NCLEX: From Uworld

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1. ACE inhibitors potentially Swelling of the tongue can be a sign of angioedema in the client taking ACE inhibitors; this can be
life-threatening symptom potentially life-threatening if the airway becomes occluded
2. Addisons crisis: CMs and Addisonian crisis is a potentially life-threatening complication of Addison's disease and commonly
emergency mgmt presents with abdominal pain, hypotension, low Na, and hypoglycemia.

Emergency management includes shock management with fluid resuscitation using 0.9% normal saline
and 5% dextrose, and administration of high-dose hydrocortisone replacement IV push.
3. Addison's Disease: Common
findings

Slow, progressive onset of weakness and fatigue

Anorexia and weight loss
Orthostatic hypotension
Hyponatremia and hyperkalemia
Salt cravings
Nausea and vomiting
Depression and irritability
4. Administering a TB skin test - Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe
- Administer injection on inner forearm at a 10-degree angle with bevel up
- Make a wheal (bleb)
- Avoid rubbing site after injection
5. Adrenal Crisis

6. Albumin normal level normal: 3.5 - 5.0 g/dL

7. Alcohol withdrawal
syndrome chart
8. Angles for IM, Subq and
intradermal injections

9. Anticipated blood Polycythemia, an increase in RBCs, is an anticipated compensatory response to chronically low blood
component lab results in oxygen levels in clients with severe COPD.
COPD
10. Appropriate actions for a -- The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the
client in Buck's skin head of the bed more than 30 degrees would promote sliding
traction include: -- Regularly assess the neurovascular status and skin integrity of the limb in traction. Loosen Velcro
straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps
if the boot is too loose as this can decrease effectiveness of the traction. When a change is made in the
application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30
minutes
-- Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client
movement and provide comfort
-- Weights should be free-hanging at all times and should never be placed onto the bed or touch the
floor. A staff member should support the weight while the client is re-positioned up in bed to prevent
excessive pull on the extremity
11. Areas of referred pain in
the abdomen:
appendicitis,
cholecystitis, angina,
pancreatitis,
nephrolithiasis

12. Atrial pacing

spike before P wave

13. Azathioprine (Imuran) Azathioprine (Imuran) is an immunosuppressant drug that can cause bone marrow suppression and
increase the risk for infection. Leukopenia, a severe adverse effect of azathioprine, should be reported to
the health care provider before the medication is administered.
14. Best indicator of
developmental hip
dysplasia in infants

Uneven skin folds on examination

15. Biggest nursing Dehydration and Sulfa crystallization in the kidneys
consideration with giving
Sulfa -- Sulfa can crystallize in the kidney if the client is dehydrated
16. BIPAP - think expelling CO2. BIPAP - think expelling CO2.
Symptomatic hypoxia + elevated CO2 + Symptomatic hypoxia + elevated CO2 + acidosis = BIPAP STAT
acidosis = BIPAP STAT
17. Bishop Score

The lower the score, the more unfavorable a vaginal delivery looks
18. Buck's Traction

19. Buerger's disease a non-atherosclerotic vasculitis involving small to medium arteries and veins of the
upper and lower extremities.
Young male smokers are typically affected.
Clients should avoid exposure to cold weather and cease using tobacco and
marijuana in all forms.
20. Care for clients with bacterial meningitis DROPLET isolation precautions
Seizure precautions
Reduced stimulus environment (eg, quiet, dimly lit)
Bed rest with the head of the bed elevated Between 10-30 degrees.
21. Care of clients in acute manic phase of - Reduction of environmental stimuli
bipolar disorder Providing a quiet, calm environment
Limiting the number of people who come in contact with the client
One-on-one interactions rather than group activities
Low lighting
- A structured schedule of activities to help the client stay focused
- Physical activities to help relieve excess energy
- Providing high-protein, high-calorie meals and snacks that are easy to eat
- Setting limits on behavior
22. CAUTION - Cancer mnemonic C-hange in bowel or bladder habits
A- sore that does not heal
U-nusual bleeding or discharge from a body orifice
T-hickening or a lump in the breast or elsewhere
I-ndigestion or difficulty in swallowing
O-bvious change in a wart or mole
N-agging cough or hoarseness
23. Cervical cancer risk factors
24. Characteristics of metabolic syndrome
"We Better Think High Glucose"
25. Cheyne-Stokes and Kussmaul (KUSSMAUL
acronym)
26. Clients receiving peritoneal dialysis should be
monitored carefully for signs and symptoms of: .... ?
27. Clopidogrel (Plavix): when to d/c before surgery
28. Cms for bacterial meningitis in children <2
also, oral contraceptive use
(any 3 of the following)
-- Increased waist circumference: =40 in (102 cm) in men, =35 in (89 cm) in
women
-- Blood pressure: =130 mm Hg systolic or =85 mm Hg diastolic or drug
treatment for hypertension
-- Triglyceride level: >150 mg/dL (1.7 mmol/L) or drug treatment for elevated
triglycerides
-- High-density lipoprotein (HDL) levels: <40 mg/dL (1.04 mmol/L) in men
and <50 mg/dL (1.3 mmol/L) in women or drug treatment for low HDL-C
-- Fasting glucose levels: =100 mg/dL (5.6 mmol/L) or drug treatment for
elevated blood glucose
respiratory compromise, including difficulty breathing, rapid respirations, and
crackles
- dialysate infused during peritoneal dialysis can enter the thoracic cavity
and enter the lungs accidentally
should be discontinued 5-7 days before surgery to decrease the risk for
excessive bleeding.
Clinical manifestations of bacterial meningitis in infants age <2 include:
Fever or possible hypothermia
Irritability, frequent seizures
High-pitched cry
Poor feeding and vomiting
Nuchal rigidity
Bulging fontanelle possible but not always present
29. CMs of acute glomerulonephritis Clinical manifestations include:
-- periorbital and facial/generalized edema,
-- hypertension,
-- oliguria, which are primarily due to fluid retention (decreased kidney filtration).
-- tea-colored and cloudy urine due to the presence of protein and blood.
30. CM's of Cholinergic crisis As a result of cholinergic crisis, the muscles stop responding to the bombardment of
ACh, leading to:
- flaccid paralysis,
- respiratory failure
- increased sweating, salivation, bronchial secretions
- miosis
31. CMs of hypoglycemia Symptoms of hypoglycemia:

Sweating & pallor

Irritability
Tremors & weakness
Tachycardia
Drowsiness
Hunger
32. CM's of Myasthenic Crisis similar to worsening CM's of myasthenia gravis:
-- Difficulty breathing or speaking
-- Weak cough with increased secretions (mucus or saliva)
-- or an inability to clear secretions
-- Weak tongue, trouble swallowing or chewing, and weight loss
33. CMs of opioid withdrawal (with nursing
mgmt )

34. CMs of ruptured ectopic pregnancy Symptoms of a ruptured ectopic pregnancy include
- hypotension
- tachycardia
- dizziness
- REFERRED SHOULDER PAIN
Ruptured ectopic pregnancy is a surgical emergency requiring immediate intervention.
35. CMs of uterine inversion Complete inversion of the uterus presents with a large, red mass protruding from the
introitus.
36. Common causes for metabolic acidosis GI bicarbonate losses (eg, diarrhea)
Ketoacidosis (eg, diabetes, alcoholism, starvation)
Lactic acidosis (eg, sepsis, hypoperfusion)
Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt)
Salicylate toxicity
37. Common causes for metabolic alkalosis
38. Common causes for
respiratory acidosis

39. Common causes for

respiratory alkalosis

40. Common Types of

Aphasia

41. Correct order of stand on right side, inspect, auscultate, percuss, then palpate.
abdominal assessment
42. Correct order when When assessing an infant, the nurse should observe, auscultate, palpate, and then perform traumatic
assessing an infant procedures (eg, examine eyes, ears, mouth). Elicitation of the Moro reflex should be performed last.
43. Creatinine clearance -- The test begins when the first urine specimen is discarded and the time is noted.
test -- Creatinine clearance is a measure of the glomerular filtration rate.
-- The test requires a 24-hour urine specimen and a blood specimen.
44. Delegation/Scope of
Practice: RN, LPN, UAP
45. Developmental milestones of toddlers: age, gross
motor, fine motor, language, social/cognitive

46. Dialysis: DDS Dialysis disequilibrium syndrome (DDS)

- a potentially life-threatening condition associated with CEREBRAL EDEMA
- Characteristic NEUROLOGIC manifestations include nausea and vomiting,
headache, restlessness, change in mentation, and seizure activity.
- If DDS is suspected, the health care provider should be contacted
immediately and dialysis should be slowed or stopped
47. Diet restrictions for CKD restricted in fluids, sodium, potassium, and phosphorus.
-- Dairy products (eg, milk, yogurt) and certain fruits (eg, bananas, oranges,
coconuts, watermelons, and avocados) contain high potassium levels.
-- Dairy products are also high in phosphorus
48. Differentiating pain in urinary conditions: - Pain in pyelonephritis is dull, constant, and maximal at the costovertebral
pyelonephritis, renal stones, bladder distention, angle area. Extends to the umbilicus from the flank
cystitis - Pain from renal stones is excruciating, sharp, and often radiates toward the
groin from the flank.
- Suprapubic pain indicates bladder distension or cystitis.
- Spasms can be seen with infection (cystitis) or manipulation of the bladder.
49. disaster triage

50. DKA vs hypermolar hyperglycemic state

51. Documentation after an adverse event (i.e. client falls, After an adverse event, the nurse should document
suspected drug use in the room) - objective
- specific assessments
- interventions
These include signs/symptoms indicating a lack of client harm and
any corrective actions taken.
52. Donning PPE

53. Drugs and their antidotes Heparin = protamine sulfate

Benzodiazepine = Flumazenil
Warfarin = Vitamin K
Anticholinergics = physostigmine/neostigmine
Beta Blockers & Calcium channel blox = glucagon
Opioids = narcan
Acetaminophen = acetylcystine
Potassium = Kayexelate, glucose, insulin, albuterol, NaHCO3
Anticholinesterase = Atropine
Digoxin = digibind
Alcohol = fomepizole
Insulin = Glucose
Calcium Gluconate = Magnesium sulfate
Tricyclic antidepressants = phyostigmine or NaHCO3
Alcohol, Wernicke-Korsakoff Syndrome = Thiamine
54. Drugs that are vesicants Vancomycin.
Aciclovir, Gancicolvir.
Gentamicin.
Phenytoin.
Amphotericin.
Cefotaxime.
Mycophenolate Mofetil
Chemo
55. Dual chamber (AV) pacing

spikes before P wave and QRS complex

56. Ear drop installation: adult vs children <3 Pull the pinna up and back to straighten the ear canal in clients >4
years old and adults.

