Nclex Review

NCLEX Review Test A Cystic Fibrosis -Resp Problem w/ copious amounts of mucous. For all resp problems involving mucous: 6 small meals Fluids No milk or milk products -Postural drainage, chest percussions with cupped hands When draining lower lobes, head is dependent Drain lower lobes before upper (only do at least 1 hr after food). Monitor/assess- clubbing -Cystic Fibrosis affects the Pancreas Pancreatic Enzymes with all food (Pancrease with all food) -Cystic Fibrosis clients excretes 4X the normal amount of salt Extra salt daily, with each meal Advise against activities to produce stress -Cystic Fibrosis is autosomal recessive (both parents must carry for child to have it) If only one parent has or carries, the child has no chance of contracting CF -Cystic Fibrosis has a growth problem/failure to thrive

Developmental Stages A 15 month old can Climb up and fall down stairs Vocabulary: 1 year old (2-6 words) 18 months -2 years ( short sentences/4 word sentences, up to 300 words) 3 year old (900 words)

Toddlers Picky about food, this is normal

Newborn Positive Babinski for 6-12 months after birth If temp becomes low, put on a cap Activities should be age AND condition appropriate Preschooler Can tie shoes Can name 5 colors School age Rules and rituals dominate play Likes to accomplish or produce Adolescents Have all permanent teeth except molars

Cardiac Do not lie a cardiac problematic person flat/ supine!! Do not use energy to walk to the car -Nitroglycerin: 1 q 5 min X3 sublingual, dark bottle will fizz under the tongue may cause headache b/c it is a vasodilator give nitro before calling 911 Coumadin can cause bleeding Melena is dark tarry stool from an upper GI bleed Echymosis, petechiae, etc. could concern you PT, PT, prothrombin time Therapeutic PT on Coumadin will be 1.5 times the normal value INR monitored (1/1.5-2/2.5) -Melana Either an upper GI Bleed or they are on Iron -Do not INCREASE intake of green leafy vegetables, continue to eat them as normal -Cranberry juice increases INR and cause more bleeding -Must tell pt on Coumadin to not buy OTC vitamins, failure to do so can be NEGLIGENT

Newborn Positive Babinski for 6-12 months after birth If temp becomes low, put on a cap Activities should be age AND condition appropriate Preschooler Can tie shoes Can name 5 colors School age Rules and rituals dominate play Likes to accomplish or produce Adolescents Have all permanent teeth except molars

Cardiac Do not lie a cardiac problematic person flat/ supine!! Do not use energy to walk to the car -Nitroglycerin: 1 q 5 min X3 sublingual, dark bottle will fizz under the tongue may cause headache b/c it is a vasodilator give nitro before calling 911 Coumadin can cause bleeding Melena is dark tarry stool from an upper GI bleed Echymosis, petechiae, etc. could concern you PT, PT, prothrombin time Therapeutic PT on Coumadin will be 1.5 times the normal value INR monitored (1/1.5-2/2.5) -Melana Either an upper GI Bleed or they are on Iron -Do not INCREASE intake of green leafy vegetables, continue to eat them as normal -Cranberry juice increases INR and cause more bleeding -Must tell pt on Coumadin to not buy OTC vitamins, failure to do so can be NEGLIGENT

OTC vitamins may have vitamin K -OTC medications may be contraindicated with Coumadin, may cause more bleeding Aspirin Gingko Biloba (for Memory) Garlic Ginger -Can cross the placental barrier Heparin is safe during pregnancy, it CANNOT cross placental barrier Pregnancy puts women at high risk for DVT, she may need prophylactic heparin if she has DVT DVT What indicates a DVT leg is edematous painful warm to touch may be pink/red Interventions for DVT Measure both extremities daily for comparison Pain medication Warm compresses to increase circulation Venous (elevate leg) (V=legs up) (A=legs down for arterial clots) Heparin What shows improvement of DVT Decreased leg circumference

What concerns you for client with DVT Pulmonary Embolism: Petechiae on chest Chest pain Cough/SOB/Respiratory Problems Hemopsis Disorientation, combative, Mental status Change

Mental Status Change -Caused by: any time BLOOD is not getting O2 and getting O2 to the BRAIN

Any respiratory problem Any cardiac problem Fluid volume deficit Fluid volume overload (pressure on the brain, ICP) Electrolyte imbalance Sodium If increases greatly, the client should be: more alert If decreases from normal to very below normal, expect: Lethargic Malaise -

-Heparin Moniter PTT (normal 15-30) Therapeutic (1.5-2.5 X 30) -Platelet count If 100,000 or less, monitor for bleeding

Digoxin Toxicity symptoms Nausea/Vomiting Anorexia Bradycardia Halo, double, blurred Vision If ct on digoxin refuses breakfast and lunch today... Check digoxin level, possible toxicity

Therapeutic Effects of Digoxin Slows and strengthens the heart Increases CO and BP Increases urine output

Theophylline (aminophylline) Bronchodilator

Accelerates everything Side effects Nausea/Vomiting Tachycardia Tachypnea Nervousness Insomnia Hypotension Always give bronchodilator before steroids Do not crush/ mix digoxin and theophylline together CHF and HF patients can have both Digoxin to slow and strengthen the heart Theophylline to help with expiratory wheezing Give these two meds to same patient, but separately

Paracentesis, Thoracentesis, Liver Biopsy Have patient void (to move bladder out of the way) Have pt take deep breath, EXHALE, hold and bear down til needle is in Do not cough during procedure After procedure monitor for signs of pneumothorax: Deviated trachea to one side Asymmetrical/ uneven chest movements Decreased breath sounds on one side Monitor for signs of hypovolemic shock: BP low (80/40) Rapid thready pulse Rapid shallow respirations Pale, cool, clammy Thoracentesis Position: Side of bed, arms on bedside table If patient is too sick, sit up in bed with arms on table over bed Paracentesis Position: Side of bed, stabilize feet If sick, semi-fowlers or fowlers

Liver biopsy Position: Lay supine, tilted on left side a little, right arm over the head post biopsy- lay on right side Lab before biopsy: Prothrombin time PT, we want it to be normal (11-15) Big risk of bleeding with liver biopsy Big risk for Bile Peritonitis (leaking Bile into peritoneum)

Peritonitis Can be caused by appendicitis or any other infection in the abdominal cavity Symptoms: Rigid/ board-like abdomen Shallow respirations (pushing on diaphragm) Severe abdominal pain

TPN w/ Central Line -can cause pneumothorax, watch for deviated septum -can cause air embolus: Petechaie on chest Chest pain Cough/resp problems Mental status change

Life Support/Ethics Only the parents of children can decide about continuation of life support

Delegation Floating Nurse Give simplest patient Give OB nurse mastectomy, hysterectomy, DVT, non-infectious, etc What patient can we send to OB? -Non infectious Pediatric nurse can care for any age client with a compatible/similar diagnosis of a pediatric client. IF pediatric nurse comes to med surg, which client do u give? 12 hrs post hysterectomy? or

Status asthmaticus 24 hours ago?- correct answer Psych nurse- Give alzheimer’s, dementia, anorexia, bulimia, etc. Do Not give traction pt who’s husband was killed (even though they have psych issues, she should not handle the medicle) ER nurse- give trauma, trachs, chest tubes, wounds CNA Can.. ADL’s Ambulate a patient with ataxia (gait problems) Ambulate a client 24 hours post laminectomy (back surgery) Ambulate client with a halo, foley catheter Strain urine for stones/renal calculi Can shave or prep surgery patient CNA Cannot.. Feed a dysphagia patient, Myasthenia Gravis Feed a drooling patient Feed a trach patient Ambulate a chest tube client Cannot get total hip, pneumonectomy, post op, post heart cath etc out of bed for first time Give instructions Monitor vitals first 15 after blood infusion Determine if patient can have water

LPN Assign simplest task but that can be performed with license Can perform teaching to patients but RN must supervise and make sure the patient has learned Lithium If patient is on Lithium, keep sodium at a normal level Carbonated drinks are high in sodium Do not do anything to make you perspire more than usual Do not eat foods high in sodium Lithium is not effective for 2-4 weeks Lithium is a mood stabilizer, for pts with bipolar disorder Cerebrovascular Accident Left stroke = Right sided weakness/issues Cane always goes in unaffected hand The cane and the bad foot forward same time, same distance then bring up good foot

If right side is weak dress right side first, always dress bad side first! Undress the GOOD side first Intrapartum Epidural anesthesia, internal monitoring is needed Before applying electrodes, the membranes must have ruptured, and presenting part must be low enough for identification Abruptio Placenta pain with bleeding Placenta previa painless bleeding First Stage of Labor Teach client to pant- not take deep breaths because we do not want her to push, panting keeps her distracted and will not allow her to push

Second Stage of Labor 10 cm dilated perineal and rectal bulging crowning 100% or completely effaced Chorionic Villus Sampling Risk for spontaneous abortion

Postpartum Immediately after: If fundus is lateral, empty bladder Fundus should be at level of umbilicus, firm and midline If fundus is at umbilicus, firm and midline, but patient is still bleeding excessively Check perineum for lacerations

If nurse floating to OB from Surgery Do not give OB Do not give High risk (15 year old, PIH) Give a c-section (surgery patient)

If you have no bed on OB but have an emergency C-Section she can be sent to Med/Surg floor after she is stable signs of post partum psychosis-irritable and can’t sleep Stillborn birth Stay with family as long as needed then give privacy Someone will take a picture of baby after family leaves Magnesium Sulfate CNS Depressant Can be used for pregnancy induced hypertension Interventions with giving this: Knee jerk/DTR’s every hour Monitor respirations (keep 12-14) (the diaphragm is a muscle) Foley to monitor output (keep at least 30mL/hr) Concerning findings with Magnesium Sulphate: An increase in BP Preeclampsia Risk for seizures When seizure occurs, the patient has Eclampsia Symptoms: Facial Edema Edema in hands Increased bp proeteinurea(albumin) For pregnant patient with bp 160/100, facial edema and 3+ albumin in urine, what is priority? Risk for seizure, have O2 / suction at bedside

