Professional Documents
Culture Documents
Compressive Ati PDF
Compressive Ati PDF
1. Do not What you can EAT E-evaluate A-assess T-teach 11. Woman in (late decels, decreased variability, fetal
delegate labor (un- bradycardia, etc) Turn pt on Left side, give
reassuring FHR) O2, stop pitocin, Increase IV fluids!
2. Addison's & Addison's = down down down up down
Cushings Cushings= up up up down up 12. Tube feeding Pt on Right side (promotes emptying of the
hypo/hypernatremia, hypo/hypertension, with decreased stomach) Head of bed elevated (prevent
blood volume, hypo/hyperkalemia, LOC aspiration)
hypo/hyperglycemia 13. After lumbar pt is flat SUPINE (prevent headache and
3. Better EleVate Veins, DAngle Arteries puncture and leaking of CSF)
peripheral oil based
perfusion? myelogram
4. APGAR Appearance (all pink, pink and blue, blue 14. Pt with heat flat with legs elevated
(pale) stroke
Pulse (>100, <100, absent) 15. during catheter is taped to the thigh. leg must be
Grimace (cough, grimace, no response)
Continuous kept straight.
Activity (flexed, flaccid, limp)
Bladder
Respirations (strong cry, weak cry, absent)
Irrigation (CBI)
5. Airborne My chicken hez tb (measles, chickenpox 16. After position on the side of AFFECTED ear, allows
precautions (varicella) Herpes zoster/shingles TB
Myringotomy drainage.
6. Airborne private room, neg pressure with 6-12 air 17. After Cateract pt sleep on UNAFFECTED side with a night
precautions exchanges/hr mask N95 for TB
surgery shield for 1-4 weeks
protective
equip 18. after low or semi-fowler's position, support head,
Thyroidectomy neck and shoulders.
7. Droplet spiderman! sepsis, scarlet fever, streptococcal
precautions pharyngitis, parvovirus, pneumonia, 19. Infant with Prone so that sac does not rupture
pertussis, Spina Bifida
influenza, 20. Buck's Traction elevate foot of bed for counter traction
diptheria, (skin)
epiglottitis,
21. After total hip don't sleep on side of surgery, don't flex hip
rubella,
replacement more than 45-60 degress, don't elevate
mumps, meningitis, mycoplasma or
Head Of Bed more than 45 degrees.
meningeal pneumonia, adeNovirus (Private
Maintain hip abduction by separating
room or cohort mask!)
thighs with pillows.
8. Contact MRS WEE
22. Prolapsed cord Knee to chest or Trendelenburg
precaution Multidrug resistant organism
Rresiratory infection 23. Cleft Lip position on back or in infant seat to prevent
Skin infection trauma to the suture line. while feeding
Wound infection hold in upright position.
Enteric infection (C diff) 24. To prevent (post operative ulcer/stomach surgeries) eat
Eye infection (conjunctivitis) dumping in reclining position. Lie down after meals
9. Skin VCHIPS syndrome for 20-30 min. also restrict fluids during
infection Varicella zoster meals, low CHO and fiber diet. small,
Cutaneous diptheria frequent meals.
Herpes simplez 25. AKA (above elevate for first 24 hours on pillow. position
Impetigo knee prone daily to maintain hip extension.
Peduculosis amputation)
Scabies
26. BKA (below foot of bed elevated for first 24 hours.
10. Air or S/S chest pain, dyspnea, tachycardia, knee position prone to provide hip extension.
Pulmonary pale/cyanotic, sense of impending doom. amputation)
Embolism (turn pt to LEFT side and LOWER the head of
bed.)
27. detached area of detachment should be in the
retina dependent position
28. administration of enema pt should be left side lying (Sim's) 46. Hyper- fatigue, muscle weakness, renal calculi, back
with knee flexed. parathyroid and joint pain (increased calcium) give a low
calcium high phosphorous diet
29. After supratentorial (incision behind hairline on
surgery forhead) elevate HOB 30-40 47. Hypovolemia increased temp, rapid/weak pulse, increase
degrees respiration, hypotension, anxiety. Urine
specific gravity >1.030
30. After infratentorial (incision at the nape of neck)
surgery position pt flat and lateral on 48. Hypervolemia bounding pulse, SOB, dyspnea,
either side. rales/crackles, peripheral edema, HTN,
urine specific gravity <1.010. semi fowler's
31. During internal radiation on bed rest while implant in
place 49. Diabetes excessive urine output and thirst,
insipidus dehydration, weakness, administer Pitressin
32. Autonomic S/S pounding headache, profuse
(decreased
Dysreflexia/Hyperreflexia sweating, nasal congestion, chills,
ADH)
bradycardia, hypertension. Place
client in sitting position (elevate 50. SIADH change in LOC, decreased deep tendon
HOB) FIRST! (increased reflexes, tachycardia. N/V HA administer
ADH) Declomycin, diuretics
33. Shock bedrest with extremities elevated
20 degrees. knees straight, head 51. hypokalemia muscle weakness, dysrhythmias, increase K
slightly elevated (modified (rasins bananas apricots, oranges, beans,
Trendelenberg) potatoes, carrots, celery)
34. Head Injury elevate HOB 30 degrees to 52. Hyperkalemia MURDER Muscle weakness, Urine (olig,
decrease ICP anuria) Resp depression, decreased cardiac
contractility, ECG changes, reflexes
35. Peritoneal Dialysis (when turn pt from side to side BEFORE
outflow is inadequate) checking for kinks in tubing 53. Hyponatremia nausea, muscle cramps, increased ICP,
muscular twitching, convulsions. give
36. Lumbar Puncture After the procedure, the pt
osmotic diuretics (Mannitol) and fluids
should be supine for 4-12 hours
as prescribed. 54. Hypernatremia increased temp, weakness, disorientation,
dilusions, hypotension, tachycardia. give
37. Myesthenia Gravis worsens with exercise and
hypotonic solution.
