NCLEX-PN CHEAT SHEETS

NCLEX-PN CHEAT SHEETS

michelle_garland7 Save Exam Cram NCLEX-PN PRACTICE Q...103 terms summer3266Preview NCLEX PN Questions for 2024-2025...Teacher 186 terms TutorDkPreview NCLEX-PN 3000 Questions 83 terms cutiemexiPreview NCLEX Teacher Tut Positioning Techniques (F) Re-position at least 1-2 hours in bed.Every 20-30 mins in a chair.• Clients who have impaired nervous or musculoskeletal systems benefit from routine therapeutic positioning.

• At least every 1 to 2 hr in bed.
• Every 20 to 30 min if in a chair to prevent skin breakdown over bony prominences.

• Tools for repositioning clients

• Pillows, foot boots.
• Trochanter rolls, sandbags.
• Hand rolls.
• Hand-wrist splints.
• Trapeze bar.
• Side rails

• All side rails cannot be up or they will be considered a restraint.

• Bed boards.
• Wedge pillow (abductor pillow).

Positions (F)

High Fowler's: 90 degrees

Fowler's: 45-60 degrees

Semi Fowler's: 30-45 degrees

Supine: On back with head and shoulders on pillow.

Prone: Flat on abdomen with head to the side. Allows dorsiflexion of feet.

Lateral: Side-lying.

Sims': On side halfway between lateral and prone.

Trendelenburg: Entire bed is tilted with the head of the bed lower than the foot of the bed. Promotes venous return.Reverse Trendelenburg: Entire bed is tilted with the foot of the bed lower than the head of the bed. Promotes gastric emptying.

Assistive Devices (F) Wheelchair.

Walker: Take a step, move walker, take another step.

Cane: Single leg or quad. Keep cane on stronger side of the body. Move cane, move weak leg, move strong leg.Crutches: 2.3.4-point gaits. When ascending stairs, good food then crutches then bad food. When descending stairs, crutches then bad foot then good foot.Splints and Braces (F) Primary Nursing Concern: Assessment and prevention of neurovascular dysfunction or compromise.Assess every hour for the first 24 hrs. Every 2-4 hours afterwards.Elevate immobilized extremity higher than the heart.Apply ice for the first 24-48 hrs prn to reduce edema.Circulatory Care (F) Perform a comprehensive appraisal of peripheral circulation: peripheral pulses, edema, capillary refill, color, temperature.Monitor degree of discomfort or pain.Protect the extremity from injury.Place extremity in a dependent position.Peripheral Sensation Management (F)

Monitor for paresthesia: numbness, tingling, hyperesthesia, hypoesthesia.

Monitor the fit of bracing devices, prostheses, shoes, and clothing.Administer analgesics prn.Discuss or identify causes of abnormal sensations or sensation changes.Care after Immobilizer Removal (F) Move extremity carefully.Support with pillows or other devices until strength and movement return.Exercise slowly with physical therapist.Wearing support stockings or elastic bandages to prevent swelling for lower extremities.

Nutrition: Older Adults (F)

Need the same nutrients but in differing amounts.Number of calories needed is less.1500 mg/day of Calcium Smell and taste decline.May add more salt to enhance taste (teach about salt subs).Decrease vision makes food prep more difficult.

Foods to Eat for Older Adults (F) Foods low in saturated fat.Foods high in fiber, like whole-grain breads and cereals.Fruits and vegetables.Moderate amounts of low-fat dairy products.Protein like poultry, fish, beans, and eggs.Foods to Avoid for Older Adults (F) Sweets and other foods high in sugar, fat, and calories should be eaten sparingly.Dysphagia (F) Occurs with a stroke or other neurological conditions.Aspiration is the first concern, followed by dehydration and malnutrition.Observe for Observe for aspiration or pocketing of food in the cheeks or other areas of the mouth.Observe for signs of dysphagia, such as coughing, choking, gagging, and drooling of food.Maintain the client in semi-Fowler's position for at least 1 hr after meals.Provide oral hygiene after meals/snacks.• Dysphagia refers to difficulty when swallowing.• Causes of dysphagia

• Neurogenic

• Stroke. Cerebral palsy. Multiple sclerosis.

• Myogenic

• Myasthenia gravis. Aging. Muscular dystrophy.

• Obstructive problems

• Candidiasis. Head and neck cancer. Inflammatory masses.Preventing Aspiration (F) Position the client in Fowler's position or in a chair.Support the upper back, neck, and head.Have the client tuck her chin when swallowing to help propel food down the esophagus.Maslow's Hierarchy of Needs (F) Physiological - Safety and security - Love and belonging - Self-esteem - Self-Actualization.

Client Identification (F)

Before client care the nurse should:

Introduce herself Verify ID by asking client to stake his name and then checking his/her ID band. Always verify 2 identifiers.Assess for any allergies by checking client records.Seizure Precautions (F) Padded side rails.

Rescue equipment at bedside: Oxygen, oral airway, suction equipment.

Remove items that may cause injury.Never put anything in the client's mouth in the event of a seizure.During a seizure (F) Do not restrain the client Lower the client to the floor or bed.Protect the client's head.Remove nearby furniture.Provide privacy.Put the client on his side if possible.Loosen clothing to prevent injury and promote dignity.Note length of time of seizure.Note movement observed during seizure.After a seizure (F) Ensure airway is clear.Monitor mental status, O2Sat, and VSs.Reorient and explain to the client what has occurred.Provide comfort, understanding, and a quiet environment for the client to recover in.Document the seizure in the client's record with any precipitating behaviors and a description of the event.Report the seizure to the provider.Fire Safety (RACE) (F)

R - Rescue: Protect and evacuate clients in immediate danger.

A - Alarm: Report the fire.

C - Contain: Contain the fire.

E - Extinguish: Extinguish the fire.

Types of Fire Extinguishers (F)

Class A: Paper, Wood, Upholstery, Rags, Other trash.

Class B: Flammable liquids and gases.

Class C: Electrical fires.