Saunders Comprehensive Review for the NCLEX -RN Examination

Saunders Comprehensive Review for the NCLEX -RN Examination the nurse is caring for a patient with a diagnosis of heart failure who suddenly complains about shortness of breath and dyspnea. the nurse should take which immediate action - elevate the head of the patients bed

early sign of hypovolemic shock - increased pulse rate

What should you consider when selecting an answer or determining the order of priority - using ABCs

A-airway B-breathing C-circulation

(exception: CPR. then remember CAB- compression, airway, breathing)

use maslow hierarchy of needs theory when prioritizing - 1). basic physiological need 2). safety and security 3). love and belonging 4). self esteem 5). self actualization

use the steps of the nursing process to prioritize - assessment analysis planning implementation evaluation

eliminate options that contain closed ended words- - all, always, every, must, none

open-ended words could possible be the correct answer - may, usually, normal, commonly, or generally

look for the umbrella option - a broad or universal option

respect for an individuals right to self-determination - Autonomy

the obligation to do or cause no harm to another - nonmaleficence

the duty to do good to others and to maintain a balance between benefits and harm - beneficence

the duty to do what one has promised - fidelity

obligation to tell the truth - veracity

examples of negligent acts - medication errors that result in injury to client

IV administration errors, such as incorrect flow rates or failure to monitor flow rate, that results in injury to client...

pg. 136

instructional directives - living wills

required to be written and signed by the client

defamation - false communication

writing- libel

verbally- slander

determines whether the client has a conductive or sensorineural hearing loss - weber test

air conduction is normally hear twice as long than bone conduction - rinne test

equilibrium test - romberg test

swaying is a postive romberg sign

palpable vibration of the chest wall resulting from speech - Tactile Fremitus

abnormal breath sounds - adventitious sounds

high pitched crackling and popping noises (discontinuous sounds) heard during the end of inspiration. not cleared by cough

-clinical example: - fine crackles (fine rales)

-may be heard in pneumonia, heart failure, asthma, restrictive pulmonary disease

medium pitched, moist sound heard about halfway through inspiration. not cleared by cough

-clinical examples - medium crackles (medium rales)

-same as fine crackles but conditions have worsen

low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration

-clinical examples: - coarse crackles (coarse rales)

-same as medium and fine but is even worse than both or is heard in terminally ill clients with diminished gag reflex. also heard in pulmonary edema and pulmonary fibrosis

high-pitched, musical sound similar to a squeak. heard more commonly during expiration, but may also be heard during inspiration. occurs only in small airway

-clinical examples: - Wheeze (sibilant wheeze)

-heard in narrowed airway diseases such as asthma

low-pitched, coarse, loud, low snoring or moaning tone. heard primarily during expiration but may be heard during inspiration. coughing my clear - Rhonchi (sonorous wheeze)`

-heard in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis