
slowly face to face, dont leave personal care objects laying around, simple/short phrases (enhance
ability to process info), respond better to routine thats reinforced (not flexible), give one instruction at
a time
postpartum implement first - check lochia flow
lumbar puncture - remain flat 8 hours after test, discomfort in leg when needle inserted, can have pain
meds after if headache, if headache assess puncture site (headache common, assess for CSF or
hematoma) (fluids not restricted before)
hepatic encephalopathy early s/s - insomina, impaired though process, hand tremors/writing changes
(ie. cant explain job)
hepatic encephalopathy late s/s - hand flapping (Asterixis), lethargy, extended sleep, incomprehensible
speech, amnesia, coma
pregnancy weight gain - excessive is over 6.6month/month, under is 2.2lb/month
ab surgery, best indicator of pain relief - incentive spirometer results improved
likely for acute renal injury - precipita hepatic encephalopathy ted by hypovolemia or heart failure
cancer with poor prognosis, increased pain and anoxeric. priority - pain assessmeent and management
cleft lip with upper airway congestion - place on side, facilitates drainage of musuc from upper airway.
After repair feed with rubber tipped syringe (avoid operative side) and bubble often (they suck up a lot
of air), no objects (straw, thermometer) in mouth til 6 weeks, sit up while feed to prevent aspiration
oxytocin piggyback with infusion pump ( not primary)
bipolar in manic phase - distract with light physical activities & remind about rules, private room (pt w
mania need quiet environment)
salem sump tube - double lumen stomach tube for decompression with suction, effective if hissing
sound
levin ng tube - provides tube feeding
pt disoriented when aroused elevate side rails until awake
pt hallucinating dark quiet room
if UAPs child has chicken pox ask have UAP had chicken pox before?
burnt pt received morphine has decreased bowel sounds and ab distention explore alternative pain
management techniques
nursing assistant ng tube - elevate hob, warm formula, clamps proximal end of feeding tube
Keofeed/Dobhoffsoft silicone rubber, medium-length tube used for long-term feedings; placement
verified by x-ray; takes 24 hours to pass from stomach into intestines; lay on right side to facilitate
passage
intestinal tubes
Cantorsingle-lumen tube with mercury-filled balloon and suction port
Miller-Abbottdouble-lumen tube with mercury-filled balloon and suction
Harrissingle-lumen tube with mercury-filled balloon and suction port
negligence - lotion on wilms tumor, can cause dissemination of cancer cells (dont touch, measure
abdominal girth)
post op patients risk of paralytic ileus (obstruction of intestine) as a result of anesthesia, prevent by
early ambulation and positioning, evidence of normal bowel functioning with bowel sounds, n/v + ab
distention
Butorphanol tartrate - pain med, assess vitals, decreases rate/depth of respirations
total laryngectomy - must learn esophageal speech, tube feed for 10 days then po, won't be able to
single/whiste/laugh, semi fowlers, cough + deep breath, further teaching if family says dad needs
feeding for months and dad looking forward to laugh
teenage client drinks lots of fluids but feels thirsy, important to ask - has your weight changed? thirst +
weightloss = diabetes
postpartum pt bottle feed infant, encourage pt - acetaminophen as directed, cool packs, supportive
bra, engorgement resolves in 5-7 days, dont stand in warm shower (causes engorgement), water only
soap can dry

low platelets 50k, low hgb, expected syptom bp 120/70, hr 100, resp 20, decreased oxygenation of
tissue (not n/v/a from chemo)
bronchoscopy - npo til gag reflex returns, most concerened if pt is tachypnic/bronchospasm/crepitus
newborn assessment must be reported to hcp - head circumference of 40cm (32-36 avg), circumoral
cyanosis, respirations 80 (30-60)
diabetic food care - cut toenails straight across, inspect daily, bathe daily in warm water, avoid extreme
temps
experiencing withdrawal, which finding indicates more sedation needed - elevated pulse rate, elevated
pulse signals impending withdrawal delirium (increasing vitals = delirium tremens) [not milld
tremors/irratabilty]
Diabetes insipidus - weight gain should be reported to hcp, medication may needa adjustment.
desmopressin ddavp or Vasopressin (Pitressin) for rest of life, low specific gravity, assess specific
gravity and daily weight
bulge test - presence of fluid in knee, lie down and extend legs
plan of care for paralysis due to stroke - Prevent flexion of the affected extremities (not active ROM, pt
cant move)
central line air embolism, central line and pt coughs, pale, dyspneic, tachy - lower head of bed
(Trendelenburg), place on left side. don't raise HOB air can go to lungs, o2 notify md. If catheter breaks,
apply tourniquet on upper arm (prevents catheter from advancing to right atrium, then check pulse)
hyperthyroidism which action is best - hyperthyroidism often exhibit exopthalmos, require artificial
tears. If treated with iodine watch for hypothyroidism complications (lethargy, cold, weight gain, dry
skin)
infant - all invasive done last so abc aren't messed up (ears, eyes, mouth)
Jackson-Pratt drain - should be attached to gown/pajama, not sheets, prevent accumulation of fluid in
wound
underlying bowel visible (evisceration) - sterile gauzed with sterile ns, hcp
cord care - several times a day and expose air frequently
hemothorax problem constant bubbling (blood clots expected)
pneumonia therapeutic response - respirations 20, thin white sputum, denies dyspnea. NOT wbc, UO,
decreasing sputum. no status of infxn
12 yo with albuterol feels heart pounding - ask how long child has been taking med, side effects may
diminish if taken over a week
thyroidectomy - monitor for respiratory distress every hour
stage 4 parkinsons - client is immobole, ROM on all extremities 4x/day
levothyroxine for hypothyroidism, favorable outcome if - increased urine output
PT/INR = warfarin, PTT = heparin 1.5 greater than normal ok
osteoarthritis in elderly, most important to instruct - warm up prior to exercise
palpate uterine contractions - one hand over fundus and press with fingertips
rheumatoid arthritis, can be d/c if client can - comb hair, brush teeth, eat independelty. ROM prevent
contractures, walk/swim, move joints daily, take warm bath. No nsaid, should be prescribed
low WBC, first action - check temp for infection
cholecystectomy - incision is high in ab wall inhibiting ventilatory movement, watch for decreased
breath sounds, no bowel sounds due to peristalsis from anesthetics
osteoporosis, most important - weight bearing develops high density bones and decreases bone
reabsorption, cant do ECT because shock might break bone, usually small framed white women,
adequate calcium + vit A
hepatitis - liver inable to detoxify meds, no tylenol, oral fecal route so wash hands (anorexia in
children). Small frequent meals due to anorexic cant eat much, high carb/low fat (fruit, veggie, lean
meat). A from bowel (contact), B+C: blood and bodily fluids
establish normal urinary pattern - keep record of daily fluid take
ileal conduit - mucus expected, apply close-fiting drainage back to stoma, soap and water for stoma
stomas - dusky stoma means poor blood supply, protruding means prolapsed, sharp pain + rigidity is
peritonitis

spinal cord injury diet - high fiber to prevent constipation, whole grain, fruit, low fat
end stage cancer, most important - turn every 2 hours to prevent skin breakdown
glucagon for diabetic - only if unresponsive
glycosylated hemoglobin assay a1c - keep below 7, avg bg last 3months, dont need to fast
hypoparathyroidism successful tx if - no numbness/tingling (tetany), (other s/s: convulsions,
arrythmias, spasm, stridor, provide high ca low phos)
hyperparathyroid/hypercalcemia - confusion, brittle bone, muscle weakness, renal calculi, back pain
(give low ca, high phos diet)
infants - respiratory 30-50 abdominal with apneic episodes, 120-160 bpm, bulging fontanel could be
crying or fluid (ok for 1 day old), acrocyanosis (blue extrem) 2-6 hours resolve itself, see infant with
bpm 185 (120-160 norm) while lying
epidural - lie on left side, hydration important before, monitor BP for hypotension, IVF bolus 1000cc,
semi fowlers side lying
hip fracture and found on floor - observe cilent rise from sitting to standing
cataract (loss of clearness) removal - position on unaffected side HOB elevated, assess loc, no jerky
movement. Get flu shot so pt wont get sick and increase IOP
hypophysectomy (remove pituitary gland) - monitor specific gravity, lack of ADH will cause DI and
decrease specific gravity
LVN has shingles - come to work as scheduled, abe to care for non high risk, no pregnant/preemies or
immunocompromised
ibuprofen, most concerned if client says - they had ulcer, side effects include epigastric distress,
nausea, occult blood loss, peptic ulceration; use cautiously with hx of GI
burning pain in epigastric - ulcer
sharp pain in lower ab - intestinal perforation (semi fowlers, emergency surgery)
see first - frequent small watery diarrhea w pain & nausea (bowel obstruction which can perforate)
heartburn when lie down - indigestion, hiatal hernia
psychiatric clients - have a right to vote, send mail to elected officials, receive phone calls
labor - gush of fluid down legs (membrane rupture), blood in vaginal discharge (bloody show), low
backache
AAA repair in shock, bp100/70, pulse 120, respirations 24, priority - bedrest, evaluate for decrease in
CVP
cytomegalovirus - transmitted by body fluids, standard precautions, if pt positive give to oldest nurse
elderly htn with cardiac involvement - normal pulse, htn, lower temp due to decreaes in BMR
visiting hours for clients - be flexible, be client advocate
TENS - above, over or below painful area, gel before electrodes, turn up until pin/needle sensation,
adrenalectomy - immediate postop, most important to observe bp alteration
caregiver burnout - cluttered home, sleep disturbance patterns, social isolation
acute hepatic encephalopathy - build of of ammonia, liver converts ammonia to o, 15-45 normal value
pt fracture hip surgery, confused - obtain ABG/blood gas, fat embolism common with long bone
fracture, lead to pulmonary embolism, confusion first symptom
gas pain - ambulate, position on right side to aid in gas release, suppository
renal calculi - drink 3L, low sodium (high sodium increase calcium excretion), drink more water in hot,
decrease caffeine
mitral valve replacement - postop open heart clients should be encouraged to be out of bed and
ambulating asap, frequently one to two days after surgery
abg - pa02 80-100, ph 7.35-7.45 hco 22-26 paco2 35-45
discharge pt, most important - assess help at home
aka, phantom limb pain - activity reduces pain, pain is common do they have pain med?
elderly always at nursing station making requests - interact at consistent intervals
oral contraceptive - decreases milk production
peritoneal dialysis outflow inadequate - turn client from side to side, if young women and outflow
bloody = check if menstruating
RA, highest priority finding - slight contracture of wrist, shows inadequate management

client with depression, most concerned if - LVN gives flurazepam (sedative SE: confusion, drowsiness,
blurred vision), last resort
pacemaker - any time pulse drops below preset rate = pacemaker malfunction, check pulse every day
meningitis due to influenza - dim lights, minimize stimuli to decrease seizure (assess more frequently
then q4h, ICP/shock)
central line insertion - supine, head low and turned away from insertion site (trendelenberg), perform
Valsalva maneuver to prevent embolism (dont deep breath)
pregnancy + insulin - increased need for insulin as pregnancy progresses
s/s meningitis -Kernig (patient is lying with thigh flexed on abdomen..opposite leg cannot completely
extend) -Brudinski (when neck is flexed, knees and hips flexion too), tachycardia, photophobia, rash,
kernigs sign
t tube - avoid strenuous activity, don't submerge tube, don't lift heavy objects, increase in drainage =
bile obstruction, green yelllow drainage = use absorbent dressing (not observe dehiscence)
myasthenia gravis - neuromuscular disease characterized by considerable weakness and abnormal
fatigue of the voluntary muscles. weakness, fatigue, dysphagia, ptosis, diplopia, difficulty breathing.
monitor respiratory, vitals, speech, sit up while eating, conserve energy
guillain barre - neuronitis of the cranial and peripheral nerves, weakness lower extremity, progressive
to upper extremity, cardiac dysrhythmia. pain management, respiratory status
myasthenia gravis - avoid alcohol/heat, activities spread throughout day, thick liquids. given tensilon,
positive for mg if muscle stronger after injection, muscle weakness, diplopia (double vision) ptosis (eye
droop), RN does feedings
diverticulitis - (inflammation of colon), LL quadrant pain, low residue no seeds, no nuts, corn, popcorn,
peas (ie. tomatoes, cucumbers, strawberries, raspberries), high fiber ok tuna whole wheat + carrots
Pregnancy induced htn treated w mag sulfate, concerned with - urinary output 70 to 30, decrease can
lead to toxicity
incentive spirometer - used for max inhale, 12r/min, raise hob, splint incision, hold breath at inspiration
for 2-3 sec
Bells palsy - paralysis of face and eyelid, cornea becomes dry, can protect with patch or
drops/ointment. Close doors to protect face, eyeshield and heat to face ok, tx facial exercise, oral
care, chew on unaffected side
client having seizure - remain with client and prevent injury, impossible to assess respirations
cholecystitis - gallbladder inflammation, s/s: nausea, belching, r upper quadrant pain radiates to
shoulder/scapula, clay colored stools, dark urine. complication: jaundice, stone in bile duct. Low fat diet
PAD peripheral artery arterial disease - walk until pain begins rest then resume, stop smoking,
decreased sensitivity so dont use warm packs, gloves/socks instead, sit with feet flat dont cross, heat
pad to ab (vasodilation of extremities) (pain, pulselessness, pallor, paresthesia, paralysis)
DAVE - legs are Dependent for Venous and Venous elevated
soap suds enema - should be 12-18inces, warmer than body temp, sims position
viral conjunctivitis - discharge from eye, redness, contagious, child restricted from school until
symptoms resolves 3-7 days
diabetic is vomiting - most important to drink liquids, DKA associated with dehydration, diet doesnt
matter if trowing up
irrigating cerumen, client reports dizziness - warm water, cold water can cause dizziness
asians and pain - assess for nonverbal cues like changing position in bed or holding hands together
those with MS taking meds start to lose hair - advise client to get wig
bronchoscopy - NPO til gag reflex returns, touch back of client's throat with tongue depressor
client has slurred speech, right sided paralysis, unequal pupils, first action - assses respiratory status
colonscopy monitor for - fluid + electrolyte balance since patient has bowel prep + NPO. bowel prep is
4L, only clear liquid after, could have hypovolemia so monitor vitals if confused
cystoscopy; prep: NPO, bowel prep (laxatives, enemas), general or local anesthesia used; post-test:
check for bleeding and infection. Scope in penis to see bladder
pt has marked dementia + disorientation, first action - observe client's behavior frequently
pt has craniotomy and chemo for a month, postop most worried about - 24hr 4000mL urinary output =
DI

nurse coordinates community placement of pt schizo/alcohol nurse take which action - collaborate with
health care team + client to schedule predischarge visit, multidisciplinary team + client
infant - report to hcp if absence of breathing longer than 15 seconds, 10 seconds is common
client recovering from pneumonia has higher degree of atelectasis (collapsed lung) - increase
frequency of spirometer (not instruct deep breaths more often)
tetralogy of fallot becomes diaphoretic and sob, nurse first action - knee-chest position treatment for
cyanotic spells
adult in hospital after auto accident, most concerned with - bp from 130/88 to 150/74 = widening pulse
pressure = increased ICP..cushing triad = upper bp, irregular breathing, brady, 96/50 + 112 = shock
Buerger - inflammation of arteries and veins in LE, men 20-35, smokers, pain at rest & coldness major
symptoms. tx - inspect toes/feet, stop smoking, avoid cold, hydration, wear shoes that fit
raynauds - female gets cold/smokes fingers get blue, white then red, pain. Limit caffeine, stay indoors
when cold, socks/clothes/gloves
levothyroxine overdose - symptoms of hyperthyroidism (graves), too much energy, nervousness
difficulty sleep, sweaty, hot
decels - switch sides, notify hcp, oxygen, iv to increase blood flow
pt has chest pain, sob, left arm pain - administer morphine to decrease cardiac demands (high fowlers
and oxygen after)
fetal distress on fhr/increased sustained hr over two minutes - d/c oxy (not decrease)
nurses uses guided imagery for pregnant client with pain, then pain again 10 min later - use another
intervention, reposition
woman in labor who is 9cmdilated and contractions every 3 min, most important action - notify hcp of
contractions, no meds during transition
hyperglycemic hyperosmolar nonketotic syndrome (HHNK) - 50 and older, diabetes 2 due to
dehydration and high bg
dexamethasone (glucocorticoid, steroid) - take w breakfast, avoid alcohol, dont abruptly stop, ulcer,
susceptibility to infxn, call if experience any cushings symptoms (hyperglycemia, hypokalemia,
osteoporosis)
dvt - tx: bed rest til heparin started, elevated 6 inches, warm moist packs, elastic stocking on
unaffected leg/TED hose, dont ambulate
thyroidectomy - watch for hypocalcemia, can damage parathyroid gland, s/s: tetany, cvostek (tap
cheek), trousseaus (bp cuff), arrhythmias, dtr, mind changes
radium transplant - low residue diet to decrease bowel (bm can dislodge implant), client conserve
energy, anti-nause med
hyperemesis - IV fluids, I/Os q4h, weights every morning, bed rest, npo 48hrs
autonomic dysreflexia - spincal cord injury t7 and up, headache, sweating, htn (200/100), place client
sitting w hob 90, loose constrictive clothing, assess bladder distention and bowel impaction (usually
caused by full bladder), give htn med
low potassium cardiac monitor first then give K
adhd child supports diagnosis - even as toddler always on the go
pt comes in with spouse and has bruises and not making eye contact - get client away from spouse (ie.
urine specimen)
infant most concered if see - yellow coloration on nose (jaundice first appears on head within 24 hours,
indicates hemolytic disease)
home care referral - CHF underwent diuresis (assess for decreased volume, hypotension, tach, s/s
hypokalemia
transabdominal pelvic ultrasound for uterine mass - drink 4 glasses of water 1 hour before test and
don't pee (not take 1 hour)
insect bite most concerened if - irregular, mottled ring (the beginning of tissue necrosis)
most at risk for pneumona - 78 year old with colon cancer (advancing age + immunosuppressed)
emphysema most concered if - patients skin color is pink within 20 minutes of o2 delivery, high hg/hct
is compensatory mechanism of chronically hypoxic, if restless/confused perform pursed lip breathing to
prevent lung collapse

pt with ulcer n/v/diarrhea for 2 days, most important statement to follow up - drinking more fluids but
urinating less (assess UO b/c can lead to FVD causing shock)
gastrojejunostomy - connection between stomach + jejunum, post-operative ulcer/stomach surgeries)
--> eat in reclining position, lie down after meals for 20-30 minutes (no fluid w meal, low Carb and fiber
diet, small frequent meals, see first if UAP says sit up pt should lie down after if sit up will get dumping
syndrome
dumping syndrome - decrease carb, small meals, lie down after eating, avoid fluids with meals
senior citizens + constipation - increase fiber from dietary soruces like apples, oranges, bananas + 810 glasses a day
Korsakoff psychosis - memory disturbance, confabulation
wernicks syndrome - confusion, moody, tire easily, diplopia (double vision), nystagmus (fast movement
of eyes)
harrington rod for scoliosis, pain med effective if - pt uses spirometer when requested
mag given to prevent preeclampsia in pregnancy, assess next? - deep tendon reflexes, hypermag CNS
depressant
frequency, urgency, dysuria (burning) - drink lots of fluid, warm sitz bath, abx for uti
candida, teaching successful - take it easy read book (immune repair itself and mind off pain),
mycostatin swished in mouth and swallowed, no mouthwash, soft/bland/nonacidic/cool liquids
barium enema - slow deep breaths during test to ease urge to defecate (barium via rectum to xray
colon)
after lumbar laminectomy supine to standing - left elbow as pivot with l hand grasping mattress edge
(maintain spine alignment), intervene if legs in contact while turning (should have pillow between legs)
most important action to take iv push - time medication administration with watch
skin biopsy, report to hcp if which statement - i've been taking aspirin for sore knee (aspirin increases
clotting time shouldnt be taken before surgery)
most important for physician to know before pacemaker insertion - client wears hearing aid (battery
can affect placement of pacemaker)
with abdominal hysterectomy, patient has pain 4/10 - administer narcotic pain med (not comfortable
position, moderate pain should be aggresively addressed), call dr if temp above 100, use sanitary pads
for bleeds, ambulate, avoid strenuous activity, cough/breath
lens implantation, most concerned with statement - vacuuming + golf (avoid jerky movements, no
aspirin)
male client has concussion, which statement by wife needs teaching - husband has headache i'll give
aspirin (supposed to give acetaminophen, it can prolong bleeding)
varicella - give acetaminophene for fever, may devleop reyes syndrome (vomiting, no energy, behavior
changes) if given aspirin
no aspirin for chlidren - can cause reyes syndrome (prefer acetaminophen), aspirin cross-sensitivity to
tartrazine (yellow dye)
sickle cell - don't give aspirin can cause hemorrhage or demerol, keep away from ppl with infections,
morphine for pain, fluids, frequent rest. give hydroxyurea report GI could be toxic
see first - client after surgery placed in room with COPD (postop + postop = ok = clean, shouldnt be
placed with dirty, overflowing bathroom = potential problem, real problem first)
client w right femuar fracture comes to ed, car to stretcher which action best - support right leg above
and below femur (splint first, assess for shock, neuro check)
ulcerative colitis - diet high pro/cal/fat low residue = risk factor for colorectal cancer
bipolar, immediate attention if - patient hasn't eaten breakfast/lunch risk for dehydration/poor nutrition
pyelolithotomy - remove stone from renal pelvis, postop: pain med, splint incision when turn,
cough/deep breath, force fluids 3L-4L, dressing change, protect from urinary drainage
autograft to burn, highest priority - immobilizing the graft
anorexic most important goal - keep potassium 3.5-5, FE imbalance (not to eat food, cardiac higher
priority)
see first - 55 yo with persistant nosebleed (compromised circulation) over 32 year with n/v past several
hours

inflammatory bowel disease (crohns or ulcerative colitis) - avoid whole grain (use white bread, no
fruit/beans), low residue/high pro/cal, no alcohol, room temp foods, no smoking, restrict fiber/fat
Judaism no meat with milk
preventable mental retardation - alcohol treatment
multi 8cm vs nulli 10cm - see multi first, -1 0 +1 +2 = +2 station closer
fluorescein angiography - tests to measure circulation in retina, wear dark glasses, yellow staining of
skin will disappear, drink fluids, tonometry measure pressure in eye
acute glomerulonephritis, nurse asks - has your child had skin infections/sore throat, caused by group a
strep infx elsewhere in body (URI, skin like impetigo, throat, SLE), occurs secondary to lupus, cirrhosis,
sickle cell, s/s: hematuria, proteinuria, fever, chills
svt - vagal maneuver, have kid blow on thumb inside mouth, other vagal = ice to face, holding breath n
bearing down, massing carotid on one side of neck, if doesnt work IV adenosine
pt intubated for mechanical ventilation, next action - assess lung sounds, assess bilateral lung sounds
and chest excursion, assess for hypotension due to decreased cardiac output
total knee replacement - most important neuro check q1h for 12 hours then q2-4h, monitor bleeding
drainage q4h
senior center intervene if see - knee high nylon stockings (constricts circulation causing thrombi)
at risk for dehiscence and evisceration - overweight, poor wound healing (diabetes), post abdominal
(most frequent)
Legionnaires disease - found in warm stagnant water, severe form on pneumonia (at risk old,
immunosuppressed (AIDS), end stage renal, diabetes, smoking, pulmonary disease)
patient comes for routine exam, clients spouse died 2 months ago, statement appropriate - i
understand your spouse died 2 months ago
Dupuytren contracture - painless thickening/contracture of tissue beneath the skean on palm/fingers,
men over 50, diabetes, gout, arthritis, alcoholism
black cohosh - herb used for menopausal symptoms, can cause hypotension in combination with
antihypertensive drugs
halo traction - physician tightens screws 24-48 hours after, headache common, assess skin, dry damp
sheepskin with hairdryer, apply powder to prevent itching, if jaw movement pain or hurts to chew
occurs indicates skull pins slipped into temporal plate
thrombocytopenia due to acute lymphocytic leukemia - private room not be infected by other patients
and health care workers
long-term cortison therapy can cause osteoporosis, weakness, muscle-wasting, depression, alopecia,
buffalo hump, obesity, mood swings, slow wound healing (cushing)
using a doppler ultrasound device intervene if - student presses firmly while moving proximal to distal
(should be distal to prox, dont press too hard till abolish pulse)
diaphragm contraceptive - remove 6 hours after six, apply spermicide if longer than 4 hours after
insertion, recheck size annually or if pt gains more than 15 lbs
situational leadership - combination of styles depending on group needs, laissez faire - no leadership
conversion hysteria - motor/sensory symptoms with no cause, waxy flexibility - abnormal posturing or
motionless, dystonic - muscle spasm, neurasthenia - unexplained chronic fatigue
hantavirus pulmonary syndrome - assess for thrombocytopenia (hematuria, hematemesis, bleeding
gums, melena) (caused by rat poo)
SIADH - s/s: tachycardia, UO decreased, specific gravity elevated, hyponatremia, anorexia, n/v, LOC
changes, hypothermia
CT with and without contrast, BUN 2.1 creatinine 2.1 - question whether scan be done with constrast
(normal creatinine 0.7-1.4, elevated indicates renal failure) bun is 7-20, decreased suggests liver
damage, low protein, overhydration, follow up if allergic to shrimp/shellfish (contrast is iodine based)s
see first - dry cough for several weeks and frequent night sweats = tuberculosis (also progressive
fatigue, lethargy, nausea, anorexia, weight loss)
short leg cast care - use palms to handle cast (so no pressure areas), elevate limb to level of heart to
decrease edema, compare toes, place fan to facilitate drying
vent alarm goes off, first action - auscultate breath sounds

student has illness, student says parents refused to take to MD, first action - discuss with parents (not
based on child's report)
leukopenia isolation - no fresh fruit/flowers
crede maneuver - apply pressure to bladder to help empty (dont for pt's need assistance, ie. spinal
cord injury)
early decel fhr 125 (120-160) returns to baseline - continue to monitor, reassuring
pneumothorax - absent movement on affected side of chest, sucking sound on inspiration/expiration sucking chest wound, results in tachypnea
postop - check dressing for bleeding (not check for infection = too soon)
CPR - maintain vertical perssure on chest with heel of hand, check pulse every minute
legally blind - call plumber to set hot water tank to 100
heroin overdose given narcan anticipate - withdrawal signs, n/v, restlessness, cramping, tachy, htn
pt has cirrhosis of liver and needs ascites management, give first - albumin (pulls fluids back into blood
vessels), then spironolactone
granular casts in urine = renal disease
pt has decreased loc, blurred vision, headache, slurred speech, first? - obtain glucose level
(hypoglycemia similar to cva)
pt has septic shock which observation concerning - blood at venipuncture site and IV catheter (DIC
disseminated intravscular coagulation, sepsis most frequent cause )
low back pain and working - ask how many breaks (clients with low back pain shouldn't stand for long
time)
parkinsons - s/s: rigidity, Propulsive gait
pt has MDI metered dose inhaler - exhale just before pressing down, call hcp if cough doesn't go away
(asthma more at risk for respiratory diease)
female students have UTI, nurse first action - teach wipe from to back (most common cause is e coli
from rectum)
depressed client admitted to unit, most important action - brief orientation to you
heat stroke - hypotension, tachypnea, tachycardia, headache, skin hot/dry, elevated temp
see first - daughter of client with cancer parent doesnt want chemo (ask if side effects)
circumcision - put vaselin on gauze pad and put over circumcision before diaper, don't remove exudate
that appears, loose diaper to prevent fiction, watch for infx (red/swollen)
see first - client gets stung by bee complaining of hot/itchy (not hypoglycemic and cerebral bleeding
from hemophilia)
client falls over cliff and hits head, lumbar puncture ordered, first action - obtain vitals (increase in ICP
contraindicated in lumbar puncture)
elderly with left hip replacement, concerned if - heels on bed (sores, keep heels off)
renal failure - low mag/high creatinine (0.5-1.5) = renal failure, diet limited protein/high carb/low K/low
phos/low Na, most important to review is specific gravity because kidneys cant concentrate urine in
renal failure, high carb for energy (pasta + bread), hyperkalemia = spike t waves, retain K and become
acidotic
pt diagnosed MI, most appropriate nursing diagnosis is alteration in CO secondary to - ventricular
dysrhthmias, reduces efficiency of heart (common after MI)
BUN - 10-20, elevated in salt/water depletion, high BUN can cause altered LOC, convulsions,
orthostatic hypotension which could easily lead to falls. High BUN normal/no creatinine = dehydration
elderly client requiers bilateral eye patches, most important to - touch client while speaking to him
(always speak when enterign room, orient to surround)
client taking estrogen, which requires follow up - my left leg is sore behind knee (indicates
thrombophlebitis)
rhinoplasty - nose surgery, can't take oral temp due to packing in nostrils
two units arguing after joining together - assign members to patients on both sides of unit (no meetings
since they didnt work before)
alzheimers pt living with daughter, observations concerns nurse - blow dryer in wall (can be mistaken
as gun, can cause burns, electric shock)

croup + respiratory, skin, wound, enteric, eye, varicella zoster, cutaenous diphteria, herpez simplex,
impetigo, pedicuosis, scabies - contact
newborn immediate action - red reflex absent (ophthalmic emergency), can lead to blindness (over low
set ears = downs, uvula two lobes = possible cleft, facial droop = paralysis usually resolves)
cardiac assessment - inspect/palpate/auscultation, abdominal - inspect, auscultate, palpate
pt on vent best mode to wean - simv (synchornized intermittent mandatory ventilation), allows for
spontaneous breaths at own rate
controlled vent - set rate, not patient initiated, assist-control ventilation - rate is variable but volume is
preset, peep - positive pressure keeping airways always open for seriously ill
45yo m acute ab pain + acute vomiting, most important question - how much alcohol do you drink
(pancreatitis associated with heavy drinking)
anorexia female client met goal of nutrition if - menstrual period regular (enough intake of fat to
maintain FSH + LH). Appropriate activity make jewelry with OT (sense of self worth)
burn pt with 75% body, which indicates shock - cool, clammy skin and tachypnea (shock,
vasoconstriction compensates for loss of fluid, low UO, tachy, weak pulse, confusion)
storm blows out window, who to transfer - pt with asthma with nebulizer ( client is at risk of ineffective
airway clearance due to particles in the air from storm debris)
OOOTTAFAGVAH - smell, vision acuity, 346 = eye movement, 5 facial sensation, 7 facial movement, 8
auditory, 9/10 taste n gag reflex, 11 head movement, 12 tongue
burn pt - high protein diet
patient immoblized right leg, most appropriate - turn every 2 hours (not install trapeze, doesnt take
pressure off boney)
client lives in senior citizens facility, most important to ask - have you received flu shot (community
acquired pneumonia follows influenza, also ask pneumococcal)
low hemoglobin 6.8, first action - 2L oxygen ( critically low hemoglobin, less circulating oxygen)
epiglottitis, most important action - pulse ox + iv, ensure patent airway, chest xray, trach. s/s: 3ds,
dysphagia, dysphonia (impaired voice), drooling .no tongue blade (can close airway)
distended bladder, straight cath, perform next - clamp catheter after 300-500mL (rapid decompression
can result in damage)
caregive has flu taking care of AIDS pt - see if someone else available to provide care
toxic shock - assign to RN Staph infection that causes vomiting, diarrhea, and shock; early diagnosis
critical to avoid involvement with other organ systems
see first - patient with esophagogastric tube (for bleeding esophageal varices)
pt has seizures back to back - administer diazepam as ordered (protect client from injury, support abc)
see first - client with Elevated serum antistreptolysin O (ASO) titer (indicates glomerulonephritis)
insulin: lispro onset: 5-15 peak: 1-2 duration 2-3, regular onset 30-60 peak 2-3 duration 3-6, nph onset
2-4 peak 6-12 duration 16-20, lantus onset 1-2 peak: none duration: 24 hours
infant has cow milk allergy - predigested formulas are recommended (no goats milk, no soy formula)
FPOT - frontal - personality/behavior, parietal - sensation, occiptal - visual, temporal - auditory
pathological jaundice - occurs before 24h and lasts 7 days (destruction of RBCs from antibody ie. blood
incompatibility and rh neg move with rh pos baby), physiological occurs after 24 hours
meningitis due to Haemophilus influenza - dim lights and minimize stimuli (prevent seizure), droplet
until 24 hours after abx
most stable to d/c - 3 day old breast-feeding with serum bilirubin of 14 (phototherapy considered for
bili over 15 at 72 hours old)
metal penetrates eye/flying object in eye - find out what material it is and if he wears glasses to see if
any other materials in there
mom bottle feeds baby, encourage which action - wear well supportive bra (no manual pump or warm
packs will increase milk)
pt w icp, appropriate if - nurse assess cough reflex/ability to swallow (ICP can affect cough/gag reflex
and increase aspiration)
heart block - atropine for bradycardia, temporary pacemaker if pulse decreases, mix isoproterenol with
d5w if below 30
Isoproterenol heart block n ventricular dysrhythmias

spinal anesthesia, most important to - ensure hydration (prevents hypotension)

ileal conduit, observation most concerning - ab pain and fever (peritonitis)
pt on vent, which parameter most important to assess after - blood pressure (pt may have hypotension
from decreased CO)
pt with casted left leg, which exercise recommend - quadricep setting of affected limb (isometric,
maintains strength while in cast)
transdermal patch - fold patch in half, clean with water (not alcohol), clean gloves
latex allergy - private room, if none treat both as latex allergy (oxygen n foley made of latex)
advanced chronic renal failure, remove from tray - oj (pt has hyperkalemia), recommend chicken, eggs,
lean meat, fish, weigh self every morning before breakfast
most difficulty adjusting psychologically - stage 4 cancer (not adoloscent with wart or colostomy pt),
stage 4 will die within 4 months
spouse keeps pushing PCA - explain purpose
37 weeks gestation most concerned - RUQ pain (sign of impending eclampsia HTN, 4+ proteinuria,
headache, epigastric pain, tx - mag sulfate, vitals, bedrest, fhr, IOs, seizure precaution)
cleft lip - native american
amniocentesis - genetic disorders or neural tube defects; takes 2 - 4 weeks to obtain results
prolapsed cord - trendelenburg / modified sims / knee chestor finger against presenting part and shift
weight off cord
pt dies, spouse seen comforting family - spouse is in shock/disbelief (denial is inability to comprehend
reality of situation), resolution/move through grieving is too soon (takes about a year)
negative self image, most appropriate intervention - Help the client identify unrealistic expectations
(identify what is unreasonable if pt keeps failing to meet them, reinforce low self esteem)
imipramine - TCA used to treat panic attacks
sigmoidoscopy, most conern if client reports - lighthead + dizzy (hypovolemic shock), (not
pressure/fullness in ab = expected)
trach dislodged - hyperextend neck
cuffed tracheostomy tube purpose - Separate the upper and lower airways, seals off lumen, prevents
aspiration
warfarin - inhibits prothrombin synthesis (pt/inr), pt check every 1-4 weeks, wear medicalert, antidote
Phytonadione (vit K)
heparin - prevents fibroinogen to fibrin and inactives thrombin (ptt), ok for pregnancy
FVD improvement - lowered specific gravity hematocrit (continued dehydration = high sg and crit)
bismuth subsalicylate (Pepto-Bismol) increases the anticoagulant effectof heparin;, do not use together.
mental health

conversion - A physical symptom or a deficit suggesting loss or altered body function

related to psychological conflict or a neurological disorder (ie. blind, deaf, paralyzed)
Hypochondriasis - Preoccupation with fears of having a serious disease

Somatization disorder - The client has multiple physical complaints involving numerous body
systems.
Dissociative amnesia - Inability to recall important personal information because it provokes anxiety
Dissociative fugue - The client assumes a new identity in a new environment, drift place to place
Depersonalization disorder- An altered self-perception in which ones own reality is temporarily lost
or changed (look in mirror cant see myself)
see first - toddler w harsh high pitched (stridor = upper airway obstruction)
cervical implant futher teaching if pt says will have no sex/tampon for 2 weeks (no sex 6 weeks)
pt has cabg, which observation worries - jugular vein distended, lungs clear (cardiac tamponade, pain
over sternum/hypothermia expected). If cold/pale on chair place in bed
breast self exam - using pads of first 3 fingers press breast against wall in circular motion
z track - used for medications that are highly irritating to subcutaneous and skin tissues
licorice can increase potassium loss and may cause digoxin toxicity
surgery for total knee replacement, most important - apply scds, improves circulation and prevents clot
formation (not spirometer 3x/day, should be every hour)
question which order - bone imaging study for pt with multiple myeloma (will cause false positives)

pt trying to gain weight, effective teaching if pt says - snack on pecans/raisins (not eat bread, more
important to increase calories)
left hemisphere - speech, math, analytical. right hemisphere - impulsive behavior, disorientation
pt with baseline decreased mental status, most important to place in which position after feeding - R
side with HOB elevated (promotes emptying of stomach while prevent aspiration)
gerd gastroesophageal refluex - place on left side with HOB elevated 12 inches, diet: low fat, nonacidic. Risk female, obese, white
probably signs of pregnancy - positive urine test, uterine enlargement, contraction, hegars sign (cervix
softening), chadwicks sign (bluish discoloration)
albumin best assessment for nutrition besides muscle strength (3.5-5.5), pt has low albumin, assess for
- edema
child falls from tree, first action - bandage legs together (prevent further injury)
eriksons: 0-18: trust vs mistrust, 18-3 years: autonomy vs. shame & doubt, 3-5: initiative vs. guilt, 6-12:
industry vs inferiority, 13-19: identity vs role confusion, 20-39: intimacy vs isolation, 40-65: generativity
vs stagnation, 65+: ego vs.despair
assess reflexes but response not readily ellicited - have pt clench teeth while testing bicep, interlace
fingers while patellar (isometic contraction can increase reflex, might be distracted also)
100cc D5W + KCl 80 meq in .5 hour, first action - report MD (rate of IV administration shouldn't be
faster than 20 mEq/h)
pt w dvt, important to report - heaviness in chest (first sign of PE, sob, chest pain)
pt has blood-tinged sputum and night weights, first action - put mask on patient (prevent spread first
priority)
comtaose patient for 2 years, first action - greet client and tell time of day (reorient client should be
conducted every 8 hours)
tb test to HIV positive pt - false negative (immunosuppressed can't initiate adequate response)
risk for penumonia - cystic fibrosis (lung disease in factor, CF causes COPD), fractured rib, bedrest and
age
degenerative joint disease (DJD) - occupation that increases stress + age, obesity, diabetes/hemophilia,
smoking, place in functional position
elderly asian htn and heart failure, most important to following up with - 5 feet, 100 lbs risk for
osteoporosis, encourage calcium and exercise,
pt takes garlic daily, most important to follow up with info - client takes insulin (can have hypoglycemia
effect, increase action of diabetic drugs)
bone scan, most important to say to client - drink fluids between tracer and test (remove excess
isotope) and avoid before scan, lie flat not painful, encourage fluid intake after
left sided - dyspnea, third heart sound, dry nonproductive cough. right sided HF - edema, jvd, weight
gain
when one yelling at another in psych unit, which response by nurse is best - address aggressor "you
sound very angry with the other client"
pt has stoma, intervene if - client inserts a few drops of water into stoma (humidifcation should be
provided, cover when shower, baths ok = provide humidification)
tb - takes 2-12 weeks before tb transmission can be detected
ekg bpm - 1500/boxes between two r waves
cpap - room air, not combustible
craniotomy, instruct aid to 0 put ice pack on eyes and cool compress on forehead (pt may habe
periorbita edema and burning after surgery)
hypothermia patient, most alert for - ventricular fibrillation (hypothermia causes myocardial irritability)
see first - headache, malaise, anorexia, and an earache when chewing (mumps)
which assessment best assist nurse in determininig expectate date of confinment - auscultation of
fetal heartbeat ( can be heard at 12 weeks; is a positive sign of pregnancy)
prostate cancer - age, race, employment 55 black factory worker
pregnant client not able to hold urine, first action - check ph of fluid (determine if fluid is alkaline or
acidic)

child development - dolls eyes/grasp reflex (disappear 2-3 month), drool + object to mouth, extrusion
disappear (4 months), respond own name (6-8 month), take steps when standing, sit unsupported, pull
to standing, simple verbal command (9-10), eats using fingers (10-12 months), stand (15 months),
tower of 3-4 blocks (16-18 months), discriminate between pics, kick ball, 6 block tower, 2-3 word
phrase (24 months), jump with both feet, first and last name, (30 months), tricycle (36 months)
growth development 8 month - recognize parents (6 months), fears strangers/separation anxiety (7-8
months, hand blanket to ease anxiety), can't say mama (10 months), moro/startle (gone by 2 months),
sit without support (7-8), birth weight doubles (5 months)
child has acute diarrhea - brat not recommended (banana, rice toast tea) for diarrhea, not nutrtional
enough, resume normal diet
carpal tunnel syndrom assessment - Put the back of your hands together and bend both wrists at the
same time., phalens maneuver, tap wrist = tinel's sign
client has anaphylaxis - establish iv with ns
which pt to give reassigned RN (treat as LVN) - MI with burning urine (not glasgow 7 or terminal cancer
with cheyne stokes respirations)
insulin adminstration - rotate vial between both hands for one minute
neurogenic bladder (urinary retention) is incontinent and has UTIs - perform catheterization for residual
urine (residual urine causes UTI)
giving abx/medicine to kid - it will make you feel better (don't bargain or offer with milk/juice)
pt receiving PN, change solution 200ml left - change as scheduled (decrease infxn)
see first oncology - breast cancer extensive bone metastasis who is irritable and confused
(hypercalcemia may occur, as a result of bone destruction by tumors, affects mental status). Risk for
breast cancer: over 50, family had breast cancer, first birth after 30. After lumpectomy loose fitting
cotton bra (assess for redness + cracking)
pt falls and thinks arm broken first action - cut away sweater on affected arm (inspect first bleeding
swelling before immobilize/observe)
clients family comes and have flu - stay 3 feet away from ppl (not "tell them to stay home")
see first - blood urea nitrogen (BUN) of 35 mg/dL and serum creatinine of 2.5 mg/dL (elevated BUN and
creatinine) = liver damage
see first - client with one episode of fainting (could be cardiac rhythm, MI) over baby w temp, n/v
several hours, asthma w/ productive cough
pt friend dies in auto accident, pt thinks shes crazy trouble sleeping, appropriate action - determine
students coping behaviors since death
icu to stepdown - client with stroke 4 days ago w/ confusion (not 1 day post op craniotomy)
pt has severe headache, first action - obtain description of headache (not: list meds)
lvn reports client chest pain + ab pain + n/v, which action nurse first - comprehensive ab assessment
(not list meds)
husband says wife w parkinsons eats but lose weight nurse should - observe client eat (food can fall on
lap)
intravenous pyelogram (xray kidney) - iodine (ask for shellfish, milk, egg allergy), bowel prep, npo after
midnight, xrays taken at intervals after dye injected
clubbing - sign of hypoxia, The angle between the nail plate and the proximal nail fold is straightened
to 180 degrees
RN should care for - excision of malignant melanoma (may require pain meds psychological support)
urolithiasis - kidney stone, hypospadias - urethra under penis
syphilis - papule like lesion in vaginal area, VDRL test detects after 2-6 weeks (pap smear = cancer of
cervix, painful blisters = herpes)
Anterior wall MI: cause L sided CHF, so pulmonary edema and hypotension
Tourniquets: 4-6 inches above IV site is the correct location, not 1-2 inches
You can leave up to 100ml of Dialysate solution inmore than that, you gotta go get it
Asthmatic: a productive cough is a sign of URI, not airway / asthma issue, so the cough is not highest
priority
Heart failure: expect right heart failure stuff (edema, JVD), but dont expect left heart stuff (rales,
pulmonary edema)

signs of infection for elderly - tachycardia, tachypnea, confusion, change in mental status (fever maybe
absent)
addison's s/s - muscle cramp, fatigue, hypotension, weakness, dehydration, decreased bp, eternal tan,
alopecia (hair loss) (symptoms of hyponatremia)
respiraory acidosis improves but pao2 still low (80-100) - increase flow rate, if pao2 low ever usually
oxygen
nosebleed that won't stop from MI patient - are you taking anticoagus? pinch nose closed 5-10min with
ice-cold washcloth
diet for low hematocrit and hemoglobin - high protein, iron (clams and oatmeal), vitamins
flail chest - monitor for shock (hypovolemia), pain med (blunt chest trauma, painful), cough/deep
breath (lung expansion), monitor abg
children type 1 diabetes - polyuria, polydipsia, polyphagia, and weight loss, bedwetting. type 2
diabetes - UTIs
preterm infant - extremities are in extension, term - extremities flexed
see first - patient just released on lithium, hot weather make sure adequate sodium and drinking water
to prevent toxicity
meningococcal/mycoplasma pneumonia droplet, mrsa/s aureus/pneumococcal pneumonia contact,
pneumocystis jiroveci pneumonia (standard)
You should expect NO DISCHARGE from any biopsy, amniocentesis if there is discharge, that is a
DANGEROUS SITUATION FOR POTENTIAL INFECTION
Spontaneous jerky movements of a newborn: hypoglycemia (if jerking, need an assessment, so check a
bG)
tb test = acid fast bacillus sputum, tb induration: more than 10mm is positive for healthy, 5mm for
immunosuppressed
CVA will have HTN and orthostatic htn, not concerned with htn
oxygen probe shouldnt be in direct sunlight or strong light, gives inaccurate results, cover with dry
washcloths, rotate q4h
estrogen for middle aged - se: change in libido, weight, dryness in eyes
client with dull pain in calf after 4 mile run (DVT, given warm,moist soaks bedrest legs elevated,
anticoag, nsaids) - first action is to come to clinic
rationalization - justification for unreasonable act to make it appear reasonable, overexplain to avoid
blame (drive drunk home to feed dog)
projection - blame others
intellectualization - use of reasoning to prevent person from feeling, put aside feelings to discuss in
rational way
reaction formation - show opposite of what you feel
suppress - voluntary deny, repress - emotions out of conscious awareness, sublimation - dealing w
feelings by substituting form of expression (mad = work out gym)
minimize SE of immunization - administer antipyretics for fever/discomfort (not check temp every 4
hours)
pancreatitis - cullens sign (ecchymosis of umbilicus) and grey turners spots (ecchymosis of flank). give
dilaudid not meperidine/morphine
pt has acute pancreatitis, intervene if - nurse administers meperdine (opiates for pain, meperidine
avoided due to toxicity)
pancreatitis - daily weights, NG suctioning, bedrest
pt hallucinates, which response - what meds? (some meds can cause hallucinations NOT: anyone in fam
schizo?)
see first - kid leaning with mouth open, tongue protruding, droolign (acute epiglottis), NOT: kid crying
pulling on ear (otitis media)
rape victim, pt raped, most important - focus on here and now (immediate needs/concerns), NOT: how
handled in past
Pernicious Anemia - Red, Beefy tongue; will take Vit.B12 for life
least at risk for pneumonia - mitral valve prolapse (alcoholic, postop, dysphagia)

cna has flu, nurse action - tell them to go home (during community outbreaks of flu, should exclude
staff with infections)
low back pain positioning - hob 45, hip/knees flexed (knees higher than hips)
anthrax - standard precautions
pacu, pt recovering from anesthesia can wiggle toes/move legs, next - obtain BP (blockage of
autonomic nervous system may still be present and cause hypotension)
laryngitis secondary to pharyngitis - give paper/pencil to write, rest voice
private room - group a strep (contact)
tb - vitamin b6, alcoholism - b1 (thiamine), pregnant b9 (folic acid)
peptic ulcer disease 3 meals a day, s/s: dull, gnawing/burning midepigastric pain, avoid milk/cream,
alcohol, caffeinteted, aspirin
young adult has surgery most concerned if - my grandfather died during surgery got too hot (malignant
hyperthermia)
early complication of hypoxia for 4 year old with epiglottis - 148bpm (normal 80-140), restlessness
als amyotrophic lateral sclerosis neurodegenerative disease attacks brain/spinal cord - difficulty
swallowing, fatigue, tongue atrophy, weakness of hands/arms
tonsillectomy - observe for frequent swallowing, restrict fluids until no signs of hemorrhage (avoid
red/brown liquid)
hypothyroidism/myxedema effective - client discusses finances (hypothyroidism slows mental
functioning)
myelomeningocele - monitor for meningitis (elevated temp, irritability, lethargy)
24 urine specimen - discard first urine, collect all for 24 hours in one container
Judaism/Jew: control pain for end of life
Navajo/indian: no sense of time, might be late for appt
cva, when creating teaching plan which action by nurse most important - ask client to discuss
perception of health status
most concern burn pt - charred, waxy, white appearance on left leg
prevent falls in seniors - take tai-chai, thin nonslip shoes (not deep treats/athletic), eye doctor, MD
reviews meds, new lamps
see first - pt with Pneumocystis jiroveci pneumonia (opportunistic infection associated with AIDS; high
mortality)
intervene if student nurse - simultanesously palpates carotid pulses (palpate carotid pulses togethre
can cause vagal response)
left sided paralysis, alert oriented, speech slurred, most important - keep head of bed elevated 30
(facilitates venous drainage from brain)
inservice about specimen collection, requires correction - victim clothing in plastic bag (should be in
paper, plastic bag bacteria can destroy DNA)
genital herpes - virus remains in body in dormant state

