NCLEX Study Guide with Images
DO NOT delegate what you can EAT!
E - evaluate
A - assess
T – teach
Addison's= Everything is DOWN except Potassium… Mineral corticoids are given in Addison's disease.
Hyponatremia, hypotension, decreased blood volume, hyperkalemia, hypoglycemia
Cushing's= Everything is UP except Potassium
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
Measles
Chicken Pox/Varicella Hez - Herpes Zoster/Shingles TB
TB… N95 MASK
SARS
Private Room - negative pressure, Exchange air 6-12 hrs. - DOOR CLOSED
Mask, N95 for TB
Gloves
Gown
Hand washing
Disposable supplies
,DROPLET
Think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - Diphtheria (pharyngeal) E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia An - Adenovirus
Private Room
Cohort Mask – Pt wears mask when leaving the room
Disposable supplies
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 - herpes simplex
I - impetigo
P - pediculosis S – scabies
Private Room- Door Open
Gloves
Gown ONLY worn when in Direct Contact
Disposable supplies
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 IV fluids)
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. 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)
17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide for
hip extension.
18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to provide for
hip extension.
19. Detached Retina --> area of detachment should be in the dependent position
20. Administration of Enema --> left side-lying (Sim's) with knee flexed
21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees
22. After Infratentorial Surgery (incision at nape of neck)--> position pt. flat and lateral on either side.
23. During Internal Radiation --> on bed rest while implant in place
, 24. 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.
25. Shock --> bed rest with extremities elevated 20 degrees, knees straight, head slightly elevated
(modified Trendelenburg)
26. Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure
27. Peritoneal Dialysis when Outflow is Inadequate --> turn pt. from side to side BEFORE checking for
kinks in tubing
28. Lumbar puncture => AFTER the procedure, the client should be placed in the supine position for 4 to
12 hrs. as prescribed.
Demerol for pancreatitis, NOT morphine sulfate
Morphine is contraindicated in Pancreatitis. It causes spasm of the Sphincter of Oddi. Therefore Demerol
should be given.
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
Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter
needle
Prior to a liver biopsy it's important to be aware of the lab result for prothrombin time (10-13 seconds)
Diarrhea)= metabolic acidosis
Vomitus)=metabolic alkalosis
DO NOT delegate what you can EAT!
E - evaluate
A - assess
T – teach
Addison's= Everything is DOWN except Potassium… Mineral corticoids are given in Addison's disease.
Hyponatremia, hypotension, decreased blood volume, hyperkalemia, hypoglycemia
Cushing's= Everything is UP except Potassium
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
Measles
Chicken Pox/Varicella Hez - Herpes Zoster/Shingles TB
TB… N95 MASK
SARS
Private Room - negative pressure, Exchange air 6-12 hrs. - DOOR CLOSED
Mask, N95 for TB
Gloves
Gown
Hand washing
Disposable supplies
,DROPLET
Think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - Diphtheria (pharyngeal) E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia An - Adenovirus
Private Room
Cohort Mask – Pt wears mask when leaving the room
Disposable supplies
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 - herpes simplex
I - impetigo
P - pediculosis S – scabies
Private Room- Door Open
Gloves
Gown ONLY worn when in Direct Contact
Disposable supplies
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 IV fluids)
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. 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)
17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to provide for
hip extension.
18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to provide for
hip extension.
19. Detached Retina --> area of detachment should be in the dependent position
20. Administration of Enema --> left side-lying (Sim's) with knee flexed
21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees
22. After Infratentorial Surgery (incision at nape of neck)--> position pt. flat and lateral on either side.
23. During Internal Radiation --> on bed rest while implant in place
, 24. 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.
25. Shock --> bed rest with extremities elevated 20 degrees, knees straight, head slightly elevated
(modified Trendelenburg)
26. Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure
27. Peritoneal Dialysis when Outflow is Inadequate --> turn pt. from side to side BEFORE checking for
kinks in tubing
28. Lumbar puncture => AFTER the procedure, the client should be placed in the supine position for 4 to
12 hrs. as prescribed.
Demerol for pancreatitis, NOT morphine sulfate
Morphine is contraindicated in Pancreatitis. It causes spasm of the Sphincter of Oddi. Therefore Demerol
should be given.
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
Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter
needle
Prior to a liver biopsy it's important to be aware of the lab result for prothrombin time (10-13 seconds)
Diarrhea)= metabolic acidosis
Vomitus)=metabolic alkalosis
