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Friday, July 18, 2008

Nclex Review Materials 1 (Saunders Nclex Notes)

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During percutaneous transhepatic cholangiography, a needle is inserted into the liver under fluoroscopic guidance while the client holds his or her breath to stabilize the liver. The dye is injected as the needle is removed. The outline of the biliary tree is visualized under fluoroscopy. The total time for the test is approximately 30 minutes.

With flail chest, the nurse applies firm yet gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the client’s respiratory status. The nurse does not move an injured person for fear of worsening an undetected spinal cord injury. Removing the victim’s shirt is of no value in this situation and could in fact chill the victim, which is counterproductive. Injured persons should be kept warm until help arrives at the scene.

Depersonalization constitutes a symptom that displays disturbance in the client’s sense of self. Magical thinking is a symptom of the content of thought of schizophrenia. Flat affect is a symptom of schizophrenic disturbance in affect. Word salad is a schizophrenic disturbance in the form of thought.

Medications such as meperidine (Demerol) are administered for pain. Morphine sulfate and other opioids are usually avoided because they cause spasms of Oddi’s sphincter. Anticholinergic agents are usually given in combination with pain medications. The client is given nothing by mouth (NPO) during acute pancreatitis to rest the pancreas. Histamine H2 antagonists are usually prescribed to decrease hydrochloric acid and thus decrease the production of pancreatic enzymes

Clinical manifestations associated with hypothyroidism include bradycardia; obesity; dry, sparse hair; flaky, dry, inelastic skin; and a lowered basal body temperature. The client’s ability to sweat also diminishes. Constipation and fecal impaction occur, and the client has an increased susceptibility to infection. Blood pressure may be normal or slightly elevated, and temperature will be normal to subnormal. Exophthalmos and hyperactivity are manifestations of hyperthyroidism.

Thyroid storm is a potentially fatal acute episode of thyroid overactivity characterized by high fever, severe tachycardia, delirium, dehydration, and extreme irritability. Because it is an emergency, thyroid storm requires heroic interventions for control. The high fever is treated with hypothermic blankets, and dehydration is reversed with intravenous fluids.

The client with hyperthyroidism is usually extremely hungry because of increased metabolism. The client should be instructed to consume a high-calorie diet with six full meals a day. The client should be instructed to eat foods that are nutritious and that contain ample amounts of protein, carbohydrates, fats, and minerals. Clients should be discouraged from eating foods that increase peristalsis and thus result in diarrhea, such as highly seasoned, bulky, and fibrous foods.

Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or traumatized during surgery. If the client develops numbness and tingling around the mouth or in the fingertips or toes, muscle spasms, or twitching, the physician should be called immediately. A hoarse or weak voice may occur temporarily if there has been unilateral injury to the laryngeal nerve during surgery. Pain is expected in the postoperative period. Calcium gluconate ampules should be available at the bedside, and the client should have a patent intravenous (IV) line in the event that hypocalcemic tetany occurs.

Temporary hoarseness and a weak voice may occur if there has been unilateral injury to the laryngeal nerve during surgery. If hoarseness or a weak voice is present, the client is reassured that the problem will probably subside in a few days. Unnecessary talking is discouraged to minimize hoarseness.

The client with hyperparathyroidism should consume at least 3000 mL of fluid per day. Measures to prevent dehydration are necessary because dehydration increases serum calcium levels and promotes the formation of renal stones. Cranberry juice and prune juice help make the urine more acidic. A high urinary acidity helps prevent renal stone formation because calcium is more soluble in acidic urine than in alkaline urine. Clients should be on a low-calcium, low-vitamin D diet. High-fiber foods are important to prevent constipation and fecal impaction resulting from the hypercalcemia that occurs with this disorder.

Assessment findings in the client who is hypocalcemic include a positive Chvostek’s sign, positive Trousseau’s sign, hyperactive deep tendon reflexes, circumoral paresthesia, and numbness and tingling of the fingers. A positive Homans' sign would be noted in thrombophlebitis.

Risk factors associated with breast cancer include a menstrual history of early menarche and a late menopause. Other risk factors include a previous history or a family history of breast cancer, including any first-degree relative (a mother or sister) with breast cancer.

