NCLEX-RN Study Guide

Question Answer
General Rule for Delegation DO NOT delegate what you can EAT!E – evaluateA – assessT – teach
Addison's vs Cushings Addisons= down, down down up downCushings= up up up down up Addisons= HypoNatremia, Hypotension, Decreased Blood Vol, HyperKalemia, HypoGlycemiaCushings= HyperNatremia, Hypertension, Incrased Blood Vol, HypoKalemia, HyperGlycemia
Addisonian Crisis Very Low BP & Coma
Addrenal Insufficiency Decreased Steroid(Primarily Cortisol) Hormones [Pituitary Tumor]
Administering K in association with urine output No Pee, no K (do not give potassium without adequate urine output)
Ele"V"ate "V"eins&d"A"ngle "A"rteries for better perfusion
APGAR A= appearance (color all pink, pink and blue, blue [pale])P= pulse (>100, < 100, absent)G= grimace (cough, grimace, no response)A= activity (flexed, flaccid, limp)R= respirations (strong cry, weak cry, absent)When is it Done?Interpret Score? APGAR done at 1 minute after birth then repeated 5 minutes after birth>/= 7 Normal4-6 Fairly Low<3 Critically Low
AIRBORNE Precaution 1. Private Room2. Negative pressure with 6-12 air exchanges/hr3. Mask/N95 for TB(My Chicken Hez TB or MTV) "My Chicken Hez TB"My – MeaslesChicken – Chicken Pox/VaricellaHez – Herpez Zoster/ShinglesTBor remember…"MTV=Airborne"MeaslesTBVaricella-Chicken Pox/Herpes Zoster-Shingles
DROPLET Precaution Private Room or cohortMask(SPIDERMAN) S – sepsis,scarlet fever, strep. pharyngitisP – parvovirus B19,pneumonia, pertussisI – influenzaD – diptheria (pharyngeal)E – epiglottitisR – rubellaM – mumps, meningitis, mycoplasma or meningeal pneumoniaAn – Adenovirus
Measles Rubeola: Fever, Cough, Coryza (Cold), Conjunctivitis, Maculopapular Rash Koplik's Spot: Whitish spots opposite the 2nd Upper Molars, that appear 2 days prior to rash)
Scarlet Fever Due to Strep. PyogenesChildren Age:?Physical Findings:? 4-8 yr oldStrawberry TongueSore ThroatFeverForchheimer Spots (Red spots on soft palate)Rash (looks as if sunburn with goosebumps (textured))
Streptococcal Pharyngitis FeverSore throatEnlarged Lymph NodesPus on tonsils
Parvovirus B19 Slapped Cheek5th DiseaseChronic Anemia (infects Bone Marrow)
Pertussis Due to Bordetella PertussisWhooping CoughTx: Antibiotics
Diptheria (pharyngeal) Due to Corynebacterium diphtheriaeBullneck
Epiglottitis Due to H. Influenza type B Airway EmergencyCherry Red EpiglottitisDroolingInspiratory StridorTripod position Have Resuscitation and Intubation equipment ready; otherwise do not attempt to visualize posterior pharynx to prevent spasms Tripod Position:(sitting supporting self with hands, chin forward and neck hyperextended as if sniffing)
German Measles Due to Rubella (3 day measles)
Mumps Contagious 6 days before onset up to 9 days after symptoms start
Meningitis FeverNeck StiffnessPhotophobiaAltered mental statusseizures Neck StiffnessKernig Sign: extending knee causes painBrudzinski: Flexinf neck while patient is laying supine causes hip and knee to flex
Mycoplasma Walking Pneumonia
Adenovirus Upper Respiratory Infection
Mneumonic for Contact Precaution MRS.WEE "MRS. WEE"M – multidrug resistant organismR – respiratory infectionS – skin infections *W – wound infxnE – enteric infxn – clostridium difficileE – eye infxn – conjunctivitis
Mnemonic for Skin Infections (Contact Precaution) VCHIPS "VCHIPS"V – varicella zosterC – cutaneous diphtheriaH – herpez simplexI – impetigoP – pediculosisS – scabies
Positioning for Air/Pulmonary Embolism Chest painDifficulty breathingTachycardiaPale/cyanoticSense of impending doom–> Turn pt to LEFT SIDE and LOWER the HEAD of the BED (HOB).
