Nclex Tips 18 (Pearson Nclex)

Antacids are generally not administered with other medications because of their interactive effects. Additionally, antacids delay the absorption of other medications The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce the intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are considered to be low-calcium foods. Sodium should not be limited for the client with hypercalcemia unless contraindicated for another reason, such as cardiac disease. When sodium is retained, then calcium is lost through the kidneys. The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurses primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse would document that the task was completed but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift. The client with a thoracic burn and smoke inhalation requires aggressive pulmonary measures to prevent atelectasis and pneumonia. These include turning and repositioning, using humidified oxygen, providing incentive spirometry, and suctioning on an as-needed basis. The client should not be left lying in a single position and should not have the head of bed flat. These could promote the development of complications by limiting chest expansion. Wound dehiscence is the disruption of the surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in low-Fowlers position and instructs the client to lie quietly. These actions will minimize protrusion of the underlying body tissues. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline. The physician is then notified and the nurse documents the occurrence and the nursing actions implemented. Adult diabetes mellitus can be diagnosed either by symptoms (polydipsia, polyuria, polyphagia), or by laboratory values. Diabetes mellitus is diagnosed by an abnormal glucose tolerance test, or when random plasma glucose levels are greater than 200 mg/dL, or fasting plasma glucose levels are greater than 140 mg/dL on two separate occasions.

Hemorrhage is a potential complication following tonsillectomy and adenoidectomy. If the client vomits large amounts of altered blood or bright red blood, or if the pulse rate or temperature rises and the client is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostats, and a waste basin for examination of the surgical site. The nurse would also gather additional assessment data, but the immediate nursing action would be to contact the surgeon. The client with hypertension is at risk for cardiovascular complications, such as angina pectoris, myocardial infarction, and heart failure. Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart. The client should know to report the onset of chest pain immediately. Lethargy, constipation, and weight gain are symptoms of hypothyroidism, which should improve with medication therapy such as levothyroxine sodium. Pulmonary embolism is a life-threatening emergency. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The ECG is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and arterial blood gases may be drawn. However, the immediate nursing action is to administer oxygen. Fludrocortisone acetate (Florinef) is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity. It is prescribed for the long-term management of Addisons disease. Mineralocorticoids cause renal resorption of sodium and chloride ions, and the excretion of potassium and hydrogen ions. These actions help restore electrolyte balance in the body. The client with diabetic neuropathy of the lower extremities has diminished ability to feel sensations in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. A traumatic open pneumothorax is an emergency. Stopping the flow of air through the opening in the chest wall is a life saving measure. In such an emergency, anything may be used that is large enough to fill the chest wound including a towel, a handkerchief, or the heel of the hand. If conscious, the victim is instructed to inhale and strain against a closed glottis. This action assists in reexpanding the lung and ejecting the air from the thorax. In the hospitalized client who experiences an open pneumothorax, the opening is plugged by sealing it with gauze impregnated with petrolatum. The client with severe osteoporosis as a result of hyperparathyroidism is at great risk for injury as a result of pathological fractures from bone demineralization. The client may or may not have a risk for impaired urinary elimination, depending on other elements in the client history, and whether or not the client is at risk for stone formation from high serum calcium levels. The client may also have a risk for constipation from the disease process, but this would be a lesser priority than client safety. A risk for ineffective health maintenance may be a

concern but is not the priority. Clients with myxedema or hypothyroidism have decreased metabolic demands from reduced metabolic rate. For this reason they often experience weight gain. The diet should be low in calories overall and yet be representative of all food groups. Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this disorder then is one that is high in calcium but low in phosphorus, because these two electrolytes have inverse proportions in the body. Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If no external air leak is present, the physician is notified immediately because an air leak may be present in the pleural space. Leaking and trapping of air in the pleural space can result in a tension pneumothorax. The client taking NPH insulin obtains peak medication effects 6 to 12 hours after administration. At the time that the medication peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse would teach the client to watch for signs and symptoms of hypoglycemia, including anxiety, confusion, difficulty concentrating, blurred vision, cold sweating, headache, increased pulse, shakiness, and hunger. Before doing a fingerstick for blood glucose measurement, the client should first wash the hands. Warm water should be used to stimulate the circulation to the area. The finger is punctured near the side, not the center, since there are fewer nerve endings along the side of the finger. The puncture is only deep enough to obtain an adequately sized drop of blood; excessively deep punctures can lead to pain and bruising. The arm should be allowed to hang dependently, and the finger can be milked to promote obtaining a good size blood drop. Diabetic clients should take in approximately 15 grams of carbohydrate every 1 to 2 hours when unable to tolerate food due to illness. The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to a lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly. This occurs because potassium is carried into the cells along with glucose and insulin, and also because potassium is excreted in the urine once rehydration has occurred. Thus, the nurse must plan to monitor the results of serum potassium levels carefully, and report hypokalemia In the immediate postoperative period following a radical neck dissection, the nurse assesses for stridor (a coarse, high-pitched sound on inspiration when auscultating over the trachea). This finding is reported immediately, because it indicates airway obstruction.

Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early, so that appropriate action can be taken In functional nursing, a task approach method is used to provide care to clients. The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are deep and nonlabored. They occur as the body tries to eliminate carbon dioxide to compensate for lactic acidosis. As ketoacidosis improves, this pattern of respiration resolves. The nurse monitors the clients respiratory status as part of the clients overall status. The client is likely to have tachycardia due to efforts by the body to compensate for the effects of anemia. The client with anemia is likely to complain of fatigue, because of decreased ability of the body to carry oxygen to tissues to meet metabolic demands. Increased respiratory rate is not an associated finding, although some clients may have shortness of breath. Spinal cord compression should be suspected in a client with metastatic disease, particularly when a new and sudden onset of back pain occurs. Spinal cord compression causes back pain before neurological changes occur. Spinal cord compression is an oncological emergency, and the physician should be notified. The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, and oysters. Iron preparations can be very irritating to the stomach and are best taken after a meal. The tablet is swallowed whole, not chewed. Because the client might experience constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. For most hematological laboratory studies, including CBC, no special care is needed either before or after the test. There is no reason to fast after midnight, drink extra liquids, or avoid red meat prior to the laboratory test being drawn. Before bone marrow aspiration, the site is cleansed with an antiseptic solution such as povidone-iodine. This helps reduce the number of bacteria on the skin, and decreases the risk of infection from the procedure. When delegating nursing assignments, the nurse needs to consider the skills and educational levels of the nursing staff. The nursing assistant can most appropriately give a shower, a bed bath, ambulate a client with a walker, take an oral temperature. The LPN can administer the rectal suppository to the client requiring the enema. The LPN is skilled in wound irrigations and dressing changes, and this client would most appropriately be assigned to this staff

member. After ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, traveling by air, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Swimming is also avoided. Clients need to avoid moving the head rapidly, bouncing, and bending over for 3 weeks. Exacerbation of Mnires disease is characterized by severe vertigo. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Activities such as reading and watching TV will worsen the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects. The client who is thrombocytopenic is at risk for bleeding. The family should observe the puncture site for bleeding for several days after the procedure, since the client is at high risk. Acetaminophen may be given for discomfort, and aspirin should be avoided because it could aggravate bleeding The client who has had surgical resection of the stomach or small intestine may develop pernicious anemia as a complication. This results from decreased production of intrinsic factor (gastrectomy) or decreased surface area for vitamin B12 absorption (intestinal resection). The client then requires vitamin B12 injections for life. Decreased iron intake leads to iron deficiency anemia, which is often easily treated with iron supplements. Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. The RN would plan to care for the client who is scheduled for surgery at 1:00 p.m. first. There are several items that need to be addressed preoperatively, including client preparation (physically and emotionally) and physician orders that need to be carried out. This preparation takes time. Additionally, many times the operating room makes late changes in the schedule, depending on room and physician availability, and requests an earlier surgical time. Therefore, it is best to ensure that this client is prepared.

Nclex Tips 4 (Pearson Nclex)

Large quantities of alcohol have been associated with an increased risk of liver cancer. However, according to the clients statement, the client understood that no alcohol may be consumed. Thus the client requires reinforcement that alcohol is the substance associated with liver cancer; however, clarification is needed that it is an excessive intake that is associated with liver cancer. Decreased aldosterone secretion results in a fluid volume deficit. Clients are encouraged to maintain an oral intake of 3000 mL/day to avoid dehydration. Clients require a high sodium diet to replace losses. Snacks between meals are encouraged, to prevent hypoglycemia. Clients with Addisons disease require hormone-replacement therapy with corticosteroids. Addisonian crisis is a serious, life-threatening response to acute adrenal insufficiency that is most commonly precipitated by a major stressor. The client with addisonian crisis may have any of the signs or symptoms of Addisons disease, but the primary problems are sudden profound weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal failure. Typical discharge instructions after AICD implantation include reporting to the physician symptoms indicating dysrhythmias, such as fainting, blackouts, rapid pulse, weakness, or nausea. The physician may want to be called each time the device discharges. At a minimum, the client should keep a log recording the date, time, symptoms, and activity before the shock, the number of shocks delivered, and how the client felt afterward. The physician will use this information in managing the ongoing medication regimen. The community emergency medical system should be notified about the device, so they are prepared if they are called to the home. Contingency plans for health care should be made before travel. The family also should become trained in cardiopulmonary resuscitation (CPR). No special restrictions are imposed after a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. No hazards to the client or staff exist from the minimal amount of radioactivity of the isotope. A hepatitis A vaccine is available for administration to protect against the infection. In addition, a standard immunoglobulin for passive immunization can be given prophylactically or after exposure. The immunoglobulin for passive immunization provides protection from infection for approximately 2 months. Hepatitis A is transmitted via the fecal-oral route Outcomes indicating that peritonitis has resolved include an afebrile condition, absence of rebound tenderness, clear appearance of dialysate, absence of

bacteria in dialysate, normal WBC count, and no redness or swelling at the catheter site. Medical management of hyperparathyroidism includes increasing urinary calcium excretion with diuretics. Clients with hypoparathyroidism experience symptoms related to hypocalcemia ranging from mild paresthesias due to the tetany and possible seizures. Treatment for the disorder involves correction of the hypocalcemia and vitamin D deficiency with pharmacological intervention such as calcium chloride, vitamin D, and calcitriol (Rocaltrol). Nurses should encourage compliance with the prescription regimen as well as teach the client that treatment for this disorder is lifelong. In addition to pharmacological compliance, the client should maintain certain dietary guidelines (high calcium, low phosphorus) if the disease is to be controlled. PTU is administered to clients in thyroid storm to block thyroid hormone synthesis of T3 and T4. Thyroid antibodies indicate whether an autoimmune disease is causing the client's symptoms. A thyroid scan provides information about whether excessive or diminished activity is present in the gland but provides no information about the degree of hormone synthesis. The TSH stimulation test differentiates primary from secondary hypothyroidism. The client learns to void after creation of a neobladder by relaxing the external sphincter while increasing the intra-abdominal pressure (Valsalva maneuver). If the client cannot perform this procedure, then the client must learn to do intermittent catheterization of the neobladder. In the absence of documented heart disease, the desired goal is to have a total cholesterol less than 200 mg/dL, low LDL levels of less than 130 mg/dL, and high HDL levels greater than 50 mg/dL. In the absence of documented heart disease or significant risk factors, the values identified in the question place the client at a low risk for heart disease. The oropharynx (mouth) should be suctioned last to prevent introducing oral bacteria into the lung field. Allowing at least 30-second intervals between suctioning times will allow the client to equilibrate. Pressure beyond 120 mm Hg will damage the mucous membranes. The suction catheter should not be left in the trachea for more than 15 seconds, or the client will experience hypoxia. MRI is a test that involves an external magnetic field to visualize soft tissues. Because of the magnetic field, this test is contraindicated in clients with pacemakers because it can reprogram the pacemaker. Although esophageal varices are caused by portal pressure, rupture of the varices may be caused by increased intrathoracic pressure such as coughing and straining. This pressure may occur during heavy weight-lifting. The term nephrotic syndrome refers to a kidney disorder characterized by

proteinuria, hypoalbuminemia, and edema. The child experiences fatigue, anorexia, increased weight, abdominal pain, and a normal blood pressure. Nicardipine hydrochloride (Cardene) is a calcium channel blocker that is used to treat chronic stable angina or primary hypertension. Before administering the medication, the nurse would check the clients blood pressure and pulse rate. Epstein-Barr virus is transmitted by contact with infectious saliva, close intimate contact with an infectious individual, or contact with infected blood. The infectious period is unknown. Commonly, the virus is shed before clinical onset of the disease until 6 months or longer after recovery. Early signs of lithium toxicity include vomiting, diarrhea, lethargy, and muscle twitching. Moderate toxicity results in ataxia, giddiness, tinnitus, blurred vision, clonic movements, and severe hypotension. Acute toxicity is characterized by seizures, oliguria, circulatory failure, and death. Poor nutrition during pregnancy can negatively influence fetal growth and development. Although pregnancy poses some nutritional risk for the mother, not all clients are at high risk. Calcium is critical during the third trimester, but must be increased from the onset of pregnancy. Intake of dietary iron is usually insufficient for the majority of pregnant women, and iron supplements are routinely encouraged. One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. A score of 8 to 10 indicates that the infant is adjusting well to extrauterine life. A score of 5 to 7 often indicates an infant who requires some resuscitative intervention. Scores of less than 5 indicate infants who are having difficulty adjusting to extrauterine life and require vigorous resuscitation. Kegel exercises strengthen the pelvic floor (pubococcygeal muscle). The increased tone of this muscle is beneficial during pregnancy and afterward. Hemorrhoids are varicosities and are likely to be precipitated during pregnancy by the pressure of the growing fetus inside the abdominal cavity. Standing aggravates the problem. Dietary factors, such as fluids and bulk, and manual reduction are measures that should be included in the plan of care. Hormonal changes are not a factor in the development of hemorrhoids during pregnancy. Oxygen is administered continuously during labor to the client with sickle cell anemia to provide adequate oxygenation and prevent sickling. HELLP is a laboratory diagnosis for a variant of severe preeclampsia and is characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). One of the signs of HELLP syndrome is a decrease in the platelet count. When performing fundal massage, one hand is placed just above the symphysis pubis to support the lower uterine segment, while the fundus is gently but firmly

