Mark Klimek Blue Book Part 1, Question Bank with answers, 2022/2023. NCLEX

Mark Klimek Blue Book Part 1, Question Bank with answers, 2022/2023. NCLEX Document Content and Description Below Mark Klimek Blue Book Part 1, Question Bank with answers, 2022/2023. NCLEX In Abruptio Placenta, the placenta ____________ from the uterine wall ____________. - Separates, prematurely Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________. - Multigravida, 35 (HTN, trauma, cocaine) How is the bleeding of Abruptio Placenta different from that in Placenta Previa? - Usually painful; bleeding is more voluminous in placenta previa If you are the nurse starting the IV on the client with Abruptia Placenta, what guage needle should you use? - 18 (in preparation to give blood if necessary) How often should you measure the VS, vaginal bleeding, fetal HR during Abruptio Placenta? - Q5-15 minutes for bleeding, maternal VS and continuous fetal monitoring Deliver baby at earliest sign of fetal distress How is an infant delivered when Abruptio Placenta is present? - Usually C-section Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa? - Higher In what trimester does Abruptio Placenta most commonly occur? - Third At what age are accidental poisonings most common? - 2 years old If a child swallows a potentially poisonous substance, what should be done first? - Call for medical help Should vomiting be induced after ingestion of gasoline? - No- not for gas or any other petroleum products When taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER? - the suspected poison An elderly client is a (high/low) risk for accidental poisoning? What about a school age child? - high - due to poor eyesight, high What types of chemicals cause burns to oral mucosa when ingested? - Lye, caustic cleaners Children at highest risk for seizure activity after ingestion are those who have swallowed _____________ and ______________. - drugs, insecticides Can impaired skin integrity ever be an appropriate nursing diagnosis when poisoning has occurred? - Yes, when lye or caustic agents have been ingested What is the causative organism of acne? - P. acnes (propionibacterium acnes) What structures are involved in acne vulgaris? - The sebaceous glands Name 3 drugs given for acne? - Vitamin A, Antibiotics, Retinoids Dietary indiscretions and uncleanliness are causes of acne? - False What are the 3 causative factors in acne vulgaris? - Hereditary, Bacterial, Hormonal Uncleanliness is a cause of acne? - False What is the most common retinoid given to people with acne? - Accutane Accutane is an analog of which vitamin? - Vitamin A What is the most common side effect of accutane? And what is most important in health teaching in adminstration? - Inflammation of the lips; Causes birth defects What is the antibiotic most commonly given to clients with acne? - Tetracycline How long will it take for the person to see results when acne is being treated? - 4 to 6 weeks Does stress make acne worse? - yes How often should the client with acne wash his face each day? - Twice a day What instructions do you give to a client taking tetracycline? - Take it on an empty stomach and avoid the sunlight (photosensitivity) What are comedones? - Blackheads and white heads What virus causes AIDS? - HIV - Human immunodeficiency virus The AIDS virus invades helper ____________. - T-lymphocytes (or CD4 cells) AIDS is transmissible through what four routes? - blood sexual contact breast feeding across placenta in utero HIV is present in all body fluids? - Yes, but it is not transmitted by all, only blood, semen and breast milk Name the 5 risk groups for AIDS - Homosexual/bisexual men IV drug users Hemophiliacs Heterosexual partners of infected people Newborn children of infected women What is the first test for HIV antibodies? - ELISA What test confirms the ELISA? - Western Blot Which test is the best indicator of the PROGRESS of HIV disease? - CD4 count A CD4 count of under __________ is associated with the onset of AIDS-related symptoms. - 500 A CD4 count of under _______ is associated with the onset of OPPORTUNISTIC INFECTIONS. - 200 Give 6 symptoms of HIV disease. - anorexia fatigue weakness diarrhea night sweats fever Which 2 classes of drugs are given in combination for HIV sero-positivity? - NRTI's (Nucleoside Reverse Transcriptease Inhibitors) and PI's (Protease Inhibitors) They prevent viral replication. NRTI (nucleoside reverse transcriptease inhibitors) - An antiviral drug used against HIV Is incorporated into the DNA of the virus and stops the building process Results in incomplete DNA that cannot create a new virus Often used in combination with other drugs PI's (Protease inhibitors) - Most potent of antiviral meds Inhibit cell protein synthesis that interferes with viral replication. Does not cure but slows progression of AIDS. Prolongs life, used prophylactically and used in AIDS to decrease viral load and opportunistic infections. What do NRTI's and PI's do? - They prevent viral replication. What does the physician hope to achieve with NRTI's and PI's for HIV? - A delayed onset of AIDS for as long as possible (usually can delay onset for 10-15 years) What is the most common NRTI used? - AZT (zidovudine) What is the most challenging aspect of combination of drug therapy for HIV disease? - The number of pills that must be taken in 24 hours can be overwhelming. The frequency also makes it hard to remember-an alarm wristwatch is used. Clients with AIDS (gain/lose) weight? - Lose weight The typical