TABLE OF CONTENTSFluids and Electrolytes 4Acid-Base Balance... 14Burns.... 19Oncology.. 28Endocrine..... 47Cardiac..... 64Psychiatric Nursing..... 90Making Room Assignments....111Priority Questions... 112Gastrointestinal... 113Neuro....128Maternity Nursing...138Respiratory..167Orthopedics.175Renal183Questions..192Final Thoughts 211Evaluations.. 219Table of Contents for the 5th Day CD.221Pediatrics..223Testing Strategies260Management and Delegation..263Hurst Review Services2

I. FLUID VOLUME EXCESS: HYPERVOLEMIADefine: too much volume in the ___________________________________A. Causes:1. CHF: heart is__________, CO__________, decreased__________ perfusion,UO__________*the volume stays in the ________________________________2. RF: Kidneys aren't____________________3. AlkaseltzerFleets enemas All 3 have a lot of _________IVF with Na4. Aldosterone (steroid, mineralocorticoid):-Where does aldosterone live?-Normal action: when blood volume gets low (vomiting, blood loss, etc.)aldosterone secretion increases retain Na/water blood volume ___________** Diseases with too much aldosterone:1._________________________________________2._________________________________________**Disease with too little aldosterone:1._________________________________________Normal Urinary Output:1ml/kg/hrGood Rule: Call the MD ifthe UO is < 30ml/hrA client feels the urge tovoid when the bladder hasapproximately250-300 ml of urine in itFluids and ElectrolytesHurst Review Services55. ADH (Anti-diuretic Hormone):-Normally makes you retain or diurese?-Retain? _________________________*Concentrated makes #s go up Urine specific gravity, sodium, and hematocrit*Dilute makes #s go downADH lives in pituitary; key words to make you think potential ADH problem: craniotomy, headinjury, sinus surgery, transphenoidal hypophysectomy or any condition that could lead to increasedICP there is a risk of an ADH problem.Trans-______________, sphenoid______________, hypophysis__________ ,ectomy____________*Another name for anti-diuretic hormone (ADH) is Vasopressin (Pitressin). The drugVasopressin (Pitressin) or Desmopressin Acetate (DDAVP) may be utilized as an ADHreplacement in diabetes insipidus.2 ADH ProblemsToo Much Not EnoughRetain Lose (diurese)Fluid Volume _________ Fluid Volume __________SIADH DISyndrome of Inappropriate ADH Secretion Diabetes Insipidus(TOO MANY _________ TOO MUCH ______)Urine UrineBlood BloodFluids and ElectrolytesHurst Review Services6B. S/S:-Distended neck veins/peripheral veins: vessels are_______________-Peripheral edema, third spacing: vessels can't hold anymore so they start to ________-CVP: measured where __________________; number goes_____More____________________....More____________________-Lung sounds:-Polyuria: kidneys trying to help you_________________________-Pulse: _______________; your heart only wants fluid to go__________________-If the fluid doesn't go forward it's going to go____________into the_____________-BP: _______________ move volume.....more_______________-Weight: _______________ any acute gain or loss isn't fat-its fluidC. Tx :-Low Na diet-Diuretics:-Loop: Example: __________________________-Bumetanide (Bumex) may be given when Furosemide (Lasix) doesntwork.-Hydrochlorothiazide (Thiazide) -Watch lab work with all diuretics-Dehydration and electrolyte problems-K+ sparing: Example: __________________________-Bed rest induces_______________________________________-in general, when you are supine you perfuse your kidneys more because you havemore cardiac output-Physical Assessment-Give IVFs slowly to elderlyCVP:Central VenousPressureNormal: 2-6 mmHg*CVP checked per MDorders usually every4 hoursFluid RetentionThink heartproblems FIRSTTesting StrategyAnytime you see assessmentor evaluation on the NCLEX,you should be looking forthe presence or absence ofthe pertinent signs andsymptomsThe ideal location of the catheter tip is within the superior vena cava (SVC), so that it isclose, but not inside, the right atrium. It reflects pressure readings in the right atrium.Fluids and ElectrolytesHurst Review Services7II. FLUID VOLUME DEFICIT: HYPOVOLEMIABig Time Deficit=ShockA. Causes:1. Loss of fluids from anywhereExamples: Thoracentesis, paracentesis, vomiting, diarrhea, hemorrhage2. Third spacing (Definition: When fluid is in a place that does you no good)-burns-ascites3. Diseases with polyuria-Polyuria Oliguria AnuriaB. S/S:-Weight-Decreased skin turgor-Dry mucous membranes-Decreased Urine Output-kidneys either aren't being__________________ or they are trying to ____________-BP? ___________ (less_____________________, less______________________)-Pulse? __________, heart is trying to pump what little is left around-CVP? __________ (less volume, less __________)-Peripheral Veins/Neck veins-Cool Extremities (peripheral ______________in an effort to shunt blood to ______________________________)-Urine Specific Gravity __________, if putting out any urine at all it will be ____________C. Tx:-Mild Deficit:-Severe Deficit:Polyuria-usually the client will have a totalurinary output of over 2000ml in 24 hoursOliguria-total urinary output between 100 mland 400ml in 24 hoursAnuria-Total urinary output of less than 100ml in 24 hoursFluids and ElectrolytesHurst Review Services8III. Quickie IV Fluid LectureA. Isotonic Solutions: Go in the vascular space and stays there!-Examples of isotonic solutions: _____________, ________________, ________________B. Hypotonic Solutions: Go in the vascular space, hang out a little while and rehydrate, but theydo not stay in the vascular space.....If they stayed in the vascular space they wouldn't behypotonic.....they would be ___________________. These solutions go in and hang out andrehydrate, then they move into the cell and the cell burns the remainder up in cellularmetabolism. They are hydrating solutions, but they won't drive your pressure up because theydo not stay in the vascular space.-Hypotonic Solution:- Causes a fluid shift from the vascular space into the cells. A solution that willcause water to enter the cell, which could induce swelling or lysis of the cell.- Examples: D2.5 W, NaCl, 0.33% NaCl, tap waterC. Hypertonic Solutions:- Volume expander and solution that draws fluids into the vascular space. Drawswater out of the cell.- Examples: D10W, 3% NaCl, 5% NaCl, D5 LR, D5 Na, D5 NaCl, TPN,Albumin.Although D5W is considered an isotonic solution due to the osmolarity it is not used often for clientsthat need a large amount of vascular volume replaced. This is because when D5W is initiallyadministered it is isotonic; however, it does metabolize into free water and is no longer isotonic.An example of when this solution is used is when a patient has hypernatremia.Quick Tips for IV SolutionsIsotonic SolutionsStay where I put it!Hypotonic SolutionsGo Out of the vesselHypertonic SolutionsEnter the VesselFluids and ElectrolytesHurst Review Services9IV. MAGNESIUM AND CALCIUMFact: Magnesium is excreted by kidneys and it can be lost other ways, too (GI tract)Hypermagnesemia HypercalcemiaA. Causes: A. Causes:-Renal Failure -Hyperparathyroidism: too much-Antacids -Thiazides (retain __________)-Immobilization (you have tobear weight to keepCa in the ______________).B. S/S: B. S/S:-Flushing -bones are brittle-Warmth -kidney stones-Mg makes you___________________ *majority made of calciumC. Tx: C. Tx:-Ventilator -Move!-Dialysis -Fluids!-Calcium gluconate -Phospho Soda & Fleets Enema*Calcium gluconate inactivates -both have phosphorousmagnesium- they inactivate each other -Ca has inverse relationshipwith _______________.**Calcium gluconate is administered -When you drive Phos up, CaIVP very slowly (Max rate: 1.5-2 ml/min) goes ______________.-Steroids-Add what to diet?-Safety Precautions-Must have Vitamin ___ to use Ca.-Calcitonin __________ serum CaHINT: If you want to get Mg & Ca questions right, think muscles 1st.* the signs and symptoms listed above in the box are common in a client with hypermagnesemia and hypercalcemia*Normal Lab ValuesMg: 1.2-2.1 mEq/LCalcium: 9.0-10.5 mg/dlWhen your serum calcium gets lowparathormone (PTH) kicks in and pullsCa from the ______________ and putsin the blood....therefore, the serumcalcium goes ___.*S/S*DTR'sMuscle ToneArrhythmiasLOCPulseRespirationsFluids and ElectrolytesHurst Review Services10Hypomagnesemia HypocalcemiaA. Causes: A. Causes:-Diarrhea - lots of Mg in intestines -Hypoparathyroidism-Alcoholism -Radical Neck-alcohol suppresses ADH & its hypertonic -Thyroidectomy-not eating-drinkingHINT: If you want to get Mg & Ca questions right, think muscles 1st.C. Tx: C. Tx:-Give some Mg -Vit D-Check _________function -Sevelamer hydrochloride (Renagel)(before and during IV Mg) -Calcium Acetate (PhosLo )-Calcium Carbonate (Os-Cal )-NCLEX scenario answers:A. call the doctorB. decrease the infusionC. Stop the infusionD. Reassess in 15 min.-Seizure Precautions -IV Ca (GIVE SLOWLY)Always make sure client is on a ____________-Eat MagnesiumWhat do you do if your client begins to c/o flushing and sweating when you start IV Mg?Not Enough__________.Normal Lab ValuesMg: 1.2-2.1 mEq/LCalcium: 9.0-10.5 mg/dlB. S/S:Muscle ToneCould my client have a seizure? __________Stridor/laryngospasm - airway is a ____________________________+Chvostek's - tap cheek (C is for Cheek)+Trousseau's - pump up BP cuffArrhythmias - heart is a ______________DTR'sMind ChangesSwallowing Probs - esophagus is a _______________________*these signs and symptoms are common in a client with hypomagnesium or hypocalcemia*Aluminum Hydroxide Gel (Amphojel ) is another phosphorusbinding drug that is used however; dont give it to renal clientsbecause they cant get rid of the aluminum and will get TOXIC!Foods high in magnesium: spinach, mustard greens, summer squash, broccoli, halibut, turnip greens, pumpkin seeds,peppermint, cucumber, green beans, celery, kale, sunflower seeds, sesame seeds, and flax seedsFluids and Electrolytes_______________________________Hurst Review Services11V. SODIUMYour Na level in your blood is totally dependent on how much water you have in your body.Hypernatremia=Dehydration Hyponatremia=DilutionToo much Na; not enough water Too much water; not enough NaA. Causes: A. Causes:-hyperventilation -vomiting or sweating thendrinking H2O for fluidreplacement-heat stroke -this only replaces the waterand dilutes the blood-DI-psychogenic polydypsia-loves to drink _________-D5W (sugar & water)-SIADHB. S/S: B. S/S:-Dry mouth -headache-Thirsty - already dehydrated by the time -seizureyou're thirsty-coma-Swollen tongueC. Tx: C. Tx:-Restrict _________________. -Client needs____________-Dilute client with IV fluids -Client doesn't need _________.-Diluting makes serum Na go __________ -If having neuro probs:needs hypertonic saline-Daily weights If you've got a Na problem you've -means "packed withgot a ______________ problem. particles"-I & O-3% NS or 5% NS-Lab workCase in Point: Feeding tube clients - tend to get ___________________Normal Lab ValuesSodium: 135-145 mEq/LNeuro changesBrain doesn't like it when Na's messed up*this sign and symptom is common in a client with hypernatremia or hyponatremia*Fluids and ElectrolytesHurst Review Services12VI. POTASSIUM-Excreted by kidneys-Kidneys not working well, the serum potassium will go ________________Hyperkalemia HypokalemiaA. Causes: A. Causes:-kidney troubles -vomiting-aldactone - makes you retain ________. -NG suction-diuretics-not eatingS /S: B. S /S:-Begins with muscle twitching -Muscle Cramps & weakness-Then proceeds to weakness,-Then flaccid paralysisC . Tx: C . Tx:-Dialysis - Kidneys aren't working -Give K+!