NCLEX-Study-Guide.pdf Download To Score A

DO NOT delegate what you can EAT!

E - evaluate

A - assess

T - teach

addisons= down, down down up down

cushings= up up up down up

addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia

cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia

No Pee, no K (do not give potassium without adequate urine output)

EleVate Veins; dAngle Arteries for better perfusion

A= appearance (color all pink, pink and blue, blue [pale])

P= pulse (>100, < 100>

G= grimace (cough, grimace, no response)

A= activity (flexed, flaccid, limp)

R= respirations (strong cry, weak cry, absent)

TRANSMISSION-BASED PRECAUTIONS:

AIRBORNE

My - Measles

Chicken - Chicken Pox/Varicella

Hez - Herpez Zoster/Shingles

TB

or remember...

MTV=Airborne

Measles

TB

Varicella-Chicken Pox/Herpes Zoster-Shingles

 Private Room - negative pressure with 6-12 air exchanges/hr

 Mask, N95 for TB

DROPLET

think of SPIDERMAN!

S - sepsis

S - scarlet fever

S - streptococcal pharyngitis

P - parvovirus B19

P - pneumonia

P - pertussis

I - influenza

D - diptheria (pharyngeal)

E - epiglottitis

R - rubella

M - mumps

M - meningitis

M - mycoplasma or meningeal pneumonia

An - Adenovirus

 Private Room or cohort

 Mask

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CONTACT PRECAUTION

MRS.WEE

M - multidrug resistant organism

R - respiratory infection

S - skin infections *

W - wound infxn

E - enteric infxn - clostridium difficile

E - eye infxn - conjunctivitis

SKIN INFECTIONS

VCHIPS

V - varicella zoster

C - cutaneous diphtheria

H - herpez simplex

I - impetigo

P - pediculosis

S - scabies

1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic,

sense of impending doom) --> turn pt to left side and lower the head of the bed.

2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal

bradycardia, etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)

3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the

stomach) with the HOB elevated (to prevent aspiration)

4. During Epidural Puncture --> side-lying

5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent

headache and leaking of CSF)

6. Pt w/ Heat Stroke --> lie flat w/ legs elevated

7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be

kept straight. No other positioning restrictions.

8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of

secretions)

9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4

weeks.

10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders.

11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture

12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction

13. After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 45-

60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating

thighs with pillows.

14. Prolapsed Cord --> knee-chest position or Trendelenburg

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15. Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line.

While feeding, hold in upright position.

16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in

reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low

CHO and fiber diet, small frequent meals)

17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to

provide for hip extension.

18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to

provide for hip extension.

19. Detached Retina --> area of detachment should be in the dependent position

20. Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed

21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees

22. After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on

either side.

23. During Internal Radiation --> on bedrest while implant in place

24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal

congestion, goose flesh, bradycardia, hypertension) --> place client in sitting position (elevate

HOB) first before any other implementation.

25. Shock --> bedrest with extremities elevated 20 degrees, knees straight, head slightly

elevated (modified Trendelenburg)

26. Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure

27. Peritoneal Dialysis when Outflow is Inadequate --> turn pt from side to side BEFORE

checking for kinks in tubing (according to Kaplan)

28. Lumbar puncture => AFTER the procedure, the client should be placed in the supine

position for 4 to 12 hrs as prescribed. (Saunders 3rd ed p. 229)

Demorol for pancreatitis, NOT morphine sulfate

Myasthenia Gravis: worsens with exercise and improves with rest.

Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms

Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse

Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use

filter needle

Prior to a liver biospy its important to be aware of the lab result for prothrombin time

From the a** (diarrhea)= metabolic acidosis

From the mouth (vomitus)=metabolic alkalosis

Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin

and hair

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Graves’ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to

heat, fine/soft hair

Thyroid storm: increased temp, pulse and HTN

Post-thyroidectomy: semi-Fowler’s, prevent ncek flexion/hyperextension, trach at bedside

Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased

calcium), high Ca, low phosphorus diet

Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased

calcium), low Ca, high phosphorus diet

Hypovolemia – incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety,

urine specific gravity >1.030

Hypervolemia – bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine

specific gravity <1>

Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration,

weakness, administer Pitressin

SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a,

HA; administer Declomycin, diuretics