NCLEX Uworld Test Bank Full Solution Pack(2022-2023)
what medications interact with grapefruit? Answer- calcium channel blockers: diltiazem, nifedipine, verapamil, etc
statins
caffeine
SSRIs
be sure to practice math! Answer- stent placement using the femoral approach puts you at risk for retroperitoneal hemorrhage Answer- what are early signs of bleeding into the retroperitoneal space? Answer- hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses
what is the grey-turner sign and what is it a sign of? Answer- bruising of the flanks and retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? Answer- intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the extremities)
transplanted hearts are expected to be Answer- tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? Answer- administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? Answer- it is perscribed after TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder
what is the nurses care of monitoring CBI? Answer- monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture Answer- periorbital hematomas (raccoon eyes),
csf fluid rhinorrhea, and battle sign (behind the ear bruising) immediate client care for basilar skull fracture Answer- cervical spime immobilization, close neurologic monitoring, and support of ABCs
vomiting with intake may mean Answer- viral or bacterial infection
tympanosomty tubes are placed for Answer- recurrent otis medias
nurse actions during a seizure Answer- assist them to lie down is standing/sitting, put them on side for patent airway, loosen tight clothing, give oxygen as needed, remove objects from immediate area, document time and duration of seizure (for tests are done later to see which type of seizure and maybe what exacerates it)
never put anything in mouth or restrain them since musclec ontractions can occur during a seizure
what are some early symptoms of ICP? Answer- altered LOC, headache, abnormal reathing, rise in bp, slow pulse, vomiting
client who has a TIA is often placed on Answer- prophylactic antithrombotic treatment like aspirin or clopidogrel
glascow coma scale ranges from Answer- 3-15; 3 being worst 15 being best condition (8 or below in a coma)
what are the 3 components? Answer- eye opening
motor response
verbal response
what is a primary component in TPN? Answer- glucose, so the nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia
when a client is on TPN, the nurse must assess for hyperglycemia why? Answer- bc a primary component is glucose. therefore the nurse must be assessing to see if the client
is getting too much glucose (hoerglycemia). and with a large urinary output like 4800, this could indicate symptoms of hyperglycemia
signs og hyperglycemia Answer- polydipsia, polyuria, restless, confused, bg over 200, fatigue, kussmaul resp
what is the goal for mass casualty events? Answer- do the greatest good for the greatest number of people
keep in mind that disaster triage ranks the likelihood of survival with treatment, not necessarily the severity of the injury Answer- what are the 4 categories for triaging? Answer- immediate (red tag)- life threatening injuries with good prognosis once treated delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines Answer- head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
extrapyramidal side effects Answer- ACUTE DYSTONIC REACTION: sudden onset sustained muscle contractions
AKATHISIA: restlessness with inability to sit still drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces
AKINISIA: loss of involuntary movement
TARDIVE DYSKININIA
NEUROLEPTIC MALIGNANT SYNDROME
dont give morphine if RR under 12 bc it can cause Answer- respiratory depression
airborne precautions Answer- tuberculosis, varicella, and rubeola (measles)
wear N95 respirator (and other as needed like for splashes) ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
UAP soft wrist restraints can: Answer- do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
a client with major depression and severe weight loss needs what type of diet? Answer- high in calories and protein, also foods that are easy to chew and dont require a lot of energy bc they may have a low energy level examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta
also small frequent meals
memorize MAOIs and remember Answer- they cant eat foods high in tyramine like aged
cheese, yogurt, fermented foods, beer, red wine, cocolate, avocados
do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart
failure or edema Answer- you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics, analgesics, and antinflammatories
examples are Answer- Mucinex, Ibuprofin, decerebrate posturing (toes point down and amrs/legs straight out) is a sign of Answer- severe brain damage
near drowning hypothermia Answer- warm iv fluids, blankets, and air also will find weak and thready pulse
a client is not dead until warm and dead!!! Answer- nc sometimes a pt is so cold that a pulse cannot be felt
intussusception
causes intestinal obstruction Answer- ileum telescopes into cecum, pain obstruction, edema, compression of BVs, bowel ischemia, rectal bleeing (CURRANT JELLY stools)
signs of intussusceotion Answer- inital periodic pain with legs drawn up to abdomen, pain is severe and progressive though, inconsolable crying, blood/mucousy stools "current jelly"
how is it treated? Answer- an air enema
guaifenesin (Mucinex) Answer- expecorant med that inc resp fluids and thins secretions to facilitate expectoration
erythropoeitin Epogen Answer- stimulates bone marrow to make RBCs and combats the effects of chemo and used for kidney disease
when is hemoccult done? Answer- when hidden (occult) blood is suspected due to dark and tarry stool
treat intussusception with Answer- AIR ENEMA
tetraology of fallot Answer- exacerbation can happen when infant or child cries, becomes upset, or is feeding
you immediately place them in KNEE CHEST position
hemolytic uremic syndrome Answer- life threatening complication of e. coli diarhea
what are the signs? Answer- anemia (pallor), low platelets (petechiae and purpura, and acute kidney injury (low UO)
cognitive behavioral therapy (CBT) 5 basic components Answer- education about pts disorder
self observing and monitoring
relaxation techniques
cognitive restructuring
