Nursing Exit Exam
Do not delegate - What you can EAT E-evaluate A-assess T-teach
Addison's & Cushings - Addison's = down down down up down
Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia
Better peripheral perfusion? - EleVate Veins, DAngle Arteries
APGAR - Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
Airborne precautions - MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles
TB
Airborne precautions protective equip - private room, neg pressure with 6-12 air exchanges/hr mask &
respirator N95 for TB
Droplet precautions - spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia,
pertussis,
influenza,
diptheria,
epiglottitis,
,rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)
Contact precaution - MRS WHISE
protect visitors & caregivers when 3 ft of the pt.
Multidrug-resistant organisms
RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-
organisms (C diff),
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the
bag
PMGG= Private room/ share same illness, mask, gown and gloves
Skin infection - VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies
Air or Pulmonary Embolism - S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending
doom. (turn pt to LEFT side and LOWER the head of bed.)
,Woman in labor (un-reassuring FHR) - (late decels, decreased variability, fetal bradycardia, etc) Turn pt
on Left side, give O2, stop pitocin, Increase IV fluids!
Tube feeding with decreased LOC - Pt on Right side (promotes emptying of the stomach) Head of bed
elevated (prevent aspiration)
After lumbar puncture and oil based myelogram - pt is flat SUPINE (prevent headache and leaking of
CSF)
Pt with heat stroke - flat with legs elevated
during Continuous Bladder Irrigation (CBI) - catheter is taped to the thigh. leg must be kept straight.
After Myringotomy - position on the side of AFFECTED ear, allows drainage.
After Cateract surgery - pt sleep on UNAFFECTED side with a night shield for 1-4 weeks
after Thyroidectomy - low or semi-fowler's position, support head, neck and shoulders.
Infant with Spina Bifida - Prone so that sac does not rupture
Buck's Traction (skin) - elevate foot of bed for counter traction
After total hip replacement - don't sleep on side of surgery, don't flex hip more than 45-60 degress,
don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with
pillows.
, Prolapsed cord - Knee to chest or Trendelenburg
oxygen 8 to 10 L
Cleft Lip - position on back or in infant seat to prevent trauma to the suture line. while feeding hold in
upright position.
To prevent dumping syndrome - (post operative ulcer/stomach surgeries) eat in reclining position. Lie
down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent
meals.
AKA (above knee amputation) - elevate for first 24 hours on pillow. position prone daily to maintain hip
extension.
BKA (below knee amputation) - foot of bed elevated for first 24 hours. position prone to provide hip
extension.
detached retina - area of detachment should be in the dependent position
administration of enema - pt should be left side lying (Sim's) with knee flexed.
After supratentorial surgery - (incision behind hairline on forhead) elevate HOB 30-40 degrees
After infratentorial surgery - (incision at the nape of neck) position pt flat and lateral on either side.
During internal radiation - on bed rest while implant in place
Autonomic Dysreflexia/Hyperreflexia - S/S pounding headache, profuse sweating, nasal congestion,
chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!
Do not delegate - What you can EAT E-evaluate A-assess T-teach
Addison's & Cushings - Addison's = down down down up down
Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia
Better peripheral perfusion? - EleVate Veins, DAngle Arteries
APGAR - Appearance (all pink, pink and blue, blue (pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)
Airborne precautions - MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles
TB
Airborne precautions protective equip - private room, neg pressure with 6-12 air exchanges/hr mask &
respirator N95 for TB
Droplet precautions - spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia,
pertussis,
influenza,
diptheria,
epiglottitis,
,rubella,
mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus
(Private room and mask)
Contact precaution - MRS WHISE
protect visitors & caregivers when 3 ft of the pt.
Multidrug-resistant organisms
RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-
organisms (C diff),
Gloves and gowns worn by the caregivers and visitors
Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the
bag
PMGG= Private room/ share same illness, mask, gown and gloves
Skin infection - VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies
Air or Pulmonary Embolism - S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending
doom. (turn pt to LEFT side and LOWER the head of bed.)
,Woman in labor (un-reassuring FHR) - (late decels, decreased variability, fetal bradycardia, etc) Turn pt
on Left side, give O2, stop pitocin, Increase IV fluids!
Tube feeding with decreased LOC - Pt on Right side (promotes emptying of the stomach) Head of bed
elevated (prevent aspiration)
After lumbar puncture and oil based myelogram - pt is flat SUPINE (prevent headache and leaking of
CSF)
Pt with heat stroke - flat with legs elevated
during Continuous Bladder Irrigation (CBI) - catheter is taped to the thigh. leg must be kept straight.
After Myringotomy - position on the side of AFFECTED ear, allows drainage.
After Cateract surgery - pt sleep on UNAFFECTED side with a night shield for 1-4 weeks
after Thyroidectomy - low or semi-fowler's position, support head, neck and shoulders.
Infant with Spina Bifida - Prone so that sac does not rupture
Buck's Traction (skin) - elevate foot of bed for counter traction
After total hip replacement - don't sleep on side of surgery, don't flex hip more than 45-60 degress,
don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with
pillows.
, Prolapsed cord - Knee to chest or Trendelenburg
oxygen 8 to 10 L
Cleft Lip - position on back or in infant seat to prevent trauma to the suture line. while feeding hold in
upright position.
To prevent dumping syndrome - (post operative ulcer/stomach surgeries) eat in reclining position. Lie
down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent
meals.
AKA (above knee amputation) - elevate for first 24 hours on pillow. position prone daily to maintain hip
extension.
BKA (below knee amputation) - foot of bed elevated for first 24 hours. position prone to provide hip
extension.
detached retina - area of detachment should be in the dependent position
administration of enema - pt should be left side lying (Sim's) with knee flexed.
After supratentorial surgery - (incision behind hairline on forhead) elevate HOB 30-40 degrees
After infratentorial surgery - (incision at the nape of neck) position pt flat and lateral on either side.
During internal radiation - on bed rest while implant in place
Autonomic Dysreflexia/Hyperreflexia - S/S pounding headache, profuse sweating, nasal congestion,
chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST!