Radiation External radiation: Not radioactive Can be in a semi-private room Can have visitors Do not wash off painted markings around radiated area Do not apply lotion or powder on area prior to radiation, it will burn

Nausea and vomiting CAN be a side effect Side effects are usually site specific head-alopecia mouth-stomatitis chest- burn abdomen- can cause diarrhea Internal Radiation: Radioactive private room far from nurses station Strict BED REST, no sitting in chairs, etc. Time, Distance, Shielding Nurse can only be in room 30 minutes for direct pt care, after that nurse must stand at door or at foot of bed Family CAN visit BRIEFLY, must stand 6 feet back Children should not be in room at all If radioactive implant is found outside pt’s body, use lead tongs to pick it up, place in lead lined container, call the radiation oncologist Stomatitis Rinse mouth with baking soda and water- soothe irritation Rinse mouth with miracle/magic mouthwash -no alcohol Do not use lemon/glycerine swabs! -will burn Do not use OTC mouthwash -alcohol Do not tell them to drink plenty of Orange Juice -will burn Do not use hard bristle toothbrush Buck’s Traction On correctly if patient is in good alignment Pt is supine Only elevate head 20-22 degrees -they may slide down in bed if higher Leg should not be rotated internally or externally Pt’s leg should not be elevated but straight out

Esophageal Varices Causes: Alcohol- can burn esophagus and cause a bleed Portal Hypertension Excessive gastro-esophageal Reflux Sengstaken Blakemore tube

Used to press/ a balloon, to press against the bleed in the esophagus Keep scissors at bedside to cut in case of emergency to make room for intubation Concerns: Fresh fruits and fresh vegetables are rough and can tear the varices that have been controlled Frequent swallowing- indicates bleeding Pale, cool, clammy- bleeding, could be in shock What is most concerning in diet of esophageal varices client? Fresh fruit/veggies or Pretzels Pretzels are ok, after chewing it becomes doughy

Tonsillectomy Post surgery Give popsicles/ jello, etc but NOT RED - this could be mistaken for blood if vomiting occurs Do not give milk products -Mucous

Lactulose (Cephalac) Potent laxative Hepatic Encephalopathy If Lactulose is given to this pt, ammonia level is sky high (possibly 140, normal 10-40), ammonia will bind with the increased loose stools and reduce symptoms of sky high ammonia. Ammonia level lowers= less lethargic

Newborn Assessment Look for fractured clavicle crepitus in right clavicle

Chron’s and Ulcerative Colitis Irritated Bowels Diarrhea Give low fiber, low residue diet to slow down bowels

Low Residue= NO MILK PRODUCTS, it is hard for bowel to break down To replace nutrients lost in diarrhea high calorie high vitamin high protein Therapeutic Communication Allow angry patient to express anger, tell them it is acceptable to express anger Colostomy, ileostomy, mastectomy, terminal illness, spinal cord injury, etc. may all have difficult times dealing with feelings/ anger. Let family and pt know it is acceptable.

Pericarditis, Endocarditis, Rheumatic, Scarlet Fever Can be caused by strep throat Ask pts with these illnesses if they have had a sore throat or cold Tell pts with these illnesses not to be around crowded places Do not be in close contact with patient with infection

Scoliosis Pants leg, skirt hem uneven Shoulder blades, iliac crest uneven

CT Scan Contraindicated for pregnant women with Contrast Ask about allergies to shellfish or contrast dye Provide fluids post procedure

Peptic Ulcer Disease H2 receptor blockers Tagumet, Carafate, Zantac, Pepcid, Losec Given 30 min-1hr before meal Antacids Malox, Mylanta given 1-2 hours after the meal

Borderline Personality Disorder Who is most at risk: Person who was abused as a child Symptoms: Rage, intense relationships, manipulation Antisocial Personality Disorder Have no responsibility or remorse, aggression, poor work history Do not assign to do chore by themselves Assign to do task with 2-3 other people to make sure it is done OCD Never eliminate or forbid a compulsion of an OCD patient Do not interrupt an OCD Do not limit Goal for an OCD psychotherapy has very little effect want behavioral change, want them to change behavior want them to do creative activities instead of automatic/impulsive behavior do creative activity to cope with anxiety, therefore decreasing compulsive behavior Antipsychotics Used for schizophrenia

Schizophrenia Keep the person in reality Tell the patient that no one else has seen the things they are seeing Do not tell them their hallucinations aren’t there or real because these things are real to them Back surgery/injury laminectomy, discectomy, spinal fusion Pt can stand and lie but has trouble sitting Always log roll

Amputation If prosthesis causes severe pain REMOVE it! -this could break down the stump, and cause need for further amputation

Tell Ct. Pre-op about phantom limb sensation Tingling, itching, etc. If post-op, they have phantom limb pain, medicate and tell them this is ok You can have 3 major complications from amputations Infection Hemorrhage- keep tourniquet at bedside contracture-most serious to prevent contracture only elevate stump for first 24 hours-to prevent edema and hemorrhage after first 24 hours lay stump flat at intervals, turn patient prone

Bacterial Meningitis Meningitis is neuro Respiratory Droplet precautions -mask within 3 feet

Meningocele Good prognosis is expected with surgery

Cholecystectomy They will probe in common bile duct to look for stones, this may cause edema of duct The t-tube prevents the bile duct from closing With T-Tube Do not want bloody drainage Do not want over 500 mL in 24 hours Concerns: Clay colored stool Dark urine Chickenpox Incubation period 7-10 days Contact isolation, gown and gloves Respiratory airborne Activities should be age appropriate

keep on contact keep quiet and busy Thyroidectomy Patient at risk for damage/ partial removal to parathyroid this could decrease the client’s calcium can cause numbness and tingling/ parasthesia around mouth/perioral, of fingers and toes Interventions Keep calcium gluconate at bedside incase calcium drops Keep trach set at bedside Concerns Dressing is getting tighter, pressure on neck- means the neck is swelling Crowing respirations (inspiratory stridor)- partial airway obstruction, swelling Frequent swallowing- bleeding Pertussis Whooping cough Respiratory Droplets Immunization can cause seizures- DPT immnization

Respiratory Droplet Bacterial Meningitis Pertussis Scarlet fever Airborne/contact Chickenpox Contact Cellulits MRSA VRE

Traction weights i.e. Russell’s traction Keep bone in good alignment

Prevent muscle spasms If not pulling, or weights are on floor, this could cause pain

Total Hip Replacement Do not sit at a total 90 degree angle Do not bend at hip, do not flex hip for 8 weeks Do not cross knees, ankles, do not adduct! Do not internally rotate Knee never higher than hip 1 day post op ambulate short distance 2-3 steps and place in a recliner with feet elevated

Rheumatoid Arthritis Want exercise for joint mobility Increased periods of rest will cause stiffness Rest frequently but not for extended amount of time We want to EXTEND joints to prevent contracture, make door knobs larger, eating utensils larger, etc. intervention for arthritic client give a warm bath in the morning warm compresses on joints prior to exercise tell them to do chores in early afternoon -they have morning stiffness COPD Only gets 2L of O2, prevent oxygen toxicity They are always short of breath, respiratory distress is when we need to be concerned Oxygen therapy Anything that could cause static electricity Nylon pajamas or blanket matchbox cars Anything that could get moist and harbor bacteria Stuffed animals/teddy bears

HIV/AIDS Does not have to be in a private room Do not place with an infection- they are neutropenic You CAN place patient with

Appendicitis, Cholecystitis, pancreatitis, diverticulitis Are NOT infections, they are inflammations!

Anorexia Nervosa low self esteem anti- social wears big clothes is a perfectionist usually 15% under ideal body weight To assess progress do a daily weight in the morning after voiding Crutches 4 point gait- baby steps, crutch THEN opposite foot, crutch THEN opposite foot 2 point gait- crutch and opposite foot same time same distance 3 point gait- partial weight bearing- both crutches and affected foot same time same distance, then bring good foot up the swing-to - no weight bearing or amputee, both crutches then swing good leg up stairs up stairs good foot first down stairs bad foot first DIC Paradoxical issue where pt bleeds and clots Monitor Hematocrit Vasectomy Must have three sperm free specimens before considered sterile Each ejaculation will have decreased sperm until sperm free Use ice on incision Manipulation from surgery can cause discoloration of scrotum, this is normal

Alzheimer’s These people like to wander Make sure their room is near a family room to ensure safety Goal for this patient Be able to do ADL’s as long as possible Goals involving recovery are unrealistic

Vegetarians Deficient in B12, B12 is found in animal products Breast Cancer Biggest at risk Nullapara-no babies First baby after 30 mensus before 13 menapause after 55 If woman has more than one of these she is at a greater risk

Dysphagia Parkinson’s, CVA, Myasthenia Gravis First symptoms of all these are difficulty swallowing, and salivation CNA cannot feed a patient with dysphagia, or a trach patient, or drooling patient CNA cannot feed a Myasthenia Gravis Diet No liquids No steak and potatoes, hot dogs, etc Soft foods Soft foods w/ sauces Developmental Stages 4 week old- grasp finger and pull to mouth *Never give toddlers hot dogs or carrots! How to get child to cooperate? speak in age appropriate language about procedure tell them just before the procedure never tell them in detail tell them what you expect of them during and after the procedure never show them the equipment, but if possible let them play with nonintimidating equipment 3 year old- can ride a tricycle 5 year old- can ride a bicycle

2-3 year old thinks dead person is asleep 4-5 year old blames themselves for the death of others and feel guilty Coping How do you know the parents of a terminally ill child are not coping? “My husband and I are strong and know our child will get better” Incident Reports Contact the physician and then complete incident report Hospital property, Do not Chart about it! Do not chart that Risk Management Team was contacted- they are only involved with data collection, do not call risk management just send the data afterwards Always chart that the Doctor was contacted, if he was contacted Incidents: Give medication to wrong patient what do you chart? Demoral 50, given IM Right deltoid, for pain 10 am, physician notified DO NOT Chart “wrong patient” If wrong IV is hanging, how do we chart? Physician ordered D5 half normal saline, but hanging is D5NS, how do we chart? D5 NS discontinued, D5 Half normal started, physician notified Do Not chart “wrong fluid”

