NClex Review Topics

(direct and indirect) contact precautions

 direct contact transmission: microorganisms are transferred from one infected person to another p
erson without a contaminated intermediate object or person

 indirect contact transmission: transfer of an infectious agent through a contaminated intermediate

object or person (especially contaminated hands of health care workers)

 gown and gloves are required for all contact

 contact transmission, e.g., VRE (vancomycin resistant enterococcus); Clostridium Difficile (C. Di
ff.) infection, excessive wound drainage; fecal incontinence

droplet precautions -

 transmission involves contact of the conjunctivae or the mucous membranes of the nose or mout
h of a susceptible person with large particle droplets containing microorganisms generated from someone
who either exhibits a disease or who is a carrier of the microorganism

 when close contact (typically within 3 feet or less) between the source client and a susceptible per
son is required, the use of a standard surgical mask is required

 group A streptococcus (for the first 24 hours of antimicrobial therapy), adenovirus, rhinovirus, Ne
isseria meningitis, pertussis, influenza virus

airborne precautions -

 used when microorganisms dispersed through the air over long distances remain infective over ti
me and distance

 preventing the spread of airborne pathogens requires special ventilation system and N95 mask or
higher

 airborne route include rubeola virus (measles), varicella-zoster virus (chickenpox), Mycobacteriu
m tuberculosis

neutropenic precautions -
 used to prevent infection in clients who have neutropenia (low white blood cell counts) or are im
munocompromised

 health care workers will wear gowns, masks, gloves when providing care

 strict hand washing

 client is in a private room

 visitors are restricted

 no raw vegetables or fruits

 client should be instructed to bathe daily

Smallpox

 causative agent: variola virus

 exposed individuals can spread infection via direct contact or prolonged face to face contact

 initially (sometimes contagious): high fever (101 to 104 degrees Fahrenheit), malaise, head and b
ody aches

 rash (most contagious): start as small, red spots on the tongue and mouth; the spots become open
sores and then spread to the rest of the body becoming pustules that crust and scab-over

 individuals are contagious until all scabs have fallen off

presumptive/possible Signs of pregnancy

 subjective findings and objective signs reported by woman, including amenorrhea, fatigue, nause
a and vomiting, breast changes, elevation of basal body temperature, skin changes

 findings may be caused by conditions other than pregnancy

probable: changes observed by examiner

 Chadwick's sign: increased vaginal vascularity contributes to bluish purple hue of the cervix, vag
ina and vulva

 Hegar's sign: increased vascularity and softening of uterine isthmus

 Goodell's sign: cervical softening caused by stimulation from estrogen and progesterone

positive: signs attributed only to presence of fetus, e.g., fetal heart tones, visualization of fetus, palpating
fetal movements

 calculate due date - Naegele's Rule (when first day of last normal period = N, then due date = N p
lus 7 days, minus 3 months, plus 1 year

physical examination of newborn

 temperature (97.9 - 99.7 F [36.6 - 37.7 C]) axillary

 apical heart rate (110 to 160 BPM)

 blood pressure (50 to 75 mm Hg)

 respirations (30 to 60 respirations per minute)

 measurements of length, head, and chest circumference (head and chest circumference same)

 bilirubin levels

 appearance of jaundice during the first day of life indicates pathological process

 evaluation indicated with hyperbilirubinemia

 15 mg/dL or greater (term)

 10 mg/dL or greater (preterm)

 The safest time to offer analgesia is when dilation is between 4 to 7 centimeters.

Preoperational: two to six years-old

Characteristics :

 object permanence becomes more established

 still egocentric in thinking

 use language as a symbol system increases

 increased magical thinking and imagination, also called animism

 perceptions rule child's thinking and reasoning

 attention span is short

 thinking is done in a non-logical, non-reversible manner

 child has better concept of time as s/he approaches school age

Nursing considerations :

 illness and hospitalization frighten toddlers and preschoolers because they lack the cognitive pow
ers to grasp these experiences

 precognitive children use fantasy and magical thinking to attempt to understand illness and hospit
alization

 precognitive children have many fears, especially separation which peaks from two through three
years of age

 these children learn best if actively involved in the learning process

 this age group relates well to discussions about what they will see and feel, which is why visual a
nd tactile learning is best

Concrete Operations: seven to ten years-old :

Characteristics :

 thinking shifts from total egocentrism, but egocentric thinking still predominates

 conscience develops

 perception no longer dominates reasoning; cause-and-effect relationships are recognized

 understands basic ideas of conversation, number, classification, and other concrete ideas

 attention span increases

 mental actions are reversible; problem-solving by trial and error

Nursing considerations :

 this age group benefits from health teaching with concrete terms and explanations
 this age group reads and understands concepts related to the human body

Formal Operations: eleven years to adult

Characteristics :

 see new logical relationships

 analyze situations and think more logically than before

 think creatively since increased abilities to think abstractly

 concern for moral and social issues are a priority over egocentric thinking

Nursing considerations :

 think much more like adults

 are able to be taught health concepts at higher levels

 more likely to understand adult vocabulary

Erikson's Eight Stages of Psychosocial Development

Trust vs. Mistrust

 Birth to 18 months

 The development of trust is based on the dependability and quality of the child's caregivers, i.e., f
eeding

