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NLE / CGFNS / Nclex Review Materials 4

51. RSV
• Droplet precaution

52. SIADH
• Sodium 128 only (Normal: 135-145)

53. Dementia of Alzheimer Type


• Check what the pt. is taking

54. PEG

55. What medicine if given shld be monitored for bleeding


• Indomethacin (NSAID)

56. GBS, priority nursing diagnosis


• Aspiration

57. Discharge teaching for Bell’s Palsy


• Provide eye care at bedtime

58. Sign of Scoliosis


• Asymmetry of the iliac crest

59. Normal for a 3 day old infant


• Describe normal tonic neck reflex

60. Manifestation of Paranoid Schizophrenia


• Inappropriate anxiety with delusion

61. Sign of Alcohol withdrawal


• Feeling of euphoria in 1st 24 hrs.

62. Activity for Alzheimer disease


• Reading magazine

63. Type 1 IDDM post renal test 48 hrs ago, watch out for:
• Hematuria

64. Correct understanding of antidepressant


• Anti-depressant takes effect after 1 week

65. DUROGESIC PATCH / FENTANYL


• For chronic pain lasts 3 days
• Maybe worn while bathing, showering, swimming
• Apply to flat, nonirritated, nonirradiated area like chest, flank, upper arm, back
• Overdose : difficulty in breathing

66. Signs of increase ICP in pt. with close head injury


• Increase systolic pressure & weak bounding pulse

67. Positive outcome for Calcium Channel blockers


• Decrease chest pain

68. Obsessive Compulsive Behavior


• To alleviate anxiety
69. Patient with back pain, proper body mechanics
• Sit with knees higher than hips

70. What to check prior administration of EPOETEN


• BP
• S/E : HPN, Seizures

71.

72. Patient with pancreatitis if developing ascites would manifest:


• Cullen’s Sign (bluish discoloration of abdomen or peri-umbilical hematoma)
• Turner’s Sign (gray-blue discoloration of flank)
• Shallow, rapid breathing
• Abdominal pain
• Dyspnea & difficulty eating
• Orthopnea

73. Digitalis + Lasix = Weight Loss

74. Side effect of Garamycin


• Ototoxicity
• Nephrotoxic
• Hypomagnesimea
• Muscular paralysis
• Hypersensitivity

75. Side Effect of Theophylline


• Tremors & tachycardia
• Insomnia

76. Nsg. Management for cleft palate infant


• Enlarged nipple for feeding
• Stimulate sucking
• Swallow
• Rest
• Burp frequently

77. Patient with expressive aphasia, best communication:


• Use picture language

78. Diet for patient with colostomy


• DAT
• Low residue food 1-2 days postopt
• Avoid gas-forming foods

79. Patient allergic to Pseudoephedrine,


What is contraindicated?
• Patient taking Ma Huang

80. Patient with testicular cancer, correct understanding?


• Testicular CA is painless

81. 1st intervention in prolapsed cord


• Positioning – knee chest/trendelenberg

82. 2nd Stage of labor


• Cervical dilatation to delivery of
baby

83. Thiazide diuretic, what to watch out for?


• Potassium

84. Manic pt. taking lithium


• Watch out for sodium serum

85. Diet for patient with ileostomy


• Post opt 4 wks -- LOW FIBER
non-irritant diet to decrease fast movement of liquid stool, after can tolerate high
fiber diet
already
• Foods that thicken stool like boiled rice, low fat cheese should be given
• Low fat diet
• Normal stool is liquid

86. G & D of a 2 y/o


• Combines 2 words
• Kicks a ball
• 50 word vocabulary

87. ALS
• Decreased sensation of touch
• Muscle weakness
• Excess glutamate

88. S/S of Kawasaki


• Desquamation of skin
• Joint pain
• Mucocutaneous lymph node syndrome

89. Watch out for in lumbar puncture


• Increased ICP
• Brain Herniation

90. S/S of DVT


• Edema
• Calf or groin tenderness
• Pain with or w/o swelling
• + Homan’s Sign
• Warm skin

91. Developmental Milestone of 10 month old


• Pincer grasp

92. Risk for breast CA


• 38 y/o female on oral contraceptive

93. Need to consider anti-coagulant therapy


• If taking Gingko Biloba

94. Check 1st before tonsillectomy


• Bleeding time

95. Complication of CAST


• Compartment syndrome
• Fat embolism
• Shock
• Avascular necrosis

96.

