Graces Rattles NCLEX Review Notes - Comprehensive Study Guide

Graces Reviews
Rattle #1 October 13th:

Post op—Nurse should do first vitals & get patient up first
oMake sure they can bear weight!
Blood transfusion
oFluids-NS
oHow long to hang blood?
4 hours, have 30 minutes to hang it from when you get it
oReaction what next?
Stop it!
oStopped it, now what?
 Disconnect, pull back blood, hang new NS with new tubing
oWhat you need before you get blood?
Vitals, type & cross, consent, verified orders, 18-20 gauge needle*
Flu- what isolation?
oDroplet (mask, goggles & gloves)
NG tube
oListening to BS, what you do before that?
Turn off suction
Afib on the monitor, physician will order what?
oAnticoagulants, Diltiazam, Amiodarone, SCDS, Compression socks
Vfib= Defib; if no defibrillator= CPR
Who can remove a chest tube?
oMD only
oIf bubbling, what do you look for?
Leaks or kinks
*gauge is too high!
Car seat safety
oStrap= armpit
oRearfacing in the middle seat and anchored
Burns
oRule of nines:
1 arm= 9%
1 leg= 18%
Torso= 18%
Back=18%
Head= 9%
Genitals= 1%
First sign of rejection from a stem cell transplant or organ transplant?
o1 degree increase in temperature
Atherosclerosis- what would you avoid eating?
oHigh cholesterol foods

, Egg yolks
oCholesterol levels: <200 total cholesterol
HDLs: >55 for females, > 45 in males
LDs: <130
Writing something bad= libel
Talking badly about someone= slander
Alternative to restraints = music
What can an RN delegate to an LPN?
oThey can pass certain meds, tube feeds, accu checks, wound dressing changes, medical
hx
oRN can not delegate what they EAT (evaluation, assessment, and teaching)
oLPN can reinforce, and reassess
Pt comes from OR, what would you do?
o#1= verify the patient, look at arm band!
o#2= Assess the patient
Pt comes up from endoscopy/surgery, on clear liquids and they start coughing, what are we
concerned about?
oAspiration, not ready to drink! Watch them!
When should an infant be able to smile?
o3-4 months
When should a child be able to hold a sippy cup?
o9-12 months
When should a child be able to pull themselves up on an arm of chair/couch?
oBy 9 months
If the child is not meeting these milestones what are they?
oDelayed
What is the primary cause of Anaphylactic shock?
oAllergy/ allergic response/ reaction
What is the primary cause of hemorrhagic/ hypovolemic shock?
oBlood loss
What is the primary cause of neurogenic shock?
oCNS damage
What is the primary cause of cardiogenic shock?
oPump failure/ Decreased cardiac output
What is the primary cause of septic shock?
oSepsis/ infection
What is shock?
oIt is a decrease in perfusion to vital organs
What is the first organ to fail?
oKidneys
What are you primarily looking for with a patient with AKI?
oDecreased urinary output
What lab in shock will come up in septic shock?

, oLactic acid
What are interventions for shock?
oPharm: Fluids, vasopressors, then tx underlying cause
Anaphylaxis, what body system response causes the primary problem?
oVascular, dilate (vasodilation)-- give vasopressors to constrict
Cardiogenic shock body system problem?
oMI- sternal chest pain
oLeft side big, stretched out= Left sided heart failure/ cardiomyopathy
Blood loss with hypovolemic shock= hypovolemia
oCauses are DI, burns etc
oStop bleeding and fluids
Anaphylaxis- what drugs?
oEpinephrine, Antihistamine and diphenhydramine (benadryl)
What is the treatment of cardiogenic shock?
oDecrease in cardiac output
oCould be MI, HF or cardiomyopathy
oDrugs? Dopamine, Dobutamine, and Epinephrine
Hypovolemic and Burns?
oFluid resuscitation
Laceration of a major artery, what is priority?
oStop the bleeding!
Neurogenic shock- loss of vessel tone, won't constrict properly= vasodilation
oAdd fluids
Septic shock caused by sepsis what happens to vessels? Vasodilation
oARDS can happen (ARDS- refractory hypoxemia, tx: PEEP)
oAntibiotics, fluids and vasopressors
Septic shock can move into respiratory distress syndrome if they stay in a compromised state.
oWhat drug would be used to tx underlying cause of sepsis?
Antibiotics
Heparin drip going, you make a change per order, what safety measure is needed?
o2 nurse verification!
oWhat labs do you watch for Heparin?
APTT, PTT and platelets
Patient asks if TPN can be disconnected what is the response? NO b/c they could go
hypoglycemic
oIf it is disconnected, what do you hang?
D10
Witnessing medication;
o2 mg morphine, but only need 1 mg?
Waist before you administer!
MI s/s: chest pain, jaw pain, increase HR, N/V, indegestion, DIAPHORESIS
oTx MI with MONA:
M= morphine