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EXAM 180 QUESTIONS AND ANSWERS.pdf
1 cup - ans8 oz 1 g (gram) - ans1000 mg 1 kg - ans2.2 lbs 1 oz - ans30 mL 1 pint - ans2 cups 1 quart - ans2 pints 1 tsp - ans5 mL Addesonian crisis - ansN/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Addison's - ansHypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Addison's & Cushings - ansAddison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia administration of enema - anspt should be left side lying (Sim's) with knee flexed. After Cateract surgery - anspt sleep on UNAFFECTED side with a night shield for 1- 4 weeks After endoscopy - anscheck gag reflex After infratentorial surgery - ansposition pt flat and lateral on either side. After lumbar puncture and oil based myelogram - anspt is flat SUPINE (prevent headache and leaking of CSF) After Myringotomy - ansposition on the side of AFFECTED ear, allows drainage. After supratentorial surgery - anselevate HOB 30-40 degrees after Thyroidectomy - anslow or semi-fowler's position, support head, neck and shoulders.
EXAM 180 QUESTIONS AND ANSWERS.pdf
After total hip replacement - ansdon't sleep on side of surgery, don't flex hip more than 45 - 60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Air or Pulmonary Embolism - ansS/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) Airborne precautions - ansMTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip - ansprivate room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB AKA (above knee amputation) - anselevate for first 24 hours on pillow. position prone daily to maintain hip extension. Angiotenson II - ansIn the lungs...potent vasodialator, aldosterone attracts sodium. anterior fontanelle closes by...posterior by.. - ans18 months, 6-8 weeks APGAR - ansAppearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) appendicitis pain - anslocated in RLQ ARDS and DIC - ansare always secondary to another disease or trauma Autonomic Dysreflexia - ans(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) Autonomic dysreflexia - anspatients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) Autonomic Dysreflexia/Hyperreflexia - ansS/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! before IV antibiotics? - anscheck allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. Before starting IV antibiotics - ansobtain cultures!
EXAM 180 QUESTIONS AND ANSWERS.pdf
Contact precaution - ansMRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves COPD and O2 - answith COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. Cor pumonae - ansRight sided heart failure caused by left ventricular failure (edema, jugular vein distention) Cushings - ansHyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump CVA - anscerebriovascular accident. brain tissue dies. dependent position - anssupported detached retina - ansarea of detachment should be in the dependent position Diabetes insipidus (decreased ADH) - ansexcessive urine output and thirst, dehydration, weakness, administer Pitressin DKA is rare - ansin DM II (there is enough insulin to prevent fat breakdown) Do not delegate - ansWhat you can EAT E-evaluate A-assess
- T-*teach Droplet precautions - ansspiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
EXAM 180 QUESTIONS AND ANSWERS.pdf
(Private room and mask) dunlap traction - ansskeletal or skin during Continuous Bladder Irrigation (CBI) - anscatheter is taped to the thigh. leg must be kept straight. During internal radiation - anson bed rest while implant in place early sign of cystic fibrosis - ansmeconium in ileus at birth eclampsia is - ansa seizure Edema is located - ansin the interstitial space, not the cardiovascular space (outside of the circulatory system) FHR patterns for OB - ansThink VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill five interventions for psych patients - anssafety setting limits establish trusting relationship meds least restrictive methods/environment for phobias - ansuse systematic desensitization Glaucoma patients lose - ansperipheral vision. Grave's Disease/ hyperthyroidism - ansaccelerated physical and mental function. Sensitivity to heat. Fine/soft hair. Gullian - Barre syndrome - ansascending paralysis. watch for respiratory problems. Head Injury - anselevate HOB 30 degrees to decrease ICP heat/cold - anshot for chronic pain; cold for accute pain (sprain etc) hemophilia is x linked - anspassed from mother to son Heroin withdrawal neonate - ansirritable, poor sucking
EXAM 180 QUESTIONS AND ANSWERS.pdf
In an emergency - anspatients with a greater chance to live are treated first Infant with Spina Bifida - ansProne so that sac does not rupture infratentorial - ans(incision at the nape of neck) Iron toxicity reversal - ansdeferoxamine lead poisoning - anstest at 12 months of age Liver biopsy (prior) - ansmust have lab results for prothrombin time LOC - ansLevel of Consciousness Lumbar Puncture - ansAfter the procedure, the pt should be supine for 4-12 hours as prescribed. Meningitis--check for - ansKernig's/ brudinski's signs multiple sclerosis - ansmyelin sheath destruction. disruptions in nerve impulse conduction Myasthenia gravis - ansdecrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. Myesthenia Gravis - ansa positive reaction to Tensilon---will improve symptoms Myesthenia Gravis - answorsens with exercise and improves with rest Myringotomy - anssurgical incision into the eardrum, to relieve pressure or drain fluid. Myxedema/ hypothyroidism - ansslowed physical and mental function, sensitivity to cold, dry skin and hair. NCLEX answer tips - anschoose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. Neutropenic pts - ansno fresh fruits or flowers never give K+ in - ansIV push pain with diverticulitis - anslocated in LLQ
EXAM 180 QUESTIONS AND ANSWERS.pdf
pathological jaundice occurs: physiological jaundice occurs: - ansbefore 24 hours (lasts 7 days) after 24 hours 1 cup - ans8 oz 1 g (gram) - ans1000 mg 1 kg - ans2.2 lbs 1 oz - ans30 mL 1 pint - ans2 cups 1 quart - ans2 pints 1 tsp - ans5 mL Addesonian crisis - ansN/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Addison's - ansHypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Addison's & Cushings - ansAddison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia administration of enema - anspt should be left side lying (Sim's) with knee flexed. After Cateract surgery - anspt sleep on UNAFFECTED side with a night shield for 1- 4 weeks After endoscopy - anscheck gag reflex After infratentorial surgery - ansposition pt flat and lateral on either side. After lumbar puncture and oil based myelogram - anspt is flat SUPINE (prevent headache and leaking of CSF) After Myringotomy - ansposition on the side of AFFECTED ear, allows drainage. After supratentorial surgery - anselevate HOB 30-40 degrees
EXAM 180 QUESTIONS AND ANSWERS.pdf
before IV antibiotics? - anscheck allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. Before starting IV antibiotics - ansobtain cultures! bethamethasone (celestone) - anssurfactant. premature babies Better peripheral perfusion? - ansElevate veins, D-Angle Arteries birth weight - ansdoubles by 6 months triples by 1 year BKA (below knee amputation) - ansfoot of bed elevated for first 24 hours. position prone to provide hip extension. brachial pulse - anspulse area on an infant bryant's traction - anschildren <3 y <35 lbs with femur fx buck's traction - ansknee immobility Buck's Traction (skin) - anselevate foot of bed for counter traction burns rule of Nines - anshead and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1% CABG - ansGreat Saphenous vein in leg is taken and turned inside out (because of valves inside). Used for bypass surgery of the heart. caput succedaneum - ansdiffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days Cardinal sign of ARDS - anshypoxemia centigrade to Fahrenheit conversion - ansF= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 Chest tubes are placed - ansin the pleural space Cholinergic Crisis - ansCaused by excessive medication ---stop giving Tensilon...will make it worse.
EXAM 180 QUESTIONS AND ANSWERS.pdf
Cleft Lip - ansposition on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. Contact precaution - ansMRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves COPD and O2 - answith COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. Cor pumonae - ansRight sided heart failure caused by left ventricular failure (edema, jugular vein distention) Cushings - ansHyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump CVA - anscerebriovascular accident. brain tissue dies. dependent position - anssupported detached retina - ansarea of detachment should be in the dependent position Diabetes insipidus (decreased ADH) - ansexcessive urine output and thirst, dehydration, weakness, administer Pitressin DKA is rare - ansin DM II (there is enough insulin to prevent fat breakdown) Do not delegate - ansWhat you can EAT E-evaluate A-assess
- T-*teach Droplet precautions - ansspiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza,
EXAM 180 QUESTIONS AND ANSWERS.pdf
hemophilia is x linked - anspassed from mother to son Heroin withdrawal neonate - ansirritable, poor sucking HOB - anshead of bed Hodgkin's disease - anscancer of the lymph. very curable in early stages Hyper Mg - ansdepresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY Hyper-parathyroid - ansfatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypercalcemia - ansmuscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! Hyperkalemia - ansMURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes Hypernatremia - ansincreased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. Hypervolemia - ansbounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's Hypo Mg - ansTremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) Hypo-parathyroid - ansCATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hypocalcemia - ansCATS Convulsions, Arrythmias, Tetany, spasms and stridor hypokalemia - ansmuscle weakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery) Hyponatremia - ansnausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids Hypovolemia - ansincreased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1. I lb - ans16 oz
EXAM 180 QUESTIONS AND ANSWERS.pdf