97. Physician orders beta-blockers, for w/c pt. should the nurse question
the order:
• Patient on insulin (B-blockers may mask signs of hypoglycemia)

98. Patient hypersensitivity


• Give macrolides like erythromycin,azithromycin (Penicillin & Cephalosporins the
same)

99. Patient with autonomic dysreflexia


• Pounding headache , piloerection

100. Pt. with carafate & antacids order, select the schedule.
• Carafate 1 hr. before meals &
antacids after meals

101. Increasing pulse pressure


• Widening pulse pressure (late sign)
• Decreased LOC, restlessness
(Early)

102. Pt. with Hemophilia & Leukemia


• Can lead to DIC

103. Effective teaching to DM patient


• Peak of NPH insulin 8 hrs.

104. Mg SO4 given to PIH pt. Nurse should watch out for?
• Epigastric pain & headache

105. Pt. with calcium oxalate stones


• Diet with fig & wheat germs

106. Cancer & Sepsis can lead to DIC


• low platelet count

107. Pt. in labor with crusted popular eruption, priority?


• Eye prophylaxis of the newborn

108. Heroin addicted mother in labor, nursing action?


• Avoid withdrawal in active stage

109. Signs of Heroin intoxication?


• Euphoria
• Decrease response to pain
• Respiratory depression
• Apathy

110.

111. Scarlett Fever isolation precaution


• Respiratory precaution
• droplet until 24 hrs. start of
treatment

112. Laryngectomy
• Avoid swimming, showering, using aerosol sprays
• Teach client clean suction technique

113. External irradiation therapy


• Time & distance shielding

114. Pt. with anorexia nervosa, signs


• Tachycardia

115. Brain injury


• Decorticate rigidity

116. Signs of renal failure


• Urine output less than 100ml/hr

117. Post-thyroidectomy patient, WOF


• Tingling sensation in the cheek
(complication)

118. Ventricular Fibrillation


• Do chest compression

119. Pt. in crutches, nurse should check


• Check armpits to see if there is pressure secondary to crutch
(Pressure shld be on the hands not on the axilla)

120. Influenza Vaccine indicated for:


• Anyone 50 y/o & above annually
• Age 6 months & up with risk like asthma
• Immunocompromised patients
• Pts with cardiac & pulmonary
disease

121. Herpes Simplex I & II


• 2 strains of herpes virus family

• HSV I – cold blisters / fever blisters


• HSV II – in STD /Genital Herpes/Shingles & varicella zoster infection same with
chicken pox

122. Above the knee amputation, patient shld


• Prevent internal or external rotation of the limb
• Place sandbag or rolled towel along side of thigh to prevent rotation

123. HIV suspect patient


• Hairy tongue and leukoplakia
(Leukoplakia, pre-malignant lesion)

124. DVT on Heparin therapeutic goal


• Ambulate ASAP
( Prevent thrombus formation)
125. Esophageal varices, refer pt if
• Cold clammy skin ( sx of shock)

126. Pregnant 39 weeks, knows true labor if


• Contractions from back going to abdomen

127. Bipolar manic patients, what to do?


• Limit group activities

128. Multiple Myeloma, care


• Force fluid from 3 - 4 L/day to offset hypercalcemia, hyperurecemia
• Encourage ambulation to prevent renal stones

129. Post pace maker transplant, correct understanding


• Patient CAN USE electricc blankets, cell phones <3 watts,microwave ovens,
metal
detectors

130. Patient taking garlic supplements should take precaution when on


aspirin therapy

131. DKA patient, what to administer 1st?


• Start IV line 0.9 NaCl

132. Hearing aid, correct teaching:


• Turn off & remove battery when not in use
• Avoid excessive wetting of hearing aid, keep dry
• Ear mold is the only part that may be washed w/ soap & water
• Cannula is cleaned with small
pipe cleaner device or toothpick

133. PEEP

134. 18 day old infant, how to assess trunk curvature


• Place in prone position & stroke spinal colum, see if infant’s body move
towards the stimulated
area

135. Postural drainage, correct understanding:


• Position—lung segment to be
drained is uppermost
• Drink a glass of water before PD to loosen secretions
136. Sign of Abdominal Aortic Aneurysm
• Pulsation between umbilicus & pubis

137. Echinacea
• To boost immune system
• Use only up to 8 weeks

138. Action of PILOCARPINE


• Increase outflow of aqueous humor
• For OPEN ANGLE GLAUCOMA