Pull the pinna down and back in clients <3 years old
57. ED care for near-drowning victims - advanced airway management,
- aggressive oxygenation
- establishing IV access and administering IV fluids (warmed if hypothermic)
- monitoring for cardiac arrhythmias and fluid imbalances
58. Erickson's developmental stages

59. Fetal presentations

60. Fifth disease Caused by Human parvovirus.

Children with fifth disease are communicable only prior to onset of symptoms (eg,
rash, joint pains).
The causative agent, human parvovirus, spreads via respiratory secretions.
Fifth disease is self-limiting and short-lived; treatment is given to alleviate
symptoms.
Isolation is not usually required for a non-hospitalized child
61. First intervention in a PACU client who has a One of the first nursing interventions is the head tilt and chin lift to open an
low O2 sat occluded airway.
-- Postoperative client care after general anesthesia requires careful monitoring for
hypoxia.
62. Fitting crutches

-- clients are taught to support body weight on the HANDS AND ARMS, not the axillae,
when ambulating
-- ensure that there is a 1-2 in (2.5-5 cm) space between the axilla and the axilla crutch
pad.
-- Crutches should be checked for proper length.
-- bottom of crutches should be 6" from feet
63. FLACC pain scale

64. Glycoprotein (GP) IIb/IIIa receptor - used as platelet inhibitors to prevent the occlusion of treated coronary arteries during
inhibitors: (eg, abciximab, eptifibatide, percutaneous coronary intervention procedures and prevent acute ischemic
tirofiban) complications
- no invasive procedures after administration (even needle sticks)
65. Good sources of folic acid

66. Group A strep pharyngitis: Nursing - Pharyngitis caused by group A ß-hemolytic Streptococcus is a bacterial throat
considerations infection that can cause renal or cardiac complications if not treated.
- It is important to discard the child's toothbrush 24 hours after starting antibiotics, test
siblings age <3 years, and complete the full course of prescribed antibiotics.
- The child may return to daycare after 24 hours of antibiotics and no fever
67. HELLP syndrome

68. Herbal supplementation: uses and potential side Ginkgo biloba

effects of common herbs -- Memory enhancement
Increased bleeding risk
--* increased bleeding risk

Ginseng
-- Improved mental performance
Increased bleeding risk
--* increased bleeding risk

Saw palmetto
-- Benign prostatic hyperplasia
--* Mild stomach discomfort & Increased bleeding risk

Black cohosh
-- Postmenopausal symptoms (hot flashes & vaginal dryness)
--* Hepatic injury

St John's wort
-- Depression & insomnia
-- * Drug interactions: Antidepressants (serotonin syndrome), OCs,
anticoagulants (↓ INR), digoxin & Hypertensive crisis

Kava
-- Anxiety & Insomnia
-- *Severe liver damage

Licorice
-- Stomach ulcers & Bronchitis/viral infections
--* Hypertension & Hypokalemia

Echinacea
-- Treatment & prevention of cold & flu
--* Anaphylaxis (more likely in asthmatics)

Ephedra
-- Treatment of cold & flu & Weight loss & improved athletic performance
--* Hypertension, Arrhythmia/MI/sudden death, Stroke, Seizure
69. Herbal supplements that can increase risk for Gingko biloba
bleeding include: Garlic
Ginseng
Ginger
Feverfew
70. Hirschsprung disease distal intestinal obstruction in infants

Clinical features - bilious vomiting, abdomial distention, failure to pass

71. Hirschsprung disease: potentially fatal
complication and CMs of enterocolitis
72. How is cholinergic crisis different from
myasthenic crisis
meconium, tight anal sphincter
Hirschsprung enterocolitis
- an inflammation of the colon, which can lead to sepsis and death.
- Enterocolitis will present with fever; lethargy; explosive, foul-smelling diarrhea;
and rapidly worsening abdominal distension.

Myathenic crisis:
- undermedication causes it
- loss of muscle control
- may need mechanical ventilation
- increased HR, RR, BP

73. How to calculate urine output in a client with
continuous bladder irrigation
74. How to care for extravasation
75. How to count ventricular rate on EKG strip
Cholinergic crisis:
- overmedication causes it
- decreased BP
- increased muscle tone and increased secretions
subtract the total amount of irrigating solution infused from the total amount in
the urine drainage bag.
>> Urine output approximates input minus insensible losses.
-- >> i.e. 2300 output - (175ml/hr x 8 hour shift) = total output for the shift
stop the infusion
aspirate drug out of the vein
remove IV
elevate extremity
COLD therapy (not heat therapy - vasoconstrict)
pain control