Autonomy vs. Shame and Doubt

 Toddlers (18mts to 3 years-old)

 Children develop a greater sense of personal control, i.e., toilet training

Initiative vs. Guilt

 Preschool (3 to 5 years-old)
 Children begin to assert their power and control over the world through directly play and other so
cial interaction, i.e., independence

Industry vs. Inferiority

 School age (6 to 11 years-old)

 Through social interactions, children begin to develop a sense of pride in the accomplishments

Identity vs. Role Confusion

 Adolescence (12 to 18 years-old)

 Exploring independence and developing a sense of self

Intimacy vs. Isolation

 Early adulthood (18 to 40 years-old)

 Exploring personal relationships is important, especially love relationships

Generativity vs. Stagnation

 Adulthood (40 to 64 years-old)

 Building careers and family

Integrity vs. Despair

 Older adult (65 years to death)

 Focused on reflecting back on life

Infancy (1 month to 12 months)

 period of very rapid growth

 doubles birth weight at six months, triples at one year

 by 1 year birth length has increased by almost 50% (occurs mainly in trunk)

 by 1 year head circumference has increased by almost 33%

 posterior fontanel closes 6 to 8 weeks of age

 anterior fontanel closes 12 to 18 months of age

 tooth eruption begins at 5 to 6 months

 has 6 to 8 teeth by 1 year of age .

 sits without support at 6 to 8 months of age

 rolls completely over at 6 months of age

 vocalization at 8 months of age

 pincer grasp at 9 to 11 months of age

 crawling 6 to 7 months of age

 stands alone 10 to 12 months of age

 cruises (walks holding on to something) 10 to 12 months of age

 walks at 12 to15 months of age

 begin feeding self at 11 months of age .

 cries, smiles, coos by 3 months

 produces chained syllables by 6 months

 says two or more words by 1 year

 understands meaning of "no" by 11 months of age

 can follow simple directions at 1 year

 Play is solitary

 game playing such as peek-a-boo and pat-a-cake by ten months

 birth to 6 months - mobiles, unbreakable mirrors, music boxes, rattles .

 6 to 12 months - blocks, nesting boxes or cups, simple take apart toys, large ball, large puzzles, ja
ck in the box, floating toys, teething toys, activity box, push-pull toys

Toddlerhood (1 to 3 years)
 gains 1.8 to 2.7 kilograms (4 to 6 pounds) per year

 grows 7.5 centimeters (3 inches) per year (occurs mainly in legs)

 lordosis and potbelly are characteristic

 head circumference usually equal to chest circumference by 1 to 2 years of age

 primary dentition complete by 30 months of age

 Motor development

 walking improves

 runs

 begins to climb and walk up and down stairs

 builds tower of eight blocks by age three years

 by end of toddlerhood can copy a circle on paper

 dresses self in simple clothing

 toilet training begins; bowel training usually accomplished before bladder

 discipline becomes necessary Inserting image...

 ritualistic: need to maintain sameness and reliability

 negativism: persistent negative response to requests

 frustration may result in temper tantrums or regression

 Moral development: Kohlberg 's preconventional or premoral level Inserting image...

 vocabulary grows from four to six words at 15 months to over 300 words by age two

 "no!" and "mine!" are key words

 Play is parallel

 Common fears include the dark, being alone, separation from parents, some animals, and loud ma
chines

 Suggested toys: push-pull toys, finger paints, thick crayons, riding toys, balls, blocks, puzzles, si
mple tape recorder, housekeeping toys, puppets, cloth picture books, large beads to string, toy telephone,
water toys, sand box, play dough or clay, chalk and chalkboard
Preschool age (3 to 6 years)

 average weight gain about 2 to 3 kilograms (5 pounds) per year

 height: increase of 6.75 to 7.5 centimeters (2.5 to 3 inches) per year (occurs in legs)

 Motor development

 very active

 can hop on one foot

 pedals tricycle

 refinement of previous learned motor skills

 draws a person with one body part/year

 Cognitive: Piaget 's period of preoperational thought Inserting image...

 Psychological: Erikson 's developmental task of initiative vs. guilt Inserting image...

 sexual curiosity

 imitation of adult roles with dress-up games

 Moral development - Kohlberg Inserting image...

 2 to 4 years: punishment and obedience

 4 to 7 years: naive instrumental orientation

 by age 5, has vocabulary of 2,100 words

 knows name and address

 asks questions constantly

 uses fantasy in stories

 "why?" is favorite word

 Preschool play is associative and cooperative

 dress-up

 fantasy play

 imaginary playmates
 Common fears of preschool child include body mutilation, animals, supernatural beings, monsters,
ghosts, unfamiliar routines, separation from trusted adults, and abandonment, annihilation

 Suggested toys: tricycle, gym and sports equipment, sandboxes, blocks, books, puzzles, computer
games, dress-up clothes, blunt scissors, picture games, construction sets, musical instruments, cash registe
rs, simple carpentry tools

School age (6 to 12 years)

 growth is slow and steady until growth spurt of adolescence.

 between ages 6 to 12, growth at average of 2 to 3 kilograms (4.5 to 6.5 pounds) per year

 brain growth is complete by 9 to 10 years of age

 height: average growth of 5 centimeters (2 inches) per year

 loss of deciduous teeth/acquisition of permanent teeth

 child is usually lean, but some may become overweight depending on eating habits and activity

 full of energy

 rides bicycle and plays active games

 most enjoy sports

 writes in cursive

 more awkward as adolescence approaches

 Cognitive: Piaget 's period of concrete operations Image

 Psychological: Erikson 's developmental task of industry vs. inferiority Image

 develops a sense of accomplishment through completion of tasks

 joins clubs

 has same-sex friends

 peer approval is strong motivating power

 Moral development - Kohlberg Image

 develops a moral code and social rules

 views rules not just as dictates from authority, but as necessary principles of life
 can judge flexibly and decide if rules apply to a given situation

 vocabulary of approximately 14,000 words

 reading skills improve dramatically

 Play is cooperative

 sports and games with rules

 fantasy play in early years

 clubs

 hero worship

 cheating

 Suggested toys and activities: board or computer games, books, collections, scrapbooks, sewing,
cooking, carpentry, gardening, painting

Adolescent (age 12 to 19)

 boys increase in muscle mass; girls increase in fat deposits

 may experience growth spurts

 puberty Inserting image...

 primary sex characteristics and secondary sex characteristics/Tanner stages

 dentition is complete

 Motor development

 increase in gross and fine motor abilities

 increase in risk-taking behaviors

 Cognitive: Piaget 's period of formal operations Inserting image...

 Psychological: Erikson' s developmental task of identity vs. role diffusion Inserting image...

 begins to develop a sense of "I"

 peers become most significant group

 separates from parents

 Moral development: Kohlberg Inserting image...

 healthy adolescents consolidate moral development

 understand that rules are not absolutes, but cooperative agreements that can be changed to fit the s
ituation

 judge themselves by internalized ideals

 group values become less significant in later adolescence

 sense of right and wrong develops from applying values to daily decisions

 centers around social interactions: dating, phone calls, etc.

 sporting and cultural activities

Early adulthood (post-adolescence through age 40)

period of optimal physical function

typically free of acute or chronic illness

effects of aging begin at about 20 years of age

growth completed about age 25

height increased by 3 to 5 mm by age 30

peak strength about age 30

men more likely to have high cholesterol level

blood pressure changes noted by race, sex and weight

after age 30, digestive juices decrease

wisdom teeth emerge

average person tends to gain weight during the 30s

fully mature in 20s

women: optimal reproductive time between 20 to 30 years of age

Erikson's developmental task of intimacy vs. isolation Image

become more self-directive in the 20s

may question previous life choices

life becomes more orderly

develop a community focus

brain cell development peaks during 20s

continues to develop a higher level of cognitive functioning

person can think abstractly

person can now perceive many different points of view

more realistic and objective

Middle adulthood (ages 40 to 65)

 signs of aging begin to show

 subtle but gradual decline in most body systems

 integumentary system

 redistribution of pigment in hands ("age spots")

 graying of hair

 progressive decrease in skin turgor

 anteroposterior diameter of chest increases

 respiratory rate 16 to 20 breaths per minute

 normal breath sounds

 normal heart sounds

 pulse 60 to 100 beats per minute

 blood pressure:

 systolic 95 to 135 mm Hg

 diastolic 60 to 85 mm Hg

 visual acuity decreases

 presbyopia
Geriatric Physical Changes ( I had a select all that apply on geriatic changes)

 dry, scaly skin

 decreased perspiration

 decreased elasticity

 senile purpura

 spotty pigmentation

 reduced vital capacity

 increased airway resistance

 kyphosis may cramp lung expansion

 decreased lung expansion

 decreased cardiac output

 baseline systolic and diastolic blood pressure may rise

 peripheral pulses weaker

 abdomen increases in size, protrudes more

 less saliva

 less gastric motility and absorption

 decreased interest in food

 decreased peristalsis

 potential for malnutrition

 decreased hepatic clearance of drugs and other substances

 constipation common

 decreased renal filtration

 decreased bladder capacity

 urgency
 stress incontinence

 menopause

 urinary frequency

 benign prostatic hypertrophy contributes to urine retention

 andropause

 reduced muscle mass and strength

 decreased joint mobility and decreased range of motion

 decreased endurance

 postmenopausal women - bone demineralization

 decreased rate of voluntary or automatic reflexes

 sleep cycle changes - require less sleep at night, frequently nap in daytime

 impaired thermoregulation - prone to hypothermia

 decreased visual acuity

 decreased accommodation

 presbyopia

 decreased hearing acuity (presbycusis)

 decreased pitch discrimination - decreasing ability to hear high-pitched sounds

 taste buds atrophy

 decreased sense of smell

 lower base line temperature

 decreased immune response - increased infection risk

 hypopigmented patches

 skin is drier, especially on lower extremities

 lesions: cherry angiomas, senile keratosis, atrophic warts

 "liver spots" - small, flat, brown macules

Assess the heart through the anterior thorax (front chest)

