Ready To Pass NCLEX

READY TO PASS INC.
READY TO PASS INC.

Disclosure Statement 2
TABLE OF CONTENTS
Review Course Objectives 3
About NCLEX 4
10 Essential Tools 11
Quick reference guide of essential facts 17
Normal Lab values 29
Physiological Integrity essential facts 50
Common respiratory medications 78
Overview of pharmacology 121
Essential medication list 139
After the Review 140

Essential Nursing Skills & Techniques 141
Alphabet list 143
Mneumonics 144
Maternal/ Newborn Care Essential Facts 147
Common maternity medications 160
Pediatric Nursing Essential Facts 161
Psychosocial Integrity Essential Facts 178
Common mental health medications 190
Practice Questions 191
Practice Questions Rationales 210
Graphics: Louise Martin and Rebecca Rivera

MAR 18
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Disclosure Statement
• Ready To Pass Inc. emphasizes the importance of consistent study habits to promote and improve your
chance of success.
• It is advised that you review all class content and answer all practice test questions. Allow 1 – 1.5 minutes.
per question
• It is recommended that you take the NCLEX® Exam within one (1) month of completing this review class.
• Students will be allowed to make up a maximum of two (2) missed class sessions during the next available
class, if space permits. There will be no refunds after the first day of class. A credit will be issued which is
valid for one (1) year from the date of registration.
• Although you will be provided with essential information to provide accurate and safe entry level care,
Ready To Pass, Inc. cannot guarantee that you will pass the NCLEX®. We will not be held liable for
unfavorable outcomes.
• If you have not successfully passed NCLEX®, you will be eligible to repeat the class once within six (6)
months of your original class date. In order to qualify for the $50 rate, you must provide proof of failure
prior to registration. You will be required to pay the registration fee of $50 and any other applicable fees
(optional new manual $75) 10 days prior to the start of the next class. If you have not taken the NCLEX®
after completing this review class, you are not eligible to repeat the class unless you pay the full
tuition amount.
• Ready To Pass Inc. prohibits taping of any class sessions. We reserve the right to inspect for any taping
equipment.
• Students attending the Review for the first time are entitled to a copy of our NCLEX® Review Study Guide.
Students who are repeating the class at the discounted rate may purchase the guide for $20 on site or
$24.95 online.
I have read and agree with the above listed terms.
Signature:_________________________________
Print Name: _______________________________
Date: ____/_____/______
ELIGIBILITY TO REPEAT THE READY TO PASS

REVIEW CLASS AT THE DISCOUNTED $50 RATE
EXPIRES ______________
(Must provide proof of failure)
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Review Course Objectives

Include but are not limited to:
• Identify and perform safe competent basic nursing care

• Apply legal and ethical principles in the performance of nursing care
• Identify basic nutritional needs throughout the life cycle
• Identify normal and abnormal emotional, social, and mental growth patterns throughout the life cycle
• Describe theories of psychosocial development according to Erickson and Maslow
• Identify and assist families to collaborate with available neighborhood resources
• Describe and apply the principles of infection control
• Recognize and identify methods to prevent and control the transmission of disease and infection
• Utilize the nursing process to determine appropriate care for alterations in psychological and
physiological well being in adults and children
• Relate the purpose, normal dosage, routes of administration and side effects of essential medications
as related to each disease
• Describe safe use of parenteral therapies
• Review prevention and early detection of diseases
• Apply appropriate communication techniques
• Prioritize nursing care
• Identify common complications of the pre/intra natal and post partum periods
• Identify normal and abnormal findings for newborn assessment
• Be aware of and respect cultural diversity in the care of all clients
• Describe physical and psychological changes that occur with aging
• Delegate care as appropriate
• Identify the environmental risks and lifestyles which affect well-being
Methodology
• Incorporation of highly effective teaching and learning models

• Class discussions
• Cooperative learning
• Video presentations
• Instructor presentations
• Group interaction
• Individual discovery
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About NCLEX
The NCLEX® is designed to determine whether you meet the minimal standard to practice as a nurse.
NCLEX® is an integrated exam, which means the subjects are all mixed together.
The test follows the April 2016 NCLEX® RN/April 2017 LPN plan. Questions are drawn from four categories
including but not limited to the topics listed below. The following test plan structure is copyright of the
National Council of State Boards of Nursing, Inc. All Rights Reserved.
I. Safe, Effective Care Environment

A. Management of Care – RN 17 - 23 % LPN 18 - 24% (Coordinated Care)
Providing integrated, cost-effective care to clients by coordinating, supervising and/or
collaborating with members of the multi-disciplinary health care team.
• Advance Directives • Establishing Priorities

• Advocacy • Ethical Practice
• Case Management • Informed Consent
• Client Care Assignment • Information technology
• Client Rights • Legal Rights and Responsibilities
• Collaboration with Interdisciplinary Team • Performance improvement
• Concepts of Management & Supervision (Quality Improvement)
• Confidentiality/Information Security • Referrals Process
• Consultation • Resource Management
• Continuity of Care • Staff education
• Delegation and Supervision • Supervision
B. Safety and Infection Control - RN 9 -15 % LPN 10-16%

Protecting clients and health care personnel from environmental hazards.
• Accident/Injury Prevention • Medical and Surgical Asepsis

• Disaster Planning/Internal & External Plans • Reporting of Incident/Event/Irregular
• Emergency Response Plan Occurrence/Variance
• Error Prevention • Safe Use of Equipment
• Ergonomic principles • Security Plan
• Handling Hazardous & Infectious Materials • Standard Precautions / Transmission-based
• Home Safety Precautions
• Least Restrictive Restraints/Safety Devices
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II. Health Promotion and Maintenance- RN 6-12% LPN 7-13%

Providing and directing nursing care of the client and family/significant others that incorporates the
knowledge of expected growth and development principles, prevention and/or early detection of
health problems, and strategies to achieve optimal health.
• Aging Process • Health and wellness

• Ante/Intra/Postpartum and Newborn Care • Health Promotion Programs
• Community Resources • Health Screening
• Data Collection Techniques • High Risk Behaviors
• Developmental Stages and Transitions • Human sexuality
• Disease Prevention • Immunizations
• Expected Body Image Changes • Lifestyle Choices
• Family Planning • Principles of Teaching & Learning Self Care
• Family Systems • Techniques of Physical Assessment*
• Growth and Development
III. Psychosocial Integrity- RN 6-12% LPN 9 -15%

Providing and directing nursing care that promotes and supports the emotional, mental, and social
well-being of the client and family/significant others experiencing stressful events, as well as clients
with acute or chronic mental illness.
• Abuse/Neglect • Psychopathology
• Behavioral Interventions • Religious and Spiritual Influences on Health
• Chemical & Other Dependencies • Sensory/Perceptual Alterations
• Coping Mechanisms • Situational Role Changes
• Crisis Intervention • Stress Management
• Cultural Diversity/Cultural Influences on • Substance Use Disorders
Health/Cultural Awareness • Support Systems
• End of Life Care and Concepts • Suicide/Violence Precautions
• Family Dynamics • Therapeutic Communications
• Grief and Loss • Therapeutic Environment
• Mental Health Concepts • Unexpected Body Image Changes
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IV. Physiological Integrity

A. Basic Care and Comfort: RN 6 -12 % / LPN 7-13%
Providing comfort and assistance in the performance of activities of daily living.
• Alternative and Complimentary Therapies • Nutrition and Oral Hydration
• Assistive Devices • Palliative/Comfort Care
• Elimination • Personal Hygiene
• Mobility/Immobility • Rest and Sleep
• Non-Pharmacological Comfort Interventions

B. Pharmacological and Parenteral Therapies: RN 12-18 % / LPN 10 -16%
Managing and providing care related to the administration of medications & parenteral therapies.
• Adverse Effects/ Contraindications and Side • Parenteral/Intravenous Therapy

Effects • Pharmacological Agents/Actions
• Blood and Blood Products • Pharmacological Interactions
• Central Venous Access Devices • Pharmacological Pain Management
• Dosage Calculations • Total Parenteral Nutrition
• Expected Actions/ Outcomes
• Medication Administration
C. Reduction of Risk Potential: RN 9 -15 % LPN 9 -15%

Reducing the likelihood that clients will develop complications or health problems related to
existing conditions, treatments or procedures.
• Diagnostic Tests • Potential for Complications from Surgical
• Laboratory Values Procedures and Health Alterations
• Monitoring Conscious Sedation • System Specific Assessments
• Potential for Alterations in Body Systems • Therapeutic Procedures
• Potential for Complications of Diagnostic • Vital Signs throughout the life span/ changes/
Tests/Treatments/Procedures abnormalities
D. Physiological Adaptation: RN 11-17 % LPN 7 -13%

Managing and providing care to clients with acute, chronic or life- threatening physical health
conditions.
• Alterations in Body Systems • Medical Emergencies
• Fluid and Electrolyte Imbalances • Pathophysiology
• Hemodynamics • Radiation Therapy
• Illness Management • Unexpected Response to Therapies
• Infectious Diseases
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ABOUT THE EXAM
• The test is computer based; you will be required to use a mouse to select the correct answer.
• There is an on screen calculator available to calculate medication dosages.
• Once a question is answered you will not be allowed to change it.
• NCLEX® is a computer adaptive test which means it adjusts based on the answers you provide
to previous questions. For example you will receive more difficult questions if you answer
correctly but easier questions if you do not. It is very important that you do not guess. It is better
to take more time to answer correctly than to choose answers randomly. At times, content
tested may be similar to a previously answered item, you should not assume that the first
item was answered incorrectly. The concepts may address different phases of the nursing
process. Always select the answer believed to be correct. Exams vary in length in order to
target candidate-specific ability.
• Six hours are allotted for the RN exam to complete a minimum of 75 to a maximum of 265
questions. Of these items, 15 are pretest items that are not scored. The LPN exam allots
5 hours and has 85 to 205 questions. There are 25 pretest items on the NCLEX PN exam.
However you should stick to the rule of allowing 1 minute per question. The analysis level
questions may require more than one minute in order to synthesize all of the information given.
The length of an exam is not an indication of a pass or fail result. The computer will stop when
it has been determined with 95% certainty that the candidate’s ability is above or below the
passing standard or the candidate has run out of time. When you run out of time before reaching the
maximum amount of items, the computer has not been able to decide whether you passed or failed with 95% certainty and has
to use an alternate rule. If you have not answered the minimum amount of items, you fail.
• If you have at least answered the minimum amount of items, the computer reviews your last 60 ability estimates:
• If your last 60 ability estimates were above the passing standard, you pass.
• If your ability dropped below the passing standard, even once, during your last 60 items, you fail.
Types of Questions: Multiple Response Multiple Choice Fill in the Blank
Ordered response Hot Spot/Graphic Chart exhibit Audio
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ESSENTIAL TEST-TAKING
TECHNIQUES
Critical Thinking Is the Key
To Successfully Answering NCLEX® Questions!
1: Determine what the question is asking.
2: Identify the topic of the question.
Determine the relevance of the facts about the client. For example, the client may not be the person with the
3: health problem – it may be the spouse, a relative, or a member of the health care team.
4: Rephrase the question, if possible.
5: Do not read into questions.
Select the best option after eliminating incorrect choices.

6: Avoid absolute words (all, every, never, always, only).
7: Focus on the last line of the question, as invariably what the question is asking will be found there.
Look carefully for facts about the client, for example, age, gender, medical history, medications, psychological
8: status. These will provide clues as to what the question is really asking.
Do not answer questions based on your personal experiences. Critical thinking requires that you think purposefully
9: with outcome directed goals. Your thinking must be aimed at making judgments based on scientific evidence
rather than tradition or guessing. NCLEX® is based on textbook knowledge not individual varied experiences.
Questions on delegation should be answered with great care. Never delegate the assessment portion of the
10: nursing process or tasks that involve complex procedures.
Don’t be too hasty to choose “Notify the health care provider” as the answer. Is there some action, some part of
11: the nursing process that you can perform before calling the physician?
Read every word in the question and each of the answer choices, looking for key words. Key words in the
stem of the question will provide clues as to the type of response you are seeking. Please study the following
12: key words and look for these in the question stem. Then rephrase the question to find out what it is really
asking.
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Remember PAIN
PRIORITY/ FIRST: This indicates that you must determine the most essential response.
Tools helpful to answering these questions include:

1. The developmental phases of Erkison (if age is designated)
2. The theorist Orem (Universal Self Care Needs)
3. Maslow (Hierarchy of Needs)
4. Nursing Process (assessment first)
5. ABC’s (airway, breathing, circulation)
6. Time
7. Expected/unexpected
8. Safety
9: Disaster & triage
ANTICIPATE: or most appropriate, correct, expected, should, include, instruct, will reinforce. These all
indicate you are looking for a correct or expected response.
INTERVENE: or requires follow-up, needs or requires additional teaching, avoid, needs reinforcement,
ineffective, notify the health care provider, all indicate that you are looking for an incorrect or unexpected
response.
NEXT: may imply you are currently in one phase of the nursing process and must proceed to the next one.
Remember ADPIE (Assessment, Diagnosis, Plan, Intervention, Evaluation).
PREPARING FOR THE EXAM
* Study consistently, at least 2-3 hours a day.

* Practice time management: allow 1 – 1.5 minutes per question.
* A positive attitude is essential for success!
* Develop a study plan and remain focused.
* Maintain a quiet, well-lit setting.
* Avoid distractions.
* Insure adequate rest, as sleep deprivation can prevent you from focusing.
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SAMPLE QUESTION
The nurse is reviewing the lab results of several clients. It would be a priority for the nurse to suggest follow-up
for the client who has a:
A. Uric acid level of 10.3 mg/dL

B. Ammonia level of 95 mg/dL
C. Albumin level 3.1 g/dL
D. Calcium 12 mg/dL
The phrase “follow-up” indicates that you are looking for an incorrect response. Although three of the lab
values are abnormal and need follow up, which of the previous choices would take priority? Knowledge of
normal lab values will help you to select the most appropriate response.
Note: The correct answer is (b). High ammonia levels will lead to hepatic encepholapathy and brain
damage. This client would take priority.
SAMPLE QUESTION
The nurse is teaching a client about crutch walking. Which of the following statements, if made by the client,
indicates an understanding of teaching?
A. “My elbows should be flexed 45 degrees while walking.”

B. “When I climb stairs, I advance my affected leg first, with my crutches.”
C. “I do not apply pressure under my arm when I use my crutches.”
D. “When I go to sit in a chair, I put both crutches in the hand of my affected side.”
The phrase “understanding of teaching” indicates you are looking for a correct statement, that is, one choice
is true, while the other three are incorrect. Knowledge of ambulation with crutches will allow you to select
the correct or true statement. Eliminate all the false or incorrect choices first!
Note: (c) is true, and the other three are false. Therefore, (c) is correct.
Schedule your test within 1 month after course completion!!

For information on scheduling or rescheduling your exam:
* National Council of State Boards of Nursing:
www.ncsbn.org or 1-518-474-3817 /1-866-293-9600
*Pearson Testing Centers: www.pearsonvue.com or 1-866-49NCLEX
*Unofficial test results available 48 hours after testing (cost $7 - $10)

1-900-776-2539
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ESSENTIAL
TOOLS
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TOOL # 2
ERIKSON’S THEORY OF DEVELOPMENT
Erikson believed that 8 major conflicts must be encountered during a lifetime, and that there are 8
developmental stages, each with a task that is to be achieved, that characterize a person’s struggle with
each of these conflicts. Either a person successfully resolves the crisis and masters the task at hand, or
does not.
On the NCLEX exam, questions giving a person’s age suggest that the corresponding developmental stage
should be considered in order to select the correct response.
AGE/STAGE PSYCHOSOCIAL CRISIS TASK

1. Infancy (0 - 18 months) Trust vs. Mistrust
Successful Resolution of Crisis Unsuccessful Resolution of Crisis
Trust in people and hope about the Difficulty relating to people; Attachment to the primary care giver
future suspicion; fear of the future
2. Toddler (18 months to 3 years) Autonomy vs. Shame & Doubt
Gains some basic control of self and
Sense of self control and adequacy; Fear of independence, severe self-
environment
will power doubt
3. Pre School (3 - 6 years) Initiative vs. Guilt
Ability to initiate one’s own Sense of inadequacy or guilt. Becomes purposeful and directive
activities; sense of purpose
4. School Age (6 - 12 years) Industry vs. Inferiority
Competence, ability to learn and Sense of inferiority, difficulty learning Develops social, physical and school skills
work and working.
5. Adolescence (12 - 20 years) Identity vs. Role Confusion
Sense of personal identity Confusion about self, identity
Develops sense of identity
submerged in relationships or group
memberships
6. Early Adulthood (20 - 35 years) Intimacy vs. Isolation
Establishes intimate bonds of love and
Ability to love deeply and commit Emotional isolation; egocentricity
friendship
7. Middle adulthood (35 -65 years) Generativity vs. Stagnation

Fulfills life goals that involve family, career,
Ability to give and care for others Self-absorption; inability to grow as
and society, volunteering
a person
8. Later (65 years to death) Integrity vs. Despair
Looks back over one’s life and accepting its
Sense of integrity and fulfillment Dissatisfaction with life
meaning
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TOOL # 3
THE NURSING PROCESS This process consists of the following, in this order:
1: Assessment 2: Diagnosis (Analysis) 3: Planning 4: Implementation 5: Evaluation

1. ASSESSMENT:
Words that mean to assess: Check, Look, Ask, Monitor, Inspect, Evaluate , Observe (CLAMIE-O)
1. Assessment is done primarily by the RN.
2. BUT the LPN must understand this process because the LPN collects data, a critical role in assessment.
3. Types of data to be collected:
• History taking
• Objective data: observable, measurable (vital signs)
• Subjective data: symptoms experienced by client (“My throat hurts”)
• Data collected from the chart
4.Confirm data collected.
5.Communicate information received in the assessment.
2. DIAGNOSIS (ANALYSIS):
1. Identify actual or potential health care needs and/or problems based on your assessment.
2. Interpret the data: validate, organize and determine if there is a need for more data collection.
3. In this phase, the nurse uses data to formulate a nursing diagnosis.
DETERMINE CLIENT’S UNIQUE NEEDS

3. PLANNING:
1.This is done to provide client care consistently and appropriately.
2. Ask yourself the following questions: What is the priority?
How does this determine the client’s needs?
How will this affect the care the client is getting?
3. This is when the nurse: determines goals, formulates outcome criteria, develops a plan of care and
collaborates with other health care professionals (the Interdisciplinary approach).
4: IMPLEMENTATION:
To begin to do something...and then doing it!!
1. Prepare: organize client’s care, gather equipment, and explain procedures to the client.
2. Counsel and Teach: directed at the client, their family members, significant others, and other members
of the health care team.
3. Perform: follow procedures, infection-control and OSHA guidelines, monitor client’s response to care
given.
4. After Care is Performed: make client comfortable, and then replace any equipment no longer needed.
5. Record and Report: document everything accurately.
6. The LPN reports findings to the RN.
7. RN reports abnormal findings to the health care provider.
5: EVALUATION:
1. Has the need been met?
2. Compare actual outcome with expected outcome.
3. Re-evaluate the problem list with the rest of the health care team.
TIP: ACTIVE CLIENT PROBLEMS TAKE PRIORITY OVER POTENTIAL PROBLEMS! 14

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TOOL #4 TOOL # 8
REMEMBER THE ABC’s THERAPEUTIC COMMUNICATION:
A. Remember to establish a patent airway 1. Remember to utilize therapeutic
for your client. communication: choose the response that
B. Be sure your client is breathing. allows the client to express his needs,
C. Check to see if your client has good fears or concerns.
circulation.
2. BUT, mental health questions may be handled
Do not wait until there is a crisis to assess differently. For example, if an RN suspects
for ABC’s!! suicide is an issue for her/his client, then direct
questioning is required (e.g., “Do you feel like
you want to hurt yourself?”)
TOOL #5 3. In mental health cases, reality orientation may
also be called for.
EXPECTED / UNEXPECTED
1. Determine what the stem of the question
is asking.
2. If 3 of the 4 choices given are correct, or TOOL # 9
are expected findings, then you should
OREM’S THEORY OF NURSING
choose the unexpected finding.
The nurse must be concerned with the
3. If 3 of the 4 choices given are incorrect, or
are unexpected findings, then you should following
choose the expected finding. UNIVERSAL HEALTH CARE NEEDS:
*Distinguish between chronic conditions 1. AIR: oxygen, airway, temperature.
vs acute conditions! 2. WATER: dehydration, fluid volume excess.
3. FOOD: malnutrition, feeding concerns.
TOOL #6 4. ELIMINATION: proper evacuation of bladder
and bowel.
TIME
The client most recently admitted is not 5. REST: sleep, comfort and freedom from
always seen first! pain (not always a low priority).
6. SOCIALIZATION: the right balance of
solitude and social interaction must be
TOOL # 7 struck.
7. HAZARDS: safety must be provided for.
REMEMBER SAFETY:
Check the client first, then the equipment! Remember: AWFERS
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TOOL # 10
DISASTER NURSING / TRIAGE:
PRIORITY #1 PRIORITY #2 PRIORITY #3 PRIORITY #4
IMMEDIATE DELAYED MINIMAL EXPECTANT

RED YELLOW GREEN BLACK
Life-threatening May require immediate Treatment is needed Injuries are intensive!
injuries survivable with attention, but can in hours to days. Chances of survival
minimal intervention. sometimes wait for Client may be moved are unlikely.
hours. away from the triage Give comfort, separate
• Chest wounds area. from others but do not
• Airway obstruction • Abdominal wounds abandon
• Shock without evidence of
• Pneumothorax • Upper extremity • Penetrating head
hemorrhage
• 2nd & 3rd degree fracture wounds
• Soft tissue injuries • Minor burns
burns to 15 – 40% of • Burns in excess of
(muscles, ligaments • Sprains
the body 60% of the body
tendons) • Small lacerations surface area (BSA)
Key Words: • Genitourinary injury without significant • Seizures or vomiting
• Anxiety • Eye injury bleeding within 24 hours of
• Apprehension • CNS injuries • Psychological exposure to radiation
• Restlessness disturbance • Profound shock with
• Confusion multiple injuries
• Change in LOC • agonal respirations
(1st sign of increased • Absent pulses,
ICP) absent blood
pressure, fixed &
dilated pupils
In the event of a disaster, the nurse may be required to discharge clients to make room for incoming victims:
- first discharge clients that are ambulatory who need minimal care.
- clients requiring assistance are next. Arrangements should be made for continuity of care at home or extended
care facility.
- DO NOT discharge clients who are unstable or require nursing care unless they are in imminent danger.
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ESSENTIAL
FACTS
WORDS OF WISDOM..........
A wise person would not attempt a job without tools and the proper
equipment.
Why should you?
Consistent studying to understand CONCEPTS is essential.
You cannot memorize answers and questions from previous exams!

...You cannot cram to understand...
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WHAT IS YOUR ROLE?

THE ROLE OF AN RN:
1. Assess clients.
2. Initiate, evaluate and update the plan of care and clinical pathways.
3. Care for the most critical and unstable clients, for example:
• Fresh post-operative clients
• Clients with a change in condition who need assessment
• Admissions • Discharges • Transfers
4. Assess available staff and their job descriptions.
5. Perform the most complex procedures, for example:
• Starting IV’s • Interpreting EKG’s • Correlating lab values
6. Collaborate with other departments and disciplines (the Interdisciplinary Approach).
7. Direct and supervise the LPN’s and other ancillary staff, i.e., Unlicensed Assistive Personnel (UAP’s).
8. Act as a client advocate.
THE ROLE OF AN LPN:

1. Provide care to clients in stable condition under the supervision of an RN or other health care
provider.
2. Perform basic therapeutic, preventative care and rehabilitative procedures, for example:
• Sterile dressing changes • Urethral catheter and NGT insertion • Application of restraints
3. Assist RN with unstable and complex clients. Continuity of care plan and clinical pathway.
4. Supervise UAP’s as well as, delegate and supervise other LPN’s within their scope of practice

LPN’S ARE USUALLY NOT ALLOWED TO:
1. Perform triage, patient assessment, case management or independently develop the nursing care
plan.
2. Perform mental health teaching.
3. Administer IV chemotherapy (however bladder installation of chemotheray is permissible).
4. Perform central line or venous port procedures or IV push medications (except saline or Heparin
flushes). *note these skills can be done in an outpatient, chronic hemodialysis setting
5. Administer blood transfusions UNLESS they have satisfactorily completed a transfusion training
program meeting criteria specified by the Department of Health and the State Education Department.
A RN must be present for supervision.
THE ROLE OF A CNA (UAP):

1. Provide routine, non-skilled care, such as bed baths, bed making, routine vital signs, enemas,
oropharyngeal suctioning, apply clean dressings (they may not change dressings), CPR.
UAP’S ARE NOT ALLOWED TO:

Administer medications, tracheal suctioning or trache care, administer O2, deliver NGT or PEG
feedings, insert urinary catheters, perform sterile or invasive procedures, assess evaluate or problem
solve, develop a nursing care plan
TIP: DELEGATION AND SUPERVISION ALONG WITH COLLABORATION CONCEPTS MUST BE

CONSIDERED WHEN SELECTING ANSWER CHOICES! 18
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LEADERSHIP AND PROFESSIONAL ISSUES
TYPES OF LEADERS:
Laissez-faire: Offers little if any guidance.
Autocratic / Authoritarian: Strict. Makes all of the decisions. Uses punishment and coercion.
Democratic: Consults with staff. Promotes participation and majority rule.
PROFESSIONAL ISSUES:
• Chain of command
• Delegation to UAP’s
• Taking verbal orders
• Effective communication - use SBAR (Situation, Background, Assessment, Recommendation)
• Documentation - should be done upon completion of care
DELEGATION: DO NOT DELEGATE WHAT YOU CAN E A T
1. The RN should never delegate the assessment portion of the nursing process.
2. The RN or LPN should never delegate the teaching or evaluation phase of patient care.
3. The RN is ultimately responsible for all tasks delegated to UAP’s.
4. Be aware of the competence and job description of those to whom you delegate.
5. Communicate effectively.
6. The nurse must be sure to follow up on all tasks that were delegated.
7. If criticism is necessary, provide privacy.
8. Document unsafe practices and procedures.
9. Manage your time effectively.
RIGHTS OF DELEGATION
TASK CAN YOU DELEGATE THIS TASK?
CIRCUMSTANCE HOW COMPLEX IS THE PATIENT? WHAT IS THE
SKILL LEVEL OF THE STAFF MEMBER?
PERSON IS THIS PERSON COMPETENT?
COMMUNICATION DID YOU GIVE CLEAR DIRECTIONS?
SUPERVISION/ FEEDBACK DID YOU MONITOR, EVALUATE, AND PROVIDE
FEEDBACK?

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LEGAL CONSIDERATIONS:
The nurse client relationship is a legal status that occurs whenever a nurse renders care to another person.
Once this relationship occurs, the law automatically imposes certain legal responsibilities upon the nurse.
The nurse should never carry out a provider’s prescription which directs her/him to commit an act which they
know, or should know is unlawful.
TERMS TO KNOW:
VERACITY: Adherence to the truth.

LIABILITY: The obligation one incurs or might incur through acting or failing to act.
MALPRACTICE: Improper use of one’s professional duties; a failure to meet care standards that causes
harm to another person.
NEGLIGENCE: The failure to provide care that a reasonable person would perform in similar
circumstances.
LIBEL: Defamation by written or printed words or pictures.
SLANDER: Defamation of character by speech.
ACTS OF OMISSION OR COMMISSION: Doing wrong by not acting; doing wrong by acting.
BENEFICENCE: To do good. Examples of beneficent actions: resuscitating a drowning victim, encouraging
smoking cessation.
NON MALEFICENCE: To do no harm. Example of a non-maleficent action: stopping a medication that is
shown to be harmful.
ASSAULT: To threaten to touch.
BATTERY: Touching someone without consent.
TORT: A wrongful act, whether intentional or accidental, from which injury occurs to another.
FALSE IMPRISONMENT:
When, for example, a client is made to believe they cannot leave a bed, room, or floor. Also, the unauthorized
use of physical (e.g., lap tray) or chemical (e.g., sedatives). HINT: Authorized physical restraints must be
checked every 15-30 minutes (depending on agency policy) and released every 2 hours in order to provide
ROM exercises and comfort measures.
INFORMED CONSENT:
This must be obtained from a client or their health care proxy for any invasive procedure. It is obtained by
the health care provider (physician), while the nurse’s role is to insure the consent is signed and in the chart
prior to the procedure. (Assent = Consent)
INVASION OF PRIVACY:
Everyone in the medical team must maintain the privacy of the client’s medical record as well as her/
his personal, physical privacy, for example, close the curtain or door when the client would otherwise be
exposed. Minimize the computer screen. The nurse has the legal duty to report to public health agencies
gunshot wounds, suspected child or elder abuse, and certain communicable diseases.
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MORE ABOUT LEGALITY
1. GOOD SAMARITAN LAW:

This act protects those persons who choose to aid others who are ill or injured from liability. It does not
cover gross negligence.
2. INCIDENT REPORTING:
Reports unusual occurrences and deviation from care standards. Facilities use the document to evaluate
care, determine potential risks or discover system problems that might have contributed to the error.
3. HARRISON NARCOTIC ACT OF 1941:

This act classified certain habit forming drugs as narcotics and began to regulate them. It was later replaced
by the Comprehensive Drug Abuse Prevention and Control Act of 1970.
Controlled substances: stored in locked system, dispose of unused narcotics immediately - waste must be
witnessed; document immediately and accurately

4. ADVANCE DIRECTIVES: (Also called MOLST in some states) - Medical Order for Life Sustaining Treatment
- written instructions recognized under state law that are related to the provision of care a person wishes to
have when she/he cannot make decisions themselves.
Living will: Prepared by a competent adult and gives health care directions in the case when that per-
son is unable to make decisions on their own.
Durable power of attorney / health care proxy: Documents that specify who will make your health
care decisions if you cannot.
Advanced care medical directive: Competent client consults with health care provider and specifies
the kind of medical care they do/do not want in specific scenarios.
5. EMANCIPATED MINOR:
A child is freed from parental custody and can become an “adult” in many ways. When a minor marries or
joins the armed forces (with parental consent and permission from the courts), she/he becomes
emancipated from her/his parents.
6. HIPAA: The Health Insurance Portability and Accountability Act

Protects the confidentiality of a patient’s health care information. It requires physicians, nurses, hospitals and
other health care providers to inform clients how their health care information is used and/or disclosed.
7. ORGAN DONATION:
• Health care provider determines if organ is suitable before approaching family.
• Organs should be removed within one hour of the client’s death.
• Each hospital has its own protocol regarding organ donation.
• Donor must be kept on life support until the organs are removed.
• Next-of-kin/closest living relative makes decisions when client cannot.

8. UTILIZATION REVIEW:
Determines effectiveness of services in a health care facility, which is related to clients’ length of stay. The
process compares requests for medical services to treatment guidelines that are deemed appropriate for such
services.
9. AUDIT REVIEW:
Review of charts along with direct assesment to determine causes of hospital acquired infections or deviations
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RELIGIOUS AND SPIRITUAL INFLUENCES ON HEALTH

RELIGION BELIEFS AND PRACTICES
JUDAISM (ORTHODOX) • Visits to dying are a religious duty
• A witness must be present at death to protect family and commit
Autopsy: Only in special
circumstances soul to God
• Torah and psalms read, prayers recited
• Conversation is kept to minimum
• Someone should be with body from death to burial usually within
24 hours
• Body must not be touched from 8 to 30 minutes after death
• Circumcision done on day 8 after birth ceremony called Briss
• Medical personnel do not touch or wash body unless death
occurs on Jewish Sabbath; then care given by nurse with gloves
• Water is removed from the room
• Mirrors may be covered at family’s request
HINDUISM • Priest ties thread around neck or wrist of deceased and pours
water in the mouth
Autopsy: Permitted • Only family and friends touch the body
BUDDHISM • Buddhist priest present at death

• Last rites are chanted at bedside
Autopsy: Personal Preference • May prefer same sex wash body
ISLAM (MUSLIM) • Before death, Koran read, prayers said
• Dying confesses sins, asks family to forgive
Autopsy: Only for medical or legal • Only family members touch or wash body
reasons • After death, body is turned towards Mecca-Southeast
ROMAN CATHOLIC • Sacrament of Sick administered to severely ill, those near death,
Autopsy: Permitted or newly dead
CHRISTIAN SCIENTIST • No ritual performed before or after death
Autopsy: Unlikely • No surgical procedures; no autopsy
CHURCH OF CHRIST (MORMON) • No ritual performed before or after death

Autopsy: Permitted • Baptism done after the age of 8
JEHOVAH’S WITNESS • No ritual performed before or after death

• Clergy ministers through counsel and prayer
Autopsy: Only if required by law • No blood or blood products accepted
EPISCOPALIAN
• Last rites optional
Autopsy: Permitted
LUTHERAN
• Last rites optional
Autopsy: Permitted
WESTERN ORTHODOX CHRISTIAN

• Last rites mandatory and given by ordained priest
Autopsy: Not encouraged
• Value silence
• Touching is unacceptable with the opposite sex
ASIAN AMERICANS • Head is considered sacred-do not touch the head
Autopsy: Permitted • Believe in yin (dark, cold) & yang (bright, hot); do not mix hot and
cold
• They prefer warm—considered good for wellness
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RELIGIONS AND DIETARY PRACTICES
7TH DAY ADVENTISTS • Alcohol, coffee, tea prohibited.

(CHURCH OF GOD) • Some groups prohibit meat. Pork is prohibited.
BAPTISTS • Alcohol prohibited, coffee, tea discouraged.
• Alcohol and drug use discouraged.

BUDDHISM
• Some sects are vegetarian.
• Avoid meat on Ash Wednesday and Good Friday.
ROMAN CATHOLICISM • During Lent, fasting is optional, meat on Fridays is discouraged.
• Children and the ill are exempt from fasting.
• Alcohol, coffee and tea prohibited.
CHURCH OF JESUS CHRIST OF • Limited consumption of meat.
LATTER DAY SAINTS (MORMON) • Avoid spices.
• Fasting is done on the first Sunday of each month.
• Beef and veal prohibited, limited meat consumed.
• Many individuals are vegetarians.
• Fasting occurs on specific days of the week, depending on which
HINDUISM
god a person worships.
• Children are exempt from fasting.
• Fasting can be complete abstinence to one meal a day.
• Pork is prohibited as is any meat not ritually killed.
• Alcohol and drugs are avoided.
ISLAM
• During Ramadan (9th month of Mohammedan year) fasting is
practiced during the daytime.
• Food to which blood has been added is prohibited.
JEHOVAH’S WITNESS
• Can consume flesh that has been drained of blood.
• Orthodox believers adhere to dietary Kosher rules.
• Meats that are allowed come from animals that are vegetable
eaters, cloven- hoofed and ritually slaughtered.
• Fish with scales and fins are allowed (can have: white fish, halibut,
haddock, canned tuna, sardines, salmon).
JUDAISM
• Sea scavengers, such as shrimp, are not allowed.
• The combination of meat and milk is prohibited.
• 24 hour fasting is observed on Yom Kippur.
• Pregnant women are exempt from fasting.
• During Passover Week, only bread that is unleavened is permitted.
• Alcohol is prohibited.
PENTECOSTAL
• Avoid food to which blood has been added.
(ASSEMBLY OF GOD)
• Some individuals avoid pork.
• Meat and dairy are abstained from on Wednesday, Friday and
during Lent.
RUSSIAN ORTHODOX • During Lent, all animal products are abstained from.
• Fasting is practiced during Advent.
• The ill or pregnant are exempt from fasting.
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HERBAL REMEDIES AND MEDICAL IMPLICATIONS

HERBAL REMEDY / USES MEDICAL IMPLICATIONS
ALOE VERA
• If ingested, may cause GI upset. May increase
• Topical anti-inflammatory for burns, abrasions
Digoxin level; Avoid with kidney disorders
• Helps with tissue injury
ECHINACEA • Avoid with ragweed allergy
• Blood purifier that fights colds, infections and • Contraindicated in breast-feeding women,
cancer children, immunocompromised
GINSENG • Caution with HTN, DM, clotting disorders
• Anemia • Avoid with Coumadin (may ↑ effect)
• Hypertension • May increase effect of stimulants
• Benign Prostatic Hypertrophy • Hold for 7 days before surgery
SAINT JOHN’S WORT
• Avoid sunlight, antidepressants
• Wound healing
• Avoid with HTN, and with immunosuppression
• Menstrual disorders
• Avoid foods containing tyramine
• Diuretic
• Decreases effect of Coumadin
• Depression
KAVA KAVA
• Increases effects of Barbiturates
• Decrease anxiety and stress
GINKO BILOBA • Contraindicated in pregnant women & children
• Improves blood circulation • Avoid Coumadin (may ↑bleeding)
• Improves attention span • Increases effect of MAOI’s.; Avoid Dilantin
• Takes 6-8 weeks to see results • Hold for 36 hours before surgery
GINGER • May cause CNS depression, cardiac arrhythmias
• Contraindicated with gallbladder disease
• Reduces morning sickness, nausea
• May increase bleeding with Coumadin
• Used to treat burns
• Caution with DM, antihypertensives, and cardiac
medications
GARLIC • May affect blood clotting, blood sugar levels
• May decrease cholesterol, BP and glucose levels • Avoid DM medications
• Have antibacterial and anti-fungal properties • May increase bleeding with Coumadin
• May improve circulation • Hold for 7 days before surgery
SAW PALMETTO
• Supports health of prostate & improves urine flow • No drug interactions.
• Anti-inflammatory • May cause stomach discomfort.
• Prevents hair loss
VALERIAN ROOT
• May increase sedation when used with: ETOH,
• Calms neuro system
barbiturates, sleeping pills, muscle relaxants &
• Promotes sleep
benzodiazepines
• Used for headaches, anxiety, nervousness
BLACK COHOSH • Overdose may cause N/V, headache, dizziness,
• Used for menstrual and menopausal symptoms tremors, reduced heart rate
• Used as a sedative, and diuretic • Contraindicated with CHF, pregnancy
• Reduces blood pressure hot flashes, night • Affects use of hormone replacement therapy,
sweats, and mood changes contraceptives, cardiac medications
FEVER FEW • Increases effect of Coumadin
• Used for migraine headaches and arthritis. • Contraindicated in pregnancy
LICORICE • Contraindicated in heart disease
• Used for peptic ulcer, GERD, weight loss, • May increase blood pressure
eczema, canker sores • Avoid with ACE inhibitors, steroids, digoxin
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MISCELLANEOUS KEY POINTS
COUMADIN hthe risk of bleeding when taken with:

yChamomile yClove yDong Quai
yGinger yGinseng yFever Few yLicorice
Saint John’s Wort ithe effect of COUMADIN!

Clients should AVOID THE SUN with the following:
(Other phrases: avoid the beach, wear long sleeves, wear sunglasses, wear a wide brimmed hat)
• Thorazine (chlorpromazine)
• Retin A (retinoic acid)
• Bactrim (trimethoprim)
• Griseofulvin (grifulvin)
• Exopthalmus (bulging eyes)
• Saint John’s Wort
• Lupus
• Duragesic Patch (fentanyl) - fold and flush to dispose
• Cipro (ciprofloxacin)
• Viagra (sildenafil citrate)
• Glucotrol (glipizide)
• Pacerone (amiodarone): discolors the skin blue-gray
• Benadryl (dipenhydramine)
• Tetracycline: do not give to pregnant women or children under eight as it stains the teeth
• Don Quai: treats menstrual cramps, menses, as muscle relaxant; blood purifier, manages
HTN (avoid with bleeding & clotting disorders)
• Diuretics (Loops & thiazides)
TIP: REMEMBER TO USE YOUR 10 TOOLS AS A THEORETICAL FRAMEWORK FOR

ASSISTING WITH YOUR DECISION MAKING!
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MEDICATION CALCULATIONS

REMEMBER:
Microdrip = 60 gtts/ml Standard IV Set = 15 gtts/ml Blood Administration = 10 gtts/ml
1.Calculate an IV Infusion: Volume (in ml) x gtt factor (e.g., 15 gtts/ml)

Time in Minutes
Sample Question: To administer 500 ml of IV fluid in 8 hours using a microdrip
set, how many drops/minute will you administer?
Answer: 500 (volume) x 60 (gtt factor) = 63 gtts/min. (rounded up from 62.5)

8 hours x 60 minutes (time in minutes)
2. Calculate Parenteral Medications: Desired Amount x Total Volume

Desire = order, prescription, want, give, administer Total Amount of Drug on Hand
Have = on hand, available

Sample Question: You have on hand Benadryl 50 mg / 2 ml.
The prescription reads: Give Benadryl 25 mg IM STAT.
Answer: 25 mg (desired amount) x 2 (total volume) = 1 ml

50 (total amount of drug on hand)
3. Calculate Oral Medications: Desire = order, prescription, want, give

Have = on hand, available
Sample Question: The prescription reads: Administer Albuterol 6 mg po, tid.

On hand is Albuterol 2 mg tablets.
Answer: 6 (desired amount) = 3 tabs.

2 (dosage on hand)
4. Calculate Critical Care Medications: Desire X Volume X Weight (kg) X Minutes

Have
Sample Question: The prescription reads: Administer Dopamine 3mcg/kg/min.

On hand: Dopamine 800mg in 250 ml D5W
The client weighs: 80 kg
The IV should run at ___________ml/hr
Answer: 3mcg X 250ml X 80kg X 60 minutes

800mg
Convert mcg to mg........... 0.003mg X 250ml X 80kg X 60 minutes

800mg

The IV should run at 4.5ml/hr
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Volume Weight
1 tsp 5 ml 1 mg 1,000 mcg
1 cup 240 ml 1 gr 60 mg
1 tbsp 15 ml
1gm 1,000 mg = 1ml
1 pint 473 ml
1 oz. 30 ml 1 kg 2.2 Ibs
1 quart 946 ml 1L 1 kg = 1,000 ml
15 –16 gtts 15-16 minims = 1 ml

Sample Question: If a child weighs 35 lbs., how much do they weigh in kg?
Answer: 2.2 lbs = 35 lbs 2.2 x = 35 x = 15.9 kg
1 kg x kg
SAMPLE QUESTION
Prescription reads: Administer Drug A 4mg/kg every 8 hours intravenously

On hand: 100mg in 50ml Normal Saline
The client weighs: 286 lbs
How many ml/dose_____________
ANSWER:
Convert 286 lbs to kg 286 ÷ 2.2 = 130kg
Multiply 130kg X 4mg = 520mg
Use formula D X V 520 X 50 = 260ml/dose
H 100
Body Mass Index (BMI): Measures body fat based on height and weight.
BMI = weight in pounds

X 703
(Height in inches) X (Height in inches)
BMI < 18 = Under Weight

< 18.5 = Thin for Height
18.6 - 24.9 = Healthy Weight
25.0 - 29.9 = Overweight for Height
> 30 = Obesity
Body Surface Area (BSA): The surface area of the body expressed in square meters.
BSA = Weight in kilograms X Height in centimeters

3600
1 kg = 2.2 lbs
1inch = 2.54cm
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MATH PRACTICE QUESTIONS

1. A nurse is preparing to administer Ringers Lactate 600 ml IV over 8 hours. The drop factor is
15 gtt/ml. The nurse should deliver how many gtt/min? Round to a whole number _____gtt/min
2. A nurse is preparing to administer Pepcid (famotidine) 20 mg IV over 15 minutes. The drug

available is 20 mg/100 ml. The nurse would be correct to set the infusion pump at _____ml/hr
3. A nurse is reviewing prescriptions. The prescription reads, administer Ceftazidime 50 mg/kg

orally every 8 hours to a child who weighs 22 pounds . The drug is available in 100 mg/ml
suspension. The nurse should administer ________ml/dose
4. A nurse is preparing to give oxycodone hydrochloride 0.03 gm po every 8hr. The amount
available is 15mg/tab. How many tab(s) should the nurse administer per dose? ______tabs
5. A nurse is teaching a client on correct use of Azithromycin. The prescription reads, give one
dose 500 mg orally. The drug available is 250 mg / tab. How many tablets should be given?
_____tab(s)
6. A nurse is preparing to administer Rocephin (ceftriaxone) 2 gm IM x 1 dose. The amount

available is 1gm/ 3.6 ml. How many ml should the nurse administer? Do not round _____ml
7. A nurse is preparing to administer 5,000 mcg of Vitamin B12 (methylcobalmin) SQ x 1 dose.

The amount available is 10 mg/ml. How many ml should the nurse administer? ______ml
8. A client’s total 24 hour intake should not exceed 3000 mL. The peripheral IV is running at 75
mL/hr. The client is also receiving Cefazolin 500 mg IVPB in 50 mL D5W q6h and Azithromyin
500 mg in 200 ml D5W IVPB daily. How much PO fluid may the client have? _______mL
9. Sarah drinks 3 cups of water, 180 ml of broth, 1 cup of pureed chicken, and 6 oz of tea. Her
total oral intake is _________ml
10. A nurse is to administer Keppra (levitiracetam) po. The maximum dose is 1.5 gm per day
to be given in 3 equally divided doses every 8 hours. The amount available is 500mg/tab.
How many tab(s) should the nurse administer? ______tab(s)
11. A nurse is preparing to administer Theophylline 160 mg PO q6h. The medication available is
Theophylline 80 mg / 15 ml. How many mL/dose? _______mL
12. A prescription is written to infuse 300 ml Dextrose IV over 10 hours. The drop Factor is
10 gtt/ml The nurse would be correct to set the flow rate to _____ gtt / min. Round to a whole
number
13. A prescription of 200 ml RL to infuse at 100 ml / hour is ordered. The drop factor is10 gtt / ml.
The flow rate should be calculated at ______ gtt / min. Round to a whole number
14. The nurse is preparing a prescription of Regular Insulin 10 units/hr IV. The bag available
contains Insulin 25 Units in 100ml NS. How many ml/hr will the client receive? _______ml
[www.dosagehelp.com] Detailed answers Page 218

10. 1tab 5. 2 tabs
14. 40 ml/ hr 9. 1080 ml 4. 2 tabs
13. 17 gtts/ min. 8. 800 ml 3. 5 ml
12. 5 gtts / min 7. 0.5ml 2. 400 ml/hr
11. 30 ml 6. 7.2 ml 1. .19 gtts/min
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CBC (COMPLETE BLOOD COUNT)

Hematocrit (HCT) 35% - 45% Female 40% - 54% Male
Hemoglobin (HGB) 12 - 16 g/dL Female 14 -18 g/dL Male
White Blood Cell Count (WBC) 5,000 - 10,000 cells/mm3
Red Blood Cell Count (RBC) 4 - 5 million/mL
Platelet Count 140,000 - 400,000 /μL
B Lymphocytes 10 - 20%
T Lymphocytes: 60 - 80 %
CD4 500 - 1000 < 200 signifies AIDS with increased risk for opportunistic infection. HIV kills
CD4 cells which results in a significantly impaired immune system.
URINALYSIS
Normal Color Yellow - Straw Child
Specific Gravity 1.005 - 1.030 1.000-1.030
pH 5.0 - 8.0
CHEMISTRY: ADULT
Sodium 135 - 145 mmol/L
Chloride 95 - 110 mmol/L
Glucose 60 - 120 mg/dL
Potassium 3.5 - 5.5 mEq/L
BUN 8.0 - 25 mg/dL Increased in dehydration and renal dysfunction
Creatinine 0.6 - 1.5 mg/dL
Carbon Dioxide 22 - 34 mmol/dL
Calcium 9.31 - 10.9 mg/dL
Amylase 53 - 123 U/L Increased in pancreatitis
Lipase 7.0 - 60 U/L Increased in pancreatitis
Magnesium 1.3 - 2.1 mg/dL
Ammonia 35 - 65 mg/dL
Uric Acid 3.5 - 7.8 mg/dL
Albumin 3.1 - 5.0 g/dL Decreased with kidney & liver disorders & decreased protein
Alkaline Phosphatase 4.5 - 13 K-A-U/dL
ALT 5 - 35 IU/L
AST 0 - 35 IU/L
Bilirubin Totals 0.1 - 1.0 mg/dL (Adult Normal) 1.2 mg/dL (Adult Critical)
1.0 - 12 mg/dL (Newborn Normal) 15 mg/dL (Newborn Critical)
**Requires treatment usually phototherapy**
HgbA1c 4% - 6% Levels > 8% indicate poor diabetic control with need for education
regarding adherence to regimen or changes in therapy**
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CHEMISTRY: CHILD
Glucose 40 - 125 mg/dL
Calcium 8.0 - 10 mg/dL
Billirubin 0.2 - 1.4 mg/dL
Platelets 150,000 - 450,000/μL
BLOOD CULTURE
• 2 bottles collected (anaerobic / aerobic) blood drawn from 2 seperate sites; must be venipuncture
• Do not draw from IV lines
• Clean skin
• Collect sample before starting antibiotics
NORMAL BLOOD GAS...Remember ROME / RAMS

pH 7.35 – 7.45
PaO2 80 – 100 mmol/L
PaCO2 35 – 45 mmol/L
HCO3 22 - 26 mmol/L
SaO2 £ 95 %
ACID - BASE IMBALANCES pH PaCO2 HCO3

Respiratory Acidosis ¤ 7.35 £ 45 mmHg N/A
Respiratory Alkalosis £ 7.45 ¤ 35 mmHg N/A
Metabolic Acidosis ¤ 7.35 N/A ¤ 22 mEq/L

Metabolic Alkalosis £ 7.45 N/A £ 26 mEq/L
SAMPLE QUESTIONS
Label the acid – base imbalances:

1. pH = 7.20, CO2 = 64, HCO3 = 26 ______________________

2. pH = 7.50, CO2 = 35, HCO3 = 32 ______________________

3. pH = 7.30, CO2 = 38, HCO3 = 18 ______________________
Compensation occurs when the body’s processes counterbalance to bring the pH within normal limits!
ANSWERS: 1. Respiratory Acidosis, 2. Metabolic Alkalosis, 3. Metabolic Acidosis
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LIPIDS (CHOLESTEROL): Test is done fasting.
TOTAL < 200 mg/dL
HDL (high-density lipids) 30 - 75 mg/dL
LDL (low-density lipids) < 130 mg/dL
COAGULATION PROFILE:
PT 10 - 14 seconds
aPTT 30 - 40 seconds
PTT 25 - 35 seconds
INR The therapeutic range is 2-3 only when the client is on anticoagulant therapy.
The PT/PTT range should be 1.5 times - 2.5 times the control when on medication.

MEDICATION THERAPEUTIC LEVELS:
Acetaminophen 10 - 20 mg/L Use with caution with liver disease. Maximum Dose 3 gm/day
Toxicity S/S: N/V, RUQ pain, jaundice, coagulation abnormalities
Lithium 0.6 – 1.2 mEq/L Monitor Na+. Hyponatremia- ↑risk of toxicity.
Toxicity S/S: N/V, blurred vision, drowsiness, slurred speech, arrthymias, renal
toxicity
Dilantin 10 -20 mcg / mL Side effects: discolored urine, gingival hyperplasia.
(phenytoin) Toxicity S/S: rapid eye movements, slurred speech, coordination problems
Theophylline 10 – 20 mcg /mL Side effects include tachycardia and palpitations.
Toxicity S/S: N/V, anorexia, palpitations, sinus tachycardia
Digoxin 0.5 -2 mg/L monitor electrolytes—hypokalemia, hypomagnesemia and
hypercalcemia predispose clients to Digoxin toxicity.
Toxicity S/S: N/V/D, anorexia, blurred vision, halos around the light
Magnesium Sulfate 4 – 7 mg/dL Areflexia is a sign of toxicity. STOP THE INFUSION!!
Toxicity S/S: CNS depression
Gentamycin 5 -10 ug/ml Causes oto, neuro and nephro toxicity.
Toxicity S/S: tinnitus, balance difficulty, visual disturbances, renal dysfunction

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Vital Signs
Vital signs must be assessed:
1. on admission
2. as per M.D. order
3. with any change of health status
4. with chest pain or any abnormal sensation
5. before and after administration of preoperative medications; after surgery or invasive
diagnostic procedures
6. before and after administration of blood and blood products or medications that affect
cardiovascular or respiratory function
7. before and after any nursing intervention that affects the cardiovascular or respiratory
system
Vital signs include temperature (T), heart rate (HR), respiratory rate (RR), blood pressure (BP),
and pain assessment, SaO2 is done as indicated.
Factors Affecting Vital Signs
Vitals Across the Lifespan

Age Pulse Rate Respiratory Rate Blood Pressure
Before birth 140 – 160 – –
Newborn 130 – 150 30 – 60 73/55
Infant 110 – 130 24 – 30 90/55
Preschool 90 – 110 20 – 24 85–90/50–60
School age 80 – 90 18 – 20 90–110/60
Adolescent 70 – 90 16 – 20 110–130/70
Adult– > 18 50 – 100 16 – 20 120–129/80– 84
Older adult >70 60 – 100 15 – 20 £diastolic
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NORMAL FLUID INTAKE AND OUTPUT
INTAKE: 1,500 – 2,500 ml over 24 hours.

