UWorld NCLEX-RN QBank 2018 PDF

2/18/2018 UWorld NCLEX-RN QBank
QId: 30030 Adult Health - Gastrointestinal/Nutrition

Post-op after laparoscopic cholecystectomy : HIGHEST PRIORTY
PLACE IN SIMS POSITION -PREVENT RESPIRATORY
COMPLICATIONS (carbon dioxide that was utilized during surgery to
fill abdominal cavity

GI/ Nutrition
Endoscopy
Esophagogastroduodenoscopy (EGD)
A SUDDEN TEMP SPIKE AFTER AN EGD (101.2), COULD BE A
SIGN OF PERFORATION OR A DEVELOPING INFECTION=
NOTIFY HCP
ABSENT GAG REFLEX AFTER PROLONGED PERIOD (6 HOURS)

REPORT TO HCP

Peptic Ulcer : AVOID
1. NSAIDS (can cause bleeding)

2. Smoking
3. Alcohol / Caffeine
4. Spicy foods
Tx for Peptic Ulcer: triple-drug therapy to avoid relapse (take for 7-14
days)
1. Omeprazole (Prilosec)
2. Amoxicillin
3. Clarithromycin (Biaxin)
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 1/103
QId: 30088 Adult Health - Neurologic

Cranial nerve IX glossophayngeal is involved in the gag reflex, ability to
swallow, phonation and taste
Post-op partial laryngectomy- teach them the supraglottic swallow:

Instructions:
1. inhale deeply
2. hold breath tightly to close the vocal cords
3. place food in mouth and swallow while continuing to hold breath
4. cough to dispel remaining food from vocal cords
5. swallow a second time before breathing
Cranial nerve VIII vestibulocochlear affects hearing and equilibrium
QId: 30105 Fundamentals - Safety/Infection Control

C-diff requires contact precautions
Required: gown and gloves
Private room or cohort with other C-diff infected clients
Discard gown and nitrile gloves before leaving room
Wash hands with soap and water
No alcohol-based hand sanitizers
Dedicated equipment remain in room (BP cuffs, stethoscope)
Airborne
required: N95
Droplet
required: surgical mask
QId: 30111 Adult Health - Integumentary

Review Rule of Nines
Head 9
Anterior Trunk 18
Posterior Trunk 18
Each arm 9 (front and back each 4.5)
Perineal 1

Know the parkland formula
4mL * (weight in kg) * (% percentage of body surface area burned)

Enteral feedings maintain gut integrity and helps prevent stress ulcers
with clients during sepsis and respiratory failure
Enteral feedings have lower infection compliations compared to

parenteral feedings (TPN)
QId: 30140 Fundamentals - Skills/Procedures

1 mg = 1000 mcg
(small to big)
1000 mcg = 1mg

(big to small)
QId: 30143 Leadership & Management - Leadership & Management

Concepts
Prioritization
Hypoglcemia= blood suger <70 is life threatening

S/S: tachycardia, shakiness, sweating, hunger, anxiety, pallor,
confusion/disorientation, impaired vision and speech, seizures and coma
QId: 30200 Critical Care - Critical Care Concepts

Spinal cord injury (Neurogenic shock) s/s: causes a disruption of the
sympathetic nervous system
Hypotension
Bradycardia
Warm/Dry skin
QId: 30213 Adult Health - Respiratory

Chest tube
Suction control chamber = EXPECT GENTLE CONTINUOUS

BUBBLING; ALWAYS KEEP 20CM OF STERILE WATER IN THIS
CHAMBER
AIR LEAK MONITOR= ITS PART OF THE WATER SEAL

CHAMBER....CONTINUOUS OR INTERMITTENT BUBBLING
INDICATES = AIR LEAK
QId: 30217 Mental Health - Mental Health Concepts

Delirium is a acute onset of disturbed state of mind
Risk factors in hospitalized clients:

1. Advanced age >65
2. Neuro-degenerative disease (stroke, dementia)
3. polypharmacy
4. coexisting medical conditions (infection)

5. acid-base/arterial blood gas imbalance (acidosis, hypercarbia,
hypoxemia)
6. Metabolic/electrolyte imbalances
7. impaired mobility- EARLY AMBULATION PREVENTS DELIRIUM
8. surgery (post-op setting)
9. untreated pain/ inadequate analgesia

Atelectasis = for post op clients that have respiratory problems such as
pneumonia, its best to use an incentive spirometer
Flid overload= best to give diuretics for fluid volume overload

Airway Clearance diagnosis - IMPAIRED WITH INADEQUATE
HYDRATION (this will help thin secretions and facilitate expectorate of
mucus) =CLIENT WITH COMMUNITY-ACQUIRED PNEUMONIA
QId: 30260 Pharmacology - Cardiovascular

SVT - DOC is ADENOSINE
Give Adenosine 6mg IV rapidly over 1-2 seconds followed by a 20 mL

saline flush
Repeat boluses of 12 mg may be given twice if rhythm persists
Injection site should be close to the heart (ANTECUBITAL AREA)
Brief period of asystole is ok bc adenosine is slowing condution in AV
node
Monitor client for flushing dizziness, chest pain, palpitations during and
after administration of ADENOSINE

COPD clients with exacerbation
Morphine and other medications such as Benzodiazepines can depress

the respiratory center and SHOULD NOT be used in clients with COPD
exacerbations, can worsen CO2 (carbon dioxide) retention
Can use during acute COPD exacerbations:

Albuterol - beta agonist; rapid and short-acting
Methylprednisolone (Solu-Medrol)- corticosteroid, can decrease
inflammation
Initiation of low flow oxygen 2 L/min by nasal cannula
QId: 30277 Pharmacology - Respiratory

Albuterol - nebulizer treatment for asthma exacerbation client
Therapeutic effects are: RESPIRATORY RATE decreases and PEAK

FLOW increases
Short Acting Beta Agonists SE: tachycardia, tremors, palpitations

restlessness and HYPOKALEMIA

MUST KNOW!
Take notes in the morning about Valsalva maneuver

Diagnosed with chronic anxiety. Client possesses resilience when:
Practices stress reduction techniques daily
Resilience centers on the adaptive techniques an individual uses to

address the resulting symptoms

CODP patient use pursed lip breathing = prevent airway collapse and
promote carbon dioxide elimination
Regular practice (5-10 minutes 4 times daily)
Pursed-Lip Breathing Steps:

1. Relax the neck and shoulders
2. Inhale for 2 secs through the nose with mouth closed
3. Exhale for 4 secs through pursed lips. If unable to exhale for this long,
exhale twice as long as inhaling

Albuterol short-acting beta agonist (SABA) for quick relief; (wheezing,
breathlessness, chest tightness) = RESCUE DRUG; AS-NEEDED
BASIS ONLY
Beclomethasone is an inhaled corticosteroid (ICS) for long-term; USED

TO PREVENT EXACERBATIONS; first-line drug for inflammation;
DO NOT OMIT EVEN IF SABA WAS EFFECTIVE
SABA FIRST.......ICS SECOND; SABA IS NOT ALWAYS TAKEN

WITH THE ICS
SABA = take it apart, wash mouthpiece only not the canister under
warm water and let air dry 1-2 times a week
ICS= take it apart and wash it daily

Partial Gastrectomy- removal part of the stomach; these clients
experience DUMPING SYNDROME (gastric contents are emptied to
rapidly into duodenum)
Dumping Syndrome s/s: HYPOTENSION, ABDOMINAL PAIN,

DIARRHEA, N/V, DIZZINESS, GENERALIZED SWEATING,
TACHYCARDIA
Dietary teachings to delay gastric emptying: small frequent meals; eat

slow; avoid high simple carbohydrates (sugar, syrup); consume DIET
HIGH IN PROTEIN, FAT, FIBER, LOW CARBS (takes longer to digest
and remain in stomach longer than carbs); fluid intake after meals or
between meals; AVOID sitting up after meals
LAYING DOWN AFTER MEALS= CLIENT DO THIS...GOOD ;-)

Albuterol is for short-term use for acute asthma exacerbation; RESCUE
INHALER
SE: insomnia, N/V, palpitations (tachycardia), mild tremor
Dosing of albuterol in an acute asthma attack should not exceed 2-4

puffs every 20 minutes x 3
If the albuterol is not effective, an inhaled corticosteroid is used to treat

the inflammatory component

Thiamine is given to clients with history of chronic alcohol abuse
Purpose for Thiamine is to prevent Wernicke encephalopathy
Gross tremors with alcoholics treated with benzodiazepines (endings

EPAM...OLAM)
Seizures with alcoholics are treated with benzodiazepines

BLOOD TRANSFUSION HEMOLYTIC REACTION
s/s: fever, chills, nausea, vomiting, pruritus, hypotension, decreased
urine output, back pain, dyspnea
Drag and drop

1. Stop transfusion
2. Using new tubing, give IV normal saline fluids
3. Administer meds to treat reaction (VASOPRESSOR,
ANTIHISTAMINES, STERIODS, IV FLUIDS)
4. Collect urine sample
5. Notify HCP
6. Document and send blood and tubing back to blood bank
QId: 30367 Pharmacology - Infectious Disease

High risk clients on ISONIAZID THERAPY for treatment of
tuberculosis may experience neurological side effects due to a decrease
in the body's ability to utilize vitamin B6 (PYRIDOXINE)

Parenteral Nutrition
Interventions to resolve TPN-associated hyperglycemia

1. reduce amount of carbohydrate in the TPN solution
2. slowing down the infusion rate
3. administering SQ insulin
The nurse should assess client blood sugar before implementing an

intervention

Manage S/S for GERD:
1. AVOID caffeine, chocolate, alcohol, peppermint, nicotine, spicy foods
2. low fat foods (no high fat foods)
3. sip water with meals / no carbonated drinks
4. eat 5-6 small meals daily
5. chewing gum / wear loose clothes
6. Elevate HOB / no eating at bedtime / do not lie down after eating
Symptom of GERD: heartburn, regurgitation, persistent sore throat,

painful swallowing, chronic cough
Tx for GERD:
1. Antacids (calcium carbonate, magnesium hydroxide
2. PPIs (omeprazole)
3. H2 receptor antagonists (ranitidine)

Theophylline toxicity = CNS stimulation (H/A, insomnia, seizures), GI
problems (N/V), cardiac toxicity (arrhythmia)
Digoxin toxicity = Alteration of color perception and visual changes
Phenytoin (Dilantin) toxicity = gum hypertrophy (gingivitis)
Acetylsalicylic acid (Aspirin) toxicity = hyperthermia and tinnitus
QId: 30394 Adult Health - Hematological/Oncological

Heparin -induced thrombocytopenia (HIT) may cause arterial or venous
thrombosis
Nurse should monitor PLATELET count in clients receving heparin and
REPORT a decrease in platelet count >50% or below 150,000 to the

HCP
QId: 30395 Maternal & Newborn Health - Labor/Delivery

Infants of diabetic mothers at risk for HYPOGLYCEMIA...and
HYPOCALEMIA
Infant blood sugar <40mg/dL is hypoglycemic (jittery, irritability,

hypotonia (low muscle tone), apnea, lethargy, temperature instability

Review about increasing ICP
QId: 30432 Pharmacology - Mental Health Concepts

SSRI and MAOIs can not be combined together..... RISK OF
SEROTONIN SYNDROME!!!
QId: 30433 Pharmacology - Gastrointestinal/Nutrition

Irritable Bowel Syndrome (IBS)
Contraindicated: Anticholinergic medication =Dicyclomine

hydrochloride (Bentyl)
ANTICHOLINERGICS ARE CONTRAINDICATED FOR CLOSED-

ANGLE GLAUCOMA, BOWEL ILEUS/OBSTRUCTION, URINARY
RETENTION (bph)
QId: 30446 Maternal & Newborn Health - Postpartum

Postpartum uterine infection may occur following vaginal or C-section
delivery. A blood culture is obtained prior to starting broad-spectrum
ANTIBIOTICS
Postpartum endometritis = fever, chills, tachycardia, uterine tenderness,

foul-smelling lochia

Calculation problem
client weight 8 lb 9 oz.....we need kg
weight in lb = 8 + 9 oz / = 8 + 0.5625 = 8.5625 lb

16 oz
weight in kg= weight (lb) = 8.5625 lb = 3.8920 kg

2.2 lb 2.2 lb
QId: 30462 Child Health - Gastrointestinal/Nutrition

Intussusception -intestines telescoping into itself
Initially has intermittent pain with the legs drawn up toward the
abdomen
RED CURRANT JELLY STOOLS
A CONTRAST ENEMA is used to diagnose and reduce intussusceptions
An AIR (pneumatic) ENEMA considered safer than a barium enema
Human recombinant erythropoietin (EPOETIN ALFA) used to combat

effects of chemotherapy and kidney disease

Read about Bishop score (maternity)
QId: 30485 Maternal & Newborn Health - Antepartum

Pregnant women receive MMR vaccination during post-partum period.
+ immune response = indicates past infection or vaccination
- nonimmune response = indicates client susceptible to rubella disease

and REQUIRES vaccination
MMR is live attenuated vaccine
QId: 30490 Child Health - Respiratory

Review Asthma in Hurst notes /Saunders
Frequent coughing at night is the warning signal that child airway is

sensitive to stimuli may be only sign in "silent" asthma
Triggers: tobacco smoke, pet dander, cockroach feces, air pollution, hay
fever, food allergies,
QId: 30507 Adult Health - Urinary/Renal

Chronic Kidney Disease clients must restrict diet in fluids sodium,
potassium, and phosphrous
Allowable foods for CKD clients include apples, pears, grapes,

pineapples, blackberries, blueberries, and plums
Dairy products (milk, yogurt)= HIGH K+/ PHOSPHORUS.... Fruits

(bananas oranges, coconuts, watermelons, avocados) = HIGH K+

Preeclampsia = HTN and proteinuria AFTER 20th week gestation
Eclampsia = onset of convulsions and seizures
DELIVERY IS ONLY CURE
Magnesium sulfate (CNS depressant) used to prevent/control seizures