Positioning for Woman in Labor w/ Un-reassuring FHR (late decels, decreased variability, fetalbradycardia, etc) –> turn on LEFT SIDE (and give O2, stop Pitocin, increase IV fluids)
Positioning for Tube Feeding w/ Decreased LOC –> position pt on RIGHT SIDE (promotes emptying of thestomach) with the HOB elevated (to prevent aspiration)
Positioning for During Epidural Puncture –> side-lying
Positioning for After Lumbar Puncture (and also oil-based Myelogram) –> pt lies in flat supine (to prevent headache and leaking of CSF)
Positioning for Pt w/ Heat Stroke –> lie FLAT w/ legs elevated
Positioning for During Continuous Bladder Irrigation (CBI) –> catheter is taped to thigh so leg should bekept straight. No other positioning restrictions.
Positioning for After Myringotomy –> position on side of affected ear after surgery (allows drainage ofsecretions)
Positioning for After Cataract Surgery –> pt will sleep on unaffected side with a night shield for 1-4weeks.
Positioning for After Thyroidectomy –> low or semi-Fowler's, support head, neck and shoulders.
Positioning for Infant w/ Spina Bifida –> position prone (on abdomen) so that sac does not rupture
Positioning for Buck's Traction (skin traction) –> elevate foot of bed for counter-traction
Positioning for After Total Hip Replacement –> don't sleep on operated side, don't flex hip more than 45-60 degrees, don't elevate HOB more than 45 degrees. Maintain hip abduction by separating thighs with pillows.
Positioning for Prolapsed Cord –> knee-chest position or Trendelenburg
Positioning for Infant w/ Cleft Lip –> position on back or in infant seat to prevent trauma to suture line.While feeding, hold in upright position.
Positioning for Prevention of Dumping Syndrome (post-operative ulcer/stomach surgeries) –> eat in reclining position, lie down after meals for 20-30 minutes (also restrict fluids during meals, low CHO and fiber diet, small frequent meals)
Positioning for Above Knee Amputation –> elevate for first 24 hours on pillow, position prone daily to provide for hip extension.
Positioning for Below Knee Amputation –> foot of bed elevated for first 24 hours, position prone daily to provide for hip extension.
Positioning for Detached Retina –> area of detachment should be in the dependent position
Positioning for Administration of Enema –> position pt in left side-lying (Sim's) with knee flexed
Positioning After Supratentorial Surgery (incision behind hairline) –> elevate HOB 30-45 degrees
Positioning for After Infratentorial Surgery (incision at nape of neck) –> position pt FLAT and LATERAL on either side.
Positioning for During Internal Radiation –> on bedrest while implant in place
Positioning for Autonomic Dysreflexia/Hyperreflexia Autonomic Dysreflexia: (S&S: Pounding headachProfuse sweatingNasalCongestionGoose fleshBradycardiaHypertension) –> place client in SITTING POSITION (elevate HOB) first before any other implementation.
Positioning for Shock –> bedrest with extremities elevated 20 degrees, knees straight, head slightlyelevated(MODIFIED TRENDELENBURG)
Positioning for Head Injury –> elevate HOB 30 degrees to decrease intracranial pressure
What to do in cases of Peritoneal Dialysis when Outflow is Inadequate –> turn pt from side to side BEFORE checking for kinks in tubing (according to Kaplan)
Positioning for Lumbar puncture –> AFTER the procedure, the client should be placed in the supine position for 4 to 12 hrs as prescribed. (Saunders 4th ed p. 1023)
Pain Medication for Pancreatitis Demorol for pancreatitis, NOT morphine sulfate
Myasthenia Gravis Autoantibodies attack Acetylcholine receptors. Progressive weakness that worsens with exercise and improves with rest. a positive reaction to Edrophonium(Tensilon) Test–will improve symptoms
Myasthenia Crisis: MG causes life-threatening respiratory muscle weakness.
Cholinergic Crisis: caused by excessive medication-stop med-giving. Edrophonium (Tensilon) will make it worse!
