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NGN NCLEX RN ACTUAL Exam V1
1. after thyroidectomy:
Answer:
low or semi fowlers, support head, neck and shoulders
2. infant with spina bifida:
Answer:
position prone (on abdomen) so that sac doesn't rupture
3. bucks traction (skin traction):
Answer:
elevate foot of bed for counter-traction
4. after total hip replacement:
Answer:
don'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
5. prolapsed cord:
Answer:
knee chest position or trendelenburg
6. infant with cleft lip:
Answer:
position on back or in infant seat to prevent trauma to suture line. while feeding, hold in upright position.
7. to prevent dumping syndrome:
Answer:
post 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
8. above knee amputation:
Answer:
elevate for first 24 hours on pillow, position prone daily to provide for hip extension
9. below knee amputation:
Answer:
foot of bed elevated for first 24 hours, position prone daily to provide for hip extension
10. detached retina:
Answer:
area of detachment should be in the dependent position
11. administration of enema:
Answer:
position patient in left side lying (sim's) with knew flexed
12. after supratentorial surgery (incision behind hairline):
Answer:
elevate HOB 30-45 degrees
13. after infatentorial surgery (incision at nape of neck):
Answer:
position pt flat and lateral on eithe rside
14. during internal radiation:
Answer:
on bed rest while implant in place
15. autonomic dysrelexia/hyperreflexia:
Answer:
S&S; pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension . . . place pt. in sitting position (elevate HOB first before any other implentation)
16. shock:
Answer:
bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified trendelenburg)
17. head injury:
Answer:
elevate HOB 30 degrees to decrease intacranial pressure
18. DO NOT delegate what you can EAT!:
Answer:
E-evaluate A-assess T-teach
19. Addisons:
Answer:
down, down, down, up, down
20. Cushings:
Answer:
up, up, up, down, up
21. Addisons:
Answer:
hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
22. Cushings:
Answer:
hypernatremia, hypertension, increased blood vol, hypokalemia, hyperglycemia
23. No Pee:
Answer:
No K do not give POTASSIUM without adequate urine output
24. APGAR:
Answer:
A=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)
25. AIRBORNE:
Answer:
MY-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
26. DROPLET:
Answer:
think of SPIDERMAN S-sepsis S-scarlet fever S-streptococcal pharyngitis P-parvovirus B19 P=pneumonia
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