OUTPUT: 1,500 – 2,500 ml over 24 hours.
INSENSIBLE LOSS: 500 – 1,000 ml / day
NORMAL FLUID FOR COLOSTOMY / ENEMA: 500 – 1,000 ml
AMNIOTIC FLUID: 500 – 1,000 ml
VAGINAL DELIVERY NORMAL BLOOD LOSS: 500 – 1000 ml / C-SECTION: 1000 ml
REMEMBER!!!
Minimum urine output is 0.5 - 1 ml/kg/hour (adult) 2ml/kg/hour (child).

The most accurate indicator of fluid lost or gained is WEIGHT!
1,000 ml = 1 kg = 2.2 lbs

BASIC ASSESSMENT
1. Obtain history:
Subjective Data:
What the client tells you; history of current illness, pain, aggravating / relieving factors.
Objective Data:
Things that can be assessed by the examiner: name, age, gender, vital signs, diet, activity level,
medications (prescribed or illicit), alcohol intake, cigarettes smoked.
ALWAYS ASSESS CLIENT FROM HEAD TO TOE

REMEMBER TO INCLUDE:
HEAD Shape and symmetry of face. Condition of hair and scalp

(e.g., thinning, balding, alopecia, etc)
EYES Appearance of sclera, color of conjunctiva, appearance of pupils

(They should be equal in size, round and regular in shape, and react to light and
accommodation) PERRLA
EARS Presence of drainage, hearing aids, pain, hearing disturbances
NOSE Drainage, sense of smell, nasal congestion
THROAT Presence of dentures

Oral hygiene
Oral mucosa (should be pink, moist)
Tracheal alignment
Presence of jugular venous distention (JVD)
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PAIN ASSESSMENT
1. Use a pain scale from 0 – 10, 0 = no pain, 10 = worst pain.

2. For a child or a client with a language barrier, use faces or OUCHER scale:
no pain moderate pain worst pain
3. Pieces of pain or color scale can also be used.
4. Assess PQRST:
P: What provokes the pain?
Q: What is the quality of the pain? (e.g., sharp, dull, stabbing).
R: Does the pain radiate? (does it move around)
S: What is the severity of the pain?
(e.g., scale from 1 -10, associated signs & symptoms, such as diaphoresis,
tachycardia, SOB)
T: What was the time of onset (constant, intermittent?)

5. Nursing implications:
Pain Relief:
• Reposition patient
• Rest and relaxation techniques
• Analgesics as per health care provider prescription
• Offer reassurance: allow client to express fears and concerns
• Distraction techniques: deep breathing, imagery, massage, eliminate stimuli, music
therapy, biofeedback (non pharmacological comfort measures)
*Rember to notify the Health Care Provider if there are significant changes in clinical findings i.e. fever,
change in B/P, limb pain or swelling.
TIP *Emphasize prioritization of care on systemic client concerns i.e. sepsis vs. localized concerns.
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NEUROLOGICAL ASSESSMENT
1. Assess Mental Status: alert

disoriented
confused
stuporous
comatose

2. Note: appearance, assess speech, affect, motor function.
3. Note: cognitive deficits or if client has trouble hearing or speaking.
4. RAPID NEUROLOGICAL ASSESSMENT: (performed on admission or on an emergent basis).

0 absent, no response
1 (+) weaker than normal
2 (++) normal
3 (+++) stronger or more brisk than normal
4 (++++) hyperactive
*Note: 1 and 3 may be normal for some individuals.
THE GLASCOW COMA SCALE
1. The Glascow Coma Scale is use to measure a client’s baseline data in three areas:
Eye opening
Motor response
Verbal response
2. The highest score is 15 normal neurological function.
3. A score below 8 coma is present.
4. The lowest score is 3 deep coma is present.
THE SCALE ITSELF

Assess the client in each area and assign a numerical score as per the scale. Then add up
the three numbers to arrive at the total score. Whatever the total is, the three numerical sign
posts in 2,3,4 above will indicate a broad description of the client’s neurological status.
EYE OPENING MOTOR RESPONSE VERBAL RESPONSE
Spontaneous 4 Obeys commands 6 Oriented 5

To sound 3 Localizes pain 5 Confused conversation 4
To pain 2 Normal flexion 4 Inappropriate words 3
No response 1 Abnormal flexion 3 Incomprehensible sounds 2
Extension 2 No response 1
No response 1

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THE BRAIN AND NERVOUS SYSTEM
Each lobe of the brain has a specific function:
Frontal lobe
Voluntary muscle movements, motor areas for control of speech, controls personality, behavioral functions,
intellectual functions i.e. memory, judgment and problem solving, autonomic functions and cardiac and
emotional responses. Damage to the frontal lobe could lead to Broca’s aphasia (expressive aphasia).
Temporal lobe
Controls taste, hearing, smell
and the interpretation of spoken
language.
Parietal lobe
Coordinates and interprets sensory
Information from the opposite side
of the body.
Occipital lobe
Interprets visual stimuli.
Temporal arteritis: inflammation and damage to the blood vessels that supply the head area.
Signs and Symptoms: headache, thrombosis, excessive sweating, fever, malaise, jaw pain with chewing
and muscle aches.
RX: Corticosteroids

LEFT-BRAIN / RIGHT-BRAIN
When cells in a part of the brain loose their blood supply, a corresponding side of the body is affected.
Remember!
Damage to one side of the brain will exhibit deficits on the opposite side (contralateral) of the body.
LEFT-SIDED BRAIN DAMAGE RIGHT-SIDED BRAIN DAMAGE

Slow, cautious behavior Quick, impulsive behavior
Speech problems, aphasia Short attention span
Trouble following verbal commands Neglects left side
Apraxia (impaired motor function) Easily distracted
Trouble performing simple tasks
Right-sided hemiplegia Left-sided hemiplegia

Dandy Walker Syndrome -congenital malformation of 4th ventricle of the brain. Results in increased ICP.
Associated with other disorders of the CNS. Treatment: placement of a VP shunt. Management of S/S.
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NERVE FUNCTION TEST
I. OLFACTORY Smell (sensory) Identify familiar odors
II. OPTIC Vision (sensory) Snellen eye chart

Most eye movements, constricts III, IV, VI test together, Check for ptosis
III. OCCULOMOTOR pupils, keeps upper lid open of lid. Assess ocular movements
IV. TROCHLEAR Eye movements inward, downward Note any eye deviation
Close jaws tightly, Touch forehead,

Facial, scalp, teeth (sensation), jaw, cheeks, chin, and cornea with cotton.
V. TRIGEMINAL chewing movement Test sensitivity to superficial pain
(sharp/dull), and temperature (hot/cold)
VI. ABDUCENS Eye movements, lateral See III, IV

Observe for facial symmetry: whistle,
VII. FACIAL Facial – movement, taste - sensory smile, raise eyebrows; Test taste
discrimination on front of tongue
Hearing (cochlear), balance
VIII. ACOUSTIC (vestibular)
Check Weber, Rinne, check balance
Taste of posterior, tongue, pharynx,

Taste discrimination on posterior 1/3 of
IX. GLOSSOPHARYNGEAL swallowing, salivating, sensation of tongue, check gag reflex
ear, raises palate, controls pharynx
Taste, palate, sensation of pharynx,
Illicit gag reflex, note hoarseness in
larynx, ear, talking, swallowing
X. VAGUS parasympathetic stimulation to heart
voice, Observe rise of uvula when
patient says, “Ahhh…”
& abdominal viscera
Shrug shoulders against resistance.
Movements of head, neck and
XI. SPINAL ACCESSORY shoulders
Turn head against opposing pressure of
the examiners hand
XII. HYPOGLOSSAL Movements of the tongue Protruded tongue, it should be midline
EXAMPLE OF A DISEASE AFFECTING A CRANIAL NERVE:

TRIGEMINAL NEURALGIA:
Trigeminal Neuralgia
This disease causes a specific type of facial pain • 5th cranial nerve
which occurs in sudden, intense, paroxysmal • frequent eye care
episodes. Affect is unilateral and confined to • good oral hygiene
the area innervated by the trigeminal nerve • frequent dental visits
(5th cranial nerve). • avoid hot & cold liquids
• wear glasses outdoors to protect
Priority nursing diagnosis: Pain eye from dust & particles
Treatment:: pain management

Tegretol (carbamazepine), Dilantin
(phenytoin), Elavil (amitriptyline)
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LUNG ASSESSMENT
Inspection – Respiratory rate, rhythm, symmetrical rise and fall of chest wall, respiratory effort, use
of accessory muscles, nasal flaring, sternal/substernal retractions, obvious injury or contusion, rash or
erythema.
Palpation – Pain, tenderness, crepitus, tracheal deviation
Percussion – Dullness (indicates possible hemothorax, pneumonia or effusion), tympany (air filled as in
pneumothorax), resonance (normal lung sounds), hyperresonance (indicates possible pneumothorax, or
emphysema)
Auscultation – assesses for normal lung sounds----should be clear and even, mostly vesicular, louder
on inspiration. Start at the top of lung field (apex), work down towards base of lungs; alternating from left
to right, anterior to posterior.
Abnormal Lung Sounds
Crackles (rales): heard on inspiration in the lower bases, it cannot be relieved by coughing.
Ronchi: Coarse, gurgling sound. Heard on expiration over trachea and bronchi, it can be relieved by
coughing.
Wheezes: High pitched squeaky sound. Heard throughout lung fields usually
on expiration. Cannot be relieved by coughing.
Stridor: high pitched sound heard on inhalation and exhalation. Indicates narrowing of upper airway or
obstruction. ***THIS SOUND REQUIRES IMMEDIATE INTERVENTION***

ABDOMINAL ASSESSMENT
Inspection: Skin, distention, presence of scars, obesity, herniations.
Auscultatation: Bowel sounds hyper: every 3 sec., Normal: every 15- 20 sec., hypo: every minute.
Percussion: Dullness: over solid organs - liver Tympany: over air filled organs, bowels
Resonance: over lungs Flatness: over muscle or bone
Palpation: pulsation, masses, tenderness, rigidity,
NOTE 1:
Always work from area of least pain towards area of most pain.
A pulsatile abdominal mass may indicate an ABDOMINAL AORTIC ANURESYM.
NOTE 2:
Board like abdomen indicates bleeding into abdomen - i.e. placenta abruption or placenta previa, peritonitis.
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EXTREMITY ASSESSMENT
Grip: Should be equal bilaterally. Assess push pull strength of feet.
Distal sensory/motor: Presence/absence of distal pulses, capillary refill, motor movement
Nail beds: note clubbing or cyanosis
Range of Motion: note any limitations
Deep Vein Thrombosis (DVT): Dorsiflex the foot for presence of calf pain, note presence of pain, venous
distention, warmth and localized tenderness. NEVER massage affected extremity.
Edema: check for dependent or non-dependent edema. Localized or diffuse.
Intermittent claudication: pain with ambulation that is relieved by rest.
SKIN ASSESSMENT
Color: Pallor, jaundice, redness, cyanosis

Temperature: Coolness, warmth
Moisture: Diaphoresis, excessive dryness
Turgor: Poor skin turgor may indicate dehydration
Edema: Edema of extremities (bilateral or unilateral), sacrum; dependent side if bed bound
Lesions: Presence of or type of skin lesions
Stages of skin breakdown (Decubitus ulcers)
Stage I: Intact; Non-blanching erythemic area
Stage II: Interruption of epidermis, dermis or both;

appears as an abrasion, blister or crater
Stage III: Full thickness crater involving damage &/or necrosis down to, but not penetrating the fascia
Stage IV: Full thickness crater, similar to stage III, but penetrating the fascia,
with involvement of muscle, bone, tendon, joint
Negative pressure wound dressing – removes fluid from the area and helps wounds to heal faster by
pulling the edges together and allows filling from the bottom up with granulation tissue. Foam is applied
to the wound. A wound drain is attached and covered with a trasparent dressing. The pump is attached to
the wound drain. Once the pump is turned on, it causes a vacuum effect which provides a seal to promote
healing. (50 - 200 mm Hg as prescribed).
Surgical wounds are changed daily. Chronic wounds are changed three times per week.
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a without infra beneath

ab,abs away from inter between
COMMON PREFIXES ad towards intra within
AND alb white juxta beside
THEIR MEANINGS
allo other meso middle
ambi both meta after
anph both milli one• thousanth
an,ana without mono single
ante before multi many
anti oppose, against neo new
auto self nan all, wide
bi two pan all
bio life para beside
brady slow per through
circum around peri around
con together or with poly many
contra against, opposed post after
dys difficult, pain pre before, in front of
ecto outside primi first
endo within pseudo false
epi above or over retro backward
eu good rube red
ex out or away from semi half
hemi half sub beneath
homeo likeness supra above
homo same tachy fast, rapid
hydro water trans across, through
hyper above, high, excessive tri three
hypo low or deficient ultra beyond
idio from one’s self uni one
im not xero dry
COMMON WORD abdomin/o abdomen arthr/o joint

ROOTS acetabul/o acetabulum arteri/o artery
aden/o gland blast/o embryonic
adip/o fat bronch/i bronchus
adrenio adrenal gland broncho bronchus
aer/o air calc/o calcium
angi/o vessel calcane/o heel bone
anter/o front cardi/o heart
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Subcutaneous injections:
average size client 45°
obese client 90° angle 41
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DIABETES: ESSENTIAL FACTS

*Native Americans,Hispanics & African Americans at highest risk
Type1 (IDDM) most prevalent in children and non-obese adults. There is little or no insulin
production by the beta cells or the islets of Langerhans.
Type II (NIDDM) - Most common in obese adults older than 40 years of age. There is a partial
decrease of insulin production and or cell resistance to insulin.
Insulin is required for transport of glucose across cell membrane. Decreased insulin results in
hyperglycemia.

Random glucose > 200 + S/S or Fasting glucose > 126 x 2 = DM
Gestational DM GTT > 135
Hyperglycemic
Clinical Diabetic Ketoacidosis
Hypoglycemia Hyperosmolar Nonketonic
Manifestations (DKA)
Coma (HHNK)
Type I Type I Type II
Too much insulin or too little Absence or deficiency of Uncontrolled DM or oral
Cause
food insulin hypoglycemic drugs
Onset Rapid (within minutes) Slow (about 8 hours) Slow (hours to days)
Appearance Symptoms of fainting Appears ill Appears ill
Rapid and deep Rapid and deep
Respirations Normal Shortness of breath Shortness of breath
Kussmaul Absence of Kussmaul
Breath odor Normal Fruity due to acetone Normal
Pulse Tachycardia Tachycardia Tachycardia
Blood Pressure No Effect Decreased Blood Pressure Decreased Blood Pressure
Anorexia
Hunger Hunger Hunger
Metabolic Acidosis
Increased
Thirst None Increased
Dehydration
Vomiting Nausea, vomiting rare Likely Likely
Eyes Staring, Double Vision Appear sunken Visual loss
Headache Common Occasionally Occasionally
Pallor
Hot Hot
Skin Perspiration
Dry Dry
Chilling sensation
Twitching common
Muscle action Twitching absent Twitching absent
Unsteady gait
Pain in abdomen None Common Common
Confusion Malaise
Confused
Erratic Drowsy
Mental status Dull
Change in mood Confusion
Coma
Unable to concentrate Coma
Administer glucose Administer IV fluids and or Administer IV fluids and or
Treatment
PO, IV, sub q, IM insulin insulin
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Insulin Chart
TimeCourse Agent Onset Peak Duration Indications
Rapid-acting Lispro (Humalog) 10-15 min 1h 3h Used for rapid
Aspart (Novolog) 10-15 min 40-50 min 4-6h reduction of
Apidra (insulin glulisine) 5 -15 min 1-2h 3-5h glucose level, to
treat postprandial
hyperglycemia and
**DO NOT MIX to prevent nocturnal
hypoglycemia
Short acting Regular ½ -1h 2-3h 4-6h Usually administered
Humalog R before a meal. May
Novolin R be taken alone or
Iletin II Regular in combination with
longer acting insulin.
Intermediate- NPH (neutral protamine Hagedorn) 2-4h 6-12h 16-20h Usually taken after
acting Humulin N 3-4h 6-12h 16-20h food
Iletin II Lente
Iletin II NPH
Novolin L (Lente)
Novolin N (NPH)
Long acting Ultralente (“UL”) 6-8h 12-16h 20-30h Used primarily to
control glucose level
Very long acting Lantus (glargine) 1h Continuous 24h Used for basal dose
**DO NOT MIX Levimir (insulin detimir) (no peak) QD at bedtime
*Discard open refrigerated vials of Insulin after 28 days. *Insulin detemir lasts 42 days
Sequence for mixing two Insulins in one syringe:

• Wash hands, then inspect the insulin
• Roll cloudy insulin gently * Do not shake
• Draw up amount of air equal to the dose of cloudy (intermediate or long acting) insulin & inject it into the
cloudy insulin vial (be sure the needle does not touch the solution)
• Draw up amount air equal to dose of clear (regular) insulin and inject into clear insulin vial
• Withdraw insulin from the clear bottle then withdraw
• Place syringe in cloudy vial, pull back on the plunger until the syringe is filled with the amount equal to
the total amount
Somogyi phenomenon:
Manifests as glucose peaks and valleys. Caused by increased insulin resulting in hypoglycemia; usually
occurs at night. Symptoms: • nightmares • sweating
• headache • ketonuria
Treatment: check blood glucose 1–2 times/ night, adjustment of insulin dosage & time, & or a bedtime snack.
Dawn phenomenon: Hyperglycemia in the morning, usually between 2:00 am and 8:00 am.
Treatment: Increase insulin and avoid a bedtime snack.
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• Complications of Diabetes Mellitus (K.N.I.V.E.S.)

Kidney disorders Neuropathy Infection Vascular changes Eye damage Skin lesions

• Females experiencing recurrent vaginal yeast infections should be tested for:
• Type II Diabetes Mellitus
• HIV infection
REMEMBER
• Hot and dry glucose is high
• Wet and clammy give hard candy
What is the relationship between diet, insulin, and exercise?
Fill in the blanks with the words increase or decrease:

A client that took too much insulin will need to ______________food
A client that exercises three times a day may need to ___________insulin
A client that missed a meal may need to ________________insulin

FACTS ABOUT ORAL HYPOGLYCEMIC AGENTS

• Prescribed for treatment of type 2 Diabetes
• Teach - avoid Alcohol
• *clients on oral medications may require Insulin therapy during times of illness or stress
(i.e. postoperatively) related to increase glucose levels as body’s response to stress.
THE AGENTS
Hold for 24 hours before and 48 hours after contrast dye
Glucophage (metformin) May cause lactic acidosis
Contraindicated with kidney disease
Glucotrol (glipizide) Give 30 minutes before meals; teach avoid sunlight
Take with meals, contraindicated in pregnancy.
Diabeta (glyburide)
Side Effects: photosensitivity, aplastic anemia.
Take with meals.
Amaryl (glimepiride) Side Effects: dizziness or weakness, blurred vision, headache, nausea and
vomiting, dark urine
Avandia (rosiglitazone)
Monitor liver enzymes; contraindicated with CHF & MI
Actos (pioglitazone)
Starlix (nateglinide)
May cause cough, SOB, seizures
Prandin (repaglinide)
Precose (acarbose) Abdominal pain, diarrhea, increased LFT’s
Onglyza (saxagliptin) URI, UTI, headache, pancreatitis, abdominal pain, drowsiness, weakness.
Januvia (sitagliptin) Administered once a day
Injectable – to treat type II DM; helps the pancreas to produce insulin more
efficiently. Administer 2 times daily 60 minutes before meals- it must be taken
Byetta (exenatide) on an empty stomach.
Side Effects: pancreatitis, hypoglycemia, renal impairment, nausea, vomiting,
diarrhea
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Infection Control Essentials
Standard Precautions–are used for the care of all clients – to prevent direct contact with all body fluids.
Standard precautions routinely practiced by health care providers include:
Wash Hands and Don Gloves: When in contact with all body fluids.
Be sure to wash hands after removing gloves.
Use mask/eye protection/ face shield: If the threat of a splash is eminent.
Don Gowns: To protect skin and clothing during procedures that may involve splashing.
TRANSMISSION BASED PRECAUTION PROCEDURES
Airborne Precautions Droplet Precautions Contact Precautions
Surgical mask within 3 feet of the
N-95 Particulate Respirator Mask Gloves and gown
patient
Negative pressure
Private room Private room Private room
Keep door closed
Patient wears surgical mask during Patient wears surgical mask during Remove gloves and gown before
transport transport leaving room
Limit transport Limit transport
WHICH DISEASES / WHICH PRECAUTIONS???
AIRBORNE PRECAUTIONS DROPLET PRECAUTIONS CONTACT PRECAUTIONS
Used for clients with suspected or Used for clients with suspected or
Used for clients with suspected or
confirmed infections transmitted confirmed infections transmitted by
confirmed infections transmitted
by airborne droplets with nuclei < by large particle droplets. direct or indirect contact.
5 microns. • Meningitis • Clostridium Difficile
• Measles (Rubeola) • Bacterial Pneumonia (PNA) • Herpes Simplex Virus
• Varicella (Chicken Pox) • Epiglottitis • Klebsiella Pneumonia
• Tuberculosis • Pertussis • RSV for 24 hrs• MRSA
• SARS (Severe Acute Respiratory • Mumps • Ebola • VRE
Syndrome) • Rubella (German Measles) • RSV
• Smallpox • HIB • Rotavirus
• H1N1 • Ebola (Haemophilus influenza type B)
• Herpes Zoster (shingles)
• Herpes Zoster (shingles) - • Group A Strep (Scarlet & • Infected pressure ulcers
Disseminated disease in any Rheumatic fever) • Major skin wound/burn infection
patient. Localized disease in • Diptheria (Pharyngeal) • SARS
immunocompromised • Adeno Virus • Fifth’s Disease • Vaccinia (cow pox)
Skin Infections:
NOTE* Infection control should be notified every time a patient • Impetigo (Group A strep)
• Pediculosis
with a communicable disease is seen and not admitted. • Scabies
• Varicella
*Also, Do not cohort post-op patients with anyone • Diptheria (cutaneous)
experiencing nausea, vomiting, diarrhea, open wounds, Viral Hemorrhagic Infections:
chest drainage or infections. • Ebola
• Viral conjunctivitis
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MORE ABOUT INFECTION CONTROL....
1. Chain of Infection – hand washing is essential to

break the chain

2. Medical Asepsis = Clean technique
A. STANDARD PRECAUTIONS:
USED FOR ALL CLIENTS regardless of diagnosis
when in contact with blood, body fluid, secretions,
excretion, non intact skin and mucous membranes.
Hand washing and personal protective equipment
are essential.
B. TRANSMISSION BASED PRECAUTIONS
Airborne; Droplet; Contact
I. Airborne Precautions particles < 5 microns

• Private room (negative pressure with at least 6 exchanges per hour)
• Door must be kept closed
• Mask (N95) to be worn at all times while in the client’s room
• Limit transport; mask the patient if transport is needed
II. Droplet Precautions

• Private room. Patients affected with same organism may share a room
• Maintain 3 feet distance between patients and visitors
• Mask to be worn when working within 3 feet of patient
• Limit transport; mask the patient if must transport
III. Contact Precautions

Direct (contact with client’s skin) or indirect (contact with contaminated surfaces)
• Private room – or cohort with same organism
• Gown and glove upon entering room
• Change gloves after contact with infective material
• Don personal protective equipment using correct sequence:
Gown, mask or respirator, goggles then gloves

Remove personal protective equipment using correct technique: (GERM)
1. Remove gloves
2. Remove goggles or face shield (handle by headband or earpiece)
3. Remove gown (inside out)
4. Remove mask (front of mask is contaminated DO NOT TOUCH). Wash hands.
• Do not touch anything in environment after hand washing.
• Limit transport of patient.
• Dedicate use of patient care equipment to this patient only; leave equipment in the room.
• Enteric precautions – GI tract i.e. clostridium difficile toxin.
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3. Surgical Asepsis Sterile technique, free from all pathogens and their spores
4. Disinfection Destruction of pathogens
5. Sterilization Destruction of all microbes
6. Antiseptic Inhibits microbial growth
A. moist heat steam under pressure (autoclave) or boiling objects in water

7. Heat sterilization
B. dry heat
A. gamma rays used to sterilize food and drugs

8. Radiation B. ultraviolet light used to inhibit the microbial population of air in operating
rooms, nurseries and laboratories
Biological Toxins (used in warfare)
Anthrax – Standard precautions (Cipro or Doxycycline)
Botulism – Standard precautions

•
Caused by clostridium botulinum toxin
•
Affects the nerves causing respiratory failure and paralysis
•
Food bourne (canned foods, aluminum foil wrapped baked potato)
•
Symptoms appears 18 to 36 hours after exposure (up to 10 days)
•
Signs & Symptoms: diplopia, drooping eyelids, slurred speech, difficulty swallowing
weak muscles and constipation
• Treatment: antitoxin
Pneumonic Plague – Droplet precautions -caused by yersinia pestis. Start antibiotic ther-
apy within 24 hours. Streptomycin, Gentamicin or Tetracycline
West Nile Virus • • • • • • Standard precautions - Teach: eliminate standing water
Handling Hazardous Wastes: nurses should be familiar with the material safety data
sheet (MSDS) for the facility. It contains data on each substance in the facility that is
considered hazardous. It includes information on safe handling of spills, first aid
interventions, and protective equipment for the management of hazards.
Read labels: use all materials solely for their intended purpose; always use required PPE;
contact biohazard department when appropriate.
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BURNS
A burn is damage to the body’s tissues caused by heat, chemicals, electricity, sunlight or radiation. It results
in a hyper metabolic state causing protein and lipid breakdown which affects wound healing. The client’s
caloric intake will need to be increased 1 1⁄2 to 2 times the BMR (basal metabolic rate), with 1.5 – 2 gm/kg
of body weight of protein daily. High metabolic rates increase the rate of infection.
DEPTH OF BURNS
• Superficial – cause slight epidermal damage resulting in redness and pain.
• Deep partial thickness – cause necrosis of epidermal and dermal layers.
• Full thickness – necrosis through all the skin layers with destruction of nerve fibers.
• Eschar (hard-leather like tissue) develops. These patients do not feel pain.
TYPES OF BURNS
• Thermal – hot objects, frostbite (rewarm area as rapidly as possible)
• Electrical – electrical current
• Chemical – acid, alkaline liquids
• Radiation – sunburn, external radiation beams
BURN ASSESSMENT
Rule of the Palm: This method uses the patient’s hand size to estimate the percent of BSA of
small burns (15% or less). The surface area of the patient’s palm equals approximately 1%.
Rule of Nines: This method divides the TBSA into segments that are multiples of 9%.
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GOALS OF CARE FOR A BURN PATIENT *No pain relief until V/S are stable
• Priority: maintain a patent airway – may require intubation; supplemental O2
• Prevent or correct hypovolemic shock

- Monitor V/S – increased HR due to decreased cardiac output, decreased B/P, due
to increased capillary permeability
- Insert large bore angiocath; IV fluid replacement with Ringer’s Lactate;
- Parkland’s formula - calculates fluid requirements in a 24 hour period:
(%TBSA x Wt. (kg) x 4 mL) - give ½ of total volume in 8hrs, 2nd ½ over next 16hrs.
Calculation of fluid requirement is started from the time of the burn rather than the
time of presentation. If presentation is delayed, fluid may need to be given more
rapidly.
- Administer blood and blood products as prescribed
- Strict I&O; daily weights; indwelling catheter
• Correct metabolic acidosis – IV fluids; Na+ Bicarbonate

• Prevent infection – Give Tetanus injection prophylactically; cover the wound with sterile or
clean dressings; Sterile dressing changes; Antibiotic therapy; Protective isolation
• Maintain nutritional status – high calorie, high protein diet, TPN; calorie count, I&O
• Restore skin integrity – skin grafts; Jobst stockings
• Prevent contractures – ROM exercises, proper positioning and alignment
• Prevent other complications – Curling’s Ulcer – stress ulcer associated with severe burns
Treatment: H2 Blockers (Pepcid - famotidine) and or PPI’s (proton pump inhibitors - Prevacid -
lansoprazole)
• Restore function as much as possible – Rehab (occupational therapy, physical therapy, and
speech therapy)- interdisciplinary approach
• Re-establish social and emotional equilibrium
*** Burns from the waist up, airway is the priority; from the waist down, fluid and electrolyte
management is the priority. ***
MEDICATIONS
• Morphine Sulfate to control pain; NSAID’s sometimes used
• Silvadene (silver sulfadiazene)
• Sulfamylon (mafenide acetate) no dressing with this med
• Silver Nitrate - keratolytic agent (breaks down keratin) May cause hypokalemia, hyponatremia,
hypochloremia
• Garamycin (gentamicin sulfate) oto, neuro and nephrotoxic – monitor BUN & Creatinine
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PHYSIOLOGICAL
INTEGRITY
TIP: When prioritizing patient care remember to select life saving measures over preserving a limb!
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PHYSIOLOGICAL INTEGRITY
I. Health Promotion and Illness Prevention
A. PREVENTION
Primary prevention: Prevents disease i.e. immunizations, protective devices - car seats, helmets,
needle exchange programs.
Secondary prevention: Early detection, screening & diagnostic tests i.e. self breast exam,
mammogram, colonoscopy, testicular self exam
Tertiary prevention: Palliative care, rehab, comfort, hospice
B. SCREENING TESTS
Angiography (cerebral, pulmonary, renal, coronary)
• X-ray of the blood vessels using contrast dye
• assess for allergy to iodine, shellfish or dye; assess kidney function; hold metformin
• increase fluids after test
Bronchoscopy
• visualization of the bronchus
• before exam – provide oral hygiene, postural drainage, NPO for 6 to 8 hours
• after exam – check for gag reflex, ice collar for swelling, observe for subcutaneous emphysema
(Crepitus): indicates air leakage/ perforation; frequent swallowing indicates bleeding.
X- ray
• no metals or jewelry
• instruct client to keep still
• assess females for pregnancy
Fasting Glucose Level
• >126 two times used to diagnose DM (Diabetes Mellitus)
• should be <70; > 135 = Gestational Diabetes
Intra-venous pyelogram (IVP)
• dye injected to assess for blockage in kidneys, ureters, and bladder
• NPO 4 - 8 hours before test
• after test increase fluids
Bladder Scan
• ultrasound to assess condition of the bladder and for presence of residual urine
• painless; 1 - 2 minutes in length
24 Hour Urine Collection
• 1st urine should be discarded
• refrigerate specimen / place on ice
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Amniocentesis
• assess fetal heart tone during and after the test (normal 120 -160). 20 - 30 mL removed
• can indicate gender, congenital abnormalities, neural tube defects, gestational age
• Rh factor, L/S ratio for lung maturity - should be 2:1 ratio
Thoracentesis
• removal of fluid or air from pleural space
• needle inserted on exhalation
• place client in orthopenic position to perform procedure
• if patient can not sit on their own, place on unaffected side
• after test assess for respiratory distress–shock, pallor, diaphoresis
• maximum fluid withdrawal 2 - 3 L
Paracentesis
• before procedure client must void first
• check weight
• check abdominal girth BID
• increase HOB 45 – 60 degrees to allow fluid to pool; position supine with HOB slightly elevated-
for withdrawal
• post – monitor I&0, abdominal girth; priority follow up – blood in urine
• maximum fluid withdrawal 4–5 L
Barium enema
• before procedure give enemas/laxatives until colon is clear of stool
• clear liquid diet the night before the procedure
• NPO 8 hours before the test
• after the procedure administer fluids, laxatives or suppositories to expel barium
• Teach: expect constipation & clay colored stools
C. NUTRITION
• Foods high in Sodium (Na+): celery, processed foods, condiments, canned foods, smoked
meats, tomato juice, pickles, butter.
Increase salty snacks in clients with Burns, Lithium therapy, Addison’s disease, and
Cystic Fibrosis (BLAC)
• Foods high in calcium (Ca+): dairy products, green leafy vegetables, kale, broccoli, fish (canned
with bones- sardines), white beans, oranges, raisins, nuts, sesame seeds. Take with Vitamin
D to increase absorption (sunlight, cod liver oil, eggs, milk, fatty fish - salmon, sardines, tuna,
oatmeal, mushrooms).
• Foods high in potassium (K+): apricots, melons, citrus fruits, potato, spinach, raisins (dried
fruits), raw vegetables, nuts, bananas, grains, kiwi, figs, avocado, pumpkin, peas, cranberries
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Foods high in Iron: green leafy vegetables, organ meats, tofu, poultry and fish
Take with Vitamin C to increase absorption
VEGETARIAN DIET DAIRY EGG MEAT
Lacto-ovo + + -
Lacto-vegetarian + - -
Ovo-vegan - + -

Pesco-vegetarian + - Only Fish

Partial/semi vegetarian
+ + Avoid selected meats
*Vegans- eliminate all animal products & dairy
Nutrition
Carbohydrate: major source of food energy

• Grains, nuts, fruit
Protein: needed for tissue building

• Found in meats, chicken, beans, legumes, tofu, eggs
Fat: insulation, energy, carry fat soluble vitamins

• Fat soluble vitamins include A, D, E, K (water soluble: B & C)
• Found in egg yolk, liver, butter, cheese, margarine

• Decrease in clients with cardiovascular and cardiac disease

Normal Values

CHO: 4 kcal/gm Protein: 4 kcal/gm Fat: 9 kcal/gm
Example: The client had a 24 hour dietary intake of 200 gm CHO, 100 gm protein and
50 gm of fat.
What is the total caloric intake for the day?

ANS: 1650 calories
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VITAMINS – necessary for normal cellular functions of the body

Vitamin B1
• B1 = Thiamine – given to alcoholics and to prevent beriberi (s/s walking difficulties,
parasthesias of hands and feet, loss of muscle function)
• Found in grains, meat, fish, nuts, legumes
Vitamin B3
• B3 = Niacin - given to decrease cholesterol & triglycerides
• Deficiency causes pellagra (s/s diarrhea, dermatitis, dementia, death)
• Found in mushrooms, tuna, chicken breast, asparagus, halibut, salmon
Vitamin B6
• B6 = Pyridoxine
• Increase with INH(Isoniazid) to decrease peripheral neuropathy
• Found in meat, fish, potatoes, vegetables
Vitamin B9
• B9 = Folic Acid -given pre-natally to prevent neural tube defects
• Found in organ meats, green leafy vegetables, fish and poultry
Vitamin B12
• B12 = Cyanocobalamin–needed for normal neurological function
• Deficiency causes pernicious anemia
• Found in brewer’s yeast, citrus fruit, dried beans, green leafy vegetables, nuts, organ
meats
Vitamin A
• Good for mucous membranes and night vision
• Deficiency causes night blindness and hair loss; Toxicity = liver damage & CNS effects
• Bile necessary for absorption
• Found in fish, liver, egg yolk, yellow and dark green vegetables
Vitamin C
• Necessary for synthesis of collagen & neurotransmitters, assists with wound healing
• Deficiency causes Scurvy (s/s irritability, bleeding gums, leg pain)
• Found in citrus fruits, green leafy vegetables, strawberries, peppers
Vitamin E
• Required for the proper function of many organs in the body. It is also an antioxidant
• Overdose S/S - nausea, stomach pain, diarrhea, headache, fatigue, blurred vision
• Found in sunflower seeds, almonds, olives, papaya, dark green vegetables & whole
grains
Vitamin K
• Necessary for clotting
• Found in green vegetables, cabbage, liver and organ meats
Omega 3 fatty acids
• Good for cardiovascular health, diabetes mellitus, immune function, joint health
(inflammation), cancer and cognitive and behavioral function
• Found in salmon, herring, mackerel, anchovies, sardines, tuna, halibut, plant and nut oils
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Diet Modifications
Progression • Clear liquid – full liquid – soft – regular
Bland Diet • Helps to heal gastric mucosa
• Decrease spices
Low Residue • Used after bowel surgery, prior to bowel exam, for internal radiation
• Avoid nuts, seeds (strawberries), milk, foods high fiber (grains)
• Crohn’s disease
Tube Feedings
• Place the client in the semi fowlers position
• Measure from the tip of the nose, to the tip of the earlobe to the zyphoid process
• Assess for placement every four hours: withdraw fluid to check pH - 4 or less indicates gastric contents.
Values greater than 6 indicates intestinal contents (fluid must be replaced). Insertion of air while listening
for air over the stomach is not a reliable method to assess placement.
• Residuals greater than 150 ml should be reported
• X-ray **most definitive** method to determine placement
PPN: Peripheral Parenteral Nutrition TPN: Total Parenteral Nutrition

Peripheral: peripheral vein is used Central Line – long term/ Jugular – less than 4 weeks
Finger sticks Q 6 hours – prone to hyperglycemia
Never stop abruptly/ taper may cause hypoglycemia
Piggy back with lipids only
Temporary supplement (4-7 days)
Change tubing daily, use a filter
Change dressing every other day using sterile technique
If TPN unavailable administer Dextrose 10% until available
Celiac Disease:
• Formerly called (Sprue)
• Avoid foods containing gluten
• Avoid barley, rye, oat, wheat (BROW)
• Can have rice, corn, soy flour, pistachios
• High protein, high calorie diet
PKU : Phenylketonuria Diet:

• Avoid phenylalanine (amino acid that cannot be metabolized)
• Avoid artificial sweeteners, bread, meat, fish, poultry, cheese, nuts, eggs, legumes
• Guthrie test performed via heel stick. If done earlier than 24 - 48 hours, test must be repeated in 7-14
days
• For infants – lofenolac formula is used (low protein, low amino acids)
• Can cause brain damage/mental retardation
Low Purine Diet (Gout: Increase Uric Acid)

• Avoid organ meat, shellfish, lobster, peas, beans, nuts, oatmeal, wheat, sardines, anchovies, alcohol,
mushrooms
• Eggs and chocolate are OK – encourage fluids – 2-3L/day
• Beneficial foods: blackberries, tofu, soybeans, salmon
Medications:
• Colcrys (Colchicine)- May decrease Vitamin B12 absorption, diarrhea - use during acute exacerbation
• Zyloprim (Allopurinal)– Bone marrow depression, arthralgias
• Benemid (Probenicid) –nausea, rash, constipation
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Safety – Fire safety To use a fire extinguisher:

Rescue/remove those in immediate danger Pull the pin
Alarm others by activating the fire alarm Aim low at the base of the fire
Confine the fire Squeeze the handle. Stand approximately ten feet from fire
Extinguish the fire if small or evacuate Sweep the hose from side to side
Important Positions for Various Conditions

Laminectomy: • log roll; post op: place in supine position
Tube inserted in GI tract: • right side
Enema: • left side lying; insert tube 3-4 inches (7-10 cm), do not hang enema bag
greater than 12-18 inches (30-45 cm). If cramping occurs- lower the bag
Amputation: • elevate stump 1st 24 hours only
(lower extremity) • elevate the bed not just the stump; to prevent contractures; place client in
prone position several times daily
Cast: • elevate part
Compression bandages • reduces edema and pain
• wrap limb distal to proximal
Gastric resection: Avoid dumping syndrome
• lie down after eating
• do not drink with meals
• Vitamin B12 replacement necessary
Liver biopsy: • pre procedure: place on left side, elevate right arm- may also be placed supine
• post procedure: place on right side with a small pillow to decrease bleeding
Pneumonectomy: • place on operative side post-op
Respiratory Distress: • high fowlers/orthopneic position
Mastectomy: DO NOT ABDUCT
• causes strain on suture line
• elevate arm on pillow (same side as operative breast)
• exercises: wall climbing, rope turning, broom lifting, hair combing
Retinal Detachment: • lay on AFFECTED side
• any other eye surgery lay on UNAFFECTED side
Venous: • keep legs elevated (V)
Arterial: • keep legs dependent (A)
Radical Neck Dissection: • affected side
Kidney Biopsy: • pre procedure: position prone
• hold aspirin 1 - 2 weeks prior to procedure
• post procedure: position supine; hematuria and pain expected for a few
days after
Hip Surgery: ABDUCT
• use abduction pillow between legs to immobilize & prevent dislocation
• never cross legs or bend over
• use a raised toilet seat; use a raised - high chair
• lay on unaffected side
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II. Perioperative Nursing
Types of surgery Reasons performed Examples

Diagnostic Determine cause of symptoms Biopsy, exploratory laparotomy
Curative Removal of diseased part Appendectomy
Strengthen weakened areas
Herniorrhaphy
Restorative Correct deformities
Mitral valve replacement
Rejoin a separated area
Palliative Relieve symptoms without curing disease Sympathectomy
Cosmetic Improve appearance Rhinoplasty
• It is the responsibility of the surgeon to obtain consent for the surgery and to explain, benefits, risks, and
possible complications.
• Preoperative teaching should include instructions for deep breathing and coughing exercises, leg
exercises, and options for pain management.
• Diagnostic and laboratory tests should include: CBC, BUN, EKG, Electrolytes, HCG (for females),
urinalysis, history and physical and Chest x- ray.
• The client should be NPO 8 - 12 hours prior to surgery. An enema or laxative may be given the night
before surgery of the GI tract. Conduct a timeout immediately before starting an invasive procedure.
• Conscious sedation used for minor procedures (extensive suturing, endoscopy, cardiac catheterization,
bone reduction) to minimally depress the level of consciousness. Patient can cooperate during the
procedure but may have partial amnesia afterwards. Versed (midazolam) or propofol may be used.
Common Post Operative Tubes and Drains

Complications include:
Jackson Pratt, Hemovac, Penrose
• Atelectasis (collapsed alveoli)
• Used post-op
• Hemorrhage of the wound
• Remove blood & fluids from the wound to prevent
• Thrombophlebitis infection
• Wound infection • Promote wound healing
• Dehiscence (separation of the wound) Nasogastric
• Evisceration (wound contents are expelled) • Used to decompress the stomach
• Urinary tract infection • Levine: (1 lumen) low intermittent suction
• Salem Sump: (2 lumens) continuous or intermittent
Risk factors include: suction
• Obesity • *Monitor drainage for consistency, color and amount
• Poor nutrition Sengstaken–Blakemore
• Used to treat esophageal varicies (medical emergency)
• Steroid therapy
• Deflate gastric balloon every 24 to 36 hours– (3 lumens)
• Keep scissors at the bedside
Pre- existing conditions:
• Diabetes Mellitus Miller Abbott
• Cardiac • Used for intestinal suction and decompression
• Respiratory Percutaneous Endoscopic, Gastrostomy (PEG tube)
• Neurological disorder • Used for long term feeding
• Not necessary to check for placement
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III. Circulatory Function and Disorders

A. Anatomy and physiology review
B. Risk factors related to the development of peripheral vascular disease:

• Smoking
• Exposure to cold
• Obesity
• Immobility
• Hypertension
• DM
C. Peripheral vascular disease assessment:

Check for 6 p’s
1. Pain
2. Paresthesia
3. Pulselessness
4. Paralysis
5. Pallor
6. Poikliothermia
Arterial Ulcers Venous Ulcers
• Lower leg affected • Ankle to knee affected
• Secondary to PVD, DM • Secondary to obesity, age, pregnancy, DVT
• Pallor and pain with leg elevation • Painless
• Ulcers are distal to the loss of blood supply • Affects medial and lateral aspect of the malleolus
• Pale, yellow or gray wound base • Ruddy or red wound base
• Skin tight and shiny with hair loss
• Regular wound margins • Irregular wound margins
• Keep legs dependent • Elevate legs
• Decreased or absent peripheral pulses • Presence of peripheral pulses
Metabolic Syndrome X - a group of risk factors that increase the risk for heart disease and other health
problems such as diabetes and stroke. People with metabolic syndrome are twice as likely to develop heart
disease and five times as likely to develop Diabetes Mellitus.
• Increased B/P 135/85 or higher
• Increased fat around the waist (over 35 inches female, over 40 inches male)
• Increased glucose level
• High triglyceride level
• Decreased HDL or Increased LDL
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D. Arterial vs. Venous disorders – smoking contributing factor

Arterial Disorders: keep extremities dependent (down)

Signs & Symptoms:
• intermittent claudication
• cold
• edema
• diminished pulses
Treatment:
• Vasodilators
• Analgesics
• Anticoagulants
• Anticholesterol Agents
• Smoking cessation
• Keep extremities warm

• Trental (pentoxifylline) decreases viscosity of blood - used to improve blood flow in clients with
circulatory problems to reduce aching, cramping & tiredness in the hands and feet
Side Effects: drowsiness, dizziness, headache.Take with meals.
1. Thromboangitis obliterans (Buerger’s disease):

Vessel occlusion occurs commonly in males 25-40 yr olds
2. Raynaud’s disease:
Arterial spasms of the fingers commonly in females between teen years and age 40
Tasks that involve repetitive finger movements increase the risks. (butcher, pianist, typist)
3. Arteriosclerosis Obliterans (occlusive arterial disease):

Found in males 50-60 years old
4. Aneurysm:
Sac formed by dilation of an artery. Males 50 - 70 are at highest risk
Dx: X-ray, aortagraphy, sonography Treatment: surgery or beta blockers if the aneurysm is small

Venous Disorders - elevate extremities

1. Thrombophlebitis: Inflammation of the vessel wall with formation of a clot.
Treatment- anticoagulant therapy, warm packs, surgery

2. Varicose veins:
Dilated veins.
Risk factors: obesity, pregnancy, heart disease, thrombophlebitis, excessive sitting or standing.
Treatment- vein ligation or sclerotherapy
Post-op care: elastic bandages – remove every 8 hours for short periods; Coumadin (warfarin)
decrease foods high in vitamin K (green vegetables, organ meat) while on this medication
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E. Hypertension: “ The silent Killer ”
Risk factors:
• Age
• Race (African Americans at highest risk)
• Family history
• Diabetes mellitus
• Cigarette smoking/ ETOH
• ↑ cholesterol
Primary hypertension: no known cause
Secondary hypertension: caused by another
condition i.e pheochromoytoma (hypersecretion
of the adrenal medulla)
Categories of Blood Pressure
Symptoms: Normal Less than 120/80
• Early morning headaches Pre-hypertension 120-139/80 - 89
• Nosebleeds
Stage 1 hypertension 140-159/ 90-99
• Fatigue
Stage 2 hypertension 160 & above/100
• SOB on exertion
Stage 3 hypertension 180/110
Recommended Life Style Changes: Treatment:
• Avoid smoking and alcohol • Beta Blockers
• Decrease sodium • Calcium Channel Blockers
• ACE inhibitors
• Increase exercise
• Angiotensin II Receptor Blockers
• Reduce stress • Diuretics
• Alpha Blockers
• Vasodilators
• Lipid Lowering Agents
IV. Cardiac Function and Disorders

P wave: Atrial depolarization (contraction) EKG PAPER

Small block: 0.04 secs
QRS wave: Ventricular depolarization (contraction) Big Block: 0.20 secs (or 5 small
blocks)
T wave: Ventricular repolarization (relaxation) 1 Second: 25 small boxes or 5
big blocks
An increased potassium level will result in an increased T wave
1 minute: 1500 small blocks or
300 big blocks
A decreased potassium level will result in a decreased T wave
*Signs of hypokalemia include: • Anorexia • Nausea • Vomiting • Faint pulse • Muscle weakness
*Signs of hyperkalemia include: • Muscle weakness • Decreased urine output • Depressed reflexes &
respirations • EKG changes • Decreased heart contractility
• Normal Sinus Rhythm: 60 - 100 bpm

• PR Interval: Measures time it takes for the impulse to get from the atria to the ventricles - 0.12-0.2 secs
• QRS Interval: Measures the time it takes for the ventricles to contract - < 0.12 secs (< 3 small blocks)
• QT Interval: Measures depolarization and repolarization time of the ventricles - < 0.42 secs (about10
small blocks)
• ST segment: Completion of ventricular depolarization - 0.08 - 0.12 seconds
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C. Disorders
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Fill in the blank- Cardiac
1. The normal PR interval is ________-_______seconds or _______-_______ boxes
2. The normal QRS interval is ________-_______seconds or _______-_______ boxes
3. The normal QT interval is ________-_______seconds or _______-_______ boxes
4. One small box =____________seconds

Answer Key
1, 0.12 - 0. 2 seconds or 3-5 boxes
2. less than 0.12 seconds or 3 boxes
3. less than 0.42 seconds or 10-11 boxes
4. 0.04 seconds
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A. Diagnostic Tests
CK- MB:
• Rises 2-5 hours after an MI
• Peaks in 24 hours
• Troponin rises in 3-12 hours and may be elevated for 2 weeks (best indicator of an MI)
Pulmonary artery Pressure Monitoring: (Swan Ganz)

• Measures pressure in the right atrium, pulmonary artery and left ventricle
• Normal is 15 mm/Hg. Pressure is increased with left sided heart failure
• Used to evaluate left ventricular and overall cardiac function
Central venous pressure reading (CVP):

• Measures pressure in the right atrium
• Normal 5 to 10 – used to monitor hydration status
• An increase indicates over hydration
• A decrease indicates fluid volume deficit
Cardiac Catheterization:
• NPO 6 to 8 hours prior to test
• Assess for allergy to latex, dye, shellfish or iodine
• Post procedure: monitor for bleeding (hematoma), decreased pulses (check the 6P’s)
• Keep leg extended 4 to 6 hours after test
Muga Scan :
• Ejection fraction study
• Radioactive tags injected
• Camera takes pictures of tagged RBC’s
• Avoid with pregnancy
Thallium Scan (stress test):

• Dye injected which acts as a tracer
• Cameras take pictures of the heart
• Areas that appear dark indicate inadequate blood flow
• Other types of stress tests: exercise (treadmill) for 9 -15 minutes. Adenosine or Lexiscan
(regadenoson) injection increases blood flow through the arteries of the heart during a
cardiac nuclear stress test in clients unable to exercise adequately
Holter Monitor:
• Painless 24hr EKG
• Teach: do not get wet
• Keep a diary of activities
Transesophageal Echocardiogram – (TEE):

• Detects blood clots, tumors, and valve problems
• 10 to 30 minute procedure
• Tube is swallowed - end is positioned in the esophagus behind the heart
• The heart is examined from different angles
Pre procedure: • NPO 6 hrs
• Place client on the left side
• IV sedative, throat anesthetic
Post procedure: • NPO X 2 hours or until gag reflex returns

• No driving for 12 hours
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CONGESTIVE HEART FAILURE (CHF)

S3 or S4 present, ↑ BNP (b type natriuretic peptide) level (100-300)
RIGHT SIDED HEART FAILURE (Body)

Signs include: jugular neck vein distention, edema of the hands and lower extremities, abdominal distention,
GI distress.
LEFT SIDED HEART FAILURE (Lung)

