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all nurses study guide
nclex review
180
Nursing
Undergraduate 4
10/12/2014

Additional Nursing Flashcards

 


 

Cards

Term
maslows hiriarchy of needs
Definition
physiologic, safety, love and belonging, esteem, and self actualization
Term
nursing process
Definition
assesment, diagnosis, planing, implementation, evaluation
Term
ABC's
Definition
• Airway
• Breathing
• Circulation
Term
Hgb
Definition
Males 14-18
• Females 12-16
Term
o Hct
Definition
Males 42-52
• Females 37-47
Term
RBCs
Definition
Males 4.7-6.1 million
• Females 4.2-5.4 million
Term
WBCs
Definition
4.5-11k
Term
o Platelets
Definition
• 150-400k
Term
PT (Coumadin/Warfarin)
Definition
11-12.5 sec (INR and PT TR = 1.5-2 times norma
Term
APTT (Heparin)
Definition
60-70 sec (APTT and PTT TR = 1.5-2.5 times normal)
Term
BUN
Definition
10-20
Term
Creatinine
Definition
0.5-1.2
Term
Glucose
Definition
70-110
Term
Cholesterol
Definition
< 200
Term
Bilirubin Newborn
Definition
1-12
Term
o Phenylalanine
Definition
Newborn < 2, Adult < 6
Term
Na+
Definition
136-145
Term
K+
Definition
3.5-5
Term
HypoK+
Definition
Prominent U waves, Depressed ST segment, Flat T waves
Term
HyperK+
Definition
Tall T-Waves, Prolonged PR interval, wide QRS
Term
Ca+
Definition
9-10.5
Term
Hypocalcemia
Definition
muscle spasms, convulsions, cramps/tetany, + Trousseau’s, + Chvostek’s, prolonged ST interval, prolonged QT segment
Term
Mg+
Definition
1.5-2.5
Term
Cl-
Definition
96-106
Term
Phos
Definition
3.5-4.5
Term
Albumin
Definition
3.5-5
Term
Spec Gravity
Definition
1.005-1.030
Term
Glycosylated Hemoglobin (Hgb A1c)
Definition
4-6% ideal, < 7.5% = OK (120 days)
Term
Dilantin TR
Definition
10-20
Term
Lithium TR
Definition
0.5-1.5
Term
Arterial Blood Gases
Definition
Used for Acidosis vs. Alkalosis
Term
PH
Definition
7.35-7.45
Term
CO2
Definition
35-45 (Respiratory driver) … High = Acidosis
Term
HCO3
Definition
21-28 (Metabolic driver) … High = Alkalosis
Term
O2
Definition
80-100
Term
O2
Definition
Sat 95-100%
Term
antidote
Digoxin
Definition
Digiband
Term
antidote
coumadin
Definition
Vitamin K (Keep PT and INR @ 1-1.5 X normal)
Term
antidote Benzodiazapines
Definition
Flumzaemil (Tomazicon)
Term
antidote Magnesium Sulfate
Definition
Calcium Gluconate
Term
antidote Heparin
Definition
Protamine Sulfate (Keep APTT and PTT @ 1.5-2.5 X normal)
Term
antidote Tylenol
Definition
Mucomist (17 doses + loading dose)
Term
antidote Opiates (narcotic analgesics, heroin, morphine)
Definition
Narcan (Naloxone)
Term
antidote Cholinergic Meds (Myesthenic Bradycardia)
Definition
Atropine
Term
antidote Methotrexate
Definition
Leucovorin
Term
Delegation
o RN Only
Definition
• Blood Products (2 RNs must check)
• Clotting Factors
• Sterile dressing changes and procedures
• Assessments that require clinical judgment
• Ultimately responsible for all delegated duties
Term
o Unlicensed Assistive Personnel
Definition
o Unlicensed Assistive Personnel
Term
o Universal (Standard) Precautions … HIV initiated
Definition
• Wash hands
• Wear Gloves
• Gowns for splashes
• Masks and Eye Protection for splashes and droplets
• Don’t recap needles
• Mouthpiece or Ambu-bag for resuscitation
• Refrain from giving care if you have skin lesion
Term
o Droplet (Respiratory) Precautions (Wear Mask)
Definition
• Sepsis, Scarlet Fever, Strep, Fifth Disease (Parvo B19), Pertussis, Pneumonia, Influenza, Diptheria, Epiglottitis, Rubella, Rubeola, Meningitis, Mycoplasma, Adenovirus, Rhinovirus
• RSV (needs contact precautions too)
• TB … Respiratory Isolation
Term
o Contact Precautions = Universal
Definition
Goggles, Mask and Gown
o No infection patients with immunosuppressed patients
Term
o Rifampin (for TB)
Definition
Rust/orange/red urine and body fluids
Term
Pyridium (for bladder infection)
Definition
… Orange/red/pink urine
Term
Glasgow Coma Scale
Definition
… < 8 = coma
Term
Myesthenic Crisis
Definition
Weakness with change in vitals (give more meds)
Term
Cholinergic Crisis
Definition
Weakness with no change in vitals (reduce meds)
Term
Diabetic Coma vs. Insulin Shock
Definition
Give glucose first – If no help, give insulin
Term
Diabetic Ketoacidosis
Definition
Fruity Breath =
Term
o Acid-Base Balance
Definition
• If it comes out of your ass, it’s Acidosis.
