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THE ULTIMATE ALGORITHM TO PASS YOUR NCLEX
4 WEEK CRASH COURSE
nclex Webinar
Day4
PREPARED AND PRESENTED BY
BENJAMIN MARTINS
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Sulindac Is a non-steroidal anti-inflammatory drug (NSAID),
consider the risks associated with this medication classification.
One of the major risks associated with NSAIDs is the risk of
bleeding, and the nurse needs to assess for any manifestations
that indicate abnormal bleeding. The client should be instructed
to contact the health care provider with any evidence of bleeding,
which includes skin bruising.
Medication administration Assess the rights of medication
administration, which minimally include the right medication,
dose, route, time, and client. Check allergies and identify the
client following institutional policy.
IM injection: The best site for an adult injection is the
ventrogluteal muscle for this site does not contain large blood
vessels or nerves. With multiple injections, the sites should be
rotated. The maximum volume that can be safely injected into the
vastus lateralis or ventrogluteal muscles is 3 mL.
Radiation therapy: Radiation therapy causes inflammation of
nearby epithelial cells, and this can result in further
consequences such as malnutrition. Fatigue is a common side
effect of radiation therapy Constipation is a side effect of
radiation to the abdominal area or chemotherapy.
Redness or desquamation can occur from radiation and can be
severe if not managed properly. At a minimum, the nurse must
assess that the client is not using deodorant or applying
commercial lotions to the area. Alopecia is related to systemic
chemotherapy or local radiation of the head.
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Colorectal Cancer Risk factors: The risk for colorectal cancer is
greater for people over 50 years of age. A diet high in fat or low in
fiber is a risk for colorectal cancer. Family history first-degree
relatives only (parents, siblings, or children) of colorectal cancer
or polyps is a risk factor History of chronic inflammatory bowel
disease is a risk factor.
Cancer Risk Factors: Cancer risk factors are conditions or
occurrences that alter the probability of developing cancer. These
factors include those situations that can be intentionally changed
(modifiable), as well as those that are unable to be controlled
(non-modifiable). Non-modifiable risk factors include age and
genetic predisposition. Modifiable risk factors include a sedentary
lifestyle, poor diet, excessive alcohol use, unprotected exposure to
ultraviolet light, and smoking.
Pulmonary embolism: Chest heaviness may be the first sign of a
pulmonary embolism and requires immediate attention. The nurse
should assess for shortness of breath and chest pain.
Symptoms of a venous thromboembolism include unilateral leg
edema, extremity pain, warm skin, and erythema. A client with a
venous thromboembolism may also be asymptomatic. A client
with a venous thromboembolism is usually encouraged to
ambulate after anticoagulant therapy has started.
Blood transfusion: Nursing interventions when providing care for
the client who needs a blood transfusion include: Teach
client/family about procedure and signs/symptoms to report,
perform hand hygiene, and wear gloves. Set up infusion
equipment with appropriate filter and tubing. Prime the tubing
with normal saline and ensure the client has a functional IV
access (no smaller than a 24- gauge) before obtaining the blood
from the blood bank. Run the transfusion slowly,
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observing client carefully for 15 minutes to observe for any
adverse reaction. Monitor vital signs. Increase rate if vital signs
are stable and client shows no signs/symptoms of reaction to
blood product. Discontinue when transfusion complete and
dispose of equipment properly.
Wound healing: Wound healing is largely dependent on the body’s
internal environment. The client needs adequate dietary protein
or a nutrient-rich infusion to promote healing. If the client is
anemic, this condition must be corrected. An adequate red blood
cell (RBC) count is needed to ensure sufficient oxygen delivery to
the traumatized tissue.
If the client demonstrates impaired systemic oxygenation, then
supplemental oxygen should be administered as prescribed.
Nursing assessment includes identifying potential barriers to
wound healing, including inadequate client hygiene, and
educating the client about infection control. Dressings are applied
to protect the wound, manage drainage, and maintain adequate
moisture in the wound bed. Goals include maintenance of pink,
moist tissue in the wound bed, which is reflective of granulation
tissue, without evidence of necrosis, tunneling, or undermining.
Risk factors that delay wound healing include advanced age,
arterial or venous insufficiency, obesity, anemia, neuropathy,
infection, diabetes, smoking, malnutrition, and medications (such
as corticosteroids). Monitor the serum protein and albumin levels.
Educate the client about maintaining adequate intake of protein,
vitamin C, and zinc to promote tissue healing.