-Calcium gluconate -Aldactonedecreases _______________-Eat K+ (See box at bottom of pg)-Glucose and insulin-Insulin carries _____________ & ___________into the cell-Any time you give IV insulin worry about__________________&___________________-Sodium Polystyrene Sulfonate (Kayexalate)-given for hyperkalemia-exchanges Na for K+ in the GI tractWe have lots of K+in our stomachSodium and Potassiumhave an_______________relationshipNormal Lab ValuesPotassium: 3.5-5.0 mEq/LLife- ThreateningArrhythmiasFoods high in potassium: spinach, fennel, kale, mustard greens, Brussel sprouts, broccoli, eggplant, cantaloupe, tomatoes,parsley, cucumber, bell pepper, apricots, ginger root, strawberries, avocado, banana, tuna, halibut, cauliflower, kiwi, oranges,lima beans, potatoes (white or sweet),and cabbage.ECG changes with hyperkalemia: bradycardia, tall and peaked T waves, prolonged PR intervals, flat or absent Pwaves, and widened QRS, conduction blocks, ventricular filbrillation.ECG changes with hypokalemia: U waves, PVCs, and ventricular tachycardiaFluids and ElectrolytesB.Hurst Review Services13D. Miscellaneous Information:-Major problem with PO K+?-Assess UO before/during IV K+.-Always put IV K+ on a _______.-Mix well!-Never give IV K+ _______!-Burns during infusion?-Is it okay to add to a bag that's already up and running?Be sure not to confuse potassium(K+) with Vitamin KFluids and ElectrolytesHurst Review Services14

VII. ACID-BASE BALANCEA. Major chemicals you have to remember:-Bicarb, Hydrogen, CO2-Lung chemicalCO2-Kidney chemicals HCO3 and H+-There's only one way to get rid of CO2. What is it?-These chemicals can either make you sick or compensate. It depends on which imbalanceyou have.B. Compensation:-In respiratory acidosis/alkalosis, which organs are sick?-Who's going to fix everything (compensate)?-What are the chemicals the kidneys use to compensate with?-In metabolic acidosis/alkalosis which organs are sick?-If they are sick, who is going to fix things (compensate)?-What is the only chemical the lungs have to compensate with?-Do the lungs compensate slowly or quickly?-Do the kidneys compensate slowly or quickly?Bicarbonate (HCO3) = BaseHydrogen (H) = AcidCarbon Dioxide (CO2) = AcidAcid-Base BalanceHurst Review Services15Compensation (cont):-The Goal of Compensation:AcidosisAlkalosisC. Respiratory Acidosis:1. Cause:-hypoventilation2. Pathophysiology:-Is this a lung problem or a kidney problem?-What's the problem chemical?-Do we have too much or too little of this chemical in the body?-Who's going to compensate?-How did this happen?-Increased C02Decreased LOC-Increased C02 Decreased 02 early hypoxia late hypoxiaHypoxia may be one of the firstsigns of Respiratory AcidosisNormal Lab ValuespH: 7.35-7.45PaO2: 80-100 mmHgPaCO2: 35-45 mmHgHCO3:Bicarbonate:22-26mEq/LMetabolic AlkalosisLungs compensateRR _____to save C02PCO2____________(*CO2 in arterial blood)Respiratory AlkalosisKidneys compensateExcrete HCO3Retain HHCO3 on ABGsMetabolic AcidosisLungs compensateRR _____to blow off C02PCO2____________(*CO2 in arterial blood)Respiratory AcidosisKidneys compensateRetain HCO3Excrete HHCO3 on ABGs_______________Acid-Base BalanceHurst Review Services163. Tx:-Fix the problem!!!!(It is a breathing problem so we need to ventilate the client)-Be aware of drugs that decrease RR.-Restless client?D. Respiratory Alkalosis:1. Cause:-hyperventilating2. Pathophysiology:-Think about the name.Whos sick? _________________ Whos going to compensate? ______________-Situation: Hysterical client.-Well, are we going to wait until the kidneys kick in?3. Tx:-Breathe into a _________________________________ .-May sedate client-Treat the problemE. Metabolic Acidosis:1. Causes:-DKA-Starvation2. Pathophysiology:-Think about the name.Whos sick? ___________________ Whos going to compensate? _____________-Scenario: DKA, Starvation-When you're starving you break down _______, produce ______, ketones are_________________.3. Tx:-Drug to help acidosis? Sodium Bicarbonate-Treat the problemRestlessness think Hypoxia FIRSTYou need to check the SaO2 leveland administer O2 as needed Acid-Base BalanceHurst Review Services17F. Metabolic Alkalosis:1. Cause:-Vomiting2. Pathophysiology:-Think about the name.Whos sick? __________________ Whos going to compensate? _______________-Scenario: Vomiting3. Tx:-Treat the problem.Acid-Base BalanceHurst Review Services18G. What would these cause?Pneumothorax R. acid R. alk M. acid M. alkAlka Seltzer/Antacids R. acid R. alk M. acid M. alkPanic Attack R. acid R. alk M. acid M. alkNG to suction R. acid R. alk M. acid M. alkContusion to lung parenchyma R. acid R. alk M. acid M. alkClient getting lots of IVP bicarb R. acid R. alk M. acid M. alkDiarrhea R. acid R. alk M. acid M. alk(Hint: Upper GI= acid, Lower GI= base)Renal insufficiency* R. acid R. alk M. acid M. alk(See factoid below)Pneumonia R. acid R. alk M. acid M. alkBroken ribs R. acid R. alk M. acid M. alkAcute Aspirin overdose R. acid R. alk M. acid M. alkHint: Anytime you have poor gasexchange, think RespiratoryAcidosis*Factoid*Metabolic Acidosis= HyperkalemiaIn a state of acidosis, the body will attempt to fix the problem by movinghydrogen into the cell. In exchange for hydrogen moving into the cell, potassiummoves out resulting in a higher amount of potassium in the blood.Metabolic Alkalosis= HypokalemiaIn a state of alkalosis, the body will attempt to fix the problem by pullinghydrogen out of the cell. In exchange for hydrogen moving out of the cell,potassium moves into the cell resulting in a lower amount of potassium in theblood.Acid-Base Balance

VIII. BURNSA. Occurance:-The risk of death increases in the very ____________ and the very __________________.-Where do most burns occur?B. Pathophysiology:-After a burn many different pathophysiological changes occur. WHY?-Why does plasma seep out into the tissue?-Increased ___________________permeability-When does the majority of this occur?-Why does the pulse increase?-Anytime you're in a ______, the pulse will ________________-Why does the cardiac output decrease? Less ___________ to pump out.-Why does the urine output decrease?-Kidneys are either trying to ________ on to fluid or they aren't being __________.-Why is epinephrine secreted?-Makes you ___________________, shunts blood to vital organs-Why are ADH and aldosterone secreted?-Retain __________ & _____________ with aldosterone and-Retain _____________with ADH-Therefore, the blood volume will go_________________.C. Miscellaneous Information:1. Airway Injury:-What is the most common airway injury? ______________________________poisoning-Normally, oxygen binds with__________________. Carbon monoxide can runmuch faster than oxygen . . . . Therefore, it gets to the hemoglobin first andbindsCan oxygen bind now? yes or no-Now the client is ______________.-Tx: ________________________BurnsHurst Review Services20-From this information, do you think it would be important to determine if the burnoccurred in an open or closed space?-When you see a client with burns to the neck/face/chest you had better think what?*What might the physician do prophylactically? __________________________2. Classification of Burn Injury:-A client is burned over 40% of their body. How do you think this is determined?*Estimate of Total Body Surface AreaD. Tx:1. Fluid Replacement:-One of the most important aspects of burn management is ________________________.-Is it important to know that the burn occurred at 11:00 p.m.?-Why? Fluid therapy (for the first 24 hours) is based on the time the injury ________,not when treatment was ______________.LeastInvasiveFIRSTCarbon monoxide poisoning cannot be determined with O2 saturations; the sat monitor picks upanything that is bound to hemoglobin so if carbon monoxide is bound to the hemoglobin then theO2 saturation may appear normal so, the SpO2 may show 100% but the client STILL needsoxygen due to the carbon monoxide poisoning.Carboxyhemoglobin: blood test to determine carbon monoxide poisoningClient will have cherry red skin coloring but they still need oxygen.BurnsHurst Review Services21Common rule: Calculate what is needed for the first ________ hours and give half of the volumecalculated during the first 8 hours. This is the ___________________Formula.-To calculate fluid replacement properly you also need to know the clients_________ (in kilograms) and TBSA affected. * l kg = 2.2 pounds-If the client is restless does it mean fluid replacement is inadequate, pain, orhypoxia?*Nurses Priority: ___________________-Which of the following would you choose to determine if a clients fluid volume isadequate? Their weight or their urine output?2. Emergency Management:-A client was wrapped in a blanket to stop the burning process. Since the flames aregone does that mean the burning process had stopped?-What else could have been done to stop the burning process?-The blanket helped byHolding in the _________________ and kept out__________.-Jewelry?-Airway injury?-Do you think there is more death with upper or lower body burns?-A clients respirations are shallow. You know they are retaining what?_____________-Therefore, which acid-base imbalance will they have?NO matter what formula the doctor usesThe formula will tell the amount of fluid the client will get per hourThis client may be receiving as much as 500 ml/hr or more!Parkland Formula(4ml of LR) X (body weight in kg) X (% of TBSA burned) = total fluid requirements for the first 24 hours after burn1st 8 hours = of total volume2nd 8 hours = of total volume3rd 8 hours = of total volume BurnsHurst Review Services223. Medication Management:a. Albumin:-It is not uncommon for albumin to be given after a major burn, but not in thefirst 24 hours.-You know that albumin holds onto ______________ in the_______________space.-Vascular volume?-Kidney perfusion?-BP?-Cardiac output?-Will this help correct a fluid volume deficit?-When you start giving a client albumin, you know that the vascularvolume will _____________.-Therefore, what will happen to the work load of the heart?-If you stress the heart TOO MUCH the client could be thrown intofluid volume ________.-If this occurs, what will happen to CO?-Lung sounds?-In a client who is receiving fluids rapidly, what you could measure hourly (hint:heart) to ensure youre not overloading the client?b. Pain Management:-A client has an order for morphine that states: Morphine 2mg IVP orMorphine 4mg IVP Q 2 hours prn pain. If the client is complaining of pain(4/10) what dosage would the nurse give to the client?-Why are IV pain meds preferred over IM with burns?BurnsHurst Review Services23c. Immunizations:-Why is the client given a tetanus toxoid plus the immune globulin?1) Tetanus Toxoid: (________ immunity)*takes 2-4 weeks to get the antibodies2) Immune globulin: think ___________protection (________immunity)E. Complications:1. Circulatory System:-A client has a circumferential burn on their arm.