UWorld & Kaplan NCLEX RN Cards

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1. 3 Point Gait
for Crutch
Walking

the patient bears weight on both crutches and then on the uninvolved leg, repeating the sequence
2. 4 Metabolic Metabolic acidosis w/hyperventilation: Diarrhea, ketoacidosis, lactic acidosis, and renal failure can cause metabolic
presentations acidosis due to loss of bicarbonate or retention of acids; the lungs would compensate by hyperventilating.

Metabolic alkalosis w/hypoventilation: Vomiting, gastrointestinal suction, and administration of alkali (ie, sodium
bicarbonate) are common causes of metabolic alkalosis; the lungs would compensate by hypoventilating.

Respiratory acidosis w/hypoventilation: Over-sedation, sleep apnea, anesthesia, drug overdose, progressive
neuromuscular disease, and chronic obstructive pulmonary disease depress the respiratory center; this leads to
alveolar hypoventilation, secondary to carbon dioxide retention, and respiratory acidosis. KEG PARTY

Respiratory alkalosis w/ hyperventilation: Hypoxia, anxiety, and pain are common causes of respiratory alkalosis,
which is due to alveolar hyperventilation (rapid breathing).
3. AAA diagram

4. Addisonian Hypotension and tachycardia

crisis s/s Dehydration
Hyperkalemia and hyponatremia
Hypoglycemia
Fever
Weakness and confusion
5. Assessing
newborn
for hip
dysplasia

Asymmetrical folds. You'd see more folds in the gluteus too.

6. Assigning give them a patient that's similar to what they're used to (rapid critical changes such as blood loss), not just what is
patients to "easy" (psych patients are not easy)
float ICU
nurses
7. Asthma Greenzone: peak exp. flow (PEF) >80%
action plan Yellowzone: take asthma medication
Redzone: if PEF does not improve after med
8. Autopsy Legally required in suicide, homicide, accident, or within 1 day of admit.
requirement Keep lines & catheters in patient (hide them ok)
for nurses Clean the room before family enters

—-
An autopsy is a postmortem examination of the deceased performed by a specially trained health care provider or
medical examiner. Laws vary by state, but autopsies are typically required when a client has died by suicide, homicide,
accident, or within 24 hours of admission to a health care facility. An autopsy for one of these legal reasons does not
require consent of the family. Family members may object to the autopsy for religious or cultural reasons but may be
required to present their case in a court of law
9. Basics of Tap/shake the person, activate EMS, feel for pulse <10 seconds, start CAB if no response
BLS
10. Beers Medication that shouldn't be given to the elderly
criteria
11. Biliroth II
and diet

low carbs (to prevent dumping syndrome?)

12. Blood transfusion IV setup

13. Bloody mucus-like discharge, Signs of estrogen exposure. Normal. Monitor for changes and reassure the guardian.
feign menstruation, mammary
gland enlargement in a
newborn
14. Cast syndrome Complications of full body casts

Watch for s/s of bowel obstruction: abdominal pain, distension, nausea, vomiting

Report to HCP, could cause paralytic ileus and bowel ischemia

15. CBT 5 components CBT involves 5 basic components:

1. Education about the client's specific disorder

2. Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and
assess the severity
3. Physical control strategies - deep breathing and muscle relaxation exercises
4. Cognitive restructuring - learning new ways to reframe thinking patterns, challenging negative
thoughts
5. Behavioral strategies - focusing on situations that cause anxiety and practicing new coping
behaviors, desensitization to anxiety-provoking situations or events
16. Central line 1. No need to ensure meds are compatible (only important if sharing lines)
2. Able to administer parenteral (not enteral) feeding
3. Wear clean gloves

