NCLEX UWorld

NCLEX UWorld When do *advanced directives* go into effect? - ✔✔when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* - *coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as signed; direct ...

NCLEX UWorld When do *advanced directives* go into effect? - ✔✔when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* - *coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as signed; directives can always be changed later by person) SBAR Communication Framekwork Components - ✔✔1. *S* = Situation - what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background - *pertinent information, relevant history, vital signs* 3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred) 4. *R* = Recommendation - *request* for *prescription* or *action* from HCP Appropriate order of actions when client found on floor - ✔✔1. *Assessment* of *physiological stability* (ABCs) 2. *Assessment* of *injuries* 3. *Moving client* 4. *Notifications* 5. *Documentation* Conditions of being *ineligible to leave AMA* - ✔✔1 *danger to self or others* 2. *lack of consciousness* 3. *Altered consciousness* 4. *Mental illness* 5. Being under *chemical influence* 6. *Court decision* Effective handoff communication components - ✔✔Nurse should: 1. Provide *identifying information* (eg client's name and room number) 2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace medication infusion bag, need to perform delayed wound care and cause of delay) 3. Provide *exact, pertinent information* (eg medication dose, time, measurable outcomes) 4. Include *multidisciplinary plans* (eg radiology examinations, family meetings, physical therapy) 5. Relay significant client changes in a clear manner *Risk factors* for *cervical cancer* - ✔✔1. Infection with high-risk HPV strains 2. History of sexually transmitted diseases 3. Early onset of sexual activity 4. Multiple or high-risk sexual partners 5. Immunosuppression 6. Oral contraceptive use 7. Low SES 8. Tobacco use what medications interact with grapefruit? - ✔✔1. *calcium channel blockers* (diltiazem, nifedipine, verapamil, etc) 2. *statins* 3. *SSRIs* Risk associated with *stent placement* using the *femoral approach* - ✔✔*retroperitoneal hemorrhage* what are early signs of bleeding into the retroperitoneal space? - ✔✔hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses what is the grey-turner sign and what is it a sign of? - ✔✔bruising of the flanks and retroperitoneal hemorrhage and is a bluish color what are some physical signs of peripheral arterial disease? - ✔✔intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the extremities) transplanted hearts are expected to be - ✔✔tachycardic like 90-110 what is the priority intervention for pain with sickle cell crisis and why? - ✔✔administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion what is the purpose of continuous bladder irrigation? - ✔✔it is perscribed after TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder what is the nurses care of monitoring CBI? - ✔✔monitor quality of drainage, titrate the inflow rate, and manurally irrigating as needed characteristics of a basilar skull fracture - ✔✔periorbital hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising) immediate client care for basilar skull fracture - ✔✔cervical spime immobilization, close neurologic monitoring, and support of ABCs vomiting with intake may mean - ✔✔viral or bacterial infection tympanosomty tubes are placed for - ✔✔recurrent otis medias nurse actions during a seizure - ✔✔assist them to lie down is standing/sitting, put them on side for patent airway, loosen tight clothing, give oxygen as needed, remove objects from immediate area, document time and duration of seizure (for tests are done later to see which type of seizure and maybe what exacerates it) never put anything in mouth or restrain them since musclec ontractions can occur during a seizure what are some early symptoms of ICP? - ✔✔altered LOC, headache, abnormal reathing, rise in bp, slow pulse, vomiting client who has a TIA is often placed on - ✔✔prophylactic antithrombotic treatment like aspirin or clopidogrel glascow coma scale ranges from - ✔✔3-15; 3 being worst 15 being best condition (8 or below in a coma) what are the 3 components? - ✔✔eye opening motor response verbal response what is a primary component in TPN? - ✔✔*glucose,* so the nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia when a client is on TPN, the nurse must assess for hyperglycemia why? - ✔✔bc a primary component is glucose. therefore the nurse must be assessing to see if the client is getting too much glucose (hoerglycemia). and with a large urinary output like 4800, this could indicate symptoms of hyperglycemia signs of hyperglycemia - ✔✔- polydipsia, - polyuria, - restless, - confused, - bg over 200, - fatigue, - headache - blurred vision - kussmaul resp Interventions to resolve TPN-associated hyperglycemia - ✔✔- reduce amount of carbohydrate in TPN solution - slow down infusion rate - administer subcutaneous insulin what is the goal for mass casualty events? - ✔✔do the greatest good for the greatest number of people keep in mind that disaster triage ranks the l