TABLE OF CONTENTSFluids and Electrolytes 4Acid-Base Balance...
14Burns.... 19Oncology.. 28Endocrine..... 47Cardiac.....
64Psychiatric Nursing..... 90Making Room Assignments....111Priority
Questions... 112Gastrointestinal... 113Neuro....128Maternity
Nursing...138Respiratory..167Orthopedics.175Renal183Questions..192Final
Thoughts 211Evaluations.. 219Table of Contents for the 5th Day
CD.221Pediatrics..223Testing Strategies260Management and
Delegation..263Hurst Review Services2
I. FLUID VOLUME EXCESS: HYPERVOLEMIADefine: too much volume in
the ___________________________________A. Causes:1. CHF: heart
is__________, CO__________, decreased__________
perfusion,UO__________*the volume stays in the
________________________________2. RF: Kidneys
aren't____________________3. AlkaseltzerFleets enemas All 3 have a
lot of _________IVF with Na4. Aldosterone (steroid,
mineralocorticoid):-Where does aldosterone live?-Normal action:
when blood volume gets low (vomiting, blood loss, etc.)aldosterone
secretion increases retain Na/water blood volume ___________**
Diseases with too much
aldosterone:1._________________________________________2._________________________________________**Disease
with too little
aldosterone:1._________________________________________Normal
Urinary Output:1ml/kg/hrGood Rule: Call the MD ifthe UO is <
30ml/hrA client feels the urge tovoid when the bladder
hasapproximately250-300 ml of urine in itFluids and
ElectrolytesHurst Review Services55. ADH (Anti-diuretic
Hormone):-Normally makes you retain or diurese?-Retain?
_________________________*Concentrated makes #s go up Urine
specific gravity, sodium, and hematocrit*Dilute makes #s go downADH
lives in pituitary; key words to make you think potential ADH
problem: craniotomy, headinjury, sinus surgery, transphenoidal
hypophysectomy or any condition that could lead to increasedICP
there is a risk of an ADH problem.Trans-______________,
sphenoid______________, hypophysis__________
,ectomy____________*Another name for anti-diuretic hormone (ADH) is
Vasopressin (Pitressin). The drugVasopressin (Pitressin) or
Desmopressin Acetate (DDAVP) may be utilized as an ADHreplacement
in diabetes insipidus.2 ADH ProblemsToo Much Not EnoughRetain Lose
(diurese)Fluid Volume _________ Fluid Volume __________SIADH
DISyndrome of Inappropriate ADH Secretion Diabetes Insipidus(TOO
MANY _________ TOO MUCH ______)Urine UrineBlood BloodFluids and
ElectrolytesHurst Review Services6B. S/S:-Distended neck
veins/peripheral veins: vessels are_______________-Peripheral
edema, third spacing: vessels can't hold anymore so they start to
________-CVP: measured where __________________; number
goes_____More____________________....More____________________-Lung
sounds:-Polyuria: kidneys trying to help
you_________________________-Pulse: _______________; your heart
only wants fluid to go__________________-If the fluid doesn't go
forward it's going to go____________into the_____________-BP:
_______________ move volume.....more_______________-Weight:
_______________ any acute gain or loss isn't fat-its fluidC. Tx
:-Low Na diet-Diuretics:-Loop: Example:
__________________________-Bumetanide (Bumex) may be given when
Furosemide (Lasix) doesntwork.-Hydrochlorothiazide (Thiazide)
-Watch lab work with all diuretics-Dehydration and electrolyte
problems-K+ sparing: Example: __________________________-Bed rest
induces_______________________________________-in general, when you
are supine you perfuse your kidneys more because you havemore
cardiac output-Physical Assessment-Give IVFs slowly to
elderlyCVP:Central VenousPressureNormal: 2-6 mmHg*CVP checked per
MDorders usually every4 hoursFluid RetentionThink heartproblems
FIRSTTesting StrategyAnytime you see assessmentor evaluation on the
NCLEX,you should be looking forthe presence or absence ofthe
pertinent signs andsymptomsThe ideal location of the catheter tip
is within the superior vena cava (SVC), so that it isclose, but not
inside, the right atrium. It reflects pressure readings in the
right atrium.Fluids and ElectrolytesHurst Review Services7II. FLUID
VOLUME DEFICIT: HYPOVOLEMIABig Time Deficit=ShockA. Causes:1. Loss
of fluids from anywhereExamples: Thoracentesis, paracentesis,
vomiting, diarrhea, hemorrhage2. Third spacing (Definition: When
fluid is in a place that does you no good)-burns-ascites3. Diseases
with polyuria-Polyuria Oliguria AnuriaB. S/S:-Weight-Decreased skin
turgor-Dry mucous membranes-Decreased Urine Output-kidneys either
aren't being__________________ or they are trying to
____________-BP? ___________ (less_____________________,
less______________________)-Pulse? __________, heart is trying to
pump what little is left around-CVP? __________ (less volume, less
__________)-Peripheral Veins/Neck veins-Cool Extremities
(peripheral ______________in an effort to shunt blood to
______________________________)-Urine Specific Gravity __________,
if putting out any urine at all it will be ____________C. Tx:-Mild
Deficit:-Severe Deficit:Polyuria-usually the client will have a
totalurinary output of over 2000ml in 24 hoursOliguria-total
urinary output between 100 mland 400ml in 24 hoursAnuria-Total
urinary output of less than 100ml in 24 hoursFluids and
ElectrolytesHurst Review Services8III. Quickie IV Fluid LectureA.
Isotonic Solutions: Go in the vascular space and stays
there!-Examples of isotonic solutions: _____________,
________________, ________________B. Hypotonic Solutions: Go in the
vascular space, hang out a little while and rehydrate, but theydo
not stay in the vascular space.....If they stayed in the vascular
space they wouldn't behypotonic.....they would be
___________________. These solutions go in and hang out
andrehydrate, then they move into the cell and the cell burns the
remainder up in cellularmetabolism. They are hydrating solutions,
but they won't drive your pressure up because theydo not stay in
the vascular space.-Hypotonic Solution:- Causes a fluid shift from
the vascular space into the cells. A solution that willcause water
to enter the cell, which could induce swelling or lysis of the
cell.- Examples: D2.5 W, NaCl, 0.33% NaCl, tap waterC. Hypertonic
Solutions:- Volume expander and solution that draws fluids into the
vascular space. Drawswater out of the cell.- Examples: D10W, 3%
NaCl, 5% NaCl, D5 LR, D5 Na, D5 NaCl, TPN,Albumin.Although D5W is
considered an isotonic solution due to the osmolarity it is not
used often for clientsthat need a large amount of vascular volume
replaced. This is because when D5W is initiallyadministered it is
isotonic; however, it does metabolize into free water and is no
longer isotonic.An example of when this solution is used is when a
patient has hypernatremia.Quick Tips for IV SolutionsIsotonic
SolutionsStay where I put it!Hypotonic SolutionsGo Out of the
vesselHypertonic SolutionsEnter the VesselFluids and
ElectrolytesHurst Review Services9IV. MAGNESIUM AND CALCIUMFact:
Magnesium is excreted by kidneys and it can be lost other ways, too
(GI tract)Hypermagnesemia HypercalcemiaA. Causes: A. Causes:-Renal
Failure -Hyperparathyroidism: too much-Antacids -Thiazides (retain
__________)-Immobilization (you have tobear weight to keepCa in the
______________).B. S/S: B. S/S:-Flushing -bones are brittle-Warmth
-kidney stones-Mg makes you___________________ *majority made of
calciumC. Tx: C. Tx:-Ventilator -Move!-Dialysis -Fluids!-Calcium
gluconate -Phospho Soda & Fleets Enema*Calcium gluconate
inactivates -both have phosphorousmagnesium- they inactivate each
other -Ca has inverse relationshipwith _______________.**Calcium
gluconate is administered -When you drive Phos up, CaIVP very
slowly (Max rate: 1.5-2 ml/min) goes ______________.-Steroids-Add
what to diet?-Safety Precautions-Must have Vitamin ___ to use
Ca.-Calcitonin __________ serum CaHINT: If you want to get Mg &
Ca questions right, think muscles 1st.* the signs and symptoms
listed above in the box are common in a client with hypermagnesemia
and hypercalcemia*Normal Lab ValuesMg: 1.2-2.1 mEq/LCalcium:
9.0-10.5 mg/dlWhen your serum calcium gets lowparathormone (PTH)
kicks in and pullsCa from the ______________ and putsin the
blood....therefore, the serumcalcium goes ___.*S/S*DTR'sMuscle
ToneArrhythmiasLOCPulseRespirationsFluids and ElectrolytesHurst
Review Services10Hypomagnesemia HypocalcemiaA. Causes: A.
Causes:-Diarrhea - lots of Mg in intestines
-Hypoparathyroidism-Alcoholism -Radical Neck-alcohol suppresses ADH
& its hypertonic -Thyroidectomy-not eating-drinkingHINT: If you
want to get Mg & Ca questions right, think muscles 1st.C. Tx:
C. Tx:-Give some Mg -Vit D-Check _________function -Sevelamer
hydrochloride (Renagel)(before and during IV Mg) -Calcium Acetate
(PhosLo )-Calcium Carbonate (Os-Cal )-NCLEX scenario answers:A.
call the doctorB. decrease the infusionC. Stop the infusionD.
Reassess in 15 min.-Seizure Precautions -IV Ca (GIVE SLOWLY)Always
make sure client is on a ____________-Eat MagnesiumWhat do you do
if your client begins to c/o flushing and sweating when you start
IV Mg?Not Enough__________.Normal Lab ValuesMg: 1.2-2.1
mEq/LCalcium: 9.0-10.5 mg/dlB. S/S:Muscle ToneCould my client have
a seizure? __________Stridor/laryngospasm - airway is a
____________________________+Chvostek's - tap cheek (C is for
Cheek)+Trousseau's - pump up BP cuffArrhythmias - heart is a
______________DTR'sMind ChangesSwallowing Probs - esophagus is a
_______________________*these signs and symptoms are common in a
client with hypomagnesium or hypocalcemia*Aluminum Hydroxide Gel
(Amphojel ) is another phosphorusbinding drug that is used however;
dont give it to renal clientsbecause they cant get rid of the
aluminum and will get TOXIC!Foods high in magnesium: spinach,
mustard greens, summer squash, broccoli, halibut, turnip greens,
pumpkin seeds,peppermint, cucumber, green beans, celery, kale,
sunflower seeds, sesame seeds, and flax seedsFluids and
Electrolytes_______________________________Hurst Review
Services11V. SODIUMYour Na level in your blood is totally dependent
on how much water you have in your body.Hypernatremia=Dehydration
Hyponatremia=DilutionToo much Na; not enough water Too much water;
not enough NaA. Causes: A. Causes:-hyperventilation -vomiting or
sweating thendrinking H2O for fluidreplacement-heat stroke -this
only replaces the waterand dilutes the blood-DI-psychogenic
polydypsia-loves to drink _________-D5W (sugar & water)-SIADHB.
S/S: B. S/S:-Dry mouth -headache-Thirsty - already dehydrated by
the time -seizureyou're thirsty-coma-Swollen tongueC. Tx: C.
