NCLEX Review - Medical/Surgical
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| show | Tachypnea, fever with chills, productive cough, bronchial breath sounds
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| show | Encourage deep breathing; increase fluid intake to 3 L/day; use humidity to loosen secretions; suction airway to stimulate coughing.
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| What symptoms of pneumonia might the nurse expect to see in an older client? | show 🗑
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| show | Deliver 100% O2 (hyperinflating) before and after each endotracheal suctioning.
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| During mechanical ventilation, what are three major nursing interventions? | show 🗑
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| When examining a client with emphysema, what physical findings is the nurse likely to see? | show 🗑
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| What is the most common risk factor associated with lung cancer? | show 🗑
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| show | Involve family and client in manipulation of tracheostomy equipment before surgery; plan acceptable communication methods; refer to speech pathologist; discuss rehabilitation program.
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| List five nursing interventions after chest tube insertion. | show 🗑
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| What immediate action should the nurse take when a chest tube becomes disconnected from a bottle or suction apparatus? What should the nurse do if a chest tube is accidentally removed from the client? | show 🗑
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| show | Do not wash off lines; wear soft cotton garments; avoid use of powders and creams on radiation site.
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| show | A mask for anyone entering room; private room; client must wear mask if leaving room.
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| List four components of teaching for the client with tuberculosis. | show 🗑
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| What should be checked if fluctuations (tidaling) in chest tube fluid ceases | show 🗑
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| show | Barrel chest is indicative of emphysema and is caused by use of accessory muscles to breathe. The person works harder to breathe, but the amount of O2 taken in is adequate to oxygenate the tissues.
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| show | Insufficient oxygenation occurs with chronic bronchitis and leads to generalized cyanosis and often right-sided heart failure (cor pulmonale).
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| show | Acute renal failure: often reversible, abrupt deterioration of kidney function. Chronic renal failure: irreversible, slow deterioration of kidney function characterized by increasing BUN and creatinine. Eventually dialysis is required.
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| During the oliguric phase of renal failure, protein should be severely restricted. What is the rationale for this restriction? | show 🗑
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| Identify two nursing interventions for the client on hemodialysis. | show 🗑
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| show | Risk for imbalanced fluid volume
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| show | Calcium and aluminum antacids bind phosphates and help to keep phosphates from being absorbed into bloodstream, thereby preventing rising phosphate levels; must be taken with meals.
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| show | Fluid intake 3 L/day; good handwashing; void every 2 to 3 hours during waking hours; take all prescribed medications; wear cotton undergarments.
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| What are the most important nursing interventions for clients with possible renal calculi? | show 🗑
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| What discharge instructions should be given to a client who has had urinary calculi? | show 🗑
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| show | The fourth day
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| After the urinary catheter is removed in the TURP client, what are three priority nursing actions? | show 🗑
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| After kidney surgery, what are the primary assessments the nurse should make? | show 🗑
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| What is a percutaneous nephrostomy | show 🗑
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| Signs of digoxin toxicity | show 🗑
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| What is the major difference between dialysate for hemodialysis and peritoneal dialysis | show 🗑
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| show | 1 mL/kg/hr; 1500-2000 mL/day
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| How do clients experiencing angina describe that pain? | show 🗑
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| Develop a teaching plan for a client taking nitroglycerin. | show 🗑
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| show | 140/90
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| show | Essential HTN has no known cause; secondary HTN develops in response to an identifiable mechanism.
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| show | Explain how and when to take medication, reason for medication, necessity of compliance, need for follow-up visits while on medication, need for certain lab tests, and vital sign parameters while initiating therapy.
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| Describe intermittent claudication. | show 🗑
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| Describe the nurse’s discharge instructions to a client with venous PVD. | show 🗑
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| show | Atherosclerosis
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| What lab values should be monitored daily in a client with thrombophlebitis who is undergoing anticoagulant therapy? | show 🗑
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| When do PVCs present a grave danger? | show 🗑
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| Differentiate between the symptoms of left-sided cardiac failure and right-sided cardiac failure. | show 🗑
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| List three symptoms of digitalis toxicity. | show 🗑
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| show | Hypokalemia (which is more common when diuretics and digitalis preparations are given together)
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| When should Digitalis be held | show 🗑
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| What lifestyle changes can the client who is at risk for HTN initiate to reduce the likelihood of becoming hypertensive? | show 🗑
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| What immediate actions should the nurse implement when a client is having a myocardial infarction? | show 🗑
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| show | Dry mouth and thirst, drowsiness and lethargy, muscle weakness and aches, and tachycardia
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| show | 60 bpm; 100 bpm
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| What precautions should clients with valve disease take prior to invasive procedures or dental work? | show 🗑
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| show | Synchronous, or demand: Pacemaker fires only when the client’s heart rate falls below a rate set on the generator. Asynchronous, or fixed: Pacemaker fires at a constant rate.