Potassium rich foods - avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes,
pork, beef, veal, raisins, spinach, strawberries, and tomatoes
Magnesium peas, cauliflower
pt has lumbar laminectomy and wants to move from supine to standing at the left side of the bed with
a walker - focus on using arms, left elbow as pivot with left hand grasping the mattress edge and the
right hand pushing on the mattress above the elbow then slide legs over side of mattress (maintain
spinal alignment)
client on bedrest order to immobilize leg because of tenderness, increased warmth, diffuse swelling,
(DVT) most appropriate nursing action - turn client every 2 hour (prevent skin breakdown)
mumps - fever, headache, malaiser, anorexia, earache when chewing
fifth disease - most contagious before rash appears
client has BKA, persistant pain after receiving pain med, most appropriate - inspect the limb
skin biospy, which report hcp - i've been taking aspirin
which requires intervention - pt with sacral decubitis lies on left side with R leg extended on mattress
(upper leg should be flexed and on pillow)
nurse in ED notified workers exposed to radioactive matierals, first action - notify director of nursing of
the incident (to initiate disaster plan)
thoracentesis complications - pulmonary edema, hypoxia, hemothorax, pneumothorax, subcutaneous
emphysema, spleen and liver puncture (SOB, faintness, chest pain, bloody sputum)
see first - cabg w/ jvd (complication of cabg = cardiac tamponade - bp that falls when breathing deeply,
tachycardia, jvd, weak/absent pulse, tachypnea)
pt with osteoarthritis 15 years ago takes aspirin multiple times a day, most appropriate question 0 ask
if clien has tinnitus (indicates toxicity)
pt stares blankly has unsteady gait, stiff muscles, eyes moving rapidly, friends think on drugs. most
important for nurse to anticipate - aggressive behaviors
see first - haldol + 102f temp
postop pt with postop pt (pneumonectomy), not dirty (COPD)
client in active labor wants epidural. nurse anticipates fluid bolus of - lactated rings (replaces
electrolytes lost in labor process + adds volume )
MDI beclomthasone - steroid, rinse mouth and throat after w warm water to remove medication and
prevent infection (candidiasis)
see first - client n/v 6 times in 24 hours (assess amount/ character/ symptoms of FVD) not leg pain after
walking
aminophylline give 4 hours early, first action - document event on incident report and notify HCP
(tachycardia/anxiey will occur)

positron emission tomography, most important to - empty bladder (so pt can lie still during procedure
2hours)
first baby (primigravida) - normal progress 1-1.2cm/hr...cervical effacement first, then descent, and
dilation
gastrostomy tube gtube receivign enteral feeding client has loose stools, most concerned if - easy to
give liquid medicine through tube (liquid med may contain sorbital which will cause diarrhea if pt
allergic)
a nurse doesnt agree with new job description for CNA, charge nurse should - Facilitate an open
discussion during a prescheduled meeting (indirect)
pt see friend get shot, shaking/crying/nervous, plan of care - remain w client, administer lorazepam,
privacy, write down important info
appropriate therapy for abusing spouse - group therapy
nephrotic syndrome caused by acute poststreptococcal glomerulonephritis, most important to instruct
client - s/s of venous thrombosis (common complication of nephrotic syndrome)
anaphylactic reaction - airway + circulation, prevent further exposure. diphenhydramine/epinephrine,
airway, cpr if not breathing, elevate hob, epi, fluids, vasopressors
see first - epigastric pain vomiting blood and alcohol breath (acute gastritis) (not pt pale/diaphoretic
severe pain radiating from flank to scrotum (renal colic)
risk for pneumonia - cystic fibrosis (lung disease), fractured rib 68y (shallow respirations), 79y fractured
hip (bedrest)
teach s/s of impending labor - i will call hcp if contractions occur every 5 minutes for an hour
nurse preps discharge requiring home oxygen therapy, most important for nurse to assess - client's
understanding of home o2 therapy
UAP says mom should breastfeed baby with tof, best response - what do you understand about her
babys illness
breast exam - use first three fingers, press breast againt breast wall in circular motion, moves from
periphery to areola and moves around breast counterclockwise
cranial IX and X supplies - tongue depressor and flashlight (vagus never, swallow + gag)
I - smell, II vision (read/peripheral), III (pupil size penlight), IV - follow finger, V (face sensation), VI (eye
movement sides), VII (facial movement/expression), VIII (hearing), IX (taste), X vagus, XI neck shoulder
movement, XII stick out tongue
locked acute inpatient psych has fire alarm in different level first action - ensure all pt out of room and
in dayroom
private room - cellulitis with group a strep (not Pneumocystis jiroveci pneumonia)
5 month visits, which observation concern - child abducts extremities and fans fingers when noise
occurs (moro should disappear by 4 months)
learning rules and how to play with others - industry vs inferiority (6-12 school age)
COPD bp 130/70, hr 84 resp 26 oxy 100 6L NC, first action - hob 45 (not wean o2)
risk for suicuide - adolescents, male over 50, depression, hx of suicide (not grief for 9 months)
8 month in pain - rub body part and crying
Hashimoto's disease is caused by autoimmunity to the thyroid gland s/s: constipation, dry pale skin,
hoarse voice, depression, muscle weakness,
ambulatory electrocardiography - interevene if pt takes shower, call md if lightheadness, decrease
roughage
md order fruit/veggie/chicken/whole grain diet which findings expect - hematocrit 40, hemoglobin 11.2
(clients w anemia should eat diet high in protein, iron, vitamins), high creatinine+bun = limited pro,
high carb, restrict K, Na, phosphorus, high alt/ast/liver increased carb, low pro, low sodium. htn low
salt/fat/limitited protein
Liver biopsy- Adm vit k , npo morning of exam 6hr, give sedative, Teach pt asked to hold breath for 510sec, supine postion w upper arms elevated. Post- postion on right side, frequent v.s., report severe
ab pain stat, no heavy lifting 1wk.
first diagnostic test for acute onset of seizure - EEG electroencephalogram, records electrical activity of
brain. prep - painless, wash hair to remove oils, stimulants held like cola/cigarettes, food/fluids ok, may

hyperventilate 3-4 min and watch bright light, kept awake night before so can sleep during test,45min
2 hours
paracentesis - void before, post op check bp, VS, report elevated temp, observe for signs of
hypovolemia (have bp cuff ready). Watch for sob, faintness, chest pain, bloody sputum (pulmonary
edema, hypoxia, hemothorax, all complications of centesis)
review md order, question which order - bone imaging study for pt with multiple myeloma (better
detected with plain radiograph)
see first - pt w small watery diarrhea and ab pain and nausea (bowel obstruction)
phenelzine diagnosed with cushing now hypokalemc, which food best - spinach + tuna (not banana n
raisin salad, banana has tyramine)
bizarre gesturing, decline in hygiene, command hallucinations, most important to - ask pt what the
voice ar saying
postpartum perineal care, further teaching if - change pads when soiled (change whenever use
bathroom and when soiled)
pt changes subject during interview at psych unit - recognize client's behavior is necesssary to relieve
discomfort
see first at diabetic clinic - sunkey eyeballs + fruity breath odor (DKA, not drinking fluids frequently +
always hungry = hyperglycemia)
teach 10 year old + parents - proper nutrition + sports safety (not water safety, suicide, sex)
brady - if symptomatic (dizzy/lightheaded) give atropine
Tachy - Vagal maneuver, persistent tachy causing hypotension/aloc = cardioversion, adenosine if
regular, beta/calcium channel blocker
pac (p waves look different) - digoxin

atrial flutter (sawtooth)- digoxin, amiodarone, cardioversion

atrial fib (no p wave, narrow QRS, irregular) dig, amiodarone, warfarin, cardioversion

svt - valsava/vagal maneuver, don't carotid massage, cough, adenosine

first degree heart block - usually no tx, atropine if symptomatic and brady (PR greater than .2)

second degree type 1 atropine, no tx(PR marches out, drops QRS)

second degree type 2 - atropine/epi, pacing (fixed PR, multiple dropped QRS)

third degree atropine, pacing (PR and QRS independent, miscommunication)

pvc lidocaine (wide QRS and inverted st)

VF/VT - lidocaine/amiodarone, shock, epi every 3-5 min,

vtach

v fib

torsades - magnesium first

Asystole: CPR 2min, Epi/atropine every 3-5 min
300 divided by how many big boxes between two R

SVT - Adenosine, Vagal Maneuver

Atrial Flutter - dig, beta blockers
Atrial Fibrillation - Digoxin, warfarin, beta blocker, calcium channel blocker
PVC - Lidocaine if normal/tachy, atropine if brady
Ventricular Tachycardia - Lidocaine
Pulseless V Tach/V Fib - Defib, CPR, Epi/Amiodarone
Torsades de Pointes - Magnesium Sulfate
1st Degree AV Block - No treatment usually
2nd Degree AV Block Type I - Atropine
2nd Degree AV Block Type II - Atropine/Epi, Pacemaker
3rd Degree AV Block Complete - Emergent Pacemaker, Atropine
Sinus Bradycardia - Atropine/Epinephrine
Sinus Tachycardia - Beta blocker, Vagal Maneuver
Asystole - CPR, Epi/Atropine

Pharmacology
Ciprofloxacin abx (report unsual calf pain, not with milk) adverse reaction: jaundice, vaginal yeast
infx, achilles tendon pain, drink fluid, avoid exposure to sun, avoid caffeine
tetracycline HCL (anti-infective) - wear sunscreen, don't take with milk, with full glass water, 1 hr before
meals or 2 hrs after, raise slowly (orthostatic hypotension, dont exercise first thing in morning), can be
used for copd, dry mouth
doxycycline (tetracycline, abx) - report if vaginal discharge, not taken within 1 hour of bedtime
(esophageal irritation), taken around the clock, don't take antacids within 1-3 hours
-cycline : are NOT to be taken at bedtime or lying flat (will cause esophageal damage), dont take
antacids within 3 hours
Carafate (ulcers) before meal, digoxin (heart) after meal
cephalexin - antibiotic, encourage yogurt/milk to maintain intestinal flora, around the clock q6h, with
food
acyclovir - antiviral for herpes, eat with food (may cause n/v)
gentamicin - decreased hearing/veritgo result of toxicity aminoglycoside (mycin) - adverse: ototoxicity
(hearing problems0
metronidazole - bacterial infection, take with meals and don't drink alcohol, can cause n/v
pentamidine isethionate - anti-infective for pneumonia in AIDS, indication working if decreased
crackles/dyspnea (neumocystis jiroveci pneumonia)
neomycin sulfate is an aminoglycoside used to suppress intestinal bacteria; acts as a bowel sterilizer;
used to prevent wound and abdominal infections and used as adjunctive therapy for hepatic coma
Spironolactone steroid for excess fluid, potassium sparing
Lasix - diet: potato, cantaloupe, dark leafy greens, white beans, dried apricot. Assess muscle weakness
ethacrynic acid - loop diuretic (potassium wasting, drink oj + K), take w/ meal, take early in day, call
md if dizzy
hydrochlorothiazide - diuretic, lose K, each dry apricots/bananas/dark leafy greens/citrus fruits, take
with food, take in morning
Furosemide/Bumetanide loop diuretic, gets rid of potassium - priority assessment: muscle weakness
Propranolol beta blocker, auscultate lungs, causes bronchoconstriction
depression/hypotension/weakness, contraindicated for copd/hf/pulmonary edema, masks signs of
hypoglycemia,
Catapres bp patch, dont need to take offer to shower, stays on for 7 days
Digoxin early signs of dig toxicity - sob, n/v, headache, dizziness, report confusion and yellow halos
around lights
Clopidrogel anticoag

Losartan treats htn (ARB), priority action for initial dose instruct client to sit on the edge of bed
before ambulating
enalapril + furosemide - may promote significant diuresis; first dose of ACE inhibitors increases risk of
"first dose" phenomenon due to vasodilation;
vtach - lidocaine, contraindicated for heartblock
svt - adenosine
asystole - atropine
chf - ace inhibitor (assume 1 liter in lungs if gain 1lb)
ACE inhibitors (pril) - SE nonproductive dry cough not (arbs - hydrochlorothiazide,-sartan)
pvc - give lidocaine, atropine for bradycardia
Hydralazine - vasodilator for htn, hf
betablockers/ace inhibitors - not as effective in african americans, calcium channel blockers work better
(-pine, verapamil, ditiazem)
ace inhibitor (pril) - block release of aldosterone promoting potassium retention (avoid salt substitutes
+ broccoli + bananas), dry cough, 1 hour before and 2 hours after meals, watch for hyperkalemia
digoxin - 0.5-2, lithium 0.8-1.5, theophylline 10-20, INR for warfarin 2-3
dopamine is indicated for correction of hemodynamic instability as a result of shock; monitoring vital
signs provides most appropriate information regarding effects of drug
beta blocker - if discontinued abruptly, may cause life-threatening dysrhythmias, hypertension, or
myocardial ischemia; should be tapered gradually over 2 weeks; take medication with meals
nifedipine (ca channel blocker) - hold if below 60 hr

Cisplatin chemo, follow up which statement: my family thinks I ignore them (toxicity with chemo, can
damage ear), risk for developing ear problems
Morphine (Roxanol) q4h for chemo for breakthrough pain
Cyclophosphamide (chemo) most important question to ask have you had any n/v?, hydration is
most important for chemo drugs
Hydrocodone for back pain (opiate) which statement requires intervention: I will have to urinate more
(opiates cause constipation drink prune juice, facial flushing, cough not as strong)
(antiemetic)
Benztropine - parkinsons (anticholinergic cant spit, see, poop, pee), treat SE of antipsychotic
Carbidopa/Levodopa (parkinsons) reduces rigidity to help ambulate (tremors dont disappear, low
protein to decrease GI UPset, watch for orthostatic hypotension, eyelid twitch = overdose,
multivitamins can reverse actions
Haloperidol given for anxiety, panic attacks, watch for tongue protrusion/muscle rigidty
extrapyramidal reaction, dystonic reaction: oculogyric crisis
Ritalin/ Methylphenidate - give in morning after breakfast to decrease appetite suppressant effects. SE:
anorexia
haldol - deep IM, SE: milk out of breasts, rise slowly to stand to avoid orthostatic hypotension
antipsychotic - assess for postural hypotension
Paroxetine SSRI, see first if I get confused, early sign of anti-depressant toxicity
fluoxetine - SSRI, takes 4 weeks, wwatch for suicidal tendencies, increased energy antidepressant (dry
mouth, orthostatic hypotension, sunscreen), positive is participates in events (not sleeps more)
citalopram SSRI, notify if symptoms include abdominal pain, fever, sweating, tachycardia,
hypertension, delirium, myoclonus, irritability, and mood changes (life threatening)
bromocriptine - parkinsons, type 2 diabetes. take with meals, cause GI upset if not taken with meals
doxepin hydrochloride - antidepressant; signs of overdosage include excitability and tremors
Ziprasidone antipsychotic, to understand action = talk coherently
Biperiden - used to treat counteract extrapyramidal side effects the client is experiencing
chlorpromazine schizo and n/v, report of difficulty urinating (anti-cholinergic [mine, line, late]
reaction:, can't see, can't pee, cant spit, cant shit, dry mouth, tachy), leukopenia

NO psych med should cause stiffness/tremorsthat is an EPS

risperidone - atypical antipsychotic: weight gain, avoid extreme temp, long sleeve in sun, change
positions slowly
pemoline - cns stimulant for adhd
Fluphenazine - anti-psychotic (schizophrenia), q1-6 weeks, takes 1-3 days for onset, causes sedation
first few weeks
clozapine - antipsychotic, contact hcp if sore throat + fever (suppress bone marrow), must return to lab
to check wbc, see first if experiencing flu like symptoms, SE: extreme salivation
Lithium = 0.8-1.5, over 1.5 = toxic, bipolar, anti manic, cause DI, Diet regular sodium + adequate
fluid intake (lithium is salt preparation and its retention related to sodium/fluid balance), need to drink
a lot of water (UO increases), may feel tachy/hypotensive, interventions include increasing water
intake, expected fine hand tremor, polyuria, thirst
Lithium toxicity early: n/v, slurred speech, muscle weakness, tinnitus (ring in ear), vertigo, drowiness
Lithium toxicity advanced: coarse hand tremors, oversedation, ataxia (uncontrolled muscle movement),
Uncontrollable eye movement (nystagmus), muscle twitch, seizure, coma, diarrhea, GI upset, mental
confusion
typical antipsychotics - watch for extrapyramidal symptoms like dystonia (spasms/muscle contraction),
akathisia (restlessness), parkinsonism (rigidity), tardive dyskinesia (jerky movements). give
benztropine or trihexyphenidyl
tranylcypromine sulfate (MAOI) anti depressants like Isocarboxazid, Phenelzine, Selegiline,
Tranylcypromine - avoid tyramine foods like cheese, yogurt, processed meat, dried fish, chocolate,
donuts, raisin, papaya, raisin, passionfruit, figs, tv dinner, nuts, beer, wine, banana, avocado, to avoid
hypertensive crisis, sunblock required, 3-4 weeks to work
call HCP if have severe headaches (hypertensive crisis), watch diet
alprazolam - anxiety, CNS depressant, no alcohol, check renal/hepatic function, don't dc abruptly
Lorazepam - anti-anxiety, benzo, sedative for anxiety, depression, insomnia, give urinal
Chlordiazepoxide - benzo, cns depressant, helps w alcohol withdrawal, after meals or with milk SE:
drowsiness and blurred vision, confusion, constipation, slurred speech, dermatitis, anorexia, polyuria,
pancytopenia, and thrombocytopenia
Carbamazepine (anti seizure, can decrease bone morrow), priority assessment platelet + hemoglobin,
interferes with oral contraceptives, also for seizure/nerve pain, mention to anesthetist cuz anesthetic
may be reduced
pheonobarbital anti-seizure, cns depressant, increases vit d metabolism
Fluphenazine decanoate - if pt schizo forgets mets (IM)
Amitriptyline tca- (depression) - take at night, postural hypotension, constipation, urinary retention,
wear sunblock, takes 3-4 weeks, blurred vision, dry mouth, increases appetite
Albuterol bronchodilator first then steroid
Theophylline - asthma, bronchodilator. Report to hcp if tachycardia/hypotension/n/v
aminophylline - treats asthma, withold if pt taking beta blocker (decreaes metabolism), cipro (decrease
hepatic clearance), contraindicated with seizure disorder, with food or glass of water
aminophylline toxicity - palpitations, nervousness, increased urine, confusion, headache, tachycardia,
seizure, n/v, dysrhythmias
Beclomethasone steroid for asthma, inhaled corticosteroids can predispose to fungal oropharynx
infection (candidiasis); rinsing mouth and gargling with warm water when each treatment is completed
is imperative to remove residual medication
ipratropium - decreases mucus with asthma
Mag sulfate which finding most concerns: respirations of 10/min
Alendronate preserve bone for osteoporosis. Understands if they experience burn in stomach, no ECT,
take in morning on empty stomach, sit for 30min, wear sunscreen
isoniazid - TB med, avoid alcohol, can increase isoniazid related hepatitis (liver inflammation
jaundice), check for jaundice (asians check hard palate), SE: peripheral neuropathy
ethambutol - treats tb, watch for optic neuritis (reduced visual acuity, ie. can't see green light)

pyrazinamide - treats tb, d/c if gout symptoms (ie. big toe hurts). All given to prevent resistant
organism
Rifampin treats tb, orange urine ok
Nitro bp 150/90, pulse 88, respirations 20 100/60, 96, respiration 20
Tamsulosin helps with BPH/difficulty peeing, alpha blocker first dose take with food due to SE of
lightheadedness, take at bed time, may cause hypotension
Zolpidem insomnia
Glipzide type 2 diabetes
glipizide - produce minimal amounts of insulin for type 2
Which to message first metoprolol tartrate with coughing and wheezing
Levothyroxine heart palpitations
Famotidine duodenal ulcer - follow up if patient takes Maalox at same time
Grapefruit juice interaction with - buspirone (anxiety), carbamazepine (seizure), simvastatin, verapamil
(bp med)
Flavoxate treats muscle spasms of bladder
Prednisone lowers K and digoxin can be toxic with low potassium, take with meals due avoid GI upset,
increase dosage of steroid before surgery because it increases demand for steroid, monitor
vitals/bg/check bleeding/infxn
steroids - delay wound healing, make you osteoporotic, immune suppressed, hyperglycemic cause
sodium retention. puts at risk for low K which can cause dig toxicity
Adalimumab/Humira, treats RA psoriasis, suppresses immune stay away from people with cold
hydrocortisone for addisons, which statement requiers intervention - low bp while taking med, expect
htn
disulfiram - unpleasant reaction to any form of alcohol, syrups, lotions, sauces, wood stain, paint.
continues for 2 weeks, even after d/c. take at night minimize sedative effects
morphine - contraindicted in head injury causes CNS depression masks increased ICP, decreases blood
return to R side heart, decrease peripheral resistance
zantac - stress uclers, promethazine for n/v
ranitidine hydrochloride - taken at hour of sleep to prevent uclers, don't give if allergy test, avoid
NSAIDs, don't smoke, avoid alcohol or any GI irritation meds
cimetidine acid reduc/ulcer, take w/ meals and hour before bed, mild diarrhea/dizziness/male hair
growth in women, for peptic ulcer disease (3 meals a day). SE: confusion for elderly, drowsiness,
headache, constipation, increase fiber
sucralfate - for uclers (empty stomach)
atorvastatin - lowers cholesterol, propranolol lowers effect, avoid grapefruit juice
ritodrine hydrochloride - stop premature birth
meperidine - pain med (dont give for pancreatitis / gerd / sickle cell)
acetylsalicylic acid (aspirin) OD, action to take - determine when client took aspirin (charcoal given
within 2 hours), ABG, temp (hyperthermia)
sulindac - nsaid, report if ecchymosis of extremities, vomiting red streaked fluid, flank pain
(nephrotoxicity)
Ketorolac (nsaid) hard on kidney, priority assess creatinine
naproxen (NSAID) - can cause gastric bleeding, notify if stools dark
heparin - antidote: protamine sulfate, aptt 20-40, therapeutic 1.5-2.5x = 100, more stop infusion and
notify md (dose must be ordered first), antidote =protamine sulfate
heparin, concerned if - Petechiae (bleeding under skin, pinpoint red marks), decreased LOC, taking
ginkgo/garlic/ginseng/ginger/kava (anti-platelet)
warfarin/coumadin - don't eat salad/dark leafy greens, vitamin K antidote, 72 hours to kick in
Magnesium hydroxide - upset stomach, pc (after meals), don't give within 30min of other meds
bismuth subsalicylate - treats upset stomach, separate from other meds, at least hour apart
fluticasone - allergies (steroid), inhaled, rinse mouth to prevent candida
status epilepticus valium
feosol - iron supplment, can cause color of stool to resemble melena, increase fruit/whole grain
because it can cause constipation

empty stomach - iron, abx (except cillin and mycin), anti-viral

with meal - diuretic, GI, anti-convulsant (phenytoin, carbamazepine, lamotrigine), antigout (allopurinol),
beta blocker (olol), antipsychotic (lithium), parkinsons (bromocriptine)
phenytoin anti-convuslant, pink urine common, avoid if pregnant. Can cause folate/vit d deficiencies
so eat cantaloupe, milk, kale. Can cause gums to change so oral care (gingival hyperplasia with long
term use), leukopenia
phenytoin/dilantin overdose - ataxia, slurred speech, nystagmus (uncontrollable eye movement),
therapeutic is 10-20g/mL, metabolized and excreted by liver avoid if impaired liver function
aluminum hydroxide - (antacid) 1hr after meals, neutralize gastric acids, increase gastric pH, and
inactivate pepsin; contains sodium check if on Na strict diet , for CRF decrease phosphate
antacids neutralize gastric acid (alumninum + magnesium hydroxide), lansoprazole decreasse gastric
acid secretion (PPI - prazole)
metoclopramide treats nausea, weigh baby to measure feeding retention
cyclosporine - no grapefruit juice, immunosuppressant for organ transplant
phenazopyridine - attacks UTI, orange urine, with meals. cal md if skin/sclera yellow
doxorubicin - for leukemia, SE: red urine, worry if fever
butorphanol tartrate - narcotic, measure rate/depth of respirations
metformin held within 48 hours of contrast media for CT - hard on kidneys, risk for lactic acidosis, take
with meals
sulfasalazine - sulfonamide, decreases bowel inflammation; administer after meals or with food,
increase fluid, orange urine
trimethoprim-sulfamethoxazole abx (UTI), SE: urticaria (rash)
epoetin alpha (Procrit) - treat anemia (report hematocrit raise from 28 to 33, htn + seizure if hematocrit
raises by more than 4 points in 2 weeks)
if allergic - hold meds (if allergic to aspirin cant give naproxen) and cefaclor (abx, if allergic to penicillin
10% allergic to cefaclor)
Calcium blocks thyroid meds so dont take calcium 2 hr before or 3 hr after synthroid
versed - for cardioversion, sedative used for procedure (may cause dizziness, avoid driving)
percocet - oxycodone with acetaminophen w/ food (for hemophilia, don't give nsaid like aspirin, motrin,
percodan)
Bethanechol - treats urinary problems/retention
cholestyramine- lowers cholesterol, SE: constipation. exercise + whole grains to prevent constipation
5-fluorouracil (5-FU) - cancer, weakens immune. see first
butorphanol tartrate - pain med (monitor rate + respirations)

Review NCLEX
about mainly on stroke, parkinson's, and psych disorders. i got 3 EKG strips! (i wanted to cry) there was
primary/secondary/tertiary prevention questions on there, and read up on types of conflict resolution - i
had a few of those. i got more questions about side effects of meds. Hirschsprung disease showed up
on mine too.
i felt like. my friend got a lot of med questions, i got more psych and stroke questions. a few growth
and development stuff too
- know precautions , like if they give you RSV, what do you have to wear and do and what about the
patient as well (I got bacterial meningitis ), they'll give you things like "put on mask" , negative
pressure room... Know it well - difference between contact , droplet , airborne and what diseases would
need it.
- priorities - these aren't easy at all and totally not obvious. It's not even that easy to use AbCs ... Just
practice them
- they'll give you diseases you'll never heard before but pay attention to root words like if they have
something with -itis at the end , it's an inflammation ... So answer it according to that even if you don't
know what the 1st part is

- know your procedure steps and preparations , Egd, biopsies, thoracentesis... Know what to tell your
patient of what they will expect
- had psych stuff as well as peds developmental stages, like a toddler likes to have dolls to play with in
the hospital
- both my classmate and I had the generic drug : adalimumab as a test question ..
- a few of them had questions with cystic fibrosis , mine liked shingles
- study heart rhythms , everyone got at least one strip. Get it right and it won't come back
- let's say you get a topic wrong like mine is shingles , they will likely bring back that question but word
it differently, use test taking strategies cause they'll end up using what was an answer choice in a
following question. It's almost like they'll ask you to see if you know something at least. Basically, if you
fuck up, you'll see the topic again.
- I got labor delivery question, asking me about the latent phase of labor

Blood Products
Factor VIII - for hemophilia
O+: universal donor, AB- : universal recipient
For blood 18 gauge or bigger, NS for blood only
Allergic reaction - hypersensitivity (hives, itching, flushing), tx- stop blood, benadryl, steroids
Hemolytic reaction - incompatibility (low backpain, hematuria, hypotension, nausea, vomiting), tx - stop
blood, o2, benadryl
Febrile reaction fever, chills, headache, tx- aspirin
Bacterial reaction - contimanted blood (fever, chill), tx- volume expanders, abx
Circulatory overaload - large volume over short time (dyspnea, crackles, tachycardia, tachypnea), tx slow/dc transfusion
Blood reaction: Stop blood, use IV NS, airway management first, benadryl, aspirin, steroids. Return
blood containers, IV back to lab. Collect blood and urine samples, monitor voiding/vitals
Parenteral Fluid
Isotonic - 0.9% NaCl, D5W
Hypertonic - D10W (pulls fluid into vessels, fluids flow higher concentration)
Hypotonic - 0.45% NaCl (pulls fluid into tissue)
Calculation of IV Flow Rate
drip factor: microdrip 60gtt/ml, macro 15 gtt/ml
Volume x drop factor/time in minutes = gtt/min
Complications
Infiltration - coolness, edema, pain tissue (d/c iv, warm compress, elevate arm)
Extravascation - vesicant solution, coolness, pain, blanching (meds - gentatmicin, penicilin, vanco,
dilantin, calcium, potassium, epinephrine, antineoplastics [warm compress]), stop iv, aspirate
Phlebitis - reddened, warm, tender blood vessel (d/c iv, warm compress)
Adrenergic (cardiac arrest, anaphylaxis, hypovolemic shock)
Norepinhrine, dopamine, epinehprine, dobutamine, nitroprusside
SE: dysrhythmias, tremors, anticholinergic (dry mouth, urinary retention)
Nursing: monitor bp/pulses, output
Anti-anxiety (manic, panic attacks, anxiety)
Chlordiazepoxide, alprazolam, lorazepam, clonazepam, hydroxyzine, equanil (CNS depressant)
SE: sedation, confusion, hepatic dysfunction, drowsiness, blurred vision
Nursing: no grapefruit juice, avoid alcohol, monitor liver function
Antacids (peptic ulcer, indigestion, reflex esophagitis)
aluminum hydroxide, magenesium hydroxide, maalox
SE: constipation (aluminum), diarrhea (magnesium), acid rebound

Nursing: interferes with absorption abx, iron preps, INH, oral contraceptives, monitor bowel function, 12 hours after eating and after meds, Fluid Electrolyte balance (monitor s/s of lab shifting, ie.
magnesium is CNS depressant)

Antidysrhythmics (a fib/flutter, tachycardia, PVCs)

Atropine sulfate, lidocaine, procainamide, isoproterenol
SE: hypotension, bradycardia, urinary retention, lightheadedness
Nursing: monitor vitals (pulses/rhythm), orthostatic hypotension
Antibiotics - General
SE: Check liver/kidney (organ toxicity, metabolized in kidney, excreted in liver)
Nursing: take until gone, encourage fluids, take 1hac or 2-3 after meals)
All empty stomach meals except sulfa (sulfonamide) and cefa- (cephalosporin)
Vancomycin monitor for flushing and hypotension (red mans syndrome)
Antibiotic: aminoglycoside (pseudomonas, e coli)
gentamicin, neomycin, streptomycin, tobramycin (-mycin)
SE: ototoxicity, nephrotoxicity, anorexia, n/v, diarrhea
Nursing: check hearing (8th cranial nerve), renal (BUN, creatinine), fluids, small frequent meals, give
when penicillin contraindicated
Antibiotic: cephalosporin (tonsillitis, otitis media, peri-operative prophylaxis, meningitis, UTI, respiratory
infxn)
cephalexin, cefaclor, ceftriaxone, cefepime
SE: bone marrow suppression, superinfection, rash
Nursing: take with food (cause GI upset), cross allergy with penicillin, avoid alcohol
Antibiotic: fluoroquinolones (anthrax, e coli, pseudomonas, s. aureus)
ciprofloxacin, levofloxacin (-floxacin)
SE: diarrhea, decreased WBC and hematocrit, elevated liver enzyme (ALT/AST)
Nursing: sunscreen, encourage fluids (1.5L-3L/day), take 1h before or 2h after meals), not with
antacid/iron
Antibiotic: macrolide (acute infxn, acne, URI, prophylaxis before dental if allergic to pcn)
erythromycin, cleocin
SE: confusion, diarrhea
Nursing: monitor liver function, take 1hac or 2-3hpc
Antibiotic: penicillin (moderate to severe infection, syphilis, Lyme disease)
amxoicillin, penicillin, ampicillin (-cillin)
SE: stomatitis (mouth + GI breakdown)
Nursing: check for hypersensitivity,
Antibiotic: sulfonamide (ulcerative colitis, Crohns disease, UTIs)
Sulfasalazine, Sulfisoxazole
SE: peripheral neuropathy, crystalluria, photosensitivity
Nursing: take with meals, good mouth care, if allergic to sulfas avoid Acetazolamide, fluids,
Antibiotics: tetracycline (infection, acne, prophylaxis for ophthalmia neonatroum))
Doxycycline, tetracycline (-cycline)
SE: discoloration of teeth of pregnant or young, phototoxic, orthostatic hypotension
Nursing: sunblock/avoid sun, avoid milk/antacids toxic if expired
UTIs
Furadantin

SE: asthma attack

Nursing: with food/milk, monitor pulmonary status

Pyridium
SE: headache, vertigo
Nursing: orange urine, urinary tract analgesic
Genitourinary
sildenafil, vardenafil, tadalfil (fil)
SE: headache, hypotension
Contraindications: nitrates, alpha blocker
Nursing: no grapefruit juice, call MD if longer than 4 hrs
Anticholinergic (opthalmic exam, motion sickness, preoperative)
propanthekine, atropine, Iproproprium
SE: urinary retention, blurred vision, dry mouth, change in heart rate
Nursing: monitor output, contraindicated with glaucoma/paralytic ileus/benign prostatic hypertrophy,
give 30min ac or 2h pc
Anticoags
Heparin
SE: hematuria, tissue irritation
Nursing: monitor clotting times PTT (normal 20-45, therapeutic 1.5-2.5 times 50-100), antidote:
protamine sulfate
Warfarin
SE: hemorrhage, alopecia (hair loss)
Nursing: INR 2-3, PT (normal 9-12, therapeutic 1.5 times 20-30), antidote - vitamin K (don't eat foods
with vit K like green veggies, pork, milk product, fish)
Herbal intercation: garlic, ginger, ginkgo will increase bleeding
Anticonvulsant
phenytoin, phenobarbital, carbamazepine, clonazepam, divalproex sodium, mag sulfate, valproic acid (tal)
SE: respiratory depression, aplastic anemia,, ataxia (lack of motor control)
Nursing: don't d/c, monitor IOs, with food, mouth care, no alcohol, caution with meds that lower
threshold (MAOIs, anti-psychotic - work against med)
Phenytoin: given too quick IV cause cardiac arrest, given alone through own port never mixed with
med, pink urine, gingival hypertrophy (overgrowth of gums), therapeutic 10-20
Mag sulfate: deep tendon reflexes assessed, respiratory arrest is SE
Valproic acid: no carbonated drinks
Antidepressant - MAOI
isocarboxazid, tranylcypromine, phenelzine, selegiline
SE: slurred speech, hypertensive crisis if taken with tyramine (aged cheese, bologna, pepperoni, liver,
figs, banana, raisins, yogurt, beer, sour cream, wine, pickled products)
Nursing: takes 3-4 weeks to work, monitor output, don't take with SSRI or cold meds
Antidepressant - SSRI
fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram
SE: anxiety, GI upset, change in appetite and bowel function, urinary retention, pink urine
Nursing: suicide precaution, takes 4 weeks for full effect, take in AM
Antidepressant - tricyclic

amitriptyline, imipramine, desipramine (-tyline)

SE: sedation, confusion, anticholinergic, postural hypotension, urinary retention
Nursing: monitior for suicide, takes 2-6 weeks to work, take at night (hs), monitor vitals, sunscreen

Antidepressant - heterocyclics
wellbutrin, desyrl
SE: wellbutrin: agitation, desyrel: sedation
Nursing: avoid alcohol + CNS depressant, wean slowly
Antidiabetic - Insulin
Short acting - regular onset: .5-1h, peak 2-4, duration 6-8
Intermediate - NPh, Humulin N onset 2h, peak 6-12, duration 18-26h
Long acting - Lantuns onset 3-4h, peak continuous, duration 24h
Antidiabetic - oral hypoglycemic (type 2)
glimepirid, glipizide, metformin, miglitol, glyburide
SE: hypoglycemia, GI upset
Nursing: take right before breakfast, monitor glucose, avoid alcohol
Interactions: MAOIs, oral contraceptives, aspirin, alcohol, sulfonamide (increase effectiveness of med,
risk for hypoglycemia)
metformin held within 48 hours of contrast media for CT risk for renal failure, risk for lactic acidosis,
take with meals
Hypoglycemia agent
glucagon
SE: hypotension, bronchospasm
Nursing: repeat in 15min if needed, IV glucose must be given if client fails to respond, give carb once
arouse from coma
Anti-diarrheal
bismuth subsalicylate, diphenoxylate hydrochloride, ioperamide
SE: constipation, anticholinergic effect
Nursing: don't use with ab pain, monitor for urinary retention, give 2h before or 3h meds
Antiemetic (vomiting)
ondansetron, trimethobenzamide, prochlorperazine, metoclopramide, promethazine
SE: sedation, anticholinergic effects
Nursing: used before chemo, when used with viral infxn can cause Reye's syndrome
Antifungal
flucanzol, metronidazole, fungizone, mycostatin (azoel)
SE: hepatoxicity, thrombocytopenia, leukopenia, puritus
Nursing: with food, small frequent meals, check hepatic function, avoid alcohol/nsaid/aspirin
Antigout

probenecid (chronic) Allopurinol, Colchicine (acute)

SE: renal calculi, aplastic anemia, agranulocytosis (low wbc), GI irriation
Nursing: monitor for renal calculi, fluids, with foods/milk

Antihistamine
Chlorpheniramine maleate, dpihenhydramine HCl, promethazine Hcl, loratadine (-ine)
SE: drowsiness, bronchospasm, dry mouth
Nursing: give with food, assess respirations, sunscreen, avoid alcohol
Antihyperlipidemic

cholestyramine, atorvastatin, niacin (statin)

SE: constipation, fat-soluble vitamin deficiency
Nursing: cholestyramine - 1h before or 4-6 after other meds (avoid blocking absorption)
statins - with meals, absorption reduced by 30% on empty stomach, dont take while pregnant