Tx:-Restrict _________________. -Client needs____________-Dilute
client with IV fluids -Client doesn't need _________.-Diluting
makes serum Na go __________ -If having neuro probs:needs
hypertonic saline-Daily weights If you've got a Na problem you've
-means "packed withgot a ______________ problem. particles"-I &
O-3% NS or 5% NS-Lab workCase in Point: Feeding tube clients - tend
to get ___________________Normal Lab ValuesSodium: 135-145
mEq/LNeuro changesBrain doesn't like it when Na's messed up*this
sign and symptom is common in a client with hypernatremia or
hyponatremia*Fluids and ElectrolytesHurst Review Services12VI.
POTASSIUM-Excreted by kidneys-Kidneys not working well, the serum
potassium will go ________________Hyperkalemia HypokalemiaA.
Causes: A. Causes:-kidney troubles -vomiting-aldactone - makes you
retain ________. -NG suction-diuretics-not eatingS /S: B. S
/S:-Begins with muscle twitching -Muscle Cramps & weakness-Then
proceeds to weakness,-Then flaccid paralysisC . Tx: C .
Tx:-Dialysis - Kidneys aren't working -Give K+!-Calcium gluconate
-Aldactonedecreases _______________-Eat K+ (See box at bottom of
pg)-Glucose and insulin-Insulin carries _____________ &
___________into the cell-Any time you give IV insulin worry
about__________________&___________________-Sodium Polystyrene
Sulfonate (Kayexalate)-given for hyperkalemia-exchanges Na for K+
in the GI tractWe have lots of K+in our stomachSodium and
Potassiumhave an_______________relationshipNormal Lab
ValuesPotassium: 3.5-5.0 mEq/LLife- ThreateningArrhythmiasFoods
high in potassium: spinach, fennel, kale, mustard greens, Brussel
sprouts, broccoli, eggplant, cantaloupe, tomatoes,parsley,
cucumber, bell pepper, apricots, ginger root, strawberries,
avocado, banana, tuna, halibut, cauliflower, kiwi, oranges,lima
beans, potatoes (white or sweet),and cabbage.ECG changes with
hyperkalemia: bradycardia, tall and peaked T waves, prolonged PR
intervals, flat or absent Pwaves, and widened QRS, conduction
blocks, ventricular filbrillation.ECG changes with hypokalemia: U
waves, PVCs, and ventricular tachycardiaFluids and
ElectrolytesB.Hurst Review Services13D. Miscellaneous
Information:-Major problem with PO K+?-Assess UO before/during IV
K+.-Always put IV K+ on a _______.-Mix well!-Never give IV K+
_______!-Burns during infusion?-Is it okay to add to a bag that's
already up and running?Be sure not to confuse potassium(K+) with
Vitamin KFluids and ElectrolytesHurst Review Services14
VII. ACID-BASE BALANCEA. Major chemicals you have to
remember:-Bicarb, Hydrogen, CO2-Lung chemicalCO2-Kidney chemicals
HCO3 and H+-There's only one way to get rid of CO2. What is
it?-These chemicals can either make you sick or compensate. It
depends on which imbalanceyou have.B. Compensation:-In respiratory
acidosis/alkalosis, which organs are sick?-Who's going to fix
everything (compensate)?-What are the chemicals the kidneys use to
compensate with?-In metabolic acidosis/alkalosis which organs are
sick?-If they are sick, who is going to fix things
(compensate)?-What is the only chemical the lungs have to
compensate with?-Do the lungs compensate slowly or quickly?-Do the
kidneys compensate slowly or quickly?Bicarbonate (HCO3) =
BaseHydrogen (H) = AcidCarbon Dioxide (CO2) = AcidAcid-Base
BalanceHurst Review Services15Compensation (cont):-The Goal of
Compensation:AcidosisAlkalosisC. Respiratory Acidosis:1.
Cause:-hypoventilation2. Pathophysiology:-Is this a lung problem or
a kidney problem?-What's the problem chemical?-Do we have too much
or too little of this chemical in the body?-Who's going to
compensate?-How did this happen?-Increased C02Decreased
LOC-Increased C02 Decreased 02 early hypoxia late hypoxiaHypoxia
may be one of the firstsigns of Respiratory AcidosisNormal Lab
ValuespH: 7.35-7.45PaO2: 80-100 mmHgPaCO2: 35-45
mmHgHCO3:Bicarbonate:22-26mEq/LMetabolic AlkalosisLungs
compensateRR _____to save C02PCO2____________(*CO2 in arterial
blood)Respiratory AlkalosisKidneys compensateExcrete HCO3Retain
HHCO3 on ABGsMetabolic AcidosisLungs compensateRR _____to blow off
C02PCO2____________(*CO2 in arterial blood)Respiratory
AcidosisKidneys compensateRetain HCO3Excrete HHCO3 on
ABGs_______________Acid-Base BalanceHurst Review Services163.
Tx:-Fix the problem!!!!(It is a breathing problem so we need to
ventilate the client)-Be aware of drugs that decrease RR.-Restless
client?D. Respiratory Alkalosis:1. Cause:-hyperventilating2.
Pathophysiology:-Think about the name.Whos sick? _________________
Whos going to compensate? ______________-Situation: Hysterical
client.-Well, are we going to wait until the kidneys kick in?3.
Tx:-Breathe into a _________________________________ .-May sedate
client-Treat the problemE. Metabolic Acidosis:1.
Causes:-DKA-Starvation2. Pathophysiology:-Think about the name.Whos
sick? ___________________ Whos going to compensate?
_____________-Scenario: DKA, Starvation-When you're starving you
break down _______, produce ______, ketones are_________________.3.
Tx:-Drug to help acidosis? Sodium Bicarbonate-Treat the
problemRestlessness think Hypoxia FIRSTYou need to check the SaO2
leveland administer O2 as needed Acid-Base BalanceHurst Review
Services17F. Metabolic Alkalosis:1. Cause:-Vomiting2.
Pathophysiology:-Think about the name.Whos sick? __________________
Whos going to compensate? _______________-Scenario: Vomiting3.
Tx:-Treat the problem.Acid-Base BalanceHurst Review Services18G.
What would these cause?Pneumothorax R. acid R. alk M. acid M.
alkAlka Seltzer/Antacids R. acid R. alk M. acid M. alkPanic Attack
R. acid R. alk M. acid M. alkNG to suction R. acid R. alk M. acid
M. alkContusion to lung parenchyma R. acid R. alk M. acid M.
alkClient getting lots of IVP bicarb R. acid R. alk M. acid M.
alkDiarrhea R. acid R. alk M. acid M. alk(Hint: Upper GI= acid,
Lower GI= base)Renal insufficiency* R. acid R. alk M. acid M.
alk(See factoid below)Pneumonia R. acid R. alk M. acid M. alkBroken
ribs R. acid R. alk M. acid M. alkAcute Aspirin overdose R. acid R.
alk M. acid M. alkHint: Anytime you have poor gasexchange, think
RespiratoryAcidosis*Factoid*Metabolic Acidosis= HyperkalemiaIn a
state of acidosis, the body will attempt to fix the problem by
movinghydrogen into the cell. In exchange for hydrogen moving into
the cell, potassiummoves out resulting in a higher amount of
potassium in the blood.Metabolic Alkalosis= HypokalemiaIn a state
of alkalosis, the body will attempt to fix the problem by
pullinghydrogen out of the cell. In exchange for hydrogen moving
out of the cell,potassium moves into the cell resulting in a lower
amount of potassium in theblood.Acid-Base Balance
VIII. BURNSA. Occurance:-The risk of death increases in the very
____________ and the very __________________.-Where do most burns
occur?B. Pathophysiology:-After a burn many different
pathophysiological changes occur. WHY?-Why does plasma seep out
into the tissue?-Increased ___________________permeability-When
does the majority of this occur?-Why does the pulse
increase?-Anytime you're in a ______, the pulse will
________________-Why does the cardiac output decrease? Less
___________ to pump out.-Why does the urine output
decrease?-Kidneys are either trying to ________ on to fluid or they
aren't being __________.-Why is epinephrine secreted?-Makes you
___________________, shunts blood to vital organs-Why are ADH and
aldosterone secreted?-Retain __________ & _____________ with
aldosterone and-Retain _____________with ADH-Therefore, the blood
volume will go_________________.C. Miscellaneous Information:1.
Airway Injury:-What is the most common airway injury?
______________________________poisoning-Normally, oxygen binds
with__________________. Carbon monoxide can runmuch faster than
oxygen . . . . Therefore, it gets to the hemoglobin first
andbindsCan oxygen bind now? yes or no-Now the client is
______________.-Tx: ________________________BurnsHurst Review
Services20-From this information, do you think it would be
important to determine if the burnoccurred in an open or closed
space?-When you see a client with burns to the neck/face/chest you
had better think what?*What might the physician do
prophylactically? __________________________2. Classification of
Burn Injury:-A client is burned over 40% of their body. How do you
think this is determined?*Estimate of Total Body Surface AreaD.
Tx:1. Fluid Replacement:-One of the most important aspects of burn
management is ________________________.-Is it important to know
that the burn occurred at 11:00 p.m.?-Why? Fluid therapy (for the
first 24 hours) is based on the time the injury ________,not when
treatment was ______________.LeastInvasiveFIRSTCarbon monoxide
poisoning cannot be determined with O2 saturations; the sat monitor
picks upanything that is bound to hemoglobin so if carbon monoxide
is bound to the hemoglobin then theO2 saturation may appear normal
so, the SpO2 may show 100% but the client STILL needsoxygen due to
the carbon monoxide poisoning.Carboxyhemoglobin: blood test to
determine carbon monoxide poisoningClient will have cherry red skin
coloring but they still need oxygen.BurnsHurst Review
Services21Common rule: Calculate what is needed for the first
________ hours and give half of the volumecalculated during the
first 8 hours. This is the ___________________Formula.-To calculate
fluid replacement properly you also need to know the
clients_________ (in kilograms) and TBSA affected. * l kg = 2.2
pounds-If the client is restless does it mean fluid replacement is
inadequate, pain, orhypoxia?*Nurses Priority:
___________________-Which of the following would you choose to
determine if a clients fluid volume isadequate? Their weight or
their urine output?2. Emergency Management:-A client was wrapped in
a blanket to stop the burning process. Since the flames aregone
does that mean the burning process had stopped?-What else could
have been done to stop the burning process?-The blanket helped
byHolding in the _________________ and kept
out__________.-Jewelry?-Airway injury?-Do you think there is more
death with upper or lower body burns?-A clients respirations are
shallow. You know they are retaining what?_____________-Therefore,
which acid-base imbalance will they have?NO matter what formula the
doctor usesThe formula will tell the amount of fluid the client
will get per hourThis client may be receiving as much as 500 ml/hr
or more!Parkland Formula(4ml of LR) X (body weight in kg) X (% of
TBSA burned) = total fluid requirements for the first 24 hours
after burn1st 8 hours = of total volume2nd 8 hours = of total
volume3rd 8 hours = of total volume BurnsHurst Review Services223.