Clinical manifestations associated with breast cancer include a mass that is usually painless, nontender, hard, irregular in shape, and nonmobile. Nipple discharge and retraction, edema with peau d’orange skin, and dimpling of the skin may be present.

A total (simple) mastectomy involves resection of breast tissue and some skin from the clavicle to the costal margin and from the midline to the latissimus dorsi. The axillary tail and pectoral fascia are also removed. Axillary nodes are not removed.

Lumpectomy involves the removal of the cancerous mass and some normal tissue to product clean margins.

Modified radical mastectomy involves the removal of the breast, the axillary lymph nodes and the overlying skin.

Standard radical mastectomy involves the removal of the breast, the overlying skin, the pectoral muscles and the axillary nodes.

All evidence discovered during an examination is recorded. Documentation of evidence includes the bodily location from which the sample was obtained and when or to whom it was delivered. Evidence should be maintained in its original condition. Clothing is stored in a paper bag instead of plastic to prevent decomposition. If clothing needs to be cut off the client, special attention is taken not to destroy evidence inadvertently.

Isopropyl alcohol or any antiseptic solution containing alcohol must not be used as a skin preparation before a blood alcohol specimen is drawn. These agents may falsely elevate the blood alcohol level and render the test invalid.

Require reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. The suspicion needs to be reported to the nursing supervisor. The nursing supervisor then notifies the Board of Nursing.

Invasion of privacy takes place when an individual’s private affairs are unreasonably intruded into. Invasion of privacy includes taking photographs of the client without the client’s consent. Assault occurs when a person puts another person in fear of a harmful or offensive contact. Confidentiality is threatened when the nurse discusses the client’s private issue, or health care issues with another without consent. Negligence involves actions that are below the standards of care.

The incident report is confidential and privileged information. It should not be copied or placed in the chart or have any reference made to it in the client’s record. It is the physician’s responsibility to sign the incident report prior to its being sent to the risk-management department. A copy should not be made or sent to the physician’s office. The incident report is not a substitute for a complete entry in the client’s record concerning the incident. A copy of the incident report is not given to the client; however, the client should be informed of the error and this is usually done by the client’s physician.

Itching can be a symptom of systemic disease, such as severe liver or renal disease. It can also follow medication hypersensitivity or blood reactions, and it may occur in the older client as a result of dry skin. Heat and low humidity also induce pruritus. During the winter months, using a moisturizer and increasing room humidity with a cool-mist vaporizer are advantageous to alleviate the problem.

Systemic corticosteroids are not normally used to treat psoriasis. Even though systemic corticosteroids will quickly stop an exacerbation, after withdrawal of the corticosteroids, a rebound effect occurs. This steroid rebound will cause an immediate exacerbation or will convert the plaque or exfoliative type of psoriasis to pustular

Ulnar drift occurs when synovitis stretches and damages the tendons and eventually the tendons become shortened and fixed. This damage causes subluxation (drift) of the joints.

The Allen test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result is severe ischemic injury to the hand, if damage to the radial artery occurs with arterial puncture. The nurse would first explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client’s ulnar and radial arteries simultaneously. While pressure is applied, the nurse asks the client to open and close the hand repeatedly; the hand should blanch. The nurse then releases pressure from the ulnar artery while maintaining compression on the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining a blood specimen.

Malignant melanoma, commonly called melanoma, is cancer of the melanocyte cells of the skin. It is an aggressive cancer that requires aggressive therapy to control its spread. Basal cell carcinoma, also known as basal cell epithelioma, is the most common form of skin cancer. It is a slow-growing cancer and seldom metastasizes, but it can grow so large that the entire area of the nose, the lip, or the ear must be removed and reconstructed.

Inhalation injuries are most common when a fire occurs in a closed space. The findings are facial burns, singed nasal hairs, and sputum tinged with carbon. Additionally, auscultation of wheezing and rales suggests an inhalation injury.

Once the initial assessment has been made and life-threatening dysfunctions have been addressed, pain medication can be administered. Narcotics administered IV are the initial medications of choice because absorption from the musculature is erratic at this time, and an ileus can be present in the burn client. The initial medication of choice is morphine sulfate, although other medications such as methadone, codeine, or hydromorphone may be used also. Narcotics are given by the IV route until fluid resuscitation is complete and gastric motility is restored.

Following breast reconstruction, the flap is inspected for color, temperature, and capillary refill. Assessment of the nipple areola is made, and dressings are designed so this area can be observed. An areola that is deep red, purple, dusky, or black around the edge is reported to the physician immediately because this may indicate a decreased blood supply to the area. The nurse would also document the findings once the physician is notified.

When rhinorrhea (a thin, watery discharge from the nose) or otorrhea (ear inflammation with serum discharge) is noted, there is a possibility of cerebrospinal fluid leakage through the fractures. The nurse checks the fluid for glucose using a test tape or Ketostix. Cerebrospinal fluid contains glucose, whereas rhinorrhea does not. Cerebrospinal fluid dries on bed linens as a concentric halo-like ring and does not crust.

Following a intermaxillary fixation for a fractured jaw, Water-related activities such as swimming should be avoided. In an emergency, the airway cannot be cleared of water rapidly when jaws are wired, and there is an increased risk of drowning. The client needs to be instructed on how to prepare a high-calorie, high-protein liquid diet; liquid multivitamins may also be helpful. The client should avoid carbonated beverages and alcohol because carbonated beverages fizz in the back of the throat and may interfere with airway clearance and alcohol can cause nausea and vomiting when combined with analgesics.

Typical symptoms of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output.

Brown-colored or bloody drainage could indicate perforation of the bowel by the peritoneal dialysis catheter. If noted, this must be reported to the physician immediately. Early signs of infection include cloudy dialysate output or fever and, most likely, abdominal discomfort. Bladder perforation could yield yellow or bloody drainage.

When tkaing ofloxacin (floxin), nurse notes that medication could cause crystalluria, the nurse should advice patient that inorder to prevent crystalluria, the client should drink at least 1500 to 2000 mL of fluid per day. Milk interferes with the absorption of the medication and should be avoided. Consumption of carbonated beverages or mineral water is not harmful.

Synercid is an antimicrobial agent. One adverse effect of the medication is superinfection, including antibiotic-associated colitis, which may result from bacterial imbalance. If the client develops diarrhea, the medication should be withheld, and the physician is notified. The nurse would not discontinue the medication. The nurse would not administer an antidiarrheal unless specifically prescribed by the physician.

Normal suture lines may be approximated or overriding. They are also mobile. Overriding suture lines are most often caused by the birthing process and resolve spontaneously. A split in the sutures as much as 1 cm is considered normal. A suture split of greater than 1 cm may indicate increased intracranial pressure.

An increased interest in sounds occurs between 6 and 8 months. Additionally, single-consonant babbling occurs at this age. Babbling sounds begin between the ages of 3 and 4 months. Between the ages of 1 and 3 months, the infant will produce cooing sounds. The use of gestures occurs between 9 and 12 months.

Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats, introduced one at a time, can begin at 6 months of age. Self-feeding can be initiated at approximately 9 months of age.

At age 15 months, the child would be expected to build a tower of two blocks. At age 18 months, the child would be expected to build a tower of four to five blocks. At age 30 months, the child would be expected to snap large snaps and put on simple clothes independently.

Laboratory findings in an infant with hypertropic pyloric stenosis include metabolic alkalosis due to vomiting and decreased serum potassium, sodium, and chloride levels. An increased pH and bicarbonate level indicate metabolic alkalosis.

The ECG uses painless electrodes, which are applied to the chest and limbs. It takes less than 5 minutes to complete, but it requires the client to lie still to avoid interference with obtaining clear tracings. The ECG measures the heart’s electrical activity to determine cardiac rate and rhythm, as well as a variety of abnormalities.

The most useful survival skills for female offender clients would include effective problem-solving and coping skills to enhance the ability to manage stress.

In a child aged 6 to 14 years, the maximum volume of intramuscular medication that can be safely administered into the vastus lateralis muscle is 1.5 mL.

Urine for specific gravity is normally 1.010 to 1.030. The nurse should monitor the specific gravity of a child with a brain tumor or at risk for increased intracranial pressure (ICP) every 4 to 6 hours. The physician should be notified if the urine for specific gravity is above 1.030 or less than 1.010. With increasing ICP, diabetes insipidus or syndrome of inappropriate antidiuretic hormone may occur.

Clients with trigeminal neuralgia report excruciating, sharp, knife-like facial pain (usually unilateral) after brushing teeth and with exposure to extremes of hot or cold, to touch, and to chewing. Paralysis of one side of the face is seen with Bell’s palsy. Massage and drinking cold beverages would not decrease the pain of trigeminal neuralgia.

Communication with a hearing impaired client is enhanced by using appropriate hand signals while voicing words. Use of normal clear speech, not shouting, is most effective because shouting increases the frequency of sounds, which makes the words harder to hear. Other helpful behaviors include speaking while positioned in front of the client, keeping hands away from the mouth while talking, having minimal distractions, and repeating and validating communications as needed.

Post-discharge instructions typically include avoiding the following: tight clothing and belts over AICD insertion sites; rough contact with the AICD insertion site; electromagnetic sources, such as electrical transformers, transmitters, metal detectors; and running motors of cars and boats. Clients must also tell all of his or her physicians or dentists about the device because certain procedures (diathermy, electrocautery, and magnetic resonance imaging) should be avoided to prevent device malfunction. Use of common electronic devices such as televisions and computers is not hazardous to the client and does not need to be limited.

The ulcer described in the question has the characteristics of a venous stasis ulcer. These ulcers are caused by conditions resulting in chronic venous congestion in the extremities. Examples of such conditions include venous insufficiency and chronic deep vein thrombosis. Pulmonary embolism is a complication of deep vein thrombosis. Arterial insufficiency is accompanied by pain, and typical findings include pale, cool extremities that have diminished or absent pedal pulses. Atrial fibrillation may cause cardiac thrombi, which could break loose and travel to anywhere in the body, including the legs. If this occurred, it would also cause acute onset of the classic symptoms found in clients with pulmonary embolism.

Arterial ischemic leg ulcers are characteristically deep, pale, and painful. By contrast, venous stasis ulcers are shallower, with a ruddy color to the ulcer. Venous ulcers are also painful, but less so than arterial ulcers. There is no ulcer that is characteristically painless.

Discharge instruction to a client with abdominal aortic aneurysm (AAA) are instructed to avoid lifting anything that weighs more than 15 to 20 pounds for the first 6 to 12 weeks following surgery. The client is also instructed to avoid any activities that involve pushing, pulling, or straining. Driving a car is also prohibited owing to general postoperative weakness.

Monopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure. It can cause tachycardia as a side effect of therapy

Nitroglycerin is a coronary vasodilator used in the management of coronary artery disease. The transdermal nitroglycerin system should never be cut or trimmed, since this will destroy the integrity of the system. The client should apply the system to a hairless site and rotate sites daily. The client should apply a new system if one falls off, because the dosage is released hourly as a controlled diffusion through the skin.

The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Signs of impaired neurovascular status accompany the occlusion, including pallor, cool temperature, diminished capillary refill, and diminished or absent pedal pulses. The nurse needs to immediately call the surgeon.

Activase is a thrombolytic medication that is used to dissolve thrombi or emboli due to thrombus. A frequent and potentially severe adverse effect of therapy is bleeding. The nurse manipulates the client’s environment to reduce the hazard of bleeding associated with use of sharp items at the bedside. The nurse would provide soft toothettes for mouth care and would allow an electric razor for shaving. The nurse would not allow dental floss, a firm-bristle toothbrush, or scissors at the bedside, which could cause bleeding in the client as the result of minor trauma.

The nurse should inform the client of measures to reverse the effects of gravity, which include leg elevation above heart level. Elastic stockings may be helpful in promoting blood return. Other helpful measures include avoiding prolonged standing and sitting, which elevate hydrostatic pressure within the veins. The client should also eliminate external sources of venous congestion, such as tight clothing.

Biofeedback is one of several stress management techniques that may be useful for clients whose hypertension is aggravated by stress.

The care of the client who has had an insertion of an IVC filter is similar to that of any surgical client. In the first 24 hours after the procedure, the nurse is most concerned with signs of bleeding. Signs of infection or poor wound healing would not be apparent during this time frame.

