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Tuesday, July 29, 2008

Nclex Exam Questions 5 Saunders

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Atrial fibrillation is a very disorganized twitching of the atria at a rate greater than 350 beats per minute. These impulses are so rapid that they cause the atria to quiver instead of contracting regularly, producing irregular wavy deflections. Since ventricular depolarization is fairly normal in atrial fibrillation, the QRS complexes appear normal and the P wave is absent or not definable. Ventricular fibrillation and ventricular tachycardia do not have normal QRS complexes. In atrial flutter there is the “saw-tooth” appearance of P waves that may or may not be regular.

Clients should get out of bed by sliding toward the mattress edge then rolling onto one side and pushing up from the bed with one or both arms. The client should keep the back straight as the legs are swung over the side. Proper body mechanics include bending at the knees, not the waist, to lift objects. The client should increase dietary fiber and fluids to prevent straining at stool, which would increase intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles.

The client with pulmonary TB generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles.

The normal serum ammonia level is 15 to 45 mcg/dL.

The client's results fall in the normal range for pH (7.35 to 7.45), PaCO2 (35 to 45) and bicarbonate level (22 to 26 mEq/L). With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis, while bicarbonate levels would be low if there was metabolic acidosis.

CPK is a cellular enzyme that can be fractionated into three isoenzymes. The MM band reflects CPK from skeletal muscle. This band would be elevated in skeletal muscle disease. The MB band reflects CPK from cardiac muscle. The BB band reflects CPK from the brain. There is no MK band.

The normal serum creatinine level for the adult male is 0.5 to 1.5 mg/dL. The normal value for women is 0.5 to 1.0 mg/dL.

The therapeutic range for the serum phenytoin (Dilantin) level is 10 to 20 mcg/mL.

The normal therapeutic serum range for digoxin is 0.5 to 2.0 ng/mL. A value of 2.4 exceeds the therapeutic range, and could be toxic to the client.

The normal serum sodium level is 135 to 145 mEq/L.

The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L.

The normal fasting blood glucose is 70 to 110 mg/dL in the adult client.

A normal platelet count ranges from 150,000 to 400,000 cells mcg/L.

The normal range for the total serum protein level in the adult client is 6.0 to 8.0 g/dL

The normal serum lipase level is 20 to 180 IU/L.

The normal hemoglobin level for an adult female client is 12 to 15 g/dL.

The normal level for glycosylated hemoglobin A1C is 4.5 to 7.5%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in blood glucose will cause elevations in the amount of glycosylation. Elevations indicate continued need for teaching related to prevention of hyperglycemic episodes.

The normal range for urine for specific gravity is between 1.015 and 1.024 in an individual with normal fluid intake.

The normal WBC count ranges from 4500 to 10,000 mcg/L.

The client should be counseled to keep the total cholesterol level under 200 mg/dL. This will aid in prevention of atherosclerosis, which can lead to a number of cardiovascular disorders later in life.

The normal BUN ranges from 5 to 25 mg/dL.

The normal fibrinogen level is 200 to 400 mg/dL in the adult. A critical value is one that is less than 100 mg/dL. With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. Option 2 is the only option that identifies a normal level.

The hallmark of stage I is the development of a skin rash within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a ‘bull’s eye’ appearance. The lesion enlarges up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons also develop flulike symptoms that last 7 to 10 days, and these symptoms may recur later.

Stage II of Lyme disease develops within 1 to 6 months in the majority of untreated individuals. The most serious problems include cardiac conduction defects and neurological disorders such as Bell’s palsy and paralysis. These problems are not usually permanent. Arthralgias and joint enlargements are noted in stage III. A rash appears in stage I.

Stage III develops within a month to several months after initial infection. It is characterized by arthritic symptoms, such as arthralgias and enlarged or inflamed joints, which can persist for several years after the initial infection. Cardiac and neurological dysfunctions occur in stage II. A rash occurs in stage I. Paralysis of the extremity where the tick bite occurred is not a directly related characteristic of Lyme disease.

There is a blood test available to detect Lyme disease; however, it is not a reliable test if performed prior to 4 to 6 weeks following the tick bite.

A 3-week course of oral antibiotics is recommended during stage I. Later stages of Lyme disease may require therapy with IV antibiotics, such as penicillin G.

When an individual comes in contact with a poison ivy plant, the sap from the plant forms an invisible film on the human skin. The nurse should instruct the parents to immediately shower the child and lather and rinse the skin several times in running water.

Kaposi’s sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate, or open, and drain. The lesions spread by metastasis through the upper body then to the face and oral mucosa. They can also move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.

Cellulitis is a skin infection into deeper dermis and subcutaneous fat that results in deep red erythema without sharp borders, and that spreads widely through tissue spaces. The skin is erythematous, edematous, tender, and sometimes nodular. Erysipelas is an acute superficial and rapidly spreading inflammation of the dermis and lymphatic tissue.

Warm, moist compresses may be used to decrease the discomfort, erythema, and edema that accompany cellulitis. After tissue and blood cultures are obtained, antibiotic therapy will be initiated. The nurse should provide supportive care, as prescribed, to manage symptoms such as fatigue, fever, chills, headache, and myalgia.

Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and survival depends on early diagnosis and treatment. It is not contagious. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed and, although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis that are characterized by local invasion and possible metastasis.

A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue-toned color. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with dry, rough adherent yellow or brown scale.

