ATI: NCLEX Live Review

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1.

Pancreatitis

NPO, TPN May

be used

2.

Diverticulitis

Clear liquids to
high fiber

3.

Cholecystis

Low-fat diet

4.

Liver disease

Decreased
protein intake

5.

Celiac disease

Avoid glutens

6.

Nausea and vomiting

Clear liquids

7.

Gout

Avoid purines

8.

Dumping syndrome

Small frequent
meals

9.

GERD

Avoid large
meals, eating
late, alcohol
caffeine

10.

Monitor for digoxin

Potassium

11.

Monitor for acetaminophen

Temperature

12.

Monitor for glipizide

Blood glucose

13.

Monitor for morphine

Respiratory rate

14.

Monitor for prednisone

Delayed wound
healing

15.

Monitor for warfarin

INR

16.

Monitor for zolpidem

Sleep patterens

17.

Monitor for Olanzapine

Mood

18.

Monitor for Levoflaxacin

Culture and
sensitivity

Erikson stage 0-1, posterior fontanelle

closes at 2 to 3 months, 1 to 5 m grasp
rattle 6 m transfer between hands, 8-9 m
uses pincer grasps, nine months bangs
toys together, 3 m holds head, 5-6 m
rolls, 9m sits up on own, 12 m stands
alone

Trust vs
mistrust, meet
social and
developemental
needs

Erikson stage 1-3, feeds self, anterior

fentanyl closes, steady gait, draw stick
figure, potty train, need routines and
rituals

Autonomy vs
shame and
doubt, provide
acceptable
options

Erikson stage 3-6, hopping, draws shapes,

walking heel to toe

Initiative vs.
guilt, provide
age appropriate
activities,
stranger
danger

19.

20.

21.

22.

Erikson stage 6-12 or games, rides bicycle,

build models, organize sports, puzzles
games, video games

Industry vs
inferiority,
encourage
participation
in care

23.

Erikson stage 12-20 pure activities, music

interest, career training, sexual
maturiation, STI's, pregnancy, substance
abuse

Identity vs role
confusion,
Provide
support
groups of
same age

24.

Erikson stage 20-35 leaves families and

seeks relationships, growth ends
childbearing, established career,

Intimacy vs
isolation,
provide
private time
with partner

25.

Erikson stage 35-65 bouncing life, aging

parent, adult children, grandchildren,
career transition, retirement, menopause,
osteoporosis, decrease in visual and
hearing

Generativity
vs stagnation

26.

Erikson stage 65+, decreased skin

elasticity, decreased cough reflects, lower
cardiac output, peridontal disease

Integrity vs
despair, use
personal items
were not
home

27.

Antidote for opoids

Naloxone

28.

Antidote for warfarin

Vitamin K

29.

Antidote for acetaminophen

Acetylcystiene

30.

Antidote for heparin

Protamine
sulfate

31.

Antidote for benzodiazepine

Flumaxenil

32.

Antidote for digitalis

Digoxin
immune fab

33.

Antidote for lead

Succimer

34.

Antidote for magnesium

Calcium
gluconate

35.

When mixed with regular insulin draw this

medication up last, 4-6 hr peak time

NPH

36.

Have client eat as soon as this medication

is given

Lispro

37.

Hold this medication 48 hours before and

after use of contrast dye

Metformin

38.

Given subcutaneously and has no peak

time

Glargine

39.

May be used to lower potassium levels,

can be given IV, also for DKA

Regular
insulin

40.

Type of solution for TPN

Hypertonic

41.

Routes TPN can be given

Picc line, tunneled

catheter

71.

LPNs cannot
what

Evaluate Assess teach, can reinforce or

reteach, iv therapy, blood therapy (rhogam)

42.

TPN is prepared how often

Daily

72.

43.

TPN is hung every_ hours

24

Dilantin or other medications that alter brain

activity

44.

Standard precaution
requirements

Nothing, gloves prn

Medication
to hold prior
to ECT

73.

30 days

45.

Contact precaution
requirements (body fluids)

Gloves and gown

46.

Droplet precaution
requirements (air)

Mask

How long
post surgery
to be on
blood
thinners

74.

Airborne precaution
requirements (air)

Mask

Priority if
chest tube
comes out

Cover with Vaseline soaked gauze

47.

48.

Normal sodium level

135-145

75.

Ebola

49.

Normal potassium level

3.5-5

Hemorrhagic fever, w/ out symptoms

quarenteen for 21 days

Normal calcium level

9-10.5

76.

