CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 1
FLUID & ELECTROLYTES
I. FLUID AND ELECTROLYTES
Please note that all normal ranges for blood tests will depend on the lab performing
the test. The normal values lis
...
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 1
FLUID & ELECTROLYTES
I. FLUID AND ELECTROLYTES
Please note that all normal ranges for blood tests will depend on the lab performing
the test. The normal values listed in this book are to be used as reference only.
A. Fluid Volume Excess/Hypervolemia:
• Define: Too much fluid in the ___________________ ________________.
1. Causes:
a. Heart Failure (HF): Heart is __________, Cardiac Output _______,
decreased _____________ perfusion, Urinary Output __________.
*The volume stays in the ____________________ ________________.
b. Renal Failure (RF): Kidneys aren’t ____________________________.
c. Three things with a lot of sodium:
1) Effervescent soluble medications
2) Canned/processed foods
3) IVF with sodium
2. Hormonal Regulation of Fluid Volume:
a. Aldosterone (steroid, mineralocorticoid):
• Where is aldosterone found? ______________ ___________
• Normal action: When blood volume gets low (vomiting,
hemorrhage, etc.)
Aldosterone secretion increases retain sodium/water
blood volume goes _________.
**Diseases with too much aldosterone:
__________________________________________
__________________________________________
**Disease with too little aldosterone:
__________________________________________
b. Atrial Natriuretic Peptide (ANP):
• Where is ANP found? _________________ of the heart
• How does it work? The ______________ of aldosterone.
• So it causes __________________ of sodium and H
2O.
Rx
Rx
Rx2
FLUID & ELECTROLYTES
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
c. Anti-diuretic Hormone (ADH):
• Normally makes you retain or diurese? ___________________
• Retain? __________________________
TWO ADH PROBLEMS
Too Much ADH Not Enough ADH
Retain _________________________
Fluid Volume ___________________
Syndrome of Inappropriate ADH
Secretion
SIADH
(TOO MANY ________________,
TOO MUCH _________________)
Urine ______________________
Blood ______________________
Lose (diurese) _______________
Fluid Volume ________________
Diabetes Insipidus
DI _________________________
Urine _______________________
Blood ______________________
*Concentrated makes the #s go up
Urine specific gravity, sodium,
and hematocrit
*Dilute makes the #s go down
• ADH is found in the ______________.
• Key words to make you think potential ADH problem:
craniotomy, head injury, sinus surgery, transsphenoidal
hypophysectomy, or any condition that can lead to an
increased ICP can lead to an ADH problem.
• Trans-________________________, sphenoid _______________,
hypophysis ______________, ectomy ______________________
*Another name for anti-diuretic hormone (ADH) is vasopressin
(Pitressin®). The drug vasopressin (Pitressin®) or desmopressin
acetate (DDAVP®) may be utilized as an ADH replacement in
diabetes insipidus.
RxCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 3
FLUID & ELECTROLYTES
3. Signs/Symptoms:
a. Distended neck veins/peripheral veins: Vessels are ___________.
b. Peripheral edema/third spacing: Vessels can’t hold
any more, so they start to ___________________.
c. Central Venous Pressure (CVP): measured where?
___________ _____________; number goes __________.
More ___________________ More _________________
d. Lungs sound:_____________________________________
e. Polyuria: Kidneys are trying to help you _____________.
f. Pulse: _____________. Your heart only wants fluid to go _____________.
g. If the fluid doesn’t go forward, it’s going to go ________________
into the lungs. Can lead to heart failure, then pulmonary edema.
h. BP: ______________; more volume, more ______________.
i. Weight: _____________________. Any acute gain or loss isn’t fat; it’s fluid.
4. Treatment:
a. Low sodium diet/ restrict fluids
b. I & O and Daily __________
c. Diuretics:
• Loop: Example: _______________________________
bumetanide (Bumex®) may be given when
furosemide (Lasix®) doesn’t work.
• hydrochlorothiazide (Thiazide®): Watch lab work with all diuretics for
dehydration and electrolyte problems.
• Potassium sparing: Example: ______________________
Rx
Rx
Rx
Rx
Rx
TESTING
STRATEGY
Fluid Retention:
Think Heart
Problems FIRST
CVP NORMAL:
2-6 mmHg
5-10 cmH
2O
*Depending on
measuring device
used*4
FLUID & ELECTROLYTES
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
d. Bed rest induces _________________________________
by the release of _______________ and, production of
________________.
e. Physical assessment
• Focus on the pertinent signs and symptoms.
f. Give IVFs slowly to the elderly and very _____________.
B. Fluid Volume Deficit: Hypovolemia:
Big Time Deficit = Shock
1. Causes:
a. Loss of fluids from __________________
Examples: Thoracentesis, paracentesis, vomiting, diarrhea, and
hemorrhage
b. Third ___________________ (Definition: When fluid is in a place
that does you no good.)
• Burns
• Ascites
c. Diseases with polyuria
• Polyuria Oliguria Anuria
2. Signs/Symptoms:
a. Weight _____________
b. Decreased skin turgor
c. Dry mucous membranes
d. Decreased urine output
• Kidneys either aren’t being ___________________ or they are
trying to hold on to _________________ (compensate).
TESTING
STRATEGY
Anytime you see
assessment or
evaluation on
the NCLEX®, you
should be looking
for the presence
or absence of the
pertinent signs
and symptoms.
RxCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 5
FLUID & ELECTROLYTES
e. BP? ________ (less ______________, less ________________)
f. Pulse? ____________; heart is trying to pump what little fluid
is left.
g. Respirations? _____________
h. CVP? ______________ (less volume, less ____________)
i. Peripheral veins/neck veins vasoconstrict (very tiny).
j. Cool extremities (peripheral _____________________ in an effort to shunt
blood to the vital organs)
k. Urine specific gravity ____________. If putting out any urine
at all, it will be very concentrated.
3. Treatment:
a. Prevent further __________.
b. Replace volume:
• Mild Deficit: __________________
• Severe Deficit: ________________
c. Safety Precautions:
• Higher risk for _____________
• Monitor for overload.
NCLEX® CRITICAL THINKING EXERCISE: Ordered Response
What sequence would you use to assess the client with
orthostatic hypotension? Number the blanks to reorder the items in
the correct sequence.
_______ Assess the vital signs with the client sitting.
_______ Assess the vital signs with the client lying.
_______ Assess the vital signs with the client standing.
_______ Record BP and pulse with the position noted.
_______ Have the client lie down for at least 3 min.6
FLUID & ELECTROLYTES
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
C. Quickie IV Fluid Lecture:
1. Isotonic Solution: Goes into the vascular space and stays there!
a. Examples: _______________ , ______________ , ________________,
and D5¼ NS
b. Uses: The client that has lost fluids through nausea, vomiting,
burns, sweating, and trauma.
• Normal Saline is the basic solution when administering blood.
c. Alert: Do not use isotonic solutions in clients with hypertension,
cardiac disease or ________________ disease.
These solutions can cause FVE, _________________, or
hypernatremia.
Hypernatremia is an alert only when administering isotonic solutions that
contain sodium.
2. Hypotonic Solution: Goes into the vascular space and then shifts out
into the cells to replace cellular fluid.
They rehydrate but do not cause _____________________.
a. Examples: D2.5W, _____________ , 0.33% NS
b. Uses: The client who has hypertension, renal or cardiac disease
and needs fluid replacement because of nausea, vomiting, burns,
hemorrhage, etc.
• Also used for dilution when a client has hypernatremia
and for cellular dehydration.
c. Alert: Watch for cellular edema because this fluid is moving out
to the cells, which could lead to fluid volume ________________
and decreased blood pressure.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 7
FLUID & ELECTROLYTES
3. Hypertonic Solutions: Volume expanders that will draw fluid
into the _________________ from the ___________.
a. Examples: D10W, 3% NS, 5% NS, D5LR, D5½ NS, D5NS,
TPN, Albumin
b. Uses: The client with hyponatremia or a client who has shifted
large amounts of vascular volume to a 3rd space or has severe
edema, burns, or ascites.
• A hypertonic solution will return the fluid volume to the
vascular space.
c. Alert: Watch for fluid volume __________. Monitor in an ICU
setting with frequent monitoring of blood pressure, pulse,
and CVP, especially if they are receiving 3% NS or 5% NS.
QUICK TIPS FOR IV SOLUTIONS
Isotonic Solutions
“Stay where I put it!”
Hypotonic Solutions
“Go Out of the vessel”
Hypertonic Solutions
“Enter the vessel”8
FLUID & ELECTROLYTES
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
Hypermagnesemia
1. Causes:
a. Renal __________
b. Antacids
2. Signs/Symptoms:
a. Flushing
b. Warmth
c. Mg makes you
_______________
3. Treatment:
a. Ventilator
b. Dialysis
c. Calcium gluconate
**Calcium gluconate is
administered IVP very slowly
(Max rate:
1.5-2 mL/min).
d. Safety precautions
HINT:
If you want to
get Mg & Ca
questions right,
think muscles
1st.
Hypercalcemia
1. Causes:
a. Hyperparathyroidism: too much ___________
When your serum calcium gets low,
parathormone (PTH) kicks in and pulls
Ca from the ______ and puts it in the
blood; therefore, the serum calcium goes
___________.
b. Thiazides (retain __________)
c. Immobilization (you have to bear weight to
keep Ca in the ________________).
2. Signs/Symptoms:
a. Bones are brittle
b. Kidney stones
*majority made of calcium
3. Treatment:
a. Move!
b. Fluids prevent ___________________
c. Ca has inverse relationship with _________.
Add what to diet? _________________
d. Steroids
e. Safety Precautions
f. Medications that decrease serum Ca:
Biphosphates (etidronate)
Calcitonin
D. Magnesium And Calcium:
Fact: Magnesium is excreted by the kidneys,
but it can be lost in other ways (GI tract).
NORMAL LAB VALUES:
Mg: 1.3-2.1 mEq/L (0.65 – 1.05 mmol/L)
Calcium: 9.0-10.5 mg/dl (2.25-2.62 mmol/L)
Signs/Symptoms that are common in a client with hypermagnesemia or hypercalcemia
1. DTRs _____________
2. Muscle Tone ____________
3. Arrhythmias _______
4. LOC _____________
5. Pulse ____________
6. Respirations _______CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 9
FLUID & ELECTROLYTES
Hypomagnesemia
1. Causes:
a. Diarrhea - lots of Mg
in intestines
b. Alcoholism
c. Alcohol suppresses
ADH & it’s hypertonic
• Not eating
• Drinking
3. Treatment:
a. Give some Mg
b. Check _________ function (before
and during IV Mg).
c. Seizure precautions
d. Eat Magnesium
e. What do you do if your client reports
flushing and sweating when you start
IV Mg? ______________________
Hypocalcemia
1. Causes:
a. Hypoparathyroidism
b. Radical neck
c. Thyroidectomy
*All these = Not Enough _________
3. Treatment:
a. PO Calcium
b. IV Ca (GIVE SLOWLY) and
always make sure client is
on a ________________.
c. Vitamin D
d. Phosphate binders:
sevelamer hydrochloride
(Renagel®) calcium
acetate (PhosLo®)
Signs/Symptoms that are common in a client with hypomagnesemia or hypocalcemia
1. Muscle Tone _________________________
2. Could the client have a seizure? ________
3. Stridor/laryngospasm- airway is a smooth
______________.
4. + Chvostek’s – tap cheek (“C” is for Cheek).
5. + Trousseau’s – pump up BP cuff.
6. Arrhythmias – heart is a
___________.
7. DTRs _____________
8. Mind Changes
9. Swallowing Problems – esophagus
is a smooth ____________.
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 seeds
NCLEX® CRITICAL
THINKING EXERCISE
Intervention is required with
which client? Client with a
history of grand-mal (Tonic/
Clonic) seizures or a client that
is 8 hrs. post heart cath.
NCLEX® CRITICAL THINKING EXERCISE
A client receiving magnesium sulfate has a drop
in output. What would be the priority nursing
intervention?
1. Call the primary healthcare provider
2. Decrease the infusion
3. Stop the infusion
4. Reassess in 15 min.
2. Signs/Symptoms: (Remember: If you want to get Mg & Ca questions right, think muscles 1st.)10
FLUID & ELECTROLYTES
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
Hypernatremia=Dehydration
Too much sodium; not enough
_________________
1. Causes:
a. Hyperventilation
b. Heat stroke
c. DI
2. Signs/Symptoms:
a. Dry Mouth
b. Thirsty-already dehydrated
by the time you’re thirsty
c. Swollen tongue
3. Treatment:
a. Restrict _________.
b. Dilute client with fluids.
Diluting makes sodium
go _________.
c. Daily weights
d. I & O
e. Lab work
Hyponatremia=Dilution
Too much water; not enough
__________________
1. Causes:
a. Drinking H2O for
fluid replacement
(vomiting, sweating)
• This only replaces
water and dilutes the
blood.
b. Psychogenic polydipsia:
loves to drink ___________
c. D
5W (sugar & water)
d. SIADH: Retaining ________
2. Signs/Symptoms:
a. Headache
b. Seizure
c. Coma
3. Treatment:
a. Client needs ____________.
b. Client doesn’t need
___________.
c. If having neuro problems:
need hypertonic saline
• Means “packed
with particles”
• 3% NS or 5% NS
E. Sodium:
The sodium level in your blood is totally dependent
on how much water you have in the blood.
NORMAL LAB VALUES:
Sodium: 135 -145 mEq/L
(135 -145 mmol/L)
TESTING STRATEGY
Neuro changes: The brain doesn’t like it when the sodium is messed up.
*Neuro changes are common in clients with hypernatremia or hyponatremia*
If you have a sodium
problem, you have a
____________ problem
Case in Point: Feeding tube clients tend to get
_____________________.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 11
FLUID & ELECTROLYTES
ECG changes with hyperkalemia: bradycardia, tall and peaked T waves, prolonged PR
intervals, flat or absent P waves, and widened QRS, conduction blocks, and ventricular
fibrillation.
ECG changes with hypokalemia: U waves, PVCs, and ventricular tachycardia.
Hyperkalemia
1. Causes:
a. Kidney trouble
b. Spironolactone
(Aldactone®) - makes
you retain
___________________.
2. Signs/Symptoms:
a. Begins with muscle
twitching
b. Then proceeds to
muscle weakness
c. Then flaccid paralysis
3. Treatment:
a. Dialysis- Kidneys aren’t
working.
b. Calcium gluconate
decreases
__________________.
c. Glucose and insulin:
Insulin carries _________
& ___________ into the
cell. Any time you give
IV insulin, worry about
____________________ &
_____________________.
d. Sodium polystyrene
sulfonate (Kayexalate®)
Hypokalemia
1. Causes:
a. Vomiting
b. NG suction
(We have lots of potassium
in our stomach.)
c. Diuretics
d. Not eating
2. Signs/Symptoms:
a. Muscle cramps
b. Muscle weakness
3. Treatment:
a. Give ____________.
b. Spironolactone
(Aldactone®)
makes the client retain
__________________.
c. _________ more
potassium.
F. Potassium:
Excreted by the kidneys
If the kidneys are not working well,
the serum potassium will go _________________.
NORMAL LAB VALUES:
Potassium: 3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
Life-Threatening
Arrhythmias
Sodium and Potassium have an
____________ relationship.12
FLUID & ELECTROLYTES
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
4. Miscellaneous Information:
a. Major problem with oral potassium? __________________________
b. Assess urinary output (UO) before/during IV potassium.
c. Always put IV potassium on a _______.
d. Mix well!
e. Never give potassium IV___________!
f. Burns during infusion? ____________
Foods high in potassium: spinach, fennel, kale, mustard greens, brussels
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.
***Please note that all normal ranges for blood tests depend on the lab
performing the test.
The values listed in this book are only to be used as a reference.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 13
ACID-BASE BALANCE
II. ACID-BASE BALANCE
A. Major chemicals you have to remember:
1. Bicarb, Hydrogen, CO2
2. Major lung chemical: CO2 ________
3. Kidney chemicals: ________ and ___________________
4. These chemicals can either make you sick or compensate.
It depends on which imbalance you have.
B. pH:
1. What does pH tell you about the blood?
• If the blood is ____________, alkaline, or neutral.
2. Normal pH range _________-________.
3. pH below 7.35 ____________
4. pH above 7.45 ____________
• If the pH is messed up it can be dangerous
5. The _________ does not like it when the pH is messed up.
6. Here’s how the body keeps the pH within normal range:
COMPENSATING ORGANS
Kidneys Lungs
Remove acid through
_________________________.
Bicarb? ______________ and
return to the blood
OR
______________ through the
urine
Kidneys take hours to days
to do their job.
One way to get rid of CO2
What is it? _______________
Hypoventilation-retain ___________
Hyperventilation-eliminate ________
Lungs respond _______________.14
ACID-BASE BALANCE
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
C. Respiratory Acidosis:
1. Pathophysiology:
a. Is this a lung problem or a kidney problem? ________
b. What chemical is causing the problem? ___________
c. Do we have too much or too little of this chemical
in the body? ____________ _____________
d. Hypoventilating or hyperventilating? ______________
e. What is going to compensate? __________________
f. How? With what chemicals? _____________
and hydrogen
g. The body must ________________ the acid.
h. The body will retain bicarb.
i. Is the pH high or low? _________
2. Causes:
• Retain _______________
Mid-abdominal incision, narcotics, sleeping pills,
pneumothorax, collapsed lung, and pneumonia
NORMAL LAB
VALUES:
pH: 7.35-7.45
PaO
2: 80-100 mmHg
PaCO
2: 35-45 mmHg
HCO
3; Bicarbonate:
22-26 mEq/L
TESTING STRATEGY:
CO
2 = LOC
CO
2 = O2
CO
2 and O2 have an
inverse relationship.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 15
ACID-BASE BALANCE
3. Signs/Symptoms:
a. Headache, ___________________, sleepy
b. If not corrected, could lead to a ________________.
c. Hypoxic
• Give them ___________________.
• Early signs and symptoms of hypoxia? _______________ & _______________
4. Treatment:
a. Fix the _____________________ problem.
b. Treat pneumonia, get rid of secretions by postural drainage, percussion
(vibration therapy), deep breathing exercises, suctioning, fluids, elevate
HOB, and incentive spirometry.
c. Pneumothorax client will have _____________ tubes.
d. Encourage post-op clients to turn, cough and _______ ___________.
TESTING STRATEGY:
Restlessness think
Hypoxia FIRST16
ACID-BASE BALANCE
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
D. Respiratory Alkalosis:
1. Pathophysiology:
a. Which organ is sick? ______________ Which organ is going to
compensate? ______________
b. Kidneys excrete ___________________and retain
___________________.
c. Problem chemical? _________________________
d. Gaining or losing CO2? ______________________
e. Hypoventilating or hyperventilating? __________________________
f. pH? _________________
2. Causes:
a. Problem? ________________________
b. Hysterical
c. Acute aspirin overdose
d. Situation: Hysterical client
3. Signs/Symptoms:
• Lightheaded or faint feeling, peri-oral numbness, numbness and
tingling in fingers and toes.
4. Treatment:
a. Do not wait for kidneys to kick in.
b. Breathe into a ____________ ____________.
c. May have to __________ client to decrease respiratory rate.
d. Treat the cause.
e. Monitor ABGs.
The client is breathing too ___________,
and therefore, removing _____________.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 17
ACID-BASE BALANCE
E. Metabolic Acidosis:
1. Pathophysiology:
a. What organ is sick? _________________ What organ is going to
compensate? ___________________
b. With what chemical? __________________________
c. Problem chemicals? _________________ &
________________________
This client is retaining ______________ or does not have
enough bicarb.
d. pH? ________
e. Respiratory rate will _________________.
2. Causes:
a. DKA
b. Starvation
c. Renal failure
d. Severe ____________________.
3. Signs/Symptoms:
a. Depend on the ______________________.
b. Hyperkalemia
• Muscle twitching, muscle weakness, flaccid paralysis, and
_________________.
c. Increased respiratory rate
4. Treatment:
a. Treat the __________.
b. Drug to help acidosis? _____________ bicarb
Cells are starving for ______________, so the
body will break down protein and ________,
and produce __________. Ketones are
___________.18
ACID-BASE BALANCE
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
F. Metabolic Alkalosis:
1. Pathophysiology:
a. What organ is sick? ___________ What organ is going to compensate? __________
b. With what chemical? ____________________
c. Problem chemicals? _____________ & hydrogen
d. The client is in alkalosis, so they are retaining too much ___________ and excreting
hydrogen.
e. pH? ____________
2. Causes:
a. Loss of upper GI contents
b. Too many antacids ... Too much _______________.
c. Too much IV bicarb
3. Signs/Symptoms:
a. Depends on cause
b. Observe LOC
c. Serum potassium will go _________ in metabolic acidosis and go
________ in metabolic alkalosis.
d. Monitor for _______________________________ and ______________________________.
4. Treatment:
a. Fix the problem.
b. Replace _____________.
TESTING STRATEGY:
Metabolic Acidosis = Hyperkalemia
Metabolic Alkalosis = HypokalemiaCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 19
ACID-BASE BALANCE
PROBLEM NORMAL
pH: 7.32 ________________ pH: acidosis 7.35 – 7.45 alkalosis
PCO
2: 41 ________________ PCO2: basic 35 – 45 acidic
HCO
3: 20 ________________ HCO3: acidic 22 - 26 basic
Interpretation: _____________________________________________________
PROBLEM NORMAL
pH: 7.56 ________________ pH: acidosis 7.35 – 7.45 alkalosis
PCO
2: 31 ________________ PCO2: basic 35 – 45 acidic
HCO
3: 25 ________________ HCO3: acidic 22 - 26 basic
Interpretation: _____________________________________________________
PROBLEM NORMAL
pH: 7.26 ________________ pH: acidosis 7.35 – 7.45 alkalosis
PCO
2: 51 ________________ PCO2: basic 35 – 45 acidic
HCO
3: 29 ________________ HCO3: acidic 22 - 26 basic
Interpretation: _____________________________________________________
PROBLEM NORMAL
pH: 7.45 ________________ pH: acidosis 7.35 – 7.45 alkalosis
PCO
2: 52 ________________ PCO2: basic 35 – 45 acidic
HCO
3: 35 ________________ HCO3: acidic 22 - 26 basic
Interpretation: _____________________________________________________
G. ABG Interpretation Practice Problems:20
BURNS
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
III.BURNS
A. Occurrence:
Where do most burns occur? ____________________________________
B. Pathophysiology:
• After a burn, many different pathophysiological changes occur.
1. Why does plasma seep out into the tissue?
Increased ___________________________ permeability
2. When does the majority of this occur? _________________________
3. Why does the pulse increase?
Anytime you’re in a ____________, the pulse will __________________.
4. Why does the cardiac output decrease? Less ___________ to pump out.
5. Why does the urine output decrease?
Kidneys are either trying to _______ on to fluid or they aren’t being
_____________ adequately.
6. Why is epinephrine secreted?
Makes you ______________________, and shunts blood to the vital organs.
With a "normal" BP of 120/80, any time the systolic BP drops below 90, the
client will not have adequate organ perfusion. This can be very dangerous.
7. Why are ADH and aldosterone secreted?
Retain _______________ & ______________ with aldosterone and
Retain _______________ with ADH
Therefore, the blood volume will go _______________.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 21
BURNS
C. Miscellaneous Information:
1. Airway Injury:
• What is the most common airway injury? ________________________
poisoning
• Normally, oxygen binds with ___________________. Carbon monoxide
travels much faster than oxygen. Therefore, it gets to the hemoglobin
first and binds. Can oxygen bind now? Yes or No
• Now the client is ___________________.
• Treatment: ___________________________
• From this information, do you think it
would be important to determine if the
burn occurred in an open or closed space? Yes or No
• When you see a client with burns to the neck/face/chest you had
better think what? ______________________
• What might the primary healthcare provider do prophylactically?
_________________________
2. Classification of Burn Injury:
• A client is burned over 40% of their body. How do you think
this is determined?
• A common formula is called the ________________________.
It is an estimate of total body surface area affected.
TESTING STRATEGY
Least invasive first22
BURNS
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
D. Treatment (Clients with burns > 20-25% TBSA):
1. Fluid Replacement:
• One of the most important aspects of burn management is
_____________________________.
• Is it important to know what time the burn occurred? ______________
• Why? Fluid therapy (for the first 24 hours) is based on the time the injury
___________, not when the treatment was __________________.
Common rule: Calculate what is needed for the first __________ hours, and give
half of the volume calculated during the first 8 hours.
This is the __________________ Formula.
CONSENSUS FORMULA:
(4mL of LR) X (body weight in kg) X (% of TBSA burned) =total fluid requirement
for the first 24 hours after burn
1st 8 hours = ½ of total volume
2nd 8 hours = ¼ of total volume
3rd 8 hours = ¼ of total volume
• To calculate fluid replacement properly, you also need to know the
client’s ___________ (in kilograms) and TBSA affected.
