NCLEX STUDY REAL.

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PICC therapy
 Insertion location is basilica or cephalic vein at least 1 finger breadth below or above antecubital
fossa
 Administration of blood, long term antibiotic therapy or chemotherapeutic agent, and TPN
 Replace initial dressing of gauze by 24 hours
 An xray should be taken
 Assess site every 8 hours, change tubing a minimum of 3 days clean insertion port with alcohol
at least 3 seconds change transparent dressing every 7 days or when wet, soiled, or loose
 Advise client to avoid submersing arm and no blood pressure in that arm
Therapeutic procedures
Transcribing orders
Feeding with dysphagia
 Assess swallowing reflex
 Clear liquids may need to be thickened
 Sit upright
 Tilt head down to facilitate swallowing
 Place food in back of mouth on unaffected side
Ob meds
Magnesium toxicity and indications for use
 Pre term labor
 decreased or no tendon reflexes
 respirations under 12
 altered LOC or mag levels about 10
 contraindicated with patients with Myasthenia Gravis

Dietary choices for diverticulitis
 No nuts,seeds
Meds for preeclampsia (no diuretic)
 Mag sulfate
 Antihypertensive meds (betas and calcium channel blockers (nifidipine)
 Avoid ACE and Arbs
Interventions after epidural
 Stay in bed
 Position patient either sitting or sidelying position
 Coach patient in pushing efforts
 Monitor blood pressure, and pulse
 Assess FHR continuously
 Maintain IV line and have oxygen and suction available
 Assess for orthostatic hypotension
 Provide client safety such as raising sides of bed. Don’t allow client to ambulate unassisted
 Assess clients for bladder distention at frequent intervals, catheritize if necessary
 Monitor for return of sensation and motor control in clients legs after delivery but prior to
standing. Assis client with standing and walking for the first time after delivery
Effectiveness of loop diuretics
 Decreased edema
  Decreased fluid in lungs  (sounds)
 Weight loss
 Decrease in blood pressure
 Increase urine output
Cushings syndrome labs
 Elevated  plasma cortisol levels
 Serum potassium and calcium levels DECREASED
 Serum glucose, sodium INCREASED
 Lymphocytes DECREASED

Intervention following mastectomy
 HOB to 30 degrees
 Have client wear sling when ambulating
 2 drains will be present
 Avoid doing anything to the affected arm
 Teach client how to care for inscision and drainage tubes
 Don’t put arm in depended arm position- will interfere with wound healing
 Early arm and hand exercises
 Don’t wear constrictive clothing
 Report numbness of fingers
 And genetic counsling for cleints who test postitive for the brca1/brca2 gene
Amnioinfusion following oligohydramnios
 LR OR NS is instilled in the amniotic cavity to supplement amount fluid ]
 Used in oligohydramnios for
 Uteroplacental insufficiency
 PROM
 Postmaturity of fetus
 Fetal cord compression secondary to postmaturity of fetus (large body)
 Membranes have to be ruptured to do this
 Continually assess fhr and contractions
 Monitor output to prevent uterine overdistention
Radiation therapy
 Have client lay in bed
 Nurse wear dosimeter
 Have people stand 6 feet away and limit to 30 minutes
 Avoid sun
 Catheter may in inserted if its internal radation to prevent dislodgment if in uterine
Dehydration in 3 month old
 Weight is the easiest indicator
 sunken fontanelles(med-severe)
 dry mucous membranes
 cap refil is delayed
Heart Failure and Pulmonary Edema: Appropriate Prescriptions (RM AMS RN 9.0 Chp 32, Active Learning
Template - System Disorder):
Heart failure:
 Diuretics
 ACE, ARBS, CALCIUM CHANNEL BLOCKERS
 MILRINONE
  Digoxin
 Beta blockers
 Vasodilators (nitro)
 Antigoagulants
Pumlonary edema:
 Rapid acting diuretics (furosemide)
 Morphine
 Vasodilator (nitro)
 Digoxin, dobutamine
 Ace inhibitors and beta blockers
Meningitis and Reye Syndrome
Meningitis:
 Presence of Petechia or a purpuric type rash requires immediate attention
 Isolate client and use droplet precautions
 Monitor vital signs, urine output fluid status, pain level, neuro status, and head circum (infants)
 Decrease environmental stimuli
 Provide comfort measures -position client without pillow and slightly elevate head, can also be
positioned side lying
Reyes:
 Maintain hydration
 Position client (Avoid extreme flexion, extension or rotation) maintain head in neutral midline
pos. head elevated to 30 degrees.