50.

Normal carbon dioxide level

35-45

Immune system, decreased white blood cells

and decreased platelets

51.
52.

Normal hydrochloride level

21-28

System
affected by
methotrexate
(steroid)

53.

Normal hemoglobin level

14-18

77.

54.

Normal Hct level

37-52%

System
affected by
sodium levels

Neurological system, seizures occur with low

levels

55.

Normal WBC level

5,000-10,000

78.

Normal cholesterol level

<200

57.

Normal platelets

150,000-400,000
enoxaparin sodium

Anticholinergic
drugs side
effects

No see no Pee no stool no drool

56.

58.

Normal PT

11-12.5 sec, rx: 1.5-2x

Coumadin

79.

Versed

Pt cannot sign for anything after recieving

80.

Married, emancipated, or has child

30-40 sec rx 1.5-2x

heparin

16 y.o can be
a majority if

81.

ED triage

Treat most severe injury first

82.

Mass casualty
triage

Do the greatest good for the greatest number

83.

Magnesium

drip needs to have one-to-one, due to side

effects (absent deep tendon reflexes),
monitor BP, resp, DTR, used for preclampsia

84.

Meningitis

symptoms: Headache, Stiff neck and

photosynthesis, Diagnostics: spinal fluid
(lumbar puncture) blood cultures,
Prevention: Hand washing, immunization,
Assessments: Brudzinski (pain with Head to
breast bone) Kernigs (Pain with knee up to
chest) Living in close spaces can cause this.

85.

Priority for
MI

Apply oxygen first

86.

2 pt gait

Partial weight-bearing on extremity walking

with crutches right leg left crutch as if they
were skiing

87.

3 pt gait

Nonweightbearing swing through crutches

88.

4 pt gait

Stability partial weight-bearing on both

extremities right leg right crutch

59.

normal aptt

60.

Normal INR

0.7-1.8, rx 2-3x Coumadin

61.

Normal glucose fasting

70-105

62.

Normal HbA1c (glycosylated

hgb)

4-6%

63.

Normal BUN level

10-20

64.

Normal creatinine level

0.5-1.2

65.

Arterial supply

Goes down in legs

66.

Venous supply

Goes up in legs

67.

Red tag

Emergent

68.

Yellow tag

Urgent within 1 to 2
hours

69.

Green tag

Non-urgent 2 to 4 hours

70.

Black tag

Not seen don't have

survival potential

89.

Walker

Step into it, arm's-length away, don't pull

self up with device

90.

Cane

Always on the strong side

91.

Up stairs

Strong leg first

92.

Down stairs

Weak leg first

93.

Yogurt

Form of calcium for lactose intolerant

patients

94.

Diet for
Christianity

Don't eat meat on ash Wednesday or

Fridays of light may have days of fasting

Diet for
Buddhism

Avoid beef pork seafood

96.

Judaism diet
(Muslims)

Kosher- can't mix milk and meat no pork

avoid fish that don't have scales

97.

Hinduism diet

No beef, may fast, many are vegetarian

98.

Interventions
for dumping
syndrome

Lay down after eating, avoid drinking one

hour before and one hour after eating,
avoid sugar and milk

99.

Interventions
for eternal
nutrition

Start slow increase rate every 8 to 12 hours,

greater than 100 residue fluid hold fluid,
head of bed 30 or higher, assess for signs
of intolerance, first feeding have x-ray
every other check pH.

100.

Lithium
toxicity

Can occur if greater than two

101.

Zolpidem

(Ambien) sleepwalk and cannot remember

102.

Side affects of
antipsychotics
(typical)

Sedation, EPS, and anti-cholinergic effects

Adverse affects
of
antipsychotics

Tardive dyskinesia,such as thumb rolling

And eye emovements, Agranulocytosis,
neuroleptic malignment syndrome,
siezures

95.

103.

104.

Risedronate

Don't lay down right away

105.

Fentanyl
patch

Remove with temperature, one for three

days, don't put heating pad over it

106.

Gentamicin

Don't use if damage to kidneys when used

with furosemide can cause hearing loss at
high doses

107.

Amoxicillin

Be aware with cephalosporins allergy

108.

Ceftriaxone

Can create C diff

109.

Adverse effects

Life-threatening

110.

varenicline

Only use up to 12 weeks for smoking

cessation

111.

Calcium
channel
blocker's, beta
blockers, ARBs,
ace inhibitors

Blood-pressure medications

112.

