NCLEX Kaplan Review

August 26, 2017 | Author: Thun Nisa | Category: Insulin, Pregnancy, Rtt, Diseases And Disorders, Medicine
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Normal Lab Values • Hgb (hemoglobin): males=14-18 females=12-16; w/ 4 points in 2 weeks= ↑ risk for

• RBC’s:

males=4.7-6.1 million

• WBC’s:

4,500-11,000 (4.5-11 K)

• Platelets:

1,500-400,000 (150-400 K)

females=4.2-5.4 million

• PT (Coumadin/Warfarin): 11-15 sec. (INR:2-3 & PT TR)… must be 1.5-2x’s normal • PTT ( Heparin): 60-70 sec. (APTT: 30-40 & PTT TR)… must be 1.5-3x’s normal • BUN: 10-20 • Creatinine: 0.5-1.2 • Specific Gravity: 1.005-1.030 • Sodium: 136-145……. 145= Cushing’s syndrome, pts w/ corticosteroids • Potassium: 3.5-5……………..5= tall peaked T waves, prolonged PR interval & wide QRS. • Calcium: 9-10.5………1.5= toxicity: fine tremors, nausea, drowsiness, slurred speech, muscle weakness, diarrhea, & vomiting. ↓Na levels puts the pt @ risk for toxicity; Maintain normal Na & fluid intake. Takes 1-4 weeks to reach therapeutic level: avoid driving until then. NO CAFFEINE! Regular blood tests & maintain weight.

• Digoxin TR: 0.8-2.0…..hold>2.0…..>2.5=toxic (visual disturbances: yellow halos/lights); greater ↑ risk w/ ↓ K+. Monitor K+ • LDL:


• Lactate level: 4=septic

• Bilirubin (newborn): 1-12 >15 requires phototherapy • ASA (therapeutic anti-arthritic levels): 20-30…>30=toxic • PSA: 1.030 ↑ CVP (normal 4-11) ↑ BUN

Fluid Volume Excess ↓ hematocrit ↑BP ↓ urine specificity

o Types of solutions: ▪ Hypotonic= hydrates the cell; tap water, .45% NaCL, .33% NaCL ▪ Isotonic= stays put; D5%W, RL, NS 0.9%. *Only sterile saline for bladder irrigation* ▪ D5W w/ KCL: should be no faster than 20 mEq/h ▪ Hypertonic= expands volume; D10%W, D5%NS, Albumin

Antidotes ⬥ Digoxin→ Digiband ⬥ Coumadin→ Vitamin K ⬥ Benzodiazepines→ Flumazenil (Tomazicon) ⬥ Mg Sulfate→ Calcium Gluconate ⬥ Heparin→ Protamine Sulfate ⬥ Tylenol→ Mucomist (17 doses + a loading dose) ⬥ Opiates (heroin/morphine)→ Narcan (Naloxone) ⬥ Cholinergic Drugs (myesthenic bradycardia)→ Atropine ⬥ Methotrexate→ Leucovorin

Pediatrics ◇ The preferred injection site for vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle in the newborn's thigh.

◇ Newborn S&S of hiatal hernia: vomiting, coughing, wheezing, short periods of apnea, and failure to thrive. ◇ Newborn w/ ↑ immunoglobin IM indicates they were exposed to an intrauterine infection ◇ Koplik spots= Rubeola (Measles) ◇ Autistic kids= bizarre behavior o Most effective approach-sitting w/ them o Not aware of others or others feelings o Stereotyped body movements ▪ Nursing interventions: communication, minimize holding, structures activities. ◇ Rheumatic fever o Strep throat hx o Carditis o Major joints hurt @ various locations o Chorea-involuntary movement o Erythema Marginatum-rash o ↑ ASO, ESR, C-Reactive protein ▪ TX= penicillin- acute phase: steroids, antipyretics, bed rest ▪ ↑ ASO titer= damage to glomerulus which can lead to glomerulonephritis ◇ Myelomeningocele= cover w/ moist sterile water dressing, prone positioningprevents meningitis ◇ NO MMR on kids w/ an egg/ neomycin ◇ Celiac disease= AVIOD: barley, wheat, & rye. Gluten free diet