Antihypertensive - General
Monitor BP, bradycardia <60 hold, orthostatic hypotension (changes positions slowly), cause lethargy
Antihypertensive - ace inhibitors (htn, chf), dilates arteries
captropril, lisinopril, enalapril (pril)
SE: orthostatic hypotension, dizziness, GI upset
Nursing: 1h ac or 3h pc (food decrease absorption), change positions slowly
Antihypertensive - beta blockers (htn, angina, SVT)
atenolol, metoprolol, propranolol (olol)
SE: changes in hr, hypotension, bronchospasm
Nursing: masks signs of shock/hypoglycemia, take with meals, don't dc abruptly
Antihypertensive - calcium channel blockers (angina, htn)
nifedipine, verapamil, diltiazem, VND very nice drugs
SE: orthostatic hypotension, constipation, renal failure, angioedema
Nursing: monitor for edema, change positions slowly, no grapefruit juice
Antihypertensive - angiotensin ii receptor blockers
candesartan, eprosartan, losartan (sartan)
SE: hypotension, dizziness, GI
Nursing: monitor vitals, don't chew
Antihypertensive - alpha 1 adrenergic blocker
Doxazosin, prazosin, terazosin (sin)
SE: reflex tachycardia, nasal congestion
Nursing: administer first dose bedtime to avoid fainting, monitor BUN/weight/edema
Antihypertensive - centrally acting alpha adrenergic
clonidine, methyldopa
SE: sedation
Nursing: dont d/c abruplty, monitor fluid retention
Antihypertensive - direct acting vasodilators
Apresoline, minoxidil
SE: tachycardia, increase hair
Nursing: teach pt to check pulse
Bipolar (manic episodes)
lithium, carbamazepine, divalproex sodium
Lithium - SE: dizziness, headache, impaired vision, fine hand tremors, nursing: fluids (3L day), target
level 0.8-1.5mEq/L
Carbamazepine - SE: dizziness, vertigo, drowiness, ataxia, chf, Nursing: monitor liver function (ast/alt),
kidney (BUN)
Divalproex sodium - SE: sedation, pancreatitis, toxic hepatitis, nursing: no carbonated drinks
General SE: GI upset, body tremors, polydipsia, polyuria
General Nursing: monitor serum levels, give with meals, fluids
Antineoplastic - alkylating agents (leukemia, multiple myeloma)
cisplatin, busulfan, cyclophosphamide

SE: hepatotoxicity (AST/ALT), bone marrow suppression, nosebleed/bleeding gums/ecchymosis,

anorexia/nausea/vomiting/diarrhea/stomatitis, alopecia
Nursing: check hematopoietic function, force fluids, good mouth care, wear gloves + mask can be
absorbed through skin

Antineoplastic - antimetabolites
fluorouracil, methotrexate
SE: n/v, oral ulceration, bone marrow suppression (wbc, rbc, platelets), alopecia
Nursing: check hematopoietic function, force fluids, good mouth care, counsel about body image, wear
gloves + mask can be absorbed through skin
Antineoplastic - antitumor abx
adriamycin, bleomycin, actinomycin
SE: bone marrow suppression, alopecia, stomatitis
Nursing: vitals, antiemetic before administration, wear gloves + mask can be absorbed through skin
Antineoplastic - hormonal agents
testosterone, tamoxifen (blocks estrogen)
SE: leukopenia (decrease wbc), bone pain, hypercalcemia, mood swings, growth of hair, hot flashes,
vaginal bleeding
Nursing: check cbc, monitor calcium, wear gloves + mask can be absorbed through skin
Antineoplastic - vinca alkaloid
vinblastine, vincristine
SE: loss of reflexs, bone marrow suppression
nursing: check reflexes, give with zyloprim to decrease uric acid, wear gloves + mask can be absorbed
through skin
Antiparkinsons
Trihexyphenidyl, Benztropine, levodopa, parlodel (dopa)
SE: ataxia, dizziness, anticholinergic
Nursing: monitor urinary retention, IOs, large doses of vit b6 reverse effects, avoid CNS depressant
Antiplatelets (PE, cva, venous thrombosis, acute coronary syndrome)
aspirin, copidrogel, dipyridamole
SE: hemorrhage, thrombocytopenia
Nursing: check for bleeding, give with food/milk
Antipsychotic
High traditional (low sedation)- haloperidol, fluphenazine
Medium traditional - perphenazine
Low traditional (high sedation)- chlorpromazine
Atypical - resperidone, ziprasidone, clozapine, olanzapine (-apine, -idone)
SE: extrapyramidal side effects (pseudoparkinonism - akathisia (restlessness), dystonia (muscle spasm
ie. tongue swelling, tight jaw, stiff neck etc late: swollen airway), Parkinsons (salvation, shuffle/rapid
gait, tremor, mask like fask), tardive dyskinesias (involuntary movement of face/chest), leukopenia
(monitor sore throat/fever), photosensitivity, jerky movements, shuffling gait, rigidity
Nursing: check cbc, vitals, airway, avoid alcohol/caffeiene, change positions slowly. Sunscreen
Tx EPS benztropine, Biperiden, diphenhydramine, trihexyphenidyl (anti parkinsons)
NMS - rigidity, fever, sweating, fluctuations in BP, dysrhythmias. tx- withdrawal med, control
hyperthermia, hydration
Antipyretic (fever)
acetaminophen, aspirin
SE: GI irritation, liver dysfunction (acetaminophen), tinnitus, dizziness

Nursing: aspirin contraindicated for bleeding disorder/under 21 (reyes syndrome)

Antithyroid (hyperthyroidism, myxedema)

methimazole, potassium iodine (SSKI), radioactive iodine
SE: leukopenia, rash, thrombocytopenia (bleeding)
Nursing: bitter taste, with meals, burn mouth, straw (stains teeth)
Thyroid replacement agent (hyperthyroidism, Graves disease)
levothyroixine, liothyronine
SE: nervousness, tachycardia, weight loss
Nursing: monitor weight, AM, monitor pulse/BP. Enhances coumadin and anti-depressant, decreases
effect of insulin/digoxin
Antitubercular
isoniazid, rifampin, streptomycin
SE: hepatitis, peripheral neuropathy (pain, tingling)
Nursing: liver function tests, vit b6 for peripheral neuropathy, no alcohol
Antitussive (coughs from URI, COPD)
benylin, robitussin
SE: bradycardia, respiratory depression, drowsiness, dizziness, anticholinergic
Nursing: monitor cough, avoid alcohol
Antiviral (Herpes simplex, HIV)
zovirax, azt, videx, famvir, cytovene
SE: headache, dizziness, GI symptoms
Nursing: encourage fluids
Attention disorder agent (ADD, nacrolepsy)
methylphenidate, dextroamphetamine
SE: restlessness, insomnia, tachycardia, palpitations
Nursing: monitor growth rate, monitor liver enzyme, give in AM
Bone reabsorption inhibitors (osteoporosis, paget's disease)
alendronate, risedronate, ibandronate (-dronate)
SE: esophagitis (dysphagia), arthralgia (joint pain), nausea, diarrhea
Nursing: take med in morning with 6-8oz water and upright for 30min
Bronchodilator
preventive: brethine, proventil, albuterol, acute: aminophylline, epinephrine, chronic: atrovent
SE: tachycardia, dysrhythmias, anticholinergic, palpitations
Nursing: monitor bp/hr, bronchodilator first then steroid, may aggravate diabetes
carbonic anhydrase inhibitor (open angle glaucoma)
diamox
SE: blurred vision, lethargy, depression
nursing: monitor systemic effects
Cardiac glycoside (left sided HF)
digoxin
SE: bradycardia, nausea, vomiting, visual disturbances. halos, blurred vision
Nursing: take apical pulse, notify if adult <60 or child <100, monitor potassium. licorice can potentiate
action by promote potassium loss, hawthorn can increase, ginseng falsely elevate levels, ephedra
increases toxicity. 0.5-2.0ng/mL, antidote - digibind, have potassium in diet (bananas, raisins, dark
leafy green)

Cytoprotective agent (duodenal ulcer)

sucralfate
SE: constipation, vertigo
Nursing: take 1h ac (before meals) or 2h before/after other meds
Diuretics
furosemide, spironlactone (K sparing), hydochlorthiazide, mannitol
SE: orthostatic hypotension, leukopenia, dizziness
Nursing: take with food/milk, in AM, monitor fluid + electrolyte
Electrolyte (FE imbalance, osteoporosis)
calcium, magnesium, potassium, sodium
SE: electrolyte imbalance
Hypercalcemia/magnesemia: depressed DTR, weak muscle tone, arrhythmias, decreased LOC,
decreased pulse/respiration
Hypocalcemia/magnesemia: rigid muscle tone, seizure, calcemia - chvostek (tap cheek), trousseau
(pump up bp cuff = tremor), elevated DTR, swallowing problems
Hypernatremia/hypo - neuro changes, dry mouth, thirsty, swollen tongue, tachycardia
Hyperkalemia - muscle twitch, paralysis, arryhthmias
Hypokalemia - muscle cramps, arryhthmias
Nursing: monitor fluid + electrolyte
Iron
ferrous sulfate, iron dextran
SE: constipation, dark stools, tachycardia
Nursing: empty stomach, vit C increases absorption, monitor hct/hgb
Eye Medication (ocular irritation)
tearisol, liquidfilm, visine, timoptic
SE: headache, dizziness, blurred vision, pupillary diation
Nursing: light pressure on lacrimal sac for 1 min after instilling drop, monitor bp/pulse
Glucocorticoids (Addisons, Crohns, COPD, leukemia)
hydrocortisone, dexamethsone, prednisone (sone)
SE: risk for infection, hypoglycemia, insomnia, hypokalemia, stunt growth, depression
Nursing: monitor fluid and electrolyte (glucose, potassium), don't d/c abruptly. increase during
stress/surgery
Mineralcorticoids (adrenal insuffciency)
florinef
SE: htn, edema, hypokalemia
Nursing: monitor BP, IOs, weight, electrolytes, give with food. Low Na, high protein, high K diet
Heavy Metal Antagonists (gold & arsenic poisoning, acute lead encephalopathy)
desferal mesylate, dimercaprol, EDTA
SE: tachycardia, pain, induration at injection site
Nursing: IOs, kidney function, seizure precaution
Immunosuppressants (prevent rejection for transplanted organs)
cyclosporine
SE: hepatotoxicity, nephrotoxicity, leukopenia, thrombocytopenia
Nursing: take once daily in AM, used with adrenal corticosteroid, monitor renal/liver tests
Laxatives/stool softeners
bisacodyl, docusate, milk of magnesia, cascara
SE: diarrhea, dependence, ab cramp, hypermagesemia

Nursing: contraindicated w acute abdomen, monitor fluid/electrolyte, chronic use may cause
hypokalemia, encourage fluids

Miotic (constrict) glaucoma

isopto-carpine, eserine, carbacel
SE: bronchoconstriction, headache, photophobia, hypotension
Nursing: apply pressure in lacrimal sac for 1min, avoid sunlight
Mydriatic (dilation) diagnostic procedure
atropine sulfate, cyclogyl
SE: tachycardia, blurred vision, photophobia, dry mouth
Nursing: contraindicated with glaucoma, wear dark glasses
Narcotics (moderate to severe pain)
morphine sulfate, codeine, meperidine, hydromorphine, oxycodone
SE: respiratory depression, hypotension, sedation, constipation
Nursing: safety precaution, avoid alcohol, vitals, antidote - narcan (short acting, usually give multiple
doses)
Antianginal (angina, HF)
nitro, isosorbide
SE: headache, hypotension, tachycardia, dizziness
Nursing: may take q5min x 3 doses, wet with saliva and place under tongue, check expiration date.
taken first onset of pain
NSAIDs (arthritis, pain, fever)
ibuprofen, naprosyn, indoethacin, naproxen, ketorolac
SE: bleeding, GI upset, dizziness, headache, fluid retention
Nursing: with food or after meals, monitor liver/renal function, check for bleeding
Thrombolytic (acute PE, MI, thrombosis)
tissue plasminogen activator, streptokinase, urokinase
SE: bleeding, bradycardia, dysrhythmias
Nursing: monitor for bleeding (hematuria, feces), check pulse/color/sensation, ekg
Contraindicated: hemophilia, active CVA, recent trauma/surgery (2 months), 75 years or older, on
heparin/coumadin. antidote - amino caproic acid
H2 receptor blockers (ulcers, gastroesophageal reflex)
cimetidine, ranitidine, famotidine, nizatidine (-tidine)
SE: impotence, hypotension, dizziness, confusion
Nursing: with meals or night, smoking decreases effectiveness, monitor liver function + cbc, can
interfere with rbc/wbc
Vitamins
cyanocobalamin (b-12), folic acid
SE: cyanocobalamin - anaphylactic shock, folic acid - bronchospasm
Nursing: monitor levels, don't mix meds
Women's Health
Oral contraceptives SE: headache, dizziness, nause, bleeding, weight gain
Nursing: no smoke, condom use, if missed take use protection, same time each day
Estrogens: menopause symptoms, cancers, osteoporosis (estradiol, estrogen). SE: nausea, contact
lense difficulty. call PCP if breast lumps, vaginal bleeding, edema, dark urine, blurred vision, chest pain
Men's Health: alpha 1 adrenergic blockers (decrease urinary urgency, hesitancy, nocturia, prostatic
hyperplasia)

terzosin, tamsulosin
SE: headache, orthostatic hypotension, dizziness
Nursing: give at bedtime, change positions slowly, avoid alcohol, CNS depressant

Herbals
Echinaecea - decrease effectiveness immunosuppressants
Garlic - increases effectiveness of anticoagulant and antiplatelets, antihyperlipidemics,
antihypertensives, antidiabetic, decrease effectiveness of oral contraception
Chondroitin - potentiate anticoagulants
Glucosamine - impedes insulin secretion or increase insulin resistance
Cayene pepper - decrease effectiveness of antihypertensive, increase risk of cough with ACE inhibitor,
potentiate antiplatelet, hypertensive crisis on MAOI, increase theophylline absorption
St Johns Wart - decreases effectiveness of digoxin, antineoplastics, antivirals, AIDS meds, antirejection
meds, theophylline, coumadin, oral contraceptives
Anaphylaxis
Symptoms - hives, rash, difficulty breathing, diaphoresis
Nursing care - epi 0.3ml of 1:1000 solution, massage site, may repeat 15-20min, o2, anti-histamine,
steroid
Delayed Allergic Reaction
Symptoms - rash, hives, swollen joints
Nursing care - d/c med, topical antihsitamine, corticosteroid, comfort measure
Stomatitis
Symptoms - swollen gums and tongue, difficulty swalloing, bad breath, mouth pain
Nursing care - good mouth care, small feedings, antifungals, local anesthetics
Superinfection
Symptoms - fever, diarrhea, black hairy tongue, vaginal itching, discharge
Nursing care - good mouth/skin care, antifungal
Bone marrow depression
Symptoms - fever, chills, sore throat, back pain, dark urine, anemia, thrombocytopenia, leukopenia
Nursing care - monitor CBC, protect from infection, avoid injury, handwashing, clean pt with clean pt
Liver Impairment
Symptoms - fever, malaise, jaundice, light stools dark urine, ab pain, elevated AST/ALT, altered PTT
Nursing care - rest, good skin care, rest
Kidney Impairment
Symptoms - elevated BUN/creatinine, decreaesd Hct, altered electrolyte (Na/K), fatigue, edema
Nursing care - diet/fluid restrictions, electrolyte replacement, dialysis, rest
Ocular Impairment
Symptoms - blurred vision, color vision, changes, blindness
Nursing care - monitor vision, monitor exposure to light
Auditory Impairment (aminoglycoside -mycin)
Symptoms - dizziness, ringing in ears, loss hearing, loss of balance
Nursing care - monitor hearing, safety measures to prevent falls
CNS Impairment
Symptoms - confusion, insomnia, drowsiness, hallucinations
Nursing care - safety measures, avoid activities that require alterntess, orient
Cholinergic Effect

Symptoms - dry mouth, dysphagia, urinary retention, impotence, nasal congestion

Nursing care - sugarless lozenges, good mouth care, void before taking med

Parkinson's-like Effects (EPS)

Symptoms - akinesia, tremors, drooling, changes in gait, rigidty, akathisia, dyskinesia
Nursing care - anticholinergic and antiparkinson med, safety measures for gait
Lipitor (atorvastatin) and anti-convulsants no grapefruit juice
Reduction of Risk Potential
Visual
Blind identify where food located, allow self-feed, encouragement
Retinopathy of Prematurity - high o2 cause retinal vessels to constrict for infant (s/s: demarcation line
with ridge)
Strabismus - deviation of eye, diplopia (tx - lens)
Detached Reina - curtain coming up or down, flashes of light (tx bed rest, eye patch, avoid stooping
or straining)
Cataracts s/s: milky white pupil, blurred vision postop: check for hemorrhage (sudden pain), sleep
unaffected side, (tx avoid strain/lifting)
Glaucoma lights with halos, decreased peripheral vision, tx miotics, beta andenergic blocker, avoid
mydriatics (atropine)
Hearing
Hearing Loss ear drops instillation, Adult: up and backward, child: pull down and backward, lie on
unaffected side
Acute otitis media infection of middle ear. s/s ringing in ear, deafness, ear tugging, crying, red
bulging tympanic membrane, tx abx, position on affected ear
Meniere s/s: n/v, vertigo, tinnitus, nystagmus. Tx bed rest, low sodium, avoid alcohol, nicotine,
caffeine
Cranial Nerve Disorder
Trigeminal neuralgia (5th cranial nerve, face) stabbing of face. Tx tegretol, analgesic. Dont temp
extremes
Bells palsy inflammation 7th cranial nerve, face) inability to close eye, speech difficulty. Tx
analgesic, isometric exercise, prevent corneal abrasion, steroid use
Acoustic Neuroma tumor 8th nerve - s/s: deafness, dizziness. Tx pre/postop for craniotomy
Nervous System
Guillan barre progressive paralysis, feet then to trunk, paresthesia, hypotension, tachycardia,
flushing, sweating (ANS). tx- steroid, aggressive respiratory care
Meningitis s/s: nuchal rigidity, kernigs sign (knees cant straighten), budzinksi (chin to chcest),
ALOC/seizure, infant: high pitched cry and bulging fontanel. Tx- droplet precaution, monitor
electrolyte/specific gravity (can cause SIADH retain Na/K)
Migraines s/s: prodromal (irritability, anorexia), aura (light flashes), headache (throbbing, unilateral
pain). Tx- aspirin, ca channel blocker
Huntington

Diagnostic
55
Basic Care & Comfort
Health Promotion and Maintenance 60

1
49
59
36

2
59
50
71

3
58
62
46

4
47
54
41

5
53
66
41

6
54
50
48

7
55
27
41

Readiness
63
55

Management of Care
Pharmacology
Physiological Adaptation
Psychosocial Integrity
Reduction of Risk Potential
Safety & Infection Control

60
62
56

44
63
36
60
66
44

50
61
20
60
66
55

46
57
60
57
78
33

Kaplan QTrainer
QT 4 - 71
QT 6 65
QT 7 - 69
LaCharity
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Chapter 12
Chapter 13
Chapter 14
Chapter 15
Chapter 16
Chapter 17
Chapter 18
Chapter 19
Chapter 20
Chapter 21

First
Second
59
69XX
54 cancer
68XX
45 immunological
55XX
74 fluid + electrolyte 91
50 infection control 61XX
50
83
66
75
67
92
68
79
52
81
68
86
47
73XX
60
92
76 other endocrine 88
85 integumentary
85
54 renal
85
46 reproductive
68XX
68 maternity
85
66 peds
93
35 emergency
68XX
41 psych
79

60s-70s
Chap. 1 Pain -- 62.05
Chap. 2 Cancer -- 77.8
Chap. 3 Fluid, Electrolyte, and Acid-Base Problems -- 86.37
Chap. 4 Immunologic Problems -- 70.6
Chap. 5 Infection Control -- 65.2
Chap. 6 Respiratory Problems -- 79.98
Chap. 7 Cardiovascular Problems -- 64.72
Chap. 8 Hematologic Problems -- 85.72
Chap. 9 Neurologic Problems -- 71.07
Chap. 10 Visual and Auditory Problems -- 57.16
Chap. 11 Musculoskeletal Problems -- 77.25
Chap. 12 Gastrointestinal and Nutritional Problems -- 70.03
Chap. 13 Diabetes and Other Endocrine Problems -- 76.69
Chap. 14 Integumentary Problems -- 85.72
Chap. 15 Renal and Urinary Problems -- 80.75
Chap. 16 Reproductive Problems -- 55.17
Chap. 17 Obstetrics and Maternity -- 68
Chap. 18 Emergencies and Disasters -- 55.9

57
30
69
61
52
44

54
60
57
35
50
33

60
54
59
58
48
52

58
54
48
66
51
71

54
56
70

LaCharity
Pain
early signs withdrawal - diaphoresis (fever, nausea, cramping late signs)
In supervision of the new RN, good performance should be reinforced first and then areas of
improvement can be addressed
Gabapentin is an antiepileptic drug, but it is also used to treat diabetic neuropathy
immediate need for IV access - acute MI w/ severe chest pain (not sharp chest pain that increases with
cough + sob)
new grad - post op needs pain med, kidney stone that needs PRN pain med, pain at peripheral site
LVN - leg cast w/ PRN pain med, arthritis with pain med and heat, client who had toe amputation and
has diabetic neuropathic pain
opioids for extended time - progressive pancreatic cancer
dr order placebo, first action - contact charge nurse for advice
risk for respiratory depression while on opioids - child with arm fracture and cystic fibrosis (factors
include elderly, low tolerance, lung disease)
pt says not receiving pain med, as charge nurse you should - have conference with nurses responsible
for care of client
prioritize - pt has chest tube/pca d/c today (chest tubes can leak/dislodged), pt with diagnostic testing
in morning, pt w meningitis AO continuous headache partially relieved by med, elderly w pca good
relief, elderly with Alzheimer
task for LVN on client who received excess narcotic - apply o2 (RN gives narcon + evaluate response)
Cancer
bleeding precautions - paper tape on fragile skin, soft toothbrush, avoid aspirin, avoid over-inflation of
pressure cuffs, pad sharp corners
pt has rectal bleeding diarrhea, constipation. while trying to teach pt gets angry and threatens to leave.
priority nursing dx - anxiety r/t unknown outcomes
pt has end of life care w terminal cancer, pt dyspneic and anxious, what should u do - obtain order for
morphine (reduce anxiety)
UAP pt w esophageal cancer - assist with oral hygiene (not initiate weighings)
Major consideration with chemo drugs - During preparation, drugs may be absorbed through the skin or
inhaled, must be given by those with special training (not the fact theyre vesicants)
pt receiving chemo which lab important - WBC count is especially important, because chemotherapy
can cause decreases in WBCs, particularly neutrophils
Tumor lysis syndrome is an emergency involving electrolyte imbalances and potential renal failure.
which pt statement would concern you the most - my pain will be relieved but I am going to die soon, I
would like to have control over my own life and death (suicide)
women 21+ should have annual pap test, age 45 for black men prostate, age 50 for colonoscopy/fecal
occult blood test, annual mammogram for women over 40
vincristine report if - paresthesia (n/v/fatigue common with chemo meds)
pt diminished LOC - check responsiveness, o2, vitals, glucose level, IV patency, electrolyte values,
ammonia
Back pain is an early sign of spinal cord compression
prioritize - tumor lysis, laparatomy scheduled, breakthrough pain last 24h, n/v last 24h
Immunologic Problems
Systemic lupus erythematosus (SLE) is an autoimmune disease in which the body's immune system
mistakenly attacks healthy tissue, SLE develop nephropathy watch BUN
pt has allergen injected and SOB, anxious, dizzy, first action - give epi IM
SLE receiving prednisone, question which order - catch up dose of varicella (live virus shouldn't be
given to those with immunosuppressive meds)
nystatin - for candida, let dissolve in mouth (intervene if given water)

protease inhibitors [antiviral (vir)] decrease the metabolism of many drugs, including midazolam,
serious toxicity can develop when protease inhibitors are given with other medications (most important
to discuss with HCP it taking protease inhibitor and pt has ordered midazolam STAT
steroids - don't need to taper for short term use (ie. 4 days)
immune suppressed/deficient may not be able to produce immune response so neg tb test can't rule
out - obtain chest radiograph and sputum smear
taking cyclosporine, most concerned if find - nontender lump (immunosuppressive meds are at
increased risk for cancer)
Pentamidine (antiprotozal, antifungal) can cause fatal hypoglycemia
HAART therapy for HIV most concerned if pt says - I've never been consistent with meds
allergy to bananas, avocados, papayas, cherry, grape, kiwi, apricot, passion fruit, chest nut, peaches =
latex allergy
pt taking interferon alfa-2a most important info to tell md - persistent n/v (dehydration)
rapid HIV tested positive, next action - discuss positive test result with patient
RA taking prednisone and naproxen, most important to tell hcp - dark colored stools (round nodules
common in RA)
HAART therapy, which test most helpful in determining response to therapy - viral load

Fluid Electrolyte
HCTZ hydrochlorothiazide - diuretic, lose potassium
SIADH monitor for - hyponatremia
low phosphorus - muscle weakness, may lead to acute muscle breakdown (rhabdomyolysis)
Which lab concerns most? K 5.2, Na 134, Calcium 10.6, mag 0.8 (mag 0.8 furthest from norm)
K 3.5-5, Na 135-145, calcium 9-10.5, mag 1.5-2.5, phosphorus 2.5-4.5
Which factor alter for acid-base imbalance? Chronic renal insufficiency (and pulmonary disease)
Kayexalate removes potassium from the body
NG pt respiratory decrease, best response - client may have metabolic alkalosis due to suctioning and
decreased respirations compensatory mechanism
abg indicates respiratory acidosis, what change in ventilator - increase ventilator rate from 6 to 10
UAP asks why pt w chronically low phosphorus and needs assistance w ADL, best response - skeletal
muscles are weak because of low phosphorus
pt dehydration and hypovolemic shock, question - d5w bolus (needs NS/LR)
calcium food - dairy, seafood, nuts, broccoli, spinach
Potassium rich foods - avocado, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef,
veal, raisins, spinach, strawberries, and tomatoes
Magnesium peas, cauliflower, dark chocolate, avocados, yogurt, dried fruit, dark chocolate
Phosphorus - seeds, cheese, fish, pork, beef, nuts
Safety & Infection
airborne - gown n95 goggles gloves, off- gloves, goggles, gown, n95
newborn - if adult handling get tetanus, diptheria, pertussis first
d/c droplet for meningitis - abx given for 24 hours
prevent vap (ventilator assisted pneumonia) - hob elevated, assess extubation, oral care
methotrexate toxicity for RA pt reduces inflammation for RA, need folic acid + vit b12 + NS, question
chlorambucil (antineoplastic)
vanco given clients neck + face get flushed - red man's syndrome, vanco given too fast, slow rate
elderly on abx and frequent watery stools, first action - place on contact for c diff
23yo shortness of breath, diarrhea, abdominal pain, and epistaxis, first action - ask if traveled to
asia/middle east, bird flu symptoms
central line insertion cleaning - 0.5% chlorhexidine in alcohol (hibistat)
med error - assess client, notify md, ask how it occurred, med error report
risk for bloodstream infection - client with nontunneled central line in left internal jugular vein (jugular
+ nontunneled are prone to infxn)

you are infection control nurse, which action most effectively reduce health care associated infection alcohol hand rubs readily available
question which order for PE warfarin 1.0 (don't use trailing 0)
pt may have been contaminated by anthrax arrives in ED, first action - escort client to decontamination
room

Respiratory
float nurse - pt who needs teaching about incentive spirometry (not TB, needs to be fitted for n95)
pt with ARDS with o2 on nrb but abg poor, you would anticipate - intubation + mechanical ventilation
(not cpap for sleep apnea)
teaching for asthma - avoid triggers, inhaler 30min before exercise, sleep 8 hrs, avoid msg
pt intubated UAP measures vitals, which vitals should UAP report to RN - temp of 101.4 (not bp
168/90). infections always a threat to patient receiving mechanical ventilation
pulmonary embolus, which finding supports diagnosis - pt in mva
LVN - auscultate, MDI, o2 sat
most important to prevent vap - head 30-45
pt has thoracentesis, which assessment info report - bp 100/48, hr 102 (removal of large fluids can
cause hypotension/tachycardia)
pt with 6L nc report nasal passage discomfort, which intervention - humidify o2 (o2 higher than 4L can
dry mucous membranes)
new RN - 38yo with asthma awaiting d/c, pt with trach needs trach care every shift (not new diabetes
type 2)
high pressure alarm goes off o2 sat 87 - manually ventilate pt while assessing possible reasons for high
pressure alarm
COPD says no flu shot or pneumonia vaccination, which vital sign report - temp 101.2
Cardiovascular
which med double check - warfarin (not digoxin) anticoags are high alert meds
put smokes, mail carrier, metoprolol, 130/60, select d/c teaching - refer program to stop smoking and
teach about impact of family history on cv risk
new grad - pt with endocarditis receiving ceftriaxone (not rheumatic fever who needs discharge
teaching)
client with sob + fatigue evaluated for heart failure. which lab result useful to monitor - b type
natriuretic peptide (increase in clients with poor left ventricular function)
pt says i dont see why i need teaching and dont think i need to change anything - can you tell me why
you dont feel that you need to make any changes
postop for pt with aaa, which finding has immediate implications for care - art line indicates bp 190/112
(htn in postop puts stress on graft suture line)
UAP - measure ankle + brachial pressuers in client for whom the ankle brachial index is to be
calculated
pt w unstable angina taking clopidogrel (blood thinner), which med clarify - omprazole (ppi affect
metabolism of clopidogrel)
HCP consider tpa for acute MI, which finding report client has pain since 8am (pain more than 12
hours indicates irreversible myocardial necrosis)
see first - client w MI with frequent PVC (PVC with MI can lead to vtach/v fib)
Hematological
sickle cell crisis first action - o2 on nrb (most important/priority for pain = hydration)
pt transfusing rbc becomes flushed, tachypneic, and having chills, first action - stop transfusion (febrile
reaction)
which value most important to report - wbc 16k (surgery postponed if elevated wbc)
pt with multiple myeloma, which info most immediate implication for care - newonset leg numbness
(spinal cord compression, bence jones protein/hyperuricemia (blood uric acid level elevated)/chronic
bone pain common)

pt required splenectomy after mva, which info immediate concern - temp 100 (pt at higher risk for
infection after splenectomy)
see first - neutropenic with temp of 100.1 (temp in neutropenic = infection)
which action intervene new RN - prime rbc transfusion with 5% dextrose in LR (should use NS)
pt has hemophilia A, which action first - transfused factor vii (maximize clotting factors)
travel rn - infusing 5% dextrose in .45% NS (cyclosporine -immunosuppressive for organ transplant for
experienced rn)

Neuro
teaching plan for migraine, key items - foods that contain tyramine should be avoided, drugs like nitro
should be avoided, abortive therapy aimed at eliminating pain, side effect is rebound headache,
complementary therapy
LVN delegation alzheimer pt - check improvement in memory after med (not mini mental state exam)
husband doesn't sleep well thinks pt will wonder, nursing dx - caregiver role strain r/t continuous need
for providing care
LVN clean, observe infection, check pressure on skin
bacterial meningitis priority - infuse ceftriaxone (abx) for infection
SCI establish bladder retraining program - stroke thigh, pull pubic hair, warm water on perneum, tap
bladder
MS pt too tired for bath, nursing dx - bathing self care deficit r/t fatigue/neuromuscular weakness
SCI pt says i dont know why we're doing all this my life is over. priority nursing dx - impaired individual
resilience r/t sci
SCI has htn and bradycardia, diaphoresis (autonomic dysreflexia) first action - check foley for kinks
stroke pt, UAP can - reposition, reapply boot, remind ROM, setup meal try + feed
phenytoin for seizure pt, which assessment concern - wbc 2300 (leukopenia adverse effect of
phenytoin)
seizuring pt - turn on side, administer lorazepam
alteplase (clot buster) - dissolves clots and may cause more bleeding for hemorrhagic stroke pt
(already bleeding)
travel nurse assigned to - chronic ALS (not newly admitted or distress pts)
student nurse action requires intervention w stroke pt tell pt to sit straight up but given puzzled look
(Pt right hemisphere stroke have neglect syndrome, think sitting upright but actually leaning)
gbs observation report immediately - shallow respirations + decreased breath sounds (gbs at risk for
respiratory failure)
Pt lethargic and confused after following down stairs a month ago transport to CT (subdural
hematoma)
Visual
experienced nurse in vision problems/eye surgery- pre/post op instructions, home health referral,
assess needs for loss of vision
LVN - administer med to child w conjunctivitis, review handwashing, show client how to cleanse eyelid
to remove crusting, perform routine check with snellen eye chart
angle closure symptoms (halos and blurred vision, sudden pain) - give miotic, oral hyperosmotic agent,
cool compress, dark room
eyedrop administration - client sit, pull tissue, hold dropper, pt look up, client close eye and move it
around, gently press lacrimal duct
new nurse documents visual acuity n/a - ask her to explain rationale for documentation
redness of the sclera, itching of the eyes, and increased lacrimation for several hours - remove contact
lens
curtain like shad - retinal detachment, change in color - cataract, crusty drainage - conjunctivitis,
UAP delegation, blind - ambulation, supplies for hygenic care (don't store/rearrange items, must be
able to locate items)
tinnitus (roar sound), assess - med history, loud noise, ear, s/s ear infection
most concern - vertigo without hearing loss (cardiac or metabolic)

LVN - irrigate ear canal, administer amoxcillin, remind client not to blow nose (can't assess labyrinthitis
for meningitis/headache/loc)

Muscoskeletal
carpal tunnel release - pain + Numbness for several days/weeks, hand movements restricted 4-6
weeks
lvn takes care of paget disease pt, nurse intervene if - applies ice (heat, ibuprofen, milk (Calcium
promotes bone health)
carpal tunnel surgery intervene - UAP puts splint in hyperextension (neutral, ok to cut meat)
carpal tunnel release surgery teaching - pain + numbness for several days to weeks, hand movements
restricted 4-6weeks
osteoporosis teaching to prevent falls - hip protector while ambulating, remove rugs, exercise, rest
pt underwent aka with depression, clarify - give fluoxetine 40mg once daily (doses greater than 20mg
should be divided to two)
osteoporosis addt teaching - take ibuprofen every morning (GI bleed)
paget notify physician - skull is invaginated (platybasia - flattening of head, can cause brainstem
manifestations)
postop cts for LVN - vitals q15min, dressing, hand above heart, neurovascular check fingers q1h
GI + nutritional
colostomy irrigation - gloves, put 500-100mL lukewarm water in container, hang container shoulder
height, lubricate stoma and insert tip into stoma, allow solution to flow slowly for 5-10min, allow 15-20
min for initial evacuation, clip irrigation sleeve and have client walk for 30-45 for secondary eval,
clean/rinse/dry skin and new pouch
t tube should not be irrigated, aspirated, clamped without order
evsiceration - stay w pt, semi fowler with knees flexed, vitals, sterile supplies, cover with sterile gauze,
prep for surgery
UAP puncture from needle - wash hands, health nurse, blood test, incident report, drug therapy, follow
up results
LVN for obese - assist in planning of toileting, turning, ambulation
diverticulitis , which tasks appropriate to delegate - tell UAP that a stool specimen must be saved to
test for occult blood (diverticulitis can cause bleeding, stool should be tested for blood)
LVN - assist physician in incision + drainage of cysts
UAP delegation - disconnect suction for ambulation to toilet (not securing tape NG)
LVN - cleint with n/v r/t chemo (client from surgery needs assessment, anorexia = hypokalemia, preop
needs teaching)
pt w ab pain, n/v, diarrhea, dementia. which concerns - fluctuating LOC and mood swings
TPN fat emulsion concerned if client has - fracture femur (risk for fat embolism)
cholecystectomy (gallbladder removal) - maintain semi flower, check drainage, inspect skin for redness
laparoscopic cholecystectomy, report immediately - right upper quadrant pain (hemorrahage or bile
leak), (can void in 6 hours, R shoulder pain = unabsorbed co2, output wont equal input for first few
hours)
transplant list, statement most concerned - going to cut down drinking soon (substance abuse can
exclude person from transplant list)
hiatal hernia repair, priority action - HOB 30 degrees
colostomy care - gloves + remove old pouch, assess stoma, wash, dry skin, skin barrier, fit pouch
priority nursing dx for ulcerative colitis - diarrhea r/t irritated bowel (immediate problem is controlling
diarrhea)
peptic ulcer disease PUD most serious assessment - boardlike ab w/ shoulder pain (perforation)
(burning (typical), projective vomiting (obstruction), coffee ground emesis (slower bleeding)
refeeding syndrome - aggressive + rapid feeding results in fluid retention + heart failure (monitor for
edema, crackles, jvd)
exploratory laparotomy (look in ab), report which assessment - distention + rigidity (hemorrhage /
peritonitis). (s/s: absent bowel sounds 1-2 days, n/v)

TPN central line - confirm, check solution, select correct tubing, thread iv, use aseptic technique,
connect tube, set infusion

Diabetes
long acting insulin mimics action of pancreas, reg insulin only one in IV
teach type 1 diabetic about exercise - can exercise vigoursly if BG 100-250, test bg before/during/after
exercise, cool down period
diabetes type 2 given insulin, asked if she always needs it talk about relationship between illness +
increased glucose
LVN - administer insulin (uap = bg check)
sick days - check q4h, test for ketones when blood ABOVE 240
foot care - clean/inspect feet every day, shoes fit, report skin breaks, cotton socks
UAP actions for 7 year old with type 1 - administer oral tab when bg below 60 (in emergency UAP can
administer), check bg, remind child to have snack
teach hypoglycemia at before - s/s of hypoglycemia, treat 10-15g (not 4-8g), retest 15min (not 30),
repeat if symptoms dont resolve, eat small snack/protein if next meal hour away
which finding important to address - morning glucose 55-70 (possible nocturnal hypoglycemia), a1c
(7.5-8.5 ok for peds)
postop diabetic, report if - glucose 190 to 236 (increased mortality, maintain 140-180, can be wound
infxn)
HHS occurs with type 2, risk factors are - diuretics + inadequate fluid intake (hctz and avoids liquids at
night)
type 2 diabetic drinks 3 beer/day, ask - when during day do u drink? (alcohol can cause alcohol induce
hypoglycemia, teach ingest after meal)
copd exacerbation + type 2 diabetes care plan - fingersticks, sliding scale, foot care (no bedrest, no
atkins)
repaglinide for preop, best response - not given drug should be given 1-30min before meals and patient
is NPO (prevents postmeal blood glucose elevation)
Other endocrine probs
delegate LVN care for hypothyroidism pt - assess rate/depth respirations, auscultate lung, remind pt
(not check bp/administer sedation med)
thyroidectomy, can injury parathyroid = watch calcium/phosphorous
which change in vital sign would UAP report for hyperthyroidism - rapid heart rate (high systolic, low
diastolic, high temp)
UAP delegate for pt w addisons = remind change positions slowly (hypotension)
hypophysectomy, most concerned if - glucose in nasal drainage (CSF leak)
prednisone for addisons, report if - excessive weight gain/swelling (excessive drug therapy)
pt with thyroidectomy, which assessment report - temp 100.2 (temp elevation for hyperthyroidism
could indicate impending thyroid storm - fever/high pulse/htn)
pt with di requires lifelong vasopressin therapy
addisons, be alert for - decreased hematocrit (risk for anemia, Na decrease, Ca+K increase)
hyperparathyroidism on NS and furosemide to - reduce serum calcium
hypothyroidism - periorbital edema, bradycardia, hoarse voice
hyperthyroidism exophthalmos, report rapid HR, hypertension, increased body temp
hypofunction of adrenal glands (addison) - patchy areas of pigment loss (vitiligo)
cushing (pituitary hypofunction) - decreased muscle strength, increased UO, alopecia
pheochromocytoma - rare adrenal tumor, don't palpate
cushing - hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN,
hirsutism (male hair growth), moonface/buffalo hump, capillary fragility (bruise/petechiae)
cushing - risk for injury r/t bruising, disturbed body image, risk for injury r/t hypertension, risk for
infection
thyroid gland - palpate gently (vigorous palpation can stimulate thyroid storm), use both hands/stand
front or behind, have pt swallow

Integumentary
LVN - apply nystatin powder for candidiasis, cleaning/changing dressing every morning, monitor
surgical site for swelling/bleeding
which action by new RN requires most immediate action - giving doxycycline with glass of milk
herpes simplex, priority nursing dx - acute pain over imbalanced nutrition (pain will need to be
controlled to increase ability to eat)
pt has blisters from toxic chemical admitted ed, first action - rinse legs with 4L NS
ulcers can be caused by nsaids or steroids like prednisone- report if epigastric pain
see first - temp 102.6 and bp 98/46 burn pt (septic shock developing)
sterile dressing burn pt - morphine, debride, obtain specimen, apply silver sulfadiazine, cover wound
which client use sunscreen - pt with tetracycline
herpes zoster vaccine - 60 or older, anaerobic culture (deep wounds)
Renal & Urinary
pt admitted to rule out interstitial cystitis, plan of care - teach pt about cystoscopy procedure
(urinalysis shows wbc/rbc but no bacteria, cystoscopy examines bladder)
pt has uti, medical history supports dx - followed prostate disease 2 years (prostate disease in men
increases risk of uti due to urinary retention)
oxybutynin (overactive bladder, anticholinergic) info teach pt - drink fluids/use hard candy when dry
mouth
DI = low specific gravity, high concentrated blood, SIADH = high specific gravity, dilute blood
deficient ADH (means DI) - specific gravity 1.002
Gentamicin - highly nephrotoxic, monitor creatinine + BUN
combine room - acute pyelonephritis + UTI
lithotripsy (shock wave to break up kidney stone) intervene if nurse says - report bruising (bruising is
expected after lithotripsy)
cystitis (UTI or inflammation of bladder), most concerned if - urine bacteria count 100,000 colonies/ml
acute kidney failure given furosemide but low UO - during oliguric phase of kidney failure, patients
don't respond well to diuretics
UTI prevention - avoid bubble bath (nylon underwear, scented toilet paper, adequate fluid intake,
cranberry juice, regular voiding)
renal cell carcinoma - chemo ineffective, nephrectomy preferred treatment
UTI medical history supports dx - prostate disease increases risk for UTI because men have urinary
retention
Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may
put out as much as 10 L of urine per day
catherization for postvoid residual - have fun, position, open kit + sterile glove, retract skin, clean,
lubricate catheter, drain, remove + clean
urolithiasis/kidney stone priority nursing dx - acute pain
oxybutynin chloride (anticholinergic) - hard candy or water when dry mouth, between meals (food
interferes with absorption)
pt with kidney failure begin continuous arteriovenous hemofiltration (CAVH), priority action - transfer to
ICU
float from SICU - pt who just underwent surgery for renal stent placement (not new acute UTI pt)
nephrotic syndrome - loss of protein (proteinuria = dark frothy), edema, decreased albumin
(hypoalbuminemia), hematuria, hyperlipidemia), anemia, anorexia, decrease UO, hypertension
bladder training - pt with urge incontinence (stress = kegel, pt with mental changes can't follow
program)
intravenous pyelography, which info stress - after procedure monitor urine output because dye
increases risk for kidney failure in elderly (bowel prep, tests kidney function)
Reproductive
which finding indicates most immediate nursing intervention - client has painful bladder spasms
(indicates blood clots are obstructing catheter, irrigate with 50mL NS with piston syringe, ok for light
pink drainage with occasional clot)

BRCA gene first degree relative - annual mammogram (x ray) + MRI

which info has immediate implications for planning of care for pt with total abdominal hysterectomy client right calf swollen (dvt, postop ambulate now bedrest)
home health aid delegation - help client connect catheter to leg bag, ambulate, shower
action for TURP spasms IRRIGATE first, pain med, IV fluids, oral fluids
anterior and posterior colporrhaphy - after repair important to have bladder empty so no stress on
suture lines (intervene if ab firm/palpation above symphysis pubis, not crackles)
pelvic inflammatory disease pt, intervene if new nurse positions pt flat to take bath (semifowlers to
prevent abscess, avoid tampon, no sex for a few weeks, heat pack)
which info most important for in determining if pt gets HPV pt has positive pregnancy test
LVN delegation for ovarian cancer - vitals every 15 min after paracentesis
pt has burning on urination, 101.3F, output 210 last shift. first action - insert catheter prn for output of
less than 300mL/8 hr (s/s of UTI, insert catheter to obtain specimen for culture before abx, prob not
emptying bladder due to painful urine)
tamsulosin for BPH - avoid changing position to quickly
see first - scrotal swelling and severe pain that has not decreased with elevation of the scrotum
(testicular torsion)
pt with radioactive implant, intervene if - assist to bedside commode for bm
priority of care - 78 year old confused postop, level 5 out of 10 pain, anxious about to be d/c, pt with
questions about postop
UAP - elevation of arm after breast lumpectomy (dressing for RN)
toxic shock syndrome first implementation - remove tampon
ED float - pt with cancer requires assessment + treatment for breakthrough pain
bladder spasm after TURP caused by clots - irrigate, administer pain med (reduce spasm), IV bolus,
offer fluids
TURP - monitor for transurethral resection syndrome (ALOC, bradycardia, high bp) high absorption of
irritant or low bp/high hr = bleed, watch catheter for blood, via spinal anesthesia cant move legs after
surgery
bph immediate action - The bladder is palpable above the symphysis pubis and the client is restless
(urinary retention)
pt arrived after dilation and curettage, assessment finding immediate action - Sharp, continuous, level
8 (out of 10) abdominal pain (uterine perforation)

Pregnancy
mag sulfate monitor - dtr (high magnesium), respiratory (resp depression), urine output (excreted by
kidney)
shoulder dystocia - no fundal pressure, can worsen problem (suprapubic pressure ok)
pregnant says shes vegetarian, first action - obtain 24 hour diet recall history (then assess deficiencies,
dont give iron/vitb-12 right away)
diabetes education - achievement of glycemic control at preconception & early pregnancy reduces risk
of congential anomalies
1 nurse can have 2 pts: 30 yo, g1p0 40 weeks, 2cm 90% effaced, -1 station and 17 yo g1p0 woman
with premature rupture of membrane, no labor
22 yo 6 weeks postpartum feeling overwhelmed and think she may hurt baby - contact provider to
evaluate pt before allowing her to leave
late decel - d/c oxytocin, o2, notify md
1 day postpartum nipple sore - assess mother baby for nursing position and latch and correct as
indicated
painless vaginal bleeding = placenta previa - digital vaginal exam contraindicated, prep for c section,
cant deliver vaginally
during phototherapy for elevated bilirubin - cover infant eyes with mask and monitor temp
need father needs addt teaching if says - bring baby back to pediatrician in 3 weeks (bring back in 2
days) and give formula at night and breastfeed day (always breast feed)
variability = cord compression -> change position

woman at 39 weeks has fetal demise, appropriate actions - stay with parents + offer care, clean and
wrap baby offer parents to hold, ask if any special rituals
29 yo g2p2 vaginal delivery has large amt of vaginal bleeding, first action - firmly massage fundus
HIV prevention transmission - medication to woman/baby, c section, and avoidance of breast feeding
assess first - 22yo g3p2 38 weeks contractions every 3 min and wants to have bm
woman give epidural, appropriate action - insert foley and encourage pt turn from side to side
abnormal finding - baby ate 4 times in last 24 hours (8-12 feeding, 6-8 voids a day after 4th day of life)
epidural has bp of 60/38 - turn pt to lateral and notify anesthesiologist

Pediatric
3 yo tetralogy of fallot crying, immediate action if - lips dusky in color (drop in partial pressure oxygen
--> knee to chest, o2, calm child), not clubbing of fingers
idiopathic thrombocytopenic purpura, which info report - hemoglobin 6.1 (active bleed)
high alert for peds - lorazepam (sedative), Methotrexate (cancer)
kawasaki disease - inflammation of blood vessels, causes Coronary artery aneurysms
kawasaki - acute: fever, red throat, swollen hands, rash, conjunctivitist. subacute - cracking lips, joint
pain. convalescent stage - appears normal
see first - endocarditis with crackles (left ventricular failure causing fluid in lungs, hypoxemia)
13yo receive chemo, sibling has chickenpox, next action - administer varicella-zoster immune globulin
sickle cell crisis (due to obstruction of blood flow by rbc) - heat packs, intervene if use cold packs
see first - fever with neutrophil of 450 (n/v 3.3 borderline low, nosebleed platelet 1000,000 no
spontaneous hemorrhage until 20k, kids can withstand low hemoglobin)
child eats but when mom comes throws tantrum, best response - behavior is normal expression of
anger
child ate vitamin, which info report to md - vitamin contains iron (can cause hemorrhage)
children receives aspirin, which info most concern - child has not vaccinations (reyes syndrome usually
follows influenza/varicella, no aspirin, use tylenol)
verify which order Phenytoin 300mg/day. 5mg/kg in 3 doses for children
new rn - 2yo with dogoxin vs teach antibiotic therapy
intussusception (obstruction) - sausage shaped mass, jelly currant like stool, dance sign (empty RLQ).
notify if normal stool, resolved on own
pain rating scales using faces for young children
immediate action of - place neutropenia child in negative pressure (should be in positive airflow, keeps
bacteria out)
new grad rn - child who needs premedication for fracture (not sickle cell who has oral analgesic and
asking for higher dose)
roof collapses with snow, which injuries for children based on physio - head, hypoxemia (thin skin),
liver/spleen, hypothermia
public school nurse, most impact on incidence of infectious disease - ensure students immunized
cystic fibrosis, nursing care activity most important - Scheduling postural drainage and chest
physiotherapy (CPT) every 4 hours
Emergency + Disaster
verify et tube placement - check co2, auscultate, confirm breath sounds, secure, obtain order
24yo tingling, sensations, palpitations, sore chest muslces, deep rapid breathing. priority action breathe into paper bag (pt hyperventilating secondary to anxiety) not o2
pt has order for dc but symptoms seem worse - express findings with MD
bioterrorist attack - protect environment, ppe, decontaminate, triage, cdc
priority action for intoxicated pt - administer thiamine (deficiency can cause wernicke-korsakoff, not
obtain history)
prioritize - pulsate ab mass (AAA
), LL quadrant pain pregnancy (ectopic pregnancy), RL pain fever nausea (appendicitis), RUQ pain with
small bile, food poisoning, midepigastric pain between meals (ulcer)
Amputated finger - wrapping cleansed digits with saline gauze, sealing them in plastic bag and placing
in ice slurry

perforation - prep for sugery, ng tube (decompress intestine), ab radiography, iv fluid, iv abx
frostbite - remove client from cold, give pain med, immerse feet in warm water, apply loose bulk
dressing, monitor for compartment syndrome
56 yo left sided chest pain, diaphoresis, dizziness. priority - o2
bowel perforation or peritonitis - guarding of ab, fever, chills, pallor, ab distention/pain, restlessness,
tachycardia, tachypnea
pt found down - establish unresponsiveness, call for help, chin lift, cpr, uap get crash cart
lvn task for sexual assault pt - emotional support and supportive communication
best for triage - experienced RN + inexperienced RN
trauma pt - assess respiration, chin lift, o2, 2 IVs, vitals, remove clothes, foley
UAP delegating for pt unresponsiveness - perform chest compressions
explosion who will have ptsd - person who injured and trapped for several hours (greatest risk are
those who had threats on own life)
UAP - help with postmortem care
prioritize - unrelieved asthma first, firefighter with respiratory stridor, teenager with crush injury, burn
to hands/forearms, 3 yo with 70% burn, cpr 1 hr pt
pt in ED reports ab pain, n/v, fever. ab rigid/boardlike and rebound tenderness has order for d/c express findings and concerns to MD
cat bite nursing priority - risk for infection r/t organisms specific to cat bites (rigorous washing of wound
site with soap and water)
heat stroke - altered LOC, poor muscle coordination, hot dry ashen skin (emergency)

Psych
new grad psych rn - pt with major depression rumination about loss/suicide (not schizo/psychosis)
UAP for anoxeric - sit with pt during meals and 1.5 hours after (dont get special food, no need for daily
weight)
pt been on unit several months no one likes him - identify 2-3 experienced nurses as primary
caregivers + psychosocial interventions
pt thinks dr smith killed people and trying to kill him. best response? - whenever you are concerned or
nervous talk to me or any nurses (acknowledge fears without agreeing/disagreeing) not we are all here
to ensure your safety
pt displaying spasms of tongue/face/neck/eyes upward gaze of haldol. priority action - obtain order for
IM/IV diphenhydramine (benadryl)
pt prob control anxiety, which symptoms concern - pacing back and forth pounding fists together
LVN complains about getting same pt with chronic depression - tell her care for today but will
remember request for future assignments
pt hx bipolar and altercation that killied someone, priority question - whats current mood/behavior?
(prep room, restraints, etc)
pt thinks he has tumor and has hypochondriasis (fear they have disease), most therapeutic response set boundaries: sir i will take vitals but i will call case manager so u can discuss schedule appt
prioritize - NMS (trifuoperazine) 103.6F, tachycardia, muscular rigidity, dysphagia. 2) agranulocytosis.
clozapine sore throat, fever, malaise, flulike symptoms wbc 2000 3. tardive dyskinesia - protruding
tongue, lip smacking, spastic facial distortion. 4. anticholinergic - dry mouth, dry eyes, urinary
hesitancy, constipation
celebrity on unit and several rns drop by so see pt - how did you find out pt was admitted to this unit?
(not i'm sorry fam only)
pt with NMS UAP can - wipe body with cool moist towels (vitals for RN)
pt with suicidal ideations, most concern comment - father/brother both committed suicide
reassign which? - young male mental health assistant with female adolescent with anorexia (teenagers,
esp w/ anorexia concerned w appearance)
pt commit suicide after dc who should participate in a root cause analysis - any dr/nurse involved w
care, case manager
conversion disorder (neuro disorder that can't be explained) priority therapeutic approach for pt w
sudden blindness - teach ways to cope with blindness

pt over past years comes in 2-3x month diagnostic tests are negative, priority nursing intervention perform physical assessment to identify any physical abnormalities
UAP - accompany elderly who wanders outside
collaborative goal for anorexic - restore normal nutrition/weight
which behavior most problematic - motor agitation (excessive physical activity risk injury or
exhaustion) avolition - lack of energy, stupid - motionless

Kaplan SATA
med error - evaluate pt, notify hcp, incident report, notify patient
PPE removal - gloves, eyewear, strings of gown, fold gown inside out, mask
R sided weakness + hypertensive - labs cbc, ct scan, lumbar puncture, IV LR
fiber - pears, split pea, lentil/beans, artichoke, raspberries, whole grain, tomatoes, carrot, apple
iron - oatmeal, clams, meat, egg yolk, organ meat
newborn bath - place infant warm surface, clean eyes, face, body, wrap towel, shampoo head
risk for mrsa - pt with foley, pt taking vincirstine through indwelling port (pts with open enrty), cd4 200
(immunocompressed normally 500-1000)
hep b - have you had unprotected sex? share needles? blood transfusion? (hep a - water contaminated, food
contamination, raw shellfish?)
hypoglycemia pt getting d50, concerned for - urine output and phlebitis (large bore needle, can cause osmotic diuresis,
hyperglycemia, hypotension, tachycardia)
which steps to ensure correct med - focus on delivery, question large dose, verify label w med x3
risk for osteoarthritis - 18yo crushing foot injury (past trauma), 24yo coal mine, 32 yo osteomyelitis (bone infection),
35 obese
newborn 97.2 - skin to skin, hat/cap, dry newborn in radiant warmer
blood adminsitration - review chart for informed consent, ensure patency, double verify blood, id pt, initiate
transfusion, evaulate reactions
administer oxytocin if - gush of blood, reports uterus cramping, umbilical cord extends out (oxytocin only if placenta
separtes)
transfusion reaction - stop transfusion, NS, notify HCP, collect urine, return blood
CF position - side lying with r side elevated, prone with thorax elevated, knee to chest and place pillows under chest
sterile - foley, flash instrument sterilization, op site prep, placement of central (not handwashing)
chest pain + heaviness, focused assessment - skin tone, neck vein distention, edema, cap refill
time out - ID patient, patient, surgeon, nurse ID site
therapeutic - nurse/client only, enhances client to express thoughts/feelings
TPN action - IOs, daily weights, fingerstick equipment
COPD home care items - o2 therapy, nebulizer, med alert
administer blood supplies - filtered piggy back tubing, 20guage, bp cuff, thermometer
notations that support anorexia - client eats carrots only, eats only at 12:15 and 6:30, thinks about eating all the time,
ate bag of chips in one sitting (binge)
angina vs MI pain - exertion can cause angina pain, angina relieved by nitro, (squeezing (angina), stabbing (MI), MI in
morning)
advise for elder - five serving fruit, sit outside for 10-15min
pt seeking pain meds but not in pain - hr normal, bp normal, pupil 2-5
medical asepsis - 3 minute scrub, hand saniziter, change crib sheet
late decel, action first 60 second - turn left, increase IV LR, o2
hip replacement devices at home - elevated toilet seat, shower chair, practice using grabber (hand break not
necessary by time pt can use car)
catheter insertion - cleanse genital area with soap/water, position client with perineal exposed, expose meatus, wipe
from front to back with cotton balls, advance catheter, inflate balloon

98/150

7.A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the
change of shift report?
A) The client lost 2 pounds in 24 hours
B) The clients potassium level is 4 mEq/liter.
C) The clients urine output was 1500 cc in 5 hours
D) The client is to receive another dose of Lasix at 10 PM
C.
8.A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the
initial nursing assessment requires quick intervention by the nurse?
A) a report of 10 pounds weight loss in the last month
B) a comment by the client "I just can't sit still."
C) the appearance of eyeballs that appear to "pop" out of the client's eye sockets
D) a report of the sudden onset of irritability in the past 2 weeks
C: the appearance of eyeballs that appear to "pop" out of the client''s eye sockets. Exophthalmos or protruding
eyeballs is a distinctive characteristic of Graves'' Disease. It can result in corneal abrasions with severe eye pain or
damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed.
12. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the
parent indicates that teaching has been inadequate?
A) "I will keep the cast uncovered for the next day to prevent burning of the skin."
B) "I can apply an ice pack over the area to relieve itching inside the cast."
C) "The cast should be propped on at least 2 pillows when my child is lying down."
D) "I think I remember that my child should not stand until after 72 hours."
D: "I think I remember that my child should not stand until after 72 hours.". Synthetic casts will typically set up in 30
minutes and dry in a few hours. Thus, the client may stand within the initial 24 hours. With plaster casts, the set up
and drying time, especially in a long leg cast which is thicker than an arm cast, can take up to 72 hours. Both types of
casts give off a lot of heat when drying and it is preferable to keep the cast uncovered for the first 24 hours. Clients
may complain of a chill from the wet cast and therefore can simply be covered lightly with a sheet or blanket. Applying
ice is a safe method of relieving the itching.
13. Which blood serum finding in a client with diabetic ketoacidosis alerts the nurse that immediate action is required?
A) pH below 7.3
B) Potassium of 5.0
C) HCT of 60
D) Pa O2 of 79%
C: HCT of 60. This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic
ketoacidosis.
Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation. In the
absence
of insulin, which facilitates the transport of glucose into the cell, the body breaks down fats and proteins to supply
energy ketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (pH < 7.3), which would
be the second
concern for this client. The potassium and PaO2 levels are near normal.
15. A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this
condition?
A) dyspnea
B) heart murmur
C) macular rash
D) Hemorrhage
B: heart murmur. Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break
off,
causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever,
anorexia,
malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen,
kidney,
coronary artery, brain and lungs, and obstruct blood flow.
18. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following
nursing
interventions should receive priority?
A) Maintaining proper body alignment
B) Frequent neurovascular assessments of the affected leg
C) Inspection of pin sites for evidence of drainage or inflammation
D) Applying an over-bed trapeze to assist the client with movement in bed
B: Frequent neurovascular assessments of the affected leg. The most important activity for the nurse is to assess
neurovascular

status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular
problem and early
intervention may prevent permanent limb damage.
20. A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the
bed at night."
Based on these complaints, the nurse would initially assess for which problem?
A) allergies
B) scabies
C) regression
D) pinworms
D: pinworms. Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability,
restlessness,
bed-wetting, distractibility and short attention span. Scabies is an itchy skin condition caused by a tiny, eight-legged
burrowing
mite called Sarcoptes scabiei . The presence of the mite leads to intense itching in the area of its burrows.
23. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which
overall imbalance?
A) Metabolic acidosis
B) Metabolic alkalosis
C) Some increase in the serum hemoglobin
D) A little decrease in the serum potassium
B: Metabolic alkalosis. Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of
acid and
lead to metabolic alkalosis. Findings include irritability, increased activity, hyperactive reflexes, muscle twitching and
elevated
pulse. Options C and D are correct answers but not the best answers since they are too general.
30. The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first?
A) Perform traumatic procedures
B) Use minimal physical contact
C) Proceed from head to toe
D) Explain the exam in detail
B: Use minimal physical contact. The nurse should approach the toddler slowly and use minimal physical contact
initially so as to gain the toddler's cooperation. Be flexible in the sequence of the exam, and give only brief simple
explanations just prior to the action.
31. What finding signifies that children have attained the stage of concrete operations (Piaget)?
A) Explores the environment with the use of sight and movement
B) Thinks in mental images or word pictures
C) Makes the moral judgment that "stealing is wrong"
D) Reasons that homework is time-consuming yet necessary
C: Makes the moral judgment that "stealing is wrong". The stage of concrete operations is depicted by logical thinking
and moral
judgments.
Piaget 0-2 sensorimotor, 2-6 preoperation pretend play, egocentrism, 7-11 concrete think logical, 12+ formal, think
abstract
33. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosemide 40 mg every day. Which of these foods would
the nurse
reinforce for the client to eat at least daily?
A) Spaghetti
B) Watermelon
C) Chicken
D) Tomatoes
B: Watermelon. Watermelon is high in potassium and will replace potassium lost by the diuretic. The other foods are
not high in
potassium.
36. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the
epiphysis. The
parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these
statements?
A) "The injury is expected to heal quickly because of thin periosteum."
B) "In some instances the result is a retarded bone growth."
C) "Bone growth is stimulated in the affected leg."
D) "This type of injury shows more rapid union than that of younger children."

B: "In some instances the result is a retarded bone growth.". An epiphyseal (growth) plate fracture in a 7 year-old often
results in
retarded bone growth. The leg often will be different in length than the uninjured leg.
39. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula
preparation,
which of the following is most important to prevent lead poisoning?
A) Use ready-to-feed commercial infant formula
B) Boil the tap water for 10 minutes prior to preparing the formula
C) Let tap water run for 2 minutes before adding to concentrate
D) Buy bottled water labeled "lead free" to mix the formula
C: Let tap water run for 2 minutes before adding to concentrate. Use of lead-contaminated water to prepare formula is
a major
source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used in
sealing
water pipes. Letting tap water run for several minutes will diminish the lead contamination.
40. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis
(lice) in students?
A) Scratching the head more than usual
B) Flakes evident on a student's shoulders
C) Oval pattern occipital hair loss
D) Whitish oval specks sticking to the hair
D: Whitish oval specks sticking to the hair. Diagnosis of pediculosis capitis is made by observation of the white eggs
(nits) firmly
attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2
years of
age, and meticulous combing and removal of all nits.
46. A 7 month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse
should
prepare the client for an immediate
A) Non stress test
B) Abdominal ultrasound
C) Pelvic exam
D) X-ray of abdomen
B: Abdominal ultrasound. The standard for diagnosis of placenta previa, which is suggested in the client''s history of
painless bleeding, is abdominal ultrasound.
53. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. The physiological
basis for this
instruction is that the medication
A) retards pepsin production
B) stimulates hydrochloric acid production
C) slows stomach emptying time
D) decreases production of hydrochloric acid
B: stimulates hydrochloric acid production. Decadron increases the production of hydrochloric acid, which may cause
gastrointestinal ulcers.
55. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?
A) Drowsiness, lethargy, and inactivity
B) Dry mouth, nasal congestion, and blurred vision
C) Rash, blood dyscrasias, severe depression
D) Hyperglycemia, weight gain, and edema
C: Rash, blood dyscrasias, severe depression. Rash and blood dyscrasias are side effects of anti-psychotic drugs. A
history of severe depression is a contraindication to the use of neuroleptics.
56. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus
type 2
infection. Which of these instructions should the nurse give the client?
A) Complete the entire course of the medication for an effective cure
B) Begin treatment with acyclovir at the onset of symptoms of recurrence
C) Stop treatment if she thinks she may be pregnant to prevent birth defects
D) Continue to take prophylactic doses for at least 5 years after the diagnosis
B: Begin treatment with acyclovir at the onset of symptoms of recurrence. When the client is aware of early symptoms,
such as pain, itching or tingling, treatment is very effective. Medications for herpes simplex do not cure the disease;
they simply decrease the level of symptoms.

57. A 14 month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see
in the child?
A) Hypothermia
B) Edema
C) Dyspnea
D) Epistaxis
D: Epistaxis. A large dose of aspirin inhibits prothrombin formation and lowers platelet levels. With an overdose,
clotting time is prolonged.
63. While interviewing a new admission, the nurse notices that the client is shifting positions, wringing her hands, and
avoiding eye
contact. It is important for the nurse to
A) ask the client what she is feeling
B) assess the client for auditory hallucination
C) recognize the behavior as a side effect of medication
D) re-focus the discussion on a less anxiety provoking topic
A: ask the client what she is feeling. The initial step in anxiety intervention is observing, identifying, and assessing
anxiety. The
nurse should seek client validation of the accuracy of nursing assessments and avoid drawing conclusions based on
limited data.
In the situation above, the client may simply need to use the restroom but be reluctant to communicate her need!
67. Therapeutic nurse-client interaction occurs when the nurse
A) assists the client to clarify the meaning of what the client has said
B) interprets the clients covert communication
C) praises the client for appropriate feelings and behavior
D) advises the client on ways to resolve problems
A: assists the client to clarify the meaning of what the client has said. Clarification is a facilitating/therapeutic
communication
strategy. Interpretation, changing the focus/subject, giving approval, and advising are non-therapeutic/barriers to
communication.
68. Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills?
A) Offer the client frequent opportunities to interact with 1 person
B) Provide the client with frequent opportunities to interact with other clients
C) Assist the client to analyze the meaning of the withdrawn behavior
D) Discuss with the client the focus that other clients have similar problems
A: Offer the client frequent opportunities to interact with 1 person. The withdrawn client is uncomfortable in social
interaction.
The nurse-client relationship is a corrective relationship in which the client learns both tolerance and skills for
relationships.
69. An important goal in the development of a therapeutic inpatient milieu is to
A) provide a businesslike atmosphere where clients can work on individual goals
B) provide a group forum in which clients decide on unit rules, regulations, and policies
C) provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions
D) discourage expressions of anger because they can be disruptive to other clients
C: provide a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions.
A
therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior.
73. Which statement made by a client indicates to the nurse that the client may have a thought disorder?
A) "Im so angry about this. Wait until my partner hears about this."
B) "Im a little confused. What time is it?"
C) "I can't find my 'mesmer' shoes. Have you seen them?"
D) "Im fine. It's my daughter who has the problem."
C: "I can''t find my ''mesmer'' shoes. Have you seen them?". A neologism is a new word self invented by a person and
not readily
understood by another. Using neologisms is often associated with a thought disorder.
81. As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up
and are
consistent with the diagnosis?
A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D) "We notice muscle weakness and some unsteadiness."
Review Information

: The correct answer is C: "Clothes are becoming tighteracross her abdomen."One of the most common signs of
neuroblastoma is increased abdominal girth.The parents'' report that clothing is tight is significant, and should be
followed byadditional assessments

85. The nurse is preparing the teaching plan for a group of parents about risks to toddlers and is including the proper
communication
in the event of accidental poisoning. The nurse should tell the parents to first state what substance was ingested and
then what
information should be the priority for the parents to communicate?
A) The parents' name and telephone number
B) The currency of the immunization and allergy history of the child
C) The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the
ingested substance
D) The affected child's age and weight
D: The affected child''s age and weight. All of the above information is important. However, after the substance is
identified the
age and weight are the priorities. This gives the appropriate health care providers an opportunity to calculate the
needed dosage
for an antidote while the child is being transported to the emergency department.
86. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent
would the
nurse suspect is relevant to this disease?
A) Our child had chickenpox 6 months ago.
B) Strep throat went through all the children at the day care last month.
C) Both ears were infected at 3 months of age.
D) Last week both feet had a fungal skin infection.
B: Strep throat went through all the children at the day care last month.. Evidence supports a strong relationship
between
infection with Group A streptococci and subsequent rheumatic fever (usually within 2 to 6 weeks).
88. A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results
show a
hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to
A) limit milk and milk products
B) encourage bed activities and games
C) plan nursing care around lengthy rest periods
D) promote a diet rich in iron
C: plan nursing care around lengthy rest periods. The initial priority for this client is rest due to the inability of red
blood cells to
carry oxygen.
90. The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized?
A) Call the Poison Control Center once the situation is identified
B) Empty the child's mouth in any case of possible poisoning
C) Keep the child as quiet as possible if a toxic substance was inhaled
D) Do not induce vomiting if the poison is a hydrocarbon
B: Empty the child''s mouth in any case of possible poisoning. Emptying the mouth of poison prevents further ingestion
and
should be done first to limit damage from the substance. Note that all of the actions are correct, but option B is the
priority.
91. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the
following
manifestations would the infant be most likely to exhibit?
A) Lethargy
B) Irritability
C) Negative Moro
D) Depressed fontanel
B: Irritability. Signs of increased intracranial pressure (IICP) in infants include bulging fontanel, instability, high-pitched
cry, and
cries when held. Vital sign changes include pulse that is variable, e.g., rapid, slow and bounding, or feeble.
Respirations are more
often slow, deep, and irregular.

92. The nurse is caring for a 4 year-old two hours after tonsillectomy and adenoidectomy. Which of the following
assessments must
be reported immediately?
A) Vomiting of dark emesis
B) Complaints of throat pain
C) Apical heart rate of 110
D) Increased restlessness
D: Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage.
93. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells.
Which of the
following is an appropriate action for the nurse when administering the infusion?
A) Storing the packed red cells in the medicine refrigerator while starting IV
B) Slow the rate of infusion if the client develops fever or chills
C) Limit the infusion time of each of the unit to a maximum of 4 hours
D) Assess vital signs every 15 minutes throughout the entire infusion
C: Limit the infusion time of each of the unit to a maximum of 4 hours. Infuse the specified amount of blood within 4
hours. If
the infusion will exceed this time, the blood should be divided into appropriately sized quantities.
94. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the
nurse
review first?
A) Prothrombin Time (PT) and partial thromboplastin time (PTT)
B) Red blood cell and white blood cell counts
C) Blood urea nitrogen and creatinine clearance
D) Liver enzymes (AST and ALT)
D: Liver enzymes (AST and ALT). Because acetaminophen is toxic to the liver and causes hepatic cellular necrosis, liver
enzymes are released into the blood stream and serum levels of those enzymes rise. Other lab values are reviewed as
96. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a
ventriculoperitoneal
shunt for hydrocephalus. The nurse needs to
A) assess for abdominal distention
B) maintain infant in an upright position
C) begin formula feedings when infant is alert
D) pump the shunt to assess for proper function
A: assess for abdominal distention. The child is observed for abdominal distention because cerebrospinal fluid may
cause
peritonitis or a postoperative ileus as a complication of distal catheter placement.
97. A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has
deformities of the
joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: My child seems to
have
problems in learning to count and recognizing basic colors. Based on this data, the nurse suspects that the child is
most likely
showing the effects of which problem?
A) congenital abnormalities
B) chronic toxoplasmosis
C) fetal alcohol syndrome (FAS)
D) lead poisoning
C: fetal alcohol syndrome (FAS). Major features of FAS consist of facial and associated physical features, such as small
head
circumference and brain size (microcephaly), small eyelid openings, a sunken nasal bridge, an exceptionally thin upper
lip, a
short, upturned nose and a smooth skin surface between the nose and upper lip. Vision difficulties include
nearsightedness
(myopia). Other findings are mental retardation, delayed development, abnormal behavior such as short attention
span,
hyperactivity, poor impulse control, extreme nervousness and anxiety. Many behavioral problems, cognitive
impairment and
psychosocial deficits are also associated with this syndrome.
98. A 15 year-old client has been placed in a Milwaukee brace. Which statement from the adolescent indicates the
need for additional
teaching?
A) "I will only have to wear this for 6 months."

B) "I should inspect my skin daily."

C) "The brace will be worn day and night."
D) "I can take it off when I shower."
A: "I will only have to wear this for 6 months.". The brace must be worn long-term, during periods of growth, usually for
1 to 2 years. It is used to correct curvature of the spine.
99. The nurse is caring for a 4 year-old admitted after receiving burns to more than 50% of his body. Which laboratory
data should
be reviewed by the nurse as a priority in the first 24 hours?
A) Blood urea nitrogen
B) Hematocrit
C) Blood glucose
D) White blood count
A: Blood urea nitrogen. Glomerular filtration is decreased in the initial response to severe burns, with fluid shift
occurring.
Kidney function must be monitored closely, or renal failure may follow in a few days.
100. The nurse is caring for a client with a colostomy pouch. During a teaching session, the nurse appropriately
recommends that the
pouch be emptied
A) when it is 1/3 to 1/2 full
B) prior to meals
C) after each fecal elimination
D) at the same time each day
A: when it is 1/3 to 1/2 full. If the pouch becomes more than half full it may separate from the flange.
104.The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to
promote healing?
A) Covering the wound with a dry dressing
B) Using hydrogen peroxide soak
C) Leaving the area open to dry
D) Applying a hydrocolloid or foam dressing
D: Applying a hydrocolloid or foam dressing. While the previously accepted treatment was a transparent cover,
evidence now
indicates that the foam (DuoDerm) dressings work best.
108. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should
recognize which
statement by the client as the most important?
A) I got back from Central America a few weeks ago.
B) I had the best raw oysters last week.
C) I have many different sex partners.
D) I had a blood transfusion 15 years ago.
D: I had a blood transfusion 15 years ago.. The client who was transfused prior to blood screening for hepatitis C may
show
findings many years later. Options B and C are associated with risk of hepatitis B.
109. Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat
last" category?
A) An infant with intermittent bulging anterior fontanel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with a lower leg fracture on one side and an upper leg fracture on the other
D) A school-age child with singed eyebrows and hair on the arms
B: A toddler with severe deep abrasions over 98% of the body. This child has the least chance of survival. Severe deep
abrasions
should be thought of as second and third degree burns. The child has great risk of both shock and infection combined.
115. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse
because a flat pink
birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
A) "Mongolian spots are a normal finding in dark-skinned children."
B) "Port wine stains are often associated with other malformations."
C) "Telangiectatic nevi are normal and will disappear as the baby grows."
D) "The child is too young for consideration of surgical removal of these at this time."
C: Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial nevi will generally
disappear
by ages 1 to 2 years.

117. A nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the
client. The next
action by the nurse should be to
A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcement of the manipulative behavior
C) Confront the client about the negative effects of behaviors on other clients and staff
D) Develop a behavior modification plan that will promote more functional behavior
A: Discuss the feeling of reluctance with an objective peer or supervisor. The nurse who experiences stress in the
therapeutic
relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the
self that
influence the nurse-client relationship.
118. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse
immediately placed
him in seclusion as a precautionary measure. The client willingly complied. The nurses action
A) may result in charges of unlawful seclusion and restraint
B) leaves the nurse vulnerable for charges of assault and battery
C) was appropriate in view of a client history of violence
D) was necessary to maintain the therapeutic milieu of the unit
A: may result in charges of unlawful seclusion and restraint. Seclusion should only be used when there is an immediate
threat of
violence or threatening behavior toward the staff, the other clients, or the client himself.
126.The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which intervention
should be included
in the plan that would be most effective for the prevention of falls?
A) Place nightlights in the bedroom
B) Wear eyeglasses at all times
C) Install grab bars in the bathroom
D) Teach muscle strengthening exercises
A: Place nightlights in the bedroom. Because more falls occur in the bedroom than any other location, begin there.
However,
work in partnership with the client and family so they are willing to move furniture, lamp cords, and storage areas, add
lighting,
remove throw rugs, and eliminate other environmental hazards.
131.A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I
have to have
my breast removed, my partner will never come near me." The nurse's best response would be which of these
statements?
A) "I hear you saying that you have a fear for the loss of love."
B) "You sound concerned that your partner will reject you."
C) "Are you wondering about the effects on your sexuality?"
D) "Are you worried that the surgery will lead to changes?"
D: "Are you worried that the surgery will lead to changes?". This is a general lead in type of response that encourages
further
discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem.
135.The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client
asks when
they will know the canister is empty. The best response is
A) Drop the canister in water to observe floating
B) Estimate how many doses are usually in the canister
C) Count the number of doses as the inhaler is used
D) Shake the canister to detect any fluid movement
A: Drop the canister in water to observe floating. Dropping the canister into a bowl of water assesses the amount of
medications
remaining in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins
to tip over.
Some of the newer canisters have counters.
140. A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by
the PN, would
need no further intervention by the charge nurse?
A) Telfa dressing with antibiotic ointment
B) Moist sterile nonadherent dressing
C) Dry sterile dressing that is occlusive

D) Sterile occlusive pressure dressing

B: Moist sterile nonadherent dressing. Before surgical closure, the sac is prevented from drying by the application of a
sterile,
moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.
141. A parent brings her 3 month-old into the clinic, reporting that the child seems to be spitting up all the time and
has a lot of gas.
The nurse expects to find which of the following on the initial history and physical assessment?
A) increased temperature and lethargy
B) restlessness and increased mucus production
C) increased sleeping and listlessness
D) diarrhea and poor skin turgor
B: restlessness and increased mucus production. This infant could be experiencing gastroesophageal reflux, or could
be allergic
to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy
based formula is
often recommended.
144. The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked
for many changes
and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this
method will
A) Improve the quality of care
B) Decrease staff turnover
C) Minimize the amount of overtime payouts
D) Improve team morale
D: Improve team morale. Nurses are more satisfied when opportunities exist for autonomy and control. The nurse
manager
becomes the facilitator of scheduling rather than the decision-maker of the schedule when self-scheduling exists.
145. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the
unit for 2 days
and now states I demand to be released now! The appropriate from the nurse is
A) You cannot be released because you are still suicidal.
B) You can be released only if you sign a no suicide contract.
C) Lets discuss your decision to leave and then we can prepare you for discharge.
D) You have a right to sign out as soon as we get the provider's discharge order.
C: Lets discuss your decision to leave and then we can prepare you for discharge.. Clients voluntarily admitted to the
hospital
have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other
interventions.
148. Which statement best describes time management strategies applied to the role of a nurse manager?
A) Schedule staff efficiently to cover the anticipated needs on the managed unit
B) Assume a fair share of direct client care as a role model
C) Set daily goals with a prioritization of the work
D) Delegate tasks to reduce work load associated with direct care and meetings
C: Set daily goals with a prioritization of the work. Time management strategies include setting goals and
prioritization . This is
similar to time management of direct care for clients
Management of Care 14/20
5. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?
A) Be with a client who self-administers insulin
B) Cleanse and dress a small decubitus ulcer
C) Monitor a client's response to passive range of motion exercises
D) Apply and care for a client's rectal pouch
D: Apply and care for a client''s rectal pouch. The RN may delegate the application and care of rectal pouches to a UAP.
This is
an uncomplicated, routine task.
6. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a
post
surgical client. The nurse checks on the clients condition and observes a cup of steaming coffee at the bedside. What
instructions are appropriate to give to the UAP?
23
A) Encourage oral fluids to prevent dehydration
B) Recheck temperature 15 minutes after removing hot liquids from the bedside

C) Ask the client to drink only cold water and juices

D) Chart this temperature elevation on the flow sheet
B: Recheck temperature 15 minutes after removing hot liquids from the bedside. Recheck temperature to eliminate
possible
artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature.
Waiting to
take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading.
Avoid
premature assumptions about explanations for findings. The other options are incorrect.
11. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma
from a fall 2
days ago. What is the best care assignment for this client?
A) Assign an RN to provide total care of the client
B) Assign a nursing assistant to help the client with self-care activities
C) Delegate complete care to an unlicensed assistive personnel
D) Supervise a nursing assistant for skin care
D: Supervise a nursing assistant for skin care. The nursing assistant can inspect the skin while giving hygiene care, but
the nurse
should supervise skin care since assessment and analysis are needed.
15. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric
unit. Which
question by the charge nurse would be most appropriate when making delegation decisions?
A) "How long have you been a UAP and what units you have worked on?"
B) "What type of care do you give on the surgical unit and what ages of clients?"
C) "What is your comfort level in caring for children and at what ages?"
D) "Have you reviewed the list of expected skills you might need on this unit?"
D: "Have you reviewed the list of expected skills you might need on this unit?". The UAP must be competent to accept
the
delegated task. Review of skills needed versus level of performance is the most efficient and effective way to
determine this.
16. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for
placement. The
social worker telephoned the hospital unit for information about the clients mental status and adjustment. The
appropriate
response of the nurse should be which of these statements?
A) "I am sorry. Referral information can only be provided by the clients providers"
B) "I can never give any information out by telephone. How do I know who you are?"
C) "Since this is a referral, I can give you this information"
D) "I need to get the clients written consent before I release any information to you"
D: In order to release information about a client there must be a signed consent form with designation of to whom
information
can be given, and what information can be shared.
17. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to
go out on
a date. The nurses response should be to
A) ask to not be assigned to this client or to work on another unit
B) tell the client that such behavior is inappropriate
C) inform the client that hospital policy prohibits staff to date clients
D) discuss the boundaries of the therapeutic relationship with the client
D: Discuss the boundaries of the therapeutic relationship with the client. The nurse-client relationship is one with
professional
not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.
Delegation 16/25
2. The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of
care
provided by a home health care aide assigned to assist with the care of this client?
A) Ask the client and family if they are satisfied with the care given
B) Determine if the home health aide's care is consistent with the plan of care
C) Investigate if the home health aide is prompt and stays an appropriate length of time for care
D) Check the documentation of the aide for appropriateness and comprehensiveness
B: Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is
the first

priority. The plan of care is based on the reason for referral, provider''s orders, the initial nursing assessment, the
clients
responses to the planned interventions, and the client''s and family''s feedback or inquires. The other possible answers
represent
aspects of accomplishing B.
3. Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel
(UAP)?
A) Assess and document skin turgor and color changes
B) Test stool for occult blood and urine for glucose and report results
C) Suggest foods high in iron and those easily consumed
D) Report mental status changes and the degree of mental clarity
B: Test stool for occult blood and urine for glucose and report results. The UAP can do standard, unchanging
procedures that
require no decision making.
6. The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed
assistive
personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy clients blood
pressure on
the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that clients left arm. Which
of
these statements is most immediately accurate?
A) The RN has no accountability for this situation
B) The RN did not delegate appropriately
C) The UAP is covered by the RNs license
D) The UAP is responsible for following instructions
D: The UAP is responsible for carrying out the activity correctly once directions have been clearly communicated
especially if
given verbally and in writing.
12. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN,
an LPN
and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?
A) Assist with plans for any clients discharged
B) Provide basic hygiene care to all clients on the unit
C) Assess a client after an acute myocardial infarction
D) Gather the vital signs of all clients on the unit
B: Basic client care, which is routine, should be delegated to a UAP since the unit is short on help. The vital signs can
be done by
the RN and PN as they make rounds since this data is more critical to making decisions about the care of the clients.
13. A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the
work area
untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?
27
A) "I will arrange for a conference with you and the UAP within the next week"
B) "I can assure you that I will look into the matter"
C) "I would like for you to approach the UAP about the problem the next time it occurs"
D) I will add this concern to the agenda for the next unit meeting
C: Helping staff manage conflict is part of the manager''s role. It is appropriate to urge the nurse to confront the other
staff
member to work out problems without a manager''s intervention when possible.
15. An RN from the womens health clinic is temporarily reassigned to a medical-surgical unit. Which of these client
assignments would be most appropriate for this nurse?
A) A newly diagnosed client with type 2 diabetes mellitus who is learning foot care
B) A client from a motor vehicle accident with an external fixation device on the leg
C) A client admitted for a barium swallow after a transient ischemic attack
D) A newly admitted client with a diagnosis of pancreatic cancer
16. The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient
with a
lunch tray. Which statement by the nurse is most appropriate?
A) "Tell the family they can bring in a pizza if the patient would prefer that."
B) "Make sure the patient gets at least 2 cartons of milk."
C) "Stop the IV if the patient is able to eat solid food."
D) "Encourage the patient to eat slowly to prevent gas."

