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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.
Circulatory Care (F) - ✔ Perform a comprehensive appraisal of peripheral circulation: peripheral pulses, edema, capillary refill, color, temperature. Monitor degree of discomfort or pain. Protect the extremity from injury. Place extremity in a dependent position. Peripheral Sensation Management (F) - ✔ Monitor for paresthesia: numbness, tingling, hyperesthesia, hypoesthesia. Monitor the fit of bracing devices, prostheses, shoes, and clothing. Administer analgesics prn. Discuss or identify causes of abnormal sensations or sensation changes. Care after Immobilizer Removal (F) - ✔ Move extremity carefully. Support with pillows or other devices until strength and movement return. Exercise slowly with physical therapist. Wearing support stockings or elastic bandages to prevent swelling for lower extremities. Nutrition: Older Adults (F) - ✔ Need the same nutrients but in differing amounts. Number of calories needed is less. 1500 mg/day of Calcium Smell and taste decline. May add more salt to enhance taste (teach about salt subs). Decrease vision makes food prep more difficult. Foods to Eat for Older Adults (F) - ✔ Foods low in saturated fat. Foods high in fiber, like whole-grain breads and cereals. Fruits and vegetables. Moderate amounts of low-fat dairy products. Protein like poultry, fish, beans, and eggs. Foods to Avoid for Older Adults (F) - ✔ Sweets and other foods high in sugar, fat, and calories should be eaten sparingly. Dysphagia (F) - ✔ Occurs with a stroke or other neurological conditions. Aspiration is the first concern, followed by dehydration and malnutrition. 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.
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) - ✔ Empty beds are used first. Routine admissions are cancelled. Types of clients discharged as needed until enough bed space is made to handle the influx of casualties
- Clients who are hospitalized for diagnosis or observation and are not bedridden.
- Clients who were already close to being discharged.
- Postnatal clients and their babies after 24 hr. Triage (F) - ✔ Highest priority: Life-threatening injuries but a high possibility of survival once stabilized. Medium priority: Injuries that involve systemic complications that are not yet life- threatening and can usually wait 45 to 60 min for treatment. Lowest priority: Local injuries with no immediate complications and can usually wait several hours for treatment.
Bio-terrorism Categories (F) - ✔ Category A: Highest priority agents. Risk to national security. Easily transmitted. High mortality rate. Examples - smallpox, botulism, anthrax, and plague. Category B: Second highest priority. Easily disseminated with moderate morbidity and low mortality rates. Examples - typhus and cholera. Category C: Emerging pathogens that could be engineered in the future for mass dissemination. Easily reproduced and/or high morbidity and mortality rates. Examples - hipha virus and hantavirus. Hazardous Material Incidents (F) - ✔ Take measures to protect self and avoid contact. Attempt to identify the hazardous material. Try to contain the material. Hazardous Material Decontamination (F) - ✔ With few exceptions, water is the universal antidote. For biological hazardous materials, use bleach. Wear gloves, gown, mask, and shoe covers. If clothing is contaminated, remove it carefully and slowly. Cleanse skin with gentle soap and water. Do not use an abrasive scrub or strong detergent. Do not shave hairy areas if there is redness or tenderness. Bomb Threaths (F) - ✔ A. When a phone call is received, prolong the conversation for as long as possible. Be alert for background noises and note distinguishing voice characteristics. Ask where the bomb will explode and what time. B. If what appears to be a bomb is found, do not touch it. Clear the areas. Obtain professional assistance. Try to isolate the object as much as possible by closing doors. Notify authorities and key personnel (Police, Director of nursing, Supervisor) 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.
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. If pulling, move the rear leg back for stability. Face the direction of movement when moving a client. Avoid twisting or bending the back. Guidelines to Prevent Injury (F) - ✔ Know your facility policy. Use assistive devices when available (Transfer belt. Hydraulic lift. Sliding board.) Plan ahead by asking for help. Rest between heavy activities to decrease fatigue. Maintain good posture. Exercise regularly (Increase strength. Prevent injury.) Use smooth movements to prevent injuries. Avoid repetitive movements. Older Homes (F) - ✔ Encouraged to have inspections for the presence of lead in paint, dust, or soil. Lead also comes from the plumbing fixtures in a home, clients should have water from each faucet tested. Infection (F) - ✔ The invasion of a susceptible host by pathogens or microorganisms, resulting in disease. Colonization (F) - ✔ When a microorganism invades a host, grows, and/or multiplies, but does not cause disease or infection unless it alters normal tissue functioning
- If it can be spread from one person to another, it is referred to as communicable. Nosocomial Infection (F) - ✔ A health care facility acquired infection. Handwashing (F) - ✔ No. 1 way to prevent the spread of infection.
