Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
NCLEX REVIEW
TeleRN
| Question | Answer |
|---|---|
| Too much volume in the vascular space | Hypervolemia aka FVE aka Fluid Volume Excess; |
| Causes of FVE (Hypervolemia) | CHF, Renal Failure, Alkaseltzer, Fleets enema, IVF w/Na, and Aldosterone |
| Alkaseltzer, Fleets ememas, and IVF w/Na have a lot of what? | Na which in turn retains fluid in the vascular space |
| Where does aldosterone live? | Adrenal glands |
| What is the normal action of aldosterone? | When blood volume gets too low (vomiting, blood loss, etc.) aldosterone is kicked in which makes the body retain NA and H2O which increases blood volume |
| What are some dx with too much aldosterone? | Cushings and hyperaldosterone (Combs) |
| What is a Dx with too little aldosterone? | Addison's (add steroids) |
| Aldosterone = | Na and H20 |
| What do you get with too little aldosterone? | Hypovolemia aka FVD aka Fluid Volume Deficit |
| What is ADH? | Anti-Diuretic Hormone |
| What does ADH do to the body? | Makes the body retain H20 |
| What are 2 ADH problems? | Too much and too little |
| Too much ADH causes what? | Body retains H20 - creating FVE, SIADH can occur (too much H20), UO decreased and blood becomes dilute |
| What happens with too little ADH? | Body loses H20 (diureses), creating FVD, DI can occur, UO increases and blood is concentrated |
| What is the #1 concern with FVD? | Shock |
| Where does ADH live? | Pituitary |
| What are key words to make you think potential ADH problems? | Craniotomy, Head injury, Sinus surgery, Transphenoidal hypophysectomy (going through nose to take out pituitary) |
| What is another name for ADH? | Vasopressin |
| What 2 drugs may be utilized as an ADH replacement in Diabetes Insipidus? | Vasopressin and DDAVP (Desmopressin acetate) |
| If a ? is about UOP with a head injury - think what? | ADH |
| Normal urine and blood do what? | Mirror each other |
| ADH problems come secondary to what? | Other major cause (they are sneaky) |
| What are the S/S of FVE? | Distended neck veins, Peripheral edema, High CVP, Crackles in lungs, Polyuria, Increased HR, Increased BP, Increased weight |
| What is the treatment of FVE? | Low Na diet, Diuretics, Bed rest |
| Name some Diuretics? | Loop (Bumex may be given when Lasix doesn't work), HCTZ and K-Sparing |
| With Diuretics, what do you want to watch carefully? | Lab work, dehydration and electrolyte problems |
| What does bed rest induce? | Diuresis (when you are supine, your kidneys perfuse more) |
| What are some interventions with FVE? | Physical Assessment (think S/S) and Give IVF's slowly to elderly and very young |
| When a pt is on bedrest, what do you want to encourage? | Fluids |
| What are some causes of Hypovolemia (FVD) | Loss of fluids anywhere (not just blood), Thoracentesis, Paracentesis, Vomiting, Diarrhea, Hemorrhage, Third spacing (such as burns and ascites) and Dx with polyuria |
| What is Third Spacing? | When fluid is in a place that does you no good |
| What are some S/S of FVD? | Weight decreases, Skin turgor decreased, Dry mucous membranes, Decreased UOP, BP decreases, HR increases, CVP decreases, Neck veins are teeny tin, Cool extremities, Urine specific gravity increased |
| Tx and Nursing Interventions for FVD? | Mild deficit = push PO fluids. Severe Deficit = IV fluids |
| When vitals all go up = | FVE |
| When vitals all go down, except HR increases = | FVD |
| What is the first organ to die during shock? | Kidneys |
| Isotonic = | Goes into vascular spave and stays there! |
| Examples of Isotonic solutions: | NS, LR, and D5W |
| Hypotonic = | They go into hte vascular space, rehydrate, then move into the cell and the cell burns the remainder up in cellular metaboism. They do hydrate, but they won't drive your pressure up b/c they don't stay in the vascular space |
| Example of Hypertonic solutions: | D10W, 3%NaCl, 5%NaCl, D5, LR, D5 1/2 NaCl, D5 NaCl, and TPN |
| Examples of Hypotonic Solutions: | D2.5 W, 1/2 NaCl, 0.33% NaCl |
| Hypertonic Solutions = | Pushing Pressure; Volume expander and solution that draws fluids into the vascular space |
| Hypotonic Solutions = | Pulling Pressure; Causes a fluid shift from the vascular space into the cells |
| If you want fluids to start switching and swaping, then you have to give what? | Something other than what the body already is, which is Isotinic (0.9) |
| Magnesium is excreted by what? | Kidneys, and it can be lost other ways too (GI tract) |
| What is Hypermagnesemia? | Too much Magnesium in the blood |
| What causes Hypermagnesemia? | Renal failure, Antacids |
| What are the S/S of Hypermagnesemia? | Flushing, Warmth (Mg makes you vasodilate) |
| What is the Tx for Hypermagnesemia? | Ventilator, Dialysis, Ca Gluconate (Ca Gluconate in the presence of Mg - they inactivate each other) |
| What is Hypercalcemia? | Too much Ca++ in the blood |
| What are some causes of Hypercalcemia?? | Hyperparathyroidism (PTH), Thiazides (retains Ca++), Immobilization (you have to bear weight to keep Ca++ in the bones), Kidney stones (majority made of Ca++) |
| What is the Tx of Hypercalcemia? | Fluids!, Phospho Soda & Fleets enema (both have phosphorous), Steroids (lowers Ca++), Add Phosphorous to diet (anything w/ protein) |
| What vitamin must you have to use Ca++? | Vitamin D |
| Calcitonin does what to serum Ca++? | Decreases |
| If you want to get Mg & Ca ?'s correct, think what first? | Muscles first!! |
| When your serum Ca++ get low Parathormone (PTH) kicks in and pulls Ca from the _______ and puts it in the blood..... therefore, the serum _______ goes up? | Bone ; Ca++ |
| PTH = | Increase Ca++ |
| S/S of Hyper Mg and Hyper Ca++: | DTR's Decrease, Muscle Tone decreases, Arrhythmias, Decrease in LOC, Decrease Pulse, Decrease RR |
| What are some causes of Hypomagnesemia? | Diarrhea (loss of Mg in intestines), Alcoholism (it supresses ADH & its hypertonic, Not eating, Not drinking |