Signs include: coughing, wheezing, dyspnea, frothy sputum
Treatment: Low Na+ diet, Aspirin, Lasix (furosemide), Lanoxin (digoxin) – slows and strengthens heart beat
– take on empty stomach, monitor apical pulse for 1 minute, monitor electrolytes.
Side effects: diarrhea, vision changes, arrhythmias
ANGINA
Inadequate oxygenation to the heart causing pain
(relieved with rest and or nitroglycerin sublingual 1 tab
every 5 minutes for 3 doses)
MYOCARDIAL INFARCTION (MI)

Occlusion of blood flow with necrosis of a vessel within
the heart (not relieved with rest).
Treatment: MONA (morphine, oxygen, nitrates, aspirin)
PULMONARY EDEMA
Fluid within the lungs-signs include: restlessness,
tachypnea, dyspnea, crackles
Treatment: Oxygen, diuretics, narcotics, vasodilators
CORONARY ARTERY DISEASE

Atherosclerosis (narrowing of arteries from deposition of fatty plaque) which causes decreased oxygenation
and tissue perfusion. May contribute to CHF, hypertension, and myocardial infarction.
PERICARDITIS
Inflammation of the pericardium usually following an infection. May accompany HIV, Rheumatic Fever, TB.
May also be caused by MI or radiation therapy to the chest. Common in men 20 to 50 years old.
Signs and Symptoms: chest pain, sharp stabbing back pain, fever, chills, pericardial friction rub, distant muffled
heart sounds, crackles.
DX: chest x-ray, echocardiogram, CT scan, heart MRI Labs: troponin, ANA, C-reactive protein, ESR, TB screen,
rheumatoid factor
Treatment: NSAID’s, colchicine, antibiotics, steroids, diuretics, pericardiocentesis
CARDIAC TAMPONADE
Compression of the heart caused by blood or fluid accumulation in the space between the myocardium and the
pericardium. May be caused by pericarditis.
Signs and Symptoms: shortness of breath, feeling faint or light headed, anxiety, coughing related to pressure
on the trachea, distended neck veins, distant muffled heart sounds, pericardial friction rub
Treatment – pericardiocentesis
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D. Related pharmacology
Antiarrhythmics:
Used for the prevention and treatment of cardiac arrythmias. The major goal is to restore NSR
Cardizem (diltiazem): Tx. of HTN, angina, tachycardia, atrial fibrillation, PVC’s
Side effects: peripheral edema, blurred vision, hypotension, palpitations, hyperglycemia
Adenocard (adenosine): Tx. of supraventricular tachycardia, atrial fibrillation, ventricular tachycardia
Side effects: shortness of breath, hypotension, palpitations, dizziness
Xylocaine (lidocaine hydrochloride): Tx. of ventricular tachycardia, ventricular fibrillation

Side effects: confusion, drowsiness, bradycardia, absent gag reflex
Calan, Isoptin (verapamil): Tx. of HTN, angina, atrial fibrillation, tachycardia
Side effects: CHF, bradycardia, tachycardia, peripheral edema, anemia, tremors
Pronestyl (procainamide): Tx. of ventricular tachycardia
Side effects: ventricular fibrillation, thrombocytopenia, neutropenia, anemia, hypotension, bradycardia
Pacerone, cordarone (amiodarone): Tx. of atrial fibrillation, ventricular tachycardia, V-Fib, PVC’s
Side effects: bradycardia, sinus arrest, CHF, peripheral neuropathy, hepatotoxicity, photosensitivity, blue- gray
skin discoloration
Rythmol (propafenone): Tx. of tachycardia, atrial fibrillation
Side effects : dizziness, nausea, edema, URI, taste changes, dyspnea – monitor electrolytes
Tambocor (flecainide): Tx. of tachycardia, atrial fibrillation, PVC’s
Side effects : dizziness, headache, weakness, constipation, yellowing of skin and eyes
Client teaching - report ankle edema, weight gain, check pulse regularly, caution patient to avoid driving or
other activities requiring alertness
Nursing interventions: check apical and radial pulse before administration. Observe for therapeutic effect
(normal vital signs, adequate urine output).
Medication titration for cardiac meds: Titration is the process of gradually adjusting the dose of a medication
until optimal results are reached.
Example: Cardizem (diltiazem) or Nipride (nitroprusside)
E. Treatment
Pacemakers: battery life 3 -15 years Teach to
avoid contact sports, avoid areas of high voltage,
wear med alert bracelet. Client should also be
taught to take apical pulse for one full minute &
have pacemaker checked at regular intervals.
ICD: Implantable Cardioverter Defibrillator - sends
shock to the heart when abnormal beat is occuring.
Signs of malfunction include: ↓ pulse below set
rate, hiccups, dizziness, SOB, weakness, chest
pains, fainting
Cardioversion: timed electrical current delivered

during QRS complex to terminate a dysrhythmia
(planned) use 50 - 200 joules, vital signs
Defibrillation: used in an emergency to treat
ventricular fibrillation and pulseless V-tach use
200-360 joules
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V. Inflammation and Infection

A. Anatomy and physiology review - Components of the immune system: bone marrow, WBC’s, lymphoid
tissue (thymus gland, spleen, lymph nodes, tonsils, adenoids)
B. Mononucleosis (Kissing disease) (Epstein Barr virus):
• Signs include: fever, sore throat, cervical lymphadenopathy, malaise, headache, nausea, and
abdominal pain.
• 4 to 6 week incubation period.
• Transmitted by direct intimate contact, infected blood and oral secretions. Standard precautions.
C. Autoimmune disorders
Systemic Lupus Erythematosus:
Chronic and progressive autoimmune disorder that affects the vascular and connective tissue of multiple
organs. There is no known cure. It is characterized by weight loss, a butterfly rash on the face, joint pain,
fever, malaise, anemia, and photosensitivity. It affects young black females predominantly.
Precipitating factors include; sunlight, pregnancy and stress.
Treatment: ASA, NSAID’s, steroids, Plaquenil (hydroxychloroquine) may be used to decrease

inflammation. Frequent eye exams are essential with this medication.
Teach: avoid sun, avoid stress, ↑rest & exercise
Sclerodoma: affects connective tissue throughout the body. Symptoms include: tight skin, dysphagia,
edema of the extremities, joint contractures and brittle nails.
Teach client to sit up after eating. Treatment is supportive (tertiary).
Lyme disease:
• Caused by the bite of a deer tick, common in MA, CT, NJ & RI
• The first sign is erythema
• Skin lesions start 2 - 30 days after the bite
• Begins as a bump (macule or papule), then the lesion expands with a
ribbed border and a clear center (bull’s eye rash - erythema migrans)
• Lab tests include: complete blood count (CBC), erythrocyte sedimentation rate (ESR)- normal,
cerebrospinal fluid test (CSF), and Lyme serology
• Treatment - Vibramycin (doxycycline) or Amoxil (amoxicillin) if diagnosed early - within 3 days of
the bite; Long term treatment – Rocephin (ceftriaxone) - side effect is a furry tongue
D. Diagnostic tests
• Antinuclear antibodies test (ANA): may be positive with Lupus

• Erythrocyte sedimentation rate: may be elevated with severe anemia, Lupus or any inflammatory
process.
• C– reactive protein: increases with acute inflammatory response
E. Transplants: Prograf (tacrolimus), Neoral (cyclosporine), Sandimmune (cyclosporine) May be given

to prevent rejection of the new organ
F. Latex allergy: clients with a latex allergy should avoid: kiwi, chestnut, pineapple, strawberries,
grapes, papaya, peaches, tomato, avocado, rye, wheat, melon, hazelnut, plums, cherry, banana,
figs, potato
Hospital products include: blood pressure cuff, tourniquets, cardiac catherization tubing, catheters
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VI. Blood Function and Disorders

Blood Type Can Receive

Blood administration: A A,O
Major blood types B B,O
1. A AB A, B, AB, O universal recipient
2. B O O universal donor
3. AB
4. O

Key points for blood administration:
• Baseline vital signs are always needed
• A Y – type tubing with filter is necessary
• An RN must always be present
• The blood is verified with 2 nurses present
• The safest blood to administer in an emergency if the blood type is unknown is O negative
• The only IVF to run with blood is Normal Saline
• If there is a blood transfusion reaction, immediately STOP the transfusion!
• Common signs of transfusion reactions include:
• Flank pain • Chills • Hives • Elevated temperature • Tachycardia
B. Disorders
Sickle Cell Anemia:
Priorities in sickle cell crisis include oxygenation, hydration and pain relief (Morphine).
Patients should avoid high altitudes. Client is at risk for priapism (prolonged erection of the penis).
Teach to drink 4-6 Liters/day , 8-10 Liters in crisis.
Pernicious Anemia:
Lack of intrinsic factor, VIT B12 injections IM monthly for life.
Diagnosed using the Schilling Test
S/P gastrectomy clients also require vitamin B12 replacement.
• Aplastic Anemia: malfunctioning bone marrow
• Hypochromic Anemia: iron or vitamin deficiency
• Hemolytic Anemia: excessive RBC destruction
• Clotting Disorders: Idiopathic Thrombocytopenic Purpura, Hemophilia, DIC (Disseminated
Intravascular Coagulation): implement bleeding precautions
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BLEEDING PRECAUTIONS: RANDI

RAZORS ELECTRIC
ASPIRIN NO!
NEEDLES: SMALL GAUGE
DECREASE STICKS
INJURY PREVENTION
Implement with:
• Anticoagulants
• Liver disease
• Decreased platelets
• Thrombolytics
• Bleeding disorders
Bleeding Assessment: BEEP

Bruising
Ecchymosis
Epistaxis
Petechiae
Polycythemia Vera (excess RBC’S, WBC’s & Platelets):
• Common clients of Jewish descent
• Signs and Symptoms: dizziness, headache, blurred vision, hypertension
• Treatment includes increased fluids and phlebotomy to remove excess RBC’S
Thalassemia:
• Also known as Cooley’s anemia
• Common in clients of Mediterranean descent
• Goal is to maintain normal hgb level, bone marrow transplant may be necessary
• Signs: anemia, pallor, increased size of liver and spleen
• Treatment is supportive: folic acid, blood transfusion, genetic counseling
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VII. Respiratory Function and Disorders

B. Diagnostic tests.

Sputum Specimen

• Deep breath and cough
• Oral hygiene – rinse mouth
• Morning specimen from deep
• Sterile container
• Avoid red fluids
• Do not begin antibiotics before collecting culture
Bronchoscopy- flexible lighted scope into bronchus

• Informed consent
• NPO after midnight
• Assess result of blood studies – coagulation profile
• Remove dentures/eyeglasses
• Atropine, sedative
• Topical anesthesia
• O2, suction/ resuscitation equipment at bedside
Post procedure
• Vital signs monitored until stable
• NPO until gag reflex returns
• Semi-fowlers position
• Monitor respiratory status/ bronchospasms
• Difficulty breathing – notify MD
• Crepitus: SQ Emphysema (bubbling under the skin): indicates perforation of bronchus
• Monitor patient for bleeding: frequent swallowing = bleeding
• Teach to expect blood streaks but not copious amounts of blood
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Pulmonary Angiography
• Diagram of pulmonary tree
• Check allergy to dye/shellfish
• NPO 8 hours prior
• Teach not to cough during test
• Emergency equipment at bedside
Post procedure
• Vital signs
• Do not do B/P on the extremity used
• Monitor neurovascular status (6 P’s)
• Increase fluids
• Assess for edema at injection site
• Check insertion site for bleeding and hematoma
Thoracentesis- Removal of pleural fluid and or air from pleural space

• Vital signs prior
• Chest X-ray/Ultrasound
• Place patient in orthopneic position
Post procedure
• Vital signs
• Monitor respiratory status
• Apply pressure dressing to puncture site
• Check for bleeding at insertion site
• Check for crepitus
• Assess for signs of pneumothorax, air embolism, respiratory distress

Lung Biopsy- analyzes tissue; cytologic exam i.e. cancer/ sarcoidosis
• Identifies pulmonary lesions– TB, pleural effusion
• NPO
Post procedure
• Vital signs
• Pressure dressing
• Monitor drainage/blood
• Signs of respiratory distress, pneumothorax, air embolus
• Chest X-ray
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ABG
• Determine acid/base balance
• Prior to ABG check Allen test - arteries are occluded to test blood supply to the hand. If test
is positive (delayed blood return to the hand) arterial puncture should not be attempted.
• Avoid suctioning prior to doing ABG – after drawing ABG place on ice
• Pressure to puncture site 5 -10 minutes (artery), longer if on anticoagulant therapy
Pulse oximetry
• 95% - 100% normal: lead placed on finger, toe, forehead, or earlobe
• Inaccurate reading could be due to poor perfusion – nail polish, temperature, hypothermia:
warm up the extremity
Chest PT (physiotherapy) - percussion and vibration to loosen secretions in the lungs

• Done with Cystic Fibrosis, COPD, pneumonia, post-op patients
• Perform 1 hour before meals or 2 - 3 hours after to prevent regurgitation. Best time is early
morning
• If patient complains of pain – stop PT
• Give bronchodilator before treatment
• Good oral hygiene following
• Contraindicated: bronchospasms, Paget’s disease, rib fracture, chest injury, chest incision,
pathological fractures, bleeding disorders
Carbon monoxide poisoning – colorless and odorless may be fatal;

• Signs & symptoms mimics the flu-headache, N/V, weakness, SOB.
• Treatment – get fresh air, Check ABG and CBC; Give 100% O2 in ER
Oxygen Therapy
• Given as supplement when blood O2 is decreased
• Requires a prescription–considered medication
• 2L without HCP prescription as immediate intervention
• Can be harmful too much can cause blindness – baby
• Delivered via nasal cannula, mask, or tent. (Mask delivers higher concentation of O2 than
cannula)
Signs & symptoms of oxygen deficit:

• Restlessness (1st sign), nasal flaring, tachycardia, tachypena, pallor, dyspnea, use of
accessory muscles (neck, chest, abdomen), wheezing
• R.A.T (early signs: restlessness, anxiety, tachycardia)
• B.E.D (late signs: bradycardia, extreme restlessness, dyspnea)

Tests: ABG. Pulse oximetry, chest X-ray, pulmonary function test
Complication:
• Knocks out respiratory drive in patient with COPD (NEVER GIVE HIGH FLOW O2)
• Prevent drying of mucous membranes; drying can cause bleeding: use a humidifier
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SUCTIONING
May be necessary for removing secretions, clients with an ineffective cough reflex, or signs of
hypoxia. Limit suctioning to less than 15 seconds to avoid hypoxia. Suction pressure should be set
to 80 -120mm Hg.
• Oropharyngeal: aseptic technique is acceptable. A Yankauer catheter is usually used. Use
surgical asepsis for all other suctioning.
• Nasopharygeal: a flexible catheter is used, the size is selected based on the size of the client’s
nares and the viscosity of secretions.
• Endotracheal: performed through a tracheostomy or endotracheal tube.
Mechanical Ventilation and causes of alarms
**High Pressure Alarm** (Obstruction) Low Pressure Alarm (Leak)

• Excess secretions; client needs to be suctioned • Tube is disconnected
• Tube is kinked • Air leak
• Displacement of tube • Low cuff pressure (not inflated enough)
• Bronchospasm – causes increased resistance • The client stops breathing spontaneously
• Coughing / wheezing
• Biting of tube
• Fighting the ventilator

Surgical interventions
Tracheostomy- a temporary or permanent opening in the trachea.

• Surgical incision
• Protects airway

Post op
• Maintain patent airway
• Assess presence of bilateral breath sounds (unilateral indicates lung collapse)

Complications
• Dislodged tube – secure trache ties, (velcro)
• Increased secretions – can lead to obstruction: suction, humidify air
• Pneumothorax
• Bleeding – with gloved hand, assess rear of patient’s neck for pooling of blood
• Prevent Infection–sterile technique during suctioning
• Erosion of tracheal wall leading to fistula - keep the cuff deflated

Person with a laryngectomy needs a permanent tracheostomy. Nursing priority: establish a means of
post-op communication (paper and pencil, flash cards, etc.)
Teach: No swimming, wear medical alert bracelet
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Pneumothorax Signs & symptoms:

• Increase air/fluid in pleural space Dyspnea, tachycardia, tachypnea, chest pain
• Increase thoracic pressure (sharp), absent breath sounds on affected side or
• Decrease vital capacity hyperresonance, decreased chest expansion on
(the amount of air you can take in forcibly) affected side, subcutaneous emphysema, tracheal
deviation to unaffected side (tension pneumothorax).
If open wound – sucking sound heard from chest; mediastinal shift towards unaffected side
Nursing Intervention: • High fowlers position • Chest X-ray

• Monitor vital signs • Dressing over open wound
• O2 as prescribed • Prepare for chest tube placement
Chest Tube Returns negative pressure to the lung space (pleural), removes
fluid/air, promotes re-expansion of the lung.
Pleur-Evac Disposable system follows 3 bottle systems.

Water seal system acts as a one way valve to prevent air and liquid
from moving back into chest cavity.
CHAMBER 1 CHAMBER 2 CHAMBER 3

Collects fluid draining from client. Serves as a water seal. Is the suction control. Suction
Intermittent bubbling + fluctuation set at 15-20 cm as prescribed.
are normal with inhalation and Nurse should see gentle
exhalation. Excessive bubbling/
continuous bubbling.
continuous = air leak. If there
are no fluctuations, assess lung
sounds & call MD. There may
be obstruction or the lungs have
re-expanded.
• Monitor respiratory status
• Maintain dry, sterile, occlusive dressing
• Chest tubes: label bottle with date and time, tell patient to expect pain when they cough.
• Drainage > 100ml/hr is excessive – Notify MD
• Have clamp at the bedside for an emergency – never clamp unless the system breaks
• If tube disconnects – place tip in sterile water until the system can be replaced
• Two chest tubes on the same side: top drains air / bottom - fluid
Removal of chest tube- have patient inhale then exhale.

Hold exhalation for tube removal (Valsalva maneuver) place
occlusive Vaseline dressing to the site. Place on unaffected
side. Obtain Chest X-ray.
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D. Disorders
COPD: emphysema and, chronic bronchitis

• Chronic obstructive pulmonary disease
• Chronic airflow limitation; limited airflow into and out of lungs
• Patient’s drive to breathe – low PO2 (give 1 1⁄2 - 2 L oxygen only)
• Alveoli – site of gas exchange; respiratory acidosis when CO2 is trapped
• Increased incidence in cigarette smokers, occupational exposure to fumes or chemicals,
genetics
• Risk for Cor pulmonale (Right sided heart failure)

Signs & Symptoms:
• SOB/hypoxia
• Easily fatigued
• Wheezing/crackles
• Recurrent cough and URI
• Increased sputum production
• Barrel chest (emphysema)
• Hypercapnia--Respiratory acidosis
• Skin color dusky to cyanotic (chronic bronchitis)
• No cyanosis (emphysema)
Teaching/ Nursing interventions

• Assess respiratory status
• Pursed lip breathing and deep breathing exercises
• Smoking cessation
• Avoid exposure to cold
• Influenza vaccine–check for egg allergy
• Pneumonia vaccine
• Avoid milk: increases mucous, high calorie, high protein, low CHO diet
• Increase fluids unless contraindicated
• Increase rest periods
• Humidified air
• Suction as necessary
Related pharmacology
• Atrovent (ipratropium bromide), Spiriva (titropium inhaled)
• Ventolin (albuterol) – short acting; rescue inhaler
• Serevent (salmeterol) long acting. Teach–take BID
• Symbicort (budesonide/formoterol) (long acting B2/corticosteroid), not used with acute episodes
• Steroids: oral, inhaled, IV – Deltasone (prednisone), Beclovent (beclomethasone), Solumedrol
(methylprednisolone)
Side effects: poor wound healing (Cushing’s Syndrome),decreased immune response, increase fluid
retention, hyperglycemia, mood swings, weight gain, oral thrush
• Antibiotics (prophylactic)

TIP: When selecting answers, choose the client with an acute condition over chronic!
COPD is not always first! If the chronic client is in exacerbation - they are the priority!74
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Pneumonia
• Inflammation/ infection of lung
Causes: • Aspiration • Mycoplasma • Fungal
• Bacterial • Viral • Protozoan infections
Bacterial pneumonia requires isolation until 24 hours after starting
antibiotics – viral does not need isolation
Common organisms: Staphylococcus aureus, staphylococcus pneumoniae, HIV – PCP.
Signs & Symptoms: • Fever • Tachypnea
• Chills • Night sweats
• Dyspnea • Increased WBC’s
• Pleural pain • Diaphoresis
• Productive cough (with rust colored, blood tinged or greenish sputum)
Diagnosis: • Chest X-ray • CBC
• ABG • Pulse oximetry
• Sputum culture (before starting antibiotics)
Treatment: • Antibiotics as prescribed • O2 as prescribed
• Chest PT • Increase fluids
• Antipyretic
Legionnaire’s Disease: spread through contaminated water
Risk factors: COPD & immunosuppression
Treatment: Erythromycin, Tetracycline, Quinolones, Zithromax (azithromycin) or Rifampin
Asthma
• Chronic inflammatory disease with bronchoconstriction
• Mucosal edema with increased mucous production
Signs & Symptoms: • Tachycardia • Apprehension/restlessness
• Tachypnea • Wheezing and night time cough
Diagnosis: • History and physical • ABG
• Pulmonary function tests • Allergy testing
Nursing intervention/ teaching:
• Avoid known triggers • Bronchodilators
• High fowler’s position • Increase fluid intake, eliminate milk
• NOAH – Nebulizer, Oxygen, Antibiotic, Hydrocortisone
• Prophalytic medication: Albuterol (B2 agonist
that opens airway) should be kept with them at all
times for rescue.
• Monitor peak flow: measures how well air moves out of lungs
• Teach zone management:
Green: PEF is 80 -100% of normal – asthma is well controlled
Yellow: PEF is 50 - 80% of personal best – asthma is flaring up
Red: PEF is < 50% of personal best – asthma is severe; emergency care needed
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Teach correct MDI technique

1. Remove the cap and hold inhaler upright.
2. Shake
3. Tilt the head back slightly and exhale
4. Open mouth. Hold inhaler 1 - 2 inches from mouth or in the mouth
making a seal
5. Press down on MDI to release the medicine
6. Breathe in slowly for 3 - 5 seconds
7. Hold the breath for 10 seconds
8. Exhale slowly through pursed lips.
Medications
• Beclovent (beclomethasone) - steroid inhalers – rinse mouth after use can cause oral thrush;
Flovent (flucitasone)
Flonase (flucitasone propionate) – used in allergic rhinitis; Azmacort (triamcinolone)
• Prednisone (p.o.) Solumedrol (methylprednisolone) (IV)
• Advair – (flucitasone/salmeterol) long acting B2/corticosteroid – do not use during exacerbation
• Symbicort –(budesonide/formoterol) – not used with acute episodes
• Brethine (terbutaline)– also used in labor (premature contractions)
• Intal (cromlyn Na+) – long acting – prevents histamine release from the mast cells
• Singular (montelukast) – daily, usually at night
• Accolate (zafirlukast) – 20 mg BID; Take on an empty stomach
Pulmonary Embolism
• Thrombus – stationary • Life threatening
• Embolus - mobile • Result of thrombophlebitis/ DVT
Signs & Symptoms: • Dyspnea • Anxious
• Pleuritic chest pain • Cough
• Tachycardia • Restlessness
• Tachypnea • Hemoptysis
Risks • Prolonged bedrest • Pregnancy
• Surgery • Obesity
• Long plane rides • CHF
Diagnosis: • Chest X-ray
• VQ scan: looks at lungs when breathing in (measures if lungs are
being perfused)
• CBC (thrombocytosis), blood test for D-dimer – if negative, it rules
out the diagnosis
• PT & PTT
• EKG
• ABG
• Assess for Homan’s sign
Nursing Intervention: • Bedrest
• O2
• Fowler’s position
• Heparin or Coumadin (warfarin)
• Thrombolitic drugs (streptokinase)
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TB (Tuberculosis)
• Mycobacterium - acid fast bacillus
• Spread by droplet nuclei
• Lodges high in lungs (highly O2 concentrated)
Risks: • Malnutrition • Alcoholics

• Large crowded living conditions • IV drug users
• Poor socioeconomic status • Immune dysfunction
Signs & Symptoms: • Can be asymptomatic • Anorexia
• Dyspnea • Fatigue/malaise
• Low grade temperature • Pallor
• Pleuritic chest pain • Weight loss
• Night sweats
• Chronic productive cough– purulent sputum / hemoptysis
Diagnosis: • Chest X-ray • Bronchoscopy
• Sputum for AFB (Acid Fast Bacillus) 3 negative AFB specimens to discontinue
isolation
• PPD – TB test; 25 gauge tuberculin syringe results read in 48-72 hours
Induration = 0 - 3 mm (normal)
4 - 7 mm (equivocal)
8 -10 mm(+)
(Note: 15mm or more is positive in patients without risk factors older than
4 years of age, 10 mm is positive in patients age 4 or less)
> 5 mm induration = + in HIV
• Quantiferon TB Gold In-tube test -measures immune response to TB
bacteria in the blood. It cannot determine is person has latent or active
TB. More specific than PPD.
Note : + PPD does not mean automatic isolation- further assessment needed
Nursing Interventions: • Respiratory isolation – 2 - 3 weeks after starting medication
• Airborne precautions – N 95 mask
• Teach to cover mouth and nose when coughing and sneezing
• Dispose contaminated tissue into paper bag – good hand washing
• Mask patient for transport
• Increase fluids/ promote proper nutrition
• O2 as prescribed
Medication: • INH (isoniazid) S.E.- peripheral neuritis, hepatotoxicity, GI upset avoid
Dilantin (phenytoin)– increased risk of toxicity. Avoid foods with Tyramine
• B6 Pyridoxine: prescribed with INH to prevent peripheral neuropathy
• Rifampin: discolors urine/contact lenses- orange; N/V, thrombocytopenia
• Streptomycin S.E. 8th cranial nerve damage 77
• *Drugs may be given in combination to decrease the risk of resistance
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Pleural Effusion
• Accumulation of fluid in pleural space • Dry nonproductive cough
• Pain on inspiration - pleuritic chest pain • Mediastinal shift away from fluid
• Dyspnea on exertion
Treatment: • Monitor breath sounds, treat underlying cause

• Antibiotics
• Chest X-ray, thoracentesis, chest tube placement
Sleep Apnea
• Characterized by episodic upper airway obstruction that occurs at night
Risks: • Obesity • Sleeping pills
• ETOH • Men affected more than women
Signs & Symptoms: • Loud snoring
• Daytime drowsiness with delayed reaction time
Diagnosis: • Sleep Study
Treatment: • CPAP (continuous positive airway pressure)
• Dental appliances
• Anatomical surgery
• Weight loss may be helpful
• Children – tonsillectomy
Complication: • Cor Pulmonale
Common Respiratory Medications
Bronchodilators
1. Adrenergic Bronchodilators: relaxes and opens the airway
A. Epinephrine: fast onset within 5 minutes lasts up to 4 hours given sub q. in an emergency. Drug may
be repeated 20 minutes after initial dose.
Epi pen: autoinjection system can be administered by self-injection into the middle aspect of the thigh.
Common causes of anaphylaxis include: foods (peanuts, eggs, milk, wheat, shellfish), medications
(penicillin, sulfa drugs, anesthetics), and insect stings.
Dosage 0.3mg or Epipen Jr. 0.15mg.

C. Proventil,Ventolin (albuterol): given via MDI or nebulizer. Teach client use as rescue medication in
acute bronchospasm. Use with caution in patients with cardiovascular disease and MAO inhibitors.
S.E. tachycardia, palpitations, headache

D. Serevent (salmeterol): long acting, given daily BID even if not symptomatic, do not use in acute
bronchospasm - onset 5 -20 minutes

E. Brethine (terbutaline): long acting agent
S/E. nervousness, tremors, also used to inhibit premature uterine contractions (pre-term labor)
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2. Xanthine Bronchodilators
A. Theophylline: prevention and treatment of bronchospasm.
• Aminophylline - I.V.
• Theo-Dur (theophylline) P.O.
Side effects: nausea, vomiting, tremors, insomnia, tachycardia, palpitations, nervousness
Teach: take on empty stomach, increase fluid intake (unless contraindicated), and do not crush or
chew. Avoid caffeine – may increase side effects
Nursing: Monitor ABG’s (acid base balance) and fluid and electrolyte balance
* Not indicated for the initial treatment of acute episodes of bronchospasm
3. Leukotriene Inhibitors
• Singular (montelukast sodium): give at night
• Accolate (zafrilucast) : BID
4. Steroids: decrease inflammation and opens airway
Nursing Implications for client’s taking respiratory medications
Client Assessment
1. Vital signs, note respiratory rate, depth, and character, skin, color, s/s of hypoxia (restlessness is an
early sign, also called thrashing), ABG, auscultate lungs noting adventitious breath sounds.
2. Assess precipitating and relieving factors of bronchospasm, note frequency and severity of attacks,
what is patient’s baseline respiratory status between attacks.
3. Assess for respiratory distress (nasal flaring, use of accessory muscles, tripoding), hypoxia, cough,
sputum, exercise intolerance, medications, drug therapy.
B. Nursing Interventions
1. Accurate administration of medication – 10 rights (see page 121).
2. Observe for therapeutic effects (relief of symptoms).
3. Observe for adverse effects
• Cardiac: arrhythmias, palpitations, tachycardia,
• CNS: agitation, insomnia, headache, restlessness, seizures, tremors
• GI: anorexia, diarrhea, nausea and vomiting
• Respiratory: cough
4. Encourage oral intake of fluids (unless contraindicated).
5. Encourage deep breathing and coughing, postural drainage, chest PT (as ordered).
6. Teach client to avoid known triggers of bronchospasm.
7. Teach importance of smoking cessation and avoidance of caffeine.
8. Use caution while driving or operating machinery until effects of medication is known.

**Do not give beta blockers to asthmatics ie. Inderal (propanolol), Corgard (nadolol).
Beta Blockers cause hypotension and bradycardia which increases oxygen consumption.
ASA, NSAID’s, and Ace Inhibitors should also be avoided with asthma.
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VIII. Fluid and Electrolyte Balance

A. Physiology review
B. Composition of body fluids
a. Intracellular
b. Extracellular
1. Interstitial
2. Intravascular
Fluid volume deficit = dehydration = hypovolemia

Treat the underlying cause. Strict I&O, IVF replacement, antipyretics, antidiarrheal agents
Fluid Volume excess = overhydration = hypervolemia
Treat underlying cause – fluid and sodium restriction, diuretics
C. Normal electrolyte values (may show slight variances by institution)
Na+ 135 - 145 mEq/L

Ca++ 9.31 - 10 mg/dL
Cl- 95 - 110 mmol/L
HCO3 22 - 26 mEq/L
K+ 3.5 - 5.5 mEq/L
PO4 2.5 - 4.5 mg/dL
Mg+ 1.3 - 2.0 mEq/L
C. Venous Access Devices- Peripheral lines, PICC, Epidural, Tunneled, Implanted
Peripheral lines: device used to access veins, the tip is distal to a central vein.
• Peripheral venous access device used for an adult - 18, 20 or 22 gauge.
• Midline - best for clients with limited peripheral veins that need an extended period of access (2-4
weeks).
• Midclavicular catheters - can be used 2 to 3 months, best suited for administering IV fluids and IV
medication short-term.
Central Venous Access Devices- placed by MD into jugular or subclavian vein above the heart.
• Implanted port (Port-A-Cath)
• PICC- peripherally insered central catheter - Do not take B/P or draw blood on the limb with the line.
• May be used for IVF & blood, TPN, monitoring CVP, administering medications & chemotherapy,
obtaining blood samples, hemodialysis or for long term use when peripheral veins are inaccessible.
Complications
• Infiltration - fluid infusion outside of the vein Treatment: warm or cold compresses, elevate the limb.
• Phlebitis - inflammation of the vein Treatment: warm, moist compresses, antibiotics, eliminate cause.
• Extravasation - infiltration of a vesicant drug (i.e chemotherapy agents, antibiotics, electrolytes,
antiemetics or vasopressors) - can lead to necrosis, disfigurement and loss of function.
Treatment: stop the infusion, use syringe to aspirate remaining drug in the line, inject antidote into
s.c. tissue if appropriatee, remove the catheter (as ordered), notify MD, elevate arm, ice or warm
compress (most require ice for 20 minutes 4 - 6 times per day for 24 - 48 hours).
• Air embolism - air entry into line. Position client on the left side in trendelenburg position. Give O2. 80
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D. Signs and symptoms of abnormal values

Imbalance and Causes Signs and Symptoms Nursing Interventions
HYPONATREMIA • Lethargy • Assess signs and symptoms
Loss of Sodium • Confusion • Monitor intake and output
• Gastrointestinal fluid loss • Anxiety • Monitor lab results
• Sweating • Muscle twitching • Assess client closely for injury risk
• Use of diuretics • Abdominal cramps • Institute safety precautions
Gain of Water • Anorexia • Encourage food and fluid high in sodium
• Drinking water • Nausea, vomiting unless contraindicated (e.g.,IVF 0.9% NS,
• Excess IV D5W (dextrose in water) • Headache table salt, bacon, ham, processed cheese)
• SIADH • Seizures, coma • Limit water intake as indicated.
HYPERNATREMIA • Thirst • Monitor intake and output
Loss of fluids • Dry, sticky mucous • Monitor mental status
• Insensible water loss membranes (e.g., restlessness disorientation)
• (Hyperventilation or fever) • Tongue red, dry, swollen • Monitor lab results
• Diarrhea • Weakness • Encourage fluid as prescribed
Water deprivation • Postural hypotension • Restrict intake of salt and foods high in
Excess salt intake • Dyspnea sodium
• IV administration of saline solutions Severe hypernatremia:
• Excessive use of table salt • Fatigue, restlessness
• Diabetes Insipidus • Decreasing LOC
• Heat Stoke • Disorientation
• Convulsions
HYPOCALCEMIA • Numbness and tingling of • Closely monitor respiratory and
• Surgical removal of the parathyroid the extremities and around cardiovascular status
glands the mouth • Initiate safety precautions to protect a
Conditions such as: • Muscle tremors, cramps; confused client
• Hypoparathyroidism untreated can progress to • Administer oral or parental calcium
• Acute pancreatitis tetany and convulsions supplements as prescribed
• Hyperphosphatemia • Cardiac dysrhythmias: • During IV administrations closely monitor
• Thyroid cancer decreased cardiac output cardiac status and ECG
• Inadequate Vitamin D intake • Positive Trousseau’s sign
• Malabsorption • Positive Chvostek’s sign
• Hypomagnesemia • Confusion
• Alkalosis • Anxiety
• Sepsis
• Alcohol abuse
HYPERCALCEMIA • Lethargy • Increase client movement and exercise
• Prolonged immobilization • Weakness • Encourage oral fluids as permitted to
Condition such as: • Depressed deep tendon maintain dilute urine
• Hyperparathyroidism reflexes • Teach clients to limit intake of food and
• Malignancy of the bone • Anorexia fluid high in calcium
• Nausea, vomiting • Increase fiber in diet to prevent
• Constipation constipation
• Polyuria • Protect a confused client; monitor for
• Hypercalciuria pathologic fractures in clients with long-
• Flank Pain secondary to term hypercalcemia
urinary calculi • Encourage intake of acid-ash fluids (e.g.,
• Dysrhythmas, possible prune or cranberry juice) to counteract
heart block deposit of calcium salt in the urine.
• Pathological fractures • Assess clients receiving digitalis
for digitalis toxicity. Hypercalcemia
increases the risk of toxicity
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HYPOKALEMIA • Muscle weakness • Monitor heart rate and rhythm
Loss of potassium • Leg cramps • Monitor clients receiving digoxin closely,
• Vomiting and gastric • Fatigue because hypokalemia increases risk of
suction • Lethargy digitalis toxicity.
• Diarrhea Anorexia • Give oral potassium as prescribed with food
• Heavy perspiration • Nausea, Vomiting or fluid to prevent gastric irritation
• Use of potassium-wasting • Decreased bowel sounds • Administer IV potassium solutions at a
drugs (e.g., diuretics) • Decreased bowel motility rate no faster than 10-20 mEq/h; never
• Poor intake of potassium • Cardiac dysrhythmais – PVC’s administer undiluted potassium IV.
(as with debilitated clients, V-tach, V-fib • IV potassium: monitor for pain and
alcoholics, anorexia • Depressed deep-tendon reflexes inflammation at the injection site. Teach
nervosa) • ABGs may show Alkalosis client about potassium-rich foods. Teach
• T wave flattening, ST segment clients how to prevent excessive loss of
Depression on ECG ; prominent K+ (e.g. through abuse of diuretics and
U waves laxatives).
HYPERKALEMIA • Diarrhea • Closely monitor cardiac status and ECG
Decreased potassium • Irritability • Administer Kayexalate (sodium
excretion • Confusion polystyrene), diuretics and other
• Renal failure • Cardiac dysrhythmias or arrest medications such as glucose and insulin as
• Potassium sparing • Muscle weakness, areflexia prescribed.
diuretics (absence of reflexes) • Hold potassium supplements and K+ sparing
• High Potassium intake • Paresthesias and numbness in diuretics
• Excessive use of salt extremities • Monitor serum K+ levels carefully; a rapid
substitutes • Peaked T wave, widened QRS drop may occur as potassium shifts into the
• Potassium shift as in burns on ECG cells
• Teach clients to avoid foods high in
potassium and salt substitutes.
HYPOMAGNESEMIA • Neuromuscular irritability with • Assess clients receiving digitalis for digitalis
• Excessive loss from the tremors toxicity. Hypomagnesemia increases the
gastrointestinal tract • Increased reflexes risk for toxicity.
• Nasogastric suction • Convulsions • Protect patient from injury, seizure
• Diarrhea, fistula drainage • Cardiac arrhythmias precautions
• Long-term use of certain • Tetany
drugs (e.g., diuretics, • Psychosis
aminoglycoside antibiotics) • Positive Chvostek’s sign
• Positive Trousseau’s sign
HYPERMAGNESEMIA • Neuromuscular depression; • Initiate safety precautions

Conditions such as: cardiac muscle depression • Monitor B/P, pulse and respirations closely
• Renal impairment (arrhythmia, asytole) • Administer Calcium Gluconate as
• DKA • Weakness
prescribed
• Dehydration • Nausea, vomiting
• CNS depression: lethargy, • Teach patients with renal disorders to avoid
• Hypothyroidism
• Addison’s disease hypotension, bradycardia preparations containing Mg+
• Use of antacids/laxatives
containing magnesium
Wilson’s Disease - is a rear inherited disorder that causes too much copper to accumulate in the
liver, brain and other vital organs.
S/S: fatigue, jaundice, easy bruising, edema of the legs, ascites, problems with speech, swallowing or
physical coordination
Treatment: Chelating agents - Penicillamine - side effects: bone marrow suppression - monitor CBC
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METABOLIC ACIDOSIS pH < 7.35 NaHCO3 < 22 • Monitor LOC
• Renal failure • Lethargy • Weakness • Strict intake and output
• Diabetes Mellitus • Confusion • Nausea, vomiting • Administer IV sodium bicarbonate
• Loss of bicarbonate i.e. diarrhea • Headache • Hyperkalemia as prescribed.
• Excessive infusion of chloride • Treat underlying problem
• Kussmaul’s respirations
containing IV fluids
(rapid, deep respirations)
• METABOLIC ALKALOSIS • pH > 7.45 NaHCO3 > 26 • Monitor intake and output
• Excessive acid loss through the • Decreased respiratory rate and • Monitor vital signs, especially
GI tract depth respiration and LOC
• Vomiting • Dizziness • Administer IV fluids as prescribed
Gastric suction • Hypokalemia • Treat underlying problem
• Excessive use of potassium • Circumoral paresthesias
wasting diuretics • Numbness and tingling of the
• Excessive adrenal corticoid extremities
hormone • Tetany
• Cushing's syndrome
• Hyperaldosteronism
• Excessive bicarbonate intake from
antacids, parenteral NaHCO3
RESPIRATORY ACIDOSIS pH < 7.35 PaCO2 > 45 • Monitor respiratory status and lung
• Acute lung conditions that • Increased pulse sounds
impair alveolar gas exchange • Increased respiratory rate • Prepare for mechanical ventilation
• Pneumonia • Headache as necessary
• Acute pulmonary edema • Dizziness • Administer pulmonary therapy
• Aspiration of foreign body • Confusion measures such as inhalation
• Near-drowning • Decreased LOC therapy, bronchodilators and
• Chronic lung disease (e.g. asthma, • Convulsions antibiotics as prescribed
cystic fibrosis or emphysema) • Warm, flushed skin • Percussion and postural drainage
• Overdose of narcotics or sedatives • Hyperkalemia (chest PT)
that depress respiratory rate and Chronic: • Monitor fluid intake and output
depth • Weakness • Monitor vital signs and ABGs
• Brain injury that affects the • Headache • Administer narcotic antagonists
respiratory center (Naloxone) as indicated
• Increase fluids 2-3 L/day
RESPIRATORY ALKALOSIS pH > 7.45 PaCO2 < 35 • Monitor vital signs and ABGs
Hyperventilation due to: • Complaints of shortness of breath, • Assist client to breathe more slowly
• Extreme anxiety chest tightness • Help client breathe in a paper bag
• Elevated body temperature/fever • Light-headedness with circumoral or apply a rebreather mask (to
• Over ventilation with a mechanical paresthesias inhale CO2)
ventilator • Numbness and tingling of the
• Hypoxia extremities
• Salicylate overdose • Difficulty concentrating
• Tremulousness
• Blurred vision
• Hypokalemia
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IX. The Client with Pain
A. Pathophysiology of pain
Most pain caused by damage to nerves or tissue. Nerve signal travels up the spinal cord to
the brain.
B. Acute vs. chronic pain

• Acute pain lasts from one second to 6 months serves as a warning signal
• Chronic pain > 6 months • • • serves no useful purpose
C. Assessment of pain
• assess the P.Q.R.S.T of pain (provoke, quality, radiation, severity, time)
• perception and cultural influence
• anxiety level
D. Pharmacological approaches
• Nonnarcotic analgesics used for mild to moderate pain, temperature reduction and treat-
ment of inflammatory disorders
1. Salicylates:
• Aspirin
• Dolobid (diflunisal)
Side effects: GI bleeding – take with food or milk.
Toxicity: tinnitus, hyperventilation, vomiting, double vision
2. Acetaminophen
• Tylenol - may be administered p.o., IV or suppository. Maximum daily dose 3000 mg
• • • Antidote• • Mucomyst (acetylcysteine)
3. Non steroidal antiinflammatory drugs (NSAID’S)

• Motrin (ibuprofen)
• Naprosyn (naproxen), Anaprox (naproxen sodium)
• Indocin (indomethacin)
• Celebrex (celecoxib)
Side effects: GI bleeding: take with food or milk, teach patient to monitor stool for blood;
drowsiness
• Teach: avoid operating machinery, hold before surgery
Remember: Differentiate between an “expected” client finding vs. an emergency or

deterioration!
Look for signs of an exacerbation in client’s current condition!
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• Narcotic analgesics: used for moderate to severe pain (acute or chronic) and sedation
• Roxanol (morphine) • Demerol (meperidine) • Dilaudid (hydromorphone)
• Duragesic (fentanyl) - dispose of patches by folding sticky edges together then
flush them down the toilet. • Dolophine (methadone)
Side effect: CNS depression
• Antidote: Naloxone
• Adjuvants: potentiates the effects of narcotic or nonnarcotic analgesics

Has own analgesic properties:
• Vistaril, Atarax (hydroxyzine)

Duragesic (fentanyl): adjuvant to anesthesia
• Teach may cause drowsiness or fatigue • Avoid hazardous activities
• Avoidance of heat from fever or environment
• May increase release resulting in toxicity
• NO: sunbathing, hot tubs, saunas, heating pads, or electric blankets
• Patient Controlled Analgesia (PCA): allows the patient to control their own narcotic
analgesic.
Drug of choice: Morphine
• Goal is to achieve more steady state of analgesia compared to prn medications.
• Nursing Management:
• Monitor patient’s level of consciousness, vital signs and pain level frequently.
• Peripheral Nerve Catheter: is used to relieve pain at the site of surgery. Catheter is placed
under the skin near the nerves to cause numbness at the surgical site. It provides
continuous local anesthesia. It could last for up to 3 days after the procedure.
E. Non pharmacological approaches
• TENS (transcutaneous electrical nerve stimulation): battery operated unit that sends a
mild electrical current along the skin, blocking pain sensation
Nursing: • Do not place electrodes over incision site, broken skin, or eyes
• Contraindicated in client with a pacemaker
• Provide skin care daily—wash skin with soap and water daily, air dry
• Exercise
• Promote rest and relaxation

• Teach relaxation techniques i.e. rhythmic breathing, guided imagery, music therapy,
biofeedback
• Positioning of body parts, immobilization, heat and cold application; massage
F. Evaluation: what is the patient’s response to the interventions? Reassessment 85

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X. The Client with Cancer
A. Physiology of cancer
• Cancer occurs when cells become abnormal and grow without control
B. Prevention and early detection

Cancer’s seven warning signs Cancer’s seven safeguards
Change in bowel or bladder habits Lung: Don’t smoke cigarettes.
A sore that does not heal Colorectum: Have a proctoscopic exam as part of a
Unusual bleeding or discharge regular checkup after age 40.
Thickening or lump in breast or elsewhere Breast: Practice monthly breast self exam.
Indigestion or difficulty in swallowing Uterus: Have a Pap test as part of a regular checkup.
Obvious change in wart or mole Skin: Avoid exposure to the sun.
Nagging cough or hoarseness Oral: Have a regular mouth exam by MD or dentist
Complete body: have an overall physical yearly or at
3 year intervals
C. Tumors
Benign Tumors: non cancerous, do not spread to other parts of body
Malignant Tumors: can metastasize and are life threatening
D. Guidelines for cancer related screening

TEST OR EXAM SEX AGE (YEARS) RECOMMENDATION
Once every 3 years. Beginning 3
> 18; under 18 If
Papanicolaou test Female years after sexual activity begins.
sexually active
No later than age 21
Pelvic Exam Female Over 18 Yearly
Monthly
Breast self exam Female Over 20
20 - 40 Every 3 years
Breast Physical Exam Female
Over 40 Yearly
35 - 40 One baseline mammogram
Mammogram Female
40 - 50 Every 1-2 years
Stool guaiac slide test Male & Female Over 50 Yearly
Digital rectal exam Male & Female Over 40 Yearly
Every 3-5 years

Sigmoidoscopic Exam Male & Female Over 50
After 2 negative, 1 year apart
Testicular Exam Male Over 15 Perform after warm shower
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E. Diet/nutritional considerations
ANTI CANCER DIET HIGH ANTIOXIDANTS
Diet
• Low fat • Berries
Some evidence suggests that the development • Apricots
• High fiber
of colorectal cancer may be associated with a • Prunes
• Whole grains
diet that is high in fat and calories. • Cereals
• Raw fruits
• High calcium • Vegetables
• Nuts
• Raw vegetables
F. Common types • Seeds
• Clove
LEUKEMIA • Oregano
• ALL (Acute Lymphocytic Leukemia) • Cinnamon
• Most common form of childhood cancer
• Results in anemia (decreased RBC’s)
• Increased risk of infection (increased immature
WBC’s)
• Increased risk for bleeding (decreased platelets)
Risk Factors:
Smoking, viruses, chemicals, radiation
Signs/Symptoms:
Fever, bruise easily, generalized weakness, bone pain
Treatment :
Chemotherapy, radiation therapy
HODGKIN’S DISEASE
Malignant neoplasm of lymphoid with a proliferation of
lymphocytes
Cause: unknown – prevalent in adolescents (males)
Risk Factors:
Epstein Barr virus, HIV, chemicals, radiation
* There is no link for Hodgkins to smoking, ETOH, diet or exercise
Major symptom: enlarged nodes in lower cervical region; fever, pruritis, night sweats
Diagnosis: presence of Reed Sternberg cells in the blood
NON HODGKIN’S LYMPHOMA

Tumor of lymphatic tissue; control is difficult; affects all age groups.
Risk Factors:
Gender (men), Epstein Barr virus, HIV, Hepatitis C, autoimmune disease, chemicals, radiation
Treatment: chemotherapy, radiation and surgery
WILM’S TUMOR
Malignant tumor of the Kidney; occurs in childhood and older white men
Signs/ symptoms: blood in urine, parent reports presence of abdominal mass
Teach: Never palpate mass- palpation may cause rupture
Treatment: nephrectomy; chemotherapy and radiation
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BREAST CANCER
Risk factors:
• Family history • Early menarche
• ETOH use • Advanced age
• Nulliparity • Late menopause
• Obesity
• Personal history of breast cancer
• Use of estrogen & progesterone
• First child late in life
• High socioeconomic status

Treatment:
• Chemotherapy and Radiation
• Surgery
• Tamoxifen may be prescribed for 5 - 10 years
(avoid Coumadin - (warfarin) may increase effect.
Monitor PT/INR. Separate antacids by 2 hours)
• Megace (megestrol) - treats breast and endometrial cancer
(also used to prevent loss of appetite and severe weight loss with AIDS patients)
LUNG CANCER
Primary risk factors:
• Cigarette smoking
• Exposure to asbestos or other carcinogens
Signs & Symptoms:
• Chronic cough
• SOB
• Hemoptysis
• Weight loss
Diagnosis: Biopsy, sputum cytology, PET scan
Treatment:
• Chemotherapy, radiation, surgery
BLADDER CANCER
Risk factors:
• Smoking
• Diet (high fat, fried meats)
• Exposure to rubber
• Gender (older white males)
• Living in urban areas
Signs/Symptoms:
• Low back pain
• Dysuria
• Polyuria
• Hematuria
Treatment:
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• Chemotherapy, radiation, surgery
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COLON CANCER
Common in 50 - 60 year olds
Risk Factors
• Risk increases with age • Race - african american • Inflammatory bowel disease
• Smoking • ETOH • Low fiber, high fat diet • Diabetes • Obesity
Signs & Symptoms:
• Bowel changes, abdominal pain • Weight loss
• Pallor • Assess stool for occult blood
Diagnosis: barium enema, colonoscopy - done under conscious sedation; place in left lateral position
during procedure.
Treatment: chemotherapy, radiation, surgery
SKIN CANCER
The most common form of cancer in the U.S.
Risk Factors:
• Sun exposure • Fair skin
• Heredity • Age over 50
Teach:
• Change in color, size, itching
• Suspicious skin or Nevi (mole) changes need further evaluation
• Avoid the sun and tanning salons
• Mole assessment: Asymmetry, Border, Color, Diameter, Evolution
Treatment: chemotherapy, radiation, surgery
MULTIPLE MYELOMA
• Malignant overgrowth of plasma cells and malignant tumor growth in bone
• Interferes with RBC, WBC, and platelet production
• Common in older men
Subjective: • bone pain • low back pain • progressive weakness
Objective:
• anemia, platelet deficiency, weight loss, cachexia, idiopathic bone fractures
• positive Bence Jones protein in blood & urine
• precipitation of protein, calcium, and uric acid in the urine
Nursing Diagnoses: Pain, risk for injury
Implementation:
• Pain control
• Increase fluids to prevent renal damage
• High nutrient dense foods (boost, nutriment)
• Immune stimulant nutrients (selenium, vitamin A, C, E, protein)
Treatment: chemotherapy, radiation, steriods, stem cell transplantation
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G. Therapeutic techniques:
• Bone marrow transplant: restores the bone marrow’s ability to produce healthy cells; major risk of infection
• Surgery
• Internal radiation: also referred to as brachy therapy
Females: • Flex and extend legs to promote circulation • Absolute bed rest
• Deep breathing and coughing exercises • Head of bed 15 degrees
• Low residue diet (decrease bowel movements) • Elastic stockings
• Catheter (keep bladder empty) • Avoid pericare
• Report nausea, vomiting, elevated temperature • Report profuse discharge
• Opioids, muscle relaxants, sedatives may be used • Keep items in easy reach
Males: • If being treated for prostate CA, 80 - 100 seeds are implanted
• Client returns home after procedure
• Avoid contact with pregnant women and infants for 2 months
• Strain urine for seeds
• Instruct on condom use with sexual intercourse for 2 weeks after implantation to
catch seeds that may pass through urethra
• External radiation: High energy beams to affected area; also referred to as tele therapy
• Avoid pressure, trauma or infection to site
• Wash affected area with plain water and pat dry
• Teach to avoid exposure to heat, cold & sunlight
• Chemotherapy: Drugs used to kill cancer cells, normal cells may be damaged
• Side effects in every body system
• Nadir: lowest point
• Pancytopenia: occurs 8 -14 days after starting chemotherapy
• Mucositis- ulceration of the mouth- secondary to chemotherapy. Rinse mouth with water, salt,
baking soda or peroxide.
• If IV infiltrates, the treatment may be to administer an antidote

