NCLEX uworld TEST BANK 2022 questions and answers | GRADED A

NCLEX uworld TEST BANK 2022 questions and answers | GRADED ANCLEX uworld TEST BANK 2022 questions and answers | GRADED A what medications interact with grapefruit? Correct Answer: calcium channel blockers: diltiazem, nifedipine, verapamil, etc statins caffeine SSRIs be sure to practice math! Correct Answer: stent placement using the femoral approach puts you at risk for retroperitoneal hemorrhage Correct Answer: what are early signs of bleeding into the retroperitoneal space? Correct 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? Correct Answer: bruising of the flanks and retroperitoneal hemorrhage and is a bluish color what are some physical signs of peripheral arterial disease? Correct 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 Correct Answer: tachycardic like 90-110 what is the priority intervention for pain with sickle cell crisis and why? Correct Answer: administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion what is the purpose of continuous bladder irrigation? Correct 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? Correct Answer: monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed characteristics of a basilar skull fracture Correct Answer: periorbital hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising) immediate client care for basilar skull fracture Correct Answer: cervical spime immobilization, close neurologic monitoring, and support of ABCs vomiting with intake may mean Correct Answer: viral or bacterial infection tympanosomty tubes are placed for Correct Answer: recurrent otis medias nurse actions during a seizure Correct 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) never put anything in mouth or restrain them since musclec ontractions can occur during a seizure what are some early symptoms of ICP? Correct Answer: altered LOC, headache, abnormal reathing, rise in bp, slow pulse, vomiting client who has a TIA is often placed on Correct Answer: prophylactic antithrombotic treatment like aspirin or clopidogrel glascow coma scale ranges from Correct Answer: 3-15; 3 being worst 15 being best condition (8 or below in a coma) what are the 3 components? Correct Answer: eye opening motor response verbal response what is a primary component in TPN? Correct 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? Correct 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 og hyperglycemia Correct Answer: polydipsia, polyuria, restless, confused, bg over 200, fatigue, kussmaul resp what is the goal for mass casualty events? Correct 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 Correct Answer: what are the 4 categories for triaging? Correct 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 Correct 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 Correct 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 Correct Answer: respiratory depression airborne precautions Correct 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: Correct 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? Correct 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 Correct 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 Correct Answer: you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics, analgesics, and antinflammatories examples are Correct Answer: Mucinex, Ibuprofin, decerebrate posturing (toes point down and amrs/legs straight out) is a sign of Correct Answer: severe brain damage near drowning hypothermia Correct Answer: warm iv fluids, blankets, and air also will find weak and thready pulse a client is not dead until warm and dead!!! Correct Answer: nc sometimes a pt is so cold that a pulse cannot be felt intussusception causes intestinal obstruction Correct Answer: ileum telescopes into cecum, pain obstruction, edema, compression of BVs, bowel ischemia, rectal bleeing (CURRANT JELLY stools) signs of intussusceotion Correct Answer: inital periodic pain with legs drawn up to abdomen, pain is severe and progressive though, inconsolable crying, blood/mucousy stools "current jelly" how is it treated? Correct Answer: an air enema guaifenesin (Mucinex) Correct Answer: expecorant med that inc resp fluids and thins secretions to facilitate expectoration erythropoeitin Epogen Correct Answer: stimulates bone marrow to make RBCs and combats the effects of chemo and used for kidney disease when is hemoccult done? Correct Answer: when hidden (occult) blood is suspected due to dark and tarry stool treat intussusception with Correct Answer: AIR ENEMA tetraology of fallot Correct Answer: exacerbation can happen when infant or child cries, becomes upset, or is feeding you immediately place them in KNEE CHEST position hemolytic uremic syndrome Correct Answer: life threatening complication of e. coli diarhea what are the signs? Correct Answer: anemia (pallor), low platelets (petechiae and purpura, and acute kidney injury (low UO) cognitive behavioral therapy (CBT) 5 basic components Correct Answer: education about pts disorder self observing and monitoring relaxation techniques cognitive restructuring behavioral strategies speicen collection from a foley is considered sterile and should not be delegated to uap Correct Answer: a clients first and last name is not PHI privileged health info Correct Answer: it is not a violation to cal them by their first and last names or have info heard inadvertently what happens if a client does not full undersnad infromed consent?q Correct Answer: the nurse must contact the doctor. the nurse is not responsible for verifiying that the client understands how to stop epistaxis Correct Answer: tilt the head forward and apply direct continuous pressure on the alaes (sides) for about 5-20 mins can also hold a cold washcloth to the bridge of nose for vasoconstriction keep child calm and quiet IV iodinated contrast used for ct scan can cause Correct Answer: kidney injury metformin is discontinued on the day of IV iodine contrast exposure Correct Answer: Amlodipine Correct Answer: calcium channel blocker used to treat hypertension Gabapentin (Neurontin) Correct Answer: used for neuropathic pain Phenytoin (Dilantin) Correct Answer: antiseizure Glipizide Correct Answer: oral sulfonylurea controls blood sugar Levofloxacin (Levaquin) Correct Answer: antibiotic testicular self examination Correct Answer: perform monthly and on same day perform while taking hot shower bc temps will relax scrotal tissue and make testis hang lower in scrotum use both hands to feel each testis separately palpate gently using thumb and first 2 fingers normal calcium level Correct Answer: 8.6-10.2 review heart rhythms Correct Answer: lactated ringers is often used for burns Correct Answer: addisons disease= hyperpigmentation of the skin Correct Answer: what is one of the earliest signs of ICP? Correct Answer: change in respsonsiveness what are some expected symptoms in a TBI? Correct Answer: low grade constant HA, slowness in thinking, memory problems, loss of balance, poor coordination, constant exhaustion, inc sensitivity to light, and heightened irritability all symtpoms that can last up to 6 weeks bacterial meningitis Correct Answer: high fever change in loc nuchal rigidity meningeal signs (positive kernig and brudzinski signs)-- treat with antibiotics what is the kernig sign? Correct Answer: patient lies supine, thigh is flexed at right angle, and it hurts to extend leg what is the brudzinski sign? Correct Answer: bending of neck causes flexion of knee and hip what are these 3 signs indicative of? Correct Answer: meningitis client identifiers Correct Answer: first and last name medical record number DOB expected term newborn findings Correct Answer: plantar creases up entire sole presence of babinski Epstein's pearls is the babinski sign present at birth? Correct Answer: yes but it disappears at 1 year what does an absent babinski or weak reflex indicate? Correct Answer: a neurological deficit babinski sign for a child less than 1 year Correct Answer: great toe bends upward and smaller toes fan out. this is NORMAL babinski sign for child more than 1 year and an adult Correct Answer: plantar flexion normal toe flexion (no babinski) what are epsteins pearls? Correct Answer: white pearl like cysts on gum an palate that are benign and usually go away within a few weeks when does the umbilical cord detach from body? Correct Answer: within 2 weeks jaundice in a newborn Correct Answer: during first 24 hours: jaundice is pathological (r/t liver problems) after 24 hours: physiological jaundice r/t inc amount of unconjugated bilirubin in system infant formula key points Correct Answer: never dilute or concentrate formula wash tops of forumla cans before opening unused prepare formula can be used for up tp 48 hours and then discarded after to warm prepared bottle, place in pan of hot water never microwave formula any forumula left over should be thrown out immediately when done long term management of hyptertension Correct Answer: important to take bp meds as perscribed what do statin drugs like atorvastatin, rosuvastatin do? Correct Answer: cut LDL drastically and reduce total cholesterol and triglycerides, and inc HDL good cholesterol Correct Answer: HDL bad cholesterol Correct Answer: LDL