Nursing Comprehensive NCLEX study guide
Appropriate use of an interpreter, FUND Ch. 35, p. 192 - answer -Arrange for an interpreter if pt. speaks different language
-Avoid using ancillary staff or family members
Cultural and spiritual nursing care: understanding the role of an interpreter, FUND Ch. 35, p. 192 - answer -Inform interpreter of questions that might be asked
-Inform the interpreter about the reason for and the type of questions that will be asked, the expected response (brief or detailed), and with whom to converse.
Preparing a change-of-shift report, FUND, Ch. 5, p. 22 - answer Blood lost
--> pt. health status, needs, priorities for care
Time management - answer - Making a list of activities to complete is the MOST important step in time management - Other planning activities are --> Setting goals, establishing priorities, and scheduling activities
- Evaluating nurse's time management skills:
--> Charge nurse should maintain notes over a period of time provides comprehensive view of the nurse's abilities --> Use clinical standards to compare nurse's skills
Transcribing prescriptions, FUND Ch. 47, p. 271 - answer Telephone prescriptions: --> REPEAT the details of the
prescription back to the provider
--> Have another nurse listen to the telephone prescription.
--> Obtain the provider's signature on the prescription within 24 hr.
Priority finding following an ischemic stroke, system disorder, QSEN, safety, FUND Ch. 39 - answer Myocardial Infarction (MI):
Pain--> Lasting >30 min --> Radiates to the LEFT arm & shoulder
Unrelieved w rest or nitroglycerin
-->Relieved only w opioids (Morphine) ECG: - ST Elevation - T-wave inversion (STEMI) Abnormal Q-wave also present (NSTEMI) Troponin:
--> Elevates within 3 hrs. remains elevated 7-10 days
Morphine:
--> Pain relieve--> decrease O2 demands (pain is priority)
Stress test: for ECG changes & ischemia
Myocardial Infarction (MI) - answer EXPECTED:
- Chest pain radiates to the left arm, Shoulder, back - Diaphoresis - Dizziness
- Squeezing or pressure feeling lasting longer than 15 minutes - Anxiety & feelings of doom - NAUSEA
- Vomiting
Troponin I: no longer evident 7-10 after MI
Troponin T: Will still be evident 10-14 days following MI
Creatinine kinase MB: No longer Evident after 3 days
Myoglobin: No longer evident after 24 hr.
Protecting clients who have latex sensitivities, QSEN, FUND Ch. 10, p. 45 - answer pt. with allergies to: (BACK)
-BANANAS -Avocados
-Chestnuts
-Kiwis
OTHERS:
-Pineapples
-Grapes
-Hazel nuts
-Potatoes At Risk:
HCW, Spina Bifida, hair dressers, food handlers, auto mechanics, multiple surgeries
Preventing contractures, FUND Ch. 40, p. 222 - answer Rheumatoid arthritis: splints/joint protecting devices during inflammation
Calcium Imbalance: At risk for injury--> Safety, help w/ ambulation
Active range of motion to increase pt. joint mobility & prevent contractures Hand Rolls
--> To maintain functional position --> a Hand roll keeps thumb pulled slightly inward towards the fingers Immobile client
--> Use trochanter rolls to prevent external rotation & abduction of the hips which will maintain correct body alignment
Contraindications for using Heat therapy, FUND, Ch. 40, p. 223 - answer Adverse reaction of cooling blanket: Shivering
Heat therapy: --> Contraindicated in very young/old, arterial disease, DM, appendicitis
Diabetes Mellitus 1
--> NO cold or Hot therapy
Teaching about use of crutches, FUND, Ch. 40, p.222 - answer 3-point gate
1) Standing, maintain weight on crutches (2-3 fingers widths from axillae, elbows flexed < 30 degrees, when palms on handles)
2) Shift weight on unaffected side 3) Unaffected followed by crutches
4) Affected leg
Contraindications for Aromatherapy, FUND Ch. 42, p. 234 - answer Herpes: --> Acupuncture contraindicated
Medication Administration through a nasogastric tube, FUND Ch. 46, p. 264 - answer -Administer meds separately -Do NOT mix with enteral feedings -Dissolve crushed tabs in 15-30 mL H20, Via gravity
-Flush tube before & after each med w 30-50 mL of N.S or H20
-Change tubing q 24hr. -Monitor blood sugar q4-6 hr. -Check residual q 4hr.
Assessing client respirations, FUND, Ch. 27, p. 137 - answer RR after radial pulse
Count for 30 sec. X 2 --> Except if very ill or irregular RR (1 full min)
Apical HR 1 min. L 5th ICS midclav line--> for irregular radial pulse or heart condition & before cardiac meds.
Collecting a specimen for urinalysis and culture, FUND, Ch. 44, p. 245 - answer -
Wash perineal area
-Clean container
-10-15 mL -FIRST morning void
Nursing action for a client who has Phlebitis, FUND Ch. 49, p. 292 - answer Phlebitis/thrombophlebitis: - WARMNESS
- redness (ERYTHEMA)
- swelling
- tender
- PAIN, throbbing, Burning - A red line up the arm w a palpable band --> STOP Infusion, Remove catheter & apply a cool compress to decrease swelling and then a warm moist compress for circulation, New IV site on another extremity --> Obtain a culture if drainage is present
Hematoma at IV infusion site - answer do NOT stop infusion --> Warm compress on insertion site --> Elevated Extremity -Cultures are NOT necessary
Infiltrated - answer INFILTRATED:
- PALLOR - Edema, LOCAL swelling - numbness - COOLNESS
- Dampness at site
- Slowed infusion --> STOP infusion, Remove Catheter, Elevate extremity & apply a cool or warm compress, notify PCP, may want you to start another IV on another extremity
Appropriate use of an interpreter, FUND Ch. 35, p. 192 - answer -Arrange for an interpreter if pt. speaks different language
-Avoid using ancillary staff or family members
Cultural and spiritual nursing care: understanding the role of an interpreter, FUND Ch. 35, p. 192 - answer -Inform interpreter of questions that might be asked
-Inform the interpreter about the reason for and the type of questions that will be asked, the expected response (brief or detailed), and with whom to converse.