 Inspection and palpation

 client in supine position or with head elevated at 45 degrees

 anatomical landmarks of the heart

 second right intercostal space - aortic area

 second left intercostal space - pulmonic area

 third left intercostal space - Erb's point

 fourth left intercostal space - tricuspid area

 fifth left intercostal space - mitral (apical) area

 epigastric area at tip of sternum

 apical impulse fourth or fifth left intercostal space, midclavicular line

antidepressants

 SSRIs: fluoxetine (Prozac), sertraline (Zoloft) had a question on side effects, escitalopram (Le
xapro), paroxetine (Paxil), citalopram (Celexa)

 MAOIs: phenelzine (Nardil), tranylcypromine (Parnate), and isocarboxazid (Marplan)

manic phase (had a select all that apply for this

 may last days to months: easily distracted, little need for sleep, poor judgment, poor temper contr
ol, reckless behavior and lack of control (such as excessive drinking, drug use, sex with many partners, sp
ending sprees), expansive or irritable mood (racing thought, talking a lot, false beliefs about self or abiliti
es), very involved in activities
 depressive episodes are more common than mania and may include: daily low mood or sadness, d
ifficulty concentrating, remembering or making decisions, eating problems (loss of appetite and weight lo
ss or overeating and weight gain), fatigue or lack of energy, feeling worthless, hopeless or guilty, loss of p
leasure in activities once enjoyed, loss of self-esteem, thoughts of death or suicide, trouble of getting to sl
eep or sleeping too much, pulling away from friends or activities that were once enjoyed

ImageAVOID concurrent use of natural remedies (St. John's wort and certain antidepressants can l
ead to serotonin syndrome)

anorexia - severe malnutrition, low potassium levels, heart problems, confusion

bulimia nervosa - constipation, dehydration, dental cavities, electrolyte imbalances, hemorrhoids, pancre
atitis, swelling of the throat, tears of the esophagus

Schizophrenia had a select all that apply for this

 defined by abnormalities in one or more of the following: delusions, hallucinations, disorganized

speech

 complications: having schizophrenia increases the risk of developing problems with drugs or alco
hol, physical illness (due to inactive lifestyle and medication side effects), suicide

 early symptoms: may include irritable or tense feelings, trouble concentrating, trouble sleeping

 later symptoms: involve thinking, emotions, and behavior, including: bizarre behaviors, hallucinat
ions, isolation, reduced emotion, problems paying attention, delusions, “loose associations”

Signs of Narcortic Use and Withdraw

 stimulants: alertness with increased vigilance, a sense of well-being and euphoria; talkative, flight
of ideas, insomnia, anorexia, tachycardia, hypertension, pupillary dilation

 opioids: symptoms of mild-to-moderate intoxication include drowsiness, pupillary constriction, sl

urred speech; for overdose, respiratory depression, stupor and coma

 depressants: drowsiness, relaxation, decreased inhibition, incoordination, slurred speech, staggere

d walk, respiratory depression

 specific to chronic alcohol use: anemia, cirrhosis, esophagitis, delirium tremens, hepatomegaly, m
alabsorption syndrome, Wernicke-Korsakoff syndrome

Nutritional needs through the life cycle

newborns and infants :

 fluid needs - adequate to maintain hydration (approximately 6-8 wet diapers per day)

 infants - protein needs approximately 2.2 gm/kg/day

 breast milk or formula alone is adequate for the first six months of life; whole milk should be intr
oduced around age 1 year

 pre-pregnancy - add 400 ug/day folic acid

 pregnancy - add per day: 300 calories, 15 mg iron, 30 g protein, 400 g calcium, and 400 ug folic a
cid in first trimester

 lactation - add 500 calories and 2 quarts extra fluid per day

 age 65 and older - adequate protein to maintain immune system

cations

sodium :

 most abundant cation in extracellular fluid

 regulates cell size via osmosis

 normal lab value for serum sodium is 135-145 mEq/L

 low levels of 125 mEq/L or less result in mental confusion, hostility, hallucinations

 excess levels may result in hypertension or generalized edema, called anasarca

potassium

 most abundant cation of intracellular fluid

 essential for polarization and repolarization of nerve and muscle fibers

 normal lab value for serum potassium is 3.5-5 mEq/L

 high and/or low findings may result in a fast or slow heart rhythm and muscle function with result
s of cramping in abdomen or legs

calcium

 needed for cardiac contraction, healthy bones and teeth, functioning of nerves and muscles, clotti
ng of blood

 vitamin D is needed for calcium absorption

 normal values - total calcium 8.5-10.5 mg/dL

 hypercalcemia -causes: hyperparathyroidism, metastasis of cancer, Paget's disease of bone, prolon

ged immobilization -findings: weakness, paralysis, decreased deep tendon reflexes

 hypocalcemia-causes: rickets, vitamin D deficiency, renal failure, pancreatitis, chelation therapy,

hypoparathyroidism -findings: muscle tingling, twitching, tetany

magnesium

 about half of total body magnesium is found in bone

 normal values - 1.5-2.5 mEq/L

 hypermagnesemia -causes: chronic renal disease, overuse of magnesium-containing antacids as
Maalox and Mylanta, Addison's disease, uncontrolled diabetes mellitus -findings: lethargy, nausea, vomiti
ng, slurred speech, muscle weakness, paralysis, decreased deep tendon reflexes, slowing of cardiac condu
ction