improves with rest
55. Hypocalcemia CATS Convulsions, Arrythmias, Tetany,
38. Myesthenia Gravis a positive reaction to Tensilon---
spasms and stridor
will improve symptoms
56. Hypercalcemia muscle weakness, lack of coordination,
39. Cholinergic Crisis Caused by excessive medication -
abdominal pain, confusion, absent tendon
--stop giving Tensilon...will make it
reflexes, shallow respirations, emergency!
worse.
57. Hypo Mg Tremors, tetany, seizures, dysthythmias,
40. Liver biopsy (prior) must have lab results for
depression, confusion, dysphagia, (dig
prothrombin time
toxicity)
41. Myxedema/ slowed physical and mental
58. Hyper Mg depresses the CNS. Hypotension, facial
hypothyroidism function, sensitivity to cold, dry
flushing, muscle weakness, absent deep
skin and hair.
tendon reflexes, shallow respirations.
42. Grave's Disease/ accelerated physical and mental EMERGENCY
hyperthyroidism function. Sensitivity to heat.
59. Addison's Hypo Na, Hyper K, Hypoglycemia, dark
Fine/soft hair.
pigmentation, decreased resistance to stress
43. Thyroid storm increased temp, pulse and HTN fx, alopecia, weight loss. GI stress.
44. Post-Thyroidectomy semi-fowler's. Prevent neck 60. Cushings Hyper Na, Hypo K, hyperglycemia, prone to
flexion/hyperextension. Trach at infection, muscle wasting, weakness, edema,
bedside HTN, hirsutism, moonface/buffalo hump
45. Hypo-parathyroid CATS---Convulsions, 61. Addesonian N/V confusion, abdominal pain, extreme
Arrhythmias, Tetany, Spasms, crisis weakness, hypoglycemia, dehydration,
Stridor. (decreased calcium) give decreased BP
high calcium, low phosphorus
diet
62. Pheochromocytoma hypersecretion of epi/norepi. 75. pt with leukemia may epistaxis due to low platelets
persistent HTN, increased HR, have
hyperglycemia, diaphoresis, tremor, 76. when a pt comes in first action of nurse is to listen to fetal
pounding HA; avoid stress, frequent
and is in active labor heart tones/rate
bathing and rest breaks, avoid cold
and stimulating foods (surgery to 77. for phobias use systematic desensitization
remove tumor) 78. NCLEX answer tips choose assessment first! (assess,
63. Tetrology of Fallot DROP (Defect, septal, Right collect, auscultate, monitor, palpate)
ventricular hypertrophy, Overriding only choose intervention in an
aortas, Pulmonary stenosis) emergency or stress situation. If the
answer has an absolute, discard it.
64. Autonomic (potentially life threatening
Give priority to the answers that deal
Dysreflexia emergency!) HOB elevate 90 degrees,
with the patient's body, not
loosen constrictive clothing, assess for
machines, or equipment.
full bladder or bowel impaction,
(trigger) administer antihypertensives 79. ARDS and DIC are always secondary to another
(may cause stroke, MI, seizure) disease or trauma
65. FHR patterns for OB Think VEAL CHOP! 80. In an emergency patients with a greater chance to live
V-variable decels; C- cord compression are treated first
caused 81. Cardinal sign of ARDS hypoxemia
E-early decels; H- head compression
82. Edema is located in the interstitial space, not the
caused
cardiovascular space (outside of the
A-accels; O-okay, no problem
circulatory system)
L- late decels; P- placental
insufficiency, can't fill 83. the best indicator of weight---and skin turgor
dehydration?
66. what to check with Never check the monitor or machine
pregnancy as a first action. Always assess the 84. heat/cold hot for chronic pain; cold for accute
patient first. Ex.. listen to fetal heart pain (sprain etc)
tones with stethoscope. 85. When pt is in is rarely a good choice
67. Position of the baby Posterior --heard at sides distress....medication
by fetal heart sounds Anterior---midline by unbilicus and administration
side 86. pneumonia fever and chills are usually present.
Breech- high up in the fundus near For the elderly confusion is often
umbilicus present.
Vertex- by the symphysis pubis.
87. before IV antibiotics? check allergies (esp. penicillin) make
68. Ventilatory alarms HOLD sure cultures and sensitivity has
High alarm--Obstruction due to been done before first dose.
secretions, kink, pt cough etc
Low alarm--Disconnection, leak, etc
88. COPD and O2 with COPD baroreceptors that detect
CO2 level are destroyed, therefore,
69. ICP and Shock ICP- Increased BP, decreased pulse, O2 must be low because high O2
decreased resp concentration takes away the pt's
Shock--Decreased BP, increased stimulation to breathe.
pulse, increased resp
89. Prednisone toxicity Cushings (buffalo hump, moon face,
70. Cor pumonae Right sided heart failure caused by high blood sugar, HTN)
left ventricular failure (edema, jugular
vein distention)
90. Neutropenic pts no fresh fruits or flowers
257. Lymes disease bullseye rash 273. bowel more important to maintain fluid balance
obstruction than to establish a normal bowel pattern
258. intraosseous often used in peds when venous
(they cant take in oral fluids)
infusion access can't be obtained. hand
drilled through tibia where 274. Basophils during an allergic response
cryatalloids, colloids, blood products reliease
and meds are administered into the histamine
marrow. one med that CANNOT be 275. Iatragenic means it was caused by treatment,
administered IO is isoproterenol, a procedure or medication
beta agonist.
276. Tamoxifen watch for visual changes--indicates toxicity
259. sickle cell crisis two interventions to prioritize: fluids
277. post pneumovax 23 is administered to prevent
and pain relief.
spelectomy pneumococcal sepsis
260. glomuloneprhitis the most important assessment is
278. Alkalosis/ ALKalosis=al K= low sis. Acidosis (K+ high)
blood pressure
Acidosis and K+
261. children 5 and up should have an explanation of what
279. No to a kid with PKU. No meat, dairy or
will happen a week before surgery
phenylalanine aspartame
262. Kawasaki disease (inflammation of blood vessles,
280. never give to a pt who has low urine output!
hence the strawberry tongue)
potassium
causes coronary artery aneurysms.
281. nephrotic characterized by massive proteinuria
263. ventriculoperitoneal watch for abdominal distention.
syndrome caused by glomerular damage.
shunt watch for s/s of ICP such as high
corticosteroids are the mainstay
pitch cry, irritability and bulging
fontanels. In a toddler watch for loss 282. the first sign of increased respirations! followed by
of appetite and headache. After ARDS dyspnea and tachypnea
shunt is placed bed position is FLAT 283. normal PCWC is 8-13 readings 18-20 are considered high
so fluid doesn't reduce too rapidly. If
(pulmonary
presenting s/s of ICP then raise the
capillary wedge
HOB 15-30 degrees
pressure)
264. 3-4 cups of milk a NO too much milk can reduce the 284. first sign of PE sudden chest pain followed by dyspnea
day for a child? intake of other nutrients especially
and tachypnea
iron. Watch for ANEMIA
285. Digitalis increases ventricular irritability ----could
265. MMR and varicella after 15 months!
convert a rhythm to v-fib following
immunizaions
cardioversion
266. cryptorchidism undescended testicles! risk factor for 286. Cold stress and biggest concern resp. distress
testicular cancer later in life. Teach
the newborn
self exam for boys around age 12--
most cases occur in adolescence 287. Parathyroid vitamin D to work
relies on
267. CSF meningitis HIGH protein LOW glucose
288. Glucagon anticoagulants
268. Head injury or skull no nasotracheal suctioning
increases the
fx
effects of?
269. otitis media feed upright to avoid otitis media!
289. Sucking stab wound cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a
closed pneumo or tension pneumo!
290. chest tube pulled out? occlusive dressing
291. PE Needs O2!
292. DKA acetone and keytones increase! once treated expect postassium to drop! have K+ ready
293. Hirschprung's diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul
smelling stools
294. Intussusception Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel
movements
295. laboring mom's water first thing--worry about prolapsed cord!
breaks?
296. Toddlers need to independence!
express
297. Addison's causes sever hypotension!
298. pancreatitis first pain relief, second cough and deep breathe
299. CF chief concern? Respiratory problems
300. a nurse makes a take it to him/her first then take up the chain
mistake?
301. nitrazine paper turns blue with alkaline amniotic fluid. turns pink with other fluids
302. up stairs with crutches first followed by good leg
crutches?
303. dumping syndrome? use low fowler's to avoid. limit fluids
304. TB drugs are hepatotoxic!