NCLEX-RN Part 1 Study Guide
When getting down to 2 answers, pick the assessment answer over intervention except in an emergency or distress situation.Assessment (Assess, Collect, Auscultate, Monitor, Palpate)
If one answer has an absolute discard it; these suggest a false response and imply there are no exceptions.Absolute (always, all, everyone, never, none, only, every, must)
If you can only do one thing to help this patientpick the most important intervention
Choose the answer that includes all the others in it; all other choices fall under it"Umbrella effect"
If 2 of the answers are the exact oppositeone is probably the answer
Do not delegate what you can EAT or PACETPlan, Asses (primary/initial), Collaborate (with RT, OT, PT, ECT), Evaluate (for trends), Teach
IV meds and unstable patientsCannot be delegated to an Unlicensed Assistive Personnel
LPN/LVPcannot handle blood
Antidote for Coumadin overdose (bleeding, black tarry stool, vomiting blood, vision or speech changes, severe headache)Vitamin K
Antidote for Heparin overdose (vomiting, hives, trouble breathing, swelling of face, lips, tongue, or feeling like you might pass out)Protamine Sulfate
Antidote for Magnesium Sulfate (Mg So4) overdose (difficulty breathing, muscle weakness, mental confusion)Calcium Gluconate (Ca Glu)
Antidote for Acetominophen overdose (abdominal pain, yellowing of the skin and eyes, irritability)Mucomyst (Acetylcysteine)
Antidote for TPA (Alteplase) overdose (chest tightness, severe stomach pain)Amicar (Aminocaproic acid)
Lactulose toxicity (severe or ongoing diarrhea)Ammonia
Acetaminophen toxicity (does not manifest for 24 - 48 hours: right upper quadrant abdominal pain or tenderness, oliguria)n-Acetylcysteine
Better psychosocial nursing responsesFocus on feelings, reflect the client's comments, communicate acceptance by the nurse rather than criticism or judgment, acknowledge the client, stay in the here and now
Eliminate the response that may be the best for a physician to makeLook for the RN role-appropriate psychosocial response; psychiatrists analyze the past, and nurses in general focus on present feelings and situations
- rights of medication administrationRight medication, right route, right client, right
dosage, right time
Think safety as the best choice when more than one answer could be right.Safety is a priority
I will call the doctor if...unexplained weight loss or gain; to clarify an order; severe side effects of a medication or signs of drug toxicity, critical side effects, or side effects are extremely unusual
Therapeutic communicationDon't ask why questions, don't patronize or compare to someone else, mirror or paraphrase what is said to keep conversation open-ended, assess the need of the caregiver, include client and caregiver whenever possible
Multidisciplinary teamworkCommunication (always 1st), Collaboration (not time to delegate), shared responsibility.
RN scope of practiceClinical assessment, initial education, discharge education, clinical judgment, initiating blood transfusion, psychosocial support
LPN/LVN scope of practice: Monitoring RN findings, reinforcing education, routine procedures,most medication administration, ostomy care, tube patency and enteral feedings, specific assessements
UAP scope of practiceADLs, hygiene, linen changes, routine stable vitals, documenting I&O, positioning
It's all about safety when assigning patients to a float nurse from another unit:Stable patients who require basic pain, peripheral, and neurovascular assessments they can handle in their unit.
G - Gravidanumber of times a woman has been pregnant
T - TermTerm pregnancies (delivered after 37 weeks)
P - Preterm pregnancyDelivered between beginning of 20 weeks and end of 37 weeks
A - AbortionSpontaneous or elective (termination of pregnancy prior to beginning of 20 weeks)
L - LivingChildren currently living
M -Multiple gestations (births)
1st level of priority in prioritization of careAirway, breathing, circulation & cardiac (cardiac becomes 1st priority in cardiac arrest), vitals
2nd level of priority in prioritization of careAltered LOC, acute pain, untreated medical problems, chronic pain, acute elimination issues, abnormal labs, risk for infection, safety
Formula for weight loss:
3500 calories = 1 pound3500 X (pounds you want to lose) divided by days to achieve goal = calories to cut back on per day
Insulin: short-acting
Regularpeak: 2 - 3 hrs
duration: 8 - 10 hrs
- slow onset & offset
- peak doesn't coincide with food peak
Analogs
- Lispro
- Aspart
* Glulisinepeak: 0.5 - 1.0
duration: 4 - 6 hrs
- fast onset & offset
- peak coincides with food peak
Long-acting
* NPHpeak: 4 - 8 hrs
duration: 12 - 18 hrs
- peak effect more likely to cause hypoglycemia
Glargine: give with mealtime hyperglycemiapeak: none
duration: 20 - 24 hrs
- peak effect less likely to cause hypoglycemia
Determir: Control between meals and overnightpeak: none
duration: 16 - 20 hrs
- Peakless profile
sometimes required admin twice daily
Pharmacology questions: 1. read base first 2. read question 3. Ask yourself, what is going on? What do I do? (what is the target of the question?)When 2 answers are left: read answers again, determine what is the safest option? Is this an emergency situation? Think time - what is faster? What causes it to happen right now?
Iron toxicity (diarrhea, severe vomiting)Deferoxamine
Digitoxin/Digoxin toxicity (decreased urine output, difficulty breathing when lying down)Digibind
Opioid analgesic Methadoneused to detoxify/treat pain in narcotic addicts
Potassiumpotentiates digoxin toxicity
Order of assessmentInspection, palpation, percussion, auscultation
Order of abdominal auscultationInspection, auscultation, percussion, palpation
No pee, no KDo not give potassium without adequate urine output
For better perfusion and PVDDangle Arteries, Elevate Legs
Peripheral arterial diseasestand up to reduce pain
A in apgarappearance:
- pts. - color all pink
- pt. - skin is pink and blue
- pts. - blue (pale)
P in Apgarpulse:
- pts. - HR > 100
- pt. - HR < 100
- pt. - HR absent
G in Apgargrimace (reflex ability)
- pts. - cough/pulls away
- pt - facial movement/grimace only with stimulation
- pt - no response
A in Apgaractivity (muscle tone)
- pt - spontaneous activity
- pt - legs flexed with little movement
- pt - limp/floppy tone
R in ApgarRespirations (effort)
- pt - 30 - 60 bpm/strong cry