NCLEX-PN CHEAT SHEETS Study Guide 2025.pdf, Exams of Nursing

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NCLEX-PN

CHEAT

SHEETS

Study Guide

Positioning Techniques (F) - Re-position at least 1-2 hours in bed. Every 20-30 mins in a chair.

• Clients who have impaired nervous or musculoskeletal systems benefit from routine therapeutic positioning.
• At least every 1 to 2 hr in bed.
• Every 20 to 30 min if in a chair to prevent skin breakdown over bony prominences.
• Tools for repositioning clients
• Pillows, foot boots.
• Trochanter rolls, sandbags.
• Hand rolls.
• Hand-wrist splints.
• Trapeze bar.
• Side rails
• All side rails cannot be up or they will be considered a restraint.
• Bed boards.
• Wedge pillow (abductor pillow). Positions (F) - High Fowler's: 90 degrees Fowler's: 45-60 degrees Semi Fowler's: 30-45 degrees Supine: On back with head and shoulders on pillow. Prone: Flat on abdomen with head to the side. Allows dorsiflexion of feet. Lateral: Side-lying. Sims': On side halfway between lateral and prone. Trendelenburg: Entire bed is tilted with the head of the bed lower than the foot of the bed. Promotes venous return. Reverse Trendelenburg: Entire bed is tilted with the foot of the bed lower than the head of the bed. Promotes gastric emptying. Assistive Devices (F) - Wheelchair. Walker: Take a step, move walker, take another step. Cane: Single leg or quad. Keep cane on stronger side of the body. Move cane, move weak leg, move strong leg. Crutches: 2.3.4-point gaits. When ascending stairs, good food then crutches then bad food. When descending stairs, crutches then bad foot then good foot. Splints and Braces (F) - Primary Nursing Concern: Assessment and prevention of neurovascular dysfunction or compromise. Assess every hour for the first 24 hrs. Every 2-4 hours afterwards. Elevate immobilized extremity higher than the heart. Apply ice for the first 24-48 hrs prn to reduce edema.

Observe for Observe for aspiration or pocketing of food in the cheeks or other areas of the mouth. Observe for signs of dysphagia, such as coughing, choking, gagging, and drooling of food. Maintain the client in semi-Fowler's position for at least 1 hr after meals. Provide oral hygiene after meals/snacks.

• Dysphagia refers to difficulty when swallowing.
• Causes of dysphagia
• Neurogenic
• Stroke. Cerebral palsy. Multiple sclerosis.
• Myogenic
• Myasthenia gravis. Aging. Muscular dystrophy.
• Obstructive problems
• Candidiasis. Head and neck cancer. Inflammatory masses. Preventing Aspiration (F) - Position the client in Fowler's position or in a chair. Support the upper back, neck, and head. Have the client tuck her chin when swallowing to help propel food down the esophagus. Maslow's Hierarchy of Needs (F) - Physiological - Safety and security - Love and belonging - Self-esteem - Self- Actualization. Client Identification (F) - Before client care the nurse should: Introduce herself Verify ID by asking client to stake his name and then checking his/her ID band. Always verify 2 identifiers. Assess for any allergies by checking client records. Seizure Precautions (F) - Padded side rails. Rescue equipment at bedside: Oxygen, oral airway, suction equipment. Remove items that may cause injury. Never put anything in the client's mouth in the event of a seizure. During a seizure (F) - Do not restrain the client Lower the client to the floor or bed. Protect the client's head. Remove nearby furniture. Provide privacy. Put the client on his side if possible. Loosen clothing to prevent injury and promote dignity. Note length of time of seizure.

