NR 452 Proctored Nursing School Exit Exam Study Notes

Proctored Nursing School Exit Exam Study Notes Renal Calculi - Pain: Flank pain ³ Kidney or Ureter (if pain radiates ³ stones in ureter or bladder) Performing Ear Irrigation: Sterile technique, warm meds, pull up & back, tilt toward affected ear Thrombolytic Therapy (Stroke): Reteplase recombinant (rTPA 3 clot buster) w/ in 4.5 hours of initial symptoms Trach care: Dressing &, inner cannula ½ hydrogen peroxide, & stoma ¥ knot Head injury (changes in LOC): Length of time unconscious & GCS General anesthesia (post-op): ABC9s 3 full body assessment, Vitals every 15 minutes, Lateral position (if unresponsive or unconscious - monitor LOC), Fluids/Electrolytes Superficial Burns: Painful, pink, red, mild edema (3-6 day healing), damage to epidermis Dialysis (reporting unexpected findings): Temp of 100 degrees, ³ BP, bleeding, 1 L of fluid = 1Kg, clotting, H/A, Nausea, Disequilibrium syndrome (rapid ³ BUN & Fluid volume), anemia, peritonitis, ± BG, ± cholesterol Pacemaker (complications): Infection, hematoma, pneumothorax, hemo-thorax, arrhythmias, pacer spikes before P or QRS, hiccups / muscle twitching ³ Increase Mg+ 1.3 Mg/dL ± Mg foods = (Dairy, dark leafy greens veges) ³ Mg causes ³ Hyperactive deep tendon reflexes * Paresthesia9s, muscle tetany, positive chvostek9s & Trousseau9s sign, hypoactive bowels, constipation, abdominal distention, paralytic Ileus. TPN Admin: (Total parenteral nutrition) -feeding that bypasses the GI tract. Fluids are given into a vein to provide most of the nutrients the body needs. Given when person cannot/ should not receive feedings or fluids by mouth. Hypertonic (20-50% dextrose), Used in chronic pain, peritonitis, burns, Infection, etc No more than 10% hourly, ± in rate for body adjustment, check BG Hyperglycemia, hypoglycemia, vitamin deficiencies, air embolism (clamp, place in Trendelenburg pos., O2) Fluid imbalance ³ Fluid volume excess