1500 / # of small squares

i.e. 1500 / 40 = 38 BPM -->

76. H's & T's of PEA Hypoxia
Hypovolemia
Hypothermia
H+ ions (acidosis)
Hypokalemia or hyperkalemia

Tablets (overdose)
Tamponade (cardiac)
Tension pneumothorax
Thrombosis (coronary)
Thrombosis (pulmonary)
77. Hypertrophic pyloric stenosis results in recurrent projectile vomiting, which leads to dehydration and hypokalemic metabolic
expected findings alkalosis.
Dehydration is manifested by hemoconcentration (elevated hematocrit) and elevated blood
urea nitrogen.
78. Immediate nursing intervention for Immediately after exposure to poison ivy, the client should be instructed to thoroughly wash
poison ivy exposure the area to remove the oily resin, which is responsible for causing the rash that follows in 12-48
hours.
79. Insufficient outflow during - Insufficient outflow results most often from constipation when distended intestines block the
peritoneal dialysis catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel
patterns and administer appropriate prescribed medications (eg, stool softeners).
- The nurse should also check the tubing for kinks and reposition the client to a side-lying
position or assist with ambulation
- The drainage bag should be maintained below the abdomen to promote gravity flow.
- The nurse should assess for fibrin clots and milk the tubing to dislodge or administer
fibrinolytics (eg, alteplase) as prescribed.
- If these measures are ineffective, an x-ray may be needed to check the catheter location.
80. Insulin chart

81. Insulin types and peak times chart

82. Ipratropium (Atrovent )
83. Laboratory results that support a
vaso-occlusive crisis (pain crisis) in
a client with sickle cell disease
a short-acting inhaled anticholinergic often used in combination with a short-acting beta-
agonist (eg, albuterol) to promote bronchodilation and reduce bronchospasm.
elevated reticulocytes, elevated bilirubin, and anemia (HGB <10)
84. Lactose-intolerance nursing -- also called lactase deficiency (lactose-intolerance)
considerations -- Clients with lactase deficiency can prevent unpleasant gastrointestinal symptoms by
avoiding lactose-containing dairy products (eg, milk, ice cream)
-- eating cheese or yogurt in moderation (these contain little to no lactose)
-- supplementing with lactase enzymes
-- Vitamin D and calcium supplementation is also recommended.
85. List of medications commonly cefazolin (Ancef)
prescribed for a client with an open tetanus toxoid
fracture to prevent infection and ketorolac (Toradol)
treat pain and muscle spasm opioids
cyclobenzaprine (Flexeril).
86. lithium toxicity CMs Chronic toxicity manifests with neurologic symptoms (ataxia, confusion or agitation, and
neuromuscular excitability) and/or diabetes insipidus (polyuria and polydipsia).
87. Long-term PPI use: adverse effects Long-term use of PPIs (eg, omeprazole, pantoprazole, esomeprazole) is associated with:
-- osteoporosis
-- C difficile infection
-- pneumonias
Clients should be encouraged to increase calcium and vitamin D intake to help prevent
osteoporosis.
88. LOW magnesium level manifestations Speeds everything up - ventricular arrhythmias and/or neuromuscular excitability (similar
to hypocalcemia), which includes tremors, positive Chvostek and Trousseau signs,
hyperactive reflexes, and seizures.
89. Macrolide antibiotics: life-threatening Macrolide antibiotics (eg, erythromycin, azithromycin, clarithromycin) can cause QT
complication prolongation, which can lead to life-threatening arrhythmias (eg, torsades de pointes). They
can also be hepatotoxic; therefore, the nurse should monitor liver function tests and an
ECG and report significant results to the HCP.
90. Magnesium sulfate toxicity or high slows everything down - irregular heartbeat, low blood pressure, confusion, slowed
serum Mg level CMs breathing, slowed reflexes, flaccid muscles, coma, and death.
91. Maslow's hierarchy of needs

