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1. Do not delegate Ais What you can EAT E-evaluate A-assess T-teach 2. Addison's & CushingsA AS Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia 3. Better peripheral perfusion? Ans EleVate Veins, DAngle Arteries 4. APGAR ARS Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) 5. Airborne precautions Ans MTV or My chicken hez tb measles, chickenpox (varicel- la) Herpes zoster/shingles TB 6. Airborne precautions protective equip Ans private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB 7. Droplet precautions Ans spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus Peduculosis Scabies 10. Air or Pulmonary Embolism Ans s/s chest pain, dyspnea, tachycardia, pale/cyan- otic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) 11. Woman in labor (un-reassuring FHR) Ans (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! 12. Tube feeding with decreased LOC Ans Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) 13. After lumbar puncture and oil based myelogram Ans pt is flat SUPINE (prevent headache and leaking of CSF) 14. Pt with heat stroke AM flat with legs elevated 15. during Continuous Bladder Irrigation (CBI) Ans catheter is taped to the thigh. leg must be kept straight. 4/57 16. After Myringotomy Ans position on the side of AFFECTED ear, allows drainage. 17. After Cateract surgery Ans pt sleep on UNAFFECTED side with a night shield for 1-4 weeks 18. after Thyroidectomy Ans low or semi-fowler's position, support head, neck and shoulders. 19. Infant with Spina Bifida Ans Prone so that sac does not rupture 20. Buck's Traction (skin) Ans elevate foot of bed for counter traction 21. After total hip replacement Ans don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. 22. Prolapsed cord Ans Knee to chest or Trendelenburg oxygen 8 to 10L 29. After supratentorial surgery Ans (incision behind hairline on forhead) elevate HOB 30-40 degrees 30. After infratentorial surgery Ans (incision at the nape of neck) position pt flat and lateral on either side. 31. During internal radiation ARs on bed rest while implant in place 32. Autonomic Dysreflexia/Hyperreflexia Ans S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! 33. Shock Ans bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) 34. Head Injury ARs elevate HOB 30 degrees to decrease ICP 35. Peritoneal Dialysis (when outflow is inadequate) ARS turn pt from side to side BEFORE checking for kinks in tubing 36. Lumbar Puncture ARS After the procedure, the pt should be supine for 4-12 hours as prescribed. 37. Myesthenia Gravis 8/57 45. Hypo-parathyroid Ans CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet 46. Hyper-parathyroid Ans fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet 47. Hypovolemia Ans increased temp, rapid/weak pulse, increase respiration, hypoten- sion, anxiety. Urine specific gravity >1.030 48. Hypervolemia AS bounding pulse, SOB, dyspnea, rales/crackles, peripheral ede- ma, HTN, urine specific gravity <1.010. semi fowler's 49. Diabetes insipidus (decreased ADH) Ans excessive urine output and thirst, dehy- dration, weakness, administer Pitressin 50. SIADH (increased ADH) AS change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics 51. hypokalemia Ans muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery) 11/57 58. Hyper Mg Ans depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY 59. Addison's Ans Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. Gl stress. 60. Cushings Ans Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wast- ing, weakness, edema, HTN, hirsutism, moonface/buffalo hump 61. Addesonian crisis Ans N/V confusion, abdominal pain, extreme weakness, hypo- glycemia, dehydration, decreased BP 62. Pheochromocytoma Ans hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) 63. Tetrology of Fallot Ans DROP (Defect, septal, Right ventricular hypertrophy, Over- riding aortas, Pulmonary stenosis) 64. Autonomic Dysreflexia Ans (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) 65. FHR patterns for OB Ans Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill 66. what to check with pregnancy Ans Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. 67. Position of the baby by fetal heart sounds 14/57 68. Ventilatory alarms Ag HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc 69. ICP and Shock Ans ICP- Increased BP, decreased pulse, decreased resp Shock-- Decreased BP, increased pulse, increased resp 70. Cor pumonae Ans Right sided heart failure caused by left ventricular failure (ede- ma, jugular vein distention) 71. Heroin withdrawal neonate Ans irritable, poor sucking 72. brachial pulse Ans pulse area on an infant 73. lead poisoning AMS test at 12 months of age 74. Before starting IV antibiotics 16/57 Ais obtain cultures! 75. pt with leukemia may have Ais epistaxis due to low platelets 76. when a pt comes in and is in active labor Ans first action of nurse is to listen to fetal heart tones/rate 77. for phobias Ans use systematic desensitization 78. NCLEX answer tips Ans choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. 79. ARDS and DIC Ais are always secondary to another disease or trauma 80. In an emergency Ans patients with a greater chance to live are treated first 81. Cardinal sign of ARDS Ans with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. 89. Prednisone toxicity ARS Cushings (buffalo hump, moon face, high blood sugar, HTN) 90. Neutropenic pts Ans no fresh fruits or flowers 91. Chest tubes are placed Ans in the pleural space 92. Preload/Afterload Ans Preload affects the amount of blood going into Right ventri- cle. Afterload is the systemic resistance after leaving the heart. 93. CABG AS Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart. 94. Unstable Angina Ans not relieved by nitro 95. PVC's ARS can turn into V fib. 99. 1 quart 
