NCLEX STUDY GUIDE -Latest Version (Graded A)

FUNDAMENTALS CPR STEPS ALWAYS ESTABLISH RESPONSIVENESS FIRST, activate rescue team, place client on a firm surface, open airway and check for breathing, if not breathing administer 2 breaths, then start compressions ...

FUNDAMENTALS CPR STEPS ALWAYS ESTABLISH RESPONSIVENESS FIRST, activate rescue team, place client on a firm surface, open airway and check for breathing, if not breathing administer 2 breaths, then start compressions Chest compressions are ONE FINGER BENEATH NIPPLE LINE DIRECTLY OVER STERNUM IV INFILTRATION Seepage of IV fluid out of the vein and into surrounding tissues occurs when it is dislodged or perforates the wall of vein. PREVENTION: Avoid puncture over area of flexion, secure with tape, use splint if pt is active/restless, monitor for decrease or cessation of flow S/S: pallor, cool to touch, swelling N/I: Remove IV immediately, Notify HCP, compress and elevation, do not rub affected area can cause hematoma INFORMED CONSENT Client’s permission to perform surgery, procedure or give information to a third party Must be informed of the type of procedure, risk and benefits, consequences if not done, treatment options and name of HCP doing procedure. Questions must be answered before signing consent. Must be signed freely without threat/pressure to client and MUST BE WITNESSED. It can be waived for urgent medical/surgical intervention. CONCEPT: pt heavily sedated/medicated which affects the cognitive ability cannot sign consent forms. A CLIENT MAY WITHDRAW CONSENT ANYTIME. Surgical consent: HCP/surgeon/anesthesiologist who performs operative procedure is responsible for explaining procedure/risks/benefits/alternative options. Incompetent clients: next of kin/appointed guardian/power of attorney must sign Minors: may NOT give legal consent. Must come from parent/legal guardian. Exceptions are made for minors who are emancipated, in an emergency, treatments related to substance abuse/STDs & AIDs/HIV testing/birth control services/pregnancy/psychiatric services/court orders. Witness: Nurse only witnesses the signature of the client on the informed consent. They verify the correct person signing the consent and that it was done voluntarily. INFORMED CONSENT FOR FOSTER CHILD PARENT/GUARDIAN still is the only one with a right to sign informed consent even with a foster family. If unable to contact parent/ guardian, COURT ORDER must be obtained. LIVING WILL/ADVANCED DIRECTIVE Addresses the withdrawal/withholding of life-sustaining interventions that unnaturally prolong life. It is witnessed and signed by two people who are UNRELATED to the client through family or care. Nurse acts as a witness. Nurse must document the event and circumstances (who was present, significant comments from pt, client’s conduct). MUST BE ANNUALLY REVIEWED WITH HCP. CRUTCH WALKING N/I: elbows should be slightly flexed, STAND ON THE AFFECTED SIDE OF PT, never rest axilla on arm rests, place crutches 6-10 inches diagonally in front of the foot CANES N/I: stand at affected side, elbow should be flexed, HOLD CANE ON UNAFFECTED SIDE, MOVE CANE WITH AFFECTED LEG CONCEPT: CANE AND WEAKER LEG WORK TOGETHER. ABOVE THE KNEE AMPUTATION POST- OP: mark bleeding/drainage if occur, explain sensation of phantom limb pain, DO NOT ELEVATE ON PILLOWS, wash limb with mild soap and water and dry completely, massage skin TOWARD suture line N/I: prevent edema, DO NOT ALLOW LIMB TO HANG OVER EDGE OF BED, avoid long periods of sitting, exercise should begin DAY AFTER SURGERY to maintain muscle tone of remaining limb G-TUBE FEEDING N/I: if residual is less than 100mL allowed to administer feeding, hold feedings if bowel sounds are absent, position in HIGH FOWLERS, check tube placing by ASPIRATING and measuring pH, make sure to return aspirated contents, warm feeding to room temperature MEDS THRU G-TUBE (IN ORDER) CHECK HCP PRESCRIPTION, prepare meds, crush meds, dissolve meds in water, verify right patient and explain procedure, check presence of bowel sounds, check tube placement and residual, draw up meds in syringe, insert meds into tube, flush with 30-50mL of water, clamp tube, document NG TUBE INTUBATION (IN ORDER) Explain procedure and discomfort pt might feel, position pt, determine which nostril is more patent, measure length of tube from BRIDGE OF NOSE TO THE EARLOBE TO XIPHOID PROCESS, swallow/drink water, when tube hits back of the throat instruct pt to swallow or drink sips of water, immediately withdraw tube if respiratory changes, secure tube with tape, check residual volumes q4hours/before feeding/after meds, aspirate and measure stomach