Beruflich Dokumente
Kultur Dokumente
Esophagogastroduodenoscopy (EGD)
A SUDDEN TEMP SPIKE AFTER AN EGD (101.2), COULD BE A
SIGN OF PERFORATION OR A DEVELOPING INFECTION=
NOTIFY HCP
Tx for Peptic Ulcer: triple-drug therapy to avoid relapse (take for 7-14
days)
1. Omeprazole (Prilosec)
2. Amoxicillin
3. Clarithromycin (Biaxin)
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 1/103
2/18/2018 UWorld NCLEX-RN QBank
Airborne
required: N95
Droplet
required: surgical mask
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 2/103
2/18/2018 UWorld NCLEX-RN QBank
Head 9
Anterior Trunk 18
Posterior Trunk 18
Perineal 1
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 3/103
2/18/2018 UWorld NCLEX-RN QBank
Prioritization
Hypotension
Bradycardia
Warm/Dry skin
SABA = take it apart, wash mouthpiece only not the canister under
warm water and let air dry 1-2 times a week
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 8/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 9/103
2/18/2018 UWorld NCLEX-RN QBank
Tx for GERD:
1. Antacids (calcium carbonate, magnesium hydroxide
2. PPIs (omeprazole)
3. H2 receptor antagonists (ranitidine)
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 10/103
2/18/2018 UWorld NCLEX-RN QBank
ANTIBIOTICS
Initially has intermittent pain with the legs drawn up toward the
abdomen
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 12/103
2/18/2018 UWorld NCLEX-RN QBank
Triggers: tobacco smoke, pet dander, cockroach feces, air pollution, hay
fever, food allergies,
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 13/103
2/18/2018 UWorld NCLEX-RN QBank
ABSOLUTES:
Prior intracranial hemorrhage
Cerebrovascular lesion
Ischemic stroke within 3 months (except within 3 hours)
Suspected aortic dissection
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 15/103
2/18/2018 UWorld NCLEX-RN QBank
If client stand up to leave, the nurse should remain silent and allow client
to leave
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 16/103
2/18/2018 UWorld NCLEX-RN QBank
Tx: Methronidazole (Flagyl) DOC; avoid alcohol and for 24 hours after
completion of the therapy (reaction can cause flushing, N/V, abdominal
pain); METALLIC TASTE; URINE DEEP RED-BROWN COLOR
When chest tube drainage stops abruptly.... look to see if its expected
finding
1620u/hr
Common colds
Impetigo is a highly contagious bacterial skin infection (honey-colored
rust) common sites are mouth and hands
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 22/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 23/103
2/18/2018 UWorld NCLEX-RN QBank
LPN: take care of stable clients, limited assessments (lug sounds, bowel
sounds, neuro checks)
UAP: ADLs, hygiene, linen change, routine stable VS, document I&Os,
positioning
UAP can change dressings only for chronic wounds using clean
technique
Serum Vancomycin trough level is monitored before the 4th dose; 15-20
is optimal
BUN/CR are monitored 2-3 times/week due to increase risk of
nephrotoxicity
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 24/103
2/18/2018 UWorld NCLEX-RN QBank
Elevate HOB
Avoid: tobacco, caffeine
Small frequent meals, low fat
Avoid: lifting and staining
Low albumin, elevated INR, elevated LFT, low K level (can increase the
risk of hepatic encephalopathy) should be reported to HCP; elevated
serum ammonia
ADVERSE EFFECTS:
NEPHROTOXICITY
OTOTOXICITY
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 26/103
2/18/2018 UWorld NCLEX-RN QBank
HYPOTENSION
RED-MAN SYNDROME (STEVEN JOHNSON)
S/S of sepsis
1. HR >90 bpm
2. temp >100.9 F (38.3) C
3. systolic BP <90 mm Hg
4. altered mental status
5. hyperglycemia > 140 in the absence of diabetes
Foods to avoid:
High fiber: popcorn, coconut, brown rice, multigrain bread
Stringy vegetables: celery, broccoli, asparagus
Seeds or pit: strawberries, raspberries, olives
Edible peels: apple slices, cucumber, dried fruit
WIDENING QT INTERVAL:
HALOPERIDOL (HALDOL), METHADONE, ZIPRASIDONE
(GEODON) and ERYTHROMYCIN
Hyperkalemia
CONTRAINDICATIONS:
aneurysm clips, metallic implants such as ICDs, pacemakers, electronic
devices, hearing aids, and shrapnel
wash hands
gown
mask or respirator
googles or face shield
gloves
hypoglycemics, warfarin)
ETHAMBUTOL- frequent eye examinations
Pre-procedure:
Fast for 8 HOURS prior to exam
Test takes up to 60-120 minutes
Post procedure
Drink plenty of fluids after exam (BARIUM IS USED....TELL CLIENT
BOWELS WILL BE CHALKY WHITE IN APPEARANCE 24-72
HOURS AFTER THE EXAM
IF BOWELS DO NOT RETURN AFTER 72 HRS, IF STOOL IS
BLACK OR TARRY, ABDOMINAL PAIN/FULLNESS= CALL HCP
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 34/103
2/18/2018 UWorld NCLEX-RN QBank
Nurse: can witness client signing consent form; if client has question