*1 kg = 2.2 pounds
• If the client is restless, it could suggest three problems:
inadequate fluid replacement, pain, or hypoxia.
*Nurse’s Priority: ___________________
• Which of the following would you choose
to determine if a client’s fluid volume is adequate?
Their weight or their urine output?
_______________________
NCLEX® CRITICAL THINKING EXERCISE
A client weighing 235 lbs. has a 30% total body surface area burn.
The primary healthcare provider’s prescription is: Titrate IV fluids to maintain
urinary output at 0.5 ml/kg/hr. What is the desired output?
Record your answer as a whole number. _____________________ mL/hr
TESTING
STRATEGY
Pain never
killed anyoneCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 23
BURNS
2. Emergency Management:
• A client was wrapped in a blanket to stop the burning process.
Since the flames are gone, does that mean the burning process
has stopped? ________________
• What else could have been done to stop the burning process?
__________________
• The blanket helped by…holding in the _____________ and keeping out
_____________
• Remove jewelry because ________________ will occur. Also, metal gets hot.
• Clothing? Remove non-adherent clothing and _______________________ with a
clean dry cloth.
• Signs of airway injury:
• Singed nose hair
• Singed ___________________
• Soot
• Coughing up stuff with ________________ or black _________
• Blisters on the oral/pharyngeal ______________
• Do you think there is more death with upper or lower body burns? ___________
• A client’s respirations are shallow. You know they are retaining what? ________
Therefore, which acid-base imbalance will they have? ______________________
3. Medication Management:
a. Albumin:
• Holds onto ___________ in the _______________ space.
• Vascular volume?__________________
• Kidney perfusion?__________________
• Blood pressure?__________________
• Cardiac output?____________________
• Will this help correct a fluid volume deficit? ________
Because we are putting more fluid where? ________________________24
BURNS
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• When giving a client albumin, the vascular volume will
_________________________.
• Therefore, what will happen to the workload of the heart?
__________________
• If you stress the heart TOO MUCH:
The client could be thrown into a fluid volume _________________.
If this occurs, what will happen to Cardiac Output? It will __________________.
Lungs sound? __________________
If a client is receiving fluids rapidly, what is a measurement you could take
hourly (hint: heart) to ensure you’re not overloading the client? ______________
b. Pain Management:
• Why are IV pain meds preferred over IM with burns?
IV meds act _______________; they act ____________________.
If an IM injection is going to work, you must have adequate
________________________ to the muscle.
c. Immunization:
1) Tetanus Toxoid: (_____________ immunity)
*takes 2-4 weeks to develop their own immunity
2) Immune globulin: think ___________________ protection
(____________ immunity)CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 25
BURNS
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 client’s vascular check in their arm is bad, what are the
names of the procedures to relieve pressure?
Escharotomy- relieves the ___________ and restores the
circulation, cuts through the eschar.
Fasciotomy- relieves the pressure and restores the
_____________________, but the cut is much deeper into
the tissue: it cuts through the fascia of the muscle.
2. Renal System:
• An indwelling catheter is inserted to 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 not being _______________________ adequately.
• What would you do if the urine was brown or red?
Call the _____________________________________.
• What drug might be ordered to flush out the kidneys?
___________________
• If there is no urine output or if it is less than 30mL/hour,
you would start worrying about? _________________
__________________
• After 48 hours, the client will begin to diurese. Why?
Because fluid is going back into the _____________ space.
Now we have to worry about fluid volume _____________.
• What will happen to urine output now?
________________________
CIRCULATORY CHECK:
1. __________________
2. __________________
3. __________________
4. __________________26
BURNS
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
3. Electrolyte Imbalance:
• The client’s serum potassium level is 5.8 meq/L (5.8 mmol/L)
Where do we find most of our potassium? ______________ the cell
• With a burn, what happens to cells? _______________________
• So, what happens to the number of potassium ions in the serum
(vascular space)? __________________
• Electrolyte imbalance? Hypokalemia OR Hyperkalemia
4. GI System:
• Why do you think magnesium carbonate (Gaviscon®), pantoprazole (Protonix®),
or famotidine (Pepcid®) are prescribed?
To prevent a _____________________________________
Name of ulcer? __________________________________________
Antacids: aluminum hydroxide gel (Amphojel®), magnesium hydroxide (Milk of
Magnesia®)
H2 Antagonists: ranitidine (Zantac®), famotidine (Pepcid®), nizatidine (Axid®)
Proton Pump Inhibitors: pantoprazole (Protonix®), esomeprazole (Nexium®)
• Why do you think the primary healthcare proivder wants the client to be NPO and
have an NG tube hooked to suction?
• Because they could develop a ___________________________
Why?
• Decreased vascular volume
• Decreased GI motility
• Hyperkalemia
• If a client doesn’t have bowel sounds, what will happen to the
abdominal girth? ___________________________________
• Do you think the client will need more or less calories?_____________________CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 27
BURNS
• The NG tube will be removed when you hear what?
___________________
• When you start GI feedings, what should you measure to
ensure that the supplement is moving through the GI tract?
_______________________________
• What is some lab work you could check to ensure proper
nutrition and a positive nitrogen balance? _______________,
total protein, or albumin.
5. Integumentary System:
a. Contractures:
Since the client has partial thickness and full-thickness burns,
is it possible that they could have problems with contractures?
______________________
CLASSIFICATION OF BURNS:
Superficial thickness: formerly called first-degree burn; damage only to
epidermis
Partial-thickness: formerly called second-degree burn; damage to entire
epidermis and varying depths of the dermis.
Full-thickness: formerly called third-degree burn; damage to entire dermis
and sometimes fat
• If they have burns on their hands, what are some specific
measures that may be taken?
Wrap each ________________ separately.
Use _______________ to prevent contractures.
• __________________ the neck (head is back).
No pillows; promotes chin-to-chest contracture.28
BURNS
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b. Infections:
• With a perineal burn, the #1 complication is ________________.
• What is eschar? __________________________________
• Does it have to be removed? ________________
• If it’s not removed, can new tissue regenerate? ______________
• What likes to grow in eschar? ___________________________
c. Treatment:
• What type of isolation will you use with the burn client?
_________________________________
• Enzymatic debridement agents may be used to remove
necrotic, dead tissue.
• Sutilains (Travase®) or collagenase (Santyl®):
enzymatic drugs these eat dead tissue
Don’t use on face.
Don’t use if pregnant.
Don’t use over large nerves.
Don’t use if area is opened to a body cavity.
• Hydrotherapy is also used to _______________________.
Give them pain medication prior to hydrotherapy.
Worry about cross contamination with immersion hydrotherapy.
COMMON DRUGS USED WITH BURNS:
a. mafenide acetate (Sulfamylon®): Can cause acid base problems and stings.
If it rubs off, apply more.
b. silver nitrate: Keep these dressings wet. Can cause electrolyte problems.
c. povidone-iodine (Betadine®): It stings and stains. May cause allergies and acid-base
problems.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 29
BURNS
• Why should these antibiotic drugs be alternated?
Bacteria will build ______________ or _____________________.
• Broad spectrum antibiotics are avoided to prevent
___________________ or ________________________.
EXCEPTION: Broad spectrum antibiotics may be used until
the wound cultures have returned.
• Always make sure that the cultures have been collected before
you start the antibiotics.
• When giving mycin drugs….we WORRY when the client’s BUN
or creatinine increases or if the client reports any hearing
loss. Mycin drugs can lead to ototoxicity (irreversible hearing
loss) and/or nephrotoxicity. Check their BUN and creatinine;
if they are increasing, assume that the client has
nephrotoxicity.
d. Grafting:
• Remove the burned dead tissue until healthy tissue is seen.
• An autograft uses the client’s own skin. Good skin is taken
from a healthy donor site and placed over the burned area.
• The donor site is an open wound, so a dressing is applied until
the bleeding stops.
• Then the donor site can be left open to air.
• If the client is well nourished, the surgeon can reharvest from
the same donor site every 12 to 14 days.
• If the skin graft should become blue or cool what could this
mean? ______________________________________________
• Sometimes the primary healthcare provider will prescribe for
you to roll sterile Q-tips over the graft with steady,
gentle pressure from the center of the graft out to the edges.
Why?___________________________________________________30
BURNS
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
e. Chemical and Electrical Burns:
1) Chemical burn? First, remove the client from the chemical and begin
__________________.
How long do you flush? ______________________
2) Electrical burn 2 wounds. What are they? ________________
and __________
• What is the first thing you do for an electrical injury?
_______________________________
How long? _______________ hours
• What arrhythmia is this client at high risk for? ____________
• With electrical burns, myoglobin and hemoglobin can build up and
cause ____________ damage.
• The client may be placed on a spine board with a c-collar.
Why? Electrical injuries occur in ______________ places.
Muscle contractions can cause fractures, and the force of the electricity
can actually throw the victim forcefully.
• Are amputations common? ___________
Why? ______________________________
• Other complications of electrical wounds or injuries: cataracts,
gait problems, and just about any type of neurological deficit.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 31
ONCOLOGY I
IV. ONCOLOGY I
A. Overview:
1. Pathophysiology:
• Cancer refers to a class of diseases.
There are several different kinds of cancer. Cancer can be
classified by:
• The tissue or blood cells where it starts
• The type
What are the two types of cancer?
___________________________ and Hematologic malignancies
a. Solid tumors arise from specific tissue.
• Types of solid tumors:
1) Sarcomas
Begin in the connective tissues, the tissues that the body
uses to connect or support other tissue.
2) Carcinomas
Originate from the _________________ tissues, and this is
the tissue that lines your organs.
These are the cancers that originate in the ______________
of organs like the lungs and liver, the breast, colon, or
prostate.
b. Hematologic malignancies
Originate from blood or lymphatic cells.
• Cancer begins with one abnormal cell that starts growing and
dividing out of control.32
ONCOLOGY I
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
2. Metastasis
• The "traveling" or extension of the _____________________ cancer
to other sites of the body.
• Metastasis occurs by:
a. Direct invasion,
b. Through the blood system, or
c. Through the _________________ system
Cancer prevention is about modifying the risk factors.
There are things we can control in our lifestyle that will help
prevent the development of cancer.
B. Risk factors:
• ____________________ is the #1 cause of preventable cancer.
• Alcohol + tobacco = co-carcinogenic
• Suspected dietary causes of cancer:
1. A low-fiber diet
2. Increased red meat
3. Increased animal fat
4. Nitrites (processed sandwich meats)
5. Alcohol
6. Preservatives and additives
• _________________, physical inactivity, and poor nutrition
• Increased incidence of cancer in the __________________________.
• The most important risk factor of cancer is ___________________.
• That is why there is a higher incidence of cancer > age 60.
• African Americans have the ________________ incidence of cancer
followed by Caucasians.
• Heredity
• Exposure to ultra-violet radiation
• Exposure to carcinogens
• Stress
• Chronic _____________ can cause uncontrolled growth
of abnormal cells.
• Previous history of other types of cancer or chemotherapy.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 33
ONCOLOGY I
C. Prevention and Screening:
1. Primary prevention:
These are ways to help _______________ the actual occurrence
of cancer.
Primary prevention includes things like:
• No __________________
• Exercise and good nutrition
• Maintain normal body weight
• Limit or eliminate alcohol intake
• Vaccines for preventable viral exposures
such as Hepatitis B and ____________
• Avoid exposure to known carcinogens
2. Secondary prevention:
This is when we use _________________ to pick-up on cancer early,
when there is a greater chance for cure or control.
a. Secondary prevention for the female:
• Breast self-awareness is recommended as secondary
prevention.
• Beginning in their 20s, women should be told about the
___________ and _______________ of monthly breast self-exam
(BSE).
What days of the menstrual cycle are best for doing the
breast self-exam? Anytime from day _____ through day twelve.
Post-menopausal or women who have had a hysterectomy
should perform the breast self-exam on the same day every
month.
• ____________ clinical breast exams for women greater than
40 years of age. Women between the ages of 20-39 need
one every three years.
• Mammogram-annually starting at age _______, with two views
of each breast.34
ONCOLOGY I
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Before a mammogram, what should you teach your
client to not apply on their body? No lotion, no powder,
no ____________________
• Pap smears beginning at age 21 and performed every
__________ years if there have been no problems.
• Colonoscopy at age ________, then every 10 years if there
have been no problems.
• Testing the stool for fecal occult blood should be done
__________ beginning at age 50, unless previous problems
or a positive family history.
b. Secondary prevention for the male:
• Provide information on breast self-awareness and have
_____________ clinical testicular exams.
• Testicular tumors grow _________ ___________, so many
clinicians recommend monthly testicular self-exams (TSE).
The major age group that gets testicular cancer is young
males, between ages 15 and 36. Teach TSE early.
• Digital rectal exam and prostate specific antigen (PSA) may be
checked annually for men over the age of 50.
• Colonoscopy at age 50 and then every 10 years, and yearly
fecal occult ___________ testing.
3. Tertiary Prevention:
• Focuses on the management of long term care for clients with
complex treatments for cancer.
• Examples of tertiary care are support groups and rehabilitation
programs.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 35
ONCOLOGY I
D. Diagnosis:
1. General Signs/Symptoms:
• CAUTION: Change in bowel/bladder habits
A sore that does not heal
Unusual bleeding/discharge
Thickening or lump in breast or elsewhere
Indigestion or difficulty swallowing
Obvious change in wart or mole
Nagging cough or hoarseness
• Cancer can invade the bone marrow which can lead to
_______________, leukopenia, and thrombocytopenia.
• Unexplained weight ___________.
Cachexia is another term that we hear used when we are
studying cancer that means extreme _______________
and malnutrition.
• Fever
• Fatigue is the ____________________ that clients report
with a diagnosis of cancer.
• Pain
2. Blood Tests:
• Abnormal CBC & diff
• Most concerned about the _________________.
• Elevated liver enzymes
• AST and ALT
• Tumor markers36
ONCOLOGY I
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
3. Positive Diagnostic Studies:
a. Chest x-ray
b. CT Scan
c. _______
d. PET Scan
e. Bone marrow biopsy
f. Tissue biopsy
g. Imaging studies
Total laryngectomy (removal of __________ cords, epiglottis and thyroid
cartilage.)
• Since the whole larynx (remember this includes the epiglottis)
is removed, this client will have a permanent tracheostomy or
_______________________________.
• Position post-op? ____________________________________
• NG feedings to protect the suture line.
(Peristalsis can disrupt the ___________________________.)
• Monitor drains
• Watch for ____________________ artery rupture
• Rupture of the innominate artery.
• Frequent ______________ care to decrease bacterial count in the mouth.
• NPO people tend to get ___________________.
• When the client leaves the hospital, a bib will be used to cover the trach
because it acts like a filter.
• A humidified environment helps.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 37
ONCOLOGY I
• With a total laryngectomy, all __________________ is done through the
________________.
So how does a client with a total laryngectomy talk?
They can use an electrolarynx, but the Blom-Singer device is the most common
device that they use to talk.
• Can the client with a total laryngectomy:
• Whistle? _________
• Drink through a straw? _________
• Smoke? _______
• Swim? _______
E. Treatment:
1. Goals of Treatment:
a. Cure
b. ________
c. Palliation
• Adjuvant is when two therapies are used _______________.
• Neoadjuvant are _____________________ therapies, or one before
the next.
• The treatment plan will be based on the:
Recommended treatment plans for the diagnosis
Grade of cancer
What the client wants
2. Types of Cancer Treatments:
a. Surgery:
1) Prevention
2) ________________
3) Treatment
4) Reconstruction
• Reconstruction is commonly used with breast cancer
• A mastectomy may be partial or total (radical).38
ONCOLOGY I
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Reconstruction can be done with the initial surgery
or a later surgery.
Post op care following a mastectomy
Bleeding check dressings, front and back
( ___________ of blood can occur).
• If reconstruction includes using their own tissue,
they will also have an abdominal surgical site.
Can harvest adipose tissue from other sites for
reconstruction, but abdomen is the most common.
• Hemovac or Jackson-Pratt drains
• Associated nursing care, if any lymph nodes were
removed with the mastectomy:
Avoid procedures on arm of the affected side for
lifetime of client:
*No constriction: no BPs, no blouses with elastic, no
watch, and no IV or injections on the affected side.
Wear gloves when gardening, watch small cuts, no nail
biting, and no sunburn.
• Brush hair, squeeze tennis balls, wall climbing,
flex and extend elbow
• Why? Promotes _________________ circulation
Successful surgery for cancer is dependent on 3 things:
• Could the cancer be completely removed?
• Had the cancer already spread at the time of surgery?
• Was the surgeon able to get adequate _________________?
b. Radiation Therapy:
1) Internal Radiation (brachytherapy)
Brachytherapy is used to get the radiation __________ to the
cancer or target tissue.
It is internal radiation so, it is _____________ the body.
Brachytherapy is very close to the target tissue because the
radiation is inside the body.
With all types of brachytherapy, the client emits _____________
for a period of time and is a hazard to others.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 39
ONCOLOGY I
Brachytherapy is either unsealed or sealed.
• Unsealed: Client and body fluids emit radiation.
• This is like a radioisotope that is given
___________________ or _____________________.
Radioactive for 24 to 48 hours.
• Sealed or solid: Client emits radiation; body fluids
are not radioactive.
Can be temporary or a permanent _____________ that is
placed close to or inside the tumor.
General radiation precautions for internal radiation.
Remember: time, distance, and shielding.
Precautions with Internal Radiation:
• Nursing assignments should be rotated ____________, so
that the nurse is not continuously exposed.
• The nurse should only care for ________ client with a
radiation implant in a given shift.
• Private room
• Wear a film badge at all times
• Restrict visitors
• Limit each visitor to 30 minutes per day
• Visitors must stay at least 6 feet from source
• No visitors less than 16 years of age
• No pregnant visitors/nurses
• Mark the room with instructions for specific isotope
• Wear gloves with risk of exposure to body fluids
How can you help prevent dislodgment of the implant?
Keep the client on ______________.
Decrease _________________ in the diet.
Prevent bladder ________________.
• What do you do if the implant becomes dislodged
and you see it?_______________________________________
*Don’t forget this client is immunosuppressed40
ONCOLOGY I
Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• After radiation can the client sleep in the same bed with
their spouse or children? ____________
• Should they use public transportation? __________
• Can they return to work immediately? ___________
• Can they share utensils or cook for others? __________
• Will one flush of the toilet after use be adequate? ________
2) External radiation (teletherapy, external beam radiation):
• A carefully focused beam of high energy rays is delivered
by a machine outside of the body.
• The client is _____________ radioactive.
• Side effects are usually limited to exposed tissues.
Erythema
Shedding of skin
Altered taste
Fatigue (side effect of radiation)
Pancytopenia (all blood components are decreased)
• Signs and symptoms are _______________ and
______________ related.
• Is it okay to wash off the markings? __________
• Is it okay to use lotion on the markings? ________
• Protect the site from sunlight and UV exposure for 1 year
after completion of therapy.
Oncology II lecture can be found in the Specialty Topic
videos in your online resources.ENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 41
V. ENDOCRINE
A. Thyroid Gland:
• Produces _____________ hormones (T3, T4 and Calcitonin)
• Calcitonin ______________ serum calcium levels by taking calcium out
of the blood and pushing it back into the bone.
• You need ______________ to make hormones. (This is dietary iodine.)
• Thyroid hormones give us ___________!
1. Hyperthyroid: TOO MUCH ENERGY!! (Graves Disease):
a. Signs/Symptoms:
• Nervous
• Irritable
• Attention span _________
• Appetite _____
• Weight _____
• Sweaty/hot
• Exophthalmos
• GI ________
• BP and Pulse_________
• Arrhythmia/palpitations
• Thyroid size ___________________________
b. Diagnosis:
• If you drew a serum thyroxine (T4) level on this client, would
it be increased or decreased? _______________
• TSH _____________
• Thyroid scan
• Client must discontinue any iodine containing
medication ____ week prior to the thyroid scan and must wait
_________ weeks to restart medications.
• ___________________/MRI/CTENDOCRINE
42 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
Amiodarone (Cordarone®), an antiarrhythmic drug, contains high levels of iodine
and may affect thyroid function.
c. Treatment:
Medications:
1) Anti-thyroids: methimazole (Tapazole®) propylthiouracil (PTU®)
• Stops the thyroid from making thyroid __________________.
• It’s used ________________________ to stun the thyroid.
• We want this client to become euthyroid
(eu=____________________).
2) Iodine Compounds: potassium iodine (SSKI® and Lugol’s solution®)
• ________________ the size and the vascularity of the gland
• ALL endocrine glands are VERY VASCULAR!
• Give in milk or juice, and use straw. Why?_____________________
3) Beta Blockers - supportive therapy: ____________________ (Inderal®)
• Decreases myocardial contractility
• Could decrease cardiac output
• Decreases HR, BP
• ______________ anxiety.
4) Radioactive Iodine therapy (_________ dose):
• Given _________ (liquid or tablet form)
**Rule out pregnancy first**
• Destroys thyroid cells _________________________
• Follow radioactive precautions.
Stay away from __________ for ______week.
Don’t ________ anyone for ____ week.
TESTING
STRATEGY
Do not give
beta blockers
to asthmatics
or diabetics.ENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 43
• Watch for thyroid storm (thyrotoxicosis and thyrotoxic
crisis). It is hyperthyroidism multiplied by 100.
Could be rebound effect post-radioactive iodine
5) Surgery: thyroidectomy (partial/complete):
• Post op: Priority - Hemorrhage
• Report feelings of ____________.
• Check for bleeding where? _____________________________________
• Assess for recurrent laryngeal nerve damage by listening for
______________________.
• Could lead to vocal cord paralysis? _______________
• When there is paralysis of both cords, _______________ obstruction
will occur requiring immediate _____________________.
• Trach set at bedside
• Swelling
• Recurrent laryngeal nerve damage (vocal cord paralysis)
• Hypocalcemia
Assess for _______________ removal.
How? Signs/Symptoms of_____________________
Sedated or not sedated?
Eye care is important for a client with hyperthyroidism. If the client can’t close their eyelids,
hypoallergenic tape may be applied to close lids (to help prevent injury or irritation). Dark
glasses may be worn if photosensitivity is present. Artificial tears are used to prevent drying
of the eyes.
Treatment of hyperthyroidism DOES NOT correct any eye or vision problems.
• Teach how to support neck.
• Put personal items _________ to them
• Positioning: HOB? __________ ______________ edema
• Nutrition (pre & post op): Client needs __________ calories.ENDOCRINE
44 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
2. Hypothyroid:
a. Signs/Symptoms:
• No _________
• Fatigue
• No expression
• Speech ______________________________
• Weight __________
• GI ______________
• Hot or cold? __________
• Amenorrhea
You may be taking care of a totally immobile client
b. Diagnosis:
• Thyroxine (T4)______________
• TSH ______________
• Just the ___________________ of lab values for
hyperthyroidism.
c. Treatment:
• Levothyroxine (Synthroid®), liothyronine (Cytomel®)
• Take on an _______________ stomach.
• People with hypothyroidism tend to have _______________
(worry about an MI when these medicines are started).
• Do they take these meds forever? _________
• What will happen to their energy level when they start
taking these meds? _______________________________ENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 45
B. Parathyroid Problems:
• The parathyroids secrete _________________________ which makes
you pull calcium from the _________________ and place it in the
blood. Therefore, the serum calcium level goes ____________.
• If you have too much parathormone in your body, the serum calcium
level will be _________.
• If you do not have any parathormone in your body, the serum calcium
level will be _________.
1. Hyperparathyroidism = Hypercalcemia = Hypophosphatemia:
a. Signs/Symptoms:
• Too much ________________________
• Serum calcium is __________. Serum phosphorus is
___________.
• Other Signs/Symptoms _____________________
b. Treatment:
• Partial parathyroidectomy – when you take out 2 of your
parathyroids…. PTH secretion ______________.
• What are you going to monitor for post op?
_______________________________________
2. Hypoparathyroidism = Hypocalcemia = Hyperphosphatemia:
a. Signs/Symptoms:
Not enough ________
Serum calcium is __________. Serum phosphorus is
______________.
Other Signs/Symptoms: ___________________
b. Treatment:
• IV ________________
• Phosphorus binding drugsENDOCRINE
46 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
C. Adrenal Glands:
• Need your adrenals to handle ____________
• You have two parts to your adrenal gland: adrenal medulla
and the adrenal cortex.
1. Adrenal medulla: (epinephrine, norepinephrine)
Adrenal Medulla Problem:
• Pheochromocytoma
Benign tumors that secrete epi and norepi in boluses
Tend to be familial, so screen the family
a. Signs/Symptoms:
• BP? __________
• HR? ____________________
• Palpitations? ________________
• Flushing/extremely diaphoretic
• Headache? _____________
b. Diagnosis:
• Catecholamine levels: VMA (vanillylmandelic acid) test
or Metanephrine (MN) test
Foods that alter the VMA and MN test: anything with vanilla in it;
caffeine, Vitamin B, fruit juices and bananas.
• A 24 hour urine specimen is done and you are looking
for increased levels of _____ and _______________ (also
called catecholamines).
With a 24 hour urine, you should throw _____________ the first
voiding and_____________ the last voiding.
• Avoid any activities that can increase epi and norepi (no stress)ENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 47
c. Treatment:
• Surgery to remove ____________
Alert: Avoid palpating the abdomen of a client with a suspected pheochromocytoma
as it may cause sudden release of catecholamines and severe hypertension.
2. Adrenal cortex: (Glucocorticoids, Mineralocorticoids,
and Sex hormones)
Even though the body secretes steroids normally, the adverse effects are going
to be more pronounced when the client is receiving oral or IV steroids.
Adrenal Cortex Steroids:
a. Glucocorticoids:
• Change your mood
Example: depressed, psychotic, euphoric, insomnia
• Alter defense mechanisms
Immunosuppressed
High risk for _________________
• Breakdown _______ and proteins
• Inhibit insulin
Hyperglycemic
Do blood glucose monitoring
b. Mineralocorticoids: Aldosterone
• Make you retain _______ & _________
• Make you lose __________
• Too Much Aldosterone:
Fluid volume excess
Serum Potassium: _______________
• Not Enough Aldosterone:
Fluid volume deficit
Serum Potassium: _______________
Both of these help
regulate ____________
metabolism.ENDOCRINE
48 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
c. Sex hormones: testosterone, estrogen and progesterone
• Too Many sex hormones:
Hirsutism
______________
Irregular menstrual cycle
• Not enough sex hormones:
Decreased axillary/pubic hair
Decreased libido
Adrenocorticotropin hormones (ACTH) are made in the pituitary and they
stimulate cortisol to be made.
Cortisol is a hormone of the adrenal cortex.
So no matter what “fancy” word the NCLEX® Lady uses…you will still get the
same result…think “steroids.”
ACTH = Cortisol level
Too many steroids = Hypercortisolism (just another word)
d. Adrenal Cortex Problems:
_________________________
_________________________
_________________________
_________________________
1) Addison’s disease: (Adrenocortical insufficiency—not
enough steroids)
• Pathophysiology:
• They do not have enough glucocorticoids,
mineralocorticoids, or sex hormones.ENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 49
• Aldosterone (mineralocorticoids)
• Normally, aldosterone makes us retain _________
and _________ and lose _________. Now we don’t have
enough (insufficient), so we will lose ___________
and _________ and retain ________.
• The serum potassium will be ______________.
• Signs/Symptoms:
• Extreme fatigue
• Nausea, _________________, and diarrhea
• Anorexia/weight loss
• Hypotension
• Confusion
• Decreased sodium, increased potassium, and
_________________
• Hyperpigmentation-bronzing color of the skin
and mucous membranes
• White patchy area of depigmented ________ (vitiligo)
• Treatment:
• Combat shock (losing ___________ and ____________)
• _______________ sodium in their diet
• Processed fruit juice/broth (has lots of __________________)
• I & O and daily weight
• If this client is losing sodium and water, their BP will probably be
_________.
• Will they probably be gaining/losing weight? ____________
• Fluid Volume _____________ENDOCRINE
50 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Medications:
Prednisolone (Prednisone®) - given ____________ a
day in split doses. Client will take ____________ of the dose
in the morning and ___________ of the dose in the evening.
Fludrocortisone - is aldosterone.
Daily weights and ________________must be
monitored.
When on a medicine where weight has to be monitored
daily, keep the weight within 2-3 lbs or 1-2 kgs (+ or
-) of their normal weight and report a gain of > 5 lbs
per week (2.27 kgs per week). Also monitor for blood
pressure changes.
• Addisonian crisis: can occur with infections, emotional
stress, physical exertion or stopping steroids abruptly.
TESTING STRATEGY
Addisonian Crisis = severe hypotension and vascular collapseENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 51
2) Cushing’s: _________________________________
a) Signs/Symptoms:
These clients have too many glucocorticoids, mineralocorticoids, and sex
hormones.
CUSHING'S
Signs/Symptoms Too Many What?
• Growth arrest
• Thin extremities/skin (lipolysis)
• Increased risk of infection
• Hyperglycemia
• Psychosis to depression
• Moon faced (fat redistribution
or fluid retention)
• Truncal obesity (fat
redistribution; lipogenesis)
• Buffalo hump
(fat redistribution)
_________________
• Oily skin/acne
• Women with male traits _________________
• High BP
• CHF
• Weight gain
• Fluid Volume ______________
_________________
• Since the client has too much mineralocorticoid (aldosterone), the serum
potassium will be ________.
• If you did a 24 hour urine on this client, the cortisol levels
would be ___________.ENDOCRINE
52 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b) Treatment:
• Adrenalectomy (unilateral or bilateral)
*If both are removedlifetime replacement
• Quiet environment
• Avoid infection.
• Diet pre-treatment?
_____ K+ _____ Na+ _____ Protein _____ Ca++
HINT:
Steroids decrease serum Calcium by
excreting it through the GI tract.
D. Diabetes:
1. Classification:
a. Type 1:
• They have little or no insulin.
• Usually diagnosed in childhood
• Causes: Auto-immune response (Type 1A) or Idiopathic (Type 1B)
• First sign may be ________________
• Appears ______________, despite years of beta cell destruction
• Classic 3 P's: polyuria, polydipsia, and polyphagia
NORMAL LAB
VALUE:
Blood Glucose:
70-110 mg/dL
(3.9-6.1 mmol/L)
NCLEX® CRITICAL THINKING EXERCISE
The nurse is monitoring the lab values of a client on long-term steroid therapy.
Which values would the nurse expect to be altered in the urine?
Select all that apply.
1. Protein
2. Glucose
3. Ketones
4. RBCs
5. Uric acidENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 53
1) Pathophysiology:
You have to have __________ to carry glucose out of the
blood and into the cell … since there is no insulin, the
glucose just builds up in the ____________. The blood
becomes hypertonic and pulls fluid into the vascular space
… the kidneys filter excess glucose and fluids (polyuria and
polydipsia)... the cells are starving so they start breaking
down protein and fat for energy (polyphagia)…when
you break down fat you get _______________ (acids) …
Now this client is ___________ (respiratory or metabolic?).
Kussmaul respirations
2) Signs/Symptoms:
• Polyuria
• Polydipsia
• Polyphagia
3) Treatment:
• Will oral hypoglycemic agents work for this client? _______
• They have to have insulin.
b. Type 2:
1) Pathophysiology:
• These clients don’t have enough ___________, or the
insulin they have is no good.
• These clients are usually _________________.
• They can’t make enough insulin to keep up with the
___________ load the client is taking in.
• This type of diabetes is not as abrupt as Type 1.
• It’s usually found by accident; or the client keeps
coming back to the primary healthcare provider for
things like a wound that won’t heal, repeated vaginal
____________, etc.
Polyuria - think shock first.
Hyperglycemia = 3 PsENDOCRINE
54 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Individuals with Type 2 diabetes should be evaluated for
_____________ syndrome (Syndrome X).
• Metabolic Syndrome is known to increase the risk for
developing Type 2 Diabetes and cardiovascular disease.
2) Treatment:
• Start with diet and exercise and then add oral agents.
Some clients may have to take ____________.
c. Gestational Diabetes:
• Resembles Type 2
• Mom needs 2-3x more ______________ than normal.
• If mom has risk factors for gestational diabetes, screen at
________ prenatal visit.
• Screen all moms at ____________________ gestation.
• Complications to baby:
Increased birth weight and ____________________________
Features of Metabolic Syndrome: must have 3 or more of these
Waist circumference:
>40 in (101.6 cm) for males,
>35 in (88.9 cm) for females,
Triglycerides> 150 mg/dL (1.60 mmols/L)
HDL < 40 mg/dL (1.036 mmols/L) for males
< 50 mg/dL (1.295 mmols/L) for females
Blood pressure > 130/85
FBS > 100 mg/dL (5.55 mmols/L)ENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 55
2. General Treatment of Diabetes: (Type 1 and Type 2)
a. Diet:
• Majority of calories should come from:
complex carbohydrates, then fats,
and lastly protein. Carbohydrates - 45% of diet;
Fats - 30 - 40% of diet and Protein - 15 - 20%.
• Why are we worried about carbohydrates? Sugar destroys vessels
just like _________.
• High fiber slows down ____________ absorption in the intestines,
therefore, eliminating the sharp rise/fall in blood sugar.
b. Exercise:
• Wait until blood sugar _________________ to begin exercise.
• What should the client do pre-exercise to prevent
hypoglycemia? ______________________
• Exercise when blood sugar is at its highest or lowest? _____________
• Exercise _____________ time and amount daily.
c. Medications: Oral Anti-diabetics and Non-Insulin injectables:
• What type of diabetes are these drugs prescribed for?
________________
• Administered either __________________ or subcutaneously.
• How do they work? By improving 2 things:
How the body _______________ insulin,
How the body uses insulin and glucose.
All oral anti-diabetic agents work to decrease the amount of circulating
glucose.
TESTING
STRATEGY
Extreme blood
sugar =
Vascular damageENDOCRINE
56 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Most widely used oral anti-diabetic is metformin (Glucophage®)
This is the first choice for most clients and you may see it used
for weight control in Type 2 diabetics and some clients with
________________________ diabetes.
• Metformin (Glucophage®) is a favorite because it reduces glucose
production and ___________________ how glucose enters the cell.
• Does not stimulate the release of more insulin, so do _________
see hypoglycemia with this drug. We don't want hypoglycemia
because it destroys vessels!
• May see them prescribed in ___________________.
• If metformin is not controlling the blood glucose levels, another
anti-diabetic will be ordered, may be glargine (Lantus®).
ALERT: Clients undergoing surgery or any radiologic procedure that
involves contrast dye should temporarily discontinue metformin.
They can resume 48 hours after the procedure if kidney function has
returned and creatinine is normal.
• How is the insulin dose determined?
Initially it is based on _______________. The average adult dose of
insulin is ___________________ units/kg/day.
The insulin dose is adjusted until the __________________ is normal
and until there is no more glucose or __________________ in the
urine.ENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 57
• Reg (__________) … NPH (_________)
• When drawing up regular and NPH insulin together, remember to draw up
the clear one first.
• All ______________ insulins are also clear and cannot be mixed with any other
insulin or given IV.
• What is the standard insulin you give IV? __________ Rapid acting insulin may
also be given IV.
• Plan is based on client's lifestyle, _________________ and activity. The goal is
to keep the __________________ meal glucose near normal at 70 to ______
mg/dL (3.89 - 7.22 mmols/L)
• The most common method of daily dosing insulin is
______________________ dosing.
• The _________ daily dose of insulin with the Basal/Bolus method
is a combination of a ___________________ insulin, and a
_____________________ insulin.
The long-acting insulin is given once a day.
The rapid-acting insulin is given throughout the day before meals in
________________ doses, and it covers the food eaten at meals.
• Snacks are _________ required with Basal/Bolus insulin dosing, but clients still
must eat when dosing with a rapid-acting insulin, so, have food available.ENDOCRINE
58 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Clients should eat when insulin is at its? __________
• When insulin is at its peak, the blood sugar is at its?
______________
• Always monitor a client on insulin for hypoglycemia.
d. Client Teaching Education:
• Glycosylated Hemoglobin (HbA1c): blood test; gives an
average of what your blood sugar has been over the
past ______________months.
• What happens to your blood
sugar when you are sick or
stressed?_____________________
The normal pancreas can handle
these fluctuations. An increase
in the blood sugar when sick or
stressed, is a normal reaction to help us fight the illness or
stressor.
TESTING STRATEGY
Illness = DKA
• Rotation of sites (Rotate _____________ an area first)
e. Insulin Infusion Pumps:
• Alternative to daily insulin injections
• Only ___________________ insulin is used in infusion pumps.
• Obtain better control: receiving a basal level of insulin from
the pump and boluses of additional insulin as needed with
_________, or if they have an _________________ blood sugar.
HbA1c is > 6.5 % is
diagnostic for diabetes.
For people with
diabetes, the ideal goal
for their HbA1c is < 7%ENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 59
REMEMBER:
1. Regular Insulin is the standard insulin that can be given in IV fluids
as an intravenous infusion.
2. Rapid-Acting Insulin is the only insulin that can be given via a
subcutaneous insulin infusion pump. Insulin infusion pumps are
small computerized devices worn by the client that provide both a
continuous (basal) dosing of rapid-acting insulin and on-demand
(bolus) dosing.
f. Hypoglycemic/Hyperglycemic Episodes:
• What are the Signs/Symptoms of hypoglycemia?
• If hypoglycemic, what should the client do? ____________________________
Snacks should be __________ grams of carbohydrates.
• Glucose absorption is delayed in foods with lots of _________.
• 15 - 15 - 15 rule
• Once the blood sugar is up, what should they do? _________________________
• You enter a diabetic client’s room and they are unconscious…
do you treat this client like they are hypo or hyperglycemic?
__________________
D50W (hard to push; and if you have a choice, you need a large bore IV)
Injectable glucagon (GlucaGen®) (used when there is no IV access; given IM)
• For prevention, teach the client to:
1. ________________________________
2. ________________________________
3. ________________________________
4. ________________________________
Hypoglycemia is a
glucose level of
70mg/dL (3.8mmol/L)
or lessENDOCRINE
60 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NCLEX® CRITICAL THINKING EXERCISE
What foods would be the best choice for Pawpaw?
Select all that apply.
1. Skim Milk
2. Apple Juice
3. Hershey chocolate bar
4. Three oatmeal cookies
5. A handful of raisins
3. Complications of Diabetes:
a. Diabetic Ketoacidosis (DKA):
1) Pathophysiology:
• Anything that increases blood sugar can throw a client
into DKA (illness, infection, skipping insulin).
• DKA may be the first sign of ______________________.
• Have all the usual Signs/Symptoms of Type 1 diabetes
• Patho: Absent or inadequate insulin blood sugar goes sky high
Polyuria, Polydipsia, Polyphagia Fat breakdown (acidosis) Kussmaul
respirations (trying to blow off CO2 to compensate for the metabolic acidosis).
Also, as the client becomes more acidotic, the LOC goes down.
• In DKA, you have very little or no insulin and severe hyperglycemia which leads to
fat break down and then metabolic acidosis.ENDOCRINE
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 61
2) Treatment:
• Find the cause.
• Hourly blood sugar and potassium levels
• IV insulin
Insulin decreases __________________ & _____________
by driving them out of the vascular space into the cell.
• ECG
• Hourly __________
• ABGs
• IVFs __________________________________________________________________
Start with NS…then when the blood sugar gets down to about
250 to 300 mg/dL (13.9 to 16.7 mmols/L), switch to D5W to prevent
_____________________________.
• Anticipate that the primary healthcare provider will want to add ____________ to
the IV solution at some point.
b. Hyperosmolar Hyperglycemic Nonketosis (HHNK) or
Hyperglycemic Hyperosmolar State (HHS):
• Looks like DKA, but no ______________
• Making just enough insulin so they are not breaking down body _____________
No fat breakdown … no ________________
No ketones … no ______________________
• Will this client have Kussmaul respirations? _______________
TESTING STRATEGY
In the NCLEX® world: Type 1 DKA Type 2 HHNK (HHS)
DKA and HHNK (HHS) are both hyperosmolar states caused by _________________ and
_______________, but there is no ______________ with HHNK (HHS).ENDOCRINE
62 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
c. Vascular Problems: Macro-vascular and Micro-vascular
• Will develop poor circulation everywhere due to __________ damage (sugar
irritates the vessel lining; accumulation of sugar will decrease the size of the vessel
lumen, therefore decreasing blood flow).
1) Diabetic retinopathy
2) Nephropathy
d. Neuropathy:
1) Sexual problems: impotence/decreased sensation
2) Foot/leg problems: pain/paresthesia/numbness
*Review Diabetic Foot Care
3) Neurogenic bladder: the bladder does not empty properly …
the bladder may empty spontaneously, called _____________, or it may not empty
at all, and this is called _______________.
4) Gastroparesis: stomach emptying is delayed so there is an increased risk for
_________________.
e. Increased Risk for __________________CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 63
CARDIAC
VI. CARDIAC
A. Normal blood flow through the heart:
The two major veins that bring blood to the right side of the heart are
the superior and inferior vena cava (This blood is deoxygenated)The
blood enters the right atrium Then the right ventricle From the
RV the blood is pumped into the pulmonary artery (this artery carries
deoxygenated blood) Then the blood goes to the lungs where it is
oxygenated Next through the pulmonary veins (they carry oxygenated
blood) It then goes to the left atrium to the left ventricle (the
big bad pump) It is then pumped into the aorta And finally this
oxygenated blood is delivered throughout the body through the arterial
system where it eventually ties back into the venous system.
AFTERLOAD
PRELOADCARDIAC
64 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
B. Cardiac Terms:
1. Preload is the amount of blood _____________ to the right side
of the heart and the muscle _______________ that the volume causes.
______________ is released when we have this stretch.
2. Afterload is the __________ in the aorta and peripheral arteries that
the left ventricle has to pump against to get the blood out.
• This pressure is referred to as resistance.
• With hypertension there’s even more _______________ for the
left ventricle to pump against. That’s why ______________
can eventually lead to HF and pulmonary edema, because high
afterload ______________ cardiac output and decreases
forward flow. Plus, it wears your heart out.
3. Stroke volume is the ____________ of blood pumped out of the
ventricles with each beat.
C. Cardiac Output:
• CO = HR x SV
• Tissue ____________ is dependent on an adequate cardiac output.
• Cardiac output changes according to the body’s __________________.
1. Factors that affect cardiac output:
a. Heart rate and certain arrhythmias
b. Blood ___________
1) Less volume = ___________ CO
2) More volume = ___________ CO
c. ______________ contractility
• MI, medication, cardiac muscle diseaseCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 65
CARDIAC
2. Pathophysiology of decreased CO:
• If your CO is decreased, will you perfuse properly? ________
a. Brain: LOC will go_______
b. Heart: Client reports ________ pain
c. Lungs: Lungs sound ____________ Short of breath? ______
d. Skin: ________ and clammy
e. Kidneys: UO goes _____
f. Peripheral pulses: ____________
Arrhythmias are no big deal UNTIL they affect your cardiac output.
g. Three Arrhythmias that are always a big deal:
1) ________________________________________
2) ________________________________________
3) ________________________________________
D. Coronary Artery Disease:
• Coronary artery disease is the most common type of cardiovascular disease.
• Coronary artery disease is a broad term that includes chronic stable
angina and acute coronary syndrome.
1. Chronic Stable Angina:
a. Pathophysiology:
1) Intermittent decreased blood flow to the myocardium leads
to ischemia or necrosis? __________________ This ischemia can
lead to temporary pain/pressure in chest.
2) What brings this pain on? Low ____________ usually due to
_______________.
3) What relieves the pain? ______________ and/or nitroglycerin SL.
Medication Effects on Cardiac Output
Preload: Vasodilate
or diurese to reduce
(decrease) preload
1) Diuretics (furosemide)
2) Nitrates (nitroglycerin)
Afterload: Vasodilate to
reduce (decrease) afterload
1) ACE Inhibitors (enalapril, fosinopril, captopril)
2) ARBS (valsartan, losartan, irbesartan)
3) Hydralazine
4) Nitrates
Improve Contractility: 1) Inotropes (dopamine, dobutamine, milrinone)
Rate Control:
1) Beta Blockers (propranolol, metoprolol, atenolol, carvedilol)
2) Calcium Channel Blocker (diltiazem, verapamil, amlodipine)
3) Digoxin
Rhythm Control: 1) Antiarrhythmics (Amiodarone)CARDIAC
66 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b. Treatment:
1) Medications:
a) Nitroglycerin (Nitrostat®): Sublingual
• Causes venous and arterial ___________________
• This dilation will cause ________________ preload and
afterload.
• Also causes dilation of the _________________ arteries
which will increase blood flow to the actual heart
muscle (myocardium)
• Take 1 every ________ min x ________ doses.
• Okay to swallow? __________
• Keep in dark, glass bottle; dry, cool
• May or may not burn or fizz
• The client will get a ________________.
• Renew how often? An average of every
_______ months
Spray? _______ years
• After nitroglycerin (Nitrostat®), what do you expect the
BP to do? ______________________
TESTING STRATEGY
RULE: NEVER LEAVE AN UNSTABLE
CLIENT.
Algorithm for NTG:
Take one NTG SL,
after 5 minutes if
chest pain/discomfort
is unimproved or
worsened, activate
emergency response.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 67
CARDIAC
b) Beta Blockers (for prevention of angina):
• Examples: propranolol (Inderal®), metoprolol
(Lopressor®/Toprol XL®), atenolol (Tenormin®),
carvedilol (Coreg®)
• What do beta blockers do to BP, P, and myocardial
contractility? _______________
• What does this do to the workload of the heart?
_______________
Beta blockers block the beta cells… these are the
receptor sites for catecholamines - the epi and norepi.
We just decreased the contractility… So what
happened to my CO? _____________.
We have _____________ the workload on my heart.
This is a good thing to a certain point, because when
we decrease the work on the heart, the need for
oxygen is decreased, and that decreases angina. But
could we decrease the client’s cardiac output (HR and
BP) too much with these drugs? ________
c) Calcium Channel Blockers (prevention of angina):
• Examples: nifedipine (Procardia XL®), verapamil
(Calan®), amlodipine (Norvasc®), diltiazem(Cardizem®)
• What do these do to the BP? ____________
• Calcium channel blockers cause vasodilation
of the arterial system.
• They dilate ____________________ arteries.
• Two benefits of calcium channel blockers are they
____________ afterload and ________________ oxygen
to the heart muscle.
d) Acetylsalicylic acid (Aspirin®):
• Dose is determined by the primary healthcare provider
(81 mg - 325 mg).CARDIAC
68 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
2) Client Education/Teaching for Chronic Stable Angina:
• Rest frequently
• Avoid overeating
• Avoid excess caffeine or any drugs that increase HR
• Wait 2 hours after eating to exercise
• Dress warmly in cold weather (any temperature extreme
can precipitate an attack)
• Take nitroglycerin prophylactically
• Smoking cessation
• Lose weight
• Avoid isometric exercise
• Reduce stress
TESTING STRATEGY
DO EVERYTHING YOU CAN TO DECREASE THE
WORKLOAD ON THE HEART.
3) Cardiac Catheterization:
a) Pre-procedure:
• Ask if they are allergic to ___________________________.
Iodine based dye is used during the procedure.
• Also, we want to check their kidney function because
you excrete the dye through the ____________.
Many primary healthcare providers prescribe
acetylcysteine (Mucomyst®) pre-procedure, especially if
the client has kidney problems. Acetylcysteine helps to
protect the kidneys.
• Hot shot
• Palpitations normalCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 69
CARDIAC
b) Post-procedure:
• Monitor VS
• Watch puncture site
What are you watching for? _______________ and
hematoma formation
• Assess extremity distal to puncture site (5-Ps).
The 5 Ps:
Pulselessness
Pallor
Pain
Paresthesia
Paralysis
• Bed rest, flat, extremity straight X 4-6 hours
• Major complication post cath? _________________________
• Report pain ASAP
• If the client is on metformin (Glucophage®)______________
this medicine for 48 hours post procedure. We are worried
about the _______________.
Unstable chronic angina = Impending MI
2. Acute Coronary Syndrome: MI, Unstable Angina:
a. Pathophysiology:
1) Decreased blood flow to myocardium ischemia, necrosis
or both? ___________
2) Does the client have to be doing anything to bring this pain
on? ______________
3) Will rest or nitroglycerin (Nitrostat®) relieve this pain?________CARDIAC
70 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b. Signs/Symptoms:
• Pain
May describe pain as
______________________, an elephant sitting
on their chest, pressure radiating to the left
arm and left jaw, N/V, or pain between their shoulder blades.
_______________ usually present with GI signs and symptoms,
epigastric discomfort or pain between the shoulders, an aching jaw or
a choking sensation.
What is the #1 sign of an MI in the elderly? _________________
• Cold/clammy/BP drops
• Cardiac output is going ________.
• ECG changes
• Vomiting
You may see the following terms in a test question:
***WORRY ABOUT THE STEMI CLIENT***
STEMI: ST-Segment Elevation Myocardial Infarction-this indicates
that the client is having a heart attack and the goal is to get them
to the cath lab for PCI in less than 90 minutes.
NSTEMI: Non-ST-Segment Elevation Myocardial Infarction-these
clients are usually less worrisome.
c. Diagnostic Lab Work:
1) CPK-MB:
• Cardiac specific _____________________
• _______________ with damage to cardiac cells
• Elevates within __________ hours and peaks in _________ hours
2) Troponin:
• Cardiac biomarker with _______ specificity to myocardial damage
• Elevates within ________ hours and remains ___________
for up to 3 weeks
LAB VALUES FOR
TROPONIN ISOMERS:
Troponin T < 0.10 ng/mL
Troponin I < 0.03 ng/mLCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 71
CARDIAC
3) Myoglobin:
• Increases within ____ hour and peaks in _____ hours
• _________________ results are a good thing.