- Friction.
- Water.
- Soap. Asepsis (F) - ✔ The absence of illness-producing microorganisms. Equipment used with aseptic techniques (Gloves. Gown. Masks. Eyewear.) Before beginning any task or procedure that requires aseptic technique, must check for latex allergies. If anyone has a latex allergy, the team must use latex-free gloves, equipment, and supplies. Medical Asepsis (F) - ✔ 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 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
- The treatment must be prescribed by the provider in writing, based on a face-to-face assessment of the client.
- The prescription must include the reason for the restraint, the type of restraint, the location of the restraint, how long the restraint may be used, and the type of behaviors demonstrated by the client that warrant use of the restraint.
- The prescription and the renewal are limited to 4 hr for an adult, 2 hr for clients ages 9 to 17, and 1 hr for clients younger than 9 years of age. Prescriptions may be renewed, if needed, with a maximum of 24 consecutive hr. Restraints Monitoring and Interventions (F) - ✔ • Restraints should be removed or replaced frequently
- Ensure good circulation to the area.
- Allow for full range of motion to the limb that has been restricted.
- Safety should be checked and documented every 15 to 30 min based on facility policy.
- Bony prominences should be padded and neurosensory checks should be performed every 2 hr to identify neurological or circulatory deficits
- Loosening or removing the restraint.
- Testing temperature, mobility, and capillary refill. The restraint should be tied to a nonmovable part of the bed frame where it will not tighten when the bed is raised or lowered.
- The restraint should be secured using a quick release knot that can be easily untied.
- The restraint should be left loose enough for range of motion and with enough room to fit two fingers between the device and the client to prevent injury.
- Regularly assess the need for continued use of the restraints to allow for discontinuation of the restraint or limiting the restraint at the earliest possible time while ensuring client safety.
- The client should not be left unattended without the restraint. Wound Specimen (F) - ✔ Apply gloves and clean the wound with sterile saline before specimen collection.
- Use a culture swab to swab the center of the wound site, collecting as much drainage as possible.
- Then, insert the swab into the culture tube without touching the outside of the tube.
- After securing the tube's top, transfer the tube into a biohazard bag for transport and perform hand hygiene. Stool Specimen (F) - ✔ Wearing gloves, use clean cup with seal top (does not need to be sterile) and tongue blade to collect small amount of stool.
- Using the tongue blade, collect needed amount of feces from client's bedpan.
- Transfer feces to cup without touching cup's outside surface.
- Dispose of tongue blade.
- Seal cup and transfer specimen into clean biohazard bag for transport.
- Remove gloves and perform hand hygiene. 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
- Preeclampsia.
- Other conditions in which stimulation worsens the underlying disease/condition. Active ROM (F) - ✔ Occurs when clients are actively and independently able to perform their own exercises and move their own joints. Passive ROM (F) - ✔ - Occurs when staff facilitates joint movements for the client.
- If nurses do not perform the exercises for the client, a variety of complications can result
- Contractures.
- Muscle atrophy
- Wasting away.
- Reducing in size.
- Joint stiffness. Assessing ROM (F) - ✔ • Ask the client to move their extremities up, down, and outward.
- Assess for symmetry, strength, and if the movement is full or partial.
- If a client is unable to move an extremity independently, the nurse should perform passive ROM exercises.
- Never force a joint to the point of pain. Continuous Passive Motion Machines (CPM) (F) - ✔ • Clients who have undergone total joint replacement surgery will be placed on a CPM machine as a part of their therapy after surgery.
- The CPM machine is used to continuously move joints and assist with healing.
- The machine will be set to a certain degree or angle of how far to move the joint.
- The degree of movement will be increased as the joint heals. Review of Normal Range of Joint Motion (F) - ✔ Complementary medicine (CAM) (F) - ✔ - Alternative treatments used in addition to conventional therapies.
- For example, using tai chi or massage in addition to prescription medicine for anxiety. Alternative medicine (F) - ✔ Alternative treatments used instead of conventional therapies.
- For example, seeing a homeopath or naturopath instead of a regular doctor. 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
- Immobility increases direct pressure on the skin
- Can lead to ischemia or lack of blood flow over bony prominences.
- This can cause skin breakdown and pressure ulcer formation. System Impairments: Changes in Metabolism of Carbohydrates, Fats, and Proteins (F) - ✔ • Complications
- Decreased metabolic rate.
