Kaplan Review Course

Kaplan Review Course

 www.ncsbn.org is a website that has good practice test questions (the hard ones) (the knockout questions)

 “safe and effective” are the two key points (is what I am going to do going to be effective?”

 Median number of questions is 118 (75 is abnormal)  [email protected]

 Missing a lot of questions in a row is bad…. Once you are consistently above the passing line, you will pass

 Stop runs of errors…. Take breaks if you are in a rut

 If you don’t cut off at 75, or close, it shows you are not being consistently above the line

 18-25 select all that apply… regardless of if you finish at 75 or 265…  The fill in the blanks are math, and maybe short answer

 To Do Tonight/Tomorrow: Do Q Banks on tutorial mode (5 questions per night USING DECISION TREE)

o Take assigned test

o Take question trainer tests 1 2 3 OVER WEEKEND (NOT THIS WEEK)

o Watch content lectures

o Watch strategy seminar (FRIDAY) o Watch test taking workshop (FRIDAY) QT1: 75 questions (Comprehension/Recall)

QT2: 75 questions (comprehension/recall) QT3: 100 Recall/Recog/Compr/Applic

 ON THURSDAY: If you get 60 or above, come at 1pm…if below 60, come at 1130 to show the results and analyze

 More than 2-3 in a row wrong is a problem…

 After Friday, only read chapters 1 and 2 (in the purple)  Chapters 8/9 are the guts

 Don’t watch content lectures unless you are weak in a highly tested area after instructor tells you to do watch…

 Decision tree is how we are going to “run our life” in class

 WHY in the answer (the word WHY) is ALWAYS WRONG ON THE NCLEX!!!!!! NEVER ASK WHY!

 Validation: how you verify that something you suspect about the patient, is accurate… (an ASSESSMENT (Proving what you think is going on with the patient))

 If two answers have the same outcome (i.e. comfort measure (abd pain and you have to choose between heating pad on abdomen and Tylenol… if two have same outcome then it cannot be the right answer))

 Healthy behavior vs. unhealthy behavior will be tested

 If you rule out an answer, then just rule it out and don’t go back to it…your gut instinct is usually right…choose another answer!

 DO NOT READ INTO THE QUESTION: There is no “go tell the nurse”, and you can’t say “come to the clinic” all of the time…there is something more important to do first, before you call them. Also, there is probably not a “there is no order”… in the emergent or urgent situations, you do what you have to do FIRST, and THEN you call to get the order



Transferring in and out of a wheelchair is best indicator of ability to complete ADL

 AGITATED MEANS HYPOXIA

 The word “ACTION” may be an action, or MAY BE AN ASSESSMENT  NEVER MILK A CATHETER… IT IS ALWAYS WRONG

 Sometimes the answer is the least risky (move the patient to their side)  You may suspect something (a patient is in pain due to appearance), but you

need to VALIDATE FIRST (“ Are you in pain?”)

 A patient in SHOCK (confirmed) needs FLUID REPLACEMENT FIRST (A 23F has Toxic shock syndrome, what is first action? Kick psychosocial out because there are physical actions… GIVE FLUID)

 Each pound of weight gain is a liter of fluid

 “Increase fluid intake”: demonstration of improved fluid status=good fluid output

 ACE inhibitors drop blood pressures…. So don’t stack 2 anti-hypertensive meds on top of each other

 Depression shows improvement when: better sleep  “Muscle tension” relates to anxiety, not depression

 Aspirin: NSAIDs have cross sensitivity (Don’t mix ASA and Aleve/Naproxen)  Cephalosporins and Penicillins always have a cross sensitivity

 If you have decreased urine output, you should expect some weight gain (pitting edema and weight gain)

 Crohn’s: need to restrict fiber and fat (don’t want to promote peristalsis)  Someone newly hired needs to verify their skill before doing something and

showing that they know how to do it right  NPO means NPO previous 8 hrs

 Glucophage cannot go anywhere near a patient who is getting IV Contrast Dye for a CT (causes lactic acidosis)

 With schizophrenics: Always try to reorient and bring them back to reality  Hct: normal is 41-49

 Specific Gravity: FIXED is bad  Specific Gravity: 1.010-1.030

 Influenza: Can’t give to people to anyone allergic to any fowl (feathery animal) (ask if they have any FOOD allergies)

 Nurses who come from a surgical floor to another unit should be assigned to a surgical patient

 Alcohol and barbiturates tox need to be admitted to the hospital due to withdrawal risks

 Vitamin B shots are once a month for loss of intrinsic  Renal failure = hyperkalemia = spiked T wave

 Hypokalemia: muscle weakness

 High BUN without a Cr number, means dehydration  High BUN but Cr normal, means dehydration

 BUN: 7-20

 Isolating someone increases confusion…. Let them socialize and be with others (unless they are contagious)

 Rubella: greatest risk is during first trimester of pregnancy

 Rubella: it is like chickenpox…you are only contagious 4-7 days before the rash appears

