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Flashcards in NCLEX PN Notes 1 Deck (58)
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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

15

Infant w/ Cleft Lip -->

position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position.

16

To Prevent Dumping Syndrome (post-operative ulcer/stomach surgeries) -->

eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals)

17

Above Knee Amputation -->

elevate for first 24 hours on pillow, position prone daily to provide for hip extension.

18

Below Knee Amputation -->

foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.

19

Detached Retina -->

area of detachment should be in the dependent position

20

Administration of Enema -->

position pt in left side-lying (Sim's) with knee flexed

21

After Supratentorial Surgery (incision behind hairline) -->

elevate HOB 30-45 degrees

22

After Infratentorial Surgery (incision at nape of neck)-->

position pt flat and lateral on either side.

23

During Internal Radiation -->

on bedrest while implant in place

24

Autonomic Dysreflexia/Hyperreflexia (S&S: pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia, hypertension) -->

place client in sitting position (elevate HOB) first before any other implementation.

25

Shock -->

bedrest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg)

26

Head Injury -->

elevate HOB 30 degrees to decrease intracranial pressure

27

Peritoneal Dialysis when Outflow is Inadequate -->

turn pt from side to side BEFORE
checking for kinks in tubing (according to Kaplan)

28

Lumbar puncture =>

AFTER the procedure, the client should be placed in the supine position for 4 to 12 hrs as prescribed. (Saunders 3rd ed p. 229)

29

worsens with exercise and improves with rest.

Myasthenia Gravis:

30

a positive reaction to Tensilon--will improve symptoms

Myasthenia Crisis: