NCLEX 35 Page study guide

NCLEX 35 Page study guide ScienceMedicineNursing Shirley_Hernandez Save mark klimek Teacher 229 terms natbelPreview 140 Must Know NCLEX Meds 141 terms eyoung389Preview NCLEX-RN Practice Questions For 2...Teacher 33 terms TutorDkPreview NCLEX 116 term Sun In delegation, nurses must take patients where there is...Evaluation Assessment Teaching Dont delegate what you can EAT Addison disease vs Cushings disease

Addisions: down down down up down

(hyponatremia, hypotension, decreased blood volume, kyperkalemia, hypoglycemia)

Cushings: up up up down up

(hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia) When do we hold potassium Do not give potassium without adequate urine output "No Pee, No K" APGAR Appearance (color all pink, pink and blue, blue/pale) Pulse (>100, <100, none) Grimace (cough, grimace, none) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, none)

For what diseases do we use airborne precautions My (measles) Chicken (chicken pox/varicella) Hez (disseminated herpes zoster, shingles)

TB (TB)

When implementing airborne precautions, what do we have to do Private, negative pressure room Must wear mask Can cohort with patient who has same organism, but not if they have different organisms Place mask on client when they are being transported For what diseases do we use droplet precautions Think SPIDERMAN

S:sepsis

S:scarlet fever

S: streptococcal pharyngitis

P:Parvovirus B19

P:Pneumonia

P:Pertussis

I:Influenza Type B

D: Diptheria (pharyngeal)

E: Epiglottitis

R: Rubella

M:mumps

M:Mengitis

M:Mycoplasm or meningeal pneumonia

An: Adenovirus

When implementing droplet precautions, what do we have to do Private room or cohort them with a client with the same infection Wear a mask Door may remain open For what diseases do we use contact precautions

MRS.WEE

M:multi drug resistant organism

R: Respiratory infection (RSV)

S: Skin infections (varicella zoster, cutaneous diptheria, herpes simplex, impetigo, pediculosis, scabies)

W:wound infection

E: Enteric infection (C Diff)

E: eye infection (pink eye)

Signs and symptoms of air/pulmonary embolism Chest pain Difficulty breathing Tachycardia Pale/Cyanotic Sense of impending doom What do we do as the nurse for air/pulmonary embolism Turn patient to the LEFT side and LOWER the head of the bed Signs and symptoms of a woman in labor with a baby who has an unreassuring FHR Late decels Fetal bradycardia Decreased variability What do we do for a woman in labor who has an unreassuring FHR Turn to the LEFT side Give O2 Stop the Pitocin Increase IV fluids (LR and NS) What position is someone in for an epidural puncture Side-lying What position is the patient in AFTER a lumbar puncture (and also oil-based myelogram) Have the pt lie Flat and Supine to prevent CSF from leaking out and prevent a headache What do we do if a patient has decreased LOC during tube feeding Position the patient on the RIGHT side (to increase gastric emptying) and RAISE the head of the bed to at least 30 degrees (to prevent aspiration) Position for a patient with a CBI The catheter is taped to the patients leg so the leg should be kept straight, but there are no other positioning limitations Position of a patient after a myringotomy Position the patient on the side of the AFFECTED EAR after surgery to allow for drainage of secretions.This procedure is surgical incision into the eardrum (tympanic membrane), to relieve pressure or drain fluid.

Position of a patient after cataract surgery Patient should sleep on the UNAFFECTED side and have a night shield for 1-4 weeks Position of a patient after a thyroidectomy Low or semi-fowlers. Support the head, neck, and shoulders. Have a trach at the bedside Position of an infant with spina bifida Prone! So their sac does not rupture Position of a patient with bucks traction Elevate the food of the bed for counter traction Position of a patient after total hip replacement Do not sleep on the operated side. No flexing the hip more than 45-60 degrees. Don't elevate the HOB more than 45 degrees. Keep the hip abducted by separating legs with a pillow or abductor Position for a mom with a prolapsed cord Knee-chest position or trendelenburg Position for an infant with a cleft lip On their back or in an infant seat to prevent trauma to the suture line. If feeding, hold in an upright position Position for an ABOVE the knee amputation Elevate for the first 24 hours on a pillow. Position prone daily to help with hip extension Position for a BELOW the knee amputation Foot of bed elevated for the first 24 hours. Position prone daily to help with hip extension Position for a detatched retina Area of detachment should be in the dependent position Position for administration of an enema Patient should be LEFT side laying with the knee flexed (Sims position) Position during internal radiation On bedrest while the implant is in place