 Monitor coagulation and prevent hemorrhage
 Implement seizure precautions
 Avoid giving aspirin
Preventing Contractures
Assess ROM capability (make sure patients move every 2 hours and in a wheelchair every 15 minutes)
 Assess muscle tone and mass- encourage active or active passive ROM 2-3x a day
 Observe for contractures-  
 Monitor gait
 Monitor nutritional intake for calcium-
 Monitor for use of assisted devices to help with ADL’s
Car Seat Safety
 Use an approved rear facing car seat in the back seat preferably in middle.  Use until 2 or child
reaches maximum height and weight.  Do not use a second hand car seat
Evaluating Client Understanding of Latex
 Latex RT sensitivity to bananas, and other fruits kiwis cherries
Hyperthermia
 Over 39 degrees celcius.  (102.2)
 Assess speciemens for blood cultures
 Assess/monitor white blood cell counts, sedimentation rates, and electrolytes
 Admin antibiotics
 Provide fluids and rest
 Provide antipyritics
 Prevent shivering
 Offer blankets and remove them when the client feels warm
 Keep environmental temp between 21-27 (70-80)
Maintaining Aseptic
  Do not put cap back on field
 Hold bottle at least 6 inches above field
 Hold bottle with label in hand
Client Positioning for Cesarean Birth
 Wedge under hip
Circumcision
 Leave yellow exudate on penis
 Keep area clean
 Change diaper every 4 hours and clean penis with warm water each time.
 With clamp procedures use petroleum jelly on each diaper for at least 24 hours
 Avoid wrapping penis in tight gauze which impairs circulation
 Do not give tub bath until it has healed, and then after, warm water should be trickled over
penis
 Notify provider if there is any redness, discharge, swelling, strong odor, tenderness, decreased
urination or excessive crying.
 Avoid using pre moistened towelettes to clean penis because they contain alcohol.
 Baby may be fussy or may sleep for several hours after the circumcision. Use tylonel for 24-48
hours.
 Will heal in a couple of weeks
Health Promotion of Preschoolers (3 to 6 Years)
 Gains control of fine and gross motor skills
 Dresses independently
3 year old:
 Rides a tricycle
 Jumps off bottom step
 Stands on one foot for a few seconds
4 years old
 Skips and hops on 1 foot
 Throws a ball overhand
5 years
 JUMPS ROPE
 WALKS BACKWARDS
 MOVES UP AND DOWN STAIRS EASILY

Exercise During Pregnancy
 Moderate exercises- swimming, walking for 30 minutes daily
 Consume 2-3 l of fluid
Assessing an Adolescent for Scoliosis
 Observe Child, who should only be wearing underwear, from the back
 Have child bend over and waist with arms hanging down and observe for asymmetry of the ribs
and flank
 Measure truncal rotation with a scoliometer
 Use cobb technique to determine degree of curvature
 Use riser scale to determine the skeletal maturity
Contraindications of Oral Contraceptives
 Pregnancy
 Hx of blood clots, stroke, cardiac problems or estrogen related cancers,
 Smoking (if over 35)
  HTN
Findings of cocaine use
 Dizziness, irritability, tremor, blurred vision
 Hallucinations, seizures, extreme fever, tachycardia, hypertension, chest pain, possible
cardiovascular collapse and death
 Rush of euphoria, and pleasure and increased energy
Stimulant Withdrawal
 Depression, fatigue, craving, sleeping, dramatic unpleasant dreams, phsycomotor retardation
agitation
Manifestations of the Manic Phase
 Grandiose thoughts
 Labile mood with euphoria
 Agitation and irritability
 Restlessness
 Increase in talking and activity
 Dislike of interference and intolerance of criticism
 Flight of ideas
 Impulsivity
 Demanding and manipulative behavior
 Distraction poor attention span
 Poor judgment
 Attention seeking behavior (makeup, flashy dress, inappropriate behavior)
 Decreased sleep
 Neglect of ADL
 Possible delusions and hallucinations
 Denial of illness
Assessing Remote Memory         
  Remote memory is assessed by asking patients about important public events that took place
decades earlier (eg, what happened in November of 1963? September of 2001?). If the
patient is a veteran, you can ask him who we were fighting in World War II. In a large
prospective study, semantic memories have been shown to be in particular decline during the
5 to 6 years just prior to the diagnosis of Alzheimer disease (Wilson et al 2011).