| What are some causes of Hypocalcemia? | Hypoparathyroidism, Radical Neck surgery, Thyroidectomy (all causing too little PTH) |
| What are the S/S of Hypo Mg & Hypo Ca++ | Rigid & tight muscle tone (watch for seizure), Stridor/Laryngospasm (airway = smooth muscle), +Chvostek's (tap cheek), +Trousseau's (hand flap w/BP cuff), Arrhythmias (heart = smooth muscle), Increased DTR's, Mind changes (psycho), Aspiration (esophagus = |
| What is the Tx for Hypo Mg? | Give Mg! |
| What is the Tx for Hypo Ca++? | Vitamin D (helps use Ca++), Amphogel (Phosphorous binding drug - when phos binds, makes it invisible, therefore Phos lowers and Ca++ rises), IV Ca++ |
| Always check what before and during IV Mg? | Kidney function |
| Always put pt on what when receiving IV Ca++? | Heart monitor b/c HR can drop and QRS can widen - a certain degree is appropriate - if too wide, give Epi & atropene, CPR and Code) |
| Hypo Mg and Hypo Ca++ will always be on what? | Seizure precautions due to rigid and tight muscles |
| What do you do if your pt begins to c/o flushing and sweating when you start IV Mg? | Assume the worst! |
| Your Na level in your body is totally dependent on what? | How much H20 you have in your body |
| Hypernatremia = | Dehydration (Too much Na; not enough H20) |
| Hyponatremia = | Dilution (too much H20; not enough Na) |
| What are some causes of HyperNa? | Hyperventilation (loss of H20 everytime you breathe), Heat stroke, DI |
| What are some causes of HypoNa? | Vomiting, Sweating then drinking H20 (this only replaces the H20, not hte electrolytes), Psychogenic Polydypsia (loves to drink H20), D5W (sugar & H20), SIADH (too much H20 being retained) |
| What are some S/S of HyperNa? | Dry mouth, Thirsty (already dehydrated by the time you're thirsty), Swollen tongue (w. severe Na increase), and NEURO CHANGES (brain doesn't like it when Na messed up - WILL KILL YOU!!!!) |
| What is the Tx of HyperNa? | Restrict Na, Dilute pt w/IV fluids (makes serum Na go down), Daily weights, I&O's, Lab work |
| Feeding tube pt's tend to become what? | Dehydrated |
| What is the Tx for HypoNa? | Pt needs Na, Pt does NOT need H20 |
| If a Hyponatremic pt is having neuro problems - what do you do? | The pt needs hypertonic saline (means "packed with particles" - pushing pressure), 3-5% NS |
| Na acts like a sponge, meaning what? | FVE and Pulmonary edema |
| K+ is excreted by what? | Kidneys |
| If the kidneys are not working well, what happens to the serum K+ levels? | Increases |
| Hyperkalemia is what? | Too much potassium |
| Hypokalemia is what? | Too little potassium |
| What are some causes of HyperK+? | Kidney troubles and Aldactome |
| What are some causes of HypoK+? | Vomiting, NG Suction, Diuretics and Not eating |
| What are some S/S of HyperK+? | Muscle twitching, then proceeds to weakness, then flacid paralysis |
| What are some S/S of HypoK+? | Muscle cramps and weakness |
| What are the PRIORITY S/S of Hyper & HypoK+? | Life Threatening Arrhythmias: VTach, VFibb and Asystole |
| What is the Tx for HyperK+? | Dialysis (Kidneys aren't working), CA++ Gluconate (decreases arrhythmias), Glucose & Insulin, Kaexalate(exchanges Na for K+ in the GI tract) |
| What is the Tx for HypoK+? | Give K+!!, Aldactone and Eat K+ |
| What kind of relationship does Na and K+ have? | Inverse |
| What is the major problem with PO K+? | GI upset so give with food |
| Assess what before and during IV K+? | UO |
| Always give IV K+ how? | On a Pump |
| Always do what with K+ before giving? | mix well so no bolus |
| Does K+ burn during infusion? | YES! |
| Is it OK to add to a bag that's already up and running? | NO, start over again with a new bag |
| What are the 2 major chemicals that must be remembered? | Bicarb (base) and H, CO2 (acid) |
| What is the "lung chemical"? | CO2 (acid) |
| What is the "Kidney chemical"? | Bicarb and H (base and acid) |
| There is only one way to get rid of CO2 - what is it? | Exhale |
| Bicarb, H+, and CO2 can either make you sick or compensate. It depends on what? | On which IMBALANCE you have. |
| In Respiratory acidosis/alkalosis, which organs are sick? | Lungs |
| During a chemical imbalance in the lungs - what organ compensates? | The kidneys |
| What are the chemicals the kidneys use to compensate with? | Bicarb and H+ |
| In matebolic acidosis/alkalosis - which organs are sick? | Kidneys |
| During a chemical imbalance with the kidneys - what organ compensates? | Lungs |
| What is the only chemical the lungs have to compensate with? | CO2 acid |
| Do the lungs compensate slowly or quickly? | Quickly |
| Do the kidneys compensate slowly or quickly? | Slowly (3 days - but efficient) |
| What is Normal pH? | 7.35 - 7.45 (7.40) |
| In Metabolic Acidosis, what is sick, and what compensates? | Kidneys are sick, lungs compensate |
| In Respiratory Acidosis, what is sick, and what compensates? | Lungs are sick, Kidneys compensate |
| In Metabolic Acidosis What happens to the RR and why? | RR increases to blow off CO2 |
| In Resp Acidosis, what do the kidneys do to compensate? | Retain/secrete Bicarb into the blood stream |
| In figuring out if something is Metabolic or Respiratory, what do you always need to remember? | If all arrows are the same = M. If arrows are different = R. Look at pH level to determine if Acid or Alka |
| In Meta Alka, what is sick? | Kidneys |
| In Resp Alka, what is sick? | Lungs |
| In Resp Acid, what is the problem chemical? | too much CO2 (acid) = RR too shallow or pt not breathing = kidneys will compensate |
| Increased CO2 = | Decreased LOC and Decreased O2 |
| What drug helps correct Acidosis? | IV Bicarb |
| What's the first thing you think of with a restless pt? | Early Hypoxia!! |
| Cyanosis + Bradycardia = | Late Hypoxia!! |
| With a Hysterical pt, think? | Resp Alkalosis (hypERventilation) |
| With Resp Alka, how do you treat? | The kidneys will take 3 days to compensate, therefore have pt breathe into paperbag to force them to take back in CO2. Sedate pt if needed to slow down RR |
| If a pt is starving, what do you think? | Meta Acidosis. The fat is being broken down, therefore producing keytones, and keytones are acid |
| When a pt is vomiting, what do you think? | The body is losing acid, leaving the pt alkaline, therefore Meta Alkalosis |
| Pneumothorax = | Resp Acid |
| Pneumonia = | Resp Acid |
| Alka Seltzer / Antacids = | Meta Alka |
| NG to suction = | Meta Alka |
| Contusion to lung parenchyma = | Resp Acid |
| Broken Ribs = | Resp Acid |
| Pt getting lots of IVP Bicarb = | Meta Alka |
| Acidosis = | Hyperkalemia (acidosis makes K+ leak out of cell) |
| Alkalosis = | Hypokalemia (alkalosis pushes K+ back into the cell) |
| Highest risk of death with a burn is with what population? | Very old and young |
| Where so burns most occur? | In the home |
| With a burn, why does plasma seep out into the tissue? | Increased capillary permeability |
| When does the majority of plasma seepage occur with a burn? | In the first 24H |
| Why does a pt's pulse increase with a burn? | Anytime you're in a FVD, pulse increases to compensate |
| What does the UO decrease with a burn pt? | Kidneys are either trying to hold on or they aren't being perfused |
| What is epi secreted in a burn pt? | Makes the ot vasoconstrict, shunts blood to vital organs |
| Why are ADH and aldosterone secreted with a burn pt? | to retain Na+ and H20 with aldosterone and retain H20 with ADH = therefore the pt's blood volume will go up |
| What is the most common airway injury with a burn pt? | Carbon Monoxide poisoning |
| Tell about CO binding with burn pt's | Normally O2 should bing w/hemoglobin. CO can run much faster then O2...therefore, it gets to the hemoglobin 1st & binds |
| Can CO levels be determined with a pulse Ox (pulse sat)? | NO, the pulse ox just shows how much hemoglobin is bound - but bound to what we don't know |
| What determines how much CO is bound in a burn pt? | Carboxyhemoglobin; blood test to determine carbon monoxide poisoning |
| If pt is hypoxic, what is the Tx? | 100% O2 (the ONLY time a pt is allowed 100% levels) |
| Why should you always determine where a burn occured? | If open space, <chance of CO poisoning. If closed place, >chance of CO poisoning |
| When you see a pt with burns to the neck / face / chest you had better think of what? | Airway! May need to intubate then trach |
| A pt is burned over 40% of their body. How is that figure determined? | Rule of nines |
| Rule of nines: Head = | 9 |
| Rule of nines: Each arm = | 9 |
| Rule of nines: Each leg = | 18 |
| Rule of nines: Anterior trunk = | 18 |
| Rule of nines: Posterior trunk = | 18 |
| Rule of nines: Genitalia = | 1 |
| One of the most important aspects of burn mgmt is what? | Fluid Replacement |
| Why is albumin given after a major burn? | Albumin holds onto fluid in the vascular space |
| What effect does albumin have on the kidneys w/ a burn pt? | It increases kidney perfusion |
| What effect does albumin have on BP w/ a burn pt? | Increases BP |
| What effect does albumin have on Cardiac Output w/ a burn pt? | Increases CO |
| When giving a burn pt albumin, why do you really have to watch the heart? | When you give albumin, the vascular volume will increase, therefore increasing the workload of the heart. The heart could be stressed, causing FVE |
| If FVE happens with a burn pt, what happens to the cardiac output? | It decreases. You will hear wet, crackle sounds |
| On any pt who is receiving fluids rapidly, what must be monitored so overload does not occur? | CVP (Cardia Vascular Pressure) |
| Why is it important to know what time the pt's burn occured? | Fluid therapy (for the 1st 24H) is based on the time the injury occured, not when Tx was started |
| If a burn pt's CVP increases suddenly during IV fluids, what do you watch for? | R sided Heart failure |
| What is the Parkland Formula for Burn Pt's? | Calculate what is needed for the first 24H and give 1/2 of it during the first 8H, 1/4 of the total volume the 2nd 8H, then the remaining 1/4 the 3rd 8H |
| To calculate fluid replacement for burn pt's (Parkland Formula) what do you need to know? | The pt's weight in kg and TBSA (total body surrface area) |
| If a burn pt is restless, what 3 things could it mean and which is PRIORITY? | Fluid replacement is inadequate, pain or hypoxia. Hypoxia is priority |
| Always check what to determine if a burn pt's fluid volume is adequate? | UO |
| A pt was given only 5mg of Morphine when the order was for a max of 10mg. Why did the nurse do this? | The pt's RR is shallow; give the least amt first; use judgement |
| Why are IV pain meds preferred over IM with burns? | They act faster. No muscle with good perfusion for IM |
| Why is a burn pt given a tetanus toxoid + the immune globulin? | For antibodies |
| Explain the Tetanus Toxoid shot with burn pt's? | Active immunity; takes 2-4 weeks to get the AB's |
| Explain the Immune Globulin with burn pt's? | Passive immunity; think immediate protection |
| Does more death's occur with upper or lower body burns? | Upper; b/c of airway |
| A pt has a circumferential burn on their arm. What does this mean and what should you be checking? | a burn all the way around the arm and cuts off circulation. Check skin color, skin temp, capillary refill, and pulse |
| If a pt's vascular checks in his burned arm (circumferential) are bad, the Dr may do what procedure to relieve pressure? | Escharotomy or Faciotomy |
| A pt was wrapped in a blanket to stop the burning process. Since the flames were gone does that mean the burning process had stopped? | No (apply cool H20 also) |
| What purpose does blankets on a burn pt do? | Stops the flames, holds in body heat and keeps out germs |
| Can ice be put on burns? | NO, ice will cause vasoconstriction therefore cutting off circulation |
