2014 STUDY GUIDE

Published

Attached is a study guide I promised for the NCLEX. Any questions, please feel free to ask2014 NCLEX study guide

Matt Briscese

Contact Precautions

Before entering: Wash hands THEN don gloves 1st and gown 2nd . Pt. gets private room.

Upon leaving: Remove gloves 1st and then gown. Gown worn during transport.

Examples: MRSA, RSV (also droplet), C. DIFF, Scabbies

Airborne Precautions

Same order for don. Wear N95 mask, and remove mask AFTER leaving the pt's room.

Keep pt's door closed at all time, private room with neg. air pressure. Mask worn during transport.

Examples: Varicella (chicken pox), Measles (Rubeola), TB, Herpes disseminated.

Droplet Precautions

Private room, and door may be open. Only need surgical mask within 3 feet of patient.

Example: Pneumonia, Menicoccal Menigitis, Influenza, RSV, Strept, Scarlet Fever, Pertussis, Rubella, Mumps, H. Influenzae type B.

ELECTROLYES/THYROID/GLUCOSE

Hypocalcemia: (CATS) - Convulsions, Arrhythmias, Tetany, Spasms.

Hypercalcemia: (Moans and Groans) - Fatigue/lethargy, Constipation, stones, muscle weakness

Hypokalemia: Anorexia, N/V, Weak Pulses, increased chance of DIG TOXICITY.

Hyperkalemia: Vfib, cardiac arrest, muscle twitching, extremity numbness

Hyponatremia: N/V, HA, twitching, confusion

Hypernatremia: Increased temperature, weakness, thirst, hypotension, tachycardia

Hyperglycemia: "Hot and Dry: Sugar High" increased thirst, fatigue, confusion, wt. loss, hot & dry skin.

Hypoglycemia: Cold and Clammy: Need some candy. Cold & Clammy skin, trembling, fatigue, blurred vision, Nausea, Fainting.

Hyperthyroidism: Hot, thinning of skin, brittle hair, restlessness, hyperactive reflexes

Hypothyroidism: Fatigue, wt. gain, cold, hair loss.

COMMON PROBLEMS

Addison's Dz: Hyponatremia, Hypotension, decreased blood volume, HYPERkalemia, hypoglycemia

Cushing's: Hypernatremia, hypertension, increased blood volume, HYPOkalemia, hyperglycemia.

Diabetic Ketoacidosis: Body is unable to produce enough insulin, breaks down fats instead which increases ketone bodies. S/S: Kussmaul respirations, fruity breath, excessive thirst, increased voiding, N/V, Ketones in urine.

Myasthenia Gravis: Signs/Symptoms start at the top. Facial droop, ptosis, diplopia, and difficulty swallowing - risk for aspiration and choking (BIG DEAL). Avoid excessive heat and alcohol. More prone for infection as well. Improves with rest.

MS: Will have numbess and Diplopia. Use steroids, sleep on stomach to avoid contractures, and avoid excessive head. At risk for injuries.

Guillain Barre: Body's immune system attacks nervous system (peripheral). Give high doses of immunoglobins. S/S: Resp. Failure, flaccid paralysis, urinary retention.

Legionnaires DZ: Severe pneumonia caused by Legionella. NOT contagious (standard precautions). Inhaled directly from source, not by person.

Menieres Syndrome: Vertigo, avoid excessive movement while communicating with patient. Decrease patient's head movement in bed.

Gastric Ulcers: Not relieved by food intake, pain most noticeable 30-60 minutes post meal.

Heroin Withdrawal: Runny nose, yawning, muscle/joint pain, diarrhea.

Plebitis: Inflammation of vein. Remove catheter, apply warm moist packs and change IV site.

Preeclampsia: Edema, proteinuria, HTN. Give Magnesium Sulfate for uterine relaxation and slow down the preterm labor.

Hip Replacement: Can keep pillow between legs, want to avoid ADDuction (displaces). Try to keep abducted, but no more than 60 degrees.

Hypoxia: Restlessness and anxiousness most commonly seen. Auscultate lungs. Seen very often with vented patients, and pneumonia/asthma patients.

IBS: Muscle contractions of colon. Cramping, bloating, diarrhea, constipation seen. Eliminate gluten, FODMAP (Fructose's, Lactose, etc.). Give FIBER, antidiarheals, anticholinergics, and antidepressants if needed.

IBD:

Ulcerative Colitis (Attacks Large intestine). Lining of colon becomes inflamed, autoimmune. This causes discomfort/emptying of stomach.

Chrons: Attacks any part of the intestine. Same S/S, and is autoimmune. Both are considered as a part of IBD.

Diet: Increase Caloric intake as well as protein. Eat only low residue foods: no RAW fruits or foods high in fiber.

Pancreatitis: Inflammation of pancreas. Upper and Mid GI pain, N/V, Fever, Increased HR. Keep pt. NPO to decrease work on pancreas. ABSOLUTELY NO ETOH, and LIMITED fats. May be caused by chronic use, or from stones obstructing the pathway of elimination.

Diverticulosis: Small pouches in digestive system lining. When INFLAMED it is known as diverticulitis. Antibiotics for infection. Increase fiber and fluids, no seeds, nuts, or corn.

Hemolytic Reaction: Hypotension, lower back pain, fever. MOST DANGEROUS.

Allergic Reaction: Urticaria (Hives), itching, respiratory distress (Wheezing), epiglottal edema. Give Benadryl.

Incentive Spirometer: Have pt. breathe IN and hold for 3 seconds before exhaling. Have patient sit up (fowlers-high fowlers) before proceding.