behavioral strategies
what medications interact with grapefruit? Answer- calcium channel blockers: diltiazem, nifedipine, verapamil, etc
statins
caffeine
SSRIs
be sure to practice math! Answer- stent placement using the femoral approach puts you at risk for retroperitoneal hemorrhage Answer- what are early signs of bleeding into the retroperitoneal space? Answer- hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses
what is the grey-turner sign and what is it a sign of? Answer- bruising of the flanks and retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? Answer- intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the extremities)
transplanted hearts are expected to be Answer- tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? Answer- administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? Answer- it is perscribed after TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder
what is the nurses care of monitoring CBI? Answer- monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture Answer- periorbital hematomas (raccoon eyes),
csf fluid rhinorrhea, and battle sign (behind the ear bruising) immediate client care for basilar skull fracture Answer- cervical spime immobilization, close neurologic monitoring, and support of ABCs
vomiting with intake may mean Answer- viral or bacterial infection
tympanosomty tubes are placed for Answer- recurrent otis medias
nurse actions during a seizure Answer- assist them to lie down is standing/sitting, put them on side for patent airway, loosen tight clothing, give oxygen as needed, remove objects from immediate area, document time and duration of seizure (for tests are done later to see which type of seizure and maybe what exacerates it)
never put anything in mouth or restrain them since musclec ontractions can occur during a seizure
what are some early symptoms of ICP? Answer- altered LOC, headache, abnormal reathing, rise in bp, slow pulse, vomiting
client who has a TIA is often placed on Answer- prophylactic antithrombotic treatment like aspirin or clopidogrel
glascow coma scale ranges from Answer- 3-15; 3 being worst 15 being best condition (8 or below in a coma)
what are the 3 components? Answer- eye opening
motor response
verbal response
what is a primary component in TPN? Answer- glucose, so the nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia
when a client is on TPN, the nurse must assess for hyperglycemia why? Answer- bc a primary component is glucose. therefore the nurse must be assessing to see if the client
is getting too much glucose (hoerglycemia). and with a large urinary output like 4800, this could indicate symptoms of hyperglycemia
signs og hyperglycemia Answer- polydipsia, polyuria, restless, confused, bg over 200, fatigue, kussmaul resp
what is the goal for mass casualty events? Answer- do the greatest good for the greatest number of people
keep in mind that disaster triage ranks the likelihood of survival with treatment, not necessarily the severity of the injury Answer- what are the 4 categories for triaging? Answer- immediate (red tag)- life threatening injuries with good prognosis once treated delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines Answer- head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
extrapyramidal side effects Answer- ACUTE DYSTONIC REACTION: sudden onset sustained muscle contractions
AKATHISIA: restlessness with inability to sit still drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces
AKINISIA: loss of involuntary movement
TARDIVE DYSKININIA
NEUROLEPTIC MALIGNANT SYNDROME
dont give morphine if RR under 12 bc it can cause Answer- respiratory depression
airborne precautions Answer- tuberculosis, varicella, and rubeola (measles)
wear N95 respirator (and other as needed like for splashes) ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
UAP soft wrist restraints can: Answer- do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
a client with major depression and severe weight loss needs what type of diet? Answer- high in calories and protein, also foods that are easy to chew and dont require a lot of energy bc they may have a low energy level examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta
also small frequent meals
memorize MAOIs and remember Answer- they cant eat foods high in tyramine like aged
cheese, yogurt, fermented foods, beer, red wine, cocolate, avocados
do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart
failure or edema Answer- you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics, analgesics, and antinflammatories
examples are Answer- Mucinex, Ibuprofin, decerebrate posturing (toes point down and amrs/legs straight out) is a sign of Answer- severe brain damage
near drowning hypothermia Answer- warm iv fluids, blankets, and air also will find weak and thready pulse
a client is not dead until warm and dead!!! Answer- nc sometimes a pt is so cold that a pulse cannot be felt
intussusception
causes intestinal obstruction Answer- ileum telescopes into cecum, pain obstruction, edema, compression of BVs, bowel ischemia, rectal bleeing (CURRANT JELLY stools)
signs of intussusceotion Answer- inital periodic pain with legs drawn up to abdomen, pain is severe and progressive though, inconsolable crying, blood/mucousy stools "current jelly"
how is it treated? Answer- an air enema
guaifenesin (Mucinex) Answer- expecorant med that inc resp fluids and thins secretions to facilitate expectoration
erythropoeitin Epogen Answer- stimulates bone marrow to make RBCs and combats the effects of chemo and used for kidney disease
when is hemoccult done? Answer- when hidden (occult) blood is suspected due to dark and tarry stool
treat intussusception with Answer- AIR ENEMA
tetraology of fallot Answer- exacerbation can happen when infant or child cries, becomes upset, or is feeding
you immediately place them in KNEE CHEST position
hemolytic uremic syndrome Answer- life threatening complication of e. coli diarhea
what are the signs? Answer- anemia (pallor), low platelets (petechiae and purpura, and acute kidney injury (low UO)
cognitive behavioral therapy (CBT) 5 basic components Answer- education about pts disorder
self observing and monitoring
relaxation techniques
cognitive restructuring
behavioral strategies
