Summary Evergreen Valley College - NUR 101|NCLEX passing it,Complete solution guide_2022
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Course
NUR 101
Institution
Evergreen College (
)
Realize that you must answer all questions in relation to what’s safe for the patient
Realize that preventing the spread of disease is top priority
CADIOVASCULAR
Realize the following in regards to a plasma cholesterol screening (measures the amount of cholesterol that one has):
x Realize tha...
Realize that you must answer all questions in relation to what’s safe for the patient
Realize that preventing the spread of disease is top priority
CADIOVASCULAR
Realize the following in regards to a plasma cholesterol screening (measures the amount of cholesterol that one has):
Realize that only sips of water are permitted for 12 hours before plasma cholesterol screening to achieve accurate results
Realize that after the application of a cast on the arm, the arm should be elevated to minimize swelling; it should be elevated for the first 24 – 48
hours; it should be protected from pressure and flattening of the cast
Realize that a Tredelenburg test is used with a client who may have varicose veins
Realize that a heartburn that radiates to the jaw indicates chest pain
Realize that when a patient is receiving thrombolytic therapy, IM injections may cause bleeding.
Realize that roasted chicken have low cholesterol
Realize that if the pulse increases, it indicates that the tissues are not being perfuse correctly
Realize that the normal RBC in males is 4.3 – 5.9 million/mm3; females 3.5 – 5.5 million
Realize that a low platelet count will give problems with no blood clotting, allowing blood to infuse joints, putting client at risk for injury
Realize that the most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which
affects the valve
Realize that the BP should always be taken on the opposite arm from the graft
Realize that a normal range for CVP is 3 – 12 cm water pressure; a reading of 8 cm indicates a desired response to fluid replacement, avoiding a
hypovolemic state
Realize that a CVP readings measures the pressure in the right atrium
Realize that a Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the
left ventricle
Realize that a pulmonary artery catheter is a multi-lumen apparatus that allows for the following measurements:
o Pulmonary artery pressures
o Myocardial filling pressures
o Cardiac output
o Pulmonary resistance
o Systemic resistance
o Cardiac index – the cardiac output divided by the body surface area
Realize that a nitroglycerine patch should be removed before an MRI test
Realize that Buerger’s disease (thromboangiitis obliterans) is a vascular occlusive disease of the extremities causing a decreased blood flow to
the feet and legs
Nurse must check for ulcers formation and gangrene
Results in thrombus
Seen in men 20 – 35 year old
Smoking is a causative factor
Pain at rest and coldness is a major system
Pain control is a goal of treatment
Fluids are not restricted
Goal of medical management is to prevent progression of disease
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Realize that the keep-open rate is the lowest possible infusion rate; this rate should not be allowed for a patient with sickle cell, as they need more
hydration
Realize that a child with sickle cell should not be given aspirin because of bleeding tendencies
Realize that the keep-vein-open (KVO) rate is (20 mL/h); this rate will keep access open
Realize that you just keep sickle cell clients away from people with infections
Realize that postoperative open heart clients should be encourage to be out of bed and ambulating as soon as possible, frequently one or two days
after surgery
Realize that elderly patient usually have lower temperature due to a lower basic metabolic rate
Realize that an elderly client is usually intolerant to cold
Realize that recognition of adult hypertension should be done after two readings taken at least five minutes apart
Realize the following about a sequential compression device (SCD)
Apply antiembolism stocking prior to applying the sequential compression device sleeves
o Realize that stocking should be worn the entire time that client is in the hospital; it should be removed before baths and
replaced after the skin is dry and before the client gets out of bed (non-ambulatory)
o Realize that stocking is worn to prevent discomfort and to increase blood flow
Realize that you need to be able to fit two fingers between the sleeve and the leg
Realize that the SCD is used to decrease venous stasis and reduce the risk of thrombus formation
Realize that if a patient has obese leg and thighs, it is not good to put elastic stocking on because it may decrease venous return because of
constriction around the thigh and legs
