—_— NCLEX® Critical Thinking Exercise: ‘You're working in the ED and an 18-month old little gir! comes into the hospital. She has been diagnosed ‘with rotavirus. She is severely dehydrated. She has not cried or wet a diaper in 5 hours. The primary healthcare provider has written the following order: Give Ds %NNS with 20mEq of KCL at 20 mL per hour per pump. Would you carry out this order? Why or why not? Fuection erde vr Abw-te eutpal notice be tion of be @ mente sito Asses NCLEX® Critical Thinking Exercise: Part Lets say that you are the charge nurse on an adult medical surgical unit. You are short an RN staff member, and the nursing supervisor has sent an RN with neonatal intensive care experience to your unit. The nurse states on arzival, “I have not worked on an adult unt for 6 yeas.” As the charge nurse, what should you do first? AZ Send the RN back to NICU and give the nurses working on the floor already an extra client, ZZ Call the nursing supervisor and demand a RN with med-surgical experience, she wo etek Wave alveacte)) 4. Assign the nurse to do nursing assistant duties. Par tt ‘Whjch of the following clients would you assign the NICU nurse that is working on your floor? hour post cholecystectomy client experiencing pain every 2hours. Just pa. vs 72C Elderly client with unexplained syncope. —“Prnae) be hawisre) An yn] AG Teenager client 8 hours post hypophysectomy. pirutra | gland > Shick presiea tl : r 4 gland shick presin tty) AE New nimi diagnosed with adrenal insufficiency. fcon's Prseeesc- NCLEX® Critical Thinking Exercise: You ae caring for a client that has hypothyroidism. Your clients scheduled tobe given an AM dose of Levothyroxine (Synthroid), While you ae inthe clients room, she tats that she's been feeling this “fallnes inher chest that started afer she ate and has lasted forthe last ?houts. What should the nurse do first? _A® hminister Aluminum/Magnesium concentrate and suspension (Maslow) 30 mL. Twa) not be Administer the Levothyroxine (Synthroid®) —> é fer ieleiyecn ow Aes Rete 3. Obiain a 12- lead ECG Critical Thinking © call the primary healtheare provider i Cony protected. Reproduction prohibited without authrizatin and release by Hurst Review Servis. ele CT rr |WUUVUIIFITFIFTTFTI ZF IITIIIVIVIVINTD Wn che parl 9tty OMe IX. GASTROINTESTINAL PO Gang A. Pancreati 1. Pathophysiology: a. The pancreas has two separate functions Suh. 1) Endocrine-_\Suli 2) Exocrine-_(higeStya. _ enzymes b. Two types of pancreatitis ool allbladder disease 1) Acute: #1 cause #2 caus 2) Chronic: #1 cause = /LICD\a»\ ea ac Hvete A WS ice paves 2 active te 2. Sis: a. Paine Does hepa ereaso decrease with ating? Ww reas lood b, Abdominal disten .s (losing protein rich fluids like enzymes and bl into the abdomen) —f ascites cc. Abdominal mass- swollen _Pinerpis @anCTa > d. Rigid board-like abdomen (guarding or bleeding) ‘¢ What does it mean? ¢. Bruising around umbilical area sign; flank area Gray Turner's sign. Cullens f. Fever (inflammation) g. NV h. Jaundice i Hypotension =_[usdnd or ascideS oduton prohibited without suorization ad eleae by Hurst Review Services, ns Copyright protected. RepThe values listed in his book are ons to be wsed us reference a. Goal: Control pain 1) Decrease gastric secretions (_NF)_, NGT to suction, bed rest) © Want the stomach empty and dry pias a as Wena hit Z/ @ 3. Dy: « a. oe Normal Lab Vales s pom tod eniytans AS ad Amen as as (a) e b. wees ft Lipase: 0-110 UL e ©. Blood ‘ A mee, Normal Lab Values e AG AST8-40 UL ‘Normal Lab ee T, AST-liver enzymes af ALT= 1030 UML Values e Se. PLPTT_prion wateresea| f Sermtiintin er eae Henatoei 8. HH (Hemoglobin & Hematocrit) Ap or, oka Male: 40-54% e © Why down _ blydiia up Ae ***P¥case note hat al normal anges Wood tet Spc sa TBpetoniag tng e e e e € e e 2) Pain Medications: ‘+ PCA narcotics morphine sulfate(Morphine®), hydromorphone (Dilaudid®) «Fentanyl patches(Duragesic®) 3) Steroids, why? _dy crogce