Nle - Cgfns - Nclex Review Materials 4

NLE / CGFNS / Nclex Review Materials 4 51. RSV • Droplet precaution 52. SIADH • Sodium 128 only (Normal: 135-145) 53. Dementia of Alzheimer Type • Check what the pt. is taking 54. PEG 55. What medicine if given shld be monitored for bleeding • Indomethacin (NSAID) 56. GBS, priority nursing diagnosis • Aspiration 57. Discharge teaching for Bell’s Palsy • Provide eye care at bedtime 58. Sign of Scoliosis • Asymmetry of the iliac crest 59. Normal for a 3 day old infant • Describe normal tonic neck reflex 60. Manifestation of Paranoid Schizophrenia • Inappropriate anxiety with delusion 61. Sign of Alcohol withdrawal • Feeling of euphoria in 1st 24 hrs. 62. Activity for Alzheimer disease • Reading magazine 63. Type 1 IDDM post renal test 48 hrs ago, watch out for: • Hematuria 64. Correct understanding of antidepressant • Anti-depressant takes effect after 1 week 65. DUROGESIC PATCH / FENTANYL • For chronic pain lasts 3 days • Maybe worn while bathing, showering, swimming • Apply to flat, nonirritated, nonirradiated area like chest, flank, upper arm, back • Overdose : difficulty in breathing 66. Signs of increase ICP in pt. with close head injury • Increase systolic pressure & weak bounding pulse 67. Positive outcome for Calcium Channel blockers • Decrease chest pain 68. Obsessive Compulsive Behavior • To alleviate anxiety

69. Patient with back pain, proper body mechanics • Sit with knees higher than hips 70. What to check prior administration of EPOETEN • BP • S/E : HPN, Seizures 71. 72. Patient with pancreatitis if developing ascites would manifest: • Cullen’s Sign (bluish discoloration of abdomen or peri-umbilical hematoma) • Turner’s Sign (gray-blue discoloration of flank) • Shallow, rapid breathing • Abdominal pain • Dyspnea & difficulty eating • Orthopnea 73. Digitalis + Lasix = Weight Loss 74. Side effect of Garamycin • Ototoxicity • Nephrotoxic • Hypomagnesimea • Muscular paralysis • Hypersensitivity 75. Side Effect of Theophylline • Tremors & tachycardia • Insomnia 76. Nsg. Management for cleft palate infant • Enlarged nipple for feeding • Stimulate sucking • Swallow • Rest • Burp frequently 77. Patient with expressive aphasia, best communication: • Use picture language 78. Diet for patient with colostomy • DAT • Low residue food 1-2 days postopt • Avoid gas-forming foods 79. Patient allergic to Pseudoephedrine, What is contraindicated? • Patient taking Ma Huang 80. Patient with testicular cancer, correct understanding? • Testicular CA is painless 81. 1st intervention in prolapsed cord • Positioning – knee chest/trendelenberg 82. 2nd Stage of labor

• Cervical dilatation to delivery of baby 83. Thiazide diuretic, what to watch out for? • Potassium 84. Manic pt. taking lithium • Watch out for sodium serum 85. Diet for patient with ileostomy • Post opt 4 wks -- LOW FIBER non-irritant diet to decrease fast movement of liquid stool, after can tolerate high fiber diet already • Foods that thicken stool like boiled rice, low fat cheese should be given • Low fat diet • Normal stool is liquid 86. G & D of a 2 y/o • Combines 2 words • Kicks a ball • 50 word vocabulary 87. ALS • Decreased sensation of touch • Muscle weakness • Excess glutamate 88. S/S of Kawasaki • Desquamation of skin • Joint pain • Mucocutaneous lymph node syndrome 89. Watch out for in lumbar puncture • Increased ICP • Brain Herniation 90. S/S of DVT • Edema • Calf or groin tenderness • Pain with or w/o swelling • + Homan’s Sign • Warm skin 91. Developmental Milestone of 10 month old • Pincer grasp 92. Risk for breast CA • 38 y/o female on oral contraceptive 93. Need to consider anti-coagulant therapy • If taking Gingko Biloba 94. Check 1st before tonsillectomy • Bleeding time 95. Complication of CAST

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Compartment syndrome Fat embolism Shock Avascular necrosis

