2023 NCLEX RN Uworld Comprehensive Study Guide 100 Pages PDF Download Bonus 2,600 + Nclex Practice Questions + Rationals what medications interact with grapefruit? - calcium channel blockers: diltiazem, nifedipine, verapamil, etc statins caffeine SSRIs be sure to practice math! - stent placement using the femoral approach puts you at risk for retroperitoneal hemorrhage - what are early signs of bleeding into the retroperitoneal space? - hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses what is the grey -turner sign and what is it a sign of? - bruising of the flanks and retroperitoneal hemorrhage and is a bluish color what are some physical signs of peripheral arterial disease? - intermittent calf muscle pain?, rest pa in, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the extremities) transplanted hearts are expected to be - tachycardic like 90 -110 what is the priority intervention for pain w ith sickle cell crisis and why? - administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion what is the purpose of continuous bladder irrigation? - it is perscribed after TURP to prevent obstruction of uri ne outflow by removing clotted blood from the bladder what is the nurses care of monitoring CBI? - monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed characteristics of a basilar skull fracture - periorbital hema tomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising) immediate client care for basilar skull fracture - cervical spime immobilization, close neurologic monitoring, and support of ABCs vomiting with intake may mean - viral or bacterial infection tympanosomty tubes are placed for - recurrent otis medias nurse actions during a seizure - assist them to lie down is standing/sitting, put them on side for patent airway, loosen tight clothing, give oxygen as needed, remove objects from immediate area, document time and duration of seizure (for tests are done later to see which type of seizur e and maybe what exacerates it) never put anything in mouth or restrain them since musclec ontractions can occur during a seizure what are some early symptoms of ICP? - altered LOC, headache, abnormal reathing, rise in bp, slow pulse, vomiting client w ho has a TIA is often placed on - prophylactic antithrombotic treatment like aspirin or clopidogrel glascow coma scale ranges from - 3-15; 3 being worst 15 being best condition (8 or below in a coma) what are the 3 components? - eye opening motor r esponse verbal response what is a primary component in TPN? - glucose, so the nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia when a client is on TPN, the nurse must assess for hyperglycemia why? - bc a primary component is glucose. therefore the nurse must be assessing to see if the client is getting too much glucose (hoerglycemia). and with a large urinary output like 4800, this could indicate symptoms of hyperglycemia signs og hyperglycemia - polydipsia, poly uria, restless, confused, bg over 200, fatigue, kussmaul resp what is the goal for mass casualty events? - do the greatest good for the greatest number of people keep in mind that disaster triage ranks the likelihood of survival with treatment, not necessarily the severity of the injury - what are the 4 categories for triaging? - immediate (red tag) - life threatening injuries with good prognosis once treated delayed (yellow) - injuries requiring treatment within hours minimal (green tag) - injuries requiring treatment within a few days expectant (black tag) - extensive injuries, poor prognosis regardless of treatment rule of nines - head: 4.5 front 4.5 back torso: 18 front 18 back each arm: 4.5 front 4.5 back (each arm is 9 total) each leg: 9 front 8 back (each is 18 total) genitals: 1 extrapyramidal side effects - ACUTE DYSTONIC REACTION: sudden onset sustained muscle contractions AKATHISIA: restlessness with inability to sit st ill drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces AKINISIA: loss of involuntary movement TARDIVE DYSKININIA NEUROLEPTIC MALIGNANT SYNDROME dont give morphine if RR under 12 bc it can cause - respiratory depression airborne precautions - tuberculosis, varicella, and rubeola (measles) wear N95 respirator (and other as needed like for splashes) ALSO (neg pressure room and HEPA) clients suspected are to wear a surgical mask after triage UAP soft wrist restraints can: - do ROM exercises reapply wrist restraints report changes in skin to nurse turn/reposition client in bed a client with major depression and severe weight loss needs what type of diet? - high in calories and protein, also foods that are easy to chew and don t require a lot of energy bc they may have a low energy level examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta also small frequent meals memorize MAOIs and remember - they cant eat foods high in tyramine like aged cheese, yogurt, fermented foods, beer, red wine, cocolate, avocados do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart failure or edema - you can give pneumonia p atient exportants, antibiotics, mucolytics, antipyretics, analgesics, and antinflammatories examples are - Mucinex, Ibuprofin,