Note movement observed during seizure. After a seizure (F) - Ensure airway is clear. Monitor mental status, O2Sat, and VSs. Reorient and explain to the client what has occurred. Provide comfort, understanding, and a quiet environment for the client to recover in. Document the seizure in the client's record with any precipitating behaviors and a description of the event. Report the seizure to the provider. Fire Safety (RACE) (F) - R - Rescue: Protect and evacuate clients in immediate danger. A - Alarm: Report the fire. C - Contain: Contain the fire. E - Extinguish: Extinguish the fire. Types of Fire Extinguishers (F) - Class A: Paper, Wood, Upholstery, Rags, Other trash. Class B: Flammable liquids and gases. Class C: Electrical fires. Using a Fire Extinguisher (PASS) (F) - P - Pull the pin. A - Aim at the base of the fire. S - Squeeze the levers. S - Sweep the extinguisher from side to side, covering the area of the fire. Mass Casualties (F) - Overwhelm the resources of the individual hospitals and possibly the resources of the community's entire health system. Internal Emergencies (F) - Include loss of electric power or potable water and severe damage or casualties within the facility related to fire, severe weather, an explosion, or terrorist act. External Emergencies (F) - Include hurricanes, floods, volcano eruptions, earthquakes, pandemic flu, industrial accidents, and terrorist acts. Nursing Responsibilities During a Disaster (F) - Triage. Prioritizing care of victims. Transferring those requiring immediate attention. Prioritizing Care During a Disaster (F) -

C. Remain calm and try not to alarm clients. Body Mechanics (F) - The coordinated efforts of musculoskeletal and nervous systems to maintain posture, balance, and body alignment. Body alignment (F) - The relationship of one body part to another body part along a horizontal or vertical line. Body balance (F) - Achieved when a relatively low center of gravity is balanced over a wide, stable base of support, and a vertical line falls from the center of gravity through the base of support. Coordinated body movement (F) - An object that is unbalanced has its center of gravity away from the midline and falls without support. Clients who fail to maintain coordinated body movement are unsteady and at risk for falling. Regulation of movement (F) - Includes movements of the skeletal, muscular, and nervous systems. Gait (F) - Manner of walking. Friction (F) - The effect of rubbing or the resistance that a moving body meets from the surface on which it moves.

• When moving clients, reduce friction to decrease the risk of skin shearing which occurs when the skin adheres to the bed and the muscles and bones move, as when the client slides down in the bed. Can tear the skin and puts the client at risk for pressure ulcer development.
• Have the client bend his or her knees and cross arms across the chest as you assist with re-positioning to reduce friction.
• Better to lift than push or drag a client.
• For clients requiring maximum assist, use a draw sheet to reduce muscle strain for the nurse and friction for the client (Large clients. Unconscious clients. Immobile clients.) 5 Functions of Bones (F) - Support. Protection. Movement. Mineral storage. Hematopoiesis (blood cell formation). Joints (F) -

Connection between bones. Ligaments (F) - White, shiny, flexible bands of fibrous tissue. Bind joints; connect bones and cartilage. Aid in joint flexibility and support. Tendons (F) - White, glistening, fibrous bands of tissue. Connect muscle to bone. Cartilage (F) - Non-vascular, supporting connective tissue. Flexibility of a firm, plastic material. Muscles (F) - Facilitate movement. Determine body form and contour. Proprioception (F) - The awareness of the position of the body and its parts. Balance (F) - Controlled by the nervous system, including the cerebellum and the inner ear. Principles of Body Mechanics (F) - The center of gravity is the center of the mass. Weight is acted on by the force of gravity. To lift an object, the weight of the object must be overcome. When upright, the center of gravity is the pelvis. When anyone moves, the center of gravity shifts. The closer the line of gravity to the center of the base of support, the more stable the client/nurse is. Use hips and abdominal muscles when moving an object. Protect your back. Lifting (F) - Use major muscle groups to prevent back strain. Distribute weight between large muscles of arms and legs to decrease injury. Flex hips, knees, and back. Keep knees bent and back straightened. Use assistance when needed. Pushing and Pulling (F) - Widen base of support. Pull object toward center of gravity. If pushing, move one foot forward.