pneumonia of AIDS is caused by ___________ ____________. - Pneumocystic carinii What type of oral/esophageal infections do AIDS patients get? - Candida What is the #1 cancer that AIDS patients get? - Kaposi's sarcoma Kaposi's sarcoma is a cancer of the ___________. - skin T/F: AIDS patients get lymphomas? - True What lab findings are present in AIDS? - Decreased RBC's, WBC's and platelets If the AIDS patient HAS leukopenia they will be on _____________ ________________. - Protective (reverse) Isolation Define Leukopenia - Decrease in WBC, indicated viral infection Without leukopenia the AIDS patient will be on ____________ precautions. - Standard precautions or blood and body fluid precautions When the AIDS patient has a low platelet count, what is indicated? - Bleeding precautions; No IM's, no rectal temperatures, other bleeding precautions Does AIDS require a single room? - Yes - if WBC counts are low When do you need a gown with AIDS? - If you are going to get contaminated with secretions When do you need a mask with AIDS? - Not usually unless they have an infection caused by an AIREBORNE bug When do you need goggles with AIDS? - Suctioning Central line start Arterial procedures If an AIDS patient's blood contaminates a counter top, with what do you clean? - 1:10 solution of bleach and water Are all articles used by AIDS patients double-bagged? - no - only those contaminated with secretions Can AIDS patients leave the floor? - Yes, unless WBC's are very low Is dietary protein limited in AGN? - Not usually, however if there is severe azotemia then it may be restricted Define azotemia? - Nitrogenous wastes in the blood (increased creatinine, BUN) What is the best indicator of renal function? - The serum creatinine Do people recover from AGN? - Yes, the vast majority of all clients recover completely from it. How can AGN be prevented? - By having all sore throats cultured for strep and treating any strep infections. What is the most important intervention in treating AGN? - Bedrest - they can walk if hematuria, edema and hypertension are gone. What is the most common dietary restriction for AGN? - Moderate Na+ restriction. Fluid restriction is #2 if edema is severe. What are the urinalysis findings on AGN? - Hematuria Proteinuria +3 to +4 Specific Gravity Up How long after strep infection does AGN develop? - 2 to 3 weeks after initial infection How do you assess fluid excess in the child with AGN? - Daily weight What organism causes acute glomerular nephritis? - Group A beta hemolytic strep What happens to the kidney in AGN? - It becomes clogged with antigen-antibody complexes which then cause inflammation and loss of function. How often are vital sign measurements taken in AGN? - Q4 hours with blood pressure Will the client have hypo or hyper tension with AGN? Why? - Hypertension, because of fluid retention What are the first signs of AGN? - Puffiness of face Dark urine What are the three adult stages of development called? - Early adulthood Middle adulthood Late adulthood What is the age range for early adulthood? - 19 - 35 What is the age range for middle adulthood? - 35 - 64 What is the age range for late adulthood? - 64 - death What is the developmental task for EARLY adulthood? - Intimacy vs. Isolation What is the developmental task for middle adulthood? - Generativity vs. Stagnation Intimacy vs. Isolation - Erikson's stage in which individuals form deeply personal relationships, marry, begin families Generativity vs. Stagnation - Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service What is the developmental task for LATER adulthood? - Ego Integrity vs. Despair Ego Integrity vs. Despair - (Erikson) People in LATE adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be relived "Time is too short to start another life, though I wish I could," is an example of ___________. - Despair "If I had to do it over again, I'd live my life just about the same," is an example of __________ __________. - Ego Integrity The result of the positive resolution of the final life crisis. Viewed as the key to harmonious personality development; the individual views their whole life with satisfaction and contentment. What does AKA mean? - Above the knee amputation What does BKA mean? - Below the knee amputation If the patient had an AKA they should lie ____________ several times per day. - Prone (to prevent flexion contracture) The #1 contracture problem in AKA is ____________ of the _____________ - flexion, hip What will prevent hip flexion contracture after AKA? - Lying prone several times a day What is the #1 contracture problem after BKA? - Flexion of the knee How do you prevent flexion contracture of the knee after BKA? - Remind the patient to straighten their knee constantly while standing To prevent post-op swelling, the stump should be __________ for 12 to 24 hours. - elevated How long should the stump be elevated to prevent post op swelling? - 12-24 hours How often should a stump be washed? - Daily When a stump is wrapped, the bandage should be tightest _____________ and loosest _____________. - distally (far from the center), proximally (neareast to the point) If after a right BKA, the client c/o pain in his right toe, he is experiencing _____________. - phantom limb sensation (which is normal) When will phantom limb sensation subside? - In a few months Is it acceptable for the patient to push the stump against a wall? - Yes, this is one way to toughen a stump so it will not breakdown due to the wear of the prosthetic leg; hitting