Mark Klimek Blue book (ALL) NCLEX Study Guide. Questions with accurate answers. 2022 update. TEST BANK

Mark Klimek Blue book (ALL) NCLEX Study Guide. Questions with accurate answers. 2022 update. TEST BANK Document Content and Description Below Mark Klimek Blue book (ALL) NCLEX Study Guide. Questions with accurate answers. 2022 update. Name the five/six essential nutrients - carbs, fats, proteins, vitamins, minerals, water Th e major source of energy for the body is - carbs carbs provide ____________ Kcalories per 1 gram - 4 Sucrose is a sugar found in ____________ and _____________. - fruits, veggies Lactose is a sugar found in ? - milk What is glycogen? - It is a stored formed of glucose/energy manufactured by the liver Is glycogen eaten in foods? - NO! It is a stored form of glucose MANUFACTURED by the liver. When the body does not receive enough carbs it burns ___________ and _____________. - protein, fat The most concentrated source of energy for the body is ___________. - fats Fats provide ___________ Kcalories per 1 gram. - 9 Fats carry vitamins - A,D,E,K (Remember FADE K!) The nutrient needed most for growth and repair of tissues is _____________. - protein (second best is Vit C) Proteins provide __________ Kcalories per 1 gram. - 4 Vitamins and minerals provide energy for the body. (T/F) - False- they are necessary for a body's chemical reactions. Water is present in ALL body tissues. (T/F) - True (even bone) Water accounts for ________ to ___________% of an adult's total weight? - 50 to 60% Name the four basic food groups - Milk & Cheese, Meat & Legumes, Veggies & Fruits, Bread & Cereal Water acounts for __________ to _________% of an infant's total weight? - 70 to 75% An individual is overweight if they are ________% above the ideal weight. - 10 An individual is obese if they weigh ________% above the ideal weight. - 20 What solution and material are used to cleanse the eyes of an infant? - Plain water, cotton balls, washcloths Can you use cotton swabs to clean the eyes, nares or ears of an infant? - No, this is dangerous Can you use the same cotton ball/washcloth edge for both eyes? - No, it would cross contaminate Should you cover an unhealed umbilical site with the diaper? - No, fold the diaper down. What temperature is appropriate for the water used to bathe an infant? - 100 to 105 What is the #1 purpose of a tepid sponge bath? - Lower body temperature during fever. How should the temperature of the water be tested if no thermometer is available? - Dropping water on inside surface of your forearm. With which body part do you begin when bathing an infant? - Eyes always When cleansing an infant's eye, cleanse from outer to inner canthus? - No, inner to outer Should you retract the foreskin of a 5 week old male, uncircumcised infant to cleanse the area? - No, not until foreskin retracts naturally and without resistance- then it should be retracted, cleansed and replaced. When sponge-bathing with tepid water the correct temp is _____________. - 98.6 F How long does it take for the umbilical stump to fall off? - 7 to 14 days The primary reason why an infant is draped during the bath is to provide privacy. (T/F) - False, the primary purpose of draping is to prevent chilling. You may use friction to remove vernix caseosa from an infant's skin. (T/F) - False, it causes damage/bruising What solution is commonly used for care of umbilical cord? - 70% alcohol to promote drying (trend is toward soap and water) What cranial nerve is affected in Bell's Palsy? - #7, facial nerve What is the #1 symptom of Bell's Palsy? - One sided (unilateral) facial paralysis Complete recovery from the paralysis of Bell's Palsy should occur in _______ to ______ months. - 4 to 6 In addition to the facial paralysis, the sense of ______ is also affected. - taste Will the patient be able to close their eye on the affected side? - no Give three eye interventions for the client with Bell's Palsy. - Dark glasses, artificial tears, cover eye at night As the prostate enlarges it compresses the ___________ and causes urinary ________. - Urethra, rentention At what age does BPH occur? - men over 50 years of age What does BPH stand for? - Benign Prostatic Hypertrophy IN BPH the man has (increased/decreased) frequency of urination - increased In BPH the force of the urinary stream is (increased/decreased). - decreased The man with BPH has a _________-stream of urine - forked The man with BPH has hesitancey. What does this mean? - Difficulty starting to void Will the man with BPH have enuresis, nocturia or hematuria? - Enuresis-No, Nocturia-Yes, and Hematuria-Maybe Enuresis - inability to control the flow of urine and involuntary urination What is the best way to screen men for BPH? - Digital rectal exam Should fluids be forced or restricted in BPH? - forced What does TURP stand for? - Transurethral resection of the prostate The most radical prostate surgery is the ____________ prostatectomy. - Perineal What type of diet is used in BPH? - Acid Ash Acid Ash diet - Decrease pH (makes urine acid) Chz, eggs, Meat, fish, oysters, poultry, Bread, Cereal, Whole Grains, Pastries, Cranberries, Prunes, Plums, Tomatoes, Peas, Corn, Legumes. What is the primary purpose of a 3 way continuous bladder irrigation (CBI) after TURP? - To keep the catheter clear of clots and to drain urine What solution is used for CBI? - Normal saline (0.9 NaCl) How fast do you run the CBI? - At whatever rate it