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Saturday, January 10, 2009

Nclex / CGFNS Review Bullets

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The client with chronic renal failure often has dry skin, accompanied by itching (pruritus) from uremia. The client should use mild soaps, lotions, and bath water oils to reduce dryness without increasing skin irritation. Products that contain perfumes or alcohol increase dryness and pruritus and should be avoided.

The client with an AICD maintains a log or diary of a variety of data. This includes recording date, time, activity before the shock and any symptoms experienced, number of shocks delivered, and how the client felt after the shock. The information is used by the physician to adjust the medical regimen, especially medication therapy, which must be maintained after AICD insertion.

The client with hypertension should avoid foods high in sodium. Foods from the meat group that are higher in sodium include bacon, hot dogs, luncheon meat, chipped or corned beef, Kosher meat, smoked or salted meat or fish, peanut butter, and a variety of shellfish.

Client instructions for oral anticoagulant therapy include taking the medication only as prescribed and at the same time each day; avoiding other medications (including over-the-counter medications) without physician approval; avoiding alcohol; notifying all caregivers about the medication; carrying a Medic-Alert bracelet or card; reporting any signs of bleeding and implementing measures to prevent bleeding; and adhering to the schedule for follow-up blood work.

Foot care instructions for the client with peripheral arterial ischemia are the same instructions given to the client with diabetic mellitus. The client with arterial disease, however, should avoid raising the legs above heart level, unless instructed to do so as part of an exercise program (such as Buerger-Allen exercises) or unless venous stasis is also present.

The typical schedule for hemodialysis is 3 to 4 hours of treatment 3 days per week. Individual adjustments may be made according to variables, such as the size of the client, type of dialyzer, the rate of blood flow, personal client preferences, and others.

The principles of maintaining IV therapy at home are the same as in the hospital. It is extremely important to ensure that the IV site is anchored properly in order to reduce the risk of phlebitis and infiltration. Massaging the site may actually contribute to catheter movement and tissue damage. Dressings surrounding peripheral IV sites are changed and cleansed at various times (usually every 2 to 5 days) depending on facility protocols. Most dressings are to remain intact unless the dressing becomes wet, soiled, or loose. Alcohol is not normally used to cleanse the IV site. Immobilizing the extremity is not routinely necessary for peripheral IV sites. Arm boards are only used if a site is near a joint and the IV flow rate is positional.

Variable deceleration with brief acceleration after a gush of amniotic fluid is a common clinical manifestation of cord compression caused by occult or frank prolapse of the umbilical cord. A manual vaginal exam can detect the presence of the cord in the vagina, confirming the problem.

Shallow respirations that occur with rib fracture predispose the client to developing atelectasis and pneumonia. It is essential that the client perform coughing and deep breathing exercises to prevent these complications. The nurse accomplishes this most effectively by premedicating the client with pain medication and assisting the client with splinting during the exercises.

The fetal heart rate should be between 120 to 160 beats per minute during pregnancy. A fetal heart rate of 100 beats per minute would require that the physician be notified and the client be further evaluated. Although the nurse would document the findings, the most appropriate nursing action is to notify the physician.

The preferred oxytocin dosage is the minimal amount necessary to maintain an adequate contraction pattern characterized by three to five contractions in a 10-minute period, with resultant cervical dilatation. If contractions are more frequent than every 2 minutes, contraction quality may be decreased.

Trimethobenzamide (Tigan) is an antiemetic agent used in the treatment of nausea and vomiting.

Tolbutamide (Orinase) is an oral hypoglycemic agent that is taken in the morning. It is not used to decrease blood pressure, enhance weight loss, or treat infection.


The client who regularly takes NSAIDs is prone to gastric mucosal injury, which gives the client epigastric pain as a symptom. Misoprostol (Cytotec) is administered to prevent this occurrence. Diarrhea can be a side effect of the medication, but is not an intended effect.

Loperamide (Imodium) is an antidiarrheal agent. It is commonly administered after loose stools. It is used in the management of acute diarrhea and also in chronic diarrhea, such as with inflammatory bowel disease. It can also be used to reduce the volume of drainage from an ileostomy.

Azithromycin (Zithromax) is a macrolide antibiotic, which is used to treat infection.

When evaluating the presence of pitting edema, the nurse presses the fingertips of the index and middle fingers against the shin and holds pressure for 2 to 3 seconds. An indentation of approximately 1 inch deep would be indicative of 4+ edema. A slight indentation would indicate 1+ edema. An indentation of approximately 1/4 inch deep indicates 2+ edema. An indentation of approximately 1/2 inch deep indicates 3+ edema.

The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed anywhere from 6 to 10 inches in front and to the side of the client’s toes, depending on the client’s body size. This provides a wide enough base of support to the client and improves balance.

Clients taking digoxin should take the pulse each day and notify the physician if the heart rate is below 60 beats per minute or above 100 beats per minute.

The client on hemodialysis should monitor fluid status between hemodialysis treatments. This can be done by recording intake and output and measuring weight on a daily basis. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight per day.

Diltiazem hydrochloride (Cardizem) is a calcium-channel blocker. It is administered before meals and at bedtime as prescribed. Hypotension can occur, and the client is instructed to rise slowly. The client should avoid tasks that require alertness until a response to the medication is established. The client should call the physician if an irregular heartbeat, shortness of breath, pronounced dizziness, nausea, or constipation occurs.

The client can walk as tolerated after repair or resection of an AAA, including climbing stairs and walking outdoors. The client should not lift objects that weight more than 15 to 20 pounds for 6 to 12 weeks or engage in any activities that involve pushing, pulling, or straining. Driving is also prohibited for several weeks.

Triamterene is a potassium-sparing diuretic, and clients taking this medication should be cautioned against eating foods that are high in potassium, including many vegetables, fruits, and fresh meats. Because potassium is very water-soluble, foods that are prepared in water are often lower in potassium.

Hemorrhagic cystitis is an adverse reaction associated with this medication. The client needs to be instructed to consume copious amounts of fluid during therapy. Avoiding contact with anyone who recently received a live virus vaccine is important because cyclophosphamide produces immunosuppression, placing the client at risk for infection. Hair will grow back, although it may have a different color and texture. A sore throat may be an indication of an infection and needs to be reported to the physician.

The liver is the largest organ in the body, weighing about 3.5 pounds (1.6 kg). It lies under the right diaphragm, spanning the upper quadrant of the abdomen from the fifth intercostal space to slightly below the costal margin. The rib cage covers a substantial portion of the liver; only the lower margin is exposed beneath it.

Bronchovesicular breath sounds are heard over the main bronchi. Specifically, their normal location is between the first and second intercostal spaces at the sternal border anteriorly, and posteriorly at T4 medial to the scapula. These sounds are moderate in pitch, medium in intensity, and the duration of inspiration and expiration is equal. Bronchial breath sounds are heard over the trachea. Vesicular breath sounds are heard over the lesser bronchi, bronchioles, and lobes.

Moist desquamation occurs when the basal cells of the skin are destroyed. The dermal level is exposed, which results in the leakage of serum. Reddened skin, a rash, and dermatitis may occur with external radiation but is not described as a moist desquamation.

Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client who is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion.

A client with dehydration has a low CVP. The normal CVP is between 4 to 11 mm H2O. Other assessment findings with fluid volume deficit are increased pulse and respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine output, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness.

Intracranial pressure, encephalopathy, and hepatic dysfunction are major symptoms of Reye’s syndrome. Reye’s syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.





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