Precise practices to reduce the number, growth, and spread of microorganisms ("clean technique"). Applies to administering oral medication, managing nasogastric tubes, providing personal hygiene, and performing many other common nursing tasks. Surgical Asepsis (F) - Precise practices to eliminate all microorganisms from an object or area and prevent contamination ("sterile technique"). Applies to parenteral medication administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures. Medical Aseptic Practices (F) - Hand washing is the No. 1 way to prevent the spread of infection. Always use proper hand hygiene: hand washing with an antimicrobial or plain soap and water; using alcohol-based products such as gels, foams, and rinses; or performing a surgical scrub. Use of masks, gowns, gloves, and protective eyewear when appropriate. Cover the mouth and nose when coughing or sneezing, using and disposing of facial tissues, and performing hand hygiene. Clean from least contaminated first. Clean to dirty. Use plastic bags to contain items (red bags for items saturated with bodily fluids). Follow isolation precaution procedures. Maintain personal hygiene

• No artificial nails.
• No rings with stones.
• Use lotion to prevent chapping. Washing your Hands (F) - With Soap and Warm Water
• Rub hands together vigorously, and rinse under running water.
• Wash for at least 15 seconds to remove transient flora and up to 2 min when hands are more soiled.
• After washing, dry hands with a clean paper towel before turning off the faucet. If the sink does not have foot or knee pedals for turning off the water, use a clean, dry paper towel to turn off the faucet(s). Changing linens (F) - Do not place items (linens) on the floor. Avoid shaking linens. When Should you Wash Your Hands? (F) -
  • When they are visibly soiled.
• Before and after client contact.
• Before performing invasive procedures.
• After contact with a source or reservoir, including clients and objects.
• After removing gloves.

Surgical Aseptic Practices (F) - Use sterile gloves for sterile procedures. Avoid coughing, laughing, or sneezing directly over sterile field. Do not reach over a sterile field. Keep nonwaterproof drapes dry. 1 - inch border of sterile drapes and packages is considered contaminated. Sterile to sterile = still sterile. Sterile to nonsterile = contaminated. Open sterile packages by unfolding top flap away from your body first and toward you last. "Lip" liquids by pouring 1 to 2 mL of solution into receptacle first before pouring into a sterile object or container. Grasp glove at folded cuff with nondominant hand and place on dominant hand. Place fingers from sterile dominant hand inside the nondominant hand glove, lift up, and place on hand. Make adjustments when both hands are gloved. Remove sterile gloves by turning inside out and placing one glove inside of the other. Restraints: Nursing Responsibilities (F) - Using restraints without an order is considered false imprisonment and is illegal. Use restraints only as a last resort. The nurse should consult with the provider and obtain a written order stating why the restraint is necessary and for how long. If a nurse uses restraints in an emergent situation, a face-to-face assessment is to be done within 1 hr by the provider. Types of Restraints (F) - Physical restraints

• Any physical, manual, or mechanical method attached to a body to restrict movement.
• Chemical restraints
• Medications used to control behavior.
• Especially dangerous in older adult clients due to increased sedation, drowsiness, and otherwise impaired cognition that could increase the risk for falls.
• Also should be used as a last resort. Rules for Restraints (F) - Restraints should:
• Never interfere with treatment.
• Restrict movement as little as it is necessary to ensure safety.
• Fit properly.
• Be easily changed
• To decrease the chance of injury.
• To provide for the greatest level of dignity. When all other less restrictive means have been tried to prevent a client from harming self or others, the following must occur in order for restraints to be used

Urine Specimen (F) - Apply gloves and use sterile cup to collect 5 to 10 ml of urine.

• Place cup or tube on clean towel in the client's bathroom.
• If the client has a urinary catheter, use a needleless safety syringe to collect specimen from sampling port on the catheter. (see manufacturer's instructions)
• Instruct client on how to obtain a clean voided specimen if not catheterized.
• Secure the top of the transfer container, label for transport, and place in a biohazard bag.
• Remove gloves and perform hand hygiene. Hazardous Materials Incidence (F) -
  • Nurses can be exposed to biological, chemical, or radiation incidents or used as weapons
• Anthrax, smallpox, Ebola, pesticides, gases.
• Protect self from exposure.
• Approach scene or client cautiously.
• Locate poison control number or MSD (material safety data) if chemical known.
• If possible, decontaminate before entering facility.
• Wear gloves, mask, water-resistant gown, and shoe covers.
• Place all contaminated items into a large plastic container and seal it. Chain of Infection (F) -
  • Causative agent
• Bacteria, virus.
• Fungus, prion, parasite.
• Reservoir
• Human, animal.
• Water, soil, insects.
• Portal of exit
• Respiratory tract, Gastrointestinal, Genitourinary.
• Skin, mucous, blood, body fluids.
• Mode of transmission
• Contact, droplet, airborne, vector-borne.
• Portal of entry
• Same as portal of exit.
• Susceptible host
• Compromised defense mechanisms. Standard Precautions: Tier 1 (F) - the most important and should be used with all clients
• Gloves.
• Handwashing Standard Precautions: Tier 2 (F) - specific, based on medical diagnosis