jtlammaerie 4) Anticholinergics, why? _lyy| { Secretion” ‘© Benztropine (Cogentin®): Diphenoxylate/Atropine (Lonox®) 5) Pantoprazole (Protonix) (proton pump inhibitor) 6) Ranitidine HCI (Zantac®), Famotidine (Pepeid®) (Hy receptor antagonist) 7) Antacids 8) Maintain fluid and electrolyte balance Stavt 9) Maintain nutritional status — ease into a diet Ud] CLL” 10) Insulin WHY? liquids © Sick Pann. + ren © Stmids Copyright protected Reproduction prohibited without utoriatin nd release by Hus Review Serves.ea 11) Daily weights 12) Eliminate alcohol 13) Referto AA if this is the cause, a “TESTING STRATEGY* © Liver elovaperr the bod} If your liver issick-your, ; hg #1 concem (Bleeding * Helpsyourblood to adit 4REST * The liver helps to metabolize (break down) _h © The liver synthesizes. Loy zans aan ‘TESTING STRATEGY* Never give Tylenol oliver people 1, Pathophysiology: Mesbainelin. * Liver cells are destroyed and are replaced wih connectivelscar issue» atercthe Lilt lectasvpithin the liver— the BP inthe liver goes Life, this salle Portal doug were ¥ Calacgeclrotarne ! : Abdominal pain liver capsule has stretched b. ©. Chronic dyspepsia (GI upset) . Change in beteed habits e. Ascites “TESTING STRATEGY" £Splenomegaly -cmstsrs When spleen ised the tna pin Sysen is involved & dicstaaed _ serum slbumin —y azgitca W dueevesed ALT& AST > tudes Ud ebro ie, BEBE R Ee mE KT TUCUULUTLULTALT LE ZE TEETER. iL Anemia 4+ Can progress to hepatic encephalopathy/coma buteloup if titra —> Debi (CePet oieci.Repoducon prokibted witout aeration ad len by Ha Review Seve3. Da: & Ultrasound ». CT, Mri Fe Liver biopsy Clotting studies pre- PT ang PIT * Vial signs pre-procedure * How do you position this tient? Ar DEN in, anes * Exhale and hold data th» Why? To get the _ hcg lit. out ofthe way * Post: Lieon_yi1/, side Vital signs, worried about belied oc. a 4 Te: Cope te) a. Antacids, vitamins, diureties a ‘more damage), 4 leeds ny ©. 1 & O and daily (Any time you have ascites you have a uid volume problem) Rest (¢. Sex oy ‘Ke. Prevent bleeding (bleeding Precautions) j\. Ash © Measure abdominal grt, Mr Alte bnadtig Paracentesis: * Removal of fluid from the Pilidezed _ cavity (ascites) © Have client void “TESTING STRATEGY= ‘Anytime you are pulling ‘luids-> worry about ‘throwing them into shock, Avold Aaaaca ach + liver can't metabolize drugs well when it's sick fever eatca BiEd etictity padtoeed tat Some med Rept hed wit eta dicen ae oe Series,Lad? tp amma 4. bene j. Di “TESTING STRATEGY* Nee Ifyou give liver client narcotics it’s the same thing Aye Decrease proteip 4.) 4 ty as double dosing them. + LowNadiet ¢ ‘Let's Get Normal Straight First! Protein— Breaks down to ammonia» The Liver converts ammonia to urea Kidneys excrete the urea C. Hepatic Coma: 1. Pathophysiology: a. When you eat protein, it transforms into Quy: Wee and the liver “SSnverts It (0 urea, Urea can be excreted through the kidneys without difficulty b. When the liver becomes impaired then it can’t make this conversion, so what chemical builds up in the blood? Wee + What does this chemical do to the LOC? Aber ade 2. sis: a. Minor mental changes/motor problems b. Difficutto A2bure, © Astetixis > Lurrroe BA ppena. (hus Shy) 4. Martie A changes ‘ @. Reflexes will decrease f. EEG pat i. Liver people tend to be GI bleeders, ©. Decrease —— Pastis nea; : ie 4. Monitor serum ammonia CoPmieh protec. Reproduction prob 129i D. Bleeding Esophageal Varices Pathophysioto a. High BP inthe liver (pert HTN) forces collateral circulation to form. M This circulation forms in 3 different places» stomach, esophagus, rectum b. When you see an alcoholic client that is GI bleeding itis usually esophageal Variees.