92. Measuring fundal height by weeks

gestation
93. Mechanical ventilator pressure alarms

94. Medications that cause Widening of the haloperidol (Haldol)

QT interval and can increase the risk of methadone
life-threatening torsades de pointes ziprasidone (Geodon)
erythromycin
95. Meds to increase WBC count in cancer Filgrastim (Neupogen) and pegfilgrastim (Neulasta)
patients - stimulate neutrophil production and are given prophylactically or if the client has an
infection and more neutrophils are needed to fight it
96. Meds to stop taking 1 week before and Amiodarone
6 weeks after a thyroid scan (drugs that Interferon
increase iodine levels) Iodine
Propylthiouracil
LITHIUM, Dilantin, carbamazepine, phenobarbital (anticonvulsants)
ACE inhibitors, ARBs, spironolactone
97. Meniere disease (endolymphatic - results from excess fluid accumulation inside the inner ear.
hydrops) - Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The
vertigo can be severe and associated with nausea and vomiting.
- Clients report feelings of being pulled to the ground (drop attacks).
98. Methadone: toxicity, monitoring, and Early signs of toxicity include nausea/vomiting and lethargy. The nurse should monitor
complications the client's respiratory rate, pulse oximetry, and electrocardiogram tracing. Respiratory
depression and QT interval prolongation can lead to life-threatening complications.
99. Metoclopramide [Reglan] Clients are at risk for EPS in Reglan toxicity
100. Mgmt of PKU - Monitoring serum levels of phenylalanine
- Include synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet
- Eliminate high-phenylalanine foods (eg, meats, eggs, milk) from the diet (Option 2)
- Encourage the consumption of natural foods low in phenylalanine (most fruits and
vegetables)
101. Needle sizes and most appropriate uses - A 14-gauge (large-bore) catheter is used to administer fluids and drugs in a prehospital
or emergency setting, or for hypovolemic shock.
- An 18-gauge catheter is typically indicated for infusing blood or large amounts of fluid
in adults.
- A 20-22-gauge catheter is sufficient for administering general IV fluids and medications
to adult clients; a 20-gauge is acceptable for blood transfusion
- A 24-gauge catheter is recommended for children and some older adults with small,
fragile veins.
102. Neonatal sepsis - Sepsis neonatorum is a medical emergency.
- Newborns may not exhibit obvious signs of infection but instead may have elevated
temperature or be hypothermic.
- Subtle changes such as irritability, increased sleepiness, and poor feeding should be
considered red flags.
- Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and
broad-spectrum antibiotics started.
103. Neurogenic shock: Classic CMs Neurogenic shock/distributive shock can occur from VASODILATION soon after spinal
injury.
-- Classic symptoms are hypotension, bradycardia, and pink and dry skin.
-- The hypotension must be treated with isotonic fluids to maintain vital organ perfusion.
104. NG tube feedings - Complications of total enteral nutrition at the start of treatment are nausea, vomiting, and
diarrhea.
- These signs and symptoms can usually be alleviated by slowing down the rate of
administration and then gradually increasing the rate to the established goal.
105. Nicotine replacement products Smoking cessation can be achieved with bupropion or varenicline but not with nicotine
replacement products.
106. Normal ALT Level 10-40 U/L (0.17-0.68 µkat/L)
107. Normal amount of drainage in - A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished
chest tube breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site.
- Excess drainage of frank red blood is indicative of hemorrhage and must be managed
immediately.
108. Normal CD4+ cell count in HIV (500-1,200/mm3 [0.5-1.2 × 109/L])
patients
109. Normal Creatinine level 0.6-1.3 mg/dL (53-115 µmol/L
110. Normal HDL level adult men is >40 mg/dL
adult women is >50 mg/dL
111. Normal INR level The target International Normalized Ratio (INR) for most conditions in which warfarin is used is
normally 2-3 and is occasionally 3.5.
112. Normal LDL levels <100 mg/dL [2.6 mmol/L]
113. Normal phenylalanine blood Normal levels of phenylalanine in the blood are less than 2 milligrams per deciliter (mg/dL).
levels
114. Normal range for Hematocrit For men, 38.8 to 50 percent.
For women, 34.9 to 44.5 percent.
115. Normal range for Hemoglobin For men, 13.5 to 17.5 grams per deciliter.
For women, 12.0 to 15.5 grams per deciliter
116. Normal theophylline levels Theophylline has narrow therapeutic index and plasma concentrations >20 mcg/mL (111 µmol/L)
117. Normal total cholesterol level adult <200 mg/dL [5.2 mmol/L]
118. Normal triglyceride level adult <150 mg/dL [1.7 mmol/L]
119. Normal TSH Levels 0.4 to 4.0 milli-international units per liter.
120. The nurse should implement the - Stop the infusion immediately and disconnect the IV tubing
following interventions when - Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while
dealing with extravasation aspirating.
- Elevate the extremity above the heart to reduce edema
- Notify the health care provider and obtain a prescription for the antidote phentolamine
(Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some
adrenergic agonists (eg, norepinephrine, dopamine)
121. Nursing considerations for Nausea, vomiting, or slow pulse rate can indicate digoxin toxicity. General guidelines are to
digoxin hold digoxin for pulse <90-110/min in infants and young children and <70/min in older children.
122. Osteomalacia Osteomalacia occurs when the body is unable to use calcium and phosphorus for bone
calcification due to a vitamin D deficiency. Nursing management focuses on implementing
safety measures, encouraging activity, and increasing intake of vitamin D, calcium, and
phosphorus.
123. Other than Malignant lung tumor patients/cancer patients
hypophysectomy/neuro patients,
what other clients are at risk for
developing SIADH?
124. PA catheter waveforms

125. Paranoid delusions: therapeutic When communicating with a delusional client, the nurse must focus on the client's
communication feelings and reinforce reality rather than argue or present evidence that the delusion
is false or irrational.
- Focusing on reality and verbally reinforcing it will decrease the time that the client
spends thinking about the delusions
126. Parkland burn formula

Parkland formula = 4 mL × weight (kg) × body surface area burned (%)

127. Partial retinal detachment A partial retinal detachment may be painless and cause symptoms such as a
curtain blocking part of the visual field, floaters or lines, and sudden flashes of
light.
128. patent ductus arteriosus: CMq Many newborns are asymptomatic except for a loud, machine-like systolic and
diastolic murmur.
129. Postmortem care steps - Wash and straighten the body
- change the linens, and place a pad under the perineum to absorb stool and urine
from relaxed sphincters.
- Place a pillow under the head to prevent blood from pooling and discoloring the
face.
- Place dentures in the client's mouth before rigor mortis sets in and close the
mouth.
- Gently close the eyes. Remove tubes, lines, and dressings per institutional policy
unless an autopsy or organ donation is to be performed.
- After the family leaves, take the client to the morgue or notify the funeral home to
arrange transportation
130. Postpartum complications: Vaginal ...
hematoma, uterine atony, inversion of uterus,
cervical lacerations
131. Postpartum uterine atony: Risk
factors, CM's, interventions