Autonomic Dysreflexia: Most commonly seen from a T6 injury and above. Excessively high BP, pounding head ache, profuse sweating, nasal congestion, Bradycardia. Decrease BP by raising HOB, take off loose clothes. THIS IS A HUGE EMERGENCY (usually top priority on NCLEX).

Diabetes Insipidus: ADH is not adequately produced. Increased voiding, and increased thirst. Electrolyte imbalance seen, Hypernatremia.

SIADH: ADH is "inappropriately" used. This causes fluid to be retained. Hyponatremia is most commonly seen.

NG Tube: Make sure to aspirate to make sure tube is in place. pH should be equal to gastric contents. Irrigate only after positioning is verified.

Wet-to-Dry Dressing: Avoid wetting dressing when taking it off so that optimum debris is removed. After removed, place new guaze in saline, squeeze until not dripping, pack into wound and cover dressing with dry pad, then tape.

Fetal Heart Rate Patterns:

VC

EH

AO

LP

V = variable decels; C = cord compression caused

E = early decels; H = head compression caused

A = accels; O = okay, not a problem!

L = late decels = placental insufficiency, can't fill

Place mother in trendelenbergs for cord compression to remove pressure off of cord, stop pitocin, and give oxygen. For LATE decels, turn mother to side, give O2. Always manually monitor fetal heart tones right after water breaks.

RH: Mother is negative, baby is positive. RhoGAM is given for second child.

SCANS

PET: Empty bladder before test, warm tracer dye is injected through IV. This test allows organs to be seen clearly. Ie. Brain cancer, poor blood flow.

MRI: Uses magnetic and radio waves to create pictures. No radiation used. Inform physician if patient has artificial heart valves, clips, pacemakers, ear devices or anything with metal.

EMG: Electrodes attached to legs generally - allows for muscles to be monitored.

CT: Uses X-rays. Some may require contrast dyes. If dyes are used, no eating for 4-6 hours before test. Increase fluid intake to remove dye and decrease work on the kidneys.

IVP: X-ray of kidneys, bladder, ureters, and urinary tract. Used to identify stones, infections, obstructions, and tumors. Contrast material used: IODINE. Check for iodine allergy. Caution with diabetes or kidney problems. Increase fluid intake to remove dye and decrease work on the kidneys.

POSITIONING

Post AKA and BKA: Avoid adduction, place in prone position often during the first 24 hours.

Blood pressures: Hypertension - put HOB up (fowlers, high fowlers). Hypotension - HOB goes down, lay patient supine. Increased ICP - keep in low fowlers.

Post Lumbar Puncture & Myelogram: Patient positioned supine to prevent leakage of CSF. Nurse should assess for clear drainage - requires IMMEDIATE attention.

Dumping Syndrome: Patient lies flat after meal for 30 minutes. Eat in reclining position.

Enema: Side lying position or sims.

Shock: Extremities elevated 20 degrees, modified Trendelenbergs.

Air/Pulmonary Embolism: Turn pt to left side and lower head of bed. S/S include sudden onset of chest pain, difficulty breathing, sense of impending doom.

DELEGATION

Nurses are the ones that can assess and teach. For priority questions, any patient that is a new admission, being discharged, just returned from surgery, or needs something taught is given to the RN.

TIPS:

- Know all lab values, and the effects on the body when they are not in range.

- Airway is always the priority. If the patient can't adequately take in oxygen, the rest of the body is USELESS.

- Cast care is key! Check for blanching and color changes. Sudden pain may be compartment syndrome. VERY SERIOUS.

- Patients with a deteriorating mental status (Decrease in Glasgow) are always given to RN. Decrease in LOC is first sign generally.

- Bleeding is usually assessed for during the first 24 hours. Infection doesn't usually occur until around 48-72 hours.

- Cane use: the "good goes up" and the "bad comes down". Good foot goes up when walking up stairs, bad foot goes first when walking down.

- Give lidocaine for VTACH, and Atropine for anything Brady.

- Draw up Regular insulin before N-Insulin. Regular is clear, N is cloudy.

- 24 hr. urine collection: discard first void of the morning, then collect in a container for the rest of the day.

- Weight doubles by 6 months and triples by 1 year for infants. Babinski's leaves by 1 year.

- Do plenty of questions (SATA and Priority)

- TB drugs are liver toxic and may turn urine orange. Assess for jaundice.

- GOOD LUCK :)

Up Vote Up Vote ×

Thanks for posting this!!!

Up Vote Up Vote ×

Lovely! Thank you!

Up Vote Up Vote ×

Thanks:up:

Up Vote Up Vote ×
Specializes in Pediatrics, Long Term Care.

This is a great study tool!

Up Vote Up Vote ×

Thanks for posting..Big help!!

Up Vote Up Vote ×

Thanks you

Up Vote Up Vote ×

what does HA stand for under hyponatremia

Up Vote Up Vote ×
Specializes in Complex pedi to LTC/SA & now a manager.

It's a non-standard abbreviation for headache

Up Vote Up Vote ×

One of my buddies is studying for the CEN and she just posted this EKG poem (which has already been posted to AN by an inactive member):

If the "R" is far from "P"... then you have a 1st degree.

Longer, longer, longer, drop!... then you have a Wenckebach.

If some "P's" just don't get through... then you have a Mobitz 2.

If "P's" and "Q's" just don't agree, then you have a 3rd degree.

Up Vote Up Vote ×

thanks for posting this. been digging through this forum for quick review sheets

Up Vote Up Vote ×
+ Join the Discussion