| Why is it important to take off jewerly on a burn pt? | Swelling |
| What things do you look for to determine if any airway injury has occured w/ a burn pt? | Soot on face, dark sputum, synged facial/nasal hair |
| Is a foley inserted with burn pt's | Yes and measured hourly. Brown/red UO is normal after a major burn, but still worry |
| Is it possible that when you insert a foley on a burn pt that no urine will return? | Yes due to kidneys attempting to conserve the fluid or not perfusing properly |
| What drugs might be ordered for a burn pt to help kidneys perfuse? | Lasix, Butnex, Dobuatonine, Dopamine |
| Why will a burn pt start to diurese after 48H? | Because the fluid is going back into the vascular space. Now worry about FVE. UO should increase during this time |
| K+ always like to live where? | Inside the cell |
| Pot is IN, Na+ is OUT | Pot is IN, Na is OUT |
| With a burn, what happens to the cells? | Rupture |
| What happens to serum K+ levels during a burn? | It increases. The K+ seeps out of the cell and into the vascular space |
| Watch K+ levels to go which way with burn pt's? | HypERK+ |
| Why is Mylanta, Protonix, Pepcid, and Reglan ordered for burn pt's? | Curling or stress ulcers |
| Name 4 Antacids: | Aluminum hydroxide, Amphogel, magnesium hydorxide and Milk of Magnesia |
| Name 3 H2 Antagonist: | Zantac, Pepcid and Axid |
| Name 2 PPI's: | Protonix and Nexium |
| Why would a Dr want a burn pt to be NPO and have an NGT hooked to suction? | Paralytic Ilius |
| If a burn pt doesn't have bowel sounds, what will happen to the addominal girth? | It will increase |
| Will a burn pt need more or less calories than before the burn? | More calories |
| If a burn pt has an NG tube, when will it be removed? | When bowel sounds are present |
| When you start GI feedings with a pt, what could you measure to ensure that the supplement was moving through the GI tract OK? | Check residual. If too much residual present, pt can vomit and could aspirate |
| What must you always do when checking residual with a GI tube? | Put the residual back in pt |
| What is some lab work you could check with a burn pt to ensure proper nutrition and a positive nitrogen balance? | Total protein or albumin |
| If a pt has 2nd and 3rd degree burns, is it possible that they could have problems with contractures? | Yes |
| If a pt has burns on their hands, what are some specific measures that may be taken? | Wrap fingers seperatly and use splints |
| If a pt has burns to his nexk, what are some specific measures that may be taken? | Hyperextend the neck and NO pillows |
| If a pt has a perineal burn, what do you think the #1 complication will be? | Infection |
| What is eschar? | Dead tissue |
| Does eschar have to be removed? | Yes |
| What type of isolation will a burn pt be in? | Reverse / Protective |
| If eschar is not removed, can new tissue regenerate? | No |
| What likes to grow in eschar? | Bacteria |
| What is Travase / Collagenase? | An enzymatic drug that eats dead tissue. They debride and very potent |
| What are the "DONT'S" with Travase / Collagenase? | Don't use on face, Don't use if pregnant, Don't use over large nerves, and Don't use if area open to a body cavity |
| What is also used to debride eschar from burn pt's? | Hydortherapy |
| What must be done before ANY debridement is done with burn pt's? | Give pain meds and allow them to kick in |
| What are the 4 Common Drugs used with burns? | Silvadine, Sulfamylon, Silver-nitrate and Betadine |
| Describe the drug Silvadene: | For burns, soothing, spply directly, if rubs off apply more, can lower the WBC, can cause rash |
| Describe the drug Sulfamylon: | For burns, can cause acid-base problems, stings, if it rubs off apply more (check allergy to sulfa????) |
| Describe the drug Silver-Nitrate: | For burns, keep these dressings wet, can cause electrolyte problems |
| Describe the drug Betadine: | For burns, stings, stains, allergines, can cause acid-base problems |
| What should the 4 common Burn drugs be alternated? | The bacteria will build a resistance |
| Why will broad spectrum antibiotics be avoided with burn pt's until the wound cultures have returned? | To prevent super-infections |
| If grafting is done on a burn pt, a pressure dressing will be applied is surgery. At what point will the wound be left open to air? | When the bleeding has stopped |
| If a skin graft with a burn pt becomes blue or cool, what does this mean? | Poor circulation - CALL DR! |
| Sometime with a burn pt, the Dr will order for you to roll sterile Q-tips over the graft with steady, gentle pressure from the center of the graft to the outer edges. Why? | So new skin will adhere |
| If a pt has a chemical burn, what do you do? | Flush with H2O. If powder chemical, dust off, then H2O |
| If a pt has an electrical burn there will usually be 2 wounds. What are they? | Entrance and exit. |
| With an electrical burn, tell about the "Iceburg Effect". | The entrance wound will be deceiving. Could be very small, but every organ in path will be destroyed. |
| If a pt comes in with an electrical injury what is the 1st thing you should do? | Heart monitor 24H |
| What type of arrhythmia is an electrical burn pt at high risk for? | V Fibb (shock before airway!) |
| With electrical burn toxins can build up and cause damage to what organ? | Kidneys |
| It is common for an electricla burn pt to be put on this.... and why? | A spine board with a c-collar. Electrical injuries usually tend to occur in high places where falls occur |
| Are amputations common with electrical burns? | Yes b/c electricity kills vascularity |
| What are some other complications of electrical wounds? | Cataracts, gait problems, and just about any type of neurological deficit |
| If you've never heard of it... | Nobody else has either! |
| If you know the subject matter well... | It will not be on the NCLEX |
