NCLEX-RN Part 1 Study Guide (Latest 2022/2023) Updated and Upgraded Version, Exams of Nursing

Download NCLEX-RN Part 1 Study Guide (Latest 2022/2023) Updated and Upgraded Version and more Exams Nursing in PDF only on Docsity! NCLEX-RN Part 1 Study Guide When getting down to 2 answers, pick the assessment answer over intervention except in an emergency or distress situation.Assessment (Assess, Collect, Auscultate, Monitor, Palpate) If one answer has an absolute discard it; these suggest a false response and imply there are no exceptions.Absolute (always, all, everyone, never, none, only, every, must) If you can only do one thing to help this patientpick the most important intervention Choose the answer that includes all the others in it; all other choices fall under it"Umbrella effect" If 2 of the answers are the exact oppositeone is probably the answer Do not delegate what you can EAT or PACETPlan, Asses (primary/initial), Collaborate (with RT, OT, PT, ECT), Evaluate (for trends), Teach IV meds and unstable patientsCannot be delegated to an Unlicensed Assistive Personnel LPN/LVPcannot handle blood Antidote for Coumadin overdose (bleeding, black tarry stool, vomiting blood, vision or speech changes, severe headache)Vitamin K Antidote for Heparin overdose (vomiting, hives, trouble breathing, swelling of face, lips, tongue, or feeling like you might pass out)Protamine Sulfate Antidote for Magnesium Sulfate (Mg So4) overdose (difficulty breathing, muscle weakness, mental confusion)Calcium Gluconate (Ca Glu) Antidote for Acetominophen overdose (abdominal pain, yellowing of the skin and eyes, irritability)Mucomyst (Acetylcysteine) Antidote for TPA (Alteplase) overdose (chest tightness, severe stomach pain)Amicar (Aminocaproic acid) Lactulose toxicity (severe or ongoing diarrhea)Ammonia Acetaminophen toxicity (does not manifest for 24 - 48 hours: right upper quadrant abdominal pain or tenderness, oliguria)n-Acetylcysteine Better psychosocial nursing responsesFocus on feelings, reflect the client's comments, communicate acceptance by the nurse rather than criticism or judgment, acknowledge the client, stay in the here and now Eliminate the response that may be the best for a physician to makeLook for the RN role-appropriate psychosocial response; psychiatrists analyze the past, and nurses in general focus on present feelings and situations 5 rights of medication administrationRight medication, right route, right client, right dosage, right time Think safety as the best choice when more than one answer could be right.Safety is a priority I will call the doctor if...unexplained weight loss or gain; to clarify an order; severe side effects of a medication or signs of drug toxicity, critical side effects, or side effects are extremely unusual Therapeutic communicationDon't ask why questions, don't patronize or compare to someone else, mirror or paraphrase what is said to keep conversation open-ended, assess the need of the caregiver, include client and caregiver whenever possible Multidisciplinary teamworkCommunication (always 1st), Collaboration (not time to delegate), shared responsibility. RN scope of practiceClinical assessment, initial education, discharge education, clinical judgment, initiating blood transfusion, psychosocial support LPN/LVN scope of practice: Monitoring RN findings, reinforcing education, routine procedures,most medication administration, ostomy care, tube patency and enteral feedings, specific assessements UAP scope of practiceADLs, hygiene, linen changes, routine stable vitals, documenting I&O, positioning It's all about safety when assigning patients to a float nurse from another unit:Stable patients who require basic pain, peripheral, and neurovascular assessments they can handle in their unit. G - Gravidanumber of times a woman has been pregnant T - TermTerm pregnancies (delivered after 37 weeks) P - Preterm pregnancyDelivered between beginning of 20 weeks and end of 37 weeks 1 pt - irregular/slow breathing/weak cry 0 pt - absent Scale with Apgar>8: no interventions 4 - 7: stimutate/rub back, give O2/ rescore 0 - 3: Full CPR/rescore Transmission-based precaution: Airborne Private room, negative pressure with 6 - 12 air exchange, mask; N95 for TBMy - Measles Chicken - Chicken pox/Varicella Hez - Herpez Zoster/Shingles TB