A central venous catheter is used to administer fluids, for simultaneous infusion of incompatible
drugs, for parenteral nutrition, and for hemodynamic monitoring. The nurse should always handle
the lumen ports and hubs aseptically with facility-approved antiseptics to prevent catheter-
associated infections.
17. Ciproflaxin complication to Fluoroquinolones (ciprofloxacin) carry a black box warning citing an increased risk of tendinitis and
watch out for rupture, especially of the Achilles tendon
18. Colorectal cancer risk factors (C.U.B.A.A)
Colorectal cancer risk factors are:
-black tarry stools
-unexplained weight loss
-anemia
-abdominal discomfort
-change in bowel habits
19. Colostomy
cleaning
instructions

Colostomy irrigation allows the client to create a bowel regimen and to apply a dressing or smaller pouch device
over the stoma. To properly irrigate the stoma, use 500-1000 mL of lukewarm water, hang the bag 18-24 inches
above the stoma, use the cone-tipped irrigator to slowly infuse the solution, and allow stool to drain through the
sleeve into the toilet.

Don't attach an enema set to irrigate the colostomy bag. That's not what it's used for.
20. Coma scale use best response
use max score 15
< 8 severe
21. Compartment Six P's
syndrome in If pain out of proportion despite meds such as morphine, notify provider immediately
nursing
22. Coombs test Needed when there is trauma or anything that makes a mixing of the maternal and fetal blood supply
indication
23. COPD SOB
exacerbation increased sputum
symptoms albuterol/ipratroprium meds ineffective
24. Cranial nerve
assessment

25. CV catheter Require intravenous heparin flushes to maintain patency and prevent clotting. Single-dose vials of 2-3 mL of 10
care units/mL or 100 units/mL are the standard of care. A dose of 1000-10,000 units is given for cases of
thromboembolism.
26. Dabigatran works through direct inhibition of thrombin, preventing fibrinogen conversion into fibrin and activation of factor XIII.
exilate
Used for clot prevention for nonvalvular afib

Same use as Warfarin, but with NO monitoring necessary

27. Delusions realign to reality
(only works for delusions, not schizophrenia or hallucinations)

do not confront
28. Discharging "Rehabilitation phase."
patient with Wounds are fully healed. Okay to use lotion, ROM, and sunscreen.
fully healed
burns. What
to teach?
Explanation:

The rehabilitation phase begins after the client's wounds have fully healed and lasts about 12 months. The initiation of
this phase depends on the extent of the burns and the client's ability to care for themselves.

Interventions in the rehabilitation phase are aimed at improving mobility and independence and minimizing the
potential for long-term complications. These interventions include:

Counseling or other psychosocial support

Gentle massage with water-based lotion to alleviate itching and minimize scarring
Planning for reconstructive surgery
Pressure garments to prevent hypertrophic scars and promote circulation (Option 4)
Range-of-motion exercises to prevent contractures (Option 2)
Sunscreen and protective clothing to prevent sunburns and hyperpigmentation (Option 3)
(Option 1) Daily application of water-based lotion is necessary to minimize scar formation and alleviate itching.
Infection is not likely as the rehabilitation phase begins after the wounds are fully healed.

Educational objective:
The rehabilitation phase begins after the client's wounds are healed. The goals of this phase are to increase the
client's ability to perform activities of daily living and prevent long-term complications.
29. Diverticulitis Pain moving to a different quadrant could indicate perforation = EMERGENCY.
emergency
sx When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left
lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis). Complications that can
occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and intestinal
perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding,
rebound tenderness).
30. Donning PPE

wash hands
gown
mask
face shield
gloves (last)
31. Dust mites home vacuum DAILY
teaching wash linens w/hot water
32. DVT manifestation

unilateral edema
calf pain, tender
low grade fever
33. Emergency 50 mL 50% dextrose with 10 units of regular insulin IV (to pee out K)
treatment for -Kayexalate poops it out--takes too long
severe
hyperkalemia IV administration of 50 mL 50% dextrose with 10 units of regular insulin is the priority intervention as it is most
effective in reducing the potassium level quickly. The insulin temporarily shifts the potassium from the
extracellular fluid back into the intracellular fluid.
34. Epiglottitis
manifestation

4 Ds: drooling, dysphonia, dysphagia, and distressed airway (inspiratory stridor).

Children are typically toxic-appearing and may be "tripoding" (sitting up and leaning forward) with inspiratory
stridor.
35. Epiglottitis tx

EMERGENCY. Do not assess first. Position first.