Medication Management:a. Albumin:-It is not uncommon for albumin to
be given after a major burn, but not in thefirst 24 hours.-You know
that albumin holds onto ______________ in
the_______________space.-Vascular volume?-Kidney
perfusion?-BP?-Cardiac output?-Will this help correct a fluid
volume deficit?-When you start giving a client albumin, you know
that the vascularvolume will _____________.-Therefore, what will
happen to the work load of the heart?-If you stress the heart TOO
MUCH the client could be thrown intofluid volume ________.-If this
occurs, what will happen to CO?-Lung sounds?-In a client who is
receiving fluids rapidly, what you could measure hourly
(hint:heart) to ensure youre not overloading the client?b. Pain
Management:-A client has an order for morphine that states:
Morphine 2mg IVP orMorphine 4mg IVP Q 2 hours prn pain. If the
client is complaining of pain(4/10) what dosage would the nurse
give to the client?-Why are IV pain meds preferred over IM with
burns?BurnsHurst Review Services23c. Immunizations:-Why is the
client given a tetanus toxoid plus the immune globulin?1) Tetanus
Toxoid: (________ immunity)*takes 2-4 weeks to get the antibodies2)
Immune globulin: think ___________protection (________immunity)E.
Complications:1. Circulatory System:-A client has a circumferential
burn on their arm.-What does this mean?
_______________________-What should you be checking?
___________________________-If a clients vascular checks in this
arm are bad the doctor may do what procedure torelieve
pressure?-escharotomy which will relieve the ______________ and
restore the____________, cut through the eschar-fasciotomy- which
will relieve the _______________and restore the_________________,
but the cut is much deeper into the tissue, cut goes through
theeschar and the fascia2. Renal System:-A foley catheter was
inserted so you could measure urine output.-How often will this
need to be monitored?-Is it possible that when you insert the
catheter that no urine will return?Why? Kidneys are either
attempting to __________ the fluid or they are notbeing
___________________adequately.-What would you do if the urine was
brown or red?-What drugs might be ordered to flush out the
kidneys?-If there is no urine output or if it is less than
20ml/hour, you would start worryingabout?-After 48 hours, the
client will begin to diurese. Why? Because fluid is going backinto
the ___________ space. Now we have to worry about fluid volume
_________.-Urine output?If client is immune suppressed in any way
(elderly, poor nutrition), if they have leukemia, on chemotherapy
drugs,or HIV positive, or on prednisone, the physician may withhold
the tetanus shot because they could develop tetanus.If they have an
uncertain history of last tetanus shot, the client will also be
given immune globulin.BurnsHurst Review Services243. Electrolyte
Imbalances:-The clients serum K+ level is 5.8.-K+ likes to live
inside OR outside of the cell?-With a burn, what happens to
cells?-So, what happens to the number of K+ in the serum (vascular
space)?-Electrolyte imbalance? hypokalemia OR hyperkalemia4. GI
System:-Why do you think Carbonate/Magnesium Carbonate (Mylanta),
Pantoprazole(Protonix), and Famotidine (Pepcid) are ordered?-Why do
you think the doctor wants the client to be NPO and have an NG
tubehooked to suction?-If a client doesnt have bowel sounds, what
will happen to the abdominal girth?-Do you think the client will
need more or less calories?-The NG tube will be removed when you
hear what?-When you start GI feedings, what could you measure to
ensure that the supplementwas moving through the GI tract
ok?Antacids: Aluminum Hydroxide Gel (Amphogel), Magnesium Hydroxide
(Milk of Magnesia)H2 Antagonist: Ranitidine (Zantac ), Famotidine
(Pepcid), Nizatidine (Axid )Proton Pump Inhibitors: Pantoprazole
(Protonix ), Esomeprazole (Nexium)BurnsHurst Review Services25-What
is some lab work you could check to ensure proper nutrition and a
positivenitrogen balance?5. Integumentary System:a.
Contractures:-Since the client has partial thickness and
full-thickness burns, is it possible thatthey could have problems
with contractures?-Since they have burns on their hands, what are
some specific measures that maybe taken?-Neck?b. Infections:-With a
perineal burn, the #1 complication is___________________-What is
eschar?-Does it have to be removed?-If its not removed can new
tissue regenerate?-What likes to grow in eschar?Pre-Albumin is a
protein with a 2-day half life that reflects your nutritional
status.Normal Lab Value: 17-40 mg/dLAlbumin testing is more often
used to test for liver or kidney disease or to learn if your body
is not absorbing enough aminoacids. Albumin can also be used to
monitor nutritional status (the client is not eating enough protein
or has a low proteindiet). Albumin has a half life of 21
days.Normal Lab Value: 3.4 to 5.4 g/dLHowever, pre-albumin changes
more quickly because of its short half life, therefore; it can be
used to detect short-termnutritional status quicker than
albumin.Classification of Burns:Superficial thickness: formally
called first degree burn; Damage only to epidermisPartial
thickness: formally called second degree burn; Damage to entire
epidermis andvarying depths of the dermis.Full-thickness: formally
called third degree burn; Damage to entire dermis and sometimes
fatBurnsHurst Review Services26c. Tx:-What type of isolation will
you use with the client?-Sutilanis (Travase) or Collagenase (Santyl
): enzymatic drug eats deadtissue-Dont use on face -Dont use over
large nerves-Dont use if pregnant -Dont use if area opened to a
body cavity-Hydrotherapy is also used to ____________________.C o m
m o n d r u g s u s e d w i t h b u r n s :a. Silver Sulfadiazine
(Silvadene)-soothing, apply directly, if rubs off applymore, can
lower the WBC, can cause a rashb. Mafenide Acetate (Sulfamylon)-can
cause acid base problems, stings, if itrubs off apply morec. Silver
nitrate-keep these dressings wet; can cause electrolyte problemsd.
Povidone-Iodine (Betadine)-stings, stains, allergies, acid-base
problems-Why should these drugs be alternated?-Broad spectrum
antibiotics are avoided to prevent _________________________.-Broad
spectrum antibiotics will be used until the wound cultures have
returned.d. Grafting:-If grafting is done, a pressure dressing will
be applied (to the donor site) insurgery.Then when the bleeding has
stopped the wound will be left open to air.-If the skin graft
should become blue or cool what would this mean?-Sometimes the
doctor will order for you to roll sterile Q-tips over the graft
withsteady, gentle pressure from the center of the graft out to the
edges. Why?When giving-mycin drugswe WORRY when the clients BUN or
creatinine increases or if the client complainsof any hearing loss
because-mycin drugs can lead to ototoxicity (irreversible hearing
loss) and/or nephrotoxcity.BurnsHurst Review Services27e. Chemical
and Electrical burns:1) Chemical burn?2) Electrical burn 2 wounds.
What are they?-Electrical injury?-What arrhythmia is this client at
high risk for?-With electrical burns _______can build up and cause
_________ damage.-It is not uncommon for this client to be placed
on a spine board with ac- collar. Why? Electrical injuries occur in
_____________ places, musclecontractions can cause fractures, and
the force of the electricity can actuallythrow the victim
forcefully.-Are amputations common? Why?-Other complications of
electrical wounds: cataracts, gait problems, and justabout any type
of neurological deficit.Burns
IX. ONCOLOGYA. General Information:1. Risk Factors:-Alcohol +
tobacco = co-carcinogenic-_____________ is the #1 cause of
preventable cancer.-Suspected dietary causes of cancer:-Low fiber
diet -Nitrites (processed sandwich meat)-Increased red meat
-Alcohol-Increased animal fat -Preservative and additives-Increased
incidence of cancer in the _________________________*that is why
there is a higher incidence of cancer > age 60-The most
important risk factor for cancer = Aging-Cruciferous veggies
(broccoli, cauliflower, and cabbage), Vitamin A foods
(coloredveggies), and Vitamin C could _________________
risk-African Americans have a _______________ incidence than
Caucasians.-Primary Prevention: Ways to prevent actual occurrence
(sunscreen and no smoking)-Secondary Prevention: Using
_______________ to detect cancer early when there isa greater
chance for cure or control-Chronic _________________ brings about
uncontrolled growth of abnormal cells.2. Prevention:a.
Female:-monthly self- breast exam-_____________clinical breast exam
for women >40 years old- Between ages 20-39 needed every 3
years-_____________ pelvic exam-Pap smear: every 3 years if there's
been no problem-Mammogram: baseline at age 35-40, yearly after age
40 (2 views of each breast)-Colonoscopy: at age 50 then every 10
years after that time.OncologyHurst Review Services29b.
Male:-____________ self-breast exam-Monthly testicular exam -
testicular tumors grow __________-Yearly digital rectal exam and
yearly PSA (prostate specific antigen) for menover age
50-Colonoscopy at age 50 then every 10 years3. General
S/S:-CAUTION: Change in bowel/bladder habitsA sore that does not
healUnusual bleeding/dischargeThickening or lump in breast or
elsewhere;Indigestion or difficulty swallowingObvious change in
wart or mole;Nagging cough or hoarseness-Cancer can invade bone
marrow ______________and thrombocytopenia-Cachexia- extreme wasting
and malnutrition4. General Tx:a. Radiation therapy:1) Internal
Radiation (brachytherapy)-With all brachytherapy, the radioactive
source is inside the client; radiation isbeing emitted-Types of
Internal Radiationa) Unsealed: client and body fluid emit
radiation-isotope is given IV or PO-usually out of system in 48
hoursb) Sealed or solid: client emits radiation; body fluids not
radioactive-implanted close or in the tumorOncologyHurst Review
Services30-In gen e r a l t e r m s , do radiation implants emit
radiation to the generalenvironment?-Nursing assignments should be
rotated ___________, so that the nurse is notcontinuously
exposed-The nurse should only care for___ client with a radioactive
implant in a givenshift-Precautions with Internal Radiation-private
room-wear a film badge at all times-restrict visitors-limit each
visitor to 30 min per day-no visitors less than 16 years of
age-visitors must stay at least 6 feet from source-no pregnant
visitors/nurses-mark the room-How can you help prevent dislodgment
of the implant?-Keep the client on _____________.-Decrease
_______________ in the diet.-Prevent bladder distention.-What do
you do if the implant becomes dislodged and you see it?*Dont forget
this client is immunosuppressed.2) External Radiation (teletherapy,
beam radiation):-Usual side effects of external radiation are
usually limited to the exposedtissues:-erythema-shedding of
skin-altered taste-fatique-pancytopenia (all blood components are
decreased)-Many signs and symptoms are___________and
___________related-Is it okay to wash off the markings? No-Is it
okay to use lotion on the markings? No-Protect site from sun for 1
year after completion of therapyOncologyHurst Review Services31b.
