Answering NCLEX Questions

HESI Hints & NCLEX Gems

• Answering NCLEX Questions

• Maslow’s Hierarchy of Needs

• Physiologic • Safety • Love and Belonging • Esteem • Self-actualization

• Nursing Process

• Assessment • Diagnosis (Analysis) • Planning • Implementation (treatment) • Evaluation

• ABCs

• Airway • Breathing • Circulation

• Normal Values

• Hgb

• Males 14-18 • Females 12-16

• Hct

• Males 42-52 • Females 37-47

• RBCs

• Males 4.7-6.1 million • Females 4.2-5.4 million

• WBCs

• 4.5-11k

• Platelets

• 150-400k

• PT (Coumadin/Warfarin)

• 11-12.5 sec (INR and PT TR = 1.5-2 times normal)

• APTT (Heparin)

• 60-70 sec (APTT and PTT TR = 1.5-2.5 times normal)

• BUN 10-20
• Creatinine 0.5-1.2
• Glucose 70-110
• Cholesterol < 200
• Bilirubin Newborn 1-12
• Phenylalanine Newborn < 2, Adult < 6

• Na+ 136-145
• K+ 3.5-5

• HypoK+ . . . Prominent U waves, Depressed ST segment, Flat T waves • HyperK+ . . . Tall T-Waves, Prolonged PR interval, wide QRS

• Ca++ 9-10.5

• Hypocalcemia … muscle spasms, convulsions, cramps/tetany, + T rousseau’s, + Chvostek’s, prolonged ST interval, prolonged QT segment

• Mg+ 1.5-2.5
• Cl- 96-106
• Phos 3-4.5
• Albumin 3.5-5
• Spec Gravity 1.005-1.030

o Glycosylated Hemoglobin (Hgb A1c): 4-6% ideal, < 7.5% = OK (120 days)

• Dilantin TR = 10-20
• Lithium TR = 0.5-1.5
• Arterial Blood Gases … Used for Acidosis vs. Alkalosis

• PH 7.35-7.45

• CO2 35-45 (Respiratory driver) … High = Acidosis • HCO3 21-28 (Metabolic driver) … High = Alkalosis

• O2 80-100

• O2 Sat 95-100%

• Antidotes

• Digoxin … Digiband
• Coumadin … Vitamin K (Keep PT and INR @ 1 -1.5 X normal)
• Benzodiazapines … Flumzaemil (Tomazicon)
• Magnesium Sulfate … Calcium Gluconate?
• Heparin … Protamine Sulfate (Keep APTT and PTT @ 1.5 -2.5 X normal)
• Tylenol … Mucomist (17 doses + loading dose)
• Opiates (narcotic analgesics, heroin, morphine) … Narcan (Naloxone)
• Cholinergic Meds (Myesthenic Bradycardia) … Atropine
• Methotrexate … Leucovorin

• Delegation

• RN Only

• Blood Products (2 RNs must check) • Clotting Factors • Sterile dressing changes and procedures • Assessments that require clinical judgment • Ultimately responsible for all delegated duties

• Unlicensed Assistive Personnel

• Non-sterile procedures

• Precautions & Room Assignments

• Universal (Standard) Precautions … HIV initiated

• Wash hands • Wear Gloves

• Gowns for splashes • Masks and Eye Protection for splashes and droplets • Don’t recap needles • Mouthpiece or Ambu-bag for resuscitation • Refrain from giving care if you have skin lesion

• Droplet (Respiratory) Precautions (Wear Mask)

• Sepsis, Scarlet Fever, Strep, Fifth Disease (Parvo B19), Pertussis, Pneumonia, Influenza, Diptheria, Epiglottitis, Rubella, Rubeola, Meningitis, Mycoplasma, Adenovirus, Rhinovirus • RSV (needs contact precautions too) • TB … Respiratory Isolation

• Contact Precautions = Universal + Goggles, Mask and Gown
• No infection patients with immunosuppressed patients

• Weird Miscellaneous Stuff

• Rifampin (for TB) … Rust/orange/red urine and body fluids
• Pyridium (for bladder infection) … Orange/red/pink urine
• Glasgow Coma Scale … < 8 = coma
• Myesthenia Gravis

• Myesthenic Crisis = Weakness with change in vitals (give more meds) • Cholinergic Crisis = Weakness with no change in vitals (reduce meds)

