NCLEX UWorld 2023

NCLEX UWorld 2023 14 studiers recently 4.0 (3 reviews) Students also studied Terms in this set (1823) Science MedicineNursing Save

NCLEX EXAM PREVIEW

110 terms kandykat1012Preview PEARSON NCLEX-RN Questions & R...199 terms Candice_Haygood Preview NCLEX - uWorld Test 1 101 terms ghostNPgurlPreview NCLEX 1,721 term kc_h When do advanced directives go into effect?when person is unable to speak for him/herself due to either:

• Mental Incapacity - coma (GCS score ≤ 7)
• Aphasia

(≠as soon as signed; directives can always be changed later by person) SBAR Communication Framekwork Components 1. S = Situation - what prompted the communication (eg what changes occurred)

• B = Background - pertinent information, relevant history, vital signs
• A = Assessment - nurse's assessment of the situation (when & what changes

occurred)

• R = Recommendation - request for prescription or action from HCP

Appropriate order of actions when client found on floor 1. Assessment of physiological stability (ABCs)

• Assessment of injuries
• Moving client
• Notifications
• Documentation

Conditions of being ineligible to leave AMA1 danger to self or others

• lack of consciousness
• Altered consciousness
• Mental illness
• Being under chemical influence
• Court decision

Effective handoff communication componentsNurse should:

• Provide identifying information (eg client's name and room number)
• Note care priorities and upcoming or outstanding tasks (eg time to replace

medication infusion bag, need to perform delayed wound care and cause of delay)

• Provide exact, pertinent information (eg medication dose, time, measurable

outcomes)

• Include multidisciplinary plans (eg radiology examinations, family meetings,

physical therapy)

• Relay significant client changes in a clear manner

Risk factors for cervical cancer1. Infection with high-risk HPV strains

• History of sexually transmitted diseases
• Early onset of sexual activity
• Multiple or high-risk sexual partners
• Immunosuppression
• Oral contraceptive use
• Low SES
• Tobacco use

what medications interact with grapefruit?1. calcium channel blockers (diltiazem, nifedipine, verapamil, etc)

• statins
• SSRIs

Risk associated with stent placement using the femoral approach retroperitoneal hemorrhage what are early signs of bleeding into the retroperitoneal space?hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses what is the grey-turner sign and what is it a sign of? bruising of the flanks and retroperitoneal hemorrhage and is a bluish color what are some physical signs of peripheral arterial disease?intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the extremities) transplanted hearts are expected to betachycardic like 90-110 what is the priority intervention for pain with sickle cell crisis and why?administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion what is the purpose of continuous bladder irrigation? it is perscribed after TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder what is the nurses care of monitoring CBI?monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed characteristics of a basilar skull fractureperiorbital hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising) immediate client care for basilar skull fracturecervical spime immobilization, close neurologic monitoring, and support of ABCs

vomiting with intake may meanviral or bacterial infection tympanosomty tubes are placed forrecurrent otis medias nurse actions during a seizureassist them to lie down is standing/sitting, put them on side for patent airway, loosen tight clothing, give oxygen as needed, remove objects from immediate area, document time and duration of seizure (for tests are done later to see which type of seizure and maybe what exacerates it) never put anything in mouth or restrain them since musclec ontractions can occur during a seizure what are some early symptoms of ICP?altered LOC, headache, abnormal reathing, rise in bp, slow pulse, vomiting client who has a TIA is often placed onprophylactic antithrombotic treatment like aspirin or clopidogrel glascow coma scale ranges from3-15; 3 being worst 15 being best condition (8 or below in a coma) what are the 3 components?eye opening motor response verbal response what is a primary component in TPN?glucose, so the nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia when a client is on TPN, the nurse must assess for hyperglycemia why?bc a primary component is glucose. therefore the nurse must be assessing to see if the client is getting too much glucose (hoerglycemia). and with a large urinary output like 4800, this could indicate symptoms of hyperglycemia signs of hyperglycemia- polydipsia,

• polyuria,
• restless,
• confused,
• bg over 200,
• fatigue,
• headache
• blurred vision
• kussmaul resp

Interventions to resolve TPN-associated hyperglycemia - reduce amount of carbohydrate in TPN solution

• slow down infusion rate
• administer subcutaneous insulin

what is the goal for mass casualty events?do the greatest good for the greatest number of people keep in mind that disaster triage ranks the likelihood of survival with treatment, not necessarily the severity of the injury

what are the 4 categories for triaging?immediate (red tag)- life threatening injuries with good prognosis once treated delayed (yellow)- injuries requiring treatment within hours minimal (green tag)- injuries requiring treatment within a few days expectant (black tag)- extensive injuries, poor prognosis regardless of treatment

rule of nineshead: 4.5 front 4.5 back

torso: 18 front 18 back

each arm: 4.5 front 4.5 back (each arm is 9 total)

each leg: 9 front 8 back (each is 18 total)

genitals: 1

extrapyramidal side effectsACUTE DYSTONIC REACTION: sudden onset sustained muscle contractions

AKATHISIA: restlessness with inability to sit still

drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces

AKINISIA: loss of involuntary movement

TARDIVE DYSKININIA

NEUROLEPTIC MALIGNANT SYNDROME

dont give morphine if RR under 12 bc it can cause respiratory depression airborne precautionstuberculosis, varicella, and rubeola (measles) wear N95 respirator (and other as needed like for splashes) ALSO (neg pressure room and HEPA) clients suspected are to wear a surgical mask after triage

UAP soft wrist restraints can:do ROM exercises

reapply wrist restraints report changes in skin to nurse turn/reposition client in bed a client with major depression and severe weight loss needs what type of diet?high in calories and protein, also foods that are easy to chew and dont require a lot of energy bc they may have a low energy level

examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta

also small frequent meals memorize MAOIs and rememberthey cant eat foods high in tyramine like aged cheese, yogurt, fermented foods, beer, red wine, cocolate, avocados do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart failure or edema you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics, analgesics, and antinflammatories examples are Mucinex, Ibuprofin, decerebrate posturing (toes point down and amrs/legs straight out) is a sign of severe brain damage near drowning hypothermiawarm iv fluids, blankets, and air also will find weak and thready pulse