NCLEX

When are restraints used?

As a last resort

What’s the criteria for using restraints?

Risk of harm to patient and others, or patient is removing their lines

When should there be HCP order for restraints?

IMMEDIATELY, FOR ALL RESTRAINTS

How often should you check restraints?

Every 15 minutes

How often are restraints reassessed? (adults)

Every 4 hours

How often are restraints reassessed? (adolescents)

Every 2 hours

How often are restraints reassessed? (9yrs and under)

Every 1 hour

How often should a patient with restraints be repositioned/given a break?

Every 2 hours

How tight should restraints be?

2 fingers; loose enough to allow circulation

How should the pinna be pulled for an adult?

UP AND BACK

How should the pinna be pulled for a child?

DOWN AND BACK

What are the six rights of medication administration?

Right patient, dose, route, drug, time, documentation

Should needles be recapped?

NO

Fall precautions?

bed lowest position, well-lit room, call bell within reach, fall screenings, and awareness that LOC will decrease with certain medications

SBAR

Situation) issue/problem

Background) history

Assessment) current findings/vitals

Recommendation) what should happen

Who should be involved first in a interpersonal conflict?

The cause of the conflict

What should the nurse do first when there’s a interpersonal conflict?

Try to resolve it themselves first

Autonomy

Patients right to make decisions

Beneficence

Doing and promoting good

Nonmaleficence

Avoiding causing harm (double-checking)

Fidelity

To stay loyal and follow through

Justice

To treat fairly and equally

Veracity

To tell the truth

Cushing’s Triad

High BP, Widening pulse pressure, low HR, Low RR

Decorticate

arms flexed towards core

Decerebrate

Arms flexed out to sides (VERY BAD)

Hyperventilation effect on CO2

Decreases CO2; decreases acid + become alkaloid

How long should you suction?

Less than 10 seconds; wait for a full minute before continuing

Highest/Best GCS score?

15

GCS score for intubation

8

Lowest/worst GCS score

3

phenytoin + barbiturates

anticonvulsant

Pupils during head injury

dilated

Pupils during pen light

constrict

Widening pulse pressure

big difference between systolic and diastolic (usually >100)

F HGB

12 -16

M HGB

14-18

F HCT

37-47

M HCT

42-52

What’s HGB

Protein in RBCs that’s responsible for o2 delivery to tissues

What’s HCT

Volume of RBCs compared to the total blood volume (RBC + plasma)

Creatinine

Waste product made by kidneys

Creatine range

Below 1.3

Seizures position

on side

Pacemaker indictation

bradycardia/ low HR

What type of prevention is screenings?

Secondary