NURSE PRIORITY WITH MAG: assess VS, I&O, monitor for s/s of
MAG TOXICITY (decreased reflexes, respiratory depression, urine
output) THERAPEUTIC MAG LEVEL 4-7 is good to prevent seizures
in a preeclamptic client
HTN meds to lower in these clients: HYDRALAZINE,

METHYLDOPA, LABETALOL (consider using is BP >160/110 mm
Hg)
Tocolytic meds: TERBUTALINE, MAG SULFATE, INDOMETHACIN,

NIFEDIPINE) = used to suppress uterine contractions in PRETERM
labor
Corticosteroid: improves fetal lung maturity

Peak flow meter is a hand held device used for measure of peak
expiratory flow rate (PEFR) and is most helpful for clients with
moderate to severe asthma. EXHALE QUICKLY AND FORCIBLY
The peak flow meter is used after a short-acting bronchodilator rescue

MDI to evaluate response (albuterol)

Clozapine (atypical antipsychotic) used to treat schizophrenia
HIGH RISK FOR AGRANULOCYTOSIS (it is reversible)
First, obtain baseline CBC and ANC

Client must have WBC count of >3500 and ANC of >2200 before
starting clozapine treatment
Call HCP immediately if fever or sore throat develops (could be a

underlying infection
Other Adverse effects Clozapine: weight gain, hyperglycemia,

dyslipidemia
QId: 30531 Child Health - Respiratory

Cystic fibrosis
Bronchial hygiene therapy, manual chest physiotherapy is used
CPT should be performed BEFORE MEALS to avoid a full stomach and

resultant regurgitation or vomiting

Heparin
Normal aPTT 25-35 secs
If patient receiving heparin infusion.... 1.5- 2 times the normal

value...therapeutic aPTT is 46-70 secs

Contraindications for THROMBOLYTICS:
ABSOLUTES:
Prior intracranial hemorrhage
Cerebrovascular lesion
Ischemic stroke within 3 months (except within 3 hours)
Suspected aortic dissection
Active bleeding or bleeding diathesis (thrombocytopenia, von

Willebrand disease, anticoagulants drugs, hemophilia)
Significant head trauma within 3 months

Involuntary Admission (mental health): if patient is a risk of harm to self
or others and grave disability (unable to adequately care for basic needs
such as food, clothing, shelter, medical care, and personal safety

Schizophrenic clients may exhibit negative symptoms that increase their
anxiety, have social withdrawals, and regressive behavior
If client stand up to leave, the nurse should remain silent and allow client
to leave

Nitroglycerin patches applied once daily for 12-14 hours; one patch at a
time
1. apply to upper body or upper arm; clean, dry, hairless and intact skin
2. choose different location daily- rotate sites
3. can wear patch in shower
4. Headaches are common with nitrates
MEDS CONTRAINDICATED WITH NITRATES:

Phosphodiesterase inhibitors-used for erectile dysfunction
(tadalafil, sildenafil, vardenafil)= severe hypotension can occur when
used with nitrates due to smooth muscle dilation
VAP is a nosocomial infection. Usually presents >2-3 days after

initiation of mechanical ventilation (MV)
S/S of VAP: purulent sputum, positive sputum culture, leukocytosis
(12,000), elevated temperature (>100.4 F), new or progressive
pulmonary infiltrates suggesting pneumonia on chest x-ray
The BEST INDICATOR OF VENTILATOR- ACQUIRED

PNEUMONIA (VAP): POSITIVE, PURULENT SPUTUM CULTURE

Mechanical ventilation
Apply suction while removing the catheter

If secretions are thick and difficult to remove, increase hydration is
recomended
Aerosols of sterile normal saline or mucolytics (acetycysteine-
Mucomyst) administer by nebulizercan be used to thin the thick
secretions = NO WATER
REQUIRED SUCTIONING: High pressure alarm sounds, Saturation

dropping, Rhonchi auscultated, secretions audible/visible

Concepts
Disaster triage uses START (Simple Triage and Rapid Transport)
(Priority is to always treat actual over potential

Respiratory acidosis - increased CO2 and low pH (DECREASED
BICARBONATE REABSORPTION)
Respiratory alkalosis - decreased CO2 and high pH (DECREASED

BICABONATE REABSORPTION)
Metabolic acidosis - to blow of CO2 rapidly (INCREASE

RESPIRATORY RATE)
Metabolic alkalosis - WHEN RESPIRATORY RATE DECREASES,

CO2 INCREASES

Positioning: Respiratory
Priority Nursing Action:

1. elevate HOB (Fowler's or High Fowler's) = to relieve SOB and
facilitate oxygenation (BREATHING) and promote lung expansion
(AIRWAY)
2. Orthopneic position: sitting in a chair, on the side, in bed leaning over

the bedside table, with one or more pillows under the arms or elbows for
support
3. Tripod position: sitting in a chair leaning forward with hands or

elbows resting on the knees; sitting upright and leaning forward

Transfer client from bed to chair: using a transfer belt
FIRST STEP: client put on nonskid shoes
2. make sure bed/chair (wheelchair) brakes are locked
3. use transfer belt
4. transfer toward stronger side NOT weaker side. If pt is weak on left
side, ask client to pivot on right side (OPPOSITE SIDE)!!
Pivot on the foot distal to the chair or bed


Trichomoniasis is a STI; frothy gray or yellow-green vaginal discharge
with a fishy odor; Pruritus (itching) is common
Tx: Methronidazole (Flagyl) DOC; avoid alcohol and for 24 hours after
completion of the therapy (reaction can cause flushing, N/V, abdominal
pain); METALLIC TASTE; URINE DEEP RED-BROWN COLOR
TREAT the partners SIMUTANEOUSLY to avoid reinfection; abstain

from sex until infection clears; NO DOUCHING

Chest tube
When chest tube drainage stops abruptly.... look to see if its expected
finding
Nurse should: auscultate breath sounds (indicates LUNG HAS RE-

EXPANDED) and there is no more drainage; tell client to cough and
deep breathe and reposition the client to facilitate improved drainage

Client with jaundice, scleral icterus (itching) and elevated bilirubin level
= USE: cool water and minimal mild soap
AVOID: hot water and strong soaps

Pulmonary embolism Review s/s in Hurst
S/S: pleuritic chest pain, hypoxemia, tachypnea, dyspnea, tachycardia,
apprehension and anxiety
Clients at risk for PE include those PROLONGED immobilized, obesity,

recent surgery, varicose veins, smoking, heart failure, advanced age,
history of VTE
ATYPICAL s/s for larger sized PE: right ventricular dysfunction,

pulmonary HTN, systemi hypotension, syncope, loss of consciousness,
distended neck veins

25000u
500ml
1620u/hr

Concepts
5th's disease "SLAPPED-CHEEK" erythema infectiosum- caused by
parvovirus B19...s/s include: bright-red facial rash, fever and general
flulike symptoms
PREGNANT WOMEN SHOULD AVOID EXPOSURE

Concepts
What clients should the nurse be concerned with doing assessment?
1. Client had a liver biopsy (LIVER VERY VASCULAR)

early s/s of blood loss/ hypovolemic shock: tachypnea, tachycardia,
agitation
LATE SIGN: HYPOTENSION
2. Client has black stools (MELENA) indicates slow UPPER

GASTROINTESTINAL BLEEDING; TACHYCARDIA may indicate
significant blood loss
3. Client post lumbar puncture. If client was bleeding, it would compress

the spinal cord causing PARALYSIS in the lower extremities
4. Client taking metoprolol has a pulse of 62/min, which is a therapeutic

effect of metoprolol. Nurse should monitor for bradycardia (common
and expected finding). BRADYCARDIA WOULD REQUIRE
NURSING INTERVENTION ONLY...ONLY IF THE CLIENT
BECAME SYMPTOMATIC (HYPOTENSION, DIZZINESS,
NAUSEA)- ATROPINE WOULD BE GIVEN
5. Client (neonate's) resting pulse is 110-160/min. Crying or vigorous

kicking can cause a temporary rise. Vital signs are concerning if they rise
when a client is at rest11

Ziprasidone hydrochloride (Geodon) used to treat acute bipolar disorder,
acute psychosis and agitation
PRIORITY: QT PROLONGATION = LEADS TO TORSADE DE

POINTES
Place client in cardiac monitor; MONITOR client for HYPOTENSION

and SEIZURES
Baseline ECG and K+ level are checked
Adverse effects increase with alcohol

Chemotherapy clients are immunocompromised and should protect from
infectious contacts (inactivated vaccine is safe and recommended for
clients who are immunocompromised
Common colds
Impetigo is a highly contagious bacterial skin infection (honey-colored
rust) common sites are mouth and hands

Greatest risk for developing pneumonia is AGE (>65)!
QId: 30741 Pharmacology - Safety/Infection Control

Aging
Beers Criteria: medications at risk for the geriatric population; HELPS

DECREASE THE FALLS CONFUSION due to polypharmacy
Sulfonylureas- GLYBURIDE- risk for severe and prolonged

hypoglycemia in geriatric population due to delayed elimination
QId: 30760 Adult Health - Musculoskeletal

Rheumatoid Arthritis (chronic autoimmune disorder) is inflammation
and damage to synovial joints and fibrosis of joint membranes
Maximize functional ability (management at-home care and symptom-

strategies):
1. Perform gentle ROM exercises daily
2. Moist HEAT= stiff joints Ice COLD= painful joints
3. frequent rest periods to decrease fatigue
4. Sleep/rest in flat and neutral position
Prolong flexion of joints (elevating of knees on pillows) increases risk of

CONTRACTURES= BAD

Death rattle sound can be treated with anticholinergic meds to dry up
secretions....ATROPINE drops administered sublingual or transdermal
SCOLOLAMINE patch
QId: 30762 Pharmacology - Hematological/Oncological

Mechanical valve replacement - therapeutic INR is 2.5-3.5
If INR >3.5..., HOLD the DOSE and call MD

Pneumococcal vaccine guidelines: prevent community-acquired
pnemonia (CAP)
ALL Adults >65 should recieve 2 pnemococcal vaccinations (PCV 13

OR 13- VALENT PNEUMOCOCCAL CONJUGATE VACCINE
(Prevnar 13) followed by PPSV23, or 23-VALENT PNEUMOCOCCAL
PNEUMONIA (PPSV23) is recommended after 5 years for clients who
are immuno-compromised, those with splenectomy, and those > 65 years
old if the first dose was given before this age
Annual flu vaccine is effective prevention for CAP

Peritonitis is a common and SERIOUS complication of PERITONEAL
DIALYSIS.
S/S: cloudy effluent, LOW-GRADE fever, chills, abdominal pain,

rebound tenderness = indicates INFECTION

Concepts
RN can delegate to another RN, LPN, UAP
RN: assess, teach, evaluate
LPN: take care of stable clients, limited assessments (lug sounds, bowel
sounds, neuro checks)
UAP: ADLs, hygiene, linen change, routine stable VS, document I&Os,
positioning
UAP can change dressings only for chronic wounds using clean
technique
QId: 30776 Adult Health - Infectious Disease

Vancomycin -aminoglycoside -MONITOR FOR NEPHROTOXICITY
Serum Vancomycin trough level is monitored before the 4th dose; 15-20
is optimal
BUN/CR are monitored 2-3 times/week due to increase risk of
nephrotoxicity

Diverticulitis can lead to the complication intestinal perforation
=PERITONITIS.... call HCP!
Immediately report abdominal pain progressing to left pper quadrant to

HCP and any signs of infection (fever, tachycardia, nausea, leukocytosis

Colostomy Post-op Stoma Appearance
GOOD= pink to brick red color
BAD= If stoma is pale, dusky, cyanotic color changes NOTIFY HCP

immediate. Surgery required to prevent ischemia and necrosis

Proper care of stoma and pouch:
Increase fluid intake 3,000 mL/ day unless contraindicated (prevents

dehydration) hot weather, increased perspiration, diarrhea
Eliminate gas/odorous foods (broccoli, cauliflower, dried beans, brussels

sprouts)
Empty pouch 1/3 full (prevent leakage; skin irritation)
ASCENDING/TRANSVERSE COLOSTOMY= SEMILIQUID

STOOLS = NO IRRIGATION NEEDED
DESCENDING/SIGMOID COLOSTOMY= FORMED STOOLS= CAN

IRRIGATE
DO NOT IRRIGATE ILEOSTOMY

Hiatal hernia:
Elevate HOB
Avoid: tobacco, caffeine
Small frequent meals, low fat
Avoid: lifting and staining
A paraesophageal hernia (rolling hernia) occurs when gastroesophageal

junction remains in place but a portion of upper stomach folds up along

the esophagus and forms a pocket= MEDICAL EMERGENCY

Cirrhosis is at risk of hepatic encephalopathy.
Hypokalemia, high protein intake, GI bleeding, constipation,
hypokalemia, and infection can precipatate hepatic encephalopathy
Low albumin, elevated INR, elevated LFT, low K level (can increase the
risk of hepatic encephalopathy) should be reported to HCP; elevated
serum ammonia

IV VANCOMYCIN ADMINISTRATION
Draw trough prior to administration

Monitor hearing and kidney function for adverse effects
Infuse over 60 minutes (<10 mg/min)
Monitor BLOOD PRESSURE -hypotension (AE)
Assess for hypersensitivity (RED MAN SYNDROME)
Monitor for anaphylaxis (rash, pruritus, laryngeal edema, wheezing)
Observe site every 30 mintues (pain, redness or swelling)-
VANCOMYCIN IS A VESICANT
Administration using a central venous catheter (PREFERRED)
Peripheral IV may be used for short-term therapy
ADVERSE EFFECTS:
NEPHROTOXICITY
OTOTOXICITY
HYPOTENSION
RED-MAN SYNDROME (STEVEN JOHNSON)

