READY TO PASS INC.

READY TO PASS INC.

Disclosure Statement 2
TABLE OF CONTENTS
3
About NCLEX 4
11
17
Normal Lab values 29
50
78
Overview of pharmacology 121
139

140
141
Alphabet list 143
Mneumonics 144
147
160
161
178
190
191
210

Graphics: Louise Martin and Rebecca Rivera

MAR 18
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About NCLEX
The NCLEX® is designed to determine whether you meet the minimal standard to practice as a nurse.
NCLEX® is an integrated exam, which means the subjects are all mixed together.
The test follows the April 2016 NCLEX® RN/April 2017 LPN plan. Questions are drawn from four categories
including but not limited to the topics listed below. The following test plan structure is copyright of the
National Council of State Boards of Nursing, Inc. All Rights Reserved.

A. Management of Care – (Coordinated Care)

• Advance Directives • Establishing Priorities

• Advocacy • Ethical Practice
• Case Management • Informed Consent
• Client Care Assignment • Information technology
• Client Rights • Legal Rights and Responsibilities
• Collaboration with Interdisciplinary Team • Performance improvement
• Concepts of Management & Supervision (Quality Improvement)
• • Referrals Process
• Consultation • Resource Management
• Continuity of Care •
• Delegation and Supervision • Supervision

B. Safety and Infection Control

Protecting clients and health care personnel from environmental hazards.

• Accident/Injury Prevention • Medical and Surgical Asepsis

• Disaster Planning/Internal & External Plans • Reporting of Incident/Event/Irregular
• Emergency Response Plan Occurrence/Variance
• Error Prevention • Safe Use of Equipment
• Ergonomic principles • Security Plan
• Handling Hazardous & Infectious Materials •
• Home Safety Precautions
• Least Restrictive Restraints/Safety Devices

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II. Health Promotion and Maintenance-

knowledge of expected growth and development principles, prevention and/or early detection of
health problems, and strategies to achieve optimal health.

• Aging Process • Health and wellness

• Ante/Intra/Postpartum and Newborn Care • Health Promotion Programs
• Community Resources • Health Screening
• Data Collection Techniques • High Risk Behaviors
• Developmental Stages and Transitions • Human sexuality
• Disease Prevention • Immunizations
• Expected Body Image Changes • Lifestyle Choices
• Family Planning • Principles of Teaching & Learning Self Care
• Family Systems • Techniques of Physical Assessment*
• Growth and Development

III. Psychosocial Integrity-

Providing and directing nursing care that promotes and supports the emotional, mental, and social

with acute or chronic mental illness.

• Abuse/Neglect • Psychopathology
• Behavioral Interventions •
• Chemical & Other Dependencies • Sensory/Perceptual Alterations
• Coping Mechanisms • Situational Role Changes
• Crisis Intervention • Stress Management
• • Substance Use Disorders
Health/Cultural Awareness • Support Systems
• End of Life Care and Concepts • Suicide/Violence Precautions
• Family Dynamics • Therapeutic Communications
• Grief and Loss • Therapeutic Environment
• Mental Health Concepts • Unexpected Body Image Changes

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IV. Physiological Integrity

A. Basic Care and Comfort:
Providing comfort and assistance in the performance of activities of daily living.
• Alternative and Complimentary Therapies • Nutrition and Oral Hydration
• Assistive Devices • Palliative/Comfort Care
• Elimination • Personal Hygiene
• Mobility/Immobility • Rest and Sleep
•

B. Pharmacological and Parenteral Therapies:

Managing and providing care related to the administration of medications & parenteral therapies.

• • Parenteral/Intravenous Therapy
• Pharmacological Agents/Actions
• Blood and Blood Products • Pharmacological Interactions
• Central Venous Access Devices • Pharmacological Pain Management
• Dosage Calculations • Total Parenteral Nutrition
• Expected Actions/ Outcomes
• Medication Administration

C. Reduction of Risk Potentia

Reducing the likelihood that clients will develop complications or health problems related to
existing conditions, treatments or procedures.
• Diagnostic Tests • Potential for Complications from Surgical
• Laboratory Values Procedures and Health Alterations
• Monitoring Conscious Sedation •
• Potential for Alterations in Body Systems • Therapeutic Procedures
• Potential for Complications of Diagnostic • Vital Signs throughout the life span/ changes/
Tests/Treatments/Procedures abnormalities

D. Physiological Adaptation:

conditions.
• Alterations in Body Systems • Medical Emergencies
• Fluid and Electrolyte Imbalances • Pathophysiology
• Hemodynamics • Radiation Therapy
• Illness Management • Unexpected Response to Therapies
• Infectious Diseases

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ABOUT THE EXAM
• The test is computer based; you will be required to use a mouse to select the correct answer.
• There is an on screen calculator available to calculate medication dosages.
• Once a question is answered you will not be allowed to change it.
• NCLEX® is a computer adaptive test which means it adjusts based on the answers you provide

correctly but easier questions if you do not. It is very important that you do not guess. It is better

to take more time to answer correctly than to choose answers randomly. At times, content

process. Always select the answer believed to be correct. Exams vary in length in order to

• Six hours are allotted for the RN exam to complete a minimum of 75 to a maximum of 265
questions. Of these items, 15 are pretest items that are not scored. The LPN exam allots

5 hours and has 85 to 205 questions. There are 25 pretest items on the NCLEX PN exam.

However you should stick to the rule of allowing 1 minute per question. The analysis level

questions may require more than one minute in order to synthesize all of the information given.
The length of an exam is not an indication of a pass or fail result. The computer will stop when

passing standard or the candidate has run out of time. When you run out of time before reaching the

maximum amount of items, the computer has not been able to decide whether you passed or failed with 95% certainty and has

to use an alternate rule. If you have not answered the minimum amount of items, you fail.

• If you have at least answered the minimum amount of items, the computer reviews your last 60 ability estimates:

• If your last 60 ability estimates were above the passing standard, you pass.

• If your ability dropped below the passing standard, even once, during your last 60 items, you fail.

Types of Questions: Multiple Response Multiple Choice Fill in the Blank

Ordered response Hot Spot/Graphic Chart exhibit Audio

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ESSENTIAL TEST-TAKING
TECHNIQUES
Critical Thinking Is the Key
To Successfully Answering NCLEX® Questions!

1: asking.

2: topic

Determine the relevance

3:

4: Rephrase

5: read

6:

7: last line

facts about the client,

8:

9:

10: nursing process or tasks that involve complex procedures.

11:

12:

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Remember PAIN

PRIORITY/ FIRST: This indicates that you must determine the most essential response.

Tools helpful to answering these questions include:

1. The developmental phases of Erkison (if age is designated)
2. The theorist Orem (Universal Self Care Needs)

6. Time
7. Expected/unexpected
8. Safety
9: Disaster & triage

ANTICIPATE: or most appropriate, correct, expected, should, include, instruct, will reinforce. These all
indicate you are looking for a correct or expected response.

INTERVENE:

response.

NEXT: may imply you are currently in one phase of the nursing process and must proceed to the next one.
Remember ADPIE (Assessment, Diagnosis, Plan, Intervention, Evaluation).

PREPARING FOR THE EXAM

* Practice time management: allow 1 – 1.5 minutes per question.

* A positive attitude is essential for success!
* Develop a study plan and remain focused.

* Avoid distractions.
* Insure adequate rest, as sleep deprivation can prevent you from focusing.

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SAMPLE QUESTION

for the client who has a:

A. Uric acid level of 10.3 mg/dL

B. Ammonia level of 95 mg/dL
C. Albumin level 3.1 g/dL
D. Calcium 12 mg/dL

values are abnormal and need follow up, which of the previous choices would take priority? Knowledge of
normal lab values will help you to select the most appropriate response.

Note: The correct answer is (b). High ammonia levels will lead to hepatic encepholapathy and brain
damage. This client would take priority.

SAMPLE QUESTION
The nurse is teaching a client about crutch walking. Which of the following statements, if made by the client,
indicates an understanding of teaching?

a correct statement, that is, one choice

is true, while the other three are incorrect. Knowledge of ambulation with crutches will allow you to select
the correct or true statement.

Note: (c) is true, and the other three are false. Therefore, (c) is correct.

Schedule your test within 1 month after course completion!!

For information on scheduling or rescheduling your exam:
* National Council of State Boards of Nursing:

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ESSENTIAL
TOOLS

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TOOL # 2
ERIKSON’S THEORY OF DEVELOPMENT

does not.

should be considered in order to select the correct response.

AGE/STAGE PSYCHOSOCIAL CRISIS TASK

1. Infancy (0 - 18 months) Trust vs. Mistrust

2. Toddler (18 months to 3 years)

Gains some basic control of self and

environment

3. Pre School (3 - 6 years)

4. School Age (6 - 12 years) Industry vs. Inferiority

Develops social, physical and school skills

5. Adolescence (12 - 20 years)

6. Early Adulthood (20 - 35 years)

friendship

7. Middle adulthood (35 -65 years)

and society, volunteering

8. Later (65 years to death) Integrity vs. Despair

meaning

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THE NURSING PROCESS This process consists of the following, in this order:

1: Assessment 2: Diagnosis (Analysis) 3: Planning 4: Implementation 5: Evaluation

1. ASSESSMENT:
Words that mean to assess: Check, Look, Ask, Monitor, Inspect, Evaluate , Observe
1. Assessment is done primarily by the RN.
2. BUT the LPN must understand this process because the LPN collects data, a critical role in assessment.

• History taking
• Objective data: observable, measurable (vital signs)
•
• Data collected from the chart

5.Communicate information received in the assessment.

2. DIAGNOSIS (ANALYSIS):
1. Identify actual or potential health care needs and/or problems based on your assessment.
2. Interpret the data: validate, organize and determine if there is a need for more data collection.
nursing diagnosis.

DETERMINE CLIENT’S UNIQUE NEEDS

3. PLANNING:
1.This is done to provide client care consistently and appropriately.
2. Ask yourself the following questions: What is the priority?
How does this determine the client’s needs?

collaborates with other health care professionals (the Interdisciplinary approach).

4: IMPLEMENTATION:
To begin to do something...and then doing it!!
1. Prepare:
2. Counsel and Teach:
of the health care team.
Perform:
given.
4. After Care is Performed: make client comfortable, and then replace any equipment no longer needed.
5. Record and Report: document everything accurately.

5: EVALUATION:
1. Has the need been met?
2. Compare actual outcome with expected outcome.

TIP: ACTIVE CLIENT PROBLEMS TAKE PRIORITY OVER POTENTIAL PROBLEMS! 14

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TOOL #4 TOOL # 8
REMEMBER THE ABC’s THERAPEUTIC COMMUNICATION:
A. Remember to establish a patent airway 1. Remember to utilize therapeutic
for your client. communication: choose the response that
B. Be sure your client is breathing.
C. Check to see if your client has good fears or concerns.
circulation.
2. BUT, mental health questions may be handled
Do not wait until there is a crisis to assess
for ABC’s!! suicide is an issue for her/his client, then direct
questioning is required (e.g., “Do you feel like

TOOL #5 In mental health cases, reality orientation may

also be called for.
EXPECTED / UNEXPECTED
1. Determine what the stem of the question
is asking.
TOOL # 9
OREM’S THEORY OF NURSING
The nurse must be concerned with the
following
. UNIVERSAL HEALTH CARE NEEDS:
*Distinguish between chronic conditions 1. AIR: oxygen, airway, temperature.
vs acute conditions! 2. WATER:
3. FOOD: malnutrition, feeding concerns.
TOOL #6 4. ELIMINATION: proper evacuation of bladder
and bowel.
TIME
The client most recently admitted is not 5. REST: sleep, comfort and freedom from
pain (not always a low priority).
6. SOCIALIZATION: the right balance of
solitude and social interaction must be
TOOL # 7 struck.
7. HAZARDS: safety must be provided for.
REMEMBER SAFETY:

Remember: AWFERS

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TOOL # 10
DISASTER NURSING / TRIAGE:

PRIORITY #1 PRIORITY #2 PRIORITY #3 PRIORITY #4

IMMEDIATE DELAYED MINIMAL EXPECTANT

RED YELLOW GREEN BLACK
Life-threatening May require immediate Treatment is needed Injuries are intensive!
injuries survivable with attention, but can in hours to days. Chances of survival
minimal intervention. sometimes wait for Client may be moved are unlikely.
hours. away from the triage Give comfort, separate
• Chest wounds area. from others but do not
• Airway obstruction • Abdominal wounds abandon
• Shock without evidence of
• Pneumothorax • Upper extremity • Penetrating head
hemorrhage
• fracture wounds
• Soft tissue injuries • Minor burns • Burns in excess of
(muscles, ligaments • Sprains
the body
tendons) • Small lacerations surface area (BSA)
Key Words: • Genitourinary injury • Seizures or vomiting
• • Eye injury bleeding within 24 hours of
• Apprehension • CNS injuries • Psychological exposure to radiation
• Restlessness disturbance • Profound shock with
• Confusion multiple injuries
• Change in LOC • agonal respirations
(1st sign of increased • Absent pulses,
ICP) absent blood

dilated pupils

In the event of a disaster, the nurse may be required to discharge clients to make room for incoming victims:

care facility.
DO NOT discharge clients who are unstable or require nursing care unless they are in imminent danger.

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ESSENTIAL
FACTS
WORDS OF WISDOM..........
A wise person would not attempt a job without tools and the proper
equipment.
Why should you?

Consistent studying to understand CONCEPTS is essential.

You cannot memorize answers and questions from previous exams!

...You cannot cram to understand...

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WHAT IS YOUR ROLE?

THE ROLE OF AN RN:
1. Assess clients.
2. Initiate, evaluate and update the plan of care and clinical pathways.
Care for the most critical and unstable clients, for example:
• Fresh post-operative clients
• Clients with a change in condition who need assessment
• Admissions • Discharges • Transfers

5. Perform the most complex procedures, for example:

• Starting IV’s • Interpreting EKG’s • Correlating lab values
6. Collaborate with other departments and disciplines (the Interdisciplinary Approach).

8. Act as a client advocate.

THE ROLE OF AN LPN:

1. Provide care to clients in stable condition under the supervision of an RN or other health care
provider.
2. Perform basic therapeutic, preventative care and rehabilitative procedures, for example:
• Sterile dressing changes • Urethral catheter and NGT insertion • Application of restraints
Assist RN with unstable and complex clients. Continuity of care plan and clinical pathway.
4.

LPN’S ARE USUALLY NOT ALLOWED TO:

1. Perform triage, patient assessment, case management or independently develop the nursing care
plan.
2. Perform mental health teaching.
Administer IV chemotherapy (however bladder installation of chemotheray is permissible).
4. Perform central line or venous port procedures or IV push medications (except saline or Heparin

5. Administer blood transfusions UNLESS they have satisfactorily completed a transfusion training

A RN must be present for supervision.

THE ROLE OF A CNA (UAP):

1.
oropharyngeal suctioning, apply clean dressings (they may not change dressings), CPR.

UAP’S ARE NOT ALLOWED TO:

Administer medications, tracheal suctioning or trache care, administer O2, deliver NGT or PEG
feedings, insert urinary catheters, perform sterile or invasive procedures, assess evaluate or problem
solve, develop a nursing care plan

TIP: DELEGATION AND SUPERVISION ALONG WITH COLLABORATION CONCEPTS MUST BE

CONSIDERED WHEN SELECTING ANSWER CHOICES! 18
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LEADERSHIP AND PROFESSIONAL ISSUES

TYPES OF LEADERS:
Laissez-faire:
Autocratic / Authoritarian: Strict. Makes all of the decisions. Uses punishment and coercion.
Democratic:

PROFESSIONAL ISSUES:
• Chain of command
•
• Taking verbal orders
•
•

DELEGATION: DO NOT DELEGATE WHAT YOU CAN E A T

1. The RN should never delegate the assessment portion of the nursing process.
2. The RN or LPN should never delegate the teaching or evaluation phase of patient care.

4. Be aware of the competence and job description of those to whom you delegate.

6. The nurse must be sure to follow up on all tasks that were delegated.
7. If criticism is necessary, provide privacy.
8. Document unsafe practices and procedures.

RIGHTS OF DELEGATION
TASK CAN YOU DELEGATE THIS TASK?
CIRCUMSTANCE HOW COMPLEX IS THE PATIENT? WHAT IS THE
SKILL LEVEL OF THE STAFF MEMBER?
PERSON IS THIS PERSON COMPETENT?
COMMUNICATION DID YOU GIVE CLEAR DIRECTIONS?
SUPERVISION/ FEEDBACK DID YOU MONITOR, EVALUATE, AND PROVIDE
FEEDBACK?

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LEGAL CONSIDERATIONS:

The nurse client relationship is a legal status that occurs whenever a nurse renders care to another person.

Once this relationship occurs, the law automatically imposes certain legal responsibilities upon the nurse.

know, or should know is unlawful.

TERMS TO KNOW:

VERACITY: Adherence to the truth.

LIABILITY: The obligation one incurs or might incur through acting or failing to act.
MALPRACTICE:
harm to another person.
NEGLIGENCE: The failure to provide care that a reasonable person would perform in similar
circumstances.
LIBEL: Defamation by written or printed words or pictures.
SLANDER: Defamation of character by speech.
ACTS OF OMISSION OR COMMISSION: Doing wrong by not acting; doing wrong by acting.
BENEFICENCE:
smoking cessation.
NON MALEFICENCE:
shown to be harmful.
ASSAULT: To threaten to touch.
BATTERY: Touching someone without consent.
TORT: A wrongful act, whether intentional or accidental, from which injury occurs to another.
FALSE IMPRISONMENT:

use of physical (e.g., lap tray) or chemical (e.g., sedatives). HINT: Authorized physical restraints must be

ROM exercises and comfort measures.

INFORMED CONSENT:
This must be obtained from a client or their health care proxy for any invasive procedure. It is obtained by

prior to the procedure. (Assent = Consent)

INVASION OF PRIVACY:

his personal, physical privacy, for example, close the curtain or door when the client would otherwise be
exposed. Minimize the computer screen. The nurse has the legal duty to report to public health agencies
gunshot wounds, suspected child or elder abuse, and certain communicable diseases.

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MORE ABOUT LEGALITY

1. GOOD SAMARITAN LAW:

This act protects those persons who choose to aid others who are ill or injured from liability. It does not
cover gross negligence.

2. INCIDENT REPORTING:
Reports unusual occurrences and deviation from care standards. Facilities use the document to evaluate
care, determine potential risks or discover system problems that might have contributed to the error.

3. HARRISON NARCOTIC ACT OF 1941:

by the Comprehensive Drug Abuse Prevention and Control Act of 1970.

witnessed; document immediately and accurately

4. ADVANCE DIRECTIVES:

have when she/he cannot make decisions themselves.

Living will: Prepared by a competent adult and gives health care directions in the case when that per
son is unable to make decisions on their own.
: Documents that specify who will make your health
care decisions if you cannot.
Advanced care medical directive:

5. EMANCIPATED MINOR:

joins the armed forces (with parental consent and permission from the courts), she/he becomes
emancipated from her/his parents.

6. HIPAA: The Health Insurance Portability and Accountability Act

other health care providers to inform clients how their health care information is used and/or disclosed.

7. ORGAN DONATION:
• Health care provider determines if organ is suitable before approaching family.
•
• Each hospital has its own protocol regarding organ donation.
• Donor must be kept on life support until the organs are removed.
•

8. UTILIZATION REVIEW:

process compares requests for medical services to treatment guidelines that are deemed appropriate for such
services.

9. AUDIT REVIEW:
Review of charts along with direct assesment to determine causes of hospital acquired infections or deviations
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RELIGIOUS AND SPIRITUAL INFLUENCES ON HEALTH

RELIGION BELIEFS AND PRACTICES
JUDAISM (ORTHODOX) • Visits to dying are a religious duty
• A witness must be present at death to protect family and commit
Autopsy: Only in special
circumstances soul to God
• Torah and psalms read, prayers recited
• Conversation is kept to minimum
• Someone should be with body from death to burial usually within
24 hours

• Circumcision done on day 8 after birth ceremony called Briss

• Medical personnel do not touch or wash body unless death
occurs on Jewish Sabbath; then care given by nurse with gloves
• Water is removed from the room

HINDUISM • Priest ties thread around neck or wrist of deceased and pours
water in the mouth
Autopsy: Permitted • Only family and friends touch the body

BUDDHISM • Buddhist priest present at death

• Last rites are chanted at bedside
Autopsy: Personal Preference • May prefer same sex wash body
ISLAM (MUSLIM) • Before death, Koran read, prayers said
• Dying confesses sins, asks family to forgive
Autopsy: Only for medical or legal • Only family members touch or wash body
reasons •
ROMAN CATHOLIC • Sacrament of Sick administered to severely ill, those near death,
Autopsy: Permitted or newly dead
CHRISTIAN SCIENTIST • No ritual performed before or after death
Autopsy: Unlikely • No surgical procedures; no autopsy

CHURCH OF CHRIST (MORMON) • No ritual performed before or after death

Autopsy: Permitted • Baptism done after the age of 8

JEHOVAH’S WITNESS • No ritual performed before or after death

• Clergy ministers through counsel and prayer
Autopsy: Only if required by law • No blood or blood products accepted
EPISCOPALIAN
• Last rites optional
Autopsy: Permitted
LUTHERAN
• Last rites optional
Autopsy: Permitted

WESTERN ORTHODOX CHRISTIAN

• Last rites mandatory and given by ordained priest
Autopsy: Not encouraged

• Value silence
• Touching is unacceptable with the opposite sex
ASIAN AMERICANS •
Autopsy: Permitted • Believe in yin (dark, cold) & yang (bright, hot); do not mix hot and
cold
• They prefer warm—considered good for wellness
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RELIGIONS AND DIETARY PRACTICES

7TH DAY ADVENTISTS •

(CHURCH OF GOD) • Some groups prohibit meat. Pork is prohibited.

BAPTISTS •

• Alcohol and drug use discouraged.

BUDDHISM
• Some sects are vegetarian.
• Avoid meat on Ash Wednesday and Good Friday.
ROMAN CATHOLICISM • During Lent, fasting is optional, meat on Fridays is discouraged.
• Children and the ill are exempt from fasting.
•
CHURCH OF JESUS CHRIST OF • Limited consumption of meat.
LATTER DAY SAINTS (MORMON) • Avoid spices.
•
• Beef and veal prohibited, limited meat consumed.
• Many individuals are vegetarians.
•
HINDUISM
god a person worships.
• Children are exempt from fasting.
• Fasting can be complete abstinence to one meal a day.
• Pork is prohibited as is any meat not ritually killed.
• Alcohol and drugs are avoided.
ISLAM
• During Ramadan (9th month of Mohammedan year) fasting is
practiced during the daytime.
• Food to which blood has been added is prohibited.
JEHOVAH’S WITNESS
•
• Orthodox believers adhere to dietary Kosher rules.
• Meats that are allowed come from animals that are vegetable

•
haddock, canned tuna, sardines, salmon).
JUDAISM
• Sea scavengers, such as shrimp, are not allowed.
• The combination of meat and milk is prohibited.
• 24 hour fasting is observed on Yom Kippur.
• Pregnant women are exempt from fasting.
• During Passover Week, only bread that is unleavened is permitted.
• Alcohol is prohibited.
PENTECOSTAL
• Avoid food to which blood has been added.
(ASSEMBLY OF GOD)
• Some individuals avoid pork.
• Meat and dairy are abstained from on Wednesday, Friday and
during Lent.
RUSSIAN ORTHODOX • During Lent, all animal products are abstained from.
• Fasting is practiced during Advent.
• The ill or pregnant are exempt from fasting.

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HERBAL REMEDIES AND MEDICAL IMPLICATIONS

HERBAL REMEDY / USES MEDICAL IMPLICATIONS
ALOE VERA
• If ingested, may cause GI upset. May increase
•
Digoxin level; Avoid with kidney disorders
• Helps with tissue injury
ECHINACEA • Avoid with ragweed allergy
• •
cancer children, immunocompromised
GINSENG • Caution with HTN, DM, clotting disorders
• Anemia •
• Hypertension •
• Benign Prostatic Hypertrophy • Hold for 7 days before surgery
SAINT JOHN’S WORT
• Avoid sunlight, antidepressants
• Wound healing
• Avoid with HTN, and with immunosuppression
• Menstrual disorders
• Avoid foods containing tyramine
• Diuretic
•
• Depression
KAVA KAVA
•
• Decrease anxiety and stress
GINKO BILOBA • Contraindicated in pregnant women & children
• Improves blood circulation •
• Improves attention span •
• •
GINGER • May cause CNS depression, cardiac arrhythmias
• Contraindicated with gallbladder disease
• Reduces morning sickness, nausea
• May increase bleeding with Coumadin
• Used to treat burns
• Caution with DM, antihypertensives, and cardiac
medications
GARLIC •
• May decrease cholesterol, BP and glucose levels • Avoid DM medications
• • May increase bleeding with Coumadin
• May improve circulation • Hold for 7 days before surgery
SAW PALMETTO
• • No drug interactions.
• • May cause stomach discomfort.
• Prevents hair loss
VALERIAN ROOT
• May increase sedation when used with: ETOH,
• Calms neuro system
barbiturates, sleeping pills, muscle relaxants &
• Promotes sleep
benzodiazepines
• Used for headaches, anxiety, nervousness
BLACK COHOSH • Overdose may cause N/V, headache, dizziness,
• Used for menstrual and menopausal symptoms tremors, reduced heart rate
• Used as a sedative, and diuretic • Contraindicated with CHF, pregnancy
• •
sweats, and mood changes contraceptives, cardiac medications
FEVER FEW •
• Used for migraine headaches and arthritis. • Contraindicated in pregnancy
LICORICE • Contraindicated in heart disease
• Used for peptic ulcer, GERD, weight loss, • May increase blood pressure
eczema, canker sores • Avoid with ACE inhibitors, steroids, digoxin

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MISCELLANEOUS KEY POINTS

COUMADIN the risk of bleeding when taken with:

Chamomile Clove Dong Quai
Ginger Ginseng Fever Few Licorice

Saint John’s Wort !

Clients should AVOID THE SUN with the following:

(Other phrases: avoid the beach, wear long sleeves, wear sunglasses, wear a wide brimmed hat)

• Thorazine (chlorpromazine)
• Retin A (retinoic acid)
• Bactrim (trimethoprim)
• Griseofulvin (grifulvin)
• Exopthalmus (bulging eyes)
•
• Lupus
•
•
•
• Glucotrol (glipizide)
•
• Benadryl (dipenhydramine)
• Tetracycline: do not give to pregnant women or children under eight as it stains the teeth
•
HTN (avoid with bleeding & clotting disorders)
• Diuretics (Loops & thiazides)

TIP: REMEMBER TO USE YOUR 10 TOOLS AS A THEORETICAL FRAMEWORK FOR

ASSISTING WITH YOUR DECISION MAKING!

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MEDICATION CALCULATIONS

REMEMBER:
Microdrip = 60 gtts/ml Standard IV Set = 15 gtts/ml Blood Administration = 10 gtts/ml

1.Calculate an IV Infusion:
Time in Minutes
Sample Question:
set, how many drops/minute will you administer?

Answer: 500 (volume) x 60 (gtt factor) (rounded up from 62.5)

8 hours x 60 minutes (time in minutes)

2. Calculate Parenteral Medications:

Desire = order, prescription, want, give, administer Total Amount of Drug on Hand
Have = on hand, available

Sample Question: You have on hand Benadryl 50 mg / 2 ml.

The prescription reads: Give Benadryl 25 mg IM STAT.

Answer: 25 mg (desired amount) x 2 (total volume) = 1 ml

50 (total amount of drug on hand)

3. Calculate Oral Medications: Desire = order, prescription, want, give

Have = on hand, available

Sample Question: The prescription reads: Administer Albuterol 6 mg po, tid.

On hand is Albuterol 2 mg tablets.

Answer: .
2 (dosage on hand)

4. Calculate Critical Care Medications: Desire X Volume X Weight (kg) X Minutes

Have

Sample Question:
On hand: Dopamine 800mg in 250 ml D5W
The client weighs: 80 kg
The IV should run at ___________ml/hr

Answer:
800mg

Convert mcg to mg...........

800mg

The IV should run at 4.5ml/hr

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Volume Weight
1 tsp 5 ml 1 mg 1,000 mcg
1 cup 240 ml 1 gr 60 mg
1 tbsp 15 ml
1gm 1,000 mg = 1ml
1 pint 473 ml
1 oz. 30 ml 1 kg 2.2 Ibs
1 quart 946 ml 1L 1 kg = 1,000 ml
15 –16 gtts 15-16 minims = 1 ml

Sample Question
Answer: 2.2 lbs =
1 kg x kg

SAMPLE QUESTION

Prescription reads: Administer Drug A 4mg/kg every 8 hours intravenously

On hand: 100mg in 50ml Normal Saline
The client weighs: 286 lbs
How many ml/dose_____________

ANSWER:

Use formula D X V 520 X 50 = 260ml/dose

H 100

BMI = weight in pounds

(Height in inches) X (Height in inches)

BMI < 18 = Under Weight

< 18.5 = Thin for Height

BSA = Weight in kilograms X Height in centimeters

1 kg = 2.2 lbs
1inch = 2.54cm
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MATH PRACTICE QUESTIONS

1. A nurse is preparing to administer Ringers Lactate 600 ml IV over 8 hours. The drop factor is
15 gtt/ml. The nurse should deliver how many gtt/min? Round to a whole number _____gtt/min

2. A nurse is preparing to administer Pepcid (famotidine) 20 mg IV over 15 minutes. The drug

available is 20 mg/100 ml. The nurse would be correct to set the infusion pump at _____ml/hr

orally every 8 hours to a child who weighs 22 pounds . The drug is available in 100 mg/ml
suspension. The nurse should administer ________ml/dose

available is 15mg/tab. How many tab(s) should the nurse administer per dose? ______tabs

5. A nurse is teaching a client on correct use of Azithromycin. The prescription reads, give one
dose 500 mg orally. The drug available is 250 mg / tab. How many tablets should be given?
_____tab(s)

6. A nurse is preparing to administer Rocephin (ceftriaxone) 2 gm IM x 1 dose. The amount

7. A nurse is preparing to administer 5,000 mcg of Vitamin B12 (methylcobalmin) SQ x 1 dose.

The amount available is 10 mg/ml. How many ml should the nurse administer? ______ml

mL/hr. The client is also receiving Cefazolin 500 mg IVPB in 50 mL D5W q6h and Azithromyin

total oral intake is _________ml

10. A nurse is to administer Keppra (levitiracetam) po. The maximum dose is 1.5 gm per day

How many tab(s) should the nurse administer? ______tab(s)

11. A nurse is preparing to administer Theophylline 160 mg PO q6h. The medication available is
Theophylline 80 mg / 15 ml. How many mL/dose? _______mL

number

14. The nurse is preparing a prescription of Regular Insulin 10 units/hr IV. The bag available
contains Insulin 25 Units in 100ml NS. How many ml/hr will the client receive? _______ml

[www.dosagehelp.com] Detailed answers Page 218

10. 1tab 5. 2 tabs
14. 40 ml/ hr 9. 1080 ml 4. 2 tabs
.
12. 5 gtts / min 7. 0.5ml 2. 400 ml/hr
1. .19 gtts/min
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CBC (COMPLETE BLOOD COUNT)

Hematocrit (HCT) Female Male
Hemoglobin (HGB) g/dL Female g/dL Male
White Blood Cell Count (WBC)
Red Blood Cell Count (RBC)

Platelet Count
B Lymphocytes
T Lymphocytes:
with increased risk for opportunistic infection. HIV kills

URINALYSIS
Normal Color Child

pH

CHEMISTRY: ADULT
Sodium mmol/L
Chloride mmol/L
Glucose mg/dL
Potassium mEq/L
BUN mg/dL Increased in dehydration and renal dysfunction
Creatinine mg/dL
Carbon Dioxide mmol/dL
Calcium mg/dL
Amylase U/L Increased in pancreatitis
Lipase U/L Increased in pancreatitis
Magnesium mg/dL
Ammonia mg/dL
Uric Acid mg/dL
Albumin g/dL Decreased with kidney & liver disorders & decreased protein
Alkaline Phosphatase
ALT IU/L
AST IU/L
Bilirubin Totals mg/dL (Adult Normal) 1.2 mg/dL (Adult Critical)
mg/dL (Newborn Normal) 15 mg/dL (Newborn Critical)
**Requires treatment usually phototherapy**
HgbA1c Levels > 8% indicate poor diabetic control with need for education
regarding adherence to regimen or changes in therapy**
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CHEMISTRY: CHILD
Glucose mg/dL
Calcium mg/dL
Billirubin mg/dL
Platelets

BLOOD CULTURE
• 2 bottles collected (anaerobic / aerobic) blood drawn from 2 seperate sites; must be venipuncture
• Do not draw from IV lines
• Clean skin
• Collect sample before starting antibiotics

NORMAL BLOOD GAS...Remember ROME / RAMS

pH
PaO2 80 – 100 mmol/L
PaCO2 mmol/L
HCO mmol/L
SaO2

ACID - BASE IMBALANCES pH PaCO2 HCO3

Respiratory Acidosis 45 mmHg N/A

Respiratory Alkalosis 7.45 mmHg N/A

Metabolic Acidosis N/A 22 mEq/L

Metabolic Alkalosis 7.45 N/A 26 mEq/L

SAMPLE QUESTIONS
Label the acid – base imbalances:

1. pH = 7.20, CO2 = 64, HCO = 26 ______________________

2. pH = 7.50, CO2

2
= 18 ______________________

Compensation occurs when the body’s processes counterbalance to bring the pH within normal limits!

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LIPIDS (CHOLESTEROL): Test is done fasting.

TOTAL < 200 mg/dL

HDL

LDL

COAGULATION PROFILE:

MEDICATION THERAPEUTIC LEVELS:

N/V, RUQ pain, jaundice, coagulation abnormalities

risk of toxicity.

N/V, blurred vision, drowsiness, slurred speech, arrthymias, renal

toxicity

(phenytoin) rapid eye movements, slurred speech, coordination problems

N/V, anorexia, palpitations, sinus tachycardia

hypercalcemia predispose clients to Digoxin toxicity.

N/V/D, anorexia, blurred vision, halos around the light

STOP THE INFUSION!!

CNS depression

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Vital Signs
Vital signs must be assessed:
1. on admission
2. as per M.D. order
with any change of health status
4. with chest pain or any abnormal sensation
5. before and after administration of preoperative medications; after surgery or invasive
diagnostic procedures
6.
cardiovascular or respiratory function
7.
system

Vital signs include temperature (T), heart rate (HR), respiratory rate (RR), blood pressure (BP),
and pain assessment, SaO2 is done as indicated.

Vitals Across the Lifespan

Age Pulse Rate Respiratory Rate Blood Pressure
Before birth 140 – 160 – –
Newborn 130 – 150 30 – 60 73/55
Infant 110 – 130 24 – 30 90/55
Preschool 90 – 110 20 – 24 85–90/50–60
School age 80 – 90 18 – 20 90–110/60
Adolescent 70 – 90 16 – 20 110–130/70
Adult– > 18 50 – 100 16 – 20 120–129/80– 84
Older adult >70 60 – 100 15 – 20 diastolic

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NORMAL FLUID INTAKE AND OUTPUT

INTAKE: 1,500 – 2,500 ml over 24 hours.

OUTPUT: 1,500 – 2,500 ml over 24 hours.
INSENSIBLE LOSS: 500 – 1,000 ml / day
NORMAL FLUID FOR COLOSTOMY / ENEMA: 500 – 1,000 ml
AMNIOTIC FLUID: 500 – 1,000 ml

REMEMBER!!!

Minimum urine output is 0.5 - 1 ml/kg/hour (adult) 2ml/kg/hour (child).

WEIGHT!
1,000 ml = 1 kg = 2.2 lbs

BASIC ASSESSMENT
1. Obtain history:

Subjective Data:
What the client tells you; history of current illness, pain, aggravating / relieving factors.

Objective Data:
Things that can be assessed by the examiner: name, age, gender, vital signs, diet, activity level,
medications (prescribed or illicit), alcohol intake, cigarettes smoked.

ALWAYS ASSESS CLIENT FROM HEAD TO TOE

REMEMBER TO INCLUDE:

HEAD Shape and symmetry of face. Condition of hair and scalp

(e.g., thinning, balding, alopecia, etc)

EYES Appearance of sclera, color of conjunctiva, appearance of pupils

(They should be equal in size, round and regular in shape, and react to light and
accommodation) PERRLA

EARS Presence of drainage, hearing aids, pain, hearing disturbances

NOSE Drainage, sense of smell, nasal congestion

THROAT Presence of dentures

Oral hygiene
Oral mucosa (should be pink, moist)
Tracheal alignment
Presence of jugular venous distention (JVD)
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PAIN ASSESSMENT

1. Use a pain scale from 0 – 10, 0 = no pain, 10 = worst pain.

2. For a child or a client with a language barrier, use faces or OUCHER scale:
no pain moderate pain worst pain

4. Assess PQRST:
P: What provokes the pain?
Q: What is the quality of the pain? (e.g., sharp, dull, stabbing).
R: Does the pain radiate? (does it move around)
S: What is the severity of the pain?

tachycardia, SOB)
T: What was the time of onset (constant, intermittent?)

5. Nursing implications:

Pain Relief:
• Reposition patient
• Rest and relaxation techniques
• Analgesics as per health care provider prescription
•
• Distraction techniques: deep breathing, imagery, massage, eliminate stimuli, music
therapy, biofeedback (non pharmacological comfort measures)

TIP *Emphasize prioritization of care on systemic client concerns i.e. sepsis vs. localized concerns.

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NEUROLOGICAL ASSESSMENT

1. Assess Mental Status: alert

disoriented
confused
stuporous
comatose

4. RAPID NEUROLOGICAL ASSESSMENT: (performed on admission or on an emergent basis).

0 absent, no response
1 (+) weaker than normal
2 (++) normal

4 (++++) hyperactive

*Note: 1 and 3 may be normal for some individuals.

THE GLASCOW COMA SCALE

Eye opening
Motor response
Verbal response

2. The highest score is 15 normal neurological function.

coma is present.

deep coma is present.

THE SCALE ITSELF

Assess the client in each area and assign a numerical score as per the scale. Then add up
the three numbers to arrive at the total score. Whatever the total is, the three numerical sign
.

EYE OPENING MOTOR RESPONSE VERBAL RESPONSE

Spontaneous 4 Obeys commands 6 Oriented 5

Extension 2 No response 1
No response 1

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THE BRAIN AND NERVOUS SYSTEM

Frontal lobe
Voluntary muscle movements, motor areas for control of speech, controls personality, behavioral functions,
intellectual functions i.e. memory, judgment and problem solving, autonomic functions and cardiac and

Temporal lobe
Controls taste, hearing, smell
and the interpretation of spoken
language.

Parietal lobe
Coordinates and interprets sensory
Information from the opposite side
of the body.

Occipital lobe
Interprets visual stimuli.

Temporal arteritis:
Signs and Symptoms: headache, thrombosis, excessive sweating, fever, malaise, jaw pain with chewing
and muscle aches.
RX: Corticosteroids

LEFT-BRAIN / RIGHT-BRAIN

Remember!

LEFT-SIDED BRAIN DAMAGE RIGHT-SIDED BRAIN DAMAGE

Slow, cautious behavior Quick, impulsive behavior

Speech problems, aphasia Short attention span

Trouble following verbal commands Neglects left side

Apraxia (impaired motor function) Easily distracted

Trouble performing simple tasks

Dandy Walker Syndrome -congenital malformation of 4th ventricle of the brain. Results in increased ICP.
Associated with other disorders of the CNS. Treatment: placement of a VP shunt. Management of S/S.
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NERVE FUNCTION TEST

I. OLFACTORY Smell (sensory) Identify familiar odors

II. OPTIC Vision (sensory) Snellen eye chart

Most eye movements, constricts III, IV, VI test together, Check for ptosis
III. OCCULOMOTOR pupils, keeps upper lid open of lid. Assess ocular movements

IV. TROCHLEAR Eye movements inward, downward Note any eye deviation

Close jaws tightly, Touch forehead,

Facial, scalp, teeth (sensation), jaw, cheeks, chin, and cornea with cotton.
V. TRIGEMINAL chewing movement
(sharp/dull), and temperature (hot/cold)

VI. ABDUCENS Eye movements, lateral See III, IV

Observe for facial symmetry: whistle,
VII. FACIAL smile, raise eyebrows; Test taste
discrimination on front of tongue
Hearing (cochlear), balance
VIII. ACOUSTIC (vestibular)
Check Weber, Rinne, check balance

Taste of posterior, tongue, pharynx,

IX. GLOSSOPHARYNGEAL swallowing, salivating, sensation of
ear, raises palate, controls pharynx
Taste, palate, sensation of pharynx,
larynx, ear, talking, swallowing
X. VAGUS parasympathetic stimulation to heart
voice, Observe rise of uvula when
& abdominal viscera
Shrug shoulders against resistance.
Movements of head, neck and
XI. SPINAL ACCESSORY shoulders
Turn head against opposing pressure of
the examiners hand

XII. HYPOGLOSSAL Movements of the tongue Protruded tongue, it should be midline

EXAMPLE OF A DISEASE AFFECTING A CRANIAL NERVE:

TRIGEMINAL NEURALGIA:

Trigeminal Neuralgia
T • 5th cranial nerve
which occurs in sudden, intense, paroxysmal • frequent eye care
• good oral hygiene
the area innervated by the trigeminal nerve • frequent dental visits
(5th cranial nerve). • avoid hot & cold liquids
• wear glasses outdoors to protect
Priority nursing diagnosis: Pain eye from dust & particles

Treatment:: pain management

Tegretol (carbamazepine), Dilantin
(phenytoin), Elavil (amitriptyline)

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LUNG ASSESSMENT

Inspection –

erythema.

Palpation – Pain, tenderness, crepitus, tracheal deviation

Percussion –
pneumothorax), resonance (normal lung sounds), hyperresonance (indicates possible pneumothorax, or
emphysema)

Auscultation –

to right, anterior to posterior.

Abnormal Lung Sounds

Crackles (rales): heard on inspiration in the lower bases, it cannot be relieved by coughing.

Ronchi: Coarse, gurgling sound. Heard on expiration over trachea and bronchi, it can be relieved by
coughing.

Wheezes:
on expiration. Cannot be relieved by coughing.

Stridor: high pitched sound heard on inhalation and exhalation. Indicates narrowing of upper airway or
obstruction. ***THIS SOUND REQUIRES IMMEDIATE INTERVENTION***

ABDOMINAL ASSESSMENT
Inspection: Skin, distention, presence of scars, obesity, herniations.
Auscultatation:

Percussion: Dullness: Tympany:

Resonance: over lungs Flatness: over muscle or bone

Palpation: pulsation, masses, tenderness, rigidity,

NOTE 1:
Always work from area of least pain towards area of most pain.
A pulsatile abdominal mass may indicate an ABDOMINAL AORTIC ANURESYM.

NOTE 2:

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EXTREMITY ASSESSMENT

Grip: Should be equal bilaterally. Assess push pull strength of feet.

Distal sensory/motor:

Nail beds: note clubbing or cyanosis

Range of Motion: note any limitations

Deep Vein Thrombosis (DVT):

distention, warmth and localized tenderness. NEVER

Edema:

Intermittent claudication: pain with ambulation that is relieved by rest.

SKIN ASSESSMENT

Color: Pallor, jaundice, redness, cyanosis

Temperature: Coolness, warmth
Moisture: Diaphoresis, excessive dryness
Turgor: Poor skin turgor may indicate dehydration
Edema: Edema of extremities (bilateral or unilateral), sacrum; dependent side if bed bound
Lesions: Presence of or type of skin lesions

Stages of skin breakdown (Decubitus ulcers)

Stage I:

Stage II: Interruption of epidermis, dermis or both;

appears as an abrasion, blister or crater

Stage III: Full thickness crater involving damage &/or necrosis down to, but not penetrating the fascia

Stage IV: Full thickness crater, similar to stage III, but penetrating the fascia,
with involvement of muscle, bone, tendon, joint

Negative pressure wound dressing

to the wound. A wound drain is attached and covered with a trasparent dressing. The pump is attached to

Surgical wounds are changed daily. Chronic wounds are changed three times per week.

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a without infra beneath

ab,abs away from inter between
COMMON PREFIXES ad towards intra within
AND alb white beside
THEIR MEANINGS
allo other meso middle
ambi both meta after
anph both milli one• thousanth
an,ana without mono single
ante before multi many
anti oppose, against neo new
auto self nan all, wide
bi two pan all
bio life para beside
brady slow per through
circum around peri around
con together or with poly many
contra against, opposed post after
dys pre before, in front of
ecto outside primi
endo within pseudo false
epi above or over retro backward
eu good rube red
out or away from semi half
hemi half sub beneath
homeo likeness supra above
homo same tachy fast, rapid
hydro water trans across, through
hyper above, high, excessive tri three
hypo ultra beyond
idio uni one
im not dry

COMMON WORD abdomin/o abdomen arthr/o joint

ROOTS acetabul/o acetabulum arteri/o artery
aden/o gland blast/o embryonic
adip/o fat bronch/i bronchus
adrenio adrenal gland broncho bronchus
aer/o air calc/o calcium
angi/o vessel calcane/o heel bone
anter/o front cardi/o heart

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Subcutaneous injections:
average size client 45°
obese client 90° angle 41
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DIABETES: ESSENTIAL FACTS

*Native Americans,Hispanics & African Americans at highest risk
Type1
production by the beta cells or the islets of Langerhans.

Type II
decrease of insulin production and or cell resistance to insulin.

Insulin is required for transport of glucose across cell membrane. Decreased insulin results in
hyperglycemia.

Random glucose > 200 + S/S or Fasting glucose

Gestational DM GTT > 135
Hyperglycemic
Clinical Diabetic Ketoacidosis
Hypoglycemia Hyperosmolar Nonketonic
Manifestations (DKA)
Coma (HHNK)
Type I Type I Type II
Too much insulin or too little Uncontrolled DM or oral
Cause
food insulin hypoglycemic drugs
Onset Rapid (within minutes) Slow (about 8 hours) Slow (hours to days)
Appearance Symptoms of fainting Appears ill Appears ill
Rapid and deep Rapid and deep
Respirations Normal Shortness of breath Shortness of breath
Kussmaul Absence of Kussmaul
Breath odor Normal Fruity due to acetone Normal
Pulse Tachycardia Tachycardia Tachycardia
Blood Pressure Decreased Blood Pressure Decreased Blood Pressure
Anorexia
Hunger Hunger Hunger
Metabolic Acidosis
Increased
Thirst None Increased
Dehydration
Vomiting Nausea, vomiting rare Likely Likely
Eyes Staring, Double Vision Appear sunken Visual loss
Headache Common Occasionally Occasionally
Pallor
Hot Hot
Skin Perspiration
Dry Dry
Chilling sensation
Twitching common
Muscle action Twitching absent Twitching absent
Unsteady gait
Pain in abdomen None Common Common
Confusion Malaise
Confused
Erratic Drowsy
Mental status Dull
Change in mood Confusion
Coma
Unable to concentrate Coma
Administer glucose
Treatment
PO, IV, sub q, IM insulin insulin
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Insulin Chart
TimeCourse Agent Onset Peak Duration Indications
Lispro (Humalog) 1h Used for rapid
Aspart (Novolog) reduction of
Apidra (insulin glulisine) glucose level, to
treat postprandial
hyperglycemia and
**DO NOT MIX to prevent nocturnal
hypoglycemia
Short acting Regular Usually administered
Humalog R before a meal. May
Novolin R be taken alone or
Iletin II Regular in combination with
longer acting insulin.
NPH (neutral protamine Hagedorn) Usually taken after
acting Humulin N food
Iletin II Lente
Iletin II NPH
Novolin L (Lente)
Novolin N (NPH)
Long acting Used primarily to
control glucose level
Very long acting Lantus (glargine) 1h Continuous 24h Used for basal dose
**DO NOT MIX Levimir (insulin detimir) (no peak) QD at bedtime
*Discard open refrigerated vials of Insulin after 28 days. *Insulin detemir lasts 42 days

• Wash hands, then inspect the insulin

• Roll cloudy insulin gently * Do not shake
• Draw up amount of air equal to the dose of cloudy (intermediate or long acting) insulin & inject it into the
cloudy insulin vial (be sure the needle does not touch the solution)
• Draw up amount air equal to dose of clear (regular) insulin and inject into clear insulin vial
• Withdraw insulin from the clear bottle then withdraw
•
the total amount

Somogyi phenomenon:
Manifests as glucose peaks and valleys. Caused by increased insulin resulting in hypoglycemia; usually
occurs at night. Symptoms: • nightmares • sweating
• headache • ketonuria
Treatment: check blood glucose 1–2 times/ night, adjustment of insulin dosage & time, & or a bedtime snack.

Dawn phenomenon: Hyperglycemia in the morning, usually between 2:00 am and 8:00 am.
Treatment: Increase insulin and avoid a bedtime snack.
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• Complications of Diabetes Mellitus (K.N.I.V.E.S.)

Kidney disorders Neuropathy Infection Vascular changes Eye damage Skin lesions

• Females experiencing recurrent vaginal yeast infections should be tested for:

• Type II Diabetes Mellitus
• HIV infection
REMEMBER
• Hot and dry glucose is high

• Wet and clammy give hard candy

Fill in the blanks with the words increase or decrease:

A client that took too much insulin will need to ______________food

A client that exercises three times a day may need to ___________insulin

A client that missed a meal may need to ________________insulin

FACTS ABOUT ORAL HYPOGLYCEMIC AGENTS

• Prescribed for treatment of type 2 Diabetes

• *clients on oral medications may require Insulin therapy during times of illness or stress

THE AGENTS
Hold for 24 hours before and 48 hours after contrast dye
Glucophage (metformin) May cause lactic acidosis
Contraindicated with kidney disease
Glucotrol (glipizide)
Take with meals, contraindicated in pregnancy.
Diabeta (glyburide)

Take with meals.

Amaryl (glimepiride)
vomiting, dark urine
Avandia (rosiglitazone)
Monitor liver enzymes; contraindicated with CHF & MI
Actos (pioglitazone)
(nateglinide)
May cause cough, SOB, seizures
Prandin (repaglinide)
Precose (acarbose)
Onglyza (saxagliptin) URI, UTI, headache, pancreatitis, abdominal pain, drowsiness, weakness.
Januvia (sitagliptin) Administered once a day
Injectable – to treat type II DM; helps the pancreas to produce insulin more

Byetta (exenatide) on an empty stomach.

diarrhea
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Infection Control Essentials

Standard Precaution
Standard precautions routinely practiced by health care providers include:

Wash Hands and Don Gloves

Be sure to wash hands after removing gloves.

Use mask/eye protection/ face shield: If the threat of a splash is eminent.

Don Gowns: To protect skin and clothing during procedures that may involve splashing.
TRANSMISSION BASED PRECAUTION PROCEDURES
Airborne Precautions Droplet Precautions Contact Precautions
Gloves and gown
patient
Negative pressure
Private room Private room Private room
Keep door closed
Patient wears surgical mask during Patient wears surgical mask during Remove gloves and gown before
transport transport leaving room
Limit transport Limit transport

AIRBORNE PRECAUTIONS DROPLET PRECAUTIONS CONTACT PRECAUTIONS

Used for clients with suspected or Used for clients with suspected or Used for clients with suspected or

by airborne droplets with nuclei < by large particle droplets. direct or indirect contact.
5 microns. • Meningitis •
• Measles (Rubeola) • Bacterial Pneumonia (PNA) • Herpes Simplex Virus
• Varicella (Chicken Pox) • Epiglottitis • Klebsiella Pneumonia
• Tuberculosis • Pertussis • RSV for 24 hrs • MRSA
• SARS (Severe Acute Respiratory • Mumps • Ebola • VRE
Syndrome) • Rubella (German Measles) • RSV
• Smallpox • HIB • Rotavirus
• H1N1 • Ebola • Herpes Zoster (shingles)
• Herpes Zoster (shingles) - • Group A Strep (Scarlet & • Infected pressure ulcers
Disseminated disease in any Rheumatic fever)
• Major skin wound/burn infection
patient. Localized disease in • Diptheria (Pharyngeal)
• SARS
immunocompromised • Adeno Virus • Fifth’s Disease • Vaccinia (cow pox)
Skin Infections:
NOTE* • Impetigo (Group A strep)
• Pediculosis
with a communicable disease is seen and not admitted. • Scabies
• Varicella
*Also, Do not cohort post-op patients with anyone • Diptheria (cutaneous)
Viral Hemorrhagic Infections:
chest drainage or infections. • Ebola
• Viral conjunctivitis
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MORE ABOUT INFECTION CONTROL....

1. Chain of Infection – hand washing is essential to

break the chain

2. Medical Asepsis = Clean technique

A. STANDARD PRECAUTIONS:
USED FOR ALL CLIENTS regardless of diagnosis

excretion, non intact skin and mucous membranes.

Hand washing and personal protective equipment
are essential.

B. TRANSMISSION BASED PRECAUTIONS

Airborne; Droplet; Contact

I. Airborne Precautions particles < 5 microns

• Private room (negative pressure with at least 6 exchanges per hour)
• Door must be kept closed
•
• Limit transport; mask the patient if transport is needed

II. Droplet Precautions

•
•
•
• Limit transport; mask the patient if must transport

III. Contact Precautions

Direct (contact with client’s skin) or indirect (contact with contaminated surfaces)
• Private room – or cohort with same organism
• Gown and glove upon entering room
• Change gloves after contact with infective material
• Don personal protective equipment using correct sequence:
Gown, mask or respirator, goggles then gloves

Remove personal protective equipment using correct technique: (GERM)

1. Remove gloves
2. Remove goggles or face shield (handle by headband or earpiece)
gown (inside out)
4. Remove mask (front of mask is contaminated DO NOT TOUCH). Wash hands.
• Do not touch anything in environment after hand washing.
• Limit transport of patient.
• Dedicate use of patient care equipment to this patient only; leave equipment in the room.
•

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3. Surgical Asepsis Sterile technique, free from all pathogens and their spores

4. Disinfection Destruction of pathogens

5. Sterilization Destruction of all microbes

6. Antiseptic Inhibits microbial growth

A. moist heat steam under pressure (autoclave) or boiling objects in water

7. Heat sterilization
B. dry heat

A. gamma rays used to sterilize food and drugs

8. Radiation B. ultraviolet light used to inhibit the microbial population of air in operating
rooms, nurseries and laboratories

Standard precautions (Cipro or Doxycycline)

Botulism – Standard precautions

• Caused by clostridium botulinum toxin
•
• Food bourne (canned foods, aluminum foil wrapped baked potato)
•
•
weak muscles and constipation
• Treatment: antitoxin
Pneumonic Plague –
apy within 24 hours. Streptomycin, Gentamicin or Tetracycline
West Nile Virus • • • • • •

Handling Hazardous Wastes: nurses should be familiar with the material safety data
sheet (MSDS) for the facility. It contains data on each substance in the facility that is

interventions, and protective equipment for the management of hazards.

Read labels: use all materials solely for their intended purpose; always use required PPE;
contact biohazard department when appropriate.
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BURNS

of body weight of protein daily. High metabolic rates increase the rate of infection.

DEPTH OF BURNS
•
• Deep partial thickness – cause necrosis of epidermal and dermal layers.
•
•

TYPES OF BURNS
• Thermal – hot objects, frostbite (rewarm area as rapidly as possible)
• Electrical – electrical current
• Chemical – acid, alkaline liquids
• Radiation – sunburn, external radiation beams

BURN ASSESSMENT

Rule of the Palm:

Rule of Nines:

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GOALS OF CARE FOR A BURN PATIENT *No pain relief until V/S are stable

• Priority: maintain a patent airway – may require intubation; supplemental O2

• Prevent or correct hypovolemic shock

to increased capillary permeability

rapidly.

• +
Bicarbonate

• Prevent infection – Give Tetanus injection prophylactically; cover the wound with sterile or
clean dressings; Sterile dressing changes; Antibiotic therapy; Protective isolation

• Maintain nutritional status – high calorie, high protein diet, TPN; calorie count, I&O

• Restore skin integrity – skin grafts; Jobst stockings

• Prevent contractures – ROM exercises, proper positioning and alignment

• Prevent other complications – Curling’s Ulcer – stress ulcer associated with severe burns

lansoprazole)

• Restore function as much as possible – Rehab (occupational therapy, physical therapy, and

management is the priority. ***

MEDICATIONS
•
• Silvadene (silver sulfadiazene)
• Sulfamylon (mafenide acetate) no dressing with this med
•
hypochloremia
• Garamycin (gentamicin sulfate) oto, neuro and nephrotoxic – monitor BUN & Creatinine

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PHYSIOLOGICAL
INTEGRITY

TIP: When prioritizing patient care remember to select life saving measures over preserving a limb!

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PHYSIOLOGICAL INTEGRITY
I. Health Promotion and Illness Prevention
A. PREVENTION

Primary prevention:
needle exchange programs.
Secondary prevention: Early detection, screening & diagnostic tests i.e. self breast exam,
mammogram, colonoscopy, testicular self exam
Tertiary prevention: Palliative care, rehab, comfort, hospice

B. SCREENING TESTS
Angiography (cerebral, pulmonary, renal, coronary)
•
•
•
Bronchoscopy
• visualization of the bronchus
• before exam – provide oral hygiene, postural drainage, NPO for 6 to 8 hours
•
(Crepitus): indicates air leakage/ perforation; frequent swallowing indicates bleeding.
X- ray
• no metals or jewelry
• instruct client to keep still
• assess females for pregnancy
Fasting Glucose Level
• >126 two times used to diagnose DM (Diabetes Mellitus)
•
Intra-venous pyelogram (IVP)
• dye injected to assess for blockage in kidneys, ureters, and bladder
•
•
Bladder Scan
• ultrasound to assess condition of the bladder and for presence of residual urine
•
24 Hour Urine Collection
• 1st urine should be discarded
• refrigerate specimen / place on ice

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Amniocentesis
•
• can indicate gender, congenital abnormalities, neural tube defects, gestational age
•

Thoracentesis
•
• needle inserted on exhalation
• place client in orthopenic position to perform procedure
•
• after test assess for respiratory distress–shock, pallor, diaphoresis
•

Paracentesis
•
• check weight
• check abdominal girth BID
•
for withdrawal
• post – monitor I&0, abdominal girth; priority follow up – blood in urine
•

Barium enema
• before procedure give enemas/laxatives until colon is clear of stool
• clear liquid diet the night before the procedure
• NPO 8 hours before the test
•
• Teach: expect constipation & clay colored stools

C. NUTRITION

• Foods high in Sodium (Na+): celery, processed foods, condiments, canned foods, smoked
meats, tomato juice, pickles, butter.
Increase salty snacks in clients with Burns, Lithium therapy, Addison’s disease, and
Cystic Fibrosis (BLAC)

•
Take with Vitamin
D to increase absorption
oatmeal, mushrooms).

• Foods high in potassium (K+): apricots, melons, citrus fruits, potato, spinach, raisins (dried

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Foods high in Iron:

Take with Vitamin C to increase absorption

VEGETARIAN DIET DAIRY EGG MEAT

Lacto-ovo + + -
Lacto-vegetarian + - -
Ovo-vegan - + -
Pesco-vegetarian + - Only Fish

Partial/semi vegetarian + + Avoid selected meats

*Vegans- eliminate all animal products & dairy
Nutrition

Carbohydrate: major source of food energy

• Grains, nuts, fruit

Protein: needed for tissue building

• Found in meats, chicken, beans, legumes, tofu, eggs

Fat: insulation, energy, carry fat soluble vitamins

• Fat soluble vitamins include A, D, E, K (water soluble: B & C)

• Found in egg yolk, liver, butter, cheese, margarine

• Decrease in clients with cardiovascular and cardiac disease

Normal Values

CHO: 4 kcal/gm Protein: 4 kcal/gm Fat: 9 kcal/gm

Example: The client had a 24 hour dietary intake of 200 gm CHO, 100 gm protein and
50 gm of fat.

What is the total caloric intake for the day?

ANS: 1650 calories

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VITAMINS – necessary for normal cellular functions of the body

Vitamin B1
•
parasthesias of hands and feet, loss of muscle function)
•
Vitamin B3
•
•
• Found in mushrooms, tuna, chicken breast, asparagus, halibut, salmon
Vitamin B6
• B6 = Pyridoxine
• Increase with INH(Isoniazid) to decrease peripheral neuropathy
•
Vitamin B9
•
•
Vitamin B12
• B12 = Cyanocobalamin–needed for normal neurological function
•
• Found in brewer’s yeast, citrus fruit, dried beans, green leafy vegetables, nuts, organ
meats
Vitamin A
• Good for mucous membranes and night vision
•
• Bile necessary for absorption
•
Vitamin C
• Necessary for synthesis of collagen & neurotransmitters, assists with wound healing
•
• Found in citrus fruits, green leafy vegetables, strawberries, peppers
Vitamin E
• Required for the proper function of many organs in the body. It is also an antioxidant
•
•
grains
Vitamin K
• Necessary for clotting
• Found in green vegetables, cabbage, liver and organ meats
Omega 3 fatty acids
• Good for cardiovascular health, diabetes mellitus, immune function, joint health

• Found in salmon, herring, mackerel, anchovies, sardines, tuna, halibut, plant and nut oils

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Progression • Clear liquid – full liquid – soft – regular

Bland Diet • Helps to heal gastric mucosa
• Decrease spices
Low Residue • Used after bowel surgery, prior to bowel exam, for internal radiation
•
•
Tube Feedings
• Place the client in the semi fowlers position
• Measure from the tip of the nose, to the tip of the earlobe to the zyphoid process
•
Insertion of air while listening
for air over the stomach is not a reliable method to assess placement.
• Residuals greater than 150 ml should be reported
•

PPN: Peripheral Parenteral Nutrition TPN: Total Parenteral Nutrition

Peripheral: peripheral vein is used
Central Line – long term/ Jugular – less than 4 weeks
Finger sticks Q 6 hours – prone to hyperglycemia
Never stop abruptly/ taper may cause hypoglycemia
Piggy back with lipids only
Change tubing daily,
Change dressing every other day using sterile technique

Celiac Disease:
• Formerly called (Sprue)
• Avoid foods containing gluten
• Avoid barley, rye, oat, wheat (BROW)
•
• High protein, high calorie diet

PKU : Phenylketonuria Diet:

• Avoid phenylalanine (amino acid that cannot be metabolized)
•
•
days
• For infants – lofenolac formula is used (low protein, low amino acids)
• Can cause brain damage/mental retardation

Low Purine Diet (Gout: Increase Uric Acid)

•
mushrooms
•
•
Medications:
• Colcrys (C
• Zyloprim (Allopurinal)– Bone marrow depression, arthralgias
• Benemid (Probenicid) –nausea, rash, constipation
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Safety – Fire safety :

Rescue/remove those in immediate danger Pull the pin
A A
C S
E Sweep the hose from side to side

Important Positions for Various Conditions

Laminectomy: • log roll; post op: place in supine position
Tube inserted in GI tract: • right side
Enema: •

Amputation: • elevate stump 1st 24 hours only

• elevate the bed not just the stump; to prevent contractures; place client in
prone position several times daily
Cast: • elevate part
Compression bandages • reduces edema and pain
• wrap limb distal to proximal
Gastric resection: Avoid dumping syndrome
• lie down after eating
• do not drink with meals
• Vitamin B12 replacement necessary
Liver biopsy: •
• post procedure: place on right side with a small pillow to decrease bleeding
Pneumonectomy: •
Respiratory Distress: • high fowlers/orthopneic position
Mastectomy: DO NOT ABDUCT
• causes strain on suture line
• elevate arm on pillow (same side as operative breast)
• exercises: wall climbing, rope turning, broom lifting, hair combing
Retinal Detachment: • lay on AFFECTED side
• any other eye surgery lay on UNAFFECTED side
Venous: • keep legs elevated (V)
Arterial: • keep legs dependent (A)
Radical Neck Dissection: •
Kidney Biopsy: • pre procedure: position prone
•
• post procedure: position supine; hematuria and pain expected for a few
days after
Hip Surgery: ABDUCT
• use abduction pillow between legs to immobilize & prevent dislocation
• never cross legs or bend over
•
•

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II. Perioperative Nursing

Types of surgery Reasons performed

Diagnostic Determine cause of symptoms Biopsy, exploratory laparotomy
Curative Removal of diseased part Appendectomy
Strengthen weakened areas
Herniorrhaphy
Restorative Correct deformities
Mitral valve replacement
Rejoin a separated area
Palliative Relieve symptoms without curing disease Sympathectomy
Cosmetic Improve appearance Rhinoplasty
•
possible complications.
• Preoperative teaching should include instructions for deep breathing and coughing exercises, leg
exercises, and options for pain management.
• Diagnostic and laboratory tests should include: CBC, BUN, EKG, Electrolytes, HCG (for females),

•
before surgery of the GI tract. Conduct a timeout immediately before starting an invasive procedure.
• Conscious sedation used for minor procedures (extensive suturing, endoscopy, cardiac catheterization,
bone reduction) to minimally depress the level of consciousness. Patient can cooperate during the
procedure but may have partial amnesia afterwards. Versed (midazolam) or propofol may be used.

Common Post Operative Tubes and Drains

Complications include:
Jackson Pratt, Hemovac, Penrose
• Atelectasis (collapsed alveoli)
•
• Hemorrhage of the wound
•
• Thrombophlebitis infection
• Wound infection • Promote wound healing
• Dehiscence (separation of the wound) Nasogastric
• Evisceration (wound contents are expelled) • Used to decompress the stomach
• Urinary tract infection • Levine: (1 lumen) low intermittent suction
• Salem Sump: (2 lumens) continuous or intermittent
Risk factors include: suction
• Obesity • *Monitor drainage for consistency, color and amount
• Poor nutrition Sengstaken–Blakemore
• Used to treat esophageal varicies (medical emergency)
• Steroid therapy
•
• Keep scissors at the bedside
:
• Diabetes Mellitus Miller Abbott
• Cardiac • Used for intestinal suction and decompression
• Respiratory Percutaneous Endoscopic, Gastrostomy (PEG tube)
• Neurological disorder • Used for long term feeding
• Not necessary to check for placement

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III. Circulatory Function and Disorders

A. Anatomy and physiology review

B. Risk factors related to the development of peripheral vascular disease:

• Smoking
• Exposure to cold
• Obesity
• Immobility
• Hypertension
• DM

C. Peripheral vascular disease assessment:

Check for 6 p’s
1. Pain
2. Paresthesia
3. Pulselessness
4. Paralysis
5. Pallor
6. Poikliothermia

Arterial Ulcers Venous Ulcers

• •

• Secondary to PVD, DM • Secondary to obesity, age, pregnancy, DVT

• Pallor and pain with leg elevation • Painless

• Ulcers are distal to the loss of blood supply •

• Pale, yellow or gray wound base • Ruddy or red wound base

• Skin tight and shiny with hair loss

• Regular wound margins • Irregular wound margins

• Keep legs dependent • Elevate legs

• Decreased or absent peripheral pulses • Presence of peripheral pulses

Metabolic Syndrome X - a group of risk factors that increase the risk for heart disease and other health
problems such as diabetes and stroke. People with metabolic syndrome are twice as likely to develop heart

• Increased B/P 135/85 or higher

• Increased fat around the waist (over 35 inches female, over 40 inches male)
• Increased glucose level
• High triglyceride level
• Decreased HDL or Increased LDL
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D. Arterial vs. Venous disorders – smoking contributing factor

Arterial Disorders:
Signs & Symptoms:
• intermittent claudication
• cold
• edema
• diminished pulses

Treatment:
• Vasodilators
• Analgesics
• Anticoagulants
• Anticholesterol Agents
• Smoking cessation
• Keep extremities warm

•
circulatory problems to reduce aching, cramping & tiredness in the hands and feet

1. Thromboangitis obliterans (Buerger’s disease):

2. Raynaud’s disease:

3. Arteriosclerosis Obliterans (occlusive arterial disease):

4. Aneurysm:

1. Thrombophlebitis
, warm packs, surgery

2. Varicose veins:
Dilated veins.
Risk factors: obesity, pregnancy, heart disease, thrombophlebitis, excessive sitting or standing.

decrease foods high in vitamin K (green vegetables, organ meat) while on this medication

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Risk factors:
• Age
• Race (African Americans at highest risk)
• Family history
• Diabetes mellitus
• Cigarette smoking/ ETOH
• cholesterol
Primary hypertension: no known cause
Secondary hypertension: caused by another
condition i.e pheochromoytoma (hypersecretion
of the adrenal medulla)
Categories of Blood Pressure
Symptoms: Normal Less than 120/80
• Early morning headaches
• Nosebleeds
Stage 1 hypertension
• Fatigue
Stage 2 hypertension 160 & above/100
• SOB on exertion
180/110
Recommended Life Style Changes: Treatment:
• Avoid smoking and alcohol • Beta Blockers
• Decrease sodium • Calcium Channel Blockers
• ACE inhibitors
• Increase exercise
• Angiotensin II Receptor Blockers
• Reduce stress • Diuretics
• Alpha Blockers
• Vasodilators
• Lipid Lowering Agents

IV. Cardiac Function and Disorders

A. Anatomy and physiology review

P wave: Atrial depolarization (contraction) EKG PAPER

Small block: 0.04 secs
QRS wave: Ventricular depolarization (contraction) Big Block: 0.20 secs (or 5 small
blocks)
T wave: Ventricular repolarization (relaxation) 1 Second: 25 small boxes or 5
big blocks
An increased potassium level will result in an increased T wave
1 minute: 1500 small blocks or
A decreased potassium level will result in a decreased T wave
*Signs of hypokalemia include: • Anorexia • Nausea • Vomiting • Faint pulse • Muscle weakness

respirations • EKG changes • Decreased heart contractility

• Normal Sinus Rhythm:

• PR Interval:
• QRS Interval:
• QT Interval:
small blocks)
• ST segment:
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C. Disorders

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4. One small box =____________seconds

Answer Key

4. 0.04 seconds

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A. Diagnostic Tests

CK- MB:
•
• Peaks in 24 hours
• Troponin

Pulmonary artery Pressure Monitoring: (Swan Ganz)

• Measures pressure in the right atrium, pulmonary artery and left ventricle
• Normal is 15 mm/Hg. Pressure is increased with left sided heart failure
• Used to evaluate left ventricular and overall cardiac function

Central venous pressure reading (CVP):

• Measures pressure in the right atrium
• Normal 5 to 10 – used to monitor hydration status
• An increase indicates over hydration
•

Cardiac Catheterization:
• NPO 6 to 8 hours prior to test
•
•
• Keep leg extended 4 to 6 hours after test

Muga Scan :
• Ejection fraction study
• Radioactive tags injected
•
• Avoid with pregnancy

Thallium Scan (stress test):

• Dye injected which acts as a tracer
• Cameras take pictures of the heart
•
• Other types of stress tests:

cardiac nuclear stress test in clients unable to exercise adequately

Holter Monitor:
• Painless 24hr EKG
• Teach: do not get wet
• Keep a diary of activities

Transesophageal Echocardiogram – (TEE):

• Detects blood clots, tumors, and valve problems
•
•
•
Pre procedure: • NPO 6 hrs
• Place client on the left side
• IV sedative, throat anesthetic

Post procedure: •
• No driving for 12 hours
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CONGESTIVE HEART FAILURE (CHF)

S

RIGHT SIDED HEART FAILURE (Body)

Signs include: jugular neck vein distention, edema of the hands and lower extremities, abdominal distention,
GI distress.

LEFT SIDED HEART FAILURE (Lung)

Signs include: coughing, wheezing, dyspnea, frothy sputum
Treatment: Low Na+ diet, Aspirin, Lasix (furosemide), Lanoxin (digoxin) – slows and strengthens heart beat
– take on empty stomach, monitor apical pulse for 1 minute, monitor electrolytes.
: diarrhea, vision changes, arrhythmias

ANGINA
Inadequate oxygenation to the heart causing pain
(relieved with rest and or nitroglycerin sublingual 1 tab

MYOCARDIAL INFARCTION (MI)

the heart (not relieved with rest).

Treatment: MONA (morphine, oxygen, nitrates, aspirin)

PULMONARY EDEMA

tachypnea, dyspnea, crackles

Treatment: Oxygen, diuretics, narcotics, vasodilators

CORONARY ARTERY DISEASE

Atherosclerosis (narrowing of arteries from deposition of fatty plaque) which causes decreased oxygenation
and tissue perfusion. May contribute to CHF, hypertension, and myocardial infarction.

PERICARDITIS

May also be caused by MI or radiation therapy to the chest. Common in men 20 to 50 years old.
Signs and Symptoms
heart sounds, crackles.
DX
rheumatoid factor
Treatment:

CARDIAC TAMPONADE

pericardium. May be caused by pericarditis.

Signs and Symptoms: shortness of breath, feeling faint or light headed, anxiety, coughing related to pressure

Treatment – pericardiocentesis

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D. Related pharmacology
Antiarrhythmics:
Used for the prevention and treatment of cardiac arrythmias. The major goal is to restore NSR
Cardizem (diltiazem): Tx. of HTN, angina, tachycardia,

Adenocard (adenosine): Tx. of supraventricular tachycardia, a

Xylocaine (lidocaine hydrochloride): Tx. of ventricular tachycardia,

Calan, Isoptin (verapamil): Tx. of HTN, angina,

Pronestyl (procainamide): Tx. of ventricular tachycardia

Pacerone, cordarone (amiodarone): tachycardia, V-Fib, PVC’s

skin discoloration
Rythmol (propafenone): Tx. of tachycardia,

Client teaching
other activities requiring alertness
Nursing interventions
(normal vital signs, adequate urine output).
Medication titration for cardiac meds: Titration is the process of gradually adjusting the dose of a medication
until optimal results are reached.
Example: Cardizem (diltiazem) or Nipride (nitroprusside)
E. Treatment
Pacemakers:
avoid contact sports, avoid areas of high voltage,
wear med alert bracelet. Client should also be
taught to take apical pulse for one full minute &
have pacemaker checked at regular intervals.
ICD:
shock to the heart when abnormal beat is occuring.
Signs of malfunction include:
rate, hiccups, dizziness, SOB, weakness, chest
pains, fainting

Cardioversion: timed electrical current delivered

during QRS complex to terminate a dysrhythmia

used in an emergency to treat

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A.
tissue (thymus gland, spleen, lymph nodes, tonsils, adenoids)
B. Mononucleosis (Kissing disease) (Epstein Barr virus):
• Signs include: fever, sore throat, cervical lymphadenopathy, malaise, headache, nausea, and
abdominal pain.
• 4 to 6 week incubation period.
• Transmitted by direct intimate contact, infected blood and oral secretions. Standard precautions.
C. Autoimmune disorders
Systemic Lupus Erythematosus:

Precipitating factors include; sunlight, pregnancy and stress.