contents, always replace tape. ACNE VULGARIS FACTORS IN TEENS heredity, increased hormone levels, growth of bacteria 24-HOUR URINE COLLECTION Void first then throw out first sample. Keep all specimen on ice. At end of 24 hour collection period empty last void and add to the collection. BLOOD PRESSURE IN THIGH SYSTOLIC BP is HIGHER in the thigh by 10-40. DIASTOLIC BP stays the same HOW TO ASSESS RASHES IN A DARK SKINNED PERSON: palpitations of warmth and induration of rather than observation, mucous membranes PITTING EDEMA 1+: barely perceptible pit 2+: deeper pit, rebounds in a few seconds 3+: deep pit rebounds in 10-20 seconds 4+: a deeper pit rebounds in more than 30 seconds HALLUCINATIONS when one of the five senses are used in perception without any actual external stimuli to prove it existed N/I: ask pt directly about hallucination, avoid reacting to it, decrease stimuli, move pt from area, do not respond negatively, focus on reality based topics, avoid touching client DELUSIONS false belief held to be true even when there’s evidence to the statement N/I: ask pt do describe delusion, be honest to prevent suspicions, focus on reality based topics, encourage to express feelings, set firm limits on amount of time to talk about delusions, do not try to convince pt that delusions are false DELIRIUM change in consciousness that occurs rapidly over time this can occur at any age S/S: reduced awareness, reduced attention to surroundings, disorganized thinking, sensory misinterpretations, irrelevant speech, disturbed sleep patterns can occur for hours. ADVENTITIOUS SOUNDS CRACKLES Can be fine, medium or coarse. Heard during the end of inspiration and not cleared by coughing Can be heard by pneumonia, HF, asthma and restrictive pulmonary diseases, pulmonary edema WHEEZE High pitched musical sound similar to a squeak. Heard during expiration occurs in small airways like asthma RHONCHI low pitched coarse loud snoring or moaning tone. SOUNDS LIKE SNORING. May clear by coughing. Heard in disease that obstruct the trachea or bronchus like bronchitis PLEURAL FRICTION RUB superficial low pitched coarse rubbing or grating sound. Sounds like two surfaces rubbing together. Not cleared by cough. Heard in pleurisy. Z-TRACK INJECTION type of IM injection technique used to prevent leakage of the medication into the subcutaneous layer. Pulling skin before injecting leaves a “Z” shape which prevents leakage. Usually given through vastus laterus or ventrogluteal STEPS: Clean injection site, relax muscle, draw air into syringe, instill air into vial, withdraw med, remove air bubbles, change needle, use one hand to PULL DOWNWARD/ AWAY on skin and hold firmly, insert at 90 DEGREE ANGLE, aspirate for blood return before injecting, wait 10 seconds, simultaneously withdraw needle and release skin, apply GENTLE PRESSURE DO NOT MASSAGE PAIN WHILE VOIDING N/I: sit in a warm sits bath when trying to void because warm water relieves pain and encourages increased circulation to the perineal area and relies the muscles SPICA CAST considered a body cast. Pillows should not be used for this kind of cast because it will thrust the chest against the cast causing discomfort and respiratory difficulty. Neuro checks are critical b/c it ensures the cast is not causing circulatory compromise. STRAINS/SPRAINS STRAINS: excessive stretching of muscle/tendon. SPRAINS: excessive stretching of a ligament caused by twisting movement. Characterized by pain and swelling. RICE (rest, ice, compression bandage and elevation). FRACTURES a breaking the continuity of the bone caused by trauma Signs include pain/tenderness, deformity, edema, muscle spasms OBTUNDED patient sleeps unless aroused and once aroused has limited interaction with the environment. Easily aroused. POISON IVY when an individual comes in contact with poison ivy, the sap is invisible on the skin. Patient should take several showers lathering the skin multiple times and rinse in running water. DO NOT LEAVE HOUSE RECEPTIVE APHASIA Affects the wernickes in the temporal. Can say the word but does not understand EXPRESSIVE APHASIA Affects the brocas which is in the frontal. Brochas can understand but CANT say ANTIEMBOLISM STOCKINGS used to prevent or reduce edema in the legs or feet by promoting venous return therefore increasing venous and arterial blood circulation to the legs and feet MUSCLE STRAIN Apply ice pack the first 24-48 hours then heat packs after.Ice first to reduce swelling then heat to in ease discomfort/promote reabsorption of blood and circulation/speed healing. PHASES OF WOUND HEALING INFLAMMATORY begins at the time of injury and lasts 3-5 days