Sepsis is an infection that is a complication of pnemonia in clients that
do not respond to ABX therapy
S/S of sepsis
1. HR >90 bpm
2. temp >100.9 F (38.3) C
3. systolic BP <90 mm Hg
4. altered mental status
5. hyperglycemia > 140 in the absence of diabetes
Assessment findings to report to HCP:

absent bowel sounds, capillary refill >3-4, serum glucose >140

Ileostomy - liquid stool = DO NOT IRRIGATE
LOW-RESIDUE DIET (LOW-FIBER)- PREVENTS OBSTRUCTION
After ileostomy heals, the client reintroduces fibrous foods one at a time.
The client is instructed to thoroughly chew food and monitor for changes
in stool output
CAN HAVE PEACHES, BANANAS, POTATOES, WHITE RICE,
REFINED GRAINS, PASTA
Foods to avoid:
High fiber: popcorn, coconut, brown rice, multigrain bread
Stringy vegetables: celery, broccoli, asparagus
Seeds or pit: strawberries, raspberries, olives
Edible peels: apple slices, cucumber, dried fruit

Delayed gastric emptying (ALSO CALLED GASTROPARESIS)

prevent aspiration pneumonia by placing client on side lying or lateral
side
Client should remain upright during and AFTER meals

Appendicitis
Initial interventions include:
1. ensure patent airway and administer oxygen if hypoxic

2. obtain IV access and administer fluids
3. draw blood samples (CBC, electrolyte levels, clotting studies, type
and cross)
4. insert urinary catheter and obtain urine sample for U/A
5. insert NG tube

Painless hematuria is the most common symptom of bladder cancer.
Cigarette smoking and other tobacoo use is the primary risk factor

Order for renal system physical assessment:
1. Client empty bladder completely

2. Observe skin and contour of abdomen and lower back
3. Auscultate the renal arteries in right and left upper quadrants
4. Percuss and palpate both the right and left kidneys
5. Document the assessment of renal system function

Acute stroke "BRAIN ATTACK" requires "PERMISSIVE

HYPERTENSION" during the first 24-48 hours to allow for adequate
perfusion; BBB= BLOOD BRAIN BARRIER is no longer intact once
blood pressure is >220/120
MILD LOWERING OF BP IS REQUIRED; SYSTOLIC PRESSURE

SHOULD NOT BE BELOW 170
GIVE IV NICARDIPINE (CARDENE)- which is a prototype of

Nipedipine = potent CCB (calcium channel blocker) HYPOTENSION
CAN OCCUR WITH OR WITHOUT REFLEX TACHYCARDIA=
DRUG MUST BE DC'D IF THIS OCCURS
WIDENING QT INTERVAL:
HALOPERIDOL (HALDOL), METHADONE, ZIPRASIDONE
(GEODON) and ERYTHROMYCIN
QId: 30880 Adult Health - Reproductive

Menopause risks are osteoporosis and heart disease
Bisphosphonates (Alendronate, Risedronate, Ibandronate) help decrease

bone resorption so loss of bone density is minimal
TAKE IN AM
EMPTY STOMACH/FULL GLASS OF WATER
AT LEAST 30 MINUTES BEFORE OTHER MEDS
REMAIN UPRIGHT FOR AT LEAST 30 MINUTES
NEED CALCIUM AND VITAMIN D
QId: 30881 Child Health - Hematological/Oncological

Sickle cell anemia (vaso-occlusive crisis / pain crisis)
1. Elevation in bilirubin - jaundice results

2. Elevated reticulocytes- immature RBCs

3. Anemia - low hemoglobin <10
Hyperkalemia

TB = AIRBORNE PRECAUTIONS
Droplets contain tubercle bacilli bacteria; through coughing, sneezing,

exhaled (breathing, singing, talking, laughing)
Healthcare workers must follow standard and airborne precautions
Required: High-efficiency particulate or N95 respirator masks

Prioritization
ABC priority = AIRWAY, BREATHING, CIRCULATION
Example: client rescued from a burning building and shows evidence of

smoke inhalation
CLIENTS WITH ASTHMA EXACERBATION, TENSION

PNEUMOTHORAX, ANAPHYLAXIS/ANGIOEDEMA, AND FLAIL
CHEST NEED EMERGENCY EVALUATION!!!!

Client has saturated perineal pad <20 mins. Nurse assessment shows
boggy uterus, deviated to the right slightly above the umbilicus.
Priority....what to do FIRST?
1. Help client void in bedpan

2. Then perform fundal massage
3.If relief of bladder distension form voiding and fundal massage failed,
client had OXYTOCIN infusion to control postpartum bleeding

MRI - gadolinium contrast is used
CLAUSTROPHOBIA
CONTRAINDICATIONS:
aneurysm clips, metallic implants such as ICDs, pacemakers, electronic
devices, hearing aids, and shrapnel

Don PPE
wash hands
gown
mask or respirator
googles or face shield
gloves

Active TB uses combination drug therapy
ISONIAZID- hepatotoxicity and peripheral neuropathy;do baseline LFT

RIFAMPIN- hepatotoxicity; do baseline LFT; changes color of body
fluids....its EXPECTED finding (urine, sweat, tears can turn red; WEAR
EYEGLASSES INSTEAD OF SOFT CONTACT LENSES; WOMEN
SHOULD USE NONHORMONAL BIRTH CONTROL
METHODS.....this medication decrease effectiveness of oral
contraceptives; increase metabolism of some drugs (oral contraceptives,
hypoglycemics, warfarin)
ETHAMBUTOL- frequent eye examinations
Clients should be advised to watch for s/s of hepatotoxicity (jaundice,

anorexia); do not drink alcohol or take acetaminophen

Emergency contraception (EC) prevents pregnancy after unprotected
intercourse
EC pills (LEVONORGESTREL-plan B) should be taken within 5 days

of intercourse; efficacy is reduced after 3 days (72 hours)

PARACENTESIS: removal of fluid from abdominal cavity
Client has ascites due to cirrhosis; SOB and abdominal pain
ONLY performed if client is experiencing impaired breathing or pain due
to ascites; use a local anesthetic
PARACENTESIS NURSE SHOULD IMPLEMENT PRIOR TO

PROCEDURE:
obtain baseline vital signs, abdominal circumference, and weight
place client in HIGH FOWLER position or as upright as possible
client should empty bladder PRIOR to procedure (dont want to puncture
the bladder)

Lactulose given to remove ammonia from the body;
Give on empty stomach
Give orally with water, juice or milk to improve flavor
Give as enema
LACTULOSE IS A LAXATIVE.....MONITOR FOR

DEHYDRATION, HYPERNATREMIA, HYPOKALEMIA
QId: 30947 Child Health - Urinary/Renal

Acute Glomerulonephritis caused by recent streptococcal infection
s/s: periorbital/ facial and generalized edema, HTN, oliguria, tea-colored
and cloudy urine
Nursing care focused on monitoring vital signs (particularly blood

pressure) and fluid status, avoid salt in diet, conserving energy

New graduate RNs should be assigned to STABLE clients who do not
require specialized skill or knowledge. Appropriate clients include those
being discharged or requiring new teaching

OPIOIDS
Nausea and vomiting are expected SE of opioid medications

(MORPHINE SULFATE) Tolerance develops quickly and persistent
nausea is rare.
tell the client to take an anti-emetic with the pain medication
QId: 30982 Pharmacology - Neurologic

Phenytoin (Dilantin) normal level 10-20 mcg/mL
>20 is TOXICITY
Early signs: horizontal nystagmus, gait unsteadiness (ataxia), slurred

speech, lethargy, confusion, coma.
Bradyarrhythmias and hypotension seen with IV Phenytoin
QId: 30983 Child Health - Growth & Development

Failure to Thrive (FTT)
PHYSIOLOGIC RISK FACTORS: preterm birth, breastfeeding

difficulties, GERD, cleft palate
SOCIOECONOMIC RISK FACTORS: poverty, social or emotional

isolation, cognitive disability or mental health disorder, lack of
nutritional education (parents may not have knowledge of proper feeding
techniques or appropriate calorie intake based on age/size of child)

An SBFT (soft bowl follow through)= takes X-RAYS to visualize the
small intestines.
Pre-procedure:
Fast for 8 HOURS prior to exam
Test takes up to 60-120 minutes
Post procedure
Drink plenty of fluids after exam (BARIUM IS USED....TELL CLIENT
BOWELS WILL BE CHALKY WHITE IN APPEARANCE 24-72
HOURS AFTER THE EXAM
IF BOWELS DO NOT RETURN AFTER 72 HRS, IF STOOL IS
BLACK OR TARRY, ABDOMINAL PAIN/FULLNESS= CALL HCP
Catheters should always be maintained below level of bladder; impaired

urine flow leads to urinary retention and distended bladder
Catheters in kidney pelvis= irrigate with gentle pressure and <5 mL of

sterile saline solution

During the emergent phase after a burn....Sodium level decrease,
potassium increases >5.0; and H&H increase due to hypovolemia
(hemoconcentration)

Concepts
INFORMED CONSENT
HCP: explains the benefits, risks, alternatives of the specific procedure;

if client has questions about procedure, risks, alternatives, or outcomes=
HCP should be contacted
Nurse: can witness client signing consent form; if client has question
about general care or health care teaching (DIET) it can be answered by
the nurse

Chest tube
Gentle, continuous bubbling in suction control chamber = Suction is

present and unit is functioning
Keep 20cm of sterile water in suction control chamber
An air leak = bubbling in Air leak Gauge or Water Seal chamber
QId: 31052 Adult Health - Cardiovascular

SUDDEN or ABRUPT DC of HTN meds can cause:
1. Rebound HTN is when a client does not take the prescribed meds to
lower and maintain a normal daily BP; or hypertensive crisis
SE: fatigue, dizziness, erectile dysfunction

Autonomic dysreflexia (autonomic hyperreflexia) EMERGENCY!
Spinal injury to T6 or higher
S/S: HTN, headache, diaphoresis, bradycardia, piloerection
(goosebumps), flushing
Tx: FIRST raise HOB, then treat the cause!
Myasthenia Gravis (autoimmune disease). S/S muscle weakness and

ptosis (drooping upper eyelid). Muscle weakness increases with activity
and by the end of the day, ptosis is present (EXPECTED FINDINGS)
MYASTHENIC CRISIS RESPIRATORY FAILURE IS PRIORITY!

Concepts
Good Samaritan laws protect nurses who stop to help injured individuals
after an accident.
THE NURSE CAN NOT RECEIVE PAYMENT FOR ANY CARE

GIVEN
Prevent Dumping syndrome: small, frequent meals, LOW CARB DIET;

with NO FLUIDS
RYGB: Roux-en-Y Gastric Bypass (anastomosis of small gastric pouch

to the Roux limb of the small intestine)
RYGB Complications:
dumping syndrome, iron deficiency anemia, cobalamin deficiency
QId: 31131 Child Health - Neurologic

EEG used to diagnose presence of seizure disorder
Teaching for parents:

Hair should be washed before and after procedure
AVOID caffeine, stimulants, CNS depressants prior to the test
Test is NOT PAINFUL; NO PAIN MED REQUIRED
Client should remember the procedure
QId: 31136 Child Health - Neurologic

Febrile seizures are convulsions caused by spike in body temperature
(fever)
Give antipyretics (acetaminophen/ibuprofen) then try other cooling
methods such as applying cool, damp compresses to forehead; increase
air circulation in room; wear loose clothes
PARENTS CALL 911 IF SEIZURE LAST > 5 MINUTES! = NEURO
DAMAGE
Hyperthermia with heat stroke: tepid water and place ice bags under
arms and around the neck

Levetiracetam (Keppra) used to treat seizures

DO NOT DO THIS:
THE NURSE SHOULD NOT DOCUMENT THAT AN INCIDENT

REPORT WAS FILED OR REFER TO THE INCIDENT REPORT IN
THE MEDICAL RECORD

Concepts
Staff nurse should not give OTC over-the-counter medication even to the
housekeeper even if they complain of a headache or etc...

Concepts
THE FIRST STEP IN MANAGEMENT ISSUES (JUST AS IN
NURSING CARE), IS ASSESSMENT
When a client complains about staff treatment, the first response should
be to ASSESS the client's perceived wrong; then the nurse can then
determine what follow-up action is needed
"Ask the client to described what happened last night"

Refractory hypoxemia is the hallmark of ACUTE RESPIRATORY
DISTRESS SYNDROME (ARDS), a progressive form of acute
respiratory failure that has a high mortality
Hypoxemia despite high concentrations of oxygen is a key sign of

ARDS and is the most important assessment finding to report to the HCP
Pneumonia s/s: cough with mucus, rhonchi and crackles are expected
findings, temperature

Hemodialysis
Client has immediate dialysis after SUDDEN KIDNEY FAILURE
Nurse should prepare client for: CENTRAL LINE PLACEMENT IN

THE GROIN AREA
Central catheters are mostly commonly used for immediate dialysis over
AVGs, AVFs, and peritoneal dialysis

Late decelerations
Stop Oxytocin
Left lateral side
Initiate IV fluids, bolus
Oxygen by facial mask (NOT A NASAL CANNULA)
Notify HCP

Benign prostatic hyperplasia (BPH)
s/s: urinary retention, urgency, frequency, nocturia urinating, hesitation,
weak and or intermittent stream urine
Elevated eosinophils = allergy exposure (ASTHMA EXACERBATION)
Elevated lymphocytes= immune system (VIRAL INFECTIONS and

HEMATOLOGIC MALIGNANCIES)
Elevated neutrophils = INDICATES INFECTION
Elevated reticulocytes= immature red blood cells; normal reticulocyte

0.5%-2.0%;= HEMOLYTIC ANEMIA or HEMORRHAGE

Acute Respiratory Distress Syndrome (ARDS) Client receives positive
pressure mechanical ventilation; positive end-expiratory pressure (PEEP)
PEEP helps to reduce oxygen toxicity
Complication associated with PEEP is BAROTRAUMA (high levels of

PEEP 10-20 cm H2O can cause overdistention and rupture of the alveoli
resulting in barotrauma to the lung; air from ruptured alveoli goes into
the pulmonary interstitial space or pleural space and cause
pneumothorax and/or subcutaneous emphysema
PEEP causes increased oxygen sats, increased intrathoracic

pressure...decreased venous return...decrease preload and cardiac
output.....and HYPOTENSION

