Tentamen (uitwerkingen)
NURS 101 Nclex-Study-Guide AMAZING
- Vak
- Instelling
NURS 101 Nclex-Study-Guide AMAZING
[Meer zien]Voorbeeld 4 van de 35 pagina's
Voorbeeld 4 van de 35 pagina's
In winkelwagen
In winkelwagen
gesponsord bericht van onze partner
Verkoper
Volgen
FLOYYD
Ontvangen beoordelingen
Voorbeeld van de inhoud
DO NOT delegate what you can EAT!E - evaluate
A - assess
T - teach
addisons= down, down down up down
cushings= up up up down up
addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia
cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia
No Pee, no K (do not give potassium without adequate urine output)
EleVate Veins; dAngle Arteries for better perfusion
A= appearance (color all pink, pink and blue, blue [pale])
P= pulse (>100, < 100, absent)
G= grimace (cough, grimace, no response)
A= activity (flexed, flaccid, limp)
R= respirations (strong cry, weak cry, absent)
TRANSMISSION-BASED PRECAUTIONS:
AIRBORNE
My - Measles
Chicken - Chicken Pox/Varicella
Hez - Herpez Zoster/Shingles
TB
or remember...
MTV=Airborne
Measles
TB
Varicella-Chicken Pox/Herpes Zoster-Shingles
Private Room - negative pressure with 6-12 air exchanges/hr
Mask, N95 for TB
DROPLET
think of SPIDERMAN!
S - sepsis
S - scarlet fever
S - streptococcal pharyngitis
P - parvovirus B19
P - pneumonia
P - pertussis
I - influenza
D - diptheria (pharyngeal)
E - epiglottitis
R - rubella
M - mumps
M - meningitis
M - mycoplasma or meningeal pneumonia
An - Adenovirus
Private Room or cohort
Mask
1
,CONTACT PRECAUTION
MRS.WEE
M - multidrug resistant organism
R - respiratory infection
S - skin infections *
W - wound infxn
E - enteric infxn - clostridium difficile
E - eye infxn - conjunctivitis
SKIN INFECTIONS
VCHIPS
V - varicella zoster
C - cutaneous diphtheria
H - herpez simplex
I - impetigo
P - pediculosis
S - scabies
1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic,
sense of impending doom) --> turn pt to left side and lower the head of the bed.
2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal
bradycardia, etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)
3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the
stomach) with the HOB elevated (to prevent aspiration)
4. During Epidural Puncture --> side-lying
5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent
headache and leaking of CSF)
6. Pt w/ Heat Stroke --> lie flat w/ legs elevated
7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be
kept straight. No other positioning restrictions.
8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of
secretions)
9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4
weeks.
10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders.
11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture
12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction
13. After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 45-
60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating
thighs with pillows.
14. Prolapsed Cord --> knee-chest position or Trendelenburg
2
,15. Infant w/ Cleft Lip --> position on back or in infant seat to prevent trauma to suture line.
While feeding, hold in upright position.
16. To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) --> eat in
reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low
CHO and fiber diet, small frequent meals)
17. Above Knee Amputation --> elevate for first 24 hours on pillow, position prone daily to
provide for hip extension.
18. Below Knee Amputation --> foot of bed elevated for first 24 hours, position prone daily to
provide for hip extension.
19. Detached Retina --> area of detachment should be in the dependent position
20. Administration of Enema --> position pt in left side-lying (Sim's) with knee flexed
21. After Supratentorial Surgery (incision behind hairline) --> elevate HOB 30-45 degrees
22. After Infratentorial Surgery (incision at nape of neck)--> position pt flat and lateral on
either side.
23. During Internal Radiation --> on bedrest while implant in place
24. Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal
congestion, goose flesh, bradycardia, hypertension) --> place client in sitting position (elevate
HOB) first before any other implementation.
25. Shock --> bedrest with extremities elevated 20 degrees, knees straight, head slightly
elevated (modified Trendelenburg)
26. Head Injury --> elevate HOB 30 degrees to decrease intracranial pressure
27. Peritoneal Dialysis when Outflow is Inadequate --> turn pt from side to side BEFORE
checking for kinks in tubing (according to Kaplan)
28. Lumbar puncture => AFTER the procedure, the client should be placed in the supine
position for 4 to 12 hrs as prescribed. (Saunders 3rd ed p. 229)
Demorol for pancreatitis, NOT morphine sulfate
Myasthenia Gravis: worsens with exercise and improves with rest.