Risk factors:
Uterine fatigue from prolonged, induced, or precipitous labor
Chorioamnionitis
Uterine overdistension (multiple gestation, polyhydramnios)
Retained placenta

Clinical features:
Most common cause of postpartum hemorrhage
Enlarged, soft, boggy, poorly contracted uterus
Interventions

Uterine fundal massage:

Correction of bladder distension
Uterotonic medications (eg, oxytocin, methylergonovine, carboprost, misoprostol)
IV fluids, blood, oxygen (if hemorrhage occurs)
Possible surgical intervention (if unresolved)
132. Potassium-sparing diuretics Spironolactone, amiloride, triamterene, and eplerenone
133. PPE Removal Sequencing

134. Preconception care topics - folic acid supplementation

- appropriate dental care and vaccinations
- avoidance of alcohol, smoking, and illicit drugs
- attempt to achieve normal weight (BMI of 18.5-24.9 kg/m2) before conceiving to improve
outcomes
135. Preeclampsia: CMs and Preeclampsia in pregnancy manifests with high blood pressure AND protein in the urine.
complications Edema is expected, but not part of the dx criteria.
Complications of preeclampsia include eclampsia, placental abruption, and HELLP
(Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome
136. Prioritization of care First-level priority problems
* Airway
* Breathing
* Circulation & cardiac (become first priority in cardiac arrest)
* Vital signs

Second-level priority problems

* Altered mental status
* Acute pain
* Untreated medical problems (eg, hyperglycemia in a client with diabetes)
* Chronic pain
* Acute elimination issues
* Abnormal laboratory results
* Risk for infection, safety
137. Priority interventions for active or Clamp the catheter to prevent more air from embolizing into the venous circulation.
suspected air embolism are as Place the client in Trendelenburg position on the left side, causing any existing air to rise
follows: and become trapped in the right atrium.
Administer oxygen if necessary to relieve dyspnea.
Notify the HCP or call an RRT to provide further resuscitation measures.
Stay with the client to provide reassurance and monitoring as the air trapped in the right
atrium is slowly absorbed into the bloodstream over the course of a few hours.
138. Pulsus paradoxus The procedure for measurement of pulsus paradoxus is as follows:

- Place client in semirecumbent position

- Have client breathe normally
- Determine the SBP using a manual BP cuff
- Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP
- Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the
pressure
- Continue to slowly deflate the cuff until you hear sounds throughout inspiration and
expiration; also note the pressure
- Determine the difference between the 2 measurements in steps 5 and 6; this equals the
amount of paradox
- The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the
presence of cardiac tamponade.
139. Pyelonephritis CMs and etio - UTI that is located in the kidney
- inflammation of the kidney parenchyma
- causes flank pain that is experienced in the back at the costovertebral angle (the angle
between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus.
140. Pyelonephritis vs cystitis UTI pain
141. Recommended bed-to-chair transfer method in full,
partial, and no weight-bearing patients

142. Risk factors for Failure to Thrive in children *Young parent age
*Unplanned or unwanted pregnancy
*Lower levels of parental education
*Single-parent home
*Social isolation
*Chronic life stresses/anxiety in the home
*Disordered feeding techniques
- Prolonged breast or bottle feeding
- Unstructured meal times
- Negative or difficult interactions at meal time
- Poor parental feeding skills
- Negative attitudes toward food - fear of obesity or an overweight
child
*Substance abuse
*Domestic violence and/or parental history of child abuse
*Poverty, food insecurity
*Parents who have a negative perception of the child
143. Risk factors for lithium toxicity dehydration, decreased renal function, low-sodium diet, and drug-drug
interactions (eg, NSAIDs and thiazide diuretics)
144. Risk factors for recurrent otitis media - Recurring exposure to tobacco smoke
- Regular pacifier use, particularly after age 6 months
- Drinking from a bottle while lying down
- Lack of immunizations, particularly the pneumococcal vaccine series
145. The RN can safely delegate these tasks to UAP - Assist with activities of daily living (eg, feeding, bathing, dressing,
hygiene)
- Ambulate and promote mobility of stable clients
- Perform oral (nonsterile) suctioning for clients during oral care
- Collect and document vital signs
- Turn and reposition stable clients

(ADAM's SVT)
146. Rule of 9's
147. Safety precautions for home - no smoking
oxygen use include the - electrical devices in good condition and plugs grounded
following: - avoiding volatile, flammable products and materials that generate static electricity (i.e. vasoline)
- staying at least 5-10 feet away from open sources of flame
- keeping fire extinguishers readily available
- regularly testing smoke detectors
148. "Sentinel event" A sentinel event is any unanticipated event in a health care setting that results in death or serious
physical or psychological injury.
149. Signs of Addisonian crisis Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia,
hyponatremia, hypoglycemia, fever, weakness, and confusion.