Peripheral Arterial Disease: PAD
Priority assessment is to check for adequacy of blood flow to the lower

extremities by palpating posterior tibial and dorsalis pedis pulses

Concepts
If a nurse comes to work smelling like alcohol and has impaired speech.
What actions should the nurse take?
Do not continue handoff report with oncoming nurse, document the

incident according to facility policy, notify charge nurse; do not confront
the impaired nurse in a hostile manner

PRIOR to starting "STATIN MEDS - ROSUVASTATIN,
SIMVASTATIN PRAVASTATIN, ATORVASATIN).....assess LIVER
FUNCTION TESTS (ALT/AST)
Statins can cause muscle aches and severe muscle injury

(RHABDOMYOLYSIS) .....report development of muscle pains
QId: 31347 Maternal & Newborn Health - Newborn

Congenital dermal melanocytosis also known as "MONGOLIAN
SPOTS"- NORMAL
benign discoloration (bluish gray color) that fade over the first 1-2 years
of life... found on back or buttocks. not caused from trauma
important for the nurse to measure and document location of markings

ACE inhibitors Adverse effects
Immediate action: ANGIOEDEMA (swelling lips, tongue throat, face

and larynx)
More common Adverse effects include dry cough, orthostatic

hypotension and hyperkalemia

Chest tubes
If chest tube disconnected and is contaminated, or chest drainage unit

breaks, cracks or malfunctions, SUBMERGE THE DISTAL END OF
THE CHEST TUBE 1-2 INCHES (2-4 CM) BELOW THE SURFACE
OF A 250 mL bottle of sterile water or saline
QId: 31364 Adult Health - Safety/Infection Control

Allergy immunotherapy injections (allergy shots) used to reduce a client
allergy symptoms when exposed to allergens (pollen, cat dander, dust
mite) GIVE SQ
CLIENT MUST REMAIN 30 MINS AFTER INJECTION TO

MONITOR FOR SEVERE REACTIONS (respiratory failure, tongue
and throat swelling)
Allergy shots initially given EVERY WEEK; the maintenance dose i

given every few weeks for 3-5 years

Warfarin
Antidote =Vitamin K
Therapeutic INR range should be 1.5-2 times the normal "control" value
(INR of 2-3) for medical reasons.....DVT, A-Fib, Stroke
An INR of 3 to 3.5 is desired for the client with a mechanial heart valve
Hold dose of Warfarin for INR > 4 and notify HCP
INR > 5.0 or higher is at risk for BLEEDING

Serotonin Syndrome
s/s: FEVER, muscle rigidity, restlessness and agitation, anxiety,
disorientation, sinus tachycardia, diaphroresis, mydriasis(dilation of the
pupils); hyperthermia, warm/moist skin, hyperreflexia, clonus, tremor,
diarrhea & hyperactive bowel sounds (Borborygmi); autonomic
instability & HTN
MEDICATIONS THAT CAUSE SEROTONIN SYNDROME:

SSRIs (e.g., Citalopram)
MAOIs
Dextromethophan- antitussive used to treat cough
Ondansestron- antiemetic
St. John's wort- herbal
Tramadol- analgesic for severe pain

HERBALS
Stop herbal therapy 2-3 weeks before surgery
They can interfere with other medications
BLACK COHOSH- used for menopausal hot flashes

Those that start with "G" GARLIC, GINGER, GINGKO, GINSENG=
lead to increased bleeding risk
ST JOHNS WORT- interfere with metabolis of other drugs
Breast Cancer
Risk factors (NON-MODIFIABLE)

female sex and age >50
first degree relative (mother or sister) with hx of Breast CA
BRCA1 and BRCA2 genetic mutations
History of endometrial or ovarian cancer
Period before AGE 12 or MENOPAUSE after age 55
Risk factors (MODIFIABLE)

hormone therapy with estrogen and/or progesterone (INCREASED
RISK IF TAKEN AFTER MENOPAUSE)
Postmenopausal weight gain and obesity as fat cells store estrogen
History of smoking and alcohol
Dietary fat intake
Sedentary lifestyle

Pregnancy
High risk for bacterial contamination (LISTERIA, TOXOPLASMOSIS)
AVOID: unpasteurized milk products, unwashed fruits and vegetables,

deli meat, hot dogs (unless heated until steaming hot); raw fish/meat;
AVOID: intake of fish high in MERCURY (shark, swordfish, king
mackeral, tilefish
AVOID: LIVER (has high amounts of vitamin A which is
TERATOGENIC)

Hyperemesis gravidarum is severe persistent nausea and vomiting during
pregnancy.
Excess loss of gastric contents leads to HYPOKALEMIA,
HYPONATREMIA, METABOLIC ALKALOSIS, NUTRITIONAL

DEFICIENCIES, KETONURIA, WEIGHT LOSS
DEHYDRATION (dry mucous membranes, poor skin turgor, decreased

urine output, tachycardia, hypotension). Urine is concentrated with
dehydration... increased specific gravity >1.030
Ketonuria = pregnant client is breaking down fat for energy due to

starvation state

Breast Cancer
Appropriate times to perform SBE:
Women with regular period = 5-7 days after period

Women with irregular period = same day each month
Women taking oral contraceptives= when a new package is initated
Women with Post-menopause= same day each month

Take notes in the morning 2/11
QId: 31479 Child Health - Infectious Disease

Standard vaccine for 12 month old: Nib, PCV (PVC13), MMR, varicella,
Hep A
LIVE VACCINE (MMR, VARICELLA) CONTRAINDICATED WITH

PRESENCE OF MARKED IMMUNOSUPPRESSION.....i.e., HIV
patients
If client has CD4 lymphocyte percentage <15% =considered severely

immunocompromised
Low CD4 counts vary from ages:

<750 for infants 12 months or younger
<500 children between ages 1-5
<200 children age >5 years and adults

Concepts
Delegate to LPN:
wound care and routine medication administration

sterile procedures can cleanse and dress wounds for which there is an
established prescription plan
RN only:
Assess, Plan and Evaluate, Teach
If client was experiencing NEW-ONSET, UNEXPLAINED PLAN
REQUIRING IV ANALGESIC ADMINISTRATION=RN WOULD DO
THIS

Causes of Pelvic Fractures:
1. Motor vehicle collusions
2. Motorcycle accidents
3. Falls
ASSESS FOR INTERNAL HEMORRHAGE ( abdominal distention,

vital signs, H&H); PARALYTIC ILEUS (absent bowel sounds);
NEUROVASCULR DEFICITS (extremity circulation, sensation,
movement) and ABDOMINAL/GU organ injuries (hematuria, urine
output <0.5 mL/kg/hr); ECCHYMOSIS OVER SUPRAPUBIC AREA
REPORT TO HCP

Buck' skin traction:
Supine or Semi Folwer's (max 20-30 degrees) to prevent sliding

Assess neuro status and skin integrity
Loosen Velcro straps if boot to tight
provide fracture pan for elimination needs
weights should be free-hanging at all times; never place in bed or on the
floor; another staff should support the weight while pulling client up in
bed
Skeletal traction (pins)

never remove the weights

Buck's skin traction
1.Do neurovascular (pulse, capillary refill, color, temperature, sensation,

movement) and skin assessments (heel, dorsum of foot) every 2 hours
2. Keep extremity in traction above the level of the heart
3. Pain assessments (neuro checks prior to giving med due to risk of
underlying nerve or muscle ischemia)
4. use over-head trapeze to lift, move upper body & change positions
DO NOT TURN CLIENT IN BUCKS TRACTION FROM SIDE TO

SIDE!!!!!!!!

Cord care Newborn
Keep cord stump open to air to dry

Fold diaper below the cord to keep cord dry and prevent contamination
with feces and urine
DO NOT APPLY: ALCOHOL, TRIPLE DYE, CHORHEXIDINE
REPORT ANY SIGNS OF INFECTION (redness, purulent drainage,
swelling) to HCP
Normal: cord turns back in 2-3 days; cord falls off around 1-2 weeks
after birth

Fat embolism syndrome - minimize movement to injured extremity to
reduce risk of fat emboli

Newborn Formula Understanding:
Wash the top of concentrated formula cans before opening
Keep bottles, nipples and caps clean
Prepared formula should be kept in refrigerator and discard after 48

hours if unused
Warm bottles in pan on stove for few minutes until lukewarm, NEVER
HOT!!! NEVER MICROWAVE
DO NOT dilute or concentrate formula
QId: 31527 Pharmacology - Hematological/Oncological

Herbal supplements for increased risk for bleeding/ these should be
discontinued prior to major surgery:
Garlic, Ginger, Ginkgo biloba, Ginseng, Feverfew "START WITH G's"
Ginkgo biloba =memory enhancement; SE: BLEEDING RISK

Ginseng= improve mental performance; SE: BLEEDING RISK
Black cohosh = post-menopausal symptoms (hot flashes/vaginal
dryness); SE: HEPATICINJURY
Saw palmetto = BPH; SE: MILD STOMACH DISCOMFORT,
BLEEDING RISK
St. John's wort = insomnia/depression; DRUG INTERACTIONS
(ANTIDEPRESSANTS...SEROTONIN SYNDROME), OCs,
ANTICOAGULANTS....decrease INR); DIGOXIN; HYPERTENSIVE
CRISIS
Hawthorn = HTN; mild to moderate HF
Kava= anxiety/ insomnia; SE: SEVERE LIVER DAMAGE
Licorice= stomach ulcers; bronchitis/viral infections; SE: HTN,
HYPOKALEMIA
Echinacea= treat and prevent of cold & flu; SE: ANAPHYLAXIS (more
likely in asthmatics)
Ephedra= treat cold/flu; weight loss & improved athletic performance;
SE: HTN, ARRHYTHMIA/MI/SUDDEN DEATH; STROKE,
SEIZURE

S/S of HIP fractures include:
Ecchymosis (bruising) and tenderness over the thigh and hip

Groin and hip pain with weight bearing
Muscle spasms in the injured areas
Shortening of affected extremity
External rotation

Cervical cancer
Pap smear testing STARTS at age 21, REGARDLESS OF SEXUAL

HISTORY
WOMEN age 21-29 should be screened with Pap test only every 3 years.
At age 30, HPV and Pap testing may be done together every 5 years

Total hip replacement to prevent dislocation of the hip prosthesis:
use abductor pillow between the legs when turning the client or
trochanter roll
AVOID: adduction and hip flexion; crossing legs; don't sleep or turn on
operative side
Maintain HOB <60 degrees

Methadone is a POTENT NARCOTIC
EARLY SIGNS OF TOXICITY: NAUSEA, VOMITING, AND

LETHARGY; CLIENT WHO FALLS ASLEEP WHILE NURSE IS
TALKING (OBTUNDED); O2 SATS <90%
Cardiac monitoring of methadone use/overdose= RISK OF QT

PROLONGATION....CAN LEAD TO TORSADES DE POINTES
ITCHING (pruritis)is a expected finding with narcotic use; manage this

with Antihistamines

Digoxin for HF clients
Administering...when to hold:
If apical pulse <90-110/min for INFANTS and young children or

<70/min for an older child

Osteroporosis Prevention:
Biphosphonate (alendronate, risedronate, zoledronic)

Calcium & Vitamin D
Smoke cessation and avoid alcohol
Weight-bearing exercises

Acrocyanosis bluish discoloration of the hands/feet; sometimes skin
around the mouth
NORMAL during the first day of life or up to 7-10 days after birth if the
infant becomes cold
Also called Transient acrocyanosis without central cyanosis in the first

day of life is considered normal

Pulmonary embolism- women who gives birth by C-section are at
increased risk for DVT!
Other risk factors: obesity, smoking, genetic predisposition
If DVT untreated, can progress to PE!
PE s/s: anxiety/restlessness, pleuritic chest pain/tightness, SOB,

tachycardia, hypoxemia, hemoptysis

NSAIDs should be avoided in 3rd trimester due to risk of premature
closure of the ductus arteriosus in the fetus
Acetaminophen in pregnant women should not exceed 4 g per day =

means 4,000 mg per day!

Concepts
Room assignment
No postoperative client should be assigned to a room with a client who

has an ACTUAL infection or the POTENTIAL for infection

Contractions during active labor if client is 6 cm dilated
Duration should not exceed 90 seconds
Frequency should not occur less than 2 minutes apart
Intensity (strength of the contraction at its peak) should not exceed 80

mm Hg
Resting tone (allows fetal oxygenation between contractions) should not

exceed 20 mm Hg

Dressing change for infected surgical incision: HOSPITALIZATION
Wear clean gloves to remove contaminated, OLD dressing

Re-dressed using aseptic technique, required to put on sterile gloves and
sterile dressing supplies
Gowns/Googles may be required if splashing is possible
Client may be able to assist in HOME SETTING

Droplet precautions have the client wear a mask during transport to
radiology to prevent the spread of the infection when the client is outside
of the room
Required: Nurse wear Mask & Private Room
GLOVES NOT REQUIRED

Supine hypotensive syndrome (vena cava syndome)
s/s: maternal hypotension and reflex tachycardia(decrease in blood
volume and in blow flow); dizziness, pallor, cold/clammy skin
PRIORITY: reposition to lateral position; left or right

PREVENTION OF VENA CAVA SYNDROME: use wedge under client
hip when in supine position

Steps for doing a Wet- to Damp dressing change
1. wash hands
2. open sterile gauze package with ungloved hand
3. hold opened gauze package 6" above the sterile field
4. place sterile gauze dressing on the sterile field 2" from the edge (first
1" is considered unsterile)

5. use sterile NSS from a recapped bottle opened <24 hours ago
QId: 31655 Pharmacology - Critical Care Concepts

Activated charcoal for aspirin ingest initially...... then give IV sodium
bicarbonate
QId: 31683 Child Health - Cardiovascular

Infant (neonate) vital signs:
HR 120-160
RR 30-60
Trisomy 21 (Down Syndrome)