96. 97. Physician orders beta-blockers, for w/c pt. should the nurse question the order: • Patient on insulin (B-blockers may mask signs of hypoglycemia) 98. Patient hypersensitivity • Give macrolides like erythromycin,azithromycin (Penicillin & Cephalosporins the same) 99. Patient with autonomic dysreflexia • Pounding headache , piloerection 100. Pt. with carafate & antacids order, select the schedule. • Carafate 1 hr. before meals & antacids after meals 101. Increasing pulse pressure • Widening pulse pressure (late sign) • Decreased LOC, restlessness (Early) 102. Pt. with Hemophilia & Leukemia • Can lead to DIC 103. Effective teaching to DM patient • Peak of NPH insulin 8 hrs. 104. Mg SO4 given to PIH pt. Nurse should watch out for? • Epigastric pain & headache 105. Pt. with calcium oxalate stones • Diet with fig & wheat germs 106. Cancer & Sepsis can lead to DIC • low platelet count 107. Pt. in labor with crusted popular eruption, priority? • Eye prophylaxis of the newborn 108. Heroin addicted mother in labor, nursing action? • Avoid withdrawal in active stage 109. Signs of Heroin intoxication? • Euphoria • Decrease response to pain • Respiratory depression • Apathy 110. 111. Scarlett Fever isolation precaution

• Respiratory precaution • droplet until 24 hrs. start of treatment 112. Laryngectomy • Avoid swimming, showering, using aerosol sprays • Teach client clean suction technique 113. External irradiation therapy • Time & distance shielding 114. Pt. with anorexia nervosa, signs • Tachycardia 115. Brain injury • Decorticate rigidity 116. Signs of renal failure • Urine output less than 100ml/hr 117. Post-thyroidectomy patient, WOF • Tingling sensation in the cheek (complication) 118. Ventricular Fibrillation • Do chest compression 119. Pt. in crutches, nurse should check • Check armpits to see if there is pressure secondary to crutch (Pressure shld be on the hands not on the axilla) 120. Influenza Vaccine indicated for: • Anyone 50 y/o & above annually • Age 6 months & up with risk like asthma • Immunocompromised patients • Pts with cardiac & pulmonary disease 121. Herpes Simplex I & II • 2 strains of herpes virus family • HSV I – cold blisters / fever blisters • HSV II – in STD /Genital Herpes/Shingles & varicella zoster infection same with chicken pox 122. Above the knee amputation, patient shld • Prevent internal or external rotation of the limb • Place sandbag or rolled towel along side of thigh to prevent rotation 123. HIV suspect patient • Hairy tongue and leukoplakia (Leukoplakia, pre-malignant lesion) 124. DVT on Heparin therapeutic goal • Ambulate ASAP ( Prevent thrombus formation)

125. Esophageal varices, refer pt if • Cold clammy skin ( sx of shock) 126. Pregnant 39 weeks, knows true labor if • Contractions from back going to abdomen 127. Bipolar manic patients, what to do? • Limit group activities 128. Multiple Myeloma, care • Force fluid from 3 - 4 L/day to offset hypercalcemia, hyperurecemia • Encourage ambulation to prevent renal stones 129. Post pace maker transplant, correct understanding • Patient CAN USE electricc blankets, cell phones <3 watts,microwave ovens, metal detectors 130. Patient taking garlic supplements should take precaution when on aspirin therapy 131. DKA patient, what to administer 1st? • Start IV line 0.9 NaCl 132. Hearing aid, correct teaching: • Turn off & remove battery when not in use • Avoid excessive wetting of hearing aid, keep dry • Ear mold is the only part that may be washed w/ soap & water • Cannula is cleaned with small pipe cleaner device or toothpick 133. PEEP 134. 18 day old infant, how to assess trunk curvature • Place in prone position & stroke spinal colum, see if infant’s body move towards the stimulated area 135. Postural drainage, correct understanding: • Position—lung segment to be drained is uppermost • Drink a glass of water before PD to loosen secretions 136. Sign of Abdominal Aortic Aneurysm • Pulsation between umbilicus & pubis 137. Echinacea • To boost immune system • Use only up to 8 weeks 138. Action of PILOCARPINE • Increase outflow of aqueous humor • For OPEN ANGLE GLAUCOMA