 Rubella: takes 2-3 weeks to incubate after first exposure to rubella…so you are not contagious until day 14 through 21…and you won’t see a rash until day 28

 Can never give Rubella vaccine to a pregnant woman

 Assume that a CHF patient has 1 liter in their lungs if they gain a pound  Fruits and veggies help prevent hypokalemia

 Patients on TB moving through the hallways need to wear a mask when moving around the hospital (i.e. going to radiology)

 Juvenile Arthritis: they should be active in NO IMPACT sports/activities  Nurses check patients….check the patient, not the monitor…. If you are

looking for something in particular, check the patient  Renal failure = retain potassium and become acidotic

 WE ARE NOT BIOMEDICAL ENGINEERS, WE ARE NURSES…. CHECK THE PATIENT AND NOT THE ECG IF THE PATIENT HAS SUDDEN SYMPTOMS  Anterior wall MI: cause L sided CHF, so pulmonary edema and hypotension  PREVENT HIP CONTRACTURES AFTER AMPUTATIONS

 Only elevate stuff after surgery for about 1 day

 Only patient who gets pillows between their legs is HIP patients  All urine collection MUST BE STERILE…NOT CLEAN!

 When there is a list of symptoms, your diagnosis has to be the one that encompasses all of the symptoms

 If someone is not NPO, and is not eating much (especially sick people at risk for malnutrition (not eating)), find out what they want and give them

ANYTHING THEY WANT! They need calories

 Milk has tons of sodium. Carbonated drinks have lots of sodium. Tomato juice has lots of sodium

 Eating disorders hide it from others… so getting them to talk about it is therapeutic

 Unexpected abnormal from transfusion reaction: stop transfusion immediately

 The longer the question, the more you have to simplify it before you answer it  Synthetic blood volume expanders: albumin, dextran, albumin (can be used

for hypovolemia) along with isotonic: LR/NS

 Tourniquets: 4-6 inches above IV site is the correct location, not 1-2 inches  If two right answers, one action and one assessment, but the action that is

 ABCs is first when determining which order to see patients

 You can leave up to 100ml of Dialysate solution in…more than that, you gotta go get it

 Only one drug do you need to alter your diet…and that med is COUMADIN patients (need to change their leafy green intake)(don’t increase))

 Antacids: one hour after meals

 Glomerulonephritis: watch for signs of other infections first, because glomerulonephritis may show up as an infection easier to spot in another body area before it will show up in kidney issues

 SLE/Lupus: decrease sunlight, high infection risk, avoid gardening, avoid UV light, avoid cuts and scrapes

 Critical K+ values: important to give IV K+ before PO K+, also checking monitor for dysrhythmias is important

 Post op: Signs of infection is highest priority, after ABCs

 TPN: Air embolus is big risk, so place patient left side head flat to keep air bubble from rising to head… if that is not a choice, keep them flat

 Gingko: anti platelet properties, so the risk for bleeding increases with ibuprofen or antiplatelet meds

 Asthmatic: a productive cough is a sign of URI, not airway / asthma issue, so the cough is not highest priority

 Rhinoplasty: nose job- cannot do oral temps because the person can’t breathe through their nose while the thermometer is in their mouth  Li toxicity: diarrhea, sedation, ataxia, tinnitus, muscle weakness  Prednisone: take with meals due to GI irritation

 After a thyroidectomy, check for paresthesias due to low serum calcium if parathyroid glands damged (and muscle twitching too)

 PAD: decreased sensation, so caution with hot pads. Exercise until start of pain, then stop, rest, and then resume exercise

 Heart failure: expect right heart failure stuff (edema, JVD), but don’t expect left heart stuff (rales, pulmonary edema)

 NO psych med should cause stiffness/tremors…that is an EPS  No bananas with MAOI

 Kidney stones: lots of water is a priority

 Below knee amputation: elevate for 24 hrs, then periods of prone to prevent contractures

 If halo in place, and the patient states it hurts to chew, that is a problem  EEG: need someone a little sleep deprived (i.e. wake at 2am before test)  Elevated BUN: ALOC, fall, confusion (N is the nitrogen)

 LVN: care for stable patient with predictable outcome

 Disseminated herpes zoster (chicken pox): air and droplet precautions  PCNs are cross sensitive to cephalosporins (cefaclor)

 -cillins and –mycins: take with food…other ABX on empty stomach

 -cyclins are NOT to be taken at bedtime or lying flat (will cause esophageal damage)

 Compartment syndrome cardinal sign: UNRELIEVED PAIN after receiving pain meds

 Decision Tree: Steps 1-2-5 are hardest, and steps 1-5 are the most challenging to figure out

 When giving a drug, and it asks “What is the priority action,” you are then required to assess for the adverse effects/worst possible outcome (i.e. blood volume expanders you are concerned with pulmonary edema…so you want to assess for pulmonary edema (lung sounds)

 Increased difficulty chewing is a risk for airway, so that patient gets their meds first

 If patient’s concern/question is “What is dialysis like” that is a good scenario to bring someone in who has undergone that same treatment….otherwise, the nurse should do the education/teaching when a patient is refusing or questioning care

 NAP/CNA can obtain a capillary blood glucose

 Intervening when supervising others, looking for negligence (What would other people in same condition do) OR practicing out of scope

 LPN/LVN MAY perform trach care on a stable patient

 ASSIST PATIENTS TO COMMODE or TOILET EVERY 2 HOURS…2 hours…2 hours!!!!! We also REORIENT every 2 hours.

 Check RESTRAINTS Q30 MIN

 2-3 BM and 10-12 wet diapers is the average for newborn  Toddler: 2-5 yrs

 Warning signs for elderly: regret about their earlier life and success/failure is a risk factor for depression/self harm

 Primigravida feel quickening/movement at 20 weeks…multipara feels quickening/movement at 18 weeks

 You should expect NO DISCHARGE from any biopsy, amniocentesis… if there is discharge, that is a DANGEROUS SITUATION FOR POTENTIAL INFECTION  Rescue position for ALL PREGNANT WOMEN IS LEFT SIDED (THEN if given the

opportunity, knees flexed up)(for all times that there is an issue with the mother not feeling well (i.e. syncope))

 BOGGY FUNDUS: MASSAGE FUNDUS UNTIL FIRM (NO TIME LIMIT!!!!!)

 Spontaneous jerky movements of a newborn: hypoglycemia (if jerking, need an assessment, so check a bG)

 Newborns withdraw from heroin 16 hrs (so assess infant cry/RR at the 12-16 hrs mark)

 With an IUD, the cervix is always a bit open…therefore monogamous relationship is important to reduce infection risk because the

boyfriend/husband may be cheating… ONLY IUD IS IN A MONOGOMOUS RELATIONSHIP

 If OCD behavior is not disruptive/destructive, we don’t try to do anything about it. If someone washes their hands raw, you have to REMOVE FROM THE STIMULI (i.e. sink) and EXTINGUISH the behavior.

 NEVER FEED INTO THEIR MONSTER (Don’t ask about someone’s delusion)  Neuroleptic Malignant Syndrome: Super high fever (suddenly stop taking

psych meds), semi-coma or seizing. Treat with BROMOCRYPTINE AND DANTROLENE SODIUM

 Benzodiazepines (Xanax)are only for anxiety/agitation

 Before you confront abusers (elderly or child), be sure you have all your ducks in a row (Child Prot Services, LASO) do you go in and confront the abuser and let them know you are reporting them. Let the supervisor know what is going on, so they are prepared for the shit storm about to occur…  SSRI (Paxil): complication includes possibly making them hyper (even though

most patients get drowsy). If they get confused, that is the abnormal we have to be confused about.

 Manic patients should be given activities to use up energy…(i.e. help clean up the floors/sweep) and remain with staff

 People on lithium (lithium sodium) need to be drinking a lot of water due to the dehydration aspect…. So new lithium patients may feel

tachycardic/hypotensive… intervention includes increasing water intake.  If someone says they are afraid of radioactivity, don’t ask them “why do you

think there is radioactivity here?”…. rather say “This is a hospital, you are safe here.”

 Geodon is an antipsychotic and helps people be more coherent

 Bacterial meningitis shots: for military, people living in group situations, dorm rooms ONCE in their life

 Adults get DT, not DPT shots

 LATE DECELS: gradually drop for the entire contraction and also decelerates at the end of the contraction

 LATE DECELS GET EMERGENCY C-SECTION

 Newborn: if BP is too low or too high, it is a congenital heart defect  Acceptable newborn: 80/45 to 60/40

 Baby chest shouldn’t move much during respirations  We turn everyone every 2 hours

 Don’t cover infants eyes under the bili lights for the entire day… they should be uncovered q4H or so

 For a patient to get C-Diff, they HAVE TO BE ON AN ANTIBIOTIC… SO……… if they are suspected to have C-Diff, need to evaluate their medications and IV fluids currently or past

 2 risk factors for cancer: virus (HPV)…. Then most cancers otherwise are caused by chronic state of inflammatory response (obese (tissue pressing on cells))

 The GOLD STANDARD for TB determination is the Acid Fast Bacillus sputum test

 TB Induration: More than 10mm is a positive for healthy/non-immunocompromised patients More than 5mm induration in immunocompromised is positive for TB

 Isoniazid for TB:

 How to make a bedroom a negative pressure room: open the window and point the fan out

 TB: Government can FORCE YOU TO TAKE MEDS…THEY CAN LOCK YOU UP IN JAIL TO FORCE YOU TO TAKE THE INH FOR A YEAR

 TB: three drug cocktail (Isoniazid) and a NEGATIVE PRESSURE ROOM (TB is the ONLY situation that you need a negative pressure room)

 If the SIDE EFFECTS FOR A SURGERY ARE MAJOR… THEN THE HOSPITALIZATION WILL BE LONGER

 HIV prejudice: There is NO RATIONAL REASON TO REFUSE CARE TO AN HIV PATIENT because we expect/anticipate everyone to be HIV positive and infected with stuff…. So we assume all people are sick…