Tumor lysis syndrome:
Complication of cancer treatment, metabolic disturbances caused by the breakdown products of dying cancer cells
Results in • Hyperkalemia
• Hyperphosphatemia,
• Increased uric acid in blood and urine,
• Hypocalcemia – leads to acute uric acid nephropathy and acute renal failure
• Treatment: Allopurinol, IV fluids, monitor electrolytes
Superior Vena Cava Syndrome

Results from obstruction of the SVC by a tumor ie hodgkins, non hodgkins or lymphoma
Signs and symptoms: • Facial edema & periorbital edema
• Distended veins in neck & chest, headaches, seizures
• + Mediastinal mass on chest x-ray
• Treatment: radiation and chemotherapy
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XI. Metabolic and Endocrine Function and Disorders

A. Pathophysiology
Endocrine System Imbalances

Gland Hyposecretion Hypersecretion
Dwarfism Hyperpituitarism
Pituitary adrenal insufficiency Acromegaly
Thyroid deficiency Gigantism
Pituitary
Hypoprolactinemia Pituitary Cushing’s syndrome
Diabetes insipidus Hyperprolactinemia
SIADH (syndrome of inappropriate ADH secretion)
Hypothyroidism Hyperthyroidism
Thyroid Cretinism Graves disease
Myxedema
Parathyroid Hypoparathyroidism Hyperparathyroidism
Adrenal Cortex Addison’s disease Adrenal Cushing’s syndrome
Adrenal medulla Pheochromocytoma
Pancreas Diabetes Mellitus Hypoglycemia
B. Disorders
1. Pituitary Gland Disorders
Anterior Pituitary
a. Growth hormone excess: • Acromegaly (adult) • Gigantism (child)
Diagnosis: • ↑ serum HCG • Xray • CT scan • MRI
Treatment: • Hypophysectomy: monitor ICP & CSF drainage
• Complication: increased ICP, Bleeding, meningitis
• Patient will need glucocorticoid replacement for life
b. Growth hormone deficit: • Dwarfism (short stature)

Treatment: • Synthetic hormone injections • Limb lengthening surgery
Complications: • Developmental delay • Spinal pressure
• Crowded teeth • Kyphosis or lordosis
Posterior Pituitary
c. Anti Diuretic Hormone (ADH): secreted by posterior pituitary
• SIADH: ADH Excess
(Syndrome of inappropriate antidiuretic hormone)
Signs/ Symptoms: • Headache • Fatigue • Hyponatremia
• Decreased urine output
• Increased specific gravity
RX: Hypertonic solution D5NS, diuretics, Demeclocycline - antibiotic used to increase water in the urine
surgery
d. Diabetes Insipidus (DI - ADH Deficit)
Signs/ Symptoms: • Polydipsia • Polyuria • Decreased specific gravity
RX: Replace ADH: • Vasopressin (petressin) • Desmopressin (DDAVP) - intranasally
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2. Thyroid Disorders Normal thyroid function test levels:

Hyperthyroidism: • Graves disease T4: 4.5 - 11.2 mcg/dl
• Exopthalmus
T3: 100 - 200 ng/dl
• Goiter
TSH: 0.4 - 4.0 mlU/L
• Hyperthroidism
Hypothyroidism: • Myxedema (adult)

• Cretinism (infant)
HYPOTHYROIDISM HYPERTHYROIDISM
O = Slow / COLD Hyper = Fast / HOT

T3, T4 a Low TSH a High T3, T4 a High TSH a Low
Weight increase (metabolism slow) Weight loss (metabolism fast)
Constipation Diarrhea
Slurred speech Insomnia
Sluggish Mood swings
Depression Palpitation
Bradycardia Tachycardia
Cold Hot
Brittle nails, hair loss, menstrual disturbances Scanty menstruation
(more frequent/lasts longer)
Dry skin Complication: Thyroid Storm = emergency
Treatment: Treatment:
• Synthroid (levothyroxine) synthetic T-4 • Propacil (propylthiouracil- PTU)
(hold for pulse greater than 110) • Tapazole (methimazole) -inhibits synthesis of
Teach: it takes 1 week to work, thyroid hormone
take early in the morning • SSKI (saturated solution of potassium iodide)
• Lugol’s Solution
• Cytomel (liothyronine sodium) synthetic T-3
• Radioactive Iodine (I131)
(requires 72 hours isolation)
• Thyroidectomy
Post op: • Trache set
Myxedema Coma: Decreased cardiac output
• Oxygen
due to bradycardia and decreased stroke
• Suction & Ca+ Gluconate at bedside
volume
TX: monitor EKG & fluid status, give IV fluids,
Dopamine, replace hormone - IV levothyroxine, Thyroid Storm: control temp, IVF, electrolyte
treat hypothermia replacement, hydrocortisone, propranolol
(blocks the action of thyroid hormone on the cells)
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Hypothyroidism (Cretinism / Myxedema) Hyperthyroidism (Graves Disease)
Hair loss Receding Hairline

Intolerance to heat Fine/ straight hair
Intolerance to cold
Dull-blank expression Bulging eyes Facial blushing
Muscle aches & weakness Warm skin
Facial & eyelid Enlarged Thyroid
Lethargy edema Weight loss
Goiter
Anorexia Thick tongue- Muscle wasting hSystolic B/P
slow speech
Constipation hDiarrhea
Dry skin Tachycardia
Extreme fatigue (coarse & scaly)
Tremors Restless, fatigue
Apathy Brittle nails & hair
Menstrual changes Localized edema
Late Clinical Manifestations (Amenorrhea)
Subnormal Temp / Bradycardia / Weight Gain
Cardiac Complications
3. Parathyroid Disorders: controls calcium and phosphate metabolism
a. Hyperparathyroidism
• Von Recklinghausen’s Disease: hypersecretion of the parathyroid gland
• Hypercalcemia
Signs/ Symptoms: • GI disturbance • Constipation • Bone pain • Renal stones • Joint pain
Rx: Observation, IV Fluids or surgery
b. Hypoparathyroidism:
• Hyposecretion of the parathyroid gland • Hypocalcemia
Signs/ Symptoms: • Positive Trousseau sign • Positive Chevostek’s sign • Tetany

• Muscle twitching • Brittle nails • Paresthesias
Rx: Replace calcium and vitamin D
4. Adrenal disorders
a. Pheochromocytoma tumor of adrenal medulla (inner portion) causes hypersecretion
• Severe hypertension
• Headache
• Hyperglycemia
• Hyperhydrosis
• Hypermetabolism

Treatment: • Regitime (phentolamine) at bedside for blood pressure management
• Nipride (nitroprusside)
• Surgical removal of tumor or gland
• Avoid caffeine
• Promote rest
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Disorders of the Adrenal Cortex (outer covering)

ADDISON’S DISEASE CUSHING’S DISEASE
Adrenal insufficiency (ACTH deficit) Adnenocorticol (ACTH excess)
• Bronze skin discoloration • Mood swings • Headache

• Muscle weakness • Hypertension • Weight gain
• Lethargy, fatigue • Buffalo hump • Moon face
SIGNS • Dizziness • Easy bruising • Purple striae
• Vomiting and diarrhea • Metabolic alkalosis
• Weight loss • Pathological fractures
• GI disturbance • Pendulous abdomen
6Blood pressure 6Temperature 6WBC (eosinophils)

DECREASED6 6Sodium Chloride 6HCT 6Potassium*
6Hypoglycemia 6Magnesium
5Facial hair in women (hirsuitism)

5Potassium*
5Gynecomastia
5Magnesium
INCREASED5 5Glucose
5Leukocytosis
5RBC’s
5Calcium
5Sodium
• Quiet environment • Provide comfort

• Increase sodium in diet • Decrease sodium in diet
• Decrease potassium in diet • Increase potassium in diet
• Daily weight • Monitor glucose
• Force fluids • Observe mood changes
Observe for signs of Addisonian • Intake and output
Crisis: • Increase protein
• Severe hypotension • Decrease calories
TREATMENT
• Shock • Surgery
• Weakness • Radiation
• Vasomotor collapse which may lead
to death Medications:
• Treat with bed rest and IV Cortisone • Cytadren (aminoglutethimide)
• Teach patient to carry injectable • Hormone replacement
cortisone at all times and wear medic
alert bracelet
RELATED PHARMACOLOGY
Steroids: used to suppress inflammation
Adverse effects: Insufficiency (Addison’s)
Excess (Cushing’s)
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Fill in the blanks with the most appropriate response based on information related to
common Endocrine Disorders:
ACTH excess_________________________________
Hypothyroidism in an infant______________________
Treatment for hypothyroidism_____________________
ADH Excess___________________________________
ACTH Deficit___________________________________
Hypersecretion of the adrenal medulla__________________
Constipation, cold, bradycardia_______________________
Increased TSH, decreased T3, T4______________________
Hunger, confusion, perspiration _______________________
Hyposecretion of the pancreas___________________________
5 H’s ______________, ______________, _________________, _______________________,
_________________
Decreased sodium, weight loss, increased potassium, bronze skin color ___________________
Test for diabetic control over a 4 - 6 week period. 4% - 6% indicates good control
__________________________________________________________
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XII. Gastrointestinal Function and Disorders

A. Review of anatomy and physiology
B. Diagnostic tests • purpose, description, nursing implications
1. Radiological exams
2. Barium enema: • Give a laxative or enema post procedure
• Expect clay colored stool for up to 72 hours
3. Endoscopic studies: NPO 6 - 8 hours before the procedure
NPO until gag reflex returns
4. Sigmoidoscopy: administer an enema before the procedure
5. ERCP (Endoscopic retrograde cholangiopancreatography)
• Fluroscopy & X• ray used to diagnose problems in the liver,
gallbladder, bile ducts, and pancreas
• NPO 6-8 hours pre procedure, check for allergies to iodine &
shellfish; multiple position changes required during procedure
Post procedure: monitor for CNS depression - sedation given
C. Common Problems related to GI tract
1. Nausea and vomiting

2. Constipation: decrease number of stools; hard difficult to expel
feces
3. Diarrhea: frequent loose, watery stools
D. Disorders
1. Hiatal hernia: client may complain of dysphagia and heartburn
Nursing Interventions: small frequent meals, antacids, elevate the
HOB. Remain in upright position for 2 hours after meals
2. Stomatitis: inflammation of the mouth
3. Gastritis: inflammation of the stomach
4. GERD: gastroesophageal reflux disease
Rx: PPI’s (proton pump inhibitors), H2 antagonists
Teach: avoid ETOH, tomatoes, coffee, spicy or fatty foods, carbonated beverages, chocolate, peppermint
5. Peptic Ulcers: Risk factors: Stress, smoking, ETOH

Gastric Ulcers Duodenal Ulcers
50 years old and older 25 - 50 years
Well- nourished Malnourished
Pain ½ - 1 hour after meals Pain 2-3 hours after meals
Eating may increase the pain Food may decrease the pain
Vomiting common Vomiting uncommon
Weight Loss Weight gain
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6. Ulcerative colitis: affects the left/ descending colon

• Severe diarrhea
• 15 - 20 stools per day, bloody, + mucus.
• Predisposition to colon cancer
• Disorder is common in 15 - 40 year old Jewish females.
Teach: • Avoid carbonated beverages

• Diet: low residue, low fat, milk free, high protein
7. Regional enteritis (Crohn’s Disease): affects the ileum and right side/ascending colon
• 3 - 4 semi- soft stools per day
• Disorder is common in 20 - 60 year olds, both sexes
Teach: • Diet: high calorie, high protein, high CHO, high vitamin, milk free, low fat

Possible treatment for ulcerative colitis and regional enteritis :
• TPN
• Colostomy (partial or total)
• Ileostomy
• Oral or rectal medications: • Antiinflammatory drugs: Humira (adalimumab), Asacol, Pentasa
(mesalamine) or Remicaide (infliximab)
• Steroids: Prednisone
• Immune suppressors: 6 mercaptopurine
• Antibiotics: Ampicillin, cephalosporins and or Flagyl (metronidazole)
• Antidiarrheals: Immodium (loperamide), Codeine
8. Hepatitis:
Hepatitis A: transmitted by fecal/ oral route - good hand washing is imperative. Contact precautions if diapered
or incontinent.
Hepatitis B: transmitted via blood/body fluids
• First immunization at birth (check for yeast allergy before administering)
TX: acute Hepatitis B - no treatment, manage symptoms; chronic - antivirals or peg-interferon
Hepatitis C: transmitted by IV drug use/ blood transfusions, multiple sex partners - flu like symptoms; can lead
to cirrhosis and liver cancer. Chronic infection leads to need for transplant.
TX: Interferon (boosts the immune system) and Reebetrol (ribavarin) -antiviral medication
Hepatitis D and Hepatitis G: Follows Hepatitis B
Hepatitis E: transmitted by fecally contaminated water in under developed areas
Risk factors: IVDA, hemodialysis, transfusions, health care workers, mutiple sex partners, tatoos and body
piercings
Teach: Use of condoms, do not share needles, do not donate blood, avoid Tylenol (acetaminophen)
9. Salmonellosis: • Bacterial infection transmitted by flies, fingers, food, & feces

• Incubation 8 – 48 hours after ingestion of contaminated food
Signs and Symptoms: • Fever • Nausea • Vomiting
• Bloody diarrhea • Abdominal cramping
Dx: Stool culture
Rx: IVF and electrolyte replacement, antibiotics - Ciprofloxacin, Ampicillin, Bactrim (trimethoprim)
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10. Cirrhosis: (scarring of the liver) Caused by many forms of liver disease.
• Laënnec’s: Caused by alcoholism
• Can lead to Portal hypertension (high blood pressure in the portal vein)
Signs and Symptoms: • Changes in mental status (hepatic encephalopathy)

• Ascites • Splenomegaly • Spider hemangiomas
• Pancytopenia • Jaundice • Itching
• Risk for esophageal varices - Sengstaken Blakemore Tube - avoid hard foods
Pertinent Lab Values for Cirrhosis:
Increased: • Alkaline Phosphatase • Sodium • AST • ALT
• Ammonia: leads to hepatic encephalopathy -↓ protein in diet
Decreased: • Albumin • Potassium • Cholesterol • Platelets
Nursing Interventions:
• Observe for asterixis (flapping hand tremors associated with hepatic encephalopathy)
• Administer Lactulose as prescribed - may cause hyperglycemia and diarrhea
•*Increase vitamin B1(thiamine) in the diet - give daily
• Encourage rest
• Restrict fluids
• Daily weights
• Monitor intake and output
• Diet: High calorie, low sodium, low fat, low protein diet (helps to control ammonia level)
• Monitor for bleeding
• TX for portal HTN = Betablockers & Nitrates
11. Appendicitis: Positive Mc Burney’s sign/ RLQ rebound tenderness Rx: Surgery
12. Peritonitis: Inflammation of the peritoneum Rx: Antibiotic therapy
13. Diverticulosis: • Outpouching of the colon may be caused by constipation

S/S - abdominal pain & tenderness in LLQ
Give High fiber diet, Avoid foods with seeds
• Diverticulitis: inflammation of the pouch Diet - NPO, progress to clear liquids
• Avoid foods with seeds - low fiber
14. Gastric Resection:

• Billroth I ( gastroduodenostomy)
• Billroth II (gastrojejunostomy)
• Total Gastrectomy: • Vitamin B12 replacement necessary for life • Will cause pernicious anemia
• To avoid Dumping syndrome teach client: not to drink with meals; lie down after eating
Signs & Symptoms: • Weakness • Fainting • Tachycardia • Diaphoresis

• Palpitations 5 - 30 minutes after eating
Teach: • Diet: High protein, high fat, low carbohydrate

• Increase foods with pectin (i.e. peaches, plums, apples)
• Avoid foods high in sugar and sodium
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15. Ostomy: surgical opening made through the abdomen with a portion of the ileum or colon brought though
the opening to allow temporary or permanent excretion of wastes

Indications: bowel obstruction, cancer, inflammatory bowel disease, abdominal trauma
Post op: assess stoma, it should be red – pink, with edema immediately post op
Enterostomal therapist: nurse with specialized training in ostomy care
Ileostomy Colostomy
Small bowel, Liquid stool; No control Large bowel
Brooke: conventional ileostomy Semi- formed to formed stool
Kock pouch: continent ileal reservoir ↓’s problem Client may gain control by diet and irrigation
of skin care; risk for peritonitis
Diet considerations with an ostomy:

Bulk forming foods: to decrease diarrhea with an ostomy
• Fish • Eggs •Yogurt • Cooked tomato • Cottage cheese • Banana • Beets • Oranges • Natural cheese
Avoid odor producing foods:
• Garlic • Broccoli • Onions • Asparagus • Cabbage • Eggs • Fish
Gas forming foods:
• Beans • Cabbage • Onions • Beers • Cheese • Sprouts
Foods causing obstruction with an ileostomy:
• Corn • Popcorn • Nuts • Celery • Raisins • Raw vegetables
Irrigation: irrigate 1 hour after meals, same time everyday, to enhance effectiveness have client change
position, ambulate, massage abdomen lightly, drink warm fluids.
16. Pancreatitis: Causes severe upper abdominal pain that may radiate to the back with N/V & fever.
Precipitating factors include:

• Smoking • Alcohol abuse • Hypercalcemia • History of liver or gallbladder disease
Signs and Symptoms: • Pain • GI distress • Decreased calcium levels

• Increased amylase lipase & bilirubin • Increased LFT’s • Leukocytosis • Hyperglycemia
Signs: • Cullens: discoloration in the periumbilical area

• Turners: bluish color in the flank.
Treatment: Pain relief: Demerol (meperidine), NPO in acute phase, NGT for decompression
Teach: Avoid ETOH. Diet: small meals, no dairy or coffee, decrease redmeat; increase vitamin B, iron, berries;
6 -8 glasses of water per day.
17. Cholecystitis: Inflammation of the gallbladder: Risk Factors: (5 F’s) Fair, Fat, Female, Forty, Fertile.
Caused by obstruction of bilary ducts by gallstones
Signs and Symptoms: • Pain in the right upper quadrant
• Increased pain with a deep breath in (Murphy’s Sign)
• Nausea • vomiting • abdominal distention • fat intolerance
Treatment: • Low fat diet
• Cholecystectomy (T- tube may be placed)
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XIII. Urinary Function and Disorders
A. Terminology
Azotemia: increased BUN and Creatinine, suggests renal impairment -asymtomatic
Uremia: full blown signs and symptoms of renal failure, decreased calcium, increased potassium
B. Pathophysiology
C. Causes and prevention of urological problems

Urinary stasis, urinary calculi, indwelling catheters, premature infants, poor toilet hygiene, wet bathing suits,
perfumed toilet paper
D. Diagnostic tests and procedures: purpose, description, nursing interventions

• Urinalysis • Fractional urine • Urine culture and sensitivity
• Urine osmolarity • BUN/Creatinine Levels • Radiological studies
• Cystogram • Cystoretrography (CMG) • IVP (Intravenous Pyelography)
• Renal biopsy • Renal ultrasonography • CT (Computed axial tomography scan)
• Cystoscopy • Radionuclide renal scan • Electromyography of the perineal muscle
*Urinary output is one of the most valuable monitors during shock treatment. Hourly measurements of the
urinary output are valuable in determining the rate of fluid replacement.
Hourly urine output should be: • Infant/child: 10 to 20 ml/hour
• Adult: 30 to 50 ml/hour
• Elderly: 20 to 30 ml/hour
E. Disorders
1. Cystitis: Inflammation of the bladder Tx: Cipro (ciprofloxacin), Pyridium (phenazopyridine)
2. Urethritis: Inflammation of the urethra
3. Nephritis (Bright’s disease): Noninfectious degeneration of cells
4. Acute glomerulonephritis: Follows Strep infection such as impetigo

Signs and Symptoms:
• Headache • Weight gain • Hypertension
• Hematuria • Oliguria • Proteinuria
• Increased BUN and creatinine • Children may have periorbital edema
Complications: • Hypertension • Encephalopathy • Heart failure • Pulmonary edema

Treatment: • Diuretics • Antihypertensives • Antibiotics • Bed rest • Low protein diet
5. Chronic glomerulonephritis:
• Increased potassium • Increased phosphorus • Decreased calcium
• Metabolic acidosis • Hypertension • Increased BUN
• Increased creatinine • Nocturia • Increased magnesium
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6. Nephrotic syndrome: usually follows another kidney disease;

Signs and Symptoms: • Proteinuria • Hypoalbuminemia • Severe edema
Treatment: • Antihypertensives, diuretics, high protein diet
• May need protective isolation when hospitalized
7. Nephrosclerosis: caused by hypertension, atherosclerosis, end stage renal disease treatment –

control hypertension
8. Pyelonephritis: chills & fever, flank pain, leukocytosis, pyuria

Treatment: IVF, IV antibiotics
9. Renal stones: can be caused by hypercalcemia – increase fluids
10. Cancer of the bladder: common in smokers, living in urban areas – exposure to nitrates, dye, and rubber
Treatment: surgery – cystectomy & ileal conduit placement
11. Cancer of the kidney: in children commonly - Wilm’s Tumor, 50-70 year olds
12. Urinary incontinence: involuntary leakage of urine
Prevention: • Bladder exercises (kegels) • Avoid caffeine & ETOH • Bladder training
Medications: • Detrol (tolterdine) - for treatment of over active bladder & urge incontinence
Side effects: dry mouth, headache, dizziness, constipation
• Ditropan (oxybutynin chloride) - used for over active bladder
Side effects: constipation, dry mouth, headache, blurred vision, dizziness
• Bethanecol (urecholine) stimulates the bladder to empty
Side effects: stomach upset, vomiting, dizziness, sweating or flushing; take on an
empty stomach
13. Acute renal failure: normal BUN 8-20:

Phases: • Oliguria begins with the renal insult and continues for 3 weeks (1-3 weeks)
• Diuresis begins when the kidneys begins to recover and continues for 1-2 weeks
• Recovery continues until renal function is fully restored (3 months -1 year)
Treatment : • Daily weight

• Monitor intake and output
• Complete bed rest
• Restrict protein, sodium, potassium, high carbohydrate
• Good skin care
• Amphogel (aluminum hydroxide) – increases calcium by binding phosphorous
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14. Chronic renal failure: Most common causes are hypertesion and diabetes mellitus
• Stage I: Normal BUN and creatinine, asymptomatic
• Stage II: Increasing BUN and creatinine, polyuria, nocturia, polydipsia
• Stage III: Azotemia, hypertension, oliguria, metabolic acidosis, nausea, headaches
anemia, edema
• Stage IV: Uremia, uremic frost, electrolyte imbalances (hyperkalemia, hypernatremia,
hyperphosphatemia, hypermagnesemia, hypocalcemia)

Treatment: Diet
• Moderate protein • High carbohydrate • Restrict-sodium • Increase calcium
• Low potassium, magnesium, phosphate
• Fluid restriction - Intake = output + 500 ml’s

Medications: Epoetin (epogen), Kayexalate (sodium polystyrene sulfonate), Amphogel (aluminum
hydroxide), antihypertensives, diuretics, iron supplements, calcium carbonate, vitamin D
F. Therapeutic regimen
1. Dialysis:
Hemo - Restrict the limb; hold antihypertensives and anticoagulants before dialysis (3 - 4 times per
week up to 4 hours each session). Monitor for cramping which occurs if fluid is removed too quickly.
Peritoneal – Dwell time 4-6 hrs, 3-4 times/day. Risks: peritonitis (cloudy diasylate), leakage.
Bloody diasylate = Infection. Protein may be lost in diasylate
Complication: dialysis disequilibrium syndrome occurs shortly after beginning hemodialysis or

peritoneal dialysis. Caused by rapid correction of metabolic abnormailities.
Signs & Symptoms: nausea & vomiting, drowsiness, headache, disorientation, can progress to seizures,
coma and death.
Treatment is prevention with slow reduction of BUN.
2. Port - a -cath - used for hemodialysis or hematology/oncology patients - small appliance installed
beneath the skin. Catheter connects the port to a vein.
3. Ileal Conduit - urinary diversion created after bladder removal. Ureters are attached to the ileum, stoma
brought to the abdomen and collection bag attached.
4. Lithotripsy – use of shock waves to disintegrate stones - side effects: internal bleeding, pain, infection
5. Kidney Transplant - Signs of rejection:

• Oliguria
• Anuria
• Elevated temperature
• Flank tenderness
• Increased specific gravity
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XIV. Reproductive System Function and Disorders

A. Female anatomy and physiology
B. Menstrual dysfunction
C. Contraception- patient teaching: no protection against STD’s
• Emergency contraception most effective if used within 72 hours of intercourse
D. Infertility
E. Diagnostic tests and procedures - purpose, description, nursing interventions
1. Breast self-exam
2. Vulva self-exam
3. Pelvic exam
4. Smears and culture
5. Endometrial biopsy
6. Colposcopy: visualization of the cervix
7. Laparoscopy: visualization of the abdomen
8. Hysteroscopy: visualization of the uterus
9. Dilatation and curettage: opening and scraping of the cervix
10. Mammography: no lotion or deodorant before procedure
11. Ultrasound - increase fluids pre-procedure; place in supine position
12. Therapeutic abortion
F. Nursing management
G. Disorders
1. Pelvic inflammatory disease (PID) - Most commonly caused by untreated Sexually Transmitted Infections:
Syphillis – Treponema Pallidum

No alcohol 24 hours before VDRL – may give a false reading; (RPR can also be done for screening)
FTA-ABS -fluorescent treponema antibody absorption test -confirms RPR & VDRL
• Stage 1 = + chancre (painless) 2 - 3 weeks for symptoms to appear
VDRL (blood test) - negative; 1- 3 months
• Stage 2 = neg chancre, + rash on palms of hands & soles of feet
+VDRL 3 months – 1 year
• Stage 3 = 1 - 30 years – asymptomatic but infection still present
Without treatment -shuffling gait, neurological symptoms
Treatment – PCN – (Doxycycline in PCN allergic) - follow up VDRL at 6 & 12 months
Chlamydia: #1 STD in USA

• may be asymptomatic in females - incubation period 7 - 21 days
• treat with Zithromax (azithromycin) PO or Vibramycin (doxycycline)
Gonorrhea:
• may be asymptomatic - untreated STI’s may lead to infertility
• vaginal or penile discharge, genital itching, swollen and painful glands
• treat with single dose of Rocephin (ceftriaxone) IM and Zithromax (azithromycin) PO or
Doxycycline for 7 days
• Erythromycin in neonates eyes to prevent/treat Chlamydia/Gonorrhea

2. Vaginitis: caused by overgrowth or invasion of microorganisms
Treatment for yeast vaginitis: Diflucan (fluconazole) PO 103
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3. Comparison of female cancers risk factors for cervical, ovarian and uterine cancer
Cervical Cancer Uterine Cancer Ovarian Cancer
Early: • No symptoms *Frequent urination, Difficult or • Vague Gl disturbance
• Irregular bleeding painful urinating • Pelvic pressure
• Metrorrhagia
• Irregular bleeding • Bloating
(bleeding between periods)
• Pelvic pain or pressure • Increased abdominal girth
Late: Watery discharge after intercourse
Advanced: • Leg pain • Vaginal discharge • Leg pain
• Dysuria • Pelvic pain
• Rectal bleeding
Diagnosis Diagnosis Diagnosis
• Biopsy • CA 125 blood test • Biopsy
• Pap smear • Median age 61 • 55-59 year olds, peak age 80
Risks Risks Risks
• Multiple sex partners • Obesity • Obesity • History of DM • Nulliparity
• Sex under age 20 • Multiparas (increased estriol level) • Infertility
• Oral Contraceptives • Family hx • Estrogen without • Increased fat in the diet
• Early childbearing
progesterone • Talc in perineum
•*Smoking
• Trunkal obesity • Breast Cancer
• Low socioeconomic status
• HPV • Breast cancer- Tamoxifen use • Obesity
• HIV infection • Gallbladder disease • Estrogen without progesterone
• Nutritional deficiencies • Nulliparity • Infertility • Family history of breast cancer,
(folate,beta carotene, Vitamin C) • Late menopause after age 52 ovarian cancer or Colorectal cancer
• Internal radiation: Absolute bed rest head of bed elevated15 degrees
• Deep breathing and coughing exercises: • Flex and extend legs to promote circulation • Elastic stockings
• Low residue diet (decrease bowel movements) • Report profuse discharge
• Indwelling catheter (keep urinary bladder empty) • Avoid pericare
• Report nausea, vomiting, elevated temperature
• Medications: Opoids, muscle relaxants, sedatives may be used
• Teach: small amount of vaginal bleeding may be expected for 1 – 3 months following internal radiation
4. Endometriosis: dysmenorrhea, dyspareunia, pelvic pain

RX: medications for ovarian suppression-oral contraceptives, Depo Provera (medroxyprogesterone
acetate) Side Effects - bone loss,amenorrhea, edema
5. Uterine prolapse (cystocele, rectocele): Rx: Colporrhaphy, Pessary - removed and cleaned every 3
months by M.D.
6. Uterine fibroids (leiomyomas): may cause abnormal uterine bleeding. Tx: Myomectomy or
hysterectomy in severe cases.
7. Sterilization: tubal ligation
8. Breast disorders:
a. Fibrocystic breast disease: continue to do monthly SBE 7-10 days after first day of menstruation
b. Mastectomy: exercises; No abduction post-op
c. Paget’s disease of the breast: malignancy of the nipple and areola.
RX: same as breast cancer
9. Lymphedema: complication of mastectomy
10. Vaginal suppository: remain in lying position for at least 20 minutes
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H. Male anatomy and physiology

I. Causes and prevention of male reproductive disorders
J. Diagnostic tests and procedures: purpose, description, nursing intervention
1. Digital rectal exam: assesses for irregularity in size shape and texture of the prostate
2. Semen analysis
3. Testicular self-exam: best done after a warm shower - (cancer common in men 15 - 35 years)
4. Transrectal ultrasound of the prostate
5. Biopsy of the prostate
6. PSA- normal less than 4ng/ml; greater than 10ng/ml needs investigation for cancer
K. Nursing management
L. Inflammation and infection of the male reproductive system
M. Disorders
1. Testicular cancer (common in young men). Risk factors: cryptorchidism, white men, family history, HIV
2. Tumors
3. Benign prostatic hypertrophy: nocturia, frequency, hesitancy, erectile dysfunction

• Proscar (finasteride) shrinks prostate • Avodart (dutasteride) - do not crush or chew
• Flomax (tamsulosin HCl) – take 30 minutes after a meal, Take with a full glass of water
• Herbs: Ginseng, Saw Palmetto
Surgical interventions:
• Nursing implications: TURP- hematuria expected for 3 days;
• CBI (continuous bladder irrigation) used post-op - expect output greater than intake
• Bladder spasms are normal; decreased urinary output is an abnormal finding
• Distended abdomen = fluid retention
4. Prostate cancer: African American males at highest risk. Pain in the back, & lower leg, painful
ejaculation
TX: • Chemotherapy, Radiation, Surgery or Hormone therapy
Lupron Depot may be prescribed. Side effects: bone pain, hot flashes, impotence, injection site
pain.

5. Impotence: may be caused by medications, alcohol or drug use
• Treatment: Viagra (sildenafil) take 30 min - 4 hours before intercourse, on an empty stomach
Cialis (tadalafil) take up to 36 hours before intercourse, after a meal
Levitra (vardenafil) take 30 min - 4 hours before intercourse, with full glass of water
• Avoid with nitrates • report sudden vision loss • report erections lasting > 4 hours
Teach correct application of condoms: Place the condom on the tip of the penis so it will unroll correctly (the condom
should unroll outwards). Lightly squeeze the tip of the condom (to remove air) as the condom is applied to the head
of the penis. Unroll the condom all the way down to the base of the penis. There should be at least 1.5 cm reservoir
between the condom and the head of the penis
6. Infertility: Sterilization - vasectomy - post-op – ice packs, scrotal support, analgesics

Teach to use condoms for 3 months or until 2 sperm free analyses
7. Penile implant: semi rigid rod (permanent semi erection), inflatable (natural erection)
8. Orchitis: inflammation of the testes. Signs and Symptoms: pain, swelling, ejaculation of blood, hematuria
Treatment: Antibiotics (cephalosporins) 105
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XV. Neurological Function and Disorders

Disorders of the Eye and Ear
A. Terminology
B. Pathophysiology
C. Causative factors/ prevention
D. Cranial nerves/function (review page 37)
E. Diagnostic tests:- purpose, description, nursing implications

When using IV contrast, check allergy to iodine or shell fish!
1. Lumbar puncture: lay flat 2-3 hours -supine or prone, increase fluids; check site for bleeding & CSF
leakage complication - headache. Teach: avoid lifting
2. EEG: before procedure: wash hair; no metals in hair; avoid caffeine. Client may need to sleep during the
test - may be asked to decrease sleep the night before.
3. EMG: Electromyography – detects neuromuscular abnormalities
4. Myelogram: inject air or dye to check spinal cord and vertebrae

• After the procedure: lay flat 6-8 hours increase fluids
• If a water soluble dye is used elevate the head of the bed for 8 hours to keep the dye from
irritating the meninges.
5. CT scan and MRI: instruct to lie still, no metals
6. Cerebral angiography
F. Neurological assessment: nursing management

1. Glasgow coma scale: (review page 35)

2. Neuro check: Perform every hour following head injury
Most important check is LOC & mentation
Change suggests deterioration in condition

3. Posturing : Decorticate - damage to the cortex of the brain
Decerebrate - damage to the mid stem of the brain
TIP: Safety is the minimization of risk factors that can cause injury or harm. When
prioritizing care, patient safety should be considered if the physiological integrity is
intact.
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G. Disorders Comparison of Common Neurological Disorders

Multiple Sclerosis
Pathophysiology: • Destruction of Myelin
Who is affected? • Young adults 20 - 40 year olds
• Women affected more than men
Symptoms: • Primary: fatigue, depression, numbness, loss of balance, diplopia
Diagnosis: • MRI • Evoked potential studies (determine the extent of disease process)
Treatment: • Avonex • Beteseron • Copaxone • Rebif
• (Inferon beta1a) (Interferonbeta-1b) • (Glatiramer Acetate) • (Inferon beta 1-a)
• Avoid hot baths
Parkinson’s Disease
Pathophysiology: • Cause unknown
• May be linked to environment, head trauma, chronic antipsychotic use
• Decreased dopamine
Who is affected? • Men affected more than women • 50’s
Symptoms: • Gradual onset, tremors at rest, rigidity, bradykinesia, shuffling gait, pill rolling
Diagnosis: • Patient history: 2 out of 3 common symptoms
Treatment: • Control symptoms; Safety is the priority
• Levodopa (sinemet) Use cautiously with glaucoma, avoid B6
• Symmetrel (amantidine)
• Eldepryl (seligiline)
• Comtan (entacapone): extends the effect of each dose of Sinemet (levodopa)
Amytrophic Lateral Sclerosis: Lou Gehrig’s Disease

Pathophysiology: • Loss of motor neurons
Who is affected? • 50 - 60 year olds • Men affected more than women
Symptoms: • Fatigue, progressive muscle weakness, cramps, twitching
Diagnosis: • Based on signs and symptoms • EMG • MRI
Treatment: • Dopamine Agonists: Requip (ropinirole), Mirapex (pramipexole), Riluzole (rilutek)
• Lioresal (baclofen), Dantrium (dantrolene): for muscle spasms
• Death in 3 years
• Supportive Care
Guillain Barre’ (Respiratory assessment is essential)

Pathophysiology: • Autoimmune attack of peripheral nerve myelin
Who is affected? Predisposing event may be: • Respiratory infection
• G.I. Infection • Vaccination
• Surgery • Pregnancy
Symptoms: • Ascending paralysis
• Dyskinesia: inability to move voluntarily
Diagnosis: • Increased serum protein in CSF
• Evoked potential studies- show loss of nerve conduction
Treatment: • Anticoagulants • IVIG: intravenous immunoglobulin G
• Plasmapheresis (side effect: hypotension)
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Alzheimer’s Disease
Pathophysiology: • Cause unknown
• Decreased acetylcholine
• Microscopic plaque found in brain tissue
Who is affected? • 65 -85 y.o. affects males and females equally
• Prevent injury
Symptoms: • Gradual loss of cognitive function, apraxia- cannot perform purposeful
movement, forgetfulness
Diagnosis: • Health history • Family history • EEG • MRI • CT Scan
Treatment: • Tacrine (cognex) • ↑ Acetylcholine
• Hepatotoxic • Aricept (donepezil)
• Exelon (rivastigmine) • Namenda (memantine)
• Razadyne (galantamine) • Supportive care
Myasthenia Gravis
Pathophysiology: • Autoimmune -affects myoneural junction
• Lack of acetylcholine
Who is affected? • Women 20 - 40 year olds more frequently than men
• Men 60 - 70 year olds
Symptoms: • Voluntary muscle weakness, increases with activity (eye muscles are affected
first), avoid crowds & constipation
• Initial: diplopia
• Myasthenic Crisis - life threatening if breathing muscles are involved
Diagnosis: • Positive tensilon test confirms diagnosis
• EMG
Treatment: • Anticholinesterase agents - Mestinon (pyridostigmine)
• Prostigmin (neostigmine): improves communication between the nerves and
the muscles S/E: abdominal pain, diarrhea, nausea
• Plasmapheresis
• IVIG: intravenous immunoglobulin G
• Surgery - Thymectomy
Huntington’s Disease
Pathophysiology: • Degeneration of neurons in certain areas of the brain
Who is affected? • Child of Huntington’s Disease parent
• Autosomal dominant
• Gene 50/50 chance
Symptoms: • Personality changes, ↓ cognitive ability, depression, balance problems &
involuntary facial movements
• Late: sudden jerky movements - Chorea
Diagnosis: • CT
• MRI
• Blood test for the gene
Treatment: • No cure: control symptoms, Klonopin (clonazepam), Haldol (haloperidol),
• Clozaril (clozapine), Prozac (fluoxetine)
• Speech therapy
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1. Increased intracranial pressure (ICP): can result from or cause brain injury - an early sign is change in
LOC. Normal ICP range 1-20 mm Hg. Intraventricular catheter used to monitor ICP or drain fluid
• Monitor for Dilation of the pupil in one eye
• Increase in systolic blood pressure, bradycardia, wide pulse pressure (Cushings Triad)
Pulse Pressure = difference between systolic and diastolic pressure

120 = 40 pulse pressure (normal)
80
Mannitol (osmitrol) is used to decrease cerebral edema - monitor urine output hourly
Decadron (dexamethasone) is a steroid that may also be prescribed for cerebral edema
2. Meningitis: inflammation of the layers covering the brain
• Signs and Symptoms: lethargy, pale skin, fever, petechiae, nuchal rigidity, seizures, nausea,
vomiting, opisthotonos (spasm of the muscles causing backward arching of the head, neck, and
spine) Kernig’s or Brudzinski sign,
• Dx: blood culture, spinal tap, CT scan of head
• Rx: IV antibiotics
• Droplet precautions
3. Encephalitis: infection of the brain
• Rx: Symptom relief
4. TIA : temporary loss of neural function: warns of impending CVA
CVA: sudden death of brain cells due to lack of oxygen, blockage or rupture of an artery.
• Signs and Symptoms: depend on part of the brain affected, most common symptom is weakness or
paralysis of one side of the body.
• Rx: antihypertensives, anticoagulants, anticholesterol agents, thrombolytics, antiplatelet agents,
• supplemental O2
5. Cerebral aneurysm/ arteriovenous malformation: ballooning of a weakened blood vessel that fills with
blood. RX: B/P control, surgery
6. Seizure disorders & epilepsy: safety is the priority
Generalized seizures involves both hemispheres of the brain
Partial seizures involve a single area of the brain
Status epilepticus - seizures lasting more than 10 minutes - life threatening TX: IV Valium (diazepam) or
Ativan (lorazepam)
• Meds: Keppra (levetiracetam) - may cause weakness, vomiting.
• Topamax (topriamate) SE – dizziness, vision changes;
• Dilantin (phenytoin) – SE: discolors urine, gingival hyperplasia
• Sabril (vigabartin) - treats complex partial seizures only in people who do not respond to other meds
SE: permanent peripheral vision loss; suicidal thoughts
7. Trigeminal neuralgia: 5th cranial nerve disorder
8. Bells Palsy 7th nerve paralysis. Reversible in 2 - 8 weeks. Eye drops may be prescribed
9. Herniated disc (herniated nucleus pulposus): bulging of cushion between vertebrae of spine
• Rx: rest, heat/ice, physical therapy, anti-inflammatory agents, steroids 109
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11. Spinal cord injury: Disrupts signal transmission to & from the brain. Log roll to stabilize the spine.
Increased risk for Autonomic Dysreflexia: results in increased B/P leading to stroke and death. Injuries at
levels of T6 or higher at risk. Avoid stimulating the bladder, the bowels, or the skin.

Signs of autonomic dysreflexia include: pounding headache, nausea, decreased pulse, profuse
diaphoresis, severe hypertension
Treatment: elevate HOB, eliminate the cause, notify MD
Level of injury Functional ability Self care capability
Inability to control muscles of Unable to care for self; ventilator support

C 3 and above:
breathing essential; usually rapidly fatal
No upper extremity muscle Unable to care for self

C 4:
function; able to move neck Respiratory difficulty
Neck movement, possible partial Can propel electric W/C. may be able to feed
C 5:
strength of shoulder & biceps self with powered devices
Can propel electric W/C. may be able to feed

Muscle function in C5 level,
C 6: self with powered devices; can write and care
partial strength in wrist
for self, can transfer from chair to bed
Muscle function in C6 level, Can propel W/C independently, can dress
C 7: partial strength in hand (no finger lower extremities with minimal assistance; can
muscle power) drive car with hand controls
Muscle function in C7 level,

C 8: (nerve) Same as C7, activities easier
normal arm, hand weakness
Good upper extremity muscle

T 1 – 10: W/C ambulation: walk with long leg braces
strength; balance difficulties
Trunk and pelvis muscle function W/C not essential; may use crutches or canes
T 11 and below:
intact for ambulation
12. Basilar skull fracture: CSF otorrhea, rhinorrhea -

Battle’s sign (bruising and ecchymosis over mastoids)
Raccoon’s eyes (periorbital ecchymosis)
13. Fibromyalgia: chronic muscle stiffness, spasms, sensory changes, insomnia - Tx: pain management
14. Migraine headaches: inflammation and pain caused by vasodilation that causes the release of chemicals
from nerve fibers around the large arteries of the brain.
Rx: Imitrex (sumatriptan), Zomig (zolmitriptan), acetaminophen or NSAID’s may also be used.
Avoid sumatriptan and zolmitriptan with ischemic heart disease, uncontrolled HTN, stroke, TIA or PVD.
Use may make these conditions worse.
15. Tension headaches: associated with chronic contraction of the muscles of the neck and scalp.
Treatment: aspirin, ibuprofen, naprosyn, indomethacin, ketorolac
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H. Care of patient with eye disorders
Instillation of eye drops:

• Have client lie down or tilt the head back.
• With the index finger, pull down the lower lid of the eye to form a pocket.
• Drop the correct number of drops (wait about 1 minute between each drop) into the
• pocket made between the lower lid and eyeball.
• Do not squeeze the bulb too hard.
I. Diagnostic tests: • Opthalmoscopy: visualization of the structures of the eye

• Visual acuity: Snellen chart
• Tonometer: test intraocular pressure
J. Common disorders
1. Cataracts:
Opacity of the lens, leads to loss of sight. Client reports a glare. Most effective treatment is surgery.
• Pre-op medications include mydriatics (atropine) and cyclopegics.
• Post-op:
• Increase the head of the bed 30-45 degrees
• Teach to wear dark glasses while outdoors.
• Significant swelling or bruising is abnormal
2. Glaucoma:
Increased intraocular pressure (normal 15-21), obstruction of the flow of the aqueous humor (slow and
insidious) loss of peripheral vision. Visual field test done to access for glaucoma.
• Acute (closed angle): sudden onset - usually unilateral pain in and around the eye, blurred vision,
nausea, vomiting and halos. Increased intraocular pressure must be relieved as soon as possible-
maintain supine position. Treatment: Diamox (acetazolamide), Timoptic (timolol), Prednisolone
• Chronic (open angle): tired feeling in the eye, “halos” around the lights
• Treatment includes: myotics (Pilocar), Diamox (acetazolamide), Mannitol, Isordil (isosorbide
dinitrate), Alphagan (brimonidine). Quiet, dark environment.
3. Retinal detachment: client reports visual gaps may report seeing flashing lights
• Pre op: place an eye patch.
• Post op: lie on operative side
4. Strabismus: both eyes unable to focus in the same direction; patch the good eye
5. Macular degeneration: loss of central vision - due to damage to the retina
6. Eye trauma: cover both eyes; never remove penetrating object
7. Diabetic retinopathy: can lead to blindness – refer to opthamology
8. Care of the prosthetic eye: review steps

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K. Therapeutic regimen
Related pharmacology
Miotics- constrict the pupil; pilocarpine (pilocar), Diamox (acetazolamide)
Mydriatics- dilate the pupil; Isopto Atropine (atropine)
Surgical intervention
L. Care of patient with ear disorders
M. Causes and prevention of hearing loss
N. Diagnostic tests: purpose, description, nursing implication

1. Rhomberg test: test to detect poor balance
2. Weber test: place tuning fork on top of the head. Client should be able to hear the sound
bilaterally.
3. Rinne test: place tuning fork on the mastoid bone and near the ear. Client should report
that the sound is loudest near the ear as air conduction is greater than bone conduction.
O. Nursing management: nursing process
P. Common disorders
1. Hearing impairment
a. Presbycusis: hearing loss associated with aging
Hearing Aid: when not in use store in a clean, dry place, clean with a toothpick or pipe cleaner
2. Ménière’s syndrome: “Ménière’s in the ears”
Signs and Symptoms: • Vertigo

• Tinnitus
• Hearing loss

RX: • Low sodium diet
• Decrease fluid
• Place patient in quiet environment
• Avoid caffeine and nicotine
• Meclizine (antivert)
• Benadryl (diphenhydramine)
• Atropine
• Valium (diazepam)
• Compazine (prochlorperazine)
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VI. Musculoskeletal Function and Disorders

A. Terminology
B. Pathophysiology
C. Causes and prevention of musculoskeletal disorders
D. Diagnostic tests: purpose, description, nursing implications
1. X-ray of bones and joints
2. Bone scan – radioactive material injected to visualize bone
3. MRI – no metals – assess for pregnancy, implantable clips, pacemaker, ability to remain in one
position 45 – 60 minutes. Remove NTG, nicoderm or birth control patches before procedure.

4. Arthroscopy- apply ice, swelling ok; elevate the part post procedure
5. Arthrocentesis - removal of fluid from the joint

E. Nursing management: nursing process including interventions to prevent
disabiity.
1. Positioning: Prevent foot drop - apply footboard
2. Special equipment: Continuous passive range of motion (CPM) device -
Used to help achieve and maintain good joint motion after sugery
- check the alignment and positioning frequently
- inspect the skin for any areas of redness or irritation
- apply padding to protect the skin
- rest the joint by turning off the machine as prescribed
3. Crutch walking/maneuvers – keep elbows extended; limit flexion to 30◦ or less
4. Two, three and four point gait
• Two point gait: move one leg together with one crutch
on & the opposite side.
• Three point gait: one leg is not in use. Move both
crutches together with the affected leg.
Four point gait: move right crutch then left foot, move
•
left crutch then right foot (four separate movements)
When ambulating stairs: Teach - “Up with the good, down with the bad.”

