ATI - NCLEX Predictor Remediation Study Notes

Renal Calculi - Pain: Flank pain → Kidney or Ureter (if pain radiates → stones in ureter or bladder) Performing Ear Irrigation: Sterile technique, warm meds, pull up & back, tilt toward affected ear Thrombolytic Therapy (Stroke): Reteplase recombinant (rTPA – clot buster) w/ in 4.5 hours of initial symptoms Trach care: Dressing ∆, inner cannula ½ hydrogen peroxide, & stoma □ knot Head injury (changes in LOC): Length of time unconscious & GCS General anesthesia (post-op): ABC’s – full body assessment, Vitals every 15 minutes, Lateral position (if unresponsive or unconscious - monitor LOC), Fluids/Electrolytes Superficial Burns: Painful, pink, red, mild edema (3-6 day healing), damage to epidermis Dialysis (reporting unexpected findings): Temp of 100 degrees, ↓ BP, bleeding, 1 L of fluid = 1Kg, clotting, H/A, Nausea, Disequilibrium syndrome (rapid ↓ BUN & Fluid volume), anemia, peritonitis, ↑ BG, ↑ cholesterol Pacemaker (complications): Infection, hematoma, pneumothorax, hemo-thorax, arrhythmias, pacer spikes before P or QRS, hiccups / muscle twitching Magnesium (Mg)Sulfate → Increase Mg+ > 1.3 Mg/dL ↑ Mg foods = (Dairy, dark leafy greens veges) ↓ Mg causes → Hyperactive deep tendon reflexes * Paresthesia’s, muscle tetany, positive chvostek’s & Trousseau’s sign, hypoactive bowels, constipation, abdominal distention, paralytic Ileus. TPN Admin: (Total parenteral nutrition) -feeding that bypasses the GI tract. Fluids are given into a vein to provide most of the nutrients the body needs. Given when person cannot/ should not receive feedings or fluids by mouth. Hypertonic (20-50% dextrose), Used in chronic pain, peritonitis, burns, Infection, etc No more than 10% hourly, ↑ in rate for body adjustment, check BG Hyperglycemia, hypoglycemia, vitamin deficiencies, air embolism (clamp, place in Trendelenburg pos., O2) Fluid imbalance → Fluid volume excess Wound Culture specimen: Sterile field, press / rotate over wound surface inside the wound (center) in drainage Diabetes Mellitus ( Nephropathy): Kidney damage d/t prolonged ↑ BG & dehydration Monitor I & O, Creatinine, BP Avoid Soda, alcohol, acetaminophen/NSAIDS / 2 – 3 L fluid from food / beverages Kidney Biopsy ( Post op): Monitor VS → Client receives sedation Assess dressings & urinary output (hematuria-blood in urine) Labs: HgB & Hct values, Admin PRN pain meds, Complications hemorrhage / infection Thyroidectomy ( Post Op): Needs Thyroid hormone replacement Client in high fowler’s position, Respiratory (trach supplies) present, Check for laryngeal nerve damage Pain management, Hypocalcemia / Tetany can occur Prioritization: Apply knowledge to Standards to determine priority action Systemic before Local – “Life before Limb” Acute before Chronic Actual Problems before Potential Future Listen carefully to clients & Don’t Assume Recognize & Respond - Trends vs. Transient findings 2 Recognize indications - Emergencies vs. Expected Delegate to LPN : Monitoring Findings, Reinforcing teaching, performing trach care, suctioning, checking NG tube patency, administer tube feedings, inserting urinary catheter, administering meds (No IV) Delegate to AP: ADLs, Bathing, Grooming, Dressing, toileting, Ambulating, feeding w/out swallowing precautions, positioning, routine tasks, bed making, specimen collection, I & O, VS for stable clients, monitoring clinical manifestations after initial RN assess/eval. Paracentesis (prep) - take out fluid from belly (peritoneal fluid) Have client VOID Bariatric Surgery: (weight loss surgery) – Semi fowlers, 6 small meals/day, liquid/pureed food for first 6 weeks (not to exceed 1cup), Vitamin / mineral supplements, & 2 servings of protein daily. Ostomy (in small intestine) Avoid odorous & gas foods (dark green veges, dairy, fish, eggs, beans, corn), yogurt ↓ gas Avoid ↑ fiber foods for first 2 months, ↑ fluid intake Dumping Syndrome: Happens within 15mins of eating. Sx: cramps, diarrhea, tachycardia, dizziness, fatigue, hypoglycemia Interventions: small frequent meals, drink liquids 1hr b4/after Parkinson’s disease: Tremor, muscle rigidity, bradykinesia (slowness in