massaged in a circular motion. Pushing on an uncontracted uterus could invert the uterus and cause massive hemorrhage. Symptoms of infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the mother should be instructed to notify a health care provider because antibiotics may be needed. If these symptoms occur, antibiotics are necessary. In term infants, jaundice first appears after 24 hours and disappears by the end of day 7. Jaundice is first noticed in the head, especially the sclera and mucous membranes. The newborn infant has a high rate of bilirubin production. The reabsorption of bilirubin from the neonatal small intestine is considerable. Criteria for early discharge in the newborn infant include no evidence of significant jaundice within the first 24 hours after birth. The infant should have urinated and passed at least one stool, completed at least two successful feedings, and have normal vital signs for at least 12 hours. These criteria may vary depending on agency policy. If the newborn infant is apneic or has gasping respirations after stimulation, or if the heart rate is below 90 beats/minute, positivepressure ventilation by bag and mask can be given. The ventilation bag used for neonatal resuscitation should have a pressure gauge. Ventilations should be given at a rate of 40 to 60 breaths/minute at pressures of 15 to 20 cm H2O. An initial pressure of 30 to 40 cm H2O may be necessary to inflate collapsed alveoli. After the placenta separates, it can usually be delivered if the mother bears down. The cord may be gently pulled to assist in the delivery of the placenta. Excess traction on the cord may cause it to break, making the placenta harder to deliver. Complete uterine rupture results in massive blood loss; however, external bleeding may not be noted because most of the blood is lost into the peritoneal cavity. Signs of shock, as evidenced by a decrease in blood pressure, tachycardia, tachypnea, pallor, cool and clammy skin, anxiety, and pain, develop quickly. Cessation of uterine contractions occurs. The nurse should report the time of the last food intake to the physician. General anesthesia may be used for an emergency cesarean delivery. Gastric contents are very acidic and can produce chemical pneumonitis if aspirated. Situational Low Self-Esteem represents temporary negative feelings about self in response to an event. Ineffective Coping implies that the person is unable to manage stressors adequately. Dysfunctional Grieving implies prolonged unresolved grief leading to detrimental activities.

Deficient Knowledge indicates a lack of information or psychomotor skill concerning a condition or treatment. Dystocia (antonym eutocia) is an abnormal or difficult childbirth or labour. Abnormal labor patterns are assessed according to the nature of the cervical dilation and fetal descent. Progressive changes in the cervix are a reassuring pattern in labor After a precipitate delivery, the mother may need help to process what has happened and time to assimilate it all. The mother may be exhausted, in pain, stunned by the rapid nature of the delivery, or simply following cultural norms. Providing support to the mother is the most appropriate and therapeutic action by the nurse. As the placenta separates, the uterus changes from a discoid to a globular shape. Other signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, and a firmly contracted uterus. The client may experience vaginal fullness, but not sudden abdominal pain. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to postpartum bleeding. The client most at risk for abruptio placenta is the woman who smokes or uses alcohol, illegal drugs such as cocaine, or caffeine during pregnancy. The normal fetal heart rate is 120 to 160 beats/minute. Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased variability, or an irregular FHR.

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Nclex Tips 2 (Pearson Nclex)

he primary symptom in placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Passage of the mucus plug appears pink or as blood-tinged mucus. A ruptured amniotic sac would include findings such as a watery vaginal drainage. Findings of abruptio placenta include dark red vaginal bleeding and abdominal pain. Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the continuation of the medication should be reassessed. The symptoms of jitteriness and tachypnea (respiratory rate of 62 breaths per minute) in a 42-week-gestation newborn infant are indicative of hypoglycemia. Hypoglycemia may develop in a 42-week-gestation newborn infant because of the insufficient stores of glycogen, which may have been depleted during the post-term period. Insufficient amounts of glucose in the infants brain could possibly cause central nervous system damage. A normal blood glucose level for newborn infants is 40 mg/dL and higher. Rho(D) immune globulin is not administered if a client has experienced a severe reaction to its component, human globulin. Rho(D) immune globulin is indicated when Rh-negative clients are exposure to Rh-positive fetal blood cells in any way, including amniocentesis and abortion. A person who lacks hope feels that life is too much to handle. By seeing no way out of the situation except death, the client meets the criteria for hopelessness. Abdominal exercises should not be started after abdominal surgery until 3 to 4 postoperative weeks to allow healing of the incision. Coagulation failure, particularly disseminated intravascular coagulopathy (DIC), is a common result of an amniotic fluid embolus. Manifestations are internal and external hemorrhage clinically determined by bleeding at the site of any trauma (pressure, needle prick, or incision), and petechiae resulting from slight to moderate touch. A postpartum woman who saturates a Peripad in 15 minutes or less is considered to be hemorrhaging, which in this case is caused by lack of coagulation at the placental site.

