Delegation - Right Person, Right Task, Right Circumstance, Right Communication,

NCLEX-RN 2022

Delegation - Right Person, Right Task, Right Circumstance, Right Communication, Right Supervision

AP's: vitals and ALDs

PN: stable clients and the expected outcome

Bleeding - Stabilize object

Colorectal Screening - Sigmoid: 5 yrs Colon: 10 years ages 50-75

Manual BP - 1 Inch above antecubital space

Manual Systolic Measurement - Palpate radial pulse, inflate until pulse disappears, inflate another 30 mmHg, release and note when pulse is palpable again

Clear Diet - Fruit juices, gelatin, broth

Cane Use - On Stronger side. Move can, move weak leg, move stronger leg past cane

Move 6-10 inches forward

Infiltration - pallor, swelling, decrease skin temp

stop, remove, elevate, ROM, cold compress, restart

hypoxemia - early: Tachypnea, increased BP

Late: Bradypnea, decrease BP

Hypernatermia Risk Factors - older age, decrease total body water content, inadequate fluid intake, altered thirst

Seizure precautions - Rescue equipment at bedside

Fire Safety - R: Rescue A: Alarm C: contain E: extinguish

P: Pull A: Aim S: Squeeze S: Sweep

Radiation Precautions - wear monitoring badge for exposure

Client Transfer - Fold arms of patient across chest while lifting head

Positioning - Prone: on stomach, post lumbar puncture, tonsillectomy

Supine: On back, spinal cord injury

Crutches - 3 inch widths between axilla and top of crutch, hand grips with elbows at 30 degree

Walker - Wrist even with hand grips

Standard Precautions - Teir One

protective equipment when in contact with blood and bodily fluids, dispose PPE in clients room, clean spills with bleach water

Transmission Precautions - Airborne: N95 mask

Droplet: Mask within 3 feet of patient

Contact: gloves and gown

Order of PPE - On: gown, mask, goggles, gloves

OFF: gloves, goggles, gown, mask

Precautions for Diseases - AIDS/HIV: standard

Varicella: airborne

C-diff: contact

Hep A: standard

Hep B: standard

Hep C: standard

Herpes simplex: standard

shingles: airborne

Measles: airborne

Meningococcal: droplet

MRSA: contact

Pneumonia: droplet

Respiratory syncytial virus: droplet

Rotovirus: contact

Rubella: droplet

Salmonellosis: contact

Shigellosis: contact

TB: airborne

Vancomycin resistant enterococci: contact

Screening Guidelines - Physical: annually

Dental: 6 months

BP: 2 years

BMI: every visit

Cholesterol: 5 years

glucose: 3 yrs

colorectal: 10 yrs

pap: 3 yrs

breast exam: 3 yrs

mammogram: yearly

testicular examination: monthly

prostate and rectal: yearly

Morse Fall Scale - Secondary Diagnosis, mental status, IV locks, ambulatory aid, history of falls, gait

Sodium - 135-145

sezuire precautions

Potassium - 3.5-5

weakness, restlessness, irritability

Magnesium - 1.3-2.1

facial flushing, calcification

Calcium - 9.0-10.5

bone pain, constipation

Pressure Ulcers - inspect every 2 hrs, barrier cream, turn every 2 hrs, 2,000-3,000 L/day, Vitamins A, C, zinc, shift weight every 15 mins

Six Rights of Medication Administration - Right Med, Right Dose, Right Route, Right Documentation, Right Patient, Right Time

Guidelines for IV - never administer meds through tubing being used for blood products

Complications with IV's - Infiltration, extravasation, phlebitis, thrombophlebitis, hematoma, catheter embolism

Infiltration Prevention - use smallest catheter for prescribed therapy, stabilize port- access, assess blood return

Extravasation Prevention - know vesicant potential before giving medication

Phlebitis Prevention - Rotate, secure, aseptic

Hematoma Prevention - avoid veins not seen

Catheter embolism Prevention - do not reinsert

Complications of central venous catheter - Pneumothorax (ultrasound), air embolism (lie flat, valsalva maneuver) lumen occlusion (flush properly), bloodstream infection (sterile technique)

Complications of PICC - Occlusion, dislodges, phlebitis, embolism, infection

Care for TPN - serum glucose levels every 4-6 hrs, change dressing every 48-72 hrs, change IV tubing every 24 hrs

Drug Classes - PRIL (ACE inhibitors) LAM (Benzos) ASONE (Corticosteroid) IDE (Oral hypoglycemic)

PRAZOLE (PPI)

ASE (Thrombolytics) PHYLLINE (bronchodilators) ARIN (anticoagulants) DINE (antiulcer) ZINE (antihistamine) TYLINE (trylic antidepressant) PRAM (SSRIs)

Side Effects - ACE Inhibitors: Angioedema

Benzos: Anterograde amnesia

Beta Blockers: bronchospasm

Ciprofloxacin: tendon rupture

Digoxin: Yellow rings

Doxycyline: tooth discoloration

Furosemide: hypokalemia

Lithium: tremors

Tobramycin: ototoxicity

Valacyclovir: thrombotic thrombocytopenia purpura

ACE inhibitors - PRIL

increases vasodilation, excretion of sodium and water

HTN, HF, MI

Angioedema = epinephrine

Calcium Channel Blockers - DIPINE

Angina, HTN