Beruflich Dokumente
Kultur Dokumente
B
Things You Forgot
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Throughout this book, we have tried to help you to simplify preparation for
the NCLEX® exam. This appendix includes information you have learned
during nursing school but might have forgotten.
Vital Signs
Here are some of the normal ranges for vital signs:
➤ Heart rate: 80–100 beats per minute
2 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anticoagulant Therapy
These are the tests to be done for the client taking anticoagulants and their
control levels. Remember that the therapeutic range is 1.5–2 times the
control:
➤ Coumadin (sodium warfarin) PT/Protime: 12–20 seconds.
➤ Contractions:
Standard Precautions
Standard precautions are a set of guidelines for the nurse to take when car-
ing for the client. These precautions protect the nurse from transmitting the
disease to another client or to herself:
➤ Gloves should be worn when there is a chance of contact with blood and
body fluids, when handling other potentially infected material, and when
performing vascular access procedures.
0789732696 AppB 4/26/05 2:20 PM Page 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Things
. . . . You
. . .Forgot
3
. . .
➤ Gloves should be changed after each client contact and between contact
procedures with the same client.
➤ Masks and protective eyewear should be worn when there is a likelihood
of splashes or when body fluids might become airborne.
➤ Gloves and aprons should be worn during procedures in which there is
the likelihood of splashes of blood or body fluids.
➤ Hand washing should be done immediately after contact with body flu-
ids or other potentially infected material and as soon as gloves are
removed.
➤ Needles and sharps should be disposed of in sharps containers. No
recapping, bending, or breaking of needles should occur.
➤ Mouth-to-mouth resuscitation should be performed using a mouthpiece
or other ventilation device.
Body fluids likely to transmit blood-borne disease include blood, semen, vaginal/
cervical secretions, tissues, cerebral spinal fluid, amniotic fluid, synovial fluid, pleural
fluid, peritoneal fluid, and breast milk. Body fluids not likely to transmit blood-borne
disease unless blood is visible include feces, nasal secretions, sputum, vomitus,
sweat, tears, urine, and saliva (the exception is during oral surgery or dentistry).
Airborne Precautions
Examples of infections caused by organisms suspended in the air for pro-
longed periods of time are tuberculosis, measles (rubella), and chickenpox.
Place these clients in a private room. Healthcare workers should wear a
HEPA mask or N-95 mask when dealing with such clients. These mask con-
tain fine fibers and filter out particles, preventing them from passing through
to the healthcare worker.
Droplet Precautions
Infections caused by organisms suspended in droplets that can travel 3 feet,
but are not suspended in the air for long periods of time are influenza,
mumps, pertussis, rubella (German measles), diphtheria, pneumonia, scarlet
fever, streptococcal pharyngitis, and meningitis. Place the client in a private
room or in a room with a client who has the same illness. The clients should
be no closer than 3 feet away from one another. Caregivers should wear a
mask, and the door can remain open.
0789732696 AppB 4/26/05 2:20 PM Page 4
4 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Contact Precautions
Infections caused by organisms spread by direct contact include RSV, scabies,
colonization with MRSA, and VRE. Place the client in a private room or
with a client with the same condition. Caregivers should wear gloves when
entering the room and wear gowns to prevent contact with the client. Hands
should be washed with an antimicrobial soap before leaving the client’s room.
Equipment used by the client should remain in the room and should be dis-
infected before being used by anyone else. The client should be transported
only for essential procedures; during transport, precautions should be taken
to prevent disease transmission.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Things
. . . . You
. . .Forgot
5
. . .
6 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If only one rescuer is present, two fingers should be used to provide chest com-
pressions while the other hand is used to support the infant’s head.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Things
. . . . You
. . .Forgot
7
. . .
8 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Things
. . . . You
. . .Forgot
9
. . .
Nutrition Notes
It is important for the nurse to be aware of different diets used in the disease
processes we have discussed. Table B.2 is a quick reference to help you
remember the diets.
(continued)
0789732696 AppB 4/26/05 2:20 PM Page 10
10 Appendix
. . . . . .B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Immunization Schedule
It is important for the nurse to be aware of the recommended immunization
schedule for various age groups. Figure B.1 is a recommended schedule.
HepB #1
HepB #3 HepB Series
HepB #2
Varicella Varicella
Hepatitis A Series