Treatment:

Sclerodoma:
edema of the extremities, joint contractures and brittle nails.
Teach client to sit up after eating. Treatment is supportive (tertiary).

Lyme disease:
• Caused by the bite of a deer tick, common in MA, CT, NJ & RI
•
•
• Begins as a bump (macule or papule), then the lesion expands with a

D. Diagnostic tests

• Antinuclear antibodies test (ANA): may be positive with Lupus

• Erythrocyte sedimentation rate:
process.
• C– reactive protein:

E. Transplants: Prograf (tacrolimus), Neoral (cyclosporine), Sandimmune (cyclosporine) May be given

to prevent rejection of the new organ

clients with a latex allergy should avoid: kiwi, chestnut, pineapple, strawberries,
grapes, papaya, peaches, tomato, avocado, rye, wheat, melon, hazelnut, plums, cherry, banana,

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VI. Blood Function and Disorders

A. Anatomy and physiology review

Blood Type Can Receive

Blood administration: A A,O
Major blood types B B,O
1. A AB A, B, AB, O universal recipient
2. B O O universal donor
3. AB
4. O

Key points for blood administration:

• Baseline vital signs are always needed
•
• An RN must always be present
•
• The safest blood to administer in an emergency if the blood type is unknown is O negative
• The only IVF to run with blood is Normal Saline
• If there is a blood transfusion reaction, immediately STOP the transfusion!
• Common signs of transfusion reactions include:
• Flank pain • Chills • Hives • Elevated temperature • Tachycardia

B. Disorders
Sickle Cell Anemia:
Priorities in sickle cell crisis include oxygenation, hydration and pain relief (Morphine).
Patients should avoid high altitudes. Client is at risk for priapism (prolonged erection of the penis).

Pernicious Anemia:
Lack of intrinsic factor, VIT B12 injections IM monthly for life.
Diagnosed using the Schilling Test
S/P gastrectomy clients also require vitamin B12 replacement.
• Aplastic Anemia: malfunctioning bone marrow
• Hypochromic Anemia:
• Hemolytic Anemia: excessive RBC destruction
• Clotting Disorders: Idiopathic Thrombocytopenic Purpura, Hemophilia, DIC (Disseminated
Intravascular Coagulation): implement bleeding precautions

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BLEEDING PRECAUTIONS: RANDI

RAZORS ELECTRIC
ASPIRIN NO!
NEEDLES: SMALL GAUGE
DECREASE STICKS
INJURY PREVENTION

Implement with:
• Anticoagulants
• Liver disease
• Decreased platelets
• Thrombolytics
• Bleeding disorders

Bleeding Assessment: BEEP

Bruising
Ecchymosis
Epistaxis
Petechiae

• Common clients of Jewish descent

• Signs and Symptoms: dizziness, headache, blurred vision, hypertension

•

Thalassemia:

• Common in clients of Mediterranean descent

• Goal is to maintain normal hgb level, bone marrow transplant may be necessary

• Signs: anemia, pallor, increased size of liver and spleen

• Treatment is supportive: folic acid, blood transfusion, genetic counseling

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VII. Respiratory Function and Disorders

A. Anatomy and physiology review
B. Diagnostic tests.

Sputum Specimen
• Deep breath and cough
• Oral hygiene – rinse mouth
• Morning specimen from deep
• Sterile container
•
• Do not begin antibiotics before collecting culture

Bronchoscopy-
• Informed consent
• NPO after midnight
•
• Remove dentures/eyeglasses
• Atropine, sedative
• Topical anesthesia
• O2, suction/ resuscitation equipment at bedside

Post procedure
• Vital signs monitored until stable
•
•
• Monitor respiratory status/ bronchospasms
•
• Crepitus: SQ Emphysema (bubbling under the skin): indicates perforation of bronchus
• Monitor patient for bleeding: frequent swallowing = bleeding
• Teach to expect blood streaks but not copious amounts of blood

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Pulmonary Angiography
• Diagram of pulmonary tree
• Informed consent
•
• NPO 8 hours prior
• Teach not to cough during test
• Emergency equipment at bedside

Post procedure
• Vital signs
• Do not do B/P on the extremity used
•
•
• Assess for edema at injection site
• Check insertion site for bleeding and hematoma

Thoracentesis
• Informed consent
• Vital signs prior
•
• Place patient in orthopneic position

Post procedure
• Vital signs
• Monitor respiratory status
• Apply pressure dressing to puncture site
• Check for bleeding at insertion site
• Check for crepitus
• Assess for signs of pneumothorax, air embolism, respiratory distress

Lung Biopsy- analyzes tissue; cytologic exam i.e. cancer/ sarcoidosis

•
• Informed consent
• NPO

Post procedure
• Vital signs
• Pressure dressing
• Monitor drainage/blood
• Signs of respiratory distress, pneumothorax, air embolus
•

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ABG
• Determine acid/base balance
•
is positive (delayed blood return to the hand) arterial puncture should not be attempted.
• Avoid suctioning prior to doing ABG – after drawing ABG place on ice
•

•
• Inaccurate reading could be due to poor perfusion – nail polish, temperature, hypothermia:

Chest PT (physiotherapy
•
•
morning
• If patient complains of pain – stop PT
• Give bronchodilator before treatment
• Good oral hygiene following
• Contraindicated:
pathological fractures, bleeding disorders

– colorless and odorless may be fatal;

•
• 2
in ER

• Given as supplement when blood O2 is decreased

• Requires a prescription–considered medication
• 2L without HCP prescription as immediate intervention
• Can be harmful too much can cause blindness – baby
• Delivered via nasal cannula, mask, or tent. (Mask delivers higher concentation of O2 than
cannula)

•
accessory muscles (neck, chest, abdomen), wheezing
• R.A.T (early signs: restlessness, anxiety, tachycardia)
• B.E.D (late signs: bradycardia, extreme restlessness, dyspnea)

Tests:

Complication:
• Knocks out respiratory drive in patient with COPD (NEVER GIVE HIGH FLOW O2)
•

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SUCTIONING

hypoxia. Limit suctioning to less than 15 seconds to avoid hypoxia. Suction pressure should be set

• Oropharyngeal: aseptic technique is acceptable. A Yankauer catheter is usually used. Use

surgical asepsis for all other suctioning.
• Nasopharygeal:
nares and the viscosity of secretions.
• Endotracheal: performed through a tracheostomy or endotracheal tube.

Mechanical Ventilation and causes of alarms

**High Pressure Alarm** (Obstruction) Low Pressure Alarm (Leak)

• Excess secretions; client needs to be suctioned • Tube is disconnected
• Tube is kinked • Air leak
• Displacement of tube •
• Bronchospasm – causes increased resistance • The client stops breathing spontaneously
• Coughing / wheezing
• Biting of tube
• Fighting the ventilator

Surgical interventions

Tracheostomy
• Surgical incision
• Protects airway

Post op
• Maintain patent airway
• Assess presence of bilateral breath sounds (unilateral indicates lung collapse)

Complications
• Dislodged tube – secure trache ties, (velcro)
• Increased secretions – can lead to obstruction: suction, humidify air
• Pneumothorax
•
• Prevent Infection–sterile technique during suctioning
•

Person with a laryngectomy needs a permanent tracheostomy. Nursing priority: establish a means of

Teach: No swimming, wear medical alert bracelet

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Pneumothora
• Dyspnea, tachycardia, tachypnea, chest pain
• Increase thoracic pressure
• Decrease vital capacity hyperresonance, decreased chest expansion on
(the amount of air you can take in forcibly)

Nursing Intervention: • High fowlers position

• Monitor vital signs • Dressing over open wound
• O as prescribed
2
• Prepare for chest tube placement

Chest Tube Returns negative pressure to the lung space (pleural), removes

Pleur-Evac
Water seal system acts as a one way valve to prevent air and liquid
from moving back into chest cavity.

CHAMBER 1 CHAMBER 2 CHAMBER 3

Serves as a water seal. Is the suction control. Suction

are normal with inhalation and Nurse should see gentle

exhalation. Excessive bubbling/
continuous bubbling.
continuous = air leak. If there
lung
sounds & call MD. There may
be obstruction or the lungs have

• Monitor respiratory status

• Maintain dry, sterile, occlusive dressing
• Chest tubes: label bottle with date and time, tell patient to expect pain when they cough.
• Drainage > 100ml/hr is excessive – Notify MD
• Have clamp at the bedside for an emergency – never clamp unless the system breaks
• If tube disconnects – place tip in sterile water until the system can be replaced
•

side. Obtain Chest X-ray.

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D. Disorders

COPD: emphysema and, chronic bronchitis

• Chronic obstructive pulmonary disease
•
• 2
• Alveoli – site of gas exchange; respiratory acidosis when CO2 is trapped
• Increased incidence in cigarette smokers, occupational exposure to fumes or chemicals,
genetics
• Risk for Cor pulmonale (Right sided heart failure)

Sign :
• SOB/hypoxia
• Easily fatigued
• Wheezing/crackles
• Recurrent cough and URI
• Increased sputum production
• Barrel chest (emphysema)
•
• Skin color dusky to cyanotic (chronic bronchitis)
• No cyanosis (emphysema)

Teaching/ Nursing interventions

• Assess respiratory status
• Pursed lip breathing and deep breathing exercises
• Smoking cessation
• Avoid exposure to cold
•
• Pneumonia vaccine
• Avoid milk: increases mucous, high calorie, high protein, low CHO diet
•
• Increase rest periods
•
• Suction as necessary

Related pharmacology
• Atrovent (ipratropium bromide), Spiriva (titropium inhaled)
• Ventolin (albuterol) – short acting; rescue inhaler
• Serevent (salmeterol) long acting. Teach–take BID
• Symbicort (budesonide/formoterol) (long acting B2/corticosteroid), not used with acute episodes
• Steroids: oral, inhaled, IV – Deltasone (prednisone), Beclovent (beclomethasone), Solumedrol
(methylprednisolone)

retention, hyperglycemia, mood swings, weight gain, oral thrush

• Antibiotics (prophylactic)

TIP: When selecting answers, choose the client with an acute condition over chronic!
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Pneumonia
•
Causes: • Aspiration • Mycoplasma • Fungal
• Bacterial • Viral • Protozoan infections
Bacterial pneumonia requires isolation until 24 hours after starting
antibiotics – viral does not need isolation
Common organisms: Staphylococcus aureus, staphylococcus pneumoniae, HIV – PCP.
Signs & Symptoms: • Fever • Tachypnea
• Chills • Night sweats
• Dyspnea •
• Pleural pain • Diaphoresis
• Productive cough (with rust colored, blood tinged or greenish sputum)
Diagnosis: • • CBC
• ABG • Pulse oximetry
• Sputum culture (before starting antibiotics)
Treatment: • Antibiotics as prescribed • O2 as prescribed
• Chest PT •
• Antipyretic

Risk factors: COPD & immunosuppression

Treatment: Erythromycin, Tetracycline, Quinolones, Zithromax (azithromycin) or Rifampin

Asthma
•
• Mucosal edema with increased mucous production
Signs & Symptoms: • Tachycardia • Apprehension/restlessness
• Tachypnea • Wheezing and night time cough
Diagnosis: • History and physical • ABG
• Pulmonary function tests • Allergy testing
Nursing intervention/ teaching:
• Avoid known triggers • Bronchodilators
• •
• NOAH – Nebulizer, Oxygen, Antibiotic, Hydrocortisone
• Prophalytic medication: Albuterol (B2 agonist
that opens airway) should be kept with them at all
times for rescue.
•
• Teach zone management:
Green:
Yellow:
Red:
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Teach correct MDI technique

1. Remove the cap and hold inhaler upright.
2. Shake
Tilt the head back slightly and exhale
4.
making a seal
5. Press down on MDI to release the medicine
6.
7. Hold the breath for 10 seconds
8. Exhale slowly through pursed lips.

Medications
•

• Prednisone (p.o.) Solumedrol (methylprednisolone) (IV)

•
• Symbicort –(budesonide/formoterol) – not used with acute episodes
• Brethine (terbutaline)– also used in labor (premature contractions)
• Intal (cromlyn Na+) – long acting – prevents histamine release from the mast cells
• Singular (montelukast) – daily, usually at night
•

Pulmonary Embolism
• Thrombus – stationary • Life threatening
• • Result of thrombophlebitis/ DVT
Signs & Symptoms: • Dyspnea • Anxious
• Pleuritic chest pain • Cough
• Tachycardia • Restlessness
• Tachypnea • Hemoptysis
Risks • Prolonged bedrest • Pregnancy
• Surgery • Obesity
• Long plane rides • CHF
Diagnosis: •
• VQ scan: looks at lungs when breathing in (measures if lungs are
being perfused)
•
out the diagnosis
• PT & PTT
• EKG
• ABG
•
Nursing Intervention: • Bedrest
• O2
•
• Heparin or Coumadin (warfarin)
• Thrombolitic drugs (streptokinase)
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TB (Tuberculosis)
•
• Spread by droplet nuclei
• Lodges high in lungs (highly O2 concentrated)

Risks: • Malnutrition • Alcoholics

• Large crowded living conditions • IV drug users
• Poor socioeconomic status • Immune dysfunction
Signs & Symptoms: • Can be asymptomatic • Anorexia
• Dyspnea • Fatigue/malaise
• Low grade temperature • Pallor
• Pleuritic chest pain • Weight loss
• Night sweats
• Chronic productive cough– purulent sputum / hemoptysis
Diagnosis: •
•
isolation
•

(Note: 15mm or more is positive in patients without risk factors older than
4 years of age, 10 mm is positive in patients age 4 or less)
> 5 mm induration = + in HIV

bacteria in the blood. It cannot determine is person has latent or active

Note : + PPD does not mean automatic isolation- further assessment needed
Nursing Interventions: •
• Airborne precautions – N 95 mask
• Teach to cover mouth and nose when coughing and sneezing
• Dispose contaminated tissue into paper bag – good hand washing
• Mask patient for transport
•
• O2 as prescribed
Medication: •
Dilantin (phenytoin)– increased risk of toxicity. Avoid foods with Tyramine
• B6 Pyridoxine: prescribed with INH to prevent peripheral neuropathy
•
• Streptomycin S.E. 8th cranial nerve damage 77
• *Drugs may be given in combination to decrease the risk of resistance
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• • Dry nonproductive cough

• •
• Dyspnea on exertion

Treatment: • Monitor breath sounds, treat underlying cause

• Antibiotics
•

Sleep Apnea
• Characterized by episodic upper airway obstruction that occurs at night
Risks: • Obesity • Sleeping pills
• ETOH •
Signs & Symptoms: • Loud snoring
• Daytime drowsiness with delayed reaction time
Diagnosis: • Sleep Study
Treatment: • CPAP (continuous positive airway pressure)
• Dental appliances
• Anatomical surgery
• Weight loss may be helpful
• Children – tonsillectomy
Complication: • Cor Pulmonale

Common Respiratory Medications

Bronchodilators
1. Adrenergic Bronchodilators: relaxes and opens the airway

A. Epinephrine: fast onset within 5 minutes lasts up to 4 hours given sub q. in an emergency. Drug may
be repeated 20 minutes after initial dose.
Epi pen:

(penicillin, sulfa drugs, anesthetics), and insect stings.

C. Proventil,Ventolin (albuterol): given via MDI or nebulizer. Teach client use as rescue medication in
acute bronchospasm. Use with caution in patients with cardiovascular disease and MAO inhibitors.
S.E. tachycardia, palpitations, headache

D. Serevent (salmeterol): long acting, given daily BID even if not symptomatic, do not use in acute

E. Brethine (terbutaline): long acting agent

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2. Xanthine Bronchodilators
A. Theophylline: prevention and treatment of bronchospasm.
• Aminophylline - I.V.
• Theo-Dur (theophylline) P.O.

* Not indicated for the initial treatment of acute episodes of bronchospasm

3. Leukotriene Inhibitors
• Singular (montelukast sodium): give at night
• Accolate (zafrilucast) : BID

4. Steroids:

Nursing Implications for client’s taking respiratory medications

Client Assessment
1.Vital signs, note respiratory rate, depth, and character, skin, color, s/s of hypoxia (restlessness is an
early sign, also called thrashing), ABG, auscultate lungs noting adventitious breath sounds.

2.Assess precipitating and relieving factors of bronchospasm, note frequency and severity of attacks,

sputum, exercise intolerance, medications, drug therapy.

B. Nursing Interventions
1. Accurate administration of medication – 10 rights (see page 121).
2.

• Cardiac: arrhythmias, palpitations, tachycardia,

• CNS: agitation, insomnia, headache, restlessness, seizures, tremors
• GI: anorexia, diarrhea, nausea and vomiting
• Respiratory: cough
4.
5. Encourage deep breathing and coughing, postural drainage, chest PT (as ordered).
6. Teach client to avoid known triggers of bronchospasm.
7.
8.

**Do not give beta blockers to asthmatics ie. Inderal (propanolol), Corgard (nadolol).
Beta Blockers cause hypotension and bradycardia which increases oxygen consumption.
ASA, NSAID’s, and Ace Inhibitors should also be avoided with asthma.

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VIII. Fluid and Electrolyte Balance

A. Physiology review

a. Intracellular
b. Extracellular
1. Interstitial
2. Intravascular

dehydration = hypovolemia
Treat the underlying cause. Strict I&O, IVF replacement, antipyretics, antidiarrheal agents

C. Normal electrolyte values (may show slight variances by institution)

Na+
Ca++
Cl
HCO
K+
PO4
Mg+

C. Venous Access Devices- Peripheral lines, PICC, Epidural, Tunneled, Implanted

Peripheral lines: device used to access veins, the tip is distal to a central vein.
•
•
weeks).
•

Central Venous Access Devices- placed by MD into jugular or subclavian vein above the heart.
•
•
• May be used for IVF & blood, TPN, monitoring CVP, administering medications & chemotherapy,
obtaining blood samples, hemodialysis or for long term use when peripheral veins are inaccessible.

Complications
• Treatment: warm or cold compresses, elevate the limb.
• Treatment: warm, moist compresses, antibiotics, eliminate cause.
• Extra

Treatment: stop the infusion, use syringe to aspirate remaining drug in the line, inject antidote into
s.c. tissue if appropriatee, remove the catheter (as ordered), notify MD, elevate arm, ice or warm

2. 80

D. Signs and symptoms of abnormal values
Imbalance and Causes Signs and Symptoms
HYPONATREMIA • Lethargy
Loss of Sodium • Confusion
• • Anxiety
• Sweating • Muscle twitching
• Use of diuretics • Abdominal cramps
Gain of Water • Anorexia
• Drinking water • Nausea, vomiting
• Excess IV D5W (dextrose in water) • Headache
• SIADH • Seizures, coma
HYPERNATREMIA • Thirst
• Dry, sticky mucous
• Insensible water loss membranes
• (Hyperventilation or fever) • Tongue red, dry, swollen
• Diarrhea • Weakness
Water deprivation • Postural hypotension
• Dyspnea
• IV administration of saline solutions Severe hypernatremia:
• Excessive use of table salt • Fatigue, restlessness
• Diabetes Insipidus • Decreasing LOC
• Heat Stoke • Disorientation
• Convulsions
HYPOCALCEMIA • Numbness and tingling of
• Surgical removal of the parathyroid the extremities and around
glands the mouth
Conditions such as: • Muscle tremors, cramps;
• Hypoparathyroidism untreated can progress to
• Acute pancreatitis tetany and convulsions
• Hyperphosphatemia • Cardiac dysrhythmias:
• Thyroid cancer decreased cardiac output
• Inadequate Vitamin D intake • Positive Trousseau’s sign
• Malabsorption • Positive Chvostek’s sign
• Hypomagnesemia • Confusion
• Alkalosis • Anxiety
• Sepsis
• Alcohol abuse
HYPERCALCEMIA • Lethargy
• Prolonged immobilization • Weakness
Condition such as: • Depressed deep tendon
• Hyperparathyroidism
• Malignancy of the bone • Anorexia
• Nausea, vomiting
• Constipation
• Polyuria
• Hypercalciuria
• Flank Pain secondary to
urinary calculi
• Dysrhythmas, possible
heart block
• Pathological fractures
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Nursing Interventions
• Assess signs and symptoms
• Monitor intake and output
• Monitor lab results
• Assess client closely for injury risk
• Institute safety precautions
•
table salt, bacon, ham, processed cheese)
• Limit water intake as indicated.
• Monitor intake and output
• Monitor mental status
(e.g., restlessness disorientation)
• Monitor lab results
•
• Restrict intake of salt and foods high in
sodium
• Closely monitor respiratory and
cardiovascular status
• Initiate safety precautions to protect a
confused client
• Administer oral or parental calcium
supplements as prescribed
• During IV administrations closely monitor
cardiac status and ECG
• Increase client movement and exercise
•
maintain dilute urine
• Teach clients to limit intake of food and
•
constipation
• Protect a confused client; monitor for
term hypercalcemia
•
prune or cranberry juice) to counteract
deposit of calcium salt in the urine.
• Assess clients receiving digitalis
for digitalis toxicity. Hypercalcemia
increases the risk of toxicity
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Imbalance and Causes Signs and Symptoms Nursing Interventions

HYPOKALEMIA
Loss of potassium
• Vomiting and gastric
suction
• Diarrhea
• Heavy perspiration
• • Decreased bowel sounds
drugs (e.g., diuretics)
• Poor intake of potassium
(as with debilitated clients,
alcoholics, anorexia
nervosa)
HYPERKALEMIA
Decreased potassium
• Renal failure
• Potassium sparing
diuretics
• High Potassium intake
• Excessive use of salt
substitutes
• Potassium shift as in burns
HYPOMAGNESEMIA
• Excessive loss from the
gastrointestinal tract
• Nasogastric suction
• • Cardiac arrhythmias
• • Tetany
drugs (e.g., diuretics,
aminoglycoside antibiotics)
• Muscle weakness • Monitor heart rate and rhythm
• Leg cramps • Monitor clients receiving digoxin closely,
• Fatigue because hypokalemia increases risk of
• Lethargy digitalis toxicity.
Anorexia • Give oral potassium as prescribed with food
• Nausea, Vomiting
• Administer IV potassium solutions at a
• Decreased bowel motility
• administer undiluted potassium IV.
• IV potassium: monitor for pain and
•
• ABGs may show Alkalosis
• clients how to prevent excessive loss of
Depression on ECG ; prominent K+ (e.g. through abuse of diuretics and
U waves laxatives).
• Diarrhea • Closely monitor cardiac status and ECG
• Irritability • Administer Kayexalate (sodium
• Confusion polystyrene), diuretics and other
• Cardiac dysrhythmias or arrest medications such as glucose and insulin as
• prescribed.
• Hold potassium supplements and K+ sparing
• Paresthesias and numbness in diuretics
extremities • Monitor serum K+ levels carefully; a rapid
• Peaked T wave, widened QRS drop may occur as potassium shifts into the
on ECG cells
• Teach clients to avoid foods high in
potassium and salt substitutes.
• Neuromuscular irritability with • Assess clients receiving digitalis for digitalis
tremors toxicity. Hypomagnesemia increases the
• risk for toxicity.
• Convulsions • Protect patient from injury, seizure
precautions
• Psychosis
• Positive Chvostek’s sign
• Positive Trousseau’s sign

HYPERMAGNESEMIA • Neuromuscular depression; • Initiate safety precautions

Conditions such as:
• Renal impairment
• DKA
• Dehydration
• Hypothyroidism
• hypotension, bradycardia
• Use of antacids/laxatives
containing magnesium
cardiac muscle depression
(arrhythmia, asytole)
• Weakness
• Nausea, vomiting
• CNS depression: lethargy,
• Monitor B/P, pulse and respirations closely
• Administer Calcium Gluconate as
prescribed
• Teach patients with renal disorders to avoid
preparations containing Mg+

Wilson’s Disease - is a rear inherited disorder that causes too much copper to accumulate in the
liver, brain and other vital organs.
S/S: fatigue, jaundice, easy bruising, edema of the legs, ascites, problems with speech, swallowing or
physical coordination

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Imbalance and Causes Signs and Symptoms Nursing Interventions

METABOLIC ACIDOSIS pH < 7.35 NaHCO3 < 22 • Monitor LOC
• Renal failure • Lethargy • Weakness • Strict intake and output
• Diabetes Mellitus • Confusion • Nausea, vomiting • Administer IV sodium bicarbonate
• Loss of bicarbonate i.e. diarrhea • Headache • Hyperkalemia as prescribed.
• Excessive infusion of chloride • Treat underlying problem
•
(rapid, deep respirations)
• METABOLIC ALKALOSIS • pH > 7.45 NaHCO3 > 26 • Monitor intake and output
• • Decreased respiratory rate and • Monitor vital signs, especially
GI tract depth respiration and LOC
• Vomiting • Dizziness •
Gastric suction • Hypokalemia • Treat underlying problem
• Excessive use of potassium • Circumoral paresthesias
wasting diuretics • Numbness and tingling of the
• Excessive adrenal corticoid extremities
hormone • Tetany
• Cushing's syndrome
• Hyperaldosteronism
• Excessive bicarbonate intake from

RESPIRATORY ACIDOSIS pH < 7.35 PaCO2 > 45 • Monitor respiratory status and lung
• Acute lung conditions that • Increased pulse sounds
• Increased respiratory rate • Prepare for mechanical ventilation
• Pneumonia • Headache as necessary
• Acute pulmonary edema • Dizziness • Administer pulmonary therapy
• Aspiration of foreign body • Confusion measures such as inhalation
• • Decreased LOC therapy, bronchodilators and
• Chronic lung disease (e.g. asthma, • Convulsions antibiotics as prescribed
• • Percussion and postural drainage
• Overdose of narcotics or sedatives • Hyperkalemia (chest PT)
that depress respiratory rate and Chronic: •
depth • Weakness • Monitor vital signs and ABGs
• • Headache • Administer narcotic antagonists
respiratory center (Naloxone) as indicated
•
RESPIRATORY ALKALOSIS pH > 7.45 PaCO2 < 35 • Monitor vital signs and ABGs
Hyperventilation due to: • Complaints of shortness of breath, • Assist client to breathe more slowly
• Extreme anxiety chest tightness • Help client breathe in a paper bag
• Elevated body temperature/fever • or apply a rebreather mask (to
• Over ventilation with a mechanical paresthesias inhale CO2)
ventilator • Numbness and tingling of the
• Hypoxia extremities
• Salicylate overdose •
• Tremulousness
• Blurred vision
• Hypokalemia

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IX. The Client with Pain

A. Pathophysiology of pain
Most pain caused by damage to nerves or tissue. Nerve signal travels up the spinal cord to
the brain.

B. Acute vs. chronic pain

• Acute pain lasts from one second to 6 months serves as a warning signal
• Chronic pain > 6 months • • • serves no useful purpose

C. Assessment of pain
• assess the P.Q.R.S.T of pain (provoke, quality, radiation, severity, time)

• anxiety level

D. Pharmacological approaches
• Nonnarcotic analgesics used for mild to moderate pain, temperature reduction and treat

1. Salicylates:
• Aspirin

Toxicity: tinnitus, hyperventilation, vomiting, double vision

2. Acetaminophen

• • • Antidote• • Mucomyst (acetylcysteine)

• Motrin (ibuprofen)
• Naprosyn (naproxen), Anaprox (naproxen sodium)
• Indocin (indomethacin)
• Celebrex (celecoxib)

drowsiness
• Teach: avoid operating machinery, hold before surgery

Remember:
deterioration!
Look for signs of an exacerbation in client’s current condition!

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• Narcotic analgesics: used for moderate to severe pain (acute or chronic) and sedation
• Roxanol (morphine) • Demerol (meperidine) • Dilaudid (hydromorphone)

• Antidote: Naloxone

•
Has own analgesic properties:
• Vistaril, Atarax (hydroxyzine)

Duragesic (fentanyl): adjuvant to anesthesia

• Teach may cause drowsiness or fatigue • Avoid hazardous activities
• Avoidance of heat from fever or environment
• May increase release resulting in toxicity
• NO: sunbathing, hot tubs, saunas, heating pads, or electric blankets

• Patient Controlled Analgesia (PCA): allows the patient to control their own narcotic
analgesic.
Drug of choice: Morphine
• Goal is to achieve more steady state of analgesia compared to prn medications.

• Nursing Management:

• Peripheral Nerve Catheter: is used to relieve pain at the site of surgery. Catheter is placed
under the skin near the nerves to cause numbness at the surgical site. It provides

E. Non pharmacological approaches

• TENS (transcutaneous electrical nerve stimulation): battery operated unit that sends a
mild electrical current along the skin, blocking pain sensation

Nursing: • Do not place electrodes over incision site, broken skin, or eyes
• Contraindicated in client with a pacemaker
• Provide skin care daily—wash skin with soap and water daily, air dry
•

•
• Teach relaxation techniques i.e. rhythmic breathing, guided imagery, music therapy,
biofeedback
• Positioning of body parts, immobilization, heat and cold application; massage

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X. The Client with Cancer

A. Physiology of cancer

• Cancer occurs when cells become abnormal and grow without control

B. Prevention and early detection

Cancer’s seven warning signs Cancer’s seven safeguards
Change in bowel or bladder habits Lung:
A sore that does not heal Colorectum: Have a proctoscopic exam as part of a
Unusual bleeding or discharge regular checkup after age 40.
Thickening or lump in breast or elsewhere Breast: Practice monthly breast self exam.
I Uterus: Have a Pap test as part of a regular checkup.
Obvious change in wart or mole Skin: Avoid exposure to the sun.
Nagging cough or hoarseness Oral: Have a regular mouth exam by MD or dentist
Complete body: have an overall physical yearly or at

C. Tumors

Benign Tumors: non cancerous, do not spread to other parts of body

Malignant Tumors: can metastasize and are life threatening

D. Guidelines for cancer related screening

TEST OR EXAM SEX AGE (YEARS) RECOMMENDATION

> 18; under 18 If

Papanicolaou test Female years after sexual activity begins.
sexually active
No later than age 21
Female Over 18 Yearly
Monthly
Female Over 20

Female
Over 40 Yearly
One baseline mammogram
Mammogram Female

Stool guaiac slide test Male & Female Over 50 Yearly

Male & Female Over 40 Yearly

Male & Female Over 50

After 2 negative, 1 year apart

Male Over 15 Perform after warm shower

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E. Diet/nutritional considerations
ANTI CANCER DIET HIGH ANTIOXIDANTS
Diet
• Low fat • Berries
Some evidence suggests that the development • Apricots
•
of colorectal cancer may be associated with a • Prunes
• Whole grains
diet that is high in fat and calories. • Cereals
• Raw fruits
• High calcium • Vegetables
• Nuts
• Raw vegetables
F. Common types • Seeds
• Clove
LEUKEMIA • Oregano
• ALL (Acute Lymphocytic Leukemia) • Cinnamon
• Most common form of childhood cancer
•
• Increased risk of infection (increased immature

• Increased risk for bleeding (decreased platelets)

Risk Factors:
Smoking, viruses, chemicals, radiation
Signs/Symptoms:
Fever, bruise easily, generalized weakness, bone pain
Treatment :
Chemotherapy, radiation therapy

HODGKIN’S DISEASE
Malignant neoplasm of lymphoid with a proliferation of
lymphocytes
Cause: unknown – prevalent in adolescents (males)
Risk Factors:
Epstein Barr virus, HIV, chemicals, radiation
* There is no link for Hodgkins to smoking, ETOH, diet or exercise
Major symptom: enlarged nodes in lower cervical region; fever, pruritis, night sweats
Diagnosis: presence of Reed Sternberg cells in the blood

NON HODGKIN’S LYMPHOMA

Risk Factors:
Gender (men), Epstein Barr virus, HIV, Hepatitis C, autoimmune disease, chemicals, radiation
Treatment: chemotherapy, radiation and surgery

WILM’S TUMOR
Malignant tumor of the Kidney; occurs in childhood and older white men
Signs/ symptoms: blood in urine, parent reports presence of abdominal mass
Teach
Treatment: nephrectomy; chemotherapy and radiation

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BREAST CANCER
Risk factors:
• Family history • Early menarche
• ETOH use • Advanced age
• Nulliparity • Late menopause
• Obesity
• Personal history of breast cancer
• Use of estrogen & progesterone
• First child late in life
• High socioeconomic status

Treatment:
• Chemotherapy and Radiation
• Surgery

Monitor PT/INR. Separate antacids by 2 hours)

(also used to prevent loss of appetite and severe weight loss with AIDS patients)

LUNG CANCER
Primary risk factors:
• Cigarette smoking
• Exposure to asbestos or other carcinogens
Signs & Symptoms:
• Chronic cough
• SOB
• Hemoptysis
• Weight loss
Diagnosis: Biopsy, sputum cytology, PET scan
Treatment:
• Chemotherapy, radiation, surgery

BLADDER CANCER
Risk factors:
• Smoking
• Diet (high fat, fried meats)
• Exposure to rubber
• Gender (older white males)
• Living in urban areas
Signs/Symptoms:
• Low back pain
• Dysuria
• Polyuria
• Hematuria
Treatment:
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COLON CANCER

Risk Factors

Signs & Symptoms:

• Bowel changes, abdominal pain • Weight loss
• Pallor • Assess stool for occult blood

during procedure.
Treatment: chemotherapy, radiation, surgery

SKIN CANCER
The most common form of cancer in the U.S.
Risk Factors:
• Sun exposure • Fair skin
• Heredity • Age over 50
Teach:
• Change in color, size, itching
• Suspicious skin or Nevi (mole) changes need further evaluation
• Avoid the sun and tanning salons
• Mole assessment: Asymmetry, Border, Color, Diameter, Evolution
Treatment: chemotherapy, radiation, surgery

MULTIPLE MYELOMA
• Malignant overgrowth of plasma cells and malignant tumor growth in bone
• Interferes with RBC, WBC, and platelet production
• Common in older men
Subjective: • bone pain • low back pain • progressive weakness
Objective:
•
• positive Bence Jones protein in blood & urine
• precipitation of protein, calcium, and uric acid in the urine
Nursing Diagnoses: Pain, risk for injury
Implementation:
• Pain control
•
• High nutrient dense foods (boost, nutriment)
• Immune stimulant nutrients (selenium, vitamin A, C, E, protein)
Treatment: chemotherapy, radiation, steriods, stem cell transplantation

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G. Therapeutic techniques:

• Bone marrow transplant:

• Surgery
• Internal radiation: also referred to as brachy therapy

Females: • Flex and extend legs to promote circulation • Absolute bed rest
• Deep breathing and coughing exercises • Head of bed 15 degrees
• Low residue diet (decrease bowel movements) • Elastic stockings
• Catheter (keep bladder empty) • Avoid pericare
• Report nausea, vomiting, elevated temperature • Report profuse discharge
• Opioids, muscle relaxants, sedatives may be used • Keep items in easy reach

• Client returns home after procedure

• Avoid contact with pregnant women and infants for 2 months
• Strain urine for seeds
• Instruct on condom use with sexual intercourse for 2 weeks after implantation to
catch seeds that may pass through urethra

• also referred to as tele therapy

• Avoid pressure, trauma or infection to site

• Teach to avoid exposure to heat, cold & sunlight

• Chemotherapy: Drugs used to kill cancer cells, normal cells may be damaged

• Nadir: lowest point

baking soda or peroxide.