◇ Epiglottitis= H influenza B… child sits upright with chin out & tongue protruding (tripod) positioning. Nurse must prepare for intubation/ trach, no direct exams (tongue depressor) & NPO!!! ◇ Cystic fibrosis= Affects GI & Respiratory tract o Problem with chloride metabolism: it blocks the pancreatic duct with thick sticky mucus. Its recommended they get their basic vaccines + yearly influenza vaccine ▪ Steatorrhea which leads to FTT (failure to thrive) ▪ COPD ▪ CHF ▪ Salty skin (sweat test check the sodium amounts) • Pancreatic enzymes are given with food • In a sweat test, the amount of sweat chloride is measured. A chloride level >60 mEq/L is considered to be a positive test result. A sweat chloride level < 40 mEq/L is considered normal.

◇ SVT- child should put thumb in mouth & blow the thumb as if it were a trumpet. ◇ Croup LTB- hx of URI; stridor, hoarseness, brassy cough o Tx=mist tent wooden toys are ok; they don’t conduct electricity & clear liquids ◇ Post-op cleft & palate repair: place on side, maintain Logan Bow & elbow restraints ◇ Tonsillitis/ Tonsillectomy: o PT & PTT (pre-op) = they are at ↑ risk for hemorrhage (1st 24 hours & then 5-10 days later w/ the sloughing of the scabs) & lose teeth. ▪ If hemorrhaging occurs turn pt to LT side & notify physician o Post op- Ice collar, soft foods, & clear cold drinks (apple juice). **No red liquids or straws**

◇ Physiologic jaundice is normal @ 2-3 days caused by a rupture of large amounts of blood cells within a short period. o Treatment consists of UV lighting w/ a bilirubin >15 which coverts indirect bilirubin to a less toxic compound. o Rh- mother w/ a + father is a risk factor for jaundice. ◇ Pathologic jaundice-Abnormal before 24 hours or lasting > 7 days. o If the area around the eyes suddenly disappears the eye patches need to repositioned to prevent UV light from entering the eyes. ◇ Caput succedaneum= edema under scalp; crosses suture lines ◇ Cephal hematoma= blood under periosteum; does not cross suture lines ◇ Jitteriness= hypoglycemia & hypocalcemia in newborns. ◇ 2 arteries (away) & 1 vein in fetus; they are obligatory nose breathers; Vit K to ↓ risk for bleeding. Circumcision care consists of Vaseline & gauze. Scarf sigh, undeveloped pubic area, no body fat = prematurity ◇ Hypothermia in newborn leads to hypoxia & acidosis. Keep warm & use bicarbonate PRN. o Hypothermia can lead- ventricular fibrillation ◇ Fetal alcohol syndrome= craniofacial abnormalities- small head circumference, ↓weight, intrauterine growth restriction, cardiac problems, abnormal palm creases & respiratory distress, ◇ **Betamethason** given w/ Mg sulfate to increase surfactant in fetal lungs. ◇ Cerebral palsy= walking-scissoring ◇ Guthrie test- for PKU is done 24 hrs after protein ingestions & @ 6 weeks through urine test o No diet drinks or proteins ◇ S&S in respiratory distress: cyanosis, tachypnea, tachycardia, retractions, apnea, & nasal flaring, expiratory grunt. o Management- positioning, suctioning

o Acrocyanosis= bluish discoloration in hands & feet in association w/ immature peripheral circulation ◇ If a newborn has a glucose level of 25, nurse should give 10% dextrose via IV infusion to ↑ glucose to at least 45 ◇ Newborns should be placed on their RT side after feeding to aid in digestion & prevent aspirations ◇ Autosomal Recessive diseases: cystic fibrosis, sickle cell anemia, albinism ◇ Conjunctivitis= contagious, child should be sent home, need antibiotics eye drops. ◇ X linked recessive diseases: muscular dystrophy hemophilia. ▪ Females are the carriers they never have the disease. Males get it but can’t pass it. 25% chance w/ each pregnancy the child will have the disease. ▪ Will get Percocet for pain; crippling knee & joint deformities. ◇ If a child is disruptive in class & does not participate they should be checked for visual impairments. ◇ Reye’s syndrome (acute encephalopathy) = viral infection + aspirin= swelling of brain & liver. Provide a quiet environment w/ dimmed lighting to ↓ stress, cerebral tissue & neuron responses. ◇ Lead poisoning: Pb> 15= health hazard; S&S: Pb> 70, neuro o TX= chelating agents, BAL in oils, calcium EDTA o Encourage milk consumption ◇ Assessment in infants: o Auscultate heart & lungs o Record HR & RR o Palpate & percuss the abdomen o Examine eyes, ears & mouth; elicit the moro reflex