Head injury medication: Mannitol (osmotic diuretic)-crystallizes at room temp so ALWAYS use filter needle
How does diarrhea/vomit affect acid/base balance? From the "ASS" (diarrhea)= metabolic "ASS"idosisFrom the mouth (vomitus)= metabolic alkalosis
Prior to a liver biospy its important to be aware of the lab result? Prothrombin time
Myxedema/ Hypothyroidism Slowed physical and mental function, sensitivity to cold, dry skin and hair Tx: (give missing hormone) Levothyroxine (T4), Triiodothyronine (T3)
Graves’ disease/Hyperthyroidism Accelerated physical and mental function; sensitivity toheat, fine/soft hairWhats the treatment? Tx: PTU – inhibits the synthesis of new thyroid hormone!
Thyroid storm: Increased Temp, Pulse and HTNWhat's the Treatment? Tx: Beta-Blockers and PTU
Positioning of Pt Post-thyroidectomy Semi-Fowler’s, prevent ncek flexion/hyperextension, trach at bedside
Hypo-Parathyroidism CATS – ConvulsionsArrhythmiasTetanySpasms & Stridor (Decreased Calcium)What is the Diet? Diet: High Ca, Low phosphorus diet
Hyper-parathyroidism FatigueMuscle weaknessRenal calculiBack and joint pain (Increased Calcium)What is the Diet? Diet:low Ca, high phosphorus diet
Hypovolemia Increased tempRapid/weak pulseIncrease respiration, HypotensionAnxiety,Urine specific gravity >1.030
Hypervolemia Bounding pulseSOBDyspneaRares/cracklesPeripheral edemaHTNUrineSpecific gravity <1.010; Position: Semi-Fowler’s
Diabetes Insipidus LOW ADH –> excessive urine output, thirst, dehydration,weaknessWhat do you give? Administer Pitressin (Vaso"pressin" another name for ADH. Comes from the "Pit"uitary Gland)
SIADH TOO MUCH ADH!change in mental status (convulsions/coma), decreased deep tendon reflexes, tachycardia, n/vheadacheWhat is the treatment? Administer DeclomycinDiureticsFluid Restriction
Hypokalemia: Muscle weaknessDysrhythmiasIncrease K intake with foods such as: Raisins, bananas, apricots, oranges,beans, potatoes, carrots, celery
Hyperkalemia "MURDER"Muscle weaknessUrine (oliguria/anuria)Respiratory depressionDecreased cardiac contractilityEKG changesReflexes EKG:Peaked t wavesWide QRS complex Prolonged PR interval Then Asystole –> Dead
Hyponatremia NauseaMuscle cramps and twitchingIncreased ICPConvulsionTx: Osmotic diuretics, fluids Osmotic diuretics get rid of only water without losing Na+.
Hypernatremia Increased tempWeakness, Disorientation/delusions, HypotensionTachycardiaTx: Hypotonic solution
Hypocalcemia "CATS" ConvulsionsArrhythmiasTetanySpasms and stridor
Hypercalcemia Muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, sedative effect on CNS
HypoMg Tremors, tetany, seizures, dyrshythmias, depression, confusion, dysphagia; dig toxicity
HyperMg Depresses the CNS, hypotension, facial flushing, muscle ewakness, absent deeptendon reflexes, shallow respirations, emergency
Addison’s Disease HypoNa+, HyperK+, Hypoglycemia, Dark pigmentation, decreased resistance to stress,fractures, alopecia, weight loss, GI distress Primary Adrenal insufficiency -> Low Aldosterone and Cortisol; Normally, Aldosterone increases serum Na and decreases serum K; Cortisol (stress hormone) increases blood sugar (energy during fight or flight) Increased melanin causes skin color
Cushing's Disease Truncal Obesity, Moonface/buffalo hump, Muscle wasting, Weakness, Edema, HTN, Hirsutism, HyperNa, HypoK, Hyperglycemia, Prone to Infection, Too much Aldosterone and Cortisol! Opposite of Addisons.