Transmission-based precautions: Droplet Private room or cohort maskSPIDERMAN sepsis, scarlet fever, streptococcal pharyngitits Parvovirus B19, Pneumonia, Pertussis Influenza Diptheria (Pharyngeal) Epliglottis Rubella Mumps, Meninitis, Mycoplasma or meningeal pneumonia Adenovirus Transmission-based precautions: ContactMRS. WEE Multidrug resistant organism Respiratory infection Skin infections Wound infection Enteric infection - C. Diff Eye infection - conjunctivitis Skin infections: VCHIPSVaricella zoster Cutaneous diphtheria herpes simplex Impetigo Pediculosis Scabies Pulmonary embolismS/S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, sense of impending doom Pulmonary embolism positioningTurn patient to left side and lower head of the bed (traps air in the right atrium) Woman in labor with un-reassuring fetal heart ratelate decels, decreased variability, fetal bradycardia Woman in labor with un-reassuring fetal heart rate positioningTurn on left side Give O2, stop Pitocin, increase IV fluids Tube feedings with decreased LOC positioningPosition patient on right side (promotes emptying of the stomach), with head of bed elevated (to prevent aspiration) Epidural Punctureside-lying position After Lumbar puncture and also oil-based MyelogramPatient lies in flat supine position (to prevent headache and leaking of CSF). Client should be in the supine position for 4 to 12 hours as prescribed. Heat strokeLie flat with legs elevated During continuous bladder irrigationCatheter is taped to thigh so leg should be kept straight; no other positioning restrictions. After MyringotomyPosition on side of affected ear (allows drainage of secretions) For 1 - 4 weeks after Cataract surgeryPosition on unaffected side with night shield After ThyroidectomyLow or semi-Fowlers position support head, neck, and shoulders Infant with Spina BifidaPosition prone so sac does not rupture Buck's TractionElevate foot of bed for counter-traction After total hip replacementDon't sleep on operated side Don't flex hip more than 45 - 60 degrees Don't elevate HOB >45 degrees Maintain hip abduction by separating thighs with pillows Prolapsed cordKnee-chest position or Trendelenburg Infant with cleft lipPosition on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position. To prevent Dumping Syndrome (post-op ulcer/stomach surgeries) Low Fowlers position recommended during meals to prevent Dumping SyndromeEat in reclining position lie down after meals for 20 - 30 min restrict fluids during meals eat low carbohydrates and fiber diet and have small, frequent meals Increase fat and protein in diet wait 1 hour after meals to drink fluids Above the knee amputationElevate for first 24 hours on pillow Position prone daily to provide for hip extension Below the knee amputationFoot of bed elevated for first 24 hours Position prone daily to provide for hip extension Detached RetinaArea of detachment should be in the dependent position Admin of EnemaPosition on left side-lying (Sims) with knee flexed After Supratentorial Surgery (incision behind hairline)Elevate HOB 30 - 45 degrees After Infratentorial surgery (incision at nape of neck)Position patient flat and lateral on either side During Internal RadiationOn bedrest while implant is in place treat patient as if they are radioactive Autonomic Dysreflexia/HyperreflexiaS&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension Autonomic Dysreflexia/Hyperreflexia positioning:Sitting position (elevate HOB) first, before any other implementation ShockBed rest with extremities elevated 20 degrees, knees straight, head lightly elevate (Modified Trendelenburg) Head injuryElevate HOB 30 degrees to decrease intracranial pressure Peritoneal Dialysis when outflow is inadequateturn patient from side to side before checking for kinks in tubing Demerol for PancreatitisMorphine is contraindicated - Causes spasm of the Sphincter of Oddi Myasthenia GravisWorsens with exercise and improves with rest caused by a disorder in the transmission of impulses fro nerve to muscle cell Does not affect the bladder and bowel Myasthenia Gravis testTensilon test if muscles are tense Hyponatremia S/S: Sodium <136Nausea, muscle cramps, increased ICP, muscular twitching, convulsions, stupor/coma, decreased tendon reflexes, ortho HTN, stomach cramps, Sz/HA Potassium