Loud cardiac murmur (Atrioventricular AV canal defect)
Tetralogy of Fallot (TOF)= KNEE-CHEST POSITION used to treat

hypoxia and cyanosis in infants/young children

Oxytocin is given to induce labor; given as secondary IV line
Nursing actions:
1. Administer IV oxytocin via promiximal port (close to the patient)
2. Assess uterine contractions pattern (q 15 mins in first stage of labor
and q 5 mins in second stage)
3. Auscultate FHR continuous
4. Monitor I&O
5. IV oxytocin should always be on infusion pump
Oxytocin can lead to water intoxication (fluid retention)= dilutional

hyponatremia, convulsions and death

Contact Precautions:
MRSA
VRE
C-DIFF
SCABIES
Required:
Private room or cohort with clients with same infection
Gown and Nitrile gloves
Dedicated equipment in room (BP cuff, etc)
Hand hygiene before exiting room: Soap and water or alcohol-based
sanitizers for MRSA and VRE
SOAP AND WATER ONLY FOR C-DIFF AND SCABIES

MRSA and VRE use hand soap and water or alcohol based hand rubs
C-difficile and scabies only soap and water

Crutches
Hold both crutches on same side when standing from chair

Touch back of legs to the seat of chair before sitting
Use armrest of seat to assistance with lowering body into chair

Iron-deficient anemia in overweight toddlers
Caused by excessive intake of milk (over 24 oz/day)
Treatment:
Oral iron supplementation and iron-rich foods (leafy-green vegetables,
red meat, poultry, dried fruit, fortified cereals
Limit milk intake (16-24 oz/day) in toddlers

Latex allergy:
These potentiate for a latex allergy: know allergy to avocados and

bananas, lip swelling when blowing up balloons, itching/burning hands
after wearing rubber gloves; Common foods can cause latex-food
syndrome (in clients with allergy to latex): avocados, bananas, tomatoes,
chestnuts, kiwis, potatoes, peaches, grapes, apricots; Hx of multiple
exposures (eg., self caths for a neurogenic bladder, multiple surgeries -as
seen with spina bifida)

Risk of colonoscopy= PERFORATION lead to PERITONITIS
S/S: abdominal pain (shoulder tip pain, + rebound tenderness, guarding,
abdominal distension, TENESMUS, boardlike (rigid) abdomen, rectal
bleeding
Expected finding post procedure: abdominal cramping, recurring flatus,

watery stools
Tenesmus- feeling like you have to have a bowel movement even you
already had one

Amoxicillin/clavulanate liquid (Augmentin) = PCN classification
Can take with or without food

common s/s: N/V/D; if N/D develops, can take with food to decrease GI
upset
Shake the liquid well prior to administering; administer at evenly spaced
intervals
Take full course of therapy even if feeling better
Calibrated devices: dropper, oral syringe, plastic measuring cup,

measuring spoon

Intracranial hemorrhage
Epidural hematoma ARTERIAL BLEED = most are associated with

fracture of the temporal bone; rupture or tear in the middle meningeal
artery
Bell's palsy (CN 7 -FACIAL NERVE) resembles a stroke symptoms
Trigeminal neuralgia (tic douloureux) CN 5-TRIGEMINAL NERVE)

unilateral facial pain triggered by touching, talking, hot/cold foods or air
DOC: Carbamazepine (Tegretrol)-used for pain, anticonvulsant, bipolar
disorders

Drugs that cause orthhostatic hypotension (dizziness/fainting when
standing):
1. Beta blockers (end LOL) metoprolol
2. Alpha blockers (end ZOSIN) terazosin
3. Antipsychotic meds (olanzapine, risperidone)
4. Antidepressants (SSRIs)
5. Diuretics (furosemide, hydrochlorothiazide
6. Vasodilators (Nitroglycerine, hydralazine)
7. Narcotics (e.g. Morphine)
Statin Meds Adverse effects are muscle cramps and liver injury
Proton Pump Inhibitors (PPI e.g., omeprazole) risk for pnemonia, C-diff
diarrhea, osteoporosis

MRI
Absolute contraindications:
cardiac pacemaker
implantable cardioverter defibrillator
cochlear implant
retained metallic foreign body, esp. in eyes
Relative contraindications:
prosthetic heart valve
metal plate, pin, brain aneurysm clip, joint prosthesis- some have
nonferrous MRI safe metals that should be verified
implanted device (insulin pump, medication port)
Transdermal metal-containing medication patches (CLONIDINE,

NICOTINE, SCOPOLAMINE, TESTOSTERONE, FENTANYL) these
are not contraindicated but NURSE should remove patch prior due to
risks of burns and replace after testing

Myastenia Gravis= autoimmune disease
S/S: weakness, ptosis/diplopia, bulbar signs (difficulty speaking or
swallowing), and difficulty breathing
MUSCLES ARE STRONGER IN THE MORNING AND BECOME

WEAKER WITH THE DAY'S ACTIVITY
TREATMENT:
***ANTICHOLINESTERASE DRUGS: PYRIDOSTIGMINE
(MESTINON)
administer this med BEFORE MEALS SO CLIENT ABILITY TO
SWALLOW IS STRONGEST DURING MEAL
MYASTHENIC CRISIS EXACERBATION OF MYASTHENIA

GRAVIS
client has too little medication related to noncompliance, illness, or
surgery

Priority for Mandibular fracture whose teeth are wired together top and
bottom is to MAINTAIN PATENT AIRWAY
IF CLIENT STARTS CHOKING = SUCTION ORAL/NASOPHARYX
IF THAT INTERVENTION DOESNT WORK (i.e., suction) CUTTING

THE WIRES MAY BE NECESSARY
Tape wire cutter to HOB at all times

Rotator cuff injury results from repetitive use or injury to the shoulder
Sports include swimming, tennis, baseball, weight lifting
S/S of rotator cuff injury: shoulder pain and weakness; severe pain when
arm is abducted between 60-120 degrees (painful arc)
QId: 31807 Child Health - Visual/Auditory

Acute otitis media s/s: FEVER, pulling at the ear, BULGING RED
tympanic membrane, refusal to eat, restlessness/irritable
Otitis externa: retracted tympanic membrane, severe pain with pressure
QId: 31815 Pharmacology - Musculoskeletal

METHOTREXATE= used to treat Rheumatoid Arthritis
ADVERSE EFFECTS OF METHOTREXATE: bone marrow

suppression (leads to anemia, leukopenia, thrombocytopenia- platelets
<100,000....PETECHIAE are small, purple hemorrhagic spots);
PURPURA; other signs of bleeding...MELENA, HEMATEMESIS,
BLEEDING GUMS); hepatotoxicity (drug-induced liver injury), and GI
irritation (N/V/D)
AVOID CAFFEINE AND FOLIC ACID

METHOTREXATE IS TERATOGENIC- AVOID PREGNANCY

Vaginal birth after cesarean (VBAC) =increased risk for uterine rupture
FIRST SIGN= abnormal fetal heart rate (FHR) patterns (FETAL
BRADYCARDIA)
other s/s: constant abdominal pain, loss of fetal station, sudden cessation
of uterine contractions
Severe rupture unrecognized: hemorrhage, hypovolemic shock, maternal

tachycardia
FETAL TACHYCARDIA causes: infection, maternal fever, stimulant

drugs

Phenytoin cause gingival hyperplasia (side effect)
Teach client to do good oral care and regular dentist visits
FOLIC ACID SUPPLEMENTALS CAN REDUCE GINGIVAL

HYPERPLASIA
Other side effects Phenytoin: increase in body hair, rash, folic acid
depletion, decreased bone density (OSTEOPOROSIS)
Teach clients they need DIET high in FOLIC ACID and CALCIUM

Nystatin - used to treat oral candidiasis (thrush)
1. Can be caused by medications such as antibiotics, corticosteroids, or
oral contraceptive pills
2. Medical conditions such as HIV, immunosuppression, uncontrolled
diabetes, denture use, an hormonal changes during pregnancy
Oral suspensions of Nystatin

1. client should swish the solution within the mouth
2. the client should swallow the solution after several minutes
QId: 31871 Child Health - Musculoskeletal

Parent concerned child at risk for hip dysplasia
Keep infant hips flexed and abducted=GOOD
Do not extend hips and or keep leg straight; do not double/triple

diapering; avoid infant swings, bouncers, car seats, wraps, that keep the
legs straight and together= BAD

Vancomycin cause nephrotoxicity!
Monitor serum creatinine levels prior to giving this medication IV

need to study normal lab values

Concepts
Prioritization about "AAA"
Abdominal Aortic Aneurysm = MEDICAL EMERGENCY BC IT

COULD RUPTURE AND CLIENT WOULD NEED EMERGENCY
SURGERY TO REPAIR
S/S: abdominal and back pain, pulsatile abdominal mass; BRUIT may be
heard over the site... Rupture can lead to death in minutes

Treatment goals for Atrial Fib: decrease ventricular rate <100 and
prevent stroke.
A) Ventricular rate control is PRIORITY! Meds used to decrease rate

control are: Calcium Channel Blockers, Beta Blockers, Digoxin
B) Antiarrhythmic meds to convert rhythm for A-FIB to sinus rhythm:

1. amiodarone 2. ibutilide
C) Anticoagulants used to prevent embolic complications (stroke)

1. warfarin (PT/INR) 2. dabigatran 3. rivaroxaban 4. apixaban
Esophageal Atresia (EA) and Tracheoesophageal fistula (TEF)
Keep infant NPO

Supine with HOB 30 degrees
Suction equipment at bedside
S/S of EA/TEF: frothy saliva, choking, coughing, drooling, apnea,

cyanosis when feeding
ASPIRATION IS HIGHEST PRIORITY with EA/TEF

REQUIRE parenteral nutrition prior to surgery...Gastrostomy tube.
FEEDINGS/IRRIGATIONS through the tube are
CONTRAINDICATED until after surgical correction of the TEF

Neuroleptic Malignant Syndrome = life threatening = CALL HCP
NMS mostly seen the "typical" - HALOPERIDOL, FLUPHENAZINE;

also seen with newer "atypical" - CLOZAPINE, RISPERIDONE,
OLANZAPINE
NMS: fever, muscular rigidity, altered mental status, Autonamic

dysfunction (sweating-diaphoresis, HTN, tachypnea, tachycardia
dysrhythmia)
IMMEDIATELY D/C ANTIPSYCHOTIC MEDICATION AND

NOTIFY HCP

Abnormal neurological assessments: nuchal rigidity; new-onset
unilateral drift of a limb; pupils <3 mm or >5 mm in diameter; absent
oculocephalic reflex; and presence of Babinski reflex in a adult client

Cerebellum 2 major functions: coordination of voluntary movement and
maintenance of balance and posture
Maintenance of balance - assess gait testing; watch normal gait first then
heel-to-toe gait (tandem means walking in str8 line for DUI drivers), on
toes, and on heels
CN 11 (accessory nerve) assess by having client shrug shoulders up

against resistance and turn head to side against resistance
CN 9 (glossopharyngeal nerve) and CN 10 (vagus nerve) client with

intact gag reflex, has ability to swallow sips of water; also observe
symmertrical rise of the soft palate and uvula by asking client to say "ah"

TIOTROPIUM (SPIRIVA) CAPSULE= long-acting; 24 hour; ANTI-
CHOLINERGIC, inhaled medication used to control COPD; NOT A
RESCUE INHALER
Its a capsule that hold powdered medication that I have to put in a

special inhaler; CAPSULE-INHALER SYSTEM (CALLED THE
HANDIHALER)
Client teaching: Capsule SHOULD NOT be swallowed; button on the

inhaler must be pushed to allow medication dispersion; Rinse mouth
after use and inhaled steroids (beclomethasone, budesonide, fluticasone)
Short-acting bronchodilators (ALBUTEROL and/or IPRATROPIUM)

are RESCUE INHALERS- ACUTE ATTACKS
Clients must discontinue IPRATROPIUM before taking TIOTROPIUM

because both are ANTI-CHOLINERGIC
ANTI-CHOLINERGIC inhaled medications (IPRATROPIUM,

TIOTROPIUM, UMECLIDINIUM) do not reduce inflammation in
airway; they do relax the airway through parasympathetic
bronchoconstriction; also help dry up airway secretions

Benzodiazepines end in "PAM" (alaprazolam-Xanax; lorazepam-Ativan;
clonazepam, diazepam) = used for GAD or panic disorder
Do not stop abruptly but TAPER DOWN slowly
Benzo's may cause sedation which can interfere with daytime activities.
Give the dose at bedtime can help client with sleep
MAOIs (tranycypromine, phenelzine) = used for depressive disorders
MAOIs eliminate tyramine foods (aged chesse, chocolate, wine, beer,

processed meats)

Lithium (Mood stabilizer)
Normal levels 0.6 -1.2 mEq/L
>1.5 levels are TOXIC
Lithium TOXICITY risks:

1. dehydration
2. decreased renal function (elderly clients)
3. low sodium diet
4. Drug-drug interactions (NSAIDS and thiazide diuretics)

Ego defenses

Central lines
Access sites in the inguinal area (femoral) are easily contaminated by

urine or feces and it is difficult to place an occlusive dressing over these
sites = HIGH RISK FOR INFECTION

Prevent urinary tract infection:
wipe front to back

drink plenty of fluids
use restroom as soon as urge to go to decrease constipation and urinary
stasis
avoid scented soaps/bubble baths
avoid anti-bacterial soaps
fill tub with water ONLY
wash hair last
avoid tight clothes and synthetic fabrics (nylon, spandex, Lycra)
COTTON UNDERWEAR is recommended

Concepts
ACUTE HEMOLYTIC TRANSFUSION= PRIORITY- LIFE-
THREATENING
S/S: chills, itching, back pain
IF UNTREATED: hypotension, vascular collapse, respiratory distress,

and DIC can occur quickly!
Methylphenidate (its a stimulate....ADHD)
take 30-45 minutes before meals

take no later than 6pm bc it interfers with sleep
SR (sustained-release) give in the morning
monitor child initially for tics

Acceptable client identifiers
Name (first and last)

Date of birth (DOB) day, month and year
Medical record number

ABX- CLASS: FLUOROQINOLONES (end in "FLOXACIN"
CIPROFLOXACIN, LEVOFLOXACIN, MOXIFLOXACIN,
NORFLOACIN, OFLOXACIN) -USED TO TX UTI
CIPROFLOXACIN- can cause photosensitivity- avoid sun and use
sunscreen
*RISK FOR TENDINITIS and TENDON RUPTURE (occurs mostly in