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A pulsating rope-like object seen in the vagina indicates the presence of the umbilical cord. Each contraction will press the presenting part downward against the bony pelvis, applying pressure to the prolapsed cord, compressing it between the presenting part and the bony pelvis. The compression will shut off the fetal circulation at the point of compression, leading to impaired fetal tissue perfusion and hypoxia of the fetus. Situational Low Self-Esteem represents temporary negative feelings about self in response to an event. This is a normal response to cesarean section. Pregnancy taxes the circulating system of every woman because both the blood volume and cardiac output increase approximately 30%. This is especially important to monitor in the client whose heart may not tolerate this normal increase. HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney and plays a role in blood pressure control. HIV infection in a pregnant woman may cause both maternal and fetal complications. Fetal compromise can occur because of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk of opportunistic infections. Individuals in the later stages of HIV are further susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections. The anterior fontanel is normally 2.5 to 5 cm in width and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could be indicative of increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated. Clients with Cushings syndrome experience weight gain with truncal obesity. The extremities appear thin with the presence of muscle wasting and weakness. The skin is often described as being thin and translucent. A butterfly rash across the cheeks of the face is seen in systemic lupus erythematosus. Polydipsia and polyphagia are seen in diabetes mellitus. Weight loss and peripheral edema may be seen in a number of conditions. Situations that precipitate sickle cell crisis include hypoxia, vascular stasis, low environmental and/or body temperature, acidosis, strenuous exercise, anesthesia, dehydration, and infections. The client undergoing radiation therapy should avoid washing the site until instructed to do so. The client should then wash with mild soap and warm or cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools).

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Prevention of recurrence of urinary stones is accomplished by drinking at least 3 L of fluid per day; voiding every 2 hours; following an acid ash diet if the stones are calcium oxalate stones; and notifying the physician promptly if symptoms of UTI occur. The client with polycystic kidney disease should report any signs and symptoms of urinary tract infection so that treatment may begin promptly. The client should also report increases in blood pressure, because control of hypertension is essential. The client may experience heart failure as a result of hypertension, and thus any symptoms of heart failure, such as shortness of breath, also are reported. The goal of therapy in nephrotic syndrome is to heal the leaking glomerular membrane. This would then control edema by stopping loss of protein in the urine. Fluid balance and albumin levels are monitored to determine effectiveness of therapy. Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. The nurse assures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level. The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. Clients often want to scrub the dead skin away, which irritates the skin. The client should avoid overexposing the skin to the sunlight. Expected outcomes for Impaired Physical Mobility for the client in traction include absence of thrombophlebitis (measurable by negative Homans' sign), active baseline ROM to uninvolved joints, clear lung sounds, intact skin, and bowel movement every other day. After three unsuccessful defibrillation attempts, CPR should be done for 1 minute, followed by three more shocks, each delivered at 360 joules. Typical discharge activity instructions for the first 6 weeks include lifting nothing heavier than 5 pounds, not driving, and avoiding any activities that cause straining. The client is taught to use the arms for balance, but not weight support, to avoid the effects of straining. These limitations are to allow sternal healing, which takes approximately 6 weeks. Clients can resume sexual activity on the advice of a physician, which generally occurs when the client can walk one block and climb two flights of stairs without discomfort. Suggestions to minimize potential problems include waiting for 2 hours after meals or alcohol consumption, making sure one feels well rested, using a comfortable position, and keeping the room at a mild (not chilly) temperature.

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Expected outcomes for the client with pulmonary edema include improved cardiac output as evidenced by stable vital signs, and urine output of at least 30 mL/hour. The clients blood gas results indicate respiratory acidosis. Symptoms of respiratory acidosis include headache, irritability, muscle twitching, behavioral changes, confusion, lethargy, and coma. When the carboxyhemoglobin levels are greater than 25% (acute toxicity), the respiratory center becomes depressed because of inadequate oxygenation, and hypoxia occurs. A long-range approach to the prevention of pulmonary edema is to minimize any pulmonary congestion. During recumbent sleep, fluid (which has seeped into the interstitium by day with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed elevated helps prevent circulatory overload. Complications after pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse notes indications of these complications, such as dyspnea, excessive pain, pallor, or diaphoresis. Mild pain is expected, because the procedure itself is painful. The nurse teaches the client that the pain of fractured ribs generally lasts for about 5 to 7 days. Full healing takes about 6 weeks, after which full activity may be resumed. Coughing and deep breathing will effectively promote lung expansion and clearance of mucus. Using an incentive spirometer is helpful, but it is most effective if the client uses it independently without coaching. The nurse may not need to suction the client if the client is not intubated Prinzmetals angina results from spasm of the coronary vessels. The risk factors are unknown, and it is relatively unresponsive to nitrates. Beta blockers may worsen the spasm. Exercise is most effective when done at least 3 times a week for a client with angina pectoris. Other positive habits include limiting salt and fat in the diet, using stress-management techniques, and knowing when and how to use medications. Nosebleeds may occur during the winter because of decreased humidity in the home. The use of a humidifier helps to alleviate this problem. If pulse oximeter values fall below a preset norm, which is usually 90% to 91%, the client should be instructed to take several deep breaths. This is especially true of a client without a respiratory history who is still under the effects of sedation. If the client did have a respiratory disease history, it might be an indication that supplemental oxygen should be put in place or increased if already in place.

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A Gram stain classifies the organism as gram-negative or gram-positive, and may be done immediately by the laboratory. This gives initial information about the type of organism when initiation of antibiotic therapy is a high priority. The specimen is then incubated on a culture medium for at least 24 hours more to identify the specific organism(s). The sensitivity test gives the physician precise information about which antibiotics the organism is sensitive to.