Tumor lysis syndrome:

Complication of cancer treatment, metabolic disturbances caused by the breakdown products of dying cancer cells
Results in • Hyperkalemia
• Hyperphosphatemia,
• Increased uric acid in blood and urine,
• Hypocalcemia – leads to acute uric acid nephropathy and acute renal failure

Superior Vena Cava Syndrome

Results from obstruction of the SVC by a tumor ie hodgkins, non hodgkins or lymphoma
Signs and symptoms: • Facial edema & periorbital edema
• Distended veins in neck & chest, headaches, seizures
•
• Treatment: radiation and chemotherapy

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XI. Metabolic and Endocrine Function and Disorders

A. Pathophysiology

Endocrine System Imbalances

Gland Hyposecretion Hypersecretion
Hyperpituitarism
Acromegaly
Gigantism
Pituitary
Hypoprolactinemia
Diabetes insipidus Hyperprolactinemia
SIADH (syndrome of inappropriate ADH secretion)
Hypothyroidism Hyperthyroidism
Thyroid Cretinism Graves disease
Myxedema
Parathyroid Hypoparathyroidism Hyperparathyroidism

Adrenal medulla Pheochromocytoma

Pancreas Diabetes Mellitus Hypoglycemia

B. Disorders
1. Pituitary Gland Disorders

Anterior Pituitary
a. Growth hormone excess: • Acromegaly (adult) • Gigantism (child)
Diagnosis:
Treatment: • Hypophysectomy: monitor ICP & CSF drainage
• Complication: increased ICP, Bleeding, meningitis
• Patient will need glucocorticoid replacement for life

Treatment: • Synthetic hormone injections • Limb lengthening surgery

Complications: • Developmental delay • Spinal pressure
• Crowded teeth • Kyphosis or lordosis

Posterior Pituitary
c. Anti Diuretic Hormone (ADH): secreted by posterior pituitary
• SIADH: ADH Excess
(Syndrome of inappropriate antidiuretic hormone)
Signs/ Symptoms: • Headache • Fatigue • Hyponatremia
• Decreased urine output

surgery

Signs/ Symptoms:
RX: Replace ADH: • Vasopressin (petressin) • Desmopressin (DDAVP) - intranasally
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2. Thyroid Disorders Normal thyroid function test levels:

Hyperthyroidism: • Graves disease
• Exopthalmus
• Goiter
• Hyperthroidism

Hypothyroidism: • Myxedema (adult)

• Cretinism (infant)

HYPOTHYROIDISM HYPERTHYROIDISM

O = Slow / COLD Hyper = Fast / HOT

Low TSH High High TSH Low
Weight increase (metabolism slow) Weight loss (metabolism fast)
Constipation Diarrhea
Slurred speech Insomnia
Sluggish Mood swings
Depression Palpitation
Bradycardia Tachycardia
Cold Hot
Brittle nails, hair loss, menstrual disturbances Scanty menstruation
(more frequent/lasts longer)
Dry skin Complication: Thyroid Storm = emergency
Treatment: Treatment:
•
(hold for pulse greater than 110)
Teach: it takes 1 week to work, thyroid hormone
take early in the morning • SSKI (saturated solution of potassium iodide)
•

(requires 72 hours isolation)

• Thyroidectomy
Post op: • Trache set
Myxedema Coma: Decreased cardiac output
• Oxygen
due to bradycardia and decreased stroke
• Suction & Ca+ Gluconate at bedside
volume
Thyroid Storm: control temp, IVF, electrolyte
treat hypothermia replacement, hydrocortisone, propranolol
(blocks the action of thyroid hormone on the cells)

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Hyperthyroidism (Graves Disease)

Hair loss Receding Hairline

Intolerance to heat Fine/ straight hair
Intolerance to cold
Dull-blank expression Bulging eyes Facial blushing
Muscle aches & weakness Warm skin
Facial & eyelid Enlarged Thyroid
Lethargy edema Weight loss
Goiter
Anorexia Thick tongue- Muscle wasting Systolic B/P
slow speech
Constipation Diarrhea
Dry skin Tachycardia
Extreme fatigue (coarse & scaly)
Tremors Restless, fatigue
Apathy Brittle nails & hair
Menstrual changes Localized edema
Late Clinical Manifestations (Amenorrhea)
Subnormal Temp / Bradycardia / Weight Gain
Cardiac Complications

3. Parathyroid Disorders: controls calcium and phosphate metabolism

a. Hyperparathyroidism

• Hypercalcemia
Signs/ Symptoms: • GI disturbance • Constipation • Bone pain • Renal stones • Joint pain
Rx: Observation, IV Fluids or surgery

b. Hypoparathyroidism:
• Hyposecretion of the parathyroid gland • Hypocalcemia

Signs/ Symptoms:
• Muscle twitching • Brittle nails • Paresthesias
Rx: Replace calcium and vitamin D

4. Adrenal disorders
a. Pheochromocytoma tumor of adrenal medulla (inner portion) causes hypersecretion
• Severe hypertension
• Headache
• Hyperglycemia
• Hyperhydrosis
• Hypermetabolism

Treatment: • Regitime (phentolamine) at bedside for blood pressure management

• Nipride (nitroprusside)
• Surgical removal of tumor or gland

• Promote rest

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ADDISON’S DISEASE CUSHING’S DISEASE

Adnenocorticol (ACTH excess)

• Bronze skin discoloration • Mood swings • Headache

• Muscle weakness • Hypertension • Weight gain
• Lethargy, fatigue
SIGNS • Dizziness • Easy bruising • Purple striae
• Vomiting and diarrhea • Metabolic alkalosis
• Weight loss • Pathological fractures
• GI disturbance • Pendulous abdomen

Blood pressure Temperature WBC (eosinophils)

DECREASED Sodium Chloride HCT Potassium*
Hypoglycemia Magnesium

Facial hair in women (hirsuitism)

Potassium*
Gynecomastia
Magnesium
INCREASED Glucose
Leukocytosis
Calcium
Sodium

• Quiet environment • Provide comfort

• Increase sodium in diet • Decrease sodium in diet
• Decrease potassium in diet • Increase potassium in diet
• Daily weight • Monitor glucose
• Observe mood changes
Observe for signs of Addisonian • Intake and output
Crisis: • Increase protein
• Severe hypotension • Decrease calories
TREATMENT
• Shock • Surgery
• Weakness • Radiation
• Vasomotor collapse which may lead
to death Medications:
• Treat with bed rest and IV Cortisone • Cytadren (aminoglutethimide)
• Teach patient to carry injectable • Hormone replacement
cortisone at all times and wear medic
alert bracelet

RELATED PHARMACOLOGY

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Fill in the blanks with the most appropriate response based on information related to
common Endocrine Disorders:
ACTH excess_________________________________
Hypothyroidism in an infant______________________
Treatment for hypothyroidism_____________________
ADH Excess___________________________________

Hypersecretion of the adrenal medulla__________________

Constipation, cold, bradycardia_______________________

Hunger, confusion, perspiration _______________________

Hyposecretion of the pancreas___________________________

_________________
Decreased sodium, weight loss, increased potassium, bronze skin color ___________________

__________________________________________________________

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XII. Gastrointestinal Function and Disorders

A. Review of anatomy and physiology
B. Diagnostic tests • purpose, description, nursing implications

1. Radiological exams
2. Barium enema: • Give a laxative or enema post procedure
• Expect clay colored stool for up to 72 hours

4. Sigmoidoscopy: administer an enema before the procedure

5. ERCP (Endoscopic retrograde cholangiopancreatography)
• Fluroscopy & X• ray used to diagnose problems in the liver,
gallbladder, bile ducts, and pancreas

C. Common Problems related to GI tract

1. Nausea and vomiting

feces

D. Disorders
1. Hiatal hernia: client may complain of dysphagia and heartburn
Nursing Interventions: small frequent meals, antacids, elevate the
HOB. Remain in upright position for 2 hours after meals
2. Stomatitis:
3. Gastritis:
4. GERD:

5. Peptic Ulcers: Risk factors: Stress, smoking, ETOH

Gastric Ulcers Duodenal Ulcers
50 years old and older
Malnourished

Eating may increase the pain Food may decrease the pain
Vomiting common Vomiting uncommon
Weight Loss Weight gain

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6. Ulcerative colitis:
• Severe diarrhea
•
• Predisposition to colon cancer
•

Teach: • Avoid carbonated beverages

• Diet: low residue, low fat, milk free, high protein

7. Regional enteritis (Crohn’s Disease):

•
•

Teach: • Diet: high calorie, high protein, high CHO, high vitamin, milk free, low fat

Possible treatment for ulcerative colitis and regional enteritis :

• TPN
• Colostomy (partial or total)
• Ileostomy
• Oral or rectal medications: • : Humira (adalimumab), Asacol, Pentasa

• Steroids: Prednisone
• Immune suppressors: 6 mercaptopurine
• Antibiotics: Ampicillin, cephalosporins and or Flagyl (metronidazole)
• Antidiarrheals: Immodium (loperamide), Codeine

8. Hepatitis:
Hepatitis A:
or incontinent.
Hepatitis B:
• First immunization at birth (check for yeast allergy before administering)

Hepatitis C:
to cirrhosis and liver cancer. Chronic infection leads to need for transplant.

Hepatitis D and Hepatitis G: Follows Hepatitis B

Hepatitis E: transmitted by fecally contaminated water in under developed areas
Risk factors: IVDA, hemodialysis, transfusions, health care workers, mutiple sex partners, tatoos and body
piercings
Teach: Use of condoms, do not share needles, do not donate blood, avoid Tylenol (acetaminophen)

9. Salmonellosis: •B
• Incubation 8 – 48 hours after ingestion of contaminated food
Signs and Symptoms: • Fever • Nausea • Vomiting
• Bloody diarrhea • Abdominal cramping
Stool culture

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10. Cirrhosis: (scarring of the liver) Caused by many forms of liver disease.
•
• Can lead to Portal hypertension (high blood pressure in the portal vein)

Signs and Symptoms: • Changes in mental status (hepatic encephalopathy)

• Ascites • Splenomegaly • Spider hemangiomas
• Pancytopenia • Jaundice • Itching
•
Pertinent Lab Values for Cirrhosis:
Increased: • Alkaline Phosphatase • Sodium • AST • ALT
• protein in diet

Decreased: • Albumin • Potassium • Cholesterol • Platelets

Nursing Interventions:
•
•
•
• Encourage rest
•
• Daily weights
• Monitor intake and output
• Diet: High calorie, low sodium, low fat, low protein diet (helps to control ammonia level)
• Monitor for bleeding
• TX for portal HTN = Betablockers & Nitrates

11. Appendicitis: Surgery

12. Peritonitis: Antibiotic therapy

13. Diverticulosis: • Outpouching of the colon may be caused by constipation

• Diverticulitis
•

14. Gastric Resection:

• Billroth I ( gastroduodenostomy)
• Billroth II (gastrojejunostomy)
• Total Gastrectomy: • Vitamin B12 replacement necessary for life • Will cause pernicious anemia
• To avoid Dumping syndrome teach client: not to drink with meals; lie down after eating

• Weakness • Fainting • Tachycardia • Diaphoresis

•P

Teach: • Diet: High protein, high fat, low carbohydrate

• Increase foods with pectin (i.e. peaches, plums, apples)
• Avoid foods high in sugar and sodium

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15. Ostomy: surgical opening made through the abdomen with a portion of the ileum or colon brought though
the opening to allow temporary or permanent excretion of wastes

Indications:
Post op: assess stoma, it should be red – pink, with edema immediately post op
Enterostomal therapist: nurse with specialized training in ostomy care

Ileostomy Colostomy
Small bowel, Liquid stool; No control Large bowel
Brooke: conventional ileostomy
Client may gain control by diet and irrigation
of skin care; risk for peritonitis

Diet considerations with an ostomy:

Bulk forming foods: to decrease diarrhea with an ostomy
• Fish • Eggs •Yogurt • Cooked tomato • Cottage cheese • Banana • Beets • Oranges • Natural cheese
Avoid odor producing foods:
• Garlic • Broccoli • Onions • Asparagus • Cabbage • Eggs • Fish
Gas forming foods:
• Beans • Cabbage • Onions • Beers • Cheese • Sprouts
Foods causing obstruction with an ileostomy:
• Corn • Popcorn • Nuts • Celery • Raisins • Raw vegetables

Irrigation:

16. Pancreatitis: Causes severe upper abdominal pain that may radiate to the back with N/V & fever.

Precipitating factors include:

• Smoking • Alcohol abuse • Hypercalcemia • History of liver or gallbladder disease

Signs and Symptoms: • Pain • GI distress • Decreased calcium levels

• Increased amylase lipase & bilirubin • Increased LFT’s • Leukocytosis • Hyperglycemia

Signs: • Cullens: discoloration in the periumbilical area

• Turners:

Treatment: Pain relief: Demerol (meperidine), NPO in acute phase, NGT for decompression
increase vitamin B, iron, berries;

17. Cholecystitis:
Caused by obstruction of bilary ducts by gallstones
Signs and Symptoms: • Pain in the right upper quadrant
• Increased pain with a deep breath in (Murphy’s Sign)
• Nausea • vomiting • abdominal distention • fat intolerance
Treatment: • Low fat diet
•
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XIII. Urinary Function and Disorders

A. Terminology

Uremia: full blown signs and symptoms of renal failure, decreased calcium, increased potassium

B. Pathophysiology

C. Causes and prevention of urological problems

Urinary stasis, urinary calculi, indwelling catheters, premature infants, poor toilet hygiene, wet bathing suits,
perfumed toilet paper

D. Diagnostic tests and procedures: purpose, description, nursing interventions

• Urinalysis • Fractional urine • Urine culture and sensitivity
• Urine osmolarity • BUN/Creatinine Levels • Radiological studies
• Cystogram • Cystoretrography (CMG) • IVP (Intravenous Pyelography)
• Renal biopsy • Renal ultrasonography • CT (Computed axial tomography scan)
• Cystoscopy • Radionuclide renal scan • Electromyography of the perineal muscle
*Urinary output is one of the most valuable monitors during shock treatment. Hourly measurements of the
.
Hourly urine output should be: • Infant/child: 10 to 20 ml/hour
• Adult: 30 to 50 ml/hour
• Elderly: 20 to 30 ml/hour

E. Disorders

4. Acute glomerulonephritis: Follows Strep infection such as impetigo

Signs and Symptoms:
• Headache • Weight gain • Hypertension
• Hematuria • Oliguria • Proteinuria
• Increased BUN and creatinine • Children may have periorbital edema

Complications: • Hypertension • Encephalopathy • Heart failure • Pulmonary edema

Treatment: • Diuretics • Antihypertensives • Antibiotics • Bed rest • Low protein diet

5. Chronic glomerulonephritis:
• Increased potassium • Increased phosphorus • Decreased calcium
• Metabolic acidosis • Hypertension • Increased BUN
• Increased creatinine • Nocturia • Increased magnesium

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6. Nephrotic syndrome: usually follows another kidney disease;

Signs and Symptoms: • Proteinuria • Hypoalbuminemia • Severe edema
Treatment: • Antihypertensives, diuretics, high protein diet
• May need protective isolation when hospitalized

7. Nephrosclerosis: caused by hypertension, atherosclerosis, end stage renal disease treatment –

control hypertension

Treatment: IVF, IV antibiotics

10. Cancer of the bladder: common in smokers, living in urban areas – exposure to nitrates, dye, and rubber
Treatment: surgery – cystectomy & ileal conduit placement

12. Urinary incontinence: involuntary leakage of urine

Prevention: • Bladder exercises (kegels) • • Bladder training

• Bethanecol (urecholine) stimulates the bladder to empty

empty stomach

Treatment : • Daily weight

• Monitor intake and output
• Complete bed rest
• Restrict protein, sodium, potassium, high carbohydrate
• Good skin care
• Amphogel (aluminum hydroxide) – increases calcium by binding phosphorous

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14. Chronic renal failure: Most common causes are hypertesion and diabetes mellitus
• Stage I: Normal BUN and creatinine, asymptomatic
• Stage II: Increasing BUN and creatinine, polyuria, nocturia, polydipsia
• Stage III: Azotemia, hypertension, oliguria, metabolic acidosis, nausea, headaches
anemia, edema
• Stage IV: Uremia, uremic frost, electrolyte imbalances (hyperkalemia, hypernatremia,
hyperphosphatemia, hypermagnesemia, hypocalcemia)

Treatment: Diet

• Low potassium, magnesium, phosphate

Medications: Epoetin (epogen), Kayexalate (sodium polystyrene sulfonate), Amphogel (aluminum

hydroxide), antihypertensives, diuretics, iron supplements, calcium carbonate, vitamin D

F. Therapeutic regimen
1. Dialysis:
Hemo

Peritoneal
Bloody diasylate = Infection. Protein may be lost in diasylate

Complication: dialysis disequilibrium syndrome occurs shortly after beginning hemodialysis or

peritoneal dialysis. Caused by rapid correction of metabolic abnormailities.
Signs & Symptoms: nausea & vomiting, drowsiness, headache, disorientation, can progress to seizures,
coma and death.
Treatment is prevention with slow reduction of BUN.

beneath the skin. Catheter connects the port to a vein.

brought to the abdomen and collection bag attached.

• Oliguria
• Anuria
• Elevated temperature
• Flank tenderness

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XIV. Reproductive System Function and Disorders

A. Female anatomy and physiology
B. Menstrual dysfunction

•
D. Infertility

4. Smears and culture

5. Endometrial biopsy
6. Colposcopy: visualization of the cervix
7. Laparoscopy: visualization of the abdomen
8. Hysteroscopy: visualization of the uterus
9. Dilatation and curettage: opening and scraping of the cervix
10. Mammography: no lotion or deodorant before procedure

12. Therapeutic abortion

F. Nursing management
G. Disorders

Syphillis – Treponema Pallidum

No alcohol 24 hours before VDRL – may give a false reading; (RPR can also be done for screening)

• Stage 1 =

• Stage 2 = neg chancre, + rash on palms of hands & soles of feet

• Stage 3 =

Treatment – PCN – (Doxycycline in PCN allergic) - follow up VDRL at 6 & 12 months

Chlamydia: #1 STD in USA

•
• treat with Zithromax (azithromycin) PO or Vibramycin (doxycycline)
Gonorrhea:
•
• vaginal or penile discharge, genital itching, swollen and painful glands
• treat with single dose of Rocephin (ceftriaxone) IM and Zithromax (azithromycin) PO or
Doxycycline for 7 days
• Erythromycin in neonates eyes to prevent/treat Chlamydia/Gonorrhea

2. Vaginitis: caused by overgrowth or invasion of microorganisms

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3. Comparison of female cancers risk factors for cervical, ovarian and uterine cancer
Cervical Cancer Uterine Cancer Ovarian Cancer
Early: • No symptoms • Vague Gl disturbance
• Irregular bleeding painful urinating • Pelvic pressure
• Metrorrhagia
• Irregular bleeding • Bloating
(bleeding between periods)
• Pelvic pain or pressure • Increased abdominal girth
Late: Watery discharge after intercourse
Advanced: • Leg pain • Vaginal discharge • Leg pain
• Dysuria • Pelvic pain
• Rectal bleeding
Diagnosis Diagnosis Diagnosis
• Pap smear • Biopsy • CA 125 blood test • Biopsy
• Median age 61
Risks Risks Risks
• Multiple sex partners • Obesity • Obesity • History of DM • Nulliparity
• Sex under age 20 • Multiparas (increased estriol level) • Infertility
• Oral Contraceptives • Family hx • Estrogen without • Increased fat in the diet
• Early childbearing
progesterone • Talc in perineum
•*Smoking
• Trunkal obesity • Breast Cancer
• Low socioeconomic status
• HPV • • Obesity
• HIV infection • Gallbladder disease • Estrogen without progesterone
• • Nulliparity • Infertility • Family history of breast cancer,
(folate,beta carotene, Vitamin C) • Late menopause after age 52 ovarian cancer or Colorectal cancer
• Internal radiation: Absolute bed rest head of bed elevated15 degrees
• Deep breathing and coughing exercises: • Flex and extend legs to promote circulation • Elastic stockings
• Low residue diet (decrease bowel movements) • Report profuse discharge
• Indwelling catheter (keep urinary bladder empty) • Avoid pericare
• Report nausea, vomiting, elevated temperature
• Medications: Opoids, muscle relaxants, sedatives may be used

4. Endometriosis: dysmenorrhea, dyspareunia, pelvic pain

5. Uterine prolapse (cystocele, rectocele):

months by M.D.
may cause abnormal uterine bleeding. Tx: Myomectomy or
hysterectomy in severe cases.
7. Sterilization: tubal ligation
8. Breast disorders:

c. Paget’s disease of the breast: malignancy of the nipple and areola.

RX: same as breast cancer
9. Lymphedema: complication of mastectomy
10. Vaginal suppository: remain in lying position for at least 20 minutes
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H. Male anatomy and physiology

I. Causes and prevention of male reproductive disorders
J. Diagnostic tests and procedures: purpose, description, nursing intervention
1. Digital rectal exam: assesses for irregularity in size shape and texture of the prostate
2. Semen analysis

4. Transrectal ultrasound of the prostate

5. Biopsy of the prostate

K. Nursing management

M. Disorders
1. Testicular cancer (common in young men). Risk factors: cryptorchidism, white men, family history, HIV
2. Tumors

3. Benign prostatic hypertrophy: nocturia, frequency, hesitancy, erectile dysfunction

• Herbs: Ginseng, Saw Palmetto

Surgical interventions:

4. Prostate cancer: African American males at highest risk. Pain in the back, & lower leg, painful
ejaculation
TX: • Chemotherapy, Radiation, Surgery or Hormone therapy

pain.

5. Impotence: may be caused by medications, alcohol or drug use

• Avoid with nitrates • report sudden vision loss • report erections lasting > 4 hours

Teach correct application of condoms: Place the condom on the tip of the penis so it will unroll correctly (the condom
should unroll outwards). Lightly squeeze the tip of the condom (to remove air) as the condom is applied to the head
of the penis. Unroll the condom all the way down to the base of the penis. There should be at least 1.5 cm reservoir
between the condom and the head of the penis

6. Infertility:

7. Penile implant:

8. Orchitis:
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XV. Neurological Function and Disorders

Disorders of the Eye and Ear
A. Terminology
B. Pathophysiology
C. Causative factors/ prevention

4. Myelogram: inject air or dye to check spinal cord and vertebrae

• If a water soluble dye is used elevate the head of the bed for 8 hours to keep the dye from
irritating the meninges.

5. CT scan and MRI: instruct to lie still, no metals

6. Cerebral angiography

F. Neurological assessment: nursing management

2. Neuro check: Perform every hour following head injury

Most important check is LOC & mentation
Change suggests deterioration in condition

TIP: Safety is the minimization of risk factors that can cause injury or harm. When
prioritizing care, patient safety should be considered if the physiological integrity is
intact.

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G. Disorders Comparison of Common Neurological Disorders

Multiple Sclerosis
Pathophysiology: • Destruction of Myelin
•
•
Symptoms: • Primary: fatigue, depression, numbness, loss of balance, diplopia
Diagnosis: • MRI • Evoked potential studies (determine the extent of disease process)
Treatment: • Avonex • Beteseron • Copaxone • Rebif
• (Inferon beta1a) • (Glatiramer Acetate) •
• Avoid hot baths

Parkinson’s Disease
Pathophysiology: • Cause unknown
• May be linked to environment, head trauma, chronic antipsychotic use
• Decreased dopamine
• •
Symptoms: •
Diagnosis: •
Treatment: • Control symptoms; Safety is the priority
• Levodopa (sinemet) Use cautiously with glaucoma, avoid B6
• Symmetrel (amantidine)
• Eldepryl (seligiline)
•

Amytrophic Lateral Sclerosis: Lou Gehrig’s Disease

Pathophysiology: • Loss of motor neurons
• •
Symptoms: • Fatigue, progressive muscle weakness, cramps, twitching
Diagnosis: • Based on signs and symptoms • EMG • MRI
Treatment: • Dopamine Agonists: Requip (ropinirole), Mirapex (pramipexole), Riluzole (rilutek)
• Lioresal (baclofen), Dantrium (dantrolene): for muscle spasms
•
• Supportive Care

Guillain Barre’ (Respiratory assessment is essential)

Pathophysiology: • Autoimmune attack of peripheral nerve myelin
Predisposing event may be: • Respiratory infection
• G.I. Infection • Vaccination
• Surgery • Pregnancy
Symptoms: • Ascending paralysis
• Dyskinesia: inability to move voluntarily
Diagnosis: • Increased serum protein in CSF
•
Treatment: • Anticoagulants • IVIG: intravenous immunoglobulin G
•
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Alzheimer’s Disease
Pathophysiology: • Cause unknown
• Decreased acetylcholine
• Microscopic plaque found in brain tissue
•
• Prevent injury
Symptoms: •
movement, forgetfulness
Diagnosis: • Health history • Family history • EEG • MRI • CT Scan
Treatment: • Tacrine (cognex) •
• Hepatotoxic • Aricept (donepezil)
• Exelon (rivastigmine) • Namenda (memantine)
• Razadyne (galantamine) • Supportive care

Myasthenia Gravis
Pathophysiology: •
• Lack of acetylcholine
•
•
Symptoms: •

• Initial: diplopia
•
Diagnosis: • Positive tensilon test
• EMG
Treatment: •
• Prostigmin (neostigmine): improves communication between the nerves and
the muscles S/E: abdominal pain, diarrhea, nausea
• Plasmapheresis
• IVIG: intravenous immunoglobulin G
•

Huntington’s Disease
Pathophysiology: • Degeneration of neurons in certain areas of the brain
•
• Autosomal dominant
• Gene 50/50 chance
Symptoms: •
involuntary facial movements
•
Diagnosis: • CT
• MRI
• Blood test for the gene
Treatment: • No cure: control symptoms, Klonopin (clonazepam), Haldol (haloperidol),
•
• Speech therapy
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1. Increased intracranial pressure (ICP): an early sign is change in

• Monitor for Dilation of the pupil in one eye

• Increase in systolic blood pressure, bradycardia, wide pulse pressure (Cushings Triad)

120 = 40 pulse pressure (normal)

80
Mannitol (osmitrol) is used to decrease cerebral edema - monitor urine output hourly

2. Meningitis:
• Signs and Symptoms: lethargy, pale skin, fever, petechiae, nuchal rigidity, seizures, nausea,
vomiting, opisthotonos (spasm of the muscles causing backward arching of the head, neck, and

• Dx: blood culture, spinal tap, CT scan of head

• Rx: IV antibiotics
• Droplet precautions
Encephalitis: infection of the brain
• Rx: Symptom relief
4. TIA : temporary loss of neural function: warns of impending CVA
CVA: sudden death of brain cells due to lack of oxygen, blockage or rupture of an artery.
•
paralysis of one side of the body.
• Rx: antihypertensives, anticoagulants, anticholesterol agents, thrombolytics, antiplatelet agents,
• supplemental O2
5. Cerebral aneurysm/ arteriovenous malformation:
blood. RX: B/P control, surgery
6. safety is the priority
Generalized seizures involves both hemispheres of the brain
Partial seizures involve a single area of the brain
Status epilepticus -
Ativan (lorazepam)
•
• Topamax (topriamate) SE – dizziness, vision changes;
• Dilantin (phenytoin) – SE: discolors urine, gingival hyperplasia
•
SE: permanent peripheral vision loss; suicidal thoughts
7. Trigeminal neuralgia: 5th cranial nerve disorder
8. Bells Palsy 7th nerve paralysis.
9. Herniated disc (herniated nucleus pulposus): bulging of cushion between vertebrae of spine
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11. Spinal cord injury: Disrupts signal transmission to & from the brain. Log roll to stabilize the spine.

levels of T6 or higher at risk. Avoid stimulating the bladder, the bowels, or the skin.

pounding headache, nausea, decreased pulse, profuse

diaphoresis, severe hypertension
Treatment: elevate HOB, eliminate the cause, notify MD

Level of injury Functional ability Self care capability

Inability to control muscles of Unable to care for self; ventilator support

C 3 and above:
breathing essential; usually rapidly fatal

No upper extremity muscle Unable to care for self

C 4:
function; able to move neck

Neck movement, possible partial Can propel electric W/C. may be able to feed
C 5:
strength of shoulder & biceps self with powered devices

Can propel electric W/C. may be able to feed

Muscle function in C5 level,
C 6:
partial strength in wrist
Muscle function in C6 level,
C 7:
muscle power)
self with powered devices; can write and care
for self, can transfer from chair to bed
Can propel W/C independently, can dress
lower extremities with minimal assistance; can
drive car with hand controls

Muscle function in C7 level,

C 8: (nerve) Same as C7, activities easier
normal arm, hand weakness

Good upper extremity muscle

T 1 – 10: W/C ambulation: walk with long leg braces

Trunk and pelvis muscle function W/C not essential; may use crutches or canes
T 11 and below:
intact for ambulation

12. Basilar skull fracture:

Battle’s sign (bruising and ecchymosis over mastoids)
Raccoon’s eyes (periorbital ecchymosis)
Fibromyalgia:
14. Migraine headaches:

Avoid sumatriptan and zolmitriptan with ischemic heart disease, uncontrolled HTN, stroke, TIA or PVD.
Use may make these conditions worse.
15. Tension headaches: associated with chronic contraction of the muscles of the neck and scalp.
Treatment: aspirin, ibuprofen, naprosyn, indomethacin, ketorolac
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H. Care of patient with eye disorders

Instillation of eye drops:

• Have client lie down or tilt the head back.
•
• Drop the correct number of drops (wait about 1 minute between each drop) into the
• pocket made between the lower lid and eyeball.
• Do not squeeze the bulb too hard.

I. Diagnostic tests: • Opthalmoscopy: visualization of the structures of the eye

• Visual acuity: Snellen chart
• Tonometer: test intraocular pressure

J. Common disorders
1. Cataracts:

•
•
•
• Teach to wear dark glasses while outdoors.
•

2. Glaucoma:

• Acute (closed angle): sudden onset

maintain supine position. Treatment: Diamox (acetazolamide), Timoptic (timolol), Prednisolone

• Chronic (open angle)
• Treatment includes: myotics (Pilocar), Diamox (acetazolamide), Mannitol, Isordil (isosorbide
dinitrate), Alphagan (brimonidine). Quiet, dark environment.

Retinal detachment: client reports visual gaps may report seeing

• Pre op: place an eye patch.
• Post op: lie on operative side

4. Strabismus: both eyes unable to focus in the same direction; patch the good eye

5. Macular degeneration: loss of central vision - due to damage to the retina

6. Eye trauma: cover both eyes; never remove penetrating object

7. Diabetic retinopathy: can lead to blindness – refer to opthamology

8. Care of the prosthetic eye: review steps

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K. Therapeutic regimen

Related pharmacology

Mydriatics- dilate the pupil; Isopto Atropine (atropine)

Surgical intervention

L. Care of patient with ear disorders

M. Causes and prevention of hearing loss

N. Diagnostic tests: purpose, description, nursing implication

1. Rhomberg test: test to detect poor balance
2. Weber test: place tuning fork on top of the head. Client should be able to hear the sound
bilaterally.

that the sound is loudest near the ear as air conduction is greater than bone conduction.

O. Nursing management: nursing process

P. Common disorders

1. Hearing impairment
a. Presbycusis: hearing loss associated with aging
Hearing Aid: when not in use store in a clean, dry place, clean with a toothpick or pipe cleaner

Signs and Symptoms: • Vertigo

• Tinnitus
• Hearing loss

RX: • Low sodium diet

•
• Place patient in quiet environment
•
• Meclizine (antivert)
• Benadryl (diphenhydramine)
• Atropine
• Valium (diazepam)
• Compazine (prochlorperazine)

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VI. Musculoskeletal Function and Disorders

A. Terminology
B. Pathophysiology
C. Causes and prevention of musculoskeletal disorders
D. Diagnostic tests: purpose, description, nursing implications

2. Bone scan – radioactive material injected to visualize bone

position 45 – 60 minutes. Remove NTG, nicoderm or birth control patches before procedure.

E. Nursing management: nursing process including interventions to prevent

disabiity.
1.
2. Special equipment: Continuous passive range of motion (CPM)
Used to help achieve and maintain good joint motion after sugery
check the alignment and positioning frequently

apply padding to protect the skin

4. Two, three and four point gait

• Two point gait: move one leg together with one crutch
on & the opposite side.
• Three point gait: one leg is not in use. Move both

•
Four point gait: move right crutch then left foot, move
left crutch then right foot (four separate movements)
When ambulati

5.
support on a pillow, check peripheral circulation, fracture bed

Teach: do not stick foreign objects into cast

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F. Disorders

1.
screws.
2. Major complications

• Fat embolism:
long bone

Arixtra (fondaparinux): anticoagulant given s/p hip fracture, hip or knee replacement
• Compartment syndrome:
permanent neurological damage may occur
• The most common fracture in children are greenstick
• A fracture of the femur will result in the leg being shortened, adducted, and externally rotated

exercises

4. Osteoporosis: deterioration of bone tissue that causes low bone mass, leads to fractures of
vertebrae and femur.

Risk factors: • • Low body weight, less than 127 pound

• Decreased physical activity • Low calcium diet
• Smoking/ alcohol •
amenorrhea
Findings: • Back pain (increases with activity and decreases with rest)
• Pathological fractures
• Decreased bone mass
Diagnosis: • Bone density studies
Interventions: • Estrogen replacement, Fosamax (aldendronate), Actonel (risendronate) or
Boniva (ibandronate), take with a full glass of water, on an empty stomach,

exercises like dancing, walking, bicycling or swimming

5. Paget’s Disease: excessive breakdown and formation of bone tissue; symptoms include constant

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6. Bone tumors - may replace healthy tissue with abnormal tissue, resulting in fractures. Bone may be
primary site of cancer or as a result of metastasis. TX: Chemotherapy, radiation or surgery
Ollier Disease

7. Amputation
Care of the patient after amputation
• Assess stump, monitor for drainage color and amount
•
• Elevate stump for the place rolled blanket along outer aspect to prevent outward
rotation. Manage pain – Phantom limb pain is real
Stump care
• Inspect for redness, blister, and abrasions
• Wash stump with mild soap, rinse with water, pat dry
• Avoid use of alcohol, oils and creams
• Change bandages two or more times per day, avoid circular turns (acts as a turniquet)

8. Osteomyelitis: bone infection caused by bacteria or fungi – may be spread from infected skin or
infection from another part of the body. S/S – bone pain, fever, swelling, redness & warmth
Rx: IV antibiotics

9. Gout: (gouty arthritis): elevated uric acid

• Low grade fever, swelling of the joints, excruciating pain, renal stones
•
• Avoid scallops, haddock, bacon. Client can have chocolate
•

Treatment: bedrest, heat or cold therapy; Colchicine, Allopurinol, Probenicid

Alkaline Ash diet: Use with Gout (increased uric acid)

Foods to include: Milk

Fruit except (cranberries, plums, and prunes)
Rhubarb
Most vegetables
Small amounts of beef, halibut, and salmon included

Acid Ash Diet Use with phosphate stones (increased calcium)

Decreases the pH – increases the acidity in the urine
Foods to include: • Cheese • Whole grains
• Eggs • Pastries
• Meat • Cranberries
• Fish • Prunes
• Poultry • Plums
• Bread • Corn
• Cereal • Legumes

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8. Arthritis
Rheumatoid Arthritis Osteoarthritis
• • Over 40 years of age
• Systemic • Degenerative joint disease
• Obesity, genetic predisposition
• Unknown cause with exacerbations and remissions
•
• (nodes around distal interpharyngeal joints)
• •
• Pain decreases with activity • weight bearing joints
• Pain increases with activity
Treatment Treatment
• ASA •
• • muscle relaxants
• Steroids • immobilization
• Humira (adalimumab) • cold packs
• Plaquenil (hydroxychloroquine) • weight loss
• Rheumatex, Trexall (methotrexate)
•
URI, headache
*Humira (adalimumab) & Enbrel (etanercept) can cause new infections or worsening of existing conditions
G. Therapeutic regimen
1. Traction: used to reduce and immobilize fractures, decrease spasms, and correct deformities.

Nursing interventions: • maintain counter traction, the weights must hang free

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XVII. Immunology /Dermatology /Integumentary

A. Disorders of the immune system

2. Hypersensitivity / allergy

B. Skin disorders

1. Infectious and parasitic skin disease:

a. diseases requiring contact isolation

2. Herpes zoster-Shingles:

standard

3. Acne:
when this medication is in use; salycillic acid may be prescribed.

4. Psoriasis: due to over production of skin cells characterized by thickening of skin with silvery plaques.
• Exacerbated by stress or change in climate
• Treatment: Treatment: Plaquenil (hydroxychloroquine), Humira (adalimumab), Enbrel
(etanercept), steroid ointments and sunlight

5. Terry’s nails:
failure, cirrhosis, DM, CHF, hyperthyroidism and or malnutrition.

6. Skin cancer: teach client to avoid the sun and tanning salons

7. Bot – blocks the chemical signals that cause the muscles to contract. Results

like symptoms, facial weakness or drooping.

• Teach: stop ASA, Warfarin & Heparin before procedure
treats severe cervical muscle dystonia (torticollis)

8. Steven Johnson Syndrome: severe form of erythema multiforme – an immune complex disorder
characterized initially by conjunctival burning and itching, fever, cough, malaise. (Flu like s/s)
• SJS typically involves the skin and the mucous membranes.
•
lower respiratory tract mucous membranes may develop in the course of the illness.
• GI and respiratory involvement may progress to necrosis.
• Lesions (painful, red, purple rash; blisters) may occur anywhere, the palms, soles, dorsum of hands, and

•
disorder with the potential for severe morbidity and even death.
•
• Treatment is systemic. Treat rash like burns.

9. Sjorgen’s syndrome: autoimmune disorder which results in loss of lubrication.

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XVIII. Care of the Client with HIV / AIDS

A. Cause: HIV is a retrovirus that integrates itself into the genetic material of the cell and changes the DNA.

system is evidenced by a decrease in CD4 count. Viral load tests and CD4 counts are done every three to
four months.
The viral load test measures the amount of HIV virus in the blood.
Low = 40 – 500 copies/ml High = 5,000 – 10,000 copies/ml
Untreated/uncontrolled = 1 million or more copies

200 and opportunistic infections occur.

• PCR (polymerase chain reaction test) can be done to test viral load. Used on
infants.
• Methods to prevent infection – hand washing, avoid crowds,
neutropenic precautions etc.
• Pancytopenia occurs

B. HIV / AIDS medications: HAART

of active virus in the blood stream

Nonnucleoside reverse transcriptase inhibitors

conversion of RNA to DNA
Viramune (nevirapine),Sustiva or Stocrin (efavirenz), Rescriptor (delavirdine),
Intelence (etravirene)

Nucleoside Reverse Transcriptase Inhibitors (NRTI’s) – inhibits DNA synthesis

AZT, Retrovir – (zidovudine) – anemia, monitor CBC,
Epivir – (lamivudine, 3TC)
DDC– (zalcitabine) –causes hepatotoxicity
(stavudine) Zerit –peripheral neuropathy
Ziagen (abacavir)
(didanosine)
damage

Protease inhibitors- prevents infection of new cd4 cells

Invirase 500 (saquinavir)– elevated liver enzymes, hyperglycemia
Crixivan (indinavir) –take on an empty stomach; causes nephrolithiasis and

Viracept
Norvir – (ritonavir) – liver dysfunction, pancreatitis, arrthymias; refrigerate liquid
Kaletra (lopinavir/ ritonavir) – nausea, vomiting, diarrhea, monitor LFTs
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• Antivirals: Foscavir- (foscarnet) Treatment of CMV retinitis in HIV patients resistant to Acyclovir

SE: seizures, renal impairment, hypocalcemia, hypo/hyperphosphatemia, hypomagnemesia,

• Multi-Class Combination Drugs

Atripla

transcriptase inhibitors (NRTIs) – Take once daily on an empty stomach

*Standard precautions when hospitalized

high protein, high calorie; liquids before meals, decrease residue

Interdisciplinary approach needed; support groups

C. Opportunistic infections
1. Bacterial: Mycobacterium complex

2. Fungal infection: candida albicans; yeast overgrowth – oral thrush, yeast vaginitis

– transmitted through infected cat feces, eating raw or under cooked meats
Rx: Pyrimethamine & Sulfadiazine
cryptosporidiosis – oral fecal spread through contaminated water. Incubation 2 days – 2 weeks.
Rx: supportive, may be prescribed Mepron (atovaquone)

5. Management Guidelines for Occupational Exposure & Post Exposure Prophylaxis:

• Two or more PEP drug regimen for 4 weeks based on the level of risk of HIV transmission
•

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XX. Care of the elderly a systemic approach

• Reproductive:
Females: ovulation and menstruation cease
Vaginal walls become thin and dry due to lubrication & estrogen levels; may lead

Males: Prostate may enlarge (PSA test, digital rectal exam)

• Endocrine:
Decrease in levels of estrogen

Lower medication dosages may be required due to slower metabolism

• Cardiovascular:
Decreased cardiac output and circulation secondary to narrow blood vessels
• Digestive:
Sense of taste may be decreased
Increased constipation
Digestive system slows down
• Urinary:

• Respiratory:
Decreased breathing capacity, decreased PaO2 to 75mm
• Musculoskeletal:
Increased osteoporosis and arthritis common
Kyphosis – R/T loss of bone mass
Slower movements
Decreased muscle strength
• Sensory:

Cataracts common

Foods have less taste

• Nervous:
Pain sensation decreases
Intelligence remains intact
Alteration in balance (priority is safety)
• Integumentary:
Increased sensitivity to cold; Skin discolorations are common
Hair looses color and thins. Skin dries and is less elastic
• Teach denture care: Brush and rinse dentures daily. Clean dentures over a
folded towel or a full sink of water. Use a denture cleanser (hand soap or mild dish
washing liquid can be used). When not in use, dentures should be placed in a
denture cleanser soaking solution or in water.
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XIX. Emergency Nursing

B. Prevention of accidents
C. Checklist for evaluating accident and emergency patients OLDCART
Onset of symptoms, Location of problem, Duration of symptoms, Characteristics client used to describe
symptoms, Aggravating factors, Relieving factors, Treatment received before arrival
D. Review CPR:

to a depth of about 2 inches. Rescue breathing is still recommended for children and anyone whose
cardiac arrest is likely due to oxygen deprivation. Sequence CAB (circulation, airway, breathing)
•
lseless ventricular tacyhcardia
E. Control bleeding: apply tourniquet above injury
F. Shock:
• Electric: injury from electricty
• Hypovolemic: caused by inadequate blood volume
• Cardiogenic: associated with decreased cardiac output which results in decreased tissue perfusion
• Distributive
• Neurogenic: occurs after injury to the spinal cord. Major clinical signs hypotension and bradycardia
Treatment:
• Intropin (dopamine) - treats heart conditions, provides additional pumping strength to stimulate
the heart muscle. May also improve kidney blood supply. SE: N/V, headache, report dizziness
• IV Fluids
• Supplemental oxygen, protect airway
• Neurogenic shock may need Atropine
G. Poisoning: Teach to contact poison control
Activated charcoal blocks the absorption of poisons in the stomach

I. Animal bites:
Tetanus vaccination may be prescribed
J. Post-mortem care:
• Formal pronouncement of death may vary slightly by state.
•
required or due to religious observance.
• Make the client appear clean and remove visible medical equipment from sight.
• Place a clean sheet over the body and do not cover the face.
• Allow family members to visit, assist in calling clergy and or funeral directors, as desired.
• Some family members may not want heath care providers to touch the deceased body immediately
after death.
• The next of kin will be responsible to make decisions regarding autopsy, organ and tissue donation,
and funeral preparations.
•
Algor mortis (algor—coldness; mortis—of death) is the change in body temperature following death.
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OVERVIEW OF PHARMACOLOGY
1. Chemical name: description of drug using chemistry composition

2. Generic name (non proprietary)

A. name assigned by government to drug; universal drug name
B. generic drug may have many trade names

Trade name (proprietary)

A. created by drug companies to sell a product

4. Rights of medication administration and safety

• Right assessment, right drug, right dose, right time, right route, right patient, right education, right
documentation, right evaluation, the patient also has the right to refuse.
• .Typically the generic name is listed on the exam. The trade name may be present, but less likely.

Pharmacology Essential Concepts:

• Medications have several actions. When answering these questions always consider what the
Clonidine is a hypertensive drug that is
Depakote (valproic acid) is used as a mood stabilizer or to
control seizures.

• All medications can potentially alter more than one body function.

• For each medication prescribed there is:

•
•
•
subsequent dosing (hives, rash, wheezing, SOB, anaphylaxis)

•
function or route of administration.

•
•
•
•
•

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Nursing responsibilities in medication administration

•
• Check for accuracy of the prescription – do not administer medications that are not correctly
prescribed

• Check results of therapeutic drug levels and report results as necessary

B/P

could also state their name and date of birth)

evaluate their response to therapy

• Determine compatibility of prescribed medications; monitor for use of home or herbal remedies

error; document in an incident report and on the chart

• Time release drugs must not be crushed or chewed (swallow whole)

Abbreviations: EC, SR, Dur, CR, LA, XL, XR, Contin

• Three medication checks should be performed prior to administration

• Promptly document medication administration and reactions if any

• Teaching: instruct the patient and or family regarding safe use of medications, dietary

restrictions and assessments (i.e. b/p, pulse) for each medication prior to discharge so that they

will be prepared for self administration. Also teach regarding safe disposal of medications.

5. Commonly used Medications

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Antihypertensives

Angiotensin Converting Enzyme Inhibitors

Treat hypertension & heart failure & protect kidney function in patients with diabetes mellitus
Drug Name Generic Drug Names
Cough
Vasotec • Enalapril
Anaphylaxis

Zestril Palpitations
• Lisinopril Taste changes
Prinivil
Orthostatic Hypotension
Altace • Ramipril
Potassium increase
Capoten • Captopril Renal impairment
Impotence
Monopril • Fosinopril
Leukocytosis
Accupril • Quinapril Nausea, vomiting, dry mouth
Headache, Dizziness
Lotensin • Benazepril
Monitor blood pressure, BUN & creatinine, electrolytes and WBC
Nursing Implications:
Contraindicated in pregnancy, avoid NSAID’s
REMEMBER: ACE Inhibitor side effects = CAPTOPRIL
Diuretics
Excrete Sodium & Fluid
Drug Name Generic Drug Names
Loop Diuretics: Potassium Depleting
• Bumetanide
Hypotension Hyponatremia
Edecrin • Ethacrynic acid Hypokalemia Constipation
• Furosemide Tinnitus Increased BUN
Photosensitivity Hyperglycemia
• Torsemide
Thiazide Diuretics: Potassium Depleting
Hydrodiuril • Hydrochlorothiazide Hypotension Hyponatremia
• Metolazone Hypokalemia Headache
Diuril • Chlorothiazide Photosensitivity Hyperglycemia

Nursing Implications: Monitor BUN, K+ & glucose levels. Monitor intake and output
Teach: increase potassium in diet
Potassium Sparing Diuretics
Aldactone • Spironolactone Hyperkalemia Headache
Constipation Dizziness
Dyrenium • Triamterene Menstrual irregularities Muscle cramps
Nursing Implications:
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Calcium Channel Blockers

Treatment of Angina & Hypertension
Drug Name Generic Drug Names
Calan, Isoptin • Verapamil • Hypotension
Procardia • Nifedipine • Headache
• Peripheral edema
Cardizem • Diltiazem
• GI upset
Plendil • Felodipine • Flushing
Norvasc • Amlodipine • Syncope
Teach –report ankle edema, avoid operating machinery, avoid
Nursing Implications:
grapefruit juice

Beta Adrenergic Blockers- OLOL Drugs

Management of hypertension, angina pectoris, congestive heart failure & MI prevention
Drug Name Generic Drug Names
Tenormin • Atenolol Hypotension
Inderal • Propranolol Bradycardia
Dizziness
Cogard • Nadolol
Impotence, diarrhea, nausea
Lopressor, Toprol • Metoprolol Hyperglycemia CHF PVD
Coreg • Carvedilol Bronchospasm

Check pulse before administration

Monitor blood glucose in diabetics
Administer with food
Nursing Implications:
Taper dose to discontinue
Contraindications ABCDE- asthma, heart block, cardiac failure, DM
(hypoglycemic shock), extremities (occlusive arteries)

Vasodilators
Relax the smooth muscles in the blood vessel
Drug Name Generic Drug Names

Apresoline • Hydralazine Palpitations Headache

Nipride Tachycardia Diaphoresis
• Nitroprusside
Tx for hypertensive crisis
Nitrostat • Nitroglycerin Hypotension Syncope
Imdur • Isosorbide mononitrate Dizziness Pallor Weakness
Isordil • Isosorbide dinitrate

Nipride (nitroprusside): protect from light, continuous EKG & B/P monitoring
Nursing Implications:
good for 3-6 months
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Alpha Agonists

Drug Name Generic Drug Names

Catapres • Clonidine Postural hypotension Drowsiness
Aldomet • Methyldopa Impotence Dry mouth

Angiotensin II Receptor Blockers

Treat hypertension & heart failure & protect kidney function in patients with diabetes mellitus

Diovan • Valsartan
Hypotension Cough
Cozaar • Losartan Hyperkalemia Renal Dysfunction
Angioedema
Atacand • Candesartan

Nursing Implications: Monitor BUN/ Creatinine and electrolytes. Cozaar prescribed P.O.

Alpha 1 Receptor Blockers

Used in the treatment of BPH and HTN

Cardura (BPH & HTN) • Doxazosin Hypotension

Palpitations
Blurred vision
Minipres (HTN) • Prazosin
Nausea
Diarrhea
Hytrin (BPH & HTN) • Terazosin Dizziness
Light headedness
(BPH) • Tamulosin Edema
Dry mouth
Administer dose at bedtime, monitor B/P, assess for edema
Nursing Implications:
Teach avoid operating machinery

Cardiac Glycosides

Drug Name Generic Drug Names

Fatigue Bradycardia
• Digoxin Anorexia Nausea & vomiting
• Digitoxin Headache Diarrhea
Visual changes
Monitor apical pulse for 1 full minute
Do not give if pulse is: less than 60 in an adult
less than 90 in a child
Nursing Implications:
less than 70 in an older child
Monitor electrolytes – hypokalemia, hypomagnesemia & hypercalcemia
increase risk of toxicity
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Anticoagulants
Prevent blood clotting
Heparin (injectable only) prevents the conversion of prothrombin to thrombin
Drug Name Generic Drug Names
Heparin Bleeding (remember other words & signs that indicate
bleeding)
• Enoxaparin
Fragmin • Dalteparin Nausea Diarrhea

Coumadin • Warfarin PO/IV Hemorrhage

Heparin – Monitor PTT/INR

Coumadin (warfarin) – Monitor PT/INR
Nursing Implications: Fragmin (dalteparin)/ Lovenox (enoxaparin) – Monitor CBC - pt at risk for
H.I.T. (heparin induced thrombocytopenia)
Teach patient to monitor for signs of bleeding

Antiplatelets
Prevent clot formation by blocking platelet aggregation
Drug Name Generic Drug Names
• Clopidogrel Bleeding
Ticlid • Ticlopidine (remember other words & signs that indicate bleeding)
Nausea Upset stomach
Aggrastat •
Stomach pain Diarrhea
Persantine • Dipyridamole Rash and itching Headache

• Dipyridamole + ASA Drowsiness

Avoid if allergic to aspirin, ibuprofen or naproxen
Hold 7-10 days before surgery
Use caution during activities requiring alertness (such as driving a car)
Nursing Implications: Teach: Monitor for signs of bleeding
Do not use any other over-the-counter medication
Avoid use of aspirin, salicylates, and NSAID’s while taking these medications
Avoid in pregnancy

Hemostatics
Used to control bleeding when blood clots are broken down too quickly

Drug Name Generic Drug Names

Amicar • Aminocaporic Acid Nausea, vomiting, diarrhea, cardiomyopathy

Nursing Implications: Taken once an hour for about 8 hours or until the bleeding is controlled
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Antibiotics
Used to treat infection
Category Drug Name
Penicillin Nausea, vomiting, diarrhea,
Penicillin’s Amoxil (Amoxicillin)
Omnipen (Ampicillin) super infection (candidiasis)

Rocephin (Ceftriaxone)
Cephalosporins Zinacef/Ceftin (Cefuroxime)
Vantin (Cefadoxime)
Fortaz (Ceftazidine)
Tobramycin
Amikacin
Aminoglycosides
Neomycin Oto, neuro & nephro toxicity
(Mycin’s) Gentamicin
Streptomycin
Tetracycline
Tetracyclines Photosensitivity, tinnitus
Vibramycin (Doxycycline)
INH (Isoniazid) Peripheral neuropathy, hepatotoxicity,
Anti-tubercular
Rifadin (Rifampin) discolors the urine & contact lenses, visual
Agents Ethambutol disturbances, precipitation of gout
Tendonitis & tendon rupture, nausea, vomiting,

avoid with theophylline,

Fluoroquinolones
diuretics, cardiac meds (quinidine, amiodarone,
betapace, bretylluim)
antacids, multivitamins, iron

Flagyl (Metronidazole)
coumadin
Macrobid (nitrofurantoin)
Macrodantin, Furadantin
CHRONIC PULMONARY REACTIONS,
Tx for: UTI
GI upset, , dizziness, pruritis, fever,
Gantrisin
Antibacterial
syndrome
(pediatric suspension) Tx for:
acute, recurrent or chronic UTI

Zyvox (linezolid)
Tx for: VRE, PNA or complicated Pancytopenia, N/V/D, fever, URI,headache
skin infections

Zithromax (Azithromycin)
Nausea, vomiting, diarrhea, thrombocytopenia,
Biaxin (Clarithromycin)
Macrolides abdominal pain, taste changes, super infection,
E’mycin (Erythromycin)
Cleocin (Clindamycin)

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Nursing Implications for Antibiotics:

• Patients should be instructed to complete the full course of therapy
•
•
• Mycin drugs –monitor BUN/Creatinine; Monitor peak and trough levels at the third or fourth dose
• Do not give Tetracycline to pregnant women and children under the age of 8 – stains the teeth.

•
•
iron. Do not take with milk or yogurt, take on an empty stomach with a full glass of water
•
• Give INH (Isoniazid) with vitamin B6 to prevent peripheral neuropathy
• Zyvox (linezolid) – monitor CBC Q week; avoid foods containing tyramine
• TB medications may be given in combination to prevent resistance
• Avoid ETOH with Flagyl (metronidazole)

Iron preparations
Treats anemias

GI distress, headache, N/V, constipation, peptic ulcers

method.

Nursing Implications:
eggs or whole grain bread within one hour after iron

Induces bowel evacuation; treatment of constipation

Type Drug Names
Bulk Forming Metamucil (psyllium)
Abdominal fullness; minor bloating
Agents Citrucel
Stool softeners A bitter taste or throat irritation,
Colace (docusate)
Surfactants skin rash, diarrhea or mild nausea
Lubricants Stomach pain, nausea & vomiting,
Mineral oil
Emollients abdominal pain
Citroma (magnesium citrate)
Hydrating Stomach pain Nausea
Agents Gas Diarrhea
Epsom salt (magnesium sulfate)
Hyperosmotic Lactulose, Sorbitol
Hyperglycemia, diarrhea
Agents Glycerin Suppositories
Stimulants Dehydration, dizziness, severe
Irritants diarrhea, abdominal cramps
Monitor for electrolyte imbalance
Metamucil (psyllium): take with 8 ounces of water
Nursing Implications: Lactulose may be used to decrease ammonia levels in clients
with hepatic encephalopathy
Teach: report rectal bleeding
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Steroids

Drug Name
Prednisone Hyperglycemia Growth retardation Hypokalemia
Solumedrol (methylprednisolone) Mood changes Hirsuitism Hypertension
Beclovent (beclamethasone)
Pulmicort (budesonide)
Immune suppression Menstrual irregularities Acne
Azamacort (triamcinolone inhaled)
Kenalog (triamcinolone topical) Delayed wound healing
Administer with or after meals
Client teaching: taper dose, wear medic alert, avoid stress, report fever &
Nursing Implications: weight gain, monitor frequent weights, increase potassium & protein in diet,
monitor glucose, rinse mouth after use of inhaled steroid to avoid oral thrush
Topical agents - contact dermatitis, hypopigmentation & maceration

Antiparkinson Agents
Increase dopamine in central nervous system

Drug Name Generic Drug Names

Nausea, vomiting, anorexia, dry mouth,
• Levodopa
Sinemet headache, urinary retention, anxiety, blurred
• Carbidopa-Levodopa
vision, dyskinesias
Use with caution in clients with glaucoma, monitor liver function
Nursing Implications: Teach: Use caution when operating machinery
May discolor saliva, urine or sweat red, brown or black
Chemotherapeutic Agents
Used to destroy tumor cells
Category Drug Names
Carboplatin
Akylating agents Bone marrow suppression
Cisplastin
Bone marrow suppression
Antimetabolites
CNS damage
Antitumor antibiotics Bleomycin Chills, confusion
Pancytopenia, immunosuppression, bone marrow
Vinblastine
Plant alkaloids suppression, N/V/D,
Vincristine
alopecia, hepatotoxicity, neuropathy
Selective estrogen Increased risk of uterine CA, blood clots
receptor blockers or stroke
Development of secondary Cancer

Nursing Implications:
Contraindicated in pregnancy – teach to use birth control
Handle with gloves

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Gastro-Intestinal Meds

Category Drug Name

Prevacid (lansoprazole)
Nausea Vomiting
Anorexia Dry mouth
Proton Pump Inhibitors
Prilosec (omperazole) Headache Dyskinesias
Reduce gastric acid production
Urinary retention Anxiety
Blurred vision Constipation

Tagamet (cimetidine)
Zantac (ranitidine) Malaise Dizziness
H2 Receptor Blockers
Pancytopenia Diarrhea
Inhibits gastric acid production Pepcid (famotidine) Headache

Amphogel (aluminum based)

Antacids Constipation, Bloody stools,
Neutralize the acid in the stomach Diarrhea
(aluminum-magnesium based)

Zofran (ondansetron)
Headache Weakness
Kytril (granisetron)
Heartburn Constipation
used to treat N/V associated with
Diarrhea Dizziness
Antiemetics chemo or radiation therapy
Prevention and treatment of
Drowsiness Dry mouth
nausea and vomiting
Reglan (metoclopramide) Extrapyramidal reactions
Neuroleptic Malignant Sydrome
Phenergan (promethazine) Dizziness Blurred vision
Constipation

antibiotics – separate dose by 6 hours after or 2 hours before

antibiotic administration (especially CIPRO).

blockers (increases acid), avoid smoking

Teach: PPI’s do not crush or chew
Nursing Implications:
Teach to use caution with the following drugs while taking H2
blockers or proton pump inhibitors: Theophylline, Coumadin
(warfarin),Dilantin (phenytoin), prescription medication for fungal
or yeast problems, Valium (diazepam), digoxin, propanolol, and
Calcium Channel Blocker’s
Monitor for extrapyramdial reactions with antiemetics & PPI’s

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Cholesterol Lowering Agents

Treatment of atherosclerosis
Type Drug Names
• Zocor (simvastatin)
• Lipitor (atorvastatin) Headache Dizziness
Statins • Pravachol (pravastatin) Nausea Diarrhea
• Mevacor (lovastatin)
HMG- COA reductase Muscle pain Fever
• Crestor (rosuvastatin)
inhibitors • Caduet (amlodipine/atrovastatin) Liver damage (jaundice, RUQ
• Vytorin (simvastatin/ezetimibe)
• Adicor (lovastatin/niacin)

• Questran (cholestyramine)
lence bad taste in the mouth
abdominal pain, back pain, diar
• Zetia (ezetimibe) rhea, joint pain, sinusitis, liver
disease
headache, constipation, vertigo,
Bile Acid
rash, eczema, nausea and/or
Sequestrants •
vomiting, fatigue and diarrhea,
dyspepsia

• B3 (niacin)
digestion, gas, vomiting & diarrhea
• Welchol (colesevelam)
dyspepsia
decreases LDL and HgbA1c
Statins contraindicated in pregnancy, give at night, avoid grapefruit juice,
Nursing Implications: monitor LFT’s. Questran (cholestyramine): mix with water or juice

Antipyretics
Reduce fever
Drug Name

Tylenol (acetaminophen) Liver damage; nausea, urticaria, rash, jaundice

GI upset, nausea

ness in the chest; swelling of the mouth, face, lips, or tongue); black or
Aspirin
bloody stools; confusion; diarrhea; dizziness; drowsiness; hearing loss;
ringing in the ears; severe or persistent stomach pain; unusual bruising;
vomiting. Reyes syndrome in children; respiratory alkalosis with toxicity.
Monitor LFT’s
Avoid with alcohol
Nursing Implications: Antidote for acetaminophen toxicity - Mucomyst (acetylcysteine)
3 GM/ day maximum dose

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Antihistamines
Used to block the release of histamine in allergic reactions
Drug Name Generic Drug Names
Benadryl • Dipenhydramine Dry mouth, nose, and throat
Drowsiness
Claritin • Loratidine
Fatigue
Zyrtec • Cetirizine Headache
Sleepiness
Dizziness
• Hydroxyzine Nausea and vomiting
Constipation

Teach: Avoid activities requiring mental alertness.

Nursing Implications:

Anticholinergics
Inhibit parasympathetic nerve impulses by blocking the action of acetylcholine
Drug Name Generic Drug Names

Mydriasis
Acute eye pain
Hypotension
Palpitations
Atrovent • Ipratropium bromide
Urinary retention
Tachycardia
Constipation
Bronchospasm
Paradoxical bronchospasm
Dry mouth
Blurred vision
Atropine
Photophobia
Tachycardia
Blurred vision
• Darifenacin
Decreased sweating leads to over
used to treat overactive bladder used in overactive bladder
heating
Teach: medications cause the mucous membranes to become dry,
take with a full glass of water
Atropine- avoid with hepatitis, glaucoma, gastrointestinal obstruction,
Nursing Implications: decreased liver or kidney function
Use caution when driving, operating machinery, or performing other
hazardous activities
Avoid use of ETOH

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Anticonvulsants/Benzodiazepines
Used to manage seizure disorders/anxiety disorders
Drug Name Generic Name
Klonopin • Clonazepam
Drowsiness
Valium • Diazepam
Lethargy

Librium • Chlordiazepoxide Slurred speech

Ativan • Lorazepam Hypotension

CNS depression
Dalmane • Flurazepam
Gingival hyperplasia Hypoglycemia (in DM)
Mild skin rash or itching Dizziness, nervousness
Discolored urine
Over dose symptoms may include:
Twitching eye movements Slurred speech
Dilantin • Phenytoin
Loss of balance Tremors
Fainting Nausea & vomiting

Slow or shallow breathing

Dizziness
Drowsiness
Tegretol • Carbamazepine Dry mouth
Nausea
Aplastic anemia
Sleepiness
Weakness
Keppra • Levetiracetam
Dizziness
Infection

Rash
Lamictal • Lamotrigene Dizziness
Headache

Avoid with liver disease and DM. Avoid alcohol

Do not chew or crush tablets.
Avoid taking antacids at the same time with Dilantin (phenytoin) - inhibits
absorption
Nursing Implications: Tegretol (carbamazepine) - take with meals, avoid grapefruit juice
Monitor LFT’s, monitor CBC

Romazicon (Flumazenil) - antidote to benzodiazipines

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Narcotics/analgesics
Used to relieve moderate to severe pain
Drug Name Generic Name
NARCOTICS
Morphine *Risk of dependency CNS depression

Duragesic • Fentanyl Nausea and vomiting Dry mouth

Pinpoint pupils Itching
Demerol • Meperidine Hives Rash

Dilaudid • Hydromorphone Diaphoresis

NSAID’s

Motrin • Ibuprofen
Nausea Epigastric pain
Indocin • Indomethacin Heartburn Diarrhea
Headche Dizziness
Naprosyn • Naproxen sodium
Vertigo Hypertension
• Celecoxib Oliguria Rash
Gastric or duodenal ulcer with bleeding
Feldene • Piroxicam
OPIODS
Respiratory depression Nausea
Ultram • Tramadol
Dizziness Constipation
TRIPTANS
Prescribed for migraine headaches
• Sumatriptan Hypotension Syncope
Tinnitus Dry mouth
Zomig • Zolmitriptan Photophobia
SKELETAL MUSCLE RELAXANTS
Soma • Carisoprodol Drowsiness
Asthma attacks
• Methocarbamol
Psychological dependence
• Cyclobenzaprine Nausea

urge to urinate, or decreased urine output, constipation, headache, diplopia,

nightmares may be sign of overdose - Antidote: Naloxone
Avoid with other meds causing CNS depression (MAOI’s, antihistamines,
Nursing Implications: NSAID’s – Take with food, Mointor for signs of bleeding, avoid use of ASA and

Opiods – taper dose to discontinue

Triptans: avoid with ischemic heart disease, uncontrolled HTN, stroke, TIA or
PVD
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Osteoporosis Medications
Used in the prevention & management of osteoporosis
Drug Name Generic Name
Bisphosphonates
Slows the rate of bone thinning and increase bone density

* irritation and ulcers of the esophagus

• Alendronate
abdominal pain, constipation, gas, or nausea

Boniva Back pain, indigestion, bronchitis, bone, joint

• Ibandronate
or muscle pain

Actonel
Bladder infection
• Risedronate
BPH in men
q month or q week as prescribed

Reclast
• Zoledronic acid Joint pain, fever, hypertension, headache
Yearly IV

Selective estrogen receptor modulator (SERM)

Slows bone thinning & causes some increase in bone thickness

Evista
• Raloxifene
edema, muscle pain

Hormone Therapy

Calcimar
Miacalcin • Calcitonin
vomiting
Given via nasal spray, IM, or SC

Stroke, blood clots, increased breast cancer

Estrogen
risk, gallstones, headaches, nausea, vaginal
Used only in women who are post hysterectomy
breast tenderness
Testosterone
Edema of the hands and feet, prostate
hyperplasia, gynecomastia, painful erections
*men only
(rare), liver dysfunction

Fosamax (alendronate), Actonel (risedronate) - sit up after

on an empty stomach, with a full glass of water, early in the morn-

Nursing Implications:
supplements. Avoid in kidney disease
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During the exam, you may encounter medications that you do not recognize. Many prescribed medications

an answer.

Review the list below:

SUFFIX DRUG CLASS DRUG NAME
VIR antivirals Combivir

OLOL beta blockers Metoprolol

PRIL ace inhibitors Accupril

COR statins (decreases cholesterol) Zocor

CORT steroids Pulmicort

SONE steroids Hydrocortisone

AFIL erectile dysfunction

AZOLE proton pump inhibitors Omperazole

TIDINE H2 receptor blockers Cimetidine

CAINE local anesthetics Lidocaine

CILLIN antibiotics Penicillin

CEPH or CEF Cephalosporins Cephalexin/cefazolin

CYCLINE Antibiotics Doxycycline

DONE opoids Oxycodone

IDE oral hypoglycemics Glyburide

PAM, LAM antianxiety Diazepam, alprazolam

MIDE diuretics Furosemide

IPINE Calcium channel blockers Amlodipine

ZINE Antipsychotics Thorazine

SARTAN Alpha 2 receptor blockers Valsartan

ZOSIN Alpha 1 receptor blockers Doxazosin

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Medication Worksheet:

1. Osin ______________________________________________________
2. Sartan_____________________________________________________

4. GL________________________________________________________
5. Setron_____________________________________________________
6. One_______________________________________________________
7. Statin______________________________________________________
8. Zepam_____________________________________________________
9. Dronate____________________________________________________
10. Done_____________________________________________________
11. Dipine_____________________________________________________
12. Olol_______________________________________________________

14. Pril________________________________________________________
15. Mide______________________________________________________
16. Ceph/Cef__________________________________________________
17. Floxacin___________________________________________________
18. Mycin ( TANGS)_____________________________________________
19. Tidine_____________________________________________________

Worksheet Answer Key

* Remember there are always exceptions. *Some exceptions: amakacin is an aminoglycoside and ends in
acin, macrolides are a class of drug that also end in mycin, loratidine is an antihistamine and ends with tidine.

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ESSENTIAL MEDICATION LIST

• •

•
• •
• •
• •
• •
•
• •
•

• •
•

• •
•
• •
• •
• •
• •
• •
• •
• •
• •
•
• •
•
• •
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
• •
• •
•
•
• •
•

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AFTER THE REVIEW

After the review class is completed, you will need to continue to study. Ready to Pass recommends that you take
the NCLEX exam within 1 month after completion of the course. It is important that you organize your time in
order to cover each section of the review book thouroghly. You must have a good understanding of the
information rather than memorizing facts. Be sure to pay attention to bolded areas, charts and areas that
were highlighted during the review. Prepare for the exam by scheduling as soon as possible. Start by reading the
study manual in order of areas of NCLEX priority.

Recommended order of study:

1.
2. Infection Control
Diabetes/Endocrine System
4.
5. Pharmacology (a) medication calculation (b) herbal remedies
6. Diagnostic tests & Lab values
7. Respiratory System
8. Maternal Child Health, Pediatrics, Mental Health
9. Everything Else

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1. Obtaining a sputum culture

2. Performing catheter irrigation (steps listed on pg 140)
Inserting a straight or an indewelling urinary catheter (steps listed on pg 140)
4. Tracheostomy care
5. Tracheostomy suctioning
6. Eye Irrigation
7. Ear Irrigation
8.
9. Changing a peripheral intravenous dressing
10. Administering intravenous medications using a secondary line
11. Changing a central line dressing
12. Insertion of and removing a nasogastric tube
Administering eye / ear medication
14. Correct use of an incentive spirometer
15. Care of the prosthetic eye
16.
17. Performing wound assessment
18. Performing wound irrigation; wound vac
19. Gastric Lavage
20. Condom catheter application (steps listed on pg 140)
21. Closed intermittent irrigation (steps listed on pg 140)
22. Obtaining a specimen from a central line and a peripheral line
Colostomy and Ileostomy stoma care
24. Safe use of devices: CPM machine, slide board, mechanical lift, gait transfer belt
25. Application of antiembolic stockings
26. Post mortem care
27. Cardiopulmonary Resuscitation (CPR)

Resources
www.LearnersTV.com
www.nursingquality.org
www.fpnotebook.com/surgery/pharm/wnddrsng.htm
http://nursingskillsvideo.blogspot.com
www.practicalclinicalskills.com
www.easyauscultation.com
www.blausen.com
www.dosagehelp.com
www.abg.ninja
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CONTINUOUS BLADDER IRRIGATION (CBI)

• Continuous bladder irrigation (CBI) of normal saline prevents the catheter from becoming obstructed.
Irrigation Return Rate Adjustment
• Pink or Lighter • Do not adjust CBI rate (desired return)
• Bright Red with clots • Increase CBI rate
Obstructed catheter
•
• Use a large piston syringe irrigate with 50 mL of irrigation solution
• Document the amount of solution instilled and the amount of solution returned.
•
Interventions:
Teach: First void after removal may appear red in color with clots present. Color should return to normal (amber)
.

CLOSED INTERMITTENT IRRIGATION

• Fill a sterile syringe with irrigant
• Clamp the catheter in the area between the injection port and extension tubing
• Clean theh injection port with an alcohol wipe
• Insert the needle of the sterile syringe into the injection port
• Inject the irrigant slowly into the catheter
• Remove the syringe and clamp
•

STRAIGHT OR INDEWELLING CATHETHER INSERTION

• Explain procedure & then perform hand hygiene
• Position client supine: Female with knees bent & apart; Male with thighs abducted slightly
• Don gloves & wash perineal area
• Remove gloves, perform hand hygiene
• Open sterile package, don sterile gloves, Apply antiseptic solution to the cotton balls
•
• Lubricate tip of catheter
• Use the sterile drape to expose the meatus, then clean the area.
• With sterile hand, insert catheter into the meatus, advance it until urine returns, then 2.5 to 5 cm further
• With the nondominant hand, stabilize catheter
•
•
•

CONDOM CATHETHER APPLICATION

• Perform hand hygiene, explain procedure
• Don gloves, apply skin prep to area
• Hold penis with nondominant hand, apply condom leaving 2.5 cm of space between tip and catheter
• Roll the condom downward to cover the shaft area
• To secure catheter apply elastic tape in a spiral method, attach to leg or collection bag
• Observe for urine

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Alphabet List Page

Letters What they Mean Related To

4 W’s

6 P’s

4 C’s

5 H’s

5 F’s

3 N’s

3 C’s

5 P’s

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RICE BROW

RACE AWFERS

BEEP

ANT HOP

PAN TPAL

RANDI AVA

FINDS STOP

MONA REEDA

PQRST PASS

ABCD CAP

IPPA BRAT

IAPP CAPTOPRIL

CAB PISSCAGE

COAL NOAH

CAUTION ABCDE

ABCL KNIVES

VEAL CHOP CLAMIE - O

BUBBLE HE RANDI

RAMS BED

ROME OLDCART

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RICE: Tx for sprains PISSCAGE: Psych assessment MONA: Tx of MI

REST PSYCHOMOTOR MOVEMENT MORPHINE
ICE DECREASED INTEREST OXYGEN
COMPRESS SUICIDAL NITRATES
ELEVATE ASA
DECREASED CONCENTRATION
CAP: Meds for Gout CLAMIEO: Assessment
COLCHICINE GUILT CHECK
ALLOPURINAL DECREASED ENERGY LOOK
PROBENECID ASK
PAN: MONITOR
RACE: Fire safety ALL INSPECT
RESCUE EVALUATE
ALARM NOAH: Tx for Asthma OBSERVE
CONFINE NEBULIZERS
EXTINGUISH OXYGEN PQRST: Pain assessment
ANTIBIOTICS PROVOKES
BRAT: Diet for diarrhea HYDROCORTISONE QUALITY
BANANAS RADIATION
RICE RANDI: Bleeding precautions SEVERITY
APPLES NO RAZORS TIME
TOAST NO ASA
REDUCE NEEDLE STICKS ABCD: Mole assessment
Early signs of hypoxia DECREASE NEEDLE GAUGE ASSYMETRY
RESTLESS INJURY PREVENTION BORDER
ANXIETY COLOR
TACHYCARDIA ABCDE: Contraindications for beta blockers DIAMETER
RIGHT (Anatomy) ASTHMA
ATRIUM HEART BLOCK BED: Late signs of hypoxia
TRICUSPID CARDIAC FAILURE BRADYCARDIA
DIABETES MELLLITUS EXTREME RESLTESSNESS
CAPTOPRIL: S/E of ACE Inhibitors EXTREMITIES DYSPNEA
COUGH (OCCLUSIVE ARTERIES)
ANGIOEDEMA IPPA: Lung assessment
POTASSIUM INCREASE HOP: INSPECTION
TASTE CHANGES HYDRATION PALPATION
ORTHOSTATIC HYPOTENSION OXYGENATION PERCUSSION
PALPITATIONS PAIN MANAGEMENT AUSCULTATION
RENAL IMPAIRMENT
IMPOTENCE IAPP: Abdominal assessment
LEUKOCYTOSIS INSPECTION
KNIVES: Complications of DM
AUSCULTATION
KIDNEY DISORDERS
ANT: Symptoms of Leukemia PERCUSSION
NEUROPATHY PALPATION
ANEMIA
INFECTIONS,
NEUTROPENIA
VASCULAR CHANGES
THROMBOCYTOPENIA
EYE DAMAGE
SKIN LESIONS

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OLDCART: First aid assessment TPAL: Pregnancy assessment

ONSET OF SYMPTOMS TERM
LOCATION OF PROBLEM PRETERM
DURATION OF SYMPTOMS CHARACTERISTICS CLIENT ABORTIONS
USED TO DESCRIBE SYMPTOMS AGGRAVATING LIVE
FACTORS
RELIEVING FACTORS SCAB: Safety
TREATMENT RECEIVED BEFORE ARRIVAL SIDE RAILS UP
CALL BELL WITHIN REACH
CAUTION: Cancer warning signs ASK IF CLIENT HAS PAIN/ COMFORT
CHANGE IN BOWEL OR BLADDER HABITS BED IN LOW POSITION
A SORE THAT DOES NOT HEAL
UNUSUAL BLEEDING OR DISCHARGE 5 F’S: Possible causes of abdominal distention
FAT
THICKENING OR LUMP IN BREAST OR ELSEWHERE
FLUID
INDIGESTION OR DIFFICULTY IN SWALLOWING
FECES
OBVIOUS CHANGE IN WART OR MOLE FLATUS
NAGGING COUGH OR HOARSENESS FETUS
BUBBLE HE: Post partum assessment
BLADDER GLAD SHOP: Chronic renal failure
UTERUS BOWELS GLOMERULONEPHRITIS
BREASTS LUPUS
LOCHIA ANALGESICS
EPISIOTOMY DIABETES MELLITUS
SYSTEMIC VASCULAR DISEASE
EMOTIONS HYPERTENSION
OBSTRUCTION
VEAL CHOP: Decelerations assessment POLYCYSTIC KIDNEY DISEASE
VARIABLE CORD
SAD: Ketoacidosis
EARLY HEAD STARVATION
ACCELERATIONS OK ALCOHOL
LATE PLACENTA DIABETES MELLITUS
CAB: Dyskinseia meds ROME: Acid-base balance
SAD PERSON: Suicide risk
COGENTIN RESPIRATORY
ARTANE OPPOSITE
AGE
BENADRYL METABOLIC
DEPRESSION
EQUAL
PREVIOUS ATTEMPT
COAL: Cane walking
ETOH
CANE BROW: Avoid with celiac disease
REALITY TESTING
OPPOSITE BARLEY
SOCIAL SUPPORT
AFFECTED RYE
ORGANIZED PLAN
LEG OATS
NO SPOUSE / NOTE
WHEAT
ABCL: Increase sodium CATS: Hypocalcemia
RAMS: Acid-base balance CONVULSIONS
BURNS RESPIRATORY ARRYTHMIAS
CYSTIC FIBROSIS ALTERNATE TETANY
LITHIUM METABOLIC SPASMS
SAME
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MATERNAL / NEWBORN CARE

