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NCLEX-RN

NCLEX Study Guide

QuestionAnswer
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
Created by: 505880971