| A question would not be asked... | Unless there is a problem |
| If there is something you can do to help the problem, you do that first... | Instead of calling the Dr, or anything that delays Tx |
| Always assume... | The worst |
| Drugs + SE = | Problem |
| If NCLEX questions states PRIORITY... | Look for the killer answer |
| Always go for the least invasive... | Procedure first |
| Pain never killed anyone... | Go to killer ranswer first |
| RR should always be perfect... | If too high or low = Problem |
| After surgery, Never pick high fowlers after PostOp... | Pick next to closest |
| If you can only do one thing between calling the Dr and checking the vitals... | Call the Dr |
| Kidney Dx = | Limit protein |
| Diabetes + Illness = | DKA |
| On pacemakers, worry if the Heart rate ... | Drops lower than the set rate |
| If you get an artery question... | Figure out what that artery feeds - that will be the answer |
| Seek out depressed pt's... | Get out from the nurses station |
| When dealing with suicide pt's, be very .... | Direct such as "Are you thinking of killing yourself"? |
| When using retraints, always use as... | The last resort and always check 1) Hydration, 2) Nutrition, and 3) Elimination |
| When a pt needs to exercise anger out... | Pick the answer that exerts the most energy without harm to pt or others (punching bag) |
| When a pt is having a hallinication... | Get them out of the hallway and back into reality |
| When putting pt's in room assignments... | Like illnesses can be placed together - EXCEPT HIV |
| Plan to protect your pt, even when you are not there... | Always plan that the next nurse is not very bright |
| On giving report, plan that the next nurse is not very bright... | Give the most life threatening info first |
| When a pt is given normal S/S in an NCLEX question... | Red flag |
| Never decrease CO in pregnant women... | Fetus will not get blood |
| Priority NCLEX questions = | Killer answer; or something to do or they will die |
| Tachycardia Postpartum = | Hemorrhage |
| Alcohol + Tobacco = | Co-Carcinogenic |
| What is the #1 cause of preventable cancer? | Tobacco |
| What are the suspected dietary causes of Cx? | Low fiber diet, Increased red meat, Increased animal fat, Nitrates (processed sandwich meat), Alcohol, and Preservatives and additives |
| Why is there an increased of Cx for people > age 60? | Immunosuppressed |
| What is the most important risk factor for Cx? | Aging |
| What could decrease risk of Cx? | Cruciferous Veggies )broccoli, cauliflower, and cabbage) and Vit A foods (colored veggies), and Vit C |
| Do African Americans have a greater risk for Cx than caucasians? | Yes |
| What is Primary prevention for Cx? | Ways to actually prevent the occurrence of Cx such as sunscreen and no smoking |
| What is Secondary Prevention of Cx? | Using screenings to pick up on Cx early when there is a greater chance for cure or control |
| Chronic ________ brings about uncontrolled growth of abnormal cells? | Irritation |
| What are the Female checks for Cx? | 1) Monthly self breat exams (day 7-12), 2) Yearly clinical breast exam >40yrs old, 3) Annual pelvic exam (Q3Y if no problem), 4) Pap smear Q3Y if no problem, 5) Mommogram baseline at 35-40, yearlty after 40, 6) Yearly colonoscopy at age 50 |
| What are Male Cx checks? | 1) Monthly self breast checks, 2) Yearly digital rectal exam and yearly PSA for >50, 3) Yearly colonoscopy at age 50 |
| What is CAUTION with Cx? | C=Change in bowel/bladder habits, A=A sore that doesn't heal, U=Unusual bleeding/discharge, T=Thickening or lump, I-Indigestion or difficulty sweallowing, N=Nagging cough or hoarseness |
| Cx can invade bone marrow which leads to what? | Anemia and thrombocytopenia |
| What is Cachexia? | Extreme wasting and malnoutrition; close to death |
| What are the 2 types of Radiation? | 1) Internal (brachytherapy) and 2) External (teletherapy or bean radiation) |
| Tell about brachytherapy. | The radioactive source is inside the pt; radiation is being emitted |
| What are the 2 types of Brachytherapy? | 1) Sealed or Solid and 2) Unsealed |
| Tell about Unsealed Brachytherapy | Pt and body fluid emits radiation; Isotope is given IV or PO; Usually out of system in 48H |
| Tell about Sealed or Solid Brachytherapy. | Body fluids are NOT radioactive; Implanted close to or in the tumor |
| Do radioactive implants eit radiation to the general environment? | Yes |
| With radioactive pt's, should the nursing assignements be rotated? | Yes on a daily basis so no one nurse gets that pt continously |
| How many radioactive pt's can a nurse take on during each shift? | 1 |
| What are the precautions with a radioactive pt? | Private room, Restrict visitors, No preggo nurses/visitors, Mark the room, Wear a film badge at all times, Limit visitors to 30minQD, Visitors must stay 6ft away, No visitors <16yrs = These pt's will become depressed!!! |
| How do you prevent a dislodgement of a radioactive implant in a Cx pt? | Keep the pt on bedrest, Decrease fiber in diet, Prevent bladder distention |
| What do you do if a radioactive implant in a Cx pt becomes dislodged and you see it? | 1) Put on gloves, 2) Pick it up with thongs, 3) Put it in a lead lined container |
| What are the Usual SE of Teletherapy or Beam Radioaction (usually limited to exposed tissues)? | Erythema, Shedding of skin, Altered taste, Fatigue, Pancytopenia (all blood components are decreased) |
| Is it OK to wash off the markings from teletherapy or beam radiation? | NO |
| What must you teach the pt of Teletherapy or Beam radiation? | Protect the site from the sun for 1Y after completion of therapy |
| Explain Chemotherapy | Works on the cell cycle, Usually scheduled Q3-4 weeks, most chemo drugs are given IV via port, Many absorb through the skin and mm; be careful handeling them |
| What are the usual SE of chemo? | Alopecia, N/V, Mucositis, immunosuppression, Anemia, Thrombocytopenia |
| A pt's WBC must be at what level before they are allowed chemo? | 3000 (normal is 5-10K) |
| What is a vesicant? | A type of chemo drug that if it infiltrates (extravates) will cause tissue necrosis |
| What are the S/S of Extravasation? | 1) Pain, 2) Swelling, and 3) No blood return |
| If you are giving a vesicant drug, what should you do? | Stay with the pt during the Tx |
| What is the #1 thing to remember with Extravasation? | Prevention |
| What do you do is Extravasation occurs? | 1) Stop infusion, 2) Ice packs to site to promote vasoconstriction, 3) Call Dr |
| What are dome general ways to prevent infection? | Private room, Wash hands, Limit people in room, Change dressings QD, Cough and deep breath, No fresh flowers, Avoid crowds, Bathe warm moist areas 2XQD, Avoid raw fruits & veggies, Drink only fresh H20 (no more than 15min old) |
| What could a slight increase in temp with a Cx pt mean? | Sepsis |
| What is very important with a Cx Pt? | Absolute neutrophil count |
| What are the risk factors for cervical Cx? | Sex/preggo at early age, repeated STD's (irritation) |
| How does Cervial Cx present? | Often asymptomatic in pre-invasive Cx, Painless vaginal bleeding in Invasive Cx stage |
| What is the #1 Invasive Cx classic S/S for Cervical Cx? | PAINLESS vaginal beeding |
| What are general S/S of cervical Cx? | Watery, blood-tinged vaginal discharge, leg pain along sciatic nerve, and back/flank pain |
| What is the prognosis with cervial Cx? | 100% cure if detected early |
| What is the best test to do for cerviacl Cx? | Pap smear |
| What is the Tx for cervial Cx? | 1) Electrosurgical excision, laser or cryosurgery, 2) Radiation and chemo for late stages, 3) Conization (remove part of hte cervix, 4) Hysterectomy |
| What are the risk factors for Uterine Cx? | >50yrs old, Family Hx, Late menopause, No pregnancy |
| What is the Major S/S of Uterine Cx? | Post menopausal bleeding |
| What are general S/S of Uterine Cx? | Watery/bloody vaginal bleeding, Low back/abd pain, pelvic pain |
| What is the Dx for Uterine Cx? | CA-125 (blood test) to R/O ovarian involvement |
| What are the test to c heck for metastasis for Uterine Cx? | CXR, IVP, BE, CT, Liver and bone scan |
| What is the most definitive Dx test for Uterine Cx? | D&C and endometrial biopsy |
| What is the Tx for Uterine Cx? | 1) Surgery, 2) Radiation, 3) Chemo, and 4) Estrogen inhibitors |
| Tell about the different surgeries for Uterine Cx? | 1) Hysterectomy |
| What is a TAH | Total Abd Hysterectomy = uterus and tubes only! |
| What si a Bilateral Oophorectomy? | Tubes and ovaries are removed |
| What is a Bilateral Salpingectomy? | Fallopian tubes are removed |
| What is a Radical Hysterectomy? | May remove all of hte elvic organs; pt may have a colostomy, ileal conduit |
| What is the greates risk time for hemorrhage following a Radical Hysterectomy? | THe first 24H, why? Pelvic congestion of blood |
| What is the major complication for Abd hysterectomy? | Hemorrhage |
| What is hte major complication for a Vaginal hysterectomy? | Infection |
| Pt's must always void within how my H after a floey is taken out or after surgery? | 8H |
| What is it important to prevent abd distension after a radical hysterectomy? | Do not want tension on the suture line, and watch for dehiscence and evisceration |
| Whay do we avoid high folwers after a hysterectomy? | blood to pelvis |
| What is 1 thing that you can do to prevent pneumonia, thrombophlebitis, and constipation with a pt that has has a hysterectomy? | Early ambulation |
| What do you teach the pt that has had a hysterectomy? | No sex and driving, avoid girdles/douches, avoid lifting heavy objects, and no baths, shower only |
| Pt's that have had a hysterectomy are at risk for hemorrhage how many days after surgery? | 10-14 DAYS |
| What are the chemo drugs given for uterine Cx? | Doxorubicin and Cisplatin |
| What are estrogen inhibitors given for Uterine Cx? | Depro-Provera, Tomoxifen and Novadex |
| What are the risk factors for developing Breast Cx? | Period onset prior to age 12, Menopause after age 50, No preganancies, First birth greater than age 30 |
| What are the S/S of Breast Cx? | Orange peel appearance, dimpling, retraction, discharge from breast, or lump |
| Where so most Breast Cx tumors originate? | Tail of Spence; 80% |
| When a pt has had surgery for breast Cx, where should the dressing always be checked? | In the back for pooling, pt may have hemovac or a JP drain |
| #1 fact to know about a pt after surgery for breast Cx: | Stay away from arm on affected side for lifetime of pt! = no constrictions, no BP's, no injections, wear gloves during gardening, watch small cuts, no nail biting and no sunburn |
| Pt that has had surgery for breast Cx will have a lot of problems with what area? | Psyc |
| What are the chemo drugs for Breasrt Cx? | Taxol, Adriamycin |
| What are the estrogen inhibitor drugs for Breast Cx pt's | Tomxifen, Nolvadex and Tamofen |
| What are the estrogen synthesis inhibitors for Breast Cx pt's? | Lupron and Zoladex |
| What is the 5yr survival rate for lung Cx pt's? | 14% |
| What is the #1 thing to watch for with the pt after a bronchoscopy? | NPO pre and NPO until gag reflex returns |
| When is the best time to obtain a sputum specimen from a pt? | 1st thing in the morning and it is sterile, but hte pt needs to rinse their mouth out first to get rid of some bacteria from the night |
| What is a lobectomy and how do you position the pt? | Removal of part of a lobe and position good lung down to enhance perfusion; this pt WILL have chest tubes |
| What is a Pneumonectomy and how do you position that pt? | Removal of hte entire lung and position bad lung down to fill cavity with blood, this pt WILL NOT have chest tubes |
| Avoid what position in pt's with any surgery on thier lungs? | Lateral position due to mediastinal shift |
