Decide What the Question is Dealing With:

Which part of the Nursing Process: Assessment; Analysis; Planning; Implementation or Evaluation?
Next, Decide the Order of Priority

INITIAL or FIRST - NURSING PROCESS – assessment? Priority ABC if answers are not Nursing
process
BEST- DISCRIMINATE out of few correct answers
MOST IMPORTANT ABC’s - MASLOW’S hierarchy of needs or REAL problem vs potential prob
MOST CONCERNED – there is a complication

3 Implementations one assessment – maybe assessment

2 assessment and 2 implementations verify what the questions asks for
First you must decide what part of the nursing process the question is connected with:

ANALYSIS--is the process of identifying potential and actual health problems. Most identify pertinent
assessment information and assimilate it into the nursing diagnosis. Prioritize the needs that have been
identified during analysis.

Some common words that are associated with ANALYSIS questions:

diagnose; contrast; compare; analyze; order; prioritize; define; classify; catagorize; synthesize; sort;
arrange;

ASSESSMENT--consists of a collection of data. Baseline information for pre and post procedures is
included. Also included the recognition of pertinent signs and symptoms of health problems both
present and potential. Verification of data and confirmation of findings are also included. Assess a
situation before doing an intervention.
Some common words that are associated with ASSESSMENT questions:
observe; gather; collect; differentiate; assess; recognize; detect; distinguish; identify; display; indicate;
describe;

PLANNING--Involves formulating goals and outcomes. It also involves various members of the health
care team and the patient's family. All outcome criteria must be able to be evaluated with a specific
time frame. Be sure to establish priorities and modify according to question.
Some common words that are associated with PLANNING questions:
rearrange; reconstruct; determine; outcomes; formulate; include; expected; designate; plan; generate;
short/long term goal; develop;

IMPLEMENTATION--Addresses the actual/direct care of a patient. Direct care entails pre, intra and
postoperative management, preforming procedures, treatments, activities of daily living. Also includes
the coordination of care and referral on discharge. It involves documentation and therapeutic response
to intervention and patient teaching for health promotion and helping the patient maintain proper
health.
Some common words that are associated with IMPLEMENTATION questions:
document; explain; give; inform; administer; implement; encourage; advise; provide; perform;

EVALUATION--Determines if the interventions were effective. Were goals met? Was the care
delivered properly? Are modification plans needed. Addresses the effectiveness of patient teaching and
understands and determines in proper care was offered. Evaluation can involve documentation,
reporting issues, evaluates care given and determine the appropriateness of delegating to others. Most
significantly, it finds out the response of the patient to care and the extent to which the goals we met.
Some common words that are associated with EVALUATION questions:
monitor; expand; evaluate; synthesize; determine; consider; question; repeat; outcomes; demonstrate;
 reestablish;
After determining what part of the nursing process the question is concerned with, next focus your
attention on determining the category of priority:
Safe and effective care environment is always first. Patient safety is related to the proper preparation
and delivery of nursing techniques and procedures as part of the nursing practice. It relates to every
aspect of the delivery of care.
Physiologic integrity is the ability to provide competent care Information that may be described as
traditionally medical- surgical and pediatric nursing falls into this category. Specific questions in this
area can be related to many direct-care aspects of nursing practice. The importance of this area is
highlighted because it is one in which planning, implementation and evaluation of care needs can
easily be identified and tested. Physiologic integrity is always a slight lower priority than safety unless
it involves airway, breathing and circulation. "ABC's" always comes first!
Psychosocial integrity tests the knowledge about a patients response to a disease or disorder. An
understanding of stress, anxiety and ways to cope are essential. This is a lower priority the
physiological integrity.
Health maintenance deals with health promotion, health teaching, disease prevention and assessment of
risk factors for health problems. Normal growth and development is a major theme in this category.
This however, is a low priority.
In Summary, when choosing the right answer for you NCLEX exam question
1) ask yourself, "what part of the nursing process is this question dealing with: analysis, assessment,
planning, implantation or evaluation? and
2) Remember to prioritize your choices: safety always being first, 2)physiological integrity unless there
is ABC
3) psychosocial integrity and health maintenance always has the lowest priority when choosing an
answer.
Other tidbits:
Avoid choices with the answers "all" "always" "never" or "none". Nothing is ever a definite in Science.
Look for answers that are different. If three answers say the same thing but in different words, choose
the answer that is different.
When given choices that are pharmacologically based or non pharmacologically based, choose the non
pharmacological intervention. It is more often then not, the correct answer.
4 impl. answers one says wash hands its prob right.