 CD4 count at or less than 300: start treating  HIV: three med cocktail

 CD4 count LESS THAN 200: AIDS

 CD4 dropping means viral load increasing

 Possibly infected nurses with TB or anything else airborne MUST WEAR A MASK FOR THEIR ENTIRE SHIFT… (Not just when you are working on the unit)  STD questions: keep them from spreading the disease

 Three diseases mean AIDS: Kaposis Sarcoma (immunocompromised), PJP/PCP, CMV retinitis

 Patient who frequently pushes the call light: Do an assessment (figure out what is wrong)

 Lead poisoning: it affects coordination, cognition, size (they will be small (they eat paint instead of food, so they are malnourished)). Lead also causes constipation. Poverty is the risk factor.

 All skin ulcerations are considered infected… prednisone patients often have infections.

 “toxic hepatitis” does not mean viral hepatitis, it often happens in blue collar workers who inhale dust (plumbers, AC technicians, etc…). So these patients are not infective…they just have an inflamed liver

 We use universal precautions to protect us from the patients

 Nurses from NEWBORN NURSERY deal with healthy kids…so they don’t have lots of transferrable skills to the other units. They should insist on requesting an orientation to the unit and let the supervisor know that you haven’t been caring for patients in several years.

 Treat actual problems before potential problems (i.e. two patients, one has an infiltrated IV, the other has nausea…go to the patient with the infiltration first… as long as the nausea patient is not vomiting)

 IF YOU ARE NOT SURE WHAT IS GOING ON, BE SURE YOU ASSESS FIRST  When doling out assignments as a charge nurse, only reassign patients IF

THERE IS A GREAT REASON…not “just because”

 MUST LOOK AT ARMBAND TO ID PATIENT, NOT VERBAL FROM PATIENT AS SINGLE SOURCE OF ID

 HEPARIN SQ: Don’t need to aspirate, since it is SQ…no blood supply

 Only a RN should feed a myasthenia gravis patient, since the way you feed the patient (pocket the food) with MG is a RN skill

 LVN/NAP shouldn’t suction, DUE TO THE ASSESSMENT ASPECT  As long as membranes are intact, the patient can walk

 When things are encased (liver, amniotic sac, spinal tap, bone from bone marrow, etc…) they should NEVER LEAK that is why they only get a bandaid on it…not a big

 When to go straight to State Board with a complaint: when the person you are complaining about is a higher up and nothing has been done internally (waiting an appropriate amount of time between incident reports)

 Assume most CVA patients have HTN

 Most patients with CVA will have orthostatic HoTN normally, so we are not overly concerned about it in the questions that ask “What are you MOST concerned about.”

 If any patient tells you “THEY FEEL FUNNY” you should be concerned….  Don’t freak out about high blood pressures, but be concerned about blood

pressures that CAUSE SYMPTOMS (Treat the patient, not the numbers) because HTN is a chronic condition that requires follow up, not necessarily acute treatment

 If they are Hypertensive with ringing in ears, that is something to be concerned about (about to stroke)

 THE BIGGER INCISION IS HIGHER PRIORITY

 CNA/NAP: Cannot assess or determine problems, and you shouldn’t tell them something they should already know

 If someone refuses an assignment, be sure to determine what the issue is, before forcing them to do the assignment (determine what the concern is)  Trach suctioning: if suctioning mouth too, do the trach first, then mouth

(sterile to unsterile), never use powder around trach, and never instill saline  Acute confusion/dyspnea after a operation often is a fat emboli, and that is

more seriousness than things (except for airway and breathing)

 During seizure: NOTHING INTO THE PATIENT’s MOUTH, and keep them safe  If a person is immune suppressed, there is a likelihood of getting a disease

from a person who has it (i.e. HIV)

 If a person is immunocompromised, there is an almost certainty that the person will get the illness from the person they are exposed to (i.e. AIDS)  MEAT TEMP MUST BE AT 165F OR HIGHER…NEVER LOWER

 Anyone immunocompromised should rinse toothbrush daily in bleach solution  Googles are only for droplet

o TB/Varicella/Measles are airborne o MENINGITIS is DROPLET

 Droplets can only get you if you are within 2 armlengths of the person

 If a elderly person has multiple symptoms, then the assessment you do has to be inclusive of all of the symptoms: often the answer is to assess all of the medications the patient is taking

 When “salt “ or salt substitutes is brought up, we are looking to address a person’s confusion due to hyper or hyponatremia issues



 Thrombotic strokes: once you are at 48+ hrs, they are in a chronic state…so not urgent

 Embolic strokes: once you are at 5 + days, they are in chronic state, so not urgent

 Healthy nap is 25-30 minutes…does not mess sleep cycle up….longer or shorter is bad

 It is always a good thing to decrease your bad habits…unless you are still contributing to disease, then it is still a bad thing

 G meds cause bleeding risk

 Asthma TRUMPS ALL… be sure their asthma is proven stable, until proven otherwise… so you need to know what the best asthma assessment is… which is PEAK EXP FLOW RATE

