NCLEX Quick Guide
General NCLEX Test Taking Info:
- When getting down to two answers, choose the assessment answer (assess, collect, auscultate, monitor, palpate) over the intervention (except in an emergency or distress situation).
- Give priority to answers that deal directly to the patient’s body, not the machines/equipment.
- Key words are very important. Avoid answers with words such as “always, never, must”
- Assessment, teaching, medication delivery, evaluation, and an unstable patient cannot be delegated to an Unlicensed Assistive Personnel.
- LPN cannot handle blood.
- When patient is in distress, medication administration is rarely a good choice. Use assessment skills and escalate your concern.
- There are usually two answers that are good choices but what is the best
Cardiac
- Preload: the amount of blood coming into the R side of the heart
- After loadis the resistance the blood has to overcome when leaving the heart
- Calcium channel blockers (Nifedipine) affect after load and allow the heart to pump with less resistance
- Chest tubes are placed in the pleural space to evacuate air, fluid or blood.
- MI: dead heart tissue present due to obstruction of a portion of the coronary that supplies blood to the heart muscle
- Treatment for MI- MONA: morphine, oxygen, nitro, ASA
- Morphine: Respiratory depression is side effect; decreased preload and afterload
- Oxygen: make sure we monitor RR on pts; helps improve and tx the ischemic portion of the heart
- Nitro: vasodilator; increase circulation
- Aspirin: decrease clot formation (could be reason why pt having MI)
- Nitroglycerine is administered up to 3 times (every 5 minutes). If chest pain does not stop go to hospital. Do not give when BP is < 90/60 because it is a vasodilator.
- Unstable angina is not relieved by nitroglycerin
- Angina(low oxygen to heart tissues) = no dead heart tissues.
- If PVCs are left untreated they can lead to VF (ventricular fibrillation).
VFib=Defib
- Cardiac output decreases with arrhythmias (Vtach, Afib, PVCs, Heart Block etc).
- Med of choice for SVT is adenosine. Adenosine STOPS the heart (flat line).
- Asystole (no heart beat) needs compressions; defibrillation won’t work for a heart in asystole
- Med of choice for Heart Failure is Ace Inhibitors, beta blockers and diuretics. ALL act to help heart beat more efficiently and have less of a workload.
- ACE Inhibitors: major side effect angioedema
- Beta Blockers: major side effects- bradycardia, bronchoconstriction (caution with asthmatics)
- S3 sound is normal in CHF, not normal in MI.
- Congenital heart defects. Remember for cyanotic -3T’s. These defects prevent blood from going to heart. If problem does not fix or cannot be corrected surgically–>CHF will occur.
- Tetrology of Fallot, Truncus arteriosus, Transposition of Great Arteries
- Tetrology of Fallot(TOF): 4 defects
- RV hypertrophy
- VSD
- Overriding aorta
- Pulmonary valve atresia/stenosis
- Truncus arteriosus: single blood vessel comes out of the right and left side of the heart instead of two (pulmonary artery and aorta)
- Transposition of the Great Arteries:Aorta attaches to the Right Ventricle and Pulmonary Artery attached to the Left Ventricle.
- With R side cardiac cath=look for valve problems
- With L side cardiac cath=look for coronary complications.
Medications
- Med of choice for anaphylactic shock is Epinephrine
- Med of choice for Status Epilepticus is Valium.
- Med of choice for Bipolar is lithium.
- Med of choice for preeclampsia Magnesium Sulfate
- Carafate (GI med) before meals to coat stomach if worried about GI ulcers.
- Give prophylactic antibiotic before any invasive procedure
- Protonix is given prophylactically to prevent stress ulcers after surgery.
- TPN(total parenteral nutrition) given via central line. 2 RN check when hanging bag- check electrolytes and dextrose composition daily.
- Amynoglycosides(like vancomycin) cause nephrotoxicity and ototoxicity.
