Nclex + 35 Page Study Guide, Nclex Uworld

Five Rights of Delegation - correct answer 1. Right Person 2. Right Task 3. Right Circumstance 4. Right Direction and Communication 5. Right Supervision and Evaluation Maslow's Hierarchy of Needs - correct answer Five Rights of Medication Administration - correct answer 1. Right Client 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time Acetaminophen (Tylenol) - correct answer Antidote/Reversal: acetylcysteine (Muscomyst) Toxic Level: 250mcg/mL Curare - correct answer Antidote/Reversal: edrophonium (Tensilon) Cyanide Poisoning - correct answer Antidote/Reversal: methylene blue Ethylene Poisoning - correct answer Antidote/Reversal: fomepizole (Antizol) Iron - correct answer Antidote/Reversal: deferoxamine (Desferal) Lead - correct answer Antidote/Reversal: succimer (Chemet) Carbamazepine - correct answer anticonvulsant Therapeutic Level: 5-12 mcg/mL Amitriptyline - correct answer antidepressant and nerve pain med Toxic Level: 500 ng/ML Gentamicin - correct answer antibiotic (renal/oto toxic) Therapeutic Level: 0.5-0.8 mcg/mL Toxic Level: 12mcg/mL Magnesium Sulfate - correct answer anticonvulsant Therapeutic Level: 4-8 mg/dL Toxic Level: 9mg/dL Antidote/Reversal: calcium gluconate 10% (Kalcinate) Methotrexate - correct answer Chemotherapy/Immunosuppressant Toxic Level: 10 mcmol over 24 hours Quinidine - correct answer antiarrhythmic/anti-parasite Therapeutic Level: 2-5 mcg/mL Toxic Level: 10 mcg/mL Salicylate - correct answer NSAID Therapeutic Level: 100-250 mcg/mL Toxic Level: 300 mcg/mL Tobramycin - correct answer Therapeutic Level: 5-10 mcg/mL Toxic Level: 12 mcg/mL Sodium (Na) - correct answer 135-145 Potassium (K) - correct answer 3.5-5 Calcium (Ca) - correct answer 8.5-10.5 Magnesium (Mg) - correct answer 1.5-2.5 Phosphorus (PO4) - correct answer 2.5-4.5 pH - correct answer 7.35-7.45 PaCO2 - correct answer 35-45 PaO2 - correct answer 80-100 HCO3 (bicarbonate) - correct answer 22-26 RBC - correct answer 4,000,000-6,000,000 Hgb - correct answer 12-18 Hct - correct answer 36-50 WBC - correct answer 5,000-10,000 Cholesterol - correct answer 200 INR - correct answer 2. Warfarin Therapeutic Range: 2-3 PT - correct answer 11-15. Warfarin Therapeutic Range: 1.5-2 times normal value (16.5-30) PTT - correct answer 25-35. Heparin Therapeutic Range: 1.5-2 times normal value. (37.5-70) Platelets - correct answer 150,000-400,000. 20,000 be very concerned. Urine Specific Gravity - correct answer 1.01-1.025. High gravity means urine is concentrated. Low gravity means urine is dilute. Creatinine - correct answer 0.6-1.2. BUN - correct answer 10-20 TPN Total Parenteral Nutrition - correct answer Hypertonic Solution Given via PICC line, tunneled catheter Prepared daily by pharmacy Use Sterile Asepsis for dressing change Check blood glucose every 4-6 hours Change bag every 24 Standard Precautions - correct answer When handling blood, bodily fluid, bodily tissue, mucous membranes, open skin PPE: depends on type of exposure (minimal is nothing) Contact Precautions - correct answer Used when germs are spread by touching ex) C. Difficile, Norovirus Minimal PPE: Gloves and Gown Droplet Precautions - correct answer Used to prevent contact with mucus and other secretions from nose, sinuses, throat, airway, and lungs. Use when contact will be within 3 ft or less ex) infulenza, mumps, pertussis Minimal PPE: Mask Airborne Precautions - correct answer Needed to prevent transmission from particles so small the can float in the air and travel long distances. ex) chickenpox, measles, Tuberculosis, SARS Minimal PPE: Well fitting mask *Use respirator mask for TB and SARS **Negative Pressure room Trust vs. Mistrust - correct answer 0-1 yr Teach parents to meet infant's physical and social needs Autonomy vs. Shame and Doubt - correct answer 1-3 yrs Provide child with acceptable options. Let them CHOOSE Initiative vs. Guilt - correct answer 3-6 yrs Assist parents to identify age/disease appropriate activities Idustry vs. Inferiority - correct answer 6-12 yrs Encourage child's participation in their care Identity vs. Role Confusion - correct answer 12-20 yrs Provide same age support group Intimacy vs. Isolation - correct answer 20-35 yrs Provide private time with partner/family Generativity vs. Stagnation - correct answer 35-65 yrs assist client with illness adaptation and home/work demands Integrity vs. Despair - correct answer 65+ yrs Encourage use of personal items when not at home HYPOnatremia - correct answer abnormally low sodium level (135) in the blood, which helps regulate the amount of H2O in and around the cells HYPERnatremia - correct answer abnormally high sodium level (145) in the blood, which helps regulate the amount of H2O in and around the cells. HYPOcalcemia - correct answer low blood calcium level (4.0). HYPERcalcemia - correct answer high blood calcium level (10.5) HYPOglycemia - correct answer HYPERglycemia - correct answer HYPOthyroidism (Hashimotos) - correct answer HYPERthyroidism (Graves Disease) - correct answer HYPOparathyroidism - correct answer HYPERparathyroidism - correct answer HYPOkalemia - correct answer HYPERkalemia - correct answer In delegation, nurses must take patients where there is... - correct answer Evaluation Assessment Teaching Dont delegate what you can EAT Addison disease vs Cushings disease - correct answer Addisions: down down down up down (hyponatremia, hypotension, decreased blood volume, kyperkalemia, hypoglycemia) Cushings: up up up down up (hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia) When do we hold potassium - correct answer Do not give potassium without adequate urine output "No Pee, No K" APGAR - correct answer Appearance (color all pink, pink and blue, blue/pale) Pulse (100, 100, none) Grimace (cough, grimace, none) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, none) For what diseases do we use airborne precautions - correct answer My (measles) Chicken (chicken pox/varicella) Hez (disseminated herpes zoster, shingles) TB (TB) When implementing airborne precautions, what do we have to do - correct answer Private, negative pressure room Must wear mask Can cohort with patient who has same organism, but not if they have different organisms Place mask on client when they are being transported For what diseases do we use droplet precautions - correct answer Think SPIDERMAN S:sepsis S:scarlet fever S: streptococcal pharyngitis P:Parvovirus B19 P:Pneumonia P:Pertussis I:Influenza Type B D: Diptheria (pharyngeal) E: Epiglottitis R: Rubella M:mumps M:Mengitis M:Mycoplasm or meningeal pneumonia An: Adenovirus When implementing droplet precautions, what do we have to do - correct answer Private room or cohort them with a client with the same infection Wear a mask Door may remain open For what diseases do we use contact precautions - correct answer MRS.WEE M:multi drug resistant organism R: Respiratory infection (RSV) S: Skin infections (varicella zoster, cutaneous diptheria, herpes simplex, impetigo, pediculosis, scabies) W:wound infection E: Enteric infection (C Diff) E: eye infection (pink eye) Signs and symptoms of air/pulmonary embolism - correct answer Chest pain Difficulty breathing Tachycardia Pale/Cyanotic Sense of impending doom What do we do as the nurse for air/pulmonary embolism - correct answer Turn patient to the LEFT side and LOWER the head of the bed Signs and symptoms of a woman in labor with a baby who has an unreassuring FHR - correct answer Late decels Fetal bradycardia Decreased variability What do we do for a woman in labor who has an unreassuring FHR - correct answer Turn to the LEFT side Give O2 Stop the Pitocin Increase IV fluids (LR and NS) What position is someone in for an epidural puncture - correct answer Side-lying What position is the patient in AFTER a lumbar puncture (and also oil-based myelogram) - correct answer Have the pt lie Flat and Supine to prevent CSF from leaking out and prevent a headache What do we do if a patient has decreased LOC during tube feeding - correct answer Position the patient on the RIGHT side (to increase gastric emptying) and RAISE the head of the bed to at least 30 degrees (to prevent aspiration) Position for a patient with a CBI - correct answer The catheter is taped to the patients leg so the leg should be kept straight, but there are no other positioning limitations Position of a patient after a myringotomy - correct answer Position the patient on the side of the AFFECTED EAR after surgery to allow for drainage of secretions. This procedure is