( (emaveds) * Usually no problem until “weuprten 2. Tx: a. b. © a. e. £ g he LLU GENY, tut udoe Lo thy We or lor, bo - Replace ntac dé) volun . VS cve Oxygen (any time someone is unwise) . Oxygen is needed) Octreotide (Sandostatin®) lowers BP in the liver. Sengstaken- Blakemore Tube What is the purpose? To hold Cleansing enema to get rid of carer he Lactulose (Neo-Fradini) (decreases ammonia) Saline lavage to get blood out of_Ateyngalr EVL: Esophageal Variceal Ligation Also an option. In this procedure a rubber- band like Ligature is slipped over the varices via an endoscope, necrosis results and the varices eventually slough off Blakemore Tube Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services. aanamaaane: ae ant Janne ees |S FeeGomme roca Reactor wiht auorzaon nd ees He Review Services. E. Peptie Uleers: 1. Pathophysiology: a. Common cause of GI Aliding b. Can be in the esophagus, stomach, duodenum . Mainly in males or females? “1/0 4. Erosion is present 2. SiS: a, Buming fo /i/ usually on the mid-epigastric area/back b, Heartburn (dyspepsia) 3. Dx: a. Gastroscopy (EGD, endoscopy): 1) NPO pre 2) Sedated 3) NPO until what returns? G24 Meplesoes 4) Watch for perforation by watching for Pai, bleeding, or ALbrta beta bh ones sng b. Upper Gi: 1) Looks at the esophagus and stomach with dye 2) NPO past midnight 3) No smoking, chewing gum, or mints. Remove the nicotine patch, to. * Smoking f stomach ~azti/; ig which will affect the test. © Smoking 4 stomach tetonig Br| 4. Tx: 7, |. Medications: cont é Fi jomach) 1) Antacids: Liquids or tablets? CUficl fy (oy stomach) ‘Take when stomach is empty and at bedtime — when som seid can get on ulcer... take antacid to protect Meer. ach is empty Inhibitors: (decrease acid secretions) 2) Proton Pump evaci razole (Prilosec®), Lansoprazole (Pr Esomeprazole (Nexium®) Famotidine (Pepcid®) Mylanta 11®) 4), Pantoprazole + Om (Protonix! 3) Hh antagonist: Ranitidine (Zantac®). s lidocaine, cin (Biaxin®), Amoxicillin jidazole (Flagy!®) so acid can’t get ‘© G1 Cocktail (donnatal, viscou thromy’ “Antibioties for H. Pylori: Clarit cin), Metron! (Amoxil®), Tetracycline (Panmy' forms a barrier over the wound © Sueralfate (Carafate®) on the ulcer. b. Client Teaching: © Decrease__at2toD © Stop Eat what you can ae avoid temperature extremes and extra spicy foods; avoid (iritant) Need to be followed for one year 5. Cla af a. Gasitc ulcers: laboring person; malnourished, pain is usually half hour to | hour afler meals; food doesn't help, but does; vomit blood .well-nourished; night time pain is common and 2-3 . Duodenal ulcers: executives; Late helps; blood in stools, hours after meal: F. Hiatal Hernia: 1. Pathophysiology: fa. Thisis when the hole inthe diaphragm is to large so the tsmmagote Late tance eee eg ue a Be caro Wh b. Other causes of hiatal hernia: congenital abnormalities, trauma, and Q1inge opr protected. Reproduction prohibited without authorization and release by Hurst Review Services.DLELALDDIGEIITS OPVTVITITIFIIITS ee c. Regurgitation ‘burn tae d. Dysphagia (difficulty b. full ryy/after eating / 3. Tx ‘a, Small frequent meals b. Sit up 1 hour after eating Keep the stomach in down position. c. Elevate HOB pene d. Surgery ce. Teach lifestyle changes and healthy diet G. Dumping Syndrome: 1. Pathophysiology: «+The stomach empties too quickly and the client experiences many uncomfortable see emade effects. usually secondary to gastric bypass gastrectomy, oF gall bladder disease 2. Sis: a. Fullness d. Weakness b. Palpitations . Cramping ¢. Faintness f. Diarrhea 3. Tx ‘a. Semi-recumbent with meals PERSTING STRATEGY®. Layo lef sid o keep fod in the stomach, . Lie down after meals €. No_tiazcidl with meals (drink in between meals) Lot © pglenae di. Decrease _Az2e/ _ (carbs empty fast) : A Copy protected. Reproduction ro cprednctionpobbited without authorization and release hocizaton and release by Hust Review Services. s 1314 Ulcerative Colitis and Crohn's Disease: 1, Pathophysiology: A. Ulcerative Coli = ulcerative inflammatory bowel disease Justin thefarge intestine D. Crohn's Disease» the 47, also called Regional Enteritis; inflammation and erosion of *can be found anywhet 2. sis: Omak nnn cee a. Diarrhea f. Dehydration b. Rectal bleeding g. Blood in stools ¢. Weight loss h. Anemia d. Vomiting i. Rebound tenderness fe. Cramping je Fever * What is rebound tenderness? Push in — let 0 GE ats cop at is rebound tendem e Agi d, What does it mean? Peritoneal tpupdagsnigle doe b. Colonoscopy « stat liquid diet for 12-24 hours. + Nee 6-8 hours pre Avoid NSAIDs + Laxatives or enemas until_ fez GoLYTELY® —> oot © Sedated for procedure ‘© Post op watch for flak op A s e a d n 9 The Large Intestine Colostomy — ascending and transverse— semi Mt AL stools Colostomy» descending or sigmoid semi formed or ‘Which one do you irrigate? Arecos av he SAdmaid Why irrigate? “h Julio chnolfl coo puck | ip utlay) When is the best time to irrigate? Same _-hivig everyday Anera_pggl ‘The further down the colon the stoma is, the more formed the stool will be because__{ni0tf je is being drawn out. The stool is more normal. Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services“TESTING STRATEGY* about is 1. Pathophysiology’ © Related to a fiber diet 2. SIS: © Generalized pain initially ‘Eventually localizes inthe right lower quadrant (MeBurney’s PO. yt ‘© Rebound tenderness “TESTING STRATEGY" Positioning is very important to learn + Nausea and vomiting as a brand new nurse Tpand ryt «© Get good history (abdominal pain 1" then N & V) + Anorexia 3. Dx: + WBC elenaded © Uhrasound > enlarged ape nei <—. cr «© Donot do enemas because you are worried about what?_fr-LegatUdae 4. Tx: © Surgery Most done via laparoscope unless perforated. ‘Afier any major abdominal surgery, what is the posit ‘ AS SEIN FD MRSS Ho VEAL VE Pressure air Su rere We TESTING STRATEGY* [Never want pressure on a suture line. The Large Intestine ; opie protected Reprotton prohibited without auheriation and release by Hurst Review Ser 7 vices Wyentation (total parenteral nutrition) (TP: see 1, Nursing Considerations: Keep refrigerated; warm hea for administration; let sit out for a few minutes prior to fre Central line needed Filter needed ‘+ Nothing else should go through this line (dedicated line) © Discontinued gradually to avoid __bU4 yougly LAVA Ca # Daily wei gints TESTING STRATEN” rere ied ag be Suc anaes (nsullv\ ena bey Je nud oncre, 8 Ve TRM ) = (ese rony damage cee according to electrolytes. Blood glucose monitoring q6 hours © Check Luan, (for _/\inar ost — Do not mix ahead- mixture changes © Can only be hung for 24 hours. © Change tubing with each new bag, swith dark bag to prevent chemical breakdown. IV bag may be covered Needs to be on a pump ze hand washing infec) © Home TPN-emphasi ‘e Most frequent complication sanicn nd reese Hart Review erie cep prc Rerdacon pict a2. Assisting the MD to insert a cen ral line: 2 i 4 Have saline available for fush; do not start fluids until positive confirmation of lav placement (CXR). position? trencked en bou A to distend veins. © Position? “12 4 putthe client in? «fair gets in the line what position do you . e = e s . s s a Ld = 2 Air Bubbles iN in the heart the client may be taken to the cath lab «When you are changing the tubing, how can you avoid getting air in the line? Clamp it off Valsalva Take a deep bysAl) and HUMMMMMM «Why is an x-ray done post-inserton? Check for_Plarunent 4 Yruumetror ac Make sure your client does not have a \ NCLEX® Critical Thinking Exercise: ‘A nutse is assisting a primary healthcare provider inserting a central line, for a client diagnosed with sepsis. After inserting the central line, which option would be most appropriate? 1, Star the ordered antibiotics. 2. Allow the primary healthcare provider to start the antibiotics as ordered. 3 3. Check for blood return, and if present, start the antibiotics ordered. Administer the stat antibiotics after you have confirmation of placement ofthe central line PEROT TTVITIIIVIUS Copyright protected Reproduction prohibited withoot authorization and release by Hust Review Services, 19