Achilles tendon)
*First site of tendon pain or swelling= STOP TAKING ABX, NO NOT
MOVE AFFECTED AREA and CALL HCP
Another med to tx UTI: NITROFURANTOIN- expect urine to turn

brown color
Aminoglycoside ABXs: hearing and balance problems (vertigo) -
GENTAMICIN

Proton Pump Inhibitor end with "PRAZOLE" (e.g. omeprazole,

pantoprazole, lansoprazole, esomeprazole)
1. Helps prevent stress ulcer due to the stress of surgery or major illness
2. Also given to client with GERD or ulcers
PPIs also increase risk for C-diff infection with ABX use!!!!
Antiemetics:
metoclopramide (Reglan)
1. used to decrease post-op nausea by promoting gastric emptying
QId: 32055 Pharmacology - Urinary/Renal

Client with UTI prescribed: (ABX)
PHENAZOPYRIDINE HYDROCHLORIDE (PYRIDIUM)
Nurse teach the client: Expect discoloration of urine- BRIGHT RED-

ORANGE; use sanitary napkins can stain bedding; wear eyeglasses bc
can stain contact lens; TAKE FULL COURSE OF ABX

Cystic fibrosis affects GI, GU, Respiratory
Autosomal recessive = genetic counseling needed

High calorie, Low fat, Pancreatic enzymes, Fat-souble vitamins ADEK

Anticholinergic: Benztropine (Cogentin) used to treat some
extrapyramidal symptoms, SE of some antipsychotic medications
Pseudoparkinsonism: resemble parkinsonism symptoms (masklike face,

shuffling gait, rigidity, resting tremor, psychomotor retardation
(BRADYKINESIA)
DYSTONIA: abnormal muscle movements of face, neck and trunk

caused by sustained muscular contractions (eg., torticollis, oculogyric
crisis, opisthotonos- backwards arching of head, neck...like in
meningitis)

Concepts
Subarachnoid intercerebral bleeding is sudden abrupt onset and presents
as "WORST HEADACHE OF MY LIFE"
HIGH PRIORITY - BLEEDING

Cystoscopy - examine that uses scope inserted through urethra into
bladder
Pre-procedure: Lithotomy position (like you having a baby)
COMPLICATIONS: URINARY RETENTION, HEMORRHAGE,

INFECTION
NOTIFY HCP IF: bright red blood when urinating, blood clots, inability
to urinate, FEVER >100.4 and chills, abdominal pain unrelieved by
analgesia
Post-procedure: Expect pink-tinged urine, frequency and dysuria up to

48 hours; increase fluids; drink 4-6 glasses of water daily; avoid
alcohol/caffeine 24-48 hours; abdominal discomfort/bladder spasms may
occur up to 48 hours after procedure (take mild
analgesic...acetaminophen, ibuprofen); warm tub/sitz bath (EXPECT
RECURRENT UTIs) for pain relief

Kawasaki disease - mucocutaneous lymph node syndrome

s/s: > 5 days of fever, bilateral nonexudative conjunctivitis, mucositis,
cervical lymphadenopathy, polymorphous rash, extremity swelling
IV immunoglobulin with aspirin is used to prevent coronary anerysms

and occlusion (USED TO PREVENT HEART DISEASE)

Concepts
Prioritization
Fat embolism= LONG BONES AND PELVIC FRACTURES; THIS IS
A LIFE-THREATENING PRIORITY
s/s: dyspnea(respiratory distress), confusion (altered mental status),
petechia(pin-sized red/purple spots)
PETECHAIE (can be on chest, axillae, soft palate)
Heroin withdrawal s/s: VOMITING, ABDOMINAL CRAMPING,

DIARRHEA, RESTLESSNESS, DIAPHORESIS, YAWNING,
RHINORRHEA, LACRIMATION, MYALGIAS, ARTHRALGIAS

Hip arthroplasty = TOTAL HIP REPLACEMENT
Complications post-op: bleeding, prosthesis dislocation, DVT, infection
Nurse: check drainage device and dressing frequently to monitor blood

loss during first several hours POST-OP
Noctural enuresis (NIGHT-TIME BED-WETTING)
Teach parents:
Medication: ORAL DESMOPRESSIN
NONPHARMACOLOGIC USE FIRST!!

1. restrict fluids after evening meals
2. child should void before bed
3. calendar showing wet days/dry days
4. avoid punishing/scolding child
5. avoid training pants/diapers at bedtime
6. child can assist with wet linen changes (reassure its NOT punishment)
7. awaken child at specified time each night to void
8. use ENURESIS ALARM (moisture-sensitive alarm wore on child's
sleep clothes and awaken the child if child starts to void

Scabies: CONTACT PRECAUTIONS
Incubation: 30-60 days....TREAT ALL PERSONS WHO HAD

CONTACT WITH INFESTED CLIENT
>2 MONTHS can receive one-time treatment with scabicide cream (1%
permethrin)- APPLIED ALL ON BODY BELOW THE HEAD
Disinfect: clothes, linens, stuffed animals in plastic bags (min. of 3

days); machine wash in hot water and drying them in hottest dryer cycle;
FUMIGATION OF LIVING AREAS IS NOT NEEDED

Hirschsprung disease is when the baby is missing nerve cells from the
distal colon; no perstalsis and stool not passing
FATAL complication is HIRSCHSPRUNG ENTEROCOLITIS-

inflammation of the colon; leading to SEPSIS AND DEATH

S/S: fever, lethargy, explosive, foul-smelling diarrhea, rapidly-worsening
abdominal distension

Pertussis (Whooping cough):
Droplet precautions
Monitor s/s of airway obstruction
Offer small amount of fluids frequently
Tx: ABX and supportive care (humidified oxygen, give fluids, suction
infants if needed) Vaccination
Position: left side to prevent aspiration

Pediculosis capitis (HEAD LICE)
CONTAGIOUS SEEN IN SCHOOL-AGE KIDS
Treatment: apply pediculicide (PERMETHRIN 1% CREAM) to head

and remove nits with nit comb or by hand
Use nit comb at least 2-3 days for 2 weeks
FREQUENTLY vacuum carpets rugs, furniture to remove lice/nits
WASH bedding in HOT WATER and DRIED on hottsest dryer setting
Non-washable items can be sealed in plastic bag for 2 weeks to kill lice
SOAK all hairbrushes, combs, ornaments in boiling water for 10 minute
or lice-killing products for 1 hour
DO NOT HAVE TO TREAT HOUSE PETS
Rotavirus is a contagious virus and leading cause of diarrhea in children

< 5 years old
Rotavirus spread fecal-oral route; contact with food, toys, diapers, and
humans; Meticulous handwashing and proper diaper disposal prevent the
spread of the virus
S/S: foul-smelling, watery diarrhea that lasts 5-7 days often acompained
by fever and vomiting.
Vaccination must be given before the child is 8 months old. ABX are not
effective against Rotavirus. Oral rehydration solutions used to combat
dehydration

Fondaparinux (Arixtra), unfractionated heparin and low molecular
weight heparin e.g., enoxaparin, dalteparin) are ANTICOAGULANTS
commonly used for DVT and Pulmonary embolism prophylaxis after
hip/knee replacement or abdominal surgery
FONDAPARINUX is not administered until more than 6 hours after the

surgery
Anticoagulants are not given while epidural catheter is in place

Client prescribed filgrastim (Neupogen) has neutropenia = that is a
correct MD order
Neutropenia - abnormal low count of a type of white blood cell

Concepts
Bronchoscopy
Post-procedure: monitor for bleeding, bronchial perforation,
pneumothorax, bronchial spasms
apply "ABC" guidelines to questions of who to see first

Prevent Botulism
Manifestations include: descending flaccid paralysis (starting with the

face), dysphagia and constipation (smooth muscle paralysis)
Main source: improperly canned or stored food; swollen/bulging end on

cans should be discarded
Infants (botulism) can occur in children under 1 if they eat honey

particularly raw (wild) honey; they have a immature gut system
Giardia= contaminated water is boiled to prevent this infestation; cause

GI disease
Escherichia coli (E -COLI) = ingestion of food or water that is

contaminated by feces; related to improper handwashing or undercookin
meat

Normal PaCO2 is 35-45
Clients with asthma exacerbations, panic attacks, pulmonary embolism,

pneumonia all will have rapid breathing; rapid breathing pushes more
CO2 out of lungs with a mild decrease in PaCO2 expected compensatory
response; retaining CO2 or a normal CO2 level fr these clients would be
more dangerous and cause respiratory failure

PTSD clients have experienced a traumatic event (war, tornado, rape,
place crash)
They RE-EXPERIENCE the traumatic event

AVOID reminders of the trauma; increased anxiety; emotional arousal
Clients with anxiety level 8/10 and PACING are demonstrating distress
and require IMMEDIATE attention; might hurt self or others

Closed head injury in a acceleration/deceleration accident (BASED ON
COUP-CONTRECOUP PHENOMENON)
Areas of the brain involved is expressive speech and vision
Frontal lobe - executive function, memory, speech (BROCA area),

voluntary movements
Occipital lobe- vision
Parietal lobe- hearing, sensory data (auditory, visual, somatic)

WERNICKE speech area (responsible for language comprehension)
Light touch (processed by sensory cortex in this lobe)
Temporal lobe- Weber test (screens for conductive hearing loss with
tuning fork held along midline of the head is heard evenly in both ears);
controls smells and hearing

Postpartum Opioid dependent mom (HEROIN, METHADONE,
HYDROCODONE)
Neonate experiences opioid withdrawl 24-48 hours after birth

S/S: irritable, jitterness, high-pitched cry, sneezing, diarrhea, vomiting,
poor feeding, stuffy nose, sweating
Place infant on right side after feeding to promote gastric emptying and
reduce risk of vomiting
Cluster care; light stimulation; dim lit nursery

Concepts
Spleen is part of the immune system to function as a filter to purify
blood and remove toxins/bacteria that cause infections
Post-splenectomy bacterial infection or rapid-onset sepsis are major

lifelong complications in a client without a functioning spleen
A infection can turn life threatening quickly......look for headache, low-

grade fever, chills= requires IMMEDIATE action

Poison ivy can cause a contact dermatitis rash. Its linear in appearance
where the plant brushed against the skin
Rash develops 12-48 hour after exposure
Immediately after exposure -First (priority) thing to do is wash the area

to remove the resin and prevent its spread to other areas of the body.
Next: after the rash has developed= apply cool, wet compresses; apply
topical cortisone; discourage child from scratching area
QId: 32293 Child Health - Musculoskeletal
Duchenne muscular dystrophy = X linked recessive (carried by females

and affects males)
s/s: pseudohypertrophy (calf muscles hypertrophy-enlarged calves)

initially; Gower sign/maneuver (place hands on thighs and push up to
stand and walk on tiptoes); frequent tripping and falling

Barium enema = used to visualize the colon
CONTRAINDICATED for clients with DIVERTICULA, can cause

PERITONITIS
PREPROCEDURE: BARIUM ENEMA

1. Take cathartic (magnesium citrate or polyethlene glycol) to empty
stool
2. Clear liquid diet day before procedure; AVOID RED/PURPLE
LIQUIDS
3. DO NOT EAT 8 HR BEFORE TEST
4. EXPECTED: ABDOMINAL CRAMPING/ URGE TO DEFECATE
POSTPROCEDURE: BARIUM ENEMA

1. EXPECTED: chalky, white stool
2. take a LAXATIVE (magnesium hydroxide (Milk of Mag.)
3. Drink plenty of fluids (hydration) and eat high fiber diet (prevent
constipation)

Concepts
Cauda equina syndrome = an injury to lumbar sacral nerve roots L4-L5,
causing motor and sensory deficits = MEDICAL EMERGENCY!!
Main symptoms include SEVERE LOWER BACK PAIN, inability to

walk, SADDLE ANESTHESIA (motor weakness/loss of sensation to

inner thighs and buttocks); BOWEL AND BLADDER
INCONTINENCE (LATE SIGN)!!!!!
Treatment: REQUIRE URGENT REDUCTION OF PRESSURE ON

SPINAL NERVES TO PREVENT PERMANENT DAMAGE
IF CLIENT PRESENT WITH LATE SIGN...INCONTINENCE=

ASSESS FIRST (PRIORITY)
Meniere disease = inner ear disorder; EXPECTED SYMPTOMS include

episodic vertigo, tinnitus, muffled hearing
Treatment for Meniere disease during acute attack (ANTIHISTAMINES,
ANTICHOLINERGICS, BENZODIAZEPINES)
KEEP CLIENT SAFE FROM FALLING
QId: 32328 Child Health - Mental Health Concepts

Autism spectrum disorder clients need to be placed in PRIVATE room
away from the nursing station (need a calm environment)
DO NOT PUT 2 CLIENTS WITH AUTISM TOGETHER..TOO MUCH

STIMULI

Pyloric stenosis
PROJECTILE VOMITING; OLIVE-SHAPED MASS (enlarged

pylorus) palpated in the epigastric region to the right of the umbilicus
s/s: DEHYDRATED (elevated Hematocrit and BUN), constantly hungry;

METABOLIC ALKALOSIS and HYPOKALEMIA

Severe liver disease = means a low serum albumin level (ex: 1.5 g/dL)
Nurse should expect hypoabuminemia = nurse should anticipate
PITTING EDEMA LOWER EXTREMITIES, PERIORBITAL EDEMA,
ASCITES
Liver makes albumin and damaged hepatocytes unable to synthesize it
Normal albumin level 3.5-5.0

RACE Protocol
Rescue clients
Alarm (active fire alarm)
Confine fire by closing doors
Extinguish fire
Visitors discouraged from using the elevator
QId: 32360 Pharmacology - Immune

Clarify prescriptions:
Loop diuretics question order if pt has hypokalemia
Isoniazid (TB med) question order if pt has increased liver tests

(ALT/AST) - drug induced hepatitis

Tinea corporis (ringworm) = highly contagious spread from person to
person
Treatment: Tolnaftate, Haloprogin, Micronazole, Clotrimazole