Chemotherapy-works on the ______________ cycle-usually scheduled
every 3-4 weeks-most Chemo drugs are given IV via port-many absorb
through the skin and mucous membranes; be careful handling
them-usual side effects: alopecia, N/V, mucositis,
immunosuppression, anemia,thrombocytopenia-A client's WBC count
must be at least 3,000 before they will receive theirtreatment.-A
vesicant is a type of chemo drug that if it infiltrates
(extravasates) willcause tissue_____________.-What are S/S of
extravasation?-The #1 thing to remember with extravasation is
prevention!-What do you do if this happens?The physician may
aspirate any infiltrated medication from the tissues and inject a
neutralizing solution into thearea to reduce tissue damage. The
drug that is used to TREAT extravasation depends on the specific
chemo drugthat extravasated and can usually be found in the drug
insert.For NCLEX, stop the infusion and think vasoconstriction to
prevent spreading.OncologyHurst Review Services32B. General Ways to
Prevent Infection-Private______________-Wash hands-Have own
_______________ in room-Limit people (visitors and nurses) in
room-Change dressing and IV tubing daily.-Cough and deep breath-No
fresh ____________or potted _________________-Avoid crowds-Do not
share toiletries-Bathe warm moist areas __________________________
(groin and under the arms)-wash hands after touching pet-Avoid raw
__________and __________-Drink only fresh waterRemember:-Slight
increase in temp may mean ______________-Absolute neutrophil count
most importantOncologyHurst Review Services33C. Specific Types of
Cancer:1. Cervical Cancer:a. Risk Factors:-Sex /pregnancy at young
__________-Repeated STDsb. S/S:-Often asymptomatic in pre-invasive
cancer-Invasive cancer classic symptom:
________________________________bleeding-Other general S/S: watery,
blood-tinged vaginal discharge, leg pain along sciaticnerve, and
back/flank pain-100% cure if detected earlyc. Dx:-What is the test
that helps diagnose this?-Abnormal ? Repeat testd.
Tx:-electrosurgical excision-laser-cryosurgery- _______________and
chemo for late stages-conization- remove part of
_____________-hysterectomyOncologyHurst Review Services342. Uterine
Cancer:a. Risk Factors:-Greater than ______years of age-Positive
family history-_________ menopause-No pregnancy (null parity)b.
S/S:-Major Symptom: post _____________ bleeding-Other S/S: watery/
bloody vaginal discharge, low back/abd pain, pelvic painc.
Dx:-CA-125 (blood test) to R/O ____________ involvement-Test to
evaluate for metastasis:-CXR (chest x-ray) -CT-IVP (Intra Venous
Pyelogram) -liver and bone scan-BE (Barium Enema)-The most
definitive diagnostic test is D&C (dilatation & curettage)
and endometrialbiopsyd. Tx:1) Surgery:-Hysterectomya) TAH (total
abd hysterectomy) = uterus and cervix only!:-Tubes & ovaries
removed?-bilateral oophorectomy (ovaries)-bilateral salpingectomy
(tubes)OncologyHurst Review Services35b) Radical Hysterectomy:-may
remove all of the pelvic organs-client may have colostomy, ileal
conduit-The greatest time for hemorrhage following this surgery
isduring the first 24 hours.-Why? Pelvic congestion of
_____________________-Major complication with abd hysterectomy?
hemorrhage-Major complication with vaginal
hysterectomy?___________-Will probably have a foley; if she doesn't
you better make sureshe does what in the next 8 hours?-Why is it so
important to prevent abdominal distension afterthis surgery?-We do
not want tension on the _____________________-Dehiscence and
Evisceration-Why do we avoid high-fowler's position in this
client?-May have an abdominal and perineal dressing to check.-As
this client is at risk for pneumonia, thrombophlebitis,
andconstipation what is one thing you can do to prevent
thesecomplications?-Avoid sex and driving. -Also avoid girdles and
douches.-Any exercise, including lifting heavy objects that will
increasespelvic __________ should be avoided.-Is it possible that
the client could hemorrhage l0-l4 days afterthis surgery? Yes-Is a
whitish vaginal discharge okay?-Showers OR baths?
showersOncologyHurst Review Services362) Radiation: intra-cavitary
radiation to prevent vaginal recurrence3) Chemotherapy: Doxorubicin
(Adriamycin), Cisplatin (Platinol-AQ)4) Estrogen inhibitors:
Medroxyprogesterone (Depro-Provera) , Tamoxifen(Nolvadex /
Soltamox)3. Breast Cancer:a. Risk Factors:-One has a 3 fold risk
increase of developing breast cancer if a ________ degreerelative
(Mother, sister, daughter) had pre-menopausal breast cancer-Known
risk factors-High dose radiation to thorax prior to age
20-___________ onset prior to age 12-Menopause after age
________-No pregnancy (null parity)-First birth greater than
________ years oldb. S/S:-Change in the appearance of the breast
(orange peel appearance, dimpling,retraction, discharge from
breast), or lump-Tail of Spence: Located in upper outer quadrantc.
Tx:1) Surgery:-Post-op care:-Bleeding check dressings, back
(pooling of blood), hemovac,Jackson- Pratt drain-Elevate arm on
______________ side-Associated nursing care: Stay away from arm on
affected side for lifetimeof client:-No watch, no constriction, no
BP's or injections, wear gloves whengardening, watch small cuts, no
nail biting, and no sunburn, no IV-Brush hair, squeeze tennis
balls, wall climbing, flex and extend elbow.-Why? Promotes
__________circulationOncologyHurst Review Services37-Look at
incision-Reach to Recovery (Support Group)-Lymphedema*Two functions
of the lymphatic system:-____________ infection and promotes
drainage2) Chemotherapy drugs: Paclitaxel (Taxol), Doxorubicin
(Adriamycin)3) Estrogen receptor blocking agents: Tamoxifen
(Nolvadex / Soltamox)4) Estrogen synthesis inhibitors: Leuprolide
(Lupron), Goserelin (Zoladex)5) Radiation:4. Lung Cancer:a. Risk
Factors:-Leading cause of cancer death worldwide-Five year survival
rate is 14%-Major risk factor : _______________*when you have
stopped smoking for 15 years, the incidence of lung cancer isalmost
like that of a non-smokerb. S/S:-hemoptysis, dyspnea (may be
confused with TB, but TB has night sweats, too),hoarseness, cough,
change in endurance, chest pain, pleuritic pain on
inspiration,displaced trach-may metastasize to bonec. Dx:1)
Bronchoscopy:-NPO pre and NPO until ___________________________
returns-Watch for respiratory depression, hoarseness, dysphagia, SQ
emphysema-Is it normal or abnormal to have respiratory depression
after a bronchoscopy?OncologyHurst Review Services382) Sputum
specimen:-Best time to obtain? In the morning-Is this sterile?-What
should the client do first?-Trying to decrease bacterial count in
the mouth.3) CT:4) MRI:d. Tx:-Surgery: The main treatment for stage
I and II1) Lobectomy:-chest tubes and surgical side up2)
Pneumonectomy:-Position on affected side (surgical side down)-No
chest tubes. Why?-Avoid severe lateral positioning mediastinal
____________________ OncologyHurst Review Services395. Laryngeal
Cancer:a. Risk factors:-______________ (any form of tobacco use),
alcohol, voice abuse, chroniclaryngitis, industrial chemicalsb.
S/S:-Hoarseness, difficulty swallowing, burning, sore throat,
swelling in neck, loss ofspeech, no early signs, mouth sores, lump
in neck, color changes in mouth/tongue,dentures do not fit anymore,
unilateral ear painc. Dx:-Laryngeal exam, MRId. Tx:1)
Surgery:-Total laryngectomy (removal of _________cords, epiglottis,
thyroid cartilage)-Since the whole larynx (remember this includes
the epiglottis) is removed thisclient will have a permanent
______________________________.-Position post-op?-NG feedings to
protect the suture line (peristalsis could disrupt suture
line)-Monitor drains-Watch for carotid artery rupture-Rupture of
innominate artery-medical emergency-Frequent
_____________care-decrease bacterial count in the mouth-NPO clients
tend to get pneumonia-Bib (acts like a filter)-Humidified
environment*Remember, with a total laryngectomy ALL breathing is
done through thestoma.OncologyHurst Review Services402)
Radiation:3) Chemotherapy:Obturator: Place obturator (smooth,
plastic trach guide) into the outer cannula & insert intostoma
to prevent tracheal collapse. Remove obturator at once (client cant
breathewell while in place). Reinsert inner cannula & lock in
place. Inflate cuff to holdeverything in place.4) Can the client
with a total laryngectomy:-Whistle? ______________________-Smoke?
_______________________-Use a straw? ___________________-Swim?
________________________5) Suctioning:-Sterile or Non-sterile
technique?-Hyperoxygenate when?-When do you stop advancing the
catheter? When you meet resistance or yourclient coughs.-Apply
suction when?-Intermittent or continuous? *Dont be mean.-Suction no
longer then _____________ seconds.-Watch for arrhythmias.-Which
nerve can be stimulated? vagus nerve-When _________________ nerve
is stimulated, heart rate _________________-Is this client
hypoxic?Early signs of hypoxia:Restlessness and tachycardiaLate
signs of hypoxia:Cyanosis and bradycardiaOncologyHurst Review
Services416. Colorectal Cancer (CRC):a. Risk Factors:-May start as
a polyp-2/3 colorectal cancer occurs in the rectosigmoidal
region-Most frequent site of metastasis: __________________-take
bleeding precautions-Other problems to watch for: Bowel
obstruction, perforation, fistula tobladder/vagina-Risk Factors:
inflammatory bowel diseases, genetic, chronic constipation
(retainingcarcinogens), dietary factors (refined carbs, low fiber,
high fat, redmeat, fried and broiled foods), if you have a first
degree relative withCRC your risk just increased 3X the norm-95% of
those who get CRC are > 50 years oldb. Dx:-Screening:-Fecal
occult blood testing should begin at ____________-Flexible
sigmoidoscopy every 5 years after age 50 orcolonoscopy every 10
years after age 50-The definitive test for CRC =
_____________________c. S/S:-Most common signs are: rectal
bleeding, anemia, and changes bowel habits/stool-Other S/S: blood
in the stool, vague abdominal pain, fatigue, abd
fullness,unexplained weight loss-May become obstructed (visible
peristaltic waves with high pitched tinkling bowelsounds)d.
Tx:-Surgery, radiation and chemo (DOC= Fluorouracil (5-FU)-May have
a colostomy post-op1) colectomy-part of _______________ removed-may
not need colostomy2) abdomino-perineal resection-removal of
______________, anus, rectum*Can you take a rectal temp on this
client?Dont take rectal temp if thrombocytopenic,
abdominal-perineal resection, immunosuppressed.Things that should
beavoided for 48 hoursprior to collection ofstool sample: ASA,Vit
C, any antiinflammatorydrug,and perioxidasecontaining foods(beets,
horseradish)OncologyHurst Review Services427. Bladder Cancer:a.
