NCLEX bootcamp fundamentals/delegation/management cheat sheet

NCLEX bootcamp fundamentals/delegation/management cheat sheet Leave the first rating Students also studied Terms in this set (62) Science MedicineNursing Save NCLEX bootcamp episode 3 109 terms brianadestiny Preview

Critical Care Class: Corewell Health...

245 terms alyssa_verbeke Preview Mark Klimek NCLEX Review - Lectur...109 terms Nurse__LizPreview MENTA 42 terms sire Practice questions for this set Learn1 / 7Study using Learn prioritize airway and safety issues first, followed by issues related to breathing, circulation, or disability (neurologic) Priority for PH imbalancesidentifying and treating the underlying cause. PH and HC03 in same direction = metabolic PH and PaCO2 in opposite direction is respiratory Choose an answer 1 How to prioritize answers in priority questions 2Priority for PH imbalances 3Donning PPE4Respiratory alkalosis intervention Don't know?

Potassium with acidosis vs alkalosisAcidosis: hyperkalemia

Alkalosis: hypokalemia

*place clients with potassium imbalances on continuous cardiac monitoring due to the risk for dysrhythmias Arterial blood drawafter radial artery is punctured for an ABG draw, hold pressure for >5 minutes to prevent hematoma formation Respiratory acidosis interventioncaused by hypoventilation and requires to improve ventilation (BiPAP, bronchodilators, increase ventilator rate) Respiratory alkalosis interventioncaused by hyperventilation and requires to slow breathing (paper bag breathing, lower ventilator rate) Metabolic acidosis causedue to bicarbonate loss (diarrhea) or acid buildup (DKA) Metabolic alkalosis causedue to bicarbonate retention or acid loss such as severe vomiting or NG suctioning Sodium #1 prioritythink neuro #1 priority would be seizure precautions due to causing confusion, seizures, and altered mental status Hyperkalemia treatmentIn severe hyperkalemia administer IV calcium to stabilize the heart and give IV insulin with dextrose to shift potassium into the cells Calcium think "muscles and bones"hypocalcemia causes muscle twitching and spasms (chvostek/trousseau) while hypercalcemia leads to weakness and kidney stones Magnesium think "calm and reflexes"Magnesium affects neuromuscular excitability. Low levels cause twitching and high levels depress mental status, reflexes, and respirations Standard precautions for all clients includehand hygiene and gloves Donning PPEgown, mask, goggles, gloves Doffing PPEgloves, goggles, gown, mask Contact precautions PPEgown and gloves, remember really sticky infections might spread droplet precaution PPEmask Airborne precaution PPErespirators and negative pressure rooms required Top priorities to prevent complications like skin breakdown, atelectasis, dvts and muscle atrophy early ambulation and frequent repositioning What position improves ventilation in clients with respiratory and cardiac issues Fowler

What lung should be positioned down in a client with lung conditions while positioned laterally the unaffected (good) lung down How to prevent injury in nurses during repositioning avoid manual lifting and always use assistive devices if lifting >35 lbs (15 kg) How to avoid axillary nerve damage with crutches clients should hold crutches so that elbows are flexed at 30 degrees and weight is distributed to the hands and arms not the axilla How to use stairs with crutches or caneLead with unaffected leg when going up and the cane and affected leg when going down (up with the good, down with the bad) Pre-op careStop taking anticoagulants, NSAIDs and herbal supplements including ginkgo and st. johns wort. before surgery to decrease bleeding risk and screen for malignant hyperthermia by asking the client about a personal or family history of adverse reactions to anesthesia What is time out before surgery?When the surgical site must be marked to prevent wrong site surgery and a final time out should be conducted just before to confirm the correct client, procedure, and site with the surgical team Surgical site infectionIf hair removal is necessary pre operatively use electric clippers instead of razors to avoid micro cuts and contamination. Post operatively monitor surgical site for infection and notify HCP of redness, warmth, and swelling Post op careSupport oxygenation by administering oxygen to keep O2 sats >90% and encouraging incentive spirometer use. Prevent atelectasis, paralytic ileus, and DVT by encouraging early ambulation and regularly assess for hypotension and tachycardia indicating bleeding or shock What to do if wound dehiscence or evisceration happens immediately cover the area with sterile saline soaked gauze and bend the clients knees and notify the HCP When are restraints usedonly used as a last resort if there is risk for harm and only after less restrictive measures have failed Assessments while clients are in restraintsperform neurovascular assessment every 2 hours checking skin color, temperature, and pulse. Ensure you can fit 2 fingers underneath restraint Interventions to prevent fallsCall light within reach and performing hourly rounding How to prevent falls at homeremove clutter and rugs from walkways

RACE and PASS in event of fireR: rescue clients

A: activate alarm

C: confine fire

E: extinguish fire

P: pull pin

A: aim at base

S: squeeze handle

S: sweep from side to side

When delegating tasks, who retains accountability for the task outcome?The nurse Who can care for unstable clients? RN, LPN, or UAP RN

RN's cannot delegate TAPE. What is TAPET: teaching; initial

A: assessment initial

P: planning

E: evaluation

RN's must perform initial assessment and teaching, LPN's can only repeat assessment and teaching for stable clients after the RN completes them first. T or D True UAP can only perform routine tasks on stable clients T or D True Define autonomyClients rights to make own decisions and is respected for that decision Define beneficenceDemonstrated by promoting clients well-being and acting in their best interest Define fidelityInvolves keeping promises, like returning to give analgesics as promised Define veracityProviding truthful and accurate information to keep clients fully informed. Like explaining diagnosis and treatment options honestly What is a ethical dilemmaThis arises when two or more ethical principles conflict and are more resolved through ethical reasoning by first gathering information and examining biases What is client advocacyProtecting the client rights and acting on the clients behalf is client advocacy.extra care should be taken to advocate for vulnerable populations including older adults, children, and clients with cognitive impairments What is cultural competenceTo promote culturally competent care, nurses should assess personal cultural biases; avoid stereotyping and conduct a cultural assessment to understand the client's values, beliefs, and traditions.Assaultthreatening a client verbally or physically Batteryunwanted physical contact including performing a procedure without consent false imprisonmentapplying restraints without cause and preventing competent clients from leaving the health care facility Who can the nurse share the clients health information with?Only with the individuals directly involved in clients care Which 3 situations require mandatory reporting by licensed nurses?

• child and older adult abuse
• health care workers who are impaired due to drugs or alcohol
• certain communicable diseases like HIV and TB