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NCLEX PN Study > NCLEX PN Notes 1 > Flashcards

NCLEX PN Notes 1 Flashcards

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1
Q

Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom) –>

A

turn pt to left side and lower the head of the bed.

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2
Q

Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal bradycardia, etc) –>

A

turn on left side (and give O2, stop Pitocin, increase IV fluids)

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3
Q

Tube Feeding w/ Decreased LOC –>

A

position pt on right side (promotes emptying of the stomach) with the HOB elevated (to prevent aspiration)

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4
Q

During Epidural Puncture –>

A

side-lying

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5
Q

After Lumbar Puncture (and also oil-based Myelogram)–>

A

pt lies in flat supine (to prevent headache and leaking of CSF)

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6
Q

Pt w/ Heat Stroke –>

A

lie flat w/ legs elevated

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7
Q

During Continuous Bladder Irrigation (CBI) –>

A

catheter is taped to thigh so leg should be kept straight. No other positioning restrictions.

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8
Q

After Myringotomy –>

A

position on side of affected ear after surgery (allows drainage of secretions)

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9
Q

After Cataract Surgery –>

A

pt will sleep on unaffected side with a night shield for 1-4 weeks.

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10
Q

After Thyroidectomy –>

A

low or semi-Fowler’s, support head, neck and shoulders.

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11
Q

Infant w/ Spina Bifida –>

A

position prone (on abdomen) so that sac does not rupture

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12
Q

Buck’s Traction (skin traction) –>

A

elevate foot of bed for counter-traction

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13
Q

After Total Hip Replacement –>

A

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.

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14
Q

Prolapsed Cord –>

A

knee-chest position or Trendelenburg

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15
Q

Infant w/ Cleft Lip –>

A

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

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16
Q

To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) –>

A

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)

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17
Q

Above Knee Amputation –>

A

elevate for first 24 hours on pillow, position prone daily to provide for hip extension.

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18
Q

Below Knee Amputation –>

A

foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.

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19
Q

Detached Retina –>

A

area of detachment should be in the dependent position

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20
Q

Administration of Enema –>

A

position pt in left side-lying (Sim’s) with knee flexed

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21
Q

After Supratentorial Surgery (incision behind hairline) –>

A

elevate HOB 30-45 degrees

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22
Q

After Infratentorial Surgery (incision at nape of neck)–>

A

position pt flat and lateral on either side.

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23
Q

During Internal Radiation –>

A

on bedrest while implant in place

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24
Q

Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension) –>

A

place client in sitting position (elevate HOB) first before any other implementation.

25
Q

Shock –>

A

bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg)

26
Q

Head Injury –>

A

elevate HOB 30 degrees to decrease intracranial pressure

27
Q

Peritoneal Dialysis when Outflow is Inadequate –>

A

turn pt from side to side BEFORE

checking for kinks in tubing (according to Kaplan)

28
Q

Lumbar puncture =>

A

AFTER the procedure, the client should be placed in the supine position for 4 to 12 hrs as prescribed. (Saunders 3rd ed p. 229)

29
Q

worsens with exercise and improves with rest.

A

Myasthenia Gravis:

30
Q

a positive reaction to Tensilon–will improve symptoms

A

Myasthenia Crisis:

31
Q

caused by excessive medication-stop med-giving Tensilon will make it worse

A

Cholinergic Crisis:

32
Q

Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle

A

Head injury medication:

33
Q

Prior to a liver biospy

A

its important to be aware of the lab result for prothrombin time

34
Q

Demorol for pancreatitis,

A

NOT morphine sulfate

35
Q

From the a** (diarrhea) =

A

metabolic acidosis

36
Q

From the mouth (vomitus) =

A

metabolic alkalosis

37
Q

slowed physical and mental function, sensitivity to cold, dry skin and hair

A

Myxedema/hypothyroidism:

38
Q

accelerated physical and mental function; sensitivity to heat, fine/soft hair

A

Graves’ disease/hyperthyroidism:

39
Q

increased temp, pulse and HTN

A

Thyroid storm:

40
Q

semi-Fowler’s, prevent ncek flexion/hyperextension, trach at bedside

A

Post-thyroidectomy:

41
Q

CATS – convulsions, arrhythmias, tetany, spasms, stridor (decreased calcium), high Ca, low phosphorus diet

A

Hypo-parathyroid:

42
Q

fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium), low Ca, high phosphorus diet

A

Hyper-parathyroid:

43
Q

– incrased temp, rapid/weak pulse, increase respiration, hypotension, anxiety, urine specific gravity >1.030

A

Hypovolemia

44
Q

– bounding pulse, SOB, dyspnea, rares/crackles, peripheral edema, HTN, urine specific gravity <1.010; Semi-Fowler’s

A

Hypervolemia

45
Q

excessive urine output and thirst, dehydration, weakness, administer Pitressin

A

Diabetes Insipidus (decreased ADH):

46
Q

change in LOC, decreased deep tendon reflexes, tachycardia, n/v/a, HA; administer Declomycin, diuretics

A

SIADH (increased ADH):

47
Q

muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, beans, potatoes, carrots, celery)

A

Hypokalemia:

48
Q

MURDER – muscle weakness, urine (oliguria/anuria), respiratory depression, decreased cardiac contractility, ECG changes, reflexes

A

Hyperkalemia:

49
Q

nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids

A

Hyponatremia:

50
Q

increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution

A

Hypernatremia:

51
Q

CATS – convulsions, arrhythmias, tetany, spasms and stridor

A

Hypocalcemia:

52
Q

muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect on CNS

A

Hypercalcemia:

53
Q

tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity

A

HypoMg:

54
Q

depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deep tendon reflexes, shallow respirations, emergency

A

HyperMg:

55
Q

hypoNa, hyperK, hypoglycemia, dark pigmentation, decreased resistance to stress, fractures, alopecia, weight loss, GI distress

A

Addison’s:

56
Q

hyperNa, hypoK, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump

A

Cushings:

57
Q

n/v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP

A

Addisonian crisis:

58
Q

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

A

Pheochromocytoma:

NCLEX PN Study (7 decks)

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