Nclex/HESI - Easy Reference Study Material - 2

Amniotic fluid:500-1200 ml (nitrozine urine-litmus paper green/amniotic fluid-litmus paper blue).
APGAR meaningA = appearanceP = pulses, G = grimace, A = activity, R = reflexes
APGAR scoring done at1 and 5 minutes
APGAR scoring:0 for absent, 1 for decreased, and 2 for strongly positive



AVA:The umbilical cord has two arteries and one vein (Arteries carry deoxygenated blood. The vein carries oxygenated blood.)
FAB 9—Folic acid = B9B stands for brain (decreases the incidence of neural tube defects); the client should begin taking B9 three months prior to becoming pregnant.
Decelerations are _______________findings on the fetal monitoring strip.abnormal
Decelerations are classified asEarly, Variable and Late
Early decelerationsBegin prior to the peak of the contraction and end by the end of the contraction. They are caused by head compression. There is no need for intervention if the variability is within normal range (that is, there is a rapid return to the baseline fetal hear
Variable decelerationsnoted as V-shaped on the monitoring strip. Variable decels can occur anytime during monitoring of the fetus. They are caused by cord compression. The intervention is to change the mother's position; if pitocin is infusing, stop infusion, alert physician
Late decelerationsOccur after the peak of the contraction and mirror the contraction in length and intensity. These are caused by uteroplacental insuffiency. The intervention is to change the mother's position; if pitocin is infusing, stop the infusion; apply oxygen;, and
TORCHS syndrome in the neonateA combination of diseases including toxoplasmosis, rubella (German measles), cytomegalovirus, herpes, and syphyllia. Pregnant nurses should not be assigned to care for the client with toxoplasmosis or cytomegalovirus.
STOP-This is the treatment for maternal hypotension after an epidural anesthesia:1. Stop pitocin if infusing. 2. Turn the client on the left side. 3. Administer oxygen. 4. If hypovolemia is present, push IV fluids.
Coumadin (sodium warfarin) PT:10-12 sec. (control).
The antidote for Coumadin isvitamin K.
Heparin/Lovenox/Dalteparin PTT:30-45 sec. (control).
The antidote for Heparin isprotamine sulfate.
Therapeutic level: It is important to maintain a bleeding time that is slightly prolonged so that clotting will not occur; therefore, the bleeding time with mediication should be:1 1/2-2 times the control.
The control (for anticoagulants) isthe premedication bleeding time.
Rule of nines for calculating TBSA for burnsHead = 9% ; Arms = 18% (9% each) ; Back = 18% ; Legs = 36% (18% each) ; Genitalia = 1%
Arab American cultural attributesFemales avoid eye contact with males; touch is accepted if done by same-sex healthcare providers; most decisions are made by males; Muslims (Sunni) refuse organ donation; most Arabs do not eat pork; they avoid icy drinks when sick or hot/cold drinks toget
Asian American cultural attributesThey avoid direct eye contact; feet are considered dirty (the feet should be touched last during assessment); males make most of the decisions; they usually refuse organ donation; they generally do not prefer cold drinks, believe in the "hot-cold" theory
Native American cultural attributesThey sustain eye contact; blood and organ donation is generally refused; they might refuse circumcision; may prefer care from the tribal shaman rather than using western medicine.
Mexican American cultural attributesThey might avoid direct eye contact with authorities; they might refuse organ donation; most are very emotional during bereavement; believe in the "hot-cold" theory of illness.
Jehovah's WitnessNo blood products should be used
HinduNo beef or items containing gelatin
JewishSpecial dietary restrictions, use of kosher foods
Renal dietHigh calorie, high carbohydrate, low protein, low potassium, low sodium, and fluid restricted to intake = output + 500 ml
Gout dietLow purine; omit poultry ("cold chicken") medication for acute episodes: Colchicine; maintenance medication: Zyloprim
Heart healthy dietLow fat (less than 30% of calories should be from fat)
ROME (respiratory opposite/metabolic equal) is a quick way of remembering that:in respiratory acid/base disorders the pH is opposite to the other components. For example, in respiratory acidosis, the pH is below normal and the C02 is elevated, as is the HC03 (respiratory opposite). In metabolic disorders, the components of the lab
pH down, C02 up, and HC03 up:respiratory acidosis
pH down, C02 down, and HC03 down:metabolic acidosis
pH up, C02 down, and HC03 down:respiratory alkalosis
pH up, C02 up, and HC03 up :metabolic alkalosis
Addison's and Cushing's are diseases of the __________________ system involving either overproduction or inadequate production of cortisol.endocrine
Treatment for the client with Addison's:increase sodium intake; medications include cortisone preparations.
Treatment for the client with Cushing's:restrict sodium; observe for signs of infection.
Treatment for spider bites/bleedingRICE (rest, ice, compression, and elevate extremity)
Treatment for sickle cell crisesHHOP (heat, hydration, oxygen, pain medications)