5. Cast care - handle wet cast with the palm of your hand,
support on a pillow, check peripheral circulation, fracture bed
pan, never use a hot dryer, check for hot spots (inflammation)
Teach: do not stick foreign objects into cast
6. Ambulation with walker – Walker with affected leg
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F. Disorders
1. Fractures- ORIF (open reduction internal fixation) - surgery done to stabilize a fracture using nails or
screws.
2. Major complications
• Fat embolism: usually occurs within 48 hours but can take up to 14 days after a break in a flat or
long bone
Signs and Symptoms: petechiae, increased pain, and swelling. Assess the 6p’s.
Arixtra (fondaparinux): anticoagulant given s/p hip fracture, hip or knee replacement
• Compartment syndrome: due to lack of circulation - pressure must be relieved in 4-6 hours or
permanent neurological damage may occur
• The most common fracture in children are greenstick
• A fracture of the femur will result in the leg being shortened, adducted, and externally rotated
3. Carpal tunnel syndrome: compression of the nerve caused by repetitive movement of the hand(s)
Treatment: NSAID’s, splint (remove several times per day to perform daily, gentle range-of-motion
exercises
4. Osteoporosis: deterioration of bone tissue that causes low bone mass, leads to fractures of
vertebrae and femur.
Risk factors: • Heredity 60-80% • Low body weight, less than 127 pound
• Decreased physical activity • Low calcium diet
• Smoking/ alcohol • Prolonged pre-menopausal
amenorrhea
Findings: • Back pain (increases with activity and decreases with rest)
• Pathological fractures
• Decreased bone mass
Diagnosis: • Bone density studies
Interventions: • Estrogen replacement, Fosamax (aldendronate), Actonel (risendronate) or
Boniva (ibandronate), take with a full glass of water, on an empty stomach,
patient must remain upright for 30 minutes after dose
Evista (raloxifene) SE- water and sodium retention; monitor weight & B/P
frequently, monitor LFT’s
• High protein, high calcium + vitamin D diet; limit caffeine and alcohol
• Brace for spine - (Corset, Philadelphia, Taylor) Encourage weight bearing
exercises like dancing, walking, bicycling or swimming
5. Paget’s Disease: excessive breakdown and formation of bone tissue; symptoms include constant
aching deep bone pain, swelling or joint stiffness, enlarged bones may cause nerve compression.
↑Alkaline phosphatase
Rx: NSAID’s, Calcitonin (calcimar), heat or massage
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6. Bone tumors - may replace healthy tissue with abnormal tissue, resulting in fractures. Bone may be
primary site of cancer or as a result of metastasis. TX: Chemotherapy, radiation or surgery
Ollier Disease - benign intraosseous cartilaginous tumors called enchondromas - prone to fractures &
shortened limb on the affected side. Treatment: Surgery to preserve the function of the limb.
7. Amputation
Care of the patient after amputation
• Assess stump, monitor for drainage color and amount
• Position patient with no flexion at hip or knee to avoid contractures
• Elevate stump for the first 24 hours only; place rolled blanket along outer aspect to prevent outward
rotation. Manage pain – Phantom limb pain is real
Stump care
• Inspect for redness, blister, and abrasions
• Wash stump with mild soap, rinse with water, pat dry
• Avoid use of alcohol, oils and creams
• Change bandages two or more times per day, avoid circular turns (acts as a turniquet)
8. Osteomyelitis: bone infection caused by bacteria or fungi – may be spread from infected skin or
infection from another part of the body. S/S – bone pain, fever, swelling, redness & warmth
Rx: IV antibiotics
9. Gout: (gouty arthritis): elevated uric acid

• Low grade fever, swelling of the joints, excruciating pain, renal stones
• Decrease purine in diet: found in shellfish, liver, kidney, sweetbread, sardines and anchovies
• Avoid scallops, haddock, bacon. Client can have chocolate
• Increase fluids to 2-3 Liters per day, alkaline ash diet
Treatment: bedrest, heat or cold therapy; Colchicine, Allopurinol, Probenicid
Alkaline Ash diet: Use with Gout (increased uric acid)

Increases the pH - reduces the acidity of the urine
Foods to include: Milk
Fruit except (cranberries, plums, and prunes)
Rhubarb
Most vegetables
Small amounts of beef, halibut, and salmon included
Acid Ash Diet Use with phosphate stones (increased calcium)

Decreases the pH – increases the acidity in the urine
Foods to include: • Cheese • Whole grains
• Eggs • Pastries
• Meat • Cranberries
• Fish • Prunes
• Poultry • Plums
• Bread • Corn
• Cereal • Legumes
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8. Arthritis
Rheumatoid Arthritis Osteoarthritis
• 20-55 years of age • Over 40 years of age
• Systemic • Degenerative joint disease
• Obesity, genetic predisposition
• Unknown cause with exacerbations and remissions
• Herberden’s Nodes
• Inflammation of small joints of hands wrists & feet (nodes around distal interpharyngeal joints)
• Morning stiffness • Bouchard’s nodes (node of proximal joints)
• Pain decreases with activity • weight bearing joints
• Pain increases with activity
Treatment Treatment
• ASA • NSAID’s
• NSAID’s • muscle relaxants
• Steroids • immobilization
• Humira (adalimumab) • cold packs
• Plaquenil (hydroxychloroquine) • weight loss
• Rheumatex, Trexall (methotrexate)
• Enbrel (etanercept) side effects - injection site pain,
URI, headache
*Humira (adalimumab) & Enbrel (etanercept) can cause new infections or worsening of existing conditions
G. Therapeutic regimen
1. Traction: used to reduce and immobilize fractures, decrease spasms, and correct deformities.
Nursing interventions: • maintain counter traction, the weights must hang free
• 6 P’s, observe for signs of thrombophlebitis
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XVII. Immunology /Dermatology /Integumentary
A. Disorders of the immune system

1. Immune deficiency
2. Hypersensitivity / allergy
B. Skin disorders
1. Infectious and parasitic skin disease:

a. diseases requiring contact isolation
2. Herpes zoster-Shingles: nerve infection caused by the chicken pox Virus- the rash clears in a few
weeks. Rx: Zovirax (acyclovir) and analgesia. Disseminated disease - airborne & contact precautions
until lesions crust over. Localized infection - immunocompromised - airborne & contact, otherwise
standard
3. Acne: Retin A- retinoic acid- avoid the sun, do not use during pregnancy; expect redness and flaking
when this medication is in use; salycillic acid may be prescribed.
4. Psoriasis: due to over production of skin cells characterized by thickening of skin with silvery plaques.
• Exacerbated by stress or change in climate
• Treatment: Treatment: Plaquenil (hydroxychloroquine), Humira (adalimumab), Enbrel
(etanercept), steroid ointments and sunlight
5. Terry’s nails: finger nails or toe nails appear white with a “ground glass” appearance. Occurs with liver
failure, cirrhosis, DM, CHF, hyperthyroidism and or malnutrition.
6. Skin cancer: teach client to avoid the sun and tanning salons
7. Botox – (botulinum toxin A) – blocks the chemical signals that cause the muscles to contract. Results
in skin that appear smoother or less wrinkled SE: pain & bruising at injection site, redness, headache, flu
like symptoms, facial weakness or drooping.
• Teach: stop ASA, Warfarin & Heparin before procedure
Myobloc - (rimabotulinum toxin B) - treats severe cervical muscle dystonia (torticollis)
Side Effects: weakness, difficulty speaking, swallowing or breathing, double vision, blurred vision
8. Steven Johnson Syndrome: severe form of erythema multiforme – an immune complex disorder
characterized initially by conjunctival burning and itching, fever, cough, malaise. (Flu like s/s)
• SJS typically involves the skin and the mucous membranes.
• Minor presentations may occur, significant involvement of oral, nasal, eye, vaginal, urethral, GI, and
lower respiratory tract mucous membranes may develop in the course of the illness.
• GI and respiratory involvement may progress to necrosis.
• Lesions (painful, red, purple rash; blisters) may occur anywhere, the palms, soles, dorsum of hands, and
extensor surfaces are most commonly affected.
• The rash may be confined to any one area of the body, most often the trunk. SJS is a serious systemic
disorder with the potential for severe morbidity and even death.
• Linked to the use of Albuterol syrup in children, NSAID’s, Dilantin (phenytoin), sulfa antibiotics, macrolides
• Treatment is systemic. Treat rash like burns.
9. Sjorgen’s syndrome: autoimmune disorder which results in loss of lubrication.

Signs and symptoms: dry eyes, dry mouth.
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XVIII. Care of the Client with HIV / AIDS
A. Cause: HIV is a retrovirus that integrates itself into the genetic material of the cell and changes the DNA.
Primary host cell is the CD4 - lymphocyte. Incubation period is 2 weeks to 6 months. Decreased immune
system is evidenced by a decrease in CD4 count. Viral load tests and CD4 counts are done every three to
four months.
The viral load test measures the amount of HIV virus in the blood.
Low = 40 – 500 copies/ml High = 5,000 – 10,000 copies/ml
Untreated/uncontrolled = 1 million or more copies
MD begins medications when CD4 is at 350 or less; disease classified as AIDS when CD4 goes below
200 and opportunistic infections occur.
• Elisa test is done first. Western blot confirms Elisa.
• PCR (polymerase chain reaction test) can be done to test viral load. Used on
infants.
• Methods to prevent infection – hand washing, avoid crowds,
neutropenic precautions etc.
• Pancytopenia occurs
B. HIV / AIDS medications: HAART – “Highly active antiretroviral treatment”. Decreases the amount
of active virus in the blood stream
Nonnucleoside reverse transcriptase inhibitors - Stop HIV production and prevents the
conversion of RNA to DNA
Viramune (nevirapine),Sustiva or Stocrin (efavirenz), Rescriptor (delavirdine),
Intelence (etravirene)
monitor CBC & chemistry - renal and hepato-toxic, dizziness – take at night

Nucleoside Reverse Transcriptase Inhibitors (NRTI’s) – inhibits DNA synthesis
AZT, Retrovir – (zidovudine) – anemia, monitor CBC,
Epivir – (lamivudine, 3TC) - avoid fatty foods
DDC– (zalcitabine) –causes hepatotoxicity
d4T- (stavudine) Zerit –peripheral neuropathy
Ziagen (abacavir) - fever, rash, N/V, malaise
Videx- (didanosine) - may cause pancreatitis, hepatotoxic, give on an empty stomach; liver
damage
Protease inhibitors- prevents infection of new cd4 cells

Invirase 500 (saquinavir)– elevated liver enzymes, hyperglycemia - give with food
Crixivan (indinavir) –take on an empty stomach; causes nephrolithiasis and
hyperbilirubinemia - avoid with grapefruit juice
Viracept (nelfinavir) - causes diarrhea, increased bleeding with hemophilia
Norvir – (ritonavir) – liver dysfunction, pancreatitis, arrthymias; refrigerate liquid
Kaletra (lopinavir/ ritonavir) – nausea, vomiting, diarrhea, monitor LFTs
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• Antivirals: Foscavir- (foscarnet) Treatment of CMV retinitis in HIV patients resistant to Acyclovir
SE: seizures, renal impairment, hypocalcemia, hypo/hyperphosphatemia, hypomagnemesia,
hypokalemia - (monitor creatinine and electrolytes)
• Multi-Class Combination Drugs
Atripla – (efavirenz (sustiva 600mg) + tenofovir (viread 300mg) + emtricitabine (Emtriva 200mg)
contains one non-nucleoside reverse transcriptase inhibitor (NNRTI) and two nucleoside reverse
transcriptase inhibitors (NRTIs) – Take once daily on an empty stomach
Side Effects: freckles, liver dysfunction
*Standard precautions when hospitalized
Diet for HIV & AIDS patient: high protein, high calorie; liquids before meals, decrease residue
Interdisciplinary approach needed; support groups
C. Opportunistic infections
1. Bacterial: Mycobacterium complex
2. Fungal infection: candida albicans; yeast overgrowth – oral thrush, yeast vaginitis
Rx: Diflucan (fluconazole)
3. Protozoal Infections: pnuemocystis carinii (PCP) -Rx: Bactrim (trimethoprim)

toxoplasmosis – transmitted through infected cat feces, eating raw or under cooked meats
Rx: Pyrimethamine & Sulfadiazine
cryptosporidiosis – oral fecal spread through contaminated water. Incubation 2 days – 2 weeks.
Rx: supportive, may be prescribed Mepron (atovaquone)
4. Malignancies: kaposi sarcoma, Non-Hodgkin’s lymphoma, cervical cancer, testicular cancer
5. Management Guidelines for Occupational Exposure & Post Exposure Prophylaxis:

• Two or more PEP drug regimen for 4 weeks based on the level of risk of HIV transmission
• Follow-up HIV testing at 6 months
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XX. Care of the elderly a systemic approach

• Reproductive:
Females: ovulation and menstruation cease
Vaginal walls become thin and dry due to ilubrication & iestrogen levels; may lead
to atrophic vaginitis (inflammation)
Males: Prostate may enlarge (PSA test, digital rectal exam)
• Endocrine:
Decrease in levels of estrogen
Weight gain, hot flashes, diabetes mellitus likely to develop
Lower medication dosages may be required due to slower metabolism
• Cardiovascular:
Decreased cardiac output and circulation secondary to narrow blood vessels
• Digestive:
Sense of taste may be decreased
Increased constipation
Digestive system slows down
• Urinary:
Urine production is less efficient; May develop stress incontinence
• Respiratory:
Decreased breathing capacity, decreased PaO2 to 75mm
• Musculoskeletal:
Increased osteoporosis and arthritis common
Kyphosis – R/T loss of bone mass
Slower movements
Decreased muscle strength
• Sensory:
Difficulty seeing objects close - presbyopia
Cataracts common
Hearing may be diminished - presbycusis
Foods have less taste
• Nervous:
Pain sensation decreases
Intelligence remains intact
Alteration in balance (priority is safety)
• Integumentary:
Increased sensitivity to cold; Skin discolorations are common
Hair looses color and thins. Skin dries and is less elastic
• Teach denture care: Brush and rinse dentures daily. Clean dentures over a
folded towel or a full sink of water. Use a denture cleanser (hand soap or mild dish
washing liquid can be used). When not in use, dentures should be placed in a
denture cleanser soaking solution or in water.
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XIX. Emergency Nursing
A. Review principles of first aid

B. Prevention of accidents
C. Checklist for evaluating accident and emergency patients - OLDCART
Onset of symptoms, Location of problem, Duration of symptoms, Characteristics client used to describe
symptoms, Aggravating factors, Relieving factors, Treatment received before arrival
D. Review CPR: Chest compressions 30:2 one rescuer for all patients
The newest guidelines dictate that a bystander should compress the victim’s chest 100 times a minute
to a depth of about 2 inches. Rescue breathing is still recommended for children and anyone whose
cardiac arrest is likely due to oxygen deprivation. Sequence CAB (circulation, airway, breathing)
• External defibrillation – the use of an unsynchronized, countershock to the heart. Used for
ventricular defibrillation or pulseless ventricular tacyhcardia
E. Control bleeding: apply tourniquet above injury
F. Shock:
• Electric: injury from electricty
• Hypovolemic: caused by inadequate blood volume
• Cardiogenic: associated with decreased cardiac output which results in decreased tissue perfusion
• Distributive: caused by insufficient intravascular volume causing hypotension
• Neurogenic: occurs after injury to the spinal cord. Major clinical signs hypotension and bradycardia
Treatment:
• Intropin (dopamine) - treats heart conditions, provides additional pumping strength to stimulate
the heart muscle. May also improve kidney blood supply. SE: N/V, headache, report dizziness
• IV Fluids
• Supplemental oxygen, protect airway
• Neurogenic shock may need Atropine
G. Poisoning: Teach to contact poison control
Activated charcoal blocks the absorption of poisons in the stomach
H. Anaphylaxis: Benadryl/ Epi-pen ; airway management is the priority
I. Animal bites: snakes- keep area dependent, no tourniquets, avoid caffeine, or stimulants
Tetanus vaccination may be prescribed
J. Post-mortem care:
• Formal pronouncement of death may vary slightly by state.
• The nurses’ role is to remove all tubes, intravenous lines, and monitors unless an autopsy is
required or due to religious observance.
• Make the client appear clean and remove visible medical equipment from sight.
• Place a clean sheet over the body and do not cover the face.
• Allow family members to visit, assist in calling clergy and or funeral directors, as desired.
• Some family members may not want heath care providers to touch the deceased body immediately
after death.
• The next of kin will be responsible to make decisions regarding autopsy, organ and tissue donation,
and funeral preparations.
• Rigor mortis- stiffness - 3-4 hours after death; Livor mortis - bluish discoloration 1-2 hours after death
Algor mortis (algor—coldness; mortis—of death) is the change in body temperature following death.
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OVERVIEW OF PHARMACOLOGY
1. Chemical name: description of drug using chemistry composition
2. Generic name (non proprietary)

A. name assigned by government to drug; universal drug name
B. generic drug may have many trade names
3. Trade name (proprietary)

A. created by drug companies to sell a product
4. Rights of medication administration and safety

• Right assessment, right drug, right dose, right time, right route, right patient, right education, right
documentation, right evaluation, the patient also has the right to refuse.
• .Typically the generic name is listed on the exam. The trade name may be present, but less likely.

Pharmacology Essential Concepts:
• Medications have several actions. When answering these questions always consider what the
desired effect is for that particular situation. Example: Clonidine is a hypertensive drug that is
effective in the treatment of ADHD or Depakote (valproic acid) is used as a mood stabilizer or to
control seizures.
• All medications can potentially alter more than one body function.
• For each medication prescribed there is:

• Desired effect – predictable outcome
• Side effects – undesirable response but usually predictable
• Allergic reaction – may occur following the first dose, but can occur with
subsequent dosing (hives, rash, wheezing, SOB, anaphylaxis)
• Dosing may need to be adjusted based on the patient’s age, disease process, kidney or liver
function or route of administration.
• Effects of medication used in combination:

• Additive effect – twice the effect
• Synergistic effect – more than twice the effect
• Antagonistic effect – decreased effect of one or both drugs
• Idiosyncratic effect – immune mediated toxic response to the drug

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Nursing responsibilities in medication administration
• Never administer medication without a provider’s prescription

• Check for accuracy of the prescription – do not administer medications that are not correctly
prescribed
• Check results of therapeutic drug levels and report results as necessary
• The nurse must be aware of the purpose, dosage range, common side effects and specific
precautions or assessment needed before giving the medication i.e. Vasotec (enalapril)-check
B/P
• Confirm patient identity using two identifiers (name & ID number is acceptable. An alert patient
could also state their name and date of birth)
• Assess patient’s condition before administration for signs to hold the dose and after dosing to
evaluate their response to therapy
• Determine compatibility of prescribed medications; monitor for use of home or herbal remedies
• In case of a medication error, report to MD, assess the patient for the effects of the medication
error; document in an incident report and on the chart
• Time release drugs must not be crushed or chewed (swallow whole)
Abbreviations: EC, SR, Dur, CR, LA, XL, XR, Contin
• Three medication checks should be performed prior to administration
• Promptly document medication administration and reactions if any
• Teaching: instruct the patient and or family regarding safe use of medications, dietary
restrictions and assessments (i.e. b/p, pulse) for each medication prior to discharge so that they
will be prepared for self administration. Also teach regarding safe disposal of medications.
5. Commonly used Medications
* The following is a small representation of various types and classifications of medications.
Focus on classifications and common side effects.
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Antihypertensives – lower B/P and increase blood flow to the heart
Angiotensin Converting Enzyme Inhibitors

Treat hypertension & heart failure & protect kidney function in patients with diabetes mellitus
Drug Name Generic Drug Names Common Side Effects
Cough
Vasotec • Enalapril
Anaphylaxis
Zestril Palpitations
• Lisinopril Taste changes
Prinivil
Orthostatic Hypotension
Altace • Ramipril
Potassium increase
Capoten • Captopril Renal impairment
Impotence
Monopril • Fosinopril
Leukocytosis
Accupril • Quinapril Nausea, vomiting, dry mouth
Headache, Dizziness
Lotensin • Benazepril
Angioedema, Steven Johnson’s Syndrome
Monitor blood pressure, BUN & creatinine, electrolytes and WBC
Nursing Implications:
Contraindicated in pregnancy, avoid NSAID’s
REMEMBER: ACE Inhibitor side effects = CAPTOPRIL
Diuretics
Excrete Sodium & Fluid
Loop Diuretics: Potassium Depleting
Bumex • Bumetanide
Hypotension Hyponatremia
Edecrin • Ethacrynic acid Hypokalemia Constipation
Lasix • Furosemide Tinnitus Increased BUN
Photosensitivity Hyperglycemia
Demadex • Torsemide
Thiazide Diuretics: Potassium Depleting
Hydrodiuril • Hydrochlorothiazide Hypotension Hyponatremia
Zaroxolyn • Metolazone Hypokalemia Headache
Diuril • Chlorothiazide Photosensitivity Hyperglycemia
Nursing Implications: Monitor BUN, K+ & glucose levels. Monitor intake and output
Teach: increase potassium in diet
Potassium Sparing Diuretics
Aldactone • Spironolactone Hyperkalemia Headache
Constipation Dizziness
Dyrenium • Triamterene Menstrual irregularities Muscle cramps
Nursing Implications: Monitor electrolytes; Decrease potassium in the diet
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Calcium Channel Blockers

Treatment of Angina & Hypertension
Calan, Isoptin • Verapamil • Hypotension
Procardia • Nifedipine • Headache
• Peripheral edema
Cardizem • Diltiazem
• GI upset
Plendil • Felodipine • Flushing
Norvasc • Amlodipine • Syncope
Teach –report ankle edema, avoid operating machinery, avoid
grapefruit juice
Beta Adrenergic Blockers- OLOL Drugs

Management of hypertension, angina pectoris, congestive heart failure & MI prevention
Tenormin • Atenolol Hypotension
Inderal • Propranolol Bradycardia
Dizziness
Cogard • Nadolol
Impotence, diarrhea, nausea
Lopressor, Toprol • Metoprolol Hyperglycemia hCHF hPVD
Coreg • Carvedilol Bronchospasm
Check pulse before administration

Monitor blood glucose in diabetics
Administer with food
Taper dose to discontinue
Contraindications ABCDE- asthma, heart block, cardiac failure, DM
(hypoglycemic shock), extremities (occlusive arteries)
Vasodilators
Relax the smooth muscles in the blood vessel
Apresoline • Hydralazine Palpitations Headache

Nipride Tachycardia Diaphoresis
• Nitroprusside
Tx for hypertensive crisis
Nitrostat • Nitroglycerin Hypotension Syncope
Imdur • Isosorbide mononitrate Dizziness Pallor Weakness
Isordil • Isosorbide dinitrate
Apresoline (hydralazine): take with food;
Nipride (nitroprusside): protect from light, continuous EKG & B/P monitoring
Nitrostat: (nitroglycerin) for sublingual use, do not swallow whole; tablets
good for 3-6 months
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Alpha Agonists
Decreases the effect of Dopamine on blood pressure
Catapres • Clonidine Postural hypotension Drowsiness
Aldomet • Methyldopa Impotence Dry mouth
Angiotensin II Receptor Blockers

Treat hypertension & heart failure & protect kidney function in patients with diabetes mellitus
Diovan • Valsartan
Hypotension Cough
Cozaar • Losartan Hyperkalemia Renal Dysfunction
Angioedema
Atacand • Candesartan
Nursing Implications: Monitor BUN/ Creatinine and electrolytes. Cozaar prescribed P.O.
Alpha 1 Receptor Blockers

Used in the treatment of BPH and HTN
Cardura (BPH & HTN) • Doxazosin Hypotension

Palpitations
Blurred vision
Minipres (HTN) • Prazosin
Nausea
Diarrhea
Hytrin (BPH & HTN) • Terazosin Dizziness
Light headedness
Flomax (BPH) • Tamulosin Edema
Dry mouth
Administer dose at bedtime, monitor B/P, assess for edema
Teach avoid operating machinery
Cardiac Glycosides
Treat atrial fibrillation, atrial flutter and CHF
Fatigue Bradycardia
• Digoxin Anorexia Nausea & vomiting
Lanoxin
• Digitoxin Headache Diarrhea
Visual changes
Monitor apical pulse for 1 full minute
Do not give if pulse is: less than 60 in an adult
less than 90 in a child
less than 70 in an older child
Monitor electrolytes – hypokalemia, hypomagnesemia & hypercalcemia
increase risk of toxicity
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Anticoagulants
Prevent blood clotting
Heparin (injectable only) prevents the conversion of prothrombin to thrombin
Heparin Bleeding (remember other words & signs that indicate
bleeding)
Lovenox • Enoxaparin
Thrombocytopenia Increased LFT’s
Fragmin • Dalteparin Nausea Diarrhea
Coumadin • Warfarin PO/IV Hemorrhage

Routine monitoring of PT/INR; Avoid OTC meds & herbal products
Heparin – Monitor PTT/INR
Coumadin (warfarin) – Monitor PT/INR
Nursing Implications: Fragmin (dalteparin)/ Lovenox (enoxaparin) – Monitor CBC - pt at risk for
H.I.T. (heparin induced thrombocytopenia)
Teach patient to monitor for signs of bleeding
Coumadin - limit cabbage & green leafy vegetables, avoid caffeine & ETOH
Antiplatelets
Prevent clot formation by blocking platelet aggregation
Plavix • Clopidogrel Bleeding
Ticlid • Ticlopidine (remember other words & signs that indicate bleeding)
Nausea Upset stomach
Aggrastat • Tirofiban
Stomach pain Diarrhea
Persantine • Dipyridamole Rash and itching Headache
Aggrenox • Dipyridamole + ASA Drowsiness

Avoid if allergic to aspirin, ibuprofen or naproxen
Hold 7-10 days before surgery
Use caution during activities requiring alertness (such as driving a car)
Nursing Implications: Teach: Monitor for signs of bleeding
Do not use any other over-the-counter medication
Avoid use of aspirin, salicylates, and NSAID’s while taking these medications
Avoid in pregnancy
Hemostatics
Used to control bleeding when blood clots are broken down too quickly
Prescribed for acute life threatening hemorrhage due to hyperfibrinolysis
Amicar • Aminocaporic Acid Nausea, vomiting, diarrhea, cardiomyopathy
Nursing Implications: Taken once an hour for about 8 hours or until the bleeding is controlled
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Antibiotics
Used to treat infection
Category Drug Name Common Side Effects
Penicillin Nausea, vomiting, diarrhea,
Penicillin’s Amoxil (Amoxicillin)
Omnipen (Ampicillin) super infection (candidiasis)
Keflex (Cephalexin)
Rocephin (Ceftriaxone)
Cephalosporins Zinacef/Ceftin (Cefuroxime) Diarrhea, furry tongue, anemia, ↑ LFT’s
Vantin (Cefadoxime)
Fortaz (Ceftazidine)
Tobramycin
Amikacin
Aminoglycosides
Neomycin Oto, neuro & nephro toxicity
(Mycin’s) Gentamicin
Streptomycin
Tetracycline
Tetracyclines Photosensitivity, tinnitus
Vibramycin (Doxycycline)
INH (Isoniazid) Peripheral neuropathy, hepatotoxicity,
Anti-tubercular
Rifadin (Rifampin) discolors the urine & contact lenses, visual
Agents Ethambutol disturbances, precipitation of gout
Tendonitis & tendon rupture, nausea, vomiting,
Cipro (Ciprofloxacin) diarrhea, rash, ↑ LFT’s, headache, photosensitivity
Avelox (Moxifloxacin) Increase effect: avoid with theophylline,
Fluoroquinolones Coumadin, glyburide, dilantin, caffeine, steroids,
Levaquin (Levofloxacin) diuretics, cardiac meds (quinidine, amiodarone,
Floxin (Ofloxacin) betapace, bretylluim)
Decrease effect: antacids, multivitamins, iron
Dark, red-brown urine, metallic taste,
Flagyl (Metronidazole) candidiasis, peripheral neuropathy, ↑ effect of
coumadin
Macrobid (nitrofurantoin)
Macrodantin, Furadantin
CHRONIC PULMONARY REACTIONS,
Tx for: UTI
GI upset, c-difficile, dizziness, pruritis, fever,
Gantrisin
Antibacterial jaundice, angioedema, Steven Johnson’s
(acetyl sulfisoxazole)
syndrome
(pediatric suspension) Tx for:
acute, recurrent or chronic UTI
Zyvox (linezolid)
Tx for: VRE, PNA or complicated Pancytopenia, N/V/D, fever, URI,headache
skin infections
Zithromax (Azithromycin)
Nausea, vomiting, diarrhea, thrombocytopenia,
Biaxin (Clarithromycin)
Macrolides abdominal pain, taste changes, super infection,
E’mycin (Erythromycin)
Steven Johnson’s syndrome
Cleocin (Clindamycin)
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Nursing Implications for Antibiotics:

• Patients should be instructed to complete the full course of therapy
• Avoid Cephalosporins in clients allergic to penicillin- give mycin, tetracycline or macrolide drugs
• Cephalosporins increase risk for C-Diff. Give 1-2 hours before meals
• Mycin drugs –monitor BUN/Creatinine; Monitor peak and trough levels at the third or fourth dose
• Do not give Tetracycline to pregnant women and children under the age of 8 – stains the teeth.
Take on an empty stomach (2-3 hours after meals). Do not take with antacids, milk or yogurt
• Take Doxycycline with a full glass of water – remain upright for 30 minutes
• Take PO CIPRO (ciprofloxacin) either 2 hours before or 6 hours after taking antacids, multivitamins, or
iron. Do not take with milk or yogurt, take on an empty stomach with a full glass of water
• Take Macrobid (macrodantin) with food to improve absorption and prevent GI side effects
• Give INH (Isoniazid) with vitamin B6 to prevent peripheral neuropathy
• Zyvox (linezolid) – monitor CBC Q week; avoid foods containing tyramine
• TB medications may be given in combination to prevent resistance
• Avoid ETOH with Flagyl (metronidazole)
Iron preparations
Treats anemias
PO - use a straw to prevent staining the teeth. Common Side Effects
Increase vitamin C- helps with absorption.
IM injections should be given using the Z- track GI distress, headache, N/V, constipation, peptic ulcers
method.
Avoid use with antacids, coffee, tea, dairy products,
eggs or whole grain bread within one hour after iron
Laxatives
Induces bowel evacuation; treatment of constipation
Type Drug Names Common Side Effects
Bulk Forming Metamucil (psyllium)
Abdominal fullness; minor bloating
Agents Citrucel
Stool softeners A bitter taste or throat irritation,
Colace (docusate)
Surfactants skin rash, diarrhea or mild nausea
Lubricants Stomach pain, nausea & vomiting,
Mineral oil
Emollients abdominal pain
Citroma (magnesium citrate)
Hydrating Stomach pain Nausea
Milk of Magnesia (magnesium hydroxide)
Agents Gas Diarrhea
Epsom salt (magnesium sulfate)
Hyperosmotic Lactulose, Sorbitol
Hyperglycemia, diarrhea
Agents Glycerin Suppositories
Stimulants Dulcolax (bisacodyl) Dehydration, dizziness, severe
Irritants Ex-Lax (senna) diarrhea, abdominal cramps
Monitor for electrolyte imbalance
Metamucil (psyllium): take with 8 ounces of water
Nursing Implications: Lactulose may be used to decrease ammonia levels in clients
with hepatic encephalopathy
Teach: report rectal bleeding
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Steroids
Used to suppress inflammation – PO, IV, Inhaled, Topical
Drug Name Common Side Effects
Prednisone Hyperglycemia Growth retardation Hypokalemia
Solumedrol (methylprednisolone) Mood changes Hirsuitism Hypertension
Beclovent (beclamethasone) Increased IOP Cushing’s Disease Skin thinning
Pulmicort (budesonide)
Immune suppression Menstrual irregularities Acne
Azamacort (triamcinolone inhaled)
Kenalog (triamcinolone topical) Delayed wound healing
Administer with or after meals
Client teaching: taper dose, wear medic alert, avoid stress, report fever &
Nursing Implications: weight gain, monitor frequent weights, increase potassium & protein in diet,
monitor glucose, rinse mouth after use of inhaled steroid to avoid oral thrush
Topical agents - contact dermatitis, hypopigmentation & maceration

Antiparkinson Agents
Increase dopamine in central nervous system
Dopaminergic agent –stimulates dopamine
Nausea, vomiting, anorexia, dry mouth,
• Levodopa
Sinemet headache, urinary retention, anxiety, blurred
• Carbidopa-Levodopa
vision, dyskinesias
Use with caution in clients with glaucoma, monitor liver function
Nursing Implications: Teach: Use caution when operating machinery
May discolor saliva, urine or sweat red, brown or black
Chemotherapeutic Agents
Used to destroy tumor cells
Category Drug Names Common Side Effects
Carboplatin
Akylating agents Bone marrow suppression
Cisplastin
Bone marrow suppression
Antimetabolites 5 FU- fluorouracil
CNS damage
Antitumor antibiotics Bleomycin Chills, confusion
Pancytopenia, immunosuppression, bone marrow
Vinblastine
Plant alkaloids suppression, N/V/D,
Vincristine
alopecia, hepatotoxicity, neuropathy
Selective estrogen Increased risk of uterine CA, blood clots
Tamoxifen
receptor blockers or stroke
Cytoxan Development of secondary Cancer
Monitor patients for potential toxic side effects during the nadir period
(Nadir – 8-14 days after chemo)
Contraindicated in pregnancy – teach to use birth control
Handle with gloves
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Gastro-Intestinal Meds
Category Drug Name Common side effects

Prevacid (lansoprazole)
Nausea Vomiting
Protonix (pantoprazole) Anorexia Dry mouth
Proton Pump Inhibitors
Prilosec (omperazole) Headache Dyskinesias
Reduce gastric acid production
Nexium (esomeprazole) Urinary retention Anxiety
Blurred vision Constipation
Aciphex (rabeprazole)
Tagamet (cimetidine)
Zantac (ranitidine) Malaise Dizziness
H2 Receptor Blockers
Pancytopenia Diarrhea
Inhibits gastric acid production Pepcid (famotidine) Headache
Axid (nizatidine)
Amphogel (aluminum based)

Antacids Aluminum Hydroxide Constipation, Bloody stools,
Neutralize the acid in the stomach Mylanta, Maalox Diarrhea
(aluminum-magnesium based)
Zofran (ondansetron)
Headache Weakness
Kytril (granisetron)
Heartburn Constipation
used to treat N/V associated with
Diarrhea Dizziness
Antiemetics chemo or radiation therapy
Prevention and treatment of
Drowsiness Dry mouth
nausea and vomiting
Reglan (metoclopramide) Extrapyramidal reactions
Neuroleptic Malignant Sydrome
Phenergan (promethazine) Dizziness Blurred vision
Constipation
Antacids, PPI’s, H2 receptor blocker may decrease effects of

antibiotics – separate dose by 6 hours after or 2 hours before
antibiotic administration (especially CIPRO).
Teach: avoid high protein, & caffeine in the diet while taking H2
blockers (increases acid), avoid smoking
Teach: PPI’s do not crush or chew
Teach to use caution with the following drugs while taking H2
blockers or proton pump inhibitors: Theophylline, Coumadin
(warfarin),Dilantin (phenytoin), prescription medication for fungal
or yeast problems, Valium (diazepam), digoxin, propanolol, and
Calcium Channel Blocker’s
Monitor for extrapyramdial reactions with antiemetics & PPI’s
* Magic mouthwash (Benadryl & Maalox, Lidocaine may be added) - used for sore throat and mouthsores
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Cholesterol Lowering Agents

Treatment of atherosclerosis
Type Drug Names Common Side Effects
• Zocor (simvastatin)
• Lipitor (atorvastatin) Headache Dizziness
Statins • Pravachol (pravastatin) Nausea Diarrhea
• Mevacor (lovastatin)
HMG- COA reductase Muscle pain Fever
• Crestor (rosuvastatin)
inhibitors • Caduet (amlodipine/atrovastatin) Liver damage (jaundice, RUQ
• Vytorin (simvastatin/ezetimibe) Pain, dark urine, elevated LFT’s)
• Adicor (lovastatin/niacin)
constipation, diarrhea and flatu-
• Questran (cholestyramine)
lence bad taste in the mouth
abdominal pain, back pain, diar-
• Zetia (ezetimibe) rhea, joint pain, sinusitis, liver
disease
headache, constipation, vertigo,
Bile Acid
rash, eczema, nausea and/or
Sequestrants • Lopid (gemfibrozil)
vomiting, fatigue and diarrhea,
dyspepsia
flushing & hot flashes, nausea, in-
• B3 (niacin)
digestion, gas, vomiting & diarrhea
• Welchol (colesevelam)
dyspepsia
decreases LDL and HgbA1c
Statins contraindicated in pregnancy, give at night, avoid grapefruit juice,
Nursing Implications: monitor LFT’s. Questran (cholestyramine): mix with water or juice
Lopid (gemfibrozil): Give 30 minutes before meals BID
Antipyretics
Reduce fever
Drug Name Common Side Effects
Tylenol (acetaminophen) Liver damage; nausea, urticaria, rash, jaundice
GI upset, nausea
Severe allergic reactions (rash; hives; itching; difficulty breathing; tight-
ness in the chest; swelling of the mouth, face, lips, or tongue); black or
Aspirin
bloody stools; confusion; diarrhea; dizziness; drowsiness; hearing loss;
ringing in the ears; severe or persistent stomach pain; unusual bruising;
vomiting. Reyes syndrome in children; respiratory alkalosis with toxicity.
Monitor LFT’s
Avoid with alcohol
Nursing Implications: Antidote for acetaminophen toxicity - Mucomyst (acetylcysteine)
3 GM/ day maximum dose
Teach: take ASA with meals; report signs of bleeding
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Antihistamines
Used to block the release of histamine in allergic reactions
Benadryl • Dipenhydramine Dry mouth, nose, and throat
Drowsiness
Claritin • Loratidine
Fatigue
Zyrtec • Cetirizine Headache
Sleepiness
Dizziness
Atarax • Hydroxyzine Nausea and vomiting
Constipation
Teach: Avoid activities requiring mental alertness.

Notify MD for vision problems, difficulty urinating or painful urination

Anticholinergics
Inhibit parasympathetic nerve impulses by blocking the action of acetylcholine
Worsening of narrow-angle glaucoma
Mydriasis
Acute eye pain
Hypotension
Palpitations
Atrovent • Ipratropium bromide
Urinary retention
Tachycardia
Constipation
Bronchospasm
Paradoxical bronchospasm
Dry mouth
Blurred vision
Atropine
Photophobia
Tachycardia
Blurred vision
Enablex • Darifenacin
Decreased sweating leads to over
used to treat overactive bladder used in overactive bladder
heating
Teach: medications cause the mucous membranes to become dry,
take with a full glass of water
Atropine- avoid with hepatitis, glaucoma, gastrointestinal obstruction,
Nursing Implications: decreased liver or kidney function
Use caution when driving, operating machinery, or performing other
hazardous activities
Avoid use of ETOH
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Anticonvulsants/Benzodiazepines
Used to manage seizure disorders/anxiety disorders
Drug Name Generic Name Common Side Effects
Klonopin • Clonazepam
Drowsiness
Valium • Diazepam
Lethargy
Librium • Chlordiazepoxide Slurred speech
Ativan • Lorazepam Hypotension
CNS depression
Dalmane • Flurazepam
Gingival hyperplasia Hypoglycemia (in DM)
Mild skin rash or itching Dizziness, nervousness
Discolored urine
Over dose symptoms may include:
Twitching eye movements Slurred speech
Dilantin • Phenytoin
Loss of balance Tremors
Fainting Nausea & vomiting
Feeling light-headed
Slow or shallow breathing
Muscle stiffness or weakness
Dizziness
Drowsiness
Tegretol • Carbamazepine Dry mouth
Nausea
Aplastic anemia
Sleepiness
Weakness
Keppra • Levetiracetam
Dizziness
Infection
Rash
Lamictal • Lamotrigene Dizziness
Headache
Avoid with liver disease and DM. Avoid alcohol

Do not chew or crush tablets.
Avoid taking antacids at the same time with Dilantin (phenytoin) - inhibits
absorption
Nursing Implications: Tegretol (carbamazepine) - take with meals, avoid grapefruit juice
Monitor LFT’s, monitor CBC
Teach: Anticonvulsant drugs should not be stopped abruptly; wear a med
alert bracelet; report easy bruising, fever or blood in the stool
Romazicon (Flumazenil) - antidote to benzodiazipines
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Narcotics/analgesics
Used to relieve moderate to severe pain
Drug Name Generic Name Common Side Effects
NARCOTICS
Morphine *Risk of dependency CNS depression
Duragesic • Fentanyl Nausea and vomiting Dry mouth

Pinpoint pupils Itching
Demerol • Meperidine Hives Rash
Dilaudid • Hydromorphone Diaphoresis
NSAID’s
Motrin • Ibuprofen
Nausea Epigastric pain
Indocin • Indomethacin Heartburn Diarrhea
Headche Dizziness
Naprosyn • Naproxen sodium
Vertigo Hypertension
Celebrex • Celecoxib Oliguria Rash
Gastric or duodenal ulcer with bleeding
Feldene • Piroxicam
OPIODS
Respiratory depression Nausea
Ultram • Tramadol
Dizziness Constipation
TRIPTANS
Prescribed for migraine headaches
Imitrex • Sumatriptan Hypotension Syncope
Tinnitus Dry mouth
Zomig • Zolmitriptan Photophobia
SKELETAL MUSCLE RELAXANTS
Soma • Carisoprodol Drowsiness
Asthma attacks
Robaxin • Methocarbamol
Psychological dependence
Flexeril • Cyclobenzaprine Nausea
Narcotics: Report problems urinating, such as pain, difficulty urinating, frequent
urge to urinate, or decreased urine output, constipation, headache, diplopia,
nightmares may be sign of overdose - Antidote: Naloxone
Avoid with other meds causing CNS depression (MAOI’s, antihistamines,
muscle relaxants); Fentanyl - discard patch by folding edges & flushing
Nursing Implications: NSAID’s – Take with food, Mointor for signs of bleeding, avoid use of ASA and
anticoagulants; avoid operating machinery. Contraindicated S/P CABG
Opiods – taper dose to discontinue
Triptans: avoid with ischemic heart disease, uncontrolled HTN, stroke, TIA or
PVD
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Osteoporosis Medications
Used in the prevention & management of osteoporosis
Drug Name Generic Name Common side effects
Bisphosphonates
Slows the rate of bone thinning and increase bone density
Fosamax * irritation and ulcers of the esophagus

• Alendronate
Daily or weekly - PO abdominal pain, constipation, gas, or nausea
Boniva Back pain, indigestion, bronchitis, bone, joint

• Ibandronate
Monthly – PO Q 3months - IV or muscle pain
Actonel
Bladder infection
Daily- PO for 2 days in a row • Risedronate
BPH in men
q month or q week as prescribed
Reclast
• Zoledronic acid Joint pain, fever, hypertension, headache
Yearly IV
Selective estrogen receptor modulator (SERM)

Slows bone thinning & causes some increase in bone thickness
Evista Hot flashes, joint pain, flu-like symptoms,

• Raloxifene
Used in women only Daily- PO edema, muscle pain
Hormone Therapy
Calcimar
Runny or stuffy nose, back pain, nausea,
Miacalcin • Calcitonin
vomiting
Given via nasal spray, IM, or SC
Stroke, blood clots, increased breast cancer

Estrogen
risk, gallstones, headaches, nausea, vaginal
Used only in women who are post hysterectomy
discharge, fluid retention, weight gain,
Given-PO, estrogen patch, vaginal ring, skin cream, gel
breast tenderness
Testosterone
Edema of the hands and feet, prostate
Given- injections, gel, or patches
hyperplasia, gynecomastia, painful erections
*men only
(rare), liver dysfunction
Q 2 to 3 weeks- IM, Q night- patch, daily- gel
Fosamax (alendronate), Actonel (risedronate) - sit up after
medication for 30 minutes, Boniva (ibandronate) - 60 minutes; take
on an empty stomach, with a full glass of water, early in the morn-
Nursing Implications: ing; Avoid taking with antacids, caffine, orange juice or calcium
supplements. Avoid in kidney disease
Calcitonin- store nasal spray in an upright position; refrigerate 136
Increase calcium and vitamin D in diet or by supplementation
READY TO PASS INC.
During the exam, you may encounter medications that you do not recognize. Many prescribed medications
have commonalities. Knowledge of the common drug suffixes may be helpful in assisting you to choose
an answer.
Review the list below:

SUFFIX DRUG CLASS DRUG NAME
VIR antivirals Combivir
OLOL beta blockers Metoprolol
PRIL ace inhibitors Accupril
COR statins (decreases cholesterol) Zocor
CORT steroids Pulmicort
SONE steroids Hydrocortisone
AFIL erectile dysfunction Sildenafil
AZOLE proton pump inhibitors Omperazole
TIDINE H2 receptor blockers Cimetidine
CAINE local anesthetics Lidocaine
CILLIN antibiotics Penicillin
CEPH or CEF Cephalosporins Cephalexin/cefazolin
CYCLINE Antibiotics Doxycycline
DONE opoids Oxycodone
IDE oral hypoglycemics Glyburide
PAM, LAM antianxiety Diazepam, alprazolam
MIDE diuretics Furosemide
IPINE Calcium channel blockers Amlodipine
ZINE Antipsychotics Thorazine
SARTAN Alpha 2 receptor blockers Valsartan
ZOSIN Alpha 1 receptor blockers Doxazosin
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Medication Worksheet:
List the classification of drug based on common (suffix, root, or prefix), give an example for use
i.e. prazole - proton pump inhibitor- lansoprazole, reduce gastric acid production
1. Osin ______________________________________________________
2. Sartan_____________________________________________________
3. Prazole____________________________________________________
4. GL________________________________________________________
5. Setron_____________________________________________________
6. One_______________________________________________________
7. Statin______________________________________________________
8. Zepam_____________________________________________________
9. Dronate____________________________________________________
10. Done_____________________________________________________
11. Dipine_____________________________________________________
12. Olol_______________________________________________________
13. Ni_________________________________________________________
14. Pril________________________________________________________
15. Mide______________________________________________________
16. Ceph/Cef__________________________________________________
17. Floxacin___________________________________________________
18. Mycin ( TANGS)_____________________________________________
19. Tidine_____________________________________________________
20. Afil_______________________________________________________
Worksheet Answer Key

Osin - alpha 1 receptor blocker - doxazosin, BPH HTN P125
Sartan - alpha 2 receptor blocker- valsartan, decrease dopamine/ BP P125
Prazole - proton pump inhibitor - lansoprazole, reduce gastric acid P130
GL - oral hypoglycemic - glipizide, rosiglitazone, Type II DM P44
Setron - antiemetic - granisetron, nausea/vomiting P130
One - steroid - beclamethasone, suppresses inflammation P129
Statin - statin/ HMG-COA reductase inhibitor- lovastatin, atherosclerosis P131
Zepam - benzodiazepine - clonazepam, seizures/ anxiety P133
Dronate - bisphosphonates - alendronate, osteoporosis P135
Done - opiods - oxycodone, pain management P136
Dipine - calcium channel blocker - felodipine, angina/ HTN P124
Olol - beta blocker - prppranolol, HTN/ CHF/ Angina P124
Ni - vasodilator - nitroprusside, relax smooth muscles in the blood vessel P124
Pril - ace inhibitor - accupril, treat HTN/ protect kidneys in clients with DM P123
Mide - loop diuretic - torsemide, excrete sodium and fluid P123
Ceph/Cef - cephalosporin - cefadoxime, antibiotic P127
*Floxacin - fluoroquinolone - oflaxacin, antibiotic P127
*Mycin ( Tangs) - aminoglycoside - tobramycin, antibiotic P127
*Tidine - h2 receptor blocker - ranitidine, inhibits gastric acid production P130
Afil – type 5 phosdiesterase inhibitor - taldalafil, erectile dysfunction P 104
* Remember there are always exceptions. *Some exceptions: amakacin is an aminoglycoside and ends in
acin, macrolides are a class of drug that also end in mycin, loratidine is an antihistamine and ends with tidine.
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ESSENTIAL MEDICATION LIST
• Respiratory medications: bronchodilators- albuterol, • AZT (zidovidine) – take on an empty stomach, check CBC
theophylline, Brethine, Intal inhaler – use even when (anemia)
symptoms are not present • Accutane, Retin A (retinoic acid)
• Accolate, Singular (montelukast)- give in the evening • *Synthroid – hold for pulse greater than 110; take in a.m.
• Dextroamphetamine (Dexedrine), Ritalin-irritability • Botox
• Anticholinergics: atropine, robinol • Tessalon Perles (Benzonatate)-antitussive
• Cholinergics: neostigmine (prostigmine)– Myasthenia • Neupogen – increases WBC’s, Epogen - increases RBC’s
Gravis, Mestinon • Dopamine –braycardia and hypotension
• Antipsychotics:Thorazine (avoid sun), Seroquel, • Flexeril; Dantrolene sodium; Baclofen (muscle relaxants)
Zyprexa; Haldol, Clozaril– weekly WBC monitoring for • *Viagra- headache/avoid nitrates, take one hour before sex;
6 months Cialis, Levitra
• Aspirin: tinnitus, GI bleeding, take w/ food • *Fosamax (alendronate)- sit up or 30 minutes after taking
• NSAIDS- ibuprofen (motrin), indomethicin (indocin) med, take on an empty stomach, with a full glass of water,
naprosyn, Celebrex: may cause bleeding early AM; Actonel (risedronate)
• *All diuretics, furosemide, torosemide, Zaroxolyn • *Zocor, Questran – decreases cholesterol, mix in juice,
• Epinephrine (epi-pen) Lopid, niacin
• Buspar (antianxiety), Valium, Xanax • Mannitol
• Magnesium sulfate • Lithium, Lithonate- bipolar disorder
• *Methergine • Lithostat- for nephrolithiasis
• Gout – allopurinol, colchicine • Gabitril (tiagabine) –CNS depression
• Humira • Morphine; Darvon
• Mycin drugs (gentamycin) – oto, neuro, nephrotoxic • Citrical – (calcium) monitor calcium levels
• Bactrim – avoid sun, wear long sleeves • Antihypertensives- may cause sexual dysfunction
• **Ativan – prevent seizures • Avoid cephalosporins if allergic to PCN (ie. Keflex), Mycin
• Tegretol, Dilantin drugs ok, Rocephin
• Tamoxifen – antineoplastic – Breast Ca (+ estrogen • Artane, cogentin
receptors) • Tacrine
• Capoten – 1 hour before meals • Xalatan-decreases intra-ocular pressure
• K-dur • *Toprol- metoprolol; Propranolol, Inderal -avoid with
• *Amphogel – antacid, TUMS
asthma, check pulse before administration
• Cardizem – check BP; Verapamil; Cozaar – taken PO,
• Cipro: 2 hrs before or 6 hrs after antacids; take on an empty
felodipine - peripheral edema
stomach, Ancef
• Nitroglycerin –avoid with Viagra, avoid with glaucoma
• Keflex; Zithromax –side effects, Bi
• Heparin, *coumadin, arixtra - anticoagulant given 6-8
• Gantrinsin (Acetyl Sulfisoxazole) –peds – Rx for chronic UTI
hrs s/p hip fracture, hip or knee replacement; Lovenox
• Lipitor- contraindicated in pregnancy, Zetia. Questran
(Enoxoparin), Fragmin (Dalteparin): low molecular
• Ginger; Kava Kava; Ginko Biloba, Echinacea, Fever few, Black
weight heparin- monitor CBC
Cohosh
• Ethambutol + INH (isoniazid) – for TB, multiple drugs
• Rifampin – discolors urine
decrease resistance
• Rocephin –furry tongue
• Mylanta – H2 antagonist – wait 1-2 hours before tak-
ing other meds • Elavil, Remeron, Zoloft, Effexor, Tofranil (imipramine)(anti-
• Evista (Raloxifene) – used for osteoporosis in post depressant), MAO inhibitors, Prozac –side effects
menopausal women • Symmetrel, levodopa
• *Digoxin – patient teaching • Desmopressin (DDAVP)- intranasally
• Iron (ferrous sulfate) • Versed – used for conscious sedation
• *Tetracycline • Ditropan, Detrol , Vesicare–treat symptoms of overactive
• Metformin (glucophage) – take with meals; Glipizide; bladder
Amaryl, Prandin, Glucotrol • Zomig –migraine headache
• Insulin Regular/ NPH (Peaks), Lispro • Oxytocin
• Depo-Provera
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AFTER THE REVIEW

After the review class is completed, you will need to continue to study. Ready to Pass recommends that you take
the NCLEX exam within 1 month after completion of the course. It is important that you organize your time in
order to cover each section of the review book thouroghly. You must have a good understanding of the
information rather than memorizing facts. Be sure to pay attention to bolded areas, charts and areas that
were highlighted during the review. Prepare for the exam by scheduling as soon as possible. Start by reading the
study manual in order of areas of NCLEX priority.
Recommended order of study:
1. Study Tools (priority setting), Page 143 Alphabet list and mneumonics
2. Infection Control
3. Diabetes/Endocrine System
4. Cardiac System - consider reviewing You Tube video “EKG for NCLEX & Beginners” Annelisse Garrison
5. Pharmacology (a) medication calculation (b) herbal remedies
6. Diagnostic tests & Lab values
7. Respiratory System
8. Maternal Child Health, Pediatrics, Mental Health
9. Everything Else
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ESSENTIAL CLINICAL NURSING SKILLS & TECHNIQUES TO REVIEW
1. Obtaining a sputum culture

2. Performing catheter irrigation (steps listed on pg 140)
3. Inserting a straight or an indewelling urinary catheter (steps listed on pg 140)
4. Tracheostomy care
5. Tracheostomy suctioning
6. Eye Irrigation
7. Ear Irrigation
8. Preparing a sterile field; Donning sterile gloves
9. Changing a peripheral intravenous dressing
10. Administering intravenous medications using a secondary line
11. Changing a central line dressing
12. Insertion of and removing a nasogastric tube
13. Administering eye / ear medication
14. Correct use of an incentive spirometer
15. Care of the prosthetic eye
16. Administering medication using Z-track technique
17. Performing wound assessment
18. Performing wound irrigation; wound vac
19. Gastric Lavage
20. Condom catheter application (steps listed on pg 140)
21. Closed intermittent irrigation (steps listed on pg 140)
22. Obtaining a specimen from a central line and a peripheral line
23. Colostomy and Ileostomy stoma care
24. Safe use of devices: CPM machine, slide board, mechanical lift, gait transfer belt
25. Application of antiembolic stockings
26. Post mortem care
27. Cardiopulmonary Resuscitation (CPR)
Resources
www.LearnersTV.com
www.nursingquality.org
www.fpnotebook.com/surgery/pharm/wnddrsng.htm
http://nursingskillsvideo.blogspot.com
www.practicalclinicalskills.com
www.easyauscultation.com
www.blausen.com
www.dosagehelp.com
www.abg.ninja
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CONTINUOUS BLADDER IRRIGATION (CBI)

• Continuous bladder irrigation (CBI) of normal saline prevents the catheter from becoming obstructed.
Irrigation Return Rate Adjustment
• Pink or Lighter • Do not adjust CBI rate (desired return)
• Bright Red with clots • Increase CBI rate
Obstructed catheter (bladder spasms, decreased irrigation outflow)
• Turn off CBI
• Use a large piston syringe irrigate with 50 mL of irrigation solution
• Document the amount of solution instilled and the amount of solution returned.
• The difference between the two amounts equals urinary output.
Interventions: Monitor vital signs, increase fluids, monitor for bleeding.
Teach: First void after removal may appear red in color with clots present. Color should return to normal (amber)
within 2 to 3 days. Expected urinary output is 150 - 200 mL every 3-4 hours.
CLOSED INTERMITTENT IRRIGATION