4) Which cardiac biomarker is the most sensitive indicator
for an MI? _________________
5) Which enzymes or biomarkers are most helpful when the client delays
seeking care? _________________
d. Complications:
Major arrhythmias:
• What untreated arrhythmias will put the client at risk for sudden death?
Pulseless V-Tach
V-Fib
______________________________
• Priority treatment for V-Fib: ___________________
• If the first shock doesn’t work and the client remains in V-Fib,
what is the first vasopressor we give? _________________
• Amiodarone (Cordarone®) is an anti-arrhythmic and is used when
V-Fib and pulseless VT are resistant to treatment, and also for fast
arrhythmias.
• What anti-arrhythmic drugs are commonly given to prevent a second
episode of V-Fib? ________________ or ___________________.
• Lidocaine toxicity: any _________ changes
• Amiodarone (Cordarone®) is the first anti-arrhythmic of choice.
Important side effect? ____________________
This hypotension can lead to further arrhythmias.CARDIAC
72 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
e. Treatment:
• What medications are used for chest pain when they get to
the ED?
_________________________________ (keep O2 sat > 90%)
_________________________________ , (chewable or tablet?)
_________________________________
_________________________________
• Head up position. Why?
Decreases _______________ on the heart and increases
_________________________.
1) Thrombolytics:
• Goal: Dissolve the clot that is blocking blood flow
to the heart muscle decreases the size of the infarction.
• Medications: alteplase (t-PA®), tenecteplase (TNKase®,
one time push), reteplase (Retavase®) and streptokinase
(Streptase®)
• How soon after the onset of myocardial pain should
these drugs be administered? Within _____________
hours
• Stroke: __________ IS BRAIN.
• Major complication: _________________
• Obtain a good _______________ history.
• Absolute contraindications:
Intracranial neoplasm, intracranial bleed, suspected
aortic dissection, or internal bleeding
• During and after administration we take
__________________ precautions.
dabigatran (Pradaxa®)
antidote: idarucizumab (Praxbind®)CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 73
CARDIAC
COMMON MEDICATIONS REQUIRING BLEEDING PRECAUTIONS:
1. Anti-coagulants and Anti-platelets: Heparin, warfarin (Coumadin®),
enoxaparin sodium (Lovenox®), eptifibatide (Integrillin®)
2. Antithrombotics: apixaban (Eliquis®), dabigatran (Pradaxa®),
rivaroxaban (Xarelto®)
3. Acetaminophen (Tylenol®)
Bleeding Precautions: Watch for bleeding gums, hematuria and black stools.
Use an electric razor, a soft toothbrush, and No IMs.
• Draw blood when starting IVs, decrease the number
of ____________ sites.
• What about ABGs? ______________
• Follow-Up Therapy: Antiplatelets are another important
component of thrombolytic therapy.
acetylsalicylic acid (Aspirin®), clopidogrel (Plavix®),
abciximab (ReoPro IV®) (continuous IV infusion to
inhibit platelet aggregation)
2) Medical Interventions:
a) PCI (Percutaneous Coronary Intervention):
• Includes all interventions such as PTCA (angioplasty)
and stents
• Major complication of an angioplasty is a _________.
Don’t forget the client may bleed from heart cath site,
or they could reocclude.
• If any problems occur go to ___________________.
Chest pain after procedure: call the primary healthcare
provider at once reoccluding!
• Anti-platelet medications:
Acetylsalicylic acid (Aspirin®)
Clopidogrel (Plavix®)
Abciximab (ReoPro IV®)
Eptifibatide (Integrilin IV®)
Given to high risk clients who
have been stented to keep
artery open and those waiting
to go to the cath labCARDIAC
74 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b) Coronary Artery Bypass Graft (CABG):
• Can be scheduled or emergency procedure
• Used with multiple vessel disease or left main coronary
artery occlusion.
• The _____________ main coronary artery supplies
the entire left ventricle.
• Left main coronary artery occlusion...
Think: __________________ or Widow Maker.
3) Cardiac Rehabilitation:
• Smoking cessation
• Stepped-care plan (increase activity gradually)
• Diet changes- _____ fat, _____ salt, _____ cholesterol
• No isometric exercises-___________________ workload
of heart
• No Valsalva
• No straining; no suppository; docusate (Colace®)
• When can sex be resumed? For clients without complications:
_______________________________________________________
• What is the safest time of day for sex?
_______________________________________________________,
when the client is well rested.
• Best exercise for MI client? _____________
• Teach Signs/Symptoms of heart failure:
Weight __________________
Ankle edema
Shortness of ______________
ConfusionCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 75
CARDIAC
E. Heart Failure (HF):
1. Causes:
• HF is a complication that can result from problems such as
cardiomyopathy, valvular heart disease, endocarditis,
acute MI, and _______________.
2. Types:
a. Left Sided Failure: the blood is not moving forward into the
aorta and out to the body … If it does not move forward, then it
will go backward into the ________.
• Signs/Symptoms:
Pulmonary congestion
Dyspnea
Cough
Blood tinged frothy sputum
Restlessness
Tachycardia
S-3
Orthopnea
Nocturnal dyspnea
b. Right Sided Failure: the blood is not moving forward into the
lungs … If it does not move forward then it goes backward
into the ___________ system.
• Signs/Symptoms:
Distended neck veins
Edema
Enlarged organs
Weight gain
Ascites
Terminology:
Systolic heart failure: heart can’t contract and eject.
Diastolic heart failure: ventricles can’t relax and fill.
Left = LungsCARDIAC
76 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
3. Diagnosis:
a. B-type (BNP) natriuretic peptide:
• Secreted by ventricular tissues in the heart when
ventricular volumes and pressures in the heart are increased
• Sensitive indicator
• Can be _________ for HF when the CXR does not indicate
a problem
• If the client is on nesiritide (Natrecor®), turn it off
_____________prior to drawing a BNP.
b. CXR: enlarged ____________________, pulmonary infiltrates
c. Echocardiogram: looks at the pumping action or ejection
fraction of the heart. An ECG can also give you information
about backflow and valve disease.
d. New York Heart Association Functional Classification
of Persons with HF:
• Classes 1-4 (Class 4 is the worst)
The Swan-Ganz
(Pulmonary Artery)
catheter is a balloon
flotation catheter that
can be floated into the
right side of the heart
and pulmonary artery.
It provides information
to rapidly determine
hemodynamic
pressures, cardiac
output and provides
access to mixed
venous blood
sampling.
Arterial lines can be placed in multiple arteries,
but the most common site is the radial artery.
It provides continuous intra-arterial blood pressure
monitoring and allows for repeated ABG samples
to be collected without injury to the client.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 77
CARDIAC
4. Treatment:
a. Medications:
Standard medication therapy for HF is ACE inhibitors and ARBs.
1) ACE Inhibitors:
• These are the Drug of Choice (DOC) for HF
• They suppress the Renin Angiotensin System (RAS)
• Prevent conversion of Angiotensin I to Angiotensin II
• Results in arterial _____________ and ______________ stroke volume.
2) ARBs:
• Block Angiotensin II receptors, and cause a ________________ in
arterial resistance and decreased BP.
Ace inhibitors and ARBs both block aldosterone. When we block
aldosterone, we lose _____________ and ____________ and retain
__________________.
It is standard practice (a core measure) that a client with HF will
be sent home on an ____________________ and/or a beta blocker.
Why?
Because, these drugs, ____________ the workload on the
heart by preventing vasoconstriction (decreasing afterload).
This will increase the cardiac output and keep blood moving
_______________ out of the heart. That’s what we wantforward
flow.
3) Digoxin (Lanoxin®):
Actions:
• Monitor for drug toxicity, especially in the elderly.
• Used when the client is in sinus rhythm or atrial fibrillation and has
accompanying chronic HF.
• Often given in combination with an ACE inhibitor, ARBs, Beta Blocker or
________________.
• Contraction? __________________________
• Heart rate? ____________________________
When the heart rate is slowed, this gives the ventricles more time to fill
with blood.CARDIAC
78 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Cardiac output will go ___________.
• Kidney perfusion _______________.
Nursing Considerations:
• Would diuresis be a good thing or bad thing for this client?
_________
• We always want to ____________ heart failure clients…they can’t
handle the fluid.
• Digitalizing dose (loading dose)
• How do you know the Digoxin is working?
Because the cardiac output goes ___________
• Signs/Symptoms of toxicity:
Early: Anorexia, nausea, and vomiting
Late: Arrhythmias and _________________ changes
• Before administering, do what? ________________________
• Monitor electrolytes
All electrolyte levels must remain normal, but potassium is the
one that causes the most trouble.
(________________+_________________=________________)
TESTING STRATEGY
Any electrolyte imbalance can promote Digoxin toxicity.
4) Diuretics:
• Examples: furosemide (Lasix®), hydrochlorothiazide
(HCTZ®), bumetanide (Bumex®), hydrochlorothiazide/
triamterene (Dyazide®), spironolactone (Aldactone®)
• Action: Decreases ____________________________
• Nursing Considerations:
When do you give diuretics? ___________________
Normal
Dig level=
____to____
ng/mLCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 79
CARDIAC
b. Low Sodium Diet:
• Decreases fluid retention and helps decrease____________________________.
• Watch salt substitutes.
Salt substitutes can contain excessive __________________.
• Canned/processed foods & OTC meds can contain a lot of _________________.
c. Elevate head of bed.
d. Weigh daily and report a gain of __________________ (1 - 2 kgs).
TESTING STRATEGY
Fluid retention-think Heart Problems 1st.
e. Report signs and symptoms of recurring failure.
f. Pacemaker:
• Your “natural” pacemaker is the SA node or sinus node.
It sends out impulses that make the heart _______________.
• If your heart rate drops to 60 or below, cardiac output can
___________________.
• Pacemakers are used to increase the heart rate with symptomatic
bradycardia.
Pacemakers may be temporary (invasive or non-invasive)
or permanent. Most permanent pacemakers are demand, but you can also see
fixed pacemakers.
• Always worry if the heart rate drops below the set rate.
• Any pacemaker will maintain a certain minimal heart rate depending on the
settings; in other words the ________________.
• A demand pacemaker kicks in only when the client needs it.
• Fixed rate pacemakers fire at a ______________ rate constantly.
• It’s okay for the rate to increase but never _________________.
• Always worry if the rate ___________ below the set rate.CARDIAC
80 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
Post-Procedure Care (for permanent pacemakers):
• Monitor the incision.
• Most common complication post-op? Electrode _____________
• Immobilize arm.
• Assisted passive range of motion to prevent frozen _______________
• Keep the client from raising the arm higher than shoulder height.
Signs/Symptoms of Malfunction:
• It’s possible that no contraction will follow the stimulus.
This is called __________________.
• Is it possible for the pacemaker to fire at inappropriate times?
_______________________________
This is called failure to __________________.
• What can cause loss of capture, failure to sense or any malfunction?
The pacemaker may not be ________________ correctly.
Electrodes can _________________.
Battery may be _______________.
• Watch for any sign of decreased CO or decreased_________________.
Client Education/Teaching:
• Check __________________ daily.
• ID card or bracelet
• Avoid electromagnetic fields (cell phones, large motors).
• Avoid MRIs.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 81
CARDIAC
F. Pulmonary Edema:
1. Who is at risk?
Any person:
• receiving IV fluids really ___________________
• the very young and the very old
• any person who has a history of __________ or __________ disease
2. Pathophysiology:
• Fluid is backing up into the _______________. The heart is unable to
move the volume _________________.
• Pulmonary edema usually occurs at __________, when the client goes to
bed.
3. Signs/Symptoms:
• Sudden onset
• Breathless
• Restless/anxious
• Severe ___________________________
• Productive cough (pink frothy sputum)
4. Treatment:
a. Oxygen:
• The priority nursing action is to administer high flow oxygen.
Monitor oxygen saturation and titrate to keep above ________%.
b. Medications:
1) Diuretics:
• Furosemide (Lasix®)
• Causes diuresis and vasodilation which traps more blood
out in the arms and legs and reduces _______________.
• 40 mg IV push slowly over 1-2 minutes to prevent __________________
and ototoxicityCARDIAC
82 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Bumetanide (Bumex®)
• Can be given IV push or as a continuous IV infusion to
provide rapid fluid _________
• 1-2 mg IV push given over 1-2 minutes
2) Nitroglycerin (Nitro-Bid® IV):
• Vasodilation: ____________ afterload
• Decreased afterload = increased CO because the heart is
pumping against less pressure, and more blood can be moved
_____________.
3) Morphine (Morphine Sulfate®):
• 2 mg IV push for vasodilation to decrease preload and afterload
4) Nesiritide (Natrecor®):
• IV infusion; short term therapy; not to
be given more than 48 hours
• Vasodilates veins and arteries and has
a diuretic effect
c. Positioning:
• _________________ position; legs down
Improves ______________________________
Promotes ______________________ of blood in lower
extremities
d. Prevention:
• Prevention when possible:
Check ________________________, and
Avoid fluid volume __________________.
Remember to
turn the nesiritide
infusion off 2 hours
before drawing a
BNP level.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 83
CARDIAC
G. Cardiac Tamponade:
1. Pathophysiology:
• _____________________, fluid, or exudates have leaked
into the pericardial sac resulting in compression of the heart.
• This can happen if the client has had a motor vehicle collision,
right ventricular biopsy, an ___________, pericarditis,
or hemorrhage post CABG.
2. Signs/Symptoms:
• Decreased cardiac output
• CVP will be _______________.
• BP will be dropping.
• Hallmark signs for cardiac tamponade
• ________________ CVP
• ________________ BP
• Heart sounds will be muffled or distant
• Neck veins _________________
• Pressures in all 4 chambers are the same
• Shock
• Narrowed pulse pressure (from the baseline)
What is the pulse pressure? It’s the difference
between the ________________ and the
______________________ pressure.
3. Treatment:
• Pericardiocentesis to remove _________________________
from around the heart
• Surgery
Narrowed
pulse pressure
think: Cardiac
Tamponade
Widened pulse
pressure
think: Increased
Intracranial
PressureCARDIAC
84 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
H. Arterial Disorders:
1. General Information:
a. Pathophysiology:
• If you have atherosclerosis in one place, you have it everywhere.
• It is a medical emergency if you have an acute arterial
_______________.
• Client will report numbness and pain
• The extremity will be cold
• No palpable pulse
• More symptomatic in ______________________ extremities
• Intermittent claudication- hallmark _________________.
• Arterial blood isn’t getting to the ____________________
coldness, numbness, decreased peripheral pulses, atrophy,
bruit, skin/nail changes, and ulcerations.
• Pain at rest means _________________ obstruction.
b. Treatment:
• Since arterial blood is having problems getting to the
tissue, if you elevate the extremity, would the pain
increase or decrease? ___________________
• Arterial disorders of the lower extremities are usually
treated with either angioplasty or endarterectomy.
We ELEVATE veins
We DANGLE arteries
We ELEVATE veins
We DANGLE arteriesCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 85
CARDIAC
CHRONIC ARTERIAL vs CHRONIC VENOUS
Symptom Chronic Arterial
Insufficiency
Chronic Venous
Insufficiency
Pain
Intermittent claudication
(progresses to pain at
rest)
None to aching pain,
depending on dependency
of area
Pulses Decreased or may be
absent
Normal (may be difficult to
palpate due to edema)
Color Pale when elevated, red
with lowering of leg
Normal (may see petechiae
or brown pigmentation with
chronic condition)
Temperature Cool Normal
Edema Absent or mild Present
Skin Changes
Thin, shiny, loss of hair
over foot/toes, nail
thickening
Brown pigmentation around
ankles, possible thickening of
skin, scarring may develop
Ulceration
If present, will involve
toes or areas of trauma
on feet (painful)
If present, will be on sides of
ankles
Gangrene May develop Does not develop
Compression Not used UsedPSYCHIATRIC NURSING
86 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
VII. PSYCHIATRIC NURSING REVIEW
A. Depression
1. Signs and Symptoms:
a. Loss of interest in life’s activities
Negative view of the ______________
Anhedonia: loss of ______________ in usually pleasurable things
b. Usually related to loss
c. What does this client look like? Poor kept appearance
1) Weight _____________ in mild depression
Weight ______________ in severe depression
2) Crying spells with ___________ to moderate depression
No more _________ with severe depression
3) Sleep disturbances are common.
4) Are their thoughts slow? ____________________. Speak slowly
when talking to them. This is a perfect time to use the therapeutic
communication technique of _________________________.
5) Can clients who are depressed have delusions and
hallucinations?_________________________CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 87
PSYCHIATRIC NURSING
2. Treatment: Nursing Considerations
a. Could they need help with their self-care? __________
b. Prevent isolation with depressed clients. Interacting with others
makes the client feel better.
c. Help them experience accomplishments.
d. Be careful with _____________________. These may make the
client feel worse.
e. If severely depressed, ______________ with client and making no
demands may be the best thing that you can do. It's a self-esteem
thing.
f. As they feel better, encourage them to _____________ their
feelings. Let the client know that you understand they are in pain
and feel powerless.
g. Help them set accomplishable goals.
h. If they are capable, activities such as ________________, running,
and weight lifting will help with depression.
i. Assess for _______________ risk. As depression lifts, what happens
to suicide risk? ____________________________
1) Observe clients with depression when they start taking
___________________ because their risk for suicide just went up.
2) A sudden change in __________ towards the better may indicate
that the client has made the decision to kill themselves.
3) Culturally, American Indians have a higher suicide rate.
__________ clients are particularly at risk for suicide. Elderly men tend
to be very successful because they generally use very ______ methods.PSYCHIATRIC NURSING
88 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
4) Ask them three very important questions
• Do they have a plan?
• What is the plan?
• How lethal is the plan?
5) Determine if they have __________ to the plan? Have they ever
attempted suicide before? Watch for things like:
• isolating themselves,
• writing a _________,
• collecting harmful objects,
• and giving __________ their belongings.
6) Suicide Interventions:
• Direct, ___________ ended statements
• Provide a ___________ environment.
• Safe-proof the room.
• Suicide is something that you should get a signed contract to
___________________.
B. Mania
One pole is ___________ and the other is _____________________.
1. Signs/Symptoms:
a. Continuous _________________
b. Emotions-labile
c. Flight of ideas
d. Delusions are just a false ____________________________.
• Delusions of grandeur (Example: Client thinks they are
_____________)
• Delusions of persecutionCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 89
PSYCHIATRIC NURSING
e. Constant motor activity ____________________
f. No Inhibitions: Inappropriate dress, hyper-sexual behaviors
g. Altered ___________ patterns
h. They have poor ___________________.
i. Manipulation makes them feel secure and ______________.
2. Treatment:
a. Decrease ____________________.
b. Don't ______________ or try to reason.
• Do you talk a lot about the delusion? ___________________
• Let the client know you accept that they need the belief or
delusion, but you do not believe it.
• Look for the underlying need in the delusion.
• Delusions of persecution: need is to feel safe
• Delusions of grandeur: need is to feel good about self
c. Set ______________________ and be consistent.
d. Feels most secure in one-on-one _____________________
e. Remove hazards.
f. Stay with client as anxiety ____________________.
g. They need a structured ________________________.
h. Provide __________________ to replace non-purposeful activity.
i. Supply finger ______________. They are too busy to stop and eat.
Walk with client during ______________.
j. Don't forget abut fluids because this client can become
dangerously dehydrated.
k. Make sure dignity is maintained.PSYCHIATRIC NURSING
90 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
Medications: Common psychotropic drugs are found under
medications in the Resource Documents online
m. ECT Treatment
1) This can induce a tonic clonic _________________.
2) It is used for clients with severe _______________
3) Pre-Procedure:
• NPO, void, and atropine is given
• A signed consent is necessary.
• Succinylcholine (Anectine®) is given to relax the muscles.
4) ECT Treatments are given in a series of treatments depending
on the client's response.
5) Post procedure:
• Position the client on the ______________ to prevent aspiration.
• Stay with the client.
• Temporary memory ____________ is expected.
• Reorient them repeatedly.
6) Return to day-to-day __________________ as soon as possible.
C. Schizophrenia
1. Signs/Symptoms:
a. Focus is inward. They create their own _____________________.
b. Inappropriate affect, flat affect, or blunted affect
c. Disorganized ________________ (looseness of associations)CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 91
PSYCHIATRIC NURSING
d. Ineffective communication skills: Communication is one of their
biggest problems.
1) Echolalia
2) Neologism: ______________________________________
• Seek clarification. “I don’t understand.”
• Do these words mean anything? ______________
3) ___________________ salads
e. Concrete thinking
f. Religiosity
g. Delusions
h. Hallucinations: auditory most __________________
2. Treatment: Nursing Considerations
a. Decrease ____________________.
b. Observe _____________________ without looking suspicious.
c. Orient frequently. (Important to remember that although the
client may know person, place, and time, delusions
and hallucinations may still occur.)
d. Keep conversations __________________________ based.
e. Observe for hallucinations.
• Warn before you ________________ them.
• Don't refer to the voices as "they" because this makes the
hallucinations seem real.PSYCHIATRIC NURSING
92 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Let the client know that you do not share the perception.
• Hallucinations are connected to times of anxiety.
• Get them involved in an ___________________.
• Elevate the head of the bed.
• Turn off the __________________.
• Offer reassurance because the client is frightened.
• Command hallucinations
Assess for: Command Hallucinations
Command hallucinations are auditory hallucinations that command the
client to hurt themselves or others. Command hallucinations are often frightening
for the client and can signal a psychiatric emergency.
D. Paranoid Personality Disorder
1. Signs/Symptoms:
a. Always suspicious, but have no reason to be; distrust of others
b. Cannot explain away their delusions or _______________
beliefs
c. Pathologic ___________________
d. Hypersensitive to comments or actions
e. Can't relax. No humor. Unemotional.
f. Abnormal anger response, responds with rage when provoked
2. Treatment:
a. Be reliable.
Your goal is to build trust. If you say you will do something, you
must do it!CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 93
PSYCHIATRIC NURSING
b. Be honest.
c. Consistent nurses and _________________ visits
d. Be matter-of-fact.
e. Respect personal space.
f. Be careful with _________________. A paranoid person cannot
handle the touchy, feely nurse.
g. Don't _______________________ medications. Always ID meds.
h. May need to eat sealed ______________.
i. Restraints: Restraints may be used when the nurse assesses
that the client is a _________________ to themselves or others.
• Used as a _______________ resort
RESTRAINTS: Joint Commission Standards
• The client must be evaluated in-person by a primary healthcare
provider within one hour of restraint.
• Orders must be renewed:
Every 4 hours for adults
Every 2 hours for ages 9-17
Every hour for less than 9 years of age
• Check client face-to-face every 15 minutes.
• Remember hydration, nutrition, and elimination. Provide
something to eat, ______________, and use of the bathroom.
• The client could be ______________ or die while in restraints,
so the need for accurate monitoring of this client cannot be
overstated!
E. Anxiety and Anxiety Disorders
1. Anxiety - Everybody has it.
a. Signs/Symptoms:
1) A universal ____________________PSYCHIATRIC NURSING
94 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
2) Becomes a disorder when it interferes with ________________ functioning
3) Increases performance at mild levels, decreases performance at high
levels
4) Client may not need the nurse's presence in mild anxiety;
however, the nurse should stay with the ____________ anxious
client.
5) The client who is highly anxious needs step-by-step __________________.
2. Generalized Anxiety Disorder (GAD)
a. Signs/Symptoms:
1) Chronic __________________
2) Called the "worry" disease
3) Client lives with it _______________.
4) Fatigued due to constant activity and muscle tension, always
uncomfortable
5) Always seek _______________.
b. Treatment:
1) Short-term use of anxiolytics
2) Relaxation techniques, deep breathing, imagery, deep muscle
relaxation, or meditation
3) Journaling over time may help to gain insight into anxiety, peaks and
valleys, and triggers.
4) Re-channel anxiety through ________________.
5) Stay calm, because anxiety is contageous.
3. Panic Disorders
a. Signs/Symptoms:
1) Onset of panic attacks start in the late _____________________.
2) They can be as frequent as _________________, or spread out, like
monthly.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 95
PSYCHIATRIC NURSING
3) The client may present in the ED with classic symptoms of an
_______________, but it will be a panic attack.
May be frightened and think they are dying
b. Treatment: Nursing Considerations
1) ___________________ with the client in a non-threatening way. Give
them space, and be calm. Don't add to the anxiety. Make them feel
secure.
2) If they are hyperventilating, slow down their breathing and breathe
with them.
3) Use simple _____________ or messages when talking. They
cannot understand complex messages.
4) Teach ways to stop anxiety. Teach that the symptoms should peak
within ____________ minutes and be gone within 20 - 30 minutes.
5) Journaling to help manage the _______________
6) Use relaxation techniques.
4. Phobias
The object the client fears often does not present a danger.