takes to keep the urine flowing and free of clots What drug is use to treat bladder spasm? - B&O suppositories (Belladonna & Opiates) Should you take a rectal temp after prostatectomy? Give stool softeners? - No rectal temperatures, yes stool softeners You should call the MD after TURP when you see _________ thick ________, _____________ clots, and ____________ urine drainage on the dressing. - Bright thick blood, persistent clots, persistent urine on dressing (don't call MD for transitory clots and urine on dressing.) If you see an increase in blood content of urine coming out of the catheter, you would first ___________. - Pull carefully on the catheter to apply local pressure on the prostate with the Foley balloon. If you see clots in the tubing you would first ____________. - Increase the flow-rate. What exercises should the post prostectomy patient do upon discharge? Why? - Perineal exercises, start and stop stream of urine, because dribbling is a common but temporary problem post op Will the post prostectomy patient be impotent? - If TURP, no impotence, if perineal prostatectomy, yes impotence How often should the drainage bag be emptied? - Every 8 hours What is the most common problem due to catheterization? - UTI What is the most common organism to cause UTI with catheterization? - E. coli What is the most common route for organisms to enter the blader when a catheterization is used? - Up through the inside of the catheter in the days following catheterization Name foods that make acid urine - Cranberry juice, apple juice (avoid citrus juices- they make alkaline urine) What is important about the level of the urinary drainage bag? - Never have the bag at a higher level than the bladder. How is the catheter taped in a male client? - To the lateral thigh or abdomen How is the catheter taped in a female client? - To the upper thigh What urinary pH prevents UTI? - Acidity, low pH Should the drainage bag ever touch the floor? - No Is it ok to routinely irrigate indwelling catheters? - No What agents are best for catheter care? - Soap and water What is the most effective way to decrease UTI with catheters? - Keep the drainage system closed, do not disconnect junction of tubing Give some signs of infection in a Foley catheter - Cloudy urine, foul smelling urine, hematuria Is urinary incontinence an indication for catheterization? - No Give three appropriate indications for bladder catheterization? - Urinary retention, to check for residual, to monitor hourly output What are the top 2 diagnoses for a client with a catheter? Which is #1? - #1- Potential for infection; Potential impairment of urethral tissue integrity What is systole? - The MAXIMAL force of blood on artery walls What is diastole? - The LOWEST force of blood on artery walls Accurate blood pressure is obtained by using a cuff that has width of __________ of the arm. - Two-thirds Which artery is most commonly used to measure blood pressure? - Brachial Can the thigh EVER be used to obtain a blood pressure? - Yes, but this is rare. When pressure is auscultated the first sound heard is the ____________ measurement. - Systolic The change in the character of the sounds is known as the ________ - First diastolic sound The cessation of sounds is known as the _________ - Second diastolic sound When 2 values are given in a blood pressure the first is the __________measurement. - Systolic When 2 values are given in a blood pressue, the bottom number stands for the change in sounds or cessation of sounds? - Cessation of sounds What is the normal adult blood pressure? - 120/80 Abnromally high blood pressure is called____________. - Hypertension What is the pulse pressure? - The difference between the systolic and the diastolic blood pressure If you deflate a cuff TOO SLOWLY, the reading will be too high or low? Why? - High, venous congestion makes the arterial pressure higher (increases resistance) If you use too narrow of a cuff the reading will be too high or low? - High Vasoconstriction will ___________ blood pressure. - Increase Vasodilation will ____________ blood pressure. - Decrease Shock will ___________ blood pressure. - Decrease Increased intracranial pressure will _________ the pulse pressure. - Increase or Widen If my blood pressure is 190/110, what is my pulse pressure? - 80 mmHg What blood test must be done before a transfusion? - Type and cross match What does a type and cross match indicate? - Whether the client's blood and donor blood are compatible. What should the nurse measure before starting a transfusion? - Vital signs With what solution should blood be transfused? - 0.9 normal saline How many nurses are requried to check the blood? - 2 nurses What happens when blood is administered with Dextrose IVs? - The cells clump together & don't flow well If a transfusion reaction occurs what should the nurse do first? - Stop the blood flow & start running the saline How long can a unit of blood be on the unit before it must be started? - Less than 1/2 hour What should the nurse do with the IV line if transfusion reaction is suspected? - Keep it open with saline If a transfusion reaction is suspected, what two samples are collected and sent to the lab? - Urine & blood If a unit of blood is infused through a central line it must be__________. - Warmed Which of the following are signs of transfusion reaction? Bradycardia, Fever, Hives, Wheezing, Increased Blood Pressure, Low Back Pain - Low