NCLEX-RN Live Review

Maslow’s Hierarchy of Needs Self actualization (not a lot of questions) Self esteem (not a lot of questions) Love and belonging Safety and security Physiological - COMES first, unless there is an immediate risk for suicide ABC’s (not always airway first) Nursing process (not always assess first) Safety and risk reduction 4. Client sustained a c3 spinal cord injury. What finding should the nurse recognize as priority of care? ● C4 and above affects the muscles for breathing ● C1/C2 on a ventilator immed. ● Respirations 10/min would be the priority 5. Nurse prepares an older adult for a scheduled colonoscopy. Which should be the nurse’s INITIAL action? ● Place portable commode at bedside ● After physiological (prior to surgery so there are no physiological issues yet), next is safety. 6. Client ER reports HX Gravida 3 Para 2. Initial Action after observing a presenting part? ● Prepare for delivery of the newborn in the ER. ● Client is already effaced and fully dilated. ● If you can DELEGATE something to a non licensed person, it's not your priority. 7. Nurse enters the room of a client who is at the foot of the bed lying on the floow. Nurses initial action? ● Assess vital signs and LOC (before the person ended up on the floor, they had to be conscious) FIRST. Mass Casualties (Pg. 22) Up and down traffic light is the order you save them. Least Restrictive/invasive Acute OVER Chronic (Acute always take priority with one exception, the chronic condition has exacerbated to the point that it is life threatening ex. Status asthmaticus) Stable vs. Unstable Red immediate Yellow delayed ..............................................CONTINUED......................................