NGN NCLEX RN ACTUAL Exam V1
1. after thyroidectomy:
Answer:
low or semi fowlers, support head, neck and shoulders
2. infant with spina bifida:
Answer:
position prone (on abdomen) so that sac doesn't rupture
3. bucks traction (skin traction):
Answer:
elevate foot of bed for counter-traction
4. after total hip replacement:
Answer:
don't sleep on operated side, don't flex hip more than 45-60 degrees, don't elevate
HOB more than 45 degrees. maintain hip abduction by seperating thighs with
pillows
5. prolapsed cord:
Answer:
knee chest position or trendelenburg
6. infant with cleft lip:
Answer:
position on back or in infant seat to prevent trauma to suture line. while feeding,
hold in upright position.
7. to prevent dumping syndrome:
Answer:
post operative ulcer/stomach surgeries . . . eat reclining position, lie down after
,meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet,
small frequent meals
8. above knee amputation:
Answer:
elevate for first 24 hours on pillow, position prone daily to provide for hip
extension
9. below knee amputation:
Answer:
foot of bed elevated for first 24 hours, position prone daily to provide for hip
extension
10. detached retina:
Answer:
area of detachment should be in the dependent position
11. administration of enema:
Answer:
position patient in left side lying (sim's) with knew flexed
12. after supratentorial surgery (incision behind hairline):
Answer:
elevate HOB 30-45 degrees
13. after infatentorial surgery (incision at nape of neck):
Answer:
position pt flat and lateral on eithe rside
14. during internal radiation:
Answer:
on bed rest while implant in place
, 15. autonomic dysrelexia/hyperreflexia:
Answer:
S&S; pounding headache, profuse sweating, nasal congestion, goose flesh,
bradycardia, hypertension . . . place pt. in sitting position (elevate HOB first before
any other implentation)
16. shock:
Answer:
bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated
(modified trendelenburg)
17. head injury:
Answer:
elevate HOB 30 degrees to decrease intacranial pressure
18. DO NOT delegate what you can EAT!:
Answer:
E-evaluate
A-assess
T-teach
19. Addisons:
Answer:
down, down, down, up, down
20. Cushings:
Answer:
up, up, up, down, up
21. Addisons:
Answer:
hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
1. after thyroidectomy:
Answer:
low or semi fowlers, support head, neck and shoulders
2. infant with spina bifida:
Answer:
position prone (on abdomen) so that sac doesn't rupture
3. bucks traction (skin traction):
Answer:
elevate foot of bed for counter-traction
4. after total hip replacement:
Answer:
don't sleep on operated side, don't flex hip more than 45-60 degrees, don't elevate
HOB more than 45 degrees. maintain hip abduction by seperating thighs with
pillows
5. prolapsed cord:
Answer:
knee chest position or trendelenburg
6. infant with cleft lip:
Answer:
position on back or in infant seat to prevent trauma to suture line. while feeding,
hold in upright position.
7. to prevent dumping syndrome:
Answer:
post operative ulcer/stomach surgeries . . . eat reclining position, lie down after
,meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet,
small frequent meals
8. above knee amputation:
Answer:
elevate for first 24 hours on pillow, position prone daily to provide for hip
extension
9. below knee amputation:
Answer:
foot of bed elevated for first 24 hours, position prone daily to provide for hip
extension
10. detached retina:
Answer:
area of detachment should be in the dependent position
11. administration of enema:
Answer:
position patient in left side lying (sim's) with knew flexed
12. after supratentorial surgery (incision behind hairline):
Answer:
elevate HOB 30-45 degrees
13. after infatentorial surgery (incision at nape of neck):
Answer:
position pt flat and lateral on eithe rside
14. during internal radiation:
Answer:
on bed rest while implant in place
, 15. autonomic dysrelexia/hyperreflexia:
Answer:
S&S; pounding headache, profuse sweating, nasal congestion, goose flesh,
bradycardia, hypertension . . . place pt. in sitting position (elevate HOB first before
any other implentation)
16. shock:
Answer:
bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated
(modified trendelenburg)
17. head injury:
Answer:
elevate HOB 30 degrees to decrease intacranial pressure
18. DO NOT delegate what you can EAT!:
Answer:
E-evaluate
A-assess
T-teach
19. Addisons:
Answer:
down, down, down, up, down
20. Cushings:
Answer:
up, up, up, down, up
21. Addisons:
Answer:
hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