36. Esophageal For the newborn, you may see frothy sputum.
atresia Suction first.
intervention
37. Ethambutol TB drug. Blurry vision. Needs eye exams.

Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin,
pyrazinamide) to treat active tuberculosis. The client must have baseline and periodic eye examinations during
therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of
decreased visual acuity and loss of color (red-green) discrimination.
38. Examples of MMR
live vaccines Varicella
(to avoid in Inhaled vaccines (such as nasal flu)
pregnant "Rubella + Varicella = UmbrElla ella ella eh eh"
women)
39. Fastest rate you NTE 10 mEq/hr! NEVER give bolus, or you'll stop the heart.
can give KCl
40. Fifth disease

Red cheeks: looks like child has been slapped. Viral illness in school age children caused by Parvo. Done in 10
days usually. Give Ibuprofen. Communicable until rash is gone but isolation not necessary.
41. First thing to do infuse IV saline (to preserve kidneys), then get urine and blood samples
with rhabdo
patient
42. Giving meds via Check for patency by aspirating contents, then replacing aspiration. Do not crush XR or ER pills. Do not mix
OG tube everything together. Always flush with water before and after each med.
43. Glyburide It's a sulfonarea.

The major adverse effects of sulfonylurea medications (eg, glyburide, glipizide, glimepiride) are hypoglycemia and
weight gain. Weight gain should be addressed. Clients taking glyburide should be taught to use sunscreen and
protective clothing as serious sunburns can occur.

Probably shouldn't give to elder patients, either.

44. GTPAL

Gravida, Term, Preterm, Abortions, Living

45. G-tube Must use Xray for confirmation. Aspiration is not confirmation of placement.
Placement
46. Heart
auscultation
sites

47. Herpes
presentation

48. Hip do not lean forward or extend hips sitting down less than 90 degrees (don't bend)
arthroplasty
sitting
concern
49. Hirschprung ...
s/s
50. HIV+ pregnant Not live vaccines (MMR).
mother vaccines Tdap and flu are ok (inactivated).

Pregnant clients who are HIV positive are immunocompromised and at increased risk for other infections. They
should receive all inactivated vaccines that are recommended for the general pregnant population, such as
tetanus-diphtheria-pertussis and intramuscular influenza. Live vaccines (eg, measles-mumps-rubella) are not given
during pregnancy.
51. Homonymous
hemianopsia

52. How to obtain must be done aseptically inline w/ a sterile syringe

urine specimen
53. Hyperthyroidism Eat high calorie diet. Avoid caffeine & spicy foods. Avoid high fiber.
diet teaching
Hyperthyroidism leads to a high metabolic rate. It is important for the nurse to teach the client nutritional
measures, including consumption of a diet high in calories (high in protein, carbohydrates, vitamins, and minerals)
to satisfy hunger and prevent weight loss and tissue wasting.
54. Infant CPR

Push just below the nipple line on the sternum

55. Infant drawing Intussusception = EMERGENCY
up the legs to
the abdomen Inconsolable crying and drawing up of the legs toward the abdomen in a child age 6-36 months could indicate
and intussusception or some other abdominal pathology (eg, appendicitis). Additional findings in intussusception
inconsolable include stools that have mucus and blood, often called "currant jelly" stools, and vomiting. Intussusception occurs
crying when one section of bowel telescopes over another, which can block the passage of intestinal contents, interrupt
blood supply, and cause intestinal tears (perforation). It is an emergency, and the client should be brought to the
emergency department for further evaluation.
56. In line trach
suction

Suction the mouth before preoxygenating and suctioning trach

—-
Clients with endotracheal tubes (ETTs) have impaired cough and gag reflexes and require suction to clear retained
bronchial secretions and promote ventilatory efficacy. Ventilator circuits for ETTs typically have a reusable in-line
endotracheal suction device, which remains sterile, in a flexible plastic sleeve. Oral secretions may pool near the
base of the ETT and drip into the trachea; therefore, oropharyngeal suctioning and oral care are performed before
ETT suctioning to prevent introduction of oral bacteria into the lungs.