Complete Blood Count (CBC) )

Name Normal Result
WBC 4.5-10.5 K/UL
LYMPH
0.6-4.1 K
/UL
LYMPH %
(10.0-58.5
%)
MID
(0.0-1.8 K/
UL)
MID %
(0.1-24.0
%)
GRAN
(2.0-7.8 K/
UL)
GRAN % (37.0-92.0
 %)
RBC
(4.04-5.48 M
/UL)
HGB
(12.2-16.2 g
/dL)
HCT
(37.7-47.9
%)
MCV
(80-97
fL)
MCH
(27.0-31.2 pG
/cell)
MCHC
(31.8-35.4 g
/dL)
RDW
(11.5-14.8
%)
PLT
(145-450 K
/uL)
MPV
(0.0-99.8
fL)

Coumadin and Warfarin have higher times .

Name Normal Result

PROTIME
(11.6-14.4
sec.)
(0.9-1.4
INR
)

CHEMISTRY
Basic & Comprehensive Metabolic Panels.
Name Normal Result
BUN (10.0-26.0 mg/dl)
CREATININE (0.6-1.4 mg/dl)
GLUCOSE (70.0-100.0 mg/dl)
CALCIUM (8.8-10.4 mg/dl)
SODIUM
(135.0-145.0 mg/dl
)
POTASSIUM (3.5-5.0 mg/dl)
CHLORIDE
(94.0-112.0 MEQ/
L)
CO2 (21.0-32.0 MEQ/L)
BUN/CREATININE (8.0-36.0 RATIO)
ANION GAP (4.0-34.0 RATIO)
ALBUMIN (3.5-5.0 G/DL)
TOTAL PROTEIN (6.3-8.1 G/DL)
DIRECT BILI (0.0-0.6 MG/DL)
TOTAL BILI (0.2-1.3 MG/DL)
ALKALINE PHOS (40.0-150.0 IU/L)
AST/SGOT (5.0-34.0 IU/L)
ALT/SGPT (0.0-55.0 IU/L)

Diabetes Our HbA1c method is calibrated using a

NGSP DCCT-referenced method. While the
'normal range' is 6.0, the target for a patient with
diabetes depends upon their clinical situation. In
general, AACE recommends a target for diabetes
patientsof 6.5 or less.
HbA1c .
Name Normal Result
HbA1c-DCCT Ref (4.00-6.00 %)

Name Normal Result

CORTISOL (2.50-25.00 ug/dL)

Urine Studies
Lab: Urine Protein 24 hr (doesn't include
volume)
Name Expected results
T.URINE
PROTEIN (6.80-15.00 mg/dL)
This is an internal calculation from
tputest
our computer that is not relevant
24 HR. TP
(30.00-150.00 mg/24 hr)
URINE

Lab: Creatinine Clearance

Name Expected Results
CREATININE (0.6-1.4 mg/dl)
URINE (1000-3000 ml/24 hrs)
VOLUME
The urine creatinine
concentration varies
URINE CREAT
significantly depending upon
amount of fluid intake
This is an internal calculation
TV from our computer that is not
relevant
CREAT (97.0-137.0 mL/min )
CLEARANCE

UA Urinalysis dipstick
Name 10/25/2007
COLOR
YELLO
W)
CLARITY
(CLEA
R)
LEUKOCYTES
(NEGATI
VE )
NITRATE
(NEGATI
VE )
UROBILINOGEN
(NEGATI
VE )
PROTEIN
(NEGATI
VE )
pH
(5.0 -
8.5 )
BLOOD
(NEGATI
VE )
SPEC. GRAVITY
(1.000 -
1.030 )
KETONE
(NEGATI
VE )
BILIRUBIN
(NEGATI
VE )
GLUCOSE
(NEGATI
VE )

UA Microscopic Add-On to dipstick

Name 10/25/2007
(NEGATIVE /HPF
WBC
)
(NEGATIVE /HPF
RBC
)
(NEGATIVE /LPF
CASTS
)
(NEGATIVE
CRYSTALS
)
(NEGATIVE
YEAST
)
(NEGATIVE /HPF
EPITHELIAL CELL
)
(NEGATIVE
TRICHOMONAS
)
(NEGATIVE
BACTERIA
)
NCLEX Lab stuff
Na 135-145
K 3.5-5.5
Ca 8-10
Mg 1.5-2.0
Platelets 150,000-450,000
ptt 30-60 seconds
WBC 5,000-11,000
RBC 4.5-6.0 million
Hct 35-45%
Hgb 12-16
BUN 7-20
Creatinine 0.5-1.5
Quickening 16 weeks
fetal heart tones 20 weeks
fetal heart rate 120-160
Litium intial 1.0-1.5, therapeutic 0.6-1.2
Dilantin 10-20
Digoxin 0.8-2.0
Heparin look at ptt and antidote is Protamine Sulfate
Coumadin look at INR and antidote is vitamin K
Mag Sulfate antidote is Calcium Gluconate
narcotic antidote is Narcan
Tyenol antidote is Mucomist
Insulin: Reg 30-60 min onset, 2-4 hr peak and 5-7 duration
NPH 1-3 hr onset, 6-12 hr peak and 18-24 duration
Lispro- fast acting and to eat right away
pH 7.35-7.45
PaCO2 35-45
PaO2 90-100%
HCO3 22-26
Rules of Nines: 9% is head and each arms, 18% is front torso, back torso and each legs and 1% is groin
5 P's with fractures: pain, pallor, pulselessness, paresthesia and paralysis
Cranial nerves: Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, Acoustic, Glassopharnygeal,
Vagus, Spinal Accessory and Hypoglossal
Fetal Heart strips: VEAL CHOP (Variable is cord, early is head, accelerations is ok and late is placental
insuffenciency)
Cancer: CAUTION signs
starve a gastric ulcer, feed a duo ulcer
200-300 ml blood loss with vaginal birth, 500 ml with c-section, over is hemorrhage
Addison's (AD-Aldosteron Deficiency to remember) disease- ↓NA and ↑ K, HYPOGLYCEMIA.
Remember – if there is low/absent NA+ in the body, than nothing holds H2O in. Thus, ↑ Urine output, Hypotension +,
Hypovolumia, dehydration and ↓ CO.
Major function of Aldosterone – is to keep NA+ in & K+ out of the body .
Cushing’s (too much glucocorticoids) syndrome is opposite to Addison’s. Adrenal hypersecretion of glucocorticoids.
↑ NA ↓K and Ca, HYPERGLYCEMIA. When assessing think of the cushion (moon face, buffalo hump, truncal
obesity).
Pheochromocytoma - HTN is a hallmark.
Urine specific gravity: 1.010-1.030
Diabetes Insipidus: â ADH, á UO (dehydration), â urine specific gravity, á serum Na
SIADH: á ADH, â UO á urine specific gravity, â serum Na,
HHNKS: glucose > 800, no ketones, acidosis
Total cholesterol: optimal <200. borderline 200-230. high > 239.
LDL: optimal <139. borderline 140-160. high >160.
AST: 10-40
ALT: 5-35
Serum albumin: 3.5-5.5
Hemophilia a: no asa, nsaids
Blood type O = universal donor. Blood type AB = universal recipient
CVP: nl 3-12. >12: hypervolemia, <3: hypovolemia
Isotonic: 0.9% NaCl, LR, D5W
Hypotonic: 0.45% NaCal
Hypertonic: D10-15W, 3% NaCl
60mg=1grain
Carbamazepine: therapeutic 5-12
Antabuse: avoid otc cough/cold-contain alcohol
24-34wks: fundal height correlates with wks gestation
No grapefruit juice: cyclosporine, carbamazepine, buspar, zocor, verapamil
OD benzodiazepines – antidote: flumazenil (romazicon)

