Tag: Assessment

Breast Cancer

Posted on March 1st, by Megan in Uncategorized. No Comments

The most common risk factors for cancer of the breast are family history of breast cancer, age over 50, and nulliparity. When assessing for a mass, signature signs to look for include fixed, painless nodes usually in the upper outer quadrant or near the axilla. Now while all of these facts are great to know about breast cancer, I have found that most NCLEX type questions are derived from the post operative procedures. SO, let me share some tips with you!

Post OP Must Know’s

Position patient in semi fowlers on unaffected side.
Elevate the affected arm above the level of the heart to promote drainage and prevent lymphedema
No IV’s, injections BP measurements on affected side
No carrying heavy items in affected arm (Books, laptop, purse)

Following a mastectomy another biggie NCLEX likes you to assess is the patient’s attitude and self esteem. How they … Read More »

Cleft Palate

Posted on February 4th, by Megan in Uncategorized. No Comments

Both cleft lip and cleft palate are congenital abnormalities that can occur in the womb. Repair surgery is usually done between 6-24 months of age. As far as nursing and NCLEX goes, prepare for assessment and interventions on caring for these types of patients.

Assessment: ability to suck, swallow, breathe, and manipulate secretions without distress.

Interventions: Hold infant in upright position to prevent aspiration. When feeding through bottle, position it into the side and back of the mouth and burp frequently.

After Repair: NO suctioning, thermometer, forks, spoons, pacifiers, straws in the mouth. A soft elbow restraint may be put on the child to prevent site being touched. (Removing the restraints every 2 hours)

Who to assess first?

Posted on December 23rd, by Megan in Uncategorized. No Comments

When your exam decides to throw you a tricky question about which patient you assess first, always remember your ABC nemonic and try to stick to it as close as possible.

A- Airway

B- Breathing

C- Circulation

For example “After receiving report, which patient would you first assess?

1. A 2 year old with decreased pedal pulses with a coarctation of the aorta

2. A 4 year old with rheumatic fever who is complaining of severe knee pain.

3. A 5 year old with endocarditis who has crackles audible throughout both lungs

4. A 12 month old with a strawberry tongue and an increase in temperature.


What did you answer? Carefully go through and ask yourself if any of the answers have to do with the airway of the patient first. If your answer was no, then check Breathing and circulation next. Luckily we got to stop at letter … Read More »


Posted on November 10th, by Megan in Uncategorized. No Comments

A strategy to use in knowing what to do first between assessment or implementation answers with a mom in labor is pretty difficult. Here is what I found to be true.

If a mom comes into the unit saying she is in active labor, the first action here would be to listen to the fetal heart sounds or observe the perineum for progress in dilation.

Once the patient’s water breaks, first check the fetal heart rate.

If there is cord prolapse, IMPLEMENT first. Place the patient in trendelenburg position.