Nclex Tips 14 (Pearson Nclex)

2253 Dimenhydrinate (Dramamine) is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory medications (Naprosyn and ibuprofen). The client should take acetaminophen for pain relief. Medication includes lansoprazole (Prevacid). A client who has a long history of antisocial and acting-out behavior needs to demonstrate the motivation to change behavior, not just verbalization that change will occur. The nurse would be therapeutic by assisting the client to look at the behaviors that indicate the motivation to change. A client in prison is knowledgeable about the rules for behavior in the correctional setting. Many clients will test the nurses capacity to be victimized and will make inappropriate statements. These behaviors need to be verbally confronted directly and then carefully documented in the clients chart. Acute toxicity of MAO inhibitors is manifested by restlessness, anxiety, and insomnia. Dizziness and hypertension may also occur. The nurse working with chronically mentally ill clients in crisis should focus on the clients strengths, modify and set realistic goals with the client, take an active role in assisting the client in the problem-solving process, and provide

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direct interventions that the individual might be able to do. Methylphenidate hydrochloride (Ritalin) is a central nervous system (CNS) stimulant and can cause insomnia. Its usually prescribed to clients with ADHD. Taking the medication at breakfast and lunch and avoiding taking the medication in the evening can prevent insomnia. It is taken orally 30 to 45 minutes before breakfast and lunch. When depressed, a client sees the negative side of everything. Neutral comments such as :You are wearing a new dress this morning" will avoid negative interpretations. In psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. These activities include Ping-Pong, volleyball, finger-painting, drawing, and working with clay. These activities provide the client a more appropriate way of discharging motor tension than pacing or ringing the hands. When a client is manic, solitary activities requiring a short attention span or mild physical exertion activities are best initially. These include writing, painting, finger-painting, woodworking, or walks with the staff. Solitary activities minimize stimuli, and mild physical activities release tension constructively. When less manic, the client may join one or two other clients in quiet, nonstimulating activities. Competitive games should be avoided because they can stimulate aggression and cause increased psychomotor activity. An inappropriate affect refers to an emotional response to a situation that is not congruent with the tone of the situation. A flat affect is an immobile facial expression or blank look. A blunted affect is a minimal emotional response and expresses the clients outward affect. It may not coincide with the clients inner emotions. A bizarre affect such as grimacing, giggling, and mumbling to ones self is marked when the client is unable to relate logically to the environment. Poverty of speech is speech that is restricted in amount and ranges from brief to monosyllabic one-word answers. Poverty of content of speech is speech that is adequate in amount but conveys little information because of vagueness, empty repetitions, or use of stereotypes or obscure phrases. Thought blocking is when the client stops talking in the middle of a sentence and remains quiet. When caring for a paranoid client, the nurse must avoid any physical contact and not touch the client. The nurse should ask the clients permission if touch is necessary, because touch may be interpreted as a physical or sexual assault. The nurse should use simple and clear language when speaking to the client to prevent misinterpretation and to clarify the nurses intent and actions. A warm approach is avoided because it can be frightening to a person who needs emotional distance. Anger and hostile verbal attacks are diffused with a nondefensive stand. The anger a paranoid client expresses is often displaced, and when a staff member becomes defensive, anger of both the client and staff

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member escalates. A nondefensive and nonjudgmental attitude provides an environment in which feelings can be explored more easily. In a paranoid client, The nurse should arrange solitary noncompetitive activities that take some concentration such as crossword puzzles, picture puzzles, photography, and typing. When the client feels less threatened, games such as bridge or chess or playing cards with another client may be appropriate. When the client is extremely distrustful of others, solitary activities are best and activities that demand concentration keep the clients attention on reality and minimize hallucinatory and delusional preoccupation. Propantheline (Pro-Banthine) is an antimuscarinic anticholinergic medication that decreases gastrointestinal secretions. It should be administered 30 minutes prior to meals. The nurse would most appropriately assess the clients eating patterns and food preferences and concerns about eating. Assessing previous and current coping skills is most appropriately related to a nursing diagnosis of Ineffective Coping. Assessing the clients feelings about self and body weight is most appropriately related to a Disturbed Body Image. Assessing the clients lack of control about the treatment plan is most closely related to the nursing diagnosis of Powerlessness. Repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language pattern used by clients with schizophrenia. Clang associations often take the form of rhyming. Echolalia is the pathological repeating of anothers word by imitation and is often seen in people with catatonia. Word salad is a phrase used to identify a mixture of phrases that is meaningless to the listener and perhaps to the speaker as well. Thought broadcasting is the belief that others can hear ones thoughts. Whenever a client has been identified as a victim of abuse, priority must be placed on ascertaining whether the person is in any immediate danger. If so, emergency action must be taken to remove the person from the abusing situation. A social phobia is characterized by a fear of appearing inadequate or inept in the presence of others and of doing something embarrassing. Thus, the client becomes anxious as the center of attention. Physical assessment findings such as bruises, along with the other assessment findings noted in the question, should alert the nurse to the potential for elder abuse. Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from ever occurring, and secondary prevention focuses on reducing the intensity and duration of the crisis during the crisis itself. A precrisis level of prevention is similar to primary prevention.