Cryosurgery involves the local application of liquid nitrogen to isolated lesions that causes cell death and tissue destruction. The nurse prepares the client for swelling and increased tenderness of the treated area when the skin thaws. Tissue freezing is followed in 1 to 2 days by hemorrhagic blister formation. The nurse instructs the client to clean the treatment site as prescribed to prevent secondary infection. A topical antibiotic may also be prescribed. Application of a warm, damp washcloth intermittently to the site will provide relief from any discomfort. Alcohol-soaked dressings will cause irritation. It is unnecessary to avoid showering.

Smoking cessation is one of the most important lifestyle changes that the client with Raynaud’s disease needs to make. The nurse should emphasize that tobacco vasoconstricts blood vessels. The nurse needs to provide information to the client about programs that are available in the community

Warfarin (Coumadin) is an anticoagulant. Bleeding is a concern while the client is taking this medication. Reddish-orange colored urine could indicate blood in the urine as an adverse effect of the medication. Bleeding may also be identified by urine that turns smoky colored, or black.

Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially from the organism Pseudomonas. Monitoring temperature and sputum is indicated in the care of the client. A closed-system method of suctioning does not harm the client and may reduce the risk of infection.

On removal, the chest tube insertion site may have a sterile petrolatum gauze applied, which is then covered with a sterile 4 × 4 gauze. The entire dressing is securely taped to make sure it is occlusive. The petrolatum dressing is the key element to make an airtight seal at the former chest tube insertion site. Elastoplast tape could be used at the discretion of the physician as the tape of choice to make the dressing occlusive, but adhesive tape is most commonly used.

Following an ABG, continuous pressure must be applied to the site. The radial artery requires at least 5 minutes of pressure, while the femoral artery requires ten. A small pressure dressing is often placed on the site afterward. The client receiving anticoagulant therapy may require that pressure be applied for a longer period of time.

Anticholinesterase agents cause respiratory effects such as increased bronchial secretions, bronchoconstriction, and weakness or paralysis of respiratory muscles. Digestive effects include salivation; increased gastric, pancreatic, and intestinal secretions; and increased motility and tone in the gut (also assess for abdominal pain and diarrhea). Urinary effects include urinary frequency and incontinence. Cardiovascular effects include bradycardia (caused by muscarinic predominance), decreased cardiac output, and hypotension.

This medication combination when taken together daily is most effective in eliminating the tubercle bacilli from the sputum and improving clinical status. Rifampin, in combination with INH, prevents the emergence of drug-resistant organisms. Rifampin produces a harmless red-orange color in all body fluids and should be taken 1 hour before or 2 hours after eating to maximize absorption. The treatment regimen is maintained for at least 6 to 9 months for effectiveness, although the therapeutic effect may be evident in 2 to 3 weeks.

The Mantoux tuberculin skin test is an accurate and reliable tuberculin skin test that determines exposure to eh tuberculi bacilli. Interpretation of the Mantoux test is based on induration only, and the reading should be done 48 to 72 hours after injection.

Corticosteroid therapy can result in glucose intolerance, leading to elevated blood glucose levels. The nurse monitors these levels to detect this side effect of therapy. With successful transplant, the client’s serum electrolyte levels should be better regulated, although corticosteroids could also cause sodium retention.

Lactulose syrup is a hyperosmotic laxative agent that has the adjunct benefit of lowering serum ammonia levels. This occurs because the medication lowers bowel pH, which aids in the conversion of ammonia in the gut to the ammonium ion, which is poorly absorbed. Magnesium hydroxide is a saline laxative, while phenolphthalein is a stimulant laxative. Metamucil is a bulk laxative.

Dumping syndrome may occur because ingested food enters the jejunum too quickly before proper mixing and processing occurs. Management involves trying to delay gastric emptying, and one way to do this is to lie down after meals. Fluids should be omitted as much as possible during meals; carbohydrates should be decreased and fats should be increased.

The usual procedure for colostomy irrigation includes using 500 to 1000 mL warm tap water. The solution is suspended 18 inches above the stoma. The cone is inserted 2 to 4 inches into the stoma but should never be forced. If cramping occurs, the client should decrease the flow rate of the irrigant as needed by closing the irrigation clamp.

The client is instructed to shampoo and dry hair the night before ECT treatment. In addition, the client is instructed not to use hair sprays or creams before ECT to reduce the risk of burns. Client is NPO 6 to 8 hours

The client may experience temporary hoarseness after neck dissection. Goals for the client include: uses nonverbal forms of communication as needed, expresses willingness to ring call bell for assistance, and utilizes services of speech pathologist, if prescribed.

The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances.

Eye drops should be administered first, followed by the eye ointment. The child should be placed in a supine position with the neck slightly hyperextended for administration. Blinking will increase the loss of medication. Touching the eye or eyelid during medication administration can contaminate the dropper and also cause eye injury.

Whenever anyone is receiving ribavirin, there are precautions to prevent exposure to the medication. Everyone who enters the room while the client is receiving the medication should wear protective items such as a gown, mask, gloves, and hair covering (depending on agency procedures). Anyone who is pregnant or is considering pregnancy and anyone with a history of respiratory problems or reactive airway disease should not care for or visit anyone who is receiving ribavirin. Good hand washing is absolutely necessary before leaving the room. Hand washing prevents the spread of germs.

With an inguinal hernia, inguinal swelling occurs when an infant cries or strains. Absence of this swelling would indicate resolution of this problem.


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