Managing a Client Who Has Dementia
 At nurses station
 Calandar at front of room
 Maybe manage money (home nurse)

Schizophrenia
 Hallucinations
 Delusions
 Alterations in speech
 Bizarre behavior
 Disordered thinking
 Inability to make decisions
 Difficulty concentrating
 Memory deficits
Biofeedback:
 Using technology to increase awareness of various neurological body responses to minimize
extremes
  Biofeedback is a technique that trains people to improve their health by controlling
certain bodily processes that normally happen involuntarily, such as heart rate, blood
pressure, muscle tension, and skin temperature.
Osteoarthritis: Nonpharmacological Pain Management
 Balance rest with activity
 Cold when edematous joints
 Use of acupuncture, tai chi, hypnosis, magnets and music therapy
 Use of splinting
 Use of assistive devices, elevated toilet seat, shower bench, long handle reacher, shoe horn
Acute and Chronic Glomerulonephritis: Dietary Choices
 Low in sodium and restrict fluid intake
Dietary Teaching Following Gastric Resection
 Watch for dumping syndrome
 Lie down after eating
 Limit amount of fluid ingestion
 Restricted sodium and protein
 Avoid milk sweet, sugars,
 Consume small frequent meals rather than large meals
 Eliminate liquids with meals for one hour prior to and following meals
 Encourage vitamins
Adverse Effects of Levothryhoxine Sodium
 Overmedication can result in indications of hyperthyroidism.  (anxiety, palpitations, tachycardia,
altered appetite, abdominal cramping, heat intolerance, weight loss, diaphoresis)
Contraindications to Nonselective Beta Blockers
 Av block and sinus bradycardia
 Reportable Findings in a Client Taking Clozapine
 Report increased thirst, urination and appetite to the provider (can be new onset of diabetes
mellitus or loss of glucose
 Report if othostatic hypotension  occurs
 Contraindications to Potassium Administration Concurrent use of potassium sparring diuretic
 Contraindicated for clients with severe kidney disease, hypoaldosteronism
 Contraindicated for clients with digitalis toxicity or AV block
 Early Decelerations
 Compression of fetal head
 Vaginal exam
 Fundal pressure
 No intervention required
 Identify labor progress (no intervention required)
Interventions After Epidural Administration
 Institute safety precautions
 Assess client for nausea and emesis
 Monitor maternal vs
 Monitor for allergic reaction
 Continue FHR monitoring
Total Parenteral Nutrition Administration
 Determine clients readiness for TPN (Obtain daily lab results, including electrolytes)
 Flow is no more than 10% hourly increase in rate
 Monitor vital signs ever 4-8 hours
  Sterile procedures to minimize risk of sepsis
 Change bag every 24 hours
 Filter is added
 Do not use line for other iv bolus solutions
 Do not add anything to it
 Use sterile procedure including mask when changing the central line dressing
Client Education Regarding an Electroencephalogram
 abstain from caffeine for several hours prior to procedure
 wash hair before and after procedure
 inform the client that he may be asked to take deep breaths and or exposed to flashes of light
during the procedure
 instruct parent to withhold sleep from child prior to test
 inform client test wont be painful
Client Teaching About Foot Care
 preform nail care after bathing
 trim toenails straight across
 wear close toed shoes
 inspect feet daily, wash feet daily with mild soap and warm water
 pat feet dry, especially between toes, avoid lotion between toes
 use mild foot powder
 do no use commercial remedies for corn or callus removal. Separate overlapping toes with
