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University of Central Florida NUR 3125 nclex study guide.

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FREE NCLEX RN Study Guide 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, increased 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 ● 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 1. 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. 2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) –> turn on left side (and give O2, stop Pitocin, increase IVfluids) 3. Tube Feeding w/ Decreased LOC –> position pt on right side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration) 4. During Epidural Puncture –>side-lying 5. After Lumbar Puncture (and also oil-based Myelogram)–> pt lies in flat supine (to prevent headache and leaking of CSF) 6. Pt w/ Heat Stroke –> lie flat w/ legs elevated 7. During Continuous Bladder Irrigation (CBI) –> catheter is taped to thigh so leg should be kept straight. No other positioning restrictions. 8. After Myringotomy –> position on side of affected ear after surgery (allows drainage of secretions) 9. After Cataract Surgery –> pt will sleep on unaffected side with a night shield for 1-4 weeks. 10. After Thyroidectomy –> low or semi-Fowler’s, support head, neck and shoulders. 11. Infant w/ Spina Bifida –> position prone (on abdomen) so that sac does not rupture 12. Buck’s Traction (skin traction) –> elevate foot of bed for counter-traction 13. After Total Hip Replacement –> 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 separating thighs with pillows. 14. Prolapsed Cord –> knee-chest position or Trendelenburg 15. Infant w/ Cleft Lip –> position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position. 16. 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)

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