-What does this mean? _______________________-What should you be checking? ___________________________-If a clients vascular checks in this arm are bad the doctor may do what procedure torelieve pressure?-escharotomy which will relieve the ______________ and restore the____________, cut through the eschar-fasciotomy- which will relieve the _______________and restore the_________________, but the cut is much deeper into the tissue, cut goes through theeschar and the fascia2. Renal System:-A foley catheter was inserted so you could measure urine output.-How often will this need to be monitored?-Is it possible that when you insert the catheter that no urine will return?Why? Kidneys are either attempting to __________ the fluid or they are notbeing ___________________adequately.-What would you do if the urine was brown or red?-What drugs might be ordered to flush out the kidneys?-If there is no urine output or if it is less than 20ml/hour, you would start worryingabout?-After 48 hours, the client will begin to diurese. Why? Because fluid is going backinto the ___________ space. Now we have to worry about fluid volume _________.-Urine output?If client is immune suppressed in any way (elderly, poor nutrition), if they have leukemia, on chemotherapy drugs,or HIV positive, or on prednisone, the physician may withhold the tetanus shot because they could develop tetanus.If they have an uncertain history of last tetanus shot, the client will also be given immune globulin.BurnsHurst Review Services243. Electrolyte Imbalances:-The clients serum K+ level is 5.8.-K+ likes to live inside OR outside of the cell?-With a burn, what happens to cells?-So, what happens to the number of K+ in the serum (vascular space)?-Electrolyte imbalance? hypokalemia OR hyperkalemia4. GI System:-Why do you think Carbonate/Magnesium Carbonate (Mylanta), Pantoprazole(Protonix), and Famotidine (Pepcid) are ordered?-Why do you think the doctor wants the client to be NPO and have an NG tubehooked to suction?-If a client doesnt have bowel sounds, what will happen to the abdominal girth?-Do you think the client will need more or less calories?-The NG tube will be removed when you hear what?-When you start GI feedings, what could you measure to ensure that the supplementwas moving through the GI tract ok?Antacids: Aluminum Hydroxide Gel (Amphogel), Magnesium Hydroxide (Milk of Magnesia)H2 Antagonist: Ranitidine (Zantac ), Famotidine (Pepcid), Nizatidine (Axid )Proton Pump Inhibitors: Pantoprazole (Protonix ), Esomeprazole (Nexium)BurnsHurst Review Services25-What is some lab work you could check to ensure proper nutrition and a positivenitrogen balance?5. Integumentary System:a. Contractures:-Since the client has partial thickness and full-thickness burns, is it possible thatthey could have problems with contractures?-Since they have burns on their hands, what are some specific measures that maybe taken?-Neck?b. Infections:-With a perineal burn, the #1 complication is___________________-What is eschar?-Does it have to be removed?-If its not removed can new tissue regenerate?-What likes to grow in eschar?Pre-Albumin is a protein with a 2-day half life that reflects your nutritional status.Normal Lab Value: 17-40 mg/dLAlbumin testing is more often used to test for liver or kidney disease or to learn if your body is not absorbing enough aminoacids. Albumin can also be used to monitor nutritional status (the client is not eating enough protein or has a low proteindiet). Albumin has a half life of 21 days.Normal Lab Value: 3.4 to 5.4 g/dLHowever, pre-albumin changes more quickly because of its short half life, therefore; it can be used to detect short-termnutritional status quicker than albumin.Classification of Burns:Superficial thickness: formally called first degree burn; Damage only to epidermisPartial thickness: formally called second degree burn; Damage to entire epidermis andvarying depths of the dermis.Full-thickness: formally called third degree burn; Damage to entire dermis and sometimes fatBurnsHurst Review Services26c. Tx:-What type of isolation will you use with the client?-Sutilanis (Travase) or Collagenase (Santyl ): enzymatic drug eats deadtissue-Dont use on face -Dont use over large nerves-Dont use if pregnant -Dont use if area opened to a body cavity-Hydrotherapy is also used to ____________________.C o m m o n d r u g s u s e d w i t h b u r n s :a. Silver Sulfadiazine (Silvadene)-soothing, apply directly, if rubs off applymore, can lower the WBC, can cause a rashb. Mafenide Acetate (Sulfamylon)-can cause acid base problems, stings, if itrubs off apply morec. Silver nitrate-keep these dressings wet; can cause electrolyte problemsd. Povidone-Iodine (Betadine)-stings, stains, allergies, acid-base problems-Why should these drugs be alternated?-Broad spectrum antibiotics are avoided to prevent _________________________.-Broad spectrum antibiotics will be used until the wound cultures have returned.d. Grafting:-If grafting is done, a pressure dressing will be applied (to the donor site) insurgery.Then when the bleeding has stopped the wound will be left open to air.-If the skin graft should become blue or cool what would this mean?-Sometimes the doctor will order for you to roll sterile Q-tips over the graft withsteady, gentle pressure from the center of the graft out to the edges. Why?When giving-mycin drugswe WORRY when the clients BUN or creatinine increases or if the client complainsof any hearing loss because-mycin drugs can lead to ototoxicity (irreversible hearing loss) and/or nephrotoxcity.BurnsHurst Review Services27e. Chemical and Electrical burns:1) Chemical burn?2) Electrical burn 2 wounds. What are they?-Electrical injury?-What arrhythmia is this client at high risk for?-With electrical burns _______can build up and cause _________ damage.-It is not uncommon for this client to be placed on a spine board with ac- collar. Why? Electrical injuries occur in _____________ places, musclecontractions can cause fractures, and the force of the electricity can actuallythrow the victim forcefully.-Are amputations common? Why?-Other complications of electrical wounds: cataracts, gait problems, and justabout any type of neurological deficit.Burns

IX. ONCOLOGYA. General Information:1. Risk Factors:-Alcohol + tobacco = co-carcinogenic-_____________ is the #1 cause of preventable cancer.-Suspected dietary causes of cancer:-Low fiber diet -Nitrites (processed sandwich meat)-Increased red meat -Alcohol-Increased animal fat -Preservative and additives-Increased incidence of cancer in the _________________________*that is why there is a higher incidence of cancer > age 60-The most important risk factor for cancer = Aging-Cruciferous veggies (broccoli, cauliflower, and cabbage), Vitamin A foods (coloredveggies), and Vitamin C could _________________ risk-African Americans have a _______________ incidence than Caucasians.-Primary Prevention: Ways to prevent actual occurrence (sunscreen and no smoking)-Secondary Prevention: Using _______________ to detect cancer early when there isa greater chance for cure or control-Chronic _________________ brings about uncontrolled growth of abnormal cells.2. Prevention:a. Female:-monthly self- breast exam-_____________clinical breast exam for women >40 years old- Between ages 20-39 needed every 3 years-_____________ pelvic exam-Pap smear: every 3 years if there's been no problem-Mammogram: baseline at age 35-40, yearly after age 40 (2 views of each breast)-Colonoscopy: at age 50 then every 10 years after that time.OncologyHurst Review Services29b. Male:-____________ self-breast exam-Monthly testicular exam - testicular tumors grow __________-Yearly digital rectal exam and yearly PSA (prostate specific antigen) for menover age 50-Colonoscopy at age 50 then every 10 years3. General S/S:-CAUTION: Change in bowel/bladder habitsA sore that does not healUnusual bleeding/dischargeThickening or lump in breast or elsewhere;Indigestion or difficulty swallowingObvious change in wart or mole;Nagging cough or hoarseness-Cancer can invade bone marrow ______________and thrombocytopenia-Cachexia- extreme wasting and malnutrition4. General Tx:a. Radiation therapy:1) Internal Radiation (brachytherapy)-With all brachytherapy, the radioactive source is inside the client; radiation isbeing emitted-Types of Internal Radiationa) Unsealed: client and body fluid emit radiation-isotope is given IV or PO-usually out of system in 48 hoursb) Sealed or solid: client emits radiation; body fluids not radioactive-implanted close or in the tumorOncologyHurst Review Services30-In gen e r a l t e r m s , do radiation implants emit radiation to the generalenvironment?-Nursing assignments should be rotated ___________, so that the nurse is notcontinuously exposed-The nurse should only care for___ client with a radioactive implant in a givenshift-Precautions with Internal Radiation-private room-wear a film badge at all times-restrict visitors-limit each visitor to 30 min per day-no visitors less than 16 years of age-visitors must stay at least 6 feet from source-no pregnant visitors/nurses-mark the room-How can you help prevent dislodgment of the implant?-Keep the client on _____________.-Decrease _______________ in the diet.-Prevent bladder distention.-What do you do if the implant becomes dislodged and you see it?*Dont forget this client is immunosuppressed.2) External Radiation (teletherapy, beam radiation):-Usual side effects of external radiation are usually limited to the exposedtissues:-erythema-shedding of skin-altered taste-fatique-pancytopenia (all blood components are decreased)-Many signs and symptoms are___________and ___________related-Is it okay to wash off the markings? No-Is it okay to use lotion on the markings? No-Protect site from sun for 1 year after completion of therapyOncologyHurst Review Services31b. Chemotherapy-works on the ______________ cycle-usually scheduled every 3-4 weeks-most Chemo drugs are given IV via port-many absorb through the skin and mucous membranes; be careful handling them-usual side effects: alopecia, N/V, mucositis, immunosuppression, anemia,thrombocytopenia-A client's WBC count must be at least 3,000 before they will receive theirtreatment.-A vesicant is a type of chemo drug that if it infiltrates (extravasates) willcause tissue_____________.-What are S/S of extravasation?-The #1 thing to remember with extravasation is prevention!-What do you do if this happens?The physician may aspirate any infiltrated medication from the tissues and inject a neutralizing solution into thearea to reduce tissue damage. The drug that is used to TREAT extravasation depends on the specific chemo drugthat extravasated and can usually be found in the drug insert.For NCLEX, stop the infusion and think vasoconstriction to prevent spreading.OncologyHurst Review Services32B. General Ways to Prevent Infection-Private______________-Wash hands-Have own _______________ in room-Limit people (visitors and nurses) in room-Change dressing and IV tubing daily.-Cough and deep breath-No fresh ____________or potted _________________-Avoid crowds-Do not share toiletries-Bathe warm moist areas __________________________ (groin and under the arms)-wash hands after touching pet-Avoid raw __________and __________-Drink only fresh waterRemember:-Slight increase in temp may mean ______________-Absolute neutrophil count most importantOncologyHurst Review Services33C. Specific Types of Cancer:1. Cervical Cancer:a. Risk Factors:-Sex /pregnancy at young __________-Repeated STDsb. S/S:-Often asymptomatic in pre-invasive cancer-Invasive cancer classic symptom: ________________________________bleeding-Other general S/S: watery, blood-tinged vaginal discharge, leg pain along sciaticnerve, and back/flank pain-100% cure if detected earlyc. Dx:-What is the test that helps diagnose this?-Abnormal ? Repeat testd. Tx:-electrosurgical excision-laser-cryosurgery- _______________and chemo for late stages-conization- remove part of _____________-hysterectomyOncologyHurst Review Services342. Uterine Cancer:a. Risk Factors:-Greater than ______years of age-Positive family history-_________ menopause-No pregnancy (null parity)b. S/S:-Major Symptom: post _____________ bleeding-Other S/S: watery/ bloody vaginal discharge, low back/abd pain, pelvic painc. Dx:-CA-125 (blood test) to R/O ____________ involvement-Test to evaluate for metastasis:-CXR (chest x-ray) -CT-IVP (Intra Venous Pyelogram) -liver and bone scan-BE (Barium Enema)-The most definitive diagnostic test is D&C (dilatation & curettage) and endometrialbiopsyd. Tx:1) Surgery:-Hysterectomya) TAH (total abd hysterectomy) = uterus and cervix only!:-Tubes & ovaries removed?-bilateral oophorectomy (ovaries)-bilateral salpingectomy (tubes)OncologyHurst Review Services35b) Radical Hysterectomy:-may remove all of the pelvic organs-client may have colostomy, ileal conduit-The greatest time for hemorrhage following this surgery isduring the first 24 hours.-Why? Pelvic congestion of _____________________-Major complication with abd hysterectomy? hemorrhage-Major complication with vaginal hysterectomy?___________-Will probably have a foley; if she doesn't you better make sureshe does what in the next 8 hours?-Why is it so important to prevent abdominal distension afterthis surgery?-We do not want tension on the _____________________-Dehiscence and Evisceration-Why do we avoid high-fowler's position in this client?-May have an abdominal and perineal dressing to check.-As this client is at risk for pneumonia, thrombophlebitis, andconstipation what is one thing you can do to prevent thesecomplications?-Avoid sex and driving. -Also avoid girdles and douches.-Any exercise, including lifting heavy objects that will increasespelvic __________ should be avoided.-Is it possible that the client could hemorrhage l0-l4 days afterthis surgery? Yes-Is a whitish vaginal discharge okay?-Showers OR baths? showersOncologyHurst Review Services362) Radiation: intra-cavitary radiation to prevent vaginal recurrence3) Chemotherapy: Doxorubicin (Adriamycin), Cisplatin (Platinol-AQ)4) Estrogen inhibitors: Medroxyprogesterone (Depro-Provera) , Tamoxifen(Nolvadex / Soltamox)3. Breast Cancer:a. Risk Factors:-One has a 3 fold risk increase of developing breast cancer if a ________ degreerelative (Mother, sister, daughter) had pre-menopausal breast cancer-Known risk factors-High dose radiation to thorax prior to age 20-___________ onset prior to age 12-Menopause after age ________-No pregnancy (null parity)-First birth greater than ________ years oldb. S/S:-Change in the appearance of the breast (orange peel appearance, dimpling,retraction, discharge from breast), or lump-Tail of Spence: Located in upper outer quadrantc. Tx:1) Surgery:-Post-op care:-Bleeding check dressings, back (pooling of blood), hemovac,Jackson- Pratt drain-Elevate arm on ______________ side-Associated nursing care: Stay away from arm on affected side for lifetimeof client:-No watch, no constriction, no BP's or injections, wear gloves whengardening, watch small cuts, no nail biting, and no sunburn, no IV-Brush hair, squeeze tennis balls, wall climbing, flex and extend elbow.-Why? Promotes __________circulationOncologyHurst Review Services37-Look at incision-Reach to Recovery (Support Group)-Lymphedema*Two functions of the lymphatic system:-____________ infection and promotes drainage2) Chemotherapy drugs: Paclitaxel (Taxol), Doxorubicin (Adriamycin)3) Estrogen receptor blocking agents: Tamoxifen (Nolvadex / Soltamox)4) Estrogen synthesis inhibitors: Leuprolide (Lupron), Goserelin (Zoladex)5) Radiation:4. Lung Cancer:a. Risk Factors:-Leading cause of cancer death worldwide-Five year survival rate is 14%-Major risk factor : _______________*when you have stopped smoking for 15 years, the incidence of lung cancer isalmost like that of a non-smokerb. S/S:-hemoptysis, dyspnea (may be confused with TB, but TB has night sweats, too),hoarseness, cough, change in endurance, chest pain, pleuritic pain on inspiration,displaced trach-may metastasize to bonec. Dx:1) Bronchoscopy:-NPO pre and NPO until ___________________________ returns-Watch for respiratory depression, hoarseness, dysphagia, SQ emphysema-Is it normal or abnormal to have respiratory depression after a bronchoscopy?OncologyHurst Review Services382) Sputum specimen:-Best time to obtain? In the morning-Is this sterile?-What should the client do first?-Trying to decrease bacterial count in the mouth.3) CT:4) MRI:d. Tx:-Surgery: The main treatment for stage I and II1) Lobectomy:-chest tubes and surgical side up2) Pneumonectomy:-Position on affected side (surgical side down)-No chest tubes. Why?-Avoid severe lateral positioning mediastinal ____________________ OncologyHurst Review Services395. Laryngeal Cancer:a. Risk factors:-______________ (any form of tobacco use), alcohol, voice abuse, chroniclaryngitis, industrial chemicalsb. S/S:-Hoarseness, difficulty swallowing, burning, sore throat, swelling in neck, loss ofspeech, no early signs, mouth sores, lump in neck, color changes in mouth/tongue,dentures do not fit anymore, unilateral ear painc. Dx:-Laryngeal exam, MRId. Tx:1) Surgery:-Total laryngectomy (removal of _________cords, epiglottis, thyroid cartilage)-Since the whole larynx (remember this includes the epiglottis) is removed thisclient will have a permanent ______________________________.-Position post-op?-NG feedings to protect the suture line (peristalsis could disrupt suture line)-Monitor drains-Watch for carotid artery rupture-Rupture of innominate artery-medical emergency-Frequent _____________care-decrease bacterial count in the mouth-NPO clients tend to get pneumonia-Bib (acts like a filter)-Humidified environment*Remember, with a total laryngectomy ALL breathing is done through thestoma.OncologyHurst Review Services402) Radiation:3) Chemotherapy:Obturator: Place obturator (smooth, plastic trach guide) into the outer cannula & insert intostoma to prevent tracheal collapse. Remove obturator at once (client cant breathewell while in place). Reinsert inner cannula & lock in place. Inflate cuff to holdeverything in place.4) Can the client with a total laryngectomy:-Whistle? ______________________-Smoke? _______________________-Use a straw? ___________________-Swim? ________________________5) Suctioning:-Sterile or Non-sterile technique?-Hyperoxygenate when?-When do you stop advancing the catheter? When you meet resistance or yourclient coughs.-Apply suction when?-Intermittent or continuous? *Dont be mean.-Suction no longer then _____________ seconds.-Watch for arrhythmias.-Which nerve can be stimulated? vagus nerve-When _________________ nerve is stimulated, heart rate _________________-Is this client hypoxic?Early signs of hypoxia:Restlessness and tachycardiaLate signs of hypoxia:Cyanosis and bradycardiaOncologyHurst Review Services416. Colorectal Cancer (CRC):a. Risk Factors:-May start as a polyp-2/3 colorectal cancer occurs in the rectosigmoidal region-Most frequent site of metastasis: __________________-take bleeding precautions-Other problems to watch for: Bowel obstruction, perforation, fistula tobladder/vagina-Risk Factors: inflammatory bowel diseases, genetic, chronic constipation (retainingcarcinogens), dietary factors (refined carbs, low fiber, high fat, redmeat, fried and broiled foods), if you have a first degree relative withCRC your risk just increased 3X the norm-95% of those who get CRC are > 50 years oldb. Dx:-Screening:-Fecal occult blood testing should begin at ____________-Flexible sigmoidoscopy every 5 years after age 50 orcolonoscopy every 10 years after age 50-The definitive test for CRC = _____________________c. S/S:-Most common signs are: rectal bleeding, anemia, and changes bowel habits/stool-Other S/S: blood in the stool, vague abdominal pain, fatigue, abd fullness,unexplained weight loss-May become obstructed (visible peristaltic waves with high pitched tinkling bowelsounds)d. Tx:-Surgery, radiation and chemo (DOC= Fluorouracil (5-FU)-May have a colostomy post-op1) colectomy-part of _______________ removed-may not need colostomy2) abdomino-perineal resection-removal of ______________, anus, rectum*Can you take a rectal temp on this client?Dont take rectal temp if thrombocytopenic, abdominal-perineal resection, immunosuppressed.Things that should beavoided for 48 hoursprior to collection ofstool sample: ASA,Vit C, any antiinflammatorydrug,and perioxidasecontaining foods(beets, horseradish)OncologyHurst Review Services427. Bladder Cancer:a. Risk Factors:-Greatest risk factor: _______________b. S/S:-Major Symptom: _________________intermittent gross/microscopic hematuriac. Dx:-Cystoscopyd. Tx:-Surgery (all/part of bladder) Urinary diversion (urostomy)-Ileal conduit (a piece of the ileum is turned into a ________; ureters are placed inone end; the other end is brought to the abd. surface as a stoma)-May be impotent-Hourly _____________________-Increase fluids: (2,000-3,000 ml of fluid per day)-flush out conduit-Mucus normal?-Intestines always make mucus (the bladder is made from a part of intestine)-Change appliance in ________________ (This is when output will be at its lowest).It is OK to place a little piece of 4 X 4 inside stoma during skin care to absorb urine.Just dont forget to remove it OncologyHurst Review Services438. Prostate Cancer:a. S/S:-This client comes to the doctor with S/S of benign prostatic hyperplasia (BPH):hesitancy, frequency, frequent infections (because the bladder is not completelyemptied), nocturia, urgency, dribbling. Many clients are asymptomatic.-Most common sign is painless ________________-Digital rectal exam done and prostate is hard /nodular; this usually means prostatecancer.b. Dx:1) Lab work:-PSA will be increased-Prostatic Specific Antigen (PSA)-This is a protein that is only produced by the prostate-Normal= l00 Apresoline (Hydralazine)-Only cure?-After delivery, how long is the client at risk for seizures?-Single room-Very quiet environment-Dim the lightsMaternity NursingHurst Review Services164I. Eclampsia:1. Definition:-What is the turning point from preeclampsia to eclampsia?2. Tx:-Monitor the FHT's-Watch _______________-Watch for ________________ failureJ. Premature Labor:1. Definition:-Labor that occurs between 20-37 weeks2. Tx:a. Stop the labor:-Tocolytics:-Mg Sulfate-Terbutaline (Brethine)-Betamethasone (Celestone), a corticosteroid, is given to Mom IM inorder to get it to baby.