surgical incision into the eardrum (tympanic membrane), to relieve pressure or drain fluid. Position of a patient after cataract surgery - correct answer Patient should sleep on the UNAFFECTED side and have a night shield for 1-4 weeks Position of a patient after a thyroidectomy - correct answer Low or semi-fowlers. Support the head, neck, and shoulders. Have a trach at the bedside Position of an infant with spina bifida - correct answer Prone! So their sac does not rupture Position of a patient with bucks traction - correct answer Elevate the food of the bed for counter traction Position of a patient after total hip replacement - correct answer Do not sleep on the operated side. No flexing the hip more than 45-60 degrees. Don't elevate the HOB more than 45 degrees. Keep the hip abducted by separating legs with a pillow or abductor Position for a mom with a prolapsed cord - correct answer Knee-chest position or trendelenburg Position for an infant with a cleft lip - correct answer On their back or in an infant seat to prevent trauma to the suture line. If feeding, hold in an upright position Position for an ABOVE the knee amputation - correct answer Elevate for the first 24 hours on a pillow. Position prone daily to help with hip extension Position for a BELOW the knee amputation - correct answer Foot of bed elevated for the first 24 hours. Position prone daily to help with hip extension Position for a detatched retina - correct answer Area of detachment should be in the dependent position Position for administration of an enema - correct answer Patient should be LEFT side laying with the knee flexed (Sims position) Position during internal radiation - correct answer On bedrest while the implant is in place Position if the patient has autonomic dysreflexia/hyperreflexia - correct answer Place the client in a sitting position (elevate the HOB to 90) FIRST before any other implementation S&S include: extreme HTN, pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia,) Position for a patient in shock - correct answer Modified trendelenberg (extremities elevated 20 degrees) with the knees straight and head slightly elevated Position for a patient with a head injury - correct answer Elevate the HOB 30 degrees to decrease ICP Position for a patient with peritoneal dialysis when the outflow is inadequate - correct answer Turn the patient from side to side BEFORE checking the tube for kinking When someone has a head injury, what medication are we likely to give - correct answer Mannitol. An osmotic diuretic that decreases ICP and increase urine output. This crystallizes at room temperature so ALWAYS use a FILTER NEEDLE What is myasthenia gravis - correct answer Muscular weakness produced by repeated movements. Disappears when the patient rests. No problems with CNS or PNS just random. We see diplopia, ptosis, impaired speech, dysphagia, respiratory distress As the nurse, what do we do for myasthenia gravis - correct answer Administer meds before eating (anti cholinesterase, corticosteroids, immunosuppressants) Optimal eye care (to prevent and help diplopia) Maintain optimal mobility Avoid things that precipitate myasthenia crisis (infections, stress, neomycin/streptomycin, surgery) What S&S will show if it proceeds to a Myasthenia crisis - correct answer Sudden inability to swallow, speak, or maintain a patent airway What test do we use to diagnose people with Myasthenia Gravis - correct answer Tensilon test. Where we inject tensilon and ask you to do activities like stand up and sit down and stand up and sit down. If you get tired we inject another dose. If you can stand up again, you probably have MG. MG is susceptible to the Tensilon test What lab value do we need to be aware of prior to a liver biopsy - correct answer PTT Thyroid storm - correct answer Caused by untreated Hyperthyroidism. Increased temp, pulses and BP Give hypothermia blanket, O2, PTU, potassium iodine Hypoparathyrodism - correct answer CATS: convulsions, arrythmias, tetany, spasms, stridor Too little calcium Hyperparathyroidism - correct answer Fatigue Muscle weakness Renal calculi Back/joint pain and pathological fractures Too much calcium Hypovolemia - correct answer Increased temp Rapid/weak pulse Increased respirations Decrease BP