| A pt that undergoes a total laryngectomy will have a permanent what? | trachestomy |
| Pulsating trach = | BAD, call Dr, nothing you can do |
| What is a Total Laryngectomy? | Removal of vocal cords, epiglottis and thyroid cartilage |
| What is hte procedure for suctioning through a trach | Sterile technique, hyperO2 b4 and after, 10sec incriments, rotate going up, never suction placing down trach, watch for arrhythmias, the nagus nerve can be stimulated so watch for hte HR to drop |
| What is the most frewuent site for metastasis with colorectal Cx? | Liver |
| What are things that should be avoided for 48H prior to a stool sample? | ASAs, Vit C, any antiinflammatory drugs, and perioxidase containing foods such as beets, horseradish, etc... |
| What is a Colectomy? | Part of teh colon removed |
| What is a Abdomino-Perineal Resection? | Removal of colon, anus and rectum |
| What is the major S/S of Bladder Cx? | Painless intermittent gors/microscopic hematuria |
| UOP is always lowest when? | In the am due to pt not drinking surng the night |
| What does a lab report of elevated Alkaline Phosphatase mean in a pt with Prostate Cx? | Bone metastasis; Prostate Cx like to go to hte spine, sacrum and pelvis |
| What is the Tx for a pt with early stage of prostate Cx? | Watchful waiting for asymptomatic or older adults with other illnesses |
| What is a TURP? | Transurethal Resecion of the Prostate |
| Should you ever hand or manually irrigatecatheter with a fresh surgery without a surgeons order? | NO!! |
| When given a priority question, always assess pt prior to what? | an implementaion answer!! Remember to always assess pt first |
| What are the hormone drugs that men will receive for prostate Cx? | Estrogens and Lupron |
| What is the #1 S/S for Stomach Cx? | Heart burn and and discomfort |
| What are general S/S of stomach Cx? | Loss of apetite, weight loss, bloody stools, coffee-ground vomitus, jaundice, apigastric and back pain, feeling of fullness, anemia, stool + for occult blood, etc... |
| After a pt has had a Gastrectomy, what position do you place them in? | Semi-flwlers to decrease stress on the suture line |
| What to always remember with the stomach? | No stomach --> no intrinsic factor --> can't absorb B-12 --> can't make good RBC's --> will need B-12 injections for life |
| The thyoid produces what the hormones? | T3, T4 and Calcitonin |
| You need what to make the thyroid hormones? | Dietary Iodine |
| Too many thyroid hormones = | Hyperthyroidism aka Graves DX |
| What does the serum T4 level look like in a Hyperthyroidism pt? | Increased |
| What is the Tx for Hyperthroidism? | Propacil, PTU and Tapazole (all make hte thyroid stop producing T4 |
| How do you give Iodine Compounds? | Give in milk and juice ; use a straw |
| What are the Tx to Hyperthyroidism? | 1) Antithyroids (Propacil, PTU, Tapazole), 2) Iodine Compounds (K+ Iodide, Lugol's solution, SSKI), 3) BBlockers (Inderol, decreases HR, BP), 4) Radioactive Iodine (1 dose, destroys thyroid cells), and 5) Surgery (partial/complete) |
| What are the BIG RULES about giving BBlockers? | Do NOT give to Asthmatics or Diabetics because they can bring on an asthma attack and they mask hypoglycemia |
| What do you always assess for afterthyroid surgery? | #1 Airway and Look for S/S of parathyroid accidentally being removed such as Tight muscles, twitching, seizure, etc... |
| What are the RULES for Radioactive Iodine? | Stay away from babies and do not kiss anyone for 24H |
| What is Hypothyroidism aka Myxedema? | Too little thyroid hormones |
| What are the S/S of Hypothyroidism aka Myexedema? | Fatigue, GI upset, Cold, slurred speech, no expression *this could be confused with depression |
| What is the Tc for Hypothyroidism aka Myexedema? | Synthroid, Proloid, Cytomel = will take meds forever |
| Pt's with Hypothyroidism tend to have what other Dx? | Coronary Artery Dx, watch for chest pain, arrythmias, etc... when giving meds to these pt's |
| What does the parathyroid secrete? | PTH, which makes you pull Ca++ from the bones and place it into the blood. THerefore the serum Ca++ level goes UP |
| If you have too much PTH in your body, what will the serum Ca++ look like? | UP |
| If you have too little PTH in your body, what will your serum Ca++ look like? | Down |
| REMEMBER: Hyperthyroidism = Hypercalcemia = Hypophosphatemia | REMEMBER: HyperPTH = HyperCa++ = HypoPhosphatemia |
| Ca++ acts like what to the body? | Sedative |
| What is the Tx for HyperPTH? | Partial parathyroidectomy, when you take out 2/4, the secretion decreases |
| REMEMBER: Hypoparathyroidism = Hypocalcemia = Hyperphosphate | REMEMBER: HypoPTH = HypoCa++ = Hyperphosphatemia |
| What is the Tx for HypoPTH? | Anphogel (it binds Phos and makes it invisible, *watch for pt to bottom out with Ca++ so they may have heart arrythmias and seizures |
| What has an inverse relationship with Ca++? | Phosphate |
| When given a PTH question on NCLEX, only answer what? | Ca++ answer |
| What are the 2 parts to the Adrenal? | Adrenal Medulla and Adrenal Cortex |
| What does the Adrenal Medulla secrete? | Your catacholemines: Epi and Norepi |
| What does the Adrenal Cortex secrete? | Glucocortoids, Mineralocorticoids and Sex Hormones |
| What does Glucocorticoids doto the body? | Changes you mood, Alters defence mechnisms (lowers immune), Breakdown of fat/protein, and Inhibits insulin (raises Bsugar = check fingersticks) |
| What do Mineralocortoids do to your body? | Makes you retain Na+ and H2O, Makes you lose K+ |
| What do lab values look like with too much Mineralocortoids in the body? | FVE, too much Na+ and H2O and too little K+ |
| What do lab values look like with too little mineralocortoids in the body? | FVD, too little Na+ and H2O and too much K+ |
| What is the problem called and what is it when you have a problem with the Adrenal Medulla? | Pheochromocytoma: BP raises, Pulse raises and flushing/Diaphoretic |