Treatment: Nursing Considerations:
1) Must develop a ______________ relationship with the client
2) Desensitization is the key to recovery, and it must occur over time.
3) Do not talk about the ____________ a lot.
• It is _______________________ anxiety that causes people to have a
phobia.
• Normal ___________________ mechanisms haven't worked and for some
reason, this fear may help them cope better.PSYCHIATRIC NURSING
96 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
5. Obsessive-Compulsive Disorder (OCD)
a. Signs/Symptoms:
1) Obsession is a recurrent _________________________.
2) Compulsion is a recurrent ________________________. They
cannot stop.
3) It comes from an unconscious conflict/anxiety.
b. Treatment:
1) Need a structured __________________________
2) Do we give them time for their rituals? ___________
• Their anxiety level goes up if they can't perform this ritual.
3) What do we do to the amount of time? ____________________
• Decrease the amount of time for performing the ritual and
increase the amount of time between the ritual.
• Never take away the ritual without replacing it with another
coping mechanism such as anxiety reduction techniques.
4) Provide distraction techniques to distance themselves from the
anxiety producing thoughts.
5) Teach relaxation techniques like meditation.
F. Eating Disorders
1. Anorexia Nervosa
a. Signs/Symptoms:
1) Distorted body image: Sees an overweight person when
looking in the mirror, even when weight is 75 pounds/34 kgs
2) Pre-occupied with food, but won't eat
3) Menses stop due to malnourishment.
• They may have lanugo.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 97
PSYCHIATRIC NURSING
4) Decreased _____________________ development
5) They lose ___________________.
6) They have _______________________ due to loss of
subcutaneous tissue.
7) Dehydration and electrolyte imbalances will result in a
_________ blood pressure and low pulse.
b. Treatment:
1) Increase _____________________ gradually. Weigh them in their
underwear because they will manipulate their weight.
2) Monitor ___________________ routine.
3) Acknowledge the difficulty of client's situation.
4) Teach healthy _______________________ and exercise.
5) Allow client's input into choosing healthy food items for meals.
6) Monitor for suicidal thoughts.
2. Bulimia Nervosa
a. Signs/Symptoms:
1) Overeat and then vomit
2) Teeth have erosion of enamel.
3) Laxative and diuretic use
4) Strict dieters: fasts, exercises, and binges
5) Binges are alone and secret.
6) Binges are pleasurable initially, but after consuming thousands
of calories, intense self-criticism may occur.
7) Normal _______________________PSYCHIATRIC NURSING
98 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b. Treatment
1) Sit with client at meals and observe for __________ hour after
eating.
2) Allow 30 minutes for meals.
3) Take focus away from the food.
4) Intense family therapy is usually needed because family
_______________________ is usually the cause.
5) Self-esteem building is important.
Clients with bulimia and anorexia nervosa - feel in ________ as long as they
are eating what they want.
G. Post-traumatic stress disorder (PTSD)
1. Signs/Symptoms:
a. Relives the experience, nightmares, and flashbacks
b. Emotionally _____________________________
c. Difficulty with relationships
d. Isolate ______________________________
2. Treatment:
a. First goal: Establish a sense of safety.
b. Engage client in learning new coping skills.
c. Support _________________.
H. Alcohol Use Disorder
• Individuals are considered to have a substance use disorder when the
use of the substance interferes with the ___________________ to fulfill
obligations such as work, school, or home.
• Alcohol is a depressant.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 99
PSYCHIATRIC NURSING
Stages of Withdrawal:
Stage I - Minor withdrawal
1) Starts within 4 - 12 hours of cessation of drinking
2) Mild tremors, nervous, nausea, insomnia, headaches and
palpitations
3) Oriented to time, place, and person.
Stage II - Moderate to Severe withdrawal
1) Increased tremors, confused, hyper-thermic, hyperactive,
nightmares, increased BP, increased respirations, hallucinations
and illusions
2) Carefully access and provide treatment during Stages I and II
so that we can prevent the client from progressing
to delirium tremens.
Stage III - Most dangerous withdrawal: Delirium Tremens (DTs)
1) Medical emergency
2) Kinesthetic DTs are most common.
• Clients feel things crawling on them.
3) Tonic clonic seizures are possible.
2. Treatment:
a. Keep the ____________________ on. Clients are very scared.
b. Encourage a close friend or family member to ____________ with
them.
c. Provide a quiet environment.
d. Walk and ___________ to them.
e. Orient the client ___________________.
f. ___________________ illusions
g. Seizure precautions
Chlordiazepoxide
(Librium®) is an
anxiolytic that is
frequently used
for outpatient
detox.PSYCHIATRIC NURSING
100 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
h. Anxiolytics: Don't be afraid to give them
Remember that the client has a tolerance to alcohol and a crosstolerance to other CNS depressants.
i. Sedatives like benzodiazepines are used because they not only
sedate, but have _______________________ qualities.
Examples: chlordiazepoxide (Librium®), diazepam (Valium®), and
lorazepam (Ativan®)
CIWA-Ar is an assessment tool that guides alcohol withdrawal medication
dosing. Frequently, treatment begins when scores reach 8-10 and client may be
transferred to ICU for scores >20. (See resource documents for copy of CIWAAr Assessment tool.
j. Keep the clients well __________________ and replace
electrolytes.
1) Usually have low thiamine, magnesium, calcium, potassium
and phosphorous because alcoholics don't eat or drink well.
2) Replacement with multi-vitamins, electrolyte solutions and
thiamine injections may be required during detox.
3) Thiamine deficiency can lead to the chronic conditions of
Wernicke's Encephalopathy and Korsakoff's Psychosis.
k. Alcohol induced delirium tremens should be prevented.
Wernicke's Encephalopathy: Most serious form of thiamine deficiency in alcoholics.
Symptoms include paralysis of the ocular muscles, diplopia, ataxia, somnolence, and stupor.
Without thiamine injections, death will occur.
Korsakoff's Psychosis: Syndrome of confusion and loss of recent memory. Often seen
when the client is coming out of Wernickes's. The two disorders are called Wernicke-Korsakoff
syndrome when they occur together.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 101
PSYCHIATRIC NURSING
3. Nursing Considerations:
a. Observe for the use of defense mechanisms. The major ones in
alcoholism are ________________ and rationalization.
b. Disulfiram (Antabuse®) is a deterrent to __________________
1) The client must sign a consent before Antabuse® is given.
2) The client must stay away from any form of ________________
including cough syrup, aftershave, colognes, and chemicals
such as varnish.
c. Must have support once detox is over
1) Family ____________________ emerge once the alcoholic is
sober. Family therapy is important for all family members.
2) 12-step program is effective.
I. Opioid Abuse:
1. Opioid abuse can start in one of two ways:
a. A ___________________________ from a primary healthcare
provider that is intended to treat a legitimate problem
b. _____________________________ use from the local dealer
The most common opiates are ______________, oxycodone, and meperidine.
2. Signs/Symptoms of Addiction:
a. Client needs _______________ drugs and needs them more
often because of built-up tolerance.
b. Drug seeking is no longer an option. It is survival.
3. Opiate Intoxication
a. Signs/Symptoms present as a triad.
1) Pinpoint ___________________
2) Respiratory depression
3) ComaPSYCHIATRIC NURSING
102 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b. Emergency Treatment
1) Administer naloxone (Narcan®) - It is an opiate antagonist
that dramatically _______________ the signs of overdose.
• May be given IV, IM, SQ, or intra-nasally
c. Follow-up Treatment:
1) All clients given naloxone in the field must go to the
hospital.
2) Naloxone is short acting and must be administered every
few _____________ until the opiate levels are non-toxic.
3) Failing to continue the naloxone dosages can lead to
death.
4) ________________________ naloxone is common in
emergency kits, in primary healthcare clinics, and AEDs.
4. Opioid Withdrawal
a. Can occur within hours to days of stopping the drug. Dependent on
specific drug.
b. Heroin users may have symptoms in 6 - 8 hours after use is
stopped.
c. Meperidine users withdraw faster than Heroine users.
The nurse is planning discharge teaching for the family of an opioid abuser. Which
information should be included? Select All That Apply
1. Naloxone by mouth is the preferred administration method.
2. CPR techniques should be learned by family members.
3. Location of the naloxone kit should be known by family members.
4. Naloxone dosage should be repeated every 10 minutes for up to 3 doses.
5. Hospitalization is not required if client recovers and respirations are greater
than 16.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 103
PSYCHIATRIC NURSING
1) Signs/Symptoms:
Agitated and ___________________ mood, nausea, vomiting,
muscle aches, excessive tearing and running nose, sweating, and
pupil dilation
2) Treatment:
• Methadone is a long acting opioid that can be substituted for the
opioid of addiction.
• Methadone can be titrated downward during rehab to ease
withdrawal symptoms.
• Users do not crave methadone.
• Users now have time to do purposeful things such as work, school,
and therapy.
• The client must be monitored in a methadone clinic long term,
because the dose is adjusted frequently.PSYCHIATRIC NURSING
104 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
4. Keep clocks, calendars, and personal items within reach and vision.
Mark days on calendar with a big X.
5. Be sure that glasses and hearing aids are accessible to
assist with orientation.
6. Identify all doors with pictures or easily identifiable labels.
Doors to rooms, closets, and bathrooms all need to be identified.
7. Monitor food and fluid intake. The client can easily become dehydrated
because they forget to eat or drink.
8. Weigh weekly.
9. Group activities of enjoyable things like dancing, singing, simple
games, exercising, and painting. Individualize activities to the client.
10. Have them dress in their own clothes whenever possible.
11. Keep the atmosphere calm.
12. Have client perform all tasks within their capacity to maintain
self-esteem
Major Neurocognitive Disorder: Alzheimer's Disease
Nursing Considerations:
1. Always identify yourself and call the client by name.
2. Communication:
a. Speak slowly so the client can process the information.
b. Use short, simple sentences and words. Focus on one piece of
information at a time.
c. Communicate face-to-face with one to two arms-length
distance to help attention and maximize verbal and non-verbal
cues.
3. Talk about meaningful things. Notice pictures in the room and
reminisce about happy times.
a. This helps the client to focus on a successful life and increase
self-esteem.
b. Do not reminisce if client has had a troubled life.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 105
RENAL
VIII. RENAL
A. Glomerulonephritis:
Acute can lead to chronic.
1. Pathophysiology:
a. Inflammatory reaction in the _______________________.
b. Antibodies lodge in the glomerulus; get scarring and
_____________ filtering.
c. Main cause: ___________________________________
2. Signs/Symptoms:
a. Sore throat
b. Malaise and headache
c. BUN & Creatinine _______
d. Sediment/protein/blood in urine
e. Flank pain (costovertebral angle tenderness - CVA tenderness)
f. BP _________
g. Facial ________
h. Urinary Output ________
i. Urine specific gravity ______
• Client going into fluid volume ______________.
3. Treatment:
a. Get rid of the strep.
b. Balance activity with rest.
c. I & O and daily weights
d. Monitor blood pressure.
e. How is fluid replacement determined?
• Fluid replacement = 24 hour fluid loss + __________.RENAL
106 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
f. Dietary needs:
• Protein? __________ Na? _____________ Carbs? ___________
g. Dialysis
h. Diuresis begins in ___ to ___ weeks after onset.
i. ___________ and protein may stay in the urine for months.
j. Teach Signs/Symptoms of_________________________.
• Malaise, headache, anorexia, nausea, vomiting,
decreased output and weight gain.
B. Nephrotic Syndrome:
1. Pathophysiology:
It’s an inflammatory response in the ________________ big holes
form so protein starts leaking out in the urine (what do we call this?
______________) Now the client is hypoalbuminemic (low albumin
in the blood) without albumin you can’t hold on to fluid in the
vascular space so where does all the fluid in the vascular space go?
___________________ Now the client is edematous since all the
fluid is going out into the tissue, what has happened to the circulating
blood volume?________ The kidneys sense this decreased volume,
and they want to help replace it The renin-angiotensin system
kicks in aldosterone is produced and causes the retention of
___________ and __________________ but is there any protein
(albumin) in the vascular space to hold it?__________ So where does
this fluid go?____________
Total Body Edema = ____________________________________.
Problems associated with protein loss:
• Blood ________(thrombosis)
They are losing proteins that normally prevent their blood
from clotting. Without these proteins, the blood can clot and
put them at risk for thrombosis.
• ______________cholesterol and triglycerides
The liver compensates by making more albumin causing an
increased release of cholesterol and triglycerides.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 107
RENAL
2. Causes: Idiopathic, but has been related to:
a. Bacteria or viral ___________
b. NSAIDs
c. Cancer and ___________ predisposition.
d. Systemic diseases such as lupus or diabetes.
e. Strep
3. Signs/Symptoms:
a. Proteinuria
b. Hypoalbuminemia
c. Edema (anasarca)
d. Hyperlipidemia
4. Treatment:
a. Diuretics
b. ___________________ to block aldosterone secretion.
c. Prednisone to _____________ inflammation.
• Shrink holes so ____________ can’t get out.
• Immunosuppressed.
d. Lipid lowering drugs for hyperlipidemia.
e. Sodium? ________________
f. Protein? ________________
g. Anticoagulation therapy for up to 6 months
h. Dialysis
Rule: Limit protein with kidney problems except with Nephrotic Syndrome.RENAL
108 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
C. Renal Failure:
• Requires bilateral failure.
1. Causes:
a. Pre-Renal Failure: _________ can’t get to the kidneys.
• Hypotension
• _________ heart rate (arrhythmia)
• Hypovolemic
• Any form of __________
b. Intra-Renal Failure: damage has occurred _________________
the kidney.
• Glomerulonephritis
• Nephrotic syndrome
• _____________ used in tests such as heart cath and CT scan
• Drugs (Aminoglycosides are nephrotoxic)
• Malignant ____________________ (uncontrolled HTN) and DM
causes severe ________________ damage.
c. Post-Renal Failure: _________ can’t get out of the kidneys.
• Enlarged ______________
• Kidney stone
• Tumors
• Ureteral obstruction
• Edematous __________ (Ileal conduit)
NCLEX® CRITICAL THINKING EXERCISE
An 18 month old has surgery for bilateral ureteral stents.
After surgery, the nurse reports a drop in urinary output.
What would be the priority nursing intervention?
1. Call primary healthcare provider
2. Turn from side to side
3. Irrigate
4. Reassess in 15 minutesCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 109
RENAL
2. Signs/Symptoms:
a. Creatinine and BUN ___________
b. Specific gravity:
• Initially _______
• Fixed specific gravity:
• May lose ability to concentrate and dilute urine.
• Fluid challenge - bolus with 250 mLs or greater
of normal saline
c. Anemia
• Not enough erythropoietin.
d. HTN
Retaining __________
e. HF
f. Anorexia, nausea, vomiting retaining ____________.
g. Itching frost (Uremic frost)
• Good skin care
h. Acid - base/fluid and electrolyte imbalances
• ____________________ could cause lethal arrhythmias.
• Metabolic acidosis.
• Retain phosphorous serum calcium _____ calcium pulled
from ____________________
3. Two phases of Acute Renal Failure:
• Kidneys have been damaged by one of the causes: this
damage leads to the oliguric phase.
a. Oliguric phase:
• What has happened to UO? ________________
• UO of _______ to _______ mL/ 24 hours.
• This client is in a fluid volume ____________.
• What do you think will happen to the potassium? ___________RENAL
110 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b. Diuretic phase:
• ____________ onset
• What is happening to the UO? _____________
• This client is in a fluid volume ______________. (Think Shock)
• What do you think will happen to the potassium? _________
D. Dialysis:
1. Hemodialysis:
a. General Information:
• The machine is the glomerulus (filter).
• Is done 3-4 times per week, so the client has to watch what
they _______ and _________ between treatments.
• To prevent blood ____________ from forming, the client is
given an anticoagulant during dialysis.
Usually Heparin - implement what?
_______________________________
• Depression Suicide
• Electrolytes and ___________ are watched constantly.
• Can all clients tolerate hemodialysis? ________
Unstable cardiovascular system can’t tolerate hemodialysis.
NCLEX® CRITICAL THINKING EXERCISE
What medications should you hold for a client
going to dialysis? Select all that apply.
1. Lisinopril
2. Nitroglycerin
3. Water soluble vitamin
4. Ampicillin
5. FamotidineCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 111
RENAL
b. Vascular Access:
• Must have a vascular access:
1) Types of Access:
• With hemodialysis, blood is being removed, cleansed,
and then returned at a rate of ______________ mL/min.
• What is a vascular access?
A site where they have access to a large blood
vessel because very rapid blood flow is essential for
hemodialysis.
• AVF (arteriovenous fistula) in forearm with an
anastomosis between an artery and a vein.
• AVG (arteriovenous graft) a synthetic graft to join
the vessels.
• Both require surgery. The access site takes weeks to
mature and to be ready for repeated venipunctures.RENAL
112 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• During dialysis two needles are inserted into the
vascular access.
One needle will allow blood to be pulled from the
circulation and sent to the hemodialysis machine.
The other is used to return the filtered blood to the
client’s circulation.
• The _________ end of the access will remove the blood
and the return is through the low pressure _________
end.
• For temporary access, the internal jugular or femoral
vein is often used for catheter placement. Surgery is
not required for temporary placement.
2) Care of Access:
• Do not use for IV access (drawing blood,
administering meds, etc.)
• When a client has an alternate vascular access, what is the
associated nursing care for that extremity?
No __________________________
No ________________ sticks
No ____________________________
3) Assessment of Access:
• Why? ______________________
• How?
Thrill - cat purring sensation (palpate)
Bruit - turbulent blood flow (auscultate)
Feel the _________ … Hear the _________.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 113
RENAL
2. Peritoneal Dialysis:
• Use peritoneal membrane as a _____________.
• Dialysate is warmed and infused into the peritoneal cavity by
gravity via a Tenckhoff catheter.
• The fluid (2000-2500 mL) fills the peritoneal cavity (takes about
10 min) and remains in the peritoneal cavity for a prescribed
amount of time. This is called the dwell time.
• Then the bag is lowered and the fluid, along with the ________,
etc., are drained.
That is called the exchange.
• Why do we warm the fluid? Cold promotes vasoconstriction
limits blood flow
We want it warm; this promotes _______________ and more
blood flow.
• What should the drainage look like?
__________, straw-colored . Cloudy = _______________
Should be able to read a newspaper through the drainage/
effluent.
• What type of client gets peritoneal dialysis? Someone who can’t
tolerate __________________ or someone who chooses peritoneal.
• What if all the fluid doesn’t come out? ________________________
a. Two Types of Peritoneal Dialysis:
1) CAPD (Continuous Ambulatory Peritoneal Dialysis):
• Must have a client that has the energy and the desire
to be active in their treatment and that also has the
ability to learn and follow instructions.
• Done ______ times a day, 7 days a week.
• 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 ________________________RENAL
114 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
2) CCPD (Continuous Cycle Peritoneal Dialysis):
• Connect their peritoneal dialysis catheter to a cycler
at ________ and their exchange is done automatically
while they sleep. Disconnected in the AM. The client
has more freedom.
b. Complications of Peritoneal Dialysis:
• Major complication is ___________________
(cloudy effluent 1st sign).
• Constant sweet taste
• May get a _____________.
• Altered body image/sexuality
• Anorexia
• Low back pain
c. Dietary Needs of the Peritoneal Dialysis Client:
• Increase what in the diet?
Fiber Have decreased peristalsis due to
abdominal fluid.
Protein Big holes in peritoneum and lose protein
with each exchange.
3. Continuous Renal Replacement Therapy (CRRT):
• Typically done in an _______ setting and is continuous so that the
client doesn’t have drastic fluid shifts.
• Never more than 80 mL of blood out of the body at one time
being filtered and therefore does not stress the cardiovascular
system as much.
• CRRT is performed on a client with:
A fragile cardiovascular status and acute ____________ failure.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 115
RENAL
E. Kidney Stones (urolithiasis, renal calculi):
1. Signs/Symptoms:
• Pain, and nausea/vomiting
• WBCs in ________________.
• Hematuria
• Anytime you suspect a kidney stone, get a ________ specimen
ASAP and have it checked for ________.
• If a kidney stone is present, the client will get pain medication
immediately.
2. Treatment:
• Ondansetron (Zofran®) and NSAIDS or opioid narcotics
• ____________ fluids.
• Maybe surgery
• Strain urine
• Extracorporeal shock wave lithotripsy (ESWL)RENAL
116 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NCLEX® CRITICAL THINKING EXERCISE
The nurse is assessing a client diagnosed with kidney stones who just returned
from extracorporeal shock wave therapy (lithotripsy).
The client is supine in bed with an indwelling catheter in place. Which finding
would be the best indicator that the treatment has been effective?
1. Total absence of pain.
2. The indwelling catheter is draining freely.
3. Rebound tenderness is absent during abdominal assessment.
4. Sand-like sediment has settled in the bottom of the indwelling catheter bag.
NCLEX® CRITICAL THINKING EXERCISE
A nurse is working in the ED and is assigned to care for the clients in examination
rooms 1, 2, and 3. The nurse received the following report from the off going
nurse:
1. The client in Room 1 is an elderly person who has fallen and is currently in CT
to rule out a subdural hematoma.
2. Client in room 2 is diagnosed with kidney stones, positive for hematuria and
has 8/10 pain.
3. The client in room 3 has a blood pressure of 90/40.
Let me ask you a question: which client would you go see first?IX. CRITICAL THINKING EXERCISES
Making Room Assignments
RULE: “LIKE ILLNESSES” CAN BE PUT IN THE SAME ROOM TOGETHER.
IN THE STEM OF THE QUESTION, THE NCLEX® LADY WILL TELL YOU THAT
THE TWO CLIENTS HAVE THE EXACT SAME CONDITION.
NCLEX® CRITICAL THINKING EXERCISE FOR MAKING ROOM
ASSIGNMENTS:
The nurse is caring for a client with AIDS that is in a semi-private room. Which
client is best to assign in the room with the client who has AIDS?
1. The client with asthma.
2. The client that is 8 hours post-appendectomy.
3. The client with bronchitis.
4. The client with partial thickness burns.
NOTES:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
CRITICAL THINKING
EXERCISES
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 117NCLEX® CRITICAL THINKING EXERCISE:
An 18 month old is admitted to the ED with a diagnosis of rotavirus and severe
dehydration. The client has no tears and has not wet a diaper in 5 hours. The
primary healthcare provider has prescribed D5 ¼ NS with 20mEq of KCL at
20 mLs per hour per pump. What would be the best action by the nurse?
NCLEX® CRITICAL THINKING EXERCISE:
PART I:
The charge nurse is making assignments for the shift. The staff includes an RN
pulled from the neonatal intensive care unit (NICU) who has not worked on an
adult floor in six years. What is the appropriate action by the charge nurse?
1. Send the RN back to NICU and give the nurses who are already working on
the floor an extra client.
2. Call the nursing supervisor and demand an RN with medical surgical
experience.
3. Attend the shift report.
4. Assign the NICU to do unlicensed assistive personnel duties.
PART II:
Which client is best to be assigned to the NICU nurse pulled to the adult medicalsurgical floor?
1. 4 hour post cholecystectomy client experiencing pain every 3 - 4 hours.
2. Elderly client with unexplained syncope.
3. Teenage client 8 hours post hypophysectomy.
4. New admit diagnosed with adrenal insufficiency.
NCLEX® CRITICAL THINKING EXERCISE:
The nurse is scheduled to administer the morning dose of Levothyroxine. The client
reports “fullness” in her chest that started after eating two hours ago. What is the
best action by the nurse?
1. Administer aluminum/magnesium suspension 30 mL.
2. Administer the Levothyroxine
3. Obtain a 12- lead ECG
4. Call the primary healthcare provider
CRITICAL THINKING
EXERCISES
118 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.NOTES:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
CRITICAL THINKING
EXERCISES
CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 119120 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NEURO
X. NEURO
A. Neurological Assessment:
1. Glasgow Coma Scale:
a. Definition: A scale that measures the degree or level of
______________________.
b. Used to assess the level of consciousness in a client who already
has _______________ consciousness or has the potential of altered
consciousness
c. Three responses of the Glasgow
Coma Scale:
1) ________ Opening
2) Motor Response
3) __________ Response
Rule: We like a high number
ranging from 13 to 15 for the
Glasgow Coma scale.