Antipsychotic medication: Chlorpromazine is a conventional
(typical) antipsychotic medication, a phenothiazine, that is used
to treat psychotic disturbances.
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This medication is contraindicated in clients experiencing alcohol
withdrawal, bone marrow suppression, closed angle glaucoma,
and severe liver and cardiovascular disease. Complete blood
counts, fasting blood glucose levels, cholesterol, and liver
function studies should be monitored periodically. Common
adverse effects include sedation, blurred vision, dry mouth,
constipation, urinary retention, photosensitivity, and orthostatic
hypotension.
Esophageal varices: Complications associated with cirrhosis
include portal hypertension, esophageal varices, ascites, hepatic
encephalopathy, and death. Balloon tamponade through an
esophagogastric tube is the treatment method used to manage
bleeding esophageal varices. Bleeding from esophageal varices
can lead to a compromised airway and a decrease in cardiac
output. With a decrease in cardiac output, there is a potential for
inadequate tissue perfusion and oxygenation.
Sexual assault: During a sexual assault question, treating urgent
medical problems must occur first to stabilize the client. Then
further assessment, documentation, and treatment can occur.
For survivors of sexual assault, the priority is the client’s safety
and stability. This requires the nurse to perform urgent
assessment and promptly address any urgent medical problems
such as wounds or lacerations. The nurse should escalate the
scenario to activate the facility’s sexual assault protocol (e.g.,
chain of command and authorities to be notified). The nurse
should also consider the client’s medicolegal aspects of care,
including, but not limited to, consent for examination, laboratory
tests, and chain of evidence documentation.
A survivor of sexual assault, care includes: treating physical
injuries; developing a trusting, therapeutic relationship; and
providing a safe environment. Follow protocols for reporting and
documenting evidence of the assault.
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Assist with the sexual assault forensic examination. Educate the
client regarding medications that may be required for prophylaxis
against pregnancy and such sexually transmitted infections
(STIs), as human immunodeficiency virus (HIV).
Urinary incontinence post prostatectomy: Due to the location of
the prostate gland in relation to the structures of the male urinary
tract, urinary incontinence is a common adverse effect after the
prostate gland is removed. One action to help reduce the incidence
of urinary incontinence after a prostatectomy is to perform pelvic
strengthening exercises. These exercises help tone the bladder,
which prevents accidental release of urine. The exercises need to
be performed consistently and may take a few weeks before
improvement in continence occurs. The nurse will use the
principles of teaching and learning to provide information and
evaluate client understanding.
Epistaxis: When providing care to a client who is experiencing
nosebleeds, the nurse might first ask about the client’s use of
allergy sprays, as these medications cause drying of the nasal
mucosa. However, for the client who has experienced a heart
attack, the treatment regimen likely includes antiplatelet or
anticoagulant medications to prevent clotting and decrease the
risk of re-infarction of the heart. While antiplatelet and
anticoagulant medications do not directly cause bleeding, these
medications interfere with the body’s ability to form clots and
stop bleeding. Even minor injuries or tissue damage (from
brushing teeth or having a large bowel movement, for example)
can result in bleeding. An uncontrollable nosebleed that
continues for more than 15 minutes is an indication to seek
treatment from a health care provider.
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When teaching the client about a prescribed medication,
determine the learner’s knowledge level; minimize distractions;
use clear, brief instructions; and allow time for discussion and
questions. Educate the client about medication, including the
rationale for administration, the dosage and frequency of
administration, and the plan for evaluating the medication’s
effectiveness. Ensure the client’s understanding of the
medication’s side effects and potential adverse effects (e.g.,
bleeding). Evaluate the effectiveness of the teaching/learning
session.
6 month of age: At 6 months, the infant should be able to sit up
alone without support, and the infant should have at least doubled
in birth weight. Also at 6 months, an infant's growth will slow to
about a pound a month. Height gain will slow to about a half an
inch each month. A 6-month-old infant should be smiling,
laughing, and babbling away ('ma- ma','ba-ba'). The nurse should
take note of any developmental delay and refer the infant for
further evaluation if delays are observed or suspected. Assess for
achievement of developmental tasks. The infant should gain 4
ounces per week in the second 6 months of life. The infant will
begin teething, will be able to turn from back to stomach, and
should be able to sit with support. Educate about the use of car
seats. Assess family dynamics. Advise parents and caregivers to
maintain open communication so that consistency in child
rearing can be maintained.