-The purpose is to stimulate maturation of the babys lungs incase preterm birth occurs.b. Preterm labor can sometimes be stopped by hydrating Mom and bytreating vaginal and urinary tract infections.Maternity NursingHurst Review Services165K. Prolapsed Cord:1. Definition:-When the umbilical cord falls down thru __________________-Most likely to happen when presenting part is not engaged andmembranes ____________________-So always, always, always check FHTs when membranes ruptureeither spontaneously or artificially.-If this occurs before complete dilation immediate _______________-If cord is being compressed you would see variable decelerations in FHT.-If cord ceases to pulsate fetal ____________; we want the cord to pulsatebecause this tells us baby is getting some oxygen-Fetal bradycardia is an indicator of _____________2. Tx:-Lift head off cord until physician arrives if possible-Keep manually pushing the head up to relieve pressure on the cord.-Let someone else do all the preparations for an emergency C-Section-Trendelenburg or ______________ chest position-Oxygen-Want to make sure what little blood is getting to baby ishyperoxygenated-Monitor ____________________________________________________-Saline dressings around cord if protruding from _____________-Push it back in? ________________Maternity NursingHurst Review Services166Group B Streptococcus(GBS)Leading cause of neonatal morbidityRoutinely assess for GBS risk factors during pregnancy and on admission to L&DTransmitted to infant from birth canal of the infected mother during deliveryAll pregnant women should be cultured between 35-37 weeks of gestationRisk factors for neonatal GBS:preterm birth less than 37 weeks, + prenatal cultures in current pregnancy, prematurerupture of membranes (longer than 18hr), positive history for early- onset neonatalGBS, intrapartum maternal fever higher than 100.4 F, previous infant with GBSTest or culture Positive?Antibiotic prophylaxis offered (IV)If they do not have a culture when the mother goes into labor or if the mother has arisk factor then an antibiotic prophylaxis is offered (IV)Treatment:Medication of Choice? PCNMaternity NursingHurst Review Services167XVI. RESPIRATORYA. Thoracic (Chest) Procedures:1. Thoracentesis:a. Pre-procedure:-_____________and _______________-Positioning: Sitting up over the bedside table-Cant sit up? Lie on _______________side with HOB at 45 b. Procedure:-Client must be very still, no coughing or deep breaths-The fluid is being removed from the ____________________________.-As the fluid is removed the lung should ________________.-Since you are removing fluid, the client could go into a fluidvolume______________.-Therefore, you should be checking the _____________________________.c. Post-procedure:-another _________________Conditions that might cause apleural effusion and mightrequire a thoracentesis:CHF, lung malignancies, orpneumonia.Other reasons a thoracentesismay be performed:Instill medication in thepleural space; remove fluidfor symptomatic relief or forbiopsy.In addition to monitoring vital signs post fluid replacement, be sure to auscultate lungs, observe chestwall symmetry, document pain level, check for pneumothorax and assess pulse.RespiratoryHurst Review Services1682. Chest Tubes:a. Chest tube Insertion:-What are the indications of a chest tube?-Client will have an occlusive sterile dressing at insertion site (around tube)-What is the purpose of the water-seal?-To promote ____________________flow out of pleural spaceb. Nursing Considerations:-Do you want to see fluctuation in the water seal chamber?-Want to see fluctuation with respiration-What are we watching the daily CXR's for?-Fluctuation will ____________when the lung has re-expanded, kink/clot intubing, or if suction is not working properly.-Why is it important to keep the bottles/chest drainage unit (CDU) below thechest?-What do you do if the tubing becomes disconnected?-What do you do if the bottles break/CDU cracks and the water seal is lost?-You do whatever you have to do to re-establish the water seal.-If the chest tube is connected to suction, gentle continuous ___________isexpected in the suction control chamber-Continuous, Vigorous/ __________ bubbling in the water seal chamber =__________________ in the system-Call MD if the drainage is >__________ml/hr or if drainage becomesBRIGHT red-Do not milk or strip a chest tube without an order-NEVER clamp a chest tube without an order-this could promote a ____________________pneumothoraxRespiratoryHurst Review Services169c. Chest Tube Removal:-When the doctor removes the chest tube the client will need to take a deepbreath and hold or valsalva and a petroleum dressing with 4X4 will beplaced over the site.d. Types of Chest Drainage Systems:Three Bottle SystemSuction control 2cm fluid water seal Collection bottleTube from patientFluiddrainageTube open toatmospherevents airStraw under20 cmH2OTube tovacuumsourceFrom box to bedsideFrom bottles to a boxCollectionchamberWater sealchamberSuctioncontrolchamberfrompatientSuctioncontrolbottleWater sealbottleCollectionbottleTo suction From patientAll pictures shown on this page have been provided with permission from Atrium Medical Corporation.RespiratoryHurst Review Services170B. Pulmonary Embolism:1. Cause:-This can occur if a client becomes dehydrated, has venous stasis, or has beentaking birth control pills. A thrombus forms, dislodges (embolus), and goes to thelungs.2. S/S:-Hypoxemia #l-Short of breath, cough, RR-Increased D Dimer + (increased with pulmonary embolus; blood test)-will tell if a clot is located anywhere in the body (not just the in the lungs)-will be increased with any clot in the body-Positive VQ scan (a ventilation/perfusion scan that can detect an embolus; done inradiology)-looks at blood flow to the lungs, dye is used, remove jewelry from chest areaso that it will not give false results-hemoptysis-Pulse?-Chest pain (Sharp, stabbing)-CXR-BP in lungs?-_____________________Hypertension-P023. Tx:-Prevent!-Oxygen-Ventilator -ABG's-Watch ______________________________ (RV) for failure-Heparin sodium, Warfarin (Coumadin), Enoxaparin (Lovenox)-Decrease painHypoxia lung BP workload on right side of heart**Hypoxia is the number one cause ofpulmonary hypertension**Little- AsymptomaticMedium-SymptomaticLarge- DeathMonitor the rightatrial pressures toassess for rightventricular heartfailure.RespiratoryHurst Review Services171C. Chest Trauma:-General treatment= _____________________, O2, CXR, ventilation and elevate_________________________________________1. Hemothorax/Pneumothorax:a. Pathophysiology:-Blood or air has accumulated in the _________________________________.-What has happened to the lung?-Hemothorax- S/S depend on size, breath sounds on affected side,respiratory distress-Pneumothorax- Subcutaneous emphysema, pleuritic pain, RRb. Tx:-Never pull out a penetrating object-Thoracentesis, chest tubes, daily CXR-If a pneumothorax is present and the client has a chest tube with no suction,what type of bubbling would be expected to see in the water seal chamber?2. Tension Pneumothorax (Trauma, PEEP):a. Pathophysiology:-___________ has built up in the chest/pleural space and has__________ thelung_____________pushes everything to the opposite side (mediastinal shift)Subcutaneous emphysema or Sub Q air or subcutaneous crepitations or crepitus all mean the samethingIt is air that is trapped under the skin (due to trauma, pnumothorax, infection) Your instructor said it feels like Rice Krispies sound!Tension Pneumothorax is associated with: Trauma, mechanical ventilation, resuscitation,obstructed/clamped chest tubeRespiratoryHurst Review Services172b. S/S:-Subcutaneous emphysema, absence of breath sounds on one side, asymmetry ofthorax, respiratory distress-Can be fatal as accumulating pressure compresses vessels decreases venousreturn, decreases __________________________________________c. Tx:-Large bore needle is placed into the 2nd ICS (by the doctor) to allow excess airto escape, find the cause, chest tubes3. Open pneumothorax (sucking wound):a. Pathophysiology:-Opening through chest allows air into the __________________________b. Tx:-Have the client inhale and hold or valsalva (take a deep breath and hold orhummmmm)-Both of these will increase the intra-thoracic pressure so no more outside air canget into the body-Then place a piece of petroleum gauze over the area Tape down how manysides?-Have client sit up if possible to expand lungs. Trauma clients stay flat.RespiratoryHurst Review Services1734. Fracture of ribs (most common) and sternum:a. S/S:-Pain & tenderness-crepitus (bones grating together)-shallow________b. Tx:1) Non-narcotic analgesic2) Support injured area with hands; turn on side (trying to limit movement)3) Respiratory Therapies/Mechanical Ventilation-These clients will usually be put on the ventilator with:a) PEEP: Positive End Expiratory Pressure-On ventilator-On rate-On end expiration the vent exerts a pressure down into the lungs tokeep alveoli open-improves gas ___________, decreases work of ___________-In this client PEEP expands the thorax, realigns ribsb) BiPAP: Bi-level Positive Airway Pressure- u sed a lot with pulmonary edema and sleep apnea; may do prior tointubation (BiPAP can be used with/without intubation)c) CPAP: Continuous Positive Airway Pressure-breathing on their own-may/may not be intubated-Anytime you see PEEP, CPAP, or pressure support on a ventilator yourpriority nursing assessment is to check bilateral ___________________.RespiratoryHurst Review Services1745. Flail Chest (multiple rib fractures):a. S/S:-Pain-Paradoxical chest wall movement (seesaw chest); chest sucks inwardly oninspiration and puffs out on expiration-To assess chest symmetry always stand at foot of bed to observe how thechest is rising and falling-Dyspnea, cyanosis-Increased pulseb. Tx:-Stabilize the area, intubate, ventilate-Positive pressure ventilation stabilizes the areaRespiratoryHurst Review Services175XVII. ORTHOPEDICSA. Fractures:1. S/S:-Continuous ________________-Unnatural _________________-Deformity (possible)-Shortening of _________________-____________________________________ (shortening of extremity)-Crepitus (bones grating together)-Swelling-Discoloration2. Tx:-Immobilize the bone ends plus the adjacent joints-Support fracture above and below site-Move extremity as little as possible-Splints help prevent _____ emboli and ________ spasm.-What do you do with open fractures?-Neurovascular checks: pulses, color, movement, sensation, capillary refill, tempWorry aboutcompartmentsyndrome!OrthopedicsHurst Review Services1763. Complications:a. Shock:b. Fat embolism:-With what type of fractures do you see this?-Symptoms depend on what?-Petechiae or rash over chest -conjunctival hemorrhages-snow storm on CXR -young males-first 36 hoursc. Compartment syndrome:1) Pathophysiology:-This is when a fracture has not been elevated and has not had ice packs._________ accumulates in the tissue and impairs tissue perfusion.The muscle becomes swollen and hard and the client complains ofsevere pain that is not relieved with pain meds.