about general care or health care teaching (DIET) it can be answered by
the nurse
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 35/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 36/103
2/18/2018 UWorld NCLEX-RN QBank
RYGB Complications:
dumping syndrome, iron deficiency anemia, cobalamin deficiency
Hyperthermia with heat stroke: tepid water and place ice bags under
arms and around the neck
When a client complains about staff treatment, the first response should
be to ASSESS the client's perceived wrong; then the nurse can then
determine what follow-up action is needed
Pneumonia s/s: cough with mucus, rhonchi and crackles are expected
findings, temperature
Central catheters are mostly commonly used for immediate dialysis over
AVGs, AVFs, and peritoneal dialysis
Stop Oxytocin
Left lateral side
Initiate IV fluids, bolus
Oxygen by facial mask (NOT A NASAL CANNULA)
Notify HCP
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 39/103
2/18/2018 UWorld NCLEX-RN QBank
If a nurse comes to work smelling like alcohol and has impaired speech.
What actions should the nurse take?
benign discoloration (bluish gray color) that fade over the first 1-2 years
of life... found on back or buttocks. not caused from trauma
Antidote =Vitamin K
Therapeutic INR range should be 1.5-2 times the normal "control" value
(INR of 2-3) for medical reasons.....DVT, A-Fib, Stroke
An INR of 3 to 3.5 is desired for the client with a mechanial heart valve
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 42/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 43/103
2/18/2018 UWorld NCLEX-RN QBank
Breast Cancer
RN only:
Assess, Plan and Evaluate, Teach
If client was experiencing NEW-ONSET, UNEXPLAINED PLAN
REQUIRING IV ANALGESIC ADMINISTRATION=RN WOULD DO
THIS
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 46/103
2/18/2018 UWorld NCLEX-RN QBank
Fold diaper below the cord to keep cord dry and prevent contamination
with feces and urine
DO NOT APPLY: ALCOHOL, TRIPLE DYE, CHORHEXIDINE
REPORT ANY SIGNS OF INFECTION (redness, purulent drainage,
swelling) to HCP
Normal: cord turns back in 2-3 days; cord falls off around 1-2 weeks
after birth
Warm bottles in pan on stove for few minutes until lukewarm, NEVER
HOT!!! NEVER MICROWAVE
HISTORY
WOMEN age 21-29 should be screened with Pap test only every 3 years.
At age 30, HPV and Pap testing may be done together every 5 years
AVOID: adduction and hip flexion; crossing legs; don't sleep or turn on
operative side
Administering...when to hold:
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 50/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 51/103
2/18/2018 UWorld NCLEX-RN QBank
1. wash hands
2. open sterile gauze package with ungloved hand
3. hold opened gauze package 6" above the sterile field
4. place sterile gauze dressing on the sterile field 2" from the edge (first
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 53/103
2/18/2018 UWorld NCLEX-RN QBank
Nursing actions:
1. Administer IV oxytocin via promiximal port (close to the patient)
2. Assess uterine contractions pattern (q 15 mins in first stage of labor
and q 5 mins in second stage)
3. Auscultate FHR continuous
4. Monitor I&O
5. IV oxytocin should always be on infusion pump
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 54/103
2/18/2018 UWorld NCLEX-RN QBank
Required:
Private room or cohort with clients with same infection
Gown and Nitrile gloves
Dedicated equipment in room (BP cuff, etc)
Hand hygiene before exiting room: Soap and water or alcohol-based
sanitizers for MRSA and VRE
SOAP AND WATER ONLY FOR C-DIFF AND SCABIES
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 55/103
2/18/2018 UWorld NCLEX-RN QBank
Treatment:
Oral iron supplementation and iron-rich foods (leafy-green vegetables,
red meat, poultry, dried fruit, fortified cereals
Limit milk intake (16-24 oz/day) in toddlers
Tenesmus- feeling like you have to have a bowel movement even you
already had one
common s/s: N/V/D; if N/D develops, can take with food to decrease GI
upset
Shake the liquid well prior to administering; administer at evenly spaced
intervals
Take full course of therapy even if feeling better
Statin Meds Adverse effects are muscle cramps and liver injury
Proton Pump Inhibitors (PPI e.g., omeprazole) risk for pnemonia, C-diff
diarrhea, osteoporosis
Absolute contraindications:
cardiac pacemaker
implantable cardioverter defibrillator
cochlear implant
retained metallic foreign body, esp. in eyes
Relative contraindications:
prosthetic heart valve
metal plate, pin, brain aneurysm clip, joint prosthesis- some have
nonferrous MRI safe metals that should be verified
implanted device (insulin pump, medication port)
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 58/103
