NCLEX UWorld
When do *advanced directives* go into effect? - Answer when person is *unable to
speak for him/herself* due to either:
1. *Mental Incapacity* - *coma *(GCS score ≤ 7)
2. *Aphasia*
(≠as soon as signed; directives can always be changed later by person)
SBAR Communication Framekwork Components - Answer 1. *S* = Situation - what
*prompted* the communication (eg *what* changes occurred)
2. *B* = Background - *pertinent information, relevant history, vital signs*
3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes*
occurred)
4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
Appropriate order of actions when client found on floor - Answer 1. *Assessment* of
*physiological stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
Conditions of being *ineligible to leave AMA* - Answer 1 *danger to self or others*
2. *lack of consciousness*
3. *Altered consciousness*
4. *Mental illness*
5. Being under *chemical influence*
6. *Court decision*
Effective handoff communication components - Answer Nurse should:
1. Provide *identifying information* (eg client's name and room number)
2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace
medication infusion bag, need to perform delayed wound care and cause of delay)
3. Provide *exact, pertinent information* (eg medication dose, time, measurable
outcomes)
4. Include *multidisciplinary plans* (eg radiology examinations, family meetings,
physical therapy)
5. Relay significant client changes in a clear manner
*Risk factors* for *cervical cancer* - Answer 1. Infection with high-risk HPV strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use
,NCLEX UWorld
what medications interact with grapefruit? - Answer 1. *calcium channel blockers*
(diltiazem, nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* - Answer
*retroperitoneal hemorrhage*
what are early signs of bleeding into the retroperitoneal space? - Answer hypotension,
back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal
pulses
what is the grey-turner sign and what is it a sign of? - Answer bruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - Answer intermittent calf
muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin,
thick brittle nails, gangrene, ulcers (all of these are in the extremities)
transplanted hearts are expected to be - Answer tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? - Answer
administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by
vasoocclusion
what is the purpose of continuous bladder irrigation? - Answer it is perscribed after
TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder
what is the nurses care of monitoring CBI? - Answer monitor quality of drainage, titrate
the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - Answer periorbital hematomas (raccoon
eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture - Answer cervical spime immobilization,
close neurologic monitoring, and support of ABCs
vomiting with intake may mean - Answer viral or bacterial infection
tympanosomty tubes are placed for - Answer recurrent otis medias
nurse actions during a seizure - Answer assist them to lie down is standing/sitting, put
them on side for patent airway, loosen tight clothing, give oxygen as needed, remove
objects from immediate area, document time and duration of seizure (for tests are done
later to see which type of seizure and maybe what exacerates it)
,NCLEX UWorld
never put anything in mouth or restrain them since musclec ontractions can occur
during a seizure
what are some early symptoms of ICP? - Answer altered LOC, headache, abnormal
reathing, rise in bp, slow pulse, vomiting
client who has a TIA is often placed on - Answer prophylactic antithrombotic treatment
like aspirin or clopidogrel
glascow coma scale ranges from - Answer 3-15; 3 being worst 15 being best condition
(8 or below in a coma)
what are the 3 components? - Answer eye opening
motor response
verbal response
what is a primary component in TPN? - Answer *glucose,* so the nurse should be
monitoring blood glucose and be assessing for signs of hyperglycemia
when a client is on TPN, the nurse must assess for hyperglycemia why? - Answer bc a
primary component is glucose. therefore the nurse must be assessing to see if the client
is getting too much glucose (hoerglycemia). and with a large urinary output like 4800,
this could indicate symptoms of hyperglycemia
signs of hyperglycemia - Answer - polydipsia,
- polyuria,
- restless,
- confused,
- bg over 200,
- fatigue,
- headache
- blurred vision
- kussmaul resp
Interventions to resolve TPN-associated hyperglycemia - Answer - reduce amount of
carbohydrate in TPN solution
- slow down infusion rate
- administer subcutaneous insulin
what is the goal for mass casualty events? - Answer do the greatest good for the
greatest number of people
keep in mind that disaster triage ranks the likelihood of survival with treatment, not
necessarily the severity of the injury - Answer
, NCLEX UWorld
what are the 4 categories for triaging? - Answer immediate (red tag)- life threatening
injuries with good prognosis once treated
delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines - Answer head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
extrapyramidal side effects - Answer ACUTE DYSTONIC REACTION: sudden onset
sustained muscle contractions
AKATHISIA: restlessness with inability to sit still
drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces
AKINISIA: loss of involuntary movement
TARDIVE DYSKININIA
NEUROLEPTIC MALIGNANT SYNDROME
dont give morphine if RR under 12 bc it can cause - Answer respiratory depression
airborne precautions - Answer tuberculosis, varicella, and rubeola (measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
UAP soft wrist restraints can: - Answer do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
a client with major depression and severe weight loss needs what type of diet? - Answer
high in calories and protein, also foods that are easy to chew and dont require a lot of
energy bc they may have a low energy level
examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta
also small frequent meals
memorize MAOIs and remember - Answer they cant eat foods high in tyramine like
aged cheese, yogurt, fermented foods, beer, red wine, cocolate, avocados
do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart
failure or edema - Answer
you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics,
analgesics, and antinflammatories
When do *advanced directives* go into effect? - Answer when person is *unable to
speak for him/herself* due to either:
1. *Mental Incapacity* - *coma *(GCS score ≤ 7)