• Fill a sterile syringe with irrigant
• Clamp the catheter in the area between the injection port and extension tubing
• Clean theh injection port with an alcohol wipe
• Insert the needle of the sterile syringe into the injection port
• Inject the irrigant slowly into the catheter
• Remove the syringe and clamp
• Direct the flow of the irrigant to drain into the drainage bag
STRAIGHT OR INDEWELLING CATHETHER INSERTION

• Explain procedure & then perform hand hygiene
• Position client supine: Female with knees bent & apart; Male with thighs abducted slightly
• Don gloves & wash perineal area
• Remove gloves, perform hand hygiene
• Open sterile package, don sterile gloves, Apply antiseptic solution to the cotton balls
• Check balloon by inflating it with the packaged prefilled syringe, then deflate it
• Lubricate tip of catheter
• Use the sterile drape to expose the meatus, then clean the area.
• With sterile hand, insert catheter into the meatus, advance it until urine returns, then 2.5 to 5 cm further
• With the nondominant hand, stabilize catheter
• For an indwelling catheter, inflate balloon, pull gently to ensure placement
• To secure the catheter, tape to client’s leg, then place drainage bag at a lower level than bladder
• For straight catheterization, once flow of urine has stopped, remove catheter
CONDOM CATHETHER APPLICATION

• Perform hand hygiene, explain procedure
• Don gloves, apply skin prep to area
• Hold penis with nondominant hand, apply condom leaving 2.5 cm of space between tip and catheter
• Roll the condom downward to cover the shaft area
• To secure catheter apply elastic tape in a spiral method, attach to leg or collection bag
• Observe for urine
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Alphabet List Page
Letters What they Mean Related To
4 W’s
6 P’s
4 C’s
5 H’s
5 F’s
3 N’s
3 C’s
5 P’s
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HOW MANY MNEUMONICS DO YOU REMEMBER?
RICE BROW
RACE AWFERS
RAT x 2 BEEP
ANT HOP
PAN TPAL
RANDI AVA
FINDS STOP
MONA REEDA
PQRST PASS
ABCD CAP
IPPA BRAT
IAPP CAPTOPRIL
CAB PISSCAGE
COAL NOAH
CAUTION ABCDE
ABCL KNIVES
VEAL CHOP CLAMIE - O
BUBBLE HE RANDI
RAMS BED
ROME OLDCART
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RICE: Tx for sprains PISSCAGE: Psych assessment MONA: Tx of MI

REST PSYCHOMOTOR MOVEMENT MORPHINE
ICE DECREASED INTEREST OXYGEN
COMPRESS SUICIDAL NITRATES
ELEVATE ↓OR ↑ SLEEP ASA
DECREASED CONCENTRATION
CAP: Meds for Gout ↓OR ↑ APPETITE CLAMIEO: Assessment
COLCHICINE GUILT CHECK
ALLOPURINAL DECREASED ENERGY LOOK
PROBENECID ASK
PAN: MONITOR
RACE: Fire safety ALL INSPECT
RESCUE EVALUATE
ALARM NOAH: Tx for Asthma OBSERVE
CONFINE NEBULIZERS
EXTINGUISH OXYGEN PQRST: Pain assessment
ANTIBIOTICS PROVOKES
BRAT: Diet for diarrhea HYDROCORTISONE QUALITY
BANANAS RADIATION
RICE RANDI: Bleeding precautions SEVERITY
APPLES NO RAZORS TIME
TOAST NO ASA
REDUCE NEEDLE STICKS ABCD: Mole assessment
RAT x 2: Early signs of hypoxia DECREASE NEEDLE GAUGE ASSYMETRY
RESTLESS INJURY PREVENTION BORDER
ANXIETY COLOR
TACHYCARDIA ABCDE: Contraindications for beta blockers DIAMETER
RIGHT (Anatomy) ASTHMA
ATRIUM HEART BLOCK BED: Late signs of hypoxia
TRICUSPID CARDIAC FAILURE BRADYCARDIA
DIABETES MELLLITUS EXTREME RESLTESSNESS
CAPTOPRIL: S/E of ACE Inhibitors EXTREMITIES DYSPNEA
COUGH (OCCLUSIVE ARTERIES)
ANGIOEDEMA IPPA: Lung assessment
POTASSIUM INCREASE HOP: Sickle Cell Disease TX INSPECTION
TASTE CHANGES HYDRATION PALPATION
ORTHOSTATIC HYPOTENSION OXYGENATION PERCUSSION
PALPITATIONS PAIN MANAGEMENT AUSCULTATION
RENAL IMPAIRMENT
IMPOTENCE IAPP: Abdominal assessment
LEUKOCYTOSIS INSPECTION
KNIVES: Complications of DM
AUSCULTATION
KIDNEY DISORDERS
ANT: Symptoms of Leukemia PERCUSSION
NEUROPATHY PALPATION
ANEMIA
INFECTIONS,
NEUTROPENIA
VASCULAR CHANGES
THROMBOCYTOPENIA
EYE DAMAGE
SKIN LESIONS
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OLDCART: First aid assessment TPAL: Pregnancy assessment

ONSET OF SYMPTOMS TERM
LOCATION OF PROBLEM PRETERM
DURATION OF SYMPTOMS CHARACTERISTICS CLIENT ABORTIONS
USED TO DESCRIBE SYMPTOMS AGGRAVATING LIVE
FACTORS
RELIEVING FACTORS SCAB: Safety
TREATMENT RECEIVED BEFORE ARRIVAL SIDE RAILS UP
CALL BELL WITHIN REACH
CAUTION: Cancer warning signs ASK IF CLIENT HAS PAIN/ COMFORT
CHANGE IN BOWEL OR BLADDER HABITS BED IN LOW POSITION
A SORE THAT DOES NOT HEAL
UNUSUAL BLEEDING OR DISCHARGE 5 F’S: Possible causes of abdominal distention
FAT
THICKENING OR LUMP IN BREAST OR ELSEWHERE
FLUID
INDIGESTION OR DIFFICULTY IN SWALLOWING
FECES
OBVIOUS CHANGE IN WART OR MOLE FLATUS
NAGGING COUGH OR HOARSENESS FETUS
BUBBLE HE: Post partum assessment
BLADDER GLAD SHOP: Chronic renal failure
UTERUS BOWELS GLOMERULONEPHRITIS
BREASTS LUPUS
LOCHIA ANALGESICS
EPISIOTOMY DIABETES MELLITUS
HOMAN’S SIGN SYSTEMIC VASCULAR DISEASE
EMOTIONS HYPERTENSION
OBSTRUCTION
VEAL CHOP: Decelerations assessment POLYCYSTIC KIDNEY DISEASE
VARIABLE CORD
SAD: Ketoacidosis
EARLY HEAD STARVATION
ACCELERATIONS OK ALCOHOL
LATE PLACENTA DIABETES MELLITUS
CAB: Dyskinseia meds ROME: Acid-base balance
SAD PERSON: Suicide risk
COGENTIN RESPIRATORY
SEX/ SINGLE/ SICKNESS
ARTANE OPPOSITE
AGE
BENADRYL METABOLIC
DEPRESSION
EQUAL
PREVIOUS ATTEMPT
COAL: Cane walking
ETOH
CANE BROW: Avoid with celiac disease
REALITY TESTING
OPPOSITE BARLEY
SOCIAL SUPPORT
AFFECTED RYE
ORGANIZED PLAN
LEG OATS
NO SPOUSE / NOTE
WHEAT
ABCL: Increase sodium CATS: Hypocalcemia
ADDISON’S RAMS: Acid-base balance CONVULSIONS
BURNS RESPIRATORY ARRYTHMIAS
CYSTIC FIBROSIS ALTERNATE TETANY
LITHIUM METABOLIC SPASMS
SAME
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MATERNAL / NEWBORN CARE
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Maternal/Newborn Care
Presumptive, Probable and Positive Signs of Pregnancy
• Subjective signs
Presumptive Signs • Cannot be used to diagnose pregnancy
Amenorrhea • Increasing levels of HCG major cause

• Due to progesterone secretion
Breast changes
• Results in increased size, tenderness, and darkening of the areola
Urinary frequency • Enlarging uterus puts extra pressure on bladder
Fatigue
Quickening • Faint abdominal fluttering felt by mother at 18 - 20 weeks
• Objective signs determined during physical examination

Probable Signs
• Result of vascular congestion in the pelvis
• Occurs irregularly at beginning

• Uterus above pubic symphysis by 12th week
Uterine enlargement
• Reaches umbilicus by 20 - 22 weeks
• Fundal height in cm matches # of weeks pregnant after 12th week
• Softening of lower uterine segment
Hegar’s sign
• Occurs in 2nd and 3rd months of pregnancy
Goodell’s sign • Softening of cervix and vagina
Chadwick’s sign • Bluish or purplish discoloration of cervix, vagina, and vulva
Ballottement • Rebounding of fetus against examiner’s fingers on palpation
Braxton-Hicks contractions • Irregular, painless contractions throughout pregnancy
Abdominal enlargement • More rapid after 12th week when uterus rises into abdominal cavity
Abdominal striae • Stretch marks
• Results from hormonal changes
Skin pigmentation changes • Nipples may darken
• Linea nigra: brown or pink line from umbilicus to pubic symphysis
Positive pregnancy test • Measures HCG
Positive Signs • Absolute indicators of pregnancy
• May be heard at 10 to 12 weeks by Doppler

Fetal heart sounds
• May be heard through regular fetoscope by 18 to 20 weeks
• Normal rate 120 to 160 beat / minute
Fetal movements • Felt by second trimester
• At 6 to 8 weeks, fetal identification positive
Ultrasound of fetus
• Earliest positive method of diagnosing pregnancy
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II. Prenatal Care

(1) Prenatal history
(2) Prenatal physical assessment
A. Exam:

• Total weight gain of 25 lbs is average
B. Pertinent diagnostic tests and lab values

• CBC • Electrolytes (chemistry)
• Blood type &screen • VDRL
First Trimester • Rubella screen • TB skin test
• HIV screen • Hepatitis B screen
• Urinalysis • Urine culture and sensitivity
• Glucose Tolerance test (GTT): Levels >135 mg/dL need follow up

Second Trimester • Alphafetoprotein (AFP): Detects neural tube defects (14-16 weeks)
• STD/STI screen
Third Trimester • Group Beta Strep: If positive Penicillin G - administer up to 4 hours
before delivery

C. Nutritional status: • 2200 to 2300 calories per day
• 2000 ml of fluid per day
• Increase protein intake
• Increase iron to decrease anemia
• Increase folic acid to prevent neural tube defects
D. Risks and hazards

E. Cardiac disease in pregnancy
(3) Nagele’s Rule: 1. Add 7 days to the first day of the last normal menstrual period
2. Subtract 3 months
3. Add one year
List The EDC: LMP: August 9, 2017 EDC___________________________
January 4, 2018 EDC___________________________
October 5, 2017 EDC___________________________
3. July 12, 2018 2. October 11, 2018 ANSWERS 1. May 16, 2018
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(4) Routine care and follow up: • 1x per month for 7 months
• 2x per month in 8th month
• 1x per week in 9th month
(5) Parity (Term Preterm Abortions Living children)

Gravida- total number of pregnancies including current pregnancy
(6) Normal pregnancy discomforts in each trimester

First Trimester Second Trimester Third Trimester
• Nausea, vomiting • Constipation • Leg cramps
• ↑ urination • Heartburn • Hemorrhoids
• Breast tingling • Pigmentation • Back pain
• Ptyalism (excessive spitting) Linea nigra becomes prominent • Urinary frequency
• PICA
• Leg cramps are normal if no
suggestion of Homan’s sign
(7) Reportable danger signs:

Vaginal bleeding Painful or burning urination
Abdominal pain Edema of face, feet or hands
Epigastric pain A sudden rush of fluid (rupture of membranes)
Visual disturbances Elevated temperature above 101° and chills
Severe, persistent headache Persistent vomiting after the 1st trimester
Change in fetal movements after quickening Absence of fetal movements after quickening
(8) High risk monitoring:

Chorionic Villus Sampling • Performed at 10 - 12 weeks gestation to detect genetic disorders
Amniocentesis • Performed after 14 weeks to rule out congenital abnormalities
• ↓levels = Down’s Syndrome - performed at 14-16 weeks

Alphafetalprotein (AFP)
• ↑levels = neural tube defects
L/S ratio • 2:1 indicates lung maturity
Genetic screening • Screening for genetically transmitted disorders
Sonogram • Determines fetal and placental position

• 5 assessment tests using ultrasound to determine fetal well being
Biophysical profile • Each has a possible score of 2; max score =10 Normal 7-10; less than
4 may need urgent delivery
Contraction stress test • Assesses FHR response to contractions
(Negative) • Fetus should not have any late decelerations in 10 minutes
Nonstress tests • FHR should accelerate 10 – 15 bpm in 10 minutes in response to body
(Reactive) movements
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(9) Complications
Pregnancy Induced Hypertension (PIH) (Preeclampsia):

Triad = • Hypertension • Weight gain (edema) • Proteinuria
Symptoms: • headache • visual disturbances

• hyperreflexia • decreased urinary output

Maternal Hypertension (PIH): • Mild: increase: 15 - 30mm/hg
• Severe: increase: 30 - 40mm/hg
• Eclampsia: 160 / 110 B/P or greater with convulsions
Tx: magnesium sulfate - antidote Calcium Gluconate

HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Lowered Platelets
Maternal Hypotension: • S top pitocin

• T urn on left side
• O xygen
• P ush IV fluids if hypovolemic
Hyperemesis Gravidarum
• Excessive nausea and vomiting in early pregnancy
• Treatment: IV hydration and antiemetics - Zofran (ondansetron) or Phenergan (promethazine)
Monitor for electrolyte imbalance and dehydration
Placenta Previa
• Partial or complete covering of the cervical os by the placenta.
• Painless vaginal bleeding (bright red bleeding may or may not be visible) after the 7th month of
pregnancy
• Common in older mothers, multiparity - no vaginal exams; May need C-section - not emergency
Placenta Abruptio:
• Premature separation of the placenta from the uterine wall
• Painful dark red vaginal bleeding
• Risk factors: PIH, multiparity, trauma, cocaine use
• Client will need an emergency C - Section
Gestational Diabetes:
• Extra glucose passes through the placenta and is metabolized by the fetus
• This causes excess insulin to be secreted by the fetus which acts as a growth hormone
• After birth the neonate may become hypoglycemic as there is a sudden drop in glucose (maternal)
and an increased insulin production by the fetus.
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III. Labor and Delivery
A. True VS. False labor
True Labor False Labor

• Begins in the back • Abdominal and groin
• Contractions • Consistent pattern • Inconsistent
• Frequency/ fast • Increases progressively • Inconsistent
• Duration/ last • Increases progressively • Inconsistent
• Pain • Increases progressively • Inconsistent
• Cervix • Dilates and effaces • Insignificant changes
Fetal Monitoring- Normal FHR 120 - 160 beats per minute
Decelerations:
EARLY LATE VARIABLE
↓ FHR before the contraction ↓ FHR after the contraction Combination of early & late
Head compression Uteroplacental insufficiency Cord compression
• Oxygen
• IV fluids • Lateral or trendelenburg position
RX: observation • Lateral position • Oxygen
• D/C pitocin • C-section
• C-section
VEAL CHOP
V ariable C ord: V or W shaped occurs during or between a contraction
E arly H ead: U shaped begins and ends with contraction
A ccelerations O K: increase of FHR above baseline. Return to normal within 10 minutes
L ate P lacenta: decreased FHR after a contraction: Fetal hypoxia
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B. Management of labor: when MD does vaginal exams expect some spotting
Cervical dilatation Duration (contraction) Interval

Fingertip - 2cm 20 - 30 seconds 6 - 8 minutes
2 cm - 4 cm 30 - 35 seconds 5 - 8 minutes
8 cm - 10 cm Transition 50 - 80 seconds 2 - 3 minutes
* Contractions should not occur faster than every 2 minutes and should not last longer
than 90 seconds (Stop Pitocin)
• Passenger
• Passage
1. FIVE P’s • Power
• Placenta
• Psyche of mother
• Risk for infection
2. PROM
• Avoid vaginal exams • Give Ampicillin
• Never put the cord back inside
3. Prolapsed cord • With sterile glove, lift presenting part off of the cord or
• Place mom in trendelenburg or knee chest position
4. Spontaneous Abortion • Loss of a fetus before the 20th week of pregnancy
• A pregnancy that occurs outside of the uterus

Signs and Symptoms:
5. Ectopic pregnancy • Vaginal bleeding • Dizziness
• Pelvic or abdominal pain radiating to the shoulder
• DX: Sonogram Rx: Methotrexate or surgery
6. Pharmacology/pain relief • Analgesics may be prescribed to take the edge off the pain
• The settling of the fetus in the lower uterine segment

• Increase in vaginal secretions
7. Lightening
• Appearance of bloody show
• False labor pains
Pregnancy losses after the 20th week
Can be stimulated by: Risk Factors:
• Urinary tract infection • Multiple gestation
8. Premature Labor • Diarrhea • Previous premature delivery
• Dehydration • Infections
• Laxatives • Smoking
• Poor weight gain
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C. True labor
Stage 1: Dilation
• First true labor contraction until complete effacement and dilation of the cervix
• Latent: 0cm - 4cm • Active: 4cm - 8cm • Transition: 8cm - 10cm
A: Presentation Part of the fetus that is coming first
B: Effacement Thinning of the cervix
C: Station Level of the fetus’ head in relation to the ischial spines
Stage 2: Birth or expulsion

• Complete dilation and effacement of the cervix until the birth of the baby
• Bulging of the perineum is an expected finding
• Fetal descent: Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation,
Expulsiion
Stage 3: Placental
• Birth of the baby until expulsion of the placenta

• Inspect the placenta for two arteries and one vein - AVA
Stage 4: Recovery Stage
• Delivery of the placenta until the mother’s condition has stabilized. Pelvic rest 4-6 weeks.
Stages of Labor First Stage Second Stage Third Stage
5 to 20 minutes
Primipara 8-20 hours 30 minutes to 2 hours Usually helped by oxytocics or
manual pressure
5 to 20 minutes
Multipara 3-8 hours 20 minutes to 1 1/2 hours
Usually helped by oxytocics

D. Culture and Pain perception during labor
1. Analgesia – Prescribed - just enough to take the edge off the pain. Morphine, Meperidine
2. Anesthesia – epidural – causes loss of sensation but not unconsciousness
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IV. Postpartum - taking in 1 -2 days, taking hold 3rd day, letting go 5th - 6th week
Assessment : BUBBLE HE
B ladder: • Encourage voiding • Check for displaced uterus

U terus: • Fundus should be firm at the level of the umbilicus immediately post delivery
B reasts: • Check for engorgement, mastitis & cracked nipples
B owels: • Assess for presence of bowel sounds
L ochia: • More than 8 pads / day needs follow up
E pisiotomy: • Redness • Edema • Ecchymosis • Discharge/Drainage • Approximation
Homan’s Sign: • Should be absent

• Assess for DVT
Emotions: • Assess for bonding
• Lochia Assessment:
RUBRA SEROSA ALBA
• Bright red • Pink • Creamy yellow
• Pinkish- brown
• Bloody • May be brownish
• Serous
• 1 - 3 days post partum • 5 - 7 days post partum • 1 - 3 weeks post partum
• No odor or slightly fleshy • No odor or stale

• No odor
• 4 - 8 pads per day is normal • Body odor
• Breast Feeding:
• Encourage 2700 - 2800 calories and 3000ml fluid if breast feeding
• Mastitis: Treatment: • Moist heat • Encourage breast feeding or pump the breast
• Engorgement / cracked nipples: Treatment: • Ice or open to air 10 - 20 minutes at a time
• Mother who does not want to breast feed: • Teach: wear tight fitting bra and ice
• Parlodel (bromocriptine) may be prescribed
• Contraindications to breast feeding include but are not limited to:

• Tuberculosis • Breast cancer • Chemotherapy
• Radiation • HIV • Hepatitis
• Lactose intolerance (infant) • Methotrexate • Lithium
• Herpes lesion on nipples
• Expected Findings: • 8 -12 feedings per day

• 6 - 8 wet diapers per day
• 4 or more yellow bowel movements per day
• If infant develops diaper rash, keep open to air, use cloth diapers
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V. Care of Newborn
A. Nursing care assessment
1. Apgar score: score < 7 requires resuscitation
APGAR NEWBORN Performed at: • 1 Minute After Birth

SCORING SYSTEM • 5 Minutes After Birth
0 1 2
Heart rate Not detectable Below 100 Above 100
Respiratory effort Absent Slow, Irregular Good (crying)
Muscle tone Flaccid Some flexion of extremities Active motion
Reflex irritability No response Grimace Vigorous Cry

Color Pale Blue Pink
• Data Collection: • Respiratory Status

• Apgar score
• Obtain vital signs
• Temperature Assessment
• Implementation: • Suction mouth then nose

• Dry baby with vigorous rubbing
• Maintain temperature
• Wrap baby in a warm blanket
• Place a stocking cap on the head
• Initiate breast feeding PRN
• Place baby in a warmer
• Ensure proper ID - footprint newborn
• Thumb print from mother
• Place ID bracelets on to assist in the prevention of infant abduction
• Administer Viamin K injection (phytonadione)
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VI. Normal Newborn

Normal Newborn Assessment
LENGTH • 18”- 21” / 46-53cm
• Average weight 6 - 8 pounds

WEIGHT • Small for gestational age (SGA) < 5 lbs or 2500 grams
• Large for gestational age (LGA) > 9 lbs or 4100 grams
• Respiratory rate: 30 -50
VITAL SIGNS • Heart rate: 110 -160 bpm
• Apnea lasting > 15 - 20 seconds requires intervention
• Anterior closes between 12-18 months

FONTANEL ASSESSMENT
• Posterior closes between birth and 3 months
HEAD CIRCUMFERENCE • 33 - 35 cm / 13 - 14 inches
CHEST CIRCUMFERENCE • 30 - 33 cm / 12 - 13 inches
ACRACYANOSIS • Normal finding
STRAWBERRY HEMANGIOMA • Raised rough area of skin
• Harmless rash that looks like little pustules on a red base on the
ERYTHEMA TOXICUM
face, trunk, legs, and arms. It disappears by 1 week.
MONGOLIAN SPOTS • Normal; fades age 1 - 2
JAUNDICE • Physiological hyperbilirubinemia: self limiting resolves in 7-10 days
PETECHIAE • Small red or purple spots
MILIA • Tiny white bumps on the nose
VERNIX CAESEOSA • White cheesy protective substance
CAPUT SUCCEDANEUM • Edematous area on the head
• Collection of blood under the periosteum

CEPHALO HEMATOMA • Risk with forcep delivery or vacuum extraction
• Note: If hematoma crosses the suture line, suspect skull fracture
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Newborn Care
AIRWAY • Suction mouth before nose
• Swaddle infant
• Keep infant covered at all times
• Put cap on newborn’s head to prevent heat loss
• Heat may be lost by:
WARMTH
• Convection – prevent drafts
• Radiation – do not place bed near window
• Conduction – do not place infant on cold surfaces
• Evaporation – keep infant dry
BATHING • Performed after temperature within normal limits
REFLEXES • Primitive- most are present at birth

• Clean with mild soap and water
CORD CARE
• Keep area clean and dry
CIRCUMCISION • Jewish child done on day 8 (Bris)
• Taste
• Touch
SOCIAL SENSES • Smell
• Sensitivity to light
• Selective listening – responds to mother’s voice
FEEDING • Bottle or Breast: teach the care giver proper positioning
• PKU - levels greater than 8: Can lead to mental retardation
• Baby will need to drink lofenolac formula Low protein formula for
life)
MEDICAL CHECK
• This is the first test performed on the newborn, done by heelstick
• Monitor the injection site for infection
• If done before 48 hours it will need to be repeated in 14 days
VII. The high risk neonate
A. Premature: • Born before 37 weeks • Low birth weight

• Transparent skin • Weak cry
• Risk for apnea • Poor feeding
• At risk for multiple health problems
B. Postmature: • Born after 42 weeks

• Increased risk for meconium aspiration
• Monitor newborn for respiratory problems

• Signs and Symptoms: • Dry peeling skin • Creases on palms & soles
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C. Complications:
1. Fetal alcohol syndrome/ drug addiction: Symptoms manifest 12-72 hours after delivery
(Neonatal abstinence syndrome) • Shrill cry • Poor weight gain
• Yawning • Sneezing • Seizures
• Jittery – swaddle the infant
• Microcephaly and facial abnormality with
alcohol syndrome
TX: Supportive care to avoid continued exposure to additional medications. Opioids or
Phenobarbital used in severe cases.
2. Facial paralysis: risk increased with forcep delivery

3. Cerebral palsy: risks include maternal age, low birth weight, anoxic episode

4. Erythroblastosis fetalis (RH incompatability): Rhogam Administered:
• 28 weeks gestation
• Within 72 hours after birth
• After voluntary termination of pregnancy
• After spontaneous termination of pregnancy
Given to RH negative mothers (occurs if father is RH positive)

Coombs test-detects hemolytic anemia in the newborn - should be negative direct- measures
presence of antibodies on the RBC surface indirect- measures antibodies in the serum
5. Sepsis in the newborn: may become infected during birth or related to PROM
T Toxoplasmosis
O Other ( gonnorhea, syphillis, varicella, Hepatis B, HIV)
R Rubella
C Cytomegalovirus
H Herpes
D. Congenital anomalies:
1. Heart disease
2. Spina bifida
3. Esophageal atresia: Three C’S • Coughing • Choking • Cyanosis
4. Apnea monitor : • Remove leads when not attached
• Unplug cord when not plugged into monitor
• Electrodes at midaxillary line 1 - 2 finger breadths below the nipple
• If apneic, gently stimulate the trunk by patting or rubbing
• Treatment: Caffeine, Aminophylline or Theophylline
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COMMON MEDICATIONS USED IN MATERNITY
Discontinue with:
Pitocin (oxytocin): Side Effects:
Sustained uterine
Labor induction Hyponatremia
contractions
Painful contractions
Postpartum hemorrhage Fetal deceleration
Contraindicated in uterine
Decreased urinary output
hypertonicity
Brethine (terbutaline): Side Effects:

Asthma Nervousness Restlessness
Tremors Hyperglycemia
Preterm labor
Hypertension
Given until 37 weeks or lung Tachycardia: check pulse prior to administration
maturity Hold if pulse is over 120
Side Effects:
Client may feel hot and flushed Side Effects for neonate:
Magnesium Sulfate:
Headache N/V Hypotonia
Pregnancy induced HTN Dizziness Nystagmus
Magnesium levels of
Seizures Lethargy Bradycardia
5 - 8mg/dl are normal
Premature labor Diarrhea Hypotension
Urinary retention Check patellar reflex in
Antidote: calcium gluconate newborn
Nurse; monitor vital signs, urinary
output, electrolyte imbalance
Erythromycin:
Used to prevent chlamydia and gonorrhea in the neonate
Eye ointment
Methergine (methylergonovine) Side Effects: Headache Dizziness
Post partum hemorrhage Nausea and vomiting Diaphoresis
Contraindicated in PIH Hypotension or hypertension Cramps
Given to mother at time of discharge
Rubella vaccine
Teach to avoid pregnancy for 3 months
Treats post partum hemorrhage after other methods have failed
Hemabate (carboporst tromethaine)
Side effects: N/V/D, abdominal cramping & flushing
Rhogam Rh negative mother
Celestone (betamethasone) Given IM to the mother Q12h X 2, then weekly until 34 weeks
Used to improve L/S ratio gestation
Common Opiods Demerol (meperidine) Stadol (butorphanol tartate)
To decrease pain Nubain (nalbuphine) Opoid antagonist - nalaxone
Induce ovulation by changing hormonal effect on ovary
Clomid (clomiphene)
May result in multiple gestation
Apresoline
Treatment for hypertension
(hydralazine hydrochloride)
Naloxone HCL Treatment for respiratory depression
Prostaglandin Softens and thins the cervix
Supplement to anesthesia, treats pain during labor
Stadol (butorphanol tartrate)
Side effects: pruritis, paresthesias, palpitations, tinnitus
Ginseng Avoid ginseng with pregnancy and lactation
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PEDIATRIC ESSENTIALS
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I. Growth and Development

• A 2 year old walks up the steps, placing both feet on steps
• A 3 year old rides a tricycle, climbs steps with alternate feet on steps
• A 3- 6 year old favors a parent of the opposite sex (Oedipus complex)
Weight: 6 - 8 lb; gains 5 - 7 ounces per week for the first 6 months
Height: 20 inches; grows 1 inch per month for the first 6 months
Head Circumference: 13 -14 inches (33 - 35 cm) equal to or slightly larger than chest circumference
Grows ½ inch per month for the first 6 months

PEDIATRIC ASSESSMENT MILESTONES ESSENTIALS
1 MONTH 5 MONTHS
Reflex activities Plays with toes
Cries to communicate Turns from abdomen to back
Mobiles Teething toys
Cuddling Noise making toys
Absent tears 1 to 3 months of age is normal
Safety: Place on back to sleep 6 MONTHS
No stuffed animals or pillow in the crib Holds bottle
Monitor temperature of formula Sits with minimal support
Rear facing car seat up to age 2 Understands name
2 MONTHS Doubles birth weight
Social smile 7 MONTHS
Lifts head
Begins to crawl
Coos
Squeeze toys
Bright pictures
Safety: Outlet covers
Hanging objects
Lock cabinets
Music
Posterior fontanel closes 8 MONTHS
Safety: Monitor temperature of bath water Sits without support
3 MONTHS Pulls to standing position
Sits with support Fear of strangers
Turn from back to side Plays games: hide and seek
Babbles 9 MONTHS
Provide rattles
Soft toys Attempts to feed self
Safety: Keep side rails up Walks holding on to furniture
4 MONTHS Peek-a-boo
Safety:
Gains head control
Supervise near water
Places objects in mouth
Consonant sounds 10 MONTHS
Squeeze toys
Can hold own bottle or cup
Grasps toys with hand
Blocks
Turns from back to abdomen
Toys that can be filled and emptied
Safety: Avoid small objects
Inspect toys
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11 MONTHS 4 YEARS
Shows moods Hops on one foot
Uses index finger and thumb to grasp (pincer Recognizes colors
grasp)
Imaginary playmates
12 MONTHS
Average weight 38 lbs
Walks with one hand held or alone Average Height 40” (double the birth length)
Triples birth weight
Safety: Car booster seat:
Safety: Guard rails on stairs
Up to 12 years old or 4’ 9” in height
Turn pot handles inward
First dental visit
5 YEARS
2100 word vocabulary
15 MONTHS
Two wheel bicycle
Pull and push toys
Throws & catches ball
Scribbles on paper
Crawls up stairs
Average Height 42”
18 MONTHS
SCHOOL AGE
Jumps on both feet Ties shoes
10 - 20 word vocabulary Games
Rules
Anterior fontanel closes
Period of industry:
Safety: Place poisons in locked cabinet
Likes to accomplish things
2 YEARS* Safety: Accident prevention
Bowel and bladder control 2-3 years Traffic and fire safety
2-3 word phrases ADOLESCENT
Climbs steps with both feet on each step Needs social approval of peers
Parallel play; puzzles, blocks; rocking horse, Change in body size & development
drum Safety: MVA’s
Can turn the doorknob
Sport injury prevention
Safety: Forward facing car seat up to 40 lbs Firearm accident prevention
then booster seat; Supervise near water; Drug
Avoid chunks of meat ETOH
2.5 YEARS* Sex education
Full set of 20 baby teeth High risk for suicide
Manipulative toys for muscle coordination
Crayons and paper
3 YEARS*
Rides a tricycle
Alternates feet on steps
900 word vocabulary
Puzzles, books, drawing
Puppets
Average Height 3 feet
Safety: Helmets
Knee pads
Stranger safety
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REFLEXES IN THE NEWBORN

• Automatic reflex of full-term newborns
Palmar Grasp • Elicited by placing finger in infant’s palm
• Present at birth, disappears at 4 months
Asymmetrical • Infant assumes fencer’s position: when head is turned to one side, arm on that
side is extended, and opposite arm is flexed
Tonic Neck Reflex • Present at birth, disappears at 4 months
• When infant is suddenly jarred or hears a loud noise, the body stiffens, the
Moro’s Reflex legs are drawn up, and the arms are brought up, out, and then in front in an
(Startle Reflex) embracing position
• When side of the mouth is touched, child turns to that side
Rooting
Reciprocal • Movements of newborns are jerky and usually alternate in the legs
Kicking • Evolving at birth, disappears at 9 months
• Infants make sucking movements when anything touches their lips

Sucking • Present at birth
• Involuntary sucking, disappears at or about 9 months
Neck Righting • When the head is turned to one side, the opposite shoulder & trunk will follow
Reflex • Evolving at 4 months, involuntary movement disappears at 9 -12 months
• Extension of the great toe on stroking the sole of the foot upwards
Babinski Reflex • Present at birth, disappears after 2 years
• ‫٭‬Abnormal in an adult; indicates neurological damage
Dancing or Stepping
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II. Nutrition: Infant
Breast milk • Most complete and easily digested
• Iron fortified can be used up to 12 months

Commercial formula
• Limit formula or milk to 32 oz per day to avoid iron deficiency anemia
• Introduced at 4 - 6 months after protrusion reflex disappears:
Solids • Cereal, fruit, vegetables then meats
• Introduce one new food/week to assess for allergies
• Given with 1:1 dilution at 6 months
Juices
• Use a cup
Chopped table foods • Given at one year
Malnutrition
• Kwashiorkor: caused by a lack of protein-lead infantile cirrhosis
• Rickets: caused by a lack of vitamin D
• Scurvy: caused by a lack of vitamin C
• Infant botulism: - caused by ingestion of honey before age 1
- first sign is constipation, irritability, and weak cry
III. Hospitalization
A. Child’s reaction
• Fear separation: encourage parent participation
INFANTS & TODDLERS
• Provide consistent care giver
Birth to 2 years old
• Provide stimulation & age appropriate toys
• Fears bodily injury: give simple explanations
PRESCHOOLERS • Parental Involvement
3 to 5 years old • Encourage expression through play
• Cover wounds
• Fears pain and bodily injury
• Fears separation from peers
• Communicate honestly
SCHOOL AGE
• Encourage participation in care
6 to 12 years old
• Allow child to make choices where possible
• Encourage visitation with peers and siblings
• Provide diversional activities
• Fears loss of independence
• Fears body image disturbance
• Fears separation from peers
ADOLESCENT
• Involve adolescent in care
13 to 18 years old
• Encourage visits
• Provide telephone
• Promote privacy
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B. Death and Dying

• No concept of death
Infants and Toddlers
• Fears separation
• See death as temporary and reversible
Preschoolers
• Magical thinking: believe bad thoughts can cause death
School Age • They see death as permanent, but do not think it will happen to them
Adolescent • Knows death is permanent and inevitable
C. Safety measures:
• Infants up to 20 lbs. or 2yrs old use rear facing car seat in the center rear of the
vehicle
• Then forward facing up to 40 lbs
• Booster seat up to 8 - 12 years old or 4’ 9” inches in height
• Check temperature of bath water
• Tepid water - 85° - 100°
• Keep side rails up at all times
• Teach injury prevention
D. Medication administration
• Oral medications can be given using a syringe

• Ear drops: • Under 3 years of age pull ear down and back
• Older child lobe is pulled up and back to straighten canal
• Intramuscular injections avoided in children
Site of choice: • Vastus lateralis, if not available use ventrogluteal
• Deltoid used over age 6
Drug Conversion for Children

1. Clark’s weight rule for pediatric dosage: Child’s weight in pounds x Adult dose
150
2. Young’ Rule: Age in years x Adult dose
Age in years + 12
3. Intravenous microdrip usually has 60 drops / ml

4. Conversion of administration units:
1 tsp = 5 ml 1kg = 2.2lbs
1 tbsp = 15 ml 1 gm = 1,000 mg = 1ml
1 ml = 16 minims 1 oz = 30 ml
1 grain = 60 mg 1 dram = 4 ml
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IIII. Infant
INFANT: NEUROMUSCULAR AND SKELETAL DISORDERS
• External rotation of hip • Limited abduction • Increased skin folds
• Shortening of leg • Ortolani’s click
Congenital Hip Dysplasia
• Treatment: immobilization - spica cast or pavlik harness to immobilize
hips and thighs
Club Foot • Dennis Brown Splints
Meningitis • Droplet precautions
Otitis Media • Amoxicillin drug of choice • Observe for hearing loss
Visual Disturbances • Strabismus - patch the good eye
INFANT: CARDIOVASCULAR DISORDERS
Cyanotic Defects: Poor suck, bradycardia, fainting spells
Acyanotic Defects: Tachycardia, tachypnea, delayed Growth
Congenital Heart Defects Goals: Decrease workload of the heart
Improve respiratory function
Maintain proper nutrition
Sickle Cell Anemia • Hydration, Oxygenation & Pain management (HOP)
INFANT: LYMPH, INFECTIOUS DISORDERS, IMMUNE SYSTEM
Acquired Immune
• Signs and symptoms seen at approximately 1 to 2 years of age
Deficiency syndrome
B. Immunizations

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Health Promotion: Assess client’s for the need for immunizations, required and recommended.
DTaP Vaccine
• Total of five given
Diphtheria, tetanus, pertussis
Should be given at: • 2 months • 4 months
IPV Vaccine • Between 6 & 18 months
Inactivated Poliovirus • Between 4 & 6 years of age
• Total of 4 doses
This vaccine helps protect young children from developing:
PCV Vaccine
• Meningitis
Pneumococcal
• Blood infection (sepsis)
• CHECK FOR EGG ALLERGY FIRST!
• Not given to anyone younger than 6 months of age.
Influenza Vaccine • The inactivated flu vaccine (flu shot) is recommended for:
- All children 6- 23 months of age
Flu
- Children 24 months and older with certain medical
conditions such as asthma, chronic heart or lung disorders,
or an imapired immune system
• CHECK FOR EGG ALLERGY FIRST!
MMR Vaccine
• May be combined or separate
Measles, mumps, & rubella
• Teach: DO NOT GET PREGNANT WITHIN 3 MONTHS!
TD Vaccine
• Recommended for anyone over age 7
Combined tetanus & diphtheria
Hepatitis B Vaccine • CHECK YEAST ALLERGY FIRST
Pertussis • Treatment for pertussis is Erythromycin
• Severe illness with fever

• Anaphylactic reaction to initial dose
• Pregnancy especially Rubella and Polio
Contraindications for Vaccines:
• HIV or immunosuppression (cancer)
• Recent blood transfusion
• Allergy to gelatin, neomycin or steroids with varicella
vaccine

C. Kawasaki Disease: Inflammation of blood vessels and lymph nodes - affects mucus membranes
Strawberry tongue – give ASA and IV gamma globulin
S/S- high fever, redness of palms and soles, swollen lymph nodes
Treatment - steroids, anticoagulants, antiplatelet drugs
Complication: Aneurysm- secondary to inflammation of coronary arteries
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INFANT: RESPIRATORY DISORDERS
Pneumonia • Droplet precautions with bacterial infection
• An inherited disease that causes thick, sticky mucus to build up in

the lungs and digestive tract. Mucus, mucus, mucus
• Steatorrhea: • Greasy, fatty stool
• May cause meconium ileus
• Dx: Sweat chloride test.
• Rx: Pancreatic enzyme supplements (Pancrease)
• Given with meals and snacks,
Cystic fibrosis • Diet: high calorie, high fat. Give salty snacks (also for Lithium)
• Supplement vitamins A, D, E & K
• Prevent respiratory distress:
• Chest physical therapy
• Bronchodilators
• Antibiotics
• Avoid cough suppressants
• Monitor for DM - may develop with aging
• Excess drooling - do not use tongue depressor to assess throat
Epiglottitis • Occurs among age 2- 7
• Inspiratory stridor
(Bacterial Croup)
• Life threatening emergency
caused by
• Mist tent with oxygen, antibiotics
H influenzae type B • Protect the airway (may need tracheostomy)
• Barking cough: Cool mist tent
• Home Care:
Croup (viral) • Breathing moist air from steamed water, a hot shower, or a cool-mist
humidifier is helpful in the majority of cases
• Coughing and stridor should improve within 20 - 30 minutes
• Caused by RSV
• Strict hand washing - Droplet precautions for 24 hours then contact
Bronchiolitis
precautions
• Common in first 2 years of life
• 3 C’s:
Tracheal • Coughing
Esophageal Fistula • Choking
• Cyanosis

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INFANT: DIGESTIVE AND ENDOCRINE DISORDERS

DIGESTIVE DISORDERS
Treatment:
Thrush
• Nystatin suspension; apply with cotton swab
• Skin level device

• Allows baby to sleep on their stomach
• Used for feedings and medications
• Flush with water after feedings and meds to avoid clogging
• • Monitor skin around site for irritation
Gastrostomy Button
- - indicates leakage
(G-button)
• Teach parent to carry extra button i • Teach parent to carry extra button in
case ballon breaks
• Seen soon after birth

• Thickening of the pyloric sphincter causing narrowing and obstruction
• Common in Caucasian - first born males
Pyloric Stenosis
• Assessment: • Olive size bulge under (R) rib cage
• Vomiting- projectile during and after feeding
• Observe rolling waves in abdomen (peristalsis)
• Failure to thrive
• Poor skin turgor
• Decreased urinary output
• Diagnostic test: • Upper GI series
• Lab findings: • Decreased sodium, K+, CL

• Increased HCT, metabolic alkalosis
• Treatment:
• Thicken feedings
• pyloromyotomy (Fedet - Ramstedt Procedure)
• Nursing interventions: • Monitor fluid and electrolytes

• Place in high fowlers
• Place on right side after eating
• Strict intake and output
• Check specific gravity
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INFANT: Intestinal Disorders
• Bloody currant jelly stools with sausage shaped mass

Intussusception Treatment: Barium enema or Surgery
*If baby has a bowel movement prior to surgery, cancel the procedure
Congenital Megacolon • Absence of ganglion cells in distal colon

Hirschsprung’s • Results in obstruction with failure to pass meconium or ribbon like stools
Disease • Treatment: surgery ; temporary colostomy
Imperforate anus No rectal temperature
• Common in young children • BRAT diet

Diarrhea • May cause dehydration: • Replace fluids- clear liquids
• Monitor electrolytes
• Malabsorbtion syndrome
• Fat or gluten intolerance
• Signs & Symptoms: diarrhea, large bulky stool, anemia, recurrent infections
Celiac disease
• Supplement vitamins A, D, E & K
• Gluten free diet - Avoid BROW
• Can eat rice and corn
• Avoid phenylalanine
PKU • No meat, fish, poultry, eggs, legumes, & nutrasweet
• Lofenolac formula
Cleft Palate and Lip • Child will need speech therapy and orthodontics
• CLEFT LIP repaired @ 2 months
• Child cannot have a respiratory infection
• Steri strips • Elbow restraints
• Logan bar used to keep pressure off the suture line
‫ ٭‬NO PACIFIERS, STRAWS OR ORAL TEMPS 7-10 DAYS
• CLEFT PALATE IS REPAIRED AT 18 MONTHS
• Risk of infection: • Use a large holed nipple • Give water after each feeding
• Burp infant between feedings
Failure to Thrive Organic and Non-organic causes
• The sudden and unexplained death of an infant under 1 year of age

Risks: • Previous SIDS death • Twin gestation
Sudden Infant Death • Prematurity • Alcohol and drug abuse
Syndrome • Smoking • Teach avoid soft mattresses & pillows
• Avoid overheating • Place on “back to sleep”
• Apnea monitoring Teenage mothers & over age 35
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IV. Toddler
TODDLER: Integumentary Disorders
• Highly contagious • Contact precautions
Impetigo • Group A Strep • Antibiotic therapy
• Child has characteristic honey crusted lesions
Burns • Rule of nines up to 12 years old
• Isolate known infected persons
Tinea Capitis (scalp) • Antifungal ointment (Lotrimin – clortrimazole)
Tinea corporis (body) • Oral Griseofulvin: • Hepatotoxic
Tinea pedis (feet) • Give with fatty meal
• Avoid prolonged exposure to sunlight
TODDLER: Musculoskeletal Disorders Fractures/Traction
• Used for children under 2 years of age
Bryants • What type of restraints should be on hand? A jacket restraint to prevent
turning and twisting out of alignment
Bucks extension • Short term immobilization, or for bone deformities
(skin traction) • The body acts as a counterweight
• Padded sling under the knee
Russell
• Check position so hip flexion is maintained
(skin traction)
• Damage to nerve under knee may cause foot drop
TODDLER:Genitourinary Disorders
• Common in boys age 2 to 7 years of age
Nephrosis
• Periorbital edema first sign
• Urethral opening on ventral surface of penis
Hypospadias • Foreskin may be needed for surgical repair
• Baby should not be circumcised
• Non tender, malignant mass of kidney
• Felt in abdomen near liver
Wilm’s Tumor
• Do not palpate - the mass may rupture
• Treatment – nephrectomy and chemotherapy
TODDLER: Cardiovascular System
• Limit milk to 24 oz./day
• Treat with supplemental iron – ferrous sulfate
• Increase vitamin C to aid absorption
Iron Deficiency Anemia
• Give liquid via straw to prevent teeth discoloration
• Give deep IM using Z track
• May cause dark colored stools
TODDLER: Gastrointestinal Disorders
• Intense pruritis at night
• Strict hand washing
Pinworms • Treat all family members.
• Treatment: Vermox (mebendazole) – single dose.
• Dose may need to be repeated in 2 – 3 weeks
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TODDLER: Neurosensory Disorders

Head injury • Concussion – temporary loss of consciousness following trauma
• Abnormal muscle tone and lack of coordination
Cerebral Palsy
• Goal is early intervention to maximize the child’s capabilities
• Bulging fontanel’s r/t increased ICP
• Sunset eyes
Hydrocephalus
• Treatment VP shunt- avoid pressure to shunt; monitor for infection & CSF
leakage
• Mother given folic acid early in pregnancy to prevent
• Avoid pressure to the sac
• Maintain moist sterile dressings
Spina Bifidapina
• Treatment is surgery
Bifida
• Child has paralysis below the defect with bowel and bladder dysfunction
• Teach: straight cath for residual urine using clean technique at home
• High risk for rubber allergy (latex)
Down’s syndrome • Risk factor – advanced maternal age
• Usually affects children prior to age 3

• Hours of repetitive behavior
• Bizarre motor behaviors
• Severely impaired communication
• Child is self absorbed and unable to relate to others
• May display, rocking, spinning, twirling
Autism/Autistic • Nursing interventions:
Disorder • Maintain consistency
• Determine the way child communicates
• Provide for safety if necessary to prevent self injury
• Refer to social programs
• Parental support
• Treatment: OT, PT, Speech therapy, special ED,
antipsychotics, antidepressants
TODDLER: Respiratory Disorders
• Tents most common form of O2 administration for children
• Flush tent with oxygen before putting client inside
Oxygen Therapy • Avoid open flames, cigarettes – post signs
• Wipe away condensation to prevent decreased visualization of child
• Keep clothes and linen dry; Plastic or rubber toys appropriate
• Leads to cognitive impairment and anemia
Lead Poisoning
• Routine screening at 12 months
(plumbism)
• Treatment – iron, chelating agents- penicillamine, increase fluids
Child Abuse:
• Be alert for contradiction between injury and explanation of cause.
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PRESCHOOL: Musculoskeletal Disorders
Duchenne’s Muscular • X- linked inheritance; occurs by age 3

• Gowers’ Sign- use of hands & arms to walk up the body from a
Dystrophy squatting position. It indicates lack of muscle in the lower limbs.
PRESCHOOL: Neurosensory Disorders
Seizure disorders • Generalized – entire brain involved
• Partial or focal – only one hemisphere of brain affected
• Protect from injury
• Anticonvulsants: Dilantin (phenytoin), Phenobarbital, Keppra
(levetiracetam), Depakote (valproic acid)
• Linked to use of ASA and phenothiazine (anti psychotics)
• Varicella or influenzae
Reye’s syndrome
• No ASA in children < 18 years old
• Tx: Mannitol, Diuretics and Barbiturates
PRESCHOOL: Cardiovascular Disorders
• X- linked inheritance
Hemophilia • Prevent injury
• Monitor for bleeding
• ALL (acute lymphoid leukemia)
Leukemia • AML (acute nonlymphoid – Myelogenous- leukemia)
• Prevent infection
PRESCHOOL: Lymph, Infectious Disorders, Immune System
• Spread by direct contact or air droplet

Chicken pox – Varicella
• Airborne & contact precautions if hospitalized
• Spread by aerosolized droplets
• Koplik spots in mouth – small, bright red spots with a blue-white center
Rubeola/Measles
• Rash appears on 4th day
• Airborne precautions
• Spread by direct and indirect contact with droplets

Rubella/ German
• Birth defects if acquired during pregnancy
measles
• Develops after URI with beta hemolytic strep

• Heart, joints, CNS, skin and subcutaneous tissue involved
• If untreated, scarring & deformity of cardiac structures leads to
Rheumatic fever Rheumatic heart disease
• Monitor the heart routinely
• Diagnosis: increased WBC, increased ESR, + C reactive protein
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PRESCHOOL: Respiratory Disorders
• Frequent swallowing is a sign of bleeding
Tonsillectomy • Post op – monitor for stridor; encourage fluids and fruit ices
• NO RED liquids
• Children under 4 at high risk
Choking hazards • Objects with small removable parts
• Several foods (hotdog, popcorn, grapes, hard candy etc.)
PRESCHOOL : Gastrointestinal Disorders
• Common cause of diarrhea in young children
• Incubation period is 2 days
• Symptoms include vomiting, diarrhea, fever and abdominal pain
Rota virus • Transmission: oral – fecal route.
• Usual age of occurrence is 2 years of age
• Can be spread in day care centers
• Treatment includes: oral hydration, & hospitalization if IVF are needed
PRESCHOOL : Genitourinary Disorders

• Primary cause or as a post infection condition related to streptococcal
or pneumococcal organism
• Gross hematuria, oliguria & proteinuria
• Maintain fluid restrictions
Glomerulonephritis • Strict intake and output
• Protective isolation
• Penicillin
• Lasix
• Antihypertensives
• E.coli most common causative organism
• Boys with UTI need further work up
Treatment for chronic UTI:
Urinary tract infections
• Gantrisin (sulfisoxazole) or
• Macrodantin (Nitrofurantoin)
• Backward flow of urine from the bladder into the kidneys - causes
Vesicoureteral Reflux recurrent UTI
• Treatment is surgery only in severe cases
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SCHOOL AGE: Respiratory Disorders
Asthma • Teach: regarding triggers, use of MDI
Erythema Infectiosum
• Characteristic red rash with “slapped face” appearance
5th disease
• Look for a rash in 4 to 14 days
• Caused by human paro virus B19
• Affects children 5 to 14 years of age
• Common in winter & spring
• Pregnant women should not be in contact or care for the
infected child
• Transmitted via direct or indirect contact or droplet spread

• Fever, red rash, strawberry tongue
Scarlet Fever group A strep • Droplet precautions until 24 hours after treatment
• Bed rest
• Antibiotic therapy
SCHOOL AGE: Integumentary Disorders
Head Lice (Pediculosis Capitus) • Do not share hats/combs
SCHOOL AGE: Musculoskeletal Disorders

• Swimming is the best exercise
• ASA is the drug of choice
Juvenile Rheumatoid arthritis
• NSAID’s and prednisone also used
• Goal is to limit deformity
• Disturbance in circulation causes aseptic necrosis of the
Legg – Calves Perthes Disease femoral head
• Treatment- Bed rest with traction
SCHOOL AGE: Neurosensory Disorders
Treatment: • Ritalin • Quillivant • Concerta (methylphenidate)

• Dextroamphetamine (dexedrine)
Attention Deficit Hyperactivity
• Strattera (atomoxetine)
Disorder - ADHD
Side Effects: • Insomnia
• Irritability
• Occurs in children and teens

• Displays a pattern of disruptive & violent behavior
Conduct Disorder • Difficulty following rules
Treatment: Psychotherapy and medications to manage
symptoms
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ADOLESCENT: Musculoskeletal Disorders

Scoliosis • S shaped curvature of spine
• Adam’s Test - forward bend test
• Less than 25 º curves – no treatment
• 25º- 45º curves require bracing
• Greater than 45º - surgery with Harrington rod placement
• Milwaukee Brace 23 hours per day
• Body image disturbance • Risk for alteration in skin integrity
ADOLESCENT: Endocrine Disorders
• Goal is to maintain blood glucose levels and prevent complications
Type 1 Diabetes Mellitus
• Nutritional teaching
ADOLESCENT: Lymph, Infectious Disorders, Immune System
Mononucleosis
• Transmitted by direct contact with Saliva • Epstein- Barr virus
“Kissing Disease”
Hodgkin Disease • Cancer in the lymph system • Biopsy shows Reed - Sternberg cells
ADOLESCENT: Reproductive
• Chlamydia and gonorrhea most common
Sexually Transmitted • Teach prevention
• Treat all contacts
Infections • Gardasil- HPV vaccine: To prevent cervical cancers & genital warts
Given at age 9-26 years male and female
• High risk for pregnancy complications
Adolescent pregnancy • Prematurity and neonatal problems
• Increase daily caloric intake by 300 to 500 calories
Mental Health
• Common in 13 - 23 year old under weight clients- introvert
• Constant exercising • Fear of gaining weight
• Patient has deliberate self starvation with weight loss
Signs and Symptoms:
• Under weight • Lanugo
Anorexia Nervosa
• Amenorrhea • Cold sensitivity
• Dehydration • Electrolyte imbalance
• Cardiac arrhythmias • Constipation
• Bradycardia & brittle nails • Withdrawal from social activities
Treatment: • Medical management • Behavioral therapy
• Common in 20 - 30 year old • Usually overweight- extrovert

• Binge eating of large amounts of food then purging by vomiting or
taking laxatives
Bulimia Signs and Symptoms: • Excessive laxative or diuretic use
• Amenorrhea • Electrolyte imbalance • Withdrawn
• Excessive dental caries and stained teeth
• Treatment: similar to anorexia, antidepressants used
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PSYCHOSOCIAL INTEGRITY
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PSYCHOSOCIAL INTEGRITY
I. Overview of Mental Health Nursing
Mental illness = inability to cope with or manage stress- any disorder that affects mood or
behavior
1. Cultural and ethical considerations
2. Legal / ethical issues
3. Therapeutic communication versus blocks to communication
Technique (therapuetic) Blocks (non-therapuetic- avoid)

Listening Hears but does not actively listen
Broad Openings Rejects/ ignores client responses
Restating Reinforces only part of the message & ignores other parts
Clarification Probes; assumes understanding
Reflection Reinforces unhealthy parts of client communication; stereotypes responses
Exploring Encourages tangential & circumstantial communication
Voicing Doubt Promotes anger; reinforces need for the idea/perception
Verbalizing the Implied Interprets to client; misunderstands the implied message
Summarization Forces conclusions; arrives at inaccurate conclusions
Informing Gives advice or inaccurate information, gives information before client is ready or able to learn
Focusing Forces client to discuss issues that are threatening
Sharing Perceptions Challenges the client
Theme Identification Ignores themes; gives advice
Humor Uses laughing-at humor; promote superficial communication; avoids a problem
Silence Asks questions; fails to break nontherapeutic silence
Suggesting Gives advice; offers suggestions too early in the problem-solving process
Evaluation Focuses on or encourages only positive appraisals
4. Psychiatric assessment: PISSCAGE

• Psychomotor movement Remember your safety ALWAYS comes first.
• Decreased Interest
Watch for nonverbal cues of aggression/ violence
• Suicidal
• ↓or ↑ Sleep (clenched fist, pacing, raised voice, verbal threats).
• Decreased Concentration Always position yourself between the patient and
• ↓or ↑ Appetite an exit. Prepare for seclusion if necessary.
• Guilt
• Decreased Energy
Priority - Assess clients for risk for self injury and violence - Clients with major
mental illness, substance abuse, and psychopathy are at increased risk for
violence.
Clients at risk for self injury:
• Family problems • relationship issues • self esteem issues
• Feelings of stress - work or school • feelings of rejection
• Bereavement • bullying • feelings of guilt
• Reaction to trauma or abuse • peer pressure
• Poor body image • difficulties associated with sexuality
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5. Techniques for answering psycho-social questions

• Determine who is the client in the question
• Always choose an answer that will decrease the client’s anxiety
• Your response should maintain confidentiality and establish trust
• Avoid responses that could be answered with a yes or no
• Never ask why
• Maintain therapeutic communication – allow client to express their feelings,
give information and feedback
• Choose a response that sets limits on behavior and presents reality
• Avoid blocks to therapeutic communication like giving advice, giving false
reassurance and being judgmental
6. Defense mechanisms: unconscious; used by client to decrease anxiety
Compensation Covering up a lack or weakness by emphasizing a desirable trait

Denial Refuse to face reality
Displacement Discharging pent-up feelings from one object to a less dangerous object
Fantasy Gratification by imaginary achievements and wishful thinking
Fixation Persistence into later life of interests and behavior patterns appropriate to an earlier age
Identification Assumption of desirable personality attributes of one admired.
Insulation Passive withdrawal. Inaccessible to avoid further threatening circumstances
Isolation Walling off of certain ideas, attitudes or feelings. Separating feelings from intellect.
Projection Attribution of one’s own undesirable traits to someone else
Rationalization The attempt to prove or justify behavior
Reaction-Formation Preventing the expression of dangerous feelings and desires by exaggerating the opposite attitude.
Regression Resorting to an earlier developmental level in order to deal with reality
Repression Unconscious process that keeps undesirable and unacceptable thoughts from entering the
conscious
Sublimation Primitive or unacceptable tendency is redirected into socially constructive channels.
Suppression Keeping unpleasant feelings and experiences from awareness
Symbolization An idea or object used by the mind to represent an actual event or object
Undoing A specific action is performed that’s considered to be the opposite of a previously acceptable action
7. Effective vs. Ineffective coping mechanisms
EFFECTIVE INEFFECTIVE
Humor, seeking support, problem-solving Denial, self blame, verbalization of inability to cope
Relaxation, physical recreation Inability to ask for help, problem solve or meet basic
needs, insomnia, withdrawal
Adjusting expectations Reluctance to participate in treatment plan
Destructive behavior toward self and others
Inappropriate use of defense mechanisms
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II. Psychiatric Nursing: 3 phases of the nurse client relationship

• Orientation: assessment of client; establish trust
• Working –planning and intervention; establish goals, problem solving,
explore thoughts and feelings; formulate nursing diagnosis
• Termination- begins at admission, evaluation of goals, allow client to discuss feelings
about termination and loss. Maintain limits of final termination.

III. Treatment Modalities
A. Milieu therapy: manipulate & control of the patient’s environment to prevent self
destructive behavior and improve coping skills.
• Individual
• Group: individuals interact together to problem solve
• Family: focus is on family, not individual
• Behavioral: reconditioning of learned behavior
B. Managing Behavioral disorders: De-escalation techniques for the agitated client -

• First attempt to reduce the level of arousal.
• The nurse must appear calm, and self assured. Anxiety can make the client feel
anxious and unsafe which can escalate aggression.
• Use a calm, low monotonous tone of voice (normal tendency is to have a high-pitched,
tight voice when scared).
• Move the situation outside or to another room, if possible. Give the client plenty of
room to move and significant space between you and him. Never turn your back for
any reason.
• Explain limits and rules in an authoritative, firm, but always respectful tone.
Suggest alternative behaviors where appropriate (“Would you like to take a walk and
have a cup of tea?”).
• Do not try de-escalation when a person has a gun or other serious weapon.
C. Somatic Therapy
1. Electroconvulsive (ECT):
• Used to treat depression, schizophrenia, & bipolar mania after medications have failed
• NPO
• No metals in hair, hair should be clean
• No caffeine
• post op - monitor for seizures
• Brain damage, temporary or permanent memory loss
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2. Psychopharmacology
A. ANTIPSYCHOTICS- PHENOTHIAZINES
TYPICAL - TREATS POSITIVE SYMPTOMS ATYPICAL - TREATS POSITIVE & NEGATIVE SYMPTOMS
• Thorazine (chlorpromazine) • Zyprexa (olanzapine)
prescribed for hiccups • Clozaril (clozapine) • Seroquel (quetiapine)
• Haldol (haloperidol) • Risperdal (risperidone) • Geodon (ziprasidone)
• Mellaril (thioridazide) • Abilify (aripiprazole)
• Prolixin (fuphenazine) • Causes Agranulocytosis - Check WBC Q week X 6
months; Q 2 weeks X 6 months
SIDE EFFECTS: ADVERSE REACTIONS:

• Hypotension • Tachycardia • Lethargy • Slurred speech
• CNS depression • Liver disease • Impaired mobility • Impotence
• Extra pyramidal reactions • Dry mouth • Urinary retention • Photosensitivity
(give Cogentin, Artane, Benadryl)
NURSING INTERVENTIONS:
• Decrease hypotension - dangle when standing • Increase fiber to decrease constipation
• Lay flat for 1 hour after medications • Change position slowly
• Give sugarless candy for dry mouth • Teach to avoid getting overheated in the sun,
• Observe for effectiveness 3-6 weeks after use sunblock
administration • Do not give Geodon (ziprasidone) to cardiac
patients with recent MI, or heart failure (prolongs
QT interval)

Neuroleptic Malignant Syndrome – fatal if untreated.
• Occurs with initiation of neuroleptic medications after change from one medication to
another after dose increase and with medication combinations
• Severe extrapyramidal side effects
• Emergency treatment needed
• Signs and Symptoms: • ⁭ Temp • ⁭ Blood pressure
• ⁭ Pulse • Muscle rigidity
• Tremors • Incontinence
• Discontinue medications
• Use these drugs with precaution as they potentiate the effect of:
• Antidepressants • Lithium • Antihypertensives • Anticholinergics
B. Antidepressants:
TRICYCLICS:
• Elavil (amitriptyline) Side Effects:
• Tofranil (imipramine) • Drowsiness
• Pamelor (nortriptyline) • Nocturnal enuresis 182

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SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI’S):

• Prozac (fluoxitine) • Cymbalta (duloxetine)
• Zoloft (sertraline) • Effexor (venlafaxine)
• Paxil (paroxitine) • Pristiq (devenlafaxine)
• Celexa (citalopram) • Lexapro (escitalopram)
Side Effects: nausea, dry mouth, dizziness, decreased appetite; contraindicated in pregnancy
SSRI Syndrome: complication of SSRI use - fever,agitation, tremors, dilated pupils, diarrhea, twitching

MAO INHIBITORS:
• Nardil (phenelzine) Dietary restrictions of foods containing tyramine
• Parnate (tranylcycpromine) Foods to avoid:
• All cheeses except cream or cottage
Clients are at risk for hypertensive crisis
• Meats (deli)
Can lead to intracranial hemorrhage • Aged or cured fish (anchovies, herring)
Signs and Symptoms: • Avocados • Figs
• Increased blood pressure • Beer • Red wine
• Palpitations • Diaphoresis • Yeast extracts • Liver
• Yogurt • Sauerkraut
• Chest pain • Headache
• Smoked meats • Soy sauce
NURSING INTERVENTIONS: DRUGS TO AVOID:
Monitor vital signs frequently • Over the counter medications
• Other antidepressants • Decongestants
DO NOT STOP ABRUPTLY • Narcotics • Stimulants
• Antacids (inhibit absorption) • Cocaine
Hold medications 2 weeks before surgery
• Amphetamines • ETOH
and between change in drug class; 6
• Asthma medications • CNS depressants
weeks before starting Prozac
• Ginko & Kava Kava Increases the effect of MAOI’s
Wellbutrin, Zyban (bupropion Hcl): May be used for smoking cessation
Side Effects:• Drowsiness • Dry mouth • Tremors • Administer with food
Remeron (mirtazapine): SE – flu like syndrome; report fever, chills, sore throat
C. MOOD STABILIZERS:
Lithium Monitor levels 1 - 2 times per week until blood level is therapeutic then every month, then
every 3 - 6 months; Normal 0.6 - 1.5 mEq/L
D. ANTIANXIETY AGENTS: E. SEDATIVES / HYPNOTICS:
Xanax (alprazolam)
Librium (chlordiazepoxide) Halcion (triazolam) - avoid using with cimetidine
Buspar (buspirone) Restoril (temazepam)
Valium (diazepam) Side Effects: CNS depression, nausea, vomiting,
Side Effects: CNS depression, physical and or diarrhea, hepatomegaly
psychological dependence.
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IV. Mood Disorders

1. BIPOLAR DISORDER – manic – depressive disorder
• Moods alternate between depression and excessive elation
• Client may be a risk to self and others------suicide or homicide risk
• Provide safe environment – PRIORITY
• During manic phase client may neglect ADL’s and nutrition - Provide finger foods
• Treatment: Eskalith (lithium), Lamictal (lamotrigene), Abilify(aripiprazole)
Individual / family / group therapy, ECT (mania)

2. MAJOR DEPRESSION – SAFETY, SAFETY, SAFETY!!!!
• Suicide – safety is the priority
• Provide 1:1 watch
• Ask patient directly if they have a plan
• Signs of suicidal ideation include elevated mood & giving away prized possessions
• Initiate suicide precautions
Treatment: antidepressants, individual or group therapy
a) Bipolar (manic-depression):
• Lithium- initial dose 600 mg tid blood level of 1.0 - 1.4 is desirable
• Check level 12 hours after last dose 2 times per week- take with food
• Maintenance dose - 300 mg to maintain a level of 0.6-1.2 mEq/L check monthly
• Toxicity greater than 1.5 mEq/L - Life threating S/E: arrhythmias, renal toxicity
• Increase sodium
SIde effects: blurred vision, polyuria, lethargy, vomiting, thirst
b) Postpartum Depression
• Occurs up to 6 months after child birth & not resolving in one or two weeks
• Inability to cope with infant care needs
• Treatment: same as depression and referral to PPD support groups
c) Dysthmic Disorder
• Depression in excess of 9 -12 months

• Treatment: same as depression
d) Seasonal Affective Disorder

• Occurs in the fall and winter months
• Related to decreased sun
• Treatment: • Vitamin B6
• St. John’s wort
• Decrease caffeine & fat in diet
• Increase fruits & vegetables
• Phototherapy
• SSRI’s
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3. ANXIETY:
MILD • Associated with every day life, can be motivating
• Focus is on immediate concerns

MODERATE • Narrow perceptual field
• Learning and problem solving can take place
• Significant reduction in perceptual field
• Focus is on specific details
SEVERE
• Learning and problem solving cannot take place
• Need directions to focus
• “Sense of impending doom”
• Personality is disorganized, cannot communicate or function effectively
PANIC
• Loss of rational thoughts
• Inability to concentrate

V. Substance Abuse Disorders
Alcohol withdrawal occurs 4-12 hours after last drink
Signs & Symptoms:
• Anxiety • Nervousness
• Caffeine
Frequently Abused • Irritability • Headache • Nausea & vomiting
• Nicotine
Substances • Levels greater than 100 mg/dl induces seizures
• Alcohol
Delirium tremens – HTN, tachycardia, delusions,
hallucinations and seizures
Treatment: IV anti-anxiety agents, Librium
(chlordiazepoxide) & IVF, Antabuse (disulfiram)
Cocaine:
• Dilated pupils • Weight loss
• Cocaine • Increased heart rate, B/P & temperature
• Perspiration & chills • Hyperactivity
• Heroin
• Overdose: Cardiopulmonary arrest and seizures
• Marijuana • Treatment: Cardiopulmonary support
• Vicodin (hydrocodone) Heroin:
Controlled & Illicit
• Percocet (oxycodone) • Euphoria • Flushing • Pinpoint pupils
Substance Abuse
• Withdrawal symptoms: N/V/D, cold flashes,
• Methadone
muscle spasms
• Seconal (secobarbital)
• Treatment: Naloxone and respiratory support
• Phenobarbital Barbiturates:
• CNS depression • Dilated pupils
• Withdrawal symptoms: seizure & delirium
• Treatment: Cardiopulmonary support
• Gambling
• Sex
• Group support
Addiction • Eating
• Behavioral therapy
• Shopping
• Internet use 185
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VI. Personality Disorders
Unpredictable, self destructive behaviors
Suicide risk
Frequent displays of inappropriate anger
Borderline
Impulsiveness
Recurrent acts of crisis such as wrist cutting, overdosing or self injury
Treatment: group therapy, medications for mood & depression
Poor impulse control
Antisocial
Suicide risk
Paranoid Delusions of persecution
Grandiosity, preoccupied with fantasies of power and success

Narcissistic
Exploit others to achieve personal goals
Characterized by a pattern of excessive emotionality & attention seeking behaviors
Excessive need for approval
Histrionic
Inappropriate seductive behavior
A need to be the center of attention
VII. Anxiety Disoders

High need for routine
Obsessive-Compulsive Limit, but do not interrupt compulsive acts.
Treatment: thought stopping techniques, anti-anxiety agents & SSRI’s
Abnormal fear of open spaces or being alone in public places
Agorophobia
Patient may refuse to leave home- results in panic attacks
Disturbed response to trauma
Post Traumatic Stress Characterized by flashbacks and feelings of guilt
Disorder Also nightmares, depression or panic attacks
Treatment : crisis management, family therapy
The person intentionally fakes, simulates, worsens or self induces

Munchausen Syndrome
injury or illness for the purpose of being treated like a medical patient
Refers to a caregiver who fakes symptoms by causing injury to

Munchausen’s by proxy
someone else and wants to be with that person in the hospital setting

VII. Somatoform Disorders
• Onset prior to age 30
• Multiple physical complaints that cannot be explained medically
Hypochondrias Physical symptoms perceived as life threatening
Conversion Symptoms without any physiological cause, usually neurological
Physical symptoms that involve more than one part of the body, but no physical
Somatization
cause can be found
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VIII. Psychotic Disorders

SCHIZOPHRENIA
Four A‘s Types
• Paranoia type • Catatonic type
• Affect • Associative
• Residual type • Disorganized type
• Ambivalence • Autistic thinking
• Undifferentiated type
Signs and symptoms characterized by:
• Disordered thinking Thought broadcasting: individual believes that others
• Disrupted affect can hear his thoughts
• Perceptual disturbances ‫٭‬At least two of these symptoms must be pres-
• Behavioral abnormalities ent for a large portion of time during a 1- month
• Impaired social interactions period for diagnosis
Symptoms usually include:
Illusions Positive symptom
Delusions Positive symptom
Hallucinations Positive symptom
Disorganized speech & bizarre behavior Positive symptom
Lack of speech, catatonic behavior Negative symptom
Poor social functioning, lack of concentration Negative symptom
Paranoid type:
• Auditory hallucinations
• May appear hostile and angry
• Provide pre-packaged foods
• Monitor for suicide
• Usually have persecutory delusions- Do not touch client
Catatonic type:
• Stupor or extreme motor agitation
• Inappropriate or bizarre body postures (body remains in a fixed position almost wax like)
• Echolalia: Involuntary repetition of words spoken by another person
• Echopraxia: Imitation of motions made by others
Disorganized type:
• Disorganized speech and behavior, inappropriate or flat affect
Undifferentiated type:
• Disorganized behaviors, psychotic symptoms (delusions, hallucinations)
Residual type:
• Absence of prominent psychotic symptoms, inappropriate affect, social withdrawal, eccentric
behavior
*Positive symptoms = increased mental experiences (thoughts, feelings, behaviors) than a normal mental state
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AUDITORY PROCESSING/PERCEPTUAL ALTERATIONS
Delusion A false fixed belief
Illusion Misperception of a stimulus
Hallucination Sensory perception but there is no stimulus
DEFINITIONS
Akathisia Restlessness – give Cogentin (benztropine), Artane (trihexyphenidyl), or
Benadryl (diphenhydramine) (CAB)
Dystonia Muscle spasm
Akinesia Lethargy – feeling of fatigue and muscle weakness
Neologism Inventing new words which are only meaningful to that person
Clang association Rhyming words in a sentence that make no sense
Word Salad Disconnected /disorganized thoughts, using recognizable words that do
not make sense.
Flight of ideas Rapid change from one topic to another that is unrelated
IX. Cognitve disorders

Delirium Acute, reversible
Chronic, irreversible syndrome that affects language, memory,
Dementia
cognition, personality and judgment
Types: Symptoms:
Early Phase:
• Alzheimer’s type • Impaired abstract thinking, judgment &
• Vascular dementia impulse control
• HIV dementia • Neglect of personal appearance & hygiene
• Dementia due to general medical conditions Late Phase:
• Substance induced dementia • Aphasia - loss of speech
• Apraxia - loss of motor function
• Inability to perform ADL’s
Alzheimer’s Disease
• Slow, progressive loss of intellectual ability
Early Stage • Forgetfulness
• Difficulty in learning new things
• Increase in memory loss
Middle Stage • Social withdrawal
• Decreased ability to perform ADL’s
• Wanders
Middle- Late Stage • Unable to perform simple tasks without repetition
• Unable to recognize familiar objects and family
• Bedridden • Difficulty swallowing
Late Stage • Profound memory loss
• Weight loss, unable to speak or ambulate
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Medications to Increase Acetylcholine
Cognex Side effects: ataxia (unsteady gait, lack of coordination) loss of appetite,
(tacrine) hepatotoxicity, nausea, vomiting, diarrhea
Aricept
Side effects: nausea, diarrhea, decreased heart rate
(donepezil)
Used to treat mild to moderate dementia of Alzheimer’s or Parkison’s
Exelon disease — take with food
(rivastigmine) Side effects: stomach pain, nausea, vomiting; anorexia, black, bloody or
tarry stools
Used to treat moderate to severe Alzheimer’s
Namenda Take with full glass of water
(memantine) Contraindicated with liver disease, kidney disease, seizures, cataracts
Side effects: dizziness, confusion, constipation, chest pain, tachycardia
Razadyne Used to treat mild to moderate Alzheimer’s

Side effects: bradycardia, syncope, anemia, N/V/D, dizziness,
(galantamine) headache, UTI

Terms: Apraxia: impaired motor function
Agnosia: inability to recognize familiar objects
5 A’s Amnesia: memory loss
Anomia: inability to remember names of things
Aphasia: inability to speak

Reminiscence Group - participants are encouraged to talk about
past events at least once per week. Used in dementia - helps improve
cognition and improve mood along with improved functional ability.
Validation Therapy - is frequently used in dementia care to

redirect behavior without causing anger or frustration. An important
component is to “agree” with them, but to also use conversation
to get them to do something else without them realizing they are
actually being redirected.
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Common Medications Used in Mental Health

ANTIPSYCHOTICS ANTICHOLINERGICS /ANTIHISTAMINES
Clozaril (clozapine)* Artane (trihexyphenidyl) *
Haldol (haloperidol)* Atarax, Vistaril (hydroxyzine)*
Mellaril (thioridazine) Benadryl (dipenhydramine)*
Navane (thiothixene) Cogentin (benztropine)*
Prolixin (fluphenazine) ANXIOLYTICS / HYPNOTICS

Thorazine (chlorpromazine)* Ambien (zolpidem)
Trilafon (perphenazine) Ativan (lorazepam)*
Risperdal (risperidone)* BuSpar (buspirone)*
Seroquel (quetiapine)* Dalmane (fluazepam)
Zyprexa (olanzapine)* Halcion (triazolam)
ANTIDEPRESSANTS Klonopin (clonazepam)
Celexa (citalopram) Librium (chlordiazepoxide)*
Desyrel (trazadone) Restoril (temazepam)
Effexor XR (venlafaxine) Valium (diazepam)*
Extended –release Xanax (alprazolam)*
Elavil (amitriptyline) MOOD STABILIZERS

Luvox (fluvoxamine) Depakote (divalproex sodium)
Paxil (paroxetine)* Depakene (valproic acid)
Prozac (fluoxetine)* Lamictal (lamotrigine)*
Remeron (mirtazapine)* Lithonate, Eskalith (lithium)*
Cymbalta (duloxetine)* Neurontin (gabapentin)*
Lexapro (escitalopram) Tegretol (carbamazepine)*
Pristiq (devenlafaxine)* STIMULANTS

Serzone (nefazodone) Adderall (dextroamphetamine)
Sinequan (doxepin) Cylert (pemoline)
Wellbutrin SR (bupropion) Dexedrine (dextroampheatamine)
Sustained-release Ritalin, Concerta (methylphenidate)*
Zoloft (sertraline)* Strattera (atomoxetine)
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PRACTICE QUESTIONS
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Safe, Effective Care Environment:

Management of Care 5. The nurse from the pediatric unit has been temporarily
assigned to the Emergency Department. It would be
1. A nurse has become aware of the following client most appropriate to assign that nurse to the client
situations. Which of the following if observed shows who
that the UAP needs further teaching? The UAP
A. reports epigastric pain that “feels like indigestion”
A. avoids washing the body of a Jewish client until B. has back pain and a pulsating abdominal mass
thirty minutes after death C. is HIV+ reporting vomiting and diarrhea
B. allows the family of a Buddhist client to chant ritual D. presents with lower abdominal pain and is six
rites at the bedside of their deceased father weeks pregnant
C. provides coffee and cookies for the visiting family
of a Mormon client 6. A nurse has become aware of the following situations.
D. removes a cup of tea from the breakfast tray of a Which should cause the greatest concern for the
Seventh Day Adventist client nurse? A client with
2. A nurse is preparing assignments for the day. Which of A. a bipolar disorder who is screaming at the nurses
the following clients should the nurse see first? station
B. congestive heart failure has bi-pedal edema
A. A client with Diabetes Mellitus drinking 8L of fluid C. a transurethral resection of the prostate (TURP)
per day has blood tinged urine in the urinary bag
B. A client who is post-operative day 7 after a coronary D. radon seed implants is seen ambulating in hall
artery bypass graft (CABG)
C. A client diagnosed with COPD with an oxygen 7. After receiving report a nurse is planning an
saturation of 92% assignment for the day. Which of the following should
D. A client with benign prostatic hypertrophy (BPH) the nurse see first? The client
complaining of scant urine flow
A. requesting a bedpan
3. A nurse is preparing assignments for the day. Which B. complaining of pain 2/10 on a pain scale
of the following clients should the nurse see first? A C. with report of excessive tiredness
client with D. who did not receive a breakfast tray
A. Type II DM complaining of having cold feet 8. The nurse is caring for clients who were recently
B. Congestive heart failure (CHF) with SOB after removed from a falling building. Who would the nurse
ambulating see first? The client with
C. abdominal surgery with temperature of 101°
D. Chronic Obstructive Pulmonary Disease (COPD) A. first degree burns and a sprained left ankle
with a CO2 of 50 B. dilated pupils and a small laceration to the left ear
C. a fracture of the right tibia and abdominal pain
4. A nurse is doing an assessment on several clients. D. confusion and soft tissue injuries
Which one of them would need follow up?
9. A nurse is preparing assignments for the day. Which
A. A client with chronic renal failure that did not void of the following clients should the nurse see first?
for 8 hours
B. A client with Bells Palsy complaining of tingling in A. A 48 y.o ventilator dependent client who needs a
the face sputum specimen
C. A client with Alzheimer’s disease sitting at the B. A 54 y.o on Bleomycin (Blenoxane) complaining
nursing station with lap buddy of vomiting
D. A client diagnosed with COPD with a pulse C. A 65 y.o with pneumonia who needs to start IV
oximetry of 92% antibiotics
D. A 72 y.o asthmatic complaining of SOB after using
Albuterol (Ventolin)
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10. Following an accident involving two cars and a bus, a 15. The nurse is teaching a group of new nurses about
nurse arrived upon the scene. Which of the following advance directives. Which of the following statements
clients should the nurse see first? A client indicates a need for clarification by the nurse?
A. who is restless and combative A. A DNR order is sometimes interpreted to mean

B. with an open fracture of the right tibia that the client requires less nursing care, when
C. with an eye injury complaining of pain in the face they actually have significant medical and nursing
D. a fractured arm who is ambulatory care needs
B. The ethical obligation to care for all patients is
11. A nurse is caring for several infants. Which newborn is clearly identified in the first statement of the Code
the priority to be seen first? of Ethics for nurses
C. A dying patient does not have the right to request
A. 2 hours old who is acyanotic that no more food or fluid be administered
B. 13 hours old infant who is jittery D. The durable power of attorney for health care
C. 20 hours old with descending testicles identifies another individual to make health care
D. 24 hours old with a heart rate of 140 bpm decisions on his or her behalf
12. The charge nurse is making assignments for the day. 16. A nursing instructor asks a nursing student to identify
Which client would you assign to an RN floated from a situation that represents an example of invasion
Maternity to a Behavioral Health unit? of privacy. Which of the following if identified by the
student indicates an understanding of a violation of
A. A client diagnosed with bipolar disorder this client right?
B. A client that frequently threatens the staff
C. A quiet patient A. Performing a procedure without consent
D. A very busy patient B. Telling the client that he or she cannot leave the
hospital
13. A nurse is caring for several infants. Which newborn is C. Threatening to give the client a medication
the priority to be seen first? D. Observing care provided to the client without the
client’s permission
A. A 1-hour old with mongolian spots
B. A 2-hour old with a respiratory rate of 70 17. The community health nurse is assigned to see four
C. A 3-hour old with a blood pressure of 80/40 clients. Which of the following clients will the nurse see
D. A 4-hour old with petechiae on the trunk first?
14. A nurse working on a pediatric unit is made aware of A. A 24 year old with gastroesophageal reflux
the following situations. Which child is the priority to be disease who does not tolerate milk
seen first? B. A 32 year old with cancer of the esophagus who
has given away his favorite shirt
A. 1 year old with Tetralogy of Fallot with bluish C. A 44 year old with Crohn’s disease who is
discoloration to the lips while crying complaining of abdominal cramps
B. 2 year old with renal failure with a potassium level D. A 55 year old with a gastrostomy tube who will
of 6.4 mEq/L begin self- feeding for the first time
C. 3 year old diagnosed with Rheumatic Fever with
an elevated ESR rate
D. 4 year old diagnosed with Rota-Virus having 5
bowel movements per 8 hour shift
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18. After receiving report from the night nurse, which of 22. The nurse received change of shift report, which
the following patients should the nurse see first? of the following clients will take the highest priority
when planning care?
A. A 30- year old woman who is 38 weeks
pregnant complaining of a small amount of A. The client with (end stage renal disease) ESRD
vaginal bleeding who has not voided in ten hours
B. A 42- year old man with left sided weakness B. The client with inflammatory bowel disease
asking for assistance to the commode who has had a recent increase in restlessness
C. A 55-year old woman complaining of chills who is C. The client who is four hours post operative
scheduled for a total abdominal hysterectomy bladder biopsy and is experiencing hematuria
D. A 77-year old man with a nasogastric tube who D. The client who is diabetic experiencing tingling
had a gastrectomy yesterday of the toes
19. After receiving report, which of the following clients 23. The nurse arrives upon the scene of a multiple
should the nurse see first? vehicle accident with several injuries. Which of the
following client’s should the nurse evaluate first?
A. A 24-year-old with Steven Johnson Syndrome
that has a rash on the trunk A. A 16 year old female who is unresponsive with
B. A 36-year-old patient scheduled for a dilated pupils
colonoscopy who is refusing care B. A 22 year old male with deformity of the right
C. A 44-year-old client with Buerger’s disease arm who is reporting pain
complaining of tingling in the digits C. A 32 year old male with a small thigh
D. A 56-year-old in sickle cell crisis with an laceration
infiltrated IV D. A 50 year old female experiencing anxiety, and
generalized weakness
20. The nurse is caring for postpartum clients who had
vaginal deliveries within the last eight hours. The 24. The RN needs to make assignments for four
nurse should first assess the client who patients. The team consists of 3 LPN’s and 1 CNA.
Which of the following clients would be appropriately
A. has a pulse rate of 66 beats per minute assigned to the CNA (Certified Nursing Assistant)?
B. has saturated one perineal pad in two hours
C. reports swelling in her right calf A. the client who needs a simple dressing change
D. asks if her baby can sleep in the nursery of an abdominal wound
tonight B. client who needs irrigation of the colostomy
C. the client receiving parenteral feedings
21. The nurse is caring for four newborns in the nursery. D. the client requiring administration of an enema
Which of the following infants is the priority while prior to a surgical procedure
planning care? The infant who is
25. Which of the following clients is appropriate to
A. one hour old experiencing acracyanosis assign to an LPN for medication administration?
B. three hours old with nasal flaring
C. one hour old whose eyes appear crossed A. A 25 year old in sickle cell crisis who will need
D. three hours old with an edematous area on the Morphine intravenously
head B. A 36 year old post operative client who is using
a PCA pump
C. A 50 year old who will need Regular Insulin
coverage for a glucose reading of 240mg/dl
D. A 60 year old who needs Dopamine
intravenously for blood pressure management
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26. The charge nurse is making assignments for the day. 31. The nurse is making assignments for the day.
Which patient would you assign to the RN floated from Which assignment should be assigned to the
the Pediatric unit to the Emergency Department? LPN?

A. A 2 year old admitted with suspected ingestion of A. Application of wrist restraints
chlorine B. Collection of a 24 hour urine specimen
B. A 5 year old being treated for Asthma that is not C. Assisting a client to ambulate after surgery
responding to bronchodilators D. Initiation of the clients plan of care
C. A 7 year old brought to the department following a
motor vehicle accident 32. The nursing team consists of a RN/LPN and UAP.
D. A 10 year old awaiting admission following cast Which action should be appropriately assigned to
placement the LPN?

27. Which client would you assign to the new grad RN? A. Bathing a child admitted with chickenpox
B. Taking the vital signs of the recently admitted
A. The client admitted for suspected Guillian-Barre´ client
exacerbation C. Transporting a client to the chapel for noon
B. The client scheduled for transfer to the ICU time prayers
C. A client experiencing chest pain after coughing D. Insertion of an indwelling catheter for a client
D. A newly admitted client who needs the initial with urinary retention
assessment completed
33. In providing care for a client being treated for fluid
28. Which action should the nurse delegate to the UAP volume excess, which of the following interventions
when providing care for the client with CHF? would be best delegated to an experienced UAP?
Select all that apply.
A. Checking the clients weight daily
B. Teaching regarding dietary restrictions A. Monitor EKG readings
C. Monitoring the amount of pedal edema B. Obtain vital signs every 30 minutes
D. Notifying the physician about the presence of a C. Check for the presence of pedal edema
cough D. Insert IV line
E. Document hourly urine output
29. The Charge nurse is making assignments for the day. F. Measure weight
The team consists of the RN/LPN-LVN and UAP. Which
client is appropriate to assign to the UAP? 34. A mental health nurse is floated to work on the
medical surgical unit. Which client would be most
A. The client who had a stroke 4 days ago with left appropriate to assign to the nurse? A client that:
sided weakness who needs feeding
B. The client who needs assistance with oral A. is 4 hours post operative following
suctioning cholecystectomy
C. A recently admitted client who needs their vital B. has dehydration and needs IV fluids
signs taken C. has mechanical ventilation and needs to be
D. A client who requires chest physiotherapy every suctioned
shift D. is in traction for a broken femur
30. You are making assignments for the day. Which client
will you assign to the Maternal Health nurse who is
floated to the medical- surgical unit?
A. A postpartum client who is ventilator dependent

B. The client with gestational diabetes admitted with
glomerulonephritis
C. The client who is 2 days post-operative following
exploratory laparotomy
D. A client scheduled for spinal surgery who needs
pre-op medications
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6. The nurse is caring for several clients requiring

Safe, Effective Care Environment:
isolation. There is one private room available on
Safety and Infection Control
the unit. The nurse should place the highest priority
on assigning which of the following clients to the
1. A nurse is caring for the following clients. Which client
private room?
is the priority for a private room? A client with

A. The client with fever and diarrhea for 2 days
A. HIV infection
after taking antibiotics
B. Cirrhosis of the liver
B. The client who is HIV + with a temperature of
C. Scabies
101°
D. Pneumonia
C. The client with low grade fever and night

sweats
D. The client with Leukemia whose temperature is
is a priority for a private room? A client with
100°

A. Rubeola
7. The infection control nurse is making rounds on
B. Rubella
a Medical Surgical unit. Which of the following,
C. Klebsiella Pneumoniae
if observed by the nurse requires immediate
D. Pediculosis
intervention?

A. A CNA is observed wearing gloves while
is a priority for a private room? A client with
emptying a foley catheter

B. An RN is observed wearing a surgical face
A. Hepatitis
mask while caring for a client with tuberculosis
B. Pyelonephritis
(TB) in a negative pressure room
C. Gastroenteritis
C. An LPN is observed wearing a gown and
D. Meningitis
gloves while caring for a mentally ill client with

Clostridium Difficile toxin
4. A client recently diagnosed with AIDS is being
D. A RN is observed wearing a gown, gloves,
discharged home from the hospital. Which of the
and shoe covers while caring for a client with
following statements if made by the client would
Pertussis.
indicate a need for further teaching?

8. The staff members of an out-patient clinic have
A. “I cannot go shopping in the mall during the
successfully assisted the clients to safety during a
holiday season.”
fire in the waiting area. Which action should the
B. “I will have to avoid fresh fruit and vegetables
nurse perform next?
now.”

C. “I will clean my bird cage as soon as I get
A. Close all open doors
home.”
B. Call for additional help
D. “I should not visit my sister since she has the
C. Attempt to extinguish the fire
flu.”
D. Assess the clients’ vital signs

5. A nursing student observes the following situation on
9. The nurse is observing a staff member caring for
the unit . Which occurrence would require an incident
clients. It would require immediate intervention if
report?
the nurse observes the staff member

A. a client reports sexual abuse by a family member
A. placing a client who had an above-the-knee
3 months ago
amputation (AKA) 24 hours ago in a prone
B. the nurse forgets to administer pre-operative
position
medication to a client who is scheduled for
B. keeping the head of the bed elevated for the
surgery
client who had an supratentorial craniotomy 12
C. a client became angry when the nurse removed
hours ago
their dentures prior to going to the O.R.
C. giving orange juice to a client who has a clear
D. the client reports dissatisfaction with the pre-
liquid diet prescribed
operative teaching provided
D. removing all liquids from the tray before giving
the tray to a client who has dumping syndrome
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10. The nurse should initiate protective precautions for the 6. A nurse is teaching a class to parents regarding
client who has appropriate toys for their infants. Which of the
following would be the most appropriate toy for a
A. Red Blood Cell Count (RBC) of 3,900/mm3 3 month-old?
B. Platelet count of 400,000μ/L
C. Hemoglobin (Hgb) 9.0 g/dl A. soft, colorful squeeze toys
D. White Blood Cell Count (WBC) 2,500/mm3 B. teething toys with small removable parts
C. soft padded books and blocks
Health Promotion and Maintenance D. low lying mobile in the crib

1. A nurse is caring for several infants, which finding is 7. A nurse is teaching a class to parents regarding
abnormal in a newborn? appropriate toys for their toddlers. Which of the
following would be the most appropriate toy for a
A. Presence of the moro reflex 2-year-old?
B. Positive babinski reflex
C. Closed posterior fontannel A. tricycle
D. Respiratory rate 38 and irregular B. rocking horse
C. puppets
2. A nurse is caring for a client experiencing late D. a ball to throw and catch
decelerations. The appropriate initial action by the
nurse is to: 8. The nurse is working in a pediatric clinic. A 2
month old baby is brought in for a well baby check
A. change the clients position up. The nurse should anticipate the following
B. notify the health care provider in charge vaccinations will be required during this visit
C. increase the Pitocin (Oxytocin) drip
D. decrease the IV fluid infusion A. Hepatitis B, Varicella, OPV
B. Hepatitis B, PCV, MMR
3. A nurse working in labor and delivery walks into the C. Hepatitis B, DTaP, HIb, IPV, PCV
room of a client that is 37- weeks- gestation and notices D. Hepatitis B, HIb, IPV, MMR, PCV
a prolapsed cord? The initial action of the nurse should
be to 9. A nurse working in a clinic is doing teaching
regarding sexually transmitted Infections. The
A. use a sterile glove to put cord back inside client cannot understand how syphillis was
B. place the client in trendelenburg position contracted because there has been no sexual
C. use a dry sterile gauze to cover the cord activity for several days. As part of teaching,
D. initiate Leopold’s Manuever to approximate the the nurse explains that the incubation period for
fetal positon syphilis is about:

4. A nurse is caring for a client experiencing mastitis. A. 1 month
Which action would be most appropriate? B. 1 week
C. 2 - 3 weeks
A. Advise the client to discontinue breast feeding D. 2 - 4 months
B. Encourage the client to express milk from the
breasts frequently 10. The nurse working in an adolescent clinic is
C. Apply ice chips every 15 minutes preparing to immunize a 14-year old female client
D. Encourage the client to wear a tight fitting bra with Measles, Mumps, Rubella (MMR) vaccine.
Important data collection prior to administration
5. A nurse in the prenatal clinic is caring for a client. should include
The last normal menstrual period was from May 3,
2017 to May 8, 2017. Calculate the expected date of A. a history of the last Tetanus & Diphtheria (TD)
confinement (EDC). injection
B. checking for allergy to yeast
A. March 15, 2018 C. date of the last menstrual period
B. January 10, 2018 D. having the client sign a consent form
C. February 10, 2018
D. February 15, 2018
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11. The nurse is assessing a 5-month-old infant. The 4. A nurse is caring for a client who is racing around
nurse should expect the infant to the unit and wringing his hands. He is breathing
rapidly and complains of “feeling his heart racing
A. turn from abdomen to back very fast.” He said he feel like he is having a heart
B. say one syllable words attack. This anxiety can be interpreted as:
C. use index finger and thumb to grasp
D. sit without support A. Mild
B. Moderate
12. A client is admitted to Labor and Delivery at 38 weeks C. Severe
gestation. The nurse would be correct to state that D. Panic
the client is in the second stage of labor when
5. A nurse is teaching a parent of an adolescent with
A. the placenta is delivered severe depression signs of an impending suicide
B. bulging is seen in the perineum attempt. Which of the following should alert the
C. contractions are irregular parent of a high risk for suicide?
D. rubra lochia is noted
A. The adolescent sleeps most of the day
Psychosocial integrity B. The adolescent has a plan to kill herself
C. The adolescent has recently lost ten pounds
1. A nurse is caring for a client taking Thorazine D. The adolescent refuses to eat, and frequently
(Chlorpromazine). Which statement shows an forces herself to vomit
understanding of instructions regarding this
medication? The client states 6. An emergency room nurse is caring for a client with
suspected phenobarbitol use. Which of the following
A. “I will take my pills every time I hear voices” will result if the client has a barbituate addiction?
B. “I will drink extra fluid to prevent this dry mouth “
C. “ I will wear a wide brim hat up at the beach” A. Watery eyes, slow shallow breathing, frequent
D. “ I will stop my medication when I feel better” sniffing
B. Dilated pupils, shallow respirations, weak and
2. A client on an inpatient psychiatric unit believes the rapid pulse
staff is trying to poison her. The nurse should: C. Constricted pupils, respirations depressed,
nausea, vomiting
A. Explain that the staff is trust-worthy D. Sluggish pupils, increased respirations,
B. Allow the client see others eat their food decreased pulse
C. Offer factory-sealed foods and beverages
D. Taste the food in front of the client to prove it is 7. A nurse is assessing a client with major depression.
edible Which statement, if made by the nurse is most
appropriate?
3. The nurse is caring for a client with bipolar disorder
who has lithium (Lithotabs) prescribed. The nurse A. Tell me more about the voices you have been
should suggest that the client have which of the hearing
following snacks? B. You seem to be very angry, when did you last
feel happy?
A. A fresh fruit cup C. Have you had any thoughts of harming
B. Coffee and oatmeal cookies yourself?
C. Peanut butter and celery sticks D. When was the last time you had fun?
D. Raw vegetables
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8. The nurse is developing a nursing care plan for a client Physiological Integrity: Basic care and
who is the manic phase of bipolar disorder. Which Comfort
intervention should the nurse include in the plan of
care? 1. The nurse is teaching a class on nutrition. Which
of the following selections would be the highest in
A. Provide the client with finger foods K+?
B. Engage the client in competitive games
C. Encourage the client to avoids foods containing A. Corn, oatmeal, tomatoes
tyramine B. Carrot, broccoli, yogurt
D. Place the client on direct suicide observation C. Milk, sardines, beef
D. Potato, spinach, avocado
9. The nurse is admitting a 20-year-old client with anorexia
nervosa. The nurse should assess the client for 2. A nurse is caring for a client admitted with
Laënnec’s cirrhosis. Which vitamin supplement
A. stained enamel of the teeth may be necessary to include?
B. lanugo-type hair on body
C. persistent ringing in the ears A. Vitamin B6
D. white patches on the tongue B. Vitamin A
C. Vitamin B1
10. The nurse has attended a staff development conference D. Vitamin C
on cultural considerations for client’s receiving hospice
care. Which of the following statements if made by the 3. A nurse is caring for a client with Celiac disease.
nurse would require follow up? Which of the following statements shows that
teaching has been effective?
A. The family of a client of the Buddhist faith may ask
for a priest to be present at the time of death A. “I enjoy eating oatmeal for breakfast.”
B. The family of a client of the Jewish faith may B. “I dislike rice so it will be easy to avoid.”
request to have mirrors covered after the death of C. “I will have popcorn and juice while I am at
the client the movies.”
C. The family of a client of the Muslim faith may D. “I can have eggs with my rye toast.”
request that the body of the client be turned to face
the South East at the time of the client’s death 4. The nurse is observing a client with renal failure
D. The family of a client of the Hindu faith may request select foods from the lunch menu. Which of the
that the client body be bathed after the client’s following selections if made by the client would
death indicate a need for further teaching?

11. A 45 year old client who was recently diagnosed with A. Haddock and spaghetti
terminal cancer says to the nurse “If God could only B. Cereal with buttermilk
let me live long enough to put my daughter through C. Corned beef and rice
college, I wouldn’t mind dealing with this illness.” The D. Egg salad on wheat toast
nurse caring for this client recognizes this statement as
reflective of which stage of grieving? 5. Mr. Jones is being treated for uric acid stones.
While doing a dietary history, which of the
A. Denial following food choices demonstrates a need for
B. Acceptance further teaching?
C. Bargaining
D. Anger A. chicken and baked potatoes
B. asparagus and liver
C. scrambled eggs and cheese
D. pancakes and bacon
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6. A client is taking dyrenium (trimterene) and is observed 10. The nurse is attempting to collect a stool sample for
eating the following foods. Which foods should the occult blood. Which of the following foods should the
nurse instruct the client to avoid? client avoid prior to the test? Select all that apply:

A. fried chicken and rice A. Oranges
B. baked potatoes and fresh spinach B. Watermelon
C. pasta and gravy C. Bananas
D. macaroni and cheese and legumes D. Kiwi
E. Avocado
7. The nurse knows that the plan of care for a client with
severe Ulcerative Colitis would include which of the 11. A client is performing quadriceps sets to strengthen
following? the muscles used for walking. When performing
these exercises, the client contracts his quadriceps
A. Low protein, high carbohydrate diet with no change in muscle length and no joint
B. Low residue, high protein movement. What term does the nurse use to
C. High protein, high residue describe this type of exercise?
D. High carbohydrate, high protein __________________

8. While providing nutritional counseling for a client with
12. A nurse is teaching a client to ambulate with
a colostomy the client should be instructed to avoid
crutches. The crutch gait the nurse should teach a
the following foods. Select all that apply
client after a single leg amputation is the:
1. cabbage

2. corn
A. two point gait
3. strawberries
B. three point gait
4. parsley
C. four point gait
5. spinach
D. swing through gait
6. fish

7. popcorn
13. A client with left-sided weakness following a cerebral
8. turkey
vascular accident (CVA) is learning to ambulate with

a cane. The nurse should teach the client to
A. 1, 2, 5, 7, 8

B. 1, 2 ,3 ,6, 7
A. hold the cane on the left side and move the
C. 2, 3 ,5, 6, 8
cane with the right leg
D. 1, 2 ,5, 6, 7
B. hold the cane on the right side and move the

cane with the left leg
9. The nutritionist is providing counseling to several
C. hold the cane on the left side and move the
clients on the unit. They are discussing various
cane with the left leg
vitamins and minerals. Which of the following
D. hold the cane on the right side and move the
statements need to be corrected by the nurse?
cane with the right leg

A. vitamin B12 may be needed if a client has a
14. A nurse is caring for a client that recently had surgery.
gastrectomy
To promote healing of a large surgical incision, the
B. vitamin D is responsible for proper utilization of
nurse should encourage the client to increase the
calcium and phosphorous
following in the diet:
C. vitamin A can be found in squash, pumpkin, and

carrots
A. honey dew
D. vitamin B6 (pyridoxine) is used to treat alcohol
B. apples
induced deficiency
C. oranges
D. banana’s
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11. A client is to receive Dopamine (Intropin) 2 mcg/kg/

Physiological integrity: Pharmacological and min. The client weighs 187 pounds. The available
Parenteral Therapies dose is 300 mg per 250 ml D5NS. How many
milliliters should be administered each hour? (Do
1. Haldol is available in 0.5mg tablets. The desired not round)
dose is 1mg. How many tablet(s) will you give? _______________________ml

____________________tablet(s) 12. The nurse is providing client teaching for a client
receiving Bumex (Bumetamide). When selecting
2. An infant is to receive Cefuroxime 10mg/kg. What is foods, it would be appropriate to include which of
the correct dosage if the child weighs 8 lbs? the following?

____________________mg A. apricots
B. organ meats
3. Vancomycin is available in 225mg. The desired dose C. sardines
is 0.45gm. How many tablet(s) should be given? D. milk

____________________tablet(s) 13. A client is complaining of painful burning on urination.
The health care provider suspects a urinary tract
4. A nurse is preparing to give a dose of Bumex IV to infection. Which of the following medications would
an infant. The prescription reads give 1mg/kg daily. be most effective?
If the infant weighed 6lbs how many mg should the
infant receive? A. Zyvox (linezolid)
B. Ciprofloxain (Cipro)
___________________mg C. Urecholine (bethanecol)
D. Gentamycin (garamycin)
5. Administer Verapamil 3.75mg IV. The dosage
strength is 2.5mg/ml. How many ml should be 14. The health care provider prescribed potassium
given? chloride 20 Meq, daily. The drug available is liquid
potassium chloride10 mEq, per 5ml. How many ml
__________________ml should the nurse administer?