Realize that talcum powder is a toilet powder composed of perfumed; if a nurse applies it to a client’s feet, it allow easier applications of the
stocking
Realize that elevating the client legs before applying the stocking prevent stagnation of blood in the lower extremities
Realize that when you apply the stocking, make sure that there are not wrinkles because they can cause irritation to the skin
Realize the following about DVT:
Realize that a patient with DVT should not be ambulating; patient should be on bedrest for 5 – 7 days to prevent pulmonary
embolisms and legs should be elevated with warm moist packs
Realize that the affected calf is expected to be warm
Realize that extremity edema is expected because of venous congestion
Realize that client needs to be given anticoagulants
Realize the following about IV sites:
Realize that if tenderness and redness at the IV insertion site is noted, the IV catheter should be removed to prevent further damage to
the vein; and warm soaks should be applied to decrease inflammation, swelling and discomfort
o Realize that reddened area with red streaks is indicative of phlebitis
Realize that IV that are infiltrated should be discontinued and restarted at a new site; elevating the extremity may increase the rate of
reabsorption of the fluid
Realize that unused solution are always discarded; site of catheter changed every 4 weeks, change IV tubing and filers every 24 hours
Realize that a marking pen should not be used on an IV bag; ink can penetrate the plastic and get into the solution; labeling should be
done on the bag label using a regular pen
Realize that hypertonic dextrose solution similar to TPN is used to wean patient off TPN
Realize that extravasation is when a vesicant has filtrated; realize that a vesicant is a medication or IV solution that causes blisters and
tissue sloughing (burning)
o Realize that the following are medications that can cause a burn if infiltrated: gentatmicin, penicillin, vancomycin, dilantin,
any antineoplastic, calcium, potassium and epinephrine
o Realize that all infiltrations needs cool compresses except for vancomycin, which needs warm compresses
Realize that if a hematoma occurs, cool compresses are needed. Realize that whenever bleeding is suspected, cool compresses is best
to constrict vessels to slow down or stop the bleeding
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Realize that if IV line is clotted, it is best to just pull it and not use it; sometimes you can just dissolve the clot but this is not always
recommended
Realize that with a CVP, after administration of medication, flush with saline and then a heparinized solution afterwards; flush every
12 hours or after medication administration
Realize that it is smart to limit manipulation of the cannula at the IV insertion site to prevent dislodgement
Realize that IV sites should not be close to joints because movements could cause displacement
Realize that the correct sequence for cardiac assessment is inspection, palpation and then auscultation
Realize that polyarteritis nodosa is inflammation of the small arteries causing diminished blood
Realize that these forms of vagal or Valsalva maneuvers can reverse SVT:
Having a child stick their thumb in the mouth, close it and the blow
Realize that if a patient is undergoing a septic shock and there is blood at the venipuncture site around an IV catheter, this is an indicator of
dissememinated intravascular coagulation (DIC), a life-threatening problem.
Realize that sepsis is the most frequent cause of DIC
Realize that the reason there maybe blood around the venipuncture site is that the septic shock causes an increase in capillary
permeability
Realize that DIC is an acquired clotting disorder from overstimulation; prolonged oozing from sites of minor trauma first symptom
Realize that disseminated intravascular coagulation (DIC) is the hyperstimulation of coagulation pathways that eventually fails,
resulting in bleeding
o Realize that disseminated intravascular coagulation (DIC) is not a disease, but a sign of an underlying condition
o Realize that disseminated intravascular coagulation (DIC) maybe triggered by (1) sepsis, (2) trauma, (3) cancer, (4)
shock, (5) abruption placentae, (6) toxins or (7) allergic reactions
o Realize that in DIC, (1) the PT and PTT are prolonged and (2) the platelet count are reduced
o Realize that the laboratory test that are specific for DIC are fibrin-split product (FSP)/fibrin degradation product
(FDP)
Realize that FDP is a group of soluble protein fragments that are produced by the proteolytic action of
plasmin on fibrin or fibrinogen
o Realize that clients with DIC should have oral swabs used in administering their oral care because it has the least potential
cause of tissue injury in the oral cavity
o Realize that clients with DIC should be protected from injury that will result in bleeding