Risk Factors:-Greatest risk factor: _______________b. S/S:-Major
Symptom: _________________intermittent gross/microscopic
hematuriac. Dx:-Cystoscopyd. Tx:-Surgery (all/part of bladder)
Urinary diversion (urostomy)-Ileal conduit (a piece of the ileum is
turned into a ________; ureters are placed inone end; the other end
is brought to the abd. surface as a stoma)-May be impotent-Hourly
_____________________-Increase fluids: (2,000-3,000 ml of fluid per
day)-flush out conduit-Mucus normal?-Intestines always make mucus
(the bladder is made from a part of intestine)-Change appliance in
________________ (This is when output will be at its lowest).It is
OK to place a little piece of 4 X 4 inside stoma during skin care
to absorb urine.Just dont forget to remove it OncologyHurst Review
Services438. Prostate Cancer:a. S/S:-This client comes to the
doctor with S/S of benign prostatic hyperplasia (BPH):hesitancy,
frequency, frequent infections (because the bladder is not
completelyemptied), nocturia, urgency, dribbling. Many clients are
asymptomatic.-Most common sign is painless ________________-Digital
rectal exam done and prostate is hard /nodular; this usually means
prostatecancer.b. Dx:1) Lab work:-PSA will be increased-Prostatic
Specific Antigen (PSA)-This is a protein that is only produced by
the prostate-Normal= l00 Apresoline (Hydralazine)-Only cure?-After
delivery, how long is the client at risk for seizures?-Single
room-Very quiet environment-Dim the lightsMaternity NursingHurst
Review Services164I. Eclampsia:1. Definition:-What is the turning
point from preeclampsia to eclampsia?2. Tx:-Monitor the FHT's-Watch
_______________-Watch for ________________ failureJ. Premature
Labor:1. Definition:-Labor that occurs between 20-37 weeks2. Tx:a.
Stop the labor:-Tocolytics:-Mg Sulfate-Terbutaline
(Brethine)-Betamethasone (Celestone), a corticosteroid, is given to
Mom IM inorder to get it to baby.-The purpose is to stimulate
maturation of the babys lungs incase preterm birth occurs.b.
Preterm labor can sometimes be stopped by hydrating Mom and
bytreating vaginal and urinary tract infections.Maternity
NursingHurst Review Services165K. Prolapsed Cord:1.
Definition:-When the umbilical cord falls down thru
__________________-Most likely to happen when presenting part is
not engaged andmembranes ____________________-So always, always,
always check FHTs when membranes ruptureeither spontaneously or
artificially.-If this occurs before complete dilation immediate
_______________-If cord is being compressed you would see variable
decelerations in FHT.-If cord ceases to pulsate fetal ____________;
we want the cord to pulsatebecause this tells us baby is getting
some oxygen-Fetal bradycardia is an indicator of _____________2.
Tx:-Lift head off cord until physician arrives if possible-Keep
manually pushing the head up to relieve pressure on the cord.-Let
someone else do all the preparations for an emergency
C-Section-Trendelenburg or ______________ chest
position-Oxygen-Want to make sure what little blood is getting to
baby ishyperoxygenated-Monitor
____________________________________________________-Saline
dressings around cord if protruding from _____________-Push it back
in? ________________Maternity NursingHurst Review Services166Group
B Streptococcus(GBS)Leading cause of neonatal morbidityRoutinely
assess for GBS risk factors during pregnancy and on admission to
L&DTransmitted to infant from birth canal of the infected
mother during deliveryAll pregnant women should be cultured between
35-37 weeks of gestationRisk factors for neonatal GBS:preterm birth
less than 37 weeks, + prenatal cultures in current pregnancy,
prematurerupture of membranes (longer than 18hr), positive history
for early- onset neonatalGBS, intrapartum maternal fever higher
than 100.4 F, previous infant with GBSTest or culture
Positive?Antibiotic prophylaxis offered (IV)If they do not have a
culture when the mother goes into labor or if the mother has arisk
factor then an antibiotic prophylaxis is offered
(IV)Treatment:Medication of Choice? PCNMaternity NursingHurst
Review Services167XVI. RESPIRATORYA. Thoracic (Chest) Procedures:1.
Thoracentesis:a. Pre-procedure:-_____________and
_______________-Positioning: Sitting up over the bedside table-Cant
sit up? Lie on _______________side with HOB at 45 b.
Procedure:-Client must be very still, no coughing or deep
breaths-The fluid is being removed from the
____________________________.-As the fluid is removed the lung
should ________________.-Since you are removing fluid, the client
could go into a fluidvolume______________.-Therefore, you should be
checking the _____________________________.c.
Post-procedure:-another _________________Conditions that might
cause apleural effusion and mightrequire a thoracentesis:CHF, lung
malignancies, orpneumonia.Other reasons a thoracentesismay be
performed:Instill medication in thepleural space; remove fluidfor
symptomatic relief or forbiopsy.In addition to monitoring vital
signs post fluid replacement, be sure to auscultate lungs, observe
chestwall symmetry, document pain level, check for pneumothorax and
assess pulse.RespiratoryHurst Review Services1682. Chest Tubes:a.
Chest tube Insertion:-What are the indications of a chest
tube?-Client will have an occlusive sterile dressing at insertion
site (around tube)-What is the purpose of the water-seal?-To
promote ____________________flow out of pleural spaceb. Nursing
Considerations:-Do you want to see fluctuation in the water seal
chamber?-Want to see fluctuation with respiration-What are we
watching the daily CXR's for?-Fluctuation will ____________when the
lung has re-expanded, kink/clot intubing, or if suction is not
working properly.-Why is it important to keep the bottles/chest
drainage unit (CDU) below thechest?-What do you do if the tubing
becomes disconnected?-What do you do if the bottles break/CDU
cracks and the water seal is lost?-You do whatever you have to do
to re-establish the water seal.-If the chest tube is connected to
suction, gentle continuous ___________isexpected in the suction
control chamber-Continuous, Vigorous/ __________ bubbling in the
water seal chamber =__________________ in the system-Call MD if the
drainage is >__________ml/hr or if drainage becomesBRIGHT red-Do
not milk or strip a chest tube without an order-NEVER clamp a chest
tube without an order-this could promote a
____________________pneumothoraxRespiratoryHurst Review
Services169c. Chest Tube Removal:-When the doctor removes the chest
tube the client will need to take a deepbreath and hold or valsalva
and a petroleum dressing with 4X4 will beplaced over the site.d.
Types of Chest Drainage Systems:Three Bottle SystemSuction control
2cm fluid water seal Collection bottleTube from
patientFluiddrainageTube open toatmospherevents airStraw under20
cmH2OTube tovacuumsourceFrom box to bedsideFrom bottles to a
boxCollectionchamberWater
sealchamberSuctioncontrolchamberfrompatientSuctioncontrolbottleWater
sealbottleCollectionbottleTo suction From patientAll pictures shown
on this page have been provided with permission from Atrium Medical
Corporation.RespiratoryHurst Review Services170B. Pulmonary
Embolism:1. Cause:-This can occur if a client becomes dehydrated,
has venous stasis, or has beentaking birth control pills. A
thrombus forms, dislodges (embolus), and goes to thelungs.2.
S/S:-Hypoxemia #l-Short of breath, cough, RR-Increased D Dimer +
(increased with pulmonary embolus; blood test)-will tell if a clot
is located anywhere in the body (not just the in the lungs)-will be
increased with any clot in the body-Positive VQ scan (a
ventilation/perfusion scan that can detect an embolus; done
inradiology)-looks at blood flow to the lungs, dye is used, remove
jewelry from chest areaso that it will not give false
results-hemoptysis-Pulse?-Chest pain (Sharp, stabbing)-CXR-BP in
lungs?-_____________________Hypertension-P023.
Tx:-Prevent!-Oxygen-Ventilator -ABG's-Watch
______________________________ (RV) for failure-Heparin sodium,
Warfarin (Coumadin), Enoxaparin (Lovenox)-Decrease painHypoxia lung
BP workload on right side of heart**Hypoxia is the number one cause
ofpulmonary hypertension**Little-
AsymptomaticMedium-SymptomaticLarge- DeathMonitor the rightatrial
pressures toassess for rightventricular
heartfailure.RespiratoryHurst Review Services171C. Chest
Trauma:-General treatment= _____________________, O2, CXR,
ventilation and elevate_________________________________________1.
Hemothorax/Pneumothorax:a. Pathophysiology:-Blood or air has
accumulated in the _________________________________.-What has
happened to the lung?-Hemothorax- S/S depend on size, breath sounds
on affected side,respiratory distress-Pneumothorax- Subcutaneous
emphysema, pleuritic pain, RRb. Tx:-Never pull out a penetrating
object-Thoracentesis, chest tubes, daily CXR-If a pneumothorax is
present and the client has a chest tube with no suction,what type
of bubbling would be expected to see in the water seal chamber?2.
Tension Pneumothorax (Trauma, PEEP):a. Pathophysiology:-___________
has built up in the chest/pleural space and has__________
thelung_____________pushes everything to the opposite side
(mediastinal shift)Subcutaneous emphysema or Sub Q air or
subcutaneous crepitations or crepitus all mean the samethingIt is
air that is trapped under the skin (due to trauma, pnumothorax,
infection) Your instructor said it feels like Rice Krispies
sound!Tension Pneumothorax is associated with: Trauma, mechanical
ventilation, resuscitation,obstructed/clamped chest
tubeRespiratoryHurst Review Services172b. S/S:-Subcutaneous
emphysema, absence of breath sounds on one side, asymmetry
ofthorax, respiratory distress-Can be fatal as accumulating
pressure compresses vessels decreases venousreturn, decreases
__________________________________________c. Tx:-Large bore needle
is placed into the 2nd ICS (by the doctor) to allow excess airto
escape, find the cause, chest tubes3. Open pneumothorax (sucking
wound):a. Pathophysiology:-Opening through chest allows air into
the __________________________b. Tx:-Have the client inhale and
hold or valsalva (take a deep breath and hold orhummmmm)-Both of
these will increase the intra-thoracic pressure so no more outside
air canget into the body-Then place a piece of petroleum gauze over
the area Tape down how manysides?-Have client sit up if possible to
expand lungs. Trauma clients stay flat.RespiratoryHurst Review
Services1734. Fracture of ribs (most common) and sternum:a.
S/S:-Pain & tenderness-crepitus (bones grating
together)-shallow________b. Tx:1) Non-narcotic analgesic2) Support
injured area with hands; turn on side (trying to limit movement)3)
Respiratory Therapies/Mechanical Ventilation-These clients will
usually be put on the ventilator with:a) PEEP: Positive End
Expiratory Pressure-On ventilator-On rate-On end expiration the
vent exerts a pressure down into the lungs tokeep alveoli
open-improves gas ___________, decreases work of ___________-In
this client PEEP expands the thorax, realigns ribsb) BiPAP:
Bi-level Positive Airway Pressure- u sed a lot with pulmonary edema
and sleep apnea; may do prior tointubation (BiPAP can be used
with/without intubation)c) CPAP: Continuous Positive Airway
Pressure-breathing on their own-may/may not be intubated-Anytime
you see PEEP, CPAP, or pressure support on a ventilator
yourpriority nursing assessment is to check bilateral
___________________.RespiratoryHurst Review Services1745. Flail
Chest (multiple rib fractures):a. S/S:-Pain-Paradoxical chest wall
movement (seesaw chest); chest sucks inwardly oninspiration and
puffs out on expiration-To assess chest symmetry always stand at
foot of bed to observe how thechest is rising and falling-Dyspnea,
cyanosis-Increased pulseb. Tx:-Stabilize the area, intubate,
ventilate-Positive pressure ventilation stabilizes the
areaRespiratoryHurst Review Services175XVII. ORTHOPEDICSA.