 POVERTY IS A RISK FACTOR FOR ASTHMA because the number one risk factor for asthma is the cockroach

 Best nutritional assessment, besides muscle strength, is albumin (normally >4.5)

 Always ask “ is the condition described affecting the patient?” unless it tells you a diagnosis (i.e. septic shock)

 Femur Fracture: Keep the limb neutrally positioned

 Hips: No more than 15 degree angle changes and don’t sit for long periods of time

 We don’t really do STERILE dressings in the home setting…just aseptic technique

 History: we want to know what happens right happens before an event  For insomnia: what happened right before sleep, and what did you do to

prepare for sleep

 If you are INVESTIGATING, you are looking for UNEXPECTED abnormal  Compartment syndrome

 Renal calculi: gets TONS of fluid…need to move the rock into the bladder to get it into bladder…. Like a liter an hour or more! AND ALL STONES ARE SCREENED AND SENT TO LAB TO RULE OUT Cancer… give MORPHINE  IT IS NEVER EVER EVER EVER EVER EVER NORMAL TO BE FORGETFUL… IF

THE ELDERLY PERSON IS HAVING TROUBLE REMEMBERING THINGS, THAT IS SOMETHING TO INVESTIGATE

 Implanted cervical radiation: we don’t do their COMPLETE bed bath unless the patient is comatose

 Nurses only get 30 minutes with patient each 4 hours with implanted radiation

 If internal radiation is a delegation question, don’t give implanted radiation therapy to the LVN…RN only

 Remember we don’t give all the personal hygiene care unless the patient is completely comatose…so if you see ALL or complete as words in the

question, it would be wrong

 Rotating patches (transdermal) is good…

 Crutches: good up, bad down (when going up/down stairs, the good leg goes up first, the bad leg goes down first)

 Degenerative Joint Disease: IF I can’t use my big joints, I use BOTH my little joints

 PCA is NEVER for terminal or chronic cancer pain…ONLY FOR ACUTE PAIN and BREAKTHROUGH PAIN

 Bipolar and adolescent boys have same problem…”no captain of the ship”(risky behavior)

 Psych therapeutic treatment:

 “Explore” is always wrong!!!! They don’t care how you got to where you are… just the behavior right in front of you at the time

 Focusing on the nurse is wrong… “We are doing all we can”… that is trying to get the nurse to feel better, not the patient…

 Never say anything close to “DON’T WORRY”…. “we do this all the time” “this is a simple procedure” and not dealing with what they are really worried about

 Guilt: never with patient “i.e. don’t worry about that, think about your family” all of those are blowing them off…

 You have to be sure you know why the patient is saying what they are saying…. Are you saying you look like a freak because you have no hair”  If you have a a list of complaints (i.e fatigue, menses, brittle hair, etc….) then

your implementation has to address ALL OF THE COMPLAINTS, not just one of them!

 DIETS

o UNLESS DIET IS VERY SPECIFIC (FULL LIQUID OR LIQUID): All have to have protein, vegetable/fruit, AND A CARB

o Focus on what you are RESTRICTING;

 Renal diet: restrict proteins (long grain rice, meats)  Seafood: +++  Meat: ++  Non meat: +  Salt:  Most: +++  Medium: ++  Least: +

 For vegetarian diet, everyone is vegan at the base (plant products only) o Lactovegetarian: milk and plant

o Ovovegetarian: eggs and plant only o Lactoovovegetarian: dairy, egg, plant

 TPN: Sepsis, air embolism, hyperglycemia are concerns… so watch for those  It is totally expected to be above normal temp a little for any type of

indwelling tube (NG, foley, etc…)

 Glomerulonephritis: the urine will look horrible…not expected to have no urine, and NEVER

 FIXED URINE SPECIFIC GRAVITY. You do expect hematuria, proteinuria…not a surprise

 If asking intake: DON’T SUBTRACT unless asking I/O…but for dialysate, only count as intake the stuff that was left behind during dialysis (i.e. 2000 dialysate in, 1900 dialysate out would equal a total of 100 input)

 Continuous ambulatory peritoneal dialysis: your activity SHOULD NOT be restricted… should be able to carry on life

 The word SUDDEN indicates it is URGENT issue and needs ABCs addressed in order (airway first)

 Post Op Day doesn’t matter…. It is the INCISION SIZE that matters on NCLEX (smaller the incision more stable the patient is)

 A Harrington rod: for scoliosis

 To test for scoliosis: bend over, and spine should run straight…

 An “UNEVEN HEM” on a little girl indicates that she has scoliosis….she is crooked

 If you don’t know why something is going wrong… you must ASSESS first (find out what is wrong first before you change things (including polling co-workers, investigating, etc….)

 NEVER TEACH THE TASK YOU ARE DELEGATING…. THEY SHOULD ALREADY KNOW IT (so you shouldn’t teach the CAN/NAP the job…don’t instruct the CAN/NAP….just give directions)…if they don’t already know it, then it shouldn’t delegated to them

 Always assume a floor has 50 beds…so unless you can do something for everyone, don’t do it (i.e. switching assignments around)

 RN must handle all new admissions and discharge planning  RNs are the SUPERVISOR of the CNAs and LVNs….