D: The professional nurse can delegate tasks with an expected outcome. The UAP is given adequate information about
the task
and how to promote the best outcome.
22. The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The
client
ambulates with a leg splint. Which task requires supervision of the UAP?
A) Report signs of redness overlying a joint
B) Monitor the client's response to ambulatory activity
C) Encouragement for the independence in self-care
D) Assist the client to transfer from a bed to a chair
B: Monitor the client''s response to ambulatory activity. Monitoring the clients response to interventions requires
assessment, a
task to be performed by an RN.
23. When walking past a clients room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP.
Which
statement requires follow-up intervention?
A) "If we work together we can get all of the client care completed."
B) "Since I am late for lunch, would you do this one client's glucose test?"
C) "This client seems confused, we need to watch monitor closely."
D) "Ill come back and make the bed after I go to the lab."
B: Only the RN and PN can delegate to UAPs. One UAP can not delegate a task to another UAP. The RN or PN is legally
accountable for the nursing care.
Prioritization 15/25
1. The nurse must know that the most accurate oxygen delivery system available is
A) the Venturi mask
B) nasal cannula
C) partial non-rebreather mask
D) simple face mask
A: the Venturi mask.
2. A client arrives in the emergency department after a radiologic accident at a local factory. The first action of the
nurse
would be to
A) begin decontamination procedures for the client
B) ensure physiologic stability of the client
C) wrap the client in blankets to minimize staff contamination
D) double bag the clients contaminated clothing
B: ensure physiologic stability of the client. The nurse must initially assist in stabilizing the patient prior to performing
the other
tasks related to radiologic contamination.
3. The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the
formation of deep vein thrombosis?
A) Elevate the foot of the bed
B) Apply knee high support stockings
C) Encourage passive exercises
D) Prevent pressure at back of knees
D: Prevent pressure at back of knees. Preventing popliteal pressure will prevent venous stasis and possibly deep vein
thrombosis.
5. The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for
puerperal
infection?
A) 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
B) 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
C) 3 days post partum, temperature of 100.8 degrees Fahrenheit the past 2 days
D) 4 days post partum, temperature of 100 degrees Fahrenheit since delivery
30
C: A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after
birth, indicates
a post partum infection.
6. The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally
disconnects
from the drainage tube. The first action the nurse should take is

A) reconnect the tube

B) raise the collection chamber above the client's chest
C) call the health care provider
D) clamp the chest tube
D: clamp the chest tube. Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse
may occur
if air enters the chest cavity. Clamping the tube close to the clients chest is the first action to take, followed by health
care
provider notification.
7. A client is placed on sulfamethoxazole-trimethoprim (Bactrim) for a recurrent urinary tract infection. Which of the
following is appropriate reinforcement of information by the nurse?
A) "Drink at least 8 glasses of water a day."
B) "Be sure to take the medication with food."
C) "It is safe to take with oral contraceptives."
D) "Stop the medication after 5 days."
A: "Drink at least 8 glasses of water a day." Bactrim is a highly insoluble drug and requires a large volume of fluid
intake. It is
not necessary to take it with food. Options C and D are incorrect instructions for those taking Bactrim.
13. When caring for a client with urinary incontinence, which content should be reinforced by the nurse?
A) hold the urine to increase bladder capacity
B) avoid eating foods high in sodium
C) restrict fluid to prevent elimination accidents
D) avoid taking antihistamines
D: avoid taking antihistamines. Antihistamines can aggravate urinary incontinence and should be avoided by these
clients.
Holding the urine, avoiding sodium, and restricting fluids have not been shown to reduce urinary incontinence.
14. A client returns from the operating room after a right orchiectomy (testicle). For the immediate post-operative
period the nursing priority would be to
A) maintain fluid and electrolyte balance
B) manage post-operative pain
C) ambulate the client within 1 hour of surgery
D) control bladder spasms
B: manage post-operative pain. Due to the location of the incision, pain management is the priority. Bladder spasms
are more related to prostate surgery.
16. A client is 2 days post operative. The vital signs are: BP - 120/70, HR -- 110 BPM, RR - 26, and Temperature - 100.4
degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray.
Which
assessment would have alerted the nurse first to the client's change in condition?
A) Heart rate
B) Respiratory rate
C) Blood pressure
D) Temperature
B: Respiratory rate. Tachypnea is one of the first clues that the client is not oxygenating appropriately. The
compensatory
mechanism for decreased oxygenation is increased respiratory rate.
21. The nurse is caring for a client several days following a cerebral vascular accident. Coumadin (warfarin) has been
prescribed. Today's prothrombin level is 40 seconds (normal range 10-14 seconds). Which of the following findings
requires
priority follow-up?
A) Gum bleeding
B) Lung sounds
C) Homan's sign
D) Generalized weakness
A: Gum bleeding. The prothrombin time is elevated, indicating a high risk for bleeding. Neurological assessments
remain
important for post-CVA clients.
Safety and Infection Control 13/20
1. After an explosion at a factory one of the employees approaches the nurse and says I am an unlicensed assistive
personnel
(UAP) at the local hospital. Which of these tasks should the nurse assign first to this worker who wants to help care for
the
wounded workers?

A) Get temperatures
B) Take blood pressure
C) Palpate pulses
D) Check alertness
C: Palpate pulses. The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could
not be
palpated, those clients would need to be seen first.
6. The parents of a toddler who is being treated for pesticide poisoning ask: Why is activated charcoal used? What
does it
do? What is the nurse's best response?
A) "Activated charcoal decreases the bodys absorption of the poison from the stomach."
B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child."
C) "This substance helps to get the poison out of the body through the gastrointestinal system."
D) "The action may bind or inactivate the toxins or irritants that are ingested by children and adults."
B: "The charcoal absorbs the poison and forms a compound that doesn''t hurt your child." All of the options are correct
responses. However, option B is most accurate information to answer the parents questions about the use and action
of activated
charcoal. The language is appropriate for a parent''s understanding.
8. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission
orders
should the nurse implement first?
A) Institute seizure precautions
B) Monitor neurologic status every hour
C) Place in respiratory/secretion precautions
D) Cefotaxime IV 50 mg/kg/day divided q6h
C: Place in respiratory/secretion precautions Meningococcal meningitis is a bacterial infection that can be
communicated to
others.
10. A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority
information for the nurse to include in client teaching is which of these statements?
A) "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after
urination or defecation."
B) "Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush
it twice."
C) "Your family can use the same bathroom that you use without any special precautions."
35
D) "Drink plenty of water and empty your bladder often during the initial 3 days of therapy."
A: "In the initial 48 hours, avoid contact with children and pregnant women, and flush the commode twice after
urination or
defecation." The client's urine and saliva are radioactive for 24 hours after ingestion, and vomitus is radioactive for 6
to 8 hours.
The client should drink 3 to 4 liters of fluid a day for the initial 48 hours to help remove the ( 131I) from the body. Staff
should
limit contact with hospitalized clients to 30 minutes per day per person.
11. The nurse is to administer a new medication to a client. Which of these actions best demonstrate awareness of
safe,
proficient nursing practice?
A) Verify the order for the medication. Prior to giving the medication the nurse should say, "Please state your name."
B) Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check
the client's name band and allergy band.
C) As the room is entered say "What is your name?" then check the client's name band.
D) Verify the client's allergies on the admission sheet and order. Verify the client's name on the nameplate outside the
room then as the nurse enters the room ask the client "What is your first, middle and last name?"
B: Upon entering the room the nurse should ask: "What is your name? What allergies do you have?" and then check
the client''s
name band and allergy band. A dual check is always done for
16. A parent calls the hospital hot line and is connected to the triage nurse. The caller proclaims: I found my child with
odd
stuff coming from the mouth and an unmarked bottle nearby. Which of these comments would be the best tool for the
nurse to determine if the child has swallowed a corrosive substance?
A) "Ask the child if the mouth is burning or throat pain is present."
B) "Take the childs pulse at the wrist and see if the child is has trouble breathing lying flat."
C) "What color is the childs lips and nails and has the child voided today?"

36
D) "Has the child had vomiting, diarrhea or stomach cramps?"
A: "Ask the child if the mouth is burning or throat pain is present." Local irritation of tissues indicates a corrosive
poisoning.
The other comments may be helpful in determining the childs overall condition, however the question concerns
evaluation for
ingesting a caustic substance.
19. Which of these clients is the priority for the nurse to report to the public health department within the next 24
hours?
A) An infant with a positive culture of stool for Shigella
B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for
Pneumocystis carinii
D) A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that
appear on the skin
B: An elderly factory worker with a lab report that is positive for acid-fast bacillus smear. Tuberculosis is a reportable
disease
because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for
a designated
time. Options A and D may need contact isolation precautions. Option C -- findings may indicate the initial stage of
autoimmune
deficiency syndrome (AIDS).
Health Promotion & Maintenece 15/20
5. A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to
leaving the
unit for the operating room. What would be the most appropriate intervention by the nurse?
A) Explain to the client that the dentures must come out as they may get lost or broken in operating room
B) Ask the client if there are second thoughts about having the procedure
C) Notify the anesthesia department and the surgeon of the client's refusal
D) Ask the client if the preference would be to remove the dentures in the operating room receiving area
D: Ask the client if the preference would be to remove the dentures in the operating room receiving area
Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation
and fosters
the client''s sense of self-esteem and self-concept.
8. A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events
and
becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?
A) "Good morning. Do you remember where you are?"
B) "Hello. My name is Elaine Jones and I am your nurse for today."
C) "How are you today? Remember, you're in the hospital."
D) "Good morning. Youre in the hospital. I am your nurse Elaine Jones."
D: "Good morning. Youre in the hospital. I am your nurse Elaine Jones." As cognitive ability declines, the nurse
provides a
calm, predictable environment for the client. This response establishes time, location and the caregivers name.
10. An appropriate treatment goal for a client with anxiety would be to
A) ventilate anxious feelings to the nurse
B) establish contact with reality
C) learn self-help techniques
D) become desensitized to past trauma
C: learn self-help techniques. Exploring alternative coping mechanisms will decrease present anxiety to a manageable
level.
Assisting the client to learn self-help techniques will assist in learning to cope with anxiety.
11. The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury.
Which
statement is true concerning long bone fractures in children?
A) Growth problems will occur if the fracture involves the periosteum
B) Epiphyseal fractures often interrupt a child's normal growth pattern
C) Children usually heal very quickly, so growth problems are rare
D) Adequate blood supply to the bone prevents growth delay after fractures
B: Epiphyseal fractures often interrupt a child''s normal growth pattern. The epiphyseal plate in children is where active
bone
growth occurs. Damage to this area may cause growth arrest in either longitudinal growth of the limb or in progressive
deformity

if the plate is involved. An epiphyseal fracture is serious because it can interrupt and alter growth.
12. While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following
assessments is appropriate for the nurse to perform?
A) Measure the length of the mass
B) Auscultate the mass
C) Percuss the mass
D) Palpate the mass
B: Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal
aneurysm
and will form the basis of information given to the provider. The mass should not be palpated because of the risk of
rupture.
Basic Care & Comfort 14/20
7. The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice
indicates the
client understands dietary needs?
A) three apricots
B) medium banana
C) naval orange
D) baked potato
D: baked potato. A baked potato contains 610 milligrams of potassium.
8. When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula
A) every four to six hours
B) continuously
C) in a bolus
D) every hour
B: continuously. Usually gastrostomy and jejunostomy feedings are given continuously to ensure proper absorption.
However,
initial feedings may be given by bolus to assess the client''s tolerance to formula.
9. An 86 year-old nursing home resident who has impaired mental status is hospitalized with pneumonic infiltrates in
the right
lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse
do
next?
A) Add a thickening agent to the fluids
B) Check the clients gag reflex
C) Feed the client only solid foods
D) Increase the rate of intravenous fluids
B: Check the clients gag reflex. When a new problem emerges, the nurse should perform appropriate assessment so
that suitable
nursing interventions can be planned. Aspiration pneumonia follows aspiration of material from the mouth into the
trachea and
finally the lung. A loss or an impairment of the protective cough reflex can result in aspiration.
11. A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids.
Which
nursing measure will provide the most comfort to the client?
A) Allow the client to melt ice chips in the mouth
B) Provide mints to freshen the breath
C) Perform frequent oral care with a tooth sponge
D) Swab the mouth with glycerin swabs
C: Perform frequent oral care with a tooth sponge. Frequent cleansing and stimulation of the mucous membrane is
important for
a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be
contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.
17. Which statement best describes the effects of immobility in children?
A) Immobility prevents the progression of language and fine motor development
B) Immobility in children has similar physical effects to those found in adults
C) Children are more susceptible to the effects of immobility than are adults
D) Children are likely to have prolonged immobility with subsequent complications
B: Immobility in children has similar physical effects to those found in adults
Care of the immobile child includes efforts to prevent complications of muscle atrophy, contractures, skin breakdown,
decreased
metabolism and bone demineralization.

20. A client in a long term care facility complains of pain. The nurse collects data about the clients pain. The first step
in pain
assessment is for the nurse to
A) have the client identify coping methods
B) get the description of the location and intensity of the pain
C) accept the clients report of pain
D) determine the clients status of pain
C: accept the clients report of pain. Although all of the options above are correct, the first and most important piece of
information in this clients pain assessment is what the client is telling you about the pain --the clients report.
Pharmacological and Parenteral Therapies 16/20
9. A nurse is providing care to a 63 year-old client with pneumonia. Which intervention promotes the clients comfort?
A) Increase oral fluid intake
B) Encourage visits from family and friends
C) Keep conversations short
D) Monitor vital signs frequently
C: Keep conversations short. Keeping conversations short will promote the clients comfort by decreasing demands on
the
clients breathing and energy.
11. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client,
which
finding suggests a side effect of the analgesic?
A) Bruising at the operative site
B) Elevated heart rate
C) Decreased platelet count
D) No bowel movement for 3 days
15. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for
the
therapeutic effectiveness of this drug?
A) Diaphoresis with decreased urinary output
B) Increased heart rate with increased respirations
C) Improved respiratory status and increased urinary output
D) Decreased chest pain and decreased blood pressure
C: Improved respiratory status and increased urinary output. Digoxin, a cardiac glycoside, is used in clients with heart
failure to
slow and strengthen the heartbeat. As cardiac output is improved, renal perfusion is improved and urinary output
increases.
Clients can become toxic on this drug, indicated by findings of bradycardia, dysrhythmia, and visual and GI
disturbances. Clients
being treated with digoxin should have their apical pulse evaluated for 1 full minute prior to the administration of the
drug.
19. A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the
administration of
feedings and medications. Which nursing action is appropriate?
A) Pulverize all medications to a powdery condition
B) Squeeze the tube before using it to break up stagnant liquids
C) Cleanse the skin around the tube daily with hydrogen peroxide
D) Flush adequately with water before and after using the tube
D: Flush adequately with water before and after using the tube. Flushing the tube before and after use not only
provides for good
flow and keeps the tube patent, it also provides water to maintain hydration.
Q&A Pharm 61/80
3. When providing discharge teaching to a client with asthma, the nurse will warn against the use of which of the
following
over-the-counter medications?
A) Cortisone ointments for skin rashes
B) Aspirin products for pain relief
C) Cough medications containing guaifenesin
D) Histamine blockers for gastric distress
B: Aspirin products for pain relief. Aspirin is known to induce asthma attacks. Aspirin can also cause nasal polyps and
rhinitis.
Warn individuals with asthma about signs and symptoms resulting from complications due to aspirin ingestion.

5. In providing care for a client with pain from a sickle cell crisis, which one of the following medication orders for pain
control should be questioned by the nurse?
A) Demerol (meperidine)
B) Morphine
C) Methadone
D) Codeine
A: Demerol. Meperidine is not recommended in clients with sickle cell disease. Normeperidine, a metabolite of
meperidine, is a
central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it
accumulates with
repetitive dosing. Clients with sickle cell disease are particularly at risk for normeperidine-induced seizures.
9. The nurse is caring for a 10 year-old client who will be placed on heparin therapy. Which assessment is critical for
the nurse
to make before initiating therapy
A) Vital signs
B) Weight
C) Lung sounds
D) Skin turgor
B: Weight. Check the client''s weight because dosage is calculated on the basis of weight.
15. A client with bi-polar disorder is taking lithium (Lithane). What should the nurse emphasize when teaching about
this
medication?
A) Take the medication before meals
B) Maintain adequate daily salt intake
C) Reduce fluid intake to minimize diuresis
D) Use antacids to prevent heartburn
B: Maintain adequate daily salt intake. Salt intake affects fluid volume, which can affect lithium (Lithane) levels;
therefore,
maintaining adequate salt intake is advised.
16. The nurse is assessing a 7 year-old after several days of treatment for a documented strep throat. Which of the
following
statements suggests that further teaching is needed?
A) "Sometimes I take my medicine with fruit juice."
B) "My mother makes me take my medicine right after school."
C) "Sometimes I take the pills in the morning and other times at night."
D) "I am feeling much better than I did last week."
C: "Sometimes I take the pills in the morning and other times at night." Inconsistency in taking the prescribed
medication
indicates more teaching is needed.
21. The nurse is teaching a group of women in a community clinic about prevention of osteoporosis. Which of the
following
over-the-counter medications should the nurse recognize as having the most elemental calcium per tablet?
A) Calcium chloride
B) Calcium citrate
C) Calcium gluconate
D) Calcium carbonate
D: Calcium carbonate. Calcium carbonate contains 400mg of elemental calcium in 1 gram of calcium carbonate.
25. A client is receiving dexamethasone (Decadron) therapy. What should the nurse plan to monitor in this client?
A) Urine output every 4 hours
B) Blood glucose levels every 12 hours
C) Neurological signs every 2 hours
D) Oxygen saturation every 8 hours
B: The drug Decadron increases glycogenesis. This may lead to hyperglycemia. Therefore the blood sugar level and
acetone
production must be monitored.
27. A newly admitted client has a diagnosis of depression. She complains of twitching muscles and a racing heart,
and
states she stopped taking Zoloft a few days ago because it was not helping her depression. Instead, she began to take
her
partner's Parnate. The nurse should immediately assess for which of these adverse reactions?
A) Pulmonary edema
B) Atrial fibrillation

C) Mental status changes

D) Muscle weakness
C: Mental status changes. Use of serotonergic agents may result in Serotonin Syndrome with confusion, nausea,
palpitations,
increased muscle tone with twitching muscles, and agitation.
29. The nurse is assessing a client who is on long term glucocorticoid therapy. Which of the following findings would
the nurse
expect?
A) Buffalo hump
B) Increased muscle mass
C) Peripheral edema
D) Jaundice
A: Buffalo hump. With high doses of glucocorticoid, iatrogenic Cushing''s syndrome develops.
46. A hypertensive client is started on atenolol (Tenormin). The nurse instructs the client to immediately report which
of these
findings?
A) Rapid breathing
B) Slow, bounding pulse
C) Jaundiced sclera
D) Weight gain
B: Slow, bounding pulse. Atenolol (Tenormin) is a beta-blocker that can cause side effects including bradycardia and
hypotension.
56. A 66 year-old client is admitted for mitral valve replacement surgery. The client has a history of mitral valve
regurgitation
and mitral stenosis since her teenage years. During the admission assessment, the nurse should ask the client if as a
child she
had
A) measles
B) rheumatic fever
C) hay fever
D) encephalitis
B: rheumatic fever. Clients that present with mitral stenosis often have a history of rheumatic fever or bacterial
endocarditis.
61. A male client is admitted with a spinal cord injury at level C4. The client asks the nurse how the injury is going to
affect his
sexual function. The nurse would respond
A) "Normal sexual function is not possible."
B) "Sexual functioning will not be impaired at all."
C) "Erections will be possible."
D) "Ejaculation will be normal."
C: "Erections will be possible." Because they are a reflex reaction, erections can be stimulated by stroking the
genitalia.
63. The unlicensed assistive personnel (UAP) reports to the nurse that a client with cirrhosis who had a paracentesis
yesterday
has become more lethargic and has musty smelling breath. A critical assessment for increasing encephalopathy is
A) monitor the client's clotting status
B) assess upper abdomen for bruits
C) assess for flap-like tremors of the hands
D) measure abdominal girth changes
C: assess for flap-like tremors of the hands. A client with cirrhosis of the liver who develops subtle changes in mental
status and
has a musty odor to the breath is at risk for developing more advanced signs of encephalopathy.
64. A client is admitted with a diagnosis of nodal bigeminy. The nurse knows that the atrioventricular (AV) node has an
intrinsic rate of
A) 60-100 beats/minute
B) 10-30 beats/minute
C) 40-70 beats/minute
D) 20-50 beats/minute
C: 40-70 beats/minute. The intrinsic rate of the AV node is within the range of 40-70 beats per minute.
67. The nurse is teaching a client with chronic renal failure (CRF) about medications. The client questions the purpose
of

aluminum hydroxide (Amphojel) in her medication regimen. What is the best explanation for the nurse to give the
client
about the therapeutic effects of this medication?
A) It decreases serum phosphate
B) It will reduce serum calcium
C) Amphojel increases urine output
D) The drug is taken to control gastric acid secretion
A: It decreases serum phosphate. Aluminum binds phosphates that tend to accumulate in the patient with chronic
renal failure
due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to accomplish this.
68. The client with goiter is treated with potassium iodide preoperatively. What should the nurse recognize as the
purpose of this
medication?
A) Reduce vascularity of the thyroid
B) Correct chronic hyperthyroidism
C) Destroy the thyroid gland function
D) Balance enzymes and electrolytes
A: Potassium iodide solution, or Lugol''s solution may be used preoperatively to reduce the size and vascularity of the
thyroid
gland.
71. The nurse enters the room of a client diagnosed with COPD. The clients skin is pink, and respirations are 8 per
minute. The
clients oxygen is running at 6 liters per minute. What should be the nurses first action?
A) Call the health care provider
B) Put the client in Fowlers position
C) Lower the oxygen rate
D) Take the vital signs
C: In clients diagnosed with COPD, the drive to breathe is hypoxia. If oxygen is delivered at too high of a
concentration, this
drive will be eliminated and the clients depth and rate of respirations will decrease. Therefore the first action should
be to lower
the oxygen rate.
74. A client is prescribed an inhaler. How should the nurse instruct the client to breathe in the medication?
A) As quickly as possible
B) As slowly as possible
C) Deeply for 3-4 seconds
D) Until hearing whistling by the spacer
C: The client should be instructed to breath in the medication for 3-4 seconds in order to receive the correct dosage of
medication.
75. After surgery, a client with a nasogastric tube complains of nausea. What action would the nurse take?
A) Call the health care provider
B) Administer an antiemetic
C) Put the bed in Fowlers position
D) Check the patency of the tube
D: Check the patency of the tube. An indication that the nasogastric tube is obstructed is a clients complaint of
nausea.
Nasogastric tubes may become obstructed with mucus or sediment.
Reduction of Risk Potential 11/20
1. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the
following
nursing assessments should be a priority?
A) Blanch nail beds for color and refill
B) Assess for post-operative arrhythmias
C) Auscultate for pulmonary congestion
D) Monitor equality of peripheral pulses
B: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction
system
of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides
into right and
left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn
over the
opening.

2. A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Addressing which
of the
following should take priority in planning care?
A) Esophagitis
B) Leukopenia
C) Fatigue
D) Skin irritation
B: Leukopenia. Clients develop leukopenia due to the depressant effect of radiation therapy on bone marrow function.
Infection
is the most frequent cause of morbidity and death in clients with cancer.
3. A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take
first?
A) Ask client to cough sputum into container
B) Have the client take several deep breaths
C) Provide a appropriate specimen container
D) Assist with oral hygiene
D: Assist with oral hygiene. Obtain a specimen early in the morning after mouth care. The other responses follow this
first
action: the client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB
specimen of
the sputum.
8. The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing
becomes
saturated with blood. The nurse's first action should be to
A) wrap the leg with elastic bandages
B) apply pressure at the bleeding site
C) reinforce the dressing and elevate the leg
D) remove the dressings and re-dress the incision
C: The interventions that must be taken are: reinforce the dressing, elevate the extremity to decrease blood flow into
the
extremity and thus decrease bleeding, and call the provider immediately. This is an emergency post surgical situation.
12. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes
off on the
ventilator. What is the first action the nurse should perform?
A) Disconnect the client from the ventilator and use a manual resuscitation bag
B) Perform a quick assessment of the client's condition
C) Call the respiratory therapist for help
D) Press the alarm re-set button on the ventilator
B: A number of situations can cause the high pressure alarm to sound. It can be as simple as the client coughing. A
quick
assessment of the client will alert the nurse to whether it is a more serious or complex situation that might then
require using a
manual resuscitation bag and calling the respiratory therapist.
13. A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not
been able to
void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to
help him void?
A) Have him drink several glasses of water
B) Perform Cred's method on the bladder from the bottom to the top
C) Assist him to stand by the side of the bed to void
D) Wait 2 hours and have him try to void again
C: When a male is not able to use a urinal unassisted, the client should stand by the side of the bed to void. This is the
most
desirable position for normal voiding for male clients. Also, given his age, he most likely has some degree of prostate
enlargement which may interfere with voiding.
16. A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the
best
explanation for the nurse to provide this client?
A) "The tube will drain fluid from your chest."
B) "The tube will remove excess air from your chest."
C) "The tube controls the amount of air that enters your chest."
D) "The tube will seal the hole in your lung."

B: The purpose of the chest tube is to create negative pressure and remove the air that has accumulated in the pleural
space.
18. A client has a chest tube inserted following a left lower lobectomy required by a stab wound to the chest. While
repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain.
What
is the most appropriate nursing action?
A) Clamp the chest tube
B) Call the surgeon immediately
C) Prepare for blood transfusion
D) Continue to monitor the rate of drainage
D: It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes
position. The
dark color of the blood indicates it is not fresh bleeding inside the chest.
20. The nurse is performing a physical assessment on a client who just had an endotracheal tube (ET) inserted. Which
finding
would call for immediate action by the nurse?
A) Breath sounds can be heard bilaterally
B) Mist is visible in the T-Piece
C) Pulse oximetry of 88 BPM
D) Client is unable to speak
C: Pulse oximetry of 88 BPM. Pulse oximetry should not be lower than 90. Placement of the ET will need to be checked,
along
with the ventilator settings.
Physiological Adaptation 21/40
3. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate
indicator of
fluid balance during the weekly visits is
A) difference in the intake and output
B) changes in the mucous membranes
C) skin turgor
D) weekly weight
D: weekly weight. The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A onekilogram or
2.2 pounds of weight gain is equal to approximately 1,000 ml of retained fluid. Other options are considered as part of
data
collection, but they are not the most accurate indicators of fluid balance.
4. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in
response to
the call. After checking the clients pulse and respirations, what should be the function of the second nurse?
A) Relieve the nurse performing CPR
B) Go get the code cart
C) Participate with the compressions or breathing
D) Validate the client's advanced directive
C: Participate with the compressions or breathing. Once CPR is started, it is to be continued using the approved
technique until
such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies
have shown
that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse to
leave the
room for equipment. The clients advanced directives should have been filed on admission and his choices known prior
to the
initiation of CPR.
5. Which these findings would the nurse more closely associate with anemia in a 10 month-old infant?
A) hemoglobin level of 12 g/dL
B) pale mucosa of the eyelids and lips
C) hypoactivity
D) a heart rate between 80 and 130
B: pale mucosa of the eyelids and lips. In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing
infant with
mild to severe tachycardia.
7. Which of these statements from clients who call the community health clinic would suggest the need for a same-day
appointment to be seen by the health care provider?

A) "I started my period and now my urine has turned bright red"
B) "I am an diabetic and today I have been going to the bathroom every hour"
C) "I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the
bathroom"
D) "I went to the bathroom and my urine looked very red and it didnt hurt when I went"
D: With this description of symptoms this client needs to be seen that day since painless gross hematuria is closely
associated
with bladder cancer. The other complaints can be handled over the phone.
8. A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis.
Which
statements by the client would be most indicative of the etiology of this crisis?
A) "I knew this would happen. I've been eating too much red meat lately."
B) "I really enjoyed my fishing trip yesterday. I caught two fish."
C) "I have really been working hard practicing with the debate team at school."
D) "I went to get a cold checked out last week, and I have gotten worse."
D: "I went to get a cold checked out last week, and I have gotten worse." Any condition that increases the body''s need
for
oxygen or alters the transport of oxygen, such as infection, trauma or dehydration may result in a sickle cell crisis.
11. A client is admitted with a tentative diagnosis of congestive heart failure. Which of the following assessments
would the
nurse expect to be consistent with this problem?
A) Chest pain
B) Pallor
C) Inspiratory crackles
D) Heart murmur
C: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of
inefficient
cardiac pumping.
13. A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurses initial evening
rounds
the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which
one
would alert the nurse to a complication?
A) "I have a sharp pain in my chest when I take a breath."
B) "I have been coughing up foul-tasting, brown, thick sputum."
C) "I have been sweating all day."
D) "I feel hot off and on."
B:Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client is grave danger since
abscesses are often
caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on
inspiration called
pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48
hours of
therapy for infections.
14. Which information is a priority for the nurse to reinforce to an older client after intravenous pyelography?
A) Eat a light diet for the rest of the day
B) Rest for the next 24 hours since the preparation and the test is tiring
C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days
D) Measure the urine output for the next day and immediately notify the health care provider if it should
decrease
D: This information would alert to the complication of acute renal failure which may occur as a complication from the
dye and
the procedure. Renal failure occurs most often in elderly patients who are chronically dehydrated before the dye
injection.
17. The nurse is assessing an 8 month-old child with atonic cerebral palsy. Which statement from the parent supports
the presence of this problem?
A) "When I put my finger in the left hand the baby doesnt respond with a grasp."
B) "My baby doesnt seem to follow when I shake toys in front of its face."
C) "When it thundered loudly last night the baby didnt even jump."
D) "When I put the baby in a back lying position thats how I find it hours later."
D: "When I put the baby in a back lying position thats how I find it hours later." Cerebral palsy is known as a condition
whereby

motor dysfunction occurs secondary to damage in the motor centers of the brain. Inability to roll over by 8 months of
age would
illustrate one delay in the infant''s attainment of developmental milestones
19. A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the clients blood
pressure
is increasing. Which action should the nurse take first?
A) Check the protein level in urine
B) Have the client turn to the left side
C) Take the temperature
D) Monitor the urine output
B: A priority action is to turn the client to the left side to decrease pressure on the vena cava and promote adequate
circulation to
the placenta and kidneys. Urine protein level and output should be checked with each voiding. Temperature should be
monitored
every 4 hours or more often if indicated, but no data in the stem supports a check of temperature.
20. A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to
lie in
every other hour during first 12 hours after admission?
A) Side-lying on the left with the head elevated 10 degrees
B) Side-lying on the left with the head elevated 35 degrees
C) Side-lying on the right with the head elevated 10 degrees
D) Side-lying on the right with the head elevated 35 degrees
A: Side-lying on the left with the head elevated 10 degrees. Gravity will draw the most blood flow to the dependent
portion of
the lung. For unilateral chest disease, it is best to place the healthiest part of the lung in the dependent position to
enhance blood
flow to the area where gas exchange will be best. Ventilation would be minimally affected in the right dependent lung.
This
position also enhances the drainage of the infected part of the lung. A head elevation of 35 degrees is
counterproductive to
therapeutic blood flow and the drainage of secretions.
21. The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first
hour of
care is
A) heart rate
B) pedal pulses
C) lung sounds
D) pupil responses
D: pupil responses. The organ most susceptible to damage in hypertensive crisis is the brain due to rupture of the
cerebral blood
vessels. Neurologic status must be closely monitored.
26. The nurse is caring for a client with uncontrolled hypertension. Which findings require immediate nursing action?
A) lower extremity pitting edema
B) rales
C) jugular vein distension
D) weakness in left arm
D: weakness in left arm. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement
with the
potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with
hypertension.
The remaining 3 choices indicate mild fluid overload and are not medical emergencies.
33. Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal
disease?
A) "I have to go at intervals for epoetin (Procrit) injections at the health department."
B) "I know I have a high risk of clot formation since my blood is thick from too many red cells."
C) "I expect to have periods of little water with voiding and then sometimes to have a lot of water."
D) "My bones will be stronger with this disease since I will have higher calcium than normal."
A: Anemia caused by reduced endogenous erythropoietin production, primarily end-stage renal disease is treated with
subcutaneous injections of Procrit or Epogen to stimulate the bone marrow to produce red blood cells.
34. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's
temperature
is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

A) call the health care provider immediately

B) administer acetaminophen as ordered as this is normal at this time
C) send blood, urine and sputum for culture
D) increase the client's fluid intake
B: Leukocytosis and fever are common starting on day 2 because of the inflammatory process associated with an
acute MI.
Nursing interventions should focus on promoting comfort.
35. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is
to be
induced. At the time of the ROM, the vital signs were T-99.8 degrees Fahrenheit, P-84, R-20, BP-130/78, and fetal heart
tones (FHT) 148 beats/min. Which assessment findings may be an early indication that the client is developing a
complication of labor?
A) FHT 168 beats/min
B) Temperature 100 degrees Fahrenheit
C) Cervical dilation of 4 cm
D) BP 138/88
36. A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most
important to
be reinforced by the nurse?
A) "Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use
another form of contraception."
B) "This procedure doesn't impede the production of male hormones or the production of sperm in the
testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate."
C) "After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't
involve hard physical labor, you can return to your job as soon as you feel to it. The stitches
generally dissolve in 7-10 days."
D) "The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain
medication to relieve any discomfort."
37. A female client talks to the nurse in the providers office about uterine fibroids, also called leiomyomas or myomas.
What
statement by the woman indicates more education is needed?
A) "I am the one out of every 4 women that get fibroids, and of women my age between the 30s or 40s,
fibroids occur more frequently."
B) "My fibroids are noncancerous tumors that grow slowly."
C) "My associated problems I have had are pelvic pressure and pain, urinary incontinence,and constipation."
D) "Fibroids that cause no problems still need to be taken out."
D: Fibroids that cause no findings may require only "watchful waiting" with no treatment. Only when the clients
findings
become disturbing to them would surgical interventions be considered.
38. A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of
the
prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider?
A) light, pink urine
B) occasional suprapubic cramping
C) minimal drainage into the urinary collection bag
D) reports of the feeling of pulling on the urinary catheter
C: Options A, B, and D are expected complaints after this procedure. Option C needs to be reported immediately since
minimal
urinary drainage puts the client at risk for bladder rupture.
Q&A Random 26/40
2. A client is admitted to the hospital with findings of liver failure with ascites. The health care provider orders
spironolactone
(Aldactone). What is the pharmacological effect of this medication?
A) Promotes sodium and chloride excretion
B) Increases aldosterone levels
C) Depletes potassium reserves
D) Combines safely with antihypertensives
A: Promotes sodium and chloride excretion. Spironolactone promotes sodium and chloride excretion while sparing
potassium
and decreasing aldosterone levels. It had no effect on ammonia levels.
4. The nurse has just received report on a group of clients and plans to delegate care of several of the clients to a
practical nurse

(PN). The first thing the RN should do before the delegation of care is
A) Provide a time-frame for the completion of the client care
B) Assure the PN that the RN will be available for assistance
C) Ask about prior experience with similar clients
D) Review the specific procedures unique to the assignment
C: Ask about prior experience with similar clients. The first step in delegation is to determine the qualifications of the
person to
whom one is delegating. By asking about the PN''s prior experience with similar clients/tasks, the RN can determine
whether the
PN has the requisite experience to care for the assigned clients.
6. The nurse is caring for a client who is 4 days post-op for a transverse colostomy. The client is ready for discharge
and asks
the nurse to empty his colostomy pouch. What is the best response by the nurse?
A) "You should be emptying the pouch yourself."
B) "Let me demonstrate to you how to empty the pouch."
C) "What have you learned about emptying your pouch?"
D) "Show me what you have learned about emptying your pouch."
D: Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client
to forget
that they have mastered the skill of emptying the pouch. The client should show the nurse how the pouch is emptied.
7. A post-operative client is admitted to the post-anesthesia recovery room (PACU). The anesthetist reports that
malignant
hyperthermia occurred during surgery. The nurse recognizes that this complication is related to what factor?
A) Allergy to general anesthesia
B) Pre-existing bacterial infection
C) A genetic predisposition
D) Selected surgical procedures
C: A genetic predisposition. Malignant hyperthermia is a rare, potentially fatal adverse reaction to inhaled anesthetics.
There is a
genetic predisposition to this disorder.
13. A 12 year-old child is admitted with a broken arm and is told surgery is required. The nurse finds him crying and
unwilling
to talk. What is the most appropriate response by the nurse?
A) Give him privacy
B) Tell him he will get through the surgery with no problem
C) Try to distract him
D) Make arrangements for his friends to visit
A: Give him privacy. A 12 year-old child needs the opportunity to express his emotions privately.
17. A 3 year-old child has tympanostomy tubes in place. The child's parent asks the nurse if he can swim in the family
pool. The
best response from the nurse is
A) "Your child should not swim at all while the tubes are in place."
B) "Your child may swim in your own pool but not in a lake or ocean."
C) "Your child may swim if he wears ear plugs."
D) "Your child may swim anywhere."
C: "Your child may swim if he wears ear plugs." Water should not enter the ears. Children should use ear plugs when
bathing or
swimming and should not put their heads under the water.
22. A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. What is the
nurse's
best response?
A) "Your doctor will advise you about your risks."
B) "Unless you had previous problems, every 2 years is best."
C) "Once a woman reaches 50, she should have a mammogram yearly."
D) "Yearly mammograms are advised for all women over 35."
C: "Once a woman reaches 50, she should have a mammogram yearly." The American Cancer Society recommends a
screening
mammogram by age 40, every 1 - 2 years for women 40-49, and every year from age 50. If there are family or
personal health
risks, other assessments may be recommended.
23. In discharge teaching, the nurse should emphasize that which of these is a common side effect of clozapine
(Clozaril)

therapy?
A) Dry mouth
B) Rhinitis
C) Dry skin
D) Extreme salivation
D: Extreme salivation. A significant number of clients receiving Clozapine (Clozaril) therapy experience extreme
salivation.
25. The mother of a 4 month-old infant asks the nurse about the dangers of sunburn while they are on vacation at the
beach.
Which of the following is the best advice about sun protection for this child?
A) "Use a sunscreen with a minimum sun protective factor of 15."
B) "Applications of sunscreen should be repeated every few hours."
C) "An infant should be protected by the maximum strength sunscreen."
D) "Sunscreens are not recommended in children younger than 6 months."
D: Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant
can be
sunburned while near water. A hat and light protective clothing should be worn.
27. The nurse administers cimetidine (Tagamet) to a 79 year-old male with a gastric ulcer. Which parameter may be
affected by
this drug, and should be closely monitored by the nurse?
A) Blood pressure
B) Liver function
C) Mental status
D) Hemoglobin
C: Mental status. The elderly are at risk for developing confusion when taking cimetidine, a drug that interacts with
many other
medications.
28. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the
child for an
emergency appendectomy, what must the nurse expect to be the child's greatest fear?
A) Change in body image
B) An unfamiliar environment
C) Perceived loss of control
D) Guilt over being hospitalized
C: Perceived loss of control. For school age children, major fears are loss of control and separation from friends/peers.
30. A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate
statement at
this time for the nurse to say is
A) "Here, I will pour a little of the juice in a medicine cup to drink it to show you that it is OK."
B) "The food has been prepared in our kitchen and is not poisoned."
C) "Let's see if your partner could bring food from home."
D) "If you don't eat, I will have to suggest for you to be tube fed."
C: Reassurance is ineffective when a client is actively delusional. This option avoids both arguing with the client and
agreeing
with the delusional premise.
37. The nurse is caring for a 10 year-old child who has just been diagnosed with diabetes insipidus. The parents ask
about the
treatment prescribed, vasopressin. A What is priority in teaching the child and family about this drug?
A) The child should carry a nasal spray for emergency use
B) The family must observe the child for dehydration
C) Parents should administer the daily intramuscular injections
D) The client needs to take daily injections in the short-term
38. The nurse is caring for a client with asthma who has developed gastroesophageal reflux disease (GERD). Which of
the
following medications prescribed for the client may aggravate GERD?
A) Anticholinergics
B) Corticosteroids
C) Histamine blocker
D) Antibiotics
A: Anticholinergics. An anticholinergic medication will decrease gastric emptying and the pressure on the lower
esophageal
sphincter.

Q&A Random #2 31/40

2. The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to
perform
the monthly exam. What is the best reply by the nurse?
A) "The first of every month, because it is easiest to remember"
B) "Right after the period, when your breasts are less tender"
C) "Do the exam at the same time every month"
D) "Ovulation, or mid-cycle is the best time to detect changes"
B: The best time for a breast self exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen
and
tender due to hormone elevation.
11. Initial postoperative nursing care for an infant who has had a pyloromyotomy would initially include
A) bland diet appropriate for age
B) intravenous fluids for 3-4 days
C) NPO then glucose and electrolyte solutions
D) formula or breast milk as tolerated
C: NPO then glucose and electrolyte solutions. Post-operatively, the initial feedings are clear liquids in small quantities
to
provide calories and electrolytes.
16. A woman in labor calls the nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on
the bed
linens. The nurse knows that fetal monitoring must now assess for what complication?
A) Early decelerations
B) Late accelerations
C) Variable decelerations
D) Periodic accelerations
C: Variable decelerations. When the membranes rupture, there is increased risk initially of cord prolapse. Fetal heart
rate
patterns may show variable decelerations, which require immediate nursing action to promote gas exchange.
26. In response to a call for assistance by a client in labor, the nurse notes that a loop on the umbilical cord protrudes
from the
vagina. What is the priority nursing action?
A) call the health care provider
B) check fetal heart beat
C) put the client in knee-chest position
D) turn the client to the side
27. When teaching a client about an oral hypoglycemic medication, the nurse should place primary emphasis on
A) recognizing findings of toxicity
B) taking the medication at specified times
C) increasing the dosage based on blood glucose
D) distinguishing hypoglycemia from hyperglycemia
B: taking the medication at specified times. A regular interval between doses should be maintained since oral
hypoglycemics
stimulate the islets of Langerhans to produce insulin.
31. The client asks the nurse how the health care provider could tell she was pregnant just by looking inside. What is
the best
explanation by the nurse?
A) Bluish coloration of the cervix and vaginal walls
B) Pronounced softening of the cervix
C) Clot of very thick mucous that obstructs the cervical canal
D) Slight rotation of the uterus to the right
A: Bluish coloration of the cervix and vaginal walls. Chadwick''s sign is a bluish-purple coloration of the cervix and
vaginal
walls, occurring at 4 weeks of pregnancy, that is caused by vasocongestion.
36. Which clinical finding would the nurse expect to assess first in a newborn with spastic cerebral palsy?
A) cognitive impairment
B) hypotonic muscular activity
C) seizures
D) criss-crossing leg movement
D: criss-crossing leg movement. Cerebral palsy is a neuromuscular impairment resulting in muscular and reflexive
hypertonicity

and the criss-crossing, or scissoring leg movements.

38. A client telephones the clinic to ask about a home pregnancy test she used this morning. The nurse understands
that the
presence of which hormone strongly suggests a woman is pregnant?
A) Estrogen
B) HCG
C) Alpha-fetoprotein
D) Progesterone
B: HCG. Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is
about
98%, but the test does not conclusively confirm pregnancy.
39. As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially
to obtain
data regarding which of the following?
A) What and how much the client drinks, according to family and friends
B) The blood alcohol level of the client
C) The blood pressure level of the client
D) The blood glucose level of the client
B: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed
determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption
are
notoriously inaccurate.
A&Q #3 27/40
5. Which of the following drugs should the nurse anticipate administering to a client before they are to receive
electroconvulsive therapy?
A) Benzodiazepines
B) Chlorpromazine (Thorazine)
C) Succinylcholine (Anectine)
D) Thiopental sodium (Pentothal Sodium)
C: Succinylcholine (Anectine). Succinylcholine is given intravenously to promote skeletal muscle relaxation.
9. A client with a panic disorder has a new prescription for Xanax (alprazolam). In teaching the client about the drug's
actions
and side effects, which of the following should the nurse emphasize?
A) Short-term relief can be expected
B) The medication acts as a stimulant
C) Dosage will be increased as tolerated
81
D) Initial side effects often continue
A: Short-term relief can be expected. Xanax is a short-acting benzodiazepine useful in controlling panic symptoms
quickly.
10. While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the
radial pulse
can be accurately assessed at about what age?
A) 1 year of age
B) 2 years of age
C) 3 years of age
D) 4 years of age
B: 2 years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate.
11. As a part of a 9 pound full-term newborn's assessment, the nurse performs a dextro-stick at 1 hour post birth. The
serum
glucose reading is 45 mg/dl. What action by the nurse is appropriate at this time?
A) Give oral glucose water
B) Notify the pediatrician
C) Repeat the test in 2 hours
D) Check the pulse oximetry reading
C: Repeat the test in 2 hours. This blood sugar is within the normal range for a full-term newborn. premature 20-60,
neonate 30-60, infant 40-90
13. During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results
indicate a
level of 11%. Based on this result, what teaching should the nurse emphasize?
A) Rotation of injection sties

B) Insulin mixing and preparation

C) Daily blood sugar monitoring
D) Regular high protein diet
C: Daily blood sugar monitoring. Normal hemoglobin A1C (glycosylated hemoglobin) level is 7 to 9%. Elevation
indicates
elevated glucose levels over time.
17. A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client
should be
instructed to immediately report which of these?
A) Double vision and visual halos
B) Extremity tingling and numbness
C) Confusion and lightheadedness
D) Sensitivity of sunlight
B: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be
reported to the
provider. It can be reversed.
19. The clinic nurse is counseling a substance-abusing post partum client on the risks of continued cocaine use. In
order to
provide continuity of care, which nursing diagnosis is a priority?
A) Social isolation
B) Ineffective coping
C) Altered parenting
D) Sexual dysfunction
C: Altered parenting. The cocaine abusing mother puts her newborn and other children at risk for neglect and abuse.
Continuing
to use drugs has the potential to impact parenting behaviors. Social service referrals are indicated.
20. An 18 month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the
nurse
obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella
(MMR)
immunization. The nurse understands that which of the following is true in regards to giving immunizations to this
child?
A) Live vaccines are withheld in children with renal chronic illness
B) The MMR vaccine should be given now, prior to the transplant
C) An inactivated form of the vaccine can be given at any time
D) The risk of vaccine side effects precludes giving the vaccine
B: MMR is a live virus vaccine, and should be given at this time. Post-transplant, immunosuppressive drugs will be
given and the
administration of the live vaccine at that time would be contraindicated because of the compromised immune system.
27. Which of these questions is priority when assessing a client with hypertension?
A) "What over-the-counter medications do you take?"
B) "Describe your usual exercise and activity patterns."
C) "Tell me about your usual diet."
D) "Describe your family's cardiovascular history."
A: "What over-the-counter medications do you take?" Over-the-counter medications, especially those that contain cold
preparations can increase the blood pressure to the point of hypertension.
28. The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is
A) touching the trapezius muscle or arm firmly
B) pinching any body part
C) shaking a limb vigorously
D) rubbing the sternum
30. A client has gastroesophageal reflux. Which recommendation made by the nurse would be most helpful to the
client?
A) Avoid liquids unless a thickening agent is used
B) Sit upright for at least 1 hour after eating
C) Maintain a diet of soft foods and cooked vegetables
D) Avoid eating 2 hours before going to sleep
D: Avoid eating 2 hours before going to sleep. Eating before sleeping enhances the regurgitation of stomach contents,
which
have increased acidity, into the esophagus. An upright posture should be maintained for about 2 hours after eating to
allow for the
stomach emptying. Options A and C are interventions for clients with swallowing difficulties.

36. Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the
provider
examine first?
A) An elderly client who stated, "My awful pain in my right side suddenly stopped about 3 hours ago."
B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
C) A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week
D) A teenager with a history of falling off a bicycle without hitting the handle bars
A: An elderly client who stated, "My awful pain in my right side suddenly stopped about 3 hours ago."
This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured, based on
the
history of the pain suddenly stopping over three hours ago.
38. The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To
minimize the
side effects, the nurse should emphasize which of the following actions?
A) Reporting joint stiffness in the morning
B) Taking the medication 1 hour before or 2 hours after meals
C) Using alcohol in moderation unless driving
D) Continuing to take aspirin for short term relief
B: Taking the medication 1 hour before or 2 hours after meals. Taking the medication 1 hour before or 2 hours after
meals will
result in a more rapid effect.
Q&A Random #4 27/40
2. A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the
process
of taking client history, which of these items should the nurse identify as related to the clients greatest risk factors for
osteoporosis?
A) History of menopause at age 50
B) Taking high doses of steroids for arthritis for many years
C) Maintaining an inactive lifestyle for the past 10 years
D) Drinking 2 glasses of red wine each day for the past 30 years
B: Taking high doses of steroids for arthritis for many years. The use of steroids, especially at high doses over time,
increases the
risk for osteoporosis. The other options also predispose to osteoporosis, as do low bone mass, poor calcium absorption
and
moderate to high alcohol ingestion. Long-term steroid treatment is the most significant risk factor, however.
9. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which
response by the nurse is correct?
A) Days 7-10
B) Days 10-13
C) Days 14-16
D) Days 17-19
87
D: Days 17-19. Ovulation occurs 14 days prior to menses. Considering that the woman''s cycle is 32 days, subtracting
14 from
32 suggests ovulation is at about the 18th day.
10. The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?
A) Periorbital edema
B) Dizzy spells
C) Lethargy
D) Shortness of breath
B: Dizzy spells. Cardiac dysrhythmias may cause a transient drop in cardiac output and decreased blood flow to the
brain. Near
syncope refers to lightheartedness, dizziness, temporary confusion. Such "spells" may indicate runs of ventricular
tachycardia or
periods of asystole and should be reported immediately.
15. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help
the woman
alleviate these symptoms?
A) Drink small amounts of liquids frequently
B) Eat the evening meal just before retiring
C) Take sodium bicarbonate after each meal
D) Sleep with head propped on several pillows

D: Sleep with head propped on several pillows. Heartburn is a burning sensation caused by regurgitation of gastric
contents. It is
best relieved by sleeping position, eating small meals, and not eating before bedtime.
16. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he
was
admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider
ordering
A) pulmonary embolectomy
B) vena caval interruption
88
C) increasing the Coumadin therapy to an INR of 3-4
D) thrombolytic therapy
B: vena caval interruption. Clients with contraindications to Heparin, recurrent PE or those with complications related
to the
medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava.
19. What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention?
A) Set good examples themselves
B) Protect their child from outside influences
C) Make sure their child understands all the safety rules
D) Discuss the consequences of not wearing protective devices
A: Set good examples themselves. The preschool years are the time for parents to begin emphasizing safety principles
as well as
providing protection.
22. The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When coming to a
conclusion
using the Ballard scale, which of these factors may affect the score?
A) Birth weight
B) Racial differences
C) Fetal distress in labor
D) Birth trauma
C: Fetal distress in labor. The effects of earlier distress may alter the findings of reflex responses as measured on the
Ballard
tool.
26. A 78 year-old client with pneumonia has a productive cough, but is confused. Safety protective devices (restraints)
have
been ordered for this client. How can the nurse prevent aspiration?
A) Suction the client frequently while restrained
B) Secure all 4 restraints to 1 side of bed
C) Obtain a sitter for the client while restrained
D) Request an order for a cough suppressant
C: The plan to use safety devices (restraints) should be rethought. Restraints are used to protect the client from harm
caused by
removing tubes or getting out of bed. In the event that this restricted movement could cause more harm, such as
aspiration, then a
sitter should be requested.
29. The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of
rebleeding, the
nurse should plan to
A) restrict visitors to immediate family
B) avoid arousal of the client except for family visits
C) keep client's hips flexed at no less than 90 degrees
D) apply a warming blanket for temperatures of 98 degrees Fahrenheit or less
A: restrict visitors to immediate family. Maintaining a quiet environment will assist in minimizing cerebral rebleeding.
31. When suctioning a client's tracheostomy, the nurse should instill saline in order to
A) decrease the client's discomfort
B) reduce viscosity of secretions
C) prevent client aspiration
D) remove a mucus plug
D: remove a mucus plug. While no longer recommended for routine suctioning, saline may thin and loosen viscous
secretions
that are very difficult to move, perhaps making them easier to suction.

36. A nurse is performing the routine daily cleaning of a tracheostomy. During the procedure, the client coughs and
displaces
the tracheostomy tube. This negative outcome could have avoided by
A) placing an obturator at the clients bedside
B) having another nurse assist with the procedure
91
C) fastening clean tracheostomy ties before removing old ties
D) placing the client in a flat, supine position
C: fastening clean tracheostomy ties before removing old ties. Fastening clean tracheostomy ties before removing old
ones will
ensure that the tracheostomy is secured during the entire cleaning procedure. The obturator is useful to keep the
airway open only
after the tracheostomy outer tube is coughed out. A second nurse is not needed. Changing the position may not
prevent a
dislodged tracheostomy.
38. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what
pathophysiological process?
A) Disruption of fetal glucose supply
B) Pancreatic insufficiency
C) Maternal insulin dependency
D) Reduced glycogen reserves
A: After delivery, the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn
continues to
secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a
day or
two.
39. A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial
temperature is
95 degrees Fahrenheit (35 degrees Celsius) axillary. The nurse recognizes that cold stress may lead to what
complication?
A) Lowered BMR
B) Reduced PaO2
C) Lethargy
D) Metabolic alkalosis
B: Reduced PaO2. Cold stress causes increased risk for respiratory distress. The baby delivered in such circumstances
needs
careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least
97 degrees
Fahrenheit (36 degrees Celsius).
Q&A 5 27/40
5. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has
decreased from
145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic
dizzy
spells. The nurse instructs the client to
A) increase fluids that are high in protein
B) restrict fluids
C) force fluids and reassess blood pressure
D) limit fluids to non-caffeine beverages
C: Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of
more than
15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms,
and autonomic
insufficiency.
8. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to
pay
more attention to the function of which area of the body?
A) the muscles
B) the cerebellum
C) the kidneys
D) the leg bones
93
A: the muscles. Rhabdomyosarcoma is the most common children''s soft tissue sarcoma. It originates in striated
(skeletal)

muscles and can be found anywhere in the body. The clue is in the middle of the word -- myo --which typically means
muscle.
16. Which of the following should the nurse implement to prepare a client for a kidney, ureter, bladder (KUB)
radiograph test?
A) Client must be NPO before the examination
B) Enema to be administered prior to the examination
C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
D) No special orders are necessary for this examination
D: No special orders are necessary for this examination. No special preparation is necessary for this examination.
22. Which individual is at greatest risk for developing hypertension?
A) 45 year-old African American attorney
B) 60 year-old Asian American shop owner
C) 40 year-old Caucasian nurse
D) 55 year-old Hispanic teacher
A: 45 year-old African American attorney. The incidence of hypertension is greater among African Americans than other
groups
in the US. The incidence among the Hispanic population is rising.
23. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse
put first on
the discharge list in order to make room for a new admission?
A) A middle aged client with a 7 year history of being ventilator dependent and who was admitted with bacterial
pneumonia five days ago
B) A young adult with Type 2 diabetes mellitus for over 10 years and who was admitted with antibiotic-induced
diarrhea 24 hours ago
C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and who was admitted with
Stevens-Johnson syndrome that morning
D) An adolescent with a positive HIV test and who was admitted for acute cellulitis of the lower leg 48 hours ago
A: The best candidate for discharge is one who has a chronic condition and has an established plan of care. The client
in option
A is most likely stable and could continue medication therapy at home.
25. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor
and
receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse
that the infusions should be discontinued?
A) Narrowed QRS complex
B) Shortened "PR" interval
C) Tall peaked T waves
D) Prominent "U" waves
C: A tall peaked T wave is a sign of hyperkalemia. The provider should be notified regarding discontinuing the
medication.
27. A nurse is evaluating the quality of home care for a client with Alzheimer's disease. It would be a priority to
reinforce
which statement by a family member?
A) "At least 2 full meals a day should be eaten."
B) "We go to a group discussion every week at our community center."
C) "We have safety bars installed in the bathroom and have 24 hour alarms on the doors."
D) "Taking the medication 3 times a day is not a problem."
C: Ensuring safety of the client with increasing memory loss is a priority of home care. Note all options are positive
statements,
however safety is most important to reinforce.
28. A child who has recently been diagnosed with cystic fibrosis (CF) is being assessed by a pediatric clinic nurse.
Which
finding of this disease would the nurse not expect to see at this time?
A) Positive sweat test
B) Bulky greasy stools
C) Moist, productive cough
D) Meconium ileus
C: Moist, productive cough. Option C is a later sign. Noisy respirations and a dry non-productive cough are commonly
the first
of the respiratory signs to appear in a newly diagnosed client with CF. The other options are the earliest findings. CF is
an

inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these
secretions
are thin and slippery, but in CF a defective gene causes the secretions to become thick and sticky. Instead of acting as
a lubricant,
the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the
most
dangerous consequence of CF.
32. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency
department.
Which of these orders should the registered nurse implement first?
A) Gastric lavage PRN
B) Antidote N-acetylcysteine (NAC) (Mucomyst) for age per pharmacy
C) Start a Dextrose 5% with 0.33% normal saline IV to keep vein open
D) Activated charcoal per pharmacy
A: Gastric lavage PRN. Removing as much of the drug as possible is the first step in treatment for this drug overdose.
This is
best done by gastric lavage. The next actions to complete would be to administer activated charcoal, then Mucomyst
and lastly
the IV fluids.
33. Which of these findings indicate that a pump set to deliver a basal rate of 10 ml per hour plus PRN morphine drip
for
breakthrough pain is not working?
A) The client complains of discomfort at the IV insertion site
B) The client states "I just can't get relief from my pain"
C) The level of the drug is 100 ml at 8 AM and is 80 ml at noon
D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon
C: The minimal dose is 10 ml per hour, which would mean 40 mls are given in a 4 hour period. Only 60 mls should be
left at
noon. The pump is not functioning when more than expected medicine is left in the container.
37. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
A) Excessive fetal weight
B) Low blood sugar levels
C) Depletion of subcutaneous fat
D) Progressive placental insufficiency
D: The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects
may be
related to hypoxia.
38. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states My blood
pressure is
usually much lower. The nurse should tell the client to
A) go get a blood pressure check within the next 48 to 72 hours
B) check blood pressure again in 2 months
C) see the health care provider immediately
D) visit the health care provider within 1 week for a BP check
A: The blood pressure reading is moderately high with the need to have it rechecked in a few days. Although the client
states it is
usually much lower, a concern exists for complications such as stroke. An immediate check by the provider of care is
not
warranted. Waiting 2 months or a week for follow-up is too long.
39. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must
wait 6
weeks before having sexual intercourse. What is the best response by the nurse to this question?
A) "You need to regain your strength before attempting such exertion.
B) "When you can climb 2 flights of stairs without problems, it is generally safe."
C) "Have a glass of wine to relax you, then you can try to have sex."
D) "If you can maintain an active walking program, you will have less risk."
B: There is a risk of cardiac rupture at the point of the myocardial infarction for about 6 weeks. Scar tissue should form
about
that time. Waiting until the client can tolerate climbing stairs is the usual advice given by health care providers.
Q &A Random Selection #6 27/40
1. Which of these women in the labor and delivery unit would the nurse check first when the water breaks (ROM) for all
of

them within a 2 minute period?

98
A) A multigravida with station at +2, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 7
cm, and 50% effacement
B) A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix dilated at 3
cm, and 10% effacement
C) A primipara with station at 0, contractions at 20 minutes apart with duration of 20 seconds, cervix dilated at 2 cm
and 10% effacement
D) A primipara with station at 1, contractions at 15 minutes apart with duration of 35 seconds, cervix dilated at 5 cm
and 50% effacement
B: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix
dilated at 3 cm, and 10% effacement. When the station is -1 or -2 and the water breaks, the risk is greater for a
prolapsed cord.
4. Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as
the best
initial approach?
A) Consider a liquid supplement to increase calories
B) Discuss consequences of an unbalanced diet with the child
C) Provide fruit, vegetable and protein snacks
D) Encourage the child to keep a daily log of foods eaten
B: Discuss consequences of an unbalanced diet with the child. It is important to educate the preadolescent as to
appropriate diet,
and the problems that might arise if diet is not adequate.
8. The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is
essential for
determining the presence of active TB?
99
A) Tuberculin skin testing
B) Sputum culture
C) White blood cell count
D) Chest x-ray
B: Sputum culture. The sputum culture is the most accurate method for determining the presence of active TB.
11. The nurse has been teaching an apprehensive primipara who has had initial difficulty in nursing the newborn. What
observation at the time of discharge suggests that initial breast feeding is effective?
A) The mother feels calmer and talks to the baby while nursing
B) The mother awakens the newborn to feed whenever it falls asleep
C) The newborn falls asleep after 3 minutes at the breast
D) The newborn refuses the supplemental bottle of glucose water
A: The mother feels calmer and talks to the baby while nursing. Early evaluation of successful breastfeeding can be
measured by
the client''s voiced confidence and satisfaction with the infant.
16. The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which
factor?
A) The increased homeless population in major cities
B) The rise in reported cases of positive HIV infections
C) The migration patterns of people from foreign countries
D) The aging of the population located in group homes
B: The rise in reported cases of positive HIV infections. Between 1985 and 2002 there has been a significant increase
in the
reported cases of TB. The increase was most evident in cities with a high incidence of positive HIV infection. Positive
HIV
infection currently is the greatest known risk factor for reactivating latent TB infections.
17. The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should
A) irrigate it as ordered with distilled water
B) irrigate it as ordered with normal saline
C) place the end of the tube in water to see if the water bubbles
D) withdraw the tube several inches and reposition it
B: irrigate it as ordered with normal saline. Nasogastric tubes are only irrigated with normal saline to maintain patency.
24. When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by
A) Reduced oxygen capacity of cells due to lack of iron
B) An imbalance between red cell destruction and production
C) Depression of red and white cells and platelets

D) Inability of sickle shaped cells to regenerate

B: An imbalance between red cell destruction and production. Anemia results when the rate of red cell destruction
exceeds the
rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from 120 days to 1220 days).
29. The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the
oral
mucous membranes. The nurse should then assess which area of the body?
A) the skin
B) the lungs
C) the muscles
D) bowel and bladder
A: the skin. A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are found
on the
buccal mucosa about 2 days before and after the onset of the measles rash.
30. A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data
would the
nurse expect to find when assessing this client?
A) Moist mucous membranes
B) Urinary frequency
C) Poor skin turgor
D) Increased blood pressure
C: The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with this
problem.
33. The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most
likely to
find?
A) Complaints of numbness and tingling in feet
B) Wheezing noted when lung sound auscultated
C) Excessive perspiration
D) Difficulty sleeping
A: Complaints of numbness and tingling in feet. A child who has unusual neurologic signs or symptoms, neuropathy,
footdrop,
or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs
when a child
ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.
37. Which action is most likely to ensure the safety of the nurse while making a home visit?
A) Observe no evidence of weapons in the home during the visit
B) Prior to the visit, review the client's record for any previous entries about violence
C) Remain alert at all times and leave if cues suggest the home is not safe
D) Carry a cell phone, pager and/or hand held alarm for emergencies
C: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee
nurses'' safety,
although the risk of violence can be minimized.
38. As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is
now going
to Hawaii for a vacation. The nurse would warn him to avoid
A) surfing
B) scuba diving
C) parasailing
D) swimming
B: scuba diving. The nurse would strongly emphasize the need for clients with history of spontaneous pneumothorax
problems to
avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative pressures could cause the lung to
collapse
again.
40. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn findings
suggests to
the nurse that the infant has fetal alcohol syndrome?
A) Growth retardation is evident
B) Multiple anomalies are identified
C) Cranial facial abnormalities are noted

D) Prune belly syndrome is suspected

C: Cranial facial abnormalities are noted. Characteristic facial abnormalities are seen in the newborn with fetal alcohol
syndrome.
Q&A 7 21/40
1. A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate
response by
the nurse manager should include
A) The escalation of fees with a decreased reimbursement percentage
B) High costs of diagnostic and end-of-life treatment procedures
C) Increased numbers of elderly and of the chronically ill of all ages
D) A steep rise in provider fees and in insurance premiums
A: The escalation of fees with a decreased reimbursement percentage. The percentage of the gross national product
representing
health care costs rose dramatically with reimbursement based on fee for service. Reimbursement for Medicare and
Medicaid
recipients based on fee for service also escalates health care costs.
2. The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion.
The nurse
manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and
report on
this at the next staff meeting." The nurse manager's leadership style is best described as
A) Laissez-faire
B) Autocratic
C) Participative
D) Group
C: Participative. A participative style of management involves staff in decision-making processes. Staff/manager
interactions are
open and trusting. Most work efforts are joint endeavors.
5. The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan
of
care?
A) Risk for injury
B) Self care deficit
C) Alteration in comfort
D) Alteration in mobility
C: Alteration in comfort. Relieving pain is the number one objective of this client's plan of care.
7. A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of
the
drug?
A) Tranquilization, numbing of emotions
B) Sedation, analgesia
C) Relief of insomnia and phobias
D) Diminished tachycardia and tremors associated with anxiety
A: Tranquilization, numbing of emotions. The anti-anxiety drugs produce tranquilizing effects and may numb the
emotions.
8. A woman who delivered 5 days ago and had been diagnosed with pregnancy induced hypertension (PIH) calls the
hospital
triage nurse hotline to ask for advice. She states, I have had the worst headache for the past 2 days. It pounds and by
the
middle of the afternoon everything I look at looks wavy. Nothing I have taken helps. What should the nurse do next?
A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her
provider within the next day.
B) Advise the client to have someone bring her to the emergency room as soon as possible.
C) Ask the client to stay on the line, get the address and send an ambulance to the home.
D) Ask what the client has taken? How often? Ask about other specific complaints.
C: Ask the client to stay on the line, get the address and send an ambulance to the home. The woman is at risk for
seizure
activity. The ambulance needs to bring the woman to the hospital. For at risk clients, PIH (preeclampsia and eclampsia)
may
occur prior to, during or after delivery. After delivery, the window of time can be up to ten days.
9. A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take AlkaSeltzer for

an upset stomach. What is the best response by the nurse?

A) Avoid Alka-Seltzer because it contains aspirin
B) Take Alka-Seltzer at a different time of day than the warfarin
C) Select another antacid that does not inactivate warfarin
D) Use on-half the recommended dose of Alka-Seltzer
A: Avoid Alka-Seltzer because it contains aspirin. Alka-Seltzer is an over-the-counter aspirin-antacid combination.
Aspirin, an
antiplatelet drug, will potentiate the anticoagulant effect of warfarin, which may result in excess bleeding.
10. The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered
medications
would most likely contribute to this change?
A) Anticoagulant
B) Liquid antacid
C) Antihistamine
D) Cardiac glycoside
C: Antihistamine. Elderly people are susceptible to the side effect of anticholinergic drugs, such as antihistamines.
Antihistamines often cause confusion in the elderly, especially at high doses.
16. To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the
A) finger and toenail quicks
B) eyes
C) perianal area
D) external ear canals
B: eyes. Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing
ointment
to the exposed cornea and a plastic bubble shield or eye patch.
21. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the
grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?
A) Death is personified as the bogeyman or devil
B) Death is perceived as being irreversible
C) The child feels guilty for the grandmother's death
D) The child is worried that he, too, might die
A: Death is personified as the bogeyman or devil. Personification of death is typical of this developmental level.
24. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic
immediately
if the following findings are present
A) Temperature of 99.5 degrees Fahrenheit with painful urination
B) An open, reddened wound on the heel
C) Insomnia and daytime fatigue
D) Nausea with 2 episodes of vomiting
B: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who
have
diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved.
Without
treatment, serious infection, gangrene, limb loss, and death may result.
27. A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the
client
A) "Be sure and eat a fat-free diet until the test."
B) "Do not eat or drink anything but water for 12 hours before the blood test."
C) "Have the blood drawn within 2 hours of eating breakfast."
D) "Stay at the laboratory so 2 blood samples can be drawn an hour apart."
B: Blood lipid levels should be measured on a fasting sample.
28. A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death
approaches
and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care
provider?
A) Decrease the analgesic dosage by half
B) Discontinue the analgesic
C) Continue the same analgesic dosage
D) Prescribe a less potent drug
C: Continue the same analgesic dosage. Dying patients who have been in chronic pain will probably continue to
experience pain

even though they cannot communicate their experience. Pain medication should be continued at the same dose, if
effective.
30. A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted
the rash
since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the
following
would the nurse recognize as highest risk for exposure?
A) Playing with toys in a back yard flower garden
B) Eating small amounts of grass while playing "farm"
C) Playing with cars on the pavement near burning leaves
D) Throwing a ball to a neighborhood child who has poison ivy
C: Playing with cars on the pavement near burning leaves. Smoke from burning leaves or stems of the poison ivy plant
can
produce a reaction.
32. The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being
evaluated for
possible myocardial infarction. The first action the nurse would perform is to
A) begin cardiopulmonary resuscitation
B) prepare for immediate defibrillation
C) notify the "Code" team and provider
D) assess airway breathing and circulation
D: assess airway breathing and circulation. The nurse must first assess the client to determine the appropriate next
step. In this
case the first step the nurse must take is to evaluate the A, B, C''s.
34. An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for
tracheoesophageal
fistula. The mother asks: When can the tube can be used for feeding? The nurse's best response would be which of
these
comments?
A) "Feedings can begin in 5 to 7 days."
B) "The feeding tube can be used immediately."
C) "The stomach contents and air must be drained first."
D) "Healing of the incision must be complete before feeding."
C: "The stomach contents and air must be drained first." After surgery for gastrostomy tube placement, the catheter is
left open
and attached to gravity drainage for 24 hours or more.
35. The community health nurse has been caring for an adolescent with a history of morbid obesity, asthma, and
hypertension,
and is 22 weeks pregnant. Which of these lab reports need to be called to the teens provider within the next hour?
A) hemoglobin 11 g/L and calcium 6 mg/dl
B) magnesium 0.8 mEq/L and creatinine 3 mg/dl
C) blood urea nitrogen 28 and glucose 225 mg/dl
D) hematocrit 33% and platelets 200,000
B: magnesium 0.8 mEq/L and creatinine 3 mg/dl. The magnesium is low and the creatinine is high which indicates
renal failure.
With the history of hypertension, the findings exhibit the risk of preeclampsia. The clients lab values are all abnormal
except for
the platelets. The client needs to be referred for immediate follow up with a provider.
36. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in this
clients
plan of care within the initial 24 hours?
A) Wear masks with shields if there is potential for fluid splash
B) Use disposable utensils and plates for meals
C) Wear gown and gloves during client contact
D) Provide soft easily digested food with frequent snacks
C: Wear gown and gloves during client contact. HAV is usually transmitted via the fecal-oral route, i.e., someone with
the virus
handles food without washing his or her hands after using the bathroom.
38. A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider's
diagnosis is
spontaneous pneumothorax. Which procedure should the nurse prepare for first?
A) Cardiopulmonary resuscitation

B) Insertion of a chest tube

C) Oxygen therapy
D) Assisted ventilation
B: Insertion of a chest tube. Because a portion of the lung has collapsed, a chest tube will be inserted to restore
negative pressure
in the chest cavity.
39. A newborn presents with a pronounced cephalhematoma following a birth in the posterior position. Which nursing
diagnosis
should guide the plan of care?
A) Pain related to periosteal injury
B) Impaired mobility related to bleeding
C) Parental anxiety related to knowledge deficit
D) Injury related to intracranial hemorrhage
C: Parental anxiety related to knowledge deficit. This hematoma is related to pressure at the time of labor and birth.
The
condition resolves within a few days. Parental anxiety must be addressed by listening to their fears and explaining the
nature of
this common alteration.
Q&A 8 23/40
1. While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for
hyperbilirubinemia.
Which of the following should be reported immediately?
A) Jaundice evident at 26 hours
B) Hematocrit of 55%
C) Serum bilirubin of 12mg
D) Positive Coombs' test
C: The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum
bilirubin of 12
mg., the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines
the therapy
appropriate after reviewing all laboratory findings.
3. During the beginning shift assessment of a client with asthma who is receiving oxygen per nasal cannula at 2 liters
per
minute, the nurse would be most concerned about which unreported finding?
A) Pulse oximetry reading of 89%
B) Crackles at the base of the lungs on auscultation
C) Rapid shallow respirations with intermittent wheezes
D) Excessive thirst with a dry cracked tongue
C: Of the given findings this has the greatest risk for potential complications. Shallow and rapid respirations may
indicate that the
client is losing muscle strength required to breath. The intermittent wheezes could be an indication of an increase in
narrowed
small airways and a worsening condition.
4. A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the "evil eye." The
nurse
should communicate to other personnel that the appropriate approach is to
A) touch the baby after looking at him
B) talk very slowly while speaking to him
C) avoid touching the child
D) look only at the parents
A: In many cultures, an "evil eye" is cast when looking at a person without touching him. Thus, the spell is broken by
touching
while looking or assessing.
8. A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast.
The
nurse should teach the parents to
A) gently rub the skin with a cotton swab to relieve itching
B) place the favorite books and push-pull toys in the crib
C) check every few hours for the next day or 2 for swelling in the baby's feet
D) turn the baby with the abduction stabilizer bar every 2 hours
C: check every few hours for the next day or 2 for swelling in the baby's feet. A child in a hip spica cast must be
checked for

circulatory impairment. The extremities are observed for swelling, discoloration, movement and sensation. For children
beyond
the neonatal period, traction and/or surgery followed by hip spica casting are usually needed.
10. Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor
glycemic
control?
A) A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up
assessments, which should occur at no longer than 3-month intervals
B) A glycosylated hemoglobin is to be obtained at least twice a year
C) A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment
D) A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-monthintervals
after the initial assessment
A: The American Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial
assessment
and then routinely as part of continuing care.
11. The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate?
A) Non-intention tremors and urgency with voiding
B) Echolalia and a shuffling gait
C) Muscle spasm and a bent over posture
D) Intention tremor and jerky movement of the elbows
B: Echolalia and a shuffling gait. Clients with Parkinson''s disease have a very distinctive gait with quick short steps
(shuffling)
which may increase in speed so that they are unable to stop.
12. During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?
A) Pleuritic pain on inspiration
B) Dry mucus membranes in the mouth
C) A decrease in respiratory rate from 34 to 24
D) Decrease in chest wall expansion
D: Decrease in chest wall expansion. The respiratory status of a client with this acute bacterial pneumonia known as
Legionnaires'' disease is critical.
15. At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She
asks about preconception
diet changes. Which of the statements made by the nurse is best?
A) "Include fibers in your daily diet."
B) "Increase green leafy vegetable intake."
C) "Drink a glass of milk with each meal."
D) "Eat at least 1 serving of fish weekly."
B: "Increase green leafy vegetable intake." Folic acid sources should be included in the diet and are critical in the preconceptual
and early gestational periods to foster neural tube development and prevent birth defects such as spina bifida.
21. A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence
or absence
of an infection, it is most important for all family members to have a
A) chest x-ray
B) blood culture
C) sputum culture
D) PPD intradermal test
D: PPD intradermal test. The administration of the PPD intradermal test determines the presence of the infection with
the
Mycobacterium tuberculosis organism. It is effective at 3 to 6 weeks after the initial infection.
24. A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced
manager
should the new manager implement initially?
A) Set daily goals and establish priorities for each hour and each day.
B) Ask for additional assistance when you feel overwhelmed.
C) Keep a time log of your day in hourly blocks for at least 1 week.
D) Complete each task before beginning another activity in selected instances.
C: Keep a time log of your day in hourly blocks for at least 1 week. Apply the nursing process to time management, so
the
assessment of the current activities is the initial step. A baseline is established for activities and time use so that
needed changes
can be pinpointed.

27. The nurse uses the DRG (Diagnosis Related Group) manual to
A) classify nursing diagnoses from the client's health history
B) identify findings related to a medical diagnosis
C) determine reimbursement for a medical diagnosis
D) implement nursing care based on case management protocol
C: determine reimbursement for a medical diagnosis. DRG''s are the basis of prospective payment plans for
reimbursement for
Medicare clients.
28. The nurse would teach a client with Raynaud's phenomenon that, after smoking cessation, it is most important to
A) avoid caffeine
B) keep feet dry
C) reduce stress
D) wear gloves
A: avoid caffeine.
30. A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28
and a
potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which
finding is most indicative of digoxin toxicity?
A) Bradycardia
B) Lethargy
C) Irritability
D) Vomiting
A: Bradycardia. The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an
infant).
31. The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist
staff in
this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach the
nurse
manager should:
A) discuss with the staff how to deal with any defensive behavior
B) explain to the unit staff why change is necessary
C) assist the staff during the acceptance of the new changes
D) clarify what the changes mean to the community and hospital
B: explain to the unit staff why change is necessary. The first phase of change, unfreezing, begins with awareness of
the need for
change. This can be facilitated by the manager who clearly understands the need and stands behind it. The phase is
completed
when staff comprehend the need for change.
32. Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce information about cancers
to a
group of young adults?
A) "You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting
all meat, and avoiding nitrate-containing foods."
B) "Prostate cancer is the most common cancer in American men with results to threaten sexuality and life."
C) "Colorectal cancer is the second-leading cause of cancer-related deaths in the United States."
D) "Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the most preventable of all
cancers."
A: It is recommended that only red meat be limited for the prevention of stomach cancer. All of the other statements
offer correct
information.
33. The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers.
Which of
these comments by the student indicates a need for clarification of information?
A) "The infant will get the hepatitis B vaccine and the hepatitis B immune globulin within 12 hours at birth at separate
injection sites."
B) "The second dose can be given at 1 to 2 months of age."
C) "The third dose should be given at least 16 weeks from the second dose."
D) "The last dose in the series is not to be given before age 24 weeks."
C: "The third dose should be given at least 16 weeks from the second dose." The third dose is to be given 16 weeks
from the first
dose and 8 weeks from the second dose. All of the other options are correct information. These infants will also need to
have the

blood tested for hepatitis titers and antibodies between 9 and 15 months.
36. A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the
nurse would
expect to note
A) high protein
B) clear color
C) elevated sed rate
D) increased glucose
A: high protein. A positive CSF for meningitis would include presence of protein, a positive blood culture, decreased
glucose,
cloudy color with an increased opening pressure, and an elevated white blood cell count.
Q&A 9 27/40
4. At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up,
the
nurse manager should initially
A) Allow the staff to change assignments
B) Clarify reasons for current assignments
C) Help staff see the complexity of issues
D) Facilitate creative thinking on staffing
D: Facilitate creative thinking on staffing. The "moving phase" of change involves viewing the problem from a new
perspective,
and then incorporating new and different approaches to the problem. The manager, as a change agent, can facilitate
staff''s
solving the problem.
5. A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize
the client,
and is aware that gradual emptying is preferred over complete emptying because it reduces the
A) potential for renal collapse
B) potential for shock
C) intensity of bladder spasms
D) chance of bladder atrophy
B: potential for shock. Complete, rapid emptying can cause shock and hypotension due to sudden changes in the
abdominal
cavity.
8. A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following
instructions
would be best for the nurse to tell the caregiver?
A) Increase bladder tone by delaying voiding
B) When laundering clothing, rinse several times
C) Use plain water for the bath, shampooing hair last
D) Have the child use antibacterial soaps while bathing
C: Use plain water for the bath, shampooing hair last. Hair should be shampooed last with a rinsing of plain water over
the
genital area. The oils in soaps and bubble bath can cause irritation, which may lead to UTI''s in young girls.
10. In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the
following
after a water deprivation test?
A) Increased edema and weight gain
B) Unchanged urine specific gravity
C) Rapid protein excretion
D) Decreased blood potassium
B: Unchanged urine specific gravity. When fluids are restricted, the client continues to excrete large amounts of dilute
urine.
This finding supports the diagnosis. Normally, urine is more concentrated with reduced fluid intake.
11. The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled
therapies.
What is the most appropriate action for the nurse to take in this situation?
A) Ask family members to dress the client
B) Encourage the client to dress more quickly
C) Allow the client the time needed to dress
D) Demonstrate methods on how to dress more quickly

C: Allow the client the time needed to dress. Clients with Parkinson''s disease often wish to take care of themselves but
become
very upset when hurried and then are unable to manage at all. Any form of hurrying the client will result in a very
upset and
immobilized client.
12. When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?
A) risk for injury: hemorrhage
B) risk for injury related to peripheral neuropathy
C) altered nutrition: less than body requirements
D) fluid volume excess: ascites
A: risk for injury: hemorrhage. Liver disease interferes with the production of prothrombin and other factors essential
for blood
clotting. Hemorrhage, especially from esophageal varices can be life threatening. This takes priority over the other
nursing
diagnosis.
20. A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this
person
brings what to situations of illness?
A) Holistic healing
B) Spiritual advising
C) Herbal preparations
D) Witchcraft potions
A: Holistic healing. This traditional folk practitioner uses holistic methods for illnesses not related to witchcraft. Many
times, the
curandero works with traditional health care providers to restore health.
21. You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which
statement
indicates further teaching may be needed by the client?
A) "I will be receiving continuous doses of medication."
B) "I should call the nurse before I take additional doses."
C) "I will call for assistance if my pain is not relieved."
D) "The machine will prevent an overdose."
B: Patient controlled analgesia offers the client more control. The client should be instructed to initiate additional doses
as
needed without asking for assistance unless there is insufficient control of the pain.
26. A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse
hears
inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What other finding would the
nurse
expect?
A) Flushed skin
B) Bradycardia
C) Mental confusion
D) Hypotension
C: Mental confusion. Crackles suggest pneumonia, which is likely to be accompanied by mental confusion related to
hypoxia.
27. The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding
that the
child has
A) achieved developmental milestones at an erratic rate
B) delay in musculoskeletal development
C) displayed difficulty with speech development
D) delay in achievement of most developmental milestones
D: The majority of children with AIDS have neurological involvement. There is decreased brain growth as evidenced by
microcephaly and abnormal neurologic findings.
33. In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to
show
loss of ability in
A) Hearing, speech, and sight
B) Endurance, strength, and mobility
C) Learning, creativity, and judgment
D) Balance, flexibility, and coordination

C: Learning, creativity, and judgment. Cognitive impairments are due to physiological processes that affect memory
and other
higher-level cognitive processes.
36. The new graduate nurse interviews for a position in a nursing department of a large health care agency, described
by the
interviewer as having shared governance. Which of these statements best illustrates the shared governance model?
A) An appointed board oversees any administrative decisions
B) Nursing departments share responsibility for client outcomes
C) Staff groups are appointed to discuss nursing practice and client education issues
D) Non-nurse managers supervise nursing staff in groups of units
B: Nursing departments share responsibility for client outcomes. Shared governance or self-governance is a method of
organizational design that promotes empowerment of nurses to give them responsibility for client care issues.
38. A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate
postoperative period
for a cleft lip repair, which nursing approach should be the priority?
A) Remove protective arm devices one at a time for short periods with supervision
B) Initiate by mouth feedings when alert, with the return of the gag reflex
C) Introduce to the parents how to cleanse the suture line with the prescribed protocol
D) Position the infant on the back after feedings throughout the day
A: The major efforts in the postoperative period are directed toward protecting the operative site. Elbow restraints
should be used
and only 1 arm released at a time with close supervision by the nurse and/or parents.
Q&A 10 31/40
4. Which behavioral characteristic describes the domestic abuser?
A) Alcoholic
B) Over confident
C) High tolerance for frustrations
D) Low self-esteem
D: Low self-esteem. Batterers were usually physically or psychologically abused as children or have had experiences of
parental
violence. Batterers are also manipulative, and have a great need to exercise control or power over their partners.
5. A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the
following
is an appropriate initial statement by the nurse?
A) "Focus on your sons' needs during the first days at home."
B) "Tell each child what he can do to help with the baby."
C) "Suggest that your husband spend more time with the boys."
D) "Ask the children what they would like to do for the newborn."
A: In an expanded family, it is important for parents to reassure older children that they are loved and as important as
the
newborn.
8. A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the
child has
suddenly begun seizing. The nurse recognizes this problem is probably due to
A) a cerebral vascular accident
B) postoperative meningitis
C) medication reaction
D) metabolic alkalosis
A: a cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly
occurs
in clients with Tetralogy of Fallot.
14. A client with schizophrenia is receiving haloperidol (Haldol) 5 mg T.I.D. The clients family is alarmed and calls the
clinic
when "his eyes rolled upward." The nurse recognizes this as what type of side effect?
A) Oculogyric crisis
B) Tardive dyskinesia
C) Nystagmus
D) Dysphagia
A: Oculogyric crisis. This refers to involuntary muscles spasm of the eye. There are medications to treat these side
effects, for
example Artane.

15. The parents of a newborn male with hypospadias (displacement of urethra) want their child circumcised. The best
response by the nurse would be to
inform them that
A) circumcision is delayed so the foreskin can be used for the surgical repair
B) this procedure is contraindicated because of the permanent defect
C) there is no medical indication for performing a circumcision on any child
D) the procedure should be performed as soon as the infant is stable
A: circumcision is delayed so the foreskin can be used for the surgical repair. Even if only mild hypospadias is
suspected,
circumcision is not done in order to save the foreskin for surgical repair if needed.
16. A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's
constantly
saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is
attempting
to meet which developmental need?
A) Trust
B) Initiative
C) Independence
D) Self-esteem
C: Independence. In Eriksons theory of development, toddlers struggle to assert independence. They often use the
word no
even when they mean yes. This stage is called autonomy versus shame and doubt.
21. The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever.
Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium
per
liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?
A) 3 episodes of vomiting in 1 hour
B) Periodic crying and irritability
C) Vigorous sucking on a pacifier
D) No measurable voiding in 4 hours
D: No measurable voiding in 4 hours. The concern is possible hyperkalemia, which could occur with continued
potassium
administration and a decrease in urinary output since potassium is excreted via the kidneys.
35. A nurse is teaching the parent of a nine month-old infant about diaper dermatitis. Which of the following measures
would be
appropriate for the nurse to include?
A) Use only cloth diapers that are rinsed in bleach
B) Do not use occlusive ointments on the rash
C) Use commercial baby wipes with each diaper change
D) Discontinue a new food that was added to the infant's diet just prior to the rash
D: The addition of new foods to the infant''s diet can be a cause of diaper dermatitis
37. The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse
anticipate?
A) unequal leg length
B) limited adduction
C) diminished femoral pulses
D) symmetrical gluteal folds
A: unequal leg length. Shortening of the affected leg is a sign of developmental dysplasia of the hip. (unequal gluteal
folds, positive ortolani/barlow sign)
Q&A 11 23/40
3. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the
client, the
first nursing action would be to
A) administer pain medication
B) suction excessive tracheobronchial secretions
C) assist client to turn, deep breathe and cough
D) monitor oxygen saturation
B: suction excessive tracheobronchial secretions. Suctioning the copious tracheobronchial secretions present in postthoracic
surgery clients maintains an open airway which is always the priority nursing intervention.
4. Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?
A) Sports and games with rules

B) Finger paints and water play

C) "Dress-up" clothes and props
D) Chess and television programs
A: Sports and games with rules. The purpose of play for the 7 year-old is developing cooperation. Rules are very
important.
Logical reasoning and social skills are developed through play.
7. A client is in the third month of her first pregnancy. During the interview, she tells the nurse that she has several sex
partners
and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?
A) Counsel the woman to consent to HIV screening
B) Perform tests for sexually transmitted diseases
C) Discuss her high risk for cervical cancer
D) Refer the client to a family planning clinic
A: Counsel the woman to consent to HIV screening. The client''s behavior places her at high risk for HIV. Testing is the
first
step. If the woman is HIV positive, the earlier treatment begins, the better the outcome.
9. Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish
staining
with pitting of the enamel. Which of the following conditions would most likely explain these findings?
A) Ingestion of tetracycline
B) Excessive fluoride intake
C) Oral iron therapy
D) Poor dental hygiene
B: Excessive fluoride intake. The described findings are indicative of fluorosis, a condition characterized by an increase
in the
extent and degree of the enamel''s porosity. This problem can be associated with repeated swallowing of toothpaste
with fluoride
or drinking water with high levels of fluoride.
12. The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most
effective in
removing respiratory secretions?
A) Administration of cough suppressants
B) Increasing oral fluid intake to 3000 cc per day
C) Maintaining bed rest with bathroom privileges
D) Performing chest physiotherapy twice a day
B: Increasing oral fluid intake to 3000 cc per day. Secretion removal is enhanced with adequate hydration which thins
and
liquefies secretions.
15. The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is
noted. The
nurse understands that this finding refers to
A) reports of difficulty falling and staying asleep
B) expression of persistent suicidal thoughts
C) lack of enjoyment in usual pleasures
D) reduced senses of taste and smell
C: lack of enjoyment in usual pleasures. Lack of enjoyment in usual pleasures is the definition of anhedonia, which is
a
common finding in depression.
18. A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that
the child at
highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child?
A) congenital cardiac defects
B) an acute febrile illness
C) prolonged hypoxemia
D) severe multiple trauma
C: prolonged hypoxemia. Most often, the cause of cardiac arrest in the pediatric population is prolonged hypoxemia.
Children
usually have both cardiac and respiratory arrest.
20. A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the
child's
mother?
A) Teaching the child self care skills

B) Preparing for independent toileting

C) Promoting the child's optimal development
D) Helping the family decide on long term care
C: Promoting the child''s optimal development. The primary goal of nursing care for a developmentally challenged
child is to
promote the child''s optimum development.
22. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires
further
follow up?
A) A 13 month-old unable to walk
B) A 20 month-old only using 2 and 3 word sentences
C) A 24 month-old who cries during examination
D) A 30 month-old only drinking from a sippy cup
D: A 30 month-old should be able to drink from a cup without a cover.
25. A registered nurse (RN) is assigned to work at the Poison Control Center telephone hotline. In which of these cases
of
childhood poisoning would the nurse suggest that parents have the child drink orange juice?
A) An 18 month-old who ate an undetermined amount of crystal drain cleaner
B) A 14 month-old who chewed 2 leaves of a philodendron plant
C) A 20 month-old who is found sitting on the bathroom floor beside an empty bottle of diazepam (Valium)
D) A 30 month-old who has swallowed a mouthful of charcoal lighter fluid
A: An 18 month-old who ate an undetermined amount of crystal drain cleaner. Drain cleaner is very alkaline. Orange
juice is
acidic and will help to neutralize this substance.
26. While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect
the
behavior?
A) Strange bed and surroundings
B) Separation from parents
C) Presence of other toddlers
D) Unfamiliar toys and games
B: Separation from parents. Separation anxiety if most evident from 6 months to 30 months of age. It is the greatest
stress
imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to
withstand other
stress.
27. The nursing care plan for a client with decreased adrenal function should include
A) encouraging activity
B) placing client in reverse isolation
C) limiting visitors
D) measures to prevent constipation
C: limiting visitors. Any exertion, either physical or emotional, places additional stress on the adrenal glands which
could
precipitate an Addisonian crisis. The plan of care should protect this client from the physical and emotional exertion of
visitors.
28. While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development
at this
age?
A) They are able to make simple association of ideas
B) They are able to think logically in organizing facts
C) Interpretation of events originate from their own perspective
D) Conclusions are based on previous experiences
B: They are able to think logically in organizing facts. The child in the concrete operations stage, according to Piaget, is
capable
of mature thought when allowed to manipulate and organize objects.
29. The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is
poisoned is
A) "You think that someone wants to poison you?"
B) "Why do you think the food is poisoned?"
C) "These feelings are a symptom of your illness."
D) "Youre safe here. I wont let anyone poison you."

