Prepared by ABUBAKER HAMED, January 24, 2023
Fundamentals of nursing NCLEX
Lung sounds
• Wheezing = ass with narrow of the airway
• Stridor = ass with URT obstruction = medical emergency
• Coarse crackles = ass with too much fluids and sections
• Pleural friction rub = ass with inflamed pleural
• Fine crackles =
• Rhonchus = normal = cleared by cough
IV
• Too large IV canula = lead to mechanical phlebitis
• Care of central venous line
• Use sterile or aseptic technique
• Flush with heparin before de-access
• Have client to wear face mask
• Aspirate blood before medication administration
• Usually gauge size 19, 22
• If not used = access and flushed once/ month
• To remove the central line catheter, place pt in Trendelenburg position
1
,Prepared by ABUBAKER HAMED, January 24, 2023
IV complications
Complications Notes
Extravasation A vesicant drug enters the SQ, apply pressure
Infiltration Non- vesicant drug enters into the SQ
Site ecchymosis Elevate and cold compression
Catheter embolism Apply torniquet
Mechanical phlebitis Warm compression- due to large IV catheter
Medications put pt risk for fall
Medications name or group Notes
Loop diuretics = bumetanide = lead to orthostatic hypotension
Alprazolam Drowsiness
Ca channel blocker =Verapamil Vasodilation
Opioids
Contraindications for oral TEMP
• Mouth breath
• Oral surgery
• Oral intake of hot or cold drinks
• Confusion or comatose pt
• Recently smoked
• Note= In pt with nasal cannula = nurse can take oral temp
2
,Prepared by ABUBAKER HAMED, January 24, 2023
Contraindications of rectal TEMP
• Cardiac pt
• Rectal surgery
• Diarrhea
• Fecal impaction
• Rectal bleeding
Pulse
• 0= absent -- 4+= strong
• Apical pulse for one minute
• If radial pulse is < apical pulse = pulse deficit
Blood pressure
• 1-3 minutes after position change
• Small cuff – false high
• Big cuff = false low
• Systolic is 10-40 mmg higher in the lower extremities
Pulse oximetry = spo2
• Normal = 95-100%
• If below normal= instruct pt to take deep breathing and recheck
• Below 90% in health pt = notify physician
3
, Prepared by ABUBAKER HAMED, January 24, 2023
Pain
• Acute
• Chronic
• Phantom
• Is subjective
• Client with cognitive problems look for non-verbal sign
• Consider culture = Asian, Arab American
• Pain management
• TENS
• Heat and cold – ice should not be left > 15-30 minutes
• Pharmacological treatment
• NSIDs = take oral dose with milk
• Taking ibuprofen with anti DM can lead to hypoglycemia
• Taking ibuprofen with Ca blocker = lead to toxicity
• Acetophenmine = not given for pt with hepatic or renal disease
Opioids
• IV route – fast effect
• Monitor RR= if < 12 don’t give and notify physician
• IF bradycardia = withhold the medication
• Monitor LOC
• Have opioid antagonist ready- naloxone
• Take oral dose with milk or snack
4
Fundamentals of nursing NCLEX
Lung sounds
• Wheezing = ass with narrow of the airway
• Stridor = ass with URT obstruction = medical emergency
• Coarse crackles = ass with too much fluids and sections
• Pleural friction rub = ass with inflamed pleural
• Fine crackles =
• Rhonchus = normal = cleared by cough
IV
• Too large IV canula = lead to mechanical phlebitis
• Care of central venous line
• Use sterile or aseptic technique
• Flush with heparin before de-access
• Have client to wear face mask
• Aspirate blood before medication administration
• Usually gauge size 19, 22
• If not used = access and flushed once/ month
• To remove the central line catheter, place pt in Trendelenburg position
1
,Prepared by ABUBAKER HAMED, January 24, 2023
IV complications
Complications Notes
Extravasation A vesicant drug enters the SQ, apply pressure
Infiltration Non- vesicant drug enters into the SQ
Site ecchymosis Elevate and cold compression
Catheter embolism Apply torniquet
Mechanical phlebitis Warm compression- due to large IV catheter
Medications put pt risk for fall
Medications name or group Notes
Loop diuretics = bumetanide = lead to orthostatic hypotension
Alprazolam Drowsiness
Ca channel blocker =Verapamil Vasodilation
Opioids
Contraindications for oral TEMP
• Mouth breath
• Oral surgery
• Oral intake of hot or cold drinks
• Confusion or comatose pt
• Recently smoked
• Note= In pt with nasal cannula = nurse can take oral temp
2
,Prepared by ABUBAKER HAMED, January 24, 2023
Contraindications of rectal TEMP
• Cardiac pt
• Rectal surgery
• Diarrhea
• Fecal impaction
• Rectal bleeding
Pulse
• 0= absent -- 4+= strong
• Apical pulse for one minute
• If radial pulse is < apical pulse = pulse deficit
Blood pressure
• 1-3 minutes after position change
• Small cuff – false high
• Big cuff = false low
• Systolic is 10-40 mmg higher in the lower extremities
Pulse oximetry = spo2
• Normal = 95-100%
• If below normal= instruct pt to take deep breathing and recheck
• Below 90% in health pt = notify physician
3
, Prepared by ABUBAKER HAMED, January 24, 2023
Pain
• Acute
• Chronic
• Phantom
• Is subjective
• Client with cognitive problems look for non-verbal sign
• Consider culture = Asian, Arab American
• Pain management
• TENS
• Heat and cold – ice should not be left > 15-30 minutes
• Pharmacological treatment
• NSIDs = take oral dose with milk
• Taking ibuprofen with anti DM can lead to hypoglycemia
• Taking ibuprofen with Ca blocker = lead to toxicity
• Acetophenmine = not given for pt with hepatic or renal disease
Opioids
• IV route – fast effect
• Monitor RR= if < 12 don’t give and notify physician
• IF bradycardia = withhold the medication
• Monitor LOC
• Have opioid antagonist ready- naloxone
• Take oral dose with milk or snack
4