• For example, different precautions will be used for different diseases, depending on how each disease is transmitted
• Contact.
• Droplet.
• Airborne. Barrier Equipment (F) -
  • Gloves
• Prevents contamination by direct/indirect contact. Single use only.
• Gloves go on after gowns and must be pulled over gown sleeves.
• Gowns
• Barrier protection against contact with infectious body/blood fluids or waste. Fluid resistant. Ripped gowns should be changed.
• Masks
• Prevents inhalation of droplet nuclei larger than 5 microns.
• Become ineffective if moist or wet. Never reuse.
• Particulate respirator
• Prevents inhalation of droplet nuclei smaller than 5 microns.
• Most commonly used for clients who have tuberculosis (TB).
• Eyewear/face shields
• Glasses or goggles with side shields to prevent contamination of the eyes from splashing/splattering of secretions. Reverse Isolation/Protective Precautions (F) -
  • Used to protect the client from health care workers and others.
• Most commonly seen in clients who have:
• Cancer.
• Immunosuppression from autoimmune disorders
• Human immunodeficiency virus (HIV).
• Acquired immune deficiency syndrome (AIDS).
• Strict hand washing for all persons in contact with client.
• Avoid fresh fruits and vegetables.
• No fresh flowers, plants, or standing water in room.
• Restrict visitors who may be ill. Removal of Protective Equipment (F) -
  • Remove gloves
• Grasp glove and pull inside out.
• Tuck finger of ungloved hand inside cuff of gloved hand, and remove inside out.
• Remove eyewear
• Remove per agency policy.
• Remove gown
• Untie waist and neck strings of gown.
• Remove hands from sleeves without touching outside of gown and fold inside out.
• Remove mask
• Untie top string and then bottom strings.

Integrative medicine (F) -

• Combining complementary treatments with conventional care.
• For example, adding a complementary treatment to an existing conventional treatment (such as taking an omega-3 fatty acid supplement in addition to statins prescribed to reduce cholesterol). Examples
• Alternative medical philosophy: Chinese medicine.
• Biological therapies: vitamins, minerals.
• Body manipulation: massage, chiropractic.
• Mind--body therapy: yoga, tai chi.
• Energy therapy: Reiki, therapeutic touch. Nursing Considerations for CAM (F) -
• Be knowledgeable.
• Be receptive to learning about clients' alternative health beliefs and practices (home remedies, cultural practices, vitamin use, modification of prescriptions).
• Learn what therapies the client is using at home.
• Identify needs of client for CAM.
• Incorporate CAM into client care
• Know contraindications to therapy
• Artificial joints: cannot have chiropractic adjustments to that joint.
• Homeopathic medications: allergy to or interaction to other medications.
• It is important for the nurse to know who can provide CAM
• Licensed or certified practitioners provide complementary or alternative therapies, which can include the following:
• Acupuncture.
• Homeopathic medicine.
• Chiropractic.
• Massage.
• Biofeedback.
• Therapeutic touch. Nursing Interventions for CAM (F) - Interventions nurses can provide
• Guided imagery (focuses on images).
• Healing intention (caring compassionate care).
• Breath work (works on patterns to reduce stress).
• Humor (reduces stress).
• Meditation (calms mind and body).
• Simple touch (provides presence, acceptance).
• Music therapy (form of distraction).
• Therapeutic communication (verbalizing emotions). Who can provide CAM (F) -

Mobility (F) - The freedom and independence in purposeful movement. Refers to adapting to and having self-awareness of the environment. Immobility (F) - The inability to move independently and freely.