Intermittent claudication is the name given to leg pain that occurs with exercise and is relieved by rest. It is the classic symptom of peripheral arterial insufficiency. Rest pain is a sharp pain that occurs when the client is not exercising and indicates a worsening of peripheral arterial disease. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses.

Symptoms of DVT include warm, reddened skin over the affected area, edema of the extremity, enlarged calf circumference, and positive Homans' sign (pain with dorsiflexion of the foot). Indications that the condition is resolving are a reduction in these signs and symptoms.

Nitroglycerin is relatively unstable, and the bottle should be replaced 6 to 9 months after it is opened. The tablets should be kept away from heat, light, and moisture. The client may take up to three doses 5 minutes apart. If chest pain is not relieved, the client should seek emergency cardiac care. Headache is an expected side effect of the medication, which usually diminishes as the client becomes accustomed to the medication.

Impotence is a common side effect of labetalol and may be distressing to the client. Other side effects of this medication are bradycardia, weakness, and fatigue

Nifedipine is a calcium-channel blocking agent, which can cause bradycardia as a side effect. For this reason, clients taking this medication are taught to monitor the pulse on a daily basis. Urinary frequency is a side effect, but urinary retention is not. Alcohol should not be used at all in the client taking a medication such as nifedipine because it could cause or worsen hypotension.

The client on a low-sodium diet is taught that any foods that derive from animal sources contain physiological saline and are therefore higher in sodium than many foods from plant sources. Powdered milk is often manufactured to be lower in sodium, so is the best dairy choice of those presented in the options for clients on a sodium-restricted diet.

Desserts that are higher in cholesterol include high-fat frozen desserts such as ice cream and high-fat cakes such as frosted and pound cakes. Most store-bought pies and cookies are also higher in fat. The best low-fat dessert choices include angel food cake, frozen desserts such as sorbet, sherbet, Italian ice, and frozen yogurt, and other desserts that are specifically labeled “low-fat.”

Theophylline (Theo-Dur) is a bronchodilators that commonly cause nervousness, anxiety, nausea and vomiting, tachycardia, and palpitations as side effects. The nurse monitors for these symptoms in clients taking this type of medication.

If bronchospasm occurs, the nurse withholds the medication. The physician is called immediately. This adverse effect is often caused by excessive use of adrenergic bronchodilators.

Oretic is a thiazide diuretic. It is used to promote fluid loss and reduce blood pressure. These are intended effects of the medication. Photosensitivity and hyperglycemia are side effects. Hypoglycemia is not a side effect of this medication.

Spironolactone (Aldactone) is a potassium-sparing diuretic used to treat edema, high blood pressure, and hyperaldosteronism. Thus, it should decrease blood pressure, increase urine output, maintain stable potassium levels, and decrease edema.

Maturational crises involve developmental crises at any transition point in life, such as marriage, pregnancy, or retirement. Situational crises are adverse happenings that disturb a person’s functioning, such as death of a loved one, divorce, or illness. Adventitious crises involve unexpected accidents, such as floods or earthquakes.

Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax would show intermittent bubbling on respiration in the water seal chamber. Continuous bubbling in the suction control chamber indicates that suction is attached to the system and is working as expected. There cannot be intermittent bubbling in the suction control chamber; either the suction is turned on (bubbling) or off (no bubbling).

For peripheral fat emulsion infusions, a 20- or 21-gauge needle is used. A 14-, 16-, 18-, or 19-gauge needle is used for the administration of blood products. A 22- or 23-gauge needle is used for standard intravenous solutions. A 25-gauge needle is most often used to administer subcutaneous injections.

Older adults are at an increased risk for infiltration because they have fragile veins. Preventive measures include avoiding venipuncture over an area of flexion, anchoring the venipuncture cannula, and looping the tubing securely. Use of an arm board or a splint is especially helpful for an active or restless person.

Isoproterenol and aminophylline are administered to prevent vasospasms and reverse ischemia. Isoproterenol produces vasodilation. Aminophylline reduces cell contractility. These actions should result in improved neurological findings. Nausea, vomiting, diarrhea, tachycardia, hypotension, and no change in the client’s condition are not positive client responses. Also, tachycardia and hypotension are side effects of the medications that the nurse should monitor.


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