A: "You think that someone wants to poison you?" This response acknowledges perception through a reflective
question which
presents opportunity for discussion, clarification of meaning, and expressing doubt.
31. The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular
fibrillation.
What should the nurse do first?
A) perform defibrillation
B) administer epinephrine as ordered
C) assess for presence of pulse
D) institute CPR
C: assess for presence of pulse. Artifact (interference) can mimic ventricular fibrillation on a cardiac monitor. If the
client is
truly in ventricular fibrillation, no pulse will be present. The standard of care is to verify the monitor display with an
assessment
of the clients pulse.
33. Which of the following conditions assessed by the nurse would contraindicate the use of benztropine (Cogentin)?
A) Neuro malignant syndrome
B) Acute extrapyramidal syndrome
C) Glaucoma, prostatic hypertrophy
D) Parkinson's disease, atypical tremors
C: Glaucoma, prostatic hypertrophy. Glaucoma and prostatic hypertrophy are contraindications to the use of
benztropine
(Cogentin) because the drug is an anticholinergic agent. Cogentin is used to treat the side effects of antipsychotic
medications.
38. A 15 year-old client with a lengthy confining illness is most at risk for altered psycho-emotional growth and
development
due to
A) loss of control
B) insecurity
C) dependence
D) lack of trust
C: dependence. The client role fosters dependency. Adolescents may react to dependency with rejection,
uncooperativeness, or
withdrawal.
Q&A 12 26/40
2. A schizophrenic client talks animatedly but the staff are unable to understand what the client is communicating. The
client is
observed mumbling to herself and speaking to the radio. A desirable outcome for this clients care will be
A) expresses feelings appropriately through verbal interactions
B) accurately interprets events and behaviors of others
C) demonstrates improved social relationships
D) engages in meaningful and understandable verbal communication
D: engages in meaningful and understandable verbal communication. The outcome must be related to the diagnosis
and
supporting data. Data support impaired verbal communication deficit as a nursing diagnosis.
5. The nurse is assessing a 4 year-old for possible developmental dysplasia of the right hip. Which finding would the
nurse
expect?
A) Pelvic tip downward
B) Right leg lengthening
C) Ortolani sign
D) Characteristic limp
D: Characteristic limp. Developmental dysplasia produces a characteristic limp in children who are walking.
6. At a routine clinic visit, parents express concern that their 4 year-old is wetting the bed several times a month. What
is the
nurse's best response?
A) "This is normal at this time of day."
B) "How long has this been occurring?"
C) "Do you offer fluids at night?"
D) "Have you tried waking her to urinate?"
B: "How long has this been occurring?" Nighttime control should be present by this age, but may not occur until age 5.
Involuntary voiding may occur due to infectious, anatomical and/or physiological reasons.

7. The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital
gown
only. What is the rationale for this nursing intervention?
A) To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
B) To cover the bony prominence and areas where there is skin breakdown
C) The client knows what type of clothing to wear when weighed
D) To reduce the tendency of the client to hide objects under his or her clothing
D: The client may conceal weights on their body to create the illusion of increased weight gain.
8. The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would
the
nurse anticipate finding?
A) Large volume of urinary output with each voiding
B) Involuntary voiding with coughing and sneezing
C) Frequent urination
D) Urine is dark and concentrated
C: Frequent urination. Clients with BPH have overflow incontinence with frequent urination in small amounts day and
night.
13. A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What
action should
the nurse perform first?
A) Provide the ordered humidified oxygen via mask
B) Suction the mouth and the nose
136
C) Check the mouth and radial pulse
D) Start the ordered intravenous fluids
C: Check the mouth and radial pulse. The first step in treatment of a toxic exposure or ingestion is to assess the
airway, breathing
and circulation, then stabilize the client. The other nursing actions would follow.
15. Which of the following statements describes what the nurse must know in order to provide anticipatory guidance to
parents
of a toddler about readiness for toilet training?
A) The child learns voluntary sphincter control through repetition
B) Myelination of the spinal cord is completed by this age
C) Neuronal impulses are interrupted at the base of the ganglia
D) The toddler can understand cause and effect
B: Myelination of the spinal cord is completed by this age. Voluntary control of the sphincter muscles can be gradually
achieved
due to the complete myelination of the spinal cord, sometime between the ages of 18 to 24 months of age.
17. The nurse is performing an assessment on a client with pneumococcal pneumonia. Which finding would the nurse
anticipate?
A) bronchial breath sounds in outer lung fields
B) decreased tactile fremitus
C) hacking, nonproductive cough
D) hyper-resonance of areas of consolidation
A: bronchial breath sounds in outer lung fields. Pneumonia causes a marked increase in interstitial and alveolar fluid.
Consolidated lung tissue transmits bronchial breath sounds to outer lung fields.
23. The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a 1
piece
drainable ostomy pouch. Which is the correct intervention?
A) Piercing the plastic of the ostomy pouch with a pin to vent the flatus
B) Opening the bottom of the pouch, allowing the flatus to be expelled
C) Pulling the adhesive seal around the ostomy pouch to allow the flatus to escape
D) Assisting the client to ambulate to reduce the flatus in the pouch
B: The only correct way to vent the flatus from a 1 piece drainable ostomy pouch is to instruct the client to obtain
privacy (the
release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and close the bottom of
the pouch.
26. Which of these principles should the nurse apply when performing a nutritional assessment on a 2 year-old client?
A) An accurate measurement of intake is not reliable
B) The food pyramid is not used in this age group
C) A serving size at this age is about 2 tablespoons

D) Total intake varies greatly each day

C: A serving size at this age is about 2 tablespoons. In children, a general guide to serving sizes is 1 tablespoon of solid
food per
year of age. Understanding this, the nurse can assess adequacy of intake.
31. The nurse measures the head and chest circumferences of a 20 month-old infant. After comparing the
measurements, the
nurse finds that they are approximately the same. What action should the nurse take?
A) Notify the provider
B) Palpate the anterior fontanel
C) Feel the posterior fontanel
D) Record these normal findings
D: Record these normal findings. The rate of increase in head circumference slows by the end of infancy, and the head
circumference is usually equal to chest circumference at 1 to 2 years of age.
32. A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home
care for
the child. Which of the following information is appropriate for the nurse to include?
A) Allow the child to continue normal activities
B) Schedule frequent rest periods
C) Limit exposure to other children
D) Restrict activities to inside the house
A: Allow the child to continue normal activities. Physical activity is important in a two year-old who is developing
autonomy.
Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucus secretion and helps
develop
normal breathing patterns.
35. The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal
diversion
poses the highest risk for skin breakdown
A) Ileostomy
B) Transverse colostomy
C) Ileal conduit
D) Sigmoid colostomy
A: Ileostomy output contains gastric and enzymatic agents that when present on skin can denuded skin in several
hours. Because
of the caustic nature of this stoma output adequate peristomal skin protection must be delivered to prevent skin
breakdown.
39. A 7 year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and
carbohydrates
is recommended. The nurse informs the child and family that the most important reason for this diet is to
A) Promote healing and strengthen the immune system
B) Provide a well balanced nutritional intake
C) Stimulate increased peristalsis absorption
D) Spare protein catabolism to meet metabolic needs
D: Spare protein catabolism to meet metabolic needs. Because of the burn injury, the child has increased metabolism
and
catabolism. By providing a high carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then
used to
restore tissue.
Q&A 13 33/40
3. The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a
priority
to assess for findings of heart conduction disturbance?
A) Arterial septal defect
B) Patent ductus arteriosus
C) Aortic stenosis
D) Ventricular septal defect
D: Ventricular septal defect. While assessments for conduction disturbance should be included following repair of any
defect, it
is a priority for this condition. A ventricular septal defect is an abnormal opening between the right and left ventricles.
The
atrioventricular bundle (bundle of His), is a part of the electrical conduction system of the heart.
16. The nurse understands that one reason domestic violence remains extensively undetected is

A) few battered victims seek medical care

B) there is typically a series of minor, vague complaints
C) expenses due to police and court costs are prohibitive
D) very little knowledge is currently known about batterers and battering relationships
B: there is typically a series of minor, vague complaints. Signs of abuse may not be clearly manifested and include a
series a
minor complaints such as headache, abdominal pain, insomnia, back pain, and dizziness. These may be covert
indications of
abuse that go undetected. Victim complaints may be vague reflecting their ambivalence about disclosing the abuse.
17. The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest
drainage
system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest
dressing and
tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to
A) check for subcutaneous emphysema in the upper torso
B) reposition the client to improve the level of comfort
C) call the provider as soon as possible
D) check for any increase in the amount of thoracic drainage
A: check for subcutaneous emphysema in the upper torso. Continuous bubbling in the water seal chamber is an
abnormal finding
2 hours after a lobectomy. Further assessment of appropriate factors was done by the nurse to rule out an air leak in
the system.
Thus the conclusion is that the problem is one of an air leak in the lung. This client may need to be returned to surgery
to deal
with the sustained air leak. Action by the provider is required to prevent further complications.
19. A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse
expect to
find?
A) S3 heart sound
B) Thready pulse
C) Flattened neck veins
D) Hypoventilation
A: S3 heart sound. Auscultation of an S3 heart sound. This is an early sign of volume overload (or CHF) because during
the first
phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of fluid left in the
ventricles.
23. The nurse is caring for a newborn who has just been diagnosed with hypospadias. When discussing the defect with
the
parents, the nurse should communicate that
A) circumcision can be performed at any time
B) initial repair is delayed until 6-8 years of age
C) post-operative appearance will be normal
D) surgery will be performed in stages
D: surgery will be performed in stages. Hypospadias, a condition in which the urethral opening is located on the ventral
surface
or below the penis, is corrected in stages as soon as the infant can tolerate surgery.
28. When making a home visit to a client with chronic pyelonephritis (kidney infection), which nursing action has the
highest priority?
A) follow-up on lab values before the visit
B) observe client findings for the effectiveness of antibiotics
C) ask for a log of urinary output
D) ask for the log of the oral intake
C: ask for a log of urinary output. The nurse must monitor the urine output as a priority because it is the best indictor
of renal
function. The other options would be appropriate after an evaluation of the urine output.
40. The nurse caring for a 14 year-old boy with severe Hemophilia A, who was admitted after a fall while playing
basketball. In
understanding his behavior and in planning care for this client, the nurse should understand that adolescents with
hemophilia
_______.
A) must have structured activities
B) often take part in active sports
C) explain limitations to peer groups

D) avoid risks after bleeding episodes

B: often take part in active sports. An age-appropriate treatment goal is to establish an age-appropriate safe
environment.
Adolescent hemophiliacs should be aware that contact sports may trigger bleeding. However, developmental
characteristics of
this age group such as impulsivity, inexperience and peer pressure, place adolescents in unsafe environments.
Q&A14 24/40
1. The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be
included in
the plan of care?
A) Monitor for hyperkalemia
B) Place in protective isolation
C) Precautions with position changes
D) Administer diuretics as ordered
C: Precautions with position changes. Because multiple myeloma is a condition in which neoplastic plasma cells
infiltrate the
bone marrow resulting in osteoporosis, clients are at high risk for pathological fractures.
4. A 30 month-old child is admitted to the hospital unit. Which of the following toys would be appropriate for the nurse
to
select from the toy room for this child?
A) Cartoon stickers
B) Large wooden puzzle
C) Blunt scissors and paper
D) Beach ball
B: Large wooden puzzle. Appropriate toys for this child''s age include items such as push-pull toys, blocks, pounding
board, toy
telephone, puppets, wooden puzzles, finger paint, and thick crayons.
9. A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third
admission for
asthma in 7 months. She describes how she doesn't really like having to use her medications all the time. Which
explanation
by the nurse best describes the long-term consequence of uncontrolled airway inflammation?
A) The alveoli will degenerate
B) Chronic bronchoconstriction of the large airways will occur
C) Lung remodeling and permanent changes in lung function will result
D) The client will experience frequent bouts of pneumonia
C: Lung remodeling and permanent changes in lung function will result. While an asthma attack is an acute event from
which
lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent
changes in
lung function.
10. Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute
glomerulonephritis?
A) Assess for generalized edema
B) Monitor for increased urinary output
C) Encourage rest during hyperactive periods
D) Note patterns of increased blood pressure
D: Note patterns of increased blood pressure. Evaluation for hypertension is a key assessment in the course of the
disease.
13. A client is experiencing hallucinations that are markedly increased at night. The client is very frightened by the
hallucinations. The clients partner asked to stay a few hours beyond the visiting time, in the clients private room.
What
would be the best response by the nurse demonstrating emotional support for the client?
A) "No, it would be best if you brought the client some reading material that she could read at night."
B) "No, your presence may cause the client to become more anxious."
C) "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."
D) "Yes, would you like to spend the night when the clients behavior indicates that she is frightened?"
C: "Yes, staying with the client and orienting her to her surroundings may decrease her anxiety."
Encouraging the family or a close friend to stay with the client in a quiet surrounding can help increase orientation and
minimize
confusion and anxiety.

15. A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4 cm by 7 cm, the
wound base is
red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate
for
this wound?
A) transparent dressing
B) dry sterile dressing with antibiotic ointment
C) wet to dry dressing
D) occlusive moist dressing
D: occlusive moist dressing. This wound has granulation tissue present and must be protected. The use of a moisture
retentive
dressing is the best choice because moisture supports wound healing.
18. At the day treatment center a client diagnosed with schizophrenia - paranoid type sits alone alertly watching the
activities of
clients and staff. The client is hostile when approached and asserts that the doctor gives her medication to control her
mind.
The client's behavior most likely indicates
A) Feelings of increasing anxiety related to paranoia
B) Social isolation related to altered thought processes
C) Sensory perceptual alteration related to withdrawal from environment
D) Impaired verbal communication related to impaired judgment
B: Social isolation related to altered thought processes. Hostile alertness and absence of involvement with people are
findings
supporting a diagnosis of social isolation. Her psychiatric diagnosis and her idea about the purpose of medication
suggest altered
thinking processes.
21. The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?
A) Widening pulse pressure
B) Pleural friction rub
C) Distended neck veins
D) Bradycardia
C: Distended neck veins, pulsus paradoxus fall of systolic blood pressure of >10 mmHg during the inspiratory)
22. At the geriatric day care program a client is crying and repeating "I want to go home. Call my daddy to come for
me." The
nurse should
A) Inform the client that she must wait until the program ends at 5:00 pm to leave
B) Give the client simple information about what she will be doing
C) Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
D) Firmly direct the client to her assigned group activity
C: Comforting and distraction, key approaches in validation therapy are the kindest and most effective for clients who
have
advancing dementia. The distressed, disoriented client should be gently oriented to reduce fear and increase the sense
of safety
and security, but reorientation often is ineffective when the client has moderate dementia and/or is upset.
Environmental changes
provoke stress and fear, especially in clients suffering from Alzheimers disease.
25. The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child
has iron
deficiency anemia. The nurse's best response is
A) "Although the results are here, your doctor will explain them later."
B) "Your child has fewer red blood cells that carry oxygen."
C) "The blood cells that carry nutrients to the cells are too large."
D) "There are not enough blood cells in your child's circulation."
B: The results of a complete blood count in clients with iron deficiency anemia will show decreased red blood cell
levels, low
hemoglobin levels and microcytic, hypochromic red blood cells. A simple but clear explanation is appropriate.
28. A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling
sad and
hopeless, the nurse would assess for
A) Anxiety, unconscious anger, and hostility
B) Guilt, indecisiveness, poor self-concept
C) Psychomotor retardation or agitation
D) Meticulous attention to grooming and hygiene

C: Psychomotor retardation or agitation. Somatic or physiologic symptoms of depression include: fatigue, psychomotor
retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite,
gastrointestinal complaints and impaired libido.
30. A nurse is conducting a community wide seminar on childhood safety issues. Which of these children is at the
highest risk
for poisoning?
A) 9 month-old who stays with a sitter 5 days a week
B) 20 month-old who has just learned to climb stairs
C) 10 year-old who occasionally stays at home unattended
D) 15 year-old who likes to repair bicycles
B: 20 month-old who has just learned to climb stairs. Toddlers are at most risk for poisoning because they are
increasingly
mobile, need to explore and engage in autonomous behavior.
32. Privacy and confidentiality of all client information is legally protected. In which of these situations would the nurse
make
an exception to this practice?
A) When a family member offers information about their loved one
B) When the client threatens self-harm and harm to others
C) When the provider decides the family has a right to know the client's diagnosis
D) When a visitor insists that the visitor has been given permission by the client
B: When the client threatens self-harm and harm to others. Privacy and confidentiality of all client information is
protected with
the exception of the client who threatens self harm or endangering the public.
33. The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood
pressure?
A) Standing and sitting
B) In both arms
C) After exercising
D) Supine position
B: In both arms. Blood pressure should be taken in both arms due to the fact that one subclavian artery may be
stenosed, causing
a false high in that arm.
34. A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this
client?
A) Hyperextension of the neck with passive shoulder flexion
B) Flexion of the hip and knees with passive flexion of the neck
C) Flexion of the legs with rebound tenderness
D) Hyperflexion of the neck with rebound flexion of the legs
B: Flexion of the hip and knees with passive flexion of the neck. This is known as a positive Brudzinskis sign (flexion of
hip
and knees with passive flexion of the neck). A positive Kernigs sign, the inability to extend the knee to more than 135
degrees
without pain behind the knee while the hip is flexed, usually establishes the diagnosis of meningitis.
Kernigs sign Loss of the ability of a supine client to straighten the leg completely when it is fully flexed at the knee
and hip; indicates meningeal irritation.
36. In a child with suspected coarctation of the aorta, the nurse would expect to find
A) strong pedal pulses
B) diminishing carotid pulses
C) normal femoral pulses
D) bounding pulses in the arms
D: bounding pulses in the arms. Coarctation of the aorta, a narrowing or constriction of the descending aorta, causes
increased
blood flow to the upper extremities resulting in increased pressure and pulses.
BP higher in upper extremities, absent femoral, cool lower extremities
Q&A 15 29/40
1. The nurse enters a 2 year-old child's hospital room in order to administer an oral medication. When the child is
asked if he is
ready to take his medicine, he immediately says, "No!". What would be the most appropriate next action?
A) Leave the room and return five minutes later and give the medicine
B) Explain to the child that the medicine must be taken now
C) Give the medication to the father and ask him to give it
D) Mix the medication with ice cream or applesauce

A: Leave the room and return five minutes later and give the medicine. Since the nurse gave the child a choice about
taking the
medication, the nurse must comply with the child''s response in order to build or maintain trust. Since toddlers do not
have an
accurate sense of time, leaving the room and coming back later is another episode to the toddler
4. The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the
nurse?
A) "Do you want to take this pretty red medicine?"
B) "You will feel better if you take your medicine."
C) "This is your medicine, and you must take it all right now."
D) "Would you like to take your medicine from a spoon or a cup?"
D: At 3 years of age, a child often feels a loss of control when hospitalized. Giving a choice about how to take the
medicine will
allow the child to express an opinion and have some control.
5. A 4 year-old child is recovering from chicken pox (varicella). The parents would like to have the child return to day
care as
soon as possible. In order to ensure that the illness is no longer communicable, what should the nurse assess for in this
child?
A) All lesions crusted
B) Elevated temperature
C) Rhinorrhea and coryza
D) Presence of vesicles
A: All lesions crusted. The rash begins as a macule, with fever, and progresses to a vesicle that breaks open and then
crusts over.
When all lesions are crusted, the child is no longer in a communicable stage.
6. The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse
anticipate?
A) Retractions in the intercostal tissues of the thorax
B) Chest pain aggravated by respiratory movement
C) Cyanosis and mottling of the skin
D) Rapid, shallow respirations
A: Retractions in the intercostal tissues of the thorax. Slight intercostal retractions are normal, however in disease
states,
especially in severe airway obstruction, retractions become extreme.
8. A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic
lab
value should the nurse monitor when a client is receiving this medication?
A) Potassium level
B) Arterial blood gasses
C) Blood urea nitrogen
D) Thiocyanate
D: Thiocyanate levels rise with the metabolism if nitroprusside is taken, and this can cause cyanide/thiocyanate
toxicity
9. A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in
diameter with
loss of subcutaneous tissue. The appropriate dressing for this wound is
A) transparent film dressing
B) wet dressing with debridement granules
C) wet to dry with hydrogen peroxide
D) moist saline dressing
D: This wound is a stage III pressure ulcer. The wound is red (granulation tissue) and does not require debridement.
The wound
must be protected for granulation tissue to proliferate. A moist dressing allows epithelial tissues to migrate more
rapidly.
12. The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse
recognize
as the cause of the findings?
A) Decreased cardiac output
B) Tissue hypoxia
C) Cerebral edema
D) Reduced oxygen saturation
B: Tissue hypoxia. When the hemoglobin falls sufficiently to produce clinical manifestations, the findings are directly

attributable to tissue hypoxia, resulting from a decrease in the oxygen carrying capacity of the blood.
20. In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the
relationship between edema formation and
A) increased retention of albumin in the vascular system
B) decreased colloidal osmotic pressure in the capillaries
C) fluid shift from interstitial spaces into the vascular space
D) reduced tubular reabsorption of sodium and water
B: decreased colloidal osmotic pressure in the capillaries. The increased glomerular permeability to protein causes a
decrease in
serum albumin, which results in decreased colloidal osmotic pressure.
26. A mother asks about expected motor skills for a 3 year-old child. Which of the following would the nurse emphasize
as
normal at this age?
A) Jumping rope
B) Tying shoelaces
C) Riding a tricycle
D) Playing hopscotch
C: Coordination is gained through large muscle use. A child of 3 has the ability to ride a tricycle.
29. The nurse is preparing a 5 year-old for a scheduled tonsillectomy and adenoidectomy. The parents are anxious and
concerned about the child's reaction to impending surgery. Which nursing intervention would best prepare the child?
A) Introduce the child to all staff the day before surgery
B) Explain the surgery 1 week prior to the procedure
C) Arrange a tour of the operating and recovery rooms
D) Encourage the child to bring a favorite toy to the hospital
B: Explain the surgery 1 week prior to the procedure. A 5 year-old can understand the surgery, and should be prepared
well
before the procedure. Most of these procedures are "same day" surgeries and do not require an overnight stay.
35. A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that
the client
should
A) eat foods high in sodium to increase sputum liquefaction
B) use oxygen during meals to improve gas exchange
C) perform exercise after respiratory therapy to enhance appetite
D) cleanse the mouth of dried secretions to reduce risk of infection
B: use oxygen during meals to improve gas exchange. Clients with emphysema breathe easier when using oxygen
while eating.
Q&A 16
1. Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?
A) "I know there is a problem since my baby is always constipated."
B) "My child doesn't like many fruits and vegetables, but she really loves her milk."
C) "I can't understand why my child is not eating as much as she did 4 months ago."
D) "My child doesn't drink a whole glass of juice or water at 1 time."
B: About 2 to 3 cups of milk a day are sufficient for the young child''s needs. Sometimes excess milk intake, a habit
carried over
from infancy, may exclude many solid foods from the diet. As a result, the child may lack iron and develop a so-called
milk
anemia. Although the majority of infants with iron deficiency are underweight, many are overweight because of
excessive milk
ingestion.
6. When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the
most
effective intervention?
A) Use medications to lower the temperature set point
B) Apply extra layers of clothing to prevent shivering
C) Immerse the child in a tub containing cool water
D) Give a tepid sponge bath prior to giving an antipyretic
A: Use medications to lower the temperature set point. Conditions such as infection, malignancy, allergy, central
nervous system
lesion and radiation cause the temperature set-point to be raised. Because the temperature set point is normal in
hyperthermia and
elevated in fever, different measures must be taken in order to be effective. The most effective intervention in the
management of

fever is the administration of antipyretics which lower the set point. Too rapid cooling of a febrile child can lead to
seizure
activity.
8. Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?
A) Risk for injury
B) Risk for knowledge deficit
C) Altered thought process
D) Disturbance in self-esteem
A: Risk for injury. Accidents increase as a result of intoxication. Studies indicate alcohol is a factor in 50% of motor
vehicle
fatalities, 53% of all deaths from accidental falls, 64% of fatal fires, and 80% of suicides.
22. The nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which of the following
demonstrates appropriate teaching by the nurse?
A) Chewable aspirin is the preferred analgesic
B) Topical cortisone ointment relieves itching
C) Papules, vesicles, and crusts will be present at one time
D) The illness is only contagious prior to lesion eruption
C: All 3 stages of the chicken pox lesions will be present on the child's body at the same time.
23. An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night.
What is the
most appropriate follow-up question for the nurse to ask?
A) "Have you had a recent heart attack?"
B) "Do you become short of breath during your normal daily activities?"
C) "How many pillows do you use at night to sleep comfortably?"
D) "Do you smoke?"
B: These are the findings of right-sided heart failure, which causes increased pressure in the systemic venous system.
To
equalize this pressure, the fluid shifts into the interstitial spaces causing edema. Because of gravity, the lower
extremities are first
affected in an ambulatory patient. This question would elicit information to confirm the nursing diagnosis of activity
intolerance
and fluid volume excess, both associated with right-sided heart failure.
25. The nurse should initiate discharge planning for a client
A) when the client or family demonstrate readiness to learn self care modalities
B) when informed that a date for discharge has been determined
C) upon admission to a hospital unit or the emergency room
D) when the client's condition is stabilized on the assigned unit
C: With decreased lengths of stay, discharge plans must be incorporated into the initial plan of care upon admission to
an
emergency room or hospital unit.
28. While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions
A: Respiratory rate of 42. Signs of impending airway obstruction include increased respiratory rate and pulse;
substernal,
suprasternal and intercostal retractions; flaring nares; and increased restlessness or agitation.
31. The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which
would be an
appropriate goal in planning care for this client?
A) Protection for the granulation tissue
B) Heal infection
C) Debride eschar
D) Keep the tissue intact
D: Keep the tissue intact. If the black tissue, (eschar) is dry and intact no treatment is necessary. If the area changes
(cellulitis,
pain) this is a sign of infection, requiring debridement.
34. The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of
congestive
heart disease. Which other finding is most likely to occur?

A) Chest pain
B) Peripheral edema
C) Nail clubbing
D) Lethargy
B: Peripheral edema. When crackles are heard bibasilarly, congestive heart failure is suspected. This is often
accompanied by
peripheral edema secondary to fluid overload caused by ineffective cardiac pumping.
35. The nurse is discussing negativity with the parents of a 30 month-old child. How should the nurse tell the parents
to best
respond to this behavior?
A) Reprimand the child and give a 15 minute "time out"
B) Maintain a permissive attitude for this behavior
C) Use patience and a sense of humor to deal with this behavior
D) Assert authority over the child through limit setting
C: The nurse should help the parents see that negativity as a normal part of growth of autonomy in the toddler. They
can best
handle the negative toddler by using patience and humor.
40. The nurse is assessing a healthy child at the 2 year check up. Which of the following should the nurse report
immediately to
the health care provider?
A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short term weight changes are uneven
A: On the growth curve, height and weight should be close in percentiles at this age. A wide difference may indicate a
problem.
Q&A Random Selection #17
2. During the two-month well-baby visit, the mother complains that formula seems to stick to her baby's mouth and
tongue.
Which of the following would provide the most valuable data for nursing assessment?
A) Inspect the baby's mouth and throat
B) Obtain cultures of the mucous membranes
C) Flush both sides of the mouth with normal saline
D) Use a soft cloth to attempt to remove the patches
D: Candidiasis can be distinguished from coagulated milk when attempts to remove the patches with a soft cloth are
unsuccessful.
4. A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program.
The
nurse must understand that a priority during withdrawal is
A) avoiding alcohol use during this time
B) observing the client for hypotension
C) abrupt discontinuation of the drug
D) assessing for mild physical symptoms
A: Central nervous system depressants interact with alcohol. The client will gradually reduce the dosage, under the
health care
provider''s direction. During this time, alcohol must be avoided.
6. A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the
following to
prevent aspirin toxicity?
A) Serum potassium
B) Protein intake
C) Lactose tolerance
D) Serum albumin
D: Serum albumin. When highly protein-bound drugs are administered to patients with low serum albumin (protein)
levels,
excess free (unbound) drug can cause exaggerated and dangerous effects.
11. A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected
planning
committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse
manager should
first
A) support the planning committee and post the new schedule

B) explore how the planning committee evaluated barriers to the plan

C) design a different approach to deliver care with fewer staff
D) retain the previous staffing pattern for another 6 months
B: The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right
to approve
or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing
change. To
smooth acceptance of the change, restraining factors need to be evaluated.
13. The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is
important to
remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
A) Skin irritation
B) Drug tolerance
C) Severe headaches
D) Postural hypotension
B: Drug tolerance. Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug,
which can
occur with continuous patch use.
18. In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider
before
administering which of the following drugs through the tube?
A) Cardizem SR tablet (diltiazem)
B) Lanoxin liquid
C) Os-cal tablet (calcium carbonate)
D) Tylenol liquid (acetaminophen)
A: Cardizem SR is a "sustained-release" drug form. Sustained release (controlled-release; long-acting) drug
formulations are
designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube
administration, sustained-release properties and blood levels of the drug will be altered. The provider must substitute
another
medication.
26. Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin
damage?
A) Ninety-ninety
B) Buck's
C) Bryant
D) Russell
A: Ninety degree-ninety degree traction is used for fractures of the femur or tibia. A skeletal pin or wire is surgically
placed
through the distal part of the femur, while the lower part of the extremity is in a boot cast. Traction ropes and pulleys
are applied.
29. A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and
elevated
blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse's best
response to this request?
A) "That's a good choice, and I know it is your favorite. You can have it today."
B) "I'm sorry, that is not a good choice, but you could have pasta."
C) "I know that is your favorite, but let me help you pick another lunch."
D) "You cannot have the peanut butter until you are feeling better."
C: Children with AGN who have edema, hypertension oliguria and azotemia may have dietary restrictions limiting
sodium,
fluids, protein and potassium. Giving the child a short explanation and offering to talk about an alternative is
appropriate for this
age.
30. A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have
A) scrotal discoloration
B) sustained painful erection
C) inability to achieve erection
D) heaviness in the affected testicle
D: The feeling of heaviness in the scrotum is related to testicular cancer and not epididymitis. Sexual performance and
related
issues are not affected at this time.

34. The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
A) instruct the client to breathe into a paper bag
B) place the client in a high Fowler's position
C) assist the client with pursed lip breathing
D) administer oxygen at 6L/minute via nasal cannula
C: Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory
muscle
coordination.
37. The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the
appropriate nursing
action?
A) Pack the nose and ears with sterile gauze
B) Apply pressure to the injury site
C) Apply bulky, loose dressing to nose and ears
D) Apply an ice pack to the back of the neck
C: Applying a bulky, loose dressing to the nose and ears permits the fluid to drain and provides a visual reference for
the amount
of drainage.
38. Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy (ECT)?
A) Permission to videotape
B) Salivary pH
C) Mini-mental status exam
D) Pre-anesthesia work-up
D: Pre-anesthesia work-up. ECT is delivered under general anesthesia and the client should be prepared as for any
procedure
involving anesthesia.
Kawasaki - delay MMR, receive immunoglobulin therapy. (s/s: strawberry toungue, japanese 5yo, red palms/feet, rash),
leads to coronary artery aneurysms
asthma - peak air flow decreases 24 hours before exacerbation
nephrotic syndrome - protein + low sodium
UAP - oral suction, ulcer care + dressing
rhogram only given if coombs test is negative (check if antibodies aren't formed)
hemodialysis - prone to infection (which assessment immediate intervention = elevated temp)
greatest risk of fall - nocturia
neutropenic - cooked/canned (no milk, raw fruit/veggies)
scoliosis early signs - preadolescent growth spurt
IM - 1ml max for child, 5ml adult
iron - cereal, dried fruits
GERD - avoid milk, caffeine, smoking, chocolate, meperdine
tricuspid/mitral insufficiency - systolic murmur
congestive heart failure. - s3 ventricular gallop
dehydration - sunken eyes, dry tongue, increased pulse
Zollinger-Ellison syndrome - tumors in pancreas (report if find peptic ulcer ie. burning at night, cramp, hematemesis)
albumin range - 3-5, protein 6-8
Women MI - fatigue, back/jaw pain
enteral feedings - biggest problem atelectasis (keep HOB 30, monitor for aspiration, check tube placement prior to
feeding or q4-8 if continuous)
glaucoma - avoid straining
PID pelvic inflammatory disease follows - chlamydia
CVP = R side of heart, Swan-Ganz catheter/PAOP = L heart function
hyperkalemia = QRS wide, loss of ST, tall T. hypokalemia - negative T wave, U wave, ST depression
hypercalcemia - wide QRS, tall T, no P. hypocalcemia - narrow QRS, reduce PR, inversed T wave, U Wave
acetaminophen OD - gastric lavage, activated charcoal, mucomyst, IV fluids
Reyes syndrome - influenza/varicella + aspirin (s/s: ALOC, altered liver function, n/v, fever)
Cystic fibrosis - high cal/protein, unrestricted fat. deficient in vitamins ADK
Minere disease - low sodium
heroin baby - jitteriness at 24-48 hours, poor feeding + irritabiltiy
elevated BUN, HCT, Cl, Na normal creatinine and K - fluid volume deficit
Elderly/diabetes/vascular disease have decreased circulation/sensation in one or both feet - examine feet, cotton socks
lithotripsy (shockwave to break up renal calculi) - drink 3-4L a day for a month
CABG is the surgical procedure to repair a diseased coronary artery.
PTCA is performed to improve coronary artery blood flow in a diseased artery
pancreatitis - cough and deep breathe is important in pancreatitis because of fluid pushing up in the diaphragm
AIDS - positive HIV + opportunitis infection or CD4 <200
fifth disease (child) - rash (slap cheek), no hospitalization, not contagious, avoid pregnant
Wilm's tumor - kidney tumor in children around 3yo, don't palpate

Pleural friction rub - pneumonia, pleurisy, PE

HF pt has dyspnea + diaphoresis - assist to sit, hcp, vitals, antianxiety
12 months baby - head = chest, tripled weight, height increase by 50%
bronchopulmonary dysplasia - newborns who have had respiratory failure, ventilator or oxygen dependent for 28 days
rheumatic fever - inquire abuot recent sore throat since fever manifests 2-6 weeks after group a beta-hemolytic strep
infection of upper respiratory tract, complication is mitral valve
meds: chlorpromazine - antipsychotic (s/s: leukopenia - watch for sore throat/fever), avoid sunlight
phenytoin - seizures (s/s: gingival hyperplasia - good oral care)
no MAOIs (isocarboxazid, tranylcypromine, phenelzine, selegiline) with SSRI (fluoxetine, fluvoxamine, paroxetine,
sertraline, citalopram)
methyldopa - anti-htn. adverse reaction - mood changes
NSAIDs - no for asthma pt
angle closure glaucoma - no atropine
sulfadiazine / sulfasalazine - crystalluria
Atropine sulfate, lidocaine, procainamide, isoproterenol - monitor ekg
quetiapine - report MD if elevated temp/sweating (NMS)
atropine (anti-cholinergic given preop) - dries secretions
Bupropion - watch for seizure
digoxin - se: n/v, bradycardia, fatigue, anorexia, weakness
morphine (peds) - 0.1mg/kg q4h
alteplase (adequate therapy if) - return of ST segment to baseline
cyclosporine (immunosuppressant for organ transplant) - at risk for infection no grapefruit juice
Alendronate - take on empty stomach, sit 30 min
corticosteroid - with food
Aminophylline toxicity - palpitations, tachycardia, restlessness
digoxin - increases the risk of vfib following cardioversion
tb meds - report numbness/tingling (Peripheral neuropathy)
fluoxetine (SSRI) - SE: diarrhea, dry mouth, weight loss, reduced libido
warfarin - contraindicated for pregnant
adalimumab - rheumatoid arthritis. SE- neuro (numbness, tingling, dizziness, weakness) adverse reaction: nausea,
alopecia, stomatitis

SATA Lippincott Alternate Format

nephrotic syndrome - edema, anorexia, proteinuria, pallor (hypoalbuminemia)
respiratory alkalosis - tachypnea, confusion, nausea, lightheadedness, tachycardia
abnormal labs - calcium 7 (9-10.5), mag 1 (1.5-2.5), neutrophils 1000 (1500+), wbc 3000 (5-10) phosphorus (2.5-4.5),
creatinine .5-1.5
hypokalemia - deep tendon hyporeflexia, weakness, u wave, hypoactive bowel sounds
peritoneal dialysis outflow less than inflow - charge position, check level of drainage bag, place pt in good body
alignment, check for kinks

Evisceration
1. Stay with client
2. Place low fowlers with knees bent
3. Vitals
4. Have colleague get supplies and call MD
5. Cover with sterile normal saline dressing
6. Prep for surgery
Prolapsed Cord
1. Elevated fetal presenting part that is lying on cord by appliyng finugre pressure with gloved hand
2. Place in trendenlenbrug / modified sims / knee chest
3. O2
4. Assess fetal HR
5. Increase IV
6. Prepare for immediate birth
Condom Catheter
1. Hand hygiene
2. Adjust height of bed
3. Expose perineal minimally
4. Put on gloves

5.
6.
7.
8.
9.
10.
11.