Addisonian crisis n/v, confusion, abdominal pain, extreme weakness, hypoglycemia,dehydration, decreased BP
Pheochromocytoma Hypersecretion of Epi and Norepinephrine (NE): Persistent HTN, Increased HR,Hyperglycemia, Diaphoresis, Tremor, Pounding HAWhat is the management? Avoid stress Frequent bating and rest breaksAvoid cold and stimulating foodsSurgery to remove tumor
Neuroleptic malignant syndrome (NMS) -NMS is like S&M;-you get hot (hyperpyrexia)-stiff (increased muscle tone)-sweaty (diaphoresis)-BP, pulse, and respirations go up &-you start to drool
Which measles is bad for pregnant mother, measles or German measles? German Measles (Rubella)Never get pregnant with a german!
When drawing up regular insulin & NPH together, you need to remember: RN ("R"egular Insulin comes before "N"PH)
Tetralogy of Fallot Pulmonary stenosisRight Ventricular HypertrophyOverriding aortaVentricular Septal Defect Tet spell: Cyanotic –> passoutChild learns to drops to floor or squats to the ground to push blood through the stenotic valve.
MAOi Antidepressants"PANAMA"PA – parnateNA – nardilMA – marplan Toxicity: Hypertensive Crisis, triggered when consuming foods high in tyramine (wine and aged cheeses)
Autonomic dysreflexia Life threatening emergency- elevate head of bed to 90 degree- loosen constrictive clothing- Assess for bladder distention and bowel impaction (triger)- Antihypertensive meds (may cause stroke, MI, seisure)- metallic bitter taste.
What should be done before giving Digoxin? Use for CHF- Causes the heart to contract harder but at a slower rate. Check pulse, less than 60 hold, check dig levels and potassium levels.
Amphogel Antacid-Aluminum Hydroxide: Tx of GERD/PUD and Kidney stones….watch out for contipation.
Vistaril tx of anxiety and also itching…watch for dry mouth. given pre-op commonlyvs given for conscious sedation…watch for resp depression and hypotension
PTU and Tapazole For the Prevention of Thyroid Storm
Sinemet (Combo drug of Carbidopa-Levodopa) Tx of parkinson…sweat, saliva, urine may turn reddish brown occassionally…causes drowsiness
Artane tx of parkinson..sedative effect also
Cogentin tx of parkinson and for extrapyramidal effects of other drugs
Tigan tx of post-op n/v and for nausea associated with gastroenteritis
Timolol (Timoptic) tx of gluacoma
Bactrim (Sulfamethoxazole-Trimethoprim) antibiotic..dont take if allergic to sulfa drugs…diarrhea common side effect…drink plenty of fluids
Gout Meds Probenecid (Benemid) Colchicine -> acute flare upAllopurinol (Zyloprim)-> use "ALL" the time for prevention
Apresoline(hydralazine) tx of HTN or CHF Report flu-like symptoms, rise slowly from sitting/lying position; take with meals.
Bentyl tx of irritable bowel….assess for anticholinergic side effects
What are Anticholinergic Side Effects? ABCD'S:AnorexiaBlurry visionConstipation/ConfusionDry MouthSedation/Stasis of urine
CALan (verapamil) CALcium channel blocker: tx of HTN, angina…assess for constipation
Carafate (Sucralfate) tx of duodenal ulcers..coats the ulcer…so take before meals
Theophylline tx of asthma or COPD..therap drug level: 10-20
Mucomyst (N-acetylcysteine) Antedote to tylenol overdose and is administered orally
Diamox (Acetazolamide) Tx of glaucoma, high altitude sickness…dont take if allergic to sulfa drugs mechanism of action: Secretes Bicarbonate (basic form of CO2) through the kidney. Acidifies the Serum.
Indocin (Indomethacin) (NSAID) Tx of arthritis (osteo, rhematoid, gouty), bursitis, and tendonitis.
Synthroid (Levothyroxine) (T4 analog) tx of hypothyroidism..may take several weeks to take effect…notify doctor of chest pain..take in the AM on empty stomach..could cause hyperthyroidism.
Librium A Benzodiazepine. Tx of alcohol w/d…dont take alchol with this…very bad nausea and vomiting can occur.
Oncovin Tx of leukemia..given IV ONLY
Kwell Tx of scabies and lice…(scabies)apply lotion once and leave on for 8-12 hours…(lice) use the shampoo and leave on for 4 minutes with hair uncovered then rinse with warm water and comb with a fine tooth comb
Premarin (Estrogen) tx after menopause estrogen replacement
Dilantin (Phenytoin) tx of seizures. thera drug level: 10-20
Navane tx of schizophrenia..assess for EPS
Ritalin tx of ADHD..assess for heart related side effects report immediately…child may need a drug holiday b/c it stunts growth.
Dopamine (Intropine) tx of hypotension, shock, low cardiac output, poor perfusion to vital organs…monitor EKG for arrhythmias, monitor BP
Mneumonic for FHR (fetal heart rate) patterns "VEAL CHOP"VC=?EH=?AO=?LP=? V = variable decels; C = cord compression causedE = early decels; H = head compression causedA = accels; O = okay, not a problem!L = late decels = placental insufficiency, can't fill
Positioning for Cord Compression Place the mother in the TRENDELENBERG position because this removes pressure of the presenting part off the cord. WHY? If the mother's head is down, the baby is no longer being pulled out of the body by gravity
What to do in case of cord prolapse? Cover the cord with sterile saline gauze to prevent drying of the cord and to minimize infection.
Positioning for late decelerations turn the mother to her left side, to allow more blood flow to the placenta.
What should you always give for any kind of bad fetal heart rate pattern OXYGEN often by mask
A priority prior to administering epidural anesthesia Hydration before hand is a priority. WHY? Hypotension and Bradypnea / Bradycardia are major risks and emergencies.
True or False: When you check on a high risk pregnant patient, you should make sure to check the monitor for vital signs before accessing the patient. FALSE! Always assess the patient first; Ex: 1st Listen for fetal heart tones/rate with your stethoscope in NCLEX land. Sometimes it's hard to tell who to check on first, the mother or the baby. If a machine is involved who should you check? it's usually easy to tell the right answer… who is the machine for the mother or baby. If you're not sure who to check first, and one of the choices involves checking the machine, that's the wrong answer.
If the baby is in posterior presentation where can you appreciate the fetal heart sounds? The fetal heart sounds are heard best at the sides
If the baby is anterior where would you appreciate the fetal heart sounds?, The fetal heart sounds are best heard closer to midline, between the umbilicus and where you would listen to a posterior presentation.
If the baby is breech presentation, the sounds are heard where? High up in the fundus near the umbilicus.
If the baby is vertex presentation where can the sounds be heart? Slightly above the symphysis pubis
High Pressure Alarm vs Low Pressure Alarm on ventalators "HOLD"High Pressure Alarm:Obstruction- due to increased secretions or decreeased size airway, kink, pt. coughs, gag or bites Low Pressure Alarm:Disconnection or leak in ventilatior or in pt. airway cuff, pt. stops spontaneous breathing
Blood Glucose Level S/S Hot and Dry-sugar high (hyperglycemia)Cold and Clammy-need some candy (hypoglycemia)
ICP AND SHOCK HAVE OPPOSITE Vital Signs ICP- Increased BP, Decreased Pulse, Decreased Respiratory Rate Shock- Decreased BP, Increased Pulse, Increased Respiratory Rate
Cor Pulmonale right sided heart failure caused by left ventricular failure (so pick edema or jvd, if it is a choice)
Herion Withdrawal in a Neonate irratable poor sucking
Jewish Diet No meat and milk together
Brachial pulse Pulse area CPR on an infant.
Test child for lead poisioning around what? 12 months
Good source of potassium Bananas, potatoes, citrus fruits source of potassium
When should specimens for Culture and Sensitivity be take? Specimen for cultures are obtained before starting IV antibiotics
Cause of epistaxis in Leukemia? Low Platelet CountWhat is normal platelet count? 150,000 – 400,000
Best way to warm a newborn: skin to skin contact covered with a blanket on mom.
What should you do first if a pt comes in and she is in active labor? nurse first action is to listen to fetal hearttone/rate
How to treat phobic disorders Systematic desensitization

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