NCLEX PN Notes 1

Question 1

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

Answer 1

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

Question 2

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

Answer 2

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

Question 3

Tube Feeding w/ Decreased LOC –>

Answer 3

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

Question 4

During Epidural Puncture –>

Answer 4

side-lying

Question 5

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

Answer 5

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

Question 6

Pt w/ Heat Stroke –>

Answer 6

lie flat w/ legs elevated

Question 7

During Continuous Bladder Irrigation (CBI) –>

Answer 7

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

Question 8

After Myringotomy –>

Answer 8

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

Question 9

After Cataract Surgery –>

Answer 9

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

Question 10

After Thyroidectomy –>

Answer 10

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

Question 11

Infant w/ Spina Bifida –>

Answer 11

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

Question 12

Buck’s Traction (skin traction) –>

Answer 12

elevate foot of bed for counter-traction

Question 13

After Total Hip Replacement –>

Answer 13

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.

Question 14

Prolapsed Cord –>

Answer 14

knee-chest position or Trendelenburg

Question 15

Infant w/ Cleft Lip –>

Answer 15

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

Question 16

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

Answer 16

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)

Question 17

Above Knee Amputation –>

Answer 17

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

Question 18

Below Knee Amputation –>

Answer 18

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

Question 19

Detached Retina –>

Answer 19

area of detachment should be in the dependent position

Question 20

Administration of Enema –>

Answer 20

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

Question 21

After Supratentorial Surgery (incision behind hairline) –>

Answer 21

elevate HOB 30-45 degrees

Question 22

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

Answer 22

position pt flat and lateral on either side.

Question 23

During Internal Radiation –>

Answer 23

on bedrest while implant in place

Question 24

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

Answer 24

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

Question 25

Shock -->

Answer 25

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

Question 26

Head Injury -->

Answer 26

elevate HOB 30 degrees to decrease intracranial pressure

Question 27

Peritoneal Dialysis when Outflow is Inadequate -->

Answer 27

turn pt from side to side BEFORE | checking for kinks in tubing (according to Kaplan)

Question 28

Lumbar puncture =>

Answer 28

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

Question 29

worsens with exercise and improves with rest.

Answer 29

Myasthenia Gravis:

Question 30

a positive reaction to Tensilon--will improve symptoms

Answer 30

Myasthenia Crisis:

Question 31

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

Answer 31

Cholinergic Crisis:

Question 32

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

Answer 32

Head injury medication:

Question 33

Prior to a liver biospy

Answer 33

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

Question 34

Demorol for pancreatitis,

Answer 34

NOT morphine sulfate

Question 35

From the a** (diarrhea) =

Answer 35

metabolic acidosis

Question 36

From the mouth (vomitus) =

Answer 36

metabolic alkalosis

Question 37

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

Answer 37

Myxedema/hypothyroidism:

Question 38

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

Answer 38

Graves’ disease/hyperthyroidism:

Question 39

increased temp, pulse and HTN

Answer 39

Thyroid storm:

Question 40

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

Answer 40

Post-thyroidectomy:

Question 41

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

Answer 41

Hypo-parathyroid:

Question 42

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

Answer 42

Hyper-parathyroid:

Question 43

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

Answer 43

Hypovolemia

Question 44

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

Answer 44

Hypervolemia

Question 45

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

Answer 45

Diabetes Insipidus (decreased ADH):

Question 46

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

Answer 46

SIADH (increased ADH):

Question 47

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

Answer 47

Hypokalemia:

Question 48

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

Answer 48

Hyperkalemia:

Question 49

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

Answer 49

Hyponatremia:

Question 50

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

Answer 50

Hypernatremia:

Question 51

CATS – convulsions, arrhythmias, tetany, spasms and stridor

Answer 51

Hypocalcemia:

Question 52

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

Answer 52

Hypercalcemia:

Question 53

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

Answer 53

HypoMg:

Question 54

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

Answer 54

HyperMg:

Question 55

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

Answer 55

Addison’s:

Question 56

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

Answer 56

Cushings:

Question 57

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

Answer 57

Addisonian crisis:

Question 58

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

Answer 58

Pheochromocytoma: