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NLE - CGFNS - Nclex Review Materials 4

This document provides information on various medical conditions, treatments, and nursing considerations. It includes items such as signs and symptoms of conditions (e.g. RSV, SIADH), appropriate nursing diagnoses (e.g. aspiration for GBS), discharge teaching topics (e.g. eye care for Bell's Palsy), normal findings in infants, proper techniques and precautions for certain procedures, side effects and nursing monitoring of medications (e.g. indomethacin, Theophylline), and developmental milestones.

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1K views6 pages

NLE - CGFNS - Nclex Review Materials 4

This document provides information on various medical conditions, treatments, and nursing considerations. It includes items such as signs and symptoms of conditions (e.g. RSV, SIADH), appropriate nursing diagnoses (e.g. aspiration for GBS), discharge teaching topics (e.g. eye care for Bell's Palsy), normal findings in infants, proper techniques and precautions for certain procedures, side effects and nursing monitoring of medications (e.g. indomethacin, Theophylline), and developmental milestones.

Uploaded by

ChieChay Dub
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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NLE / CGFNS / Nclex Review Materials 4

51. RSV
• Droplet precaution

52. SIADH
• Sodium 128 only (Normal: 135-145)

53. Dementia of Alzheimer Type


• Check what the pt. is taking

54. PEG

55. What medicine if given shld be monitored for bleeding


• Indomethacin (NSAID)

56. GBS, priority nursing diagnosis


• Aspiration

57. Discharge teaching for Bell’s Palsy


• Provide eye care at bedtime

58. Sign of Scoliosis


• Asymmetry of the iliac crest

59. Normal for a 3 day old infant


• Describe normal tonic neck reflex

60. Manifestation of Paranoid Schizophrenia


• Inappropriate anxiety with delusion

61. Sign of Alcohol withdrawal


• Feeling of euphoria in 1st 24 hrs.

62. Activity for Alzheimer disease


• Reading magazine

63. Type 1 IDDM post renal test 48 hrs ago, watch out for:
• Hematuria

64. Correct understanding of antidepressant


• Anti-depressant takes effect after 1 week

65. DUROGESIC PATCH / FENTANYL


• For chronic pain lasts 3 days
• Maybe worn while bathing, showering, swimming
• Apply to flat, nonirritated, nonirradiated area like chest, flank, upper arm, back
• Overdose : difficulty in breathing

66. Signs of increase ICP in pt. with close head injury


• Increase systolic pressure & weak bounding pulse

67. Positive outcome for Calcium Channel blockers


• Decrease chest pain

68. Obsessive Compulsive Behavior


• To alleviate anxiety
69. Patient with back pain, proper body mechanics
• Sit with knees higher than hips

70. What to check prior administration of EPOETEN


• BP
• S/E : HPN, Seizures

71.

72. Patient with pancreatitis if developing ascites would manifest:


• Cullen’s Sign (bluish discoloration of abdomen or peri-umbilical hematoma)
• Turner’s Sign (gray-blue discoloration of flank)
• Shallow, rapid breathing
• Abdominal pain
• Dyspnea & difficulty eating
• Orthopnea

73. Digitalis + Lasix = Weight Loss

74. Side effect of Garamycin


• Ototoxicity
• Nephrotoxic
• Hypomagnesimea
• Muscular paralysis
• Hypersensitivity

75. Side Effect of Theophylline


• Tremors & tachycardia
• Insomnia

76. Nsg. Management for cleft palate infant


• Enlarged nipple for feeding
• Stimulate sucking
• Swallow
• Rest
• Burp frequently

77. Patient with expressive aphasia, best communication:


• Use picture language

78. Diet for patient with colostomy


• DAT
• Low residue food 1-2 days postopt
• Avoid gas-forming foods

79. Patient allergic to Pseudoephedrine,


What is contraindicated?
• Patient taking Ma Huang

80. Patient with testicular cancer, correct understanding?


• Testicular CA is painless

81. 1st intervention in prolapsed cord


• Positioning – knee chest/trendelenberg

82. 2nd Stage of labor


• Cervical dilatation to delivery of
baby

83. Thiazide diuretic, what to watch out for?


• Potassium

84. Manic pt. taking lithium


• Watch out for sodium serum

85. Diet for patient with ileostomy


• Post opt 4 wks -- LOW FIBER
non-irritant diet to decrease fast movement of liquid stool, after can tolerate high
fiber diet
already
• Foods that thicken stool like boiled rice, low fat cheese should be given
• Low fat diet
• Normal stool is liquid

86. G & D of a 2 y/o


• Combines 2 words
• Kicks a ball
• 50 word vocabulary

87. ALS
• Decreased sensation of touch
• Muscle weakness
• Excess glutamate

88. S/S of Kawasaki


• Desquamation of skin
• Joint pain
• Mucocutaneous lymph node syndrome

89. Watch out for in lumbar puncture


• Increased ICP
• Brain Herniation

90. S/S of DVT


• Edema
• Calf or groin tenderness
• Pain with or w/o swelling
• + Homan’s Sign
• Warm skin

91. Developmental Milestone of 10 month old


• Pincer grasp

92. Risk for breast CA


• 38 y/o female on oral contraceptive

93. Need to consider anti-coagulant therapy


• If taking Gingko Biloba

94. Check 1st before tonsillectomy


• Bleeding time

95. Complication of CAST


• Compartment syndrome
• Fat embolism
• Shock
• Avascular necrosis

96.

97. Physician orders beta-blockers, for w/c pt. should the nurse question
the order:
• Patient on insulin (B-blockers may mask signs of hypoglycemia)

98. Patient hypersensitivity


• Give macrolides like erythromycin,azithromycin (Penicillin & Cephalosporins the
same)

99. Patient with autonomic dysreflexia


• Pounding headache , piloerection

100. Pt. with carafate & antacids order, select the schedule.
• Carafate 1 hr. before meals &
antacids after meals

101. Increasing pulse pressure


• Widening pulse pressure (late sign)
• Decreased LOC, restlessness
(Early)

102. Pt. with Hemophilia & Leukemia


• Can lead to DIC

103. Effective teaching to DM patient


• Peak of NPH insulin 8 hrs.

104. Mg SO4 given to PIH pt. Nurse should watch out for?
• Epigastric pain & headache

105. Pt. with calcium oxalate stones


• Diet with fig & wheat germs

106. Cancer & Sepsis can lead to DIC


• low platelet count

107. Pt. in labor with crusted popular eruption, priority?


• Eye prophylaxis of the newborn

108. Heroin addicted mother in labor, nursing action?


• Avoid withdrawal in active stage

109. Signs of Heroin intoxication?


• Euphoria
• Decrease response to pain
• Respiratory depression
• Apathy

110.

111. Scarlett Fever isolation precaution


• Respiratory precaution
• droplet until 24 hrs. start of
treatment

112. Laryngectomy
• Avoid swimming, showering, using aerosol sprays
• Teach client clean suction technique

113. External irradiation therapy


• Time & distance shielding

114. Pt. with anorexia nervosa, signs


• Tachycardia

115. Brain injury


• Decorticate rigidity

116. Signs of renal failure


• Urine output less than 100ml/hr

117. Post-thyroidectomy patient, WOF


• Tingling sensation in the cheek
(complication)

118. Ventricular Fibrillation


• Do chest compression

119. Pt. in crutches, nurse should check


• Check armpits to see if there is pressure secondary to crutch
(Pressure shld be on the hands not on the axilla)

120. Influenza Vaccine indicated for:


• Anyone 50 y/o & above annually
• Age 6 months & up with risk like asthma
• Immunocompromised patients
• Pts with cardiac & pulmonary
disease

121. Herpes Simplex I & II


• 2 strains of herpes virus family

• HSV I – cold blisters / fever blisters


• HSV II – in STD /Genital Herpes/Shingles & varicella zoster infection same with
chicken pox

122. Above the knee amputation, patient shld


• Prevent internal or external rotation of the limb
• Place sandbag or rolled towel along side of thigh to prevent rotation

123. HIV suspect patient


• Hairy tongue and leukoplakia
(Leukoplakia, pre-malignant lesion)

124. DVT on Heparin therapeutic goal


• Ambulate ASAP
( Prevent thrombus formation)
125. Esophageal varices, refer pt if
• Cold clammy skin ( sx of shock)

126. Pregnant 39 weeks, knows true labor if


• Contractions from back going to abdomen

127. Bipolar manic patients, what to do?


• Limit group activities

128. Multiple Myeloma, care


• Force fluid from 3 - 4 L/day to offset hypercalcemia, hyperurecemia
• Encourage ambulation to prevent renal stones

129. Post pace maker transplant, correct understanding


• Patient CAN USE electricc blankets, cell phones <3 watts,microwave ovens,
metal
detectors

130. Patient taking garlic supplements should take precaution when on


aspirin therapy

131. DKA patient, what to administer 1st?


• Start IV line 0.9 NaCl

132. Hearing aid, correct teaching:


• Turn off & remove battery when not in use
• Avoid excessive wetting of hearing aid, keep dry
• Ear mold is the only part that may be washed w/ soap & water
• Cannula is cleaned with small
pipe cleaner device or toothpick

133. PEEP

134. 18 day old infant, how to assess trunk curvature


• Place in prone position & stroke spinal colum, see if infant’s body move
towards the stimulated
area

135. Postural drainage, correct understanding:


• Position—lung segment to be
drained is uppermost
• Drink a glass of water before PD to loosen secretions
136. Sign of Abdominal Aortic Aneurysm
• Pulsation between umbilicus & pubis

137. Echinacea
• To boost immune system
• Use only up to 8 weeks

138. Action of PILOCARPINE


• Increase outflow of aqueous humor
• For OPEN ANGLE GLAUCOMA

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