KAPLAN missed Q

- Cranial nerve VII – asymmetry of face

- Cranial Nerve IX – swallowing problems
- Cranial Nerve I – loss of smell
- Cranial nerve III – Ptosis
- Older client – hydration – check BP
- Older client - sudden confusion – infection
- Hemophilia is sex linked disorder - Mother to son
 - Insert suction catheter until resistance, than withdraw and apply intermittent suctioning twirling motion.
- Fear of height – projection and displacement
- Dilaudid – narcotic analgesic - measure for hypotension and respiratory distress
- Older – renal glucose is elevated in their urine – false negative reading
- Enema – left side lying position
- Laryngotracheobronchitis – early sympt.- inspiratory stridor and restlessness
- Extrapyramidal side effects – Akathisia – motor restlessness
- Dystonias – protrusion of tongue, abnormal posturing
- Pseudoparkinsonism – tremors, rigidity
- Dyskinesia – stiff neck, difficult swallowing
- Early preeclampsia – facial swelling and proteinuria
- CVA – facial paralysis – protect eye from corneal abrasion
- Lithium toxicity – early fine tremors, nausea, vomiting, diarrhea
- Infant – solid food – rice cereal – start around4-5 months
- Solitary play – infant
- Parallel play – toddler
- Associative play – preschool
- Addisonian crisis – restlessness, rapid weak pulse
- 4th stage of labor – fundus – palpable at umbilicus
- Alcohol problem – symptoms are tremors, ↑ temp., nocturnal leg cramps…
- Antibiotic ( Rocephin) – watch for overgrowth of organisms on tongue or mouth
- Rinne test – fork next to mastoid bone than front auditory canal
- Clomiphene (Clomid) – induces ovulation by changing hormones in ovary
- Naproxene (Naprosyn) – NSAID – SE HA, dizziness, GI, pruritus and rash
- Cortisol – anti-inflammatory agent
- Verapamil – check Heart rate
- Blood transfusion – allergic reaction – respiratory wheezing, urticaria (hives), facial flushing, and epiglottal
edema.
- Pacemaker purpose is – increase the cardiac output by regulating cardiac rhythm.
- Plasma cholesterol screening instruct client to only sip water 2 hrs before the procedure
- Lead poisoning – best fluids milk – vit. D helps remove lead from bones
- Stages of terminal illness – 1 – denial, isolation 2 – anger 3 – bargaining 4 – depression 5 – acceptance.
- Intravenous pyelogram IVP – examines by x-ray of urinary tract evaluates kidney function
- SHARE is a group who supports parents who lost a newborn or had miscarriage.
- Fluid balance in older – maintain an accurate intake and output
- Early stage of nephritic syndrome – adequate protein intake and low sodium
- Colostomy irrigation should be initiated at same time each day for normal pattern
- Ataxia – supervise ambulation
- Amniocentesis – detect hemolytic disease of the newborn
- Blood transfusion – hemolytic reaction – chills, headache, backache, dyspnea, cyanosis, chest pain, tachycardia,
hypotension.
- Sputum culture – collect in the morning, cough deeply and expectorate
- Radiology department is responsible for handling radium implant
- Sodium VS Lithium
- Fetal alcohol Syndrome – replace vitamins – poor maternal diet
- Radical mastectomy – first - care for patient’s pain
- Tetrahydrozoline (Visine) – no for closed-angle glaucoma, caution in hypertension
- Methenamine (Mandelamine) – avoid alkaline foods and fluids such as milk
- Estrogen - side effect – nausea
- Exploratory laparotomy – intestinal obstruction – distended abdomen with pain
- Hyperparathyroidism – Highest Cardiac dysrythmias
- Reactive depression – most physical and psychic energy in the morning
- Young adult – Erickson’s intimacy versus isolation
- Pt. with gastric ulcer have pain – ½ hr to 1 hr after a meal
- Diabetes insipidus – dry lips, ↑urinary output, low specific gravity 1.004 - N(1.010-1.030)
- Narcan is used when respiratory depression cause by Opiates – can be repented in 2-3 minutes.
- Abdominal muscles help support lumbar spine
- Who should nurse see first think ABC
- Compazine – controls nausea and vomit
- Epidural used for pain relief monitor for urinary incontinence, hypotension, respiratory depression, nausea and
vomiting
- Right cataract surgery – do not place on R side, do not put a pressure on the surgery.
- Fetus produces ↑ amount of insulin to match mothers increased glucose levels, after birth infant has increased
insulin and ↓ level of glucose…
- Cystic fibrosis - ↑ protein, ↑ calories ↓ fat
- PSA and phosphatase test for prostatic cancer
- Biopolar – combative behavior – gain control with physically aggressive – administer sedatives and mood
stabilizing meds.
- Hiatal hernia – hallmark – awakening at night with heartburn
- Captopril – antihypertensive measure BP
- Pneumonia infection – cellulitis infection
- ↑ temperature – body compensatory - ↑ respiratory, tachycardia, ↑ pulse rate
- Irritable bowel syndrome – diarrhea and constipation
- 5 years – boy talk on a toy phone and imitates father
- 6 months old – DTP, 15 months – MMR 2-4-12-18 months polio, chickenpox and smallpox not recommended
- Pain = inflammation and infection
- Obsessive compulsive rituals help avoid anxiety
- Guillain-Barre Syndrome – diagnosis – respiratory failure, flaccid paralysis (paralysis of the muscles) urinary
retention (loss of sensation)
- Propranolo Inderal – se – airways – wheezing, shortness of breath, Bronchospasm – nonproductive cough
- Draining abscess – contact precautions – gown and gloves
- Prosthetic hip implant - side-lying affected hip in abduction,
- Cuffed tracheostomy tube – seals trachea helps prevent aspiration
- Electroconvulsive therapy – call physician when backache present
- Babinski reflex gone 1 year, Moro’s gone 3-4 months, Tonic neck reflex – 3-4 months, Palmar grasp gone 3
months and Plantar gone by 8 months
- Best nursing action – assess bf implementing (ask yourself if assessment was done and if its enough if not assess)
- Hypoparathyroidism – risk for laryngospasm – have tracheostomy set
- Naegele’s rule add 7 days to first day of menstrual period and subtract three months
- Question 86