• Physiologic effects
• When a client is immobile for a period of time, each body system is at risk for impairments.
• The degree of impairment can be affected by factors including the client's
• Age.
• Overall physical and mental health status.
• Degree of immobility. System Impairments: Respiratory System (F) - Decreased movement results in decreased oxygenation and stasis of secretions, which can result in atelectasis and pneumonia.
• Postoperative clients must be instructed in ways to prevent complications
• Coughing and deep breathing.
• Adequate hydration.
• Timely pain management.
• How to splint incisions.
• Encourage early ambulation and use of incentive spirometry.
• Chest physiotherapy can help loosen secretions for expectoration.
• Maintain a patent airway
• If clients become too weak to cough, suctioning can be needed to keep airway patent and prevent pneumonia.
• Monitor clients for green-yellow sputum production, fever, and pain. System Impairments: Cardiovascular System (F) -
  • Complications within the cardiovascular system can include
• Orthostatic hypotension.
• Decreased cardiac output.
• Increased risk of thrombus.
• Teach the client to avoid the Valsalva maneuver.
• Encourage position changes and leg exercises to prevent deep-vein thrombosis (DVT).
• Use elastic stocking(s) to promote venous return
• Should be removed and reapplied every 8 hr.
• Intermittent pneumatic compression or sequential compression devices (SCDs) are plastic sleeves placed on the legs.
• The sleeves are then connected to an air pump that alternately inflates and deflates in a rhythmic motion up and down the legs to promote venous return.

• Complications
• Renal calculi.
• Poor perineal care.
• Decreased peristalsis leading to constipation.
• Fecal impaction.
• Assess bowel sounds frequently.
• Monitor I&O, characteristics of stool and urine.
• Offer hydration and administer stool softeners as prescribed.
• Psychosocial condition
• Immobile clients are at risk for sensory deprivation, depression, anxiety, sleep/wake pattern alterations, and ineffective coping.
• Provide diversional activities and one-on-one interaction.
• Maintain call light within reach.
• Encourage family visits. Pain (F) -
  • Thought of as the fifth vital sign.
• It is a nurse's responsibility to evaluate for pain regularly
• Review vital signs.
• Evaluate effectiveness of all pain interventions.
• Premedicate before starting painful procedures or therapy.
• The client's report of pain is the most reliable diagnostic measure Evaluating Pain (F) - Ask
• PQRSTU
• P: Palliative or provocative factors
• What makes it better or worse?
• Q: Quality
• How do you describe your pain?
• R: Region or radiation
• Where does it hurt? Does it spread somewhere else?
• S: Severity
• How bad is your pain now? (0--10, FACES)
• T: Timing
• Is your pain consistent, intermittent?
• U: Effect of pain
• Does it prevent you from doing what you would like to do? Non-pharmacological Pain Relief Interventions (F) -
  • Biofeedback
• Helps change perception of pain, alter pain, and provide a sense of control.
• Is completed with help from a licensed specialist.
• Chiropractic
• Acupuncture and Acupressure

• Vibration or electrical stimulation via tiny needles inserted into the skin and subcutaneous tissues at specific points.
• Guided imagery
• Focusing on a pleasant thought to divert.
• Relaxation/guided imagery
• Includes meditation, yoga, and progressive muscle relaxation.
• Distraction
• Includes ambulation, deep breathing, visitors, television, and music.
• Massage.
• Therapeutic touch.
• Cutaneous stimulation
• TENS unit.
• Interruption of pain pathways.
• Cold for inflammation.
• Heat to increase blood flow and to reduce stiffness.
• Aromatherapy. Palliative Care (F) - A management approach for end-of-life issues that prevents, relieves, and eases symptoms without compromising medical interventions. Hospice (F) -
  • Comprehensive, specialized care delivery system for the terminally ill
• Care is provided to client and entire family.
• Interprofessional approach.
• Controlling symptoms is priority.
• Directed by a provider and managed by a nurse.
• Volunteers are used for nonmedical care.
• May be provided as inpatient or in a client's home.
• Can be given within 6 months of expected death.
• Bereavement services postmortem are offered to the family. Palliative Care Inter-professional Team (F) -
  • Doctors.
• Nurses.
• Social workers.
• Massage therapists.
• Occupational therapists.
• Music/art therapists.
• Touch/energy therapists. Signs of Impending Death (F) - Nursing Interventions for a Dying Client (F) -
  • Comfort from distress.