NCLEX-PN EXAM - A-assess T-teach Addisons - answerdown, down, d...

NCLEX-PN EXAM

DO NOT delegate what you can EAT! - answerE-evaluate A-assess T-teach Addisons - answerdown, down, down, up, down Cushings - answerup, up, up, down, up Addisons - answerhyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia Cushings - answerhypernatremia, hypertension, increased blood vol, hypokalemia, hyperglycemia No Pee - answerNo K do not give POTASSIUM without adequate urine output APGAR - answerA=appearance (color all pinks, pink and blue, blue (pale) P= pulse (>100, <100, absent) G=grimace (cough, grimace, no response) A=activity (flexed, flaccid, limp) R=respirations (strong cry, weak cry, absent) AIRBORNE - answerMY-Measles Chicken-Chicken Pox/Varicella Hez=Herpez Zoster/Shingles TB or remember . . .MTV=Airborne Measles TB Varicella-Chicken Pox/Herpes Zoster-Shingles *Private Room-negative pressure with 6-12 air exchanges/hr mask, N95 for TB DROPLET - answerthink of SPIDERMAN

S-sepsis S-scarlet fever S-streptococcal pharyngitis P-parvovirus B19 P=pneumonia P-pertussis I-influenza D-diptheria (pharyngeal) E=epiglottitis R-rubella M-mumps M-meningitis M-mycoplasma An-adenovirus *Private Room or cohort* *Mask*

CONTACT PRECAUTION - answerMrs. Wee M-multidrug resistant organism R-respiratory infection S-skin infections W-wound infxn E-enteric infxn - clostridum difficile E- eye infxn - conjunctivitis SKIN INFECTIONS - answerVCHIPS V-varicella zoster C-cutaneous diptheria H-herpez simplex

I-impetigo P-pediculosis S-scabies Air/Pulmonary Embolism - answerS&S;chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom turn patient to left side and lower the head of the bed Woman in Labor w/un-reassuring FHR - answerlate decels, decreased variability, fetal bradycardia, etc.turn patient to the left side (and give O2, stop pitocin, increase IV fluids Tube feeding w/decreased LOC - answerposition patient on the right side (promote emptying of the stomach) with HOB elevated (to prevent aspiration) During Epidural Puncture - answerside lying After Lumbar Puncture - answerand also oil myelogram . . .patient lies flat supine (to prevent headache and leaking of CSF) patient with heat stroke - answerlie flat w/legs elevated during continuous bladder irrigation (CBI) - answercatheter is taped to thigh so leg should be straight. no other position restrictions after myringotomy - answerposition on side of affected ear after surgery (allow for drainage of secretions) after cataract surgery - answerpatient will sleep on unaffected side with night shield for 1-4 weeks after thyroidectomy - answerlow or semi fowlers, support head, neck and shoulders infant with spina bifida - answerposition prone (on abdomen) so that sac doesn't rupture bucks traction (skin traction) - answerelevate foot of bed for counter-traction after total hip replacement - answerdon't sleep on operated side, don't flex hip more than 45-60 degrees, don't elevate HOB more than 45 degrees. maintain hip abduction by seperating thighs with pillows prolapsed cord - answerknee chest position or trendelenburg infant with cleft lip - answerposition on back or in infant seat to prevent trauma to suture line.while feeding, hold in upright position.to prevent dumping syndrome - answerpost operative ulcer/stomach surgeries . . . eat reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals

above knee amputation - answerelevate for first 24 hours on pillow, position prone daily to provide for hip extension below knee amputation - answerfoot of bed elevated for first 24 hours, position prone daily to provide for hip extension detached retina - answerarea of detachment should be in the dependent position administration of enema - answerposition patient in left side lying (sim's) with knew flexed after supratentorial surgery (incision behind hairline) - answerelevate HOB 30-45 degrees after infatentorial surgery (incision at nape of neck) - answerposition pt flat and lateral on eithe rside during internal radiation - answeron bed rest while implant in place autonomic dysrelexia/hyperreflexia - answerS&S; pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension . . . place pt. in sitting position (elevate HOB first before any other implentation) shock - answerbedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified trendelenburg) head injury - answerelevate HOB 30 degrees to decrease intacranial pressure peritoneal dialysis when outflow is inadequate - answerturn pt. from side to side BEFORE checking the tubing for kinks lumbar puncture - answerafter the procedure, the client should be placed in the supine position for 4-12 hours as prescribed demorol for pancreatitis - answerDO NOT GIVE MORPHINE SULFATE myasthenia gravis - answerworsens with excercise and improves with rest myasthenia crisis - answera positive reaction to tensilon . . .will improve symptoms cholinergic crisis - answercaused by excessive medication . . stop med giving tension will make it worse head injury medication - answermannitol (osmotic diuretic) crystallizes at room temp so ALWAYS usse filter needle prior to liver biopsy - answerimportant to be aware of lab result for prothrombin time from the a** (diarrhea) - answermetabolic acidosis from the mouth (vomiting) - answermetabolic alkalosis myxedema/hypothyroidism - answerslowed physical and mental function, sensitivity to cold, dry skin and hair