- Deal with patients rather than with machines.

NCLEX-RN NOTES

TIPS:

• Deal with patients rather than with machines.

- AVOID: never, always, must, “why?”, “I understand”.

• If 2 opposites (e.g. hyper-/hypo-), one is correct.
• Do not leave the patient alone.
• Choose physical over psychological.

- IDK the answer: pick the one with the most information.

ABC (except in emergencies, distress situations & CPR) Assessment vs. Implementation Acute vs. Chronic Stable vs. Unstable Expected vs. Unexpected Real vs. Potential Odd man out

DO NOT DELEGATE (PACET):

• Planning;
• Assessment (initial);
• Collaboration;
• Evaluation;
• Teaching.

 UAP’s cannot be delegated: “EAT”, medication & unstable

patients. LPN’s cannot be delegated anything related with blood and are assigned the most stable patients.

• tsp = 5 ml 1 pint = 2 cups (16 oz)
• tbsp = 3 tsp (15 ml) 1 quart = 2 pints (32 oz)
• oz = 30 ml 1 gr (grain) = 60 mg
• cup = 8 oz 1 kg = 2,2 lbs
• g = 1 ml (diapers) ºF = (ºC x 1,8) + 32

Temperature normal range: 98,6ºF ±1 (37ºC

±0,5)

MAP: (systolic + 2xdyastolic)/3

Normal: 70-105 mmHg (>60 mmHg)

CVP: 2-8 mmHg (CVP can indicate right

ventricular failure or fluid volume overload)

ETHICS & LEGAL ISSUES

• Veracity is truth and is an essential component of a

therapeutic relationship between a health care provider and his patient.

• Beneficence is the duty to do no harm and the duty to do

good. There’s an obligation in patient care to do no harm and an equal obligation to assist the patient.

• Nonmaleficence is the duty to do no harm.

- Tort: litigation in which one person asserts that an injury

(physical, emotional or financial) occurred as a consequence of another’s actions or failure to act.

- Negligence: harm that results because a person didn’t act

reasonably.

- Malpractice: professional negligence.

- Slander: character attacked and uttered in the presence of

others.

- Assault: act in which there is a threat or attempt to do bodily

harm.

- Battery: unauthorized physical contact.

CULTURAL CONSIDERATIONS

• African Americans
• Higher incidence of high blood pressure and obesity;
• High incidence of lactose intolerance.
• Arab Americans
• May remain silent about STIs, substance abuse, and mental

illness;

• After death, the family may want to prepare the body and

autopsy is discouraged unless required by law;

• Use same-sex family members as interpreters.
• Asian Americans
• Believe in the yin/yang “hot-cold” theory of illness;
• Sodium intake is generally high because of salted and dried

foods;

• Usually refuse organ donation;
• May nod without necessarily understanding.
• Latino Americans
• Family members are typically involved in all aspects of

decision making such as terminal illness;

• May see no reason to submit to mammograms or

vaccinations.

• Native Americans
• Diet may be deficient in vitamin D and calcium because many

suffer from lactose intolerance or don’t drink milk;

• Obesity and diabetes are major health concerns.

RELIGIOUS CONSIDERATIONS

- Jehovah’s Witness: no blood products should be used.

- Hindu: no beef or items containing gelatin.

- Jewish: special dietary restrictions, use of kosher foods.

- Adventists: no pork nor alcohol and sometimes no meat.

- Muslims: no pork nor alcohol; people with chronic illnesses

and women that are pregnant, breast-feeding or menstruating don’t fast during Ramadan.

ORDER OF ASSESSMENT:

Inspection Palpation Percussion Auscultation

ABO BLOOD TYPE COMPATIBILITY

Blood Type Can receive from: Can donate to:

O O O, A, B, AB

A A, O A, AB

B B, O B, AB

AB O, A, B, AB AB

Abdomen:

1º Inspection 2º Auscultation 3º Percussion 4º Palpation @NursingTestsBank

TRACTIONS

- Buck’s traction: knee immobility

- Russell traction: femur or lower leg

- Dunlap traction: skeletal or skin

- Bryant’s traction: children <3y, <35 lbs with femur fracture.

INFANT’S DEVELOPMENT:

2-3 months: turns head side to side

4-5 months: grasps, switch & roll

6-7 months: sit at 6 and waves bye-bye

8-9 months: stands straight at eight

10-11 months: belly to butt (phrase has 10 letters)

12-13 months: twelve and up, drink from a cup

ERIKSON’S STAGES OF PSYCHOSOCIAL DEVELOPMENT

BURNS

Parkland formula:

4ml/kg/%body burned

- 1st 8h: ½ total volume

• 2

nd

/ 8h: ¼ total volume

• 3

rd

8h: ¼ total volume

CRANIAL NERVES (Sensory=S |Motor=M |Both=B)

Cranial nerve What it controls I Olfactory Smell test II Optic Visual acuity and visual fields III Oculomotor Pupil constriction and extraocular movements IV Trochlear

Extraocular movements: inferior

adduction V Trigeminal Clench teeth and light touch VI Abducens

Extraocular movements: lateral

abduction

VII Facial Facial movement: close eyes, smile

VIII Auditory Hearing and Romberg test IX Glossopharyngeal Gag reflex X Vagus Say “ah” – uvular and palate movement XI Accessory Turn head and lift shoulders to resistance XII Hypoglossal Stick out tongue

PPE (Personal Protective Equipment)

TRANSMISSION-BASED PRECAUTIONS

Hepatitis transmission:

Consonants (B, C, D):

• Blood and body fluids.