-Unpredictable-___________is disproportionate to the injury-If undetected may result in_____________ damage and possibleamputation.-Common areas?2) Tx:-loosen the cast; bi-valve the cast-fasciotomy-be careful of the answer Remove cast.-orthopedic nurses have cast cutters readily available-instruct the client the cast saw does not touch the skin, but it does vibrated. Healing Concerns:1) Delayed union:-healing doesn't occur at a normal rate2) Non-union:-failure of bone ends to unite; may require bone grafting-S/S (both): persistent discomfort and _______________OrthopedicsHurst Review Services1774. Cast Care:-Ice packs on sides-No indentations-Use_____________ for 1st 24 hours - casting material is wet-Keep uncovered and ______________-Do not rest cast on hard surface or sharp edge-Cover cast close to ________________with plastic-Elevate-Neurovascular ______________What do you do if your client complains of pain?5. Traction:a. Miscellaneous Information:-Decreases ____________________________, reduces, immobilizes-Should it be intermittent or continuous?-Weights should hang _______.-Keep client pulled up in bed and centered with good alignment.-Exercise non-immobilized______________-Ropes should move _____________and knots should be ___________-Egg crate-Foot _______________OrthopedicsHurst Review Services178b. Types of Traction:1) Skin traction:-This is when tape or some type of material is stuck to the skin and theweights pull against it.-Is the skin penetrated?-Types: Buck's (used most often with hip fractures) & Russell's (used mostoften with femoral fractures)-Must do good skin assessmentsOrthopedicsHurst Review Services1792) Skeletal traction:-This traction is applied directly to the bone with ________ and___________.-Used when prolonged ____________ is needed.-Types: Steinman pins, Crutchfield, Gardner-Wells tongs, Halo vest-Must monitor the pin sites and do pin care.-Sterile tech?-Remove crusts?-Is serous drainage okay?OrthopedicsHurst Review Services180B. Total Hip Replacement:1. Pre-Op Care:-Buck's traction is used frequently pre-op2. Post-Op Care:a. Nursing Considerations:-Neurovascular checks-Monitor drains (Don't want fluid to accumulate in tissue)-Firm mattress (joints need support)-Over-bed trapeze-Positioning:-neutral rotation - toes to the ceiling-limit flexion; want extension of hip-abduction or adduction?-What exercise can the client do while still confined to bed?-What is the purpose of the trochanter roll?-No weight-bearing until ordered by physician-Avoid crossing legs, bending over-Is it okay to sleep on operated side?-Is hydration important with this client?-Stresses to new hip joint should be minimal in the first 3-6 months.-Is it okay to give pain meds in the operative hip?b. Complications:1) Dislocation circulatory/nerve damageS/S: -shortening of leg, abnormal rotation, cant move extremity - pain2) Infection:-prophylactic antibiotics (just like with heart valve replacement)-remove foley and suction ASAP if not needed-these will serve as a portal for infectionOrthopedicsHurst Review Services1813) Avascular Necrosis: (death of tissue due to poor circulation)4) Immobility problemsc. Client Education/Rehabilitation:-Best exercise?-Avoid flexion low chairs, traveling long distances, sitting more than 30minutes, lifting heavy objects, excessive bending or twisting, stair climbing-CPM: (Continuous Passive Motion) used mainly for knee replacements-very important to check the angle of flexion.could ruin the surgery iftoo much flexion occursC. Amputations:1. Miscellaneous Information:-Performed at the most distal point that will heal. The doctor tries to preserve theknee and elbow.2. Immediate Post-Op Care:-Keep what at the bedside?-Elevate on pillow for first 24 hours. Then how do you elevate?-Prevent hip/knee contractures. How?-Phantom pain-What is the first intervention to decrease phantom pain?diversional ___________-Seen more with AKA's-Usually subsides in 3 months.NCLEX Tip:Pain: use other things first prior to pill; the definition of pain is what the client says itis; Always assess the clients pain by having them rate their pain on a pain scale (i.e.0-10).OrthopedicsHurst Review Services1823. Rehabilitation:-Why is limb shaping important?-What is worn under the prosthesis?-Why is it important to strengthen the upper body?-Is it okay to bear weight on a new stump/prosthesis?-Is it okay to massage the stump? Promotes ________________________and decreases _____________________________-How do you teach a client to toughen the stump?-Press into a ________ pillow-Then a ________ pillow-Then the _________-Then a _________OrthopedicsHurst Review Services183XVIII. RENALA. Glomerulonephritis:1. Pathophysiology:-Acute can lead to chronic-Inflammatory reaction in the _________-Antibodies lodge in the glomerulus; get scarring & decreased filtering-Main cause: Streph2. S/S:-sore throat -flank pain CVA (costovertebral angle) tenderness-malaise -BP-headache -facial edema-BUN & Creatinine -UO-sediment/protein in urine -urine specific gravity-fluid volume _________ -anemia erythropoetin3. Tx:-Get rid of the strep-Dialysis-If the BUN is increased what should be done with the protein in the diet?-Na?-Carbohydrates? -Keeps us from breaking down protein for energy.-Bed rest-I & O and daily weights-How is fluid replacement determined?-to account for insensible fluid loss-Diuresis begins in l-2 weeks after onset.-Blood and protein may stay in the urine for months.-Teach S/S of renal failure:-Malaise, headache, anorexia, nausea, vomiting, decreased output, weightgainNormal Lab ValuesBUN= 6-20 mg/dLCreatinineMale: 0.6-1.3 mg/dLFemale: 0.5-1.0 mg/dLSpecific Gravity (urine)1.010-1.025RenalHurst Review Services184B. Nephrotic Syndrome:1. Pathophysiology:2. Tx:-Bed rest-Diuretics-Prednisone-shrink holes so protein cant get out-immunosuppressed-Na?-Protein?-DialysisCommon Rule:Limit protein with kidney problems except with Nephrotic Syndrome.Causes of Nephrotic Syndrome(think inflammation):Many causes are idiopathic, butmany clients that developnephrotic syndrome will also havesome systemic disease.Causes: NSAIDS, heroin,Hodgkins disease, bacterial (strepor syphilis) or viral infections,(hepatitis or HIV), allergicreactions, diabetes and systemiclupus erythematosusRenalInflammatory response in the glomerulus big holes form so protein starts leaking out in theurine now the pt is hypoalbuminemic (no albumin in the blood) without albumin you can'thold on to fluid in the vascular space so where does all the fluid in the vascular spacego?_______________ now the patient is edematous since all the fluid is going out intothe tissue what has happened to the circulating blood volume?_________ the kidneys sensethis decreased volume and they want to help replace it renin-angiotensin system kicksin aldosterone produced retention of____________and ______________ but is thereany protein (albumin) in the vascular space to hold it? so where does this fluid go? _______Total Body Edema = ___________________________Hurst Review Services185C. Renal Failure:-Requires bilateral failure1. Causes:a. Pre (blood can't get to the kidney)-Decreased cardiac output caused by arrhythmias, hypotension, decreasedheart rate, FVD, any form of shock, sepsis, hemorrhageb. Intra (damage has occurred inside the kidney)-glomerulonephritis, nephrotic syndrome, dyes (X-ray), drugs (see box below),malignant hypertension (such as with PIH), Diabetes Mellitus-malignant hypertension (uncontrolled HTN) and DM cause severevascular damagec. Post (urine can't get out of the kidney)-enlarged prostate, kidney stone, tumors, ureter obstruction, edematousstomaNCLEX Sample Question Answers:a. Call MDb. Turn from side to sidec. Irrigated. Reassess in 15 minMedications that could cause Intrarenal damage or should be used withcaution in clients with renal damage:Streptomycin sulfate(Streptomycin),Amikacin sulfate (Amikin),Gentamicin sulfate (Garamycin),Netilmicin sulfate (Netromycin)Amphotericin B,Vancomycin,Loop Diuretics,Ciprofloxacin (Cipro),Levofloxacin (Levaquin),Ofloxacin (Floxin),Azithromycin (Zithromax),Clarithromycin (Biaxin)Erythromycin ( Erythrocin)Clindamycin (Cleocin)THINK MYCINSRenalHurst Review Services1862. S/S:-Creatinine and BUN-Specific gravity-Fixed specific gravity-May lose ability to concentrate and dilute urine.-Fluid challenge, 250ml bolus (done in acute renal failure, not in chronic)-Anemia-not enough erythropoietin-HTNRetaining volume-CHF-Anorexia, nausea, vomiting-Itching frost-uremic frost-good skin care-Acid-base/fluid and electrolyte imbalances-retain phosphorous serum calcium ______ calcium pulled from _______3. Two phases of Acute Renal Failure:a. Oliguric phase:-What has happened to UO?-This client is in a fluid volume ___________?-What do you think will happen to the K+?b. Diuretic phase:-What is happening to the UO?-This client is in a fluid volume _____________. (Shock)-What do you think will happen to the K+?In the early stage of renal failure, blood pH changes little because the remaining healthy nephrons cancompensate by increasing their rate of acid excretion. In later stages of renal failure many nephronsare lost, acid excretion (hydrogen ions) is reduced and metabolic acidosis results.RenalHurst Review Services187D. Dialysis:1. Hemodialysis:a. Miscellaneous Information:-The machine is the glomerulus-If the client is allergic to _______________ they can't be hemodialyzed-This is a generally accepted standard in many areas (a good way to thinkfor NCLEX); however, if the client is allergic to heparin, hemodialysiscan be used if another solution with an anti-clot property (ex. sodiumcitrate) is used.-In regard to the site used for hemodialysis (the access area/port): If thisclient is allergic to heparin, then we must use another solution to prevent aclot from forming at the end of our access port (vascular access catheter);usually a product called Alteplase (Cathflo) is used instead of heparin inthis situation.-Is done 3-4 times per week; so the client has to watch what in betweentreatments?-depression-suicide-Electrolytes and BP are watched constantly.-Can all clients tolerate hemodialysis?-unstable cardiovascular system cant tolerate hemodialysis2. Circulatory Access:-Must have a circulatory access:1) Types of Access:-A-V shunt-Fistula-Graft-Temporary catheters (Asch catheter)-utilized for short term access while the permanent access matures-Typically used for 90 days or less due to the increase risk ofinfection.RenalHurst Review Services1882) Care of Access:-Do not use any of the above for IV access (drawing blood,administering meds. etc.)-When a client has an alternate circulatory access what is the associatednursing care?3) Assessment of Access:-Thrillcat purring sensation-Bruit-Feel a thrillHear the bruit!-If you do not feel the thrill or hear the bruitthe physician should benotified2. Peritoneal Dialysis:a. Miscellaneous Information:-This is when dialysate is warmed and infused into the peritoneal cavity bygravity through a catheter.-The fluid (2000-2500 ml) stays in for an ordered amount of time (dwell time).-Then the bag is lowered and the fluid along with the toxins, etc., are drainedb. Nursing Considerations:-Why do we warm the fluid?