Calcium
channel
blocker's side
effects

Bradycardia, decreased contractility,

peripheral edema

113.

Ace inhibitor
side effects

Dry hacking cough, angioedema

114.

20 gauge
catheter

Can be used for packed RBCs, dextrose

5%, 9% sodium chloride, not used for TPN,
amirodone, vancomycin

115.

Clean wound
with _ before
getting culture

Saline or sterile water

116.

V tach

First action drug Amerodone then

lidocaine then prepare for cardioversion

117.

CAGE

Screening tool for alcoholism, cutdown use

of alcohol, ever felt anger when people tell
you to cut down, ever feel guilty about
how much you drink, eye-opener to quit

118.

Wilms tumor

On adrenal gland needs to be removed

prior to bursting

119.

1 pound

3500 calories

120.

Intropic agents

Increases myocardial contraction, and

cardiac output, digoxin, dopamine,
dubotamine

121.

Digoxin
toxicity

Halos around everything, <6

122.

Dopamine and
dubotamine

Monitor heart rate urine output and

blood pressure

123.

BNP

Diagnostic test for CHF, normal is lower

than 100, 100 to 300 heart failure is
possible, 300 to 600 heart failure is mild,
600-900 moderate heart failure, severe hf
> 900

124.

Packed RBCs

Treat anemia, monitor hemoglobin

125.

Platelets

Treats thrombocytopenia, monitor

platelets

126.

Plasma

Treats Burns, monitor albumin, 3.5-5

127.

Factor 8

Treats hemophilia, monitor ptt

128.

1 unit of blood

Expect 1g/dl increase in hgb ex. 7.8-8.8

129.

Kidneys

Monitor I&O, electrolytes, BUN, creatinine,

Hgb, BP (BUN & creatinine increases with
kidney failure)

130.

Complications
with central
lines

Pneumothorax, air embolism, occlusion,

infection, with air embolism lay on left
side and Trendelenburg position with
insertion

131.

Hyperthyroidism

PTU & Tapazole, or remove thyroid

(calcium at bedside) Think of Tigger
orange and hyper

132.

Hypothyroidism

Levothyroxine, Think of eeyore, slow

moving, depressed

133.

Affected system
of potassium

Cardiac, cardiac arrest with severe levels

134.

Insulin
withdrawal
when mixing

Clear to cloudy (regular-NPH)

135.

Oxytocin

Monitor fhr, contractions, BP, hr, rr

136.

Quetiaphine
fulmarate

Bipolar, monitor for suicidal thinking,

dizziness, leukopenia

137.

Risperidone

Bipolar, monitor for sedation insomnia

pseudoparkinsonism,

138.

Lithium
carbonate

Bipolar, no levels of lithium,

139.

SSRI

Antidepressant that blocks reuptake of

serotonin

140.

SNRI and
tricyclics

Antidepressant that box reuptake of

serotonin and norepinepherine

141.

MAOI

Focus on diet

142.

Atypical
antidepressants

Selectively inhibits dopamine and

stimulates CNS, side effects: seizures
psychotic symptoms, Buproprion

Developing
cancer with
birth control

Only with smoking

144.

Naegeles rule

1st day menstrual cycle-3 months, +7

days

145.

First stage of
labor

Latent 0 to 3 cm, active 4 to 7, transition 8

to 10,

146.

Second stage of
labor

Pushing stage

147.

Third stage of
labor

Delivery of placenta

148.

Fourth stage of
labor

Bonding with newborn

149.

Taking in phase

It's all about me

150.

Taking hold
phase

It's all about the baby

151.

Letting go phase

Getting back to the new normal

152.

Anemia side
effects

Weakness paler fatigue

143.

153.

Anemia
interventions

Food sources that contain red meat, organ

meat, egg yolks, leafy green vegetables, use z
track method for Iran dextran

154.

Blood
compatibility

Remember this by what factor they have a

or B or both AB or neither o patient doesn't
have that factor they can't receive the blood,

155.

Hemophilia
signs and
symptoms

Risk for bleeding, Hematomas, G.I. and G

you bleeding, brain hemorrhage, and
bleeding mucous membranes

156.

Hemophilia
nursing
interventions

Assess for joint pain, monitor vitals,

admonister factor replacement, avoid
injections and NSAIDs, assess LOC and
bleeding

157.

MI diagnostic
labs

Troponins

158.

Sickle cell
anemia and
crisis

Most common in African Americans, blood

comes and causes severe pain, oxygen is
limited to the cells of the body because cells
cannot carry oxygen as well, don't do well in
cold weather or high altitude

159.

