Nclex review Uworld –BSN 101
• Clozapine is an atypical antipsychotic medication used to treat schizophrenia that has not responded to
standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis and is
therefore used only in clients with treatment-resistant schizophrenia. must have their WBC and ANC
monitored regularly throughout the course of therapy (initially once every week). the health care
provider (HCP) immediately if fever or a sore throat develops, as this may indicate an underlying
infection from neutropenia. also cause metabolic syndrome (weight gain, hyperlipidemia, insulin
resistance/diabetes) and seizures.
• Weight gain—a baseline height, weight, and waist circumference should be obtained, and a BMI can be
calculated
• Hyperglycemia—symptoms of hyperglycemia (eg, increased thirst and urination, weakness, increased
blood glucose) should be monitored
• Dyslipidemia—a lipid profile should be obtained
A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain
tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP)
(Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must
remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform
neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any
acute changes (Option 5).
Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should:
• Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors
• Administer stool softeners to reduce strain during bowel movements (Option 1)
• Reduce exertion, maintain strict bed rest, assist with activities of daily living
• Maintain head in midline position to improve jugular venous return to the heart
Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and
prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these
drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia
should be used (eg, metformin)
Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased
permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of
albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid
to leak out of the vascular spaces. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and
water (renin-angiontensin-aldosterone system). Clients will have generalized edema, weight gain, loss of
appetite (from ascites), and decreased urine output. Loss of immunoglobulins makes children susceptible to
infection. Treatment typically includes:
• Corticosteroids and other immunosuppressants (eg, cyclosporine)
• Loss of appetite management by making foods fun and attractive
• Infection prevention (eg, limiting social interaction until the child is better)
Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below
are the 4 classic manifestations of nephrotic syndrome:
,• Massive proteinuria – caused by increased glomerular permeability
, • Hypoalbuminemia – resulting from excess protein loss in the urine
• Edema – specifically periorbital and peripheral edema and ascites; caused by low serum protein and
albumin as fluid is pulled into interstitial spaces and body cavities
• Hyperlipidemia – related to increased compensatory protein and lipid production by the liver
Additional symptoms include decreased urine output, fatigue, pallor, and weight gain.
The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is
generally considered idiopathic. Less common secondary causes may be related to systemic disease or
infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome.
Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally
valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is
not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron
deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship
between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and
hematocrit levels to screen for the presence of anemia.
Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain.
Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting,
nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients
are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by
anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit.
Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness
(caused by anesthesia). These clients should be placed on their side and should receive antiemetics to prevent potential
airway and breathing complications.
The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the
head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into
the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety.
The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a
"heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.
Essential nursing actions related to a needle liver biopsy include checking coagulation, blood type, and crossmatch
beforehand, positioning the client on the right side for hours afterward, and monitoring vital signs and for potential signs
of shock.
Albuterol (Proventil) is a short-acting beta-2 agonist that produces immediate bronchodilation by relaxing smooth
muscles. Bronchodilation decreases airway resistance, facilitates mucus drainage, decreases the work of breathing, and
increases oxygenation. Peak flow will improve. The most frequent side effects are tremor, tachycardia, restlessness, and
hypokalemia.
Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to
prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when
having a bowel movement for these reasons.
Central chemoreceptors located in the respiratory center of the brain (medulla) respond to changes in blood
carbon dioxide and hydrogen ions by either increasing or decreasing ventilation to normalize the pH. When the
receptors sense a low pH (acidosis), ventilation increases to rid the body of excess carbon dioxide; when the
receptors sense a high pH (alkalosis), ventilation decreases to retain carbon dioxide. Peripheral chemoreceptors
, located in the carotid and aortic bodies respond to low levels of oxygen and stimulate the respiratory center to
increase ventilation.
Many clients with COPD breathe because their oxygen levels are low rather than because carbon dioxide levels
are high. This is commonly referred to as the hypoxemic drive. If they receive too high a level of inspired
oxygen, this drive can be blunted. It is therefore important for these clients to receive a "guaranteed" amount of
oxygen as an increase in inspired oxygen can decrease the drive to breathe.
To promote adequate gas exchange, the nurse should use a high-flow Venturi mask to deliver a specified,
guaranteed amount of oxygen. Because this device has a mechanism that controls the mixture of room air, the
inspired oxygen concentration remains constant despite changes in respiratory rate, depth, or tidal volume. It is
the most appropriate intervention to promote adequate gas exchange.
Amniotomy refers to the artificial rupture of membranes (AROM) and may be performed by the health care
provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is
not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The
nurse should assess the fetal heart rate before and after the procedure (Option 1).
The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and
without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong,
foul odor may indicate infection (Option 5). Once the membranes are ruptured, there is an increased risk for
infection. The nurse should monitor the client's temperature at least every 2 hours after AROM (Option 2).
