Exam (elaborations)
NCLEX Review- Uworld rationales
- Course
- Institution
NCLEX Review- Uworld rationales
[Show more]
Content preview
NCLEX Review- Uworld rationales Thoracentesis Post procedure monitoring.Assess: - correct answer - Level of alertness
- Lung sounds
- Oxygen Sat
- Resp pattern
- Vital signs
- Check for leakage of fluid, location of puncture site, client tolerance. - Sterile dressing after.
- Check CXR to ensure absence of pneumothorax.
Complication of thoracentesis: - correct answer Pneumothorax, Bleeding (less common)
Signs of pneumothorax - correct answer Include increased respiratory rate, increased respiratory effort, respiratory distress, low oxygen saturation, and absent breath sounds on the side where the procedure was done (where the lung is collapsed). T ension pneumothorax may also develop, with tracheal shift to the unaffected side, severe respiratory distress, and cardiovascular compromise. NCLEX Review- Uworld rationales Orthostatic vital signs involve: - correct answer Measuring the client's BP and heart rate in
the supine, sitting, and standing positions. Each measurement should be obtained after maintaining each position for 2 minutes. If any position change produces decreased systolic BP ≥20 mm Hg, decreased diastolic BP ≥10 mm Hg, and/or increased pulse ≥20/min from supine values, the nurse should discontinue assessment, place the client in a recumbent position, and notify the health care provide
T o prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: - correct answer Instruct to lie in a supine position. Instruct to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure.
Apply an air-occlusive dressing (usually gauze with a T egaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line.
Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel. NCLEX Review- Uworld rationales T o reduce the risk of complications and injury during ET suctioning, the nurse should: - correct answer - Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes.
- Suction only while withdrawing the catheter from the airway.
- Use strict sterile technique throughout suctioning
- Limit suctioning to ≤10 seconds on each suction pass
Upper Airway Obstruction: Assessment - correct answer - inability to breathe or speak.
- Cyanosis - Collapse - Death can occur within 4-5 mins
Tracheostomy - correct answer - Cuff is used to prevent aspiration and to facilitate ventilation. - Maintain cuff pressure 20-25 mm Hg - Encourage fluids to facilitate removal of secretions. - Sterile suctioning if necessary. - Frequent oral hygiene
Indications for suctioning tracheostomy - correct answer - Noisy respiration. NCLEX Review- Uworld rationales - Restlessness - Increased pulse - Increased respirations. - Presence of mucus in airway
Nursing Care for patients hospitalized with Acute Epiglottitis, Acute laryngotracheobronchitis - correct answer - Maintain airway (Keep tracheostomy set at bedside)
- Oxygen hood
- Monitor HR and RR for early sign of hypoxia
- Oxygen with humidification.
- IV fluids - Meds: antipyretics, bronchodilators, nebulized epinephrine, steroids - Position infant seat or prop with pillow
Implementation for Myocardial Infarction - correct answer - Thrombolytic therapy w/in 6 hrs,
- Relieve client's and family's anxiety.
- Bed rest- bedside commode for bowel movement. - Semi Fowler position
- Monitor I & O ( 2L fluid intake)
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Chloelunar. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $20.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
79223 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now