Vowals (A, E):

• Fecal and oral.

Airborne: MTV

Measles TB Varicella (Chicken Pox/Herpes Zoster-Shingles)

AGE STAGES CHARACTERISTICS

Infancy (0-18m) Trust vs.Mistrust Development of trust based on caregivers Early childhood (18m-3yrs) Autonomy vs.Shame & doubt Development of sense of personal control Preschool (3-5yrs) Initiative vs.Guilt Development of sense of purpose and directive School age (6- 11yrs) Industry vs.Inferiority Development of pride in accomplishments Adolescence (12-18yrs) Identity vs.Role confusion Exploration of independence and development of self Early adulthood (18- 40yrs) Intimacy vs.Isolation Development of personal relationships and love Adulthood (40- 65yrs) Generativity vs. Stagnation Fulfilling goals and building career and family Older adult (>65yrs) Integrity vs.Despair Looking back on life with acceptance Oh (Olfactory I) Oh (Optic II) Oh (Oculomotor III) To (Trochlear IV) Touch (Trigeminal V) And (Abducens VI) Feel (Facial VII) A (Auditory VIII) Girls (Glossopharyngeal IX) Vagina (Vagus X) And (Accessory XI) Hymen (Hypoglossal XII) Some Say Marry Money But My Brother Says Big Bras Matter More Don PPE Remove PPE

• Hand hygiene
• Gown
• Mask
• Goggles
• Gloves
• Gloves
• Goggles
• Gown
• Mask
• Hand hygiene

@NursingTestsBank

Droplet: SPIDERMAN

Sepsis Scarlet fever Streptococcal pharyngitis Parvovirus B19 Pneumonia Pertussis Influenza Diphtheria (pharyngeal) Epiglottitis Rubella Mumps Meningitis Mycoplasma or meningeal pneumonia A(n)denovirus

Contact: MRS.WEE

Multidrug resistant organisms Respiratory infection Skin infections (*VCHIPS) Wound infection Enteric infection (C. difficile) Eye infection (conjunctivitis)

LABORATORY VALUES

- BUN: 5-20 mg/dL

- Creatinine: 0.6-1.3 mg/dL

- Creatinine clearance: 90-130 ml/min

- Total cholesterol: 140-199 mg/dL

- HDL: 30-70 mg/dL

- LDL: <130 mg/dL

- Triglycerides: <200 mg/dL

- Protein: 6-8 g/dL

- Albumin: 3.4-5 g/dL

- Alanine aminotransferase (ALT): 10-40 units/L

- Aspartate aminotransferase (AST): 10-30 units/L

- Total Bilirubin: <1.5 mg/dL

- Uric acid: 3.5—7.5 mg/dL

- CPK: 21-232 U/L

- Glucose: 70-110 mg/dL

- Hemoglobin A1c:

4%-5.9%: nondiabetic

<7%: good diabetic control

7% to 8%: fair diabetic control

>8%: poor diabetic control

- Hemoglobin:

Female: 12-15 g/dL

Male: 14-16.5 g/dL

- Hematocrit:

Female: 35%-47%

Male: 42%-52%

- Platelets: 150,000-400,000 cells/mm3

- aPTT:

20-36 sec, depending on testing method

Therapeutic (Heparin): 46-70 seconds

- Prothrombin time (PT): 9.5-11.8 sec

- International Normalized Ratio (INR):

2-3: standard warfarin therapy

3-4.5: high-dose warfarin therapy

- Erythrocytes (RBC): 4.5-5.0 million/L

- Leucocytes (WBC): 4,500-11,000 cells/mm3 (Neutropenia

<1000/mm 3

/ Severe neutropenia: <500/mm

3 )

- Neutrophils: 1800-7800 cells/mm3

- Lymphocytes: 1000-4800 cells/mm3

- Potassium: 3.5-5.0 mEq/L

- Sodium: 135-145 mEq/L

- Chloride: 98-107 mEq/L

- Phosphate: 2.5-4.5 mg/dL

- Magnesium: 1.6-2.6 mg/dL

- Phosphorus: 2.7-4.5 mg/dL

- Calcium: 8.6-10 mg/dL

- Digoxin: 0.8—2.0 ng/ml

- Lithium: 0.8—1.5 mEq/L

- Phenytoin: 10—20 mcg/dL

- Theophylline (Aminophylline): 10—20 mcg/dL

ABG VALUES & EVALUATION

- pH: 7.35—7.45

- HCO3: 24—26 mEq/L

- CO2: 35—45 mEq/L

- PaO2: 80%—100%

- SaO2: >95%

HYPOKALEMIA

Causes:

“Your body is trying to DITCH potassium” Drugs (laxatives, diuretics, corticosteroids) Inadequate consumption of K (NPO, anorexia).Too much water intake (dilutes the K).Cushing’s syndrome (the adrenal glands produce excessive amounts of aldosterone).Heavy fluid loss (NG suction, vomiting, diarrhea, wound drainage, excessive diaphoresis).

