NCLEX-STUDY-GUIDE-with-images Chamerlain 2023

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.