S/S: local edema, pain, redness, warmth FIBROBLASTIC begins fourth day after injury lasts 2-4 weeks. Scar tissues forms and granulation tissue forms MATURATION 1st Intention: wound edges help in place until healing occurs POST OPERATIVE WOUND CHANGING STERILE TECHNIQUE is used when a certain body cavity is open or skin integrity is broken. TEPID BATH used to reduce elevated temperature in pt who are febrile taken for about 20-30 minutes MEDICATION ERROR CONCEPT: ONLY NOTIFY THOSE WHO CAN DO SOMETHING ABOUT THE ERROR EX: PRESCRIBER/NURSING SUPERVISOR/PHARMACIST MIST TENT used to decrease respiratory tract edema that causes croup liquifies secretions by creating a cool/moist environment the confinement of the mist text may cause anxiety HEIMLICH MANEUVER hands should be placed on the abdomen RIGHT ABOVE NAVEL CHEMICAL BURNS TO THE EYE EYE IRRIGATION helps prevent vision loss and prevents formation of permanent tissue scar TROPONIN proteins found in MYOCARDIAL/ SKELETAL muscle increased amounts of troponin is released in blood when there is damage to the myocardium related to MYOCARDIAL INJURY ISOTONIC DEHYDRATION water and electrolytes are lost in the same amount as they exist in the body. Serum sodium levels remain normal here (135-145) FARENHEIGHT TO CELCIUS C = (F-32) / 1.8 ERICKSON’S STAGES OF DEVELOPMENT INFANCY (BIRTH-18MONTHS): TRUST vs MISTRUST attachment to the mother, trust in others N/I: hold the infant often, offer comfort after manful procedures, encourage parents to help with care EARLY CHILDHOOD (18 MONTHS-3 YEARS): AUTONOMY vs SHAME & DOUBT getting some basic control over self and environment, will power N/I: allow self feeding, encourage to remove and put on clothes, allow for choice LATE CHILDHOOD (3 YEARS-6 YEARS): INITIATIVE vs GUILT becoming purposeful/directive, ability to initiate one’s own activities or sense of purpose N/I: offer medical equipment for play, accept childs choices and feelings SCHOOL AGE (6 YEARS-12 YEARS): INDUSTRY vs INFERIORITY developing social/physical/learning skills, ability to learn and work N/I: encourage child to continue schoolwork, bring favorite leisure activities (board games, electronic games, books) ADOLESCENCE (12 YEARS- 20 YEARS): IDENTITY vs ROLE CONFUSION developing a sense of identity N/I: perform exam without parents present, introduce teen to other teens with same health condition EARLY ADULTHOOD (20 YEARS- 35 YEARS): INTIMACY vs ISOLATION establishing intimate bonds of love and friendship, ability to love deeply and commit to oneself N/I: include support from client’s significant other MIDDLE ADULTHOOD (35 YEARS-65 YEARS): GENERATIVITY vs STAGNATION fulfilling life goals that involve family/career/society, ability to care for others N/I: encourage volunteer activities LATER (65 YEARS-DEATH): INTEGRITY vs DESPAIR looking back over one’s life and accepting its meaning, sense of integrity and fulfillment N/I: listen attentively to reminiscing about life’s accomplishments, assist with making changes to living arrangement HOW TO PUT PPE (IN ORDER) put on MASK first, then the GOWN, lastly GLOVES. WHEN LEAVING THE ROOM: first remove GLOVES, followed by GOWN, last the MASK STEPS: GOWN, MASK GOGGLES, GLOVES, GLOVES, GOGGLES, GOWN, MASK. CHEYNNE STOKES RESPIRATIONS breaths become progressively deeper followed by shallow respirations with apnea periods KUSSMAUL BREATHING rapid, deep breaths with pauses INCENTIVE SPIROMETER N/I: sit upright, place mouth tightly around the mouthpiece, inhale slowly to raise and maintain flow rate between 600-900, hold the breath for 5 seconds and exhale through pursed lips, repeat 10 times every hour EVISCERATION Notify HCP or RN, stay with client, place pt in LOW FOWLERS with KNEES BENT, cover the wound with sterile normal saline dressing and keep dressing moist, take V/S PULSES ARMS RADIAL: on radial side of the forearm at the wrist BRACHIAL: above the elbow at the antecubital fossa, between bicep and tricep ULNAR: opposite side of radial at the wrist LEGS FEMORAL: below inguinal ligament midway between symphysis pubis and anterosuperior iliac spine POPLITEAL: located behind the knee DORSALIS PEDIS: top of the foot in line with the groove between the extensor tendons of the great and first toes POSTERIOR TIBIAL: inside of the ankle, behind and below the medial malleolus (ankle bone) ABDOMINAL ASSESSMENT IN ORDER: inspection, auscultation for 5 minutes, percussion, palpation HEALTH CARE MEMBERS PHYSICAL THERAPIST assists in examining, testing and treating physically disabled clients OCCUPATIONAL THERAPIST develops adaptive devices that help chronically ill or handicapped clients perform