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| What is the antagonist for Heparin? | show 🗑
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| show | PTT at 1.5-2.5 times normal
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| What is the atntagonist for warfarin (Coumadin)? | show 🗑
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| What lab value determines the efficacy of warfarin (Coumadin)? | show 🗑
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| show | 10 to 20 mg/dL
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| show | 0.6 to 1.2 mg/dL
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| What medications/treatments should be administered with MIs | show 🗑
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| List four nursing interventions for the client with a hiatal hernia. | show 🗑
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| show | Antacids, H2 receptor blockers, mucosal healing agents, proton pump inhibitors
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| List the symptoms of upper and lower GI bleeding. | show 🗑
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| show | Early mechanical obstruction: high-pitched sounds; late mechanical obstruction: diminished or absent bowel sounds
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| show | Irrigate daily at same time; use warm water for irrigations; wash around stoma with mild soap and water after each ostomy bag change; ensure that pouch opening extends at least ⅛ inch around the stoma.
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| show | Scleral icterus (yellow sclera), dark urine, chalky or clay-colored stools
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| show | Fried, spicy, and fatty foods
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| List five symptoms indicative of colon cancer. | show 🗑
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| show | Avoid injections; use small-bore needles for IV insertion; maintain pressure for 5 minutes on all venipuncture sites; use electric razor; use soft-bristle toothbrush for mouth care; check stools and emesis for occult blood.
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| What is the main side effect of lactulose, which is used to reduce ammonia levels in clients with cirrhosis? | show 🗑
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| show | Homosexual males, IV drug users, those who have had recent ear piercing or tattooing, and health care workers
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| How should the nurse administer pancreatic enzymes? | show 🗑
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| What is fetor hepaticus | show 🗑
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| What are the recommendations for early detection of colon cancer? | show 🗑
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| show | T3, T4
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| show | Hypothyroidism, requiring thyroid replacement
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| State three symptoms of hyperthyroidism and three symptoms of hypothyroidism. | show 🗑
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| List five important teaching aspects for clients who are beginning corticosteroid therapy. | show 🗑
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| Describe the physical appearance of clients who have Cushing syndrome. | show 🗑
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| Which type of diabetes always requires insulin replacement? | show 🗑
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| Which type of diabetes sometimes requires no medication? | show 🗑
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| List five symptoms of hyperglycemia. | show 🗑
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| show | Hunger, lethargy, confusion, tremors or shakes, sweating
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| Name the necessary elements to include in teaching a client newly diagnosed with diabetes. | show 🗑
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| show | Draw up regular insulin first; rotate injection sites; may reuse syringe by recapping and storing in refrigerator.
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| Identify the peak action time of the following types of insulin: rapid-acting regular insulin; intermediate-acting insulin; long-acting insulin. | show 🗑
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| When preparing a client with diabetes for discharge, the nurse teaches the client the relationship between stress, exercise, bedtime snacking, and glucose balance. State the relationships among each of these. | show 🗑
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| When making rounds at night, the nurse notes that a client prescribed insulin is complaining of a headache, slight nausea, and minimal trembling. The client’s hand is cool and moist. What is the client most likely experiencing? | show 🗑
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| Identify five foot-care interventions that should be taught to a client with diabetes. | show 🗑
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| Why do clients with diabetes have trouble with wound healing? | show 🗑
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| What is Addison crisis | show 🗑
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| show | Chvostek sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. Trousseau sign is a carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes.
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| show | 9.0 to 10.5 mEq/L.
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| show | Propylthiouracil (PTU) and methimazole (Tapazole)
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| Differentiate between rheumatoid arthritis and OA in terms of joint involvement. | show 🗑
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| Identify the categories of drugs commonly used to treat arthritis. | show 🗑
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| show | Warm, moist heat (compresses, baths, showers); diversionary activities (imaging, distraction, self-hypnosis, biofeedback); and medications
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| What measures should the nurse encourage female clients to take to prevent osteoporosis? | show 🗑
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| What are the common side effects of salicylates? | show 🗑
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| show | Administer or teach client to take drugs with food or milk.
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| List three of the most common joints that are replaced. | show 🗑
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| show | Elevate residual limb (stump) for first 24 hours. Do not elevate residual limb (stump) after 48 hours. Keep residual limb (stump) in extended position, and turn client to prone position three times a day to prevent flexion contracture.