The steps for suctioning an ETT include:

Perform hand hygiene and don clean gloves (Option 5).

Suction the oropharynx and perform oral care (Option 6).
Ensure that the system is connected to appropriate wall suction (<120 mm Hg).
Hyperoxygenate the lungs (100% FiO2) (Option 4).
Advance the catheter into the trachea just until resistance is met (level of the carina) (Option 1). Do not suction
while advancing the catheter.
Gently remove the catheter while suctioning and rotating it. Do not suction for more than 10 seconds (Option 3).
Evaluate client tolerance; if further secretions remain, suctioning can be repeated 1 or 2 times. Document the
procedure when complete (Option 2).
Resume oxygenation and ventilation settings as prescribed.
Educational objective:
Tracheal suctioning through an endotracheal tube helps clear retained bronchial secretions and increases
ventilatory efficacy. The nurse must follow strict asepsis to prevent the introduction of bacteria into the lungs,
hyperoxygenate the lungs to prevent hypoxia, and use appropriate technique to prevent airway trauma.
57. Intussusception classic TRIAD symptoms:
s/s -abdominal pain (baby puts feet up to belly & inconsolable)
-sausage shape mass on RUQ abdomen
-currant jelly stool

Intussusception is a common obstructive disorder in infancy that occurs when one segment of the bowel
telescopes into another. The classic clinical TRIAD is intermittent, severe, crampy abdominal pain; a palpable
"sausage-shaped" mass on the right side of the abdomen; and "currant jelly" stools. Other manifestations include
inconsolable crying, drawing the knees up to the chest during episodes of pain, and vomiting. The child may
appear normal and comfortable between episodes.
58. I/O 1 cup = 8 oz 1 oz = 30 mL 1 cup = 240 mL
measurement
conversions
59. Kidney biopsy uncontrolled blood pressure (RAAS)
consideration
60. Lactulose For hepatic encephalopathy
dosing Want patient to have 3 soft stools per day
Once reached, maintain dose
61. Levothyroxine It is a normal hormone found in the body so it is ok
in pregnant
women
62. Lovenox platelet & potassium
concerns
63. Meds to hold HTN meds &:
before
dialysis Commonly held medications are water-soluble vitamins (eg, vitamins B and C), antibiotics, and digoxin.
64. Memantine for Alzheimer's patients

Memantine is a medication used in the treatment of moderate to severe Alzheimer disease (AD). It slows the
progression of AD symptoms, and improvement may be seen in the client's behavior, cognitive functioning, and
ability to perform activities of daily living.
65. MERS (PPE) Gown, gloves, N95 respirator, and eye protection

Middle East respiratory syndrome (MERS) is a viral respiratory illness caused by the coronavirus (MERS-CoV).
Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those
afflicted. The incubation period is 5-6 days but can range from 2-14 days. How the virus spreads is not fully
understood, but it is thought to spread via respiratory secretions. Because it has easily spread to those who care for
infected persons, the Centers for Disease Control and Prevention recommends the use of standard, contact, and
airborne precautions with eye protection when caring for clients with MERS.
66. Mg sx Tremors and DTR
67. Mixing insulin
procedure

1. insert air: "cloudy into clear air"

2. draw insulin: "clear first then cloudy showers"
68. Must notify critical lab results, such as positive blood cultures
HCP right
away as soon
as you get it
69. Myasthenia gravis (all) Myasthenia gravis:
decreased acetylcholine,
sx: fluctuating muscle weakness as time goes by, ptosis, bulbar signs (what's
that?)

tx: drugs: anticholinesterase before meals

70. No pediatric AED pads available. Only adult. What
to do?

If <8 yrs old, place one in front and one behind.