back pain, wheezing, fever, hives What are three types of transfusion reactions that can occur? - Hemolytic, febrile, allergic What would you do first if you suspected transfusion reaction? - Stop the blood and start the saline What are the signs and symptoms of a hemolytic transfusion reaction? - Shivering, HA, low back pain, increased pulse & respirations, decreasing BP, oliguria, hematuria What are the signs and symptoms of a febrile transfusion reaction? - Low back pain, shaking HA, increasing temperature, confusion, hemoptysis What are the signs of symptoms of an allergic reaction to a transfusion? - Hives- uticaria, wheezing, pruritus, joint pain, (arthralgia) Give three reasons for a blood transfusion - Restore blood volume secondary to hemorrhage, maintain hemoglobin in anemia, replace specific blood components What does blood-typing mean? - Check for surface antigen on the red blood cell When does typing and cross matching need to be done? - Whenever a client is to get a blood product. It is only good for 24 hours. What does blood cross matching mean? - Mixing a little of the client's blood with the donor blood and looking for agglutination. When are hemolytic transfusion reactions likely to occur? - In the first 10 to 15 minutes When is a febrile reaction likely to occur? - Within 30 minutes of beginning the transfusion What test identifies Rh factor? - Coombs test detects antibodies to Rh What is the difference between whole blood and packed cells? - Packed cells don't have nearly as much plasma or volume as whole blood does What would you do if the client had an increasing temperature and was to get blood? - Call the MD because blood is often held with an elevated temperature How long should it take for one unit of blood to infuse? - From one hour to three hours How long should you stay with the patient after beginning a transfusion? - At least 15 to 30 minutes What blood type is the universal recipient? - AB What blood type is the universal donor? - O What is the routine for vital sign measurement with a transfusion? - Once before administration Q15 x 2 after administration is begun Q1 x1 after transfusion has stopped What IV solution is hung with a blood transfusion? - 0.9 normal saline (No glucose) What gauge needle is used with a blood transfusion? - Large gauge, 18 gauge What other things are appropriate after a reaction? - Call MD, get a blood sample, get urine sample, monitor vitals, send blood to lab Can blood be given immediately after removal from refrigeration? - No, it has to be warmed first for only about 20 to 30 minutes. With what solution & when should a breast feeding mother cleanse the areola? - Plain water, before & after each feeding For a woman who doesn"t have retracted nipples, is towel drying or air drying better? - Air drying of the nipples is best The goal is for the infant to breast feed for __________ minutes per side. - 20 How does the mother break the suction of the breast feeding infant? - She inserts her little finger into the side of the infant's mouth When should the breast feeding infant be burped? - After feeding from each breast Assuming no mastitis, on which side should the breastfeeding begin? - Begin nursing on the side that the baby finished on the last feeding How long can breast milk be refrigerated? - 24 hours How long can breast milk be frozen? - 6 months In what type of container should breast milk be stored? - Sealed plastic bags Can you microwave frozen breast milk in order to warm/thaw it? - Never Which two nutrients is breast milk lower in? - Fluoride and iron What should you tell a breast feeding mother about her milk supply when she goes home from the hospital? - Milk should come in postpartum day 3. Breastrfeed every 2-3 hours to establish good milk supply. Can a woman on oral contraceptives breastfed? - Should not use OCP during the first 6 weeks after birth because the hormones may decrease milk supply. Estrogen is not recommended. Non-hormonal methods are recommended. Remember, breastfeeding is an unreliable contraceptive. What is another name for Buerger's disease? - Thromboangiitis obliterans Which extremities are affected by it? - Lower only Which sex does it affect the most often? - Males The group with the highest incidence of Buerger's disease is __________. - Smokers Upon walking the patient with Buerger's experiences _______ _________. - Intermittent Claudication What is intermittent claudication? - Pain in calf upon walking A first degree burn is pale or red? - Red A first degree burn has vesicles (T/F)? - False A second-degree burn is pale or red? - Red A second-degree burn is dull or shiny? - Shiny A second-degree burn has vesicles? (T/F) - True A Second degree-burn is wet or dry? - Wet A third-degree burn is white or red? - White A third-degree burn is wet or dry? - Dry A third degre burn is hard or soft? - Hard Of first, second and third degree burns which has less pain? Why? - Third degree burns, nerve damage has occured For what purpose do you use the rule of nines? - To estimate the percentage of body surface burned; is NOT used for children. In the rule of nines, the head and neck receive _______: each arm receives_______. - 9%, 9% In the rule of nines, the front trunk gets_____, the posterior trunk gets_____, each leg gets ______ and the genitalia gets________. - 18%, 18%, 18%, 1% What is the only IM given to a burn patient? - Tetanus toxoid- if they had a previou