NCLEX Part 3

Lying on the RIGHT side

* Avoid Simple Sugars
* Avoid Fiber
* Eat a diet high in proteins
* Avoiding stimulating your metabolism by exercising right after eating.

eyedrops that promote constriction.

Patient should not swallow, there is a high risk for bleeding/hemmorhaging.`

Health care providers should limit their exposure to the radiation by limiting time spent in the clients room.

Controls personality/behavior/ intellect

* Low WBC
* Nausea
* Stomatitis
*Alopecia

Patients on this medication should not be ashmatics, it is contraindicated.

Signs include: in the infant frothy sputum that is excessive. This babies are at risk for aspiration.

honey-colored crust, vesicles that are reddish macules which appear around the neck.
* It is an infection.
* No isolation is required

Measures fluid volume.
Normal Value is 3 to 12

This causes damage to the mucousal membrane, it should never be placed on continous suctioning.

Lactated Ringers

D5 in Water

Normal Saline

this procedure takes 1 to 3 days for treatment. Patient will be on strict bed rest on her back with head of bed elevated no more than 20 degrees, movement is restricted. A foley catheter is inserted into bladder to prevent the implant from being dislodged by a full bladder or by voiding attempts. Severe radiation burns can result from a distended bladder.

this is a common cause of SIADH, which results in increased water absorption, and dilutional hyponatremia. Diuretics are used to promote fluid loss.

this is strongest during the first 2 months it should disappear after 3 to 4 months of age.

if a patient is on this device and complains of unrelieved pain it may be a sign of acute compartment syndrome, a neurovascular assessment is necessary.

When debriding a burn the RN should adminster analgesics 30 minutes before wound care, that may be proceded by hydrotherpay. It is important to organize time for the dressing change and provide emotional support.

which a patient is using crutches assess that the weight of the body is transffered to the hands and the arms. The arms should be bent at a 35 degree angle.

Clear fluids by mouth are not recommended, these fluids usually are high in cimple sugars or simple carbohydrates, are very low in electrolyes and have a high osmolality, which can exacerbate vomiting and diarrhea.

Patients with AI need to enchance arterial blood supply, they can do this by sitting on the side of the bed this would promote circulation.

If the client in early lab complains of frequently voiding. You can determine if that fluid is amniotic fluid (alkaline) or urine (acidic) by taking the pH of the fluid.

this is used to treat trigeminal neuralgia (tic douloreux) its theraputic effect is relieving the agonizing pain that may result in severe depressing and suicide. Tegretol inhibits nerve impulses and reduces the pain of the condition.

1. Doll eye's reflex disappears
2. begins drooling
3. Responds to own name
4. Takes deliberate steps when standing
5. Picks up bite-size pieces of cereal

For absent bicep and patellar deep tendon reflex include retesting the bicep while the patient clenchs the teeth, and retest the patellar while the patient interlaces the fingers and pulls them against each other.

Isometric contracton of other muscles can increase the generalized reflex response/activity of the body.

Distraction may also be a reason for thsi effectiveness, as tension can inhibit a reflex being elicited.

Te best instructions from the RN to a patient with an above knee amputation is to expose the stump to air daily. It will facilitate healing of the stump, they should inspect it daily for pressure areas, dermatitis, and blisters.

A client complaining of drinking lots of water and still feeling thirsty, is displaying symptoms that suggest type I diabetes, polyuria, polyphagia, and polydipsia.

It will display as a papule like lesion in the vaginal area. Chancre develops iwthin two to six weeks; appears at point of entry; starts as small papule, develops into painless ulcer.

A conditioon infants with congenital heart disease get, where the infant becomes weak, fatigue easily, and need to be fed carefully and with the least amount of required effort on their part.

After this procedure the potential complication is urinary retention manifested by lower abdomen enlargement and sounds dull on percussion. This occurs because of closeness of bladder to the surgical site and occurence of rectal spasms and anorectal tenderness; catheterize to empty bladder.

this occurs before the peak of the contraction, it results from fetal head compression.

this occurs after peak of the contraction; results from cord compression

this occurs anytime during contractions, its results from cord compression

irregular fluctations in the baseline of the Fetal Heart Rate. Usually occurs after narcotics have been adminstered.

Uterine enlargement, aouffle, and contraactions, positive urine pregnancy test, Hegar's Sign and Chadwick's Sign.

When the angle between the nail plate and the proximal fold is straightened to 180 degrees this indicated early clubbing a sign of hypoxia.The base of the nail is also spongy upon palpation.

this procedure is similar to hemodialysis its done to remove antibodies that may be causing symptoms such as chills and hypothermia. Patients need warm blankets.

the primary problem for these patients is difficult forming relationships with a marked inability to trust others

Right Side 2nd-3rd ICS

Left Side 2nd to 3rd ICS

Left Side 5th and 6th ICS

A fever of a few days while on an antipsychotic medication such as Haldol may indicate impending neuroleptic malignant syndrome.

The fundus rises to level to umbilicus to 6 to 12 hours after delivery; beginnging with day one, the fundus descends about 1 fingerbreadth per day.

Performing the valsalva maneuver can reverse SVT, blowing should occur for 30 to 60 seconds; other possible vagal maneuvers include ice to the face, holding the breath and bearing down, also massaging the carotid artery on only one side of the neck.

this is a type of compartment syndrome caused by obstruction of arterial blood flow to the forearm and hand; cannot straighten fingers, has severe pain, and there may be signs of diminished circulation.