Myasthenia Crisis: a positive reaction to Tensilon--will improve symptoms
Cholinergic Crisis: caused by excessive medication-stop med-giving Tensilon will make it worse
Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use
filter needle
Prior to a liver biospy its important to be aware of the lab result for prothrombin time
From the a** (diarrhea)= metabolic acidosis
From the mouth (vomitus)=metabolic alkalosis
Myxedema/hypothyroidism: slowed physical and mental function, sensitivity to cold, dry skin
and hair
3
, Graves’ disease/hyperthyroidism: accelerated physical and mental function; sensitivity to
heat, fine/soft hair
Thyroid storm: increased temp, pulse and HTN
Post-thyroidectomy: semi-Fowler’s, prevent ncek flexion/hyperextension, trach at bedside
Hypo-parathyroid: CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased
calcium), high Ca, low phosphorus diet
Hyper-parathyroid: fatigue, muscle weakness, renal calculi, back and joint pain (increased
calcium), low Ca, high phosphorus diet
Hypovolemia – incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety,
urine specific gravity >1.030
Hypervolemia – bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine
specific gravity <1.010; Semi-Fowler’s
Diabetes Insipidus (decreased ADH): excessive urine output and thirst, dehydration,
weakness, administer Pitressin
SIADH (increased ADH): change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a,
HA; administer Declomycin, diuretics
Hypokalemia: muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges,
beans, potatoes, carrots, celery)
Hyperkalemia: MURDER – muscle weakness, urine (oliguria/anuria), respiratory depression,
decreased cardiac contractility, ECG changes, reflexes
Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic
diuretics, fluids
Hypernatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia;
hypotonic solution
Hypocalcemia: CATS – convulsions, arrhythmias, tetany, spasms and stridor
Hypercalcemia: muscle weakness, lack of coordination, abdominal pain, confusion, absent
tendon reflexes, sedative effect on CNS
HypoMg: tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity
HyperMg: depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deep
tendon reflexes, shallow respirations, emergency
Addison’s: hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress,
fractures, alopecia, weight loss, GI distress
Cushings: hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness,
edema, HTN, hirsutism, moonface/buffalo hump
Addisonian crisis: n/v, confusion, abdominal pain, extreme weakness, hypoglycemia,
dehydration, decreased BP
Pheochromocytoma: hypersecretion of epi/norepi, persistent HTN, increased HR,
hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bating and rest breaks,
avoid cold and stimulating foods, surgery to remove tumor
1. Neuroleptic malignant syndrome (NMS):
-NMS is like S&M;
-you get hot (hyperpyrexia)
-stiff (increased muscle tone)
-sweaty (diaphoresis)
-BP, pulse, and respirations go up &
-you start to drool
4
Voordelen van het kopen van samenvattingen bij Stuvia op een rij:
Verzekerd van kwaliteit door reviews
Stuvia-klanten hebben meer dan 700.000 samenvattingen beoordeeld. Zo weet je zeker dat je de beste documenten koopt!
Snel en makkelijk kopen
Je betaalt supersnel en eenmalig met iDeal, creditcard of Stuvia-tegoed voor de samenvatting. Zonder lidmaatschap.
Focus op de essentie
Samenvattingen worden geschreven voor en door anderen. Daarom zijn de samenvattingen altijd betrouwbaar en actueel. Zo kom je snel tot de kern!
Veelgestelde vragen
Wat krijg ik als ik dit document koop?
Je krijgt een PDF, die direct beschikbaar is na je aankoop. Het gekochte document is altijd, overal en oneindig toegankelijk via je profiel.
Tevredenheidsgarantie: hoe werkt dat?
Onze tevredenheidsgarantie zorgt ervoor dat je altijd een studiedocument vindt dat goed bij je past. Je vult een formulier in en onze klantenservice regelt de rest.
Van wie koop ik deze samenvatting?
Stuvia is een marktplaats, je koop dit document dus niet van ons, maar van verkoper FLOYYD. Stuvia faciliteert de betaling aan de verkoper.
Zit ik meteen vast aan een abonnement?
Nee, je koopt alleen deze samenvatting voor €17,66. Je zit daarna nergens aan vast.
Is Stuvia te vertrouwen?
4,6 sterren op Google & Trustpilot (+1000 reviews)
Afgelopen 30 dagen zijn er 67163 samenvattingen verkocht
Opgericht in 2010, al 14 jaar dé plek om samenvattingen te kopen