Peritoneal Dialysis

GI/ Nutrition
Obesity
Individuals who are trying to lose weight should consume these

beverages with few or no calories:
1. WATER
2. CLUB SODA (FLAVORED/UNFLAVORED)
3. CLUB SODA OR SPARKLING WATER WITH A SPLASH OF
FRUIT JUICE
4. UNSWEETENED TEA AND/OR COFFEE
5. NON-FAT OR LOW-FAT MILK (in limited amounts)

Rhabdomyolysis muscle injury caused from exercise, heart stroke or
physical trauma. Acute renal failure occurs when elevated myoglobin
overwhelms kidneys filtration ability.
NURSE PRIORITY: PREVENT KIDNEY DAMAGE USE RAPID IV

FLUID RESUSCITATION TO FLUSH DAMAGING MYOGLOBIN
FROM THE BODY!!!!!
S/S of Rhabdomyolysis are oliguria, dark amber urine, bloody urine

muscle pain, fatigue
Hypothermia- give warm blankets, IV warmed fluids
The trunk should be warmed before the extremities to reduce the risk of
afterdrop (means the core temp drops further)
PRIORITY place client on cardiac monitor (The client should be

handled gently.....V-FIB can occur if touched or moved)
NURSE SHOULD ANTICIPATE DEFIB with these clients

AIRING MTV!!!
Airborne:
Measles, TB, Varicella, SARS

Concepts
Bronchiolitis is a LOWER respiratory infection caused by RSV
Infant will have difficulty feeding and can become DEHYDRATED
Suction before feeding the infant
Medical care: SUPPORTIVE (suctioning, oxygen, hydration)
IRRITABILITY means signs of HYPOXIA

Concepts
Prioritization
Sepsis Neonatorum = MEDICAL EMERGENCY

s/s: elevated temperature, hypothermic; SUBTLE CHANGES include:
irritable, increased sleepiness and poor feeding= RED FLAGS
Nurse should obtain blood, urine, CSF cultures immediately and broad-
spectrum antibiotics started

Newly diagnosed Quadriplegia (Tetraplegia)= INJURY TO CERVICAL
SPINAL CORD
Priority: assess vital capacity and tidal volume; assess breath sounds,
accessory muscle use, ABGs: AIRWAY MANAGEMENT AND
OXYGENATION

Concepts
Prioritization
Tension Pneumothorax
hypotension and deviated trachea
THIS IS LIFE-THREATENING EMERGENCY
CLIENT NEEDS EMERGENCY LARGE-BORE NEEDLE

DECOMPRESSION and CHEST TUBE PLACEMENT

Concepts
Review acute epiglottitis= LIFE-THREATENING
Caused by H. influenzae type b (Hib) infection
s/s: restlessness,fever, sore throat, stridor, drooling, tripod positioning

due to dysphagia
The nurse should prepare for EMERGENT ENDOTRACHEAL

INTUBATION

Concepts
UAP can obtain the blood product from the blood bank
UAP can take vital signs before the transfusion begins and ANY TIME
after the first 15 minutes of infusion
QId: 33132 Child Health - Urinary/Renal

Hemolytic uremic syndrome = life threatening complication of E-Coli
Diarrhea, results in red cell hemolysis, low platelets, acute kidney injury
(low urine output);This results in anemia (PALLOR) and low
PLATELETS (petechiae or purpura)
NO fruit juices in acute diarrhea bc of high suger

Placental abruption, eclampsia, HELLP syndrome are complications of
Pre-eclampsia

Newborn: Necrotizing enterocolitis
Occurs in preterm infants

PRIORITY: measure abdominal girth daily (assessing for worsening gas-

associated swelling)
Nursing intervention:
NPO
Supine/ undiapered
NG suction (to decompress stomach/intestines)
Parental hydration and nutrition
IV antibiotics
NO RECTAL TEMPS= due to risk of perforation
QId: 33349 Adult Health - Skills/Procedures

Autopsy is a postmortem examination of the decreased. By law it is
required when a client has died by suicide, homicide, accident, or within
24 hours of admission to a health care facility.
An autopsy for one of these legal reasons does NOT REQUIRE

CONSENT of the family.
When an autopsy is required, the nurse should NOT REMOVE ANY

TUBES OR IV LINES
Based on institutional policy, drainage bags should be removed and

tubes/lines cut and covered or taped to the body
Clean the room as much as possible and unnecessary equipment

removed before family member visit the deceased client
The family should be allowed to visit the deceased client, after the client
and room have been prepared

Can only infuse K+ through peripheral line 10 mEq/hr...................... if
the order says 10 mEq of K+ to infuse over 30 minutes that is
wrong!!!!!!

Counter transference = the nurse unconsciously displace feelings and
behaviors related to a person in the nurse past
Transference= the client unconsciously displace feelings and behaviors

related to a person in the client past
"Sharing my thoughts with you will be difficult; you remind me of my
sister" Example
This is not good for the nurse-client relationship

Near-Drowning accident in cold weather = unable to breathe for an
extended period; organs begin to shut down from lack of oxygen and
permanent injury
Most severe brain injury: DECEREBRATE POSTURE (ARMS/LEGS

STRAIGHT OUT, TOES POINTED DOWN, HEAD/NECK ARCHED
BACK
A CLIENT IS NOT DEAD UNTIL WARM AND DEAD

Infant vomits green bile (COMES FROM THE INTESTINE)
THIS WOULD INDICATE BOWEL OBSTRUCTION
=EMERGENCY!!!
Monitor hydration status and weight gain
Bowel obstruction can lead to rupture, peritonitis, sepsis

Dependent personality disorder

Concepts
Influenza = DROPLET precautions; viral infection
Private room
Antiviral medication to treat flu (ZANAMIVIR, OSELTAMIVIR)

Priapism - painful erection associated with sickle cell anemia
BLUISH DISCOLORATION MOST CONCERN=ISCHEMIA TO
PENIS
FACTORS THAT CAUSE PRIAPISM:

1. Alcohol
2. spinal cord injury
3. meds: phosphodiesterase-5 enzyme inhibitor (Sidenafil)
psychotropic (Trazodone)
illegal (cocaine, cannabis)
Blood thinners
SSRIs

Chest tubes
Client with a chest tube should be assessed for signs of air/fluid in the
chest (DIMINISHED BREATH SOUNDS); excessive drainage (>100
mL/hr), pain and infection
*FRANK RED BLOOD = HEMORRHAGE= REPORT TO HCP

IMMEDIATELY

Growth and Development:
3 yr old should be able to eat with a spoon
4 yr old can copy or draw a square with a pencil or crayon; also can
jump on one foot
5 yr old can copy shapes other than a circle

Review cast care Hurst pg 168

Anticholinergic medications are used for overactive bladder and urge
urinary incontinence
Examples: TOLTERODINE (Detrol LA), OXYBUTYNIN (Ditropan),

SOLIFENACIN (Vesicare) are antimuscarinic/anticholinergic
medications used for above issues
Manage dry mouth with these meds: artificial saliva products, sugar free
hard candy and gum
Occasional dizziness SE of TOLTERODINE. Teach client to rise and

change position slowly
Constipation with these meds: increase fiber in diet, fluids, stool

softners, laxatives

Vasectomy/ Sterilization- procedure performed for permanent male

sterilization. Vas deferens is cut and sealed (preventing sperm from
entering the ejaculate)
USE ALTERNATVE BIRTH CONTROL UNTIL HCP CONFIRMS

THAT SEMEN SAMPLES TAKEN AT A FOLLOW-UP ARE FREE
OF SPERM; this prevents unwanted pregnancies

Dicyclomine is an anticholinergic/antispasmodic to help manage
symptoms of IBS; This medication is CONTRAINDICATED IF: client
has paralytic ileus
Review tumor lysis syndrome.....can lead to acute renal

failure......Allopurinol is given to promote purine excretion and prevent
acute kidney injury
Fluoroquinolone ABXs (i.e., Levofloxacin) can be given if client has

allergies to PCN

Educational seminar to inform female college students which 2
infections are leading causes of pelvic inflammatory disease and
fertility? Gonorrhea and chlamydia "referred to as silent infections"
Annual screenings for both infections recommended by CDC for all

sexually active females <25 and older females with risk factors
Both are treatable
Use of latex condoms will reduce the risk
Priority question: about ERCP
Epigastric pain after Endoscopic Retrograde Cholangiopancreatography

=ACUTE PANCREATITIS IS A LIFE-THREATENING
COMPLICATION AFTER AN ERCP
S/S: acute epigastric or left upper quadrant pain, often radiating to the
back, and a rapid rise in pancreatic enzymes (AMYLASE, LIPASE)

Sexual assault is a medical emergency = seek immediate medical
attention (DO NOT bathe, brush teeth. urinate, douche, or change clothes
Delayed a medical- forensic examination can interfere with evidence

retrieval and preservation

Normal Vancomycin level 10-20
Elevated trough levels > 20, creatinine> 1.3, and BUN >20 ARE
ASSOCIATED WITH NEPHROTOXICITY AND SHOULD BE
REPORTED TO THE HCP
QId: 33961 Fundamentals - Basic Care & Comfort/Pain Management

Blindness
Help client with ambulation with use of assistive aids (SIGHTED

GUIDES, CANES, GUIDE DOGS)
NURSE WALKS SLIGHTLY AHEAD AND TO THE SIDE OF THE

CLIENT...CLIENT HOLDS THE ELBOW OF NURSE'S ARM

Transdermal fentanyl patch used for moderate to severe chronic pain.
Continuous analgesia for up to 72 hours. Its absorbed slowly into the
skin into systemic circulation; can take up to 17 hours to reach full
effect.
NOT RECOMMENDED for treating acute postoperative, temporary, or

intermittent pain!!!!!

Acute prostatitis = inflammation of the prostate gland; caused by
bacterial infection; s/s of BPH
Management: antimicrobial and anti-inflammatory medications

(ibuprofen); Alpha-adrenergic blockers end in "ZOSIN, SIN" helps
bladder and prostate; may need SUPRAPUBIC CATH
CONTRAINDICATION: URETHRAL CATH (MAKES PAIN WORST)
INSTRUCT CLIENTS:
hydrate with clear liquids; AVOID: coffee, tea, caffeinated beverages;
complete full cours of ABX; can engage in sexual intercourse or
masturbation to reduce discomfort related to retained prostatic fluid; use
condoms to prevent transmission of organism; take stool softners; SITZ
baths (warm baths)

Sucralfate is used to protect the stomach lining from acid/enzymes; used
to treat ulcers
1. Give PO; take on empty stomach with full glass of water

2. Do not give with warfarin, phenytoin, digoxin
3. All other meds administer 1-2 hour before or after sucralfate
4. Antacids and other acid-reducing meds (PPI or H2 blockers) should
not be taken 30- 1 hour before or after taking sucralfate

5. CONSTIPATION is a common side effect
Quick facts pg 11 pharm
QId: 34048 Pharmacology - Musculoskeletal

Topical Capsaicin cream (Zostrix) for minor pain relief (osteoarthritis,
neuralgia). Use regularly (3-4) time daily....weeks to months
Nurse teaching:
1. Wait 30 mins after massaging cream into hands before washing hands
to ensure adequate absorption
2. Avoid contact with nose, mouth, eyes, skin thats not intact
(CAPSAICIN IS A COMPONENT OF HOT PEPPERS = BURNS)
3. Applying to knee for example, client should wear gloves or wash
hands immediately after application
4. NO HEAT WITH CAPSAICIN= CONTRAINDICATED
5. Local irritation (burning, stinging, erythema) is common and should
subside within first week of use. If client has persistent pain, redness,
blistering= DISCONTINUE, NOTIFY HCP

Concepts
Inguinal hernia is a protrusion of intraperitoneal contents through a
weakened area in the abdominal wall
s/s: pain, distension, nausea and vomiting
STRANGULATION OF BOWEL CAN LEAD TO INFECTION AND

DEATH
Medications with anti-cholinergic properties are: Antihistamines

(Diphenhydramine), Tricyclic Antidepressants (Amitriptyline)

Toxic Epidermal Necrosis is a severe form of STEVENS-JOHNSON
SYNDROME
s/s: erythema, blistering, epidermal shedding, kertoconjunctivitis and

skin erosion (denuded skin)
PREVENT INFECTION
Basic supportive care:

wound care (moist, sterile dressings); infection prevention (REVERSE
ISOLATION, monitor for signs of infection); monitor fluids and urine
output to prevent hypovolemia; oral feedings; prevent hypothermia; pain
medications around the clock and before procedures; eye care (sterile
cool compressions to relieve discomfort and lubricants to relieve
dryness)

Chronic Kidney Disease -elevated serum creatinine level= CAN NOT
TAKE NSAIDs (used to treat pain) due to NEPHROTOXIC
Examples include: Indomethacin, Ibuprofen, Naproxen, Ketorolac
A client can't take 2 types of NSAIDs at the same time (can be toxic to
the stomach and kidneys

Child Abuse
Findings including human bite marks, cigarette burns, bruises in various

stages of healing REPORT THESE TO AUTHORITIES
Alternative medicine
Garlic application
Cupping - steamed cup is placed on skin, causes circular bruised
blemishes
Coining (Chinese, Vietnamese) - rounded surface (coin, spoon) is firmly
stroked on lubricated skin of the back and produce welt-like linear
lesions

Client receiving IV sodium bicarbonate for acute metabolic acidosis
Hyperkalemia occur with acidosis; risk for cardiac arrhythmias
How to know if the sodium bicarbonate has been effective (corrected

acidosis)?
pH, HCO3 and serum potassium = within normal limits

Myasthenia gravis is an autoimmune disease of the neuromusclar
junction= results in MUSCLE WEAKNESS
TREATMENT: PYRIDOSTIGMINE (MESTINON)- increases the
acetylcholine in the synaptic junction; IMPROVES MUSCLE
STRENGTH
Infection, undermedication, and STRESS can precipitate a life-

threatening MYASTENIC CRISIS... oropharyngeal/respiratory muscle
weakness and respiratory failure
Example: client with a fever (infection) and increasing difficulty

swallowing indicates need for immediate intervention

Osteomalacia = reversible bone disorder caused by vitamin D and

calcium deficiency; WEAK, SOFT, PAINFUL bones, easy to
FRACTURE = RISK OF FALLS (ESP ELDERLY CLIENTS)
Nursing management:
Safety (canes, walkers -prevent falls and injury)
Light to moderate activity
Increase calcium, phosphorus and Vitamin D

Gastric lavage is only indicated if overdose is lethal and can be initiated
within 1 hour of overdose
Intubation /suction supplies should ALWAYS be present at bedside

during GL....in case of aspiration or respiratory distress
Activated charcoal is standard TX for overdose but its ineffective for

these drugs (LITHIUM, IRON, ALCOHOL)

Multiple Sclerosis = progressive disease of the CNS interrupts nerve
impulses
S/S of MS: muscle weakness, spasticity, incoordination, loss of balance,
and FATIGUE
*** RISK FOR FALL/ INJURY
*WALK WITH FEET APART= HELPS TO INCREASE SUPPORT
BASE, IMPROVE STEADINESS and GAIT
** ASSISTIVE DEVICES (CANE/WALKER) usually REQUIRED
ROM, STRENGTHENING, STRETCHING= HELPS LIMIT

SPASTICITY and CONTRACTURES in clients with MS
Clients should balance EXERCISE with REST

CLIENTS SHOULD EXERCISE IN COOL WEATHER AND STAY
HYDRATED.... DEHYDRATION and EXTREMES IN

TEMPERATURES cause EXACERBATION

Marfan syndrome= Autosomal dominant
NO COMPETITIVE, CONTACT SPORTS ARE DISCOURAGED DUE

TO RISK OF CARDIAC INJURY AND SUDDEN DEATH

CPR
1. chest compressions (adults and in single-rescuer CPR for any age) a

cycle of 30 compressions followed by 2 breaths
2. center of chest (between the nipples) place heel of the hand over lower
half of sternum (breastbone)
arms straight, should aligned over hands
3. compress 2-2.4 inches (5-6 cm) at rate of 100-120 /minute
4. chest should RECOIL COMPLETELY after each compression
IF CLIENT HAS ADVANCED AIRWAY, continuous compressions and

10 breaths/min should be given

Ventricular paced rhythm = PACEMAKER (pacer spikes on EKG)

Cyclobenzaprine (Flexeril) = muscle relaxant; metabolized by the liver
DO NOT GIVE IF PATIENT HAS HEPATITIS- CAN LEAD TO
INCREASED CNS DEPRESSION (weakness, confusion, drowsiness,
lethargy)
Bupropion and Varenicline- smoking cessation can cause

neuropsychiatric effects (depression and suicide)
Metronidazole (Flagyl) ABX used to treat Trichomonas infection

How to obtain WOUND CULTURE:
1. wash hands and apply CLEAN GLOVES; remove old dressing and
discard gloves
2. wash hands and apply STERILE GLOVES; assess wound bed;
cleanse wound bed and surrounding skin with normal saline (flushing,
swabbing with gauze) to remove drainage and debris; remove and
discard gloves
3. wash hands and apply CLEAN GLOVES; gently swab wound bed
with sterile swab from CENTER OF WOUND toward OUTERWARD;
AVOID contact with skin on wound edge (can contaminate specimen)
4. place swab in sterile speciman container (DO NOT TOUCH
OUTSIDE OF CONTAINER)
5. apply topical medication (bacitracin) after obtaining cultures (it
prevents microorganisms from spreading) apply new dressing
6. remove and discard gloves, wash hands; label the specimen; document
the procedure

Insulin can cause severe hypoglycemia

Nasoenteric tube has decreased risk of aspiration compared to
nasogastric tube
Nasoenteric tubes can become DISLODGED to the lungs, causing

aspiration of enteral feedings
If client with feeding tube develops signs of ASPIRATION

PNEUMONIA (diminished or adventitious lung sounds [crackles,
wheezing], dyspnea, productive cough) STOP FEEDING and CHECK
TUBE PLACEMENT via...measure insertion depth, obtain x-ray, assess
aspirate pH

Rib fractures
Give pain medication as priority if client has shallow breathing and

reports deep pain on inspiration before instructing client to TCBD
Focus on pain management and pulmonary hygiene techniques; prevent

atelectasis and pneumonia

A client wants to switch from a tricyclic antidepressant (TCA)-
imipramine, amitripyline, nortriptyline) to a monoamine oxidase
inhibitor (MAOI) - phenelzine, isocarboxazid, tranylcypromine
A DRUG-FREE PERIOD OF AT LEAST 2 WEEKS SHOULD

ELAPSE BETWEEN THE TAPERED D/C OF THE TCA AND THE
INITIATION OF THE MAOI; IF NOT:
CLIENT COULD EXPERIENCE HYPERTENSIVE CRISIS (blurred

vision, dizziness, severe headache, shortness of breath). If TCA is
withdrawn abruptly, the client may experience discontinuation syndrome
MAOI- avoid tyramine-foods

Amyotrophic lateral sclerosis (ALS or Lou Gehrig disease) its a
neurodegenerative disease with NO CURE! Survive only 3-5 YEARS
Symptoms: fatigue, progressive muscle weakness, twitching, muscle

spasms, DIFFICULTY SWALLOWING, DIFFICULTY
BREATHING/SPEAKING, RESPIRATORY FAILURE
Medication - RILUZOLE used to slow the progression of ALS

Coarse crackles are loud and low-pitched heard during INSPIRATION....
NOT CLEARED BY COUGHING
(its in the lower respiratory tract and treated with Diuretics i.e.,
Furosemide)
Asthma or COPD develop wheezing (treated with BROCHODILATORS

i.e., albuterol, ipratropium)
Emphysema use pursed-lip breathing
PNEUMOTHORAX/ HEMOTHORAX, PLEURAL EFFUSION (has

diminished or absent lung sounds)

Neurologic
Diabetes Insipidus s/s:
decreased urine gravity <1.003

elevated serum osmolality >295
hypernatremia >145
hypovolemia / hypotension
polydipsia (excessive oral water intake)

polyuria

Internal radiation implant (brachytherapy) emits radiation in or near a
tumor to treat certain malignancies
Keep long-handled forceps and a lead-lined container should be kept in

the patient room
If dislodgement occurs, the nurse should use long-handled forceps

FIRST to place implant in a lead-lined container to contain radiation
exposure

Von Willebrand disease is a genetic BLEEDING DISORDER
Intranasal desmopressin or topical (thrombin) stops minor bleeding-
epistaxsis
Wear medical ID bracelet

Notify HCP signs of bleeding: (severe joint pain or swelling, H/A, bood
in urine/stool, uncontrollable nosebleed); humidifier/nasal spray reduces
risk of nosebleed; AVOID ASPIRIN AND NSAIDS; AVOID
CONTACT SPORTS; soft bristle tooth brush and gentle floss; REPORT
heavy menstrual bleedings (soak a pad <3 hours)

Huntington disease (HD) = autosomal dominant hereditary disease;
affects impaired movement, swallowing, speech, cognitive abilities.
Chorea (involuntary tic-like movement) is a HALLMARK SIGN
HD is confirmed by genetic testing.

Genetic counseling is recommended for clients who have a parent with

HD and are considering having biological children
AUTOSOMAL DOMINANT= REQUIRES ONLY ONE COPY OF

THE AFFECTED GENE (FROM ONE CARRIER PARENT) TO
MANIFEST; 50% CHANCE OF INHERITANCE

Review breast prosthesis in Saunders

Casted extremity
ACUTE COMPARTMENT SYNDROME (ACS) = REPORT
EXPECTED FINDINGS: mild to moderate edema,warmth/ throbbing
secondary to edema, pain on movement; pain that improve with
analgesics; itching (pruritus); dry skin under cast
HIGH PRIORITY SYMPTOMS FOR CASTS: REPORT TO HCP

severe pain (pain meds dont help)
immobility of digits (fingers/toes)
changes in sensation (TINGLING/NUMBNESS)
lack of pulses in distal extremity (absence of pulses
=ADVANCED/SEVERE ACS
Cool/pale distal extremity

TCA overdose - antidepressant - CHILDREN
Example: Amitriptyline
TCA manifestations of an Overdose:

CNS changes: mental status changes (drowsiness, delirium, coma);
seizures, respiratory depression
Cardiovascular changes: sinus tachy, hypotension; prolonged

PR/QRS/QT intervals; arrhythmias (V-Tach and V-Fib) = NEED ECG
MONITORING IN EMERGENCY DEPARTMENT
Anticholinergic: dry mouth, blurred vision, dilated pupils, urinary

retention, flushing, hyperthermia

Motor vehicle collsion; client arrives to ER UNRESPONDSIVE and on
a MECHNICAL VENTILATOR....
Nurse should perform what actions?

Med-Alert bracelet/necklaces, allergy status, emergency contact, code
status
Remove contact lens if no eye trauma present
Medication patches: to prevent drug interaction and what conditions
currently being treated before removing patches (e.g., clonidine for
HTN, Nitro for angina)= may harm the client
Remove tampon (female) replace with menstrual pad to prevent toxic
shock syndrome of infection
Remove rings/jewelry: prevent constrictive injury or vascular damage if
edema occur

Concepts
Critical laboratory results (POSITIVE BLOOD CULTURES showing
bacteria AND SEVERE ELECTROLYTE IMBALANCES) requires
IMMEDIATE INTERVENTION=CALL HCP NOW, STAT
BACTEREMIA requires timely treatment to prevent further

complications (SEPTIC SHOCK)

Phenytoin is an antiseizure medication with a therapeutic index of 10-20
Tube feedings decrease pheytoin absorption, which reduces SERUM

DRUG CONCENTRATIONS AND MAY PRECIPITATE SEIZURES
Nursing action:
The nurse should pause tube feedings for 1-2 hours before and after
phenytoin administration to ensure adequate absorption
Phenytoin toxicity produces nystagmus, dysarthria, ataxia,

encephalopathy

Aortic Dissection: PRIORITY
Prevent rupture by giving beta blockers to maintain blood pressure
within prescribed parameters
Acute dissection acute onset or sharp or "RIPPING" chest pain that

radiates to the back= NEED EMERGENCY SURGERY TO REPAIR

Carotid Endarterectomy is a surgical procedure performed to remove
plaque from the carotid artery to improve cerebral perfusion. Nurse
should assess for new or worsening alternations in neuro status = risk for
stroke
FAST acronym to assess for stroke:

Facial drooping: numbness or droopiness on one side of face
Arm weakness: weakness or drifting of one arm when raised to shoulder

level
Speech difficulties: slurring of words incomprehensible speech, inability
to understand others
Time: Notation of the time of symptom onset (critical for treatment)

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2/18/2018 UWorld NCLEX-RN QBank

QId: 30030 Adult Health - Gastrointestinal/Nutrition

QId: 30031 Adult Health - Gastrointestinal/Nutrition

ABSENT GAG REFLEX AFTER PROLONGED PERIOD (6 HOURS)

QId: 30035 Adult Health - Gastrointestinal/Nutrition

1. NSAIDS (can cause bleeding)

QId: 30088 Adult Health - Neurologic

Post-op partial laryngectomy- teach them the supraglottic swallow:

Cranial nerve VIII vestibulocochlear affects hearing and equilibrium

QId: 30105 Fundamentals - Safety/Infection Control

QId: 30111 Adult Health - Integumentary

Each arm 9 (front and back each 4.5)

QId: 30112 Adult Health - Integumentary

4mL * (weight in kg) * (% percentage of body surface area burned)

QId: 30135 Adult Health - Gastrointestinal/Nutrition

Enteral feedings have lower infection compliations compared to

QId: 30140 Fundamentals - Skills/Procedures

1000 mcg = 1mg

QId: 30143 Leadership & Management - Leadership & Management

Hypoglcemia= blood suger <70 is life threatening

QId: 30200 Critical Care - Critical Care Concepts

QId: 30213 Adult Health - Respiratory

Suction control chamber = EXPECT GENTLE CONTINUOUS

AIR LEAK MONITOR= ITS PART OF THE WATER SEAL

QId: 30217 Mental Health - Mental Health Concepts

Risk factors in hospitalized clients:

4. coexisting medical conditions (infection)

QId: 30253 Adult Health - Respiratory

Flid overload= best to give diuretics for fluid volume overload

QId: 30254 Adult Health - Respiratory

QId: 30260 Pharmacology - Cardiovascular

Give Adenosine 6mg IV rapidly over 1-2 seconds followed by a 20 mL

QId: 30267 Adult Health - Respiratory

COPD clients with exacerbation

Morphine and other medications such as Benzodiazepines can depress

Can use during acute COPD exacerbations:

QId: 30277 Pharmacology - Respiratory

Therapeutic effects are: RESPIRATORY RATE decreases and PEAK

Short Acting Beta Agonists SE: tachycardia, tremors, palpitations

QId: 30284 Adult Health - Gastrointestinal/Nutrition

QId: 30299 Mental Health - Mental Health Concepts

Practices stress reduction techniques daily

Resilience centers on the adaptive techniques an individual uses to

QId: 30301 Adult Health - Respiratory

Pursed-Lip Breathing Steps:

QId: 30302 Pharmacology - Respiratory

Beclomethasone is an inhaled corticosteroid (ICS) for long-term; USED

SABA FIRST.......ICS SECOND; SABA IS NOT ALWAYS TAKEN

ICS= take it apart and wash it daily

QId: 30316 Adult Health - Gastrointestinal/Nutrition

Dumping Syndrome s/s: HYPOTENSION, ABDOMINAL PAIN,

Dietary teachings to delay gastric emptying: small frequent meals; eat

LAYING DOWN AFTER MEALS= CLIENT DO THIS...GOOD ;-)

QId: 30321 Pharmacology - Respiratory

SE: insomnia, N/V, palpitations (tachycardia), mild tremor

Dosing of albuterol in an acute asthma attack should not exceed 2-4

If the albuterol is not effective, an inhaled corticosteroid is used to treat

QId: 30331 Adult Health - Neurologic

Gross tremors with alcoholics treated with benzodiazepines (endings

Seizures with alcoholics are treated with benzodiazepines

QId: 30354 Fundamentals - Safety/Infection Control

Drag and drop