*LOC is always #1 with neurological
assessment
d. Factors that can alter the
Glasgow Coma scale:
• Drug use
• Alcohol intoxication
• Shock
• Hypoxia
GLASGOW COMA SCALE
Eye Opening (E):
Spontaneous - 4
To verbal command - 3
To pain - 2
No response – 1
Motor Response (M):
To verbal command - 6
To localized pain - 5
Flexed/withdraws - 4
Flexes abnormally - 3
Extends abnormally - 2
No response – 1
Verbal Response (V):
Oriented/talks - 5
Disoriented/talks – 4
Inappropriate words – 3
Incomprehensible sounds – 2
No response - 1
Total = E + M + V
CRITICAL THINKING EXERCISE:
Assessment data
1. Opens eyes when talked to but goes back to sleep between questions.
2. Answers with mumbles and moans and gives no reliable data.
3. Slaps your hand away with pressure on nail beds.
Score: ________________CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 121
NEURO
2. Pupillary changes (normal pupil size is 2-6 mm) PERRLA
3. Hand grips/lifts legs/pushing strength of _______________ (strength,
equality)
Also assessing if they can follow a command
4. Reflex assessment
a. Babinski Reflex:
• Normal in a child up to ______ year
• Abnormal in the __________
• The adult or child greater than one year should
have a normal reflex or curling of the toes when
the bottom of the foot is stroked.
• What does it mean if the adult has a positive Babinski reflex or
fanning of the toes when you stroke the bottom of the foot?
A severe problem in the ________________ nervous system
(Tumor or lesion on the brain or spinal cord, multiple sclerosis,
Lou Gehrig’s disease)
b. Reflexes:
GRADING REFLEX RESPONSES:
0 = No response (absent)
1+ = Present, but sluggish or diminished
2+ = Active or expected response (normal)
3+ = More brisk than expected. Slightly hyperactive, but not necessarily
pathological
4+ = Brisk, hyperactive, with intermittent or transient clonus
Ankle clonus - a series of abnormal reflex movements of the foot,
induced by sudden dorsiflexion.
A normal reflex response would be documented as _______________.
Negative Babinski
Positive Babinski122 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NEURO
B. General Diagnostic Tests:
1. Computerized Tomography (CT):
a. With/without contrast (dye)
Will you need the client to sign a consent form prior to the test
when using dye? ____________________
b. Takes pictures in _____________
c. Keep __________________ still
d. No ____________________
2. Magnetic Resonance Imaging (MRI):
a. Which is better, CT or MRI? ___________
b. Is dye used? _____________
• Is radiation used? _____________
• A _____________ is used
c. Will be placed in a tube where client will have to lie flat
d. Remove ______________________.
e. No credit cards
f. No _______________________________
g. Do fillings in teeth matter? _____________
h. Do tattoos matter? _____________
i. Will hear a thumping sound
j. What type of client can’t tolerate this procedure?
___________________________________________
k. Can talk and hear others while in the _______________
3. Cerebral Angiography:
Will a consent form be needed? __________
Why?__________________________________
X-ray of cerebral circulation
Go through the _____________________ artery.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 123
NEURO
a. Pre - procedure:
1) Well hydrated/void/peripheral pulses/groin prepped
• Anytime an iodine based dye is used, the client will need
to be well hydrated to promote excretion of the dye.
Watch:
BUN and Creatinine
Urinary Output
Hold metformin (Glucophage®)
2) Explain that they will have warmth in the face and a metallic
taste;
3) Allergies? ________________ or __________________
• An iodine based dye is used.
b. Post - procedure:
1) Bed rest for 4-6 _______________
2) Watch for bleeding at the femoral artery site
(BLEEDING/HEMORRHAGE)
3) Possible complication: Embolus
• An embolus can go to a lot of different places:
Arm, Heart, Lung, Kidney
• Since we are performing a test on the brain … if
the embolus goes to the brain… the client will have
a change in _____________, one-sided weakness, and
______________________, and motor/sensory deficits.
4. Electroencephalography (EEG):
a. Records electrical activity of the brain
b. Helps diagnose ________________ disorders and evaluate the
types of seizures occurring
c. Evaluates loss of consciousness and dementia124 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NEURO
d. Screening procedure for __________________
e. Indicator of __________________________ death
f. Used to diagnose sleep disorders like narcolepsy, cerebral infarct,
and brain tumors or abscesses
g. Pre procedure:
• Hold sedatives. Why? _________________________
• No ____________________________
• Not ___________________________________ (drops blood
sugar)
h. Beginning of the procedure:
• Will get a baseline first with client lying quietly (resting EEG)
• May be asked to hyperventilate to assess brain circulation,
assess photo stimulation for seizures, or sedate for sleep
study.
• If you have someone who is completely unconscious,
a pain response or noxious stimuli may be introduced to
stimulate a brain wave. This can be anything from a strong
smell like ammonia to a bright light.
5. Lumbar Puncture:
a. Puncture site: lumbar subarachnoid space
b. Purpose:
1) To obtain ___________ fluid to analyze for _________, infection,
and tumor cells.
2) To measure pressure readings with a manometer
3) To administer drugs intrathecally (brain, spinal cord)
c. How is the client positioned, and why? ________________________
___________________________________________________
d. Inspect the surrounding skin at the puncture site for any infection.
e. CSF should be clear and colorless (looks like water)CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 125
NEURO
f. Post-procedure:
• Lie flat or prone for 2-3 hrs.
• Increase ____________ to replace lost spinal fluid.
• What is the most common complication? _________________
• The pain of this headache ______________________ when the
client sits up and ________________ when they lie down.
• How is this headache treated? Bed rest, fluids, pain med,
and a ________________ patch
g. Life threatening complications:
• Brain herniation: With known increased ICP, a lumbar puncture
is contraindicated.
• Meningitis
Can bacteria get into the puncture site? ________
Can bacteria get into the spinal fluid? _________
What would that cause? ____________________
C. General Care for Any Client with Increased Intracranial Pressure:
1. Signs and Symptoms of ICP:
a. Early Signs:
1) Earliest sign? Change in________________
2) Speech? ____________________ or ___________________
3) Delay in response to _________________ suggestion.
Slow to respond to commands
4) Increasing drowsiness
5) Restless with no apparent reason
6) Confusion
b. Late Signs:
1) Marked change in LOC progressing to stupor, then
____________.
NORMAL LAB VALUE:
ICP: 0 -15 mm Hg126 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NEURO
2) Vital sign changes:
Called Cushing’s Triad and requires ____________________________
intervention to prevent brain ischemia.
Cushing’s Triad:
• Systolic hypertension with a ____________________ pulse
pressure.
• Slow, full, and bounding pulse
• ____________________ respirations. Look for a change in
pattern, like Cheyne Stokes or ataxic respirations.
3) Posturing: A response to ______________ or noxious stimuli.
Posturing indicates that the motor response centers of the brain are
compromised.
• Decorticate posturing: Arms flexed ______________ and bent in
toward the body and the legs are extended.
• Decerebrate posturing: All __________ extremities in rigid
extension; WORST.
• Client will be rigid, tight, and burning ___________________.
c. Miscellaneous Signs:
1) Headaches
2) Changes in _______________ and pupil response. (In profound
coma - fixed and dilated)
3) Projectile ___________________ can occur because the vomiting
center in the brain is being stimulated.
2. Complications of Increased ICP:
a. Brain Herniation: This herniation obstructs the blood ___________
to the brain leading to anoxia and then brain _____________.
b. DI and SIADH: Can be either, so you must assess for both.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 127
NEURO
3. Treatment of ICP:
a. Maintain ________________________.
• Decreased O2 levels and high CO2 levels cause cerebral
vasodilation which increases ICP.
b. Maintain adequate cerebral perfusion.
• Don’t want _______________________ or bradycardia because
that would ________________ brain perfusion.
• Isotonic saline and inotropic agents: dobutamine (Dobutrex®)
and norepinephrine (Levophed®)
c. Keep temperature below ______________________________.
1) An increased temperature will increase cerebral metabolism
which increases ICP.
2) The hypothalamus may not be working properly, and a cooling
blanket may be needed.
3) Hypothermia is used as a treatment to decrease cerebral
_______________ by decreasing the metabolic demands
of the brain.
d. Elevate the _________________________.
e. Keep head midline so the jugular veins can ______________.
f. Watch the ICP monitor with __________________, etc.
g. Avoid __________________, bowel/ bladder distention, hip
flexion, Valsalva, and isometrics. No sneezing and no nose
_________________
h. Limit ____________________ and coughing.
i. _______________ nursing interventions.
• Anytime you do something to your client, ICP increases.
j. Monitor the Glasgow coma scale
Rule: If the Glasgow coma score is below 8, think intubate.128 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NEURO
k. Monitor vital signs for Cushing’s Triad.
l. Barbiturate induced coma-________________ cerebral metabolism:
phenobarbital (Luminal®).
m. Osmotic diuretics: mannitol (Osmitrol®) ___________ fluid from
brain cells and filters it out through the kidneys.
This ______________ the ICP.
n. Steroids: dexamethasone (Decadron®) – decreases cerebral
_____________
o. ICP monitoring devices:
• Ventricular catheter monitor or subarachnoid screw
• Greatest risk? _____________________
• No loose connections
• Keep dressings __________. (Bacteria can travel through
something that is wet much easier than something that is dry.)
D. Neurological Alterations:
1. Meningitis:
a. Definition: Meningitis is ___________________ of the spinal cord
or brain.
b. Causes: Can be either viral or ___________________
Bacterial is primarily transmitted through the respiratory system.
c. Signs and Symptoms:
1) Chills and Fever
2) Severe ___________________
3) Nausea and Vomiting
4) Nuchal rigidity (stiff neck)
5) PhotophobiaCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 129
NEURO
d. Treatment:
1) Steroids
2) Antibiotics if _________________
3) Analgesics
4) Droplet ______________________ for bacterial meningitis
• Bacterial meningitis is a very contagious
medical emergency. It has a high mortality and
________________________ are recommended
for college aged students.
5) Viral meningitis is usually transmitted by feces and requires
________________ precautions.
• Commonly seen in infants and children
2. Seizures:
a. Define:
• Should be thought of as a ______________ of an underlying disorder
rather than a disease
• Seizures are not considered ___________________ if they discontinue
when the disease has gone away.
b. Classifications:
1) Partial Seizure:
• A partial seizure is limited to a specific _______________ area of
the brain.
• An aura may be the only manifestation.
• Called _______________ seizures
• Symptoms can range from simple to complex.
Simple means _______________ loss of consciousness; will see
numbness, tingling, prickling or ____________
Complex means that they have impaired consciousness and may
be confused and unable to respond.130 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NEURO
2) Generalized Seizure:
• Involves the ______________ brain
• Called non-focal seizures.
• Loss of consciousness is the ________________ manifestation.
INTERNATIONAL CLASSIFICATION OF SEIZURE DISORDERS:
Tonic /Clonic – formerly known as grand mal
Myoclonic – sudden, brief contractions of a muscle or group of muscles
Absence – formerly called petit mal and characterized by a brief loss of
consciousness.
c. Complications of Seizures:
1) Status epilepticus: a continuous seizure without returning to
consciousness __________________ seizures.
2) Trauma: Protect the client
d. Treatment:
1) Neurological examination including lab and X-ray
2) Anticonvulsants:
• Can be ___________ or short term therapy.
Rapid acting: lorazepam (Ativan®) and diazepam (Valium®)
Long Acting: phenytoin (Dilantin®) or phenobarbital
RULE: The NCLEX® lady only uses the generic name of a drug in an NCLEX®
question.
• Have ____________ side effects
• Monitor drug levels for toxicity through lab values.
• Abrupt _____________________ can cause a seizure.
3) Don’t forget the basics of _______________ and safety during
a seizure.
RULE: Do not put anything in the mouth of a seizing client.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 131
NEURO
E. Neurological Injuries:
1. Skull Injury:
• May/may not damage ___________
• Open fracture dura is ______________
• Closed fracture dura is _________ torn
• With basal skull fractures, you see bleeding where?
__________________
• Battle’s sign: bruising over ________________
• Raccoon eyes (peri-orbital bruising)
• Cerebrospinal rhinorrhea- leaking spinal fluid from your
____________________
• How do we tell CSF from other drainage? Positive for
____________________ and the halo test
• Non-depressed skull fractures usually do not require surgery;
depressed fractures do require surgery.
2. Brain Injury:
a. Concussion:
• Temporary loss of neurologic function with
_________________ recovery
• Will have a short (maybe seconds) period of unconsciousness
or may just get dizzy/see spots
• Teach caregiver to bring client back to ED if the following
occur:
Difficulty awakening/speaking, confusion,
severe headache, vomiting, pulse changes,
unequal pupils, one-sided weakness
All of these are
signs that the
ICP is going
______________!132 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NEURO
b. Hematomas:
A small hematoma that develops rapidly may be fatal, while a
massive hematoma that develops slowly may allow the client to
_________________________.
1) Epidural Hematoma:
• Pathophysiology:
This is rupture of the middle meningeal artery (fast bleeder
under high pressure).
Injury Loss of consciousness Recovery period Can’t
compensate any longer Neuro changes
• Treatment:
Burr Holes and remove the clot; control the _____________.
Ask questions to ID the type of injury and the treatment
needed:
• Did they pass out and stay out?
• Did they pass out and wake up and pass out again?
• Did they just see stars?
• Epidural hematoma is an ___________________.
2) Subdural Hematoma:
• Pathophysiology:
Usually a ___________________ bleed
Can be acute (fast), subacute (medium), or chronic (slow)
• Treatment:
Chronic: imitates other conditions;
Bleeding & compensating
Neuro changes = maxed out
Acute or Chronic: immediate craniotomy and remove
________: control ___________CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 133
NEURO
3. Spinal Cord Injury:
Autonomic dysreflexia:
a. Pathophysiology:
• With __________ spinal cord injury (above T6), the major
complication to look for is autonomic dysreflexia or
hyperreflexia.
b. Signs/Symptoms:
• It is a syndrome characterized by: severe _____________
and headache, bradycardia, nasal stuffiness, flushing,
sweating, blurred vision, and ____________________.
• Sudden onset. It is a neurological emergency. If not treated
promptly, a hypertensive _______________ could occur.
c. Causes:
• What can cause it? Distended ________________, constipation,
or painful stimuli.
d. Treatment:
• First, sit the client up to lower _____________ _______________.
• Treat the cause: Put in catheter, ________________ impaction,
look for skin_______________, painful stimuli, or a cold draft
breeze in the room.
• Teach prevention measures.
Autonomic dysreflexia is the result of a faulty response from the sympathetic nervous
system to a stimulus that occurs below the spinal cord lesion.
NCLEX® CRITICAL THINKING EXERCISE:
Which shoes would you buy for a Parkinson’s client?
1. Hot pink furry slippers
2. New Balance tennis shoes134 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NEURO
NCLEX® CRITICAL THINKING EXERCISE:
Which home health client would you go see first?
1. The Alzheimer’s client who fell yesterday and confusion has increased a little
2. The Type 2 diabetic client who has been out of medicine for three days
NCLEX® CRITICAL THINKING EXERCISE:
Your client has been diagnosed with an ischemic stroke. Signs and symptoms: right side
paralysis, trouble swallowing, and difficulty speaking. What is the priority intervention for
this client?
1. Prevent aspiration
2. Assist with range of motion exercises
3. Promote self-care
4. Provide a communication boardCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 135
GASTROINTESTINAL
XI. GASTROINTESTINAL
A. Pancreatitis: Auto-digestion of the Pancreas
1. Pathophysiology:
a. The pancreas has two separate functions:
1) Endocrine -_______________
2) Exocrine -______________________________ enzymes
b. Two types of pancreatitis:
1) Acute: #1 cause = ________________
#2 cause = gallbladder disease
2) Chronic: #1 cause = ______________
2. Signs/Symptoms:
a. Pain - Does the pain increase or decrease with eating?
___________________
b. Abdominal distention/ascites (losing protein rich fluids like enzymes
and blood into the abdomen) ascites
c. Abdominal mass - swollen ___________________________
d. Rigid, board-like abdomen (guarding or bleeding)
• What does it mean? Bleeding that can lead to __________________.
e. Bruising around umbilical area ____________ sign; flank area
Gray Turner’s sign.
f. Fever (inflammation)
g. Nausea/Vomiting
h. Jaundice
i. Hypotension =_______________ or ________________GASTROINTESTINAL
136 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
3. Diagnosis:
a. Serum lipase and amylase _______
b. WBCs __________
c. Blood sugar ______________
d. ALT, AST - liver enzymes _______
e. PT, aPTT ___________________
f. Serum bilirubin ______
g. H/H (Hemoglobin & Hematocrit) ___________
or _________
• Why down? _______________ Why up? __________________
4. Treatment:
a. Goal: Control pain
1) Decrease gastric secretions (___________,
NGT to suction, bed rest).
• Want the stomach empty and dry.
2) Pain Medications:
• PCA narcotics: morphine sulfate
(Morphine®), hydromorphone
(Dilaudid®)
• Fentanyl patches (Duragesic®)
b. Steroids, why? _____________________________
c. Anticholinergics, why? __________________
• benztropine (Cogentin®), diphenoxylate/
atropine (Lonox®)
d. GI Protectants:
1) Pantoprazole (Protonix®) - proton pump
inhibitor
2) Ranitidine HCI (Zantac®), famotidine
(Pepcid®) - H2 receptor antagonists
3) Antacids
e. Maintain fluid and electrolyte balance.
NORMAL LAB
VALUES:
Amylase:
30-220 U/L
Lipase: 0-110 U/L
NORMAL LAB
VALUES:
AST = 8-40 U/L
ALT= 10-30 U/L
TESTING
STRATEGY
Client with
pancreatitis:
Keep stomach
empty and dry.
NORMAL LAB
VALUES:
Hemoglobin:
Male: 14 -18 g/dl
(8.7-11.2) mmol/L
Female: 12 -16 g/dl
(7.9-9.9 mmol/L)
Hematocrit:
Male: 42-52%
(0.42-0.52 volume
fraction)
Female: 37- 47%
(0.37-0.47 volume
fraction)CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 137
GASTROINTESTINAL
f. Maintain nutritional status ease into a diet.
g. Insulin WHY?
• __________________________
• __________________________
• __________________________
h. Daily weights
i. Eliminate alcohol
j. Refer to Alcoholics Anonymous if this is the cause.
B. Cirrhosis:
1. 4 Major Functions of the Liver:
• _________________________ the body.
• Helps your blood to __________________.
• The liver helps to metabolize (break down)
___________________________.
• The liver synthesizes __________________.
2. Pathophysiology:
• Liver cells are destroyed and are replaced with
connective/scar tissue alters the
________________within the liver the BP in the
liver goes _____, this is called portal
___________________________.
3. Signs/Symptoms:
a. ___________, nodular liver
b. Abdominal pain – liver capsule has stretched
c. Chronic dyspepsia (GI upset)
d. Change in _____________ habits
e. Ascites
f. Splenomegaly
g. _________________ serum albumin
h. _________________ ALT & AST
TESTING
STRATEGY
If your liver is sick,
your #1 concern:
Bleeding.
TESTING
STRATEGY
If your liver is sick,
decrease the dose
of medications.
TESTING
STRATEGY
When the spleen is
enlarged, the immune
system is involved.
TESTING
STRATEGY
Never give
acetaminophen
to people with liver
problems.
Antidote for
acetaminophen
(Tylenol®) overdose
is acetylcysteine
(Mucomyst®).GASTROINTESTINAL
138 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
i. Anemia
j. Can progress to hepatic encephalopathy/coma.
4. Diagnosis:
a. Ultrasound
b. CT, MRI
c. Liver biopsy
• Clotting studies pre-procedure: PT, INR, and aPTT
• Vital signs pre-procedure
• How do you position this client? ___________________________
______________________
• Exhale and hold _____________________.
Why? To get the _________________ out of the way.
• Post-procedure: Lie on _____________ side.
Vital signs, worried about______________________________.
5. Treatment:
a. Antacids, vitamins, diuretics
b. No more ______________ (don’t need more damage).
c. I & O and daily _____________ (Any time you have ascites, you
have a fluid volume problem.)
d. Rest
e. Prevent bleeding (bleeding precautions)
f. Measure abdominal girth. Why? ______________________________
g. Paracentesis:
• Removal of fluid from the __________________ cavity (ascites).
• Have client void.
• Position _____________________________
________________________
• Vital signs
With "shocky" clients, the BP goes
______ and the pulse goes ______.
TESTING
STRATEGY
Anytime you are
pulling fluids you
can throw them
into shock.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 139
GASTROINTESTINAL
h. Monitor jaundice – good ___________ care.
i. Avoid _________________ - liver can’t metabolize
drugs well when it’s sick.
j. Diet:
• Decrease protein
• Low sodium diet
Let’s Get Normal Straight First!
Protein Breaks down to ammonia The Liver converts ammonia to urea
Kidneys excrete the urea
C. Hepatic Coma:
1. Pathophysiology:
a. When you eat protein, it breaks down into ______________________,
and the liver converts it to urea. Urea can be excreted through the
kidneys without difficulty.
b. When the liver becomes impaired, it can’t make this conversion.
What chemical builds up in the blood?_________________________
c. What does this chemical do to the LOC? _____________
2. Signs/Symptoms:
a. Minor mental changes/motor problems
b. Difficult to ______________
c. Asterixis
d. _____________________ changes
e. Reflexes will decrease.
f. EEG ________________________
g. What is fetor? Breath smells like _____________.
h. Anything that increases the ammonia level will aggravate
the problem.
i. Liver people tend to be GI bleeders.
TESTING
STRATEGY
If you give a liver
client narcotics, it's
the same thing as
double dosing them.GASTROINTESTINAL
140 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
3. Treatment:
a. Lactulose (decreases serum ammonia)
b. Cleansing enemas
c. Decrease _________________ in the diet.
d. Monitor serum ammonia
D. Bleeding Esophageal Varices:
1. Pathophysiology:
a. High BP in the liver (________________ HTN) forces collateral
circulation to form.
• This circulation forms in 3 different places stomach,
esophagus, and the rectum.
b. When you see an alcoholic client that is GI bleeding, it is usually
esophageal varices.
• Usually no problem until _______________
2. Treatment:
a. Replace ____________
b. VS
c. CVP
d. Oxygen (any time someone is ____________, oxygen is needed)
e. Octreotide (Sandostatin®) lowers BP in the liver.
f. Balloon Tamponade
• Sengstaken-Blakemore Tube is a type of balloon tamponade
tube.
• It is an infrequently used emergency procedure that may be
used to stabilize clients with severe hemorrhage. It should not
be used more than 12 hours. Many of the safety implications
for the Blakemore tube can be applied to other oropharynx or
nasopharynx tubes.
• What is the purpose? To hold ______________________ on
bleeding varices.
g. Cleansing enema to get rid of ________________________.
h. Lactulose (decreases ammonia)
i. Saline lavage to get blood out of _________________.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 141
GASTROINTESTINAL
E. Peptic Ulcers:
1. Pathophysiology:
a. Common cause of GI ___________________________
b. Can be in the esophagus, stomach, or duodenum
c. Mainly in males or females? _________________, but increasing
in ______________
d. Erosion is present
2. Signs/Symptoms:
a. Burning _________ usually in the mid-epigastric area/back
b. Heartburn (dyspepsia)
3. Diagnosis:
a. Gastroscopy (EGD, endoscopy):
1) NPO pre-procedure
2) Sedated
3) NPO until what returns? _________________________
4) Watch for perforation by watching for ____________, bleeding,
or if they are having trouble _______________________.
EVL or Endoscopic
Sclerotherapy
EVL and Endoscopic
Sclerotherapy are more
commonly used for
esophageal varices. EVL uses
a banding procedure and
Endoscopic Sclerotherapy is
when the physician injects
a sclerosing agent into the
varices via an endoscope.GASTROINTESTINAL
142 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b. Upper GI:
1) Looks at the esophagus and stomach with dye
2) NPO past midnight
3) No smoking, chewing gum, or mints. Remove the nicotine
patch, too.
• Smoking increases stomach ______________ ,which will
affect the test.
• Smoking _______________ stomach secretions, which will
increase the chance of aspiration.
4. Treatment:
a. Medications:
1) Antacids: Liquid or tablets? __________ (to _________ stomach)
• Take when the stomach is empty and at bedtime. When
the stomach is empty, acid can get on the ulcer, so take
antacids to protect the ulcer.
2) Proton Pump Inhibitors: (decrease acid secretions)
• Omeprazole (Prilosec®), lansoprazole (Prevacid®),
pantoprazole (Protonix®), esomeprazole (Nexium®)
3) H2 antagonist: ranitidine (Zantac®), famotidine (Pepcid®)
• GI Cocktail (donnatal, viscous lidocaine, Mylanta II®)
• Antibiotics for H. Pylori: clarithromycin (Biaxin®),
amoxicillin (Amoxil®), tetracycline (Panmycin®),
metronidazole (Flagyl®)
• Sucralfate (Carafate®): forms a barrier over the wound so
acid can’t get on the ulcer.
b. Client Teaching:
• Decrease _______________________________
• Stop __________________________________
• Eat what you can tolerate; avoid temperature extremes and
extra spicy foods; avoid _____________________ (irritant).
• Need to be followed for one yearCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 143
GASTROINTESTINAL
5. Classifications:
a. Gastric ulcers: malnourished; pain is usually half hour to 1 hour
after meals; food doesn’t help, but ____________ does;
vomit blood
b. Duodenal ulcers: well-nourished; night time pain is common and
also occurs 2-3 hours after meals; __________ helps; blood in
stools
F. Hiatal Hernia:
1. Pathophysiology:
a. This is when the hole in the diaphragm is too large so the
__________ moves up into the thoracic cavity.
b. Main cause is a large ____________________.
c. Other causes of hiatal hernia: congenital abnormalities, trauma,
and straining.
2. Signs/Symptoms:
a. Heartburn
b. _________ after eating
c. Regurgitation
d. Dysphagia (difficulty __________________)
3. Treatment:
a. Small frequent meals
b. Sit up 1 hour after eating Keep the stomach in down position.
c. Elevate HOB
d. Surgery
e. Teach life style changes and healthy diet.
G. Dumping Syndrome:
1. Pathophysiology:
• The stomach empties too quickly after eating and
the client experiences many uncomfortable to severe
side effects … usually secondary to gastric bypass,
gastrectomy, or gall bladder disease.GASTROINTESTINAL
144 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
2. Signs/Symptoms:
a. Fullness
b. Weakness
c. Palpitations
d Cramping
e. Faintness
f. Diarrhea
3. Treatment:
a. Semi-recumbent with meals
b. Lie down after meals.
c. No ___________ with meals (drink in between meals)
d. Meals should be small and frequent rather than large.
e. Avoid foods high in _______________ and electrolytes.
• Carbs and electrolytes empty fast.
H. Ulcerative Colitis and Crohn’s Disease:
1. Pathophysiology:
a. Ulcerative Colitis ulcerative inflammatory bowel disease
• Just in the large intestine
b. Crohn’s Disease also called Regional Enteritis; inflammation
and erosion of the ________________ but it can be found
anywhere in the small or large intestines.
2. Signs/Symptoms:
a. Diarrhea f. Dehydration
b. Rectal bleeding g. Blood in stools
c. Weight loss h. Anemia
d. Vomiting i. Rebound tenderness
e. Cramping j. Fever
• What is rebound tenderness? Push in let go ____________
• What does it mean? Peritoneal ____________________________
TESTING STRATEGY
Lay on left side to keep food in
the stomach.
Left side lying = Leaves it in
Right side lying = Releases itCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 145
GASTROINTESTINAL
3. Diagnosis:
a. CT
b. Colonoscopy
• _________________ liquid diet for 12-24 hours pre-procedure.
• _________________ 6-8 hours pre-procedure.
• Avoid NSAIDs
• Laxatives or enemas until ___________________.
• Polyethylene glycol (Go-Lytely®)
• To help your client drink a colon prep more easily, get it
___________________.
• Sedated for procedure
• Post-op: watch for _______________________. We are going to
assume the WORST! The signs of perforation are pain or
unusual ________________.
c. Barium Enema
• BE or lower GI series
• Done if colonoscopy is incomplete.
4. Treatment:
a. Diet:
• High fiber or low fiber? ______________
Trying to limit GI motility to help save fluid.
• Avoid cold foods, hot foods, and smoking
All of these can _______________ motility.
b. Medications:
• Antidiarrheals
Only given with mildly symptomatic ulcerative colitis
clients; does not work well in severe cases.
• Antibiotics
• Steroids (decrease _____________________)GASTROINTESTINAL
146 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
Biologics are genetically engineered medications that come from living
organisms and their products, like proteins. Biologics like adalimumab
(Humira®) and infliximab (Remicade®) are the newest class of
medications for the treatment of UC and Crohn’s Disease. Biologics
work by interfering with the body’s immune response. Biologic agents
are advantageous because they act selectively, unlike steroids which
tend to suppress the entire immune system.
c. Surgery:
1) Ulcerative Colitis:
• Total Colectomy (ileostomy formed)
• Kock’s ileostomy or a J Pouch (no external bag)
A Kock’s Pouch has a nipple valve that opens
and closes to _________ intestines
The J Pouch procedure removes the colon and attaches
the ileum to the rectum.
2) Crohn’s: (try not to do surgery)
• May remove only the ________________ area.
• The client may end up with an ileostomy or a colostomy.
It just depends on the area affected.
• An ostomy in the ileum is called an ________________ and an
ostomy in the colon is called a ______________________.
d. Post op Care:
1) Ileostomy Care:
• It’s going to drain ___________________ all the time.
Don’t have to irrigate ileostomies.
• Avoid foods hard to digest and rough foods: ______________
motility.
• Gatorade® or a similar electrolyte replacement drink in the
summer
• At risk for kidney stones (always a little _________________)
2) Colostomy Care:
• What happens as waste moves through the colon?
Water and nutrients are being absorbed and the
_____________ is forming.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 147
GASTROINTESTINAL
• Colostomy ascending and transverse semi __________ stools
• Colostomy descending or sigmoid semi formed or ___________.
• Which ones do you irrigate? __________________ & _______________
• Why irrigate? ________________________________________
• When is the best time to irrigate?
Same ______________ everyday
After a __________________________
• The further down the colon the stoma is, the more formed the stool
will be because ________________ is being drawn out. The stool is
more normal.
• When irrigating an ostomy, use the same principles as if administering
an enema.
• Anytime you are giving an enema, if the client starts to cramp,
________ the fluids, lower the bag and/or check the _______________
of the fluid.
TESTING STRATEGY
Positioning is very important to learn as a brand new nurse.GASTROINTESTINAL
148 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
I. Appendicitis:
1. Pathophysiology:
• Related to a ______________ fiber diet
2. Signs/Symptoms:
• Generalized pain initially.
Eventually localizes in the right lower quadrant (McBurney’s
__________).
• Rebound tenderness
• Nausea and vomiting
• Get good history (abdominal pain 1st, then nausea & vomiting)
• Anorexia
3. Diagnosis:
• WBC ______________
• Ultrasound
• CT
• Do not give enemas or laxatives because you are worried about
what? ________________
TESTING STRATEGY
#1 thing to worry about
is ruptureCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 149
GASTROINTESTINAL
TESTING STRATEGY
Never want pressure on a
suture line
TESTING STRATEGY
Protein can’t leak through
the glomerulus unless
there is kidney damage.
4. Treatment:
• Surgery
Most done via laparoscope unless
perforated.
After any major abdominal surgery, what is
the position of choice? ___________________________________
J. Total Parenteral Nutrition (TPN) Sometimes Called Hyperalimentation:
1. Nursing Considerations:
• Keep refrigerated; warm for administration; let sit out for a few
minutes prior to hanging.
• Central line needed
• Filter needed
• Nothing else should go through this line (dedicated line).
• Discontinued gradually to avoid ___________________________.
• Daily ___________
• May have to start taking___________________.
• Blood glucose monitoring every 6 hours.
• Check urine (for ______________ &
______________)
• Do not mix ahead- mixture changes everyday
according to electrolytes.
• Can only be hung for 24 hours.
• Change tubing with each new bag.
• IV bag may be covered with dark bag to prevent chemical breakdown.
• Needs to be on a pump.
• Home TPN - emphasize hand washing.
• Most frequent complication _______________________________GASTROINTESTINAL
150 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
2. Assisting the primary healthcare provider to Insert a Central Line:
• Have saline available for flush; do not start fluids until positive
confirmation of placement (CXR).
• Position? __________________________ to distend veins
• If air gets in the line, what position do you put the client in?
_______________, __________________
When an air embolus is suspected in the heart, the client may be
taken to the cath lab for removal of the air.
• When you are changing the tubing, how can you avoid getting air
in the line?
Clamp it off.
Valsalva
Take a deep ____________ and HUMMMMMM.
• Why is an x-ray done post-insertion?
Check for _____________________.
Make sure your client does not have a _____________________.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 151
RESPIRATORY
XII. RESPIRATORY
A. Thoracic (Chest) Procedures:
1. Thoracentesis:
a. Pre-procedure:
• _____________ and baseline ___________________
• Positioning:
Sitting up leaning over the bedside table
Sit in a chair backwards, propped up over the back of the
chair.
Can’t sit up? Lie on ______________ side with HOB at 45º.
b. Procedure:
• Client must be very still; no coughing or deep breaths.
• The fluid/blood/exudate is being removed from the
________________________.
• As the fluid is removed, the lung should____________________.
• Since you are removing fluid, the client could go into a fluid
volume ___________.
• You should be checking the ____________________.
c. Post-procedure:
• Another _________________RESPIRATORY
152 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
2. Chest tubes:
a. Chest Tube insertion:
• What has happened that the client needs a chest tube?
The lung has __________________________.
• If the chest tube is placed in the upper anterior chest, (2nd
intercostal space) then it is for removal of _______________.
• If the chest tube is placed laterally in the lower chest, (8th or
9th intercostal space) then it is for _______________.
Why? Air ________ and drainage _______________________.
• Can the client have both? _______
They are y-connected together and attached to a closed
chest drainage unit (CDU).
• The chest tube is sutured to the chest wall and an
______________ dressing is applied around the
chest tube exit site.
The chest tube is then connected to a closed chest
drainage unit.
• What is the purpose of the CDU?
It is to restore the normal vacuum pressure in the pleural
space. The CDU does this by removing all air and fluid in a
closed ____________ system until the problem is corrected.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 153
RESPIRATORY
b. Three chambers of the CDU:
1) Drainage collection chamber:
• The chest tube connects to a 6 foot connection tube that
leads to the _________________ collection chamber.
• What if this chamber fills up? _____________________
2) Water seal chamber:
• What is the purpose of the water seal?
• To promote ______________ flow out of the pleural space
which will prevent __________ from moving back up the
system and into the chest.
• The drainage chamber and water seal chamber are
connected by a straw-like channel that allows the drainage
to remain in the first chamber and the __________ to go
down into the water of the water seal chamber.
This chamber contains 2 cm of water which acts as a oneway valve. In other words, we are preventing backflow.
• You may see ___________ in this chamber when the client
coughs, sneezes, or exhales.
• You will see a slight rise and fall of water in the water seal
tube as the client ______________.
• This fluctuation is called ______________ and is normal.
If tidaling stops, it usually means that the lung
has re-expanded.
• The air exits the water seal chamber and enters the third
chamber called the suction control chamber. This allows
any air to be vented out through the air vent found at the
top of the suction control chamber.
3) Suction Control Chamber:
• If the client needs suction to remove air
and fluid, this chamber controls the
amount of ____________ applied.
• Sterile water is placed in this chamber
up to the 20 cm line. This is the usual
prescribed amount.
• Turn on the wall vacuum suction until you
have ___________ gentle continuous bubbling.
If a dry suction system
is used, water is not
used to regulate the
pressure and therefore
has no bubbling. A dial
is used to set the desired
negative pressure. Once
again, increasing the
vacuum wall suction will
not increase the pressure.RESPIRATORY
154 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
B. Management of Closed Chest Drainage Systems
1. Assessment:
• Assess dressing.
It must be kept _________ and __________.
• Listen to lung sounds bilaterally.
• Monitor pulse oximetry and report anything < ______.
• Record drainage every hour for 24 hours and then every _______.
• Notify primary healthcare provider of _______ mL of drainage or
greater in one hour, and if there is a change in color to bright
______.
• Deep breathe, cough, and use incentive spirometer.
• Watch for fever, WBCs, and drainage because they could
develop an ___________ at insertion site.
• Watch daily chest x-rays for ___________________.
NCLEX® CRITICAL THINKING EXERCISE:
A stable client hospitalized with a chest tube is scheduled for a chest
x-ray. Who can the Charge Nurse delegate the task of transporting this
client to radiology for their x-ray?
Select all that apply.
1. Transport Tech
2. RN
3. LPN/LVN
4. Radiology Tech
5. Unlicensed Assistive Personnel/UAPCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 155
RESPIRATORY
2. Maintaining CDU:
• Keep _______ level of chest
If you lift it too high " __________ will go back in.
We want to promote gravity drainage.
• Keep tubing straight and free of _____________ and dependent
loops.
• Tape connections. It must be a ______________ system.
• Monitor the water levels in the system.
• Want to see tidaling (fluctuations) with respirations.
Fluctuations will _________ when the lung has
re-expanded, if there is a kink/clot in tubing,
or a dependent loop is present in the system.
3. Trouble Shooting:
a. What do you do if the tubing becomes disconnected?
1) Keep another ________________ connector at bedside.
2) Reconnect as fast as you can.
b. What if my CDU falls over and the water leaks out or shifts to the
drainage compartment?
Do whatever you can to _______________ the water seal.
Set CDU upright, check all the chambers, and fill the water
seal chamber to 2 cm of water.
Have the client deep breathe and cough in case any air went
into the ____________________ space.
If there is no water in the water seal chamber, then air can do
what? Collapse the ___________
• What if the chest tube is accidentally pulled out?
Occlusive dressing taped down on ________ sides.
Otherwise, every time they take a breath, they will pull air into
the __________________________________.RESPIRATORY
156 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
c. When is bubbling normal?
Chest tube connected to suction - gentle _____________
bubbling is expected in the suction chamber.
If a client with a pneumothorax is coughing, sneezing,
or just taking a deep breath and exhaling, you may see
_______________ bubbling in the water seal chamber.
As long as there is intermittent bubbling, the client needs the
chest tube because air is still leaking out of the pleural space.
d. When is bubbling a problem?
• If there is ________________ bubbling in the water seal
chamber, then you have an air leak in the system.
• Never clamp a chest tube without a prescription.
It could lead to a ______________ pneumothorax.
4. Chest tube removal:
• Have client take a deep breath and ___________ (or Valsalva) and
place an occlusive petroleum dressing over the site.
C. Chest Trauma:
1. Hemothorax/Pneumothorax:
a. Pathophysiology:
• Blood or air has accumulated in the _______________________.
• What has happened to the lung? ________________________
b. Signs/Symptoms:
• SOB
• Increased HR
• Diminished breath sounds on the ______________ side.
• _________________ movement on the affected side.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 157
RESPIRATORY
• Chest pain
• Cough
• What will show up on the chest x-ray? _________ or __________
• Subcutaneous emphysema is air trapped in the tissue (usually
neck, face, and chest).
c. Treatment:
• Thoracentesis, chest tubes, daily CXR
• If a pneumothorax is present and the client has a chest tube,
what type of bubbling would be expected in the water seal
chamber? ________________________ bubbling
2. Tension Pneumothorax:
a. Causes: Trauma, PEEP, clamping a chest tube, or taping an open
pneumothorax on all 4 sides without an air valve can cause a
tension pneumothorax.
b. Pathophysiology:
• ________________ has built up in the chest/pleural space
and has collapsed the lung " ___________ pushes
everything to the opposite side (mediastinal shift).
c. Signs/Symptoms:
• Subcutaneous emphysema, absence of ____________
sounds on one side, asymmetry of thorax, respiratory
distress.
• Can be fatal as accumulating pressure compresses
vessels " decreases venous return " decreases
_________________________.
d. Treatment:
• Large bore needle is placed into the 2nd intercostal space (by
the primary healthcare provider) to allow excess __________ to
escape.
Then the cause is found, and chest tubes will be inserted.
RULE:
Never pull out
a penetrating
object.RESPIRATORY
158 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
3. Open pneumothorax (sucking chest wound):
a. Pathophysiology:
• Opening through chest that allows air into the _________________.
b. Treatment:
• Have the client inhale and hold or Valsalva or hummmmm.
These will __________ the intra-thoracic pressure so no
more outside air can get into the body.
• Then place a piece of petroleum gauze over the area.
Tape down how many sides? _______________
Fourth side acts like a what? ______________________________
• Have client sit up (if possible) to expand lungs.
Trauma clients stay flat, until evaluated for other injuries.
4. Fractures of ribs and sternum:
• Most common injuries from chest trauma.
a. Signs/Symptoms:
• Pain & tenderness
• Crepitus (bones grating together)
• Shallow ______________________
• Respiratory acidosis
b. Treatment:
• Non-narcotic analgesic
• Nerve block to assist with productive coughing
• Support injured area with hands.
• Not recommended to immobilize with chest binders
and straps; this could lead to shallow breathing, atelectasis
and pneumonia
• Observe for complications such as pneumothorax,
hemothorax and flail chest.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 159
RESPIRATORY
5. Flail Chest (occurs with multiple rib fractures):
a. Signs/Symptoms:
• Pain
• Paradoxical chest wall movement (see - saw chest); chest sucks
inwardly on inspiration and puffs out on expiration.
To assess chest symmetry, always stand at foot of bed to
observe how the chest is rising and falling.
• Dyspnea, cyanosis
• Increased pulse
b. Treatment:
• Stabilize the area, intubate, and ventilate.
• Positive pressure ventilation stabilizes the area.
1) PEEP (Positive End Expiratory Pressure):
• With PEEP, the client is on the ______________.
• On end expiration, the vent exerts _____________
down into the lungs to keep the alveoli open.
• Improves gas exchange and decreases the work
of _______________.
• It ___________ and realigns the ribs so they can start
growing back together.
• PEEP may also be used to treat pulmonary edema or
severe hypoxemia.
• The classic reason to use PEEP is Acute Respiratory
Distress Syndrome (ARDS).
2) BiPAP (Bi-level Positive Airway Pressure):
• Used for ARDS in clients with COPD, heart failure,
and sleep apnea.
• Exerts different levels of positive pressure support,
along with oxygen.RESPIRATORY
160 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
3) CPAP (Continuous Positive Airway Pressure):
• Pressure is delivered continuously during
______________ breathing, for both inspiration
and expiration.
• Used for obstructive sleep apnea
• Anytime you see PEEP, CPAP, or Bi-PAP, your priority
nursing assessment is to check bilateral
_______________ sounds.
D. Pulmonary Embolism:
1. Causes:
• Dehydration, venous stasis from prolonged immobility or surgery,
or birth control pills
• Clotting disorders or heart arrhythmias like A-Fib
2. Signs/Symptoms
• Hypoxemia #1
• PaO2? _______
• Short of breath, cough, RR
• Increased D-dimer (increased with pulmonary embolus)
Will tell if a clot is located ___________ in the body (not just
in the lungs)
• Positive VQ scan (a ventilation/perfusion scan that can detect an
embolus; done in radiology)
Looks at ________________ to the lungs. Dye is not used.
Remove _________ from chest area so that it will not give
false results.
• A positive spiral CT or CT angiography
• Hemoptysis, which is: _________________________
• Pulse? ________ because you’re ______________
• Chest pain (sharp, stabbing)
• CXR will show ____________________.
• BP in lungs? _____ (which is...)
• ___________________ hypertensionCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 161
RESPIRATORY
3. Treatment:
• Prevent!
Ambulate and __________.
• Oxygen
• ABGs
• Decrease pain.
• Heparin sodium, warfarin (Coumadin®),
enoxaparin (Lovenox®)
• What are the common anticoagulant drugs?
Heparin sodium, warfarin (Coumadin®), enoxaparin
(Lovenox®), dabigatran etexilate (Pradaxa®)
These drugs prevent a clot from getting _______________.
• While on warfarin (Coumadin®), limit ____________ leafy
vegetables. Limit foods high in ________________.
• Bleeding precautions
• Surgery
CLOTTING STUDIES
NORMAL LAB VALUES:
(may vary with institution)
aPTT: 30 - 40 seconds
PT: 11.0 - 12.5 seconds
Therapeutic INR: 2.0 - 3.0RESPIRATORY
162 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Bedrest
• Elevate extremities to increase venous blood return;
________________ pooling.
• TED hose; ______________________ venous return and decrease
pooling
Often used with SCDs
• Warm, moist heat ________________ inflammation
Never put cold on a vein = excessive vasoconstriction
Never put hot on a vein = excessive vasodilation
• Remember, prevention is the key.
We ___________________ and _________________ the client.
Also for prevention, put on SCDs and get the client to do isometric
exercises.
Isometrics decrease __________________.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 163
ORTHOPEDICS
XIII. ORTHOPEDICS
A. Fractures:
1. Signs/Symptoms:
a. __________ and tenderness
b. Unnatural _________________
c. Deformity (possible)
d. Shortening of ___________________
• Caused by muscle spasm
e. Crepitus (bones grating together)
f. Swelling
g. Discoloration
h. Worry about _________________________________
2. Treatment:
a. Immobilize the bone ends plus the adjacent joints.
b. Support fracture above and below site.
c. Move extremity as little as possible.
d. Splints help prevent ___________ emboli and _____________
spasms.
e. What do you do with open fractures? ______________________________
Preferably something ___________________
f. Most important thing: ____________________________ checks
g. Neurovascular checks: pulses, color, movement, sensation,
capillary refill, and temperatureORTHOPEDICS
164 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
3. Complications:
a. Shock: (Hypovolemic)
b. Fat embolism:
• With what type of fractures do you see this? The same
fractures that can lead to shock:
Long bones, (femur)
______________ fractures, and
______________ injuries
• Symptoms depend on what?___________________________
Petechiae or rash over chest
Conjunctival hemorrhages
Snow storm on CXR
• Young males
• First 36 hours
c. Compartment syndrome:
• Increased _______________ within a limited space
1) Pathophysiology:
• ______________ accumulates in the tissue and impairs
tissue perfusion.
The muscle becomes swollen and hard and the client
reports severe _________ that is not relieved with
pain meds.
• Pain is unpredictable.
______________ is disproportionate to the injury.
If undetected, may result in _______________
damage and possible amputation.
Common areas? _______________ & _____________CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 165
ORTHOPEDICS
2) Treatment and Prevention:
• Elevate extremity.
• Soft cast, then rigid cast
• Loosen the cast to restore
____________________.
• Be careful in picking the answer “remove
cast.”
• Cast cutters to remove cast
Instruct the client that the cast saw does not touch
the skin, but it does ___________.
(So be a nice nurse, and warn them.)
• Fasciotomy
4. Cast Care:
a. Plaster and Fiberglass Casts:
• Ice packs on the side for first 24 hours because cast is still wet
• No indentations
• Use _________________ for 1st 24 hours – casting material
is wet.
• Keep uncovered and allow for air _______________.
• Do not rest cast on a hard surface or sharp edge.
Rest on soft pillow; no plastic.
• Mark breakthrough bleeding. Circle area; date and time site.
• Cover cast close to ____________________ with plastic
(once the cast is dry).
• Neurovascular _____________ with the 5 Ps
• What do you do if your client reports of pain?
______________________________
Most pain is relieved by elevation, cold packs and
analgesics. (If these things do not relieve the pain … think
complication.)
Preventive
MeasuresORTHOPEDICS
166 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
b. Fiberglass Cast:
• More common than plaster casts
• Advantageous because they are lightweight, waterproof
and are ____________________ than plaster casts.
• Provides earlier ______________________ than plaster casts.
5. Traction:
a. Miscellaneous Information:
• Decreases ___________ ______________, reduces, and
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
______________.
• Special air filled or foam mattress
b. Types of Traction:
1) Skin traction:
• Used short term to relieve
_______________ spasms and
immobilize until _________________.
• This is when tape, a boot, splint, or
some type of material is stuck to the
skin and the weights pull against it.
• Is the skin penetrated? ______
• Common Type: Buck’s (used with hip
and femoral fractures)
• Must do good skin assessments.
TESTING
STRATEGY
Never release
traction (unless
you've got a
primary healthcare
provider's
prescription)CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 167
ORTHOPEDICS
2) Skeletal traction:
• This traction is applied directly to the bone with
_____________ and ___________.
• Used when prolonged ____________ is needed.
• Types: Steinman pins, Crutchfield, Gardner - Wells tongs,
and Halo vest
• Must monitor the pin sites and do pin
care.
Sterile technique? _____________
Remove crusts? __________
Is serous drainage okay? _______
B. Total Hip Replacement:
1. Pre-Op Care:
• Buck’s traction is used frequently pre-op.
2. Post-Op Care:
a. Nursing Considerations:
• Neurovascular checks
• Monitor drains (Don’t want fluid to accumulate in the tissues).
• Firm mattress (joints need support)
• Over-bed trapeze to build upper body strength
• Positioning:
___________ rotation - toes to the ceiling
Limit flexion; want _______________ of hip
Abduction or adduction? ________________
• What exercise can the client do while still confined to bed?
___________________
• What is the purpose of the trochanter roll?
To prevent ___________________ rotation.
Document in nurse’s notes.
• No weight-bearing until prescribed by the primary healthcare
provider.
TESTING STRATEGY
Clients with orthopedic or
joint problem require a
firm mattress for support.ORTHOPEDICS
168 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
• Avoid crossing legs or bending over.
• Is it okay to sleep on the operated side? _______
• Is hydration important with this client? ________
• Stresses to new hip joint should be minimal in the first 3-6
_____________.
• Is it okay to give pain meds in the operative hip? __________
b. Complications:
1) Dislocation " circulatory and _________ damage.
• Signs/Symptoms: shortening of leg, abnormal rotation,
can’t move extremity, and pain
2) Infection:
• Prophylactic antibiotics (just like with a heart valve
replacement)
• Remove indwelling catheters and drains as soon as
possible.
These will serve as a portal for ____________________.