2/18/2018 UWorld NCLEX-RN QBank
TREATMENT:
***ANTICHOLINESTERASE DRUGS: PYRIDOSTIGMINE
(MESTINON)
administer this med BEFORE MEALS SO CLIENT ABILITY TO
SWALLOW IS STRONGEST DURING MEAL
S/S of rotator cuff injury: shoulder pain and weakness; severe pain when
arm is abducted between 60-120 degrees (painful arc)
Other side effects Phenytoin: increase in body hair, rash, folic acid
depletion, decreased bone density (OSTEOPOROSIS)
Teach clients they need DIET high in FOLIC ACID and CALCIUM
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 61/103
2/18/2018 UWorld NCLEX-RN QBank
S/S: abdominal and back pain, pulsatile abdominal mass; BRUIT may be
heard over the site... Rupture can lead to death in minutes
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 62/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 63/103
2/18/2018 UWorld NCLEX-RN QBank
Maintenance of balance - assess gait testing; watch normal gait first then
heel-to-toe gait (tandem means walking in str8 line for DUI drivers), on
toes, and on heels
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 64/103
2/18/2018 UWorld NCLEX-RN QBank
Benzo's may cause sedation which can interfere with daytime activities.
Give the dose at bedtime can help client with sleep
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 65/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 66/103
2/18/2018 UWorld NCLEX-RN QBank
PPIs also increase risk for C-diff infection with ABX use!!!!
Antiemetics:
metoclopramide (Reglan)
1. used to decrease post-op nausea by promoting gastric emptying
NOTIFY HCP IF: bright red blood when urinating, blood clots, inability
to urinate, FEVER >100.4 and chills, abdominal pain unrelieved by
analgesia
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 70/103
2/18/2018 UWorld NCLEX-RN QBank
Teach parents:
Medication: ORAL DESMOPRESSIN
Droplet precautions
Monitor s/s of airway obstruction
Offer small amount of fluids frequently
Tx: ABX and supportive care (humidified oxygen, give fluids, suction
infants if needed) Vaccination
Position: left side to prevent aspiration
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 72/103
2/18/2018 UWorld NCLEX-RN QBank
Rotavirus spread fecal-oral route; contact with food, toys, diapers, and
humans; Meticulous handwashing and proper diaper disposal prevent the
spread of the virus
S/S: foul-smelling, watery diarrhea that lasts 5-7 days often acompained
by fever and vomiting.
Vaccination must be given before the child is 8 months old. ABX are not
effective against Rotavirus. Oral rehydration solutions used to combat
dehydration
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 73/103
2/18/2018 UWorld NCLEX-RN QBank
Bronchoscopy
Post-procedure: monitor for bleeding, bronchial perforation,
pneumothorax, bronchial spasms
Clients with anxiety level 8/10 and PACING are demonstrating distress
and require IMMEDIATE attention; might hurt self or others
Place infant on right side after feeding to promote gastric emptying and
reduce risk of vomiting
Next: after the rash has developed= apply cool, wet compresses; apply
topical cortisone; discourage child from scratching area
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 76/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 78/103
2/18/2018 UWorld NCLEX-RN QBank
Rescue clients
Alarm (active fire alarm)
Confine fire by closing doors
Extinguish fire
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 79/103
2/18/2018 UWorld NCLEX-RN QBank
1. WATER
2. CLUB SODA (FLAVORED/UNFLAVORED)
3. CLUB SODA OR SPARKLING WATER WITH A SPLASH OF
FRUIT JUICE
4. UNSWEETENED TEA AND/OR COFFEE
5. NON-FAT OR LOW-FAT MILK (in limited amounts)
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 80/103
2/18/2018 UWorld NCLEX-RN QBank
The trunk should be warmed before the extremities to reduce the risk of
afterdrop (means the core temp drops further)
Airborne:
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 81/103
2/18/2018 UWorld NCLEX-RN QBank
Prioritization
Nurse should obtain blood, urine, CSF cultures immediately and broad-
spectrum antibiotics started
Priority: assess vital capacity and tidal volume; assess breath sounds,
accessory muscle use, ABGs: AIRWAY MANAGEMENT AND
OXYGENATION
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 82/103
2/18/2018 UWorld NCLEX-RN QBank
UAP can take vital signs before the transfusion begins and ANY TIME
after the first 15 minutes of infusion
Nursing intervention:
NPO
Supine/ undiapered
NG suction (to decompress stomach/intestines)
Parental hydration and nutrition
IV antibiotics
NO RECTAL TEMPS= due to risk of perforation
The family should be allowed to visit the deceased client, after the client
and room have been prepared
wrong!!!!!!
