NCLEX Live Stuff

Question 1

Pulse pressure

Answer 1

difference between systolic and diastolic BP

Question 2

Cold and clammy…

Answer 2

give em candy

Question 3

Hot and dry

Answer 3

sugars high!

Question 4

“Vfib…..

Answer 4

Dfib”

Question 5

Vtach and awake…

Answer 5

drugs he must take

Question 6

Vtach and a nap…

Answer 6

zap zap zap

Question 7

What to do for Premature rupture of membranes (pregnancy)

Answer 7

Rupture of membranes before 37 weeks
Maintain bed ress, avoid vag exams

–confirm fluid is amniotic, VS every 4 hours, nonstress test

Question 8

What to do for patients on radiation

Answer 8

visitors stand 6 feet away, and limited

caution sign on the door, and need to assign the client to a private room

max amount of pt care time is 30 minutes

Question 9

Restraints

Answer 9

Rx must state reason,
allows for 4 hours of restraints,
max 24 hours

Question 10

Enteral Nutrition

Answer 10

NG, jejunal, or gastric tubes (G)

Usually started full strength at slow rate, HCP increases hourly rate every 8-12 hr to reach desired rate

Increase HOB 30 or higher to minimize risk of aspiration

Signs of intolerance= cramping, nausea, vomiting, diarrhea, high gastric residuals

Residuals amts (check every 4 hours or immediately before next intermediate feed) and hold if it is more than 250 mL

Question 11

Diets

Answer 11

Pancreatitis---> NPO, TPN 
Diverticulitis→ clear liquids, then high fiber 
Cholecystitis→ low fat 
Liver disease→ decrease protein 
Celiac→ avoid glutens 
Dumping syndrome→ small, frequent meals
Gout-----> avoid purines 
Nausea/vomiting----> clear liquids

Question 12

How to draw up insulin

Answer 12

Air in NPH, Air reg, draw up reg, draw up NPH

Reg before NPH!

Question 13

NG tube med

Answer 13

Measure gastric residual
Flush w 15 mL sterile water
Aspirate gastric contents and check for pH
Push meds through using a syringe

Question 14

Chest tubes!

Answer 14

Closed, 3 chamber wet system
Suction chamber: continuous bubbling gently,
Middle (water seal) TIDAL waves like
the ocean that tidals with inspiration and expiration w/intermittent gentle bubbling,
Drainage (should not be bubbling)

Question 15

TPN

Answer 15

hypertonic sln, so puts you at risk for fluid volume deficit
So monitor blood glucose

add D10 if you run out

Question 16

Crutches, canes, etc

Answer 16

Upstairs- good leg goes up the stairs (good people go up to heaven)
Followed by the crutches and the bad simultaneously
Downstairs- crutches/bad then the good

Always hold on to that which is most stable, but put the weak leg next to the rail

Cane on the strong side tho
Advance the cane, never leave the bad/weak alone (so advance it w the cane or the crutches)

Cane should be at the greater trochanter

Question 17

Teach suctioning

Answer 17

Pre oxygenate pt with 100% O2

Lube end of suction cath w/ 0.9% sodium chloride

Use a suction catheter that is half the size of the lumen

Suction pressure should be 120 mmHg

Question 18

TPN

Answer 18

• use infusion pump
• flush every 4 hours
• check residual every 4-8 hours
• this is gross, BUT, return the residual into the stomach
• reassess if the residual volume is greater than the prescribed amount

-can mix basically all meds except pain meds