Fractures:1. S/S:-Continuous ________________-Unnatural
_________________-Deformity (possible)-Shortening of
_________________-____________________________________ (shortening
of extremity)-Crepitus (bones grating
together)-Swelling-Discoloration2. Tx:-Immobilize the bone ends
plus the adjacent joints-Support fracture above and below site-Move
extremity as little as possible-Splints help prevent _____ emboli
and ________ spasm.-What do you do with open
fractures?-Neurovascular checks: pulses, color, movement,
sensation, capillary refill, tempWorry
aboutcompartmentsyndrome!OrthopedicsHurst Review Services1763.
Complications:a. Shock:b. Fat embolism:-With what type of fractures
do you see this?-Symptoms depend on what?-Petechiae or rash over
chest -conjunctival hemorrhages-snow storm on CXR -young
males-first 36 hoursc. Compartment syndrome:1)
Pathophysiology:-This is when a fracture has not been elevated and
has not had ice packs._________ accumulates in the tissue and
impairs tissue perfusion.The muscle becomes swollen and hard and
the client complains ofsevere pain that is not relieved with pain
meds.-Unpredictable-___________is disproportionate to the injury-If
undetected may result in_____________ damage and
possibleamputation.-Common areas?2) Tx:-loosen the cast; bi-valve
the cast-fasciotomy-be careful of the answer Remove
cast.-orthopedic nurses have cast cutters readily
available-instruct the client the cast saw does not touch the skin,
but it does vibrated. Healing Concerns:1) Delayed union:-healing
doesn't occur at a normal rate2) Non-union:-failure of bone ends to
unite; may require bone grafting-S/S (both): persistent discomfort
and _______________OrthopedicsHurst Review Services1774. Cast
Care:-Ice packs on sides-No indentations-Use_____________ for 1st
24 hours - casting material is wet-Keep uncovered and
______________-Do not rest cast on hard surface or sharp edge-Cover
cast close to ________________with plastic-Elevate-Neurovascular
______________What do you do if your client complains of pain?5.
Traction:a. Miscellaneous Information:-Decreases
____________________________, reduces, immobilizes-Should it be
intermittent or continuous?-Weights should hang _______.-Keep
client pulled up in bed and centered with good alignment.-Exercise
non-immobilized______________-Ropes should move _____________and
knots should be ___________-Egg crate-Foot
_______________OrthopedicsHurst Review Services178b. Types of
Traction:1) Skin traction:-This is when tape or some type of
material is stuck to the skin and theweights pull against it.-Is
the skin penetrated?-Types: Buck's (used most often with hip
fractures) & Russell's (used mostoften with femoral
fractures)-Must do good skin assessmentsOrthopedicsHurst Review
Services1792) Skeletal traction:-This traction is applied directly
to the bone with ________ and___________.-Used when prolonged
____________ is needed.-Types: Steinman pins, Crutchfield,
Gardner-Wells tongs, Halo vest-Must monitor the pin sites and do
pin care.-Sterile tech?-Remove crusts?-Is serous drainage
okay?OrthopedicsHurst Review Services180B. Total Hip Replacement:1.
Pre-Op Care:-Buck's traction is used frequently pre-op2. Post-Op
Care:a. Nursing Considerations:-Neurovascular checks-Monitor drains
(Don't want fluid to accumulate in tissue)-Firm mattress (joints
need support)-Over-bed trapeze-Positioning:-neutral rotation - toes
to the ceiling-limit flexion; want extension of hip-abduction or
adduction?-What exercise can the client do while still confined to
bed?-What is the purpose of the trochanter roll?-No weight-bearing
until ordered by physician-Avoid crossing legs, bending over-Is it
okay to sleep on operated side?-Is hydration important with this
client?-Stresses to new hip joint should be minimal in the first
3-6 months.-Is it okay to give pain meds in the operative hip?b.
Complications:1) Dislocation circulatory/nerve damageS/S:
-shortening of leg, abnormal rotation, cant move extremity - pain2)
Infection:-prophylactic antibiotics (just like with heart valve
replacement)-remove foley and suction ASAP if not needed-these will
serve as a portal for infectionOrthopedicsHurst Review
Services1813) Avascular Necrosis: (death of tissue due to poor
circulation)4) Immobility problemsc. Client
Education/Rehabilitation:-Best exercise?-Avoid flexion low chairs,
traveling long distances, sitting more than 30minutes, lifting
heavy objects, excessive bending or twisting, stair climbing-CPM:
(Continuous Passive Motion) used mainly for knee replacements-very
important to check the angle of flexion.could ruin the surgery
iftoo much flexion occursC. Amputations:1. Miscellaneous
Information:-Performed at the most distal point that will heal. The
doctor tries to preserve theknee and elbow.2. Immediate Post-Op
Care:-Keep what at the bedside?-Elevate on pillow for first 24
hours. Then how do you elevate?-Prevent hip/knee contractures.
How?-Phantom pain-What is the first intervention to decrease
phantom pain?diversional ___________-Seen more with AKA's-Usually
subsides in 3 months.NCLEX Tip:Pain: use other things first prior
to pill; the definition of pain is what the client says itis;
Always assess the clients pain by having them rate their pain on a
pain scale (i.e.0-10).OrthopedicsHurst Review Services1823.
Rehabilitation:-Why is limb shaping important?-What is worn under
the prosthesis?-Why is it important to strengthen the upper
body?-Is it okay to bear weight on a new stump/prosthesis?-Is it
okay to massage the stump? Promotes ________________________and
decreases _____________________________-How do you teach a client
to toughen the stump?-Press into a ________ pillow-Then a ________
pillow-Then the _________-Then a _________OrthopedicsHurst Review
Services183XVIII. RENALA. Glomerulonephritis:1.
Pathophysiology:-Acute can lead to chronic-Inflammatory reaction in
the _________-Antibodies lodge in the glomerulus; get scarring
& decreased filtering-Main cause: Streph2. S/S:-sore throat
-flank pain CVA (costovertebral angle) tenderness-malaise
-BP-headache -facial edema-BUN & Creatinine
-UO-sediment/protein in urine -urine specific gravity-fluid volume
_________ -anemia erythropoetin3. Tx:-Get rid of the
strep-Dialysis-If the BUN is increased what should be done with the
protein in the diet?-Na?-Carbohydrates? -Keeps us from breaking
down protein for energy.-Bed rest-I & O and daily weights-How
is fluid replacement determined?-to account for insensible fluid
loss-Diuresis begins in l-2 weeks after onset.-Blood and protein
may stay in the urine for months.-Teach S/S of renal
failure:-Malaise, headache, anorexia, nausea, vomiting, decreased
output, weightgainNormal Lab ValuesBUN= 6-20 mg/dLCreatinineMale:
0.6-1.3 mg/dLFemale: 0.5-1.0 mg/dLSpecific Gravity
(urine)1.010-1.025RenalHurst Review Services184B. Nephrotic
Syndrome:1. Pathophysiology:2. Tx:-Bed
rest-Diuretics-Prednisone-shrink holes so protein cant get
out-immunosuppressed-Na?-Protein?-DialysisCommon Rule:Limit protein
with kidney problems except with Nephrotic Syndrome.Causes of
Nephrotic Syndrome(think inflammation):Many causes are idiopathic,
butmany clients that developnephrotic syndrome will also havesome
systemic disease.Causes: NSAIDS, heroin,Hodgkins disease, bacterial
(strepor syphilis) or viral infections,(hepatitis or HIV),
allergicreactions, diabetes and systemiclupus
erythematosusRenalInflammatory response in the glomerulus big holes
form so protein starts leaking out in theurine now the pt is
hypoalbuminemic (no albumin in the blood) without albumin you
can'thold on to fluid in the vascular space so where does all the
fluid in the vascular spacego?_______________ now the patient is
edematous since all the fluid is going out intothe tissue what has
happened to the circulating blood volume?_________ the kidneys
sensethis decreased volume and they want to help replace it
renin-angiotensin system kicksin aldosterone produced retention
of____________and ______________ but is thereany protein (albumin)
in the vascular space to hold it? so where does this fluid go?
_______Total Body Edema = ___________________________Hurst Review
Services185C. Renal Failure:-Requires bilateral failure1. Causes:a.
Pre (blood can't get to the kidney)-Decreased cardiac output caused
by arrhythmias, hypotension, decreasedheart rate, FVD, any form of
shock, sepsis, hemorrhageb. Intra (damage has occurred inside the
kidney)-glomerulonephritis, nephrotic syndrome, dyes (X-ray), drugs
(see box below),malignant hypertension (such as with PIH), Diabetes
Mellitus-malignant hypertension (uncontrolled HTN) and DM cause
severevascular damagec. Post (urine can't get out of the
kidney)-enlarged prostate, kidney stone, tumors, ureter
obstruction, edematousstomaNCLEX Sample Question Answers:a. Call
MDb. Turn from side to sidec. Irrigated. Reassess in 15
minMedications that could cause Intrarenal damage or should be used
withcaution in clients with renal damage:Streptomycin
sulfate(Streptomycin),Amikacin sulfate (Amikin),Gentamicin sulfate
(Garamycin),Netilmicin sulfate (Netromycin)Amphotericin
B,Vancomycin,Loop Diuretics,Ciprofloxacin (Cipro),Levofloxacin
(Levaquin),Ofloxacin (Floxin),Azithromycin
(Zithromax),Clarithromycin (Biaxin)Erythromycin (
Erythrocin)Clindamycin (Cleocin)THINK MYCINSRenalHurst Review
Services1862. S/S:-Creatinine and BUN-Specific gravity-Fixed
specific gravity-May lose ability to concentrate and dilute
urine.-Fluid challenge, 250ml bolus (done in acute renal failure,
not in chronic)-Anemia-not enough erythropoietin-HTNRetaining
volume-CHF-Anorexia, nausea, vomiting-Itching frost-uremic
frost-good skin care-Acid-base/fluid and electrolyte
imbalances-retain phosphorous serum calcium ______ calcium pulled
from _______3. Two phases of Acute Renal Failure:a. Oliguric
phase:-What has happened to UO?-This client is in a fluid volume
___________?-What do you think will happen to the K+?b. Diuretic
phase:-What is happening to the UO?-This client is in a fluid
volume _____________. (Shock)-What do you think will happen to the
K+?In the early stage of renal failure, blood pH changes little
because the remaining healthy nephrons cancompensate by increasing
their rate of acid excretion. In later stages of renal failure many
nephronsare lost, acid excretion (hydrogen ions) is reduced and
metabolic acidosis results.RenalHurst Review Services187D.
