NCLEX 2022/2023 -370 Set Q&A with Complete solution

Airborne diseases - ANSWER Varicella, measles, TB Contact diseases - ANSWER Impetigo, C-diff, MRSA, Scabies, Shigella Droplet diseases - ANSWER Rubella, Influenza Type B, Mumps, Pneumonia, Pertussis, RSV Standar ...

Airborne diseases - ANSWER Varicella, measles, TB Contact diseases - ANSWER Impetigo, C-diff, MRSA, Scabies, Shigella Droplet diseases - ANSWER Rubella, Influenza Type B, Mumps, Pneumonia, Pertussis, RSV Standard Disease (No special precaution) - ANSWER HIV & Hepatitis B ABG: If it's a respiratory problem it's a - ANSWER respiratory issues (respiratory ABG opposite PH 7.35-7.45 & HC03 22-26) Normal HCO3 - ANSWER 22-26 Normal pH - ANSWER 7.35-7.45 Normal sodium levels - ANSWER 135-145 Normal potassium levels - ANSWER 3.5-5.0 Normal calcium levels - ANSWER 8.5-10.5 Normal creatinine levels - ANSWER 0.6-1.2 Normal INR range - ANSWER 2-3 Borborygmi - ANSWER Increased bowel sounds: a rumbling or gurgling noise made by the movement of fluid and gas in the intestines If pH is low - ANSWER everything is low except potassium - Bradycardia - Decreased Bowel Sounds - Hypotension - Lethargy - Flaccid - Hyporefelxia (0 - 1+) - Hyperkalemia If pH is high - ANSWER everything is high except potassium - Tachycardia/Tachypnea - HTN (hypertension) - Hyperreflexes (3+ 4+) - Irritability - Seizures (requires suctioning) - Diarrhea - Borborygmi - Hypokalemia In respiratory alkalosis - ANSWER pt is overventilating (Over 7.45) In respiratory acidosis - ANSWER pt is underventilating (under 7.35) ABG: When you don't know what to pick - ANSWER pick Metabolic Acidosis Prolonged vomiting or suctioning cause - ANSWER Metabolic Alkalosis *everything else is acidosis Ventilators: High pressure alarm - ANSWER Increased resistance check for - Kinks in tubbing (unkink) - Condensation in the dependent tubes (drain water) - Mucus plugs (turn, cough, deep breath & then suction) Ventilators: Low pressure alarm - ANSWER Decrease in resistance check for - Main tube disconnect - O2 sensor tube disconnect In both cases reconnect the tube unless it is on the floor in this case bag pt and call respiratory The number one psychological problem in ABUSE is - ANSWER Denial Definition of denial - ANSWER Refusal to accept reality of their problem Confront the pt with denial issues - ANSWER point out the difference between what they say and what they do... Example: You say you'r not an alcoholic but it's 10 am and you have already had a 6 pack of beer. Don't say you - ANSWER say I (I seem to be frustrating you not you seem to be frustrated) Grief and loss - ANSWER DABA (denial, arguing, bargaining and acceptance) Manipulation - ANSWER the abuser gets the significant other to do things that can be harmful to the pt. Treat manipulation by - ANSWER setting limits and enforcing them Wernicke-Korsakoff syndrome - ANSWER - Psychosis induced by vitamin B1 or thiamine deficiency - S&S include amnesia (memory loss) with confabulation (making up stories) - DO NOT CONFRONT (Redirect the patient instead) Characteristics of Wernicke-Korsakoff syndrome - ANSWER - It is preventable (Take B1) - Arrestable: stop getting worse (take B1) - Irreversible (70%) Antabuse & Revia (disulfiram) - ANSWER Aversion therapy - Reacts with alcohol to cause severe sickness - Onset & duration 2 WEEKS Antabuse & Revia (disulfiram) interactions - ANSWER Alcohol Mouthwash Aftershave Colone & Perfumes Bug Spray Elixer Medications Hand Sanitizer Uncooked icings (They can have the red wine vinegret) Upper Drugs - ANSWER Caffeine Cocain PCP/LSD (Psychedelics/Hallucinogens Methamphetamines Adderall (ADD Drug) S&S of upper drugs - ANSWER everything goes up - tachycardia - hypertension - Euphoria - restlessness - irritability - borborygmi - +3 & +4 reflexes (hyper) Downer drugs - ANSWER everything thats not an upper drug is a downer! (memorize the 5 uppers) S&S of downer drugs - ANSWER - hypotension - lethargy - respiratory depression - constipation - bradicardia After you know if the drug is an upper or a downer you assess for - ANSWER Overdose or withdrawal - Overdose = too much - withdrawal = not enough If you have withdrawal of an upper medication - ANSWER you have too little If you are withdrawing from a downer - ANSWER everything will be too high - seizures Overdose at birth - ANSWER always assume intoxication within the first 24hrs after 24hrs assume withdrawal Alcohol withdrawal syndrome (AWS) - ANSWER 24hrs after stoping drinking - not life threatening - not a danger to self or others - CARE: Regular diet, Simi privet any wear, up at liberty no restraints Delirium Tremens (DT) - ANSWER 72hrs after stoping