NCLEX-LPN: Nursing Basics Exam Study Guide

Supine Position - "Spine position" Patient is placed flat on back Sims' Position - "semi-prone position" Patient is in a side lying position partially on abdomen. Used when administering enemas or suppositories. Trapeze Bar - A device placed over the bed to aid the patient in positions changes, transfers or performing upper-extremity exercises Trendelenburg Position - Patient is positioned by lowering HOB below the feet causing a shift of intravascular volume from the lower extremity and abdomen to the upper body. Done for patients w/severe hypotension an or shock. Fowlers Position - HOB is elevated to 45-60 degrees, pillow is placed under knees to keep them slightly flexed. Improves ventilation and also chest tube drainage. Semi-Fowlers Position - HOB is 30 degrees High-Fowlers Position - HOB is 90 degrees Side-lying Position - Patient's body alignment is in a lateral position at about 30 degrees. Used when turning patients to avoid pressure ulcers. Prevents supine vena cava syndrome and increases uterine and renal perfusion during pregnancy. Trochanter Roll - While pt. is in a supine position. A rolled up towel is placed slightly underneath each hip preventing external rotation of the hips. Ankle-Foot Orthotic Device (AFO) - Aides in keeping pt. in anatomical position, prevents "foot drop" dorsiflexion of the ankle (can be debilitating and cause gait abnormalities. Prone Position - Patient is positioned lying face down. Pillow is placed under legs to promote dorsiflextion. Thin pillow is placed to prevent hyperextension of the neck. What are the Vital signs? - Temperature 96.8* - 100.4*F Blood Pressure - 120/80 Pulse - 60-100 BPM Respiratory Rate - 12-20/minute Oxygen Saturation - (95-100%) Pain (pain scale 1-10) Respiration vs Ventilation - R: Bodies ability to move oxygen into the blood and into the cells, at the same time removing CO2 from the body. V: the movement of air/gas in and out of the lungs (respiratory rate) Blood Pressure - The measure of force exerted on the artery walls when the heart contracts and blood is pushed out from the ventricles. It is important to use the right size cuff or readings will be altered. Systolic Pressure - "sky" the high pressure, range (90-120mmHg) caused by the heart contracting and blood being pushed into the aorta. Diastolic - "down" the low pressure, range (60-80mmHg) measures the amount of continous pressure on the artery walls after contraction of the heart and the ventricles relax. Oxygen Saturation - Measurement of bodies ability to diffuse and perfuse read by an LED light reflected form the hemoglobin molecules. Patient with nail polish, hypothermia, vasoconstriction, peripheral edema, or abnormal hgb levels will produce an inaccurate reading. Nerovascular Asseement - Pain -universal sym in compartment syn Paresthesia- pins and needles sensation Pulse- diff in rate/quality Pallor- color of extremity Pressure- rise = compartment syndrome Paralysis- sensation/mobility of limb Paresthesia - First sign of an impending problem, "pins and needles" sensation may include numbness or tingling as a result of inadequate circulation, nerve damage or compartment syndrome. Pallor - Refers to the color of the extremity along w/temp assessed against unaffected side. Capillary refill return in 3 secs. Pulse (nerovasc asses.) - compared to unaffected extremity for diff in rate and quality. Diminished or absent distal to the injury may indicate vascular dysfunction. Insufficiency should be reported to provider immediately. Paralysis (nerovasc asses.) - Partial of full loss of sensation or function may be a late sign of neurovascular damage. Inability to move limb distal to the injury may indicate compartment syndrome or significant muscle and nerve damage. Pain (nerovasc asses.) - the universal symptom in compartment syndrome, related to edema, movement of bone fragments, or muscle spasms; increases as the pressure in the compartment rises.