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 85/103
2/18/2018 UWorld NCLEX-RN QBank
Client with a chest tube should be assessed for signs of air/fluid in the
chest (DIMINISHED BREATH SOUNDS); excessive drainage (>100
mL/hr), pain and infection
4 yr old can copy or draw a square with a pencil or crayon; also can
jump on one foot
Manage dry mouth with these meds: artificial saliva products, sugar free
hard candy and gum
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 88/103
2/18/2018 UWorld NCLEX-RN QBank
S/S: acute epigastric or left upper quadrant pain, often radiating to the
back, and a rapid rise in pancreatic enzymes (AMYLASE, LIPASE)
Elevated trough levels > 20, creatinine> 1.3, and BUN >20 ARE
ASSOCIATED WITH NEPHROTOXICITY AND SHOULD BE
REPORTED TO THE HCP
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 89/103
2/18/2018 UWorld NCLEX-RN QBank
INSTRUCT CLIENTS:
hydrate with clear liquids; AVOID: coffee, tea, caffeinated beverages;
complete full cours of ABX; can engage in sexual intercourse or
masturbation to reduce discomfort related to retained prostatic fluid; use
condoms to prevent transmission of organism; take stool softners; SITZ
baths (warm baths)
Nurse teaching:
1. Wait 30 mins after massaging cream into hands before washing hands
to ensure adequate absorption
2. Avoid contact with nose, mouth, eyes, skin thats not intact
(CAPSAICIN IS A COMPONENT OF HOT PEPPERS = BURNS)
3. Applying to knee for example, client should wear gloves or wash
hands immediately after application
4. NO HEAT WITH CAPSAICIN= CONTRAINDICATED
5. Local irritation (burning, stinging, erythema) is common and should
subside within first week of use. If client has persistent pain, redness,
blistering= DISCONTINUE, NOTIFY HCP
PREVENT INFECTION
A client can't take 2 types of NSAIDs at the same time (can be toxic to
the stomach and kidneys
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 92/103
2/18/2018 UWorld NCLEX-RN QBank
Alternative medicine
Garlic application
Cupping - steamed cup is placed on skin, causes circular bruised
blemishes
Coining (Chinese, Vietnamese) - rounded surface (coin, spoon) is firmly
stroked on lubricated skin of the back and produce welt-like linear
lesions
Nursing management:
Safety (canes, walkers -prevent falls and injury)
Light to moderate activity
Increase calcium, phosphorus and Vitamin D
1. wash hands and apply CLEAN GLOVES; remove old dressing and
discard gloves
2. wash hands and apply STERILE GLOVES; assess wound bed;
cleanse wound bed and surrounding skin with normal saline (flushing,
swabbing with gauze) to remove drainage and debris; remove and
discard gloves
3. wash hands and apply CLEAN GLOVES; gently swab wound bed
with sterile swab from CENTER OF WOUND toward OUTERWARD;
AVOID contact with skin on wound edge (can contaminate specimen)
4. place swab in sterile speciman container (DO NOT TOUCH
OUTSIDE OF CONTAINER)
5. apply topical medication (bacitracin) after obtaining cultures (it
prevents microorganisms from spreading) apply new dressing
6. remove and discard gloves, wash hands; label the specimen; document
the procedure
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 96/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 97/103
2/18/2018 UWorld NCLEX-RN QBank
Example: Amitriptyline
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 100/103
2/18/2018 UWorld NCLEX-RN QBank
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 101/103
2/18/2018 UWorld NCLEX-RN QBank
Nursing action:
The nurse should pause tube feedings for 1-2 hours before and after
phenytoin administration to ensure adequate absorption
http://www.uworld.com/ClientApp/V1/apps/Qbank/index.html#/test/notes/3656232 103/103