Informed Consent for NCLEX

Informed consent- is a permit for an operation.

It is part of the nurse's role as client advocate to confirm that the client understands the
information that they are given.

Question: Who obtains the consent?

Answer: The surgeon or doctor performing the procedure.

Question: What procedures do I need an informed consent for?

Answer: 1. Every operation no matter how minor

2. Diagnostic procedures- MRI, bronchoscopy, thoracentesis, CT
3. Anesthesia
Question: When is the informed consent not necessary?
Answer: In emergency situations where there is an immediate threat to life
Basic nursing care such as NG, IVs, Foley catheters.
Question: What make up the parts of an informed consent?
Answer:

The treatment or procedure to be performed

The person who will perform the treatment or procedure
The purpose of the proposed treatment or procedure
The expected outcomes of the proposed treatment or procedure
The benefits of the proposed treatment or procedure
The possible risks associated with the proposed treatment or procedure
The alternatives to the particular treatment or procedure
The benefits and risks associated with alternatives to the proposed treatment or procedure
The client's right to refuse a proposed treatment or procedure
Signature lines for the patient, doctor, and witness
Question: Who signs the consent for a minor (under 18)?
Answer: Adult or legal guardian. If parents are not there they can give over the phone with 2
witnesses to document.
These are the minors who are able to sign a consent form.
1. Married individuals
2. In military services
3. Pregnant females
4. Anyone female who has given birth

Question: Who signs the witness portion of the consent form?

Answer: Informed consent may be signed by the nurse, another physician or authorized person.

NCLEXtips:

Consent document should be in client's native language

Opt-out consent is also known as giving consent by not declining to give consent.
The nurse witness should specify whether it is a witness of client understanding explanation or
signature of client.
Addiction & Substance Abuse
Substances that patients are addicted to:

Alcohol
Tobacco
Caffeine
Narcotics
Methamphetamines

Signs of addiction

Rhinorrhea
Agitation
Perspiration
Underweight
Malnourished
*Poor dental health
Little personal success
Needle marks-opioid addiction
Terms to Remember

Habituation- physical and psychological dependence

Tolerance- the condition of physical dependency to a drug in which the presence of the drug in
increasingly higher dosage is needed to achieve the same effect. The biggest cause of overdose.
Addiction- physical, psychological dependence on a substance with increasingly higher doses of
the drug to achieve the same effect. Basically habituation + tolerance =addiction
Most addicts are in denial.
Diet for addiction
Diet for addiction- High-Calorie, High Protein, High Vitamin

Medications for addiction

Methadone-is legally dispensed. The benefit is addict gets a controlled dose that is the same
every time. This medication is not used to treat complaints of pain!
Disulfiram- used for alcohol dependence. Clients must avoid all forms of alcohol such as
mouthwash, hand sanitizer, cough syrups any substance with alcohol will have a severe
reaction. Flushing, vomiting, and dizziness are reactions.

*Other treatment-group therapy with other addicts, avoid isolation.

NCLEX Points to Remember

1. A patient can be addicted to 2 substances at a time.
2. There is no medication to cure addiction, abstinence is the only way to guarantee not using.
3. Family members and loved ones are most often enablers and co-dependent.
4. If you suspect a co-worker is using drugs report them to the supervisor!
Alzheimer's Disease for NCLEX
Alzheimer's disease is a form of dementia. In dementia there is memory decline along with
personality and behavioral changes. Alzheimer's is the biggest portion of dementia patients.

Remember for NCLEX patients with Alzheimers are ALERT even though they are confused.
Signs

Stage Timeframe Clinical signs

Early 2-4 years Poor memory

*Starts to use notes
Frontal lobe problem
Declining interest
May lose job
(Normal EEC & CT
*Increased risk for SUICIDE

Middle 4-8 years Progressive memory loss.

(Disorientation to time, place
events.
Can not follow simple
directions or math
*Neglects personal hygiene
May experience episodes of
violent behavior

Late 8-12 years Extreme weight loss

Severe impairment of
cognitive function
*Incontinence
Bedridden
Abnormal CT dilated
ventricles
Diagnosis: The only way to be sure of dementia is by autopsy.
Medications to know:

Medications NCLEX Tips

Take once daily at bedtime

Donepezil (Aricept) Increases cognition
Can cause bradycardia & weight loss

Rivastigmine (Exelon) Can cause nausea, diarrhea etc.

Can be worn as a patch
Benefit that it has no drug interactions
Also treats Parkinson’s disease

Nursing Priority: Reorient the Patient

Do not restrain-increase agitation
Create environment that is safe, bed in lowest position, clocks and calendars
Diet: High fiber, finger foods are a good choice.
Care of the Client in Traction
Traction is a pulling force exerted on bones. There are many reasons traction is applied to a
patient such as preventing deformities, reducing muscle spasm, and immobilizing fractures.

On NCLEX there are 2 types of traction that you must know:

1. Skeletal
2. Skin

Skeletal traction

Skeletal traction is where the traction is applied direction to the patient's bones using pins,
wires, or tongs. This is done surgically. This requires the nurse to provide pin care and assess
the skin frequently for any redness, drainage, or odor at the surgical site. Cleaning the pin
insertion site is done according to hospital policy. Weights are used to call the traction
"balanced".

Thomas splint is usually used with skeletal traction.

*Thomas Splint Traction Notes: Pad the top off the splint. Hip should be flexed at 20 degrees. A
footplate may be needed to prevent foot drop.

Other NCLEX priorities for skeletal traction:

Do not rest affected limb on foot of bed

Plantar flexion & dorsiflexion exercises are good.
Use overhead trapeze to assist with moving

skin Traction
In skin traction weights are attached to an elastic strip and then secured by another device so
that the affected limb can be covered. No surgery is needed.
There are two types of skin traction you want to know for NCLEX.

1. Buck's extension
2. Russell traction

Buck's Extension

Buck's extension uses weights to pull straight on the affected extremity. Normally seen in
patients with a:

fractured hip
fractured knee
fractured femur
Monitor patient does not slide to foot of bed. "Shock blocks" may be used to help this not to
happen.
Bed should not be placed in high fowler's position.

Russell's Traction
Russell's traction requires the knee to be suspended in a sling that is attached to a rope or
pulley. This will create an upward pull from the knee. Weights are also attached to the foot of
the bed like Buck's extension. This is generally used to stabilize fractures of the femur before
surgery.

Russell's Traction Notes:

Head of bed should be flat.
Foot of bed can be slightly elevated.
Watch for DVT as pressure is on popliteal space.
Pad the sling.
Clients may turn slightly from side to side without moving body below the waist.

Other NCLEX general priorities for traction:

Do not rest affected limb on foot of bed

Plantar flexion & dorsiflexion exercises are good.
Use overhead trapeze to assist with moving
Nurse may need to make bed from Head to Foot.
NCLEX Oral Hygiene Solutions
Glycerine
Uses- Initially refreshing but last only 20-30 seconds
Disadvantages- Can over-stimulate the salivary glands

Tap water
Uses- Refreshing, ideal pH, easy to obtain low cost
Disadvantages- Short lasting and does not contain a bactericide

Chlorhexidine gluconate
Uses- Inhibits bacterial growth
Disadvantages- Tastes unpleasant and stains teeth with long term use

Pineapple juice
Uses-Refreshing, promotes saliva production, contains an enzyme that helps cleanse the mouth
Disadvantages- Cannot be used for clients who are NPO

Toothpaste
Uses- Effective at removing debris
Disadvantages- Can dry the mouth if not rinsed thoroughly

Nystatin
Uses- Effected for fungal infections
Disadvantages- Tastes unpleasant, must be prescribed
Lesson 56: NG TUBES & Teaching
A nasogastric tube, or NG tube, is a special tube that carries food and medicine to the stomach
through the nose.

Other reasons for a NG tube:

Compression of stomach
Decompression of stomach
Lavage of stomach

NCLEX Things to take NOTE of when inserting an NG tube:

Anatomical Measuring Measure from the tip of the nose, to
Points the tip of the ear lobe, to the tip of the
xiphoid
(Length of tube)

Patient position High Fowlers

If you feel resistance Don’t stop immediately apply

downward pressure first to see if you
can make progress.
* Always use lubrication

Help make it easier Have patient lean forward and take sips
of water

Check for correct Aspirating gastric contents

placement:
Checking for pH of gastric contents
(looking for less than 4)

If can’t aspirate anything Push the tube down further FIRST then
recheck placement

Secure tube Tape

Common sense tips:

· If a patient is confused or a baby get help
· A cup of Water is needed. NOT to prevent dry mouth but to help facilitate
the tube going down the back of the throat.
· Listening for air bubble in the tube is NOT a good answer for NCLEX. Don’t
pick it as a way to check for accurate placement.
· If patient vomits, clean them up and keep trying to put that NG down. Let
them know the tube will make them feel better and keep them from throwing up
in the future (if decompression is the indication)
Lesson 53: Trach Care for NCLEX Part 1
Here are the four general reasons that a patient may require a trach
1. Ventilation- patient requires long-term mechanical ventilation because of chronic
respiratory failure
2. Airway obstruction- patient has tumors within the airway, paralyzed vocal cords, swelling,
etc
3. Airway protection- patients who cannot protect their airway
and patients with an inefficient swallow and/or coughing mechanisms
4. Secretions- patients who cannot mobilize or manage their secretions may also require a
tracheostomy

A tracheostomy tube may be placed surgically or percutaneously (through the skin).

Tracheostomy tubes can be made from different kinds of materials. A plastic tracheostomy
tube should be used for initial placement. Trach tubes can be made from metal but the
disadvantages are

NCLEX TEACHING: Metal tracheostomy tubes are rigid, lack a cuff, and
cannot be attached to a ventilator or a bag-valve mask.