activities of daily living RESPIRATORY THERAPIST delivers treatments designed to improve the client’s ventilation and oxygenation status TRANSFERRING PATIENT BED TO STRAIGHT CHAIR/WHEELCHAIR Lower bed to lowest position, raise HOB, support patients shoulders while swinging legs to edge of bed, put slippers on, have chair position bedside with seat facing foot of bed, FOR WHEELCHAIR: place at right angle and lock wheels. FOR CHAIR: place against wall or have other nurse hold chair, stand in from of patient and place hands at patient waist level, allow patients to use arms to push down on bed while moving, assist patient to stand and swing back toward the seat of chair UNNA BOOT used for venous stasis ulcers put layer of gauze then unna paste HEMMORHAGIC/ HYPOVOLEMIC SHOCK caused by decrease in fluid volume from bleeding, prolonged vomiting, diarrhea fluid burns S/S: decreased oxygen to brain, increase in HR, lowered BP N/I: provide fluid replacement, establish airway, place supine with legs slightly higher than head, maintain body temperature BURN INTERVENTIONS Cooled immediately but NOT ICED, cold compresses to decrease pain, sterile dressing placed over burn site to prevent infection, establish airway before edema occurs, CAB is priority, all clothing should be removed, burned areas should be elevated, flush chemical burns with a lot of water, withhold oral fluids, do not break vesicles open KALEMIA HYPOKALEMIC Less than 3.5, kidneys not conserving potassium S/S: severe diarrhea, excessive diaphoresis, decreased cardiac function, muscle weakness, decreased bowl sounds, diminished reflexes, irregular pulse, kidney damage, paralytic ileus N/I: increase foods high in potassium HYPERKALEMIC More than 3.5, potassium not excreted adequately overstimulation of cardiac activity S/S: n/v, diarrhea, colic, ECG changes, irregular pulse rate, numbness, tingling, skeletal muscle weakness Treatment: calcium gluconate, sodium bicarbonate, insulin N/I: administer loop diuretics AMPHETAMINE ABUSE Ex: Ritalin CNS STIMULANT; they cause everything to go UP and FAST S/S: weight loss, anorexia, malnutrition, overstimulation of the heart, increase in BP, brain damage, tachycardia , vasoconstriction, hyperthermia, DILATED PUPILS EYEDROPS ADMINISTRATION CLEANING: Gather equipment, perform hand hygeine, identify patient, introduce self and explain procedure, provide privacy, position head on pillow, direct face toward ceiling, don gloves, remove exudate and clean eye, use one swipe per cotton ball inner canthus to outward APPLYING DROPS: expose lower conjunctival sac by looking upward while gentle pulling to lower eyelid, put drops into sac NOT EYEBALL, use tissue to apply gentle pressure about bone at inner corner of eyelid for 1-2 minutes, leave in comfortable position APPLYING OINTMENT: expose lower conjunctival scabby pulling lower eyelid, squeeze ointment into lower sac, ask patient to close eye and massage in circular motion, leave pt in comfortable position EARDROPS ADMINISTRATION CLEANING: gather equipment, perform hand hygiene, identify patient, introduce self and explain procedure, provide privacy, determine which ear, don gloves PEOPLE OLDER THAN 3: turn head with affected ear up, pull UPWARD AND BACK, instill drops KIDS YOUNGER THAN 3: turn head with affected ear up, pull DOWNWARD AND BACK, instill drops AFTER: tell pt to remain in same position for 5-10 minutes, place cotton ball loosely into ear, remove gloves, leave pt in comfortable position LOCATION OF ORGANS RUQ: Liver, gallbladder, duodenum, pancreas and right kidney LUQ: Spleen, left kidney HEARING LOSS CONDUCTIVE interruption of the transmission of sound through external auditory canal and middle ear related to cerumen (earwax) impaction or otitis media SENSORINEURAL inner ear, auditory nerve, brainstem, cortical auditory pathways do not function properly so sound waves aren't interpreted correctly MIXED both conductive and sensorineural PRESBYCUSIS most common hearing loss in older adults difficulty hearing high pitched toned and conversational speech N/I: provide good visual contact to allow lip reading, reduce background noise, speak at normal rate and volume, do not shout or overarticulate, use short sentences, pause at the end of each sentence, use facial expressions WARNING SIGNS OF CANCER S/S: nagging cough, indigestion, sore that doesn’t heal, unusual bleeding or discharge, thickening or lump in the breast, changes in warts/moles, hoarseness IDENTIFYING A CHILD safest method is to check ID bracelet on for Childs name and medical record number then compare to medical record sheet GENITAL HERPES average incubatio