Signs and
symptoms of
sickle cell
anemia

Anemia, hypoxic damaged tissue,

dehydration, susceptibility to infection,
knowledge deficit and powerlessness

160.

Nursing
interventions
for sickle cell
anemia

Oxygen as needed, manage pain, and her

vitals, monitor H&H, Mr. fluids as needed,
assess for signs and symptoms of infection,
teach self-care, causes and prevention of
crisis

161.

Cervical
cancer

Contributing factors: HPV/ multiple partners,

manifestations: abnormal bleeding,
Dianosing: pap/DNA test, prevention:
Gardisil

162.

Breast cancer

Contributing factors: family history, lifestyle,

Manifestations: Lumps, thickening,
Diagnosing: mammogram, Prevention: Diet,
weight, excercise

163.

When is a
colposcopy
used?

abnormal pap test

164.

Stable angina

pt is awake and doing something when

having chest pain. Pain is able to be treated
with first nitro

165.

Unstable
angina/
preinfarction

Moving around but not relieved with nitro.

166.

Prinemetal/
Coronary
spasm

Sound asleep and woken up by pain in

chest

167.

168.

Protocol for
American Heart
Association regarding
MI

Sit down take a nitro, wait 5 min, call

911, take another nitro, wait 5 min
and take final nitro.

Nursing interventions
for MI

Morphine (decreases preload &

afterload)
Oxygen (First, treats ischemic
myocardium)
Nitro (increases coronary
perfusion)
Aspirin- (decreases clot formation)
MONA

185.

DKA

Symptoms include: kussmaul respirations,

fruity breath

186.

Thyroidectomy

Check for positive Chvotesek sign

187.

Hyponatremia

Causes: Diuretics, renal disease,

Treatment: SIADH, Symptoms: confusion->
seizures, muscle weakness, cramping

188.

Hypernatremia

Causes: Water deficit, Cushings, Symptoms:

Confusion->siezures, muscle weakness

189.

Hypokalemia

Causes: Diuretics, corticosteriods,

suctioning, diarhea. Symptoms: muscle
weakness, shallow respirations,
Dysrrhithmias

190.

Hyperkalemia

Causes: salt substitutes, renal failure,

packed RBCs, Addisons Symptoms:
Dysrhythmias, peaked T waves

191.

Addisons

Low cortisol

192.

Cushings

High cortisol (steroid symptoms)

Aortic femoral Bypass

(restoring blood
supply to blocked
area) interventions

peripheral pulses, skin temp,

anticoags, avoid crossing legs,
monitor site, KEEP BP LOW

Heart sounds
mnemonic

Ape to man
Aortic, pulmonic, erbs point,
tricuspid, mitral

171.

Where do I listen to
S2?

aortic and pulmonic

193.

Kayexalate
enema

pulls off potassium

172.

Where do I listen to
S1?

tricuspid and mitral

194.

Hypocalcemia

173.

S3 and S4 sounds

kentucky (going into CHF)

Tennessee (Angina)

Causes: hypoparathyroidism, renal failure,

malabsorption Symptoms: Changes in HR,
prolonged ST, tetany, changes in LOC,
siezures

195.

Angioplasty

NI: cardiac diet, check vitals every

15 min, cardiac monitor, pressure @
site. Complications: dysrhithmias,
bleeding, hypovolemia

Hypercalcemia

174.

Causes: Hyperthyroidism, Excessive intake

Symptoms: Dysrhithmias, cardiac arrest

196.

Isotonic

No fluid crosses the cell membrane 0.9%NS

197.

Hypotonic

fluid moves into the cell 0.45% NS

169.

170.

175.

P wave

atrium are contracting

198.

Hypertonic

fluid moves out of the cell D5 NS

176.

QRS

ventricles contract

199.

Cirrhoises

177.

T wave

ventricles relax, Don't want PVC's to

hit T wave

178.

Cardioversion

Use with unstable v tach, machine

synchronizes with the heart rhythm
because you do not want to hit the t
wave

Symptoms: hypertension, esophageal

carices, clotting abnormalities, hepate
encephalopathy, ascites, peritonitis. NI:
Assess fluid balance, assess bleeding,
safety precaustions, high calorie diet, fluid
restrictions, low protien

200.

Rule of 9's

Each arm= 9%, Anterior leg=9%, Posterior

leg=9% Head=9%, Back=18% Chest=18%,
Perineum=1%

201.