ICP Normal is 0-15 If pt has neuro surgery, head injury or CVA Place head at 30 or 45 degrees to prevent increased ICP Do not flex neck or hips! Do not sit at 90 degrees/high fowlers Do not lay flat/supine or prone MRSA and VRE Contact isolation, gown and gloves Wipe off equipment used on patient *when gloves are removed use alcohol solution EXCEPT with c-diff, wash with soap and water and THEN alcohol solution Delirium If spouse brings husband to ER with delirium, what question do we ask her?

What medication is he currently on Delirium- disoriented to time and place ACUTELY, maybe for a couple hours Dementia- disoriented progressively, CHRONIC, possibly for years Cervical Cancer Risks Smoking Multiple sex partners

SLE/Lupus Can be exacerbated by: Stress, physiological or psychological Butterfly rash over nose and cheeks Discoid lesions/coin like lesions over the body photo-sensitive Can damage Kidneys, nephritis (BUN, Creatinine, albumin in urine(should be 0), Output) Intermittent claudication pain with walking but subsides with rest arterial intervention (A = legs down, dependent) elevating legs of arterial patient can cause pallor and blanching

Pancreatitis Fatty foul smelling stools Nausea, vomiting Left upper quadrant pain Abdominal pain Numbness and tingling of fingers, toes, around mouth from low calcium

Peritoneal Dialysis You want clear outflow, not cloudy Lung resection/lobectomy Place on unaffected side as to expand the affected lung Best air exchange is obtained semi-fowlers Pneuonectomy

Do not lie on unaffected side, lie on side without the lung so they can expand the only lung they have Best air exchange is obtained in semi-fowlers Bulemia Nervosa Tooth decay Callouses on fingers -from gagging herself

Ampicillin/ antibiotics observe for white spots in the mouth (candida) give nystatin or mycostatin swish and swallow- adults for babies- put in syringe, squirt into cheeks, not straight towards throat to prevent aspiration ampicillin can also cause diarrhea

Ileostomy Do not irrigate- it is liquid stool Must wear bag at all times- bowel schedule not regulated If ct has not had stool in 3 hours, this is a concern! Must monitor electrolytes more closely for this than colostomy

Colonoscopy Post colonoscopy may have rectal bleeding with clots (normal) Patient should not be on aspirin or steroids prior to procedure

Glomerulonephritis Can damage the kidneys BUN CreatinineC Albumin Output Tetracycline Do not give with milk, food or antacids-will not absorb well Do not give to pregnant lady- can stain babies teeth Do not give to small children- can stain teeth Makes patient photo-sensitive

Thorazine, elavil, halidol, Bactrim- all make pt photosensitive people with SLE/Lupus are also photosensitive Elavil Causes photosensitivity Shows results in 2-4 weeks Bryant’s Traction Little bryant is 2 years or less 20 lbs or less has fractured femur or dislocated hip buttocks off mattress, legs straight up 90 degrees to mattress Renal Disease Restrict: Protein Potassium Sodium Fluids Lactated Ringer’s has sodium and potassium!! If they are on dialysis they CAN have protein *ALWAYS SEE FIRST patient unrelieved by pain meds 1 hour after administration! Or pain unrelieved by narcotic analgesia

Addison’s Needs to ADD some cortisol (an anti-inflammatory) These people have no anti-inflammatory they can get critical fast! See them first for fever, pain, diaphoresis, signs of infection Older adults Do not drink enough water Eat less than they did earlier in life (still have appetite) Get up early and take naps Tympanic membrane thins (worse at hearing) Do not drive at night because of glare Presbyopia - difficulty seeing things up close Black older people Get bluish spots on the sacrum

Nutrition Toddlers that drink too much milk may become anemic from lack of room for iron rich foods Babies’ milk consumption should be reduced once solid foods can be introduced in the diet How to get people who aren’t eating well to eat well Let person eat with other people Make the food attractive and appetizing

Tuberculosis If sputum culture is Acid Fast Bacillus Positive ISOLATE, TB positive Respiratory airborne Negative pressure vented to outside N95 Respirator, Fitted/ Particulate Mask Family must wear surgical mask while at hospital (but not at home) Report TB to health department Teach to cover mouth/nose with tissue when cough or sneeze (cloth handkerchiefs are concerning, they cannot be burned for disposal) If they need to be taken out of the room Call ahead to place they are going to make sure they have a room ready (x-ray, ct, mri etc.) and put a SURGICAL MASK on patient for transport and give them a disposable recepticle (plastic bag) for tissue disposal early symptoms: cough chest pain low grade fever (esp in afternoon) night sweats anorexia weight loss Late symptoms: hemopsis Isoniazid (INH) and Rifampin can damage liver and kidneys what would concern nurse if pt is on INH? Yellow skin and sclera (any answer involving the liver) Check BUN albumin Creatinine output (kidney fxn) Must be taken for 9-12 months!