- Always check for allergies before administering antibiotics(especially Penicillin). Make sure culture and sensitivity has been done before administration of first dose of antibiotic if suspected sepsis.
- Aspirincan cause Reye’s syndrome (encephalopathy) when given to children.
- When aspirin is given once a day it acts has an antiplatelet effect.
- Prednisonetoxicity: cushing’s syndrome
- S/S of Cushings: buffalo hump, moon face, high glucose, hypertension.
- Morphine is contraindicated in Pancreatitis. It causes spasm of the Sphincter of Oddi. Therefore Demerol should be given for pain relief.
- Never giveK+ in IV push. This can lead to cardioplegia and subsequently death. Give K+ over a minimum of 1 hour.
- Mineral corticosteroids are given in Addison’s disease.
- Dilantin level (10-20):Anticonvulsant; Major side effect is gingival hyperplasia.
- Rifampin: medication used in TB; MAJOR side effect is turning secretions orange and its toxic effects on the liver (hepatotoxicity)
- Amiodorone is effective in both ventricular and atrial arrythmias.
- Digoxin: improves strength and efficiency of heart while controlling arrythmias. S/S of dig toxicity: Nausea/Vomiting- earliest*, blurred vision, Irregular heart rhythm, Muscle weakness
- Med of choice for Heart Failure is Ace Inhibitors, beta blockersand diuretics. ALL act to help heart beat more efficiently and have less of a workload.
- ACE Inhibitors: major side effect angioedema
- Beta Blockers: major side effects- bradycardia, bronchoconstriction (caution with asthmatics)
- Heparin prevents platelet aggregation and therefore thins the blood
- PT/PTTare elevated when patient is on blood thinners (Heparin, Coumadin, Aspirin)
- Normal aPTT is 30-40 secs when NOT on anti-coagulant.
- Therefore when on an anti-coagulant, want 1-1.5x longer (between 45-80 seconds to be therapeutic)
Disease Processes
- ARDS(fluid in alveoli) and DIC (disseminated intravascular coagulaton: hemorrhage+clotting) are always secondary to another disease process or insult to body.
- Cardinal sign of ARDSis hypoxemia (low oxygen level in tissues) due to impaired gas exchange.
- In pH regulation (7.35-7.45), the 2 organs of concern are lungs/kidneys. When kidneys compensate for respiratory acidosis, it takes longer than when lungs compensate for metabloic acidosis.
- Wherever there is sugar (glucose/dextrose) water follows. This is key with peritoneal dialysis.
- Cor pulmonale is enlargement of the R side of the heart as a result of diseased lungs or pulmonary vessels–> R sided HF.
- COPDis chronic whereas pneumonia is acute.
- Emphysema and bronchitis are both COPD.
- Pneumonia:fever and chills are usually present. For the elderly confusion is often present.
- COPD:patient’s baroreceptors (receptors that detect CO2 level in body) are impaired. Therefore, O2 level must be low because high O2 concentration initiates the patient’s stimulus for breathing.
- Diverticulitis(inflammation of the diverticulum in the colon) leads to pain is around left lower quadrant.
- Appendicitis(inflammation of the appendix) pain is in right lower quadrant with rebound tenderness.
- Portal hypertension + albuminemia= Ascites.
- Beta cells of pancreas produce insulin–> malfunctioning beta cells leads to Type I Diabetes.
- With chronic pancreatitis, pancreatic enzymes are given with meals in order to allow food to be digested.
- Trousseau and Chovoski signs observed in hypocalcemia.
- Trousseau: carpopedal spasm when BP cuff inflated
- Chovoski: facial twitch when tapping facial nerve
- Diabetic ketoacidosis(DKA)= when body is breaking down fat instead of sugar for energy. Fats leave ketones (acids) that cause pH to decrease.
- DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats. DKA associated with Type I DM.
- Glaucoma patients lose peripheral vision. Treated with medications.
- Cataract:cloudy, blurry vision. Treated by lens removal surgery.
- Autonomic dysreflexia(life threatening inhibited sympathetic response, decreased HR and decreased BP, of nervous system to a noxious stimulus) is usually caused by a full bladder.
- Multiple sclerosis:myelin sheath destruction and disruption in nerve impulse conduction.
- Myasthenia gravis: decrease in receptor sites for acetylcholine. Since smallest concentration of ACTH receptors are in cranial nerves.
- S/S: fatigue and weakness in eye, mastication, pharyngeal muscles.
- Tensilon test given if muscle is tense in myasthenia gravis.
- Guillain-Barre syndrome: ascending paralysis. Keep eye on respiratory system. Patients typically make a full recovery in time.
- Parkinson’s: RAT- rigidity, akinesia (loss of muscle movement), tremors.
Treat with levodopa.
- Alzheimer’s disease is a chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of all dementias.
- TIA(transient ischemic attack) mini stroke with no dead brain tissue. Typically precedes a full blown stroke.
- CVA(cerebrovascular accident) is with dead brain tissue.
- Hodgkin’s disease= cancer of lymph is very curable in early stage.
- Wilm’s tumor is usually encapsulated above the kidneys causing flank pain. Common pediatric cancer.
- Hemophilia is x-linked therefore mother passes disease to son.
- For Meningitis check for Kernig’s/ Brudzinski’s signs
- S/S: Headache, stiff neck, fever, photophobia
- Spinal shock occurs immediately after spinal injury
- Rheumatic fever can lead to cardiac valves malfunctions later in life
- Cerebral palsy:poor muscle control due to birth injuries and/or decrease oxygen to brain tissues.
- ICP(intracranial pressure) should be <2. Measure head circumference to monitor.
- Spinal shock occurs immediately after spinal injury
- Cushing‘s: 3 S’s are elevated
- Increased Sodium, Sugar, Steroid
- Addison‘s: 3 S’s decreased
- Decreased sodium, Sugar, Steroid
OB/Maternity:
- Birth weight doubles by 6 months and triples by 1 year of age.
- Placenta should be in upper part of uterus
- Patient with a vertical c-section surgery will more likely have another c-section. Although it is possible to have a VBac (Vaginal birth after C Section)
- Can perform amniocentesis before 20 week gestation to check for cardiac and pulmonary abnormalities.
- Rh-mothers receive rhogam to protect next baby.
- Anterior fontanelle closes by 18 months. Posterior fontanel closes around 6 to 8 weeks.
- Caput succedaneum:diffuse edema of the fetal scalp that crosses the suture lines. NORMAL: Swelling reabsorbs within 1 to 3 days.
- Pathological jaundice: occurs before 24hrs and last7 days.
- Physiological jaundice occurs after 24 hours.
- Placenta previa: there is no pain, however there’s bleeding.
- Placenta abruption: pain, but no bleeding.
- Bethamethasone (celestone)=surfactant. Medication given to help mature baby’s lungs and promote expansion.
- Dystocia: baby cannot make it down to canal
- Pitocin med used for uterine stimulation
- Magnesium sulfate(used to halt preterm labor): contraindicated if deep tendon reflexes are ineffective.
- If patient experiences seizure (possible side effect) during magnesium administration. Get the baby out stat (emergency).
PSYCH
- Milieu therapy: taking care of patient/environment
- Do not use why or I understand statement when dealing with patient
- Cognitive therapy: counseling
- Crisis intervention: short term.
- FIVEInterventions for psych patients:
- Safety
- setting limits
- establish trusting relationship
- meds
- less restrictive methods/environment.
- SSRI’s (antidepressants) take about 3 weeks to work.
- If patients have hallucinations redirect them.
- If patients have delusions distract them.
- Thorazine, haldol(antipsychotic) can lead to EPS (extrapyramidal side effects)
Reversal Agents
- Heparin= protamine sulfate
- Coumadin= vitamin K
- Ammonia= lactulose
- Acetaminophen= n-Acetylcysteine.