drinking - life threatening - A danger to self & others - CARE: NPO or clear liquids, privet room near nurses station, fall risk, restraints Treatment for Alcohol withdrawal syndrome - ANSWER Antihypertensive Tranqulizer Multi vitamin containing B1 Restraint used for Delirium Tremens (DT) patients - ANSWER Vest Restraint Two point lock letters (Opposite hand and leg) Rotate 2 point restraints every 2 hrs Aminoglycosides - ANSWER Antibiotics (when nothing else works) End in Mycin NOT a Mycin - ANSWER Erythromycin Erythromycin Clarithromycin If it has thro in it throw it off the aminoglycoside list Top 5 drugs on NCLEX - ANSWER Psychiatric drugs Insulin Anticoagulants Digitalis Amino-glycosides OTHERS - Steroids - BB - CCB - Pain Meds - OB Meds Toxic effects of aminoglycosides - ANSWER Ototoxic (Think Mice ears) - Tinitus - Hearing loss*** - Vertigo/dizziness Nephrotoxicity (human ear looks like the kidney) - monitor creatinine (24hr is better then the serum) Toxic to cranial nerve number 8 and administer them every 8 hrs (Think Number 8) Aminoglycoside Rout - ANSWER IM or IV (PO not absorbed only given for hepatic coma to reduce ammonia levels and pre op bowl surgery to sterilize the bowel) Who can sterilize my bowels? - ANSWER Neo Can - Neomycin - Kanamycin PO not absorbed only given for hepatic coma to reduce ammonia levels and pre op bowl surgery to sterilize the bowel Peak Levels - ANSWER show the highest concentration drawn after administration trough level - ANSWER lowest blood level of a drug drawn before next administration When do you draw an IV med peak level - ANSWER 15-30min after bag is empty When do you draw a SL (sublingual) peak level - ANSWER 5-10min after drug is dissolved When do you draw an IM peak level - ANSWER 30-60 min after administration Always draw trough - ANSWER 30 min before the next dose!!! Calcium Channel Blockers - ANSWER Weaken, Slow down and depress the heart Calcium channel blocker's treat - ANSWER A AA & AAA - Anti Hypertensives - Anti Angina (works by decreasing oxogen demand) - Anti Atrial Arrhythmia (Atrial Flutter, Atrial Fibrillation and SVT is the only ventricular) Calcium Chanel blocker adverse effects - ANSWER Headache Hypertension Always check on a select all that apply - ANSWER Headache! names of calcium channel blockers - ANSWER Everything ending in -dipine -verapamil -cardazem (continuous IV drip) What should you do before administering a calcium channel blocker - ANSWER Check BP - hold medication if the systolic is under 100 Normal Sinus Rythym (NSR) - ANSWER P wave before every QRS and a T wave after every QRS complex and the QRS complexes are evenly spaced ventricular fibrillation - ANSWER the rapid, irregular, and useless contractions of the ventricles (no pattern) ventricular tachycardia - ANSWER a very rapid heartbeat that begins within the ventricles (pattern) Asystole - ANSWER absence of contractions of the heart QRS depolarization - ANSWER always ventricular If it says P wave it's - ANSWER atrial unless it says lack of a P wave then its ventricular No QRS - ANSWER asystole Saw tooth - ANSWER flutter Cyanotic = - ANSWER fibrillation Bizarre - ANSWER tachycardia Periodic wide, bizarre QRS's - ANSWER PVCs PVC's - ANSWER Never reach high priority PVC pt's are low priority unless there are more than 6 in a minuet, 6 in a row. then they are moderate priority. lethal arrhythmias - ANSWER Asystole (No heart rate, flat line) V fib High priority! potentially life-threatening arrhythmia - ANSWER V-tach PVC and V tach treatment - ANSWER lidocaine and amiodarone Atrial treatment - ANSWER ABCD's - Adenocard - Beta Blockers (olol) - Calcium Channel Blockers - Digitalis/Digoxin (lanoxin) Lanoxin - ANSWER Digitalis/Digoxin IV push - ANSWER When you don't know you go slow IV push Adenocard - ANSWER Push FAST!!!!! Beta Blockers - ANSWER -olol (atenolol) For Vfib you - ANSWER D fib (Shock them) In a pneumothorax the chest tube removes - ANSWER air In a hemothorax the chest tube - ANSWER removes blood In a hemopneumothorax the chest tube removes - ANSWER air and blood Chest tube location apical - ANSWER The chest tube is on top of the lung to remove air Chest tube location basilar - ANSWER At the bottom of the lungs and remove blood Unilateral - ANSWER one-sided Bilateral - ANSWER both sides Assume chest surgery is - ANSWER unilateral unless otherwise specified pnumonectomy - ANSWER removal of a lung (NO CHEST TUBES NEEDED) What do you give for Asystole - ANSWER Epi first then Atropine What do you do if you knock over a Jackson-Pratt drain - ANSWER pick it up and have the pt take some deep breaths What do you do FIRST if the seal of the chest tube breaks - ANSWER Clamp the tube What do is BEST to do if the seal of the chest tube breaks - ANSWER Submerge tube in water Person has Ventricle Fibrillation with no pulse what is the FIRST thing the nurse should do - ANSWER Place back board Person has Ventricle Fibrillation with no pulse what is the BEST thing the nurse should do - ANSWER Start Chest Compressions What do you do if the chest tube gets pulled out? - ANSWER 1. Cover it up with your gloved hand 2. Have someone prepare a sterile vasoline gauze 3. Do a switchout from holding the glove to putting the gauze over it 4. Put a dry sterile gauze over the vasoline gauze to tape it to the person 5. Tape it on 3 sides What is the BEST thing to do when a chest tube gets pulled out? - ANSWER put a gasoline gauze over it What is the FIRST thing to do when a chest tube gets pulled out? - ANSWER cover it with a gloved hand Intermittent bubbling in the water seal chamber is - ANSWER GOOD Continuous bubbling in the water seal chamber is - ANSWER BAD, an AIR LEAK (put tape over it to seal) Intermittent bubbling in the suction control chamber - ANSWER BAD (suctioning is too low) Continuous bubbling in the suction control chamber - ANSWER GOOD document bubbling Congenital Heart Defect - ANSWER Trouble heart defect start with the letter T - They will all have a murmur trouble or not - Echocardiogram gram is done on all cardiac defects TRouBLe heart defects blood shunt blood - ANSWER Right to Left (R before L in the word trouble) What do you do if the seal of the chest tube breaks - ANSWER CLAMP IT CUT the tube SUBMERGE in water UNCLAMP (It's in alphabetical order) Tetralogy or fallot symptoms - ANSWER VarieD PictureS Of-A RancH - Ventricular Defect - Pulmonary Stenosis - Overriding Aorta - Right Hypertrophy Hep B transmission - ANSWER Hep Blood (blood transfusion) Staph infection precautions - ANSWER Contact precaution Hep A transmission - ANSWER Hep Anus (fecal oral) Cushing's triad - ANSWER bradycardia, hypertension, and widening pulse pressure Rule of 9's for burns - ANSWER 9 (head), (4.5/4.5) 18 (arms), (4.5 X4) 36 (thorax), (18X2) 36 (legs) (9 X 4) 1 (perineum) equal 99. Warfarin (Coumadin) antidote - ANSWER Vitamin K Heparin antidote - ANSWER protamine sulfate How do you measure crutches - ANSWER 2-3 finger widths below the anterior axillary fold to a point lateral to and slightly in front of the foot elbow flexion on properly fitted crutches - ANSWER 30* Two point gate - ANSWER move a crutch and an opposite foot together Three point gate - ANSWER move two crutches and the bad leg together Four point gate - ANSWER move everything separately (very slow but very stable) Swing through gait - ANSWER for non weight barring (move both crutches at the same time as a bad leg) Use 4 point gate for a - ANSWER sever problem (sever bilateral weaknesses) Use a 2 point gate for - ANSWER miles problems (mild bilateral weaknesses) When to use a crutch gate - ANSWER odd for odd and even for even - 1 leg is effected use an odd point gate (1 & 3) - 2 legs are effected use a even point gate (2 & 4) Crutches - ANSWER up with the good down with the bad - when you go down the stairs start with the bad - when you go up the stairs start with the good Cane ambulation - ANSWER hold the cane on the STRONG side Walkers and bags - ANSWER tie stuff to the side NOT the front - Do not put wheels on walkers Nerotic = - ANSWER non psychotic Contact precaution - ANSWER - Privet room preferred unless pt has the same disease - Walkers - ANSWER pick them up set them down walk to them psych patients - ANSWER are they psychotic or non psychotic Delusion - ANSWER False fixed idea or belief Hallucination - ANSWER False, fixed sensory experience. - auditory (sound) Example: I hear demon voices - visual (sight) - tactile (feeling) - gustatory (taste) - olfactory (smelling) Illusions - ANSWER False, fixed sensory experience with a referent - There is actually something there but they miss intemperate it... Example: The client hears the nurses talking and says "I hear demon voices" Functional Psychosis - ANSWER schizophrenia, schizo affective, major depression, mania pt has potential to learn reality Psychotic Patients - ANSWER Dementia, Seniel, Delirium - Redirect them - Re orientate to person, place and time but not to reality about the situation they are confused about Functional Psychotic - ANSWER Potential to learn reality - Acknowledge feeling - Present reality - Set a limits (Stop talking about...) - Enforce limits delirium tremens - ANSWER a disorder involving sudden and severe mental changes or seizures caused by abruptly stopping the use of alcohol (Therapeutic response: You Are Safe)