Nclex Updated Study Guide Nclex RN

P - pediculosis S - scabies *MRSA - Contact precaution ONLY *VRSA - Contact AND airborne precaution (Private room, door closed, negative pressure) *During the acute stage of Hep-A: gown and gloves are required. In the convalescent stage it is no longer contagious. 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 HA & leaking of CSF). AFTER the procedure, place in the supine position for 4- 12 hrs as prescribed. 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 afected ear after surgery (allows drainage of secretions) 9. After Cataract Surgery → pt will sleep on unafected 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 > 45 degrees. Maintain hip abduction by separating thighs with pillows. 14. Prolapsed Cord → knee-chest position or Trendelenburg -The umbilical cord comes out of the vagina before the baby. Elevate the cord. 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-op ulcer/stomach surgeries) → eat in reclining position, lie down after meals for 20-30min (also restrict fluids during meals, low CHO & fiber diet , small frequent meals) & increase fat and protein, wait 1 hr after meals to drink. Unusual positional tip - Low-fowlers recommended during meals to prevent dumping syndrome. 17. Above Knee Amputation → elevate for first 24 hours on pillow, position prone daily to provide for hip extension. -Evaluate closest proximal pulse 4 18. Below Knee Amputation → foot of bed elevated for first 24 hours, position prone daily to provide for hip extension. -Discharge: Inspect Skin for redness, use a residual limb shrinker 19. CANE→ up with the good and down with the bad." Lead with the cane 1st going down. Move cane 2nd going up  Remember the phrase “step up” when picturing a person going up stairs with crutches. The good leg goes up first, followed by the crutches and the bad leg. The opposite happens going down. The crutches go first, followed by the good leg. When getting up from chair use crutch on weak side. 19. Detached Retina → area of detachment should be in the dependent position - Flashes of light/floaters. Complication: Hemorrhage S&S: Veil or curtain. Surgery: Laser or Cryosurgery 20. Administration of Enema → position pt in 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 bedrest while implant in place, treat pt as they are radioactive. Tongs 24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, HTN ) → place client in sitting position (elevate HOB) 1st - Assess for distended bladder which is a trigger 25. Shock → bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg) Early S&S- Septic Shock: Peripheral Vasodilation. Monitor: 02 Stat during fluid resuscitation. a Stages of Shock: CPR: Compensatory, Progressive, Refractory b Causes of Shock: HAVANA: Hypovolemia, Adrenal crisis, Vascular stasis, Acute respiratory obstruction, Neurogenic, Anaphylaxis 26. Head Injury → elevate HOB 30 degrees to decrease ICP 27. -Early S&S- Lethargy, Late S&S-Confusion & papilledema. 28.Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle 29. Prior to a liver biopsy it’s important to be aware of the lab result for prothrombin time 30. Peritoneal Dialysis when Outflow is Inadequate → turn pt from side to side BEFORE checking for kinks in tubing 31. Meperidine(Demerol) for Pancreatitis, NOT morphine sulfate. 1. Morphine is contra in Pancreatitis. It causes spasm of the Sphincter of Oddi. Myasthenia Gravis: worsens w/exercise & improves w/rest caused by a disorder in the transmission of impulses from nerve to muscle cell (does not affect the bladder & bowel). *Tensilon test given if muscle is tense in myasthenia gravis. -#1 S&S: Severe Muscle weakness. Snarling smile Med: Pyridostigmine (Mestonin)- anticholinesterase- Muscle strengthener. Must be given at the exact same time every day! Give before meals Med: Neostigmine- Given 45 min before meals, to help w/chewing & swallowing. Myasthenia Crisis: a p