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| Describe nursing care for the client who is experiencing phantom pain after amputation. | show 🗑
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| A nurse discovers that a client who is in traction for a long bone fracture has a slight fever, is short of breath, and is restless. What does the client most likely have? | show 🗑
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| What are the immediate nursing actions if fat embolization is suspected in a client with a fracture or other orthopedic condition? | show 🗑
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| show | Venous thrombosis, urinary calculi, skin integrity problems
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| List three nursing interventions for the prevention of thromboembolism in immobilized clients with musculoskeletal problems. | show 🗑
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| show | avoiding sunglight is key in the management of lupus erythematosus
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| What are the classifications of the commonly prescribed eye drops for glaucoma? | show 🗑
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| Identify two types of hearing loss. | show 🗑
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| Write four nursing interventions for the care of the blind person and four nursing interventions for the care of the deaf person. | show 🗑
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| show | An objective assessment of the level of consciousness based on a score of 3 to 15, with scores of 7 or less indicative of coma
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| show | Ineffective breathing pattern, ineffective airway clearance, impaired gas exchange, and decreased cardiac output
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| show | Position for maximum ventilation (prone or semiprone and slightly to one side); insert airway if tongue is obstructing; suction airway efficiently; monitor arterial PO2 and PCO2; and hyperventilate with 100% O2 before suctioning.
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| show | Persons with histories of HTN, previous TIAs, cardiac disease (atrial flutter or fibrillation), diabetes, or oral contraceptive use; and older adults
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| Complications of immobility include the potential for thrombus development. State three nursing interventions to prevent thrombi. | show 🗑
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| show | Anoxia, distended bladder, covert bleeding, or a return to consciousness
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| show | Irrigation of eyes PRN with sterile prescribed solution, application of ophthalmic ointment every 8 hours, close assessment for corneal ulceration or drying
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| show | When peristalsis resumes as evidenced by active bowel sounds, passage of flatus or bowel movement
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| What is the most important principle in a bowel management program for a client with neurologic deficits? | show 🗑
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| show | A disruption of blood supply to a part of the brain, which results in sudden loss of brain function
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| show | Left
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| show | Right: impulsive, unaware, confabulates, euphoric, smiling, impaired humor; Left: slow, cautios, anxious when attempting new tasks, depression/catastrophic repsonse to illness, sense of guild, worthlessness, worried, quick to anger
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| Ehsy drugs are administered to Parkinson patients to control symptoms | show 🗑
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| What are the symptoms of spinal shock? | show 🗑
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| show | HTN, bladder and bowel distention, exaggerated autonomic responses, headache, sweating, goose bumps, and bradycardia
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| show | A change in the level of responsiveness
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| show | Increased BP, widening pulse pressure, increased or decreased pulse, respiratory irregularities, and temperature increase
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| A neighbor calls the neighborhood nurse stating that he was knocked hard to the floor by his very hyperactive dog. He is wondering what symptoms would indicate the need to visit an emergency department. What should the nurse tell him to do? | show 🗑
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| What activities and situations that increase ICP should be avoided? | show 🗑
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| show | They dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent reabsorption, and by drawing fluid from the extravascular spaces into the plasma.
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| Why should narcotics be avoided in clients with neurologic impairment? | show 🗑
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| Headache and vomiting are symptoms of many disorders. What characteristics of these symptoms would alert the nurse to refer a client to a neurologist? | show 🗑
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| How should the head of the bed be positioned for postcraniotomy clients with infratentorial lesions? | show 🗑
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| Is multiple sclerosis thought to occur because of an autoimmune process? | show 🗑
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| Is paralysis always a consequence of spinal cord injury? | show 🗑
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| show | Anticholinesterase drugs, which inhibit the action of cholinesterase at the nerve endings to promote the accumulation of acetylcholine at receptor sites; this should improve neuronal transmission to muscles.
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| Define Apraxia | show 🗑
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| Define Dysarthria | show 🗑
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| Define Dysphasi | show 🗑
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| show | loss of the ability to speak
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| show | loss of the ability to write
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| Define Alexia | show 🗑
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| Define Dysphagia | show 🗑
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| show | tremors (a coarse tremor of fingers and thumb on one hand that disappears during sleep and purposeful activity; also called “pill rolling”), rigidity, hypertonicity, and stooped posture.
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| show | ACTH, cortisone, cyclophosphamide (Cytoxan), and other immunosuppressive drugs. Nursing implications for administration of these drugs should focus on the prevention of infection.
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| show | Corticosteroids to reduce swelling; Agents and osmotic diuretics to reduce secretions (atropine, glycopyrrolate [Robinul]); gents to reduce seizures (phenytoin);Prophylactic antibiotics
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| show | 100 mL
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| show | Diet lacking in iron, folate, or vitamin B12; use of salicylates, thiazides, diuretics; exposure to toxic agents, such as lead or insecticides
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| Write two nursing diagnoses for the client suffering from anemia. | show 🗑
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| show | Normal saline
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| show | Turn off transfusion. Take temperature. Send blood being transfused to lab. Obtain urine sample. Keep vein patent with normal saline.
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| show | Use a soft toothbrush, avoid salicylates, do not use suppositories.
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| show | Oral cavity and genital area
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| show | Glandular meats (liver), milk, green leafy vegetables
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| show | Use strict aseptic technique. Change dressings two or three times per week or when soiled. Use caution when piggybacking drugs; check purpose of line and drug to be infused. When possible, use lines to obtain blood samples to avoid “sticking” client.
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| show | Double-check order with another nurse. Check for blood return. Use a new IV site daily for peripheral chemotherapy. Wear gloves when handling the drugs, and dispose of waste in special containers to avoid contact with toxic substances.
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| show | Leucovorin is used as an antidote with methotrexate to prevent toxic reactions.
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| Describe the method of collecting the trough and peak blood levels of antibiotics. | show 🗑
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| show | Protect from infection. Observe for anemia. Encourage high-nutrient foods. Provide emotional support to client and family.
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| show | Handwashing technique. Avoid infected persons. Avoid crowds. Maintain daily hygiene to prevent spread of microorganisms.
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| show | Severe menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics, severe uterine enlargement causing pressure on other organs, severe low back and pelvic pain
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| List the symptoms and conditions associated with a cystocele. | show 🗑
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| show | Avoid taking rectal temperatures and rectal manipulation; manage pain; and encourage early ambulation.
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| show | Do not permit pregnant visitors or pregnant caretakers in room. Discourage visits by small children. Confine client to room. Nurse must wear radiation badge. Nurse limits time in room. Keep supplies and equipment within client’s reach.
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| show | Pap smear. Women ages 30 to 70 with three consecutive normal results may have Pap smears every 2 to 3 years (screening for HPV).
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| show | Altered body image related to uterine removal; pain related to postoperative incision
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| show | Breast self-examination monthly; mammogram baseline at age 35, followed by exams every 1 to 2 years in 40s and every year after age 50; physical examination by a professional skilled in examination of the breast
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| show | Position arm on operative side on pillow. Avoid BP measurements, injections, and venipunctures in operative arm. Encourage hand activity and use.
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| Name three priorities to include in a discharge plan for a client who has had a mastectomy. | show 🗑
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| show | Chlamydia trachomatis
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| What is the causative organism of syphilis? | show 🗑
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| Malodorous, frothy, greenish-yellow vaginal discharge is characteristic of which STD? | show 🗑
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| Which STD is characterized by remissions and exacerbations in both males and females? | show 🗑
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| show | Signs and symptoms of STD; mode of transmission; avoiding sex while infected; providing concise written instructions regarding treatment, and requesting a return verbalization to ensure that the client understands; teaching safer sex practices
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| show | IM dose of penicillin (such as benzathine penicillin G, 2.4 million units). Obtain a sexual history, including the names of his sex partners, so that they can receive treatment.
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| What is the anatomic significance of a prolapsed uterus? | show 🗑
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| List four categories of burns. | show 🗑
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| show | Superficial partial-thickness, first degree: pink to red skin (e.g., sunburn), slight edema, and pain relieved by cooling; Deep partial-thickness, second degree: destruction of epidermis and upper layers of dermis; white or red, very edematous, sensitive
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| Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of the burned client. | show 🗑
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| show | Administer pain medication, especially prior to dressing wound. Teach distraction and relaxation techniques. Teach use of guided imagery.
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| show | Provide a patent airway because intubation may be necessary. Determine baseline data. Initiate fluid and electrolyte therapy. Administer pain medication. Determine depth and extent of burn. Administer tetanus toxoid. Insert NG tube.
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| Nutritional status is a major concern when caring for a burned client. List three specific dietary interventions used with burned clients. | show 🗑
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| Describe the method of extinguishing each of the following burns: thermal, chemical, and electrical. | show 🗑
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| show | Singed nasal hairs, circumoral burns; sooty or bloody sputum, hoarseness, and pulmonary signs, including asymmetry of respirations, rales, or wheezing
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| Why is the burned client allowed no “free” water? | show 🗑
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| Describe an autograft. | show 🗑
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