NCLEX - Study Points 1

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Above the Knee

Amputation:
Care

Care Includes: Elevate for the first 24 hours

on a pillow, position prone daily to provide
for hip extension.

Addison's
Disease

(Remember: DOWN, DOWN, DOWN,

UP, DOWN)
- HYPOnatremia, HYPOtension,
DECREASED blood volume,
HYPERkalemia, and HYPOglycemia

Administration
of an Enema

Here, position the patient in left sidelying (Sims) w/ Knee Flexed.

After A
Infratentorial
Surgery
(Incision at the
nape of the
Neck): Care

Care Includes: Position the patient FLAT

and lateral on either side.

After a Lumbar
Puncture (also
an Oil Based
Myelogram):
Care

Care Includes: patient lies

FLAT/SUPINE (This is done to prevent
headache and leaking of CSF)

After A
Supratentorial
Surgery
(Incision
Behind
Hairline): Care

Care Includes: Elevate HOB 30-45 degrees

After an
Myringotomy:
Care

Care Includes: Position patient on the side

of the affected ear after surgery. (This
allows drainage of secretions)

After Cataract
Surgery: Care

Care Includes: The patient will sleep on the

unaffected side with a night shield for 1 4 weeks.

After
Thyroidectomy:
Care

Care Includes: Position LOW or semi fowlers, support the head, neck and
shoulders.

After Total Hip

Replacement:
Care

Care Includes: Don't sleep on the operated

side; don't flex hip for more than 45 - 60
degrees, don't elevate HOB more than 45
degrees. Also maintain hip ABDUCTION
by separating thighs with pillows.

Air/Pulmonary
Embolism: S&S
and Care

S&S Include: chest pain, difficulty

breathing, tachycardia, pale/cyanotic,
sense of impending doom.
Care: turn patient to the LEFT SIDE and
LOWER the head of the bed

AIRBORN Transmission
Precautions: MTV

M = Measles
T = Tuberculosis
V = Varicella (Chicken
Pox)/Herpes Zoster (Shingles)
Remember: Private room w/
negative pressure w/ 6 - 12 air
exchange/hr AND MASK. N95
mask for TB.

13.

APAGR: R

Respirations - strong cry/weak

cry/absent

14.

APGAR: A (1st A)

Appearance - color pink/pink

and blue/blue [pale]

15.

APGAR: A (2nd A)

Activity - flexed/flaccid/limp

16.

APGAR: G

Grimace - cough/grimace/no
response

17.

APGAR: P

Pulse - >100/<100/Absent

Autonomic
Dysreflexia/Hyperflexia:
S&S and Care

- Acutely, this is a reaction of the

autonomic (involuntary)
nervous system to
overstimulation (due to lesions
or injury of the spinal cord)
S&S Include: Pounding
headache, profuse sweating,
nasal congestion, goose flesh,
bradycardia, Hypertension
Care Includes: Place the client in
Sitting Position (elevate HOB)
FIRST before any other
implementation.

Below Knee Amputation:

Care

Care Includes: Foot of the bed

elevated for the first 24 hours,
position prone daily to provide
for hip extension.

Buck's Traction (Skin

Traction): Care

Care Includes: Elevate the foot of

the bed for counter-traction.

CONTACT Precautions:
MRS WEE

M = Multidrug Resistant
Organism
R = Respiratory Infection
S = Skin Infections
W = Wound Infections
E = Enteric Infection
(Clostridium Difficile)
E = Eye Infections
(Conjunctivitis)

Cushing's Disease

(Remember: UP, UP, UP,

DOWN, UP)
- HYPERnatremia,
HYPERtension, INCREASED
blood volume, HYPOkalemia,
HYPERglycemia

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25.

Detached Retina:
Care

Care Includes: Area of detachment

should be in the dependent position.

DO NOT delegate
what you can...EAT
(Acronym)

Evaluate, Assess, Teach

DROPLET
Precautions:
SPIDERMAN (Some
letters are repeated
consecutively)

S = Sepsis
S = Scarlet Fever
S = Streptococcal Pharyngitis
P = Paravirus 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
Remember: Private room or cohort
and MASK

During Epidural
Puncture: Care

Care Includes: position the patient

SIDE LYING

During Internal
Radiation: Care

Care Includes: On bedrest while

implant is in place.

28.

Head Injury: Care

Care Includes: Elevate the HOB 30

degrees to decrease ICP.

29.

Heat Stroke: Care

Care Includes: Lie FLAT w/ legs

Elevated

Increased perfusion
for VEINS and
ARTERIES

EleVate Veins (Think V,V) and

DAngle Arteries. (Think A,A)

Infant w/ Cleft Lip:

Care

Care Includes: Position on the back

or in an infant seat to prevent
trauma to the suture line. While
feeding, hold in the upright
position.

Infant w/ Spina
Bifidia: Care

Care includes: Position prone (on

abdomen) so the sac does not
rupture.

Lumbar Puncture:
Care After Procedure

Care Includes: Place the client in the

supine position for 4 to 12 hours as
prescribed.

No PEE, No ??

K+; DO NOT give Potassium

without adequate urine output.

Pain medication for

Pancreantitis

With this, give DEMEROL not

Morphine Sulfate.

Peritoneal Dialysis
w/ Inadequate
outflow: Care

Care Includes: Turn patient from

side to side BEFORE checking for
kinks in the tubing (According to
Kaplan)

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Prolapsed
Cord: Care

Care Includes: Knee to Chest position OR

Trendelenburg

Shock: Care

Care Includes: Bed-rest w/ extremities

elevated 20 degrees, knees straight, head
slightly elevated (modified trendelenberg)

SKIN
Infections: V
CHIPS

V = Varicella
C = Cutaneous Diptheria
H = Herepes Zoster
I = Impetigo
P = Pediculosis
S = Scabies

To Prevent
Dumping
Syndrome:
Care

(Post-Operatvie Ulcer/Stomach Surgeries)

Care Includes: Eat in the reclining position,
lie down after meals for 20-30 minutes. Also
restrict fluids during meals, LOW
CHO and fiber Diet, and small frequent
meals.

Tube Feeding
w/
DECREASED
LOC: Care

Care Includes: Position pt on right side

(this promotes emptying of the stomach)
with the HOB elevated (to prevent
aspiration)

Woman in
Labor w/
NONReassuring
FHR: S&S and
Care

S&S Include: late decelerations, decreased

variability, fetal bradycardia, etc.
Care: turn on LEFT SIDE (also give O2,
stop pitocin and increase fluids)