If >8 yrs, same similar position as adult.
71. Normal CVP 6-12 mmHg
72. Normal lymph node presentation ~1 cm, superficial & movable, nontender (tender = inflammation, hardness =
WARNING)
73. The only acceptable abbreviations for med orders Acceptable abbreviations include "ac," "pc," "QID," and "cm."
74. Order of infection dx severity in ICU "Sir, sep, sep shock, mods"

systemic inflam. response

sepsis
septic shock
multiple organ dysfunction syndx
75. PAD

Hurts more when patient raises his legs. Arterial vs. venous insufficiency.
76. PAD risk factors Hypertension: Vessel damage from chronically elevated vascular resistance

Diabetes mellitus: Inflammatory vascular changes from hyperglycemia

Hyperlipidemia: Increased plaque formation (ie, atherosclerosis)

Smoking: Chronic vasoconstriction from nicotine inhalation

77. Paralytic lieus Patient must be NPO
nursing concerns NG Tube may be used

Paralytic ileus is characterized by temporary paralysis of a portion of the bowel, which affects peristalsis and
bowel motility. Signs and symptoms include abdominal discomfort, distension, and nausea/vomiting. Risk factors
for paralytic ileus include:

Abdominal surgery
Perioperative medications (eg, anesthesia, analgesics)
Immobility (eg, stroke)
To prevent further abdominal distension and resulting nausea, the client should remain NPO. Nasogastric tube to
wall suction may be necessary to decompress the stomach (Option 3). IV fluid and electrolyte replacement (eg,
normal saline) may be necessary to correct losses that occur from nasogastric suction (Option 2). Nausea can
be treated with prescribed antiemetics (eg, ondansetron, promethazine) (Option 4).
78. Parent in the ER form of child abuse (neglect)
while other
young children at
home by
themselves
79. Perioperative Explanation:
thyroidectomy
Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical
area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had
thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be
activated.

(Not O2sat?) Although low oxygen saturation is a sign of impending airway compromise, it is also commonly
seen in all types of postoperative clients, making it a less specific sign of airway obstruction than noisy breathing
in the thyroidectomy client.

Educational objective:
Airway swelling is a life-threatening complication of thyroid surgery. Signs of respiratory distress such as stridor
and dyspnea require rapid intervention.
80. Peritoneal
dialysis spike bag
technique

PD - must use aseptic technique when spiking the bag.

81. Positioning for HOB 30 degrees. When placing, make sure that patient can swallow?
NG tube feeding
82. Post-mortem care

Don't remove dentures (need it to shape the face). No need to call autopsy if not
requested.
83. Preferred needle size for administering 18 gauge
blood
84. Prioritization of Care First level:
-Airway
-Breathing
-Circulation & cardiac (become first priority
in cardiac arrest)
-Vital signs

Second level:
Altered mental status
Acute pain
Untreated medical problems (eg, hyperglycemia in a client with diabetes)
Chronic pain
Acute elimination issues
Abnormal laboratory results
Risk for infection, safety
85. Prioritization of care FIRST LEVEL
Airway
Breathing
Circulation & cardiac (become first priority
in cardiac arrest)
Vital signs

SECOND LEVEL
Altered mental status
Acute pain
Untreated medical problems (eg, hyperglycemia in a client with diabetes)
Chronic pain
Acute elimination issues
Abnormal laboratory results
Risk for infection, safety
86. Priority after ABCs, VS SECOND LEVEL
Altered mental status
Acute pain
Untreated medical problems (eg, hyperglycemia in a client with diabetes)
Chronic pain
Acute elimination issues
Abnormal laboratory results
Risk for infection, safety
87. Priority assess: Vomiting and dry heaving place increased mechanical stress on surgical wound edges and increase the risk for
obese client wound dehiscence and evisceration. Obese clients who have undergone extensive abdominal surgery are
post-op gastric especially vulnerable. Therefore, the nurse should first assess the client who is nauseated and dry heaving and
bypass administer an antiemetic medication
88. Priority: What's Lasix is faster
faster for SOB?
IV
methylprednisone
or furosemide?
89. Radioactive RAI is the primary form of treatment for individuals with hyperthyroidism. It destroys or damages the thyroid
iodine teaching gland (or a part of it). RAI has a delayed response and may take up to 3 months to have a maximum effect. For
this reason, other medications should be maintained to lower thyroid hormone synthesis and treat symptoms of
hyperthyroidism until RAI begins to have maximum effect (Option 4). Depending on dosage, clients who receive
RAI should be taught to use the following precautions for up to 1 week:

Avoid close proximity to pregnant women or children

Do not breastfeed as RAI may be excreted through breast milk and could harm the infant (Option 1)
Do not share utensils with others or use bare hands to handle food that is to be served to others
Isolate personal laundry (eg, bed linens, towels, daily clothes) and wash it separately
Use a separate toilet from the rest of the family and flush 2-3 times after each use
Wash hands frequently and thoroughly, especially after restroom use
Drink plenty of fluids
Sleep in a separate bed from others and do not sit near others in an enclosed area for a prolonged period of
time (eg, train or flight travel)
Educational objective:
RAI destroys or damages the thyroid (or part of it) but has a delayed response and may take up to 3 months to
have a maximum effect. It is important for the nurse to teach the client about precautions to prevent exposing
others to this radioactive substance.
90. Referred
abdominal pain
for pancreatitis,
cholecystitis,
appendicitis

91. Retinal "It feels like curtains coming across my eyes"

detachment:
subjective
92. RN responsibility Do not explain procedure, surgeon will
for consent Ensure patient is competent
Witness signature
Document time and date signed
93. SATA Pharmacology, 1) CORRECT- The total daily dosage may exceed the maximum daily recommended dosage of 4 g/day.
which order is/are
inappropriate?: 2) INCORRECT- The maximum dosage of ibuprofen is 3200 mg/day. This prescription is appropriate.

1. Acetaminophen 500 3) CORRECT- The parameters for blood pressure need to be specific and numerical. The nurse would
mg 1 to 2 tablets PO request clarification as to the parameters for "elevated" blood pressure.
every 4 hours.
2. Ibuprofen 600 mg 4) CORRECT - Statin medications are most effective at night when cholesterol synthesis is highest. The
PO every 8 hours PRN nurse should clarify whether medication is to be given at bedtime rather than in morning.
pain.
3. Clonidine 0.1 mg SL 5) CORRECT - Insulin glargine is a long-acting insulin and should be given once daily.
every 4 hours PRN for
elevated blood
pressure.
4. Lovastatin 20 mg PO
every morning.
5. Insulin glargine 10
units subcutaneous
before meals and at
bedtime.
94. Schizophrenia assess the patient for hallucinations, determine if harmful, help the client deal with it
95. Separation anxiety for Start at 6mo - 3yrs.
children
Starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. It produces more
stressthan any other factor (eg, pain, injury, change in surroundings) for children in this age range.
However, separation anxiety is normal and resolves by age 3 years.
96. Septic client develops Symptom of DIC. Clotting platelet mechanism dynsfunction. Excessive bleeding may occur. EMERGENCY.
petechiae
97. SIADH in one word drowning
98. SIADH patho

99. Snack for a toddler string cheese

(string cheese or
carrots?)
100. Teach client about It is a test for checking the blood flow to the heart. A nuclear traces is injected and followed by a special
cardiac nuclear camera.
pharmacologic stress
testing Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the
day of the test; avoid both caffeinated and decaffeinated products for 24 hours before the test; and avoid
taking theophylline or antianginal medications unless otherwise instructed by the health care provider.
101. Teaching
getting up
from a chair
w/crutches