3) Avascular Necrosis: (death of tissue due to poor circulation)
4) Immobility problems
c. Client Education/Rehabilitation:
• Best exercise? _____________
Avoid flexion: low chairs, traveling long distances, sitting
more than 30 minutes, lifting heavy objects, excessive
bending or twisting, or stair climbing.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 169
ORTHOPEDICS
C. Total Knee Replacement (Arthroplasty):
1. CPM (Continuous Passive Motion):
2. Keeps knee in motion and prevents formation of ____________
____________.
3. PT will set machine to ____________ increase flexion and extension
of knee.
4. Never _________________ or hyperflex knee.
5. Neurovascular checks.
6. Pain relief.
D. Amputations:
1. Miscellaneous Information:
• Amputations are performed at the most __________ point that
will heal.
• The surgeon tries to preserve the __________ and ___________.
2. Immediate Post-Op Care:
a. Keep what at the bedside? ___________________
b. Elevation post-op is controversial, because of hip contractures.
If prescribed, only elevate for a short time to reduce swelling.
c. Do not elevate on pillow. Elevate foot of bed.
d. Prevent hip/knee contractures. How? _______________
e. Inspect the residual limb daily to be sure that it lies completely
______________ on the bed.
f. Phantom pain
• What is the first intervention to decrease phantom pain?
Diversional ___________________
• Seen more with AKA’s (above the knee amputations)
• Usually subsides in 3 months.
NCLEX® TIP (TESTING STRATEGY)
Pain: may need to try other techniques first prior to medication;
the definition of pain is what the client says it is. Always assess the
client’s pain by having them rate their pain on a pain scale (i.e.,
0-10).ORTHOPEDICS
170 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
3. Rehabilitation:
a. Why is limb shaping important? _________________________
b. How do you want the stump shaped at the end? _______________
c. What is worn under the prosthesis? ____________________
d. Why is it important to strengthen the upper body?
They will be using crutches or a _________________ to ambulate.
e. Is it okay to massage the stump? ___________ It promotes
circulation and decreases __________________________.
f. How do you teach a client to toughen the stump?
Press into a ___________ pillow
Then a ____________ pillow
Then the ______________
Then a ________________
g. Walkers
Walk _________ a walker.
h. Crutches
Crutches should be 1-2 inches (25.4 - 50.8 mm) below the
_____________ to prevent risk of brachial nerve damage.
When ambulating stairs with crutches, it’s up with the good
leg, and down with the bad leg.
i. Canes
Used on the strong side of the bodyCRITICAL THINKING AND APPLICATION | STUDENT MANUAL 171
NCLEX STRATEGY
QUESTIONS
XIV. NCLEX® STRATEGY QUESTIONS
1. The nurse is caring for a client that has metabolic acidosis secondary to
acute renal failure. What is the initial client response to this problem?
1. Respiratory rate increases to blow off acid.
2. Respiratory rate decreases to conserve acid and buffer
the kidneys' response.
3. Kidneys will excrete hydrogen and retain bicarb.
4. Sodium will shift to cells and buffer the hydrogens.
2. The daytime charge nurse identifies that a client was treated for what
condition during the night after reading the following chart entries?
Exhibit:
PROGRESS NOTES:
1/22/18 – 0125 Restless, picking at sheets. Disoriented to place
and time. Dyspnea on exertion. Dr. Timmons notified. Stat
ABGs ordered.
–
1/22/18 – 0145 Oxygen started at 2 liters per nasal cannula.
Incentive Spirometry and deep breathing exercises initiated.
Head of bed elevated to 30º. –
LAB REPORTS:
pH - 7.30
paO2 - 91mmHg
paCO2 - 50 mmHg
HCO3 - 24 mEq/L
(24 mmol/L)
1. Respiratory Alkalosis
2. Respiratory Acidosis
3. Metabolic Alkalosis
4. Metabolic Acidosis172 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NCLEX STRATEGY
QUESTIONS
3. A client is hospitalized hundreds of miles from home for a bone marrow
transplant. The client is in a protective environment while undergoing
intense chemotherapy. The client’s sibling comes to visit and has obvious
manifestations of an upper respiratory infection. Which nursing action
would be most appropriate at this time?
1. Do not allow the sibling to visit, and do not upset the client by
mentioning the sibling’s visit.
2. Allow the sibling to wave at the client through the window or
door, then offer the use of the unit phone so they can talk.
3. Allow the sibling to visit after donning a sterile gown, mask,
and gloves, but prohibit physical contact.
4. Allow the sibling to visit after donning a sterile gown, mask,
and gloves, and have the client wear a mask.
4. The client has returned to the unit after an escharotomy of the forearm.
What is the priority nursing assessment?
1. Infection
2. Incision
3. Pain
4. Tissue perfusion
5. A client is admitted to the medical unit with a diagnosis of Addison’s
disease. What nursing interventions should the nurse implement for this
client? Select all that apply.
1. Monitor for decreased potassium levels.
2. Assist the client to select food low in sodium.
3. Administer fludrocortisone as prescribed.
4. Monitor intake and output.
5. Record daily weight.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 173
NCLEX STRATEGY
QUESTIONS
6. Which statements made by a client after receiving education regarding
bleeding precautions would indicate to the nurse that teaching was
successful? Select all that apply.
1. “I cannot shave while I am at risk for bleeding.”
2. “It is important to gargle with a commercial mouthwash three
times a day.”
3. “Stool softeners will help prevent rectal bleeding.”
4. “Prior to sexual intercourse, I will use a water-based lubricant.”
5. “I will use a soft toothbrush.”
7. A client is reporting shortness of breath and neck pressure following a
thyroidectomy. What is the priority nursing intervention?
1. Elevate the head of bed, remove the dressing, and stay with the
client.
2. Call a code, open the trach set, and position the client supine.
3. Have the client say “EEE” to check for laryngeal integrity and
assess Chvostek’s sign.
4. Call the primary healthcare provider, and assess vital signs.
8. The nurse observes a client in the manic phase of bipolar disorder in
group therapy. The client has interrupted the counselor’s group session
multiple times and states “I already know this information dealing with
others when you are down.” Which nursing action is appropriate?
1. Engage the client to walk with the nurse to make a pot of coffee.
2. Ask the group to reflect on the client’s behavior to determine if it
is appropriate.
3. Ask the group to tell the client how they feel about the
disruptions.
4. Instruct the client to perform jumping jacks to get rid of some
energy.174 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NCLEX STRATEGY
QUESTIONS
9. After examining the eyes of the following client, the nurse would expect
which correlating lab work?
1. Elevated cortisol level
2. Elevated thyroxine level
3. Decreased parathormone level
4. Increased calcitonin level
10.Which client should the nurse identify as being at highest risk for
suicide?
1. Seventy six year old widower with chronic renal failure
2. Nineteen year old taking antidepressants
3. Twenty eight year old, post-partum, crying weekly
4. Fifty year old with obsessive-compulsive disorder (OCD)
11.The client is transferred to the rehabilitation facility following an ischemic
stroke affecting the right side and aphasia. Which nursing action would
promote communication with the client?
1. Encourage client to shake head in response to questions.
2. Speak in a loud voice during interactions.
3. Speak using phrases and short sentences.
4. Encourage the use of a radio to stimulate the client.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 175
NCLEX STRATEGY
QUESTIONS
12.The nurse is caring for a client with pneumonia. Which nursing
observation would indicate a therapeutic response to the treatment for
the infection?
1. Oral temperature of 101º F. (38.3º C); increased chest pain
with non-productive cough
2. Productive cough with thick green sputum; states feels tired
3. Respirations 20, with no reports of dyspnea; moderate
amount of thick, white sputum
4. White cell count of 10,000 mm3, urine output at 40 mL/hr,
and no sputum
13. An elderly client is prescribed to begin ambulation with a walker
following hip replacement surgery. Which intervention by the nurse will
best help this client?
1 Sit in a low chair for ease in getting up with a walker.
2. Make sure rubber caps are present on all 4 legs of the walker.
3. Begin weight-bearing on the affected hip immediately.
4. Practice tying your shoes before using the walker.
14.A client has been admitted to the medical unit with elevated ALT, AST,
and bilirubin levels.
Identify the location the nurse would anticipate discomfort. Place an “x”
in the correct location.176 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NCLEX STRATEGY
QUESTIONS
15.A client had surgery for cancer of the colon and a colostomy was
performed. Prior to discharge, the client asks, "Will I still be able to
swim?" The nurse’s response would be based on which understanding?
1. Swimming is not recommended. The client should begin looking
for other areas of interest.
2. Swimming is not restricted if the client wears a dressing over the
stoma at all times.
3. The client cannot go into water that is over the stoma area, but
can go into water up to the stoma area.
4. There are no restrictions on the activity of a client with a
colostomy; all previous activities may be resumed.
16.The nurse is evaluating whether a client understands the procedure for
collecting a 24 hour urine sample. The nurse recognizes that teaching
was successful when the client makes which statements?
Select all that apply.
1. “I should start the 24 hour urine collection at the time of my first
saved urine specimen.”
2. “If I forget to collect any urine, I will need to start over.”
3. “It is important to ensure that no feces or toilet tissue mixes
with the urine.”
4. “When the 24 hours is up, I need to void and collect that
specimen.”
5. “The urine specimen should be stored in my refrigerator during
collection.”
17.A six year old client has been receiving chemotherapy for two weeks.
The laboratory results show a platelet count of 20,000/mcL. What is the
priority nursing action?
1. Encourage quiet play.
2. Avoid persons with infections.
3. Administer oxygen PRN.
4. Provide foods high in iron.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 177
NCLEX STRATEGY
QUESTIONS
18.The nurse is caring for a client that has two IV access sites. Where is the
best site for the nurse to administer 20 mEq (20 mmol/L) of potassium
chloride (KCL) in 100 mL of normal saline (NS) over 4 hours
Exhibit:
INTRAVENOUS FLOW SHEET
IV Site/Needle
Size
Continuous/
Saline port
Date/Time
Initiated
IV Fluid/
Blood
Products
Date/Time
Administered
IV
rate
Signature
Left antecubital Continuous 01/01/2018
@1020
Normal
Saline
01/01/2018
@1020
KVO
Double lumen
central lineProximal line
Continuous 01/01/2018
@1300
Total
Parenteral
Nutrition
01/01/2018
@1300
50
mL/
hr
Double lumen
central lineDistal line
Saline port 01/01/2018
@1300
Saline Flush 01/01/2018
@1300
Double lumen
central lineDistal line
Saline port 01/01/2018
@1500
Blood draw
for lab.
Saline Flush
01/01/2018
@1500
1. Central line port that is being used for lab draws
2. Same line with the Total Parenteral Nutrition
3. Large bore antecubital
4. Start another peripheral IV
19.The nurse is admitting a client with new onset diabetes mellitus. Which
findings does the nurse expect while completing the medical history and
physical examination of this client? Select all that apply.
1. Recurrent yeast infections
2. Reports intolerance to cold
3. Slow, slurred speech
4. Prescription glasses changed twice in past year
5. Reports wanting to eat all the time
6. Absence of menses178 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
NCLEX STRATEGY
QUESTIONS
20.A client is admitted for evaluation of cardiac arrhythmias. What would be
the most important information for the nurse to obtain when assessing
this client?
1. Ability to perform isometric exercises.
2. Changes in level of consciousness or behavior.
3. Recent blood glucose changes.
4. Compliance with dietary fat restrictions.
21.A nurse is caring for a client diagnosed with heart failure (HF). The client
currently takes furosemide 40mg every morning, potassium 20mEq daily,
and digoxin 0.25mg every day. Which client comment should the nurse
assess first in caring for this client?
1. “My fingers and feet are swollen.”
2. “My weight is up 1 pound (0.45 kg).”
3. “There is blood in my urine.”
4. “I am having trouble with my vision.”
22.A client with a T4 lesion is being cared for on the neuro rehabilitation
unit. The client suddenly reports a severe, pounding headache. Profuse
diaphoresis is noted on the forehead. The blood pressure is 180/112 and
the heart rate is 56. What interventions should the nurse initiate?
Select all that apply.
1. Place the client supine with legs elevated.
2. Assess bladder and bowel for distention.
3. Examine skin for pressure areas.
4. Eliminate drafts.
5. Administer nifedipine if BP does not return to normal.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 179
NCLEX STRATEGY
QUESTIONS
23.The nurse is caring for a client in the 8th week of pregnancy. The client
is spotting, has a rigid abdomen, and is on bed rest. What is the most
important assessment at this time?
1. Protein in the urine
2. Fetal heart tones
3. Cervical dilation
4. Hematocrit level
24. Which tasks would be appropriate for the nurse to delegate to an
LPN/VN? Select all that apply
1. Prepare a client's room from surgery.
2. Observe for pain relief in a client after receiving acetaminophen
with codeine.
3. Assist a client with perineal care after having diarrhea.
4. Clean nares around a client's NG tube.
5. Pour a can of tube feeding into a client's percutaneous
endoscopic gastrostomy
25.A nurse in an urgent care clinic is assisting with triage when five clients
present to the clinic at the same time. Prioritize the order in which the
nurse should attend to the clients.
________ 1. The client who is limping after “spraining” the right ankle.
________ 2. The client who is experiencing heaviness in the chest after
eating a big meal.
________ 3. The client who is running a fever and reports muscle aches
and malaise.
________ 4. The client who is applying pressure to the hand after
sustaining a minor cut.
________ 5. The client who is having difficulty breathing after eating
shellfish.180 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
HOW TO PASS
XV. HOW TO PASS
• You are NOT SUPPOSED to know everything right now.
• You have everything you need to pass if you study the information
properly.
• It's up to you!
• When a question comes up on the screen at the testing center, this is
what you need to be thinking to answer correctly:
• I know my core content and nothing is going to change my mind
about it.
• I am going to think like a brand new nurse with 2 weeks of vast
nursing knowledge.
• I am going to be very careful not to harm the client...It's a safety
test to protect the public.
• I will think NCLEXY; I will assume the worst, fix the problem,
and not be a killer nurse.
• You do not have to go back and study all of your notes from school or
read your Med-Surg book.
• Nobody can KNOW that much information.
• YOU do not have to know that volume of material because the
NCLEX® people know you are a BRAND NEW NURSE.
But you better know this material, and I mean ALL OF IT!
Ways to study:
1. Repetition, Repetition, Repetition
2. Once you think you know a topic (like FVE), write out skimpy notes
with just cue words on them and see if you can lecture.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 181
HOW TO PASS
– When you are looking at your cue words, is anything coming to
mind?
– Nothing coming into your mind… you need to study more!
Example:
Fluid Volume Excess
– Another word for it?
– What is it?
– HF?
– Renal Failure?
– Aldosterone?
– If you cannot look at these words one at a time and hold
your head up and lecture on it OUT LOUD, then you need to
study more.
3. Record yourself lecturing on one topic at a time.
– Listen to self ____________; Listen for your ______________
– Check yourself against your notes to see what you are leaving out.
– If you can ________ it, you can _________ it!
– We have said things a CERTAIN way on PURPOSE…you need to say
it that way too!
4. The "Why?" question
– Do you know the "Whys" behind Signs/Symptoms, causes,
and interventions?
5. Study at least the Med-Surg with a friend who has taken the Hurst
course with you.
(Watch the required video lectures from your Hurst account or you
will not get credit for them).182 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
HOW TO PASS
6. Practice studying the right way.
– RULE: If you learn this information the way we are telling you, then
you will be able to pass the first time.
Let’s practice
– Tell your friend, how HF causes FVE.
– Tell your friend how aldosterone can cause shock.
7. Review the online resource material through your online account at
www.hurstreview.com from the "My Review" tab.
• Watch the specialty area videos and fill in the blanks in the
student pages.
• Do not try to memorize all the online "Resource Documents" but
use them to refresh your memory in areas where you are weak.
We just made these documents available so you wouldn’t have to
look it up!
– This is the icing on the cake
– There is a LOT of information here… You do not have to print
out every document unless you want to do so.
– Study the Pharmacology handouts along with the core content.
If you are studying cardiac content, study the handout section
on cardiac at the same time.
8. Take your Q-Review Simulator tests only when you know your core
content without a doubt and hesitation.
– Don't say, "Well I think I am going to take one test just to see how
prepared I am." No! Use the 1000-item practice test bank called
the Q Review Customizer to practice questions.
– You must know the material first, then take your Simulator tests.
– You only have a limited number, so don't take one until you are
prepared.
– The Q Review Simulator will allow you to launch 4 different
NCLEX® style tests that are 125 questions each and are based on
the NCLEX® test plan.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 183
HOW TO PASS
– Once you have taken a test, you will be able to view the questions
and the rationales for both the right and wrong answers.
– You will note on your study guide that we would like for you to average
77 out of 125 questions correctly on your Q Review Simulator tests. If
you are not, we want you to go back and study more!
9. Are you going to get questions on topics you’ve never heard
of before? _______________________
– Can I still pass? _____________
– If I haven’t heard of it … nobody else has either!
10. If I purchase every NCLEX® question book in the world, will I have all
of the questions?_________________
11.When I select an answer, will I feel confident I got it right?___________
– You must not get upset if you are not feeling confident.
12.If you study properly, the higher the level of questions you will get,
the worse you will feel, and the better you’ll do on the test!
– If all the answers look right, you either haven’t studied or you are in
the higher level questions.
13.You will never be more motivated than you are right now to pass.
– Have a new job
– Have a new car note
– Your family is excited for you!
14.Major life events
– If you are getting married, or divorced, if there is a death or
sickness, then these are distracters. (Many unpreventable)
15.Alternate format items184 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
HOW TO PASS
ALTERNATE ITEM FORMATS MAY INCLUDE:
• Multiple-response items (Select all that apply) require a candidate to select
from a list of five to six options. The final answer is either correct or incorrect;
NO partial credit given.
• Fill-in–the-blank items require a candidate to type in number(s) in a
calculation item.
• Hot spot items ask a candidate to identify one or more area(s) on a picture
or graphic.
• Chart/exhibit format: Candidates will be presented with a problem and will
need to read the information in the chart/exhibit to answer the problem. You
do not have to read all the exhibits. But remember, if the data is there, it is
important to answering the question. So, open and read all exhibits.
• Audio item format: The candidate is presented an audio clip and uses
headphones to listen and select the option that applies.
• Graphic Options: Presents the candidate with graphics instead of text for the
answer options. You will be required to select the appropriate graphic answer.
• Sequencing/Drag and Drop/Ordered Response: The candidate is required
to place options in an order by either clicking on an option and dragging it to
the correct order OR highlighting and clicking an arrow to move the option in
the proper direction. All options must be used.
• Any item format, including standard multiple-choice items, may include
multimedia, charts, tables, or graphic images.
– _________ questions on your test will be pilot questions- this is for the
RN. These do not count for you or against you, and you will not know
which ones are pilot questions.
– The LPN will have 25 pilot questions.
– All of these may be alternate format items which would make you think
that your entire test was alternate format questions.
– Don't fear... know your core content and you can answer any question!
– You will see examples of these type of questions in both the student
tutorial at http://www.pearsonvue.com/nclex/ and the Test Plan for
Educators at www.ncsbn.com.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 185
HOW TO PASS
16.What is the #1 reason people fail boards (and it is NOT testing
anxiety)? Knowledge Deficit!!!!!
On the next few pages, you have Hurst Strategies. We have divided
them into two categories: Core Content Strategies and Testing
Strategies.
If you want something to read the day before you take the test, these
things are good tips for you to remember.186 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
HOW TO PASS
HURST REVIEW STRATEGIES
Testing Strategies:
1. If it is an option in the question, you have a prescription for it.
2. The NCLEX® hospital is perfect, and you have to care for only one client…the one on
the screen.
3. Drug calculation problems or fill in the blanks will tell you exactly how many spaces
past the decimal point that they want. All you must remember is to round off at
the end.
4. There is no fluff content in a question; if data is there, you need to know it to answer
the question or it would not be there.
5. Least invasive first
6. If you have never heard of it, don’t pick it.
7. Do not pick an answer that delays care or treatment.
8. Never pick an answer that does not allow your client to speak.
9. Select a client focused answer.
10. With priority questions… Remember, you can only send one message to the NCLEX®
lady…so you must pick the “killer answer.”
11. There will not be a test question unless there is something to WORRY about.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 187
HOW TO PASS
12. Assume the WORST.
13. Only call the primary healthcare provider if there is NOTHING that you can do about
the problem as a nurse.
14. Like illnesses can be put in the same room together.
15. If there are any long term consequences to your client with the answer you pick,
you should not pick it.
16. If you see words like “assessment” or “evaluation” in the stem of the question…think
signs and symptoms.
17. You will report something “new” or “different” or “possible” to the next shift nurse.
18. If you can narrow the answers down to 2 answers…pick the most life threatening
answer.
19. Never pick an answer that puts off work on someone else.
20. Never pick an answer that ignores or brushes off the client’s report of something.
21. If the answer is not applicable to the situation, don’t pick it. Airway may not be
appropriate to the situation!!!
22. When answering “Select All That Apply” questions, look at each option as a true/false
question. If the option is true, then select it as a correct answer.188 Copyright protected. Reproduction prohibited without authorization and release by Hurst Review Services.
HOW TO PASS
Core Content Strategies:
1. Pain never killed anybody
2. Never release traction UNLESS you have a prescription from the primary healthcare
provider to do so.
3. Polyuria – think shock first
4. Anytime you see fluid retention…think heart problems first.
5. ADH – Think H2O
6. Aldosterone – Think sodium and water.
7. With SIADH – TOO many letters TOO much WATER.
8. More Volume – More Pressure
9. Less Volume – Less Pressure
10. Hypoxia may be the first sign of respiratory acidosis.
11. With restless client…think hypoxia first.
12. Limit protein in kidney clients EXCEPT with nephrotic syndrome and those on
peritoneal dialysis.
13. If you have a fluid problem…you will do I&O and daily weights.
14. Anytime you have a magnesium or calcium question…think muscles first.
15. Digoxin + hypokalemia = toxicity
16. Elevate veins and dangle arteries.
17. Always worry if the rate decreases below the set rate with a pacemaker.CRITICAL THINKING AND APPLICATION | STUDENT MANUAL 189
HOW TO PASS
Hurst Review Check List for NCLEX-RN® Success
COMPLETE HURST REVIEW GUIDELINES
Live Review: While you are attending the live review, please come rested,
on time and ready to learn. If you come with an attitude of openness for
reviewing the Hurst NCLEX® way, you will have a head start on passing the
NCLEX® the first time. Listen carefully to your instructor, fill in the blanks,
and start thinking NCLEXY. This is the time your critical thinking skills
transition from those of a graduate nurse to those of a registered nurse.
Oncology II
Specialty Lectures: At www.hurstreview.com you will find access to the
specialty area videos and resource documents under My Review. We
recommend that you watch the specialty area online lectures of Oncology
II, Maternity, Complications of Maternity, Pediatrics, and Management and
Delegation as soon as possible after your live review. You have access to
these lectures and our Resource Documents for 9 months after your first live
review. A link for the Resource Documents, found under My Review, will
provide you with additional information on infection control, pharmacology,
pediatrics, and other areas that you may want to review. This is icing on the
cake and is provided only if you need additional review.
Maternity
Complications of
Maternity
Pediatrics
Management/
Delegation
Online Review of Lectures covered in Live Review: You have access to
all lectures by video for 14 days after the end of your first live review. Your
online access will allow you to watch all the lectures as many times as you
need for a 14 day period. During this 14 day period, you should devote
as much time as you require toward learning the core content “without a
doubt or hesitation.” You should use all of the techniques that Aunt Marlene
talked about, such as finding cue words on each page and audio recording
as you recite the materials. These lectures are accessed by signing into your
Hurst account at www.hurstreview.com and clicking on My Review. The 14
Day Access start date will be set by you at the completion of your first Live
Review. If you want access to these lectures again, they can be purchased
for a discounted price for 30 days.
Intense Study Time: Now that you have your student book filled out, it is
time to study like Aunt Marlene instructed. If you have forgotten her hints,
re-read your How to Pass student pages for review. No one can tell you how
long to study or when you have studied enough, but it should take you a
minimum of 2 to 3 weeks to learn the content without a doubt or hesitation.
Don’t go into the biggest test of your life unprepared. During this study
time use the Hurst Customizer questions to develop mastery of content.
Q Review 1 Q Review: Once you have learned all of your materials, you are ready
to take a Q Review Simulator test. The Q Review Simulator provides four
tests that are 125 questions. Each test consists of the eight “Client Needs”
categories based on the percentages defined by the NCLEX-RN® Test Plan.
Only you know when you have studied properly and know the core content
"without a doubt or hesitation." You can access these tests through the Q
Review link for 9 months after your first live review. You should review each
of the completed tests with rationales under your "Previously Taken Tests"
on your Q Review Simulator page. A median score of 77/125 is common
among students who pass the first time. If you are not scoring close to this
number, you should study more.
Q Review 2
Q Review 3
Q Review 4
Check List Complete? ➞ Meet with the NCLEX® Lady Date:
Unsuccessful?
[Show More]
.png)