movement), postural instability Stages: 1. Unilateral shaking / tremor of one limb 2. Bilateral limb involvement, difficulty walking/balance 3. Slowed physical movements 4. Akinesia & Rigidity make ADL’s difficult 5. Unable to stand/walk, dependent of cares, dementia Assault: threat Battery: touching Hypoglycemia Sx: Shakiness, confusion, sweating, tachycardia, diaphoresis, palpitations, H/A, lack of coordination, blurred vision, seizures, coma Oral Hypoglycemic Agents : promote insulin release from pancreas (Type2 DM) Glipizide (Glucotrol), Chlorpropamide (Diabines), Glyburide (Diabinese), Metformin (Glucophage). * Med for insulin overdose = Glucagon Radiation Adverse Effects: Skin changes, hair loss, debilitating fatigue, 30 minute visits / stays 6ft away / private room Infection control in clients home: good hygiene, avoid crowded areas, avoid raw foods (veges/meats), avoid cleaning litter boxes, clean home and avoid sick family. Client evacuation in response to fire: greatest good for the greatest amount of people Client in seclusion: 18 yo+ → 4 hours, 9 – 17 yo →2 hours, 8 yo & younger →1 hour Conduct Disorders: lack of remorse, bullies, threatens, low self-esteem, tempers, physical cruelty, destroys property, truant, and shoplifts Manic Phase: ↑ mood, irritable, lasts at least a week, euphoria, agitation, restless, ↑ in talking, flight of ideas, grandiose view of self, impulsive, manipulative, poor judgement, attention seeking. Paranoid: distrust / suspiciousness Schizoid: emotional detachment, disinterest in relationships, indifferent to praise/criticism, uncooperative Schizotypal: odd beliefs, eccentric appearance, magical thinking, perceptual distortions 3 Antisocial: disregard for others, lack of empathy, unlawful, failure to accept responsibility, manipulative, impulsive, seductive Borderline: instability of affect, identity & relationships, splitting behaviors, fear of abandonment, self-injurious, impulsive Histrionic: attention seeking, seductive, flirtatious Narcissist: arrogant, constant admiration, lack of empathy Avoidant: anxious, wants close relationships, fear of rejection Dependent: dependency on another individual OCD: perfectionist, orderly, and control Clozapine (Anti-psychotic Atypical ) Adverse effects: metabolic syndrome, orthostatic hypotension, anti-cholinergic effects, agitation, dizziness, sedation, mild EPS, ↑ prolactin levels(galactorrhea, amenorrhea, gynecomastia), & sexual dysfunction Anti-lipemic Agents: ( Statins) – treats high levels of fats/cholesterol in blood -called lipid-lowering drugs Monitor liver enzyme levels (hepatotoxicity) and muscles – monitor CK levels (myopathy & peripheral neuropathy) Med interactions: Fibrates (Genfibrozil) - ↑ myopathy risk, Erythroycin & Ketoconazole, Amiodarone, & Cyclosprine = Grapefruit juice can ↑ statin levels Gentamicin (effects urine output) -causes ototoxicity w/ diuretics, digoxin, lithium, ototoxic meds, NSAIDs, & anti-hypertensives Long term therapy for RA: DMARDs (methotrexate, etanercept, infliximab, adalimubrab, Azathioprine, Cyclosporine) ** Slow joint degradation Glucocorticoids (Prednisone) & NSAIDs provide symptom relief from inflammation & pain Bulb Syringe (for babies): Mouth first, then nose, depress. Then insert into mouth, avoid center of mouth- may stim. gag reflex. Priority action to an allergic response: Mild rashes/hives – Benadryl Anaphylaxis - treat with epi, bronchodilators, and anti-histamines Provide respiratory support & notify HCP Losartan (ARBs -Anti-Hypertensive (HTN) & kidney disease) - Cough & hyperkalemia are for ace inhibitors. Side Effects: Angioedema, hypotension, dizziness Tracheostomy Care: 2 xtra tubes, adequate humidification, oral care every 2 hours, trach care every 8 hours, sterile suctioning, surgical asepsis to remove / clean inner cannula, secure trach ties before removing old, square knot, clean from stoma outward Appropriate Doc.: Subjective/objective data, Accurate/concise, Complete/current, Organized/ date/ time/ blk ink Crutch safety: Support bodyweight at hand grips with elbows at 30 degrees, Position crutches on unaffected side when sitting or rising from a chair