6. An IV of RL 1,000 ml is to infuse over 8 hours. The __________________________ml
drop factor is 15gtt/ml. Calculate the rate of flow.
15. The Nurse Practitioner ordered Tetracycline
__________________gtt(s)/min hydrochloride 80 mg by mouth Q6h. The bottle
available reads125mg/5ml. How many ml’s should
7. 12mg:6ml as 10mg: the nurse administer? (do not round)
___________________ml __________________________ml

8. Dilantin is prescribed for a child that weighs 44lbs. 16. A nurse is monitoring a client initiated on Lasix
The prescription reads give 6mg/kg. How many mg (furosemide) 20mg intravenously daily for the past
should the nurse administer? 2 days. Which of the following should be included?
____________________mg Select all that apply

9. Heparin 7500 units is desired. The available dose A. encourage increased fluids
is 10,000 units/ml. How many ml should the nurse B. tell the client to stand slowly while getting out of
administer? bed
_____________________ml C. monitor electrolytes
D. teach the client to avoid foods high in
10. A client is to receive Dopamine (Intropin) 3 mcg/kg/ potassium
min. The client weighs 185 pounds. The available E. administer the medication at night
dose is 400 mg per 500 ml D5NS. How many mil- F. monitor weight
liliters should be administered each hour? (Round to
the nearest tenth)
______________________ml
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17. A client is to receive 1500ml of ringers lactate (RL) over 22. A physician has selected a medication for a client
a period of 8 hours. The drop factor is 20gtts/ml. The with glaucoma that is to be administered one time
fluid should infuse at which of the following rates? per week. Which of the following medications is
a direct acting parasympathomimetic agent used
A. 43 gtts per minute as a miotic in the treatment of glaucoma?
B. 53 gtts per minute
C. 63 gtts per minute A. humorsol (demecarium)
D. 73 gtts per minute B. cyclogyl (cyclopentolate)
C. pilocarpine (pilocar)
18. The nurse is caring for a client with AIDS and is to D. timolol (timoptic)
administer Retrovir (AZT). Which of the following should
the nurse be aware of? 23. A client with Meniere’s disease is discharged
home from the hospital. While reviewing the
A. the drug may cause drowsiness medications prescribed which of the following
B. it is usually taken once a day in the morning statements if made by the client requires further
C. the client should avoid foods high in protein teaching?
D. the drug may cause renal and hepatic impairment
A. “The meclizine (antivert) will help with my
19. A client has been diagnosed with rheumatoid arthritis. dizziness.”
A prescription for Plaquenil (hydroxychloroquine) has B. “The diazepam (valium) will help to control
been prescribed. The nurse should inform the client: my vertigo.”
C. “The promethazine (phenergan) will help my
A. it will be necessary to have frequent opthalmological nausea.”
exams D. “The hydrochlorothiazide (hydrodiuril) will
B. that the medication may cause diarrhea and require me to avoid food with potassium.”
hypertension
C. it is best absorbed on an empty stomach 24. The nurse is caring for a client taking the
D. fluid intake should be decreased in the first 48 medication Clozaril (Clozapine). Which of the
hours following statements if made by the client shows
that teaching has been effective?
20. A nurse is preparing to administer Cefazolin sodium
(Kefzol) IV. It is available as 500mg in 50 ml of 5% A. “I will increase my glucose intake.”
dextrose in water. It is to be administered over a 20- B. “I should include bulk and fluids in my diet”
minute period. The drop factor is 15 drops per milliliter. C. “I should expect a decrease in my risk of
How many drops per minute should the nurse regulate infection.”
the infusion to run at: D. “I must remember that hypertension is
__________________gtt/min common.”

21. A physician prescribes Ceftriaxone (rocephin) 2.5g 25. A student nurse is preparing to administer Cardura
IVBP every 8 hours for a client. The vial is labeled 5g (Doxazosin). Which of the following should be
per 10ml. The nurse would be correct to administer included in teaching? Select all that apply
_________ ml.
A. avoid driving
A. 1.25 ml B. expect increased libido
B. 2.5 ml C. double doses if one dose is missed
C. 3 ml D. continue to take cold remedies
D. 5 ml E. blurred vision may occur
F. palpitations are expected
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26. The nurse is teaching a client about the use of Amaryl 30. The nurse is teaching a client about the use of
(Glimepiride). Which of the following is a possible Cotazym (Pancrelipase). Which of the following
adverse reaction? if stated by the client shows a need for further
instruction?
A. hyperglycemia
B. thrombocytopenia A. “My capsules may be opened and sprinkled on
C. hypernatremia my food.”
D. leukocytosis B. “I will administer the medication before or with
my meals.”
27. The nurse is teaching a client about possible adverse C. “I should eat more chicken with this
reactions to the drug Thorazine (Chlorpromazine). medication.”
Which of the following should be included in client D. “My tablet can be mixed with apple sauce and
teaching? Select all that apply chewed.”

A. blurred vision may be expected 31. The nurse is collecting data from a clients chart who
B. avoid going to the beach is receiving Norvir (Ritonivir). Which of the following
C. diarrhea is common is not related to the use of this medication?
D. expect an increase in appetite
E. sugarless candy may be helpful A. cholesterol level of 250mg/dl
F. 10-25mg twice daily may be prescribed for B. calcium level of 15.0mg/dl
psychoses in an adult C. creatinine level of 5.0mg/dl
D. glucose level of 200mg/dl
28. The parent of a child taking Concerta (Methylphenidate)
calls the clinic and reports the following symptoms. 32. A nurse is doing data collection regarding commonly
The nurse knows which of the following is an expected used herbal products. Which of the following is not
side effect? true?

A. lethargy A. Black Cohash may be used for dysmenorrhea
B. increased appetite B. Don Quai should not be used while taking
C. weight gain aspirin
D. metallic taste in the mouth C. Echinachea may be used to treat Multiple
Sclerosis
29. The nurse is teaching a client about the use of D. Ephedra should not be used with coffee
the medication Prilosec (Omeprazole). Which of
the following if verbalized by the client shows an 33. A nurse is interviewing a client regarding the use
understanding? Select all that apply of several herbal remedies. Which of the following
statements if made by the client indicates a need for
A. “My tablet may be crushed and mixed with further teaching? Select all that apply
water.”
B. “I will ask my husband to drive my car.” A. “I usually take my Fever Few on an empty
C. “This medication should be taken before meals.” stomach.”
D. “Antacids will not interfere with absorption.” B. “Ginkgo Biloba helps my memory.”
E. “Dizziness is uncommon.” C. “The use of Hawthorne may contribute to my
F. “I can expect flatulence.” hypertension.”
D. “Kava Kava may contribute to my insomnia.”
E. “Valerian Root causes my insomnia.”
F. “Ginger may help with my nausea and
vomiting.”
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34. The nurse is teaching a class about diuretics. Which 39. A health care provider prescribes Digoxin
of the following diuretics require additional potassium (Lanoxin) for a client. It would be a priority for the
consumption? nurse to ask the client if they are using which of
the following herbal remedies?
A. midamor (amiloride)
B. aldactone (spironolactone) A. Ginseng
C. demadex (torsemide) B. Echinacea
D. dyrenium (triamterene) C. Aloe Vera
D. Black Cohash
35. A client drank 71/2 oz of apple juice, 6 oz of tea, and 8
oz of egg nog. The calculated intake would be: 40. The nurse is providing discharge teaching for
the client receiving Prozac (Fluoxetine). Patient
A. 515 ml teaching must include avoidance of which herbal
B. 585 ml remedy?
C. 625 ml
D. 645 ml A. St. Johns Wort
B. Echinacea
36. The nurse is caring for a 76 year old client whose past C. Valerian Root
medical history includes coronary artery disease. A D. Saw Palmetto
review of the laboratory results reveal: HDL 34, LDL
168 and total Cholesterol 270. Which of the following Physiological integrity: Reduction of Risk
medications might be included in the plan of care? Potential

A. Tagamet (Cimetidine) 300 mg po four times a day 1. The nurse is caring for a client with Chronic Renal
B. Coumadin (Warfarin Sodium) 2 mg po at bedtime Failure. Which lab is of most concern?
C. Questran (Choleystyramine) 4 gms po every day
D. Reglan (Metoclopramide) 10mg po as needed A. potassium 7.2 mml/L
B. creatinine 15 mg/dl
37. While administering Actonel (Risedronate) the nurse is C. blood urea nitrogen 68 mg/dl
aware of the importance of which the following health D. calcium 7.8 mg/dl
teachings?
2. A nurse is caring for a client who is complaining of
A. remain in a sitting position for 30 minutes after muscle spasms and rigidity. It would be a priority
administration for the nurse to check which lab value?
B. take medication after breakfast daily
C. change position slowly while taking this A. K+
medication B. NA+
D. monitor the pulse rate prior to administration C. Ca+
D. mg-
38. A nurse is teaching a class on common medications
used in Labor and Delivery. The nurse would be 3. A nurse is reviewing the chart and notes the
correct to state that the drug used to stimulate lung following values. Which lab result is of most
development in the fetus is concern?

A. Terbutaline (Brethine) A. K+ 5.2 meq/L
B. Oxytocin (Pitocin) B. Na+ 134 meq/L
C. Hydralazine (Apresoline) C. Ca+ 10.9 mg/dL
D. Bethamethasone (Celestone) D. Mg- 0.8 meq/L
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4. A nurse is caring for a client with Multiple Myeloma. 9. Which of the following statements regarding cancer
The nurse would expect abnormalities in which of the is false?
following lab values?
A. young men ages 15-30 are at high risk for
A. ammonia testicular cancer
B. red blood cells B. the risk for cancer of the prostate increases
C. glucose with age
D. potassium C. early cervical cancer rarely produces
symptoms
5. A nurse is reviewing a client’s record and notes that D. pap smears are essential to detect uterine
the physician documented that the client has a renal cancer
disorder. Which of the following would be indicative of
the condition? 10. While teaching a class about the risks for breast
cancer the nurse should include which of the
A. hemoglobin level of 16 following risk factors? Select all that apply:
B. potassium level of 4.0 mEq/L
C. blood urea nitrogen (BUN) level of 40mg/dl A. Early onset of menstruation
D. white blood count of 5,000 B. Low fat diet
C. Menopause after age 55
6. The nurse is visiting a client with renal calculi. Which D. First child late in life
of the following statements if made by the client E. Nulliparity
indicates a need for further teaching? F. History of fibrocystic breast disease

A. “I will eats lots of spinach and take my calcium 11. A client who has had a colostomy is one day
supplements daily” postoperative. A nurse assesses that the client’s
B. “I will take my pain medication as prescribed” colostomy stoma is moist and pink with no drainage.
C. “If I have burning during urination I will notify the Which of these actions should the nurse take?
heath care provider”
D. “I will increase my fluid intake to 2000 ml per A. Irrigate the colostomy with normal saline
day” B. Apply petroleum gauze dressing to the stoma
C. Document the condition of the stoma
7. Your client has received intravenous fluids for 3 days D. Palpate the abdomen around the stoma
postoperatively. You plan to observe for signs of fluid
overload. You know that the signs of fluid overload 12. The nurse is assessing a new graduate nurse
include who is caring for a client with a nasogastric tube.
The nurse would intervene immediately if the new
A. weight loss graduate
B. decrease in blood pressure
C. decreased inspiratory rate A. Instilled 30 ml of normal saline into the tube as
D. coughing and wheezing she placed her stethoscope over the stomach
to listen for bowel sounds
8. A 45-year-old male who has just had a routine pre- B. Stated “the length of the tube placement is
employment physical had the following laboratory determined by measuring from the nostril to the
results. Which laboratory finding warrants further and earlobe to the zyphoid process”
prompt investigation? C. Aspirated 30cc of gastric contents and replaced
the fluid after confirmation of placement
A. hemoglobin of 16 g/dl D. Asked the patient to sit in high fowlers position
B. white blood count of 7500/cm3 before initiating the feeding
C. prostate specific antigen of 19.6ng/ml
D. blood urea nitrogen of 15 mg/dl
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13. An emergency room physician is caring for a child 17. A client was recently admitted into the emergency
brought into the emergency room after swallowing a cup room reporting rapidly progressing visual
of chlorine bleach. After interviewing the parent, which impairment and loss of peripheral vision. The
of the following would cause the greatest concern? most likely diagnosis for this client is:

A. the parent called the poison control center to obtain A. macular degeneration
information B. closed angle glaucoma
B. the parent administered a glass of milk C. exacerbation of cataracts
C. the parent administered syrup of ipecac D. retinal detachment
D. he parent attempted to perform CPR when the
child could not respond 18. A nurse is caring for a client with a diagnosis of
gout. Which of the following laboratory values
14. A nurse is using the Glasgow coma scale to assess would the nurse expect to note in the client?
a client who had a head injury. During assessment,
the following is observed: Eyes open to speech, motor A. uric acid level of 9.0mg/dl
response appropriate, client obeys commands, and B. calcium level of 9.0mg/dl
conversation is confused. The client should receive a C. phosphorous level of 3.0mg/dl
score of: D. potassium level of 4.0 mEq/L

A. 3-5 19. The nurse is caring for an adult client that was
B. 6-10 injured in a welding accident. According to the
C. 11-13 “rule of nines,” burn victims experiencing burns
D. 14-15 to their anterior chest and arm have an injury that
approximates:
15. The nurse is caring for a client status post trauma to the
brain. The nurse should be aware that the normal range A. 9% of their body surface
of intracranial pressure is: B. 18% of their body surface
C. 27% of their body surface area
A. 5-8 mm hg D. 36% of their body surface area
B. 10-20 mm hg
C. 20-35 mm hg 20. A nurse is caring for a client that recently had
D. 75-120 mm hg surgery on the left inner ear and is being discharged
home. Which of the following statements if made
16. The nursing student is caring for a client with Ménière’s by the client would indicate a need for further
Disease. Which of the following actions if taken by the teaching?
student would be most appropriate?
A. “My hair will smell since I cannot wash it.”
A. The student offers the client salted pretzels and B. ”I will open my mouth if I have to cough.”
water for snack C. “My airplane will leave at 9:00AM.”
B. The client is offered Benadryl with a small sip of D. “My husband will have to tie my shoes.”
water
C. The client is encouraged to ambulate frequently in 21. The nurse is caring for a client who underwent
the hall surgical repair of a detached retina of the right
D. The student places the client in a room close to the eye. Which of the following interventions should
nurses station the nurse perform? Select all that apply.

A. place the client in the prone position
B. approach the client from the left side
C. encourage deep breathing and coughing
D. discourage bending at the waist
E. orient the client to his environment
F. administer a stool softener as prescribed
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22. The patient with emphysema reports dyspnea at night. 26. The nurse has attended a staff development
Which of the following positions would be appropriate conference on preparing clients for neurological
for the nurse to advise the patient’s wife to use at diagnostic tests. Which of the following statements,
night? if made by the nurse would require follow-up?

A. Lying flat with one pillow A. “The electromyogram (EMG) is performed
B. Side lying with the head propped up by introducing small needle electrodes into
C. Supine position with 4 pillows under his head muscles.”
D. Place the patient in a recliner to sleep B. “After having a Positron Emission Tomography
(PET) of the head the client can resume normal
23. The nurse is caring for a client with hyperthyroidism. activities.”
Expected findings for this disorder include: Select all C. “The electroencephalogram (EEG) will require
that apply the client to be NPO for 12 hours before the
test.”
A. Diarrhea D. “After the lumbar puncture (LP) the client will
B. Dry skin need to lie flat for about 3 hours
C. Anorexia
D. Tachycardia 27. While doing a routine check up with the gynecologist,
E. Excessive menstruation a 32 year old client complains of frequent yeast
F. Heat intolerance infections. The nurse knows which of the following
may be noted?
24. The nurse is caring for a client with hypothyroidism.
Expected findings for this disorder include: Select all A. a fasting glucose of 132 mg/dl
that apply B. a white blood count of 10,000 cc mm
C. a HGB (hemoglobin) of 15 mg/dl
A. Constipation D. a BUN (blood urea nitrogen) of 19 mg/dl
B. Dry skin
C. Anorexia 28. The nurse is assessing a client who is 5 hours
D. Insomnia status post a transurethral resection of the prostate
E. Bradycardia (TURP). Which of the following findings requires
F. Palpitations immediate intervention?

25. A nurse is teaching a client being discharged after A. bladder spasms
surgery on the right eye for glaucoma. Which of the B. abdominal distention
following statements if made by the client requires C. blood tinged urine
further teaching? D. nausea

A. “I will avoid wearing restrictive clothing” 29. A client who has had a spinal cord injury is scheduled
B. “I will ask my wife to tie my shoes” for discharge. To prevent autonomic dysreflexia a
C. “I will formulate a new exercise plan” nurse should instruct the client to avoid
D. “I will sleep on my left side”
A. foods that are spicy
B. people who have upper respiratory infections
C. developing urinary retention
D. emotional stress
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30. The nurse has become aware of the following situations. 3. The nurse is instructing a class on common
It would be a priority for the nurse to follow-up if a client neurological disorders. Which of the following
who statements, if made by the nurse is incorrect?

A. had a gasterectomy lies down for 30 minutes after A. Guillain-Barre is characterized by ascending
eating paralysis and may be caused by a predisposing
B. had a transurethral resection of the prostate (TURP) event such as respiratory or gastrointestinal
24 hours ago reports blood in the urinary bag infection
C. had a fractured femur 2 days ago reports a rash on B. Alzheimer’s disease affects males and
the chest females equally and may be caused by a
D. removed a hearing aid requests a toothpick for decrease in acetylcholine
cleaning C. Parkinson’s disease may be linked to
environmental trauma and is commonly
31. A nursing student is positioning a client that has just treated with Levodopa
returned to the unit after a liver biopsy. The nursing D. Multiple Sclerosis is common in middle aged
student would be correct to position the client adults and can be confirmed with the tensilon
test
A. in the trendelenburg position
B. on the right side with a small pillow 4. A nurse is noted to ask a client to protrude the
C. on the abdomen with the legs abducted tongue and move it from side to side. Which
D. in semi-fowlers position with the head of bed cranial nerve is the nurse assessing?
elevated 45 degrees
A. Glossopharyngeal (IX)
B. Vagus (X)
Physiological Integrity: Physiological C. Spinal accessory (XI)
Adaptation D. Hypoglossal (XII)

1. A nurse is providing care for a client with Type I DM 5. A community health nurse is teaching a class
complaining of a headache. What should the nurse do about the risks for developing cervical cancer.
first? The nurse would be correct in saying that risks
include: select all that apply
A. Give one cup of orange juice
B. Call the nurse in charge A. sex after age 20
C. Check the clients glucose level B. a history of fibroids
D. Administer insulin as prescribed C. nulliparity
D. smoking
2. A client is experiencing acute renal failure that is post E. multiple sex partners
renal in nature. The nurse should know that this is F. exposure to the human papilloma virus
probably due to (HPV)

A. cardiogenic shock 6. The nurse is caring for a client who reports
B. hypovolemia right side facial pain associated with drinking
C. nephrotoxic substances hot beverages. The nurse suspects a possible
D. urethral obstruction diagnosis of
E. “I will sleep on my left side”
A. Trigeminal neuralgia
B. Bell’s Palsy
C. Guillian Barre’ Syndrome
D. Transient Ischemic Attack
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7. The nurse is caring for a newborn infant who has

been diagnosed with Coarctation of the Aorta. Which
of the following findings is most indicative of this
diagnosis?

A. Weak femoral pulses
B. Bluish discoloration to the lips while crying
C. Clubbing of the fingers
D. Respiratory distress

8. A client is admitted to the hospital with a diagnosis
of type 1 Diabetes Mellitus. The nurse is assessing
the client for signs of Diabetic Ketoacidosis. The
following should be expected? Select all that apply

A. Fruity breath
B. Anorexia
C. Kussmaul respirations
D. Metabolic acidosis
E. Increased blood pressure
F. Bradycardia

9. The nurse is caring for a client that is suspected to
have Diabetes Insipidus. Which of the following
symptoms would be suggestive of this condition?
Select all that apply
A. urinary frequency
B. hyponatremia
C. dehydration
D. specific gravity of 1.030
E. increased thirst
F. preference for hot liquids

10. The nurse is reviewing a client’s arterial blood gas
(ABG) results which reveal the following: pH: 7.35;
PaO2: 75 mm Hg; PaCO2: 55 mm Hg; HCO3: 30
mEq/L. The nurse should recognize that this result is
suggestive of which acid base imbalance?
A. compensated metabolic acidosis

B. compensated respiratory acidosis
C. compensated metabolic alkalosis
D. compensated respiratory alkalosis
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RATIONALES FOR PRACTICE

QUESTIONS
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Rationales
9. D. Albuterol is a short acting bronchodilator which
Safe, Effective Care Environment: should improve breathing. If there is no change in
Management of care respiratory effort, this client is the priority.

1. C. The statement further teaching indicates you 10. A. Restlessness and combativeness are signs of
are looking for an incorrect response. Clients of the hypoxia. This client would take priority. According
Mormon faith abstain from alcohol, coffee, and tea. to disaster triage Choices B and D are (priority level
Choices A, B, and D are correct. 3) and choice C is a (priority level 2).
2. A. Average fluid intake is 1500-2500ml per day. 8L or 11. B. Jitteriness is indicative of opioid withdrawal in
8,000ml can result in fluid volume excess. Choices B, the newborn. Choices A, C, and D are normal for a
C, and D are expected findings. newborn.

3. C. A client with a temperature of 101◦ may indicate an 12. C. A quiet patient is most likely exhibiting signs
infection. This client should be seen first. According to of depression. The maternity nurse can manage
the nursing theorist “Orem” a client with an infection this patient. Clients A, B, and D should be cared
has an “Air” need. Choices A, B, and D are expected for by the behavioral health nurse who has more
findings. experience in this area.

4. C. The term follow up indicates you need to intervene. 13. B. The normal respiratory rate for a newborn is 30-
The client with a lap tray or (lap buddy) needs 60 per minute. A rate of 70 indicates tachypnea
intervention as this is considered an illegal restraint. suggestive of distress. Choices A, C, and D are
Choices A, B, and D are expected findings. normal findings.

14. B. The normal potassium level is 3.5-5.5 mEq/L.
5. C. Vomiting and diarrhea can be managed on a non- Hyperkalemia places the client at risk for arrythmias.
emergent basis; clients reporting “indigestion” may be This infant is the priority. Choices A, C, and D are
experiencing a cardiac event; clinical manifestations expected findings.
suggestive of abdominal aortic aneurysm include
abdominal mass and abdominal throbbing; the client 15. C. The need for clarification indicates that you are
who is 6 weeks pregnant experiencing abdominal looking for an incorrect statement. A dying client does
pain must be evaluated to rule out ectopic pregnancy have the right to refuse food therefore clarification is
which could be life threatening. needed. Choices A, B, and D are correct findings.

6. D. A client with radon seed Implants should be on 16. D. Clients have the right to privacy while hospitalized.
absolute bed rest in a private room to avoid emission Permission should be granted prior to observation
of radioactive material. Clients should also avoid of any care provided.
infants and pregnant women. Choices A, B, and C
are expected findings. 17. B. Clients that give away their favorite possessions
may be an increased suicide risk. This client should
be seen first. Choices A, C, and D can be seen at a
7. C. Excessive tiredness may be a sign of hypertension later time.
or increased intracranial pressure. This client should
be seen first. Choices A, B, and D are not a priority 18. C. Chills may indicate a temperature elevation.
at this time. According to the nursing theorist “Orem” a client with
an infection has an “Air” need. This client should be
8. D. Confusion is the first sign of increased intracranial seen first.
pressure and or hypoxia. According to disaster
triage choices A and C are considered (priority level 19. D. Priorities for a client in sickle cell crisis include
3) and choice B is a (priority level 4) which are lower oxygenation, hydration, and pain relief. Choices A,
priorities. B, and C can wait to be seen at a later time.
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20. C. Reports of swelling in the calf 8 hours postpartum 31. A. This task can safely be delegated to the LPN. Choice
may be suggestive of the development of a deep vein B & C should be delegated to the UAP. Initiation of the
thrombosis, a potentially life threatening condition. client’s plan of care should be done by the RN
Immediate intervention is needed; other symptoms
include pain, warmth, chills, diminished peripheral 32. D. Choices A and C would be most appropriate to
pulses, erythema, or shiny white skin on the extremity. delegate to a UAP. Choice B requires assessment and
should be seen by the RN.
21. B. Nasal flaring in an infant indicates respiratory
distress; therefore this infant is the priority. Choices A, 33. B, E, F are correct. Choices A, C, and D should be
C, and D are expected findings in a neonate. done by a nurse.
22. B. Restlessness is suggestive of hypoxia so this client 34. B. Administration of intravenous fluids has a predictable
should be seen first. Choices A, C, and D are expected outcome. A, D and C require the more experienced
findings. med-surg nurse
23. D. Anxiety may indicate hypoxia. This client should be

Safe, Effective Care Environment: Safety
evaluated first. According to disaster nursing triage
Choice A would be considered (category 4) and choices and Infection Control
B and C would be considered (category 3).
1. D. Bacterial Pneumonia requires droplet precautions

Viral Pneumonia needs standard. The type of
24. D. The CNA can administer an enema prior to surgery.
pneumonia is not specified. As a result, this client
Choices A, B, and C need a LPN or RN. should be isolated. A client with HIV and cirrhosis of
the liver do not require automatic isolation. A client with
25. C. Care of the client requiring insulin administration Scabies requires contact precautions which would
is appropriate for the LPN. Choices A, B, and D, may not take priority over droplet precautions if sufficient
require assessment and are therefore more appropriate isolation rooms were not available.
to delegate to the RN.
2. A. Rubeola requires airborne isolation which is
26. D. This client is stable and appropriate for management the priority. Rubella requires droplet precautions.
by the pediatric nurse. Choices A, B, and C are unstable Klebsiella Pneumoniae and Pediculosis require
and should be cared for by the emergency room contact precautions.
nurse.
3. D. Meningitis requires droplet precautions. Choices
27. C. A client experiencing chest pain after coughing is A, B, and C do not require isolation unless further
appropriate for the new graduate RN. The coughing information is given ie (infectious diarrhea)
may explain why the pain is being manifested. Clients
A, B, and D need assessment and should be seen by
4. C. Clients with AIDS have the potential for
an experienced RN. immunosuppression. As a result they are at increased
risk for acquiring an infection. Contact with pets
28. A. Checking daily weight is an appropriate task to should be limited or avoided. Choices A, B, and D are
delegate to a UAP. Choices B, C, and D should correct.
performed by the nurse.
5. B. According to the department of occupational health
29. B. This choice is the most appropriate to delegate to and safety: accidents or incidents involving property
a UAP. Choices A and D are stable clients and can be damage, personnel, student, or visitor injury are
seen by an LPN. Initial vital signs should be done by an reported in accordance with the Hospital Incident
RN. Report Program. If a nurse forgets to administer a
medication the nurse can be liable for negligence.
30. C. A maternal child health nurse has experience in Sexual abuse by a family member may constitute the
caring for clients after a caesarean section (C- Section) need to report to legal authorities such as the police
delivery. An exploratory laparotomy is also abdominal or child abuse reporting agency depending on the age
surgery therefore this client would be appropriate. of the client. Choices C and D does not require an
Choices A, B, and D would be most appropriate for the incident report to be filed.
medical surgical nurse to care for.
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6. C. A client with low grade fever and night sweats is 4. B. A client with mastitis should relieve the breasts of
exhibiting signs of tuberculosis (TB). TB requires airborne milk frequently. This should be done by encouraging
isolation. Choices A and B do not require a private room. the baby to suck or by using a breast pump if the
A client with leukemia may require a private room if they baby is unable to suck. Choices, A, C, and D are
are immunosuppressed. However, they would not take incorrect.
priority over a client with TB.
5. C. Subtract 3 months and add 7 days to the first day
7. B. The CDC guidelines mandate the use of a N95 of the last normal menstrual period (LNMP). Add
respirator mask prior to entry into a room with a client on one year if the pregnancy occurs in April through
airborne precautions. The surgical mask is appropriate December.
when coming within 3 feet of the person on droplet
precautions. 6. A is correct. Small removable parts are unsafe.
Blocks are appropriate for a 2 year old a low lying
8. B. When responding to a fire, there are four sequential mobile is a strangulation hazard.
priorities that must be followed: Rescue the clients,
which was already done in this situation, Alarm (call for 7. B. is correct. A tricycle and puppets are appropriate
additional help), Confine the fire, Extinguish the fire. for an older toddler (age 3). A ball to throw and catch
is appropriate for a 5-year-old.
9. C. Placing a client in prone position after above the knee
amputation is done to prevent contractures; following 8. C. This indicates the 2008 recommended schedule
supratentorial surgery the head of the bed is elevated for routine administration of childhood vaccines at
30 degrees to promote venous outflow. Removing all this age.
liquids is not necessary for clients experiencing Dumping
Syndrome. The client should be taught to avoid drinking 9. C. The time between infection with syphilis and the
with meals. start of the first symptom can range from 10 to 90
days (average 21 days).
10. D. A white blood cell count of 2,500/mm3 is low therefore
the client is at risk for infection. Protective precautions 10. C. The MMR vaccine should not be administered
should be implemented. The normal White blood cell within 3 months of pregnancy. A yeast allergy should
count (WBC) is 5,000 – 10,000/mm3; The normal red be assessed prior to administering the Hepatitis B
blood cell count (RBC) is 4 – 5 million/mm3, a deficit
vaccine. Choices A and D are incorrect.
of red blood cells is indicative of anemia. The normal
platelet count is 150,000 – 400,000µ/Liter. A low platelet
count predisposes the client to bleeding; the normal 11. A is correct. The infant should be able to say a one
hemoglobin value is 13.5 – 18g/dl male and 12 -16g/dl syllable word at approximately 6 months, sit without
female. Low hemoglobin is suggestive of anemia and support at 8 months and use the pincer grasp
possible active bleeding. between 9 and 11 months of age.
12. B. Stage 2 is known as the birth or expulsion stage

Health Promotion and Maintenance
and is characterized by complete dilation and
effacement of the cervix until the birth of the baby.
1. C. The posterior fontannel closes between birth and 2
Choices A, C, and D are incorrect.
months of age. The fontannel should not be closed at
birth this is suggestive of a congenital defect. Choices A,
B, and D are normal. Psychosocial Integrity
.
2. A. The client’s position should be changed initially to see 1. C. Clients using the drug Thorazine should stay out
if the FHR tracing improves. Choices B, C, and D are not of the sun secondary to the risk of photosensitivity.
indicated at this time.
2. C. Offering the client food that is factory- sealed will
3. B. Trendelenburg or knee chest positions are the most diminish the client’s anxiety and paranoia regarding
appropriate positions for a client with a prolapsed cord. the staff trying to poison her.
Choices A, C, and D are incorrect.
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3. C. The client receiving Lithium (Eskalith) should 11. C. During the bargaining stage the client attempts to
be careful to include sodium in the diet to prevent negotiate to prolong their life. Kübler-Ross identified
hyponatremia which predisposes the client to the stages of death and dying as denial (disbelief),
Lithium toxicity; Caffeine should be avoided anger (hostility), bargaining, depression (sadness)
because of the diuretic effect which will further and acceptance (coming to terms with death).4.
increase the risk of hyponatremia; There is no
contraindication for fresh fruit or raw vegetables. Physiological Integrity: Basic Care and Comfort

4. D. Panic is a form of anxiety that is characterized 1. D. Potato, spinach and avocado are all sources of
by unexpected and repeated episodes of intense potassium. This is the best choice.
fear accompanied by physical symptoms that may
include chest pain, heart palpitations, shortness 2. C. Laënnec’s cirrhosis, common in alcoholics can
of breath, dizziness, or abdominal distress lead to thiamine deficiency. Deficiency of this vitamin
can lead to alcoholic brain disease.
5. B. When a client actually has a plan they are at
the highest risk to commit suicide. 3. C. Barley, rye, oat and wheat (BROW) are foods to be
avoided with Celiac Disease. Corn (popcorn) and rice
6. B. is correct. A, C, and D are incorrect choices. are allowed.

7. C. When clients have thoughts of harming 4. C. Clients with renal failure require decreased sodium
themselves they are more likely to carry out the in the diet. Corned beef is high in sodium.
act. Choices A, B, and D are incorrect.
5. B. Clients with an increase in uric acid or Gout should
8. A. A client in the manic phase of bipolar disorder decrease purine in the diet. Foods such as organ meat,
may have difficulty meeting nutritional needs sweetbread, sardines, beer, mushroom, spinach,
because of their inability to sit still; competitive asparagus and anchovies should be avoided.
games are avoided because the client is
hyperactive, impulsive and distractible. Structured 6. B. Dyrenium is a potassium sparing diuretic and foods
activity is more appropriate; foods containing
high in potassium should be avoided.
tyramine are avoided in clients prescribed MAO
inhibitors; placing the client on suicide observation
may be indicated during the depressed phase. 7. B. is correct.
9. B. Lanugo type hair on the body is a characteristic 8. B. Cabbage, strawberries and popcorn may cause
of anorexia nervosa; stained enamel of the teeth an obstruction, fish is odor producing. These foods
is associated with bulimia nervosa related to should be avoided.
the frequent vomiting; persistent ringing in the
ears and white patches on the tongue are not 9. D. Vitamin B1 (thiamine) is used to treat alcohol
associated with anorexia nervosa. induced deficiency not B6.
10. D. It is customary in the Hindu faith that only

family members touch the body after death. The
other statements are correct. Follow up is not
necessary.
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10. A, B, D. Foods high in vitamin C should be avoided 7. 5 ml

3-5 days before the test as they may give a false 12mg : 6ml :: 10mg : Xml
positive result; Red foods should be avoided as they
may be mistaken for blood. 12 X = 60 = 5 OR Desire 10mg X 6 60
12 12 Have 12mg 12
11. Isometric is the correct term to describe this type of
exercise. 8. 120mg
Remember 2.2 lbs = 1 kg
12. B. When using the 3-point gait first move both
44 lbs ÷ 2.2 = 20 kg
crutches and the weaker limb forward. Then bear
20kg X 6mg = 120 mg
all your weight down through the crutches, and then
move the stronger or unaffected lower limb forward.
This eliminates all weight bearing on the affected 9. 0.75 ml 7,500 units X 1 ml = 0.75
leg. 10,000 units
13. B. The proper technique to be used when teaching a 10. 18.9ml or if instructed to round 19ml/hr
client to ambulate with a cane is to hold the cane in Formula: Desire X Volume X Weight X Min.
the hand opposite the affected leg. Have
Remember 2.2 lbs = 1 kg 185 lbs ÷ 2.2 = 84.09 kg
14. C. Vitamin C is necessary to improve wound healing.
Oranges and other citrus fruit are a good source of
3mcg X 500ml X 84.09 kg X 60 minutes
vitamin C.
400 mg
Physiological Integrity: Pharmacological and

Convert 400 mg to mcg = 400,000 mcg
Parenteral Therapies
3mcg X 500ml X 84.09 kg X 60 minutes
1. 2 Tablets Desire 1.0 mg = 2 mg
400,000 mcg
Have 0.05 mg
Simplify division by dividing 500ml into 400,000mcg
2. 36 mg
Remember 2.2 lbs = 1 kg
3mcg X 5ml X 84.09 kg X 60 mins = 75,681
8 lbs ÷ 2.2 = 3.6 kg
4,000 mcg
3.6 kg X 10 mg = 36mg
18.9ml if instructed round to 19ml/hr
3. 2 Tablets
Desire 0.45 gm (convert gm to mg)
11. 8.5ml
Have 225mg
Formula Desire X Volume X Weight X Min.
Have
450mg = 2 tablets
225mg Remember 2.2 lbs = 1 kg 187 lbs ÷ 2.2 = 85 kg
2mcg X 250 ml X 85 kg X 60 minutes
4. 2.7 mg 300mg
Remember 2.2 lbs = 1 kg Convert 300 mg to mcg = 300,000 mcg
6lbs ÷ 2.2 = 2.7 kg
2mcg X 250 ml X 85 kg X 60 ninutes
2.7kg X 1MG = 2.7mg 300,000 mcg
Simplify division by dividing 250ml into 300,000mcg
2mcg X 25 ml X 85 kg X 60 mins = 255,000
5. 1.5 ml Desire 3.75mg = 1.5ml 30,000 mcg
Have 2.5 mg Ans. 8.5ml
6. 31 gtts/min 1000 ml X 15 gtt/ml = 31.25gtts/min

(8hrs X 60 minutes)
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12. A. Bumex is a potassium wasting diuretic. As

a result, foods/ fruits with potassium should be volume 50 ml X 15 gtts/ml = 750 = 37.5
increased in the diet. minutes 20 20
13. B. Cipro is classified as a fluoroqinolone used in 21. D. 5 ml

the treatment of urinary tract and gynecological
infections. Zyvox is an anti- infective used
5gm: 10ml : : 2.5gm : Xml
for the treatment of vancomycin- resistant
5X = 25 = 5ml
infections, nosocomial pneumonia and skin
infections. Urecholine is a urinary tract stimulant 5X 5
used for urinary retention. Gentamycin is an
aminoglycoside used for serious gram negative OR Desire 2.5gm X Volume 10ml = 25 =5
infections. Have 5gm 5
14. 10ml 22. C is correct. Humorsol is a cholinergic that is

20 mEq : Xml :: 10 mEq : 5ml used when miotics are not effective. Cyclogyl is a
10 X = 100 X = 10 ml mydriatic. Timolol is a beta blocker used for ocular
10 10 hypertension.
OR Desire 20 mEq X Volume 5ml 23. D. The phrase further teaching indicates that you
are looking for an incorrect response. Clients on
Have 10 mEq
hydrochlorothiazide need additional potassium as it
is a potassium wasting diuretic.
15. 3.2 ml

80mg : Xml :: 125mg : 5ml
24. B. Constipation is a common side effect of Clozaril.
125 X = 400 = 3.2 ml
Choices A, C, and D are incorrect. Hyperglycemia,
125 125 an elevated white blood count and hypotension are
common.
OR Desire 80 mg X Volume 5ml

Have 125 mg 25. A, E, and F are correct. Cardura may decrease libido.
Choices C and D are incorrect.
16. B, C, F are correct. A, D, E are incorrect
26. B. is correct. Hypoglycemia, hyponatremia, and
17. 63 gtts per minute (62.5) leukopenia are possible adverse reactions.
Volume 1500ml X drop factor 20 gtts/ml = 27. A, B, E, and F are correct. Constipation and anorexia
Minutes (60X8) = 480 are common.
18. D. AZT causes insomnia not drowsiness. It 28. D is correct. Hyperactivity, anorexia, and weight loss
should be taken around the clock. There is no are common adverse reactions.
direct relationship with protein.
29. B, C, D, and F are correct. Prilosec should not be
19. A. Plaquenil may cause retinopathy and/or vi- crushed. Dizziness is a common adverse reaction.
sual disturbances. Dark glasses may be worn
in sunlight to decrease this risk. Hypotension 30. D. Cotazym should not be chewed therefore further
is common. It should be taken with food or
teaching is required.
milk to minimize GI distress not on an empty
stomach. It is not necessary to decrease fluids
31. B. An elevated calcium level is not expected with the
while taking Plaquenil. use of Ritonivir. Hyperlipidemia, renal insuficiency
and hyperglycemia are common.
20. 38 gtt/ min
32. C. Echinacea is contraindicated in clients with
Multiple Sclerosis. Choices A, B, and D are correct.
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READY TO PASS INC.
33. A, C, and E. The phrase need for further teaching 6. A. a client with renal stones should avoid foods
indicate you are looking for an incorrect response. A, with high oxylate content. These include but
C, and E are incorrect. Fever Few should be taken are not limited to; spinach, eggplant, chocolate,
with food. Hawthorne causes hypotension and Valerian beer, peanuts, oatmeal, strawberries, kiwi, and
root is used to treat insomnia. Choices B, D, and F are drinking beer. Also, a diet high in calcium causes a
correct. predisposition to renal calculi.
34. C. Demedex is not potassium sparing, therefore 7. D. Coughing and wheezing may indicate left sided
additional potassium is indicated when using this heart failure as a result of fluid volume excess.
medication.
8. C. PSA levels of 4ng/ml warrant further diagnostic
35. D. 645 ml. 7.5 + 6 + 8 = 21.5 testing. Levels of 10 or greater may suggest prostate
Remember 30 ml equals 1 ounce infection, inflammation or cancer.
21.5 X 30 = 645
9. D. Pap smears can only detect cervical not uterine
36. C. Questran is a lipid lowering agent. cancer. Choices A, B, and C are true.
37. A. Actonel should be taken 30 minutes prior to breakfast. 10. A, C, D, E are true. Choices B and F are not risk
The client should be encouraged to participate in factors for the development of breast cancer.
exercise. The pulse rate does not need to be monitored
prior to administration. 11. C. A stoma that is moist and pink is normal. No
further interventions are needed at this time.
38. D. Glucocorticoids are given to stimulate growth in the
lungs of the fetus. Brethine is given to control premature 12. A. 30 ml of air should be instilled. The installation of
contractions. Apresoline is given for hypertension and normal saline or any liquid can result in aspiration.
Pitocin may be given to induce labor.
13. C. The poison control center should be called
39. C. Aloe Vera may increase the risk for Digoxin toxicity. first. Administering Syrup of IPECAC may result
in damage to internal organs and structures as
40. A. St. John’s Wort is contraindicated with the use of the substance is regurgitated. The national poison
Prozac as they both have an antidepressant effect. control telephone number is 1-800-222-1222.

14. C. The glascow coma scale is the most widely used
Physiological integrity: Reduction of Risk Potential scale to quantify level of consciousness following
traumatic brain injury. The maximum score is 15 the
1. A. Hyperkalemia increases the risk for cardiac changes minimal score is 3. Levels less than 8 indicate a
including weak pulse and cardiac arrest. This lab result coma. The following scores should be given. Eye
opening to speech (3), client obeys commands (6),
is the priority at this time.
confused conversation (4) total 13.
2. C. These symptoms are representative of
hypocalcemia. 15. B. is correct.
3. D. The lab value that is most deviated from normal is 16. B. is correct. Sodium should be restricted. The
the magnesium. Normal magnesium level is 1.3-2.1 mg/ client is encouraged to remain still and rest in a
dl. The normal calcium level is 9.3-10.9 mg/dl, normal quiet environment.
sodium is 1345-145 mmol/L and normal potassium is
3.5-5.5 mEq/L. 17. B. Glaucoma is characterized by loss of peripheral
vision. Macular degeneration is characterized by
4. B. Multiple Myeloma causes an interference with red loss of central vision. Cataracts cause opacity of
the lens. Retinal detachment will cause the client to
blood cell, white blood cell and platelet production.
have an increase in the number of floaters or see
“flashing lights”.
5. C. An increase in BUN indicates an impairment in renal
function. Choices A, B, and D are normal.
217
READY TO PASS INC.
18. A. Gout is indicated by a uric acid level greater

than 7.8 mg/dl. Physiological integrity: Physiological Adaptation
19. C. According to the “Rule of Nines” the anterior 1. C. The nurse should assess the client’s glucose level
chest accounts for 18% plus 9% for the arm before proceeding to the subsequent steps.
totaling 27%.
2. D. Post renal failure is caused by an acute obstruction
20. C. Flying in an airplane will cause an increase that affects the normal flow of urine out of both kidneys.
in pressure which is contraindicated after ear The blockage causes pressure build in all of the renal
surgery. Choices A, B, and D are correct therefore nephrons. The excess pressure causes the kidneys
no further teaching is required. to shut down. Cardiogenic shock and hypovolemia
cause pre renal ARF. Nephrotoxins result in intrarenal
21. B, D, E, F. The client should be placed on the ARF.
affected side. Coughing is contraindicated after
eye surgery. 3. D. Myasthenia Gravis is diagnosed using the tensilon
test. Choices A, B, and C are correct.
22. C. High fowlers or orthopneic position is most
appropriate for a client having difficulty breathing. 4. D. The hypoglossal nerve controls tongue movements.
The glossopharyngeal and vagus nerves are assessed
23. A, D, F Dry skin and anorexia are common in a by eliciting the gag reflex. The spinal accessory nerve
client with hypothyroidism. Menstruation will be is tested by assessing muscle strength of the head
scanty. and shoulders.
24. A, B, C, E. Insomnia and palpitations are common 5. D, E, F. Risk factors for developing cervical cancer
in a client with hyperthyroidism. includes smoking, multiple sex partners, Human
Papilloma Virus (HPV) sex before the age of 20 is a
risk factor. Nulliparity and a history of fibroids are not
25. C. Exercise is contraindicated after eye surgery.
risk factors.
26. C. NPO is not required prior to an EEG. The client
is allowed to have breakfast if prescribed. Caffeine 6. A. Trigeminal Neuralgia is a disorder that causes
and other stimulants should be avoided for 24 intense pain along the areas innervated by the
hours prior to the procedure; the other statements 5th cranial nerve. Extremes in temperature can
are true of those diagnostic tests, therefore follow exacerbate the pain symptoms.
up is not required.
7. A. Coarctation of the Aorta is an acyanotic defect
27. A. A female with frequent yeast infections should characterized by narrowing of the aorta which affects
the outflow of blood. It leads to higher blood pressure
be evaluated for Diabetes Mellitus and HIV.
in the upper extremities than the lower. There may also
be a heart murmur and diminished or absent pulses
28. B. Abdominal distention may indicate a distended
below the femur. The other choices are symptoms of
bladder which indicates a complication after a
cyanotic defects.
(TURP).

8. A, B, C, D are correct. The other choices are incorrect.
29. C. Clients with a spinal cord injury should avoid
The patient experiences low blood pressure and
stimulating the bowels, bladder and skin which
increased heart rate.
may lead to autonomic dysreflexia.
9. A, C, E are correct. The other symptoms include
30. C. A fat embolism is a possible complication after a
hypernatremia, low specific gravity related to urinary
fracture of a long bone. Petechiae, increased pain,
dilution and a preference for cold liquids.
and swelling are some signs of a fat embolism.

31. B. Clients should be placed on the right side after
a liver biopsy to minimize the risk of bleeding.
218
READY TO PASS INC.
10. B. The normal pH is 7.35-7.45; the normal pCO2 is 35-45 mmHg. The normal HCO3 is 22-26 mm Hg. With respiratory
acidosis there is an increase of carbon dioxide. Generally the renal and pulmonary systems compensate for each
other to return the pH to normal. In this situation, the kidney increased the retention of HCO3 to normalize the pH.
Study Tool
Arterial Blood Gas Respiratory Respiratory Metabolic Metabolic

Normal range Acidosis Alkalosis Acidosis Alkalosis
pH 7.35-7.45 ↓ ↑ ↓ ↑
pCO2 35-45mm Hg ↑ ↓ ↓ or norm ↑ or norm
HCO3(bicarbonate) ↑ or norm ↓ or norm ↓ ↑

22-26 mm Hg
When the pH is within normal range and the pCO2 and or HCO3 are not, consider compensation.

Infection Control- list the type of isolation required:
HIB_______________________________ Bacterial Pneumonia_____________________
MRSA_____________________________ Klebsiella Pneumonia____________________
TB_______________________________ Group A Strep__________________________
Epiglottitis_________________________ Small pox______________________________
Fifths Disease______________________ Rubeola______________________________

Infection Control- list the type of isolation required: Page 45
HIB - droplet Bacterial Pneumonia - droplet
MRSA - contact Klebsiella Pneumonia - contact
TB - airborne Group A Strep - droplet
Epiglottitis - droplet Small pox - airborne
Fifths Disease - droplet Rubeola - airborne
219
READY TO PASS INC.
Detailed Answer Key for Page 28
1. 600ml_ X 15 gtt/mL = 9000 8. 75ml/hr x 24hrs = 1800ml

(60 X 8 hours) = 480 minutes (60 min = 1hr) 50mlx 4 (Q6hrs) = 200ml
200ml x 1 = 200ml
Answer: 18.75 = 19 gtt/min 2200ml in IV Fluids
3000ml total minus 2200ml IVF

Answer: 800ml PO
2. 100ml x 60 (minutes in 1 hour) = 4 x 100mL 9. 240ml x 3oz = 720ml
15 minutes 180ml
30ml x 6oz = 180ml
Answer: 400 ml/hr 1080ml
Formula: Volume X 60 Answer: 1080ml

minutes ordered *Do not add pureed chicken, it is a solid
3. 50mg X 10 kg 10. 1500 mg/day = 500mg per dose
3 doses
(22lbs/2.2 remember 2.2 lbs =1kg)
Answer: 1 tablet/500mg per dose
500 mg X 1mL = 5ml
100 mg
Answer: 5ml
4. 0.03gm = 30mg = 2 11. 160mg x 15ml = 30
15mg 80mg
Answer: 2 tabs Answer: 30ml
5: 500mg = 2 12. 300ml x 10gtt/ml = 5

250mg 600 minutes (60min x 10 hours)
Answer: 2 tabs Answer: 5gtts/min
6. 2gm x 3.6ml = 7.2 ml 13. 100ml x 10gtt/ml = 16.6

1gm 60 minutes (60 minutes = 1 hour)
Answer: 7.2 ml Answer: 17gtts/min
7. 5000mcg = 5mg x 1ml = 0.5ml 14. 10 units/hr x 100ml = 1000 = 40ml/hr

10 mg 25units 25
(remember 1mg = 1000 mcg) Answer: 40 ml/hr
Answer: 0.5ml
220

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READY TO PASS INC.

READY TO PASS INC.

After the Review 140

Graphics: Louise Martin and Rebecca Rivera

I have read and agree with the above listed terms.

Print Name: _______________________________

ELIGIBILITY TO REPEAT THE READY TO PASS

Review Course Objectives

• Identify and perform safe competent basic nursing care

• Incorporation of highly effective teaching and learning models

I. Safe, Effective Care Environment

• Advance Directives • Establishing Priorities

B. Safety and Infection Control - RN 9 -15 % LPN 10-16%

• Accident/Injury Prevention • Medical and Surgical Asepsis

II. Health Promotion and Maintenance- RN 6-12% LPN 7-13%

• Aging Process • Health and wellness

III. Psychosocial Integrity- RN 6-12% LPN 9 -15%

IV. Physiological Integrity

• Adverse Effects/ Contraindications and Side • Parenteral/Intravenous Therapy

C. Reduction of Risk Potential: RN 9 -15 % LPN 9 -15%

D. Physiological Adaptation: RN 11-17 % LPN 7 -13%

target candidate-specific ability.

Types of Questions: Multiple Response Multiple Choice Fill in the Blank

Ordered response Hot Spot/Graphic Chart exhibit Audio

1: Determine what the question is asking.

2: Identify the topic of the question.

4: Rephrase the question, if possible.

5: Do not read into questions.

Select the best option after eliminating incorrect choices.

Tools helpful to answering these questions include:

PREPARING FOR THE EXAM

* Study consistently, at least 2-3 hours a day.

A. Uric acid level of 10.3 mg/dL

A. “My elbows should be flexed 45 degrees while walking.”

Schedule your test within 1 month after course completion!!

*Unofficial test results available 48 hours after testing (cost $7 - $10)

AGE/STAGE PSYCHOSOCIAL CRISIS TASK

7. Middle adulthood (35 -65 years) Generativity vs. Stagnation

1: Assessment 2: Diagnosis (Analysis) 3: Planning 4: Implementation 5: Evaluation

DETERMINE CLIENT’S UNIQUE NEEDS

TIP: ACTIVE CLIENT PROBLEMS TAKE PRIORITY OVER POTENTIAL PROBLEMS! 14

Check the client first, then the equipment! Remember: AWFERS

PRIORITY #1 PRIORITY #2 PRIORITY #3 PRIORITY #4

IMMEDIATE DELAYED MINIMAL EXPECTANT

Consistent studying to understand CONCEPTS is essential.

You cannot memorize answers and questions from previous exams!

WHAT IS YOUR ROLE?

THE ROLE OF AN LPN:

THE ROLE OF A CNA (UAP):

UAP’S ARE NOT ALLOWED TO:

TIP: DELEGATION AND SUPERVISION ALONG WITH COLLABORATION CONCEPTS MUST BE

LEADERSHIP AND PROFESSIONAL ISSUES

DELEGATION: DO NOT DELEGATE WHAT YOU CAN E A T

VERACITY: Adherence to the truth.

MORE ABOUT LEGALITY

1. GOOD SAMARITAN LAW:

3. HARRISON NARCOTIC ACT OF 1941:

6. HIPAA: The Health Insurance Portability and Accountability Act

RELIGIOUS AND SPIRITUAL INFLUENCES ON HEALTH

BUDDHISM • Buddhist priest present at death

CHURCH OF CHRIST (MORMON) • No ritual performed before or after death

JEHOVAH’S WITNESS • No ritual performed before or after death

WESTERN ORTHODOX CHRISTIAN