Dialysis:1. Hemodialysis:a. Miscellaneous Information:-The machine
is the glomerulus-If the client is allergic to _______________ they
can't be hemodialyzed-This is a generally accepted standard in many
areas (a good way to thinkfor NCLEX); however, if the client is
allergic to heparin, hemodialysiscan be used if another solution
with an anti-clot property (ex. sodiumcitrate) is used.-In regard
to the site used for hemodialysis (the access area/port): If
thisclient is allergic to heparin, then we must use another
solution to prevent aclot from forming at the end of our access
port (vascular access catheter);usually a product called Alteplase
(Cathflo) is used instead of heparin inthis situation.-Is done 3-4
times per week; so the client has to watch what in
betweentreatments?-depression-suicide-Electrolytes and BP are
watched constantly.-Can all clients tolerate hemodialysis?-unstable
cardiovascular system cant tolerate hemodialysis2. Circulatory
Access:-Must have a circulatory access:1) Types of Access:-A-V
shunt-Fistula-Graft-Temporary catheters (Asch catheter)-utilized
for short term access while the permanent access matures-Typically
used for 90 days or less due to the increase risk
ofinfection.RenalHurst Review Services1882) Care of Access:-Do not
use any of the above for IV access (drawing blood,administering
meds. etc.)-When a client has an alternate circulatory access what
is the associatednursing care?3) Assessment of Access:-Thrillcat
purring sensation-Bruit-Feel a thrillHear the bruit!-If you do not
feel the thrill or hear the bruitthe physician should benotified2.
Peritoneal Dialysis:a. Miscellaneous Information:-This is when
dialysate is warmed and infused into the peritoneal cavity
bygravity through a catheter.-The fluid (2000-2500 ml) stays in for
an ordered amount of time (dwell time).-Then the bag is lowered and
the fluid along with the toxins, etc., are drainedb. Nursing
Considerations:-Why do we warm the fluid?-Cold promotes
vasoconstriction limits blood flow-Want vasodilatation-What should
the effluent/drainage/fluid look like?-____________, straw-colored
cloudy = _______________-should be able to read a newspaper through
the drainage/effluent-What type of client gets peritoneal
dialysis?-What if all the fluid doesnt come out?RenalHurst Review
Services189c. Two Types of Peritoneal Dialysis:1) CAPD (Continuous
Ambulatory Peritoneal Dialysis):2) CCPD (Continuous Cycle
Peritoneal Dialysis):-connects their peritoneal dialysis catheter
to a cycler at night andperforms the exchange while sleeping;
Disconnects in the AM; has morefreedomCAPD (cont):-A type of
peritoneal dialysis-Must have a semi-strong client that has the
energy and the desire to beactive in their treatment and that also
has the ability to learn and followinstructions.-Done 4 times per
day; 7 days a week-Is an exchange done at night?-Could a client
with disc disease or arthritis do this?-Fluid causes pressure on
back-Could a client with a colostomy do this?-high risk for
__________________________d. Complications of Peritoneal
Dialysis:-peritonitis #1 (abd pain, peritonitis, cloudy effluent
lst sign)-constant sweet taste -anorexia-hernia -low back
pain-altered body image/sexualityRenalHurst Review Services190e.
Dietary Needs of the Peritoneal Client:-Increase what in the
diet?-Fiber have decreased peristalsis due to abdominal
fluid-Protein Big holes in peritoneum and lose protein with each
exchange3. Continuous Renal Replacement Therapy (CRRT):4.
Ultrafiltration:-Only pulling off water-May be utilized with
peritoneal dialysis or hemodialysis-Same principles applied as with
hemodialysis-Prisma is the name brand of the kidney (filter)
utilized in manyfacilities.-Typically done in an ICU setting on
clients whose cardiovascularstatus would have difficulty with
hemodialysis due to the drastic fluidshifts.-Hemodialysis is more
aggressive; at any given time duringhemodialysis there is
approximately 300 ml of blood in the machine(kidney); however, with
CRRT there is only approximately 80 ml ofblood in the
machine.RenalHurst Review Services191E. Kidney Stones
(urolithiasis, renal calculi):1. S/S:-Pain
(nausea/vomiting/vasovagal response)-WBCs in
urine-Hematuria-Anytime you suspect a kidney stone get a urine
specimen ASAP and have itchecked for RBCs.-If RBCs are present,
then its probably a kidney stone and the client will get
painmedicine immediately.2. Tx:- Ketorolac (Toradol), anti-emetics
Promrthazine (Phenergan), Ondansetron,(Zofran), Hydromorphone
(Dilaudid)-Increase fluids-Maybe surgery-Strain
urine-Extracorporeal shock wave lithotripsy (ESWL)-worry about
arrhythmias-client will also have blood in urine and possible
bruising on back area dueto the shock waves post
procedure.Ketorolac (Toradol)may not be given as itmay lead to
renaldamage.Ketorolac (Toradol) is a NSAID so it wouldbe sure to
take good bleeding history!RenalHurst Review Services192Fluid &
Electrolyte and Acid- Base1. Evaluation of successful resolution of
a fluid volume deficit may be demonstrated by whichof the
following?1. The client demonstrates an absence of postural
hypotension and tachycardia2. The client adheres to prescribed
dietary sodium restrictions3. The client maintains weight loss4.
The client maintains a serum Na above 145 mEq2. Ms. Stone is
admitted with a serum magnesium deficit. Assessment reveals a
positiveTrousseaus and Chvosteks signs. Which of the following
nursing diagnosis would be mostappropriate?1. High risk for injury
R/T increased neuromuscular irritability2. High risk for injury R/T
fractures secondary to loss of calcium3. Fluid volume deficit R/T
dehydration4. Activity intolerance R/T skeletal muscle weakness3.
Ms. Fair is a 77-year-old female. Her husband reports that she has
had a poor appetite overthe past two weeks, with occasional nausea
and vomiting. When placed on a cardiac monitorvarious abnormal
heart beats are noted. Based on this data, the nurse would suspect
that Ms.Fair is experiencing.1. Hyponatremia2. Hypermagnesemia3.
Hypercalcemia4. Hypokalemia4. The nurse is caring for a thoracotomy
client, one day post operative on 40% humidifiedoxygen. ABG results
are: PO2=90, PCO2=49, pH=7.30, HCO3=26. Based on thisinformation,
which of the following nursing actions would be best?1. Position in
high fowlers and encourage coughing, deep breathing, evaluate
airwaypatency2. Place in prone position and request respiratory
therapy to perform postural drainage andpercussion therapy3. Call
the doctor and advise him of the ABGs; anticipate increase in
oxygen percentage4. Administer anti-anxiety agent and assist the
client with a rebreathing device to increaseoxygen
levelsQuestionsHurst Review Services1935. It is 0600 and a client
is scheduled for a cardiac catheterization at 0800. Laboratory
workcompleted five days ago showed: K 3.0 mEq/L, Na 148 mEq/L,
glucose 178 mg/dL. Hecomplains of muscle weakness and cramps. Which
nursing action should be implemented atthis time?1. Hold 0700 dose
of spironolactone (Aldactone)2. Encourage eating bananas for
breakfast3. Call the physician to suggest a stat K level4. Call for
a twelve lead ECGBurns6. A client is admitted to the ER with second
and third degree burns to her anterior chest, botharms, and right
leg. Priority information to determine at the time of admission
would includewhich of the following?1. Percentage of burned surface
area2. Amount of IV fluid necessary for fluid resuscitation3. Any
evidence of heat inhalation or airway problems4. Circumstances
surrounding the burn and contamination of the area7. A family
member of a client who has sustained an electrical burn states, I
dont understandwhy he has been here a week, the burn doesnt look
that bad. The nurses response would bebased on which of the
following?1. Electrical burns are more prone to infections2.
Electrical burns are always much worse than they look on the
outside3. Cardiac monitoring is important since burns always affect
cardiac function4. Electrical burns can be deceptive as underlying
tissue is damaged8. A client has severe second and third degree
burns over 75 percent of his body. Whichassessment finding
indicates an early problem with shock?1. Epigastric pain and
seizures2. Widening pulse pressure and bradycardia3. Cool and
clammy skin and tachypnea4. Kussmaul respirations and lethargy9.
During a first aid class, the nurse is instructing clients on the
emergency care of seconddegree burns. Which of the following
interventions for second degree burns of the chest andarms will
best prevent infection?1. Wash the burn with an antiseptic soap and
water2. Remove soiled clothing and wrap victim in a clean sheet3.
Leave blisters intact and apply an ointment4. Do nothing until the
victim arrives in a burn unit.QuestionsHurst Review
Services194Oncology10. To promote safety in the care of a client
receiving internal radiation therapy the nursewould:1. Restrict
visitors who may have an upper respiratory infection2. Assign only
male care givers to the client3. Plan nursing activities to
decrease nurse exposure4. Wear a lead lined apron whenever
delivering client care11. Which of the following measures should
the nurse take while a client has a radium implantfor the treatment
of uterine cancer?1. Evaluate the position of the applicator every
two hours2. Place on a low residue diet to decrease bowel
movements3. Encourage the use of the bedside commode every 1-2
hours4. Decrease fluid intake to decrease radiation in bladder12. A
client with lung cancer and bone metastasis is grimacing and
states, I am a littleuncomfortable, may I have something for pain?
Which of the following should the nurse dofirst before
administering pain medication?1. Check the chart to determine last
medication2. Encourage client to refocus on something pleasant3.
Notify doctor that medication is not working4. Assess the severity
and location of pain13. A client on chemotherapy has a WBC count of
1200 mm. Based on this data, which of thefollowing nursing actions
should the nurse take first?1. Check temperature q4h2. Monitor
urine output3. Assess for bleeding gums4. Obtain an order for blood
cultures14. A client is admitted to the outpatient unit in the
Cancer Center for his chemotherapy. He islethargic, weak, and pale.
His WBC count is 3000. Which of the following nursinginterventions
would be most important for the nurse to implement?1. Establish
emotional support2. Position for physical comfort3. Maintain
respiratory isolation4. Hand washing prior to careQuestionsHurst
Review Services19515. Which of the following properly stated
nursing diagnoses would be a priority for a 65-yearoldclient
immediately after her modified radical mastectomy and axillary
dissection?1. Anxiety related to the mastectomy2. Skin integrity,
impairment of, related to mastectomy3. Alteration in comfort
related to incisional pain4. Self-care deficit related to dressing
changes16. A client had a radical mastectomy for cancer in her
right breast. After she returns to yourunit, which of the following
would be the most appropriate for her?1. Left side with right arm
protected in a sling2. Right side with right arm elevated3.
Semi-fowlers position with right arm elevated4. Prone position with
right arm elevated17. A client with prostatic cancer is admitted to
the hospital with neutropenia. Which signs andsymptoms are most
important for the nurse to report to the next shift?1. Arthralgia
and stiffness2. Vertigo and headache3. General malaise and
anxiety4. Temperature elevation and lethargy18. A 32-year-old male
with acute lymphocytic leukemia (ALL) is admitted with shortness
ofbreath, anemia, and tachycardia. Based on this nursing
assessment, the most appropriatelystated nursing diagnosis would
be:1. Altered protection, immunosuppression: Leukemia2. Impaired
gas exchange related to decreased RBCs3. Potential for infection
related to altered immune system4. Potential injury to decreased
plateletsQuestionsHurst Review Services196Endocrine19. A client is
admitted with diabetic ketoacidosis. You note his respiratory rate
to be 38.Considering his condition you are aware that this
increased rate is a result of:1. An effort by the body to
compensate for respiratory acidosis2. An effort by the body to
remove excess acid from the body3. An effort by the body to supply
more oxygen to the depleted tissues4. An effort by the body to
conserve CO220. The client is admitted with acute
hypoparathyroidism. To maintain client safety, which itemis most
important to have available?1. Tracheostomy set2. Cardiac monitor3.