2. *Aphasia*
(≠as soon as signed; directives can always be changed later by person)
SBAR Communication Framekwork Components - Answer 1. *S* = Situation - what
*prompted* the communication (eg *what* changes occurred)
2. *B* = Background - *pertinent information, relevant history, vital signs*
3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes*
occurred)
4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
Appropriate order of actions when client found on floor - Answer 1. *Assessment* of
*physiological stability* (ABCs)
2. *Assessment* of *injuries*
3. *Moving client*
4. *Notifications*
5. *Documentation*
Conditions of being *ineligible to leave AMA* - Answer 1 *danger to self or others*
2. *lack of consciousness*
3. *Altered consciousness*
4. *Mental illness*
5. Being under *chemical influence*
6. *Court decision*
Effective handoff communication components - Answer Nurse should:
1. Provide *identifying information* (eg client's name and room number)
2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace
medication infusion bag, need to perform delayed wound care and cause of delay)
3. Provide *exact, pertinent information* (eg medication dose, time, measurable
outcomes)
4. Include *multidisciplinary plans* (eg radiology examinations, family meetings,
physical therapy)
5. Relay significant client changes in a clear manner
*Risk factors* for *cervical cancer* - Answer 1. Infection with high-risk HPV strains
2. History of sexually transmitted diseases
3. Early onset of sexual activity
4. Multiple or high-risk sexual partners
5. Immunosuppression
6. Oral contraceptive use
7. Low SES
8. Tobacco use
,NCLEX UWorld
what medications interact with grapefruit? - Answer 1. *calcium channel blockers*
(diltiazem, nifedipine, verapamil, etc)
2. *statins*
3. *SSRIs*
Risk associated with *stent placement* using the *femoral approach* - Answer
*retroperitoneal hemorrhage*
what are early signs of bleeding into the retroperitoneal space? - Answer hypotension,
back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal
pulses
what is the grey-turner sign and what is it a sign of? - Answer bruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - Answer intermittent calf
muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin,
thick brittle nails, gangrene, ulcers (all of these are in the extremities)
transplanted hearts are expected to be - Answer tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? - Answer
administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by
vasoocclusion
what is the purpose of continuous bladder irrigation? - Answer it is perscribed after
TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder
what is the nurses care of monitoring CBI? - Answer monitor quality of drainage, titrate
the inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - Answer periorbital hematomas (raccoon
eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising)
immediate client care for basilar skull fracture - Answer cervical spime immobilization,
close neurologic monitoring, and support of ABCs
vomiting with intake may mean - Answer viral or bacterial infection
tympanosomty tubes are placed for - Answer recurrent otis medias
nurse actions during a seizure - Answer assist them to lie down is standing/sitting, put
them on side for patent airway, loosen tight clothing, give oxygen as needed, remove
objects from immediate area, document time and duration of seizure (for tests are done
later to see which type of seizure and maybe what exacerates it)
,NCLEX UWorld
never put anything in mouth or restrain them since musclec ontractions can occur
during a seizure
what are some early symptoms of ICP? - Answer altered LOC, headache, abnormal
reathing, rise in bp, slow pulse, vomiting
client who has a TIA is often placed on - Answer prophylactic antithrombotic treatment
like aspirin or clopidogrel
glascow coma scale ranges from - Answer 3-15; 3 being worst 15 being best condition
(8 or below in a coma)
what are the 3 components? - Answer eye opening
motor response
verbal response
what is a primary component in TPN? - Answer *glucose,* so the nurse should be
monitoring blood glucose and be assessing for signs of hyperglycemia
when a client is on TPN, the nurse must assess for hyperglycemia why? - Answer bc a
primary component is glucose. therefore the nurse must be assessing to see if the client
is getting too much glucose (hoerglycemia). and with a large urinary output like 4800,
this could indicate symptoms of hyperglycemia
signs of hyperglycemia - Answer - polydipsia,
- polyuria,
- restless,
- confused,
- bg over 200,
- fatigue,
- headache
- blurred vision
- kussmaul resp
Interventions to resolve TPN-associated hyperglycemia - Answer - reduce amount of
carbohydrate in TPN solution
- slow down infusion rate
- administer subcutaneous insulin
what is the goal for mass casualty events? - Answer do the greatest good for the
greatest number of people
keep in mind that disaster triage ranks the likelihood of survival with treatment, not
necessarily the severity of the injury - Answer
, NCLEX UWorld
what are the 4 categories for triaging? - Answer immediate (red tag)- life threatening
injuries with good prognosis once treated
delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines - Answer head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
extrapyramidal side effects - Answer ACUTE DYSTONIC REACTION: sudden onset
sustained muscle contractions
AKATHISIA: restlessness with inability to sit still
drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces
AKINISIA: loss of involuntary movement
TARDIVE DYSKININIA
NEUROLEPTIC MALIGNANT SYNDROME
dont give morphine if RR under 12 bc it can cause - Answer respiratory depression
airborne precautions - Answer tuberculosis, varicella, and rubeola (measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
UAP soft wrist restraints can: - Answer do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
a client with major depression and severe weight loss needs what type of diet? - Answer
high in calories and protein, also foods that are easy to chew and dont require a lot of
energy bc they may have a low energy level
examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta
also small frequent meals
memorize MAOIs and remember - Answer they cant eat foods high in tyramine like
aged cheese, yogurt, fermented foods, beer, red wine, cocolate, avocados
do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart
failure or edema - Answer
you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics,
analgesics, and antinflammatories