• Vomiting = Alkalosis
Term
Cystic Fibrosis
Definition
Skin Tastes Salty
Term
Lipitor (statins)
Definition
in PMs only – No grapefruit juice
Term
o Stroke
Definition
Tongue points toward side of lesion (paralysis), Uvula deviates away from the side of lesion (paralysis)
Term
Hold Digoxin if
Definition
HR < 60
Term
after first ACE Inhibitor dose
Definition
Stay in bed for 3 hours
Term
with Ca++ Channel Blockers
Definition
Avoid Grapefruit juice
Term
Anthrax
Definition
Multi-vector biohazard
Term
o Pulmonary air embolism prevention
Definition
Trendelenburg (HOB down) + on left side (to trap air in right side of the heart)
Term
Head Trauma and Seizures
Definition
Maintain airway = primary concern
Term
Peptic Ulcers
Definition
Feed a Duodenal Ulcer (pain relieved by food)
Term
gastric ulcer
Definition
Starve, not food relieved
Term
Acute Pancreatitis
Definition
Fetal position, Bluish discoloration of flanks (Turner’s Sign), Bluish discoloration of pericumbelical region (Cullen’s Sign), Board like abdomen with guarding … Self digestion of pancreas by trypsin.
Term
Hold tube feeding if
Definition
residual > 100mL
Term
In case of Fire
Definition
RACE and PASS
Term
Check Restraints
Definition
every 30 minutes … 2 fingers room underneath
Term
Gullain-Barre Syndrome
Definition
… Weakness progresses from legs upward – Resp arrest
Term
Trough draw
Definition
~30 min before scheduled administration
Term
Peak Draw =
Definition
30-60 min after drug administration
Term
Most suicides occur
Definition
after beginning of improvement with increase in energy levels
Term
MAOIs
Definition
Hypertensive Crisis with Tyramine foods
• Nardil, Marplan, Parnate
• Need 2 wk gap from SSRIs and TCAs to admin MAOIs
Term
Lithium Therapeutic Range
Definition
0.5-1.5
Term
Phenothiazines (typical antipsychotics)
Definition
– EPS, Photosensitivity
Term
Atypical Antipsychotics
Definition
work on positive and negative symptoms, less EPS
Term
Benzos (Ativan, Lorazepam, etc)
Definition
good for Alcohol withdrawal and Status Epilepticus
Term
Antabuse for Alcohol deterrence
Definition
Makes you sick with OH intake
Term
Alcohol Withdrawal
Definition
Delerium Tremens – Tachycardia, tachypnea, anxiety, nausea, shakes, hallucinations, paranoia … (DTs start 12-36 hrs after last drink)
Term
Opiate (Heroin, Morphine, etc.) Withdrawal
Definition
Watery eyes, runny nose, dilated pupils, NVD, cramps
Term
Stimulants Withdrawal
Definition
Depression, fatigue, anxiety, disturbed sleep
Term
Hypoventilation
Definition
Acidosis (too much CO2)
Term
Hyperventilation
Definition
Alkalosis (low CO2)
Term
Mastectomy
Definition
No BP or IV on that side
Term
Opiate OD
Definition
Pinpoint Pupils
Term
Lesions of Midbrain
Definition
= Decerebrate Posturing (Extended elbows, head arched back)
Term
Lesions of Cortex
Definition
Decorticate Posturing (Flexion of elbows, wrists, fingers, straight legs, mummy position)
Term
Urine Output of 30 mL/hr
Definition
minimal competency of heart and kidney function
Term
Kidney Stone
Definition
Cholelithiasis
• Flank pain = stone in kidney or upper ureter
• Abdominal/scrotal pain = stone in mid/lower ureter or bladder
Term
Renal Failure
Definition
• Fluid and electrolyte problems … Watch for HyperK+ (dizzy, wk, nausea, cramps, arhythmias)
• Pre-renal Problem = Interference with renal perfusion
• Intra-renal Problem= Damage to renal parenchyma
• Post-renal Problem = Obstruction in UT anywhere from tubules to urethral meatus.