- Decreased protein metabolism.
- Calcium resorption.
- Pancreatic activity decreases, as does the body's ability to tolerate glucose.
- Insulin production is not enough to lower serum glucose levels.
- This can happen in as little as 3 days.
- As protein is metabolized, nitrogen is produced as an end product
- Nitrogen balance provides a reliable indicator of protein use by the body.
- A negative nitrogen balance exists when the excretion of nitrogen from the breakdown of protein exceeds intake
- Can lead to problems with wound healing and tissue growth.
- Results in increased percentage of body fat and the loss of lean body mass.
- Monitor
- Anthropometric measurements
- Body measures of height and weight.
- Skin-folds.
- Intake &Output.
- Electrolytes.
- Nutritional intake.
- Serum protein and albumen levels.
- Be aware anorexia can occur
- Encourage a balanced diet plan
- Carbs, proteins, and fats specific to the client's needs.
- Collaboration with a dietitian can be helpful. System Impairments: Elimination and Psychosocial Condition (F) - ✔ • Elimination
- 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.
- Care is provided with dignity and sensitivity while attending to the desires of the client and family per their cultural, religious, and social practices.
- The client's family becomes the nurse's primary focus.
- Nurses can cope with their feelings through:
- Attending the funeral procession.
- Writing a letter of condolence to the family.
- Seeking out other nurses.
- Stress management techniques.
- Debriefing with a professional counselor. Postmortem Care: Preparing the Body for Viewing (F) - ✔ Preparing the body for viewing includes:
- Maintaining privacy.
- Shaving facial hair if applicable and desired by family.
- Removing all tubes and dirty linens (unless organs are to be donated or this is a coroner's case).
- Removing all personal belongings to be given to the family.
- Cleaning and aligning the body with a pillow under the head.
- Applying fresh linens and a gown.
- Brushing/combing the client's hair, replacing any hair pieces.
- Caring for dentures per agency policy.
- Pulling top sheet to below chin with arms outside sheet or per agency protocol.
- Removing excess equipment or linens from the room. Postmortem Care: Viewing and Other Considerations (F) - ✔ • Provide a calm environment by dimming the lights, if possible.
- Ask family if they would like to visit with the body
- Any decision is to be honored.
- Clarify where the client's personal belongings should go
- With the body or to a designated person.
- Identify cultural/religious needs of family members.
- Be sensitive to cultural/religious practices when providing postmortem care. Post-Viewing Nursing Responsibilities (F) - ✔ • Applying nametags per protocol.
- Completing documentation.
- Remaining aware of visitor and staff sensitivities during transport. Postmortem Documentation (F) - ✔ • Completion of forms following federal and state laws typically includes:
- Person pronouncing the death and at what time.
- Consideration of and preparation for organ donation.
- Disposition of personal articles.
- Names of people notified and decisions made.
- Location of ID tags.
- The time the body left the facility/agency and the destination.
Organ Donation: Nursing Responsibilities (F) - ✔ • Maintain ventilatory and cardiovascular support for vital organ retrieval.
- Use a private area for any family discussion concerning donation.
- Recognize that requests for tissue and organ donations must be made by specially trained personnel. Factors Influencing Heat and Cold Tolerance (F) - ✔ • Duration of application (should not exceed 15 to 20 min).
- Body part.
- Damage to body surface.
- Prior skin temperature.
- Body surface area.
- Age and physical condition.
- Temperature of therapy.
- Type of application
- Moist.
- Dry. Heat and Cold Client Education and Safety (F) - ✔ • Use cautiously in:
- Older adults.
- Clients who have sensory impairment.
- Clients who are immobile.
- Clients who have diabetes mellitus.
- Clients who have nerve damage.
- Bony prominences are more sensitive and should be monitored frequently.
- No heat application to the abdomen of a pregnant woman.
- Cold applications not appropriate for clients who have vascular insufficiency.
- Assess site every 5 to 10 min
- Redness.
- Pain.
- Numbness.
- Shivering.
- Blisters.
- Cyanosis.
- Pallor.
- Discontinue the application if any of the above occur, or remove the application at the predetermined time (usually 15 to 20 min). Applying Heat and Cold Therapy (F) - ✔ The nurse should make sure the provider has written a prescription that includes the following:
- Location.
- Duration and frequency.
- Specific type (moist or dry).
- Temperature to use. Heat Therapy (F) - ✔ • Vasodilation