▪ Normal finding: • Head circumference: 33-35 cm • Chest circumference 1 in less than head • Acrocyanosis & edema of scalp

◇ Assessment findings: o Posterior fontanel closes @ 2 months o Cooing @ 2 months o Monosyllabic babbling 3-6 months o Rooting disappears by 4 months o Moro reflex disappears by 4 months o Palmar grasp disappears by 4 months. o Head control by 4 months o Back to side by 4 months o Turns over @ 5-6 months o Sits with support @ 6 months o Responds to own name @ 6-8 months o Hand to hand transfer @ 7 months o Sits unsupported by 8 months o Crawls by 7-8 months o Sits up from a lying position 7-9 months o Stranger anxiety 7-9 months o Understand NO & love peek a boo 7-9 months o Mama-dada @ 7-9 months

o Pincer grasps (cereal) @ 9 months o Stands 11-12 months; cruise & walk while holding on o Mama-dada + few words @ 10-12 months o Drinks from a cup, plays with push-pull toys, 10-12 months o Walks @ 1 year o Birth weight triples @ 12 months o Birth length ↑ by 50% @ 12 months o Anterior fontanel closes @ 12-18 months o Babinski reflex disappears by 1 yr o Throws ball over head @ 18 months o 18 months walks alone & climbs stairs o Build tower of 3-4 blocks @ 18 months o 2-3 word sentence @ 2 years o 50% of adult height @ 2 years o Runs (after a ball) @ 2 years o Toilet training 2.5-3 years o Uses tricycles @ 3 years o 3 year old toys: pull toys, large balls, crayons, truck/dolls o Uses scissors @ 4 years o Birth length doubles @ 4 years o Hops & skips @ 4 years o Ties shoes @ 5 years o Throws & [email protected] 5 years o Jump ropes @ 5 years

o Copies an X or O; we learn if they are now LT or RT handed @ 5 years o Hops on 1 foot @ 5 years o Alternates feet on stairs @ 5 years o Concept of time “next week” @ 5 years

◇ Hydrocephalus- nursing priority includes repositioning frequently o S&S: ▪ ↓pulse ▪ ↑BP ▪ Bulging fontanels ▪ High pitched cry • V-P shunt may be placed, do not sit them up immediately- hemorrhage ◇ Toddler stages of anxiety ▪ Protest-crying ▪ Despair- sucking thumb not crying ▪ Denial- when mom & dad come & they prefer the nurse ◇ Respiratory rates: • Newborn= 30-60 • 1-11 months= 25-35 • 1-3 years= 20-30 • 6-10 years= 18-22 • 11-16 years 16-20 ◇ Heart rates o Fetal: 120-160 ◇ Gestational ages ▪ Preterm: 20-37 weeks

▪ Term: 38-42 weeks ▪ Post term >42 weeks ◇ APGAR (HR 0-2,respirations 0-2, muscle tone 0-2, reflex irritability 0-2, color 0-2) @ 1 & 5 min • 7-10= good • 4-6 moderate resuscitative needs • 1-3 mostly dead

• Erikson’s o 0-12 months= trust vs mistrust (solitary play) o

1- 3 years= autonomy vs shame & doubt… fear of intrusive procedures, security objects good- blankets, stuffed animals (parallel play)

o 3-6 years= initiative vs guilt… fear of mutilation, Band-Aids-are good, likes to help parents (associative play)- pretend kitchen or workshop o 6-12 years= industry vs inferiority… games good, peers are important, fear of loss of control over their bodies, projects are important (cooperative play-teams) o 12-19 years= identity vs role confusion… teens

• Paget’s o 0-2 years= sensorimotor- learns about reality & object permanence. o 2-4 years= preoperational- concrete thinking (magical thinking/ no cause & effect) o 4-7 years= preoperational- intuitive o 7-11 years= concrete operational- abstract thinking, o 11- adult= formal operational- abstract & logical thinking.