INH: vitamin b6 is given to prevent neuropathies Rifampin: can turn secretions (tears, saliva, urine) orange * Peridium can turn urine red/orange Nurse is negligent if she does not tell TB patient? Do not be in contact with pregnant women or small children ( they are at high risk)

TB Skin Test Anterior aspect of forearm 26-27 gauge needle Hold at 15 degree angle (intradermal) 0.1 mL of solution Check site at 48 and 72 hours 10 mm induration is positive AIDS patients-5 mm positive If checking site at 48 hours and it is 8 mm induration, check again in 72 If site checked at 48 hours and is a 6 mm induration and 8 mm redness, you would know...results are inconclusive at present, check again in 72

Dehydration monitor for seizures (mental status change)

Tracheoesophageal Fistula Opening between trachea/esophagus Monitor for Aspiration

Aortic Anerysm Repair (arteriogram) Check all pulses Check lower extremities for cool temp and discoloration Check for bleeding (hypotension)

Myasthenia Gravis Extremely weak muscles Difficulty swallowing Difficulty breathing Soft foods/ sauces, no liquids etc. Prostigman- drug of choice for MG Peak in 30 min to 1 hour What doctors order do we question? He ordered valium for MG pt. - this is a muscle relaxer, they’re already weak How do we know MG pt is getting worse? Drooping of 1 or both eyelids If you give Myasthenia Gravis pt Prostigman, what would we expect? I can breathe and swallow better See the pt who needs prostigman first! They need help breathing!

Eye Surgery Concern- Intraocular Pressure Do not life or bend Do not do valsalva

Glaucoma Do not give Atropine or Antihistamine - drying agents, will dry the eyeball They do not have peripheral vision- stand directly in front to talk to them

*If in ER and give benedryl, you are negligent if you do not tell Do not drive or operate heavy equipment Pilocarpine Is a myotic, it constricts the pupil affects aqueous humor more than the vitrus humor Timolol/ timoptic drops -Beta blocker Optic Drops

Place finger in the inner canthus (tear duct) for 1 minute after administration to keep medicine from going systemic Cataracts Speak to them on unaffected side

Glascow Coma Scale 7 or below is coma 3 is lowest score Raynaud’s Vasospasm of small vessels in the fingers and toes Causes numbness and tingling on exposure to cold Interventions: Do not smoke -vasoconstrictor Reduce stress Spica Cast Give toy too large to stick down into cast- Teddy bear, etc.

Fractures Fractures of long bones can cause Fat Emboli Fat emboli: Petechiae on chest Chest Pain Cough Shortness of Breath Hemopsis Mental status change Laryngeal Cancer Difficulty swallowing- causes increased salivary secretions/drooling Pt can do three things: Radiation Chemotherapy Surgery If they have surgery (laryngectomy) they will have a trach For trach pt: Use communication board

After trach can be removed they have a permanent trach stoma 3 methods of speech after trach removal: Prosthesis-allows them to be able to cover stoma with finger and speak Electrolarynx- Sounds like a robot Esophogeal Speech- burp the words A thin scarf can be worn over stoma Cover stoma when putting on make-up Cover stoma when shaving the face Cover stoma when showering but not with a plastic bag Teach to install a smoke detector (they cannot smell smoke anymore) Teach someone to check food periodically (they can’t smell if it’s spoiled)

Heart Failure Left Left=lung: Dyspnea Orthopnea Wheezing, rales, rhonci Pleural effusion Pulmonary edema Pulmonary hypertension Pink, frothy sputum Right heart failure (COR PULMONALE) caused from left heart failure Right ventricular hypertrophy (trying to push the blood into already full lungs) System symptoms: JVD Ascites anascarca (generalized edema) Hepato/Spleno meglia

*vesicular breath sounds normal *adventitious breath sounds abnormal (a for adven.. and abnormal) NG/TPN If infusing too fast or is too concentrated- Diarrhea If NG or TPN pt has diarrhea, call doctor and ask to slow rate or decrease concentration

TPN Monitor: glucose electrolytes if through central line monitor for: air embolus pneumothorax (deviated trachea or absent breath sounds, unequal chest movements)

When central line is inserted, tell patient: take deep breath and HOLD IN - to prevent air embolus

Aminoglycocides All “mycin” medications Can damage: hearing kidneys If client is on Vancomycin for MRSA, what concerns the nurse? BUN is 50 Gastrectomy or Gastric Bypass Dumping syndrome: For 30 minutes after eating with gastrectomy or gastic bypass patients they have symptoms of GI virus (diarrhea, distention) Intervention: Rest/ lie down for 30 min after eating Do not give liquids with the meal- give 30-45 min before or 30-45 min after meal Give 6 small dry feedings Do not give concentrated sweets We want to promote protein for tissue repair Milwaukee Brace Used for scoliosis Worn 23 hours a day