Signs & Symptoms:

Everything is going to be SLOW and LOW.

• Weak pulses (irregular and thread).
• Orthostatic hypotension.
• Shallow respirations with diminished breath sounds.
• Confusion and weakness.
• Flaccid paralysis.
• Decrease deep tendon reflexes.
• Decreased bowel sounds.

Varicella zoster Cutaneous diphtheria Herpes simplex Impetigo Pediculosis Scabies ROME Respiratory – Opposite Metabolic – Equal @NursingTestsBank

HYPERKALEMIA

Causes:

“The body CARED too much about potassium” Cellular movement of K from intracellular to extracellular (burns, tissue damages, acidosis).Adrenal insufficiency with Addison’s Disease.Renal failure.Excessive K intake.Drugs (K-sparing like spironolactone, triamterene, ACE inhibitors, NSAIDS).

Signs & Symptoms (MURDER):

Muscle weakness.Urine production little or none (renal failure).Respiratory failure.Decreased cardiac contractility (weak pulse, low BP).Early signs of muscle twitches/cramp…Late profound weakness, flaccidity.Rhythm changes.

HYPOCALCEMIA

Causes (LOW CALCIUM):

Low parathyroid hormone due (any neck surgery: check the Ca

level).Oral intake inadequate (alcoholism, bulimia etc.).Wound drainage (especially GI system).Celiac’s & Crohn’s disease (malabsorption of Ca).Acute pancreatitis.Low vitamin D levels.Chronic kidney issues (excessive excretion).Increased phosphorus levels in the blood.Using certain medications (Ma supplements, laxatives, loop diuretics, Ca binder drugs).Mobility issues.

Signs & Symptoms (CRAMPS):

Confusion.

Reflexes: hyperactive.

Arrhythmias.Muscle spasms in calves or feet, tetany, seizures.Positive Trousseau’s (happens before Chvostek’s sign and tetany).Signs of Chvostek’s.

HYPERCALCEMIA

Causes (HIGH CAL):

Hyperparathyroidism (++ Ca released in the blood).Increased intake of Ca.Glucocorticoids (suppresses Ca absorption).Hyperthyroidism.Calcium excretion decreased (Diuretics, renal failure, bone cancer).Adrenal insufficiency (Addison’s disease).Lithium usage (affects the parathyroid gland).

Signs & Symptoms:

“The body is too WEAK” Weakness of muscles (profound).EKG changes.Absent reflexes & minded (disorientated), Abdominal distention from constipation.Kidney stone formation.

HYPONATREMIA

Causes (NO Na):

Na excretion increased (renal problems, NG suction, vomiting, diuretics, sweating, diarrhea, secretion of aldosterone).Overload of fluid (congestive heart failure, hypotonic fluids infusions, renal failure).Na intake low (low salt diets or NPO).Antidiuretic hormone over secretion (SIADH).

Signs & Symptoms (SALT LOSS):

Seizures & Stupor.Abdominal cramping, Attitude changes (confusion).Lethargic.Tendon reflexes diminished, Trouble concentrating (confused).Loss of urine and appetite.Orthostatic hypotension, Overactive bowel sounds.Shallow respirations (due to skeletal muscle weakness).Spasms of muscles.

HYPERNATREMIA

Causes (HIGH SALT):

Hyperventilation, Hypercortisolism (Cushing’s syndrome).Increased intake of sodium (oral or IV).GI feeding (tube) without adequate water supplements.Hypertonic solutions.Sodium excretion decreased and corticosteroids.Aldosterone insufficiency.Loss of fluids, infection (fever), diaphoresis, diarrhea, and diabetes insipidus).Thirst impairment.

Signs & Symptoms:

“No FRIED foods for you!” Fever, Flushed skin.Restless, Really agitated.Increased fluid retention.Edema, Extremely confused.Decreased urine output, Dry mouth/skin.

HYPOPHOSPHATEMIA

Causes (Low PHOSPHATE):

Pharmacy (aluminum hydroxide-based or magnesium-based antacids cause malabsorption in the GI system).Hyperparathyroidism (there is an over secretion of PTH which causes phosphate to not be reabsorbed).Oncogenic osteomalacia.

Syndrome of Refeeding: causes electrolytes and fluid problems

due to malnutrition or starvation (watch for per os after TPN).Pulmonary issues such as respiratory alkalosis.@NursingTestsBank