• Parietal lobe (A)-primary center for sensation

• Temporal lobe (B)-auditory reception area
• Frontal lobe (C)-CORRECT-involved with personality, behavior, emotions, and intellectual function
• Occipital lobe (D)-primary visual receptor center

- Take the cholestyramine (Questran) with meals- appropriate action; never take powder dry because it will cause
esophageal irritation Increase intake of whole grain cereals.- side effect is constipation; increase intake of fiber and
fluids Walk for 30 min, 3-4 times per week. - cholestyramine (Questran) is an antilipemic; regular exercise will
prevent atherosclerosis
- Hypokalemia
- A patient diagnosed with multiple sclerosis receiving prednisone 200 mg PO- corticosteroids cause hypokalemia
- A patient diagnosed with systemic scleroderma receiving total parenteral nutrition.-TPN causes hypokalemia
- A patient diagnosed with acute ulcerative colitis preparing for an ileostom -diarrhea causes hypokalemia

- Hypokalemia - Electrocardiographic changes include inverted T waves, ST segment depression, and prominent U
waves. Absent P waves are not a characteristic of hypokalemia

- Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or
controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by
bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is
recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting.
The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored
closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary
output during administration and contacts the physician if the urinary output is less than 30 mL/hr.
- A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Clients who experience cellular shifting
of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or
respiratory acidosis, are at risk for hyperkalemia.
- A serum potassium level higher than 5.1 mEq/L indicates hyperkalemia. Electrocardiographic changes include flat
P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves.
- Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a
positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular
excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include
increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
- Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A
shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with
hypokalemia.
- Diltiazem is a calcium channel blocker that inhibits calcium movement across cell membranes of cardiac and
smooth muscle. It dilates coronary arteries and peripheral arteries and arterioles. Diltiazem decreases the heart rate
and slows SA and AV conduction.
- The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel.
The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5 hours
- Kawasaki disease - In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands,
rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation
of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the
convalescent stage, the child appears normal, but signs of inflammation may be present.
- Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include
hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate
increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant,
muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea
accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain.
- Rifampin – TB - Soft contact lenses may be permanently damaged by the orange discoloration in body fluids
caused by rifampin. Any sign of possible jaundice (yellow-colored skin) should always be reported. If rifampin is
not tolerated on an empty stomach, it may be taken with food. The client may be on the medication for 12 months
even if cultures give negative results.
- Peyer patches are lymphoid nodules located in the small intestine where T cells congregate.
- The therapeutic phenytoin (Dilantin) level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary
movements of the eyeballs (nystagmus) appears. At a level higher than 30 mcg/mL, ataxia and slurred speech
occur.
- If a client complains of chest pain, the initial assessment question would be to ask the client about the pain
intensity, location, duration, and quality. Although options 1, 3, and 4 all may be components of the assessment,
none of these questions would be the initial assessment question in this client.
- BuSpar should relieve rapid heartbeat, or anxiety. Buspirone (BuSpar) is not recommended for the treatment of
drug or alcohol withdrawal, thought disorders, or schizophrenia. Buspirone hydrochloride most often is indicated
for the treatment of anxiety.
- Magnesium sulfate is a central nervous system (CNS) depressant and the client could experience adverse effects
that includes depressed respiratory rate (below 12 breaths/min), severe hypotension, and absent deep tendon
reflexes (DTRs).
- Risk factors for PUD include Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids,
aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), caffeine, alcohol, and stress. Ibuprofen is an NSAID, and
when taken as often as is typical for osteoarthritis, it will cause problems with the stomach. Certain medical
conditions such as Crohn’s disease, Zöllinger-Ellison syndrome, and hepatic and biliary disease also can increase