 Pain that is sharp and unrelenting is a concern… if it comes and goes it is less worrisome

 Your boss is your boss…and that is who you report to…you REPORT TO YOUR IMMEDIATE SUPERVISOR

 FLOATING: Never give a floater a specialized patient…try to match their skill o i.e. post partum nurse can get a post op patient

o you can only give chemo if chemo certified o match the skill to the nurse

 You assess gag ONE TIME before the first time you use the mouth after NPO)  We do things every 2 hours (water, reassess, organize thoughts, etc…)

 After CVA, you should be in THERAPY most of the day… don’t waste the CVA patient energy with menial things

 When determining WHO TO CALL FIRST, call the person with the UNEXPECTED abnormal

 ACTION: DON’T LEAVE YOUR PATIENT!!!!!!!!!! EVER  OBTAIN=LEAVING YOUR PATIENT, SO DON’T DO IT

 Agitated: May leave the patient in a darkened room, but that is an exception  A patient taking a medication for the first time, about 3 days to develop an

adverse reaction, so stop taking the meds, THEN come into the clinic/office… (ASSUME THE WORSE OUTCOME (even if you are wrong later))

 STEROIDS: delay wound healing, make you osteoporotic, immune suppressed, hyperglycemic

 Immunosuppressed patients can only go in a room with a clean patient  Blood tests done routinely/monitored: coumadin, lithium, etc..

 G-G-G-G-K: cause really fucking bad thrombocytopenia (both Ginkgo and Kava are very bad..pull them off it)

o G: Garlic o G: Ginseng o G: Ginger

o G: Ginkgo o Kava

 Everyone should use soft toothbrush and drink 8-10 glass water a day…that is good

 Benzotropine (cogentin): not for glaucoma (atropine/anticholinergic)  Pediatrics should not lose weight… come to clinic/see doctor

 Do bronchodilator before steroid for inhalers….  MRI/MRA (magnet):

 Dyes are not iodine based when scanning stuff above the diaphragm

 “itching and swelling” from dyes are important when dealing with angiograms between groin and diaphragm…otherwise, not an iodine based scan

 If the diuretic is causing symptoms, it would be muscle cramps, not nausea  When a patient is out of the health care setting, and there is an adverse

effect from a medication (an unexpected outcome), you need to go to the hospital or doctor…can’t treat the patient in the home or field setting

 Lasix: be sure you check for muscle weakness (if K is low, muscle weakness)  “Most concerns” refers to a complication of a medication:

 Never check Homan’s

 I/O: should be 1500-2000 per day  Urine Output: 300cc/24 hrs is OK

 Respiratory Rate: 12-20…if 10/min, that is low

 When you see two diseases listed in a question, think about what those two diseases share as a complication (i.e. Raynaud’s and DM1: peripheral

circulation issues)

 Don’t put SpO2 and BP cuff on same arm  BPs best on left arm

 OK to delegate SpO2 to CNA, but don’t assume anything (give explicit instructions, no assessment portion)

 RN never delegate assessment, teaching, or tasks requiring clinical judgment  Most unstable patient to RN

 LVN only get patients with predictable outcomes and stable (never do admission or discharge! Those involve teaching), never prepare for pre-op, but they can give the meds. Never teaching for LVN. Never flush a tube (NG, ET, IV, etc…), never let LVN give blood.

 LVN, on test, MAY: stable patients, sterile procedure with predictable outcome (no assessment portion) (“Go do dressing change in room 5, if it is pink and dry, that is fine…if it is anything else, come get me.)

 LVN may not do PRN (because assessment portion involved, so they can’t do it)

 LVN may never mess with IVs

 Nursing assistants CAN DO ACCUCHECK…

 “Tube feeding”: NAP/CNA can do it (take out plunger, pour feeding into). They cannot do the residual or placement check, only RN.

 Pumps: RN only

 All women should be on calcium and Vit D… so it is not the answer if someone has bone loss…they should have been on it before that  Platelets: normal 140K-400K

 Bleeding high risk: less than 50K  Big trouble for platelets less than 20K  RICE: rest, ice, compression, elevation  Thrombocytopenia bangs arm… ice the arm

 People calling from HOME (especially after an outpatient procedure) with an unexpected abnormal… come in and be seen or follow up with doctor is the answer

 1 cup: 240ml, 1 oz 30ml

 You can’t grow bone back, so you can’t restore bone loss (don’t expect to grow bone back if it is gone)

 All cath labs: post cath, distal pulse assessment is more important than checking for slight bleeding…CHECK DISTAL PULSES

 Post paracentesis, most important thing to do is check BP right after  Third space fluid IS part of your circulation, so removing it can cause

hypovolemia

 STEROID trumps most other things as it relates to wound healing (if on steroids, higher risk for poor healing than diabetes or smoker)

 Most meds should not be taken before laying flat  Patient statements are always assessments

 Treat the primary tumor first, before the metastasis

 NEVER GIVE SHORT ACTING NARCS ON A TIMED SCHEDULE! Always PRN for breatkthrough pain (i.e. NEVER GIVE MS at 7-11-5p…. the answer is NEVER DO IT)

 Prune juice is good for patients on opiates… because it reduces constipation (acts as a stool softener)

 NTG/nitroglycerin (happy Rebecca???) : cause BP drop and HR increase  Old people: move slower, stiffer, renal insufficiency (not liver problems

normally)

 ALOC: sodium may be the cause

 Older old (over 70): move slower, stiffer, renal insufficiency

 We want people to pee every 2 hours if they have stress incontinence or other incontinence

 Flomax: slows down the frequent peeing… take it at bedtime. It is an alpha blocker, and may cause hypotension…best time to take it the first time is before they go to bed

 Stop a medication for angioedema

 How to know a treatment is effective? Answer is looking for the NORMAL assessment

o HDL is good cholesterol: >40 o Cholesterol: <200

o Tg: <150 o LDL<137

 Stomach is most empty overnight, so best to take PPI at night, to reduce acid  Calcium blocks thyroid meds… so don’t take calcium 2 hr before or 3

hr after synthroid  Synthroid taken at night

 Chemo drugs: the most important thing is hydration (N/V must be controlled to avoid hydration issues)

 CK and CRP for MI assessment

 Temperatures brought on by disease… don’t worry until OVER 102.5F… THEN CALL DOCTOR

 Surgical temps or anything done to your body: EXPECT slight temp for first 48 hrs but NOT MORE THAN 101.5F… AFTER 48 HRS, NO TEMPERATURE ABOVE NORMAL

 ALT/AST for liver disease  BUN/Cr: kidney problems

 RESTLESS = HYPOXIA = IMMEDIATE NEED FOR INTERVENTION

 Vomiting around a NG means the fenestrated end holes are clogged…so you know what the problem is, and you need an action

 NEVER change suction to continous (in NCLEX or real life)

 Pretty much when something is draining, and not it stopped, it is probably clogged

 FLUSH-MED-FLUSH-MED-FLUSH (avoids compatibility issues)

 Never hook up G-Tube for 30 minutes after you give a med….WAIT TO RESTART FEEDINGS

 With PEEP on an ET:

o Great for cardiac output, but bad for venous return, so expect some edema (normal to have edema and some weight gain)

o Normal ET cuff pressure is 18-20mmHg

 “Following up” means you are concerned about something that was done or said

 Ileostomy: Should always have a never ending river of green goo…that is normal… but can cause orthostatic HoTN, so be careful

 Native American Highest Chance of DM2

 Hispanics at risk because of their native American heritage

 Dumping syndrome: imagine sitting at a green light, being late, and having a funeral procession crossing on your cross street…. The dumping is a

syndrome of food going into mouth, then 10 minutes later being eliminated… the whole system runs way too quickly (GI Tract too quick)… need frequent small meals, not 3 regular meals a day. Lots of fat/protein in diet, lie down after meals, and don’t drink and eat at same time

 Unexpected abnormal: call the doctor unless it is a position change only  Humira: immunosuppressant (avoid people who are sick)

 HIV Prejudice on NCLEX

 Pregnant women: no more than 1 serving fish per week (due to mercury)  Steroids all cause SODIUM RETENTION, that puts them at risk for low K

(hypokalemia), which can cause dig toxicity…so don’t mix steroids plus digoxin

 Hct normal: 41-49

 BUN : high end of normal is 20 (normal 16-20)

 Bleeding/ecchymosis around umbilicus: we know the problem, so start an IV (no assessment needed…we know the problem)

 N/V with a DM1: check blood glucose, then (if in the question), start a sliding scale and do normal insulin (this is how you treat diabetics on their sick days)  Autonomic Dysreflexia causes: something is binding them (a tube clogged, or

too much swaddling up (like an infant), or constipation)

 A patient who has massive urine output with head injury, probably has Diabetes insipidus (but needs validation (assessment))

 Spec gravity: 1.010-1.030

 Fixed specific gravity is bad… it should vary during the day.  Fixed low is DI, fixed high is renal failure (tea colored)

 The only way wild side effects are allowed are for chemo drugs (SIADH, for example)

 Best assessment of hypomagnesemia

 Tetralogy of fallot: DO NOT OVER FATIGUE THE CHILD (such as use high flow nipple for feeding)

 Infants are fed every 2 hours when awake… no exceptions  No oral replacement for infants who are hypovolemic…IV only

 When looking at comparing normals, the best normal is the one in the middle  If they are awake enough to gag then they should not be getting an NG for

suctioning.

o You are chocking someone, so take it out!!!