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Thioridazine hydrochloride (Mellaril), an antipsychotic medication, has a higher likelihood of producing impotence than other neuroleptics A nurse who is preparing a medication-teaching plan for a client who is receiving fluphenazine decanoate would be certain to advise the client to immediately report any clinical manifestations such as a sore throat or fever, because these signs could signal the onset of agranulocytosis. In addition, any extrapyramidal symptoms also require the physicians immediate attention. Trifluoperazine (Stelazine) can cause the clients urine to turn pink to reddish-brown. This condition is not harmful; it disappears when the medication is discontinued. Nevertheless, the nurse will want to instruct the client to report its occurrence to the nursing staff or the medical staff. One of the side effects of antipsychotic agents is that they decrease moisture around the eyes. This can cause difficulty for clients who wear contact lenses. Because the client has emphasized the importance of these lenses, it is a potential problem that may occur and lead to medication noncompliance by the client. The most commonly occurring side effects of antipsychotic agents include dry mouth, blurred vision, nasal stuffiness, and weight gain. Additional side effects include difficulty in urinating, constipation, risk of infection, decreased sweating and increased sensitivity to heat, increased sensitivity to sunlight, yellowing of the eyes (especially the whites of the eyes), and decreased moisture around the eyes. Painful or interrupted menstruation, vaginal dryness, dizziness, drowsiness, breast enlargement/lactation, skin rash or itchy skin, and anhedonia can also occur. Lithium and sodium, similar in chemical structure, compete to occupy sites within the body. Therefore, sodium levels often decrease, which causes lithium to be reabsorbed. When this happens, it increases the amount of lithium in the body, causing side effects. For this reason, the nurse instructs the client to drink 2 to 3 liters of water each day and eat a diet that is adequate in sodium. Once the clients lithium level is established (usually within 2 weeks), a blood lithium level will be drawn every 1 to 2 months. The most therapeutic response for the nurse to make to effectively teach the client about lithium is the one that emphasizes the necessity that the client does not discontinue the medication even if feeling an upset stomach. Clients who are taking this medicine are instructed to take their medication with meals to minimize the occurrence of an upset stomach. Depersonalization constitutes a symptom that displays disturbance in the clients sense of self. A flat affect is a symptom of schizophrenic disturbance in affect. Magical thinking is a symptom of the content of thought in schizophrenia. Word salad is a schizophrenic disturbance in the form of thought.

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Fluphenazine decanoate (Prolixin) can decrease the normal bacteria in the oral cavity and increase sensitivity to infection. This can be prevented by instructing the client to avoid high-sugar foods; increase the frequency of mouth care (brushing, including the tongue, flossing, and gargling with mouthwash); and frequently inspect the tongue for a thick, white coating, which signals infection. Lithium is contraindicated in pregnancy and for breastfeeding mothers. The client will be taught that breastfeeding is not possible while taking this medication and will be instructed to notify the physician immediately if pregnancy is even suspected or is being planned. Tranylcypromine (Parnate), an antidepressant, can cause serious and potentially fatal adverse reactions if used with other antidepressants. Its use is avoided within 2 weeks of another antidepressant. For clients with somatoform disorder, they are told to exercise because it helps to release endorphins, which enhance the feeling of well-being. If a client who is taking an antidepressant complains of tiredness, the nurse instructs the client to report the side effect to the psychiatrist, take medication at hour of sleep (except fluoxetine hydrochloride [Prozac], which must be taken in the morning), and avoid alcohol or alcohol-containing foods (even over-the-counter medications that contain alcohol). The client should also be instructed to lie down and rest. Some of the side effects of benzodiazepines are drowsiness, lethargy and confusion, dizziness, blurred vision, rash or itchy skin, unusual irritability or nervousness, headache, and nausea. The Abnormal Involuntary Movement Scale (AIMS) scale is used to assist the nurse to recognize tardive dyskinesia. The three areas of examination are facial and oral movements, extremity movements, and trunk movement. Tardive dyskinesia can occur from the use of antipsychotics.

http://www.nursereview.org/2008/08/nclex-tips-14-pearson-nclex.html

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hi guyz heres something to rememberDigitalis Toxicity includes.. N - nausea A - anorexia V - vomiting D - diarrhea A - abdominal pain Drugs which can cause URINE DISCOLORATION Adriamycyn------ Reddish Rifabutin--------- Red orange Rifampicin------- Red orange Bactrim---------- Red orange Robaxin--------- Brown, Black or Greenish Azulfidine------ Orange yellow Flagyl------------ Brownish Dilantin---------- Pink tinged Anti Psychotic-- Pinkish to Red brown Early signs of hypoxia: R-restlessness A-anxiety T-Tachycardia Late signs of hypoxia: B-bradycardia E-extreme restlessness D-dyspnea In pediaF-feeding difficulty I-inspiratory stridor N-nares flare E-expiratory grunting S-sternal retractions Respiratory Patterns Kussmaul- fruity acetone breath odor Cheyne-stokes- near death breathing pattern