Parkland
formula

used for determining amount of lactated

ringersfor burn patient. Begin time at time
of burn. Administer through central line
and have foley cath. 4mL x kg x %TBSA=
1/2 total in first 8 hrs, 1/2 in remaining 16
hours

179.

v fib

whole ventricles are shaking like

jello and not firing

180.

Common heart
rhythm with anemia

Sinus tachycardia

181.

Left sided heart

failure

Fluid backs up into lungs, crackles

in lungs, dyspnea

182.

Right sided heart

failure

Fluid backs up into heart, S3 gallop,

peripheral edema

183.

Normal pulmonary
wedge pressure

4-12

184.

Heart failure

NI: O2, fowlers, lung sounds, I&O,

fluid restriction, daily weights,
diuretics, ACE inhibitors, digitalis

202.

Head injury

Signs: Changes in LOC, Increased ICP,

Brady, tachypnea, hypo/hypertension,
hyperthermia, bradycardia, posturing.
Interventions: Assess neurostatus w/
glascow coma scale (higher the better), I &
O, Elevate HOB, monitor electrolytes,
decrease stimulation, monitor ICP, vitals,
nutritional support.

219.

Carseat

Middle of backseat for 2 years or 20

lbs

220.

Donning order

Gown-Mask- goggles-gloves-enter

221.

Doffing order

gloves- gown- goggles-mask

222.

Nasal Cannula

1-6 L/min over 2 needs humidifyer

223.

Simple face mask

6-8L/ min

203.

Spinal shock

occurs right away, hypotension,

224.

Venturi face mask

4-8L/min

204.

Autnomic
dyreflexia

Spinal injury, can occur after several

weeks only in T6 or higher, hypertension,
flushing, headache Treatment: lower BP
and treat cause.

225.

Non- Rebreather

12L/min

226.

RSV

contagious for 1 week after antibiotic

227.

C-Diff and VRE

use soap and water

228.

Droplet (infections)

measles, influenza, can cohort

229.

Airborne(infections)

chicken pox, TB, cant cohort

230.

Contact (infections)

MRSA, C-diff can cohort

231.

Abuse phases

Tension building-> battering->

honeymoon-> tension building

232.

PTSD

symptoms are delayed, assess for

irritibility, difficulty sleeping and
concentration, decrease excessive
stimulus, help evaluate coping
mechanisms

233.

Bipolar disorder

Depression and mania, inflated self

esteem, flight of ideas, buying sprees,
decreased needs for sleep, coexist
with substance abuse.

234.

Borderline
personality disorder

Manipulative behavior

235.

Depression

R/f: female, unmarried, low

socialeconomic class, postpartum
period, medical illness, early child
hood trauma. Symptoms: Insomnia,
anergia, feelings of worthlessness
decreased concentration.

236.

Grief

Denial-> Anger-> Bargaining->

Depression-> Acceptance

237.

Cluster A

Paranoid, schizoid, Schizotypal

238.

Cluster B

Antisocial, Borderline, Histronic,

Narcissistic

239.

Cluster C

Avoidant, Dependent, Obsessive

Compulsive

240.

When patient hears

voices

"What are the voices saying to your?"

205.

Cervical spine

Top 8, worry about breathing

206.

Thoracic spine

Middle 12, quadroplegic

207.

Lumbar spine

Bottom 5, paraplegic

208.

Spinal cord
injury

Intervention: Immobilization, assess

respiratory status, assess vital signs,
institue bowel sounds and bladder
program, prevent DVT, urinary retention,
constipation, skin break down.

VEAL CHOP
MINE

Menomic for decelerations

Variable Cord compression Move patient
Early Head compression Identify labor
progress
Accelearate Okay No action
Late Placental insufficiency Execute STAT

Precalampsia

NI: Monitor BP, protein in urine, weight,

watch edema
eclampsia occurs with seixures

209.

210.

211.

Uncompensated

pH is off and 1 other is off

212.

Partially
compensated

pH is off as well as other two are off

213.

fully
compensated

pH is normal other two are off

Metabolic
alkalosis

Vomiting loose acid and left with base

215.

Metabolic
acidosis

Diarrhea loose base and left with acid

216.

High pressure
with
mechanical
ventilation

NI: assess for need to suction, pt needs

tomlet machine breath for them.

217.

Low pressure
with
mechanical
ventilation

check tubes for leaks

218.

Cancer internal
radiation

NI: visitors should maintain 6 feet away

and visit no longer then 30 min, staff
needs a dosimeter badge.

214.