it with pillows is another good method. An aneurysm is an abnormal _______________ of the wall of a(n) artery. - widening (it is also weakening) What artery is widened in a thoracic aneurysm? - the aorta An aneurysm can result from an _____________ and from ____________. - infection, syphillis The most common symptom of abdominal aneurysm is: - A pulsating mass above the umbilicus Which aneurysm is most likely to have no symptoms? - the abdominal is most often "silent" Which vital signs are most important to measure in clients with aneurysm? - The pulse and blood pressure An aneurysm will most affect which of the following, the blood pressure or the pulse? - The pulse --many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change. What activity order is the client with an aneurysm supposed to have? - Bedrest. DO NOT get these people up. If the client with aneurysm is physically unstable, should you encourage turning, coughing and deep breathing? - No, BEDREST until the client is stable! What class of drugs is the client with an aneurysm most likely to be on? - Antihypertensives What is the BIG danger with aneurysms of any type? - Rupture, leads to shock and death If an aneurysm is ruptured how would you know it? - All signs of shock Decreased LOC (restlessness) Tachycardia Hypotension If an aneurysm ruptures what is the #1 priority? - Get them to the operating room ASAP Is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room? - Yes, if available you can get them into ANTISHOCK TROUSERS but not if this causes a delay in getting them to the operating room The post op thoracic aneurysm is most likely to have which type of tube? - Chest tube, because the chest was opened The post op abdominal aneurysm repair client is most likely to have which type of tube? - NG tube for decompression of bowel If you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hours? - check the distal extremity (far from center) color temperature pain pulse also MUST document What causes angina pectoris? - Decreased blood supply to myocardium, resulting in ischemia and pain Describe the pain of angina pectoris - Crushing substernal chest pain that may radiate What drug treates angina pectoris? - Nitroglycerine How do you tell if a client has angina or an MI? - The pain of the two is similar, the way to tell the difference is if nitro and rest relieve the pain. Angina = nitro and rest relieve the pain MI = nitro and rest DO NOT relieve the pain How many nitroglycerine tablets can you take before you call the doctor? - 3 tablets How many minutes should lapse between the nitro pills you take? - 5 minutes - take 1 nitro tab every 5 minutes 3 times, if no relief, call MD By what route do you take nitro? - Sublingual What is the action of nitro? - Dilates coronary arteries to increase blood supply (O2 supply) and reduces preload. What are the top 2 side effects of nitro? - hypotension and headache What precaution must the nurse take when administering topical nitro paste? - wear gloves, nurse may get a dose of the med Everyone with angina needs bypass surgery. (T/F) - False Anorexics are usually __________ under the age of _____. - females, 25 The diagnosis of anorexia nervosa is made when there is a weight loss of _______% or more of body weight. - 15 (pt weighs less than 85% of normal body weight) Hospitalize if 30% weight loss A major mental/emotional nursing diagnosis seen in anorexia nervosa is ___________. - Altered body image The pulse rate of anorexics is tachycardic or bradycardic? - Bradycardic List the most common gynecologic symptom of anorexia nervosa? - amenorrhea What is found over the body of the client with anorexia nervosa? - lanugo (soft downy hair) What is the top priority in the care of the client with anorexia nervosa? - Intake of enough food to keep them alive, have them gain weight The best goal to evaluate the progress of the client with anorexia nervosa? - An adequate WEIGHT GAIN What is the apgar scale? - Quick objective way to evaluate the vital functions of the newborn When is APGAR scoring performed on infants? - At 1 minute and again at 5 minutes after the birth Name the 5 criteria that are recorded on an apgar scale - Cardiac status Respiratory effort Muscle tone Neuromuscular irritability Color The total apgar score can range from - 0 to 10 The maximum score an infant can receive on any one of the criteria is... - 2 A 10 on the apgar means the baby is - in terrific health A 0 on the APGAR is ________ (bad/good). - Bad, the baby is stillborn On heart rate or cardiac status, a 2 means that the HR is above _______ BPM. - 100 On the HR criteria an infant scores a "1" if their HR is _________ than 0 and ____________ 100 - greater, less than In order to score a 0 on HR the infant must have a rate of _________. - Zero A high score of 2 is given for respiratory effort if the newborn_____________. - Cries vigorously An infant is given a score of 1 if their respirations are _______ or ________. - Slow or irregular An infant is given a score of 0 for respiratory effort if __________. - They do not breathe In order to get a score of 2 on muscle tone the infant must_________________. - Move spontaneously (actively) To get a score of 1 on the APGAR for muscle tone the newborn must place their extremities in _______________. - Flexion A newborn receives a score of 0 on muscle tone when there is__________ - No movement (limp) To score the maximum of 2 points on nueromuscular reflex irritability the infant must ______________. - Cry If th