 risk for PUD by changing the amount of gastric and biliary acids produced. Ulcer disease in a first-degree relative
also is associated with increased risk for an ulcer.
- Immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable
suction, which drains serosanguineous fluid. In the first 24 hours after surgery, the drainage may total 80 to 120
- Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with
the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic
encephalopathy is developing.
- Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo,
bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Atropine sulfate must be
available in the event of systemic toxicity. Pindolol is a β blocker. Naloxone hydrochloride is an opioid antagonist
used to reverse narcotic-induced respiratory depression. Protamine sulfate is the antidote for heparin.
- Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually
signal an inability to move air. A “silent chest” is an ominous sign during an asthma episode. With treatment,
increased wheezing actually may signal that the child’s condition is improving.
- Shunting occurs when a portion of the lung area has adequate capillary perfusion but is not being ventilated. As a
result, no gas exchange occurs. Anatomical dead space normally is present in the conducting airways, where
pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and
pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the
pulmonary capillaries and air exchange in the alveolar units of the lungs.
- A prolapsed stoma is one in which the bowel protrudes, causing an elongated and swollen appearance to the
stoma. A retracted stoma is characterized by sinking of the stoma. Ischemia of the stoma would be associated with
a dusky or bluish color. A stoma with a narrow opening is described as being stenosed.
- Tamsulosin hydrochloride FLOMAX is used to relieve mild-to-moderate manifestations that occur in benign
prostatic hypertrophy. The medication also improves urinary flow rates.
- Somatotropin (Humatrope) should not be administered during or after epiphyseal closure. Efficacy of therapy
declines as the client grows older and is usually lost entirely by age 20 to 24 years.
- Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII,
and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited.
- Ergotamine CAFERGOT produces vasoconstriction by stimulating α-adrenergic receptors, which suppresses
vascular headaches when the medication is given in the therapeutic dose range. The nurse periodically assesses for
hypertension, cool, numb fingers and toes, muscle pain, and nausea and vomiting.
- Clinical manifestations of respiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo,
convulsions, hypokalemia, and hypocalcemia
- Nesiritide NATRECOR is a recombinant version of human B-type natriuretic peptide, which vasodilates arteries
and veins. It is used for the treatment of decompensated heart failure, increases renal glomerular filtration, and
increases urine output.
- Salicylate compounds such as sulfasalazine (Azulfidine) act by inhibiting prostaglandin synthesis and reducing
inflammation. The nurse teaches the client to take the medication with a full glass of water and to increase fluid
intake throughout the day. The medication needs to be taken after meals to reduce gastrointestinal irritation.
- A quad cane may be used by the client requiring greater support and stability than is provided by a straight leg
cane. The quad cane provides a four-point base of support and is indicated for use by clients with partial or
complete hemiplegia.
- The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of
inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the
endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection
at any location of the ventilator parts.
- High-pressure alarm would sound if present of mucous plug, kinks in the ventilator tubing, excessive secretions
- Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The
biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The
client usually requires mild analgesics; more severe pain usually indicates that complications are arising.

PRECAUTIONS
The nurse observes that staff members enter patient rooms wearing a mask, gown, and gloves, and the doors to the
patient rooms remain open
A patient diagnosed with influenza.-staff member is following droplet precautions; acute viral respiratory infection that
is spread by droplets
- A patient with a draining abscess that is uncovered.
abscess with no dressing requires contact precautions
- A patient diagnosed with bronchitis-inflammation of large airway; standard precautions
- A patient diagnosed with Hantavirus pulmonary syndrome- cardiopulmonary illness caused by a virus transmitted by
direct or indirect contact with rodents; standard precautions
- A patient diagnosed with tonsillitis-inflammation of large airway; standard precautions
- A patient diagnosed with respiratory syncytial virus-acute viral infection causing bronchiolitis; contact precautions
- A patient diagnosed with cystic fibrosis- hereditary dysfunction of exocrine glands causing obstruction because of
flow of thick mucus; standard precautions.

standard precautions airborne contact precautions droplet precautions

precautions
scrub suit gown and glowes a mask, gown, and gloves,
and the doors to the
patient rooms remain open
3 feet space bt pt and
visitors.
Pneumocystis carinii pneumonia tuberculosis Respiratory Syncytial rubella requiring an IM
with an elevated temperature requiring Virus injection
opportunistic infection of HIV administration of
rifampin
cancer complaining of a sore draining abscess that is acute viral respiratory
mouth uncovered. infection
Candida abscess with no dressing
herpes zoster with an ophthalmic Salmonella - bacterium influenza
infection
Kawasaki Disease mononucleosis Pertussis-private room,
spatial separation 3 feet
Toxic Shock Syndrome between visitors and pt.

Lyme’s Disease Wound with S Aureus

Infectious Mononucleosis
bronchitis-inflammation of large
airway
Hantavirus pulmonary
syndrome- cardiopulmonary
illness caused by a virus
transmitted by direct or indirect
contact
tonsillitis-inflammation of large
airway
cystic fibrosis- hereditary
dysfunction of exocrine glands
causing obstruction because of
flow of thick mucus
Bronchitis – inflammations of
large airways

Risk to develop a pulmonary embolism

- A 16-year-old boy with a fractured left femur due to a sledding accident.
-fat emboli is sequelae of fracture of long bones; among pediatric-aged patients, adolescents are most likely to have
pulmonary emboli because of nature of their injuries
- A 42-year-old obese postpartum woman who is gravida 5, para 5.
-pregnancy, obesity, increased maternal age, and high parity are predisposing factors for developing DVT
- A 72-year-old man taking a 3-day car trip from Missouri to California.
-prolonged sitting causes venous stasis, which predisposes to the development of DVT
- An 80-year-old man diagnosed with lung cancer and a history of deep vein thrombosis.
lung cancer causes hypercoagulability; advancing age and history of DVT are also predisposing factors