• Freud: Id, Super ego, Ego o Oral (birth- 1 year) o Anal (1-3 years) pleasure of retention & pooping (toilet training); “No to everything”

o Phallic (3-6 years) pleasure w/ genital & superego development; marrying parents o Latency (6-12 years) sex urges & growth of ego o Genital (>12 years) satisfying sexual relations

• Kohlberg o Pre-conventional: reward & punishment o Conventional: conforms to rules to please others o Post-conventional: rights, principles, & conscience

• Immunization schedule o Hep B:

0,2,6 months

o DTP:

2,4,6 months

o HIB:

2,4,6 months


2, 4 months

o PCV:

2,4,6 months

o MMR:

4-6 years

12-15 months 15-18 months

4- 6 years

12-15 months

15 months

o Varicella: o TB testing:

15-18 months

4-6 years

12-15 months 12 months

4-6 yrs

14- 16 yrs

(DTP= diphtheria, tetanus, pertussis) (HIB- haemophilus influenza B) (PCV- pnemoccocal conjugate vaccine) (MMRmeasles, mumps, rubella; “German measles”) •

Flu vaccine in children < than 2 yrs

Maternity ◇ Priority nursing action for a pt w/ ectopic pregnancy? Monitoring pulse- An elevated pulse rate is an indicator of shock

◇ Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. ◇ After epidural the mother is given 500 cc bolus to counteract vasodilation. ◇ Retained placental fragments and infections are the primary causes of subinvolution. ◇ RhoGam is given 300 MG @ 28 weeks & post-partum w/ a – Coombs test… no antibodies. Also with a spontaneous abortion before the age of variability even if we don’t know if the fetus was Rh+. ◇ Calorie intake ↑ by 300 calories/ day; ↑ protein 30 g/ day ◇ Amniotic fluid= 800-1200ml ( than expected. ◇ DIC ↑ risk= fetal demise, infection, abruption placenta, preeclampsia, or hemorrhage. ◇ WBC count are elevated up to 25,000 for 10 days post-partum ◇ It’s safe for PG women to be on TB medications ( Isoniazid & rifampin)

◇ PG women w/ cardiac disease should drink adequate amounts of fluid & ↑fiber (↓ Valsalva maneuver which causes the blood to rush into the heard & overload the cardiac system). No Pitocin can be used on them. ◇ Hep. B prevention of PG mother should include hand washing & drying hands before/ after perineal care & usage of gloves when feeding.

◇ Assessment findings: ✓ Amenorrhea=presumptive sign/ subjective ✓ Fatigue= presumptive sign/ subjective ✓ Nausea/vomiting= presumptive sign/ subjective ✓ Urinary frequency= presumptive sign/ subjective ✓ Breast changes= presumptive sign/ subjective ✓ + pregnancy test=Probable sign/objective ✓ Ballottement (finger is placed in vagina & taps gently upward, fetus rises & then sinks causing examiner to feel a gentle tap)= Probable sign/objective ✓ Uterine enlargement= Probable sign/objective ✓ Braxton hicks: >4 months= Probable sign/objective ✓ Chadwick’s sign= bluing of the vagina as early as 4 weeks= Probable sign/ objective ✓ Hegar’s sign= softening of the isthmus of the cervix… 8 weeks= Probable sign/ objective ✓ Goodell’s sign= softening of the cervix= Probable sign/objective ✓ Heart beat @ 8 weeks ✓ Sex can be determined @ 12 weeks ✓ Quickening 14-20 weeks. ✓ Starts showing @ 14 weeks ✓ Able to hear the lungs @ 38 weeks ✓ Schultz presentation= shiny side-fetal side