Cardiac catheterization (e.g., coronary angiogram) requires the
use of iodine-based contrast media. Clients who are allergic to
shellfish may not get the iodine-based contrast media or require
premedication with diphenhydramine IV prior to the procedure.
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It is also essential for the nurse to inform clients taking
metformin to hold the medication 2 days before or after coronary
angiogram to prevent kidney damage since metformin is
nephrotoxic and the iodine- based contrast media is cleared by
the kidneys. The nurse should review the client’s baseline blood
urea nitrogen (BUN) and creatinine. Typically, clients with acute
or chronic kidney injury do not have procedures requiring
contrast media due to the risk for kidney failure. Prior to cardiac
catheterization, instruct the client to avoid eating or drinking for
6 hours before the procedure. Assess for allergies to contrast,
seafood, and iodine. Monitor kidney function. Insert an IV access
device. Follow organizational protocol to prepare the area for
cardiac catheter insertion. Ensure a consent form is signed.
During the procedure, if coronary artery occlusion is detected,
angioplasty can be performed and a stent can be inserted. After
the procedure, assess the puncture site and peripheral pulses in
the affected extremity. Monitor vital signs. Complications of the
procedure include bruising, bleeding, damage to artery or cardiac
tissue, allergic reaction to dye, sepsis, stroke, and myocardial
infarction.
Handwashing & Burns: Correct and consistent handwashing is
the single most effective technique for preventing infection
transmission on burn units. This is the priority measure for the
nurse to communicate. Burns result in damage to the skin from
either heat, radiation, chemical, or electrical sources.
A client risk associated with burn injury is infection. This risk can
be decreased through hand washing. Hand hygiene should be
performed before and after having direct contact with client’s
skin; after contact with blood, body fluids, excretions, wounds,
and medical equipment in the client’s room; and after removing
gloves.
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Alcohol-based hand sanitizers are the most effective products for
reducing the number of germs on the hands of health care
providers. Antiseptic soaps and detergents are the next most
effective and non-antimicrobial soaps are the least effective.
Wash with soap and water when hands are visibly dirty.
Transmission of infectious microorganisms is the major
complication of poor hand hygiene. Sickle Cell Anemia: Sickle cell
disease is a severe form of anemia in which a mutated form of
hemoglobin distorts the red blood cells into a crescent shape at
low oxygen levels. The nurse needs to educate the parents about
promoting optimal oxygenation while providing adequate rest
periods, hydration, nutrition, and pain management.
Sickle cell anemia patients have abnormally-shaped red blood
cells that become trapped in blood vessels and organs. Cold
temperatures, including application of cold compresses or ice
packs, will cause vasoconstriction and may further limit blood
flow. To effectively control pain, analgesic medication should be
administered at regular intervals as prescribed. Omitting
medication doses or waiting until the pain becomes severe before
taking analgesic medication is not advised. Triggers for sickle cell
crisis include dehydration and infection. Adequate hydration and
preventing infection are essential to preventing sickle cell crisis.
Sickle cell anemia patients especially pediatric population should
includes proper hand hygiene; vaccination against influenza,
pneumonia, and meningitis; avoiding certain pets such as turtles,
snakes, and lizards; not eating raw or unpasteurized milk or other
dairy products; and antibiotic prophylaxis as ordered.
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Colon cancer S&S: The ascending (right), transverse, descending
(left), and sigmoid are the four segments that make up the colon
or large intestine. The major function of the colon is to absorb
water, salt, and some nutrients and secrete mucous. Tumors in
the colon are typically slow growing and a client may not
experience symptoms until the tumor is advanced. Clinical
manifestations vary depending on the location of the tumor.
Tumors in the ascending or right colon include abdominal pain,
night sweats, anemia, and fever, whereas tumors in the
descending or left colon include changes in bowel pattern
(constipation and/or diarrhea), blood in stool, abdominal pain
and/or distention, and vomiting.
Thyroidectomy: Removal of the parathyroid glands may occur
with removal of the thyroid gland since they are embedded in the
thyroid tissue A complication of thyroidectomy is hypocalcemia.
Muscle flaccidity results from hypercalcemia, not hypocalcemia.
Other complications include hemorrhage, respiratory distress,
laryngeal nerve damage, and thyroid storm.
Injury to parathyroid glands during surgery causes a decrease in
serum calcium. It is most important for the nurse to assess for
tingling around the mouth, toes, and fingers, along with muscular
twitching. Confusion is an indication of hyperthyroidism. The
nurse needs to assess electrolytes, specifically calcium and
phosphorus, if the parathyroid glands are removed.
Latex allergy: People with a food allergy to avocado are at
increased risk for latex allergy. A history of asthma, not chronic
bronchitis, increases a client’s risk for latex allergy. A client with
a history of multiple surgical procedures is at increased risk for
latex allergy. Health care workers are at increased risk for latex
allergy secondary to increased exposure to latex.
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The nurse is aware though true latex allergies resulting in
anaphylaxis are not common and life-threatening. Every
potential latex allergy is taken very seriously. The nurse is alert
that allergies to apples, bananas, carrots, celery, kiwi, melons,
papaya, and tomato are risk factors. The nurse needs to remember
latex is found in gloves, syringes, vial stoppers, stethoscopes, IV
tubing, catheters, tape, and other medical supplies and
equipment.
Herpes Zoster: Standard precautions are recommended for
localized herpes zoster and nonimmunocompromised clients.
Acyclovir is an antiviral medication that is prescribed to decrease
pain and slow the progression of the disease. The patient’s room
door does not need to be closed at all times for standard
precautions. The nurse with a positive history for chicken pox
means the worker has immunity to the varicella virus. Susceptible
health care workers should not enter the room if a caregiver who
is immune is available. Slow rhythmic breathing encourages
relaxation to help the client cope with the discomfort. Herpes
zoster is a painful skin rash, caused by the varicella zoster virus,
that usually appears in a band, a strip, or a small area on one side
of the face or body.
Cerebrospinal Fluid & ICP: The nurse should report the presence
of colorless drainage immediately because it may be cerebrospinal
fluid. The nurse will monitor for signs of increased intracranial
pressure, hemorrhage, and meningitis. The nurse should assess
the colorless drainage for glucose, which would confirm that the
drainage is cerebrospinal fluid (CSF). If the drainage were to
contain blood, assessing the drainage for glucose would not
provide verification that the drainage is CSF, since blood contains
glucose, too. In that case, the nurse could look for a halo sign by
allowing some fluid to leak on a white gauze pad.
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After a few minutes, the blood would coalesce in the center and a
yellowish ring would encircle the blood if CSF is present. A tumor
in the brain causes swelling within the rigid skull, thus putting
pressure on the underlying structures and increasing the
intracranial pressure.
Should a brain tumor be present, it may be treated with
chemotherapy, radiation, and/or surgery. If the client has
surgery, the nurse needs to frequently assess the client's
neurologic status and observe the surgical site for cerebrospinal
fluid (CSF), which is clear.
ECT: When caring for a client receiving electroconvulsive therapy
(ECT), the nurse should: Assess the client for suicidal tendencies.
Assess vital signs and mental status. Assess the client’s ability to
understand the procedure and the intended results. Clients who
may be harmed during ECT include those with a recent heart
attack or stroke, pregnant clients, and those with
musculoskeletal disorders (osteoporosis).
SIDS: Infants should not routinely take naps in car seats,
strollers, or swings. They may slump enough to obstruct the
airway. Infants should ideally be dressed warmly in pajamas,
sleepers, or sleep sack instead of using blankets. If a blanket is
used, it should be placed no higher than infant’s waist. The edges
of the blanket should be tucked under the mattress to prevent
blankets from covering the infant’s face. Use of a pillow increases
the risk for suffocation. Infants should not sleep on soft surfaces
like a sofa, armchair, soft mattress, or waterbed.
Cimetidine: is an H 2 receptor antagonist that may be prescribed
to treat conditions such as gastric and duodenal ulcers,
heartburn, or gastroesophageal reflux disease with erosive
esophagitis. Histamine stimulates parietal cells to produce acid,
so cimetidine is more commonly used, orally or intravenously, for
control of stomach acid and allowing gastric ulcers to heal.
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Instruct the client to avoid cigarette smoking to prevent
increasing gastric acid secretion. Evaluate outcomes of the
administered medication.
Shock: The nurse caring for a client at risk of shock should: Assess
baseline vital signs. Monitor blood pressure and heart rate for
changes. Assess strength of peripheral pulses, color of skin,
warmth, and other indicators of perfusion. Assess urinary output.
When hypotensive, keep client flat in bed or use modified
Trendelenburg position to enhance blood flow and oxygenation to
the brain. Administer IV fluids as prescribed. Assess
hemodynamic pressures and titrate medications and fluids as
needed. Assess client tolerance of fluid administration. If client
has arterial line to monitor blood pressure, assess blood pressure
continuously.
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