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2022 UPDATE NCLEX-PN CHEAT SHEET COMPLETE DOCS
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
- 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.
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. 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.
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.
- 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
- 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
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.
- Do not touch outside of mask and dispose immediately in garbage. When not to Perform ROM (F) - • Hypertensive crisis.
- Conditions that result in a higher intracranial pressure.
- 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.
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