o Realize that patients with DIC may bleed from (1) mucous membrane, (2) veni-puncture sites and (3) the GI and
urinary tract
o Realize that during the initial process of DIC, the patients may have no new symptoms
o Realize that the diagnosis of DIC is often established by (1) a drop in platelet count, (2) an increase in PT and aPTT, (3) an
elevation in fibrin degradation product and (4) measurement of one or more clotting factor
Realize that client diagnosed with anemia needs a diet high in protein, iron and vitamins
Realize that the following foods have iron:
Beef
Brown rice
Raisins
Green beans
Carrots
Oatmeal-raisin
Realize that hypothermia causes vasoconstriction and hypertension
Realize that hypothermia causes myocardial irritability, which disrupts conduction system of the heart and causes the heart to be near
the fibrillation threshold, especially ventricular fibrillation
Realize that the external re-warming technique can cause re-warming shock and temperature afterdrop, which can lead to ventricular
fibrillation
Realize that during a paracentesis, shock may occur so a blood pressure cuff needs to be left on for monitoring
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Realize that the following are complications of paracentesis: abdominal pain, rigidity and distention, nausea and vomiting
Realize that the nurse should make sure that the client voids just before a paracentesis to prevent a puncture of the bladder
Realize that heat can facilitate hypotension
Realize that isometric exercises such as heavy weight-lifting and rowing are contraindication in a hypertensive client
Realize that a patient with a constant nose bleed needs to be told to pinch nose for 5 – 10 minutes with an ice-cold washcloth
Realize that silver nitrate applicator and gelfoam may be required to stop bleeding
Realize that elevated blood glucose levels places a person at risk for heart disease
Realize that defibrillation should be set to 200 joules, then 200 – 300 joules, and then 360 joules; these are emergency treatment for ventricular
fibrillation; completely depolarizes myocardial cells so SA nodes can reestablish as pacemaker
Realize that cardio-version is the restoration of normal sinus rhythm by chemical or electrical means
Realize that a sedative/hypnotic is used for sedation for the procedure
Realize that digitalis must be withheld for 48 hours before procedure to prevent ventricular fibrillation after cardioversion
Realize that the sync button on the defibrillator is used for cardio-version to treat the following:
Atrial flutter
Atrial fibrillation
Supraventricular tachycardial synchronizes shock with R wave
Realize that it is important not to touch the bed when using the defibrillator; it is a priority to prevent accidental countershock
Realize that following a total knee replacement, surgery may interrupt blood supply to the affect extremity
Realize that checking the incisional bleeding and recording the drainage is done every 4 hours
Realize that after a heart attack, a male client can resume sexual activity when he can tolerate the physical activity of climbing two flights or
stairs or walking one block without SOB or chest pain; patient should maintain a supine position and not have intercourse after a heavy meal
Realize that a low fat and low cholesterol diet is recommended for a patient with hypertension; fried foods should be avoided; baking, roasting,
boiling, or broiling are the only appropriate way of cooking for client with hypertension
Realize that a patient with arteriosclerotic heart disease (ASHD) requires a diet that is low fat and low sodium.
Realize that baked chicken without the skin is low in fat and sodium
Realize that green vegetables low in fat and sodium
Realize that hotdogs and canned soup are high in sodium
Avocado is high in fat
Realize that ham is high in sodium
Realize that scrambled eggs, orange slices and milk have low sodium
Realize that the following are risk factors of CVA: being black, being a male, substance abuse (cocaine especially), smoking, heavy alcohol use,
diabetes, obesity, heart murmur, oral contraceptive use, sedentary lifestyle (job), migraines, history of myocardial infarction, elevated cholesterol
Realize the following in regards to a migraine:
May have throbbing headache
May take ergotamines at the start of the migraine
Realize that when a vascular sound or bruit (a swooshing sound) is heard over the abdominal aorta, it most often indicates aneurysm is present;
physician should be notified immediately
Realize that it is mandatory to check the pedal pulses after a cardiac catheterization immediately after the procedure and repeat it every 15
minutes for several hours to detect changes in circulation
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