cotton or lambs wool
 wear clean absorbant socks made of cotton or wool
 do not use hot water bottles or heating pads to warm the feet
Identifying Manifestations of Glaucoma
 leading cause of blindness
 reduced vision
 mild eye pain
Risks for Delayed Wound Healing
 loss of skin turgor
 skin fragility
 decrease in peripheral circulation and oxygenation
 slower tissue regeneration
 a decrease in absorption of nutrients
 decrease in collagen
 impaired function of the immune system
Client Teaching Following Repair of Retinal Detachment
 Don’t watch TV for a long time
 Don’t life heavy objects
 Driving should be avoided
 Increase in altitude should be avoided until cleared with doctor
 Traveling should be avoided for some time
Adverse Effects of Radiation Therapy
 Skin changes
 Hair loss
 Debilitating fatigue
 Can be administered internally with an implant or externally with a radiation beam
Action to Take Prior to Cardiac Catheterization
  Maintain NPO
 Ensure client consent form is signed
 Assess the client and family understanding of procedure
 Assess renal fuction
 Admin premedications methyprednisone and diphenhydramine
Risk Factors for Glomerular Disease
 Step infection with a specific strain of group a b-hemolytic strep
Or
 Minimal change nephrotic syndrome
 Secondary nephrotic syndrome
 Congenital nephrotic syndrome
Pulmonary Artery Wedge Pressure
 is the pressure measured by wedging a pulmonary catheter with an inflated balloon into a
small pulmonary arterial branch
 hemodynamic status is assessed with PAWP
 balloon inflation port is intermittently used for PAWP measurements. When not in use, it should
be left deflated and in the locked position
 Cleft Palate for feeding
 Position infant upright while cradling the head
 Use a specialized bottle with a one-way valve and specially cut nipple
 Burp infant frequently
 Syringe feeding may be necessary for the infant who is unsuccessful with other methods
Ischemic Stroke
 Antithrombic med
Laboratory Results Indicating Rheumatic Fever
 Throat culture for GABHS
 Serum antistreptolysin-o
 C-reactive protein
 Erythrocyte sedimentation rate
Reportable finding to report in newborn
 Grunting
 HR over 160 or under 100
 Respirations under 25 or over 60  (normal resp 40-60)
 Temp that are not stabilized over 10 hours. (normal is 36.5-37.2)
Needle Disposal in Home Settings
 Coffee container and bring in 2/3 full. You can use a plastic container and put up high
Teaching About Pediculosis Capitis
 Store linens in bag for 14 days
 Visibly remove nits in hair and eggs
 Contact transmission

 Sibling Bonding
 Let sibling be one of first ones to see baby
 Provide a gift from baby to give the sibling
 Have one parent spend time with sibling and one to baby
 Allow older sibling to help in providing care
 Provide preschooler with doll to care for
Medications for adhd
  Do not chew extended release
 Admin med on regular schedule
 Transdermal on hip daily in morning and leave on for no longer than 9 hours and alternate hips
 Instruct parents ADHD is not cured by medication. Management in conjunction with an overall
treatment plan will improve outcome
 Instruct the parents to have special handling procedures controlled by fed law handwritten
prescriptions are required for medication refills.
 High development potential for substance use disorder
Communicating With a Client who is Hallucinating
 Ask client directly about the hallucinations. The nurse should not argue or agree with the clients
view. But may offer a comment such as I don’t hear anything but you seem to be feeling
fightened.