Preparing a change-of-shift report, FUND, Ch. 5, p. 22 - answer Blood lost
--> pt. health status, needs, priorities for care
Time management - answer - Making a list of activities to complete is the MOST important step in time management - Other planning activities are --> Setting goals, establishing priorities, and scheduling activities
- Evaluating nurse's time management skills:
--> Charge nurse should maintain notes over a period of time provides comprehensive view of the nurse's abilities --> Use clinical standards to compare nurse's skills
Transcribing prescriptions, FUND Ch. 47, p. 271 - answer Telephone prescriptions: --> REPEAT the details of the
prescription back to the provider
--> Have another nurse listen to the telephone prescription.
--> Obtain the provider's signature on the prescription within 24 hr.
Priority finding following an ischemic stroke, system disorder, QSEN, safety, FUND Ch. 39 - answer Myocardial Infarction (MI):
Pain--> Lasting >30 min --> Radiates to the LEFT arm & shoulder
Unrelieved w rest or nitroglycerin
-->Relieved only w opioids (Morphine) ECG: - ST Elevation - T-wave inversion (STEMI) Abnormal Q-wave also present (NSTEMI) Troponin:
--> Elevates within 3 hrs. remains elevated 7-10 days
Morphine:
--> Pain relieve--> decrease O2 demands (pain is priority)
Stress test: for ECG changes & ischemia
Myocardial Infarction (MI) - answer EXPECTED:
- Chest pain radiates to the left arm, Shoulder, back - Diaphoresis - Dizziness
- Squeezing or pressure feeling lasting longer than 15 minutes - Anxiety & feelings of doom - NAUSEA
- Vomiting
Troponin I: no longer evident 7-10 after MI
Troponin T: Will still be evident 10-14 days following MI
Creatinine kinase MB: No longer Evident after 3 days
Myoglobin: No longer evident after 24 hr.
Protecting clients who have latex sensitivities, QSEN, FUND Ch. 10, p. 45 - answer pt. with allergies to: (BACK)
-BANANAS -Avocados
-Chestnuts
-Kiwis
OTHERS:
-Pineapples
-Grapes
-Hazel nuts
-Potatoes At Risk:
HCW, Spina Bifida, hair dressers, food handlers, auto mechanics, multiple surgeries
Preventing contractures, FUND Ch. 40, p. 222 - answer Rheumatoid arthritis: splints/joint protecting devices during inflammation
Calcium Imbalance: At risk for injury--> Safety, help w/ ambulation
Active range of motion to increase pt. joint mobility & prevent contractures Hand Rolls
--> To maintain functional position --> a Hand roll keeps thumb pulled slightly inward towards the fingers Immobile client
--> Use trochanter rolls to prevent external rotation & abduction of the hips which will maintain correct body alignment
Contraindications for using Heat therapy, FUND, Ch. 40, p. 223 - answer Adverse reaction of cooling blanket: Shivering
Heat therapy: --> Contraindicated in very young/old, arterial disease, DM, appendicitis
Diabetes Mellitus 1
--> NO cold or Hot therapy
Teaching about use of crutches, FUND, Ch. 40, p.222 - answer 3-point gate
1) Standing, maintain weight on crutches (2-3 fingers widths from axillae, elbows flexed < 30 degrees, when palms on handles)
2) Shift weight on unaffected side 3) Unaffected followed by crutches
4) Affected leg
Contraindications for Aromatherapy, FUND Ch. 42, p. 234 - answer Herpes: --> Acupuncture contraindicated
Medication Administration through a nasogastric tube, FUND Ch. 46, p. 264 - answer -Administer meds separately -Do NOT mix with enteral feedings -Dissolve crushed tabs in 15-30 mL H20, Via gravity
-Flush tube before & after each med w 30-50 mL of N.S or H20
-Change tubing q 24hr. -Monitor blood sugar q4-6 hr. -Check residual q 4hr.
Assessing client respirations, FUND, Ch. 27, p. 137 - answer RR after radial pulse
Count for 30 sec. X 2 --> Except if very ill or irregular RR (1 full min)
Apical HR 1 min. L 5th ICS midclav line--> for irregular radial pulse or heart condition & before cardiac meds.
Collecting a specimen for urinalysis and culture, FUND, Ch. 44, p. 245 - answer -
Wash perineal area
-Clean container
-10-15 mL -FIRST morning void
Nursing action for a client who has Phlebitis, FUND Ch. 49, p. 292 - answer Phlebitis/thrombophlebitis: - WARMNESS
- redness (ERYTHEMA)
- swelling
- tender
- PAIN, throbbing, Burning - A red line up the arm w a palpable band --> STOP Infusion, Remove catheter & apply a cool compress to decrease swelling and then a warm moist compress for circulation, New IV site on another extremity --> Obtain a culture if drainage is present
Hematoma at IV infusion site - answer do NOT stop infusion --> Warm compress on insertion site --> Elevated Extremity -Cultures are NOT necessary
Infiltrated - answer INFILTRATED:
- PALLOR - Edema, LOCAL swelling - numbness - COOLNESS
- Dampness at site
- Slowed infusion --> STOP infusion, Remove Catheter, Elevate extremity & apply a cool or warm compress, notify PCP, may want you to start another IV on another extremity
