Nclex-Rn

Delegation - ANSWER-Right Person, Right Task, Right Circumstance, Right Communication, Right Supervision AP's: vitals and ALDs PN: stable clients and the expected outcome Bleeding - ANSWER-Stabilize object Colorectal Screening - ANSWER-Sigmoid: 5 yrs Colon: 10 years ages 50-75 Manual BP - ANSWER-1 Inch above antecubital space Manual Systolic Measurement - ANSWER-Palpate radial pulse, inflate until pulse disappears, inflate another 30 mmHg, release and note when pulse is palpable again Clear Diet - ANSWER-Fruit juices, gelatin, broth Cane Use - ANSWER-On Stronger side. Move can, move weak leg, move stronger leg past cane Move 6-10 inches forward Infiltration - ANSWER-pallor, swelling, decrease skin temp stop, remove, elevate, ROM, cold compress, restart hypoxemia - ANSWER-early: Tachypnea, increased BP Late: Bradypnea, decrease BP Hypernatermia Risk Factors - ANSWER-older age, decrease total body water content, inadequate fluid intake, altered thirst Seizure precautions - ANSWER-Rescue equipment at bedside Fire Safety - ANSWER-R: Rescue A: Alarm C: contain E: extinguish P: Pull A: Aim S: Squeeze S: Sweep Radiation Precautions - ANSWER-wear monitoring badge for exposure Client Transfer - ANSWER-Fold arms of patient across chest while lifting head Positioning - ANSWER-Prone: on stomach, post lumbar puncture, tonsillectomy Supine: On back, spinal cord injury Crutches - ANSWER-3 inch widths between axilla and top of crutch, hand grips with elbows at 30 degree Walker - ANSWER-Wrist even with hand grips Standard Precautions - ANSWER-Teir One protective equipment when in contact with blood and bodily fluids, dispose PPE in clients room, clean spills with bleach water Transmission Precautions - ANSWER-Airborne: N95 mask Droplet: Mask within 3 feet of patient Contact: gloves and gown Order of PPE - ANSWER-On: gown, mask, goggles, gloves OFF: gloves, goggles, gown, mask Precautions for Diseases - ANSWER-AIDS/HIV: standard Varicella: airborne C-diff: contact Hep A: standard Hep B: standard Hep C: standard Herpes simplex: standard shingles: airborne Measles: airborne Meningococcal: droplet MRSA: contact Pneumonia: droplet Respiratory syncytial virus: droplet Rotovirus: contact Rubella: droplet Salmonellosis: contact Shigellosis: contact TB: airborne Vancomycin resistant enterococci: contact Screening Guidelines - ANSWER-Physical: annually Dental: 6 months BP: 2 years BMI: every visit Cholesterol: 5 years glucose: 3 yrs colorectal: 10 yrs pap: 3 yrs breast exam: 3 yrs mammogram: yearly testicular examination: monthly prostate and rectal: yearly Morse Fall Scale - ANSWER-Secondary Diagnosis, mental status, IV locks, ambulatory aid, history of falls, gait Sodium - ANSWER-135-145 sezuire precautions Potassium - ANSWER-3.5-5 weakness, restlessness, irritability Magnesium - ANSWER-1.3-2.1 facial flushing, calcification Calcium - ANSWER-9.0-10.5 bone pain, constipation Pressure Ulcers - ANSWER-inspect every 2 hrs, barrier cream, turn every 2 hrs, 2,000- 3,000 L/day, Vitamins A, C, zinc, shift weight every 15 mins Six Rights of Medication Administration - ANSWER-Right Med, Right Dose, Right Route, Right Documentation, Right Patient, Right Time Guidelines for IV - ANSWER-never administer meds through tubing being used for blood products Complications with IV's - ANSWER-Infiltration, extravasation, phlebitis, thrombophlebitis, hematoma, catheter embolism Infiltration Prevention - ANSWER-use smallest catheter for prescribed therapy, stabilize port-access, assess blood return Extravasation Prevention - ANSWER-know vesicant potential before giving medication Phlebitis Prevention - ANSWER-Rotate, secure, aseptic Hematoma Prevention - ANSWER-avoid veins not seen Catheter embolism Prevention - ANSWER-do not reinsert Complications of central venous catheter - ANSWER-Pneumothorax (ultrasound), air embolism (lie flat, valsalva maneuver) lumen occlusion (flush properly), bloodstream infection (sterile technique) Complications of PICC - ANSWER-Occlusion, dislodges, phlebitis, embolism, infection Care for TPN - ANSWER-serum glucose levels every 4-6 hrs, change dressing every 48-72 hrs, change IV tubing every 24 hrs Drug Classes - ANSWER-PRIL (ACE inhibitors) LAM (Benzos) ASONE (Corticosteroid) IDE (Oral hypoglycemic) PRAZOLE (PPI) ASE (Thrombolytics) PHYLLINE (bronchodilators) ARIN (anticoagulants) DINE (antiulcer) ZINE (antihistamine) TYLINE (trylic antidepressant) PRAM (SSRIs) Side Effects - ANSWER-ACE Inhibitors: Angioedema Benzos: Anterograde amnesia Beta Blockers: bronchospasm Ciprofloxacin: tendon rupture Digoxin: Yellow rings Doxycyline: tooth discoloration Furosemide: hypokalemia Lithium: tremors Tobramycin: ototoxicity Valacyclovir: thrombotic thrombocytopenia purpura ACE inhibitors - ANSWER-PRIL increases vasodilation, excretion of sodium and water HTN, HF, MI Angioedema = epinephrine Calcium Channel Blockers - ANSWER-DIPINE Angina, HTN slows calcium and increases dilation DO NOT GIVE TO HR or heartblock NO GRAPEFRUIT Alpha Adrenergic Blockers - ANSWER-ZOSIN dilation primary hypertension precautions for hypotension dizziness take at bedtime centrally acting alpha 2 agonists - ANSWER-decrease peripheral resistance Guanfacine and clonidine Primary Hypertension, hypertensive crisis, cancer pain Dry mouth, sore black tongue, leukopenia Beta Blockers - ANSWER-decreases cardiac exciatability, cardiac output, and oxygen demand HTN, angina, tachydyrthmias, HF, MI Bronchospasm's HOLD IF SYSTOLIC below 100 or HR below 60 Vasodilators - ANSWER-Nitro Increases dilation Digoxin - ANSWER-increases force, increases stroke volume, increase ventricular filling HF, A-fib Hypokelmoa, digoxin toxcitiy Apical pulse for 1 min before administration hold if under 60 Dysrththmias - ANSWER-Phenytoin