Priority emergency management of addisonian crisis includes shock management, with fluid
resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose
hydrocortisone replacement IV push
150. Signs of increased
intracranial pressure in peds

"sunset eyes" is the big one

151. Sinus Bradycardia flowchart

152. SIRS
(sepsis = SIRS + infection)
153. Splenectomy major complications
154. SSRI side effects (ending in "ine"):
fluoxetine, sertraline..
155. Steps to delay gastric emptying to
prevent dumping syndrome
156. Stimulants (eg, methylphenidate,
dextroamphetamine, lisdexamfetamine) for
ADHD: nursing considerderation/teaching
157. Supine hypotensive syndrome
158. A teaching plan for a client prescribed
rifampin, isoniazid, & ethambutol for active
TB includes these instructions:
159. Tetracycline antibiotic nursing
considerations
Systemic Infection
- Overwhelming postsplenectomy bacterial infection or rapid-onset sepsis are major
lifelong complications in a client without a functioning spleen.
- A minor infection can quickly become life-threatening, and so any indicator of
infection such as a low-grade fever, chills, or headache needs immediate intervention
(eg, cultures, imaging, antibiotic therapy).
- Any client reporting even minor signs of infection should be the priority client
-Loss of appetite; weight loss or weight gain
- Gastrointestinal disturbances (nausea, vomiting, diarrhea)
- Headaches, dizziness, drowsiness, insomnia
- Sexual dysfunction
-- Consume small, frequent meals to reduce the amount of food in the stomach at any
one time
-- Eat slowly in a relaxed environment.
-- Avoid meals high in simple carbohydrates (eg, sugar, syrup) as these may trigger
dumping syndrome when carbohydrates are broken down into simple sugars
-- Consume meals high in protein, fat, and fiber, which take longer to digest and
remain in the stomach longer than carbohydrates
-- Separate fluids from meals. If fluids are taken with meals, stomach contents pass
more easily into the jejunum and worsen symptoms. Fluid intake should occur only
after or between meals, separated from solid intake by at least 30 minutes
-- Avoid sitting up after a meal. Gravity increases gastric emptying. Lying down after
meals slows down the gastric emptying and is preferred
- Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually
30-45 minutes before meals.
- As a stimulant, methylphenidate may interfere with sleep and should be given no
later than around 6:00 PM.
- The sustained-release preparation should be given in the morning.
Supine hypotensive syndrome is usually seen in the third trimester of pregnancy when
the weight of the uterine contents compresses the inferior vena cava.
The resultant maternal hypotension is best treated initially by turning the client to the
right OR left side to relieve pressure on the vena cava.
- Isoniazid causes hepatotoxicity and peripheral neuropathy.
- Rifampin (Rifadin) also causes hepatotoxicity. Therefore, baseline liver function tests
should be obtained.
- Clients should be advised to watch for signs and symptoms of hepatotoxicity (eg,
jaundice, anorexia).
- Ethambutol causes ocular toxicity, and clients will need frequent eye examinations
- Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide
distribution.
- Tears can turn red, making contact lenses appear discolored.
- Client should wear eyeglasses instead of soft contact lenses while taking this
medication.
- Women should use nonhormonal birth control methods while taking this drug as it
can decrease the effectiveness of oral contraceptives
-- Tetracyclines should be taken 1 hour before or 2 hours after meals with plenty of
water.
-- They should not be taken with dairy products or within 2 hours of taking antacids.
-- Clients should use sunblock due to photosensitivity
-- plan to use additional contraceptive techniques
-- Take during the day with plenty of water
160. Thoracentesis

161. Thyroid Storm CMs

Fever, altered mentation, and excess autonomic activity (eg, severe hypertension, tachycardia) are common.
Early recognition and treatment are crucial.
162. Tiotropium/Ipratropium (Spiriva) anticholinergic inhaled meds for COPD
* Typically administered as a capsuled powder via a special inhaler.
* not a rescue med, not used to reduce inflammation in airway
* rinse mouth out after use
* can be used in acute asthma attacks along with albuterol/levalbuterol
163. Topical Capsaicin: -- Local irritation (burning, stinging, erythema) is quite common.
Nursing -- The client should wait at least 30 minutes before washing the affected area to ensure adequate
Considerations absorption.
164. Treatment for Diphenhydramine (Benadryl)
anaphylactic shock IM epinephrine
Inhaled beta agonists
Methylprednisolone (Solu-Medrol).

They modify the histamine response and treat pruritus, reverse bronchoconstriction, and decrease airway
inflammation, respectively. IM epinephrine can be repeated for poor response.
165. Treatment for a sprain Rest, Ice, Compression, and Elevation (RICE) for the first 24-48 hours following the injury, mild analgesia
with a nonsteroidal anti-inflammatory drug, and an exercise rehabilitation program when pain subsides
166. Treatment of includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate
myesthenia gravis vaccinations.
exacerbation
i.e.
Azathioprine (Imuran, Azasan)
Cyclosporine A (Neoral, Sandimmune, Gengraf)
Cyclophosphamide.
Mycophenolate mofetil (CellCept)
Methotrexate (Otrexup, Rasuvo, Trexall)
167. Tricyclic antidepressants
168. Umbilical cord prolapse: CMs
169. Vaccines to hold after IVIG administration
(i.e. for Kawasaki disease)
170. ventricular pacing
171. Ways clients manage symptoms in IBS
172. What 2 classes of BP meds should be held
if a patient has low HR (< 60 bpm)?
173. What 2 non-narcotic pain relieving
classes of medication are associated with
increased risk of cardiac events?
174. what are s/s of aspirin/NSAID toxicity
175. What assessment finding is an
emergency in sickle cell crisis
Have "tri" in the name: "ami'tri'ptylline"
-- The most common side effects experienced by clients taking tricyclic
antidepressants include dizziness, drowsiness, dry mouth, constipation,
photosensitivity, urinary retention, and blurred vision.
-- The priority nursing action is to teach caution in changing positions due to the
increased risk for falls from dizziness and orthostatic hypotension, especially in elderly
clients.
- Umbilical cord prolapse causes cord compression, fetal heart rate deceleration, and
disruption of fetal oxygen supply.
- The priority with fetal bradycardia after suspected rupture of membranes is to assess
for a prolapsed cord. The nurse should then manually elevate the presenting fetal part
off the cord, leave the hand in place, and call for help.
Live vaccines (eg, varicella, MMR) should be delayed for up to 11 months after IVIG
administration as IVIG therapy may decrease the child's ability to produce the
appropriate amount of antibodies to provide lifelong immunity.
spike before QRS
-- by avoiding gas-producing foods (eg, broccoli), caffeine, alcohol, and
gastrointestinal irritants (eg, high-fructose corn syrup, spices, dairy products)
-- by increasing fiber
Calcium Channel blockers: i.e. Diltiazem
Beta Blockers: "olol"
COX inhibitors and NSAIDS
- Aspirin and other NSAIDs inhibit platelet aggregation, resulting in GI bleeding
complications.
- They also promote development of gastric ulcers with long-term use.
- Tinnitus (ringing in the ears) is the earliest sign of aspirin toxicity
Enlarged spleen on palpation
- Splenic sequestration crisis is a potentially life-threatening emergency of sickle cell
disease.
- A rapidly enlarging spleen and hypotension are the characteristic assessment
findings.
176. What causes acute glomerulonephritis - Acute glomerulonephritis is most often caused by recent streptococcal infection.
- Nursing care is focused on monitoring vital signs (particularly blood pressure) and fluid
status, avoiding salt in the diet, and conserving energy.
177. what classes of antibiotics should be penicillins and cephalosporins
held if the client is allergic to
penicillin
178. What is a complication a neonate can
have when the mother took narcotics
throughout pregnancy

WITHDRAWAL acronym
- opioid therapy is the treatment
179. What is BiPAP? - bilevel positive airway pressure (BIPAP) machine
- provides positive pressure oxygen and expels CO2 from the lungs.
- used in increased CO2 levels where o2 is dropping/LOC is declining
180. What is Meniere disease? Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the
inner ear.
Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness.
The vertigo can be severe and is associated with nausea and vomiting.
Clients report feeling being pulled to the ground (drop attacks).
181. What is the antidote used in Flumazenil is the appropriate antidote for a benzodiazepine overdose.
benzodiazepine overdose
i.e. chlordiazepoxide, clorazepate, diazepam, oxazepam, alprazolam, clonazepam,
clorazepate, lorazepam
182. What is the greatest indicator that Adequate urine output
fluid resuscitation therapy has been
effective? Adequate urine output (at least 30 mL/hr, or 0.5 mL/kg/hr) depends on adequate renal
perfusion and is the greatest indicator that fluid resuscitation therapy has effectively
restored tissue perfusion.
183. What is the recommended serum 140-180 mg/dL (7.8-10.0 mmol/L)
glucose for those on TPN/nutrition -- intervention needed if glucose is > 180 or < 120
support therapy
184. What med class to question in COPD Morphine and other medications (eg, benzodiazepines) that can depress the respiratory
exacerbation center should not be used in clients with COPD exacerbation as they can further worsen
CO2 retention.
185. What should clients be taught who clients who follow a vegan diet should be taught about vitamin B12 deficiency and the
follow a vegan diet? importance of supplementation. Vitamin B12 deficiency affects the entire nervous system,
from peripheral nerves to the spinal cord and brain.
186. When a client needs IMMEDIATE dialysis
access, what type of access is used?
187. When should patients with mitral valve
regurgitation see the doctor?
188. When to give Heimlich maneuver vs back
blows and chest presses for choking
189. Which meds can not be crushed and
administered via NG tube?
190. Which two drug classes are the most common
for triggering bronchospasms in patients with
asthma
191. Why is MIDCAB a more painful incision
location?
192. Z track method
Central catheters
- Central catheters are most commonly used for immediate dialysis access over
AVGs, AVFs, and peritoneal dialysis
- AVGs and AVFs require time for the site to mature and are not normally used for
immediate access.
Clients are often asymptomatic but are instructed to report any NEW symptoms
indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue)
Children < 1 year old: back blows and chest presses
Children >1 and all adults: Heimlich maneuver
enteric-coated
slow-release
extended-release
sustained-release drug
** crushing disrupts designed time of release and is contraindicated. The nurse
should contact the PHCP for an alternate prescription if such a drug is prescribed
via NG route.
Ibuprofen and aspirin are common over-the-counter anti-inflammatory drugs that
can cause bronchospasm in some clients with asthma