NEXLEX STUDY GUIDE

NCLEX Prep Fundamentals  Pts who has an allergy to apricots, cherries, grapes, kiwis, passion fruit, chestnut, tomatoes, peaches can also be allergic to LATEX.  ASSESSMENT order: Inspection, palpitation, percussion, auscultation.  ASSESSMENT FOR ABDOMEN: Inspect, auscultate, percuss, palpate.  CANE WALKING: o C: Cane o O: Opposite o A: Affected o L: Leg  “STEP UP” up the stairs the good leg goes up 1 st fallowed by the crutches and the bad leg. The opposite with going down the stairs.  RN DO NOT DELGATE WHAT THEY CAN EAT, EVALUATE, ASSESS OR TEACH. PERCAUTIONS:  AIRBORN :” MY CHICKEN HEZ TB” o MEASLES o CHICKEN POX o HERPES ZOSTERS o TB  MANAGEMENT FOR AIRBORN : negative pressure room, private room, mask, and N-95 mask for TB.  DROPLET: “SPIDER MAN” o SEPSIS o SCARELT FEVER o STREP o PERTUSSIS o PNEUMONIA o PARVOVIRUS o INFLEUNENZA o DIPTHERIA o EPIGLOTTIS o RUBELLA o MUMPS o ADENOVIRUS  Management for DROPLET : private room and mask  CONTACT: “MRS WEE” o MRSA, VRSA, RSV o Skin infections o Wound infections o Enteric infections (C-diff) o Eye infection (conjunctivitis)  Management for DROPLET: Gown, gloves, googles, private room.

Integumentary and Peripheral Vascular System  Cyanosis: Bluish for light skin tones in general and on the palms and soles for darker skin tones; for brown skin tones a change to yellow brown, for darker skin tones, black pigmented skin turns grayish. o Location: nail bed, lips, mouth mucosa, skin, palms o Indication: Hypoxia or impaired venous return  Jaundice: Yellow to orange o Indication: liver dysfunction, red blood -cell destruction.  Erythema: Redness, clients who have darker skin, erythema can be difficult to see. Palpate the skin for warmth, compared to other secretions of skin; inflamed areas can feel firmer or wood-like and be tender. o Location: face, skin, trauma, and pressure sore areas. o Indication : Inflammation, localized vasodilation, substance use, sun exposure, rash, elevated body temperature. Primary lesions: arise healthy skin tissue.  Macule: Nonpalpable, skin color change, smaller than 1cm o Freckle, petechiae  Papule: Palpable, circumscribed, solid elevation of skin, smaller than 1cm o Elevated nevus  Nodule: Palpable, circumscribed, deep, firm, 1-2 cm o Wart  Vesicle: serous fluid-filled, smaller than 1cm o Blister, herpes simplex, varicella  Pustule: Pus-filled, varies in size o Acne  Tumor: Solid in mass, deep, larger than 1-2cm o Epithelioma  Wheal: Palpable, irregulars’ borders, edematous o Insect bite  Atrophy: Thinning of skin with loss or normal skin furrow. Skin is shiny and translucent. o Arterial insufficiency Infiltration or Extravasation  Iv solution or medication leaks into the subcutaneous tissue. Infiltration is the leak of a non-vesicant; extravasation is the leak of a vesicant solution which can damage the tissues. With extravasation, prior to regular treatment, the nurse must withdraw the solution form the clients IV access and might need to administer an antidote prior to discontinuing the IV access. Findings include pallor, local swelling at the site, decreased skin temperature arounds the site, damp dressing or slowed rate infusion.  Treatment: o Stop the infusion and remove the catheter.