IV monitor4. Heating pad21. To evaluate for the desired response of
calcium gluconate in treating acutehypoparathyroidism the nurse
would monitor the client most closely for:1. Intake and output2.
Confusion3. Tetany4. Bone deformities22. Which symptom is most
important for the nurse to report to the next shift about theclient
with hyperparathyroidism?1. Abdominal discomfort2. Hematuria3.
Muscle weakness4. Diaphoresis23. The nurse would caution the client
with hypothyroidism about avoiding:1. Warm environmental
temperatures2. Narcotic sedatives3. Increased physical exercise4.
Numbness and tingling of fingers24. In planning care for the client
with hyperthyroidism, the nurse would anticipate the client
torequire:1. Extra blankets for warmth2. Ophthalmic drops on a
regular basis3. Increased sensory stimulation4. Frequent low
calorie snacksQuestionsHurst Review Services19725. The elderly
client with hyperparathyroidism should be cautioned about:1.
Pathological fractures2. Decreasing fluid intake3. Tetany and
tingling of fingers4. Increasing physical activity26. The nurse is
aware that which of the following statements made by the client
indicates acorrect understanding of steroid therapy for Addisons
Disease?1. Ill take the medicine in the morning because if I take
it at night it might keep meawake.2. Ill take the same amount from
now on.3. Ill increase my potassium by eating more bananas.4. Ill
be eating foods low in carbohydrates and salt.27. Which nursing
action has the highest priority in caring for the client
withhypoparathyroidism?1. Develop a teaching plan2. Plan measures
to deal with cardiac arrhythmias3. Take measures to prevent a
respiratory infection4. Assess laboratory results28. A client is
going to have a parathyroidectomy. Which of the following foods
would thenurse discourage the client from eating?1. Milk products2.
Green vegetables3. Seafood4. Poultry products29. Which of the
following types of foods would the nurse encourage the client
withhypoparathyroidism to eat?1. High phosphorus2. High calcium3.
Low sodium4. Low potassium30. A client is admitted for a series of
tests to verify the diagnosis of Cushings syndrome.Which of the
following assessment findings would support this diagnosis?1.
Buffalo hump, hyperglycemia, and hypernatremia2. Nervousness,
tachycardia, and intolerance to heat3. Lethargy, weight gain, and
intolerance to cold4. Irritability, moon face, and dry
skinQuestionsHurst Review Services19831. One hour after receiving 7
units of regular insulin, the client presents with
diaphoresis,pallor, and tachycardia. The priority nursing action
would be:1. Notify the doctor2. Call the lab for a blood glucose
level3. Offer the client milk and crackers4. Administer Glucagon32.
A client was admitted for regulation of her insulin. She takes 15
units of Humulin insulinat 8:00 a.m. every day. At 4:00 p.m., which
of the following nursing observations wouldindicate a complication
from the insulin?1. Acetone odor to the breath, polyuria, and
flushed skin2. Irritable, tachycardia, and diaphoresis3. Headache,
nervousness, and polydipsia4. Tenseness, tachycardia, and
anorexia33. A client received regular insulin, 6 units, 3 hours
ago. Which of the following assessmentswould be most important to
report to the next shift?1. Kussmauls respirations and
diaphoresis2. Anorexia and lethargy3. Diaphoresis and trembling4.
Headache and polyuriaQuestionsHurst Review
Services199Cardiovascular34. A client with sudden onset of deep
vein thrombosis is started on a heparin IV drip. Which ofthe
following additional orders should the nurse question?1. Cold wet
packs to the affected leg2. Elevate foot of bed six inches3.
Commode privileges without weight-bearing4. Elastic Stockings on
unaffected leg35. The nurse is caring for a client with deep vein
thrombosis (thrombophlebitis) of the left leg.Which of the
following would be an appropriate nursing goal for this client?1.
To decrease inflammatory response in the affected extremity and
prevent emboliformation2. To increase peripheral circulation and
oxygenation of affected extremity3. To prepare client and family
for anticipated vascular surgery on affected extremity4. To prevent
hypoxia associated with the development of pulmonary emboli36.
Which of the following signs indicate effective CPR?1. Adequate
capillary refill2. Normal skin color3. Symmetrically dilated
pupils4. Palpable carotid pulse37. A permanent demand pacemaker set
at a rate of 72 is implanted in a client for persistentthird degree
block. Which of the following nursing interventions would indicate
apacemaker dysfunction?1. Pulse rate of 88 and irregular2. Apical
pulse rate regular at 683. Blood pressure of 110/80, pulse of 784.
Tenderness at site of pacemaker implant38. A client with an
irregular pulse rate of 181 and a K level of 3.0 mEq/L has
Lanoxinordered. The nurse should:1. Give the digoxin since the
pulse is within normal limits2. Holds the digoxin since the pulse
is irregular3. Call the doctor to report the potassium4. Hold the
digoxin since toxicity occurs with high potassium
levelsQuestionsHurst Review Services20039. The nurse has
administered sublingual nitroglycerin (Nitrostat) to a client
complaining ofchest pain. Which of the following observations is
most important for the nurse to report tothe next shift?1. The
client indicates the need to use the bathroom2. Blood pressure has
decreased from 140/80 to 90/603. Respiratory rate has increased
from 16 to 244. The client indicates the chest pain has subsided40.
A 72-year-old client has an order for digoxin (Lanoxin) 0.25 mg PO
in the morning. Thenurse reviews the following information:apical
pulse: 68respirations: 16plasma digoxin level: 2.2 ng/mlBased on
this assessment, which nursing action is appropriate?1. Give the
medication on time2. Withhold the medication, notify the
physician3. Administer epinephrine 1:1000 stat4. Check the clients
blood pressure41. Question deleted due to NCLEX changes. We are
sorry for the inconvenience, but wewant to make sure that you have
the most up to date information.QuestionsHurst Review
Services201Respiratory42. When obtaining a specimen from a client
for sputum culture and sensitivity which of thefollowing
instructions would be best?1. After pursed lip breathing cough into
container2. Upon awakening cough deeply and expectorate into
container3. Save all sputum for 3 days in covered container4. After
respiratory treatment expectorate into container43. Which of the
following is the most effective method for the nurse to evaluate
theeffectiveness of tracheal suctioning?1. Note subjective data
such as, My breathing is much improved now.2. Note objective
findings such as decreased respiratory rate and pulse3. Consult
with respiratory therapy to determine effectiveness4. Auscultate
the chest for change or clearing in adventitious breath sounds44.
After a bronchoscopy is completed with a client, which of the
following nursingobservations would indicate a complication?1.
Depressed gag reflex2. Sputum streaked with blood3. Tachypnea4.
Widening pulse pressure45. The nurse is caring for a client with
pneumonia. Which of the following nursingobservations would
indicate a therapeutic response to the treatment for the
infection?1. Oral temperature of 101F, increased chest pain with
non-productive cough2. Cough productive of thick green sputum,
client state he feels tired3. Respirations at 20, with no
complaints of dyspnea, moderate amount of thick whitesputum4. White
cell count of 10,000 mm, urine output at 40 ml/hr, decreasing
amount of sputum46. During the shift report, a clients ventilator
alarm is activated. Which action would the nurseimplement first?1.
Notify the respiratory therapist2. Check the ventilator tubing for
excess fluid3. Deactivate the alarm and check the spirometer4.
Assess the client for adequate oxygenationQuestionsHurst Review
Services20247. The nurse is caring for a client who has a 5 year
history of chronic lung disease. Thenursing assessment reveals a
severely dyspneic client, pulse at 140, respirations labored,and
slightly cyanotic. An appropriate nursing action to relieve the
clients dyspnea wouldinclude:1. Administer oxygen at 40% heated
mist2. Assist the client to cough and deep breathe3. Elevate the
head of the bed, low flow oxygen4. Position the client prone and
assess breath sounds48. Question deleted due to NCLEX changes. We
are sorry for the inconvenience, but wewant to make sure that you
have the most up to date information.49. The nurse is caring for a
client who has been immobilized for three days following aperineal
prostatectomy. The client begins to experience sudden shortness of
breath, chestpain, and coughing with blood-tinged sputum. Immediate
nursing actions would include:1. Elevate the head of the bed, begin
oxygen, assess respiratory status2. Assist the client to cough, if
unsuccessful then perform nasotracheal suctioning3. Position in
supine position with legs elevated; monitor CVP closely4.
Administer morphine for chest pain; obtain a 12 lead ECG to
evaluate cardiac status50. Your client becomes extubated while
being turned. He is cyanotic and has bradycardia andarrhythmias.
Which action would be the highest priority while waiting for a
physician toarrive?1. Immediately begin CPR2. Increase the IV
fluids3. Provide oxygen by ambuing and maintaining the airway4.
Prepare the medication for resuscitationQuestionsHurst Review
Services203Orthopedic51. A client had a below-the-knee amputation
due to problems with gangrene. During the first 2hours after
surgery which nursing action would be most important?1. Notify the
doctor of a small amount of serosanguineous drainage2. Elevate the
stump on a pillow to decrease edema3. Maintain the stump flat on
the bed by placing the client in the prone position4. Do passive
range of motion TID to the unaffected leg52. A client is admitted
with a fractured right hip. The doctor writes an order for
Buckstraction. In planning care for a client in Bucks traction, the
nurse would:1. Turn the client every two hours to the unaffected
side2. Maintain client in a supine position3. Encourage client to
use a bedside commode4. Prevent foot drop by placing a foot board
to the bed53. Question Deleted Due To NCLEX Changes. We are sorry
for the inconvenience, but wewant to make sure that have the most
up to date information.54. Following hip replacement surgery, an
elderly client is ordered to begin ambulation with awalker. In
planning nursing care, which statement by the nurse will best help
this client?1. Sit in a low chair for ease in getting up in the
walker2. Make sure rubber caps are present on all 4 legs of the
walker3. Begin weight-bearing on the affected hip as soon as
possible4. Practice tying your shoes before using the walker55. To
prevent neurological complications for a pre-school client with a
full-leg cast, the nursewould schedule regular checks of:1. Femoral
pulses2. Levels of consciousness3. Blood pressure readings4.
Sensory testing of affected footQuestionsHurst Review
Services20456. A teenager has had a repair of an open compound
fracture of the tibia and fibula. Anexternal fixation device has
been applied to stabilize the fracture. Before administering
pinsite care, the nurse should check which of the following?1.
Correct alignment2. Appearance of pin sites3. Tightness of screws4.
Vital signs57. Which nursing assessment suggests a complication of
a plaster of paris cast application tothe arm?1. The client states
that the wet cast feels warm2. The client is able to move his
fingers and thumb freely3. The client states that his little finger
feels asleep4. The wet cast appears gray and smells slightly
mustyQuestionsHurst Review Services205Renal58. In planning the diet
teaching for a child in the early stage of nephrotic syndrome, the
nursewould discuss with the parents the following dietary
changes:1.