ICP and Shock - ansICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp if HR is <100 (children) - ansHold Dig In an emergency - anspatients with a greater chance to live are treated first Infant with Spina Bifida - ansProne so that sac does not rupture infratentorial - ans(incision at the nape of neck) Iron toxicity reversal - ansdeferoxamine lead poisoning - anstest at 12 months of age Liver biopsy (prior) - ansmust have lab results for prothrombin time LOC - ansLevel of Consciousness Lumbar Puncture - ansAfter the procedure, the pt should be supine for 4-12 hours as prescribed. Meningitis--check for - ansKernig's/ brudinski's signs multiple sclerosis - ansmyelin sheath destruction. disruptions in nerve impulse conduction Myasthenia gravis - ansdecrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. Myesthenia Gravis - ansa positive reaction to Tensilon---will improve symptoms Myesthenia Gravis - answorsens with exercise and improves with rest Myringotomy - anssurgical incision into the eardrum, to relieve pressure or drain fluid. Myxedema/ hypothyroidism - ansslowed physical and mental function, sensitivity to cold, dry skin and hair. NCLEX answer tips - anschoose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. Neutropenic pts - ansno fresh fruits or flowers
EXAM 180 QUESTIONS AND ANSWERS.pdf
PVC's - anscan turn into V fib. Rh mothers receive Rhogam - ansto protect next baby russell traction - ansfemur or lower leg S3 sound - ansnormal in CHF. Not normal in MI Shock - ansbedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) SIADH (increased ADH) - anschange in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics Skin infection- VCHIPS - ansVaricella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Spinal shock occurs - ansimmediately after injury SSRI's - anstake about 3 weeks to work supratentorial - ans(incision behind hairline on forhead) e Tetrology of Fallot - ansDROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) the best indicator of dehydration? - answeight---and skin turgor Thyroid storm - ansincreased temp, pulse and HTN TIA - anstransient ischemic attack....mini stroke, no dead tissue. To prevent dumping syndrome - ans(post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. TPN given in - anssubclavian line Trousseau and Chvostek's signs observed in - ansHypocalcemia
EXAM 180 QUESTIONS AND ANSWERS.pdf
Tube feeding with decreased LOC - ansPt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) Unstable Angina - ansnot relieved by nitro Ventilatory alarms - ansHOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc what to check with pregnancy - ansNever check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. when a pt comes in and is in active labor - ansfirst action of nurse is to listen to fetal heart tones/rate when phenylaline increases - ansbrain problems occur When pt is in distress....medication administration - ansis rarely a good choice wilm's tumor - ansencapsulated above kidneys...causes flank pain Woman in labor (un-reassuring FHR) - ans(late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! 1 cup - ans8 oz 1 g (gram) - ans1000 mg 1 kg - ans2.2 lbs 1 oz - ans30 mL 1 pint - ans2 cups 1 quart - ans2 pints 1 tsp - ans5 mL Addesonian crisis - ansN/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Addison's - ansHypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Addison's & Cushings - ansAddison's = down down down up down Cushings= up up up down up
EXAM 180 QUESTIONS AND ANSWERS.pdf
Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) appendicitis pain - anslocated in RLQ ARDS and DIC - ansare always secondary to another disease or trauma Autonomic Dysreflexia - ans(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) Autonomic dysreflexia - anspatients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) Autonomic Dysreflexia/Hyperreflexia - ansS/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! before IV antibiotics? - anscheck allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. Before starting IV antibiotics - ansobtain cultures! bethamethasone (celestone) - anssurfactant. premature babies Better peripheral perfusion? - ansElevate veins, D-Angle Arteries birth weight - ansdoubles by 6 months triples by 1 year BKA (below knee amputation) - ansfoot of bed elevated for first 24 hours. position prone to provide hip extension. brachial pulse - anspulse area on an infant bryant's traction - anschildren <3 y <35 lbs with femur fx buck's traction - ansknee immobility Buck's Traction (skin) - anselevate foot of bed for counter traction burns rule of Nines - anshead and neck 9% each upper ext 9% each lower ext 9% front trunk 18%
EXAM 180 QUESTIONS AND ANSWERS.pdf
back trunk 18% genitalia 1% CABG - ansGreat Saphenous vein in leg is taken and turned inside out (because of valves inside). Used for bypass surgery of the heart. caput succedaneum - ansdiffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days Cardinal sign of ARDS - anshypoxemia centigrade to Fahrenheit conversion - ansF= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 Chest tubes are placed - ansin the pleural space Cholinergic Crisis - ansCaused by excessive medication ---stop giving Tensilon...will make it worse. Cleft Lip - ansposition on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. Contact precaution - ansMRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves COPD and O2 - answith COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. Cor pumonae - ansRight sided heart failure caused by left ventricular failure (edema, jugular vein distention) Cushings - ansHyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump CVA - anscerebriovascular accident. brain tissue dies.
