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NCLEX-RN
NCLEX Study Guide
| Question | Answer |
|---|---|
| Addisions | down,down, down, up, down hyponatremia, hypotension, increased blood volume, hyperkalemia, hypoglycemia |
| Cushings | up, up, up, down, up hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia |
| NO Pee | NO K - do not give potassium without adequate urine output |
| EleVate Veins | dAngle arteries for petter perfusion |
| APGAR | appearance, pulse, grimace, activity, respirations |
| Do not delegate what you can EAT | E- evaluate A- assess T- Teach |
| AIRBORNE | MTV Measles, TB, Varicells (chix pox, herpes, shingles). Private room, negative pressure with 6-12 air exchanges/hr Mask, N95 for TB |
| Droplet precaution | Superman Sepsis, Scarlet Fever, Streptococcal pharyngitis , parvovirus B19, Pneumonia, pertusis influenza diphtheria(pharyngeal), epiglottis rubella mumps, menngitis, mycoplasma, or meingeal pneumonia Advenovirus Private room or cohort mask |
| Contact precaution | Mrs. Wee Mulitdrug resistant organisms Respiratory infections skin infections wound infection enteric infection - clostridium difficile eye infection - conjunctivitis |
| Skin infections | vchips Varicella zoster cutaneous diptheria herpez sinplelx impetigo pediculosis scabies |
| Air/pulmonary Embolism | chest pain, diff. breathing, tachycardia, pale/cyanotic, sense of depending doom. Turn pt to left side and lower the head of the bed |
| Woman in labor w/ un-reassuring FHR | late decals, decreased variability, fetal bradycardia) turn on left lise and give 02, stop piton, increase IV fluids |
| Tube feeding w/ decreased LOC | Position pt on right side - this promotes emptying of the stomach. HOB elevated to prevent aspiration |
| during epidural | side lying |
| after lumbar puncture (myelogram) | pt lies in flat supine (to prevent headache and leaking of CSF) |
| Pt with heat stroke | lie flat with legs evaluated |
| During continuous bladder irrigation | Catheter is taped to thigh so leg should be kept straight. no other positions restrictions. |
| after myringotomy | position on side of affected ear after surgery (allows drainage of secretions) |
| after cataract surgery | pt will sleep on unaffected side with a night shield for 1-4 weeks |
| after Thyroidectomy | low or semi-fowlers, support head, neck and shoulders |
| infant withe Spina Bifida | prone, or abdomen - so that sac does not rupture |
| Bucks transaction | elevate foot of bed for counter traction |
| after total hip replacement | don’t sleep on operated side, don’t flex hip more than 45-60 degrees. don’t elevate HOB more that 45 degrees. Maintain hip adduction by separating thighs with pillows |
| prolapsed cord | knew chest position of trendelenburg |
| infant with cleft lip | position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position. |
| To prevent dumping syndrome | (post operative ulcer/stomach surgeries) - eat in reclining position, lie down after meals for 20-3- minutes (also restrict fluids during meals, low CHO and Fiber diet, small frequent meals. |
| Above knee amputation | elevate for first 24 hours on pillow, position prone daily to provide for hip extension |
| Below knee amputation | foot of bed elevated for first 24 house, position prone daily to provide for hip extension. |
| Detached Retina | area of detachment should be in the dependent position |
| Administration of Enema | position pt in left side lying (sim’s) with knee flexed |
| After Supratentorial Surgery | (Incision behind hairline) - elevate HOB 30-45 degrees |
| After Infratentorial Surgery | (Incision at nape of neck) - position pt flat and lateral on either side |
| During internal radiation | on bed rest while implant in place |
| Autonomic dysreflexia/Hyperreflexia | pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension - pt in sitting position, (elevate HOB) first before any other implementation. |
| Shock | bed rest with extremities elevated 20 degrees to decrease intracranial pressure |
| Head Injury | elevate HOB 30 degrees to decrease intracranial pressure |
| Peritoneal Dialysis when Outflow is inadequate | turn pt from side to side before checking for kinks in tubing |
| Lumbar puncture | after the procedure, the client should be placed in the supine position for 4-12 hours as prescribed |