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Seasonal Affective Disorder (SAD) may affect over 10 million Americans. The typical symptoms of SAD include depression, lack of energy, increased need for sleep, a craving for sweets and weight gain. Symptoms begin in the fall, peak in the winter and usually resolve in the spring. Some individuals experience great bursts of energy and creativity in the spring or early summer. Susceptible individuals who work in buildings without windows may experience SAD-type symptoms at any time of year. Some people with SAD have mild or occasionally severe periods of mania during the spring or summer. If the symptoms are mild, no treatment may be necessary. If they are problematic, then a mood stabilizer such as Lithium might be considered. There is a smaller group of individuals who suffer from summer depression. SAD is recognized in the DSM-IV (The American Psychiatric Association's diagnostic manual) as a subtype of major depressive episode. Some individuals who work long hours inside office buildings with few windows may experience symptoms all year round. Some very sensitive individuals may note changes in mood during long stretches of cloudy weather. A sign of improvement from dehydration would be a decreased urine specific gravity and a decreased/decreasing hematocrit. So the SG of 1.015 and a Hct of 46% would be the answer. It is the best answer of the two you had in you question. The normal urine SG is 1.003-1.035 (Usually between 1.010-1.025 with normal hydration and volume) (different texts give a slightly different range). SG 1.025-1.030+ (concentrated urine) SG 1.001-1.010 (dilute urine) SG 1.001-1.018 in infants under 2 years of age Specific gravity is a measurement of the kidney's ability to concentrate urine. The range of urine's SG depends on the state of hydration and varies with urine volume and the load of solids to be excreted under standardized conditions; when fluid intake is restricted or increased, SG measures the concentrating and diluting functions of the kidney. Loss of these functions is an indication of renal dysfunction. SG values usually vary inversely with amounts of urine excreated (decrease in urine volume = increase in specific gravity). However in some conditions this is not the case. EYE ABBREVIATIONS

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OU- both eyes OR- right eye OS- left eye CUSHINGS (Hypersecretion of Adrenal Cortex Hormones) C = Check VS, particularly BP U = Urinary output & weight monitoring S = Stress Management H = High CHON diet I = Infection precaution N = Na+ restriction G = Glucose & Electrolytes Monitoring S = Spousal support ADDISON'S (Hyposecretion of Adrenal Cortex Hormones) Always Remember the 6 A's of Addison's disease 1.) 2.) 3.) 4.) 5.) 6.) Avoid Stress Avoid Strenuous Avoid Individuals with Infection Avoid OTC meds A lifelong Glucocorticoids Therapy Always wear medic alert bracelet

Hirschsprungs diagnosed with rectal biopsy looking for absence of ganglionic cells. Cardinal sign in infants is failure to pass meconium, and later the classic ribbon-like and foul smelling stools. Intussusception common in kids with CF. Obstruction may cause fecal emesis, currant jelly-like stools (blood and mucus). A barium enema may be used to hydrostatically reduce the telescoping. Resolution is obvious, with onset of bowel movements. With omphalocele and gastroschisis (herniation of abdominal contents) dress with loose saline dressing covered with plastic wrap, and keep eye on temp. Kid can lose heat quickly. After a hydrocele repair provide ice bags and scrotal support. No phenylalanine with a kid positive for PKU (no meat, no dairy, no aspartame). Second voided urine most accurate when testing for ketones and glucose.

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Never give potassium if the patient is oliguric or anuric. Nephrotic syndrome is characterized by massive proteinuria (looks dark and frothy) caused by glomerular damage. Corticosteroids are the mainstay. Generalized edema common. A positive Western blot in a child <18 months (presence of HIV antibodies) indicates only that the mother is infected. Two or more positive p24 antigen tests will confirm HIV in kids <18 months. The p24 can be used at any age. For HIV kids avoid OPV and Varicella vaccinations (live), but give Pneumococcal and influenza. MMR is avoided only if the kid is severely immunocompromised. Parents should wear gloves for care, not kiss kids on the mouth, and not share eating utensils. Hypotension and vasoconstricting meds may alter the accuracy of o2 sats. An antacid should be given to a mechanically ventilated patient w/ an ng tube if the ph of the aspirate is <5.0. Aspirate should be checked at least every 12 hrs. Ambient air (room air) contains 21% oxygen. The first sign of ARDS is increased respirations. Later comes dyspnea, retractions, air hunger, cyanosis. Normal PCWP is 8-13. Readings of 18-20 are considered high. First sign of PE (pulmonary embolism) is sudden chest pain, followed by dyspnea and tachypnea. High potassium is expected with carbon dioxide narcosis (hydrogen floods the cell forcing potassium out). Carbon dioxide narcosis causes increased intracranial pressure. Pulmonary sarcoidosis leads to right sided heart failure. An NG tube can be irrigated with cola, and should be taught to family when a client is going home with an NG tube.

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