Whenever a patient has a tracheostomy these things are at the bedside:

· functional suctioning system
· an oxygen source
· a manual resuscitation bag
· complete tracheostomy kit

NCLEX Post-Operative Care: priorities of care for a patient with a new

tracheostomy include ensuring that the tracheostomy tube is securely in
place and is patent. Also making sure proper equipment is at the bedside

Lesson 54: Trach Care for NCLEX Part 2

General NCLEX Trach Teaching

1. All supplies to replace a tracheostomy tube should be at the bedside or within

reach.
2. If no aspiration, tracheostomy tube cuffs should be deflated when a patient no
longer requires mechanical ventilation.
3. The first change of a tracheostomy tube should normally be performed by an
experienced physician with assistance from another clinician.
4. Use of a defined tracheostomy care protocol for patient and caregiver education
before discharge will improve patients’ outcomes and decrease complications.
5. Patients and their caregivers should be informed of what to do in an emergency
before discharge.
6. In an emergency, a dislodged tube from a mature tracheostomy should be
replaced with the same size tube or a tube 1 size smaller
or an endotracheal tube through the tracheostomy wound.
7. In an emergency, patients with a dislodged tracheostomy tube that cannot be
reinserted should be intubated.
8. A patient should not be discharged from the hospital with the tracheostomy tube
sutured in place.
9. Acute occlusion of a tracheostomy tube is most likely caused by a mucous plug,
obstructing granuloma, or insertion of the tube into
a false track.
10. A patient can be turned in bed once the security of the tube has been assessed
to avoid accidental decannulation.
****Cleansing the Stoma
The stoma should be cleaned every 4 to 8 hours.23
The skin should be inspected for indications of irritation
or infection, such as erythema, pain, or dried secretions. Gloves should be worn at all times.
Use normal saline or diluted hydrogen peroxide if necessary.
Lesson 55: Trach Care for NCLEX Part 3
Complications to watch out for:
Infections
Tracheomalacia- Tracheomalacia is the breakdown of the natural rigid
structure of the trachea that leads to a flaccid airway
Skin breakdown
Tracheoesophageal fistula- abnormal connection (fistula) between the esophagus and the
trachea
NCLEX PROBLEMS You need to know how to solve:
Dislodgement of the tracheal tube during the first postoperative week is considered a
medical
emergency; therefore, tube security is a priority.
1. hemorrhage- A small amount of bleeding is expected after the initial procedure and after
every tracheostomy tube change. This small amount of bleeding is normally self-limited. If
bleeding is more than minimal or if it continues, the surgeon should be contacted.
2. tube dislodgement- (If stoma new and is less than a week old) Immediate treatment in
complete decannulation includes mask ventilation and then orotracheal intubation
(If stoma is older than a week) If the problem is discovered quickly, the tube can usually
be easily replaced.
3. loss of airway- (If stoma new and is less than a week old) Immediate treatment in
complete decannulation includes mask ventilation and then orotracheal intubation
(If stoma is older than a week) If the problem is discovered quickly, the tube can usually
be easily replaced.
 4. tube obstruction- The 1ST step in caring for a tracheostomy patient in respiratory distress
is to remove and inspect the inner cannula. If the cannula is clogged with secretions, it can be
quickly cleaned and/or replaced with a new one. If the patient remains in distress, the nurse
should immediately call for help and then attempt to insert a suction catheter. Easy passage of
the suction catheter with return of tracheal secretions confirms that the tube is in proper
position. If you feel resistance or can only get the suction catheter a few inches in then you may
be in a false passage.
DELEGATION

Title NCLEX Tasks

Aide STABLE PATIENTS: Feeding, Positioning,

Bathing, Ambulation, Transferring

Licensed Practical Nurse PATIENTS CAN BE SICK BUT THEY MUST HAVE
PREDICTABLE OUTCOMES: Measurements,
Foley catheters, Sterile Dressings, Heating
blankets/Cooling Pads, Oral suctioning,
Proper Documentation

Registered Nurse PATIENTS ARE UNSTABLE: Crisis situations,

Triage, IVs, Wound Vacs, Trach care,
Evaluating lab results, Assigning patients,
Admissions/Triage, Teach, Proper
Documentation

ReMar Career Reminder: Licensed nurses (RN/PNs) have ultimate accountability for the
management and provision of nursing care, including all delegation decisions.
Most people say don’t delegate what you can’t EAT (Evaluate, Assess, TEACH) but it goes way
deeper than that on NCLEX.
ReMar NCLEX Tips:
1. If patient is unstable in any way DO NOT give to AIDE
2. AIDEs are NOT allowed to make judgement calls
3. It is the responsibility of the nurse to make sure the AIDE is competent in delegated tasks
4. Don’t rely on what you see in the “real world”
5. Nurses are also the supervisors of the aide

The 5 Rights of Delegation are:

1. Right task – The task must meet all of the previously cited criteria and be appropriate to
delegate.
2. Right circumstance – Delegation must be appropriate to the client population and practice
setting.
3. Right person – The nurse must ensure the right task/activity is being delegated to the right
person (UAP) and competence has been validated by an RN.
4. Right communication – The nurse must provide clear, concise instructions for performing the
taskactivity.
5. Right supervision -The nurse must provide appropriate supervision/monitoring, evaluation,
and feedback of the performance of the tasks/ activities.