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NCLEX EXAM PREVIEW

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ACLS P

60 terms dad NEVER a Priority Teaching Labs Tests Procedures

Chronic conditions:

Renal Failure Chronic Heart Failure COPD/Emphysema (unless worsening or new complaint of SOB) Pain (unless affecting respiratory effort like incisional pain) ALWAYS a Priority New Admits Immediate Post-Op's Transfers Deteriorating conditions SaO2 less than 90 PaO2 less than 60

Head, face, neck, chest: trauma, burns, or surgery

Altered level of consciousness Homecare client with central line Elevated temp/sore throat in immunosuppressed patients Any cast complaints except itching Any "crisis"

NEVER Delegate New Admits Discharges Post-op's, less than 72 hrs Blood transfusion IV meds Unstable clients Pancreatitis Panic Attacks TURPS Refusing meds (RN only) Initialing anything Sterile procedures to STNA's Nursing process (assess, teaching, evaluate, coach, observe, advise, check recommend, review, monitor, encourage) Delegate Stable clients "Reinforce" (LPN) teaching

Routine tasks: NG, Foley, blood sugar check

Suture removal (LPN) "Remind" (STNA) "Record" (STNA) Best Roomates RAT = Renal, Asthma, Thyroid Mandatory Private Rooms Airbourne Precautions Diarrhea: VRE, C-Diff, Rotavirus, Colitis, stool incontinence, Crohns, food poisoning, gastritis, shigella, "Enteric", Giardiasis, Hepatitis A&E, Dumping Syndrome, Steatorrhea, Pancreatitis, Irritable Bowel Syndrome, Inflammatory Bowel Syndrome, Crypto, Meningitis Immunosuppression No GI or Liver Disease Roomates (DMARDS): Cushings, Addison's, Chemo Radiation, Leukemia/Lymphoma, Multiple Myeloma, Bone marrow & organ transplant, Aplastic Anemia, Grafts, MS, MG, ALS/LG, GB, Lupus, Steroids/DMARDS, RA, AIDS, Asplenia, Burns, Post-op, "penia"

Seizure Precautions PRIVATE Room Dim Lights BL, BO, Side Rails up x 4 & padded Most liver & neuro conditions Pre-Eclampsia Neuroleptic Malignant Syndrome Head injury Autonomic Dysreflexia Severely elevated BP/high fever Hepatic Encephalopathy Pancreatitis Esophageal Varices Cirrhosis Meningitis Alcohol/Drug withdrawal DT's Low sodium, calcium, magnesium, blood sugar Magnesium (Miss)

1.5 - 2.5

Often low with alcohol Phosphorus (Piggy)

2.5 - 4.5

Will kill kidneys if high & ...Potassium (Kermit)

3.5 - 5.3

Watch EKG, GI, kidneys Calcium (Came)

8 - 10

Tetany, Chavosteks, Trousseau if low HCO3 (Home)

22 - 26

(Bicarbonate)

Oxygen (On)

95 - 100

Chloride (Cloud)

95-105

Sodium (Nine)

135 - 145

Hyponatremia = SIADH if low sodium, high potassium Bun & Creatinine

• - 15 & 0.7 - 1.5

Monitor with Lupus Hematocrit & Hemoglobin

Women: 36 & 12

Men and Newborns: higher

If more than 45 & 15 = Dehydration Platelets

150,000 - 300,000

DIC when less than 25,000 Maybe see first if less than 100,000 ROME

Blood pH: 7.35 - 7.45

pCO2: 35 - 45

Blood Sugar

Fasting: Less than 100

Random: 70 - 120

2 hour PP: 140

If any above 200 = Diabetes Mellitus White Blood Cell Count

5,000 - 10,000

If below 1,500 = immunosuppressed If above 10,000 = infection