34 PAGE Nclex Study Guide MUST READ Before TEST

DO NOT delegate what you can EAT!

E - evaluate A - assess T - teach

addisons= down, down down up down

cushings= up up up down up

addisons= hyponatremia, hypotension, decreased blood vol, hyperkalemia, hypoglycemia

cushings= hypernatremia, hypertension, incrased blood vol, hypokalemia, hyperglycemia

No Pee, no K (do not give potassium without adequate urine output) EleVate Veins; dAngle Arteries for better perfusion

A= appearance (color all pink, pink and blue, blue [pale])

P= pulse (>100, < 100>

G= grimace (cough, grimace, no response)

A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent) 

TRANSMISSION-BASED PRECAUTIONS:

AIRBORNE

My - Measles

Chicken - Chicken Pox/Varicella

Hez - Herpez Zoster/Shingles TB

or remember...

MTV=Airborne

Measles TBVaricella-Chicken Pox/Herpes Zoster-Shingles

 Private Room - negative pressure with 6-12 air exchanges/hr

 Mask, N95 for TB

DROPLET

think of SPIDERMAN!

S - sepsis

S - scarlet fever

S - streptococcal pharyngitis

P - parvovirus B19

P - pneumonia

P - pertussis

I - influenza

D - diptheria (pharyngeal)

E - epiglottitis

R - rubella

M - mumps

M - meningitis

M - mycoplasma or meningeal pneumonia

An - Adenovirus

 Private Room or cohort

 Mask

1

CONTACT PRECAUTION

MRS.WEE

M - multidrug resistant organism

R - respiratory infection 

S - skin infections *

W - wound infxn

E - enteric infxn - clostridium difficile

E - eye infxn - conjunctivitis

SKIN INFECTIONS

VCHIPS

V - varicella zoster

C - cutaneous diphtheria

H - herpez simplex

I - impetigo

P - pediculosis

S - scabies

1. Air/Pulmonary Embolism (S&S: chest pain, difficulty breathing, tachycardia, pale/cyanotic, 

sense of impending doom) --> turn pt to left side and lower the head of the bed.

2. Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetal 

bradycardia, etc) --> turn on left side (and give O2, stop Pitocin, increase IV fluids)

3. Tube Feeding w/ Decreased LOC --> position pt on right side (promotes emptying of the 

stomach) with the HOB elevated (to prevent aspiration)

4. During Epidural Puncture --> side-lying

5. After Lumbar Puncture (and also oil-based Myelogram)--> pt lies in flat supine (to prevent 

headache and leaking of CSF) 6. Pt w/ Heat Stroke --> lie flat w/ legs elevated

7. During Continuous Bladder Irrigation (CBI) --> catheter is taped to thigh so leg should be 

kept straight. No other positioning restrictions. 8. After Myringotomy --> position on side of affected ear after surgery (allows drainage of 

secretions) 9. After Cataract Surgery --> pt will sleep on unaffected side with a night shield for 1-4 weeks. 10. After Thyroidectomy --> low or semi-Fowler's, support head, neck and shoulders. 11. Infant w/ Spina Bifida --> position prone (on abdomen) so that sac does not rupture 12. Buck's Traction (skin traction) --> elevate foot of bed for counter-traction

13. After Total Hip Replacement --> don't sleep on operated side, don't flex hip more than 45-

60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating 

thighs with pillows. 14. Prolapsed Cord --> knee-chest position or Trendelenburg