 Asses the client for paranoid delusions
 Provide for safety if the client is experiencing command hallucinations
 Focus conversation back to reality
 Identify triggers
 Be genuine and empathetic
Nonpharmacological Pain Management Strategies
 Lamaze, patterned breathing
 Aroma therapy
 Breathing techniques
 Imagery
 Music
 Use of focal points
 Subdued lighting
 Back rubs
 Effleurage
 Sacral counter pressure
 Heat or cold therapy
 Hydrotherapy
 Acupressure
 Change position (sitting, squatting, kneeling)
Manifestations of Dehydration in a child
Mild:
 Behavior, mucus membranes, anderior fontanel, pulse and blood pressure all WLN
 Cap refil is greater than 2 seconds
 Slight thirst may be experienced
moderate:
 Capilarry refil is between 2 and 4 seconds
 Thirst and irritability may be experienced
 Pulse is slightly increased
 Mucous membranes are dry and tears are skin turger are decreased
 Slight tachypnea
 Normal to sunken anterior fontanel on infants
Severe:
Cap refil is greater than 4
 Tachycardia is present and orthostatic blood pressure may progress to shock
 Extreme thirst
  Mucus membranes are dry and skin is tented
 Hyperpnea
 No tearing with sunken eyeballs
 The anterior fontanel is sunken
 Oliguria or anuria is present
Dietary Guidelines for Celiac Disease
 No BROW (BARLEY, RYE, OATS WHEAT
 Rice is good
 Corn
 Eggs
 Potatoes
 Fruits ,veggies
Parkinson’s Disease: Client safety
 Teach client to stop occasionally when walking
 Encourage exercise
 Encourage assistive devices
 Pace activities by providing rest
Dietary Teaching for Acute Kidney injury
 Restriction of sodium and fluid
 Restrict foods high in potassium
 Provide small frequent meals
Adverse Effects of Clozapine
 New onset diabetes (instruct client to report increased, increased urination and appetite)
 Weight gain
 Hypercholesterolemia with increased risk for HTN and other CV disease
 Orthostatic hypotention
 Anticholonergic effects
 Agitation, dizziness, sedation and sleep disturbances
 Mild EPS such as tremor
Peripherally Inserted Central Catheter
 Use up to 12 months
 Insert location- basilic or cephalic vein at least 1 finger’s breadth below or above the antecubital
fossa, the catheter should be advanced until the tip is positioned in the lower 1/3 of the superior
vena cava.
 For- admin of blood, long term admin of chemotherapeutic agents, antibiotics and TPN.
 XRay initially to ensure proper placement
 Assess site every 8 hours
 Change tubes every 3 days
 Use 10 ml to flush
 Use transparent dressing
 Do not immerse arm in water
 No blood pressure on PICC arm.
Long-Term Adverse Effects of Proton Pump Inhibitors
 Increases risk of OSTEOPEROSIS
Diagnostic Test for Pernicious Anemia
 Bone marrow aspiration/biopsy is used to diagnose pernicious anemia
Client Teaching About Magnetic Resonance Imaging
 Assess for allergy to shellfish or iodine
  Ensure client jewelry is removed
 Refrain from fluids and food 4-8 hours if sedation is expected
 Check for hx of claustrophobia
 Question about any implanted devices
Risk Factors for Hypoglycemia
 Maternal diabetes
 Preterm infant
 LGA OR SGA
 Stress at birth such as cold stress and asphyxia
 Maternal epidural
Teaching About the Nonstress Test
 Noninvasive procedure that monitors response of the FHR to fetal movement
 Client pushes a button when she feels fetal movement
 Allows nurse to assess FHR in relationship to fetal movement
Monitoring a Water Seal Drainage System
 Chamber must be kept upright and below the chest tube insertion
 Tidaling (movement of fluid level with respiration)
 Cessation of tiadaling in the water seal chamber signals lung reexpansion or an obstruction
within the system
 Continuous bubbling is not good. Means air leak
Interventions for Increased Intracranial Pressure
 Decrease environmental stimuli
 Keep head of bed at 30
 Do not blow nose
 Indwelling urinary catheter
 Administer laxatives
Caring for a Child Who Has Kawasaki Disease
 Monitor VS and cardiac output
 Assess for client heart failure
 Monitor i&o and dw
 Administer IV fluids to prevent dehydration
 Administer IV gamma globin
 Administer aspirin
Hyperthyroidism: Assessment Findings
 Nervousness
 Irritability hyperactivity, emotional lability, decreased attention span
 Weakness, easy fatigability, exercise intolerance
 Heat intolerance
 Weight change (loss) and increased appetite
 Insomnia and interrupted sleep
 Frequent stools and diarrhea
 Menstrual irregularities
 Libido increased
 Warm sweaty flushed
 Tremor, hyperkinesia hyperreflexia
Fat Embolism
 Adults between 70-80 are at the greatest risk. Hip and pelvis fx are at highest risk
 Occur after injury usually 48 hours following fractures or total joint arthroplasty
  Dyspnea
 Decreased mental acuity
 Respiratory destress
 Tachycardia
 Tachypnea
 Fever
 Petechiae
Pulmonary Embolism: Expected Manifestations
 Anxiety
 Feelings of impending doom
 Pressure in chest
 Pain upon inspiration
 Dyspnea and air hunger
 Pleurisy
 Pleural friction rub
 Tachycardia
 Hypotension
 Tachypnea
 Adventitious breath sounds
 Heart murmur
 Diaphoresis
 Low grade fever
 Devreased oxygen sat levels
 Petechiae
 Pleural effusion
Effectiveness of allopurinol (for gout)
 Improvement in pain caused by a gout attack
 Decrease in number of gout attacks
 Decrease in uric acid levels
Client care for implanted venous port
 Palpate skin to locate portb ody septum
 Clean skin with alcohol for at least 3 ceconds and allow to dry
 Access with noncoring needle
 Flush with NS after every use and at least once per month
Interventions for chronic renal failure:
 Maintain bed rest
 Low protein, potassium, high carb diet
 Stict I&O
Priority assessment for weight loss:
 S&s for dehydration
 Electrolytes
Prevention of uric acid stones
 Urinary stasis, urinary retention, immobilization, and dehydration contribute to an environment
favorable for stone formation.
  -Decreased fluid intake or increased incidence of dehydration among older adult clients may
increase the risk of stone formation        
  Decrease intake of purine sources (organ meats, poultry, fish, gravies, red wine,
sardines).
Medications
XAllopurinol (Zyloprim) is used to prevent the formation of uric acid.
XPotassium or sodium citrate or sodium bicarbonate is used to alkalinize the
urine
Preventing of refeeding syndrome
 Potentially fatal complication that can occur when fluids, electrolytes and carbohydrates are
introduced to a severely malnourished client
 Care for client in a hospital setting
 Consult with provider and determine a controlled rate of nutritional support
 Monitor electrolytes and fluid replacement
Teaching a client about breastfeeding with hep C
 You can breastfeed
Screening tests at 16 weeks gestation
 Quad marker and alpha-fetoprotein (AFP) screening
 For likelihood for fetal birth defects
 Low AFP indicates downs
 High AFP indicates neural tube defects
Developmental tasks for 24 months old
 300 words
 Multiword sentences combining two to three words
 Grows 3 inches a year
 Head and chest should be equal
 Walks up and down stairs
 Builds six or 7 block tower
Cranial nerve xi
 Places hands on shoulders and tell pt to shrug
Cranial nerve V
 Have pt clench teeth while you palpate masseter and temporal muscels.
 Have client close eyes and touch her face with cotton
VII
 Have patient smile
Nursing interventions for lyme disease:
Action for electrical hazard:
 Good repair
 Well grounded
Intermitten catheter
 intermittent irrigationdorsal recumbent or supine position
 avoid cold solution bec may result in bladder spasm
 clamp cath just below soft injection port
 cleanse injection port with antiseptic swab (same port as specimen collection)insert needle
through port at 30degree angle
 slowly inject fluid into cath and bladder
 withdraw syringe remove clamp and allow solution to drain into drainage bag if ordered by MD,
keep clamped to allow solution to remain in bladder for short time
Transmission of varicella
  droplet precautions
 direct contact
 from person with shingles
infectious mono
 saliva spread
 fever, sore throat, swollen lymph glands, increased wbc, splenomegaly, enlarged liver
 ]