• Usually 3 phases (Oligouric, Diuretic, Recovery)
• Monitor Body Wt and I&Os
Term
Cushing’s Syndrome symptoms)
Definition
Steroid Effects = Moon face, hyperglycemia, acne, hirsutism, buffalo hump, mood swings, weight gain – Spindle shape, osteoporosis, adrenal suppression (delayed growth in kids)
Term
Addison’s’ Crisis =
Definition
medical emergency (vascular collapse, hypoglycemia, tachycardia … Admin IV glucose + corticosteroids) … No PO corticosteroids on empty stomach
Term
Potassium sparing diuretic
Definition
Aldactone (Spironolactone) … Watch for hyperK+ with this and ACE Inhibitors.
Term
Cardiac Enzymes
Definition
Troponin (1 hr), CKMB (2-4 hr), Myoglobin (1-4 hr), LDH1 (12-24 hr)
Term
MI Tx
Definition
Nitro – Yes … NO Digoxin, Betablockers, Atropine
Term
Fibrinolytics =
Definition
Streptokinase, Tenecteplase (TNKase)
Term
CABG
Definition
Coronary Artery Bypass Graft
Term
PTCA
Definition
Percutaneous Transluminal Coronary Angioplasty
Term
Sex after MI
Definition
it is ok when able to climb 2 slights of stairs without exertion (Take nitro prophylactically before sex)
Term
BPH Tx
Definition
TURP (Transurethral Resection of Prostate) … some blood for 4 days, and burning for 7 days post-TURP.
Term
for Bladder Irrigation
Definition
Only isotonic sterile saline
Term
Post Thyroidectomy
Definition
Keep tracheostomy set by the bed with O2, suction and Calcium gluconate
Term
Pericarditis
Definition
… Pericardial Friction Rub, Pain relieved by leaning forward
Term
Post Strep URI Diseases and Conditions:
Definition
• Acute Glomerulonephritis
• Rheumatic Fever … Valve Disease
• Scarlet Fever
Term
If a chest-tube becomes disconnected
Definition
do not clamp … Put end in sterile water
Term
Chest Tube drainage system
Definition
hould show bubbling and water level fluctuations (tidaling with breathing)
Term
o TB
Definition
Treatment with multidrug regimen for 9 months … Rifampin reduces effectiveness of OCs and turns pee orange … Isoniazide (INH) increases Dilantin blood levels
Term
Use bronchodilators
Definition
before steroids for asthma … Exhale completely, Inhale deeply, Hold breath for 10 seconds
Term
Ventilators
Definition
Make sure alarms are on … Check every 4 hours minimum
Term
Suctioning
Definition
Pre and Post oxygenate with 100% O2 … No more than 3 passes … No longer than 15 seconds … Suction on withdrawal with rotation
Term
COPD:
Definition
• Emphysema = Pink Puffer
• Chronic Bronchitis = Blue Bloater (Cyanosis, Rt sided heart failure = bloating/edema)
Term
o O2 Administration
Definition
• Never more than 6L/min by cannula
• Must humidify with more than 4L/hr
• No more than 2L/min with COPD … (CO2 Narcosis)
• In ascending order of delivery potency: Nasal Cannula, Simple Face Mask, Nonrebreather Mask, Partial Rebreather Mask, Venturi Mask
• Restlessness and Irritability = Early signs of cerebral
Term
IVs and Blood Product Administration
Definition
o 18-19 gauge needle for blood with filter in tubing
o Run blood with NS only and within 30 minutes of hanging
o Vitals and Breath Sounds … before, during and after infusion (15 min after start, then 30 min later, then hourly up to 1 hr after)
o Check Blood: Exp Date, clots, color, air bubbles, leaks
o 2 RNs must check order, pt, blood product … Ask Pt about previous transfusion Hx