✓ Lochia no > 4-8 pads/day & no clots >1cm. Fleshy smell=normal; foul=infection ⬥ Rubra (bright red) 2-4 days, if prolonged this indicates slowed involution or retained placenta fragments. ⬥ Serosa (brown/dark red) 4-10 days ⬥ Alba (white/yellow discharge) 10 days→ 3-6 weeks ✓ With mastitis the mother will get antibiotics & breast feeding is okay. Clean nipples with water & air dry. ✓ Pica cravings- iron deficiency anemia ✓ Good exercise during pregnancy- swimming ✓ Encourage pregnant women to wear panty hose/support hose & non slip shoes. ✓ When cramping occurs teach pt to bend foot towards body (dorsiflexion) while extending the knee. ✓ Kick counts= # of movements/ kicks in a sitting/ lying position 140/90), & edema (hands/face) ⬥ Pts with epigastric pain & ↑ BP= keep pt safe w/ impeding seizure. ⬥ Preeclamptic pt demonstrates clonus; nurse should count # of taps & record it in medical record. ✓ Full bladder= uterine atony & hemorrhage. ✓ Iron deficiency anemia= fatigue, cold, ↑ BP, koilonychias- upward curvature, glossitis

✓ PG pt w/ thrombophlebitis should apply= warm soaks to affected leg ✓ The cardiovascular system is the most developed by 3 weeks gestation. ✓ Post-partum assessment finding: ⬥ Temp >100.4=dehydration ⬥ Orthostatic hypotension, help is needed when getting out of bed, ⬥ Bowel sounds return within 2-3 days ⬥ Locia flow: heavy= 1 perineal pad/ hr; Excessive= 1 perineal pad in 15 minutes. **Earliest sign of hemorrhage= ↑ pulse** ✓ Teaching: perineal care involves changing perineal care everytime they go to RR & when they are soiled. ✓ Station ⬥ (-) = above the ichial spine… (+)= outside the vagina. ✓ Station 0= Engagement; common problem to fetus remaining in this station is the mother has a full bladder. ✓ Positioning ⬥ LOA= occiput is facing the left anterior pelvis… **Most Common** ⬥ LOP= occiput is facing the left posterior pelvis ⬥ ROA= occiput is facing the right anterior pelvis ⬥ ROP= occiput is facing the right posterior pelvis ✓ Dilation- opening of the cervix 10 cm ✓ Effacement= thinning of the cervix; loss of cervical canal ✓ Stages of labor ⬥ 1= beginning of regular contractions to full dilation & effacement ⬥ 2= 10 cm dilation to delivery ⬥ 3= delivery of placenta ⬥ 4= 1-4 hrs following delivery- fundus palpable @ umbilicus

✓ Fundal heights: if they fall below= intrauterine growth restriction. ⬥ 12-14 weeks= level of symphysis ⬥ 20 weeks (20 cm)= level of umbilicus (rises 1cm per week) ⬥ 36 weeks= xyphoid process ✓ Post-partum= @ 1 hr level of umbilicus, @ 12 hrs 1 cm above the umbilicus, descends at least 1 cm/day ◇ Non-stress test: reactive= healthy (↑ w/ fetal movement) → HR (120-160) w/ >2 accelerations of 65= tachypnea o Renal threshold ↑ o Alzheimer’s ▪ Stage 1: memory loss- names, location of objects; emotionally unstable ▪ Stage 2: lasts 2-12 yrs., loss of recent memory, inappropriate social actions, can’t concentrate. • agnosia= can’t figure out what object is for (comb/toothbrush) • aphasia= speech problems • apraxia= tying shoes, cooking ▪ Stage 3: months- 5 yrs. inability to communicated, delusions, hallucinations, paranoia, agitation, loss of physical functioning. o Dementia= irreversible (Alzheimer’s)… depression, sun downing (place them near the windows-natural lighting) - very disoriented @ night, memory deficit- loss of family recognition irritable, poor judgment, & confabulation. o Delirium= “acute” secondary to another problem= reversible (UTI’s, infection, or pneumonia common cause) ▪ When they become combative first thing to check for is their O2 levels ▪ Alcoholics ▪ Erikson’s o 20-35 years= Intimacy vs isolation: “us” career or marriage o 35-65 years= Generativity vs stagnation: teaching Sunday school, girl scouts, clubs, tends to contribute to society. o >65 years= Integrity vs despair: voluntarism vs rocking chair

