When do advanced directives go into effect? - Answer when person is unable to

NCLEX UWorld When do *advanced directives* go into effect? - Answer 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 - Answer 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 - Answer 1. *Assessment* of *physiological stability* (ABCs)

• *Assessment* of *injuries*
• *Moving client*
• *Notifications*
• *Documentation*

Conditions of being *ineligible to leave AMA* - Answer 1 *danger to self or others*

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

Effective handoff communication components - Answer Nurse 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 cancer* - Answer 1. 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 1 / 4

NCLEX UWorld what medications interact with grapefruit? - Answer 1. *calcium channel blockers* (diltiazem, nifedipine, verapamil, etc)

• *statins*
• *SSRIs*

Risk associated with *stent placement* using the *femoral approach* - Answer *retroperitoneal hemorrhage* what are early signs of bleeding into the retroperitoneal space? - Answer 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? - Answer bruising of the flanks and retroperitoneal hemorrhage and is a bluish color what are some physical signs of peripheral arterial disease? - Answer 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 be - Answer tachycardic like 90-110 what is the priority intervention for pain with sickle cell crisis and why? - Answer administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion what is the purpose of continuous bladder irrigation? - Answer 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? - Answer monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed characteristics of a basilar skull fracture - Answer periorbital hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising) immediate client care for basilar skull fracture - Answer cervical spime immobilization, close neurologic monitoring, and support of ABCs vomiting with intake may mean - Answer viral or bacterial infection tympanosomty tubes are placed for - Answer recurrent otis medias nurse actions during a seizure - Answer assist 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) 2 / 4

NCLEX UWorld never put anything in mouth or restrain them since musclec ontractions can occur during a seizure what are some early symptoms of ICP? - Answer altered LOC, headache, abnormal reathing, rise in bp, slow pulse, vomiting client who has a TIA is often placed on - Answer prophylactic antithrombotic treatment like aspirin or clopidogrel glascow coma scale ranges from - Answer 3-15; 3 being worst 15 being best condition (8 or below in a coma) what are the 3 components? - Answer eye opening motor response verbal response what is a primary component in TPN? - Answer *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? - Answer 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 - Answer - polydipsia,

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

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

• slow down infusion rate
• administer subcutaneous insulin

what is the goal for mass casualty events? - Answer 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 - Answer 3 / 4

NCLEX UWorld what are the 4 categories for triaging? - Answer 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 nines - Answer head: 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 effects - Answer ACUTE 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 - Answer respiratory depression airborne precautions - Answer tuberculosis, 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: - Answer 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? - Answer 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 remember - Answer they 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 - Answer you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics, analgesics, and antinflammatories

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