Opportunisitic infection associated with AIDS like PCP causes progressive hypoxemia and cyanosis.

is located on the top of the foot in line with the groove between extensor tendons of the great toe and the first toe.

Diagnostic tests used to detect cardiac tamponade is a chest x-ray which shows a slightly widened mediastinum and enlarged cardiac silhouette.

Diagnostic tests for this is echocardiography which records pericardial effusion with signs of right ventricular and atrial compression.

the treatment for cariac tamponade is pericardiocentesis or needle aspiration of pericardial cavity, it is done to relieve tamponade.

The ET may be repositioned in a intubated patient to prevent skin breakdown.

clients with AIDS receiving pentamidine isethionate should have their blood sugar levels monitored frequently because that drug can cause permanent diabetes mellitus.

Bronchoscopy can help diagnose TB and obtain specimens while clearing the bronchial tree of secretions.

After 4 weeks of treatment for TB the disease is no longer considered infectious but the client must continue to take their medication.

a sign of progressing parkinson;s is impaired speech and is due to a disturbance in muscle control.

A condom catheter can be an appropriate intervention for an elderly male client who is incontinent of urine because it used a condom-type device to drain urine away from the client.

Cardiac Glycosides may be used safely for a pregnant client with cardiovascular disease, also comon antiarrhytmics, such as procainamide and quinidine may be used. If anticoagulants are needed, heparin is the drug of choice, not warfarin.

By the age of 2, the DPT, IPV, MMR, Hib, Varicella, Pneumoccal, and Hepatitis B vaccines should have been recevied.

Late stage of cirrhosis is hypoxia due to fluid in the lungs and weak chest expansion.

UTI early signs is a fever an change in the clarity of the urine.

Indicates a need for monitoring the client for signs and symptoms of an acute attack.

After a thoracentesis the client should be positioned upright because this allows fluid to drain and collect at the base.

Purulent discharge from the cervix, urthera or Bartholin's gland is associated with several STD such as chlyamydia.

The snellen chart is used to test the function of the optic nerve. Testing the cardinal fields assesses the oculomotor, trochlear, and abducens nerves. Corneal light reflex reflects the function of the oculomotor nerve.

Apgar scores are used to indicate a need for resuscitation at birth.

During breast-feeding, the client should examine each breast after neonate has emptied the breast. Women must continue to examine their breasts, even if they're lactating.

Dorsiflexion of the foot is the recommended intervention to relieve a leg cramp during pregnancy.

Adolescent girls, especially those age younger than 15 years are at a higher risk for delivering low birth weight neonates unless they gain adequate weight during pregnancy.

An acute attack for appendicitis localizes as pain and tenderness in the LRQ.

this drug will calm and relax the client, decrease the respiratory rate, anxiety, and stress thus decreasing myocardial oxygen demand.

This vitamin enhances the synthesis of protein and is essential for the maturation and repair of tissue.

This is usually present when the client has pneumonia.

the pulmonary capillary wedge pressure is the reflection of the pressure in the left ventricle at rest, which is end diastole.

this is a sign of hypocalcemia its abnormal facial msucle and nerve spasms elicitied when the facial nerve is tapped.

this sign indicated DVT.

At home, the procedure of tracheostomy care is clean or medically aspetic because of the cost and difficulty of performing a completely sterile procedure.

The area of the GI tract identified as the cause of reduced pressure associated with GERD is the lower esophageal sphincer. Reflux occurs when pressure in the stomach exceeds LES pressure.

this drug prescribed to prevent a thromboembolic stroke it inhibits platlet aggregation by interferring with adenosine diphosophate releases in the coagulation cascade and is used to prevent thrombomblic stroke.

Prolonged use of Steriodal Anti-inflammatory agents is a risk fact for catarcts

Clear fluid draining from the ear or nose of a client may mean a CSF leak which is common in basilar skull fracture.

Lumbar puncture is contraindicated with increased intracranial pressure.

Lowering the CO2 level, lowers the ICP.

After hypophysectomy, or removal of the pituitary gland, the body can synthesize ADH. Vasopressin is given post operatively to replace ADH normally secreted from the pituitary.

These include Ptosis and Dipolpa. Late signs include dysphagia, and respiratory distress occur later.

MS is more common in white women ages 20 to 40 years with a secondary onset between ages 40 to 60 years.

Symptoms of MS include slurred speech and diplopia.

Injury in the cervical areas of the spine (C) result in quadraplegia. Injury in the Thoracic cord (T) and below result in paraplegia.

C 4= diaphragm location

Symptoms of neurogenic shock include hypotension, bradycardia, warm, and dry skin due to loss of adrengic stimulation below the level of the lesion.

this condition displays an anxiety, flushing above the level of lesion, piloerection, hypertension, and bradycardia.

Suction should be applied for 10 to 15 seconds at a time. Sunction is regulated to 80 to 120 cm. Suction should be applied only during withdrawal of the catheter. When suctioning the trachea, the catheter is inserted 4" to 6' or until resistance is felt.

(Nyctalopia) may be caused from a vitamin A deficiency or dysfunctional rod receptors.