Medical-Surgical ▪ Respiratory o Assess cough reflex & ability to swallow before giving fluids= ↑ ICP & risk for aspiration. o Rifampin for TB= turns urine rusty/red/orange * NO eye contacts. o Isoniazid (INH) for TB= ↑ Dilantin levels o Use bronchodilators before steroids!!! ( exhale completely → inhale deeply → hold breath for 10 seconds ) o COPD never >2 L/min → CO2 narcosis ▪ Emphysema= pink puffer: AVOID carbohydrates, the convert to CO2 ▪ Chronic bronchitis= blue bloater→ Right sided HF= cyanosis & peripheral edema

o Flail chest: chest on affected side is pulled inward during inspiration & outward (bulges) during expiration. ▪ Monitor VS for shock ▪ Pain med [email protected] regular intervals ▪ Encourage turn, cough, & deep breath ▪ Monitor ABG’s o PE prevention: Trendelenburg HOB ↓ on the left side (traps air on the right side of the heart). o If chest tube becomes disconnected do NOT clamp but put the ends in sterile water. o Chest tube drainage system should show bubbling & water level fluctuations (tidaling w/ breathing) o Ascending order of potency: nasal cannula → simple face mask (40-60%) → nonrebreather mask (80-90%) → partial rebreather mask → venturi mask (100%) ▪ CPAP: uses room air not O2 its not combustible: its used to keep the alveoli open & ↓ hypoxia o Histoplasmosis is a fungal infection from bird or bat droppings. Typical S&S similar to TB: include fever, dyspnea, cough, and weight loss. Tx: Amphotericin B- SE= bone marrow suppression, local phlebitis, kidney damage (monitor I & O) o Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion. o Respiratory alkalosis: ↑RR & depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. o TB test is read with fingers (induration). Most conclusive test to detect TB= sputum. Pt will remain under isolation until the sputum comes back negative. ▪ >5 mm in immunocompromised ▪ >10mm in children < 4 yrs. old ▪ > 15 mm in people > 4 yrs. • Vit. B6 will be needed o Air leaving cavity in water seal= gentle intermittent bubbling. No bubbling this means the lung has reinflated or there’s an obstruction. Think about how long it’s

been placed. *Listen to breathe sounds *(2-3 cm/water)… petroleum gauze (air occlusive) dressing must be available for tube removal or for accidental removal. o If there is no bubbling in suction control- *check if it’s turned on 1st*, then check for leaks; should have gentle continuous bubbling. (15-20 cm/water) o Chest PT- best is between meals, bedtime, or early in the morning. Never after a meal. o Pt on mechanical ventilation …NO WOOL carpeting. ▪ 1st thing to assess following ventilation is BP may cause hypotension from ↓ CO2. o Humidifier is needed w/ o2 >4 L o When doing tracheal suctioning & pts begin to cough we must remove the catheter & let them cough= better when getting rid of secretions. ▪ Pressure Never >20; should be checked every 8 hrs. o Always hyperoxygenate before & after suctioning 300 o Neg. inspiratory force: -20

• Peek pressures: o High= requires suctioning/ sedation (biting tube, pulmonary edema, ↓ lung resistance) o Low= tube is disconnected, dislodged, partially intubated, or there is a lot of water in tubing; ambu bag the pt. & call RT stat) o **Good lung UP- Bad lung DOWN** ▪ Pts w/ RT lower lobe pneumonia complaining of unrelieved pain should be encouraged to lie down on RT side. o **Adventitous sounds** ▪ Tachypnea= rapid respirations (pneumothorax) ▪ Stridor- upper airway obstruction *life threatening* ▪ Crackles- air passing through secretions ▪ Cheyne strokes- rhythmic respirations w/ periods of apnea ▪ Kussmauls- deep grasping pattern (diabetic coma) • Hyperpnea= deep rapid respirations (metabolic acidosis, DKA)

▪ Cardiac ♥ Hold digoxin
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