-Cold promotes vasoconstriction limits blood flow-Want vasodilatation-What should the effluent/drainage/fluid look like?-____________, straw-colored cloudy = _______________-should be able to read a newspaper through the drainage/effluent-What type of client gets peritoneal dialysis?-What if all the fluid doesnt come out?RenalHurst Review Services189c. Two Types of Peritoneal Dialysis:1) CAPD (Continuous Ambulatory Peritoneal Dialysis):2) CCPD (Continuous Cycle Peritoneal Dialysis):-connects their peritoneal dialysis catheter to a cycler at night andperforms the exchange while sleeping; Disconnects in the AM; has morefreedomCAPD (cont):-A type of peritoneal dialysis-Must have a semi-strong client that has the energy and the desire to beactive in their treatment and that also has the ability to learn and followinstructions.-Done 4 times per day; 7 days a week-Is an exchange done at night?-Could a client with disc disease or arthritis do this?-Fluid causes pressure on back-Could a client with a colostomy do this?-high risk for __________________________d. Complications of Peritoneal Dialysis:-peritonitis #1 (abd pain, peritonitis, cloudy effluent lst sign)-constant sweet taste -anorexia-hernia -low back pain-altered body image/sexualityRenalHurst Review Services190e. Dietary Needs of the Peritoneal Client:-Increase what in the diet?-Fiber have decreased peristalsis due to abdominal fluid-Protein Big holes in peritoneum and lose protein with each exchange3. Continuous Renal Replacement Therapy (CRRT):4. Ultrafiltration:-Only pulling off water-May be utilized with peritoneal dialysis or hemodialysis-Same principles applied as with hemodialysis-Prisma is the name brand of the kidney (filter) utilized in manyfacilities.-Typically done in an ICU setting on clients whose cardiovascularstatus would have difficulty with hemodialysis due to the drastic fluidshifts.-Hemodialysis is more aggressive; at any given time duringhemodialysis there is approximately 300 ml of blood in the machine(kidney); however, with CRRT there is only approximately 80 ml ofblood in the machine.RenalHurst Review Services191E. Kidney Stones (urolithiasis, renal calculi):1. S/S:-Pain (nausea/vomiting/vasovagal response)-WBCs in urine-Hematuria-Anytime you suspect a kidney stone get a urine specimen ASAP and have itchecked for RBCs.-If RBCs are present, then its probably a kidney stone and the client will get painmedicine immediately.2. Tx:- Ketorolac (Toradol), anti-emetics Promrthazine (Phenergan), Ondansetron,(Zofran), Hydromorphone (Dilaudid)-Increase fluids-Maybe surgery-Strain urine-Extracorporeal shock wave lithotripsy (ESWL)-worry about arrhythmias-client will also have blood in urine and possible bruising on back area dueto the shock waves post procedure.Ketorolac (Toradol)may not be given as itmay lead to renaldamage.Ketorolac (Toradol) is a NSAID so it wouldbe sure to take good bleeding history!RenalHurst Review Services192Fluid & Electrolyte and Acid- Base1. Evaluation of successful resolution of a fluid volume deficit may be demonstrated by whichof the following?1. The client demonstrates an absence of postural hypotension and tachycardia2. The client adheres to prescribed dietary sodium restrictions3. The client maintains weight loss4. The client maintains a serum Na above 145 mEq2. Ms. Stone is admitted with a serum magnesium deficit. Assessment reveals a positiveTrousseaus and Chvosteks signs. Which of the following nursing diagnosis would be mostappropriate?1. High risk for injury R/T increased neuromuscular irritability2. High risk for injury R/T fractures secondary to loss of calcium3. Fluid volume deficit R/T dehydration4. Activity intolerance R/T skeletal muscle weakness3. Ms. Fair is a 77-year-old female. Her husband reports that she has had a poor appetite overthe past two weeks, with occasional nausea and vomiting. When placed on a cardiac monitorvarious abnormal heart beats are noted. Based on this data, the nurse would suspect that Ms.Fair is experiencing.1. Hyponatremia2. Hypermagnesemia3. Hypercalcemia4. Hypokalemia4. The nurse is caring for a thoracotomy client, one day post operative on 40% humidifiedoxygen. ABG results are: PO2=90, PCO2=49, pH=7.30, HCO3=26. Based on thisinformation, which of the following nursing actions would be best?1. Position in high fowlers and encourage coughing, deep breathing, evaluate airwaypatency2. Place in prone position and request respiratory therapy to perform postural drainage andpercussion therapy3. Call the doctor and advise him of the ABGs; anticipate increase in oxygen percentage4. Administer anti-anxiety agent and assist the client with a rebreathing device to increaseoxygen levelsQuestionsHurst Review Services1935. It is 0600 and a client is scheduled for a cardiac catheterization at 0800. Laboratory workcompleted five days ago showed: K 3.0 mEq/L, Na 148 mEq/L, glucose 178 mg/dL. Hecomplains of muscle weakness and cramps. Which nursing action should be implemented atthis time?1. Hold 0700 dose of spironolactone (Aldactone)2. Encourage eating bananas for breakfast3. Call the physician to suggest a stat K level4. Call for a twelve lead ECGBurns6. A client is admitted to the ER with second and third degree burns to her anterior chest, botharms, and right leg. Priority information to determine at the time of admission would includewhich of the following?1. Percentage of burned surface area2. Amount of IV fluid necessary for fluid resuscitation3. Any evidence of heat inhalation or airway problems4. Circumstances surrounding the burn and contamination of the area7. A family member of a client who has sustained an electrical burn states, I dont understandwhy he has been here a week, the burn doesnt look that bad. The nurses response would bebased on which of the following?1. Electrical burns are more prone to infections2. Electrical burns are always much worse than they look on the outside3. Cardiac monitoring is important since burns always affect cardiac function4. Electrical burns can be deceptive as underlying tissue is damaged8. A client has severe second and third degree burns over 75 percent of his body. Whichassessment finding indicates an early problem with shock?1. Epigastric pain and seizures2. Widening pulse pressure and bradycardia3. Cool and clammy skin and tachypnea4. Kussmaul respirations and lethargy9. During a first aid class, the nurse is instructing clients on the emergency care of seconddegree burns. Which of the following interventions for second degree burns of the chest andarms will best prevent infection?1. Wash the burn with an antiseptic soap and water2. Remove soiled clothing and wrap victim in a clean sheet3. Leave blisters intact and apply an ointment4. Do nothing until the victim arrives in a burn unit.QuestionsHurst Review Services194Oncology10. To promote safety in the care of a client receiving internal radiation therapy the nursewould:1. Restrict visitors who may have an upper respiratory infection2. Assign only male care givers to the client3. Plan nursing activities to decrease nurse exposure4. Wear a lead lined apron whenever delivering client care11. Which of the following measures should the nurse take while a client has a radium implantfor the treatment of uterine cancer?1. Evaluate the position of the applicator every two hours2. Place on a low residue diet to decrease bowel movements3. Encourage the use of the bedside commode every 1-2 hours4. Decrease fluid intake to decrease radiation in bladder12. A client with lung cancer and bone metastasis is grimacing and states, I am a littleuncomfortable, may I have something for pain? Which of the following should the nurse dofirst before administering pain medication?1. Check the chart to determine last medication2. Encourage client to refocus on something pleasant3. Notify doctor that medication is not working4. Assess the severity and location of pain13. A client on chemotherapy has a WBC count of 1200 mm. Based on this data, which of thefollowing nursing actions should the nurse take first?1. Check temperature q4h2. Monitor urine output3. Assess for bleeding gums4. Obtain an order for blood cultures14. A client is admitted to the outpatient unit in the Cancer Center for his chemotherapy. He islethargic, weak, and pale. His WBC count is 3000. Which of the following nursinginterventions would be most important for the nurse to implement?1. Establish emotional support2. Position for physical comfort3. Maintain respiratory isolation4. Hand washing prior to careQuestionsHurst Review Services19515. Which of the following properly stated nursing diagnoses would be a priority for a 65-yearoldclient immediately after her modified radical mastectomy and axillary dissection?1. Anxiety related to the mastectomy2. Skin integrity, impairment of, related to mastectomy3. Alteration in comfort related to incisional pain4. Self-care deficit related to dressing changes16. A client had a radical mastectomy for cancer in her right breast. After she returns to yourunit, which of the following would be the most appropriate for her?1. Left side with right arm protected in a sling2. Right side with right arm elevated3. Semi-fowlers position with right arm elevated4. Prone position with right arm elevated17. A client with prostatic cancer is admitted to the hospital with neutropenia. Which signs andsymptoms are most important for the nurse to report to the next shift?1. Arthralgia and stiffness2. Vertigo and headache3. General malaise and anxiety4. Temperature elevation and lethargy18. A 32-year-old male with acute lymphocytic leukemia (ALL) is admitted with shortness ofbreath, anemia, and tachycardia. Based on this nursing assessment, the most appropriatelystated nursing diagnosis would be:1. Altered protection, immunosuppression: Leukemia2. Impaired gas exchange related to decreased RBCs3. Potential for infection related to altered immune system4. Potential injury to decreased plateletsQuestionsHurst Review Services196Endocrine19. A client is admitted with diabetic ketoacidosis. You note his respiratory rate to be 38.Considering his condition you are aware that this increased rate is a result of:1. An effort by the body to compensate for respiratory acidosis2. An effort by the body to remove excess acid from the body3. An effort by the body to supply more oxygen to the depleted tissues4. An effort by the body to conserve CO220. The client is admitted with acute hypoparathyroidism. To maintain client safety, which itemis most important to have available?1. Tracheostomy set2. Cardiac monitor3. IV monitor4. Heating pad21. To evaluate for the desired response of calcium gluconate in treating acutehypoparathyroidism the nurse would monitor the client most closely for:1. Intake and output2. Confusion3. Tetany4. Bone deformities22. Which symptom is most important for the nurse to report to the next shift about theclient with hyperparathyroidism?1. Abdominal discomfort2. Hematuria3. Muscle weakness4. Diaphoresis23. The nurse would caution the client with hypothyroidism about avoiding:1. Warm environmental temperatures2. Narcotic sedatives3. Increased physical exercise4. Numbness and tingling of