- Iron= deferoxamine
- Mag sulfate= Calcium Gluconate
- Digoxin= digibind
- Alcohol withdraw= Librium.
- Methadone is an opioid analgesic used to detoxify/treat pain in narcotic addicts.
- Opiod OD=Narcan (Naloxone)
Diet
- Pancreatitis: NPO/TPN; very painful, inflammatory and need to rest bowel for period of time
- Diverticulitis: clear liquids and high fiber; want to be careful d/t inflammation and we don’t want constipation or pouching to the area
- Cholecystitis: low-fat; pain located in upper right quadrant
- If we give them fat, can initiate more pain as bile secretions increase it gets clogged in gallbladder
- Liver Disease: decrease protein intake
- 4 basic Liver functions: SSDD- synthesis, storage, decomposition, detoxification
- Can’t metabolize protein therefore increase ammonia (NH3) levels
- Celiacs: avoid gluten (oats, wheat, barley, rye)
- Gout: low purine (sardines, fatty foods, beer)
- Dumping Syndrome: small frequent meal
- GERD: avoid large meals, eating late, alcohol, caffeine
General Information
- Use Cold compress for acute pain (eg. Sprain ankle) and Heat for chronic pain (rheumatoid arthritis)
- Guided imagery is great for chronic pain.
- Neutropenic patients: No live vaccines, no fresh fruits, no flowers
- 4 options for cancer management: chemo, radiation, surgery, allow to die with dignity.
- Neutropenic patients: No live vaccines, no fresh fruits, no flowers
- Low residue diet means low fiber.
- Sign of fat embolism is petechiae. Treated with heparin.
- For knee replacement use continuous passive motion machine.
- Co2causes vasoconstriction. O2 causes vasodilation.
- Most spinal cord injuries are at the cervical or lumbar regions. The higher the injury, the more deficits the patient will have.
- Rule of NINES for burns:
- Head and Neck= 9%
- Each upper extremity: 9%
- Each lower extremity: 9%
- Front trunk: 18%
- Back trunk: 18%
- Genitalia: 1%?
- In an emergency, patients with greater chance to live are treated first. Tagged based on chance of survival.
- When phenylalanine increases, brain problems occur.
- Types of Traction:
- 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 fx.
- General traction advice: place apparatus first then place the weight when putting traction on someone
- After endoscopy check gag reflex.
- Early sign of increasedICP– change of LOC/mentation
- Blood Transfusions: Stay with client for first 15 minutes and take VS q15 min.Stop blood immediately if any signs of transfusion reaction (flank pain, itchiness, fever, anxiety)
- Complete infusion within 4 hrs (MAX amt of time)
- Stages of grief: different for everyone; not predictable
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
Lab Values
- Hemoglobin: 14-18 (male); 12-16 (female)
- Hematocrit: 42-52% (male); 37-47% (female)
- Platelets: 150,000-400,000
- aPTT: 30-40 secs
- PT/INR: 11-12 seconds; 0.8-1.1
- WBC: 4,000-11,000 cells/ml
- BUN: 10-20 mg/dL
- Creatinine: 0.6-1.2 mg/dL
- K+: 3.5-5.3 mEq
- Na+: 135-145 mEq
- pH: 7.35-7.45
- PaCO2: 35-45 mmHg
- PaO2: 80-100 mmHg
- HCO3: 22-26 mEq
- Glucose: 70-110 mg/dL
- Hemoglobin A1C: 4-5.7% (non-diabetic); Diabetic: <7%
- Cholesterol: <200 mg/dL
Measurements
- 1 t (teaspoon)= 5 ml
- 1 T(tablespoon)= 3 t = 15 ml
- 1 oz= 30 ml
- 1 cup= 8 oz
- 1 quart= 2 pints
- 1 pint= 2 cups
- 1 gr (grain)= 60 mg
- 1 g (gram)= 1000 mg
- 1 kg= 2.2 lbs
- 1 lb= 16 oz