Use your good hand when getting up from a chair. Put the crutches both on one side
102. tiotropium ...
103. Tiotropium Anticholinergic for COPD patients
(Spiriva)
104. Treatment for Desmopressin
DI
105. Tumor If patient had tuberculosis test first. (The drug inhibits immune system)
necrosis drug
check before
giving
106. Types of Most severe:
breast cancer Inflammation, pitting craters in skin (p'eau se orange)—> notify HCP
s/s
Benign:
Small round painless mobile lumps (fibroadenoma)
Soft moveable modules that change size during menstruation (fibrocystic breast nodule)
107. Urine test 24-hour urine collection.
needed for
CrCl? Start by peeing, throw that sample away, then you may begin the countdown.
108. VP shunt A ventriculoperitoneal shunt is used to treat hydrocephalus and is usually placed at age 3-4 months. Blockage and
infection are complications of shunt placement. Blockage results in signs of increased intracranial pressure (ICP).
The normal pulse range for a 1-year-old is 100-160/min. A pulse of 78/min is considered bradycardia, a part of
Cushing's triad (bradycardia, slowed respiration, widened pulse pressure)
109. VP shunt

110. Warfarin "Keep K Konsistent"

patient
teaching A sudden increase in vit K could decrease blood thinning and make client susceptible to clots; Whereas a sudden
decrease in vit K will make pt prone to bleeding
111. What age to >3 years old
pull the pinna
UP to give
meds on a
child
112. What case managers do Examples: Communicate with HCPs, obtain health records, visit the hospital (but only check
records)

Case managers don't do direct patient care

nurse case manager is to facilitate provision of quality care across a continuum, decrease
fragmentation of care across various settings, and contain costs.
113. What if a provider wants to A PCA should always have saline to keep vein open (KVO). Confirm with HCP.
discontinue the saline that's why
connected to PCA?
114. Wheezing symptom of asthma high-pitched expiratory
115. When an emergency happens Choose the step that makes more sense than the others
116. When can you give pajn meds to a
pregnant woman

Only give meds on ACTIVE (2-10 cm) Stage 1 of Labor

Systemic analgesia may be administered to the laboring client who is in the active phase of
stage 1 labor. Systemic analgesia crosses the blood-brain barrier to provide a central
analgesic effect.
117. When to use phototherapy on Phototherapy is considered for the neonate with a total serum bilirubin greater than 15
jaundiced infant? (What bili amount?) mg/dL (257 µmol/L) at 72 hours of age.
118. WHICH TESTS Educational objective:
SHOULD BE The nurse should routinely monitor laboratory values prior to administering medications. A complete blood count
ORDERED FOR should be assessed periodically in clients receiving enoxaparin to monitor for bleeding and thrombocytopenia.
WHICH MED? Digoxin and potassium levels should be assessed with the administration of digoxin. Glucose levels should be
monitored in the client receiving glucocorticoids.
Allergies: None
Medications
Time
Prednisone: 20 Explanation:
mg by mouth,
daily 0900 The complete blood count (hemoglobin, hematocrit, platelet count) should be assessed periodically with the
Metoprolol: 50 administration of enoxaparin, an anticoagulant that can cause bleeding and thrombocytopenia (Option 4).
mg by mouth,
daily 0900 Digoxin levels are monitored for suspicion of digoxin toxicity (ie, serum levels >2 ng/mL) (Option 1). Potassium
Digoxin: 0.5 mg levels should also be monitored in clients receiving digoxin, as hypokalemia can potentiate digoxin toxicity
by mouth, daily (Option 5).
1300
Enoxaparin: 40 Prednisone is a glucocorticoid that can cause hyperglycemia. Glucose levels should be monitored periodically in
mg clients receiving this medication (Option 2).
subcutaneously,
every 12 hours (Option 3) Low-molecular-weight heparins (eg, enoxaparin, dalteparin) produce a stable response at
recommended dosages and negate the need for monitoring of activated partial thromboplastin time (aPTT) or
1. Digoxin level international normalized ratio (INR) levels. aPTT is monitored when administering unfractionated heparin. INR is
2. Glucose monitored in clients receiving warfarin (Coumadin).
3. INR
4. Platelet
count
5. Serum
potassium