• Clozapine is an atypical antipsychotic medication used to treat schizophrenia that has not responded to
standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis and is
therefore used only in clients with treatment-resistant schizophrenia. must have their WBC and ANC
monitored regularly throughout the course of therapy (initially once every week). the health care
provider (HCP) immediately if fever or a sore throat develops, as this may indicate an underlying
infection from neutropenia. also cause metabolic syndrome (weight gain, hyperlipidemia, insulin
resistance/diabetes) and seizures.
• Weight gain—a baseline height, weight, and waist circumference should be obtained, and a BMI can be
calculated
• Hyperglycemia—symptoms of hyperglycemia (eg, increased thirst and urination, weakness, increased
blood glucose) should be monitored
• Dyslipidemia—a lipid profile should be obtained
A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain
tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP)
(Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must
remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform
neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any
acute changes (Option 5).
Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should:
• Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors
• Administer stool softeners to reduce strain during bowel movements (Option 1)
• Reduce exertion, maintain strict bed rest, assist with activities of daily living
• Maintain head in midline position to improve jugular venous return to the heart
Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and
prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these
drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia
should be used (eg, metformin)
Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased
permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of
albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid
to leak out of the vascular spaces. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and
water (renin-angiontensin-aldosterone system). Clients will have generalized edema, weight gain, loss of
appetite (from ascites), and decreased urine output. Loss of immunoglobulins makes children susceptible to
infection. Treatment typically includes:
• Corticosteroids and other immunosuppressants (eg, cyclosporine)
• Loss of appetite management by making foods fun and attractive
• Infection prevention (eg, limiting social interaction until the child is better)
Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below
are the 4 classic manifestations of nephrotic syndrome:
,• Massive proteinuria – caused by increased glomerular permeability
, • Hypoalbuminemia – resulting from excess protein loss in the urine
• Edema – specifically periorbital and peripheral edema and ascites; caused by low serum protein and
albumin as fluid is pulled into interstitial spaces and body cavities
• Hyperlipidemia – related to increased compensatory protein and lipid production by the liver
Additional symptoms include decreased urine output, fatigue, pallor, and weight gain.
The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is
generally considered idiopathic. Less common secondary causes may be related to systemic disease or
infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome.
Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally
valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is
not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron
deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship
between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and
hematocrit levels to screen for the presence of anemia.
Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain.
Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting,
nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients
are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by
anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit.
Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness
(caused by anesthesia). These clients should be placed on their side and should receive antiemetics to prevent potential
airway and breathing complications.
The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the
head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into
the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety.
The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a
"heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours.
Essential nursing actions related to a needle liver biopsy include checking coagulation, blood type, and crossmatch
beforehand, positioning the client on the right side for hours afterward, and monitoring vital signs and for potential signs
of shock.
Albuterol (Proventil) is a short-acting beta-2 agonist that produces immediate bronchodilation by relaxing smooth
muscles. Bronchodilation decreases airway resistance, facilitates mucus drainage, decreases the work of breathing, and
increases oxygenation. Peak flow will improve. The most frequent side effects are tremor, tachycardia, restlessness, and
hypokalemia.
Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to
prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when
having a bowel movement for these reasons.
Central chemoreceptors located in the respiratory center of the brain (medulla) respond to changes in blood
carbon dioxide and hydrogen ions by either increasing or decreasing ventilation to normalize the pH. When the
receptors sense a low pH (acidosis), ventilation increases to rid the body of excess carbon dioxide; when the
receptors sense a high pH (alkalosis), ventilation decreases to retain carbon dioxide. Peripheral chemoreceptors
, located in the carotid and aortic bodies respond to low levels of oxygen and stimulate the respiratory center to
increase ventilation.
Many clients with COPD breathe because their oxygen levels are low rather than because carbon dioxide levels
are high. This is commonly referred to as the hypoxemic drive. If they receive too high a level of inspired
oxygen, this drive can be blunted. It is therefore important for these clients to receive a "guaranteed" amount of
oxygen as an increase in inspired oxygen can decrease the drive to breathe.
To promote adequate gas exchange, the nurse should use a high-flow Venturi mask to deliver a specified,
guaranteed amount of oxygen. Because this device has a mechanism that controls the mixture of room air, the
inspired oxygen concentration remains constant despite changes in respiratory rate, depth, or tidal volume. It is
the most appropriate intervention to promote adequate gas exchange.
Amniotomy refers to the artificial rupture of membranes (AROM) and may be performed by the health care
provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is
not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The
nurse should assess the fetal heart rate before and after the procedure (Option 1).
The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and
without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong,
foul odor may indicate infection (Option 5). Once the membranes are ruptured, there is an increased risk for
infection. The nurse should monitor the client's temperature at least every 2 hours after AROM (Option 2).
