HESI Hints NCLEX Gems

HESI Hints & NCLEX Gems

• 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, + Trousseau’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

•

• Antidotes O2 Sat 95-100%

• 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