fingers24. In planning care for the client with hyperthyroidism, the nurse would anticipate the client torequire:1. Extra blankets for warmth2. Ophthalmic drops on a regular basis3. Increased sensory stimulation4. Frequent low calorie snacksQuestionsHurst Review Services19725. The elderly client with hyperparathyroidism should be cautioned about:1. Pathological fractures2. Decreasing fluid intake3. Tetany and tingling of fingers4. Increasing physical activity26. The nurse is aware that which of the following statements made by the client indicates acorrect understanding of steroid therapy for Addisons Disease?1. Ill take the medicine in the morning because if I take it at night it might keep meawake.2. Ill take the same amount from now on.3. Ill increase my potassium by eating more bananas.4. Ill be eating foods low in carbohydrates and salt.27. Which nursing action has the highest priority in caring for the client withhypoparathyroidism?1. Develop a teaching plan2. Plan measures to deal with cardiac arrhythmias3. Take measures to prevent a respiratory infection4. Assess laboratory results28. A client is going to have a parathyroidectomy. Which of the following foods would thenurse discourage the client from eating?1. Milk products2. Green vegetables3. Seafood4. Poultry products29. Which of the following types of foods would the nurse encourage the client withhypoparathyroidism to eat?1. High phosphorus2. High calcium3. Low sodium4. Low potassium30. A client is admitted for a series of tests to verify the diagnosis of Cushings syndrome.Which of the following assessment findings would support this diagnosis?1. Buffalo hump, hyperglycemia, and hypernatremia2. Nervousness, tachycardia, and intolerance to heat3. Lethargy, weight gain, and intolerance to cold4. Irritability, moon face, and dry skinQuestionsHurst Review Services19831. One hour after receiving 7 units of regular insulin, the client presents with diaphoresis,pallor, and tachycardia. The priority nursing action would be:1. Notify the doctor2. Call the lab for a blood glucose level3. Offer the client milk and crackers4. Administer Glucagon32. A client was admitted for regulation of her insulin. She takes 15 units of Humulin insulinat 8:00 a.m. every day. At 4:00 p.m., which of the following nursing observations wouldindicate a complication from the insulin?1. Acetone odor to the breath, polyuria, and flushed skin2. Irritable, tachycardia, and diaphoresis3. Headache, nervousness, and polydipsia4. Tenseness, tachycardia, and anorexia33. A client received regular insulin, 6 units, 3 hours ago. Which of the following assessmentswould be most important to report to the next shift?1. Kussmauls respirations and diaphoresis2. Anorexia and lethargy3. Diaphoresis and trembling4. Headache and polyuriaQuestionsHurst Review Services199Cardiovascular34. A client with sudden onset of deep vein thrombosis is started on a heparin IV drip. Which ofthe following additional orders should the nurse question?1. Cold wet packs to the affected leg2. Elevate foot of bed six inches3. Commode privileges without weight-bearing4. Elastic Stockings on unaffected leg35. The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg.Which of the following would be an appropriate nursing goal for this client?1. To decrease inflammatory response in the affected extremity and prevent emboliformation2. To increase peripheral circulation and oxygenation of affected extremity3. To prepare client and family for anticipated vascular surgery on affected extremity4. To prevent hypoxia associated with the development of pulmonary emboli36. Which of the following signs indicate effective CPR?1. Adequate capillary refill2. Normal skin color3. Symmetrically dilated pupils4. Palpable carotid pulse37. A permanent demand pacemaker set at a rate of 72 is implanted in a client for persistentthird degree block. Which of the following nursing interventions would indicate apacemaker dysfunction?1. Pulse rate of 88 and irregular2. Apical pulse rate regular at 683. Blood pressure of 110/80, pulse of 784. Tenderness at site of pacemaker implant38. A client with an irregular pulse rate of 181 and a K level of 3.0 mEq/L has Lanoxinordered. The nurse should:1. Give the digoxin since the pulse is within normal limits2. Holds the digoxin since the pulse is irregular3. Call the doctor to report the potassium4. Hold the digoxin since toxicity occurs with high potassium levelsQuestionsHurst Review Services20039. The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining ofchest pain. Which of the following observations is most important for the nurse to report tothe next shift?1. The client indicates the need to use the bathroom2. Blood pressure has decreased from 140/80 to 90/603. Respiratory rate has increased from 16 to 244. The client indicates the chest pain has subsided40. A 72-year-old client has an order for digoxin (Lanoxin) 0.25 mg PO in the morning. Thenurse reviews the following information:apical pulse: 68respirations: 16plasma digoxin level: 2.2 ng/mlBased on this assessment, which nursing action is appropriate?1. Give the medication on time2. Withhold the medication, notify the physician3. Administer epinephrine 1:1000 stat4. Check the clients blood pressure41. Question deleted due to NCLEX changes. We are sorry for the inconvenience, but wewant to make sure that you have the most up to date information.QuestionsHurst Review Services201Respiratory42. When obtaining a specimen from a client for sputum culture and sensitivity which of thefollowing instructions would be best?1. After pursed lip breathing cough into container2. Upon awakening cough deeply and expectorate into container3. Save all sputum for 3 days in covered container4. After respiratory treatment expectorate into container43. Which of the following is the most effective method for the nurse to evaluate theeffectiveness of tracheal suctioning?1. Note subjective data such as, My breathing is much improved now.2. Note objective findings such as decreased respiratory rate and pulse3. Consult with respiratory therapy to determine effectiveness4. Auscultate the chest for change or clearing in adventitious breath sounds44. After a bronchoscopy is completed with a client, which of the following nursingobservations would indicate a complication?1. Depressed gag reflex2. Sputum streaked with blood3. Tachypnea4. Widening pulse pressure45. The nurse is caring for a client with pneumonia. Which of the following nursingobservations would indicate a therapeutic response to the treatment for the infection?1. Oral temperature of 101F, increased chest pain with non-productive cough2. Cough productive of thick green sputum, client state he feels tired3. Respirations at 20, with no complaints of dyspnea, moderate amount of thick whitesputum4. White cell count of 10,000 mm, urine output at 40 ml/hr, decreasing amount of sputum46. During the shift report, a clients ventilator alarm is activated. Which action would the nurseimplement first?1. Notify the respiratory therapist2. Check the ventilator tubing for excess fluid3. Deactivate the alarm and check the spirometer4. Assess the client for adequate oxygenationQuestionsHurst Review Services20247. The nurse is caring for a client who has a 5 year history of chronic lung disease. Thenursing assessment reveals a severely dyspneic client, pulse at 140, respirations labored,and slightly cyanotic. An appropriate nursing action to relieve the clients dyspnea wouldinclude:1. Administer oxygen at 40% heated mist2. Assist the client to cough and deep breathe3. Elevate the head of the bed, low flow oxygen4. Position the client prone and assess breath sounds48. Question deleted due to NCLEX changes. We are sorry for the inconvenience, but wewant to make sure that you have the most up to date information.49. The nurse is caring for a client who has been immobilized for three days following aperineal prostatectomy. The client begins to experience sudden shortness of breath, chestpain, and coughing with blood-tinged sputum. Immediate nursing actions would include:1. Elevate the head of the bed, begin oxygen, assess respiratory status2. Assist the client to cough, if unsuccessful then perform nasotracheal suctioning3. Position in supine position with legs elevated; monitor CVP closely4. Administer morphine for chest pain; obtain a 12 lead ECG to evaluate cardiac status50. Your client becomes extubated while being turned. He is cyanotic and has bradycardia andarrhythmias. Which action would be the highest priority while waiting for a physician toarrive?1. Immediately begin CPR2. Increase the IV fluids3. Provide oxygen by ambuing and maintaining the airway4. Prepare the medication for resuscitationQuestionsHurst Review Services203Orthopedic51. A client had a below-the-knee amputation due to problems with gangrene. During the first 2hours after surgery which nursing action would be most important?1. Notify the doctor of a small amount of serosanguineous drainage2. Elevate the stump on a pillow to decrease edema3. Maintain the stump flat on the bed by placing the client in the prone position4. Do passive range of motion TID to the unaffected leg52. A client is admitted with a fractured right hip. The doctor writes an order for Buckstraction. In planning care for a client in Bucks traction, the nurse would:1. Turn the client every two hours to the unaffected side2. Maintain client in a supine position3. Encourage client to use a bedside commode4. Prevent foot drop by placing a foot board to the bed53. Question Deleted Due To NCLEX Changes. We are sorry for the inconvenience, but wewant to make sure that have the most up to date information.54. Following hip replacement surgery, an elderly client is ordered to begin ambulation with awalker. In planning nursing care, which statement by the nurse will best help this client?1. Sit in a low chair for ease in getting up in the walker2. Make sure rubber caps are present on all 4 legs of the walker3. Begin weight-bearing on the affected hip as soon as possible4. Practice tying your shoes before using the walker55. To prevent neurological complications for a pre-school client with a full-leg cast, the nursewould schedule regular checks of:1. Femoral pulses2. Levels of consciousness3. Blood pressure readings4. Sensory testing of affected footQuestionsHurst Review Services20456. A teenager has had a repair of an open compound fracture of the tibia and fibula. Anexternal fixation device has been applied to stabilize the fracture. Before administering pinsite care, the nurse should check which of the following?1. Correct alignment2. Appearance of pin sites3. Tightness of screws4. Vital signs57. Which nursing assessment suggests a complication of a plaster of paris cast application tothe arm?1. The client states that the wet cast feels warm2. The client is able to move his fingers and thumb freely3. The client states that his little finger feels asleep4. The wet cast appears gray and smells slightly mustyQuestionsHurst Review Services205Renal58. In planning the diet teaching for a child in the early stage of nephrotic syndrome, the nursewould discuss with the parents the following dietary changes:1.