NCLEX Uworld Study guides, Class notes & Summaries

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 assessm...

When do *advanced directives* go into effect? - ANSWER 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 - ANSWER 1. *S* = Situation - what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background - *pertinent information, relevant history, vital signs* 3. *A* = Assessment - nurs...

When do *advanced directives* go into effect? - ANSWER 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 - ANSWER 1. *S* = Situation - what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background - *pertinent information, relevant history, vital signs* 3. *A* = Assessment - nurs...

Lactulose - ANSWER Decrease intestinal ammonia absorption Will improve mental status by removing ammonia Used for: liver disease/damage Spironolactone - ANSWER Aldosterone Inhibitor/ K+ sparing diuretic Used for: liver damage Used to: promote diuresis, prevent fluid retention

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN). The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device. What is the priority action before initiating the TPN infusion? - Answer Check the results of the portable chest x-ray. Defense mechanisms - Answer Strategies or responses, usually unconscious, used by individuals to distance themselves from a full awar...

The labor and delivery (L&D) nurse is floated to a medical-surgical floor for a shift. Which client is MOST APPROPRIATE for the charge nurse to assign to the L&D nurse? # (14) 1. Child with an occluded arteriovenous fistula receiving IV heparin infusion. 2. Client with cirrhosis and ascites who requires bedside paracentesis. 3. Client with diabetes who is one day postoperative below-the-knee amputation. 4. Client with pyelonephritis who is febrile and receiving IV antibiotics - Answer 4 ...

PD dwell time immediate nurse - Answer crackles present in L & R lung PD monitor: RR compromise - difficulty breathing, rapid RR, crackles HyperK - Answer ECG change + hyperK 1st => give calcium gluconate = stabilize cardiac muscle Assign to LPN - Answer 2 days post op aortic valve surgery - needs urinary cath reinsert d/t unable to void RN - Answer -clinical assessment -initial client education -discharge education -clinical judgement -initiate blood transfusion ...

When do *advanced directives* go into effect? - Answer 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 - Answer 1. *S* = Situation - what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background - *pertinent information, relevant history, vital signs* 3. *A* = Assessment...

Nephrotoxic Meds - Answer -mycin antibiotics (aminoglycides) -keterolac (Toradol) -NSAIDs -digoxin Hepatotoxic Meds - Answer -tylenol -NSAIDs Naloxone (Narcan) - Answer -weans in 1-2 hours -IV or nasal spray -if unresponsive d/t anesthesia or opioids: administer oxygen, assess respiratory rate, notify HCP, prepare second dose Narcan, no need to call rapid response/code team NSAIDs - Answer NON-STEROIDAL ANTI-INFLAMMATORY DRUGS -ex: aspirin, ibuprofen, naproxen -use at...

what medications interact with grapefruit? - Answer calcium channel blockers: diltiazem, nifedipine, verapamil, etc statins caffeine SSRIs be sure to practice math! - Answer stent placement using the femoral approach puts you at risk for retroperitoneal hemorrhage - Answer what are early signs of bleeding into the retroperitoneal space? - Answer hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses what is the grey-turne...