| WHen doing a 24H urine test, what should you do? | Discard the first am void and save the last void |
| What has an inverse relationship with K+? | Na+ |
| ACTH means the same thing as what? | Cortisol aka Steroids (they refer to the hormones of the Adrenal Cortex |
| Too many steroids = ? | Hypercortisolism |
| When you hear Adrenal Cortex, think what? | Steroids |
| When you hear Addisons Dx, think what? | Add Steroids (pt has too little) |
| What are the S/S of Addison's? | Anorexia/N, Decreased bowel sounds, GI upset, Hypoglycemia, Dark palms, Vitiligo (white patchy areas on skin) |
| When you hear Addison's Dx, what hormone should you think of? | Aldosterone = Normally Aldosterone makes us retain Na+ and H2O and lose K+, this is NOT happening, it is opposite |
| What is the Tx for Addison's? | Prevent shock! Losing Na+ and H2O, pt's BP will be going down due to FVD |
| It a pt soes not have enoung Aldosterone (Addison's Dx), what drug will be given? | Florinef |
| What must be checked when giving a pt Florinef (for Addison's) | Weight - it will help in adjusting the med |
| What is hte RULE with weight and meds? | Keep pt's weight within +- 2lbs of their norm |
| Addison's Crisis = | Severe HypoTSN and Vascular Collapse |
| Why must Steroids be tapered off? | When giving synethic steroids, your Adrenal Cortex stops making them, if stop abruptly, you will have NONE |
| Are steroid doses always chaning? | Yes |
| Cushings Syndrome = | Too MANY steroids (opposite of Addisons) : Exogenous administration such as someone taking steroids for something |
| Cushings Dx = | Too many steroids (opposite of Addisons) : Endogenous (inside body such as bilateral adrenal hyperplasia, etc... |
| S/S of too many Glucocorticoids (Cushings) | Growth arrest, Thin extremities/skin, Increased risk for infection, Hyperglycemia, Psychosis to depression |
| S/S of too many Sex Hormones (Cushings) | Central obesity, buffalo hump, heavy trunk, oily skin.acne, women w/male traits, Poor sex drive |
| S/S of too many Mineralocortoids (Cushings) | High BP, CHF, weight gain, moon face |
| Anytime steroids are messed up = | pt can not handle stress |
| Steroids decrease what? | Ca++ by making you excrete it through GI tract |
| What may be he first sign of Type 1 Diabetes? | DKA |
| What is hte patho pf DKA? | Since there is no insulin, hte glucose just builds up in the vascular space (blood)...the cells are starving so they break down protein/fat for energy...when you break down fat you get keytone acids...now pt is in Metabolic Acidosis |
| Hyperglycemia = | 3P's |
| What are the 3P's with Hyperglycemia? | Polyuria, Polydypsia and Polyphagia |
| What is the Somogyi Phenomenon? | Type 1 pt has normal and increased BS at bedtime, then BS drops in early am (~2-3am). Pt's body attempts to compensate by producing hormones to increase BS resulting in HYPERGLYCEMIA |
| What is the Tx for Somogyi Phenomenon? | Increase bedtime snack and decrease intermediate acting insulin (NPH, Lente) |
| What is the Dawn Phenomenon? | Resulting from a decrease in the tissue sensitivity to insulin that occurs between 5-8am (prebreakfast hyperglycemia) caused by a release of nocturnal growth hormones |
| What is the Tx for Dawm Phenomenon? | Give intermediate-acting insulin (NPH, Lente) at 10pm |
| Polyuria --> | Oliguria --> Anuria |
| Polyuria --> | Shock |
| What is hte Tx for Type 2 Diabetes? | Start with diet and exercise, then ass oral agents, then add insulin |
| What is the general Tx for Type 2 Diabetes? | Complex Carbs 55-60%, Fats 20-30%, Protein 12-20% (limit protein) |
| Why are diabetics prone to CAD? | Sugar deposits destroys vessels just like fat |
| Why should diabetics be on a high fiber diet? | It keeps the BS steady (may have to decrease insulin). High fiber slows down glucose absorption in the intestines, therefore eliminating the sharp rise/fall of the BS |
| What should the diabetic do pre-exercise to prevent hypoglycemia? | Eat a low carb snack |
| A diabetic should exercise at what BS point? | the highest |
| The diabetic should exercise at regular times, why? | you can train the BS |
| **How do you give mixed insulins????? | Air in cloudy, air in clear, draw up clear, draw up cloudy |
| What insulin is clear? | Regular |
| What insulin is cloudy? | NPH |
| What is the only type of insulin that can be given IV? | Regular |
| What is the Hemoglobin A1C test? | Blood test: gives an average of what the BS has been over the past 3 months |
| Diabetics should eat when? | When insulin is at it's peak: "Peak" = think Hypoglycemia |
| What happens to BS when you are stressed /sick? | It goes up; probably will need to increase dose |
| Should you aspirate insulin? | No, too much tissue trauma |
| What are the S/S of Hypoglycemia? | Cold, clammy, weakness, nervous, increased pulse, nausea, confusion, headache |
| What should the pt with hypoglycemia do? | Eat a simple sugar fast |
| You enter a pt's room and they are unconscious...do you treat as Hyper or Hypoglycemia????? | Hypo; that is the worst, brain damage. Give D50W, injectable glucogon when no IV site accessed |
| Diabetes + illness = | DKA |
| With every drop in BS, pt loses what? | Few brain cells |
| What are the IVFs with a pt in DKA? | Start w/NS, then when BS gets down to about 300 switch to D5W to prevent throwing the pt into Hypoglycemia (anticipate the Dr will order Ka+ to the IV solution at some point) |
| What is HHNK? | Looks just like DKA, but no keytones (acidosis) |
| DKA = | Type 1 |
| HHNK = | Type 2 |
| Diabetics will have what other problems related to Dx? | 1) Vascular problems (poor circulation, diabetic retinopathy, nephropathy), 2) Neuropathy (sex problems, foot/leg problems, neurogenic bladder, gastroparesis), 3) Increased risk for infection (full of sugar) |
Created by:
stacypoor
Popular Nursing sets