o Stay with Pt for first 15 minutes … If transfusion rxn … Stop and KVO with NS
o Pre-medicate with Benadryl prn for previous urticaria rxns
Term
o Isotonic Solutions
Definition
• D5W
• NS (0.9% NaCl)
• Ringers Lactate
• NS only with blood products and Dilantin
Term
Diabetes and Insulino When in doubt
Definition
Treat for Hypoglycemia first
Term
First IV for DKA
Definition
NS, then infuse regular insulin IV as Rx’d
Term
Hypoglycemia
Definition
confusion, HA, irritable, nausea, sweating, tremors, hunger, slurring
Term
Hyperglycemi
Definition
weakness, syncope, polydipsia, polyuria, blurred vision, fruity breath
Term
Insulin may be kept
Definition
at room T for 28 days
Term
Draw insulin
Definition
Regular (Clear) insulin into syringe first when mixing insulins
Term
Rotate Injection Sites
Definition
Rotate in 1 region, then move to new region
Term
Rapid Acting Insulins
Definition
Lispro (Humalog) and Aspart (Novolog) … O: 5-15 min, P: .75-1.5 hrs
Term
Short Acting Insulin
Definition
Regular (human) … O: 30-60 min, P: 2-3 hrs (IV Okay)
Term
Intermediate Acting Insulin
Definition
Isophane Insulin (NPH) … O: 1-2 hrs, P: 6-12 hrs
Term
Long Acting Insulin
Definition
Insulin Glargine (Lantus) … O: 1.1 hr, P: 14-20 hrs (Don’t Mix)
Term
Oral Hypoglycemics
Definition
decrease glucose levels by stimulating insulin production by beta cells of pancreas, increasing insulin sensitivity and decreasing hepatic glucose production
• Glyburide, Metformin (Glucophage), Avandia, Actos
• Acarbose blunts sugar levels after meals
Term
o Leukemia
Definition
Anemia (reduced RBC production), Immunosuppression (neutropenia and immature WBCs), Hemorrhage and bleeding tendencies (thrombocytopenia)
Term
Acute Lymphocytic
Definition
most common type, kids, best prognosis
Term
Testicular Cancer
Definition
Painless lump or swelling testicle … STE in shower > 14 yrs … 15-35 = Age
Term
Prostate Cancer
Definition
… > 40 = Age
• PSA elevation
• DRE
• Mets to spine, hips, legs
• Elevated PAP (prostate acid phosphatase)
• TRUS = Transurethral US
• Post Op … Monitor of hemorrhage and cardiovascular complication
Term
Cervical and Uterine Cancer
Definition
• Laser, cryotherapy, radiation, conization, hysterectomy, exenteration … Chemotherapy = No help
• PAP smears should start within 3 years of intercourse or by age 21
Term
o Ovarian Cancer
Definition
leading cause of death from gynecological cancer
Term
Breast Cancer
Definition
Leading cause of cancer in women
• Upper outer quadrant, left > right
• Monthly SBE
• Mammography … Baseline @ 35, Annually after age 50
• Mets to lymph nodes, then lungs, liver, brain, spine
• Mastectomy … Radical Mastectomy = Lymph nodes too (but no mm resected)
• Avoid BP measurements, injections and venipuncture on surgical side
Term
Anti-emetics given with Chemotherapy Agents
Definition
(Cytoxan, Methotrexate, Interferon, etc.)
• Phenergan (Promethazine HCl)
• Compazine (Prochlorperazine)
• Reglan (Metocolpramide)
• Benadryl (Diphenhydramine)
• Zofran (Ondansetron HCl)
• Kytril (Granisetron)
Term
Syphilis (Treponema pallidum)
Definition
Chancre + red painless lesion (Primary Stage, 90 days) ... Secondary Stage (up to 6 mo) = Rash on palms and soles + Flu-like symptoms … Tertiary Stage = Neurologic and Cardiac destruction (10-30 yrs) … Treated with Penicillin G IM.
Term
Gonorrhea (Neisseria Gonorrhea)
Definition
Yellow green urethral discharge (The Clap)
Term
Chlamydia (Chlamydia Trachomatis)
Definition
Mild vaginal discharge or urethritis … Doxycyclin, Tetracycline
Term
Trichomoniasis (Trichomonas Vaginalis)
Definition
Frothy foul-smelling vaginal discharge … Flagyl
Term
Candidiasis (Candida Albicans)
Definition
Yellow, cheesy discharge with itching … Miconazole, Nystatin, Clomitrazole (Gyne-Lotrimin)
Term
Herpes Simplex 2
Definition
Acyclovir
Term
HPV (Human Pappilovirus
Definition
Acid, Laser, Cryotherapy
Term
HIV …
Definition
Cocktails
Term
• Perioperative Care
Definition
o Breathing Es taught in advance (before or early in pre-op)
o Remove nail polish (need to see cap refill)
o Pre Op … Meds as ordered, NPO X 8 hrs, Incentive Spirometry & Breathing Es taught in advance, Void, No NSAIDS X 48 hrs
o Increased corticosteroids for surgery (stress) … May need to increase insulin too
Term
Post Op restlessness may
Definition
hemorrhage, hypoxia
Term
Wound dehiscence or extravisation
Definition
Wet sterile NS dressing + Call Dr
Term
Call Dr. post op if
Definition
< 30 mL/hr urine, Sys BP < 90, T > 100 or < 96
Term
o Post Op Monitoring VS and BS
Definition
… Every 15 minutes the first hour, Every 30 min next 2 hours, Every hour the next 4 hours, then Every 4 hours prn
Term
1-4 hrs Post Op
Definition
Immediate Stage
Term
2-24 hrs Post Op
Definition
Intermediate Stage
Term
… 1-4 days Post Op
Definition
Extended Stage
Term
o Post Op Positioning
Definition
• THR … No Adduction past midline, No hip flexion past 90 degrees
• Supratentorial Sx … HOB 30-45 degrees (Semi-Fowler)
• Infrantentorial Sx … Flat
• Phlebitis … Supine, elevate involved leg
• Harris Tube … Rt/back/Lt – to advance tube in GI
• Miller Abbott Tube … Right side for GI advancement into small intestine
• Thoracocentesis … Unaffected side, HOB 30-45 degrees
• Enema … Left Sims (flow into sigmoid)
• Liver Biopsy … Right side with pillow/towel against puncture site
• Cataract Sx … Opp side – Semi-Fowler
• Cardiac Catheterization … Flat (HOB no more than 30 degrees), Leg straight 4-6 hrs, bed rest 6-12 hrs
• Burn Autograph … Elevated and Immob 3-7 days
• Amputation … Supine, elevate stump for 48 hrs
• Large Brain Tumor Resection … On non-operative side
Term
o Incentive Spirometry
Definition
Inhale slowly and completely to keep flow at 600-900, Hold breath 5 seconds, 10 times per hr
Term
Post Op Breathing Exercises
Definition
Every 2 hours
• Sit up straight
• Breath in deeply thru nose and out slowly thru pursed lips
• Hold last breath 3 seconds
• Then cough 3 times (unless abd wound – reinforce/splint if cough)
o Watch for Stridor after any neck/throat Sx … Keep Trach kit at bed side
Term
Staples and sutures
Definition
removed in 7-14 days – Keep dry until then
Term
post op exercises
Definition
No lifting over 10 lbs for 6 weeks (in general)
Term
If chest tube comes disconnected,
Definition
put free end in container of sterile water
Term
Removing Chest Tube
Definition
Valsalvas, or Deep breath and hold
Term
If chest tube drain stops fluctuating
Definition
the lung has re-inflated (or there is a problem)
Term
if pt has S. Blakemore Tube (for esoph varices)…
Definition
Keep scissors by bed Sudden respiratory distress – Cut inflation tubes and remove
Term
Tracheostomy patients
Definition
Keep Kelly clamp and Obturator (used to insert into trachea then removed leaving cannula) at bed side
Term
Turn off NG suction
Definition
30 min after PO meds
Term
NG Tube Removal
Definition
Take a deep breath and hold it
Term
Stomach contents pH
Definition
< 4 (gastric juices aspirated)
Term
NG Tube Insertion
Definition
If cough and gag, back off a little, let calm, advance again with pt sipping water from straw
Term
NG Tube Length
Definition
End of nose, to era lobe, to xyphoid (~22-26 inches)
Term
Decubitus (pressure) Ulcer Staging
Definition
• Stage 1 = Erythema only
• Stage 2 = Partial thickness
• Stage 3 = Full thickness to SQ
• Stage 4 = Full thickness + involving mm /bone
Term
• Acute Care
o CVA
Definition
Hemorrhagic or Embolic
Term
• A-fib and A-flutter
Definition
thrombus formation
Term
Dysarthria
Definition
(verbal enunciation/articulation
Term
Apraxia
Definition
perform purposeful movements
Term
Dysphasia
Definition
(speech and verbal comprehension),
Term
Aphasia
Definition
speaking
Term
Agraphia
Definition
writing
Term
Alexia
Definition
reading
Term
Dysphagia
Definition
swallowing
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