 Tracheostomy – general anesthesia – most important thing to observe?

o 120 mm – 160 mm Hg of suctioning, usually no more than 120. So 180 mm Hg would be too high.

o Coarse wheezes are normal for a patient with a trach.  Ok lung sounds;

o Fine crackles with bases OK

o One lobe OK cause its just one lobe o At the bases is OK

o NOT ok lung sounds; o 2 lobes

o One whole side

o If 2 answers are saying the same thing (ie, better lung sounds), then neither is the answer

 Honey Colored Crusts: Impetigo (an infection) o Treat with ABX

o Wash hands

o Not food allergy…a bacterial infection o ABX after 24 hr, ok to interact with others  Toddler: 2-5 yrs

 Teaching stuff: The NURSE MUST BE PRESENT and do things… not showing a video and leaving the room.

 Play is as vital as oxygen to a kid  PLAY is the key to their world

 Assessing and teaching with kids is always related to playing  Eye surgeries: keep pressure down, don’t sneeze or bend over, no

constipation

 Never apply ice to tips (Ears, nose, fingers, toes)  No ASA for kids under 10yrs Reyes Syndrome

 Moderate sedation is “procedural sedation” and risk for airway is highest concern

 Always VALIDATE your thought/interpretation of what is going on, with an assessment, unless the question specifically tells you the diagnosis

 “Checking vital signs” is very broad and not specific…so often not the answer  Elderly pulling out tubes: give him something else to hold onto…like a towel  NEVER ASK A FAMILY MEMBER TO BE THE SITTER… USE A TRAINED PERSON…

they are not trained

 Private rooms: immunocompromised or super infected (gonna get sick or will make others sick)

o High WBC

 Respiratory Acidosis and alkalosis: pH/CO2 opposite (ph up, CO2 down, etc…)  Metabolic Acidosis and alkalosis: ph/HCO3 match (up and up or down and

down)

 Suctioning is an assessment driven procedure (only when needed) therefore ONLY RNs CAN SUCTION!

 On the test, don’t believe: o Substance abusers o Anorexics

o Bulimics

 If PaO2 is low, almost always on test answer is “OXYGEN”

 If you already know that they are hypoxic, no reason for pulse ox…just do something to fix it.

 Paperwork comes after psychosocial (lowest priority)

DECISION TREE

1) Figure out what the question is really asking a. Cover all answer choices

b. Read only stem of the question

c. ID what the question is asking by rewording the question in your own words (2-3 words) (i.e. “Priority… toxic….shock”)

d. If you can ID topic of the question, proceed to step 2 (SIMPLIFY THE TOPIC)

2) Are the answers assessments or implementations? IF VALIDATION IS

REQUIRED, IT IS AN ASSESSMENT (IE “I HAVE TO LISTEN TO LUNGS FOR PE”) (If they give all the info, that is an implementation issue, not an assessment issue…they are telling you what you need to know) TRAP: If you thought you needed an assessment with validation, but they are all implementation answers, then just go forward)

a. A mix of assessments and implementation

i. If yes, read stem to determine if you should assess or implement (if validation required (you need more info), then it is an assessment)

1. Select correct answer

b. Are answers ALL assessment or implementation? i. If yes, go to step 3

3) Does Maslow Heirarchy fit? (Physical needs outweigh psychosocial needs) (Meds to allow a procedure to be undertaken (i.e. reduction of dislocation) is physical…. Requesting pain meds for pain relief is a psychosocial issue. ONCE A PHYSICAL ISSUE IS THERE, IT OUTWEIGHS/TRUMPS ALL PSYCHOSOCIAL. PAIN MEDS FOR PAIN IS PSYCHOSOCIAL…NOT PHYSICAL

a. If yes, eliminate psychosocial answers i. Do physical needs make sense?

1. Apply ABCs b. If no, are all answers physical

i. Yes: Step 4

ii. No, all answers psychosocial 1. If yes, proceed to step 5 4) Are all answers physical???

a. ABCs

5) What is the OUTCOME of each of the remaining answers? (TRAP: Don’t select answers that “sound” right)

a. If all answers are assessment, ID why each assessment is performed. Determine the outcome of each assessment. Is it desired for the situation.

b. Are all answers implementation: ID why each implementation is performed. Determine outcome of each answer. Is it desired?

Step 5 Sub Parts

A) Expected abnormal vs. unexpected abnormal i. i.e.: Asthma: wheezing is not unexpected,

but absent lung sounds is problematic… Heart failure: right sided issues are normal and expected, but left side symptoms are bad and worrisome. Post op slight bleeding is expected abnormal, but pools of blood is an unexpected abnormal and worrisome. B) Chronic vs. Acute: When to decide who to see

first, chronic diseases with chronic drugs is not a high priority… acute diseases and acute issues are higher priority

C) Worse case ABC (ABCs first) (AIRWAY ISSUES BEFORE CIRCULATION OR BLEEDING ISSUES) (ASTHMATIC WITH ANY AIRWAY BREATHING ISSUE WILL BE SEEN BEFORE HEART ATTACKS… AS LONG AS MI HAS AIRWAY AND BLEEDING. IE: Femur fracture, worse case scenario is bleeding…so a

patient with an airway issue must come first on NCLEX