• Diabetic Coma vs. Insulin Shock … Give glucose first – If no help, give insulin
• Fruity Breath = Diabetic Ketoacidosis
• Acid-Base Balance

• If it comes out of your ass, it’s Acidosis.• Vomiting = Alkalosis

• Skin Tastes Salty = Cystic Fibrosis
• Lipitor (statins) in PMs only – No grapefruit juice
• Stroke … Tongue points toward side of lesion (paralysis), Uvula deviates away

from the side of lesion (paralysis)

• Hold Digoxin if HR < 60
• Stay in bed for 3 hours after first ACE Inhibitor dose
• Avoid Grapefruit juice with Ca++ Channel Blockers
• Anthrax = Multi-vector biohazard
• Pulmonary air embolism prevention = Trendelenburg (HOB down) + on left side

(to trap air in right side of heart)

• Head Trauma and Seizures … Maintain airway = primary concern
• Peptic Ulcers … Feed a Duodenal Ulcer (pain relieved by food) … Starve a gastric

ulcer

• Acute Pancreatitis … Fetal position, Bluish discoloration of flanks (Turner’s Sign),

Bluish discoloration of pericumbelical region (Cullen’s Sign), Board like abdomen with guarding … Self digestion of pancreas by trypsin.

• Hold tube feeding if residual > 100mL
• In case of Fire … RACE and PASS
• Check Restraints every 30 minutes … 2 fingers room underneath
• Gullain-Barre Syndrome … Weakness progresses from legs upward – Resp arrest
• Trough draw = ~30 min before scheduled administration … Peak Draw = 30 -60

min after drug administration.

• Mental Health & Psychiatry

• Most suicides occur after beginning of improvement with increase in energy

levels

• MAOIs … Hypertensive Crisis with Tyramine foods

• Nardil, Marplan, Parnate • Need 2 wk gap from SSRIs and TCAs to admin MAOIs

• Lithium Therapeutic Range = 0.5-1.5
• Phenothiazines (typical antipsychotics) – EPS, Photosensitivity
• Atypical Antipsychotics – work on positive and negative symptoms, less EPS
• Benzos (Ativan, Lorazepam, etc) good for Alcohol withdrawal and Status

Epilepticus

• Antabuse for Alcohol deterrence – Makes you sick with OH intake
• Alcohol Withdrawal = Delerium Tremens – Tachycardia, tachypnea, anxiety,

nausea, shakes, hallucinations, paranoia … (DTs start 12-36 hrs after last drink)

• Opiate (Heroin, Morphine, etc.) Withdrawal = Watery eyes, runny nose, dilated

pupils, NVD, cramps

• Stimulants Withdrawal = Depression, fatigue, anxiety, disturbed sleep

• Medical-Surgical

• Hypoventilation = Acidosis (too much CO2)
• Hyperventilation = Alkalosis (low CO2)
• No BP or IV on side of Mastectomy
• Opiate OD = Pinpoint Pupils
• Lesions of Midbrain = Decerebrate Posturing (Extended elbows, head arched

back)

• Lesions of Cortex = Decorticate Posturing (Flexion of elbows, wrists, fingers,

straight legs, mummy position)

• Urine Output of 30 mL/hr = minimal competency of heart and kidney function
• Kidney Stone = Cholelithiasis

• Flank pain = stone in kidney or upper ureter • Abdominal/scrotal pain = stone in mid/lower ureter or bladder

• Renal Failure … Restrict protein intake

• Fluid and electrolyte problems … Watch for HyperK+ (dizzy, wk, nausea, cramps, arhythmias) • Pre-renal Problem = Interference with renal perfusion • Intra-renal Problem= Damage to renal parenchyma • Post-renal Problem = Obstruction in UT anywhere from tubules to urethral meatus.• Usually 3 phases (Oligouric, Diuretic, Recovery) • Monitor Body Wt and I&Os

• Steroid Effects = Moon face, hyperglycemia, acne, hirsutism, buffalo hump,

mood swings, weight gain – Spindle shape, osteoporosis, adrenal suppression (delayed growth in kids) . . . (Cushing’s Syndrome symptoms)

• Addison’s’ Crisis = medical emergency (vascular collapse, hypoglycemia,