Bromocriptine (Parlodel) – take with meals to lower GI upset

Decelerations of FHR while having IV oxytocin – stop oxytocin to increase FHR (it will decrese contractions and
remove uterine pressure from a child)
Cushing syndrome – respirations priority, client prone to fluid overload and CHF due to sodium and water retension.
Detached retina – photophobia – bright flashes, loss of a portion of visual field – dark
Magnesium sulfate can slow respirations, can cause hyporeflexia, Newborn RR 30-60 min
Doxepin hydrochloride (sinequan) – report change theraphy when developes tremors, and is excitable (overdose)
Cardiac cath. – bed rest 8-12 hrs and pressure dressing over cath insertion
Peripheral pulses checked q 15 min for 1st hr, 30 min for 2hrs, next q4 hrs, NPO midnight before procedure
Mitral stenosis and CHF can be caused by rheumatic fever cause carditis (valves)
Swan-Ganz cathether measures pulmonary artery wedge pressure indirect reading of the pressure in the left ventricle
Hypoglycemia – tachycardia, cold clammy skin, weakness and pallor, check blood sugar offer milk
Low platelets (150,000-400,000) decrease causes problems with blood clotting – risk for injury
Post-op abdominal abscess had drain inserted – what to assess? – character of the drain – purulent or other?
Pregnancy – epigastric pain – impending convulsion
Hypoglycemia – cool, clammy skin, diaphoresis, nervousness, weakness, hunger, confusion, HA, slurred speech, come
Relaxed uterus – put infant to the breast – cause natural oxytocin release to contract uterus
Addison’s during stress pt needs more sodium – increase sodium intake
S3 ventricular gallop is earliest sign of CHF
PCA if itching its SE of narcotics
Trifluoperazine (Stelazine) – notified nurse if difficult urinating
MASLOW safety nr 1 unless there is ABC as an option
Digoxin level 0.5-2 ng/ml
Three chamber water seal drainage (Pleur-evac) – no fluid fluctuation noted what to do – fluctuations stopped lungs
might be re-expanding, take x-ray to confirm
RN- head injured client with Glasgow come nr 5
Appendectomy – H in protein, H in calories H in vit C
Cholestyramine (Questran) – sprinkle on food or drink, let it stand than stir
Pharatjyroidectomy – preop diet - low-calcium diet
Isoniazid (INH) – report if fatigue and dark urine seen – hepatic dysfunction
Baby aspirin overdose symptoms – tinnitus and gastric distress
Hemophilia A – oxycodone (Percodan) can cause bleeding contains aspirin
MRI remove nitroglycerine patch bf the procedure
Dehydration give give hypotonic solution 0.45% NaCL
10 year old draw the pictures bf cardiac cath.
Nitroglycerin – watch for Decreasing BP
Piperacillin (Pipracil) check for allergis
Sucking tumb – normal behavior for 17 months and disappears 24 moths of age
Tranylcypromine sulfate (Parnate) avoid foods with tyramine to prevent hypertensive crisis
Hydralazine Apresoline BP is 90/60 do not adnminister any extra dose due to low BP, check with DR
Hyperparathyroism report if hematuria due to renal calculi over 50% have renal stones
Discharge teaching multiple sclerosis – avoid heat and cold – damage to sensation
Naproxen sodium (Anaprox) – NSAIDS can cause GI bleeding – stool turns dark – call doctor
Transitional stage of labor active labor – use pursed lips to breath – control pain and help to oxygenate fetus
Cystic fibrosis – [positive sweat test – replace enzymes
Sengstaken-Blakemore tube in place – women in respiratory distress – cut the balloon ports and remove tube
Sucralfate Carafate – best on empty stomach
Vaginal delivery – check pt’s lochial flow for hemorrhage (First nursing action) Circulation
Isoniazid (INH) – may cause peripheral neuropathy – hands and feet tingle also nausea
Lumbar puncture – stay flat in bed after the proc for 8 hrs.
Hepatic encephalopathy – early symptoms – impaired thought process
Oxytocin (Pitocin) – always a secondary infusion controlled by an IV pump
Mtronizadole (Flagyl) – no alcochol can cause Antabuse like reaction nausea, vomiting, HA, cramps, flushing.
Aspirin – sickle cell crisis - hemorrhage
Magnesium sulfate CNS depressant SE is oliguria (decrease UO)
Humulin R is clear drawn up first than Humulin N (cloudy)
Butorphanol (stadol) – check VS (med decreases Rate and depth or respirations)
pH increased and CO2 increased pt is hyperventilating due to alkalosis – breath to paper bag
Polio vaccine – life virus no immunocompromised
Chloropromazine hydrochloride (Thorazine) – give medication evening time if possible to reduce daytime sedation
Bronchoscopy – assess pt for symptoms of respiratory distress from swelling due to procedure like tachypnea,
tachycardia, respiratory stridor, and retractions
Cephalexin monohydrate (Keflex) good foods are to help maintain normal intestinal flora Keflex destroids it…
Tracheostomy tube out quick replace the tracheostomy tube to secure the airway
Head circumference N is 32-36 increased indicate hydrocephaly or IICP
Meglumine Diatrizoate (Gastrografin)
Remember 5 rights of medication administration – if there is a medication and you gave 1 medication impl. Right it
might be correct…..???
Neostigmine bromide Prostigmin – delay in taking the med may cause difficulty in swallowing, diffucult in taking
medication
Problem with a chest tube – constant bubbling in the water seal chamber due to an air leak
Disoriented client keep side rails up SAFETY
Question asks about a drug which is Diuretic look for an answer desired for what diuretic does – look for urine output
or clear lungs etc…
Hep A communicable for 2-3 weeks bf jaundice and 1 week after jaundice. child can return to school 1 week af
jaundice
Alcohol withdraw delirium – need more sedation if pulse rate is Increased
Bulge test – checks for fluid in the knee, extend legs
Expected Embolism in lungs position patient on her left side and Lower the HOB – air bubbles stay away
Haemophilus Influenzae (meningitis) droplet precautions for 24 hrs after antibiotics therapy
Pneumonia - therapeutic response – RR regular no dyspnea, moderate amount of white sputum
Cromolyn sodium (Intal) for asthma - lowers allergic triggers take before vigorous exercise
Fluid excess orthopnea, dyspnea, crackles, decrease IV fluids
Labor FHR is 59 what to do – fetal bradycardia might be cord compression or separation of placenta its fetal distress L
side reduces compression of Vena Cava and aorta – turn L side give O2 by NC start IV
Stage four Parkinson’s disease pt is immobile do ROM to 4 extremities 4 times per day
Element of MALPRACTICE are duty, breach of duty, causation, and injury to be sued and win all elements must to
match if not nurse is innocent