has an inverse relationship withSodium Causes of hyponatremiaosmotic diuretics, lithium toxicity Hypernatremia S/S: Sodium >145Increased temp, weakness, disorientation/delusions, eventual hypotension, tachycardia, fever, flushed skin, restless (irritable), edema, decreased urinary output/dry skin, thirst Hypercalcemia S/S: Ca+ >10.5Muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect of CNS, constipation, joint pain, kidney stones Hypercalcemia causes:decreased Phosphorus, thiazide diretics, glucocorticoids, adrenal insufficiency Hypercalcemia treatment:Calcitonin, dialysi, dilute, diuretics Hypocalcemia S/S: <9.0Convulsions, arrhythmias, tetany, spasms, stridor, +Trousseau, + Chvostek's (cheek), long ST and QT intervals Hypocalcemia causes:Chrons, Celiac dx, kidney failure, alkalosis, pancreatitis, increased Phosphorus Hypocalcemia tx:Al-hydroxide to decrease phosphorus calcium supplements after meals Hypoparathyroidism (decreased calcium)S/S: Convulsions, arrhythmias, tetany, spasms, stridor Hypoparathyroidism tx:High calcium & low phosphorus diet Hyperparathroidism (increased calcium)S/S: fatigue, muscle weakness, renal calculi, back and joint pain Hyperparathroidism tx:Low calcium & high phosphorus diet Polyuria is commonwith hypercalcemia caused by hyperparathyroidism Hypermagnesmia magnesium >2.5Depresses the CNS: confused, hypotension, facial flushing, muscle weakness, absent DTRs, shallow respirations - This is an emergency!! Increased HR/BP, + Trousseau's & +Chekovstek's Hypermagnesmia causes:laxatives, antacids, renal insufficiency Hypermagnesmia tx:stop magnesium intake give diuretics & Calcium Gluconate Hypomagnesmia S/S Magnesium <1.5tremors/seizures, tetany, dysrhythmias, CNS depression, dysphagia, decreased HR/BP Hypomagnesmia causes:vomiting/diarrhea, C&C, diuretics, alcoholism Hypomagnesmia tx:greens, Ps, cauliflower Addison's labslow: Na, BP, blood volume, blood sugar high: potassium Cushing's labs:high: Na, blood pressure, blood volume, blood sugar low: potassium Addison's (need to "add" hormone)decreased resistance to stress, fractures, alopecia, weight loss, sad (like Golem), GI distress Addisonian crisisn/v, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP In a patient with adrenal insufficiency (Addison's)Managing stress is paramount because if the adrenal glands are stressed further it could result in Addisonian crisis. Most important assessment parameterBlood pressure: Watch for severe hypotension Cushing's (extra "cushion" of hormones)prone to infection, muscle wasting, weakness, edema, HTN, moonface/buffalo hump, happy, 3 Ss {increased blood sugar, salt, sex (androgens)}, cataracts, ulcers, obesity, osteoporosis, necrosis of femoral head, HTN Cushing's tx:decreased calcium and increased protein in diet Prednisone toxicity causesCushing's syndrome Cushing ulcer is r/tbrain injury Cushing's triad r/tICP in brain (HTN, bradycardia, irregular RR) Pheochromocytoma: hypersecretion of epi/norepipersistent HTN, hyperglycemia, tremor, pounding HA Pheochromocytoma tx:avoid stress, cold and stimulating foods take frequent baths and rest breaks have surgery to remove tumor 5 Ps of PheochromocytomaPressure (HA d/t inc. BP & HR), palpation, pallor, perspiration (diaphoresis), pain Neuroleptic Malignant Syndrome (NMS)hyperpyrexia, increased muscle tone, diaphoresis (Fever, Encephalopathy, unstable vitals, elevated WBC/CK, muscle rigidity) Serotonin syndromeHARMED: hyperthermia, autonomic instability, rigidity, myoclonus, encephalopathy, diaphoresis never get pregnant by a GermanGerman measles is dangerous to the fetus Order for drawing up regular insulin and NPH togetherNichole Ritchie RN Air into NPH, then air into Regular, draw up Regular, then draw up NPH Tetralogy of fallot: think DROPDefect, septal Right Ventricular hypertrophy Overriding Aorta Pulmonary Stenosis MAOI: No popular medsParnate, Nardil, Marplan Do not take with MAOIbarbituates, tricyclic antidepressants, antihistamines/HTN, stimulants, CNS depressants, OTC cold medicines - need medic alert bracelet, low-tyramine diet (no chocolate, cheese, pickled foods, wine, left out food) Autonomic dysreflexia: potentially life threatening emergency (T5 or higher spinal cord injury)elevate HOB to 90 degrees loosen constrictive clothin assess for bladder distention and bowel impaction (trigger) administer antihypertensive meds (may cause stroke, MI, Sz) Digoxin (0.5 - 2.0)Check pulse, if <60 hold, check dig & potassium levels (low K = Dig toxicity) avoid salt and potassium substitutes when taking digoxin (many salt substitutes are potassium-based) Oncovin (Vincristine)Tx of leukemia Give IV only side effects: change in sensation, hair loss, constipation, difficulty walking, HA H-Aweantidote for Oncovin client may have epitaxis b/c of low plts d/t the increase of dysfunctional WBC production KwellTx of scabies and lice scabies: apply lotion once and leave on for 8 - 12 hrs lice: use the shampoo and leave on for 4 min. with hair uncovered, then rinse with warm water and comb with a fine-toothed comb PremarinTx after menopause Estrogen replacement Dilantin (Phenytoin)Tx of seizures Side effects: gingival hyperplasia (good hygiene), rash (stop med), yellow-browning of skin, interference with B12 metabolism (anemia), Hirsutism Toxicity: poor gait + coordination, slurred speech, nausea, lethargy, diplopia NavaneTx of Schizophrenia assess for EPS (dystonia, akineasia, akathisia, tardive dyskinesia) Tardive DyskinesiaIrreversible, involuntary movements of the tongue, face, extremities may happen after prolonged use of antipsychotics AIMS test to assess for it Akathisiamotor restlessness can be mistaken for agitation Thorazinesedative effects, seizures, and EPS Haldolanti-psychotic RitalinTx of ADHD assess for heart related side effects - report immediately child may need drug holiday - stunts growth Dopamine (Intropine)Tx of hypotension, shock, low cardiac output, poor perfusion to vital organs monitor EKG for arrhythmias monitor BP Veal Chop ToolVariable decels - Cord Compression - Trendelenburg Veal Chop ToolEarly decels - Head compression - Observe (monitor & document) Veal Chop ToolAccelerations - okay, not a problem - observe (monitor & document) Veal Chop ToolLate decels - Placental insufficiency - turn mother to her left side If cord is prolapsedcover with sterile saline gauze to prevent drying of the cord and to minimize infection Epidural anesthesiapriority to hydrate before Major risks with epidural anesthesiahypotension, bradypnea, bradycardia Never check the monitor or machine as a first actionalways assess patient first When not sure who to check first, mother or babythe answer that involves the machine is the wrong answer Baby is breechsounds are high up in the fundus, near the umbilicus Baby is anteriorsounds are heard closer to midline, between the umbilicus and where you want to listen to a posterior presentation Baby is posterior presentationsounds are heard at the sides Baby is vertexsounds are a little bit above the symphysis pubis Effacement0: 0-30% 1: 40 - 50% 2: 60 - 70% 3: 80% Station0: -3 1: -2 2: -1, 0 3: +1, +2 Hard or soft (consistency)0: firm 1: moderately firm 2: soft (ripe) opening (dilation)0: closed 1: 1 -2 cm 2: 3 - 4 cm 3: 5+ cm Presenting part0: posterior 1: mid-line 2: anterior Bishop scorea score of 5 or less is unfavorable, Mother may need cervical ripening >6 is good to induce cervix; cervix is ripe and induction may be successful Skin to skin contact, covered with a blanket on mombest way to warm a newborn Nurses first action for a mother in active laborlisten to fetal heart tones/rate Ventilator alarmswhen in doubt...bag!! High pressure alarmsobstruction due to increased secretions, kink, pt. cough, gags, or bites Low pressure alarmsDisconnection/leak in ventilator or in pt. airway cuff, pt. stops spontaneous breathing ICP and shock have opposite vsICP: Increased BP, decreased pulse, decreased resp shock: decreased BP, increased pulse, increased resp Cor pulmonaleright-sided heart failure caused by left ventricular failure Heroine S/S in the newbornirritable poor sucking MuslimsNurse must allow time for prayer and fasting in Ramadhan JewishNo meat and milk together Jehovahs witnessno blood Brachial pulsepulse check for infant during CPR BP cuffcovers 75% of arm (2 cm above AC Test child for lead poisoning (Plumbism)12 months remove environmental source start chelation therapy Lead poisoningABCDEFG: Anemia, Basophilic stripping, Collicky pain, Diarrhea, Encephalopathy, Foot drop, Gum (lead lined) When are cultures obtainedbefore starting IV antibiotics always