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Maternal/Newborn Care
Presumptive, Probable and Positive Signs of Pregnancy

• Subjective signs
Presumptive Signs • Cannot be used to diagnose pregnancy

Amenorrhea • Increasing levels of HCG major cause

• Due to progesterone secretion
Breast changes
• Results in increased size, tenderness, and darkening of the areola
Urinary frequency • Enlarging uterus puts extra pressure on bladder
Fatigue
Quickening •

• Objective signs determined during physical examination

Probable Signs
• Result of vascular congestion in the pelvis

• Occurs irregularly at beginning

• Uterus above pubic symphysis by 12th week
Uterine enlargement
•
• Fundal height in cm matches # of weeks pregnant after 12th week
• Softening of lower uterine segment
Hegar’s sign
•
Goodell’s sign • Softening of cervix and vagina
Chadwick’s sign • Bluish or purplish discoloration of cervix, vagina, and vulva
Ballottement •
• Irregular, painless contractions throughout pregnancy
Abdominal enlargement • More rapid after 12th week when uterus rises into abdominal cavity
Abdominal striae • Stretch marks
• Results from hormonal changes
Skin pigmentation changes • Nipples may darken
• Linea nigra: brown or pink line from umbilicus to pubic symphysis
Positive pregnancy test • Measures HCG

Positive Signs • Absolute indicators of pregnancy

• May be heard at 10 to 12 weeks by Doppler

Fetal heart sounds
• May be heard through regular fetoscope by 18 to 20 weeks
• Normal rate 120 to 160 beat / minute
Fetal movements • Felt by second trimester
•
Ultrasound of fetus
• Earliest positive method of diagnosing pregnancy
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II. Prenatal Care

(1) Prenatal history
(2) Prenatal physical assessment

• Total weight gain of 25 lbs is average

B. Pertinent diagnostic tests and lab values

• CBC • Electrolytes (chemistry)
• Blood type &screen • VDRL
First Trimester • Rubella screen • TB skin test
• HIV screen • Hepatitis B screen
• Urinalysis • Urine culture and sensitivity

•
Second Trimester •

• STD/STI screen
Third Trimester •
before delivery

C. Nutritional status:

• Increase protein intake

• Increase iron to decrease anemia
• Increase folic acid to prevent neural tube defects

D. Risks and hazards

E. Cardiac disease in pregnancy

(3) Nagele’s Rule:

List The EDC: LMP: August 9, 2017 EDC___________________________

January 4, 2018 EDC___________________________

October 5, 2017 EDC___________________________

ANSWERS

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(4) Routine care and follow up: • 1x per month for 7 months
• 2x per month in 8th month
• 1x per week in 9th month

(5) Parity (Term Preterm Abortions Living children)

Gravida- total number of pregnancies including current pregnancy

(6) Normal pregnancy discomforts in each trimester

First Trimester Second Trimester Third Trimester
• Nausea, vomiting • Constipation • Leg cramps
• urination • Heartburn • Hemorrhoids
• Breast tingling • Pigmentation • Back pain
• Ptyalism (excessive spitting) Linea nigra becomes prominent • Urinary frequency
• PICA
• Leg cramps are normal if no

(7) Reportable danger signs:

Vaginal bleeding Painful or burning urination
Abdominal pain Edema of face, feet or hands
Epigastric pain
Visual disturbances Elevated temperature above 101° and chills
Severe, persistent headache Persistent vomiting after the 1st trimester
Change in fetal movements after quickening Absence of fetal movements after quickening

(8) High risk monitoring:

Chorionic Villus Sampling •

Amniocentesis • Performed after 14 weeks to rule out congenital abnormalities

•
Alphafetalprotein (AFP)
• levels = neural tube defects
L/S ratio • 2:1 indicates lung maturity

Genetic screening • Screening for genetically transmitted disorders

Sonogram • Determines fetal and placental position

• 5 assessment tests using ultrasound to determine fetal well being
•
4 may need urgent delivery
Contraction stress test • Assesses FHR response to contractions
(Negative) • Fetus should not have any late decelerations in 10 minutes
Nonstress tests • FHR should accelerate 10 – 15 bpm in 10 minutes in response to body
(Reactive) movements
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(9) Complications

Pregnancy Induced Hypertension (PIH) (Preeclampsia):

Triad = • Hypertension • Weight gain (edema) • Proteinuria

Symptoms: • headache • visual disturbances

Maternal Hypertension (PIH):

HELLP Syndrome: Hemolysis, Elevated Liver enzymes, Lowered Platelets

Maternal Hypotension: • S top pitocin

• T urn on left side
• O xygen
•P
Hyperemesis Gravidarum
• Excessive nausea and vomiting in early pregnancy
•
Monitor for electrolyte imbalance and dehydration

Placenta Previa
• Partial or complete covering of the cervical os by the placenta.
• Painless vaginal bleeding (bright red bleeding may or may not be visible) after the 7th month of
pregnancy
•

Placenta Abruptio:
• Premature separation of the placenta from the uterine wall
• Painful dark red vaginal bleeding
• Risk factors: PIH, multiparity, trauma, cocaine use
•

Gestational Diabetes:
• Extra glucose passes through the placenta and is metabolized by the fetus
• This causes excess insulin to be secreted by the fetus which acts as a growth hormone
• After birth the neonate may become hypoglycemic as there is a sudden drop in glucose (maternal)
and an increased insulin production by the fetus.
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III. Labor and Delivery

A. True VS. False labor

True Labor False Labor

• Begins in the back • Abdominal and groin
• Contractions • Consistent pattern • Inconsistent
• Frequency/ fast • Increases progressively • Inconsistent
• Duration/ last • Increases progressively • Inconsistent
• Pain • Increases progressively • Inconsistent
• Cervix • •

Decelerations:

EARLY LATE VARIABLE

before the contraction after the contraction

Head compression Cord compression

• Oxygen
• Lateral or trendelenburg position
RX: observation • Lateral position • Oxygen
• D/C pitocin

VEAL CHOP

V ariable C ord: V or W shaped occurs during or between a contraction

E arly H ead: U shaped begins and ends with contraction

A ccelerations O K: increase of FHR above baseline. Return to normal within 10 minutes

L ate P lacenta: decreased FHR after a contraction: Fetal hypoxia

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Cervical dilatation Duration (contraction) Interval

* Contractions should not occur faster than every 2 minutes and should not last longer
than 90 seconds (Stop Pitocin)
• Passenger
• Passage
1. FIVE P’s • Power
• Placenta
• Psyche of mother
• Risk for infection
2. PROM
• Avoid vaginal exams • Give Ampicillin
• Never put the cord back inside
3. Prolapsed cord
• Place mom in trendelenburg or knee chest position

4. Spontaneous Abortion • Loss of a fetus before the 20th week of pregnancy

• A pregnancy that occurs outside of the uterus

Signs and Symptoms:
5. Ectopic pregnancy • Vaginal bleeding • Dizziness
• Pelvic or abdominal pain radiating to the shoulder
• DX: Sonogram Rx: Methotrexate or surgery

6. Pharmacology/pain relief •

• The settling of the fetus in the lower uterine segment

• Increase in vaginal secretions
7. Lightening
• Appearance of bloody show
• False labor pains
Pregnancy losses after the 20th week
Can be stimulated by: Risk Factors:
• Urinary tract infection • Multiple gestation
8. Premature Labor • Diarrhea • Previous premature delivery
• Dehydration • Infections
• Laxatives • Smoking
• Poor weight gain
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C. True labor
Stage 1: Dilation

• First true labor

• Latent: 0cm - 4cm • Active: 4cm - 8cm • Transition: 8cm - 10cm

A: Presentation

Thinning of the cervix

C: Station ischial spines

• Fetal descent: Engagement, Descent, Flexion, Internal Rotation, Extension, External Rotation,
Expulsiion

Stage 3: Placental

• Birth of the baby until expulsion of the placenta

AVA

Stage 4: Recovery Stage

Stages of Labor First Stage Second Stage Third Stage

5 to 20 minutes
Primipara Usually helped by oxytocics or
manual pressure
5 to 20 minutes
Multipara 20 minutes to 1 1/2 hours
Usually helped by oxytocics

D. Culture and Pain perception during labor

2. Anesthesia – epidural – causes loss of sensation but not unconsciousness

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Assessment : BUBBLE HE

B ladder: • Encourage voiding • Check for displaced uterus

U terus: •
B reasts: • Check for engorgement, mastitis & cracked nipples
B owels: • Assess for presence of bowel sounds
L ochia: • More than 8 pads / day needs follow up
E pisiotomy: • Redness • Edema • Ecchymosis • Discharge/Drainage • Approximation

H
• Assess for DVT
Emotions: • Assess for bonding

• Lochia Assessment:

RUBRA SEROSA ALBA

• Bright red • Pink • Creamy yellow

• Bloody • May be brownish

• Serous

• No odor or stale
• No odor
• Body odor

• Breast Feeding:
•
• Mastitis: Treatment: • Moist heat • Encourage breast feeding or pump the breast
• Engorgement / cracked nipples: Treatment: •
• Mother who does not want to breast feed: • Teach:
• Parlodel (bromocriptine) may be prescribed

• Contraindications to breast feeding include but are not limited to:

• Tuberculosis • Breast cancer • Chemotherapy
• Radiation • HIV • Hepatitis
• Lactose intolerance (infant) • Methotrexate • Lithium
• Herpes lesion on nipples

• •
•
• 4 or more yellow bowel movements per day
• If infant develops diaper rash, keep open to air, use cloth diapers
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V. Care of Newborn

A. Nursing care assessment

1. Apgar score: score < 7 requires resuscitation

APGAR NEWBORN Performed at: • 1 Minute After Birth

SCORING SYSTEM • 5 Minutes After Birth
0 1 2
Heart rate Not detectable Below 100 Above 100

Absent Slow, Irregular Good (crying)

Muscle tone Flaccid Active motion

No response Grimace Vigorous Cry

Color Pale Blue Pink

• Data Collection: • Respiratory Status

• Apgar score
• Obtain vital signs
• Temperature Assessment

• Implementation: • Suction mouth then nose

• Dry baby with vigorous rubbing
• Maintain temperature
• Wrap baby in a warm blanket
• Place a stocking cap on the head
• Initiate breast feeding PRN
• Place baby in a warmer

• Thumb print from mother

• Place ID bracelets on to assist in the prevention of infant abduction
• Administer Viamin K injection (phytonadione)

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VI. Normal Newborn

Normal Newborn Assessment

LENGTH •

WEIGHT • Small for gestational age (SGA) < 5 lbs or 2500 grams
• Large for gestational age (LGA) > 9 lbs or 4100 grams
•
VITAL SIGNS •
•

•
FONTANEL ASSESSMENT
•

HEAD CIRCUMFERENCE •

CHEST CIRCUMFERENCE •

ACRACYANOSIS •

STRAWBERRY HEMANGIOMA • Raised rough area of skin

• Harmless rash that looks like little pustules on a red base on the
ERYTHEMA TOXICUM
face, trunk, legs, and arms. It disappears by 1 week.

MONGOLIAN SPOTS •

JAUNDICE •

PETECHIAE • Small red or purple spots

MILIA • Tiny white bumps on the nose

VERNIX CAESEOSA • White cheesy protective substance

CAPUT SUCCEDANEUM • Edematous area on the head

• Collection of blood under the periosteum

CEPHALO HEMATOMA • Risk with forcep delivery or vacuum extraction
• Note: If hematoma crosses the suture line, suspect skull fracture

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Newborn Care
AIRWAY • Suction mouth before nose

• Swaddle infant
• Keep infant covered at all times
•
• Heat may be lost by:
WARMTH
• Convection – prevent drafts
• Radiation – do not place bed near window
• Conduction – do not place infant on cold surfaces
• Evaporation – keep infant dry

BATHING • Performed after temperature within normal limits

REFLEXES •
• Clean with mild soap and water
CORD CARE
• Keep area clean and dry
CIRCUMCISION • Jewish child done on day 8 (Bris)
• Taste
• Touch
SOCIAL SENSES • Smell
• Sensitivity to light

FEEDING • Bottle or Breast: teach the care giver proper positioning

levels greater than 8: Can lead to mental retardation
• Baby will need to drink lofenolac formula Low protein formula for
life)
MEDICAL CHECK
• Monitor the injection site for infection
• If done before 48 hours it will need to be repeated in 14 days

VII. The high risk neonate

A. Premature:
• Transparent skin • Weak cry
• Risk for apnea • Poor feeding
• At risk for multiple health problems

B. Postmature: • Born after 42 weeks

• Increased risk for meconium aspiration
• Monitor newborn for respiratory problems

• Signs and Symptoms: • Dry peeling skin • Creases on palms & soles

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C. Complications:

(Neonatal abstinence syndrome) • Shrill cry • Poor weight gain

• Yawning • Sneezing • Seizures
• Jittery – swaddle the infant
• Microcephaly and facial abnormality with
alcohol syndrome
TX: Supportive care to avoid continued exposure to additional medications. Opioids or
Phenobarbital used in severe cases.
2. Facial paralysis: risk increased with forcep delivery

4. Erythroblastosis fetalis (RH incompatability): Rhogam Administered:

• 28 weeks gestation
• Within 72 hours after birth
• After voluntary termination of pregnancy
• After spontaneous termination of pregnancy

Given to RH negative mothers (occurs if father is RH positive)

5. Sepsis in the newborn: may become infected during birth or related to PROM
T Toxoplasmosis
O Other ( gonnorhea, syphillis, varicella, Hepatis B, HIV)
R Rubella
C Cytomegalovirus
H Herpes

D. Congenital anomalies:

1. Heart disease

Three C’S • Coughing • Choking • Cyanosis

4. Apnea monitor : • Remove leads when not attached

• Unplug cord when not plugged into monitor

• If apneic, gently stimulate the trunk by patting or rubbing

• Treatment:

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COMMON MEDICATIONS USED IN MATERNITY

Discontinue with:
Sustained uterine
Labor induction Hyponatremia
contractions
Painful contractions
Postpartum hemorrhage Fetal deceleration
Contraindicated in uterine
Decreased urinary output
hypertonicity

Brethine (terbutaline):
Asthma Nervousness Restlessness
Tremors Hyperglycemia
Preterm labor
Hypertension
Given until 37 weeks or lung Tachycardia: check pulse prior to administration
maturity Hold if pulse is over 120

Magnesium Sulfate:
Headache N/V Hypotonia
Pregnancy induced HTN Dizziness Nystagmus
Magnesium levels of
Seizures Lethargy Bradycardia
Premature labor Diarrhea Hypotension
Urinary retention
Antidote: calcium gluconate newborn
Nurse; monitor vital signs, urinary
output, electrolyte imbalance
Erythromycin:
Used to prevent chlamydia and gonorrhea in the neonate
Eye ointment
Methergine (methylergonovine) Headache Dizziness
Post partum hemorrhage Nausea and vomiting Diaphoresis
Contraindicated in PIH Hypotension or hypertension Cramps
Given to mother at time of discharge
Rubella vaccine

Treats post partum hemorrhage after other methods have failed

Hemabate (carboporst tromethaine)
Rhogam Rh negative mother
Celestone (betamethasone)
Used to improve L/S ratio gestation
Common Opiods Demerol (meperidine) Stadol (butorphanol tartate)
To decrease pain

Clomid (clomiphene)
May result in multiple gestation
Apresoline
Treatment for hypertension
(hydralazine hydrochloride)
Treatment for respiratory depression
Prostaglandin Softens and thins the cervix
Supplement to anesthesia, treats pain during labor
Stadol (butorphanol tartrate)

Ginseng Avoid ginseng with pregnancy and lactation

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PEDIATRIC ESSENTIALS

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I. Growth and Development

• A 2 year old walks up the steps, placing both feet on steps
• A 3 year old rides a tricycle, climbs steps with alternate feet on steps

Weight:
Height:
Head Circumference:

PEDIATRIC ASSESSMENT MILESTONES ESSENTIALS

1 MONTH 5 MONTHS
Plays with toes
Cries to communicate Turns from abdomen to back
Mobiles Teething toys
Cuddling Noise making toys

Safety: Place on back to sleep 6 MONTHS

Holds bottle
Monitor temperature of formula Sits with minimal support
Rear facing car seat up to age 2 Understands name
2 MONTHS Doubles birth weight
Social smile 7 MONTHS
Lifts head
Begins to crawl
Coos
Squeeze toys
Bright pictures
Safety: Outlet covers
Hanging objects
Lock cabinets
Music
Posterior fontanel closes 8 MONTHS
Safety: Monitor temperature of bath water Sits without support
3 MONTHS Pulls to standing position
Sits with support Fear of strangers
Turn from back to side Plays games: hide and seek
Babbles 9 MONTHS
Provide rattles
Soft toys Attempts to feed self
Safety: Keep side rails up Walks holding on to furniture
4 MONTHS
Safety:
Gains head control
Supervise near water
Places objects in mouth
Consonant sounds 10 MONTHS
Squeeze toys
Can hold own bottle or cup
Grasps toys with hand
Blocks
Turns from back to abdomen
Safety: Avoid small objects
Inspect toys
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11 MONTHS 4 YEARS
Shows moods Hops on one foot
Recognizes colors
grasp)
Imaginary playmates
12 MONTHS
Walks with one hand held or alone
Triples birth weight
Safety: Car booster seat:
Safety: Guard rails on stairs
Turn pot handles inward
First dental visit
5 YEARS
2100 word vocabulary
15 MONTHS
Two wheel bicycle
Pull and push toys
Throws & catches ball
Scribbles on paper
Average weight 40 lbs
Crawls up stairs
18 MONTHS
SCHOOL AGE
Jumps on both feet Ties shoes
Games
Rules
Anterior fontanel closes
Period of industry:
Safety: Place poisons in locked cabinet
Likes to accomplish things
2 YEARS* Safety: Accident prevention

ADOLESCENT
Climbs steps with both feet on each step Needs social approval of peers
Parallel play; puzzles, blocks; rocking horse, Change in body size & development
drum Safety:
Can turn the doorknob
Sport injury prevention
Safety: Forward facing car seat up to 40 lbs Firearm accident prevention
then booster seat; Supervise near water; Drug
Avoid chunks of meat ETOH
2.5 YEARS* Sex education
Full set of 20 baby teeth High risk for suicide
Manipulative toys for muscle coordination
Crayons and paper
3 YEARS*
Rides a tricycle
Alternates feet on steps
900 word vocabulary
Puzzles, books, drawing
Puppets

Safety: Helmets
Knee pads
Stranger safety
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REFLEXES IN THE NEWBORN

•
Palmar Grasp •
• Present at birth, disappears at 4 months

Asymmetrical •

• Present at birth, disappears at 4 months

•
legs are drawn up, and the arms are brought up, out, and then in front in an
embracing position
• Present at birth, disappears at 4 months
• When side of the mouth is touched, child turns to that side
Rooting
• Present at birth, disappears at 4 months

Reciprocal • Movements of newborns are jerky and usually alternate in the legs
Kicking • Evolving at birth, disappears at 9 months

• Infants make sucking movements when anything touches their lips

Sucking • Present at birth
• Involuntary sucking, disappears at or about 9 months

Neck Righting • When the head is turned to one side, the opposite shoulder & trunk will follow
•
• Extension of the great toe on stroking the sole of the foot upwards
• Present at birth, disappears after 2 years
• Abnormal in an adult; indicates neurological damage

Dancing or Stepping

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II. Nutrition: Infant

Breast milk • Most complete and easily digested

•
Commercial formula
•
•
Solids • Cereal, fruit, vegetables then meats
• Introduce one new food/week to assess for allergies
• Given with 1:1 dilution at 6 months
Juices
• Use a cup

Chopped table foods • Given at one year

Malnutrition
• Kwashiorkor:
• Rickets: caused by a lack of vitamin D
• Scurvy: caused by a lack of vitamin C
• Infant botulism:

III. Hospitalization
A. Child’s reaction
• Fear separation: encourage parent participation
• Provide consistent care giver
Birth to 2 years old
• Provide stimulation & age appropriate toys
• Fears bodily injury: give simple explanations
PRESCHOOLERS • Parental Involvement
3 to 5 years old • Encourage expression through play
• Cover wounds
• Fears pain and bodily injury
• Fears separation from peers
• Communicate honestly
SCHOOL AGE
• Encourage participation in care
6 to 12 years old
• Allow child to make choices where possible
• Encourage visitation with peers and siblings
• Provide diversional activities
• Fears loss of independence
• Fears body image disturbance
• Fears separation from peers
ADOLESCENT
• Involve adolescent in care
13 to 18 years old
• Encourage visits
• Provide telephone
• Promote privacy
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B. Death and Dying

• No concept of death
Infants and Toddlers
• Fears separation
• See death as temporary and reversible
Preschoolers
• Magical thinking: believe bad thoughts can cause death

School Age • They see death as permanent, but do not think it will happen to them

Adolescent • Knows death is permanent and inevitable

C. Safety measures:

• Infants up to 20 lbs. or 2yrs old use rear facing car seat in the center rear of the
vehicle
• Then forward facing up to 40 lbs

• Check temperature of bath water

• Keep side rails up at all times

• Teach injury prevention

D. Medication administration

• Oral medications can be given using a syringe

• Ear drops: •
• Older child lobe is pulled up and back to straighten canal
• Intramuscular injections avoided in children
Site of choice: • Vastus lateralis, if not available use ventrogluteal
• Deltoid used over age 6

Drug Conversion for Children

Child’s weight in pounds
150
Age in years
Age in years + 12

4. Conversion of administration units:

1 tsp = 5 ml 1kg = 2.2lbs
1 tbsp = 15 ml 1 gm = 1,000 mg = 1ml
1 ml = 16 minims
1 grain = 60 mg 1 dram = 4 ml

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IIII. Infant
INFANT: NEUROMUSCULAR AND SKELETAL DISORDERS
• External rotation of hip • Limited abduction • Increased skin folds
• Shortening of leg •
Congenital Hip Dysplasia
•
hips and thighs
Club Foot • Dennis Brown Splints
Meningitis • Droplet precautions
Otitis Media • Amoxicillin drug of choice • Observe for hearing loss
Visual Disturbances •
INFANT: CARDIOVASCULAR DISORDERS
Cyanotic Defects: Poor suck, bradycardia, fainting spells
Acyanotic Defects: Tachycardia, tachypnea, delayed Growth
Congenital Heart Defects Goals: Decrease workload of the heart
Improve respiratory function
Maintain proper nutrition
Sickle Cell Anemia • Hydration, Oxygenation & Pain management (HOP)
INFANT: LYMPH, INFECTIOUS DISORDERS, IMMUNE SYSTEM
Acquired Immune
• Signs and symptoms seen at approximately 1 to 2 years of age
B. Immunizations

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Health Promotion: Assess client’s for the need for immunizations, required and recommended.

DTaP Vaccine
•
Diphtheria, tetanus, pertussis
Should be given at: • 2 months • 4 months
IPV Vaccine • Between 6 & 18 months
Inactivated Poliovirus • Between 4 & 6 years of age
• Total of 4 doses
This vaccine helps protect young children from developing:
PCV Vaccine
• Meningitis
Pneumococcal
• Blood infection (sepsis)
• CHECK FOR EGG ALLERGY FIRST!
• Not given to anyone younger than 6 months of age.
•
- All children 6- 23 months of age
Flu
- Children 24 months and older with certain medical
conditions such as asthma, chronic heart or lung disorders,
or an imapired immune system
• CHECK FOR EGG ALLERGY FIRST!
MMR Vaccine
• May be combined or separate
• Teach: DO NOT GET PREGNANT WITHIN 3 MONTHS!
TD Vaccine
• Recommended for anyone over age 7

Hepatitis B Vaccine • CHECK YEAST ALLERGY FIRST

Pertussis • Treatment for pertussis is Erythromycin

• Severe illness with fever

• Anaphylactic reaction to initial dose
• Pregnancy especially Rubella and Polio
Contraindications for Vaccines:
• HIV or immunosuppression (cancer)
• Recent blood transfusion
• Allergy to gelatin, neomycin or steroids with varicella
vaccine

C. Kawasaki Disease:
Strawberry tongue – give ASA and IV gamma globulin

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INFANT: RESPIRATORY DISORDERS

Pneumonia • Droplet precautions with bacterial infection

• An inherited disease that causes thick, sticky mucus to build up in

the lungs and digestive tract. Mucus, mucus, mucus
• Steatorrhea: • Greasy, fatty stool
• May cause meconium ileus
•
•
• Given with meals and snacks,
• Diet: high calorie, high fat. Give salty snacks (also for Lithium)
• Supplement vitamins A, D, E & K
• Prevent respiratory distress:
• Chest physical therapy
• Bronchodilators
• Antibiotics
• Avoid cough suppressants

Epiglottitis
• Inspiratory stridor
(Bacterial Croup)
• Life threatening emergency
caused by
• Mist tent with oxygen, antibiotics
type B • Protect the airway (may need tracheostomy)
• Droplet precautions
• Barking cough: Cool mist tent
• Home Care:
Croup (viral)

• Caused by RSV

Bronchiolitis
precautions

• 3 C’s:
Tracheal • Coughing
Esophageal Fistula • Choking
• Cyanosis

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INFANT: DIGESTIVE AND ENDOCRINE DISORDERS

DIGESTIVE DISORDERS

Treatment:
Thrush
• Nystatin suspension; apply with cotton swab

• Skin level device

• Allows baby to sleep on their stomach
• Used for feedings and medications
• Flush with water after feedings and meds to avoid clogging
• • Monitor skin around site for irritation
Gastrostomy Button
- indicates leakage
(G-button)
• Teach parent to carry extra button i • Teach parent to carry extra button in
case ballon breaks

• Seen soon after birth

• Thickening of the pyloric sphincter causing narrowing and obstruction

Pyloric Stenosis
• Assessment: • Olive size bulge under (R) rib cage
• Vomiting- projectile during and after feeding
• Observe rolling waves in abdomen (peristalsis)
• Failure to thrive
• Poor skin turgor
• Decreased urinary output

• Diagnostic test: • Upper GI series

• Decreased sodium, K+, CL

• Increased HCT, metabolic alkalosis

• Treatment:
• Thicken feedings

• Nursing interventions:
• Place in high fowlers
• Place on right side after eating
• Strict intake and output

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INFANT: Intestinal Disorders

• Bloody currant jelly stools with sausage shaped mass

Intussusception Treatment: Barium enema or Surgery
*If baby has a bowel movement prior to surgery, cancel the procedure

Congenital Megacolon • Absence of ganglion cells in distal colon

Hirschsprung’s • Results in obstruction with failure to pass meconium or ribbon like stools
Disease • Treatment: surgery ; temporary colostomy

Imperforate anus No rectal temperature

• Common in young children • BRAT diet

Diarrhea • May cause dehydration:
• Monitor electrolytes
• Malabsorbtion syndrome
• Fat or gluten intolerance
• Signs & Symptoms: diarrhea, large bulky stool, anemia, recurrent infections
Celiac disease
• Supplement vitamins A, D, E & K

• Can eat rice and corn

• Avoid phenylalanine
PKU • No
• Lofenolac formula
Cleft Palate and Lip • Child will need speech therapy and orthodontics
• CLEFT LIP repaired @ 2 months
• Child cannot have a respiratory infection
• Steri strips • Elbow restraints

NO PACIFIERS, STRAWS OR ORAL TEMPS 7-10 DAYS

• CLEFT PALATE IS REPAIRED AT 18 MONTHS
• Risk of infection: • Use a large holed nipple • Give water after each feeding
• Burp infant between feedings

Failure to Thrive

• The sudden and unexplained death of an infant under 1 year of age

Risks: • Previous SIDS death • Twin gestation
Sudden Infant Death • Prematurity • Alcohol and drug abuse
Syndrome • Smoking • Teach avoid soft mattresses & pillows

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IV. Toddler
TODDLER: Integumentary Disorders
• Highly contagious • Contact precautions
Impetigo • Group A Strep • Antibiotic therapy
• Child has characteristic honey crusted lesions
Burns • Rule of nines up to 12 years old
• Isolate known infected persons
Tinea Capitis (scalp) • Antifungal ointment (Lotrimin – clortrimazole)
Tinea corporis (body) • Oral Griseofulvin: • Hepatotoxic
Tinea pedis (feet) • Give with fatty meal
• Avoid prolonged exposure to sunlight
TODDLER: Musculoskeletal Disorders Fractures/Traction
• Used for children under 2 years of age
Bryants • What type of restraints should be on hand? A jacket restraint to prevent
turning and twisting out of alignment
• Short term immobilization, or for bone deformities
(skin traction) • The body acts as a counterweight
• Padded sling under the knee
Russell
•
(skin traction)
• Damage to nerve under knee may cause foot drop
TODDLER:Genitourinary Disorders
• Common in boys age 2 to 7 years of age
Nephrosis
•
• Urethral opening on ventral surface of penis
Hypospadias • Foreskin may be needed for surgical repair
• Baby should not be circumcised
• Non tender, malignant mass of kidney
• Felt in abdomen near liver
Wilm’s Tumor
•
• Treatment – nephrectomy and chemotherapy
TODDLER: Cardiovascular System
• Limit milk to 24 oz./day
• Treat with supplemental iron – ferrous sulfate
• Increase vitamin C to aid absorption
• Give liquid via straw to prevent teeth discoloration
• Give deep IM using Z track
• May cause dark colored stools
TODDLER: Gastrointestinal Disorders
• Intense pruritis at night
• Strict hand washing
Pinworms • Treat all family members.
• Treatment: Vermox (mebendazole) – single dose.
•
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TODDLER: Neurosensory Disorders

Head injury • Concussion – temporary loss of consciousness following trauma
• Abnormal muscle tone and lack of coordination
Cerebral Palsy
•
•
• Sunset eyes
Hydrocephalus
•
leakage
• Mother given folic acid early in pregnancy to prevent
• Avoid pressure to the sac
• Maintain moist sterile dressings
pina
• Treatment is surgery
• Child has paralysis below the defect with bowel and bladder dysfunction
• Teach: straight cath for residual urine using clean technique at home
• High risk for rubber allergy (latex)
Down’s syndrome • Risk factor – advanced maternal age

•
• Hours of repetitive behavior
• Bizarre motor behaviors
• Severely impaired communication
• Child is self absorbed and unable to relate to others
• May display, rocking, spinning, twirling
Autism/Autistic • Nursing interventions:
Disorder • Maintain consistency
• Determine the way child communicates
• Provide for safety if necessary to prevent self injury
• Refer to social programs
• Parental support
• Treatment: OT, PT, Speech therapy, special ED,
antipsychotics, antidepressants
TODDLER: Respiratory Disorders
• Tents most common form of O2 administration for children
• Flush tent with oxygen before putting client inside
•
• Wipe away condensation to prevent decreased visualization of child
• Keep clothes and linen dry; Plastic or rubber toys appropriate
• Leads to cognitive impairment and anemia
Lead Poisoning
• Routine screening at 12 months
(plumbism)
•

Child Abuse:
• Be alert for contradiction between injury and explanation of cause.
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PRESCHOOL: Musculoskeletal Disorders

Duchenne’s Muscular •
•
Dystrophy squatting position. It indicates lack of muscle in the lower limbs.
PRESCHOOL: Neurosensory Disorders
Seizure disorders • Generalized – entire brain involved
•
• Protect from injury
• Anticonvulsants: Dilantin (phenytoin), Phenobarbital, Keppra
(levetiracetam), Depakote (valproic acid)
• Linked to use of ASA and phenothiazine (anti psychotics)
•
Reye’s syndrome
• No ASA in children < 18 years old
• Tx: Mannitol, Diuretics and Barbiturates
PRESCHOOL: Cardiovascular Disorders
•
Hemophilia • Prevent injury
• Monitor for bleeding
• ALL (acute lymphoid leukemia)
Leukemia •
• Prevent infection
PRESCHOOL: Lymph, Infectious Disorders, Immune System

• Spread by direct contact or air droplet

• Airborne & contact precautions if hospitalized
• Spread by aerosolized droplets
•
Rubeola/Measles
• Rash appears on 4th day
• Airborne precautions

• Spread by direct and indirect contact with droplets

Rubella/ German
• Birth defects if acquired during pregnancy
measles
• Droplet precautions

• Develops after URI with beta hemolytic strep

• Heart, joints, CNS, skin and subcutaneous tissue involved
• If untreated, scarring & deformity of cardiac structures leads to
Rheumatic fever Rheumatic heart disease
• Monitor the heart routinely
• Diagnosis: increased WBC, increased ESR, + C reactive protein
• Droplet precautions

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PRESCHOOL: Respiratory Disorders

• Frequent swallowing is a sign of bleeding
Tonsillectomy •
• NO RED liquids
• Children under 4 at high risk
Choking hazards • Objects with small removable parts
• Several foods (hotdog, popcorn, grapes, hard candy etc.)
PRESCHOOL : Gastrointestinal Disorders
• Common cause of diarrhea in young children
• Incubation period is 2 days
• Symptoms include vomiting, diarrhea, fever and abdominal pain
Rota virus • Transmission: oral – fecal route.
• Usual age of occurrence is 2 years of age
• Can be spread in day care centers
• Treatment includes: oral hydration, & hospitalization if IVF are needed

PRESCHOOL : Genitourinary Disorders

• Primary cause or as a post infection condition related to streptococcal
or pneumococcal organism
• Gross hematuria, oliguria & proteinuria
•
Glomerulonephritis • Strict intake and output
• Protective isolation
• Penicillin
• Lasix
• Antihypertensives
• E.coli most common causative organism
• Boys with UTI need further work up
Treatment for chronic UTI:
Urinary tract infections

• Macrodantin (Nitrofurantoin)

•
recurrent UTI
• Treatment is surgery only in severe cases

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SCHOOL AGE: Respiratory Disorders

Asthma • Teach: regarding triggers, use of MDI

Erythema Infectiosum
•
5th disease
• Look for a rash in 4 to 14 days
• Caused by human paro virus B19
•
• Common in winter & spring
• Droplet precautions
• Pregnant women should not be in contact or care for the
infected child

• Transmitted via direct or indirect contact or droplet spread

• Fever, red rash, strawberry tongue
Scarlet Fever group A strep • Droplet precautions until 24 hours after treatment
• Bed rest
• Antibiotic therapy
SCHOOL AGE: Integumentary Disorders

Head Lice (Pediculosis Capitus) • Do not share hats/combs

SCHOOL AGE: Musculoskeletal Disorders

• Swimming is the best exercise
• ASA is the drug of choice
Juvenile Rheumatoid arthritis
•
• Goal is to limit deformity
• Disturbance in circulation causes aseptic necrosis of the
Legg – Calves Perthes Disease femoral head
•
SCHOOL AGE: Neurosensory Disorders

Treatment: • Ritalin • Quillivant • Concerta (methylphenidate)

• Dextroamphetamine (dexedrine)
• Strattera (atomoxetine)
Disorder - ADHD
• Irritability

• Occurs in children and teens

• Displays a pattern of disruptive & violent behavior
Conduct Disorder •
Treatment: Psychotherapy and medications to manage
symptoms
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ADOLESCENT: Musculoskeletal Disorders

Scoliosis • S shaped curvature of spine

• Less than 25 º curves – no treatment

• Body image disturbance • Risk for alteration in skin integrity

ADOLESCENT: Endocrine Disorders
• Goal is to maintain blood glucose levels and prevent complications
Type 1 Diabetes Mellitus
• Nutritional teaching
ADOLESCENT: Lymph, Infectious Disorders, Immune System
Mononucleosis

Hodgkin Disease
ADOLESCENT: Reproductive
• Chlamydia and gonorrhea most common
• Teach prevention
• Treat all contacts
Infections

• High risk for pregnancy complications

Adolescent pregnancy • Prematurity and neonatal problems

Mental Health

• Constant exercising • Fear of gaining weight

• Patient has deliberate self starvation with weight loss
Signs and Symptoms:
• Under weight • Lanugo
• Amenorrhea • Cold sensitivity
• Dehydration • Electrolyte imbalance
• Cardiac arrhythmias • Constipation
• Bradycardia & brittle nails • Withdrawal from social activities
Treatment: • Medical management • Behavioral therapy

• Binge eating of large amounts of food then purging by vomiting or

taking laxatives
Bulimia Signs and Symptoms: • Excessive laxative or diuretic use
• Amenorrhea • Electrolyte imbalance • Withdrawn
• Excessive dental caries and stained teeth
• Treatment: similar to anorexia, antidepressants used
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PSYCHOSOCIAL INTEGRITY

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PSYCHOSOCIAL INTEGRITY
I. Overview of Mental Health Nursing
Mental illness = inability to cope with or manage stress-
behavior
1. Cultural and ethical considerations
2. Legal / ethical issues

Technique (therapuetic) Blocks

Listening Hears but does not actively listen
Broad Openings Rejects/ ignores client responses
Restating Reinforces only part of the message & ignores other parts
Probes; assumes understanding
Reinforces unhealthy parts of client communication; stereotypes responses
Exploring Encourages tangential & circumstantial communication
Voicing Doubt Promotes anger; reinforces need for the idea/perception
Verbalizing the Implied Interprets to client; misunderstands the implied message
Summarization Forces conclusions; arrives at inaccurate conclusions
Informing Gives advice or inaccurate information, gives information before client is ready or able to learn
Focusing Forces client to discuss issues that are threatening
Sharing Perceptions Challenges the client
Ignores themes; gives advice
Humor
Silence Asks questions; fails to break nontherapeutic silence
Suggesting Gives advice; offers suggestions too early in the problem-solving process
Evaluation Focuses on or encourages only positive appraisals

4. Psychiatric assessment: PISSCAGE

• Psychomotor movement
• Decreased Interest
Watch for nonverbal cues of aggression/ violence
• Suicidal
• Sleep
• Decreased Concentration Always position yourself between the patient and
• Appetite an exit. Prepare for seclusion if necessary.
• Guilt
• Decreased Energy
Priority
mental illness, substance abuse, and psychopathy are at increased risk for
violence.
Clients at risk for self injury:
• Family problems • relationship issues • self esteem issues
•
• Bereavement • bullying • feelings of guilt
• Reaction to trauma or abuse • peer pressure
•
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• Determine who is the client in the question

•
•
• Avoid responses that could be answered with a yes or no
• Never ask why
• Maintain therapeutic communication – allow client to express their feelings,
give information and feedback
• Choose a response that sets limits on behavior and presents reality
• Avoid blocks to therapeutic communication like giving advice, giving false
reassurance and being judgmental

6. Defense mechanisms: unconscious; used by client to decrease anxiety

Compensation Covering up a lack or weakness by emphasizing a desirable trait

Denial Refuse to face reality
Displacement Discharging pent-up feelings from one object to a less dangerous object
Fantasy
Fixation Persistence into later life of interests and behavior patterns appropriate to an earlier age
Assumption of desirable personality attributes of one admired.
Insulation Passive withdrawal. Inaccessible to avoid further threatening circumstances
Isolation Walling off of certain ideas, attitudes or feelings. Separating feelings from intellect.
Projection Attribution of one’s own undesirable traits to someone else
Rationalization The attempt to prove or justify behavior
Preventing the expression of dangerous feelings and desires by exaggerating the opposite attitude.
Regression Resorting to an earlier developmental level in order to deal with reality
Repression Unconscious process that keeps undesirable and unacceptable thoughts from entering the
conscious
Sublimation Primitive or unacceptable tendency is redirected into socially constructive channels.
Suppression Keeping unpleasant feelings and experiences from awareness
Symbolization An idea or object used by the mind to represent an actual event or object
Undoing

EFFECTIVE INEFFECTIVE
Denial, self blame, verbalization of inability to cope
Relaxation, physical recreation Inability to ask for help, problem solve or meet basic
needs, insomnia, withdrawal
Adjusting expectations Reluctance to participate in treatment plan
Destructive behavior toward self and others
Inappropriate use of defense mechanisms

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II. Psychiatric Nursing: 3 phases of the nurse client relationship

• Orientation: assessment of client; establish trust
• Working –planning and intervention; establish goals, problem solving,
explore thoughts and feelings; formulate nursing diagnosis

III. Treatment Modalities

A. Milieu therapy:
destructive behavior and improve coping skills.
• Individual
• Group: individuals interact together to problem solve
• Family: focus is on family, not individual
• Behavioral: reconditioning of learned behavior

B. Managing Behavioral disorders:

• First attempt to reduce the level of arousal.
• The nurse must appear calm, and self assured. Anxiety can make the client feel
anxious and unsafe which can escalate aggression.

tight voice when scared).

