with 100% Verified Answers and Detailed Rationales – Full Exam Review for
NCLEX Success
Do not delegate
What you can EAT
E-evaluate
A-assess
T-teach
Alcohol withdrawal medications
diazepam
Cleaning a catheter
clean with soap and water then DRY it with a clean towel afterwards
Potassium
3.5-5.0
Chloride
98-106
Calcium
9-10.5
magnesium
1.3-2.1
spinach
Phosphorus
3.5-4.5
A lead level greater than 45 µg/dL or 2.17 µmol/L in a child's blood most often indicates the need for treatment.
Iron levels think of hemoglobin. low hemoglobin indicates iron deficiency anemia. ~12-16
Better peripheral perfusion?
Elevate veins, D-Angle 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)
neutropenic precautions
gloves, gown, mask when entering room
brush your teeth twice a day
Private when possible, thorough hand hygiene before entering client's room; allow no staff with cold or sore
throat to care for client; no fresh flowers or standing water; clean room daily; Meticulous body hygiene;
Inspect IV site - meticulous IV site care
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
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 theterm-1 outside of the
bag
PMGG= Private room/ share same illness, mask, gown and gloves
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)
,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
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)
Decrease deep tendon reflex
hypermagnesium
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.
Myringotomy
surgical incision into the eardrum, to relieve pressure or drain fluid.
, 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
dependent position
supported
administration of enema
pt should be left side lying (Sim's) with knee flexed.
supratentorial
(incision behind hairline on forhead) e