 hypomagnesemia -causes: malnutrition, toxemia in pregnancy, malabsorption, alcoholism, diabet

ic acidosis -findings: mood irritability, cardiac irritability, muscle tingling, twitching, tetany, delirium, con
vulsions

low purine diet

 prevents uric acid stone; used for clients with gout

 lowers levels of purine, the precursor of uric acid

 restricts glandular meats, gravies, fowl, anchovies, beer and wine

low calcium diet

 limit to 400 mg per day instead of normal 800 mg

 restricts dried fruits and vegetables, shell fish, cheese, nuts

acid ash diet

 prevents kidney stone formation

 restricts carbonated beverages, dried fruits, banana, figs, chocolate, nuts, olives, pickles

gluten-restricted or gluten-free

 used for people with sensitivity to glutens (proteins) in wheat, oats, rye, and barley

 may eat rice, corn and millet products

low cholesterol

 used for cardiovascular disease, high serum cholesterol levels

 normal amount of cholesterol intake - 250 to 300 mg/day

 restricts eggs, beef, liver, lobster, ice cream

restricts eggs, beef, liver, lobster, ice cream

high fiber

used to correct constipation, prevent diverticulitis, lower risk of colon cancer

30 to 40 gram fiber/day recommended

increased intake of fruits, vegetables, bran cereals, whole grains

low residue

 used for conditions such as diarrhea, acute diverticulitis

 reduce fiber intake: canned fruit, refined carbohydrates, pasta, strained vegetables

 foods high in refined carbohydrates are usually low fiber

 increased use of ground meat, fish, broiled chicken without skin, white bread

mechanical soft

 used with difficulty in chewing, such as poorly fitted dentures or edentulous clients (no teeth)

 includes any foods which can be easily broken down by chewing

puree diet

 used with dysphagia or difficulty in chewing

 used for tube feedings, small babies

 food is blended to smooth consistency

liquid diets

 clear liquid: coffee without cream, tea, popsicles, fruit juices, including apple, cranberry, grape, a
nd carbonated beverages

 full liquid: includes all clear liquids plus milk, cream, ice cream, pudding, yogurt, vegetable juice,
creamy peanut butter

nursing interventions - for gastric-placed tubes

 keep head of bed raised at least 30 degrees or semi-Fowler's position, to prevent aspiration for 1.5
to 2 hours after feeding is infused

 recheck placement of tube prior to each feeding

 obtain radiologic (x-ray) confirmation before instilling any feedings or medications or if there are
concerns about other forms of assessment

 recommended practice is to aspirate gastric contents and check if pH is acidic (pH should be acidi
c)

 injecting ten mL air into nasogastric tube (NG tube) and listening with stethoscope for rush of air
over stomach is no longer an accepted method to verify placement

 prevent bacterial growth by limiting infusions to hang for less than 8 hours and changing tubing
every 24 hours

 prevent fluid and electrolyte imbalances by administering at a rate of no more than 300 mL/hour

 check gastric residual

 every 4 hours if continuous feeding or prior to intermittent feedings

 if residual is greater than 100-150 mL (or using facility policy), hold feeding
 reinsert residual into tube to prevent metabolic alkalosis

 flush tube with 30 to 60 mL water after feeding

Nutritional supplements and liquids for dehydration or diarrhea

Had a select all that apply about what to give infant who has diarrhea nd vomiting

 infants: Infalyte, Pedialyte®, Ricelyte®

 older children: sports electrolyte replacement drinks

 infant formulas: standard and high-calorie

 predigested, e.g., Pregestimil, Nutramigen

 breast milk

 no juice or carbonated beverages

indwelling catheter

Had a few questions about inserting catheters this was one of the choices

 advance catheter almost to bifurcation of catheter, especially in male clients

 inflate balloon within guidelines of manufacturer only after urine is draining properly, then slightl
y withdraw catheter

 secure catheter to patient's thigh, allowing for some slack to accommodate movement and to lesse
n drag on patient; ensure tubing is over client's leg

 monitor intake and output

care of indwelling catheter

 cleanse around area where catheter enters urethral meatus, using soap and water

 catheter care should be done during the daily bathing routine and after defecation

 do not pull on catheter while cleansing

 do not use powder or spray around perineal area

 maintain a closed drainage system

 avoid raising the drainage bag above the level of the bladder

 avoid clamping the drainage tubing

 catheter is only irrigated when an obstruction, usually following prostate or bladder surgery when
blood clots are anticipated

 remove catheter when no longer medically necessary - use a decision-making algorithm for deter
mining when to remove the catheter

intermittent self-catheterization

procedure

 gather equipment: catheter, water-soluble lubricant, soap, water, urine collection container

 wash hands

 cleanse urethral meatus and surrounding area

 lubricate tip of catheter

 insert catheter until urine flows

 withdraw catheter when urine flow stops

 clean off residual lubricant from meatus

 dispose of urine

 wash hands

St. John's wort is the number one herbal product .

interacts with over 60 percent of all prescription drugs

the interaction is to make drugs less effective, including digoxin, cyclosporine tamoxifen, highly active an
tiretroviral therapies (HAART) and combined oral contraceptives
As a general rule, classes of drugs have the same generic "last" name:

"PRILS" = ACE inhibitors (enalapril, lisinopril)

"SARTANS" = angiotensin receptor blockers (losartan, valsartan)

"TRIPTANS" = treatment of acute migraine headache

"STATINS" = lower LDL cholesterol (simvastatin, rosuvastatin)

"DIPINES" = calcium channel blockers (amlodipine, nifedipine)

"PRAZOLES" = proton pump inhibitors (omeprazole)

"AZOLES" = antifungals (miconazole)

nasal spray

 gently blow nose before administration

 shake container

 tilt head slightly back

 occlude one nostril, insert spray tip into the other nostril

 activate spray and gently inhale

rectal suppositories

 if used for systemic indication, have client defecate if possible to allow facilitation of medication

 position client on left lateral position and insert just beyond internal sphincter

 instruct client to retain the medication for 20 to 30 minutes for stimulation of defecation and 60
minutes for systemic absorption

vaginal suppositories

 position client supine with knees bent, feet flat on bed and close to hips (a modified lithotomy pos
ition)
 use application device to insert suppository

Ophthalmic

 wash hands and apply gloves - rinse powdery residue from gloves

 instruct client to recline or tilt head back

 instruct client to look up

technique - eye drops Instilling Eye Drops

1. Wash hands and apply gloves; rinse powdery residue from gloves

2. Instruct client to recline or tilt head back

3. Instruct client to look up

4. Pull lower lid down and to the side

5. Apply drop at lower, outer aspect of eye (lower conjunctival sac)

6. Apply mild pressure to inner canthus for 1 minute to decrease systemic absorption

7. Instruct client to gently close eyes

8. Wait 2 to 5 minutes before instilling additional eye drop (in same eye)

technique - eye ointment

 apply a thin line of ointment along the edge of the lower lid moving from inner canthus to outer c
anthus

 instruct the client to gently close the eye and move the eye around

Otic

 ear drops preparation .

 warm medication
 ensure tightly sealed medication container

 run container under warm water

 position client on unaffected side with affected ear facing up

 remove ear drainage or cerumen with cotton-tip applicator; avoid pushing cerumen into ear canal

 open ear canal

 In a child younger than age 3, pull the lobe down and back

 In a child older than 3 years, pull the pinna up and back

instillation of drops

 fill dropper with medication

 hold dropper about 1/2 inch above ear canal

 gently squeeze bulb on dropper to instill prescribed number of ear drops

 instruct client to remain in place for 5 to 10 minutes

 repeat in other ear if necessary after waiting 5 to 10 minutes

 if cotton balls are prescribed - place in outermost part of ear canal and remove in 15 minutes

Transfusion reactions & risks associated with transfusions

Allergic reaction

 most common type of reaction

 findings: hives and itching

 may be treated with antihistamines, e.g., diphenhydramine (Benadryl)

Febrile reaction

 a reaction to the white blood cells in the donated blood

 more common in clients who have had previous transfusions and in multi-para women
 findings: fever within 24 hours of the transfusion, including headache, nausea, chills, or a general
feeling of discomfort

 may be treated with antipyretic, e.g., acetaminophen (Tylenol)

Transfusion-related acute lung injury (TRALI)

 may occur with any type of transfusion but more common with fresh frozen plasma or platelets

 more common in clients who are gravely ill

 findings: trouble breathing, often within 1 to 2 hours of starting the transfusion but may begin up
to 72 hours post transfusion

 findings are often under-recognized (which leads to a delay in treatment and an increased mortalit
y rate)

Acute hemolytic reaction

 rare, but most serious type of transfusion reaction

 occurs when donor and client blood types do not match

 usually the result of human error, e.g., mislabeled pre-transfusion specimen, transfusion of proper
ly labeled blood to the wrong person, clerical errors

 findings: chills, fever, chest and lower back pain, nausea progressing to hypotension, bronchospas
m, vascular collapse and disseminated intravascular coagulation (DIC)

Delayed hemolytic reaction

 this reaction involves the body slowly attacking the antigens on the transfused blood cells

 usually none, but may develop fever 4 to 8 days, up to 1 month, after blood transfusion

 lab findings include falling hematocrit and a positive direct antiglobulin (Coombs) test

 more common in clients who have had previous transfusions

Nursing interventions
Guidelines for administration

 signed consent forms required for blood administration

 retrieve the blood from the blood bank area

 together with another RN, compare the blood and the crossmatch slip from the blood bank and co
mpare data with the client's ID bracelet - verify client's name, ID number, blood type and Rh factors, dono
r number on the blood container and expiration date

 establish baseline data and monitor (follow agency policy for frequency and duration)

 vital signs, SaO2, and check skin after first 15 minutes of transfusion, during administration (as p
er policy), and 1 hour post transfusion

 breath sounds, crackles, dyspnea, jugular vein distention

 prime intravenous tubing with normal saline for whole blood administration (never use dextrose s
olutions - may cause clumping of RBCs) and ensure the insertion site is patent

 initiate transfusion slowly for 15 to 20 minutes

 remain at bedside

 question client about unusual feelings

 monitor vital signs every 5 minutes or follow agency polic

 benign hives may occur

 return transfusion record to blood bank when infusion is complete

Nursing care for transfusion reaction

 immediately stop transfusion, take vital signs

 clamp IV tubing and disconnect at hub of catheter - return entire administration set and blood bag
to blood bank (or follow agency policy)

 do not allow additional blood to enter client's system, do not flush tubing with saline to clear

 for findings of circulatory overload (cough, shortness of breath, crackles, hypertension, tachycard
ia, distended neck veins)... place client with high Fowler's position, administer diuretic and oxygen as nee
ded, monitor I &O

 for findings of sepsis (including rapid onset of chills and fever, vomiting, diarrhea, hypotension, s
hock)... obtain blood cultures, send blood transfusion bag for analysis and treat sepsis with antibiotics, IV
fluids, vasopressors, and steroids

quinidine and procainamide reserved for use after many other therapies have failed

client teaching ,citrus juices, antacids, and milk products

procedure Trach Suctioning

 sterile procedure used in institutions (clean procedure used in client home)

 suction when rhonchus is heard

Steps

 adjust suction control to between 80 to 120 mm Hg

 hyperoxygenate client

 insert suction catheter with suction off until resistance is met, then withdraw catheter an inch or t
wo

 apply suction intermittently when withdrawing catheter

 rotate catheter during withdrawal

 from time of insertion, spend no more than 5 to 10 seconds

 re-establish ventilation and oxygenation

 repeat procedure as indicated

 pharyngeal suctioning - less depth, less risk of complications than with tracheal suctioning

nursing interventions trach care

 explain procedure to client

 explain that coughing, sneezing or gagging is normal

 place client in semi-Fowler's position (or higher if condition allows)

 maintain standard precautions

 do not routinely instill saline into airway

 if secretions are thick, increase humidity of inspired air and fluid intake

 provide patient with extra oxygen and extra deep breaths before, during and after procedure

 if patient is receiving mechanical ventilation, use ventilator

 if patient is breathing spontaneously, use manual resuscitation bag or instruct to deep breathe

 compare client's respiratory status before and after suctioning

 do not force catheter

Chest drainage

 Chest tube placement

 in the pleural space to remove air, fluid, or both

 anterior and superior chest wall to remove air

 posterior and inferior chest wall to remove fluid

 mediastinal tube -drains blood or fluid from around heart

 no tidaling in mediastinal drainage because tube is not placed in lung cavity

Chest drainage devices

 collection chamber - collects fluid

 monitor rate and nature of drainage

water seal chamber

 provides a one-way valve so that air leaves and cannot reenter chest

 check for bubbling in this chamber - indicates air leak in the lung (a normal finding in initial 48 to
72 hours of therapy for a pneumothorax)

 if no bubbling, check water level in this chamber

 check for tidaling (expected to rise with inspiration, fall with exhalation)

suction control chamber

 negative pressure transmitted to pleural space is determined by this chamber, not by the setting on
the wall vacuum

 expected finding is continuous bubbling in chamber

 may be stopped to

 send client to x-ray department

 auscultate breath sounds more accurately

Nursing interventions

 explain procedure to the client

 position the tubing on the bed so that there is straight gravity drainage to the collection device; do
not allow dependent loops to form in the tubing

 do not routinely strip or milk the tubing

 do not routinely clamp the chest tube (clamping blocks drainage, which could result in tension pn
eumothorax or cardiac tamponade)

 check suction and suction connections (suction is usually set at -15 to -20 cm H2O for adults)

 if tube is dislodged, with no air leak

 apply occlusive dressing - vaseline gauze covered totally with adhesive tape

 monitor for respiratory distress

 depending on client's condition, tube may or may not need to be replaced

 notify care provider promptly

 if tube is dislodged, and there is an air leak

 apply non-occlusive dressing to allow air to leave the chest and prevent tension pneumothorax

 contact provider for immediate reinsertion of tube

 tape all connections with adhesive tape

 assist with tube removal

 have occlusive dressing ready to apply

 remove all equipment with standard precautions in mind

 know that along with agency policies chest tube dressings are to be occlusive and not changed

 complications - when to notify provider

 if a chest tube dressing has drainage

 drainage volume over 100 mL/hour postoperatively

 subcutaneous emphysema

Use these simple techniques to reduce the hazards associated with gamma rays: Radiation had a s
elect all that apply on this

 Mark the client's room with appropriate signage

 Place client in a private room

 Place wristband on client indicating that the client is receiving internal radiation therapy

 Put on shoe covers and protective gloves before entering the client's room; remove equipment bef
ore exiting the room

 Wear gloves

 When handling secretions/excretions of a client receiving systemic isotopes; flush toilet twice

 When changing linens of clients receiving systemic isotopes

 Plan care to minimize time at the client's bedside

 Work quickly, but effectively and courteously

 Maintain the greatest distance possible from the client consistent with effective care

 Restrict care to a maximum of one (1) hour every eight (8) hours

 Prepare meal trays outside the room

 Position items within client's reach so as to facilitate as much self-care as possible

 Schedule only one radioactive client to a nurse at a time

 Ensure a long handled forceps and a lead container are in the client's room in case of implant disl
odgement

 In the event that a source becomes dislodged, notify the Radiation Oncologist

 Do not attempt to handle the dislodged implant unless trained to do so

 Wear a film badge while caring for client to monitor exposure; have it checked per agency policy

 No pregnant nurses, visitors, or children should be allowed near the client

Some topics I had on my exam

fetal alcohol syndrome - thin upper lip, flat bridge on nose, up turned nose, FAS is defined by four crite
ria: maternal drinking during pregnancy; a characteristic pattern of facial abnormalities; growth retardatio
n; and brain damage, which often is manifested by intellectual difficulties or behavioral problems.

Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of t
he preadolescent growth spurt. It is more common in females than in males.

Pheochromocytoma: hypersecretion of epi/norepi, persistent HTN, increased HR,

hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bating and rest breaks, avoid col
d and stimulating foods, surgery to remove tumor

Glomularnephritis - always assess the bp for HTN, need to restrict sodium and protein due to edema, us
ually follows a strep infection

Mean arterial pressure must be 70-90 mm Hg to adequately perfuse the organs. MAP is calculated as (dias
tolic BP x 2 + systolic BP), which is divided by 3.

TB to increase intake of protein, iron, and vitamin C. Foods rich in vitamin C include citrus fruits, berries,
melons, pineapple, broccoli, cabbage, green peppers, tomatoes, potatoes, chard, kale, asparagus, and turni
p greens. Food sources that are rich in iron include liver and other meats.

Hyperthermia, severe muscle rigidity, and malignant hypertension are findings associated with neurolept
ic malignant syndrome (NMS). This is a serious complication of the use of antipsychotic drugs; even the
newer atypical antipsychotics can cause NMS
The Joint Commission defines negligence as "failure to use such care as a reasonably prudent and careful
person would use under similar circumstances" and malpractice as "improper or unethical conduct or unre
asonable lack of skill ( I had a Q on what an example of negligence would be)

A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are fou
nd on the buccal mucosa in the mouth about two days before and after the onset of the measles rash.

The first phase of the grieving process is shock, denial or disbelief. Then follows anger, bargaining, depre
ssion and acceptance. Each stage can take any amount of time to work through.

Wine, beer, cheese, liver and chocolate, These foods are tyramine rich and ingestion of these foods while t
aking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.

Common Drugs ( on my exam they were all generic drugs I didn't recognize, I did have a few dig a
nd lithium questions tho)

Digoxin-check pulse, less than 60 hold, check dig levels and potassium levels.

Amphojel: tx of GERD and kidney stones....watch out for contipation.

Vistaril: tx of anxiety and also itching...watch for dry mouth. given preop commonly

Versed: given for conscious sedation...watch for resp depression and hypotension

PTU and Tapazole- prevention of thyroid storm

Sinemet: tx of parkinson...sweat, saliva, urine may turn reddish brown occassionally...causes drowsiness

Artane: tx of parkinson..sedative effect also

Cogentin: tx of parkinson and extrapyramidal effects of other drugs

Tigan: tx of postop n/v and for nausea associated with gastroenteritis

Timolol (Timoptic)-tx of gluacoma

Bactrim: antibiotic..dont take if allergic to sulfa drugs...diarrhea common side effect...drink plenty of fluid
s

Gout Meds: Probenecid (Benemid), Colchicine, Allopurinol (Zyloprim) Apresoline(hydralazine)-tx of HT

N or CHF, Report flu-like symptoms, rise slowly from sitting/lying position; take with meals.

Bentyl: tx of irritable bowel....assess for anticholinergic side effects.

Calan (verapamil): calcium channel blocker: tx of HTN, angina...assess for constipation

Carafate: tx of duodenal ulcers..coats the ulcer...so take before meals. Theophylline: tx of asthma or COP
D..therap drug level: 10-20

Mucomyst is the antedote to tylenol and is administered orally

Diamox: tx of glaucoma, high altitude sickness...dont take if allergic to sulfa drugs Indocin: (nsaid) tx of a
rthritis (osteo, rhematoid, gouty), bursitis, and tendonitis. Synthroid: tx of hypothyroidism..may take sever
al weeks to take effect...notify doctor of chest pain..take in the AM on empty stomach..could cause hypert
hyroidism.

Librium: tx of alcohol w/d...dont take alchol with this...very bad nausea and vomiting can occur. Oncovin
(vincristine): tx of leukemia..given IV ONLY kwell: tx of scabies and lice...(scabies)apply lotion once and
leave on for 8-12 hours...(lice) use the shampoo and leave on for 4 minutes with hair uncovered then rinse
with warm water and comb with a fine tooth comb

Premarin:tx after menopause estrogen replacement

Dilantin: tx of seizures. thera drug level: 10-20

Navane: tx of schizophrenia..assess for EPS

Ritalin: tx of ADHD..assess for heart related side effects report immediately...child may need a drug holid
ay b/c it stunts growth.

dopamine (Intropine): tx of hypotension, shock, low cardiac output, poor perfusion to vital organs...monit
or EKG for arrhythmias, monitor BP

Lithium- narrow therapuetic range, must drink extra fluids, have an adequate sodium intake, treatment for
bipolar

echinacea- should not take longer than 8 weeks, may interfere with bleeding, should not take with steroids
or other immunosuppressant agents