NCLEX-RN 2020 Exam With Complete Solution

2020 Delegation - Right Person, Right Task, Right Circumstance, Right Communication, Right Supervision AP's: vitals and ALDs PN: stable clients and the expected outcome Bleeding - Stabilize object Colorectal Screening - Sigmoid: 5 yrs Colon: 10 years ages 50-75 Manual BP - 1 Inch above antecubital space Manual Systolic Measurement - Palpate radial pulse, inflate until pulse disappears, inflate another 30 mmHg, release and note when pulse is palpable again Clear Diet - Fruit juices, gelatin, broth Cane Use - On Stronger side. Move can, move weak leg, move stronger leg past cane Move 6-10 inches forward Infiltration - pallor, swelling, decrease skin temp stop, remove, elevate, ROM, cold compress, restart hypoxemia - early: Tachypnea, increased BP Late: Bradypnea, decrease BP Hypernatermia Risk Factors - older age, decrease total body water content, inadequate fluid intake, altered thirst Seizure precautions - Rescue equipment at bedside Fire Safety - R: Rescue A: Alarm C: contain E: extinguish P: Pull A: Aim S: Squeeze S: Sweep Radiation Precautions - wear monitoring badge for exposure Client Transfer - Fold arms of patient across chest while lifting head Positioning - Prone: on stomach, post lumbar puncture, tonsillectomy Supine: On back, spinal cord injury Crutches - 3 inch widths between axilla and top of crutch, hand grips with elbows at 30 degree Walker - Wrist even with hand grips Standard Precautions - Teir One protective equipment when in contact with blood and bodily fluids, dispose PPE in clients room, clean spills with bleach water Transmission Precautions - Airborne: N95 mask Droplet: Mask within 3 feet of patient Contact: gloves and gown Order of PPE - On: gown, mask, goggles, gloves OFF: gloves, goggles, gown, mask Precautions for Diseases - AIDS/HIV: standard Varicella: airborne C-diff: contact Hep A: standard Hep B: standard Hep C: standard Herpes simplex: standard shingles: airborne Measles: airborne Meningococcal: droplet MRSA: contact Pneumonia: droplet Respiratory syncytial virus: droplet Rotovirus: contact Rubella: droplet Salmonellosis: contact Shigellosis: contact TB: airborne Vancomycin resistant enterococci: contact Screening Guidelines - Physical: annually Dental: 6 months BP: 2 years BMI: every visit Cholesterol: 5 years glucose: 3 yrs colorectal: 10 yrs pap: 3 yrs breast exam: 3 yrs mammogram: yearly testicular examination: monthly prostate and rectal: yearly Morse Fall Scale - Secondary Diagnosis, mental status, IV locks, ambulatory aid, history of falls, gait Sodium - 135-145 sezuire precautions Potassium - 3.5-5 weakness, restlessness, irritability Magnesium - 1.3-2.1 facial flushing, calcification Calcium - 9.0-10.5 bone pain, constipation Pressure Ulcers - inspect every 2 hrs, barrier cream, turn every 2 hrs, 2,000-3,000 L/day, Vitamins A, C, zinc, shift weight every 15 mins Six Rights of Medication Administration - Right Med, Right Dose, Right Route, Right Documentation, Right Patient, Right Time Guidelines for IV - never administer meds through tubing being used for blood products Complications with IV's - Infiltration, extravasation, phlebitis, thrombophlebitis, hematoma, catheter embolism Infiltration Prevention - use smallest catheter for prescribed therapy, stabilize port-access, assess blood return Extravasation Prevention - know vesicant potential before giving medication Phlebitis Prevention - Rotate, secure, aseptic Hematoma Prevention - avoid veins not seen Catheter embolism Prevention - do not reinsert Complications of central venous catheter - Pneumothorax (ultrasound), air embolism (lie flat, valsalva maneuver) lumen occlusion (flush properly), bloodstream infection (sterile technique) Complications of PICC - Occlusion, dislodges, phlebitis, embolism, infection Care for TPN - serum glucose levels every 4-6 hrs, change dressing every 48-72 hrs, change IV tubing every 24 hrs Drug Classes - PRIL (ACE inhibitors) LAM (Benzos) ASONE (Corticosteroid) IDE (Oral hypoglycemic) PRAZOLE (PPI) ASE (Thrombolytics) PHYLLINE (bronchodilators) ARIN (anticoagulants) DINE (antiulcer) ZINE (antihistamine) TYLINE (trylic antidepressant) PRAM (SSRIs) Side Effects - ACE Inhibitors: Angioedema Benzos: Anterograde amnesia Beta Blockers: bronchospasm Ciprofloxacin: tendon rupture Digoxin: Yellow rings Doxycyline: tooth discoloration Furosemide: hypokalemia Lithium: tremors Tobramycin: ototoxicity Valacyclovir: thrombotic thrombocytopenia purpura ACE inhibitors - PRIL increases vasodilation, excretion of sodium and water HTN, HF, MI Angioedema = epinephrine Calcium Channel Blockers - DIPINE Angina, HTN slows calcium and increases dilation