Sickle Cell Anemia Interventions: Plenty fluids (most important) Oxygen Pain medication (poor circulation causes aching and pain) Apply heat to pains Do not travel by plane or go to high altitudes (Denver, Colorado) If doctor orders for a patient with sickle cell anemia, 1 and 1/2 times the normal amount of fluids? Give as ordered

PTSD Don’t want to talk about it Show no emotion Flashbacks insomnia nightmares What would make the nurse feel the PTSD is improving? Talks a little about the incident in group therapy and cried

Leukemia Immunosuppressed Neutropenic Thallium Stress Test, PET Scan, MUGA Scan NPO 6-8 hours prior Nuclear Medicine *Bone Scan is only nuclear medicine test that is NOT NPO *Cardiac Cath is NPO 6-8 hours but uses dye, not nuclear medicine Enema Turn patient on left side (direction of bowel)

Manic Patient, Inappropriate Behavior

Restrain only last resort Medicate only if last resort Always tell them that behavior is unacceptable first! Then remove them from the situation If violence is threatened, ask for assistance to take patient to room Self Breast Exam Pre-menopausal: do bse 7-10 days after period Post-menopausal: tell to do on the same day of the month every month Do this in front of the mirror or in the shower Use finger tips not palms Start circular around nipple Extend and include the axilla If a mass is found, it will most likely be in the upper outer sector of breast While examining one side she can put her arm upward, hand behind head or hand on hip mastectomy Don’t carry heavy bag on that side No sticks, IVs, BP cuffs on that arm No watches, jewelry, anything tight on that arm At risk for lymphedema for life No injuries, sunburns, even pin pricks on that arm Never leave the arm dependent, even at night it is elevated If standing in a long line, etc, put arm across chest do not let it hang down

Tegretol Can damage bone marrow What lab would we monitor if client is on tegretol? CBC If pt is on Tegretol monitor for: Anemia Red Cells Bleeding Platelets Infection White cells Multiple Myeloma Bone cancer Affects bone marrow Interventions

Monitor CBC, anemia, infection, bleeding Give Back brace-pathologic fractures of vertebrae can cause death Ambulate-drives calcium back into the bones Give fluids-excess calcium in blood can cause kidney stones

Aphasia Expressive Aphasia Ask yes or no, simple questions Always speak at a normal tone/volume and do not use gestures (this goes for hearing impaired patients too) Receptive Aphasia When patient doesn’t understand statement, Say the same statement in the exact same words to let the mind program what is being said What concerns you with receptive aphasia patient being discharged this afternoon? Multiple family/ friends coming to visit, patient will not understand all the info Renal What can damage kidneys? Lupus/SLE TB Medication (INH, Rifampin All “Mycin” drugs/ aminoglycosides can damage hearing and kidneys Amphotericin B- an antifungal Chemo medication can damage liver and kidneys Who do we not give milk? Milk is hard for bowels to break down.. Chron’s Gastroenteritis Diverticulitis Ulcerative Colitis Immunization Live vaccines (varicella, rubella) Do not give to pregnant women May have slight fever after shot Do not give to a sick child

Antibiotics/Cultures

Always get a culture before starting antibiotic or it could ruin the culture Hepatitis A and E Oral-fecal transmission If they come in with vomiting and/or diarrhea-contact isolation gown and gloves with enteric precautions (disposable plates and utensils) Who is most at risk? child care worker (diaper changes) CNA (bed pans) people who eat fish from contaminated water The cook/chef who does not wash hands

Hepatitis B,C,D Dialysis Hemophilia IV Drug users Healthcare workers Unprotected Sex Epiglottitis Cherry red epiglottis Throat is rapidly swelling/edematous Have trach set equipment ready at bedside-risk of respiratory distress May be drooling (cannot swallow) Do not check or swab the throat - could cause spasm Let sit on parents lab-do not want them to cry and cause spasm If Inspiratory stridor, crowing respirations- partial airway obstruction! what do we do first? Head tilt chin lift!

If your client this morning for breakfast had 3 ounces of juice, 4 ounces of coffee, 6 ounces of milk.. how many milliliters? 30 mL = 1 ounce

Menieres “menieres has fluid in the ears” Vertigo

Dizziness Tinnitus (ringing in the ears) Stand immediately in front to speak to patient They are a fall risk Low sodium diet (fluid build up) Do not give foods high in sodium-Peanut butter is high in salt! Best for meniere’s client?? Elevate head of bed, pillows etc or Place in dark quiet room with distant/soft music- correct answer (helps with ringing in ears, vertigo) Lyme Disease Bite from deer tick Doxicycline is drug of choice Bull’s Eye Lesion (remember you shoot deer, “deer tick”, bull’s eye) Best time to check for ticks-bath time Gout Build up of uric acid Caused by eating too much purine food red meats organ meats fish (sardines) Monitor uric acid levels No alcohol Reduce weight if overweight Meds Cholchicine Allopurinol ProBenicid First symptoms-pain or inflammation of great toe Osteoporosis Post menopausal women- advise to remove risks for falls, wear non skid shoes, well fitted etc. What is best to advise a 62 year old woman? enroll in dance class -correct answer (any activity to keep calcium in bones) or take multivitamins (very little calcium in multis)

Most at risk person-person who smokes or drinks alcohol Padgets Disease Loss of bone mass, replaced with deformities Give (also for osteoporosis) Fosemex Actinel Boniva Give these with Vitamin D to aid in calcium absorption Give with lots of water on empty stomach Must sit or stand for 30 min-1 hour Placing clint into a room Condition and age appropriate AIDS Does not need private room Do not place with infectious client-neutropenic Diverticulitis, pancreatitis, appendicitis, cholecystitis are not infectious Lupus, Hep B,C,D are not infectious they are standard precautions Surgery clients do not place with infectios clients Don’t mix infectious clients!

GENERAL REVIEW

WHO TO SEE FIRST? *Dysphagia (difficulty swallowing)- aspiration risk Increased salivary secretions, drooling, etc. (unless its a 6 month old/teething) *Pain 1 hour after pain medication or Pain unrelieved by pain medication *Post thyroidectomy with a dressing that is tightening-edema of airway! or Crowing respiration/inspiratory stridor

Numbness or tingling in fingers, toes around mouth,- low calcium give Calcium Gluconate! *Frequent swallowing Tonsillectomy thyroidectomy rhinoplasty esophageal varices *Blood Once blood arrives at unit start ASAP- within 30 minutes note: CNA cannot monitor vitals the first 15 minutes! -student nurses can *Blood transfusion Reaction Febrile reaction: fever and chills Allergic: pruritis, uticaria (hives), anaphylaxis Hemolytic: back and/or chest pain

*Addison’s Patient with sore throat, diaphoresis and chilling *Open fracture of femur- they can bleed and go into shock *Client with burned face, singed nasal hair, etc *Right pneumonectomy that is placed on left side *Mom not bonding with newborn who has a cleft lip *Platelet count of 80,000 with bleeding gums *client with a head injury who returned home from ER 2 hours prior with a headache Need to check vitals, neuro status, if they are vomiting, drowsy, etc. *

a baby with bulging fontanels

*client with prolapsed cord Interventions: knee chest position elevate hips Trendelenburg Sterile gloved hand to hold presenting part off cord (if dilated enough!)

*client who has had ruptured membranes Check fetal heart rate *14 year old with edema and scrotal pain- twisted testicle, have an hour to get surgery *Post thyroidectomy, laryngectomy, tonsillectomy *Over 400 Blood Glucose *status asthmaticus who suddenly stopped wheezing- they’ve arrested, BAD *restless and trouble breathing start oxygen and call doctor *restless and in pain align them if in traction/ cast etc *restless, pale, cool, clammy elevate feet about a foot

*panic and manic patient -safety risk to self/others note: never see first any patient with fixed pupils and glascow coma scale of 3 before other patients (others could be saved, this person is unlikely to survive)

SAMPLE QUESTIONS While talking with client and they fall over in a chair what to do first? apical pulse? Call for help? Tap shoulder and assess if unresponsive?- correct answer! While making rounds, client is on ventilator and trach is out of place, what do you do? Call code? Assess for breathing?- Correct answer Replace the trach?

Making rounds, ct’s IV site is red and edematous and is receiving O2 at 2L nasal cannula. O2 is out of nose but patient is fine, what do you do? Replace oxygen (they may need it discontinued if they are doing better but if it is ordered put it back asap!)

IV pump is beeping, pt having pain and pain meds are due, priority? Give pain meds! if a unit of blood has been in nursing unit for 10 minutes and thyroidectomy starts complaining of numbness around mouth, what is priority? The blood can be taken back to blood bank to be re-refrigerated (never put in any other refrigerator because it is not controlled) Check thyroidectomy!

Who do we see first? A COPD with resp 26 and O2 92% or 24 hours post head injury with GCS decreased from 14-12 or 12 hours post total knee, client is restless with petechiae on chest -correct answer! Client has restlessness (first symptom of hypoxia) Which would you see first? Post thoracotamy with closed drainage or Post thyroidectomy -correct answer or Bilateral knee replacement with wound vac

PLACE IN ORDER (DRAG AND DROP) Removal of a central line Heimlich Maneuver How to Remove a Trach How to Move Patient in Traction up In Bed Stabalize traction (put weights on bed) Head of bed down Get assistance to pull up

Put HOB back up Replace traction weights How to draw up regular or NPH insulin Roll NPH Clean top of vial and inject air into NPH Inject air and clean top of regular DRAW UP REGULAR Draw up NPH How to use Metered Dose Inhaler (MDI) How to use a C-PAP Pursed Lip Breathing Take deep breath Hold 2-3 seconds Exhale slowly through pursed lips Purpose of Incentive Spirometer? Expand the lungs. How to use it Exhale and take a slow very deep breath to make ball go up Deeper they inhale the higher the ball goes How to insert an NG tube How to insert a vaginal suppository How to put on sterile gloves How to get dressed and undressed for contact isolation Venturi Mask 21% is 1-2 L 35% is about 4 L

QUESTION A DOCTOR’S ORDER IF