NCLEX-RN Review

NCLEX-RN Review Leave the first rating Students also studied Terms in this set (789) Science MedicineNursing Save Fundamentals Clinical Judgement a...48 terms ella_miller03Preview Infection Control Post Test 11 terms lizz_RNLOADING Preview

NCLEX-RN PREP 2025

Teacher 47 terms wasalynPreview ATI dia

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jlwh

Do not delegate what you can EATDon't delegate what you can:

E- Evaluate A- Assess T- Teach *if unsure ask charge nurse Follow up with performed task that has been delegated.Baker Actprovides individuals who have a mental illness, or who may harm or neglect themselves or others, with an emergency service and temporary detention for psychiatric evaluation and voluntary or involuntary short-term community inpatient treatment.nursing consideration

-pt must have a 1:1 sitter at bedside

• within or post 24hr post baker act pt must be seen by psych.

Infants with MENINGITISs/s: poor or shrill cry (infants)

decrease LOC (lethargy) no appeitie fever n/v

DX: LP

NSG INTV:

*Meningitis at 6 months (newborn) may have cerebral palsy IV ABT tx after LP culture sent to lab HOB elevated monitor for s/s of increased ICP Initiate seizure precaution.

PREVENTION Recommendation: pneumococcal vaccine at 2 months

ASSESSMENTAlways done at the beginning of the shift.

ALWAYS ASSESS YOUR PT WHEN PROVIDING ANY TYPE OF NSG CARE (ex: pt

c/o pain perform a pain assessment) Head to Toe at the beginning of shift and systems or focused assessment at least every hour during the shift

*questions: always think what you can do right then and there for the pt.

Priority care in nursingAssessment of patient, invasive sites, bleeding Provide O2 (usually 2L via NC) Monitor VS Elevate HOB Check any tubes for kinks Neurological assessment includesLOC (especially in head injury, PE/DVT, and fat embolism) Mental Status Emotional status AAO x4 (person, place, time , and situation) Assess cranial nerves Assess sensory and motor reflex

PERRLA

Assess eye (sclera, conjunctiva, symmetry) Pupil size (normal 3-4mm) Monitor pain, temp, sensation, reflexes Assess motor function and balance/coordination

*Infant or neonates: check fontanels

Respiratory AssessmentLOC ABG* when indicated Lung sounds (auscultate) Respiration patterns or effort Inspect chest symmetry pulse oximetry VS (specifically O2, RR and HR)

NSG INTV:

Check physiotherapy

TCDB Q2H

Incentive spirometer (10x/hr) oral care Elevate HOB Cardiovascular assessmentLOC VS (HR and BP) *apical pulse Assess pulses ( grading of pulse (+1,+2)) (regular, irregular) Heart sounds Cap refill Assess CMS

GI assessmentObserve abdomen shape and contour (flat, round, distended) Palpate for pain or tenderness Percussion

Auscultate: Bowel sounds

*Assess girth measurement if indicated.Assess last BM Renal AssessmentUrinary patterns (frequency, urgency) Monitor VS (BP AND WEIGHT) Assess hydration (skin turgor) Renal labs (BUN, creatinine, specific gravity, urea, albumin, UA C&S) Urinary output (assess for foley) Monitor I&O Daily weights *usually for renal failure and HF Skin assessmentAssess for color, moisture, temperature, texture, turgor, vascularity, edema, lesions, rash Assess hair and scalp Assess for bruising, wounds, and pressures Assess mucosas and oral cavity (pink, most, lesions) Assess extremities Assess bony parts for breakdown r/t high risk areas of pressure ulcer formation MS assessmentROM Assess Gait Assess posture Muscle strength symmetry (right and left extremities) Assess CMS Assess skin condition (for injuries) Assess pulses Assess functions (ADL) Assess for pain based on location

Addisons: Down, Down, Down, Up, Down

Cushings: Up, Up, Up, Down, Up

Addisons: Hyponatremia, Hypotension, Decreased blood volume, Hyperkalemia,

Hypoglycemia

Cushings: Hypernatremia, Hypertension, Increased Blood Volume, Hypokalemia,

Hyperglycemia DX test in neurologicalCT brain scan MRI PET scan Cerebral angiography Myelography EEG EMG LP Nerve conduction test Grapefruit juice effectcan inhibit the metabolism of certain drugs, thereby raising their blood levels

AVOID!!!!

EEGUsed to detect seizure disorders -used to determine brain death (especially in pt in coma) -may show that tumor, abscess, brain scar, blood clots, and infection present.

NO PAIN PROCEDURE

PT MUST LIE STILL

AVOID STIMULANTS 1-2 days prior ex:

-coffee -chocolate -tea -caffine EMGNeedle electrodes introduced into Skeletal Muscles to measure changes in electrical potential of the muscles & the nerves leading to them.

Used to detect:

• Neuromuscular disorder
• Determines weakness from neuropathies

No Pee, No KDon't give potassium without adequate urine output. (ADV: Adult: 30 ml/hr Child: 20-30 ml/hr) Monitor I&O EleVate Veins & DAngle Arteries forBetter perfusion so as not to have impaired tissue perfusion Arteries Veins Away from the heart To the heart

• gram1 ml

Cholesterol LevelsLDL: lower than 130mg/dL; <160>

HDL: 30-70 mg/dL

Total <200>

TX: diet with whole grain, fruit, vegetable, olive or canola oil

• pound453.6 grams
• liter of fluid/1 kg2.2 lbs

Purpose of renal systemmaintain body's homeostasis -regular fluids and electrolytes -remove waste -urine formation -control BP -Regulate RBC production *via erythropoietin -Acid-base balance *kidney reabsorb or produce HCO3 to maintain body pH.