Five Ps of fractures and compartment syndrome—These are symptoms of fractures and compartment syndrome:Pain, Pallor, Pulselessness, Paresthesia, Polar (cold)
Hip fractures commonly:hemorrhage
Femur fractures are at risk for:fat emboli
Profile of gallbladder diseaseFair, fat, forty, five pregnancies, flatulent (actually gallbladder disease can occur in all ages and both sexes)
Delegate sterile skills such as dressing changes to the:RN or LPN.
Where nonskilled care is required, you can delegate the stable client to the:nursing assistant.
Choose the most critical client to assign to the______such as the client who has recently returned from chest surgery.RN
Clients who are being discharged should have final assessments done by the:RN
The PN, like the RN, can monitor clients withIV therapy, insert urinary catheters and feeding tubes, apply restraints, discontinue IVs, drains, and sutures.
For room assignments, do not coassign the post-operative client with clients who have:vomiting, diarrhea, open wounds, or chest tube drainage.
Remember the ___________________ when answering questions choices that ask who would you see first.A, B, Cs (airway, breathing, circulation)
For hospital triage, care for the client with a ________________ or__________________ illness or injury
For disaster triage, choose to triage first those clients who can:be saved with the least use of resources.
The ___ and the __________ institute seclusion protection.RN, Physician
The ____ or the _________ nurse can pronounces client dead.MD, hospice
Angiotensin-converting enzyme inhibiting agents:Benazepril (Lotensin), lisinopril (Zestril), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), moexipril (Univas), quinapril (Acupril), ramipril (Altace)
Beta adrenergic blockers:Acebutolol (Monitan, Rhotral, Sectral), atenolol (Tenormin, Apo-Atenol, Nova-Atenol), esmolol (Brevibloc), metaprolol (Alupent, Metaproterenol), propanolol (Inderal)
Anti-infective drugs:Gentamicin (Garamycin, Alcomicin, Genoptic), kanamycin (Kantrex), neomycin (Mycifradin), streptomycin (Streptomycin), tobramycin (Tobrex, Nebcin), amikacin (Amikin)
Benzodiazepine drugs:Clonazepam (Klonopin), diazepam (Valium), chlordiazepox-ide (Librium), lorazepam (Ativan), flurazepam (Dalmane)
Phenothiazine drugs:Chlopromazine (Thorazine), prochlorperazine (Compazine), trifluoperazine (Stelazine), promethazine (Phenergan), hydroxyzine (Vistaril), fluphenazine (Prolixin)
Glucocorticoid drugs:Prednisolone (Delta-Cortef, Prednisol, Prednisolone), prednisone (Apo-Prednisone, Deltasone, Meticorten, Orasone, Panasol-S), betametha-sone (Celestone, Selestoject, Betnesol), dexamethasone (Decadron, Deronil, Dexon, Mymethasone, Dalalone), cortisone (Co
Antivirals:Acyclovir (Zovirax), ritonavir (Norvir), saquinavir (Invirase, Fortovase), indinavir (Crixivan), abacavir (Ziagen), cidofovir (Vistide), ganciclovir (Cytovene, Vitrasert)
Cholesterol-lowering drugs:Atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), simvas-tatin (Zocar), rosuvastatin (Crestor)
Angiotensin receptor blocker drugs:Valsartan (Diovan), candesartan (Altacand), losartan (Cozaar), telmisartan (Micardis)
Cox 2 enzyme blocker drugs:Celecoxib (Celebrex), valdecoxib (Bextra)
Histamine 2 antagonist drugs:Cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), rantidine (Zantac)
Proton pump inhibitors:Esomeprazole (Nexium), lansoprazole (Prevacid), pantopra-zole (Protonix), rabeprazole (AciPhex)
Anticoagulant drugs:Heparin sodium (Hepalean), enoxaparin sodium (Lovenox), dalteparin sodium (Fragmin)
Schedule I drugsResearch use only (example LSD)
Schedule II drugsRequires a written prescription (example Ritalin)
Schedule III drugsRequires a new prescription after six months or five refills (example codeine)
Schedule IV drugsRequires a new prescription after six months (example Darvon)
Schedule V drugsDispensed as any other prescription or without prescription if state law allows (example antitussives)
AntacidsReduce hydrochloric acid in the stomach
AntianemicsIncrease red blood cell production
AnticholenergicsDecrease oral secretions
AnticoagulantsPrevent clot formation
AnticonvulsantsUsed for management of seizures/bipolar disorder
AntidiarrhealsDecrease gastric motility and reduce water in bowel
AntihistaminesBlock the release of histamine
AntihypertensivesLower blood pressure and increase blood flow
Anti-infectivesUsed for the treatment of infections
BronchodilatorsDilate large air passages in asthma/lung disease
DiureticsDecrease water/sodium from the Loop of Henle
LaxativesPromote the passage of stool
MioticsConstrict the pupils
MydriaticsDilate the pupils
Narcotics/analgesicsRelieve moderate to severe pain
tortlitigation in which one person asserts that an injury, which may be physical, emotional, or financial, occurred as a consequence of another's actions or failure to act.
negligenceharm that results because a person did not act reasonably
malpracticeprefessional negligence
slandercharacter attacked and uttered in the presence of others
assaultact in which there is a threat or attempt to do bodily harm
batteryunauthorized physical contact

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