• Move the situation outside or to another room, if possible. Give the client plenty of

any reason.

Suggest alternative behaviors where appropriate (“Would you like to take a walk and

• Do not try de-escalation when a person has a gun or other serious weapon.

C. Somatic Therapy
1. Electroconvulsive (ECT):
• Used to treat depression, schizophrenia, & bipolar mania after medications have failed
• NPO
• No metals in hair, hair should be clean

• Brain damage, temporary or permanent memory loss

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2. Psychopharmacology
A. ANTIPSYCHOTICS- PHENOTHIAZINES
TYPICAL - TREATS POSITIVE SYMPTOMS ATYPICAL -
• Thorazine (chlorpromazine) • (olanzapine)
prescribed for hiccups • Clozaril (clozapine) • Seroquel (quetiapine)
• Haldol (haloperidol) • Risperdal (risperidone) • Geodon (ziprasidone)
• Mellaril (thioridazide) • Abilify (aripiprazole)
• Prolixin (fuphenazine)

SIDE EFFECTS: ADVERSE REACTIONS:

• Hypotension • Tachycardia • Lethargy • Slurred speech
• CNS depression • Liver disease • Impaired mobility • Impotence
• Extra pyramidal reactions • Dry mouth • Urinary retention • Photosensitivity
(give Cogentin, Artane, Benadryl)
NURSING INTERVENTIONS:
• •
• • Change position slowly
• Give sugarless candy for dry mouth • Teach to avoid getting overheated in the sun,
• use sunblock
administration • Do not give Geodon (ziprasidone) to cardiac
patients with recent MI, or heart failure (prolongs
QT interval)

Neuroleptic Malignant Syndrome – fatal if untreated.

• Occurs with initiation of neuroleptic medications after change from one medication to
another after dose increase and with medication combinations

• Emergency treatment needed

• Signs and Symptoms:

• Tremors • Incontinence
• Discontinue medications

• Antidepressants • Lithium • Antihypertensives • Anticholinergics

B. Antidepressants:
TRICYCLICS:
• Elavil (amitriptyline)
• Tofranil (imipramine) • Drowsiness
• Pamelor (nortriptyline) • Nocturnal enuresis 182
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SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI’S):

• Cymbalta (duloxetine)
• Zoloft (sertraline)
• Paxil (paroxitine) • Pristiq (devenlafaxine)
• Celexa (citalopram) • Lexapro (escitalopram)

MAO INHIBITORS:
• Nardil (phenelzine) Dietary restrictions of foods containing tyramine
• Parnate (tranylcycpromine) Foods to avoid:
• All cheeses except cream or cottage
Clients are at risk for hypertensive crisis
• Meats (deli)
Can lead to intracranial hemorrhage •
Signs and Symptoms: • Avocados • Figs
• Increased blood pressure • Beer • Red wine
• Palpitations • Diaphoresis • Yeast extracts • Liver
• Yogurt • Sauerkraut
• Chest pain • Headache
• Smoked meats • Soy sauce
NURSING INTERVENTIONS: DRUGS TO AVOID:
Monitor vital signs frequently • Over the counter medications
• Other antidepressants • Decongestants
DO NOT STOP ABRUPTLY • Narcotics • Stimulants
• Antacids (inhibit absorption) • Cocaine
Hold medications 2 weeks before surgery
• Amphetamines • ETOH
and between change in drug class; 6
• Asthma medications • CNS depressants
weeks before starting Prozac
•
Wellbutrin, Zyban (bupropion Hcl): May be used for smoking cessation
• Drowsiness • Dry mouth • Tremors • Administer with food
Remeron (mirtazapine):
C. MOOD STABILIZERS:
Lithium Monitor levels 1 - 2 times per week until blood level is therapeutic then every month, then

D. ANTIANXIETY AGENTS: E. SEDATIVES / HYPNOTICS:

Xanax (alprazolam)
Librium (chlordiazepoxide)
Buspar (buspirone) Restoril (temazepam)
Valium (diazepam)
diarrhea, hepatomegaly
psychological dependence.
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IV. Mood Disorders

1. BIPOLAR DISORDER – manic – depressive disorder
• Moods alternate between depression and excessive elation

• Provide safe environment – PRIORITY

• Treatment: Eskalith (lithium), Lamictal (lamotrigene), Abilify(aripiprazole)

Individual / family / group therapy, ECT (mania)

2. MAJOR DEPRESSION – SAFETY, SAFETY, SAFETY!!!!

• Suicide – safety is the priority
• Provide 1:1 watch
• Ask patient directly if they have a plan
• Signs of suicidal ideation include elevated mood & giving away prized possessions
• Initiate suicide precautions
Treatment: antidepressants, individual or group therapy

a) Bipolar (manic-depression):

• Increase sodium

b) Postpartum Depression
• Occurs up to 6 months after child birth & not resolving in one or two weeks
• Inability to cope with infant care needs
• Treatment: same as depression and referral to PPD support groups
c) Dysthmic Disorder

• Treatment: same as depression

• Occurs in the fall and winter months

• Related to decreased sun
• Treatment: • Vitamin B6

• Increase fruits & vegetables

• Phototherapy

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3. ANXIETY:
MILD • Associated with every day life, can be motivating

• Focus is on immediate concerns

MODERATE
• Learning and problem solving can take place

SEVERE
• Learning and problem solving cannot take place
• Need directions to focus

PANIC
• Loss of rational thoughts
• Inability to concentrate

V. Substance Abuse Disorders

Signs & Symptoms:

• Anxiety • Nervousness
•
Frequently Abused • Irritability • Headache • Nausea & vomiting
• Nicotine
Substances • Levels greater than 100 mg/dl induces seizures
• Alcohol
Delirium tremens – HTN, tachycardia, delusions,
hallucinations and seizures
Treatment: IV anti-anxiety agents, Librium

Cocaine:
• Dilated pupils • Weight loss
• Cocaine • Increased heart rate, B/P & temperature
• Perspiration & chills • Hyperactivity
• Heroin
• Overdose: Cardiopulmonary arrest and seizures
• Marijuana • Treatment: Cardiopulmonary support
• Vicodin (hydrocodone) Heroin:
• Percocet (oxycodone) • Euphoria • Flushing • Pinpoint pupils
Substance Abuse
• Withdrawal symptoms:
• Methadone
muscle spasms
• Seconal (secobarbital)
• Treatment: Naloxone and respiratory support
• Phenobarbital Barbiturates:
• CNS depression • Dilated pupils
• Withdrawal symptoms: seizure & delirium
• Treatment: Cardiopulmonary support
• Gambling
• Sex
• Group support
Addiction • Eating
• Behavioral therapy
• Shopping
• Internet use 185
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VI. Personality Disorders

Unpredictable, self destructive behaviors
Suicide risk
Frequent displays of inappropriate anger
Borderline
Impulsiveness
Recurrent acts of crisis such as wrist cutting, overdosing or self injury
Treatment: group therapy, medications for mood & depression
Poor impulse control
Antisocial
Suicide risk

Paranoid Delusions of persecution

Grandiosity, preoccupied with fantasies of power and success

Narcissistic
Exploit others to achieve personal goals
Characterized by a pattern of excessive emotionality & attention seeking behaviors
Excessive need for approval
Histrionic
Inappropriate seductive behavior
A need to be the center of attention

High need for routine

Obsessive-Compulsive Limit, but do not interrupt compulsive acts.

Abnormal fear of open spaces or being alone in public places

Agorophobia

Disturbed response to trauma

Post Traumatic Stress
Disorder Also nightmares, depression or panic attacks
Treatment : crisis management, family therapy

The person intentionally fakes, simulates, worsens or self induces

Munchausen Syndrome
injury or illness for the purpose of being treated like a medical patient

Refers to a caregiver who fakes symptoms by causing injury to

someone else and wants to be with that person in the hospital setting

VII. Somatoform Disorders

• Multiple physical complaints that cannot be explained medically

Hypochondrias Physical symptoms perceived as life threatening

Conversion Symptoms without any physiological cause, usually neurological

Physical symptoms that involve more than one part of the body, but no physical
Somatization
cause can be found
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VIII. Psychotic Disorders

SCHIZOPHRENIA
Four A‘s Types
• Paranoia type • Catatonic type
• Residual type • Disorganized type
• Ambivalence • Autistic thinking

Signs and symptoms characterized by:

• Disordered thinking Thought broadcasting: individual believes that others
• can hear his thoughts
• Perceptual disturbances At least two of these symptoms must be pres-
• Behavioral abnormalities ent for a large portion of time during a 1- month
• Impaired social interactions period for diagnosis
Symptoms usually include:
Illusions Positive symptom
Delusions Positive symptom
Hallucinations Positive symptom
Disorganized speech & bizarre behavior Positive symptom
Lack of speech, catatonic behavior Negative symptom
Poor social functioning, lack of concentration Negative symptom
Paranoid type:
• Auditory hallucinations
• May appear hostile and angry
•
• Monitor for suicide
•

Catatonic type:
• Stupor or extreme motor agitation
• Inappropriate or bizarre body postures
• Echolalia: Involuntary repetition of words spoken by another person
• Echopraxia: Imitation of motions made by others

Disorganized type:
•

• Disorganized behaviors, psychotic symptoms (delusions, hallucinations)

Residual type:
•
behavior

*Positive symptoms = increased mental experiences (thoughts, feelings, behaviors) than a normal mental state
*Negative symptoms = a lack of feelings or behaviors that are usually present 187
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AUDITORY PROCESSING/PERCEPTUAL ALTERATIONS

Delusion
Illusion Misperception of a stimulus
Hallucination Sensory perception but there is no stimulus
DEFINITIONS
Akathisia Restlessness – give Cogentin (benztropine), Artane (trihexyphenidyl), or
Benadryl (diphenhydramine) (CAB)
Dystonia Muscle spasm
Akinesia Lethargy – feeling of fatigue and muscle weakness
Neologism Inventing new words which are only meaningful to that person
Clang association Rhyming words in a sentence that make no sense
Word Salad Disconnected /disorganized thoughts, using recognizable words that do
not make sense.
Flight of ideas Rapid change from one topic to another that is unrelated

IX. Cognitve disorders

Delirium Acute, reversible
C
Dementia
cognition, personality and judgment

Types: Symptoms:
Early Phase:
• Impaired abstract thinking, judgment &
• Vascular dementia impulse control
• HIV dementia • Neglect of personal appearance & hygiene
• Dementia due to general medical conditions Late Phase:
• Substance induced dementia

Alzheimer’s Disease
• Slow, progressive loss of intellectual ability
Early Stage • Forgetfulness

• Increase in memory loss

Middle Stage • Social withdrawal

• Wanders
Middle- Late Stage • Unable to perform simple tasks without repetition
• Unable to recognize familiar objects and family

Late Stage • Profound memory loss

• Weight loss, unable to speak or ambulate
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Medications to Increase Acetylcholine

ataxia (unsteady gait, lack of coordination) loss of appetite,

(tacrine) hepatotoxicity, nausea, vomiting, diarrhea

Aricept
nausea, diarrhea, decreased heart rate
(donepezil)

disease — take with food

(rivastigmine) stomach pain, nausea, vomiting; anorexia, black, bloody or
tarry stools

Namenda Take with full glass of water

(memantine) Contraindicated with liver disease, kidney disease, seizures, cataracts
dizziness, confusion, constipation, chest pain, tachycardia

Razadyne
bradycardia, syncope, anemia, N/V/D, dizziness,
(galantamine) headache, UTI

Terms: Apraxia: impaired motor function

Agnosia: inability to recognize familiar objects
5 A’s Amnesia: memory loss
Anomia: inability to remember names of things
Aphasia: inability to speak

Reminiscence Group

cognition and improve mood along with improved functional ability.

Validation Therapy
redirect behavior without causing anger or frustration. An important

to get them to do something else without them realizing they are

actually being redirected.

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Common Medications Used in Mental Health

ANTIPSYCHOTICS ANTICHOLINERGICS /ANTIHISTAMINES
Clozaril (clozapine)* Artane (trihexyphenidyl) *

Haldol (haloperidol)* Atarax, Vistaril (hydroxyzine)*

Mellaril (thioridazine) Benadryl (dipenhydramine)*

Navane (thiothixene) Cogentin (benztropine)*

ANXIOLYTICS / HYPNOTICS
Thorazine (chlorpromazine)* Ambien (zolpidem)

Trilafon (perphenazine) Ativan (lorazepam)*

Risperdal (risperidone)* BuSpar (buspirone)*

Seroquel (quetiapine)*

Zyprexa (olanzapine)* Halcion (triazolam)

ANTIDEPRESSANTS Klonopin (clonazepam)

Celexa (citalopram) Librium (chlordiazepoxide)*

Desyrel (trazadone) Restoril (temazepam)

Valium (diazepam)*

Extended –release Xanax (alprazolam)*

Elavil (amitriptyline) MOOD STABILIZERS

Depakote (divalproex sodium)

Paxil (paroxetine)* Depakene (valproic acid)

Lamictal (lamotrigine)*

Remeron (mirtazapine)* Lithonate, Eskalith (lithium)*

Cymbalta (duloxetine)* Neurontin (gabapentin)*

Lexapro (escitalopram) Tegretol (carbamazepine)*

Pristiq (devenlafaxine)* STIMULANTS

Serzone (nefazodone) Adderall (dextroamphetamine)

Sinequan (doxepin) Cylert (pemoline)

Wellbutrin SR (bupropion) Dexedrine (dextroampheatamine)

Ritalin, Concerta (methylphenidate)*

Zoloft (sertraline)* Strattera (atomoxetine)

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PRACTICE QUESTIONS

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Management of Care
1. A nurse has become aware of the following client
situations. Which of the following if observed shows
that the UAP needs further teaching? The UAP
A. avoids washing the body of a Jewish client until
thirty minutes after death
B. allows the family of a Buddhist client to chant ritual
rites at the bedside of their deceased father
of a Mormon client
D. removes a cup of tea from the breakfast tray of a
Seventh Day Adventist client
2. A nurse is preparing assignments for the day. Which of
per day
artery bypass graft (CABG)
C. A client diagnosed with COPD with an oxygen
D. A client with benign prostatic hypertrophy (BPH)
A nurse is preparing assignments for the day. Which
client with
A. Type II DM complaining of having cold feet
B. Congestive heart failure (CHF) with SOB after
ambulating
C. abdominal surgery with temperature of 101°
D. Chronic Obstructive Pulmonary Disease (COPD)
with a CO2 of 50
4. A nurse is doing an assessment on several clients.
Which one of them would need follow up?
A. A client with chronic renal failure that did not void
for 8 hours
B. A client with Bells Palsy complaining of tingling in
the face
nursing station with lap buddy
D. A client diagnosed with COPD with a pulse
READY TO PASS INC.
5. The nurse from the pediatric unit has been temporarily
assigned to the Emergency Department. It would be
most appropriate to assign that nurse to the client
who
B. has back pain and a pulsating abdominal mass
C. is HIV+ reporting vomiting and diarrhea
D. presents with lower abdominal pain and is six
weeks pregnant
6. A nurse has become aware of the following situations.
Which should cause the greatest concern for the
nurse? A client with
A. a bipolar disorder who is screaming at the nurses
station
C. a transurethral resection of the prostate (TURP)
has blood tinged urine in the urinary bag
D. radon seed implants is seen ambulating in hall
7. After receiving report a nurse is planning an
assignment for the day. Which of the following should
A. requesting a bedpan
B. complaining of pain 2/10 on a pain scale
C. with report of excessive tiredness
D. who did not receive a breakfast tray
8. The nurse is caring for clients who were recently
removed from a falling building. Who would the nurse
B. dilated pupils and a small laceration to the left ear
C. a fracture of the right tibia and abdominal pain
D. confusion and soft tissue injuries
9. A nurse is preparing assignments for the day. Which
A. A 48 y.o ventilator dependent client who needs a
sputum specimen
B. A 54 y.o on Bleomycin (Blenoxane) complaining
of vomiting
C. A 65 y.o with pneumonia who needs to start IV
antibiotics
D. A 72 y.o asthmatic complaining of SOB after using
Albuterol (Ventolin)
192

10. Following an accident involving two cars and a bus, a
nurse arrived upon the scene. Which of the following
A. who is restless and combative
B. with an open fracture of the right tibia
C. with an eye injury complaining of pain in the face
D. a fractured arm who is ambulatory
11. A nurse is caring for several infants. Which newborn is
A. 2 hours old who is acyanotic
C. 20 hours old with descending testicles
D. 24 hours old with a heart rate of 140 bpm
12. The charge nurse is making assignments for the day.
Maternity to a Behavioral Health unit?
A. A client diagnosed with bipolar disorder
C. A quiet patient
D. A very busy patient
14. A nurse working on a pediatric unit is made aware of
the following situations. Which child is the priority to be
A. 1 year old with Tetralogy of Fallot with bluish
discoloration to the lips while crying
B. 2 year old with renal failure with a potassium level
of 6.4 mEq/L
an elevated ESR rate
bowel movements per 8 hour shift
READY TO PASS INC.
15. The nurse is teaching a group of new nurses about
advance directives. Which of the following statements
A. A DNR order is sometimes interpreted to mean
that the client requires less nursing care, when
care needs
B. The ethical obligation to care for all patients is
of Ethics for nurses
C. A dying patient does not have the right to request
D. The durable power of attorney for health care
decisions on his or her behalf
16. A nursing instructor asks a nursing student to identify
a situation that represents an example of invasion
student indicates an understanding of a violation of
this client right?
A. Performing a procedure without consent
B. Telling the client that he or she cannot leave the
hospital
C. Threatening to give the client a medication
D. Observing care provided to the client without the
17. The community health nurse is assigned to see four
clients. Which of the following clients will the nurse see
disease who does not tolerate milk
has given away his favorite shirt
complaining of abdominal cramps
D. A 55 year old with a gastrostomy tube who will
193

18. After receiving report from the night nurse, which of
pregnant complaining of a small amount of
vaginal bleeding
asking for assistance to the commode
scheduled for a total abdominal hysterectomy
had a gastrectomy yesterday
19. After receiving report, which of the following clients
that has a rash on the trunk
colonoscopy who is refusing care
complaining of tingling in the digits
20. The nurse is caring for postpartum clients who had
vaginal deliveries within the last eight hours. The
A. has a pulse rate of 66 beats per minute
B. has saturated one perineal pad in two hours
C. reports swelling in her right calf
D. asks if her baby can sleep in the nursery
tonight
21. The nurse is caring for four newborns in the nursery.
Which of the following infants is the priority while
planning care? The infant who is
A. one hour old experiencing acracyanosis
C. one hour old whose eyes appear crossed
D. three hours old with an edematous area on the
head
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22. The nurse received change of shift report, which
of the following clients will take the highest priority
when planning care?
A. The client with (end stage renal disease) ESRD
who has not voided in ten hours
who has had a recent increase in restlessness
C. The client who is four hours post operative
bladder biopsy and is experiencing hematuria
D. The client who is diabetic experiencing tingling
of the toes
vehicle accident with several injuries. Which of the
A. A 16 year old female who is unresponsive with
dilated pupils
B. A 22 year old male with deformity of the right
arm who is reporting pain
laceration
D. A 50 year old female experiencing anxiety, and
generalized weakness
24. The RN needs to make assignments for four
Which of the following clients would be appropriately
A. the client who needs a simple dressing change
of an abdominal wound
B. client who needs irrigation of the colostomy
C. the client receiving parenteral feedings
D. the client requiring administration of an enema
prior to a surgical procedure
25. Which of the following clients is appropriate to
assign to an LPN for medication administration?
A. A 25 year old in sickle cell crisis who will need
Morphine intravenously
a PCA pump
C. A 50 year old who will need Regular Insulin
coverage for a glucose reading of 240mg/dl
D. A 60 year old who needs Dopamine
intravenously for blood pressure management
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26. The charge nurse is making assignments for the day.

Which assignment should be assigned to the
the Pediatric unit to the Emergency Department? LPN?

A. A 2 year old admitted with suspected ingestion of A. Application of wrist restraints

chlorine B. Collection of a 24 hour urine specimen
B. A 5 year old being treated for Asthma that is not C. Assisting a client to ambulate after surgery
responding to bronchodilators D. Initiation of the clients plan of care
C. A 7 year old brought to the department following a
motor vehicle accident
D. A 10 year old awaiting admission following cast Which action should be appropriately assigned to
placement the LPN?

27. Which client would you assign to the new grad RN?
exacerbation
B. The client scheduled for transfer to the ICU
C. A client experiencing chest pain after coughing
D. A newly admitted client who needs the initial
assessment completed
A. Bathing a child admitted with chickenpox
B. Taking the vital signs of the recently admitted
client
C. Transporting a client to the chapel for noon
time prayers
D. Insertion of an indwelling catheter for a client
with urinary retention

28. Which action should the nurse delegate to the UAP volume excess, which of the following interventions
when providing care for the client with CHF? would be best delegated to an experienced UAP?
Select all that apply.
A. Checking the clients weight daily
B. Teaching regarding dietary restrictions A. Monitor EKG readings
C. Monitoring the amount of pedal edema
D. Notifying the physician about the presence of a C. Check for the presence of pedal edema
cough D. Insert IV line
E. Document hourly urine output
29. The Charge nurse is making assignments for the day. F. Measure weight

client is appropriate to assign to the UAP?

medical surgical unit. Which client would be most
A. The client who had a stroke 4 days ago with left appropriate to assign to the nurse? A client that:
sided weakness who needs feeding
B. The client who needs assistance with oral A. is 4 hours post operative following
suctioning cholecystectomy
C. A recently admitted client who needs their vital
signs taken C. has mechanical ventilation and needs to be
D. A client who requires chest physiotherapy every suctioned
shift D. is in traction for a broken femur

will you assign to the Maternal Health nurse who is

A. A postpartum client who is ventilator dependent

B. The client with gestational diabetes admitted with
glomerulonephritis

exploratory laparotomy
D. A client scheduled for spinal surgery who needs

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6. The nurse is caring for several clients requiring

isolation. There is one private room available on
Safety and Infection Control
the unit. The nurse should place the highest priority
on assigning which of the following clients to the
1. A nurse is caring for the following clients. Which client
private room?
is the priority for a private room? A client with
A. The client with fever and diarrhea for 2 days
A. HIV infection
after taking antibiotics
B. Cirrhosis of the liver
B. The client who is HIV + with a temperature of
C. Scabies
101°
D. Pneumonia
C. The client with low grade fever and night
sweats
2. A nurse is caring for the following clients. Which client
D. The client with Leukemia whose temperature is
is a priority for a private room? A client with
100°
A. Rubeola
7. The infection control nurse is making rounds on
B. Rubella
a Medical Surgical unit. Which of the following,
C. Klebsiella Pneumoniae
if observed by the nurse requires immediate
D. Pediculosis
intervention?

A. A CNA is observed wearing gloves while

is a priority for a private room? A client with
emptying a foley catheter
B. An RN is observed wearing a surgical face
A. Hepatitis
mask while caring for a client with tuberculosis
B. Pyelonephritis
(TB) in a negative pressure room
C. Gastroenteritis
C. An LPN is observed wearing a gown and
D. Meningitis
gloves while caring for a mentally ill client with
4. A client recently diagnosed with AIDS is being
D. A RN is observed wearing a gown, gloves,
discharged home from the hospital. Which of the
and shoe covers while caring for a client with
following statements if made by the client would
Pertussis.
indicate a need for further teaching?

A. “I cannot go shopping in the mall during the

successfully assisted the clients to safety during a
B. “I will have to avoid fresh fruit and vegetables
nurse perform next?
C. “I will clean my bird cage as soon as I get
A. Close all open doors
B. Call for additional help
D. “I should not visit my sister since she has the

5. A nursing student observes the following situation on

the unit . Which occurrence would require an incident
clients. It would require immediate intervention if
report?

A. a client reports sexual abuse by a family member

amputation (AKA) 24 hours ago in a prone
position
medication to a client who is scheduled for
B. keeping the head of the bed elevated for the
surgery
client who had an supratentorial craniotomy 12
C. a client became angry when the nurse removed
hours ago
their dentures prior to going to the O.R.
C. giving orange juice to a client who has a clear
liquid diet prescribed
operative teaching provided
D. removing all liquids from the tray before giving
the tray to a client who has dumping syndrome

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10. The nurse should initiate protective precautions for the 6. A nurse is teaching a class to parents regarding
client who has appropriate toys for their infants. Which of the
following would be the most appropriate toy for a

C. Hemoglobin (Hgb) 9.0 g/dl A. soft, colorful squeeze toys

B. teething toys with small removable parts
C. soft padded books and blocks
Health Promotion and Maintenance D. low lying mobile in the crib

7. A nurse is teaching a class to parents regarding

abnormal in a newborn? appropriate toys for their toddlers. Which of the
following would be the most appropriate toy for a

C. Closed posterior fontannel A. tricycle

B. rocking horse
C. puppets
2. A nurse is caring for a client experiencing late D. a ball to throw and catch
decelerations. The appropriate initial action by the
nurse is to: 8. The nurse is working in a pediatric clinic. A 2
month old baby is brought in for a well baby check
A. change the clients position up. The nurse should anticipate the following
B. notify the health care provider in charge vaccinations will be required during this visit
C. increase the Pitocin (Oxytocin) drip
A. Hepatitis B, Varicella, OPV
B. Hepatitis B, PCV, MMR
C. Hepatitis B, DTaP, HIb, IPV, PCV
D. Hepatitis B, HIb, IPV, MMR, PCV
a prolapsed cord? The initial action of the nurse should
be to 9. A nurse working in a clinic is doing teaching
regarding sexually transmitted Infections. The
A. use a sterile glove to put cord back inside client cannot understand how syphillis was
B. place the client in trendelenburg position contracted because there has been no sexual
C. use a dry sterile gauze to cover the cord activity for several days. As part of teaching,
the nurse explains that the incubation period for
fetal positon syphilis is about:

4. A nurse is caring for a client experiencing mastitis. A. 1 month

Which action would be most appropriate? B. 1 week

A. Advise the client to discontinue breast feeding

B. Encourage the client to express milk from the
breasts frequently
C. Apply ice chips every 15 minutes
5. A nurse in the prenatal clinic is caring for a client.
10. The nurse working in an adolescent clinic is
with Measles, Mumps, Rubella (MMR) vaccine.
Important data collection prior to administration
should include

2017 to May 8, 2017. Calculate the expected date of A. a history of the last Tetanus & Diphtheria (TD)
injection
B. checking for allergy to yeast
A. March 15, 2018 C. date of the last menstrual period
B. January 10, 2018 D. having the client sign a consent form
C. February 10, 2018
D. February 15, 2018

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4. A nurse is caring for a client who is racing around

nurse should expect the infant to the unit and wringing his hands. He is breathing
rapidly and complains of “feeling his heart racing
A. turn from abdomen to back
B. say one syllable words attack. This anxiety can be interpreted as:

D. sit without support A. Mild

B. Moderate
C. Severe
gestation. The nurse would be correct to state that D. Panic
the client is in the second stage of labor when
5. A nurse is teaching a parent of an adolescent with
A. the placenta is delivered severe depression signs of an impending suicide
B. bulging is seen in the perineum attempt. Which of the following should alert the
C. contractions are irregular parent of a high risk for suicide?
D. rubra lochia is noted
A. The adolescent sleeps most of the day
Psychosocial integrity B. The adolescent has a plan to kill herself
C. The adolescent has recently lost ten pounds
1. A nurse is caring for a client taking Thorazine D. The adolescent refuses to eat, and frequently
(Chlorpromazine). Which statement shows an forces herself to vomit
understanding of instructions regarding this
medication? The client states 6. An emergency room nurse is caring for a client with
suspected phenobarbitol use. Which of the following
will result if the client has a barbituate addiction?

A. Watery eyes, slow shallow breathing, frequent

B. Dilated pupils, shallow respirations, weak and

2. A client on an inpatient psychiatric unit believes the rapid pulse
C. Constricted pupils, respirations depressed,
nausea, vomiting
D. Sluggish pupils, increased respirations,
B. Allow the client see others eat their food decreased pulse

D. Taste the food in front of the client to prove it is 7. A nurse is assessing a client with major depression.
edible Which statement, if made by the nurse is most
appropriate?

who has lithium (Lithotabs) prescribed. The nurse A. Tell me more about the voices you have been
should suggest that the client have which of the hearing
following snacks? B. You seem to be very angry, when did you last
feel happy?
A. A fresh fruit cup C. Have you had any thoughts of harming
yourself?
C. Peanut butter and celery sticks D. When was the last time you had fun?
D. Raw vegetables

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8. The nurse is developing a nursing care plan for a client Physiological Integrity: Basic care and
who is the manic phase of bipolar disorder. Which Comfort
intervention should the nurse include in the plan of
care? 1. The nurse is teaching a class on nutrition. Which
of the following selections would be the highest in
K+?
B. Engage the client in competitive games
C. Encourage the client to avoids foods containing A. Corn, oatmeal, tomatoes
tyramine B. Carrot, broccoli, yogurt
D. Place the client on direct suicide observation C. Milk, sardines, beef
D. Potato, spinach, avocado

nervosa. The nurse should assess the client for 2. A nurse is caring for a client admitted with

A. stained enamel of the teeth may be necessary to include?

C. persistent ringing in the ears A. Vitamin B6

D. white patches on the tongue B. Vitamin A
C. Vitamin B1
D. Vitamin C

care. Which of the following statements if made by the

nurse would require follow up? Which of the following statements shows that

A. The family of a client of the Buddhist faith may ask

for a priest to be present at the time of death
B. The family of a client of the Jewish faith may
request to have mirrors covered after the death of C. “I will have popcorn and juice while I am at
the client
C. The family of a client of the Muslim faith may
request that the body of the client be turned to face
4. The nurse is observing a client with renal failure
D. The family of a client of the Hindu faith may request select foods from the lunch menu. Which of the
following selections if made by the client would
death indicate a need for further teaching?

11. A 45 year old client who was recently diagnosed with A. Haddock and spaghetti
terminal cancer says to the nurse “If God could only B. Cereal with buttermilk
let me live long enough to put my daughter through C. Corned beef and rice
D. Egg salad on wheat toast
nurse caring for this client recognizes this statement as
5. Mr. Jones is being treated for uric acid stones.
While doing a dietary history, which of the
A. Denial following food choices demonstrates a need for
B. Acceptance further teaching?
C. Bargaining
D. Anger A. chicken and baked potatoes
B. asparagus and liver
C. scrambled eggs and cheese
D. pancakes and bacon

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6. A client is taking dyrenium (trimterene) and is observed 10. The nurse is attempting to collect a stool sample for
eating the following foods. Which foods should the occult blood. Which of the following foods should the
nurse instruct the client to avoid? client avoid prior to the test? Select all that apply:
A. fried chicken and rice A. Oranges
B. baked potatoes and fresh spinach B. Watermelon
C. pasta and gravy C. Bananas
D. macaroni and cheese and legumes D. Kiwi
E. Avocado
7. The nurse knows that the plan of care for a client with
severe Ulcerative Colitis would include which of the 11. A client is performing quadriceps sets to strengthen
following? the muscles used for walking. When performing
these exercises, the client contracts his quadriceps
A. Low protein, high carbohydrate diet with no change in muscle length and no joint
B. Low residue, high protein movement. What term does the nurse use to
C. High protein, high residue describe this type of exercise?
D. High carbohydrate, high protein __________________
8. While providing nutritional counseling for a client with
12. A nurse is teaching a client to ambulate with
a colostomy the client should be instructed to avoid
crutches. The crutch gait the nurse should teach a
the following foods. Select all that apply
client after a single leg amputation is the:
1. cabbage
2. corn
A. two point gait
B. three point gait
4. parsley
C. four point gait
5. spinach
D. swing through gait
7. popcorn
8. turkey
vascular accident (CVA) is learning to ambulate with
a cane. The nurse should teach the client to
A. 1, 2, 5, 7, 8
A. hold the cane on the left side and move the
cane with the right leg
D. 1, 2 ,5, 6, 7
B. hold the cane on the right side and move the
cane with the left leg
9. The nutritionist is providing counseling to several
C. hold the cane on the left side and move the
clients on the unit. They are discussing various
cane with the left leg
vitamins and minerals. Which of the following
D. hold the cane on the right side and move the
statements need to be corrected by the nurse?
cane with the right leg
A. vitamin B12 may be needed if a client has a
14. A nurse is caring for a client that recently had surgery.
gastrectomy
To promote healing of a large surgical incision, the
B. vitamin D is responsible for proper utilization of
nurse should encourage the client to increase the
calcium and phosphorous
following in the diet:
C. vitamin A can be found in squash, pumpkin, and
carrots
A. honey dew
D. vitamin B6 (pyridoxine) is used to treat alcohol
B. apples
C. oranges

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11. A client is to receive Dopamine (Intropin) 2 mcg/kg/

Physiological integrity: Pharmacological and
Parenteral Therapies
1. Haldol is available in 0.5mg tablets. The desired
dose is 1mg. How many tablet(s) will you give?
min. The client weighs 187 pounds. The available
milliliters should be administered each hour? (Do
not round)
_______________________ml

____________________tablet(s) 12. The nurse is providing client teaching for a client

receiving Bumex (Bumetamide). When selecting
2. An infant is to receive Cefuroxime 10mg/kg. What is foods, it would be appropriate to include which of
the correct dosage if the child weighs 8 lbs? the following?

____________________mg A. apricots
B. organ meats
Vancomycin is available in 225mg. The desired dose C. sardines
is 0.45gm. How many tablet(s) should be given? D. milk

____________________tablet(s)
The health care provider suspects a urinary tract
4. A nurse is preparing to give a dose of Bumex IV to infection. Which of the following medications would
an infant. The prescription reads give 1mg/kg daily.
If the infant weighed 6lbs how many mg should the
infant receive? A. Zyvox (linezolid)

___________________mg C. Urecholine (bethanecol)

D. Gentamycin (garamycin)
5.
strength is 2.5mg/ml. How many ml should be 14. The health care provider prescribed potassium
given? chloride 20 Meq, daily. The drug available is liquid
potassium chloride10 mEq, per 5ml. How many ml
__________________ml should the nurse administer?

6. An IV of RL 1,000 ml is to infuse over 8 hours. The __________________________ml

15. The Nurse Practitioner ordered Tetracycline

__________________gtt(s)/min hydrochloride 80 mg by mouth Q6h. The bottle

7. 12mg:6ml as 10mg: the nurse administer? (do not round)

___________________ml __________________________ml

8. Dilantin is prescribed for a child that weighs 44lbs. 16. A nurse is monitoring a client initiated on Lasix
The prescription reads give 6mg/kg. How many mg (furosemide) 20mg intravenously daily for the past
should the nurse administer? 2 days. Which of the following should be included?
____________________mg Select all that apply

9. Heparin 7500 units is desired. The available dose

is 10,000 units/ml. How many ml should the nurse B. tell the client to stand slowly while getting out of
administer? bed
_____________________ml C. monitor electrolytes
D. teach the client to avoid foods high in
10. potassium
min. The client weighs 185 pounds. The available E. administer the medication at night
dose is 400 mg per 500 ml D5NS. How many mil F. monitor weight
liliters should be administered each hour? (Round to
the nearest tenth)
______________________ml

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17. A client is to receive 1500ml of ringers lactate (RL) over
a period of 8 hours. The drop factor is 20gtts/ml. The
22. A physician has selected a medication for a client
with glaucoma that is to be administered one time
per week. Which of the following medications is
a direct acting parasympathomimetic agent used
as a miotic in the treatment of glaucoma?

18. The nurse is caring for a client with AIDS and is to
administer Retrovir (AZT). Which of the following should
the nurse be aware of?
A. the drug may cause drowsiness
B. it is usually taken once a day in the morning
C. the client should avoid foods high in protein
D. the drug may cause renal and hepatic impairment
19. A client has been diagnosed with rheumatoid arthritis.
A prescription for Plaquenil (hydroxychloroquine) has
been prescribed. The nurse should inform the client:
A. it will be necessary to have frequent opthalmological
exams
B. that the medication may cause diarrhea and
hypertension
C. it is best absorbed on an empty stomach
hours
A. humorsol (demecarium)
B. cyclogyl (cyclopentolate)
C. pilocarpine (pilocar)
D. timolol (timoptic)
home from the hospital. While reviewing the
medications prescribed which of the following
statements if made by the client requires further
teaching?
A. “The meclizine (antivert) will help with my
B. “The diazepam (valium) will help to control
C. “The promethazine (phenergan) will help my
D. “The hydrochlorothiazide (hydrodiuril) will
24. The nurse is caring for a client taking the
medication Clozaril (Clozapine). Which of the
following statements if made by the client shows

20. A nurse is preparing to administer Cefazolin sodium

minute period. The drop factor is 15 drops per milliliter. C. “I should expect a decrease in my risk of
How many drops per minute should the nurse regulate
the infusion to run at: D. “I must remember that hypertension is
__________________gtt/min

21. A physician prescribes Ceftriaxone (rocephin) 2.5g 25. A student nurse is preparing to administer Cardura
IVBP every 8 hours for a client. The vial is labeled 5g (Doxazosin). Which of the following should be
per 10ml. The nurse would be correct to administer included in teaching? Select all that apply
_________ ml.
A. avoid driving
A. 1.25 ml B. expect increased libido
B. 2.5 ml C. double doses if one dose is missed
D. continue to take cold remedies
D. 5 ml E. blurred vision may occur
F. palpitations are expected

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26. The nurse is teaching a client about the use of Amaryl

(Glimepiride). Which of the following is a possible Cotazym (Pancrelipase). Which of the following
adverse reaction? if stated by the client shows a need for further
instruction?
A. hyperglycemia
B. thrombocytopenia A. “My capsules may be opened and sprinkled on
C. hypernatremia
D. leukocytosis B. “I will administer the medication before or with

27. The nurse is teaching a client about possible adverse C. “I should eat more chicken with this
reactions to the drug Thorazine (Chlorpromazine).
Which of the following should be included in client D. “My tablet can be mixed with apple sauce and
teaching? Select all that apply

A. blurred vision may be expected

B. avoid going to the beach is receiving Norvir (Ritonivir). Which of the following
C. diarrhea is common is not related to the use of this medication?
D. expect an increase in appetite
E. sugarless candy may be helpful A. cholesterol level of 250mg/dl
B. calcium level of 15.0mg/dl
psychoses in an adult C. creatinine level of 5.0mg/dl
D. glucose level of 200mg/dl
28. The parent of a child taking Concerta (Methylphenidate)
calls the clinic and reports the following symptoms.
The nurse knows which of the following is an expected used herbal products. Which of the following is not
true?

A. lethargy A. Black Cohash may be used for dysmenorrhea

B. increased appetite B. Don Quai should not be used while taking
C. weight gain aspirin
D. metallic taste in the mouth C. Echinachea may be used to treat Multiple
Sclerosis
29. The nurse is teaching a client about the use of
the medication Prilosec (Omeprazole). Which of
the following if verbalized by the client shows an
understanding? Select all that apply of several herbal remedies. Which of the following
statements if made by the client indicates a need for
A. “My tablet may be crushed and mixed with further teaching? Select all that apply

A. “I usually take my Fever Few on an empty

C. “The use of Hawthorne may contribute to my

F. “Ginger may help with my nausea and

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of the following diuretics require additional potassium (Lanoxin) for a client. It would be a priority for the
consumption? nurse to ask the client if they are using which of
the following herbal remedies?
A. midamor (amiloride)
B. aldactone (spironolactone) A. Ginseng
C. demadex (torsemide) B. Echinacea
D. dyrenium (triamterene) C. Aloe Vera
D. Black Cohash

oz of egg nog. The calculated intake would be: 40. The nurse is providing discharge teaching for
the client receiving Prozac (Fluoxetine). Patient
A. 515 ml teaching must include avoidance of which herbal
B. 585 ml remedy?
C. 625 ml
D. 645 ml A. St. Johns Wort
B. Echinacea
C. Valerian Root
medical history includes coronary artery disease. A D. Saw Palmetto

168 and total Cholesterol 270. Which of the following Physiological integrity: Reduction of Risk
medications might be included in the plan of care? Potential

1. The nurse is caring for a client with Chronic Renal

B. Coumadin (Warfarin Sodium) 2 mg po at bedtime Failure. Which lab is of most concern?
C. Questran (Choleystyramine) 4 gms po every day
D. Reglan (Metoclopramide) 10mg po as needed A. potassium 7.2 mml/L
B. creatinine 15 mg/dl
C. blood urea nitrogen 68 mg/dl
aware of the importance of which the following health D. calcium 7.8 mg/dl
teachings?
2. A nurse is caring for a client who is complaining of
muscle spasms and rigidity. It would be a priority
administration for the nurse to check which lab value?
B. take medication after breakfast daily
C. change position slowly while taking this A. K+
medication B. NA+
D. monitor the pulse rate prior to administration C. Ca+

used in Labor and Delivery. The nurse would be

correct to state that the drug used to stimulate lung following values. Which lab result is of most
development in the fetus is concern?

A. Terbutaline (Brethine) A. K+ 5.2 meq/L

B. Oxytocin (Pitocin)
C. Hydralazine (Apresoline) C. Ca+ 10.9 mg/dL
D. Bethamethasone (Celestone)

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4. A nurse is caring for a client with Multiple Myeloma. 9. Which of the following statements regarding cancer
The nurse would expect abnormalities in which of the is false?
following lab values?

A. ammonia testicular cancer

B. red blood cells B. the risk for cancer of the prostate increases
C. glucose with age
D. potassium C. early cervical cancer rarely produces
symptoms
D. pap smears are essential to detect uterine
the physician documented that the client has a renal cancer
disorder. Which of the following would be indicative of
the condition? 10. While teaching a class about the risks for breast
cancer the nurse should include which of the
A. hemoglobin level of 16 following risk factors? Select all that apply:
B. potassium level of 4.0 mEq/L
C. blood urea nitrogen (BUN) level of 40mg/dl A. Early onset of menstruation
D. white blood count of 5,000 B. Low fat diet
C. Menopause after age 55
6. The nurse is visiting a client with renal calculi. Which D. First child late in life
of the following statements if made by the client E. Nulliparity
indicates a need for further teaching?

A. “I will eats lots of spinach and take my calcium 11. A client who has had a colostomy is one day

colostomy stoma is moist and pink with no drainage.

C. “If I have burning during urination I will notify the Which of these actions should the nurse take?

A. Irrigate the colostomy with normal saline

B. Apply petroleum gauze dressing to the stoma
C. Document the condition of the stoma
D. Palpate the abdomen around the stoma

12. The nurse is assessing a new graduate nurse

include who is caring for a client with a nasogastric tube.
The nurse would intervene immediately if the new
A. weight loss graduate
B. decrease in blood pressure
C. decreased inspiratory rate
D. coughing and wheezing she placed her stethoscope over the stomach
to listen for bowel sounds
B. Stated “the length of the tube placement is
employment physical had the following laboratory determined by measuring from the nostril to the

prompt investigation?

A. hemoglobin of 16 g/dl D. Asked the patient to sit in high fowlers position

before initiating the feeding

D. blood urea nitrogen of 15 mg/dl

205

brought into the emergency room after swallowing a cup
of chlorine bleach. After interviewing the parent, which
of the following would cause the greatest concern?
A. the parent called the poison control center to obtain
information
B. the parent administered a glass of milk
C. the parent administered syrup of ipecac
D. he parent attempted to perform CPR when the
child could not respond
14. A nurse is using the Glasgow coma scale to assess
a client who had a head injury. During assessment,
the following is observed: Eyes open to speech, motor
response appropriate, client obeys commands, and
conversation is confused. The client should receive a
score of:
15. The nurse is caring for a client status post trauma to the
brain. The nurse should be aware that the normal range
of intracranial pressure is:
Disease. Which of the following actions if taken by the
student would be most appropriate?
water for snack
water
C. The client is encouraged to ambulate frequently in
the hall
D. The student places the client in a room close to the
nurses station
READY TO PASS INC.
17. A client was recently admitted into the emergency
room reporting rapidly progressing visual
impairment and loss of peripheral vision. The
most likely diagnosis for this client is:
A. macular degeneration
B. closed angle glaucoma
C. exacerbation of cataracts
D. retinal detachment
18. A nurse is caring for a client with a diagnosis of
gout. Which of the following laboratory values
would the nurse expect to note in the client?
A. uric acid level of 9.0mg/dl
B. calcium level of 9.0mg/dl
D. potassium level of 4.0 mEq/L
19. The nurse is caring for an adult client that was
injured in a welding accident. According to the
to their anterior chest and arm have an injury that
approximates:
20. A nurse is caring for a client that recently had
surgery on the left inner ear and is being discharged
home. Which of the following statements if made
by the client would indicate a need for further
teaching?
21. The nurse is caring for a client who underwent
surgical repair of a detached retina of the right
eye. Which of the following interventions should
the nurse perform? Select all that apply.
A. place the client in the prone position
B. approach the client from the left side
C. encourage deep breathing and coughing
D. discourage bending at the waist
E. orient the client to his environment
F. administer a stool softener as prescribed
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22. The patient with emphysema reports dyspnea at night.

Which of the following positions would be appropriate conference on preparing clients for neurological
diagnostic tests. Which of the following statements,
night?

A. “The electromyogram (EMG) is performed

B. Side lying with the head propped up by introducing small needle electrodes into
C. Supine position with 4 pillows under his head
D. Place the patient in a recliner to sleep B. “After having a Positron Emission Tomography
(PET) of the head the client can resume normal

C. “The electroencephalogram (EEG) will require

that apply the client to be NPO for 12 hours before the

A. Diarrhea D. “After the lumbar puncture (LP) the client will

B. Dry skin
C. Anorexia
D. Tachycardia 27. While doing a routine check up with the gynecologist,
E. Excessive menstruation
F. Heat intolerance infections. The nurse knows which of the following
may be noted?
24. The nurse is caring for a client with hypothyroidism.

that apply B. a white blood count of 10,000 cc mm

C. a HGB (hemoglobin) of 15 mg/dl
A. Constipation D. a BUN (blood urea nitrogen) of 19 mg/dl
B. Dry skin
C. Anorexia 28. The nurse is assessing a client who is 5 hours
D. Insomnia status post a transurethral resection of the prostate
E. Bradycardia
F. Palpitations immediate intervention?

25. A nurse is teaching a client being discharged after A. bladder spasms

surgery on the right eye for glaucoma. Which of the B. abdominal distention
following statements if made by the client requires C. blood tinged urine
further teaching? D. nausea

29. A client who has had a spinal cord injury is scheduled

nurse should instruct the client to avoid

A. foods that are spicy

B. people who have upper respiratory infections
C. developing urinary retention
D. emotional stress

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neurological disorders. Which of the following

who statements, if made by the nurse is incorrect?

eating paralysis and may be caused by a predisposing

B. had a transurethral resection of the prostate (TURP) event such as respiratory or gastrointestinal
24 hours ago reports blood in the urinary bag infection
C. had a fractured femur 2 days ago reports a rash on
the chest females equally and may be caused by a
D. removed a hearing aid requests a toothpick for decrease in acetylcholine
cleaning
environmental trauma and is commonly
treated with Levodopa
returned to the unit after a liver biopsy. The nursing D. Multiple Sclerosis is common in middle aged
student would be correct to position the client
test
A. in the trendelenburg position
B. on the right side with a small pillow 4. A nurse is noted to ask a client to protrude the
C. on the abdomen with the legs abducted tongue and move it from side to side. Which
cranial nerve is the nurse assessing?
elevated 45 degrees
A. Glossopharyngeal (IX)
B. Vagus (X)
Physiological Integrity: Physiological C. Spinal accessory (XI)
Adaptation D. Hypoglossal (XII)

1. A nurse is providing care for a client with Type I DM 5. A community health nurse is teaching a class
complaining of a headache. What should the nurse do about the risks for developing cervical cancer.
The nurse would be correct in saying that risks
include: select all that apply
A. Give one cup of orange juice
B. Call the nurse in charge A. sex after age 20
C. Check the clients glucose level
D. Administer insulin as prescribed C. nulliparity
D. smoking
2. A client is experiencing acute renal failure that is post E. multiple sex partners
renal in nature. The nurse should know that this is F. exposure to the human papilloma virus
probably due to (HPV)

A. cardiogenic shock 6. The nurse is caring for a client who reports

B. hypovolemia right side facial pain associated with drinking
C. nephrotoxic substances hot beverages. The nurse suspects a possible
D. urethral obstruction diagnosis of

A. Trigeminal neuralgia

D. Transient Ischemic Attack

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7. The nurse is caring for a newborn infant who has

been diagnosed with Coarctation of the Aorta. Which

diagnosis?

A. Weak femoral pulses

B. Bluish discoloration to the lips while crying

D. Respiratory distress

8. A client is admitted to the hospital with a diagnosis

of type 1 Diabetes Mellitus. The nurse is assessing
the client for signs of Diabetic Ketoacidosis. The
following should be expected? Select all that apply

A. Fruity breath
B. Anorexia
C. Kussmaul respirations
D. Metabolic acidosis
E. Increased blood pressure
F. Bradycardia

9. The nurse is caring for a client that is suspected to

have Diabetes Insipidus. Which of the following
symptoms would be suggestive of this condition?
Select all that apply

A. urinary frequency
B. hyponatremia
C. dehydration

E. increased thirst
F. preference for hot liquids

mEq/L. The nurse should recognize that this result is

suggestive of which acid base imbalance?

A. compensated metabolic acidosis

B. compensated respiratory acidosis
C. compensated metabolic alkalosis
D. compensated respiratory alkalosis

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RATIONALES FOR PRACTICE

QUESTIONS

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Rationales
Management of care
1. C. The statement further teaching indicates you
are looking for an incorrect response. Clients of the
Choices A, B, and D are correct.
2.
4. C. The term follow up indicates you need to intervene.
The client with a lap tray or (lap buddy) needs
intervention as this is considered an illegal restraint.
5.
experiencing a cardiac event; clinical manifestations
suggestive of abdominal aortic aneurysm include
abdominal mass and abdominal throbbing; the client
who is 6 weeks pregnant experiencing abdominal
pain must be evaluated to rule out ectopic pregnancy
which could be life threatening.
6. D. A client with radon seed Implants should be on
absolute bed rest in a private room to avoid emission
of radioactive material. Clients should also avoid
infants and pregnant women. Choices A, B, and C
7. C. Excessive tiredness may be a sign of hypertension
or increased intracranial pressure. This client should
at this time.
8.
pressure and or hypoxia. According to disaster
triage choices A and C are considered (priority level
priorities.
READY TO PASS INC.
9. D. Albuterol is a short acting bronchodilator which
should improve breathing. If there is no change in
10. A. Restlessness and combativeness are signs of
hypoxia. This client would take priority. According
to disaster triage Choices B and D are (priority level
11. B. Jitteriness is indicative of opioid withdrawal in
the newborn. Choices A, C, and D are normal for a
newborn.
12. C. A quiet patient is most likely exhibiting signs
of depression. The maternity nurse can manage
this patient. Clients A, B, and D should be cared
for by the behavioral health nurse who has more
experience in this area.
60 per minute. A rate of 70 indicates tachypnea
suggestive of distress. Choices A, C, and D are
Hyperkalemia places the client at risk for arrythmias.
This infant is the priority. Choices A, C, and D are
looking for an incorrect statement. A dying client does
needed. Choices A, B, and D are
16. D. Clients have the right to privacy while hospitalized.
Permission should be granted prior to observation
of any care provided.
17. B. Clients that give away their favorite possessions
may be an increased suicide risk. This client should
later time.
18. C. Chills may indicate a temperature elevation.
19. D. Priorities for a client in sickle cell crisis include
oxygenation, hydration, and pain relief. Choices A,
B, and C can wait to be seen at a later time.
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20. C. Reports of swelling in the calf 8 hours postpartum
may be suggestive of the development of a deep vein
thrombosis, a potentially life threatening condition.
Immediate intervention is needed; other symptoms
include pain, warmth, chills, diminished peripheral
pulses, erythema, or shiny white skin on the extremity.
distress; therefore this infant is the priority. Choices A,
22. B. Restlessness is suggestive of hypoxia so this client
Choice A would be considered (category 4) and choices
1. D. Bacterial Pneumonia requires droplet precautions
24. D. The CNA can administer an enema prior to surgery.
Choices A, B, and C need a LPN or RN.
25. C. Care of the client requiring insulin administration
is appropriate for the LPN. Choices A, B, and D, may
require assessment and are therefore more appropriate
to delegate to the RN.
2. A. Rubeola requires airborne isolation which is
26. D. This client is stable and appropriate for management
by the pediatric nurse. Choices A, B, and C are unstable
and should be cared for by the emergency room
nurse.
27. C. A client experiencing chest pain after coughing is
appropriate for the new graduate RN. The coughing
may explain why the pain is being manifested. Clients
A, B, and D need assessment and should be seen by
4. C. Clients with AIDS have the potential for
an experienced RN.
28. A. Checking daily weight is an appropriate task to
delegate to a UAP. Choices B, C, and D should
performed by the nurse.
5. B. According to the department of occupational health
29. B. This choice is the most appropriate to delegate to
a UAP. Choices A and D are stable clients and can be
seen by an LPN. Initial vital signs should be done by an
RN.
Section)
delivery. An exploratory laparotomy is also abdominal
surgery therefore this client would be appropriate.
Choices A, B, and D would be most appropriate for the
medical surgical nurse to care for.
READY TO PASS INC.
B & C should be delegated to the UAP. Initiation of the
. Choices A and C would be most appropriate to
delegate to a UAP. Choice B requires assessment and
should be seen by the RN.
done by a nurse.
outcome. A, D and C require the more experienced
and Infection Control
Viral Pneumonia needs standard. The type of
should be isolated. A client with HIV and cirrhosis of
the liver do not require automatic isolation. A client with
Scabies requires contact precautions which would
isolation rooms were not available.
the priority. Rubella requires droplet precautions.
Klebsiella Pneumoniae and Pediculosis require
contact precautions.
D. Meningitis requires droplet precautions. Choices
A, B, and C do not require isolation unless further
information is given ie (infectious diarrhea)
immunosuppression. As a result they are at increased
risk for acquiring an infection. Contact with pets
should be limited or avoided. Choices A, B, and D are
correct.
and safety: accidents or incidents involving property
damage, personnel, student, or visitor injury are
reported in accordance with the Hospital Incident
Report Program. If a nurse forgets to administer a
medication the nurse can be liable for negligence.
Sexual abuse by a family member may constitute the
need to report to legal authorities such as the police
or child abuse reporting agency depending on the age
of the client. Choices C and D does not require an
212

6. C. A client with low grade fever and night sweats is
exhibiting signs of tuberculosis (TB). TB requires airborne
isolation. Choices A and B do not require a private room.
A client with leukemia may require a private room if they
are immunosuppressed. However, they would not take
priority over a client with TB.
7. B. The CDC guidelines mandate the use of a N95
respirator mask prior to entry into a room with a client on
airborne precautions. The surgical mask is appropriate
precautions.
priorities that must be followed: Rescue the clients,
which was already done in this situation, Alarm (call for
9. C. Placing a client in prone position after above the knee
amputation is done to prevent contractures; following
supratentorial surgery the head of the bed is elevated
liquids is not necessary for clients experiencing Dumping
Syndrome. The client should be taught to avoid drinking
with meals.
10. D. A white blood cell count of 2,500/mm is low therefore
the client is at risk for infection. Protective precautions
should be implemented. The normal White blood cell
count (WBC) is 5,000 – 10,000/mm ; The normal red
blood cell count (RBC) is 4 – 5 million/mm
of red blood cells is indicative of anemia. The normal
platelet count is 150,000 – 400,000µ/Liter. A low platelet
count predisposes the client to bleeding; the normal
female. Low hemoglobin is suggestive of anemia and
possible active bleeding.
Health Promotion and Maintenance
1. C. The posterior fontannel closes between birth and 2
months of age. The fontannel should not be closed at
birth this is suggestive of a congenital defect. Choices A,
B, and D are normal.
if the FHR tracing improves. Choices B, C, and D are not
indicated at this time.
appropriate positions for a client with a prolapsed cord.
Choices A, C, and D are incorrect.
READY TO PASS INC.
4. B. A client with mastitis should relieve the breasts of
milk frequently. This should be done by encouraging
the baby to suck or by using a breast pump if the
baby is unable to suck. Choices, A, C, and D are
incorrect.
of the last normal menstrual period (LNMP). Add
one year if the pregnancy occurs in April through
December.
6. A is correct. Small removable parts are unsafe.
Blocks are appropriate for a 2 year old a low lying
mobile is a strangulation hazard.
7. B. is correct. A tricycle and puppets are appropriate
8. C. This indicates the 2008 recommended schedule
for routine administration of childhood vaccines at
this age.
9. C. The time between infection with syphilis and the
days (average 21 days).
10. C. The MMR vaccine should not be administered
be assessed prior to administering the Hepatitis B
vaccine. Choices A and D are incorrect.
11. A is correct. The infant should be able to say a one
syllable word at approximately 6 months, sit without
support at 8 months and use the pincer grasp
between 9 and 11 months of age.
12. B. Stage 2 is known as the birth or expulsion stage
and is characterized by complete dilation and
Choices A, C, and D are incorrect.
Psychosocial Integrity
.
1. C. Clients using the drug Thorazine should stay out
of the sun secondary to the risk of photosensitivity.
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11. C. During the bargaining stage the client attempts to

be careful to include sodium in the diet to prevent
hyponatremia which predisposes the client to
increase the risk of hyponatremia; There is no
contraindication for fresh fruit or raw vegetables.
the stages of death and dying as denial (disbelief),
anger (hostility), bargaining, depression (sadness)
and acceptance (coming to terms with death).4.
Physiological Integrity: Basic Care and Comfort

4. D. Panic is a form of anxiety that is characterized 1. D. Potato, spinach and avocado are all sources of
by unexpected and repeated episodes of intense potassium. This is the best choice.
fear accompanied by physical symptoms that may
include chest pain, heart palpitations, shortness
of breath, dizziness, or abdominal distress
can lead to alcoholic brain disease.
5. B. When a client actually has a plan they are at
the highest risk to commit suicide.
avoided with Celiac Disease. Corn (popcorn) and rice
6. B. is correct. A, C, and D are incorrect choices. are allowed.

7. C. When clients have thoughts of harming
themselves they are more likely to carry out the
act. Choices A, B, and D are incorrect.
8. A. A client in the manic phase of bipolar disorder
because of their inability to sit still; competitive
games are avoided because the client is
hyperactive, impulsive and distractible. Structured
activity is more appropriate; foods containing
tyramine are avoided in clients prescribed MAO
inhibitors; placing the client on suicide observation
may be indicated during the depressed phase.
4. C. Clients with renal failure require decreased sodium
in the diet. Corned beef is high in sodium.
5. B. Clients with an increase in uric acid or Gout should
decrease purine in the diet. Foods such as organ meat,
sweetbread, sardines, beer, mushroom, spinach,
asparagus and anchovies should be avoided.
6. B. Dyrenium is a potassium sparing diuretic and foods
high in potassium should be avoided.
7. B. is correct.

9. B. Lanugo type hair on the body is a characteristic 8. B. Cabbage, strawberries and popcorn may cause
of anorexia nervosa; stained enamel of the teeth
is associated with bulimia nervosa related to should be avoided.
the frequent vomiting; persistent ringing in the
ears and white patches on the tongue are not 9. D. Vitamin B1 (thiamine) is used to treat alcohol
associated with anorexia nervosa.

10. D. It is customary in the Hindu faith that only

family members touch the body after death. The
other statements are correct. Follow up is not
necessary.

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10. A, B, D. Foods high in vitamin C should be avoided 7. 5 ml

12mg : 6ml :: 10mg : Xml
positive result; Red foods should be avoided as they
may be mistaken for blood. 12 X = 60 = 5 OR Desire 10mg X 6 60
12 12 Have 12mg 12
11. Isometric is the correct term to describe this type of
exercise. 8. 120mg
Remember 2.2 lbs = 1 kg
44 lbs ÷ 2.2 = 20 kg
crutches and the weaker limb forward. Then bear
20kg X 6mg = 120 mg
all your weight down through the crutches, and then

9. 0.75 ml 7,500 units X 1 ml = 0.75

leg. 10,000 units

10. 18.9ml or if instructed to round 19ml/hr

client to ambulate with a cane is to hold the cane in Formula: Desire X Volume X Weight X Min.
Have
Remember 2.2 lbs = 1 kg 185 lbs ÷ 2.2 = 84.09 kg
14. C. Vitamin C is necessary to improve wound healing.
Oranges and other citrus fruit are a good source of
vitamin C.
400 mg

Physiological Integrity: Pharmacological and

Convert 400 mg to mcg = 400,000 mcg
Parenteral Therapies

1. 2 Tablets Desire 1.0 mg = 2 mg

400,000 mcg
Have 0.05 mg
Simplify division by dividing 500ml into 400,000mcg
2. 36 mg
Remember 2.2 lbs = 1 kg
4,000 mcg

18.9ml if instructed round to 19ml/hr

2 Tablets
Desire 0.45 gm (convert gm to mg)
11. 8.5ml
Have 225mg
Formula Desire X Volume X Weight X Min.
Have
450mg = 2 tablets
225mg Remember 2.2 lbs = 1 kg 187 lbs ÷ 2.2 = 85 kg
2mcg X 250 ml X 85 kg X 60 minutes
4. 2.7 mg
Remember 2.2 lbs = 1 kg
6lbs ÷ 2.2 = 2.7 kg
2mcg X 250 ml X 85 kg X 60 ninutes
2.7kg X 1MG = 2.7mg

2mcg X 25 ml X 85 kg X 60 mins = 255,000

5. 1.5 ml
Have 2.5 mg Ans. 8.5ml

6. 31 gtts/min 1000 ml X 15 gtt/ml

(8hrs X 60 minutes)
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12. A. Bumex is a potassium wasting diuretic. As

a result, foods/ fruits with potassium should be volume 50 ml X 15 gtts/ml = 750
increased in the diet. minutes 20 20

21. D. 5 ml
the treatment of urinary tract and gynecological
infective used
5gm: 10ml : : 2.5gm : Xml
5X = 25 = 5ml
infections, nosocomial pneumonia and skin
infections. Urecholine is a urinary tract stimulant 5X 5
used for urinary retention. Gentamycin is an
aminoglycoside used for serious gram negative OR Desire 2.5gm X Volume 10ml = 25 =5
infections. Have 5gm 5

14. 10ml 22. C is correct. Humorsol is a cholinergic that is

20 mEq : Xml :: 10 mEq : 5ml
10 X = 100 X = 10 ml mydriatic. Timolol is a beta blocker used for ocular
10 10 hypertension.

OR Desire 20 mEq X Volume 5ml

are looking for an incorrect response. Clients on
Have 10 mEq
hydrochlorothiazide need additional potassium as it
is a potassium wasting diuretic.
80mg : Xml :: 125mg : 5ml
125 X = 400
Choices A, C, and D are incorrect. Hyperglycemia,
125 125 an elevated white blood count and hypotension are
common.
OR Desire 80 mg X Volume 5ml
Have 125 mg 25. A, E, and F are correct. Cardura may decrease libido.
Choices C and D are incorrect.
16. B, C, F are correct. A, D, E are incorrect
26. B. is correct. Hypoglycemia, hyponatremia, and
leukopenia are possible adverse reactions.

Volume 1500ml X drop factor 20 gtts/ml = 27. A, B, E, and F are correct. Constipation and anorexia
Minutes (60X8) = 480 are common.

18. D. AZT causes insomnia not drowsiness. It 28. D is correct. Hyperactivity, anorexia, and weight loss
should be taken around the clock. There is no are common adverse reactions.
direct relationship with protein.
29. B, C, D, and F are correct. Prilosec should not be
19. A. Plaquenil may cause retinopathy and/or vi crushed. Dizziness is a common adverse reaction.
sual disturbances. Dark glasses may be worn
in sunlight to decrease this risk. Hypotension
is common. It should be taken with food or
teaching is required.
milk to minimize GI distress not on an empty

while taking Plaquenil.

and hyperglycemia are common.

Multiple Sclerosis. Choices A, B, and D are correct.

216

indicate you are looking for an incorrect response. A,
C, and E are incorrect. Fever Few should be taken
with food. Hawthorne causes hypotension and Valerian
root is used to treat insomnia. Choices B, D, and F are
correct.
additional potassium is indicated when using this
medication.
The client should be encouraged to participate in
exercise. The pulse rate does not need to be monitored
prior to administration.
lungs of the fetus. Brethine is given to control premature
contractions. Apresoline is given for hypertension and
Pitocin may be given to induce labor.
Physiological integrity: Reduction of Risk Potential
1. A. Hyperkalemia increases the risk for cardiac changes
including weak pulse and cardiac arrest. This lab result
is the priority at this time.
2. C. These symptoms are representative of
hypocalcemia.
4. B. Multiple Myeloma causes an interference with red
blood cell, white blood cell and platelet production.
5. C. An increase in BUN indicates an impairment in renal
function. Choices A, B, and D are normal.
READY TO PASS INC.
6. A. a client with renal stones should avoid foods
with high oxylate content. These include but
are not limited to; spinach, eggplant, chocolate,
beer, peanuts, oatmeal, strawberries, kiwi, and
drinking beer. Also, a diet high in calcium causes a
predisposition to renal calculi.
7. D. Coughing and wheezing may indicate left sided
8. C. PSA levels of 4ng/ml warrant further diagnostic
testing. Levels of 10 or greater may suggest prostate
9. D. Pap smears can only detect cervical not uterine
cancer. Choices A, B, and C are true.
10. A, C, D, E are true. Choices B and F are not risk
factors for the development of breast cancer.
11. C. A stoma that is moist and pink is normal. No
further interventions are needed at this time.
normal saline or any liquid can result in aspiration.
in damage to internal organs and structures as
the substance is regurgitated. The national poison
14. C. The glascow coma scale is the most widely used
scale to quantify level of consciousness following
traumatic brain injury. The maximum score is 15 the
coma. The following scores should be given. Eye
15. B. is correct.
16. B. is correct. Sodium should be restricted. The
client is encouraged to remain still and rest in a
quiet environment.
17. B. Glaucoma is characterized by loss of peripheral
vision. Macular degeneration is characterized by
loss of central vision. Cataracts cause opacity of
the lens. Retinal detachment will cause the client to
217

18. A. Gout is indicated by a uric acid level greater
than 7.8 mg/dl.
20. C. Flying in an airplane will cause an increase
in pressure which is contraindicated after ear
surgery. Choices A, B, and D are correct therefore
no further teaching is required.
21. B, D, E, F. The client should be placed on the
eye surgery.
22. C. High fowlers or orthopneic position is most
client with hypothyroidism. Menstruation will be
scanty.
24. A, B, C, E. Insomnia and palpitations are common
in a client with hyperthyroidism.
25. C. Exercise is contraindicated after eye surgery.
26. C. NPO is not required prior to an EEG. The client
and other stimulants should be avoided for 24
hours prior to the procedure; the other statements
are true of those diagnostic tests, therefore follow
up is not required.
27. A. A female with frequent yeast infections should
be evaluated for Diabetes Mellitus and HIV.
28. B. Abdominal distention may indicate a distended
bladder which indicates a complication after a
(TURP).
29. C. Clients with a spinal cord injury should avoid
stimulating the bowels, bladder and skin which
fracture of a long bone. Petechiae, increased pain,
and swelling are some signs of a fat embolism.
a liver biopsy to minimize the risk of bleeding.
READY TO PASS INC.
Physiological integrity: Physiological Adaptation
before proceeding to the subsequent steps.
2. D. Post renal failure is caused by an acute obstruction
The blockage causes pressure build in all of the renal
nephrons. The excess pressure causes the kidneys
to shut down. Cardiogenic shock and hypovolemia
cause pre renal ARF. Nephrotoxins result in intrarenal
ARF.
test. Choices A, B, and C are correct.
4. D. The hypoglossal nerve controls tongue movements.
The glossopharyngeal and vagus nerves are assessed
is tested by assessing muscle strength of the head
and shoulders.
5. D, E, F. Risk factors for developing cervical cancer
includes smoking, multiple sex partners, Human
Papilloma Virus (HPV) sex before the age of 20 is a
risk factors.
6. A. Trigeminal Neuralgia is a disorder that causes
intense pain along the areas innervated by the
5th cranial nerve. Extremes in temperature can
exacerbate the pain symptoms.
7. A. Coarctation of the Aorta is an acyanotic defect
in the upper extremities than the lower. There may also
be a heart murmur and diminished or absent pulses
below the femur. The other choices are symptoms of
cyanotic defects.
8. A, B, C, D are correct. The other choices are incorrect.
The patient experiences low blood pressure and
increased heart rate.
9. A, C, E are correct. The other symptoms include
dilution and a preference for cold liquids.
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2
acidosis there is an increase of carbon dioxide. Generally the renal and pulmonary systems compensate for each
other to return the pH to normal. In this situation, the kidney increased the retention of HCO to normalize the pH.

Study Tool

Arterial Blood Gas Respiratory Respiratory Metabolic Metabolic

Normal range Acidosis Alkalosis Acidosis Alkalosis
pH 7.35-7.45

pCO2 35-45mm Hg

HCO3(bicarbonate)
22-26 mm Hg

Infection Control- list the type of isolation required:

HIB_______________________________ Bacterial Pneumonia_____________________
MRSA_____________________________ Klebsiella Pneumonia____________________
TB_______________________________ Group A Strep__________________________
Epiglottitis_________________________ Small pox______________________________
Fifths Disease______________________ Rubeola______________________________

Infection Control- list the type of isolation required: Page 45

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Detailed Answer Key for Page 28

1. 600ml_ X 15 gtt/mL = 9000 8. 75ml/hr x 24hrs = 1800ml

(60 X 8 hours) = 480 minutes (60 min = 1hr) 50mlx 4 (Q6hrs) = 200ml
200ml x 1 = 200ml
Answer: 18.75 = 19 gtt/min 2200ml in IV Fluids

Answer: 800ml PO
2. 100ml x 60 (minutes in 1 hour) = 4 x 100mL
15 minutes 180ml
180ml
Answer: 400 ml/hr 1080ml

Formula: Volume X 60 Answer: 1080ml

minutes ordered *Do not add pureed chicken, it is a solid
10. 1500 mg/day = 500mg per dose

(22lbs/2.2 remember 2.2 lbs =1kg)

Answer: 1 tablet/500mg per dose
500 mg X 1mL = 5ml
100 mg
Answer: 5ml
=2 11. 160mg
15mg 80mg

Answer: 2 tabs

5: 500mg = 2 12. x 10gtt/ml = 5

250mg 600 minutes (60min x 10 hours)

Answer: 2 tabs Answer: 5gtts/min

6. = 7.2 ml 100ml x 10gtt/ml = 16.6

1gm 60 minutes (60 minutes = 1 hour)

Answer: 7.2 ml Answer: 17gtts/min

7. 5000mcg = 5mg x 1ml = 0.5ml 14. 10 units/hr x 100ml = 1000 = 40ml/hr

10 mg 25units 25

(remember 1mg = 1000 mcg) Answer: 40 ml/hr

Answer: 0.5ml

220