NCLEX bootcamp Fundamentals

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NCLEX BOOTCAMP

16 terms trinitykamalei Preview acute k 24 terms gab Rubella spreads throughdroplet precautions Droplet precautions require healthcare workers to wear surgical masks within 3 feet of the client

Pressure injury prevention includes:Lift and floating devices.

Shifting weight.Preventing moisture.ROM and strengthening exercises.

HOB ≤30°.

Proper nutrition; monitoring weight and prealbumin levels.pressure injury risksimpaired sensory perception impaired mobility and inactivity shear (sliding, repositioning) friction presence of moisture impaired nutrition (malnourished, NPO) hypokalemia causescardiac and muscle dysfunction Before NG tube removalplace client in high-Fowler, clamp, and disconnect tubing from suction and feedings Instruct client to breathe deeply, then hold their breath during tube removal to reduce aspiration risk.

Management of constipation includes:Physical activity

High-fiber diet Adequate fluid intake Leaning forward during defecation Defecating at first urge Avoiding the use of opioids Interventions for severe hearing loss promote effective communication, including Hand gestures.Minimizing background noise.Removing cerumen.Adaptive devices and settings.Clients diagnosed with streptococcal pharyngitis require

Droplet Precautions, including:

Private room or roommate with same pathogen Surgical mask if working within three feet of client Surgical masking of a client if transporting to another department Skin manifestations are less visually apparent in dark- skinned clients.

Assessment strategies include:

Palpating for inflammation or bruises Inspecting mucous membranes and sclera for jaundice Assessing lining of eyelids, palms, and soles for cyanosis Comparing sides of the body for abnormalities Anticipated interventions for clients with dilutional hyponatremia include Preparing oral suction equipment Restricting oral fluid intake Encouraging a high-sodium diet

N95 respirators are:For airborne precautions

Fitted annually or for changes (e.g., face shape, model, or mask manufacturer) Removed outside of the client's room with the door closed EnemasAre administered with the client in Sims position Can cause anticipated discomfort (e.g., cramping, abdominal distention) Should be isotonic for clients at risk for dehydration Hypocalcemia causesneuromuscular excitability (e.g., muscle spasms, tetany) Trousseau sign occurs whenthe hand and fingers flex when a BP cuff is inflated on the arm.Before performing a tube feed via a PEG tubeGastric residual volume is assessed to minimize aspiration risk Reinstilling aspirated stomach contents prevents nutrient and electrolyte loss pH testing assesses tube placement To maintain a safe home environment, older adults

should:

Line the edges of stairs and doorways with a bright color.Properly store cleaning solutions.Wear shoes or non-skid socks.Use a raised toilet seat and install bathroom grab bars.When assessing the risk for impaired wound healing, the nurse should prioritize evaluating the client's protein intake status, which is best done using serum prealbumin levels When facing a delay in TPN administration, it's essential to ensure the client's blood glucose levels remain ____ stable

Replacing TPN with ______ is the best immediate action to provide a source of glucose to the client.10?xtrose solution

Restraint alternatives include:Distraction (activity apron, TV)

Medication review for side effects Stockinette to cover VAD site Moving client's room close to nurses' station Nasal cannula tubing can cause skin breakdown, so the nurse should consider placing this padding on the ears Venturi masks are most commonly used for clients with COPD is a venturi mask low or high flowhigh flow oxygen signs of acute hemolytic transfusion reaction caused by administering incompatible blood Fever, flank pain, and impending doom When performing sputum specimen collection, the nurse

should:

Position the client in semi or high-Fowler's position.Ensure the client has not brushed their teeth.Never suction longer than 10-15 seconds.Warn the client that coughing may occur during suctioning.Surgical asepsis includes:Performing surgical scrubbing before donning surgical gown Opening the first sterile kit flap away from the body Discarding sterile objects if packaging becomes wet Keeping hands above waist Keeping sterile objects away from the nonsterile 1-inch border indications for blood transfusionTrauma, anemia, and gastrointestinal bleeding Risk factors for restraint complications include factors

that:

Compromise circulation (diabetes, snug restraint application) Cause constipation (immobility, opioids) Compromise airway (supine position) Constipation treatment includesexercise as tolerated, high-fiber foods, adequate fluid intake, and medications (laxatives and stool softeners).Injury prevention during ambulation includes:Determining assistance needed before ambulating Using gait belts to guide clients, not support them Assisting clients to the floor during a fall Having an awareness of any physical limitations Clients with varicella requireairborne isolation precautions Interventions at end of life focus on comfortpleasurable tastes, oral morphine, elevated head of bed, frequent oral care, blankets for warmth

Clients following a vegan diet:Do not eat any animal products, including dairy and eggs Require B12 supplementation Should pair iron-rich foods with foods high in vitamin C to promote absorption what is TPN forintravenous administration of a solution of dextrose, lipids, and amino acids for clients who cannot receive nutrition enterally When giving TPN:Check glucose every 6 hours and electrolytes daily to monitor for refeeding syndrome, hyperglycemia, or hypoglycemia.Change IV tubing daily to prevent sepsis.Corrosive poison ingestion:Can cause upper airway edema that can lead to respiratory distress Interventions include preparing for intubation, IV fluids, and pain medications.Contraindications include inducing emesis and neutralizing the substance.a priority intervention for pressure injury prevention and treatment Repositioning or turning clients at least every 2 hours Interventions to prevent a CAUTI include:Keeping the perineal area clean and handling the catheter with gloved hands Preventing backflow of urine into the bladder by emptying regularly and keeping below the level of the bladder interventions that can prevent contracture formation Range of motion exercises, splinting, and stretching some proteins in latex are similar to those in certain foods such as bananas and kiwis should clients on airborne precautions room together no prevents the spread and risk of infection

Risk factors for dysphagia include:Regular alcohol consumption

History of stroke Parkinson disease End of life Esophageal cancer Radiation therapy targeting the head or neck Decreased and increased serum calcium

Good sleep hygiene includes:Getting out of bed if unable to sleep

Maintaining a consistent sleep schedule and bedtime routine Avoiding daytime napping Engaging in daily physical exercise (>2 hr before bedtime) Avoiding caffeine, alcohol, and heavy meals before bed

Overflow incontinence:Results from chronic urinary retention

Causes lower abdominal discomfort and leaking of urine Increases the risk for UTIs