NCLEX RN STUDY GUIDE

NCLEX RN STUDY GUIDE | Initial Assessment, Teaching, IV drips, Evaluations only RN AIRBORNE TRANSMISSION-BASED PRECAUTIONS: MTV Measles TB Varicella-Chicken Pox/Herpes Zoster-Shingles Private Room: Negative pressure with 6-12 air exchanges/hr Mask: N95 for TB DROPLET TRANSMISSION-BASED PRECAUTIONS: Think of SPIDERMAN! Sepsis Scarlet fever Streptococcal Pharyngitis (Streptococcus group A/ Strep Throat): Can Lead to Glomerulonephritis & Rheumatic Parvovirus B19 Fever. Pneumonia Pertussis Influenza/ Haemophilus influenza type B Diphtheria (Pharyngeal): Serious bacterial infection. Epiglottitis: Medial Emergency! No Throat Inspection. Rubella/ German measles 1 2 NCLEX RN STUDY GUIDE Mumps Meningitis/ Neisseria Meningitidis Mycoplasma/ Meningeal Pneumonia An - Adenovirus Private Room or Cohort Surgical mask PRN for Procedures Mask 3ft Distance CONTACT PRECAUTION TRANSMISSION-BASED PRECAUTIONS: MRS.WEE Multidrug resistant organism/ MRSA/ VRE Respiratory infection Skin infections Wound infection Enteric infection - Clostridium Difficile Eye infection – Conjunctivitis *MRSA - Contact precaution ONLY. Use Chlorhexidine Wipe! *VRSA - Contact & Airborne precaution (Private room, door closed, negative pressure) *SARS (Severe Acute Resp Syndrome) Airborne & Contact (just like Varicella) SKIN INFECTIONS- VCHIPS- CONTACT Varicella Zoster Cutaneous Diphtheria (Bacteria Infection in the Wound) Herpes Simplex Impetigo (Bacterial Skin Infection) Pediculosis (Lice) Scabies (Itchy Skin condition. Burrowing Trail of the Scabies Mite) Middle East Respiratory Syndrome (MERS): Viral respiratory illness caused by Coronavirus (MERS-CoV). 2 2 NCLEX RN STUDY GUIDE S/S: Fever, Cough, SOB, and Death. The Incubation Period is 5-6 days but can range from 2-14 days. CDC: Standard (Gloves), Contact (Gown), Eye Protection (Goggles), Airborne Precautions (N95) Negative room: Negative disease (TB, Disseminated Herpes Zoster) Positive room: Protect the Patient (HIV, Cancer) Addison’s= hyponatremia, hypotension, decreased blood vol, hypoglycemia, hyperKalemia, HyperCalcemia. Cushing’s= HyperNatremia, HyperTension, Incr. Blood Vol, HyperGlycemia, hypokalemia, hypocalcemia. Managing Stress in a patient with Adrenal Insufficiency (Addison’s) is paramount, because if the Adrenal glands are stressed further it could result in Addisonian Crisis. Addison’s: Remember BP is the most Important assessment parameter, as it causes Severe Hypotension. Addison’s: (need to "add" hormone): Hypoglycemia, Dark pigmentation, Decr. Resistance to Stress, fractures, Alopecia, Weight Loss, GI distress. Vitiligo. Mood swings (Normal) Need to Report S/S of Infection/ Fever (Addisonian Crisis) Tx: Mineral Corticoids. Addisonian Crisis: Hypoglycemia, Confusion, n/v, Abd Pain, Extreme Weakness, Dehydration, Decr. BP. Cushings: (have extra "Cushion" of Hormones): Hyperglycemia, prone to Infection, Muscle Wasting, Weakness, Edema, HTN, Hirsutism, Moonfaced/Buffalo Hump Cause: Excessive production of Corticotropin (Hyperplasia of the Adrenal Cortex) & Cortisol-secreting Adrenal Tumor. Prednisone Toxicity: Cushing’s syndrome- Buffalo Hump, Moon face, Hyperglycemia, Hypertension. Acetaminophen: 10-20. Max 4000mg per day. Acetaminophen Poisoning: Possible Liver Failure for about 4 days. Close observation required. Tx: (Antidote) n-AcetylCysteine/Mucomyst 3 2 NCLEX RN STUDY GUIDE AcetylSalicyclic Acid (ASA): Metabolic Acidosis. S/S: Tinnitus, Coffee Ground Emesis (Old Blood), Black tarry stools (Melena), Bruising, Tachycardia, Hypotension, GI Ulcers. Tx: Activated Charcoal, then IV Na+ Carbonate. Acromegaly: Coarse Facial feature. Assess Cardiac Problems (eg. S3, S4). Acute Respiratory Distress Syndrome (ARDS): The 1st Sign is Incr. Respirations. Later comes Dyspnea, Retractions, Air Hunger, Cyanosis. Cardinal sign is Hypoxemia (Low O2 level in tissues). Refractory Hypoxemia is the hallmark of ARDS, a progressive form of acute respiratory failure that has a high Mortality rate. It can develop following a Pulmonary Insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the Lung. The Inability to improve Oxygenation With Incr. in O2 concentration. The insult triggers a Massive Inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a Noncardiogenic Pulmonary Edema. The lungs become Stiff and Noncompliant, which makes Ventilation and Oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. ARDS (fluids in alveoli), DIC (Disseminated Intravascular Coagulation) are always Secondary to something else (another disease process). – Impaired Gas Exchange. PreOxygenated with 100% O2, and Suction should be applied for no more than 10 seconds to prevent hypoxia. The nurse must wait 1-2 minutes between passes to ventilate to prevent hypoxia. Deep reBreathing should be encouraged. The Suction catheter should be No more than half the width of the artificial airway and inserted without suction. Don Sterile gloves if it is not have a closed suction system. 4 2 NCLEX RN STUDY GUIDE Suction should be set at Medium Pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as Excess pressure will traumatize the mucosa and can cause hypoxia. Clients usually Cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, Retracted 1 cm before applying suction. You will ask every New Admission if he has an Advance Directive, and if not you will explain it, and he will have the option to sign or not. Alcohol: a Toxin that causes CNS Depression. Alcohol withdrawal generally starts within 8 hours after the last drink and peaks at 24-72 hours. Acute alcohol intoxication: Confusion, Coordination Impairment, Drowsiness, Slurred Speech, Mood Swings, and Uninhibited actions. Hypoglycemia. Chronic Alcohol Abuse/Alcoholism: Benzodiapepine (lorazepam, diazepam, chlordiazepoxide) – to Treat Gross Tremors, Seizures, Delirium symptom. Chlordiazepoxide: For Alcohol withdrawal. Don’t take with Alcohol (terrible N/V can occur) Thiamine (B1): to treat Wernicke Encephalopathy, a Serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Also can lead to death or neurologic morbidity (Korsakoff Psychosis). Give before or with IV Glucose. Alzheimer’s Disease: Chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of All Dementias. Memantine: Cognition Enhancing medication. It can treat Dementia associated with Alzheimer's disease. Improve symptoms cognition, Daily function, Behavioral problems. Donepezil: Cognition Enhancing medication. Amyotrophic Lateral Sclerosis (ALS): a condition in which there is a Progressive, Degeneration of Motor Neurons in both the Upper & Lower Motor Neuron systems. Upper Motor Neuron issue: Hyper Reflexes Lower Motor Neuron issure: Absent Reflexes 5 2 NCLEX RN STUDY GUIDE S/S: Limb weakness, Dysarthria (difficulty speaking), and Dysphagia. Iron: IM: should be given Z-track so they don't leak into SQ tissues IV: Iron Dextran (Imferon). Can cause hypersensitivity reaction (anaphylaxis), test dose needs to be given First. PO: give with Vitamin C or on an Empty stomach or Btw Meals. Place it on the back of the Month (Stain teeth). Expect Black/Green Tarry Stools. Take iron elixir with juice or water.... Never with milk (Vit D). Iron Poisoning: GI Bleed. Antidote: Deferoxamine Iron Deficiency Anemia: Microcytic anemia. S/S: Fatigue, Pallor, Fissures at the corner of the mouth, Spooning of the fingernail, Reduced exercise tolerance Thalassemia Major (Cooley’s Anemia): Microcytic anemia. S/S: Maxillary Hyperplasia, Frontal Bossing. Caused by: Defects in both Beta-chains of the Hgb molecule. Pernicious Anemia: Macrocytic anemia, Lack of required Intrinsic factor (B12 Deficiency) S/S: Pallor, Tachycardia, Sore Red Tongue (Beefy tongue), Enlarged Liver that can lead to R-sided HF. Take Vit. B12 for life. Shilling Test: Test for Pernicious Anemia. How well one absorbs Vit B12 Folate (Folic Acid) Deficiency: Macrocytic anemia. Risk: Alcoholism or Diet Low in Vegetables. S/S: Stomatitis, Ulcerations on the tongue. Dysphagia, Flatulence, watery Diarrhea 6 2 NCLEX RN STUDY GUIDE Aplastic Anemia: Normocytic Anemia. Decline in blood cell production r/t to Bone Marrow Depression. Can cause an Extremely Low Hgb of 7 g /dL Severe Anemia: (Female hgb 11.7 ~ 15.5) Tachycardia. SOB (Dyspnea). Pallor. (Male hgb 13.2 ~ 17.3) Anorexic: Absence of Menstruation leads to Osteoporosis. Bulimia: Chipmunk Face. Antibiotic: Obtain Cultures before starting IV antibiotics. IV push should go over at least 2 Minutes. Always check for Allergies before Administering (especially PCN). Make sure Culture & Sensitivity has been done before First dose. Give Prophylactic Antibiotic therapy before any Invasive Procedure. Aminoglycocide ( _Mycin e.g. Vancomycin; except Erythromycin): Cause Nephrotoxicity and Ototoxicity. Adverse Effects are Bean Shaped - Nephrotoxic to Kidneys & Ototoxic to Ears Macrolide (Azithromycin, Erythromycin, Clarithromycin): can cause Prolonged QT interval. My lead to Torsade de Pointes (Life-threatening Arrhythmias). Antacids will Limit the Absorption of the antibiotics. Concurrent use of other prolong QT interval (Amiodarone, Sotalol, Haloperidol, Ziprasidone, Azole, Antifungals) will Incr. the risk. Risk of Hepatotoxicity: when taken in High doses. Report Elevated AST and ALT. Sulfamethoxazole/Trimethoprim: (Tx for UTI, PJP). Don’t take if Allergic to Sulfa drugs. Drink plenty of fluids. S/S: Diarrhea 7 2 NCLEX RN STUDY GUIDE Penicillin Allergy: No Cephalexin, Cephalosporin. Amphotericin B: (antifungal) causes Hypokalemia. Premeditate Before giving. Pts will most likely get a Fever. Mebendazole: (antiparasite) Take it with High Fat diet (increases absorption). Anticholinergic Effects: Assessment Blocks the action of Acetylcholine (Neurotransmitter), blocks involuntary muscle movement. Many antihistamine (diphenhydramine) have anticholinergic effect. Dry mouth (Xerostomia)- can't spit Urinary retention- can't pee Constipated- can't poop Blurred vision- can't see Decreased Acetylcholine is related to Senile Dementia. Glucagon increases the effects of Oral Anticoagulants (Rivaroxaban). Appendicitis: Pain is in RL quadrant with Rebound Tenderness. Continuous. Guarding. Anorexia. N/V. McBurney’s Point – pain in RLQ indicative of appendicitis. Position on Right side with legs flexed After Appendectomy. Risk for Peritonitis.