Study Guide Notes for NCLEX

1 Study Guide Notes (for NCLEX)

DO NOT delegate what you can EAT!E - evaluate A - assess T - teach addisons= down, down down up down cushings= up up up down up addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia

No Pee, no K (do not give potassium without adequate urine output)

EleVate Veins; dAngle Arteries for better perfusion

A= appearance (color all pink, 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)

TRANSMISSION -BASED PRECAUTIONS:

AIRBORNE

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 DROPLET think 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 1 / 4

2 M - mycoplasma or meningeal pneumonia An - Adenovirus Private Room or cohort Mask

CONTACT PRECAUTION

MRS.WEE

M - multidrug resistant organism R - respiratory infection S - skin infections * W - wound infxn E - enteric infxn - clostridium difficile E - eye infxn - conjunctivitis

SKIN INFECTIONS

VCHIPS

V - varicella zoster C - cutaneous diphtheria H - herpez simplex I - impetigo P - pediculosis S - scabies

• Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic,

sense of impending doom) --> turn pt to left side and lower the head of the bed.

• Woman in Labor w/ Un -reassuring FHR (late decels, decreased variability, fetal

bradycardia, etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)

• Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the

stomach) with the HOB elevated (to prevent aspiration)

• During Epidural Puncture --> side-lying
• After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to

prevent headache and leaking of CSF)

• Pt w/ Heat Stroke --> lie flat w/ legs elevated
• During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should

be kept straight. No other positioning restrictions.

• After Myringotomy --> position on side of affected ear after surgery (allows drainage of

secretions)

• After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4

weeks.

• After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders.
• Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture
• Buck's Traction (skin traction) --> elevate foot of bed for counter-traction 2 / 4

3

• After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than

4560 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows.

• Prolapsed Cord --> knee-chest position or Trendelenburg
• Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line.

While feeding, hold in upright position.

• To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in

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 --> elevate for first 24 hours on pillow, position prone daily to

provide for hip extension.

• Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to

provide for hip extension.

• Detached Retina --> area of detachment should be in the dependent position
• Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed
• After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees
• After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on

either side.

• During Internal Radiation --> on bedrest while implant in place
• Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal

congestion, goose flesh, bradycardia, hypertension) --> place client in sitting position (elevate HOB) first before any other implementation.

• Shock --> bedrest with extremities elevated 20 degrees, knees straight, head slightly

elevated (modified Trendelenburg)

• Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure

• Peritoneal Dialysis when Outflow is Inadequate --> turn pt from side to side BEFORE

checking for kinks in tubing (according to Kaplan)

• Lumbar puncture => AFTER the procedure, the client should be placed in the supine

position for 4 to 12 hrs as prescribed. (Saunders 3rd ed p. 229) Demorol for pancreatitis, NOT morphine sulfate

Myasthenia Gravis: worsens with exercise and improves with rest.

Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms

Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle 3 / 4

4 Prior to a liver biospy its important to be aware of the lab result for prothrombin time

From the a** (diarrhea)= metabolic acidosis From the mouth (vomitus)=m etabolic alkalosis

Myxedema/hypothyroidism : slowed physical and mental function, sensitivity to cold, dry skin and hair Graves’ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to heat, fine/soft hair

Thyroid storm: increased temp, pulse and HTN

Post-thyroidectomy: semi-Fowler’s, prevent ncek flexion/hyperextension, trach at bedside Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium), high Ca, low phosphorus diet Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium), low Ca, high phosphorus diet Hypovolemia – incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity >1.030 Hypervolemia – bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine specific gravity <1.010; Semi-Fowler’s Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration, weakness, administer Pitressin SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, HA; administer Declomycin, diuretics Hypokalemia: muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia: MURDER – muscle weakness, urine (oliguria/anuria), respiratory depression, decreased cardiac contractility, ECG changes, reflexes Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids Hypernatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution

Hypocalcemia: CATS – convulsions, arrhythmias, tetany, spasms and stridor

Hypercalcemia: muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect on CNS HypoMg: tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity HyperMg: depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deep tendon reflexes, shallow respirations, emergency Addison’s: hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress Cushings: hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump Addisonian crisis: n/v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Pheochromocytoma : hypersecretion of epi/norepi, persistent HTN, increased HR,

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