NCLEX Bootcamp notes

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Expressive Aphagia: Difficult speaking

Remove Restraints for toileting, skin check, food, fluids every

• hours

Check vitals in restraints every15 mins Choose an answer 1Left Stroke2 Remove Restraints for toileting, skin check, food, fluids every 3Becks triad4Sitting Visually Impaired pt Don't know?

Restraints must be tied to theBED FRAME

-NOT SIDE RAILS

Walking w visually Impaired behind or ahead?Slightly AHEAD Sitting Visually Impaired ptPlace pts hand on chair Patent Ductus Arteriosus (PDA)Continuous Murmur -Indomethacin Patent Ductus Arteriosus txIndomethacin Tetralogy of Fallot S/sCyanosis (worse w cry, feed) Dyspnea Hypoxia Squatting -Murmur -Clubbing Tetralogy of Fallot Interventions-Knee Chest FIRST -Calm

-O2 100%

-IV Fluids -Morphine tet spell where they become cyanoticKnee Chest Position Latex AllergyAvocado Banana Kiwi Chestnut

Post Op CABG (coronary Artery Bypass)-Monitor for Becks: Muffled, JVD, LOW BP

(Tamponade)

-NO LIFTING, ARM RAISE

-Splint when cough or sneeze

Becks triad-Hypotension -JVD -Muffled Heart Sounds

(CARDIAC TAMPONADE)

Cardiac Tamponade S/S-JVD -Muffled Heart Sounds -Hypotension (Low BP) Cardiac Tamponade TXEmergency pericardiocentesis LevofloxacinFluoroquinolone Antibiotic -AVOID MILK & ANTACIDS -STOP if JOINT PAIN (tendon rupture risk) Achilles Pain w LevofloxacinSTOP DRUG Avoid w LevofloxacinMilk Antacids Lyme Disease DxELISA and Western Blot Post Op Transsphenoidal Hypophsectomy-NO Cough Sneeze, Blowing Nose -Monitor for DI (INCR URINE , Low Osmolality) -Oral Rinse NO BRUSHING TEETH -Clear Nasal Drainage=> TEST GLUCOSE FOR CSF LEAK Monitor for after Transsphenoidal Hypophysectomy -POLYURIA (DI) -Glucose in Nasal Drainage (CSF) If Nitro doesn't stop pain in 5 minCALL 911!!!!-Take 2 more 5 min apart while WAITING for EMS OTC Coated Baby AspirinPrevent Platelet Aggregation -Use in angina

Glipizide-DM

-ONLY W MEALS

MetforminDo not hold even if not eating Glucose over 600Hyperosmolar Hyperglycemic Syndrome Incr BUN & Creatinine HyperGlycemia Hyperkalemia Nausea Edema CKD Peritoneal Dialysis-Weight Before & After -Sterile Gloves & Mask -Check Glucose -Warm Dialysate -Effluent vol Always GREATER than instilled -Clear drainage -Tachycardia -Palpitations -Diaphoresis -Weakness -Confusion -Dizzy -Lethargic Hypoglycemia Arthrocentesissurgical puncture to remove fluid from the joint space Post Arthrocentesis-Compression Dressing -Monitor for HYPERGLYCEMIA -COLD Compress

-Report: Fluid/Blood Leak