Skin prep on penis

Hold penis with nondominant hand a put condom on tip with 2.5cm of space
Roll down sides of condom over shaft
Use tape to secure
Attach catheter to leg
Observe presence of urine
Remove gloves and hand hygiene

Foley
1. Hand hygiene
2. Setup sterile field
3. Provide Privacy
4. Lower side rail and raise bed to height
5. Put on gloves and wash perineal area
6. Remove gloves and hand hygiene
7. Open sterile package and put on sterile gloves
8. Put antiseptic on cotton balls and check balloon inflation
9. Lubricate catheter and apply drape exposing meatus
10. Cleanse meatus working down glands, repeat 3x
11. Insert catheter into meatus with sterile hand
12. Advance until urine returns and continue to advance 2.5-5cm
13. Release penis and stabilize catheter with non-dominant hand
14. Slowly inflate balloon and release hand and pull back gently
15. Secure catheter to leg and place drainage below level of bladder
16. Dispose of equipment, replace side rail and hand hygiene
Sterile Dressing
1. Wash hands
2. Provide privacy and position
3. Setup disposable bag and apply clean gloves
4. Remove tape and dressing
5. Dispose dressing and gloves
6. Setup sterile field and open sterile supplies
7. Pour cleaning solution into sterile container
8. Apply sterile gloves
9. Inspect wound
10. Cleanse wound
11. Apply dry sterile dressing
12. Secure dressing with tape
13. Date, time initial dressing
14. Remove supplies and wash hands

Positioning

Autograft site immobilized

Burns face + neck HOB elevated
Skin graft elevate and immobilize graft
Burn extremity - elevate above heart
Mastectomy HOB 30 (semi fowler), arm elevated on pillow
Perineal & vaginal lithomy position
Hypophysectomy (pituitary, ADH) elevated HOB
Thyroidectomy semi or fowlers, pillows or sandbags for head/neck support
Hemorrhoidectomy side lying/lateraly
GERD reverse Trendelenburg
Liver biopsy R side lying and pillow/towel under puncture side
Paracentesis semi fowlers or upright in chair with feet supported
NG tube insertion: high fowlers, irrigation/tube feed: HOB 30-45, continuous tube feed: remains
elevated, intermittent tube feeding: up for 1 hour
Rectal enema/irrigation left sims position
Senstaken-blakemore/Minnesota tube HOB elevated, if resp distress cut cord
COPD - sitting position, leaning forward with arms over several pillows or overbed table

Laryngectomy (radial neck dissection) - semi fowlers or fowlers to maintain airway

Bronchoscopy - semi fowlers to prevent aspiration from impaired swallowing
postural drainage - trendelenburg to drain lung
thoracentesis - during: sitting edge of bed leaning over table to promote drainage or lying in bed on
unaffected side with HOB elevated 45, lying in bed on unaffected side
AAA - hob 45, can be turned from side to side
amputation of lower extremity - during first 24, elevate foot of bed, prone 2x/day 20-30min
Cardiac cath bedrest 4-6 hr if femoral artery used, extremity straight, hob 30
CHF, pulmonary edema upright and legs dangling
Arterial vascular grafting of an extremity - bedrest 24 hrs, extremity straight
dvt - bedrest with leg elevated
varicose veins - leg elevation above heart, minimize prolonged sitting/standing
cataract - back or nonoperative side
cerebral aneurysm - bedrest hob 30-45
cerebral angiography - bedrest, extremity with contast straight and immbolized for 6-8 hours
cva - hob 30, for ischemic stroke - hob flat
craniotomy - don't position on operated side, hob 30-45, midline and netural, avoid hip/neck flexion
laminectomy (remove back part of vertebra that covers spinal cord) - logroll, back kept straight
ICP - hob 30-45
lumbar - during: sidelying with back bowed, knees flexed to ab, neck flex to chest. after - supine for 412 hours
myelogram (dye xray for spinal cord) - hob elevated for oil/water dye, hob lower than trunk if air, stop
taking anti depressive/psychotic meds

Answering NCLEX Questions

Maslows Hierarchy of Needs
Physiologic
Safety
Love and Belonging
Esteem
Self-actualization
Nursing Process
Assessment
Diagnosis (Analysis)
Planning
Implementation (treatment)
Evaluation
ABCs
Airway
Breathing
Circulation
Normal Values
Hgb
Males 14-18
Females 12-16
Hct
Males 42-52
Females 37-47
RBCs
Males 4.7-6.1 million
Females 4.2-5.4 million
WBCs
4.5-11k

Platelets
150-400k
PT (Coumadin/Warfarin)
11-12.5 sec (INR and PT TR = 1.5-2 times normal)
APTT (Heparin)
60-70 sec (APTT and PTT TR = 1.5-2.5 times normal)
BUN- 10-20
Creatinine - 0.5-1.2
Glucose- 70-110
Cholesterol- < 200
Bilirubin Newborn- 1-12
Phenylalanine Newborn- < 2, Adult < 6
Na+ 136-145
K+ 3.5-5
HypoK+ . . . Prominent U waves, Depressed ST segment, Flat T waves
HyperK+ . . . Tall T-Waves, Prolonged PR interval, wide QRS
Ca++ 9-10.5
Hypocalcemia muscle spasms, convulsions, cramps/tetany, + Trousseaus, + Chvosteks, prolonged ST interval, prolonged QT
segment
Mg+ 1.5-2.5
Cl- 96-106
Phos 3-4.5
Albumin 3.5-5
Spec Gravity 1.005-1.030
Glycosylated Hemoglobin (Hgb A1c): 4-6% ideal, < 7.5% = OK (120 days)
Dilantin TR = 10-20
Lithium TR = 0.5-1.5
Arterial Blood Gases Used for Acidosis vs. Alkalosis
PH 7.35-7.45
CO2 35-45 (Respiratory driver) High = Acidosis
HCO3 21-28 (Metabolic driver) High = Alkalosis
O2 80-100
O2 Sat 95-100%
Antidotes
- Digoxin Digiband
- Coumadin Vitamin K (Keep PT and INR @ 1-1.5 X normal)
- Benzodiazapines Flumzaemil (Tomazicon)
- Magnesium Sulfate Calcium Gluconate?
- Heparin Protamine Sulfate (Keep APTT and PTT @ 1.5-2.5 X normal)
- Tylenol Mucomist (17 doses + loading dose)
- Opiates (narcotic analgesics, heroin, morphine) Narcan (Naloxone)
- Cholinergic Meds (Myesthenic Bradycardia) Atropine
- Methotrexate Leucovorin
Delegation
- RN Only
Blood Products (2 RNs must check)
Clotting Factors
Sterile dressing changes and procedures
Assessments that require clinical judgment
Ultimately responsible for all delegated duties
- Unlicensed Assistive Personnel
Non-sterile procedures
Precautions & Room Assignments
Universal (Standard) Precautions HIV initiated
Wash hands
Wear Gloves
Gowns for splashes
Masks and Eye Protection for splashes and droplets
Dont recap needles
Mouthpiece or Ambu-bag for resuscitation
Refrain from giving care if you have skin lesion
Droplet (Respiratory) Precautions (Wear Mask)
Sepsis, Scarlet Fever, Strep, Fifth Disease (Parvo B19), Pertussis, Pneumonia, Influenza, Diphtheria, Epiglottitis, Rubella, Rubeola,
Meningitis, Mycoplasma, Adenovirus, Rhinovirus
RSV (needs contact precautions too)
TB Respiratory Isolation
Contact Precautions = Universal + Goggles, Mask and Gown
*No infection patients with immunosuppressed patients*
Weird Miscellaneous Stuff

- Rifampin (for TB) Rust/orange/red urine and body fluids

- Pyridium (for bladder infection) Orange/red/pink urine
- Glasgow Coma Scale < 8 = coma
- Myasthenia Gravis
- Myesthenic Crisis = Weakness with change in vitals (give more meds)
- Cholinergic Crisis = Weakness with no change in vitals (reduce meds)
- Diabetic Coma vs. Insulin Shock Give glucose first If no help, give insulin
- Fruity Breath = Diabetic Ketoacidosis
Acid-Base Balance
If it comes out of your ass, its Acidosis.
Vomiting = Alkalosis
- Skin Tastes Salty = Cystic Fibrosis
- Lipitor (statins) in PMs only No grapefruit juice
- Stroke Tongue points toward side of lesion (paralysis), Uvula deviates away from the side of lesion (paralysis)
- Hold Digoxin if HR < 60
- Stay in bed for 3 hours after first ACE Inhibitor dose
- Avoid Grapefruit juice with Ca++ Channel Blockers
- Anthrax = Multi-vector biohazard
- Pulmonary air embolism prevention = Trendelenburg (HOB down) + on left side (to trap air in right side of heart)
- Head Trauma and Seizures Maintain airway = primary concern
- Peptic Ulcers Feed a Duodenal Ulcer (pain relieved by food) Starve a gastric ulcer
- Acute Pancreatitis Fetal position, Bluish discoloration of flanks (Turners Sign), Bluish discoloration of pericumbelical region
(Cullens Sign), Board like abdomen with guarding Self-digestion of pancreas by trypsin.
- Hold tube feeding if residual > 100mL
- In case of Fire RACE and PASS
- Check Restraints every 30 minutes 2 fingers room underneath
- Guillain-Barre Syndrome Weakness progresses from legs upward Resp arrest
- Trough draw = ~30 min before scheduled administration Peak Draw = 30-60 min after drug administration.
Mental Health & Psychiatry
- Most suicides occur after beginning of improvement with increase in energy levels
MAOIs Hypertensive Crisis with Tyramine foods
Nardil, Marplan, Parnate
Need 2 wk gap from SSRIs and TCAs to admin MAOIs
- Lithium Therapeutic Range = 0.5-1.5
- Phenothiazines (typical antipsychotics) EPS, Photosensitivity
- Atypical Antipsychotics work on positive and negative symptoms, less EPS
- Benzos (Ativan, Lorazepam, etc.) good for Alcohol withdrawal and Status Epilepticus
- Antabuse for Alcohol deterrence Makes you sick with OH intake
- Alcohol Withdrawal = Delirium Tremens Tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia (DTs start
12-36 hrs. after last drink)
- Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose, dilated pupils, NVD, cramps
- Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep
Medical-Surgical
- Hypoventilation = Acidosis (too much CO2)
- Hyperventilation = Alkalosis (low CO2)
- No BP or IV on side of Mastectomy
- Opiate OD = Pinpoint Pupils
- Lesions of Midbrain = Decerebrate Posturing (Extended elbows, head arched back)
- Lesions of Cortex = Decorticate Posturing (Flexion of elbows, wrists, fingers, straight legs, mummy position)
- Urine Output of 30 mL/hr. = minimal competency of heart and kidney function
Kidney Stone = Cholelithiasis
Flank pain = stone in kidney or upper ureter
Abdominal/scrotal pain = stone in mid/lower ureter or bladder
Renal Failure Restrict protein intake
Fluid and electrolyte problems Watch for HyperK+ (dizzy, wk, nausea, cramps, arrhythmias)
Pre-renal Problem = Interference with renal perfusion
Intra-renal Problem= Damage to renal parenchyma
Post-renal Problem = Obstruction in UT anywhere from tubules to urethral meatus.
Usually 3 phases (Oligouric, Diuretic, Recovery)
Monitor Body Wt. and I&Os
- Steroid Effects = Moon face, hyperglycemia, acne, hirsutism, buffalo hump, mood swings, weight gain Spindle shape,
osteoporosis, adrenal suppression (delayed growth in kids) . . . (Cushings Syndrome symptoms)
- Addisons Crisis = medical emergency (vascular collapse, hypoglycemia, tachycardia Admin IV glucose + corticosteroids) No
PO corticosteroids on empty stomach
- Potassium sparing diuretic = Aldactone (Spironolactone) Watch for hyperK+ with this and ACE Inhibitors.
- Cardiac Enzymes Troponin (1 hr.), CKMB (2-4 hr.), Myoglobin (1-4 hr.), LDH1 (12-24 hr.)
- MI Tx Nitro Yes NO Digoxin, Beta-blockers, Atropine
- Fibrinolytics = Streptokinase, Tenecteplase (TNKase)
- CABG = Coronary Artery Bypass Graft
- PTCA = Percutaneous Transluminal Coronary Angioplasty

- Sex after MI okay when able to climb 2 slights of stairs without exertion (Take nitro prophylactically before sex)
- BPH Tx = TURP (Transurethral Resection of Prostate) some blood for 4 days, and burning for 7 days post-TURP.
- Only isotonic sterile saline for Bladder Irrigation
- Post Thyroidectomy Keep tracheostomy set by the bed with O2, suction and Calcium gluconate
- Pericarditis Pericardial Friction Rub, Pain relieved by leaning forward
Post Strep URI Diseases and Conditions:
Acute Glomerulonephritis
Rheumatic Fever Valve Disease
Scarlet Fever
- If a chest-tube becomes disconnected, do not clamp Put end in sterile water
- Chest Tube drainage system should show bubbling and water level fluctuations (tidaling with breathing)
- TB Treatment with multidrug regimen for 9 months Rifampin reduces effectiveness of OCs and turns pee orange Isoniazid
(INH) increases Dilantin blood levels
- Use bronchodilators before steroids for asthma Exhale completely, Inhale deeply, Hold breath for 10 seconds
- Ventilators Make sure alarms are on Check every 4 hours minimum
- Suctioning Pre and Post oxygenate with 100% O2 No more than 3 passes No longer than 15 seconds Suction on
withdrawal with rotation
COPD:
Emphysema = Pink Puffer
Chronic Bronchitis = Blue Bloater (Cyanosis, Rt sided heart failure = bloating/edema)
O2 Administration
Never more than 6L/min by cannula
Must humidify with more than 4L/hr.
No more than 2L/min with COPD (CO2 Narcosis)
In ascending order of delivery potency: Nasal Cannula, Simple Face Mask, Nonrebreather Mask, Partial Rebreather Mask, Venturi
Mask
Restlessness and Irritability = Early signs of cerebral hypoxia
IVs and Blood Product Administration
- 18-19 gauge needle for blood with filter in tubing
- Run blood with NS only and within 30 minutes of hanging
- Vitals and Breath Sounds before, during and after infusion (15 min after start, then 30 min later, then hourly up to 1 hr. after)
- Check Blood: Exp Date, clots, color, air bubbles, leaks
- 2 RNs must check order, pt., blood product Ask Pt. about previous transfusion Hx
- Stay with Pt. for first 15 minutes If transfusion rxn Stop and KVO with NS
- Pre-medicate with Benadryl prn for previous urticaria rxns
Isotonic Solutions
D5W
NS (0.9% NaCl)
Ringers Lactate
NS only with blood products and Dilantin
Diabetes and Insulin
- When in doubt Treat for Hypoglycemia first
- First IV for DKA = NS, then infuse regular insulin IV as Rxd
- Hypoglycemia confusion, HA, irritable, nausea, sweating, tremors, hunger, slurring
- Hyperglycemia weakness, syncope, polydipsia, polyuria, blurred vision, fruity breath
- Insulin may be kept at room T for 28 days
- Draw Regular (Clear) insulin into syringe first when mixing insulins
- Rotate Injection Sites (Rotate in 1 region, then move to new region)
- Rapid Acting Insulins Lispro (Humalog) and Aspart (Novolog) O: 5-15 min, P: .75-1.5 hrs
- Short Acting Insulin Regular (human) O: 30-60 min, P: 2-3 hrs (IV Okay)
- Intermediate Acting Insulin Isophane Insulin (NPH) O: 1-2 hrs, P: 6-12 hrs
- Long Acting Insulin Insulin Glargine (Lantus) O: 1.1 hr., P: 14-20 hrs (Dont Mix)
- Oral Hypoglycemics decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity
and decreasing hepatic glucose production
Glyburide, Metformin (Glucophage), Avandia, Actos
Acarbose blunts sugar levels after meals
Oncology
- Leukemia Anemia (reduced RBC production), Immunosuppression (neutropenia and immature WBCs), Hemorrhage and bleeding
tendencies (thrombocytopenia)
- Acute Lymphocytic = most common type, kids, best prognosis
- Testicular Cancer Painless lump or swelling testicle STE in shower > 14 yrs. 15-35 = Age
- Prostate Cancer > 40 = Age
PSA elevation
DRE
Mets to spine, hips, legs
Elevated PAP (prostate acid phosphatase)
TRUS = Transurethral US
Post Op Monitor of hemorrhage and cardiovascular complication
- Cervical and Uterine Cancer
Laser, cryotherapy, radiation, conization, hysterectomy, exenteration Chemotherapy = No help
PAP smears should start within 3 years of intercourse or by age 21
- Ovarian Cancer = leading cause of death from gynecological cancer
- Breast Cancer = Leading cause of cancer in women

 Upper outer quadrant, left > right

Monthly SBE
Mammography Baseline @ 35, Annually after age 50
Mets to lymph nodes, then lungs, liver, brain, spine
Mastectomy Radical Mastectomy = Lymph nodes too (but no mm resected)
Avoid BP measurements, injections and venipuncture on surgical side
- Anti-emetics given with Chemotherapy Agents (Cytoxan, Methotrexate, Interferon, etc.)
Phenergan (Promethazine HCl)
Compazine (Prochlorperazine)
Reglan (Metoclopramide)
Benadryl (Diphenhydramine)
Zofran (Ondansetron HCl)
Kytril (Granisetron)
Sexually Transmitted Diseases
- Syphilis (Treponema palladium) Chancre + red painless lesion (Primary Stage, 90 days) ... Secondary Stage (up to 6 mo.) =
Rash on palms and soles + Flu-like symptoms Tertiary Stage = Neurologic and Cardiac destruction (10-30 yrs.) Treated with
Penicillin G IM.
- Gonorrhea (Neisseria Gonorrhea) Yellow green urethral discharge (The Clap)
- Chlamydia (Chlamydia Trachomatis) Mild vaginal discharge or urethritis Doxycycline, Tetracycline
- Trichomoniasis (Trichomonas Vaginalis) Frothy foul-smelling vaginal discharge Flagyl
- Candidiasis (Candida Albicans) Yellow, cheesy discharge with itching Miconazole, Nystatin, Clomitrazole (Gyne-Lotrimin)
- Herpes Simplex 2 Acyclovir
- HPV (Human Pappilovirus) Acid, Laser, Cryotherapy
- HIV Cocktails
Perioperative Care
- Breathing Es taught in advance (before or early in pre-op)
- Remove nail polish (need to see cap refill)
- Pre Op Meds as ordered, NPO X 8 hrs, Incentive Spirometry & Breathing Es taught in advance, Void, No NSAIDS X 48 hrs
- Increased corticosteroids for surgery (stress) May need to increase insulin too
- Post Op restlessness may = hemorrhage, hypoxia
- Wound dehiscence or extravasation Wet sterile NS dressing + Call Dr.
- Call Dr. post op if < 30 mL/hr. urine, Sys BP < 90, T > 100 or < 96
- Post Op Monitoring VS and BS Every 15 minutes the first hour, Every 30 min next 2 hours, Every hour the next 4 hours, then
Every 4 hours prn
- 1-4 hrs Post Op = Immediate Stage 2-24 hrs Post Op = Intermediate Stage 1-4 days Post Op = Extended Stage
- Post Op Positioning
THR No Adduction past midline, No hip flexion past 90 degrees
Supratentorial Sx HOB 30-45 degrees (Semi-Fowler)
Infrantentorial Sx Flat
Phlebitis Supine, elevate involved leg
Harris Tube Rt/back/Lt to advance tube in GI
Miller Abbott Tube Right side for GI advancement into small intestine
Thoracocentesis Unaffected side, HOB 30-45 degrees
Enema Left Sims (flow into sigmoid)
Liver Biopsy Right side with pillow/towel against puncture site
Cataract Sx Opp side Semi-Fowler
Cardiac Catheterization Flat (HOB no more than 30 degrees), Leg straight 4-6 hrs, bed rest 6-12 hrs
Burn Autograph Elevated and Immob 3-7 days
Amputation Supine, elevate stump for 48 hrs
Large Brain Tumor Resection On non-operative side
- Incentive Spirometry Inhale slowly and completely to keep flow at 600-900, Hold breath 5 seconds, 10 times per hr.
- Post Op Breathing Exercises Every 2 hours
Sit up straight
Breath in deeply thru nose and out slowly thru pursed lips
Hold last breath 3 seconds
Then cough 3 times (unless abd wound reinforce/splint if cough)
- Watch for Stridor after any neck/throat Sx Keep Trach kit at bedside
- Staples and sutures removed in 7-14 days Keep dry until then
- No lifting over 10 lbs. for 6 weeks (in general)
- If chest tube comes disconnected, put free end in container of sterile water
- Removing Chest Tube Valsalvas, or Deep breath and hold
- If chest tube drain stops fluctuating, the lung has re-inflated (or there is a problem)
- Keep scissors by bed if pt. has S. Blakemore Tube (for esoph varices) Sudden respiratory distress Cut inflation tubes and
remove
- Tracheostomy patients Keep Kelly clamp and Obturator (used to insert into trachea then removed leaving cannula) at bedside
- Turn off NG suction for 30 min after PO meds
- NG Tube Removal Take a deep breath and hold it
- Stomach contents pH = < 4 (gastric juices aspirated)
- NG Tube Insertion If cough and gag, back off a little, let calm, advance again with pt. sipping water from straw
- NG Tube Length End of nose, to era lobe, to xyphoid (~22-26 inches)
- Decubitus (pressure) Ulcer Staging
Stage 1 = Erythema only

 Stage 2 = Partial thickness

Stage 3 = Full thickness to SQ
Stage 4 = Full thickness + involving mm /bone
Acute Care
- CVA Hemorrhagic or Embolic
A-fib and A-flutter = thrombus formation
Dysarthria (verbal enunciation/articulation), Apraxia (perform purposeful movements), Dysphasia (speech and verbal
comprehension), Aphasia (speaking), Agraphia (writing), Alexia (reading), Dysphagia (swallowing)
Left Hemisphere Lesion aphasia, agraphia, slow, cautious, anxious, memory okay
Right Hemisphere Lesion cant recognize faces, loss of depth perception, impulsive behavior, confabulates, poor judgment,
constantly smiles, denies illness, loss of tonal hearing
- Head Injuries
Even subtle changes in mood, behavior, restlessness, irritability, confusion may indicate increased ICP
Change in level of responsiveness = Most important indicator of increased ICP
Watch for CSF leaks from nose or ears Leakage can lead to meningitis and mask intracranial injury since usual increased ICP
symps may be absent.
- Spinal Cord Injuries
Respiratory status paramount C3-C5 innervates diaphragm
1 wk to know ultimate prognosis
Spinal Shock = Complete loss of all reflex, motor, sensory and autonomic activity below the lesion = Medical emergency
Permanent paralysis if spinal cord in compressed for 12-24 hrs
Hypotension and Bradycardia with any injury above T6
Bladder Infection = Common cause of death (try to keep urine acidic)
- Burns
Infection = Primary concern
HyperK+ due to cell damage and release of intracellular K+
Give meds before dressing changes Painful
Massive volumes of IV fluid given, due to fluid shift to interstitial spaces and resultant shock
First Degree = Epidermis (superficial partial thickness)
Second Degree = Epidermis and Dermis (deep partial thickness)
Third Degree = Epidermis, Dermis, and SQ (full thickness)
Rule of 9s Head and neck = 9%, UE = 9% each, LE = 18% each, Front trunk = 18%, Back Trunk = 18%
Singed nasal hair and circumoral soot/burns = Smoke inhalation burns
- Fractures
Report abnormal assessment findings promptly Compartment Syndrome may occur = Permanent damage to nerves and vessels
5 Ps of neurovascular status (important with fractures)
Pain, Pallor, Pulse, Paresthesia, Paralysis
Provide age-appropriate toys for kids in traction
Special Tests and Pathognomonic Signs
- Tensilon Test Myasthenia Gravis (+ in Myesthenic crisis, - in Cholinergic crisis)
- ELISA and Western Blot HIV
- Sweat Test Cystic Fibrosis
- Cheilosis = Sores on sides of mouth Riboflavin deficiency (B2)
- Trousseaus Sign (Carpal spasm induced by BP cuff) Hypocalcemia (hypoparathyroidism)
- Chvosteks Sign (Facial spasm after facial nerve tap) Hypocalcemia (hypoparathyroidism)
- Bloody Diarrhea = Ulcerative Colitis
- Olive-Shaped Mass (epigastric) and Projectile Vomiting = Pyloric Stenosis
- Current Jelly Stool (blood and mucus) and Sausage-Shaped Mass in RUQ = Intussusception
- Mantoux Test for TB is + if 10 mm induration 48 hrs post admin (previous BCG vaccine recipients will test +)
- Butterfly Rash = SLE Avoid direct sunlight
- 5 Ps of NV functioning Pain, paresthesia, pulse, pallor, paralysis
- Cullens Sign (periumbelical discoloration) and Turners Sign (blue flank) = Acute Pancreatitis
- Murphys Sign (Rt. costal margin pain on palp with inspiration) = GB or Liver disease
- HA more severe on wakening = Brain Tumor (remove benign and malignant)
- Vomiting not associated with nausea = Brain Tumor
- Elevated ICP = Increased BP, widened pulse pressure, increased Temp
- Pill-Rolling Tremor = Parkinsons (Tx with Levodopa, Cardidopa) Fall precautions, rigid, stooped, shuffling
- IG Bands on Electrophoresis = MS Weakness starts in upper extremities bowel/bladder affected in 90% Demyelination - Tx
with ACTH, corticosteroids, Cytoxan and other immunosuppressants
- Reed-Sternberg Cells = Hodgkins
- Koplik Spots = Rubeola (Measles)
- Erythema Marginatum = Rash of Rheumatic Fever
- Gowers Sign = Muscular Dystrophy Like Minors sign (walks up legs with hands)
Pediatrics
Bench Marks
Birth wt. doubles at 6 months and triples at 12 months
Birth length increases by 50% at 12 months
Post fontanel closes by 8 wks.
Ant fontanel closes by 12-18 months
Moro reflex disappears at 4 months

 Steady head control achieved at 4 months

Turns over at 5-6 months
Hand to hand transfers at 7 months
Sits unsupported at 8 months
Crawls at 10 months
Walks at 10-12 months
Cooing at 2 months
Monosyllabic Babbling at 3-6 months, Links syllables 6-9 mos.
Mama, Dada + a few words at 9-12 months
Throws a ball overhand at 18 months
Daytime toilet training at 18 mo. - 2 years
2-3 word sentences at 2 years
50% of adult Ht at 2 years
Birth Length doubles at 4 years
Uses scissors at 4 years
Ties shoes at 5 years
Girls growth spurt as early at 10 years Boys catch up ~ Age 14
Girls finish growing at ~15 Boys ~ 17
Autosomal Recessive Diseases
CF, PKU, Sickle Cell Anemia, Tay-Sachs, Albinism,
25% chance if: AS (trait only) X AS (trait only)
50% chance if: AS (trait only) X SS (disease)
Autosomal Dominant Diseases
Huntingtons, Marfans, Polydactyl, Achondroplasia, Polycystic Kidney Disease
50% if one parent has the disease/trait (trait = disease in autosomal dominant)
X-Linked Recessive Diseases
Muscular Dystrophy, Hemophilia A
Females are carriers (never have the disease)
Males have the disease (but cant pass it on)
50% chance daughters will be carriers (cant have disease)
50% chance sons will have the disease (not a carrier = cant pass it on)
This translates to an overall 25% chance that each pregnancy will result in a child that has the disease
- Scoliosis Milwaukee Brace 23 hrs/day, Log rolling after Sx
- Down Syndrome = Trisomy 21 Simian creases on palms, hypotonia, protruding tongue, upward outward slant of eyes
- Cerebral Palsy Scissoring = legs extended, crossed, feet plantar-flexed
- PKU leads to MR Guthrie Test Aspartame (NutraSweet) has phenylalanine in it and should not be given to PKU patient
- Hypothyroidism Leads to MR
- Prevent Neural tube disorders with Folic Acid during PG
- Myelomeningocele Cover with moist sterile water dressing and keep pressure off
- Hydrocephalus Signs of increased ICP are opposite of shock
Shock = Increased pulse and decreased BP
IICP = Decreased pulse and increased BP (+ Altered LOC = Most sensitive sign)
Infants ... IICP = Bulging fontanels, high pitched cry, increased hd circum, sunset eyes, wide suture lines, lethargy Treat with
peritoneal shunt dont pump shunt. Older kids IIPC = Widened pulse pressure
IICP caused by suctioning, coughing, straining, and turning Try to avoid
- Muscular Dystrophy X-linked Recessive, waddling gait, hyper lordosis, Gowers Sign = difficulty rising walks up legs (like Minors
sign), fat pseudohypertrophy of calves.
- Seizures Nothing in mouth, turn hd to side, maintain airway, dont restrain, keep safe Treat with Phenobarbital (Luminol),
Phenytoin (Dilantin: TR = 10-20 Gingival Hyperplasia), Fosphenytoin (Cerebyx), Valproic Acid (Depakene), Carbamazepine
(Tegritol)
- Meningitis (Bacterial) Lumbar puncture shows Increased WBC, protein, IICP and decreased glucose
May lead to SIADH (Too much ADH) Water retention, fluid overload, dilutional hyponatremia
- CF Kids taste salty and need enzymes sprinkled on their food
- Children with Rubella = threat to unborn siblings (may require temporary isolation from Mom during PG)
- Pain in young children measured with Faces pain scale
- No MMR Immunization for kids with Hx of allergic rxn to eggs or neomycin
- Immunization Side Effects T < 102, redness and soreness at injection site for 3 days give Tylenol and bike pedal legs
(passively) for child.
- Call Physician if seizures, high fever, or high-pitched cry after immunization
- All cases of poisoning Call Poison Control Center No Ipecac!
- Epiglottitis = H. influenza B Child sits upright with chin out and tongue protruding (maybe Tripod position) Prepare for
intubation or trach DO NOT put anything into kids mouth
- Isolate RSV patient with Contact Precautions Private room is best Use Mist Tent to provide O2 and Ribavirin Flood tent with
O2 first and wipe down inside of tent periodically so you can see patient
- Acute Glomerulonephritis After B strep Antigen-Antibody complexes clog up glomeruli and reduce GFR = Dark urine,
proteinuria
- Wilms Tumor = Large kidney tumor Dont palpate
- TEF = Tracheoesophageal Atresia 3 Cs of TEF = Coughing, Choking, Cyanosis
- Cleft Lip and Palate Post-Op Place on side, maintain Logan Bow, elbow restraints
- Congenital Megacolon = Hirschsprungs Disease Lack of peristalsis due to absence of ganglionic cells in colon Suspect if no
meconium w/in 24 hrs or ribbon-like foul smelling stools
- Iron Deficiency Anemia Give Iron on empty stomach with citrus juice (vitamin C enhances absorption), Use straw or dropper to
avoid staining teeth, Tarry stools, limit milk intake < 32 oz./day

- Sickle Cell Disease Hydration most important SC Crisis = fever, abd pain, painful edematous hands and feet (hand-foot
syndrome), arthralgia Tx + rest, hydration Avoid high altitude and strenuous activities
- Tonsillitis usually Strep Get PT and PTT Pre-Op (ask about Hx of bleeding) Suspect Bleeding Post-Op if frequent swallowing,
vomiting blood, or clearing throat No red liquids, no straws, ice collar, soft foods Highest risk of hemorrhage = first 24 hrs and
5-10 days post-op (with sloughing of scabs)
- Primary meds for ER for respiratory distress = Sus-phrine (Epinephrine HCl) and Theophylline (Theo-dur) Bronchodilators
-Must know normal respiratory rates for kids Respiratory disorders = Primary reason for most medical/ER visits for kids
Newborn 30-60
1-11 mo. 25-35
1-3 years 20-30
3-5 years 20-25
6-10 years 18-22
11-16 years 16-20
Cardiovascular Disorders
- Acyanotic = VSD, ASD, PDA, Coarc of Aorta, Aortic Stenosis
Antiprostaglandins cause closure of PDA (aorta - pulmonary artery)
- Cyanotic = Tetralogy of Fallot, Truncus Arteriosis (one main vessel gets mixed blood), TVG (Transposition of Great Vessels)
Polycythemia common in Cyanotic disorders
3 Ts of Cyanotic Heart Disease (Tetralogy, Truncus, Transposition)
- Tetralogy of Fallot Unoxygenated blood pumped into aorta
Pulmonary Stenosis
VSD
Overriding Aorta
Right Ventricular Hypertrophy
TET Spells Hypoxic episodes that are relieved by squatting or knee chest position
- CHF can result Use Digoxin TR = 0.8-2.0 for kids
- Ductus Venosus = Umbelical Vein to Inferior Vena Cava
- Ductus Arteriosus = Aorta to Pulmonary Artery
- Rheumatic Fever Acquired Heart Disease Affects aortic and mitral valves
Preceded by beta hemolytic strep infection
Erythema Marginatum = Rash
Elevated ASO titer and ESR
Chest pain, shortness of breath (Carditis), migratory large joint pain, tachycardia (even during sleep)
Treat with Penicillin G = Prophylaxis for recurrence of RF
Maternity
- Day 1 of cycle = First day of menses (bleeding) Ovulation on Day 14 28 days total Sperm 3-5 days, Eggs 24 hrs
Fertilization in Fallopian Tube
- Chadwicks Sign = Bluing of Vagina (early as 4 weeks)
- Hagars Sign = Softening of isthmus of cervix (8 weeks)
- Goodells Sign = Softening of Cervix (8 weeks)
- Pregnancy Total wt. gain = 25-30 lbs. (11-14 kg)
- Increase calorie intake by 300 calories/day during PG Increase protein 30 g/day Increase iron, Ca++, Folic Acid, A & C
- Dangerous Infections with PG TORCH = Toxoplasmosis, other, Rubella, Cytomegalovirus, HPV
- Braxton Hicks common throughout PG
- Amniotic fluid = 800-1200 mL (< 300 mL = Oligohydramnios = fetal kidney problems)
- Polyhydramnios and Macrosomia (large fetus) with Diabetes
- Umbelical cord: 2 arteries, 1 vein Vein carries oxygenated blood to fetus (opposite of normal)
- FHR = 120-160
- Folic Acid Deficiency = Neural tube defects
- Pre-term = 20-37 weeks
- Term = 38-42 weeks
- Post-term = 42 weeks+
- TPAL = Term births, Pre-term births, Abortions, Living children
- Gravida = # of Pregnancies regardless of outcome
- Para = # of Deliveries (not kids) after 20 wks. gestation
- Nagales Rule Add 7 days to first day of last period, subtract 3 months, add 12 months = EDC
- Hgb and Hct a bit lower during PG due to hyperhydration
- Side-lying is best position for uteroplacental perfusion (either side the left is traditional)
- 2:1 Lecithin:Sphingomyelin Ratio = Fetal lungs mature
- AFP in amniotic fluid = possible neural tube defect
- Need a full bladder for Amniocentesis early in PG (but not in later PG)
- Lightening = Fetus drops into true pelvis
- Nesting Instinct = Burst of Energy just before labor
- True Labor = Regular contractions that intensify with ambulation, LBP that radiates to abdomen, progressive dilation and
effacement
- Station = Negative above ischial spines, Positive below
- Leopold Maneuver tries to reposition fetus for delivery
- Laboring Maternal Vitals Pulse < 100 (usually a little higher than normal with PG - BP is unchanged in PG). T < 100.4
- NON-Stress Test Reactive = Healthy (FHR goes up with movements)
- Contraction Stress Test (Oxytocin Challenge Test) Unhealthy = Late decels noted (positive result) indicative of UPI Negative
result = No late decels noted (good result)
- Watch for hyporeflexia with Mag Sulfate admin . . . Diaphragmatic Inhibition

 Keep Calcium gluconate by the bed (antidote)

Firsts
Fetal HB 8-12 weeks by Doppler, 15-20 weeks by fetoscope
Fetal movement = Quickening, 14-20 weeks
Showing = 14 weeks
Braxton Hicks 4 months and onward
- Early Decels = Head compression = OK
- Variable Decels = Cord compression = Not Good
- Late Decels = Utero-placental insufficiency = BAD!
- If Variable or Late Decels Change maternal position, Stop Pitocin, Administer O2, Notify Physician
- DIC Tx is with Heparin (safe in PG) Fetal Demise, Abruptio Placenta, Infection
Fundal Heights
12-14 wks. At level of symphysis
20 weeks 20 cm = Level of umbilicus
Rises ~ 1 cm per week
Stages of Labor
Stage 1 = Beginning of Regular contraction to full dilation and effacement
Stage 2 = 10 cm dilation to delivery
Stage 3 = Delivery of Placenta
Stage 4 = 1-4 Hrs following delivery
- Placenta Separation Lengthening of cord outside vagina, gush of blood, full feeling in vagina Give oxytocin after placenta is out
Not before.
- Schultz Presentation = Shiny side out (fetal side of placenta)
Postpartum VS Schedule
Every 15 min X 1 hr.
Every 30 min X next 2 hours
Every Hour X next 2-6 hours
Then every 4 hours
- Normal BM for mom within 3 days = Normal
- Lochia no more than 4-8 pads/day and no clots > 1 cm Fleshy smell is normal, Foul smell = infection
- Massage boggy uterus to encourage involution empty bladder ASAP may need to catheterize Full bladder can lead to uterine
atony and hemorrhage
- Tears 1st Degree = Dermis, 2nd Degree = mm/fascia, 3rd Degree = anal sphincter, 4th Degree = rectum
- APGAR = HR, R, mm tone, Reflex irritability, Color 1 and 5 minutes 7-10 = Good, 4-6 = moderate resuscitative efforts, 1-3 =
mostly dead
- Eye care = E-mycin + Silver Nitrate for gonorrhea
- Pudendal Block = decreases pain in perineum and vagina No help with contraction pain
- Epidural Block = T10-S5 Blocks all pain First sign = warmth or tingling in ball of foot or big toe
- Regional Blocks often result in forceps or vacuum assisted births because they affect the mothers ability to push effectively
- WBC counts are elevated up to 25,000 for ~10 days post partum
- Rho(D) immune globulin (RhoGAM) is given to Rh- mothers who deliver Rh+ kids Not given if mom has a +Coombs Test She
already has developed antibodies (too late)
- Caput Succedaneum = edema under scalp, crosses suture lines
- Cephalhematoma = blood under periosteum, does not cross suture lines
- Suction Mouth first then nostrils
- Moro Reflex = Startle reflex (abduction of all extremities) up to 4 months
- Rooting Reflex up to 4 months
- Babinski Reflex up to18 months
- Palmar Grasp Reflex Lessens by 4 months
- Ballard Scale used to estimate gestational age
- Heel Stick = lateral surface of heel
- Physiologic Jaundice is normal at 2-3 days Abnormal if before 24 hours or lasting longer than 7 days Unconjugated bilirubin is
the culprit.
- Vitamin K given to help with formation of clotting factors due to fact that the newborn gut lacks the bacteria necessary for vitamin
K synthesis initially Vastus lateralis mm IM
- Abrutio Placenta = Dark red bleeding with rigid board like abdomen
- Placenta Previa = Painless bright red bleeding
- DIC = Disseminated Intravascular Coagulation clotting factors used up by intravascular clotting Hemorrhage and increased
bleeding times result Associated with fetal demise, infection and abruptio placenta.
- Magnesium Sulfate used to reduce preterm labor contractions and prevent seizures in Pre-Eclampsia Mg replaces Ca++ in the
smooth mm cells resulting relaxation Can lead to hyporeflexia and respiratory depression Must keep Calcium Gluconate by bed
when administering during labor = Antidote Monitor for:
Absent DTRs
Respirations < 12
Urinary Output < 30/hr.
Fetal Bradycardia
- Pitocin (Oxytocin) use for Dystocia If uterine tetany develops, turn off Pitocin, admin O2 by face mask, turn pt. on side. Pitocin
can cause water intoxication owing to ADH effects.
- Suspect uterine rupture if woman complains of a sharp pain followed by cessation of contractions
- Pre-Eclampsia = Htn + Edema + Proteinuria
- Eclampsia = Htn + Edema + Proteinuria + Seizures and Coma Suspect if Severe HA + visual disturbances
- No Coumadin during PG (Heparin is OK)
- Hyperemesis Gravidarum = uncontrollable nausea and vomiting May be related to H. pylori Reglan (metaclopromide)

- Insulin demands drop precipitously after delivery

- No oral hypoglycemics during PG Teratogenic Insulin only for control of DM
- Babies born without vaginal squeeze more likely to have respiratory difficulty initially
- C-Section can lead to Paralytic Ileus Early ambulation helps
- Postpartum Infection common in problem pregnancies (anemia, diabetes, traumatic birth)
- Postpartum Hemorrhage = Leading cause of maternal death Risk factors include:
Dystocia, prolonged labor, over distended uterus, abrutio placenta, infection
Tx includes Fundal massage, count pads, VS, IV fluids, Oxytocin, notify physician
- Jitteriness is a symptom of hypoglycemia and hypocalcemia in the newborn
- Hypoglycemia tremors, high pitched cry, seizures
- High pitched cry + bulging fontanels = IICP
- Hypothermia can lead to Hypoxia and acidosis Keep warm and use bicarbonate prn to treat acidosis in newborn.
- Lay on right side after feeding Move stomach contents into small intestine
- Jaundice and High bilirubin can cause encephalopathy < 12 = normal Phototherapy decomposes bilirubin via oxidation
Protect eyes, turn every 2 hours and watch for dehydration The dangerous bilirubin is the unconjugated indirect type.
Nutrition
- K+ Bananas, dried fruits, citrus, potatoes, legumes, tea, peanut butter
- Vitamin C Citrus, potatoes, cantaloupe
- Ca++ Milk, cheese, green leafy veggies, legumes
- Na+ Salt, processed foods, seafood
- Folic Acid Green leafy veggies, liver, citrus
- Fe++ Green leafy veggies, red meat, organ meat, eggs, whole wheat, carrots, oatmeal, clams, egg yolk
Fiber pears, split pea, lentil/beans, artichoke, raspberries, whole grain, tomatoes, carrot, apple
Use Z-track for injections to avoid skin staining
- Mg+ Whole grains, green leafy veggies, nuts
- Thiamine (B1) Pork, beef, liver, whole grains
- B12 Organ meats, green leafy veggies, yeast, milk, cheese, shellfish
Deficiency = Big red beefy tongue, Anemia
- Vitamin K Green leafy veggies, milk, meat, soy
- Vitamin A Liver, orange and dark green fruits and veggies
- Vitamin D Dairy, fish oil, sunlight
- Vitamin E Veggie oils, avocados, nuts, seeds
- BMI 18.5-24.9 = Normal (Higher = Obese)
Gerontology
- Essentially everyone goes to Hell in a progressively degenerative hand-basket
Thin skin, bad sleep, mm wasting, memory loss, bladder shrinks, incontinence, delayed gastric emptying, COPD, Hypothyroidism,
Diabetes
- Common Ailments:
Delirium and Dementia
Cardiac Dysrhythmias
Cataracts and Glaucoma
CVA (usually thrombotic, TIAs common)
Decubitus Ulcers
Hypothyroidism
Thyrotoxicosis (Graves Disease)
COPD (usually combination of emphysema and CB)
UTIs and Pneumonia Can cause confusion and delirium
- Memory loss starts with recent progresses to full
- Dementia = Irreversible (Alzheimers) Depression, Sun downing, Loss of family recognition
- Delirium = Secondary to another problem = Reversible (infections common cause)
- Medication Alert! Due to decreased renal function, drugs metabolized by the kidneys may persist to toxic levels
- When in doubt on NCLEX Answer should contain something about exercise and nutrition.
Advanced Clinical Concepts
Erickson Psycho-Social Development
0-1 yr. (Newborn) Trust vs. Mistrust
1-3 yrs. (Toddler) Autonomy vs. Doubt and Shame Fear intrusive procedures - Security objects good (Blankies, stuffed
animals)
3-6 yrs. (Pre-school) Initiative vs. Guilt Fear mutilation Band-Aids good
6-12 yrs. (School Age) Industry vs. Inferiority Games good, Peers important Fear loss of control of their bodies
12-19 yrs. (Adolescent) Identity vs. Role Confusion Fear Body Image Distortion
20-35 yrs. (Early Adulthood) Intimacy vs. Isolation
35-65 yrs. (Middle Adulthood) Generativity vs. Stagnation
Over 65 (Older Adulthood) Integrity vs. Despair
Piaget Cognitive Development
Sensorimotor Stage (0-2) Learns about reality and object permanence
Preoperational Stage (2-7) Concrete thinking
Concrete Operational Stage (7-11) Abstract thinking
Formal Operational Stage (11-adult) Abstract and logical thinking
Freud Psycho-Sexual Development

 Oral Stage (Birth -1 year) Self gratification, Id is in control and running wild
Anal Stage (1-3) Control and pleasure wrt retention and pooping Toilet training in this stage
Phallic Stage (3-6) Pleasure with genitals, Oedipus complex, SuperEgo develops
Latency Stage (6-12) Sex urges channeled to culturally acceptable level, Growth of Ego
Genital Stage (12 up) Gratification and satisfying sexual relations, Ego rules
Kohlberg Moral Development
Moral development is sequential but people do not aromatically go from one stage to the next as they mature
Level 1 = Pre-conventional Reward vs. Punishment Orientation
Level 2 = Conventional Morality Conforms to rules to please others
Level 3 = Post- Conventional Rights, Principles and Conscience (Best for All is a concern)
Calculations Rules & Formulas
-Round final answer to tenths place
-Round drops to nearest drop
-When calculating mL/hr., round to nearest full mL
-Must include 0 in front of values < 1
-Pediatric doses rounded to nearest 100th. Round down for peds
-Calculating IV Flow Rates
-Total mL X Drop Factor / 60 X #Hrs = Flow Rate in gtts/min
Calculating Infusion Times
Total mL X Drop Factor / Flow Rate in gtts/min X 60 = Hrs to Infuse
Conversions
-1 t = 5mL
-1 T = 3 t = 15 mL
-1 oz. = 30 cc = 30 mL = 2 T
-1 gr = 60 mg
-1 mg = 1000 ug (or mcg)
-1 kg = 2.2 lbs.
-1 cup = 8 oz. = 240 mL
-1 pint = 16 oz.
-1 quart = 32 oz.
-Degrees F = (1.8 X C) + 32
-Degrees C = (F 32) / 1.8
-37 C = 98.6 F
-38 C = 100.4 F
-39 C = 102.2 F
-40 C = 104 F
Fall Precautions
-Room close to nurses station
-Assessment and orientation to room
-Get help to stand (dangle feet if light headed)
-Bed low with side rails up
-Good lighting and reduce clutter in room
-Keep consistent toileting schedule
-Wear proper non-slip footwear
-At home
Paint edges of stairs bright color
Bell on cats and dogs
Neutropenic (Immunosuppressed) Precautions
-No plants or flowers in room
-No fresh veggies Cooked foods only
-Avoid crowds and infectious persons
-Meticulous hand washing and hygiene to prevent infection
-Report fever > 100.5 (immunosuppressed pts. may not manifest fever with infection)
Bleeding Precautions (Anticoagulants, etc.)
-Soft bristled toothbrush
-Electric razor only (no safety razors)
-Handle gently, Limit contact sports
-Rotate injection sites with small-bore needles for blood thinners
-Limit needle sticks, Use small bore needles, Maintain pressure for 5 minutes on venipuncture sites
-No straining at stool - Check stools for occult blood (Stool softeners prn)
-No salicylates, NSAIDs, or suppositories
-Avoid blowing or picking nose
-Do not change Vitamin K intake if on Coumadin