Nclex High Yield Review A+ 2024

Nclex High Yield Review A+ 2024
DI NO ADH NOTES

Specific gravity Low High
Serum sodium High Low  “FOA”
LOA/Seizures
Serum High Low
osmolality
H&H High Low One main cause of siadh
 sm cell lung cancer
Tx: Desmopressin Hypertonic saline Correct sodium slowly to
0.3% NS prevent CPM central
pontine myelinolysis aka
locked in syndrome

PPE DONNING  reverse, mask OFFING  abc order
2nd
Gown Gloves
Mask/respirator Goggles
Goggles/face shield Gown
Gloves Mask

Isolation precautions

 Standard
o Hand hygiene
o Gloves
o WHO:
 All pts
 Risks of contact w/fluids
 Contact
o Direct physical contact
 Standard precautions + Gown
o WHO:
 MRSA
 VRE
 C-Diff
 Droplet
o Transmission
 Droplets from sneezing or coughing
o Standard precautions + Surgical Mask
o WHO:
 Meningitis
 Pertussis
 Influenza
 Airborne “MTV”
o Transmission

, Nclex High Yield Review A+ 2024
 Breathing – airborne particles
o Standard precautions + N95 Respirator or Hood
o WHO:MTV
 Measles
 TB
 Varicella
 MMR-measles-mumps-rubella vaccine is a live vaccine &contraindicated in
pregnancy due to the risk of teratogenic effects to the fetus. Clients should get
vaccine in the postpartum period. Avoid preg for at least 1-3 months after
immunization.

 Indirect Coombs Testscreens for Rh sensitization in Rh-negative mothers. If the test
results are positive, the fetus and subsequent pregnancies are at risk for serious
complications.
o Rh immune globulin (eg, RhoGAM) given at 28 weeks’ gestation & w/in 72
hrs postpartumas well as any time there is maternal trauma.

 Autonomic dysreflexia (spinal cord injuries of T6 & above at risk) uncompensated
sympathetic nervous system stimulation.
o Classic signs include hypertension (up to 300 mm Hg systolic)
o throbbing headache
o diaphoresis above the level of injury
o bradycardia (30-40/min)
o piloerection ("goose bumps"), flushing, and nausea.
 life-threatening immediate intervention to prevent complications (eg, hypertensive
stroke, seizures).
 most common cause bladder irritation due to distention client needs to be
catheterized or the possibility of a kink in the existing catheter must be assessed. Bowel
impaction can also be a cause; a digital rectal examination should be
performed. Constrictive clothing should be removed to decrease skin stimulation.
 Notify HCPalpha-adrenergic blocker or an arteriolar vasodilator (eg, nifedipine) may
be prescribed.
 HA associated w/autonomic dysreflexia, typically due to severe hypertension & often
resolve after BP has been treated.
 Elevate HOB 45 degrees or high Fowler's to lower BP.

 NSAIDs (eg, indomethacin, ibuprofen, naproxen, ketorolac)
o Nephrotoxicavoid in clients with kidney disease should not take a
different/other NSAID meds at same time.

Addison’s Assessment MnemonicUnder-secretion of adrenal cortex  rarest endocrine
disorder
 Hyper-pigmented skin (very tan/look healthy)bronze/tan
 Don’t adapt well to stress
 Low BP & Low glucose = shock
o TX: steroids  glucocorticoids, end in -SONE

, Nclex High Yield Review A+ 2024
 prednisone
 methylprednisone
 S- Sugar and sodium low
 T- Tired and muscle weakness
 E- Electrolyte imbalance of high potassium & high calcium
 R- Reproductive change
 O- lOw blood pressure
 I- Increased pigmentation of the skin
 D- Diarrhea and nausea, Depression
Cushing’s Assessment Mnemonic Over-secretion of adrenal cortex
 S/S of steroids same as S/S of Cushing’s
o Moon face
o Hirsutism -excess hair
o Central/truncal obesity
o Gynecomastia  man boobs
o Buffalo hump  kyphosis
o Atrophy of extremity muscles
o Retain Na & Water
o Hypokalemia
o Striae  stretch marks (purplish)
o HYPERglycemia high serum glucose
o Bruise easily
o Easily irritable
o Immunosuppressed

 TX: if primary or secondary tumor  need to get rid of tumorAdrenalectomy
(bilateral  removes all), which ends up causing Addison’s

 Labs check cortisol & ACTH


 S- Skin fragile
 T- Truncal obesity with small arms
 R- Rounded face
 E- Ecchymosis, Elevated blood pressure
 S- Striae on the extremities and abdomen (Purplish)
 S- Sugar extremely high
 E- Excessive body hair especially in women, Electrolytes imbalance: hypokalemia
 D- Dorsocervical fat pad (Buffalo hump), Depression


Milieu Therapy providing a therapeutic and social environment


ICP in clients w/ increased ICP, HOB should be elevated 15 to 30 degrees & the head placed
at midline to promote venous outflow.